Sunday, February 14, 2016

Infant and Young Child Feeding

Key facts

Every infant and child has the right to good nutrition according to the Convention on the Rights of the Child.
Under nutrition is associated with 45% of child deaths.
Globally in 2013, 161.5 million children under 5 were estimated to be stunted, 50.8 million were estimated to have low weight-for-height, and 41.7 million were overweight or obese.
About 36% of infants 0 to 6 months old are exclusively breastfed.
Few children receive nutritionally adequate and safe complementary foods; in many countries less than a fourth of infants 6–23 months of age meet the criteria of dietary diversity and feeding frequency that are appropriate for their age.
Over 800 000 children's lives could be saved every year among children under 5, if all children 0–23 months were optimally breastfed . Breastfeeding improves IQ, school attendance, and is associated with higher income in adult life. 1
Improving child development and reducing health costs through breastfeeding results in economic gains for individual families as well as at the national level.
Under nutrition is estimated to cause 3.1 million child deaths annually or 45% of all child deaths. Infant and young child feeding is a key area to improve child survival and promote healthy growth and development. The first 2 years of a child’s life are particularly important, as optimal nutrition during this period lowers morbidity and mortality, reduces the risk of chronic disease, and fosters better development overall.

Optimal breastfeeding is so critical that it could save over 800 000 under 5 child lives every year.

WHO and UNICEF recommend:
early initiation of breastfeeding within 1 hour of birth;
exclusive breastfeeding for the first 6 months of life; and
introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding up to 2 years of age or beyond.
However, many infants and children do not receive optimal feeding. For example, only about 36% of infants aged 0 to 6 months worldwide are exclusively breastfed over the period of 2007-2014.

Recommendations have been refined to also address the needs for infants born to HIV-infected mothers. Antiretroviral drugs now allow these children to exclusively breastfeed until they are 6 months old and continue breastfeeding until at least 12 months of age with a significantly reduced risk of HIV transmission.

Exclusive breastfeeding for 6 months has many benefits for the infant and mother. Chief among these is protection against gastrointestinal infections which is observed not only in developing but also industrialized countries. Early initiation of breastfeeding, within one hour of birth, protects the newborn from acquiring infections and reduces newborn mortality. The risk of mortality due to diarrhoea and other infections can increase in infants who are either partially breastfed or not breastfed at all.

Breast milk is also an important source of energy and nutrients in children aged 6 to 23 months. It can provide half or more of a child’s energy needs between the ages of 6 and 12 months, and one third of energy needs between 12 and 24 months. Breast milk is also a critical source of energy and nutrients during illness, and reduces mortality among children who are malnourished.

Children and adolescents who were breastfed as babies are less likely to be overweight/obese. Additionally, they perform better on intelligence tests and have higher school attendance. Breastfeeding is associated with higher income in adult life. Improving child development and reducing health costs result in economic gains for individual families as well as at the national level.1

Longer durations of breastfeeding also contribute to the health and well-being of mothers; it reduces the risk of ovarian and breast cancer and helps space pregnancies–exclusive breastfeeding of babies under 6 months has a hormonal effect which often induces a lack of menstruation. This is a natural (though not fail-safe) method of birth control known as the Lactation Amenorrhoea Method.

Mothers and families need to be supported for their children to be optimally breastfed. Actions that help protect, promote and support breastfeeding include:

adoption of policies such as the International Labour Organization’s Maternity Protection Convention 183 and Recommendation No. 191, which complements Convention No. 183 by suggesting a longer duration of leave and higher benefits;
the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions;
implementation of the Ten Steps to Successful Breastfeeding specified in the Baby-Friendly Hospital Initiative, including:
skin-to-skin contact between mother and baby immediately after birth and initiation of breastfeeding within the first hour of life;
breastfeeding on demand (that is, as often as the child wants, day and night);
rooming-in (allowing mothers and infants to remain together 24 hours a day);
not giving babies additional food or drink, even water, unless medically necessary;
provision of supportive health services with infant and young child feeding counselling during all contacts with caregivers and young children, such as during antenatal and postnatal care, well-child and sick child visits, and immunization; and
community support, including mother support groups and community-based health promotion and education activities.
Breastfeeding practices are highly responsive to supportive interventions, and the prevalence of exclusive and continued breastfeeding can be improved over the course of a few years.

