HISTORICAL PERSPECTIVE

Sexually transmitted Disease control Programme in India has been in operation

since 1946 – relying on diagnosis and treatment. Until 1990s the then existing
Maternal and Child Health approach and STD Control programme was too narrow
to deal with health problems in women. The reproductive health propleanous have
a substantial impact on female reporcluctive ability, mental health, ability to work
and perform soulire physical activities. Besides being a source of constant distress
to women, sometimes they may the starting point and earliest manifestations of
major gynecological disorders.

Reproductive health is a major and crucial component of general health and

provides a sound base for human development in response to this, a new broader
concept of reproductive health emerged which intended to offer a more
comprehensive and integrated approach to the current health needs of all women
in reproductive age group.

The International conference on population and development 1994

established an international consensus on a new approach to policies to achieve
population stabilization through reproductive health approach. In the context of
evolving a holistic approach to child survival, maternal health and contraceptive
issues, proved a turning point in the Endeavour while seeking to enhance
boundaries of reproductive health service to provide more comprehensive services.

India became a signatory to the ICPD plan of action which referenced that
no development is complete or sustainable unless gender equity, equality and
women’s empowerment are ensured. It shifted the focus from family planning to
reproductive health to be addressed with in the social, cultural and economic
context.

Following the ICPD (1994) there was a paradigm shift in the attitude
towards family planning sexual health and reproductive health in policies of the
nations world wide. It was realized that reproductive health programs should focus
the needs of actual and potential clients, not only for limiting births but also for
healthy sexuality and child bearing.
Following international conference on population and development, Cairo
in 1994 and the fourth world conference of women, Beizing 1995, India launched
the reproductive and child health programme in 1997 RCH programme phase II
has been started in 2004. The principle goal of the programme is to reduce
unwanted fertility, to address unmet needs of contraception, treat and control
reproductive for act and sexually transmitted infections, mainstreaming gender and
equity through provision of quality health care services. The programme aims at
maximum coverage by improving accessibility, availability for women of
reproductive age group, adolescents, socio economically backward groups, tribal
and slum olwellers thus ensuring equity.

RCH Phase-II was started in response to the Who first global strategy for
reproductive health 2004. Being concerned about the show progress made in his
proving reproductive and sexual health, the strategy is intended for the audience of
policy makers within governments, international agencies, professional
associations, NGO, and other institutions. In this strategy the following five
priority areas were targeted -.

(Reference:- Women empowerment and development are vital for achieving

reproductive health goals. National institute of health & comity welfare New Delhi
March 2005-6-1-2).

- Improving antenatal, delivery, postpartum and newborn care.

- Providing high quality services for family planning and infertility services.

- Eliminating unsafe abortion.

- Combating sexually transmitted infections, HIV.

- Human immuno deficiency virus infection, reproductive tract infections,

cervical cancer and other gynecological morbidities.

- Promoting sexual health.

STI/RTI management in adolescent girls and women is provided under the

RCH phase-II programme in the communities. It is cost effective and provided
through primary health care infrastructure. By introducing prevention and
management of RTI/STIS as one of the components of RCH care another goal was
set, to achieve reproductive health for all (RHFA) by 2015.

The limitations of the previous traditional approaches of treatment of STIS

by etiological diagnoses after laboratory diagnosis and treatment, a new approach
in the management of STIS was introduced. This has led to development and
advocacy of a third strategy which is the syndromic approach. The syndromic
management of STIS is operating most effectively performing better then the lab
test bread approach with many advantages like increased compliance and overall
cure rates. Syndromic case management is providing impressively high (95%)
cure rates after a single visit for individuals with STIS. Early treatments,
counseling, condom provision and ensured usage and partner treatment are a part
of the syndromic management. This has led to better cure rate and decreased
transmission of HIV significantly in the community.
 Global burden of STIS:- In all societies sTIS rank among the most common of
all infections diseases, with more than 30 infections now classified as
predominantly sexually transmitted or transmissible. In developing countries with
three quarters of the worlds population and 90% of worlds STIS such factors as
population growth, rural to urban migration, wars, and poverty create exceptional
vulnerability to disease resulting from risky sexual behaviors.

HIV has become the leading cause of death in some developing countries
and HPV and hepatitis B virus (HBV) remain important causes of cervical and
hepato cellular carcinoma respectively – the two most comment malignancies of
the developing world.

Sexually transmitted herpes simplex virus infections now cause most

genital herpes in developing countries with generalized intractable problem.

Globally five curable STIS – gonorrhea Chlamydia infection, syphilis,

chancroid and trichom caused 350 new million infections. Upto 50% of women of
reproductive age in developing countries have bacterial vaginosis. All six of these
curable infections have seen associated with increased risle of HIV transmission or
acquisition.

