1. 1 “Community-Based HIV Surveillance” Online Course 2016 Module 1: [Basic] Unit 2: [Main components of second generation HIV surveillance] Lesson 5: [STI surveillance]

2. Introduction 2 In this lesson, you will learn about the definition and components of sexually transmitted infection (STI) surveillance as a main component of second generation surveillance. You will also learn how STI surveillance data can be used in understanding HIV epidemics. HIV estimates and projections Use of data for action Data analysis Monitoring & Evaluation HIV/AIDS Case reporting Biological surveillance Behavioural surveillance Data management STI surveillance

3. Warm Up Questions 3 What does STI surveillance mean? What are the differences between etiologic and syndromic STI surveillance? What are the advantages and disadvantages of universal and sentinel case reporting? Which data sources can be used to obtain information related to STIs?

4. Objectives 4 The objectives of this lessen is to understand: The link between STIs and HIV The role of STIs in better understanding of HIV epidemic. The components of STI surveillance and related issues to each component The types of STI case reporting and data sources

5. STI Surveillance 5 Sexually transmitted infections (STIs) are diseases that are spread from person to person during sexual contact. There are more than 20 pathogens that can be transmitted sexually. STI surveillance is an ongoing and systematic collection, analysis, interpretation and dissemination of data to describe and monitor rates and trends of sexually transmitted infections. This information is needed to guide STI control efforts. Different STIs (or STI syndromes) are monitored depending on factors such as how common they are and how feasible they are to identify. STI surveillance is very important in design and implementation of HIV/AIDS programs, because: 1.STIs facilitate HIV transmission 2.STIs are markers of high-risk behaviors that also spread HIV That's why STI surveillance is one of the main component of second generation surveillance. As you remember from previous sessions, HIV epidemic can be in three stages: low level, concentrated and generalized.In all three epidemic stages, STI surveillance can help as: An early warning system for HIV infection and emergence of HIV in new groups or new geographical areas; An evaluation tool for HIV prevention programs.

6. Components of STI Surveillance 6 Three components of STI surveillance are: 1.STI case reporting 2.STI prevalence assessment and monitoring 3.Specific STI surveillance activities such as: laboratory assessment of antimicrobial resistance validation of syndromic STI management other special surveys and functions

7. STI Case Reporting 7 There are two types of STI case reporting: 1. Etiologic case reporting: cases are diagnosed and reported using laboratory results that identify the specific microbial organism that cause the STI. 2.Syndromic case reporting: cases are diagnosed and reported according to a set of clinical signs and symptoms that correspond to a few clinical syndromes (for example, genital ulcer disease and male urethral discharge). Diagnostic laboratory tests are not used to make a diagnosis of a STI syndrome. In both syndromic and etiologic case reporting, clinicians should use uniform case definitions in recording their diagnoses and reporting cases (you can find the recommended WHO case definition criteria in “surveillance for sexually transmitted infections, WHO,2007”).

8. Etiologic Case Reporting 8 Etiologic case reporting requires: Well-developed systems of laboratory diagnosis incorporated into routine STD clinical care Diagnosis based on laboratory testing For example, STI etiologic case definitions for surveillance of syphilis(primary and secondary) is: – Probable: an illness with ulcers (primary) or mucocutaneous lesions (secondary) and a reactive serologic test (non- treponemal or treponemal). – Confirmed: demonstration of Treponema pallidum in clinical specimens by dark field microscopy, DFA-TP, nucleic acid test, or equivalent methods. – Depending on the sexual transmitted infection, there may exist one confirmed diagnosis or two probable and confirmed diagnosis. In etiologic STI case reporting, all probable and confirmed cases should be reported. The main limitations of etiologic case reporting are: 1. Many STIs are not useful for monitoring trends in incidence. For example recently detected latent syphilis in both men and women and Clamidya, Gonorrhea and Trichomonasis in women usually reflect infections which were acquired at an unknown time before and can not be used for monitoring trend in incidence, but primary and secondary Syphilis in men and women, and Gonorrhea in symptomatic men are very useful for monitoring trend in incidence. 2. Etiologic case reporting is more useful for monitoring trends in STI incidence in men as compared to women. because most of STI cases are asymptomatic in women. 3. Availability of diagnostic tests does not assure quality procedures have been in place during the application. 4. Sensitivity of diagnostic tests is often less than 100%.In etiologic reporting, if a person has a genital ulcer but his/her test for specific pathogen is negative, the diagnosis is considered negative even though the patient be actually infected.

