1. Sunita Rajbanshi
BPH 4th semester
Koshi Health and Science Campus
Biratnagar
6/11/2015 1

2. STDs
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3. Outline
Introduction
Significance of STIs
Global STIs situation
National STIs situation
STIs of bacterial etiology
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4. INTRODUCTION
 The sexually trasmitted infections are a group of
communicable diseases, that are trasmitted
predominantly by sexual contact and caused by a
wide range of bacterial, viral, protozoal and fungal
agents and ectoparasites.
 Most of the recently recognized STIs are now
referred to as second generation STIs.
STIs are caused by more than 30 different
pathogens .
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5. The significance of STIs
It is estimated that after maternal causes, STIs are responsible for the
greatest number of healthy life years lost among women in developing
countries.
Although STIs are primarily transmitted through sexual intercourse, it can
also be transmitted from mother to child during pregnancy and
childbirth, and also occasionally through blood and blood products.
Because of the rooted stigma and discrimination associated to STI, failure
to diagnose and treat STIs in time may result in serious complications and
sequelae including infertility, fetal wastage, neonatal infections, ectopic
pregnancy, cervical cancer and even death.
Moreover, STIs also account for massive expenditures and thus have
enormous socio-economic impact (WHO).
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6. STIs Increases Infectivity of HIV
HIV is found in the genital fluid of both HIV
infected male and female and also from the
exudates of genital ulcers.
The shedding of HIV in genital fluids is
increased by STI-related inflammatory
responses and exudates from lesions, making
men and women who are STI-infected and HIV-
positive, more infective.
Studies have shown that, treating STIs reduces
both the infectivity and the amount of HIV .
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7. HIV impacts STI,HIV lowers the immune status
and thereby increases the susceptibility(prone)
to STIs.
It also alters the natural history of some STIs
resulting in:
 Bizarre presentation
 Difficulty in making diagnosis
Abnormal serological tests results
Not responding to the common drug in their
normal doses and needing prolonged duration
and
Increasing drug resistance and drug interactions
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8. STIs impact on HIV
Both ulcerative and non-ulcerative STIs have
been found to facilitate HIV transmission either
by increasing HIV susceptibility or HIV
infectiousness or both.
Early and correct treatment of STIs along with
the effective prevention program greatly
reduces the risk of sexual transmission of HIV.
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9.  People with STIs have 3-10 times greater
risk of being infected with HIV.
 In a single sexual act, the STIs can increase
HIV risk from 1:1,000 to more than 1:10.
 In many countries, STIs are a major ‘driving
force’ of the HIV epidemic.
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10. Global STI situation
340 million new cases of syphilis, gonorrhea,
Chlamydia and trichomoniasis occur in men
and women aged 15–49
 Syphilis :12 million
Gonorrhoea: 62 million
Chlamydial infections: 92 million
 Trichomoniasis:173 million
(WHO, 1999)
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11. Some of the factors which have placed an ever
increasing proportion of population at risk for STIs
The increasing mobility of people across the
world,
 urbanization
 poverty
socio-demographic changes especially in
developing countries,
sexual exploitation of women and changes in
sexual behavior (Dam et al, 1998; WHO 1999).
In Sub-Saharan Africa 70% of HIV infection was
found in patients with an STI and likewise 15-30%
of STI patients in Thailand were found to be HIV
positive (Over and Piot,1996).
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12. Scientific evidence suggests that 80% of HIV
infections are spread by the sexual route and
there is interrelationship between HIV and
STI (Adler, MV, 1996).
Both ulcerative and non-ulcerative STIs have
been recognized to increase the risk of
sexual transmission and acquisition(gaining)
of HIV (WHO).
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13. STI situation in Nepal
Research by Zeeb (1996) estimated a total of
6,000–8,000 annual STI clients in Kaski district
alone.
According to the Annual Report of HMIS
(2064/65 BS) a total of 28,229 STIs and1,640
HIV/AIDS cases were reported out of
12,137,059 OPD cases.
According to the Annual Report of DOHS
(2069/70 BS) a total of 1443 HIV/AIDS cases
were reported out of 88793 OPD cases.
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14. Among FSWs of Terai highways, Prevalence of current
• syphilis : 3.5%,
• gonorrhea:1.5 %
• Chlamydia: 8.3%
Among IDUs prevalence of syphilis
• East Terai : 1.7%
• west Terai: 1.7%,
• Pokhara:0.5%
• KTM:1.5%
(IBBS,2009)
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15. In Kathmandu valley, 42 % of FSWs were having
at least one STI symptom and prevalence of
syphilis among them was 1 percent
(IBBS, 2008)
In Pokhara 30 % of the FSW reported to have at
least one symptom of STI and 1.5 % had
syphilis (IBBS , 2008).
