A world look at the venereal diseases: recrudescence of the venereal diseases.

PIP: Factors affecting the increased incidence of the venereal diseases syphilis and gonorrhea throughout the world since World War 2 are considered. Both diseases declined after the war to a minimum in about 1957, but they have since increased, particularly gonorrhea to even higher incidence in many countries. Late and congenital syphilis, however, have declined almost universally. Factors invoked to explain the recrudescence include decreased virulence of both organisms, perhaps aided by better nutrition and hygiene. An important trend is antibiotic resistance. Sulfonamide resistance was noted during World War 2. A relative penicillin resistence, threatening the convinient use of cheap single-dose treatment, is particularly frequent in the Far East. Other antibiotics and penicillin-probeneoid combinations are still available and have contributed to improved cure rates in some countries, e.g., Canada, United Kingdom, Denmark, Greenland and Norway. Environmental fa ctors suggested are more susceptible persons, greater population mobility, promiscuity, use of pills and IUDs instead of condoms, and changed sexual practices resulting in rectal and oral infections. Hopes for control in the future include formation of adequate case finding organizations in more places, health education, modification of behavior, discovery of a serologic test for gonnorrhea, and although unlikely, immunization. The author concluded that the problems of venereal disease will probably increase: even if syphilis and gonorrhea were controlled, the other sexually transmitted entities (spirochetes, bacteria, virus, protozoa, fungi, parasites and possible cervical carcinoma) will pose problems.^ieng

The rectum as viewed by the venereologist.

About 2-2 1/2 million people do, or will repeatedly, participate in ano-rectal sexual intercourse in Britain alone. The anus and the rectum of these individuals are thus vulnerable to all the sexually transmitted diseases (except trichomoniasis). Male homosexuals appear to be more prone to these conditions than female heterosexuals, possibly because a large minority is indiscriminately promiscuous. Over the last 20 years homosexually acquired infections--particularly syphilis--have increased in Britain; these are now more readily admitted to because of changes in the law and in public opinion. The frequent changes of sexual partner among male homosexuals is the most notable epidemiological factor in the spread of venereal disease.

Sexual behaviour and sexually transmitted disease patterns in male homosexuals.

Male homosexual behaviour is not simply either "active" or "passive", since penile-anal, mouth-penile, and hand-anal sexual contact is usual for both partners, and mouth-anal contact is not infrequent. A simplified method for recording sexual behaviour--a "sexual behaviour record (SBR)"--can be of value in determining the sites to be investigated and as a basis for further epidemiological questioning. Mouth-anal contact is the reason for the relatively high incidence of diseases caused by bowel pathogens in male homosexuals. Trauma may encourage the entry of micro-organisms and thus lead to primary syphilitic lesions occurring in the anogenital area. Similarly, granuloma inguinale, condylomata acuminata, and amoebiasis may be spread from the bowel of the passive homosexual contact. In addition to sodomy, trauma may be caused by foreign bodies, including stimulators of various kinds, penile adornments, and prostheses.

Venereal diseases in the islands of the South Pacific.

The island territories of the South Pacific vary considerably in area and in size of population; Pitcairn has a population of 100 in two square miles whereas Papua New Guinea has a population of 2,990,000 in approximately 175,000 square miles. Today the whole ocean is traversed by air routes. Recently, the prevalence of gonorrhoea has decreased in the northern region but increased in the eastern and western; in all these regions the reported prevalence exceeds 200 cases per 100,00 population. In an area where yaws was once widespread, syphilis is being increasingly recognised. Although the figures for syphilis are clearly higher because of the greater use of serological screening, many of the reported cases are of early infection. Yaws has been eliminated from most of the South Pacific Islands but is still present in the western region--more than 99% of the reported cases occurring in Papua New Guinea, particularly in the offshore islands.

