GONORRHOEA SITUATION IN SOUTH GREENLAND IN THE … · GONORRHOEA SITUATION IN SOUTH GREENLAND IN THE SUMMER OF 1964* BY GUNNARLOMHOLTAND OLEBERG Froni the GonococcusLaboratory,Julianehab,

Brit. J. vener. Dis. (1966), 42, 1.

GONORRHOEA SITUATION IN SOUTH GREENLANDIN THE SUMMER OF 1964*

BY

GUNNAR LOMHOLT AND OLE BERGFroni the Gonococcus Laboratory, Julianehab, Greenland, and Auken and Lomholt's Dermatological Clinic, Copenhagen,

Denmark

Greenland is the largest island in the world,situated north-east of the North American continent(Fig. 1). Its length from north to south is 2,700 km.and its width from east to west 1,050 km., the totalarea being 2,175,600 sq. km. Of this total area 84per cent. is covered with an ice cap, called theinland ice, the ice-free areas along the coast makingup only about 341,700 sq. km. The country is typicallymountainous, with very few flat stretches. The coastis bordered by skerries and indented by many deepfiords which often stretch right to the inland ice.Greenland is part of the Kingdom of Denmark,

but has quite extensive home rule. This large countryis inhabited by only 35,000 people, most of whom

* Received for publication May 13, 1965

live in small towns of 1,000 to 3,000 inhabitants,with a hospital, school, power station, telegraphstation, and major or minor industrial plants. Inrecent years, these small towns have begun to de-velop into modern urban communities on a WesternEuropean pattern, but to this day 43 per cent. of thepopulation live in small, isolated communities. Owingto the enormous distances and the difficult com-munications, many of these trading stations andsettlements are not visited by a doctor as often aswould be desirable. The doctor often has to travelfor days by boat or dog sledge to visit his vastmedical district. Therefore, the daily supervision ofthe population in these distant places is left to a

Greenlandic midwife with very moderate theoreticaland practical education.

S ION NORD

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FIG. 1.-Map of Greenland.

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BRITISH JOURNAL OF VENEREAL DISEASES

The original population of Greenland consistedof Eskimos, but to-day a pure Eskimo is rare, almostthe entire population bearing the marks of thepresence of Danes since 1605.

Traditionally, the Greenlandic population's viewson sexual relations are extremely free (von Osten,1789; Bertelsen, 1935; Marcussen and Rendal, 1951).Gonorrhoea is a comparatively new disease in

Greenland. The first case was diagnosed in 1864(Lange, 1864), but since 1913 the disease has beenspreading rapidly (Folke, 1935). In recent years, theincrease has been explosive, the number of caseshaving doubled between 1955 and 1962 (B0ggild,1965). Merely from 1961 to 1962 there was anincrease of not less than 43 per cent. in the notifiedcases (Fig. 2).

4.000w

O 3.500

H, 3.000w

a

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d 2.000z

: 2.500c

ol.1955 56 57 58 59 60 61 62Year

FIG. 2.-Annual number of recorded cases of gonorrhoea in Green-land, 1955-62.

In 1962, 4,000 cases of gonorrhoea were recordedin the population of 35,000. This gives quite asombre picture of the conditions. In Denmarkproper, i.e. in a population of 4 5 millions, theannual number of diagnosed cases is only twice thatin the small Greenlandic population. Moreover,there is no record of the incidence of gonorrhoeaamong the inhabitants of the trading stations who,as already mentioned, make up 43 per cent. of thetotal population.The situation became critical in 1962 when treat-

ment failures were experienced in 27 per cent. ofcases, and it has been ascertained that 86 per cent.of the gonococcal strains showed reduced sensitivityto penicillin (B0ggild, 1965). The development of somany gonococcal strains with reduced sensitivity topenicillin is presumably due to the fact that at thetime treatment took the form of a single dose of 2-4million units of the preparation Penilente Novo forte,containing 600,000 units sodium penicillin, 600,000units procaine penicillin, and 1 - 2 million unitsbenzathine penicillin. This gives a high initial con-

centration of penicillin and maintains a long-lasting,but low concentration (Perdrup, 1961). This latterfact increases the risk of selection of penicillin-resistant strains.Even after the treatment was changed to procaine

penicillin, 1 - 2 million units daily for 3 days, failuresstill occurred in 28 per cent. of cases.

