a brief seminar about sexually transmitted infections and various government strategies to combat it

1. BY:
ABHISHEK AGARWAL
EPIDEMIOLOGY AND RECENT ADVANCES OF
SEXUALLY TRANSMITED INFECTIONS AND
REPRODUCTIVE TRACT INFECTIONS
1

2. 1990
HISTORICAL PROSPECTS OF STI / RTI
VENEREAL
DISEASES
DERIVED FROM LATIN
WORD VENEREUS
1999
SEXUALLY TRANSMITTED INFECTIONS
TO INCLUDE MORE
INFECTIONS AND
ASYMPTOMATIC CASES
2

3. SEXUALLY TRANSMITTED INFECTIONS(STIs):
“Sexually transmitted infections (STIs) are infections that are spread primarily
through person-to-person sexual contact”
REPRODUCTIVE TRACT INFECTIONS (RTIs):
“Reproductive tract infections are infections of the genital tract”
DEFINITION
3WHO

4. RTIs
Iatrogenic
infections
Endogenous
infections
BOTH STIs AND
RTIs
Syphilis
Trichominiasis
Chlamydia
Gonorrhea
STIs
HIV / AIDS
Hepatitis B
EXAMPLES OF STI AND RTI
4

5. More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide.
Each year, there are an estimated 357 million new infections with 1 of 4 STIs: chlamydia, gonorrhea, syphilis
and Trichominiasis.
More than 530 million people are living with HSV 2 that causes genital herpes.
WORLD SCENARIO OF STI / RTI
5

6. More than 290 million women have a human papillomavirus (HPV)
infection
The majority of STIs have no symptoms or only mild symptoms that may
not be recognized as an STI.
STIs such as HSV type 2 and syphilis can increase the risk of HIV
acquisition.
Over 900 000 pregnant women were infected with syphilis resulting in
approximately 350 000 adverse birth outcomes including stillbirth in 2012 .
6

7. 80%20%
INCIDENCE OF STI / RTI
DEVELOPING DEVELOPED
WORLD SCENARIO
7

8. 1%22%
37%
40%
INCIDENCE OF CURABLE STI / RTI
SYPHILLIS GONORRHOEA CHLAMYDIA TRICHOMONIASIS
WORLD SCENARIO
8

9. SCENARIO OF INDIA
9

10. CASES OF STI / RTI IN INDIA
30 MILLION CASES
5% - 6%
PREVALENCE
ICMR STUDY 2002 - 03 10

11. MEN WOMEN
6%
12%
PREVALENCE OF ANY STD
MEN WOMEN
PREVALENCE OF ANY STD
ICMR MULTICENTER RAPID ASSESSMENT SURVEY,
2005
11

12. SYPHILLIS GONORRHOEA
33570
97180
NO. OF CASES
SYPHILLIS GONORRHOEA
CASES OF SYPHILLIS AND GONORRHOEA
SEROLOGICAL SURVEY, 2013
12

13. URETHRAL
DISCHARGE, 17
VAGINAL
DISCHARGE, 45
GENITAL ULCER
(NON
HERPETIC), 10
PENICILLIN
RESISTANT
GENITAL ULCER
(NON…
GENITAL ULCER
( HERPETIC), 5
LOWER
ABDOMINAL
PAIN, 20
INGUINAL
BUBO, 1
PREVALENCE OF VARIOUS SYNDROMES
PREVALENCE OF VARIOUS DISEASES
13

14. EPIDEMIOLOGICAL DETERMINANTS
OF STI / RTI 14

15.  BACTERIAL
Neisseria gonorrhea
Chlamydia Trachomatis
Treponema Palladium
Hemophilia ducreyi
AGENT FACTORS
Mycoplasma hominis
Ureaplasma urealyticum
C. Granulomatosis
Shigella spp.
15

16. Neisseria Gonorrhea
CERVICITIS URETHRITIS EPIDIDYMITIS PELVIC INFLAMMATORY DISEASE
TREATMENT
CEFIXIME
CEFTRIAXONE
SPECTINOMYCIN
LABORATORY
GRAM STAINING
CULTURE: THAYER MARTIN
MEDIUM
SEROLOGICAL TESTING
16

