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Course Sample:
Introduction Sexually transmitted diseases(STDs) is the terminology used when referring to a group of conditions or diseases that can be transmitted by genital, oral, or anal sexual contact. This group of conditions is the most prevalent of communicable diseases except for the common cold and flu. Nurses have an important role in providing preventive education, screening high-risk populations, and ensuring follow-up for identified and treated individuals. This course will identify the most prevalent STDs, the current incidence statistics, primary and secondary preventative measures, risk factors, transmission, symptoms, diagnosis/testing, and treatment indicated. Public health and specific population factors related to the specific disease will be presented. Since implications for nursing are applicable to all STDs this will be discussed following the overview of the major and most common conditions. The STDs that will be presented in this course include: Chlamydia, Gonorrhea, Genital Herpes, Genital warts, and Syphilis. Due to the extensive complexity of HIV disease and Hepatitis B, these STDs will not be included in this course. Significance of STDs There are 13 million new cases of STDs, not including HIV and AIDS, each year. This number constitutes those cases that are reported, not the ones that go undetected. Absence of symptoms in either males or females contributes to the lack of identification of some STDs. Another factor in the underestimation of the problem is that clinics and private physicians overwhelmed with paper work may not submit the necessary information regarding identified cases of STDs to the authorities. The need to identify and treat all sexual partners of individuals infected with STDs presents an additional burden on public health officials. Heterosexual, bisexual, or same sex partners can transmit sexually transmitted diseases. Having one STDs does not provide immunity to individuals on subsequent exposure. Furthermore, more than one STD may coexist in the same individual. The major risks and resulting conclusion of STDs is born primarily by women who may develop fertility problems, cervical cancers, chronic pelvic pain, and high-risk pregnancies. STDs cause one-third of all perinatal, neonatal, and maternal deaths. In the United States in 1994, approximately $10 billion was spent on major STDs (other than HIV/AIDS) and their preventable complications. This figure rises to approximately $17 billion if sexually transmitted HIV infections are included. Despite major developments in antibiotic therapy for infectious diseases in general since the early 1950's, the increase in cases of STDs is attributed largely to two unrelated factors. The emergence of oral contraceptives in the 1960s brought about a changing attitude of sexual behavior. More people began sexual activity at a younger age, and a greater laxity in sexual mores followed with the decreased risk of pregnancy. A second issue involved the frequent use of antibiotic therapy producing antibiotic-resistant strains of organisms. In general, STDs primarily involve adolescents and young adults in their 20's. National Institute of Health statistics indicate that approximately two thirds of people who acquire STDs in the U.S. are younger than 25. This population is most likely to have unprotected sex, sex with multiple partners, and often choose higher risk partners. The number of STDs is also expanding with the number of diseases that can be transmitted reaching over 50. Chlamydia Of all STDs in the United States the most common bacterial infection is caused by Chlamydia trachomatis. Data from the 2001 CDC National Overview of STDs indicate that there were 783,242 cases of this STD in 2001 corresponding to over a 10% increase since year 2000. "The increase in chlamydia case reports in 2001 most likely represents a continued increase in screening for this infection and also increased use of more sensitive chlamydia screening tests than used in prior years "(CDC, 2003). Since 2000 laws have been passed in all states requiring the reporting of cases of Chlamydia trachomatis and as of December 2001 C. trachomatis infections were the most widely reported communicable disease in the U.S. Significance: Although Chlamydia is treatable people infected with the organism often are asymptomatic and therefore do not seek medical care. Both women and men can transmit the organism, experience the effects of the disease, and untreated pregnant women subsequently infect their newborn infants. Women suffer the most serious consequences primarily because of the potential development of pelvic inflammatory disease (PID) that causes infertility, ectopic pregnancy, and chronic pain. The following graphs demonstrate the dramatic rise in reported cases and the age and sex specific rates: Figure 1  Figure 2  Transmission: Chlamydia is transmitted by vaginal, anal, or oral sexual contact with an infected partner through semen, vaginal mucous secretions, and blood. Neonatal transmission takes place during delivery by an infected woman. Nearly 25% of infected infants develop chlamydial pneumonia and 50% of infants will develop chlamydial conjunctivitis. High Risk Populations and Prevention Strategies: Factors that place