Learning Objectives. Sexual Transmission. Partners. The Hidden Epidemic Published in: STD Medical Update

Transcription

1 STD Medical Update Learning Objectives Patricia R Jennings DrPH, PA C Professor, University of Alabama at Birmingham Alabama / North Carolina Sexually Transmitted Disease Prevention and Training Center 1. Discuss and demonstrate the approach to taking a sexual history. 2. Discuss and demonstrate the counseling messages surrounding condoms, lubricants and microbicides Discuss how the internet may increase the risk of STD transmission / acquisition in adolescents and adults Describe the epidemiology/demographisc of STDs in the U.S. The Hidden Epidemic Published in: 1997 In the United States, more than 65 million people are currently living with an incurable sexually transmitted disease (STD). An additional 15 million people become infected with one or more STDs each year. Yet, STDs are one of the most underrecognized health problems in the country today. Sexual Transmission The most reliable way to avoid transmission of STD s is to abstain from sexual intercourse (i.e. oral, vaginal, anal) or to be in a long term mutually monogamous relationship with an uninfected partner. Counseling that encourages abstinence from sexual intercourse is crucial. Both partners should be tested for STD s, including HIV before initiating sexual intercourse. Sexual History The 5 P s Partners (number, gender) Practices (exposed areas, alcohol, recreational drugs, sexual enhancement devices, etc.) Protection from STDs (barrier use, how often, with whom) Past history of STDs (AND vaginitis) Prevention of pregnancy Partners Do you have sex with men, women or both? In the past 2 months, how many partners have you had sex with? In the past 12 months, how many partners have you had sex with? Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were still in a sexual relationship with you? 1

2 Practices To understand your risks for STDs, I need to understand the kind of sex you have had recently. Have you had vaginal sex, meaning penis in vagina sex? If yes, Do you use condoms: never, sometimes or always? Have you had anal sex, meaning penis in your bottom? If yes, Do you use condoms: never, sometimes or always? Have you had oral sex, meaning penis in your mouth? If yes, Do you use condoms: never, sometimes or always? Protection from STDs What do you do to protect yourself from STDs? Condom use: If never : Why don t you use condoms? If sometimes : In what situations (or with whom) do you not use condoms? Past History of STDs Have you ever had an STD? (May need say STD by name) Have any of your partners had an STD? Prevention of Pregnancy What are you doing to prevent pregnancy? Additional Questions Sexual History Have you ever paid for sex? (exchanged sex for drugs or exchanged sex for money) Consensual versus non consensual? Resident in a correctional facility? Has your judgement ever been impaired by the use of alcohol or drugs? Screening for STD s (CDC) All sexually active females aged <25 years visiting health care providers for any reason should be screened for chlamydia and gonorrhea at least once per year. All young, sexually active men should be screened routinely for chlamydial and gonococcal infections in settings or sub populations in which the prevalence is >2%. Older individuals should be screened yearly if they are high risk. 2

3 High Risk Individuals: (any age) Individuals who abuse substances including alcohol and recreational drugs. Individuals who have a history of STD s. Individuals who have more than one sex partner/yr Commercial sex workers Long distance truck drivers Military recruits Individuals in correctional facilities. Resident of a community with high rates of STDs. Individuals already infected with HIV. Prevention Male Condoms Use a new condom with each act of sexual intercourse Carefully handle the condom to avoid damaging it with fingernails, teeth, or other sharp objects Put the condom on after the penis is erect and before any genital contact with the partner Confusing? 3

4 Polyurethane Male Condoms Female Condom The female condom Reality consists of a lubricated polyurethane sheath with a ring on each end that is inserted into the vagina, is an effective mechanical barrier to viruses, including HIV. If used consistently and correctly, the female condom may substantially reduce the risk for STD s. When a male condom cannot be used properly, sex partners should consider using a female condom. Female Condom Women will try it, however, experienced users of male condoms and tampons are more likely to try and succeed. Use is more likely within main partnerships User satisfaction low High frequency of user problems and discontinuation Users prefer the male condom New products in development (Path, Reddy, latex) Dating Site - Free Photos Online Dating at Match.com Browse Profiles and Pics for Free! Dating.Match.com 100% Free Dating Why Pay for Online Dating? When You Can Use Us for Free! Free Teen Chat Rooms Chat with teens & make new friends. Set up a profile now. Totally Free! Dating & Beauty Tips Get Closer This Summer With Beauty & Dating Tips on GilletteVenus.com 4