17. Chlamydia Trachomatis
LGV URETHRITIS PELVIC INFLAMMATORY DISEASE
TREATMENT
AZITHROMYCIN
DOXYCYCLINE
LABORATORY
MICROSCOPY
ISOLATION: EMBRYONATED EGG
DEMONSTRATION OF ANTIGEN
DEMONSTRATION OF ANTIBODIES
CERVICITIS
17

18. Treponema Pallidium
CONGENITAL
SYPHILLIS PRIMARY SYPHILLIS
TREATMENT
BENZATHINE PENCILLIN
G
CEFTRIAXONE
LABORATORY
MICROSCOPY: DARK GROUND MICROSCOPY
SEROLOGICAL TESTS
MUCOCUTANEOUS
LESIONS
18

19. Haemophilus Ducreyi
SOFT CHANCRE
TREATMENT
SULPHONAMIDES
TETRACYCLINES
LABORATORY
MICROSCOPY
ISOLATION: FRESH CLOTTED RABBIT
BLOOD
CHOCOLATE AGAR 19

20.  VIRAL AGENTS
Herpes Simplex Virus 1,2
Hepatitis B
HPV
Molluscum Contagiosum
HIV
AGENT FACTORS
 PROTOZOAL AGENTS
Entamoeba Histolytica
Trichomonas Vaginalis
Giardia Lamblia
 FUNGAL INFECTIONS
Candida albicans
20

21. Herpes Simplex Virus
GENITAL HERPES
TREATMENT
ACYCLOVIR
LABORATORY
MICROSCOPY : TZANCK SMEAR
ISOLATION: CHICK EMBRYO
SEROLOGICAL TESTS 21

22. Hepatitis B
ACUTE AND CHRONIC
HEPATITIS
TREATMENT
ACUTE : SYMPTOMATIC
CHRONIC : ENTACAVIR
INTERFERONS
LABORATORY
SEROLOGICAL TESTS
22

23. Trichomonas Vaginalis
VAGINITIS
TREATMENT
METRONIDAZOLE
TINIDAZOLE
LABORATORY
WET MOUNT MICROSCOPY
23

24. HOST FACTORS
24

25. HOST FACTORS : BIOLOGICAL FACTORS
AGE :
YOUNGER FEMALES ARE MORE PRONE FOR STI’s
SEX:
FEMALES ARE MORE PRONE FOR STI’s
IMMUNITY :
LOW IMMUNITY PERSONS ARE MORE
PRONE 25

26. HOST FACTORS : BEHAVIOURAL FACTORS
MORE THAN 1
SEXUAL PARTNERS
FREQUENT SEXUAL
PARTNERS EXCHANGE
SEX WITH CASUAL
PARTNERS
PREVIOUS
HISTORY OF
STI
EXCHANGING SEX FOR DRUGS
EXCHANGING SEX FOR
MONEY
NOT USING CONDOMS
FOR SEXUAL
INTERCOURSE
26

27. SKIN PIERCING
CONSUMPTION OF
ALCHOHAL AND DRUGS
BLOOD
TRANSFUSION
HOST FACTORS : BEHAVIOURAL FACTORS
27

28. RURAL AREAS
RELIGION
EDUCATION
CASTE
MIGRATION
SEX
AGE OF MARRIAGE
SOCIAL FACTORS
28

29. HIGH RISK GROUPS
ADOLESCENTS
TRANSGENDER
S
STREET
CHILDREN
FEMALE SEX
WORKERS
MALE SEX
WORKERS
TRUCK
DRIVERS 29

30. WHY WE NEED TO FOCUS ON STI / RTI ?
30

31. STI / RTI are increasing and constitute one of the major cause of ill
health in our country.
STI / RTI infection increases the risk of HIV transmission.
STI / RTI causes serious complications in men and women, including
infertility.
STI / RTI are responsible for reproductive loss: Spontaneous abortion,
ectopic pregnancy, still birth, prematurity, neonatal infections.
If Left untreated and unscreened one of the serious consequences is
cervical cancer in women in India. 31

32. Pelvic inflammatory disease
Premature labor and delivery
Spontaneous abortion
Ectopic pregnancy
Infertility
Inflammation of testis
Cardiovascular and neurological complications
Cervical cancer
Deaths
Increased chances of HIV
COMPLICATIONS
32

