A world look at the venereal diseases: recrudescence of the venereal diseases.

PIP: Factors affecting the increased incidence of the venereal diseases syphilis and gonorrhea throughout the world since World War 2 are considered. Both diseases declined after the war to a minimum in about 1957, but they have since increased, particularly gonorrhea to even higher incidence in many countries. Late and congenital syphilis, however, have declined almost universally. Factors invoked to explain the recrudescence include decreased virulence of both organisms, perhaps aided by better nutrition and hygiene. An important trend is antibiotic resistance. Sulfonamide resistance was noted during World War 2. A relative penicillin resistence, threatening the convinient use of cheap single-dose treatment, is particularly frequent in the Far East. Other antibiotics and penicillin-probeneoid combinations are still available and have contributed to improved cure rates in some countries, e.g., Canada, United Kingdom, Denmark, Greenland and Norway. Environmental fa ctors suggested are more susceptible persons, greater population mobility, promiscuity, use of pills and IUDs instead of condoms, and changed sexual practices resulting in rectal and oral infections. Hopes for control in the future include formation of adequate case finding organizations in more places, health education, modification of behavior, discovery of a serologic test for gonnorrhea, and although unlikely, immunization. The author concluded that the problems of venereal disease will probably increase: even if syphilis and gonorrhea were controlled, the other sexually transmitted entities (spirochetes, bacteria, virus, protozoa, fungi, parasites and possible cervical carcinoma) will pose problems.^ieng

Clinical and laboratory study of first episode genital herpes in Singapore.

A prospective study of the epidemiology, clinical aspects and laboratory features of first episode genital herpes was carried out in Middle Road Hospital, Singapore between June 1986 and December 1987. A total of 68 patients were studied. There were more women than men in the study population with a female to male ratio of 7.5 to 1. The peak incidence of first episode genital herpes was between 20 and 29 years of age. Specimens from 63 patients yielded positive culture for herpes simplex virus (HSV). HSV-1 was isolated from 21 patients (30.9%), HSV-2 from 41 patients (60.3%) and untyped HSV from one patient (1.5%). True primary genital herpes was diagnosed in 43 patients (68.3%) using a test for complement fixing antibodies to HSV. HSV-1 was found to be the causative agent in 18 (41.9%) of the true primary infections, HSV-2 in 24 (55.8%) and untyped HSV in one (2.3%). In comparison, HSV-1 was isolated in only 2 (10%) of the 20 patients with non-primary first episode genital herpes; HSV-2 was found in 13 patients (65%) and the culture was negative in 5 (25%).

PIP: A prospective study of the epidemiology, clinical aspects, and laboratory features of 1st episode genital herpes was conducted in Middle Road Hospital, Singapore between June 1986-December 1987. A total of 68 patients were studied and there were more women than men in the study population; the ratio of females:males was 7.5:1. The peak incidence of 1st episode genital herpes was between 20-29 years of age. Specimens from 63 patients yielded positive culture for herpes simplex virus (HSV). HSV-1 was isolated from 21 patients (30.9%), HSV-2 from 41 patients (60.3%), and untyped HSV from 1 patient (1.5%). True primary genital herpes was diagnosed in 43 patients (68.3%) using a test for complement fixing antibodies to HSV. HSV-1 was found to be the causative agent in 18 (41.9%) of the true primary infection, HSV-2 in 24 (55.8%), and untyped HSV in 1 (2.3%). In comparison, HSV-1 was isolated in only 2 (10%) of the 20 patients with nonprimary 1st episode genital herpes; HSV-2 was found in 13 patients (65%), and the culture was negative in 5 (25%).

Isolation of anaerobes from clinical chancroid associated with fluctuant bubo in men.

Microbial flora especially anaerobes were studied in 67 patients with genital ulcers due to chancroid (diagnosed clinically) and 53 controls with genital ulcers due to other causes. The aerobic flora was similar in patients of chancroid with or without associated bubo and in controls. Anaerobes were however, isolated with higher frequency from chancroid ulcers associated with fluctuant bubo compared to those without bubo (P less than 0.01) and with non-fluctuant bubo (P less than 0.05). Anaerobic bacteria like Bacteroides melaninogenicus, B. fragilis and anaerobic cocci may play a role in the perpetuation of genital ulcers and development of bubo in chancroid.

