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Sexually Transmitted Infection
(STI) in the Forgotten Age Group
Melecia Antonio-Velmonte, MD
Melecia Antonio-Velmonte, MD
Professor Emeritus, UP College of Medicine
18th PIDSP Annual Convention, February 3, 2011
Crowne Plaza, Quezon City
DEFINITIONS
Age Groups as Defined by WHO
Children – person with age between 0-9 yrs.
Adolescents – person with age between 10-19 yrs.
Adolescents – person with age between 10-19 yrs.
Youth – persons with age between 15-24 yrs.
Young people – person with age between 10-24
years
DEFINITIONS
Sexually Transmitted Infections
A group of infections, caused by different
pathogens, spread through person to person sexual
pathogens, spread through person to person sexual
contact
Maybe transmitted from mother to child during
pregnancy and childbirth through contact with blood
and tissues.
Common Sexually Transmitted
Pathogens
Bacteria Diseased Caused
Neisseria gonorrheae
Chlamydia trachomatis
Gonorrheal Infection
Chlamydia infection
Chlamydia trachomatis
Triponema pallidum
Hemophilus Ducreiji
Klbesiella granulomatis
Chlamydia infection
Syphilis
Chancroid
Granuloma inguinale
Common Sexually Transmitted Pathogens
Viruses Disease Caused
Human
Immunodeficiency virus
Herpes Simplex type 2
Human Pappiloma Virus
HIV
Anogenital herpes
Genital Warts,
Human Pappiloma Virus Genital Warts,
cervical ca
Hepatitis B
Cytomegalovirus
Hepatitis
Others:
Trichomonas Vaginalis
Candida Albicans
Vaginitis
Vulvo vaginitis
Mode of Transmission of Sexually
Transmitted Pathogens
Primarily sexual Intercourse
Mother to child
Mother to child
Blood body fluid and Tissues
Epidemiology of STI
Global Burden
• STI constitute a huge health and economic burden
• STI accounts for 17% of economic loss caused by
illnesses
• More than 340 million new cases of curable STI
• More than 340 million new cases of curable STI
occur every year in the 15-49 age group
• The largest proportion of cases are in South,
Southeast asia followed by Subsaharan Africa then
Latin America
• Socioeconomic conditions, sexual behavior
increases vulnerability to STI
Epidemiology of STI
Global Burden (Adolescents)
• Every year one (1) in 20 adolescents
contract a bacterial STI
• STI disproportionally affect women and
adolescents girls
• age of acquisition is becoming younger
Epidemiology of STI in US
• Overall prevalence rate decreased in all age group
• Adolescents and young adults higher than any other
group
• Prevalence rate highest among adolescents
• Reported rates of chlamydia and gonorrhea highest
among females 15-19 years
among females 15-19 years
• High AIDS prevalence in 25-39 age group
presumably acquired over previous decade at age
15-29 years.
• Many HPV infection acquired during adolescent
years.
(MMWR Dec. 2010)
Chlamydia—Rates by Age and Sex, United States, 2009
3,800 3,040 2,280 1,520 760 0 0 760 1,520 2,280 3,040 3,800
10–14
15–19
20–24
25–29
13.8
735.5
1,120.6
573.3
127.9
3,329.3
3,273.9
1,234.0
Men Women
Rate (per 100,000 population)
Age
30–34
35–39
40–44
45–54
55–64
65+
Total
286.0
141.3
81.9
36.0
219.8
2.9
11.0
511.7
205.8
88.4
32.0
593.4
2.1
9.1
Gonorrhea—Rates by Age and Sex, United States,
2009
750 600 450 300 150 0 0 150 300 450 600 750
10–14
15–19
20–24
25–29
5.0
250.0
407.5
238.9
25.3
568.8
555.3
229.4
Men Women
Rate (per 100,000 population)
Age
30–34
35–39
40–44
45–54
55–64
65+
Total
145.0
85.6
60.8
33.6
92.2
2.7
11.4
106.2
47.6
22.9
8.7
105.7
0.5
2.1
Human Papillomavirus—Prevalence of High-risk and Low-risk
Types Among Females Aged 14–59 Years, National Health and
Nutrition Examination Survey, 2003–2004
25
30
35
40
45
Low-risk HPV*
Prevalence, %
High-risk HPV
* HPV = human papillomavirus.
NOTE: Error bars indicate 95% confidence intervals. Both high-risk and low-risk HPV types were detected in some
females.
