YAWS

ITS ERAilCATlON
IN THE AMERICAS

Fred L. Soper, Director
Pan American Sanitary Bureau
  Regional Office of the
World Health Organization


YAWS ERADICATION IN THE AMERICAS*

Development of the Haitian Method

Fred L. Soper, Director
Pan American Sanitary Bureau
Regional Office of the
World Health Organization

A great demonstration in public health administration has been
in the making in Haiti since 1950. The field: The eradication
technique as applied to yaws. The administrative staff: The Health
Department of Haiti, with international support. The beneficiaries:
The rural people of Haiti and, indirectly, the millions of people
in the world who still suffer from this disfiguring and crippling
disease and those who might get it. For the yaws eradication
program has served to orient the attack on this disease by the
health departments of many nations.

Yaws is a disease of the tropics, favored by high humidity and
heavy rainfall. Poverty, ignorance, over-crowding and lack of the
facilities for personal cleanliness all contribute to its spread.
Yaws is a non-venereal disease caused by a treponema so close-
ly resembling that of syphilis that the two cannot be distinguished
under the microscope. Unless treated, yaws may progress through
a variety of eruptions and ulcers, and in advanced stages may eat
through the flesh causing loss of a finger, a toe or the nose, leaving
ugly scars. Painful lesions on the palms of the hands and the soles
of the feet may incapacitate victims, often preventing them from
working or even from walking. The disease causes great economic
xs in addition to human suffering.
Today yaws in the Americas is largely a rural disease, cam-
paigns based on prolonged treatment with salvarsan having been
concentrated for the past quarter of a century largely in towns
and larger villages. The introduction of penicillin, which, in
single doses, cures a large proportion of cases and renders the
remaining cases non-infective for others, has facilitated treatment
of entire populations.

Five years ago yaws was the most important health problem in
Haiti, where nearly a million cases were estimated for the popu-
lation of somewhat over three million.
In 1949 the Government of Haiti requested the collaboration
of the Pan American Sanitary Bureau in planning a program for


the complete, final solution to the yaws problem. Previous con-
trol campaigns had served to reduce the number of cases tempo-
rarily, but such campaigns had been followed by a recrudescence
of the disease. Now Haiti insisted on eradication. The concf
of the program for the eradication of yaws in Haiti was essentia
similar to that developed in Brazil in the eradication of th%
yellow fever mosquito, AEdes aegypti, and later applied in Brazil
and in Egypt to the eradication of Anopheles gambiae, malaria's
most dangerous carrier.
The Bureau outlined a plan for the Government for the eradi-
cation of yaws with the technical collaboration of the Bureau,
and with material and supplies of UNICEF. Some months later
the World Health Organization came to participate in this plan
under a general agreement with UNICEF and another with the
Pan American Sanitary Organization. Thus it was that the Haitian
method of yaws eradication was developed through the collabora-
tion of the Government, the Pan American Sanitary Bureau, the
World Health Organization and the United Nations Childrens
Fund. The PASB/WHO contributed technicians who advised on
the organization of the campaign; UNICEF supplied needed equip-
ment, penicillin and vehicles; the Government supplied head-
quarters and personnel. Teams of workers were recruited locally
and intensively trained prior to the launching of the campaign in
July, 1950.
The eradication of yaws, in the public health sense, may be
accepted as accomplished when all transmission from ill to healthy
persons ceases, that is, when new infections no longer occur. The
importance of eradication as a concept for the solution of the
yaws problem can be appreciated only in the light of pre-existing
practice. Until only a few years ago the control of yaws was
limited essentially to the dispensary or hospital treatment of in-
dividual cases. This was extremely costly and failed to reach t!
great mass of cases in infected rural areas.
Haiti has demonstrated that the technique used in its campaign
can effectually eradicate yaws in a short period of time at a low
per capita cost. The approach has been on a total population,
rather than on an individual basis, with, as nearly as possible,
simultaneous single injections of penicillin to every infected person
in each district.  Since infected persons cannot be recognized
during the incubation period, all contacts have been treated. In
Haiti, all persons resident in infected areas have been classified
as  "contacts."  Fortunately the mass treatment of the rural
population has been both more rapid and less expensive than any
selective procedure could have been.
During the initial training and organizational stage of the eradi-
cation campaign in Haiti, the initially planned house-to-house
method required for complete coverage of the rural population