individuals at high risk for chlamydial infections include having multiple sexual partners, having unsafe, unprotected sex, being sexually active under age of 21, abuse of drugs and/or alcohol, having current or history of other STDs, failing to comply with prescribed treatment for STDs, having a low socioeconomic status, or belonging to a racial or ethnic minority. Education about STDs in general and chlamydia in particular is an essential component of prevention. Schools, health clinics, recreational facilities, and wellness centers can serve as sites to disseminate information about STDs, contraceptive counseling, health and hygiene practices, and the importance of forming monogamous relationships. Secondary prevention involves screening those individuals who are at risk but asymptomatic. Screening for Chlamydia trachomatis should be carried out annually for all sexually active women 20-25, pregnant women, and all women during annual gynecological examinations and those seeking birth control measures. Since the rate of infection among adolescents and young adults is highest special emphasis should be on the education and screening of this population. Known sexual contacts of the infected individual must be notified and seek treatment within 30 days as Chlamydia trachomatis is a reportable condition. CDC advises rescreening women at 3-4 months after initial treatment as reinfection raises the risk of PID (pelvic inflammatory disease). Symptoms: Evidence of the disease often is non existent initially. As many as 90% of infected women are asymptomatic and can carry the disease and transmit chlamydia trachomatis. Typical symptoms that may appear often 1 to 3 weeks after exposure include abnormal, milky or yellow mucus vaginal discharge. Cervicitis often develops and produces vaginal bleeding or pain after intercourse. Urinary symptoms such as painful and/or frequent micturation may also be present. Because women are often asymptomatic the likelihood of developing serious complications such as PID is high. The infection spreads along the endometrial wall to the fallopian tubes producing an acute salpingitis with subsequent scarring and invasion into the pelvic cavity. This can further develop into an acute pelvic peritonitis that can be life threatening. The recurrent inflammation and resulting scar tissue formation leads to infertility and potential ectopic pregnancies. Chlamydia trachomatis produces non-specific urethritis in males. Symptoms include mild, sticky, milky or mucus discharge from the penis, penile irritation, testicular and/or groin pain, swollen testes, and painful urination. Testicular involvement or epididymitis may lead to infertility if the condition remains untreated. Other symptoms associated with Chlamydia trachomatis include proctitis (inflamed rectum), oral/pharyngeal infections, and conjunctivitis. A particular strain of chlamydia called lymphogranuloma venereum (LGV) invades the skin through minute fissures or cuts and after months or years can spread to lymph nodes throughout the body. Diagnosis/Testing: Point of care tests for C. trachomatis are helpful in confirming clinical diagnosis and initiating therapy although the tests do lack somewhat in sensitivity and specificity and they are more expensive. The tests use antibody identification to detect the bacterium and results are interpreted within 30 minutes. The use of point of care tests should be restricted to the clinical care site and used when patient treatment can then be started. A reliable laboratory test is the nucleic acid amplification tests (NAAT), a DNA analysis of the Chlamydia trachomatis bacteria in a sample of urine or secretions taken from an infected area. Chlamydia trachomatis can easily be confused with gonorrhea as the symptoms, when present, are similar. Also the two conditions can and often do occur together. The NAAT can detect both chlamydia and gonorrhea with one patient sample. It takes about one week to obtain results from the NAAT. Other tests for the chlamydia bacterium may take up to two weeks for results. Specimens for culture, which must stored at 4 C, can be obtained by urethral or cervical swab. Chlamydia trachomatis can also be diagnosed by direct fluorescent antibody (DFA) or by enzyme immunoassay (EIA). These tests generally provide results within two weeks. It is important to stress that retesting may be needed upon completion of therapy to evaluate if response was effective. Also potential reinfection can occur if treatment regime was not followed or known exposed partners did not receive treatment. Treatment: Oral antibiotics are effective in treating Chlamydia trachomatis. All sexual partners must be examined and treated to prevent reinfection. Treatment for pregnant women may prevent transmission to infants during birth. Penicillin, while often used for some STDs, is not effective for chlamydia infections. Patients must be advised to take all the medication and avoid unprotected sexual contact until the therapy is completed. Single dose therapy may be indicated for infected individuals with erratic health-seeking behavior or poor treatment compliance. A follow up visit 1 to 2 weeks after completion of treatment is encouraged to evaluate response. The following table lists the recommended treatment for Chlamydia trachomatis. |
