Of Expert Committees to the Executive Board

OFFICIAL RECORDS OF THE WORLD HEALTH ORGANIZATION No. 15

REPORTS OF EXPERT COMMITTEES TO THE EXECUTIVE BOARD

These reports of expert committees are printed in the form in which they were presented to the Executive Board at its second session, held in Geneva from 25 October to 11 November 1948. The observations and decisions of the Executive Board are recorded as footnotes.

WORLD HEALTH ORGANIZATION

Palais des Nations, Geneva

April 1949

TABLE OF CONTENTS

Page EXPERT COMMITTEE ON TUBERCULOSIS :Report on the third session 5

EXPERT COMMITTEE ON VENEREAL DISEASES :Report on the second session 18

EXPERT COMMITTEE ON THE UNIFICATION OF PHARMACOPOEIAS :Report On the third session 39

3708 Lop

[WHO/TBC/3] II October 1948

EXPERT COMMITTEE ON TUBERCULOSIS

REPORT ON THE THIRD SESSION 1 Held 30 September-4 October 1948, Office International d'Hygigne Publique, Paris

Contents Proposals of the Delegation of Czechoslovakia 2

. Consideration of matters referred to the The listed suggestions for tuberculosis control, committee by the Health Assembly and made in the first part of the Czechoslovak pro- the Executive Board posals, are in accord with the general principles 2. Reconsideration of previous reports set out in the committee's first and second reports.8 Since, however, conditions vary from country to 3 .Other items country, the committee feels that advice on a Annexes detailed plan of operations should be given by the tuberculosis section of WHO in each individual case.For example, the committee ques- The Expert Committee on Tuberculosis held tions the value of attempting " registration of its third session in Paris from 30 September to every case of confirmed and suspected tubercu- 4 October 1948. The following members were losis " in such large countries as China and India, present : where at present little use would be made of such Dr. P. M. D'Arcy Hart, Farm Laboratories, information. NationalInstituteforMedicalResearch The other comments of the delegation of (Medical Research Council), London, United Czechoslovakia consisted of suggested modifica- Kingdom tions to the committee's first and second reports. Dr. H. E. Hilleboe, Commissioner of Health, They will now be considered in sequence. New York State Department of Health, The committee agrees that, to the four special Albany, N.Y., USA fields in which it was stated as essential to have Dr. J. H. Holm, Chief, Tuberculosis Division, trained medical officers in tuberculosis in each State Serum Institute, Copenhagen, Denmark country and to grant travelling fellowships, there (Chairman) should be added a fifth, namely, public-health nursing. (The member from the USSR has not yet been nominated.) The committee also accepts the recommendation regarding WHO fellowships-that facilities should Dr. J. B. McDougall (Secretariat) was secretary be provided in training centres for training of the committee. teams, as well as individuals. It was noted that the Executive Board of the The committee fully agrees that, in the train- World Health Organization at its first session ing of fellows from central and eastern Europe, appointed the expert committee of the Interim full consideration should be given to the health Commission to serve as an ad hoc committee conditions in these countries following the war. until a new committee is appointed. The committee agrees also with the comments made on the scope of consultation services and 1. Consideration of Matters referred to the mass radiography. Committee by the Health Assembly and the The committee is of the opinion that it is not Executive Board possible to prepare a general statement, applicable to all countries throughout the world, on the type The committee noted that the reports of its and size of buildings, number of beds, clinical first and second sessions were generally accepted equipment and provision of staff needed for by the World Health Assembly.It first con- effective tuberculosis control.It feels that these sidered matters referred to it by the Health details must be determined by a first-hand survey Assembly and the Executive Board. of the country concerned by qualified personnel, taking into account current local conditions. 1 The Executive Board, at its second session, " took note of the report of the third session of With regard to the proposal that the production the Expert Committee on Tuberculosis and decided and distribution of tuberculin, streptomycin and to publish it as submitted, without observations but with a note stating that the Board had postponed discussion of the report until itsthird 2 See Annex 1, p. 8 session ". Oft. Rec. World Hlth Org. 14, 19 3 Off. Rec. World Hlth Org. 8, 49 ;11, 5 TUBERCULOSIS - 6 -

BCG vaccine be increased, steps in these matters establishment of WHO and of the decisions made are being taken by the Joint Committee on Health by the first Health Assembly in the field of Policy, UNICEF/WHO. The recommendation of tuberculosis.7 the expert committee's own Sub-Committee on Streptomycin contains practical suggestions on the distribution and use of streptomycin. 2.1Composition of Expert Committee on Tuber- The Sub-Committee on Tuberculin and BCG culosis 8 has made recommendations on uniform procedures under these headings.(Annex 2 and Appendix This ad hoc committee has carefully considered pp. 9, TO.) the question of the size and type of representation The expert committee agrees that when advice is of the new Expert Committee on Tuberculosis given to a country by the Secretariat on the plan- of WHO. On the basis of extensive experience ning of the WHO tuberculosis programme for that in a number of countries, the committee is firmly country, special attention should be given to the of the opinion that the number should be as needs, resources and attitudes of the people in small as is consistent with effectiveness. A small assessing what could be accomplished in the first committee works more rapidly than a large one, year. To assist in this, the committee has drawn is more economical, and reduces language diffi- up, as part of the report on its third session, an culties.Itpermits the members to become outline of the stages of a campaign that might acquainted with one another more quickly, so be undertaken in a country with an undeveloped that they act as an integrated advisory body. programme. The committee is in full agreement with the The type of representation on the new com- suggestion that WHO should, at the beginning, mittee should include administrators, epidemio- concentrate its work on areas of the greatest logists,laboratory experts and clinicians,so need and in which the best results could be asto consider tuberculosisasa community achieved in the most economical way.It believes problem as well as a disease affecting the indi- also that, in the first year, WHO should place vidual. What is wanted is special knowledge of special emphasis on stimulating provision for all the main phases of tuberculosis control and laboratory facilities for the exact detection of not only that of the clinical care of patients. tubercle bacilli ;this is an essential first step in the prevention of the spread of the disease Geographical representation should also be given from infectious cases. careful consideration. Accordingly, it is recommended that the new 1.2Proposals of the Delegation of Greece 4 expert committee consist of six regular members, and that a panel of five specialists, including Experience of the UNICEF teams now operat- a public-health nurse, should also be formed ; ing in the field has demonstrated that the pro- one or more of the panel should be co-opted for posals concerning three-monthly tuberculin-test- special problems under Rule 14 of the Rules of ing of children and adolescents are impracticable. Procedure for Expert Committees and their Sub- Accordingly,therecommendations were not Committees.9 The regular committee should meet accepted. twice a year to consider current problems, and at one of these meetings each year one or more 1.3 BCG Vaccination 5 of the panel, as well as further specialists if need The expert committee has reviewed this docu- be, should be brought in to consider special ment and wishes to restate the views expressed problems and -alb long-term plan. In this way, in its previous reports, namely, that BCG vaccina- special problems could be handled in the future tionalone cannot control tuberculosisina through the co-option of individual specialists, country ;however,it can play an important rather than through sub-committees. part in the preventive aspects of the total control programme. 2.2Regionalization 1.4Addition to Expert Committee The committee noted that the Health Assembly The expert committee discussed the recom- gave high priority to tuberculosis.Therefore, in mendations of the Executive Board,6 that a fifth the development of the regional programme of member who is expert in antibiotics should be WHO, the committee recommends that there be added to it.Because of the fact that one of its attached to each of the regional offices a full- members is recognized as expert in the field of antibiotics in tuberculosis, the committee is of the opinion that this field is well covered. 7 Off. Rec. World Hlth Org. 13, 300, 302 8 The Executive Board, at its second session, made the following comment :" Concerning the 2. Reconsideration of Previous Reports composition and meetings of the expert committee, the Board agreed that (r) the membership should The expert committee then reconsidered matters be increased to nine, taking into account the need for specialists in all the different aspects of the in its previous reports in the light of the final problems and adequate geographical distribution, and (2) no definite number of meetings a year 4 See Annex /, p. 9 should be specified. " Oft. Rec. World Hlth Org. 14, 5 Og. Rec. World Hlth Org. 13, 300 6 Ibid. 14, ir 9 og. Rec. World Hlth Org. 13, 376 - 7 TUBERCULOSIS time tuberculosis specialist from the tuberculosis project as soon as sufficient personnel have been section of WHO. trained.Thus, the success of a demonstration team should be measurable not only by the work accomplished prior to withdrawal, but also by what 2.3Fellowships remains of permanent value ;that is, by the momentum given to the country's own tuber- The committee wishes to make additional culosis programme. recommendations regarding travelling fellowships and training : 2.6Uniform Procedures (a)that the training course for fellows in a In implementation of its programme of develop- teaching centre should be drawn up on a formal ing and recommending uniform procedures, the basis with a regular time-schedule ; expert committee has the following to report : (b)that, as far as practicable, training in all 2.6.1.Report of the Sub-Committee on Tuber- the five fields (administration, epidemiology, culin and BCG.(Annex 2, p.9.) The com- laboratory and clinical work, and public-health mittee reviewed the report of the Paris meeting nursing) should be available in the same centre (16 June 1948) of this sub-committee, and recom- so as to make it possible to train simultaneously mends its acceptance by the Executive Board. teams from countries as well as individual 2.6.2Report of the Sub-Committee on Strepto- fellows ; mycin.(Annex 3, p. it.)The committee has reviewed the recommendationsoftheSub- (c)thatthetuberculosis sectionof WHO Committee on Streptomycin (New York City, should assume responsibility for surveying and July 1948).It recommends the report for accep- reporting on the suitability of existing and tance by the Executive Board with the following proposed training-centres. comments : (a) The potential importance of chemothera- peutical agents in all phases of tuberculosis 2.4Circulation of Specialist Literature control is such that the committee strongly The committee recommends that certain emi- urges that the way be left open to call together, nent specialists be invited by WHO to contribute if necessary, at an appropriate time in the memoranda on given subjects, which will be future, a group of experts in this field. circulated to governments with permission to (b) The committee would like to draw the publish in their national literature.These articles attention of countries using streptomycin in should give the latest practical information. The tuberculous meningitis, particularly in children, following is suggested as an initial list : to one important consideration-that they will have to provide additional facilities to allow (a) The present status of BCG vaccination. for continual hospitalization and convalescence, otherwise badly needed hospital beds will be (b) How to start tuberculosis control in a blocked. country with an undeveloped programme. (c) Laboratory diagnosis of the presence of 2.7International Lists of Diseases and Causes tubercle bacilli. of Death The statement on the classification of tuber- (d) Home-nursing care of the tuberculous. culosis prepared by the Chairman of the Expert (e)X-ray interpretation in the diagnosis of Committee on International Lists of Diseases tuberculosis. and Causes of Death (Annex 4, p. 15) was discussed at length. It was recommended that a letter should be 2.5Field Services for Demonstrating Practical sent to that committee in which the expert com- Activities in Tuberculosis Control mittee would clarify its position.It was believed tfiat no difference in aims existed between the The committee has reviewed the secretary's two committees, and that no joint meeting would report of the field service programme during the be needed at present. past year by the officers of the tuberculosis section of WHO. The experience gained has enabled it to see more clearly both the advantages and the 2.8Relationship with other Organizations disadvantages of such assistance to governments. 2.8.1International Union against Tuberculosis. The committee strongly re-emphasizes the view The committee welcomes the resolution regarding set out in their first report," namely, that teams the reorganization of the International Union sent out are for demonstration purposes for a against Tuberculosis passed at the meeting of short period of time. They are not intended to the Council of the Union held in Paris on 27-29 September 1948.This should result in a more serve as semi-permanent advisers, or to provide effective voluntary agency in the control of relief services which cannot be continued when tuberculosis, working alongside WHO. the teams depart. The country receiving assis- The appointment of a qualified Executive tance must agree beforehand to take over the Director of the International Union will greatly facilitate the work of WHO in the international 10 Off. Rec. World Hlth Org. 8, 50 control of tuberculosis. TVI3ERCUOSIS - 8 -

2.8.2UNICEF. The expert committee wel- 3.2Suggestions for the Control of Tuberculosis in comes the formation of the Joint Committee on Countries with Undeveloped Programmes Health Policy, UNICEF/WHO. This will ensure close co-operation between these two organiza- The tuberculosis section of WHO has had many demands made upon it for specific informa- tions. tion on the best method to develop tuberculosis control programmes in countries with little or 3. Other Items no existing programme. The Secretariat has asked the expert committee for its advice on the 3.1Modern Laboratory Methods steps that must be taken in such countries. The The committee recommends that the tuber- details of its recommendations are set forth in culosis section of WHO give special emphasis to Annex 5 (see p. 16). the desirability of providing personnel and facilities for the accurate demonstration of tubercle 3.3Work of the Secretariat in Geneva bacilli by modern laboratory methods. This applies not only to countries with undeveloped The committee considered the report on the programmes, but also to countries with more work accomplished in Geneva by the tuberculosis advanced programmes. This provision will include sectionandexpressedtheirappreciationof the training of personnel in laboratory diagnosis the manner in which the members had been kept and theestablishmentofcentraldiagnostic informed of the progress of the work both at laboratories in each country for this purpose. headquarters and in the field.

Annex 1 [A/Prog/29/Rev.I] 13 July 1948 PROPOSALS SUBMITTED TO THE FIRST WORLD HEALTH ASSEMBLY

DRAFT RESOLUTION ON TUBERCULOSIS PROPOSED BY THE DELEGATION OF CZECHOSLOVAKIA

Whereas the World Health Organization is of to the report on the first session of the expert the opinion that it is of the greatest importance committee. " to promote tuberculosis control throughout the We are proposing that the following be referred world, to the expert committee for further consideration : The World Health Assembly (a) thatthespecialworkersmentioned- RECOMMENDS that governments take-subject namely, a tuberculosis administrator, epidemio- to the conditions in their countries-preventive, logist, laboratory worker and clinical worker- curative,legislative,social and other measures should be supplemented by a public-health necessary for tuberculosis control, particular atten- nurse ; tion being paid to the following : (b) that, instead of studies by these workers (i) registration of every case of confirmed and at different places, provision be made for a suspected tuberculosis and of death from tuber- combined training in a well-organized tuberculosis culosis ; control establishment in one place in order that (ii)free treatment of tuberculosis patients in they may put into practice the already co- institutions, or if that is not possible, at home, ordinated experiences they gain during their with as adequate isolation as possible ; training.In other words, training should be given to working teams and not only to indi- (iii)establishmentofclinicsfordiagnostic examination and follow-up, with such service viduals. available free of charge ; As to the third paragraph of item 3.2 of the (iv)establishment of procedures to getall report on the second session,12 we are proposing persons suspected of having tuberculosis exa- the addition of a training-centre for central and mined ; eastern Europe. There is no need to dwell on the (v)the securing of a sufficient number of beds reason for this proposal.It is a recognized fact in tuberculosis hospitals ; that the war has affected morbidity and mortality (vi)routine tuberculin-testing free of charge from tuberculosis in these areas. when indicated ; As to the fourth paragraph, we feel that highly (vii)BCG vaccination free of charge when indi- specific consultation services of short duration cated ; with regard to tuberculosis are rather expensive, (viii)mass x-ray examination free of charge compared with the results, and ineffective without when indicated ; constructive advice from an experienced public- health administrator as to how to improve the (ix)compensationfortheloweredearning ability of the afflicted person ; inadequate system of a particular country. rehabilitation of patients ; As to the first paragraph of item 3.3, we should (x) like to suggest a minor rephrasing in a positive (xi)extermination of tuberculous cattle. In addition to our suggestions for regulating the proposals of the expert committee by legis- 11 Off. Rec. World Hlth Org. 8, 50, item 3.2 lature, we are submitting certain modifications 12 Ibid. 11, 5 - 9 - TUBERCULOSIS way, that countries intending to acquire mass whole globe, but also of what could be undertaken x-ray equipment should make provision for full in a year.The governments should be clearly clinical investigation and disposition of cases with informed that the programme would at the be- abnormal x-ray findings. ginning be applied to areas of the greatest need As to the next paragraph, the recommendations and in which the best results could be achieved should not be confined to construction of per- in the most economical way. manent buildings, but should include institutions based on up-to-date information as to the type and size of buildings, number of beds, the clinical [AIProg/3o] equipment and provision of staff. In this connexion, we would request that the expert committee pre- 5 July 1948 pare a plan to the end of 1948, indicating the number of hospital beds needed for effective tuber- PAPER SUBMITTED BY THE DELEGATION OF GREECE culosis control. In the last paragraph, we would like to stress The Delegation of Greece proposes : that WHO should concentrate on increasing the r.that children and adolescents up to the age production of tuberculin, streptomycin and BCG of 18 should be subjected, every three months if vaccine, and supervise an equal distribution of possible, to tuberculin cuti-reactions, and, should these products among the nations in need of them. these prove negative, to tuberculin intradermal This should be the section on tuberculosis in the reactions in increasing doses of r/r000, r/roo and Provisional Agenda.13 even 1/50 or undiluted. Regarding item 3.7(r) and(2), we wish to (This reaction is suggested because during the request that this be undertaken at the earliest latent allergic and even during the allergic stages, possible moment. cuti-reactions are largely negative, whereas intrader- In item 3.7, we propose that immediate action mal reactions are quicker to give positive results.) be taken on the basis of the results of those studies 2.that as soon as allergy has been ascertained, pursued in consultation with FAO. the usual precautions should be taken and tests As to item 6, the dissemination of information carried out, e.g. tracing bacilli by washing out of on the WHO tuberculosis programme to govern- the stomach, sedimentation, x-ray photographs, etc. ments should be given in realistic terms, i.e., not 3.thatallsubjects with serious lesions and to inform them of the total programme in gene- whose sputum contains bacilli should be regarded ral terms only, which might create the impression assourcesof contamination and immediately that it could be carried out within a year over the isolated.(It would be desirable to advise governments tocreatespecial towns for tuberculous 13 00. Rec. World Hlth Org. 10, 8, item 12.1.5.3.2.2 subj ects.)

