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Edit Comment Close Premium member Presentation Transcript SEXUALLLY TRANSMITTED DISEASES (STD) : SEXUALLLY TRANSMITTED DISEASES (STD) Dr.N.Bayapa Reddy MBBS,(MD) Dept of Community Medicine S.V.Medical College Tirupati-517507 Andhra-Pradesh India SEXUALLLY TRANSMITTED DISEASES (STD) : SEXUALLLY TRANSMITTED DISEASES (STD) Problem & Epidemiology, Control Slide 3: STD’s : group of Communicable Diseases Mode of transmission: Predominantly by Sexual Contact Agents: Bacterial, Viral, Protozoal, Fungal, Ectoparasites Causes for increased prevalence : Causes for increased prevalence Increased promiscuity and multiple sex partners Better understanding of modes of transmission Better screening tests Antibiotic resistance Increasing DNA virus infection 5 Classical STDs : 5 Classical STDs Syphilis Gonorrhoea Chancroid Lymphogranuloma venereum (LGV) Granuloma Inguinale (Donovanosis) A: Bacterial Agents : A: Bacterial Agents N.gonorrhoea Chlamydia trachomatis Treponema pallidum Haemophilus ducreyi Mycoplasma hominis Ureaplasma urealyticum Calymmatobacterium granulomatis Shigella Sps. Campylobacter spp. Group B streptococcus Bacterial vaginosis-associated organisms B: Viral Agents : B: Viral Agents Human (alpha) herpesvirus 1 or 2 (herpes simplex virus) Human (beta) herpesvirus 5 (formerly cytomegalovirus) Hepatitis virus B Human papilloma virus Molluscum contagiosum virus Human immunodeficiency virus C: Protozoal agents : C: Protozoal agents Entamoeba histolytica Giardia lamlia Trichomonas vaginalis E: Ectoparasites : E: Ectoparasites Candida albicans D: Fungal Agents Phthirus pubis Sacrcoptes scabiei Problem Statement : Problem Statement World: Underreporting WHO estimation other than HIV –in 1999 Incidence: 340 millions/year Gonorrhoea: 62 millions Genital chlamydial: 92 millions Syphilis: 12 millions Chancroid: 7 millions Genital herpes: 20 millions Human Papilloma virus: 30 millions Trichomonas vaginalis: 173 millions Problem (contd) : Problem (contd) INDIA: Syphilis: Aurangabad (Maharashtra) VDRL – Antenatal clinics – 2.4% Kerala study – 1.4% Gonorrhoea – More prevalent than syphilis LGV – Higher in South India Donovanosis: Coastal areas Kakinada: 6.1% Male & 6.9% female cases -1966 Chancroid / soft sore- widely prevalent HOST FACTORS : HOST FACTORS Age: 20-24 yrs; 25-29; 15-19 yrs Sex: M > F: morbidity higher in women Marital status: Single, divorced, separated SE status: Higher in Lower groups Demographic factors: Population increase especially young Rural – urban migration Higher edu.opportunities –women – delay in marriage SOCIAL FACTORS : SOCIAL FACTORS Prostitution Broken homes Sexual disharmony Easy money Emotional immaturity Urbanization & industrialization SOCIAL FACTORS (contd) : SOCIAL FACTORS (contd) Social disruption International travel Changing behavioural patterns Social stigma Alcoholism Slide 15: Clinical features Chlamydia Infection : Chlamydia Infection Most common reportable disease in the U.S. Estimated 3million cases annually Incidence is highest among sexually active adolescents and young adults Most infections are asymptomatic Leading cause of preventable infertility in women or vertical transmission during child birth leads to conjenctivitis in Newborn Men : urethritis with possible epiddidymitis Treatment : Doxycycline or Azithromycin Chlamydia Infections in Women, Men, and Neonates : Chlamydia Infections in Women, Men, and Neonates Genitals Cervicitis PID Urethritis Eye (Conjunctivitis) Throat (Pharyngitis) Rectum (Proctitis) Eye (conjunctivitis) Lungs (pneumonia) 70-80% ASYMPTOMATIC Genitals (Urethritis) (Epididymitis) Rectum(Proctitis) Throat (Pharyngitis) Eye(Conjunctivitis) Systemic (Reiter’s Syndrome) >50% ASYMPTOMATIC Chlamydia Age- and sex-specific rates : Chlamydia Age- and sex-specific rates Chlamydia InfectionClinical Manifestations : Chlamydia InfectionClinical Manifestations Cervical Ectopy : Cervical Ectopy Ectopy SCJ Minimal ectopy STD Atlas, 1997 Chlamydia Screening & Treatment : Chlamydia Screening & Treatment Decreases community prevalence Prevents pelvic inflammatory disease Cost effective CDC estimates that “for every dollar spent on chlamydia screening, we could save $12” Opportunity to increase awareness and provide risk reduction counseling Chlamydia Screening Recommendations : Chlamydia Screening