Download STIs syndromic management

STIs syndromic
management Part-1
Dr. Esmael Wabela
FHAPCO/FMOH
Mar-2008
1
Outline


Definition of STIs
Epidemiology of STIs

The Complications and Health and
Economic Impacts of STIs
Strategies for STI Prevention and
Control
Challenges of Controlling STI

HISTORY TAKING AND EXAMINATION

Specific STI syndromes


2

STIs are infectious
diseases transmitted by
sexual activity and,
sometimes, by blood
transfusion and from
mother to child
3
Epidemiology
of STI
4
Epidemiology of STIs

STIs are major public health problems globally



In many developing countries STIs are among the
top five disease
There is little information of STIs in Ethiopia
Except for adult prevalence of HIV( 2.1 (2007) )&
syphilis (2.7 %) there is no uniformity in reporting of
STIs in Ethiopia
Total of 451,686 cases reported between June 1988 & June
2002 in Ethiopia
5


Globally 340 million new cases of curable STIs occur
every year (69 million are in sub-Saharan Africa)
Distribution of STIs




Prevalence higher in urban than rural
Higher in unmarried & young adults
More frequent among females than males
between the ages of 14-19
After the age of 19, there is slight male
preponderance
6
STI statistics are underestimated

Reasons for underestimation:






people with asymptomatic STIs do not seek treatment
Poor access: health facilities offering treatment for
STIs may be too far away for many people
Missed opportunity: people seeking other health care
such as antenatal services may not be routinely
screened for STIs
Stigma: many patients perceive a stigma in attending
modern STIs services
Non-reporting facilities: large number of people visit
private and traditional care providers that are not
reporting,
Cost of services etc…
7
The accuracy of STI statistics
cont….
Symptomatic
Asymptomatic
8
STI transmission dynamics at population level
General population
Bridging population
Core
transmitters
9
Factors Affecting Transmission


Behavioral Factors
-Many partner
-Change of partners
-Not using condoms
- Casual sex
- Sex with CSW & partner
- Alcohol & substance use
Personal factors
- Delay in getting Rx
- Stigma being ashamed
- Noncompliance to Rx


Socio-economic
-Poverty
-Religious Restrictions
- Women’s position
Cultural
-HTP

Biological & clinical
- Assymptomatic STIs
- Age
- Sex
- Vulnerability, immunity
10
Factors influencing transmission of
STI: Socio-cultural factors



Cultural and social pressure on Women
 Little decision making power over sexual practices and
choices, including use of condoms
 Sexual violence directed
 Early marriage of girl-child to an adult
Permissive attitude for men to have more sexual partner.
Harmful traditional practices
 Skin-piercing
 Unsterile needles to give injections or tattoos
 Scarification or body piercing
 Circumcision using shared knives
11
The Complications and
Health and Economic
Impacts of STIs
12
Medical Complications of STIs
CAUSE
COMPLICATIONS
Gonococcal &
Chlamydial infections
Infertility, Eectopic pregnancy,
chronic pelvic pain, urethral
stricture, peritonitis
Gonorrhea
Blindness in infants,
Disseminated gonococcal infection
Chlamydia
pneumonitus in infants
Acquired syphilis
Permanent brain, Heart disease
Congenital syphilis
Extensive organ & tissue damage
Human papilloma virus Genital cancer, obstructed labor
13
The link between STI & HIV
Both share same behavior & mode of
transmission

STIs facilitate the transmission of HIV

The presence of HIV can make people more
susceptible to the acquisition of STIs

The presence of HIV increases the


severity of STIs and
their resistance to standard treatment
14
Clinical presentations of HIV and
STI co-infection







Atypical presentation of Syphilis rapid progression
to neurosyphilis
Atypical lesions of chancroid
Recurrent or persistent genital ulcers from HSV2
Severe genital herpes may require suppression of
recurrence with acyclovir
Human papilloma virus with exophytic genital warts
Risk of treatment failure with single injection of
Benzathine Penicillin in primary syphilis
Topical anti-fungals are less effective
15
Other Impacts of STI

Social:



Stigmatization
Divorce & family disruption as a result of infertility
Economic:


Cost of STI drugs may place heavy financial
burden on families , communities, & the country
at large
Unproductivity
16
Strategies for STI
Prevention and Control
17
The Main Aims of STI Prevention
and Control are:
Interrupting the transmission of STI

Prevent development of disease and
complications

Reducing the risk of acquiring and
transmitting HIV
18
Prevention and Control of STIs
Involves

Promotion of safer sexual behavior
Promotion of health care-seeking behavior
Early diagnosis and treatment

Targeting vulnerable groups


19
Health Care Seeking Behaviour – People with STIs
Target for Control
Stage 1 Preventing new infection
Stage 2 Detection & Rx of asymptomatics
Stage 3 Improving health seeking behavior
Stage 4 Improving Rx
Stage 2
Population
with any
STI
With
Without
symptoms symptoms
With STI
STI so far
prevented
Stage 1
Total adult
population
Stage 3
Symptoms
recognized
Not
Seeking
Rx
Seeking
Rx
Inadequate
Rx
Stage 4
Presenting
for Rx
Adequate
Rx
20
Primary prevention

Safer sexual behaviors






abstention from sexual activity altogether
delaying the age of sexual debut
life-long mutual monogamy
condoms (male or female) are used
engaging only in non-penetrative sex acts public education
campaigns
Program and service package


public education campaigns
providing quality STI care


providing non-stigmatizing and non-discriminatory service
ensuring a continuous supply of highly effective drugs & condoms 21
Secondary prevention

case finding and screening:





examining minimally symptomatic women attending clinics for
maternal and child health and family planning
partner notification and treatment
education, investigation and treatment of targeted population
groups who may have placed themselves at risk of infection
testing of blood donors for syphilis, HIV and hepatitis B
community-based screening

Provision of prophylactic antibiotics against major STIs
for victims of sexual violence

Integration of STI services within primary care

training of service providers in case management
22
Secondary prevention

rapid and effective treatment of people with STIs:

comprehensive case management of STI syndromes
 to make a correct diagnosis
 to provide correct antimicrobial therapy for the STI
syndrome
 to educate on the nature of the infection, safer sexual
behaviour, safe sex acts and risk reduction in order to
prevent or reduce future risk-taking behaviour
 to educate on treatment compliance
 to demonstrate the correct use of condoms and provision
of condoms
 to advise on how the patient’s partners may be treated
and to issue a Partner Referral card for the patient to
pass on to his/her partner(s).
23
Challenges of
Controlling STI
24
Challenges are due to:



Factors relating to health system
Biological factors
Social & behavioral factors
25
Health System Factors



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Health service may be unavailable, too far
away , expensive, or considered stigmatizing
There may be little emphasis on preventive
education & other efforts to prevent infection
Health services may not have effective drugs
Difficulty of partner management
26
Biological factors


70%-80% of infected women may be
asymptomatic and so will not seek
treatment
Such people will continue to be
infected, risking complications and
perhaps infecting others
27
Social & behavioral factors



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Reluctance to seek health care
Ignorance or misinformation
A preference for alternative health care
service- usually with poor quality
Reluctance to follow safe sex practices
The social stigma often attached to STIs
Failure to take full prescribed course of
treatment
Difficulty of notifying sexual partners
28
Major Problems of STI Prevention and
Control Program at National level

Human resource:



Lack of focal person for STIs at all levels
Shortage of trained manpower
Other resources

Inadequate allocated to STI control program.