Annex 2 [WHO/TBC/3]

TUBERCULIN AND BCG

REPORT OF THE SUB-COMMITTEE ON TUBERCULIN AND BCG TO THE EXPERT COMMITTEE OF THE WORLD HEALTH ORGANIZATION

The Sub-Committee on Tuberculin and BCG was not possible for representatives from these met in Paris on 16 June 1948, at 43 Avenue Mar& countries to attend.) chal Fayolle, at lo a.m. The following were Thesecretarytothesub-committee(Dr. present : McDougall) pointed out that the object of this Dr. J. Bretey, Chef de la Division de la Tuber- meeting was to consider how and in what form culose, Institut Pasteur, Paris, France the discussion which had been held on the previous day with the representatives of UNICEF, Dr. R. G. Ferguson, Director and Superintendent, and which would have to be specially considered, Antituberculosis League, Fort San, Saskatche- should be submitted to the Expert Committee on wan, Canada Tuberculosis. Dr.I.Gonda(formerlyGoldstein),Chief, Tuberculosis ControlDivision,Department 1. Prospective Meeting with the Expert Committee on of Public Health for Slovakia,Bratislava, Biological Standardization of WHO Czechoslovakia The chairman (Dr. Holm) referred to the pre- Dr.F.R.G.Heaf, Senior MedicalOfficer, vious meeting of the Expert Committee on Biologi- London CountyCouncil,London,United cal Standardization of the Interim Commission and Kingdom to the fact that that committee had drawn up a report 14 which, he felt, ought to be circulated Dr. J. H. Holm, Chief, Tuberculosis Division, to the members of this present committee.It State Serum Institute, Copenhagen, Denmark was agreed that the secretary should circulate (Chairman) this report to members. Dr. C. E. Palmer, Senior Surgeon, US Public It was also agreed that the secretary should Health Service, Washington, D.C., USA notify all members of this sub-committee of the place and time of the next meeting of the Expert Dr. J. B. McDougall and Dr. M. Pascua (Interim Committee on Biological Standardization, so that Commission of WHO) were in attendance. all members could, if possible, attend. (As no replies had been received from the governments of the USSR and Argentina, it 14 Oft. Rec. World Hlth Org. 11, 8 TnEticutbsIs

2. Report of the Joint 'UNICEF (Medical Sub-Committee) In some instances surgical intervention had been and WHO Interim Commission (Sub-Committee on necessary. The experience of Dr. Palmer indicated Tubereulin-Testing and BCG Vaccination) Meeting that there was no real danger, and that it ought held on 15 Janie 1948 not to be set on record that the sub-committee It was the unanimous opinion of the sub- should be permanently against vaccinating without committee that they should endorse the view, previous tuberculin testing. already expressed by the Expert Committee on The sub-committee adopted the following reso- Tuberculosis, to the effect that the collaboration lution : between WHO and UNICEF in the campaign being launched for mass tuberculin-testing and " In the light of our present knowledge, the BCG vaccination was to be welcomed, and they sub-committee expressed their appreciation at being invited to RECOMMENDS, at present, that BCG vaccination take part in these discussions. as a routine prophylactic method should not be The sub-committeediscussedparagraph by used without previous tuberculin-testing." paragraph the draft report of the previous day's meeting and made certain suggestions prior to 6. Criteria for Revaccination by BCG its submission to the Medical Sub-Committee of Dr. Palmer gave notice that he would like to UNICEF. have this question discussed at the next meeting The report, as finally agreed upon (Annex 2, of the committee.This was agreed. Appendix),is now in the form inwhichit will be presented to the Executive Board of UNICEF, and to the Expert Committee on Tuber- 7. Future Meetings culosis. The chairman recalled that the next meeting of the committee would probably be in September 3. Financial Implications for WHO, arising out of the and that there would be meetings both with Report UNICEF representatives and with the committee The secretary pointed out that this matter was on Biological Standardization of WHO. The one of considerable importance and it would have exact dates and times would be notified to the to be known if adequate provision were to be members as soon as the meetings could be arranged. made in the 1949 budget of the World Health Assembly.As, however, the details of the programme had still to be worked out, it might be [WHO/TBC/3] advisable to delay further discussion until the Appéndix September meeting of the committee, when the whole question could be reconsidered.It was REPORT OF THE JOINT .UNICEF (MEDICAL SUB- agreed that this was the only course to be adopted COMMITTEE) AND WHO INTERIM COMMISSION at present. (SUB-COMMITTEE) MEETING ON TUBERCULIN- TESTING AND BCG VACCINATION 4. Demonstration Teams on Tuberculosis (WHO) The secretary explained the present position of The meeting was held at Avenue Maréchal demonstration teams of the Interim Commission of Fayolle, Paris, on 15 June 1948. The following WHO and suggested that there should be no over- were present : lapping between the work of these teams and that Chairman :Dr.J.H. Holm, WHO Interim of teams organized by UNICEF. At present, the Commission/UNICEF WHO teams were working on BCG outside Europe, and so long as UNICEF was confining its activities WHO.IC UNICEF to Europe this arrangement might well continue. Dr. Boulanger Dr. R. Debré If, however, UNICEF expanded its programme Dr. J. Bretey Dr. Th. Madsen of BCG vaccination to countries outside Europe, Dr. R. G. Ferguson Dr. L. Rajchman it would be advisable for the work to be done by Dr. I. Gond a Dr. W. M. Schmidt UNICEF and not by WHO, so far as BCG vacci- Dr. F. R. G. Heaf nation was concerned. WHO teams, however, Dr. C. E. Palmer would still be free to visit countries, at the request of governments, to advise on other aspects of Secretaries : Secretary : 'tuberculosis control,It was agreed that this course Dr. J. B. McDougall Dr. L. J. Verhoestraete should be adopted. Dr. M. Pascua Observers : 5. BCG Vaccination without previous Tuberculin-Testing Dr. G. Hansen This question was placed on the agenda because Dr. Z. S. Hantchef reports had been received to the effect that this Dr. J. Lundquist practice was apparently becoming more common Dr. H. J. Ustvedt in certain parts of the world.A letter had also recently been received from China, asking whether Dr. Rajchman gave an account of the sequence BCG vaccination by the scarification method could of events which led up to the convening of the be used on large numbers of children and young meeting.He outlined the relations between the adults in that country without the necessity of joint enterprise and the Interim Commission of previous testing. A decision from this committee WHO. was considered to be important. The chairman (Dr. Holm) gave an account of All members participated in the discussion, and the negotiations which have so far been conducted interesting facts were brought to light by Dr. between the joint enterprise and a number of Bretey from experiences of other observers in countries in Europe ;he described the present North Africa.Dr. Ustvedt (who was invited to position and the future possibilities concerning take part in the discussion as an observer) gave teams of Scandinavian and local composition in his experiences, and came to the conclusion that, eleven European countries receiving aid from while there was no danger from the health stand- UNICEF. point, yet there was frequently considerable incon- Dr. McDougall and Dr.Pascual (Secretariat venience in the form of intensive reactions at the of the Interim Commission) pointed out that the site of inoculation, in cases sensitive to tuberculin. Interim Commission of WHO had agreed at its - II - TUBERCULOSIS fifth session 15 to give advice and to co-operate higher age groups the final screen test should be with UNICEF on the BCG programme as out- a Mantoux test with ten tuberculin units. lined, but that the Interim Commission did not Another method could be by means of the take any responsibility for the actual field work von Pirquet test with Adrenalin-OT. undertaken by the joint enterprise. The reading of the tests should be made on the third day, and a positive Mantoux reaction Drafting Committee. Dr. Heaf and Dr. Palmer is indicated by a degree of induration not less were appointed members of a drafting committee than 6 mm. in diameter ; redness alone does not with Dr. McDougall as secretary. constitute a positive reaction. Tuberculin.For the Mantoux test, either PPD Methods to be suggested for Analysis of the immediate or OT may be used.It was recommended that and long-term Results of the Campaign a decision as to the preference for PPD or OT Dr. Pascua presented a report on the scientific should be left to a later date.Only standardized evaluation of BCG vaccination as a protective tuberculin should be used. measure against tuberculosis which he had pre- For retesting after BCG vaccination, the same pared for the consideration of the joint committee. method and doses should be used as that employed He emphasized that his report implied moral and before vaccination. legal problems for parents of children as well as BCG Vaccination.Professor Debré described for authorities of respective countries, which would the pilot stations to be set up in France under no doubt make the inquiry extremely difficult, and the auspices of UNICEF, which would study even impossible to be carried out in the form different methods of application of BCG vacci- proposed. nation, the development and the detection of It was generally agreed that the UNICEF pro- tuberculin sensitivity after vaccination, and the gramme did not lend itself to the kind of scientific immediate and remote clinical results in selected evaluation of the effect of BCG which would groups. require that a groupofnon-vaccinatednon- The question of what should be considered a reactors to tuberculin were left as controls.It recognized standard for BCG vaccine to be used was, however, the opinion of the meeting that by the joint enterprise should be left for further significant information as to the value of BCG consideration, for this question was deemed to be vaccination might be forthcoming if the cards of within the province of the Expert Committee on all persons tuberculin-tested and vaccinated were Biological Standardization of the Interim Com- retained for studies on mortality and morbidity. It was therefore recommended that the cards mission of WHO. should be carefully preserved and filed in central Cards.Dr. Rolm explained the details of the places in the respective countries for subsequent cards which are being used in all countries in the use, and that the details for the programme should European investigation.It was agreed that the be worked out for the utilization of these records, form was sufficiently complete for the purpose in connexion with current and Iong-term statistical in view. studies on tuberculosis (especially mortality- and Age groups.. Some discussion took place on the morbidity-rates) in the different countries. lower age groups to be vaccinated, and it was It was the consensus of opinion of the meeting recommended (/) that all children over one year that the suggested method of reporting the results of age should be included in the mass vaccination of the programme is sufficient for the immediate programme and (2) even though BCG vaccination documentation of results and for certain limited is harmless and effective in children under one studies on the effect of BCG vaccination. year of age,yet,for psychological and other Techniques.After a general discussion of the reasons, it would be better to exclude this age methods of tuberculin-testing, it was agreed that group from the mass campaign. different methods of tuberculin-testing could be However, children under one year of age should used at the discretion of each country, provided be vaccinated as soon as possible, preferably in that the same method is used throlighout the dispensaries or institutions. country. Isolation.It was agreed (a) that for the mass It was therefore recommended that the Moro vaccination programme, isolation of vaccinated Ointment Patch test may be used in children up to persons was not necessary ;(b) that segregation 12 years of age, as the final tuberculin-test ;in of open cases, even though desirable for other reasons, is considered not to be an essential measure 15 Off. Rec. World Hlth Org. 7, 252 for a mass BCG vaccination programme.

Annex 3 [WHO/TBC/3]

STREPTOMYCIN

RECOMMENDATIONS OF THE SUB-COMMITTEE ON STREPTOMYCIN OF THE EXPERT COMMITTEE ON TUBERCULOSIS OF WHO, ON THE USE AND VALUE OF STREPTOMYCIN IN THE TREATMENT OF TUBERCULOSIS

The Sub-Committee on Streptomycin of the chosen by WHO for their experience in the treat- Expert Committee on Tuberculosis of the Interim ment of various forms of tuberculosis with strepto- Commission of WHO held its meeting on 30 and mycin and because of their eminence in various 31 July 1948, in New York City, in accordance medical specialities : with the authority of the Executive Board.The Dr. K. Choremis, Director, Children's Clinic, sub-committee consisted of the following members, University of Athens, Greece TUBERCULOSIS - 12 -

Dr. C. Cocchi, Director, Clinica Pediatrica, Uni- vented a full presentation by each member of all versity of Florence, Italy his case reports. Dr. R. Cruickshank, Director, Central Public An agenda was adopted, which included reports Health Laboratory, London, United Kingdom on .Che use of streptomycin by the countries repre- Dr. M. Daniels, Farm Laboratories, National sented, discussion periods and a visit to the New InstituteforMedicalResearch(Medical York State Tuberculosis Hospital. Research Council), London, United Kingdom After two days of intense and fruitful discussion ProfessorR.Debré,Fa cultéde Médecine ; Directeur de la Clinique médicale infantile, by members ofthe sub-committee and short Hôpital des Enfants-Malades, Paris, France statements by some of the invited guests, the follow- Dr. R. Dubois, Professeur de Pédiatrie, Uni- ing recommendations were made concerning the versité libre de Bruxelles, Belgium use and value of streptomycin in tuberculosis. Dr. H. E. Hilleboe, Commissioner of Health, New York State DepartmentofHealth, 1. General Statement Albany, N.Y., USA, member of the Expert Committee on Tuberculosis of WHO (Chair- Carefully documented studies on the use of man) streptomycin in clinical tuberculosis have establis- Dr. H. Corwin Hinshaw, President, American hed the fact that this new antibacterial agent exerts Trudeau a beneficial therapeutic effect on several forms Society, Mayo Clinic,Rochester, of tuberculosis.At its best, however, it is only Minn., USA an auxiliary to the general treatment in most Dr. H. McLeod Riggins, Chairman, Committee on Medical Research and Therapy of the forms of the disease, and is partially dependent, American Trudeau Society, Bellevue Hospital, for its full effect, upon other more common thera- New York City, USA peutic measures, such as rest in bed, pneumo- thorax, and chest surgery. The following American guests were invited Skill and experience in the selection and sur- to attend the clinical meetings, so as to provide veillance of patients who are to receive the drug the foreign members of the sub-committee with are as necessary as is the choice of patients who information on the principal investigations in the are to receive thoracoplasty. Even under the best USA at the present time : conditions, serious toxic manifestations do occur, Dr.J.Barnwell,Veterans'Administration, some of them fairlyfrequently.Furthermore, Washington, D.C. tubercle bacilli in certain patients acquire resistance to streptomycin, and this necessitates termination Dr. R. Dubos, Rockefeller Foundation, New of specific therapy. In addition to this effect on York City tubercle bacilli in the patient concerned, there Dr. F. Feldmann, National Institute of Health, is the potential risk of spread of streptomycin- Bethesda, Md. resistant organisms to exposed contacts. This is Dr. E. P. Fowler, Jr.,Otolaryngologist, New a public-health hazard, the extent of which cannot York City atfirstbe gauged ;but it may be of great Dr. K. S. Howlett, Laurel Heights Sanatorium, importance in the continued use of streptomycin Shelton, Conn. in tuberculosis. Dr.Edith Lincoln,BellevueHospital, New During the initial period of study and use of York City this new antibacterial agent, it is recommended Dr. E. Medlar, Bellevue Hospital, New York that streptomycin be distributed, by governments, City only to institutions, medical centres, and teaching Dr. J. Perkins, National Tuberculosis Association, hospitalsregularly concerned with the study, New York City diagnosis and treatment of tuberculosis.With Mr. W. Steenken, Saranac Laboratory, Saranac such safeguards, availablesuppliesofstrepto- Lake, N.Y. mycin will be beneficially employed under the Dr. M. V. Veldee, National Institute of Health, supervision of physicians experienced in strepto- Bethesda, Md. mycin therapy, aware of its dangers and contra- Dr. S. Willis, State Sanatorium, N.C. indications, and prepared to carry on further research in the more precise use of this and other The chairman explained to the group that the newly developed antibacterial agents against tuber- Expert Committee on Tuberculosis, at itsfirst culosis. meeting in Paris in July 1947, had recommended that a conference be called as early as possible in 1948 to discuss the use and value of strepto- 2. Types of Cases suitable for Treatment mycin in tuberculosis. The chairman and executive Streptomycin is not believed to be suitable for secretary of the Interim Commission of WHO all types and stages of tuberculosis ;therefore, agreed to this, and the official members of the the choice of cases and selection of the exact and sub-committee were appointed after consultation most favourable time for treatment will require with their respective governments. The chairman told the members of the sub- wise judgment, long clinical experience, and great committee on streptomycin that their recommen- skill. dations would be transmitted through the Direc- Patients with tuberculous meningitis and genera- tor-General to the Expert Committee on Tuber- lized haematogenous or miliary tuberculosis should culosis for consideration at its next meeting in be given prior consideration, because of the ex- Paris in September 1948. When they were appro- tremely high mortality-rate among untreated cases ved by the expert committee, they would be sub- and the lack of any other dependable therapeutic mitted to the Executive Board with the recommen- approach. Despite very encouraging results follow- dation that they be made available to all Member ing present regimens of streptomycin therapy, Nations of WHO. The chairman also stated that studies now in progress will probably result in the limited time available for the meeting pre- even more effective treatment procedures. TUBERCULOSIS

