654 THE EPIDEMIC
Public Health
epidemic of chancroid from JanOctober, 1978, for Greenland as a whole and for Godthab is shown in fig. 1. In Godthab’s neighbouring communities the first cases of chancroid appeared in April, 1977, and in the subsequent months of 1977 the epidemic spread along the west coast. 975 cases were reported in Greenland in 1977, 401 from The
EPIDEMIC OF CHANCROID IN GREENLAND 1977-78
LISE LYKKE-OLESEN TORKILD GROS PEDERSEN
LARS LARSEN
KNUD GAARSLEV
of the
course
uary, 1977,
to
Godthab and 574 from 10 out of 15 other district clinics. The number of cases increased until April in Godthab and until October, 1977, in the rest of Green-
District Medical Clinic, Godthåb, Greenland; Department of
Dermato-Venereology, Hvidovre Hospital, University of Copenhagen, Denmark; and Department of Diagnostic Bacteriology, Statens Seruminstitut, Copenhagen In Greenland there has been a rapid increase in the incidence of gonorrhoea and syphilis during past decades. In 1977 there was an epidemic of chancroid along the west coast of Greenland, with 975 cases reported from some 32 500 adults. The number of reported cases increased until October, 1977, and subsequently decreased. 186 patients were studied. Many of these had previously had gonorrhoea
Summary
and syphilis. Male patients were both Eskimoan and Danish but female patients were solely Eskimoan. The sex ratio (M/F) was 1·6/1. The incubation period was 4 days in men and 13 days in women. Symptom-free female carriers did not seem to be an important reservoir of infection. 15% of the patients were admitted to hospital with buboes or extensive lesions. The clinical course was uncomplicated in most cases. Ulcers healed within a week of treatment with sulphonamide. Chancroid can be expected to disappear in Greenland within a short time.
of chancroid cases per month in Greenland and in Godthab from January, 1977, to October, 1978.
Fig. 1-Number
INTRODUCTION
FOR several years sexually transmitted diseases have been an increasing public health problem in Greenland. Since 1967 gonorrhoea and, since 1972, syphilis have spread extensively in the population.! In 1977, 10 195 cases of gonorrhoea and 673 cases of syphilis were reported in a population of approximately 50 000 (adult population some 32 500).. In January, 1977, a few cases of chancroid were observed at the district medical clinic in Godthab, Greenland’s administrative centre and main town, and by the spring there was an epidemic. A rising number of cases were soon reported from neighbouring communi ties on the west coast of Greenland. Chancroid is predominantly a disease of developing tropical and subtropical countries .2,3 In Europe the disease is rare and is concentrated among prostitutes in seaports. We describe here the introduction and spread of chancroid in an Arctic area.
2-186 1977.
Fig.
cases
Distribution
per
of chancroid in Godthab from January to June week according
to sex
and ethnic origin.
BACKGROUND
During the past three decades Greenland has been transformed from a society based on hunting and fishing to an industrial society. The population doubled in 25 years. Because the standard of living rose and more people began living in towns traditional family patterns changed but the educational level remained low and alcohol abuse became common. In 1977, Godthab, which is situated on the west coast, had a population of 8545, 60% of whom were between 15 and 49 years old. The male/female population ratio for this age group is 1.2/1. ’
Fig.
3-186
cases
of chancroid in Godthab from January to June,
1977. Distribution on age groups
according to sex and ethnic origin.
655
land, and then declined through
what was left of 1977 and through 1978. We studied the 186 patients who presented with chancroid in Godthab during the first 26 weeks of 1977 (fig. 140 were born in Greenland (70 men and 70 women) and 46 were born outside Greenland (45 men and 1 woman). The male/female case ratio was 1-6/1. Males were aged 15-69 and females were aged 10-59 (fig. 3). The patients were 3.9% of the men and 2.8% of the women aged, 15-49 years in Godthab.
2).
