Chapter 3Infectious Diseases Related To Travel
Sexually Transmitted Diseases
Sexually transmitted diseases (STDs) are the infections and resulting clinical syndromes caused by more than 25 infectious organisms.
MODE OF TRANSMISSION
Sexual activity is the predominant mode of transmission, through genital, anal, or oral mucosal contact.
STDs are among the most common infections. Annually, an estimated 448 million infections occur worldwide, and 19 million infections occur in the United States. Some STDs can be more prevalent in developing countries (chancroid, lymphogranuloma venereum, granuloma inguinale) and may be more likely to be imported into developed countries by travelers returning from such locales. International travelers are at risk for contracting STDs, including HIV, if they have sexual contact with partners in locales where the prevalence of STDs is high.
Increased sexual promiscuity and casual sexual relationships tend to occur during travel to foreign countries and are frequently detected in long-term overseas travelers. Commercial sex in various destinations, such as Southeast Asia, attracts many foreign travelers. Travelers who have sex with commercial sex workers in endemic areas may have high rates of STDs, such as gonorrhea.
Knowledge of the clinical presentation, frequency of infection, and antimicrobial resistance patterns is needed to manage STDs that occur in travelers to specific destinations. Assessing risk for men who have sex with men is important because of the recent increased rates of infectious syphilis, quinolone-resistant gonorrhea, and lymphogranuloma venereum in various geographic locations.
Many infections may be asymptomatic (chlamydia, gonorrhea), so screening for such infections at anatomic sites of contact and serologic testing for syphilis should be encouraged among travelers who might have been exposed to an STD. Any traveler who might have been exposed and who develops vaginal, urethral, or rectal discharge, an unexplained rash or genital lesion, or genital or pelvic pain should be advised to cease sexual activity and promptly seek medical evaluation.
Genital ulcer evaluation should include a serologic test for syphilis, a culture or antigen test for genital herpes, and a culture for chancroid (if exposure occurred in areas where chancroid can occur, such as Africa, Asia, and Latin America). Lymphadenopathy can accompany genital ulceration with these infections, as well as with lymphogranuloma venereum and donovanosis. Lymphogranuloma venereum should be suspected in a traveler with tender unilateral inguinal or femoral lymphadenopathy or proctocolitis. Genital and lymph node specimens should be tested for Chlamydia trachomatis by culture, direct immunofluorescence, or nucleic acid testing. Donovanosis is endemic in some areas, including India, Papua New Guinea, central Australia, and southern Africa, and is diagnosed with a crush tissue preparation from the lesion.
Chlamydia and gonorrhea testing at the anatomic site of exposure with nucleic acid amplification testing or culture is available to detect C. trachomatis and Neisseria gonorrhoeae. Culture and antibiotic susceptibility testing should be done when gonorrhea is suspected, because of geographic differences in antimicrobial susceptibility. Various diagnostic methods are available to identify the origin of an abnormal vaginal discharge, including microscopic evaluation and pH testing of vaginal secretions, DNA probe-based testing, and culture. Anyone who seeks evaluation and treatment for STDs should be screened for HIV infection.
Etiologic treatment directed toward the specific pathogen is the historical norm for most STDs in industrialized countries. Syndromic management, of interest in developing countries, requires broad clinical manifestations with risk assessment, followed by treatment of the main causes of the syndrome without identification of a specific pathogen. Evaluation and management of STDs should be based on standard guidelines (CDC and the World Health Organization), and the frequency of antimicrobial resistance in different geographic areas should be considered. Early detection and treatment are important. STDs can often result in serious and long-term complications, including pelvic inflammatory disease, infertility, stillbirths and neonatal infections, genital cancers, and an increased risk for HIV acquisition and transmission.
PREVENTIVE MEASURES FOR TRAVELERS
The prevention and control of STDs are based on education and counseling. Specific messages to avoid acquiring or transmitting STDs should be part of the health advice given to travelers. Abstinence or mutual monogamy is the most reliable way to avoid acquiring and transmitting STDs.
For people whose sexual behaviors place them at risk for STDs, correct and consistent use of the male latex condom can reduce the risk of HIV infection and some STDs, including chlamydia, gonorrhea, and trichomoniasis, and by limiting lower genital tract infections might reduce the risk of pelvic inflammatory disease in women. Condoms might protect against herpes simplex virus-2 and syphilis, although data are limited. Only water-based lubricants (such as K-Y Jelly or glycerin) should be used with latex condoms because oil-based lubricants (such as petroleum jelly, shortening, mineral oil, or massage oil) can weaken latex condoms. Vaginal spermicides containing nonoxynol-9 are not recommended for STD/HIV prevention, as nonoxynol-9 can increase the risk of HIV transmission. Contraceptive methods that are not mechanical barriers offer no protection against HIV or other STDs.
Prompt evaluation of sexual partners is necessary to prevent reinfection and disrupt transmission of many STDs. Preexposure vaccination is among the most effective methods for preventing some STDs. Two human papillomavirus (HPV) vaccines are available and licensed for girls and women aged 9–26 years to prevent cervical precancers and cancers: the quadrivalent HPV and the bivalent HPV vaccine. The quadrivalent vaccine also prevents genital warts. Preexposure vaccination against hepatitis A and B is recommended, as these infections can be sexually transmissible. Hepatitis A vaccine is recommended for all unvaccinated sexually active men who have sex with men or injection drug users. Hepatitis B vaccine is recommended for all unvaccinated men who have sex with men, people with a history of an STD, people who have had more than 1 sexual partner in the previous 6 months, and people who use or who have a sex partner who uses injection drugs.
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