Sexually transmitted diseases
Kolářová M., EPI Autumn 2017
More than 30 different bacterias, viruses and parasites
are known to be transmitted through sexual contact.
Eight of these pathogens are linked to the greatest
incidence of sexually transmitted diseases.
Of these 8 infections:
4 are currently curable: syphillis, gonorrhoea,
chlamydia and trichomoniasis.
the other 4 are viral infections and are incurable:
hepatitis B, herpes simplex virus (HSV or herpes),
HIV, and human papillomavirus (HPV).
Symptoms or disease due to the incurable viral infections
can be reduced or modified through treatment.
 STIs are spread predominantly by sexual
contact, including vaginal, anal and oral sex.
 Some STIs can also be spread through nonsexual
means such as via blood or blood
products.
 Many STIs—including chlamydia,
gonorrhoea, primarily hepatitis B, HIV, and
syphilis—can also be transmitted from
mother to child during pregnancy and
childbirth and through breastfeeding.
 A person can have an STI without having
obvious symptoms of disease.
 Common symptoms of STIs include:
 vaginal discharge,
 urethral discharge or burning in men,
 genital ulcers,
 and abdominal pain.
Key facts
• More than 1 million STIs are acquired every day.
• Each year, there are estimated 357 million new infections with 1 of 4
STIs:
 chlamydia (131 million),
 gonorrhoea (78 million),
 syphilis (5.6 million) and
 trichomoniasis (143 million).
More than 500 million people are living with genital HSV (herpes) infection.
At any point in time, more than 290 million women have an HPV infection,
one of the most common STIs.
• STIs like herpes and syphilis can increase the risk of HIV
acquisition three-fold or more.
• Mother-to-child transmission of STIs can result in stillbirth,
neonatal death, low-birth-weight and prematurity, sepsis,
pneumonia, neonatal conjunctivitis, and congenital deformities.
Over 900 000 pregnant women were infected with syphilis
resulting in approximately 350 000 adverse birth outcomes
including stillbirth in 2012.
• HPV infection causes 528 000 cases of cervical cancer and
266 000 cervical cancer deaths each year.
• STIs such as gonorrhoea and chlamydia are major causes of
pelvic inflammatory disease (PID) and infertility in women.
Vaccines
 Safe and highly effective vaccines are available for 2 STIs: hepatitis B and HPV.
These vaccines have represented major advances in STI prevention. The
vaccine against hepatitis B is included in infant immunization programmes in
93% of countries and has already prevented an estimated 1.3 million deaths
from chronic liver disease and cancer.
 HPV vaccine is available as part of routine immunization programmes in 65
countries, most of them high- and middle-income.
HPV vaccination could prevent the deaths of more than 4 million women over
the next decade in low- and middle-income countries, where most cases of
cervical cancer occur, if 70% vaccination coverage can be achieved.
 Research to develop vaccines against herpes and HIV is advanced, with
several vaccine candidates in early clinical development.
Research into vaccines for chlamydia, gonorrhoea, syphilis and
trichomoniasis is in earlier stages of development.
Other biomedical interventions
• Other biomedical interventions to prevent some STIs include
adult male circumcision and microbicides.
• Male circumcision reduces the risk of heterosexually acquired
HIV infection in men by approximately 60% and provides some
protection against other STIs, such as herpes and HPV.
• Tenofovir gel, when used as a vaginal microbicide, has had
mixed results in terms of the ability to prevent HIV acquisition,
but has shown some effectiveness against HSV-2.
SYPHILIS
The bacterium Treponema pallidum. It is susceptible to the
environment
After an incubation period of 10 to 90 days (three weeks on average) clinical
symptoms appear: at first a primary lesion at the site of infection (chancre),
then a series of eruptions on mucous membranes and skin (secondary
syphilis), followed by long periods of latency (latent or tertiary syphilis). If
untreated, many years after the initial infection, tertiary syphilis lesions might
finally appear (visceral, multi-organ involvement, including serious vascular and
neurological damage).
By direct contact through infectious exudates of infected persons - most commonly
through sexual intercourse (saliva, sperm, blood, vaginal secret).
Transmission by blood transfusion - a blood donor in a seronegative stage.
