Sexual Transmitted Diseases Dr. Asad Ramlawi DGPHC

What are the consequence & complications of STD? Infants infected at birth with blinding eye infections or pneumonia Women suffering chronic abdominal pain or infertility Men with infertility. After the initial infection, STD as syphilis & AIDS,kill infants & adults alike. Indirectly,STD, kill through spontaneous abortion, ectopic pregnancy, & cervical cancer.

Distribution of the STD by age Most children below 14 years of age are free from infection other than for congenital syphilis, ophthalmia neonatorum & HIV- infection. Between the ages of 14 & 19 years cases occur more commonly among females. This reflects the fact that the start of sexual activity is earlier for girls than for boys

The rate of sexual activity of risk tends to be highest in the age group, reducing in later ages. This is clearly reflected in the table for gonorrhoea, as it is for other STD

What social & economic factors may influence high- risk behavior? 1.Occupation prostitutes & their clients run the highest risk of becoming infected. STD also occur commonly among long distance truck drivers, uniformed service persons & migrate laborers. 2.War political instability & insecurity influence sexual behavior & the rates of STD 3.Circumcision, the foreskin in uncircumcised males may increase the risk of AIDS 4.Gender STD are primarily transmitted to women through vaginal intercourse. It is increased for women who have poor general health & suffer from genital legions, inflammation secretion.

5- Age genital immaturity facilitate transmission during sexual intercourse. Young women are specially at risk in cultures where they marry or become sexually active during their early teenage years. 6-In addition, young people tend to practice risky sexual behavior, so being most at risk of STD

Biological & social factors that influence transmission Having more than one sexual partner Change sex partners often Having sex with casual partners, Sexual practices as anal sex

Social factors Failure to follow safe sex measures, as using condoms. Delay in getting STD treatment Failure to bring in sexual partners for treatment Not taking the full prescribed treatment for STD.

# both men & women may suffer from a symptomatic STD but women more so than men, - 70 % of women & 30% of men infected with chlamydia may be a symptomatic. - 30% of women & 5% of men infected with gonorrhoea may also be asymptomatic # clinics offering treatment for STD may not be accessible to many of the population # many people with STD do not seek care,& in developing countries people are not routinely screened for STD when they seek other health care.

STD patients avoid the public sector clinics due to the following reasons : # The subject of sex is a taboo & a lot of stigma is attached to STD, hence many STD patients try to hide the occurrence of STD & avoid seeking treatment especially from the public sector, delay treatment, or take self – treatment

# The public sector clinics are usually crowded and lack privacy & confidentiality. # There is usually an inadequate supply of drugs & condom which serves as disincentive to the patients for seeking care # A number of health care providers are moralistic & judgmental ?& their attitudes discourage the STD patients from seeking care.

# Services in general may be more accessible to men than women, for example,where men migrate to urban areas for employment # Sexually transmissible infections after produce no symptoms or only mild symptoms in women, so fewer women come forward for treatment and appear in statistics. # As we have discussed before, cultural constraints as shame might also prevent a proportion of women from attending for treatment

The recommended treatment for the syndromes Syndrome Treat for Urethral discharge Gonorrhea, Chlamydia Vaginal discharge gonorrhea,chlamydia, vaginitis Genital ulcer Syphilis, Chancroid Lower abdominal pain Pelvic inflammatory disease Scrotal swelling Gonorrhea, Chlamydia Inguinal bubo Lymphogranuloma venerium Neonatal conjunctivitis First for Gonorrhea & if not cured,then for chlamydia

Urethral Discharge A patient complaining of urethral discharge From the penis Examine milk urethral If necessary Discharge confirmed Ulcer present -Educate -Counsel if needed -Promote/ provide condoms Treat for Gonorrhea & Chlamydia Educate Counsel if needed Partner management Return if necessary Use appropriate flow chart No Yes

An ulcer is a break in the continuity of the skin or mucous membrane surface. In men look at external genitalia “ not forgoting the inner surface of the foreskin & the parts normally covered by the foreskin. In women examine the skin of the external genitalia and then separate the labia and look at the mucous surface for ulcers.