33. 33
PREVENTION AND CONTROL OF STI / RTI
INFECTIONS

34. 34
PREGNANT WOMEN
BLOOD DONORS
INDUSTRIAL WORKERS
ARMY
POLICE
REFUGEES
PROSTITUTES
CONVICTS
SCREENING FOR HRGs

35.  EDUCATION FOR HRGs
 AT RISK OF STIs
TRUCKERS
MIGRANTS
PROSTITUTES
 ADOLESCENTS
• CONDOM AVAILABILITY IN ALL
HEALTH CENTER FACILITIES.
PATIENTS EDUCATION
35

36.  PROPER SUPPLY OF CONDOMS MEANS:
Adequate supply of condoms
Quality of condoms
Affordable condoms at health facility
Social marketing of condoms.
CONDOM SUPPLY
36

37. informing the partner(s) or spouse about the STI diagnosis
assessing the patient’s risk for HIV and deciding whether or not to
undergo testing for HIV
learning about, and coming to terms with, worrisome complications
of STIs, such as infertility and congenital syphilis
dealing with an incurable STI, such as herpes genitalis, which may be
transmitted to the partner(s) or spouse
preventing future infections, including strategies to discuss and
introduce condom use with partner(s) or spouse
COUNSELLING
37

38. 38
EARLY DETECTION AND TREATMENT

39. THE CASES
REPORTED TO
HOSPITAL
“TIP OF ICEBERG”
THE CASES NOT
REPORTED TO
HOSPITAL
“SUBMERGED PORTION
OF ICEBERG”
SOCIAL STIGMA
EMBARRASED / FRIGHTENED TO
ASK
FEAR
SHAME
CULTURAL BARRIERS
GENDER INEQUITIES
39

40. TREATMENT FOR STI / RTI
ETIOLOGIC
APPROACH
SYNDROMIC
APPROACH
TREATMENT FOR STI / RTI
40

41.  DIAGNOSIS MAY BE WRONG IN
CERTAIN CASES.
 OVER TREATMENT OF PATIENT AS
WELL AS PARTNER MAY HAPPEN.
 THE PATIENT IS DIAGNOSED AND
TREATED IN ONE VISIT.
 NO LOSS TO FOLLOW UP
 RELATIVELY INEXPENSIVE AS IT
AVOIDS USE OF LABORATORY TESTS.
SYNDROMIC APPROACH
 POSSIBLE TO GET AN EXACT DIAGNOSIS
USING LABORATORY TESTS
 AVOIDS OVER TREATMENT
 PATIENT MUST RETURN FOR TEST
RESULTS AND MUST WAIT FOR
TREATMENT TILL THE LAB RESULTS
COMES.
 MORE CHANCES OF LOST TO FOLLOW UP
 EXPENSIVE AS TRAINED LABORATORY
TECHNICIANS AS WELL AS
INFRASTRUCTURE AND SUPPLIES ARE
NEEDED
ETIOLOGIC APPROACH
COMPARISON FOR ETIOLOGIC AND SYNDROMIC APPROACH41

42. KIT 1 URETHRAL DISCHARGE
TREATMENT, HEALTH EDUCATION
COUNSELLING, EXAMINATION AND
TREAT PARTNER
LAB INVESTIGATIONS
FOLLOW UP FOR 7 – 14 DAYS
DISCHARGE PERSISTS
NO COMPLIANCE TO
TREATMENT
COMPLIANCE TO TREATMENT
START THE PROTOCOL
AGAINREFFER
CLINICAL CURE
42

43. KIT 1
SCROTAL
SWELLING
HISTORY
LAB
INVESTIGATIONS
MANAGEMENT
IN
PREGNANT WOMEN
TREATMENT
FOR
CHLAMYDIA, GONNORHEAE
EXAMINATION
SPECIFIC GUIDELINES FOR
PARTNER MANAGEMENT43

44. KIT 2 VAGINAL
DISCHARGE
HISTORY
LAB
INVESTIGATIONS
MANAGEMENT
IN
PREGNANT WOMEN
TREATMENT
VAGINITIS
CERVICITIS
EXAMINATION
SPECIFIC GUIDELINES FOR
PARTNER MANAGEMENT
44

45. KIT 3 GENITAL ULCER
HISTORY
LAB
INVESTIGATIONS
MANAGEMENT
IN
PREGNANT WOMEN
TREATMENT
IF VESICLES OR MULTIPLE
PAINFUL ULCERS
EXAMINATION
SPECIFIC GUIDELINES FOR
PARTNER MANAGEMENT
TREATMENT
IF VESICLES NOT SEEN AND
ONLY ULCERS SEEN
HERPE
S
SYPHILLIS
CHANCROID
45

