Yaws is a chronic bacterial infection that affects skin, bone, and cartilage, caused by Treponema pertenue. India launched a Yaws Eradication Programme in 1996-97, treating cases and contacts with antibiotics. Through surveillance and treatment, India declared elimination of yaws in 2006 and eradication in 2016, making it the first country certified by the WHO as free of yaws.

1. YAWS ERADICATION
PROGRAMME
APARNA .M .AJAY
ASST.PROFESSOR

2.  Yaws is a chronic infection that affects
mainly the skin, bone and cartilage. The
disease occurs mainly in poor communities in
warm, humid, tropical areas of Africa, Asia and
Latin America. The causative organism is a
bacterium called Treponema pertenue, a
subspecies of Treponema pallidum that
causes venereal syphilis.

3. Yaws: The long challenging path
towards eradication

 India has achieved breakthrough public health
milestones in the past by eradication of
smallpox and guinea worm disease. There
has been a concerted effort to target other
diseases in the country which are amenable to
eradication/elimination. One such disease,
yaws has been the target since decades and
particularly after the inception of yaws
eradication programme (YEP) since 1996-97.

4.  Epidemiology

 Yaws belongs to a group of chronic bacterial
infections (endemic treponematoses, non-
venereal spirochete diseases) caused by
treponemes. The organism responsible for
yaws is
Treponema pallidum subspecies pertenue. It is
morphologically and immunologically identical
to T. pallidum (the organism that causes
venereal syphilis).

5.  Other diseases belonging to this group are
bejel (endemic syphilis) and pinta. Yaws is the
most common among these three and occurs
primarily in the warm, humid and tropical areas
of Africa, Central and South America, the
Caribbean, Indian peninsula and the equatorial
islands of South-East Asia.


6.  It is usually prevalent among the people living
in primitive, unhygienic conditions in hot and
humid areas like those found in tropical
countries.

7.  In India, this disease was seen among poor,
most marginalized and difficult to reach
population living in remote, hilly, forested areas
of the country and particularly affected the
tribal population.

8.  The infection put these marginalized
population at a further disadvantage because
of morbidity, disability & economic burden
associated with the disease

9. Mode of transmission
 Yaws is transmitted by direct (person-
to-person) contact with the exudates and
serum from infectious lesions. The total
duration of infectiousness for an untreated
yaws patient, including relapse is probably of
the order of 12-18 months.

10.  Clinical manifestations
 After the bacterium has "penetrated" into the
skin, within a period of 3 to 4 weeks (with a
range from 10 to 90 days), early lesion
appears near the infection. Early secondary
lesion appears usually after an interval of 6-16
weeks (or even upto 2 years) of the primary
lesion.

11.  Yaws most commonly occurs in young children
is characterized by a primary skin lesion (Early
Yaws). It starts as a small papule, but reaches
up to 5 cm in diameter, becomes lifted, is often
ulcerated, and may resemble a raspberry.

12.  Papilloma is the most common presentation
and is often pruritic facilitating spread of the
infection to other areas of the body by
scratching. These lesions may persist for 3-6
months and heal spontaneously, often leaving
a scar.

13.  The early secondary skin lesion is papular and
may occur any time from 4 to 12 weeks after
the initial infection.

14.  The rash covers the limbs, neck, and buttocks
and may spread onto the body. It is at this
stage that the serological tests become
positive.

15.  Nocturnal bone pain and tenderness of the
tibia and other long bones due to periostitis
are common and may persist for up to 6
months.

16.  Usually after 5 years of onset of illness,
destructive lesions of the skin, bone and
cartilage (Late yaws) may appear which are
non-infectious but may result in disabilities like
gangosa and pathological fractures.

17.  Yaws simulates the lesions of scabies,
impetigo, skin tuberculosis, tinea versicolor,
tropical ulcer, leprosy and psoriasis. The yaws
may also coexist with any of these lesions.
There is no natural immunity.

