Signs Symptoms and Treatment of Syphilis

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum subspecies pallidum. The signs and symptoms of syphilis vary depending in which of the four stages it presents (primary, secondary, latent, and tertiary). The primary stage classically presents with a single chancre (a firm, painless, non-itchy skin ulceration) but there may be multiple sores. In secondary syphilis a diffuse rash which frequently involves the palms of the hands and soles of the feet occurs. There may also be sores in the mouth or vagina. In latent syphilis there are little to no symptoms which can last for years. In tertiary syphilis there are gummas (soft non-cancerous growths), neurological, or heart symptoms. Syphilis has been known as "the great imitator" as it may cause symptoms similar to many other diseases.

Syphilis is most commonly spread through sexual activity. It may also be transmitted from mother to baby during pregnancy or at birth, resulting in congenital syphilis. Other human diseases caused by related Treponema pallidum include yaws (subspecies pertenue), pinta (subspecies carateum), and bejel (subspecies endemicum). Diagnosis is usually made by using blood tests; the bacteria can also be detected using dark field microscopy. The Center for Disease Control recommends all pregnant women be tested.

The risk of syphilis can be decreased by latex condom use or not having sex. Syphilis can be effectively treated with antibiotics. The preferred antibiotic for most cases is benzathine penicillin G injected into a muscle. In those who have a severe penicillin allergy, doxycycline or tetracycline may be used. In those with neurosyphilis intravenous penicillin G potassium or ceftriaxone is recommended. During treatment people may develop fever, headache, and muscle pains, a reaction known as Jarisch-Herxheimer.

In 2013 syphilis infected about 315,000 people. During 2010 it caused about 113,000 deaths down from 202,000 in 1990. After decreasing dramatically with the availability of penicillin in the 1940s, rates of infection have increased since the turn of the millennium in many countries, often in combination with human immunodeficiency virus (HIV). This is believed to be partly due to increased promiscuity, prostitution, decreasing use of condoms, and unsafe sexual practices among men who have sex with men. In 2015, Cuba became the first country in the world to eliminate mother-to-child transmission of syphilis.

Signs and symptoms

Syphilis can present in one of four different stages: primary, secondary, latent, and tertiary, and may also occur congenitally. It was referred to as "the great imitator" by Sir William Osler due to its varied presentations.

Primary

Primary syphilis is typically acquired by direct sexual contact with the infectious lesions of another person. Approximately 3 to 90 days after the initial exposure (average 21 days) a skin lesion, called a chancre, appears at the point of contact. This is classically (40% of the time) a single, firm, painless, non-itchy skin ulceration with a clean base and sharp borders between 0.3 and 3.0 cm in size. The lesion may take on almost any form. In the classic form, it evolves from a macule to a papule and finally to an erosion or ulcer. Occasionally, multiple lesions may be present (~40%), with multiple lesions more common when coinfected with HIV. Lesions may be painful or tender (30%), and they may occur outside of the genitals (2–7%). The most common location in women is the cervix (44%), the penis in heterosexual men (99%), and anally and rectally relatively commonly in men who have sex with men (34%). Lymph node enlargement frequently (80%) occurs around the area of infection, occurring seven to 10 days after chancre formation. The lesion may persist for three to six weeks without treatment.

Secondary

Secondary syphilis occurs approximately four to ten weeks after the primary infection. While secondary disease is known for the many different ways it can manifest, symptoms most commonly involve the skin, mucous membranes, and lymph nodes. There may be a symmetrical, reddish-pink, non-itchy rash on the trunk and extremities, including the palms and soles. The rash may become maculopapular or pustular. It may form flat, broad, whitish, wart-like lesions known as condyloma latum on mucous membranes. All of these lesions harbor bacteria and are infectious. Other symptoms may include fever, sore throat, malaise, weight loss, hair loss, and headache. Rare manifestations include liver inflammation, kidney disease, joint inflammation, periostitis, inflammation of the optic nerve, uveitis, and interstitial keratitis. The acute symptoms usually resolve after three to six weeks; about 25% of people may present with a recurrence of secondary symptoms. Many people who present with secondary syphilis (40–85% of women, 20–65% of men) do not report previously having had the classic chancre of primary syphilis.

Latent

Latent syphilis is defined as having serologic proof of infection without symptoms of disease. It is further described as either early (less than 1 year after secondary syphilis) or late (more than 1 year after secondary syphilis) in the United States. The United Kingdom uses a cut-off of two years for early and late latent syphilis. Early latent syphilis may have a relapse of symptoms. Late latent syphilis is asymptomatic, and not as contagious as early latent syphilis.

Tertiary

Tertiary syphilis may occur approximately 3 to 15 years after the initial infection, and may be divided into three different forms: gummatous syphilis (15%), late neurosyphilis (6.5%), and cardiovascular syphilis (10%). Without treatment, a third of infected people develop tertiary disease. People with tertiary syphilis are not infectious.

Gummatous syphilis or late benign syphilis usually occurs 1 to 46 years after the initial infection, with an average of 15 years. This stage is characterized by the formation of chronic gummas, which are soft, tumor-like balls of inflammation which may vary considerably in size. They typically affect the skin, bone, and liver, but can occur anywhere.

Neurosyphilis refers to an infection involving the central nervous system. It may occur early, being either asymptomatic or in the form of syphilitic meningitis, or late as meningovascular syphilis, general paresis, or tabes dorsalis, which is associated with poor balance and lightning pains in the lower extremities. Late neurosyphilis typically occurs 4 to 25 years after the initial infection. Meningovascular syphilis typically presents with apathy and seizure, and general paresis with dementia and tabes dorsalis. Also, there may be Argyll Robertson pupils, which are bilateral small pupils that constrict when the person focuses on near objects, but do not constrict when exposed to bright light.

Cardiovascular syphilis usually occurs 10–30 years after the initial infection. The most common complication is syphilitic aortitis, which may result in aneurysm formation.

Congenital

Congenital syphilis is that which is transmitted during pregnancy or during birth. Two-thirds of syphilitic infants are born without symptoms. Common symptoms that develop over the first couple of years of life include enlargement of the liver and spleen (70%), rash (70%), fever (40%), neurosyphilis (20%), and lung inflammation (20%). If untreated, late congenital syphilis may occur in 40%, including saddle nose deformation, Higoumenakis sign, saber shin, or Clutton's joints among others

Cause of Syphilis

Bacteriology

Treponema pallidum subspecies pallidum is a spiral-shaped, Gram-negative, highly mobile bacterium. Three other human diseases are caused by related Treponema pallidum, including yaws (subspecies pertenue), pinta (subspecies carateum) and bejel (subspecies endemicum). Unlike subtype pallidum, they do not cause neurological disease. Humans are the only known natural reservoir for subspecies pallidum. It is unable to survive without a host for more than a few days. This is due to its small genome (1.14 MDa) failing to encode the metabolic pathways necessary to make most of its macronutrients. It has a slow doubling time of greater than 30 hours.

Transmission

Syphilis is transmitted primarily by sexual contact or during pregnancy from a mother to her fetus; the spirochaete is able to pass through intact mucous membranes or compromised skin. It is thus transmissible by kissing near a lesion, as well as oral, vaginal, and anal sex. Approximately 30 to 60% of those exposed to primary or secondary syphilis will get the disease. Its infectivity is exemplified by the fact that an individual inoculated with only 57 organisms has a 50% chance of being infected. Most (60%) of new cases in the United States occur in men who have sex with men. It can be transmitted via blood products. It is tested for in many countries and thus the risk is low. The risk of transmission from sharing needles appears limited.

It is not generally possible to contract syphilis through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing. This is mainly because the bacteria die very quickly outside of the body, making transmission via objects extremely difficult.

Diagnosis

Syphilis is difficult to diagnose clinically early in its presentation. Confirmation is either via blood tests or direct visual inspection using microscopy. Blood tests are more commonly used, as they are easier to perform. Diagnostic tests are unable to distinguish between the stages of the disease.

Blood tests

Blood tests are divided into nontreponemal and treponemal tests. Nontreponemal tests are used initially, and include venereal disease research laboratory (VDRL) and rapid plasma reagin tests. As these tests are occasionally false positives, confirmation is required with a treponemal test, such as treponemal pallidum particle agglutination (TPHA) or fluorescent treponemal antibody absorption test (FTA-Abs). False positives on the nontreponemal tests can occur with some viral infections such as varicella and measles, as well as with lymphoma, tuberculosis, malaria, endocarditis, connective tissue disease, and pregnancy. Treponemal antibody tests usually become positive two to five weeks after the initial infection. Neurosyphilis is diagnosed by finding high numbers of leukocytes (predominately lymphocytes) and high protein levels in the cerebrospinal fluid in the setting of a known syphilis infection

Direct testing

Dark ground microscopy of serous fluid from a chancre may be used to make an immediate diagnosis. Hospitals do not always have equipment or experienced staff members, whereas testing must be done within 10 minutes of acquiring the sample. Sensitivity has been reported to be nearly 80%, thus can only be used to confirm a diagnosis but not rule one out. Two other tests can be carried out on a sample from the chancre: direct fluorescent antibody testing and nucleic acid amplification tests. Direct fluorescent testing uses antibodies tagged with fluorescein, which attach to specific syphilis proteins, while nucleic acid amplification uses techniques, such as the polymerase chain reaction, to detect the presence of specific syphilis genes. These tests are not as time-sensitive, as they do not require living bacteria to make the diagnosis

Prevention

As of 2010, there is no vaccine effective for prevention. Several vaccines based on treponemal proteins reduce lesion development in an animal model, and research is ongoing. Abstinence from intimate physical contact with an infected person is effective at reducing the transmission of syphilis, as is the proper use of a latex condom. Condom use does not completely eliminate the risk. Thus, the Centers for Disease Control and Prevention recommends a long-term, mutually monogamous relationship with an uninfected partner and the avoidance of substances such as alcohol and other drugs that increase risky sexual behavior.

