Serologic observation and risk factor of yaws in Hamadi Public Health Center, Jayapura

Background: Yaws remained an unfinished health problem in Jayapura City, as there still yaws case found. This research aimed to obtain serological prevalence data and determine the risk factors for yaws transmission in Jayapura. Methods: These was descriptive and cross-sectional research, and TPHA was the standard laboratory test used during the research. Results: The risk factor of a frambusia in the history of having experienced frambusia has twice as much potential for experiencing frambusia again. The risk factor of frambusia has increased twice as much in less healthy behaviors: rarely bathing and without using soap and having a rare / non-slip habit. Potential risk increased three times in the habit of sharing a towel together. Conclusion: Serology with positive TPHA was obtained in 111 samples of cases and contacts. Not clean and healthy behavior is a risk factor that affects the incidence of frambusia. (Health Science Journal of Indonesia 2016;8(1):25-29) Keyword: TPHA, yaws, risk factor, personal hygiene Health Science Journal of Indonesia Arisanti, et al. 26 Yaws is a non-venereal infectious disease caused by Tripnonema pallidum subspecies pertenue1 and it is correlated with self-hygiene and sanitation2. This bacteria triumph in humid environment so that it really favor living in the in tropics. It has the world’s concern since 50’s proofed by the campaign held and mass treatment using Penicillin as an eradication effort3. Yaws remains becoming such a serious health problem in Papua, mainly in Jayapura City. As the capital of Papua province, Jayapura also becomes yaws pocket, currently this disease yet optimally eradicated despite routine mass treatment using Penicillin already conducted by Hamadi’s Public Health Center. The incidence of Yaws in Papua recorded 729 cases during 2012 and 26,7% of the total case found in Jayapura City. The total case declined in 2013 which recorded 714 cases for Papua. However, the case increased to be 31% in Jayapura City. In 2014 the total case returned decreasing, 237 cases recorded, and 53% of the total case found in Jayapura City. Hamadi’s working area was the highest contributor for Yaws case in Jayapura City. Since 2010 such program to eradicate yaws already performed in its working area. However, until 2010 the increase for new yaws cases occurred, and it was recorded 543 patients. Yaws has three different stadium, primary lesion we called ”Mother yaws”4, in secondary stadium, the lesion heals, but it keeps shifting location then it resides within Lymph5. This condition leads to such misdiagnose, and make it difficult to perform such a fixed diagnose. The disappearing lesion is not the only reason that misdiagnose for yaws occurs, it is also triggered by a mistaken physical check happened in a given condition where the yaws primary lesionlike seems appearing. One of the test that can be used to test the yaws is TPHA (Treponema pallidum Haemaglutinaton assay), similar to principle of antibody test in which it detects syphilis. The positive result of TPHA shows that a person is previously exposed to Treponema pallidum6. Thus, according to the data and facts above, a research to observe the serological description and also the risk factors of yaws including house contact needs to be conducted.

Yaws is a non-venereal infectious disease caused by Tripnonema pallidum subspecies pertenue 1 and it is correlated with self-hygiene and sanitation 2 . This bacteria triumph in humid environment so that it really favor living in the in tropics. It has the world's concern since 50's proofed by the campaign held and mass treatment using Penicillin as an eradication effort 3 . Yaws remains becoming such a serious health problem in Papua, mainly in Jayapura City. As the capital of Papua province, Jayapura also becomes yaws pocket, currently this disease yet optimally eradicated despite routine mass treatment using Penicillin already conducted by Hamadi's Public Health Center.
The incidence of Yaws in Papua recorded 729 cases during 2012 and 26,7% of the total case found in Jayapura City. The total case declined in 2013 which recorded 714 cases for Papua. However, the case increased to be 31% in Jayapura City. In 2014 the total case returned decreasing, 237 cases recorded, and 53% of the total case found in Jayapura City. Hamadi's working area was the highest contributor for Yaws case in Jayapura City. Since 2010 such program to eradicate yaws already performed in its working area. However, until 2010 the increase for new yaws cases occurred, and it was recorded 543 patients.
Yaws has three different stadium, primary lesion we called "Mother yaws" 4 , in secondary stadium, the lesion heals, but it keeps shifting location then it resides within Lymph 5 . This condition leads to such misdiagnose, and make it difficult to perform such a fixed diagnose. The disappearing lesion is not the only reason that misdiagnose for yaws occurs, it is also triggered by a mistaken physical check happened in a given condition where the yaws primary lesionlike seems appearing. One of the test that can be used to test the yaws is TPHA (Treponema pallidum Haemaglutinaton assay), similar to principle of antibody test in which it detects syphilis. The positive result of TPHA shows that a person is previously exposed to Treponema pallidum 6 . Thus, according to the data and facts above, a research to observe the serological description and also the risk factors of yaws including house contact needs to be conducted.