SOURCE: Dunne EF, Unger ER, Sternberg M, McQuillan G, Swan DC, Patel SS, et al. Prevalence of HPV infection
among females in the United States. JAMA. 2007;297(8):813-9.
Copyright ©2007 American Medical Association. All rights reserved.
0
5
10
15
20
50–59
40–49
30–39
25–29
20–24
14–19
Age
Genital Warts—Initial Visits to Physicians’ Offices,
United States, 1966–2009
300
400
500
Visits (in thousands)
NOTE: The relative standard errors for genital warts estimates of more than 100,000 range from 18% to
30%.
SOURCE: IMS Health, Integrated Promotional Services™. IMS Health Report, 1966–2009.
0
100
200
2008
2005
2002
1999
1996
1993
1990
1987
1984
1981
1978
1975
1972
1969
1966
Year
Primary and Secondary Syphilis—Rates Among Females
Aged 15–19 Years by Race/Ethnicity, United States, 2000–
2009
15
20
Whites
Hispanics
Blacks
Asians/Pacific Islanders
American Indians/Alaska Natives
Rate (per 100,000 population)
0
5
10
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Year
Primary and Secondary Syphilis—Rates Among Males
Aged 15–19 Years by Race/Ethnicity, United States, 2000–
2009
20
25
30
Whites
Hispanics
Blacks
Asians/Pacific Islanders
American Indians/Alaska Natives
Rate (per 100,000 population)
0
5
10
15
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Year
Epidemiology of STI/RTI
in the Philippines
in the Philippines
Prevalence of STI’s Among the Different Groups
RTI/STI Prevalence Survey in Selected Sites in the Philippines
February to May 2002 (n=300)
STI Female
(Gen. Pop;n
Male
(Gen. Pop;n
Female
(Youth)
Male
(Youth)
Chlamydial
infection
5.75 4.4 7.7 9
Gonorrhea 0.75 1.1 0.7 1.7
Syphillis 0.17 0.2 N/D N/A
Syphillis 0.17 0.2 N/D N/A
Hepatitis B 3.2 9.6 N/D N/A
Trichomonas 3.18 N/A N/D N/A
Bacterial
vaginosis
28.56 N/A N/D N/A
Candidiasis 17.16 N/A N/D N/A
DOH/FHI 2002
RTI/STI Prevalence Among Youth (January to
June 2001)
RTI/STI Prevalence in Selected Sites in the Philippines
Adolescent Pregnancy
Percent of Teenager 15-19 years who are
mothers or pregnant with their first child
Age %
15 0.5
15 0.5
16 1.3
17 3.6
18 10.3
19 19.0
ALL 29.7
(DHS 1993)
Reported Non Regular Sexual Partnerships in the
last 12 months
Age group (yrs) Male (%) Female (%)
15-19 37.5 0
15-49 16.1 1.3
20-24 40.3 10
25-39 15.3 1.2
40-49 7.1 0
50+ 41 0
KABP Behavioral Studies 1992
Epidemiology of HIV/AIDS in RP
(Updates)
In UNAIDS 2010 global AIDS report, releases in
late November, the Philippines was one of seven
countries in which HIV incidence increased by
countries in which HIV incidence increased by
more than 25 percent between 2001 and 2009.
Among Asian countries, only Philippines and
Bangladesh were reporting increases in HIV
cases, with others either stable or decreasing.
DOH Updated HIV/AIDS
DOH Updated HIV/AIDS
Surveillance
Newly Diagnosed HIV Cases in the Philippines
(Jan. 1984 – December 2010
Number of HIV/AIDS Cases Reported in the Philippines by Year,
January 1984 to December 2010
Comparison of the Distribution of Male and Female HIV Cases by Age-
Group and Certain Highlighted Years
Why Are Adolescents Vulnerable to
STI
1. Decreasing age of sexual debut
2. Modern technology
3. Outmigration of parents (AIDS in RP
2010)
4. Low condom use
4. Low condom use
5. Increasing number of youth initiated into
sex work with booth male and female sex
partners
Why Are Adolescents Vulnerable to
STI
6. Persistently high prevalence of drugs
and other substances use
7. Lower education across different section
of population
8. Survival sex (exchanging sex for money,
8. Survival sex (exchanging sex for money,
drugs, shelter and food)
9. Multiple obstacles in accessing services
10.Increased susceptibility to infections due
to anatomic, physiological and hormonal
changes.