PIP: The microbial isolates in 67 men with genital ulcers due to chancroid and 53 controls with genital ulcers due to other causes were investigated. The study subjects comprised 14% of men presenting to a sexually transmitted disease facility in India in 1986. Bubo was present in 37 of the chancroid patients and was fluctuant in 20. At least 1 organism was isolated in both subjects and controls. Monomicrobial growth was observed in 20 chancroid patients and 20 controls; the remainder were polymicrobial. Anaerobic cocci were isolated in 44 (66%) of men with chancroid and 25 (47%) of those with ulcers of miscellaneous etiology, while aerobes were present in 52 (77%) men with chancroid and 39 (73%) controls. Finally, anaerobes were isolated in 17 (57%) of ulcers without bubo, 11 (65%) of ulcers with nonfluctuant bubo, and 18 (90%) of chancroid ulcers associated with fluctuant bubo. There was a significant difference in the anaerobe isolation rate in men with fluctuant bubo and those without bubo (pp0.01) and between patients with fluctuant non nonfluctuant bubo (p0.05). The finding that anaerobes were isolated more frequently, but not at a statistically significant level, from chancroid ulcers than ulcers of other etiology fails to support the hypothesis that anaerobes are a major cause of chancroid. On the other hand, the data do support the view that anaerobes such as anaerobic cocci and Bacteroides melaninogenicus are significant in the perpetuation of chancroid ulcers and the development of fluctuant bubo.

Nongonococcal urethritis.

Nongonococcal urethritis (NGU) and its counterparts in women are the most common sexually transmitted disease syndromes in the United States and Western Europe. Chlamydia trachomatis causes 40 to 50 percent of the cases of NGU and is a major cause of mucopurulent cervicitis and urethral infection in women, epididymitis in young men, pelvic inflammatory disease, acute perihepatitis, and neonatal conjunctivitis and pneumonia. Chlamydial infection also has been linked with Reiter's syndrome, infertility, cervical dysplasia, stillbirth, postpartum endometritis, and other syndromes. Tetracycline HCl is the treatment of choice for NGU and related syndromes, and for the sexual partners of infected patients.

Pattern of sexually transmitted diseases in a Malagasy population.

BACKGROUND: Data concerning the spectrum and antimicrobial susceptibility of STDs in Madagascar are scarce. OBJECTIVES: Improvement of STD patient management in Madagascar. GOAL OF THE STUDY: Assessment of the spectrum of STDs and improvement of therapy. STUDY DESIGN: Etiologic study of 400 patients (169 men, 231 women) under consultation at the major STD service in Antananarivo for one or more of the STD syndromes, urethral discharge, cervicovaginal discharge, genital ulcers, or condylomata according to a fixed diagnostic schedule. RESULTS: Of genital ulcers, syphilis accounted for 46%, lymphogranuloma venereum for 24%, chancroid for 16%, and herpes for 1%. Of the syphilis cases, 51% presented as condyloma lata. Discharge was found in 124 men and 210 women. Counting concomitant infections separately, gonorrhea occurred in 69% of the men and 20% of the women with discharges, chlamydia infection in 42% and 52%, trichomoniasis in 9% and 31%, candidiasis in 12% and 30%. Bacterial vaginosis was found in 37% of the women with discharges. In 32% of male and 71% of female gonorrhea cases, there was concurrent chlamydia infection. Infection with HIV 1 or 2 was not detected. Determination of the antibiotic susceptibility of Neisseria gonorrhoea revealed high efficacy of ampicillin, ciprofloxacin, and spectinomycin; but frequent resistance to tetracycline and cotrimoxazole. CONCLUSIONS: High priority should be given to the management of infections with chlamydia and with Treponema pallidum as well as to educational measures to increase awareness of genital ulcer disease.

