V.D. PROPHYLAXIS AND PREVENTION

by Maj. M. P. Vora
The Indian Practitioner
Volume No. XXXI, number. 5 of May 1978.
Page No. 221 to 225.

Paper read at the Second National Conference of the Indian Association for the Study of Sexually Transmitted Diseases and Silver Jubilee Celebrations of the Institute of Venereology (STD) at Madras in Dec. 1977.

IN SPITE of the availability of specific and effective drugs to cure both syphilis and gonorrhoea, there are more people with V.D. than before. This paradoxical situation is due to various reasons, which are beyond the scope of the subject. One factor which is seldom thought of is that the individual, who offers himself or herself at the risk of acquiring V.D. has available (but does not commonly use) means of protection, which require no intervention of a doctor.

A century ago, the use of 2% silver nitrate solution (Crede’s method of prophylaxis) came into use to prevent blindness in newly-born infants due to gonococcal infection during birth. Within the next thirty years, technics for preventing both syphilis and gonorrhoea in sexual contacts were introduced with encouraging results. Subsequent and prolonged trials have confirmed the usefulness of these mechanical and chemical means of prophylaxis. Though experience indicates a definite decrease in the rate of V.D transmission, prophylaxis against V.D. by various means has unfortunately received very little attention in the medi- or health- care. Hence, the urgency to heed this deficiency and attempt its correction.

While doctors use antibiotics to cure venereal diseases, this is of limited value unless the individual, when engaged in sexual relations, takes the responsibility of protecting himself or herself against the risk of passing on or acquiring a venereal disease. The agents to prevent transmission of V.D. are available and close at hand. If the disease shows up despite the prophylaxis, the individual must assume the responsibility and seek immediate medical help to protect himself or herself as well as his or her partner. It is, therefore, necessary to re-introduce and propagate the use of prophylactic measures and to make people aware of their advantages. They should be made to realise their responsibilities and induce to protect themselves during casual sexual encounters. Once the potential V.D. patient accepts their responsibility, there would be no need for an increased expenditure on V.D. or a massive increase in public health man-power for case-finding and treatment.

According to Dr. William M. Edwards, M.D., M.P.H. (1971), (Second International Venereal Diseases Symposium held at St. Louis, Missouri in 1972.) a study in controlled fashion was undertaken on Nevada prostitutes with ‘PROGONASYL’, a vaginal instillation, containing orthoiodobenzoic acid in a special oil base. The preparation successfully warded off not only venereal diseases but also bacterial and monilial infections, T.Vaginalis and pregnancy. It clearly showed a significant reduction in V.D. rate. There was no case of syphilis among them. To develop in our country, a prototype, a safe and effective topical preparation against V.D. for female use, is a very urgent need and ought to get top priority.

When properly employed, the condom as a V.D. prophylactic for the male is cent per cent effective against gonorrhoea and to a lesser extent against syphilis too. Some thirty years ago, nearly ten per cent of the males attending V.D. clinics used it as a contraceptive as well as V.D. prophylaxis. Today, in apparent contrast, less than two per cent males use condoms probably due to the use of pills or steroids to prevent pregnancy. Sexually active individuals can benefit both from contraception and disease prevention, but very few males seem to be inclined today to use rubber sheaths, which they consider unnatural, uncomfortable and interfering with sex. But these objections can be annulled by proper and adequate education. The condom has lately undergone many improvements in quality. High quality acceptable condoms must be made freely available and their use popularised by intensive propaganda. This is the only way to tackle the present decline in their use. The public must be urged to use them, especially during casual sexual relations.

Another measure, Epidemiological Procedure or ‘epi’ treatment is quite effective as a V.D. preventive. Giving preventive epidemiologic treatment to named contacts, who have no clinical evidence of V.D. on the first physical examination, has gained increasing acceptance in many countries. This is not a therapeutic measure and its selective use can be invaluable. Contacts of infectious patients can be the sources of V.D., even if the presence of disease is not established. Here, it is assumed that the people exposed to the proved V.D. cases are at risk and need prevention. Adequate treatment during the incubation period can prevent the development of clinical manifestations and thereby prevent the spread of disease to uninfected persons. Such a procedure can also provide protection against re-infection for a short period of time. The major thrust of V.D. control and prevention is the energetic application of epidemiological procedure routinely to all reported cases and their contacts.

