What do u know about STis? Rattiya Techakajornkeart MD. Bangrak institute, Bureau of AIDS, TB and STIs, Department of Disease Control, MOPH, Thailand

Thailand STIs situation

Reported total cases of STIs per 100,000 population by disease,Thailand,2010-2015 (B.E.2553-2558) 23.24 Median 20.65 2553 2554 2555 2556 2557 2558

Reported total cases of STIs per 100,000 population by disease,Thailand,2010-2015 (B.E.2553-2558) Now a day increasing of STIs 2553 2554 2555 2556 2557 2558

โรคหนองใน และ ซิฟิลิส ประเทศไทย ปี 2553-2558 จำแนกตามอายุ 15-24 25-34 35-44

โรคหนองใน และ ซิฟิลิส ประเทศไทย ปี 2553-2558 จำแนกตามอาชีพ รับจ้าง นักเรียน

Sexually transmitted infections?

STIs Infections are commonly spread by sex, especially vaginal intercourse, anal sex , neovagina intercourse, oral sex and skin- to skin contact. Most STIs initially do not cause symptoms.

STD VS STIs

STD STIs The infections are commonly /have a high probability of being spread from person to person through sexual contact. the infections may not cause any symptoms. Silent epidemic

SEX?

STD VS HIV infection they're three to five times more likely than individuals without STDs to transmit HIV during sexual activity.

Is Condom safe to avoid all STD ?

No Not 100% Better than nothing. Condom prevents direct skin to skin contact. Genital areas not covered by condoms may still be infected e.g. herpes, condyloma. Condom ≠ safe sex Condom = safer sex

Condoms

Female condom and oral dam Anal sex can use famale condom.

Can we use male and female condom together?

Causes?

Causes of STIs More than 30 different bacteria, viruses, and parasites can cause STis. Bacteria chlamydia, gonorrhea, and syphilis Virus e.g. herpes, HIV/AIDS, and genital warts Parasite e.g. trichomoniasis

STIs Syphilis Gonorrhea Non-gonoccocal urethritis Chancroid LGV Herpes Trichomoniasis Wart

Syphilis

Caused :Treponema pallidum A Gram-negative, thin, motile, spiral shaped bacterium in the order Spirochaetales. Incubation period ~3 wk ( 10–90 days )

Caused :Treponema pallidum A Gram-negative, thin, motile, spiral shaped bacterium in the order Spirochaetales. Incubation period ~3 wk ( 10–90 days ) Transmission mode 1. Sexual contact with infected lesion or body fluid (most common) 2. Tranplacenta (less common) 3. Blood tranfusion (rare) 4. Accidental inoculation (rare)

Manifestations of syphilis Syphilis has 3 distinct stages Primary syphilis Secondary syphilis Latent stages Early latent syphilis Late latent syphilis Tertiary Syphilis

Primary syphilis Principal lesion = Hard chancre ( Hard chancre and regional lymphadenitis ) Principal lesion = Hard chancre o Syphilitic chancres are indurated o Painless o Highly infectious o Occur anywhere on the body o Heal in 3-6 weeks.

Secondary syphilis Mucous patches Patchy alopecia Begin 6-8 weeks after the appearance of the initial chancre - There is a high bacteremia during secondary syphilis Mucous patches Patchy alopecia

Secondary syphilis

Same ?

Latent syphilis - Detectable by abnormal serologic test results - Asymtomatic Definition: persons with serological evidence for syphilis who have never received treatment for this disease and who have no clinical manifestations are said to have latent syphilis.

Latent syphilis Early latent syphilis ( infection onset ≤ 1 yr.) Late latent syphilis ( infection onset ≥ 1 yr. or unknown duration) 1/3 slowly progress to 3 ° syphilis The rest remain asymptomatic

Tertiary syphilis 1 - 20 years from the acute infection to clinical onset of the late or tertiary stages of disease. In the preantibiotic era, about one-third of untreated infections were followed by tertiary syphilis. In the antibiotic era, all but neurosyphilis are now curiosities in the developed world, probably because of the effects of intermittent antibiotics on the development of gummas and cardiovascular disease.