5 Society for Adolescent Medicine 2002 Young adults who seek sex partners online may be at significantly greater risk for sexually transmitted diseases than their peers who do not seek sex partners online. These data point to an urgent need for online sexual health promotion. Tell them if you've been exposed to an STD send an anonymous e card. I got diagnosed with Chlamydia since we were together. Get checked out soon. Examination Examine the hands, skin and hair Secondary syphilis 5

6 Gonococcal conjuntivitis Genital Examination Inspect pubic hair Palpate lymph nodes Inspect skin of scrotum Palpate testis and epididymis between thumb and first two fingers. Palpate glans and shaft of penis Pediculosis Pubis Pubic lice, commonly known as crabs, are small yellow grey parasites that resemble a crab. It is spread primarily through sexual contact and occasionally through clothing, bedding and towels. It usually affects the pubic area and adjacent hairy areas but can infest beard and armpit hair and occasionally eyebrows and eyelashes. 6

7 Scabies Human scabies is caused by an infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). The microscopic scabies mite burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple like skin rash. The scabies mite usually is spread by direct, prolonged, skin to skin contact with a person who has scabies. Jock Itch Tinea cruris, a pruritic superficial fungal infection of the groin and adjacent skin, is the second most common clinical presentation for dermatophytosis. Tinea cruris is a contagious infection transmitted by fomites, such as contaminated towels or hotel bedroom sheets, or by autoinoculation from a reservoir on the hands or feet (tinea manuum, tinea pedis, tinea unguium). 7

8 Circumcised Uncircumcised Inspect glans and urethra Compress glans and inspect urethra for discharge. May have patient strip or milk shaft of penis if discharge is reported but not seen. 8

9 Obtain Specimen Asymptomatic males: urine No void for 1 hour prior to test Collect first portion of urine Obtain no more than 30 cc s Symptomatic males: gram stain urethra Other sites: culture unless laboratory has validated extragenital sites for NAAT (anal, pharynx, eye) Nucleic Acid Amplification Test (NAAT) * Aptima Test (example) endocervical swabs, male/female urethral swabs, urine Laboratory Testing Laboratory Testing NAAT *Aptima Test urine specimen both men and women (first void portion, do not urinate for 1 hour prior to test) Improved sensitivity when compared to the antigen detection (GenProbe) 30 cc max Culture: plate immediately (bedside)(thayer Martin), refrigerate. Gram stain Diagnostic in symptomatic males. Gram Stain 9

10 Physical Examination Hypospadia Hypospadia is a common congenital disease of the penis with an abnormal ventral opening of the meatus of the urethra. Hypospadia are often associated with a ventral curvature of the penis (chordee) and/or a deficient ventral prepuce (foreskin) with a dorsal "hood". Hypospadia Family history: about 7% of patients with hypospadia have children with hypospadia; and 14% of male siblings of the index patient with hypospadia. Further risk factors: increased maternal age, low birth weight, in vitro fertilization. Epispadia Epispadia is a rare abnormality and is seen in only 1 / 300,000 newborns. It also occurs in girls (1 girl: 5 boys). Here the urinary meatus is localized on the upper side of the penis or clitoris. 10

11 Most Common Hernia Less Common Least Common Hernia If mass is detected in scrotum, darken the room and try to transilluminate it with a strong flashlight. Differential A scrotal mass can be benign or malignant. Benign scrotal masses include: Varicocele a varicose vein along the spermatic cord Hydrocele fluid collection in the scrotum Hematocele blood collection within the scrotum Spermatocele a cyst like mass within the scrotum that contains fluid and dead sperm cells 11