Congenital syphilis in the newborn can be prevented by screening mothers during early pregnancy and treating those who are infected. The United States Preventive Services Task Force (USPSTF) strongly recommends universal screening of all pregnant women, while the World Health Organization recommends all women be tested at their first antenatal visit and again in the third trimester. If they are positive, they recommend their partners also be treated. Congenital syphilis is still common in the developing world, as many women do not receive antenatal care at all, and the antenatal care others receive does not include screening, and it still occasionally occurs in the developed world, as those most likely to acquire syphilis (through drug use, etc.) are least likely to receive care during pregnancy. Several measures to increase access to testing appear effective at reducing rates of congenital syphilis in low- to middle-income countries.

Syphilis is a notifiable disease in many countries, including Canada the European Union, and the United States. This means health care providers are required to notify public health authorities, which will then ideally provide partner notification to the person's partners. Physicians may also encourage patients to send their partners to seek care. The CDC recommends that sexually active men who have sex with men be tested at least yearly.

Several strategies have been found to improve follow-up for STI testing including email and text messaging as reminders of appointments

Treatment

Early infections

The first-choice treatment for uncomplicated syphilis remains a single dose of intramuscular benzathine penicillin G. Doxycycline and tetracycline are alternative choices for those allergic to penicillin; due to the risk of birth defects these are not recommended for pregnant women. Resistance to macrolides, rifampin, and clindamycin is often present. Ceftriaxone, a third-generation cephalosporin antibiotic, may be as effective as penicillin-based treatment. It is recommended that a treated person avoid sex until the sores are healed.

Late infections

For neurosyphilis, due to the poor penetration of penicillin G into the central nervous system, those affected are recommended to be given large doses of intravenous penicillin for a minimum of 10 days. If a person is allergic, ceftriaxone may be used or penicillin desensitization attempted. Other late presentations may be treated with once-weekly intramuscular penicillin G for three weeks. If allergic, as in the case of early disease, doxycycline or tetracycline may be used, albeit for a longer duration. Treatment at this stage limits further progression, but has only slight effect on damage which has already occurred.

Jarisch-Herxheimer reaction

One of the potential side effects of treatment is the Jarisch-Herxheimer reaction. It frequently starts within one hour and lasts for 24 hours, with symptoms of fever, muscles pains, headache, and a fast heart rate. It is caused by cytokines released by the immune system in response to lipoproteins released from rupturing syphilis bacteria.

History of syphilis

The history of syphilis has been well studied, but the exact origin of syphilis is unknown. There are two primary hypotheses: one proposes that syphilis was carried to Europe from the Americas by the crew of Christopher Columbus, the other proposes that syphilis previously existed in Europe but went unrecognized. These are referred to as the "Columbian" and "pre-Columbian" hypotheses.

In late 2011, newly published evidence suggested that the Columbian hypothesis is the valid one.

The first written records of an outbreak of syphilis in Europe occurred in 1494/1495 in Naples, Italy, during a French invasion. Because it was spread by returning French troops, the disease was known as "French disease", and it was not until 1530 that the term "syphilis" was first applied by the Italian physician and poet Girolamo Fracastoro. The causative organism, Treponema pallidum, was first identified by Fritz Schaudinn and Erich Hoffmann in 1905. The first effective treatment (Salvarsan) was developed in 1910 by Sahachirō Hata in the laboratory of Paul Ehrlich which was followed by the introduction of penicillin in 1943. Many famous historical figures including Franz Schubert, Arthur Schopenhauer, and Édouard Manet are believed to have had the disease.

Origin

The exact origin of syphilis is unknown. Two primary theories have been proposed. It is widely agreed upon by historians and anthropologists that syphilis was present among the indigenous peoples of the Americas before Europeans traveled to and from the New World. However, whether strains of syphilis were present in the entire world for millennia, or if the disease was confined to the Americas in the pre-Columbian era, has been debated.

The Columbian theory holds that syphilis was a New World disease brought back by Columbus and Martín Alonso Pinzón. This would be an example of a Columbian Exchange. Columbus's voyages to the Americas occurred three years before the Naples syphilis outbreak of 1494. This theory is supported by genetic studies of venereal syphilis and related bacteria, which found a disease intermediate between yaws and syphilis in Guyana, South America.

The pre-Columbian theory holds that syphilis was present in Europe before the arrival of Europeans in the Americas. Some scholars during the 18th and 19th centuries believed that the symptoms of syphilis in its tertiary form were described by Hippocrates in Classical Greece. Skeletons in pre-Columbus Pompeii and Metaponto in Italy with damage somewhat similar to that caused by congenital syphilis have also been found.[ However, these claims have not been submitted for peer review, and the evidence that has been made available to other scientists is weak. Nevertheless Douglas W. Owsley, a physical anthropologist at the Smithsonian Institution, and other supporters of this idea, say that many medieval European cases of leprosy, colloquially called lepra, were actually cases of syphilis. Although folklore claimed that syphilis was unknown in Europe until the return of the diseased sailors of the Columbian voyages, Owsley says that "syphilis probably cannot be "blamed"—as it often is—on any geographical area or specific race. The evidence suggests that the disease existed in both hemispheres from prehistoric times. It is only coincidental with the Columbus expeditions that the syphilis previously thought of as "lepra" flared into virulence at the end of the 15th century." Lobdell and Owsley wrote that a European writer who recorded an outbreak of "lepra" in 1303 was "clearly describing syphilis."

Historian Alfred Crosby suggests both theories are partly correct in a "combination theory". Crosby says that the bacterium that causes syphilis belongs to the same phylogenetic family as the bacteria that cause yaws and several other diseases. Despite the tradition of assigning the homeland of yaws to sub-Saharan Africa, Crosby notes that there is no unequivocal evidence of any related disease having been present in pre-Columbian Europe, Africa, or Asia. Crosby writes, "It is not impossible that the organisms causing treponematosis arrived from America in the 1490s...and evolved into both venereal and non-venereal syphilis and yaws." However, Crosby considers it more likely that a highly contagious ancestral species of the bacteria moved with early human ancestors across the land bridge of the Bering Straits many thousands of years ago without dying out in the original source population. He hypothesizes that "the differing ecological conditions produced different types of treponematosis and, in time, closely related but different diseases."

However, in late 2011 the Yearbook of Physical Anthropology published an appraisal by George Armelagos of Emory University, Molly Zuckerman, and Kristin Harper of previous studies that the "skeletal data bolsters the case that syphilis did not exist in Europe before Columbus set sail." The scientific evidence as determined by a systematic review of all published, peer-reviewed instances, best supports the theory that syphilis was unknown in Europe until Columbus returned from the Americas.

Skeletal evidence that reputedly showed signs of syphilis in Europe and other parts of the Old World before Christopher Columbus made his voyage in 1492 does not hold up when subjected to standardized analyses for diagnosis and dating, according to an appraisal in the current Yearbook of Physical Anthropology. This is the first time that all 54 previously published cases have been evaluated systematically, and bolsters the case that syphilis came from the New World.

— Science Daily, Skeletons point to Columbus voyage for syphilis origins

The historical origin of syphilis has modern social effects. The arrival of Europeans in the New World resulted in the damaging effects of colonialism and the spread of deadly diseases like smallpox that European explorers unintentionally brought to the Americas. According to biologist Marlene Zuk, "The origin of syphilis has always held an implied accusation: if Europeans brought it to the New World, the disease is one more symbol of Western imperialism run amok, one more grudge to hold against colonialism."

European outbreak

The first well-recorded European outbreak of what is now known as syphilis occurred in 1495 among French troops besieging Naples, Italy. It may have been transmitted to the French via Spanish mercenaries serving King Charles of France in that siege. From this centre, the disease swept across Europe. As Jared Diamond describes it, "[W]hen syphilis was first definitely recorded in Europe in 1495, its pustules often covered the body from the head to the knees, caused flesh to fall from people's faces, and led to death within a few months." The disease then was much more lethal than it is today. Diamond concludes,"[B]y 1546, the disease had evolved into the disease with the symptoms so well known to us today." The epidemiology of this first syphilis epidemic shows that the disease was either new or a mutated form of an earlier disease.

Researchers concluded that syphilis was carried from the New World to Europe after Columbus' voyages. Many of the crew members who served on this voyage later joined the army of King Charles VIII in his invasion of Italy in 1495, resulting in the spreading of the disease across Europe and as many as five million deaths. The findings suggested Europeans could have carried the nonvenereal tropical bacteria home, where the organisms may have mutated into a more deadly form in the different conditions and low immunity of the population of Europe. Syphilis was a major killer in Europe during the Renaissance. In his Serpentine Malady (Seville, 1539) Ruy Diaz de Isla estimated that over a million people were infected in Europe.

