Sexually Transmitted Diseases (STDs) - Global & India Overview PDF

# Sexually Transmitted Diseases ## Extent of the Problem **World** - True incidence of STDs is unknown. - Not all STDs are notifiable. - Secrecy surrounds STDs. - Prevalence is high. - 1 million STIs are acquired every day. - 374 million new infections per year. - Estimated 129 million chlamydia...

# Sexually Transmitted Diseases ## Extent of the Problem **World** - True incidence of STDs is unknown. - Not all STDs are notifiable. - Secrecy surrounds STDs. - Prevalence is high. - 1 million STIs are acquired every day. - 374 million new infections per year. - Estimated 129 million chlamydia, 82 million gonorrhoea, 7.1 million syphilis and 156 million trichomoniasis infections occurred in 2020. - Over 500 million people are living with genital HSV infections. - Over 300 million women have HPV infections. - 296 million people are living with chronic hepatitis B. - STIs can have serious consequences beyond the infection itself. - Herpes and syphilis can increase risk of HIV acquisition. - Mother-to-child transmission can result in stillbirth, neonatal death and low-birth-weight. - Congenital deformities and adverse birth outcomes, including stillbirth, can be caused by syphilis. - HPV infection causes around 528,000 cases of cervical cancer each year and 266,000 deaths. - Gonorrhoea and chlamydia are major causes of pelvic inflammatory disease and infertility. **India** - STDs are becoming a major public health problem. - **Syphilis:** - 17,787 cases reported in 2020. - 6,088 males and 11,699 females. - 40 deaths. - Serological surveys are the best source of information. - **Gonorrhoea:** - 27,582 cases in 2020. - 8,669 males and 18,903 females. - 5 deaths. - Most cases are not reported. - More prevalent than syphilis. - **Chancroid:** - Fairly prevalent. - **LGV:** - More prevalent in Southern India. - **Donovanosis:** - Endemic in South India. - **Other STDs:** - No reporting system. - Data is not readily available. ## Epidemiological Determinants **Agent Factors** - Over 20 pathogens have been found to be sexually transmitted. - Pathogens and diseases caused by them are classified in Table 2. **Table 2** | Pathogen | Disease or syndrome | | ---------------------------------------- | -------------------------- | | *Neisseria gonorrhoeae* | Gonorrhoea, urethritis, cervicitis, epididymitis, salpingitis, PID, neonatal conjunctivitis | | *Treponema pallidum* | Syphilis | | *Haemophilus ducreyi* | Chancroid | | *Chlamydia trachomatis* | LGV, urethritis, cervicitis, proctitis, epididymitis, infant pneumonia, Reiter's syndrome, PID. neonatal conjunctivitis | | *Calymmatobacterium granulomatis* | Donovanosis (granuloma inguinale) | | Herpes simplex viruses | Genital herpes | | Hepatitis B virus | Acute and chronic hepatitis | | Human papillomaviruses | Genital and anal warts | | Human immunodeficiency virus (HIV) | AIDS | | Molluscum contagiosum | Genital molluscum contagiosum | | Candida albicans | Vaginitis | | Trichomonas vaginalis | Vaginitis | **Host Factors** - The highest STD rates are found among 20-24 year olds, followed by those aged 25-29 and 15-19. - The majority of serious morbidity is observed during foetal development and in neonates. - Overall morbidity rates are higher for men than for women, but infection is generally more serious in women. - Individuals from lower socio-economic groups are at a higher risk of infection. - People who are single, divorced and separated experience higher infection rates than married couples. **Demographic Factors** - Factors contributing to an increase in STDs in developing countries include: - Population explosion. - Increase in the number of young people. - Rural to urban migration. - Increasing educational opportunities for women, which often results in later marriage and higher STD risks. **Social Factors** - Factors contributing to higher STD rates include: - Prostitution: A significant influence in the spread of STDs. - Broken Homes: Promiscuity is often linked to people from broken homes. - Sexual Disharmony: Married individuals with strained relationships, as well as separated or divorced persons, are more likely to contract STDs. - Easy Money: In poverty-stricken regions, prostitution is common as it provides an easy way to earn money. - Emotional Immaturity: A key factor in acquiring STDs. - Urbanization and Industrialization: These factors increase vulnerability to STDs due to factors such as: - Long working hours. - Relative