|Year : 1996 | Volume
| Issue : 1 | Page : 3-12
Std trends in chengalpattu hospital
VR Krishnamurthy, V Ramachandran
V R Krishnamurthy
Source of Support: None, Conflict of Interest: None
A retrospective data analysis was carried out to find the trends in frequency and distribution of different STDs at Chengalpattu during 1988-1994. Of the 4549 patients who attended the clinic 3621 (79.6%) were males and 928 (20.4%) were females. The commonest STD was Chancroid (24.4%) in men and Syphillis (29%) in women. Balanoposthitis (11.4%) ranked third among STDs in males. Though the STD attendance showed a declining trend, most diseases showed a constant distribution. The percentage composition of secondary and latent syphillis, Genital Warts, Genital Herpes and the Non-Venereal group showed an increased composition in recent years. Primary syphillis in females showed a definite declining trend. The HIV sero-positive detection rate was 2.06%. Of the 1116 patients screened for HIV antibody, 23 patients were detected sero-positive. Time Series Regression Analysis was used to predict the number of patients who would attend the STD clinic with various STDs in 1995 and 1996 to help in the understanding of the disease load and pattern in future, in resources management and in developing and evaluating preventive measures.
Keywords: Sexually transmitted disease, Epidemiology, HIV serology
|How to cite this article:|
Krishnamurthy V R, Ramachandran V. Std trends in chengalpattu hospital. Indian J Dermatol Venereol Leprol 1996;62:3-12
|How to cite this URL:|
Krishnamurthy V R, Ramachandran V. Std trends in chengalpattu hospital. Indian J Dermatol Venereol Leprol [serial online] 1996 [cited 2019 Apr 26];62:3-12. Available from: http://www.ijdvl.com/text.asp?1996/62/1/3/4292
| Introduction|| |
Sexually Transmitted Diseases have created a great impact on the transmission of Human Immunodeficiency Virus. Cross sectional studies have shown a strong association between HIV infection and other STDs, especially those causing genital ulcers such as chancroid, syphilis and genital herpes. Peter Piot expressed the view that a high prevalence of STD led to increased susceptibility to HIV which in turn led to a high prevalence of HIV which then interacted with a high prevalence of STD. STD patients thus serve as early warning symptoms for HIV transmission. It is therefore essential to study the trends in STDs in order to develop effective preventive measures. Changing clinical patterns have been noted worldwide and this requires introspection by medical professionals.
We have presented here a comprehensive study of the morbidity trends of STDs between 1988 to 1994, at the Chengalpattu hospital and have also tried to predict the likely future trends.
| Materials and Methods|| |
Medical record sheets of patients treated at the STD clinic between 1988 and 1994 were analyzed for the study. Trends among the various STDs were understood. Separate TimeSeries Regression Analysis was used to obtain an equation for the various groups of STDs. The method of least squares was used to plot straight line graphs. The graphs were then extrapolated to predict the likely number of patients in each group in 1995 and 1996. In order to match with the other studies conducted in India, the Non-venereal class (patients with h/o exposure who attended the STD clinic but with no clinical lesion and negative laboratory tests) was analyzed separately. Separate analysis was also carried out for males and females to remove the influence of one class over the other.
| Results and Discussion|| |
A total of 4549 patients who attended the STD clinic between '88 & '94 were studied. 3621 were males and 928 females. Of them 2491 men and 534 women suffered from STDs. Thus though the attendance ratio between males and females was found to be 3.9:1, that among STD patients was 4.7:1. This was probably due to the fact that most female patients with STD attend the Gynecology OPD., Also, many females who attended the STD clinic were wives of the male attendees.