Present InvestigationsAt the request of the Ministry for Greenland and

the National Health Service, we conducted a pilotstudy of the gonorrhoea situation in the threesouthernmost medical districts of Greenland in thesummer of 1964. This area is populated by approxi-mately 6,500 people. The investigation was assistedby a gonococcus laboratory from the Serum Institutein Copenhagen. The study was conducted on thebasis of epidemiological surveys with meticuloustracing of contacts.

In the course of 2j months we investigated 1,083persons for venereal and dermatological diseasesand detected 228 cases ofgonorrhoea. Thegonococcuslaboratory examined a total of 2,510 culture speci-mens.

In order to obtain material from the tradingstations, the local midwives were instructed in takingspecimens for culture from the urethra of males aswell as females. Special iceboxes and thermo-containers were procured for the storage andtransport of the tubes containing the culture medium(Fig. 3, opposite).

All who applied to the midwife were treatedimmediately with penicillin, without waiting for theresult of the bacteriological investigations. The sameapplied to the patients' contacts. This system func-tioned satisfactorily during the period of the study.

FindingsOn the basis of these investigations it may be

estimated that the annual incidence of gonorrhoea inGreenland must be around 20 per cent., being highest(40 per cent.) in the southernmost district. Massiveinfection was also found among the population ofthe trading stations, the findings indicating an annualincidence of approximately 30 per cent.Owing to the need to record the material before

the authors left Greenland on September 1, theanalysis includes only the first 142 patients who werestarted on treatment in the two northernmost medicaldistricts before August 15th.Sex Ratio.-These 142 patients comprised seventy

males and 72 females-a strikingly equal sex ratio.Statistics from other countries usually show a con-siderable preponderance of males. In Denmark, forinstance, twice as many cases are recorded among

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GONORRHOEA IN SOUTH GREENLAND

FIG. 3.-Thermocontainer for transport and icebox for storage of tubes with culture medium.

males-according to some authors even four timesas many-as among females (WHO Expert Com-mittee, 1963). The equal sex ratio in the presentseries indicates that the tracing of contacts has beenquite effective.Age Distribution.-83 per cent. of the males and

86 per cent. of the females were between 15 and 29years of age (Table I).

TABLE IAGE DISTRIBUTION OF GREENLANDERS AND DANES

SexAge Group __ __

Country (yrs) Male Female

No. Per cent. No. Per cent.

Under 15 0 115-19 18 30 29 4120-24 23 39 83 26 37 86

Greenland 25-29 8 14 J 7J

30-34 6 635-44 1l 17 2} 1445- 3 2J

Total .. 59 71

20-24 7Denmark 25-29 2

30-34 2

Total .. 11

Marital Status.-It is evident from Table II thatthe majority of the patients were single, marriedpatients being exceptional.

Previous History (Table III).-Among the Green-landic patients with gonorrhoea, 8 per cent. of themales and 10 per cent. of the females stated that theyhad not previously had gonorrhoea. After omittingthe patients whose history was unknown (almost

TABLE IIMARITAL STATUS OF GREENLANDERS AND DANES

SexCountry Marital

Status Male Female

Single 50 63Greenland Married .. 5 7

Not Known 4 1

Total 59 71

Single .. 9Denmark Married2.

Total .. 11

exclusively patients in whom the diagnosis was basedon a positive result of a specimen sent in by the localmidwife who did not report on this point) 49 per cent.of the males and 68 per cent. of the females reportedhaving had three or more previous attacks ofgonorrhoea.

TABLE IIIPREVIOUS INFECTION WITH GONORRHOEA

Number of GreenlandersPrevious _ _ _ Danish

Infections with Males Females MalesGonorrhoea

No. Percent. No. Per cent.