DIAGNOSIS
patients had painful, non-indurated genital ulcers, often multiple and often with inguinal lymphadenopathy. In men the ulcers were predominantly The
located in the coronal groove and at the frenulum. In women ulcers were common on the labia and in the posterior commissure of the vulva and were infrequent on the portio or in the vagina. Treponema pallidum could not be demonstrated by dark-field microscopy, except in a few cases of mixed chancre. Autoinoculation tests were positive. The ulcers healed after sulphonamide therapy. Standard tests for syphilis and the complement-fixation test for lymphogranuloma venereum were negative. A
positive Ducrey skin test confirmed the diagnosis. In direct microscopy of exudate from ulcers or autoinoculation sites multiple intracellular and extracellular small Gram-negative rods were demonstrated. The purulent cells typically contained scattered polymorphonuclear leucocytes containing 1-50 Gram-negative rods. In general, attempts to grow the bacteria were unsuccessful, but in several cases organisms were isolated which corresponded with earlier descriptions of Hæmophilus ducreyi. After the diagnosis of chancroid had been established early in the epidemic the diagnosis was subsequently based on clinical criteria with proper exclusion of primary syphilis. SPECIAL EPIDEMIOLOGICAL AND CLINICAL FEATURES
patients, 29%
had a tender inguinal lymin a quarter of the cases. which fluctuated phadenopathy the were admitted to hospital, mainly of 15% patients because they had buboes or extensive lesions. Concomitant gonorrhoea was diagnosed in 13% of the patients. In 5% of the cases dark-field microscopy aroused suspicion of mixed chancre and supplementary antisyphilitic therapy was needed. In general, lesions healed within a week of starting 14 days of sulphadiazine therapy. Bubonic cases were treated with a sulphadiazine-streptomycin combination and by lymph-node aspiration. The mean incubation period was 4 days for men (range 2-9, n=20) and 13 days for women (range 7-18,
Of the 186
n=8). During
the 3-month period before infection, half of both the male and the female patients had had three or more different sexual partners. Almost half of the patients had been registered as cases of gonorrhoea during the preceding 12 months, the majority twice or more. In 5% of the male and 12% of the female patients, syphilis had been diagnosed during the preceding 12 months.
transmitted diseases
spread rapidly but, in contrast to gonorrhoea and syphilis, can be expected to disappear within a short time. This
study
was
supported by
Danish Medical Research Council
grants 512-8470 and 512-8846.
Requests for reprints should be addressed to T. G. P., Department of Dermato-Venereology, Hvidovre Hospital, Kettegard Alle 30, DK-2650 Hvidovre. Denmark. REFERENCES 1. Annual
DISCUSSION
Sexually
health problem in Greenland which has been complicated by the introduction of chancroid in 1977. The disease was probably imported by sea and spread rapidly; chancroid became more common than syphilis in that year. A decline in the reporting of chancroid started in Godthab in April, 1977, and in Greenland as a whole in November, 1977, and this trend continued in 1978. A public debate about this "new" venereal disease in Godthab in April, 1977, and effective efforts to trace contacts may be the main reasons for this decline. In the same period a decline was also reported for syphilis. Perhaps the appearance of a painful venereal disease motivated many patients to seek an earlier contact with the health authorities, also allowing an earlier diagnosis of some cases of syphilis. The incubation period was difficult to assess exactly because information about the time of exposure was in many cases imprecise. For a small group of the patients we observed a longer incubation period in women than in men, which has not previously been reported. The male/female case ratio of 1 6/1 in Godthab is in contrast to the high male/female case ratios usually reported.3 The case ratio is consistent with an equal promiscuity for men and women, whereas a spread from a few prostitutes would give a far higher proportion of men. Taking into account the uneven sex distribution in the population the corrected male/female case ratio is 1-4/1. The longer incubation period for women probably parallels a longer period of communicability in women, favouring a case ratio above 1. Consequently, this study suggests that symptom-free female carriers are not important in spreading the disease although a few women without symptoms, traced as sexual contacts, had lesions on the portio or in the vagina. In the male population in Godthab chancroid was encountered in the Eskimoan and Danish population approximately according to the representation of these two ethnic groups. In contrast, chancroid in females with the exception of one case-was confined to the female Eskimoan population. The diagnosis of solitary cases of chancroid can be difficult but when an epidemic is established the diagnosis relies on case history and the rather characteristic clinical appearance. Repeated dark-field examination of exudate from the ulcer is essential for the exclusion of primary syphilis and for the recognition of mixed chancre which was frequent in this study because syphilis was frequent. The microscopic recognition of H. ducreyi is easy, but needs experience Since 1967 gonorrhoea and from 1972 syphilis have been reported with increasing incidence and both diseases are now endemic in Greenland. In 1977 chancroid
Reports from
the Chief Medical Officer in Greenland 1951-1975.
Sydgrønlands bogtrykkeri, Godthåb. are
a
major public
2. King, A., Nicol, C., Venereal Diseases; p. 236. London, 1975. 3. Gaisin, A., Heaton, C. L. Int. J. Dermat. 1975, 14, 188.