Complementary feeding
Around the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided by breast milk, and complementary foods are necessary to meet those needs. An infant of this age is also developmentally ready for other foods. If complementary foods are not introduced around the age of 6 months, or if they are given inappropriately, an infant’s growth may falter. 

Guiding principles for appropriate complementary feeding are:
continue frequent, on-demand breastfeeding until 2 years of age or beyond;
practise responsive feeding (e.g. feed infants directly and assist older children. Feed slowly and patiently, encourage them to eat but do not force them, talk to the child and maintain eye contact);
practise good hygiene and proper food handling;
start at 6 months with small amounts of food and increase gradually as the child gets older;
gradually increase food consistency and variety;
increase the number of times that the child is fed: 2-3 meals per day for infants 6-8 months of age and 3-4 meals per day for infants 9-23 months of age, with 1-2 additional snacks as required;
use fortified complementary foods or vitamin-mineral supplements as needed; and
during illness, increase fluid intake including more breastfeeding, and offer soft, favourite foods.

Feeding in exceptionally difficult circumstances
Families and children in difficult circumstances require special attention and practical support. Wherever possible, mothers and babies should remain together and get the support they need to exercise the most appropriate feeding option available. Breastfeeding remains the preferred mode of infant feeding in almost all difficult situations, for instance:

low-birth-weight or premature infants;
HIV-infected mothers;
adolescent mothers;
infants and young children who are malnourished; and
families suffering the consequences of complex emergencies.

HIV and infant feeding
Breastfeeding, and especially early and exclusive breastfeeding, is one of the most significant ways to improve infant survival rates. However, HIV can pass from mother to child during pregnancy, labour or delivery, and also through breast milk. In the past, the challenge was to balance the risk of infants acquiring HIV through breastfeeding versus the higher risk of death from causes other than HIV, in particular malnutrition and serious illnesses such as diarrhea and pneumonia, among HIV-exposed but still uninfected infants who were not breastfed.

The evidence on HIV and infant feeding shows that giving antiretroviral drugs (ARVs) to HIV-infected mothers can significantly reduce the risk of transmission through breastfeeding and also improve her health. This enables infants of HIV-infected mothers to be breastfed with a low risk of transmission (1-2%). HIV-infected mothers and their infants living in countries where diarrhoea, pneumonia and malnutrition are still common causes of infant and child deaths can therefore gain the benefits of breastfeeding with minimal risk of HIV transmission.

Since 2010, WHO has recommended that mothers who are HIV-infected take ARVs and exclusively breastfeed their babies for 6 months, then introduce appropriate complementary foods and continue breastfeeding up to the child’s first birthday. Breastfeeding should only stop once a nutritionally adequate and safe diet without breast milk can be provided.

Even when ARVs are not available, mothers should be counselled to exclusively breastfeed for 6 months and continue breastfeeding thereafter unless environmental and social circumstances are safe for, and supportive of, feeding with infant formula.

WHO's response
WHO is committed to supporting countries with implementation and monitoring of the "Comprehensive implementation plan on maternal, infant and young child nutrition", endorsed by Member States in May 2012. The plan includes 6 targets, one of which is to increase, by 2025, the rate of exclusive breastfeeding for the first 6 months up to at least 50%. Activities that will help to achieve this include those outlined in the "Global Strategy for Infant and Young Child Feeding", which aims to protect, promote and support appropriate infant and young child feeding.

WHO has formed a Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant WHA resolutions called NetCode. The goal of NetCode is to protect and promote breastfeeding by ensuring that breastmilk substitutes are not marketed inappropriately. Specifically, NetCode is building the capacity of Member States and civil society to strengthen national Code legislation, continuously monitor adherence to the Code, and take action to stop all violations. In addition, WHO and UNICEF have developed courses for training health workers to provide skilled support to breastfeeding mothers, help them overcome problems, and monitor the growth of children, so they can identify early the risk of undernutrition or overweight/obesity.