Consequences of Sexually
Transmitted Infection
• Acute Infection
• Delayed Serious consequences
– Pelvic inflammatory disease
– Ectopic pregnancy
– Ectopic pregnancy
– Infertility
– Cervical cancer
– Untimely death of infants and adults
• Increased risk of acquiring or transmitting
HIV
Consequences of Sexually
Transmitted Infection
• Untreated chlamydia infection
– 10-40% of chlamydia infection in women
leads to symptomatic pelvic inflammatory
disease (PID) and 6 – 10x likely to develop
disease (PID) and 6 – 10x likely to develop
ectopic pregnancy
• Untreated gonorrhea and chlamydia
infection; 30-50% of infants born of
infected mothers develop serious eye
infections leading to blindness
Despite the high prevalence of STI among
adolescents, healthcare professionals
frequently fail to inquire about
• Sexual behavior
• Sexual behavior
• Assess STI risks
• Counsel about risk reduction and screen
for STI
STI Case Management
The care of a persons with STI related
symptoms or positive test for one or more
STI
• History taking
• History taking
• Clinical examination
• Correct diagnosis
• Early and effective treatment
• Case reporting
• Clinical diagnosis appropriate
Screening for STI (History)
Features of Adolescents that Increase the Risk of
Contracting STI
• Sexual contact with person(s) with known STI or
history of STI
• Symptoms or signs of STI
• Symptoms or signs of STI
• Multiple Sexual Partners
• Street involvement (eg., homelessness)
• Sexual intercourse with new partner during last
2 months
• More than 2 sexual partners during previous 12
months
• No or consistent use of barrier methods
Screening for STI (History)
Features of Adolescents that Increase the Risk of
Contracting STI
• Survival sex (eg., exchanging sex for money,
drugs, shelters or food
• Time spent in detention facilities
• Time spent in detention facilities
• Having been a patient in an STI Clinic
• Having been pregnant or having requested a
pregnancy test
• Injection drug use
• Males who have sex with males
Screening For STI
(Clinical Examination)
Female
• Vulvo vaginitis/itching
• Vaginal discharge
• Urethral discharge urethritis
• Urethral discharge urethritis
• Lower abdominal pain
• genital lesions
• Inguinal swelling
Screening For STI
(Clinical Examination)
Male
• Urethral discharge (dysuria)
• Anogenital lesions (ulcerations, warts)
• Scrotal/inguinal swelling
• Scrotal/inguinal swelling
Asymptomatic STI
• Gonococcal RP
– 70-85% in females 31%
– 10% in males 88%
• No gonococcal
• No gonococcal
- 25% both
Diagnostic Tests for STI
1. Microscopic Examination
• Grain stain of urethral discharge
• Tzank smear of vesicles – ulcers
• Wet mount of vaginal discharge
2. Culture Isolation
• For N. gonorrhea
• Tissue culture for herpes
3. NAATS (PCR)
• C. Trachomatis
• N. gonorrhea
4. Serologic Tests
• T. pallidum
• HIV
Syndromic Management of STI
Based on:
- Identification of consistent groups of symptoms and
easily recognized signs (syndrome) and
- Provision of treatment that will deal with majority of or
the most serious organism causing the syndrome.
the most serious organism causing the syndrome.
Rationale:
• Problem of inavailability of equipments and supplies and
trained personnel in low resource areas
• High lost of commercially available specific diagnostic
tests.
Main Syndromes of Common STI
Urethral Discharge
Genital Ulcers satisfactory
Lower Abdominal pain
Vaginal discharge – with limitations
Vaginal discharge – with limitations
Urethral Discharge
Take History and examine
Milk urethra if necessary
Patients complains of urethral
discharge or dysuria
Educate and counsel
Discharge confirmed?
TREAT FOR GONOCOCCAL INFECTION AND
CHLAMDYIA TRACHOMATIS
 Educate and counsel
Promote condom use and provide condoms
Manage and treat partner
Offer HIV Counseling and Testing if both
facilities are available
Ask patient to return in 7 days if symptoms
persist
Educate and counsel
Promote condom
use and provide
condoms
Offer HIV counseling
and testing if both
facilities are available
Review if symptoms
persist
Use appropriate flowchart
Any other genital
disease?
Recommended Syndromic
Treatment for Urethral Discharge
The major pathogens causing urethral discharge
are Neisseria gonorrhoeae (N. gonorrhoeae) and
Chlamydia trachomatis (C. trachomatis). In the
syndromic management, treatment of a patient
syndromic management, treatment of a patient
with urethral discharge should adequately cover
these two organisms. Where reliable laboratory
facilities are available, a distinction can be made
between the two organisms and specific treatment
instituted.
