Unit 2: STI Surveillance Methods, Concepts and Terms

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Unit 2 STI Surveillance Methods, Concepts and
Terms
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Warm Up Questions Instructions

• Take five minutes now to try the Unit 2 warm up
  questions in your manual.
• Please do not compare answers with other
  participants.
• Your answers will not be collected or graded.
• We will review your answers at the end of the
  unit.

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What You Will Learn

• By the end of this unit you should be able to
• discuss the components of an STI surveillance
  system
• discuss the uses of STI surveillance data
• describe the difference between aetiologic and
  syndromic STI diagnosis and surveillance
• determine the difference between basic and
  advanced STI surveillance activities and how
  these activities should be used, depending on the
  type of HIV epidemic
• describe IDS case reporting

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Figure 2.1. Components of an STI Surveillance
System
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Which Components Should Be Used?

• Some components are more important for
  second-generation HIV surveillance activities,
  such as
• combined STI/HIV behavioural surveillance surveys
• Others are important to STI control programme
  activities
• assessing syndrome aetiologies
• anti-microbial resistance monitoring
• Some are important for both
• STI case reporting
• STI prevalence assessment and monitoring

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Which Components Should Be Used, Cont.

• Consider existing programmes in your country,
  especially the following issues
• the needs of STI control programmes established
  by your Ministry of Health
• existing surveillance systems for other
  communicable diseases
• the health management information used
• existing health services infrastructure
• the state of the HIV epidemic in your country

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Symptomatic and Asymptomatic STIs

• To accurately calculate incidence and prevalence,
  the STI surveillance system needs to identify
• which STIs are newly acquired
• which have been present for a long time
• To identify these conditions, it is important to
  understand the role of symptomatic and
  asymptomatic STIs.

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Symptomatic STIs

• Symptomatic infections are recently acquired and
  represent true incidence.
• Herpes simplex virus is an exception since
  symptoms can recur without new infection, making
  it impossible to determine the duration of
  infection.
• Examples include
• chancroid
• gonorrhea
• early syphilis
• chlamydia

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Asymptomatic STIs

• Asymptomatic infections do not produce symptoms.
• They can be present for a long time without
  patients knowing they are infected.
• They are more useful for calculating prevalence
  than incidence.
• Examples include (but are not limited to)
• latent syphilis
• chronic Herpes simplex virus type 2
• chlamydia
• gonorrhoea

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How STI Surveillance Data Are Used

• Assess overall burden of STIs
• Monitor trends in recently acquired STIs
• Provide information for physicians to treat STI
  patients and their sex partners
• Provide information to assist in planning and
  managing STI and HIV prevention and control
  programme efforts
• Provide data for advocacy, resource mobilisation,
  programme planning, targeting, monitoring
  evaluation
• Serve as a marker of HIV risk behaviours
• Monitor the number of people infected with HIV
  who develop an STI

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Aetiologic and SyndromicCase Reporting

• STI cases can be reported by one of the following
  strategies
• In aetiologic case reporting, the specific STI
  pathogen is identified by laboratory methods to
  make a diagnosis.
• In syndromic case reporting, the symptom complex
  is used for diagnosis in the absence of
  laboratory confirmation of the STI pathogen.

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Aetiologic Case Reporting

• Aetiologic case reporting requires laboratory
  confirmation of diagnoses. 
• Aetiological case reporting is only possible
  where well-developed systems of laboratory
  diagnosis are incorporated into routine STI
  clinical case management.
• In Africa, the use of laboratory services for
  diagnosis is often not available for routine
  care, so the syndromic approach is recommended.

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Syndromic Case Reporting

• Only urethral discharge in men and genital ulcers
  in men and women reflect recent infection.
  Therefore, they are important for detecting
  trends in STI incidence. 
• Syndromic case reports are a poor tool for
  assessing disease burden among women, since
  womens infections are often asymptomatic.

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Syndromic Case Reporting, Cont.

• Gonorrhoea and chlamydia infections in women may
  be symptomatic, but the symptoms are difficult to
  distinguish from other conditions.
• When possible, STI prevalence assessment and
  monitoring for women should be undertaken as a
  supplement to case reporting.

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Case Definitions

• When syndromic case reporting is used, healthcare
  workers should make diagnoses based on a standard
  case definition. 
• Uniform case definitions should be used
  throughout the country.
• Cases should only be recorded if they meet the
  standard case definition, not simply based on the
  assigned diagnosis.

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Table 2.1. Recommended Case Definitions for
Select STI Syndromes
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Source UNAIDS/WHO, 1999.
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Using the IDS Strategy to Report

• Under IDS, STI cases are reported from the
  district using forms similar to those used for
  other priority communicable diseases. 
• Data are collected, analysed and disseminated in
  an integrated way.
• The STI portion of IDS includes reports for
• cases of urethral discharge in men
• cases of non-vesicular genital ulcers in men and
  women

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Table 2.2. Recommended Aetiological Case
Definitions for Selected STI Syndromes
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Basic and Advanced STI Surveillance

• Two levels of STI surveillance activities can be
  planned 
• Basic STI surveillance activities should be
  undertaken in areas with limited resources.
• Advanced STI surveillance activities can be
  conducted in countries with more extensive
  resources and well-developed laboratories.

