Cardiovascular risk assessment prior to commencing moderate to high intensity exercise

The P.N.G government in recent times has devoted billions into the construction of huge sporting venues with the aim of promoting sports and exercise in the community.  This is commendable however in Port Moresby as is the case in all the major urban areas in PNG there is still a very limited number of affordable and family safe venues for people to participate in structured or unstructured exercise.

Exercise has always been recognised as something that is good for health.  Two major studies give overwhelming evidence that exercise is good for both the prevention of diabetes and the optimising of blood glucose levels in people with diabetes.

In the Finnish diabetes prevention study  Jaana Lindström et al (2003) showed that people who participated in an intensive lifestyle intervention program involving exercise and diet show significantly better outcomes in terms of anthropometric measures (body mass index, waist circumference and central abdominal obesity), diabetes incidence and also in the biochemical parameters like blood glucose and lipids level.

The US diabetes prevention program (DPP) also showed similar benefits of exercise, National Institute of health (2008):

The DPP’s results indicate that millions of high-risk people can delay or avoid                         developing type 2 diabetes by losing weight through regular physical activity and                   a diet low in fat and calories. Weight loss and physical activity lower the risk of                       diabetes by improving the body’s ability to use insulin and process glucose.

For someone wishing to embark on an exercise program that is more intense then say brisk walking it is recommended they they undergo a health check by a suitably qualified health care practitioner.  This assessment is important to identify any pre-existing condition that may cause harm or at worse be fatal if they are not identified and appropriate precautions taken.

Mitigating the risk of heart attacks.

One issue that is of particular concern and should be assessed in high risk individuals is the risk of having a heart attack during moderate to high intensity exercise.

Heart attacks are caused by the narrowing and eventual blocking of the coronary arteries, the arteries that supply oxygen and nutrients to the heart muscle. Major risk factors for this narrowing and blockage include: cigarette smoking, high blood pressure, diabetes and high cholesterol.  These risk factors are termed modifiable risk factors because they can be modified in order to reduce their contribution to the overall risk.  Exercise along with a healthy diet and when indicated specific medication has been shown to be effective in reducing these modifiable risk factors.

A number of very well validated cardiovascular risk calculator tools have been developed that can allow the determination of an individual’s risk of developing a heart attack over the next 10 years.  By plugging in the individual’s value for blood pressure, total and HDL cholesterol, their sex and whether or not they have diabetes or whether or not they smoke, a percentage risk of developing a heart attack in the next 10 years can be determined.

An example of this is the Australian absolute cardiovascular disease calculator that can be found here

The individual may already have a pre-existing narrowed coronary artery the extent of which determine the symptoms and risk of having a heart attack.  If a pre-existing narrowing of coronary artery is left undetected (through an appropriate health assessment) and that person commences a medium to high intensity exercise program it may precipitate a heart attack.

One way of determining whether a person has narrowing of their coronary arteries is by doing an exercise stress test.  An exercise stress test involves connecting a patient to an electrocardiogram (ECG) while they perform some physical exercise of progressively increasing intensity either on a treadmill or an exercise bike.  The patients is monitored for signs and symptoms of cardiac ischemia (low oxygen delivery to the heart) and changes in the ECG that suggest ischemia.  If the person shows changes in his or her ECG during the test they have narrowing of their coronary arteries and it is recommended for them to undergo further more invasive test to assess the severity of this narrowing.

The exercise stress test does not need to be done on every person who wishes to commence an exercise program, this would be too costly and subject people to unnecessary testing.

The American Diabetes Association recommends that an individual should have an exercise stress test to identify an underlying coronary artery occlusion if their 10 year cardiovascular risk is greater or equal to 10% or 1% per year using the

In Papua New Guinea even this relatively simple test,  (the ECG stress test) is not readily available and therefore in a patient who has a 10 year cardiovascular risk of equal to or greater than 10% I will always suggest light to moderate exercise, like regular  brisk walking, until they undergo an exercise stress test after which they can undertake exercise of higher intensity if the stress test turns out negative

To the best of my knowledge only the Port Moresby General Hospital and the Pacific International Hospital are the only two health facilities that do exercise stress testing.

