Annex
Improving national sexually transmitted infections
surveillance
in Pacific Island countries and territories
Consensus document
on
sexually transmitted infections case definitions and minimum data set
Prepared by the Sexually Transmitted Infections
Working Group for the Pacific
including
WHO
UNFPA
SPC
UNICEF
OSSHHM
CDC
PRHP
8 May 2008
BACKGROUND
As shown by a number of studies, including the recent second-generation surveillance studies, there is a high
prevalence of sexually transmitted infections (STIs) in the Pacific region. Developing a programme that will
effectively address this situation will depend on how STI data from the region are collected and analysed.
One of the goals of the Pacific Regional Strategy on HIV Implementation Plan (2004–2008) is to enhance
national-level routine surveillance systems for HIV and other STIs. One of the identified barriers to achieving
this goal is the lack of regionally appropriate case definitions and a minimum data set for STIs that would
allow the collection of high-quality, comparable data across the region. Adopting a consistent approach to
definitions and reporting STI cases will enable more accurate and consistent data for monitoring trends in
STI incidence and prevalence over time.
To ensure that national and regional programmes seriously address the high prevalence of STIs, the Sexually
Transmitted Infections Working Group for the Pacific (STIWGP) was established in late 2006. The STIWGP is
a technical working group comprised of representatives from the Secretariat of the Pacific Community (SPC),
World Health Organization (WHO), United Nations Population Fund (UNFPA), Centers for Disease Control
and Prevention (CDC), United Nations Children’s Fund (UNICEF), Pacific Regional HIV/AIDS Project (PRHP)
and Oceania Society for Sexual Health and HIV Medicine (OSSHHM).
The following recommendations are made by a consensus of representatives from the STIWGP. This
document has adapted the WHO ‘Guidelines for Sexually Transmitted Infections Surveillance’ (1999).1
Case definitions from WHO1 and CDC2, such as that for syphilis, have been simplified to enable use of more
practical and consistent definitions in Pacific small island countries and territories.
This document would be useful for public health staff, STI program managers, laboratory and clinical staff.
Part A provides recommendations for STI case definitions, presented according to whether they are defined
by laboratory tests or clinical presentation.
Part B provides recommendations for a minimum data set for STI surveillance.
1
2.
2
See www.who.int/hiv/pub/me/en/GuidelinesforSTISurveillance1999_English.pdf
See www.cdc.gov/std/stats/app-casedef.htm
PART A: CASE DEFINITIONS
Case definitions based on laboratory (aetiologic) diagnosis
Gonorrhoea case definition
a) Demonstration of Neisseria gonorrhoeae in a clinical specimen by a DNA probe or PCR test OR
b) Culture of gram-negative, oxidase-positive diplococci (presumptive Neisseria gonorrhoeae) from a
clinical specimen OR
c) Observation of gram-negative intracellular diplococci on microscopy from an eye or a male
urogenital swab
Note: For assessment of antimicrobial susceptibility, culture is required.
Gonococcal antibiotic sensitivity surveillance
Total number of isolates tested over a specified period of time, e.g. 1 year
Number and percentage of isolates resistant to x antibiotic during time period
Number and percentage of isolates resistant to y antibiotic during time period.
(Repeated for each antibiotic tested)
Chlamydia case definition
Positive DNA probe or PCR test or antigen detection test for Chlamydia trachomatis
Trichomonas case definition
a) Presence of motile (moving) trichomonads by microscopy of a wet mount (saline microscopy) of
genital swabs from women OR
b) Presence of trichomonads detected by cervical (Pap) smears
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Syphilis case definition (where history of testing and treatment is unknown)
Note: The definitions for syphilis are for surveillance purposes only and are not intended to replace clinical
management protocols or guide management.
Treponemal tests refer to any treponemal (specific) tests, including TPHA, TPPA, FTA and EIA, and rapid
treponemal tests, such as Determine TP. VDRL is a non-specific test that is no longer used in the region;
however, the terminology is often used to refer to RPR. The use of the correct terminology to describe syphilis
tests should be encouraged.
