RTI/STI MANAGEMENT AND PREVENTION Dr. Dilip Kumar Das Community Medicine

1. RTI/STI MANAGEMENT AND PREVENTIONDr. Dilip Kumar DasCommunity Medicine

2. Public Health Importance of RTIs/STIs

3. What is RTI/STI ? • Reproductive Tract Infections (RTIs): Any infection of reproductive tract in male and female • Sexually Transmitted Infections (STIs): STIs are infections caused by germs such as bacteria, viruses, or protozoa that are passed from one person to another through sexual contact.

4. RTIs • RTIs in both men and women include: - STIs • RTIs in women also include: - Disruption of normal vaginal flora (Candida and bacterial vaginosis) - Postpartum and post abortion infections - Infections following procedures (e.g. IUD insertion) • RTIs in men also include: - Prostatitis and epididymitis

5. Situation in world • 340 million new cases of curative STIs every year - 75-85% in developing countries - 10 % adults newly infected with curable STIs • 12 million new cases of syphilis • 62 million new cases of gonorrhoea • 90 million new cases of chlamydia • 176 million new cases of trichomonas

6. Situation in India • Prevalence of suggestive symptoms of STIs Women: 23-43% Men: 4-9% • STI clinic data for men indicates: Syphilis: 12.6 – 57% Chlamydia: 20-30% Chancroid: 9.9 -34.7% Gonorrhoea: 8.5 – 23.9% Overall prevalence of STIs among adults: 6 %

7. Factor contributing to RTI/STI spread Human behaviour Lack of access to healthcare Lack of awareness about STIs Migrating population Healthcare providers not adequately trained Poor medical services Hygiene and environmental factors Hormonal and other factors

8. High risk groups • Adolescent boys and girls • Women who have multiple partners • Sex workers and their clients • Men and women who has to stay away from families for long • Men having sex with men • Partners of various high risk groups • Street children

9. Factors increasing risk of transmission • Biological - Age - Sex - Immune status • Behavioural - Personal sexual behaviour - Other non-sexual personal behaviour - Even without any risk behaviour • Social - Status of women in society - Sexual violence - Child marriages

10. Why women are at a higher risk? • Biological differences -Thin lining of vaginal mucosa - Larger exposed area - Genital fluids stay in contact for longer time - Young women- Immature genital tract - Symptoms less reliable indicator • Use of vaginal douches • Different socio-cultural norms for men and women

11. STI – HIV Link

12. RTIs/STIs – A Public Health Problem • Major cause of ill health in country • Cause serious complications in men and women • Increases risk of HIV transmission • Responsible for reproductive loss • Increases cost to health system

13. Barriers – system and providers side Failure to recognize magnitude Not all seek treatment form trained providers Overemphasis on lab based diagnosis Irrational use of drugs No standardized treatment regimen by all providers Less emphasis on patient education and counseling Specialized clinics carry stigma

14. Barriers – Client side Lack of knowledge Misconceptions Asymptomatic infections Reluctance to discuss sexual matters Stigma Fear of judgmental attitude of providers Reluctance for physical examination

15. Problems in management of RTIs/STIsPiot – Fransen model

16. Operational model of the role of health services in STI case management Population with STI Aware and worried Seeking care Correct diagnosis • Promotion of health care • seeking behaviour • Improve quality of care • Attitudes of personnel Correct treatment Treatment completed Cure

17. Operational model of the role of health services in STI case management Population with STI Aware and worried Seeking care • Syndromic approach • Include STI drugs in essential list • Prescribe single dose • Counsel about compliance Correct diagnosis Correct treatment Treatment completed Cure

18. Operational model of the role of health services in STI case management Population with STI Aware and worried asymptomatic STI Seeking care Correct diagnosis • Partner notification • Case finding • Screening • Selective mass treatment Correct treatment Treatment completed Cure

19. Common RTIs/STIs and their Complications Module 3

20. Common sites for RTIs/STIs

21. Common RTIs/STIs • Male and female - Gonorrhoea - Chlamydia - Syphilis - Chancroid - Genital herpes - Lymphogranulomavenerium - Trichomonas - Genital warts - Candidiasis - HIV - HBV - Scabies - Pubic lice - Molluscumcontagiosum • Only in females - PID - Bacterial vaginosis • Only in males - Epidydimitis/Orchitis

22. Symptoms and signs of RTIs/STIs in Men Urethral discharge Burning or pain during micturition or urination. Genital itching Inguinal swelling/Scrotal swelling /swollen and painful testes Blisters or ulcers on the genitals, anus, mouth, lips Itching or tingling in genital area. Warts on genitals, anus or surrounding area. Fever, body ache, muscle ache, jaundice.

23. Symptoms and signs of RTIs/STIs in Women • Unusual vaginal discharge • Genital itching • Abnormal and/or heavy vaginal bleeding • Dyspareunia • Lower abdominal pain • Blisters/ulcers on the genitals, anus, mouth, lips • Burning micturition • Itching or tingling in genital area. • Warts on genitals, anus or surrounding area. • Fever, body ache, muscle ache, jaundice.