Historical terms

The name "syphilis" was coined by the Italian physician and poet Girolamo Fracastoro in his pastoral noted poem, written in Latin, titled Syphilis sive morbus gallicus (Latin for "Syphilis or The French Disease") in 1530. The protagonist of the poem is a shepherd named Syphilus (perhaps a variant spelling of Sipylus, a character in Ovid's Metamorphoses). Syphilus is presented as the first man to contract the disease, sent by the god Apollo as punishment for the defiance that Syphilus and his followers had shown him. From this character Fracastoro derived a new name for the disease, which he also used in his medical text De Contagionibus ("On Contagious Diseases").

Until that time, as Fracastoro notes,[not in citation given] syphilis had been called the "French disease" in Italy, Poland and Germany, and the "Italian disease" in France. In addition, the Dutch called it the "Spanish disease", the Russians called it the "Polish disease", and the Turks called it the "Christian disease" or "Frank (Western European) disease" (frengi). These "national" names were generally reflective of contemporary political spite between nations and frequently served as a sort of propaganda; the Dutch, for example, had a colonial rivalry with the Spanish, so referring to Syphilis as the 'Spanish' disease reinforced a politically useful perception that the Spanish were immoral or unworthy. The inherent xenophobia of the terms also stemmed from the disease's particular epidemiology, often being spread by foreign sailors and soldiers during their frequent sexual contact with local prostitutes.

During the 16th century, it was called "great pox" in order to distinguish it from smallpox. In its early stages, the great pox produced a rash similar to smallpox (also known as variola). However, the name is misleading, as smallpox was a far more deadly disease. The terms "Lues" (or Lues venerea, Latin for "venereal plague") and "Cupid's disease" have also been used to refer to syphilis. In Scotland, syphilis was referred to as the Grandgore. The ulcers suffered by British soldiers in Portugal were termed "The Black Lion"

Historical treatments

There were originally no effective treatments for syphilis, although a number of remedies were tried. Mercury was a common, long-standing treatment for syphilis, and its use has been suggested to date back to The Canon of Medicine (1025) by the Persian physician Ibn Sina (Avicenna), although this is only possible if syphilis existed in the Old World prior to Columbus (see Origins section). Giorgio Sommariva of Verona is recorded to have used mercury to treat syphilis in 1496, and is often recognized as the first physician to have done so, although he may not have been a physician. During the sixteenth century, mercury was administered to syphilitic patients in various ways, including by rubbing it on the skin, by applying a plaster, and by mouth. A "Fumigation" method of administering mercury was also used, in which mercury was vaporized over a fire and the patients were exposed to the resulting steam, either by being placed in a bottomless seat over the hot coals, or by having their entire bodies except for the head enclosed in a box (called a "tabernacle") that received the steam. The goal of mercury treatment was to cause the patient to salivate, which was thought to expel the disease. Unpleasant side effects of mercury treatment included gum ulcers and loose teeth. Mercury continued to be used in syphilis treatment for centuries; an 1869 article by TJ Walker discussed administering mercury by injection for this purpose.

Guaiacum was a popular treatment in the sixteenth century and was strongly advocated by Ulrich Von Hutten and others. Because guaiacum came from Hispaniola where Columbus had landed, proponents of the Columbian theory contended that God had provided a cure in the same location from which the disease originated. In 1525, the Spanish priest Francisco Delicado, who himself suffered from syphilis, wrote El modo de adoperare el legno de India discussing the use of guaiacum for treatment of syphilis. Although guaiacum did not have the unpleasant side effects of mercury, guaiacum was not particularly effective, at least not beyond the short term, and mercury was thought to be more effective. Some physicians continued to use both mercury and guaiacum on patients. After 1522, the Blatterhaus — an Augsburg municipal hospital for the syphilitic poor — would administer guaiacum (as a hot drink, followed by a sweating cure) as the first treatment, and use mercury as the treatment of last resort.

Another sixteenth-century treatment advocated by the Italian physician Antonio Musa Brassavola was the oral administration of Root of China, a form of sarsaparilla (Smilax). In the seventeenth century, English physician and herbalist Nicholas Culpeper recommended the use of heartsease (wild pansy).

Before effective treatments were available, syphilis could sometimes be disfiguring in the long term, leading to defects of the face and nose ("nasal collapse"). Syphilis was a stigmatized disease due to its sexually transmissible nature. Such defects marked the person as a social pariah, and a symbol of sexual deviancy. Artificial noses were sometimes used to improve this appearance. The pioneering work of the facial surgeon Gasparo Tagliacozzi in the 16th century marked one of the earliest attempts to surgically reconstruct nose defects. Before the invention of the free flap, only local tissue adjacent to the defect could be harvested for use, as the blood supply was a vital determining factor in the survival of the flap. Tagliacozzi's technique was to harvest tissue from the arm without removing its pedicle from the blood supply on the arm. The patient would have to stay with their arm strapped to their face until new blood vessels grew at the recipient site, and the flap could finally be separated from the arm during a second procedure.

As the disease became better understood, more effective treatments were found. An antimicrobial used for treating disease was the organo-arsenical drug Salvarsan, developed in 1908 by Sahachiro Hata in the laboratory of Nobel prize winner Paul Ehrlich. This group later discovered the related arsenic, Neosalvarsan, which is less toxic. Unfortunately, these drugs were not 100% effective, especially in late disease, and were sometimes unpredictably toxic to patients.

It was observed that sometimes patients who developed high fevers were cured of syphilis. Thus, for a brief time malaria was used as treatment for tertiary syphilis because it produced prolonged and high fevers (a form of pyrotherapy). This was considered an acceptable risk because the malaria could later be treated with quinine, which was available at that time. Malaria as a treatment for syphilis was usually reserved for late disease, especially neurosyphilis, and then followed by either Salvarsan or Neosalvarsan as adjuvant therapy. This discovery was championed by Julius Wagner-Jauregg, who won the 1927 Nobel Prize for Medicine for his discovery of the therapeutic value of malaria inoculation in the treatment of neurosyphilis. Later, hyperthermal cabinets (sweat-boxes) were used for the same purpose. These treatments were finally rendered obsolete by the discovery of penicillin, and its widespread manufacture after World War II allowed syphilis to be effectively and reliably cured.

History of diagnosis

In 1905, Schaudinn and Hoffmann discovered Treponema pallidum in tissue of patients with syphilis. One year later, the first effective test for syphilis, the Wassermann test, was developed. Although it had some false positive results, it was a major advance in the detection and prevention of syphilis. By allowing testing before the acute symptoms of the disease had developed, this test allowed the prevention of transmission of syphilis to others, even though it did not provide a cure for those infected. In the 1930s the Hinton test, developed by William Augustus Hinton, and based on flocculation, was shown to have fewer false positive reactions than the Wassermann test. Both of these early tests have been superseded by newer analytical methods.

While working at the Rockefeller University (then called the Rockefeller Institute for Medical Research) in 1913, Hideyo Noguchi, a Japanese scientist, demonstrated the presence of the spirochete Treponema pallidum in the brain of a progressive paralysis patient, associating Treponema pallidum with neurosyphilis. Prior to Noguchi's discovery, syphilis had been a burden to humanity in many lands. Without its cause being understood, it was sometimes misdiagnosed and often misattributed to damage by political enemies. It is called "the great pretender" for its variety of symptoms. Felix Milgrom developed a test for syphilis. The Hideyo Noguchi Africa Prize, was named to honor the man who identified the agent in association with the late form of the infectious disease

Health Benefits of Jaggery

Jaggery is a traditional non-centrifugal cane sugar consumed in Asia and Africa.It is a concentrated product of date, cane juice, or palm sap (see palm sugar) without separation of the molasses and crystals, and can vary from golden brown to dark brown in color. It contains up to 50% sucrose, up to 20% invert sugars, and up to 20% moisture, with the remainder made up of other insoluble matter, such as wood ash, proteins, and bagasse fibers. Jaggery is mixed with other ingredients, such as peanuts, condensed milk, coconut, and white sugar, to produce several locally marketed and consumed delicacies.

Unrefined, it is known by various names, including panela, in other parts of the world.

Origins and production

Jaggery is made of the products of sugarcane and the date palm tree. The sugar made from the sap of the date palm is both more prized and less commonly available outside of the regions where it is made. The date palm is tapped for producing jaggery in West Bengal, South India, Bangladesh, Pakistan, Nepal and Sri Lanka. In Sri Lanka, syrup extracts from kithul (Caryota urens) trees are widely used for jaggery production. This is considered the best jaggery available on the local market and is more highly valued than that from other sources.

All types of the sugar come in blocks or pastes of solidified concentrated sugar syrup heated to 200 °C (392 °F). Traditionally, the syrup is made by boiling raw sugarcane juice or palm sap in large, shallow, round-bottom vessels.

Preparation of jaggery

Cutting of sugar cane in a field in India.