Mostly it is a donor dependent and project specific program
Inadequate and irregular Drugs and other supplies
29
Major Problems of STI Prevention and
Control Program at National level

System related

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Lack of STI focused IEC/BCC activities
weak monitoring and evaluation system

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Absence of STIs sentinel surveillance system
Lack of uniformity in STI case management, recording and
reporting system
Focused on curative services, i.e., lack case
finding/detection mechanisms
Training on STI case management,
supervision…etc.,
Research (epidemiological, behavioral and
operational)
30
The Way Foreword








Promote syndromic management of STIs
Regular and adequate supply of STI drugs,
condoms and other supplies
Intensive trainings on syndromic STI management
Improve M&E system
Evaluation and improvement of syndromic
diagnosis in women
Encourage standardized STI service delivery by
the private and informal sectors
Special services for people at high risk
Development of feasible methods to influence
health care seeking behavior
31
Approaches to STI diagnosis

Classical approaches



Etiologic diagnosis – using lab to identify the causative
agent
Clinical diagnosis –using clinical experience to identify
causative agent
Syndromic: identifying & treating the Syndrome
!! a group of symptoms patient complains & clinical
signs you observe during examination !!
!! Different organisms that cause STIs give rise to
limited number of syndromes
32
Etiologic diagnosis

Advantages: Avoids over treatment
 Conforms to traditional clinical training
 Satisfies patients who feel not properly
attended to
 Can be extended as screening for the
asymptomatics
33
Disadvantages of etiologic
approach





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
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Requires skilled personnel & consistent supplies
Treatment does not begin until results are
available
It is time consuming & expensive
Testing facilities are not available at primary level
Some bacteria are fastidious & difficult to culture
(H.ducrey, C.trachomatis)
Lab. results often not reliable
Mixed infections often overlooked
Miss-treated/untreated infections can lead to
complications and continued transmission
34
Clinical Diagnosis:


Advantages: Saves time for patients
 Reduces laboratory expenses
Disadvantages: Requires high clinical acumen
 Most STIs cause similar symptoms
 Mixed infections are common & failure to treat
may lead to serious complications
 Doesn’t identify asymptomatic STIs
35
Syndromic: Treat the seven syndromes
SYNDROME
Vaginal discharge
MOST COMMON CAUSE
Urethral discharge in men
Vaginitis (trichomoniasis,
candidacies)
Cervicitis (gonorrhea, Chlamydia)
Gonorrhea, chlamydia
Genital ulcer
Syphilis, chancroid, herpes
Lower abdominal pain
Scrotal swelling
Gonorrhea, chlamydia, mixed
anaerobes
Gonorrhea, chlamydia
Inguinal bubo
LGV, Chancroid
Neonatal conjunctivitis
Gonorrhea, Chlamydia
36
Principles of Syndromic Approach


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STI sign and symptoms are rarely specific to a
particular causative agent
Laboratories are either non-existent or non
functional due to lack of resources
Dual infections are quite common and both
clinician and laboratory may miss one of them
Waiting time for lab. results may discourage
some patients
Failure of cure at first contact
37
Advantages of Syndromic management



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Problem oriented (responds to patient’s
symptoms )
Highly sensitive & does not miss mixed
infections
Treats the patient at first visit
Can be implemented at primary health care level
Use flow charts with logical steps
Provides opportunity & time for education &
counseling
38
Limitations of syndromic
management



Misses sub-clinical infection
Needs validation study
 Require prior research to determine
the common causes of particular
syndrome and its treatment
Needs training
39
Criticisms of syndromic
approach

Syndromic approach is not scientific



Too simple for a physician to use




based on wide range of epidemiological studies
Validation studies: algorism and sensitivity
Serves for all simply & effectively
Give more time for education for behavior change
Fails to make service provider’s clinical skills &
experience
It results in waste of drugs because of over
treatment

studies have shown that it is less expensive
40
Key features & steps in syndromic
STI case management

Syndromic diagnosis and treatment,

Use of flow charts: steps to be taken through a
process of decision making & action







History taking and examination
Education on risk reduction
Providers initiated HIV Counseling & testing
Condom promotion and provision for safer sex
Partners notification and management
Follow up
Referral
41
Clinical problem
Decision
box
Patient complaints of ..(dysuria, UD, VD, …)
History & Examine [Ask, look, assess]
Signs present?
Specific to
syndrome
Yes
Treat for common agents
•Educate on risk reduction
•Offer HCT
•Promote & provide condoms
• Partner management
• Advise to return
No
Look for
Other
STIs?
No
• Educate on RR
• Offer CTP
• Promote & provide
condoms
Yes
Use
appropriate
flow chart
Action
Box
42
Figure 1
Syndromic Diagnosis Approach
Symptom
Decision
Identify all possible agents that could cause
that specific syndrome and give
recommended treatment based on
epidemiologic and laboratory data
Action
action
action
action
43
Choice of Treatment

Cost

Efficacy at least 95%

Oral administration

Single dose

Safety

Availability
44

HISTORY TAKING AND
EXAMINATION
45
The three aims of history taking and
examination are to:
1. Make an accurate and efficient
syndromic STI diagnosis.
2. Establish the patient’s risk of
transmitting or contracting STI.
3. Find out about partners who may have
been infected.
46
Things to consider during history
taking and examination

The patient’s basic needs


The environment


The patient may be concerned or embarrassed, so
it is important that the service provider and the
environment set him or her at ease
Confidentiality and privacy are crucial: somewhere
to talk where others cannot see or hear – and a
particular need for patient confidentiality
The service provider