In addition to epidemiologic procedure, surveillance activity plays an important role in the discovery of unknown V.D. cases. An extensive mass screening – serologic and bacteriologic (smears and cultures)- undertaken among vulnerable and high – risk groups (Age 15 to 40), applied at all levels of health and medical services, is the most efficient method in detection of early V.D. and identifying asymptomatic persons, who are often missed in detection of V.D. by mere clinical or physical examinations. It discloses the undiagnosed reservoir of infection in the population and acts as the most effective V.D. preventive. It is, therefore, imperative to adopt this novel concept as a national policy throughout the country. It provides an unparalleled opportunity to prevent disease in time and the compensation is so great that it fully justifies the efforts in screening tests. The patient comes to the doctor not because of a complaint or clinical sign but a laboratory dictum, which now stands as a cardinal manifestation of V.D. Asymptomatic carriers of V.D. probably represent a significant and potential source of infection. Hence every one, providing medical or health services must be able to offer this facility, V.D. education and information to his or her patients. The integration of these activities, therefore, into the general health services is essential. Public health care, family planning, primary health centres, gynaec departments, ante- and pre- natal departments, hospitals, diagnostic centres, laboratories and private medicine- all these have to work together in close co-operation. In fact, the private medical sector occupies the front line position in providing direct medical services to venereal patients. It is, therefore, in urgent need of recent knowledge and technics in the management of V.D. and prompt and reliable laboratory services as well. Doctors should be alert to V.D., should stress prophylaxis, try prevention and inform the public to avoid V.D. or if infected, to seek early diagnosis and treatment rather than remain infectious and spread the disease by continued sexual activity. The total disregard for personal and social dangers in individual sex behaviour springs from a lack of elementary knowledge that a long lag period exists between the time of exposure to the risk of infection and appearance of clinical manifestations of V.D. and that this period as well as the latency of a disease can be dangerous.

Few procedures in preventive medicine are as effective and inexpensive as the routine prevention of congenital syphilis. And yet there are hundreds of cases in the first year of life, the most distressing feature of present medicare. It indicates a total failure on the part of the public and private medicine to employ blood serology routinely in pregnant women. A couple of blood tests during the second and third trimesters of pregnancy should be obligatory to overcome the possibility of transmission of syphilis to unborn infants and prevent the disease in each case. Premarital and ante- natal blood tests should be made compulsory. Enforcement of these measures is not likely to pose any difficulty and the benefit will be much greater.

Venereal disease is fundamentally a behavioural disease, and affects predominantly sexually active persons. Its prevention is to be based accordingly on studies in human sexual behaviour. The key to the prevention of V.D. is the prevention of sexual promiscuity. Hence motivational research into human sexual behaviour assumes great importance and would provide considerable insight into various anomalies and abnormalities of human sex behaviour. Promotion of sexual maturity should be the aim of sex education, which has various aspects such as moral, biologic, physiologic, pathologic and social hygiene. Fear of V.D. or pregnancy does not influence the attitude of promiscuous adults, adolescents, youths and young men and women. During the mature reproductive life, the most fundamental of the human needs is sex – an undeniable fact. Sexual ejectivity in the male and receptivity in the female exert the most powerful physiologic effect on humans. To ignore this natural phenomenon would be unwise.

With increasing attempts to popularize prophylaxis and prevention, there would be an automatic and progressive reduction in the incidence of V.D. The key stone of V.D. prophylaxis and prevention is the prevention of the disease before it manifests itself clinically, serologically and bacteriologically. Both the patient and the contact are treated for the same purpose. Venereal disease is not necessarily accompanied by signs and symptoms. It may not have a single pattern of appearance and may present diverse features. Undiagnosed V.D. with few or no symptoms presents a major challenge to the practicing physician. The clinicians, therefore, must have a high index of suspicion, adequate knowledge, training and experience to recognize a variety of manifestations; to locate unusual sites of primary infection, and find out silent carriers of infection, who are the prime spreaders of disease. An early detection of venereal disease constitutes a medical emergency. Due emphasis, therefore, must be placed on the proper education of doctors, the public health personnel and the lay public.

Earnest efforts must be made to develop more effective and fool-proof methods of V.D. prophylaxis for both sexes. A high research priority must be given to this objective in view of its importance. Till the development of an effective vaccine against V.D. (and when it is accomplished, it will, indeed, be a great and a memorable achievement) one must continue to use the present methods of V.D. prophylaxis and preventive such as condom, chemical methods, epidemiological procedure and screening. With growing sexual permissiveness, the dangers of exposure to V.D. will increase. The sexual relationship between the female taking pills and the male not using condom may well be one reality of the sex behaviour of the educated youths and middle-class people. Hence the rise in V.D. in these groups becomes inevitable. V.D. prophylaxis and V.D. prevention by epidemiological procedure and screening demand a close and serious attention in the provisions of general medical and health services and in the V.D. control programmes of the Country. The old adage, prevention is better than cure, is worth remembering.