18. 
Diagnosis
 Most latent and incubating cases are found in
clusters around an infectious case and can
usually be diagnosed by epidemiological
tracing. Serological tests to detect treponemal
antibodies can be useful in diagnosis of yaws
only if sexual transmitted syphilis is excluded..

19.  In field situation, these tests support a clinico-
epidemiological diagnosis of yaws but are not
as specific as the dark-field examination.

20.  Commonly used tests are Venereal Disease
Research Laboratory (VDRL) test and the
rapid plasma reagin (RPR) test which are
inexpensive, rapid and simple to perform. It
takes time for sero-positivity to appear after
the onset of disease and hence, initial (mother)
case may be sero-negative

21.  Sub-species of Treponema pallidum,
i.e., Treponema pallidum
 subsp. pallidum, Treponema
pallidum subsp. pertenue, and Treponema
pallidum subsp.endemicum cannot be serially
cultured in vitro, are indistinguishable by dark-
field microscopy.

22.  However, sub-species specific genetic
signatures permit molecular differentiation
using methods that involve polymerase chain
reaction (PCR), restriction fragment
length polymorphism (RFLP) and DNA
sequencing of specific treponemal DNA
sequences

23.  . Real-time polymerase chain reaction (RT-
PCR) has been proved to be very efficient in
molecular differentiation among all subspecies
of treponemes. It is very fast, highly sensitive
and highly specific assay.

24. Treatment
 Single dose of injection benzathine benzyl
Penicillin was the treatment of choice for both
cases and contacts of yaws.

25.  In patients allergic to penicillin,
erythromycin/ tetracycline was the alternative
treatment of choice and India used the same
treatment to counter the disease. However, off
late WHO recommends use of single dose of
azithromycin as the preferred treatment of
choice.

26.  Yaws: Global Overview
 Since the creation of WHO in 1948, the fight
against endemic treponematoses (yaws, bejel
and pinta) has been a priority for the
Organization.

27.  A review of historical documents from the
1950s, shows that at least 88 countries and
territories within the tropical belt of 20 degrees
north and south of the equator were endemic
for yaws. Published reports suggest presence
of yaws in many parts of the world viz

28.  . South East Asia (India, Indonesia, Timor-
Leste, Thailand, Sri Lanka), Western Pacific
(Solomon Island, Papua New Guinea), Africa
(Congo, Ghana, Ivory Coast, Togo), PAHO
(Haiti, Eucador) etc

29.  In the period 1952-1964, WHO in close
collaboration with UNICEF, launched the
global endemic treponematoses control
programme (TCP), which became a real
success story. More than 50 million patients
were treated in 46 countries, reducing the
overall prevalence of these diseases by more
than 95%.

30.  The control strategy subsequently changed
from a vertical programme to be integrated into
the basic health services. These basic health
services were to cope with the remaining “last
cases” of endemic treponematoses in the
community until eradication has been
achieved.

31.  The goal of eradication was not attained due
to the complacency following gradual
dismantling of the vertical programmes &
premature integration of yaws control activities
into weak/ non-existent primary health-care
systems in yaws endemic areas and
disappearance of the resources and
commitment for yaws control.

32.  A number of foci of transmission remained and
by the end of the 1970s a resurgence of the
endemic treponematoses had occurred in
many areas of the world.

33.  The necessity for renewed efforts was
recognized by the World Health Assembly and
expressed in WHA Resolution 31.58.

34.  In 1995, WHO estimated that 460,000
infectious cases of yaws occurred worldwide:
400,000 in West and Central Africa; 50,000 in
South-East Asia and the remainder in other
tropical regions.

35.  Yaws: Indian scenario
 In India, there was a paucity of literature on
yaws. Reports suggest that the first cases of
yaws were reported from among tea plantation
workers in Cachar district of Assam in 1887.
The disease was later detected in states of
Orissa, Chhattisgarh, Madhya Pradesh and
other areas.

36.  In India, the disease is mostly known by the
name of the tribes which are mostly affected
by yaws in any region. For example, the
disease is called ‘Madia Roga’ and ‘Gondi
Roga’ in Maharastra and Madhya Pradesh.