9. Syndromic Case Reporting 9 Most developing countries do not have sufficient laboratory infrastructure for routine etiologic case reporting. In these countries, syndromic case reporting is the only option. Syndromic case reporting require no laboratory diagnostic test. For example a syndromic case definition for urethral discharge syndrome is: – Urethral discharge in men with or without dysuria. (This syndrome is most commonly caused by Neisseria gonorrhoeae and Chlamydia trachomatis; other infectious agents associated with urethral discharge include Trichomonas vaginalis, Ureaplasma urealyticum, and Mycoplasma spp.) – syndromic case reporting is easier, cheaper and generally more widely used, does not need any specific laboratory facilities and can be performed at any epidemic level – If it is well implemented, syndromic case reporting can provide reliable information to guide design, implementation and monitoring of HIV/AIDS programs. Where syndromic case reporting is used, clinicians should use uniform case definitions in recording their diagnoses and reporting cases.

10. Syndromic Case Reporting, Cont. 10 The main limitations of syndromic case reporting are: – The syndromes are not specific to a particular pathogen. There may be more than one pathogen with similar signs and symptoms. – Use of syndromic case reporting provides a poor assessment of disease burden and trends in women compared with men. Some of STIs in women are asymptomatic and syndromic case reporting may underestimate burden of these STIs in women. In contrast, usually a high proportion of vaginal discharge cases are not caused by STIs, nor are a substantial proportion of cases of lower abdominal pain in women, or of clinically apparent cervicitis. Reporting all of them as STI syndromic cases overestimate the burden of disease. The most useful STI syndromes which are likely to reflect recent infection and can be used to monitor incidence trends are male urethral discharge and male or female genital ulcers. In women, STI prevalence assessment and monitoring are essential, even in resource-poor settings In countries where substantial clinical diagnosis is performed both syndromically and etiologically, some experts believe that a combined system of syndromic and etiologic case reporting may be used, although care should be taken that STI cases occurring in individual patients not be reported to both systems. In countries where etiologic diagnosis is performed, multiple infections in the same person can be reported separately (e.g., gonorrhoea and chlamydia).

11. STI Case Reporting Approaches 11 Both etiologic and syndromic STI cases can be reported by two approaches: universal and sentinel case reporting. – In universal STI case reporting, basic information about STIs – including data on age and gender – are collected from all health facilities in the country. – In Sentinel STI case reporting some reporting sources (usually healthcare facilities which are more reliable in reporting STI cases) are selected and more detailed information are collected from these pre-arranged sites. – Data from sentinel surveillance systems must be interpreted with care taking into account how sentinel sites may be similar to or different from other health care facilities in the country.

12. Advantages and Disadvantages of Universal STI Case Reporting 12 AdvantagesDisadvantages  It is the most readily available source of STI surveillance data.  It is easy to collect from health facilities.  It provides data on the burden of STIs as seen at the health facility level, important for planning health services.  When consistent, it can be used to track population-level STI trends.  It is based on recognition of symptoms and thus provides a poor assessment of the true disease burden among women (compared with men, STIs are more often asymptomatic in women).  It does not provide a direct estimate of the population burden of STIs because people with asymptomatic infection do not realize they are infected so they do not seek care.  It is affected by fluctuations in healthseeking behaviours of the population not related to the burden of disease (for example, availability of drugs or introduction of user fees at clinics).

13. Advantages and Disadvantages of Sentinel STI Case Reporting 13 AdvantagesDisadvantages  Regular supervision, feedback and logistical support can be relatively easily provided because sentinel sites are located in fewer facilities.  Higher quality data can be obtained from a few sites with intensive support of training, supervision and logistics.  A sentinel STI case reporting system is less expensive to run and maintain than a universal reporting system.  Sentinel STI case reporting is generally more flexible than universal case reporting. Additional studies that collect STI and/or behavioral data can be added without changing the basic structure.  Sentinel STI surveillance cannot provide minimum population based estimates of disease burden. Sentinel sites are located in only a few health facilities. Therefore, data from sentinel sites only represent the sites and their catchment populations and not the whole district, province or nation.  Sentinel sites cannot be considered representative of other clinics due to the special attention that they receive. Information from these sites is only representative of the populations they serve.