PIP: The island territories of the South Pacific vary considerably in area and population size; Pitcairn has a population of 100 in 2 square miles whereas Papua New Guniea has a population of 2,990,000 in approximately 175,000 square miles. Today, the whole ocean is traversed by air routes. Recently, the prevalence of gonorrhea has decreased in the northern region but has increased in the eastern and western regions; the reported prevalence in all these regions exceeds 200 cases/100,000 population. In an area where yaws was once widespread, syphilis is being increasingly recognized. Although the figures for syphilis are clearly higher because of the greater use of serological screening, many of the reported cases are of early infection. Yaws has been eliminated from most of the South Pacific islands but is still present in the western region--more than 99% of the reported cases occurring in Papua New Guinea, particularly in the offshore islands.

Treatment of syphilis.

THE RESULTS OF THE TREATMENT OF EARLY SYPHILIS WITH PENICILLIN HAVE BEEN EXCELLENT: patients are rendered non-infectious within hours, sero-reversal to tests with lipid antigens occurs within months and insignificant numbers of patients with cardiovascular or neurosyphilis are found among those who have received adequate treatment. On the other hand, seropositivity to tests with treponemal antigens may persist, sometimes indefinitely, and reinfections are, today, by no means uncommon. The physician also has a responsibility to persuade the patient with early infectious syphilis to induce the person who was the source of the infection and subsequent sexual partners to undergo examination and treatment.In late syphilis, no treatment can repair structural damage that has already occurred, e.g., severed neurons in the nervous system or loss of elastic tissue in the aortic wall, and clinical progression may occur in spite of treatment. Nevertheless, penicillin provides the basis of therapy.Early congenital syphilis, like the acquired infection, responds well to penicillin. However, because benzathine penicillin penetrates poorly into the cerebrospinal fluid much higher doses of procaine penicillin are now recommended, or alternatively the use of crystalline penicillin G.A recent WHO Scientific Group on Treponemal Infections has made new recommendations concerning the treatment of syphilis and these will be considered by the next WHO Expert Committee on Venereal Diseases, Treponematoses and Neisseria infections. Some of these recommendations are outlined in this article.

Venereal diseases in the islands of the North Pacific.

Apart from the Japanese islands, and those of Karabati (lately Gilbert Islands), which lie just north of the equator, the islands of the northern Pacific Ocean are either American owned or otherwise administered. Even the Japanese islands were controlled by the USA for varying numbers of years after the second world war. Venereal disease statistics from Guam, the Trust Territory of the Pacific Islands, and the Gilbert Islands have been collated by the South Pacific Commission and will be presented in a second paper. Those from the Hawaiian Islands (the fiftieth state of the USA) are published by the United States Public Health Service and include those from Honolulu, the capital. While the rates per 100 000 for both syphilis and gonorrhoea are lower than those for the USA as a whole, the trends since 1970 have been less satisfactory in the state of Hawaii than for the whole of the United States. While the disturbing increasing incidence of primary and secondary syphilis was checked in 1977, that of gonorrhoea has continued to rise. The number of cases of gonorrhoea also increased in Guam and the Trust Territory of the Pacific Islands but there has been a recent fall from earlier peak figures. The pattern of venereal disease in the most developed Pacific islands is thus gradually approaching what may be expected elsewhere in modern western society and it would seem logical to expect that this trend will continue.

Venereal diseases in the Pacific Islands. Papua New Guinea.

Papua New Guinea, which contains nearly three-quarters of the population of the 20 islands, or island groups, studied by the South Pacific Commission has a commensurate proportion of reported cases of syphilis and gonorrhoea. It is a country with an exceptional interest for the venereologist as it exhibits all the facets of venereal disease problems as experienced the world over. With the opening up of communications syphilis has gained a foothold in what were areas previously endemic with yaws; moreover, some yaws still remains (particularly in the offshore islands)--the two conditions tending to be mutually exclusive. In the area around the capital, Port Moresby, the prevalence of Donovanosis is unparalleled.

PIP: Papua New Guinea, which contains nearly 3/4 of the population of the 20 islands or island groups studied by the South Pacific Commission has a commensurate proportion of reported cases of syphilis and gonorrhea. It is a country with an exceptional interest in the venereologist as it exhibits all facets of venereal disease problems as experienced in the world. With the expansion of communication, syphilis has gained a foothold in what were areas previously endemic with yaws; moreover, some yaws still remain (particularly offshore in the islands)--the 2 conditions tend to be mutually exclusive. In the area surrounding the capital, Port Moresby, the prevalence of Donovanosis is unparalleled.

