Yaws class for MBBS students

1. ARMY COLLEGE OF MEDICAL SCIENCES
DELHI CANTT.
YAWS
Dr. Jyotismita
Pathak
Assistant Professor
Community Medicine

2. YAWS (PIAN, BUBAS or FRAMBOESIA)
• Chronic, Contagious, highly infectious, Non- venereal disease
• Caused by Spirochaete : Treponema pallidum pertenue
• Usually begins in early childhood.
• Primary skin lesion followed by generalised eruption and a late stage
of destructive and disfiguring and debilitating lesions of skin and
bone.
• Chronic disease showing relapses over several years.

3. GEOGRAPHIC DISTRIBUTION
• Exclusively confined to the belt between the Tropic of Cancer and
Capricorn.
• Significant public health problem in Africa, South-east Asia and
Central America in the past
• Resurgence in certain areas of Africa (e.g. Benin, Ghana, Ivory Coast,
etc.)
• In Asia : Indonesia, Papua New Guinea and the South Pacific.
• Persistent low level in Sri Lanka and India.

4. GEOGRAPHIC DISTRIBUTION

5. YAWS : GLOBAL BURDEN
• 13 countries :currently endemic with Yaws
• 8 reported > 46 000 cases in 2015.
• About 89 million people live in the 13 countries endemic for yaws
• Assessment to determine interruption of transmission so that WHO
can take steps to certify them free of the disease as part of the global
eradication process.
• In May 2016, WHO declared India free of yaws. Although Ecuador has
reported no cases for several years, it has not yet been verified as free
of yaws.

6. YAWS IN INDIA
• Reported from tribal communities living in hilly forests and difficult to
reach areas in 49 districts of 10 states.
• States affected – Andhra Pradesh, Assam, Chhattisgarh, Gujrat,
Jharkhand, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, U.P.
• No. of cases brought down from 3500 in 1996 to zero in 2004.
• Certification for disease free status: on 19th Sept. 2011.
• Yaws : considered a sign of backwardness "where the road ends, yaws
begins"

7. YAWS IN INDIA
Source: Yaws eradication. CD Alert 2008; 12 : 1-8.

8. AGENT
• Treponema pallidum pertenue
• Resembles T. pallidum culturally and morphologically
• Occurs in the epidermis of lesions, lymph glands, spleen and bone
marrow.
• Reservoir- Man is the only known reservoir
• Most latent cases found in cluster around an infectious case
• Source of infection- Skin lesions and exudates from early lesions

9. HOST FACTORS
• Age
• Primarily a disease of childhood and adolescence.
• predominantly affects children younger than 15 years
• Peak incidence occurs in children aged 6-10 years.
• Gender- Affects both genders equally. However, M > F
• Immunity – - No natural immunity.
- Yaws provides partial immunity to venereal syphilis

10. ENVIRONMENTAL FACTORS
• Climate – Endemic in warm and humid climate.
• Social Factors – More common in tribal people
• Predisposing Factors: Scanty clothing, Poor personal hygiene,
overcrowding, bad housing and low standards of living are important
socio-economic factors

11. MODE OF TRANSMISSION
• Direct Contact : Major route is person-to-person. The ulcerative skin
lesions present early in the disease are teeming with spirochetes,
which can be transmitted via direct skin-to-skin contact and via
breaks in the skin from trauma, bites, or excoriations.
• Fomites
• Vectors : Small flies and other insects

12. CLINICAL MANIFESTATIONS
• In most patients, yaws remains limited to the skin
• Early bone and joint involvement can occur
• Yaws lesions disappear spontaneously, but secondary bacterial
infections and scarring are common complications.
• Cardiovascular and neurological abnormalities almost never occur

13. CLINICAL MANIFESTATIONS
• The incubation period is 2-6 weeks.
• The prodromal period:
• Headache;
• weakness;
• chill;
• fever (39 °C);
• Arthralgia, muscle and joint pains in night time.

14. CLINICAL MANIFESTATIONS
• The primary lesion: 2 weeks to 6 months after inoculation.
• Seen on exposed parts of body: begins as a papule  papilloma.
• With in next 3-6 weeks generalised eruption appears consists of large
yellow, crusted, granulomatous eruptions
• Lymph glands are enlarged.
• During this stage, the treponeme may disseminate by means of the
bloodstream or the lymphatics or topically through excoriation by the
individual.
• Heals after 3–6 months pitted scar with dark margins.

15. PRIMARY LESION

16. CLINICAL MANIFESTATIONS
Secondary disease:
• Relapses often occur for up to 5 years, after which they diminish in
severity and frequency.
• Can involve multiple cutaneous lesions, including macules, papules,
nodules, hyperkeratoses, and ulcerations.
• Lymphadenitis with swollen and tender lymph nodes may occur
proximal to lesions.
• Periosteal infection and destruction of cartilage occur later in the
course of the disease.

17. CLINICAL MANIFESTATIONS
• Approximately 10% of untreated patients develop late disease,
including periosteal lesions that damage bone.
• LATE YAWS - Destructive and deforming lesions of skin, bone and
periosteum develop.
• Other late-stage manifestations include hyperkeratosis of the palms
and soles and gummas of the skull, sternum tibia, and other bones.
• CRAB Yaws – lesions of palm and soles
• Gangosa – lesions of soft palate, hard palate and nose

18. PERIOSTEAL LESIONS

19. LATE COMPLICATIONS
Saber Shin

20. DIAGNOSIS OF YAWS
• Serological tests e.g. TPPA, RPR used (npon-specific)
• Point-of care rapid-tests : cannot differentiate past and current inf.
• Polymerase chain reaction (PCR) technology
• The application of PCR in yaws eradication will be very useful after
mass treatment when the few cases that occur must be proven to be
yaws.

