Description

Sexually transmitted diseases (STDs) are the infections and resulting clinical syndromes caused by more than 25 infectious organisms transmitted through sexual activity, which includes organisms that are typically thought of as gastrointestinal pathogens. Because STDs are communicable diseases with far-reaching public health consequences, early detection and treatment are important for the sexual and reproductive health of the individual, as well as the community. STDs can often result in serious long-term complications, including pelvic inflammatory disease, infertility, stillbirths and neonatal infections, genital cancers, and an increased risk for HIV acquisition and transmission (1).

Occurrence

Sexually transmitted diseases are among the most common infections, with an estimated 18.9 million new infections annually in the United States and 340 million infections worldwide (2). Travelers who have sexual interactions with members of core groups of efficient STD transmitters (e.g., commercial sex workers) in endemic areas may have high rates of acquisition of a STD, such as gonorrhea. Some STDs are 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.

Risk for Travelers

International travelers are at risk of contracting STDs, including HIV, if they have sexual contact with partners in locales with high STD prevalence. Increased sexual promiscuity and casual sexual relationships tend to occur during travel abroad to foreign countries and are frequent in long-term overseas travelers (3-5). Commercial sexual service in various destinations (e.g., Southeast Asia) attracts many foreign travelers, and rates of infectious syphilis, quinolone-resistant gonorrhea, and lymphogranuloma venereum have increased in various locations among men who have sex with men (MSM) (6;8-10).

Clinical Presentation

Any traveler who may have been exposed to an STD 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 care. Screening for asymptomatic infection should be encouraged among travelers who have had casual sexual activity.

Prevention

The prevention and control of STDs are based on education and counseling; specific measures the traveler can take to avoid acquiring or transmitting STDs should be part of the health advice given to travelers (11-13). Abstinence or mutual monogamy are the most reliable way to avoid acquisition and transmission of STDs. For persons 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, trichomoniasis, and might protect women from developing pelvic inflammatory disease (11). Condoms might afford protection against transmission of herpes simplex virus-2, although data for this effect are more limited (10). Only water-based lubricants (e.g., K-Y Jelly or glycerine) should be used with latex condoms, because oil-based lubricants (e.g., petroleum jelly, shortening, mineral oil, or massage oils) can weaken latex condoms. Vaginal spermicides containing nonoxynol-9 are not recommended for STD/HIV prevention (14). Travelers should be instructed to wash hands immediately after handling a condom used during anal sex and after touching the anus or rectal area.

Pre-exposure vaccination is an effective method for prevention of sexually acquired hepatitis A and B infections. Hepatitis A vaccine is recommended for all unvaccinated sexually active men who have sex with men (MSM) or those using injection drugs whether or not they travel. As well, hepatitis B vaccine is recommended for all unvaccinated persons with a history of STD, of multiple sexual partners, or of use or partner use of injection drugs, or MSM. Candidate vaccines for herpes simplex virus are currently in clinical trials, and a quadravalent vaccine against human papillomavirus (HPV) is available for females 9-26 years of age.

Treatment

Etiologic treatment directed toward a specific pathogen is the historical norm for the management of 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. Knowledge of the clinical presentation, frequency of infection, and antimicrobial resistance patterns (e.g., quinolone-resistant Neisseria gonorrhoeae) are important in the management of STDs that occur in travelers from specific destinations (6;7). Evaluation and management of STDs should be based on standard guidelines (CDC, WHO) with consideration of the high frequency of antimicrobial resistance in different geographic areas (14;15).

References

1. Workowski KA, Levine W, Wasserheit JN. Sexually transmitted diseases treatment guidelines: an opportunity to unify clinical and public health practice. Ann Intern Med. 2002;137:255-62.  
2. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004;36:6-10.
3. Memish ZA, Osoba OA. Sexually transmitted diseases and travel. Int J Antimicrob Agents. 2003;21:131-4.  
4. Matteelli A, Carosi G. Sexually transmitted diseases in travelers. Clin Infect Dis. 2001;32:1063-7.  
5. Mulhall BP. Sexual behavior in travellers. Lancet. 1999;353:595-6.
6. CDC. Increases in fluoroquinolone-resistant Neisseria gonorrhoeae among men who have sex with men — United States, 2003, and revised recommendations for gonorrhea treatment, 2004. MMWR Morbid Mortal Wkly Rep. 2004;53(no. MM16):335-8.
7. Tapsall J. Antibiotic resistance in Neisseria gonorrhoeae. Clin Infect Dis. 2005;41:S263-8.  
8. CDC. Lymphogranuloma venereum among men who have sex with men—Netherlands, 2003-4. MMWR Morbid Mortal Wkly Rep. 2004;53(no. MM42):985-7.
9. Peterman TA, Heffelfinger JD, Swint EB, Groseclose SL. The changing epidemiology of syphilis. Sex Transm Dis. 2005;32:S4-S10.
10. Wald A, Langenberg AG, Krantz E, Douglas JM Jr, Handsfield HH, DiCarlo RP, et al. The relationship between condom use and herpes simplex virus acquisition. Ann Intern Med. 2005;143:707-13.
11. Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bull World Health Organ. 2004;82:454-61.
12. Kamb ML, Fishbein M, Douglas JM Jr, Rhodes F, Rogers J, Bolan G, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. JAMA. 1998;280:1161-7.
13. Schmid G, Steen R, N’Dowa F. Control of bacterial sexually transmitted diseases in the developing world is possible. Clin Infect Dis. 2005;41:1313-5.
14. CDC. Sexually transmitted diseases treatment guidelines 2006. MMWR. 2006;55(No. RR-11):1.
15. Tietz A, Davies SC, Moran JS. Guide to sexually transmitted disease resources on the internet. Clin Infect Dis. 2004;38:1304-10.