|Ahead of print publication
Emerging trends in sexually transmitted diseases in a tertiary care center in Davangere, Karnataka: A five year study
M Anirudh, Sugareddy, Aishwarya Sivuni, Nadiga Rajashekhar, HC Mangala
Department of Dermatology, Venereology and Leprosy, JJM Medical College, Davangere, Karnataka, India
|Date of Submission||10-Oct-2020|
|Date of Decision||16-Oct-2021|
|Date of Acceptance||28-Apr-2022|
|Date of Web Publication||01-Aug-2022|
Department of Dermatology, Venereology and Leprosy, JJM Medical College, MCC B Block, Davangere, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Sexually transmitted diseases (STDs) are a public health challenge, and the epidemiological profile is variable by geographical region and distinct from that of other diseases. Accurate knowledge of emerging disease trends is crucial for formulating effective control strategies. Aims and Objectives: The aim and objective of this study were to identify the changing scenario and emerging trends of STDs in Davangere, Karnataka, by evaluating patients attending a tertiary care center. Materials and Methods: A tertiary care-based retrospective study was conducted by analyzing the clinical records of the attendees presenting to the STD clinic at Chigateri General Hospital affiliated to JJM Medical College in Davangere, Karnataka, for a period of 5 years from January 2015 to December 2019. The collected data were analyzed and statistically compared with other studies. Results: Out of the 614 patients studied, the male-to-female ratio was 2:1, with 30–39 age groups being most affected. Eighty-eight percent of patients were married, with 36.64% giving a history of extramarital contact. Homosexual and bisexual contacts were observed to be 5.21% and 0.65%, respectively. Viral STDs affected nearly half of the patients (49.51%), followed by fungal (28.88%), bacterial (22.63%), and others (3.1%). The most common STD observed was herpes genitalis as seen in 101 (24.48%) patients, followed by candidal balanoposthitis (17.1%). Thirty-three (5.7%) patients were diagnosed with more than one STD. Of these patients, 13 were seropositive for HIV, resulting in a prevalence of 2.12%. Conclusion: The epidemiological profile of STDs is ever changing, and this study found an increase in viral and fungal STDs and downward trend of bacterial STDs comparable to that of studies from other regions.
Keywords: Balanoposthitis, fungal sexually transmitted diseases, herpes genitalis, sexually transmitted disease, viral sexually transmitted diseases
|How to cite this URL:|
Anirudh M, Sugareddy, Sivuni A, Rajashekhar N, Mangala H C. Emerging trends in sexually transmitted diseases in a tertiary care center in Davangere, Karnataka: A five year study. Indian J Sex Transm Dis [Epub ahead of print] [cited 2022 Nov 28]. Available from: https://www.ijstd.org/preprintarticle.asp?id=352912
| Introduction|| |
Sexually transmitted diseases (STDs) are diseases transmitted by sexual intercourse and conventionally include infections, resulting in clinical diseases that may involve the genitalia and other parts of the body participating in sexual interaction. The epidemiology of an STD is the consequence of the interplay between the causative organisms, attributes, and tendencies of the patient and the control measures being enforced in a given region. As STDs are more widespread among the sexually active than other infections, the resultant epidemiological profile takes on a more specific yet variable form due to the various social, cultural, and economic factors at play as well as the sex education and sexual practices prevalent among the sexually active population in the area.,, Therefore, a structured, regular, large-scale analysis of the prevalence of STDs among STD clinic attendees would not only help to observe trends of STDs and formulate appropriate control measures but also to evaluate the effectiveness of existing control programs in a given region.
| Materials and Methods|| |
This was a retrospective study wherein the case records of the patients attending the STD clinic of the Department of Dermatology, Venereology and Leprosy at Chigateri General Hospital and Bapuji Hospital affiliated to JJM Medical College in Davangere, Karnataka, for 5 years from January 2015 to December 2019 were collected. Detailed history and demographic data of the patients, which included age, gender, occupation, origin, marital status, and sexual history, were noted, and a diagnosis was made following clinical examination and conducting relevant laboratory investigations.