My recommendation would be for every adult (especially those living in urban areas) to have a cardiovascular risk assessment every 1 to 2 years and if indicated from this initial assessment they should undergo a stress test.

 

References

  1. National Institute of health (2008), ‘Diabetes Prevention Program (DPP)’ available at https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp/Documents/DPP_508.pdf, accessed 16/02/2017.
  2. Jaana Lindström et al (2003), ‘The Finnish Diabetes Prevention Study (DPS) Lifestyle intervention and 3-year results on diet and physical activity’ DIABETES CARE, VOLUME 26, NUMBER 12, DECEMBER 2003.
  3. Sheri R. Colberg (2010), ‘Exercise and Type 2 Diabetes – The American College of Sports Medicine and the American Diabetes Association: joint position statement’ Diabetes Care 2010 Dec; 33(12): e147-e167

 

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Recently I found a word to described feelings of tension that I get all the time and that word is cognitive dissonance!

While sitting there contemplating the meaning of this old psychology term (newly discovered by me), I decided to stand up! and scribble one of my thoughts on the whiteboard in the hope that at least some of my thoughts, through my words may at least follow and reach the PNG Prime Minister, Hon. Peter O’neil and his delegates to Cuba.

And since I am not yet super-organised administratively I decided to cut this corner short and upload the pic…

OLYMPUS DIGITAL CAMERA

Thoughts from PNG to Cuba 22nd November 16

 

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A journey of a thousand mile begins with a single step – what is the immediate things the Government of PNG (GoPNG) should do about diabetes?

In countries with more developed economies the generally accepted wisdom is that it is more cost beneficial overall to invest resources (MONEY) into preventing or at least delaying the long term complications of diabetes rather than facing the huge costs of treating people who will eventually develop (earlier than if they were properly managed through well known and validated treatment) the long-term devastating complications of .diabetes which includes:
• Adult blindness
• Early heart attacks
• Strokes
• Chronic kidney disease
• Leg amputations and
• Nerve problems

According to the very large study recently published in the Lancet journal, NCD Risk Factor Collaboration (2016)

The burden of diabetes, both in terms of prevalence and number of adults affected,                has increased faster in low-income and middle-income countries than in high-                      income countries.

Diabetes has increased most dramatically in Pacific island nations and in the Middle              East and North Africa region, which now have the highest diabetes levels in the                      world. In Polynesia and Micronesia, where prevalence is highest, more than one in                five adults have diabetes. In Nauru and American Samoa, the number is nearly one                in every three men and women. NCD Risk Factor Collaboration (2016).

One of the principle investigator in this study, Professor Majid Ezzati and as cited by Wighton K (2016) stated that “…the data (from the study) reveals that the disease has reached levels that can bankrupt some countries’ health systems”.

These findings should be extremely concerning to all Papua New Guineans.

The smaller island nations mentioned above have small populations and therefore are able to collect, collate and have these data available for planning purposes. For us in PNG, to the best of my knowledge, we do not have a national database for diabetes and my guess is that any figures that is out there in the international diabetes literature is a gross underestimation of what the real situation is.

Despite these alarming numbers and our knowledge of them, it seems to me that there is a total lack of enthusiasm from the PNG Government to allocate the appropriate level of funding to develop the type of infrastructure and expertise that will be required to curb this tsunami of diabetes and lifestyle illness that can, if we ignore it, in affect severely pull us back as a nation. Undermining whatever gains we may have achieved in our short history
The country’s largest tertiary hospital, Port Moresby General Hospital (PMGH) which also serves as the teaching hospital for the University of Papua New Guinea has perhaps the busiest diabetes clinic in the country. This clinic runs every Tuesday and is led by Dr. Loyde Ipai.

Despite being severely under-resourced, Dr. Ipai and his team and doing the best with what they have and have managed to at least keep the clinic going till now. BUT THEY NEED MORE GOVERNMENT SUPPORT

The 1st Step

As an immediate measure our government must move as swiftly as possible to ensure that the PMGH diabetes clinic is well equipped, both with the appropriate point of care diagnostic and diabetes monitoring equipment and also invest into increasing the number of personnel with appropriate expertise. So apart from doctors specialising in or with a special interest in diabetes we also need more diabetes educators, podiatrists (health professionals who take care of feet), optometrists, counselors, dieticians and others who will form a chronic health care team that has the patient in the centre.