0 5 8 7 10 7

2 141 21 36 8J 13 18 0

3-4 1 1 27 15-6 61 71 07-8 2 .25 42 71}42 59 09-10 41 1 011+ 2J 0 0

Not Known 8 14 9 13 1

Total .. 59 100 71 100 11

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Time of Last Infection with Gonorrhoea (TableIV).-The great majority of patients had had repeatedrecurrences of gonorrhoea during the past few years.

TABLE IVDATE OF LAST INFECTION WITH GONORRHOEA

Sex Percentage Date of Infection

17-4 Before 19612-2 1961

Male 8-7 196230 4 196341-3 1964

33*0 After April 1, 1964

10-9 Before 19615-5 19613-6 1962

Female 20-0 196360-0 1964

40*0 After April 1, 1964

Tracing of Contacts.-Meticulous tracing ofcontacts is of fundamental significance for con-fining and fighting venereal diseases in a given area(Marcussen and Rendal, 1951; Rahbek, 1962). Fromthe very outset, we attached great importance to thisaspect of the study. The number of different con-tacts admitted within approximately the previous3 weeks is shown in Fig. 4. Men reported an averageof 1 .9 contacts and women an average of 2-7, andwe succeeded in examining 1 -5 contacts per malepatient and 2-1 contacts per female patient. Thus,79 per cent. of the contacts reported by the malesand 76 per cent. of those reported by the femaleswere examined by the team.Gonorrhoea was found in 69 per cent. of the

contacts of the males and 57 per cent. of those of thefemales. Converted to total reported contacts,gonorrhoea was demonstrated in 55 per cent. of thecontacts of males and 43 per cent. of those of females.

30 Males (70)

25-

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i 10

0 1 2 3 4 5 II-?No. of Cases Reported 6-10

Reason for Investigation (Table V).-This aspectof the study clearly displays the necessity of carefulcontact tracing. Only one of the 72 female patientswith gonorrhoea presented herself on her owninitiative, and 45 were found as contacts of malepatients in whom gonorrhoea had been diagnosed.

TABLE VREASON FOR EXAMINATION

SexReason for Examination

Male Female Total

Reported as contact 20 45 65Presented of own accord 34 1 35Re-infection .. 6 2 8Recurrence after treatment

elsewhere .. 2 2 4"G-day" 7 20 27Rape or attempted rape, incest 1 1 2Routine examination post par-tum .. 0 1 1

Total 70 72 142

Efforts were made to follow up all patients byobtaining specimens for culture three times at weeklyintervals before finally discharging them. One ofthese follow-up studies was arranged so that allpatients from the past months were asked to presentthemselves for investigation on the same day-theso-called "G day"-and on this day all the patientswere given extra treatment. The motivation for thisextra treatment was that on one single day we wantedto make sure that a given portion of the "hard core"had been cured of the disease. The concept "G day",however, comprises also the initial, broadly-plannedfollow-up and treatment of all patients treated forgonorrhoea within the 4 months before the start ofthe investigation. This extraordinary follow-up dis-closed a total of 32 cases within the entire period ofthe study.

Females (72)

I I-10

FIG. 4.-Number of different contacts reported by 70 males and 72 females within approximately the previous 3 weeks.?=number of contacts not known-almost exclusively patients from trading stations examined by midwives.

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Sensitivity Determinations.-Sensitivity tests topenicillin, tetracycline, and streptomycin were carriedout on 152 gonococcal strains, 47 per cent. of themshowed reduced sensitivity to penicillin (Fig. 5),whereas only 9 per cent. showed reduced sensitivityto tetracycline (Fig. 6); 15 per cent. of the testedstrains were resistant to streptomycin (Table VI).This distribution is very different from that found byB0ggild (1965) in Godthab (Greenland) and bySchmidt (1962) in Copenhagen (Denmark).

