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SHORT-TERM STAY SHELTER PROTOCOL






PRESUMPTIVE TREATMENT OF SEXUALLY TRANSMITTED
INFECTIONS AND SYNDROMIC MANAGEMENT OF
GENITOURINARY INFECTIONS
IN TRAFFICKED WOMEN AND GIRLS





Kathleen Morrow, CNM, MA
Doctors of the World-USA
Kosovo, 2005

 

TABLE OF CONTENTS


Page

Acknowledgements 3


I. Purpose Statement 4


II. Informed Consent 5


III. General Guidelines and Assessment 6


IV. Rationale for Presumptive Treatment 7


V. STI Treatment Guidelines for Women Age 19 Years and Older 9


VI. STI Treatment Guidelines for Adolescent Girls Age 12 to 18 Years 15


VII. Bacterial Vaginosis 22


VIII. Candidiasis 23


IX. Urinary Tract Infection 24


X. Head Lice, Scabies, and Phthirus (Pediculosis Pubis) 26


XI. Additional Health Considerations 29


XII. Endnotes 30



ACKNOWLEDGEMENTS


Special thanks are due to the Sexually Transmitted Infections Team of the Department
of Reproductive Health and Research, World Health Organization, for critically
reviewing several versions of this document

I extend my particular thanks to Dr. Julia Samuelson, Technical Officer from the
Department of Reproductive Health & Research for coordinating the review process in
the World Health Organization. In addition, I want to thank the two reviewers, Dr.
Francis J. Ndowa and Dr. Sibongile Dludlu, for their time, recommendations and editing
assistance in developing this protocol in order to better serve the reproductive health
care needs of trafficked women and girls in Kosovo.

I would like to thank Claire Appelmans, MS, NP, in the Santa Clara County Public
Health Department, who generously volunteered her time and effort to assist me with
editing and technical advice.



SHORT-TERM STAY SHELTER PROTOCOL

PRESUMPTIVE TREATMENT OF SEXUALLY TRANSMITTED INFECTIONS AND
SYNDROMIC MANAGEMENT OF GENITOURINARY INFECTIONS IN WOMEN AND
GIRLS



I. PURPOSE STATEMENT


This protocol is intended for the treatment of trafficked women and girls on arrival to the
Center to Protect Victims and Prevent Trafficking of Human Beings shelter in Kosovo.
The short-term stay protocol is for treatment of those who will stay in the shelter for two
to seven days. Presumptive treatment for chlamydia, gonorrhea, incubating or early
syphilis, and trichomoniasis should be offered to trafficked women and girls who report
possible exposure resulting from sexual exploitation and rape. In addition, syndromic
treatment may be provided for head lice, scabies, phthirus (pediculosis pubis), bacterial
vaginosis (BV), candidiasis, and urinary tract infection (UTI). Due to low resources and
inadequate laboratory facilities for microbiological testing in Kosovo, the following
guidelines are provided for presumptive and syndromic treatment. For the purposes of
these guidelines, a minor is an adolescent girl between the age of 12 to 18 years and an
adult woman is 19 years and older.

Every individual should be offered presumptive treatment only after she has been
informed of the risk of exposure to, and the dangers of, untreated sexually transmitted
infections (STIs). In addition, the benefits of treatment and possible side effects of the
medications should be explained and informed consent obtained.

The treatment protocols are based on the World Health Organization's Guidelines for
the Management of Sexually Transmitted Infections, 2003 and the Centers for Disease
Control and Prevention's (CDC) Sexually Transmitted Diseases Treatment Guidelines,
2002.

 

II. INFORMED CONSENT


Obtaining informed consent from adults is a recommended step when providing all
medical care and services. However, obtaining informed consent from trafficked
adolescent girls is problematic. According to the First Annual Report on Victims of
Trafficking in South Eastern Europe1:

There are no specialized procedures and services for internally or foreign
trafficked minors in Kosovo... In theory, the Centers for Social Work (CSW) should
grant formal permission for each stage of the assistance process for minors, but
this does not happen at present. Service providers and Kosovo’s CSW must
create practical protocols and service agreements regarding assistance for foreign
minors [and internal minors], including appropriate allocation of responsibility and
availability of respective organizations... These guidelines must address the
division of responsibility and practical allocation of service provision for minors, in
addition to protocols for appointment of a guardian and mechanism for obtaining
consent in cases of medical emergencies.