Recommended Syndromic
Treatment for Urethral Discharge
Treatment Options for
Gonorrhea
Treatment Options for
Chlamdyia
Ciprofloxacin
Cefrtiaxone
Cefixime
Doxycycline
Azithromycin
Cefixime
Spectinomycin
Alternatives
Amoxycillin
Erythromycin (if Tetracycline
contrainidcated
Ofloxacin
Tetracycline
Recommended Syndromic Treatment for
Genital Ulcer Disease
Drug Options
for Syphilis
Drug options
for Chancroid
Drug Options
for
Granuloma
inguinale
Drug Options
for LGV
Drug Options
for genital
herpes
Benzathine
benzylpenicillin
Ciprofloxacin
Erythromycin
Azithromycin
Azithromycin
Doxycycline
Doxycycline
Erythromycin
Acyclovir
Valaciclovir
Famciclovir
Alternatives Alternatives Alternatives Alternatives
Alternatives Alternatives Alternatives Alternatives
Procaine Ceftriaxone Erythromycin
Tetracycline
Trimethoprim/
sulfamethoxaz
ole
tetracycline
benzylpenicillin
Penicillin allergy and non-pregnant
Doxycycline
Tetracycline
Recommended Syndromic Treatment for
Genital Ulcer Disease
The decision to treat for chancroid, granuloma
inguinale or LGV depends on the local epidemiology of
the infections.
Specific treatment for herpes genitalis is
recommended as it offers clinical benefits to most
symptomatic patients. Health education and
counseling regarding the recurrent nature of genital
herpes lesions, the natural history, sexual
transmission, probable perinatal transmission of the
infection and available methods to reduce
transmission, are an integral part of genital herpes
management.
Management of STI
Effective control and prevention of STI can
be achieved using a combination of
approaches
Major Components of STI Control
• Education of individual at risk, on modes of
transmission and means of reducing the risk of
transmission
• Detection of infection in asymptomatic subjects
and symptomatic but unlikely to seek diagnostic
and symptomatic but unlikely to seek diagnostic
and therapeutic services
• Effective management of individuals seeking
care
• Treatment and education of sexual partners
• Primary prevention by vaccination.
Criteria for the Selection of STI
Drugs
1. High efficiency (at least 95% effective)
2. Low cost
3. Safety – acceptable toxiety and tolerance
4. Organism resistance not likely to be delayed
5. Single dose if possible
6. Oral administration
7. Not contraindicated for pregnant or lactating
women
Gonococcal Isolate Surveillance Project (GISP)—
Percentage of Neisseria gonorrhoeae Isolates with
Resistance or Intermediate Resistance to Ciprofloxacin,
1990–2009
15
20
Intermediate Resistance
Resistance
Percentage
NOTE: Resistant isolates have ciprofloxacin minimum inhibitory concentrations (MICs) 1 µg/ml. Isolates
with intermediate resistance have ciprofloxacin MICs of 0.125–0.5 µg/ml. Susceptibility to ciprofloxacin was
first measured in GISP in 1990.
0
5
10
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Year
Uncomplicated Gonococcal Infection;
Treatment of Children Beyond the Newborn
Period and Adolescents
Disease Prepubertal Children Who
Weigh 100 lb(45kg)
Uncomplicated
vulvovaginitis, cervicitis,
urethritis, proctitis, or
Ceftriaxone, 125 mg, IM, in a single dose
OR
Spectinomycin, 40 mg/kg (maximum 2g),
urethritis, proctitis, or
pharyngitis
Spectinomycin, 40 mg/kg (maximum 2g),
IM in a single dose
PLUS
Azithromycin, 20 mg/kg (maximum 1 g),
orally, in a single dose
OR
Erythromycin, 50 mg/kg per day
(maximum 2g/ day), orally, in 4
divided doses for 14 days
Uncomplicated Gonococcal Infection;
Treatment of Children Beyond the Newborn
Period and Adolescents
Disease Patients Who Weigh 100
lb(45kg) and Who are 8
Years or Older
Uncomplicated
endocervicitis,
Ceftriaxone, 125 mg, IM, in a single
dose
endocervicitis,
urethritis,
proctitis, or
pharyngitis
dose
OR
Cefixime, 400 mg, orally, in a single
dose
PLUS
Azithromycin (1 g, orally, in a single
dose)
OR
Doxycycline (100 mg, orally, twice a
day for 7 days)
How Can We Help the
Forgotten Age Group?