Recent developments in the treatment of gonorrhoea.

PIP: Rising failure rates with single injections of penicillin in gonorrhea are causing alarm. In the Far East, the failure rate is about 30% after single injections of 2.4 mega units of aqueous procaine penicillin. In London, although there is rising gonoccoccus resistance to penicillin, single injections of 1.2 mega units of aqueous procaine penicillin nets a cure rate of 85.8% to 91.5% in male patients. Other recent experiences in the treatment of gonorrhea in London men are outlined in this article. The failure rate was reduced to 5.8% when a single injection of 2.4 mega units of procaine penicillin was given. When 1 gm probenecid was given orally along with 1.2 mega units of procaine penicillin, the failure rate was 6.6%. Streptomycin is so ineffective now against gonorrhea that it is no longer acceptable even as a first treatment in patients who are allergic to penicillin. In London, the failure rate with streptomycin is 31.7%. Experts think the rate will jump to 85.8% in the next year. Many other antibiotics can be used against gonorrhea, but, as in the case of streptomycin, they may lose their effectiveness. Some recent experiences show that a combination of rolitetracycline by injection and tetracycline by mouth does not give as good results as a single injection of aqueous procaine penicillin but that comparable results can be obtained with single oral doses of rifampicin and superior results (95.7% success) were obtained with 2 oral doses of dementhylchlortetracycline.^ieng

Importance of the so-called 'other' sexually-transmitted diseases.

(1) Some data are presented concerning the frequency and potential morbidity of sexually-transmitted organisms other than T. pallidum or N. gonorrhoeae. (2) Most of the diseases with which these organisms are associated are more prevalent than syphilis and some, at least in one sex, are as common as gonorrhoea. A number appear to carry considerable morbidity, which in the case of Type II herpes virus--if it is responsible for cervical cancer--may ultimately cause more fatalities than syphilis. (3) It is concluded: (a) that, if syphilis and gonorrhoea were reduced to the point of representing no public health concern, many other sexually-transmitted conditions would still remain to pose significant problems: and (b) that health education and other methods of prevention should, where possible, be designed to take into consideration the epidemiological implications of the other organisms listed.

Mass treatment campaigns against the endemic treponematoses.

In pre-antibiotic times, mass campaigns against the endemic treponematoses required multiple injections of arsenicals and bismuth. The essentiality of a population census, an examination of the total population, and the treatment of clinical and latent cases were all appreciated, as was the value of a multipurpose approach. It was also recognized that, in combination with the anticipated slow correction of economic circumstances and attitudes, chemotherapy was the chief weapon against disease but that this weapon, even if successful in a particular area, could not prevent later reintroduction of infection. With the introduction of single-dose penicillin therapy and the impetus of worldwide, internationally assisted mass campaigns came a dramatic reduction in incidence. However, in some areas continued surveillance by the local health services did not materialize. Thus, there has been not just a low-level continuum of disease but a resurgence, particularly in Africa, where a return to mass therapy has once again proved necessary--this time combined with multipurpose immunization.

Epidemiological importance of concealed nongonococcal urethritis.

Of the 229 806 new male patients attending venereal disease clinics in England in 1976, 31.9% had recognisable non-specific genital infection (NSGI), which was easily the most common diagnostic category of the sexually transmitted diseases (STDs) and one which had increased more markedly than all the others in the previous 25 years. Many more cases of nongonococcal urethritis (NGU) are concealed under the diagnosis of gonorrhoea, as is clear from the high incidence of post-gonococcal infection following treatment with penicillin. From 44% to 56% of male patients with gonorrhoea can also have non-specific genital infection during the same year. A practical treatment schedule for gonorrhoea which is also effective against simultaneously acquired non-gonococcal urethritis would be of great value.

How suitable are available pharmaceuticals for the treatment of sexually transmitted diseases? (2) Conditions presenting as sores or tumours.