The idea would be to create a PNG Diabetes Centre of Clinical Excellence at PMGH which can also serve to provide training to people from other centres throughout PNG so that similar sites can begin to proliferate throughout the country.

While the benefits of having such a centre established would be immense and immediately visible and measurable, it must be appreciated by people and organisations who may want to be a part of such development that this is not a straight forward job and as much as possible the drivers of such a concept must aim to integrate into and synergise with the existing health facilities and medical education institutions.

The details of how this “Diabetes Centre of Clinical Excellence” may look like and operate is out of the scope of this article but my hope is that this important 1st step is taken.
How ready and willing is the GoPNG to take this first step?

From my perspective, as a strong advocate for improvement of diabetes care in PNG if I were asked to assess the government’s readiness to make changes to improve the provision of care to our diabetic patients I would say we are at a “pre-contemplative” stage, i.e the GoPNG is not even contemplating making any real investments into curbing this big problem. My fear is that the level of devastation caused by the long term complications of diabetes in the general population will reach tragic proportions at before the government start contemplating making investments as a reactionary approach. I hope my pessimism is wrong.

 

References
1) NCD Risk Factor Collaboration (2016), “Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4•4 million participants”, Lancet; 387: 1513–30

2) Wighton K (2016) , Imperial College London, available at http://www3.imperial.ac.uk/newsandeventspggrp/imperialcollege/newssummary/news_6-4-2016-18-52-11#authorbox, accessed on 22/11/2016

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Highlight on some landmark international studies on diabetes

WHAT P.N.G SHOULD BE DOING IF WE ARE TO AVOID BEING OVERWHELMED BY THE DEVASTATING COMPLICATIONS OF DIABETES

I recently enrolled in an online diploma program in diabetes which has been a real eye opener for me.

What I am learning is allowing me to reassess my own practice and apply what I am learning to better care for my patients as a GP.

The knowledge about diabetes: pathogenesis, natural history and response to various modes of and approaches to treatment has come a long way over recent years thanks to several major landmark studies that have define how we think about and how we clinically manage diabetes.  As we find out more and more about this condition our approach to treatment of individuals and our public health approach is also changing.

I’d like to highlight some of these landmark studies and how the results of these studies have influence modern diabetes care as I have come to understand it.

Diabetes research goes back a long way however let us start this story with one of the important modern studies into diabetes, the United Kingdom Prospective Study (UKPDS). 

This study was one of the biggest prospective, multicentre studies spanning from the year 1977 to 1997 and was designed and conducted two gentlemen the late Professors Robert Turner and the late Professor Rury Holman, The Diabetes Trial Unit (2016)

In essence the study involved the follow up of about 4000 newly diagnosed diabetics who were randomly allocated into two treatment pathway arms.  The the clinical outcomes of the people allocated to the two different arms were then analysed and compared.

Management Pathway 1 – The patients’ glucose control was intensively managed to achieve glucose levels as near to normal as possible using appropriately indicated pharmacological treatment.  The target for this “intensively managed” arm of the treatment pathway was a HbA1c level equal to or below 7%.

Management Pathway 2 –This less intensely managed arm of the two pathways involved; initially diet and exercise regimes alone and as and when the individual’s general blood glucose control worsen (as decided when fasting plasma glucose levels reached 15mmol/L and above) pharmacological agents were added.

The main conclusions from this landmark study according to the Diabetes Trials Unit (DTU), which is a part of the Univeristy of Oxford’s Radcliff Department of Medicine was:

Reducing glucose exposure (HbA1c 7.0 % (intensive arm) versus 7.9 % (less                                 intensive arm) over median 10.0      years), with     sulphonylurea or insulin                                 therapy,reduced the risk of “any diabetes-related endpoint” by 12% and                                 microvascular disease by 25%, with a 16% trend to a reduced risk of myocardial                         infarction (P=0.052). DTU (2016??)

For insulin and sulphonyluria treatment for type 2 diabetics the UKPDS as cited by DTU (2016) showed that “though neither of these therapies impaired quality of life, both increased risk of hypoglycaemia and weight gain”.  These two aspects of these treatment must be well communicated to patients so that they understand from the outset of treatment.

