Canada Communicable Disease Report
Volume 32 ACS-5
1 May 2006
An Advisory Committee Statement (ACS)
Committee to Advise on Tropical Medicine
and Travel (CATMAT)*†
Statement on travellers and Sexually
Transmitted Infections
PDF Version
24 Pages - 476 KB
Preamble
The Committee to Advise on Tropical Medicine and Travel (CATMAT)
provides the Public Health Agency of Canada (PHAC) with ongoing
and timely medical, scientific, and public health advice relating to tropical
infectious disease and health risks associated with international
travel. PHAC acknowledges that the advice and recommendations set
out in this statement are based upon the best current available scientific
knowledge and medical practices, and is disseminating this document
for information purposes to both travellers and the medical community
caring for travellers.
Persons administering or using drugs, vaccines, or other products
should also be aware of the contents of the product monograph(s) or
other similarly approved standards or instructions for use. Recommendations
for use and other information set out herein may differ
from that set out in the product monograph(s) or other similarly
approved standards or instructions for use by the licensed manufacturer(s). Manufacturers have sought approval and provided evidence
as to the safety and efficacy of their products only when used in
accordance with the product monographs or other similarly approved
standards or instructions for use.
Introduction
Sexually transmitted infections - global overview
In the last 20 to 30 years, population mobility both within and
across national boundaries has increased dramatically. Approximately
1 billion people crossed international borders for work,
study, or pleasure in 2003 to 20041. All mobile populations that
are sexually active are at increased risk of acquiring sexually
transmitted infections (STIs)2-4. The anonymity of travel, the
sense of isolation brought on by unfamiliar surroundings, and the
desire for unique experiences can encourage sexual activity. The
risk of acquiring an STI may be enhanced by poor understanding
of the global epidemiology of these infections5 and the means
available to mitigate risk. Rates of STIs may be elevated among
migrant and marginalized populations (e.g. refugees, internally
displaced, street youth), and these populations may be overrepresented
among commercial sex workers (CSW) in many
countries3,6-10.
STIs are among the most common notifiable infections worldwide,
and rates are particularly high in developing countries11. In
1990, theWorld Health Organization estimated the global burden
of curable STIs at > 250 million cases (syphilis, gonorrhoea
[GC], chlamydia, and trichomonas). Estimates rose to 333 and
340 million new cases of these infections in 1995 and 1999
respectively5,11. The 1999 estimate includes 151 million cases in
South/Southeast Asia, 38 million in Latin America, and 69 million
in Africa12,13. In many countries, these increasing numbers
have been fuelled by the economic and societal disruption of the
HIV pandemic. In sub-Saharan Africa, in particular, there has
been an explosive growth in the number of children who have
lost one or both parents (~14 to 20 million in 2000)14. Many of
these children have been driven to trade sex for food in order to
survive15.
More than 20 different infectious agents can be acquired and/or
spread by various types of sexual contact5,16 (e.g. vaginal sex,
anal sex, oral-genital/oral-anal contact) (Table 1). Chlamydia
trachomatis is the most prevalent bacterial STI worldwide.
Although prevalence rates for many of these infectious agents still
vary widely by geographic region (e.g. human T lymphotropic
virus type 1 [HTLV-1], chancroid), changes in migration, immigration,
and travel patterns during the last 50 years have ensured
that almost any STI can be acquired anywhere in the world. As a
result, the risk of acquiring a given STI in any particular setting is
best considered in quantitative rather than qualitative terms.
Table 1. Sexually transmitted infections
Viral diseases |
Hepatitis A virus
(oral-anal contact) |
HIV-1/2 | HSV II
Cytomegalovirus |
Hepatitis B virus |
HTLV-1 | Epstein Barr virus |
Hepatitis C virus (low risk
of sexual transmission) |
Human papillomavirus
Moluscum contagiosum | |
Delta agent |
HSV* I | |
Bacterial diseases |
Syphilis (Treponema
pallidum) |
Neisseria gonorrhoeae | Chlamydia trachomatis
(NGU‡) |
Haemophilus ducreyi
(chancroid) |
Chlamydia trachomatis
L1-3 (LGV†) | |
Mycobacterium tuberculosis |
Calymmatobacterium
granulomatosis
(granuloma inguinale,
donovanosis) | |
Fungal diseases |
Candida albicans
(not usually considered sexually transmitted) |
|
|
Parasitic diseases |
Trichomonas vaginalis |
Entamoeba histolytica |
|
Ectoparasitic diseases |
Scabies |
Lice |
|
* Herpes simplex virus
† Lymphogranuloma venereum
‡ Non-gonococcal urethritis |
Many STIs are hyperendemic in developing countries of the
world5. Prevalence data for most of these countries are derived
largely from ad hoc surveys. Such surveys provide useful estimates
but must be interpreted with caution because they may not
be representative of the total population17 (Table 2). On the
other hand, surveys that focus on CSW may accurately reflect the
risk to travellers, since these individuals may be the most likely to
engage in sex acts with foreigners. Not surprisingly, surveys of
CSW in the developing world reveal high rates of the curable
STIs: 13% to 32% for chlamydia, 11% to 45% for GC, and 5% to
55% for syphilis5,27,28.When prevalence rates for the major
non-curable viral infections are included (e.g. HIV29, hepatitis B
virus [HBV]30, hepatitis C virus [HCV]31,32, HTLV-133),
(Table 3), the risk of exposure to an STI through sexual contact
with a CSW is high. It is certainly worth noting that the presence
of one or more STIs can increase the risk of HIV transmission by
a factor of three to 10 or more5.