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14 Anal Examination Inspect the anus Syphilis (2009) 1. District of Columbia 2. Louisiana 3. Georgia 4. Arkansas 5. Alabama 6. Mississippi 7. Texas 8. Tennessee 9. North Carolina 10. New York 11. Illinois 12. Florida 13. Puerto Rico 14. Maryland 15. U.S. Total 14

15 CDC Surveillance Figures from 2010 (Syphilis) 1. Louisiana 2. Georgia 3. Mississippi 4. Arkansas 5. Illinois 6. Florida 7. California 8. New York 9. Alabama 10. Texas CDC Surveillance Figures from 2011 (Syphilis) ** District of Columbia 1. Louisiana 2. Georgia 3. Illinois 4. Florida 5. California 6. Mississippi 7. Arkansas 8. New York 9. Washington state 10. Alabama Primary and Secondary Syphilis Rates by State, United States and Outlying Areas, 2011 Primary and Secondary Syphilis Rates by Age and Sex, United States, 2011 NOTE: The total rate of primary and secondary syphilis for the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was 4.5 per 100,000 population. Syphilis Primary stage: Infectious disease caused by Treponema pallidum. Painless ulcer with clean base and firm indurated borders Regional lymphadenopathy Syphilis After the organism inoculates and penetrates the mucosal surfaces or abraded skin, a primary lesion develops in approximately 2 6 weeks. It typically begins as a painless papule, whose surface necroses to form a hard based, well circumscribed, ulcerated lesion (chancre) that is loaded with treponemes. It should be noted that a primary lesion does not develop in every case or it may go unnoticed. Without treatment, the lesion heals in 3 6 weeks 15

16 Syphilis Chancroid Differential Diagnosis of genital ulcer Lesions Tenderness Edge Base Adenopathy Usually single Usually multiple None or mild Indurated Clean Indolent Marked Soft Dirty Tender, fluctuant Herpes Multiple Marked Soft Clean Tender Herpes Herpes Simplex Virus (HSV): is the most common cause of genital ulceration in the United States LGV Single None Soft Eroded papule Prominent, tender Lymphogranuloma venereum (LGV): Lymphogranuloma venereum (LGV): is caused by C. trachomatis serovars L1, L2, or L3. The most common clinical manifestation of LGV among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is typically unilateral. A self limited genital ulcer or papule sometimes occurs at the site of inoculation. Chancroid Haemophilus ducreyi: although rarely seen in the US, chancroid caused by H. ducreyi and characterized by painful lesions with irregular borders, could be part of the differential diagnosis (esp. if history of travel) Incidence (annual) of Chancroid: 5,000 cases in 1988; most recent data reveals 28 reported cases in the US in

17 Chancre Treponema pallidum (syphilis): wellcircumscribed indurated ulcer with a clean base and regional lymphadenopathy: syphilis, caused by T. pallidum Syphilis Secondary stage One or more areas of the skin break into a rash that usually does not itch. Rash often appears as rough, red or reddish brown spots both on the palms of the hands and on the bottoms of the feet. Even untreated, rashes clear up on their own. Manifestations of secondary syphilis can develop while the chancre is still present Secondary syphilis 17

18 Neurosyphilis It is important to note that because the central nervous system (CNS) is often invaded during the septicemic phase (circulating spirochetes), neurological manifestations can occur during ANY phase or stage of the disease. Serologic Tests for Syphilis Nontreponemal Tests (VDRL, RPR) Quantitative Treponemal Tests (FTA ABS, MHA TP) Treponemal Antigens Qualitative Sensitivity of Serological Tests in Untreated Syphilis Stage of Disease (Percent Positive [Range]) Diagnosis Test Primary Secondary Latent Tertiary VDRL 78 (74-87) (88-100) 71 (37-94) RPR 86 (77-99) (95-100) 73 FTA-ABS* 84 (70-100) Treponemal Agglutination* 76 (69-90) (97-100) 94 EIA *FTA-ABS and TP-PA are generally considered equally sensitive in the primary stage of disease. Syphilis Therapy: Goals 1. Cure of disease: improvement of clinical signs and symptoms; prevention of disease progression 2. Prevention of disease transmission 3. Reduction of risk for HIV acquisition 18

