Download WORKSHOP FOR MEDICAL OFFICERS ON RTI/STI

RTI/STI
MANAGEMENT AND PREVENTION
Dr. Dilip Kumar Das
Community Medicine
Public Health Importance of RTIs/STIs
What is RTI/STI ?
 Reproductive Tract Infections (RTIs):
Any infection of reproductive tract in male and female
 Sexually Transmitted Infections (STIs):
STIs are infections caused by germs such as bacteria, viruses,
or protozoa that are passed from one person to another
through sexual contact.
RTIs
 RTIs in both men and women include:
- STIs
 RTIs in women also include:
- Disruption of normal vaginal flora (Candida and bacterial vaginosis)
- Postpartum and post abortion infections
- Infections following procedures (e.g. IUD insertion)
 RTIs in men also include:
- Prostatitis and epididymitis
Situation in world
 340 million new cases of curative STIs every year
- 75-85% in developing countries
- 10 % adults newly infected with curable STIs
 12 million new cases of syphilis
 62 million new cases of gonorrhoea
 90 million new cases of chlamydia
 176 million new cases of trichomonas
Situation in India
 Prevalence of suggestive symptoms of STIs
Women: 23-43%
Men: 4-9%
 STI clinic data for men indicates:
Syphilis: 12.6 – 57%
Chlamydia: 20-30%
Chancroid: 9.9 -34.7%
Gonorrhoea: 8.5 – 23.9%
Overall prevalence of STIs among adults: 6 %
Factor contributing to RTI/STI spread
 Human behaviour
 Lack of access to healthcare
 Lack of awareness about STIs
 Migrating population
 Healthcare providers not adequately trained
 Poor medical services
 Hygiene and environmental factors
 Hormonal and other factors
High risk groups
 Adolescent boys and girls
 Women who have multiple partners
 Sex workers and their clients
 Men and women who has to stay away from families for long
 Men having sex with men
 Partners of various high risk groups
 Street children
Factors increasing risk of transmission
 Biological
- Age
- Sex
- Immune status
 Behavioural
- Personal sexual behaviour
- Other non-sexual personal behaviour
- Even without any risk behaviour
 Social
- Status of women in society
- Sexual violence
- Child marriages
Why women are at a higher risk?
 Biological differences
-Thin lining of vaginal mucosa
- Larger exposed area
- Genital fluids stay in contact for longer time
- Young women- Immature genital tract
- Symptoms less reliable indicator
 Use of vaginal douches
 Different socio-cultural norms for men and women
STI – HIV Link
RTIs/STIs – A Public Health Problem
 Major cause of ill health in country
 Cause serious complications in men and women
 Increases risk of HIV transmission
 Responsible for reproductive loss
 Increases cost to health system
Barriers – system and providers side
 Failure to recognize magnitude
 Not all seek treatment form trained providers
 Overemphasis on lab based diagnosis
 Irrational use of drugs
 No standardized treatment regimen by all providers
 Less emphasis on patient education and counseling
 Specialized clinics carry stigma
Barriers – Client side
 Lack of knowledge
 Misconceptions
 Asymptomatic infections
 Reluctance to discuss sexual matters
 Stigma
 Fear of judgmental attitude of providers
 Reluctance for physical examination
Problems in management of RTIs/STIs
Piot – Fransen model
Partner treatment
Treatment effective
Compliance
Treat correctly
Go to health unit
Seek treatment
Symptomatic
Women with RTI
0
20
40
60
80
100
Operational model of the role of health services
in STI case management
Population with STI
Aware and worried
Seeking care
Correct diagnosis
• Promotion of health care
seeking behaviour
Correct treatment
• Improve quality of care
• Attitudes of personnel
Treatment completed
Cure
Operational model of the role of health services
in STI case management
Population with STI
Aware and worried
Seeking care
Correct diagnosis
Correct treatment
Treatment completed
Cure
• Syndromic approach
• Include STI drugs in essential list
• Prescribe single dose
• Counsel about compliance
Operational model of the role of health services
in STI case management
Population with STI
Aware and worried
asymptomatic STI
Seeking care
Correct diagnosis
Correct treatment
Treatment completed
Cure
• Partner notification
• Case finding
• Screening
• Selective mass treatment
Module 3
Common RTIs/STIs and
their Complications
Common sites for RTIs/STIs
Common RTIs/STIs
 Male and female
- Gonorrhoea
- Chlamydia
- Syphilis
- Chancroid
- Genital herpes
- Lymphogranuloma venerium
- Trichomonas
- Genital warts
- Candidiasis
- HIV
- HBV
- Scabies
- Pubic lice
- Molluscum contagiosum
 Only in females
- PID
- Bacterial vaginosis
 Only in males
- Epidydimitis/Orchitis
Symptoms and signs of RTIs/STIs in Men
 Urethral discharge
 Burning or pain during micturition or urination.