The intensive treatment arm included appropriate blood pressure treatment to also control it to as near normal as possible using again appropriately indicated lifestyle and pharmacological interventions.

Some of the main conclusions that the UKPDS researchers arrived at as summarised below by the Diabetes Teaching Center at the University of California, San Francisco (2016):

       Intensive blood glucose control & management of hypertension resulted in fewer            diabetes related complications, and approximately

20% decrease in death related to diabetes

40% decrease in eye, kidney, and nerve diabetes complications

40% decrease in blockage of the blood vessels to the lower limbs

15% decrease in heart attack

Despite all this high level evidence of the benefits of intensive treatment of diabetes, it was recognised that the optimal targets in regards to glycaemic control, blood cholesterol levels, and blood pressure that translated to these benefits were not being met by the vast majority of diabetics.

According to Saaddine et al (2006), analysing data from National Health and Nutrition Examination Surveys (1988-1994 and 1999-2002) in the USA:

·       2 in 5 persons with diabetes still had poor LDL cholesterol control

·       1 in 3 persons still had poor blood pressure control

·       1 in 5 persons still had poor glycemic control with HbA1c levels of 9% or above

·       Only 42% of adults had HbA1c values < 7%

These findings triggered a lot of question about the way diabetes care was being delivered and a new surge of research arose to answer the question –  why was it that even in the USA, a country with one of the most developed healthcare systems in the world these life prolonging target were not being reached. The DAWN study which was the topic of my last blog post was another landmark study that came about because of these questions

 

The Papua New Guinea Perspective

If these are the finding in the USA then the figures in Papua New Guinea (PNG) if we had any credible statistics into the issue would be even more staggering.  It is very hard to say what the actual situation is like in however it would be a very safe bet that it is grim

The vast majority of people do not even know what diabetes is, let alone the treatment needed and the targets need to be reached to see a prolongation of their lives.  The majority of diabetics in PNG find out for the first time that they are diabetic when they fall ill with one of the complications of diabetes –  they may have an early heart attack, visual impairment or blindness, chronic kidney disease or failure, a serious gangrenous lower limb which needs to be amputated or some other serious infection.

Even if a person is diagnosed with diabetes the services available to them is of such low quality and so under resourced that any hope of reaching these life prolonging targets would be quite low.

As an example, the biggest hospital in the country the Port Moresby General Hospital despite being very busy, does not have the appropriate number of qualified staff and does not have a reliable and continuous laboratory support.  Even tests that should be considered basic essential test for a diabetes clinic like HbA1c, Lipids profile and urinary micro-albuminuria are not always available.  The bewildering thing is that the Governments own official Diabetes Clinical Practice Guideline recommends that these tests be available in all the district level hospitals.  I think this is overly ambitious however it would be fair to expect that all provincial hospitals at least should have the capacity to do HbA1c, Urinary microalbuminuria and lipids.  The cost involved in ensuring this is not anywhere close to what the PNG government has seen fit to spend on other infrastructure however the benefits of having these tests available on an ongoing basis would be tremendous.

This grim picture in PNG is likely to get grimmer unless the PNG Government takes the issue seriously and make appropriate investments into improving and sustaining the provision of diabetes care in the country.

There needs to be specific investments into developing the pool of expertise within the country including, diabetes educators, podiatrists, diabetes nurses, doctors with a higher diploma in diabetes.  And to support these experts there needs to be investments into appropriate equipment to assist them to do their jobs more effectively.

From a wider societal point of view and especially in the urban centres where dwellers there are becomming to sedentary there needs to be investments into more accessible, family friendly and “wallet friendly” exercise facilities.  The built up infrastructure must also be developed to cater for the vast majority of citizens who do not have vehicle.  Good standard footpaths have to be made safe so people can walk or bike ride with comfort and safety.

 

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The Diabetes, Attitudes, Wishes and Needs (DAWN) Study.

A common source of frustration faced by health practitioners trying earnestly to assist our clients adopt a healthier lifestyle through diet, exercise and adhering to their medications is when the diabetic patients themselves seem to not take their condition serious. They seem to downplay the seriousness of their conditions, they seem to avoid any conversation about diabetes and make their condition a low priority in their life.  These patients are often said to be stuck in the denial phase of a grief response.