19 2009 CDC STD TREATMENT GUIDELINES Early Syphilis Recommended Benazthine Penicillin G, 2.4 Mu IM SYPHILIS THERAPY: RESPONSE TO THERAPY Primary or Secondary Syphilis Fourfold (2 dilution) or greater decline in RPR or VDRL titers by time of 3 month follow up Penicillin Allergy Doxycyline 100 mg PO, BID x 14d Limited Data Ceftriaxone 1.0 g IM or IV x 8 10d Partner Therapy Current CDC guidelines suggest that individuals (known contacts) who were exposed to syphilis within the 90 days preceding the diagnosis of primary, secondary or early latent syphilis in a sex partner be treated presumptively, even if the individual (known contact) is seronegative for syphilis. Sensitivity of Serological Tests in Untreated Syphilis Stage of Disease (Percent Positive [Range]) Diagnosis Test Primary Secondary Latent Tertiary VDRL 78 (74-87) (88-100) 71 (37-94) RPR 86 (77-99) (95-100) 73 FTA-ABS* 84 (70-100) Treponemal Agglutination* 76 (69-90) (97-100) 94 EIA *FTA-ABS and TP-PA are generally considered equally sensitive in the primary stage of disease. SYPHILIS THERAPY: RESPONSE TO THERAPY Titer Primary or Secondary Syphilis Fourfold (2 dilution) or greater decline in RPR or VDRL titers by time of 3 month follow up Early Latent Syphilis Fourfold (2 dilution) or greater decline in RPR or VDRL titers by time of 6 month follow up 1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 Two tube or fourfold dilution decrease 128/4 = 32 19

20 Common STIs 1. Mississippi 2. Louisiana 3. South Carolina 4. Alabama 5. Arkansas 6. Illinois 7. North Carolina 8. Michigan 9. Georgia 10. Ohio Gonorrhea (2009) CDC Surveillance Figures from 2010 (Gonorrhea) CDC Surveillance Figures from 2011 (Gonorrhea) 1. Mississippi 2. Louisiana 3. Alaska 4. South Carolina 5. Alabama 6. Arkansas 7. Georgia 8. North Carolina 9. Ohio 10. Michigan District of Columbia 1. Louisiana 2. Mississippi 3. Alabama 4. North Carolina 5. South Carolina 6. Georgia 7. Arkansas 8. Ohio 9. Alaska 10. Illinois Gonorrhea Rates by State, United States and Outlying Areas, 2011 Gonorrhea by sex and age 2011 NOTE: The total rate of gonorrhea for the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was 99.6 per 100,000 population. 20

21 Urethritis Cervicitis Proctitis Pharyngitis Prostatitis Other extragenital sites N. Gonorrhea Gonorrhea Antimicrobial resistance remains an important consideration. Overall, 28.1% of isolates collected by the Gonococcal Isolate Surveillance Project (GISP) were resistant to penicillin, tetracycline, or both. Ongoing data from CDC 's Gonococcal Isolate Surveillance Project (GISP) demonstrate that fluoroquinolone resistant gonorrhea is continuing to spread and is now widespread in the United States. As a consequence, and as reported in the MMWR, April 13, 2007, this class of antibiotics is no longer recommended for the treatment of gonorrhea in the United States. Gonorrhea Treatment For uncomplicated gonococcal infections of the cervix, urethra, and rectum, recommended treatments are ceftriaxone 250 mg in a single intramuscular (IM) dose plus Azithromycin 1g once or doxycycline 100mg BID for 7 days Gram Stain Nucleic Acid Amplification Test (NAAT) endocervical swabs, male/female urethral swabs, urine * if laboratory is validated, testing other sites such as rectum and pharyngeal may be performed Laboratory Testing Gonococcal Urethritis N. Gonorrhea Culture: plate immediately (bedside)(thayer Martin), refrigerate. Gram stain Diagnostic in symptomatic males. 21

