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Current Overview of Sexually Transmitted Diseases (STDs)

Current Overview of Sexually Transmitted Diseases (STDs). Linda Creegan, FNP California STD/HIV Prevention Training Center. Common STDs. Bacterial diseases Chlamydia (CT) Gonorrhea (GC) Syphilis Trichomoniasis (Trich) Viral diseases Human Papillomavirus (HPV)

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Current Overview of Sexually Transmitted Diseases (STDs)

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  1. Current Overview of Sexually Transmitted Diseases (STDs) Linda Creegan, FNP California STD/HIV Prevention Training Center

  2. Common STDs • Bacterial diseases • Chlamydia (CT) • Gonorrhea (GC) • Syphilis • Trichomoniasis (Trich) • Viral diseases • Human Papillomavirus (HPV) • Genital herpes (HSV-2 or HSV-1) • Hepatitis B

  3. Common STDsEstimated U.S. Annual Incidences • Human Papillomavirus: 5.5 million • Trichomoniasis: 5 million • Chlamydia: 3 million • Genital herpes: 1 million • Gonorrhea: 650,000 • Hepatitis B: 120,000 • Syphilis: 70,000

  4. Reportable STDs • Regulations vary from state to state • Reportable in all states • Chlamydia • Gonorrhea • Syphilis • Chancroid • Hepatitis B • AIDS Generally not reportable Human Papillomavirus Genital herpes Trichomoniasis

  5. Chlamydia Infection • Most common reportable disease in the U.S. • Estimated 3million cases annually • Incidence is highest among sexually active adolescents and young adults • Most infections are asymptomatic • Leading cause of preventable infertility in women • Direct and indirect costs estimated at $1.7 billion annually

  6. Chlamydia Rates: U. S., 1984–2002

  7. Chlamydia — Rates by state: U.S. and outlying areas, 2002 Note: The total rate of chlamydia for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 293.6 per 100,000 population.

  8. Chlamydia Age- and sex-specific rates: U.S., 2002

  9. Prevalence of Genital CTin Selected Settings

  10. Genitals Cervicitis PID Urethritis Eye (Conjunctivitis) Throat (Pharyngitis) Rectum (Proctitis) Eye (conjunctivitis) Lungs (pneumonia) Chlamydia Infections in Women, Men, and Neonates • Genitals • (Urethritis) • (Epididymitis) • Rectum(Proctitis) • Throat(Pharyngitis) • Eye(Conjunctivitis) • Systemic • (Reiter’s Syndrome) 70-80% ASYMPTOMATIC >50% ASYMPTOMATIC

  11. Acute PID Silent PID Genital Chlamydia in Women:Complications Ectopic pregnancy 9% Untreated genital CT infection 20-50% 18% Chronic pelvic pain Infertility 14-20%

  12. Chlamydia InfectionClinical Manifestations

  13. How Chlamydia Usually Looks…. Note: most cases give no symptoms

  14. Cervical Ectopy Ectopy SCJ Minimal ectopy STD Atlas, 1997

  15. What IS Screening????? • Screening testing • Looking for disease which gives no symptoms • Most effective when done for a common disease with bad consequences using a highly accurate, non-invasive, inexpensive test • Diagnostic testing • Looking for the cause of abnormal signs, symptoms, etc

  16. Chlamydia Screening & Treatment • Decreases community prevalence • Prevents pelvic inflammatory disease • Scholes et al., NEJM, 1996; 334:1362-6 • Cost effective • CDC estimates that “for every dollar spent on chlamydia screening, we could save $12” • Opportunity to increase awareness and provide risk reduction counseling

  17. Chlamydia prevalence among women tested in FP clinics by age: Region X, 1988-1998

  18. What about chlamydia screening among men? • Obvious source of transmission • Urine-based testing advantage • Unpublished cost effectiveness analysis demonstrate community and future partner benefits • Limited data on prevalence & outcomes • No guidelines available

  19. Chlamydia Screening Recommendations • CDC, NCQA HEDIS, USPSTF, ACOG and others are similar • All sexually active women under 26 yoa • Initial screen • Repeat annually • Consider repeat with new or multiple sex partners • Repeat 2-3 months after an infection • All pregnant women under 26 yoa • Men, and women 26 and older, consider with • New or multiple sex partners, • Inconsistent condom use

  20. Urine-Based CT Tests • Highly accurate • Non-invasive collection • High patient acceptability • Only test appropriate for screening asymptomatic males • Screening in non-clinical settings • Community settings • Home testing

  21. Chlamydia Partner Management • Transmissibility: • male to female: 45-55% (culture) to 70% (PCR) • female to male: 28-42% (culture) to 68% (PCR) • Partners with contact during the 60 days preceding the diagnosis should be evaluated, tested and treated

  22. Chlamydia Reinfection Rates Whittington et al. 2001; Fortenberry et al. 1999; Blythe et al. 1992

  23. Patient-Delivered Partner Therapy • Repeat CT infections place women at greater risk for PID and infertility than first infection • Most important risk factor for re-infection is an untreated partner • Multi-center CDC trial demonstrated 20% decrease in re-infection with PDT • Single-dose azithromycin has very few adverse reactions • Authorized by law in California

  24. Chlamydia: KEY POINTS • Most common bacterial (curable) STD in the U.S. • Most cases in women and men give no symptoms • Leading cause of PID and infertility in women • All sexually active women 25 y.o.a. and younger should be tested at least annually

  25. Gonorrhea Infection • Caused by Neisseria gonorrhoeae • Overall rates falling, but incidence in certain groups remains high • Most common in young adults and adolescents • CT co-infection of GC cases remains at about 40% • Resistance to medication is an spreading problem

  26. Gonorrhea Rates: U.S. 1970–2002 and the Healthy People 2010 objective Note: The Healthy People 2010 objective for gonorrhea is 19.0 cases per 100,000 population.