Table 2. Examples of STI prevalence rates in healthy populations in the developing world (percentage of clinic visits)
Country |
n |
Source
of
subjects |
GC |
Syphilis |
Chla-
mydia |
Tricho-
monas |
Chan-
croid |
Gardne-
rella |
HIV |
HBV |
HSV2 |
Genital warts |
Nigeria18 |
230 |
Antenatal |
1.3 |
1.7 |
- |
7.4 |
- |
3.9 |
- |
- |
- |
- |
Zimbabwe 19 |
175 |
Prenatal/STI |
17.8 |
- |
5.9 |
25.5 |
17.8 |
- |
- |
- |
- |
13.7 |
Ethiopia 20 |
1,907 |
Family plan-
ning & others |
56-66 |
35-39 |
61-64 |
- |
- |
- |
|
- |
- |
19-20 |
South Africa 21 |
lit rev/ rev. litt. |
Various clinics |
8.0 |
5-15 |
16.0 |
- |
- |
20-49 |
- |
38-40 |
38-4 |
- |
Ctr Afr Rep 22 |
481 |
Antenatal |
3.1 |
6.7 |
6.2 |
9.9 |
- |
29 |
12.2 |
- |
- |
- |
Thailand 23 |
1,021 |
Antenatal |
0.2 |
0.5 |
5.7 |
- |
- |
- |
3-7 |
- |
- |
- |
India 24 |
1,981 |
Various clinics |
- |
- |
- |
- |
- |
- |
1.8 |
5.3 |
- |
- |
Mongolia 25 |
pop/ pop. |
Various |
1.4 |
0.3 |
- |
1.6 |
- |
- |
< 0.001 |
- |
- |
- |
Brazil 26 |
13,986 |
Antenatal & various |
- |
- |
- |
- |
- |
- |
- |
- |
43 |
- |
Table 3. Examples of STI prevalence rates in commercial sex workers (CSW) in the developing world (percentage of clinic visits)
Country |
n |
Source of subjects |
GC |
Syphilis |
Chlamydia |
Tricho-monas |
Chancroid |
Gardne
rella |
HIV |
HBV |
HSV2 |
Genital warts |
Senegal 34 |
374 |
Female CSW |
24.9 |
29.4 |
- |
46 |
- |
- |
- |
- |
- |
- |
South Africa 35 |
145 |
Female CSW |
14.3 |
42.1 |
16.3 |
41.3 |
- |
71 |
50.3 |
- |
- |
- |
China 36 |
966 |
Female CSW |
24.9* |
29.4 |
24.9 |
46 |
- |
- |
|
- |
- |
- |
Indonesia 37-39 |
1,340 |
Female CSW |
10-60 |
7-30 |
9-18 |
4-8 |
- |
- |
0.5 |
- |
37.7 |
- |
Bangladesh 40 |
286 |
Female CSW |
28* |
57.1 |
28* |
- |
- |
- |
0 |
- |
- |
- |
Indonesia 41 |
296 |
Male CSW |
04-13 |
43.6 |
2.4-3.8 |
- |
- |
- |
- |
- |
- |
- |
Venezuela 42 |
212 |
Female CSW |
- |
2-4 |
- |
- |
- |
- |
0 |
13.8 |
- |
- |
Brazil 43 |
- |
Female CSW |
- |
- |
- |
1.6 |
- |
- |
- |
10.9 |
- |
- |
Peru 44 |
966 |
Female CSW |
- |
- |
- |
- |
- |
- |
0.3 |
59.8 |
- |
0.7 |
Uruguay 45 |
200 |
Male CSW |
- |
- |
- |
- |
|
- |
21.5 |
50.5 |
- |
6.5 |
DRC† 46 |
1,144 |
Female CSW |
- |
- |
- |
- |
- |
- |
34.1 |
- |
|
6.6 |
* Clinical evidence of cervicitis (either GC or chlamydia)
† Democratic Republic of Congo |
Drug resistance in STIs
A steadily increasing proportion of STIs acquired abroad are
resistant to standard antibiotics47. Beta lactamase-producing
strains of Neisseria gonorrhoeae (NG) are prevalent in Africa, the
Caribbean, and Asia48-55. In Canada, the rate of penicillinresistant
NG rose from 8.7% in 1992 to 15% to 22% in 200356.
Similarly, resistance to other antibiotics has been reported for NG
in many other countries of the industrialized world56-58. Chromosomally
mediated tetracycline resistance is also common among
NG isolates in developing world settings59, and spectinomycin
resistance has begun to appear in some industrialized regions as
well56,60. Fluoroquinolone-resistant NG, which first appeared in
1992, is most prevalent in the Far East but occurs throughout the
world, including the UK, US, and Canada61. Antibiotic resistance
in Haemophilus ducreyi, the causative agent of chancroid, continues
to spread globally52: resistance to trimethoprim/ sulphonamide
combination drugs is now widespread in Southeast Asia
(e.g. Thailand, Viet Nam, Laos, Cambodia)47, 62. The development
of highly resistant HIV strains is an emerging issue63-65.