Vaginal Discharge A patient complaining of vaginal discharge Risk assessment Positive ? -Educate -Treat for vaginal Only Counsel if needed -Promote/ provide condoms Treat for cervicitis & vaginitis Educate Counsel if needed Partner management Return if necessary No Yes

Women develop a symptom of vaginal discharge if they have vaginitis or cervicitis & also if they have endometrrial infection & pelvic inflammatory disease. A vaginal discharge is considered as normal or physiologic during & after sexual activity, before, during & after menstrual period & during pregnancy & lactation. The causes of vaginitis are T. vaginalis ( trichomoniasis ), candidacies, bacterial vaginosis.

The causes of cervicitis include gonorroea & C.Trachomatis. There are NO Rapid test to differentiate between Vaginitis & Cervicitis Symptom of vaginal discharge is nither sensitive nor specific for vaginitis or cervicitis

The risk factors for cervicitis in women presenting with vaginal discharge Partner has urethral discharge / genital ulcer Patient is aged less than 21 years Patient is not married Patient has had sex with more than one person in the preceding three months Patient has had sex with a new partner in the preceding three months

Risk assessment positive Does your partner have a urethral discharge or sore in the penis ? Are you less than 21 years old ? Are you single? Do you have more than one partner ? Have you had a new partner during the last three months? If the patient answer yes to the first question or to any two of the other 4 questions, the risk is positive, if not the risk is negative

Treat for vaginitis ( also include treatment for trichomonisis, candidiasis, & bacterial vaginosis ) -Metronadazole 2 g as a single oral dose - Metronidazole 400mg orally twice daily for 7 days. Treatment for both trichomoniasis & bacterial vaginosis -Meronidazole NOT use in the first trimester of pregnancy. -Nystatin units intravaginally daily for 14 days use for vaginal candidiasis

Metronidazol /clotrimazole 200mg may be inserted into vagina daily for 3 days Clotrimazole 500mg is inserted to the vagina once only

For the treatment for gonococcal cervicitis give Ciprofloxacin 500 mg in a single oral in a single oral dose For the same effective drugs : Ceftriaxone 250 mg single IM dose Cefixime 400 mg single oral dose Spectinomycin 2g single IM dose Kanamycin 2g single IM dose Trimethoprim 800mg /sulphamethoxazole 4 g orally daily for 3 days

Treatment for gonorrhoea Ciprofloxacin 500 mg single oral dose Ceftriaxone 250 mg single IM dose Cefixime 400 mg single oral dose Spectinomycin 2 g single IM dose Kanamycin 2g single IM dose Trimethoprim 800 mg/ sulphamethoxazole 4 g orally daily for 3 days

Treatment for chlamydia Doxycycline 100 mg orally twice for 7 days Alternatively use : Tetracycline 500mg orally 4 times a day for 7 days Erythromycin 500 mg orally 4 times a day for 7 days Sulfisoxazole 500 mg orally 4 times a day for 10 days

Treatment for anaerobic bacteria Metronidazole 400 mg orally twice a day for 10 days # Note : Metronidazole should not be used in the first trimester of pregnancy. Also ciprofloxacin, doxycycline & tetracycline should not be used during pregnancy & during lactation

Treatment for Gonorrhoea Ciprofloxacin 500 mg single oral dose Ceftriaxone 250 mg single IM dose Cefixime 400 mg single oral dose Spectinomycin 2 g single IM dose Kanamycin 2g single IM dose Trimethoprim 800 mg/ sulphamethoxazole 4 g orally daily for 3 days

Treatment for chlamydia Doxycycline 100 mg orally twice for 7 days Alternatively use : Tetracycline 500mg orally 4 times a day for 7 days Erythromycin 500 mg orally 4 times a day for 7 days Sulfisoxazole 500 mg orally 4 times a day for 10 days Note: Ciprofloxacin, doxycycline, & tetracycline should not be used in lactation women.

