Lewis garp sa website 0

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