Module 4: Final Case Study # 4-CS-1

Case Study: Instructions v Try this case study individually. v We’ll discuss the answers in class. # 4-CS-2

Answers to Final Case Study Question 1 1.What are the benefits of conducting STI surveillance in: a.A country with a low-level HIV epidemic? In countries with a low-level HIV epidemic, STI surveillance can act as an early warning system for HIV infection and emergence of HIV in new groups or new geographical areas. STI surveillance can also be used as an evaluation tool for HIV prevention programmes # 4-CS-3

Answers to Final Case Study Question 1, continued 1.What are the benefits of conducting STI surveillance in: b.A country with a concentrated HIV epidemic? In a concentrated HIV epidemic, the presence of STIs can serve as a marker for the emergence of HIV in new groups. STI surveillance can also measure how successful prevention programmes have been in high-risk populations. # 4-CS-4

Answers to Final Case Study Question 1, continued 1.What are the benefits of conducting STI surveillance in: c.A country with a generalised HIV epidemic? In generalized HIV epidemics, STI surveillance can help to measure how successful prevention programmes have been in the general population. # 4-CS-5

Answers to Final Case Study Question 2 2. You are a public health officer for Inyo Province in the Mono Republic. Your province currently conducts syndromic STI surveillance with universal reporting. Your province has recently been given funds to begin aetiologic case reporting to determine the prevalence of the micro-organisms that cause urethral discharge and genital ulcer. # 4-CS-6

Answers to Final Case Study Question 2, continued a.Which micro-organisms would you include to determine the causative agent of genital ulcer disease in men and women? syphilis, chancroid and HSV-2 b.Which micro-organisms would you monitor to determine the most common causes of urethral discharge in men? Gonorrhoea and chlamydia c.How frequently should STI aetiologies be assess? Syndrome aetiologies should be assessed every two to three years or more frequently if the need arises. # 4-CS-7

Answers to Final Case Study Question 3 3.Looking at last years surveillance data for Inyo Province you find that many of the variables indicated on the data collection forms were left blank and that there were many inconsistencies in the way data was collected. How would you improve the completeness and consistency of reporting? You must establish processes to ensure that data collection and reporting is as complete and consistent as possible. At the health facility level, data should be double-entered to avoid errors and must be carefully checked before analysis. A frequency tabulation can be run after data are entered to re-check for implausible values. You should follow up with any health facility site that has missing or inconsistent data. Do this before forwarding the forms to the regional or national level. When the district level carefully reviews facility forms, the quality of data received at the national level is high. # 4-CS-8

Answers to Final Case Study Question 4 4.Due to sub-optimal prescribing practices and poor adherence to prescribed regimens, resistance to the drugs that treat N. gonorrhoeae has recently become a problem in Inyo province. # 4-CS-9

Answers to Final Case Study Question 4, continued a.What are the laboratory requirements of monitoring anti-microbial resistance? Surveillance surveys for anti-microbial resistance of STI pathogens are usually organised and conducted by the national AIDS/STI control programme. The laboratory should have the facilities necessary to culture the organism, perform biochemical and serologic confirmatory tests and perform minimum inhibitory concentration (MIC) agar dilution testing of anti-microbial agents. # 4-CS-10

Answers to Final Case Study Question 4, continued b.If your country’s national reference laboratory does not have the capacity to conduct susceptibility testing, what would you do? You may send isolates to a regional laboratory in another country for testing. Regional networks supported by WHO Collaborating Centres have been established in several WHO regions to conduct anti-microbial susceptibility testing. #4-CS-11

Answers to Final Case Study Question 4, continued # 4-CS-12 c.How often would you review the results of resistance testing? Results of resistance testing should be reviewed each quarter to ensure that data are complete and that patterns are generally consistent from quarter to quarter.

Answers to Final Case Study Question 4, continued d.What information would you include when nationally distributing data on anti-microbial resistance? How frequently would you distribute this data? Reports should summarise the proportion of isolates that were found to be resistant to the anti-microbial agents and should be stratified by sentinel site. It may also be useful to summarise the proportion of isolates that were of intermediate sensitivity. Reports should include: the gender of patients, the clinic setting where the patients were tested and changes that have occurred in the sentinel sites over time. Reports should be distributed nationally at least once a year. New resistant strains should be reported as soon as possible to a WHO Collaborating Centre. # 4-CS-13

Answers to Final Case Study Question 5 5.Syndromic STI surveillance in Inyo Province conducted in 2005 found the following data: Site 1Site 2Site 3Site 4Site 5 Total number tested Prevalence of: Genital ulcer disease 11%16%22%8%13% Urethral discharge (among men only) 26%21%29%14%18% HIV 7%5%12%2%3% # 4-CS-14

Answers to Final Case Study Question 5, continued # 4-CS-15 A figure that shows the prevalence of genital ulcer disease, urethral discharge and HIV in Inyo Province by site.

Answers to Final Case Study Question 5, continued At all sentinel sites, the prevalence of urethral discharge among men was higher than that of genital ulcer disease or HIV among men and women. Whereas, site 4 had the lowest prevalence of genital ulcer disease (8%), urethral discharge (14%) and HIV (2%), site 3 had the highest prevalence of genital ulcer disease (22%), urethral discharge (29%) and HIV (12%). The limitations of this data include: Only one year of data was presented; the sample size at each site was small; surveillance assess STI syndromes opposed to STI aetiologies. # 4-CS-16

Questions, Process Check v Do you have any questions on the information we just covered? v Are you happy with how we worked on the final case study? v Do you want to try something different that will help the group? # 4-CS-17