Recommendations All sexually active women under 26 yrs Initial screen Repeat annually Consider repeat with new or multiple sex partners Repeat 2-3 months after an infection All pregnant women under 26 yrs Men, and women 26 and older, consider with New or multiple sex partners, Inconsistent condom use Urine-Based CT Tests : Urine-Based CT Tests Highly accurate Non-invasive collection High patient acceptability Only test appropriate for screening asymptomatic males Screening in non-clinical settings Community settings Home testing Chlamydia Partner Management : Chlamydia Partner Management Transmissibility: male to female: 45-55% (culture) to 70% (PCR) female to male: 28-42% (culture) to 68% (PCR) Partners with contact during the 60 days preceding the diagnosis should be evaluated, tested and treated Chlamydia: KEY POINTS : Chlamydia: KEY POINTS Most common bacterial (curable) STD Most cases in women and men give no symptoms Leading cause of PID and infertility in women All sexually active women 25 y.o.a. and younger should be tested at least annually Gonorrhea Infection : Gonorrhea Infection Caused by Neisseria gonorrhoeae Overall rates falling, but incidence in certain groups remains high Most common in the reproductive age group (menarche to menopause) Incubation period -2 to 10 days CT co-infection of GC cases remains at about 40% Resistance to medication is an spreading problem Gonorrhea Infection in Women:Complications : Gonorrhea Infection in Women:Complications Untreated genital GC infection Ectopic pregnancy Infertility Chronic pelvic pain 9% 14-20% 18% 20-50% Gonorrhea Age- and sex-specific rates : Gonorrhea Age- and sex-specific rates Gonorrhea Infections in Men, Women and Neonates : Gonorrhea Infections in Men, Women and Neonates Men are usually symptomatic (urethra), women are commonly asymptomatic Men: urethral infection, epididymitis Usually gives pain with urination and heavy, thick penile discharge; few may be asymptomatic carriers Women: cervical infection, PID ~50% women asymptomatic, others have pain with urination, vaginal discharge or bleeding Other sites of infection: throat, rectum, eye Neonates: eye and skin infections Gonorrhea InfectionsClinical Manifestations : Gonorrhea InfectionsClinical Manifestations GC Management : GC Management Ciprofloxacin , spectinomycin , cetriaxone Is used for treatment Transmissibility: Male to female: 50 - 90% Female to male: 20 - 80% Partners with contact during the 60 days preceding the diagnosis should be evaluated, tested and treated If no sex partners in previous 60 days, treat the most recent partner GonorrheaScreening Recommendations : GonorrheaScreening Recommendations Targeted screening: consider in Populations with prevalence of 1-2% or more MSM High-risk women Young age New or multiple partners Pregnant women Gonorrhea: KEY POINTS : Gonorrhea: KEY POINTS Second most common bacterial (curable) STD. Concentrations of infection in MSM in urban areas Resistance to medications is a spreading problem Syphilis : Syphilis Incidence had been steadily declining in the U.S. since 1990 28 U.S. counties account for 50% of the reported cases In 1999, the CDC initiated a nation-wide Syphilis Elimination Effort, targeting these areas Recently, local outbreaks centered in urban areas among MSM Syphilis : Syphilis Caused by bacteria called Trepenoma pallidum. If not treated Syphilis can be very dangerous and can cause brain damage and other serious health problems. If you are diagnosed as having the disease you can be treated with antibiotics. Anyone with whom you’ve had sex will also need to be treated Congenital Syphilis : Congenital Syphilis Note: The surveillance case definition for congenital syphilis changed in 1988. Reported cases for infants <1 year of age and rates of primary and secondary syphilis among women: United States, 1970–2002 SyphilisDistribution of the Organism : SyphilisDistribution of the Organism Primary Syphilis : Primary Syphilis Photos: Dr. Joseph Engelman, San Francisco City Clinic Rash of Secondary Syphilis : Rash of Secondary Syphilis Photo: Dr. Joseph Engelman, San Francisco City Clinic Secondary Syphilis Other Symptoms : Secondary Syphilis Other Symptoms Comdyloma lata Syphilis New Therapies : Syphilis New Therapies Penicillin G (an injectable) remains the first line treatment Limited data support the