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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 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 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 Lack of STI focused IEC/BCC activities weak monitoring and evaluation system 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 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 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 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