isolation from families. - Geographical and social mobility. - Casual sexual encounters. - Social Disruption: Caused by disasters, wars and unrest. - International Travel: Can result in the import and export of infection and has contributed to the spread of resistant strains of *N. gonorrhoeae* and HIV. - Changing Behavioral Patterns: Relaxation of traditional moral values surrounding chastity. - Social Stigma: Contributes to the non-detection of cases, reluctance to disclose sources of infection, dropping out of treatment, seeking alternative care and self-treatment. - Alcoholism: Alcohol consumption can encourage prostitution. ## Clinical Spectrum ### Gonococcal Infection - Causes inflammation of the genital tract, including the urethra, cervix, rectum, throat and eyes. - Complications in women include PID, chronic pelvic pain, increased risk of ectopic pregnancy, infertility and inflammation of the epididymis. - Complications in men include inflammation of the epididymis, sub-fertility, and urethral strictures. - Potential complications in infants include *eye infection* which can lead to blindness if left untreated. - Infections respond to ciprofloxacin, ceftriaxone, cefixime or spectinomycin. ### Syphilis - Causes ulceration of the uro-genital tract, mouth or rectum. - Later stage symptoms include skin eruptions and complications of the cardiovascular and nervous systems. - Congenital syphilis is a significant cause of stillbirth. - Infections respond to penicillin, doxycycline and erythromycin. ### Chlamydial Infection - Often asymptomatic. - Symptoms are similar to gonorrhea. - Complications include infertility in women and conjunctivitis, eye inflammation and urethritis in infants. - Men can experience urethritis and epididymitis. - Infections respond to doxycycline, azithromycin, amoxycillin, ofloxacin, erythromycin or tetracycline. ### Trichomoniasis - Causes *vaginitis* and vaginal discharge in women. - Often asymptomatic in men but can cause urethritis. - Increasingly linked to adverse pregnancy outcomes such as low birth weight and premature rupture of the membranes. - Infections respond to metronidazole or tinidazole. ### Chancroid - Characterized by a small papule that erodes into an ulcer. - Pain is severe in the ulcer stage. - Bubo (painful swelling of lymph nodes in the groin) can occur. - Infections respond to ciprofloxacin, erythromycin, ciftriaxone and azithromycin. ### Lymphogranuloma Venereum - Causes swelling of lymph nodes in the groin. - Initially, a small, painless genital ulcer will occur. - Untreated, the disease can cause extensive lymphatic damage and elephantiasis (deformity, e.g. genital swelling). - Complications include rectal stricture. - Infections respond to doxycycline, erythromycin and tetracycline. ### Donovanosis - Also known as granuloma inguinale or granuloma venereum. - Characterized by a painless papule that ruptures into a granulomatous lesion. - Infections respond to azithromycin and doxycycline. - Infections also respond to erythromycin, tetracycline, and trimethoprim-sulfamethoxazole. ### Genital Herpes - Caused by HSV-2. - Characterized by papular lesions that progress to blisters and ulcers. - First episodes are characterized by a prolonged ulceration. - Antiviral treatment can shorten the duration of the first episode and reduce severity. - **Syphilis**, **chancroid**, and **genital herpes** are the most common causes of genital ulcers and are treated separately from **gonococcal infection**. - Individuals will have recurrent symptoms. - There is no cure. - Oral antiviral medications can reduce severity and duration of the first HSV episode. - Topical creams are less effective. ### Human Papillomavirus (HPV) - Causes ano-genital warts. - Common types include soft, flesh-coloured warts, papular flat warts and cauliflower-like warts. - Warts can appear anywhere on the genitalia, including the perianal region. - HPV is also linked to cervical cancer. - Treatment is generally reserved for larger lesions as sub-clinical infections tend to resolve on their own. - Regular cervical cytology screening and colposcopy are crucial for the early detection of cervical cancer. ## Syndromic Approach to STD - STDs can share similar clinical manifestations. - Common syndromes and sequelae are described in table 3. **Table 3** | Common Syndromes and Sequelae | | ---------------------------------------------------------------------- | | Male urethritis | | Lower genital syndromes in women: *vaginitis/cervicitis/urethritis* | | Genital