The frequency and distribution of the various STDs is illustrated in [Table - 1].The commonest STDs were chancroid (22.5%), syphilis (21.0%), gonorrhea (10.6%), balanoposthitis (9.4%), NGU (8.6%), and genital warts (7.9%), Among males, however the order was chancroid (24.4%), syphilis (19.3%), balanoposthitis (11.4%), gonorrhea (10.8%), and NGU (9.6%) and among females, syphilis (29.0%) ranked first followed by trichomonas vaginalis (17.2%), chancroid, (13.7%), gonorrhea (9.9%) and candidiasis (8.6%). Amoungst syphilis, primary syphilis accounted for 68.6% among men and 59.4% among females. Secondary and latent syphilis were responsible for 11.9% and 19.3% in males and 17.4% and 23.2% in females, respectively. One patient was diagnosed as suffering from neurosyphilis in 1989 and a female infant was diagnosed as congenital syphilis in 1993.
Differences in the proportions of the various STDs observed, is due to the regional variations in the incidence and distribution of STDs due to biological, technical, environmental, cultural and socio economic factors. Though the proportion of balanoposthitis varies between 1.25% to 5.6% of males in the various studies in India, it ranked fourth among STDs with a proportion of 11.4%. Very few reports are available on this entity. Elderly individuals (>40 years) and diabetics commonly presented with this condition. Further research is essential to elucidate the factors responsible for balanoposthitis
The analysis of the data in [Table - 2]-[Table - 6] clearly reveal an overall decreasing trend in the clinic attendance and also among STD sufferers. The percentage composition and trends of various STDs are well depicted in the tables. The salient features of the trends are discussed below:
The decreasing trend in STDs was in accordance with the findings elsewhere in India and has been implicated to the decreasing promiscuty due to the fear of AIDS and due to the different measures to prevent HIV transmission,, though this trend has been observed even before preventive measures and awareness programmes for AIDS and STDs were introduced. The sudden rise in NV group in 1993-94 could however explain the 'fear' theory, since a wide media coverage was given in Chengalpattu during '92-94 as part of the AIDS awareness programme. Another factor that could have contributed to the STD decline is the widespread use of antibiotics and greater number of physicians and quakes treating STDs. The reasons for the lower STD: NV ratio among females has been explained earlier.
Syphilis : Syphilis was the commonest STD diagnosed among females. There is an overall decreasing trend in syphilitics attending the clinic since 1989 with an abrupt rise in 1992. However, it showed a constant proportion among STDs throughout the period of study. Primary syphilis showed a pattern similar to the group with a spurt in '92.
Secondary syphilis showed an unique distribution with peaks every even year ('88, '90, '92, '94). Though the average composition of secondary syphilis was 11.9% amongst males, the peak average was 16.25% and trough average was 5.6%. Females too showed a similar trend with secondary syphilis comprising 17.4% among female syphilitics and peak average and trough average being 21.7% and 12.5% respectively. The increase in '92 of syphilis is essentially due to an increase in secondary syphilis in both sexes.
Latent syphilis showed variations in absolute numbers but within the syphilis group, it showed an increasing trend from 10.4% in'88 to 26.2% in '94 among males and 11.5% in '88 to 60.0% in '94 with a dip in '92 (15.38%) among females.
The ulcerative lesions of syphilis thus showed a declining trend with a steady rise among secondary and latent syphilis. Though there are reports of secondary syphilis being the commonest presentation in females [14,18] and latent syphilis being common in the civilian population, the change in trend observed here is more significant. This could be due to a variant presentation probably because of antibiotics prescribed for other conditions. This may abort or delay the early stage of infection, minimising or abolishing early symptoms. Reasons for the rise in secondary syphilis every alternate year needs further investigation.
Chancroid : The patients with chancroid attending the clinic showed a progressive downward trend. Chancroid which was the commonest STD among males till '91 was replaced by Syphilis in '92 and '94. However, it still continues to be the commonest cause of genital ulcer in men. The high prevalence of chancroid in males (M:F=8.3:1) has been attributed to the existence of asymptomatic carrier state in women, transmitting the infection to a number of men. Increasing AIDS awareness, and improvement of local hygiene could have led to the observed declining trend.
