Unit 2: STI Surveillance Methods, Concepts and Terms

1. Unit 2: STI Surveillance Methods, Concepts and Terms #4-2-1

2. Warm Up Questions: Instructions • Take five minutes now to try the Unit 2 warm up questions in your manual. • Please do not compare answers with other participants. • Your answers will not be collected or graded. • We will review your answers at the end of the unit. #4-2-2

3. What You Will Learn • By the end of this unit you should be able to: • discuss the components of an STI surveillance system • discuss the uses of STI surveillance data • describe the difference between aetiologic and syndromic STI diagnosis and surveillance • determine the difference between basic and advanced STI surveillance activities and how these activities should be used, depending on the type of HIV epidemic • describe IDS case reporting #4-2-3

4. Figure 2.1. Components of an STI Surveillance System #4-2-4

5. Which Components Should Be Used? • Some components are more important for second-generation HIV surveillance activities, such as: • combined STI/HIV behavioural surveillance surveys • Others are important to STI control programme activities: • assessing syndrome aetiologies • anti-microbial resistance monitoring • Some are important for both: • STI case reporting • STI prevalence assessment and monitoring #4-2-5

6. Which Components Should Be Used, Cont. • Consider existing programmes in your country, especially the following issues: • the needs of STI control programmes established by your Ministry of Health • existing surveillance systems for other communicable diseases • the health management information used • existing health services infrastructure • the state of the HIV epidemic in your country #4-2-6

7. Symptomatic and Asymptomatic STIs • To accurately calculate incidence and prevalence, the STI surveillance system needs to identify: • which STIs are newly acquired • which have been present for a long time • To identify these conditions, it is important to understand the role of symptomatic and asymptomatic STIs. #4-2-7

8. Symptomatic STIs • Symptomatic infections are recently acquired and represent true incidence. • Herpes simplex virus is an exception since symptoms can recur without new infection, making it impossible to determine the duration of infection. • Examples include: • chancroid • gonorrhea • early syphilis • chlamydia #4-2-8

9. Asymptomatic STIs • Asymptomatic infections do not produce symptoms. • They can be present for a long time without patients knowing they are infected. • They are more useful for calculating prevalence than incidence. • Examples include (but are not limited to): • latent syphilis • chronic Herpes simplex virus type 2 • chlamydia • gonorrhoea #4-2-9

10. How STI Surveillance Data Are Used • Assess overall burden of STIs • Monitor trends in recently acquired STIs • Provide information for physicians to treat STI patients and their sex partners • Provide information to assist in planning and managing STI and HIV prevention and control programme efforts • Provide data for advocacy, resource mobilisation, programme planning, targeting, monitoring & evaluation • Serve as a marker of HIV risk behaviours • Monitor the number of people infected with HIV who develop an STI #4-2-10

11. Aetiologic and SyndromicCase Reporting • STI cases can be reported by one of the following strategies: • In aetiologic case reporting, the specific STI pathogen is identified by laboratory methods to make a diagnosis. • In syndromic case reporting, the symptom complex is used for diagnosis in the absence of laboratory confirmation of the STI pathogen. #4-2-11

12. Aetiologic Case Reporting • Aetiologic case reporting requires laboratory confirmation of diagnoses.  • Aetiological case reporting is only possible where well-developed systems of laboratory diagnosis are incorporated into routine STI clinical case management. • In Africa, the use of laboratory services for diagnosis is often not available for routine care, so the syndromic approach is recommended. #4-2-12

13. Syndromic Case Reporting • Only urethral discharge in men and genital ulcers in men and women reflect recent infection. Therefore, they are important for detecting trends in STI incidence.  • Syndromic case reports are a poor tool for assessing disease burden among women, since women’s infections are often asymptomatic. #4-2-13

14. Syndromic Case Reporting, Cont. • Gonorrhoea and chlamydia infections in women may be symptomatic, but the symptoms are difficult to distinguish from other conditions. • When possible, STI prevalence assessment and monitoring for women should be undertaken as a supplement to case reporting. #4-2-14

15. Case Definitions • When syndromic case reporting is used, healthcare workers should make diagnoses based on a standard case definition. • Uniform case definitions should be used throughout the country. • Cases should only be recorded if they meet the standard case definition, not simply based on the assigned diagnosis. #4-2-15

16. STI syndrome Case definition Additional information Urethral discharge • urethral discharge in men with or without dysuria • caused by N. gonorrhoeae and C. trachomatis • other possible infectious agents include T. vaginalis, U. urealyticum and Mycoplasma spp. Genital ulcer (non-vesicular) • ulcers on the penis, scrotum or rectum in men • ulcers on the labia, vagina or rectum in women • caused by syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale or atypical types of genital herpes • reporting only non-vesicular genital ulcers excludes most herpes infections Table 2.1. Recommended Case Definitions for Select STI Syndromes Source: UNAIDS/WHO, 1999. #4-2-16

17. Using the IDS Strategy to Report • Under IDS, STI cases are reported from the district using forms similar to those used for other priority communicable diseases. • Data are collected, analysed and disseminated in an integrated way. • The STI portion of IDS includes reports for: • cases of urethral discharge in men • cases of non-vesicular genital ulcers in men and women #4-2-17

18. Table 2.2. Recommended Aetiological Case Definitions for Selected STI Syndromes #4-2-18

19. Basic and Advanced STI Surveillance • Two levels of STI surveillance activities can be planned: • Basic STI surveillance activities should be undertaken in areas with limited resources. • Advanced STI surveillance activities can be conducted in countries with more extensive resources and well-developed laboratories. #4-2-19