46. KIT 7
INGUINAL BUBO
HISTORY LAB INVESTIGATIONS
MANAGEMENT
IN
PREGNANT WOMEN
TREATMENT
CHLAMYDIA TRACHOMATIS
HAEMOPHILUS DUCREYI
EXAMINATION
SPECIFIC GUIDELINES FOR
PARTNER MANAGEMENT
46

47. 47
SYNDROMIC APPROACH: KITS

48. 48
FACILITIES AT VARIOUS LEVELS

49. VILLAGE LEVEL
49
SERVICES
ASHA
LINK WORKERS
HEALTH WORKERS
(M/F

50. SUBCENTER LEVEL
50
SERVICES
ANM
HEALTH WORKERS
(M/F

51. PHC, CHC, UHC, RURAL HEALTH HOSPITAL, SUB
DIVISIONAL HOSPITAL LEVEL
51SERVICES
MEDICAL OFFICER
STAFF NURSE
LADY HEALTH VISITOR
LAB TECHNICIAN

52. DISTRICT HOSPITAL / MEDICAL COLLEGES
HOSPITALS
52SERVICES
MEDICAL OFFICER
STAFF NURSE
COUNSELLOR
LAB TECHNICIAN

53.  Service Providers:
Medical Officer
Counsellor
ANM
 Modalities:
Static Clinic
Referrals
Services for High Risk Group at Target
Intervention Projects
53

54. REGIONAL STI TRAINING RESEARCH
LABORATORY
54
MICROBIOLOGIST
LAB TECHNICIAN
EXPERTS FROM OTHER
DEPARTMENTS
Validation of syndromic diagnosis
Monitor Gonococci drug resistance patterns
Conduct Syphilis EQAS
STI / RTI Surveillance

55. SBVP HOSPITAL
55
MEDICAL OFFICER
COUNSELLOR
SURAKSHA CLINIC
PPTCT CENTRE
VCTC CENTRE

56. 56
EXISTING POLICIES TO COMBAT STI / RTI
BURDEN

57. 57
 Previously called STD Control Program
 Running under NACP and RCH II program since
1992.
National STI/RTI Control and
Prevention Programme

58. 58
TENETS OF THE PROGRAM
Reduce STD cases and there by control HIV
transmission by minimizing the risk factors.
Prevent the short term as well as long term
morbidity and mortality due to STD.

59. 59
Develop adequate and effective program management
Promote IEC activities for the prevention of transmission of STD and HIV infection.
Make adequate arrangement for comprehensive case management including
diagnosis, treatment, counseling, partner notification and screening for diseases.
Increasing access to health care for STD by strengthening existing facilities and
structures.
STRATEGIES

60. 60
 Launched in 1999
 Funded by NACO
 Objective : to reduce the new infection.
 Services :
SURAKSHA CLINIC
TARGET INTERVENTION NGOs
BLOOD BANKS
ART CENTRES
STRENGTHENING SIMS
UP STATE AIDS CONTROL SOCIETY (UP SACS)

61. 61
CHARACTERISTIC INDIA UP
STI CLINICS 1,115 96
STI EPISODES
TREATED IN 2013 - 14
67,68,225 4,95,720
PRESENT SITUATION
STATE FACT SHEET, NACO,
2014

62. 62
SURAKSHA CLINIC UP MEERUT
SURAKSHA CLINIC 98 03
TARGET
INTERVENTION NGO
84 01
INFRASTRUCTURE
UP SACS,2015-16

63. 63
CHALLENGES WITH MANAGEMENT OF STI /
RTI

64. 64
LACK OF KNOWLEDGE
MISCONCEPTIONS
TREATMENT BY
QUACKS
EXAMINATION BY PERSON OF
OPPOSITE SEX
FEAR TO DISCUSS

65. 0 20 40 60 80 100 120
WOMEN WITH STI / RTI
SEEK TREATMENT
TREAT CORRECTLY
TREATMENT EFFECTIVE
PIOT - FRANSEN MODEL
PIOT FRANSEN MODEL:
PROBLEMS IN MANAGEMENT OF RTI
65
ASYMPTOMATIC CASES