ulceration | | Proctitis/colitis | | Salpingitis | | Epididymitis/orchitis | | Infertility/ectopic pregnancy | | Postnatal and perinatal morbidity | | Hepatitis/hepatic carcinoma | | Genital carcinoma | | Acquired Immuno Deficiency Syndrome (AIDS) | - The traditional methods of diagnosing STDs using labs is often not viable due to lack of availability or high cost. - Syndromic management of STDs is a more effective option as it allows for accessibility, early detection and immediate treatment. - Diagnosis is based on the presentation of symptoms. - It is more cost-effective than lab-based diagnosis. ## Syndromic Management of Urethral Discharge in Males - **Clinical Presentation:** - Urethral Discharge - **Treatment**: - Tab. Cefixime 400 mg orally, single dose + Tab Azithromycin 1 gram orally, single dose, under supervision. - Patients should return 7 days after the start of treatment. - If symptoms persist or recur, treat for *T*.*vaginalis*. - Tab. Secnidazole 2 gm orally, single dose. - If symptoms persist, refer to a higher centre. - If allergic to azithromycin, administer erythromycin 500 mg four times per day for 7 days. - **Partner Management:** - Treat all recent partners. - Treat female partners for gonorrhoea and chlamydia. - Advise sexual abstinence. - Provide condoms. - Educate partners about correct and consistent use. - Refer for voluntary counselling and testing for HIV, syphilis and Hepatitis B. - Schedule a return visit 7 days later. - **Pregnancy:** - In pregnant patients, use cephalosporins to cover gonococcal infection. - Recommended regimen is Tab. Cefixime 400 mg orally, single dose or Ceftriaxone 125 mg by intramuscular injection. - Cover chlamydial infection with erythromycin 500 mg orally four times per day for seven days or cap amoxicillin 500 mg orally, three times per day for seven days. - Quinolones are contraindicated in pregnancy. - **Follow-up:** - 7 days later. - Assess for: - Treatment failure. - Reinfection. - If symptoms persist, refer for further consultation. ## Syndromic Management of Vaginal Discharge - Discharge confirmed by clinician. - **Clinical History:** - Menstrual history to rule out pregnancy. - Nature and type of discharge. - Genital itching. - Burning while urinating. - Presence of ulcer or swelling. - Genital complaints in sexual partners. - Low backache. - **Examination:** - Per speculum examination to differentiate between vaginitis and cervicitis. - *Vaginitis:* - Trichomoniasis - greenish frothy discharge - Candidiasis - curdy white discharge - Bacterial vaginosis - adherent discharge - Mixed infections may present with atypical discharge. - *Cervicitis:* - Cervical erosions or ulcers. - Mucopurulent cervical discharge. - Bimanual pelvic examination to rule out pelvic inflammatory disease. - If speculum examination is not possible or the client is hesitant, treat for both vaginitis and cervicitis. - **Laboratory Investigations:** - Wet mount microscopy. - 10% KOH preparation. - Gram's stain. - **Treatment:** - **Vaginitis:** - Tab. Secnidazole 2 gm orally, singles dose or Tab Tinidazole 500 mg orally, twice daily for 5 days. - Consider Tab. Metoclopropramide to prevent gastric intolerance. - Candidiasis: Tab Fluconazole 150 mg orally, single dose or local Clotrimazole 500 mg vaginal pessaries. - Cervical infection: Tab. cefixime 400 mg orally, single dose + Azithromycin 1 gram, 1 hour before lunch. - **Pregnancy:** - Candidiasis: Local treatment with Clotrimazole only in the first trimester. - BV or Trichomoniasis: Metronidazole pessaries/cream in the first trimester. Metronidazole can be orally administered in the 2nd and 3rd trimesters. - **Partner Management:** - Treat the current partner if there is no improvement after initial treatment. - Treat the partner if they are symptomatic. - Advise sexual abstinence. - Provide condoms. - Educate partners about correct and consistent use. - Schedule a return visit 7 days later. ## Syndromic Management of Lower Abdominal Pain in Females - **Clinical History:** - Lower abdominal pain - Fever - Vaginal discharge - Menstrual irregularities - Dysmenorrhea - Dyspareunia - Dysuria - Low backache - Contraceptive use, like IUD - **Examination:** - General examination: temperature, pulse, blood pressure. - Per speculum examination: vaginal/cervical discharge, congestion or ulcers. - Per abdominal examination: lower abdominal tenderness or guarding. - Pelvic examination: uterine/adnexal tenderness, cervical movement tenderness. - Urine pregnancy