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Sexually Transmitted Infections • Cristina Muñoz • Division of Women’s Primary Healthcare • Department of Obstetrics and Gynecology • [email protected] Sexually Transmitted Infections • Where do you find information in future? (in case you sleep through the whole talk, or God forbid, forget a little of what you learn in medical school) • Defining characteristics of STIs • Surveillance, epidemiology, disparities • Pattern recognition (pictures) Sexually Transmitted Disease Treatment Guidelines 2006 • • • • Free and easy to download Multiple formats available Updated regularly National standard of care • http://www.cdc.gov/std/treatment/ North Carolina Department of Health and Human Services, HIV/STD Prevention and Care Branch Sexually Transmitted Disease Assessment, Prevention, and Treatment Protocols July 2008 http://www.epi.state.nc.us/epi/hiv/stdmanual/toc.html Other useful resources • Contraceptive Technology, 19th ed. includes information on protection from STIs and alternate modes of sexual expression • Planned Parenthood CDC PowerPoint Resources • STD 101 in a Box – Readymade PowerPoint talks on STDs, epidemiology, prevention efforts http://www.cdc.gov/std/training/std101/presentations.htm • STD clinical slides – Many pictures http://www.cdc.gov/std/training/clinicalslides/slides-dl.htm Why are STIs Special? • They are different from each other, biologically: Viruses: HIV Hepatitis B Photo courtesy of Dr. CW Leung, Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong. Hepatitis C Human Papilloma Virus Herpes Viruses Molluscum contagiosum Bacteria: Chlamydia Source: Seattle STD/HIV Prevention Training Center Gonorrhea Syphilis Parasites: Trichomonas vaginalis Lice Why are STIs Special? • They are different from each other, biologically, but…. • They share common modes of transmission. Historical Question… • June 5, 1981, MMWR published a report of five cases of Pneumocystis carinii pneumonia (PCP) among previously healthy young men in Los Angeles. All of the men were described as “homosexuals”; two had died. Soon other reports documented a similar illness in other groups, including injection drug users, Haitians, and hemopheliacs. • Based on what you know about Hepatitis B, which had similar epidemiology, what would you guess about the mode of transmission of the new disease? What is sex? (It depends on what the meaning of the words 'is' is.) • [A] person engages in "sexual relations" when the person knowingly engages in or causes -- (1) contact with the genitalia, anus, groin, breast, inner thigh, or buttocks of any person with an intent to arouse or gratify the sexual desire of any person . . . . "Contact" means intentional touching, either directly or through clothing. 849-DC-00000586 STIs Resemble Non-sexually Transmitted Illnesses • Syphilis vs other spirochetal illnesses—bejel, pinta, yaws, Lyme disease, relapsing fever, rat bite fever – Different mode of entry, but similar binding to cellular and circulating proteins, tissue tropisms, biphasic illness pattern, treatments, treatment reactions. – When you reach a roadblock on one disease (e.g. if you can’t culture Treponema pallidum, you can use Borrelia burgdorferi data to make hypotheses about syphilis Pathogenic Neisseracaea: Similar but Different • Different route of entry • 1978 - IgA protease production in both N. gonorrheae and N. meningiditis may explain why these are pathogenic and other strains are not. • 2006 – geneomes of pathogenic and nonpathogenic Neisseriaceae are known, so structure and function of secreted proteins is known Some STIs are non-sexually transmitted Herpes Type I and Type II (In this case, the resemblance between the “sexually transmitted infection” of “genital herpes” and the non sexually transmitted form “oral herpes” is so strong, that you can not tell which is which without labs) STIs are Stigmatized* (*when people understand transmission) • Example – Herpes – What is the effect of disclosure to a potential sexual partner? – How does your patient feel when she has an outbreak of Herpes type II in a long-term monogamous marriage? Changes in HSV-2 Seroprevalence between NHANES III and NHANES’99-00 HSV-2 Seroprevalence (%) 50 40 NHANES III NHANES '99-00 30 20 10 0 14-19 20-29 30-39 Age Groups (Years) Slide from: www.cdc.gov/stdconference/2004/Slides/SponSymposium/Xu.pps 40-49 Bad and Good Sides of Stigma • Failure to disclose disease or risk status • Failure to seek treatment • Underestimation of risk • Public clinics more available than for other illness • Mandated disease reporting, surveillance • Public funding for research, prevention, treatment STI Surveillance NC law requires the following people to make reports to the local health director: • Physicians (GS 130A-135) • School principals and child care operators (GS 130A-136) • Operators of restaurants/other food or drink establishments (GS 130A-138) • Persons in charge of laboratories (GS 130A-139) Reportable Illnesses in NC • • • • • • • • • • • • (1) acquired immune deficiency syndrome (AIDS) - 24 hours; (6) chancroid - 24 hours; (7) chlamydial infection (laboratory confirmed) - 7 days; (18) gonorrhea - 24 hours; (19) granuloma inguinale - 24 hours; (25) hepatitis B - 24 hours; (26) hepatitis B carriage - 7 days; (27) hepatitis C, acute - 7 days; (28) HIV infection confirmed - 24 hours; (35) lymphogranuloma venereum - 7 days; (42) nongonococcal urethritis - 7 days; (46) pelvic inflammatory disease – 7 days; Rates of STDs in USA – 2007* • • • • Syphilis Gonorrhea Chlamydia Chancroid 40,920 355,991 1,108,374 23 *these are reported cases Cases of sexually transmitted diseases reported by state health departments and rates per 100,000 population: United States, 1941–2007, Sexually Transmitted Disease Surveillance, 2007 http://www.cdc.gov/STD/stats07/natoverview.htm Estimated Burden of STD in U.S. - 1996 STD Chlamydia Gonorrhea Syphilis Incidence 3 million 650,000 70,000 Prevalence 2 million ----- Trichomoniasis HSV HPV 5 million 1 million 5.5 million --45 million 20 million Hepatitis B HIV 77,000 20,000 750,000 560,000 Source: The Tip of the Iceberg: How Big Is the STD Epidemic in the U.S.? Kaiser Family Foundation 1998 Worldwide Burden of Disease • STIs/RTIs cause a large proportion of the global burden of ill-health. WHO estimates that over 340 million new cases of four curable STIs (gonorrhoea, chlamydia, syphilis and trichomoniasis) occurred in 1999. If viral STIs such as human papilloma virus (HPV), herpes simplex virus (HSV) and human immunodeficiency virus (HIV) infections are included, the number of new cases may be three times higher. Sexually transmitted and other reproductive tract infections A guide to essential practice. http://www.who.int/reproductive-health/publications/rtis_gep/index.htm Worldwide Burden of Disease • Transmission and prevalence (how common they are) are influenced by social and economic factors as well as by biology and behaviour. The burden of STIs/RTIs thus varies greatly from region to region, and from community to community. Where STIs/RTIs are common, so are their complications. • STIs such as syphilis, gonorrhoea and chancroid spread more rapidly in places where communities are disrupted, migrant labour is common and commercial sex networks are active. • Iatrogenic infections are more common where there are many STIs, and where health care providers do not have the training or supplies to perform procedures safely. Postpartum and postabortion infections are more common where safe services and follow-up care are not available. Sexually transmitted and other reproductive tract infections A guide to essential practice. http://www.who.int/reproductivehealth/publications/rtis_gep/index.htm Stunning Disparities in STIs • • • • • • By age By sex By social class By race By sexual orientation and sexual practices Disparities exist in incidence AND effects Disparities by Age – Chlamydia Age & Sex Specific Rates, United States, 2006 Men 3000 Rate (per 100,000 population) 2400 1800 1200 600 0 11.6 545.1 Age 10-14 0 Women 600 1200 2797.0 25-29 222.2 1141.2 30-34 415.7 120.8 35-39 65.1 40-44 27.8 45-54 25.6 9.1 55-64 6.8 2.8 65+ 2.2 173.4 From: Chlamydia Sexually Transmitted Disease Surveillance 2006 http://www.cdc.gov/STD/stats06/slides/AllSurvReportSlides2006.ppt Total 3000 2862.7 20-24 480.8 2400 121.5 15-19 856.9 1800 174.2 69.0 517.0 2008 National STD Prevention Conference Confronting Challenges, Applying Solutions Chicago, Illinois March 10-13, 2008 • 26% of female adolescents in the United States have at least one of the most common STIs • • • • HPV (High risk or EGW strains) Chlamydia HSV-2 infection trichomoniasis • • Only half of respondents had had sex Infection rate among sexually active was 40% 18.3% 3.9% 1.9% 2.5% Oral Abstract D4a – Prevalence of Sexually Transmitted Infections and Bacterial Vaginosis among Female Adolescents in the United States: Data from the National Health and Nutritional Examination Survey (NHANES) 2003-2004. Presented by Sara Forhan. Adolescents/Young Adults • Risk is due to behaviors: multiple partners, “serial monogamy”, alcohol & drug use • Cervical anatomy different in adolescents (ectopy) • Teen women often have sex with 20-25 year old men Disparities by Gender: Body parts play a part Disparities in Morbidity • Many women undiagnosed (mild to no symptoms) • Chronic infection causes PID, chronic pelvic pain, infertility, ectopic pregnancy Disparities by Gender Chlamydia, US, 1988–2007 Source: CDC STD Surveillance Reports 2007 http://www.cdc.gov/std/stats07/figures/1.htm Note: transmission rates to men and women from an infected partner are similar, but women may have more infections, or more screening. Maternal-Fetal Transmission Maternal-Infant Transmission • • • • • HIV Herpes Gonorrhea Chlamydia Syphilis Neonatal Herpes Courtesy of Dr. Félix Omeñaca Terés, Hospital Materno Infantil La Paz, Madrid, Spain Ophthalmia Neonatorum Medical Trivia • In 1930, Dr. Cecil George Paine, a pathologist who had studied under Alexander Fleming, treated babies with Penicillin for gonococcal ophthalmia neonatorum . These cases