A lecture I gave recently for a Masters in Public Health & Epidemiology course: 'Epidemiology & impact of Sexually Transmitted Infections in Ireland'

1. Epidemiology & Impact of STIs
in Ireland
Cian O’Brien
BSc, RGN, NQEMT, MPH -Student

6. Sex = Awesome

7. STIs ≠Awesome

8. Overview
• What is an STI?
• Public Health Importance
• The most common STIs in Ireland
• Epidemiology of STIs
• Sex Education in Ireland
• The impact of STIs

9. What is an STI?
• A Sexually Transmitted Infection (STI) is any kind of
bacterial or viral infection that can be spread
through sexual contact.
• This does not just mean unprotected sex
– Some STIs can be passed on through oral sex and some
can be passed through touching and skin-to-skin contact
(Mettey et al, 2003)

11. What is epidemiology?
• Distribution and determinants of disease within a
population
– Who, what and where
• Why is epidemiology important?
– Lets us know where disease is occurring and who is getting it
– Lets us plan for control and prevention activities
• Part of the core function of public health
– Assessment
– Policy development
(Bonita et al. 2006)

12. Epidemiology of STIs in Ireland
• Changes in sexual behaviour, new diagnostic
techniques and social, economic and
demographic shifts within society have seen
remarkable changes in STI incidence rates

13. Public Health Importance
• STIs place a significant burden on healthcare
resources
• Directly
Individuals seeking treatment & care
• Indirectly
Management of complications of untreated disease
• STIs are unequally distributed, disproportionately
affect men who have sex with men, young people

14. Risk Factors for STIs
• Having unprotected sex
• Having sexual contact with multiple partners
• Having a history of STIs
• Abusing alcohol/Using recreational drugs
• Adolescent female
(Balfe & Brugha, 2009 & Svare et al. 2002)

15. Health Surveillance

16. Objectives of STI Surveillance
• Detection of changes in disease patterns to enable action to be taken
when appropriate
– Determine the extent of the problem
– Monitor trends
– Identification of ‘at risk’ groups
– Identify unusual increases and conduct investigations
• Evaluation of disease control measures
– Monitor public health interventions
– Monitor targets set out by government
• Provision of data for health service planning
– Inform service/policy developments
– Local/national campaigns (raising awareness, targeting groups)
(Lowndes & Fenton, 2004)

17. Common STIs in Ireland
Bacteria
• Chlamydia
• Gonorrhoea
• Syphilis
Viruses
• Herpes
• Genital warts
(HSPC, 2014)

18. @CianSOBrien
#STIEpidemiology

21. 70%

22. ♂
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24. Q. 2
Q. 4

25. 25%

31. Chlamydia
• Caused by bacterium, Chlamydia trachomatis
• Most commonly diagnosed STI
• 2/3 of diagnoses made in the less than 25 years
• Most individuals (70% female, 50% male)
asymptomatic
• May cause serious complications PID in women (lead
to ectopic pregnancy,urethritis, & epididymitis)
• Untreated infected pregnant women can pass the
infection on to the baby
• Once diagnosed, chlamydia is easy to treat and cure
with antibiotics

32. Epidemiology of Chlamydia
• Incidence
– Most frequently notified STI, accounting for 66.7% of
notifications in 2013 (N=6267)
– The notification rate is 134.3 per 100,000 population
• Rates 1.25 higher in females
– Higher screening rates in women
– But male screening is increasing due to urine-based
testing

34. Gonorrhoea
• Caused by bacterium, Neisseria gonorrhoeae
• Second most common bacterial STI in Ireland
• 50% of those diagnosed under 25 years old
• Proportion of cases asymptomatic (higher in
women)
• Can lead to serious complications – PID in
women
• Treated with antibiotics – problem with
development of resistance

35. Epidemiology of Gonorrhoea
• Incidence
– Number of gonorrhoea notifications continued to
increase +32.9% in 2013 (N=1294)
– Notification rate is now 24.1 per 100,000 population
which is the highest rate ever recorded in Ireland
• This rate is also much higher than the latest data
available from Europe; 12.6 per 100,000
population for 28 EU Member States in 2011

37. Herpes
• Caused by herpes simplex virus (HSV)
• Two types of HSV. Both types can cause genital
herpes
• Most common ulcerative STI in Ireland
• Efficiency of sexual transmission is greater from
men to women than from women to men
• No cure – infection is lifelong
• Antiviral drugs can reduce the length and severity
of the infection

38. Epidemiology of Genital Herpes
• Incidence
– Accounts for 12.11% of all STI notifications
(N=1138)
– Notifications of herpes simplex (genital)
decreased by 16.5% between 2012 and 2013
• The notification rate was 25.29 per 100,000
population

40. Syphilis
• Caused by bacterium, Treponema pallidum
• Uncommon but diagnoses are increasing
• High % of cases in MSM (men who have sex with
men)
• Number of stages of infection (late stages –
problems with cardiac, respiratory & CNS)
• Infection during pregnancy may cause
miscarriage, still birth or foetal abnormality if
untreated
• Treated with antibiotics

41. Epidemiology of Syphilis
• Incidence
– Accounts for 6.6% of notifications in 2013 (N=616)
– An increase of 19% in notifications since 2012
• The notification rate is 13.43 per 100,000
population

43. Genital Warts
• More than 100 types of human papillomavirus
(HPV), 40 can infect the genital tract and are
sexually acquired
• HPV types 6 & 11 cause the majority of genital
warts
• HPV types 16 & 18 are associated with genital
cancers
• Most common viral STI diagnosed in Ireland
• Most cases are diagnosed in those under 25 years
• Treated warts can reoccur