Transplacental transmission or intranatal infection – (congenital syphilis).
General
The source
of infection
Route of
transmission
Etiology:
Susceptibility
Preventive measures:
Health education aimed at young people. Active search for persons with latent syphilis , and
adequate treatment. Serologic examination of females in the early stage of gravidity prevention
of congenital syphilis
10
Helical structure of Treponema pallidum with the periplasmic flagella.
Buygenericmds.com
12
Secondary syphilis with typical skin rash.
SYPHILIS (Treponema pallidum)
• Clinical Criteria
• — Primary syphilis
Any person with one or several (usually painless) chancres in the genital,
perineal, anal area or mouth or pharyngeal mucosa or elsewhere
extragenitally
• — Secondary syphilis
Any person with at least one of the following five:
• — Diffuse maculo-papular rash often involving palms and soles
• — Generalised lymphadenopathy
• — Condyloma lata
• — Enanthema
• — Allopetia diffusa
• — Early latent syphilis (< 1 year)
A history of symptoms compatible with those of the earlier stages of
syphilis within the previous 12 months
• — Late latent syphilis (> 1 year)
Any person meeting laboratory criteria (specific serological tests)
• Laboratory Criteria
• At least one of the following four laboratory tests:
— Demonstration of Treponema pallidum in lesion exudates or tissues by
dark-field microscopic examination
— Demonstration of Treponema pallidum in lesion exudates or tissues by
DFA test
— Demonstration of Treponema in lesion exudates or tissues by
PCR
— Detection of Treponema pallidum antibodies by screening test (TPHA,
TPPA or EIA) AND additionally detection of Tp-IgM antibodies (by IgMELISA,
IgM immunoblot or 19S-IgM-FTA-abs) — confirmed by a second
IgM assay
• Epidemiological Criteria
• — Primary/secondary syphilis
• An epidemiological link by human to human
(sexual contact)
• — Early latent syphilis (< 1 year)
• An epidemiological link by human to human
(sexual contact) within the 12 previous months
• Case Classification
• A. Possible case NA
• B. Probable case
• Any person meeting the clinical criteria and
with an epidemiological link
• C. Confirmed case
• Any person meeting the laboratory criteria for
case confirmation
0 1000 2000 3000 4000 5000 6000 7000 8000
Belgium
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Dominican Republic
Estonia
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Italy
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Norway
Poland
Portugal
Romania
Slovakia
Slovenia
Spain
Sweden
United Kingdom
Trend in the number syphillis cases by transmission category, EU/EEA, 2009-2013
SYPHILIS, CONGENITAL AND NEONATAL (Treponema pallidum)
• Clinical Criteria
• Any infant < 2 years of age with at least one of the following
10:
• — Hepatospenomegaly
• — Mucocutaneous lesions
• — Condyloma lata
• — Persistent rhinitis
• — Jaundice
• — Pseudoparalysis (due to periostitis and osteochondritis)
• — Central nervous involvement
• — Anaemia
• — Nephrotic syndrome
• — Malnutrition
• Laboratory Criteria
• — Laboratory criteria for case confirmation
• At least one of the following three:
• — Demonstration of Treponema pallidum by dark field
microscopy in the umbilical cord, the placenta, a nasal
discharge or skin lesion material
• — Demonstration of Treponema pallidum by DFA-TP in the
umbilical cord, the placenta, a nasal discharge or skin
lesion material
• — Detection of Treponema pallidum — specific IgM (FTAabs,
EIA)
• AND a reactive non-treponemal test (VDRL, RPR) in the
child’s serum
• — Laboratory criteria for a probable case
• At least one of the following three:
• — Reactive VDRL-CSF test result
• — Reactive non-treponemal and treponemal
serologic tests in the mother’s serum
• — Infant’s non-treponemal antibody titre is four-fold
or greater than the antibody titre in the mother’s
serum
• Epidemiological Criteria
• Any infant with an epidemiological link by human to
human transmission (vertical transmission)
• Case Classification
• A. Possible case NA
• B. Probable case
• Any infant or child meeting the clinical criteria and
with at least one of the following two:
• — An epidemiological link
• — Meeting the laboratory criteria for a probable
case
• C. Confirmed case
• Any infant meeting the laboratory criteria for case
confirmation
Gonorrhoea
Neisseria gonorrhoeae bacteria..