Active exudative types of pulmonary tubercu- muscular andintrathecalroutesshouldbe losis of recent origin, which have not progressed utilized. beyond the possibility of healing, may frequently be ameliorated by streptomycin, but residual (b) Regimens should be employed which are lesions of a more chronic and destructive character most likely to exert a beneficial therapeutic may require other forms of treatment. effect, but which are least likely to cause severe Some of the most distressing complications of or irreversible toxic effects. The degree of seve- pulmonarytuberculosis,especiallytuberculous rity of toxicity that may be risked should be laryngitis and tuberculous enteritis, may be greatly determined in part by the immediate or remote benefited by appropriate streptomycin treatment. threat of the disease if it were not treated with Streptomycin isparticularly effective in the streptomycin.Regimens should be used which treatment of tuberculous sinuses and fistulae ; minimize the emergence of streptomycin-resis- less favourable results have so far been reported tant strains of tubercle bacilli. Toxic effects in renal tuberculosis and in tuberculosis of bones, are related to the size of the daily dosage. joints and glands. Streptomycin-resistance is related to duration Streptomycin may be used with justification as of treatment in cases of pulmonary tuberculosis a prophylactic in chest surgery only when there with positive sputa. is a considerable risk of post-operative tuberculous (c) A subsequent or second course of strepto- complications. Treatment isbeneficial in post- mycin may be indicated if the disease worsens operative spread of infection. or if a relapse occurs, provided the tubercle Other therapeutic measures of accepted value bacilli have not become predominantly strepto- should not be neglected or postponed in cases mycin-resistant.This point cannot be specified which may be considered suitable for streptomycin precisely in the present state of our knowledge, treatment. These other measures should be continued, as indicated, both during and after but must be appraised after careful review of streptomycin therapy, because the latter is fre- all clinical and laboratory data on each case. quently effective only for a limited period of time. (d)Thereissome evidence that combined Streptomycin is not at present recommended therapy (streptomycin plus sulfone derivatives for those types of tuberculosis which are likely to or para-amino-salicylic acid) may be more effec- respond favourably to conventional therapeutic tive in some forms of tuberculosis than any of measures . the drugs used alone. At the present time, com- Streptomycinshouldbereserved,whenever bined therapy shows greatest promise in the supplies are limited,for those patients whose treatment of miliary tuberculosis and tuber- disease may reasonably be expected to respond culous meningitis in childhood. favourably within two to three months of treatment with streptomycin.If treatment were so (e) Controlled studies on the most effective regtricted, the appearance of resistant tubercle regimens for streptomycin therapy are now being bacilli would be less frequently observed. made in the United States of America and in Streptomycin cannot be expected to yield lasting Europe. Reports will quickly be made available beneficial results in the late stages of destructive to WHO for distribution, from time to time, as tuberculosis of organs with poor power of regene- more precise knowledge on regimens becomes ration, and where irreparable mechanical damage available. has developed so that surgica 1 treatment is impracticable. 4. Need for Uniform Records and Diagnostic Criteria for each Form of Tuberculosis treated 3. Regimen of Treatment with Streptomycin in Tuber- culosis It is strongly recommended that the Expert By regimen is meant the total daily dosage of Committee on Tuberculosis prepare a uniform streptomycin, the frequency and methods of ad- record system for analysis and evaluation of strepto- ministration, and duration of treatment. mycin studies in tuberculosis throughout the world. This will require joint planning and collaboration Optimum streptomycin regimens for thedif- by experts in the fields of epidemiology, biostatis- ferent forms of tuberculosis have not been determined with sufficient precision to make exact tics, and public health, in addition to the ser- recommendations possible at the present time. vices of clinicians experienced in the use of strepto- Because of these limitations, great skill must be mycin. It is not sufficient to record data accurately exercised in the use of streptomycin, and strict for each study.It is necessary to have agreement caution observed in its continued application. on diagnostic criteria for each form of tuberculosis treated.This is especially true for such Details concerning regimens now being used forms as tuberculous meningitis and miliary tuber- in various forms of tuberculosis may be found in culosis. Greater uniformity in the methods of published reports, including those of the members of this sub-committee. isolation of tubercle bacilli and in testing for streptomycin-resistance of tubercle bacilli isalso Certain principles may be set forth for guidance desirable. Comparable records should be kept in the selection of proper regimens for treatment on the pathology and histology of treated cases with streptomycin.These are as follows : that end fatally, so that new knowledge may be gained for future use. (a) There is no single streptomycin regimen suitable for all forms of tuberculosis.Just as The National Institute of Health of the United in other drug therapy, each regimen must be States of America and the Medical Research Coun- designedtomeetindividualrequirements. cil of Great Britain have already established cer- However, in general, in the treatment of tuber- tain criteria for recording the results of strepto- culous meningitis with streptomycin, both intra- mycin treatment in tuberculosis.These criteria TUBERCULOSIS - 14 - could be used as a basis for the establishment of 6.Cases of tuberculous meningitis with or with- uniform record systems, including diagnostic and out miliary tuberculosis should be reported prognostic criteria, to be used in all future studies. separately from cases of miliary tuberculosis The sub-committee will be glad to participate in without meningitis at the start of treatment. the establishment and development of such uniform record systems. 7.The type of tubercle bacillus (human or After discussing results of work of the countries bovine) should be stated.The resistance to represented, the sub-committee findsthat the streptomycin of the organisms isolated before, wide variations in methods of reporting constitute during, and after treatment should be stated. a serious obstacle to comparison of results.The sub-committee therefore recommends the adoption of minimum standards o i reporting which 5. Research in Streptomycin Therapy and the Search will render such comparisons possible and valid for more effective Antibiotics in Tuberculosis It is recommended that the following infor_ mation be included in any report on the result- The usefulness of streptomycin in treatment of of antibacterial treatment of tuberculosis : some forms of tuberculosis, particularly acute severe forms, has been demonstrated, but the drug is far 1. Selection of group : from being a cure for the disease in all its forms. Moreover, the problem of optimum dosage to obtain (a)Age distribution of cases. Results related maximum therapeutic effect,with minimum toxicity to age. and with minimum development of drug-resistance, (b) Method of selection of cases for treat- and the problem of combined action with other ment. chemotherapeutic agents, have yet to be solved. Research along these lines is urgently needed and (c) Type and state of disease ; results related should go forward speedily. thereto. For example, in tuberculous menin- It is recommended that WHO encourage and gitis the distribution of patients at different facilitate international co-operative study in this stages of illness on admission should be given, field by : and the results in these groups ; a statement should also be made concerning limitations (a)Attempting to obtain, directly and indi- on acceptance of advanced cases for treat- rectly,suppliesof streptomycinfor usein ment ;if cases dying within the first few centres for clinical research. weeks are excluded from the main analysis, brief particulars of them should be given. (b) Organizing and supporting, at the earliest ofbiological 2.Duration of symptoms and course of disease practicablemoment,exchange material (e.g. cultures of certain strains of the before treatment was begun. tubercle bacillus) and of new antibiotic and 3.Diagnostic criteria : synthetic drugs giving promise of therapeutic Cases not proved bacteriologically by culture value. or guinea-pig inoculation, or at post-mortem (c) Facilitating the exchange of expert per- examination, should be excluded from the main sonnel among biological and clinical research analysis, and reported separately.Information centres throughout the world. should be given on criteria (other than bacteriological) which were used for diagnosis of tuber- (d)Establishing contact with manufacturers culous meningitis and miliary tuberculosis. of streptomycin and other antibacterial agents, soasto be constantly informed regarding 4. Duration of observation and treatment : supplies of drugs for export and new types of The data on which the report is made, and the drugs which may become available. date of admission of the last patient in the series, should be given in order to indicate the It is principally by such means that there will minimum period of observation of survivors. be created a periodic and prompt exchange of (Thus, a report should not include all cases scientific information among nations. admitted up to the time of reporting.) The period of observation from the beginning of treatment should be not less than six months. 6. Future Meetings An ideal method is to report the condition of patients at definite periods of time after ad- The Sub-Committee on Streptomycin recom- mission ; thus, for meningitis, analysis could be mends a second meeting early in the course of made of results at one month, three months, 1949.The foundation for future conferences on six months, one year, and two years after the use of streptomycin and other antibiotics and admission, and after the begiUning of therapy. drugs in the treatment of tuberculosis has been If some cases have been lost from observation, established.The next meeting should be held in a statement should be made to that effect. one of the European medical centres to enable the sub-committee to observe the results of experi- 5.Clinical and, where possible, laboratory find- mental and clinical research with streptomycin ings at the time of reporting should be given and other antibacterial agents in treatment of for each case separately. tuberculosis. - 15 - TUBERCULOSIS

Annex 4 [WHO.IC/200.Add.I] [WHO.IC/MS/42.Add.I] 21 June 1948

EXPERT COMMITTEE FOR THE PREPARATION OF THE SIXTH DECENNIAL REVISION OF THE INTERNATIONAL LISTS OF DISEASES AND CAUSES OF DEATH (Report on the third session, 4-7 May 1948, Geneva)

STATEMENT REGARDING THE REPORT ON THE SECOND SESSION OF THE EXPERT COMMITTEE ON TUBERCULOSIS

Submitted by the Chairman of the Expert Committee on International Lists

The Expert Committee on Tuberculosis indi- and socialsecurity agencies,and successive cated in the report on its first session 36 that it revisions 19 have been prepared on the basis of wished to make suggestions on the classification the proposals received. proposed by the Expert Committee for the Prepa- The few concrete suggestions of the com- ration of the Sixth Decennial Revision of the mittee on tuberculosis were given favourable International Lists of Diseases and Causes of considerationin amending theclassification. Death.This committee had received at the time Otherwise the comments ofthis committee of its second session 17 a few suggestions from Dr. D'Arcy Hart, member of the committee .on consisted of : tuberculosis. During its second session 18the (a) expression of grave doubts as to the Expert Committee on Tuberculosis restated its value of the classification for international disagreement with the classification in the pre- comparison of morbidity statistics ; sence of the secretary of the committee on international lists.After this session the secretary of (b)references to a more suitableclassifi- the committee on international lists prepared a cation prepared by the committee on tuber- statement explaining the purposes and functions culosis (N.B.This classification has not been of the classification.This statement was sub- submitted for review or study to the committee mitted to the executive secretary, to the secre- on international lists). tary of the committee on tuberculosis and to the chairman of the committee on international lists, (3) The committee on tuberculosis maintains who discussed it with Dr. D'Arcy Hart. that " it is possible to develop a classification Item 3.7 (3) came to the attention of the chair- more on the basis of objective findings, some man and vice-chairman of the committee on of them quantitative in nature, including the international lists after the main body of this results of various laboratory and clinical exami- committee had left Geneva after its third session. nations ". The chairman wishesto make thefollowing This, however, could not apply to a classi- comments based on his discussions with the vice- fication which groups diagnoses after they have chairman and secretary : been established and recorded. It would appear (1) The exact title of the document referred that the importance of objective criteria should to is :" International Statistical Classification be rather stressed in the process of establishing of Diseases, Injuries, and Causes of Death ", the diagnoses themselves and not in classifying which title indicates the purpose of the classi- theseend-productsofthephysician'sdeli- fication and suggests the principles underlying berations. its structure. Beinga statisticalclassification,thislist (4) Reliable basic data as provided by accurate groups singly recorded statements into cate- and properly recorded diagnoses are essential gories suitable for statistical analysis. There for meaningful statistics, and any action pro- existseveralthousandindividualdiagnoses moting uniform medical terminology and objec- covering the range of morbid conditions and tive diagnostic standards would enhance the there are many different ways of grouping them. value of morbidity and mortality statistics. A uniform system of classifying diagnoses for tabulation is essential in order to allow com- It should, however, be realized that statisticians parative study of statistics from different sources. generally are not the first users of diagnoses It has been repeatedly stressedthat the stated in medical records.Diagnoses are pri- classification is not a nomenclature with the marily established for other purposes, such as purpose of indicating the most acceptable diag- propertreatment,prognosis,applicationof nostic term for describing a clinical case, but public-health measures. For these purposes, a working tool for coding and classifying diag- accurate andreliablediagnosesare just as noses found on medical records and death certi- important - or even more so - as for morbidity ficates. statistics. (2) The classification under discussion was at (5) The committee on international lists does the several stages of its development widely not believe that the proposed list is the ideal circulated for comments and suggestions to classification,butitconsiders,nevertheless, national health-administrations, statistical offices that the list represents the best available inter- 16 Off. Rec. World Hlth Org. 8, 5 1 17 Ibid. 8, 21 19 WHOJC/MS// 5, WH O. IC/MS/1 5, Add . i,WHO. 18 Ibid. 11, 6 IC/MS/38, unpublished working documents TuBERcULosTS -- 16 -

national compromise, since it takes account of (6) There is perfect agreement with the pro- the diversity in medical terminology in different posed joint meetings of the committee on tuber- countries and of the various levels of develop- culosis and the committee on health statistics. ment in medical practice. As for previous inter- Expert committees of WHO will need the nationallists,revisionsare envisaged when co-operationof the committee onstatistics indicated by progress in medical science, and which in turn will profit from the work of any if necessary on the basis of experience in using WHO committee dealing with aparticular these lists. disease.

Annex 5 [WHO/TBC/3]

PLAN FOR CONTROL PROGRAMMES

SUGGESTIONS FOR THE CONTROL OF TUBERCULOSIS IN COUNTRIES WITH UNDEVELOPED PROGRAMMES

The Expert Committee onTuberculosisof 2. Central Group WHO has already, at its first meeting, laid down theessentialsof a comprehensive tuberculosis The second step is to find a leader in tubercu- control programme.It realizes that such a pro- losis control - he can be obtained locally, be trai- gramme must be developed step by step, in proper ned to become the leader, or brought in temporarily order, depending upon the local situation in each from the outside-who will develop and direct country. The pattern has to be modified to meet the central group that will set up and carry on varying needs,resources and attitudes of the tuberculosis control activities in the country. peoples concerned.In the present document, the This central group must be chosen so that the committee sets forth the preliminary outline of a following fields of activity are covered : workable plan of tuberculosis control in countries (a)Public-health administration with little or no existing programme. We must always keep in the foreground the (b) Epidemiology epidemiological principlesof the control of a (e) Laboratory chronic infectious disease like tuberculosis. A (d) Clinical sound plan for the control of this disease must (e) Public-health nursing have the following objectives : One person of the group could cover more than . The prevention of spread of tuberculosis from known infectious cases. one of the special fields mentioned. However, the leader must have training in public-health adminis- 2 .The protection of groups highly exposed to tration.It may not be possible to obtain all tuberculosis and most likely to get the disease. members of the group at the beginning of the 3 All other preventative and curative measures. programme. In many countries the best assistance that WHO can give to help control tuberculosis will be to train personnel as a group in special In order to accomplish these objectives there centres where they can train together. When are definite steps that can be taken in the follow- the central group returns to its country it must ing order : take responsibility and initiative in teaching other personnel who will serve as members offield teams throughout the country as the programme 1. Survey develops. A survey of the needs, resources and attitudes It is necessary that the person chosen to be the of the people in the country must be made by an leader must be employed by the government and outside expert in tuberculosis, whom WHO is be the official in charge of tuberculosis control prepared to provide.It should be made in the for the country. shortest possible time and in co-operation with the leader in tuberculosis control in the country being surveyed, from whom can be obtained most 3. Exact Diagnosis quickly all available data, and also the opinions Provision must be made for the exact diagnosis of other tuberculosis specialists in the country. of infectious cases of tuberculosis by means of It may be necessary to make a " spot check " demonstration of tubercle bacilli by modern cul- by mass radiography and temporary laboratory ture methods.In each country it is essential to facilities, so as to determine morbidity-rates in have one central laboratory, preferably associated various segments of the country. To obtain with a general bacteriological laboratory, so as to further information on the attitudes of the people ensure uniformity and correctness of diagnosis inthe country, both governmental and non- throughout the country.In countries with large governmental, it is highly desirable to meet jointly populations it may be necessary, for_ purposes of with representatives of the medical profession and also voluntary groups interested in tuberculosis efficiency and economy, to have sub-laboratories so as to obtain the opinion of all types of people established in various places. and to stimulate their interest and gain their support. A written document must be prepared which 4. Records will include all the pertinent quantitative data Simple records must be set up in the central bearing on the problem. control office for those cases diagnosed as definite - 17 - TUBERCULOSIS tuberculosis by laboratory examination, so that obtain dispensaries.Whichever opportunity pre- there may be accurate information at least on sents itself, advantage should be taken of setting this number of cases.These records could form up such medical services whose principal purpose the nucleus for a more comprehensive record is to help prevent spread of the disease. system on all cases of tuberculosis when it becomes possible to extend compulsory reporting of tuber- Comment culosis throughout the nation.There islittle From the foregoing it is evident that the com- value in setting up a complicated system of report- mittee isstrongly of the opinion that limited ing cases and deaths from tuberculosis until a funds should not be expended on the construc- sound system of providing bacteriological evidence tion and maintenance of the most modern type of the disease has been instituted: of sanatorium with every facility for surgical and other new types of treatment.Such a costly 5. Home Nursing Services institution would only provide care for a small number of patients. The main purpose is to pro- It has already been stated that the most impor- vide the largest number of hospital beds for the tant objective in tuberculosis control is the pre- isolation of positive sputum cases and, at the same vention of spread of the disease from known infec- time, to provide a reasonable amount of treat- tious cases.This can best be done by isolation ment to arrest the disease.Similarly, in countries in hospitals ;unfortunately there are numerous with limited resources, little can be accomplished countries where this cannot be done because there by spending large sums of money to set up and are no institutional facilities. maintain a model tuberculosis-control programme Home nursing services must be established and in a small selected area. This will have little effect expanded in order to cut down the aomunt of on the total tuberculosis-control problem of the infection spread in the home from known cases. whole country. The visiting nurse can teach the patient and the The committee is firmly convinced that mass family how to dispose of infectious material, and radiography should not be employed in countries how to obtain at least partial isolation of the with limited or no facilities for exact diagnosis patient in the home. Such services can be effective and supervision of patients (laboratory services, even in the absence of hospital facilities.Further- dispensary care, and institutional care).In other more, they will become an important part of the words, it is of no value simply to take thousands field programme as the plan develops.In those of x-ray films of the lungs of people and then do countries where no visiting nurses are available, nothing more about it. Mass radiography is WHO can make a great contribution to tubercu- effective as a control procedure only in those losis control by assisting in the provision of training countries with well-developed tuberculosis pro- for persons who can carry on home nursing. grammes, prepared to examine and follow through It is recognized that the home nursing service large groups of the population within a definite at best can accomplish only partial segregation period of time. On the other hand, if large num- of infectious cases and must be regarded as a bers of expectorating persons who require sputum temporary measure until such time as hospital examination to confirm or exclude the diagnosis facilities can be provided. of infectious tuberculosis are already known to physicians in the country, there is no point in detecting an additional number of suspects by 6. Hospital Facilities mass radiography until laboratory examinations The next step to be taken is the development and exact diagnoses have been made upon the of a realistic plan to obtain hospital facilities for expectorating group.The examination of sputa isolation and treatment of infectiouscasesof of this group is the most economical way to find tuberculosis. the principal sources of spread of the disease. The exact number of beds needed and the time schedule for their procurement can best be 8. BCG Vaccination determined by a current study of the local situa- The only practical way known so far of pro- tion of the country concerned.The commonly ducing specific resistance against tuberculosis is used ratios (numbers of beds per annual deaths, BCG vaccination ; but this method alone cannot or numbers of beds per reported annual cases) be expected to control the disease. The full effec- have littleapplicability from one country to tiveness of BCG vaccination is realized only if it another.Efforts should be made to obtain the is carried on as part of a general programme of simplest type of hospital facilities. control ; this can be done at any time during the Since the principal purpose of the institutional development of the major aspects of this total programme is to provide isolation of infectious programme. cases, it is recommended that preference for institutional care should be given to persons with positive sputum, rather than to minimal cases. Comment Fortunately, UNICEF has provided funds to support mass BCG vaccination involving 50 million 7. Dispensaries children in Europe, and additional numbers of As soon as qualified personnel can be obtained children in countries outside Europe.This pro- or trained, efforts must be directed towards estab- gramme is going forward rapidly as a co-operative lishing dispensaries, where possible attached to venture of the Scandinavian Red Cross voluntary existing hospitals.These dispensaries should be organizations, and UNICEF and WHO. The actual centres for tuberculosis control in the commu- field operations are under the direction of the nities in which they are located.Here again Scandinavian groups.It is fortunate that WHO WHO can assist greatly by providing training for need not concern itself with the BCG vaccination, the different types of personnel needed.In some but can concentrate on the major problem, the communities it may be possible to establish hos- development of a well-planned long-term pro- pital facilities first.In others it may be easier to gramme of tuberculosis control. [WHO/VD/r2] 25 October 1948

EXPERT COMMITTEE ON VENEREAL DISEASES

REPORT ON THE SECOND SESSION 1 Held 15-19 October 1948, Office International d' Hygiène Publique, Paris

Contents Dr. G. L. M. McElligott, Adviser on Venereal Diseases, Ministry of Health, London, United . Newconsiderations Kingdom 2. Fields of activity Dr.J.F. Mahon0, Medical Director, VD 3 .InternationalHealthRegulationsfor Research Laboratory,(US Public Health Venereal Diseases and the Brussels Agree- Service), Staten Island, N.Y., USA ment of 1924 4. Bejel Dr. R. V. Rajam, Professor of Venereology, Principal,MedicalCollege,Universityof 5 .Polish Antisyphilis Plan Madras, India 6 . WHO Expert Committee on Venereal Infections Corresponding member Summary of Recommendations of the Dr.S.Hellerstrom,Professor of Dermato- Expert Committee Syphilology, University of Stockholm, Sweden Annexes Consultants 2 The Expert Committee on Venereal Diseases Dr. H. Brun-Pedersen, Venereal-Disease Con- held its second session from 15 to 19 October 1948 trol Officer, Danish Maritime Services, Copen- at the premisesof theOfficeInternational hagen, Denmark d'Hygiène Publique, Paris. The following were Dr. E. H. Hermans, Medical Director, Venereal present : Diseases, Port of Rotterdam, Netherlands