Patients need to feel that the service provider
understands and respects them and wants to
listen
47
Establishing a good rapport
with the patient

When the service provider makes
interviews he/she should:



smile and use a welcoming tone of voice
introduce himself/herself
use the patient’s name
48
Establishing a good rapport
with the patient cont…




offer the patient a seat
begin the history-taking only when there is
privacy
make eye contact if culturally appropriate
be respectful and understanding –
especially when the patient stammers and
hesitates.
49
Non verbal communication skills




maintain appropriate eye contact
listen carefully to what the patient says
reflect the patient’s behavior
stay as close to the patient as is
culturally acceptable
50
General Verbal Skills



always phrase your questions politely
and respectfully, however busy or
rushed you may be
use words that the patient understands
make your questions specific, so that
the patient knows exactly how to
answer
51
General Verbal Skills




ask one question at a time: double
questions confuse
keep your questions free of moral
judgments
avoid ‘leading’ questions that ask the
patient to agree with you: let people
answer in their own words
ask the patient’s permission before
asking about his/her STI or sexual
behavior
52
Specific Verbal Skills

Facilitation


using words, sounds or gestures to
encourage patients to keep on talking
Direction


Useful when a patient is confused and does
not know where to begin, or when they are
talking quickly and mixing up issues of
concern.
It helps people to sort out ideas and give
information in a sequence
53
Specific Verbal Skills

Summarizing and checking


enable service provider to check that
he/she have understood the patient
correctly. The patient is also able to correct
any misunderstanding.
Use this skill when the patient has
mentioned a number of things that you
want to confirm
54
Specific Verbal Skills

Empathy


Important skill when dealing with the
patient’s feelings
Reassurance

To show that you accept the patient’s
feelings and that the problem need not last
forever
55
Specific Verbal Skills

Expressing partnership


Confirms a commitment to help the patient
This commitment could be with the service
provider personally, or on behalf of the health
centre team
56
Establishing a good rapport with the patient

The service provider










smiling and welcoming tone
introduce himself/herself
use the patient’s name if he/she has it
offer the patient a seat
history-taking in privacy
eye contact & stay closer (culture)
be respectful and understanding
listener & full attention
use words that the patient understands
question: one at a time, specific & free of
moral judgments.
57
Specific
STI
syndromes
58
Urethral
Discharge
59
Agents: N.gonnorhea C. trachomitis
T. vaginalis U. urealaticum M. genitalium
Clinical presentation
 Burning sensation on urination, dysuria
 Urethral discharge
 Meatal excoriation


Complications
 Local spread and Dissemination
 Stricture and infertility
 Reiter's syndrome
Treatment


Ciprofloxacin 500mg PO state or Spectinomycin 2gm IM state
Plus
Doxycycline 100mg bid, 7d or TTC 500mg qid, 7d or Eryth.500
qid,7d
60
Urethral discharge
61
Urethral discharge
complains of urethral discharge or dysuria
Take history & Examine [Milk urethra if necessary]
Discharge present?
No
Yes
Treat for GC & CT
•Educate on risk reduction
•Offer HCT
•Promote & provide condoms
• Partner management
• Advise to return in 7 days if
symptoms persist
Other
STIs?
Yes
No
• Educate on RR
• Offer CTP
• Promote &
provide condoms
Use appropriate flow
chart
62
Figure 1
Recommended treatment for
Ciprofloxacin 500 tablet mg po stat
Or
Spectinomycin 2 grams IM stat
PLUS
Doxycycline 100 mg po bid for 7 days
Or
Tetracycline 500 mg qid for 7 days
Or
Erythromycin 500mg qid for 7 days if the patient has
contraindications for tetracyclines (children, pregnancy)
63
Management of
Recurrent/Persistent Urethritis

Look for objective signs of urethritis

Possible causes for recurrence/reappearance

non-compliant or i.e. inadequately treated or

re-infected


T. Vaginalis


Treat with Metronidazole 2 gm p.o. Stat [avaoid alcohol]
Drug resistance


Re-treat with initial regimen
Refer
morning milking syndrome due to fear of acquiring STD
64
Genital
Ulcers
65
Genital ulcer
66
Vesicular
HSV2: Genital Herps
Non-Vesicualr
T. Pallidum: Syphilis
H. Ducreyi: Chancroid
C. Trachomatis Serovars L1-L3: LGV
K.Granulomatis K. Granulomatis):
Granuloma ingunale
67
Syphilis

Acute and Chronic infection caused by T.
pallidum



Transmission: Sexual, MTC & contaminated
blood
Incubation period 21 days ( 10-90 days and
depends on inoculum's dose)
Diverse presentation
68
Primary syphilis

-
-
Solitary genital ulcer
Non tender hard ulcer
Painless inguinal adenopathy
69
Syphilis cont’d

Secondary syphilis
-
Disseminated spirochetemia
8 weeks after infection
Skin rash is common feature
Alopecia ; moth-eaten appearance
Atypical facial plaques
Mucosal ulcerations
Condylomata lata
Painless generalized lymphadenopathy
70
Secondary Latent syphilis

where there are no clinical signs but
syphilis serology is reactive
1.
2.
Early latent = infection less than one year
Late latent= infection occur for over one
year
71
Tertiary syphilis
- Gumma
-
-
Cardiovascular: aortitis leading to
valve incompetence and aneurysm
Neuro-syphilis
72
Neurosyphilis
•
•
•
•
•
Stroke like presentation ( meningovascular)
Asymptomatic but positive VDRL on CSF
Tabes dorsalis
Paralysis of the insane
Cranial palsy (cranial nerve VIII, III, optic
atrophy)
73
Chancroid






Lesions are painful, progressing from a small
papule to pustule and then to ulcer with soft
margins described as soft chancre
Inguinal adenopathy that becomes necrotic
and fluctuant (buboes) follow the ulcer
Not found to be a common cause of genital
ulcer syndrome in the validation study
The incubation period is usually 2-10 days
Transmitted exclusively by sexual contact
A cofactor for HIV transmission; high rates of
HIV infection among patients
74
Lymphogranuloma Venereum
(LGV)




Caused by C. trachomatis serovars L1, L2, or L3.
LGV primarily infects the lymphatics
Most common clinical manifestation is tender
inguinal and/or femoral lymphadenopathy - most
commonly unilateral
Women and homosexually active men may have
proctocolitis or inflammatory involvement of
perirectal or perianal lymphatic tissues resulting
in fistulas and strictures
75
Lymphogranuloma Venereum
(LGV)



