'There can scarcely be anyone in the country who is not aware of the routes of transmission, signs and symptoms of this infection. Most importantly, the public are aware of the measures necessary to prevent its spread."
This is an extract of a letter which appeared in The Irish Times recently, and given that its author, Dr Louise Pomeroy, is a genito-urinary physician, you could have assumed that she was referring to sexually transmitted infections.
You would have been wrong. Dr Pomeroy was considering the success of the mass media campaign mounted to alert people to foot-and-mouth disease, which created a high level of public awareness and led to necessary attitudinal and behaviour changes. The aim of her letter was to contrast this with the relatively low level of national awareness regarding sexually transmitted infections (STIs) at a time when clinics throughout the country are reporting a significant and alarming increase in such conditions.
She is a consultant working in Dublin, and sees in her own practice the evidence of an infection increase among women and men of all ages, but specifically in the 20-30 age group.
"It came to me forcibly that in a few weeks there was a high level of knowledge and awareness about foot-and-mouth and the mode of transmission among the general public, compared to the poor knowledge of sexually transmitted infections. The contrast was really striking."
She also contrasts general awareness of the risk of pregnancy with complacency regarding STIs. "The Pill will not protect against STIs. Nor does oral sex protect against STIs. Oral sex is not safe sex, it poses less of a risk, but it can cause sexually transmitted infections.
"I wrote the letter from the heart. The Government did a good job so quickly, with the economy depending on their getting it right. But the health of our young people is one of our greatest assets, what about that?"
Last week, the National Disease Surveillance Centre posted the STI figures for 2000 on its website (see graphic). Specifically, the increase has been in genital warts, in chlamydia gonorrhoea and in syphilis among gay men living in Dublin and Cork.
Sexually transmitted infections are passed through intimate sexual contact, both heterosexual and homosexual, including intercourse and oral sex. It is relatively easy for bacteria to gain a foothold and thrive in the moist, warm genital environment.
"All STIs should be taken seriously because many are asymptomatic, and if untreated can severely affect morbidity, sexual relationships and quality of life," says the director of the National Disease Surveillance Center, Dr Mary Cronin. "For example, chlamydia is a bacterial infection known as the silent sexual disease, as there may be no symptoms.
"According to reliable UK research, one in three people, men and women, with untreated chlamydia will develop pelvic inflammatory disease (PID), and one in five of those with PID will be infertile. So chlamydia is a real worry where young people are concerned."
Gonorrhoea, a bacterial infection caused by bacteria in the genital tract, may be found in conjunction with chlamydia, showing itself via a discharge, sores or pain on urination - or it may also be asymptomatic.
Genital warts, affecting both women and men, are caused by a viral infection. This condition too may be silent, or people may suddenly find the warts growing around their genital areas. "The warts are essentially a skin infection, but infections in this area can be traumatic and distressing," says Dr Pomeroy. Other types of this virus are associated with the later development of cervical cancer.
Syphilis can show itself as a painless sore in the genital region, and in pain in passing water, with indications developing in some cases into an itchy body rash, mouth sores and flu-like symptoms. Untreated syphilis can cause damage to the heart, lungs, eyes and nervous system in the long-term. Other STIs include genital herpes and pubic lice.
The good news about most STIs, however, is that they are eminently treatable by antibiotics. "Short courses of antibiotics can effectively treat bacterial STIs," Dr Pomeroy asserts. "Genital warts can take longer. You may get rid of them through the use of local creams or, if more intractable, by treating with laser or cauterisation."
Prevention is obviously better than cure, she continues. "Condoms offer high protection if used at the right time and in the right way. I liken it to the fact that, even with using a seat belt, there can still be a collision, but your chances of injury are greatly reduced."
The need for STIs to be treated early if serious consequences are to be avoided places current low awareness levels in a particularly worrying light. Of significant concern also is the well-documented association between the presence of STI and HIV transmission. "Increasing levels of STI and HIV transmission. "Insexually active population, combined with a poor level of awareness, create the conditions in which a sudden and rapid increase in HIV infection could occur," says Dr Pomeroy.