• Women may experience a yellow or bloody discharge and find urination painful.
However, many women with gonorrhoea will have no or mild symptoms. Men
may experience a burning sensation when urinating and a pus-like discharge
from the penis.
• It may take anywhere from three to 14 days after sexual contact with an
infected person to develop symptoms. However, some infected people may not
develop any symptoms but can still transmit the infection to sexual partners.
Untreated cases may remain infectious from six months to more than one year.
Gonorrhoea is transmitted through sexual contact including sex without using a
condom, vaginal intercourse, anal and oral sex. During sexual intercourse,
gonorrhoea is more likely to be transmitted from men to women than from women to
men. The infection can also be transmitted from mother-to-child during childbirth.
General
The source
of infection
Route of
transmission
Etiology:
Susceptibility
Preventive measures:
Using a condom and avoiding risky sexual behaviours, like having lots of partners,
can protect against getting STIs, including gonorrhoea.
GONORRHOEA (Neisseria gonorrhoeae)
• Clinical Criteria
• Any person with at least one of the following eight:
• — Urethritis
• — Acute salpingitis
• — Pelvic inflammatory disease
• — Cervicitis
• — Epididymitis
• — Proctitis
• — Pharyngitis
• — Arthritis
• OR
• Any newborn child with conjunctivitis
• Laboratory Criteria
• At least one of the following four:
• — Isolation of Neisseria gonorrhoeae from a clinical specimen
• — Detection of Neisseria gonorrhoeae nucleic acid in a clinical
specimen
• — Demonstration of Neisseria gonorrhoeae by a non-amplified
nucleic acid probe test in a clinical specimen
• — Microscopic detection of intracellular gram negative diploccocci in
a urethral male specimen
• Epidemiological Criteria
• An epidemiological link by human to human
transmission (sexual contact or vertical
transmission)
• Case Classification
• A. Possible case NA
• B. Probable case
• Any person meeting the clinical criteria and with
an epidemiological link
• C. Confirmed case
• Any person meeting the laboratory criteria
Number of gonorrhea cases per 100 000 population
in selected EU/EEA countries, 2004-2013
Number of gonorrhea cases per 100 000 population
in selected EU/EEA countries, 2004-2013
Number of gonorrhea cases per 100 000 population
in selected EU/EEA countries, 2004-2013
Gonorrhoea
Gonorrhoea is a sexually transmitted infection (STI)
caused by Neisseria gonorrhoeae bacteria. Urethral
infections in men and uro-genital infections in women
are the main presenting feature, but a broad spectrum
of clinical presentations can occur, including systemic
dissemination with fever and skin and joint
involvement. Throat and ano-rectal infections also
occur.
Gonorrhoea
Urethral symptoms and vaginal discharge
may appear after a short incubation (2–7
days following exposure), but in women
cervicitis may remain without symptoms.
Once a diagnosis is made, uncomplicated
gonorrhoea is usually cured by a single
dose of a suitable antibiotic. Partner
notification and treatment is essential to
curtail transmission.
Gonorrhoea
Symptoms
Women may experience a yellow or bloody discharge and find urination
painful. However, many women with gonorrhoea will have no or mild
symptoms. Men may experience a burning sensation when urinating and a
pus-like discharge from the penis.
• It may take anywhere from three to 14 days after sexual contact with an
infected person to develop symptoms. However, some infected people
may not develop any symptoms but can still transmit the infection to sexual
partners. Untreated cases may remain infectious from six months to more
than one year.
Complications
If left untreated, women can develop pelvic inflammatory disease (PID) as
the infection spreads further in the upper genital tract. PID may cause
pelvic pain, discharges and bleeding but may also be without specific
symptoms. If the infection goes untreated, it can spread further in to the
fallopian tubes and lead to ectopic pregnancy or infertility. The infection
can then spread even further and affect the abdomen and liver.
Gonorrhoea
Ways to catch gonorrhoea
Gonorrhoea is transmitted through sexual contact including sex
without using a condom, vaginal intercourse, anal and oral sex.