Sexual behaviour of travellers
The sexual attitudes and behaviours of travellers to the developed
world have been extensively studied in the last 10 to 15
years(3,29,53,54,66-78). Rates of reported casual sexual exposures (CSE)
during travel vary between 5% and 51%70,73. Since all of these
studies have used questionnaires, and no study has achieved a
100% response rate (some as low as 30%), the reported figures
are therefore likely to be underestimates. In an “intention-tohave-
sex” study of young Australian males travelling to Thailand,
only 34% reported a definite intention not to have sex77.
Although early studies demonstrated that men were far more
likely than women to have CSE while travelling, more recent
studies suggest that male and female travellers are quite similar in
their willingness to acquire new partners while abroad73-81. However,
both quantitative and qualitative behavioural differences
persist between the sexes (e.g. number of partners, willingness to
pay for sex, consistent condom use, and partner choice)75,82-86.
Factors that increase the chances of a given individual engaging
in sex while travelling include youth, male sex, travelling alone or
with a same-sex group, a history of casual sex or multiple partners
at home, repeated visits to the same region, history of previous
STIs higher social status longer duration of stay, travelling on
business, being a smoker, and using alcohol or illicit drugs83,87,88.
As with other high-risk behaviours, there is considerable evidence
that alcohol and drugs contribute to CSE in both men and
women8,75,80,88-94. The syndrome of sun, stimulants, and sex has
been described as “situational disinhibition”95,96.
Groups at particular risk
Expatriates: Long-term overseas workers or expatriates are more
likely than other types of traveller to engage in sexual activity
while abroad. In studies of Peace Corps volunteers and European
expatriates, 13% to 60% reported at least one CSE while living
overseas82-85,97,98. Many contacts are with local residents (31% to
41%), and condoms are inconsistently used (usually 30% to
50%). Although both male and female expatriates have CSE while
abroad, men are much more likely to pay for sex85. These figures help to explain why expatriates can have STI prevalence “profiles”
intermediate between those of their countries of origin and
their host countries84-86.
VFR travellers: Travellers returning to their countries of origin to
visit family and relatives (so-called “VFR travellers”) are at high
risk of acquiring a number of travel-related illnesses99,100. VFR
travellers may be at particularly high risk of acquiring STIs
through their choice of setting in which to solicit sex101,102, more
intimate contact with the local population, and a willingness to
use substandard, locally purchased condoms73,103.
Military personnel and seamen: Seamen and military personnel
are reported to have high rates of sexual contact with overseas
nationals, ranging from 45% to 56%104-112. These numbers are
only slightly higher than in other expatriate groups. Again, both
male and female military personnel are at risk113, and reported
condom use is, at best, erratic107. However, a 2004 representative
survey of the Regular component of the Canadian Forces indicated
that only 7% of Canadian Forces members who were
deployed in the previous 12 months had had a sexual encounter
outside of a committed relationship while deployed; of those,
58% had always used a condom during these encounters and15%
had never used a condom (Dr. Martin Tepper, Department of
National Defence: personal communication, 2006).
Men who have sex with men: Men who have sex with men are at
least as likely to engage in CSE while travelling as heterosexual
men45,114,115. In a Norwegian study, homosexual/bisexual travellers
were twice as likely to have paid for sex while overseas as
heterosexuals (64% vs 32% respectively)90.
Condom use
At least one-third to over one-half of travellers do not consistently
use condoms116,117. Limited and/or inconsistent condom
use in travellers appears to be independent of country of origin,
travel “style” (e.g. business, back-packer) and country of destination69,70,78,83,85,86,90,97,98,114,118-120. Although many travellers carry condoms,
they often “forget” to use them in the heat of the
moment88,89. Even when they use condoms, there may be greater
risks of failure because of the poor quality of locally purchased
products103, improper storage (i.e. at the bottom of the knapsack
for 2 months at 40° C), and improper application or sexual practices
that may lead to higher likelihood of condom failure (e.g.
anal penetration)109,121,122.
Profile of the traveller who will have sex overseas
There is no single profile of the traveller likely to have CSE while
travelling83,87.With few exceptions, questions related to anticipated
or actual sexual activity are appropriate for almost every
pre-travel interview and every post-travel review of systems. In
this context, it is worth pointing out that the teenage peak in new
sexual partner acquisition can be followed by a second peak
among men and women 35 to 55 years of age: the “just-divorced”
group123. Finally, an ever-greater number of elderly Canadians
are travelling to exotic locations124, and STIs among the elderly
are easily overlooked125. On the basis of their studies of Dutch travellers, der Graaf and colleagues divided travellers into four
groups with regard to CSE overseas82:
- the “unprepared” (who are surprised when sex happens)
- the “fanatical” (who must have sex to have a successful
vacation)
- the “unaffected” (who feel that sex abroad is the same as sex
at home), and
- the “slightly accessible” (who feel that sex abroad is different
and come prepared).
Sexual tourism
Sexual tourism is defined as travel expressly for the purpose of
engaging in sexual activity29,126. Such travel is highly risky with
respect to STIs, and prevention/harm reduction measures should
be encouraged (i.e. consistent and correct use of condoms, reduction
in number of partners). In some instances, sexual tourism
can be exploitative or illegal (i.e. seeking sex with minors), in
which case such travel should be strongly discouraged126.
Sexual tourism by another name: The subtlety of sexual predation
in the developing world needs to be explained to travellers.