Often, out of my own frustrations I have even thought of using a “in your face” shock tactic of showing gruesome, potentially disturbing pictures for e.g an amputated leg, in order to trigger some of my clients into (from my perspective) positive action.

For me I think one of the reasons for my frustrations are due to the basic concept I have preset in my mind that I am the expert and that the patients comes to me to be taught by me, and I assume that they will learn and I assume that the patient will respect what I tell them as “gospel truth” and therefore follow my advice to the end.  When my clients don’t make appropriate adjustments, (and many don’t) I get frustrated.

These patients whom I perceive as being resistant to change, have their own perspectives, beliefs, world views, life circumstance which may contribute one way or an other to their ambivalence (having two minds) towards adopting a healthier lifestyle. I am now more appreciative of that and my approach in my interactions with these clients must be such that I seek ways to understand their perspective and work with them to uncover some of these reasons that may be holding them back and facilitate the discovery of their own motivation and own solutions.

Overwhelming evidence had already existed that showed that interventions (non-pharmacological and or pharmacological) that help patients achieve near normal blood  glucose (HbA1c <7%), the control of lipids and BP levels and the cessation of smoking lead to better overall morbidity and mortality outcomes for diabetics.  DCCT Research Group (1993) and UKPDS Group (1996).

Why the DAWN study came about.

Despite this well establish knowledge and the availability of improved treatment options and technologies which if utilised properly will assist in achieving these aims, it was recognised that many diabetics are still not achieving the ideal levels of glucose, lipids and blood pressure that were associated with lower risks of cardiovascular events.

According to Saddinne J B et al (2006) as cited Funnell M M (2006), In the USA “only 42% of adults have hemoglobin A1c (A1C) values < 7%, and one in five still have A1C levels > 9%”  Saddine J B et al (2006) also go on to highlight other aspects of diabetes care and therapeutic targets that were not being met by a substantial number of diabetics in the USA.

The Diabetes Attitude Wishes and Needs (DAWN) study, now seen as a landmark study, Funnell MM (2006), was done because it was recognised by opinion leaders and especially the International Diabetes Federation (Whom were one of the main collaborators in the this cross-sectional multicentre study, international study) that the situation as highlighted above was not unique to the USA but similar findings were seen around the world.

It had became apparent that knowledge about diabetes alone was not enough for diabetic patients to make the appropriate lifestyle adjustments and treatment adherence necessary to achieve better outcomes as measured by their glycaemic control, blood pressure and lipid control and ultimately better mortality (death rates) and morbidity (Sickness) outcomes.

It was thought that there was a need to incorporate into the diabetes care protocols and guidelines mechanisms and principles that allowed greater understanding by the health care team (and health policy maker) of the patients’ psycho-social issues, which may act as a barrier to them achieving better outcomes.

According to the official DAWN study website (DAWN 2016)

The DAWN (Diabetes Attitudes Wishes and Needs) study in 2001 was a massive              collaborative undertaking involving Novo Nordisk, the International Diabetes                          Federation and an international expert advisory board the largest diabetes                                study of its kind ever conducted.

My initial concern and question from the perspective of a primary care doctor living in a developing country was – will the good intentioned recommendations from the DAWN study be applicable in my country?

(Developing countries are anticipated to have the highest rise in prevalence of T2DM IDF (2016))

As I read more I am somewhat reassured and I can see ways by which I can extract and utilise many of the recommendations from this landmark study to apply in my practice that would be appropriate to the avaerage urban dwelling Papua New Guinea.  Aspects of the DAWN study reccommendations will need to be modified to some extend to retain local relevance.

 

The summary of the key findings/recommendations of the DAWN study as highlighted in the official website, DAWN (2016) are:

  • Enhance communications between people with diabetes and healthcare providers
  • Promote team-based diabetes care
  • Promote active self-management
  • Overcome emotional barriers to effective therapy
  • Enable better psychological care for people with diabetes

Reassuringly for me these recommendations are applicable to varying extent in my country especially if the existing pool of specialist get together to develop locally appropriate strategies.

An important ingredient in the success of a drive towards bettering diabetes care services in strong commitment from the PNG Government.