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Table 2.3. Comparing the Approach for Basic and
Advanced STI Surveillance

• Basic Surveillance
• Sentinel or universal syndromic reporting (with
  minimal data elements collected) of
• male urethral discharge
• non-vesicular genital ulcer disease in men and
  women

• Advanced Surveillance
• Aetiologic reporting of
• syphilis (by stage)
• gonorrhoea
• chlamydia

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Table 2.3. Comparing Prevalence Assessment and
Monitoring for Basic and Advanced Surveillance

• Basic Surveillance
• Conduct periodically in high-risk populations
• Test all pregnant women for syphilis
• Focus only on serologic testing for syphilis

• Advanced Surveillance
• Conduct periodically in general and high-risk
  populations
• women at family planning clinics
• military recruits
• sex workers, STI patients
• Include urine testing for gonorrhoea and
  chlamydia and serologic testing for syphilis
• Can be combined with behavioural surveys

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Table 2.3. Comparing Assessment of Syndrome
Aetiologies for Basic and Advanced Surveillance

• Basic Surveillance
• Assess genital ulcer disease and urethral and
  vaginal discharge every three years

• Advanced Surveillance
• Assess causes of genital ulcer disease at least
  every three years
• Assessment of genital discharge is not needed
  because aetiologic case reporting is used

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Table 2.3. Comparing Special Studies for Basic
and Advanced STI Surveillance

• Basic Surveillance
• Investigate
• anti-microbial resistance monitoring for N.
  gonorrhoeae annually
• conduct evaluation of STI treatment guidelines
  every three years

• Advanced Surveillance
• Investigate outbreaks of diseases with low
  incidence
• Conduct special studies of
• anti-microbial resistance monitoring for N.
  gonorrhoeae annually
• serologic surveys of HSV-2 especially in
  adolescents and young adults
• human papilloma virus infections
• prevalence studies of bacterial vaginosis

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Table 2.4. Planning for Advanced STI Surveillance
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In Summary

• STI surveillance includes routine data collection
  and special studies.
• It relies on aetiologic or syndromic case
  reporting, but syndromic case reporting is
  recommended for sub-Saharan Africa.
• Basic STI surveillance activities should be
  undertaken in areas with limited resources.
• Advanced activities are conducted where there are
  more resources and better laboratories.

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Warm Up Review

• Take a few minutes now to look back at your
  answers to the warm up questions at the beginning
  of the unit.
• Make any changes you want to.
• We will discuss the questions and answers in a
  few minutes.

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Answers to Warm Up Questions

• 1. True or false? Some elements of an STI
  surveillance system are more important for HIV
  surveillance activities. Others are more
  important for STI control programme activities.

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Answers to Warm Up Questions

• 1. True or false? Some elements of an STI
  surveillance system are more important for HIV
  surveillance activities. Others are more
  important for STI control programme activities.
  True

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Answers to Warm Up Questions, Cont.

• 2. True or false? STI surveillance data can serve
  as an indicator of trends in HIV risk behaviours.

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Answers to Warm Up Questions, Cont.

• 2. True or false? STI surveillance data can serve
  as an indicator of trends in HIV risk behaviours.
  True

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Answers to Warm Up Questions, Cont.

• 3. True or false? Aetiologic reporting of
  syphilis (by stage), gonorrhoea, chlamydia, and
  congenital syphilis is considered a basic
  surveillance activity in the African region.

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Answers to Warm Up Questions, Cont.

• 3. True or false? Aetiologic reporting of
  syphilis (by stage), gonorrhoea, chlamydia, and
  congenital syphilis is considered a basic
  surveillance activity in the African region. False

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Answers to Warm Up Questions, Cont.

• Which of the following is not a component of an
  STI surveillance system?
• STI universal case reporting
• STI sentinel surveillance systems
• STI testing and treatment
• STI prevalence assessment and monitoring

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Answers to Warm Up Questions, Cont.

• Which of the following is not a component of an
  STI surveillance system?
• STI universal case reporting
• STI sentinel surveillance systems
• STI testing and treatment
• STI prevalence assessment and monitoring

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Answers to Warm Up Questions, Cont.

• 5. True or false? In generalised HIV epidemics,
  prevalence assessments should include monitoring
  gonorrhoea and chlamydia.

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Answers to Warm Up Questions, Cont.

• 5. True or false? In generalised HIV epidemics,
  prevalence assessments should include monitoring
  gonorrhoea and chlamydia. True

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Answers to Warm Up Questions, Cont.

• 6. True or false? An STI surveillance system
  includes conditions that are newly acquired, as
  well as those that represent past infections.

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Answers to Warm Up Questions, Cont.

• 6. True or false? An STI surveillance system
  includes conditions that are newly acquired, as
  well as those that represent past infections. True

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Answers to Warm Up Questions, Cont.

• 7. In __________ case reporting, STI cases are
  reported by the specific microbial organism that
  caused the STI, while in syndromic case
  reporting, STI cases are reported by the clinical
  syndrome with which the patient presents.

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Answers to Warm Up Questions, Cont.

• 7. In aetiologic case reporting, STI cases are
  reported by the specific microbial organism that
  caused the STI, while in syndromic case
  reporting, STI cases are reported by the clinical
  syndrome with which the patient presents.

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Small Group Discussion Instructions

• Get into small groups to discuss these questions.
  
• Choose a speaker for your group who will report
  back to the class.

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Small Group Reports

• Select one member from your group to present your
  answers.
• Discuss with the rest of the class.

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Case Study Instructions

• Try this case study individually.
• Well discuss the answers in class.

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Case Study Review

• Follow along as we go over the case study in
  class.
• Discuss your answers with the rest of the class.

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Questions, Process Check

• Do you have any questions on the information we
  just covered?
• Are you happy with how we worked on Unit 2?
• Do you want to try something different that will
  help the group?

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