Download Gonorrhoea - PapScreen Victoria

An overview of
Sexually Transmitted Infections (STIs)
Vanessa Hamilton
Advanced Sexual Health Nurse,
Nurse Educator
Melbourne Sexual Health Centre
Relevant
Sexually
Transmitted
Infections
Other related
Infections
Other Sexually
transmitted
Infections
Disease
Bacteria
Disease
Virus
Infestation
Parasite
Chlamydia
Chlamydia trachomatis
HIV
Human Immunodeficiency Virus
Pubic Lice (crabs)
Phthirus Pubis
Gonorrhoea
Neisseria gonorrhoeae
HBV
Hepatitis B
Trichomoniasis
Trichomonas vaginalis
Genital Warts
Human Papilloma Virus (HPV)
Sypilis
Treponema pallidum
Genital Herpes
Herpes Simplex Virus (HSV)
Bacterial Vaginosis
HCV
Hepatitis C
Thrush
HAV
Hepatitis A
MG
Mycoplasma `genitalium
Lymphogranuloma Venereum (LGV)
Chlamydia trachomatis L1, L2 or L3 strains
Scabies
Sarcoptes Scabiei
Important local points
*Source: DHS Victoria vidb Jul 2007
•
HIV
91% HIV cases diagnosed in men, *
81% of these men-who-have-sex-with-men (MSM)*
Decrease in number of diagnoses of AIDS since
94-95 (HAART)
12 cases heterosexual (1 born high prevalence
country;6 reported sex in high prevalence country; 3
IDU; 2 – locally acquired?)*
•
Gonorrhoea
80% in MSM, *
nearly all amongst MSM; heterosexual – sex overseas*
increasing amongst MSM; Issue – antibiotic resistance
•
Syphilis
300% increase in infectious syphilis*
90% amongst MSM*
•
Chlamydia
4 fold increase in last decade in Australia
mostly impacting young women
–
:
Chlamydia
• Most commonly reported bacterial infection in
Australia
• Increasing in all states
• Significantly increased rates in Indigenous
Australians in NT
• Urgent public health situation– notified cases in
Victoria almost tripled since 1990s
Epidemiology: Chlamydia trachomatis
Source: DHS Victoria www.dhs.vic.gov.au/ideas
Chlamydia by year and
State/Territory
Diagnosis rate per 100 000
300
250
200
150
100
50
0
1997
1998
1999
2000
Males
2001
2002
2003
2004
2005
Females
2006
Source: National Notifiable Diseases Surveillance System
Chlamydia by year
and age group
Diagnosis rate per 100 000
1000
900
800
700
600
500
400
300
200
100
0
1997
1998
0-4
1999
5 - 14
2000
2001
15-19
2002
Year
20-29
2003
30-39
2004
2005
2006
40+
Source: National Notifiable Diseases Surveillance System
Chlamydia
Sites
• cervix, urethra,
• can also infect the anus and less commonly eyes
and throat
Transmission
• vaginal, anal and less commonly oral sex
Chlamydia
• The highest burden of infection is in the 15- 29 year
age group slightly more common in 20-29
• Usually asymptomatic
• Significant personal and public (financial)
consequences if not detected
• However it is relatively cheap and easy to diagnose
• Relatively cheap and easy to treat
Chlamydia-symptoms in males
• 50% or more of men with chlamydia urethritis are
asymptomatic (30-60% quoted depending on study)
• Symptomatic urethritis has an incubation period of
usually 7-14 days
• Symptoms are urethral dishcharge (white or grey),
dysuria, discomfort, redness at urethral opening
Chlamydia complications in males
• Epididymitis
• Sexually reactive arthritis – inclduign Reiter’s
syndrome
• Transmission to others especially women
Chlamydia – symptoms in females
•
•
•
•
•
•
•
Cervical STIs are most often asymptomatic
Unusual vaginal discharge
dysuria
deep dyspareunia,
intermenstrual or Post coital bleeding
lower abdominal pain
cervix may appear inflamed with a mucopurulent
