Sexually Transmitted Diseases
Reference: Maxcy-Rosenau 13th Edition. Chapter 6 -Page 99
MMWR - CDC
[Note the questions/considerations can be answered on the discussion web]
Sexually Transmitted diseases since 1945 (W.W. II)
These diseases have been written about for more than 4000 years!
Until W.W.II (Archie Bunker’s War!) the most commonly diagnosed STDs were gonorrhea and syphilis. While there were several others, these were the ones on which most emphasis was focused. Some medical staffs refused to treat individuals with STDs believing the diseases were punishment for immoral behavior. The only treatment for Gonorrhea was irrigation of the urethra with silver nitrate solution. This left permanent strictures that had to be dilated at least once weekly. A drop of a weak solution of silver nitrate was routinely used to cleanse the eyes of newborns to prevent blindness from GC infection, which might occur during passage through the vagina. Treatment for Syphilis was injection of multiple doses of bismuth and arsphenamine. These materials could be seen at deposits in the gluteal muscles on X-ray.
Because syphilis infection during pregnancy frequently led to congenital deformity of new born children, premarital testing became required (since 1945). Syphilis remains dormant for years during the tertiary stages until it erodes joint, blood vessels or the brain as part of its final destructive effects. Health departments developed clinics for diagnosis and treatment, because many people did not wish to go to their doctor for treatment of an "immoral" disease, and because so many physicians treated the diseases poorly. Similarly, at the end of W.W.II many GIs failed to report STDs, because of mandatory punishment meted out by the U.S. Armed Forces Disciplinary Board.
Just prior to W.W.II penicillin and sulfa drugs were developed. They revolutionized the treatment of gonorrhea and syphilis. Initially CC could be treated with a single dose of 20,000 units! Syphilis needed 2 to 3 doses of a slightly higher level. Until the 1950s and early 1960s it was still common to see patients with tertiary syphilis and ‘Charcot’s joints’, Aortic aneurysms, and General Paresis of the lnsane (GPI.) Skin rashes and aortic aneurysms were considered pathognomonic of syphilis until proven otherwise. It was because of the early skin rashes that syphilology became a subspecialty of dermatology. Additionally, until the mid 1950s tertiary syphilis was often treated with "Fever Therapy!" The patient was given a dose of malaria infected blood to induce a high fever which killed the heat sensitive syphilis bacterium (at about 106-7 degrees if the fever did not kill the patient!
In the 1960s, we believed we could eliminate STDs! We did not believe that people would fail to change their behavior when given clear information about the deadly effects of a disease that was both preventable and curable. [Think about information you may already have about disease & behavior] Although penicillin worked and worked well GC has become fairly resistant to penicillin, and a number of other drugs. Penicillin is still the choice for syphilis.
Despite decades of research we have failed to find an acceptable animal model for these diseases which can be sued to study treatment and develop vaccines. Most diseases confer protection after curative treatment. Recurrence of syphilis is rare if treated properly. Appropriate treatment is still a problem in many primary physician’s offices today. It is difficult to culture syphilis, We still use blood tests for antibodies and antigens [Think about why states stopped premarital blood testing]. A good blood test for GC still eludes us. Despite careful follow-ups with demonstrated cures, a single individual can become infected with gonorrhea many times a year. It is not an innocuous disease. It can and does kill. Moreover, it is now frequently resistant to penicillin and other drugs. [Why and when should quarantine be used? Should treatment be mandated?]
Since the 1950s many other STDs have been identified and become ‘politically’ popular. These include Herpes, Chlamydia Trachoma, Hepatitis-B (precursor of liver cancer), Human Genital Papilloma Virus (a probable precursor of cervical cancer), and HIV. Other disease that are often transmitted during sex include TB, and many of the intestinal flora, due to lack of hygiene and variety of sexual practice by individuals interests in each other’s various organs and orifices. Fifty years ago, we thought of sexual relations as only involving the ‘missionary’ position. Masters & Johnson’s research stimulated exploration of individual sexual behavior. These studies removed taboos about sexual practices, previously viewed as deviant. The changes in behavior leading to STDs however, did not occur. Few people (male or female) accepted responsibility to protecting either oneself or partner from mutually communicated diseases. With use of the contraceptive pill males saw little need to use condoms. It took a decade for infectious disease medical staff to realize that STDs were increasing in variety. How quickly we forgot what history had taught us about these diseases!
