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E. Sexually Transmitted Infections (STI = STD = VD)
MMWR
TABLE II. Provisional cases of selected notifiable diseases, United States.
2010
Reporting Area
Population
Hepatitis B
Syphilis
Gonorrhea
Chlamydia
Michigan
10,071,822
125
207
13,317
48,286
U. S.
303,755,274
4,737
12,164
280,555
1,194,652
What all STIs have in common:
 Transmission – direct mucosal contact with infected individual
 Asymptomatic
 Can be acquired multiple times
 Having one predisposes you for the others
 Can cause infertility and other permanent complications
Prevention –
 Abstinence – the only guarantee
 Monogamy
 Latex condoms
 Regular screening – all sexually active women should be screened for STIs every 6 months!
Disease – Gonorrhea = “the clap”
Agent – Neisseria gonorrhea (bacterium, GNC, oxidase +, humans only)
Virulence  capsule
 fimbriae
 induces inflammation  pus
Transmission rate –
female to male – 1 in 5
male to female – 1 in 2
Target organs – epithelial cells of the reproductive tract, including the cervix, uterus, and fallopian
tubes in women, and the urethra in women and men. The bacterium can also grow in the mouth,
throat, eyes, and anus.
Clinical picture
In men – 10% of men have no symptoms at all. 90% of men have symptoms that appear 2-5
days after infection; symptoms can take as long as 30 days to appear. Symptoms include a
burning sensation when urinating, or a white, yellow, or green discharge from the penis.
Sometimes men with gonorrhea get painful or swollen testicles.
In women – In women, the symptoms of gonorrhea are often mild, but 50% of women who are
infected have no symptoms at all. Even when a woman has symptoms, they can be so nonspecific as to be mistaken for a bladder or yeast infection. The initial symptoms and signs in
women include a painful or burning sensation when urinating, increased vaginal discharge, or
vaginal bleeding between periods. Women with gonorrhea are at risk of developing serious
complications from the infection, regardless of the presence of or severity of symptoms.
Complications - Untreated gonorrhea can cause serious and permanent health problems in both
women and men.
In men
 painful swelling of the testicles
 disseminated infection
 infertility
In women

Pelvic Inflammatory Disease (PID)