Currently, there are no legal procedures for minors to provide informed consent for
medical treatment. However, the risk and impact of untreated STIs cannot be
overlooked, and should be weighed against the potential benefit of presumptive
treatment.

When providing education on STIs and medical treatment for minors, care must be
taken to use language and terms they can understand. Once the physician feels that
the minor understands the risks and benefits of treatment, the medications may be
provided. Therefore, the process of obtaining informed consent from a minor follows
the same recommendations as for an adult.

In this setting, informed consent is the process of providing essential information and
education in order for the individual to understand the need for presumptive STI
treatment. Provide the following information, ideally in the primary spoken language:

 

III. GENERAL GUIDELINES AND ASSESSMENT

The individual needs to be interviewed and examined in a private room, and should be
reassured that all information will be considered confidential. A medical chart will
contain the following information:

IV. RATIONALE FOR PRESUMPTIVE TREATMENT

Sexually transmitted infections remain a public health problem of major significance in
most parts of the world. The incidence of acute STIs is believed to be high in many
countries. Failure to diagnose and treat STIs at an early stage may result in serious
complications and sequelae, including infertility, pregnancy loss, ectopic pregnancy,
anogenital cancer, premature death, as well as neonatal and infant infections.

Effective management of STIs is integral to STI control, as it prevents the development
of complications and sequelae, decreases the spread of those infections in the
community, and offers a unique opportunity for targeted education about HIV
prevention.

Appropriate treatment of STIs at the first contact between patient and health care
provider is therefore an important public health measure. Adolescent patients are at a
critical stage of development, and there is the potential to influence future sexual
behavior and treatment-seeking practices.

Lack of patient compliance with multi-dose antibiotic regimens is a problem that
seriously limits their effectiveness. Single-dose or very short course regimens should
therefore be given preference. Appropriate counseling and health education have been
shown to increase compliance and should be a part of clinical management.

Presumptive treatment or prophylaxis may be provided in low-resource settings where
laboratory testing and diagnosis are not feasible prior to treatment. These guidelines
are to be used if the individual has no fever or other symptoms of severe infection, such
as pyelonephritis or PID, and accepts presumptive treatment.

Many low-resource settings lack the equipment and trained personnel required for
etiologic diagnosis of STIs. To overcome this problem, WHO has developed a
syndrome-based approach for the management and treatment of STIs. The syndromic
approach is based on identification of consistent groups of symptoms and easily
recognized signs (syndromes), and the provision of treatment that will deal with the
majority of, or the most serious, organisms responsible for producing the syndrome.

This protocol combines presumptive treatment and syndromic management.
Presumptive treatment guidelines are based on the potential exposure of women and
adolescent girls who have reported sexual exploitation and rape that included
unprotected vaginal, anal, or oral penetration. Therefore, presumptive treatment is for
chlamydia, gonorrhea, incubating or early syphilis, and trichomoniasis. Syndromic
management offers treatment for symptoms of bacterial vaginosis, candidiasis, and
uncomplicated urinary tract infection.

The following documents highlight the need for medical treatment for adolescent girls in
the shelter:

V. STI TREATMENT GUIDELINES FOR WOMEN 19 YEARS
AND OLDER3,4


This section covers the management of women 19 years and older. Other severe
medical conditions and infections should first be ruled out as outlined in Sections III and
IV. A spontaneous complaint of vaginal discharge is most commonly a result of a
vaginal infection with Trichomonas vaginalis, bacterial vaginosis or Candida albicans.
Sometimes a vaginal discharge may be the presenting symptom of gonorrhea and
chlamydia, or these may be present as co-infections. Without access to laboratory
testing, identification of the causative organism is not possible, hence the need to treat
presumptively. This is particularly important when the population is at high risk of
having an STI.