Many people in developing countries engage in sexual acts simply
to survive15,126. In many settings, the fact that a traveller is not
paying cash for sex does not mean that he/she is not buying sex.
Effective “currencies” in many poor countries include food, gifts,
and even hope (i.e. the chance to emigrate). The commercial
nature of such transactions is often not appreciated or acknowledged
by the Western traveller. After travel, more females than
males make longer-term commitments with sexual contacts89,120.
Risk of acquiring an STI during international travel
The risk of acquiring one or more STIs while travelling depends
entirely on the behaviour of the traveller. There is no such thing
as the “standardized sexual act”. As a result, accurate estimates
for rates of STI transmission per exposure are very hard to generate.
However, the following general rules apply to all situations:
- Most STIs are more readily transmitted from males to
females than the reverse.
- Individuals with obvious lesions (e.g. sores, ulcers, vesicles)
are more likely to transmit the agents that caused the lesions
as well as co-pathogens (e.g. HIV, HBV) than individuals
without any evident genital pathology.
- Decisions about sexual partners and/or sexual activities
made under the influence of alcohol or drugs will increase
the risk of acquiring STIs.
- Sex acts that result in bleeding or that occur during menses
significantly enhance the risk of transmitting and/or acquiring
sexually transmitted, blood-borne viruses (e.g. HIV,
HBV, and HCV).
Because so many factors can influence risk, there have been relatively
few attempts to quantify the risk of transmitting any given
STI through individual sex acts. However, the risk of acquiring
HIV, HBV, or HCV from a percutaneous injury are relatively well
defined (0.5%, 4% to 30%, and 3% to 10% respectively)127)-. The
risks following a single, unprotected, heterosexual and consensual sex act are thought to be much lower: ~ 0.001% for HIV128
and 0% to 0.6% forHCV129. However, the presence of genital
lesions can dramatically increase the risk of acquiring HIV and
possibly other sexually transmitted viruses130. The transmission
of gonorrhea and chlamydia is highly efficient during both heterosexual
and homosexual sex. A single episode of vaginal intercourse
incurs a 20% to 50% risk of acquiring gonorrhea131. The
transmission efficiencies for open syphilis and chancroid lesions
are probably at least as high. C. trachomatis is transmitted heterosexually
with only slightly lower efficiency than gonorrhea (0.8%
to 8%/episode)132. In a large study of Swiss travellers, Steffen et
al. estimated that HBV, GC, and syphilis were acquired at rates of
4, 3, and ~1 per 1,000 traveller-months133. Prior to HBV vaccination,
the reported rates of HBV acquisition by unvaccinated,
long-term travellers were as high as 4% to 7% per year134,135.
The consequences of acquiring an STI while travelling
STIs can result in both short-term problems (e.g. genital ulcers,
urethritis, cervicitis) and long-term or chronic complications (e.g.
infertility and ectopic pregnancy, pelvic inflammatory disease or
chronic pelvic pain, liver disease secondary to HBV, cervical
dysplasia secondary to human papillomavirus [HPV], immunodeficiency
due to HIV). Several of these chronic infections can
significantly shorten life (e.g. cancers secondary to hepatitis
viruses or HPV infections, liver cirrhosis due to HBV, progression
of HIV infection). Infections that are manifest during travel can
expose travellers to products (e.g. antibiotics) that are not used in
the developed world and to suboptimal medical practices and
environments (e.g. unsterilized, reusable needles/instruments).
Some drugs and products (e.g. antiretrovirals) may not be available
in some areas of the world or may be of unpredictable or
unacceptably low potency. Infections that are manifest only upon
the traveller’s return can also be problematic. Several STIs remain
rare in North America and may go undiagnosed or be treated
inappropriately by physicians unfamiliar with them (e.g.
chancroid, lymphogranuloma venereum). Finally, travellers who
bring one or more STIs “home” to previous partners must also
consider the enormous emotional price, including lost trust and
broken relationships.
Public health perspective
Travellers who have CSE overseas may be more likely to engage
in CSE back in their home country. As a result, there are both
small and large public health issues with CSE among travellers.
At the micro level, transmission of rare and/or resistant STIs to
the non-travelling partner(s) must always be considered in the
presence of a confusing clinical presentation. At the macro level,
the potential to import exotic and/or resistant STIs is very
real3,57,58,79,136,137. Because so many people are currently travelling,
the risk-taking behaviour of individuals can add up to epidemic
spread rather quickly66,68,71,138. Many of these imported STIs
exhibit unusual or broad spectrum antibiotic resistance138,139.
Management of STI
The treatment of STIs has recently been reviewed in both the
general population140-142 and specifically in travellers28,70. The
following general statements apply to all STIs:
- the only way to avoid the risk of STIs altogether is abstinence,
- monogamous sex with a stable, uninfected partner is another
way to avoid STIs,
- condoms reduce the risk of almost all STIs to some degree,
- prevention of STIs is preferred over treatment,
- partner notification is essential to prevent STI spread,
- prompt diagnosis and therapy can reduce both complications
and spread,
- therapy should be guided by culture and sensitivity tests
when possible,
- the presence of one STI should trigger a search for others,
- global resistance patterns should be considered when choosing
antimicrobials.
