Sexually transmitted infection

OBJECTIVES
• By the end of these seminar you will
be able to :
• 1- identify , types ,mode of
transmission and risk factors of STIs
• 2- appreciate the burden of STIs
through out the world.
• 3- explain the serious complication
that can arise from un treated STIs .
4- know about syndromic management
approach of Sexual transmitted infections
4-know how to prevent and control sexual
transmitted infection .
 INTRODUCTION
• Sexually transmitted infections (STIs)
are infections that spread primarily
through person to person sexual
contact .
• STIs are a common and
serious problem worldwide.
The most widely known are
gonorrhoea, syphilis and the
human immunodeficiency virus
(HIV) – but there are more than
20 others.
 Many of these are curable with
effective treatment, but they continue to
be a major public health concern in both
industrialized and developing countries.
• Can be caused by a number of
microorganisms that vary in size , life
cycle and symptom and susceptibility
of treatments.
 TYPES OF STIS
• 1-Bacterial :
• -syphilis
• -gonorrhea
• -chancroid
• -chlamydial
• 2-viral:
• - genital and anorectal warts
• -genital herpes
• -HIV infection
• 3-Parasitic :
• -trichomoniasis
• -scabies
 MODE OF TRANSMISSION
• 1-unprotected penetrative sexual
intercourse (vaginal or anal).

• 2- unsafe (unsterile) use of needles or

injections or other contact with blood
or blood products (e.g. syphilis, HIV
and hepatitis).
• 3- Tattoo or body piercing
• 3- from mother to child:
• – during pregnancy (e.g. HIV
and syphilis).
– at delivery (e.g. gonorrhoea,
chlamydia and HIV).
- through breast milk (e.g. HIV);
 Factors that increase risks of
transmission
• Not all acts of unprotected sexual
intercourse result in the transmission of
an STI from an infected person to a
partner. Whether or not a person will
be infected depends on many factors,
both biological and behavioral.
 BIOLOGICAL FACTORS

1-Age:
•The vaginal mucosa and cervical tissue
in young women is immature and makes
them more vulnerable to STIs than older
women.
2-Sex
•Infections enter the body most easily
through a mucosal surface such as the lining
of the vagina .Since the mucosal surface that
comes into contact with the infective agent is
much greater in women than in men, women
can be more easily infected than men.
3-Immune status
•The immune status of the host and
virulence of the infective agent affect
•transmission of STIs.
 BEHAVIORAL FACTORS

• Many behavioral factors may affect the

chance of getting an STI. Such behaviors
are known as "risky".
• Personal risky sexual behaviors
include:
1-changing sexual partners
frequently
2-having more than one sexual
partner
3- having sex with "casual"
 4 -having unprotected penetrative
sexual intercourse in a situation where
either partner has an infection; or having
had an STI in the last year .
• Other personal behaviors may be
associated with increased risk,
including :
1- skin piercing
2 -use of alcohol or other drugs
before or during sex;
EPIDEMIOLOGY

khlood alsaid
 EPIDEMIOLOGY OF STIs
• More than 1 million sexually transmitted
infections (STIs) are acquired everyday
world wide.

Each year,there an estimated 357 million new

infection with one of 4 STIs: chlamydia,
gonorrhoea , syphilis and trichomoniasis.
• More than 290 million women have a
human papilloma virus (HPV) infection.

• More than 500 million people are estimated

to have genital infection with herpes
simplex virus (HSV).
• Syphilis in pregnancy lead to 300,000 fetal
and neonatal death every year.

• HPV infection is responsible for an

estimated 530,000 cases of cervical cancer.
 GLOBAL INCIDENCE
ESTIMATES
• The total number of new cases of four STIs in
2012 among people ages 15-49 yrs was
estimated to be 357 million:
• 131 million cases of C.trachomatis.
• 78 million cases of N. gonorrhoea
• 6 million cases of syphilis
• 142 million cases of T. vaginitis.
•
 Prevalence
• The prevalence of STIs in 2012,is about 273 million cases of the four
curable STI among adults aged 15–49 years:
• 128 million cases of chlamydia.
• 27 million cases of gonorrhoea.
• 101 million cases of trichomoniasis.
• 18 million cases of syphilis.

