Diploma medical and health science

1. Institut Latihan Kementerian Kesihatan Malaysia
Diploma in Medical And Health Science (DMHS)
SEMESTER 4
MHCH 2163
2.7 Control and prevention Genito
Urinary Infectious Related Sexuality &
Sexual Transmitted Disease(STD)

2. Learning outcome (LO)
i. Explain concept and method to control and
prevention Genito Urinary Infectious Related
Sexuality & Sexual Transmitted Disease(STD.
ii. Describe epidemiology close contact diseases and
epidemiology approach in control prevention.
iii. Describe role of AMO in control and prevention
Genito Urinary Infectious Related Sexuality & Sexual
Transmitted Disease(STD.

3. 3.1.1 OVERVIEW OF GENITO URINARY INFECTIOUS
RELATED SEXUALITY & SEXUAL TRANSMITTED
DISEASE(STD)
More than 30 different bacteria, viruses and parasites are known to be
transmitted through sexual contact. Eight of these pathogens are linked
to the greatest incidence of sexually transmitted disease. Of these, 4
are currently curable: syphilis, gonorrhoea, chlamydia and
trichomoniasis. The other 4 are viral infections which are incurable:
hepatitis B, herpes simplex virus (HSV or herpes), HIV and human
papillomavirus (HPV).

4. 3.1.1 OVERVIEW OF GENITO URINARY INFECTIOUS
RELATED SEXUALITY & SEXUAL TRANSMITTED
DISEASE(STD)
STIs are spread predominantly by sexual contact, including vaginal, anal
and oral sex. Some STIs can also be transmitted from mother-to-child
during pregnancy, childbirth and breastfeeding.
A person can have an STI without showing symptoms of disease.
Common symptoms of STIs include vaginal discharge, urethral
discharge or burning in men, genital ulcers and abdominal pain.
World Health Organisation

5. 3.1.1 OVERVIEW OF GENITO URINARY INFECTIOUS
RELATED SEXUALITY & SEXUAL TRANSMITTED
DISEASE(STD)
• More than 1 million STIs are acquired every day. In 2020, WHO
estimated 374 million new infections with one of four STIs: chlamydia
(129 million), gonorrhoea (82 million), syphilis (7.1 million) and
trichomoniasis (156 million).
• More than 490 million people were estimated to be living with genital
HSV (herpes) infection in 2016, and an estimated 300 million women
have an HPV infection, the primary cause of cervical cancer. An
estimated 296 million people are living with chronic hepatitis B
globally. Both HPV and hepatitis B infections are preventable with
vaccination.

6. 3.1.2 CONCEPT AND METHOD
• Sexually transmitted diseases (STDs), or sexually transmitted
infections (STIs), are infections that are passed from one person to
another through sexual contact. The contact is usually vaginal, oral, or
anal sex.
• It’s possible to contract an STD without developing symptoms. But some
STDs cause obvious symptoms. In men, common symptoms include:
• pain or discomfort during sex or urination
• sores, bumps, or rashes on or around the penis, testicles, anus, buttocks,
thighs, or mouth
• unusual discharge or bleeding from the penis
• painful or swollen testicles

7. CONCEPT AND METHOD
• In many cases, STDs don’t cause noticeable symptoms. When they do,
common STD symptoms in women include:
• pain or discomfort during sex or urination
• sores, bumps, or rashes on or around the vagina, anus, buttocks, thighs, or
mouth
• unusual discharge or bleeding from the vagina
• itchiness in or around the vagina

8. 3.1.3 EPIDEMIOLOGY OF STD AND RELATED
DISEASES
• (Akta Pencegahan dan pengawalan penyakit berjangkit 1988) :
1. Vagina Discaj;
• Trichomoniasis vaginitis
• Vaginal candidiasis
• Gonococcal endocervicitis
• Bacterial anaerobic vaginosis
2. Uretra discaj / dysuria male;
• Gonorhea
• Post gonococcal uretheritis
• Chlamydial / non spesefic uretheritis (NSU)