Harrison

Sexually transmitted infections: overview and climical approach king K Holiness

Harvisons principles of internal medicine – 2008.
124-821 – 222

Estimated prevalence and Incidence of STDs by region

Region Prevalence Incidence (per

(Per 1000) 1000)
Sub-Saharan Africa 208 254
South and Southeast Asia 128 160
Latin America and Caribbean 95 145
Eastern Europe and Central Asia 75 112
North America 52 91
Australia 52 91
Western Europe 45 77
Northern Africa and Middle East 40 60
East Asia and the Pacific 19 28
 Total 85 -

Global Burden of Sexually Transmitted infections

9 MAJOR HEALTH PROBLEMS

144
Global total 333 million

Eastern Europe and Central Asia

13 Million
North America Western Europe
14 million 16 million

East Asia and Pacific

23 million

North Africa and Middle East

9.7 million
South and Southeast Asia
150 million
Latin America and
The Caribbean Sub-Saharan Africa
36 million 65 million
Australaisa
1 million
Estimated new cases of curable TDs among adults (1995)

Who has been responsible for a services of estimates of the size of problem due to STIS.
WHO – suggested an annual total of 340 million worldwide out which 160 million
infections occur in south and south east asia.
Minimal estimates of yearly incidence of four major STDs are

Bacterial STD-
Gonorrhea – 62 million
Genital Chlamydeal infection – 92 million
 Syphilis – 12 million
Chancroid – 7 million
Roughly estimated viral STD
Gential Herpes – 20 million
Gential Human Pappiloma virus – 30 million
Source: Page 289; sTD – Parks text book of Preventive Medicine).

I. STD statistics worldwide

A World Health Organization (WHO) report published in 2001 provides

estimates of the extent of the worlds STD epidemics as they were in 1999.
The WHO estimates that 340 million new cases of syphilis, gonorrhea,
Chlamydia and Trichomoniasis occurred throughout the world in 1999 in
men and women aged 15-49 years.

Estimated Prevalence and Annual incidence of curable STDs by region

1999

Region Adult New Chlamydi Gonorrhea Syphilis

Population infections a

North America 156 14 3.93 1.56 0.107

Western Europe 203 17 5.22 1.11 0.136

North Africa &

165 10 3.15 1.47 0.364
Middle East

Eastern Europe
205 22 5.97 3.31 0.105
& Central Asia

Sub-saharan
269 69 15.59 17.03 3.828
Africa

South & South

955 151 42.89 27.20 4.038
east Asia
 East Asia &
815 18 3.27 0.244 0.244
Pacific

A World Health Organization (WHO) Report Published in 2001.

2. Reproductive Health in South East Asia Region– A Report

Country 10-24 yrs as Average age % currently % giving birth % using

% total at first married by age 20 contraceptive
population marriage (Females) (15-19 yrs)
(15-19 yrs)
(females)

BAN 34 18 48 66 25

IND 30 20 38 49 07

NEP 32 17.9 50 50 01

SRL 29 24.4 07 60 20

INO 31 21.1 17 33 36

MMR 30 22.4 16 - -

THA 30 22.7 16 24 43

Ref: Reproductive health in South East Asia Region – A Report WHO Regional Office of
South East Asia 1997 gend war – 1-8.

Sexually transmitted infections are a major public health problem in the world over and
India is no exception. It is virtually impossible to assess magnitude of the problem in
India due to lack of reliable data and gross under reporting. It is estimated that more than
40 million case are reported new cases every year and as many as 1 or 2 women in every
ten are ineffectual with a sexually transmit disease.
Ref:- Fore ward – Dr. J.V.R. Prasada Rao – Forward – National AIDS CONTROL
PROGRAMME INDIA NACO, Ministry of Health & Family Welfare GOI – July 98-1.
Management of Sexually Transmitted infections Report of an Inter country work shop
Yangon Myanmar 16-20 July 2001
India - WHO – Project – ICP RHR001

Persons with STIS may seek care in the formal health sector comprising private and
public sector based facilities.
One study in chemai showed that STIS commonly encountered include
Hepatitis B – 5.3%
Trichomoniaris – 5.1%
Chlaneydial infection – 3.9%
Gonorrhea 3.7%
HIV infection – 1.8%
Syphilis – 0.3%
Chanereid – 0.1%
World Health organization Regional Office for South East Asia New Delhi – December
2001.

1. National AIDS control organization (NACO) carried out community level survey to
estimate the STD prevalence in India in 2001 in high prevalence states which included
Andhra Pradesh.
 STD Symptoms in Female STD Symptoms in
from STD sites Female from OBG.OPD

Cervical discharge 60% 69%

Genital ulcer 24% 19%

Ulcer & discharge 11% 9%

Genital warts 5% 2%

Others 2% 1%

2. National Family Health Survey III has done a community based study self reported
prevalence of sexually transmitted infections and ST symptoms by state in women of
reproductive age.

STD STI Abnormal Genital sore STI / genital

vaginal or ulcer discharge or ulcer
discharge

Andhra Pradesh 0.2 3..0 0.4 3.1

Karnataka 0.3 2.1 0.8 2.9

Kerala 0.4 6.3 6.6 10.9

Tamil Nadu 0.2 2.3 2.9 4.0

India 1.5 9.9 2.2 11.1

Epidemiology: World wide most adults require at least one sexually transmitted
infection and many remain at risk of complications. Certain sexually transmitted
infections such as syphilis, gonorrhea, HIV infection, hepatitis B, and chancroid
are concentrated with in core population, characterized by high rates of partner
change, multiple, concurrent partners, or dense highly connected sexual networks
commercial sexual workers, and their clients, homosexual men, and persons
involved in use of illicit dings other sexually transmitted infections chamy dial
infections, genital infections with HPV > genital herpes spread in relatively low
risk pulations. HSV infections occur throughout the year with contact with persons
having active legions Genital HSV-2 I may reactivate and recur more frequently
than HSV-1.