,.
 AFRICAN REGION
• The WHO African Region comprises 46
countries with an estimated population in
2008 of 384.4 million adults between the
ages of 15 and 49.
• Total incidence of selected curable STIs
for the WHO African Region is 92.6
million
 INCIDENCE
The total number of new cases of the four
STIs in 2008 was estimated to be 92.6
million:
• 8.3 million cases of C. trachomatis.
• 21.1 million cases of N. gonorrhoea.
• 3.4 million cases of syphilis.
• 59.7 million cases of T. vaginitis.
 PREVALENCE
 At any point in time 2008 it was estimated
That :
• 9.1 million adults were infected with C.
trachomatis.
• 8.2 million with N. Gonorrheae.
• 14.3 million with syphilis.
• 42.8 million with T. vaginalis.
 STIs in Sudan (2012)

• Sexually transmitted infections

distributed in the 15 northern state.
• The epidemiological data on STIs in
Sudan are scattered and as expected it is
difficult to find reliable and valid data.
• STIs higher in urban areas than in rural ones , and
higher in unmarried people and younger adults .
• Most Children under 14 years of age are not
affected by STIs, other than by congenital syphilis,
ophthalmia neonatorum and HIV infection.
• The most frequent cases in the 15–44 age group,
decreasing in older adults.
 STIs – the problem

BY:
MAAB MAHDI JUMAA ADAM
 Trichomoniasis
 It is parasitic infection caused by genus
Trichomonas vaginalis .

 It has highest estimated prevalence and

incidence rates by WHO in african
region among M&F aged15-49 years.
 Infected men are usually asymptomatic
while in women it cause vaginitis .

 Usually treatment consists of

mitronidazole and tinidazole.
 Chlamydia
 Chlamydia is a common bacterial
sexually transmitted disease caused by
Chlamydia trichomatis .
 It affect both men and women cuasing
urethral discharge and cervicitis ,can
also affect neonate leading to
conjunctivitis
 The incubation period varies from 1
week to few months .

 The Standard regimens for treatment of

chlamydial infection are Azithromycin
and Doxacyclin
 Gonorrhoea
 Gonorrhoea is a major public health
challenge today due to high incidence of
infections accompanied by global threat of
antimicrobial resistance

 The causative organism is Neisseria

gonorrhoeae with incubation period
between 2-10 days
 Infected men are more sypmtomatic than
women suffering of urethral discharge
while in women can cause cervicitis . It
also can cuase neonatal conjunctivitis in
infected pregnant woman .

 The drug of choice in uncomplicated

gonococal infection is ceftrixone
 Syphilis
 Syphilis is sexually transmitted bacterial
infection through abrasions in skin and
mucous membrane with the spirochaete
treponema pallidum.
 The highest prevalence and incidence
rates for syphilis were found in the
WHO African Region.
 Symptoms of acquired syphilis in adults are
divided into Early Stage which include :
• Primary syphilis incubation period of
14-28 days characterize by chancer
associated with inguinal lymphadenopathy.
• Secondary syphilis occur 6-8 w after
the developmant of chancer characterize by
generalize maculopapular rash,condylomata
lata and generalized lymphadenopathy .
• Latent syphilis characterised by
presence of + syphilis serological test
without clinical evidence.
 Late stage include :
• Late latent syphilis this may
persist for life.
• Tertiary syphilis this may develop
between 3-10 years and can be benign
charchterized by the gumma lesion or
malignant stage characterised by
cardiovascular syphilis and
neurosyphilis .
• Transplacental infection of the fetus can
occur leading to congenital syphilis
 Syphilis can be diagnosed by dark
ground microscope and serological
tests which include specific and non
specific tests .

 Penecillin remains the drug of choice

for all stages of infection .
 Complication of STIs
 Infertility in men and women
 Epididymitis
 Ectopic pregnancy due to tubal damage.
 Blindness in infant
 Pelvic inflammatory disease and
generalized peritonitis
 Permanant brain and heart disease
 Extensive organ and tissue destruction
in Children .
 Genital cancer
SYNDROMIC MANAGEMENT
APPROACH OF STIS
Maab Mahdi
Linda Elsadig
 OBJECTIVES
-Define the syndromic management
approach of sexual transmitted infections.

-list a number of problems associated with

classic approaches to treating patients with
sexual transmitted infections .
 - identify the main features of syndromic case
management
-List the steps in using flowcharts to treat
patients.