9. 3.1.3 AKTA BERKAITAN
4. Vagina Discaj
• Shyphilis (all types)
• Chancroid
• Gonococcal endocervicitis
• Genital Herpes
• Uretra discaj / dysuria male;
• Gonorhea
5. Conjunctivitis neonatal
• Gonococcal conjunctivitis
• Chlamydia conjuntivitis
• Bacterial conjuntivitis

10. Trichomoniasis vaginitis
• Trichomoniasis (or “trich”) is a very common sexually
transmitted disease (STD). It is caused by infection with
a protozoan parasite called Trichomonas vaginalis.
Although symptoms of the disease vary, most people
who have the parasite cannot tell they are infected.
• The parasite passes from an infected person to an
uninfected person during sex.
• About 70% of infected people do not have any signs or
symptoms. When trichomoniasis does cause
symptoms, they can range from mild irritation to
severe inflammation. Some people with symptoms get
them within 5 to 28 days after being infected. Others
do not develop symptoms until much later. Symptoms
can come and go.

11. • Men with trichomoniasis may notice:
• Itching or irritation inside the penis;
• Burning after urination or ejaculation;
• Discharge from the penis.
• Women with trichomoniasis may notice:
• Itching, burning, redness or soreness of the
genitals;
• Discomfort with urination;
• A change in their vaginal discharge (i.e., thin
discharge or increased volume) that can be clear,
white, yellowish, or greenish with an unusual fishy
smell.

12. Vaginal candidiasis
• Candidiasis is an infection caused by a yeast (a type of
fungus) called Candida. Candida normally lives inside
the body (in places such as the mouth, throat, gut, and
vagina) and on skin without causing any problems.
• Sometimes Candida can multiply and cause an
infection if the environment inside the vagina changes
in a way that encourages its growth. Candidiasis in the
vagina is commonly called a “vaginal yeast infection.”
Other names for this infection are “vaginal candidiasis,”
“vulvovaginal candidiasis,” or “candidal vaginitis.”

13. • The symptoms of vaginal candidiasis include:
• Vaginal itching or soreness.
• Pain during sexual intercourse.
• Pain or discomfort when urinating.
• Abnormal vaginal discharge.
• Some female can develop severe infections involving
redness, swelling, and cracks in the wall of the vagina.
• Women who are more likely to get vaginal candidiasis
include those who:
• Are pregnant.
• Use hormonal contraceptives.
• Have diabetes.
• HIV infection or medicines that weaken the
immune system, such as steroids and
chemotherapy.
• Are taking or have recently taken antibiotics.

14. Gonococcal Endocervicitis
• Sexually transmitted disease (STD) caused by infection
with the Neisseria gonorrhoeae bacterium. N.
gonorrhoeae infects the mucous membranes of the
reproductive tract, including the cervix, uterus, and
fallopian tubes in women, and the urethra in women
and men.

15. • Symptoms of cervicitis may include:
• vaginal itching or irritation
• bleeding between periods
• pain when having sex
• bleeding after sex
• pain during a cervical exam
• frequent and painful urination
• unusual grey or white discharge that may smell
• a pressurized feeling in the pelvis
• lower back pain
• abdominal pain.
• Some women may not experience any symptoms when
they have cervicitis. Severe cervicitis may lead to a
thick, yellow or green vaginal discharge that resembles
pus.

16. Bacterial Anaerobic Vaginosis
• Bacterial vaginosis is a type of vaginal
inflammation caused by the overgrowth of
bacteria naturally found in the vagina, which
upsets the natural balance.
• Women in their reproductive years are most
likely to get bacterial vaginosis, but it can
affect women of any age. The cause isn't
completely understood, but certain activities,
such as unprotected sex or frequent douching,
increase your risk.

17. • Bacterial vaginosis signs and symptoms may
include:
• Thin, gray, white or green vaginal discharge
• Foul-smelling "fishy" vaginal odor
• Vaginal itching
• Burning during urination
• Many women with bacterial vaginosis have no
signs or symptoms.