• Increase their awareness about STI/HIV
Risks
Signs and Symptoms
Prevention
Through IEC campaign and peer education
Through IEC campaign and peer education
• Behavior Change
• Establish and strengthen innovative youth
friendly health services to include RTI/STI
• Extend effective and appropriate intervention to
adolescents and youth
• Strengthen surveillance of RTI/STI
www_pidsphil_org_home_wp-content_uploads_2017_02_11Lec-STI-in-the-forgotten-age-group_pdf.pdf

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www_pidsphil_org_home_wp-content_uploads_2017_02_11Lec-STI-in-the-forgotten-age-group_pdf.pdf

  • 1. Sexually Transmitted Infection (STI) in the Forgotten Age Group Melecia Antonio-Velmonte, MD Melecia Antonio-Velmonte, MD Professor Emeritus, UP College of Medicine 18th PIDSP Annual Convention, February 3, 2011 Crowne Plaza, Quezon City
  • 2. DEFINITIONS Age Groups as Defined by WHO Children – person with age between 0-9 yrs. Adolescents – person with age between 10-19 yrs. Adolescents – person with age between 10-19 yrs. Youth – persons with age between 15-24 yrs. Young people – person with age between 10-24 years
  • 3. DEFINITIONS Sexually Transmitted Infections A group of infections, caused by different pathogens, spread through person to person sexual pathogens, spread through person to person sexual contact Maybe transmitted from mother to child during pregnancy and childbirth through contact with blood and tissues.
  • 4. Common Sexually Transmitted Pathogens Bacteria Diseased Caused Neisseria gonorrheae Chlamydia trachomatis Gonorrheal Infection Chlamydia infection Chlamydia trachomatis Triponema pallidum Hemophilus Ducreiji Klbesiella granulomatis Chlamydia infection Syphilis Chancroid Granuloma inguinale
  • 5. Common Sexually Transmitted Pathogens Viruses Disease Caused Human Immunodeficiency virus Herpes Simplex type 2 Human Pappiloma Virus HIV Anogenital herpes Genital Warts, Human Pappiloma Virus Genital Warts, cervical ca Hepatitis B Cytomegalovirus Hepatitis Others: Trichomonas Vaginalis Candida Albicans Vaginitis Vulvo vaginitis
  • 6. Mode of Transmission of Sexually Transmitted Pathogens Primarily sexual Intercourse Mother to child Mother to child Blood body fluid and Tissues
  • 7. Epidemiology of STI Global Burden • STI constitute a huge health and economic burden • STI accounts for 17% of economic loss caused by illnesses • More than 340 million new cases of curable STI • More than 340 million new cases of curable STI occur every year in the 15-49 age group • The largest proportion of cases are in South, Southeast asia followed by Subsaharan Africa then Latin America • Socioeconomic conditions, sexual behavior increases vulnerability to STI
  • 8. Epidemiology of STI Global Burden (Adolescents) • Every year one (1) in 20 adolescents contract a bacterial STI • STI disproportionally affect women and adolescents girls • age of acquisition is becoming younger
  • 9. Epidemiology of STI in US • Overall prevalence rate decreased in all age group • Adolescents and young adults higher than any other group • Prevalence rate highest among adolescents • Reported rates of chlamydia and gonorrhea highest among females 15-19 years among females 15-19 years • High AIDS prevalence in 25-39 age group presumably acquired over previous decade at age 15-29 years. • Many HPV infection acquired during adolescent years. (MMWR Dec. 2010)
  • 10. Chlamydia—Rates by Age and Sex, United States, 2009 3,800 3,040 2,280 1,520 760 0 0 760 1,520 2,280 3,040 3,800 10–14 15–19 20–24 25–29 13.8 735.5 1,120.6 573.3 127.9 3,329.3 3,273.9 1,234.0 Men Women Rate (per 100,000 population) Age 30–34 35–39 40–44 45–54 55–64 65+ Total 286.0 141.3 81.9 36.0 219.8 2.9 11.0 511.7 205.8 88.4 32.0 593.4 2.1 9.1
  • 11. Gonorrhea—Rates by Age and Sex, United States, 2009 750 600 450 300 150 0 0 150 300 450 600 750 10–14 15–19 20–24 25–29 5.0 250.0 407.5 238.9 25.3 568.8 555.3 229.4 Men Women Rate (per 100,000 population) Age 30–34 35–39 40–44 45–54 55–64 65+ Total 145.0 85.6 60.8 33.6 92.2 2.7 11.4 106.2 47.6 22.9 8.7 105.7 0.5 2.1