The presumptive treatment plan is for chlamydia, gonorrhea, incubating or early
syphilis, and trichomoniasis. The recommended regimens are for single-dose
treatments. Alternative dose regimens for pregnant women and individuals with drug
allergies are provided, along with special notations. Treatment for chlamydia and
gonorrhea may be given on the same day, one hour before meals or two hours after
meals. The following day, give treatment for incubating or early syphilis and
trichomoniasis. In the unusual event of an individual staying 48 hours or less, all single-
dose treatments may be given within 24 hours.

As with all antibiotics, observe for allergic reactions, such as rash, hives, respiratory
difficulty, and anaphylactic shock. Often mild drug intolerances can occur, such as
diarrhea, nausea or vomiting, headache or body aches. If vomiting occurs shortly after
an oral dose, wait one day and repeat treatment with small amount of food. Antibiotics
used for treatment may worsen or trigger symptoms of candidiasis, though this is
uncommon with single-dose therapies.


Chlamydia Treatment Non-Pregnant:

Recommended Regimen:
Azithromycin 1 g orally: in a single dose.

Alternative Regimen:
Doxycycline 100 mg orally: 2 times a day for 7 days.
OR
Erythromycin 500 mg orally: 4 times a day for 7 days.

Special Notations:

Chlamydia Treatment During Pregnancy:

Recommended Regimen:

Special Notations:



Gonorrhea Treatment Non-Pregnant:

Recommended Regimen:


Gonorrhea Treatment During Pregnancy:

Recommended Regimen:


Early Syphilis

Early syphilis is defined as primary, secondary, and early latent syphilis of not more that
two years duration. Primary syphilis is characterized by an ulcer or chancre at the site
of infection or inoculation. Clinical manifestations of secondary syphilis include a skin
rash, condylomata lata, mucocutaneous lesions, and generalized lymphadenopathy.
Latent syphilis has no clinical manifestations. An infection of more than two years and
without clinical evidence of treponemal infection is referred to as late latent syphilis.
Late syphilis refers to late latent syphilis, gummatous, neurological and cardiovascular
syphilis. The following treatment regimens are not adequate for the treatment of late
latent syphilis, gummatous, neurological, or cardiovascular syphilis but only for early
stages of infection. Refer to other guidelines for further details.

Early Syphilis Treatment Non-Pregnant:

Recommended Regimen:


Early Syphilis Treatment During Pregnancy:

Recommended Regimen:


Trichomoniasis Treatment Non-Pregnant:

Recommended Regimen:


Trichomoniasis Treatment During Pregnancy:

Recommended Regimen:

 

VI. STI TREATMENT GUIDELINES FOR ADOLESCENT GIRLS
AGE 12 to 18 YEARS5,6


This section covers the management of adolescent girls 12 to 18 years of age. In the
unusual case of a girl being less than 12 years of age, consult with a pediatrician before
treatment. Other severe medical conditions and infections should first be ruled out as
outlined in Sections II, III, and IV. A spontaneous complaint of vaginal discharge is
most commonly a result of a vaginal infection with Trichomonas vaginalis, bacterial
vaginosis, or Candida albicans. Sometimes a vaginal discharge may be the presenting
symptom of gonorrhea and chlamydia, or these may be present as co-infections.
Without access to laboratory testing, identification of the causative organism is not
possible, hence the need to treat presumptively. This is particularly important when the
population is at high risk of having an STI.

The presumptive treatment plan is for chlamydia, gonorrhea, incubating or early
syphilis, and trichomoniasis. The recommended regimens are for single-dose
treatments. Alternative dose regimens for pregnant adolescent girls and individuals with
drug allergies are provided, along with special notations. Treatment for chlamydia and
gonorrhea may be given on the same day, one hour before meals or two hours after
meals. The following day, give treatment for early syphilis and trichomoniasis. In the
unusual event of an individual staying for less than 48 hours, administer all single-dose
treatments within a 24-hour period of time.