18. • Bacterial vaginosis doesn't generally cause
complications. Sometimes, having bacterial
vaginosis may lead to:
• Preterm birth. In pregnant women, bacterial vaginosis
is linked to premature deliveries and low birth weight
babies.
• Sexually transmitted infections. Having bacterial
vaginosis makes women more susceptible to sexually
transmitted infections, such as HIV, herpes simplex
virus, chlamydia or gonorrhoea. If you have HIV,
bacterial vaginosis increases the odds that you'll pass
the virus on to your partner.
• Infection risk after gynaecologic surgery. Having
bacterial vaginosis may increase the risk of developing
a post-surgical infection after procedures such as
hysterectomy or dilation and curettage (D&C).
• Pelvic inflammatory disease (PID). Bacterial vaginosis
can sometimes cause PID, an infection of the uterus
and the fallopian tubes that can increase the risk of
infertility.

19. Gonorhea
• Gonorrhea is an infection caused by a
sexually transmitted bacterium that
infects both males and females.
Gonorrhea most often affects the
urethra, rectum or throat. In females,
gonorrhea can also infect the cervix.
• Gonorrhea is most commonly spread
during vaginal, oral or anal sex. But
babies of infected mothers can be
infected during childbirth. In babies,
gonorrhea most commonly affects the
eyes.

20. • Signs and symptoms of gonorrhoea infection
in men include:
• Painful urination.
• Pus-like discharge from the tip of the penis.
• Pain or swelling in one testicle.
• Gonorrhea can also affect these parts of the body:
• Rectum. Signs and symptoms include anal
itching, pus-like discharge from the rectum,
spots of bright red blood on toilet tissue and
having to strain during bowel movements.
• Eyes. Gonorrhea that affects your eyes can
cause eye pain, sensitivity to light, and pus-like
discharge from one or both eyes.
• Throat. Signs and symptoms of a throat
infection might include a sore throat and
swollen lymph nodes in the neck.
• Joints. If one or more joints become infected
by bacteria (septic arthritis), the affected joints
might be warm, red, swollen and extremely
painful, especially during movement.

21. Post Gonococcal Urethritis
• Postgonococcal urethritis refers to the clinical
syndrome in which symptoms recur after
treatment for gonorrhoea. It is a manifestation
of dual urethral infection. Chlamydia
trachomatis has been recovered from 11-50%
of men with gonorrhoea. Occasionally, dual
infection with ureaplasma may occur.

22. Chlamydial / Non Specific Uretheritis (NSU)
• Non-gonococcal urethritis (NGU) refers to
urethritis that is not caused by gonorrhoea
(Neisseria gonorrhoeae). Most commonly,
NGU is caused by chlamydia (Chlamydia
trachomatis) and can affect both men and
women. Another term, non-specific urethritis
(NSU) means that urethritis is neither caused
by gonorrhoea nor chlamydia. NSU can have
some non-sexual causes, such as irritation
from a catheter or soap.
• NGU and NSU are usually caused by an
infection which has been passed on during
unprotected anal, oral and vaginal sex. Very
rarely NSU can be caused by excessive friction
during masturbation or sex, or an allergic
reaction to soap or detergent.

23. Syphilis
• Syphilis may manifest at any stage and
may affect multiple or single organs,
mimicking many other disorders.
Syphilis may be accelerated by
coexisting HIV infection; in these cases,
eye involvement, meningitis, and other
neurologic complications are more
common and more severe.

25. Chancroid
• Chancroid is caused by the bacterium
Haemophilus ducreyi that attacks the genital
area tissues and creates an open sore that is
also referred to as a Chancroid or an Ulcer.
This chancroid or ulcer may bleed or may
produce a contagious fluid that might spread
the bacterium during intercourse. Chancroid
may also pass through skin to skin touch with
an affected person.
• Women may experience a burning or painful sensation
while urinating or while passing bowel movements; after
the bumps become ulcerated, or open.
• men who are infected with H.ducreyi bacterium, there
may be a small red bump on their genitals that may
change to an open sore in a couple of days. The ulcer may
be formed on any portion of the genitals, which may
include the scrotum and also the penis.

26. Genital Herpes
• Genital herpes is an STD caused
by two types of viruses
• Herpes Simplex Virus Type 1 (HSV-1).
often causes oral herpes, which can result
in cold sores or fever blisters on or around
the mouth. However, most people with
oral herpes do not have any symptoms.
Most people with oral herpes get it during
childhood or young adulthood from non-
sexual contact with saliva.
• Herpes Simplex Virus Type 2 (Hsv-2).