The incidence of gonorrhea is higher in developing countries Gonorrhea is

transmitted more efficiently than in opposite direction. Who data has established
that some strains of HPV cause cervical cancer more than 95% of cervical cancers
contain HPV DNA of ancogenic types such as 16, 18, 31, 33 and 35 STI Burden in
India.
India the prevalence of RTI/STI was 28.8% in the reproductive age group women
based on the District bared rapid household survey conducted.
Current trends of STIS in India:
Sexually transmitted infections are more dynamic than other infections prevailing
in the community. The relation between sTDs and risk of HIV infection has been a
subject of interest, hence a study was conducted in the STD clinic of the
department of dermatology and sTD, JIPMER, Pondicherry, South India, between
January 1993 and December 1997 to estimate the incidence of different STDS and
frequency of HIV seropositivity among various STDs.

The study group constituted all new consecutive sTD cases having high risk
behaviour out of 1110 patients recorded, 168 were seropositive for HIV giving a
prevalence of 15.14% . Annual breakdown revealed 8.6% in 1993 to 23.52% in
1997. Mean age group was 29.8 years with a male to female ratio 3.6:3.1. HIV
was higher in group with ulcerative STDs (17.1%) than those with non ulcerative
STDs – 9.5%.
 Another study of 686 patients with STDs were analyzed for a 10 years
period 1990 among patents attending Medical College Hospital, Kottayam. There
were 504 males and 182 females. Genital ulcer diseases accounted for the
maximum number of STDs with 504 (73.5%) cases condylomate acuminate 17.5%
gonorrhea (10.1%).

Reference:- Devinder Mohan Thappa Sowmy a Kaimal sexually fransmitted

infections in India Current Status. Department of Dermatology and sTD JIPMER
Pondicherry – CME Article 2007/52/2:78-82

SEXUALLY TRANSMITTED AND SEXUALLY TRANSMISSIBLE

MICRO ORGANISMS
Bacteria Viruses Other
Transmitted in adults Predominantly by Sexual Intercourse
Neisseria gonorrhoeae vaginalls HIV (type 1 and 2 ) Tri
Chomonas
Chlamydia trachomatis Phthirus Human T-cell lymphotropic virus
pubis type 1
Treponema pallidum Herpes simplex virus type 2
Haemophilus ducreyi Human pailloma virus (multiple
genotypes)
Calymmatobacteriumm Hepatities B virus
Ureaplasma urealyticum Molluscum contagiosum virs
Sexual Transmission Repeatedly Described but Not Well
Defined or Not the Predominant Mode
Mycoplasma hominis Cytomegalvirus
Mycoplasma genitallum Human T-cell lymphotropic virus Candida
Alibicants type II
Gardeneralla varginalis and (?) Hepatitis C, D viruses Sarcoptes
scabiel
Other vaginal bacteria Herpes simplex virus type i
Group B Streptococcus (?) Epstein-Barr virus
Mobiluncus spp Homan herpesvirus type 8
Helicobacter cinaedi
Helicobacter fennelliae
SEXUALLY TRANSMITTED AND SEXUALLY TRANSMISSIBLE
MICRO ORGANISMS
Shigella spp Hepatitis A virus Giardia Lambia
Campylobacter spp. Entamoeba histolytica Entamoeba
Includes protozoa,
ectoparasites, and fungi

(Sources: Harrisons Principles of Internal Medicine – Pg. 822 Table. 124-1)

DIAGNOSTIC FEATURES AND MANAGEMENT OF VAGINAL

INFECTION
Normal
Vulvovaginal Trichomonal
Feature Vaginal Bacterial Vaginosis
Candidiasis Vaginitis
Examination
Associated with
Uninfected; Garderella vaginalis,
Biology lactobacilli Candida albicants Trichomonas vaginalis various anaerobic and/or
predominant noncultured bacteria, and
mycoplasmas
Vulvar itching and/or Profuse purulent Malodorous, slightly
Typical symtoms None
Irritation discharge; vulvar itching increased discharge
Discharge Variable; usually
Scant Often profuse Moderate
amount scant
Clear or slightly
Colour White White or yellow White or gray
white
Homogeous, low
Nonhomogeneou
Consistency Clumped; adherent plaques Homogeneous viscosity, uniformly coasts
s floccular
vaginal walls
Erythema of vaginal
Inflammation of Erythma of vaginal and
epithelium, introitus;
vulvar or vaginal None vulvar epithelium; None
vulvar dermatities, fissures
epitheium colpitis macularis
common
pH of vaginal
fluid amine Usually <4.5 Usually <5.0 May be
odeor with Usually <4.5 none Usually > 4.5 Present
none present
10% KOH
Microsocope Normal Leukocytes, epithelial Leukocytes; motile Clue cells; few
epithelial cells; cells; mycelia or trichomonads seen in 80- leukocytes; no lactobacilli
lactobacilli pseudomycelia in up to 90% of symptomatic or only a few
predominiant 80% of C albicans culture- patients, less often in the outnumbered by profuse
positive persons with absence of symptoms mixed flora, nearly always
 including G. Vaginalls
typical symptoms plus anaerobic species on
Gram's stain

Other laboratory Isolation of T vaginalis

Lsolation of Candida spp.
findings of positive NAAT
Source: Harrison’s Principles of Internal Medicine Chapter 124 page.826
Refernece: King K Hoolmess: Sexually Transmitted infections: Overinual and Chimical Approach-
Harrisonis Principles of Internal Medical – 2008 17th edition 2008 111-821-35:
 ETIOLOGY, CLINICAL AND LAB DIAGNOSIS

CANDIDIASIS

The genus candida encompasses more than 150 species ubiquitous in nature
these organisms are found on inanimate objects in foods and on animals and are
normal commensals of human. Candida is small thin walled, ovoid yeast that
measures 4-6 mm in diameter and reproduces by budding, organisms occur in
three forms.