cleared up dramatically.. • When his old notes were discovered in 1983, Paine was asked why he did not report what was in fact the first and successful clinical use of Penicillin. He modestly said, 'I was a poor fool who didn't see the obvious when placed in front of me.' http://bookshop.blackwell.co.uk/jsp/welcome.jsp?page=/jsp/promo/umh.jsp&source=heroes Congenital Syphilis • About 400-500 cases a year • Cause of stillbirth, neonatal death, deafness, retardation, bony deformities, seizures • Rate down >50% by targeting specific areas (e.g. prenatal care for uninsured women in the South) • The bacteria can be cleared, but the damage is permanent Disparities by Social Class “Statistically significant differences in health care utilization by neighbourhood income status were observed for chlamydia, gonorrhea, hepatitis C. The rate ratios increased in size when comparing lowincome neighbourhoods to high-income neighbourhoods.” • • Lemstra M, Neudorf C, Opondo J. Health disparity by neighbourhood income. Can J Public Health. 2006 Nov-Dec;97(6):435-9. Note: these data are not from the US, but illustrate the kind of work that can be done when there is universal health care and extensive prospective data collection. Disparities by Race • African Americans had 73.3% of reported cases of GC and 49.8% of cases of primary & secondary syphilis. • Native Americans at increased risk of chlamydia, increasing risk of GC • Hispanics at increased risk of chlamydia, GC, syphilis; marked increase in congenital syphilis. Cross-border migration of illness. Gonorrhea — Rates by race and ethnicity: United States, 1981–2003 Rate (per 100,000 population) 2,500 White Black Hispanic Asian/Pac Isl Am Ind/AK Nat 2010 Target 2,000 1,500 1,000 500 0 1981 83 85 87 89 91 Source: CDC/NCHSTP 2003 STD Surveillance Report 93 95 97 99 2001 03 “Individual risk behavior and sociodemographic characteristics of African Americans do not seem to account fully for increased STD rates for African Americans.” • Newman LM, Berman SM, Epidemiology of STD disparities in African American communities. Sex Transm Dis. 2008 Dec;35(12 Suppl):S4-12. Review. The Legacy of Tuskeegee • Mistrust of medical research • Mistrust of doctors, clinics, educational programs Disparity by Sexual Orientation • Self-reported viral STD rates higher among bisexual women (15.0% to 17.2%) than among lesbians (2.3% to 6.7%). Tao G. Sexual orientation and related viral sexually transmitted disease rates among US women aged 15 to 44 years. Am J Public Health. 2008 Jun;98(6):1007-9. Disparity by Sexual Orientation • 53 percent of the estimated 56,000 cases of new HIV infection in 2006 were among gay and bisexual men. Estimates of New HIV Infections in the United States http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/incidence.htm HIV/AIDS Estimated AIDS Incidence* among Adults/ Adolescents, Diagnosed by Sex and Exposure Category, United States, 2003 •Data adjusted for reporting delays and estimated proportional redistribution of cases initially reported without risk. •Source: CDC/NCHSTP 2003 HIV/AIDS Surveillance Report Disproportionate Burden of Disease in HIV Infection • HIV may drive other epidemics – Syphilis – “the canary in the coal mine” • cervical cancer progression from dysplasia STD/HIV Inter-Relationships STD increases HIV susceptibility • STD causes infection and desquamation of squamous or columnar cells producing an inflammatory response • Results in increased number of HIV target cells (lymphocytes) on mucous membrane surfaces and a portal of entry for HIV STD/HIV Inter-Relationships STD increases HIV transmission For a person with HIV, having an STD: • Brings inflammatory cells loaded with HIV to the genital tract • Increases HIV viral shedding from mucous membranes Design Your Own STD • • • • • Likes warm, moist places Transmitted through blood, mucus, semen, fomites Mild symptoms, especially at first Long infectious period (years) Infection aided by microtrauma and vulnerable epithelium • Evolves fast - ahead of immunity, antibiotics • Spread through young, mobile Take Home Question • What will I do to help stop STIs? – In daily practice: ask about risk factors, encourage abstinence (especially in the young), safer sex practices, support behaviors to decrease risk – Screen asymptomatic people based on epidemiology of the area and your patient population – Give all available vaccines – In community: disease reporting, support evidencebased decisions, teach young people to be safe Other fun questions: • Which STIs cause cancer? (HIV, HPV, Hep B, Hep C) • Which are vaccine preventable? (4 strains of HPV, Hep B. HSV vaccine is not very good.) • Which STIs can be prevented by a condom? • Which STIs can be prevented by abstinence? • What is most common STD? (chlamydia has highest reported incidence, HSV prevalance is highest. Most common curable STI in young women is trichomonaisis. What about lifetime occurrence of HPV?—nobody knows. • If you get a needlestick, which is most infectious: HIV, Hep B, Hep C, Syphilis? And who do you call when stuck?