08_XXX_MM1 Controlling Sexually Transmitted and Reproductive Tract Infections Team Sexually Transmitted Infections Transmitted Sexually Training Course in Sexual and Reproductive Health Research Department of Reproductive Health & Research

Epidemiology World Health Organization Geneva Geneva 2011

08_XXX_MM2

STItransmission, epidemiology:populations,determinants: 7 Introduction: 3 WHO STI 75 Library: examples:54 and specific country regionSTI Epidemiology: 45 Resistance: Antimicrobial STI 15 Burden:Regional andGlobal – Overview of presentation

6

–

80

–

53

–

44

– –

74

14

2003 08_XXX_MM3

2003

... and, since BC, the STIs epidemic 1500

BC 1700

1968

1800

1900

2002

2003

08_XXX_MM4 Sexually Transmitted Infections, STIs There are about syndromes that result from STIs 30 STIs

or disease

08_XXX_MM5 Parasites Viruses Pubic lice ( Pubiclice B B ( Hepatitisvirus) virus) simplexherpes (herpes Genital papillomavirus) Genitalwarts cervicaland ( ( (

Treponema

( Phthirus Chlamydia trachomatisChlamydia

( Trichomonas

pubis

STIs pallidum gonorrhoeae

) ducreyi —

mainly

) vaginalis

)

- ) ) cancer (human cancer

)

08_XXX_MM6 Since the 80’s: HIV, the new, devastating, STI

08_XXX_MM7 population If Ro

< 1, the infection eventually disappears from the the from disappears eventually infection < 1, the * * MayRM, Anderson RM., Transmission dynamics of HIV infection, Nature. 1987 Mar 12 D C  Ro

- - -

population mean probabilityof permeantransmission exposure mean duration of infectiousness of the of infectiousnessnewlymean duration the withinchangemean rate of sexualpartner infected persons !

= 

Rate of spread of x c x D

STIs *

-

18;326(6109):137 - 42.

08_XXX_MM8 Tertiary Latent Secondary Primary Syphilis * Neisseria Chlamydia Infection

World Average duration of infection for individuals with Average for individuals of infection duration

Health and Average Syphilis depending on stage in which they are are theyin which stage on dependingSyphilis

gonorrhoeae

Trichomonas

Organization vaginalis

.

Prevalence duration of infection for infection of duration :

Methods 5 months 1.25 years Male Neisseria

and

Asymptomatic and not treated and

incidence

Results

of treated* used

selected 15 3 years 3 months 1 month

by gonorrhoeae 6 months 1.25 years Female

WHO years

Sexually to

generate

Transmitted

2005

estimates Infections, 2 weeks 4 weeks Male Chlamydia *

Symptomatic and treated

.

WHO, Chlamydia

Geneva ,

Neisseria 4 8 weeks Female

2010 weeks

and .

Gonorrhoeae

,

08_XXX_MM9 STI transmission dynamics at population level group Core

population Bridging

population General

08_XXX_MM10 • ------  - - - -  Microenvironment Chapter 4 Chapter :

Behavioural Immunological Biological drug male sex anal sexual multiple age pregnancy coexistance age gender

during

at

sex

or circumcision

coital

practices

alcohol

sexual

«

Global Global Sexuallyof Epidemiology Infections Transmitted

of debut

other use partners :

STIs

Determinants of STIs epidemic*

»

 - -  -  - - - - -  Macroenvironment

Political Demographic Epidemiological Cultural, sex population STIs stigma silent health gender inequality poverty

ratio

prevalence on

seeking and

and

Social sex

age

discrimination

structural

issues

behaviours structure and

Economic

08_XXX_MM11

!

Some STIs

increase the risk of HIV transmission

08_XXX_MM12 Darrow, 1987 Darrow, Holmberg,1988 Stamm,1988 Bollinger,1997 Mbizvo,1996 Limpakarnjanarat, 1999 1993Telzak, Cameron, 1989 Craib,1995 Kassler, 1994 Laga, 1993 1991 Plummer, Reference Studies on sexually transmitted infection as

ISBN ISBN 9789241563475. Geneva 2007. World Health Organization. Global Strategythe for prevention and control of sexually transmitted infections: 2006 risk factor for HIV transmission* MCM, United States of MCM, America UnitedMCM, States of America United States of MCM, America attendees, India Sexuallytransmitted infection clinic Antenatal care Zimbabwe women, Thailand Female sex workers, Heterosexual Unitedmen, States of America Heterosexual Kenyamen, Cohort of MSM,Canada States of America Heterosexual cohort, United Republicof the Congo Democratic Female sex workers, Kenya Female sex workers, population Study

Syphilis Herpes syphilisHerpes, GUD PID +GUD andGUD herpes Syphilis chancroid GUD, chancroid Mainly Rectal gonorrhoea Gonorrhoea Trichomoniasis Gonorrhoea Chlamydia Chlamydia studied infection Sexually transmitted

Relative risk

1.5 3.3 4.4 3.0 4.7 – –

2.2 8.5

Odds ratio Odds 2.0 - 3.18 2015. 4.2 5.8 3.7 2.5 1.9 4.8 3.6 3.6 –

2.4

08_XXX_MM13

! HIV in Malawi, AIDS 2006, 20:1869 * Victor Mwapasa et al, Maternal syphilis infection is associated with increased risk of mother mother of co

S yphilis infection may increase the HIV viral load - infected patients, and may increase the - to - child transmission of HIV* - 1877.