Trichomoniasis

Study design: - The design used in this study is a descriptive design. This survey aimed at reaching an estimation of magnitude ( Prevalence ) of Trichomoniasis & Candidiasis in Palestine [ West Bank & Gaza]

Study area & Targeted population This study conducted in governmental reproductive health clinics, in addition to UNRWA & private sector reproductive health clinics in Palestine [ West Bank & Gaza] All samples are collected by the physician of the clinic after getting women’s written consent on special form prepared for the purpose of this survey. This survey included urban & rural areas, in addition to Palestinian refugee camps.

Sample size The sample were collected from 2003 women of childbearing age from all districts in WB & Gaza. The number of samples was selected according to the estimated population in the year 2003.

Collection of data 1.Questionnaire & consent form design: A questionnaire & consent form were designed according to WHO recommendation for STDs & HIV, it included data elements for STI prevalence study, which are study site, date of specimen collection, sex, date of birth & all data needed for such a study investigation. 2.Women who agreed to participate in this survey provided the investigators by their name & signature on the consent form before starting the vaginal screening.

3.The sample was taken from posterior fornix of vagina [ WHO 1999] 4.Two vaginal swabs from each women were collected using sterile swabs containing Stuart media which is a transport media with charcoal in polypropylene test tube that maintain the viability of the organism for 24 hours 5.Litmus paper for pH testing,pH determined by placing it against the lateral vaginal wall. The color then compared to the colors & corresponding pH values on a standard chart. 6.Samples were collected daily by vehicles of the governmental public health department.

7. Ambulances were used to facilitate & ensure the proper arrival within the required time of the collected samples under proper conditions of sample collection. 8. Immediate action was taken by lab. staff even at night, upon the arrival of samples to ensure the viability of T. Vaginalis which is guaranteed for 24 hours only 9. Sample screening were planed to be conducted for five consecutive days by excluding the positive one. 10. The samples were collected from all women in childbearing age attending reproductive health clinics of MoH, ANRWA, & NGOs in addition to the other governmental & private hospitals.

Methods Upon the arrival of the swabs, an immediate inoculation of the swab into T. vaginalis media was conducted, then it was incubated at 37C for T. vaginalis mobility testing. Microscopically, after 24 hrs the confirmed positive results were conserved at – 72 C for further testing. The negative one was incubated again up to 5 consecutive days.

The second swabs were inoculated for yeast isolation for a period of 48hrs for growth monitoring. 0.5 ml of human plasma was added to the small amount of positive samples to have germ tube productions in order to microscopically distinguish C. albicans from other types of yeast. After obtaining the results, the data was analyzed by using SPSS program.

Introduction Genital trichomoniasis is STDs affecting male & female. Approximately, 180 million women worldwide may be infected with T.v. A frequency of 20% - 30% in sexual patterns of infected women has been reported. In women, it causes vaginitis, cervicitis, pelvic inflammatory disease & cystitis. In men, it causes urithritis & prostatitis.

Some times, T.v. causes no symptoms at all in either sex It is rarely reported in females before puberty & after menopause, but it is common in childbearing age & peaks during pregnancy. Men are commonly asymptomatic carriers. Symptoms may appear in chronic & acute forms

Symptoms In women: 1.Unusual & increased vaginal discharge ( bubbly, pale green, or gray) with an unpleasant odor. 2.Itching, burning, or redness of vulvae & vagina. In men: 1.Discharge from the penis. 2.Burning with urination.

Epidemiology & mode of transmission Among US women, race has been identified several studies as predictive of infection with T. vaginalis This association is probably multifactorial including access to care, personal health practices, & socio economic factors Older age, history of previous STI prostitutions, pregnancy, & drug users have also been associated with Tricomoniasis.