A self-limited genital ulcer sometimes
occurs at the site of inoculation
By the time patients seek care, the
ulcer usually has disappeared
There is little information on the
prevalence of LGV as a cause of genital
ulcer in Ethiopia.
76
Granuloma inguinale





Chronically progressive ulcerative disease
without systemic symptoms
The etiologic agent is Calymmatobacterium
granulomatis
Incubation period generally is 1-4 weeks,
may be up to 1 year
It is transmitted primarily by sexual contact
There is little information on the prevalence
of Donovanosis as a cause of genital ulcer in
Ethiopia.
77
Complications of GU
Disease Etiology
Complications
Syphilis
T. pallidum
secondary syphilis, Latent syphilis,
Aortitis with valvulitis, Aortic aneurysm,
Gumma, Neurosyphilis
G. herpes
Herpes
simplex virus
Recurrence,
Chancroid
H. ducreyi
Penile auto-amputation
LGV
C. trachomatis, Genital edema, Salphingitis,
L1,L2,L3
Infertility, PID
Garanuloma
inguinale
C.
granulomatis
Aseptic meningitis and encephalitis
Genital pseudoelephantiasis,
Adhesion, Urethral, vaginal or rectal
stenosis
78
Patient complains of genital sore or ulcer
Take history &
examine
Vesicular recurrent
Ulcers or > three ulcers
No
Yes
Treat HSV2
No
Solitary nonrecurrent
Non-vesicular ulcer,
•Educate on RR
• Promote &
provide condoms
•Offer HIV testing
Yes
Treat syphilis, chancroid, HSV2
•Educate on risk reduction
•Promote & provide condoms
•Offer HIV testing & Partner management
ulcers healed
ulcers improved
No
Refer
Yes
•Educate & provide condoms
•Offer HIV testing
•Consider episodic Rx
Continue Rx
79
Figure 3
Recommended treatment
Benzathine penicillin 2.4 million units IM stat
or (in penicillin allergy)
Doxycycline 100 mg bid for 14 days
Plus
Ciprofloxacin 500mg bid orally for 3 days.
Or
Erythromycin tablets 500 mg qid for 7 days
Plus
Acyclovir 400mg tid orally for 10 days (or 200mg five
times per day of 10 day)
If only vesicular, recurrent & multiple ulcer
Acyclovir 400mg tid orally for 10 days (or 200mg five
times per day of 10 day)
80
Vaginal
discharge
syndrome
81
Vaginal discharge
82
Common causes of vaginal
discharge

Sexually transmitted
Neisseria gonorrhoeae4
5
 Chlamydia trachomatis
3
 Trichomonas vaginalis


Endogenous infection
Gardnerella vaginalis1
2
 Candida albicans

83
Initial evaluation of patients
with vaginal discharge include

Risk assessment





Age less than 25 years
Having multiple sexual partner in the last three
months
Having new partner in the last three months
Having ever traded for sex
Clinical speculum examination to determine
site of infection
84
Vaginitis & Cervicitis
VAGINITIS
CERVICITIS
Trichomoniasis, candidiasis,
bacterial vaginosis
Gonorrhea & chlamydia
Most common cause of
vaginal discharge
Less common cause of
vaginal discharge
Easy to diagnose
Difficult to diagnose
No complications
Major complications
Partner treatment unnecessary Partner treatment needed
Complication: PID; Premature rupture of membrane
Pre -term labor; Infertility; Chronic pelvic pain
85
VD or vulval/Itching /burning
Take Hx, examine patient (external,
speculum & bimanual) & assess risk
Educate on risk reduction
Offer HCT
Promote & provide
condoms
No
Abnormal discharge
present?
Yes
Lower abdominal tenderness or
cervical motion tenderness
No
Yes
Use LAP flowchart
Yes
Treat GC, CT, BV, TV
Is Risk assessment +?
No
Treat for BV & TV
Vulvar oedema/curd like
Yes
Discharge, Erythema, Excoriations
present?
No
Treat for
CA
Educate, Offer HCT
86
Promote & provide condoms
Recommended treatment
RISK ASSESMENT
POSITIVE
RISK ASSESMENT
NEGATIVE
Ciprofloxacin tablets 500 mg
po stat
or
Spectinomycin 2 gm IM stat
Plus
Doxycycline 100 mg po bid
for 7 days
Plus
Metronidazole 500 mg bid
for 7 days
Metronidazole 500 mg
bid for 7 days
Plus
Clotrimazole vaginal tabs
200 mg at bed time for
3 days
87
Recommended regimens for
pregnant women


Metronidazole is not recommended for use in the
first trimester of pregnancy
Treatment may be given where early treatment
has the best chance of preventing adverse
pregnancy outcomes


Metronidazole, 200 or 250 mg orally, 3 times daily for 7
days, after first trimester
Metronidazole 2g orally, as a single dose, if treatment
is imperative during the first trimester of pregnancy
88
Lower
Abdominal
Pain
89
PID



Infection of pelvis not related to pregnancy or
surgery
 Ascending infection of the uterus , fallopian tubes,
ovaries and or adjacent structures
Sexually transmitted: N.gonorrhea, C.trachomatis
May or may not be sexual: Anaerobes i.e. (poly
microbial)
 M.Hominis, Bacteroids, Streptococcus, E. Coli, H.
Influenza
90
Diagnosis of PID
Diagnosis is often difficult & inconsistent clinical
presentations are common
Bilateral or unilateral lower abdominal pain (except
endometritis) & vaginal discharge support diagnosis

History
 Erratic bleeding
 Missed period
 Recent delivery
 Miscarriage

P. Exam:
 temperature
 Palpate abdomen for
tenderness, guarding & mass
 vaginal bleeding &
abnormal discharge
91
Complications of PID





Peritonitis and intra-abdominal abscess
Adhesion and intestinal obstruction
Ectopic pregnancy
Infertility
Chronic pelvic pain
92
complains of lower abdominal pain
Take history & examine (abdominal & vaginal)
•Missed/overdue period,
•Pregnancy
•Recent delivery/ abortion
/Miscarriage
• Abdominal guarding/
rebound tenderness
• Vaginal bleeding
•Abdominal mass
•Vaginal bleeding
No
cervical
excitation,
tenderness or
lower abdominal
tenderness & VD
Yes
Yes
• Refer patient for surgical
or gynaecological
assessment
• set up IV line
• Resuscitate if measures
Yes
Manage
appropriately
Treat for PID
& review in 3 days
improved?
No
Any other
illness?
No
Yes
• Continue treatment
• Educate on RR
• Offer HCT
• Condom use
Refer
patient for
admission
93
Figure 9
Recommended treatment
Out patient
in patent
Ciprofloxacin tablet 500 mg po stat Ceftriaxone 250 mg IV/IM daily
OR
OR
Spectinomycin 2 gm im stat
Spectinomycin 2 gm im bid
Plus
Plus
Doxycycline tablet 100 mg po bid
Doxycycline 100 mg bid for 14
for 14 days
days
Plus
Plus
Metronidazole 500 mg bid for 14
Metronidazole 500 mg bid for 14
days
days or chloramphenicol 500 mg
IV qid.
Admit if there is no improvement
within 72 hours
94
Indications for hospitalizations
in PID