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could not be used. The first year's experience with temporary
field clinics showed that treatment centers fail to give adequate
population coverage for an eradication program. Some cases do
not reach these centers because they cannot walk, while others
lack the initiative to seek treatment away from home.
From October, 195 1 until the end of 1954, house-to-house
and family-to-family coverage were the basis of the campaign,
which was conducted along a solid front, continually broadening
and extending until it embraced all the infected areas. Post-
treatment surveys showed that the house-to-house campaign had
reached over 95 per cent of the population, and that very few
infectious cases had been missed. As a matter of fact, such sur-
veys have generally failed to reveal infection rates of more than
one half of one per cent.
With the reduction in yaws to a very low level, intensive mass
methods have been abandoned for a countrywide program based
on the search for infected individuals, with concentrated treatment
of population groups where infection persists. Haiti has been
divided into areas, with a trained insnector assigned to each area,
under appropriate supervision, to maintain a constant search for
cases among the inhabitants of his area.
In five years, yaws has been virtually eliminated from Haiti
and complete eradication shown to be feasible. Haiti has shown
that there is no excuse, with the present low cost of penicillin,
for the continued existence of yaws anywhere (the cost has been
only 30 cents (U.S.) per person treated-20 cents to Govern-
ment and 10 cents to PASB, WHO and UNICEF).
The day is not far distant when the presence of yaws will be
recognized as a public disgrace, seriously reflecting on the tech-
nical standing of local and national health services.
The economic benefits to the Haitian economy resulting from
the eradication of yaws, a disease that attacked a large percentage
of the rural population of this predominantly agricultural country,
handicapping and incapacitating many, are incalculable.
In the final analysis, the only safeguard against the re-introduc-
tion of yaws into Haiti, once it no longer exists there, is its eradi-
cation from other countries.
Fortunately, the striking success of the Haiti program has stimu-
lated the demand for similar eradication campaigns elsewhere,
campaigns, which are essential for the continued freedom of Haiti
itself from reinfection.
Encouraged by the success of the campaigns in Haiti, the health
administrations of Brazil and a number of the Caribbean islands
have requested the collaboration of PASB/WHO and UNICEF,
in the eradication of yaws. Plans for several of these eradication
campaigns are now in preparation. The eventual objective of the

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Bureau is, of course, the eradication of yaws from all of the
Americas.

Statistics on the incidence of yaws elsewhere in the Americas
are either lacking or incomplete. The incidence of yaws was higher
in Haiti than in other parts of the Americas, but the disease is a
serious problem in several other countries and other islands of
the Caribbean, particularly Jamaica and the Lesser Antilles. Yaws
extends also to the mainland in British and French Guiana and
in Surinam, throughout sections of Venezuela, of western Colom-
bia, of Ecuador and Peru, from the slopes of the Andes to the
Pacific and in some scattered rural areas east of the Andes.
Treatment campaigns in the contiguous infected areas of Ecuador
and Colombia have for some years been coordinated under the
auspices of the Institute of Inter-American Affairs, U.S. Inter-
national Cooperation Administration. In Bolivia high infection
rates of up to 50% are reported to have been greatly reduced
by treatment during the past 5 or 6 years. A few localities of
Central America are known to be infected.

Yaws is found in many parts of Brazil. It is a minor problem
in the south, but a serious one throughout the north, north-east
and eastern States, where, in certain areas, it is not uncommon
to find up to fifteen per cent of the population affected. Available
reports indicate from 350,000 to 500,000 cases in the known in-
fected areas in the States of Parai, Maranhxo, Ceara', Rio Grande
do Norte, Paracba, Pernambuco, AlagBas, Bahi& Espirito Santo,
Minas Gerais and Rio de Janeiro. Although control measures
have been in force for some years, the area of its distribution
in Brazil seems to be on the increase, due, in part, to the recent
migrations from the drought-stricken north-east to other parts of
the country.

Although much remains to be done, public health history will
surely register the fact that the eradication of yaws in the Ameri-
cas began with the decision of the Government of Haiti in 1949
to request the Bureau to prepare a plan for the final solution of
its problem.

The success of the yaws campaign in Haiti has served to stimu-
late interest in other health programs in the Republic, whose Gov-
ernment is one of the first to accept the challenge of the XIV
Pan American Sanitary Conference to transform malaria control
projects into a continental malaria eradication program.

Washington. LI. C., May, 1956


(BEFORE)

(AFTER)

Single penicillin treatmenf clears up yaws lesions
     in ten days fo fortnight

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