Syphilis Technical Instructions for Civil Surgeons

Transcription

1 National Center for Emerging and Zoonotic Infectious Diseases Syphilis Technical Instructions for Civil Surgeons Joanna J. Regan, MD, MPH, FAAP Medical Officer Medical Assessment and Policy Team Immigrant, Refugee, and Migrant Health Branch Division of Global Migration and Quarantine November 14, 2018 Learning Objectives At the conclusion of this session, you should understand how to test for and treat syphilis. Syphilis Technical Instructions for Civil Surgeons 1

2 New Syphilis Technical Instructions Made changes to allowable confirmatory tests Clarified that civil surgeons must test and treat applicants for syphilis Required Physical Examination Extensive syphilis is a systemic disease and requires evaluation of External genitalia* Oral mucosa Integument Lymph nodes Neurologic system Ophthalmologic system *Only if history suggestive of syphilis, or test results positive Syphilis Technical Instructions for Civil Surgeons 2

3 Changes to Confirmatory Tests Confirmatory tests allowed in old TI TP-PA MHA-TP EIA CIA Confirmatory tests allowed in new TI TP-PA Treponema pallidum haemagglutination (TPHA) test EIA CIA Fluorescent treponemal antibody absorbed (FTA-ABS) tests Immunoblots * Rapid assays * * Must be approved by US Food and Drug Administration (FDA) Civil Surgeon Syphilis Technical Instructions Testing process (use same sample for initial and confirmatory tests): 15 years of age Negative No further testing required Screening tests * : VDRL or RPR Positive Confirmatory tests : TP-PA, TPHA, EIA, CIA, FTA- ABS, immunoblots, or rapid treponemal assays * Venereal Disease Research Laboratory (VDRL) or Rapid Plasma Reagin (RPR) T. pallidum passive particle agglutination (TP-PA) assay, Treponema pallidum haemagglutination (TPHA) test, enzyme immunoassays (EIAs), or chemiluminescence immunoassays (CIAs), fluorescent treponemal antibody absorbed (FTA-ABS) tests Syphilis Technical Instructions for Civil Surgeons 3

4 Syphilis Background: Disease Stages Primary Infection Secondary Infection Latent Infection Ulcer or chancre at the infection site Manifestations include skin rash, mucocutaneous lesions, lymphadenopathy Stage lacks clinical manifestations; detected only by serologic testing Tertiary Infection Gumma or cardiac lesions Primary and Secondary Syphilis Goals of treatment: Heal lesions Prevent transmission Prevent late sequelae Benzathine penicillin G 2.4 million units IM in a single dose UNLESS neurologic findings are present Standard benzathine penicillin product (Bicillin L-A) Do not use benzathine-procaine penicillin (Bicillin C-R) Syphilis Technical Instructions for Civil Surgeons 4

5 Latent Syphilis Seroreactivity without other evidence of disease Patients diagnosed with latent syphilis who demonstrate any of the following criteria should have a prompt central nervous system examination: Neurologic findings (e.g., auditory disease, cranial nerve dysfunction, acute or chronic meningitis, stroke, acute or chronic altered mental status, and loss of vibration sense) or ophthalmic signs or symptoms Evidence of active tertiary syphilis (e.g., aortitis, gumma) Serologic treatment failure Early Latent Syphilis Latent syphilis acquired in preceding year Must review titer, symptoms, and history to confirm early latent syphilis Evaluate for mucosal lesions and exclude primary syphilis Oral cavity, perianal area, perineum Underneath the foreskin in uncircumcised men Treatment Prevent complications Benzathine penicillin G 2.4 million units IM, single dose Syphilis Technical Instructions for Civil Surgeons 5

6 Late Latent Syphilis or Latent Syphilis of Unknown Duration Asymptomatic individuals with seroreactivity and no other evidence of disease Acquired more than 1 year ago (or unknown) Treatment Benzathine penicillin G 7.2 million units total Three doses of 2.4 million units IM each 1-week intervals Tertiary Syphilis Gumma or cardiovascular syphilis, but not all neurosyphilis If symptomatic late syphilis, CSF examination required before therapy Treatment Benzathine penicillin G 7.2 million units total Three doses of 2.4 million units IM each 1-week intervals Some providers treat all individuals who have cardiovascular syphilis with a neurosyphilis regimen Manage with an infectious disease specialist Syphilis Technical Instructions for Civil Surgeons 6

7 Neurosyphilis Can occur during any state of syphilis A CSF examination should be performed if clinical evidence of neurologic involvement is observed Cognitive dysfunction Motor or sensory deficits Ophthalmic or auditory symptoms Cranial nerve palsies Symptoms or signs of meningitis Treatment Aqueous crystalline penicillin G IV for 10 to 14 days OR Consider two-drug IM and oral treatment, if adherence can be assured Congenital Syphilis Severe, disabling, and often life-threatening A pregnant mother can spread syphilis to her unborn infant Pregnant women should receive serologic screening during the first prenatal visit Syphilis Technical Instructions for Civil Surgeons 7

8 Treatment Must Be Provided by Civil Surgeons Stage of syphilis Recommended treatment Primary or secondary Benzathine penicillin G 2.4 million units IM in a single dose Early latent Late latent Tertiary Neurosyphilis Benzathine penicillin G 2.4 million unites IM in a single dose Benzathine penicillin G 7.2 million units total - Three doses of 2.4 million units IM each - At 1-week intervals Benzathine penicillin G 7.2 million units total - Three doses of 2.4 million units IM each - At 1-week intervals Aqueous crystalline penicillin G IV for 10 to 14 days Syphilis Classifications No treatment Class A (inadmissible) Treatment Class B (with or without residual disability) Syphilis Technical Instructions for Civil Surgeons 8

9 Thank you! For more information, contact CDC CDC-INFO ( ) TTY: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Syphilis Technical Instructions for Civil Surgeons 9