Sexually Transmitted Diseases

(STDs)

Imran Ahmed Abdulkadir

BSPH, M.Sc. PTH
Dec. 2022
 Sexually Transmitted Diseases (STDs)
• Definition
• Sexually transmitted infections (STIs) are infections that
are spread primarily through person-to-person sexual
contact.

• They are one of the most common group of infectious

diseases worldwide.
• The incidence of complications is high.
• They play a role in the transmission of the HIV.
 Scope of the problem
• In 2020, WHO estimated 374 million new infections with 1 of 4
STIs: chlamydia (129 million), gonorrhoea (82 million), syphilis
(7.1 million) and trichomoniasis (156 million).
• More than 490 million people were estimated to be living with
genital herpes in 2016, and an estimated 300 million women
have an HPV infection, the primary cause of cervical cancer
and anal cancer among men who have sex with men.
• An estimated 296 million people are living with chronic
hepatitis B globally.
 Scope of the problem
• STIs have a direct impact on sexual and reproductive
health through stigmatization, infertility, cancers
and pregnancy complications and can increase the
risk of HIV.
• Drug resistance is a major threat to reducing the
burden of STIs worldwide.
Estimated new cases of curable sexually transmitted infections
(gonorrhoea, chlamydia, syphilis and trichomoniasis
 Complications and Consequences
• STIs can have serious consequences beyond the immediate
impact of the infection itself.
• STIs like herpes, gonorrhoea and syphilis can increase the risk
of HIV acquisition.
• Mother-to-child transmission of STIs can result in stillbirth,
neonatal death, low-birth weight and prematurity, sepsis,
pneumonia, neonatal conjunctivitis and congenital
deformities.
• HPV infection causes cervical cancer.
• Hepatitis B resulted in an estimated 820 000 deaths in 2019,
mostly from cirrhosis and hepatocellular carcinoma (primary
liver cancer).
• STIs such as gonorrhoea and chlamydia are major causes of
pelvic inflammatory disease (PID) and infertility in women.
 Transmission of STDs
• The main ways STDs are transmitted are:
• By intimate, usually sexual, contact – horizontal
transmission.
• STIs are spread predominantly by sexual contact, including
vaginal, anal and oral sex.
• From a pregnant mother to her child – vertical transmission.
• Many STIs—including syphilis, hepatitis B, HIV, chlamydia,
gonorrhoea, herpes, and HPV—can also be transmitted
from mother to child during pregnancy and childbirth.
• Via contaminated blood products.
• Some STIs can also be spread through non-sexual means
such as via blood or blood products.
 Risk determinants and markers
• Risk determinants are variables that are direct related to the
risk of STDs.
• Risk markers are variables associated with, but not direct
related to STD.
• Risk determinants and markers affect the individual’s
probability of:
• Exposure to an STDs
• Infection following exposure
• Complications of infection.
 Risk determinants of STDs

Sexual behaviours Health behaviours

• Number of partners
• Use of barrier contraception
• Rate of new partner
acquisition
• Sexual orientation
• Sexual practices.
• Willingness to seek medical
advice
• Referral of partners
• Compliance with therapy
• Vaginal douching
• Choice of health care.
 Risk markers
• These are variables that are associated with, but not
direct related to, STDs. They include:
• Age
• Gender
• Ethnic origin
• Marital status
• Rural or urban residence
 Types of STDs
• For epidemiological purposes, STDs can be
divided into:
• Curable STDs
• Incurable STDS
 Types of STDs
• STDs defined as curable by • Incurable STDs are more
the WHO are: common than curable STDs
• Gonorrhoea in developing countries.
• Chlamydia • They include infection with:
• Syphilis • Genital human
• Chancroid papillomavirus (HPV)
• Trichomoniasis • Herpes simplex virus
(Parasitic infection) (HSV)
• HIV
• Hepatitis B virus (HBV).
 Core groups
• For an STDs pathogen to remain in a human
population it must:
• Infect a human host
• Be transmitted from that host to at least one more
susceptible individual.
• Core groups: a core group member is an individual
whose average rate of sex partner change is high
enough to keep more one.
 Modifiable risk determinants
• For the prevalence of a disease to fall, Specific measures to
be achieve include:
• Use of condoms?
• Condoms are important in reducing transmission of STDs
among individuals with high rate of sex partners change.
• Treatment of STDs
• Diagnosis and effective treatment of STDs reduces the
duration of infection.
• Sexual behaviour change
• Education and skill building exercises to modify sexual and
health care hebaviour will help to reduce the:
• Transmission of STDs and Rate of sex partner change
 Bacterial STDs
Gonorrhoea
• Gonorrhoea is caused by Neisseria gonorrhoeae, a
Gram-negative diplococcus.
• Incubation period is 2-14 days.
• Modes of transmission:
• Sexual contact (most symptoms present between
2-5 days).
• Mother to child transmission.
 Clinical features of gonorrhoea

