Transcript Common Sexually Transmitted Diseases. Something for Everyone!

1st Advanced Course: “Health on the move” Migrants’ and displaced populations’ health
Sexually Transmitted Diseases
and HIV/AIDS
Evangelos Vryonis MD, MSc
Athens , January 14 & 15 2012
Sexually Transmitted Infections or STI’s
• STI’s are infections that are spread primarily
through person-to-person sexual contact.
• There are more than 30 different sexually
transmissible bacteria, viruses and parasites.
• Several, in particular HIV and syphilis, can also
be transmitted from mother to child during
pregnancy and childbirth, and through blood
products and tissue transfer.
Background Information
Knowledge About STDs
Among Americans
Unable to name
any STDs
12
Believe all STDs are
curable
17
Unaware that STDs
increase risk of HIV
infection
56
0
10
20
30
40
Percentage of Americans 18-64 years old
Source: Kaiser Family Foundation, 1996
50
60
Background Information
Percent of Women Who Said Topic Was Discussed During
First Visit With New Gynecological or Obstetrical
Doctor/Health Care Professional
Breast Self Exam
4%
69%
Pap Smear
60%
12%
Birth Control
33%
20%
Mammograms
34%
7%
Sexual History and/or Current…
Alcohol Use
1%
24%
HIV/AIDS
STDs other than HIV/AIDS
3%
36%
12%
0%
HCP asked
Pt. asked
2%
19%
3%
20%
40%
60%
Percentages may not total to 100% because of rounding or respondents answering “Don’t know” to the question
“Who initiated this conversation?”
Source: Kaiser Family Foundation/Glamour National Survey on STDs, 1997
80%
Background Information
Sexually transmitted infections (STIs) are a
public health issue
• >448 million new infections of curable sexually transmitted (syphilis,
gonorrhoea, chlamydia and trichomoniasis) infections occur yearly.
• Some STIs exist without symptoms
• In pregnant women with untreated early syphilis, 25% of pregnancies
result in stillbirth and 14% in neonatal death.
• Sexually transmitted infections are the main preventable cause of
infertility, particularly in women.
• Regional distribution (The largest number of new infections occurs in the
region of South and Southeast Asia, followed by sub-Saharan Africa, Latin America,
and the Caribbean)
• In low-income countries, STIs rank in the top five disease categories
for which adults seek health care.
• 1 in 4 sexually active teens has an STI.
WHO, Fact sheet N°110, August 2011
Common pathogens
Bacterial infections
Viral infections
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Neisseria gonorrhoeae (causes
gonorrhoea or gonococcal infection)
Chlamydia trachomatis (causes
chlamydial infections)
Treponema pallidum (causes syphilis)
Haemophilus ducreyi (causes chancroid)
Klebsiella granulomatis (previously
known as Calymmatobacterium
granulomatis causes granuloma inguinale
or donovanosis).
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•
Human immunodeficiency virus (causes
AIDS)
Herpes simplex virus type 2 (causes
genital herpes)
Human papillomavirus (causes genital
warts and certain subtypes lead to cervical
cancer in women)
Hepatitis B virus (causes hepatitis and
chronic cases may lead to cancer of the
liver)
Cytomegalovirus (causes inflammation in
a number of organs including the brain,
the eye, and the bowel).
Parasites
•Trichomonas vaginalis (causes vaginal trichomoniasis)
•Candida albicans (causes vulvovaginitis in women; inflammation of the glans penis and foreskin
[balano-posthitis] in men).
..WHO recommends a syndromic approach to diagnosis and
management of sexually transmitted infections…
Although many different pathogens cause STIs, some display similar or overlapping
signs and symptoms.
Some of these signs and symptoms are easily recognizable, giving what is known as a
syndrome that signals the presence of one or a number of pathogens.
For example, a discharge from the urethra in men can be caused by gonorrhoea alone,
chlamydia alone or both together.
The main syndromes of common STIs are:
• urethral discharge
• genital ulcers
• inguinal swellings (bubo, which is a swelling in the groin)
• scrotal swelling
• vaginal discharge
• lower abdominal pain
• neonatal eye infections (conjunctivitis of the newborn).