Historically, the sugar cane cultivators used crushers which were ox-driven. Nowadays all the crushers are power-driven. These crushers are located in fields near the sugar crop. The cut and cleaned sugar cane is put into the crusher. The extracted sugar cane juice is collected in a big vessel. A certain quantity of the juice is transferred to a smaller vessel for heating on a furnace.

The vessel is heated for about one hour. Dried wood pulp from the crushed sugar cane is used as fuel for the furnace. While boiling the juice, some lime is added to it so that all the wood particles are collected on top of the juice in a froth during boiling which is skimmed off. Finally the juice is thickened and reduced to nearly one- third of the original volume. This hot liquid is golden in color. It is stirred continuously and lifted with a spatula to observe whether it forms a thread or drips dropwise while falling. If it forms many threads, it has completely thickened. Now it is poured into a shallow flat bottomed concrete tank to cool and solidify. The tank is large enough to allow only a thin coat of this hot liquid to form at its bottom, so as to increase the surface area for quick evaporation and cooling. After cooling down the jaggery becomes a soft solid which is now pressed into the desired shape for selling at the market.

The quality of the jaggery is judged by its color; brown means it is higher in impurities and golden-yellow implies it is relatively pure. Due to this grading scale there are malpractices of adding color or harmful chemicals to simulate the golden color.

Jaggery, also called gurh, is used as an ingredient in sweet and savory dishes across India, Pakistan, Bangladesh, Nepal, Sri Lanka as well as in Afghanistan and Iran. For example, a pinch of it is sometimes added to sambar, rasam, and other staples. Jaggery is added to lentil soups (dal) to add sweetness to balance the spicy, salty and sour components, particularly in Gujarati cuisine.

Maharashtra is the largest producer and consumer of jaggery most vegetable dishes, curries, and dals contain it. This is specially used during Makar Sankranti for making a dessert called tilgul. In Gujarat, known as gô during Makara Sankranti, a similar preparation called tal na ladu or tal sankli is made. In rural Maharashtra and Karnataka, water and a piece of jaggery is given when someone arrives home from working under a hot sun.

Molasses a byproduct of the production of jaggery, is used in rural Maharashtra and Karnataka as a sweetener. It contains many minerals not found in ordinary sugar and is considered beneficial to health in traditional Ayurvedic medicine. It is an ingredient of many sweet delicacies, such as gur ka chawal ("jaggery rice"), a traditional Rajasthani or Punjabi dish.

Jaggery is high in vitamin and minerals such iron, which helpful to anaemia patient. It also contains many minerals like Magnesium, Potassium, Calcium, Selenium, Manganese and Zinc which are very important for healthy body.

1. Prevents constipation: Jaggery activates the digestive enzymes in the body, stimulates bowel movements and thus helps prevent and relieve constipation.

2. Detoxes the liver: Jaggery helps cleanse the liver by flushing out harmful toxins from the body. So if you want to effectively detox your body, bite into a piece of jaggery.

3. Treats flu-like symptoms: Fight symptoms of a cold and cough with the help of gur. All you need to do is mix it with warm water and drink up, or even add it in your tea instead of sugar to reap the benefits.

4. Blood purifier: One of the most well-known benefits of jaggery is its ability to purify the blood. When consumed on a regular basis and in limited quantities, it cleanses the blood, leaving your body healthy.

5. Boosts immunity: Jaggery is loaded with antioxidants and minerals such as zinc and selenium, which in turn help prevent free-radical damage and also boost resistance against infections. Jaggery also helps increase the total count of haemoglobin in the blood.

6. Cleanses the body: Jaggery is one of the best natural cleansing agents for the body, hence it is advised to eat jaggery to remove unwanted particles from the body. It efficiently cleans the respiratory tract, lungs, intestines, stomach and food pipe. Eating jaggery is highly recommended for people working in heavily polluted areas such as factories or coal mines.

7. Eases menstrual pain: Jaggery contains many important nutrients, which important for healthy body, so it is very effective for menstrual problem. Gur is also useful to gives relief from cramp and stomach ache which are related to menstruation.

8. Cure Anaemia: Jaggery is great source of iron and folate. Iron and Folate maintain normal level of red blood cells and help to treat anaemia. Jaggery also gives an instant energy which cures the problem of fatigue and gives energy to your body, which one of the best Benefits of Jaggery for Pregnant Women.

9. Boosts intestinal health: Jaggery also boosts intestinal strength due to its high magnesium content. With every 10 gram of jaggery, you get 16 mg of magnesium, which is 4 percent of the daily requirement of this mineral.

10. Cools the stomach: Jaggery helps in maintaining normal body temperature which helps in keeping your stomach cool. Experts recommend drinking Gur Sharbat (jaggery soaked in ice cold water) during the summer months to cool off.

11. Maintain Blood Pressure: Jaggery is a rich source of potassium and sodium and both are very helpful to maintain a level of acid in your body. It also takes care of level of blood pressure in your body. It is one of Best Benefits of Jaggery to maintain your blood pressure level.

12. Cure Cough and Cold: It has ability to cure naturally cold and cough efficiently. Eating raw jaggery is very beneficial. You can make tea using gur or mix it with warm and drink to reduce problem of cold and cough. Jaggery is also very effective of migraines and headaches.

13. Relieves joint pain: "If you suffer from aches and pains in your joints, eating jaggery can provide you with much-needed relief", says Dr. Manoj K. Ahuja, Sukhda Hospital. You can eat it with a piece of ginger to alleviate joint pain, or even drink a glass of milk with jaggery every day to help strengthen the bones, thus preventing joint and bone problems such as arthritis.

14. Improve Metabolism and Help in weight loss: It is high in potassium, and it help to maintain electrolytes and also building up of muscles and boost metabolism in body. These things play a vital role to reduce weight, make it able to help in weight lose.

"Jaggery is surprisingly effective as an aid for weight loss. This is because jaggery is a rich source of potassium, which is a mineral that helps in the balance of electrolytes as well as building muscles and boosting metabolism. Potassium also helps in the reduction of water retention, which helps in managing your weight", says Delhi-based Nutritionist Anshul Jaibharat. These factors play an important role in effective weight loss, so if you're looking to lose some unwanted pounds, include this food in your diet.

15. Good source of energy: While sugar is a simple carbohydrate that gets absorbed in the bloodstream instantly and gives instant energy, jaggery is a complex carbohydrate that gives energy to the body gradually and for a longer time. This means that the levels of blood sugar do not get raised immediately. It also helps prevent fatigue and weakness of the body.

16.Good for sperm count : As per Ayurveda, consume it with powder of amla can beneficial to improve the quality of sperm count. It also helps in production of sperm in your body. It can reduce weakness in men and remove urinary problem in men. It is great Benefits of Jaggery for Sex life. Also it contain high amount of iron which great to improve hair growth.

17.Beauty Benefits of Jaggery or Gur:There are many Benefits of Jaggery for skin like nourish your skin, make skin healthy and glowing, reduce acne, blemish free skin, reduce sign of aging, and remove dark spot and wrinkles. Jaggery has natural properties which can your skin to stay healthy to all time

18. Maintain Temperature of Body : It has anti-allergic ingredient, which can help your body to maintain you temperature. It is great for the patient of Asthma, because Asthma patient must need a general temperature of body for all time. It is wonderful Benefits of Jaggery for the patient of Asthma.

19. Treat Urinary Problem : It last but not Least Health Benefits of Gur. Jaggery is made from sugarcane and sugarcane is works as natural diuretic, so it is useful to stimulate urination. It can also help in reduce inflammation of bladder. You can drink glass of milk with it to cure urinary problem and also to improve urine flow.

Consumption of Alcohol Harmful for People with HIV

Safe drinking limits for people living with HIV may need to be lower than the recommendations for the rest of the population, according to a large American study. The drinking habits and health outcomes of over 18,000 men living with HIV were compared with those of over 42,000 men who didn’t have HIV. Most participants were in their forties, fifties and sixties.

Alcohol contributes to a wide range of cancers, liver disease, stroke and heart disease.

Looking at deaths from any cause, the researchers found a strong relationship between the amount people with HIV drank and their risk of death. After adjusting for other factors that could influence the results, men who had 30 to 70 alcoholic drinks a month (i.e. one or two a day) had a 30% higher risk of death than men who hardly drank at all. Men who drank more than this (70 or more drinks a month) had a 50% greater risk.

In contrast, only the higher level of drinking (70 or more a month) made a difference to deaths in HIV-negative men.

There were similar results when looking at results of blood tests, liver function tests and other markers of poorer health – there wasn’t any level of alcohol consumption which was ‘safe’ for men with HIV.

One limitation of the study is that it only includes data on men. Nonetheless, the greater harm caused by a unit of alcohol in women is well established. The overall findings probably apply to women, but at lower levels of alcohol consumption.

Some other studies suggest that a person living with HIV who consumes the same amount of alcohol as an HIV-negative person would have higher levels of alcohol in their blood than the person without HIV. This effect may be especially pronounced in people who aren’t taking HIV treatment.

The researchers concluded that people with HIV who drink more than 30 alcoholic drinks a month are at increased risk of health problems. This was an American study, using American standard drinks – for example, one drink is a small can of beer, a small glass of wine or a shot of whisky. No more than 30 drinks a month would amount to no more than one drink a day.