It is estimated that one in five sexually active women will be infected with T.v in their life time Transmission is mainly by physical contact as T. v can only survive outside the host for a short period of time. In US annually, 8 million women are infected with T. v. & the annual number worldwide is approximately 180 million Trichomoniasis facilitate spread of HIV epidemic. one theoretical calculation concludes that if infection with T. v. increased the risk of HIV transmission by 90% in a population with 25 % prevalence of Trichomoniasis.

Samples distribution Infection rate of Trichomoniasis by district in Palestine. PalestineNo. examinedNo. positive% positive West Bank % Gaza % Total %

West BankNo. examinedNo. positive% positive Jerusalem % Jericho % Bethlehem % Hebron % Tulkarem % Nablus % Qalqilia % Jenin % Salfeet35720 % Ramallah % Total %

GazaNo. examinedNo. positive% positive North % Gaza % Mid Zone % Khanyounos % Rafah % Total %

Age Distribution No. examinedNo. positive% positive **522.7 % 19 – % % 31 – % 36 – %  % Missing* % Total % Palestine *Missing : information is not available in questionnaire **insignificant value, ( if Dominator -#examined-less than 30 or the Nominator -# positive less than 5 Infection rate of Trichomoniasis by Age distribution

Age Distribution No. examinedNo. positive% positive % 19 – % % 31 – % 36 – %  % Missing* % Total % West Bank * Missing : information is not available in questionnaire

Age Distribution No. examinedNo. positive% positive % 19 – % % 31 – % 36 – %  % Missing* % Total % Gaza * Missing : information is not available in questionnaire

Marital status No. examinedNo. positive% positive Married % Divorced600.0 % widow % Total % Palestine Infection rate of Trichomoniasis by marital status

Marital status No. examinedNo. positive% positive Married % Divorced300.0 % widow % Total % West Bank

Marital status No. examinedNo. positive% positive Married % Divorced300.0 % widow300.0 % Total % Gaza

W. education No. examinedNo. positive% positive School % University % Missing100.0 % Total % Palestine Infection rate of Trichomoniasis by women’s education

W. education No. examinedNo. positive% positive School % University % Total % West Bank

W. education No. examinedNo. positive% positive School % University % Missing100.0 % Total % Gaza

District No. examinedNo. positive% positive Urban % Rural % Camps % Missing*500.0 % Total % Palestine * Missing : information is not available in questionnaire Infection rate of Trichomoniasis according residency distribution

District No. examinedNo. positive% positive Urban % Rural % Camps % Total % West Bank

District No. examinedNo. positive% positive Urban % Rural % Camps % Missing*500.0 % Total % Gaza * Missing : information is not available in questionnaire

Type No. examinedNo. positive% positive IUD % Pills % Injection % others % Missing* % Total % Palestine * Missing : information is not available in questionnaire Infection rate of Trichomoniasis by type of contraceptives

Type No. examinedNo. positive% positive IUD % Pills % Injection % others % Missing* % Total % West Bank * Missing : information is not available in questionnaire

Type No. examinedNo. positive% positive IUD % Pills % Injection % others11100 % Missing* % Total % Gaza * Missing : information is not available in questionnaire

pH No. examinedNo. positive% positive 1 – % 4 – % > % Missing* % Total % Palestine * Missing : information is not available in questionnaire Infection rate of Trichomoniasis according to pH of vagina

pH No. examinedNo. positive% positive 1 – % 4 – % > % Missing* % Total % West Bank * Missing : information is not available in questionnaire

pH No. examinedNo. positive% positive 1 – % 4 – % > % Missing* % Total % Gaza * Missing : information is not available in questionnaire

Discharge No. examinedNo. positive% positive Yes % No % Missing*100.0 % Total % Palestine * Missing : information is not available in questionnaire Infection rate of Trichomoniasis according to Vaginal discharge

