Syphilis on the Rise in MN: Who Should Be Concerned and Why

Transcription

1 Syphilis on the Rise in MN: Who Should Be Concerned and Why MARRCH Conference, 10/31/2017 Candy Hadsall, RN, MA STD Prevention Nurse Specialist Minnesota Department of Health STD/HIV and TB Section STD/HIV and TB Section

2 What We ll Cover Sexual Health STD Facts, Categories Epidemiology of syphilis, chlamydia, gonorrhea in MN Syphilis Basics Messages to Give Clients Risk Assessments Referrals

3 What is Sexual Health? Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. World Health Organization 2002

4 Context of Sexuality in Life Sexuality influences all parts of life Sex is important for continuation of species Desire for sex: unique to humans Sex feels good so people will do it Talking about sex: personal, intimate, and difficult to talk about especially in sexnegative society

5 Context (cont) Disease prevention is only one part of sexual health Discuss positives aspects, don t focus on negatives only Remember to acknowledge pleasure Clients may remember what you say years later and you won t know

6 Determinants of Sexual Health Source: Amended from Zubrick et al (2008), Solar & Irwin (2007), Scottish Executive (2003) Socioeconomic, political, and cultural context e.g. Policy, gender norms, faith, culture, ethnicity, norms and values Health Care Distal social environment e.g. Neighborhood, community, school, work, faith group Proximal social and sexual networks e.g. Sexual partner(s), family, peers, teachers Individual characteristics e.g. Biology, social skills, cognitive ability, knowledge, attitudes, confidence, competence Characteristics Physical Cognitive Behavioral Emotional Social Sexual Health and Wellbeing Outcomes Emotional Reproduction Disease (avoidance) Violence (avoidance) Conception Adulthood

7 Sex, Sexuality, Silence, Treatment and Recovery Do you talk with clients about sexuality and sexual health during treatment and/or recovery?

8 Sexually Transmitted Diseases

9 STD Basic Facts Are almost always spread from person to person by sexual intercourse, and Are spread most commonly by anal or vaginal intercourse but also through oral sex. Some STDs, such as hepatitis B or HIV infection, are also transmitted through blood-to-blood contact, sharing of needles or equipment to inject drugs, body piercing or tattoo. Pregnant women may pass infections to infants during pregnancy/birth or through breast feeding.

10 STDs Discriminate Transmission easier male to female than reverse More women asymptomatic or with atypical, nonspecific symptoms: delayed care CT=75% asymp (F), 40% asymp (M) Diagnosis more difficult in women no symptoms, don t seek care, don t get treated Complications more frequent in women, often severe/permanent

11 Categories of STDs Bacterial - cured with antibiotics Chlamydia Gonorrhea Syphilis Chancroid NGU - Nongonoccal urethritis (various organisms other than CT or GC)

12 Categories (cont) Viral - no cure for most, treat symptoms Herpes HPV (Genital warts) HIV Hepatitis Hepatitis C now curable

13 Other: Categories (cont) Pubic lice ( crabs ) - by crab louse Scabies - by mite Vaginitis - Trichomonas Yeast Bacterial vaginosis (usually gardenerella)

14 Screening and Treatment for STDs

15 Screening for STDs Screening = test performed based on risk behaviors, not symptoms, to check to see if disease is present Tests are disease-specific Not all diseases are included in Routine testing/screening UNLESS client specifically requests or risk assessment warrants Examples: herpes, warts viruses, syphilis No publicly funded programs in MN offer herpes, HPV blood testing

16 Rates of Screening are Low Shame, stigma, secrecy Believe STD symptoms should be severe May attribute symptoms to other causes May wait for symptoms to disappear Fear/distrust of medical system Embarrassed/afraid to talk to partners Reluctant to discuss drug use/history (part of risk assessment)

17 Treatment Bacterial Antibiotics - oral and IM Viral No cure for any disease other than Hep C, treat symptoms Vaccinations for Hep A & B, HPV Other Oral, topical, intravaginal meds

18 STDs in Minnesota Surveillance Data

19 2016 STDs in Minnesota: Number of Cases Reported Total of 28,631 STD cases reported to MDH in 2016: 22,675 Chlamydia cases 14,451 cases in year olds 5,104 Gonorrhea cases 852 Syphilis cases (all stages) 0 Chancroid cases 290 HIV cases (not part of 28,631) Data Source: Minnesota STD Surveillance System 2016 STDs in Minnesota: Annual Review

20 Rate of Chlamydia and Gonorrhea * P&S = Primary and Secondary STDs in Minnesota Rate per 100,000 by Year of Diagnosis, Chlamydia Gonorrhea P&S* Syphilis Year Rate of P&S Syphilis