Members Observers Dr. W. E. Coutts, Chief, Department of Social Hygiene, Public Health Administration, San- Mr. J.L. Mowat, Chief, Maritime Section, tiago, Chile International Labour Office, Geneva, Switzer- land 1 The Executive Board, at its second session, Dr. A. J. Cavaillon, Secrétaire général de l'Union " approved the report of the ad hoc Expert Com- Internationale contre le Péril vénérien, Paris, mittee on Venereal Diseases, making the following observations : France (I)Regarding penicillin production and distri- Dr. D. Borensztajn, Inspector-General, Vene- bution, including rehabilitation of UNRRA plants, real-DiseaseControl Division, Ministry of the Director-General was requested to arrange for surveys by an adequate team of experts with a Health, Warsaw, Poland view to rehabilitating the plants.The various economic commissions of the Economic and Social Council of the United Nations were to be ap- Seven meetings were held during the session. proached on this matter. Dr. J. F. Mahoney was chairman.Dr. G. L. M. (2) Since ILO had been instrumental in the McElligott took the chair during the discussion establishment of the Brussels Agreement of 1924, on the Brussels Agreement and during the seventh it was agreed the revision and expansion of that agreement into a wider instrument, comprising meeting.Dr.M.Grzybowski(Poland)was international regulationsfor venereal diseases, unable to attend. Dr. T. Guthe, venereal diseases should be made in consultation with that body. section,WHO, wassecretaryofthecom- Therefore, the provisional text of such regula- mittee. tions should be circulated to ILO and the competent intergovernmental organizations. (3) The Board noted the commendation by The committee noted that the Executive Board the expert committee of the progress made in of WHO at its first session had appointed the the Polish antisyphilis campaign and the recom- expert committee of the Interim Commission to mendations regarding consultation and demonstration teams. (4) It was decided that the report should be 2 Co-opted by the committee for advice on published, preceded by a note setting forth the maritime aspects of the venereal-disease problem ; Board's observations." Off. Rec. World Hlth Org. also ob3ervers for the International Union against 14, 19 Venereal Diseases. - 19 - VENEREAL DISEASES serve as an ad hoc committee until the Expert been maintained, and the venereal-disease pro- Committee on Venereal Infections of WHO was gramme of WHO must be seen in the light of established.3Since the first session of the expert these developments in its first years of opera- committee of the Interim Commission, Dr. R. V. tion, when the elements of the programme are Rajam, Madras, India had been appointed to the considered in detail as a basis for action by Expert Committee on Venereal Infectionsof WHO. WHO. Since the advent of penicillin,it has been The chairman noted the terms of reference of considered possible that the use of the antibiotic the committee and invited those present to express in an increasing number of early infections might their opinions in regard to the items on the have thefollowing far-reachingpublic-health agenda.Full consideration was given by the implications : committee to the views put forward. During its discussions, the committee took the recommenda- (a)The curtailment of the duration of the tions of the Interim Commission's expert com- infectious stages of syphilis might result in mittee into full account, and considered them in reducing the opportunities for transmission. the light of developments since that time and This in turn might involve a progressive decline in relation to new items on the agenda.Supple- in incidence of a far-reaching character.In mentary as well as new recommendations, which many areas of southern United States, where have necessitated adjustment of the pattern used the problem is complicated by the large Negro in the report of the Interim Commission's exiiert population, a decline in early infections has committee,4 have been made. been effected and a precipitous decrease in congenital syphilis is demonstrable. The effec- 1.New Considerations tiveness of penicillin in the treatment of syphilis in pregnancy and congenital syphilis has been Each year millions of people acquire venereal demonstrated in the United States, the United diseases. An untold number are severely in- Kingdom, and other countries ;anditis capacited or succumb to untreated congenital significantthatthispreventivenon-toxic or acquired infections.Syphilis contributes signi- weapon permits healthy infants to be born, in ficantly to individual and social misery and to more than 95% of the cases, regardless of important economic losses in industry and agri- trimester of pregnancy in which treatment is culture.In the United States the yearly cost given. in labour lost due to syphilis was estimated in 1940 at more than ioo million dollars.In other (b)As a result of adequate therapy being more regions of the world where syphilis is known to be freely available, the disease may lose much of highly prevalent and where only rudimentary its capacity to injure.This is well exemplified venereal-disease services exist the costisin- in the recent history of gonorrhoea, which, estimable. The initiation of venereal-disease con- through effective therapy, has been reduced to trol work in such regions should be one of the the status of an innocuous infection. Whether primary objectives of WHO programmes and, or not the incidence of gonorrhoea has been on epidemiological principles, the problem should ' be approached in terms not only of the individual, lessened cannot be stated ;that the clinical but also of population groups. and public-health aspects of the disease have been favourably altered cannot be doubted. The committee notes with satisfaction that such a public-health approach was endorsed both by (c)Ease of therapy may have the effect of the Interim Commission and the Health Assembly causing treatment to be undertaken without and that the international venereal-disease pro- the formality of a confirmed diagnosis.This gramme of WHO should pay particular attention may lead to a decline in the use of serological to early syphilis ;gonorrhoea, chancroid, lympho- tests for syphilis and of the dark-field method of granuloma venereum, and granuloma inguinale identifyingTreponemapallidum,adecline being considered in order of relative importance, similar to that observed in many countries in where special geographical or racial considerations the use of culture methods for the identification are concerned, or in the spread of disease from of the gonococcus, following the introduction country to country. of penicillin therapy for gonorrhoea. At the meeting of the Interim Commission's While it is recognized that experience in the Expert Committee on Venereal Diseases, it was recognized that syphilis, the methods employed penicillin therapy of syphilis is now based on in its control, and the relationship between the more than half a million cases in the United States disease and serology, were passing through a alone, extending over a period of more than period of transition.It was recognized also that five years, much of the early work was based on any plans formulated on the basis of the best pharmaceutical preparations, imperfect in quality information available might, within a relatively and variable in unitage. Dosage schedules initially short period, be rendered obsolete because of used were tentative and below the minimum now rapidly accumulating experience and information. considered necessary.Further, since this therapy The tempo of progress apparent at that time has was frequently based on intermittent injections of penicillin over a period of time, the inconve- nience of the régime tended to make its applica- 3O. Rec. World Hlth Org. 14, II 4 Ibid. 8, 6o tion to mass treatment of syphilis dependent VENEREAL DISEASES - 20 - upon the hospital beds available, and upon the 2.Fields of Activity cost of hospitalization during the required treatment period. Although in some countries, such as the Scandinavian countries and the United 2.1Availability of Drugs Kingdom, it may be possible by other means (voluntary or compulsory) to keep a relatively The drug of foremost importance to all countries large proportion of patients under treatment, the in the treatment of venereal diseases is penicillin. régime required in the original penicillin therapy The committee has limited itself to a discussion was not an effective ambulatory procedure. of this antibiotic. The committee notes that the Health Assembly, With the advent of repository penicillin preparations, a medium well adapted to ambulatory when considering the report of the Interim Coni- therapy appears to have been developed, permission's Expert Committee on Venereal Diseases, mitting curtailment of the infectious period and decided that the question of penicillin production potentially the control of early syphilis.The use and distribution, including the rehabilitation of of a routine modelled on the above would prevent the UNRRA penicillinplants, should be an patientsfromlapsingfromtreatment,and activity of WHO, separate from the venereal- markedly reduce the cost of any syphilis pro- disease programme. gramme and increase the ease with which the Although penicillin is of vital importance for treatment could be carried out. A most important the treatment of diseases other than venereal development is therefore the growing evidence infections, a very large proportion is used in the supporting the belief that an adequate ambulatory therapy of syphilis and gonorrhoea, for which therapy for early syphilis, based on penicillin purpose a steadily increasing demand is evidea. andsuitableformasstreatment,isnow available. Should penicillin become freelyavailableall over the world, indications are that by far the The committee recognizes the established value largest proportion of the drug would be used in of arsenicals and bismuthinsypnilotherapy. treatment of syphilis and gonorrhoea. The sum- Since the international inquiry fifteen years ago marized information, made available to the com- by the Health Organization of the League of mittee through the Secretariat, on the production Nations into the efficacy of neosalvarsan-bismuth and requirements of penicillin in 71 countries régimes, some countries have been able to ensure stresses the limited production and the worldwide satisfactory follow-up of pa tients over a period need for this antibiotic.In fact, the committee of time with such régimes, while in other countries is of the opinion that the limited availability of case-holding has proved a difficult and uncertain procedure. A further development, particularly penicillin is the outstanding restricting factor in important during the second World War, was venereal-disease control in the world today. the introduction of foreshortened methods based For this reason, the committee feels justified on arsenoxides.After the war, foreshortened in maintaining a continued interest in the pro- treatment methods based on penicillin (alone or gress of WHO in its efforts to encourage produc- combined) have attracted the interest of the tion and ensure an equitable distribution of the medical profession all over the world. antibiotic to all countries, particularly to those The committee believes that in its advisory where it is not now available. capacity to WHO it should keep abreast of devel- Experiments which have recently been con- opments, based on sound technical information, cluded in one country in the production of and considers foreshortened ambulatory treatment penicillin dispense with the growth-media usually methods ofearly syphilis with penicillinas employed, which are often difficult to obtain in offering possibilitiesfor large-scale treatment, sufficientquantitites,andutilizeinsteada previously unobtainable and impossible. The substancegenerallyavailablebut containing need from the public-health viewpoint for such similar growth-factors.Should this process stand methods has been emphasized by experiences in the test of mass production, it might form the South-East Asia, the Far East and Africa ;it basis for a wider production and a wider accessi- has been brought forward in detail in the report 5 on a survey of venereal diseases carried out by bility of penicillin than at present, provided that WHO in Ethiopia in 1948. it could be made generally available.It would appear to be one of the objectives of WHO to The committee considers that it is now prac- promote a wide application of such processes. ticable to approach the control problem of early The committee notes that funds have been syphilis in terms of population groups as well as made available by WHO for a survey of the of the individual. The realization of this possi- needs of the UNRRA penicillin plants in certain bility on a wide scale is, however, conditioned European and Far Eastern countries, but that by several shortcomings, particularly the limited UNRRA residual funds will not be granted for availability and the inequitable distribution of the rehabilitation of these plants.It is hoped penicillin.Another important obstacleisthe shortage of trained personnel and the lack of that other means may be found to get these information on the new techniques. plants into operation.In the meantime, itis suggested that the matter might be studied by the United Nations Economic Commission for interest in industrial 5 An article on this report will be published in Europe, in view of its Bull. World HUI; Org. 1949, 2 rehabilitation. - 21 - VENEREAL DISEASES

The committee observes that the UNICEF Fellowships might be classified into two groups : allocation of two million dollars for penicillin (a)for senior physicians and personnel : short- programmes to combat syphilisinpregnant women and children will help to make penicillin term travel grants, three to six months ; more widely available. (b)for physicians, laboratory workers, public- WHO should be prepared to advise on the health nurses or social workers :six months to quality and standard of the various types of one year's training. penicillin : penicillin in oil and beeswax, procaine penicillin in oil, procaine aluminium-monostearate, or other types. Judged by the ease of 2.2.2Training Facilities.Certain requirements administration and by concentrations of penicillin should be laid down as to the type and standard achieved in the blood, crystalline penicillin G of training facilities. Fellows should visit only is the most satisfactory in repository prepara- centres and institutions of recognized standing tions. recommended by WHO ;theadministrative In view of the growing importance of such aspects of venereal-disease control should be studied at large health departments of repute in preparations in syphilotherapy, and the necessity for an accurate evaluation of results, the com- countries with advanced venereal-disease contro- programmes, or at recognized schools of public mittee wishes to emphasize its previous statement that crystalline penicillin G should be used in health and hygiene where teaching of venereal- the treatment of syphilis, while the amorphous disease control, including its practical aspects, forms a major part of the curriculum.Labora- products may be used in gonorrhoea. tory workers should study only in the principal It is recommended that further information be serologicallaboratoriesfamiliar with modern collected by WHO on penicillin production and sero-diagnostic and other laboratory methods. distribution, and that further steps be taken to Clinical aspects of venereal disease should be ensure a wider availability of the drug, that the studied only in large hospitals or clinics recom- rehabilitation of the UNRRA plants be con- mended by WHO where other elements of control sidered as soon as the contemplated survey of work are also a part of the activities. these plants has been carried out, and that this Fellowships for public-health nurses or social matter also be studied by the United Nations workers should be considered in the light of the Economic Commission for Europe ; WHO should availability of such fellowships through other further be prepared to advise on the quality internationalorganizations(UnitedNations, and standard of penicillin products. UNESCO). For applicants from some countries, special aspects of social work in connexion with venereal-disease control isof importance. For 2.2Training maritime nations, it would be important that such fellowships be granted for study in large 2.2.1Fellowships. The committee notes that in ports where a developed venereal-disease control the structure of WHO there will be one administra- programme is in operation, and where the outlook tive office for all fellowships. The applications on the problem of venereal disease among sea- for venereal-disease fellowships, the qualifications farers is not too remote from that in the country of candidates, the planning of visits and the of the candidate. selection of the best places for training should The committee recognizes the heavy burden be evaluated in close consultation with the section placed on schools and training institutions in all on venereal diseases in the Secretariat of WHO. fields of medicine since the second World War ; The committee is under the impression that inter- difficulties might be encountered in arranging national fellowships are sometimes granted to for candidates to study in certain laboratories, candidates who display less interest in the study hospitals and clinics.The committee believes, of the speciality for which the grant is made than therefore, that it would be of importance for in the cultural aspects of travel. A more rigid WHO, as soon as possible, to explore the possi- scrutiny of applications for grants might be bilities of utilizing the facilities of countries of made, especially as regards general adaptability high medical standing with advanced venereall and proficiency in the speciality selected. The disease control programmes. The committee has committee is of the opinion that further criteria noted the continued willingness of the United for the selection of fellows should be estab- States Public Health Service to make available lished on the basis of medical, scientific and the training facilitiesof its Venereal Disease other achievements, age, linguistic ability, etc. Research Laboratory in New York for key Assurance should be obtained that the candi- medical personnel. The committee further be- dates will return to positions of responsibility in lieves that with respect to serological and labo- venereal-disease control work in their respective ratory aspects, the possibilities in the principal countries.Reports should be submitted on the laboratories in the United Kingdom, Denmark benefits derived from the studies of the candidates and other countries with a high standard of during and at the end of the period of training. serological work should be specifically examined. VENEREAL DISEASES - 22 -

Generally, the committee considers that WHO as far as possible in 1949 and 1950, and that should be prepared to assist governments by services of the type suggested be provided. granting fellowships, on request, through regional organizations, wherever this is practicable and may appear desirable for reasons of language etc. 2.3.2Teams. The committee notes with satis- (e.g. Pan American area). faction that the World Health Assembly approved that WHO should be prepared to meet requests In its report, the expert committee of the from governments for field demonstration and Interim Commission recommended that 12 fellow- consultation teams in areas where knowledge of ships in venereal-disease control be provided in modern public-health methods is limited, and that the first year of the operations of WHO. The provision has been made for teams in the 1949 committee notes that the fellowship programme budget of WHO. The committee reaffirms the of the Interim Commission of WHO covered belief that súch assistance to local and national countries receiving UNRRA aid. A larger number venereal-disease control programmes is one of of fellowships has been granted to such countries the important ways in which countries can be during the past year than had been tentatively stimulated toinitiatethe organizationof a proposed for the first year of WHO operations, venereal-disease control programme. which was to cover all Members of the Organiza- tion.Further, the interest expressed by Govern- The committee believes that, in view of the ments in venereal-disease fellowships is consi- foreshortened penicillin treatment methods now derable (Annex i, p. 32). The committee, there- available, the basis for a mass attack on syphilis fore, believes that a larger share of fellowships in underdeveloped areas can be laid by demonstra- should be made available for venereal diseases tion and consultation teams.It has been observed than had been originally anticipated. thatin many underdeveloped areas-South- East Asia, the Far Eastern and the African The committee recommends that the above regions-the patients lapse from treatment when criteria for selection of candidates and the stan- initialsyphilitic lesions disappear following a dards of training facilities be used as the basis limited number of arsenical or bismuth injections. for the granting of venereal-disease fellowships, Itis now possible with penicillin therapy to and that, subject to these criteria, the needs of complete the treatment of such patients, and governments be met as far as possible ;that thus to contribute substantially towards breaking particular attention be paid to the granting of the chain of infection and shrinking the reservoir such fellowships as are necessary to implement of syphilis and gonorrhoea. venereal-disease programmes carried out with the assistance of WHO or in penicillin programmes Suppliesofpenicillinand equipmentare against prenatal and infantile syphilis recom- available in underdeveloped areas only to a mended by the Joint Committee on Health limited extent, and it is therefore of paramount Policy, UNICEF/WHO. importance that WHO provide the teams with the necessary supplies and equipment with which to carry out their work. The committee welcomes 2.3Demonstration and Consultation the principle of providing basic supplies and equipment to the teams, as approved by the 2.3.1Expert Consultants. The committee notes Health Assembly, but believes that it is necessary that several requests have been received for expert to make these available on a larger scale, enabling consultants (Annex 1, p. 32) ; also in this respect a broader approach to the control problem to be further requests might be anticipated for 1949 made, until such time as the government con- and 1950.Detailed information from govern- cerned is capable of carrying the work forward ments should be obtained as soon as possible as itself.The committee notes that expenditures to the special aspect of venereal-disease control for supplies and equipment by WHO are recover- in which the expert consultants are needed. able from governments. In some instances, they may be required for It is important that the teams should be self- consultation with the health authorities to give sufficientand self-containedalsoasregards advice on diagnostic, therapeutic, legal, social or means of transportation, and that arrangements administrative aspects of venereal-disease control. are made for supplies to be maintained through In other instances, expert consultants may be WHO, local and national health authorities and wanted to lecture at venereal-disease training through WHO regional organizations. The de- centresandinstitutionsgivingpostgraduate monstrations in venereal-disease control should training in venereal-disease control.Requests be planned on a scale which could be adapted from governments may also include consultation and expended by the governments concerned. with professional organizations, such as dermato- Although the teams might be administratively venereological societies, etc. ;advice and assis- responsible to the regional offices of WHO, they tance in organizing courses in venereal-disease should be under the technical direction of the control in institutions or regions not at the venereal-disease control officers in the operational moment provided with such facilities ;the initia- division of WHO, at Headquarters or at the tion or follow-up of venereal-disease programmes regional offices. carried out with the assistance of WHO. The duration of the services of the teams cannot The committee recommends that a possibly be determined, since the needs may vary from increased demand for expert consultants be met area to area. They would remain in the field - 23 - VENEREAL DISEASES

