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Dit rapport geeft een overzicht van de huidige stand van zaken met betrekking tot de voor de volksgezondheid belangrijkste seksueel overdraagbare aandoeningen (SOA): gonorroe, syfilis, infectie met Chlamydia trachomatis, genitale infecties met humaan papillomavirus (HPV), hepatitis B, herpes genitalis, HIV-infectie en AIDS. Er wordt ingegaan op het ziektebeeld, de microbiologie van de ziektever-wekker en de pathogenese van de aandoening. Aandacht is besteed aan de transmissie en de besmettelijkheid van de aandoeningen omdat dit een belangrijke factor is in het kader van de volksgezondheid. Ook wordt ingegaan op de therapeutische mogelijkheden die er zijn per aandoening. Met betrekking tot het voorkomen van SOA in Nederland wordt een overzicht gegeven van de in Nederland beschikbare gegevens en aandacht besteed aan de gerelateerde morbiditeit, mortaliteit en is een vergelijking gemaakt met de buitenlandse situatie. De organisatie en financiering van de bestrijding van SOA in Nederland en ontwikkelingen op dit terrein krijgen eveneens aandacht. De belangrijkste ontwikkelingen zijn in een beschouwend hoofdstuk beschreven. De trends in gonorroe en syfilis zijn de laatste jaren gestabiliseerd. Recent zijn echter verontrustende toenames gerapporteerd in verschillende steden in Europa, waaronder ook Amsterdam. Door verandering in de wetgeving is de aangifteplicht voor deze SOA vervallen, waardoor het onduidelijk is of deze trend ook landelijk zichtbaar is. Met betrekking tot chlamydia zijn er geen landelijke continue gegevens beschikbaar. Recent zijn wel diverse prevalentiestudies verricht in huisartsenpraktijken in Amsterdam. Op grond van onder meer deze gegevens is de kosteneffectiviteit van screening onderzocht. In 2001 zal de Gezondheidsraad adviseren over het landelijke beleid ten aanzien van chlamydia screening. De gegevens over HPV en herpes in Nederland zijn alleen gebaseerd op de SOA-registratie en de jaarverslagen van de SOA-poliklinieken. Voorlopige resultaten uit seroprevalentieonderzoek in een steekproef uit de Nederlandse bevolking laat zien dat gemiddeld een op de twaalf Nederlanders een HSV-2-infectie heeft doorgemaakt. Voor hepatitis B bestaat al een aantal jaren een stabiele situatie. In 2001 wordt een advies inzake de universele vaccinatie van hepatitis B door de Gezondheidsraad verwacht. Door het beschikbaar komen van de combinatietherapieen voor HIV-infecties is de klinische diagnose AIDS vervaagd en is de waarde van de AIDS-registratie beperkt. Het lijkt daarom gewenst een monitoring te ontwikkelen gebaseerd op HIV-infecties. Voor zowel SOA als HIV bestaat de uitdaging om op korte termijn een nieuw surveillance-systeem te implementeren. Een standpunt van het ministerie van VWS hierover wordt in het voorjaar van 2001 verwacht.

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A 24-year-old immune-competent woman was admitted to hospital with a three-day history of fever and headache. On examination bilateral facial nerve palsy, lumbosacral radicular pain, reduced sacral sensibility and urinary retention were found. Open perianal lesions were suspect for genital herpes. The symptoms were compatible with a meningoradiculitis including a sacral polyradiculitis. On testing, cerebrospinal fluid was found to be abnormal with a lymphocytic cell reaction. Polymerase chain reaction (PCR) of cerebrospinal fluid and of the perianal lesions was positive for herpes simplex virus type 2 (HSV-2). An MRI scan showed colouration of part of the cauda equina. The patient was treated by intravenous injections of acyclovir 10 mg/kg t.i.d. for 21 days, after which she completely recovered. HSV-2 infection of the nervous system can cause lymphocytic, and sometimes recurrent meningitis as well as sacral polyradiculitis. It may also occur without any symptomatic genital herpes infection. A positive result from a PCR test of the cerebrospinal fluid confirms this diagnosis. Treatment with acyclovir should be started as soon as possible.

The Dutch Institute for Health Care Improvement revised guideline, 'Sexually transmitted diseases and neonatal herpes' summarises the current scientific position on the diagnosis and treatment of a great number of sexually transmitted diseases (STD) and neonatal herpes. Symptomatic treatment of suspected Chlamydia trachomatis infection and gonorrhoea without previous diagnosis is not recommended. Treatment can be started immediately, once samples have been taken. Risk groups eligible for screening or proactive testing on C. trachomatis infection include: partners of C. trachomatis-positive persons, visitors of STD clinics, women who will undergo an abortion, mothers of newborns with conjunctivitis or pneumonitis, young persons of Surinam or Antillean descent, young women with new relationships and individuals whose history indicates risky sexual behaviour. A period of 3 months can be adopted between a risky contact and the HIV test (this used to be 6 months), unless post-exposure prophylaxis was used. For the treatment of early syphilis no distinction is drawn between HIV-infected and non-HIV-infected persons. It is no longer recommended that women in labour with a history of genital herpes are tested for the herpes simplex virus. Virological testing of the neonate is only advised if the mother shows signs of genital herpes during delivery.