The human pathogens are C albicans, C guilliermondii, C.krusei,

C.glabrate and few other. They inhabit the gastrointestinal tract, the female genital
tract and the skin.

Etiologic Agent: Candida is small thin walled, ovoid yeast that measures 4-6 mm
in diameter and reproduces by budding. The organism of this genus occurs in three
forms in tissue as blastospores, pseudohyphae and hyphae.

Pathogenesis: In the most serious form of Candida infection the organism’s

disseminte homogenously and form micro abscesses in organs

Innate immunity is the most important defense mechanism against

disseminated candidiasis.

Main clinical manifestations are mucocutaneous candidiasis and deeply

invasive candidiases.

Mucocutaneous: Candidiasis the clinical manifestations are mostly thrush and

vuluo vaginal candidiasis.
Vulvovaginal candidiasis: Vulvovaginal candidiasis produces valvar pruritis,
burning and irritation. Signs of candidiasis include vulvar erythema, edema,
fissures and tenderness.

John E Ewards Jr. Candidasis – Hassisons 2008-1961 1254-6.

A white scanty, vaginal discharge in the form of white plagues or cotton

chease like curds adherent loosely to vaginal mucosa. C albicans accounts for
nearly all cases of vaginal candidiasis. Vulvovaginal candidiasis occur in women
with un controlled diabetes, pregnancy, debilitation and immuno suppression.

Diagnostic Criteria: Clinical and laboratory - Based on clinical findings, scanty

discharge with thick cheesy or curdy precipitate adherent to the vagina and labia
associated with intense puritis. May be accompanied by excoriation and
inflammation of vulva and vagina.

Lab diagnosis: The diagnosis of vulvovaginal candidiasis is by demonstration of

pseudo hyphae or hyphae by microscopic examination of vaginal fluid.

To a drop of the suspension of vaginal discharge in saline on a slide, add a drop of

10% KOH solution and examine under microscope.

Gram stained smear of vaginal discharge shows – oval budding yeast calls.

Culture – on Saborauds medium reveals rounded oval shaped colonies 1-2mm in

diameter within 48-72 hrs.

Mode of Transmission:- Candida are commendable on humans most common

nosocomial pathogens.

They inhabit gastrointestinal tract, female genital tract and skin.

Predisposing factors are – Antibacterial agents, cylo toxics chemotherapy,
intrarasenlar catheters.

BACTERIAL VAGINOSIS

Bacterial vaginosis is caused by G. Vaginalis, Mycoplasma hominis and several

anaerobic bacteria – Mobilunfus, prevollella species and Pepto – streptococcus spp

Haemophilis vaginalis or gardnerella vaginalis is the most associated organism.

Clinical features:- Bacterial vaginosis is conventionally diagnosed clinically

with the Amsel criteria which are as follows.

1. Increased white homogenous molodorous vaginal discharge.

2. Vaginal discharge with a PH of >4.5

3. Liberation of a distinct fishy odor attributable to volalite amines.

4. Microscopic demonstration of clue cells coated with coccobacillary organisms

which have a granular appearance and indistinct borders.

Laboratory findings:

Grams stained samear of vaginal discharge shows – clue cells with bacilli, gram
negative rods which are gardeneralla vaginalis and pleomorphic bacteriods which
include other anaerobic bacteria.

A wet mount is prepared by mixing vaginal secretions with normal saline 1:L1
ratio and drop is placed on a lide and observed for clue cells.

Mode of transmission – Sexual transmission, vorsocomial infections and even

community acquired infection during child birth, unhygienic menstrual practices.
King – K- Holiness by Sexually transmitted infections: On review and clinical
approach – Parrisons Principles 2008-124-821-135.
 TRICHOMONIASIS

Microbiology: Various species of trichomonads can be found in mouth and

gastrointestinal tract, Trichomonas vaginalis one of the most prevalent protozoal
parasites is a pathogen of the genito urinary tract and a major cause of
symptomatic vaginitis.

Etiologic agent: Trichomonas vaginalis is a pear shaped, actively motile organism

that measures about 10x7mm inhabits the lower genital track of females and the
urethra and prostate of males. Trichomonas was originally considered a
commensal organism until 1950 when its role as sexually transmitted infection has
known,

Clinical features of vaginal trichomoniasis: Vaginal trichomoniasis

characteristically produces a profuse, yellow, purulent, homogenous vaginal
discharge with vulvar irritation and inflammation of vulvar epithelium and
petechial lesions on the cervix the so called straw berry cervix. Trichomonas is
associated with vaginitis, cervicitis, urethritis, PID and adverse birth outcomes.
Trichomonas vaginalis was originally considered a commensal organization until
1950 when its role as sexually transmitted began to evolve. Trachomonas has been
associated with vaginitis, cervicitis, ureothrits peliric inflammatory disease and a
dverse birth out comes.

Mode of Transmission: Can transmitted by direct contact, person to person

venereal contact, its prevalence is greatest among multiple sexual partners.

Laboratory findings
Wet preparation technique: The swab is agitated in 0.9% saline and a drop of this
is observed under wet mount microscopy. Motile pear shaped organism is seen in
positive specimens. Culture is the gold standard technique with a sensitivity of
more than 70% but takes upto 7days for results to be obtained.

Polymerase chain reaction and latex agglutination tests are also available.

