STD/STI : sexually transmitted disease/infection

Sexually Transmitted Infections : Sexually Transmitted Infections Dr. Tanmay Mehta Ahmedabad ,India

Slide 2 : The name of this group of diseases was changed from “venereal diseases” to “sexually transmitted diseases” or “STDs” Now many persons call them “sexually transmitted infections or “STIs.” 2

Sexually Transmitted Infections : Sexually Transmitted Infections A STI is an infection that is transmitted through sexually activity 3

Importance of STIs : Importance of STIs Most neglected area of healthcare in developing countries (vaginitis, cervicitis and PID) Major cause of infertility in both females and males 4 Source: Lande 1993; WHO 1996.

Slide 5 : 5 Account for up to 40% of gynecologic hospital admissions Cofactor in HIV and HBV transmission STDs are almost as common as malaria: 333 million new cases each year Importance of STDs

STDs are a Significant Problem : STDs are a Significant Problem The consequences of untreated STDs Ectopic pregnancy (7-10 times increased risk in women with history of PID) Increased risk of cervical cancer Chronic abdominal pain (18% of females with a history of PID) 6 Source: Lande 1993.

STIs are a Significant Problem : STIs are a Significant Problem Infertility: 20-40% of males with untreated chlamydia and gonorrhea 55-85% of females with untreated PID (8-20% of females with untreated gonorrhea develop PID) Increased risk of HBV and HIV/AIDS transmission 7 Source: Lande 1993.

STIs are a Significant Problem : STIs are a Significant Problem Infants can: Be infected at birth with blinding eye infections and pneumonia (chlamydia, genital herpes and gonorrhea) Suffer central nervous system damage or die (syphilis or genital herpes) as a result of STDs 8

STIs - classification : STIs - classification BACTERIAL VIRAL PROTOZOAL FUNGAL ECTOPARASITES 9

Slide 10 : BACTERIA Neisseria gonorrhoeae gonorrhea Chlamydia trachomatis chlamydia Treponema pallidum Syphilis Hemophilus ducreyi Chancroid Calymmatobacterium granulomatis Donovanosis (granuloma inguinale) Gardnerella vaginalis Gardnerella-associated ("nonspecific") vaginosis OTHERRS :eg. Mycoplasma hominis ,Ureaplasma urealyticum? 10

VIRUSES : VIRUSES Herpes simplex virus Human papilloma virus Hepatitis B virus HIV (AIDS) Cytomegalovirus Molluscum contagiosum virus 11

PROTOZOAL : PROTOZOAL Trichomonas vaginalis Trichomonal vaginitis Entamoeba histolytica Amebiasis in homosexual men Giardia lamblia Giardiasis in homosexual men 12

Slide 13 : FUNGI ?Candida albicans Vulvovaginitis, balanitis ECTOPARASITES Phthirius pubis Pubic lice infestation Sarcoptes scabiei Scabies 13

Bacterial STDs : Bacterial STDs

Chlamydia : Chlamydia • Bacteria - Chlamydia trachomatis Unusual very small bacteria because it lives inside cells that it infects 15

CHLAMYDIA : CHLAMYDIA Most common STD Females outnumber males 6 to 1 Cervix is site of infection Most women are asymptomatic until the pain and fever from PID occur 16

CHLAMYDIA : CHLAMYDIA If symptomatic - discharge, painful urination, lower abdominal pain, bleeding, fever and nausea Complications include; cervicitis, infertility, chronic pain, salpingitis, ectopic pregnancies, stillbirths, reactive arthritis. 17

Chlamydia - consequences : Chlamydia - consequences 20-40% of women infected with chlamydia will develop PID (Pelvic Inflammatory Disease) 9% ectopic pregnancy 20% will become infertile 18% chronic pelvic pain 18

Chlamydia : Chlamydia Urethritis Epididymitis Proctitis Cervicitis Endometritis Salpingitis Perihepatitis Otitis media in infants Inclusion conjunctivitis Sterility 19