21. CONTROL OF YAWS : PRINCIPLES
1. SURVEY
• Clinical survey of all families in endemic area.
• Should not cover less than 95% of total population.
2. TREATMENT
Single dose of Azithromycin (30mg/kg) or single long acting Penicillin
will cure infection e.g. Benzathine Penicillin G (1.2 million units)
Simultaneous treatment of cases and their likely contacts in the
community will interrupt transmission

22. CONTROL OF YAWS
WHO has recommended 3 treatment policies-
• TOTAL MASS TREATMENT- Hyperendemic areas (>10% prevalence of
clinically active Yaws). Treatment Pn G to entire population)
• JUVENILE MASS TREATMENT – Mesoendemic areas(5-10%
prevalence). Treatment to cases, contacts and all children <15 years
• SELECTIVE MASS TREATMENT – Hypoendemic areas (<5% prevalence)
Treatment to cases, household and other obvious contacts

23. CONTROL OF YAWS
3. RESURVEY AND TREATMENT- Resurveys every 6-12 months to assess
problem magnitude.
4. SURVEILLANCE- Surveillance and Containment measures for affected
villages, households and contacts of known Yaws cases. Epidemiological
investigations to trace possible sources of infection, prophylactic
treatment of contacts, monthly follow up of households (for at lest 3-4
months of the treatment of last active case

24. CONTROL OF YAWS
5. ENVIRONMENT IMPROVEMENT
• an attack on social and economic conditions of life is as important as
an attack on the biological cause.
• Improvement of personal and domestic hygiene, adequate water
supply, liberal use of soap, better housing conditions and
improvement of the quality of life.
6. RENEWED ERADICATION EFFORTS-
• Based on treatment of Yaws with single dose Azithromycin

25. CONTROL OF YAWS
Since January 2012, when the WHO roadmap for NTDs were set, WHO
has taken steps to move the renewed eradication efforts by developing
a new treatment strategies. These are:
• Total community treatment (TCT) - treatment of the endemic
community, irrespective of the number of active clinical cases;
• Total targeted treatment (TTT) treatment of all active clinical cases
and their contacts (household, school, playmates).

26. CONTROL OF YAWS
7. EVALUATION:
• Serological studies : Whether or not yaws has been brought under
control
• No Yaws antibodies s/b found among children born since the yaws
mass campaign was completed

27. YAWS ERADICATION PROGRAMME
• One of the first diseases targeted for eradication by WHO and UNICEF
in the 1950s.
• WHO renewed global efforts to eradicate yaws in 2012.
• 13 countries currently known to be endemic for yaws, of which only 8
regularly report data to WHO.
• There are 73 countries previously endemic for yaws that need to
confirm the current status of the disease.

28. YAWS ERADICATION PROGRAMME
• National Institute of Communicable Diseases : nodal agency for
planning, guidance, coordination, monitoring and evaluation
• The programme was started in 1996-97 in Koraput district of Odisha
then extended to endemic states as a centrally sponsored health
scheme with the objectives of:
1. Interrupting the transmission of yaws infection (no case) in the
country
2. Eradication of Yaws (i.e. no sero reactivity to RPR/VDRL in children
below 5 years of age) from the country.

29. YAWS ERADICATION PROGRAMME
• The programme implemented by State Health Directorates of Yaws
endemic states utilizing existing health care delivery system with the
coordination and collaboration of department of tribal welfare and
other related institutions.
• The number of reported cases has come down from more than 3,500
to Nil during the period from 1996 to 2004, since then no new case
has been reported.
• Certification for disease free status: 2011

30. RENEWED ERADICATION EFFORTS:
Progress So Far
• 2012 : WHO developed the Yaws Eradication Strategy
• Aka "the Morges strategy", shift from 60 years' use of the BPG to
Azithromycin
• 2012 WHO Roadmap for Neglected Tropical Diseases and resolution
WHA66.12 of the 2013 World Health Assembly, yaws is targeted for
eradication by the year 2020.
• Pilot implementation of the Yaws Eradication Strategy in 5 countries
(Congo, Ghana, Papua New Guinea, Solomon Islands and Vanuatu)

31. CRITERIA FOR ERADICATION
WHO Expert Committee on Venereal Infections and Treponematoses
established 2 criteria:
• Absence of new indigenous cases for 3 consecutive years.
• Absence of evidence of transmission for 3 continuous years measured
with sero-surveys among children aged between 1–5 years
After 2010 a new criterion was added:
• Negative PCR in suspected lesions (to differentiate from H. ducreyi)

32. PROSPECTS OF ERADICATION BY 2020
• Different experiences from the pilot implementation of the Yaws
Eradication Strategy (the Morges strategy)
• If a sustainable supply of azithromycin can be secured, interruption of
transmission by 2020 is feasible in some countries.
• India`s triumph over yaws provides positive lessons to other countries
to strive further

33. THANK YOU