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Syphilis resurgent in China
Comment
Syphilis resurgent in China See Articles page 132
Syphilis was a major cause of morbidity and mortality during the past 500 years and perhaps earlier.1 Penicillin treatment for syphilis substantially reduced prevalence in many countries, and the elimination of syphilis is thought to be an achievable goal, at least in the developed world.2 However, to paraphrase Mark Twain, rumours of the demise of syphilis seem to have been exaggerated. In today’s Lancet, Zhi-Qiang Chen and colleagues report a striking resurgence of infectious and congenital syphilis in China.3 This study follows on the heels of the increased incidence of infectious syphilis in the USA, Canada, and Europe,4,5 and it might seem that China is in a similar position to other economically vibrant areas of the world. However, resurgent syphilis in China has particular resonance because it epitomises the reversal of publichealth achievements (such as near-eradication of sexually transmitted diseases) from the decades after Chinese Communists came to power in 1949.6 For syphilis, public-health successes occurred after the introduction of a collective centralised economy. Furthermore, key components of apparently successful public-health programmes included both laudable measures (eg, elimination of debt in the peasant population to reduce the likelihood of women being sold into prostitution),6 and those regarded as draconian (eg, incarceration of sex workers in so-called re-education camps).7 The resurgence of syphilis occurs in the context of China’s explosive economic growth, which has been accompanied by: re-establishment of the sex trade;8 increased internal migration and inequalities in income;
Science Photo Library
The printed journal includes an image merely for illustration
Treponema pallidum
84
and profound under-investment in the infrastructure for public health9—all of which may facilitate spread of sexually transmitted infections such as syphilis. Moreover, the very success of China’s earlier efforts to control syphilis probably created a population that was highly susceptible to infection with Treponema pallidum, further augmenting disease transmission.10 In both relative and absolute terms, the 25-times increased risk of syphilis reported by Chen and colleagues dwarfs that seen in the USA, Canada, and Europe.4,5 Furthermore, the resurgence of congenital syphilis, which translates into about 3400 infected infants a year in China,3,11 adds an additional dimension to this tragedy. Under-reporting, which is common with sexually transmitted infections, may mean that the true situation is worse. So should we lament the passing of an era of heavy-handed, but apparently effective, publichealth intervention in China? Or should we regard the resurgence of syphilis as an unfortunate, but expected, consequence of increasing commercial freedom and overall prosperity in China, which might ultimately improve population health? The answer, predictably, is complicated, and highlights the tensions between effective disease-control activities, commercial freedom, prosperity, and individual rights, not only in China, but also globally. The link between commercial activity and transmission of infectious disease has a long history. Because epidemics depend on the introduction of a pathogen into a susceptible population, it is not surprising that global events associated with mass movements of people and goods have seen the concomitant emergence of new threats of infectious disease. Major historical challenges to public health and subsequent advances in the control of communicable disease frequently emerged in important trading centres—eg, 14th century Venice, Italy; 19th century London, UK; and 20th century New York, USA. Current challenges in Chinese population centres fit this pattern. Can China win this fight? A complete return to centralised programmes of public health that disregard individual rights and freedoms is neither desirable nor likely. China might look to emulate models of disease control from countries that have tried to maintain the delicate balance between rights of the individual and www.thelancet.com Vol 369 January 13, 2007
Comment
those of the community for control of communicable disease. In many countries, this balance is maintained through statutes that restrict individual rights for the purpose of communicable-disease control, but which are used rarely, such that their existence may come as a surprise to many citizens.12 China and other countries must accept that disease control is an issue of public good that cannot be achieved through market forces alone.13 Investment in infrastructure for public health that respects individual rights and freedoms will give China and other countries the seatbelt necessary for safe travel on the global economic superhighway. David N Fisman Research Institute of the Hospital for Sick Children and Ontario Public Health Laboratories Branch, Toronto, Ontario, Canada M5G 1E2 david.fi[email protected] I declare that I have no conflict of interest. 1
Quetel C. The history of syphilis. Baltimore: Johns Hopkins University Press, 1990.