Chlamydia : Chlamydia Diagnostic Methods : Direct fluorescent antibody Enzyme immunoassay Nucleic acid hybridization (DNA probe) Cell culture DNA amplification 20

Recommended Treatment : Recommended Treatment Doxycycline 100 mg orally 2 times a day for 7 days or Azithromycin (Zithromax) 1 g orally 21

Chlamydia : Chlamydia Azithromycin and doxycycline are equally effective abstain from sexual intercourse for 7 days sex partners must be evaluated and treated 22

Symptoms Among Males Diagnosed With Chlamydia : Symptoms Among Males Diagnosed With Chlamydia 23

Symptoms Among Females Diagnosed With Chlamydia : Symptoms Among Females Diagnosed With Chlamydia 24

Gonorrhea : Gonorrhea Females: gonococcal cervicitis slight yellow-green discharge or vulvar irritation Male: gonococcal urethritis odorous cloudy discharge; urinary burning; swollen, tender lymph glands in groin 25

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GONORRHEA : GONORRHEA Mucus membranes affected include: cervix, anus, throat, eyes Bacteria neisseria gonorrhea organism attacks cervix as first site of infection 27

GONORRHEA : GONORRHEA Symptoms are thick discharge, burning urination, and severe menstrual or abdominal cramps 10 to 40 percent women develop PID Untreated gonorrhea can result in arthritis, dermatitis, and tenosynivitis 28

Gonorrhea : Gonorrhea Urethritis Epididymitis Proctitis Cervicitis Endometritis Salpingitits Perihepatitis Pharyngitis Conjunctivitis (new born & other) Amniotic infection syndrome Disseminated gonococcal infection 29

Gonorrhea : Gonorrhea Consequences: FEMALE : PID with sterility; ectopic pregnancy, severe pelvic pain; infant conjunctivitis. MALE: prostate abscesses with fever, difficult urination; gonococcal epididymitis with ? sterility 30

Gonorrhea : Gonorrhea Both: transmitted to eyes, anus, throat; may enter the bloodstream & invade joints, heart, liver, CNS Treatment: dual treatment for chlamydia & gonorrhea; resistant bacteria require special treatment 31

Gonorrhea : Gonorrhea Treatment should include coverage against chlamydia as well as gonorrhea (e.g. azithromycin or doxycycline to cover chlamydia) Cefixime - advantage can be given orally, but bactericidal levels less than ceftriaxone Ceftriaxone - extensive clinical trials (99.1% cure) 32

GonorrheaDiagnostic Methods : GonorrheaDiagnostic Methods Gram stain of endocervical smear Culture DNA probe 33

Recommended Treatment : Recommended Treatment Ceftriaxone (Rocephin) 125 mg IM or Cefixime 400 mg orally or Ciprofloxacin (Cipro) 500 mg orally or Ofloxacin (Floxin) 400 mg orally Plus: (for chlamydia) Doxycycline 100 mg 2 times a day for 7 days or azithromycin 1 g orally 34

Bacterial Infections - Nongonococal Urethritis : Bacterial Infections - Nongonococal Urethritis Female: few or no symptoms; may itch, urinary burning, mild vaginal discharge of pus Male: penile discharge ,urinary burning 35

Bacterial Infections - Nongonococal Urethritis : Bacterial Infections - Nongonococal Urethritis Consequences: inflamed cervix or PID; spread to prostate or epididymis; rare cases of arthritis Treatment: doxycycline or erythromycin 36

SYPHILIS : SYPHILIS Spreads throughout the body within hours of infection Caused by bacteria treponema pallidum Transmitted primarily through sexual intercourse, but also from infected mother to fetus 37

SYPHILIS : SYPHILIS Appearance of red or brown painless sore on mouth, fingers, reproductive organs in primary syphilis(CHANCERS) 38

SYPHILIS : SYPHILIS Appearance of rash on palms, soles, looks like eczema, psoriasis, measles or sunburn and flu like symptoms or mononucleosis in secondary syphilis (maximum infectivity) 39

