•Dr Fayemiwo
Adetona Fayemiwo is an Associate Professor of Medicine, Consultant Clinical Microbiologist, and Head of the Department of Medical Microbiology and Parasitology at the University College Hospital, Ibadan. In this interview with Nigerian Tribune, he states that it is impossible to develop immunity against sexually transmitted infections, and that the best protection is mutual faithfulness by couples and abstinence for adolescents.
NEISSERIA gonorrhoea and Chlamydia are examples of sexually transmitted infections that you treat in the clinic as a consultant clinical microbiologist. What are these diseases, and how common are they?
These are two separate organisms that negatively impact human beings but have different manifestations in different groups of people. Chlamydia causes non-gonococcal urethritis in males and non-gonococcal cervicitis in females. Gonorrhoea, commonly referred to as “atosi” in Yoruba, however, causes gonococcal urethritis in men or gonococcal cervicitis in females.
These organisms are most often sexually transmitted. Their transmission can also be from an infected mother during childbirth. When twins are born, the germ most commonly affects the first twin. Although syphilis can be contracted through blood transfusion, Neisseria gonorrhoea and Chlamydia are rarely transmitted via blood transfusion.
However, cases of chlamydia and gonorrhoea in women are a bit serious because they might not feel or notice any symptoms for as long as two years or more. As such, many patients wouldn’t even know that they contracted these infections. Many women get to know until after engaging in sexual intercourse with their male partners, who, within three days—one week—start to have yellowish pus-like discharge or drip from their penis in the case of gonorrhoea and watery discharge in the case of Chlamydia.
What are the other things people with these two organisms are likely to experience?
Many women with gonorrhoea have no symptoms in the early phase. The men often experience a burning sensation during urination, yellowish discharge, and pain or swelling in the testicles. There could also be pain in one or both testicles and swelling. In women, there may be a vaginal discharge and bleeding between periods, as well as pain in the lower abdominal area.
Men often wrongly assume that the watery discharge due to Chlamydia is because they are sexually stimulated and wouldn’t present early for treatment at the hospital. But in light-skinned men, the area around the penis opening will be reddened; they may experience a burning sensation during urination, urgency to urinate, and pain in one or both testicles. Some of them will also experience pains around the loins.
Unfortunately, in females, the disease-causing germs end up affecting all the structures in the pelvis region. It’s an ascending infection; it comes in through the vagina and spreads to the cervix, the womb, the fallopian tubes, and finally the ovary. That’s why, without prompt treatment, they may end up with blocked fallopian tubes and thereafter infertility.
So, whenever there is a discharge, it should be a cause for concern and enough reason for a man to go to the hospital for treatment. We don’t usually want to attend to some of them until they bring their partners. Usually, the male partners are like saviours to the female partners. It’s of public health importance. That is why we also want to ensure that we break their chain of transmission within that community. I’ve seen a situation where a lady has five to six sexual contacts who have contracted the infection from her. It is one of them that came to the hospital. The other partners had visited nearby pharmacists for treatment; some just took herbal medicine. So, all these have negative impacts on public health.
What were your findings on gonorrhoea and Chlamydia infections in the community in your recent study?
The study was carried out among perceived infertile women. Some time ago, one of its authors mentioned that there are so many requests from the O&G department to Radiology for one investigation called HSG, where they put a contrast through the cervix to assess a woman’s fallopian tubes. Most of them were discovered to have blocked fallopian tubes. So, we decided to screen them for Chlamydia and Gonorrhoea infections.
Our finding was that a lot of these women were referred for HSG because they had previously had pelvic inflammatory disease (PID), chlamydia infections, gonorrhoea infections, trichomoniasis, and other genital sexually transmitted infections.
In the group, about 2.4%, 17.6%, 11.2%, and 17.7% of the women had gonorrhoea, chlamydia, trichomoniasis, and a previous pelvic inflammatory disease, respectively. That means that they must have been infected with either of these agents, chlamydia or gonorrhoea, for a very long time. For you to develop PID, you must have had gonorrhoea or chlamydia infection in the past.
So, as a result of this study, the policy in our teaching hospital now is that no infertile woman should go for HSG investigation without being screened first for Sexually transmitted infections(STI).
In women, some of these infections will not show any symptoms for two to three years. And then when you now push a contrast through the cervix to the fallopian tubes, it makes the infection spread further, so worsening the case.
Is it possible to have two or more STI germs coexisting in a woman?
It is possible that chlamydia and gonorrhoea can coexist in a woman. For instance, gonorrhoea and trichomoniasis can coexist because trichomoniasis will affect the cells that line the vagina, making it more susceptible to acquiring gonorrhoea or chlamydia. Also, other infections, especially HIV, also increase the chances of coming down with gonorrhoea or chlamydia.
The majority of people acquire chlamydia and gonorrhoea through sex. It could result in serious complications, including infection in the newborn, infertility, and ectopic pregnancy in a woman. When the infection spreads into the pelvic area, it can lead to PID. In women, PID can cause difficulty getting pregnant or infertility. In men, it can affect the testicles, so sperm may not be produced or produced abnormally.