Males Females
• Urethral discharge • Vaginal discharge
• Dysuria • Urethritis
• Pharyngitis • Pharyngitis
• Rectal involvement • Rectal involvement
• Disseminated infection • Disseminated infection
• Complications • Complications
• Epididymitis • PID
• Prostatitis • Infertility
• Infertility • Infection of Bartholin’s
• Urethral stricture gland.
Gonococcal urethritis Gonococcal cervicitis
Gonorrhea - gram stain of urethral Bartholin’s abscess
discharge
Disseminated gonorrhea - skin lesion

Gonococcal ophthalmia
 Diagnosis and treatment
• Diagnosis techniques on samples from the urethral, cervix,
throat and rectum are:
• Microscopy and culture.
• Treatment
• Single dose antimicrobial for uncomplicated anogenital
infection include:
• Ciprofloxacin
• Cefixime
• Ceftriaxone
 Genital chlamydial infections
• Genital chlamydial infections are caused by Chlamydia
trachomatis. Serotypes:
• D – K cause urethritis, salpingitis (inflammation of the
fallopian tubes) and proctitis (inflammation of the
rectum and anus).
• L1 and L3 cause lymphogranuloma venereum (LGV).

• It has an incubation period of 1–3 weeks.

• Mode of transmission:
• Sexual contact
• It is mostly asymptomatic.
 Clinical features of genital chlamydial infections

Males Females
• Urethritis • Urethritis
• Epididymitis • PID
• Proctitis • Cervicitis
• Bubo and genital ulcer • Proctitis
• Bubo and genital ulcer (LGV)

Complications
• Female infertility secondary to PID
• Late complication of LGV
• Neonatal conjunctivitis and pneumonia.
 Diagnosis and treatment
• Diagnosis techniques on samples from the urethra, cervix etc
include:
• Tissue culture, ligase chain reaction (LCR), enzyme immunoassay
and Blood for LGV.
• Treatment
• Recommended antimicrobials include:
• Doxycycline
• Tetracycline
• Erythromycin
• Azithromycin
 Chancroid
• Chancroid is caused by Haemophilus ducreyi, a
Gram-negative bacillus.

• Clinical features
• Papules
Genital lesions
• Pustules
• Ulcers
• Lymphadenopathy
 Complications include:
secondary infection of
ulcers, phimosis, fistulae
rs
lce
id u
o
ncr
Cha

Chancroid Male - regional

adenopathy
 Diagnosis and treatment
• Diagnostic techniques include:
• Culture
• Antibody and DNA detection
• Microscopy has low specificity and is not recommended.
• Treatment: recommended antimicrobials include:
• Erythromycin
• Co-trimoxazole
• Ciprofloxacin
• Azithromycin
• Ceftriaxone
 Syphilis
• Syphilis is caused by the spirochaete Treponema
pallidum, subspecies pallidum.

• Stages Syphilis
• Primary
• Secondary
• Latent (asymptomatic)
• Tertiary
 Stages Syphilis
• Primary syphilis has three stages:
• A painless papule at the site of inoculation
• Ulceration of the papule to form a chancre.
• Inguinal lymphadenopathy.
• Clinical features of secondary syphilis include:
• A rash that affects the trunk, palms and soles.
• Mucosal ulcers
• Condylomata lata
• Generalized lymphadenopathy.
 Syphilis - Images

Primary stage syphilis Primary stage Primary stage syphilis

sore (chancre) on syphilis sore sore (chancre) on the
glans (head) of the (chancre) inside the surface of a tongue.
penis. vaginal opening.
 Secondary stage Secondary stage Secondary syphilis
syphilis sores (lesions) syphilis sores rash on the back.
on the palms of the (lesions) on the
hands. bottoms of the feet.