14. Factors to Consider When Selecting Sentinel Sites 14 Some important factors that should be considered for selecting a sentinel site are as follows: Geographical representativeness to ensure inclusion of both rural and urban populations. Inclusion of public and private sectors and non- governmental organizations that provide health services. Inclusion of sites that provide services to populations of interest and hard-to-reach populations. Inclusion of populations that are proxy for the general population, e.g., antenatal and family planning clinic attendees. Inclusion of specialized clinics (e.g., STI clinics) where additional studies such as antimicrobial resistance testing and determination of etiologies of syndromes may be conducted. Inclusion of other relevant specialties' such as dermatology, gynecology, pediatrics and urology. Adequate financing and provision of commodities. Human resource in terms of numbers and trained of staff Integrate STI surveillance activities with other ongoing surveillance activities, such as HIV/AIDS sentinel surveillance to permit integrated analyses.

15. Combined Universal and Sentinel Surveillance Case Reporting 15 Ideally, all health facilities in a country should report through the universal system using integrated disease surveillance (IDS). A combination of universal case reporting and sentinel surveillance provides added advantages: Universal case reporting provides minimum estimates of incidence and prevalence of STIs. Sentinel site case reporting provides epidemiological and clinical detail on a subset of cases. In combined systems, data from sentinel sites are included in both the universal case reporting system as well as the sentinel site case reporting system

16. Data Elements in Routine STI Case Reporting 16 Core data elements that are essential to reporting a case should routinely be collected on clinic logs and reporting forms. Additional data elements may be collected at some sites, which can provide more detail on patient demographics, risk characteristics and treatment. The selection of additional data elements will depend on the specific purposes for which the data will be used.

17. Importance of STI Case Reporting in Understanding HIV/AIDS Epidemic 17 In second-generation HIV surveillance, STI case reporting is used as a proxy for HIV transmission. This is because STIs are transmitted in the same way as sexually transmitted HIV and because programs that target prevention of sexually transmitted HIV should also prevent transmission of STIs. Several STIs cause acute symptoms and represent recently acquired infection. These may indicate trends in HIV incidence as well. Surveillance of the main STI syndromes – male urethral discharge syndrome, male and female non-vesicular genital ulcer disease – can, therefore, serve two functions: 1.They indicate where HIV transmission could be occurring (for instance, a geographical area or a population group). 2.They indicate where HIV prevention programs are failing (if the rates of STIs are rising) or succeeding (if the rates of STIs are falling). (Other STI syndromes – including female lower abdominal pain, male scrotal swelling, male and female inguinal bubo – can provide supplemental data to confirm trends of the main syndromes.)

18. STI Prevalence Assessment and Monitoring 18 The second component of STI surveillance is STI prevalence assessment and monitoring. This core surveillance function is similar to HIV seroprevalence surveys, and includes collecting biological specimens (such as blood, urine or swabs) for identification of STIs as well as basic demographic information about the person tested. STI prevalence assessment means using surveys to determine what percentage or how many people have STIs when compared to the total population. STI prevalence monitoring refers to the determination of trends in STI prevalence over time. Information obtained through prevalence assessments and monitoring can be used to understand which groups are at greater risk for infection. STI prevalence assessment and monitoring can be useful for: Identify population sub-groups with high prevalence of STIs; Monitor trends in STI prevalence among defined populations; Measure the overall population burden of STIs. HIV and STI programme planning, management and evaluation. For example, High syphilis prevalence in pregnancy is an indicator of HIV risk in the community. If STI surveillance data show that STI transmission is occurring, then HIV transmission may be occurring as well. You can make this inference because STIs and sexually transmitted HIV are transmitted the same way.

19. STI Prevalence Assessment and Monitoring, Cont. 19 Prevalence assessments are usually planned at the national level as one of the following: part of a national HIV seroprevalence survey a stand-alone project part of a combined STI/HIV behavioral survey STIs that are frequently included in surveys include: syphilis gonorrhea Chlamydia Herpes simplex virus hepatitis B Among the most common seroprevalence surveys are those based on syphilis screening programmes. These are similar to HIV seroprevalence surveys. But unlike HIV, these surveys are linked to individuals. In other words, the patients know their blood has been drawn for screening, and they receive the results and any needed treatment.