During sexual intercourse, gonorrhoea is more likely to be
transmitted from men to women than from women to men. The
infection can also be transmitted from mother-to-child during
childbirth.
People most at risk
Those who have had gonorrhoea infection in the past may be
re-infected in the future. People particularly at risk include those
who have multiple sexual partners and concurrent partnerships;
people who don’t use condoms; people whose partners are
infected or who have partners with risky sexual behaviour;
young people, particularly those under the age of 25; men who
have sex with men (MSM); people with a history of sexually
transmitted infections (STIs) or who are HIV positive and;
commercial sex workers.
Gonorrhoea
Diagnosis
Samples from the genital area of an infected person
are examined under a microscope and laboratory tests
are carried out to diagnose gonorrhoea. However,
because many women with gonorrhoea do not have
any symptoms, it can lead to a delay in being
diagnosed and getting treatment which, in turn, can
lead to complications.
Treatment
Gonorrhoea is caused by bacteria and therefore can
be treated with antibiotics. Anyone infected with
gonorrhoea should be treated immediately to reduce
the chance of spreading the infection further and
getting complications. Ideally, all of a patient’s recent
sexual partners should also be treated immediately.
Chlamydia infectionThe obligate intracellular Gram negative bacterium Chlamydia
trachomatis. Chlamydia trachomatis is one of four species in the
genus Chlamydia and the family Chlamydiaceae which also
include C. pneumoniae, C. psittaci and C. pecorum.
Chlamydia disease surveillance shows that the number of Chlamydia infections is
increasing in Europe: there are now more than 250 000 new cases reported each
year. Many Chlamydia infections do not produce symptoms, and the growing
number of reported cases is likely to be the result of increased awareness about the
disease and intensified testing.
Sexually active young people are most at risk of chlamydia, and women below 24
years of age have the highest number of infections in Europe.
General
The source
of infection
Route of
transmission
Etiology:
Susceptibility
Preventive measures:
Control of genital chlamydia focuses on reducing sexual risk behaviour, condom use,
early diagnosis, and effective management of sexual partners in order to break the
chain of transmission.
CHLAMYDIAL INFECTION (Chlamydia trachomatis),
INCLUDING LYMPHOGRANULOMA VENEREUM (LGV)
• Clinical Criteria
• Any person with at least one of the following clinical
forms:
• Chlamydial infection non-LGV
• At least one of the following six:
• — Urethritis
• — Epididymitis
• — Acute salpingitis
• — Acute endometritis
• — Cervicitis
• — Proctitis
• In newborn children at least one of the following two:
• — Conjunctivitis
• — Pneumonia
• LGV
• At least one of the following five:
• — Urethritis
• — Genital ulcer
• — Inguinal lymphadenopathy
• — Cervicitis
• — Proctitis
• Laboratory Criteria
• Chlamydial infection non-LGV
• At least one of the following three:
• — Isolation of Chlamydia trachomatis from a specimen of the ano-genital
tract or from the conjunctiva
• — Demonstration of Chlamydia trachomatis by DFA test in a clinical
specimen
• — Detection of Chlamydia trachomatis nucleic acid in a clinical specimen
• LGV
• At least one of the following two:
• — Isolation of Chlamydia trachomatis from a specimen of the ano-genital
tract or from the conjunctiva
• — Detection of Chlamydia trachomatis nucleic acid in a clinical specimen
• AND
• — Identification of serovar (genovar) L1, L2 or L3
• Epidemiological Criteria
• An epidemiological link by human to human transmission (sexual contact or
vertical transmission)
• Case Classification
• A. Possible case NA
• B. Probable case
• Any person meeting the clinical criteria and with an epidemiological link
• C. Confirmed case
• Any person meeting the laboratory criteriaEN 27.9.2012 Official Journal of
the European Union L 262/9
Chlamydia infections (genital)
Genital chlamydia is the leading sexually transmitted infection in
Europe and the cause of considerable acute morbidity and long
term reproductive health problems, particularly in young people.
Many infections are asymptomatic resulting in delayed
diagnosis and uninterrupted transmission. Chlamydia salpingitis
can cause tubal adhesions and is an important risk factor for
female infertility and extra-uterine pregnancy. It is an important
cause of pelvic inflammatory disease. Chlamydia is under
epidemiological surveillance within the EU. The reported
national incidence rates vary widely and most of the more than
250 000 cases reported to ECDC for 2007 were notified by only
five countries. The number of reported cases reflects the
intensity of testing rather than true differences in disease
burden.