- to - child transmission of risk risk of 08_XXX_MM14 HIV

– global morbidity of congenital syphilis, oral presentation * Stoner BP, Schmid G, Guraiib M, Adam T, Broutet N, Syphilis seroconcordance in pregnant women*

HIV SEROPREV PREG WOMEN 10 15 20 25 30 0 5 0 1 2 - SYPH SEROPREV PREG WOMEN PREG SEROPREV SYPH

African Region 3 4

R .Use .Use of maternal syphilis seroprevalence data to estimate the 2

ISSTDR =0.79 5

Congress Congress 2005. 6 - 7

8

9

08_XXX_MM15

STI WHO toInternational "Surveillance"approach

visit at:RHR WHO is currently doingthem for WHO this and1995,did1999 in

visit WHO at:

http://www.who.int/reproductive

www.who.int STI GlobalBurden

2005 2008

- health/

!

-

Estimations

08_XXX_MM16

Estimated new cases of curable Total number of cases: (WHO, 2005) Male 243 500 Female 204 750 000

448 250 000 000

STIs

08_XXX_MM17

STI Global Burden, 2005

-

Incidence per STI Incidence

-

Trichomoniasis Syphilis Gonorrhea Chlamydia 10 700 000

101 500 000 87 700 000

250 500 000

08_XXX_MM18 TOTAL Western Pacific Region South Region European Region Mediterranean Eastern the Region of Americas Region African Region WHO vaginalis *

World - East East Region Asia Estimated incidence ofcurable STIs by

Health :

Methods

Organization

and

Results

region, inmillion(WHO 2005) .

Prevalence

used

by

WHO

101.5 41.6 6.6 15.2 5.7 22.4 10.0 Chlamydia and

to incidence

generate

of

2005

selected

estimates 87.7 26.9 22.7 4.6 6.5 9.5 17.5 Neisseria

Sexually

gonorrhoeae

.

WHO,

Transmitted

Geneva

2010

Infections,

.

Chlamydia 10.7 1.1 2.9 0.3 0.6 2.4 3.4 Syphilis

,

Neisseria

248.5 39.10 38.60 24.50 12.60 54.9 78.8 Trichomonas

Gonorrhoeae vaginalis

* ,

Syphilis

and

Trichomonas Total 448.40 108.70 109.70 70.80 44.60 25.40 89.20

08_XXX_MM19

Incidence per 1000 100 150 200 250 300 350

50 0 AFRO AMRO Females EMRO EURO - Incidence per STI and region per STIand Incidence STI Global Burden, 2005 SEARO

WPRO Trichomoniasis Syphilis Gonorrhoea Chlamydia Males -

08_XXX_MM20

Estimated new cases of syphilis (WHO, 2005)

Total cases numberof Female Male 10 700 000 10 700

5 000 540 5 060 000

08_XXX_MM21 Global TotalGlobal Western Pacific Region South Region European Region Mediterranean Eastern Region the of Americas Region African Region WHO Syphilis *

World - East East Region Asia

Health and Estimated new cases of syphilis amongst

Trichomonas

Organization

vaginalis .

Prevalence :

Methods

and 3.02 1.1 3.33 0.68 2.14 5.06 8.34 Females 1000 perIncidence and

incidence

Results

of used

adults selected by 3.19 1.07 3.02 0.68 2.09 5.33 10.82 Males

WHO

Sexually

to generate

Transmitted

5.06 0.52 1.45 0.15 0.29 1.16 1.49 Females millions)(inNewcases 2005

estimates Infections,

.

WHO, Chlamydia 5.54 0.53 1.40 0.15 0.30 1.23 1.92 Males

Geneva

,

Neisseria

2010

.

Gonorrhoeae Total 10.7 1.05 2.85 0.30 0.59 2.39 3.41 ,

08_XXX_MM22 !

overall responsible for result in a In pregnancy, untreated early syphilis will 2006 World Health Organization. Global Strategy for the prevention and control of sexuallytransmitted infections: - 2015. ISBN 9789241563475. Geneva 2007. perinatal mortality of about 40% stillbirth rate of 25% 14% of neonatal deaths

and be .

–

an 08_XXX_MM23 539463 C. B. A. 344,331 298,420 164,223

Regional Estimates of Maternal Syphilis 705725 C. B. A. Seroprevalence 529,294 458,721 252,438

172154 C. B. A. C. B. A. 446909 335,182 290,491 159,859 129,116 111,900 61,579

134522 157532 C. B. A. 100,892 87,439 48,119

08_XXX_MM24 Zambia Uganda Tanzania Nigeria Mozambique Congo Democratic of Republic Botswana Country Syphilis prevalence rates amongst pregnant women pregnant amongst rates prevalence Syphilis

6,8 1,6 1,6 1,87 4,7 0 4,8 Prevalence

y.o. pregnant women attending ANC clinic 15 Entebbe hospital, district pregnant women attending booking visitat y.o. women attending one 6 of ANC clinics, 15 visit pregnant women attending ANC clinic first for pregnant women attending ANC clinic pregnant women attending ANC clinic pregnant women attending ANC clinic Studied population - 40 40 y.o.