20. Table 2.3. Comparing the Approach for Basic and Advanced STI Surveillance • Basic Surveillance • Sentinel or universal syndromic reporting (with minimal data elements collected) of: • male urethral discharge • non-vesicular genital ulcer disease in men and women • Advanced Surveillance • Aetiologic reporting of: • syphilis (by stage) • gonorrhoea • chlamydia #4-2-20

21. Table 2.3. Comparing Prevalence Assessment and Monitoring for Basic and Advanced Surveillance • Basic Surveillance • Conduct periodically in high-risk populations • Test all pregnant women for syphilis • Focus only on serologic testing for syphilis • Advanced Surveillance • Conduct periodically in general and high-risk populations: • women at family planning clinics • military recruits • sex workers, STI patients • Include urine testing for gonorrhoea and chlamydia and serologic testing for syphilis • Can be combined with behavioural surveys #4-2-21

22. Table 2.3. Comparing Assessment of Syndrome Aetiologies for Basic and Advanced Surveillance • Basic Surveillance • Assess genital ulcer disease and urethral and vaginal discharge every three years • Advanced Surveillance • Assess causes of genital ulcer disease at least every three years • Assessment of genital discharge is not needed because aetiologic case reporting is used #4-2-22

23. Table 2.3. Comparing Special Studies for Basic and Advanced STI Surveillance • Basic Surveillance • Investigate: • anti-microbial resistance monitoring for N. gonorrhoeae annually • conduct evaluation of STI treatment guidelines every three years • Advanced Surveillance • Investigate outbreaks of diseases with low incidence • Conduct special studies of: • anti-microbial resistance monitoring for N. gonorrhoeae annually • serologic surveys of HSV-2especially in adolescents and young adults • human papilloma virus infections • prevalence studies of bacterial vaginosis #4-2-23

24. Table 2.4. Planning for Advanced STI Surveillance #4-2-24

25. In Summary • STI surveillance includes routine data collection and special studies. • It relies on aetiologic or syndromic case reporting, but syndromic case reporting is recommended for sub-Saharan Africa. • Basic STI surveillance activities should be undertaken in areas with limited resources. • Advanced activities are conducted where there are more resources and better laboratories. #4-1-25

26. Warm Up Review • Take a few minutes now to look back at your answers to the warm up questions at the beginning of the unit. • Make any changes you want to. • We will discuss the questions and answers in a few minutes. #4-2-26

27. Answers to Warm Up Questions 1. True or false? Some elements of an STI surveillance system are more important for HIV surveillance activities. Others are more important for STI control programme activities. #4-2-27

28. Answers to Warm Up Questions 1. True or false? Some elements of an STI surveillance system are more important for HIV surveillance activities. Others are more important for STI control programme activities. True #4-2-28

29. Answers to Warm Up Questions, Cont. 2. True or false? STI surveillance data can serve as an indicator of trends in HIV risk behaviours. #4-2-29

30. Answers to Warm Up Questions, Cont. 2. True or false? STI surveillance data can serve as an indicator of trends in HIV risk behaviours.True #4-2-30

31. Answers to Warm Up Questions, Cont. 3. True or false? Aetiologic reporting of syphilis (by stage), gonorrhoea, chlamydia, and congenital syphilis is considered a basic surveillance activity in the African region. #4-2-31

32. Answers to Warm Up Questions, Cont. 3. True or false? Aetiologic reporting of syphilis (by stage), gonorrhoea, chlamydia, and congenital syphilis is considered a basic surveillance activity in the African region. False #4-2-32

33. Answers to Warm Up Questions, Cont. • Which of the following is not a component of an STI surveillance system? • STI universal case reporting • STI sentinel surveillance systems • STI testing and treatment • STI prevalence assessment and monitoring #4-2-33

34. Answers to Warm Up Questions, Cont. • Which of the following is not a component of an STI surveillance system? • STI universal case reporting • STI sentinel surveillance systems • STI testing and treatment • STI prevalence assessment and monitoring #4-2-34

35. Answers to Warm Up Questions, Cont. 5. True or false? In generalised HIV epidemics, prevalence assessments should include monitoring gonorrhoea and chlamydia. #4-2-35

36. Answers to Warm Up Questions, Cont. 5. True or false? In generalised HIV epidemics, prevalence assessments should include monitoring gonorrhoea and chlamydia. True #4-2-36

37. Answers to Warm Up Questions, Cont. 6. True or false? An STI surveillance system includes conditions that are newly acquired, as well as those that represent past infections. #4-2-37

38. Answers to Warm Up Questions, Cont. 6. True or false? An STI surveillance system includes conditions that are newly acquired, as well as those that represent past infections. True #4-2-38

39. Answers to Warm Up Questions, Cont. 7. In __________ case reporting, STI cases are reported by the specific microbial organism that caused the STI, while in syndromic case reporting, STI cases are reported by the clinical syndrome with which the patient presents. #4-2-39

40. Answers to Warm Up Questions, Cont. 7. In aetiologic case reporting, STI cases are reported by the specific microbial organism that caused the STI, while in syndromic case reporting, STI cases are reported by the clinical syndrome with which the patient presents. #4-2-40

41. Small Group Discussion: Instructions • Get into small groups to discuss these questions. • Choose a speaker for your group who will report back to the class. #4-2-41

42. Small Group Reports • Select one member from your group to present your answers. • Discuss with the rest of the class. #4-2-42

43. Case Study: Instructions • Try this case study individually. • We’ll discuss the answers in class. #4-2-43

44. Case Study Review • Follow along as we go over the case study in class. • Discuss your answers with the rest of the class. #4-2-44

45. Questions, Process Check • Do you have any questions on the information we just covered? • Are you happy with how we worked on Unit 2? • Do you want to try something different that will help the group? #4-2-45