Tissue smears and discharge were subject to wet mount, Gram and Giemsa staining, KOH examination, dark-ground microscopy and culture wherever applicable, and serum samples of all patients were subject to ELISA for HIV and Venereal Disease Research Laboratory (VDRL) after taking informed consent and for treponema pallidum hemagglutination (TPHA) in suspected cases. Chest radiograph, histopathology, and fine-needle aspiration cytology were done wherever additionally required. Diagnosis of each condition is as follows: chancroid ‒ GRAM stain of ulcer smear for Gram-negative coccobacillus and culture for Haemophilus ducreyi; donovanosis ‒ Giemsa stain of ulcer smear for Donovan bodies; syphilis ‒ VDRL and TPHA of sera, and dark-ground microscopy to visualize Treponema pallidum; gonococcal urethritis (GU) – urethral discharge for Gram-negative diplococci and polymorphonuclear cells; lymphogranuloma venereum (LGV) – Giemsa staining of tissue smear for elementary and inclusion bodies; chlamydial urethritis – culture of urethral discharge for Chlamydia trachomatis; bacterial vaginosis – Amsel's criteria; herpes genitalis (HG) – Tzanck smear (Giemsa stain) of vesicle base for multinucleated giant cells; genital warts – on a clinical basis, molluscum contagiosum (MC) – on clinical diagnosis, HIV-ELISA, candidal balanoposthitis (BP), and vaginal candidiasis (VC) – KOH mount and culture of discharge specimens for Candida albicans after obtaining a positive history of similar lesions in sexual partner to rule out nonvenereal candidal infection, trichomoniasis – wet mount of discharge to visualize Trichomonas vaginalis, genital scabies – wet mount of scrapings to visualize mite after obtaining a positive history of similar lesions in partner to rule out nonvenereal scabies. The collected data were compiled and analyzed.
| Results|| |
Of the 614 STD clinic attendees, males were 415 (67.59%) and females 199 (32.41%), with male-to-female ratio being 2.08:1. The most common age group to be affected was 30–39 years, constituting 38.76% of cases closely, followed by the 20–29 age groups (32.25%), as shown in [Table 1].
Majority of the patients hailed from rural areas (62.21%). The unemployed constituted 29.48%, whereas the employed were small business owners (22.64%), professionals (17.26%), unskilled and laborers (16.29%), and semiskilled and farmers (14.33%). The bulk of the patients were married (88.27%). Premarital sexual activity was recorded in 58 (9.45%) patients, out of which 89.65% were men and 10.34% were women. Similarly, of the 225 (36.64%) patients engaged in extramarital sexual activity, 80.4% were men and 19.55% were women. At the time of presentation, 37.30% of patients gave a history of partners having similar complaints. Homosexuals constituted 5.21% of patients and bisexuals 0.65%, and all the nonheterosexuals were male. Barrier contraception was the most popular contraception method employed by both males and females during intercourse, and tobacco chewing was the most common addiction [Table 1].
While a considerable number had asymptomatic lesions (180, 29.32%), a majority of patients presented with the chief complaint of itching in the genital area (210, 34.2%), followed by pain (106, 17.26%), burning sensation (64, 10.42%), genital discharge (40, 6.51%), and genital swelling (14, 2.28%) as the primary complaint. Lymphadenopathy was observed in 26.55% (163) of patients.
Viral STDs affected nearly half of the patients (49.51%), followed by fungal (28.88%) and then bacterial (22.63%). The most common STD observed was HG as seen in 151 (24.58%) patients. Among the bacterial STDs, syphilis was the most prevalent seen in 56 (9.12%) patients, followed by chancroid (21, 3.42%). GU was more frequent as compared to chlamydial urethritis. Among women, VC was the most common form of vaginal discharge observed in 69 (11.89%) patients [Table 2].
Twenty-two (3.58%) patients were diagnosed with more than one sexually transmitted infection. Of these patients, 13 were seropositive for HIV, resulting in a prevalence of 2.12% in this study. Among retropositive patients, four had concurrent infection with HG and two with MC and one each with candida BP, VC, genital warts, LGV, and chancroid. One patient had both HG and VC and another with both genital warts and VC. Among HIV patients, concurrent viral STDs were most prevalent (61.5%), after which was fungal (38.46%) and then bacterial (15.38%).