Investigation of the incidence of neonatal herpes in the Netherlands between 1992 and 1998.Inventory questionnaire survey.All virological laboratories in the Netherlands were sent a questionnaire on the number of culture proven cases of neonatal herpes recorded between 1992 and 1998 and on the type of herpes simplex virus (HSV-1 or HSV-2). The gynaecological and paediatric departments of all university hospitals and of half of the general hospitals were sent questionnaires as well. Gynaecologists were asked how often caesarean section was performed in order to prevent neonatal herpes and how frequently pregnant women were seen with genital herpes. Paediatricians were asked how often they observed neonatal herpes, the type of HSV and the possible transmission route. Based on these data the figures for the whole of the Netherlands were estimated.The incidence of neonatal herpes in the Netherlands in the period 1992 to 1998 was 2.4 per 100,000 neonates. HSV-1 was the cause of neonatal herpes in 73%, HSV-2 in 9%, and in 18% of the cases the type of infection was not recorded. The number of pregnant women with genital herpes had increased, but, in agreement with a consensus statement, the gynaecologists hardly performed caesarean sections any more to prevent neonatal herpes (2 per year).The incidence of neonatal herpes in the Netherlands had not increased. There was no predominant role of HSV type 2 causing neonatal herpes.

To determine the incidence of sexually transmitted diseases (STDs) and to compare data reported by general practitioners (GPs) and specialists with those reported by microbiological laboratories.Retrospective.All 593 GPs and gynaecologists, dermatologists and urologists in Limburg, the Netherlands, in 1998 were asked to fill in a questionnaire about the number of cases of Chlamydia trachomatis, condylomata acuminata, genital herpes and gonorrhoea in 1997, by sex, age and diagnostic test. Data were compared with information gathered from the six laboratories of medical microbiology. For gonorrhoea the results were compared with those from a study in 1985.The response to the enquiry amounted to 75%. A total of 2730 cases were reported (32 per 10,000 of the population. Infection with C. trachomatis was the most frequent sexually transmitted disease (46%), followed by condylomata acuminata (28%), genital herpes (17%) and gonorrhoea (8%). Of the diseases 84% occurred in persons younger than 35 years of age and 66% in women. The GPs saw 79% of the STDs, they diagnosed 'gonorrhoea' in 25% of the cases merely on the basis of the clinical picture. Compared to 1985 the number of gonorrhoea cases was decimated in Limburg in 1997. Of those who answered the questions about warning the partner (approximately 50% of those concerned), 87% reported that they had let the partner know. It appears from the data of the six laboratories that the incidence of C. trachomatis infection was 3.2 and that of gonorrhoea 0.6 per 10,000 of the population. For the diagnosis of infection with C. trachomatis the GPs and specialists use a culture in 50% of the cases, as against 2% of the laboratories, for the ligase chain reaction and polymerase chain reaction tests these proportions were 20 and 78%.

In two patients, women, aged 32 and 30 years respectively, acute urinary retention after a viral infection was diagnosed. This is known as the Elsberg syndrome: urinary retention as a result of sacral myeloradiculitis. One of the patients had a blank history, the other suffered from a genital herpes infection. They were catheterised and instructed to perform catheterisation themselves. One was given an indwelling catheter. In the literature the Elsberg syndrome is mentioned relatively often after a genital herpetic infection. The treatment consists in (self)catheterisation. There may be hypesthesia in the sacral dermatomes. There is a strong tendency to recovering of spontaneous micturition in four to ten days.

Since 1981 sexually transmitted diseases (STD) diagnosed at the STD clinics of the Municipal Health Service of Amsterdam, are registered by sex, sexual orientation and prostitution. Numbers of diagnoses per 1,000 new consultations are compared for each group of visitors over the period 1981-1987. Among heterosexual visitors there has been a steady decline of gonorrhoea and trichomoniasis since 1981. Genital herpes and venereal warts after increasing until 1985 have reached a plateau. Because of the early appearance of these trends they cannot be attributed to changes in heterosexual behaviour brought about by the AIDS epidemic. Nongonococcal urethritis has been increasing since 1981, possibly due to insufficient Chlamydia trachomatis detection in the country. After several years of decline, early syphilis has been increasing since 1987 among heterosexual men and women. Among homo/bisexual men the numbers of cases of gonorrhoea and early syphilis as well as the number of consultations for STD have decreased strongly since 1984, which may well be the result of changes in homosexual behaviour because of AIDS.