in Africa

, 14

- - 44 49 surveillance report: 1994 Zambia Tann al, 2006 CJ et Yahya April 2006 pregnant women attending ANC clinics. seroprvalence sentinel surveyamong 2005 National HIV/Syphillis Federal MinistryHealth, of Nigeria: Lujan et 2008 al, Kinoshita Romoren al., 2007 et M, Reference - Malima Malima al, 2008 et

antenatal - Moleka 2008 R, et al.,

clinic

sentinal

-

2004. (2005)

08_XXX_MM25

*Joseph *Joseph et Syphilisal, D., and Social Upheaval in China, N Engl J Med 2010; 362:1658 Reported Overall Incidence of Syphilis per 100,000 Data Data are the from National Center STD Control for in Nanjing, China. Population and Incidence of Congenital Syphilis per 100,000 Live Births in China*

- 1661

08_XXX_MM26

Estimated new cases of genital gonorrhoea

Total cases numberof (WHO, 2005) Female Male 87 650 000 87 650

47 740000 39 910 000 39 910

08_XXX_MM27 Global TotalGlobal Western Pacific Region South Region European Region Mediterranean Eastern the Region of Americas Region African Region WHO vaginalis *

World Estimated new cases of gonorrhoea infections -

East East Region Asia Health :

Methods

Organization

and

Results

.

Prevalence used

by

WHO

and

to incidence

generate 23.8 35 16.32 10.71 19.14 13.89 45.61 Females 1000 per Incidence in adults, 2005*

of

2005

selected

estimates

Sexually .

WHO,

Transmitted 27.47 20.94 33.61 9.72 27.32 27.17 52.68 Males

Geneva

2010

Infections, .

Chlamydia 39.91 16.47 7.11 2.42 2.57 3.18 8.16 Females millions) (in cases New

,

Neisseria

Gonorrhoeae 47.74 10.41 15.55 2.22 3.91 6.29 9.36 Males

,

Syphilis

and

Trichomonas 87.65 26.88 22.66 17.52 Total 4.64 6.48 9.47

08_XXX_MM28

! gonococcal and chlamydial infections. infections attributable to untreated maternal become blind every year because of eye

Worldwide, 2006 World Health Organization. Global Strategy for the prevention and control of sexuallytransmitted infections: - 2015. ISBN 9789241563475. Geneva 2007. up to 4 000 newborn babies

08_XXX_MM29 Neisseria gonorrhoeae prevalence studies among Zimbabwe Tonga South Africa Nepal Mozambique Mongolia Lao Kenya Ghana Fiji Congo Democratic of Republic China Botswana Country

1,1 2,5 8 2,3 2,5 6,1 0,8 1,2 0,6 1 0,4 0,8 3 Prevalence ,

7

pregnant women pregnant pregnant women attending ANC clinic ANC clinic attendees attending central hospital pregnant women attending ANC clinic residing in rural Nepalsoutheastern Women who are week6 postpartum with birth live pregnant women attending ANC clinic 10 randomly selected ANC clinicals Sethiathirath MCHor hospital pregnant women (<20 weeks)visit to at first pregnant women attending ANC clinic hospital pregnant women attending ANC Korle at Bu teaching ANC pregnant women attending ANC clinic pregnant women; 1st ANC visit pregnant women attending one 13 of ANC clinics Studied

clinic

population

attendees

in

Suva

Mbizvo Cliffe al, 2008 et SJ PDJ Sturm al, 2004 et Christian P 2005 et al, Lujan et 2008 al, 2007 Report Mongolia, from MOH Thammalangsy al, 2006 et S Moses et al, S 2003 Apea Cliffe Kinoshita Chen al, XS 2006 et Romoren al., 2007 et M, Reference

- SJ Kubi et al, 2004

EM

et - Moleka 2008 R, et al.,

al, et et 2001 al,

2008

08_XXX_MM30 Mozambique Lao Japan Ireland Ghana Fiji China Brazil Botswana Country Chlamydia

3 29 10,1 9,4 8 Prevalence 4,1 9,6 3,7 3,7

prevalence studies among pregnant

Pregnant Pregnant women attending antenatal clinic Sethiathirath MCHor hospital pregnant women (<20 weeks)visitto at first pregnant women, 14 15 pregnant women hospital pregnant women attending ANC Korle at Bu teaching ANC clinic attendees in Suva pregnant women; 1st ANC visit backgrounds, 11 ANC clinic 13 ANC clinics Population –

50 50 y.o.

-

diverse emo and socio economic

- women 47 47 y.o. -

asymptomatic, asymptomatic, - 46 46 y.o.

Lujan Thammalangsy al, 2006 et S Shimano et al, S 2004 McMillan et 2006 al, Apea Cliffe al, 2008 et SJ Chen al, XS 2006 et de DST e Aids. 2008 Vigilância Saúde. em Programa Nacional Brasil. Ministério da Saúde. Secretaria de Romoren M Reference -

Kubi et al, 2004 et et 2008 al, , et ,

al., al., 2007

08_XXX_MM31

Estimated new cases of genital infections (WHO, 2005) Total cases numberof Female Male 101 520101 000

47 480000 54000 040

Chlamydia

08_XXX_MM32 Global TotalGlobal Western Pacific Region South Region European Region Mediterranean Eastern the Region of Americas Region African Region WHO vaginalis *

World -

East East Region Asia Health :

Estimated new cases of genital infections (in million) among adults, 2005* Methods

Organization

and

Results

.