The pharmaceutical industry is not supplying the penicillin preparations that are required for the treatment of syphilis. For those in whom penicillin hypersensitivity is suspected there is a need for a safe injectable alternative that is effective if given once daily or, preferably, at two- or three-day intervals. Existing treatments for chancroid, lymphogranuloma venereum, and granuloma inguinale are described, but even collectively there are few cases and treatments for other sexually transmitted diseases merit priority. Treatments for scabies and pediculosis pubis, although not perfect, are reasonable. There is a need for better local treatment for condylomata acuminata and systemic immunological methods, including those that increase cell-mediated immunity, deserve attention. The same is true for molluscum contagiosum. There is an urgent need for an effective, safe treatment of herpes genitalis that is able to eradicate the virus from the host. If it is proved that the herpes virus is responsible for carcinoma of the cervix this could then be the most serious sexually transmitted disease as in many countries such carcinomas are responsible for approximate seven times more deaths in women than is syphilis in men and women together. The limitations of prophylactic methods in preventing all possibility of infection with one or more of the sexually transmitted diseases are discussed.

How suitable are available pharmaceuticals for the treatment of sexually transmitted diseases? 1: Conditions presenting as genital discharges.

The relative prevalence of sexually transmitted diseases and the agents available for the treatment of these diseases commonly presenting as genital discharges-namely, gonorrhoea, candidosis, trichomoniasis, and non-specific genital infection-are reviewed. The many agents that are active against gonorrhoea are listed, but none is ideal. Penicillin, in spite of its allergic side effects, has remained the drug of choice for 25 years because it is cheap, easily obtained, lacks toxicity even in pregnancy, and is effective. Its use is now threatened by the emergence of some strains that are able to produce penicillinase. At present the policy is to obtain the best results from penicillin while these are acceptable, but the clinician in some countries is badly served by the availability of procaine penicillin in aqueous suspension. There is a need for an effective penicillin or cephalosporin that is penicillinase resistant and cheap. Cefuroxime offers considerable hope but it is likely to be expensive in the immediate future.There are many preparations for the local treatment of candidosis. The confidence expressed by the manufacturers in recommending a three-day treatment is, it is hoped, based on a superior product. Nevertheless there is a need for a safe systemically absorbed fungicide which could be used orally, or some substance that could render the vagina an inhospitable environment for the organism.In the treatment of trichomoniasis the pharmaceutical industry in providing substances more than 90% effective in a single dose has done all that can be expected. Any further advances lie in the field of human behaviour rather than pharmaceutical research.In the treatment of non-specific genital infection the needs are more of research than of therapy. More knowledge is required of the cause of the condition and the relative role of contending pathogens, and of the results of treatment of patients and contacts in which Chlamydia or other suspect pathogens have been isolated.

Single oral dose of 1-5g. talampicillin in the treatment of gonorrhoea.

81 patients have been treated with single oral doses of 1-5 g. (6 tablets) of talampicillin without probenecid. The failure rate amongst those followed was only 4-2 per cent. No side-effects were reported. These results were superior to those obtained with 2-0g. or equivalent of ampicillin, amoxycillin, or pivampicillin with probenecid. Talampicillin is thus the most potent ampicillin-like antibiotic so far available for the treatment of gonorrhoea and is capable of curing the disease with a smaller single dose without probenecid than is necessary for other preparations.

VD education in developing countries. A comparison with developed countries.

No new method of control of the sexually transmitted diseases is imminent. Reliance has to be placed on existing methods including health education. Health education has a double role, being a primary method in its own right, and--of equal or greater importance--being involved in the enforcement of all of the other tried methods. A comparison is made of the situation in countries with a developed or an underdeveloped venereal disease control service, in respect of organization, statistical reporting, the various agencies treating venereal disease, clinic and diagnostic facilities, personnel concerned in venereal disease management, and other aspects. The vicious circle inherent in developing countries is outlined. A lack of awareness of the extent of the problem and the presence of other serious competing diseases lead to a low budget, thence to poor diagnostic and treatment facilities, and to few cases being seen in the official clinics and hospitals. Thus relatively small numbers of cases are reported and there is consequently a continuing lack of awareness of the problem. A method of cutting through such a circle is suggested, and the importance of health education activities during this period is emphasized.