PIP: Between November 1992 and April 1993, interviews were conducted with 400 patients (169 men, 231 women) aged 14-52 years at the sexually transmitted disease (STD) clinic of the Institut d'Hygiene Sociale in Antananarivo, Madagascar, to determine the pattern of STDs and to improve treatment of the leading STDs. The 400 patients presented with 434 syndromes. 124 men had urethral discharge. 210 women had cervicovaginal discharge. 43 men and 18 women had genital ulcers. Clinicians could not establish a diagnosis in 33 patients. 171 patients had more than one infection. Chlamydia infection was the most common infection associated with another STD (gonorrhea in 22% of men and 11% of women with discharge, trichomoniasis in 2.4% of men and 13% of women, candidiasis in 1.6% of men and 9% of women, and bacterial vaginosis in 15% of women with discharge). Gonorrhea was the most common etiology for male discharge (69%) while chlamydia infection was for female discharge (52%). Women with discharge were more likely than men with discharge to have chlamydia infection (52% vs. 42%), trichomoniasis (30% vs. 9%; p 0.00001), and candidiasis (32% vs. 12%; p 0.00001). 37% of women with discharge had bacterial vaginosis. Chlamydia infection was the most common STD in this population (45%). 32% of male and 71% of female gonorrhea cases also had chlamydia infection. 70 patients had syphilis. 36 of them had secondary stage syphilis. No one had HIV-1 or HIV-2 infection. The most efficacious antibiotics for gonorrhea were ampicillin, ciprofloxacin, and spectinomycin (100% susceptibility). 31% and 26% of isolates were susceptible to tetracycline and cotrimoxazole, respectively. Public facilities in Madagascar do not have the capabilities to diagnosis chlamydia, resulting in many untreated chlamydia cases. These findings stress the need to improve combined treatment of gonorrhea and chlamydia infection and for educational efforts to increase awareness of genital ulcer disease.

Etiology of nongonococcal urethritis.

Chlamydia trachomatis was isolated from the urethra from 48 (42 per cent) of 113 men with non-gonococcal urethritis (NGU), four (7 per cent) of 58 without overt urethritis, and 13 (19 per cent) of 69 with gonorrhea. Postgonococcal urethritis (PGU) developed in 11 of 11 men who had C. trum antibody to C. trachomatisis developed. The immunotype specificity of chlamydial antibody corresponded to the immunotype isolated. Among culture-negative patients. chlamydial antibody prevalence correlated with the number of past sex partners and with previous NGU. Herpesvirus hominis, cytomegalovirus, T-mycoplasma, Mycoplasma hominis, other bacteria, and Trichomonas vaginalis were not implicated in NGU or PGU. Thus, the cause of chlamydia-negative NGU and PGU remains obscure. Endocervical chlamydia were found in sex partners of 15 of 22 NGU patients with and two of 24 without urethral chlamydial infection (p smaller than 0.001). Tetracycline treatment of both sex partners appears advisable.

PIP: Chlamydia trachomartis was isolated from the urethra from 48 (42%) of 113 men with nongonococcal uethritis (NGU), 4 (7%) of 58 without overt urethritis, and 13 (19%) of 69 with gonorrhea. Postonococcal urethritis (PGU) developed in 11 of 11 men who had C. trachomatis. In 9 of 17 culture-positive seronegative patients with NGU or PGU, serum antibody to C. trachomatis developed. The immunotype specificity of chlamydial antibody corresponded to the immunotype isolated. Among culture-negative patients, chlamydial antibody prevalence correlated with the number of past sex partners and with previous NGU. Herpesvirus hominis, cytomegalovirus, T-mycoplasma, mycolpasma hominis, other bacteria, and Trichomanas vaginalis were not implicated in NGU or PGU. Thus, the cause of chlamydia-negative NGU and PGU remains obscure. Endocervical chlamydia were found in sex partners of 15 of 22 NGU patients with and 2 of 24 without urethral chlamydial infection (p0.001). Tetracycline treatment of both sex partners appears advisable.

Herpes simplex virus in clinically suspected chancroid in Nairobi, Kenya.