UK health authorities calculate alcohol quantities differently, but recently released advice from the Chief Medical Officer is consistent with the recommendations of the American study. One “unit” of alcohol in the UK is roughly half of a standard drink in the US. The UK government now recommends alcohol consumption below 14 units a week, which is the same as 8 American standard drinks a week – i.e. roughly one drink a day. 

However very few people in the general population and even fewer people with HIV drink this little. But this is the first major study to show that there are particular advantages for people living with HIV to cut back on alcohol.

Infant and Young Child Feeding

Key facts

Every infant and child has the right to good nutrition according to the Convention on the Rights of the Child.

Under nutrition is associated with 45% of child deaths.

Globally in 2013, 161.5 million children under 5 were estimated to be stunted, 50.8 million were estimated to have low weight-for-height, and 41.7 million were overweight or obese.

About 36% of infants 0 to 6 months old are exclusively breastfed.

Few children receive nutritionally adequate and safe complementary foods; in many countries less than a fourth of infants 6–23 months of age meet the criteria of dietary diversity and feeding frequency that are appropriate for their age.

Over 800 000 children's lives could be saved every year among children under 5, if all children 0–23 months were optimally breastfed . Breastfeeding improves IQ, school attendance, and is associated with higher income in adult life. 1

Improving child development and reducing health costs through breastfeeding results in economic gains for individual families as well as at the national level.

Overview

Under nutrition is estimated to cause 3.1 million child deaths annually or 45% of all child deaths. Infant and young child feeding is a key area to improve child survival and promote healthy growth and development. The first 2 years of a child’s life are particularly important, as optimal nutrition during this period lowers morbidity and mortality, reduces the risk of chronic disease, and fosters better development overall.

Optimal breastfeeding is so critical that it could save over 800 000 under 5 child lives every year.

WHO and UNICEF recommend:

early initiation of breastfeeding within 1 hour of birth;

exclusive breastfeeding for the first 6 months of life; and

introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding up to 2 years of age or beyond.

However, many infants and children do not receive optimal feeding. For example, only about 36% of infants aged 0 to 6 months worldwide are exclusively breastfed over the period of 2007-2014.

Recommendations have been refined to also address the needs for infants born to HIV-infected mothers. Antiretroviral drugs now allow these children to exclusively breastfeed until they are 6 months old and continue breastfeeding until at least 12 months of age with a significantly reduced risk of HIV transmission.

Breastfeeding

Exclusive breastfeeding for 6 months has many benefits for the infant and mother. Chief among these is protection against gastrointestinal infections which is observed not only in developing but also industrialized countries. Early initiation of breastfeeding, within one hour of birth, protects the newborn from acquiring infections and reduces newborn mortality. The risk of mortality due to diarrhoea and other infections can increase in infants who are either partially breastfed or not breastfed at all.

Breast milk is also an important source of energy and nutrients in children aged 6 to 23 months. It can provide half or more of a child’s energy needs between the ages of 6 and 12 months, and one third of energy needs between 12 and 24 months. Breast milk is also a critical source of energy and nutrients during illness, and reduces mortality among children who are malnourished.

Children and adolescents who were breastfed as babies are less likely to be overweight/obese. Additionally, they perform better on intelligence tests and have higher school attendance. Breastfeeding is associated with higher income in adult life. Improving child development and reducing health costs result in economic gains for individual families as well as at the national level.1

Longer durations of breastfeeding also contribute to the health and well-being of mothers; it reduces the risk of ovarian and breast cancer and helps space pregnancies–exclusive breastfeeding of babies under 6 months has a hormonal effect which often induces a lack of menstruation. This is a natural (though not fail-safe) method of birth control known as the Lactation Amenorrhoea Method.

Mothers and families need to be supported for their children to be optimally breastfed. Actions that help protect, promote and support breastfeeding include:

adoption of policies such as the International Labour Organization’s Maternity Protection Convention 183 and Recommendation No. 191, which complements Convention No. 183 by suggesting a longer duration of leave and higher benefits;

the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions;

implementation of the Ten Steps to Successful Breastfeeding specified in the Baby-Friendly Hospital Initiative, including:

skin-to-skin contact between mother and baby immediately after birth and initiation of breastfeeding within the first hour of life;

breastfeeding on demand (that is, as often as the child wants, day and night);

rooming-in (allowing mothers and infants to remain together 24 hours a day);

not giving babies additional food or drink, even water, unless medically necessary;

provision of supportive health services with infant and young child feeding counselling during all contacts with caregivers and young children, such as during antenatal and postnatal care, well-child and sick child visits, and immunization; and

community support, including mother support groups and community-based health promotion and education activities.

Breastfeeding practices are highly responsive to supportive interventions, and the prevalence of exclusive and continued breastfeeding can be improved over the course of a few years.

Complementary feeding

Around the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided by breast milk, and complementary foods are necessary to meet those needs. An infant of this age is also developmentally ready for other foods. If complementary foods are not introduced around the age of 6 months, or if they are given inappropriately, an infant’s growth may falter. 

Guiding principles for appropriate complementary feeding are:

continue frequent, on-demand breastfeeding until 2 years of age or beyond;

practise responsive feeding (e.g. feed infants directly and assist older children. Feed slowly and patiently, encourage them to eat but do not force them, talk to the child and maintain eye contact);

practise good hygiene and proper food handling;

start at 6 months with small amounts of food and increase gradually as the child gets older;

gradually increase food consistency and variety;

increase the number of times that the child is fed: 2-3 meals per day for infants 6-8 months of age and 3-4 meals per day for infants 9-23 months of age, with 1-2 additional snacks as required;

use fortified complementary foods or vitamin-mineral supplements as needed; and

during illness, increase fluid intake including more breastfeeding, and offer soft, favourite foods.

Feeding in exceptionally difficult circumstances

Families and children in difficult circumstances require special attention and practical support. Wherever possible, mothers and babies should remain together and get the support they need to exercise the most appropriate feeding option available. Breastfeeding remains the preferred mode of infant feeding in almost all difficult situations, for instance:

low-birth-weight or premature infants;

HIV-infected mothers;

adolescent mothers;

infants and young children who are malnourished; and

families suffering the consequences of complex emergencies.

HIV and infant feeding

Breastfeeding, and especially early and exclusive breastfeeding, is one of the most significant ways to improve infant survival rates. However, HIV can pass from mother to child during pregnancy, labour or delivery, and also through breast milk. In the past, the challenge was to balance the risk of infants acquiring HIV through breastfeeding versus the higher risk of death from causes other than HIV, in particular malnutrition and serious illnesses such as diarrhea and pneumonia, among HIV-exposed but still uninfected infants who were not breastfed.

The evidence on HIV and infant feeding shows that giving antiretroviral drugs (ARVs) to HIV-infected mothers can significantly reduce the risk of transmission through breastfeeding and also improve her health. This enables infants of HIV-infected mothers to be breastfed with a low risk of transmission (1-2%). HIV-infected mothers and their infants living in countries where diarrhoea, pneumonia and malnutrition are still common causes of infant and child deaths can therefore gain the benefits of breastfeeding with minimal risk of HIV transmission.

Since 2010, WHO has recommended that mothers who are HIV-infected take ARVs and exclusively breastfeed their babies for 6 months, then introduce appropriate complementary foods and continue breastfeeding up to the child’s first birthday. Breastfeeding should only stop once a nutritionally adequate and safe diet without breast milk can be provided.

Even when ARVs are not available, mothers should be counselled to exclusively breastfeed for 6 months and continue breastfeeding thereafter unless environmental and social circumstances are safe for, and supportive of, feeding with infant formula.

WHO's response

WHO is committed to supporting countries with implementation and monitoring of the "Comprehensive implementation plan on maternal, infant and young child nutrition", endorsed by Member States in May 2012. The plan includes 6 targets, one of which is to increase, by 2025, the rate of exclusive breastfeeding for the first 6 months up to at least 50%. Activities that will help to achieve this include those outlined in the "Global Strategy for Infant and Young Child Feeding", which aims to protect, promote and support appropriate infant and young child feeding.

WHO has formed a Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant WHA resolutions called NetCode. The goal of NetCode is to protect and promote breastfeeding by ensuring that breastmilk substitutes are not marketed inappropriately. Specifically, NetCode is building the capacity of Member States and civil society to strengthen national Code legislation, continuously monitor adherence to the Code, and take action to stop all violations. In addition, WHO and UNICEF have developed courses for training health workers to provide skilled support to breastfeeding mothers, help them overcome problems, and monitor the growth of children, so they can identify early the risk of undernutrition or overweight/obesity.

In addition, WHO and UNICEF have developed courses for training health workers to provide skilled support to breastfeeding mothers, help them overcome problems, and monitor the growth of children, so they can identify early the risk of undernutrition or overweight/obesity.

WHO provides simple, coherent and feasible guidance to countries for promoting and supporting improved infant feeding by HIV-infected mothers to prevent mother-to-child transmission, good nutrition of the baby, and protect the health of the mother.

Healthy Diet

Key facts
A healthy diet helps protect against malnutrition in all its forms, as well as noncommunicable diseases (NCDs), including diabetes, heart disease, stroke and cancer.