 Genital itching
 Inguinal swelling/Scrotal swelling /swollen and painful testes
 Blisters or ulcers on the genitals, anus, mouth, lips
 Itching or tingling in genital area.
 Warts on genitals, anus or surrounding area.
 Fever, body ache, muscle ache, jaundice.
Symptoms and signs of RTIs/STIs in Women
 Unusual vaginal discharge
 Genital itching
 Abnormal and/or heavy vaginal bleeding
 Dyspareunia
 Lower abdominal pain
 Blisters/ulcers on the genitals, anus, mouth, lips
 Burning micturition
 Itching or tingling in genital area.
 Warts on genitals, anus or surrounding area.
 Fever, body ache, muscle ache, jaundice.
Ways of classifying RTIs/STIs
 According to causative organisms
 According to modes of transmission
 According to most common presenting symptoms
According to causative organisms
 Bacterial:
- Gonorrhoea, Chlamydia, syphilis
 Viral:
- Herpes, HPV, HIV
 Protozoal:
- Trichomonas
 Fungal:
- Candidiasis
 Mixed:
- PID, epididymitis
According to modes of transmission
 Endogenous infection:
- yeast infection, vaginosis
 Sexually Transmitted Infections:
- Gonorrhoea, chlamydia, syphilis
 Iatrogenic Infections:
- PID following abortion or transcervical procedure
Complications in Men
 Urethral stricture
 Phimosis/paraphimosis
 Disfigurement of genitals
 Infertility
 Cardiovascular complications (syphilis)
 Neurosyphilis
Complications in Women
 Pelvic Inflammatory Disease (PID)
 Infertility
 Ectopic pregnancy
 Spontaneous abortions
 Stillbirths
 Low birth weight babies
 Increased susceptibility to opportunistic infections
 Cervical cancer
 Chronic pelvic pain
Complications in neonates
 Congenital eye infections – Syphilis, chlamydia, gonorrhoea
 Sepsis
 Arthritis
 Meningitis
 Infant pnumonias
 Mental retardation
Systemic infections
 Gastrointestinal: Proctitis, proctocolitis
 Renal: Acute membranous granulonephritis
 Neurological: GPI, Tabes dorsalis
 Cardiovascular: Myocarditis, aortitis
 Ophthalmic: Iritis, coroidoretinitis
 Musculoskeletal: Osteomyelitis, arthritis
 Septicemia
Module 4
Approaches for RTI/STI
Management
RTI/STI Case Management
 Correctly diagnosing and treating symptomatic patients.
 Providing patient education and partner management.
 Preventing re-infection
Steps in Clinical Case Management
 History taking
 Clinical examination
 Laboratory tests
 Diagnosis
 Treatment
 Advice and counseling
 Follow up
Approaches to RTI/STI Case Management
 Traditional clinical approach
 Laboratory assisted approach
 Syndromic approach
Traditional Clinical Approaches:
Advantages
 Simple
 Inexpensive
 Can be used in any settings
 Immediate diagnosis.
 Immediate treatment.
 No lab expense.
Traditional Clinical Approach :
Limitations
 Diagnosis is often incorrect or incomplete
(especially in mixed infections).
 More than one STI is often present at the same timefocus is on diagnosing a single cause.
 Asymptomatic infections could not be diagnosed.
Lab-Assisted Approach
Advantages
 Exact diagnosis using laboratory tests.
 Avoids over-treatment.
 Avoids wrong treatment.
 May avoid antibiotic resistance.
 Avoids the negative consequences
 Asymptomatic infections can also be detected.
Lab-Assisted Approach
Limitations
 Expensive.
 Trained laboratory technicians are needed.
 Infrastructure and supplies are needed.
 Patient must return for test results.
 Patient must wait for treatment.
Syndromic Approach
 Diagnosis is based on the identification of syndromes,
which are combinations of the symptoms the client reports
and the signs the health care provider observes.
 The provision of the most effective therapy at patient’s first
contact with a health or medical facility.
 The recommended treatments are effective for all the
diseases that could cause the identified syndrome.
 Provides single dose treatment as far as possible
 Comprehensive to include patient education on risk
reduction, counseling, condom promotion and
provision, partner notification, follow up.