In addition, WHO and UNICEF have developed courses for training health workers to provide skilled support to breastfeeding mothers, help them overcome problems, and monitor the growth of children, so they can identify early the risk of undernutrition or overweight/obesity.

WHO provides simple, coherent and feasible guidance to countries for promoting and supporting improved infant feeding by HIV-infected mothers to prevent mother-to-child transmission, good nutrition of the baby, and protect the health of the mother.

Friday, February 12, 2016

Healthy Diet

Key facts
A healthy diet helps protect against malnutrition in all its forms, as well as noncommunicable diseases (NCDs), including diabetes, heart disease, stroke and cancer.

Unhealthy diet and lack of physical activity are leading global risks to health.
Healthy dietary practices start early in life – breastfeeding fosters healthy growth and improves cognitive development, and may have longer-term health benefits, like reducing the risk of becoming overweight or obese and developing NCDs later in life.

Energy intake (calories) should be in balance with energy expenditure. Evidence indicates that total fat should not exceed 30% of total energy intake to avoid unhealthy weight gain , with a shift in fat consumption away from saturated fats to unsaturated fats , and towards the elimination of industrial trans fats .

Limiting intake of free sugars to less than 10% of total energy intake  is part of a healthy diet. A further reduction to less than 5% of total energy intake is suggested for additional health benefits.
Keeping salt intake to less than 5 g per day helps prevent hypertension and reduces the risk of heart disease and stroke in the adult population.

WHO Member States have agreed to reduce the global population’s intake of salt by 30% and halt the rise in diabetes and obesity in adults and adolescents as well as in childhood overweight by 2025.

Consuming a healthy diet throughout the life course helps prevent malnutrition in all its forms as well as a range of noncommunicable diseases and conditions. But the increased production of processed food, rapid urbanization and changing lifestyles have led to a shift in dietary patterns. People are now consuming more foods high in energy, fats, free sugars or salt/sodium, and many do not eat enough fruit, vegetables and dietary fiber such as whole grains.

The exact make-up of a diversified, balanced and healthy diet will vary depending on individual needs (e.g. age, gender, lifestyle, degree of physical activity), cultural context, locally available foods and dietary customs. But basic principles of what constitute a healthy diet remain the same.

For adults

A healthy diet contains:
Fruits, vegetables, legumes (e.g. lentils, beans), nuts and whole grains (e.g. unprocessed maize, millet, oats, wheat, brown rice).
At least 400 g (5 portions) of fruits and vegetables a day. Potatoes, sweet potatoes, cassava and other starchy roots are not classified as fruits or vegetables.
Less than 10% of total energy intake from free sugars  which is equivalent to 50 g (or around 12 level teaspoons) for a person of healthy body weight consuming approximately 2000 calories per day, but ideally less than 5% of total energy intake for additional health benefits . Most free sugars are added to foods or drinks by the manufacturer, cook or consumer, and can also be found in sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.
Less than 30% of total energy intake from fats. Unsaturated fats (e.g. found in fish, avocado, nuts, sunflower, canola and olive oils) are preferable to saturated fats (e.g. found in fatty meat, butter, palm and coconut oil, cream, cheese, ghee and lard) . Industrial trans fats (found in processed food, fast food, snack food, fried food, frozen pizza, pies, cookies, margarines and spreads) are not part of a healthy diet.
Less than 5 g of salt (equivalent to approximately 1 teaspoon) per day and use iodized salt.

For infants and young children
In the first 2 years of a child’s life, optimal nutrition fosters healthy growth and improves cognitive development. It also reduces the risk of becoming overweight or obese and developing NCDs later in life.

Advice on a healthy diet for infants and children is similar to that for adults, but the following elements are also important.

Infants should be breastfed exclusively during the first 6 months of life.
Infants should be breastfed continuously until 2 years of age and beyond.
From 6 months of age, breast milk should be complemented with a variety of adequate, safe and nutrient dense complementary foods. Salt and sugars should not be added to complementary foods.
Practical advice on maintaining a healthy diet

Fruits and vegetables
Eating at least 400 g, or 5 portions, of fruits and vegetables per day reduces the risk of NCDs , and helps ensure an adequate daily intake of dietary fiber.