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16. Only 4.7 % male labor migrants to India in
western and 10 % in far western district
reported to have at least one symptom of STI in
the last one year (IBBS 2008).
Prevalence of current syphilis among the
Truckers in Terai highway districts was
o.3%(IBBS 2009).
Among Men who have Sex with Men (MSM) in
Kathmandu prevalence of
• Syphilis :1.5 %;
• Rectal Gonorrhea : 12.5%
• Chlamydia:5% (IBBS 2009)
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17. Preliminary findings from IBBS 2009
(NCASC/FHI) among FSWs show that
prevalence of current
• Syphilis: 3.5%
• Gonorrhea :1.5%
• Chlamydia:8.3%
• syphilis in Truckers:0.3%
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18. Data of 26 districts reported from)
Data of kathmandu and pokhara
SN Disease name Percentage
1 STI 89.5
2 Cervicitis 41.7
3 Trichomonous infection 12.6
4 RPR Reactive 4.8
5 UDS 47.8
6 Genital Warts 15.9
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ASHA project(oct.2006-may.2009

19. Diagnosis and Treatment of (STI)
• Self reported prevalence of STI(Source: NDHS
2006, 2011)
Regions 2006 2011
Men Women Men Women
Eastern 0.2 0.0 0.9 0.0
Central 0.5 0.4 0.6 0.6
Western 0.1 0.0 0.1 0.3
Mid western 0.9 0.2 0.4 0.0
Far western 0.2 0.0 0.4 0.0
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20. Annually Reported Cases of STIs in Nepal
28229
50148 50112
42992 41370
45892
0
10000
20000
30000
40000
50000
60000
2064/65 2065/66 2066/67 2067/68 2068/69 2069/70
No.of STI case
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(Source: Annual Report of DoHS)

21. Components of national strategy
Recognition that STIs are global burden at the
policy level.
Awareness regarding the impact of effective STI
prevention and controls program at the national
level:
Reduction of STI related morbidity and
mortality.
Prevention of HIV infection
Prevention of serious complications resulting
from untreated STIs in both women and men.
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22. Prevention of STIs related adverse pregnancy
outcomes.
Seeking opportunities for an accelerated
response towards :
Cost effective interventions for HIV
preventions .
Multi-sectoral approaches and new
partnership.
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23. New technologies for strengthened
response.
Strengthening STI prevention and control
programs across all level of health facilities.
Condom promotion to the general
population particularly to population
engaging in high risk behavior.
Remove obstacles to the provision of service
for STI control.
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24. MDG
GOAL 6:
COMBAT HIV/AIDS, MALARIA
AND OTHER DISEASES

25. Sexually transmitted disease
of bacterial etiology
• The STD’s are a group of communicable disease
that are predominately transmitted by sexual
contact and caused by a wide range of
bacteria,virus,fungi,protozoa and ectoparasites.
Bacterial STDs includes:
• Gonorrhoea
• Genital Chlamydial infection
• Syphilis
• Chancroid
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26. Sign and Symptoms
Male Female
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27. Epidemiological determinant
Agent Factors
• Bacterial agents
 Neisseria gonorrhoeae
 Chlamydia trachomatis
 Treponema pallidum
 Haemophilus ducreyi
 Mycoplosma hominis
 Ureaplasma urealyticum
 Calymmatobacterium granulomatis
 Shigella spp.
 Campylobacter spp.
 Group B streptococcus
 Bacterial vaginosis -associated organisms
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28. Host factors
Age
 The highest rates of
incidence are observed in
2O-24 year.
 The most serious morbidity
is observed during foetal
development and in the
neonate .
Gender
 The overall morbidity rate is
higher for men than for
women, but the morbidity
caused by infection is
generally much more severe
in women, as for example,
pelvic inflammatory disease.
Marital status
 The frequency of STI
infection is higher
among single, divorced
and separated persons
than among married
couples.
Socio-economic
status
 Individuals from the
lowest socioeconomic
groups have the highest
morbidity rate.