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7 8
9 10
11
12 13
Rompalo AM. Can syphilis be eradicated from the world? Curr Opin Infect Dis 2001; 14: 41–44. Chen Z, Zhang G, Gong X, et al. Syphilis returns to China: results of the national surveillance program from the Chinese Center for STD Control, Nanjing, China. Lancet 2007: 369: 132–38. Weir E, Fisman D. Syphilis: have we dropped the ball? CMAJ 2002; 167: 1267–68. Payne L, Berglund T, Henriksson L, Berggren-Palme I. Re-emergence of syphilis in Sweden: results from a surveillance study for 2004. Euro Surveill 2005; 10: E051110.1 http://www.eurosurveillance.org/ew/2005/051110. asp#1 (accessed Dec 18, 2006). Cheng T. Disease control and prevention. In: Wegman M, Lin T, Purcell E, eds. Public health in the People’s Republic of China. Philadelphia: Wm F Fell, 1973: 185–207. Hualing F. Re-eduation through labour in historical perspective. China Q 2005; 184: 811–30. Hesketh T, Zhang J, Qiang DJ. HIV knowledge and risk behaviour of female sex workers in Yunnan Province, China: potential as bridging groups to the general population. AIDS Care 2005; 17: 958–66. Blumenthal D, Hsiao W. Privatization and its discontents—the evolving Chinese health care system. N Engl J Med 2005; 353: 1165–70. Pourbohloul B, Rekart ML, Brunham RC. Impact of mass treatment on syphilis transmission: a mathematical modeling approach. Sex Transm Dis 2003; 30: 297–305. US Central Intelligence Agency. The world factbook 2006. China. http://cia.gov/cia//publications/factbook/geos/ch.html (accessed Dec 18, 2006). Kalogerakis G. TB carrier threat to public, MDs say: court asked to force treatment on him. Montreal Gazette Nov 29, 2000: A1. Garrett L. Betrayal of trust: the collapse of global public health. New York: Hyperion, 2000.
Phenotype and coronary outcome in Kawasaki’s disease Kawasaki’s disease continues to be a diagnostic and prognostic conundrum. There is no single diagnostic laboratory test or unique clinical finding to distinguish the disease from other acute febrile exanthems of childhood. Despite increased recognition of the typical clinical syndrome of prolonged fever, rash, conjunctival injection, oral-mucosal erythema, extremity changes, and cervical lymphadenopathy, there have not been parallel improvements in therapy and coronary outcome. The lack of a specific diagnostic test for this disease continues to hinder the identification of at-risk individuals, and the lack of predictive markers of the heterogeneous disease course challenges the development of the optimum individualised therapy in affected children. Investigators have searched for clinical predictors of coronary outcome. In Kawasaki’s disease, cervical lymphadenopathy is the least common feature reported at diagnosis, varying from 24% to 50–70% reported in other large studies.1–3 Lymph nodes are often non-tender without evidence of superficial skin erythema. Some have speculated whether under-detection contributes to the lower number of www.thelancet.com Vol 369 January 13, 2007
children reported with lymphadenopathy. The term incomplete or atypical Kawasaki’s disease refers to children who do not exhibit the full clinical phenotype and have prolonged fever but less than four of the five diagnostic clinical features. In our studies of children with incomplete Kawasaki’s disease, the occurrence of each of the five clinical criteria was decreased as expected, but the proportionate decrease in occurrence was greatest for cervical lymphadenopathy, which was present in only 28% of children with the incomplete form compared with 74% of those meeting the full diagnostic criteria. Furthermore, the finding of cervical lymphadenopathy varies directly with age, with the youngest children, which is the population predisposed to incomplete Kawasaki’s disease, having the lowest occurrence of enlarged lymph nodes.1 Kawasaki’s disease is endemic with seasonal fluctuations punctuated with epidemic outbreaks.4 Many of the clinical features of the disease are outbreak dependent with a different spectrum of clinical findings in one mini-outbreak compared with another, and with cases having similar clinical phenotypes clustering temporally. 85
Syphilis resurgent in China See Articles page 132
