OPERATIONAL APPROACH TO S.T.D.
by Maj. M. P. Vora
Maharashtra Medical Journal
Volume No – XXVI, Number – 9 of December 1979.
Page No. 417 to 421.
Note – This paper was presented at the IV, National Conference of I.A.S.S.T.D. held at VISAKHAPATNAM on 23/24 February 1980.
THOUGH THERE ARE YEARLY MORE THAN SIXTY MILLION NEW CASES OF VENEREAL DISEASES and nearly ten percent annual rise in their incidence, this fact has disturbed no one’s composure! The assumption that everything regarding health services to venereal patients is going on well is hardly true and tenable. Would it be wise and prudent to ignore such a problem of great magnitude and gravity? The fundamental concepts of V.D. control and therapy are well established though specifics are continuously evolving. An increasing attention must be directed to these diseases for reducing their incidence to a minimal. The control of venereal diseases has to be based on the nation-wide network of venereal clinics, set up with competent manpower, essential equipments and suitable accommodation. The most desirable location of a clinic should be in the teaching hospital in particular. Each clinic has to be directed by a specialist of a consultant status, whose sole speciality shall be venereology. There shall be venereal consultants in every medical college and for its attached hospitals. The teaching and training of under- and post-graduates medical students as also the training of the staff must be entrusted to those consultants. V.D. represents a medical emergency and clinics ought to fulfil this basic concept. Other important components in the control of V.D. are:
All these components should be located in the clinic and be parts of it for a close co-operation and speedy action.
Clinics: All clinics must provide free and essentially the same standard of efficient service, which is outlined as under:
Accurate diagnosis: This is the first important principle in the management of V.D. This involves full and detailed history, a careful clinical examination, tactful interrogation in strict privacy, a careful collection of appropriate specimens of ano-genital secretions and exudates for microscopic and cultural examinations. Facilities for bright and dark-field microscopy must be available on the spot to examine immediately specimens for the presence of Neissarian gonococci and Treponema pallida respectively. Blood sample is taken from every new case for the serologic test for syphilis. The obvious implications are that doctors and the staff must be thoroughly skilled and experienced in clinical examination, collection of specimens, their staining and microscopy. The clinic staff also needs the active co-operation of a good bacteriologist for regular culture for the growth of gonococci, a serologist for serum antibody tests for syphilis and a properly equipped laboratory. The new selective gonococcal culture media that would give better results in clinical use than non-antibiotic containing media must be made available and employed as a routine. Transport media and courier service for doctors in private practice have to be developed. A variety of serum antibody tests for syphilis are in use but the VDRL test and RPR test are the best for routine use as they are cheap, simple, reliable and reproducible. Among the specific tests, the TPH test has proved to be the most specific and sensitive of all, the only exception is the earliest stages of early syphilis. The test is simple, reproducible and fits well with VDRL test, as a laboratory procedure. Facilities for microscopy, satisfactory gonococcal culture and serum tests for syphilis antibodies are major and essential requirements. Once these are secured, the other procedures may be undertaken when money, time and opportunities permit. These include development of media and culture for Trichomonas vaginalis, candida, herpes virus, mimeae, Trick agent, T- strain mycoplasma, Donovan bodies, Chlamydia, ureass plasma electronic microscope, automation of STS etc. All these have a lower or second priority. Regular evaluation and assessment of laboratory techincs and procedures are necessary to maintain high standards.
Effective treatment and careful follow-up: No treatment is given as far as possible without accurate diagnosis. Once the precise diagnosis is made, the effective treatment is given only after ascertaining penicillin sensitivity of a patient.
A case of early syphilis is given 600,000 units of aqueous procain penicillin G.I.M. daily for 8 to 10 days. One may go in for PAM or Benzathine penicillin G, which can be given I.M. on alternate days. In case of penicillin sensitivity, erythromycin estolate or tetracycline hydrochlor 2 gms orally daily, in divided dose, is given for 15 days. A patient is seen, after the treatment, at least seven times in two years. Each time, a careful clinical examination and quantitative serologic test for syphilis are repeated. The study of the CSF is done at six months after the treatment.
A fresh case of uncomplicated gonorrhoea is given one of the following schedule courses.
After the therapy, the patient is examined at least four times in four weeks, when a careful clinical examination, Gram stained smear and culture, at each occasion are done. Finally, urethroscopy should be done.
The best method of ensuring the efficiency of antivenereal therapy is a careful follow-up. This means examining the patient frequently after the treatment and repeating the necessary laboratory investigations. It is true that some patients do not co-operate, but it is worthwhile to carry out this routine. While most time and efforts are expended on venereal patients with syphilis, gonorrhoea and chancroid and to a lesser extent on the non-specific urethritis, every patient with other sexually transmitted disease should be seen at least two or three times after the treatment. All patients are directed to return for blood tests for syphilis three times in three months after their first attendance. This covers the incubation period of a concurrent or incubating acquired syphilis, which is often not recognised at the earlier examination. These follow-up measures provide opportunities for patients to get their querries answered, improve contact-tracing, help to evaluate the results of treatment, to detect relapses in time, to permit the most economic use of therapies and finally to maintain a lower incidence of these diseases.