27. • Spread by having vaginal, anal, or oral sex
with someone who has the infection. You
can get herpes if you have contact with:
• A herpes sore;
• Saliva from a partner with an oral herpes
infection;
• Genital fluids from a partner with a genital
herpes infection;
• Skin in the oral area of a partner with oral
herpes; or
• Skin in the genital area of a partner with
genital herpes.

28. Gonococcal Conjunctivitis
• Gonococcal conjunctivitis (GC) is characterized
by severe mucopurulent discharge associated
with conjunctival injection, eyelid edema,
tenderness, and often preauricular
lymphadenopathy. This condition is due to
ophthalmic infection with Neisseria
gonorrhoeae and was considered
predominantly a disease of neonates.
• Typical findings of gonococcal conjunctivitis
are marked bilateral eyelid edema, chemosis,
and copious purulent discharge.

29. Chlamydia Conjuntivitis
• The microorganism Chlamydia trachomatis
is an obligate intracellular parasite (i.e. it
cannot replicate outside a host cell)
• Serotypes A-C cause trachoma, the leading
cause of infectious blindness worldwide
• Serotypes D-K are responsible for
Ophthalmia Neonatorum and adult
inclusion conjunctivitis many patients (up
to 70%) have a concurrent genital
infection (may be asymptomatic).
• Most common in young adulthood (15-35
years)
• Sexual activity leading to genital infection
with C. trachomatis

30. • Signs of chlamydial conjunctivitis
• hyperaemia and chemosis
• mucopurulent conjunctivitis
• large follicles in upper and lower
fornices (double eversion of lid
needed to view upper fornix)
• limbal and/or bulbar follicles may
also be present

31. Bacterial Conjunctivitis
• Bacterial conjunctivitis is an infection of the
eye's mucous membrane, the conjunctiva,
which extends from the back surface of the
eyelids (palpebral and tarsal conjunctiva), into
the fornices, and onto the globe (bulbar
conjunctiva) until it fuses with the cornea at
the limbus.
• Primary due to Staphylococcus aureus,
Streptococcus pneumoniae, and Haemophilus
influenzae.
• Chronic conjunctivitis is primarily due to
Chlamydia trachomatis.

32. 3.1.4 Epidemiologic aproach in method of controle & method of
prevention & surveillance activities at Klinik Kesihatan , Pejabat
Kesihatan Daerah , Negeri , Kebangsaaan (KKM/Kerajaan).
• As there is a wide variety of sexually transmitted infections and
infestations there is no place for chemoprophylaxis in STD. Being a
disease with an obnoxious social stigma we need to take positive but
not punitive steps to encourage patients and contacts to come
forward for treatment to prevent transmission of STD.

33. • The following guidelines and principles are of immense importance in the
fight against STD:
• Identification of infectious agent by laboratory tests for appropriate treatment and
medico-legal reasons.
• Proper collection and handling of specimens.
• Accurate interpretation of laboratory data.
• Highly effective and well supervised therapy.
• Treatment rendered as early as possible.
• Ensure compliance of therapy by patients.
• Case holding and tests of cure.
• Epidemiological treatment may be considered to prevent transmission and re-
infection.
• Child Abuse.
• Careful, judicious notification, contact tracing and counselling to encourage patients
to come forward for advice and treatment.
• Safe sex and safe-life style may be the only measures available.
• Screening for other common STD's.

34. • Principles of Management of STD :
• Identification of Infectious agent by laboratory tests.
• Tests of Cure Proper collection and handling of specimens
• Accurate interpretation of laboratory data
• Treatment rendered as early as possible to prevent transmission and
complications
• Supervised and highly effective therapy
• Ensure patient's compliance
• Screening for other STD
• Contact tracing
• Child abuse
• Counselling
• Blind therapy and prophylaxis avoided
• Epidemiological therapy
• · Notifiable Infectious Diseases

35. COMPREHENSIVE CASE MANAGEMENT OF STI
• Identification of the syndrome: This can be done through syndromic
diagnosis or laboratory tests.
• Educating the patient: Patients should be informed about the nature
of the infection, the importance of taking the full course of
medication, among other things.
• Antibiotic treatment for the syndrome: Whichever means is used for
diagnosis — flow charts or laboratory tests — the availability and use
of effective antibiotics is an absolute requirement.