H.Suygard, A.sena, M.Hobbs and Mhai Cohen. Trichominar, Clinicla manifestations diagnosis
and management British Medical Journal 2004 – 1801 2, 91-5 2008 – 124 – 821 -35

2. Pelvic inflammatory disease: Pelvic inflammatory disease refers to infection that ascends
from the cervix or vagina to involve the endometrium and fallopian tubes.

The agents most often implicated in PID include N. Gonorrhoease and C.Trachomatis and
organisms that can be regarded as components of an altered vaginal flora.

3. Ulcerative Genital or Perianol legions: Genital ulceration reflects a set of important STI,
most of which sharply increase the risk of sexual acquisition and shedding of HIV.

a. Syphilis: painiless, non tender non vasenlar indurated ulcers with form njon
tender inguinal adnopathy suggest primary syphilis.

b. Herpes: Atypical, clinically trival superficial tender, erythmatous nonvascular

associated with tender bilaterly lymphadenopathy.
 CLINICAL FEATURES OF GENITAL ULCERS

Lymhogranuloma
Feature Syphilis Herpes Chancroid Donovanosis
Venereum

Incubation 1-4 weeks (up to

9-90 days 2-7 days 1-14 days 3 days-6 week
period 6 months)

Papule, pustule, or
Early primary Pustule Usually vesicle Usually one,
lesions No. of Papule Usally one Vesicle Multiple mulitiple, may often not detected Papule variable
lesions coalesce despite
lymhadenopathy
Diameter 5-15 mm 1-2 mm Variable 2-10 mm Variable
Sharply
demarcated, Undermined, Elevated,
Edges Erythmatous Elevated, round or oval
elevated, round, or ragged irregular irregular
oval
Depth Superficial or deep Superficial Excavated Superficial or deep Elevated
Smooth,
Serous,
nonpurulent, Purulent, bleeds Red and velvety,
Base erythematous, Variable, nonvasular
relatively easily bleeds readily
nonvascular
nonvascular
Induration Firm None Soft Occasionally firm Firm
Frequently
Pain Uncommon Usually very tender Variable Uncommon
tender
Firm, tender, Tender, may
Tender, may suppurate, None; pseudo
Lymphadenop Firm, nontender, often bilateral suppurate,
loculated, usually
athy bilateral with initial loculated, usually buboes
unilateral
episode unilateral

Source: Harrisons’ Principles of Internal Medicine Chapter 124 page 832

GONOCOCCAL INFECTIONS

Gonorrhea is a sexually transmitted infection of epithelium and commonly

manifests as cerivicitis, urethritis, proctitis and conjunctivitis. If untreated lead to
complications such as endometritis, salpingitis, tuboovarian abscess, bartholinitis
and peritonitis in female patients. Gonorrhoea is transmitted from males to females
more efficient by than in opposite direction.

Etiologic agent: Neisseria gonorrhea is a gram negative non motile, non-spore

forming organism that grows singly and in pairs. Neisseria gonorrhoeae other
species by their ability grow on selective medoa.
Clinical manifestations: Gonococcal infection in females is the most common
STI in women. Women infected may remain asymptomatic or develop symptoms
which include – scantwaginal discharge and dysuuria and dysparunea.

P/s – Exa mination – edemators and friable cericalectopy & endo cervical
bleeding.

Physical examination way reveal a purulent discharge (Mucopus) from the

cervicaos.

Laboratory diagnosis: Grams stain of vaginal discharge – Gram negative

intracellular monococci and diplococcic. Most common STI manifests as
cervicities, urethritis, proctitis, salpingitis, tuborvarion mass, sastholinitis.
Gonerrhea is pregnancy can have serious consequences on the other and infant.
Polymorphonuclear leucocytes (PMNS) are often seen on the endocervix on grams
stain, Vaginal discharge should be incluted on to a plate of Thayer – Martin
medium for culture.

Nucleic acid probe tests are sometimes substituted for culture for direct detection
of N. Gonaorrhoeae in urogential specimens.

Mode of Transmission: Through contact, sexual contact & common in 15-19

years old women. More efficiently transmitted from males to females.

Inclubation period = 2-7 days.

Transmitted to infents during birth, from mother causing fumisiles, sepris or

ophthalmia neonatorum & Disseminalid Gonococcal infection in the new born is
one of the most common main festation:
 CHLAMYDIAL INFECTIONS

Three Chlamydial species cause human infections Chlamydia trachomatis,

Chlamydia and Chlamydophilva Psittaci and Chlamydophila pneumonia.

Chlamydia are Obligate intracellular bacteria that are classified in order

Chlamydiales. Chlamydia possess both DNA and RNA, have a cell wall and
ribosomes similar to those of gram negative bacteria. Studies with nucleotide
sequencing have delineated 20 serotypes of Chlamydia trachomatis. Serovars L1,
L2, L3 produce Lymphogranuloma venerum (LGV)

Etiological Agent: Unique feature of all Chlamydiae is their complex

reproductive cycle. Two forms of microorganism-the extra cellular elementary
body (EB) and the intracellular reticulate body (RB). EBS attach to susceptible
target cells and enter the cells inside a phagosome and reorganize into RBS which
are adapted to intracellular survival and multiplication. Genital infection caused by
chlmaesdia is the most common bacterial sexually transmitted infection.

Pathogenesis: Chlamydia trachomatis preferentially infects the columnar

epithelium of the eye and the respiratory and genital tracts.