Unhealthy diet and lack of physical activity are leading global risks to health.

Healthy dietary practices start early in life – breastfeeding fosters healthy growth and improves cognitive development, and may have longer-term health benefits, like reducing the risk of becoming overweight or obese and developing NCDs later in life.

Energy intake (calories) should be in balance with energy expenditure. Evidence indicates that total fat should not exceed 30% of total energy intake to avoid unhealthy weight gain , with a shift in fat consumption away from saturated fats to unsaturated fats , and towards the elimination of industrial trans fats .

Limiting intake of free sugars to less than 10% of total energy intake  is part of a healthy diet. A further reduction to less than 5% of total energy intake is suggested for additional health benefits.

Keeping salt intake to less than 5 g per day helps prevent hypertension and reduces the risk of heart disease and stroke in the adult population.

WHO Member States have agreed to reduce the global population’s intake of salt by 30% and halt the rise in diabetes and obesity in adults and adolescents as well as in childhood overweight by 2025.

Overview

Consuming a healthy diet throughout the life course helps prevent malnutrition in all its forms as well as a range of noncommunicable diseases and conditions. But the increased production of processed food, rapid urbanization and changing lifestyles have led to a shift in dietary patterns. People are now consuming more foods high in energy, fats, free sugars or salt/sodium, and many do not eat enough fruit, vegetables and dietary fiber such as whole grains.

The exact make-up of a diversified, balanced and healthy diet will vary depending on individual needs (e.g. age, gender, lifestyle, degree of physical activity), cultural context, locally available foods and dietary customs. But basic principles of what constitute a healthy diet remain the same.

For adults

A healthy diet contains:

Fruits, vegetables, legumes (e.g. lentils, beans), nuts and whole grains (e.g. unprocessed maize, millet, oats, wheat, brown rice).

At least 400 g (5 portions) of fruits and vegetables a day. Potatoes, sweet potatoes, cassava and other starchy roots are not classified as fruits or vegetables.

Less than 10% of total energy intake from free sugars  which is equivalent to 50 g (or around 12 level teaspoons) for a person of healthy body weight consuming approximately 2000 calories per day, but ideally less than 5% of total energy intake for additional health benefits . Most free sugars are added to foods or drinks by the manufacturer, cook or consumer, and can also be found in sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.

Less than 30% of total energy intake from fats. Unsaturated fats (e.g. found in fish, avocado, nuts, sunflower, canola and olive oils) are preferable to saturated fats (e.g. found in fatty meat, butter, palm and coconut oil, cream, cheese, ghee and lard) . Industrial trans fats (found in processed food, fast food, snack food, fried food, frozen pizza, pies, cookies, margarines and spreads) are not part of a healthy diet.

Less than 5 g of salt (equivalent to approximately 1 teaspoon) per day and use iodized salt.

For infants and young children

In the first 2 years of a child’s life, optimal nutrition fosters healthy growth and improves cognitive development. It also reduces the risk of becoming overweight or obese and developing NCDs later in life.

Advice on a healthy diet for infants and children is similar to that for adults, but the following elements are also important.

Infants should be breastfed exclusively during the first 6 months of life.

Infants should be breastfed continuously until 2 years of age and beyond.

From 6 months of age, breast milk should be complemented with a variety of adequate, safe and nutrient dense complementary foods. Salt and sugars should not be added to complementary foods.

Practical advice on maintaining a healthy diet

Fruits and vegetables

Eating at least 400 g, or 5 portions, of fruits and vegetables per day reduces the risk of NCDs , and helps ensure an adequate daily intake of dietary fiber.

In order to improve fruit and vegetable consumption you can:

always include vegetables in your meals

eat fresh fruits and raw vegetables as snacks

eat fresh fruits and vegetables in season

eat a variety of choices of fruits and vegetables.

Fats

Reducing the amount of total fat intake to less than 30% of total energy intake helps prevent unhealthy weight gain in the adult population.

Also, the risk of developing NCDs is lowered by reducing saturated fats to less than 10% of total energy intake, and trans fats to less than 1% of total energy intake, and replacing both with unsaturated fats.

Fat intake can be reduced by:

changing how you cook – remove the fatty part of meat; use vegetable oil (not animal oil); and boil, steam or bake rather than fry;

avoiding processed foods containing trans fats; and

limiting the consumption of foods containing high amounts of saturated fats (e.g. cheese, ice cream, fatty meat).

Salt, sodium and potassium

Most people consume too much sodium through salt (corresponding to an average of 9–12 g of salt per day) and not enough potassium. High salt consumption and insufficient potassium intake (less than 3.5 g) contribute to high blood pressure, which in turn increases the risk of heart disease and stroke.

1.7 million deaths could be prevented each year if people’s salt consumption were reduced to the recommended level of less than 5 g per day.

People are often unaware of the amount of salt they consume. In many countries, most salt comes from processed foods (e.g. ready meals; processed meats like bacon, ham and salami; cheese and salty snacks) or from food consumed frequently in large amounts (e.g. bread). Salt is also added to food during cooking (e.g. bouillon, stock cubes, soy sauce and fish sauce) or at the table (e.g. table salt).

You can reduce salt consumption by:

not adding salt, soy sauce or fish sauce during the preparation of food

not having salt on the table

limiting the consumption of salty snacks

choosing products with lower sodium content.

Some food manufacturers are reformulating recipes to reduce the salt content of their products, and it is helpful to check food labels to see how much sodium is in a product before purchasing or consuming it.

Potassium, which can mitigate the negative effects of elevated sodium consumption on blood pressure, can be increased with consumption of fresh fruits and vegetables.

Sugars

The intake of free sugars should be reduced throughout the lifecourse. Evidence indicates that in both adults and children, the intake of free sugars should be reduced to less than 10% of total energy intake, and that a reduction to less than 5% of total energy intake provides additional health benefits . Free sugars are all sugars added to foods or drinks by the manufacturer, cook or consumer, as well as sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.

Consuming free sugars increases the risk of dental caries (tooth decay). Excess calories from foods and drinks high in free sugars also contribute to unhealthy weight gain, which can lead to overweight and obesity.

Sugars intake can be reduced by:

limiting the consumption of foods and drinks containing high amounts of sugars (e.g. sugar-sweetened beverages, sugary snacks and candies); and eating fresh fruits and raw vegetables as snacks instead of sugary snacks.

How to promote healthy diets

Diet evolves over time, being influenced by many factors and complex interactions. Income, food prices (which will affect the availability and affordability of healthy foods), individual preferences and beliefs, cultural traditions, as well as geographical, environmental, social and economic factors all interact in a complex manner to shape individual dietary patterns. Therefore, promoting a healthy food environment, including food systems which promote a diversified, balanced and healthy diet, requires involvement across multiple sectors and stakeholders, including government, and the public and private sector.

Governments have a central role in creating a healthy food environment that enables people to adopt and maintain healthy dietary practices.

Effective actions by policy-makers to create a healthy food environment include:

Creating coherence in national policies and investment plans, including trade, food and agricultural policies, to promote a healthy diet and protect public health:

Increase incentives for producers and retailers to grow, use and sell fresh fruits and vegetables;

Reduce incentives for the food industry to continue or increase production of processed foods with saturated fats and free sugars;

Encourage reformulation of food products to reduce the contents of salt, fats (i.e. saturated fats and trans fats) and free sugars;

Implement the WHO recommendations on the marketing of foods and non-alcoholic beverages to children;

Establish standards to foster healthy dietary practices through ensuring the availability of healthy, Safe and affordable food in pre-schools, schools, other public institutions, and in the workplace;

Sxplore regulatory and voluntary instruments, such as marketing and food labelling policies, Economic incentives or disincentives (i.e. taxation, subsidies), to promote a healthy diet; and

encourage transnational, national and local food services and catering outlets to improve the nutritional quality of their food, ensure the availability and affordability of healthy choices, and review portion size and price.

Encouraging consumer demand for healthy foods and meals:

Promote consumer awareness of a healthy diet,

Develop school policies and programmes that encourage children to adopt and maintain a healthy diet;

Educate children, adolescents and adults about nutrition and healthy dietary practices;

Encourage culinary skills, including in schools;

Support point-of-sale information, including through food labelling that ensures accurate, Standardized and comprehensible information on nutrient contents in food in line with the Codex Alimentarius Commission guidelines; and

provide nutrition and dietary counselling at primary health care facilities.

Promoting appropriate infant and young child feeding practices:

Implement the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions;

Implement policies and practices to promote protection of working mothers; and

Promote, protect and support breastfeeding in health services and the community, including through the Baby-friendly Hospital Initiative.

WHO response

The “WHO Global Strategy on Diet, Physical Activity and Health” (12) was adopted in 2004 by the World Health Assembly (WHA). It called on governments, WHO, international partners, the private sector and civil society to take action at global, regional and local levels to support healthy diets and physical activity.

In 2010, the WHA endorsed a set of recommendations on the marketing of foods and non-alcoholic beverages to children (13). These recommendations guide countries in designing new policies and improving existing ones to reduce the impact on children of the marketing of unhealthy food. WHO is also helping to develop a nutrient profile model that countries can use as a tool to implement the marketing recommendations.