More than 2,500 Irish people have contracted HIV, and the official HIV figures published in mid-May were the highest on record: a jump of 342 new cases last year compared with an increase of 209 cases in 1999, itself the highest to date. "The statistics are worrying, and early figures this year show the increase in new HIV cases is continuing," says Dr Cronin. The biggest increase is among heterosexuals, with 125 new cases in 2000, compared to 59 in 1999 and 74 in 1998, and with seven out of 10 in the 20-40 age group.
"STIs are not new, they've been around since Adam was a boy," remarks Dr Sheila Jones, medical director of the Irish Family Planning Association. "The difference today is that far more people are sexually active, we have a huge young population, they are travelling abroad, using alcohol - which can affect judgment - also, our detection rates are better.
"A lot of people are aware of the need for responsible sex and use both Pill and condom. On the other hand, we get people where the thought of an STD never enters their head. They don't think they are at risk because they associate an STD with promiscuity, with drug users, with holidaying in Greece, with being gay, and they don't feel they fit into that category. But they may fit right in. Young people have their own definition of going steady, it can be as short as six months. A young person can have 2-3 partners a year, placing themselves at risk."
A straw poll of some mid-20-year-olds seems to confirm her view. "We are all aware of STDs but not very concerned," sums up Rory, a 26-year-old, accompanied by nods from his friends of both sexes sitting in the sunshine outside a pub.
Dr Pomeroy agrees that concern about catching a sexually transmitted infection is not high on people's agenda when setting off for a night out. "I would like it to be more of an issue, resulting in people using condoms if they are sexually active. You might also consider having a decreased number of partners, just being more aware of the possible consequences of your actions, and going for STI screening if you feel your behaviour may have put you at risk.
"We have STI clinics throughout the country offering screening," echoes Dr Cronin. "Some are attached to hospitals, others offer a community public health service. They are confidential, discreet and non-judgmental, and free. We are also considering a screening programme for chlamydia geared to young women at GP level."
Last November, the Department of Health launched a cleverly-worded PR campaign called Think Twice, designed to encourage people to pause and consider before plunging into thoughtless sex, and to use two methods - barrier and Pill - to protect both against pregnancy and STDs.
This led to an information pack for GPs and pharmacies. Last month, a series of health board workshops was held round the country, involving social partners concerned with sexual health, such as employers and trade unions.
A Department spokesperson says it now awaits the report from the consultants who organised the workshops, which will help the Health Promotion Unit decide on the next public awareness approach to take.
So how do you sell safe sex? Health professionals agree that such campaigns are difficult to put across because they can seem dull or censorious. The safe-sex message in late 1980s turned a lot of people off, and many of the young movers and shakers now needing to be reached were not even born then.
"Mass media campaigns will raise awareness," says Dr Cronin, "but research has shown that information alone does not change behaviour. You need to segment the public and give culturally appropriate messages to each target group. We plan to introduce a new monitoring system next month which will give much greater detail on new cases of the HIV virus. This should help a targeted campaign. The sexually active 20-30-year-olds are the most difficult to reach because they are not necessarily in touch with services."
A public health campaign to lower the risk of STDs will also have the knock-on effect of lowering incidence of HIV spread. Uganda is a good example of this, says Dr Pomeroy. Its decision to tackle STDs very actively has led to a decrease in new cases of HIV. The publicity needs to be ongoing with lots of different approaches."
Dr Jones favours a direct, inclusive response. "Any public awareness campaign must get over the message that anyone who is having sex is at risk. If you sleep with someone, you sleep with everyone they've ever slept with. This is not a very romantic message. We have a genital wart epidemic at the moment, and it's not an easy thing to ask a new partner if they have genital warts, or ever had them.
"It should be a mass media campaign. It's no longer good enough to put up signs on toilet doors, it makes it sleazy. Would we have handled a measles epidemic in the same way? We wouldn't do it with any other infection, and we did it with this because it is sexual. It's because of our own baggage. We need to demystify and destigmatise STIs because they can happen to anyone.
"We also need to give information about the clinics. People can self-refer, and all records are kept separate. So if, for example, you get treatment at a hospital STD clinic, and some years later present with appendicitis, say, your STD files won't come up. The clinics are as user friendly as possible, which is the way it should be."
The National Disease Surveillance Centre website is at: www.ndsc.ie