Sexually Transmitted Infections

1. Sexually Transmitted Infections • Cristina Muñoz • Division of Women’s Primary Healthcare • Department of Obstetrics and Gynecology • cmunoz@med.unc.edu

2. Sexually Transmitted Infections • Where do you find information in future? (in case you sleep through the whole talk, or God forbid, forget a little of what you learn in medical school) • Defining characteristics of STIs • Surveillance, epidemiology, disparities • Pattern recognition (pictures)

3. Sexually Transmitted Disease Treatment Guidelines 2006 • Free and easy to download • Multiple formats available • Updated regularly • National standard of care • http://www.cdc.gov/std/treatment/

4. North Carolina Department of Health and Human Services, HIV/STD Prevention and Care Branch http://www.epi.state.nc.us/epi/hiv/stdmanual/toc.html

5. Other useful resources • ContraceptiveTechnology, 19th ed. includes information on protection from STIs and alternate modes of sexual expression • Planned Parenthood

6. CDC PowerPoint Resources • STD 101 in a Box – Readymade PowerPoint talks on STDs, epidemiology, prevention efforts http://www.cdc.gov/std/training/std101/presentations.htm • STD clinical slides – Many pictures http://www.cdc.gov/std/training/clinicalslides/slides-dl.htm

7. Why are STIs Special? • They are different from each other, biologically:

8. Viruses: HIV

9. Hepatitis B Photo courtesy of Dr. CW Leung, Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong.

10. Hepatitis C

11. Human Papilloma Virus

12. Herpes Viruses

13. Molluscum contagiosum

14. Bacteria: Chlamydia Source: Seattle STD/HIV Prevention Training Center

15. Gonorrhea

16. Syphilis

17. Parasites: Trichomonas vaginalis

18. Lice

19. Why are STIs Special? • They are different from each other, biologically, but…. • They share common modes of transmission.

20. Historical Question… • June 5, 1981, MMWR published a report of five cases of Pneumocystis carinii pneumonia (PCP) among previously healthy young men in Los Angeles. All of the men were described as “homosexuals”; two had died. Soon other reports documented a similar illness in other groups, including injection drug users, Haitians, and hemopheliacs. • Based on what you know about Hepatitis B, which had similar epidemiology, what would you guess about the mode of transmission of the new disease?

21. What is sex? (It depends on what the meaning of the words 'is' is.) • [A] person engages in "sexual relations" when the person knowingly engages in or causes -- (1) contact with the genitalia, anus, groin, breast, inner thigh, or buttocks of any person with an intent to arouse or gratify the sexual desire of any person . . . . "Contact" means intentional touching, either directly or through clothing. 849-DC-00000586

22. STIs Resemble Non-sexually Transmitted Illnesses • Syphilis vs other spirochetal illnesses—bejel, pinta, yaws, Lyme disease, relapsing fever, rat bite fever • Different mode of entry, but similar binding to cellular and circulating proteins, tissue tropisms, biphasic illness pattern, treatments, treatment reactions. • When you reach a roadblock on one disease (e.g. if you can’t culture Treponema pallidum, you can use Borrelia burgdorferi data to make hypotheses about syphilis

23. Pathogenic Neisseracaea: Similar but Different • Different route of entry • 1978 - IgA protease production in both N. gonorrheae and N. meningiditis may explain why these are pathogenic and other strains are not. • 2006 – geneomes of pathogenic and nonpathogenic Neisseriaceae are known, so structure and function of secreted proteins is known

24. Some STIs are non-sexually transmitted

25. Herpes Type I and Type II(In this case, the resemblance between the “sexually transmitted infection” of “genital herpes” and the non sexually transmitted form “oral herpes” is so strong, that you can not tell which is which without labs)

27. STIs are Stigmatized*(*when people understand transmission) • Example – Herpes • What is the effect of disclosure to a potential sexual partner? • How does your patient feel when she has an outbreak of Herpes type II in a long-term monogamous marriage?

28. Changes in HSV-2 Seroprevalence between NHANES III and NHANES’99-00 Slide from: www.cdc.gov/stdconference/2004/Slides/SponSymposium/Xu.pps

29. Bad and Good Sides of Stigma • Failure to disclose disease or risk status • Failure to seek treatment • Underestimation of risk • Public clinics more available than for other illness • Mandated disease reporting, surveillance • Public funding for research, prevention, treatment

30. STI Surveillance NC law requires the following people to make reports to the local health director: • Physicians (GS 130A-135) • School principals and child care operators (GS 130A-136) • Operators of restaurants/other food or drink establishments (GS 130A-138) • Persons in charge of laboratories (GS 130A-139)

31. Reportable Illnesses in NC • (1) acquired immune deficiency syndrome (AIDS) - 24 hours; • (6) chancroid - 24 hours; • (7) chlamydial infection (laboratory confirmed) - 7 days; • (18) gonorrhea - 24 hours; • (19) granuloma inguinale - 24 hours; • (25) hepatitis B - 24 hours; • (26) hepatitis B carriage - 7 days; • (27) hepatitis C, acute - 7 days; • (28) HIV infection confirmed - 24 hours; • (35) lymphogranuloma venereum - 7 days; • (42) nongonococcal urethritis - 7 days; • (46) pelvic inflammatory disease – 7 days;

