YAWS ERADICATION

PROGRAMME
APARNA .M .AJAY
ASST.PROFESSOR
 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.
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.
 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).
 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.

 It is usually prevalent among the people living in
primitive, unhygienic conditions in hot and humid
areas like those found in tropical countries.
 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.
 The infection put these marginalized population at
a further disadvantage because of morbidity,
disability & economic burden associated with the
disease
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.
 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.
 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.
 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.
 The early secondary skin lesion is papular and may
occur any time from 4 to 12 weeks after the initial
infection.
 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.
 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.
 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.
 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.


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

 Single dose of injection benzathine benzyl Penicillin

was the treatment of choice for both cases and
contacts of yaws.
 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.
 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.
 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
 . 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
 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%.
 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.
 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.
 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.
 The necessity for renewed efforts was recognized
by the World Health Assembly and expressed in
WHA Resolution 31.58.
 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.
 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.
 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.
 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.
 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
 . Madhya Pradesh, Tamil Nadu, Assam, Jharkhand,
Uttar Pradesh and Gujarat are other states from
where cases had been reported earlier.
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.
 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
  . 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.
 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.
 In 1985, NICD collected information using mailed
questionnaire method from various districts of five
states (Andhra Pradesh, Madhya Pradesh, Orissa,
Maharashtra and Tamil Nadu).
 The data suggested that problem of yaws continued
to linger on in India albeit at a low level.
 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
 (YEP) in Koraput district (undivided) of Orissa and
was then expanded to cover all the eleven yaws
endemic states of the country.
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).
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.
 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.
 The programmes was subjected to independent
appraisal frequently and in all Six Independent
Appraisals of the programme were undertaken
since the beginning of YEP.
 After years of continuous fight against yaws, the
last case was reported in India in October, 2003.
 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.
 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.
 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.
 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..
 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
 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..
 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.
 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
 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.
 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.
 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)
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.
 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.
 The discovery in 2012 that a single, oral dose of
the antibiotic azithromycin can completely cure yaws
has added momentum to eradication.
 Today, only 13 countries are known to be endemic.
India is the first country officially declared free of
yaws by WHO in 2016.
Facts of yaws eradication
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.
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.
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%
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.
5.Health education
6.Breakthrough Azithromycin as
alternative to injection
7.The magic tablet accelerate the path
to eradication.
The renewed eradication strategy
Who certifies india a free of yaws
Global eradication feasible by 2020