In 1980 we started getting reports of Kaposi’s Sarcoma (a rare skin cancer usually seen among older Jewish males) among a small group of homosexuals on the west coast. This rare disease was not usually seen in clusters. Just like other ‘newly recognized’ diseases, once we started looking, we found more of this disease. Concurrently, we found significant debilitating disease and a sudden increase in frequency of death among homosexual males from destruction of the immune system. The public health system failed to respond rapidly, probably because the disease appeared to be limited to a small west coast ‘deviant’ group. Over the next 18-24 months epidemiologists identified the disease as blood borne, and similar in transmission to syphilis and hepatitis-B. The news media published stories and identified fringe pressure groups who wanted immediate answers (irrespective of scientific capability) that could not be provided.
As news about the disease spread by word of mouth, and the printed, audio and visual media this disease was given extensive exposure. The impression was given that rather than this being one more STD which could easily be prevented by appropriate behavioral intervention media, it was portrayed as the impending destruction of civilization..
State Health Commissioners were besieged by legislators to allow only those with pure (clean) blood to be married. This was the 1930 approach to syphilis all over again. Many children (such as Ryan White) who had either HIV (not AIDS) or came from a family with a member with HIV were banned from school and attempts made to throw families out of the community. Quarantines similar to those used on lepers centuries ago, or during the time of the Black Death, were invoked. The public health community had great difficulty recommending any rational approach to limiting the spread of HIV infection.
Physicians and nurses would not talk to, or treat, individuals with HIV or AIDS. They wanted then locked up in a Class IV infectious disease control chamber. Unscrupulous individuals threatened to throw their blood on people if not given money, or threatened to bite law enforcement officers who tried to arrest them.
Communities wanted special laws against prostitutes who might transmit disease. In Alexandria, Virginia, the Commonwealth's attorney found he had no ability to restrict (quarantine) an activist prostitute who loudly proclaimed her intent to keep on working, in spite of an active HIV infection. Others wanted any place where gay people congregated closed down (particularly bath houses). Symbolism was (and still is) more important than reality.
The HIV virus, like Hepatitis B, or like the Syphilis bacterium or malaria trypanosome is blood born. It can be passed in transfusions not tested for antibody or antigen. There is treatment for syphilis and Malaria, and immunization to prevent transmission of Hepatitis B. One issue that arose was a potential for transmission by mosquitoes, just as malaria is spread by mosquitoes.. We can control prevalence of mosquitoes. In the U.S., you are far more likely to be given encephalitis by a mosquito bite than Malaria. There is no evidence of transmission of HIV by mosquitoes. Now some groups wanted all HIV positive individuals and homosexuals excluded from any community with mosquitoes present! HIV is very easy to kill. Very small doses of chlorine or exposure to air kill HIV rapidly.
Many individuals involved in homosexuality were also involved in drug abuse, particularly abuse of cocaine. HIV quickly spread among intravenous drug abusers. This is now a prevalent form of transmission in many communities.
Finally, another basic premise of epidemiologists, herd exposure. In this theory a disease spreads among a herd only in relation to the proportion of susceptible individuals in the herd. A number of epidemiologists noted that the disease was not an airborne transmission, like measles. That the susceptible herd (once blood was rendered safe) was the herd of homosexuals and heterosexuals involved in anal sex, and injecting drugs. They estimated that because of the long latent period of the disease that it would be 10-15 years before the disease started to peak and decline. This is now occurring. The peak appears to have occurred in the homosexual community (although a cohort of younger homosexuals who have not yet seen their friends die are having sex without protection). There has been no peak yet in the drug abusing or heterosexual groups, but they are a much larger group. We now have treatment which, while not as effective as we would like is starting to show he value of prophylactic use of the available drugs, particularly by pregnant HIV positive women with a very significant decrease in transmission of the disease to the newborn.
We failed to accept the lessons shown by history. We have repeated all the worst behaviors seen in working with Lepers, Syphilitics, and Malaria. We failed to get the story of the epidemic across in a non judgmental way to the public. The media did great disservice to everyone, as did the activists who made journalistic sound bites. Perception is still more important than science to the media and to many politicians.