A clinical audit on management of first episode of anogenital warts in Sexually Transmitted Disease (STD) clinic, Chilaw

Introduction: A clinical audit was carried out at STD clinicChilaw on management of first episode of anogenital warts . Objectives: The objective of the audit was to assess the management of patients with first episode of anogenital warts . Methods: The study population was all newly diagnosed patients with anogenital warts during 2016 in STD clinic, Chilaw (n=68) . Patient management and documentation were assessed using a standard questionnaire from British Association for Sexual Health and HIV (BASHH) national audit group . Results: All patients were managed according to the clinic protocol . First line treatment option was trichloro acetic acid for 91 % of patients . None of the patients had documentation on factors that influenced the choice of treatment or offer of a self-applied method . Documentation of the site of warts was 88% at first visit . However, documentation on extent or description of warts was zero . Only seven percent of females were offered Pap smear . Follow up review was offered and documented in 12% of patients . Outcome of the patient after 3 months was documented in 19% of patients, whereas 53% of patients were loss to follow up . None of the patients had documentation on offering information on genital warts . Condom promotion was done on three percent of patients . No patient was offered partner notification for genital warts . All patients were offered the first line treatment according to the clinic protocol . However, documentation at first visit, offering follow up visits, health education and condom promotion were poor . Therefore, training of doctors to overcome the deficits and re-auditing is recommended . Conclusions: All patients were offered the first line treatment according to the clinic protocol . However, documentation at first visit, offering follow up visits, health education and condom promotion were poor . Therefore, training of doctors to overcome the deficits and re-auditing is recommended .


Introduction
According to the annual report of the National STD/AIDS Control Program (NSACP), Sri Lanka, there have been 21,973 new patients registered in STD clinics and out of them, 11,048 new patients were diagnosed with STDs in Sri Lanka in 2016 . (1) Most common STDs in 2016 in Sri Lanka were Genital herpes, Non Gonococcal Urethritis, Genital Warts, Syphilis, Gonorrhea and Trichomonaiasis in descending order of prevalence . (1) STDs are mostly transmitted via unprotected sexual intercourse but there can be other ways of transmission as well . e .g ., via contaminated needles/ sharp instruments, blood and blood products and mother to child . Unprotected receptive anal sex is the most risky sexual practice but these diseases can be transmitted in vaginal or oral sex as well . There are several factors that contribute to transmission of STDs . Among them social factors like lack of knowledge and lack of access to affordable protective mechanisms, cultural and religious reasons, inability to negotiate with the partner for safe sex: biological factors like younger age, female gender, behavioural factors like multiple partners, regular changing of partners, injectable drug use are common contributors .
Having one STD makes a person vulnerable to acquire more STDs because the genitalia become inflamed and open up a pathway for infections . Women are at a higher risk than men as their area of genital exposure is larger than men and they usually start sexual life earlier than men .
Anogenital warts are caused by the human papilloma virus (HPV) of which over 100 genotypes have been identified . The mode of transmission is often by sexual contact but HPV may be transmitted perinatally and genital lesions resulting from transfer of infection from hand warts have been reported in children .
Anogenital warts are benign epithelial lesions and about 90% are caused by HPV types 6 or 11 . Some lesions may contain oncogenic HPV types . Oncogenic HPV types most commonly cause anogenital dysplastic lesions and cancers . Most of HPV infections are asymptomatic and resolve within one year of infection . Total number of new patients with genital warts registered in STD clinics in Sri Lanka in 2016 was 2,078 which accounted for 23% of new STD patients for the year . (1) Safe sexual practices are the best methods for prevention . Delaying sexual debut, monogamous partnership, correct and consistent use of condoms and changing from high risk penetrative sex to low risk non-penetrative sex are among them .
In Sri Lanka, NSACP is the place where prevention and treatment programs for STDs are being implemented and monitored . There is one central STD clinic in Colombo, 30 full time peripheral STD clinics and 23 branch clinics scattered in Sri Lanka to control and treat STDs .
According to the British Association for Sexual Health and HIV (BASHH) guidelines in 2015, there are many treatment options for genital warts . However, there is no strong evidence to suggest a first line treatment option for management of genital warts . Treatment choice depends on the morphology, number, distribution of warts and patients' preference .(2) NSACP has published guidelines for management of STDs . It includes treatment for current episode, health education on STDs, counseling on safe sexual practices, partner notification and treatment, condom promotion and follow up .(3)

