Transcript Sexually Transmitted Infections

SEXUALLY
TRANSMITTED DISEASE
NORTHERN IRELAND
WALLACE DINSMORE
Aims of this presentation;
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Trends in Sexually Transmitted Infections
To outline a basic description of the most
common sexually acquired infections
To identify the pathogenesis and
progression
Commonly used treatments
Definition
“Sexually transmitted infections are infections
whose primary route of transmission is through
sexual contact and can be caused by bacteria,
viruses or protozoa”
Adler et al (2004)
Regional Trends
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Northern Ireland has seen an increase in the
diagnosis of HIV, chlamydia, gonorrhoea, syphilis,
genital herpes and genital warts.
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Rates of infection are generally highest in the 20-24
year old age group.
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Men who sleep with men are at a higher risk of
contracting syphilis, gonorrhoea and HIV.
A Public Health Challenge
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STI diagnoses and other GUM workload more than doubled in
the five years to 2011.
Syphilis diagnoses increased by 23% in one year (2011).
More than 750,000 cases of STI were diagnosed in GUM
clinics in 2011
The number of people receiving care for HIV doubled in the
five years to 2011
A third of HIV infections in the UK are undiagnosed.
Over one in ten young people screened for Chlamydia test
positive
Number of New Patient Registration
N.I. GUM Clinics
1982 - 2005
Surveillance data for sexually transmitted infections in Northern Ireland is
provided by a statuartory KC60 each quarter from GUM clinics
Number of STI diagnoses and workload at GUM clinics by
country: 1990 – 2005*
* Data are unavailable for Northern Ireland in 1990
Data source: KC60 statutory returns and ISD(D)5 data.
Number of new diagnoses of selected STIs, GUM
clinics, United Kingdom: 2010
2011
% change
2010-2011 2001-2011
Chlamydia
109,958
5%
207%
Genital warts
81,137
1%
26%
Genital herpes
19,837
4%
18%
Gonorrhoea
19,392
-13%
54%
Syphilis
2,814
23%
1,954%
Data source: KC60 statutory returns and ISD(D)5 data.
Bacterial Infections
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Chlamydia
Lymphogranuloma
Venereum
Gonorrhea
Syphilis
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Incubation period preceding symptomatic
infection can range from 7 – 21 days.
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Asymptomatic infection can persist for long
periods;
Up to 50% men Asymptomatic
Up to 70% women Asymptomatic
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Prevalence is highest in
teenage women and in men in
their early 20s. Prevalence
reduces with age in both
sexes, probably partially due to the
development of immunity.
Sites of Infection
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Male Urethra – found in 215% of GUM attendees. It is the
cause of 20-50% of Non Gonococcal
Urethritis (NGU) or more commonly
Non Specific Urethritis (NSU).
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Symptoms – commonly
dysuria, urethral discharge,
occasionally oedema & erythema of
urethral meatus
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Complications - epididymoorchitis, reactive arthritis.
The Cost of Chlamydia
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Chlamydia and complications resulting from
untreated Chlamydia, such as pelvic
inflammatory disease, ectopic pregnancy and
infertility cost the NHS in NI £2 million p.a.
Throughout the UK costs are estimated at £100
million p.a.
Gonorrhoea
Caused by a bacterium Nisseria
gonorrhoea
- a gram negative diplococcus
(arranged in pairs) sometimes referred
to a ‘clap’ ‘drip’
 Non motile and non spore forming and
red under microscope when Gram
stained
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Gonorrhoea
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Diagnostic rates in NI remain the lowest in the UK.
An increase of 7% in 2011 at GUM clinics.
84% of these were males.
The highest risk group were 20-24 year olds, both
male and females.
Males were 3 times higher than females.
24% were MSM.
Sites of Infection
Men -
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Urethral discharge may be profuse,
creamy yellow and purulent oozing from
the urinary meatus
Throat/rectum (autoinoculation)
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Conjunctiva less common
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Symptoms;
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Dysuria Pain - likened to ‘passing a razor
blade’
Reddened meatus and enlarged lymph
nodes and sometimes tender
Anal discharge, discomfort, rectal
bleeding, tenesmus & constipation.
Complications
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Can spread to epididymis and prostate,
cellulitis, abcess, strictures
Women 
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May be asymptomatic
Sometimes associated with other
infections i.e. trichomonas vaginalis or
bacterial vaginosis
Commonly infected sites: cervix,
urethera, - - rectum and oropharynx
depending on sexual practices
Complications;
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Bartholin’s Abcess
Pelvic Inflammatory Disease (PID)
Premature labour / vertical transmission
to neonate
Treatment
Recommended Treatment
 Cefixime 400mg stat
 Ceftriaxone 500mg IM
Syphilis
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A multistage systemic
disease.
A bacterial infection
caused by the spirochaete
Treponema Pallidum
Under a microscope the
spirochaete is corkscrew
shaped with 6-18 spirals
The incubation period is
stated as 6-90 days
Stages of disease process
Primary Syphilis
Secondary Syphilis
Early latent Syphilis
21
Days
Early (Infectious)
Weeks
to months
< 2 Years
Late (low level
Late latent Syphilis
Tertiary Syphilis
Up to 15 years
Up to 40 years
infectivity)
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Primary Syphilis – The
chancre, a painless, usually solitary ulcer
appears 9-90 days after sexual contact at
the site of initial infection.