While the total number of cases has been steady from 2015 to 2018, a rise of up to 142 cases was observed in 2019. Viral STDs have been consistently more in number than bacterial STDs over the past 5 years, with a sudden spike of 36.9% in 2019 owing to the abrupt escalation in the number of patients who attended the STD clinic. In 2017 and 2018, fungal STDs were observed to be the greatest in number among the other STDs. Other STDs consisting of protozoal and parasitic infections were scarce over the 5 years [Figure 1].
|Figure 1: Total number of STD cases and trends of bacterial, viral, and fungal STDs from 2015 to 2019. STD: Sexually transmitted diseases|
Click here to view
| Discussion|| |
In the current study, males outnumbered females in a ratio of 2:1. The current demographic ratio was found to be similar to findings in other studies.,,, In a study conducted by Murugesh et al. in the same region in 2004, male-to-female ratio was almost 3:1. The improved sex ratio could possibly be due to better social attitude toward female health, health-care-seeking behavior among women, contact tracing, and spousal screening through better health awareness as well as in addition to increased referrals from the gynecology department.
The most common age group affected was the 30–39 years range, as noted by other workers as well.,,, It has been well established that members of this age group experience greater sexual activity and promiscuity; in addition to social and monetary independence, better health care awareness could be the reason why their numbers were more prominent.
Two-thirds of the patients hailed from rural areas. Unemployed members were nearly one-third which was similar to the observations by Nair et al. and Murugesh et al., indicating that lack of employment is still a major risk factor for contracting STDs.
A majority (88.27%) of the patients were married, comparable to the findings of other studies,, and a greater percentage of women were married as compared to the men (91.45% and 86.74%, respectively). High-risk sexual behavior such as pre and extramarital intercourse was noted considerably more among males, and similar complaints in the partner as to what the patient was experiencing were noted by 40% of men and 56.78% of women. The number of married women denying external contact but being affected, and noticing similar complaints in the partner, points towards a conjugal spread to female partners. The higher rate of extramarital contact among the men suggests a tendency of males to be more involved in high-risk sexual behavior and acting as a source contributing to the transmission of infection.,,
Homosexuals constituted 5.21% of cases and bisexuals 0.65%. Across various studies, homosexuality and bisexuality were observed in 0.4%–2.8% and 0.8%–4.6%, respectively.,,
HG was the most common STD in this study at 24.58%. The prevalence of HG varied between 3.7% and 43.33% in other studies conducted across India.,,,,,, Anogenital warts were the next common viral STD at 13.52% compared to the previous reports, with the prevalence ranging from 0.98% to 17.5%.,,,,,, The prevalence of genital MC was on the higher side at 9.28%, with earlier studies reporting a much lesser prevalence.,,,,
Fungal STDs were the second major cause of infection in this study, constituting 28.88% of cases, with other workers noting similar prevalence.,, Candidal BP was overall the second-highest STD in this study (17.10%), with Arakkal et al..and Tada et al. noting lesser values (8.79 and 4%, respectively) and Zamzachin et al. and Sharma et al. noting greater (20% and 33.33%, respectively). VC was seen in 11.89% of patients which was greater than that reported in other studies.,,
Among the ulcerative bacterial STDs, syphilis was most common, constituting 9.12%, with similar higher incidences observed by other reports.,, The prevalence of chancroid (3.42%) too was comparable to that of other findings ranging between 0.27% and 10.8%.,,,,,, LGV (2.44%) and donovanosis (1.47%) were the next common ulcerative bacterial STDs occurrence of which ranged from 0.1% to 4.8% for LGV,,,, and two studies reporting 0.6% for donovanosis., GU was the most frequent cause of urethral discharge (3.36%) in contrast to numerous studies,, but comparable to the findings of Narayanan et al. Scabies in our study was found to be 2.61% which is less compared to that other reports.,,,
The prevalence of HIV in this study (2.12%) had been found to be significantly less as compared to earlier reports.,, The most common STD observed in retropositive patients was HG, followed by genital warts, as with other studies.,
In comparison to an older study from the same region conducted 15 years ago [Table 3], there has been a drastic increase in STDs of viral origin as well as fungal STDs. Ulcerative bacterial STDs such as syphilis, chancroid, donovanosis, and LGV have shown a downward trend as well as urethritis. Genital scabies though has remained unchanged. The upward trend of the viral and downward trend of bacterial STD have been evident in other studies, the reason most likely due to persistence and recurrence of viral STDs and increased use and easy accessibility to antibiotics and syndromic approach to the management of bacterial STDs by general practitioners.,, Fungal STDs could be more on the rise, possibly due to unwarranted use of antibiotics, poor hygiene, use of occlusive clothing, and the rise of diabetes mellitus among the general population.