discharge and contact bleeding. (MPC mucopurulent
cervicitis)
Chalamydia complications in women
• 50% will have endometritis
• Between 10-40% of women infected with chlamydia
develop PID
• Tubo-ovarian abscess
• Ectopic pregnancy; infertility
Chlamydia Diagnosis
• Nucleic Acid Amplification Tests (NAATs)
Detect Chlamydia trachomatis in swabs and urine
• These DNA amplification tests include
PCR polymerase chain reaction
LCR ligase chain reaction
• Check with your local lab as to which test they use
Chlamydia Diagnosis cont…
Male
• Urethral, urine
• Rectum (MSM)
Rectum and throat not validated
Female
• Endocervical, high vaginal, urine
Management
• Antibiotic Treatment
– Azithromycin 1g orally once or
– Doxycycline 100mg bd for 10 days or
– Roxithromycin 300mg daily as a single dose (or
150mg bd) for 10 days
– Recommended to avoid sex during and for seven
days after treatment
Chlamydia Management Continued
• Contact Tracing
• TORI – 3 months
Gonorrhoea
• Bacterium Neisseria gonorrhoeae
• Mucous membranes of the urethra,
cervix, anus throat and eyes
• Readily transmitted by anal, vaginal and
oral sex
Gonorrhoea
• Rates going up more recently on NSW and
VIC and SA – MSM
• Rates much higher in NT and WA specifically
due to rates in Indigenous Australian
populations
Gonorrhoea by year and
State/Territory
Diagnosis rate per 100 000
60
50
40
30
20
10
0
1997
1998
1999
Males
2000
2001
2002
2003
2004
2005
2006
Females
Source: National Notifiable Diseases Surveillance System
Gonorrhoea by year
and age group
Diagnosis rate per 100 000
150
100
50
0
1997
1998
0-4
1999
2000
5 - 14
2001
2002
Year
15-19
2003
20-29
2004
30-39
2005
2006
40+
Source: National Notifiable Diseases Surveillance System
Gonorrhoea
• Highest rates in 15-29 year age group
• Different to CT as also somewhat higher rates
in 30-35 year old due to higher incidence in
MSM and Indigenous Australian populations
Gonorrhoea - Diagnosis
• Isolation of N. gonorrhoeae by culture is the
diagnostic standard
• DNA based tests
• Advantages
– Rapid results
– Good for remote areas – transport
– Urine or tampon
– Sensitivity equal or better than culture
Gonorrhoea
• Ceftriaxone 250mg via IMI recommended treatment
in Australia
• Sensitivity tests in April 2003 of MSM showed 7%
resistance to Ciprofloxacin
• Gonorrhoea resistance not covered here.
• Please refer to Venereology Society of Victoria,
National Management Guidelines for STIs, 2002 or
MSHC website
Syphilis
Infectious syphilis by year
and sex
Diagnosis rate per 100 000
8
6
4
2
0
2004
2005
Males
2006
Females
Source: National Notifiable Diseases Surveillance System
Syphilis
• A complex systemic illness with multiple clinical
manifestations
• Syphilis can be acquired:
– Through sexual contact
– By passage through the placenta
– By kissing or other close contact with an infected lesion
– By transfusion of fresh human blood
– By accidental direct inoculation
Serologic Tests
• Nonspecific nontreponemal tests
– The RPR
– Cheap, rapid
– Convenient for screening large numbers of sera
– Indicates disease activity
• Specific antibody tests
– TPHA, FTA-Abs
– Establish the high likelihood of infection
– Generally remain reactive over time, even after
treatment
Sypilis treatment
• Early Syphilis:
Benzathine penicillin 1.8 gm IM single dose
or Doxycycline 100mg twice daily for 14 days if
allergic to penicillin
• Late latent syphilis:
Benzathine penicillin 1.8 gm IM weekly for three
weeks
HIV Victorian Prevelence
The HIV epidemic in Victoria
Cumulative figures to 31 December 2006
• HIV diagnoses
-
5,390
• AIDS
-
2,041
• Deaths
-
1,481
Diagnoses of HIV infection
1
and AIDS in Australia
2500
Number
2000
1500
1000
500
0
1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005
Year
HIV diagnoses
1. AIDS diagnoses adjusted for reporting delays.
AIDS diagnoses
Source: State and Territory health authorities
The HIV epidemic in Australia
Cumulative figures to 31 December 2006
• HIV diagnoses
-
26,267
• AIDS
-
10,125
• Deaths
-
6,723
Global summary of the HIV/AIDS
pandemic,
as of December 2007
Number of people living with HIV/AIDS
Total 33.2 million (30.6 – 36.1 million)
Adults
30.8 million (28.2 – 33.6 million)
Women 15.4 million (13.9 – 16.6 million)
Children under 15 years
2.5 million
(2.2 – 2.6 million)
People newly infected with HIV in 2007
Total
2.5 million (1.8 – 4.1 million)
Adults
2.1 million (1.4 – 3.6 million)
Children under 15 years
420 000
(350 000 - 540 000)
AIDS deaths in 2007
Total
2.1 million (1.9 – 2.4 million)
Adults
1.7 million (1.6 – 2.1 million)
Children under 15 years
330 000
(310 000 - 380 000)
The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the
best available information.
Post-exposure Prophylaxis
• There is some evidence that antiretroviral therapy,
given within 72 hours of exposure, may reduce the
risk of infection
• Treatment is given for four weeks
• A risk-assessment must be performed, and weighed
against the side-effects and possible development of
drug resistance
• balance between the amount of HIV produced each
day and the amount of HIV cleared by the immune
system
Further Reading
• ASHM, HIV/Hepatitis: a guide for primary
care, 2001
• Holmes KK et al, Sexually Transmitted
Diseases, 3rd edition, 1999, McGraw-Hill
Trichomoniasis
• Trichomonas Vaginalis
• Vaginal infection
• Vaginal sex
Trichomoniasis
• Symptoms variable: thin, frothy, malodorous vaginal
discharge
• 50% women may be asymptomatic
• 95% men asymptomatic (and ? self-limiting)
Diagnosis
• Wet prep from posterior fornix of vagina
• Culture
• DNA testing – not widely available
Management
Antibiotics
– Tinidazole 2g orally stat or
– Metronidazole 2g orally stat
– Metronidazole 400mg bd for 5/7 or
– Clotrimazole 1% PV daily for 6 days
Treat partner
BACTERIAL VAGINOSIS
• What is it?
• Not a Sexually Transmitted Infection
• Syndrome of disordered vaginal ecology
Typical presentation of BV
• Malodour
• Increased vaginal discharge, more noticeable
after menstruation or coitus
• But mostly asymptomatic
Complications of BV?
•
•
•
•
PID?
Premature rupture of membranes
LBW
Post-partum endometritis
VAGINAL DISCHARGE
Normal
Candidiasis
Trichomonas
Bacterial
vaginosis
Discharge
Varies with
cycle
White, thick
Bubbly,
profuse,
yellow green
Scanty, grey
or white
Odour
Nil
Nil, yeasty
Fishy
Fishy
pH
< 4.5
< 4.5
> 4.5
> 4.5
Associated
symptoms
Nil
Itch, redness,
swelling,
splitting
Soreness
?Mild itch
Wet prep
Lactobacilli,
epithelial cells
Pseudohypha
espores
Trichomonads
Clue cells,
whiff test +ve
Lactobacilli
Present
Present
Absent or
scanty
Absent or
scanty
Polymorphs
Occasional
Present
Numerous
Few
Herpes simplex Virus
• Type 1 and Type 2
NEW KNOWLEDGE
• HSV I is now a more common cause of genital
herpes in some populations
• Genital herpes can substantially facilitate the
transmission of HIV infection
Biology of Herpes Simplex:
Biological Differences Between
HSV 1 and 2
• Either type is equally adept at infecting
sacral or trigeminal ganglia
– HSV-1 establishes competent latency in
trigeminal ganglia
– HSV-2 establishes competent latency in sacral
ganglia
Biology and Latency
Epidemiology: HSV-1
• Age-specific variations in HSV-1
seroprevalence
– 95% in the middle-aged and elderly
– 70% in the 20-35 year age group, and about
– 50% in adolescents
– HSV-1 causes approximately 50% of primary
genital herpes
Epidemiology: HSV-2
• ~15-20% of sexually active persons have
acquired HSV-2 by age 30
Making the Diagnosis
• Think herpes!
• Always examine someone with genital
symptoms
• Any skin break in the genital area could be a
herpes infection
• All that itches is not thrush
• Take a swab!