22 Laboratory Testing Site of Infection is Important NAAT urine specimen both men and women (first void portion, do not urinate for 1 hour prior to test) 30 cc max Gonococcal Conjunctivitis Disseminated Gonococcus Ceftriaxone 1g IM in a single dose, and lavage the infected eye with saline solution once. Refer to an ophthalmologist. 1. Mississippi 2. Alaska 3. Louisiana 4. South Carolina 5. Alabama 6. Delaware 7. Arkansas 8. New Mexico 9. Tennessee 10. New York Chlamydia 2009 CDC Surveillance Figures from 2010 (Chlamydia) 1. Alaska 2. Mississippi 3. Louisiana 4. New Mexico 5. South Carolina 6. Alabama 7. Arkansas 8. New York 9. Delaware 10. Michigan 22

23 CDC Surveillance Figures from 2011 (Chlamydia) Chlamydia Rates by State, United States and Outlying Areas, 2011 District of Columbia 1. Alaska 2. Mississippi 3. Louisiana 4. South Carolina 5. Alabama 6. North Carolina 7. Georgia 8. New Mexico 9. Arkansas 10. New York NOTE: The total rate of chlamydia for the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was per 100,000 population. Chlamydia trachomatis The most frequently reported STD in the U.S. 75% of women and 50% of men have no symptoms. The majority of cases therefore go undiagnosed and unreported. Chlamydia CDC estimates that more than 3 million new cases occur each year. Overall rate reported was four times higher in women than men. The lower rates among men suggest that many of the sex partners of women with chlamydia are not diagnosed or reported. As many as 1 in 10 adolescent girls tested for chlamydia is infected. CDC fact sheet y.o. represent 46% of infections; y.o. represent 33% of infections. Chlamydia Chlamydia may be one of the most dangerous sexually transmitted diseases among women today. Up to 40% of women with untreated chlamydia will develop pelvic inflammatory disease (PID) and 1 in 5 women with PID becomes infertile. Women infected with chlamydia are 3 5 times more likely to become infected with HIV, if exposed. NAAT * Aptima Test endocervical swabs, male urethral swabs, urine Improved sensitivity when compared to the antigen detection (GenProbe) Laboratory Testing 23

24 Laboratory Testing Chlamydia Conjunctivitis NAAT *Aptima Test urine specimen both men and women (first void portion, do not urinate for 1 hour prior to test) 30 cc max Treatment Azithromycin 1 gram orally (once) or Doxycycline 100mg orally BID for 7 days Non gonococcal Urethritis Etiologies (common) Chlamydia Mycoplasma hominis Ureplasma Mycoplasma genitalium Treatment: Azithromycin 1 g (once) or Doxycycline 100mg BID for 7 days. New guidelines Mycoplasma genitalium is believed to produce symptoms of urethritis and urethral inflammation and account for 15 25% of NGU cases in the U.S. and possibly some cases of cervicitis. While azithromycin and doxycycline are effective for chlamydial urethritis and cervicitis treatment, it should be noted that M. genitalium responds better to azithromycin. Bacterial Vaginosis Yeast Trichomonas Vaginitis 24

25 Yeast Clue Cells seen in B.V. TRICHOMONIASIS Trichomoniasis is the most common curable STD in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men (CDC 2007) Symptoms include: vaginal discharge, pruritis in females but may be asymptomatic. (Males usually asymptomatic, but can cause NGU) TRICHOMONAS WET PREP TRICHOMONAS PAP SMEAR 25

26 OSOM Test Stick TRICHOMONIASIS TREATMENT Metronidazole or tinidazole 2 gm orally, single dose; treat partners The OSOM Trichomonas Rapid Test is an immunochromatographic assay that detects pathogen antigens directly from vaginal swabs. Results are rapid, occurring within approximately 10 minutes. The only CLIA-waived rapid test identified by the CDC and ACOG for the detection of Trichomonas Vaginalis. Positive test result A blue Test Line and a red Control Line is a positive result for the detection of Trichomonas antigen. Alternative Regimen Metronidazole 500 mg orally twice a day for 7 days Questions? Patricia R Jennings DrPH, PA C Professor, UAB rd Ave South Birmingham, Alabama E mail: pjennings@uab.edu 26