Uncertain diagnosis
Acute abdomen can not be excluded
Pelvic abscess is suspected
Severe illness precludes management on an
outpatient basis
Pregnancy
The patient is unable to follow or tolerate an
outpatient regimen
The patient has failed to respond to
outpatient therapy
95
Scrotal
Swelling
96
Scrotal swelling
Painful testis/ epididymis

< 25 years N. Gonorrhoea & C.Trachomatis

> 25 years other organisms, TB possible
(Other infectious causes are brucellosis, mumps, onchocerciasis
or W. babcrofti)

In pre-pubertal children is coliform,
pseudomonas or mumps virus
Mumps epidedimorchitis is usually noted within a
week of parotid enlargement
Other causes of scrotal swelling
 testicular torsion;
Trauma;
Tumor
 incarcerated inguinal hernia


97
Presentation


Clinical presentations
 Testicular infarction and atrophy
 Abscess formation
 Chronic epididymitis
 Impotence and Infertility
Complications
 Epididymitis
 Infertility
 Impotence
 Prostatitis
98
complains of scrotal swelling/pain
Take history and examine
Swelling/pain
confirmed?
•Reassure patient/educate
•Promote and provide
condoms
•Offer HIV testing
•Analgesics
No
Yes
Testis rotated or
elevated, or
history of
trauma?
Yes
Refer immediately
for surgical opinion
No
Treat GC & CT
•Educate on RR
•Promote & provide
condoms
•Partner management
•Offer HIV testing
•Review in 7 days or earlier if
necessary, if worse, refer
99
Recommended treatment
Ciprofloxacin 500 mg po stat
Or
Spectinomycin 2 gm im stat
Plus
Doxycycline 100 mg PO bid for 7 days
Or
Tetracycline 500 mg PO bid for 7 days.
100
Inguinal
Bubo
syndrome
101
Swollen glands
102
Inguinal Bubo


a painful, often fluctuant, swelling of the
lymph nodes in the inguinal region (groin)
The common sexually transmitted pathogens
that are associated with inguinal bubo include

C. trachomatis (serovar L1, L2 and L3): LGV:

H. ducreyi: Chancroid


K.Granulomatis (Calymmatobacterium granulomatis):
Granuloma ingunale
Rarely systemic symptoms except LGV
103
Inguinal Bubo T. pallidum

Sometimes T. pallidum can be a cause of
inguinal lymphadenopthy



unlike the other causes, it doesn't generally produce
necrosis and abscess collection in the lymph nodes.
In conditions where the clinical examination doesn't
reveal a fluctuant bubo, syphilis should be additionally
considered and treated accordingly
Surgical incisions are contraindicated and the pus
should only be aspirated using a hypodermic needle.
104
Inguinal Bubo Flow Chart



Men affected more than females
Common predisposing factor for the spread of
HIV
Complications:
 Abscess formation and PID
 Lymphatic obstruction
 Stenosis and Infertility
105
complains of inguinal swelling
Take history and Examine
No
Inguinal/femoral
bubo(s) present?
Yes
Ulcer(s) present?
Other
STIs
No
Educate on RR
Offer HCT
Condom use
Yes
Yes
Use appropriate flowchart
No
Rx LGV, chancroid, GI
•Educate on RR
•Provide condoms
•Partner management
•Offer HIV testing
•Advise to return in 7days
Use GU
flowchart
106
Recommended treatment
Ciprofloxacin 500 mg bid orally for 3 days
Plus
Doxycycline 100mg bid orally for 14 days
Or
Erythromycin 500 mg po qid for 14 days
107
Neonatal
Conjunctivitis
108
Neonatal Conjuctivitis

It is a purulent conjuctivitis occurring in a
baby less than one month of age.




Sight-threatening condition
Common presentation are Redness, swelling of the
eye lid & discharge from the eye (sticky eye)
The most important causes are gonorrhoea (20-75%)
& chlamydia (15-35%)
 If caused by gonorrhoea, blindness often follows
For babies older than one month, the cause is
unlikely to be an STI
109
Neonate with eye discharge
Take history and
Examine
Bilateral or
unilateral swollen
eyelids with
purulent discharge
•Reassure mother
•Advise to return if
necessary
No
Yes
Rx child & mother for GC &
Chlamydia
•For mother only:
•Educate on RR
•Provide condoms
•Offer HIV testing
•Advise to return in 3days
Yes
Improved
No
Refer
110
Management

Prevention



As soon as the baby is born, carefully wipe both
eyes with dry, clean cotton wool;
Then apply 1% silver nitrate solution or 1%
tetracycline eye ointment into the infant’s eyes;
other options: 0.5% Erythromycin ointment or
2.5% povidone iodine solution;
Treatment



Ceftriaxon 125mg IM stat (max 50mg/kg) or
Spectinomycin 25mg/kg IM stat (max 75mg) plus
Erythromycin 50 mg/kg PO in four divided doses
for 14 days
111
Neonatal Herpes


The risk for transmission to the neonate
from an infected mother is high (30%50%) among women who acquire genital
herpes near the time of delivery
Low (<1%) among women with history
of recurrent herpes at term or who
acquire genital HSV during the first half
of pregnancy
112
Neonatal Herpes



Prevention of neonatal herpes
 preventing of genital HSV infection during late
pregnancy
 Avoiding exposure of the infection to herpetic
lesions during delivery
 In women with active genital herpetic lesions
delivery by caesarean section is recommended to
prevent neonatal herpes
Abdominal delivery does not completely eliminate the
risk for HSV transmission to the infant
In addition to severe skin disease, the neonate may
develop aseptic meningitis or encephalitis and it is
frequently fatal
113
Recommended treatment
for neonatal herpes


Acyclovir 10 mg /Kg IV three times
daily for 14 days for localized mucosal
or dermal infections
Acyclovir 20 mg /Kg IV three times
daily for 21 days for disseminated
infections
114
STIs
115
STIs syndromic
management Part-2
Dr. Esmael Wabela
FHAPCO/FMOH
Jan-2006
116
Outline




STIs IN CHILDREN AND
ADOLESCENTS
MANAGEMENT OF STIs NOT
PRESENTING WITH SYNDROMES
PATIENT EDUCATION AND
COUNSELING
M&E
117
STIs IN
CHILDREN
AND
ADOLESCENTS
118
Factors that increase vulnerability of
adolescents to STIs and HIV infection


Biological factors
 Mucosal tear during sexual act
 Underdeveloped vaginal epithelium, which could
be easily infected by etiologies of STI.
 Cervical ectropion
Social factors
 Multiple sexual partnerships
 Commercial sex
 Poor health seeking behavior
 Poor self-esteem
 Lack of youth friendly services
119
Issues to consider during
management of STI in adolescents

Limited access to health care and may not seek
care adequately.