Syphilis was a major cause of morbidity and mortality during the past 500 years and perhaps earlier.1 Penicillin treatment for syphilis substantially reduced prevalence in many countries, and the elimination of syphilis is thought to be an achievable goal, at least in the developed world.2 However, to paraphrase Mark Twain, rumours of the demise of syphilis seem to have been exaggerated. In today’s Lancet, Zhi-Qiang Chen and colleagues report a striking resurgence of infectious and congenital syphilis in China.3 This study follows on the heels of the increased incidence of infectious syphilis in the USA, Canada, and Europe,4,5 and it might seem that China is in a similar position to other economically vibrant areas of the world. However, resurgent syphilis in China has particular resonance because it epitomises the reversal of publichealth achievements (such as near-eradication of sexually transmitted diseases) from the decades after Chinese Communists came to power in 1949.6 For syphilis, public-health successes occurred after the introduction of a collective centralised economy. Furthermore, key components of apparently successful public-health programmes included both laudable measures (eg, elimination of debt in the peasant population to reduce the likelihood of women being sold into prostitution),6 and those regarded as draconian (eg, incarceration of sex workers in so-called re-education camps).7 The resurgence of syphilis occurs in the context of China’s explosive economic growth, which has been accompanied by: re-establishment of the sex trade;8 increased internal migration and inequalities in income;
Science Photo Library
The printed journal includes an image merely for illustration
Treponema pallidum
84
and profound under-investment in the infrastructure for public health9—all of which may facilitate spread of sexually transmitted infections such as syphilis. Moreover, the very success of China’s earlier efforts to control syphilis probably created a population that was highly susceptible to infection with Treponema pallidum, further augmenting disease transmission.10 In both relative and absolute terms, the 25-times increased risk of syphilis reported by Chen and colleagues dwarfs that seen in the USA, Canada, and Europe.4,5 Furthermore, the resurgence of congenital syphilis, which translates into about 3400 infected infants a year in China,3,11 adds an additional dimension to this tragedy. Under-reporting, which is common with sexually transmitted infections, may mean that the true situation is worse. So should we lament the passing of an era of heavy-handed, but apparently effective, publichealth intervention in China? Or should we regard the resurgence of syphilis as an unfortunate, but expected, consequence of increasing commercial freedom and overall prosperity in China, which might ultimately improve population health? The answer, predictably, is complicated, and highlights the tensions between effective disease-control activities, commercial freedom, prosperity, and individual rights, not only in China, but also globally. The link between commercial activity and transmission of infectious disease has a long history. Because epidemics depend on the introduction of a pathogen into a susceptible population, it is not surprising that global events associated with mass movements of people and goods have seen the concomitant emergence of new threats of infectious disease. Major historical challenges to public health and subsequent advances in the control of communicable disease frequently emerged in important trading centres—eg, 14th century Venice, Italy; 19th century London, UK; and 20th century New York, USA. Current challenges in Chinese population centres fit this pattern. Can China win this fight? A complete return to centralised programmes of public health that disregard individual rights and freedoms is neither desirable nor likely. China might look to emulate models of disease control from countries that have tried to maintain the delicate balance between rights of the individual and www.thelancet.com Vol 369 January 13, 2007
Comment
those of the community for control of communicable disease. In many countries, this balance is maintained through statutes that restrict individual rights for the purpose of communicable-disease control, but which are used rarely, such that their existence may come as a surprise to many citizens.12 China and other countries must accept that disease control is an issue of public good that cannot be achieved through market forces alone.13 Investment in infrastructure for public health that respects individual rights and freedoms will give China and other countries the seatbelt necessary for safe travel on the global economic superhighway. David N Fisman Research Institute of the Hospital for Sick Children and Ontario Public Health Laboratories Branch, Toronto, Ontario, Canada M5G 1E2 david.fi[email protected] I declare that I have no conflict of interest. 1
Quetel C. The history of syphilis. Baltimore: Johns Hopkins University Press, 1990.