use of Azithromycin (in a one-time oral dose) as an alternative regimen Azithromycin 2 gm orally in a single dose as treatment for early syphilis Azithromycin 1 gm orally in a single dose as prophylactic treatment for contacts to infectious syphilis Has not been well-studied in HIV + patients; larger trials ongoing Cefrtiaxone almost certainly effective, but best dose/duration has not been established Syphilis: KEY POINTS : Syphilis: KEY POINTS Outbreaks in MSM in urban areas since 2000 Serious systemic infection Strong connection with HIV transmission Yearly testing of all HIV-positive patients is recommended Genital Herpes: Overview : Genital Herpes: Overview Caused by Herpes Simplex Viruses HSV 1: orolabial herpes HSV 2: genital herpes Both symptomatic & asymptomatic infections are common Can cause serious complications Asymptomatic shedding is well documented Genital HerpesTransmission : Genital HerpesTransmission Major routes: sexual & mother-to-infant Most sexual transmission probably occurs when index case is asymptomatic Efficiency of transmission is greater from men to women than women to men Genital Herpes Natural History : Genital Herpes Natural History Initial infection Virus enters through microscopic breaks in skin Establishes chronic infection Virus becomes latent in nerves cells along spinal cord Infection persists despite host immune response Virus may remain latent indefinitely or can reactivate Virus can reactivate Precipitating factors: trauma, fever, UVL, stress Virus reproduces and moves along nerve axon to skin or mucosa, and recurrent lesions can occur Reactivation (shedding) can also be asymptomatic Genital Herpes Patient’s Perception of Etiology : Genital Herpes Patient’s Perception of Etiology Women Vaginitis UTI Menstrual complaint Hemorrhoids Allergies (condoms, sperm, spermicide, pantyhose Rash from sex, shaving, bike seat Men Folliculitis Jock itch “Normal” itch Zipper burns Hemorrhoids Allergy to condom Irritation from tight jeans, sex, bike seat Insect bite Genital HerpesAsymptomatic Shedding : Genital HerpesAsymptomatic Shedding Multiple studies have documented asymptomatic shedding with culture and DNA amplification techniques Occurs in up to 90% of patients with HSV-2 Most common in first two years after infection (5-10% of days), less common thereafter (2% of days) Shedding may occur from cervix, vulva, urethra, rectum, penis Asymptomatic shedding reduced by antiviral suppression HerpesTransmission in Pregnancy : HerpesTransmission in Pregnancy Most transmission occurs at time of delivery, rarely in utero Risk factors: primary infection, new infection, scalp electrodes Over half of infants with neonatal infection are born to mothers with no history of genital herpes Blood Tests for Herpes : Blood Tests for Herpes Older blood tests did not distinguish HSV-1 from HSV-2 antibody Newer blood tests accurately distinguish type-specific glycoproteins gG1 and gG2 HSV Serology TestingPotential Uses, Diagnostic Testing : HSV Serology TestingPotential Uses, Diagnostic Testing Confirm diagnosis Recurrent undiagnosed GUD Atypical presentations (e.g. urinary symptoms) Note: positive test does not necessarily correlate with symptoms Can help differentiate between Primary & non-primary infections Newly-acquired and older infections HSV Serology TestingBenefits and Limitations of Screening : HSV Serology TestingBenefits and Limitations of Screening May be useful to patients for informing partners May be helpful for pregnant couples or for planning pregnancy Does not tell How long infected If person has had or will have symptoms How likely a person is to shed asymptomatically HSV Serology TestingPotential Uses, Screening : HSV Serology TestingPotential Uses, Screening Not recommended for routine screening May be useful in certain at-risk populations and individuals Patients with other STDs HIV infected persons and contacts Contacts to HSV Certain prenatal patients Genital HerpesTreatment Options : Genital HerpesTreatment Options Treatment of symptomatic outbreaks Suppression of symptoms by daily medication Daily medication to lessen chance of transmission Genital HerpesPsychological Impact : Genital HerpesPsychological Impact A diagnosis of herpes can cause significant psychological distress Depression Anger Fear of rejection/discord in relationship Fear of passing