Yaws: Neglected and Abandoned?

Time to Re-Emerged

Erda Avriyanti, Pati Aji Achdiat

Department of Dermatology and Venereology, Faculty of Medicine,

Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung 40161, Indonesia

Keywords: epidemiology, South East Asia, Treponema pallidum subspecies pertenue, yaws

Abstract: Yaws, a disease caused by Treponema pallidum subspecies pertenue infection, is a neglected tropical

disease. Until now, yaws is still one of the public health problems in South East Asia, even though it had

been forgotten before. But, recently it has re-emerged once again. Yaws becomes the aim of the mass-

treatment eradication of World Health Organization (WHO) by 2020 through the mass-treatment program.

The main target of the success of this campaign is a good knowledge of the disease epidemiology. We

undertook a review of the historical trends and new information from endemic countries, with a point of

view to assessing the state of knowledge about yaws. The plague of yaws now exists in Africa, Asia, and the

South Pacific. About 12 countries establish as endemic countries, one of them is Indonesia that located in

South East Asia region. Between 2008 and 2012 more than 300,000 new cases into the WHO. Based on

Ministry of Health Regulation Republic of Indonesia No. 8 in 2017 on eradication of yaws, it is necessary to

administer continuous, effective, and efficient program. Several dilemmas of yaws are low levels of

reporting, potential misdiagnosis, and limited documentation on the prevalence of asymptomatic infections.

The current data is likely to underestimate the agonize of the disease. Thereupon, more effort is needed to

improve the current interactive data, that is likely to have positive vibes on yaws eradication plan.

1 INTRODUCTION

Yaws or also called framboesia, pian, buba, paru,

parangi,(Perine et al., 1984; Marks et al., 2015) or

patek (GREEN and HARMAN, 1986) is an

infectious disease caused by Treponema pallidum

subspecies pertenue (T. pallidum subsp. pertenue),

also have a close taxonomy with Treponema

pallidum subspecies pallidum (T. pallidum subsp.

pallidum), as syphilis causes.(Marrouche et al.,

2012) The yaws term was first introduced by the

Dutch physician Willem Piso in the seventeenth

century to describe the clinical picture of the disease

in South America from the term ulcers which in

Carib are yaya.(Piso and Marcgrave, 1648) Its

clinical picture resembling raspberries, so it is also

known as yaws derived from the French "framboise"

which means raspberry.(Marks et al., 2015)

The clinical features of yaws are divided into

several stages, namely primary, secondary, latent,

and tertiary stages. The available serological tests

cannot distinguish between yaws and syphilis.

Though yaws has different characteristics with

syphilis, such as in the form of basic ulcers of dirty

lesions, the size could reach 5 cm, pain, and itching,

and have a predilection in lower limbs. If left

untreated, the lesion may become chronic and

destructive,(Marks et al., 2015) causing potentially

disability, pain, and social problems in the

patient.(Marrouche et al., 2012) Other things that

distinguish yaws with syphilis include geographic

distribution, patient’s age characteristics, non-

venereal type of transmission, that is transmitted

through skin contact rather than sexual contact, and

the clinical picture of the disease.(Mitja et al., 2013;

Marks et al., 2015)

Yaws generally attacks children who live in the

tropical area.(Marrouche et al., 2012; Marks et al.,

2015) This disease is still a public health problem in

Indonesia as a tropical country in terms of

eradication of yaws. The World Health Organization

(WHO) aims to eradicate yaws by 2020, which

consists of an initial mass treatment of endemic

communities followed by surveys every 6 months to

actively detect and treat remaining cases and their

contacts.(Marks et al., 2015) The changed of use of

a single oral dose of azithromycin from benzathine

penicillin injection has made mass treatment more

Avriyanti, E. and Achdiat, P.

Yaws: Neglected and Abandoned? Time to Re-emerged.

DOI: 10.5220/0008154902450248

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 245-248

ISBN: 978-989-758-494-7

 2021 by SCITEPRESS – Science and Technology Publications, Lda. All rights reser ved

245

feasible and is currently recommended in areas

where yaws is prevalent. Due to benzathine

penicillin injection therapy has several

disadvantages such as causing pain in the patient,

difficulties of drug storage process, and limited

supply so that oral azithromycin is preferred.

Indonesia is the only country in Southeast Asia to

report cases of yaws in WHO report year

2012.(International Symposium on Yaws and Other

Endemic Treponematoses, 1985) Based on Ministry

of Health Regulation Republic of Indonesia No. 8 in

2017 on eradication of yaws, it is necessary to

administer the continuous, effective, and efficient

program.(The Ministry of Health Republic of

Indonesia, 2017) One of the key determinants of the

success of the eradication campaign is a good

understanding of the disease epidemiology,

particularly its geographic distribution and risk

factors. Based on the description above, this review

hopefully could be an insight of accurate of yaws

specifically in Indonesia region.

2 THE ORIGIN OF YAWS

Yaws has been known since the early 16th century

that happened to slaves in Spain. In the 17th century,

the disease was reportedly suffered by slaves in

North America. In the early 1950s, an estimated 50-

150 million people worldwide experienced yaws.