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Serology 1. Nontreponemal test : Use for screening and to follow therapeutic response - VDRL(Venereal disease research laboratory) - RPR (rapid plasma reagin)

Serology 1. Nontreponemal test : Use for screening and to follow therapeutic response - VDRL(Venereal disease research laboratory) - RPR (rapid plasma reagin) 2. Treponemal tests : Use to confirm reactive nontreponemal test result - FTA-ABS (Fluorescent treponemal antibody absorption) - TPHA (Treponema pallidum haemagglutination) - CIA (Chemiluminescence immunoassays)

Peeling, R. W., & Ye, H. (2004). Diagnostic tools for preventing and managing maternal and congenital syphilis: an overview.  Bulletin of the World Health Organization, 82(6), 439-446

- + +/- Contact Primary ( Chancre ) Secondary Early latent Late latent VDRL/ RPR FTA - ABS TPH A - + +/- Contact 3 wk. ( 10 – 90 d) Primary ( Chancre ) 3 – 12 wk Secondary 4 – 12 wk Early latent ( 1 yr from contact ) Late latent (≥ 1 yr ) Remission ( 2/3) Tertiary ( 1/3 )

Interpretation of Different Serological Tests in Syphilis Nontreponemal tests Treponemal tests Interpretation + - Syphilis

Benzathine penicillin G 2.4 mu IM Treatment Contact 3 wk. ( 10 – 90 d) Primary ( Chancre ) 3 – 12 wk Early syphilis Secondary 4 – 12 wk Early latent ( 1 yr from contact ) Benzathine penicillin G 2.4 mu IM Late latent (≥ 1 yr ) Late Syphilis Remission ( 2/3) Tertiary ( 1/3 ) Penicillin allergy:

Treatment failure in syphilis New clinical symptom Titers rise 4-fold Titers do not decrease 4-fold

Special conditions Pregnancy HIV infection Benzathine penicillin G If penicillin allergy : HIV infection

Follow up F/U VDRL/RPR: 3,6,12,24 m F/U VDRL/RPR (HIV infection): 3,6,9,12,24 m

Gonorrhea

Male Genitalia

Female Genitalia Asymptomatic Leucorrhea (some) PID

Pharyngeal Gonorrhea Relatively common Asymptomatic Reservoir for infection

Rectal Gonorrhea It is a frequent site of infection in receptive anal intercourse.

proctitis Many rectal infections are asymptomatic. The symptoms of rectal gonococcal infection Minimal anal pruritus Painless mucopurulent discharge (often manifested only by a coating of stools with exudate) Scant rectal bleeding Proctitis (severe rectal pain, tenesmus, and constipation) proctitis

Gonorrhea conjuctivitis conjunctivitis

Cause : Neisseria gonorrhoeae Gram stain : Gram-Negative intracellular diplococci OR Culture : Neisseria gonorrhoeae positive

Uncomplicated urogenital, anorectal gonorrhea Ceftriaxone 250 mg IM Azithromycin 1 gm or Doxycycline(100)1*2 for 14 days Avoid sex at least for 1 week following treatment.

Treatment of Pharyngeal Gonorrhea Ceftriaxone 250 mg IM and Azithromycin 1 gm Providers should ask their patients with urogenital or rectal GC about oral sexual exposure Sex partener Antimicrob. Agents Chemother. 2012, 56(7):4039.

Non-gonococcal urethritis

Male NGU

Female NGU Mucopurulent discharge

Proctitis and Conjunctivitis

Cause : Not Neisseria gonorrhoeae Other organism not gonorrhea - Chlamydia trachomatis (50%) - Ureaplasma urealyticum (10-40%) - Mycoplasma genitalium (15-20%) - Haemophilus vaginalis - etc.

INVESTIGATIONS Gram stain (urethral) : WBC ≥ 5 cells/oil field OR Mucopurulent discharge from cervix OR Culture : Chlamydia positive

Treatments Azithromycin 1 gm OR Doxycycline (100) 1*2 pc 14 d Avoid sex at least for 1 week following treatment.

WArt

Wart HPV type 6,11,16,18 Treatment 80-100%TCA 25% Podophyllin 5% Imiquimod Electrocuatery

Don’t forget Sex partner(s) (60d) Avoid sex during treatment Avoid alcohol when take doxycycline Education Follow up