infection to sex partners or infants Frustration regarding lack of a cure Uncertainty about asymptomatic shedding Genital HerpesCounseling about Transmission : Genital HerpesCounseling about Transmission Encourage patients to inform their sex partners of the herpes diagnosis Advise patients to abstain from sexual activity when lesions are present Discuss possibility of asymptomatic shedding Discuss treatment options Encourage condom use with new or uninfected partners Perinatal Herpes InfectionPrevention : Perinatal Herpes InfectionPrevention Emphasize preventing acquisition of genital HSV during late pregnancy Counsel susceptible pregnant women whose partners have oral or genital HSV to avoid unprotected genital & oral sexual contact in late pregnancy Examine women in labor for genital herpes Abdominal delivery is recommended with prodrome or active lesions at onset of labor Suppressive therapy near term to reduce number of C-sections in women with recurrent herpes is under investigation Genital HerpesCondom Effectiveness : Genital HerpesCondom Effectiveness Latex condoms, when used consistently and correctly, are highly effective for: HIV And can reduce the risk of: GC, CT, and Trichomonas Genital herpes, syphilis, chancroid, and HPV, only when the infected areas are covered by the condom CDC, 2002 Genital HerpesVaccine Development : Genital HerpesVaccine Development SmithKline Beecham Biologicals Two multicenter, double-blind, randomized placebo-controlled trials Participants had no history of genital herpes and a regular sex partner with HSV-2 73% reduction in symptomatic cases in women who were also HSV-1 negative Protects against symptoms of genital herpes, although not against acquisition of HSV-2 virus No protective effect found in men Genital Herpes: KEY POINTS : Genital Herpes: KEY POINTS About 1/5 of adult Americans have HSV 2 Most do not recognize or get symptoms New type-specific blood tests can accurately diagnose HSV 2 infection even when no symptoms are present Treatment to control symptoms and lessen the chance of transmission are available Genital Human Papillomavirus (HPV) : Genital Human Papillomavirus (HPV) Two disease processes caused by different viral types Precancer and cancer of the genital tissues (abnormal Paps and anal carcinoma) Skin growths in the anogenital area (genital warts) Slide 61: > 80 HPV Types Dermal HPVs nonsexual contact (>50 types) “Common” Warts (e.g., hands/feet) Genital HPVs sexual contact (>30 types) “High-risk” types “Low-risk” types low grade cervical abnormalities cancer precursors genital cancers low grade cervical abnormalities genital warts respiratory papillomatosis 6,11,42,43,44 16,18, 31,33,35,39, 45,51,52,56,58 Typical Genital Warts : Typical Genital Warts DOIA Website, 2000 The “New” Kind of Pap : The “New” Kind of Pap Thin-Layer Paps vs Conventional Paps Generally compare favorably Simple collection procedure for the clinician Provides a better sample Can be read more accurately in the lab More expensive ThinPrep Pap Test Conventional Pap The “New” Test for HPVHPV DNA Tests : The “New” Test for HPVHPV DNA Tests Hybrid Capture Test (Digene) detects high-risk HPV by typing nucleic acids Results are reported as positive or negative for the most common cancer-associated HPV types(16,18,31,33,35 etc) Can be performed on same specimen collected for thin-layer Pap HPV DNA Tests: Possible Uses : HPV DNA Tests: Possible Uses NOT recommended for screening NOT recommended for diagnostic purposes with external genital warts Can be useful in management of certain abnormal Paps ASCUS Paps: Proposed Algorithm : ASCUS Paps: Proposed Algorithm Routine Pap smear, including specimen collection for HPV ASCUS Conduct HPV test on stored specimen SIL Normal Routine Pap schedule Usual follow-up and treatment Repeat Pap 6 - 12 mo Colposcopy HPV (+) HPV (-) Cervical Disease Management of HIV Infected Women : Cervical Disease Management of HIV Infected Women Dysplasia more common Progression of dysplasia is more likely if untreated Risk dependent on CD4 count and viral load Sensitivity of Pap probably equal Colposcopic exam may be warranted if follow-up is uncertain (ASC-US or higher) Recommend semi-annual Pap and careful follow-up HPV: KEY POINTS : HPV: KEY POINTS Extremely common virus Some types cause genital warts Other types cause cervical and anal