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SEXUALLY TRANSMITTED DISEASE NORTHERN IRELAND. WALLACE DINSMORE. Aims of this presentation;. Trends in Sexually Transmitted Infections To outline a basic description of the most common sexually acquired infections To identify the pathogenesis and progression Commonly used treatments.

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Aims of this presentation
Aims of this presentation;

  • Trends in Sexually Transmitted Infections

  • To outline a basic description of the most common sexually acquired infections

  • To identify the pathogenesis and progression

  • Commonly used treatments


Definition
Definition

“Sexually transmitted infections are infections whose primary route of transmission is through sexual contact and can be caused by bacteria, viruses or protozoa”

Adler et al (2004)


Regional trends
Regional Trends

  • Northern Ireland has seen an increase in the diagnosis of HIV, chlamydia, gonorrhoea, syphilis, genital herpes and genital warts.

  • Rates of infection are generally highest in the 20-24 year old age group.

  • Men who sleep with men are at a higher risk of contracting syphilis, gonorrhoea and HIV.


A public health challenge
A Public Health Challenge

  • STI diagnoses and other GUM workload more than doubled in the five years to 2011.

  • Syphilis diagnoses increased by 23% in one year (2011).

  • More than 750,000 cases of STI were diagnosed in GUM clinics in 2011

  • The number of people receiving care for HIV doubled in the five years to 2011

  • A third of HIV infections in the UK are undiagnosed.

  • Over one in ten young people screened for Chlamydia test positive


Surveillance data for sexually transmitted infections in Northern Ireland is provided by a statuartory KC60 each quarter from GUM clinics


Number of sti diagnoses and workload at gum clinics by country 1990 2005
Number of STI diagnoses and workload at GUM clinics by country: 1990 – 2005*

* Data are unavailable for Northern Ireland in 1990 Data source: KC60 statutory returns and ISD(D)5 data.


Number of new diagnoses of selected stis gum clinics united kingdom 2010
Number of new diagnoses of selected STIs, GUM clinics, United Kingdom: 2010

Data source: KC60 statutory returns and ISD(D)5 data.


Bacterial infections
Bacterial Infections United Kingdom: 2010

  • Chlamydia

  • Lymphogranuloma Venereum

  • Gonorrhea

  • Syphilis


  • Incubation period preceding symptomatic infection can range from 7 – 21 days.

  • Asymptomatic infection can persist for long periods;

    Up to 50% men Asymptomatic

    Up to 70% women Asymptomatic

  • . Prevalence is highest in teenage women and in men in their early 20s. Prevalence reduces with age in both sexes, probably partially due to the development of immunity.


Sites of infection
Sites of Infection from 7 – 21 days.

  • Male Urethra – found in 2-15% of GUM attendees. It is the cause of 20-50% of Non Gonococcal Urethritis (NGU) or more commonly Non Specific Urethritis (NSU).

  • Symptoms – commonly dysuria, urethral discharge, occasionally oedema & erythema of urethral meatus

  • Complications - epididymo-orchitis, reactive arthritis.


The cost of chlamydia
The Cost of Chlamydia from 7 – 21 days.

Chlamydia and complications resulting from untreated Chlamydia, such as pelvic inflammatory disease, ectopic pregnancy and infertility cost the NHS in NI £2 million p.a.

Throughout the UK costs are estimated at £100 million p.a.


Gonorrhoea
Gonorrhoea from 7 – 21 days.

  • Caused by a bacterium Nisseria gonorrhoea

    - a gram negative diplococcus (arranged in pairs) sometimes referred to a ‘clap’ ‘drip’

  • Non motile and non spore forming and red under microscope when Gram stained


Gonorrhoea1
Gonorrhoea from 7 – 21 days.

  • Diagnostic rates in NI remain the lowest in the UK.

  • An increase of 7% in 2011 at GUM clinics.

  • 84% of these were males.

  • The highest risk group were 20-24 year olds, both male and females.

  • Males were 3 times higher than females.

  • 24% were MSM.


Sites of infection1
Sites of Infection from 7 – 21 days.