21 Summary of 2016 STD Trends in MN Resurgence of syphilis over past decade in MN, with MSM and HIV + men especially impacted. Between 2015 and 2016, early syphilis cases increased by 29%. Number of cases in females = near record high for last decade. Epidemic of chlamydia over 22,000 cases in Numbers evenly distributed across Twin Cities, suburbs, Gr MN Especially impacted: females under age 24 Gonorrhea also growing, especially in Twin Cities concern about antibiotic resistance Persons of color continue to be disproportionately affected by STDs

22 CHLAMYDIA AND GONORRHEA Minnesota Department of Health STD Surveillance System STD/HIV/TBSection

23 25-34 yrs 13% CT Disproportionately Impacts Youth MN Population in 2010 Chlamydia Cases in 2016 (n = 5,303,925) (n = 22,675) 35+ yrs 53% yrs 18% yrs 15% yrs 14% <15 yrs 20% yrs 64% <15 yrs 1% 45+ yrs 2%

24 25-34 yrs 13% GC Disproportionately Impacts Youth MN Population in 2010 (n = 5,303,925) 35+ yrs 53% Gonorrhea Cases in yrs 22% (n = 5,104) yrs 24% 45+ yrs 7% yrs 14% <15 yrs 20% yrs 46% <15 yrs 1%

25 Age-Specific CT Rates by Gender, Males Females Rate per 100,000 persons Age in Years

26 Age-Specific Gonorrhea Rates by Gender Minnesota, 2016 Males Females RATE PER 100,000 PERSONS AGE IN YEARS

27 Chlamydia Facts 80-85% of cases in females are asymptomatic, 50-90% of cases in males are asymptomatic If don t have symptoms = think no problem Don t get screened = delayed treatment Develop serious complications Chlamydia = leading preventable cause of tubal infertility

28 Chlamydia Complications Untreated Genital Chlamydial Infection 70%-80% Asymptomatic Female Urethritis >50% Asymptomatic Male Urethritis Neonatal Infection Chronic Pelvic Pain 18% 20-50% PID (Acute & Silent) 14-20% Infertility 9% Ectopic Pregnancy Epididymitis Orchitis Source: CDC Chlamydia in the United States. April 2001

29 Chlamydia Rates in Minnesota, Projected to 2018 Rate per 100,000 Year

30 CDC Chlamydia and Gonorrhea Screening Recommendations Sexually active women 25 years and younger yearly Women above age 25 years if at risk: new partner or multiple partners, known contact Re-screen women with CT infection 3-4 months after treatment to screen for reinfection (not because medication didn t work) Routine screening of males not recommended for CT; base on risk, special settings Screen MSM all ages; swabs from multiple sites

31 TREATMENT

32 2015 Recommended Treatment of Chlamydia Azithromycin 1 g orally, single dose (preferred) Or Doxycycline 100 mg bid x 7 days No sex for 7 days after completing treatment

33 2015 Recommended Treatment for Gonorrhea Ceftriaxone 250 mg IM, single dose PLUS Azithromycin 1 g orally No sex for 7 days after completing treatment See CDC Treatment Guidelines for treatment of oral GC

34 PARTNER TREATMENT Expedited Partner Therapy

35 What is Expedited Partner Therapy (EPT)? Treatment of sexual partners without clinic visit or being seen by provider One form of EPT = Patient Delivered Partner Therapy (PDPT): Delivery of prescription or medication by original patient to her/his partner(s) Legal in MN in 2008

36 When to Use EPT EPT should be used when: Patient + for CT, GC and Partner(s) unlikely to seek care Other management options are impractical or unsuccessful Not for MSM, pregnant partners of males Clinical evaluation of partner still #1 choice

37 SYPHILIS

38 Kittson Roseau Marshall Pennington RedLake Polk Norman Mahnomen Clearwater Lake of the Woods Beltrami Koochiching Itasca St.Louis Lake Cook 2016 Minnesota Primary & Secondary Syphilis Rates by County Hubbard Clay Becker Cass CrowWing Wadena Aitkin Carlton Wilkin OtterTail Traverse Big Stone Todd Grant Douglas Morrison Stevens Benton Pope Stearns Sherburne Swift Anoka Kandiyohi Wright Chippewa Meeker Pine Kanabec Isanti Lac quiparle Hennepin Ramsey McLeod Carver YellowMedicine Renville Dakota Scott Sibley Lincoln Lyon Redwood Goodhue Nicollet Le Sueur Rice Wabasha Brown Pipestone Murray Cottonwood Steele Dodge Olmsted Watonwan Blue Earth Waseca Mille Lacs Chisago Washington Winona Rate per 100,000 persons > 9.2 City of Minneapolis City of St. Paul Suburban # Greater Minnesota 33.7 (129 cases) 8.1 (23 cases) 3.1 (68 cases) 1.1 (26 cases) # 7-county metro area, excluding the cities of Minneapolis and St.Paul Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston

39 Number of Early Syphilis Cases by Gender Minnesota, All Male MSM Women 468 Number of Cases Year MSM=Men who have sex with men. Figure does not include cases diagnosed in transgender persons (1 each in 2005, 2007, 2009, 4 in 2013, 1 in 2014, 2 in 2015). Early Syphilis includes primary, secondary, and early latent stages of syphilis.