(World Health Organization, 2013) Approximately

75% of patients are children aged less than 15 years

(peak incidence occurs in children aged 6-10 years).

Men and women have the same opportunities for

this disease. (World Health Organization, 2006)

At least 90 countries have reported endemic

yaws,(Hackett, 1989; World Health Organization,

2013.) especially in Africa with an incidence rate of

over 10,000 cases per year, and the highest

incidence is reported in four countries: Ivory Coast,

Ghana, Cameroon and the Congo reaches more than

100,000 cases per year.(Hackett, 1989) In Asia,

however, yaws was reported in areas of India, China,

Thailand, Cambodia, Laos, Malaysia, and

Indonesia.(Kazadi et al., 2014)

In the mid-1950s and early 1960s, WHO

undertook a worldwide mass treatment of yaws

around the world with benzathine penicillin injection

treatment that dramatically decreased the prevalence

of the disease.(Mitja et al., 2013) Since 1990,

reporting to WHO was not mandatory because it did

not become endemic anymore in many countries, so,

epidemiological data becomes very limited. But,

based on the WHO report up to 2013, 12 countries

were reportedly endemic, consisting of 8

countries in Africa namely Benin, Cameroon,

Central African Republic, Ivory Coast, Republic of

Congo, Democratic Republic of Congo, Ghana, and

Togo; three countries in the Western Pacific region

namely Vanuatu, Papua New Guinea, and the

Solomon Islands; and one country from the

Southeast Asian region, Indonesia (Figure 1). (Mitja

et al., 2013; Kazadi et al., 2014)

Figure 1. Worldwide distribution of yaws in 2012.(Kazadi

et al., 2014)

In 1950, according to WHO, cases of yaws in

Indonesia occurred in Aceh, Jambi, Bengkulu, South

Sumatra, East Java, and most of Eastern Indonesia

covering Nusa Tenggara, Sulawesi, Maluku and

Papua.(World Health Organization, 2006) The

decrease of yaws cases prevalence in Indonesia was

significantly reported in 1995, from 2,210 per

10,000 population in 1985 to less than 1 case per

10,000 population in 1995. In the report, it was

found that the number of cases in Java and Sumatera

in 1995 was less than 0.1 cases per 100,000

residents; while in East Indonesia, Papua, Maluku,

East Nusa Tenggara, and Sulawesi, the number of

cases of yaws was still more than 1 case per 100,000

population.(General Directory of Disease Control

and Health Environmental, 2005) In 2004, there

were 4,015 cases of yaws in Indonesia. While in the

period of 2008, there was an increment of yaws

cases became 5,926 cases in Indonesia, with the

highest prevalence in East Nusa Tenggara, Maluku,

and Papua. Figure 2 shows the spread of yaws cases

especially in Indonesia, that prominently found in

the province of East Nusa Tenggara. During the

period 2010-2013, reported cases of yaws as many

as 13,084 cases.(Mitjà et al., 2015)

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Figure 2. The distribution of yaws in South East Asia in

period of 2010-2013.14

3 NEW SPIRITS FOR

ERADICATION

In 2014, there were 1,521 cases of yaws reported in

Indonesia, particularly in Banten, East Nusa

Tenggara, Southeast Sulawesi, Maluku, Papua, and

West Papua provinces.(The Ministry of Health

Republic of Indonesia, 2017) The 2012 serological

survey results in several districts/municipalities

indicated that the prevalence of yaws ranged from

20-120 per 100,000 population aged 1-15 years.

Some areas with a history of endemic of yaws, such

as Aceh, Jambi, and South Sumatra provinces, did

not report any presence of yaws, but it could not

ascertain those regions as free area of yaws.(The

Ministry of Health Republic of Indonesia, 2017)

Indonesia has point of target for yaws eradication by

2017 (following global target) using active and

passive case detection and prompt treatment; some

of the major problems faced by the program include

the difficulty of reaching endemic communities scat-

tered over many small islands.

Indonesia has a combined yaws and leprosy

programme which functions under the Sub-

Directorate of Leprosy and Yaws. This allows for

the use of common resources to detect and manage

both diseases at national, provincial and district

levels.

Recently, in the early year of 2017, several

regions in Indonesia have been visited by WHO

team to assess eradication efforts and review the

implementation of the national elimination plan.

After achieving interruption of transmission of yaws,

a country needs to report zero yaws cases for three

consecutive years and provide serological evidence

to support the interruption of transmission in

children aged 1-5 years in order to request yaws-free

status by WHO. Indonesia and East Timor are the

only two remaining yaws-endemic countries in

WHO’s South-East Asia region.World Health

Organization, 2006 Furthermore, in West Java,

Indonesia, yaws patients were detected in Baduy

village people, the disease itself are prone to the

communities live there, since the people still have

culture and habit of not aware of the hygiene of the

environment. Thus, seeing those phenomena, the

eradication program of yaws should have more

concern related with the prevention and

management.

4 CONCLUSIONS

The accurate data is likely to exclude

underestimation of the agonizing of the disease.

Therefore, more works are needed to improve the

current interactive data, that is likely to have better

on the impact on yaws eradication plan, to emerge

another point of view of yaws. Then, yaws should

not be forgotten, because of this disease still around

us.

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