test should be done in all women suspected of having PID to rule out ectopic pregnancy. - **Laboratory Investigations:** - Wet smear examination. - Gram stain for gonorrhea - Complete blood count. - ESR. - Urine microscopy for pus cells. - **Treatment:** - Mild or moderate PID (in the absence of tubo-ovarian abscess): - Tab. Cefixime 400 mg orally, twice daily for 7 days + Tab. Metronidazole 400 mg orally, twice daily for 14 days. - Doxycycline 100 mg orally, twice daily for 2 weeks to cover *N gonorrhoeae* and *C trachomatis*. - Tab. Ibuprofen 400 mg orally, three times per day for 3-5 days. - Tab. Ranitidine 150 mg orally, twice daily to prevent gastritis. - Remove intrauterine device, if present, under antibiotic cover of 24-48 hours. - Advise abstinence during the course of treatment and educate on correct and consistent use of condoms. - Observe for 3 days. - If no improvement (e.g., absence of fever, reduction in abdominal tenderness, reduction in cervical movement, adnexal and uterine tenderness) or if symptoms worsen, *refer for inpatient treatment*. - **Partner Management:** - Treat all partners in the past 2 months. - Treat male partners for urethral discharge (gonorrhea and chlamydia). - Advise sexual abstinence during the course of treatment. - Provide condoms. - Educate partners about correct and consistent use. - Refer for voluntary counselling and testing for HIV, syphilis and Hepatitis B. - Inform partners about the complications of leaving infection untreated. - Schedule return visits after 3 days, 7 days and 14 days to ensure compliance. - **Pregnancy:** - Pregnant women suspected to have PID should be referred to a district hospital. - Hospitals should treat pregnant women with a parenteral regimen which is safe for pregnancy (e.g., ceftriaxone and metronidazole). - **Doxycycline** is contraindicated in pregnancy. - **Metronidazole** is generally not recommended in the first trimester. - **Hospitalization** should be seriously considered when: - The diagnosis is uncertain. - Surgical emergencies (e.g. appendicitis or ectopic pregnancy) cannot be ruled out. - A pelvic abscess is suspected. - The patient is pregnant. - The patient cannot follow or tolerate an outpatient regimen. - The patient has failed to respond to outpatient therapy. ## Syndromic Management of Genital Ulcers - **Clinical History:** - Genital ulcer/vesicles. - Burning sensation in the genital region. - Sexual exposure to high-risk practices. - **Examination:** - Presence of vesicles. - Presence of genital ulcers (single or multiple). - Associated inguinal lymph node swelling. - Ulcer characteristics: - Painful vesicles and ulcers (single or multiple) - herpes simplex. - Painless ulcer with shotty lymph node - syphilis. - Painless ulcer with inguinal lymph nodes - chancroid and LGV. - Painful ulcer (usually single) - chancroid. - **Laboratory Investigations:** - RPR test for syphilis. - Refer to a higher centre for further investigations. - **Treatment:** - If vesicles or multiple painful are ulcers are present, treat for herpes with Tab. Acyclovir 400 mg orally, three times per day for 7 days. - If vesicles are not seen and there is only an ulcer, treat for syphilis and chancroid. - Counsel patients on herpes genitalis. - **Syphilis:** - Inj Benzathine penicillin 2.4 million IU IM after a test dose (with emergency tray ready). - Consider Tab. Doxycycline 100 mg, twice daily for 14 days if allergic or intolerant to penicillin. - **Chancroid:** - Tab. Azithromycin 1 g orally, single dose. - Tab. Ciprofloxacin 500 mg orally, twice daily for 3 days. - Continue treatment for more than 7 days if ulcers have not epithelialized. - Refer to a higher centre in these cases: - If the patient is not responding to treatment. - Genital ulcers co-exist with HIV. - Recurrent lesions. - **Partner Management:** - Treat all partners in the past 3 months. - Treat partners for syphilis and chancroid. - Advise sexual abstinence. - Provide condoms. - Educate partners about correct and consistent use. - Refer for voluntary counselling and testing for HIV, syphilis and Hepatitis B. - Schedule a return visit 7 days later. - **Pregnancy:** - Quinolones and doxycycline are contraindicated in pregnancy. - Pregnant women with a positive RPR should be considered to have syphilis unless adequate treatment is documented. - Pregnant women with primary, secondary or early latent syphilis should receive a second dose of 2.4 million units IM following a test dose one week later. - Pregnant women