29. Environmental factors
Demographic factors
• Population explosion
• Marked increase in the
number of young people
• Rural to urban migration
• Increasing educational
opportunities for women
• Delaying female marriage
increases STD risks
Social Factors
1.Prostitution
2.Broken Homes
3.sexual disharmony
4.Easy money
5.Emotional Immaturity
6.Urbanization and
industrialization
7.International travels
8.Changing behavior pattern
9.Social stigma
10.Alcoholism
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30. Syphilis
Introduction
• Syphilis is caused by infection, through abrasions in
the skin or mucous membranes, with the spirochaete
Treponema pallidum.
• In adults the infection is usually sexually acquired;
however, transmission by kissing, blood transfusion
and percutaneous injury has been reported.
• Transplacental infection of the fetus can occur.
• The natural history of untreated syphilis is variable.
Infection may remain latent throughout, or clinical
features may develop at any time.6/11/2015 30

31. Classification
I. Congenital (born with) syphilis
II. Acquired(infected later in the life) syphilis
Depending on the duration of the infection
acquired by the individual both types are
broadly grouped into two subtypes:
a. Early syphilis (< 2 years duration)
b. Late syphilis (> 2 years duration)
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32. • Acquired syphilis is further sub-classified as:
Early:
i. Primary syphilis
ii. Secondary syphilis
iii. Early latent syphilis
Late:
i. Late latent syphilis
ii. Tertiary syphilis
• Neurosyphilis
• Cardio-vascular syphilis
• Gummatous syphilis
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33. Sign and symptoms
Primary syphilis
• The sore may be a single
but there may be
multiple sores too.
• The sore is usually firm,
round, and painless.
Because the sore is
painless, it can easily go
unnoticed.
• The sore lasts 3 to 6
weeks and heals
regardless of whether or
not treatment.
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34. Secondary syphilis
• There have skin rashes and/or
sores in mouth, vagina, or anus
(also called mucous membrane
lesions).
• This stage usually starts with a
rash on one or more areas of the
body.
• The rash can look like rough,
red, or reddish brown spots on
the palms of hands and/or the
bottoms of the feet. The rash
usually won’t itch and it is
sometimes so faint that people
won’t notice it.
• Other symptoms includes fever,
swollen lymph glands, sore
throat, patchy hair loss,
headaches, weight loss, muscle
aches, and fatigue (feeling very
tired).
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35. Latent and Late Stages
• The latent stage of syphilis begins when
all of the symptoms had earlier
disappear.
• If people do not receive treatment then
can continue to have syphilis in the body
for years without any signs or symptoms.
• Symptoms of the late stage of syphilis
include difficulty coordinating muscle
movements, paralysis (not able to move
certain parts of the body), numbness,
blindness, and dementia (mental
disorder).these symptoms may occur
only in 10-30 yrs.
• In the late stages of syphilis, the disease
damages internal organs and can result
in death.
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36. Diagnosis
• Syphilis is difficult to diagnose clinically early
in its presentation.
• Confirmation is either via blood tests or direct
visual inspection using microscopy.
• Diagnostic tests are, however, unable to
distinguish between the stages of the disease.
Incubation period
• The incubation period is usually between 14
and 28 days with a range of 9-90 days.
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37. Laboratory diagnosis
Non-treponemal (non-specific) tests
• Venereal Diseases Research Laboratory (VDRL) test
• Rapid plasma reagin (RPR) test
Treponemal (specific) antibody tests
• Treponemal antigen-based enzyme immunoassay
(EIA) for IgG and IgM
• T. pallidum haemagglutination assay (TPHA)
• T. pallidum particle agglutination assay (TPPA)
• Fluorescent treponemal antibody-absorbed (FTA-
ABS) Test
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38. Treatment
• Penicillin is the drug of choice
• Doxycycline is indicated for patients
allergic to penicillin, except in
pregnancy.
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39. Gonorrhea
Introduction
• Caused by infection with Neisseria gonorrhoeae
and may involve columnar epithelium in the lower
genital tract, rectum, pharynx and eyes.
• Transmission through vaginal, anal or oral sex.
• Gonococcal conjunctivitis may be the result of
accidental infection from contaminated fingers.
• Vertical transmission may result in ophthalmia
neonatorum .
• Infection of children beyond the neonatal period
is usually indicative of sexual abuse.
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40. Reservoir:
• Man is only the reservoir of this disease.
Etiological agent: Nesseria gonorrhoea
Mode of transmission:
• Through contact of
exudates(serum,fibrin,WBC)through sexual
activities. Communicability from female from
months to year if untreated as it is mostly
asymptomatic.