44. Epidemiology of Genital warts
• Incidence
– Accounts for 15.6% of notifications in 2012
(N=1981)
– An decrease of 24% in notifications since 2011
• The notification rate is 44.02 per 100,000
population

49. • Ireland's 'hit and miss' approach to
sex education has failed
• Many young people reach
adulthood without a proper
understanding of how their body
work
• The Dept. of Education needs to
develop a more comprehensive sex
education programme that informs
young people about sexuality and
reproduction

51. Personal Impact of STIs
• Impact of stigma associated with having an STI
• Impact of STI on sexuality
• Impact of STI on relationships
• Feelings about disclosing STI to a
regular/casual partner

52. STIs Impact Women Differently from
Men
• STIs can lead to serious health complications
and affect a woman’s future reproductive
plans
• HPV is the most common sexually transmitted
infection in women, and is the main cause of
cervical cancer
• Women who are pregnant can pass STIs to
their babies

56. What Factors Influence STI trends?
• Testing volume
– Test venue – GUM clinics, GPs
– Screening of asymptomatics
– Acceptability: non-invasive
• Diagnosis test
– Sensitivity:↑ detection of positives
– Specificity:↓ false positives
• Sexual behaviour
– Health promotion, education
• Access to care
Case Detection
Infection Transmission

57. 2
1
1 2
1
1

62. Chris and Claire
• Chris and Claire had been attracted to each
other for a long time. When they finally began
to going out, things moved very quickly and
they decided to have sex. Almost a month
after having unprotected sex with Clare, Chris
developed small, fluid-filled blisters on his
genitals.

63. 1. What should Chris do?
– Attend an STI clinic or visit his GP
2. What STI might Chris have?
– Herpes
3. How can this STI be treated?
– There is no cure for herpes. Medication can heal sores more
quickly and to reduce multiplication of the virus
4. How can Claire be protected from getting this STI?
– Use condoms and don’t have sex when sores are present or
signs of an outbreak

64. • Greg recently started at UCC. He began to
visit Rearden’s on weekends. One night, Greg
went home with Sarah, who he had just met
at the bar and they had unprotected sex. A
few weeks later, Greg experienced pain with
urination and discharge from his penis.

65. 1. What should Greg do?
– Attend an STI clinic or visit his GP
2. What STI might Greg have?
– Gonorrhea/chlamydia
3. How can this STI be treated?
– Antibiotics
4. What will happen if Greg does not get treated?
– May transmit gonorrhea/chlamydia to his sexual
partner(s) or become infertile

67. Take Home Points
• Sex = Awesome
• STIs ≠Awesome
• STIs – Bacterial or Virus
• Risk Factors
• Sexual Education
• Practice safe sex

68. Questions?
Nothing too hard,
please!

70. Reference List
• Balfe, M. & Brugha, R. (2009) What prompts young adults in Ireland to attend health services for STI testing? BMC Public Health 9 311-319
• Bonita, R, Beaglehole & Kjellstrom, T. (2006) Basic Epidemiology. 2nd edition World Health Organisation. China
• European Centre for Disease Prevention and Control. Sexually transmitted infections in Europe 2011. Stockholm: ECDC; 2013.
• Lowndes, CM & Fenton, KA. (2004) Surveillance systems for STIs in the European Union: facing a changing epidemiology. Sexually Transmitted
Infections 80 264-271
• Mettey, A. Crosby, R, DiClemente , RJ. & Holtgrave, DR. Associations between internet sex seeking and STI associated risk behaviours among men
who have sex with men Sexually Transmitted Infection 79 466-468
• Public health benefits of partner notification for sexually transmitted infections and HIV
http://www.ecdc.europa.eu/en/publications/Publications/Partner-notification-for-HIV-STI-June-2013.pdf [Accessed on 21.03.2014]
• Sex education in Ireland has failed – IFPA http://www.irishhealth.com/article.html?id=5031
• STD symptoms: Common STDs and their symptoms http://www.mayoclinic.org/diseases-conditions/sexually-transmitted-diseases-stds/in-depth/std-
symptoms/art-20047081 [Accessed 26.03.2014]
• STI Case Studieshttp://www.hawaii.edu/hivandaids/STI%20Case%20Studies%20Lesson%20Plan.pdf [Accessed 26.03.2014]
• STI Reports Health Protection Surveillance Centre http://www.hpsc.ie/hpsc/A-Z/HIVSTIs/SexuallyTransmittedInfections/Publications/STIReports/
[Accessed 26.03.2014]
• Svare, EL, Kjaer, SK, Worm, AM, Osterlind, A, Meijer, CJLM & Van den Brule, AJC. (2002) Risk factors for genital HPV DNA in men resemble those
found in women: a study of male attendees at a Danish STD clinic. Sexually Transmitted Infections 78 215-218
• SYPHILIS IN IRELAND, 2012 http://www.hpsc.ie/hpsc/A-
Z/HIVSTIs/SexuallyTransmittedInfections/Syphilis/EpidemiologicalData/AnnualReports/File,14359,en.pdf [Accessed 17.03.2014]
• Trends in sexually transmitted infections in Ireland 1995-2012 http://www.hpsc.ie/hpsc/A-
Z/HIVSTIs/SexuallyTransmittedInfections/Publications/STIReports/STIAnnualandQuarterlyReports/2012/File,14375,en.pdf [Accessed 17.03.2014]