Prevalence

used

by

WHO

and

to incidence

generate 32.22 43.31 9.2 39.89 19.35 53.04 32.79 Females 1000 per Incidence

of

2005

selected

estimates

Sexually .

WHO, 27.32 42.7 5.63 27.06 21.4 44.32 23.39 Males

Transmitted

Geneva

2010

Infections, .

54.04 20.38 4.01 9.03 2.6 12.15 5.86 Females millions) (in cases New

Chlamydia

,

Neisseria

Chlamydia

Gonorrhoeae 47.48 21.22 2.6 6.17 3.06 10.26 4.16 Males

,

Syphilis

and

Trichomonas

101.52 41.60 15.20 22.41 10.02 Total 6.61 5.66

08_XXX_MM33

! One inflammatory disease in upto 40% infections in women will result in

Untreated gonococcal and chlamydial 2006 World Health Organization. Global Strategy for the prevention and control of sexuallytransmitted infections:

in four of these will result in . - 2015. ISBN 9789241563475. Geneva 2007.

pelvic

of cases.

08_XXX_MM34 Thailand Sweden Norway New Zealand Netherlands Luxembourg Korea Japan France Country

Chlamydia

6 male 7,5 female 6 male 4,6 female 5,8 male 6,7 female 2,7 female 1,5 male 2,5 female 0,9 male 2,3 female 5 male 6,8 female 1,4 male 1,6 female Prevalence

students students 2 vocational at colleges, 15 General population, 15 General population, 18 university students, 18 General population, 15 High school students, under 25 y.o. y.o. sexually and not sexually active university students, 18 Cityincluded students sexually active and 18 not, professional schools) in located the suburbs of Miyazaki students from nine schools (5 universities and 4 General population, 18 population Studied prevalence studies in different

populations

- 25 25 y.o. - – – –

35 35 y.o.+ 25 25 y.o. 29 y.o. 44 y.o.

-

21 21 y.o.

- 35 35 y.o. - 25

Whitehead Whitehead al, 2008 et Novak DP Karlsson & 2006 RB, Steen et al, 2008 Referenced in ECDC Baker M 2005 et al, Van Bergen 2005 J et al, Chlamydia Activitiesin Countries EU ECDC. 2008. Techincal Review of Lee et al. SJ 2005 H et Imai al, 2004 Countries. 2008 May Clamydia Control Activitiesin EU ECDC Technical Report: Review of ANRS. Quoted INSERM. INED. in Reference

08_XXX_MM35

Estimated new cases of trichomoniasis Total cases numberof Female Male (WHO, 2005) 248 480248 000

142 850 000 142 850 105 630105 000

08_XXX_MM36 Global TotalGlobal WesternPacific Region South Region European Region Mediterranean Eastern the Region of Americas Region African Region WHO vaginalis *

World Estimated new cases of trichomoniasis among -

East East Region Asia Health :

Methods

Organization

and

Results

.

Prevalence

used

by

WHO

and

to incidence

generate 62.98 39.73 40.3 55.6 44.76 119.55 130.74 Females 1000 per Incidence

adults in 2005* of

2005

selected

estimates

Sexually

.

WHO,

82.21 41 45.53 52.01 46.23 118.83 311.83 Males Transmitted

Geneva

2010

Infections, .

105.63 18.7 17.56 12.59 6.01 27.4 23.38 Females millions) (in cases New

Chlamydia

,

Neisseria

142.85 20.37 21.06 11.87 6.62 27.51 55.43 Males Gonorrhoeae

,

Syphilis

and

Trichomonas 248.48 39.07 38.62 24.46 12.63 54.91 78.81 Total

08_XXX_MM37

! Are we underestimating the risk diagnostics (

T richomoniasis in the era of new generation 2006 World Health Organization. Global Strategy for the prevention and control of sexuallytransmitted infections: - 2015. ISBN 9789241563475. Geneva 2007. LCR

and PCR ).

?

08_XXX_MM38 Samoa Mongolia Lao China Australia Country

Trichomoniasis prevalence studies amongst

Prevalence 20,8 6,7 1,8 3,2 7,2

with the remainder living in Apia (132, 31.4%). outside of Apia on the main island of Upolu (28, 68.2%), pregnant women; out of the women livingin villages 10 randomly selected ANCclinics or MCH hospital, Population pregnant women (<20 weeks) at first visit to Sethiathirath pregnant women; 1st ANCvisit services in Townsville(provincial urban centre) cohort of womenattending aboriginal and islander health Studied population pregnant women

Sullivan 2007 Report from MOH Mongolia, Thammalangsy S et al, 2006 Chen et XS al, 2006 Panaretto KS et al, 2006 Reference

EA

et et al, 2004

08_XXX_MM39

! over more than

Herpes Simplex Virus Type II

two - prevention. Ann Intern Med 1983; 98: 958 Corey L, et al. simplex virus infections: current concepts in diagnosis, therapy, and thirds 5%

of recurrent cases. of all episodes of genital herpes and - 972.

is responsible for

08_XXX_MM40 Total Zealand and AustraliaNew South South Asia Pacific Japan AsiaEastern Asiacentral Europe Eastern and Europe Western Sub Middle East AfricaNorth and the the Caribbean LatinAmericaand AmericaNorth *Looker Regional estimates of the prevalence of the herpes Oct - Saharan Saharan Africa

; - Region 86 east Asia

simplex virus type 2 infection among males and

(

10

KJ,

)

:

805

et

al

- 12 .