20. Data Sources 20 There are two main sources for STI screening data: 1.General population surveys: Two most common settings for general population serological screening for STIs are: Antenatal clinics (ANCs) and Blood donation sites. There is less selection bias when the people being tested are from these types of facilities than when people are seeking care because they have symptoms. 2.Sentinel sites surveys: Syphilis screening can also be done at sentinel sites that are participating in the sentinel case reporting system such as STI clinics, hospital-based clinics, primary health-care centers or private clinics. Data can be collected from all patients screened at the sentinel site or for specific demographic or risk groups

21. Specific STI Surveillance Activities 21 There are some activities used as supplementary of other components of STI surveillance. Some are most useful for the management of STI control programs, and others are useful for HIV programs. These activities include:  Monitoring etiologies for STI syndromes (conducting laboratory tests to diagnosis related organism)  Measuring antimicrobial resistance patterns (the resistance of related organism to antimicrobial therapies)  Behavioral surveys and especially behavioral surveys that are combined with STI and HIV testing.  Research studies to address aspects of STI epidemiology that cannot be addressed by routine surveillance.

22. Which Components Should be Used? 22 The three components of STI surveillance(STI case reporting, STI prevalence assessment and monitoring and four specific STI surveillance activities) should be used together to generate a complete picture of the STI burden in a country or region. Some components of an STI surveillance system, such as combined STI/HIV behavioral surveillance surveys, are important for second-generation HIV surveillance activities. Other STI surveillance components(such as assessing syndrome etiologies and antimicrobial resistance monitoring) are more important for STI control program. Finally some components are equally important for second-generation HIV surveillance and STI control, for example: STI case reporting and STI prevalence assessment and monitoring.

23. Passive vs. Active STI Surveillance 23 STI surveillance data can be reported using a passive or an active surveillance system: Passive surveillance: health facilities provide case reports directly and health authorities take no action while waiting for report forms to be submitted. When the facilities are understaffed or not trained, the reports may be late, incomplete or not delivered at all. Active surveillance: Active surveillance involves outreach by the public authority, such as regular telephone calls or visits to laboratories, hospitals, and providers to stimulate identifying and reporting of STI cases. Because it places intensive demands on resources, implementation of active surveillance should be limited to brief or sequential periods of time and for specific purposes. It is generally employed when it is expected that more cases are in the community than is shown in the passive surveillance systems.

24. Summary 24 STIs and HIV are inter-related because of behavioral, epidemiological and host factors. STIs increase susceptibility to HIV and also increase the risk of transmitting HIV. STI surveillance data can be used as an early warning of the emergence of HIV and as an evaluation tool for HIV prevention programs. Three components of STI surveillance are: STI case reporting, STI prevalence assessment and monitoring and some supplementary STI surveillance activities. STI case reporting can be based on either etiologic or syndromic case reporting or both. Both etiologic and syndromic STI case reporting can occur through universal STI case reporting, sentinel STI case reporting or a combination of the two. Universal reporting data tend to be more representative of the entire population, while sentinel case reporting produces higher quality, more detailed and more reliable surveillance data, at moderate incremental cost. STI prevalence assessments can be used to monitor STI prevalence trends in both the general population and in specific population sub-groups and geographical sites. Finally some supplementary activities such as monitoring etiologies for STI syndromes, measuring antimicrobial resistance patterns and conducting behavioral surveys can be useful for the management of STI and HIV management programs.

25. References 25 Content of this session was provided from the below references: 1.Guidelines for Second Generation HIV Surveillance. Second generation surveillance for HIV: The next decade. World Health Organization and Joint United Nations Program on HIV/AIDS, 2000. 2.Surveillance for Sexually Transmitted Infections. Module 4.Participant Manual.WHO,2007 3.Guidelines for Sexually Transmitted Infections Surveillance UNAIDS/WHO Working Group on Global HIV/AIDS/STI Surveillance, 1999 4.Program Operations Guidelines for STD Prevention. Surveillance and data management. CDC. 5.Guidelines for Sexually Transmitted Infections Surveillance. UNAIDS/WHO Working Group on Global HIV/AIDS/STI Surveillance.1999

26. 26 End of Lesson 5- Unit 2