40 Characteristics of Early Syphilis Cases Among MSM, Minnesota, 2016 Gay and bisexual men account for 77% of cases among men. 62% of cases among MSM are White, but a disproportionate number of cases (17%) are African American. 44% of cases are also infected with HIV. MSM=Men who have sex with men Early Syphilis includes primary, secondary, and early latent stages of syphilis.

41 2017 Syphilis Outbreak 49 cases, all but 4 within same social/sexual network; all treated Specific geographic area, ethnic group Common: drug use- especially heroin, methamphetamine, prescription opiates Male & female 6 pregnant Co-infections with hepatitis C; no HIV

42 Syphilis Increase in Women in Minnesota

43 Female Early Syphilis Cases Number of Cases Year

44 Congenital Syphilis In MN 2 cases of congenital syphilis reported to MDH 2015, 6 cases in 2016, no cases so far in 2017 No reported cases in 4 years prior to 2015 Consequence of untreated syphilis in pregnant women includes congenital syphilis, stillbirth and irreversible effects on the newborn. Congenital syphilis can be severe and life threatening. MDH - new perinatal screening guidelines in 2016: All pregnant females should be screened for syphilis at first prenatal visit, 28 weeks gestation (at minimum weeks), and at delivery.

45 2016 MN Syphilis Screening Guidelines for Pregnant Women Test ALL pregnant women at: First prenatal visit 28 weeks gestation (at minimum weeks) Delivery Test any woman w/fetal death after 20 weeks Test, tx sex partners of patients who test positive Peds: check mother s results on all births. Complete sexual history including risk factors Report cases within 24 hours to MDH

46 Basics of Syphilis (the great imitator)

47 Caused by bacterium, Treponema pallidum Transmission: Basics of Syphilis Skin-to-skin contact with primary chancre or moist mucosal patches (2 nd stage) Oral, vaginal, and/or anal sex Perinatal transmission can occur at any point during pregnancy and at any stage of infection

48 Complications: Stages of Syphilis PRIMARY Painless chancre, appears days after exposure (average 21 days) on site of exposure to infectious lesion, highly infectious, resolves without treatment SECONDARY 3-6 weeks after primary chancre, usually flat, painless rash on palms/soles (palmar-plantar), may often include swollen lymph nodes, alopecia, and moist mucosal patches in mouth/genitals (highly infectious) LATENT: asymptomatic Early latent: Duration <1 year (negative test, confirmed exposure) Late latent: Duration > 1 year (negative test, confirmed exposure)

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50 3 rd Stage Complications (cont) 70% of untreated patients remain asymptomatic 30% of untreated patients progress to tertiary stage in 5-20 years Gummas: destruction of soft tissue, cartilage, internal organs and bone Cardiovascular involvement: aortic aneurysm, aortic insufficiency Central nervous system involvement: memory loss, vision issues, unsteady gate, hearing loss Neurological involvement Neuro-involvement can occur at any stage of disease Diagnosed with a Lumbar puncture Increasing diagnosis of ocular syphilis

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53 Syphilis Testing and Treatment

54 Syphilis : Diagnosis Evaluation for syphilis includes multiple factors: Serologic evaluation: Reactive screening and confirmatory blood tests, with quantitative values to monitor treatment response History: History of prior infection & treatment Signs or symptoms recently or in the past? Clinical presentation: Complete examination for signs of disease- care not to miss subtle findings that could misclassify stage of infection Identifying T. pallidum in lesions or tissue

55 Screening Tests Traditional sequence - still recommended by CDC: Nontreponemal test (RPR/VDRL) followed by testing of blood with+ results w/treponemal test Reverse sequence: Treponemal test (EIA/CIA) first, followed by nontreponemal testing of reactive specimens. Can result in differing results need 3 rd test Always confirm the initial screening test. 2 out of 3 reactive tests needed to rule out false positive.

56 Diagnosis, Treatment, Management Test: RPR or rapid; confirm w/blood test. Tests measure antibodies. Treat: penicillin (doses vary depending on stage of disease) Management: Blood test at intervals (6 & 12 months), depending on 1) client compliance, 2) stage of disease, and 3) HIV status. See more details in Resource slides

57 QUESTIONS, COMMENTS

58 HIV PREVENTION Screening PrEP

59 HIV Screening Recommendations All patients aged years at least once in all health care settings Patients who report high risk behaviors Preliminary positive test must be followed by additional test to confirm diagnosis

60 What is PrEP? Pre-Exposure Prophylaxis is: Risk reduction strategy HIV prevention For HIV negative people at high risk for HIV MSM, transgender, sex workers, others Taking HIV medication Truvada - daily HIV, STD testing at every visit at least q 3 mos; also preg Covered by most insurance plans Safe and effective in trials A way for discordant couples to preserve the relationship while safeguarding health.