-explain why education and counselling are so

vital in Sexual transmitted infection case
management
•.
 -explain why "partner management" is
such an important part of sexual
transmitted infection case management
• The syndromic management approach
is based on the identification of
consistent groups of symptoms and
easily recognized signs , and the
provision of treatment that that deals
with majority of organisms causes
these syndromes.
 STI - ASSOCIATED SYNDROMES
• There are seven Clinical syndromes
caused by sexually transmitted Agent.

1.Urethral discharge (persistent or

recurrent).

2.Genital ulcer.
3. inguinal bubo.

4. Scrotal swelling.

5.Vaginal discharge (cervical infection, vaginal

infection).

6. Lower abdominal pain .

7. Neonatal conjunctivitis
Syndrome Symptoms Signs Most common
causes

Vaginal Unusual vaginal Abnormal vaginal VAGINITIS:

discharge discharge discharge – Trichomoniasis
Vaginal itching – Candidiasis
Dysuria CERVICITIS:
(pain on urination) – Gonorrhoea
Dyspareunia – Chlamydia
(pain during sexual
intercourse

Urethral Urethral discharge Urethral discharge Gonorrhoea

discharge Dysuria (if necessary ask Chlamydia
Frequent urination patient
to milk urethra

Genital ulcer Genital sore Genital ulcer Syphilis

Chancroid
Genital herpes
Lower Lower abdominal Vaginal discharge Gonorrhoea
abdominal pain Lower abdominal Chlamydia
pain Dyspareunia tenderness on Mixed anaerobes
palpation
Temperature >38°
Scrotal Scrotal pain and Scrotal swelling Gonorrhoea
swelling swelling Chlamydia

Inguinal Painful enlarged Enlarged inguinal LGV

bubo inguinal lymph lymph Chancroid
nodes nodes
Fluctuation
Abscesses or
fistulae

Neonatal Swollen eyelids Oedema of the Gonorrhoea

conjunctivitis Discharge eyelids Chlamydia
Baby cannot open Purulent discharge
eyes
 TRADITIONAL APPROACHES
MANAGEMENT
• It depended on one of two approaches
to STI diagnosis:
• Etiological diagnosis and clinical
diagnosis which are problematic
• Etiological diagnosis is expensive ,time
consuming
• Also laboratory testing require skilled
personnel ,consistent support and
supply which are not available
• Clinical diagnosis:
• Some STI cause similar symptom
• So mix infections are common
• Patients with multiple infections need
to treated for each.
 THE KEY FEATURE OF
SYNDROMIC CASE
MANAGEMENT
• Is problem-oriented (it responds to the
patient’s symptoms).
• Is highly sensitive and does not miss
mixed infections.
• Treats the patient at the first visit.
• Makes STI care more accessible as it
can be implemented at primary health-
care level.
• Uses flowcharts that guide the health
worker through logical steps.
• Provides opportunity and time for
Education and Counseling
 STEP OF SYNDROMIC ABBROCH
MANAGEMENT

1.History taking and examination.

2.Diagnosis and treatment.

3.Educating and counseling the patient.

4.Partner management.
5. Data gathering (recording).
 FLOWCHART

• Is a diagram or map representing step

to be taken through a process of
decision making.
• . Each decision or action is enclosed in
a box, with one or two routes leading
out of it to another box, with another
decision or action.
EACH FLOWCHART IS MADE UP OF
THREE SORTS OF STEPS
1. Clinical problem.
2. Decision to make
3. An action to take ; what you need to
do
 Major Benefits of flowchart
 offer prompt treatment because patients
with STIs are treated at their first visit;
 many more patients with STIs have
access to treatment;
 there are opportunities for introducing
preventive and promotive measures such
as education and condom distribution.
Urethral Discharge
PERSISTENT/RECURRENT URETHRAL
DISCHARGE IN MEN
GENITAL ULCERS
SCROTAL SWELLING
INGUINAL BUBO
LOWER ABDOMINAL PAIN
VAGINAL DISCHARGE
NEONATAL CONJUNCTIVITIS
 EDUCATION AND COUNSELLING

• Health education and counseling for

STI are important for individual to
appreciate their own responsibilities
and opportunities to reduce STI
transmission
 EDUCATING AND COUNSELING
THE PATIENT

• Health education is the provision of

accurate and truthful information so
that a person can become
knowledgeable about the subject and
make an informed choice.
• Counseling is a two-way interaction
between a client and a provider.
 WAY ARE EDUCATION AND
COUNSELLING SO IMPORTANT