long enough to enable them to appraise the pre- 2.4Venereal-disease Information liminary results of the work, particularly with regard to early syphilis. The committee notes the needs of governments The committee is of the opinion that it would for new technical information in the various not be possible to specify the actual size and departments of venereal-disease control (Annex 1, composition of the teams since the needs would p. 32).Replies received from governments by vary depending on the particular character of WHO reveal particularly a need for information the control problem, the requests of governments, on modern therapeutic and laboratory aspects. etc.The teams should have, at least, a venereal- disease control officer with clinical and administra- The committee notes that consultations are tive experience, a skilled serologist, and a public- proceeding between WHO and UNESCO with health nurse or social worker.Auxiliary per: regard to co-ordination of abstracting services in sonnel already trained, or to be trained, should respect of general and specialized medical journals. be provided by the government concerned, which It is hoped that a service may be established, should also provide medical personnel to under- based on an interchange of abstracts between study the activities of the team and to take the various journals and interested bodies, where- over the programme after the demonstration by duplication of work can be avoided. period. Since it is visualized that demonstration teams The committee notes the work of WHO in will primarily be requested for tropical or sub- distributing summary extracts from principal tropical areas, WHO might benefit from such articles to a number of health administrations, experiences as have already been gathered by health departments and venereologists. This work similar teams. The committee notes that in should be continued and mailing lists expanded. Guatemala teams have been working in the field In view of the particular needs for knowledge over a period of time as part of the venereal- of syphilotherapy based on penicillin, and the disease research activities of the United States importance from a public-health viewpoint of Public Health Service and that this work will disseminating such information, the committee shortly be taken over by Guatemala and the feels that this subject should be critically reviewed Pan American Sanitary Organization. The com- by the members of the expert committee, since mittee welcomes the offer of the United States summary articles on this subject are few, not Public Health Service to make available to WHO always critical and often of a national character. the services of one or two key medical officers Such a review would also be a practical reference from these teams. As the committee is of the for expert consultants, teams and personnel when opinion that WHO should increase the scope of going into the field in various countries under the venereal-disease field-work in 1950, it suggests action programme of WHO. that WHO should investigate the possibilities of obtaining on loan from other goveramerts the The committeerecallstheveryvaluable services of medical and other person_nel suitable information on venereal-disease control methods for field-work. resulting from the studies in the Scandinavian Several governments have so far expressed countries by the venereal-disease commissions interestinobtaining venereal-diseasecontrol from the United States and the United Kingdom teams (Annex 1, p. 32) ;further requests may be prior to the second World War. A rapid develop- anticipated and increased activities should be ment of venereal-disease control has taken place visualized for 1950 and later.In studying the in the Western Hemisphere in the last decade requests so far received by WHO, the committee and important new elements have been introduced observes that countries located in four of the into venereal-disease control programmes. The six WHO regions have applied for teams, emphasiz- committee believes,therefore,that an inter- ing the wide need for such services.After con- national study-group, to be appointed by WHO, sidering the individual requests from govern- consisting of a limited number of outstanding ments, as well as the report of the Regional venereologists from Europe and otherareas, Committee for South-East Asia, the committee should visit the United States in 1949 to study is of the opinion that the first team available control methods currently in use in that country, should be allocated to India. The team should with particular reference to penicillin treatment go into action as soon as possible.Further, the in syphilis and to the effectiveness of new ele- committee favours the allocation of a second ments in venereal-disease programmes. A closer team to Egypt by the end of 1949.Requests exchange of techniques and methods between from other countries in the same or other regions nationswould bedevelopedthroughsuch should be further studied and more specific anevaluation. The committeenotesthat information collected. such an evaluation has been requested by the United States Government. The committee recommends that supplies and equipment be made available to teams on a It is recommended that WHO study ways and broader scale than that proposed in the 1949 means for an increased dissemination of technical programme and that increased team activities be information on venereal-disease control methods. planned for 1950 and later. The committee recommends that in 1949 one It is further recommended that a temporary field team be formed as soon as possible and study-group, consisting of a limited number of allocated to India, and that a second team be outstanding venereologists from Europe and other allocated to Egypt by the end of the year. regions, be established in 1949 to evaluate the VENEREAL DISEASES - 24 - venereal-disease control methods in the United almost any desired degree of reactivity.Once States as to their effectiveness in national and the optimal level of sensitivity has been deter- international programmes. mined, an antigen designed as a reference standard can be prepared and made available for use by any laboratory or commercial concern desiring 2.5Serological Standardization and Laboratory to manufacture antigens for a given test. WHO Aspects might usefully promote this study as well as Some of the major features of the serological the selection of a repository for the resultant aspects of syphilis have remained essentially as reference standard antigen. depicted in the report of the Interim Commission's expert committee.Others may be influenced by 2.5.3The Influenceof Environmental Factors the changes which are taking place at the present upon the Serology of Syphilis.Preliminary obser- time. As a consequence of the introduction of vations in certain countries give rise to the belief foreshortened treatment methods based on peni- that environmental factors of a widespread nature cillin, the need for sero-diagnostic procedures may may be responsible for the high percentage of become less in view of the ease of treatment, the positive serological findings encountered in some shorter period of time involved and the freedom population groups in which the disease is in- from untoward reactions. On the other hand, the frequently observed. A thorough study of the introduction of penicillin therapy in syphilis has problem will be essential to the development of emphasized the need for quantitation of serological a control programme in many tropical areas. methods as a follow-up evaluation of the efficacy Without more complete and precise knowledge of therapy and the occurrence of serological of the phenomenon it may be difficult to determine relapses or failure in individual patients.Plan- the extent of the syphilis problem in a given ning in this field is therefore extremely com- area or the effectiveness of any control measures plicated, and some revision of theoriginally taken. proposed serological programme of WHO may A study of the problem could be attempted be required. only by means of large-scale clinical and laboratory investigation of representative population- 2.5.1.Antigens.Early experience indicates that groups in different geographical areas.Careful cardiolipin-lecithin antigens give promise of being attention would have to be devoted to the rela- of great value in sero-diagnosis.Test-methods tionships between positive serological findings and employing this type of antigen appear to be seasonal and climatic factors, dietary and living more specific than methods employing lipoidal characteristics, and the existence of intercurrent antigens. There seems to be reasonable evidence infections and infestations. WHO may well look that cardiolipin will replace the older type of forward to the initiation of studies designed to products in the majority of test-methods. resolve this problem. While the manufacture and distribution of the essential material are not satisfactory at present, 2.5.4International Serological Laboratory Con- it is expected that adequate amounts will be ference.The plans proposed by the chairman of available in the near future. The promotion of the expert committee and the preliminary work the use of cardiolipin-lecithin antigens throughout of WHO in preparation for the serological labo- the world may well become a worth-while activity ratory conference to be held not earlier than 1950 of WHO. were considered by the committee. The objectsofthis conference have been 2.5.2Uniform Level of Reactivity of Serological outlined in the committee's first report.6 The Tests for Syphilis.It has been recognized that a principal reasons supporting such an action remain pressing need in the serology of syphilis is correc- valid, though the scope of the contemplated tion of the many discrepancies which are observed conference should be geared to the new trends when different tests are employed. A proportion in the control of syphilis, and to the possible of these discrepancies results from a lack of changes in the relationship of syphilis to serology. uniformity in the level of reactivity (sensitivity) Plans should be further advanced in the coming of the various test-methods. Up to the present year, and a preliminary programme should be time, however, the level of reactivity of each worked out, with regard to the actual practical test has been a matter of personal opinion of the conduct of the conference, to be considered by originator of the method. Moreover, no concerted the WHO Expert Committee on Venereal Infec- effort has been made by the various originators tions. To enable this work to proceed, it would to decide upon a uniform level of sensitivity be necessary to constitute as soon as possible in and to adjust the various test-methods to that 1949 the sub-committee on serology and labo- level.Of still greater importance, no systematic ratory aspects proposed by the Interim Com- effort has been made to determine the level of mission's expert committee. reactivity which would contribute the most in The studies carried out by WHO on serological terms of clinical syphilis and at the same time test performance in the principal laboratories in escape the influence, to a maximum degree, of Ethiopia and Bulgaria were also considered by reacting substances produced by diseases other the committee. Such test-performance evalua- than syphilis.Until this optimal level has been tions will shortly be carried out in Poland. defined, discrepant findings cannot be avoided Extension of such activities to several other whenever multiple tests are employed. The coming of cardiolipin-lecithin antigens has made possible the preparation of antigens of 6 Off. Rec. World Hlth Org. 8, 62 - 25 - VENEREAL DISEASES countries is in progress.In this work WHO has urethritis is reported to be of increasing impor- availed itself of the facilities of the United States tance in Canada, Chile, United Kingdom and Public Health Service Venereal Disease Research certain other countries. The treatment-resistance Laboratory in New York, the laboratory acting in general of these conditions, and their un- as an international serological reference centre. Apart from the guidance furnished to the labo- classified etiology, might be considered by the ratories themselves, these studies contribute also WHO Expert Committee on Venereal Infections to the evaluation of the effect of transportation as worthy of a special research-project, sponsored on serum samples under variousconditions. by WHO, should the incidence of such conditions Experience of considerable value to national increase so as to become a problem of public- standardization is accumulating, and the infor- health importance.Meanwhile, the committee mation acquired is an important preliminary to considers that WHO should collect and distribute the contemplated international serological labo- further material on these conditions. ratory conference. It is recommended that a sub-committee on serology and laboratory aspects be established as 2.6.2Syphilis.Experience in syphilotherapy, soon as possible, to be composed of not more based on penicillin, has to a very great extent than four members, and that a preliminary been accumulating on the American continent. programme for the conduct of the next inter- nationalserologicallaboratory conference be In Europe penicillin is used, combined or alone, drawn up as soon as possible for consideration by in early syphilis to some extent only in United the WHO Expert Committee on Venereal Infec- Kingdom, Poland and occupied Germany. The tions. limited experience with penicillin in many Euro- pean countries and the slight knowledge of its use in many other areas where much syphilis 2.6Therapy exists has led to varying opinions as to the The committee does not feel it necessary to actual status of syphilis treatment. comment on the established treatment methods of syphilis by arsenicals and bismuth, or of General agreement appears to exist on the gonorrhoea by sulfonamides, since these have advantages of penicillin treatment in prenatal been extensively evaluated in the past. With and early infantile syphilis and also on the regard to the therapeutic aspects of the " minor " advantage of rapid curtailment of the infectious venereal diseases (chancroid, lymphogranuloma stages in early acquired syphilis.Consolidation venereum, granuloma inguinale) these should be through additional therapy with arsenicals and/or reviewed in detail by the WHO Expert Committee bismuthisconsidereddesirableby several on Venereal Infections at a later date. At present investigationgroups,particularlyinEurope. it would appear advisable to consider only certain aspects relating to gonorrhoea and particularly While experimental evidence in animals suggests to therapy in syphilis, in view of the priority that arsenicals and/or bismuth added may be given by the Health Assembly to the public- advantageous,suchbenefitshave not been health aspects of venereal-disease control, and definitely demonstrated in man. The addition the significance of the developments in therapy of oxophenarsine hydrochloride and bismuth in during the last few years. suitable amounts to concurrent penicillin therapy It is not impossible that the antibiotics on has not significantly reduced the failure rates. which relianceis now largely placed in the What is more important, a practically innocuous therapy of syphilis and gonorrhoea may encounter treatment method is changed into a more dan- progressively increasing resistance on the part gerous one.In some countries, e.g., the United of the gonococcus and T. palliclum.Isolated Kingdom, there have been found to be some instances of possible penicillin-resistance have practical advantages, from the point of view of been observed experimentally, but the concern case-holding, in a combined treatment attack. expressedinmany quartersthatpenicillin- resistant gonorrhoea and syphilis might develop, analogous to the familiar sulfonamide-resistant The committee is aware that any scientifically gonorrhoea and arsenic- and bismuth-resistant sound method will stand or fall on its merits, syphilis has so far not been substantiated. and observes that experience in penicillin treatment of syphilis is now passing into its sixth year. The greaterproportionofclinicalor 2.6.1Gonorrhoea. Any adequate treatment syphilisoccurs schedule of gonorrhoea with penicillin, by the serologicalrelapsesinearly use of amorphous or crystalline penicillin, will between the fourth and ninth months after cure 95% or more of acute cases of gonorrhoea. treatment. Examples of acceptable treatment schedules in gonorrhoea are given in Annex 2, p. 33. The committee observes that, where adequate penicillin treatment has been given, the re- On the basis of inadequate diagnostic and follow-up criteria, non-specific urethritis is often treatment rate in early syphilis does not exceed diagnosed as gonorrhoea.In this connexion, the 5% in the best controlled series in the United committee notes the information collected and States (Annex 3, p. 33), though higher failure- distributed by WHO on genito-infectionsof rates have been reported in other treatment unclassifiedor ill-definednature.Non-specific series.

-WORLD HEALTH ORGANISATION MONDIALE DE LASARA VENEREAL DISEASES - 26 -

The committee notes with considerable interest certain aspects relating to venereal diseases-and the follow-up of the original patients treated with considers that any extension of the details of the penicillin after Mahoney and his collaborators' original recommendations of the committee should discovery in 1943 of the spirochaeticidal value of be referred for consideration to the WHO Expert penicillin. The absence of observed neurosyphi- Committee on Venereal Infections.In the opinion litic manifestations in these patients, and the ofthecommittee, WHO shouldencourage extremely low incidenceofneuro-relapseor nationalandinternationalvoluntaryhealth abnormal spinal fluids reported in other ade- organizations to assume responsibility for inform- quately treatedseriesofpatients,does not ing the public and gaining its support for venereal- indicatethatsuchmanifestations may not disease control programmes. develop with time. There is, however, reason to believe that the incidence of neuro-relapses will The committee notes with considerable interest be low as compared to previous systems of metal the investigation carried out in Denmark attempt- chemotherapy, and may average I% to 2°,/o. ing to measure the effect of a venereal-disease campaign undertaken by the Danish Union against Venereal Disease. A nation-wide Gallup poll was 2.6.2.1In prenatal syphilis the advantages of carried out in that country before the campaign penicillintreatmentofpregnant mothers are in 1944, and a follow-up poll was undertaken in generally accepted (non-toxicity, protection of 1947, after its termination. An interesting feature the foetus regardless of trimester of application of the campaign itself was the mailing of 1,200,000 of treatment, etc.).The mother must be fol- pamphlets to households in the country (the total lowed clinically and with quantitative serological population of Denmark is about 4 million).In tests after completion of treatment. The infant view of the techniques employed and the pattern must be adequately followed after birth, clinically, developed in this investigation, it is suggested that serologically and roentgenologically. this material be made available to other health administrations. 2.6.2.2In early congenital syphilis (up to two years), the best results have so far been reported with aqueous penicillin.Indications are that 2.8Basic Data equally good results can be obtained with reposi- The committee notes the deficiencies in many tory preparations. countries of data on syphilis and gonorrhoea, as evidenced by the information and statistics 2.6.2.3In late congenital syphilis it cannot be collected by the Secretariat of WHO and published ascertained for many years whether penicillin in the Epidemiological and Vital Statistics Report will permanently arrest the progress of the various for May 1948. forms of late syphilis. The committee reaffirms its belief, indicated in the report on the first session, that countries Treatment schedules in early syphilis which should be encouraged to record at least basic were indicated in the report of the expert com- data on the incidence of venereal diseases, and mittee of the Interim Commission (penicillin G, that the emphasis should be put on syphilis. aqueous, and penicillin in oil and beeswax) and In this connexion, the committee notes that the other examples of acceptable treatment schedules resolution on venereal diseases adopted by the with various forms of penicillin are given in first Health Assembly 7 recommends that govern- Annex 2 (p. 33) to this report, where also are ments pay particular attention to the necessity given schedules used in the Polish antisyphllis for notification and recording of primary and campaign. secondary syphilis, these stages of the disease being the most important from the epidemiological With regard to procaine penicillin with 2% and public-health point of view. aluminium monostearate, studies have indicated that demonstrable concentrations of the antibiotic In its report, the expert committee of the may be produced in the blood for periods ranging Interim Commission also expressed its approval up to 96 hours following one single injection of of the principle of unification of nomenclature 300,000 units. On the basis of three injections for causes of morbidity and mortality, so that of 600,000 units, 24 hours apart, penicillin is comparable statistical information might even- demonstrable in the blood for as long as 7 days. tually become available in various countries. On this basis, an ambulatory therapy completed The committee further recommended that recip- within a 48-hour period becomes possible, accom- rocal consultations should take place between plishing as much as 500,000 units penicillin in oil the Expert Committee on Venereal Infections of and beeswax every 24 hours for ro injections. WHO and the Expert Committee on Health Statistics when these committees were eventually established. 2.7Health Education The committee welcomes in principle the adoption by thefirst Health Assembly of WHO The committee notes that the Health Assembly Regulations No. i on health statistics, in accor- decided that health education should be among dance with the provisions of the WHO Constitu- the activities of WHO, as part of a public-health tion, and notes that these Regulations will become administration programme. The committee awaits effective as from I January I950. The corn- the establishment of a WHO programme for public-healtheducationin1949-toinclude 7 CV. Rec. World HMI Org. 13, 302 - 27 - VENEREAL DISEASES mittee considers that, although the establishment should preferably be granted to countries where of these Regulations-with the recording in each a structure for venereal-disease control exists, country of diseases in such a way that they can and where introduction of penicillin treatment be included under three groupings -represents a would serve to stimulate the control work in step forward, a more satisfactory classification such a way that a mass attack against syphilis forsyphilis might be sought in view of the might be carried out ;where there are problems expressed wish of governments to emphasize the of endemic syphilis ;or where it is desirable to public-health importance of venereal diseases. It encourage the development by governments of would, for instance, appear to be particularly im- broader venereal-disease control programmes. portant to study the differing opinions in various The committee further considers it advisable countries on the definition of early and late syphilis. that any such programme should be initiated by demonstrations in suitable medical institutions with training and teaching facilities, thus con- 2.9Relations with other International Organiza- tributing to the widest possible propagation of tions concerning Venereal Diseases technical informationonpenicillintreatment methods. 2.9.1United Nations. The committee notes the The considerations and proposals made by the relevant paragraphs of the resolution adopted committee are set forth in a note (Annex 4, by the Health Assembly with regard to co-opera- p. 34) submitted to the Joint Committee on Health tion with the United Nations and other inter- Policy on 20 October 1948.In the event of the national organizations in combating prostitution joint committee, and subsequently the executive and traffic in women and children. The com- boards of WHO and UNICEF, accepting the mittee observes the progress made by the United main recommendations of the note, WHO should Nations towards unification of the International be prepared to carry out the necessary activities Agreements and Conventions of 1904, 1910, 1921, and to provide the necessary qualified personnel 1933 and 1937, on traffic in women and children, to initiate the programmes in Bulgaria, Finland, suppression of white slave traffic and prostitution, Hungary and Yugoslavia and to conduct the into one single international instrument ;and relevantsurveysinAlbania,Czechoslovakia, further notes that the draft text, as discussed Greece, Italy and Roumania during 1949 and by the Economic and Social Council at its seventh 1950. The demonstration programmes in India, session in Geneva, contains a provision for " free Pakistan and Siam would also have to be organ- and confidential treatment of venereal diseases ". ized. A summary tableof the requests of Since no further definition has been given of governments to UNICEF and the recommended this article, the committee feels that clarification activities, etc., is attached (Annex 5, p. 36). on this point is desirable.If it is intended to It, is recommended that WHO should be pre- mean that epidemiological investigations in rela- pared to provide such qualified are tion to venereal diseases are not desirable, this required to conduct surveys, initiate and follow would represent an outlook contrary to that up prenatal and infantile antisyphilis programmes unanimously agreed on by thefirstHealth recommended by the Joint Committee on Health Assembly.Since it appears desirable that similar Policy, UNICEF/WHO and accepted by the viewpoints prevail in United Nations bodies and executive boards of the two organizations. in the World Health Organization, the question should be studied by WHO. 2.9.3International Union against Venereal Dis- eases.The committee notes that the Executive 2.9.2United NationsInternationalChildren's Board of WHO decided at its first session that Emergency Fund. The committee welcomes the priority should be given at its second session to contribution by UNICEF to the international theapplicationoftheInternationalUnion venereal-disease control programme in allocating against Venereal Diseases for admission to official two million dollars for the combating of prenatal relationship. and infantile syphilis. The committee expresses The committee further notes the activities and its approval of theestablishment of a joint resolutions of the Union during the last year. committee on health policy of UNICEF and It appears that the Union is in agreement with WHO sothat programmes undertaken may the basic principles of the international venereal- proceed on the recommendation of that com- disease programme of WHO, and that activities mittee. The committee has reviewed the terms of the Union, particularly in education and social of reference of the joint committee 8 and notes welfare, would contribute to the carrying forward the various technical aspects on which the WHO of the WHO programme. The committee notes expert committees are to advise. that the Union was instrumental in the establish- The committee has examined thevarious ment of the Brussels Agreement in 1924 ; that a requests received from governments in Europe, sub-committee on the revision of this agreement and has reviewed the report of the UNICEF met in The Hague (March 1948) ;that a draft Survey Mission to the Far East, noting also the text for revision of the agreement was submitted relevantrecommendationsforpenicillinpro- to the expert committee for its consideration in grammes in the South-East Asia region. connexion with the drafting ofinternational In general, the committee believes that assis- regulations for venereal diseases. tance in combating prenatal and infantile syphilis 2.9.4The .roth International Congress on Derma- tology and Syphilology. The committee notes 8 Off. Rec. World Hlth Org. 14, 49 that the loth International Congress on Derma- VENEREAL DISEASES 28 - tology and Syphilology has been tentatively diseases from one country to another. On the scheduled to meet in 1950.It believes that WHO basis of contact reports and other similar material should participate in this congress and that the available in the Scandinavian countries and the possibilities of co-operating with this organization United States of America, an evaluation and should be studied. possible control of international venereal-disease hazards would be a desirable economic objective towards which all maritime nations might work. 3.International Health Regulations for Vene- A special investigation project is therefore pro- real Diseases and the Brussels Agreement of posed in one or more large ports in northern 1924 or southern Europe or in the Far East. A control mechanism could be established incorporating The committee notes the information received the best thinking and pooled information on from and the opinions expressed by 40 govern- case-finding, diagnosis, treatment and epidemio- ments in reply to a circular letter on the Brussels logy, and enlisting the help of several nations, Agreement. The committee notes further the any one of which might be in danger of infection proposals made at the Health Assembly by from anuncontrolledarea.Such aproject Portugal 9 and the statement made by Iceland 19 would be designed to find out the perpetuation as well as the relevant paragraph in the resolu- of disease within a geographical group, as well tion on venereal diseases adopted by the As- as being a means of curtailing the speed with sembly." The committee also notes the resolu- which these infections are spread from within. tion pertaining to the 1924 Agreement submitted Such a project was originally suggested by the by the International Union against Venereal US Public Health Service in 1947. Diseases. Inreviewingthequestion,theprinciples The project should be considered in relation adopted by the Interim Commission and by the to ILO and other international organizations Health Assembly (outlined in the report of the interested in the hygiene of seafarers, and in this expert committee of the Interim Commission) connexion the committee notes that the Health were taken as a basis by the committee for the Assembly decided to establish a joint committee drafting of international regulations for venereal with ILO. diseases,including matters contained inthe Brussels Agreement. WHO should consider such a project and consult The committee agreed on the following pro- with relevant authorities in countries interested cedure :a provisional text based on the extensive with a view to carrying it out in 1950. discussions of the committee should be considered by the legal section of the WHO Secre- The committee notes that some international tariat before being circulated to the members aspects of the maritime venereal-disease problem of the expert committee. The draft text should are of a regional character.Special problems then be submitted to the Members of WHO and may arise along large inland waterways or in relevant international organizations for observa- countries bordering circumscribed sea-basins. The tions and comments. In the light of the informa- committee notes the resolution of the Inter- tion thus received a final draft should be proposed national Union against Venereal Diseases, adopted to the Health Assembly. by its Assembly in Copenhagen in September The committee notes that one of the limitations 1948, that a commission composed of representa- of the Brussels Agreement was the lack of pro- tives of the countries concerned be established vision for collection of data illustrating services under the auspices of WHO to study the per- actually provided by, and rendered to,the petuation of venereal diseases in the Rhine area, signatory parties, and information permitting a and to aim at the co-ordination of venereal- statistical and epidemiological evaluation of the disease control in this area. The countries con- maritime venereal-disease problem. In drafting cerned are :Belgium, France, Germany, Holland a provisional text for international regulations and Switzerland. for venereal diseases, there should therefore be It is recommended that a provisional text for kept in mind Articles 64 and 65 of the WHO International Regulations on Venereal Diseases Constitution, which state that Members may be prepared for circulation to Members of WHO, provide such statistical and epidemiological infor- and that a final draft be submitted to the Health mation to WHO as the Assembly may determine, Assembly. and transmit such additional information pertaining to health, at the request of the Executive It is also recommended that a special investiga- Board, as may be practicable. tion project be established in a major port in Information available from several countries northern or southern Europe or in the Far indicates a relative decrease in the incidence of East,collateralto the implementationofa venereal diseases in rural and inland areas, while revised Brussels Agreement. a similar decrease is not recorded in ports.In the opinion of the committee this emphasizes It is further recommended that the relevant the problem of maritime transfer of venereal authorities in Belgium, France, Germany, Holland and Switzerland be approached by WHO with a view to the establishment of a commission, com- 9 Off. Rec. World Hlth Org. 13, 145 posed of representatives from these countries, to 10 Ibid. 13, 67 study and recommend measures for co-ordination 11 Ibid. 13, 303 of venereal-disease control in the Rhine area. 29 VENEREAL DISEASES