It is also worth pointing out that the treatment options for some
of the most serious STIs remain very limited (e.g. HBV)142. For
an overview of screening and diagnosis, see Table 4; for general
treatment recommendations of the most common STIs see
Table 5. These recommendations have been abstracted largely
from the guidelines of the Public Health Agency of Canada140
and Center for Disease Control and Prevention141. The reader is
encouraged to visit these sites to obtain more complete information:<http://www.phac-aspc.gc.ca/std-mts/sti_2006/sti_intro2006_e. html> and <http://www.cdc.gov/STD/treatment/default.htm>.
Prevention of STIs
Health care professionals who see international travellers should
make advice about STIs a routine part of the pre-travel visit.
Among the microbiological risks associated with travel, the STIs
are probably second only to malaria in terms of their potential for
serious morbidity and mortality. Safer sex and harm reduction
counselling should be emphasized. Sexual activity within a stable,
monogamous relationship and avoidance of high-risk encounters
are the best ways to prevent STIs during travel. Barrier contraceptive
devices, specifically male and (possibly) female condoms140,143-145, provide the best alternatives by preventing direct
contact with infective genital lesions.
Condoms : Although male and female condoms are likely to have
similar efficacy for many STIs when used appropriately, almost
all of the available data come from studies of male condom use.
Condoms made from latex provide a more effective barrier than
“natural” condoms made from animal membranes143. If possible,
latex condoms should be purchased in a developed country, since
the quality of condoms produced in many regions of the world is
inconsistent103. Only water-based lubricants should be used with
condoms, since oil-based products (e.g. petroleum jelly, mineral
oil, massage oil) can significantly weaken latex condoms and lead
to breakage143. High-quality polyurethane condoms are available in most developing world countries for travellers with latex allergies146. The reported efficacy of latex condoms against STIs
ranges from 40% to 70%147. The most serious limitation of condoms
is behavioural (i.e. failure to use them). The most common
factors involved in condom breakage include inappropriate application,
repeated or prolonged use, and anal intercourse. Although
early studies suggested that spermicides, such as nonoxynol-9,
could reduce STI risk148, a recent Cochrane Database review suggests
that nonoxynol-9 has no protective effect against a range of pathogens149,150. Too frequent vaginal use of nonoxynol-9 or use
in anal receptive intercourse can disrupt epithelial integrity and
lead to increased transmission of HIV and other STIs142,149,150.
Table 4. Overview* of STI screening and diagnosis
Clinical presentation
(differential diagnosis) |
Appropriate investigations and follow-up |
Asymptomatic but at risk
(i.e. unprotected sexual
activity while travelling
where STI status of contact(s) is not known) |
- Culture or nucleic acid amplification testing
(NAAT) for N. gonorrhoeae from all points of
sexual contact (culture only, not NAAT for
rectal and pharyngeal specimens), and/or
urine for NAAT
- NAAT or culture for C. trachomatis (urethral,
cervical), culture for rectal and pharyngeal
specimens (if the only point of sexual contact),
and/or urine for NAAT
- Serology for syphilis to include a
non-treponemal test (e.g. RPR, VDRL) or
treponemal-specific ELISA (or both)
- Advise or consider HIV testing
- HBV serology and offer HBV vaccination if
not immune
- Consider wet mount and/or culture for
Trichomonas vaginalis
- Consider HAV serology especially in the
case of oral-anal contact
- Consider HCV serology especially in the
case of IDU history
|
Genital ulcer(s)
(syphilis, HSV-II, HSV-I,
chancroid, LGV,
granuloma inguinale
(donovanosis)) |
- Dark field microscopy or
immunofluorescence for Treponema
pallidum (if available)
- Serology for syphilis to include a
non-treponemal test (e.g. RPR, VDRL) or
treponemal-specific ELISA (or both)
- Culture or NAAT (where available) or antigen
test for HSV
- Consider serology for HSV (if lesions not
present or not suitable for above tests)
- Culture or NAAT for C. trachomatis (which if
positive can be sent for DNA sequencing or
RFLP to confirm LGV)
- Culture or NAAT (where available) for
H. ducreyi (alert laboratory to suspicion of
chancroid diagnosis - not available in most
laboratories)
- Advise or consider HIV testing
- Follow-up in 3 to 7 days
|
Purulent urethritis/cervicitis
(N. gonorrhoeae,
C. trachomatis, rarely
HSVI/II) |
- Urethral or cervical swab; or urine specimen
for NAAT
- Gram stain of discharge (looking for > 5
WBCs per oil-immersion field and GC)
- Culture or NAAT for N. gonorrhoeae (special
culture medium required)
- Culture or NAAT for C. trachomatis
|
Sexual assault |
- Culture or NAAT for C. trachomatis and N.
gonorrhoeae from all partially or fully penetrated
orifices (culture only for rectal and
pharyngeal specimens)
- Cultures should be repeated 1 to 2 weeks
after exposure in the absence of prophylaxis
- Urine for NAAT for C. trachomatis and N.
gonorrhoeae should also be collected
- Wet mount and/or culture for T. vaginalis
- A non-treponemal (e.g. RPR, VDRL) and a
treponemal test (e.g. TPPA) for syphilis
(repeat at 12 and 24 weeks after exposure
and possibly at 2 to 4 weeks after assault if
high risk)
- If patient known to be immune to HBV no
testing is required, if not, serum sample for
baseline antibodies to hepatitis B surface
antigen
- Baseline HIV antibody (repeat HIV serology
at 6, 12, and 24 weeks)
- Baseline HCV antibody is optional (consider
HCV risk of perpetrator and associated
trauma during the assault - if performed
should be repeated at 12 and 24 weeks)
|
*This table is designed as a quick reference and is not meant to replace more comprehensive guidelines (e.g. those from the Public Health Agency of Canada140or CDC141).