37.  Some synonyms of yaws are based on its
clinical features e.g. it is called ‘Domaru
Khahu’ in Assam which indicates a fig like
eruption. ‘Chakawar’ is a term used for chronic
ulcers so commonly seen in Central India and
part of Uttar Pradesh.

38.  The disease was reported from the
communities living in hilly and forested areas
in the tribal inhabited districts in states of
Chhattisgarh, Odisha, Andhra Pradesh,
Telangana and Maharashtra

39.  . Madhya Pradesh, Tamil Nadu, Assam,
Jharkhand, Uttar Pradesh and Gujarat are
other states from where cases had been
reported earlier.

40.  During 1952-1964 mass campaign were
launched with assistance from WHO and
UNICEF in the States of Orissa, Madhya
Pradesh, Maharashtra, Andhra Pradesh and
Madras (now Tamil Nadu) and about 0.2
million cases were detected from these
states.

41.  The strategies adopted were house-to-house
survey in the villages to identify cases followed
by selective mass treatment of all cases, their
household and other contacts with a single
injection of PAM (Penicillin G in oil with 2%
aluminium monostearate). This resulted in
marked reduction of yaws cases in India and
disease prevalence was brought down from
14.0 per cent to below 0.1 per cent in many
areas

42.  . Following this dramatic decline in disease
transmission, active anti-yaws activities were
abandoned in the majority of the States. In
1977, yaws resurgence occurred in Madhya
Pradesh.

43.  In 1981, the National Institute of
Communicable Diseases (NICD), Delhi
undertook a rapid survey to assess the
situation; wherein A total of 18,196 individuals
from three districts of Orissa, one district of
erstwhile Madhya Pradesh, Maharashtra,
Andhra Pradesh were examined and twenty-
six cases were detected, six of them
serologically positive, indicating continuing
yaws transmission in some areas of the
country.

44.  In 1985, NICD collected information using
mailed questionnaire method from various
districts of five states (Andhra Pradesh,
Madhya Pradesh, Orissa, Maharashtra and
Tamil Nadu).

45.  The data suggested that problem of yaws
continued to linger on in India albeit at a low
level.

46.  In 1995, NICD prepared a project document on
Yaws Eradication Programme in India, which
was approved by Government of India for
initiating the yaws Eradication Programme

47.  (YEP) in Koraput district (undivided) of Orissa
and was then expanded to cover all the eleven
yaws endemic states of the country.

48. objectives of the programme were
to achieve:
 v Cessation of transmission of yaws in the
country (defined as nil reporting of new yaws
cases) and
 v Eradication of yaws defined as absence of
new cases for a continuous period of three
years, supported by absence of evidence of
transmission through sero-survey among
under-five children (i.e. no sero reactivity to
RPR/VDRL in <5 yr children).

49. The programme strategy adopted
to achieve these objectives:
 · Creating yaws consciousness and
awareness in health professionals and
community members,
 · Trained manpower development,
 · Detection and treatment of cases and
contacts,
 · Monitoring and evaluation, and
 · IEC activities harnessing multi-sectoral
approach.

50.  A high-level National Task Force (NTF) was
established under the chairmanship of DGHS
for undertaking periodic reviews and for
monitoring the progress in implementation and
to advice on Annual Plans of the action.

51.  The programmes was subjected to
independent appraisal frequently and in all Six
Independent Appraisals of the programme
were undertaken since the beginning of YEP.

52.  After years of continuous fight against yaws,
the last case was reported in India in October,
2003.

53.  The Zero incidence of yaws cases was
validated by eminent experts and based on
recommendations of the task force the disease
was finally declared as eliminated by
Honorable union health & FW minister at
Vigyan Bhawan on 19thSeptember 2006.

54.  Journey from Elimination to Eradication
 Subsequently, India embarked upon the journey
for eradication of yaws from India.
 In post elimination phase apart from ongoing
activities three new activities were started:
 · Sero-survey among children to assess
cessation of transmission of infection for 3-5 years
 · Rumour reporting
 · Investigation and cash incentive scheme to
encourage voluntary reporting of the cases by the
community.