Justification:
Puttalam district is situated in North Western province in Sri Lanka . STD clinic, Chilaw is the main clinic that manages patients with STDs in the Puttalam district .
There have been 1010 new patients registered in the STD clinic-Chilaw in 2016, of which 657 patients were diagnosed of having one or more STDs . There has been a significant rise in number of new patients registered and the number of newly diagnosed STDs in comparison with 2015 annual report . The most prevalent presentations to the STD clinic-Chilaw in 2016 were non gonococcal urethritis, genital herpes, genital warts and late syphilis .
It was noticed during the preliminary survey, that there are some gaps in management of genital warts in the STD clinic-Chilaw .
Considering these facts and that inadequate management of STDs can lead to increase in transmission of HIV, it was decided to carry out an audit on management of genital warts in STD clinic, Chilaw . To carry out an audit on management of first episode of anogenital warts in STD clinic, Chilaw .

Methods
The study population was all patients with first episode of anogenital warts presented during 2016 to STD clinic, Chilaw (n=68) . Data collection was completed during 1 st June 2017 to 30 th July 2017 by the principal investigator .
Patient management and documentation were assessed using a standard questionnaire from British Association for Sexual Health and HIV (BASHH) national audit group . (4) Secondary data was extracted from the clinical records of all patients who presented to STD clinic-Chilaw with first episode of anogenital warts during 2016 . The data extraction sheet was prepared according to the standard questionnaire .
Informed consent was obtained from the consultant and from all the medical officers who were involved in patient management in STD clinic-Chilaw . Data analysis was done using SPSS version 13 .
Assessment was done on proper documentation, cervical cytology screening, offering of treatment options, offering of follow up visits, outcome assessment, provision of health education, condom promotion and partner notification .

Background characteristics
Distribution of basic characteristics of the sample is mentioned in the table 1 .

Management for anogenital warts according to the clinic protocol /algorhythm
All the patients were managed according to the clinic management protocol . There is no customized, documented protocol for the STD clinic-Chilaw . The clinic uses the national STD guidelines as the clinic protocol which is produced by the NSACP .

Documentation of sites of anogenital warts
Documentation was satisfactory at the first episode of anogenital warts . However, some patient records did not have documentation of sites of anogenital warts .

Documentation of the extent of anogenital warts
None (0%) of the patients had documentation of the extent of anogenital warts at the management of first episode in the clinic Documenting the description of the anogenital warts. None (0%) of the patient records had the description of the anogenital warts at the management of first episode of in the clinic .

Offering pap smear for female patients with anogenital warts
There were 27 female patients in the audit . However, only two (02) patients were offered pap smear at the first episode .

Treatment options offered
In STD clinic-Chilaw, there are limited options for the treatment of anogenital warts . The clinic has 70% Tri-Chloro Acetic Acid (TCA), 90% TCA and podophillin . Therefore the treatment options are limited to these three methods of treatment . Documentation of factors influenced the choice of treatment -None (0%) of the patient records had documentation regarding the factors that influenced the choice of treatment at the first episode of treatment .
Offering self-applied treatment -None (0%) of the patient records had documentation regarding offering self-applied treatment .
Offering a clinic review-Offering a clinic review is very important to assess the treatment response and to repeat treatment if necessary . However, documented evidence of offering a clinic review was very poor . Time scale for follow up -Out of those who were offered the follow up, most were offered a follow up within one month after the first consultation .

Documentation of outcomes after three months
Documentation of outcomes after three months from the first visit was assessed . Most of the patients were lost to follow up after three months whereas some were referred to other clinics for further follow up . Offering information regarding anogenital warts-There was no documentation on offering information to the patient on anogenital warts in the clinic .
Advice regarding the use of condom -Documentary evidence of condom promotion was found only in two (02) patient records out of 68 patient records (3%) Offering partner notification -None (0%) of the patient records had documentation on offering partner notification .

Discussion
Management of patients with anogenital warts were done according to the National STD guidelines with the available limited resources at the STD clinic-Chilaw . However, the documentation is not satisfactory in most of the aspects in the holistic patient management .

Conclusions
Management of patients with first episode of anogenital warts in the clinic was done according to the clinic protocol . Frequency of offering treatment options with the available facilities is also high . However, documentation on the assessment, management and follow up are not up to a satisfactory level . Patient education and promotion of safe sexual practices are also not satisfactory .
Considering all above factors, more training programs on management of STIs with proper documentation and patient education is recommended . It should be followed by re-auditing the above components .