SEXUALLY TRANSMITTED INFECTIONS

1. SEXUALLY TRANSMITTED INFECTIONS Dr Y P Beh SpR GUM 25/10/2011

2. OVERVIEW Definition of Sexual Health Transmission factors Epidemiology of STIs Worldwide UK Sexually transmitted Infections Summary

3. Definition of Sexual Health (WHO) Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; Not merely the absence of disease, dysfunction or infirmity. Requires a positive and non judgemental approach to sexuality and sexual relationships Sexual rights of all persons must be respected, protected and fulfilled

4. Factors involved in Transmission Prevention & control interventions STI/HIV Epidemics Individual factors Socio-demographic factors Health beliefs Health seeking behaviours High risk sexual behaviours Individual factors Socio-demographic factors Health beliefs Health seeking behaviours High risk sexual behaviours Environmental Factors Socio-economic deprivation Limitations to use of, and access to, curative services Infectious agents Antimicrobial resistance Prevalence, incidence and duration of infectivity

5. STIs Around 30 different STIs Common bacterial infections Chlamydia trachomatis Neisseria gonorrhoea Treponema pallidum (causes syphilis) Lymphogranuloma venereum ( caused by chlamydia) Haemophilus ducreyi (causes chancroid) Klebsiella granulomatis (previously known as Calymmatobacterium granulomatis) causes granuloma inguinale or donovanosis.

6. Common viral infections Human immunodeficiency virus (1&2) Herpes simplex virus type 1 & 2 Human papillomavirus Hepatitis B virus Protozoal infection Trichomonas vaginalis (causes vaginal trichomoniasis) Fungal infections Candida albicans ( Thrush)

7. Global prevalence of STI

8. Estimated New Cases Of Curable STI Among Adults, 1999 • Source:WHO

9. Worldwide • > 340 million new cases of STIs every year • Untreated early syphilis in pregnancy • Stillbirth (25%), Neonatal deaths (14%) • 40% Perinatal mortality • Untreated gonococcal and chlamydial infections in women result in pelvic inflammatory disease in up to 40% of cases. One in four of these will result in infertility • 4000 newborn babies/yr become blind due to untreated maternal gonococcal and chlamydial infections • Herpes simplex virus type 2 infection - leading cause of genital ulcer disease in developing countries

10. STIs in UK

13. Number of STIs based on sex

14. Number of STIs based on sex

16. Proportional increase in STIs Routine GUM clinic returns Sexually Transmitted Infections, HPA Centre for Infections

18. Sexually Transmitted Infections (STIs)

19. Classification on the Basis of Presentation STD Urethritis Ulcerative Vaginal Discharge Systemic Miscellaneous Chlamydia Gonorrhoea Non-specific urethritis Genital Herpes Syphilis Chancroid LGV Donovanosis Bechet`s Disease Chlamydia Gonorrhoea Trichomonal infection Candidiasis Bacterial vaginosis HIV Hepatitis A Hepatitis B Hepatitis C SARA PID Epididymo-orchitis Genital warts Molluscum Contagiosum Scabies Pubic lice *Not Transmitted sexually

20. Chlamydia Trachomatis Most common sexually transmitted infection 5 -10% of sexually active women under 24 yrs and men between 20-24 yrs may be currently infected Incubation period up to 2 weeks Caused by serovars D-K Risk Factors Age under 25yrs New sexual partner/ >1 sexual partner in the past year New sexual partner being more important than number of partners Lack of consistent use of condoms

21. Symptoms of chlamydial infection Men - 50% asymptomatic - Discharge and dysuria Women - 70-80% asymptomatic - Discharge and dysuria • Intermenstrual/ postcoital bleeding(cervicitis/endometritis) - Abdominal pain • 70% asymptomatic

22. Complications associated with Chlamydia • Endometritis/ Salpingitis/ PID • Ectopic pregnancy • Infertility • Chronic pelvic pain • Pregnancy complications • Reiter’s syndrome • Epididimo-Orchitis • Fitz-Hugh Curtis syndrome

23. Chlamydia Diagnosis Nucleic Acid Amplification Technique (NAAT) Specimen: urine (males), endocervical swab/self swab (females) Sensitive 90-95% Specificity 99% ( 93 – 100%) Treatment Azithromycin 1gm stat (or) Doxycycline 100mg bd 7 days

24. National Chlamydia Screening Programme Establishedin 2002 Opportunistic Screening in all health settings (Outside GU medicine) Women & men ,16 –25 yrs Positives advised to attend GU clinic for treatment & screening, especially those with symptoms

25. Gonorrhoea Second commonest bacterial STI in UK Neisseria gonorrhoea – intracellular, gram negative diplococci Incubation period 2-5 days but can be up to 2 weeks Men symptomatic >80%, women asymptomatic 50% Symptoms include dysuria, discharge, lower abdominal pain Extra-genital infection possible (pharyngeal) Disseminated - skin lesions, arthralgia, arthritis and tenosynovitis.