TABLE VISENSITIVITY OF 152 GONOCOCCAL STRAINS TO

STREPTOMYCIN

StrainsSensitivity

No. Per cent.Resistant (:25 jig./ml.) 26 15Sensitive (225 ±Lg./ml.) 126 85

Boggild, GodthMb (1962) 57 per cent. resistantSchmidt, Copenhagen (1960-61) 9 per cent. resistant

Gonococcal Complement-fixation Test.-This waspositive in 31 per cent. of the patients so investigated.Positive reactions were considerably more commonin the trading stations than in the towns, presumablybecause patients from the trading stations harbourtheir infection longer before being treated and somehave probably been treated insufficiently by themidwives.

Complications.-There was a striking paucity ofcomplications (only one case of prostatitis, two ofsalpingitis, one of epididymitis, and three of gonor-rhoeal arthritis). It must be emphasized, however,that it was not possible to employ bidigital palpation

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Sensitive Less Sensitive 9%/s5/ 4

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systematically. Gisslen, Hellgren, and Starck (1961)in Gothenburg, Sweden, found gonorrhoeal sal-pingitis in 10 per cent. of their female patients withgonorrhoea and sterility in 2 to 3 per cent. In GreatBritain, Rees (1964) has demonstrated an increasingincidence of gonorrhoeal salpingitis, reaching 11 -6per cent. in 1962. In a population like that of Green-land, a considerable number of severe complicationswould have been expected, but the actual figures areamazingly low.Pregnancies.-Gonorrhoea was diagnosed by

culture in six pregnant women, one of them 6months and three 8 months pregnant. Furthermore,gonorrhoea was demonstrated in one woman byroutine culture immediately post partum. It iscomforting to know that Crede's prophylacticinstillation of silver nitrate is carried out routinely inGreenland.

TreatmentAs treatment with benzathine penicillin in a single

dose as well as with procaine penicillin for threeconsecutive days had failed, preliminary studies oncombined treatment with probenecid and sodiumbenzyl penicillin were performed in collaborationwith Schmidt and Roholt (1965) before the authors'departure for Greenland. These experiments hadshown blood levels of penicillin which might bepresumed to cover a penicillin resistance patternlike that demonstrated by B0ggild (1965). Previously,Jensen, Kvorning, and N0rredam (1962) had reportedthat such combined treatment was effective ingonorrhoea resistant to penicillin.

35.-30-

a 25.a'6 20-0

.0E 10z

S.

FIG. 5.-Sensitivity of 152 gonococcal strains to penicillin.

[1

Sensitive Less Sensitive

H910/a 90/a

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QOd dddd-0 cm (4 U6500/a Inhibitory Concentrations of

Tetracycline (152 strains)

FIG. 6.-Sensitivity of 152 gonococcal strains to tetracycline.

o'o'oooo 0000 d008 nb8. 8 once trio o P ( strains)

50%/ Inhibitory Concentrations of Penicillin (152strains)

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It was decided, therefore, to introduce a standardtreatment consisting of 1 g. probenecid, followedafter half an hour by an intramuscular injection of 5million units sodium benzyl penicillin dissolved in8 ml. 0* 5 per cent. lidocaine. Lidocaine was used as asolvent in order to eliminate the quite severe paincaused by the injection of such a large dose ofpenicillin into the tissue.

Therapeutic Results.-This treatment was veryefficacious; there was only one recurrence and eightre-infections. In distinguishing between recurrenceand re-infection, we stressed the three followingpoints:(1) Whether negative cultures had been obtained in the

interim;(2) Whether sexual intercourse had taken place with a

person having presumed or definite gonorrhoeaprior to this exposure to risk;

(3) Repeated determinations of sensitivity to penicillin,tetracycline, and streptomycin.

All eight cases of re-infection fulfil at least two ofthese requirements.

Side - Effects.-From 400 to 500 injections ofpenicillin were given, and only four persons developedurticaria of a maximum duration of one day.No other side-effects were recorded.

The Trading StationsIn order to elucidate the conditions among the

population of the trading stations, a total investi-gation was conducted of all adults present at twotrading stations, a total of 309 persons (Lomholt andBerg, 1965). Among the important findings were thefollowiing:

40 per cent. of male as well as female Greenlandersreported having had gonorrhoea three or more times.28 per cent. of single men and 27 per cent. of thewomen had been treated for gonorrhoea within thepast 6 months. Among 52 women in the age range16 to 29 years, only five had not previously hadgonorrhoea.