In order to improve fruit and vegetable consumption you can:
always include vegetables in your meals
eat fresh fruits and raw vegetables as snacks
eat fresh fruits and vegetables in season
eat a variety of choices of fruits and vegetables.
Reducing the amount of total fat intake to less than 30% of total energy intake helps prevent unhealthy weight gain in the adult population.

Also, the risk of developing NCDs is lowered by reducing saturated fats to less than 10% of total energy intake, and trans fats to less than 1% of total energy intake, and replacing both with unsaturated fats.

Fat intake can be reduced by:
changing how you cook – remove the fatty part of meat; use vegetable oil (not animal oil); and boil, steam or bake rather than fry;
avoiding processed foods containing trans fats; and
limiting the consumption of foods containing high amounts of saturated fats (e.g. cheese, ice cream, fatty meat).
Salt, sodium and potassium
Most people consume too much sodium through salt (corresponding to an average of 9–12 g of salt per day) and not enough potassium. High salt consumption and insufficient potassium intake (less than 3.5 g) contribute to high blood pressure, which in turn increases the risk of heart disease and stroke.

1.7 million deaths could be prevented each year if people’s salt consumption were reduced to the recommended level of less than 5 g per day.

People are often unaware of the amount of salt they consume. In many countries, most salt comes from processed foods (e.g. ready meals; processed meats like bacon, ham and salami; cheese and salty snacks) or from food consumed frequently in large amounts (e.g. bread). Salt is also added to food during cooking (e.g. bouillon, stock cubes, soy sauce and fish sauce) or at the table (e.g. table salt).

You can reduce salt consumption by:
not adding salt, soy sauce or fish sauce during the preparation of food
not having salt on the table
limiting the consumption of salty snacks
choosing products with lower sodium content.
Some food manufacturers are reformulating recipes to reduce the salt content of their products, and it is helpful to check food labels to see how much sodium is in a product before purchasing or consuming it.
Potassium, which can mitigate the negative effects of elevated sodium consumption on blood pressure, can be increased with consumption of fresh fruits and vegetables.

The intake of free sugars should be reduced throughout the lifecourse. Evidence indicates that in both adults and children, the intake of free sugars should be reduced to less than 10% of total energy intake, and that a reduction to less than 5% of total energy intake provides additional health benefits . Free sugars are all sugars added to foods or drinks by the manufacturer, cook or consumer, as well as sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.

Consuming free sugars increases the risk of dental caries (tooth decay). Excess calories from foods and drinks high in free sugars also contribute to unhealthy weight gain, which can lead to overweight and obesity.

Sugars intake can be reduced by:
limiting the consumption of foods and drinks containing high amounts of sugars (e.g. sugar-sweetened beverages, sugary snacks and candies); and eating fresh fruits and raw vegetables as snacks instead of sugary snacks.

How to promote healthy diets
Diet evolves over time, being influenced by many factors and complex interactions. Income, food prices (which will affect the availability and affordability of healthy foods), individual preferences and beliefs, cultural traditions, as well as geographical, environmental, social and economic factors all interact in a complex manner to shape individual dietary patterns. Therefore, promoting a healthy food environment, including food systems which promote a diversified, balanced and healthy diet, requires involvement across multiple sectors and stakeholders, including government, and the public and private sector.

Governments have a central role in creating a healthy food environment that enables people to adopt and maintain healthy dietary practices.