36. • Condom supply: With people being encouraged to use condoms, health
authorities should ensure that there is an adequate supply of good-quality,
affordable condoms at health facilities and at various other distribution
points in the community. Social marketing of condoms is another way of
increasing access to condoms.
• Counselling: Counselling should be made available for cases where it is
needed — for example, in chronic cases of genital herpes or warts — either
for individuals or for couples in a sexual relationship.
• Information on partner notification and treatment: Contacting sex partners
of clients with STI, persuading them to present themselves to a site offering
STI services, and treating them — promptly and effectively — are essential
elements of any STI control programme.

37. 3.1.5 ROLE OF ASSISTANT MEDICAL OFFICER IN PRIMARY
CARE MANAGEMENT
• The feasibility of providing STI case management must be assured
within any health care setting, whether within the public or private
sector.
• An essential component will be privacy for consultation. Depending
on source of care there may also be need to provide facilities such as
an examination table or couch with adequate lighting, gloves,
syringes, specula, sterilization equipment and laboratory supplies.
Thus, for individuals seeking evaluation for an STI appropriate care
consists of the following components:

38. • History taking, including behavioural, demographic and medical risk
assessment
• Physical examination is essential, particularly of the genital area,
which in some cultures may be sensitive.
• Establishment of a diagnosis, syndromic or laboratory based
• Curative or palliative therapy, using the most effective antimicrobial
for the pathogen, at the first port of call of the patient
• Patient education and counselling (where counselling services are
available), including information on:

39. • compliance
• nature of infection
• importance of partner notification and treatment therefore
• risk reduction and prevention of further STI transmission HIV risk perception
and assessment.
• Case reporting
• Clinical follow up when appropriate and feasible
• Screening for asymptomatic infection (where feasible).

40. • Education and counselling during an STI consultation
• A consultation for an STI provides an opportunity for the health worker to
discuss and explore with the patient, on a one-to-one basis, his or her risk
factors for HIV/STI and other issues related to prevention and treatment.
• Notification and management of sexual partners
• The sexual partners of STI patients are likely to be infected themselves and
should be offered treatment. Further transmission of STI and re-infection are
prevented by referral of sexual partners for diagnosis and treatment..

41. • The strategy selected will depend on:
• The risk of infection.
• The seriousness of the disease.
• The availability of effective diagnostic tests.
• The likelihood of a person returning for follow-up.
• The availability of effective treatment.
• The likelihood of spread if epidemiological treatment is not given.
• The available infrastructure for follow-up of patients.

42. Management and Collaboration
• Active and Passive Case Detection
• Conduct investigations and specimen collection
• Assist in treating patients
• Collecting diseases related data
• Administration of Vaccines and Immunization
• Counselling
• Health education and health promotion
• Collaborate in clinic management
• Conducting research

43. Books
Communicable Disease Surveillance And Response System-Guide To
Monitoring And Evaluating.(2006). W.H.O.
Connolly M.A (2005) . Communicable Disease Controle In Emegencies. WHO
David L, Heymann. (2004). Controle Of Communicable Disease Manual.
American Public Health Association.
Garis Panduan Pemasaran Sosial Dalam Program Promosi Kesihatan.(2010).
Bahagian Pendidikan Kesihatan , KKM.
Garis Panduan Pendidikan Kesihatan Di Klinik Kesihatan
KKM.(2014).Kementerian Kesihatan Malaysia.
Roger Webber.(2009) Communicable Disease Epidemiology And Control.
.

44. Refferences
Manual pengurusan pesakit kelamin (STI) Melalui Modified Syndromic
Approach Di Peringkat Penjagaan Kesihatan Primer.(2000). Cawangan
AIDS STI , Kementerian Kesihatan Malaysia.
Sexually Transmitted Diseases Treatment Guidelines.(2015). Centre For
Disease Control And Prevention (CDC) , U.S. Department of Health and
Human Services Centers for Disease Control and PreventionU.S.
Department of Health and Human Services Centers for Disease Control
and Prevention