Chlamydia infections (genital)
The pathogen
• Genital chlamydia is caused by the obligate intracellular Gram
negative bacterium Chlamydia trachomatis.
• Chlamydia trachomatis is one of four species in the genus
Chlamydia and the family Chlamydiaceae which also include
C. pneumoniae, C. psittaci and C. pecorum.
• Chlamydia trachomatis causes acute eye infections,
trachoma, genital infections and the more invasive sexually
transmitted infection; lymphogranuloma venereum (LGV).
• The strains that cause eye and genital infections are labelled
D through K and grow only in the columnar and squamocolumnar
epithelial cells that make up the conjunctivae and
the mucosa in the respiratory tract, urethra, cervix and
rectum.
• Lymphogranuloma venereum is caused by the invasive L1, L2
and L3 strains of C. trachomatis, sometimes referred to as the
LGV serovars.
Chlamydia infections (genital)
Clinical features and sequelae
• Genital infections with C. trachomatis present as urethritis and proctitis in
men and women, cervicitis, salpingitis, endometritis and pelvic inflammatory
disease (PID) in women, and orchitis, epididymitis and prostatitis in men.
• Perinatal transmission of C. trachomatis can result in conjunctivitis
(ophthalmia neonatorum) and pneumonia in newborns and young infants.
• Conjunctivitis and respiratory infections can be the result of contact with
contaminated hands, or direct exposure to semen and vaginal fluids.
• At least 70% of genital C. trachomatis infections in women and 50% in men
are asymptomatic at the time of diagnosis.
• The natural course of genital chlamydia infections is not well understood:
– Spontaneous resolution of asymptomatic infections is not uncommon.
– Asymptomatic infections, particularly endocervical infections, can persist for long
periods.
– Many patients with asymptomatic infections will at some point develop symptoms
and clinical disease.
– Asymptomatic infections can result in complications such as blocked tubes and
pelvic inflammatory disease.
• Lymphogranuloma venereum (LGV) affects both men and women.
Chlamydia infections (genital)
Urethritis
• Symptoms include urgency, frequency, burning sensation and pain when
passing urine in both men and women.
• Dysuria in women often reflects concurrent urethral and endocervical
infections.
• Acute urethral syndrome is a condition with symptoms suggestive of lower
urinary tract infection in the absence of significant bacteruria (< 105
organisms/ ml of urine) that can be caused by C. trachomatis.
• In men, genital chlamydia typically presents as dysuria and urethral
discharge. The discharge tends to be less profuse than that produced by
gonococcal infections, but there is significant overlap between the two
diseases and chlamydia cannot be distinguished clinically from gonorrhoea or
other causes of urethritis.
• Only about half of genital C. trachomatis infections in men are symptomatic.
In one study in which infected men were observed without treatment for a
minimum of 21 days, one in eight developed symptomatic urethritis.
• Some 30% to 50% of non-gonococcal urethritis is believed to be due to C.
trachomatis.
Chlamydia infections (genital)
Cervicitis
• Endocervical chlamydia infections present as vaginal discharge, bleeding
between periods, mild abdominal pain, and often dysuria.
• Seven out of ten women with endocervical infection have no or only mild
symptoms that may not prompt medical contact.
• About half of all genital chlamydia infections in women are concurrent
urethral and cervical infections.
Salpingitis
• Salpingitis is typically the result of an ascending lower reproductive tract
infection and can be symptomatic or without clinical signs and symptoms.
• Symptoms include fever, discomfort and pain in the lower abdomen, and
tenderness on palpation.
Proctitis
• Proctitis manifests as anal pruritis and rectal discharge. The infection is
limited to the rectum and resembles gonococcal proctitis.
• Asymptomatic rectal infections are common.
• C. trachomatis is a common cause of proctitis in men who have sex with
men. Proctitis can result from direct inoculation of the rectum in both men
and women through anal intercourse, or through secondary spread of
secretions from the cervix.