Effective actions by policy-makers to create a healthy food environment include:

Creating coherence in national policies and investment plans, including trade, food and agricultural policies, to promote a healthy diet and protect public health:
Increase incentives for producers and retailers to grow, use and sell fresh fruits and vegetables;
Reduce incentives for the food industry to continue or increase production of processed foods with saturated fats and free sugars;
Encourage reformulation of food products to reduce the contents of salt, fats (i.e. saturated fats and trans fats) and free sugars;
Implement the WHO recommendations on the marketing of foods and non-alcoholic beverages to children;
Establish standards to foster healthy dietary practices through ensuring the availability of healthy, Safe and affordable food in pre-schools, schools, other public institutions, and in the workplace;
Sxplore regulatory and voluntary instruments, such as marketing and food labelling policies, Economic incentives or disincentives (i.e. taxation, subsidies), to promote a healthy diet; and
encourage transnational, national and local food services and catering outlets to improve the nutritional quality of their food, ensure the availability and affordability of healthy choices, and review portion size and price.
Encouraging consumer demand for healthy foods and meals:
Promote consumer awareness of a healthy diet,
Develop school policies and programmes that encourage children to adopt and maintain a healthy diet;
Educate children, adolescents and adults about nutrition and healthy dietary practices;
Encourage culinary skills, including in schools;
Support point-of-sale information, including through food labelling that ensures accurate, Standardized and comprehensible information on nutrient contents in food in line with the Codex Alimentarius Commission guidelines; and
provide nutrition and dietary counselling at primary health care facilities.
Promoting appropriate infant and young child feeding practices:
Implement the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions;
Implement policies and practices to promote protection of working mothers; and
Promote, protect and support breastfeeding in health services and the community, including through the Baby-friendly Hospital Initiative.
WHO response
The “WHO Global Strategy on Diet, Physical Activity and Health” (12) was adopted in 2004 by the World Health Assembly (WHA). It called on governments, WHO, international partners, the private sector and civil society to take action at global, regional and local levels to support healthy diets and physical activity.

In 2010, the WHA endorsed a set of recommendations on the marketing of foods and non-alcoholic beverages to children (13). These recommendations guide countries in designing new policies and improving existing ones to reduce the impact on children of the marketing of unhealthy food. WHO is also helping to develop a nutrient profile model that countries can use as a tool to implement the marketing recommendations.

In 2012, the WHA adopted a “Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition” and 6 global nutrition targets to be achieved by 2025, including the reduction of stunting, wasting and overweight in children, the improvement of breastfeeding and the reduction of anaemia and low birth weight (7).

In 2013, the WHA agreed to 9 global voluntary targets for the prevention and control of NCDs, which include a halt to the rise in diabetes and obesity and a 30% relative reduction in the intake of salt by 2025. The “Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020” (8) provides guidance and policy options for Member States, WHO and other UN agencies to achieve the targets.

With many countries now seeing a rapid rise in obesity among infants and children, in May 2014 WHO set up the Commission on Ending Childhood Obesity. The Commission is developing a report specifying which approaches and actions are likely to be most effective in different contexts around the world.

In November 2014, WHO organized, jointly with the Food and Agriculture Organization of the United Nations (FAO), the Second International Conference on Nutrition (ICN2). ICN2 adopted the Rome Declaration on Nutrition (14) and the Framework for Action (15), which recommends a set of policy options and strategies to promote diversified, safe and healthy diets at all stages of life. WHO is helping countries to implement the commitments made at ICN2.

Wednesday, February 10, 2016

Sexually Transmitted Infections

Key facts

More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide.
Each year, there are an estimated 357 million new infections with 1 of 4 STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis.
More than 500 million people are estimated to have genital infection with herpes simplex virus (HSV).
More than 290 million women have a human papillomavirus (HPV) infection.2
The majority of STIs have no symptoms or only mild symptoms that may not be recognized as an STI.
STIs such as HSV type 2 and syphilis can increase the risk of HIV acquisition.
In some cases, STIs can have serious reproductive health consequences beyond the immediate impact of the infection itself (e.g., infertility or mother-to-child transmission)
Drug resistance, especially for gonorrhoea, is a major threat to reducing the impact of STIs worldwide.

What are sexually transmitted infections and how are they transmitted?

More than 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact. Eight of these pathogens are linked to the greatest incidence of sexually transmitted disease. Of these 8 infections, 4 are currently curable: syphilis, gonorrhoea, chlamydia and trichomoniasis. The other 4 are viral infections and are incurable: hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human papillomavirus (HPV). Symptoms or disease due to the incurable viral infections can be reduced or modified through treatment.