An ,

A

estimate . 15

25.8 0.03 0.03 1.7 4.1 0.4 2.6 2.7 0.7 9.0 1.0 2.6 0.9 y.o - 19

of 20

39.4 0.06 0.04 13.1 3.1 5.4 0.6 4.4 3.9 1.3 1.5 4.5 1.5 y.o the - 24

global 25 46.5 0.09 0.05 13.6

4.0 5.5 0.7 7.1 4.3 1.8 1.6 5.8 2.0 y.o prevalence - 29

30 51.5 0.06 11.1 12.5 0.1 4.6 5.4 0.7 4.3 2.2 1.5 6.4 2.6 y.o - 34

Female and

females, in 2003*

incidence 35 52.9 0.06 12.8 11.2 0.2 4.9 4.9 0.6 4.3 2.6 1.4 6.7 3.2 y.o -

39

of 40 50.8 0.06 11.9 10.0

0.2 4.8 4.3 0.6 4.7 2.6 1.3 6.6 3.8 y.o herpes - 44

Regional prevalence in millions,by age

simplex 45 47.9 0.05 12.0 0.2 4.4 3.7 0.6 4.7 2.5 8.8 1.1 6.0 3.9 y.o - 49

virus 314.8 Total 27.6 33.2 61.8 28.9 13.7 78.2 38.6 17.9 0.9 0.3 4.1 9.6

type

2

infection 15 14.6 0.02 0.05 0.02 3.1 1.8 2.0 0.6 0.2 4.1 1.4 0.9 0.6 y.o - 19

.

Bull 20 24.1 0.03 0.08 0.05 5.2 3.1 3.4 1.1 0.5 6.5 1.6 1.6 1.0 y.o - 24

World

25

30.5 0.05 0.09 0.08 Health 6..3 4.0 5.4 1.5 0.7 7.5 1.5 2.1 1.4 y.o - 29

Organ 30 36.1 0.06 0.09 6..9 4.8 0.1 8.4 1.8 1.1 7.5 1.3 2.4 1.7 y.o - 34

Male .

2008 35 38.8 0.08 0.09 7.0 5.2 0.1 9.8 2.1 1.4 7.1 1.1 2.7 2.2 y.o

- 39

40 38.8 0.08 0.1 6.6 5.4 0.1 9.3 2.6 1.6 6.7 0.9 2.8 2.5 y.o - 44

45 37.8 0.06 0.1 6.0 5.2 0.2 9.5 2.8 1.7 6.2 0.8 2.7 2.6 y.o - 49

220.7 Total 41.2 29.4 47.8 12.3 45.5 15.1 11.9 0.4 0.5 0.7 7.2 8.6

08_XXX_MM41

! cancer every year in resource approximately 240 000 women infection could stop the

New vaccines against human papilloma virus 2006 World Health Organization. Global Strategy for the prevention and control of sexuallytransmitted infections: - 2015. ISBN 9789241563475. Geneva 2007. untimely death of

- poor settings.

from cervical

08_XXX_MM42 * Sexually Transmitted SexuallyTransmitted Infections

Country Human papilloma virus, prevalence studies South AfricaSouth Denmark Tanzania Sweden Canada Greece Russia Croatia among female population, 1995 USA 0 . Ivonne Camaroni, Antonio Gerbase. 2,8 5 10 13 15 15,4 Chapter 4 Chapter 20 19,8 Prevalence 22

«

Global Global Sexuallyof Epidemiology Infections Transmitted 25 30 29 35 34 36,3 40 39,2 - 2001* 45

», 27 PP 50

- 43.

08_XXX_MM43

!

circumcised is higher among R isk of contracting gonorrhoea, syphilis and

ones. uncircumcised men

than among HPV

08_XXX_MM44 High Multiple ≥1 HR HR New Multiple HR Multiple Single HR risk ratio. Note. Randomized Trial in Rakai, Uganda. The Journal of Infectious Diseases 2010; 201(10):000 *David Serwadda et Circumcisional. of HIV Incidence Incidence of Single and Multiple HR Circumcision reduces the prevalence and incidence of incidence and prevalence the reduces Circumcision

– -

Samples Samples are those had that amplifiable cellular viralor DNA both at enrolment and follow HPV genotype infection genotypeHPV

- HPV InfectionsHPV - HPV genotype infection genotypeHPV - HPV genotype infections genotypeHPV - Risk Papillomavirus infections in HIV infections Papillomavirus Risk

-

Infected Infected Men: Effects on High Men (Uganda, 2007) (Uganda, Men

- HPV infections over 24 Months, by Study Arm* No.(%)of samples with infection, Intervantion 26 (32.1) 34 (42.0) 8 ( (n=81)

9.9 - bystudy arm Risk Human Risk Human Papillomavirus Infections in )

Control (n=93) 23 ( 30 (32.2) 53 (57.0)

- 000. 24.7 -

up up Cl,confidence interval; IRR inc

)

IRR, intervention vsintervention IRR, 1.00 (0.65 1.00 (0.54 0.74 0.40 (0.19 0.40 control (95% Cl) (95%control - positive positive – – -

0.84) 1.53) 1.01) idence idence

08_XXX_MM45 Status quo Antimicrobial Resistance

or new challenges!?