Suggestions for Future Measures against Gonorrhoeain Greenland

On the basis of the above study, Lomholt (1965)has submitted the following suggestions to theGreenland National Council, the Ministry forGreenland, and the National Health Service:

All patients treated for gonorrhoea within thepast 6 months should be requested to present them-selves on the same day throughout the country forafter-treatment. This would make it possible to-eradicate, on the same day, the "hard core" fromwhich the disease is being maintained. Since in thetrading stations there is no reliable information as towho has previously had gonorrhoea and as in these

localities the disease is very widespread, it is sug-gested that all single persons in the age range 16 to 29years should have the treatment.Such an extraordinary investigation and treatment

would have to be repeated at 6-monthly intervals, ifthe high incidence of gonorrhoea among the Green-landers is to be permanently reduced. Lomholtsuggested that this programme be introduced as apreliminary measure for 18 to 24 months.The risk of carrying through such an extraordinary

treatment is slight, not exceeding that of the con-tinued individual treatment of the cases.The proposal does not appear to be an un-

reasonable encroachment on a group of youngpeople who continue to present themselves withre-infection-often several times in a year. Thisgroup of the population must also be the one forwhich it is most important to reduce the risk ofgonorrhoeal infection. To the remaining part of thepopulation the situation is intolerable.

In early October, 1964, the Greenland NationalCouncil unanimously carried a proposal on theselines.The reason why this proposal could be advanced

in August 1964 is that, unlike other arctic areas(Smith, 1868; Guckel, 1927; Barnett, Fields, Milles,Silverstein, and Bernstein, 1947), Greenland has sofar been spared infection with syphilis. There havebeen only a few sporadic cases, transmitted byvisitors and each time the disease has been locatedand eliminated by energetic measures on the part ofthe health authorities (Fan0e, 1877; Helms, 1894;Marcussen and Rendal, 1950). But after the proposalwas put forward, an epidemic of syphilis broke outin South Greenland, and Lomholt and Kvorningspent 6 weeks in Greenland, trying to elucidate theextent of the epidemic by investigating the wholepopulation in the threatened area. It is hoped thatthis epidemic will be suppressed, and that thereafterthe proposed scheme for eliminating gonorrhoea canbe carried out according to the lines sketched above.

SummaryA pilot study on the incidence of gonorrhoea in the

Greenlandic population is reported. The study wasconducted on the basis of epidemiological surveys.According to the findings the annual incidence isestimated to be approximately 20 per cent, but inone area it was as high as 40 per cent. The diseaseaffects mainly single persons in the age range 15 to29 years. Among the persons with gonorrhoea 49per cent. of the males and 68 per cent. of the femaleshad a history of 3 or more previous attacks. Thenumbers of male and female cases were equal. Withinthe previous 3 weeks the females reported 2- 7

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and the males 1 * 9 contacts. The importance ofcarefully tracing contacts is emphasized, since onlyone of the female patients presented herself spon-taneously; all the others were found by tracingcontacts and by following up patients with a historyof gonorrhoea. An account is given of the principlesof the extraordinary examination and treatmentprogramme, called "G day". Complications appearto be strikingly uncommon. The sexual habits of theGreenlanders are analysed.The sensitivity of 152 gonococcal strains to

penicillin, tetracycline, and streptomycin was tested.As a high resistance to the ordinary treatment withbenzathine penicillin and procaine penicillin in megadoses had been demonstrated, treatment with pro-benecid combined with sodium benzyl penicillin wastried. The effect of this treatment proved favourable,with only one recurrence among 228 treated cases.A plan for reducing the very high incidence of

gonorrhoea among Greenlanders is outlined. Thisplan, which has a purely epidemiological aim, hasbeen adopted by the Greenland National Counciland will presumably be carried into effect in thenear future.

REFERENCESBarnett, H. E., Fields, J. Milles, G., Silverstein, J., and

Bernstein, A. (1947). J. Amer. med. Ass., 135, 500.Bertelsen, A. (1935-43). "Gr0nlandsk medicinsk statistik

og nosografi i: Meddelelser fra Gr0nland". 117.Reitzel, K0benhavn.