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SYPHILIS : SYPHILIS Destructive lesions, organ destruction(Gumma), meningitis, and linkage to HIV in tertiary syphilis phase 41

SyphilisDiagnostic Methods : SyphilisDiagnostic Methods Clinical appearance Dark-field microscopy Nontreponemal serologic test Rapid plasma reagin VDRL Treponemal test 42

Recommended Treatment : Recommended Treatment Primary and secondary syphilis and early latent syphilis (<1 year duration): benzathine penicillin G 2.4 million units IM in a single dose. Late latent syphilis or latent syphilis of unknown duration and late syphilis (gumma or cardiovascular syphilis, but not neurosyphilis): Benzathine penicillin G 7.2 million units total, as 3 doses of 2.4 million units IM, at 1-week intervals. Neurosyphilis: Aqueous penicillin G, 18-24 million units a day, as 3-4 million units IV q4h for 10-14 days. 43

Viral STDs : Viral STDs Herpes simplex Genital Warts (HPV) Hepatitis B virus HIV ( AIDS virus)

Herpes : Herpes Recurrent, incurable viral disease HSV-2 -genital herpes 80% are asymptomatic or do not recognize the symptoms 45

HERPES SIMPLEX VIRUS : HERPES SIMPLEX VIRUS Contagious viral infection that spreads from direct skin to skin contact particularly in the oral and genital areas 46

HERPES SIMPLEX VIRUS : HERPES SIMPLEX VIRUS HSV-1 in form of cold sores, fever blisters, primarily around the mouth affects @ 80 % of all adults HSV-2 genital herpes infects 1 in 6 adults 47

HSV 2 : HSV 2 Symptoms vary from one individual to another Active phase may include itching, burning, swelling, and flu like symptoms Appearance of small painful blisters on genitals rupture, crust over and heal 48

HSV 2 : HSV 2 Virus travels down nerve to ganglia near spine & remains dormant until another outbreak and virus travels up nerve to skin Control efforts for HSV 2 are difficult because 75% are unaware they are infected 49

HSV 2 : HSV 2 There is no cure for HSV2, the drug acyclovir is prescribed for minimizing the discomfort Sexual activity should be avoided when sores are active 50

HSV : HSV Antiviral drugs neither eradicate latent virus nor affect the risk, frequency or severity of recurrences 51

Recommended Treatment : Recommended Treatment First clinical episode: Acyclovir 400 mg orally 5 times a day for 7-10 days, or famciclovir 250 mg orally 3 times a day for 7-10 days, or valacyclovir 1 g orally 2 times a day for 7-10 days. 52

Recommended Treatment : Recommended Treatment Recurrent episodes: acyclovir 400 mg orally 3 times a day for 5 days, or 800 mg orally 2 times a day for 5 days or famciclovir 125 mg orally 2 times a day for 5 days 53

HUMAN PAPILLOMA VIRUS : HUMAN PAPILLOMA VIRUS HPV refers to a group of over 70 different types of viruses 1/3 of which cause genital problems Found in @40% of sexually active women in there 20’s 54

HUMAN PAPILLOMA VIRUS : HUMAN PAPILLOMA VIRUS A small percentage develop genital warts which can lead to a precancerous condition 55

HUMAN PAPILLOMA VIRUS : HUMAN PAPILLOMA VIRUS Genital warts or condyloma are usually spread by direct contact on vaginal and/or anal areas Warts remain undetected when located inside vagina, cervix or anus 56

Slide 57 : 57 Female HPV

Human Papillomavirus (HPV) : Human Papillomavirus (HPV) More than 70 different types of HPV 30 types can infect the genital tract Cervical CACER and HPV HPV-16 HPV-18, 31 and 45 58

Human Papillomavirus (HPV) : Human Papillomavirus (HPV) 75% of the reproductive-age population has been infected with > 1 sexually transmitted HPV Genital warts affect 1% of sexually active adults 59

HPV : HPV Warts can be small to large, raised to flat, or single to clustered There is no cure for HPV although lesions can be removed Methods include: cryotherapy, chemicals, and laser therapy 60