Discharge syndromes
Discharge syndromes-“Drips”
• Discharge syndromes . Urethral/vaginal discharge and dysuria are the
hallmarks of
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Gonorrhea,
Chlamydia,
Trichomoniasis,
Bacterial vaginosis,
Candidiasis
Mycoplasma genitalium infections are increasingly recognized as causes of
sexually transmitted discharge syndromes in adolescents and young adults.
– …genital herpes ?(sometimes associated with dysuria and a scant, mucoid
urethral discharge, but nearly always in association with other genital lesions)
• Characteristics of the discharge, such as color (eg, clear, mucoid, yellow,
green) are unreliable indicators of the etiology.
Discharge syndromes
Gonorrhea
• Urethritis - male
– Incubation: 1-14 d (usually 2-5 d)
– Sx: Dysuria and urethral discharge
(5% asymptomatic)
– Dx: Gram stain urethral smear (+)
> 98% culture
– Complications
• Urogenital infection - female
– Endocervical canal primary site
– 70-90% also colonize urethra
– Incubation: unclear; sx usually in l0
d
– Sx: majority asymptomatic; may
have vaginal discharge, dysuria,
urination, labial pain/swelling, abd.
pain
– Dx: Gram stain smear (+) 50-70%
culture
– Complications
Neisseria gonorrhoeae
Gram-negative diplococci
Gonorrhoea world map
Discharge syndromes
Nongonococcal
Urethritis
Chlamydia
trachomatis
• Etiology:
– 20-40% C. trachomatis
– 20-30% genital mycoplasmas
(Ureaplasma urealyticum,
Mycoplasma genitalium)
– Occasional Trichomonas
vaginalis, HSV
– Unknown in ~50% cases
• Sx: Mild dysuria, mucoid
discharge
• Dx: Urethral smear  5 PMNs
(usually 15)/OI field
Urine microscopic  10
PMNs/HPF
Leukocyte esterase (+)
More than 3 million new cases
annually in US
Responsible for causing
Cervicitis
Urethritis
Proctitis
Lymphogranuloma venereum
Pelvic Inflammatory Disease
Direct and indirect cost of
chlamydial infections run into
billions of dollars
Potential to transmit to newborn
during delivery
Conjunctivitis
Pneumonia
Discharge syndromes
Normal Cervix
Chlamydia Cervicitis
Genital ulcer syndrome (GUS)- “Sores”
– Primary syphilis -important diagnostic consideration, especially in the
setting of commercial or high-risk sexual networks ± drug use
– Genital Herpes -US most common (HSV-2, HSV-1)
– Chancroid (Hemophilus ducreyi)
– Lymphogranuloma venereum (Chlamydia trachomatis)
– Granuloma inguinale (Calymmatobacterium granulomatis)
Genital ulcer syndrome
Does It Hurt?
• Painless
– Syphilis
– Lymphogranuloma venereum
– Granuloma inguinale
• Painful
– Genital herpes simplex
– Chancroid
Genital ulcer syndrome
Primary Syphilis
• Incubation: 10-90 days
(average 3 weeks)
• Chancre
– Early: macule/papule
erodes
– Late: clean based, painless,
indurated ulcer with
smooth firm borders
– Resolves in 1-5 weeks
– Unnoticed in 15-30% of
patients
– HIGHLY INFECTIOUS
Age-standardised disability-adjusted life year (DALY) rates
from Syphilis by country. WHO 2009
Treponema pallidum
Genital ulcer syndrome
Secondary Syphilis
• Represents
hematogenous
dissemination of
spirochetes
• Usually 2-8 weeks
after chancre appears
• Findings:
– rash - whole body
(includes
palms/soles)
– mucous patches
– condylomata lata -
HIGHLY INFECTIOUS
– constitutional
symptoms
• Sn/Sx resolve in 2-10
weeks
Genital ulcer syndrome
Genital ulcer syndrome
Portrait of Gerard de Lairesse by
Rembrandt van Rijn, ca. 1665 oil
on canvas.