ectopic pregnancy

disseminated infection

infertility
In neonates

blindness

joint infections

life-threatening blood infections
Treatment – Several antibiotics can successfully cure gonorrhea. However, drug-resistant strains
of gonorrhea are increasing, and successful treatment of gonorrhea is becoming more difficult.
Because many people with gonorrhea also have chlamydia, antibiotics for both infections are
usually given together. Persons with gonorrhea should be tested for other STIs.
Although antibiotic therapy will stop the infection, it will not repair any permanent damage done
by the disease.
Frequency – declining, but more than 700,000 persons in the U.S. get new gonorrheal infections/yr.
Gonorrhea rates are highest among adolescents and young adults. The overall gonorrhea rate is
highest for 20- to 24-year-olds, which is over 4 times higher than the national gonorrhea rate.
Among females, 15- to 19- and 20- to 24-year-olds have the highest rates of gonorrhea; among
males, 20-to 24-year-olds have the highest rate.
Disease – Chlamydia or non-gonococcal urethritis or NGU
Agent – Chlamydia trachomatis (bacterium, obligate intracellular)
Chlamydia trachomatis infections are the most commonly reported notifiable disease in the U.S.
Virulence – intracellular growth ruptures infected cells and induces inflammation
Target organs - the reproductive tract, including the cervix, uterus, and fallopian tubes in women,
and the urethra in women and men.
Clinical picture - Chlamydia is easily confused with gonorrhea because the symptoms of both
diseases are similar and the diseases can often occur together. Chlamydia is usually asymptomatic
(in 75% of women and 50% of men). Those who do have symptoms will experience them 1-3
weeks after infection and may have an abnormal discharge (mucus or pus) from the vagina or penis
or experience pain while urinating. These early symptoms may be very mild.
Complications
In men
 swelling of testicles or prostate gland
 infertility
In women
 Pelvic Inflammatory Disease (PID) (in 40% of untreated cases)
 ectopic pregnancy
 infertility (the leading cause of)
In neonates
 premature delivery
 blindness
 pneumonia
Treatment – antibiotics (azithromycin)
Frequency – the most frequently reported bacterial STI in U.S; more than 3 million people are
newly infected each year.
Among women, the highest age-specific rates of reported chlamydia are among 15- to 19-year-olds
and 20- to 24-year- olds. These increased rates in women may be, in part, due to increased
screening in this group. Age-specific rates among men, while substantially lower than the rates in
women, were highest in the 20- to 24-year-olds.
Disease – syphilis – “the great pox”
Agent – Treponema pallidum (bacterium, GN spirochete)
Virulence – enzyme hyaluronidase that degrades connective tissue
Clinical picture – infection may pass through multiple stages:
The initial infection causes an ulcer at the site where bacteria enter the body. The bacteria,
however, move throughout the body, damaging many organs over time. Medical experts describe
the course of the disease by dividing it into four stages-primary, secondary, latent, and tertiary
(late).
Primary Syphilis – contagious stage
The first symptom of primary syphilis is an ulcer called a chancre. The chancre can appear within
10 days to 3 months after exposure, but it generally appears within 2 - 6 weeks. Because the
chancre may be painless and may occur inside the body, the infected person might not notice it. I t
usually is found on the part of the body exposed to the infected partner's ulcer, such as the penis,
vulva, or vagina. A chancre also can develop on the cervix, tongue, lips, or other parts of the body.
The chancre disappears within a few weeks whether or not a person is treated. Infection may be
arrested by the immune system at this point, but if not treated during the primary stage, about 1/3
of people will go on to the chronic stages.
Secondary syphilis – contagious stage
A skin rash, with brown sores about the size of a penny, often marks this chronic stage of syphilis.
The rash appears anywhere from 3 - 6 weeks after the chancre appears. While the rash may cover
the whole body or appear only in a few areas, it is almost always on the palms of the hands and
soles of the feet.
Because active bacteria are present in the sores, any physical contact-sexual or nonsexual-with the
broken skin of an infected person may spread the infection at this stage. The rash usually heals
within several weeks or months.
Other symptoms also may occur, such as mild fever, fatigue, headache, sore throat, patchy hair
loss, and swollen lymph glands throughout the body. These symptoms may be very mild and, like
the chancre of primary syphilis, will disappear without treatment. T he signs of secondary syphilis
may come and go over the next 1 - 2 years of the disease.
A pregnant woman with untreated, active syphilis is likely to pass the infection to her unborn
child. In addition, miscarriage may occur in as many as 25 - 50% of women acutely infected with
syphilis during pregnancy. Between 40 - 70% of women with active syphilis will give birth to a
syphilis-infected infant.
Some infants with congenital syphilis may have symptoms at birth, but most develop symptoms
between 2 weeks and 3 months later. These symptoms may include
 skin ulcers
 rashes
 fever
 weakened or hoarse crying sounds
 swollen liver and spleen
 yellowish skin (jaundice)
 anemia (low red blood cell count)
 various deformities
Latent syphilis – not contagious
If untreated, syphilis may lapse into a latent stage during which the disease is no longer contagious
and no symptoms are present. Many people who are not treated will suffer from no further signs
and symptoms of the disease.
Tertiary (= late) syphilis – not contagious
Approximately 1/3 of people who have had secondary syphilis go on to develop the complications
of late, or tertiary, syphilis, in which the bacteria damage the heart, eyes, brain, nervous system,
bones, joints, or almost any other part of the body. This stage can last for years, or even for
decades. Late syphilis can result in mental illness, blindness, other neurologic problems, heart
disease, and death.
Treatment - Penicillin, given by injection.
Unfortunately, the early symptoms of syphilis can be very mild, and many people do not seek
treatment when they first become infected. People with neurosyphilis may need to be retested for
up to 2 years after treatment. In all stages of syphilis, proper treatment will cure the disease. But
in late syphilis, damage already done to body organs cannot be reversed.
Frequency of syphilis– by Race/Ethnicity, Age, and Sex
 African Americans - highest among women aged 20-24 years and among men aged 25-29.
 non-Hispanic whites - highest among women aged 20-24 years and among men aged 35-39.
 Hispanics - highest among women aged 20-24 years and among men aged 35-39 years.
 Asian/Pacific Islanders - highest among women aged 20-24 years and among men aged 30-34.
 American Indian/Alaska Natives - highest among women aged 35-39 years and among men
aged 30-34.
FYI
Disease – genital herpes
Agent – Herpes Simplex virus (HSV-2, HSV-1) (Herpesviridae), ds DNA, enveloped
Clinical picture
 Primary lesion 3-7 days post infection
 Local lymph nodes are swollen, may be fever, headache
 Healing takes up to 2 wks
 But virus travels up nerve endings to infect the neurons (persistent) at base of spine
 Can travel down to reactivate – 88%, every 3-4 months
Treatment
 No cure
 Antiviral medications can shorten and prevent outbreaks during the period of time the person
takes the medication.
 Daily suppressive therapy for symptomatic herpes can reduce transmission to partners.
Frequency – very common in the U.S. At least 45 million people ages 12 and up, or 1 out of every
5 adolescents and adults.