PIP: No new method of control of sexually transmitted diseases is imminent. Reliance must be placed on existing methods including health education. Health education has a double role, being a primary method in its own right and being involved in the enforcement of all other tried methods. A comparison is made of the situation in countries with a developed or underdeveloped venereal disease control service, with respect to organization, statistical reporting, various agencies treating venereal disease, clinic and diagnostic facilities, personnel involved in venereal disease management, and other aspects. The vicious circle inherent in developing countries is outlined. A lack of awareness of the extent of the problem and the presence of other serious competing diseases lead to a low budget, thus to poor diagnostic and treatment facilities, and to a few cases being seen in the official clinics and hospitals. Thus, relatively small numbers of cases are reported and there is consequently, a continuing lack of awareness of the problem. There is emphasis placed on the importance of health education activities during this period, and a method of cutting through such a vicious cycle is suggested. There is a worldwide need for better training of physicians, paramedical workers, and nurses in the management of venereal disease, including case finding and health education. In a great many developing and developed countries, the bulk of such management is conducted by general practitioners and it is logical that they should be involved more closely in the program by providing them with assistance in diagnosis, contact tracing, and postgraduate education. As pharmacists are legally or unofficially involved in many areas with few facilities, it may be questioned how their contribution may be more effective pending the development of more extensive official programs.

Teaching of genitourinary medicine (venereology) to undergraduate medical students in Britain.

Twenty-six medical schools in the United Kingdom have recently taken part in a survey on the teaching of genitourinary medicine (venereology) to undergraduates. Four of the schools were unable to run their own formal lecture courses and a further three could not offer clinical attachments. The mean number of lectures given per centre was six, clinic attendances 10 hours, and total teaching time (lectures and clinical attachment combined) 15 hours. This represents a reduction in teaching hours over the last 15 years and contrasts with the ever-increasing clinical problems associated with the sexually transmitted diseases.

Minocycline in the treatment of non-gonococcal urethritis.

108 male patients with non-gonococcal urethritis have been treated with minocycline given as two 100 mg. tablets initially, followed by one tablet twice a day over a period of 6 days (13 tablets). Of 96 patients followed, re-treatment for non-gonococcal urethritis within 3 months was undertaken in ten (10.4 per cent.). The findings are compared with those previously reported in seven series involving six other tetracyclines and with nine other treatment regimens. All of the tetracyclines proved superior to other agents and the best results combined with simplicity of administration were obtained with minocycline. Two patients complained of soreness of the mouth after 1 week but no other side-effects were reported. Minocycline thus gives excellent results in the treatment of non-gonococcal urethritis. In the dosage used it was also successful against gonorrhoea in seven patients treated. It is therefore particularly useful in cases in which gonorrhoea is suspected but not found in the smears or in which the smears cannot be read immediately.

Treatment of gonorrhoea with single oral doses of rifampicin.

Of 103 cases of acute uncomplicated gonorrhoea treated with single oral doses of 900 mg. of a new antibiotic rifampicin 89 were followed, and 10 (11.2%) apparent failures were found.Rifampicin gives results which compare favourably with those obtained under like conditions with similar doses of other orally administered antibiotics. It provides an alternative means of single-session therapy for patients in whom penicillin is contraindicated.

Which Neisseria?

A case of disseminated gonococcal infection in which the gonococcus was isolated from the blood and genitalia and the meningococcus from the throat is described. A second patient, in whom the meningococcus was isolated from the throat and the gonococcus from the genitals but in whom no organisms were recovered from the blood, had lesions resembling those of a disseminated infection. The results of 150 throat cultures from patients who were examined at a clinic because they had a history of oral sexual intercourse are presented. The meningococcus was isolated nearly six times more often in patients with genital gonorrhoea than in those in whom genital cultures were negative, while the gonococcus was found 2 1/2 times more often in those who carried the meningococcus in the throat than in those who did not. If these findings can be confirmed it could indicate an individual susceptibility to the acquisition of Neisserian organisms that would merit further investigation.