08_XXX_MM46 • • • • • • • • • • In adults Urethral strictures Urethral Increased HIVtransmission Infertility (male &female) Post abortionsSpontaneous Ectopic pregnancy pain pelvic Chronic (PID) diseaseinflammatory Pelvic - partum infections The clinical implications of persistent

gonococcal infections

• • • • • In children Blindness Lowbirth weight Prematurity Stillbirths

08_XXX_MM47 08_XXX_MM48 Macrolides ciprofloxacin) (norfloxacin, Quinolones ( Aminoglycocides Sulphonamides in Antimicrobial resistance

() Neisseria gonorrhoeae

(, (ceftriaxone,

cefixime , kanamycin) ,

)

08_XXX_MM49 resistance in 9048 strains of Papua NewPapua Guinea Hong Kong SAR New Caledonia New Zealand *@Thailand Philippines *Sri Lanka *Sri Lanka Singapore *Myanmar # Country Mongolia Malaysia Australia *# Lao Lao PDR Vietnam Brunei Tonga Japan Korea China *India Bhutan Fiji

1393 1403 3110 153 733 160 258 152 141 328 320 351 161 14 34 84 32 12 91 43 60 n 9

PPNG 592 434 543 201 373 No. 40 90 18 76 20 23 18 20 20 1 6 0 2 2

26.1% 80.8% 56.3% 52.9% 90.5% 62.5% 16.7% 53.5% 12.8% 33.3% 31.2% 38.7% 70.5% 7.1% 2.3% 0.0% 0.6% 6.3% 12% %

N. gonorrhoeae CMRP 45/53 ND^

169 994 No. 12 57 77 88 44 11

0 1 0 2 2 8 3 0 5 9

in 22 Asian countries in 2008 84.9% 22.1% 66.7% 54.6% 26.8% 12.1% 12.5% 5.9% 3.4% 0.0% 7.5% 2.9% 0.0% 6.3% 1.3% 3.3% 0.0% 8.3% 32 %

AllPen R 1367 102 603 245 161 No. 49 19 76 22 63 10 23 95 90 25 31 7 1 2 3 #

63.8% 55.9% 90.5% 68.8% 24.4% 83.3% 53.5% 67.4% 27.4% 41.7% 43.3% 69.8% 100% 7.1% 1.3% 3.3% 9.7% 32% 78% 44% %

08_XXX_MM50 Quinolone resistancein 8731strains of Papua NewPapua Guinea Hong Kong SAR New Caledonia New Zealand Country Philippines *Sri Lanka *Myanmar Singapore *Thailand Mongolia Lao Lao PDR Malaysia Australia Vietnam *Bhutan Brunei Japan Korea China *India

1393 1403 3110 153 754 160 258 152 141 328 353 161 34 84 32 12 91 43 60 n 9

Less susceptible Less No. Asian countries in 2008 162 10 35 29 14 10 12 53 92 34 5 0 4 0 2 2 4 6

21.5% 33.3% 38.5% 20.6% 16.7% 26.1% 3.3% 6.3% 0.0% 4.8% 0.0% 0.8% 1.3% 4.3% 0.9% 3.8% 1.1% 14% %

Resistant 1362 1348 1651 No. 147 570 106 240 168 119 26 68 53 34 29 50 0 3 6 1

Neisseriagonorrhoeae

97.80% 96.0% 75.6% 74.4% 76.5% 81.0% 20.5% 50.0% 37.4% 67.4% 75.2% 73.2% 83.3% 96.1% 47.6% 53.1%

0.0% 2.0% 11% %

All QRNG All 1374 1401 1685 No. 152 732 129 135 254 260 153 26 72 55 10 69 35 60 0 5 1

in 20 100.0% 21.3% 54.2% 99.3% 97.1% 80.6% 76.5% 85.7% 83.3% 75.8% 81.4% 95.7% 77.4% 98.6% 99.9% 73.7% 0.0% 3.3% 95% 11% %

08_XXX_MM51 Cephalosporins* N. gonorrhoeae

Number of Strains Year 10 20 30 40 50 60 70 80 90 0 *Source: *Source: Public Health Agency of Canada

Totals mg/L .25 Cefixime + .125mg/L Ceftriaxone .125mg/L Ceftriaxone mg/L .25 Cefixime 2001 N=3

Ceftriaxone Ceftriaxone (0.125 mg/L and 0.25 mg/L) MICs Cefixime (0.25 mg/l and 0.5 mg/L) and

strains with strains with decreasedsusceptibility to 2002

N=0

2003 N=1

2004 N=3

Ceftriaxone .125 mg/L + Cefixime .5 mg/L .5 Cefixime + .125mg/L Ceftriaxone mg/L .25 Ceftriaxone mg/L .5 Cefixime 2005 N=0

2006 N=3

2007 N=14

2008 N=85

08_XXX_MM52 Malta Italy Greece Germany France Sweden Spain Slovenia Scotland Portugal Netherlands England/Wales Denmark Belgium Austria

Modal ceftriaxone MICs

<0.002 = 0.002 for fold calculation MICs rounded up to full dilution <0.002 <0.002 <0.002 <0.002 <0.002 <0.002 <0.002 <0.002 <0.002 2004 0.004 0.004 0.004

<0.002 <0.002 <0.002 2006 0.008 0.008 0.004 0.004 0.004 0.016 0.016

Courtesy: Cathy Ison CathyCourtesy: <0.002 <0.002 2007 0.016 0.008 0.004 0.016 0.016 0.008 0.004 0.004 0.004 0.004 0.008 0.016 0.016

–

Europe data 2008 0.032 0.004 0.008 0.004 0.008 0.004 0.016 0.008 0.004 0.004 0.004 0.016 0.008 0.016

(1 Fold increase Fold increase st

Decrease to last year) 2 4 2 2 2 2 4 2 2 2 2 8 4 4

08_XXX_MM53

Ceftriaxone reduced Ceftriaxone gonorrhoeae - susceptibility strains of strains susceptibility

–

WHO/WPR/SEAR,2006

Ceftriaxone Ceftriaxone reduced Neisseria Neisseria

- susceptible

08_XXX_MM54 The STI Epidemic, Eastern Europe and Central Asia Things are not the same anymore! Late 1990s Late BUT….