Syndromic Management- Advantages
 Fast—the patient is diagnosed and treated in one visit.
 Highly effective for most of the syndromes.
 Relatively inexpensive since it avoids use of laboratory.
 No need for patient to return for lab results.
 All possible STIs are treated at once.
 Scientifically tested in many part of the world.
 Easy for health workers to learn and practice for patients.
 Integrated into primary health care services more easily.
 Can be used by providers at all levels.
Syndromic Management- Limitations
 Not useful in asymptomatic individuals.
 Over-treatment in patient with one STI that causes a syndrome.
 Financial cost of over-treatment, side- effects.
 Increases potential for antibiotic resistance especially if full
course not completed.
 Not effective in some cases such as vaginal discharge
The Syndromes
 Urethral discharge
 Vaginal discharge
 Genital ulcer non-herpetic
 Genital ulcer herpetic
 Lower abdominal pain
 Inguinal bubo
 Scrotal swelling
To sum up ………
 Syndromic management is a scientific and proven approach.
 Syndromic approach does not deny use of lab tests, it can
supplement the approach (Enhanced syndromic approach).
 This approach ensures correct and complete treatment of all
most common organisms responsible for a particular syndrome.
 Syndromic management goes beyond pharmaceutical treatment
to include client education and counseling.
 The clinical skills of a doctor are well utilized in syndromic
approach.
Module 4
Syndromic Management
Flowcharts
Using Flow Charts
 Determine the clinical problem
 Pick up appropriate flow chart by looking at the clinical problem








box at the top
Take history
Perform clinical examination
Make decisions based on history and clinical examination –
choosing “yes” or “no”
Followed by more boxes to consider and make choices
Follow the arrows
No skipping of steps
One step at a time until you reach the end of the branch
Each exit path leads to action box - how to manage the case
Man complains of scrotal swelling and
pain
Take history & examine
Painful scrotal swelling confirmed
Testes rotated/ elevated
or history of trauma
Refer immediately for a
surgical opinion
Testes normal. No history of
trauma
Treatment for Gonorrhoea and
Chlamydia.
Patient Education, counselling
 Provide and promote condom
Partner management
Cured
Return in 7 days if
symptoms persist
No improvement
Refer to higher care center
Why Syndromic Management?
 Simple
 Treatment at first visit
 Treatment for all common causative organisms
 Standardized at all sites
 Patient education, an integral part
Criteria for Selection of Drugs
 High efficacy (at least 95%)
 Low cost
 Acceptable toxicity and tolerance
 Organism resistance unlikely to develop or likely to be
delayed
 Single dose
 Oral administration
 Not contraindicated for pregnant or lactating women
To sum up ……………..
 The drugs use in syndromic management are chosen based
on scientific criteria
 Syndromic management is a comprehensive approach which
includes:
 Treatment of index client
 Treatment of partners
 Risk reduction
 Client education and counseling
 Referral, as necessary
Module 6
History Taking and Risk
Assessment
Goals of history taking for RTIs/STIs
 Make an accurate and efficient syndromic diagnosis
 Establish the client’s risk of transmitting and contracting
RTIs/STIs
 Find out about partners who may have been infected
Pre-requisites for good history taking
 Privacy
 Confidentiality
 Good verbal and non-verbal communication skills
 Unbiased/non-judgmental attitude of provider
 Patient- friendly atmosphere
Sexual history
 Currently active sexually
 Current partners
 New partners in last 3 months
 Risky sexual and other behaviour
Risk assessment
Risk assessment is a process of confidentially asking a
patient particular questions to determine his or her chance of
contracting or transmitting a RTI/STI (e.g. many women may
be at risk due to the behavior of their husbands or partners).
Why risk assessment?
 To determine RTI/STI treatment
 To tailor patient education messages
 Determine need for lab test
 Determine need for specific referrals (ICTC)
Module 7
Clinical Examination in
RTI/STI Clients
Why clinical examination is important?