HPV : HPV HPV is associated with cervical cancer or cervical dysplasia Early detection reduces mortality Also linked to cancers of the oral cavity. 61

(HPV) - Goal of treatment : (HPV) - Goal of treatment Symptomatic Decrease the bulk of the lesion Without treatment, warts may resolve on their own, remain unchanged or increase in size and/or number Often treatment is worse than lesion 62

(HPV) - Treatments : (HPV) - Treatments Patient applied Podofilox 0.5% solution or gel Provider applies Cryotherapy Podophyllin resin 10-25% Surgery, intralesional interferon, laser 63

Slide 64 : External warts: Patient may apply podofilox 0.5% solution or gel 2 times a day for 3 days, followed by 4 days of no therapy, for a total of up to 4 cycles, or imiquimod 5% cream at bedtime 3 times a week for up to 16 weeks. Treatment area should be washed with mild soap and water 6- 10 hours after application or podophyllin resin 10-25% in compound tincture of benzoin in small amounts to each wart, repeat weekly if necessary; ; or surgical removal. Vaginal warts: cryotherapy with liquid nitrogen, or TCA 80-90%, or podophyllin 10-25% 64

HEPATITIS B VIRUS : HEPATITIS B VIRUS Transmission is similar to HIV Through bloodborne pathogens, unprotected SI, Tattoos, ear piercings, injections and acupuncture 65

HEPATITIS B VIRUS : HEPATITIS B VIRUS HBV is more easily transmitted than HIV Nearly 95 % of persons with HBV recover Vaccination for HBV recommended especially for health personnel 66

HBV : HBV Persons at highest risk for contacting HBV include: Hemodialysis patients Injectable drug users Health care workers Infants born to HBV infected mothers Gay men Sexually active heterosexuals 67

HBV : HBV Hepatitis B virus is present in all body fluids Severe HBV includes jaundice and may result in prolonged illness or death 68

Human Immune Deficiency Virus (HIV) : Human Immune Deficiency Virus (HIV) HIV - retrovirus that targets & destroys helper T-4 cells that assist the immune response to disease 69

ACQUIRED IMMUNE DEFICIENCY SYNDROME : ACQUIRED IMMUNE DEFICIENCY SYNDROME AIDS is the third leading cause of death among all women between 15-44 Worldwide, women constitute @40% of all HIV positive cases The majority of women who contract AIDS are heterosexual, injecting drug users, hemophiliacs 70

DEFINING HIV/AIDS : DEFINING HIV/AIDS Human immunodeficiency virus HIV is the organism that causes AIDS Majority of AIDS victims will die AIDS includes pulmonary TB, recurrent pneumonia, and invasive cervical cancer 71

CONTRACTING AIDS : CONTRACTING AIDS HIV is carried from one person to another through blood, semen and vaginal secretions Transmitted through: sexual contact Sharing injecting drug needles From infected mother to infant during childbirth HIV is not transmitted through causal contact, tears or saliva 72

SYMPTOMS OF HIV : SYMPTOMS OF HIV Symptoms of AIDS may be similar to other diseases Difference is that they take longer to disappear or may recur 73

HIV(AIDS) : HIV(AIDS) Common early symptoms include: Night sweats Rapid weight loss without diet or exercise Diarrhea lasting longer than several weeks Thick white spots coating the mouth A dry cough and shortness of breath Purple spots on skin, in mouth, and rectum 74

DIAGNOSIS OF HIV : DIAGNOSIS OF HIV Two tests are used for diagnosis: 1. Enzyme-Linked ImmunoSorbent Assay (E L I S A test): a general screening with a high sensitivity 2. Western blot test, a less sensitive, more expensive but more specific test for the HIV antibody 75

DIAGNOSIS OF HIV : DIAGNOSIS OF HIV A women must wait @ a month from the time of suspected exposure before getting tested It takes @ 45 days between exposure and body’s building enough antibodies for detection Experts recommend two sets of tests @ 6 months apart 76