cancer HPV tests can help in managing female patients with abnormal Paps Best approach to anal dysplasia is unclear Trichomoniasis: KEY POINTS : Trichomoniasis: KEY POINTS Caused by Trichomonas vaginalis, flagellated anaerobic protozoa In women, causes malodorous yellow-grey discharge with irritation and vulvar itching. straw berry vegina is characteristic In men, usually gives no symptoms but can cause urethritis Resistance to common treatment (metronidazole) does occur Pubic Lice (Crabs) : Pubic Lice (Crabs) Pubic lice are tiny insects that can crawl from the pubic hair of one person to the pubic hair of another person during sex. You will be prescribed or told to buy medication that kills the lice and their eggs. You will also need to dry clean or use very hot water to wash all of your bedding, towels, or recently worn clothing to kill the lice. Tell your partner. Pubic lice can be spread even when you use a condom. Syndromic approach to STD : Syndromic approach to STD Many Different agents causing - STD - Similar or overlapping clinical manifestations Common Syndromes & Sequelae - STD -Male urethritis ,lower genital syndromes in women. Genital ulceration. Proctitis, colitis Salpingitis, epididy. Orchitis infertility /Ecto pregnancy Postnatal and perinatal morbity Hepatitis/Hepatic carcinoma. & genital carcinoma AIDS STD Diagnosis - By lab. Tests : Not available, & are expensive Slide 73: Solution: Syndromic management to the patients presenting recognized signs & symptoms of STD (WHO 1990 ) Syndromic Approach – is scientifically derived . Efficient & effective Accessible, Immediate treatment CONTROL : CONTROL Initial Planning Intervention Strategies Support components Monitoring & Evaluation INITIAL PLANNING : INITIAL PLANNING Problem definition Establishing priorities Setting objectives Considering strategies Problem definition : Problem definition Prevalence Psychosocial consequences Other health effects: by geographic areas by population groups (sero-epidemiological surveys and population surveys) Establishing priorities : Establishing priorities Magnitude Consequences Feasibility of control Groups categorised on the basis of Age, Sex place of residence occupation drug addiction Setting objectives : Setting objectives Unambiguous Quantifiable Considering strategies : Considering strategies Intervention strategies INTERVENTION STRATEGIES : INTERVENTION STRATEGIES Case detection: Screening Contact tracing Cluster testing Case holding & treatment Epidemiological treatment Personal prophylaxis: Contraceptives (condoms, diaphragms ) vaccines Health education Screening : Screening Testing of apparently healthy volunteers Screening of special groups Pregnant women Blood donors Industrial workers Army Refugees Police Prostitutes Convicts Hotel staff Sensitivity, Specificity, Predictive value Contact Tracing : Contact Tracing The technique by which the sexual partners of diagnosed patients are identified, located, investigated and treated Disclose all sex contacts voluntarily Cluster testing : Cluster testing The patients are asked to name other persons of either sex who move in same socio-sexual environment Then persons are screened for STD’s Slide 84: Case holding & treatment Epidemiological treatment Personal prophylaxis: Contraceptives (condoms, diaphragms ) vaccines Health education STD Control Programme : STD Control Programme Started in 1946 Now part of NACP Emphasis: Diagnosis & treatment of STD Supported by: 5 Reg. STD reference centres Skin-leprosy clinics – in Medical Colleges 735 STD clinics – district hospitals SUPPORT COMPONETNS : SUPPORT COMPONETNS STD clinic Lab services Primary health care Information system Legislation Social welfare measures Immoral Traffic (prevention) Act, 1986 : Immoral Traffic (prevention) Act, 1986 Purpose of legislation: To encourage pts to seek early treatment To name their sexual contacts To screen high risk groups To improve notification To health educate the people Social welfare measures : Social welfare measures Rehabilitation of prositutes Provision of recreation facilities Marriage counselling Prohibiting the sale of sexually stimulating literature, pornography books, Photographs Internet cafés Slide 89: Monitoring and Evaluation Disease trend programme activities Slide 90: TanQ You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.