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Sexually Transmitted Infections
• Cristina Muñoz
• Division of Women’s Primary Healthcare
• Department of Obstetrics and Gynecology
• cmunoz@med.unc.edu
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
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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
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(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*
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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
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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
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HPV (High risk or EGW strains)
Chlamydia
HSV-2 infection
trichomoniasis
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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
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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.”
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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
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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?