Year : 2014 | Volume
: 59 | Issue : 1 | Page : 105-
Management of STI: Looking beyond the index case
Umesh S Kamat, Ferreira AMA
Department of Preventive and Social Medicine, Goa Medical College, Goa, India
Umesh S Kamat
Department of Preventive and Social Medicine, Goa Medical College, Goa
|How to cite this article:|
Kamat US, AMA F. Management of STI: Looking beyond the index case.Indian J Dermatol 2014;59:105-105
|How to cite this URL:|
Kamat US, AMA F. Management of STI: Looking beyond the index case. Indian J Dermatol [serial online] 2014 [cited 2020 Aug 11 ];59:105-105
Available from: http://www.e-ijd.org/text.asp?2014/59/1/105/123538
The group, sexually transmitted infections (STIs) is aptly labeled as social disease.  Domestic sexual violence has been closely associated in the epidemiology of STIs. ,,,, Being a social disease the scope of its management extends much beyond the index patient to include the principle of contact tracing. The following case describes how the principles of counseling, compliance, contact tracing, and condom were effectively used in treatment of syphilis in a 21-year-old girl who contracted syphilis following a forced sexual intimation with her elder brother when she was 15 years.
The brother worked as a sea-man, an epidemiologically high risk occupation for contracting STI and had forced the patient in to sexual relation while he had come for their father's last rites. The patient was incidentally found to be Venereal Disease Research Laboratory (VDRL) test positive while she was being assessed for fitness for a job abroad; later the diagnosis was confirmed by Treponema Pallidum Hemagglutination Assay (TPHA) test. The patient was counseled and given 3 weekly doses of benzathine penicillin 1.2 MU intramuscular injection, following which the VDRL titers fell over a period of 6 months and eventually VDRL became nonreactive. In this course of time she shared the history of domestic sexual assault, her only possible route of contracting syphilis. She was asked to follow-up with her brother who was scheduled to come home for his marriage plans. Syphillis in the brother was confirmed using the laboratory tests and he too was initiated on treatment. At the counseling session, the brother gave history of sexual exposure with another male colleague, who he said had not returned back to the job following his last vacation a year back. It was concluded that the brother could have contracted syphilis following the Male having Sex with Male (MSM) activity, which he transmitted to the index case while she was sexually abused taking advantage of her emotionally vulnerable status following her father's death. The brother was advised to use condom during sexual intimation with his wife in future, till the VDRL tested nonreactive to prevent the transmission further.
Childhood sexual abuse is a common epidemiologic determinant of STIs, including syphilis, among adolescents. A survey by Government of India  involving 12,447 children aged 5-18 years estimated that 53% of the children faced sexual abuse. Although the exact proportion of children with sexual abuse is difficult to estimate due to underreporting, 2-10% of abused children are claimed to have STIs.  Conversely, 5-74% of children with STI report sexual abuse.  A community-based survey by Bal et al., estimated 9% prevalence of sexual abuse among street children in Kolkata and 4% of these tested positive for syphilis.  Neighbors and relatives are the most common perpetrators of the abuse.  Although the victims may present with complains ranging from acute injury to sexual organs to behavioral disorders or recurrent urinary infections, most children have normal to nonspecific findings, that is, asymptomatic  as in this case detected at routine screening for a job abroad. Confirmation is usually done by treponema-specific tests like TPHA, Flourescent Treponemal Antibody-Absorption (FTA-ABS), and Treponema Pallidum Particle Agglutination (TPPA) assay. Nonconfronting approach, psychological support together with the health education as in this case could help elicit significant history, which otherwise the patient may be reluctant to disclose. This history could give valuable insight in to the possible source of infection, the treatment of which would interrupt the chain of transmission of the social evil of STI. These social aspects of treatment are as important as the pharmacological treatment of individual case with intramuscular benzathine penicillin injection. Ideally all cases of child abuse should be reported by the treating physician to the department of Women and Child Development. In the absence of strong legal and social support system to whom the child could be referred, the social management varies depending on the social background of the child, for example, disclosure to the parents may be self remedial in case of a child with good family support while seeking legal help and shifting the child to a safety home may be considered for other children.
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