RPR = rapid plasma reagin; VDRL = venereal disease research laboratory test; ELISA = enzyme-linked immunoassay;
IDU = intravenous drug use; RFLP = restriction fragment
length polymorphism; LGV = lymphogranuloma venereum; WBC = white blood cells;
TTPA = Treponoma pallidum particle agglutination |
Table 5. Choice of antimicrobial therapy for selected STIs (preferred regimens are listed first, followed by alternatives)
Chancroid
(Haemophilus ducreyi)
|
Ciprofloxacin 500 mg PO x 1 OR
Erythromycin base 500 mg PO TID x 7 days OR
Azithromycin 1 g PO x 1 OR
Ceftriaxone 250 mg IM x 1 (CAUTION: treatment
failure with ceftriaxone commonly reported in
HIV co-infected patients) |
Bacterial vaginosis
|
(Characterized by an overgrowth of genital tract
organisms, e.g. Gardnerella, Prevotella,Mobiluncus spp., and a depletion of lactobacilli) (not usually
considered sexually transmitted)
Metronidazole 500 mg PO BID x 7 days OR Metronidazole gel (0.75%) 5 g intravaginally QD x
5 days OR
Clindamycin cream (2%) 5 g intravaginally QD x 7
days |
Granuloma inguinale
(Calymmatobacterium
granulomatis)
|
Doxycycline 100 mg PO BID x 21 days (at least)*
OR
Trimethoprim-sulfamethoxazole DS (800 mg/160
mg) PO BID for 21 days (at least) OR
Ciprofloxacin 750 mg PO BID for 21 days (at least)
OR
Erythromycin base 500 mg PO QID for 21 days (at
least) OR
Azithromycin 500 mg PO daily or 1 g PO once per
week for 3 weeks (at least) |
HSV-II
|
For severe primary disease, IV acyclovir 5 mg/per
kg infused over 60 minutes every 8 hours is optimal,
with conversion to oral therapy when substantial
improvement has occurred. (In addition
to antiviral therapy, analgesia and laxativesmay
be required.) |
(First episode)
|
Acyclovir 200 mg PO five times/day x 5 to 10 days
OR
Acyclovir 400mg POTID x 7 to 10 days
Famciclovir 250 mg PO TID x 5 days OR
Valacyclovir 1 g PO BID x 10 days |
HSV-II (recurrent)
|
Valacyclovir 500 mg PO BID x 5 days OR
Valacyclovir 1 g POQDx 3 days OR
Famciclovir 125 mg PO BID x 5 days OR
Acyclovir 200 mg PO 5x/day x 5 days OR
Acyclovir 800 mg PO TID x 2 days
(Suppressive therapy may also be considered.) |
Human papillomavirus |
(For external genital warts)
Patient-applied:
Imiquimod cream (5%) applied to warts QHS 3 x
per week for up to 16 weeks (should be washed
off after 6 to 8 hours)
Podofilox (0.5% solution or gel) applied QHS to
warts x 3 days then 4 days of “rest” for up to 4
cycles
A cycle can be repeated for up to 6 weeks only,
with total dose per day not to exceed 0.5 mL
(There are office-based treatment options,
including cryotherapy, podophyllin 10% to 25%,
bi- or trichloroacetic acid, electrofulguration, CO2
laser ablation, and surgical excision; please refer
to the 2006 PHAC STI guidelines140) |
Lymphogranuloma
venereum
(C. trachomatis L1-3) |
Doxycycline 100 mg PO BID x 21 days OR
Erythromycin base 500 mg PO QID for 21 days
OR
Azithromycin 1g PO once per week for 21 days |
Neisseria gonorhoeae |
(All regimens should be followed by empiric
treatment for chlamydial and non-gonococcal
infections.)
Cefixime 400 mg PO x 1 OR
Ceftriaxone 125 mg IM x 1 OR
Ciprofloxacin 500 mg PO x 1 OR (unless not recommended
because of quinolone resistance)
Ofloxacin 400 mg PO BID x 7 days OR (unless not
recommended because of quinolone resistance)
Alternative ONLY if quinolones not recommended
and cephalosporin allergy or immediate/
anaphylactic allergy to penicillin:
Azithromycin 2 g PO x 1 OR
Spectinomycin 2 g IMx 1 |
Chlamydia trachomatis or
non-gonococcal urethritis or
mucopurulent cervicitis |
Azithromycin 1 g PO x 1 OR
Doxycycline 100 mg PO BID x 7 days OR
Erythromycin base 2 g/day PO in divided doses x
7 days OR
Erythromycin base 1 g/day PO in divided doses x
14 days OR
(Erythromycin dosages refer to erythromycin
base. Equivalent dosages of other formulations
may be substituted. If erythromycin has been
used for treatment, test of cure should be performed
3 to 4 weeks after completion of therapy.)