Granuloma Inguinale : Having dropped from 20 cases in '89 among males to 5 in 90, GI got stabilised with just few cases every year. Females did not report with GI for 3 consecutive years from '90. Later one patient reported with GI every year. Improvement in the level of sanitation, economic development and health awareness could be responsible for the decline. The absence of cases in males in '92 and among females for 3 consecutive years from '90 followed by few cases in '93 and '94 could possibly point to importation of the disease from elsewhere by truck drivers and the like.
Genital Herpes : Though the number of patients attending the clinic was more or less constant, there was a slow rise in the proportion of genital herpes from 1.6% in '88 to 5.4% in '94. Females with genital herpes showed variation in attendance.
Rise in genital herpes has been observed worldwide., The constant attendance with increasing proportion, point to a relative increase due to the fact that most bacterial diseases are treated at the primary level with a large number of newer antibiotics. The lower prevalence among women is because of the disease being not easily recognisable in them.
Ulcerative STDs : In order to analyse the trends in the genital ulcers which has been predicted to form a high risk group for HIV transmission and to overcome misclassification, symptomatic ulcerative conditions like syphilis, herpes, chancroid, GI and erosive balanitis were grouped and analyzed.
Ulcerative STDs comprised 53.3% of STDs in males and 34.3% in females. It showed a declining trend in the absolute number of cases falling from 282 in '89 to 87 in '94 among males and 43 in '89 to 7 in '94 in females. Among STDs too, this group indicated a declining trend from '89 till '94 except for a spurt in '92 in both sexes. Chancroid (45.7%) was the commonest cause of ulcerative STDs among males while primary syphilis (50.3%) ranked first among females. The spurt in '92 appears to be due to a rise in primary syphilis in males and genital herpes in females.
LGV : Among males, LGV showed a steady decline from 30 cases in '88 to 6 in '94, with a constant percentage composition since '89 and an average composition of 4.3% among STDs. A constant reporting rate of 2-3 cases was observed in the clinic among females. In males, the inguinal nodes are commonly affected and among females, the iliac. Females with LGV therefore, present to the Gynaecology clinic with pelvic complaints. This could explain the lower reporting of females in the clinic.
A higher incidence of LGV is reported in this study in contrast to those presented in North Indian studies where it ranges from 0.1% to 0.6% of STDs. It is however much lower than North-East Indian report (10%) and comparable to the reported incidence by Rangiah (3.3%).
Gonorrhoea : Gonorrhoea showed a definite decline in attendance among both males and females. It showed a high composition among STDs during the period '88-'90, declined between '91-'93 and then rose to 11.9% in '94 comparable to that in the initial years of study. The percentage composition among females remained constant till '93 and then dipped in '94.
Drug resistance could have contributed to the sudden rise of Gonorrhoea in males in '94. Further studies are essential in order to identify the cause. Asymptomatic nature, difficulty in diagnosis, absence of culture facilities and smaller attendance to the STD clinic prevents an inference on the decline observed in females.
Genital Warts : The number of patients with genital warts attending the STD clinic did not show significant change. Though it ranged from 20 to 33 in males, the overall composition showed a constant distribution among STDs till '92 with a steady rise from '93 onwards. Females too showed a constant percentage composition with a sporadic rise in '93.
As with genital herpes, genital warts too showed an increasing composition since '93, among STDs. Bhushan Kumar attributes this trend to the increasing antibiotic use to treat bacterial diseases, thereby increasing the reference rate of these diseases. Increasing self reporting by patients in the propaganda era could have played a role in the observed trend.
Trichomonas vaginalis : The number of patients attending the STD clinic showed wide variations. After a dramatic fall in attendance in '92-'93, it rose back in '94. The disease which is essentially female dominated, was identified in a large proportion of males who were either asymptomatic or had presented with some other STD. Screening of the female or male spouse as the case may be led to the observed data.
Trends in HIV Seropositives : The number of HIV seropositives following up in this department have gradually increased. The present HIV detection rate is 2.06%.