Discharge No. examinedNo. positive% positive Yes % No % Total % West Bank

Discharge No. examinedNo. positive% positive Yes % No % Missing*100.0 % Total % Gaza * Missing : information is not available in questionnaire

Burning No. examinedNo. positive% positive Yes % No % Missing*500.0 % Total % Palestine * Missing : information is not available in questionnaire Infection rate of Trichomoniasis according to Burning sensation

Burning No. examinedNo. positive% positive Yes % No % Missing*400.0 % Total % West Bank * Missing : information is not available in questionnaire

Burning No. examinedNo. positive% positive Yes % No % Missing*100.0 % Total % Gaza * Missing : information is not available in questionnaire

Candidiasis

Candidiasis is the 2 nd most frequent vaginal infection in US & primary vaginal infection in Europe. Candida species are the most common fungal pathogens affecting human. Candida causes a wide spectrum of diseases, from noninvasive superficial skin infection to deep- seated infections of solid organs. Usually C. albicans live in vaginal atmosphere because of the acid pH ( 4 – 5 ) but the true home of candida is the little intestine mucous.

The Candida infection can be difficult to be diagnosed, even by good gynecologist. The important thing is to keep in mind the general symptom picture that accompanies the vaginal infection in different measure. Candida increased when immune system’s efficiency reduced due to endogenous & exogenous toxin present

Vulvovaginal Candidiasis VVC is the 2 nd most common cause of vaginitis in US & Europe. An estimate 75 % of women have VVC. & 5 % have recurrent episodes. C. albicans is the infecting agent in 80 – 90 % of patients. Risk factors for uncomplicated VVC have been difficult to determine, but studies showed that the risk of it increased in women who use oral contraceptive pills or IUD.

Other risk factors include young age at first intercourse, intercourse more than four times per a month & receptive oral sex. VVC risk increased in women who have diabetes, pregnant or taking antibiotics. Complication of VVC are rare. In VVC, the discharge is usually white without odor & normal pH. Microscopic examinations of a wet mount & KOH preparations are positive in 50 – 70 % of patients with Candidal infections.

Epidemiology Candida, or yeast, is present as apart of the normal vaginal flora in % of healthy adult women & in up to 30-40% of pregnant women. Approximately % of all women experience symptoms of infection caused by Candida at least once & 40 % have recurrent infection. In US the incidence of mycotic vaginitis has doubled between these data have been associated with an 80% increase in the number of prescriptions written for antimycotics during that time.

Samples distribution Infection rate of Candidiasis by district in Palestine No. examinedNo. positive% positive West Bank % Gaza % Total %

West BankNo. examinedNo. positive% positive Jerusalem % Jericho % Bethlehem % Hebron % Tulkarem % Nablus % Qalqilia % Jenin % Salfeet % Ramallah % Total %

GazaNo. examinedNo. positive% positive North % Gaza % Mid Zone % Khanyounos % Rafah % Total %

Age Distribution No. examinedNo. positive% positive % 19 – % % 31 – % 36 – %  % Missing* % Total % Palestine * Missing : information is not available in questionnaire I nfection rate of Candidiasis by Age distribution

Age Distribution No. examinedNo. positive% positive % 19 – % % 31 – % 36 – %  % Missing* % Total % West Bank * Missing : information is not available in questionnaire

Age Distribution No. examinedNo. positive% positive % 19 – % % 31 – % 36 – %  % Missing* % Total % Gaza * Missing : information is not available in questionnaire

Marital status No. examinedNo. positive% positive Married % Divorced61*16.7 % widow % Total % Palestine Infection rate of Candidiasis by marital status Insignificant No. when Dominator -# examined less than 30 Or Nominator -# positive less than 5

Marital status No. examinedNo. positive% positive Married % Divorced % widow % Total % West Bank

Marital status No. examinedNo. positive% positive Married % Divorced300.0 % widow300.0 % Total % Gaza