  • 12. Human Papillomavirus—Prevalence of High-risk and Low-risk Types Among Females Aged 14–59 Years, National Health and Nutrition Examination Survey, 2003–2004 25 30 35 40 45 Low-risk HPV* Prevalence, % High-risk HPV * HPV = human papillomavirus. NOTE: Error bars indicate 95% confidence intervals. Both high-risk and low-risk HPV types were detected in some females. SOURCE: Dunne EF, Unger ER, Sternberg M, McQuillan G, Swan DC, Patel SS, et al. Prevalence of HPV infection among females in the United States. JAMA. 2007;297(8):813-9. Copyright ©2007 American Medical Association. All rights reserved. 0 5 10 15 20 50–59 40–49 30–39 25–29 20–24 14–19 Age
  • 13. Genital Warts—Initial Visits to Physicians’ Offices, United States, 1966–2009 300 400 500 Visits (in thousands) NOTE: The relative standard errors for genital warts estimates of more than 100,000 range from 18% to 30%. SOURCE: IMS Health, Integrated Promotional Services™. IMS Health Report, 1966–2009. 0 100 200 2008 2005 2002 1999 1996 1993 1990 1987 1984 1981 1978 1975 1972 1969 1966 Year
  • 14. Primary and Secondary Syphilis—Rates Among Females Aged 15–19 Years by Race/Ethnicity, United States, 2000– 2009 15 20 Whites Hispanics Blacks Asians/Pacific Islanders American Indians/Alaska Natives Rate (per 100,000 population) 0 5 10 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 Year
  • 15. Primary and Secondary Syphilis—Rates Among Males Aged 15–19 Years by Race/Ethnicity, United States, 2000– 2009 20 25 30 Whites Hispanics Blacks Asians/Pacific Islanders American Indians/Alaska Natives Rate (per 100,000 population) 0 5 10 15 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 Year
  • 16. Epidemiology of STI/RTI in the Philippines in the Philippines
  • 17. Prevalence of STI’s Among the Different Groups RTI/STI Prevalence Survey in Selected Sites in the Philippines February to May 2002 (n=300) STI Female (Gen. Pop;n Male (Gen. Pop;n Female (Youth) Male (Youth) Chlamydial infection 5.75 4.4 7.7 9 Gonorrhea 0.75 1.1 0.7 1.7 Syphillis 0.17 0.2 N/D N/A Syphillis 0.17 0.2 N/D N/A Hepatitis B 3.2 9.6 N/D N/A Trichomonas 3.18 N/A N/D N/A Bacterial vaginosis 28.56 N/A N/D N/A Candidiasis 17.16 N/A N/D N/A DOH/FHI 2002
  • 18. RTI/STI Prevalence Among Youth (January to June 2001) RTI/STI Prevalence in Selected Sites in the Philippines
  • 19. Adolescent Pregnancy Percent of Teenager 15-19 years who are mothers or pregnant with their first child Age % 15 0.5 15 0.5 16 1.3 17 3.6 18 10.3 19 19.0 ALL 29.7 (DHS 1993)
  • 20. Reported Non Regular Sexual Partnerships in the last 12 months Age group (yrs) Male (%) Female (%) 15-19 37.5 0 15-49 16.1 1.3 20-24 40.3 10 25-39 15.3 1.2 40-49 7.1 0 50+ 41 0 KABP Behavioral Studies 1992
  • 21. Epidemiology of HIV/AIDS in RP (Updates) In UNAIDS 2010 global AIDS report, releases in late November, the Philippines was one of seven countries in which HIV incidence increased by countries in which HIV incidence increased by more than 25 percent between 2001 and 2009. Among Asian countries, only Philippines and Bangladesh were reporting increases in HIV cases, with others either stable or decreasing.
  • 22. DOH Updated HIV/AIDS DOH Updated HIV/AIDS Surveillance
  • 23. Newly Diagnosed HIV Cases in the Philippines (Jan. 1984 – December 2010
  • 24. Number of HIV/AIDS Cases Reported in the Philippines by Year, January 1984 to December 2010
  • 25. Comparison of the Distribution of Male and Female HIV Cases by Age- Group and Certain Highlighted Years
  • 26. Why Are Adolescents Vulnerable to STI 1. Decreasing age of sexual debut 2. Modern technology 3. Outmigration of parents (AIDS in RP 2010) 4. Low condom use 4. Low condom use 5. Increasing number of youth initiated into sex work with booth male and female sex partners
  • 27. Why Are Adolescents Vulnerable to STI 6. Persistently high prevalence of drugs and other substances use 7. Lower education across different section of population 8. Survival sex (exchanging sex for money, 8. Survival sex (exchanging sex for money, drugs, shelter and food) 9. Multiple obstacles in accessing services 10.Increased susceptibility to infections due to anatomic, physiological and hormonal changes.