with a penicillin allergy should be treated with erythromycin. - Treat the neonate following delivery. - Pregnant women with a history of genital herpes or signs of genital herpes should be carefully examined for herpetic lesions. - Women without symptoms can deliver vaginally. - Women with herpetic lesions at the onset of labour should be delivered by cesarean section to prevent neonatal herpes. - Acyclovir can be orally administered to pregnant women with a first episode of genital herpes or severe recurrent herpes. ## Syndromic Management of Scrotal Swelling - **Clinical History:** - Swelling and pain in scrotal region. - Pain or burning while passing urine. - Systemic symptoms like malaise and fever. - Sexual exposure to high-risk practices. - **Examination:** - Scrotal swelling. - Redness and edema of overlying skin. - Tenderness of the epididymis and vas deferens. - Presence of urethral discharge/genital ulcer/inguinal lymph nodes. - A transillumination test to rule out hydrocele should be done. - **Laboratory Investigations:** - Gram's stain examination of the urethral smear will show gram-negative intracellular diplococci in the case of complicated gonococcal infection. - In non-gonococcal urethritis, more than 5 neutrophils per oil immersion field in the urethral smear or more than 10 neutrophils per high power field in the sediment of the first void urine are observed. - **Treatment:** - Tab. Cefixime 400 mg orally, twice daily for 7 days + Cap. Doxycycline 100 mg orally, twice daily for 14 days. - Refer to a higher centre as soon as possible, as complicated gonococcal infections require parenteral and longer durations of treatment. - Supportive therapy to reduce pain (bed rest, scrotal elevation with T-bandage and analgesics). - **Partner Management:** - Treat the partner depending on the clinical findings. - **Pregnancy:** - Doxycycline is contraindicated in pregnancy. - Erythromycin base/Amoxicillin can be used in pregnancy. - Erythromycin estolate is contraindicated in pregnancy due to hepatotoxicity. - Erythromycin base or erythromycin ethyl succinate should be used. ## Syndromic Management of Inguinal Bubo - **Clinical History:** - Swelling in the inguinal region which may be painful. - Preceding history of genital ulcer or discharge. - Sexual exposure to high-risk practices. - Systemic symptoms like malaise and fever. - **Examination:** - Localized enlargement of lymph nodes in the groin. - Inflammation of skin over the swelling. - Presence of multiple sinuses. - Edema of genitals and lower limbs. - Presence of genital ulcer or urethral discharge. - **Laboratory Investigations:** - Diagnosis is based on clinical grounds. - **Treatment:** - Start Cap. Doxycycline 100 mg orally, twice daily for 21 days (to cover LGV). - Start Tab. Azithromycin 1 g orally single dose or Tab. Ciprofloxacin 500 mg orally, twice daily for three days (to cover chancroid). - Refer to a higher centre as soon as possible. - **Partner Management:** - Treat all partners who are in contact with the patient in the last 3 months. - Treat partners for LGV and chancroid. - Advise sexual abstinence during the course of treatment. - Provide condoms. - Educate partners about correct and consistent use. - Refer for voluntary counselling and testing for HIV, syphilis and Hepatitis B. - Schedule a return visit after 7 days and 21 days. - **Pregnancy:** - Quinolones and doxycycline are contraindicated in pregnancy. - Pregnant women should be treated with erythromycin 500 mg orally, 4 times daily for 21 days and refer to a higher centre. - Consider adding a parenteral amino glycoside. - Erythromycin estolate is contraindicated in pregnancy due to hepatotoxicity. - Erythromycin base or erythromycin ethyl succinate should be used. ## Control of STDs The overall aim is to prevent ill-health from STDs through various interventions. Intervention may focus on primary prevention (prevention of infection), secondary prevention (minimizing the adverse health effects of infection) or a combination of these. ### Initial Planning - **Problem Definition:** - Assess the disease problem by geographic areas, population groups, and prevalence. - Collect data on psychosocial consequences and other health effects. - Conduct sero-epidemiological and population surveys. - **Establish Priorities:** - Consider the magnitude of the disease problem, consequences, and the feasibility of control. - Identify priority groups based on factors such as age, sex, place of residence, occupation, drug