Lesions of secondary
syphilis.
Condylomata lata
 Stages Syphilis
• Tertiary (late) syphilis
• This occurs after many years of latency. Clinical
features include:
• Bening gumma of the skin, bone and viscera.
• Neurological involvement, eg. tabes dorsalis
• Cardiovascular involvement
 Diagnosis
• Diagnostic techniques include:
• Dark-field microscopy
• Nonspecific test such as:
• Venereal disease research laboratory (VDRL) rest.
• Rapid plasmin reagin (PRP) test.
• Specific test:
• Treponema pallidum haemagglutination assay
(TPHA).
 Treatment
• Recommended antimicrobials include:
• Benzathine penicillin G
• Aqueous crystalline penicillin G
• Procaine penicillin
• Doxycycline
 Trichomoniasis
• Parasitic Infection.
• Etiology:
• Trichomonas Vaginalis (Flagellated protozoa), it can attach
to the squamous epithelium infecting the vagina and
urethra.

• Mode of transmission:
• Sexual contact.
• Perinatally, from mother to child.
 Signs and symptoms
• Men:
• Usually present as the asymptomtic sexual partners of
infected women.
• They may complain of urethral discharge, irritation or urinary
frequency.
• Women:
• The major complaint are vaginal discharge.
• Local irritation.
• The cervix may have multiple small hemorrhagic areas which
lead to the description ‘strawberry cervix’.
 Complications
• Genital inflammation, making it easier to get infected
with other STIs.
• During pregnancy
• Preterm delivery
• Low birth weight

Strawberry cervix
 Diagnosis and Treatment
• Diagnosis:
• Dark-ground microscopy.
• Culture techniques are good and confirm the
diagnosis.
• Treatment:
• Metronidazole is the treatment of choice.
 Viral STDs

Genital herpes
• Genital herpes is caused by the herpes simplex virus
(HSV).
• It is DNA virus of two types:
• Type 1 – mainly orolabial herpes
• Type 2 – mainly genital herpes
 Primary infection
• The first episode of genital herpes is the most severe.
• Clinical features include:
• Genital ulcers
• Genital discharge
• Inguinal lymphadenopathy (groin)
• Fever
• Malaise
• Complications
• Local, eg. Secondary infection
• Neonatal infection
 Diagnosis
• Laboratory methods include:
• Cytological staining
• Tissue culture
• Antigen detection test
• DNA detection

• Genital herpes cannot be cured. Aciclovir reduces

disease progression.
 Genital warts
• Genital warts are causes by the double
stranded DNA human papilomavirus (HPV).

• More than 20 of the 70 different subtypes can

cause lesions of the genital tract.
 Clinical manifestation
• Sites of warts • Genital HPV lesions are:
• Male • Papular or macular initially.

• Corona sulcus, Frenulum,

Urinary meatus, Urethra , • The association between HPV
Perianal area. and carcinoma of the cervix is:
• Well established
• Female
• Associated with certain
• Fourchette, Vulva,
subtypes of HPV (16, 18, 33,
Perineum , Cervix, Vagina 35)
, Anus.
 Hepatitis B
• Hepatitis B is a potentially life-threatening liver infection
caused by the hepatitis B virus (HBV).
• It is a major global health problem. It can cause chronic
infection and puts people at high risk of death from cirrhosis
and liver cancer.

• Hepatitis B virus (HBV), a hepadnavirus, double-stranded DNA

virus.

• Geographical distribution: Worldwide.