Ofloxacin 300 mg PO BID x 7 days |
Sexual assault |
Cefixime 400 mg PO x 1 OR
Ciprofloxacin 500 mg PO x 1 (unless not recommended
because of resistance) AND
Azithromycin 1 g PO x 1 OR doxycycline 100 mg
PO BID x 7 days
(Metronidazole should only be given if positive
test for trichomonas - not for prophylaxis) PLUS
consider HIV post-exposure prophylaxis
(anti-retrovirals, i.e triple therapy such as zidovudine
(AZT) + 3-TC + efavirenz)
Should be started ASAP and no later than 72
hours after exposure and continued for 28 days
Hepatitis B immune globulin (HBIG) up to 14 days
after exposure and HBV vaccination (if
unvaccinated) |
Syphilis (T. pallidum)
(primary) |
Benzathine penicillin G 2.4 million units IM x 1 OR
Doxycycline 100 mg PO BID x 14 days OR
Azithromycin 2 g PO x 1
In light of recent reports of failure of
azithromycin for the treatment of early syphilis
and the rapid development of azithromycin resistance
in T. pallidum, this agent should not be routinely
used as a treatment option for early or
incubating syphilis unless adequate and close
follow-up can be ensured, and only in jurisdictions
where little to no azithromycin genotypic
resistance in T. pallidum has been demonstrated
OR
Ceftriaxone 1 g IV or IMQD x 10 days (to be used
in exceptional circumstances) |
T. vaginalis |
Metronidazole 2 g PO x 1 OR
Metronidazole 500 mg PO BID x 7 days |
*Note: Treat until lesions have healed completely. An aminoglycoside can be added to the regimens above if no improvement is seen in the first week of therapy (e.g.
gentamicin 1mg/kg IV every 8 hours). |
Screening for STIs is appropriate for many travellers who report
CSE while abroad151. Such screening should be guided by the
nature of the sexual contact and current or past symptoms and
could include an examination of the genitals, a cervical/urethral/
anal/pharyngeal swab and/or urine testing, and serologic tests for
syphilis, HIV, and possibly HBV and HCV (Table 4).
The morning after " STI pill: Although it may be tempting to “arm” travellers likely to engage in high-risk sexual activities with
a morning-after course of antibiotic therapy, this practice is not
recommended. Ready access to antibiotics could lead to a false
sense of security and increased exposure to STIs not targeted by
the therapy provided (e.g. HIV, herpes simplex virus, HPV). Such
behavioural effects have recently been documented among
CSW152.
Post-exposure prophylaxis for sexual assault victims: The management
of sexual assault victims has recently been
reviewed153,154.Women travelling for prolonged periods of time
in developing world countries should be counselled with regard
to risk mitigation strategies in the event of sexual assault. In all
such long-term travellers (male and female), verification of hepatitis
B vaccination status should be routine. Unvaccinated travellers
who have been assaulted should begin active HBV
immunization as well as HBIG if a trustworthy product can be
found locally. Individuals with incomplete immunization schedules
must be reviewed on a case-by-case basis (i.e. complete or
re-initiate active immunization with or without HBIG). Although
post-exposure prophylaxis (PEP) for HIV using three drugs
would be appropriate in many circumstances, these combinations
are expensive (e.g. ~ $1,500 for 28 days of AZT +3TC +
efavirenz) and would not be appropriate to prescribe for all
travellers. Such an expenditure might be reasonable for groups
living or working overseas for prolonged periods (e.g. a semester
abroad, large international projects). A lower cost strategy for
individual travellers might be the purchase of a “starter kit” with
a 3 to 5 day supply of PEP drugs ($160 to $260) to initiate PEP
rapidly while risk assessment decisions are being made. Should
the final risk assessment determine the need to complete a 28-day
course of HIV PEP, then the exposed traveller will either need to
have the remaining PEP drugs couriered to them or they will
need to return home to complete the regimen (Table 4). Prophylaxis
for other STIs should be offered if it is unsure whether the
patient will return for follow-up, if the assailant has a known STI,
if prophylaxis is requested by the patient, or if the patient has
signs or symptoms of an STI.While the efficacy of antibiotic
prophylaxis has not been studied in sexual assault, prophylaxis
should be offered as recommended for treatment of specific
infections140.
Unintended pregnancy may also result from sexual assault. The
emergency contraceptive pill may be considered for prevention of
pregnancy. Treatment should be taken as soon as possible, up to
72 hours after exposure (for maximum efficacy), but may be of
benefit up to 120 hours after exposure. The cost is reasonable and
may be appropriate to prescribe for female travellers155.
Special groups
Pregnant women
Pregnancy is also one of the major risks of CSE in any setting.
Although limited data are available, pregnancy does not appear to
be a major risk factor for the acquisition or evolution of most
STIs, although treatment can be complicated by the presence of
the fetus. Alternative means of sexual activity during pregnancy
(e.g. anal intercourse) can certainly put the pregnant woman at
higher risk of STIs.
Children
As a general rule, most children who travel do so with their parents
and are relatively unlikely to be at high risk of STIs. However,
it is worth repeating that developing world children are
common targets of the sex trade6,15.
Adolescents and young adults
Adolescents and young adults are at particularly high risk of
acquiring and spreading STIs. The acquisition of new sexual
partners peaks in most cultures during the teen and early adult
years123.