In 2012, the WHA adopted a “Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition” and 6 global nutrition targets to be achieved by 2025, including the reduction of stunting, wasting and overweight in children, the improvement of breastfeeding and the reduction of anaemia and low birth weight (7).

In 2013, the WHA agreed to 9 global voluntary targets for the prevention and control of NCDs, which include a halt to the rise in diabetes and obesity and a 30% relative reduction in the intake of salt by 2025. The “Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020” (8) provides guidance and policy options for Member States, WHO and other UN agencies to achieve the targets.

With many countries now seeing a rapid rise in obesity among infants and children, in May 2014 WHO set up the Commission on Ending Childhood Obesity. The Commission is developing a report specifying which approaches and actions are likely to be most effective in different contexts around the world.

In November 2014, WHO organized, jointly with the Food and Agriculture Organization of the United Nations (FAO), the Second International Conference on Nutrition (ICN2). ICN2 adopted the Rome Declaration on Nutrition (14) and the Framework for Action (15), which recommends a set of policy options and strategies to promote diversified, safe and healthy diets at all stages of life. WHO is helping countries to implement the commitments made at ICN2.

Sexually Transmitted Infections

Key facts

More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide.

Each year, there are an estimated 357 million new infections with 1 of 4 STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis.

More than 500 million people are estimated to have genital infection with herpes simplex virus (HSV).

More than 290 million women have a human papillomavirus (HPV) infection.2

The majority of STIs have no symptoms or only mild symptoms that may not be recognized as an STI.

STIs such as HSV type 2 and syphilis can increase the risk of HIV acquisition.

In some cases, STIs can have serious reproductive health consequences beyond the immediate impact of the infection itself (e.g., infertility or mother-to-child transmission)

Drug resistance, especially for gonorrhoea, is a major threat to reducing the impact of STIs worldwide.

What are sexually transmitted infections and how are they transmitted?

More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact. Eight of these pathogens are linked to the greatest incidence of sexually transmitted disease. Of these 8 infections, 4 are currently curable: syphilis, gonorrhoea, chlamydia and trichomoniasis. The other 4 are viral infections and are incurable: hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV). Symptoms or disease due to the incurable viral infections can be reduced or modified through treatment.

STIs are spread predominantly by sexual contact, including vaginal, anal and oral sex. Some STIs can also be spread through non-sexual means such as via blood or blood products. Many STIs—including chlamydia, gonorrhoea, primarily hepatitis B, HIV, and syphilis—can also be transmitted from mother to child during pregnancy and childbirth.

A person can have an STI without having obvious symptoms of disease. Common symptoms of STIs include vaginal discharge, urethral discharge or burning in men, genital ulcers, and abdominal pain.

Scope of the problem

STIs have a profound impact on sexual and reproductive health worldwide.

More than 1 million STIs are acquired every day. Each year, there are estimated 357 million new infections with 1 of 4 STIs: chlamydia (131 million), gonorrhoea (78 million), syphilis (5.6 million) and trichomoniasis (143 million). More than 500 million people are living with genital HSV (herpes) infection. At any point in time, more than 290 million women have an HPV infection, one of the most common STIs.

STIs can have serious consequences beyond the immediate impact of the infection itself.

STIs like herpes and syphilis can increase the risk of HIV acquisition three-fold or more.

Mother-to-child transmission of STIs can result in stillbirth, neonatal death, low-birth-weight and prematurity, sepsis, pneumonia, neonatal conjunctivitis, and congenital deformities. Syphilis in pregnancy leads to approximately 305 000 fetal and neonatal deaths every year and leaves 215 000 infants at increased risk of dying from prematurity, low-birth-weight or congenital disease.1

HPV infection causes 528 000 cases of cervical cancer and 266 000 cervical cancer deaths each year.2

STIs such as gonorrhoea and chlamydia are major causes of pelvic inflammatory disease (PID) and infertility in women.

Prevention of STIs

Counselling and behavioural approaches

Counselling and behavioural interventions offer primary prevention against STIs (including HIV), as well as against unintended pregnancies. These include:

comprehensive sexuality education, STI and HIV pre- and post-test counseling;

safer sex/risk-reduction counselling, condom promotion;

interventions targeted at key populations, such as sex workers, men who have sex with men and people who inject drugs; and

education and counseling tailored to the needs of adolescents.

In addition, counseling can improve people’s ability to recognize the symptoms of STIs and increase the likelihood they will seek care or encourage a sexual partner to do so. Unfortunately, lack of public awareness, lack of training of health workers, and long-standing, widespread stigma around STIs remain barriers to greater and more effective use of these interventions.

Barrier methods

When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely by national programmes as male condoms.

Diagnosis of STIs

Accurate diagnostic tests for STIs are widely used in high-income countries. These are especially useful for the diagnosis of asymptomatic infections. However, in low- and middle-income countries, diagnostic tests are largely unavailable. Where testing is available, it is often expensive and geographically inaccessible; and patients often need to wait a long time (or need to return) to receive results. As a result, follow up can be impeded and care or treatment can be incomplete.

The only inexpensive, rapid tests currently available for STIs are for syphilis and HIV. The syphilis test is already in use in some resource-limited settings. The test is accurate, can provide results in 15 to 20 minutes, and is easy to use with minimal training. Rapid syphilis tests have been shown to increase the number of pregnant women tested for syphilis. However, increased efforts are still needed in most low- and middle-income countries to ensure that all pregnant women receive a syphilis test.

Several rapid tests for other STIs are under development and have the potential to improve STI diagnosis and treatment, especially in resource-limited settings.

Treatment of STIs

Effective treatment is currently available for several STIs.

Three bacterial STIs (chlamydia, gonorrhoea and syphilis) and one parasitic STI (trichomoniasis) are generally curable with existing, effective single-dose regimens of antibiotics.

For herpes and HIV, the most effective medications available are antivirals that can modulate the course of the disease, though they cannot cure the disease.

For hepatitis B, immune system modulators (interferon) and antiviral medications can help to fight the virus and slow damage to the liver.

Resistance of STIs—in particular gonorrhoea—to antibiotics has increased rapidly in recent years and has reduced treatment options. The emergence of decreased susceptibility of gonorrhoea to the “last line” treatment option (oral and injectable cephalosporins) together with antimicrobial resistance already shown to penicillins, sulphonamides, tetracyclines, quinolones and macrolides make gonorrhoea a multidrug-resistant organism. Antimicrobial resistance for other STIs, though less common, also exists, making prevention and prompt treatment critical.

STI case management

Low- and middle-income countries rely on identifying consistent, easily recognizable signs and symptoms to guide treatment, without the use of laboratory tests. This is called syndromic management. This approach, which often relies on clinical algorithms, allows health workers to diagnose a specific infection on the basis of observed syndromes (e.g., vaginal discharge, urethral discharge, genital ulcers, abdominal pain).

Syndromic management is simple, assures rapid, same-day treatment, and avoids expensive or unavailable diagnostic tests. However, this approach misses infections that do not demonstrate any syndromes - the majority of STIs globally.

Vaccines and other biomedical interventions

Safe and highly effective vaccines are available for 2 STIs: hepatitis B and HPV. These vaccines have represented major advances in STI prevention. The vaccine against hepatitis B is included in infant immunization programmes in 93% of countries and has already prevented an estimated 1.3 million deaths from chronic liver disease and cancer.

HPV vaccine is available as part of routine immunization programmes in 65 countries, most of them high- and middle-income. HPV vaccination could prevent the deaths of more than 4 million women over the next decade in low- and middle-income countries, where most cases of cervical cancer occur, if 70% vaccination coverage can be achieved.

Research to develop vaccines against herpes and HIV is advanced, with several vaccine candidates in early clinical development. Research into vaccines for chlamydia, gonorrhoea, syphilis and trichomoniasis is in earlier stages of development.

Other biomedical interventions to prevent some STIs include adult male circumcision and microbicides.

Male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60% and provides some protection against other STIs, such as herpes and HPV.

Tenofovir gel, when used as a vaginal microbicide, has had mixed results in terms of the ability to prevent HIV acquisition, but has shown some effectiveness against HSV-2.

Current efforts to contain the spread of STIs are not sufficient

Behaviour change is complex

Despite considerable efforts to identify simple interventions that can reduce risky sexual behaviour, behaviour change remains a complex challenge. Research has demonstrated the need to focus on carefully defined populations, consult extensively with the identified target populations, and involve them in design, implementation and evaluation.

Health services for screening and treatment of STIs remain weak

People seeking screening and treatment for STIs face numerous problems. These include limited resources, stigmatization, poor quality of services, and little or no follow-up of sexual partners.

In many countries, STI services are provided separately and not available in primary health care, family planning and other routine health services.

In many settings, services are often unable to provide screening for asymptomatic infections, lacking trained personnel, laboratory capacity and adequate supplies of appropriate medicines.

Marginalized populations with the highest rates of STIs—such as sex workers, men who have sex with men, people who inject drugs, prison inmates, mobile populations and adolescents—often do not have access to adequate health services.

WHO response

WHO develops global norms and standards for STI treatment and prevention, strengthens systems for surveillance and monitoring, including those for drug-resistant gonorrhoea, and leads the setting of the global research agenda on STIs.