From a national policy perspective the greatest challenge in Papua New Guinea is the small pool of healthcare professional that will be required to form the multidisciplinary team which the DAWN study strongly advocates for.

If any appropriate GoPNG official is reading this? I strongly urge the GoPNG to partner with certain people and groups that have the energy and passion and genuine desire to see diabetes care services improve in PNG.

The GoPNG must be seen to be doing something constructive about a huge public health issue that is already having a huge negative impact on individuals, families, communities and the nation as a whole.

This problem will be with us long after the big resource hungry events like the SP Games, Under 20 Women’s FIFA World and the APEC summit have come and gone.

Reference

  1. DAWN (2016), Study Result, Available at http://www.dawnstudy.com/dawn-programmes/study-results.html# Accessed: 9/11/2016

 

  1. DCCT Research Group (1993), ‘ The Effect of Intensive Treatment of Diabetes on the development and progression of long term complications in IDDM, The New England Journal of Medicine, Sept 30, Vol 329, No. 14

       3. Funnell M M 2006, ‘Diabetes Attitudes, Wishes and Needs” (A review article),                          Clinical Diabetes, Volume 24, Number 4,

4.  UKPDS Group. (1996) ‘UK Prospective Diabetes Study 17: A nine-year update of a                     randomized, controlled trial on the effect of improved metabolic control on                               complications in non-insulin-dependent diabetes mellitus’. Ann Intern Med; 124:                 136–4

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Accuracy of Home Blood Glucose Monitors – an evidence based update

Guest posting: Dr Poyap Rooney, Clinical Chemist, Port Moresby General Hospital, PNG. Summary There are many Home Glucose Monitoring Devices on the market. HGMD are now accepted by the major diabet…

Source: Accuracy of Home Blood Glucose Monitors – an evidence based update

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Syphilis- an old disease that will not go away.

By Dr. Poyap J Rooney – General Practitioner and Pathologist
Korobosea Medical Clinic and Port Moresby General Hospital.

Sex is a wonderful part of life and one that should be celebrated in the healthiest way possible! While sex is a necessary means of human survival, our sexual lives also served as the means of survival of several microorganisms (bugs) that have quite cleverly made themselves a part of our lives. Understanding them is important if we are to avoid their negative impact on us individually and our communities.

Sexually transmitted infections (STIs) are caused by bugs that spread from one person to another during sexual intercourse. Getting infected with one of these “bugs” isn’t a good thing as they can lead to various long term complications that can make our lives miserable.

Traditionally the open discussion of our sexual lives has been a taboo; however people are becoming more open about discussing sex, sexuality, sexual behaviours and both the good and bad things that they are associated with.

Though sensitivity must still be applied when using certain words that may cause offense, it is important to have appropriately sanction places whereby frank and open conversations can be had about sex and STIs. Health care facilities like health centres, hospital clinics, and private GP clinics are perhaps the most appropriate places to carry out these discussions.

It is important that health care workers carrying out counselling, testing and treatment for STIs have the necessary qualifications and experience in STIs and carry out their job in a professional manner. CONFIDENTIALITY AND THE PROTECTION OF CLIENT’S PRIVACY IS AN IMPORTANT CORNERSTONE OF STI TREATMENT.

Whatever the mode of sexual intercourse the main “ingredient” for STIs to transmit from one person to another is an environment that allows the exchange of bodily fluids like, blood, semen AND vaginal fluid (all of which may contain the bugs that cause STIs.

The different major STIs

IN THIS ARTICLE I WANT TO TALK ABOUT SYPHILIS.

How can one get infected with syphilis?

The bug T. Pallidum usually spreads from an infected person to an uninfected person when certain bodily fluids containing the bug enter the body of the uninfected person. As an example, if you were uninfected and you had vaginal sexual intercourse (kuap) and /or anal intercourse (kuap-hars) with another infected person and the bodily fluids (eg. Karn-wara or kok-wara) of this infected person enters your body you may get infected with the bug and develop syphilis. Syphilis can also be transmitted through blood donations if donated blood is not checked properly.

How does syphilis affect my body?

Syphilis can show itself and affect your body in a number of ways.