METHODS
The research was descriptive and designed to be cross sectional. The sample collection conducted in Hamadi's Public health center working area. The research duration was 10 months started in January to October 2016. The total research subject was 322 people aged above 5 years old, previously diagnosed having Yaws, and already got treatment.
The data collection performed by house-visit to the case subject, as well as doing the screening for physical examination to house-contact, remained in Hamadi's Public Health Centre working area. The examination executed by doctor and nurse who had already participated in yaw's workshop. Structured interview using questioner was applied in order to identify risk factors including age, sex, yaws history, towel usage, soap usage, sandal usage and the selfhygiene habit. Serology data was collected by using vein blood sample. The blood was taken for 1 mL, which then saved into the tube then transferred to Laboratory of Microbiology in Institute of Research and Development for Biomedicine in Jayapura.

Result of serological examination using TPHA
This research enrolled 322 subjects which consisted of 43 cases and 279 house-contacts.

TPHA (+)
TPHA (-)  TOTAL  111  211  322 According to the table, TPHA result's ratio showed that the positive result was higher in case subject (72, 1%) compared to house contacts, and vice versa for the negative result. TPHA is quite effective to distinguish syphilis and yaws, which refers to its manifest of infection. The positive result is indicated by the blood mass formation due to the antigen-antibody reaction.
In such certain condition, TPHA can perform false negative result as too high antibody or immunity drop status, and vice versa it can perform false positive result, which can be triggered by past infection such as syphilis.
TPHA can be assigned as single assay for treponemal infection, however it's much better combining TPHA along with another serological assay, as a comparison, for example the TPPA. The combination can perform higher validity result. Serological diagnosing needs two different antibodies detection; first is dedicated to against such a treponemal and the remaining one is needed to against the nontreponemal antigent. Nontreponemal Agglutination assay as RPR and VDRL slide test can act reactive during the early infection's period and commonly turned to be negative after treatment. In the opposite, treponemal agglutination assay including TPHA, TPPA, and FTA, will remain reactive despite the treatment applied. Nontreponemal assay can be used to indicate such active infection and also its transmission that currently occurring in such given area.

Result of Treponema Pallidum Haemagglutination
Test for case and contacts

DISCUSSION
Apparently different with syphilis yaws doesn't have a particular transmission path through sexual contact, and instead it transmits through direct physical contact. So that such an analysis to any factors related to direct transmission as the sharing of the common daily household usage collectively, should get a serious concern, mainly the self-hygiene habits. The simplest example in this case was the sharing of daily soap usage in a family. Furthermore, not only the commons sharing usage of the daily household utensil, but also the total individual in a given house who actively performed sharing for household utensil, with the ones who infected by yaws. Such high direct contact density around the ones with Yaws provided bigger chance for the increasing of yaws transmission. This fact can be inferred basically from the TPHA result, where the positive contacts had treponemal infection detected. This result led to an explanation that transmission kept occurring although this short conclusion asked for further study, due to the TPHA could not specifically showed a fixed justification that the positively tested bacteria was the Treponema pallidum subspecies pertenue.
Risk factors obtained in this research then already analyzed for its correlation to Yaws incidence. People habit to keep their heath well was still inadequate, for instance, they infrequently used soap when they bath, didn't put sandal on their feet, lousy and dirty cloth to wear, and their body-hygiene seemed worst including their nails. The bad personal and surround hygiene and also the lack of Yaws understanding, could be designated to factors which correlated to Yaws incidence. This also was in accordance to the final conclusion of yaws international summit for eradication, that yaws was mostly transmitted through skin direct contact to ones who had bad self-hygiene 7 .
Along with the risk factors, in this research also revealed that lacking quality of self-hygiene had 18 times higher for chance to get infected by yaws, with explanations including; infrequently using soap for bathing had risk factor 2 times higher, habits to share single towel after bathing had potency 3 times higher, and had their feet unprotected by sandal had risk factor 2 times higher. Additional information stated that even Yaws can be transmitted one to another human indirectly through contact with stuffs which already contaminated with infectious mucus originated from yaws lesion. Finally from those explanation above, slightly can be inferred that risk factor for Yaws isn't simply single but complex and affecting one and another. Unhealed and watery lesion also attracts fly to come and make yaws even easier to get spread and transmitted to other persons. Personal history for self-experience infected previously by Yaws 2 times higher for its incidence. Most of secondary lesion of yaws can get relapsed after treatment in which got dormant for several weeks or several months. Furthermore yaws basically will be able to relapse after 5 years and if it doesn't get proper treatment since the early infection then Yaws will appear as chronic symptom, relapsed, and difficult to predict and finally trigger long period severe bones deformity Yaws risk factor actually was not a single but multiple related. 12,9 Soap usage habit that rarely had roles in the incidence of yaws, was in accordance with the WHO statement which said that yaws could spread among people who rarely shower using soap. The influence of the use of soap into the defender had strong impact on the disease. Dirty wet yaws lesions were very attracting to flies that could spread the disease easily. Good bathing habits could reduce the incidence of yaws 13 .
History of suffering from yaws had 2 times greater potency against the incidence of yaws. All secondary yaws lesions could be relapsed after treatment, and it would be varied within few weeks to months. Patients may got relapsed after 5 years, when yaws was not treated at an early stage, then it could be turned into a chronic disease, and relapsed would be unpredictable and could trigger severe bone deformities in the long term suffering 9,14,15 In conclusion, Serology with positive TPHA was obtained in 111 samples of cases and contacts. Not clean and healthy behavior is a risk factor that affects the incidence of frambusia.