Clinical manifestations: Non gonococcal urethritis in men and muccopurulent

cervicitis in women. C. trachomatis is identified in fallopian tubes of 50% of
women with pelvic inflammatory disease. Mucopurulent cervicitis is followed by
endometritis, endosalpingitis and pelvic peritonitis. Mild or asymptomatic
infections of fallopian tubes cause ongoing tubal damage and infertility.
Lymphogranuloma venerum is caused by Chlamydia trachomatis strains of the L1
L2 and L3 sedrovars. Also causes Fitz, Hug-curtis syndrome (Perihepatilis).
Laboratory diagnosis

Four types of laboratory procedures are available to confirm C trachomatis

infection.

Walter E stmon – Cheamy dial infections – Harisms principles – 2008 – 169 –

1070 – 3.

Direct microscopic examination of tissue scrapings for typical intracyto plasmic

inclusions or EBs.

Isolation of organism in cell cultures Direct immune fluorescent antibody slide test
by staining with fluorescein, – conjugated monoclonal antibody for Chlamydial
antigens and Observation of fluorescing EBs confirms the diagnosis.

ELISA techniques are available for detection of Chlamydial antigens.

NAATs can detect Chlamydial genes in first void urine samples and vaginal
discharge swabs.

(ELISA – Enzyme Linked Immune Sorbent Assay)

(NAAT – Nucleic Acid Amplification Test)

Age of peak incidence is late teens and early twenties (18 yeas – 24 years)

Chilamy dra trachomatis is major cause of sexually transimitted and perinatal

infection.

Mode of transmission through contact, most commonly sexually transmitted.

Incubation period – 5-14 days.

Substantial (8%) symptomatic chlamydial infection have been demonstrated in
young female military secruits in USA use of oral contracephne pills and presence
of cervical eccsopy also confer an increased risk of chlamydeal infection.
 SYPHILIS

Syphilis, a chronic systemic infection caused by Treponema Pallidum subspecies

pallidum is usually sexually transmitted.

The spirochaetales include three genera that are pathogenic for humans.

Leptospira which causes human leptospirosis, Borrelia which causes – Lymes

disease. Genus Treponema includes T pallidum subspecies pallidum causes
veneral syphilis, T.pallidum subspecies pertenue which causes yaws, subspecies
endemicum which causes endemic syphilis or bejel and T. carateum which causes
pinta.

Actiologic Agent

T. pallidum subspecies pallidum is a thin spiral organism, has a cell body

surrounded by a trilaminar cytoplasmic membrane, a delicate peptidoglycan layer
and a lipid rich outer membrane. Endo flagella wind around the cell body and are
responsible for motility.

Pathogenesis: T.pallidum penetrates into mucous membranes or micro abrasions

in skin and mucous membranes and enters the lymphatics and blood to produce
systemic infection and metastatic foci.

Clinical manifestations

Primary syphilis: Primary chancre is a single painless papule that rapidly erodes
and becomes indurated with a characteristic cartilaginous consistency on palpation
of the edge and base of the ulcer. Common sites of occurrence are cervix and labia
in women.
Secondary Syphilis: The protean manifestations of secondary syphilis are localized
or diffuse mucocutaneous lesions and generalized non tender lymphadenopathy.

Typical skin rash consisting of macular, papular, papulo squamous and pustular
lesions, mucous patches. Papules enlarge to produce condylomata late.

Typical mucous patch is a painless silvery grey erosion with a red periphery
hextlime Latent syphilis – Positive serologic tests for syphilis and absence of
clinical manifestations together with a normal CSF examination is the diagnostic
feature of latent syphilis.

Laboratory examination

Dark field microscopy and immunoflouresence antibody and staining are done to
identify spirochete in moist lesions.

Serologic tests for syphilis:

a) Non treponemal tests RPR and VDRL tests measure IgG and IgM directed
against a cardiolipin, lecithin – cholesterol antigen complex.

b) Trepomal Tests: Flourscent treponemal antibody absorbed (FTA – ABS) test.

Micro heamagglutination assay to T. pallidum.

Uses of serologic tests

1. Screening or diagnostic purpose (-RPR-VDRL)
2. Quantitative measurement of antibody to assess clinical syphilis activity and
monitor response to therapy.

3. Confirmation of a syphilis diagnosis in patients reactive to RPR and VDRL

4. Persons newly diagnosed with syphilis have to be tested for HIV.

Mode of transmission:Treponema pallidum rapidly penetrates intact mucus
membranes or microscopic abrasions in skin and spreads to lyphatics.Blood from a
patient with incubating or early slyphisis is infections.

Transmission of T. Pallidum from a symphilitic women to her fetus may occur at

any stage of pregnancy.

Median incubation period – 21 dyas.

Shelia A Lukehart – Spirochactal diseases

Haresisonis Principles: 2008 – 162 – 10038 - 45

 HERPES SIMPLEX VIRUSES

Herpes simplex viruses (HSV-1 HSV-2) produce a variety of infections involving

mucocutaneons surfaces, central nervous system and on occasion visceral organs.

Etiologic Agent

The genome of Herpes Simplex Virus is a linear double strand DNA molecule that
encodes more than 90 transcription units.

The viral genome is packaged in a regular icosahedral protein shell composed of

162 copsomeres. The outer covering of the virus is a lipid containing memberane
acquired as DNA containing capsid buds through the inner nuclear membrane of
the host cell.

Pathogenesis: Exposure to HSV at mucosal surfaces or abrased skin sites permits

entry of virus and initiation of its replication in cells of epidermis and dermis.