08_XXX_MM55 Incidence of syphilis in the RegionWHO EURO 1.5

142.0 42.2 105.2 115.9 91.3

-

207.0 rate per 100,000 population per rate 100,000 142.0 154.2

21.8

1999/2000 29.1 37.3

161.4

17.3 66.9

157.3

-

08_XXX_MM56 Kazakhstan, Moldova, Russia, Ukraine, 1990

Per 100,000 Incidence of syphilis in Belarus, Estonia, -

rate per 000rate 100 -

-

2000

08_XXX_MM57

Incidence rate of syphilis by age groups and sex in the Russian Federation (2009)* * Source: * Source: Здравоохранение в России. 2009: Стат.сб./Росстат. (per. population) 000100

-

М., М., 2009.

-

365 с.

08_XXX_MM58 Incidence rate of gonorrhea by age groups and sex in the Russian Federation (2009)* * Source: * Source: Здравоохранение в России. 2009: Стат.сб./Росстат.

(per. 100population) (per. 000

-

М., М., 2009. -

365 с.

08_XXX_MM59 Thailand 100% Use Programme Indonesia May4 cutback its STI rates in thelight of theHIV epidemic‖ 16th International AgainstSexually Infection, Bali, Dr Chavalit Mangkalaviraj, Bangrak Hospital, Bangkok Thailand. ― The HIV Epidemic - 6, 6, 2010.

–

how Thailand

08_XXX_MM60 3 4 5 0 1 2 1982 1983 AIDS in 1984 First case of 1984 Incidence of STIs in Thailand 1985

1986 1987 initiated initiated in 1989 100 1988

% condom (1982 1989 1990

- 2000) 1991 1992 completed in 1992 100 % condom LGV syphilis gonorrhoea

1993 1994

1995 1996

chancroid N.S.U. 1997 1998 2000 Department Department Disease of Ministry Control, of Public Health Source National : Surveillance and Bureau AIDS, of & STIsTB 08_XXX_MM61

Condom use rate (%) Number of reported 100 use Rate Among sex workers in Thailand : 10 20 30 40 50 60 70 80 90 0 1987 762 1988 1987 697 1989 50

1990 646

1991 448 65

- 83

Indonesia 4 May rates in back its STI the light the of epidemic‖ HIV 16th International Against Sexually Infection, Bali, Dr Chavalit Mangkalaviraj, Bangrak Hospital, Bangkok Thailand. ― The Epidemic HIV 320 1992 2007

93 odmueo e orkers w condom sex of use 207 1993 95 162 1994 (Rate : 100 000 population) 000 : 100 (Rate 111 - 95

6, 2010. 6, 2010. 1995 72 1996 48

1997 STIs 37 99 1998

97

1999 30

96 cases and Condom 2000 26 98 25 2001 97 2002 24 98 2003 21 97

2004 17 STIs 94 2005 21 19 95 2006 98 2007 15

99 17 –

how Thailand cut 0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 750 800 850

Rate of STIs 08_XXX_MM62 STI cases reported ( thousands)( reported cases STI 100 10 20 30 40 50 60 70 80 90 0

STI cases reported STI cases condomusingClients STI Cases Reported Clients Using and Source : Sentinel Serosurveillance, Division of Epidemiology,Division Serosurveillance, Sentinel Ministry Health. Public : of

-

Thailand % using condoms using %

100

10 20 30 40 50 60 70 80 90 0

08_XXX_MM63 100 120 20 40 60 80 0 1987 1988 Sources of infection in Male STIs patients 1989 1990 1991 Against Against SexuallyInfection, Bali, Indonesia May4 how Thailand cut back its STI rates in the light of the HIV epidemic‖ 16th International *Dr Chavalit Mangkalaviraj, Bangrak Hospital, Bangkok Thailand. ― The HIV Epidemic 1992 Thailand, 1987 1993 1994 1995 1996 1997

1998 1999 - 2007* 2000 - 6, 6, 2010. 2001 2002

2003 2004 2005 Other SP Casual RegularSP CSW 2006

2007 –

08_XXX_MM64

The STI Epidemic, Western Europe, North Are we America and Australia missing missing something

!?