Early syphilis*
Reactive treponemal test
AND
Reactive RPR with a titre equal to or greater than 1:8
* If a painless genital ulcer is present, classify as early syphilis regardless of RPR titre.
Late syphilis and syphilis of unknown duration
Reactive treponemal test
AND
Non-reactive or reactive RPR with a titre less than 1:8
Note: Testing can be done in either order.
Syphilis case definition (where history of testing and treatment is known)
Early syphilis
a) New infection (sero-conversion) within the previous 2 years
Reactive treponemal test (with either a reactive or non-reactive RPR)
AND
Documented previously non-reactive treponemal test within the previous 2 years with no history of treatment
b) New infection acquired within the previous 2 years
2 titre (fourfold) increase in the RPR titre within the previous 2 years
AND
Reactive treponemal test
Note: Testing can be done in either order.
Late syphilis
Evidence of syphilis not acquired within the previous 2 years:
Reactive treponemal test
AND
Reactive or non-reactive RPR
AND
No history of treatment
Note: Testing can be done in either order.
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Congenital syphilis case definition
Presumptive
a) An infant whose mother had untreated or inadequately treated* syphilis at delivery
Confirmed
b) The infant or child has a reactive treponemal test AND any of the following:
qq evidence of congenital syphilis on physical examination
qq long bone x-rays compatible with congenital syphilis
qq an elevated CSF (cerebrospinal fluid) cell count or protein (without other cause)
qq a positive IgM antibody test in blood or CSF
c) Stillbirth (foetal death):
qq a foetal death that occurs at >20 weeks OR
qq a foetal death in which the foetus weighs >500g
when the mother had untreated or inadequately treated* syphilis at delivery
* Inadequately treated is defined as:
- Non-penicillin treatment OR
- Incomplete penicillin treatment course OR
- Penicillin treatment completed within 30 days of delivery
Case definitions based on clinical syndromes
Male urethral discharge AND/OR dysuria syndrome
Urethral discharge and/or dysuria in men
Genital ulcer syndrome
Non-vesicular
Ulcer on penis, scrotum or ano-rectum in men or on labia, vagina or ano-rectum in women. (This
syndrome can be caused by syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale or
genital herpes.)
Vesicular (blisters)
Genital or anal vesicles (blisters) in men or women. (This syndrome is typically caused by genital HSV
infection.)
Opthalmia neonatorum
Conjunctivitis with discharge in a newborn within 4 weeks of delivery
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Vaginal discharge syndrome and lower abdominal pain in women syndrome
Vaginal discharge syndrome and lower abdominal pain in women syndrome have NOT BEEN INCLUDED,
as they are poor predictors of STI among women. WHO’s STI surveillance guidelines do not recommend
reporting these syndromes for STI surveillance as they are not reliable for assessment of STI incidence or
prevalence; therefore, this consensus document has not included them.
Health services may wish to collect data on these syndromes for their own health service planning needs.
Definitions are available at:
www.who.int/hiv/pub/me/en/GuidelinesforSTISurveillance1999_English.pdf
PART B: MINIMUM DATA SET
Operational aspects
Depending on individual circumstances, for routine STI surveillance Pacific Island countries and territories
may rely solely on laboratory (aetiologic)-based surveillance, solely on clinical syndrome-based surveillance,
or on a mixture of the two.
In order for high-quality surveillance data to be collected at a country level, certain information should be
available on each individual being tested (laboratory- or aetiologic-based reporting) or diagnosed (clinical
syndrome-based reporting). This minimum information is listed on the next page.
For laboratory (aetiologic)-based reporting, ideally a computerised database would be established for the
recording of the information. In the long term, such a computerised system could also replace laboratory log
books.
For reporting of clinical syndromes, it is anticipated that tally sheets would be used at clinical facilities (see
sample in this document).
For specified time periods the information is summarised into country data for local interpretation and
regional reporting. It is recommended that reporting be monthly for country data and three-monthly for
regional data. Reporting would be done either via running a report on a computerised database or manually
tabulating the data using tally sheets or laboratory log books. The information required for these summary
data sets is presented on pages 9-10.
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