55.  Based on the recommendation of the sixth
independent appraisal, the seventh Task force
meeting on YEP under the chairmanship of
DGHS on 25th July, 2014 recommended
seeking Yaws eradication status for India.

56.  Following this WHO was approached for
certification of Yaws eradication. In this
context, WHO sent an international Verification
team (IVT) of experts for assessment of yaws
free status of India during 4–17th October,
2015..

57.  Based on the recommendations of the IVT,
WHO Director General declared India free of
Yaws at Geneva on 5th May, 2016.
 A celebratory function was organized to mark
the end of Yaws from India on 14th July, 2016
at National Media Center, Raisina Road, New
Delhi

58.  The Honorable Union Health and Family
Welfare minister Mr. Jagat Prakash Nadda
was the Chief Guest and Honorable Minister of
State for Health and Family Welfare, Ms.
Anupriya Patel was the Guest of Honor in the
event..

59.  Several other dignitaries including the
Secretary (Health and Family welfare),
Director General of Health Services, Regional
Director of WHO South East Asian Region,
Additional Secretary (Health) and Mission
Director National Health Mission, Director
NCDC and Mr. James from UNICEF graced
the occasion.

60.  The function was also attended by officials
from the ministry of health and family welfare,
Govt. of India and special invitees from local
administration, district & state health officials
and NGOs working in the erstwhile yaws
endemic states in India

61.  The Honorable Union Minister of Health and
Family Welfare formally declared India as free
of Yaws in presence of the august gathering in
the function.

62.  He lauded the dedicated and concerted effort
of health authorities of endemic states/districts
in implementing and monitoring the Yaws
Eradication Programme under the able
leadership of the National Centre for Disease
Control, the national nodal agency for the
Yaws eradication programme.

63.  The dignitaries also released a monograph
titled “YAWS DISEASE-END OF SCOURGE
IN INDIA”.
 The Union Health Minister expressed his
gratitude to all who worked tirelessly to make
the endeavor of yaws eradication a reality.
 Declaration of yaws Free India (14 July,
2016)

64. 10 facts on yaws eradication
 June 2016
 Yaws is a chronic infectious disease that is
closely linked to poverty. It is eradicable as
humans are the only hosts.

65.  A global campaign using benzathine penicillin
injection reduced 95% of global cases in the
late 1960s. However, abandonment of
programmes and weak surveillance led to
resurgence in many countries, prompting
WHO to re-start control programmes in 2007.

66.  The discovery in 2012 that a single, oral dose
of the antibiotic azithromycin can completely
cure yaws has added momentum to
eradication.

67.  Today, only 13 countries are known to be
endemic. India is the first country officially
declared free of yaws by WHO in 2016.

68. Facts of yaws eradication

69. Tackling a postwar public health
1948-1958
 When WHO established in 1948,yaws and
other bacterial infections caused by treponema
such as endemic syphylis bejel penta were
some of the pressing public health problems it
had to tackle head on.Once 50 million people
mainly children were affected.

71. Fact2: Yaws begins where road
ends
 Historically,yaw is considered as an end of
road disease because people affected are
mostly poor in live in difficult to access areas.
Health workers faced serious difficulties in
reaching affected population.

73. Fact3:start of eradication campaign
in 1952
 Between 1952 and 1964,WHO and UNICEF
supported mass treatment campaign in 46
countries. WHO provided technical support
and UNICEF gave logistical assisstance. An
estimates of 300 million people were screened
and over 50 million treated, reduce disease
burden by 95%

75. A MAGIC TABLET THAT
REVOLUTIONAZIED THE
TREATMENT
 The development of benzathine pencillin
coincided with the birth of WHO in 1948.The
second world health assembly1949 adopted a
resolution to control yaws.

77. 5.Health education

78. 6.Breakthrough Azithromycin as
alternative to injection

79. 7.The magic tablet accelerate the
path to eradication.

80. The renewed eradication
strategy

81. Who certifies india a free of
yaws

82. Global eradication feasible by 2020