2 3
4 5
6
7 8
9 10
11
12 13
Rompalo AM. Can syphilis be eradicated from the world? Curr Opin Infect Dis 2001; 14: 41–44. Chen Z, Zhang G, Gong X, et al. Syphilis returns to China: results of the national surveillance program from the Chinese Center for STD Control, Nanjing, China. Lancet 2007: 369: 132–38. Weir E, Fisman D. Syphilis: have we dropped the ball? CMAJ 2002; 167: 1267–68. Payne L, Berglund T, Henriksson L, Berggren-Palme I. Re-emergence of syphilis in Sweden: results from a surveillance study for 2004. Euro Surveill 2005; 10: E051110.1 http://www.eurosurveillance.org/ew/2005/051110. asp#1 (accessed Dec 18, 2006). Cheng T. Disease control and prevention. In: Wegman M, Lin T, Purcell E, eds. Public health in the People’s Republic of China. Philadelphia: Wm F Fell, 1973: 185–207. Hualing F. Re-eduation through labour in historical perspective. China Q 2005; 184: 811–30. Hesketh T, Zhang J, Qiang DJ. HIV knowledge and risk behaviour of female sex workers in Yunnan Province, China: potential as bridging groups to the general population. AIDS Care 2005; 17: 958–66. Blumenthal D, Hsiao W. Privatization and its discontents—the evolving Chinese health care system. N Engl J Med 2005; 353: 1165–70. Pourbohloul B, Rekart ML, Brunham RC. Impact of mass treatment on syphilis transmission: a mathematical modeling approach. Sex Transm Dis 2003; 30: 297–305. US Central Intelligence Agency. The world factbook 2006. China. http://cia.gov/cia//publications/factbook/geos/ch.html (accessed Dec 18, 2006). Kalogerakis G. TB carrier threat to public, MDs say: court asked to force treatment on him. Montreal Gazette Nov 29, 2000: A1. Garrett L. Betrayal of trust: the collapse of global public health. New York: Hyperion, 2000.
Phenotype and coronary outcome in Kawasaki’s disease Kawasaki’s disease continues to be a diagnostic and prognostic conundrum. There is no single diagnostic laboratory test or unique clinical finding to distinguish the disease from other acute febrile exanthems of childhood. Despite increased recognition of the typical clinical syndrome of prolonged fever, rash, conjunctival injection, oral-mucosal erythema, extremity changes, and cervical lymphadenopathy, there have not been parallel improvements in therapy and coronary outcome. The lack of a specific diagnostic test for this disease continues to hinder the identification of at-risk individuals, and the lack of predictive markers of the heterogeneous disease course challenges the development of the optimum individualised therapy in affected children. Investigators have searched for clinical predictors of coronary outcome. In Kawasaki’s disease, cervical lymphadenopathy is the least common feature reported at diagnosis, varying from 24% to 50–70% reported in other large studies.1–3 Lymph nodes are often non-tender without evidence of superficial skin erythema. Some have speculated whether under-detection contributes to the lower number of www.thelancet.com Vol 369 January 13, 2007
children reported with lymphadenopathy. The term incomplete or atypical Kawasaki’s disease refers to children who do not exhibit the full clinical phenotype and have prolonged fever but less than four of the five diagnostic clinical features. In our studies of children with incomplete Kawasaki’s disease, the occurrence of each of the five clinical criteria was decreased as expected, but the proportionate decrease in occurrence was greatest for cervical lymphadenopathy, which was present in only 28% of children with the incomplete form compared with 74% of those meeting the full diagnostic criteria. Furthermore, the finding of cervical lymphadenopathy varies directly with age, with the youngest children, which is the population predisposed to incomplete Kawasaki’s disease, having the lowest occurrence of enlarged lymph nodes.1 Kawasaki’s disease is endemic with seasonal fluctuations punctuated with epidemic outbreaks.4 Many of the clinical features of the disease are outbreak dependent with a different spectrum of clinical findings in one mini-outbreak compared with another, and with cases having similar clinical phenotypes clustering temporally. 85