Public Health
epidemic of chancroid from JanOctober, 1978, for Greenland as a whole and for Godthab is shown in fig. 1. In Godthab’s neighbouring communities the first cases of chancroid appeared in April, 1977, and in the subsequent months of 1977 the epidemic spread along the west coast. 975 cases were reported in Greenland in 1977, 401 from The
EPIDEMIC OF CHANCROID IN GREENLAND 1977-78
LISE LYKKE-OLESEN TORKILD GROS PEDERSEN
LARS LARSEN
KNUD GAARSLEV
of the
course
uary, 1977,
to
Godthab and 574 from 10 out of 15 other district clinics. The number of cases increased until April in Godthab and until October, 1977, in the rest of Green-
District Medical Clinic, Godthåb, Greenland; Department of
Dermato-Venereology, Hvidovre Hospital, University of Copenhagen, Denmark; and Department of Diagnostic Bacteriology, Statens Seruminstitut, Copenhagen In Greenland there has been a rapid increase in the incidence of gonorrhoea and syphilis during past decades. In 1977 there was an epidemic of chancroid along the west coast of Greenland, with 975 cases reported from some 32 500 adults. The number of reported cases increased until October, 1977, and subsequently decreased. 186 patients were studied. Many of these had previously had gonorrhoea
Summary
and syphilis. Male patients were both Eskimoan and Danish but female patients were solely Eskimoan. The sex ratio (M/F) was 1·6/1. The incubation period was 4 days in men and 13 days in women. Symptom-free female carriers did not seem to be an important reservoir of infection. 15% of the patients were admitted to hospital with buboes or extensive lesions. The clinical course was uncomplicated in most cases. Ulcers healed within a week of treatment with sulphonamide. Chancroid can be expected to disappear in Greenland within a short time.
of chancroid cases per month in Greenland and in Godthab from January, 1977, to October, 1978.
Fig. 1-Number
INTRODUCTION
FOR several years sexually transmitted diseases have been an increasing public health problem in Greenland. Since 1967 gonorrhoea and, since 1972, syphilis have spread extensively in the population.! In 1977, 10 195 cases of gonorrhoea and 673 cases of syphilis were reported in a population of approximately 50 000 (adult population some 32 500).. In January, 1977, a few cases of chancroid were observed at the district medical clinic in Godthab, Greenland’s administrative centre and main town, and by the spring there was an epidemic. A rising number of cases were soon reported from neighbouring communi ties on the west coast of Greenland. Chancroid is predominantly a disease of developing tropical and subtropical countries .2,3 In Europe the disease is rare and is concentrated among prostitutes in seaports. We describe here the introduction and spread of chancroid in an Arctic area.
2-186 1977.
Fig.
cases
Distribution
per
of chancroid in Godthab from January to June week according
to sex
and ethnic origin.
BACKGROUND
During the past three decades Greenland has been transformed from a society based on hunting and fishing to an industrial society. The population doubled in 25 years. Because the standard of living rose and more people began living in towns traditional family patterns changed but the educational level remained low and alcohol abuse became common. In 1977, Godthab, which is situated on the west coast, had a population of 8545, 60% of whom were between 15 and 49 years old. The male/female population ratio for this age group is 1.2/1. ’
Fig.
3-186
cases
of chancroid in Godthab from January to June,
1977. Distribution on age groups
according to sex and ethnic origin.
655
land, and then declined through
what was left of 1977 and through 1978. We studied the 186 patients who presented with chancroid in Godthab during the first 26 weeks of 1977 (fig. 140 were born in Greenland (70 men and 70 women) and 46 were born outside Greenland (45 men and 1 woman). The male/female case ratio was 1-6/1. Males were aged 15-69 and females were aged 10-59 (fig. 3). The patients were 3.9% of the men and 2.8% of the women aged, 15-49 years in Godthab.
2).