PIP: Of 110 males selected for review with possible chancroid, 96 were clinically diagnosed as having chancroid, 7 as having herpetic lesions, and 7 as having syphilis. Of the 96 patients diagnosed clinically as chancroid, 76 (79.2%) were culture positive for H. ducreyi. 9 (9.4%) of these 96 patients yielded Herpes Simplex Virus (HSV). Both HSV and H. ducreyi were isolated from 5 of the patients, and from 4 of the patients HSV alone was isolated. 7 patients (6.4%) were clinically diagnosed as having herpetic ulcers. 5 of these grew HSV. Overall, 14 of the 110 patients (12.7%) yielded HSV. 1 patient, who presented with small vesicular lesions characteristic of HSV, yielded the virus on culture. The vesicles were initially negative for H. ducreyi, but 6 days later he had developed deep purulent ulcers in the same sites as the vesicular lesions and became culture positive for H. ducreyi snd HSV-negative. The possible association between HSV and chancroid is discussed in the light of these findings and comparisons made between the results of the present study and earlier findings made in Kenya and elsewhere, with suggestions being given as to the reasons for the apparent differences. The HSV isolation techniques used in this study may be less sensitive than those used in other studies, but it is highly unlikely that this possibility alone accounts for all of the observed differences. Patients with hepetic ulcers may be less likely to present early in the course of the disease, if at all, believing the infection to be minor and one that will heal on its own. It is also possible that HSV infection is less common in Kenya, either alone or as an initiator of chancroid, than in the US or Europe, becuase of a higher rate of childhood HSV infections in Kenya, which may confer a degree of immunity against genital HSV infection in this population. The lower prevalence of HSV in association with H. ducreyi reported may be at least partly the result of a much higher incidence in Kenya of chancroid which is not initiated by HSV. A higher incidence of HSV genital infection in Europe and America would also make it more likely that HSV would fortuitously be isolated more frequently from H. ducreyi positive lesions.^ieng

Advances in the diagnosis and management of chancroid.

Improved technologies for the cultural diagnosis of chancroid have resulted in increased interest in the management and control of genital ulcer disease. New treatment regimens have been identified, and new control strategies have evolved. These strategies now permit localized introductions of chancroid into developed countries to be contained rapidly. However, additional work is still necessary in developing countries.

PIP: Physicians paid little attention to chancroid and its causative agent Hemophilus ducreyi until the late 1970s and early 1980s. Therefore diagnoses are insufficient. In addition, physicians do not manage chancroid well and public health officials cannot control its spread. Chancroid is endemic in developing countries, but periodically chancroid epidemics do occur in developed countries. Gram positive cocci which also flourish in chancroid ulcers often overgrow H. ducreyi (a gram negative rod) making it hard to diagnose infection. Besides, for optimal chance of H. ducreyi isolation, a health worker must directly inoculate pus from the ulcer onto either gonococcal or Mueller-Hinton agar in the Petri dish. To further complicate diagnosis, clinical and epidemiological characteristics of patients who are H. ducreyi culture negative are like those of patients who are H. ducreyi culture positive. Moreover genital ulceration varies like it does with Treponema pallidum or herpes simplex virus. In fact, only about 40% of men and 29% of women have an ulcer. Nevertheless a chancroid lesion starts out as papule that soon turns into an ulcer. Around 33% of all patients experience lymphadenopathy. If chancroid is not treated, the lymph nodes swell and exude pus. They eventually burst and drain chronically. Prostitutes and other sexually active females with ulcers tend to be reservoirs of H. ducreyi. As of late 1990, researchers could not culture H. ducreyi from asymptomatic males. Another exacerbation of the problems with chancroid is that H. ducreyi is resistant to most antibiotics. Yet erythromycin, ceftriaxone, and cefotaxime treatment yield positive results. A study in Kenya shows that treatments with 1000 mg, 500 mg, and 250 mg ceftriaxone cured 97% of men with genital ulcer disease. Since diagnosis is difficult; anyone with chancroid and his/her contacts should be treated immediately.

AUVDT recommendations for management of gonorrhoea and genital ulcers in Africa.