Immunocompromised hosts
A recent survey of 133 HIV-positive Canadian travellers (93%
male) suggested that these individuals are as likely as their
non-infected peers to engage in casual sex while overseas (23%)
and are just as likely to use condoms inconsistently (only
58%)156. STIs facilitate the transmission of HIV and, conversely,
the diagnosis, clinical presentation, and treatment of STIs can be
adversely influenced by HIV157-160. Most HIV-positive subjects
with an STI can nonetheless be expected to respond to standard
therapy (with the exception of neurosyphilis, which can be
difficult to treat in those with HIV)140,142,159,161. It is worth noting
that HIV testing is increasingly demanded of immigrants and
refugees in many countries107,162. There has been a parallel worldwide
increase in mandatory HIV testing for long-term, nonresident
visas.
The mature or elderly traveller
Sexual activity is a central part of a healthy life at all ages124,125,163).
It is important not to make assumptions about the actual or
intended sexual activity of either male or female travellers at any
age.
Conclusion
Canadians who acquire new sexual partners while travelling,
especially those who pay for sex or have multiple CSEs overseas,
are at risk of a wide range of STIs. Although the behaviours of
some travellers put them at higher risk of contracting STIs, there
is no single profile of the at-risk traveller. Condoms can provide some degree of protection against many STIs, but 100% protection
cannot be achieved even with meticulous use. Only HAV
and HBV can currently be prevented by licensed vaccines.
Although drug resistance is more commonly encountered in STIs
acquired overseas, all of the bacterial STIs can be treated successfully
at the current time if appropriate antimicrobials are chosen.
A series of evidence-based recommendations for managing travellers
and sexually transmitted infections are presented in the next
section.
Summary and recommendations
Recommendations related to behaviours
- A frank discussion of sex and STI risk and prevention should
be a routine part of pre-travel counselling (AIII).
- Safer sex and harm reduction counselling should be emphasized
(AIII).
- Abstinence is the only way to avoid STIs altogether (AIII).
- Monogamous sex with a stable, uninfected travel partner is
another way to avoid STIs (AIII).
- Condoms reduce the risk of most, but not all, STIs (AII).
- Alcohol and drugs contribute to unhealthy decisions with
regard to sexual partners and condom use (AII).
- Sexual contact with CSW is always a high-risk behaviour
(EIII).
- Men and women with multiple sexual partners at home or a
history of STIs are more likely to have CSE while travelling
(AIII).
- Sexual tourism is highly risky with respect to STIs and may
be exploitative (EIII).
- Sexual tourism with minors is illegal (EIII).
- It is not possible to make any assumptions about who will
have CSE during travel (AIII).
Recommendations related to prophylaxis
- Hepatitis B vaccination should be offered to all travellers
who may have CSE (AI).
- Hepatitis A vaccination should be offered to all travellers
who may have CSE (AII).
- Spermicides should not be used without a condom (AII).
- Condoms should be used for all casual sexual encounters
(male AI, female AII).
- Condoms should be used that have been manufactured in
the developed world and stored appropriately (AI).
- Condoms must not be reused (AI).
- Double or “extra strength” condoms should be used for anal
intercourse (AI).
- Natural condoms do not protect against viral STIs and
should not be used if reliable latex condoms are available
(although they are probably better than nothing) (DI).
- Condoms must be applied before genital contact and
removed before detumescence (AIII).
- Reuse of condoms and use for anal intercourse will increase
the risk of breakage (AII).
- Oil-based lubricants should not be used with latex condoms
(EI).
- Advice should be provided with regard to post-exposure care
if a sexual assault takes place during travel (AIII).
- Short-course antiretroviral therapy and a course of antibiotics
for common bacterial pathogens should be considered as
post-exposure prophylaxis for high-risk sexual exposures
(e.g. sexual assault) (AII).
Recommendations related to treatment and screening
- During the pre-travel visit, travellers should be instructed,
should one or more CSE occur, to seek STI screening. They
should be advised where such screening can be obtained
overseas and locally (AIII).
- Thorough STI screening should be pursued in a returned
traveller who acknowledges one or more CSE overseas
(AIII).
- Follow-up screening to rule out HIV, HBV, and HCV transmission
is appropriate at 6 months (CSE) or more frequently
(0, 1, 3, and 6 months) in the case of sexual assault (AI).
- All of the possible STIs to which a traveller may have been
exposed during CSE should be considered and travellers
screened appropriately (AIII).
- Testing and sensitivity testing should be obtained when
appropriate for all bacterial STIs acquired while travelling
(AIII).
- Canadian guidelines for the treatment of STIs should be followed
while waiting for culture results (AI).
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* Members:
Dr. B.Ward (Chair); Dr. C. Beallor; M. Bodie-Collins (Executive
Secretary);
Dr. K. Gamble; Ms. A. Henteleff; Dr. S. Houston; Dr. S. Kuhn;
Dr. A. McCarthy;
Dr. K.L. McClean; Dr. P.J. Plourde; Dr. J.R. Salzman.
Liaison Representatives:
Dr. R.J. Birnbaum; Dr. C. Greenaway; Dr. C. Hui;
Dr. R. Saginur; Dr. P. Teitelbaum; Dr. M.Woo.
Ex-Officio Representatives:
Dr. J. Given,
Dr. F. Hindieh; Dr. J.P. Legault;
Dr. P. McDonald; Dr. R. Paradis; Dr. C. Reed; Dr. M. Smith; Dr. M. Tepper
Member Emeritus: Dr. C.W.L. Jeanes.
† This statement was prepared by Dr. B. Ward and Dr. P. Plourde and approved by CATMAT.
[Canada Communicable Disease Report]
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