66. ELIMINATION OF PARENT TO
CHILD TRANSMISSION OF SYPHILIS
REVISION OF TREATMENT GUIDELINES
STRATEGIC INFORMATION
MANAGEMENT SYSTEM (SIMS)
SUSTAINABLE
DEVELOPMENT GOALS
RECENT ADVANCES
66

67. 67
EARLY REGISTRATION
EARLY SCREENING FOR BOTH SYPHILIS AND HIV
FOLLOW UP OF NEW BORN UPTO 18 MONTHS
ELIMINATION OF PARENT TO CHILD
TRANSMISSION OF SYPHILIS
HIV, ANNUAL REPORT,NACO 2015 - 16

68. 68
COMPUTER MANAGEMENT INFORMATION
SYSTEM
CMIS TO SIMS
STRATEGIC INFORMATION MANAGEMENT
SYSTEM
200
2
200
8

69. Anti microbial resistance.
Changing epidemiology of STIs
Updation of Syndromic Management
New Rapid Point of Care of Diagnostic Tests (POCTs)
Access to technology is needed.
WHY WE NEED REVISION OF TREATMENT
GUIDELINES:
69

70. PHASES TOPICS TIMEFRAME
PHASE 1 TREATMENT OF SPECIFIC STIs:
CHLAMYDIA TRACHOMATIS, NISSERIA
GONORRHOEA
HSV 2, TREPONEMA PALLIDIUM
SYPHILLIS SCREENING AND TREATMENT OF
PREGNANT WOMEN
NOVEMBER
2013 – APRIL
2016
STI SYNDROMIC APPROACH
CLINICAL MANAGEMENT PACKAGE
MAY 2016 –
DECEMBER
2017
PHASE 2 STI PREVENTION: CONDOMS, BEHAVIOUR CHANGE
COMMUNICATION, BIOMEDICAL INTERVENTIONS
AND VACCINES
2017 – 18
PHASES OF DEVELOPMENT OF STI / RTI GUIDELINES
70

71. PHASES TOPICS TIMEFRAME
PHASE 3 TREATMENT OF SPECIFIC STIs / RTIs NOT
ADDRESSED
IN PHASE 1:
TRICHOMONAS VAGINALIS, BACTERIAL VAGINOSIS
CANDIDA ALBICANS, H. DUCREYI, KLEBSIELLA
HPV, SARCOPTES SCABEI, PHTHIRUS PUBIS
2017 - 18
PHASE 4 STI LABORATORY DIAGNOSIS AND SCREEING 2017 – 18
PHASES OF DEVELOPMENT OF STI / RTI GUIDELINES
71

72. 72
GOAL
“Ending Sexually transmitted infection epidemics as
major public health concern”
SUSTAINABLE DEVELOPMENT GOALS

73. 73
TARGETS
90 %
REDUCTION
90 %
REDUCTION
90 %
COVERAGE
< 50 /
100,000
CASES
TO BE
ACHIEVED BY
2030

74. 74
SUMMARY

75. 75
1. Prak’s Textbook of Preventive and Social Medicine,
K.Park, 23rd edition, 2015, M/s Banarsidas Bhanot.
2. National Health Programs of India, J.Kishore’s, 11th
edition.
3. WHO guidelines for the Treatment of Gonorrhea, 2016
4. WHO guidelines for the Treatment of Syphilis, 2016
5. WHO guidelines for the Treatment of Chlamydia, 2016
6. Global health sector strategy on Sexually transmitted
Infections, WHO, 2016
7. Training of Medical officers to deliver STI / RTI Service,s,
Participants Handout, NRHM, NACO, 2005 – 2012.
References

76. 76
1. State fact sheet, March 2014, Department of AIDS Control,
NACO, MOHFW.
2. Operational Guidelines for programme providers, for
strengthening STI / RTI Services, MOHFW, May 2011
3. National STI / RTI Control Program, NACP, Phase III, NACO,
MOHFW.
4. WHO, Fact Sheets, Sexually Transmitted Infections, August
2016.
5. Images : Google Search engine
6. www.upsacs.in, last accessed on 3/11/2016
7. www.naco.gov.in last accessed on 3/11/2016
8. Annual AIDS Report, NACO, 2015 – 16
References

77. 77
1. https://en.wikipedia.org/wiki/Sexually_transmitted_infe
ction last accessed on 3/11/16
2. Ananthnarayan Text book of microbiology, 7th Edition.
References

78. 78
THANK YOU