33. Rates of STDs in USA – 2007* • Syphilis 40,920 • Gonorrhea 355,991 • Chlamydia 1,108,374 • Chancroid 23 *these are reported cases Cases of sexually transmitted diseases reported by state health departments and rates per 100,000 population: United States, 1941–2007, Sexually Transmitted Disease Surveillance, 2007 http://www.cdc.gov/STD/stats07/natoverview.htm

34. Estimated Burden of STD in U.S. - 1996 Source: The Tip of the Iceberg: How Big Is the STD Epidemic in the U.S.? Kaiser Family Foundation 1998

35. Worldwide Burden of Disease • STIs/RTIs cause a large proportion of the global burden of ill-health. WHO estimates that over 340 million new cases of four curable STIs (gonorrhoea, chlamydia, syphilis and trichomoniasis) occurred in 1999. If viral STIs such as human papilloma virus (HPV), herpes simplex virus (HSV) and human immunodeficiency virus (HIV) infections are included, the number of new cases may be three times higher. Sexually transmitted and other reproductive tract infections A guide to essential practice. http://www.who.int/reproductive-health/publications/rtis_gep/index.htm

36. Worldwide Burden of Disease • Transmission and prevalence (how common they are) are influenced by social and economic factors as well as by biology and behaviour. The burden of STIs/RTIs thus varies greatly from region to region, and from community to community. Where STIs/RTIs are common, so are their complications. • STIs such as syphilis, gonorrhoea and chancroid spread more rapidly in places where communities are disrupted, migrant labour is common and commercial sex networks are active. • Iatrogenic infections are more common where there are many STIs, and where health care providers do not have the training or supplies to perform procedures safely. Postpartum and postabortion infections are more common where safe services and follow-up care are not available. Sexually transmitted and other reproductive tract infections A guide to essential practice. http://www.who.int/reproductive-health/publications/rtis_gep/index.htm

37. Stunning Disparities in STIs • By age • By sex • By social class • By race • By sexual orientation and sexual practices • Disparities exist in incidence AND effects

38. Disparities by Age – ChlamydiaAge & Sex Specific Rates, United States, 2006 From: Chlamydia Sexually Transmitted Disease Surveillance 2006 http://www.cdc.gov/STD/stats06/slides/AllSurvReportSlides2006.ppt

39. 2008 National STD Prevention ConferenceConfronting Challenges, Applying SolutionsChicago, Illinois March 10-13, 2008 • 26% of female adolescents in the United States have at least one of the most common STIs • HPV (High risk or EGW strains) 18.3% • Chlamydia 3.9% • HSV-2 infection 1.9% • trichomoniasis 2.5% • Only half of respondents had had sex • Infection rate among sexually active was 40% Oral Abstract D4a – Prevalence of Sexually Transmitted Infections and Bacterial Vaginosis among Female Adolescents in the United States: Data from the National Health and Nutritional Examination Survey (NHANES) 2003-2004. Presented by Sara Forhan.

40. Adolescents/Young Adults • Risk is due to behaviors: multiple partners, “serial monogamy”, alcohol & drug use • Cervical anatomy different in adolescents (ectopy) • Teen women often have sex with 20-25 year old men

41. Disparities by Gender:Body parts play a part

42. Disparities in Morbidity • Many women undiagnosed (mild to no symptoms) • Chronic infection causes PID, chronic pelvic pain, infertility, ectopic pregnancy

43. Disparities by GenderChlamydia, US, 1988–2007 Source: CDC STD Surveillance Reports 2007 http://www.cdc.gov/std/stats07/figures/1.htm Note: transmission rates to men and women from an infected partner are similar, but women may have more infections, or more screening.

44. Maternal-Fetal TransmissionMaternal-Infant Transmission • HIV • Herpes • Gonorrhea • Chlamydia • Syphilis

45. Neonatal Herpes Courtesy of Dr. Félix Omeñaca Terés, Hospital Materno Infantil La Paz, Madrid, Spain

46. Ophthalmia Neonatorum

47. Medical Trivia • In 1930, Dr. Cecil George Paine, a pathologist who had studied under Alexander Fleming, treated babies with Penicillin for gonococcal ophthalmia neonatorum . These cases cleared up dramatically.. • When his old notes were discovered in 1983, Paine was asked why he did not report what was in fact the first and successful clinical use of Penicillin. He modestly said, 'I was a poor fool who didn't see the obvious when placed in front of me.' http://bookshop.blackwell.co.uk/jsp/welcome.jsp?page=/jsp/promo/umh.jsp&source=heroes

48. Congenital Syphilis • About 400-500 cases a year • Cause of stillbirth, neonatal death, deafness, retardation, bony deformities, seizures • Rate down >50% by targeting specific areas (e.g. prenatal care for uninsured women in the South) • The bacteria can be cleared, but the damage is permanent

49. Disparities by Social Class “Statistically significant differences in health care utilization by neighbourhood income status were observed for chlamydia, gonorrhea, hepatitis C. The rate ratios increased in size when comparing low-income neighbourhoods to high-income neighbourhoods.” • Lemstra M, Neudorf C, Opondo J. Health disparity by neighbourhood income.Can J Public Health. 2006 Nov-Dec;97(6):435-9. • Note: these data are not from the US, but illustrate the kind of work that can be done when there is universal health care and extensive prospective data collection.

50. Disparities by Race • African Americans had 73.3% of reported cases of GC and 49.8% of cases of primary & secondary syphilis. • Native Americans at increased risk of chlamydia, increasing risk of GC • Hispanics at increased risk of chlamydia, GC, syphilis; marked increase in congenital syphilis. Cross-border migration of illness.