V.D. CONTROL IN GREAT BRITAIN

by Maj. M. P. Vora, M.B.B.S., D.V.D.

Former Hon. Senior Venereologist,

St. George’s Hospital, Bombay.

Current Medical Practice

A monthly journal devoted to Modern Medicine and Surgery.

Volume No- 20, Number – 8 of August 1976.

Page no. 358 to 362.

The investigation and management of venereal diseases has undergone great changes during the last few decades and has become increasingly specialised, requiring special skills and technics. The need for combined and coordinated approach by different categories of workers has become essential to solve difficult and complicated problems connected with V.D. The concept of unification of medical procedures has taken a step further with the formation of teams or units, which include various categories of workers such as teachers, clinicians, residents, trainees, researchers, investigators, bacteriologists, virologists, technicians, social workers, educators etc. The facilities thus established have distinct advantage both to the patient and doctors. They offer opportunities for perfecting special techincs, advancement of knowledge, research and post-graduate training.

An efficient organisation has been built over the year and considerable labour, resources and thinking have gone into it during the period. The Public Health (Venereal Diseases) Regulation of 1916 defined V.D. as syphilis, gonorrhoea and chancroid and made it imperative for the individual practitioner to have an adequate knowledge of the subject. In no other department of medicine is there greater responsibility on the practitioner to maintain a constantly high index of suspicion as to the possibility of V.D. and to detect or exclude infection at the earliest possible moment and bear in mind dangers of neglect of adequate treatment, contact-tracing and tests of cure. British venereologists have been proud to remain venereologists to serve a despised and neglected subject and by giving their best and leaving the subject far better than they found it, have earned the respect of their colleagues. They have concentrated on improving and if necessary, extending their works in their own region and diseases. They find work time-consuming, fascinating, sufficiently rewarding and have achieved high standards of medical service, contact-tracing and V.D. control. Only by this way is respect to be achieved not by calling something else and changing the labels on the doors. Any change in the name will increase the confusion of the public still further, will soon acquire the stigma and certainly do nothing to help V.D. patients, so long as our attitudes to V.D. remain unchanged. They do not regard V.D. as a just punishment or sin. They realise that most major advances in medical knowledge come about as the result of specialisation and that this trend is essential, if the knowledge was to advance and the sick were to get modern and expert line of treatment and recover quickly from illness. They sincerely believe that there is, therefore, sufficient justification for making venereology as a separate speciality and maintaining it so. To their credit, they have British Journal of Venereal Diseases, the Institute of Technicians in Venereology and its Bulletin. Both are regularly published, widely read and highly esteemed. They have also adopted a special neck-tie, Venereology Tie, for all those who work in venereal clinics, to promote a team spirit. They could infuse abiding interest and dedication in young doctors, imprint a profound and induring conviction of the importance of venereology. In a short span, a continued chain of dedicated venereologists, some of them well known in the world, have been produced. This is an unquestionable testimony to the importance given to the subject in that country. According to Dr. C.S. Nicol (1971) Britain has 2.5 cases of syphilis and 54 cases of gonorrhoea per 100,000 population and the seropositivity rate of 0.025 per cent.

The venereal diseases control measures can be classified under three headings:

• A nation-wide net- work of clinics for early diagnosis and treatment;
• Nation-wide facilities for speedy contact-tracing and
• Public and professional education on V.D. All three elements are inseparably associated.

Of these, public education is at present not as effective as it should be, though it is increasingly recognised as the element with the greatest potential and the real key to the ultimate solution. It is being continuously expanded and multiplicity of approaches are devised. It has been the policy to maintain and expand such education in schools, colleges and high-risk groups through news outlets, mass communication media like films, radio, T.V. newspapers, magazine and communications. Permanent mobile exhibitions have been constructed and 24 hour telephone answering services have been installed. A few objective means are available to evaluate the effects of these on V.D. The case load of gonorrhoea in V.D. clinics in England and Wales has shown a great upsurge i.e. increase of 25 per cent in males and 118 per cent in females. These findings confirm a growing degree of sexual freedom in the U.K., which has affected the attitudes and behaviour of girls and young women more than boys and young men. This is conclusively proved by changing male: female ratio in clinics in England and Wales over the period i.e. 4:1 in 1960 to 2.2 to 1 in 1970. A part of this change may be attributed to educational efforts. Patients are promoted to attend clinics by propaganda over the mass media, local advertisement, notices fixed in prominent places like post-offices, railway stations, public urinals and word of mouth. The most precise index of measurement is the number of people infected with gonorrhoea.

The greatest local efforts have been directed at the young at the schools and colleges. Almost all these are now involved in V.D. education and information. The percentage of teenagers infected with gonorrhoea has not been very high. One other index i.e. duration between the onset of urethral discharge and seeking medical help shows substantial reduction. Early reporting is now common. Men aged 25 years and over show that they are fully informed and have adequate knowledge of V.D., while women of the same age show the least knowledge of the subject. It is observed that television programme, educational lectures and articles published in newspapers frequently produce a crop of anxious patients within a couple of days. Today, young people are better informed. As a source of contact data, they are much more frank, uninhibited and honest than they used to be in the past. Public education and information do have a positive effect on the control of V.D. The effects have apparently been most marked in young females and these are the individuals whose sexual activity has increased most markedly in recent years, due to easy availability of safe and effective contraceptives.