*As Northern Ireland data from the time period 1931 Northern *Asthe 1931 Ireland fromtime2000 data period theyto are been figureincompletefrom excluded have this # not Scottish Equivalent prior 2000 available aredata to and 1945 for 08_XXX_MM65 latent in the first 2 years of infection) seen in GUM Number of diagnoses

(England & Wales) Diagnoses of syphilis (primary, secondary and clinics, England, Scotland and Wales, 1931 to 10,000 12,000 2,000 4,000 6,000 8,000 0 1931 1937 1943 1949

1955 1961 2000* 1967

1973 Scotland - female - Scotland male - Scotland female - Wales & England male - Wales & England 1979 1985 1991 Source: PHLS, UK PHLS, Source: 1997 0 1,000 2,000 3,000 4,000 5,000 6,000

Numver of diagnoses (Scotland) 08_XXX_MM66 Mandatory notifications, Gonorrhea and syphilis in Italy 1955 - 1999 Source: Suligo et al. et Suligo Source:

08_XXX_MM67 Annual incidence of gonorrhoea per 100 000 population in Nordic countries (1981 Source: Source: Adler, Meheus, Adler, – JEADV JEADV

1996) 2000;14:370 2000;14:370 -

377

08_XXX_MM68

Rate per 100,000 population Diagnoses of infectious syphilis (primary and 0.5 1.5 2.5 0 1 2 secondary) in GUM clinics by sex and age 1995 1996 Males Males 1997

1998 group, UK: 1995 *Data are unavailablefrom Scotlandfor 2000 andfrom N.Irelandfor 1996 1997 & 1999 2000 Source: ESSTI/PHLS, UK ESSTI/PHLS, Source: 45+ 35-44 25-34 20-24 16-19 <16

2.5 0.5 1.5 0 1 2

- 1995 2000* Females Females 1996

1997 1998 1999

2000 08_XXX_MM69 Lues: Lues: 1999: + 120%; MSM 333% heter 54% fem 40%; 2000: + 63% (MSM 136% ) GO: 1999: + 46%;MSM 59% heter 16% fem 66%; 2000: + 45%; 33% 56% 72% clinic (annual reports, GG&GD, Amsterdam). Netherlands: Go 1000 1200 200 400 600 800 0 1994 1995 gonorrhoea syphilis norrhoea and syphilis, STD 1996 1997 1998 1999

Source: ESSTI/PHLS, UK ESSTI/PHLS, Source: 2000 0 20 40 60 80 100 120 140

Disease Disease Control). Netherlands: notified cases of gonorrhoea per 100 000 inhabitants, 1976; Sweden: number of clinically reported England Wales:and cases of gonorrhoea seen in GUMclinics, 1991 SOURCES: 08_XXX_MM70

Trends in gonorrhoea in England and Wales, Smittsamma Sjukdomar Smittsamma 1999 France, the Netherlands, and Sweden . . Stockholm:Smittskyddsinstitutet, 2000) 2000; France: trends gonococcal in infections RENAGO in laborat

Neisseria Neisseria gonorrhoeae ories, 1991 cases, cases, 1991 9

99 (adapted from Smittskyddsinstitutet(Swedish Institute for Infectious Source: NicollHamers,& BMJ BMJ 2002;324:1324

– 7

08_XXX_MM71 Percentage of unprotected anal intercourse among HIV - negative young (< 35 years) homosexual men (n=877), Amsterdam, 1984 2002 FEBRUARY 7 No2 Vol. EUROSURVEILLANCE al. et Stolte Source: - 1999

08_XXX_MM72 and early syphilis diagnosed among homo among diagnosedsyphilis and early therapies, Amsterdam STD outpatients clinic, 1994 clinic, therapies, STDoutpatients Amsterdam Relative numbers (infection rate) of rectal gonorrhoea rectal of rate) (infection numbers Relative men before and after the introduction of anti HIV of anti introduction the after and before men 2002 FEBRUARY 7 No2 Vol. EUROSURVEILLANCE al. et Stolte Source: -

and bisexual and bisexual - 1999

08_XXX_MM73

! among men who America and Australia. have sex with men

Recent outbreaks of due to in Western Europe, North

08_XXX_MM74 countries. countries. JClin Eur Microbiol Dis.2010 Infect Aug;29(8):917 Martin No of cases - Number of LGV proctitis reported in Europe, Iguacel Iguacel al. R, et 500 100 200 300 400 0 Lymphogranuloma venereum : a silent endemic in disease men who have sex with men in industrialised France, 2005 France, 244 North America, 2005 Netherlands, 2007 Netherlands, 232 - 25

UK, 2007 492 - 2007*

Canada, 2007 88 08_XXX_MM75 The startedpast Never endingNever story?

The working is present

08_XXX_MM76 Traditionexits

08_XXX_MM77 Progress is made

08_XXX_MM78 visit RHR at: visitRHR visitWHO at: Updated version of the Guidelines for of Sexuallythe GuidelinesversionUpdated Transmitted Transmitted Infections of Sexuallyfor of the management the GuidelinesversionUpdated Infections Surveillance http://www.who.int/reproductive www.who.int

Coming… - health/

08_XXX_MM79

Drs Drs Nathalie Broutet, Francis Ndowa and Igor Toskin, Health Sector, World Health Organization Organization Department of Reproductive Health & Research (RHR), World Health Sexually Transmitted and Reproductive Tract Infections (STI) Team, Dr Dr Antonio Carlos Gerbase, Department of HIV/AIDS,

Acknowledgements Acknowledgements

Controlling Controlling Prevention Prevention in the

For further information: 1. http://www.who.int/reproductive-health/ http:// www.who.int

2. Dr. Igor Toskin [email protected] Controlling Sexually Transmitted and Reproductive Tract Infections Team Department of Reproductive Health and Research World Health Organization Geneva, Switzerland