Our work is currently guided by the Global Strategy for the Prevention and Control of Sexually Transmitted Infections: 2006-2015, adopted by the World Health Assembly in 2006, and the 2015 United Nations Global Strategy for Women's, Children's and Adolescents’ Health, which highlight the need for a comprehensive, integrated package of essential interventions, including information and services for the prevention of HIV and other sexually transmitted infections. WHO is developing 3 new 2016-2021 Global Health Sector Strategies for HIV/AIDS, Viral Hepatitis, and STIs.

WHO works with countries to:

Scale-up effective STI services including:

STI case management and counseling

syphilis testing and treatment, in particular for pregnant women

hepatitis B and HPV vaccination.

Promote strategies to enhance STI-prevention impact including:

integrate STI services into existing health systems

promote sexual health

measure the burden of STIs

monitor and respond to STI antimicrobial resistance.

Support the development of new technologies for STI prevention such as:

point-of care diagnostic tests for STIs

additional drugs for gonorrhoea

STI vaccines and other biomedical interventions.

How Lifestyle Impacts Your Health

Starting in the mid-20th century, the primary causes of death worldwide shifted from infections to chronic conditions, such as heart disease and cancer. The School has meticulously documented this change, standing at the forefront of both basic and applied research. Its discoveries in nutrition, exercise, and other individual risk factors have reconfigured the public health landscape.

The Nurses’ Health Study I, ­ a collaboration begun in 1976 among School scientists and researchers at Brigham and Women’s Hospital and the Channing Laboratory, ­ was the first of a series of prospective cohort investigations, now among the largest and oldest in the world. The study produced a lengthy list of surprising findings. Among these: that a high-fat diet increases colon cancer risk but not breast cancer risk; that weight gain after adolescence raises death rates in midlife; and that light smoking more than doubles the risk of heart disease. The Physicians’ Health Study showed that an aspirin a day reduces the risk of heart attack.

The School’s Department of Nutrition, founded in 1942, was the first such department in a medical or public health school in the world. Its groundbreaking research includes work on the health benefits and hazards of proteins and fats; the components of a well-balanced diet; and clinical aspects of obesity. School scientists created the first animal model for hypercholesterolemia and demonstrated the protective nature of HDL cholesterol and the blood vessel-damaging potential of LDL cholesterol.

In the 1970s, School scientists helped map the government’s Dietary Guidelines for Americans; decades later, they proposed an alternative Healthy Eating Pyramid based on the Mediterranean diet and including recommendations for daily exercise and weight control. In 2006, when the U.S. Food and Drug Administration ordered that nutrition labels for packaged foods list all harmful trans fatty acids, it signified a victory for School scientists, led by Walter Willett. A vigorous public health advocate, Willett not only amassed evidence that these solid fats raise the risk of coronary artery disease, type 2 diabetes, and other ills, but also waged a campaign to label and ultimately eliminate the ingredient from manufactured food products and restaurant meals.

Established in 1988, the Center for Health Communication has used entertainment media and mass communication to shift social norms in healthier directions. Among its innovations, it worked with Hollywood to incorporate the Swedish-originated designated-driver concept into entertainment programming, which decreased alcohol-related traffic crashes. So successful were the School’s efforts that the Random House Webster’s College Dictionary (1991 edition) added “designated driver” to the American lexicon.

In a similar vein, School faculty have led the charge for worldwide tobacco control, providing the scientific expertise to convince nations in Europe and Asia to pass smoking bans for public places. In a pair of 2008 studies, School investigators revealed a deliberate strategy among tobacco companies to recruit and addict young smokers by manipulating menthol content and by heavily advertising in places that cater to youth.

In 2008, School researchers published the largest and longest-running study to estimate the impact of a combination of lifestyle factors on mortality. The study concluded that not smoking, maintaining a healthy weight, regular physical activity, and a nutritious diet dramatically lowered the risk of dying from all causes during the 24 years of the study. In 2009, resolving a long-simmering scientific and popular debate, School investigators found that diets that reduced calories led to weight loss, ­ regardless of the proportion of carbohydrates, protein, or fat.

How Lifestyle Impacts Your Health

Lifestyle includes the behavior and activities that make up your daily life. This includes:

• the work you do

• your leisure activities

• the food you eat 

• your interaction with family, friends, neighbors,coworkers and strangers. 

Making Decisions about the Way You Live:

People make decisions based on beliefs, attitudes,and values. Our life experience and interaction with others also shapes our thoughts and actions.Personal behavior is affected by the information you learn at home and school, and from the radio,newspapers, and television. The good news is:

you can change the way you live

Thinking about changing your lifestyle?

• Pay attention to the way you live (or your lifestyle and health habits) and the work you do every day. 

• Talk with friends and family about lifestyle and health decisions.

• Discuss what you may want to change with them.

• Improve the quality of life for you and your family

Make a Healthy Choice Today!

Making Decisions about the Foods We Eat:
The foods we eat affect on our health. Many studies show that good nutrition lowers the risk for many diseases. Our food habits can bring on heart disease, stroke, some types of cancer, diabetes, and osteoporosis …or help prevent them!

You may like to eat foods from your family’s country of origin, following their customs and traditions. You can usually improve traditional family recipes for better health by substituting ingredients.

Make a Family Recipe Book: 

• Collect family recipes in a booklet.

• Share the recipes with a nutrition expert and find out which recipes are healthy ones. 

• Ask how to change some ingredients of old favorites that are sort of unhealthy. 

• Make those changes to the recipes and taste them with your family.

• Share the book of healthier recipes with everyone in your family

Change the way you eat. It can be fun and tasty

Work and Leisure Activities

The work we do affects our health. Apart from exposure to environmental hazards such as UV radiation and toxic chemicals like smoke, asbestos or pesticides, certain types of work involve prolonged repetitive actions and/or reduced levels of activity that may lead to muscular or skeletal problems, strained vision, and other health problems

Even the person with the busiest schedule can make room for stretching, physical activity, and having fun. Before or after work or before meals might be a good time to do this. Think about your daily schedule and look for ways to be more active

Tips for Becoming More Active:

• Walk as much as possible 

• Park the car farther away 

• Take the stairs instead of the elevator or escalator

• Try gardening or home repair activities

• Dance!

Studies have shown that regular mild aerobic exercise four times a week may help lower cholesterol, reduce the risk of heart disease, and improve diabetes management.

Leisure activities such as reading, playing cards, listening to music, and other pastimes have also been shown to have a positive impact on health by reducing stress.

Steps to Healthy Eating:

• Make good nutrition part of every day living. 

• Eat healthy at home, work and play. 

• Eating healthier will make you be and feel healthier.

Tips for Healthy Eating: 

• Eat at least 5-9 servings of fruits and vegetables every day. Try them canned, frozen, or as juice. 

• Choose whole grain bread and cereal. 

• Choose low-fat milk and cheeses. 

• Choose lean meats, poultry, fish. 

• Eat more beans and grains 

• Use less salt, sugar, alcohol, and saturated fat. 

• Drink lots of water between meals.

Other Things You Can Do to Stay Healthy: 

• If you smoke now, quit! 

• Get a handle on stress! 

• If you drink alcohol, beer, or wine only drink in moderation

Lifestyle-based analytics hold promise for proactive care

Lifestyle-based analytics may be an "emerging" predictive health model, but experts note that it's "simply taking data that we already have at our fingertips" and analyzing it in ways that weren't possible before.

The benefit? “Moving from a reactive mode to a proactive mode” in healthcare, says Chris Stehno, senior manager at Deloitte Consulting.

In the past, predictive healthcare modeling has used claims data, but the majority of the population doesn’t have good data – making predictions about life events and diseases difficult.

Stehno says their model uses consumer spending data, which is “chock-full“ of information on how individuals lead their lives. This data also provides high correlations for lifestyle-based diseases, which account for 75 percent of the total medical dollars spent in the U.S.

As Bill Preston, a principal at Deloitte, points out, when a person changes addresses, he or she starts getting bombarded with offerings for new siding – because consumer data indicates they're a new home buyer. Preston says their model takes that same data and it mines it for “specific variables that will be indicative of a particular situation or disease.”

For instance, Preston and Stehno note studies that have shown that individuals with a commute of 90 minutes or longer round-trip are 20 percent more likely to become diabetic or obese.

“Where in claims data you know for sure that they have a condition,” in the lifestyle based analytics, “this information doesn’t tell you that [this individual] has diabetes it tells you that they have an elevated risk for diabetes," says Stehno.

Preston notes that this can allow health insurers and providers to be proactive and not wait to do something until they are sick, which lowers overall healthcare spending.

But the model can also indicate an individual's “willingness to change.” For example, says Stehno, if an individual is seen to have purchased weight loss training products, it suggests that he or she has “change behavior” in mind. This can help identify people at risk when the chances of helping them can be maxmized, he says.

With the diagnoses codes changing due to healthcare reform and ICD-10, predictive modeling will have to be rebuilt, Preston notes.

"Lifestyle based analytics gives them a way to bridge that gap while this work is being done,” he explains.

For health insurers and providers, “the biggest hurdle,” says Stehno, is changing their “mindset and strategy” about how they approach people, and how they will use their existing programs to talk to people and reach out to them.