Men -

  • Urethral discharge may be profuse, creamy yellow and purulent oozing from the urinary meatus

  • Throat/rectum (autoinoculation)

  • Conjunctiva less common

    Symptoms;

  • Dysuria Pain - likened to ‘passing a razor blade’

  • Reddened meatus and enlarged lymph nodes and sometimes tender

  • Anal discharge, discomfort, rectal bleeding, tenesmus & constipation.

    Complications

  • Can spread to epididymis and prostate, cellulitis, abcess, strictures


Women - from 7 – 21 days.

  • May be asymptomatic

  • Sometimes associated with other infections i.e. trichomonas vaginalis or bacterial vaginosis

  • Commonly infected sites: cervix, urethera, - - rectum and oropharynx depending on sexual practices

    Complications;

  • Bartholin’s Abcess

  • Pelvic Inflammatory Disease (PID)

  • Premature labour / vertical transmission to neonate


Treatment
Treatment from 7 – 21 days.

Recommended Treatment

  • Cefixime 400mg stat

  • Ceftriaxone 500mg IM


Syphilis
Syphilis from 7 – 21 days.

  • A multistage systemic disease.

  • A bacterial infection caused by the spirochaete Treponema Pallidum

  • Under a microscope the spirochaete is corkscrew shaped with 6-18 spirals

  • The incubation period is stated as 6-90 days


Stages of disease process
Stages of disease process from 7 – 21 days.

Primary Syphilis

Early (Infectious)

Secondary Syphilis

Early latent Syphilis

Late (low level infectivity)

Late latent Syphilis

Tertiary Syphilis


  • Primary Syphilis – from 7 – 21 days.The chancre, a painless, usually solitary ulcer appears 9-90 days after sexual contact at the site of initial infection.

  • Secondary Syphilis– Approx 90% present with a rash, it is generalized with the trunk being affected in 80% and the palms and soles in 50%. 75% also have lymphadenopathy. Other clinical manifestations include mouth ulcers, patchy alopecia, meningitis and hepatitis. These features are caused by a systemic vasculitis caused by high levels of treponema in the blood and associated immunological response.


Sites of primary syphilis
Sites of primary syphilis from 7 – 21 days.

  • EXTRAGENITAL

  • Lip

  • Tongue

  • Mouth, tonsil, pharynx

  • Fingers

  • Eyelid

  • Nipple

  • Any pat of the skin or mucous membranes.

GENITAL

  • Shaft of Penis

  • Coronal sulcus

  • Glans Penis

  • Prepuce

  • Urethral Meatus

  • Anal Margin and Canal

  • Rectum

  • Labia minora, labia majora

  • Fourchette

  • Clitoris

  • Vaginal Wall

  • Cervix



Transmission
Transmission serology up to 2 years.

  • Sexual contact

  • Previously blood transfusion (now blood tested)

  • Mother to foetus via placenta or during birth

  • Not contracted from toilet seats, swimming pools or saunas


Testing
Testing serology up to 2 years.

  • Serological testing (Preferred choice)

  • Treponema pallidum enzyme immunoassay (EIA) is recommended as it tends to be more sensitive in primary infection.

  • Direct detection of T.pallidum in primary and secondary syphilis. Dark ground microscopy. (ltd to specialist areas, not suitable for oral lesions)

  • Lymph node aspiration

  • Follow up monitoring at 3, 6 and 12 months.


Treatment1
Treatment serology up to 2 years.

Early Syphilis

  • Procaine Penicillin G (IM) 600-750mg daily 10 days

  • Benzathine Penicillin 2.4g IM twice, a week apart.

  • Doxycycline 100mg bd 14 days

    Latent Syphilis

  • Procaine penicillin G (IM) 600-750mg daily 17 days

  • Benzathine Penicillin 2.4g IM x3, a week apart.

  • Doxycycline 200mg bd 28 days

  • Neurosyphilis – specialist care.


Statistics
Statistics serology up to 2 years.

  • Between 2001-2011 there has been a 1954% increase in diagnosis of infectious syphilis.

  • Since the outbreak in 2001 – 2011, 4090 cases.