Adolescent friendly arrangements to ensure
compliance and future follow up.
Partner notification and management is often
difficult, thus risk of re-infection exists.
Pregnancy should be considered and screening
should be pertinent.
120
Comprehensive care package for
children and adolescents with STI







Effective medical treatment
Education on risk reduction
Counseling including testing for HIV
antibodies
Contact tracing and management
Promotion and provision of condoms
Ensure follow up management
Legal and emotional support
121
Treatment
Syndrome Infectious agent Regimen
Urethritis in male
(dysuria and
urethral discharge)
N. Gonorrhoeae
C. Trachomatis
Vaginitis/cervicitis T. vaginalis
(vaginal discharge)
Adolescents:
Spectinomycin 125 mg IM
stat Plus doxycycline 100
mg bid for seven days.
Children:
ceftriaxone 50 mg IM stat
Plus
Erythromycin 10 mg/kg qid
for seven days.
Note: Use metronidazole
10mg/kg bid for seven
days for persistent
122
symptoms
Treatment
Syndrome Infectious
agent
HSV type 2
T. Pallidum
Genital
H.ducreyi
Ulcer
Regimen
Adolescents:
Acyclovir 400 mg TID x 10
days Plus benzathine penicillin
2.4 million units IM x 1 Plus
erythromycin 500 mg QID x 7
days
Children:
Acyclovir 10 mg/kg TID x 7
days Plus B. penicillin G
100,000 units/kg IM single dose
Plus Erythromycin 10 mg/kg
qid for seven days.
123
Treatment
Syndrome Infectious agent
PID
N. Gonorrhoeae
C. Trachomatis
Anaerobes
Regimen
Adolescents:
Ceftriaxone 125mg stat
Plus Doxycycline 100
mg bid x 14d
OR
Erythromycin 500 mg
QID x 14d Plus
Metronidazole 500 mg
BID x 14 days
124
For victims of violence do the
following:




Baseline assessment including taking
specimen for gram stain and/or culture for
identification of N. gonorrhea whenever
feasible,
Reassess after 7 days for incubating
infections that could cause discharge
syndrome,
Consider testing and counseling at baseline
and 12 weeks to exclude HIV and syphilis,
Refer immediately for HIV post exposure
prophylaxis if the assailant is suspected to
have HIV infection.
125
Congenital Syphilis
 Early
 Late
126
Early congenital syphilis






Rhinitis and serosanguinous discharge
from nostrils
Bullous skin lesions
Periostitis with pseudo paralysis
Hepatosplenomegaly
Nephrotic syndrome
Chorioretinitis
127
Diagnosis of early congenital
syphilis

Confirmed diagnosis


Demonstration of the spirochete on dark field
microscopy from placenta or lesions from infant
Presumptive


Any infant whose mother had untreated syphilis
Reactive specific treponemal tests with or
without manifestation of congenital syphilis.
128
Treatment of early congenital
syphilis



Aqueous crystalline penicillin G 50,000
units/kg IV tid for 10 days
Or
Procaine Penicillin G 50,000 units/kg IM daily
for 10 days.
Note: CSF should be examined with RPR
to exclude involvement of the CNS
129
late congenital syphilis



Deformity of long bones or nasal bridge
Hutchinson’s triad consisting of
deafness, keratitis and peg shaped
incisor teeth.
Hydrocephalus with evidence of mental
retardation.
130
Treatment of late congenital
syphilis (2 or more years)


Aqueous crystalline penicillin G
50,000 units/kg IV or IM QID for 10
days
Alternative regimen for penicillinallergic patients, after the first
month of life

Erythromycin 7.5-12.5 mg/kg orally, QID
for 30 days
131
MANAGEMENT OF STIs
NOT PRESENTING WITH
SYNDROMES
132
Syphilis
in
Pregnancy
133
Syphilis in Pregnancy



Adverse pregnancy outcomes include
 miscarriage or stillbirth
 congenital syphilis in the newborn
 progression of latent syphilis in the mother
RPR test should be routinely done on pregnant
mothers in their first trimester and treatment
should be instituted if the RPR test shows
strong reactivity
Weak reactivity should warrant specific
serologic tests before decision to treat is made.134
Recommended regimen for or
reactive RPR test in pregnancy


If primary syphilis, secondary syphilis, or history of
reactive RPR test within the past 2 years:
 Benzathine penicillin G 2.4 million units IM stat
or ceftriaxone 1 gm IM daily x 8 – 10 days (pen. allergy)
If infected more than two years or prior history of
reactive RPR test:
 Benzathine penicillin G 2.4 million units IM x weekly for 3
weeks OR
or erythromycin 500 mg PO QID x 30 days (pen. Allergy)
Note:
 Repeat RPR in the 3rd trimester or delivery
135
Recommended regimen for
neurosyphilis


Aqueous bezylpenicillin 10-12 million IU
IV, administered daily in doses of 2-4
million IU, every 4 hours for 14 days.
Alternative regimen:

Procaine benzyl penicillin, 1.2 million IU IM,
once daily, and probenecid, 500 mg orally,
4 times daily, both for 10-14 days.
136
Genital Warts
137
Genital warts, HPV infection, cervical cancer
138
The most Common STIs in human

Human Papilloma Virus (HPV)





The single most important risk factor for
cervical cancer
Flat or filliform or papillary growth (penile,
cervix)
Extensive and exophitic in HIV infection
Epithelial dysplasia
PAP smear for screening is important
139
Clinical Features



Genital warts may not cause
symptoms and can regress naturally.
Genital warts may be large and
extensive among patients who have
concomitant infection with HIV.
Exclude secondary syphilis as the
lesions sometimes could mimic one
another
140
Treatment of Genital Warts


The primary goal for treatment of
genital wart is to eliminate the
symptoms caused by the visible warts.
Eradication of the virus and elimination
of infectivity is difficult to achieve.
141
Treatment of Genital Warts
1. Patient applied


Topical application of podophyllotoxin
0.5% bid for 3 days, followed by 4 days of
no treatment, the cycle continued up to
four times.
Imiquimod 5% cream to be applied
directly on the warts 3 times per week for
up to 16 weeks.