26. Gonorrhoea Diagnosis Test: NAAT and Culture, microsopy Specimens : urine/urethral swab(males),endocervical swabs Treatment First Line – Ceftriaxone with Azithromycin Increased resistance to Penicillins, Ciprofloxacin, Tetracyclines.

27. Non-specific urethritis Present in males Diagnosis depends on symptoms ie discharge and dysuria and microscopy showing pus cells May be STI – usually chlamydia, less frequently mycoplasma, ureaplasma sps. May be trauma, allergic reaction, dermatitis Treatment – similar to chlamydia treatment (Azithromycin/Doxycycline)

28. SYPHILIS • Classification • Congenital • Acquired • Late • Stigmata • Early • (<2 years) • Late • (> 2 years) • Early • <2years • Primary • Late latent • Tertiary • Secondary • Early latent • <2years Infectious Stage

29. Primary Syphilis Spirochaete – Treponema Pallidum Primary chancre Appears 9 – 90 days post-infection at site of inoculation Classically – solitary and painless BUT can be multiple and painful and atypical Often ignored when atypical Resolves spontaneously within weeks

30. Primary Syphilis Treponema pallidum Primary Chancre

31. Secondary Syphilis Around 6 weeks later Alopecia, lymphadenopathy, snail track ulcers, condylomata lata, maculopaular rash (palms and soles), hepatitis……

32. Snail track Ulcers

33. Secondary Syphilis

34. Syphilis Diagnosis Direct: demonstration of Treponema pallidum Dark field microscopy Direct fluorescent antibody (DFA) test PCR Indirect: different serological test VDRL TPPA EIA Treatment: Penicillin

35. Genital Herpes Caused by herpes simplex virus Same virus that causes cold sores HSV-1 vs HSV-2 Spread by skin to skin contact – condoms do reduce risk of transmission Transmission occurs with or without lesions

36. Clinical features of Herpes 60% of primary genital HSV infections asymptomatic Multiple, painful ulcers Flu–like symptoms Can lead to urinary retention, especially in women First outbreak almost always worst Recurrences decrease in frequency with time

39. Pathway of Herpes Infection

40. Genital Herpes Diagnosis: Clinical HSV PCR, culture infrequently used Treatment General advice Recommended regimens (all for five days): Aciclovir 200 mg five times daily/ 400mg tds Famciclovir 250 mg tds Valaciclovir 500 mg bd Reduces severity and duration of outbreak No effect on recurrence rates Low doses can be used prophylactically

41. Trichomonas vaginalis A flagellated protozoan. Found in the vagina, urethra and paraurethral glands. Vulval itching, dysuria, offensive odour, strawberry cervix Associated with preterm delivery and low birth weight.

42. Trichomonas vaginalis Diagnosis Clinical (strawberry cervix and discharge) Posterior fornix vaginal wet film TV culture TV PCR based tests Treatment Metronidazole 2g orally in a single dose Metronidazole 400 – 500mg bd 5/7 Partners need treatment

43. Molluscum Contagiosum Could be sexually transmitted Look like warts Caused by pox-virus Spread by skin to skin contact Common in children In adults, not commonly seen on face

44. Lymphogranuloma veneruem Caused by Chlamydia trachomatis serovars L1,2,3 Seen in MSM in the UK Symptoms include rectal discomfort, rectal discharge and bleeding. Test : NAAT testing sent to reference lab Needs longer course of antibiotics

45. Genital Warts Caused by human papilloma virus Over 100 strains Low risk types 6 and 11 causes visible lesions High risk types 16 and 18 – vaccine preventable types in UK. HPV-16 and 18 contribute to over 70% of all cervical cancer cases HPV prevalence in normal cytology – 8.9% Can be carried without symptoms

46. HPV Genital Warts Treatment usually topical – creams, cryotherapy, TCA, curettage