STIs are spread predominantly by sexual contact, including vaginal, anal and oral sex. Some STIs can also be spread through non-sexual means such as via blood or blood products. Many STIs—including chlamydia, gonorrhoea, primarily hepatitis B, HIV, and syphilis—can also be transmitted from mother to child during pregnancy and childbirth.

A person can have an STI without having obvious symptoms of disease. Common symptoms of STIs include vaginal discharge, urethral discharge or burning in men, genital ulcers, and abdominal pain.

Scope of the problem

STIs have a profound impact on sexual and reproductive health worldwide.

More than 1 million STIs are acquired every day. Each year, there are estimated 357 million new infections with 1 of 4 STIs: chlamydia (131 million), gonorrhoea (78 million), syphilis (5.6 million) and trichomoniasis (143 million). More than 500 million people are living with genital HSV (herpes) infection. At any point in time, more than 290 million women have an HPV infection, one of the most common STIs.

STIs can have serious consequences beyond the immediate impact of the infection itself.

STIs like herpes and syphilis can increase the risk of HIV acquisition three-fold or more.
Mother-to-child transmission of STIs can result in stillbirth, neonatal death, low-birth-weight and prematurity, sepsis, pneumonia, neonatal conjunctivitis, and congenital deformities. Syphilis in pregnancy leads to approximately 305 000 fetal and neonatal deaths every year and leaves 215 000 infants at increased risk of dying from prematurity, low-birth-weight or congenital disease.1
HPV infection causes 528 000 cases of cervical cancer and 266 000 cervical cancer deaths each year.2
STIs such as gonorrhoea and chlamydia are major causes of pelvic inflammatory disease (PID) and infertility in women.
Prevention of STIs

Counselling and behavioural approaches
Counselling and behavioural interventions offer primary prevention against STIs (including HIV), as well as against unintended pregnancies. These include:

comprehensive sexuality education, STI and HIV pre- and post-test counseling;
safer sex/risk-reduction counselling, condom promotion;
interventions targeted at key populations, such as sex workers, men who have sex with men and people who inject drugs; and
education and counseling tailored to the needs of adolescents.
In addition, counseling can improve people’s ability to recognize the symptoms of STIs and increase the likelihood they will seek care or encourage a sexual partner to do so. Unfortunately, lack of public awareness, lack of training of health workers, and long-standing, widespread stigma around STIs remain barriers to greater and more effective use of these interventions.

Barrier methods
When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely by national programmes as male condoms.

Diagnosis of STIs

Accurate diagnostic tests for STIs are widely used in high-income countries. These are especially useful for the diagnosis of asymptomatic infections. However, in low- and middle-income countries, diagnostic tests are largely unavailable. Where testing is available, it is often expensive and geographically inaccessible; and patients often need to wait a long time (or need to return) to receive results. As a result, follow up can be impeded and care or treatment can be incomplete.

The only inexpensive, rapid tests currently available for STIs are for syphilis and HIV. The syphilis test is already in use in some resource-limited settings. The test is accurate, can provide results in 15 to 20 minutes, and is easy to use with minimal training. Rapid syphilis tests have been shown to increase the number of pregnant women tested for syphilis. However, increased efforts are still needed in most low- and middle-income countries to ensure that all pregnant women receive a syphilis test.

Several rapid tests for other STIs are under development and have the potential to improve STI diagnosis and treatment, especially in resource-limited settings.

Treatment of STIs

Effective treatment is currently available for several STIs.

Three bacterial STIs (chlamydia, gonorrhoea and syphilis) and one parasitic STI (trichomoniasis) are generally curable with existing, effective single-dose regimens of antibiotics.
For herpes and HIV, the most effective medications available are antivirals that can modulate the course of the disease, though they cannot cure the disease.
For hepatitis B, immune system modulators (interferon) and antiviral medications can help to fight the virus and slow damage to the liver.
Resistance of STIs—in particular gonorrhoea—to antibiotics has increased rapidly in recent years and has reduced treatment options. The emergence of decreased susceptibility of gonorrhoea to the “last line” treatment option (oral and injectable cephalosporins) together with antimicrobial resistance already shown to penicillins, sulphonamides, tetracyclines, quinolones and macrolides make gonorrhoea a multidrug-resistant organism. Antimicrobial resistance for other STIs, though less common, also exists, making prevention and prompt treatment critical.