|Table 3: Comparison of prevalence of sexually transmitted diseases in an earlier study and the present study|
Click here to view
Limitations of this study include small sample size and missing out of patients in the incubation period as only those with signs and symptoms suggestive of STD at the time of presentation to the STD clinic were subject to testing. Also, some patients were treated other department OPDs such as obstetrics and gynecology and hence were not recorded at the STD clinic. Diagnosing true venereal genital scabies as a result of sexual contact as opposed to the acquisition of infestation through close contact with partner proved to be difficult in some cases. Several diagnosed patients refused to reveal or inform their sexual partners or spouses for testing as a result of stigma.
| Conclusion|| |
The epidemiological profile of STDs is ever changing, and this study found an increase in viral and fungal STDs and downward trend of bacterial STDs from the previous studies from the same region but in concordance to that of studies from other areas of the country. Conducting research at timely intervals helps to detect subtle trends and formulate prevention and treatment strategies to optimize the control of STDs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thappa DM, Kaimal S. Sexually transmitted infections in India: Current status (except human immunodeficiency virus/acquired immunodeficiency syndrome). Indian J Dermatol 2007;52:78-82. [Full text]
Sharma VK, Khandpur S. Epidemiology of sexually transmitted diseases. In: Sharma VK, editor. Sexually Transmitted Diseases and AIDS. 2nd
ed. New Delhi: Viva Books Private Limited; 2009. p. 3-54.
Sharma VK, Khandpur S. Changing patterns of sexually transmitted infections in India. Natl Med J India 2004;17:310-9.
Sharma PK. A profile of sexually transmitted diseases in Port Blair. Indian J Sex Transm Dis 1994;15:21-2.
Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999;75:3-17.
Devi SA, Vetrichevvel TP, Pise GA, Thappa DM. Pattern of sexually transmitted infections in a tertiary care centre at Puducherry. Indian J Dermatol 2009;54:347-9.
] [Full text]
Arakkal GK, Damarla SV, Kasetty HK, Chintagunta SR. Changing trends in sexually transmitted infection (STI) clinic attendees – Current scenario. Int J Med Sci Public Health 2014;3:1215-8.
Nair TG, Asha LK, Leelakumari PV. An epidemiological study of sexually transmitted diseases. Indian J Dermatol Venereol Leprol 2000;66:69-72.
] [Full text]
Narayanan B. A retrospective study of the pattern of sexually transmitted diseases during a ten-year period. Indian J Dermatol Venereol Leprol 2005;71:333-7.
] [Full text]
Murugesh SB, Sugareddy, Raghunath S. Pattern of sexually transmitted diseases at Davangere. Indian J Sex Transm Dis 2004;25:9-12.
Saikia L, Nath R, Deuori T, Mahanta J. Sexually transmitted diseases in Assam: An experience in a tertiary care referral hospital. Indian J Dermatol Venereol Leprol 2009;75:329.
] [Full text]
Tada DG, Shrimali G, Khandelwal N, Parmar R, Padmaraj R. Trends of different sexually transmitted diseases in a STD clinic of a tertiary care hospital: Comparison between viral origin and bacterial origin STDs. Natl J Med Res 2012;2:358-61.
Vora R, Kota RS, Rochit S. Changing trends in sexually transmitted infections at a rural-based tertiary health-care center in Gujarat: An 8-year study. Indian J Community Med 2017;42:242-3.
] [Full text]
Zamzachin G, Singh NB, Devi TB. STD trends in regional institute of medical sciences, Manipur. Indian J Dermatol Venereol Leprol 2003;69:151-3.
] [Full text]
Sharma A, Rattan R, Sood, A. Pattern of sexually transmitted infections in a district hospital from Himachal Pradesh. Int J Community Med Public Health 2017;4:1028-31.
Jayashree P, Binitha MP, Najeeba R, Biju G. Clinical and epidemiological profile of sexually transmitted infections in a tertiary care centre in Kerala: A 1-year observational study. Indian J Dermatol Venereol Leprol 2015;81:500-3.
[Table 1], [Table 2], [Table 3]