  • In 2011 829 new cases 68% among msm.


Diagnoses of infectious syphilis (primary, secondary and early latent) by sex and sexual orientation, London enhanced syphilis surveillance: April 2001 - December 2011

Data source: London Enhanced Syphilis Surveillance


Viral infections
Viral Infections early latent) by sex and sexual orientation, London enhanced syphilis surveillance: April 2001 - December 2011

  • Genital Warts

  • Herpes

  • HIV


Genital warts hpv
Genital Warts/ HPV early latent) by sex and sexual orientation, London enhanced syphilis surveillance: April 2001 - December 2011

  • Caused by human papilloma virus (HPV) 90 different types of HPV, approx 30 types associated with genital infection, Approx. 90% are types 6 and 11.

  • Acquired through sexual contact, skin-to-skin contact and thought also to be from sharing of sex toys

  • The virus enters the skin through normal friction of skin-to-skin rubbing during sex or close physical contact

  • Infectivity is thought to be approximately 60% with an incubation period of 2-8 months (Adler 1995)

  • Only a small proportion of infected patients develop macroscopic genital warts, the remainder go undetected.

  • Once in the epithelium it proliferates causing a wart formation


Genital warts
Genital Warts early latent) by sex and sexual orientation, London enhanced syphilis surveillance: April 2001 - December 2011

  • 2941 episodes of 1st diagnosis at GUM clinics in NI.

  • 54% were males.

  • 73% were first infection.

  • Highest risk group, 20-24 year olds.

  • Females 16-19 years old were twice as susceptible to infection than males of the same age. However, over 19 years old, the rate is higher in males.

  • 2% of diagnosis occurred in MSM.


Herpes
HERPES early latent) by sex and sexual orientation, London enhanced syphilis surveillance: April 2001 - December 2011

  • Caused by Herpes simplex virus

  • There are 2 types - HSV 1

    - HSV 2

  • HSV 1 associated with both oropharyngeal & genital disease, increasing in incidence. Type 1 has fewer symptomatic recurrences and less subclinical shedding.

  • HSV 2 associated with genital disease.

  • Incubation 3-14 days


Genital herpes
Genital Herpes early latent) by sex and sexual orientation, London enhanced syphilis surveillance: April 2001 - December 2011

  • 2011: 418 episodes of 1st and recurrent infection diagnosed at GUM clinics in NI.

  • 268 were females.

  • 66% were 1st attacks.

  • 39% were males.

  • Females aged between 20-24 are 3 times more at risk than males.

  • 5 diagnosis were made in MSM.


HIV early latent) by sex and sexual orientation, London enhanced syphilis surveillance: April 2001 - December 2011

  • What does HIV mean?

  • Human

  • Immunodeficiency

  • Virus

  • What is HIV?

  • Virus attacks the immune system and slowly destroys it.

  • Infected/infectious for life.

  • May be no obvious symptoms and you may look and feel well.

  • Could be signs of immune damage detectable by blood tests.


HIV attacks the immune system. early latent) by sex and sexual orientation, London enhanced syphilis surveillance: April 2001 - December 2011

  • A healthy immune system can fight off infection easily.

  • A weakened immune system does not offer much protection and the person will become ill.


Hiv transmission

3 main routes of transmission. early latent) by sex and sexual orientation, London enhanced syphilis surveillance: April 2001 - December 2011

1. Unprotected sex with an

infected partner.

2. Infected blood getting into someone else’s bloodstream (trauma, IVDU).

3. From infected mother to baby.

HIV Transmission.


Hiv test

Simple blood test (antibody). early latent) by sex and sexual orientation, London enhanced syphilis surveillance: April 2001 - December 2011

GUM Clinic or GP.

Positive = infected and infectious.

Negative may not mean negative.

Window period (12 weeks since possible exposure risk)

Pre and post test discussions.

HIV Test.


N ireland statistics

Approximately 700 people have been tested positive with HIV/AIDS in Northern Ireland.

In 2011 there were 106 registrations

N Ireland Statistics.


Thank you

THANK YOU HIV/AIDS in Northern Ireland.


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