In Great Britain, free treatment for all sexually transmitted diseases (S.T.D) including those labeled “venereal” is provided in specific clinics, under the control of National Health Service. Attendance is voluntary. All treatment is confidential. All patients are under the care of a specialist in venereology. Under the National Health Service Act of 1944, venereology is recognised as a speciality in its own right and venereologists have been accepted as experts in S.T.D. or venereology. National Health Services New Regulation of 1968 made compulsory reporting of venereal cases, contact-tracing and education (a) of medical profession and (b) of the public in general. Whenever N. gonococcus is isolated and identified or a reactive serologic test for syphilis is reported, the local doctors make it a point to send copies of laboratory reports to the venereologists in the area. Medical confidence and the highest degree of doctor-patient rapport and relationship are scrupulously maintained. In almost every case, the V.D. patient is referred to the venereologists for contact-tracing and surveillance, if not for treatment. There are some 350 clinics in London alone.

Over the years, the public has found that the best medical care and treatment for sexually transmitted diseases can be obtained at such special clinics. Both the government and the public acknowledge that S.T.D. are social in nature, requiring not only medical but social management also for their control. This medico-social management is provided by a specialised team. On the medical side are venereologists, registrar, trainees, resident, nurses, technicians and adequate and efficient laboratory service. On the social side are social workers, health visitors, investigators, welfare workers and community nurses. Together medical specialists provide an accurate diagnosis – both bacteriologic and anatomic- based on thorough case history, careful clinical examination and taking of necessary specimens for laboratory use. In this way, the correct treatment is given to each patient. This offers better disease control, reduces failure rate and complications. The care and consideration the patients receives in the clinic helps to build up their good will, an essential requirement, if they are to co-operate later with social workers and investigators responsible for contact-tracing efforts or getting defaulters in treatment to attend clinics to complete the treatment. Contact-tracing is an integral part of the service. Efforts are based on accurate diagnosis. In general no treatment is given without confirmation of diagnosis, on which depends the appropriate therapy. Prophylactic treatment, whenever successful, carries with it grave risk that infective contacts remain undiscovered; hence it is not generally advised except under special circumstances. Interviewing of confirmed V.D. patients is carried out in strict privacy by women, specially trained in the job. They are found to do good work and obtain more accurate information from male patients.

Separate premises, well away from the special clinics are usually available for the examination and treatment of the “Innocent” partners- usually wives. Doctors and workers are fully aware of their responsibilities and usually helpful. They know that it is not their job to break marriages or stable relationships and ensure that all at risk are examined and if necessary treated in complete privacy. They carefully avoid causes that may disturb the family affairs or relations.

During the interview with the patient, the contact-tracer either asks the patient to bring the contact to the clinic or gives the patient a card to present it to the contact. The card includes address of the local clinic, telephone number, working hours and a code for the name of the contact and the patient’s diagnosis. At times, the contact-tracer either visits or phones the contact or leaves a message to phone a certain number and ask for a certain person. When the contact calls back, he or she is urged to have an examination and investigations. This work of interviewing contacts, their identification, examination and treatment if necessary is done consistantly with tact, speed and thoroughness on a nation-wide basis. It is a full time occupation for the doctor and the investigator, involves careful handling, prolonged and repeated interviews of contacts and their contacts in turn and persuading them to submit to an examination, tests and treatment if necessary- an enormous job indeed. This has a tremendous effect on the V.D. morbidity rate. Its effectiveness can be illustrated; from one case of gonorrhoea, a record of 1,639 people were found infected and treated, thus removing the great reservoir of infection from the community.

Appointments to attend special clinics or separate premises are given to the patients concerned or contact’s general practitioner. In the former case, the patient gives the contact a card to take it to the clinic at the stated date and time. In the latter case, the medical practitioner in consultation with the contact-tracer makes an appointment at the clinic. No two persons are given the same time. Services are available at all times. The usefulness of contact-tracing, efficient medical service and other V.D. control measures in Great Britain is reflected in relatively lower incidence of syphilis and gonorrhoea as compared with that of other countries of the world.

The incidence of V.D. among men and women is reported separately. Non-specific urethritis (NSU) in men exceeds gonorrhoea; while T. vaginalis is almost as common as gonorrhoea in women. Other S.T.D. represent a greater problem than does real V.D. Venereal diseases i.e. syphilis and gonorrhoea account for less than quarter of the clinic load. The other sexually transmitted diseases account for over half. In those patients attending clinics in England, the percentage found free from venereal disease (NVD) is greater than the percentage found to be infected. This does not hold true for Scotland. The fact that a large number of persons with no V.D. attend clinics clearly disproves a myth of stigma attached to V.D. based on misconception and false attitude- which need urgent modifications.

In Great Britain generally, the control of other S.T.D. now possess a greater problem to the venereology service than does that of the classic V.D. themselves.

Note- The tables are taken from and the article is based on the proceedings of the Third International Symposium on V.D. 1973.

*New cases of S.T.D. reported in England and Scotland during 1971. Rates/100,000 population.

*The percentage distribution of the board diagnostic categories of new cases reported in England and Scotland during 1971.

Abbreviations:

N.S.G.I. = Non- specific genital infection

N.S.U. = Non- specific urethritis

T.V. = Trichomonas vaginalis

S.T.D. = Sexually transmitted diseases

O.S.T.D. = Other sexually transmitted diseases

N.V.D. = No venereal disease

The basis of contact tracing

• Accuracy of diagnosis. No treatment without diagnosis.
• Interviewing of patients about contacts by women in privacy.
• All information given is treated as confidential.
• Separate premises are used for examination and treatment of “innocent” partners.

The methods used in contact tracing

• The patient brings the contact or is given a card to present it to the contact.
• The contact-tracer visits or phones the contact.
• An appointment is made for the contact to attend either through the patient or the contact’s own doctor.
• A contact tracing form is sent to another special clinic.
• International contact tracing – information is sent direct to the venereologists concerned or via a nominated doctor in the medical executive of the Central Government.