TESTING PROCEDURES : TESTING PROCEDURES If a person tests positive for the HIV antibody with the ELISA test, a second ELISA test is conducted on the same person If the second test is positive, the Western blot test is conducted If the Western blot test is positive, the person is said to be HIV-positive 77

Symptoms of HIV & AIDS : Symptoms of HIV & AIDS Developing HIV antibodies Patterns of progression rapidly progressive (3 years) usual progression (8-11 years) long-term nonprogression (> 10 yrs) 78

Symptoms of Full-Blown AIDS : Symptoms of Full-Blown AIDS Diagnosis of Opportunistic Infections Pneumocystis carinii pneumonia Cytomegalovirus (CMV) Encephalitis Meningitis Tuberculosis & Salmonella Toxoplasmosis Lymphomas, cervical cancer, Kaposi’s sarcoma * Death within 1-2 years 79

Treatment : Treatment NO CURE Combination drug therapy shows best results for slowing progress Prevention is the best solution 80

VAGINITIS : VAGINITIS One in ten women who visit wheir health-care provider complain about vaginal discharge Over 90% of vaginitis is classified as: 1. Trichomoniasis - caused by 1 celled protozoa 2. Bacterial vaginosis 3. Candidiasis - yeast , fungus infection, monila usually not sexually transmitted 81

TRICHOMONIASIS : TRICHOMONIASIS One celled parasite Found in both men and women Remains dormant in asymptomatic women Causes vaginal irritation, itching, and diffuse malodorous discharge in symptomatic women Women may see red spots on the vaginal walls Most men are a symptomatic Both partners must be treated with antibiotics 82

CANDIDIASIS : CANDIDIASIS ?Not a sexually transmitted disease Symptoms include itching, discharge, burning, or irritation Pregnant women commonly experience yeast infections Factors most often associated with repeat infections: diabetes, obesity, suppressed immunity, antibiotics, corticosteroids, or birth control pills 83

BACTERIAL VAGINOSIS : BACTERIAL VAGINOSIS Discharge is white and ordorus Associated with: 1. Cervicitis 2. PID 3. Postpartum endometritis 4. Premature labor 5. Recurring urinary tract infections Treatment: oral, cream or gel application of Flagyl male treated if infection recurs 84

Ectoparasitic Infections : Ectoparasitic Infections Pubic Lice: transmitted through sexual contact or infected linen/clothing SX: little to severe itchiness Treatment: prescribed Kwell ; pyrinate. launder linens & clothing 85

Ectoparasitic Infections : Ectoparasitic Infections Scabies: transmitted though close physical or sexual contact or from infected linen or clothing SX: small, red rash around primary lesion; intense itching, esp. at night Treatment: topical scabicide launder or dry clean linens & clothing 86

Guidelines for ?ing Risk : Guidelines for ?ing Risk Always use condoms & spermicides Avoid multiple sexual partners 87

PREVENTION STRAGETIES : PREVENTION STRAGETIES Sexual abstinence is the only 100% effective method to prevent sexually transmitted diseases Male condoms are one of the most effective methods for preventing STD’s 88

STIs and Family Planning: What Can Be Done : STIs and Family Planning: What Can Be Done Most STIs (e.g., gonorrhea, syphilis) can be treated. All STIs can be prevented. If not prevented, early diagnosis and treatment can decrease the possibility of serious complications such as infertility in both women and men. 89

A Final Word on STI control : A Final Word on STI control Contraceptive pills and injections and surgery for preventing pregnancy DO NOT PREVENT TRANSMISSION OF STIs ! 90

One of many reasons why STI control is difficult is that :many persons have these infections or are carrying the micro-organisms without knowing it : One of many reasons why STI control is difficult is that :many persons have these infections or are carrying the micro-organisms without knowing it 91

Summary : Summary STDs are common STD infections can be present without symptoms STDs can be costly in terms of personal health and health care spending STDs need to be diagnosed and treated early 92

Slide 93 : THANK YOU 93