N ational STI M icrobiological Surveillance Programme David A. Lewis FRCP(UK) PhD Sexually Transmitted Infections Reference Centre National Institute of Communicable Diseases (NHLS) South Africa
Mission statement of the NICD
“To be a resource of knowledge and expertise in regionally relevant communicable diseases to the South African Government, to SADC countries, and to the African Continent at large, in order to assist in the planning of policies and programmes and to support appropriate responses to communicable diseases issues�
Key players in STI surveillance in South Africa N at ional Depart ment of Healt h STI Reference Cent re ( co-ordinat ion) Collaborat ing Universit ies N at ional Healt h Laborat ory Service
Patient Issues Prot ocol approved by Sout h A frican
N at ional Depart ment of Healt h Et hics approval from t he HREC
( M edical) - Universit y of t he Wit wat ersrand Clinic-based surveillance syst em I nformed writ t en consent
A nonymous t est ing Pat ient s managed syndromically I deally 3 mont hs’ collect ion period
Male urethral syndrome (MUS) Pathogens N eisseria gonorrhoeae Chlamydia t rachomat is Trichomonas vaginalis M ycoplasma genit alium First-line treatment • Dox ycycline 1 0 0 mg bd x 7 d. • Cefix ime 4 0 0 mg st at p.o. N on-responders • Re-t reat wit h first -line agent s if lik ely re-infect ion • Give ceft riax one 2 5 0 mg st at i.m. ( resist ant gonorrhoea) • M et ronidazole 2 g st at p.o. for ot hers
Vaginal discharge syndrome (VDS) Pathogens/ Conditions N eisseria gonorrhoeae Chlamydia t rachomat is Trichomonas vaginalis M ycoplasma genit alium Bact erial vaginosis Candidiasis First-line treatment • Dox ycycline 1 0 0 mg bd x 7 d. • Cefix ime 4 0 0 mg st at p.o. • M et ronidazole 2 g st at p.o. I f candidiasis suspected • Give Add clot rimazole pessary + / cream
Genital ulcer syndrome (GUS) Pathogens Herpes simplex virus Treponema pallidum Haemophilus ducreyi Chlamydia t rachomat is L1 -L3 Klebsiella granulomat is First-line treatment • Benzat hine penicillin 2 .4 M U st at I .M . • Eryt hromycin 5 0 0 mg 6 hourly p.o. x 7 d. • Acyclovir 4 0 0 mg 8 hourly p.o. x 7 days N on-responders • Refer
Patient Specimens
Serum from all pat ient s
Swabs from genit al ulcers
ulcer smear for granuloma inguinale ulcer swab for N A A Ts
M ale uret hrit is syndrome
HI V, RPR, HSV-2 ant ibodies
endouret hral smear for Gram st ain* endouret hral cult ure for gonococci endouret hral swab/ urine for N A A Ts
Vaginal discharges
high vaginal swab for slide endocervical swab for N A A Ts
* In Gauteng NMS only
Gonococcal Culture I solat ion of N eisseria
gonorrhoeae on select ive N ew York Cit y medium M I C det erminat ion using E
t est s Cefix ime, Ceft riax one and
Ciproflox acin E t est s init ially A gar dilut ion M I Cs t o be lat er
performed on st ored isolat es ( ot her ant imicrobial agent s)
NAAT Testing for STI Pathogens Genit al ulcers
-
Herpes simplex virus ( herpes) Treponema pallidum ( syphilis) Haemophilus ducreyi ( chancroid) Chlamydia t rachomat is L1 -L3 ( LGV)
Uret hral/ vaginal discharge
- N eisseria gonorrhoeae ( gonorrhoea) - Chlamydia t rachomat is D-K ( ‘ chlamydia’ ) - Trichomonas vaginalis ( t richomoniasis) - M ycoplasma genit alium
Aetiology of MUS by Diagnosis 90 80 70 60 50 40 30 20 10 0
Gauteng Western Cape Mpumalanga M .g en ita l iu m
Tr i ch om on ia
si s
a
Northern Cape Ch la m yd i
G
on or rh oe a
Prevalence (%)
(2006-2007 Surveys)
Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged
Aetiology of VDS by Diagnosis (2006-2007 Surveys)
Prevalence (%)
70 60 50 40
Gauteng
30
Western Cape
20 10
Mpumalanga Northern Cape
0
G
ea o rrh o on
C
ia yd am hl T
is as i on m ho ri c
s m si iu l o n ta gi ni a e lv .g a i M r te c Ba
C
is as i d di n a
Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged
Aetiology of GUD by Diagnosis (2006-2007 Surveys) 70 60 50 Prevalence (%)
40
Gauteng
30
Western Cape
20
Mpumalanga
10
Northern Cape ae ti o lo gy No
Do no va no s is
oid Ch an cr
V LG
Sy ph i lis
He rp es
0
Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged
Seroprevalence of RPR (≼ 1:4) by Province (2006-2007 Surveys)
Prevalence (%)
30 25 20 15 10 5 0
Gaut eng
West ern Cape
Mpumalanga
Nort hern Cape
MUS
1
1
4
7
VDS
3
5
4
5
GUS
4
15
9
26
Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged
Seroprevalence of HSV-2 by Province (2006-2007 Surveys)
Prevalence (%)
100 80 60 40 20 0
Gaut eng
West ern Cape
Mpumalanga
Nort hern Cape
MUS
60
30
81
46
VDS
76
38
78
61
GUS
81
29
85
77
Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged
Seroprevalence of HIV by Province (2006-2007 Surveys)
Prevalence (%)
80 60 40 20 0
Gaut eng
West ern Cape
Mpumalanga
Nort hern Cape
MUS
39
25
54
42
VDS
52
43
58
44
GUS
75
29
71
69
Sharing of data by Professors Willem Sturm and Preshnie Moodley, Nelson Mandela School of Medicine, University of KZN, Durban is gratefully acknowledged
Microbiological Resistance (%)
Rise of Ciprofloxacin Resistant Gonorrhoea in South Africa 35
Change to Cefixime
30 25 20
Johannesburg
15
Cape Town
10 5 0 2004 2005 2006 2007 2008 2009 Year
In 2007, the ciprofloxacin resistant phenotype was significantly associated with HIV serostatus (p = 0.034) in Cape Town and Johannesburg.
N ew STI Guidelines 2 0 0 8
Evidence-based
Ciproflox acin removed as first line t reat ment for gonorrhoea
Cefix ime for M US/ VDS
Ceft riax one for SSW/ LA P
Acyclovir for GUS
Conclusions STI s remain a major problem in Sout h A frica and lik ely
cont inue t o play a role in driving t he HI V epidemic Gonorrhoea remains t he most frequent cause of t he M US
syndrome Q uinolone resist ance has increased mark edly in much of t he
world and many count ries have swit ched t herapy t o a 3 rd generat ion cephalosporin
Trichomoniasis is t he most common STI in women wit h VDS Genit al herpes is t he major cause of genit al ulcerat ion –
pat ient s require careful healt h educat ion concerning t his recurring condit ion I t is import ant t o follow perform regular aet iological and
ant imicrobial resist ance surveillance for STI s