De Lairesse, himself a painter and
art theorist, suffered from
congenital syphilis that severely
deformed his face and eventually
blinded him
Posthumous portrait of Christopher
Columbus (1451 – 1506) by Sebastiano del
Piombo.
Genital ulcer syndrome
Treponema pallidum
DISEASE
Smallpox
Influenza
Typhus
Measles
Malaria
Diphtheria
Whooping Cough
(Pertussis)
Genital ulcer syndrome
Genital Herpes
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One of the 3 most common STDs, increased
30% from late 70s to early 90s
25% of US population by age 35
HSV-2: 80-90%, HSV-1: 10-20% (majority of
infections in some regions)
Most cases subclinical
Transmission primarily from subclinical
infection
Complications: neonatal transmission,
enhanced HIV transmission, psychosocial
issues
Vesicles  painful ulcerations  crusting
Recurrence a potential
Diagnosis:
– Culture
– Serology (Western blot)
– PCR
Pelvic Inflammatory Disease (PID)
• Common sequela of genital gonorrhea and
chlamydia infections (l0%-20%)
• In Europe and North America, higher proportion
of C. trachomatis than N. gonorrhoeae in women
with symptoms of PID
• Douching may increase the risk of developing
PID, especially when performed frequently
• CDC minimal criteria
– uterine adnexal tenderness, cervical motion
tenderness
• Other symptoms include
– endocervical discharge, fever, lower abd. pain
• Complications:
– Infertility: 15%-24% with 1 episode PID secondary
to GC or chlamydia
– 7X risk of ectopic pregnancy with 1 episode PID
– chronic pelvic pain in 18%
Dermatologic syndromes
• The most common STD with primarily
dermatologic presentation is genital warts
(condyloma acuminata) caused by HPV
• Secondary Syphilis- Skin rash Condyloma lata
• Gonococcal infection- Skin rash is also a common
manifestation of disseminated disease
Human papillomavirusHPV
• Infection is generally
indicated by the
detection of HPV DNA
• HPV infection is causally
associated with cancer
• Over 99% of cervical
cancers have HPV DNA
detected within the
tumor
• Routine Pap smear
screening ensures early
detection (and
treatment) of precancerous lesions
HIV/AIDS
HIV
HUMAN
IMMUNODEFICIENCY
VIRUS
AIDS
ACQUIRED
IMMUNODEFICIENCY
SYNDROME
Acquired Immunodeficiency Syndrome (AIDS) is a disease of the human immune system
caused by the human immunodeficiency virus (HIV).
The illness interferes with the immune system making people with AIDS much more likely
to get infections, including opportunistic infections and tumors that do not affect people
with working immune systems. This susceptibility gets worse as the disease continues.
Modes of transmission of HIV varies in different countries.
In resource-limited areas
•vaginal sex 70-80% percent of AIDS
•perinatal transmission 5-10%
•injection drug use 5-10% percent
In contrast in USA, male-to-male sexual contact and IDU accounted for about one-half of
cases
Natural History and Progression of HIV Disease
A generalized graph of the relationship between HIV copies (viral load) and CD4 counts over the average course of
untreated HIV infection; any particular individual's disease course may vary considerably.
HIV-1 infection is divided into stages of primary infection with seroconversion, clinical latency, early symptomatic
disease, and AIDS
Age-standardised disability-adjusted life year (DALY) rates from HIV/AIDS
by country (per 100,000 inhabitants).
The amplifying effect of STDs in HIV
transmission
• At least 2 to 5-fold increased risk of HIV
seroconversion confirmed by data from 4
continents
• Greater infectiousness because of prevalence &
magnitude of HIV shedding increased by STDs;
• STD treatment reduces HIV shedding to baseline
levels
• 40% reduction in HIV incidence achieved in
randomized trial of treatment of symptomatic
STDs in Tanzania
Despite common occurance of conflicts
between old and new establishments, migratory
flows have contributed significantly to human
development
>130 million people living in foreign countries
>4 million people cross the boundaries
>23 million refugees worldwide
?? numbers of clandestines
2-3% of the world population
migration flow map