  • 28. Consequences of Sexually Transmitted Infection • Acute Infection • Delayed Serious consequences – Pelvic inflammatory disease – Ectopic pregnancy – Ectopic pregnancy – Infertility – Cervical cancer – Untimely death of infants and adults • Increased risk of acquiring or transmitting HIV
  • 29. Consequences of Sexually Transmitted Infection • Untreated chlamydia infection – 10-40% of chlamydia infection in women leads to symptomatic pelvic inflammatory disease (PID) and 6 – 10x likely to develop disease (PID) and 6 – 10x likely to develop ectopic pregnancy • Untreated gonorrhea and chlamydia infection; 30-50% of infants born of infected mothers develop serious eye infections leading to blindness
  • 30. Despite the high prevalence of STI among adolescents, healthcare professionals frequently fail to inquire about • Sexual behavior • Sexual behavior • Assess STI risks • Counsel about risk reduction and screen for STI
  • 31. STI Case Management The care of a persons with STI related symptoms or positive test for one or more STI • History taking • History taking • Clinical examination • Correct diagnosis • Early and effective treatment • Case reporting • Clinical diagnosis appropriate
  • 32. Screening for STI (History) Features of Adolescents that Increase the Risk of Contracting STI • Sexual contact with person(s) with known STI or history of STI • Symptoms or signs of STI • Symptoms or signs of STI • Multiple Sexual Partners • Street involvement (eg., homelessness) • Sexual intercourse with new partner during last 2 months • More than 2 sexual partners during previous 12 months • No or consistent use of barrier methods
  • 33. Screening for STI (History) Features of Adolescents that Increase the Risk of Contracting STI • Survival sex (eg., exchanging sex for money, drugs, shelters or food • Time spent in detention facilities • Time spent in detention facilities • Having been a patient in an STI Clinic • Having been pregnant or having requested a pregnancy test • Injection drug use • Males who have sex with males
  • 34. Screening For STI (Clinical Examination) Female • Vulvo vaginitis/itching • Vaginal discharge • Urethral discharge urethritis • Urethral discharge urethritis • Lower abdominal pain • genital lesions • Inguinal swelling
  • 35. Screening For STI (Clinical Examination) Male • Urethral discharge (dysuria) • Anogenital lesions (ulcerations, warts) • Scrotal/inguinal swelling • Scrotal/inguinal swelling
  • 36. Asymptomatic STI • Gonococcal RP – 70-85% in females 31% – 10% in males 88% • No gonococcal • No gonococcal - 25% both
  • 37. Diagnostic Tests for STI 1. Microscopic Examination • Grain stain of urethral discharge • Tzank smear of vesicles – ulcers • Wet mount of vaginal discharge 2. Culture Isolation • For N. gonorrhea • Tissue culture for herpes 3. NAATS (PCR) • C. Trachomatis • N. gonorrhea 4. Serologic Tests • T. pallidum • HIV
  • 38. Syndromic Management of STI Based on: - Identification of consistent groups of symptoms and easily recognized signs (syndrome) and - Provision of treatment that will deal with majority of or the most serious organism causing the syndrome. the most serious organism causing the syndrome. Rationale: • Problem of inavailability of equipments and supplies and trained personnel in low resource areas • High lost of commercially available specific diagnostic tests.
  • 39. Main Syndromes of Common STI Urethral Discharge Genital Ulcers satisfactory Lower Abdominal pain Vaginal discharge – with limitations Vaginal discharge – with limitations
  • 40. Urethral Discharge Take History and examine Milk urethra if necessary Patients complains of urethral discharge or dysuria Educate and counsel Discharge confirmed? TREAT FOR GONOCOCCAL INFECTION AND CHLAMDYIA TRACHOMATIS Educate and counsel Promote condom use and provide condoms Manage and treat partner Offer HIV Counseling and Testing if both facilities are available Ask patient to return in 7 days if symptoms persist Educate and counsel Promote condom use and provide condoms Offer HIV counseling and testing if both facilities are available Review if symptoms persist Use appropriate flowchart Any other genital disease?
  • 41. Recommended Syndromic Treatment for Urethral Discharge The major pathogens causing urethral discharge are Neisseria gonorrhoeae (N. gonorrhoeae) and Chlamydia trachomatis (C. trachomatis). In the syndromic management, treatment of a patient syndromic management, treatment of a patient with urethral discharge should adequately cover these two organisms. Where reliable laboratory facilities are available, a distinction can be made between the two organisms and specific treatment instituted.