Presenting Complaints : Of the 23 patients diagnosed HIVseropositive, I male died due to surgical complications and 3 patients (2 M and 1 F) were reported missing with loss of their record sheets. Of the remaining 19 patients, 8 presented with syphilis (4 M and 4 F) while two each with warts, gonorrhoea and chancroid (1 M and 1 F) and one each with extensive fungal infection of the groin, fatigue with vaginal discharge (F), scabies and generalised lymphadenopathy. One male with history of genital warts was detected HIV positive. A history of genital ulcer within six months of presentation was given by two patients-one with scabies and the other with generalised lympadenopathy. One patient with early latent syphilis gave a history of genital ulcer six years back and another a female with multiple painful ulcers over the labia majora with profuse vaginal discharge and cervicitis and positive VDRL. Thus, 11 of 19 patients either presented with a genital ulcer or of its history supporting claims of higher seropositivity among ulcerative STDs. Age group analysis revealed that 55.6% of all HIV positive patients (46.1% in males and 80.0% in females) belonged to the 25-30 year age group.
The lower seropositive rates in our study is due to the screening of all STD attendees. It is however too premature to comment upon as the screening has just started. All patients with HIV seropositivity gave atleast a history of a STD.
| Predictions for the years 1995 and 1996|| |
Assuming the prevailing trends, we have attempted to predict the number of patients who would present with various disorders to the STD clinic at the Chengalpattu hospital. As the number of samples and sample size is small, the confidence interval is quite large. However, the worst has to be anticipated in order to be better equipped. We emphasize that the epidemiological factors should remain constant for the prediction to hold true. Regression analysis does not account for changes in the factors responsible for a disease.
The data analysis shows a decreasing trend amongst most STDs in both sexes. However, in the absence of an epidemiological study, this observation cannot be used to represent the population. The view that there is a distribution of patients among the increasing doctors and quacks necessitates further study, involving all STD therapists in an effort to identify the true incidence and also enable the preventive measures to reach the grass root level. Proper maintenance of records is essential for a meaningful analysis. Gynaecology department should be actively involved in the identification of STDs and a better coordination with the STD department is desired.
All patients with STDs, especially syphilis, should undergo a test of cure. Atleast two repeat VDRL is recommended at 1 and 6 months after therapy. Reports variously describe a 4 or greater fold decrease in the titres among patients with primary or secondary syphilis in 3 to 6 months. In early latent syphilis, the decrease of only 4 fold at 12 months is described. A reasonable conclusion of a treated syphilis, therefore, could be a decrease in titres in the two specimens at 1 and 6 months.
The asymptomatic nature of herpes in a large number of patients, especially females, could be the reason for the constant number of patients attending the STD clinic. The true incidence can only be found by performing serological tests. Wagner reports that the age specific HSV-2 seroprevalence rate could provide a sensitive and objective measure of sexual behaviour in adolescence and may thus be a useful tool for evaluating behavioural interventions against the AIDS epidemic.
The rising HIV infection is a cause for great concern. Suniti Solomon reports a rise in HIV infection among antenatal mothers and voluntary blood donors suggesting that the virus has trickled into the general population. Control measures are therefore suggested for the population as a whole. Behavioural changes are thought to have contributed for the decreasing number of new patients with AIDS in UK. Emphasis should therefore be laid on fidelity. Counseling of patients with genital ulcers and its prevention is essential to bring down the rates of transmission. Proper counseling and follow-up of HIV seropositive patients is necessary to prevent them from transmitting the infection.
Though our studies showed that only patients with STDs attending the STD clinic were HIV seropositives, it is always better to screen all STD attendees for HIV antibody. Further studies of HIV antibodies in urine may throw light on the pathophysiology of HIV infection and also its role in early diagnosis.
| Acknowledgement|| |
We sincerely thank Dr Thirumalai, Dean, Chengalpattu Medical College and Hospital, for having given us the permission to use the hospital data for this study. We convey our gratitude to the staff members of the STD clinic for their cooperation in the collection of data required for this study. We are grateful to Dr K Swaminathan, Associate Professor, IIT Madras; Dr Rajagopalan Distinguished Fellow, MSSRF and Mrs Anathalakshmi for their encouragement and valuable advise.
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[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8]