4.Bej el 5.The Polish Antisyphilis Plan The committee notes that the paper on bejel " The committee takes note of the progress submitted to the Health Assembly by the Govern- report (Annex 6, p. 37) on the antisyphffis cam- ment of Iraq was subsequently referred by the paign in Poland, as presented by the representa- Executive Board at its first session to the expert tive of the Polish Ministry of Health. committee. In considering the various technical and other aspectsoftheprogramme,thecommittee Treponematosis in general and its manifesta- notes the high priority given by thePolish tionsindifferent environments areof great authorities to the combating of syphilis on a mass interest, but have been explored only to a limited basis. It notes further the considerable financial extent. The relationship between pinta, yaws, appropriations " since the beginning of the year to bejel and other spirochaetal infections is a problem carry the programme actively forward. More of basic interest with which WHO might well than half a million persons have been examined occupy itself, since millions of people in certain serologically and more than 43,000 cases of syphilis regions are probably affected by such infections. and 27,000 cases of gonorrhoea have been treated. Foreshortened treatment methods based on repo- Various investigators believe that the " mild " sitory penicillin (POB) have been employed. " syphilis observed in African deserts, Ethiopia The committee considers that the case-finding and other tropical and sub-tropical areas con- mechanism and theforeshortenedtreatment forms to the benign " Arab syphilis " or bej el. methods-based on penicillin-used in the Polish In the paper submitted by the Government of campaign have made a large-scale attack on syphilis Iraq information is given indicating that the possible.There is reason to believe that the characteristics encountered in bejel are different decline in the incidence in syphilis now discernible from those in syphilis,particularly that the in. Poland as a result of the campaign will con- transmission of bej elisusually non-venereal. tinue, and the committee hopes that the Polish The committee, in view of its terms of reference Ministry of Health will present a detailed analysis -to act as an advisory body to WHO in the field of its experience during the first year of operations of venereal diseases-believes that the study of at the meeting of the WHO Expert Committee bejel and relateddiseases should rather be on Venereal Infections in 1949. regarded as a separate activity of WHO, unless The committee wishes to express its commenda- its terms of reference are expanded. tion of the way in which the programme has been In the meantime, the committee believes that launched despite technical and other difficulties. more information should be acquired on the The committee observes that funds have been epidemiological, clinical, therapeutic and labo- madeavailablethrough UNICEF for some ratory aspects of bejel in areas where this and supplies of penicillin and a certain amount of related diseases are prevalent. The WHO Secre- laboratory and other equipment to combat pre- tariat should particularly communicate further natal and infantile syphilis in Poland. with the Iraqi health authorities and with the University of Baghdad in this respect. 6. WHO ExpertCommitteeonVenereal It is recommended that WHO consider bejel Infections and related non-venereal diseases as a separate activity.It would be of considerable interest The committee notes thedecisionofthe that further information be acquired by WHO Executive Board at its first session that initially on the nature and extent of bejel and related a nucleus of five members should be appointed " diseases. to the WHO Expert Committee on Venereal Infections, in accordance with the draft Pro- visional Appointment Regulations for Expert 12 Bejel : Paper submitted by the delegation of Committees and their Sub-Committees." The Iraq : committee further notes the Regulations and In recent years, a disease which goes by the Rules of Procedure for Expert Committees and popular name of " bejel " has been observed in theirSub-Committees." The committeealso South Syria and Iraq.Bejel has been included in medical textbooks under this name.The disease notes the provision that the assistance of spe- is spirochaetal and infective, and may be regarded cialists from various countries as " corresponding as intermediate between mild syphilis and yaws. members " may be obtained. Further investigationofbejel,especially in In view of the considerable responsibility to be regard to experimental immunological studies in animals, is required.The following clinical fea- placed on the WHO Expert Committee on tures are of interest : Venereal Infections, the committee has carefully (x) Infection seems to be extragenital considered, in the light of Regulation 4 of the (2) Bejel is commonly found in children whose above-mentioned Regulations, the question of parents are free from syphilis size and type of representation of the future (3) The common lesionoccursasmucous patches in the labial commissure of the mouth " About 2.5 million dollars have been expended (4) Bejel is extremely sensitive to antisyphi- (official rate of exchange). litic therapy 14 Treatment schedules employed in the Polish The delegation of Iraq recommends that pro- antisyphilis campaign are given in Annex 2 to vision should be made under Section 12.1.6.3.2.1. this report (p. 33). (Off. Rec. World Hlth Org. 10, 9) for field studies 15 Off. Rec. World Hlth Org. 14,xi of bejel, in view of its importance from the pro- 16 Ibid. 14, 38 phylactic and legislative points of view. ,7 Ibid. 13, 376 VENEREAL DISEASES - 30 - advisory committee to WHO on venereal diseases. International Serology Laboratory Conference in The committee believes that the definitive com- 1950, the establishment of a sub-committee on mittee should include outstanding specialists in serology and laboratory aspectsisnecessary. administrative, epidemiological, clinical and labo- The services of three or four competent specialists ratory aspects of venereal diseases, so that these should be secured as soon as possible for this infections can be considered as a problem of sub-committee. population groups as well as diseases of the The members of the ad hoc committee have individual. Adequate consideration should be already prepared a listof names of qualified given to geographical representation. specialists on the various aspects who may be To fulfil these requirements, the WHO Expert suitable for appointment. Further names will Committee on Venereal Infections should consist be proposed so as to ensure an adequate basis for of ten regular members, and other experts in selection of the panel of corresponding members. specialized fields should be co-opted when required Itis recommended that the WHO Expert (Regulation 14 of the above-mentioned Regula- Committee on Venereal Infections be composed tions). of ro members and that a sub-committee on In view of the necessity for further studies, as serology and laboratory aspects be established well as for guidance in the preparation of the consisting of not more than 4 members.

SUMMARY OF RECOMMENDATIONS OF EXPERT COMMITTEE

1.New Considerations the rehabilitation of the UNRRA penicillin plants be further considered as soon as the The advent of penicillin in the therapy of early contemplated survey of these plants has syphilis may have far-reachingpublic-health been carried out, and that this matter be implications. The developments in this branch studied also by the United Nations Economic of control work offer possibilities for large-scale Commission for Europe ; treatment, permitting an approach in terms of WHO be prepared to advise on the quality population groups as well as of the individual. and standard of penicillin products. One of the first objectives of WHO in its action programme should be to initiate control work in The expert committee further recommends regions with limited venereal-diseaseservices (2.2) that : where syphilis is highly prevalent and where it the criteria outlined be used as a basis for causes untold individual and social misery and selection of candidates for venereal-disease inestimable economic losses. fellowships and that study-periods be spent In the light of developments since the meeting at training places, of the highest standard, of the Interim Commission's expert committee, recommended by WHO ; supplementary as well as new recommendations particular attention be paid to the granting have been made by the ad hoc committee. of fellowships to implement venereal-disease programmes carried out with the assistance of WHO, or under the programmes to combat 2.Fields of Activity prenatal and infantile syphilis recommended by the Joint Committee on. Health Policy, The international venereal-disease programme UNICEF/WHO ; of WHO indicates that WHO should :promote the needs of governments for training of production and distributionofanti-venereal personnel in venereal diseases be met by drugs ;generally assist governments in initiating WHO in 1949 as far as possible, subject to venereal-disease programmes or developing con- the suggested criteria, and that provisions trolsystemsalreadyinexistence ;promote be made to meet increased requests for training of skilled personnel, the dissemination training in 1950. of technical information and the adoption of uniform diagnostic, therapeutic and other pro- It is also recommended (2.3, 2.9) that : cedures ;co-operatewithotherinternational one WHO consultation and demonstration organizations interested in venereal-disease con- team be allocated to India and one to Egypt trol, etc. in 1949 ; In view of the adoption of these principles by supplies and equipment to teams be made WHO and of the recent developments in venereal- available on a broader scale than that pro- disease control, the ad hoc Expert Committee posed under the 1949 programme ; on Venereal Diseases recommends (2.1) that provisions for qualified personnel be made further information on penicillin production to meet an increased demand by governments and distribution be collected, and that active for demonstration and consultation services measures be taken by WHO and other for 1949 and 1950,including individual international organizations to ensure a wider experts necessary to implement the recom- availability of the antibiotic ; mendations of the Joint Committee on Health 31 - VENEREAL DISEASES

Policy, UNICEF/WHO, to conduct surveys, establishment of a commission, composed of initiate demonstrations and follow up pro- representatives of those countries, to study grammes to combat prenatal and infantile and recommend measures foractive co- syphilis in several countries. ordination of venereal-disease control in the Rhine river area. It is recommended (2.4) that : WHO study ways and means to increase dissemination of technical information on venereal-disease control methods to meet 4.Bej el the requests of governments ; Bejel and related spirochaetoses are a problem a temporary study-group, consisting of a of considerable importance to the health of the limited number of outstanding venereologists people in tropical and sub-tropical areas, and their from Europe and other regions, be established manifestations in different environments have in 1949 to evaluate the venereal-disease been studied only to a limited extent.Itis control methods in use in the USA as to recommended (4) that : their effectivenessinnational and international programmes. WHO study the problem of bejel, the nature and extent of this and related spirochaetoses, It is further recommended (2.5) that : and that it be made a separate activity of the sub-committee on serology and labo- WHO in view of the predominantly non- ratory aspects proposedinthe adopted venereal nature of these conditions. programme ofthe Interim Commission's expert committee be established, and that a tentative plan for the conduct of the next 5.Polish Antisyphilis Plan international serological laboratory conference be drawn up as soon as possible for The expert committee expresses its commenda- consideration by the WHO Expert Com- tion of the progress made since the Polish anti- mittee on Venereal Infections. syphilis plan was put into operation at the beginning of the year. The treatment of 43,000 cases of syphilis and 27,000 cases of gonorrhoea 3.International Health Regulationsfor up to August represents a public-health achieve- Venereal Diseases and the Brussels Agreement ment. The programme could not have been of 1924 carried out except through a systematic large- scale approach through case-finding and fore- In view of the adoption by the Health Assembly shortened treatment methods. of the principles on the basis of which the Brussels Agreement should be revised and expanded, and of the particular importance to many nations of 6. WHO Expert Committee on Venereal Infec- the maritime aspects of the epidemiology of tions venereal diseases, it is recommended (3) that : a provisional text for international regula- Consideringthetechnicalaspects and the tions for venereal diseases be prepared for scope of the problems of venereal-disease control circulation to the Members of WHO and in relation to the international programme of that subsequently a final draft be submitted WHO, a representative advisory expert body of to the Health Assembly for its consideration ; specialists in the various departments of control a special investigation project be established work isrequired, and itis recommended (6) in a major port in northern or southern that : Europe or in the Far East, collateral to the the Expert Committee on Venereal Infec- implementation of a revised Brussels Agree- tions of WHO be composed of ten members ment ; and that a sub-committee on serology and the relevant authorities in Belgium, France, laboratory aspects be established as soon as Germany, Netherlands and Switzerland be possible, the latter to be composed of not approached by WHO with a view to the more than four members. VENEREAL DISEASES - 32

Annex 1

SUMMARY OF REQUESTS RECEIVED FROM GOVERNMENTS UNDER THE WHO VENEREAL-DISEASE PROGRAMME

Regions Demonstrations Equipment Technical Expert advice Fellowships (teams and experts) and supplies information

South-East Asia Burma * * * * Ceylon * * * India * * * Siam * European Austria Belgium Bulgaria Czechoslovakia Finland France Hungary Ireland Italy Netherlands Norway Poland Portugal Switzerland Acknowledgement United Kingdom Yugoslavia * . Eastern Mediterranean Egypt * * * * Iran * * * Pakistan * * * * * Turkey * * * American Bolivia Interim reply Dominican Republic Haiti * * Mexico Interim reply United States Western Pacific New Zealand Acknowledgement Philippines Interim reply African South Africa

TOTAL (until 2 0 October 1948) 3 2 Members 6 21 18 4 2 I - 33 - VENEREAL DISEASES

Annex 2

A.EXAMPLES OF ACCEPTABLE TREATMENT SCHEDULES WITH PENICILLIN

Total injections Drug Dosage per injection (dosage)

. Gonorrhoea Penicillin aqueous 50,000 u. at o hr 3 50,000 u. at r hr (zoo,000 units) roo,000 u. at 2 hrs Penicillin in oil and 300,000 u. beeswax (300,000 units)

2. Earlyandprenatal Penicillin G aqueous 50,000 u. every 2 hrs 90 syphilis (also other (4.5 million units) forms, except central nervous system, cardio- Penicillin G inoil 500,000 u. every 24 hrs '0 vascular and and beeswax (5millionunits) congenital) (POB liquid)

Procaine penicillin G 600,000 u. every 24 hrs, 3 in2% aluminium or600,000u.twice ( r .8 million units) monostearate weekly for two weeks 4 (2.4 million units) 3. Congenital syphilis Penicillin G aqueous 170,000-200,000 u. per (early) kg. body-weight divi- ded into 170-zoo doses ; each dose every 2 hrs

B.TREATMENT SCHEDULES USED IN THE POLISH ANTISYPHILIS PROGRAMME

r .Sero-negative primary syphilis 3,000,000 u. of penicillin in oil and beeswax given in ro doses of 300,000 u. daily plus 4 bismuth injections o.2 g. administered on the 1st, 4th, 7th and roth day 2. Sero-positive primary syphilis 4,200,000 u. of penicillin in oil and beeswax administered in Secondary syphilis 14 doses of 300,000 u. daily plus ro injections of mapharsen Early latent syphilis o.o6 g. and ro injections of bismuth 0.2 g. administered on the 4th, 7th, roth, 13th, r6th, 19th, 22nd, 25th, 28th and 31st day 3. Pregnant women 6,000,000 u. of penicillin in oil and beeswax 4. Children with congenital 200,000 U. of penicillin in oil and beeswax per kg. body-weight syphilis administered in ro days