Chlamydia: High numbers,
low awareness
1. Chlamydia is the most common sexually transmitted infection in Europe and particularly
affects young people.
Chlamydia is the most frequently reported sexually transmitted infection in Europe, and the
number of cases is steadily increasing. It disproportionately affects young people. Studies
have shown that up to 10% of sexually active people younger than 25 years are infected.
2. Chlamydia can have long-term consequences for sexual and reproductive health.
Untreated chlamydia can have serious reproductive health consequences for women. Both
asymptomatic and symptomatic chlamydia infections can result in blockage of the Fallopian
tubes, a leading cause of difficulties becoming pregnant (tubal infertility) and pregnancy
outside of the womb (ectopic pregnancy).
3. Chlamydia can be controlled through prevention, case finding and effective case management.
Easy access to STI services for young people, rapid diagnosis and treatment, contact tracing,
and partner management are key components of successful chlamydia control programmes.
Active case-finding, which should include opportunistic testing and contact tracing, should
target young and sexually active people.
Human papillomavirus infection
HPV is a group of viruses, of which more than 100 types have been
described. About 40 of them can infect the genitals.
HPV 16 and HPV 18 are the most common types, causing about 70
percent of all cases of cervical cancer. ‘Low risk’ HPV types, most
commonly HPV 6 and HPV 11, are responsible of about 90% of cases of
condylomata acuminata (genital warts).
Cervical cancer is the second most common cancer after breast cancer
to affect women aged 15–44 years in the European Union. Each year,
there are around 33 000 cases of cervical cancer in the EU, and 15 000
deaths. The primary cause of cervical cancer is a persistent infection of
the genital tract by some specific types of human papillomavirus (HPV).
HPV is present in most cases of cervical lesions, which can further
develop into cancer.
Sexual contact.
general
Sexually active young people are most at risk of chlamydia, and women below 24
years of age have the highest number of infections in Europe.
General
The source
of infection
Route of
transmission
Etiology:
Susceptibility
Preventive measures:
Two prophylactic HPV vaccines have been licensed in Europe, a bivalent and a quadrivalent vaccine: both have a good safety
profile and protect against the high-risk HPV types 16 and 18. The quadrivalent vaccine also protects against HPV 6 and 11.
Both vaccines have been shown to prevent more than 90% of precancerous lesions associated with HPV 16 and 18.
The vaccines are given in three doses over a six-month period. They do not cure existing infections and should therefore be
given before onset of sexual activity.
Genital warts
• are…
• …various sorts of warts found on or
around the penis, anus or vagina caused
by the human papilloma virus (HPV).
Symptoms
• They can be small pimples, smoothtopped
pimples or nodules or large
outward-growing masses and may cause
itching, bleeding or mild burning.
Genital warts
• Symptoms
• They can be small pimples, smooth-topped
pimples or nodules or large outward-growing
masses and may cause itching, bleeding or mild
burning.
• Complications
• Complications are unusual. Once genital warts
have developed they can show minimal change
over time, get larger or reduce spontaneously.
Genital warts
• Ways to catch genital warts
• Genital warts are passed on through direct skin-to-skin
contact, usually during sexual activity.
• People most at risk
• Genital warts are one of the most common viral, sexually
transmitted infections (STIs) and are strongly associated
with having a high number of sexual partners and having
unprotected sex without using a condom. They are most
common among young adults aged 16–24. The majority
of genital warts cases are acquired through heterosexual
sex, although rates are increasing in men who have sex
with men (MSM).
Genital warts
• Diagnosis
• Diagnosis of warts is based on a doctor
examining the clinical symptoms.
• Treatment
• A number of treatments are available for genital
warts, although there is not one specific
treatment that will completely get rid of the HPV
or stop warts from recurring in future. Treatment
choice depends on the form, structure and
extent of the warts and the patient’s choice.
Genital warts
• How to avoid getting genital warts
• There is one HPV vaccine that protects against
the virus strain that is responsible for most
genital warts. The use of condoms may not
prevent HPV infection but can considerably
reduce the risk.
• What to do if you have genital warts
• Screening for other sexually transmitted
infections is recommended in patients who have
genital warts. Current sexual partners could also
have undetected warts or other STIs and may
benefit from testing.
LGV