DIAGNOSIS
patients had painful, non-indurated genital ulcers, often multiple and often with inguinal lymphadenopathy. In men the ulcers were predominantly The
located in the coronal groove and at the frenulum. In women ulcers were common on the labia and in the posterior commissure of the vulva and were infrequent on the portio or in the vagina. Treponema pallidum could not be demonstrated by dark-field microscopy, except in a few cases of mixed chancre. Autoinoculation tests were positive. The ulcers healed after sulphonamide therapy. Standard tests for syphilis and the complement-fixation test for lymphogranuloma venereum were negative. A
positive Ducrey skin test confirmed the diagnosis. In direct microscopy of exudate from ulcers or autoinoculation sites multiple intracellular and extracellular small Gram-negative rods were demonstrated. The purulent cells typically contained scattered polymorphonuclear leucocytes containing 1-50 Gram-negative rods. In general, attempts to grow the bacteria were unsuccessful, but in several cases organisms were isolated which corresponded with earlier descriptions of Hæmophilus ducreyi. After the diagnosis of chancroid had been established early in the epidemic the diagnosis was subsequently based on clinical criteria with proper exclusion of primary syphilis. SPECIAL EPIDEMIOLOGICAL AND CLINICAL FEATURES
patients, 29%
had a tender inguinal lymin a quarter of the cases. which fluctuated phadenopathy the were admitted to hospital, mainly of 15% patients because they had buboes or extensive lesions. Concomitant gonorrhoea was diagnosed in 13% of the patients. In 5% of the cases dark-field microscopy aroused suspicion of mixed chancre and supplementary antisyphilitic therapy was needed. In general, lesions healed within a week of starting 14 days of sulphadiazine therapy. Bubonic cases were treated with a sulphadiazine-streptomycin combination and by lymph-node aspiration. The mean incubation period was 4 days for men (range 2-9, n=20) and 13 days for women (range 7-18,
Of the 186
n=8). During
the 3-month period before infection, half of both the male and the female patients had had three or more different sexual partners. Almost half of the patients had been registered as cases of gonorrhoea during the preceding 12 months, the majority twice or more. In 5% of the male and 12% of the female patients, syphilis had been diagnosed during the preceding 12 months.
transmitted diseases
spread rapidly but, in contrast to gonorrhoea and syphilis, can be expected to disappear within a short time. This
study
was
supported by
Danish Medical Research Council
grants 512-8470 and 512-8846.
Requests for reprints should be addressed to T. G. P., Department of Dermato-Venereology, Hvidovre Hospital, Kettegard Alle 30, DK-2650 Hvidovre. Denmark. REFERENCES 1. Annual
DISCUSSION
Sexually
health problem in Greenland which has been complicated by the introduction of chancroid in 1977. The disease was probably imported by sea and spread rapidly; chancroid became more common than syphilis in that year. A decline in the reporting of chancroid started in Godthab in April, 1977, and in Greenland as a whole in November, 1977, and this trend continued in 1978. A public debate about this "new" venereal disease in Godthab in April, 1977, and effective efforts to trace contacts may be the main reasons for this decline. In the same period a decline was also reported for syphilis. Perhaps the appearance of a painful venereal disease motivated many patients to seek an earlier contact with the health authorities, also allowing an earlier diagnosis of some cases of syphilis. The incubation period was difficult to assess exactly because information about the time of exposure was in many cases imprecise. For a small group of the patients we observed a longer incubation period in women than in men, which has not previously been reported. The male/female case ratio of 1 6/1 in Godthab is in contrast to the high male/female case ratios usually reported.3 The case ratio is consistent with an equal promiscuity for men and women, whereas a spread from a few prostitutes would give a far higher proportion of men. Taking into account the uneven sex distribution in the population the corrected male/female case ratio is 1-4/1. The longer incubation period for women probably parallels a longer period of communicability in women, favouring a case ratio above 1. Consequently, this study suggests that symptom-free female carriers are not important in spreading the disease although a few women without symptoms, traced as sexual contacts, had lesions on the portio or in the vagina. In the male population in Godthab chancroid was encountered in the Eskimoan and Danish population approximately according to the representation of these two ethnic groups. In contrast, chancroid in females with the exception of one case-was confined to the female Eskimoan population. The diagnosis of solitary cases of chancroid can be difficult but when an epidemic is established the diagnosis relies on case history and the rather characteristic clinical appearance. Repeated dark-field examination of exudate from the ulcer is essential for the exclusion of primary syphilis and for the recognition of mixed chancre which was frequent in this study because syphilis was frequent. The microscopic recognition of H. ducreyi is easy, but needs experience Since 1967 gonorrhoea and from 1972 syphilis have been reported with increasing incidence and both diseases are now endemic in Greenland. In 1977 chancroid
Reports from
the Chief Medical Officer in Greenland 1951-1975.
Sydgrønlands bogtrykkeri, Godthåb. are
a
major public
2. King, A., Nicol, C., Venereal Diseases; p. 236. London, 1975. 3. Gaisin, A., Heaton, C. L. Int. J. Dermat. 1975, 14, 188.