Contact-tracing: This is an essential and integral part of venereal diseases management and an important aspect of V.D. control programme. The high re-infection rates reflect the futility of treating V.D. patient alone, without treating the source of his or her infection. The main responsibility to obtain all relevant information from every patient with V.D. or other STD, to trace contacts and to induce defaulters in treatment or follow-up tests of cure, rests on specially trained persons, who are a part of the clinic staff. Their work consists of:
When the doctor has made the precise diagnosis and arranged for the treatment, the contact-tracer interviews the patient, ensures that the patient has adequate understanding of the disease, and hands over a card or slip showing the original clinic, the patient’s number, the name of the contact and the disease in code to give it to his or her sexual partner. Together they work out contacts at risk. Often the contact-tracer has to motivate the patient to trace his or her own contacts. When the patient returns the next day, he or she is re-interviewed to discover any more contacts, to stimulate contact-tracing and to answer any questions, the patient may have. The contact card or slip serves to introduce the contact, when he or she arrives at the clinic and minimises any embarrassment or mental tension. The card can be presented to any clinic in the country. The same procedure is followed, when the patient has other STD. when contacts report, they are interviewed to find more contacts, who need to be located and interviewed. Infected contacts become patients and have to trace their contacts. When the patients will not or cannot trace his or her own contacts, the contact-tracer has to go out in the community and do the contact-tracing, though it is rather difficult, time-consuming and expensive. The contact-tracers have their office in the clinic and their own network of communications. When the contact is in other town, they phone or post details to their colleagues in that town, who then complete the job. Besides, they have to trace defaulters in treatment and induce them to complete treatment and follow-up tests of cure. This is usually done by telephone, a letter or a personal visit.
For the conservation of time, energy and efforts, it is now customary to divide contacts into two groups i.e. main transmitters and fring or non-transmitters of infections. The former group consists of travellers, sailors, homosexuals, drug addicts, prostitutes and habitually promiscuous persons, who are the prime spreaders of infections, are poorly motivated, have many partners and know very little about their contacts and demand great efforts in contact-tracing. While the latter group consists of spouses, finances and regular partners of stable relations who generally do not have sex relations outside the regular partnership; the spread of infection, therefore, stops with them. Their contacts are easily traceable and need limited efforts. Occasionally, these groups may interact with one another. This classification economises time and efforts in contact-tracing.
It must be emphasised that success in this important work depends on the tact, tenacity, human understanding and proper handling of patients by contact-tracers. The care and consideration that the patients receive in the clinics help to build up their confidence and to ensure their co-operation in case-finding. The public has to be convinced that the best treatment for VD and other STD can be had in these clinics, where an efficient medico-social management is the basis. A person’s privacy and confidentiality are guarded carefully.
Screening for VD and other STD: Routine screening for these diseases especially in high-risk groups 15 to 35 age is the most realistic approach for the detection of asymptomatic cases and prevention of spread of diseases. This procedure ought to form an integral part of any physical examination of a person. This plays an important role in keeping a low incidence of these diseases. Often, more than one disease is present, at one time in one patient. Clinical examination should involve looking for signs of all VDs and STDs. Though patients are investigated for common and important conditions, this helps to detect less obvious infections and to control their spread.
Record-keeping and accurate returns: This is necessary for an appreciated of the accurate size of the problem, the locality involved and direction of efforts for the control of these diseases. Of course, this depends on precise diagnosis, careful record-keeping and forwarding returns at regular intervals to the venereal authority in Department of Health. For this purpose, uniforms and standard forms need to be introduced. A trained record-keeper and a statistician for each clinic are a dire necessity. The efforts and resources can be directed to meet the situation on the basis of these reports.
Education: This can be for the lay public as well as for the professionals like doctors, nurses, staff and social workers. Education of the public, students of higher secondary schools and colleges, concerning venereal diseases, as an integral part of personal and social health education, rather than an isolated subject, must be provided, on-going and never-ending, as a national policy. Isolation of VD from the general context of health education is undesirable. This must provide facts regarding these diseases, their early signs and symptoms, infectious nature, methods of prevention behavioural advice, location and timings of the clinics etc. to protect themselves and other members of the community. A well organised and comprehensive health programme can achieve marvelous results in the field of VD prevention and control. Identification of vulnerable persons, social, behavioural and educational aspects of VD require the same attention as the topic of VD diagnosis and treatment. The key to the VD and its spread is the on-going education of high-risk groups, promotion of sexual maturity, checking or demoting promiscuity, and instilling self-restrain. VD clinics and primary health centres should be responsible for all aspects of health education. The mass communication media like TV, radio, slides, films, exhibitions and talks can contribute a good deal. In absence of such an activity, young persons are likely to be exposed to the risk of acquiring VD increasingly.
Education of the professionals is equally important. Venereology is the most difficult and exacting speciality, in which laboratory investigations follow clinical studies and precede therapy. A sound understanding of VD its knowledge, procedures, technics and skills are necessary. Increasing emphasis must be on prevention and early detection to retard events of serious consequences. It is a matter of satisfaction that the relative importance of this subject is just being increasingly appreciated. As doctors are responsible for diagnosis, treatment and control of VD, the need for sound and thorough training for them and para-medical personnel, change in their manners and attitudes to these patients in the management of VD and other STD and the observance of fundamental principles cannot be over-emphasised.
Conclusion: The important criteria in the management of VD have been given in compact form. Free and efficient treatment for VD and STD must be provided all over the country, as a part of comprehensive health service. Venereologists have to be accepted as experts and be given the charge of clinics, education and training. The control of these diseases has to be based on sound medical principles, namely careful examination, tactful inter rogation, investigations, accurate diagnosis, effective treatment, careful follow-up plus prompt case-tracing and education of the public as well as the medical professionals. An average patient must be made to feel that he or she is being looked after well and is expected to derive maximal benefit from the care provided in clinics. Patients should be made to feel at home and are encouraged to play a vital role in stemming the spread of these diseases.
Doctors have the capacity to achieve a notable success, provided they become conversant with the operational approach to VD, follow basic principles, find the source and contacts of their patients and deal with them promptly. The major responsibility rests on them for an effective and rapid action all over the country.