  27. Gonorrhea Rates by stateU.S. and outlying areas, 2002 Note: The total rate of gonorrhea for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 123.4 per 100,000 population. The Healthy People 2010 objective is 19.0 cases per 100,000 population.

  28. GonorrheaAge- and sex-specific rates: U.S., 2002

  29. Gonorrhea Infections in Men, Women and Neonoates • Men are usually symptomatic (urethra), women are commonly asymptomatic • Men: urethral infection, epididymitis • Usually gives pain with urination and heavy, thick penile discharge; few may be asymptomatic carriers • Women: cervical infection, PID • ~50% women asymptomatic, others have pain with urination, vaginal discharge or bleeding • Other sites of infection: throat, rectum, eye • Neonates: eye and skin infections

  30. Gonorrhea InfectionsClinical Manifestations

  31. GC Partner Management • Transmissibility: • Male to female: 50 - 90% • Female to male: 20 - 80% • Partners with contact during the 60 days preceding the diagnosis should be evaluated, tested and treated • If no sex partners in previous 60 days, treat the most recent partner

  32. Increasing Medication Resistance in the U.S. • Almost all GC isolates testing in Asia are resistant to fluoroquinolones (Cipro and related medications) • Resistant GC is spreading to the U.S. • About 9% of isolates in Hawaii, 2002 • More than 10% of isolates in California, 2002

  33. Gonococcal Isolate Surveillance Project (GISP) Participating Clinics and Regional Laboratories Twenty-five sentinel sites across the nation monitor culture isolates of GC for antibiotic resistance

  34. GISPPercent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2002 Note: Resistant isolates have ciprofloxacin MICs > 1 g/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 g/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

  35. Gonorrhea InfectionScreening Considerations • Screening is probably not warranted when GC prevalence is under 1% • Accuracy of screening is dependent on: • Prevalence of disease in the population • Sensitivity and specificity of test used • Screening a low-prevalence population can result in more false-positives than true-positives

  36. GC Screening in a Youth Correctional Setting • Urine screening of adolescents for GC at juvenile halls in Los Angeles from 2/97 - 12/97 • 2500 girls screened: 4% positive • 2032 boys screened: 0.6% positive

  37. GonorrheaScreening Recommendations • Targeted screening: consider in • Populations with prevalence of 1-2% or more • MSM • High-risk women • Young age • New or multiple partners • Pregnant women

  38. Gonorrhea: KEY POINTS • Second most common bacterial (curable) STD in the U.S. • Concentrations of infection in MSM in urban areas • Resistance to medications is a spreading problem

  39. Syphilis • Incidence had been steadily declining in the U.S. since 1990 • 28 U.S. counties account for 50% of the reported cases • In 1999, the CDC initiated a nation-wide Syphilis Elimination Effort, targeting these areas • Recently, local outbreaks centered in urban areas among MSM

  40. Primary and Secondary SyphilisRates: U.S., 1970–2002 and the Healthy People 2010 Objective Note: The Healthy People 2010 objective for primary and secondary syphilis is 0.2 case per 100,000 population.

  41. Primary and Secondary SyphilisRates by state: U.S. and outlying areas, 2002 Note: The total rate of primary and secondary syphilis for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 2.5 per 100,000 population. The Healthy People 2010 objective is 0.2 case per 100,000 population.

  42. Primary and Secondary SyphilisRates by region: U.S., 1981–2002 and the Healthy People 2010 objective

  43. Primary and Secondary SyphilisRates by sex: U.S., 1981–2002 and the Healthy People 2010 Objective

  44. Primary and Secondary SyphilisAge- and sex-specific rates: U.S., 2002

  45. Congenital Syphilis Reported cases for infants <1 year of age and rates of primary and secondary syphilis among women: United States, 1970–2002 Note: The surveillance case definition for congenital syphilis changed in 1988.

  46. Regional Syphilis Hotspots • Higher endemic levels in rural South and Phoenix, AZ • Outbreaks among MSM in many urban areas • SF, LA, Denver, NY, Chicago, District of Columbia, Miami

  47. Understanding STD Trends in MSM • Why? (increases in unprotected anal sex) • Assumptions about reduced HIV infectivity in HAART era • Less personal exposure to persons with advanced AIDS • STDs considered minorand readily treatable nuisances • Who? • Subsets of MSM (minority MSM, older men, both HIV-&+ ) • Mixing by HIV serostatus • What contexts? • Drug use (Methamphetamines, Viagra) • Anonymous venues for meeting partners (internet, bathhouses, circuit parties) C. Celum,“Sleepless in Seattle” Study, 1999

  48. STD Atlas, 1997 SyphilisDistribution of the Organism

  49. Primary Syphilis Photos: Dr. Joseph Engelman, San Francisco City Clinic

  50. STD Atlas, 1997 Rash of Secondary Syphilis Photo: Dr. Joseph Engelman, San Francisco City Clinic

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