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Incident versus
prevalent cases
To accurately calculate incidence and prevalence, the STI surveillance system needs to identify:
-
which STIs are newly acquired
-
which may have been present for a long time.
To identify these conditions, it is important to understand the role of symptomatic and asymptomatic infections. Some STIs produce symptoms rapidly after infection. Other STIs may be asymptomatic.
Incident versus prevalent cases, continued
Symptomatic infections are recently acquired and represent true incident cases. Herpes simplex virus is an exception to this rule. Because its symptoms can recur without new infection, it is not possible to determine if the infection is newly acquired or longstanding. Symptomatic STIs include:
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chancroid
-
gonorrhoea
-
early syphilis
-
chlamydia.
Asymptomatic infections do not produce clinical symptoms. They can be present for a long time (often months or even years), without the patient knowing he or she is infected. For this reason, asymptomatic infections cannot be used to measure incidence. They can, however, be used to measure prevalence. Asymptomatic STIs include:
-
latent syphilis (although there can be symptoms associated with tertiary syphilis)
-
chronic H. simplex virus type 2 (HSV-2)
-
chlamydia
-
gonorrhoea.
Differences
between men
and women
Women have symptoms less often than men, especially for gonorrhoea and chlamydia. Their asymptomatic infections can only be detected by laboratory tests.
In general, reporting of male urethritis (inflammation of the urethra) and male and female non-vesicular genital ulcer disease can be considered to represent recently acquired infections. Based on the above information, consider the following information when interpreting STI surveillance data:
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Diagnoses of urethral discharge in men and non-vesicular ulcers in men and women reflect recently acquired infections. Non-vesicular ulcers are caused by syphilis and chancroid.
-
Vesicular ulcers are usually caused by H. simplex virus and may represent an infection that occurred in the past. However, the vesicles may easily be scraped off, leaving an ulcer. This makes it difficult to make a clinical diagnosis of herpes.
Diagnosis of STI syndromes should be based on standard case definitions (Annex 1). A case definition is standard terminology for deciding whether a person has a particular disease using clinical and/or laboratory criteria.
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Uniform case definitions should be used throughout the country to allow data gathered from the reporting systems to be compared.
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When a clinician makes and records a diagnosis, he or she must do so according to the standard case definition. This helps record officers or other designated staff to tally correctly. If a clinician counts cases that do not meet the standard case definitions, this might overestimate STI incidence.
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At the health-facility level, record clerks and persons preparing surveillance reports should be knowledgeable of the standard case definitions. They will determine whether or not the diagnosis meets the case definition. Cases should only be recorded if they meet the standard case definition, and not simply based on the assigned diagnosis.
You should be aware that the syndromes used for surveillance purposes are only a sub-set of syndromes that would be identified in clinical care.
Components of STI Surveillance Systems
Third-generation
surveillance
Third-generation surveillance uses a variety of methods and tools to gain a more thorough understanding of the country’s HIV epidemic. These are based on a country’s needs and resources.
The components of an effective STI surveillance system include routine data collection and special studies, such as:
-
STI universal case reporting, where all cases of a particular disease are reported to health authorities. Universal case reporting can be either aetiologic or syndromic.
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Universal STI reporting, where data on cases diagnosed at health facilities are aggregated by age, gender and location (for example, place of residence, health facility, region, county, etc). This can be either aetiologic or syndromic.
-
Additional STI surveillance techniques:
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STI prevalence assessment and monitoring
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combined STI/HIV and behavioural surveillance surveys
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monitoring anti-microbial resistance of STI pathogens
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assessing STI syndrome aetiologies
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monitoring and assessing healthcare access, usage and quality for STI management.
Levels of STI Surveillance – Basic, Intermediate and Advanced
Three levels of STI surveillance are described here:
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Basic-level STI surveillance activities should be undertaken in areas with limited resources and/or weak surveillance systems.
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Intermediate-level STI surveillance activities can be conducted in countries with well-established surveillance systems and good laboratory infrastructure to support testing.
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Advanced-level STI surveillance activities can be conducted in countries with more extensive resources, well-developed laboratories and strong surveillance systems.
CAREC
recommendations
Table 6.3. Three levels of STI surveillance, and recommendations for trends analyses and data reporting to CAREC.
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Surveillance component
|
Data source
|
Recommendation for trends analysis and reporting
|
Basic-level surveillance system
|
Routine syndromic reporting of:
Routine aetiologic testing and reporting of:
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syphilis in pregnant women
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congenital syphilis
Periodic surveys for aetiologies (for example, every three years).
| -
laboratories (public and private)
-
public health facilities (hospitals and health centre)
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STI clinics
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ANC clinics
|
Collect and analyse aggregate data on a quarterly basis, by age group, gender and area of residence/health facility.
Send quarterly reports to CAREC.
|
Intermediate-level surveillance system
|
Aetiologic reporting of:
-
gonorrhoea
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chlamydia
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trichomonas
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bacterial vaginosis
-
syphilis
-
Herpes simplex virus
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lymphogranuloma venereum
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chancroid
-
congenital syphilis
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ophthalmia neonatorum
| -
laboratories (public and private)
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public health facilities (hospitals and health centre)
-
STI clinics
-
ANC clinics
|
Collect and analyse aggregate data on a quarterly basis, by age group, gender, and area of residence/health facility.
Send quarterly reports to CAREC.
|
Table 6.3. Three levels of STI surveillance, and recommendations for trends analyses and data reporting to CAREC, continued
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Advanced-level surveillance system
|
Routine aetiologic reporting of :
-
Behavioural and biological HIV/STI surveillance surveys
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Antibiotic resistance testing
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Surveys for quality of care/treatment
|
Population surveyed will depend on epidemic state and risk groups
|
The frequency of surveys will depend on the objectives, epidemic state and available resources.
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An example
As an example, think about the STI surveillance components that would be needed in the following situation.
Cariba has a nearly perfect reporting system for STIs diagnosed syndromically in public health facilities. Although the existing surveillance infrastructure provides good data on the annual burden of STI syndromes in public health facilities, additional information is necessary to estimate the true population burden of STIs and how the STIs relate to HIV. To do this, the country would need special studies to establish:
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how many STI patients seek care from government or private health facilities
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how many seek STI care from other providers (for example, private clinics, traditional medicine or pharmacies) or medicate themselves
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which organisms are causing specific STI syndromes
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which medications should be used to treat the different STIs
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what behaviours are contributing to the spread of STIs.
Small group
discussion
Get into small groups to discuss these questions.
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What are the most common STIs in your country?
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Describe the current ongoing surveillance for STIs in your country?
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How does the STI surveillance system in your country relate to the HIV/AIDS surveillance systems that currently exist?
An example
Reports of STI case reporting from Cariba. Assume that the population size has not changed between 2000 and 2003.
Table 6.4. Reports of STI case reporting from Cariba.
STI condition
|
2000
|
2001
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2002
|
2003
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Male urethral discharge
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2 529
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28 95
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2 978
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2 985
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Male non-vesicular genital ulcer
|
642
|
783
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749
|
769
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Female non-vesicular genital ulcer
|
534
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697
|
630
|
690
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Look at the STI data provided in the table.
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What do the data suggest about the trends in the incidence and prevalence of these conditions in Cariba?
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What do these data suggest about trends in HIV risk behaviours?
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What additional data would you be interested in reviewing to assess burden of STI infection and incidence of STI infection in the province, and why would you be interested?
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