  • 42. Recommended Syndromic Treatment for Urethral Discharge Treatment Options for Gonorrhea Treatment Options for Chlamdyia Ciprofloxacin Cefrtiaxone Cefixime Doxycycline Azithromycin Cefixime Spectinomycin Alternatives Amoxycillin Erythromycin (if Tetracycline contrainidcated Ofloxacin Tetracycline
  • 43. Recommended Syndromic Treatment for Genital Ulcer Disease Drug Options for Syphilis Drug options for Chancroid Drug Options for Granuloma inguinale Drug Options for LGV Drug Options for genital herpes Benzathine benzylpenicillin Ciprofloxacin Erythromycin Azithromycin Azithromycin Doxycycline Doxycycline Erythromycin Acyclovir Valaciclovir Famciclovir Alternatives Alternatives Alternatives Alternatives Alternatives Alternatives Alternatives Alternatives Procaine Ceftriaxone Erythromycin Tetracycline Trimethoprim/ sulfamethoxaz ole tetracycline benzylpenicillin Penicillin allergy and non-pregnant Doxycycline Tetracycline
  • 44. Recommended Syndromic Treatment for Genital Ulcer Disease The decision to treat for chancroid, granuloma inguinale or LGV depends on the local epidemiology of the infections. Specific treatment for herpes genitalis is recommended as it offers clinical benefits to most symptomatic patients. Health education and counseling regarding the recurrent nature of genital herpes lesions, the natural history, sexual transmission, probable perinatal transmission of the infection and available methods to reduce transmission, are an integral part of genital herpes management.
  • 45. Management of STI Effective control and prevention of STI can be achieved using a combination of approaches
  • 46. Major Components of STI Control • Education of individual at risk, on modes of transmission and means of reducing the risk of transmission • Detection of infection in asymptomatic subjects and symptomatic but unlikely to seek diagnostic and symptomatic but unlikely to seek diagnostic and therapeutic services • Effective management of individuals seeking care • Treatment and education of sexual partners • Primary prevention by vaccination.
  • 47. Criteria for the Selection of STI Drugs 1. High efficiency (at least 95% effective) 2. Low cost 3. Safety – acceptable toxiety and tolerance 4. Organism resistance not likely to be delayed 5. Single dose if possible 6. Oral administration 7. Not contraindicated for pregnant or lactating women
  • 48. Gonococcal Isolate Surveillance Project (GISP)— Percentage of Neisseria gonorrhoeae Isolates with Resistance or Intermediate Resistance to Ciprofloxacin, 1990–2009 15 20 Intermediate Resistance Resistance Percentage NOTE: Resistant isolates have ciprofloxacin minimum inhibitory concentrations (MICs) 1 µg/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125–0.5 µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990. 0 5 10 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 Year
  • 49. Uncomplicated Gonococcal Infection; Treatment of Children Beyond the Newborn Period and Adolescents Disease Prepubertal Children Who Weigh 100 lb(45kg) Uncomplicated vulvovaginitis, cervicitis, urethritis, proctitis, or Ceftriaxone, 125 mg, IM, in a single dose OR Spectinomycin, 40 mg/kg (maximum 2g), urethritis, proctitis, or pharyngitis Spectinomycin, 40 mg/kg (maximum 2g), IM in a single dose PLUS Azithromycin, 20 mg/kg (maximum 1 g), orally, in a single dose OR Erythromycin, 50 mg/kg per day (maximum 2g/ day), orally, in 4 divided doses for 14 days
  • 50. Uncomplicated Gonococcal Infection; Treatment of Children Beyond the Newborn Period and Adolescents Disease Patients Who Weigh 100 lb(45kg) and Who are 8 Years or Older Uncomplicated endocervicitis, Ceftriaxone, 125 mg, IM, in a single dose endocervicitis, urethritis, proctitis, or pharyngitis dose OR Cefixime, 400 mg, orally, in a single dose PLUS Azithromycin (1 g, orally, in a single dose) OR Doxycycline (100 mg, orally, twice a day for 7 days)
  • 51. How Can We Help the Forgotten Age Group? • Increase their awareness about STI/HIV Risks Signs and Symptoms Prevention Through IEC campaign and peer education Through IEC campaign and peer education • Behavior Change • Establish and strengthen innovative youth friendly health services to include RTI/STI • Extend effective and appropriate intervention to adolescents and youth • Strengthen surveillance of RTI/STI