W. education No. examinedNo. positive% positive School % University % Missing100.0 % Total % Palestine Infection rate of Candidiasis by women’s education

W. education No. examinedNo. positive% positive School % University % Total % West Bank

W. education No. examinedNo. positive% positive School % University % Missing100.0 % Total % Gaza

District No. examinedNo. positive% positive Urban % Rural % Camps % Missing* % Total % Palestine * Missing : information is not available in questionnaire Infection rate of Candidiasis according residency distribution

District No. examinedNo. positive% positive Urban % Rural % Camps % Total % West Bank

District No. examinedNo. positive% positive Urban % Rural % Camps % Missing* % Total % Gaza * Missing : information is not available in questionnaire

Type No. examinedNo. positive% positive IUD % Pills % Injection % others % Missing* % Total % Palestine * Missing : information is not available in questionnaire Infection rate of Candidiasis by type of contraceptives

Type No. examinedNo. positive% positive IUD % Pills % Injection % others % Missing* % Total % West Bank * Missing : information is not available in questionnaire

Type No. examinedNo. positive% positive IUD % Pills % Injection % others100.0 % Missing* % Total % Gaza * Missing : information is not available in questionnaire

pH No. examinedNo. positive% positive 1 – % 4 – % > % Missing* % Total % Palestine * Missing : information is not available in questionnaire Infection rate of Candidiasis according to pH of vagina

pH No. examinedNo. positive% positive 1 – % 4 – % > % Missing* % Total % West Bank * Missing : information is not available in questionnaire

pH No. examinedNo. positive% positive 1 – % 4 – % > % Missing* % Total % Gaza * Missing : information is not available in questionnaire

Discharge No. examinedNo. positive% positive Yes % No % Missing*100.0 % Total % Palestine * Missing : information is not available in questionnaire Infection rate of Candidiasis according to Vaginal discharge

Discharge No. examinedNo. positive% positive Yes % No % Total % West Bank

Discharge No. examinedNo. positive% positive Yes % No % Missing*100.0 % Total % Gaza * Missing : information is not available in questionnaire

Burning No. examinedNo. positive% positive Yes % No % Missing*500.0 % Total % Palestine * Missing : information is not available in questionnaire Infection rate of Candidiasis according to Burning sensation

Burning No. examinedNo. positive% positive Yes % No % Missing*400.0 % Total % West Bank * Missing : information is not available in questionnaire

Burning No. examinedNo. positive% positive Yes % No % Missing*100.0 % Total % Gaza * Missing : information is not available in questionnaire

The percentage of one infection or more according to the total number in Palestine Infection# of cases% T. Vaginalis % C.Albicans % Yeast % T.Vaginalis & Yeast293.9 % T.Vaginalis & Candida & Yeast % Total infected %

Recommendation Sexually transmitted diseases are a public health problem in Palestine, as the case in other countries in the region. Dealing with STDs and STIs should receive more attention by MOH and other health providers. The National committee for Prevention and Control of AIDS and STDs should be reactivated and supported.

Condom promotion for preventive purposes should be adopted and implemented by all health providers. This survey should be disseminated to all health providers, including those in the private sector, in order to ensure their involvement with MOH in prevention and control.

Health education program should be developed, carried out, and implemented by the National Health Education Committee. Medical and community awareness should be increased by all means. Adaptation and implementation of WHO guideline on STDs (etiological and Syndromic approach to diagnosis and treatment should be reinforced.

Clinics and laboratotories should be provided with dugs needed for the treatment and prophylactic treatment, in addition to condoms for preventive purposes, as well as reagents needed for diagnosis. STDs surveillance system should be improved by promoting notification and reporting by all health providers

Plans for surveys on other STDs are required in order to have a complete picture about STDs in Palestine, which can assist in as improved planning of prevention activities. Medical staff should receive training on diagnosis, treatment and counseling. Laboratory technicians and health workers should be included in the training programs.

THANK YOU