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Yaws Eradication Programme (YEP)
YAWS: Elimination To Eradication
India has achieved eradication of two human scourges, smallpox and guinea worm disease, since independence. National efforts are now going on to eradicate/eliminate others. One disease, which is amenable for eradication, is yaws and the disease has been eliminated from the country in 2006. This disease primarily affects tribal population living in remote, hilly and forest areas having difficult terrain. It is responsible not only for great deal of misery to the affected people but also contributes significantly to the economic strain of the already impoverished segments of our society.

Yaws belongs to a group of chronic bacterial infections (endemic treponematoses, nonvenereal spirochetal diseases) caused by treponemes. Other diseases belonging to this group are bejel (endemic syphilis) and pinta. Yaws is the most common of all 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.

Yaws is characterized by a primary skin lesion (Early Yaws) which usually occurs in children and adolescents in endemic situation. These lesions may persist for 3-6 months and heal spontaneously, often leaving a scar. Nocturnal bone pain and tenderness of the tibia and other long bones due to periostitis are common. 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 make a person disabled. 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). Yaws is transmitted by direct (person-to-person) contact with the exudates and serum from infectious lesions.

Yaws simulates the lesions of scabies, impetigo, skin tuberculosis, tinea versicolor, tropical ulcer, leprosy and psoriasis. It may also accompany these diseases. Penicillin treatment (drug of choice) is very useful in differential diagnosis because of miraculous relief seen in yaws but not in other skin diseases. 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 will 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.

Treatment is same for cases and contacts. Penicillin (Injection Benzathine Pencillin) is the drug of choice. Though reaction to penicillin in tribal areas is rare but intradermal skin test to detect penicillin hypersensitivity should be performed in every case. In patients allergic to penicillin, alternate drugs such as Tetracycline and Erythromycin may be used.

The potential for eradication of yaws exists with the following factors in favour:

Man is the only reservoir of infection;
a “magic bullet” is available for intervention i.e., a single injection of long-acting penicillin, which is easily available at low cost, has no toxicity and is a stable preparation and;
the infection was localized to small pockets.
No case has been reported after 2003.

The following factors need active pursuance and action to achieve the target of eradication:

There are 5-10 times more latent cases than clinical cases;
there are no visible lesions during the latent stage, but infectious relapses may occur which can cause new outbreaks; therefore, after an initial control effort, communities must be frequently re-surveyed to detect remaining cases;
serological surveillance is needed to establish that transmission of infection has been interrupted.

Endemic treponematoses can serve as an indicator for the effectiveness of primary health care. Effective Primary health care services should lead to the eradication of endemic treponematoses. Where these are still prevalent, control efforts can be used as a catalyst for developing primary health care services. Cure and eradication could induce a feeling of great achievement in workers and considerably enhance their respect in the community.

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. 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 and a number of foci of transmission remained. 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.
Indian scenario
In India, literature on yaws is rather scanty. Reports suggest that yaws was non-existent in India till 1887 when the cases were first noticed among tea plantation labourers in Assam. From Assam, yaws later spread to the states of Orissa, Chattishgarh, Madhya Pradesh and other areas.

In India, the disease is mostly known by the name of the tribes affected most in any region. Thus for example, the disease is called ‘Madia Roga’ and ‘Gondi Roga’ in Bastar area of Chattishgarh and Sironcha area of Maharashtra respectively and ‘Koya rogam’ in Andhra Pradesh and Orissa. 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 inhabitied districts in states of Chattishgarh, Orissa, Andhra Pradesh and Maharashtra. Madhya Pradesh, Tamilnadu, Assam, Jharkhandr, Uttar Pradesh and Gujarat are other states from where cases had been reported earlier.

In 1950s, mass campaign launched with assistance from WHO and UNICEF 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; data indicated that transmission of yaws continued to occur in some areas of the country. In addition, a new focus was suspected in Dang district of Gujarat. In 1985, NICD collected information using mailed questionnaire method from various districts of five states (Andhra Pradesh, Madhya Pradesh, Orissa, Mahrashtra 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 programme in Koraput district (undivided) of Orissa and was then expanded to cover all the yaws endemic states of the country. The disease was finally declared as eliminated on 19th Sept 2006.
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