B0ggild, J. (1965). Ugeskr. Leg., 127, 476, 483.Fan0e, G. (1877). Hospitalstidende, 2 ser., 4, 345.Folke, L. (1935). Ugeskr. Lieg., 97, 309.Gisslen, H., Hellgren, L., and Starck, V. (1961). Bull. Wld

Hlth Org., 24, 367.Giuckel. E. (1927) Muinch. med. Wschr., 74, 899.Helms, 0. (1894). Ugeskr. Lag., 5 Rk., 1, 265.Jensen, P. E., Kvorning, S. A., and N0rredam, K. (1962).

Proc. North. derm. Soc., 49.Lange, C. (1864). Bibl. Lag., 5 Rkc., 8, 15.Lomholt, G. (1965). Ugeskr. Lwg., 127, 485.

and Berg, 0. (1965). Ibid., 127, 457.Marcussen, P. V., and Rendal, J. (1950). Amer. J. Syph.,

34, 144.(195 1). Ibid., 35, 356.

Osten, I. A. von (1788-89). "Anstilte iagttagelser iGr0nland, 1742-44". Samleren 11 and III,K0benhavn.

Perdrup, A. (1961). Ugeskr. Leg., 123, 764.Rahbek, M. (1962). Ibid., 124, 722.Rees, E. (1964). Brit. med. J., 2, 47.Schmidt, H. (1962). Nord. Med., 68, 1479.

and Roholt, K. (1965). Ugeskr. Lwg., 127, 478.Smith, C. E. (1868). Edinb. med. J., 13, 858.WHO Expert Committee on Gonococcal Infections,First

Report. (1963). Wld Hlth Org. tech. Rep. Ser.,No. 262.

L'etat de la blennorragie dans le sud du Groenland pendant1'et de 1964REsuME

Une enquete speciale a propos de l'incidence de lablennorragie chez les Groenlandais est presente. L'en-quete a &te menee selon les releves epidemiologiques.Selon ces constatations l'incidence annuelle est estim6ea 20% a peu pres, mais dans une region elle a memeatteint 40%. Cette maladie attaque principalement lescelibataires ages de 15 a 29 ans. Parmi les personnesatteintes de la blennorragie, 490% des hommes et 680%des femmes ont indique un passe revelant trois ou plu-sieurs attaques. Le nombre de cas chez les hommes et lesfemmes a ete le meme. Pendant les trois semainesprecedentes les femmes ont devoile 2,7 contacts et leshommes 1,9. L'importance de depister avec soin lescontacts est soulignee parce qu'une seule femme s'estpresentee volontairement, toutes les autres ont etretracees en depistant les contacts ou en questionnantceux affectes par la maladie. Un aperqu appele "Jour G"est donne des principes employes pour 1'examen et letraitement detailles. Les complications semblent d'unerarete surprenante. La sexualite des Groenlandais estanalysee.

L'effet de la penicilline, de la tetracycline et de lastreptomycine sur 152 differentes souches de gonocoquesa et teste. Comme une forte resistance a et demontreeapres le traitement routinier avec la procaine-penicillineet la benzathine-penicilline en doses de 1,000,000 unites,le traitement avec la probenecide combinee a la benzyl-penicilline sodique a et essaye. L'effet de ce traitements'est montre favorable, une seule recidive ayant etconstatee sur 228 cas traites.Un plan pour la reduction de l'incidence tres elevee de

la blennorragie chez les Groenlandais est esquisse. Ceplan qui n'a qu'un but epidemiologique a et adopte parle Conseil National du Groenland et sera probablementmis en vigueur dans un avenir prochain.

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GONORRHOEA SITUATION IN SOUTH GREENLAND IN THE … · GONORRHOEA SITUATION IN SOUTH GREENLAND IN THE SUMMER OF 1964* BY GUNNARLOMHOLTAND OLEBERG Froni the GonococcusLaboratory,Julianehab,