After polio, India becomes yaws-free

On July 14, 2016, the WHO felicitated India for having eliminated yaws as a public health problem. Yaws? What yaws? Majority of the people would not have heard about yaws. Yaws is a neglected tropical disease of the most neglected people.

In India, it has been reported amongst the people living in the backward and primitive areas of Andhra Pradesh, Assam, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Maharashtra, Odisha, Tamil Nadu and Uttar Pradesh. It’s a disease which begins where the road ends. It’s a disease of the poorest of the poor, of the most impoverished. Yaws does not kill, hence it does not create headlines in the media.
Yaws is caused by bacteria and is transmitted mainly through direct skin to skin contact with an infected individual. Bacteria enters through a break in the skin like a scratch or a cut or an injury. At the point of entry of the bacteria, a bump or a boil develops which breaks down into an ulcer-like wound.

Soon, multiple boils appear on the body. The bacteria eats away into the soft tissue and burrows  deep in the skin causing destructive lesions of skin, soft tissues, and drills down to the bones. If left untreated, the ulcers lead to disfiguration and deformity of the legs, nose, palate, and upper jaw.

Predominantly, it affects children between the ages of five and 15 years. Overcrowding, poor personal hygiene and poor sanitation facilitate the spread of the disease.

In India, cases have been reported from 10 states, but 90% of them occur in Odisha, Chhattisgarh and Andhra Pradesh among the marginalised populations living in hard to reach areas where access to health services is difficult. Though sophisticated tests are available, treatment is a single injection of long-acting penicillin.

Yaws is not a disease confined to India, though the burden is not known because there is no official notification of the disease globally. According to the WHO, about 5,000 new cases are reported annually in South-East Asia, mainly in Indonesia and Timor Leste.

India’s yaws elimination effort is an inspiring but little-known story. The earliest report of a yaws case was in 1887 from the tea gardens of Assam. Between 1950 and 1970, WHO and Uni-cef led a worldwide campaign to control yaws in 46 countries. India launched the yaws control programme in 1952 and its prevalence fell from 15% to less than 0.1% and the cases confined to 51 districts across 11 states. In the 1970s, the vertical programmes in many countries were dismantled and yaws activities were integrated into the primary health care system. 

Last case

Resources, attention and commitment for yaws activities dwindled. While control activities were declining globally, India sustained its efforts and launched yaws eradication programme in 1996-97 and scaled up the operations to full geographical coverage by 1999. 

The last case of yaws was seen in 2003 and India declared that yaws was eliminated in 2004. After a team of experts verified interruption of the disease transmission in the country, in May 2016 WHO certified India as yaws-free. This comes after India has been certified polio-free.

It has been achieved using the existing health systems, and health workforce. Sustained political commitment and clear policies, unified strategies, close supervision and monitoring have been hallmarks of the programme. It has been funded primarily by the Government of India with technical and financial support from the WHO. Tireless efforts of front line workers has been key to the success.

Health workers have travelled to hilly, remote, inaccessible terrain and in forest areas where there are no roads and limited means of transport. The journey became more difficult as they travelled in hot and humid climate. Since the tribal people leave the village before sunrise and return after sunset, the health worker had to work at odd hours. Tribal populations are shy and do not easily mingle with other populations.

Gaining their confidence and convincing them to take treatment would have been a Herculean task. It was important that not even a single case was missed and those diagnosed got the treatment. Adequate coverage of the contacts of the case had to be ensured. A high quality surveillance for new cases had to be mounted and sustained for three years before certification. Eliminating yaws is an eloquent example of triumph of public health in the most testing circumstances.

(The writer is Senior Advisor – Infectious Diseases, Public Health Foundation of India, and Senior Country Adviser, Indian Network of Neglected Tropical Diseases. Views are personal)

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