PIP: The African Union Against Venereal Diseases and Treponematoses (AUVDT), inaugurated in 1979, held its 3rd biannual conference in Nairobi in March 1983 with local participants and participants from 15 English and French speaking countries as well as from Europe, USA and Canada. The conference was devoted to high level training and discussion, workshops on genital ulcer diseases (GUD) and scientific sessions during which many papers were read and discussed. Resolutions and recommendations were made concerning STD in Africa and later passed on to relevant health authorities for necessary action. It was agreed that all African governments who have not already done so should set their own STD control committees as soon as possible. The establishment of microbiological laboratories was strongly urged as well as specific training of health workers. It was felt that gonorrhea and genital ulcer disease were the most frequent sexually transmitted diseases and so management recommendations were made. The efficacy of current regimens using penicillin is increasingly dropping and trimethoprim sulfametrole should be substituted. Failure rates of over 10% would indicate the need to review the accepted regimen. The ideal drug should be effective, orally administered as a single dose, whithout harmful side-effects and preferably not masking syphilis. National programs can purchase drugs through WHO's and UNICEF's purchasing channels at very low prices and governments should utilize these channels. Monitoring of antimicrobial sensitivities should be encouraged and assistance should be sought from university departments of microbiology whenever possible. Genital Ulcer Disease (GUD) is an important public health problem in Africa. Chancroid is the most frequently diagnosed and etiologically proven GUD in eastern, central and southern Africa, accounting for 3-60% of GUD cases. Syphilis, herpetic ulceration, lymphogranuloma venereum and donovanosis are other GUDs found in Africa. Consideration of efficacy, availability, and compliance should be given to treatment. Recent studies have shown that single doses or short-term therapy regimens are as efficient for both ulcers and bubos. Syphilis may be treated with benzathine penicillin im or aqueous procaine penicillin G. No current curative therapy is available for herpes. Local management includes keeping lesions clean and dry; symptomatic treatment involves giving analgesics.^ieng

Epidemiology of sexually transmitted diseases: the global picture.

Sexually transmitted diseases (STD) are now the commonest group of notifiable infectious diseases in most countries, particularly in the age group of 15 to 50 years and in infants. Their control is important considering the high incidence of acute infections, complications and sequelae, their socioeconomic impact, and their role in increasing transmission of the human immunodeficiency virus (HIV). The worldwide incidence of major bacterial and viral STD is estimated at over 125 million cases yearly. STD are hyperendemic in many developing countries. In industrialized countries, the bacterial STD (syphilis, gonorrhoea, chancroid) declined from the peak during the Second World War till up to the late fifties, then increased during the sixties and early seventies, and they have been decreasing again from the late seventies till the present. In the industrialized world, diseases due to Chlamydia trachomatis, genital herpes virus, human papillomaviruses and human immunodeficiency virus are now more important than the classical bacterial ones; both groups remain major health problems in most developing countries. Infection rates are similar in both women and men, but women and infants bear the major burden of complications and serious sequelae. Infertility and ectopic pregnancies are often a consequence of pelvic inflammatory disease, and are preventable. Sexually transmitted diseases in pregnant women can result in prematurity, stillbirth and neonatal infections. In many areas 1-5% of newborns are at risk of gonococcal ophthalmia neonatorum, a blinding disease; congenital syphilis causes up to 25% of perinatal mortality. Genital and anal cancers (especially cervical cancer) are associated with viral sexually transmitted diseases (genital human papillomavirus and herpes virus infections). Urethral stricture and infertility are frequent sequelae in men.

PIP: Sexually transmitted diseases (STDs) are now the most common group of identifiable infectious diseases in many countries, especially among those ages 15-50 and in infants. Their control is important considering the high incidence of acute infections, complications and sequelae, their socioeconomic impact, and their role in increasing transmission of the human immunodeficiency virus (HIV). THe worldwide incidence of major bacterial and viral STDs is estimated to be over 125 million cases yearly. STDs are hyperendemic in many developing countries. However, in industrialized countries, the bacterial STDs such as syphilis, gonorrhea, chancroid declined from their peak during WW II until the late 1950s, increased during the 1960s and early 1970s, and have again decreased since that time. In the industrialized world, diseases due to Chlamydia trachomatis, genital herpes virus, human papillomaviruses, and HIV are now more significant than the classical bacterial ones; both groups remain major health problems in most developing countries. Infection rates are similar in both men and women, but women and infants bear the major burden of complications and serious sequelae. Infertility and ectopic pregnancy are often a result of pelvic inflammatory disease and are preventable. STDs in pregnant women can result in prematurity, stillbirth, and neonatal infections. In many areas, 1-5% of newborns are at risk of gonococcal ophthalmia neonatorum, a disease that blinds and congenital syphilis causes up to 25% of perinatal mortality. Genital and anal cancers (especially cervical cancer) are associated with viral STDs (genital human papillomavirus and herpes virus infections). Urethral stricture and infertility are frequent sequelae in men. (author's modified)