Primary syphilis
Within 2 to 3 week after the bug enters your body you may (but not always) develop sores on the area of exposure (eg. kok, karn, hol-blo-hars or maus). The main feature of these sores is that they are usually painless and they usually disappear by themselves after 1 or 2 weeks. A lot of people who develop these sores never seek medical attention because the sores are painless and disappear without treatment and they may not even notice that they even have these sores which may appear in a hidden place like inside the anus (hol-blo-hars) or inside the vagina (hol-blo-karn). The photographs below are of painless sores in patients with primary syphilis.

Pics primary syphilis

It is during this primary stage of syphilis that the risk of spread from an infected person to an uninfected person is highest.

 

Secondary syphilis

During the primary syphilis stage your own body’s defense system attacks the bug and in most cases the sores of primary syphilis disappear. However, your body’s defense system in most cases will not totally exterminate the bug from your body and after some period in hiding (about a month) syphilis may show itself as secondary syphilis. This occurs when the bug goes into the blood stream and spreads throughout the body.

In secondary syphilis you may feel a general feeling of UNWELLNESS, fatigue and headache. You may lose a significant amount of weight, you may develop some fever and muscle ache.

In PNG many people blame malaria for these nonspecific symptoms which in actual fact may be due to syphilis or any other infectious disease (illness caused by pathological microorganisms)

You may also develop signs that are more specific to secondary syphilis including generalised rash on your skin, sores inside your mouth, and the lining of your throat and food pipe, anus and if you are female, and your vagina. You may also develop swollen painful lymph nodes throughout your body.

Rash and condylomata lata

 

Again during this secondary phase of syphilis your body defense system will put up a fight against the syphilis and in most cases these signs and symptoms will resolve by themselves without any specific medical treatment. The syphilis will then enter the latent (or sleeping phase) where once again it goes into hiding.

Tertiary syphilis
After about 4 to 10 years after the primary syphilis, for reasons not too well understood syphilis may once again emerge out of hiding to cause havoc. Tertiary syphilis can affect the bones, spinal, and the soft linings of the mouth, food pipe and the vagina and anus. Tertiary syphilis can also affect your heart causing life threatening problems.

This photograph depicts the destruction of a patient’s left knee joint, which was determined to be a case of neuropathic arthropathy, also known as Charcot’s joint, brought on by a tertiary syphilitic infection.

Photo courtesy of Public Health Image library (CDC). http://www.phil.cdc/phil/details.asp

Neuro-syphilis.
The brain and the nervous system can also be affected by syphilis and this can occur very early in the course of disease or it may take some years to develop.

Congenital syphilis.
Pregnant women can pass syphilis onto their unborn child. This can lead to the death of the baby while it is still in the womb or shortly after it is born. If a child becomes infected and is born alive they may have certain birth defects. In PNG it is usual for for pregnant mothers to be offered this test and if syphilis is found it can be treated.

How do I know if I have syphilis?

Your genital normally should be clean, free of any sores, abnormal discharge, smells or odd sensations. You should be concerned if you develop any of the signs and symptoms that I have explained above and visit a health care worker that you trust, ASAP!! Your health care worker should take proper notes of your complaints, do appropriate physical examinations and take appropriate samples for special diagnostic tests.

There are quick and simple blood tests available that can be done if you and your doctor are concerned about any specific problems.

Is there treatment for syphilis?

YES! Syphilis is easily treated with modern medication and if you have syphilis you should be treated even if you do not have symptoms. However syphilis is best handled by a health care worker with a special interest and experience in treating STIs. Special test need to be done before the start of treatment and some weeks after to make sure the treatment has worked.
TAKE HOME MESSAGE!!!!

If you have a strange sore, discharge and/or a strange feeling in your genital area, especially after having recent (1 to 2 weeks) unprotected sex with someone whom you do not know the STI status of – seek help at a health facility that you trust and get it checked out.

Enjoy sex with one regular partner that has had a full STI testing with you and you both have been cleared. Use a condom in the proper manner if you are unsure of the STI status of your sexual partner or if you know that they are infected and they are undergoing treatment.

Condom use is not a 100% protective however it has been shown to greatly reduce the risk STI transmission.

Some of you may see condoms as a nuisance or annoying however many condoms these days are designed to add a bit more fun into people’s sex lives. Shop around for some “fun” condoms!

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