Annex 3

RESULTS IN, AND FOLLOW-UP OF, PENICILLIN THERAPY IN EARLY SYPHILIS ( Venereal Disease Research Laboratory, US Public Health Service, Staten Island, N.Y ., USA)

Treatment :200,000 units every 2 hours for 36 doses Total Penicillin :7,200,000 units

Period Number Number Number Number Number (months) treated observed positive negative re-treated

I- 4 451 373 240 127 6 5- 8 451 304 97 201 6 9-12 381 182 36 142 4 13-18 242 82 II 71 VENEREAL DISEASES - 34 -

Annex 4 [JC2/UNICEF/WHO] 20 October 1948

NOTE BY WHO AD HOC EXPERT COMMITTEE ON VENEREAL DISEASES

ALLOCATIONS BY UNICEF TO PROGRAMMES AND PROJECTS FOR COMBATING SYPHILIS IN PREGNANT WOMEN AND IN CHILDREN UP TO 1 8 YEARS OF AGE

Many aspects of venereal-disease control have that the various technical aspects on which the undergone major changes in the past few years. expert committeeshalladviseareextensive. In the therapy of syphilis, penicillin has removed Among items on which advice is requested is pro- many of the dangers and the drawbacks formerly duction ofpenicillin.This would appear to be associated with arsenic, heavy metal and other outside the fieldof competence of the expert therapy.Results are spectacular, particularly in committee and only general observations have treatment of infected pregnant women, and the been made in this connexion. prospect of a child being born healthy is 95% The committeehas examinedtheoriginal regardless of trimester of pregnancy in which the requests by governments to UNICEF for assistance mother is being treated.Penicillin has therefore in prenatal and infantile syphilis programmes, as introduced a hopeful outlook for prevention of well as the detailed supplementary documentation congenital syphilis. Gonorrhoea has lost much of obtained by WHO from these governments in its capacity to injure the human being, as a result accordance with the decision of the joint committee. of introduction of penicillin therapy.Gonococcal Requests were originally received from the govern- infections of the eye and genitalia in children can ments of Bulgaria, Czechoslovakia, Finland, Greece, be successfully treated with penicillin. Hungary,Poland, Roumania andYugoslavia. While this outlook exists in the world today The committee has further examined the reports with regard to therapy itself, the limited availability of the WHO Secretariat and the UNICEF ad hoc and inequitable distribution of penicillin is the venereal-disease consultant on Bulgaria, Hungary outstanding restricting feature of venereal-disease and Yugoslavia, supplementing the above inform- control.The allocation of two million dollars by ation, as well as additional requests from Albania UNICEF for programmes and projects to combat and Italy.The committee has further reviewed syphilis in pregnant women and in children is the report of the UNICEF Survey Mission to the therefore welcomed by the committee. The expert Far East, and notes the relevant chapters therein committee of the Interim Commission in January recommending that penicillin programmes against 1948 recommended that steps should be taken to prenatal and infantile syphilis be established on encourage distribution of penicillin to all countries, a limited scale in India, Pakistan and Siam. particularly to those where it is not now available. In principle, the committee feels that in view The UNICEF allocation will help to implement this of the considerable prevalence of syphilis in mothers recommendation. The expert committee hopes and children in many of these countries in Europe that UNICEF will also be in favour of further and Asia, programmes and projects should be allocation of funds for such syphilis programmes carried out : for mothers and children as may be requested by governments. (a) as part of an overall venereal-disease campaign where the introduction of penicillin treat- It is assumed that, in such penicillin programmes as may be launched, treatment will not be re- ment would serve to stimulate the control work stricted to syphilis, but will also include gonorrhoea and to expand already existing venereal-disease in women and children in view of the preventive control activities in such a way that a mass aspects of the problem (blindness etc.) and the attack against syphilis might be carried out ; practicability of the procedure. (b) where a particular section of a population The committee expresses its approval of the is involved and a special endemic problem may establishment of a Joint Committee on Health exist ; Policy, UNICEF/WHO, so that medical programmes (e) where pilot demonstrations ina limited undertaken will proceed on the recommendations number of clinics and hospitals can be established of the joint committee and international medical and where facilities for teaching and training activities will be carried out in accordance with exist. the authority in this field. The expert committee also welcomes the grant The committee recalls the commendation of of one million dollars made to WHO from UNRRA the Polish antisyphilis plan by the Interim Com- funds for WHO financial participation in such mission's Expert Committee on Venereal Diseases medical programmes as the joint committee on in its first report 10 and notes with satisfaction that health policy may recommend. the joint committee, and the Programme Committee The committee has reviewed the terms of refer- and Executive Board of UNICEF acted on a ence of the joint committee 18with regard to request from the Polish Government for assistance programmes andprojectsto combat syphilis in the prenatal and infantile phase of the anti- in expectant mothers and in children, and notes syphilis programme in that country. The committee

18 Off. Rec. World Hlth Org. 14, 49 10 00. Rec. World Hlth Org. 8, 66 - 35 - VENEREAL, DISEASES notes that the possibility of obtaining such assist- the demonstration programme now in operation ance represented a considerable stimulus in the in Naples, has requested that this programme be preparations for, and the initiation of, this cam- expanded to cover other. areas. paign.About 43,000 cases of syphilis had been treated under this programme up to August 1948. The committee is aware of the limited proposals The committee believes that the information for India, Pakistan and Siam made by the UNICEF submitted by Bulgaria, Finland, Hungary and Survey Mission to the Far East. Yugoslavia indicates that a basic structure for The committeenotesthesurveymission's yenereal-disease control exists and that programmes recommendation that penicillin be made available for combating prenatal and infantile syphilis could in India and Pakistan for women and children in be put into operation through the network of groups of displaced persons.In view of the prac- venereal-diseaseclinics and the maternity and tical difficulties, arising from the reported large child-health centres in these countries. The com- numbers of displaced persons, which might be mittee is particularly of the opinion that penicillin met in the administration of a proper penicillin programmes to be put into operation should be programme inthesecountries,the committee initiated through model demonstrations in clinics feels that the establishment of a model demon- or hospital centres of repute before the work is stration in one or more clinics where such groups expanded.Duringthisdemonstrationperiod, would be treated would be a sound procedure. advantage should be taken by the national health- The value of such demonstrations would be greatest administrations concerned to train medical per- when a suitable area in which training and teaching sonnel in the relevant clinical and other methods facilities exist was selected. In India, clinics in employed.It would also be necessary to include one or more of the cities of Madras, Calcutta, the establishment of serological units, essential Bombay and Delhi may be chosen, or penicillin for diagnosis and follow-up purposes in any peni- allocated to India may be used by the WHO cillin treatment programmes for syphilis, where field demonstration and consultation team requested such units do not exist. by the Indian Government and recommended by the expert committee for 1949. In Pakistan, further In the case of Yugoslavia, further attention is information as to a suitable demonstration centre drawn to the desirability of launching a rapid mass should be obtained. The committee suggests attack with penicillin in the endemic syphilis area that clinics in Karachi or Lahore be chosen. The in Bosnia Herzegovina.This area was surveyed UNICEF Survey Mission to the Far East proposes with the assistance of the Rockefeller Foundation that in the case of Siam a demonstration be orga- before the second World War.The committee nized in a clinic in Bangkok. The committee notes notes previous efforts in treatment of these endemic that further information requested by the WHO problems with arsenic and bismuth, and the failure Secretariat for a detailed plan in this connexion of this approach because of the prolonged nature of these methods and the special geographical, has as yet not been received. social, economic and other conditions in the area. In principle, the committee isin agreement It would appear that this area is particularly with the UNICEF Survey Mission that it would suitable for a penicillin programme in view of the be of considerable importance to initiate penicillin great prevalence of the disease.Such a project treatment of prenatal and infantile syphilis in would be of national as well as international interest Far Eastern countries. The value of such penicillin and importance, since similar endemic areas of high programmes would be greater in the education prevalence also exist in other parts of the world and training of medical opinion than in actual (Asia, Africa). contribution towards diminishing the immense reservoirs of syphilitic infection reported in this Since the supplies which may be made available region.Only through the gradual expansion of from a UNICEF allocation are designed to cover demonstrations, which have inprinciple been only infantile and prenatal syphilis, the committee recommended alsounder the proposed WHO does not recommend that a penicillin programme venereal-disease programme in the South-East be launched in this endemic area unless supplemen- Asia area, could a more lasting contribution to tary penicillin could be obtained from other sources, the creation of venereal-disease control structures making an overall attack on the problem possible. be made and important benefits be derived from The committee notes the indications by the the use of penicillin in areas with a high prevalence above countries that special efforts will be made in of syphilis. carrying out the programmes proposed as an The committee notes the request for fellowships integralpartofthenationalvenereal-disease under the prenatal and infantile syphilis pro- control campaigns. It also notes that the prenatal grammes. These fellowships should be granted on and infantile syphilis programmes will be carefully the basis of individual merit, subject to the criteria followed up, and that accumulated data will be of selection, etc., proposed by the expert committee made available to WHO ;and that individual for the WHO fellowship programme. The granting experts will be welcomed to discuss and follow up of fellowships should be co-ordinated with the the results in an effort to evaluate the efficacy of field work in such a way that Fellows returning the programmes as they develop. from their study-tours could carry forward the The committee is of the opinion that the requests model demonstration programmes. from the governments of Albania, Czechoslovakia, In view of the importance of these initial demon- Greece, Italy and Roumania should be studied, and strations in forming medical opinion in the countries that venereal-disease experts appointed by WHO concerned, the technical standards required should should visit these countries with a view to initiating be of the highest. The services of skilled technical personnel to establish the proposed demonstration demonstrations which might form a basis for the and follow-up programmes should be obtained establishment of broader prenatal and infantile by WHO. syphilis programmes and increased venereal-disease activities. Treatment in the prenatal and infantile syphilis programmes should follow the set of acceptable The committee notes that the Italian Govern- treatment schedulessuggested by theexpert ment, on the basis of the experience acquired from committee. VENEREAL DISEASES - 36 -

WHO should assist UNICEF in the procurement the activities of the latter organization should of penicillin and take steps to ensure that the be discontinued. supplies obtained are of acceptable quality, and It is recommended that : in conformity with the standards recommended funds be appropriated for penicillin programmes by the expert committee. The penicillin preparations against prenatal and infantile syphilis from the to be used should be of the crystalline type G, UNICEF allocation for this purpose in Bulgaria, preferablycrystallinepenicillin G inoiland Finland, Hungary and Yugoslavia ; beeswax, or procaine with 2 % aluminium monostearate. WHO experts consult with the health administrations in Albania, Czechoslovakia, Greece, Italy The committee notes that the penicillin pro- and Roumania, with a view to initiating demon- ductionplantsgiven by UNRRA tocertain strations in these countries as a basis for broader European countries arestill not in operation. programmes ; While funds have been allocated by the Health Assembly to survey these plants as to the require- UNICEF accept the proposal of its Survey ments enabling them to go into operation, the Mission to the Far East to initiatepenicillin committee notes that the proposed million dollars programmes ; that these programmes be launched for rehabilitation of these plants has not been in the form of demonstrations ; that the proposed obtained by WHO. Since UNRRA residual expenditure for such programmes be increased, funds may be transferred to the United Nations and that the programmes be extended to include and UNICEF, the attention of the latter organiz- other Far-Eastern countries ; ation is directed to the desirability of bringing WHO assist UNICEF in procurement of penicillin theseplants intooperation through UNICEF with special reference to the quality of the products; funds. It isalso suggested that the question the question of penicillin production be studied should be placedbefore theUnited Nations by WHO and the United Nations (UNICEF and Economic Commission for Europe in view of the Economic Commission for Europe) ; its interest in industrial rehabilitation. the carrying forward of the proposed programmes The committee believes that some continuity in be studied by WHO and UNICEF in the possible the proposed programme should be provided by event that the latter organization should discontinue WHO and UNICEF in the possible event that its activities.

Annex 5

SUMMARY OF REQUESTS BY GOVERNMENTS TO UNICEF FOR ASSISTANCE UNDER THE PREGNANT WOMEN AND INFANTILE SYPHILIS PROGRAMME

WHO EXPERT CONSULTANTS Laboratory Regions Penicillin megaunits or other Fellowships (m.u.) or $ equipment Initiation Survey of Remarks programmes

South-East Asia India $36,000 Pakistan $20,000 Siam $25,000

European Albania - Bulgaria 21,000 111.11. * - Czechoslovakia 39,900 m.u. - * - Finland 6,000 m.u. * * Greece - Hungary 76,000 111.U. - Italy $300,000 * Initial demons- trationproject in Naples - active Poland 215,000 Mal. Allocated-programme active Roumania Yugoslavia 240,000 In.1.1.

TOTAL, 13 Members 4 4 5 9

20 WHO expert consultants (or staff)are required to implement the recommendations of the expert committee and the Joint Committee on Health Policy, UNICEF/WHO as the programmes develop. - 37 - VENEREAL DISEASES

Annex 6

PROGRESS REPORTON THE POLISH ANTISYPHILIS CAMPAIGN 21

It will be recalled that when the Polish anti- able in health centres, many specimens for dark- venereal-disease campaign was originally presented field examination had to be sent to the urban to the Interim Commission's Expert Committee centres of the districts concerned, causing delays on Venereal Diseases in January 1948, action was of three to four days. From January to October contemplated in three phases : 1948, 42 dark-field microscopes had been provided.

. Planning and elaboration of the programme As it is realized that treatment of syphilis based 2.Organizationofa network of treatment- on penicillin requires careful follow-up of the facilities patients with quantitative serological techniques, an effort has been made to obtain sufficient person- 3. Otherimplementationoftheprogramme nel and equipment for such procedures.Trained through case-finding (mass screening), treat- personnel for this purpose is now available, but ment, health education of the public, and other the limited availability of equipment in laboratories means. is now the outstanding restricting feature. The first phase was completed in January 1948, In March 1948, the establishment of mobile when the Polish venereal-disease control programme units to participate in the venereal-disease campaign was presented to the Interim Commission's expert was initiated. These units were originally intended committee in Geneva. to reach villages located at great distance from Eighty per cent of the second phase was com- the health centres and to remain in the area until pleted by April 1948. During this phase 300 county case-finding and treatment had been completed. health-centres were organized as central health The initial experience with these mobile squads units co-ordinating venereal-disease control within indicated that they might be employed to greater the counties,keeping recordsofallpatients, advantage for case-finding purposes through mass being responsible for tracing of infectious contacts, screening examination and for health education health education of the public, etc. of the public.The present programme of these The organization of the health centres necessi- mobile units now includes examination of the tated provision for : entire population living in the areas and the direction of positive cases to the nearest health r.recruitment and training of necessary personnel centre.It has been the policy to send these units 2. availability of necessary equipment and sup- to areas where a high rate of venereal disease is pliesfordiagnosticand treatmentpurposes. suspected on the basis of information received from medical officers in the districts or the towns. With reference to the first point, 240 physicians, The mobile units distribute literature and anti- 300 nurses and 250 public-health nurses or social venereal-diseasepropaganda,andarrangefor workers had been recruited up to the end of April venereal-disease educational films ;the medical 1948.Once this personnel had been recruited, officer in charge of the unit gives lectures to the post-graduate courses of three days' duration, public. at whichattendance wasobligatory forthe venereal-disease controlofficersof the public- While the second phase of the programme, the health service, were organized.The courses were organization of a network of treatment facilities, also open to all physicians, were free of charge, was still proceeding, supplies and equipment were and all medical officers attending received travel- being made available to the health centres and ling expenses and accommodation. to the university clinics.Some health centres Up to r July 1948, 16 such courses had been started operations in January and February 1948, organized with an attendance of more than 480 but action on a large scale was not started before physicians.The courses were conducted in the April, when considerable supplies of penicillin in university clinics in the country, and the programme oil and beeswax were received.Penicillin supplies covered the following aspects of venereal-disease have also been distributed to university clinics control (including demonstrations) : and the health centres of the main cities. Diagnosis The educational campaign was also started in April 1948. All the principal newspapers published Treatment, with particularreferenceto the daily, or every other day, an article on the subject ; modern concepts of rapid therapy, based on broadcasting stations gave instructive talks on penicillin the same subject ;1,200,000 booklets were distri- Socialaspects,with particularreferenceto buted and 200,000 posters were employed.The tracing of infectious contacts and health education public was told of the dangers of venereal diseases ; of the public the role of alcoholism in facilitating their spread ; Similar courses were organized for nurses and the epidemiological importance of getting infectious social workers. cases under treatment ;the necessity for early treatment ; the availability of short and adequate The provision of equipment proved to be diffi- treatment based on penicillin ;the assurance of cult in view of the scarcity of essential diagnostic discretion and the availability of treatment free and other equipment after the second World War. of charge. Although some dark-field microscopes were avail- The effect of this campaign was that by the end of June and early in July 1948, there was not 21 Report by the Inspector-General, Venereal- sufficient penicillin to meet the demands of patients Disease Control Division, Polish Ministry of Health, reporting for treatment. This penicillincrisis Warsaw. was overcome by rapid delivery by aeroplane of VENEREAL DISEASES - 38 -

7 the necessary amounts of penicillin in oil and been examined. Positive tests were further checked beeswax. with the Kahn flocculation test and Wassermann Although the Polish antisyphilis campaign is complement fixation.A preliminary estimate of based on rapid treatment with penicillin for ten the prevalence of syphilis indicates that it ranges days, an approach which appealed to the public from r % to 3%. The other case-finding mechanism and to the medical and venereal-disease officers, employed was tracing of infectious contacts. From it was subsequently found practicable to extend the first 20,000 cases treated, information was the period of administration of penicillin to two obtained of 18,000 persons named as infectious weeks for certain cases of syphilis and to add To contacts ;ro,000of these were foundto be injections of mapharsen o.o6 g. and ro of bismuth positive. 0.2 g. to the treatment schedule. This supplemen- In proceeding with the campaign, the Polish tary therapy is being administered over a period of Ministry of Health is of the opinion that the 30 days.Although it has so far not been proved following points should be stressed : that such supplementary therapy improves the results in man, a compromise was necessary in (a) Intensification of public education view of the opinions of many practitioners and (b) Provision of equipment for health centres some university professors whose experience in and laboratories syphilis therapy in the past had been more from (c) Strengthening of case-finding and follow-up the clinical than from the overall public-health mechanism, particularly with reference to the point of view. In their opinion penicillin had not yet fully proved its value for exclusive use in tracing of infectious contacts syphilotherapy.These opinions sometimes in- (d) Extensivepostgraduatetraining on the fluenced the patients to insist on additional treat- various aspects of venereal-disease control ment. (e) Extensionofthe network of treatment Up to the end of August 1948, about 43,000 facilities cases of syphilis had been treated with the original (f) Careful study of the value of serological tests and the modified dosage, and in addition about in mass screening of syphilis. 27,000 cases of gonorrhoea. It was found that the most practicable mass Finally, the Polish Ministry of Health wishes screening serological test for syphilis to be employed to express its appreciation of the privilege of in Poland was the Chediak method. Although not presenting this programme report to the WHO perfect, it was found to have many advantages from Expert Committee on VenerealDiseases, and the point of view of ease of obtaining specimens and thanks the members of the committee for the of postal dispatch to the laboratories. Up to the interest taken in and the valuable guidance given end of August 1948, about 540,000 persons had to the antisyphilis programme in Poland. [WHO/Pharm/4o Rev.i] 28 October 1948