 Confirmation of client’s symptoms
 Elicit signs to confirm symptoms
 Find out signs for something the patient is not complaining
 To arrive at a clinical dignosis
Pre-requisites for clinical examination
 Visual and auditory privacy
 Assistant of same sex that of client, if examining opposite sex
 Explain process to client (with pictorials/diagram)
 Take permission from client
 Well lit room
 Approach in a confident manner
Male Syndromes
Inguinal Bubo
Genital Ulcer
Scrotal Swelling
Genital Ulcer
Vaginal Discharge Syndrome
SYNDROME: VAGINAL DISCHARGE
VAGINITIS
TRICHOMONIASIS
CERVICAL HERPES
CERVICITIS
Module 8
Laboratory Tests for
RTIs/STIs
Use of Lab in RTI/STI Control
 Screening and detection
 Screening asymptomatic in high risk population
 To diagnose single and mixed infections
 Improve diagnostic value of syndromic management
 Detection of infection in asymptomatic
 Epidemiological data – prevalence, incidence
 Testing for antimicrobial resistance
 Sentinel surveillance
 Accurate etiological diagnosis
Diagnostic tests for RTIs/STIs
 Microscopic examination:
-Wet mount: Trichomoniasis, candida, bacterial vaginosis
- Gram staining: Gonorrhoea, Bacterial vaginosis
- Dark field: Syphilis
 Antigen detection: EIA for gonorrhoea and chlamydia
 Antibody test: EIA for Syphilis and HIV
 Vaginal pH : Bacterial vaginosis
 Culture: Trichomonous, Candida albicans, Chlamydia
 DNA detection
 DNA detection by amplified technique
Lab tests for detection of common
RTIs/STIs
 Vaginal pH
 Wet mount microscopy
 Whiff test
 Gram stain microscopy
 Rapid Plasma Reagine (RPR) for syphilis
Limitations of laboratory tests
 Costly
 Time consuming
 Need trained manpower
 Need expensive equipment
 Delay in diagnosis and treatment
 Not all tests are high sensitivity and/or specificity
We must remember …….
 Some simple lab tests can assist us enhancing the
effectiveness of syndromic management.
 The doctors are expected to interpret the results of lab tests.
 Do not delay the syndromic treatment for the sake of
laboratory results.
 Lab tests can be useful for specific diagnosis of the infections
and for collecting epidemiological data.
Module 9
Client Education and
Counseling
Importance of Client Education and
Counseling
 Better compliance to treatment if clients know the
logic/reasons
 To reduce chance of re-infection
 To enable clients change behavior
 Satisfied clients return for other services too
 Satisfied clients refer others to health center
Goals of Client Education
 Help clients resolve current infection
 Prevent future infections
 Make sure sex partners are also treated and educated.
What Clients Needs to Know
 Prevention of RTIs/STIs
- Risk reduction
- Correctly and consistent use of condoms, availability
- Limiting the number of partners
- Alternatives to penetrative sex
 Information about RTIs/STIs
- How they are spread between people
- Consequences of RTIs/STIs
- Links between RTIs/STIs and HIV
- RTI/STI symptoms - what to look for
What Clients Needs to Know
 RTI/STI Treatment
- How to take medications
- Signs that call for a return visit to the clinic
- Importance of partner referral and treatment
- Acknowledge gender inequalities
Cont…
Creating Opportunities for Client Education
 Use every place where client is likely to visit
 Use every interaction as an opportunity
 Use various media
 Reinforce consistent messages
Module 10
Partner Management
What is Partner Management ?
 Partner management is an activity in which the partners of
those identified as having RTI/STI are located, informed of
their potential risk of infection, and offered treatment and
counseling services.
Timely management is important
because……..
 Prevention of re-infection in index client/s
 Prevention of transmission in partner/s
 Timely treatment of symptomatic partners
 Identification of asymptomatic partners and their treatment
Approaches to Partner Management
 Referral by index clients:
- Index clients inform partners
- Does not involve extra person hence inexpensive
- May include client-initiated therapy
 Referral by providers:
- Providers approach partner/s through referral card
- Needs extra staff and hence expensive
General principles of partner treatment
 Partners to be treated for same infections as index client.
 Provider should be reasonably sure of presence of STI,
especially in vaginal discharge cases.
 Special care for PID cases due to serious complication.
 Call for follow up – for compliance/cure and to see test
reports, if advised
Partner Treatment
Syndrome of index patient
Urethral discharge
Genital ulcer
Treatment for partner/s
Treat partner/s for gonorrhea and
chlamydia
Treat partner/s for syphilis and
chancroid
Vaginal discharge:
Patient treated for vaginitis and Treat partner/s for gonorrhea and
cervicitis
chlamydia
Patient treated for vaginitis
Not necessary for partners to be
treated unless there is recurrent
discharge
Pelvic inflammatory disease
Scrotal swelling
Inguinal bubo
Neonatal conjunctivitis
Treat partner/s for gonorrhea and
chlamydia
Treat partner/s for gonorrhea and
chlamydia
Treat partner lymphogranuloma
venereum
Treat both parents for gonorrhea
and chlamydia