• Patients are more likely to comply with

treatment if they understand why it is
important to do so.
• A person with an STI has a high
likelihood of being reinfected.
• Preventing reinfection requires
sustained behavior change Patients
often need education and counselling
to enable them to change behavior and
adopt safer sexual practices.
 EXPLAINING THE STI AND IT IS
TREATMENT
• The first issue is to explain what a
sexually transmitted infection is. It is
important that the patient understands
that the infection is transmitted mainly
through sexual intercourse with an
infected person.
• Explain that sexually transmitted
organisms can be bacterial (e.g. the
gonococcus), parasitic (e.g.
Trichomonas vaginalis or pubic lice),
or viral (e.g. herpes simplex virus or
HIV).
• find out what the patient understands
about the STI and its treatment and
what questions and concerns he or she
may have:
• advise about any common side-effects
of the treatment;
• encourage the patient to comply with
treatment.
 PARTNER MANAGEMENT

• Who to treat?
• These are the main features of partner
management:
• treatment of all the patient’s sexual partners

• for the same STI as the patient, and

• treatment of any new STI identified.

• A patient we diagnose as
having an STI has been
infected during unprotected
sexual intercourse with an
infected partner:
TWO APPROACHES TO PARTNER
MANAGEMET
• If the purpose of partner management
is to treat as many of the patient’s
sexual partners as possible, there are
two approaches to contacting sexual
partners:
• By the patient: this is known as patient
referral.
• By a service provider: this is known as
provider referral.
 PATIENT REFERRAL
• In this option, the patient takes
responsibility for contacting partners and
asking them to come for treatment. For
reasons we have explained already, many
patients might feel unwilling or unable to
discuss the STI with partners, so the
service provider’s aim is to help the
patient decide what to do.
In fact, a patient might approach partners
in several ways:
•By directly explaining about the STI
and the need for treatment.
•By accompanying a partner to the health
center or asking the partner to attend
without specifying why.
•By giving each partner a card asking
him or her to attend the center.
 PROVIDER REFRRAL

• This is where a member of the health team

contacts the partners of a patient with an
STI. The service provider might be the
person who treated the initial patient or
someone whose role includes searching for
and treating partner.
• The service provider asks the
partner to attend the clinic for
treatment.
 DISADVANTAGES

• Over-diagnosis and over-treatment that

may result in increased drug costs,
possible side-effects of multiple drugs,
alterations in vaginal flora and
potential for increased drug resistance.
• Cannot be used to detect infections
among asymptomatic individuals.
PREVENTION AND
CONTROL
Khozma mahgoub
 A\ PREVENTION
• THE OBJECTIVE :-
• To reduce the prevalence (total No. of
cases)
• Effective prevention and care can be
achieved by use of a combination of
responses. Services for prevention and
for care of people with sexually
transmitted infection should be expanded
and embrace public health package that
include the following element
• 1\ promotion of safer sexual behavior
• 2\ promotion of early health care
seeking behavior
• 3\introduction of prevention and care
activities across all primary health care
programme
• 4\ social marketing of commodities for
control (condoms)
•
 TYPES OF PREVENTION
• PRIMARY :- (prevent the infection)
• Effective Interventions at the clinic and
outside
• Achieved by:
• 1\safer sexual behavior & activity
• 2\vaccination
• 3\promote the use of condoms
• SECONDARY :-
• 1\promoting care seeking behavior
• 2\rapid & effective treatment
• 3\case finding
 B\CONTROL
• Public health outcome, measured as
reduced incidence (NEW
INFECTION) & prevalence,
• Achieved BY:-
• 1\behavior changes
• 2\risk reduction
• 3\condom use
• 4\effective treatment
• 5\education
REFERENCE:
1-WHO.(2016)World Health Organization.
Available from: www.who.int/en/ .
]accessed:1st march2016].
2- CDC.(2016)Center for disease control and
prevention. Available from: cdc.gov. [accessed:1st
march 2016].
3-WHO.(2007) Training modules for the
syndromic management of sexually transmitted
infections.
4-Newman L, Rowley J, Vander Hoorn
S,Wijesooriya NS, Unemo M, Low N, et al.
(2015) Global Estimates of the Prevalence
and Incidence of Four Curable Sexually
Transmitted Infections in 2012 Based on
Systematic Review and Global Reporting.
PLoS ONE 10(12):e0143304.
doi:10.1371/journal.pone.0143304.
[ accessed:13th march 2016]