Surveillance issues in STDs

1. Surveillance issues in STDs • Public Health Perspectives on Women’s Health • Epidemiology of Hepatitis • Evaluation of Partner Notification for HIV • Surveillance issues • Contraception

2. Role of an Epidemiologist • Surveillance • Evaluation • Hypothesis testing • Communicating Information

3. STD Control • Two main function: • To interrupt the transmission of infection • To prevent the development of complications and sequelae.

4. The importance of STI surveillance for public health Purposes of surveillance • setting of priorities • planning and allocating resources for service • defining population subgroups and risky behaviors for targeted interventions • directing public health policy • informing diagnostic and therapeutic practice • evaluation of interventions • stimulating further research

5. Surveillance Systems • Are active or passive • Can be for a whole population or for a selected group (sentinel) • Have to have a good case definition • Surveillance is better if it is reportable • Have to have quality assurance

6. Other STD Surveillance

7. Other STDsSexually Transmitted Disease Surveillance 1998 Division of STD Prevention

8. Herpes Simplex Virus 2 • In U.S. 50 million infections, 1million each year. • Both HSV-1 and HSV-2 are acquired through contact with infectious secretion on oral or genital mucosal surfaces. • HSV-1 acquired orally with latency in the trigeminal nerve root. HSV-2 acquired genitally with latency in the sacral root ganglia. • Reactivation occurs throughout life and can be either clinically symptomatic, symptomatic but unrecognized as herpes, or subclinical. • High prevalence related to chronicity of disease and high frequency of unrecognized infection

9. Diagnosis of HSV-1 • Probably the most difficult STD to diagnose. • Clinical spectrum is diverse. Clinical diagnosis has reasonable specificity, but poor sensitivity • Viral isolation or demonstration of HSV antigens in genital lesions has been the only accurate lab diagnosis to confirm herpes and it is only 50% sensitive. • Serodiagnostics (i.e. PCR) are expensive and are indirect and can be imprecise (also pick up chancroid and syphilis)

10. Clinical differences in lesions

11. Genital herpes simplex virus type 2 - Percent seroprevalence according to age in NHANES* II (1976-1980) and NHANES III (1988-1994) Note: Bars indicate 95% confidence intervals. *National Health and Nutrition Examination Survey

12. Human papillomavirus (genital warts) - Initial visits to physicians' offices: United States, 1966-1998 and the Healthy People year 2000 objective SOURCE: National Disease and Therapeutic Index (IMS America, Ltd.)

13. Nonspecific urethritis - Initial visits to physicians' offices by men: United States, 1966-1998 SOURCE: National Disease and Therapeutic Index (IMS America, Ltd.)

14. Trichomonal and other vaginal infections - Initial visits to physicians' offices: United States, 1966-1998 SOURCE: National Disease and Therapeutic Index (IMS America, Ltd.)

15. Pelvic Inflammatory Disease • Lower genital tract infections can lead to endometrial and tubal infection and intern to complications such as infertility, ectopic pregnancy and chronic pelvic pain. • Usually caused by Ct, but can be caused by Gc. • Symptoms vary. Chandelier sign is indicative but doesn’t always occur. Best test is the invasive laparoscopy. • Scholes found in a randomized clinical trial that selective testing for Ct prevented PID.

16. Bacterial versus Viral • Bacterial usually treatable, viral usually not • After screening, bacterial usually incidence, viral usually prevalence • Screening generally easier for bacterial and more difficult for viral

17. Contraception and Women’s reproductive health

18. Contraception • Important in STD research because it causes behavior change • It is associated with lesser incentive to have protective sex • May have some protective effect in certain diseases.

19. Contraception

20. Prevalence of Contraceptive Methods in US 1993

21. Sterilization • Tubal • Vasectomy • Hysterectomy • No STI protection • Return to fertility is possible

22. Norplant - implants • levonorgestrel • last 5 years • prevents ovulation , causes luteal insufficiency, impaired oocyte maturation and progestin-induced hostile cervical mucus • No STI prevention • return to fertility is rapid

23. Depo provera • depot medroxyprogesterone acetate (DMPA) - The Shot • last 3-4 months • can cause menstrual changes, irregular bleeding, spotting, amenorrhea, headaches • return to fertility can be one year • No STI prevention

24. Post Coital Contraception • Morning after pill - intended for pregnancy prevention when women are exposed to a single episode of unprotected coitus • Only Mifepristone (RU486) is FDA approved • prevent implantation • No STI prevention

25. Oral Contraception • Prevents ovulation by suppressing pituitary gonadotropin secretion. • Monophasic - constant dose of estrogen and progestin in 21 active tablets • Progestin-only oral low dose contraceptives (mini-pills) • Phasic alter progestin and estrogen. • Associated with increased cervial chlamydia; protective against symptomatic PID

26. Health Benefits of OCP • Prevention of gynecologic cancer (epithelial ovarian cancer and endometrial adenocarcinoma) • Menstrual improvements (regularity, less dysmenorrhea, few days and amount of flow, less anemia, restoration of regular menses in anovulatory women) • Prevention of benign conditions (breast fibroadenoma, ectopic pregnancy) • Possible benefits (atherosclerosis, severe rheumatoid arthritis)

27. Intrauterine device • copper intrauterine implant Copper T 380A IUD - creates intrauterine environment that is spermicidal • progesterone-releasing IUD (Progestasert) inhibit sperm survival and implantation. • PID can result if CT or GC are present • No STI prevention

28. Natural Methods • Periodic abstinence (calendar method, temperature method, cervical mucus method, symptothermal method) • Lactational contraception • Withdrawal • None of these method provide STI prevention • Fertility return is rapid

29. Barrier Methods • Latex Condom • Diaphragms and cervical caps • spermicidal foams, films, jellies or suppositories • Do protect against STIs

30. Diaphragm and Cervical Cap • Diaphragm 80-94% effective • Cervical cap 60-90% effective • Not effective against STDs • can be messy • cost $13-$25, exam $150 • only four sizes of cervical caps (hard to fit all women)

31. Foams and suppositories

32. Vaginal Contraceptive Film • Can't be felt by either partner • Effective for up to one hour • Nothing to remove Begins to dissolve instantly • Used by thousands of clinics • Contains: 28% Nonoxynol 9, the spermicide most recommended by doctors • Numerous clinical studies conducted worldwide on safety and efficacy

33. Emergency Contraception • Yupee Method • Take one dose within 72 hours and a second dose 12 hours after that • If you are using Ovral, each dose is two pills. If you are using Alesse, each dose is five pills. If you are using any of the other combination pills listed above, each dose is four pills. • IUD can be inserted within 5 days of un-protected intercourse. • Reduced risk of unintended pregnancy be 75%

34. Male Methods • Condoms • Vasectomy • Others