As with all antibiotics, observe for allergic reactions, such as rash, hives, respiratory
difficulty, and anaphylactic shock. Often mild drug intolerances can occur, such as
diarrhea, nausea or vomiting, headache, or body aches. If vomiting occurs shortly after
an oral dose, wait one day and repeat treatment after a small amount of food.
Antibiotics used for treatment may worsen or trigger symptoms of candidiasis, though
this is uncommon with single-dose therapies.


Chlamydia Treatment Non-Pregnant:

Recommended Regimen:
Azithromycin 1 g orally: in a single dose.

Alternative Regimen:
Doxycycline 100 mg orally: 2 times a day for 7 days.
OR
Erythromycin 500 mg orally: 4 times daily for 7 days.

Special Notations:


Chlamydia Treatment During Pregnancy:

Recommended Regimens:

Gonorrhea Treatment Non-Pregnant:

Recommended Regimen:


Gonorrhea Treatment During Pregnancy:

Recommended Regimen:

Early Syphilis

Early syphilis is defined as primary, secondary, and early latent syphilis of not more that
two years duration. Primary syphilis is characterized by an ulcer or chancre at the site
of infection or inoculation. Clinical manifestations of secondary syphilis include a skin
rash, condylomata lata, mucocutaneous lesions, and generalized lymphadenopathy.
Latent syphilis has no clinical manifestations. An infection of more than two years
duration and without clinical evidence of treponemal infection is referred to as late latent
syphilis. Late syphilis refers to late latent syphilis, gummatous, neurological and
cardiovascular syphilis. The following treatment regimens are not adequate for the
treatment of late latent syphilis, gummatous, neurological, or cardiovascular syphilis, but
only for early stages of infection. Refer to other guidelines for further details.


Early Syphilis Treatment Non-Pregnant:

Recommended Regimen:

Early Syphilis Treatment During Pregnancy:

Recommended Regimen:



Trichomoniasis Treatment Non-Pregnant:

Recommended Regimen:

Special Notations:


Trichomoniasis Treatment During Pregnancy:

Recommended Regimen:
Metronidazole 2 g orally: in a single dose (avoid during first 12 weeks of
pregnancy).

Alternative Regimen:

 

VII. BACTERIAL VAGINOSIS11


Bacterial Vaginosis (BV):

An individual with symptoms such as: vaginal discharge with prominent “fishy” odor,
and/or vulvar irritation, but usually without redness or swelling, may be treated with:

Recommended Regimen:

VIII. CANDIDIASIS


Candidiasis:

An individual with symptoms of vulvar itching and a curd-like vaginal discharge or noted
signs of genital redness, excoriation, and/or swelling, may be presumptively treated as
follows. All of these regimens may be used in pregnancy and for adolescent girls.

Recommended Regimen:

 

IX. URINARY TRACT INFECTION


Urinary Tract Infection (UTI):

Acute cystitis is the most common clinical manifestation of uncomplicated urinary tract
infection, especially in young women. Signs of an acute infection of the lower urinary
tract include dysuria, urgency, frequency, and hematuria. Dysuria may be easily
confused with secondary symptoms due to superficial vulvar burning on urination that
could be caused by herpes simplex ulcers, trauma of the vulva, or vaginal infections.
An examination of the external genitalia will assist in developing a differential diagnosis.
The dysuria resulting from chlamydia or gonorrhea may be indistinguishable from the
symptoms of cystitis. Therefore, consideration should be given to presumptively
treating an individual presenting with dysuria for STIs as well. Individuals with dysuria,
frequency and hesitation, with or without hematuria, may be presumptively treated as
follows.

Recommended Regimen:

X. TREATMENT FOR HEAD LICE, SCABIES AND PHTHIRUS
(PEDICULOSIS PUBIS)12,13


Careful inspection of the scalp, skin, pubic region and adjacent hairy areas is necessary
for identification and diagnosis of ectoparasitic infestations. Treat according to the
following guidelines.

Head Lice:

Recommended Regimen:
X. TREATMENT FOR HEAD LICE, SCABIES AND PHTHIRUS
(PEDICULOSIS PUBIS)12,13


Careful inspection of the scalp, skin, pubic region and adjacent hairy areas is necessary
for identification and diagnosis of ectoparasitic infestations. Treat according to the
following guidelines.