Genital infections: First episode of primary genital herpes is characterized by

fever, headache, malaise and myalgias pain, itching dysuria vaginal discharge and
tender inguinal lymphadenopathy are the predominant local symptoms. Widely
spaced bilateral lesions of external gentelia are characteristic.

Diagnosis

Clinical diagnosis: Presence of characteristic multiple vesicular lesions on an

erythematous base.

Lab diagnosis: Staining of scrapings from the base of lesions with Wrights,
(Giemsa’s Tzank preparation), or papanicolou’s stain to detect gaint cells or
intranuclear inclusions of herpes virus infection.
HSV DNA detection by PCR is the most sensitive laboratory technique.

Mode of transmission – Transmission can result from contact with persons who
have active ulcerative lesions or from asymplomatic persons who are shedding
virus without climicaLl man festations. The large rescovoir of unidentified
asymplomotic reactivation from the gental tract fortered contions spread of genital
Herpes through out the world. In cubation period 1- 26 days.
 HUMAN PAPILLOMA VIRUS INFECTIONS

Human papilloma viruses selectively infect the epithlium of skin and

mucous membranes. These infections may be symptomatic, produce warts and are
associated with a variety of benign and malignant neoplasms.

Etiologic Agent papilloma viruses are members of the family

Papillomaviride. They are non enveloped, measure – 50-55 nm in diameter, have
icosahedral capsids composed of 72 capsomeres and contain a double strand
circular DNA genome of 7900 base pairs.

HPV-1 causes planter wart s

HPV-6 causes anogenital warts and

GPV = 16 infection can produce cervical dysplasia and invasive

cervical cancer.

Pathogenesis: The incubation period of HPV disease usually 3-4 months and may
range from 1 month ot 2 years. All types of squamous epithelium can be infected
by HPV.

Episomal HPV DNA is present in the nuclei of infected cells in benign lesions
caused HPV. HPV infection also elicits a detectable serologic response in many
patients.

Diagnosis: Most warts are visible to the naked eye and can be diagnosed correctly
by physical examination alone.

Specific methods of virologic diagnosis include polymerase chain reaction or

hybrid capture assay to detect HPV nucleic acids.
Mode of transmission- HIV infections are transmitted through direct contact with
infected legions / close personal contact may paly arole.

Incubation period – 3-4 months (1 month to 2 years)

High Risk HPV typers such as 16, 18, 31, 33 and 45 are associated with synamous
cell carcinomas of penis, anus, vagina and rulra.

II Intgernational Studies

1. ReproSalud project conducted community based research studies in rural

women of Peru and reported that vaginaldischarge was the most common
symptom accounting for 51% followed by lower abdominal pain (29.3%), itching
(4.1%), dyspareunia (1.2%). Socio-demographic data of the women in the survey
revealed that 50% of them were married with 75% being primary literate; mean no
of pregnancies – 5.2, number of live births – 4.6 per woman and the IUCD
acceptances was 7% Common RTI/STI found in the study were bacterial vaginosis
(43.7%), trichomoniasis (16.5%), candidasis (4.5%), Muco-purulent cervicitis
(MPC) including Chlamydia infection (6.8%), Gonorrhoea (1.2%), cervical HPV
(4.9%), genital warts & ulcers (2.8%) and syphilis (1.7%), Studies conducted in
Stockholm & Sweden during 2004 reportred that the proportion of candidial
vaginitis was 12% and chlamydial cervicitis – 9% Human Papilloma Virus
infection – 11% and Herpes Simplex Virus infection was 2%. Clinic based study
in Sydney (Austrralia) in July 1999 reported that 50% of the women harbouring
these abnormal bacteria are asymptomatic. More than 3.5 million annually suffer
from RTI/STI in the United States.

2. Reproductive Health: Ever ones right every ones responsibility Rate of HIV
infection among pregnant women 1996 region wise.

3.British studies: British studies revealed thast prevalence of Chlamydia

trachomatis infection was 2.5 to 8.5% being more prevalent in adolescents.
Studies from southern Afcrica reported that Neisseria gonorrhea was 7-17% and
C. Trachomatis infection was 6-11%. Community based surveys in Uganda,
Tanzania showed that prevalence of N.gonorrheaz was 1.8 6 2.3% and C.
trachomatis was 1.6 – 13%. The higher prevalence of these infections in east and
South Africa might to some extent explained by the sex workers in these study
populations. Indian studies revealed 1-4% of Gonorrhoea Chlamydia infections.

Source of Infection: Coramouest source of infection is a human source – The

disease is maintained in core population from where it is transmitted general
population.

Mode of Transmission of STIs

- Unprotected sexual intercourse.

- The most inorportant mode of transmission in STIs is the unprotected

sexual intercourse with an infected partner – the sexual act can be aval,
vaginal or oral.

- Direct contact – STIs require direct contact of mucus membrances, or open

cuts or sores coming in contact with infected blood or other body fenids
(semen, vaginal secretions)

- Blood and blood products: Syphiclis, Hepatitis B, Hepatitis C, HIC can be

transmitted by unchecked trans fusion or people having ents and wounds
neucus mentisances exposed to blood and blood products.

- Infacted mother to child – during in utero, or while delivery due to passage

through the vaginal secretions – syphilis, hepatitis B/C, HIV herpes
genitals, gonorrhea.

- Sharing of contaminated needles – Syphitis hepatitis B/C, HIV.

(Ref- AP State AIDS control/Society)

Period of communicability:

Individuals are infective as long as they remain untreated. Some sexually

transmitted infections such as bacterial vaginosis, candidasis trichommiasis and
herpes recurs frequently even if treated and many need treatment every time
they occur in order to prevent spread others or decrease acquisition of HIV –
Diseases like syphilis and chaneriod need long term treatment.