The treatment areas should be washed with soap
and water 6-10 hours after application. Hands
should be washed immediately after application.
142
Treatment of Genital Warts
2. Provider administered.



Cryotherapy
Podophyllin resin 10-25% to be applied
on the warts, avoiding normal tissue.
Wash thoroughly 1-4 hours after
application. Treatment should be
repeated at weekly intervals.
Surgical removal
Note: Referral of patients with meatal or cervical warts
is necessary for cryotherapy or surgical
removal, as podophyllotoxin is not
recommended. Do not use
podophyllotoxin during pregnancy.
143
Genital Scabies
144
Clinical Features





Caused by the mite Sarcoptes scabie
Transmitted by close contact with an infected
case, either sexual or non-sexual.
Itching is the main complaint.
Erythematous papules and burrows tunneled by
the female mite can be seen using a hand lens.
Can be complicated by secondary infection, which
could change the clinical course of the patient.
145
Recommended Treatment


Lindane1% lotion or cream applied
thinly to all areas of the body and
washed off thoroughly after 8 hours.
Benzyl benzoate 25%, lotion applied to
the entire body from the neck down
every night for two days. Bath 24
hours after the final application.
146
Pediculosis Pubis
147
Clinical Features




The pubic louse, Phthirus pubis is
transmitted by sexual contact
Produce itching around the pubic area.
The parasite can spread to the thighs,
chest, axillae and even to the eyelids.
The diagnosis is established by clinical
examination, as the parasite is visible by
the naked eyes.
148
Recommended treatment


Benzyl benzoate emulsion 25% to be
applied for 24 hours.
Lindane1% lotion or cream to be
applied to the infected & adjacent hairy
areas and washed off thoroughly after 8
hours
149
PATIENT
EDUCATION
AND
COUNSELING
150
Basic principles
of counseling
and health
education
151
Definitions

Health education Vs counseling
Health education is the provision of
accurate and truthful information so that a
person can become knowledgeable about
the subject and make an informed choice.
152
Definitions



Counselling is a two-way interaction between a
client and a provider
It is an interpersonal, dynamic communication
process that involves a kind of contractual
agreement between a client and a counselor
who is trained to an acceptable standard and
who is bound by a code of ethics and practice
It requires empathy, genuineness and the
absence of any moral or personal judgment
153
The Importance of
Education and Counseling


patients are more likely to comply with
treatment if they understand why it is
important to do so
a person with STI has a high likelihood of
being re-infected

preventing re-infection requires sustained
behavior change
154
The link between treatment and prevention
is very important because:



it reaches people when they are ready:
the patient has come to you
the patient’s initial visit is a unique
opportunity for patient education
opportunities for brief, repeated and
cumulative messages are more likely at
the primary health centre than a referral
centre
155
Contents of
health education
for STI patients
156
The goals of patient education are

To help the patient
deal with current infections
 prevent future infections
 make sure that sex partners are also
treated and educated.

157
Issues you need to address on
Explain STI and its treatment
Explain which STI the patient has and what
treatment will be necessary

Check patient understands

Elicit questions and concerns
Discuss common side-effects, drug
interaction (if any)
Encourage the patient to comply with
treatment
158
Issues to discuss
Educate on prevention of future infection

Changing sexual behavior from high risk to low risk
 Advise and demonstrate on condom use

Inform clients that some sexual practices have a
higher risk of infection.



For example, anal sex, whether it is male to female or
male to male, carries a higher risk than penile-vaginal
sex
Inform on existing prevention methods such as
the use of spermicides, bactericidal; microbicides or
vaccines
Advise on personal hygiene and cultural
practices
159
Counseling
for STI
160
Basic considerations during counseling
Assessing the patient’s risk level
1. Personal sexual behavior





Number of sexual partners in the past
Sex with a new or different partner with
in 3 months
Any other STIs in the past
The exchange of sex for money, goods or
drugs
Use of vaginal drying agent, or similar
practices
161
2. HIV infection



Use of skin-piercing instruments such as
needles (injections, tattoos), scarification
or body-piercing tools, circumcision
knives.
Blood transfusion
For children, all risk factors of parents
3. Personal drug use



Use of alcohol or other drugs (which
drugs?) before and during sex
Sharing needles or ‘works’ (high risk of
transmitting or being infected with HIV)
Exchange of sex for drugs
162
4. Partner(s) sexual behavior

Does the patient’s partner(s):
 have sex with other partners?
 also have an STI?
 have HIV infection?
 inject drugs?
 if male, have sex with other men?
163
5. Patient’s protective behavior



What the patient does to protect him/
herself from STIs
Use of condoms: when and how, with
whom, why
Low-risk or safe sexual activities the
patient might practice: when and how,
with whom, why?
164
Options for safer sex:




Limiting sexual partners to one faithful
partner.
Using condoms consistently and correctly
Replacing high-risk penetrative sex with lowrisk non-penetrative sex
Abstinence from sexual intercourse:

a preventive strategy that should be encouraged,
especially in the young and in couples when one
partner is being treated for STI.
165
The need and changes the client
should make in his/her behavior


Help patients to analyze the costs and benefits of
changing their behavior
If client agreed;



Ask how they will put it into practice
When and what they will do if they are tempted to
practice risky sex
Discuss on possible barriers to change behavior
@It is not quite enough simply to have the client agree and
choose a particular safe behavior]@
166
Barriers to changing behavior
1. Gender barriers
a) Women have little control over when,
with whom, and under what
circumstances they have sex.
a)
For men, young men in particular can
be under peer and social pressure to
conform to local male norms.
167
Barriers to changing behavior
2. Cultural practices
 age differences at marriage
 wife inheritance
 puberty rites
 child-rearing
 values of family and community
168
Barriers to changing behavior
3. Religion

May contribute if discourages open
discussion about sexuality and use of
protective measures ex. condom
169
Barriers to changing behavior
4. Poverty, social disruption and civil
unrest
 Force women and girls in particular into
exchanging sex for material favors or even for
survival
 Lack of access to education and employment
may force women to exchange sex with a
number of partners
170
PARTNER
MANAGEMENT
171
Principles and
Approaches
172
Principles