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41. Clinical feature
In males
 A burning sensation
when urinating
 A white, yellow, or
green discharge from
the penis
 Painful or swollen
testicles (although this
is less common).
In females
 Painful or burning
sensation when
urinating
 Increased vaginal
discharge
 Vaginal bleeding
between periods
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42. Rectal infections may either cause no
symptoms or cause symptoms in both men
and women that may include:
• Discharge;
• Anal itching;
• Soreness;
• Bleeding;
• Painful bowel movements
Incubation period
• In males :2-9 days
• In females: 2-5 days
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43. Investigations
• Gram-negative intracellular diplococci may be
seen on microscopy of smears from infected
sites.
• Pharyngeal smears are difficult to analyse due
to the presence of other diplococci so the
diagnosis must be confirmed by culture.
TREATMENT
• Cefixime 400 mg stat or
• Ciprofloxacin 500 mg orally stat or
• Ofloxacin 400 mg orally stat or
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44. Complication
• PID
• Formation of scar tissue that blocks fallopian
tubes;
• Ectopic pregnancy (pregnancy outside the
womb);
• Infertility (inability to get pregnant);
• Long-term pelvic/abdominal pain.
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45. Chancroid
• It is an ulcerative STI caused by a gram negative
bacillus called Haemophilus ducreyi.
Clinical manifestation
• Non-indurated or soft ,painful and friable(easily
breakable)genital ulcers with purulent base
(usually multiple),with or without tender
unilateral inguinal lymphadenopathy,which
becomes fluctuant (bubo) in both males and
female.
• Fever and systematic symptoms are often
present.
• History of recent sexual exposure.
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46. Diagnosing Chancroid
Diagnosing involve taking samples of the
fluid that drains from the sore.
These samples are sent to a laboratory for
analysis.
 Diagnosing chancroid is currently not
possible through blood testing. Physician
may also examine the lymph nodes in the
groin for swelling and pain.
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47. Treatment
• Azithromycin 1 gm po,single dose
or
• Ciprofloxacin 500mg po, bid for 3 days
or
• Ceftriaxone 250mg IM single dose
or
• Erythromycin 500mg po, qid for seven days.
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48. Control Of STDs
1. Initial planning
2. Intervention strategies
3. Support components
4. Monitoring and evaluation
Initial planning
• PROBLEM DEFINITION
• ESTABLISHING PRIORITIES
• SETTING OBJECTIVES
• CONSIDERING STRATEGIES
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49. INTERVENTION STRATEG IES
• Case detection
1.SCREENING
2. CONTACT TRACING
3. CLUSTER TESTIIVG
• Case holding and treatment
• Epidemiological treatment
• Personal prophylaxis
Contraceptives
• Health education
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50. SUPPORT COMPONENTS
1. STD clinic
2. Laboratory services
3. Primary health care
4. Information system
5. Legislation
6. Social welfare measures
Monitoring and evaluation
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51. Prevention of sexually transmitted
infections
The objectives of STI prevention and control
traditionally are:
Interrupting the transmission of sexually
acquired infections primarily through the
targeted intervention among MARPS.
 Preventing development of diseases,
complications and sequelae
 Reducing the risk of HIV infection
Promoting safer sexual behaviour
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52. Primary prevention activities are:
• Abstinence
• Promotion of safer sexual behavior including
consistent and correct use of condoms
• Provision of condoms at affordable prices
• Making the condom accessible
• Reducing rates of partner change by being
faithful to only one sexual partner
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53. Secondary prevention activities are:
• Promotion of health care seeking behavior
directed particularly towards those at
increased risk of acquiring STIs including HIV
infection.
• The provision of accessible, effective and
acceptable services which offer diagnosis
and effective treatment for both
symptomatic and asymptomatic patients
with STIs and their partners.
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54. Bibliography
• JE Park & K Park, A Textbook of Preventive & Social
medicine ; 22nd edition.
• Davidson’s principles and practice of medicines,20th edition
• National Guidelines on Case Management of Sexually
Transmitted Infections,2009/2011
• Annual Report ,Department of Health Service 69/70
• Annual Report ,Department of Health Service 68/69
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55. • Factsheet 4: Diagnosis and Treatment of
Sexually Transmitted Infection (STI) 2014
• www.cdc.gov
• www.myoclinic.org
• www.ncasc.gov.np
• Integrated Biological and Behavioral
Surveillance (IBBS)2008/2009.
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