addiction, and other factors. - **Setting Objectives:** - Convert priorities into measurable and achievable objectives. - Focus on reducing the magnitude of the problem in a given population within a stated time frame. - Objectives should be quantifiable and unambiguous. - **Considering Strategies:** - Determine the combination of intervention strategies that are most appropriate for the setting. ### Intervention Strategies - **Case Detection:** - Treat apparently healthy volunteers for early detection of the disease. - High-risk groups include pregnant women, blood donors, industrial workers, soldiers, police, refugees, prostitutes, convicts, restaurant and hotel staff. - **Contact Tracing** Identifies and treats sexual partners of individuals with diagnosed STDs. - This is a key strategy for preventing the spread of infection. - Individuals are interviewed for their sexual contacts and are persuaded to attend a STD clinic for examination and treatment. - **Cluster Testing:** - Asks patients to identify other persons of either sex who move in the same socio-sexual environment. - These individuals are then screened for STDs. - **Case Holding and Treatment:** - Ensure adequate treatment, for both patients and their contacts. - Address patients disappearing before treatment is complete. - Recommend appropriate treatment regimens for STDs. - **Epidemiological Treatment:** - Administration of full therapeutic doses of treatment to individuals recently exposed to STDs while awaiting laboratory test results. - Not a long-term solution unless combined with venereological examination and contact tracing. - **Personal Prophylaxis:** - **Contraceptives:** - Mechanical barriers (e.g. condoms). - Use spermicides with condoms. - Wash exposed parts with soap and water as soon as possible. - **Vaccines:** - Hepatitis B vaccines are available. - Research is ongoing to develop vaccines for other STDs. - **Health Education:** - Aim is to alter behaviour in order to avoid STDs. - Target groups include: - General public. - Patients. - Priority groups. - Community leader. ### Support Components - **STD clinic:** - Provides consultation, investigations, treatment, contact tracing and other relevant services. - Should be easily accessible, free, and available for long hours each day. - Should be designed to ensure the privacy of patients. - Should include separate treatment areas for female patients. - **Laboratory Services:** - Provide diagnostic tests to: - Ensure accurate diagnosis and treatment decisions. - Facilitate contact tracing. - Monitor morbidity. - Detect antimicrobial resistance. - **Primary Health Care:** - Integrate STD control activities into the primary health care system. - Involve primary health care workers in the STD "health team" to provide more effective treatment to a greater number of cases. - **Information System:** - Planning, information, and evaluation components of an effective program. - Require data on: - Clinical notifications. - Laboratory notifications. - Sentinel and adhoc surveillance. - Needs to include: - National notification systems, - Sentinel surveillance systems, - Population-based sample surveys. - Focus on: - The number of people interviewed. - The number of villages visited. - The number of cultures examined. - **Legislation:** - Necessary to: - Establish responsibilities. - Define standards. - Encourage early treatment and contact tracing. - Increase notification by general practitioners. - Promote health education. - Address the exploitation of individuals for sexual purposes. - **Social Welfare Measures:** - Support the rehabilitation of prostitutes. - Provide recreation facilities. - Provide decent living conditions. - Promote marriage counseling. - Prohibit the sale of sexually stimulating media. ### Monitoring and Evaluation - Monitor the effectiveness of the program activities by: - Assessing trends in STDs. - Evaluating programs. - Analyzing program activities to determine if they are being implemented satisfactorily. - Determining the effectiveness of selected intervention strategies. - **Global Health Sector Strategy on HIV, Hepatitis and Sexually Transmitted Infections, 2022-2030:** - Develop global targets. - Establish norms and standards. - Strengthen STI surveillance. - Monitor antimicrobial resistance. - Support the global research agenda regarding the development of diagnostic tests, vaccines and additional drugs for gonorrhea and syphilis. - **National STD Control Programs** - Involve intersectoral coordination.