 Mode of transmission
• In highly endemic areas, hepatitis B is most commonly
spread from mother to child at birth (perinatal
transmission).
• The development of chronic infection is very common in
infants infected from their mothers or before the age of 5
years.
• Hepatitis B is also spread by needlestick injury, tattooing,
piercing and exposure to infected blood and body fluids,
such as saliva and, menstrual, vaginal, and seminal fluids.
• Sexual transmission of hepatitis B may occur, particularly in
unvaccinated men who have sex with men and heterosexual
persons with multiple sex partners or contact with sex
workers.
• Transmission of the virus may also occur through the reuse
of needles and syringes either in health-care settings or
among persons who inject drugs. In addition, infection can
occur during medical, surgical and dental procedures,
through tattooing, or through the use of razors and similar
objects that are contaminated with infected blood.
 Incubation period
• The hepatitis B virus can survive outside the body for at
least 7 days. During this time, the virus can still cause
infection if it enters the body of a person who is not
protected by the vaccine.

• The incubation period of the hepatitis B virus is 75 days

on average, but can vary from 30 to 180 days. The virus
may be detected within 30 to 60 days after infection and
can persist and develop into chronic hepatitis B.
 Symptoms and signs
• Acute hepatitis B does not often cause symptoms and signs,
but when it does, patients can have fatigue, nausea,
vomiting, abdominal pain and jaundice (yellowing of the skin
and eyes).

• Chronic hepatitis B patients have signs related to liver failure

(such as swelling of the abdomen, abnormal bleeding and
changing mental status) as the disease progresses.
• Other serious complications that occur in people with
chronic infection include cirrhosis and liver cancer.
 Prevention and control of STDs
• The key aims of prevention and control are to:
• Interrupt the transmission of STD infection.
• Prevent the development of STDs and their
complications.
• Control elements
• Effective management
• Trained staff
• Primary prevention
• Secondary prevention
• Support components, eg. Research
• Target intervention.
 Primary and secondary prevention
• Primary prevention strategies aims to prevent exposure to
STDs in uninfected individuals.
• Health education, eg. To reduce high risk behaviour.
• Promotion and provision of condoms.
• Secondary prevention strategies aim to provide care for
infected individuals.
• STD treatment and prophylaxis
• Partner modification and management
• Screening for asymptomatic infection.
HPV vaccines for girls aged between 9 and 13 years
Type of vaccine Recombinant protein capsid, liquid vaccine
Total number of doses 2
Bivalent (HPV types 16 and 18; • There is no maximum interval between
GSK Cervarix®) doses – as long as the girl is under 15
years of age at the time of the first dose,
Quadrivalent (HPV types 6, 11, two doses are sufficient
16 and 18; Merck Gardasil®) • If the interval between doses is less than 5
months, a third dose should be given at
least 6 months after the first dose.
• Note: For females >15 years of age, or
who are known to have a compromised
immune system and/or are HIV-infected, a
3-dose schedule (at 0, 1 or 2 and 6
months) is recommended.
Contraindications Anaphylaxis or hypersensitivity (allergy) after a
previous dose
Adverse events Mild: injection site reactions; fever, dizziness,
nausea
Special precautions • Postpone vaccination for pregnancy
• Adolescents should be seated during
injections and for 15 minutes afterwards since
they sometimes faint.
Dosage 0.5 ml
Injection site Deltoid muscle of upper arm
Injection type Intramuscular
Storage • Between +2 °C and +8 °C
• Do not freeze
 HepB-containing vaccine
Type of vaccine Recombinant DNA or plasma-derived
Total number of doses 3 or 4 (including birth dose)

HepB birth dose followed • 3-dose primary series: stand-alone HepB as

by pentavalent soon as possible after birth (<24h),
pentavalent1, pentavalent3
• 4-dose primary series: stand-alone HepB as
soon as possible after birth (<24h),
pentavalent1, pentavalent2, pentavalent3
• Minimum interval of 4 weeks between doses
required for both series.
Contraindications Anaphylaxis or hypersensitivity (allergy) after a
previous dose.
Adverse events Mild: injection site reactions (pain, redness,
swelling); headache; fever
Special Use only stand-alone HepB vaccine for the birth
precautions dose (do not use pentavalent vaccine for the birth
dose).

Dosage 0.5 ml
Injection site • Anterolateral (outer) thigh in infants
• Deltoid muscle of upper arm in older children
and adults

Injection type Intramuscular

Storage • Between +2 °C and +8 °C
• Do not freeze
Thanks