Head Lice:

Recommended Regimen:
Permethrin 1% lotion is applied to the wet hair and left on for 10 minutes. The
hair is then rinsed, dried, and nits (eggs) are combed from the hair shafts.
Treatment may be repeated after one week if necessary.
OR

Lindane 1% shampoo is worked into the hair and left on for 4 minutes. The hair is
then rinsed, dried, and nits (eggs) are combed from the hair shafts. Re-treatment
is rarely needed.

Special Notations:


Scabies:

Recommended Regimen:

Benzyl benzoate 25% lotion/cream applied to the entire body from the neck down
to and including feet, nightly for 2 nights; patients may bathe before reapplying
the drug, and then should not bathe until 24 hours after the second application.
OR

Crotamiton 10% lotion applied to the to all areas of the body from the neck down
to and including the feet, nightly for 2 nights and washed off thoroughly 24 hours
after the second application. Crotamiton has the advantage of an antipruritic
action.
OR

Lindane 1% lotion/cream applied sparingly to all areas of the body from the neck
down to and including feet, and washed off thoroughly after 8 hours. Usually
only one application is needed.


Special Notations:


Phthirus (Pediculosis Pubis/Crab Louse):

Recommended Regimen:

Permethrin 1% lotion is applied to the infested area and adjacent hairy areas and
washed off after 10 minutes; re-treatment is indicated after 7 days if lice are
found or eggs are observed at the hair-skin junction.
OR

Crotamiton 10% lotion is rubbed gently but thoroughly into the infested area and
adjacent hairy areas and washed off after 8 hours.
OR

Lindane 1% lotion/cream is rubbed gently but thoroughly into the infested area
and adjacent hairy areas and washed off after 8 hours; as an alternative Lindane
1% shampoo, applied and thoroughly washed off after 4 minutes.

Special Notations:

XI. ADDITIONAL HEALTH CONSIDERATIONS
Individuals are to be informed and advised to undergo screening for the following
sexually transmitted infections and health screening after returning to their home
country:

Individuals may also be referred for the following services as appropriate:

 

XII. ENDNOTES



1
First Annual Report on Victims of Trafficking in South Eastern Europe, pgs. 135, 151
and 154. Counter-Trafficking Regional Clearing Point: ICMC, Stability Pact and IOM.
www.icmc.net/files/rcp100301.en.pdf.

2
Guidelines for the Management of Sexually Transmitted Infections,
pgs. 1-3, 65 and 83. WHO 2003.

7
Budapest Declaration On Public Health & Trafficking In Human Beings, pg. 2.
March 2003.

8
Summary & Report of the Regional Conference On Public Health &Trafficking in
Human Beings in Central, Eastern & Southeast Europe, pg. 7. Budapest, Hungary,
March 19-21, 2003.

9
Clinical Management of Survivors of Rape, pg. 25. WHO/RHR/02.08.

10
Fact Sheet, New CDC Treatment Guidelines Critical to Preventing Health
Consequences of Sexually Transmitted Diseases: “Re-screening for Chlamydia Helps
Protect Young Women from Infertility.”
www.cdc.gov/od/oc/media/pressrel/fs020509.htm.

3
Guidelines for the Management of Sexually Transmitted Infections,
pgs. 21-55. WHO 2003.

4
Clinical Management of Survivors of Rape, pg. 39. WHO/RHR/02.08.

5
Clinical Management of Survivors of Rape, pgs. 17, 20, 27 and 40. WHO/RHR/02.08.

6
Guidelines for the Management of Sexually Transmitted Infections,
pgs. 21-55. WHO 2003.

11
Guidelines for the Management of Sexually Transmitted Infections,
pgs. 56-58. WHO 2003.

12
European STI Guidelines, International Journal of STI & AIDS, Vol. 12,
Supplement 3, pgs. 58-62. WHO, October, 2001.

13
Guidelines for the Management of Sexually Transmitted Infections,
pgs. 60-62. WHO 2003.