Diseases like Hepatitis B, Hepatitis C and HIV donot return to reinfection –

levels and are infection throughout their lives inspite of treatment.

Age: Most of the sexually transmitted infections occur in the reproductive age
group with peak occurance in 15-24 years.

Ganorrhea, Candidiasis and herpes genitals occur in younger age adolescents

and are prone for recurrences.

Trichomances veginalis and bacterial vaginosis are common in married women

of reproductive agen peacking 25 – 34 years.

Reasons for high incidence of sexually transmitted infections in this age group
are

-low levels of protective cervical antibodies.

-increased sexual activity

-influence of reproductive harmones causing vast changes in tissue thast lead to

susceptibility to sexually transmitted infections Barousse MM, Vander Pol BJ,
Fortenberry D1 Orr D and Vagiral yeast colonization Fidel Jr. PL.

Gaginal yeast colonization, Prevalence of vaginitis and associated local

immunity in adolescents sexually transmited infections 2004/180/48-53.
Economy and gender mluerability:

Women’s economic and social dependency on men greatly effects the uses of
services and ability to treatments and other regimens. Women’s economic
dependence makes it impossible for women to negotiate safe sex or it forces
them to exchange sex for survival. By curtailing women’s sexual rights and
autonomy encouraging irresponsible and risky behaviour among man. Women
are more valuerable to consequences and HIV morbidity and morfality and
other sexually transmitted infections.

(S.Garg, P Sharma : Operationalizing gender in context of HBIV/AIDS Indian

Journal of Community Medicine Jul- Sep 2006 volume 31-3 – 117-9.

Literacy: Sexually transmitted infections are more common in illiterate

people.

Marital Status: Sexually transmitted infection are common in married people

and commercial sex workers and their cliehts:

Parity:- High parity is usuall associated with greater risk of STI like vaginal
infections, cervicitis, cervical erosion that may lead to encorhec in women.

Socio cultural:- A statistically significant association was found between

leucorrhea and socio economic status. This may be due to women in low socio
economic status groups have poor personal hygrene and menstrual hygience
elue to illiteracy and ignorance.

Malhutrition, poverty, illiteracy and low socio economic status – the age old
risk factors are still operating.
 (1 Ref Chakravarty BN – Cha Gupta S.K. Kunder N. Lencorrhea in
parimenopausal women. Journal of Indian Medical Assosication 1976 67 – 10-
3).

6. The prevalence of reproductive tract infections and sexually transmitted

diseases among married women in the reproductive age group in a rural area.

A community based corss sectional study of 452 married women in a rural

area of district of Sirmour H.P. in 2002, Prevalence of RTI was 51.9% with
maximum prevalence in the age group 25-34 years old – 63.6% Prevalence of
RTI was higher in illiterate women 72.2% and showed a decreasing trend with
an increase in level of educations using my contraceptive at the time of survey.

7. Estimation of Prevalence of RTIs/STDs among women of reproductive age

group in District Area.

Study done in 600 married women of reproductive age group in 60 clusters

of rural and urban area in district of Agra.

Prevalence of RTI/STD came out to be 35.2% with rural prevalence 49% than
urban prevalence 27%. More than two thirds of symptom positive women
were less than 34 years symptoms among women as per syndromic case
definition.

Symptoms Rural Urban Total

Vaginal discharge 27 287 563

Lower abdomen 167 160 327

pain

Urethral discharge 21 17 38
in partner

Out of 563 women with vaginal discharge

282 (47%) had curdy discharge

224 (37%) had water discharge

57 (10%) had mixed type

180 women – 30% of women have told their discharge was foul smelling.

Occupation: High risk groups as commercial sex workers, employees of transport

industry and people working in agricultural sector have increased risk of sexually
transmitted disease due to multiple partners and sexual promiscuity.

M. TOPPO, S.C. Tiwari, G.C. Dixit Nandeswar – Study of shedy of sTD Pattern
in Hamidia Hospital, Bhopal and its Associated Risk Factors.

Indian Journal of Community Medicine April June 2004 Vol. 2912 1 65-6.

Sex wise distribution of sexually transmitted disease.

Diagnosis Females N-69 Males N-181

Syphilis 18 (26%) 59 (32.6%)

Ganeorrhea 08 (11.5%) 40 (22.1%)

Heopes Genitalis 02 (03%) 31 (18.2%)

Chanorrid -- 18 (9.9%)
Trichomoniasis 12 (17.3%)

Candidiasis 08 (11.6%)

LGV 02 (03%)

Risk factors for STDs among men and women

Males n-181 Females n-69

N % n %

Multiple 170 (93.9) 25 36.2

Sex partner

Visit to FSW 121 (66.8) --

Touring work 49 (27.1) --

Spusehas STD 13 (7.18) 14 (20.29)

Sexual relations 137 (75.6) 20 (28.9)

Out of wetock.

4. Sexually transmitted and reproductive tract infections in female sex workers.

The study was conducted in 300 female sex workers from Surat city in 2005-06.

Prevalence of sTD among Total Percentage

FSWs n=300

HIV 35 (11.6%)

Hepatitis B 10 (3.66%)

Syphilis 20 (6.66%)
Candidiasis 31 (10.33%)

Bacterial vaginosis 40 (13.33%)

Genital Ulcer

Trichomonas 6 (2%)

Gonococci 0 (0%)