Each STI patient is a sole source of infection to
sexual partner (s) until treatment is completed
Treated STI patient can be cured but not immune
(re-infection is possible)
Treatment of all the patient’s sexual partners for
the same STI as the index case, and treating any
new STI identified are the main features of partner
management
As the management is syndromic, the treatment
must be given presumptively and the partner
treated even if there are no symptoms or signs of
STI
173
Advantages of Partner
Notification





Break cycle of infection
Eliminate asymptomatic infection
Prevent re-infection
Prevent complication by early
detection
Education & risk reduction
counseling
174
Two Approaches to Partner
Management
1. Patient referral (passive contact
tracing)
2. provider referral (active contact
tracing)
175
Patient referral could be done in
several ways



By directly explaining about the STI
& the need for treatment
Asking the partner to attend a
health center with out specifying
the purpose of the visit
By giving a partner a card to attend
the center
176
Issues to consider




Explain the importance of treating all
patients’ partners
Remind the patient how to avoid re
infection
Help the patient decide how to
communicate with the partner
If possible obtain names of the patients’
partner (s)
177
Patient Referral Cards




facilitate partner management
could be extremely useful to help identify the
necessary treatment for any partner referred by
a patient with STI
can contain any extra information that is
required, but should never threaten anyone’s
confidentiality or risk them being stigmatized
one or more can be given to every patient with
an STI syndrome.
178
Provider Referral




Possible if index patients are prepared to
disclose full contact information
It is resource intensive
The success depends on health care
providers communication skills
Can be used when


Patients refuse to refer partner
Patient has agreed to refer partners but they
have not come for treatment
179
Challenges



Failure of patient referral
Patient refuses to refer patient
A partner fails to come for treatment
Treatment of partner

History taking, treating, educating &
managing partners is exactly the same as
the index patient
180
Partner management
INDEX PATIENT
TREATMENT OF PARTNER
Urethral discharge
Treat for gonorrhea & Chlamydia
Vaginitis & Cervicitis
Treat for gonorrhea & Chlamydia
Vaginitis
No partner treatment needed
PID
Treat for gonorrhea & Chlamydia
Scrotal swelling
Treat for gonorrhea & Chlamydia
Inguinal bubo
Treat for LGV
Neonatal conjunctivitis
Treat for gonorrhea & Chlamydia
Genital ulcer
Treat for syphilis & chancroid
181
Monitoring & Evaluation /M & E
182

Monitoring is a process for checking that activities are being
implemented as planned

Monitoring mainly looks at inputs, process and outputs


The monitoring phase tracks and counts events, activities,
people and objects and can consist of either periodic or
continuous data collection
The information gathered in this process, such as new trends
and strengths and weaknesses of the program, should be
used to improve programs.
183



Evaluation makes judgment of the effectiveness
of those activities and mainly looks at outcome
(short-term effects) and impact (long term
effects)
The evaluation phase periodically measures and
analyzes progress toward attainment of stated
goals and objectives
This analysis may be based on existing
monitoring data that is aggregated or otherwise
manipulated, or on a separate, unique data
collection system
184
Level of M & E





Inputs are the financial, human and
material resources that are necessary to
produce the intended out put of a
project/program.
Activities/processes
Outputs are the immediate results of
the activities conducted.
Outcomes are the medium term results
of one or several activities.
Impact/goal/ refers to the highest
level of results, to the long-term results
expected of the project/program.
185
M&E levels with example

Inputs
Activities
/Processes/
Funds, Trainees,
Trainers, Stationary
materials, Electronic
equipments,
Manuals,
Rooms, Furniture,
Power, Logistics,
etc
Health
workers
training
on STI
SCM
Outputs
Health
workers
trained
on STI
SCM
Outcomes
Increased
number
of clients
receiving
STI
SCM
Impact
/goal/
Reduced
Incidence
&
Prevalence
of STIs &
HIV/AIDS
186

Provider interviews

Direct observations

Record review

Patient exit interview

Periodic surveys
187

STI case reporting (through universal
case reporting or sentinel surveillance
sites)

Monitoring STI trends and cases makes it
possible to project resource needs and
program impact.
188

Periodic prevalence assessment and
monitoring (general population or special
groups)
 The primary purposes of STI prevalence
assessment are: to identify population
subgroups with high prevalence of STIs and
to monitor trends in STI incidence among
defined populations

Diagnostic tests are required for assessing
prevalence of STIs
189

Assessment of STI syndrome etiologies

Periodic assessment of etiologies of STI
syndromes is a core STI surveillance
activity

The primary purposes of assessing
syndrome etiologies are to:
1) provide data for guiding STI syndromic
management
2) assist in the interpretation of syndromic
case reports and the assessment of
disease burden due to specific pathogens
and
3) provide data to guide appropriate
antimicrobial drug selection.
190

Periodic or continuous monitoring of antimicrobial
susceptibility, e.g., N. gonorrhoeae, H. ducreyi

Antimicrobial susceptibility testing for H. ducreyi
is more difficult than for N. gonorrhoeae;

The principal objective of monitoring
antimicrobial resistance in N. gonorrhoeae is:
1)
2)
to obtain data necessary for developing and
revising guidelines for treatment and
to detect newly emerging resistance,
191

Special studies on STIs behavioural
surveillance
 Special studies may include:
 incidence and prevalence of STI-related
complications
 prevalence of viral STIs
 HIV prevalence among persons with other
STIs or vice-versa
 assessment of health care-seeking behavior,
192
etc.,



To assess the burden of STI, by providing an
indicator of minimum incidence of recently
acquired infections
To monitor trends in the incidence of recently
acquired infections if health-seeking behavior
is stable and consistent
To provide information necessary for
management of patients and their sex
193


To provide data necessary for planning
and managing health services
To provide data for the purpose of
advocacy and resource mobilization and
for program planning, targeting,
monitoring and evaluation
194
RECORDING AND REPORTING
195




At the start of a week or month, each service provider starts
a fresh tally sheet, recording each patient or episode treated
for STI as the tally sheet requires
At the end of the week or month, a designated provider or
clerk collects the tally sheets and collates the data
The data is interpreted, then made available to staff at the
centre. Information is then complied in the monthly
recording format to send to the RHB
At the federal MOH epidemiology unit all data received from
RHBs is compiled and distributed in periodic reports
196

Let us review the sample forms
197197
STIs
198