During pregnancy, gonorrhoea can cause miscarriage, premature labour and birth, and the baby being born with conjunctivitis. In men, when gonorrhoea has been left untreated, it can spread through the bloodstream and cause life-threatening infections in other parts of the body (sepsis) in rare cases.
Are cases of STIs on the rise?
Well, cases of STIs are on the rise. Initially, it was a bit controlled when we had HIV under check. But with good reports about HIV, people are now more relaxed since they are taking their ARV drugs. The fear of acquiring HIV is no longer there, so cases of other STIs are now on the rise. Also, the fact that you are well-treated for gonorrhoea today doesn’t mean that when you are exposed again, there cannot be a reinfection. There is no immunity for gonorrhoea. You can have it as many times as the number of times one gets exposed to it.
In our clinic, the most common STI presented is genital wart. Genital warts can be anywhere on the body, including the perineum, vagina, breast folds, and penis. It can be on the penis; it can be on the shaft; it can be everywhere.
What about cases of syphilis, gonorrhoea, and trichomoniasis?
The incidence of syphilis, gonorrhoea, and trichomoniasis is also on the increase. In a study, which cuts across the six geopolitical zones of Nigeria, we found that the rise in these STI cases was higher in the northwest and the southeast. The increasing incidence of STIs is because people are not protecting themselves; they are not using condoms. We have been preaching barrier methods for a very long time. However, people are not too comfortable using condoms. They want the actual contact. That is even one of the reasons why cases of genital warts are on the rise. This virus spreads through contact, depending on where the infected sexual organ is in contact with.
In addition, another sexually transmitted infection whose incidence is on the increase is the herpes simplex virus, causing genital herpes. We have herpes simplex type 1 and herpes simplex type 2. Herpes simplex virus type 1 is more in the upper part of the body, while herpes simplex virus type 2 causes genital herpes. More people now have oral sex, so we now have more of herpes simplex type 1 causing the genital infection.
Are there other things that predispose individuals to complications from these infections?
Antimicrobial resistance is a contributory factor for those STIs like gonorrhoea and Chlamydia. These are bacterial infections treated with antibiotics, unlike viral infections like herpes simplex and warts. Resistance to antibiotics has caused us to abandon the usage of different classes of antibiotics in their treatment. For instance, doxycycline and penicillin are almost useless in treating gonorrhoea and chlamydia. Part of the reason for the antibiotic resistance is because of abuse of these drugs. A lot of people take inadequate dosages of these drugs. This is also partially the reason why cases of STIs are on the rise.
Can individuals protect themselves from chlamydia and gonorrhoea? Do they come in contact with these germs?
Protection is a bit subjective. At a presentation I gave in Ethiopia, where I emphasised monogamous relationships, a gentleman stood up to ask if, in the name of protecting himself, he should divorce his four wives. He did not agree with the suggestion. But we now emphasise more on individuals having faithful partners. For instance, if a man has four wives, he needs to be faithful to these wives just as these wives should not be having sexual intercourse with anybody else than their husbands. That is a kind of protection; that’s substantial protection.
For young adults or adolescents, abstinence is still the best way. If you know that you cannot abstain, then protect yourself using a condom. Many young people are sexually exposed even before they are 15 years old, and their parents are not aware. I’ve heard of a case of a young lady suspected to have viral conjunctivitis. She had washed her face with her urine. She had gonococcal conjunctivitis. If care is not taken, she could go blind within 72 hours. When the 17-year-old girl was asked if she was sexually exposed, the mother declared her to be a virgin. But on examination and testing, we discovered she had gonorrhoea and trichomoniasis. The next thing is to stick to a faithful partner and then use a condom.
Another unconventional method is to be in a well-lit area before having sex. It’s a bit unconventional. There are different manifestations of STIs; genital warts are highly visible, and partners can view them and ask questions. In the case of gonorrhoea, you will see a purulent discharge; for herpes simplex, you will see some vesicles that look like tiny boils all around the genital; and for chancroid, there will be blisters or sores. No matter how sexually motivated, when the light is on and you see these things on the male or female genital organs, you will pull back. It is a bit unconventional, but it is still a mode of preventing STIs. These signs and symptoms can serve as red flags because they are visible. Some of my patients with giant genital warts say they only have sex in the dark. They even put on strong perfume to cover up the smell arising because of the genital wart.
When they present late, can they be helped?
They can be helped whenever they present in the hospital. They are always helped in one way or another. But not all of them can be cured; some cannot be cured. It is not only HIV that cannot be cured; herpes simplex virus and hepatitis B cannot be cured, but others like gonorrhoea, chlamydia, and trichomoniasis can be cured, even when they present late. One of the goals of treatment is to prevent these complications. Some of these complications, like a blocked fallopian tube, are irreversible.