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Secondary Syphilis–
Approx 90% present with a rash, it is
generalized with the trunk being affected
in 80% and the palms and soles in 50%.
75% also have lymphadenopathy. Other
clinical manifestations include mouth
ulcers, patchy alopecia, meningitis and
hepatitis. These features are caused by a
systemic vasculitis caused by high levels
of treponema in the blood and associated
immunological response.
Sites of primary syphilis
GENITAL
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Shaft of Penis
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Coronal sulcus
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Glans Penis
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Prepuce
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Urethral Meatus
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Anal Margin and Canal
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Rectum
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Labia minora, labia majora
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Fourchette
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Clitoris
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Vaginal Wall
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Cervix
EXTRAGENITAL
• Lip
•Tongue
•Mouth, tonsil, pharynx
•Fingers
• Eyelid
•Nipple
•Any pat of the skin or mucous
membranes.
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Latent Syphilis – (Early) A-symptomatic with
positive serology up to 2 years.
(late) A-symptomatic with positive serology
over two years after acquisition.
Tertiary Syphilis - Gumma
- Cardiovascular
- Neurological
Transmission
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Sexual contact
Previously blood transfusion (now blood
tested)
Mother to foetus via placenta or during
birth
Not contracted from toilet seats, swimming
pools or saunas
Testing
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Serological testing (Preferred choice)
Treponema pallidum enzyme immunoassay (EIA) is
recommended as it tends to be more sensitive in
primary infection.
Direct detection of T.pallidum in primary and
secondary syphilis. Dark ground microscopy. (ltd to
specialist areas, not suitable for oral lesions)
Lymph node aspiration
Follow up monitoring at 3, 6 and 12 months.
Treatment
Early Syphilis
 Procaine Penicillin G (IM) 600-750mg daily 10 days
 Benzathine Penicillin 2.4g IM twice, a week apart.
 Doxycycline 100mg bd 14 days
Latent Syphilis
 Procaine penicillin G (IM) 600-750mg daily 17 days
 Benzathine Penicillin 2.4g IM x3, a week apart.
 Doxycycline 200mg bd 28 days
 Neurosyphilis – specialist care.
Statistics
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Between 2001-2011 there has been a 1954%
increase in diagnosis of infectious syphilis.
Since the outbreak in 2001 – 2011, 4090 cases.
In 2011 829 new cases 68% among msm.
Diagnoses of infectious syphilis (primary, secondary and early
latent) by sex and sexual orientation, London enhanced
syphilis surveillance: April 2001 - December 2011
Data source: London Enhanced Syphilis Surveillance
Viral Infections
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Genital Warts
Herpes
HIV
Genital Warts/ HPV
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Caused by human papilloma virus (HPV) 90 different types of HPV,
approx 30 types associated with genital infection, Approx. 90% are
types 6 and 11.
Acquired through sexual contact, skin-to-skin contact and thought
also to be from sharing of sex toys
The virus enters the skin through normal friction of skin-to-skin
rubbing during sex or close physical contact
Infectivity is thought to be approximately 60% with an incubation
period of 2-8 months (Adler 1995)
Only a small proportion of infected patients develop macroscopic
genital warts, the remainder go undetected.
Once in the epithelium it proliferates causing a wart formation
Genital Warts
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2941 episodes of 1st diagnosis at GUM clinics
in NI.
54% were males.
73% were first infection.
Highest risk group, 20-24 year olds.
Females 16-19 years old were twice as
susceptible to infection than males of the same
age. However, over 19 years old, the rate is
higher in males.
2% of diagnosis occurred in MSM.
HERPES
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Caused by Herpes simplex virus
There are 2 types
- HSV 1
- HSV 2
HSV 1 associated with both
oropharyngeal & genital disease,
increasing in incidence. Type 1 has
fewer symptomatic recurrences and less
subclinical shedding.
HSV 2 associated with genital disease.
Incubation 3-14 days
Genital Herpes
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2011: 418 episodes of 1st and recurrent infection
diagnosed at GUM clinics in NI.
268 were females.
66% were 1st attacks.
39% were males.
Females aged between 20-24 are 3 times more at
risk than males.
5 diagnosis were made in MSM.
HIV
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What does HIV mean?
Human
Immunodeficiency
Virus
What is HIV?
Virus attacks the immune system and slowly destroys it.
Infected/infectious for life.
May be no obvious symptoms and you may look and feel
well.
Could be signs of immune damage detectable by blood tests.
HIV attacks the immune system.
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A healthy immune
system can fight off
infection easily.
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A weakened immune
system does not offer
much protection and the
person will become ill.
HIV Transmission.
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3 main routes of transmission.
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1. Unprotected sex with an
infected partner.
2. Infected blood getting into someone
else’s bloodstream (trauma, IVDU).
3. From infected mother to baby.
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HIV Test.
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Simple blood test (antibody).
GUM Clinic or GP.
Positive = infected and infectious.
Negative may not mean negative.
Window period (12 weeks since
possible exposure risk)
Pre and post test discussions.
N Ireland Statistics.
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Approximately 700 people
have been tested positive with
HIV/AIDS in Northern
Ireland.
In 2011 there were 106
registrations
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