STI case management
Low- and middle-income countries rely on identifying consistent, easily recognizable signs and symptoms to guide treatment, without the use of laboratory tests. This is called syndromic management. This approach, which often relies on clinical algorithms, allows health workers to diagnose a specific infection on the basis of observed syndromes (e.g., vaginal discharge, urethral discharge, genital ulcers, abdominal pain).

Syndromic management is simple, assures rapid, same-day treatment, and avoids expensive or unavailable diagnostic tests. However, this approach misses infections that do not demonstrate any syndromes - the majority of STIs globally.

Vaccines and other biomedical interventions

Safe and highly effective vaccines are available for 2 STIs: hepatitis B and HPV. These vaccines have represented major advances in STI prevention. The vaccine against hepatitis B is included in infant immunization programmes in 93% of countries and has already prevented an estimated 1.3 million deaths from chronic liver disease and cancer.

HPV vaccine is available as part of routine immunization programmes in 65 countries, most of them high- and middle-income. HPV vaccination could prevent the deaths of more than 4 million women over the next decade in low- and middle-income countries, where most cases of cervical cancer occur, if 70% vaccination coverage can be achieved.

Research to develop vaccines against herpes and HIV is advanced, with several vaccine candidates in early clinical development. Research into vaccines for chlamydia, gonorrhoea, syphilis and trichomoniasis is in earlier stages of development.

Other biomedical interventions to prevent some STIs include adult male circumcision and microbicides.

Male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60% and provides some protection against other STIs, such as herpes and HPV.
Tenofovir gel, when used as a vaginal microbicide, has had mixed results in terms of the ability to prevent HIV acquisition, but has shown some effectiveness against HSV-2.
Current efforts to contain the spread of STIs are not sufficient

Behaviour change is complex
Despite considerable efforts to identify simple interventions that can reduce risky sexual behaviour, behaviour change remains a complex challenge. Research has demonstrated the need to focus on carefully defined populations, consult extensively with the identified target populations, and involve them in design, implementation and evaluation.

Health services for screening and treatment of STIs remain weak
People seeking screening and treatment for STIs face numerous problems. These include limited resources, stigmatization, poor quality of services, and little or no follow-up of sexual partners.

In many countries, STI services are provided separately and not available in primary health care, family planning and other routine health services.
In many settings, services are often unable to provide screening for asymptomatic infections, lacking trained personnel, laboratory capacity and adequate supplies of appropriate medicines.
Marginalized populations with the highest rates of STIs—such as sex workers, men who have sex with men, people who inject drugs, prison inmates, mobile populations and adolescents—often do not have access to adequate health services.
WHO response

WHO develops global norms and standards for STI treatment and prevention, strengthens systems for surveillance and monitoring, including those for drug-resistant gonorrhoea, and leads the setting of the global research agenda on STIs.

Our work is currently guided by the Global Strategy for the Prevention and Control of Sexually Transmitted Infections: 2006-2015, adopted by the World Health Assembly in 2006, and the 2015 United Nations Global Strategy for Women's, Children's and Adolescents’ Health, which highlight the need for a comprehensive, integrated package of essential interventions, including information and services for the prevention of HIV and other sexually transmitted infections. WHO is developing 3 new 2016-2021 Global Health Sector Strategies for HIV/AIDS, Viral Hepatitis, and STIs.

WHO works with countries to:

Scale-up effective STI services including:
STI case management and counseling
syphilis testing and treatment, in particular for pregnant women
hepatitis B and HPV vaccination.
Promote strategies to enhance STI-prevention impact including:
integrate STI services into existing health systems
promote sexual health
measure the burden of STIs
monitor and respond to STI antimicrobial resistance.
Support the development of new technologies for STI prevention such as:
point-of care diagnostic tests for STIs
additional drugs for gonorrhoea
STI vaccines and other biomedical interventions.