Thrush and Herpes
• If you don’t look for herpes
you won’t find herpes!
New Diagnosis
• PCR (polymerase chain reaction) is now the gold
standard and has supplanted viral culture
• PCR is quicker, cheaper and has fewer falsenegative results
• It is performed at VIDRL (Victorian Infectious
Diseases Service)
• “Multiplex PCR” = HSVI, HSVII, CMV & ZVZ
Serological Detection of HSV
Antibody
• Nonspecific tests are of little clinical use
• Western Blot type-specific serology is useful in:
– discordant couples
– staging first presentations
– typing culture -ve primary herpes
– confirming atypical HSV-2 infection
– excluding HSV-2 infection?
– screening?
Infectivity
• High titres of virus particles are shed from obvious
lesions
• Episodes of viral shedding occur in asymptomatic
individuals, and between overt recurrences
• About 70% of cases of first-episode genital herpes
are acquired from asymptomatic partners
Atypical Herpes
Barry
• 26 yo single male
• 18 mo recurrent postcoital “thrush”
• Responds to topical
antifungals
• Examination:
fissuring of prepuce
Barry
• HSV-2 DNA detected by PCR
• Asymptomatic on suppressive valaciclovir
Louisa
• 18 yo HSC student
• Asymptomatic partner
• No penetrative sex
• Acute vulvitis; HSV-1 detected
HSV – Asymptomatic shedding
• Transmissions mainly occur during
transmissions of asymptomatic shedding
• Most HSV –2 infections are acquired from a
person with no history of GH
• In HSV –2 pos individuals who have a history
of recurrent GH. Most transmissions occur
when lesions are not present
Transmission of GH
The risk of heterosexual transmission of
HSV-2 is estimated to be on average 10%
over a 1-year period
1. Wald et al. N Engl J Med 1995; 333: 770–5.
Prevention of Transmission
• Condoms
• Suppressive antiviral therapy
• Sexual practices/recognition of sx
• Vaccines?
Further Information…
• Australian Herpes Management Forum
– www.ahmf.com.au
• Melbourne Herpes Self-Help Group
– www.home.vicnet.net.au/~mhshg
• Sydney Herpes Support Group
– www.geocities.com/sydneygroup
Snapshot of Sex and Relationships
Figure 1.9
Population and
diagrammatic representation
of the core group concept
Non core Group – Fewer
partners; more sex acts
per partner
[Serial Monogamy]
Bridge Group
Core Group – More
partners; less sex
acts per partner.
[Concurrent
partnerships]
How do you control STIs?
R0[t] = βcD(χ)
R0
β
C
D
Reproductive Rate
[t]=time
Transmission
probability per
partnership
Rate of partner change
Duration of Infection
Priority Group: Gay or other homosexually active men
R0 = βcD
β– Good degree condoms use; co-infection with
another STI
c – high rate of partner change
D – access to screening
• Male sexuality – sex drive etc.
• Heterosexism
• Homophobia
STI / HIV Prevention
•
•
•
•
•
condoms for vaginal, anal and oral sex
non-penetrative contact
partner notification and treatment
raised awareness and education about
STI’s
regular screening and treatment with
antibiotics if detected
•
early detection may prevent complications
and transmission of the STI to other
sexual partners
•
regular screening encouraged amongst
MSM
Resources and Supports
MSHC Services – WITS (Walk-In
Triage Service)
•
•
•
•
On site clinical services
General Clinic
Green Room
Special Clinics (Thai, Korean, Chinese
Sex Workers; Vulval, Dermatology
Clinic) – and MSM Clinics (Thursday
Evening)
Results and Information Line
(9347 0244 and follow prompts)
Outreach
Sex-On Premises Venue
Street based Sex workers (RhED)
VACCHO and CALD Projects
Prisons Project
Partner Notification Officers (DHS) –
Ph: 9347 1899
•
MSHC Resources and Support
www.mshc.org.au
• Web-based Patient Information ‘Check
Your Risk’
http://checkyourrisk.org.au/
• Web-based GP resources
www.mshc.org.au/gpassist
• Sexual Health Physician Advice Line:
1800 009 903 (Toll Free)
Hours available:
Monday – Friday
09.00 -12.30 and
13.30 - 17.00