EXPERT COMMITTEE ON THE UNIFICATION OF PHARMACOPOEIAS

REPORT ON THIRD SESSION Held at the Palais des Nations, Geneva, 15-23 October 1948

Contents The committee noted that : (a) the first World Health Assembly had ap- .Matters arising from report on second proved the establishment of a section on the session unification of pharmacopoeias in the Secretariat 2 .Preparation of an international pharma- of WHO and of an expert committee, and had copoeia made budgetary provision for the publication in 1949 of an international pharmacopoeia in English, 3 .Consultation with otherexpertcom- French and Spanish ; mittees (b) the Executive Board at its first session had 4 .Date of next meeting decided to set up an expert committee with an Annexes initial membership of seven. 1. MattersarisingfromReport on Second Session 2 The Expert Committee on the Unification of i.iNegotiations for the Establishment of a single Pharmacopoeias held its third session in Geneva International Secretariat for Pharmacopoeias from 15 to 23 October 1948. The following mem- The committee noted a telegram received from bers were present : the Belgian Government intimating that the Belgian Government would prefertheinter- Professor H. Baggesgaard-Rasmussen, Chair- national secretariat for pharmacopoeias to remain man, Chemical Division, Danish Pharmaco- in Brussels. A confirmatory letter was stated to poeia Commission, Copenhagen, Denmark be on the way. E. Fullerton Cook, M.Sc., Chairman, Com- mittee of Revision of the Pharmacopoeia of 1.2Pan American Pharmacopoeia the United States of America, Philadelphia, The committee noted a letter which had been Pa, USA received from the Deputy-Director of the Pan American Sanitary Bureau with reference to the I. R. Fahmy, Ph.D., Professor of Pharmaco- proposed Pan American Pharmacopoeia. After gnosy, Fouad I University, Cairo, Egypt ; hearing a statement from the Secretariat on the Secretary, Egyptian Pharmacopoeia Com- present state of the negotiations for the integration mission of the Pan American Sanitary Bureau with WHO, H. Flück, Dr.Sc.Nat., Professor of Pharma- the committee agreed that the Secretariat should cognosy,Eidgenlissische Technische Hoch- pursue the question of the proposed Pan American schule, Zürich, Switzerland ;Membre de la Pharmacopoeia. Commission fédérale de la Pharmacopée Dr. C. H. Hampshire, Secretary, British Phar- 1.3Table of Usual and Maximal Doses 3 macopoeiaCommission,GeneralMedical After discussing the table submitted by Pro- Council Office, London, United Kingdom fessor Hazard, the committee decided that a note (Chairman) should be inserted to the effect that a physician may exceed the dose, but that if he does he must Dr. R. Hazard, Professeur de Pharmacologie indicate that there is no mistake. et de Matière médicale à la Faculté de Méde- The committee agreed that the corrected list cine de l'Université de Paris, France prepared by Professor Hazard should be circulated Professor D. van Os, Professor of Pharmaceu- to the members of the committee for the opinion tical Chemistry and Toxicology, University of physicians of their respective countries. of Groningen ;Chairman, Netherlands Phar- macopoeia Commission, Groningen, Nether- 2. Preparation of an International Pharmaco- lands. poeia 1 The Executive Board, at its second session, The greater part of the session was devoted " noted the report of the ad hoc Expert Com- to the consideration of monographs and reports. mittee on the Unification of Pharmacopoeias on its third session and decided to publish this report 2 Off. Rec. World Hlth Org. 11, 62 without comments ". Og. Rec. World Hlth Org.14, is WHO. IC/Pharmf31, unpublished working docu- 24 ment UNIFICATION OF PHARMACOPOEIAS - 40 -

2.1Consideration of Draft Monographs 2.3Synonyms The 105 draft monographs, which had been After consideration of a report 4 by Professor prepared by the members since the first and FullertonCook,thecommitteeagreedthat second sessions of the committee, were placed synonyms should be confined to exceptional before the committee. Of 91 draft monographs cases and inserted when finally reviewing mono- considered, 59 were approved with amendments, graphs. additions, or subject to reports by members of Professor Fullerton Cook submitted a proposal the committee, 15 were deferred, 3 were trans- for the preparation of a list giving the name of ferred to class B, and 14 were withdrawn from the same drug in the principal languages of the the programme of the committee. The list of world.After discussion, the committee decided the draft monographs considered, with the action to defer the proposal for the time being. taken, is given in Annex i (p. 41). 2.4The Title " International Pharmacopoeia " 2.1.1Hormones. In a general discussion on the melting range of hormones and hormone com- A letter had been received from Professor pounds, it was pointed out that the new French Fullerton Cook expressing the views of the Board Codex will contain narrower ranges, since purer of Trustees of the United States Pharmacopoeia, preparations were now available. The committee which was opposed to the use of the title " Inter- agreed that these more precise figures would be national Pharmacopoeia ". discussed again, after consultation with manu- Professor Fullerton Cook explained tothe facturers. committee thathis Board wasincomplete sympathy with the work of the expert committee. 2.1.2Antitoxins(seraantitoxica).Afterdis- It was objecting only to the word " Pharmaco- cussion on the nomenclature, the committee poeia " in the title. agreed that antitoxins should be designated as The committee pointed out that there was no " sera antitoxica ".The committee recommended intention that the suggested international phar- that this international designation should be macopoeia should take the place of any national inserted as a synonym in the national pharma- pharmacopoeia. copoeias. The committee considered that any objection The committee agreed that in the section on tothetitle" InternationalPharmacopoeia " labelling two additional paragraphs should be could be applied equally to thetitle" Pan added, stating : American Pharmacopoeia ", the compilation of 1.that the name of the manufacturer and the which was on the agenda of the first Pan American manufacturer's reference number should be given Congress of Pharmacy, to be held at Havana, on the labels and wrappers ; December 1948. Although the committee was reluctant to drop the word " Pharmacopoeia ", 2.that the name and proportion of bacteriosta- the members felt, at the same time, that it was tics added should also be given. desirable to endeavour to reach general agree- The committee decided that, for each of the ment. Alternative names were considered by the monographs on sera antitoxica, tests for potency committee, and the following was thought to be and toxicity should be proposed and accepted on most suitable for further consideration :Codex theunderstanding that they would notbe Medicamentarius Internationalis. obligatory. The committee agreedthatthe chairman The committee further decided to include a should write a letter to Professor Cook for sub- fourth gas-gangreneantitoxin, namely Serum mission to his Board, giving a résumé of the Antihistolyticum, and the chairman agreed to discussions of the committee on the question of prepare a draft monograph. the title.As the members of the committee expressed the wish to think over the question, 2.1.3Toxoids. The committeedecidedthat toxoids should be removed from the programme and to have further consultations in their own of the committee until such time as international countries on this subject, a final decision was standards for them had been established by the deferred until the next session. Expert Committee on Biological Standardization. 2.5List of Common Designations of Medicaments 2.1.4Vaccinia. The secretary of the Expert Committee on Biological Standardization ques- A report 5 by Professor Hazard was deferred tioned whether vaccines should be included as no for consideration to a later session. international standard had yet been established. He thought that probably all that could be done 2.6General Principles discussed and approved for the present was to adopt minimum require- 2.6.1Chromatographic analysis.The committee ments. The only exception was Tuberculinum considered a report submitted by Professor van Pristinum, for which an international standard Os on aluminium oxide for quantitative chroma- existed. tographic analysis. The committee decided that, with the excep- The chromatographic method in general and tion of Tuberculinum Pristinum, the inclusion of the quality of aluminium oxide to be used were other vaccines should wait until, international discussed.It was agreed that the matter should standards were available. be rediscussed at the next session and that 2.2Consideration of Draft Reports members should produce reports. The committee considered a number of reports 4 WHO/Pharm/39, unpublished working docu- which had been prepared by members of the comment mittee. These were adopted with amendments 5 WHO. IC/Pharm/35 and Annex, unpublished where necessary. working document -- UNIFICATION OF PHARMACOPOEIAS 2.6.2Botanicalnomenclature. The committee coming meeting would probably be dealing with agreed that the botanical nomenclature should liposoluble vitamins. follow the international rules of nomenclature The committee agreed that the collaboration approved by the International Botanical Con- of the Expert Committee on Biological Standar- gress, Amsterdam, 1935. dization should be invited in regard to the tests for potency of sera antitoxica and of Tuberculinum 2.6.3Melting range andboilingrange. The Pristinum. committee considered a report on melting range and temperature submitted by a working group 3.2Expert Committee on Habit-forming Drugs consisting of Professors Baggesgaard-Rasmussen, Fahmy, Flück and van Os, and accepted it with The committee agreed that monographs on amendments. narcotic drugs should first be completed and the The committee agreed that the figures for the comments of the Expert Committee on Habit- melting range and boiling range which had forming Drugs obtained. alreadybeenapprovedinthemonographs accepted should be reviewed.Professors Bagges- 3.3Expert Committee on Malaria gaard-Rasmussen, Fahmy, Flück and van Os The committee agreed that the monograph on agreed to collaborate in this work. Quinini Sulfas 6should be submitted to the 2.6.4Chemical nomenclature. The committee Expert Committee on Malaria with the following decided that the chemical nomenclature should comment :" The Expert Committee on the be inserted with the formula in every monograph. Unificationof Pharmacopoeias discussed fully the quality of Quinini Sulfas to be prescribed in 2.6.5Ultravioletabsorption. The committee an international pharmacopoeia. The degree of decided that ultraviolet absorption should be purity,asexpressed bytheKerner-Weller mentioned in all. cases where itis considered ammonia test, was selected as 6.5 ml. of ammonia useful, and that a method should be included in solution, this representing a lower quality than a general appendix. that of the Dutch and some other pharmacopoeias. The committee believed that any higher standard, 2.6.6Potent tinctures. The committee decided that is to say any lower proportion of other that, in the international monographs on all cinchona alkaloids, would inevitably raise the potenttinctures,twoconcentrationsofthe price, and be to the disadvantage of the world active principle should be recognized, one express- control of malaria." ing the quantity of active principle per unit- The committee agreed that suggestions for the volume of the tincture, the other expressing the inclusion of antimalarial drugs should be invited same quantity per unit-weight of the tincture, from the Expert Committee on Malaria, and that and a note added, stating that " the country the chairman should prepare draft monographs concerned will decide which of these concentra- on any drugs so recommended. tions will be adopted for that country ". The attention of the committee was drawn to the report on the second session of the Expert 3. Relations with other Expert Committees Committee onMalaria,'whichcontaineda critical review of modern antimalarial drugs. 3.1Expert Committee on Biological Standardiza- tion 4. Date of Next Meeting The committee agreed that the appendices on The committee recommended thatits next the determination of the therapeutic potency of meeting should be held towards the end of April Sulfarsphenamina and of Neoarsphenamina should 1949, the dates 20-30 April being suggested. be decided after consultation with the Expert Committee on Biological Standardization. 6 WHO. IC/Pharm/Mon/6. Rev. r, unpublished The committee noted that the Expert Com- working document mittee on Biological Standardization at its forth- 7 Oft. Rec, World Huth Org. 119 43

Annex 1

LIST OF MONOGRAPHS CONSIDERED 8 Monographs have been listed under the nomenclatureadopted at thissession.Names in paren- theses represent the previous nomenclature.

1.Monographs accepted with amendments or subject to reports WHO.IC/Pharm/Mon/ WHOJC/Pharm/Mon/ 44 Acidum Benzoicum 58 Neoarsphenamina 52 Thiopentalum Natricum cum 59 Sulfarsphenamina Natrii Carbonas (Thiopentalum App. 60-64 Sera Antitoxica (Antitoxina) Sodium) 6o Serum Anti-Vibrio Septicum (Anti- 56 Tinctura Digitalis toxinum Septicum) Serum Antiperfringens (Antitoxi- 8 Unpublished working documents num Welchicum) UNIFICATION OF PHARMACOPOEIAS - 42- WHO.IC/Pharm/Mon/ WHO.IC/Pharm/Mon/ 62 Serum Antioedematiens (Antitoxi- 124 Oleoresina Aspidii num Oedematicum) 125 Oleum Ricini 63 Serum Antitetanicum(Antitoxi- 126 Oleum Chenopodii num Tetanicum) 127 Opium 64 Serum Antidiphthericum(Anti- i28 Pulvis Opii toxinum Diphthericum) 148 Picrotoxinum 73 Acidum Nicotinicum 151 Phenolum Liquefactum 74 Nicotinamidum 152 Solutio Kalii Arsenitis 75 Oleum Jecoris Aselli (Oleum Mor- 154 Amphetamina rhuae) 155 Chloramina 76 Oleum Jecoris Hippoglossi (Oleum 160 Amyleni Hydras Hippoglossi) 16i Cresol 77 Calciferol 164 Amphetaminae Sulfas 78 Menadionum 166 Tuberculinum Pristinum 8o Riboflavinum 168 Biological Assay of Tuberculinum Si Thiaminae I-IY.drochloridum Pristinum 82 Aether Vinylicus 169 Pentetrazol (Metrasolum) 87 Carbonei Dioxidum 170 Chiniofonum 96 Digoxinum 174 Tetrachloraethylenum 97 Lanatosidum C 176 Carbacholum 102 Mepacrinae Hydrochloridum 177 Solutio Formaldehydi (Liquor For- 103 Methyltestosteronum maldehydi) 104 Oxidum Nitrosum 178 Mersalylum 105 Oestradiol 182 Neostigminae Bromidum o6 Oestradiolis Benzoas 184 Tribromethanolum 107 Oestronum 185 Pethidinae Hydrochloridum 108 Oxygenium 188 Phenantoinum 112 Progesteronum 191 Neostigminas Methylsulfas 113 Testosteroni Propionas 197 Ouabainum

2. Monographsconsideration of which was deferred WHO.IC/Pharm/Mon/ WHO.IC/Pharm/Mon/ 70 Heparinum 162 Benzylis Benzoas 79 Menadioni Sodii Bisulfis 167 Tuberculini Derivatinum 95 Digitoxinum Proteinicum Purificatum 98 Injectio Insulini 180 Tabellae Glycerylis Trinitratis 99 InjectioZinco-InsuliniProtami- 187 Injectio Mersalyli et Theophyllini nati 195 Dicoumarol iii Injectio Pituitarii Posterioris 196 Injectio Diodoni 129 Tinctura Opii 198 Stibophenum 130 Tinctura Opii Benzoica

3.Monographs transferred to Class B WHO.IC/Pharm/Mon/ WHO.IC/Pharm/Mon/ 121 Acetum Scillae Mellitus 123 Aloinum 122 Aloe

4.Monographs removed from theprogramme of the committee WHO.IC/Pharm/Mon/ WHO.IC/Pharm/Mon/ 133 Codeini Sulfas 202 Toxinum DiphthericumDetoxi- 149 Strophanthinum-K catum 179 Vaccinum Antirabicum 203 Vaccinum Choleraicum 183 Acrifiavina 203 Vaccinum Pestis 189 Proflavinae Sulfas 203 Vaccinum Typhosum 200 Toxinum Tetanicum Detoxicatum 203 Vaccinum Typho-paratyphosum 201 Toxinum Diphthericum Diagnos- 204 Vaccinum Febris Flavae ticum 205 Vaccinum Vacciniae

Annex 2

PREPARATION OF DRAFT MONOGRAPHS, REPORTS AND EXPERIMENTAL INVESTIGATIONS

Professor Baggesgaard-Rasmussen agreed : To review the figures for the melting range and To prepare a draft monograph on Phenantoinum boiling range in monographs accepted (with Natricum Professors Fahmy, Fliick and van Os) To check an assay of Menadionum to be supplied To report on the following : by Professor Cook with that in the British The chromatographic analysis of Butacaine Pharmacopoeia (with Professor Fahmy) The chromatographic test for the assay of To prepare a table giving details of weights and Tetracainae Hydrochloridum and chromato- measures, and abbreviations graphic tests in general (with Professor van Os) - 43 - UNIFICATION OF PHARMACOPOEIAS Specific gravity and refractive indices for the Chromatographic assay of Pilocarpinae Hy- General Notices drochloridum (with Dr. Hampshire, Professors The general principles of ultraviolet absorption van Os and Fahmy) The limits of ash,acid-insoluble ash and Vegetable drugs in general sulphated ash Ash and insoluble ash A bulkiness test for Bismuthi Subcarbonas Monographs concerning Herba Belladonnae (with Professor Flück) and Herba Hyosciami Dr. Hampshire agreed : Professor Fullerton Cook agreed : To prepare draft monographs on : To prepare draft monographs on : Serum Antihistolyticum Amino Acid Preparations Any antimalarialdrugssuggested by the Gonadotrophinum Chorionicum Expert Committee on Malaria Streptomycin Dichlorophenarsinae Hydrochloridum To supply an assay of Menadionum Oxophenarsinae Hydrochloridum To report on Heparinum Penicillinum To report on the tests for Arseniuretted Hydrogen, To report on : Phosphoretted Hydrogen and Carbon Monox- Sulfadiazinum. The test in lines 56-58 and the ide in the British Pharmacopoeia monograph method suggested by Professor Baggesgaard- on Oxidum Nitrosum Rasmussen To submit chemical and physical tests for the Chromatographic assay of Pilocarpinae Hy- draft monograph on Digitoxinum drochloridum (with Professors van Os, Fahmy and Flück) The methods of preparing sterile solutions for Professor Fahmy agreed : inj ections To check an assay of Menadionum to be supplied To prepare by Professor Cook with that in the British Pharmacopoeia (with Professor Baggesgaard- A list of reagents Rasmussen) A list of qualitative and limit tests To report on the chromatographic assay of The standardization of Ergot Pilocarpinae Hydrochloridum (with Dr. Hamp- shire, Professors van Os and Fliick) Professor Hazard agreed : To review the figures for the melting range and To report on : boiling range in monographs accepted (with Tests to control the qualities of glass to be Professors Baggesgaard-Rasmussen, Flück and used as containers (with Professor Fahmy) van Os) To report on tests to control the qualities of Professor van Os agreed : glass to be used as containers (with Professor To prepare an assay of Metacresol (with Pro- Hazard) fessor Flück) To review the figures for the melting range and Professor Flück agreed : boiling range in monographs accepted (with ProfessorsBaggesgaard-Rasmussen, Fahmy To prepare an assay of Metacresol (with Pro- and Flück) fessor van Os) To report on : To review the figures for the melting range and Chromatographic assay of Pilocarpinae Hy- boiling range in monographs accepted (with drochloridum(withDr.Hampshire,Pro- ProfessorsBaggesgaard-Rasmussen,Fahmy fessors Flück and Fahmy) and van Os) The chromatographic test for the assay of To report on the following : Tetracainae Hydrochloridum and chromato- A bulkiness test for Bismuthi Subcarbonas graphictestsingeneral(withProfessor (with Professor Baggesgaard-Rasmussen) Baggesgaard-Rasmussen)