24. Ways of classifying RTIs/STIs According to causative organisms According to modes of transmission According to most common presenting symptoms

25. According to causative organisms • Bacterial: - Gonorrhoea, Chlamydia, syphilis • Viral: - Herpes, HPV, HIV • Protozoal: - Trichomonas • Fungal: - Candidiasis • Mixed: - PID, epididymitis

26. According to modes of transmission • Endogenous infection: - yeast infection, vaginosis • Sexually Transmitted Infections: - Gonorrhoea, chlamydia, syphilis • Iatrogenic Infections: - PID following abortion or transcervical procedure

27. Complications in Men Urethral stricture Phimosis/paraphimosis Disfigurement of genitals Infertility Cardiovascular complications (syphilis) Neurosyphilis

28. Complications in Women Pelvic Inflammatory Disease (PID) Infertility Ectopic pregnancy Spontaneous abortions Stillbirths Low birth weight babies Increased susceptibility to opportunistic infections Cervical cancer Chronic pelvic pain

29. Complications in neonates Congenital eye infections – Syphilis, chlamydia, gonorrhoea Sepsis Arthritis Meningitis Infant pnumonias Mental retardation

30. Systemic infections Gastrointestinal: Proctitis, proctocolitis Renal: Acute membranous granulonephritis Neurological: GPI, Tabes dorsalis Cardiovascular: Myocarditis, aortitis Ophthalmic: Iritis, coroidoretinitis Musculoskeletal: Osteomyelitis, arthritis Septicemia

31. Approaches for RTI/STI Management Module 4

32. RTI/STI Case Management Correctly diagnosing and treating symptomatic patients. Providing patient education and partner management. Preventing re-infection

33. Steps in Clinical Case Management History taking Clinical examination Laboratory tests Diagnosis Treatment Advice and counseling Follow up

34. Approaches to RTI/STI Case Management Traditional clinical approach Laboratory assisted approach Syndromic approach

35. Traditional Clinical Approaches: Advantages Simple Inexpensive Can be used in any settings Immediate diagnosis. Immediate treatment. No lab expense.

36. Traditional Clinical Approach :Limitations Diagnosis is often incorrect or incomplete (especially in mixed infections). More than one STI is often present at the same time- focus is on diagnosing a single cause. Asymptomatic infections could not be diagnosed.

37. Lab-Assisted Approach Advantages Exact diagnosis using laboratory tests. Avoids over-treatment. Avoids wrong treatment. May avoid antibiotic resistance. Avoids the negative consequences Asymptomatic infections can also be detected.

38. Lab-Assisted ApproachLimitations Expensive. Trained laboratory technicians are needed. Infrastructure and supplies are needed. Patient must return for test results. Patient must wait for treatment.

39. Syndromic Approach • Diagnosis is based on the identification of syndromes, which are combinations of the symptoms the client reports and the signs the health care provider observes. • The provision of the most effective therapy at patient’s first contact with a health or medical facility. • The recommended treatments are effective for all the diseases that could cause the identified syndrome. • Provides single dose treatment as far as possible • Comprehensive to include patient education on risk reduction, counseling, condom promotion and provision, partner notification, follow up.

40. Syndromic Management- Advantages • Fast—the patient is diagnosed and treated in one visit. • Highly effective for most of the syndromes. • Relatively inexpensive since it avoids use of laboratory. • No need for patient to return for lab results. • All possible STIs are treated at once. • Scientifically tested in many part of the world. • Easy for health workers to learn and practice for patients. • Integrated into primary health care services more easily. • Can be used by providers at all levels.

41. Syndromic Management- Limitations • Not useful in asymptomatic individuals. • Over-treatment in patient with one STI that causes a syndrome. • Financial cost of over-treatment, side- effects. • Increases potential for antibiotic resistance especially if full course not completed. • Not effective in some cases such as vaginal discharge

42. The Syndromes Urethral discharge Vaginal discharge Genital ulcer non-herpetic Genital ulcer herpetic Lower abdominal pain Inguinal bubo Scrotal swelling

43. To sum up ……… Syndromic management is a scientific and proven approach. Syndromic approach does not deny use of lab tests, it can supplement the approach (Enhanced syndromic approach). This approach ensures correct and complete treatment of all most common organisms responsible for a particular syndrome. Syndromic management goes beyond pharmaceutical treatment to include client education and counseling. The clinical skills of a doctor are well utilized in syndromic approach.

44. Syndromic Management Flowcharts Module 4

45. Using Flow Charts • Determine the clinical problem • Pick up appropriate flow chart by looking at the clinical problem box at the top • Take history • Perform clinical examination • Make decisions based on history and clinical examination – choosing “yes” or “no” • Followed by more boxes to consider and make choices • Follow the arrows • No skipping of steps • One step at a time until you reach the end of the branch • Each exit path leads to action box - how to manage the case

46. Man complains of scrotal swelling and pain Take history & examine Painful scrotal swelling confirmed Testes normal. No history of trauma Testes rotated/ elevated or history of trauma • Treatment for Gonorrhoea and Chlamydia. • Patient Education, counselling • Provide and promote condom • Partner management Refer immediately for a surgical opinion Cured Return in 7 days if symptoms persist No improvement Refer to higher care center

47. Why Syndromic Management? Simple Treatment at first visit Treatment for all common causative organisms Standardized at all sites Patient education, an integral part

48. Criteria for Selection of Drugs • High efficacy (at least 95%) • Low cost • Acceptable toxicity and tolerance • Organism resistance unlikely to develop or likely to be delayed • Single dose • Oral administration • Not contraindicated for pregnant or lactating women

49. To sum up …………….. • The drugs use in syndromic management are chosen based on scientific criteria • Syndromic management is a comprehensive approach which includes: • Treatment of index client • Treatment of partners • Risk reduction • Client education and counseling • Referral, as necessary

50. History Taking and Risk Assessment Module 6