61 More Information prep/

62 PARTNER SERVICES IN GREATER MN

63 Following Patients and Partners MDH receives case report forms that ID people untreated or contacts for positives Disease Investigators (DIS) talk to these people, get them treated when necessary, help tell partners All cases of pregnant, untreated CT and all untreated GC All cases of syphilis, HIV Tim Heymans (MDH) covers Greater MN ( ) IDEPC field epidemiologists will assist Tim and interview new cases, contacts

64 Confidentiality Privacy is a cornerstone of the Partner Services program Original patient identity is not revealed to partners People reached discretely and identities verified

65 What a DIS Says to Another Person Basic example of a call or field visit: Hello. I m calling for. If the person is not in: How I can reach her today? (conversation begins ) May I leave a message? Please have her call Tim regarding an important personal matter.

66 How Counselors Can Help Tell clients to get tested, treated if necessary If +, urge to contact partners If they decline, call Partner Services for help Let syphilis, HIV, co-infected patients know Disease Interventionist (DIS) will contact them; info confidential Encourage them to cooperate If DIS calls treatment center, is not HIPPA violation to disclose presence. Contact is necessary to stop spread

67 If you have questions: Partner Services Supervisor Contact Information:

68 COUNSELING CLIENTS

69 Cognitive skills - What to ask - How to respond Interactive skills Skills Needed - Non-judgmental, empathetic, supportive, communicative Affective beliefs - Trust in value of doing history - Not embarrassed/angered by patient response

70 General Considerations Recognize client s anxiety Make no assumptions based on appearance, behavior, or prior knowledge Start with general, non-threatening questions Exhibit confidence, acknowledge what you don t know and offer to get answers Account for cultural differences and make adjustments as necessary If interpreter is needed, try to use someone not related to client

71 Considerations (cont) Employ good boundaries, ethical guidelines Ask ALL clients about gender, number of partners, orientation; use gender neutral language Ask about specific sexual practices. Be explicit and clarify definitions/explanations Trust your gut instincts about answers Ask further probing questions if uncertain Keep discussion appropriate to individual s developmental level.

72 Purpose of Risk Assessment Guides discussion to assess risk for STIs Allows clinicians to diagnose and screen for STI/HIV Allows patient/client to express concerns and ask questions In CD setting: can ID problematic sexual and/or relationship issues Provides education re: risk behaviors Enables appropriate referrals

73 Definition of Risk Assessment Gather specific details regarding on-going or recent risk factors related to partners, sexual behaviors/activities Clinicians use to determine who needs to be screened Requires counselor/clinician to ask personal questions about sex/sexuality Models exist for clinics;?? CD counseling??

74 Possible Barriers for Counselors/Providers Discomfort discussing sexual topics Feel awkward using sexual language Lack of knowledge/understanding Anxiety about responses Fear of offending patient/client Fear of identifying with patient s issue or experience Belief in motivation by fear Fear actually has only short-term affect

75 Keys to Success: Education, Training Get comfortable talking about sex Be familiar with content, sexual language, slang Personal experience may be helpful but insufficient and/or inappropriate to share Refresh counseling skills as they apply to asking questions about sexuality Know own beliefs, values, biases re: sexuality Be open to hearing different ideas If new at asking sexual questions, observe others, practice, role play with experienced staff, get feedback

76 MESSAGES FOR CLIENTS SPECIFIC TO SYPHILIS

77 Messages for Clients While typical syphilis symptoms include sores and a rash, screening is the only way to detect the infection, because symptoms can be small/unnoticeable or hidden in the body (for receptive partners) Additionally, some people may have no symptoms at all screening is a must. Condoms are great, but not 100% effective, because syphilis is spread through skin-to-skin contact

78 Syphilis Take-Home Points Syphilis = easily treatable, but very serious; needs case mgmt Many symptoms not obviously STD Traditionally, syphilis in Minnesota was primarily an issue for men who have sex with men, but increasing heterosexual transmission (including pregnant women) Rapid testing will only tell you if a person has ever had syphilis, so ideal for populations without much history Mandated reporting helps us control syphilis Partner services always available to help stop the spread of infection within sexual networks

79 Messages for Clients Educate, counsel people at risk on how to avoid STDs by changing their behavior Reduce number of partners Use condoms Get screened Counsel sex partners of infected persons to get tested Encourage people at risk for vaccine-preventable STDs to get vaccinated (HPV, Hepatitis A and B)

80 Bottom Line- What You Can Do Remember - Majority of people with STDs HAVE NO SYMPTOMS!! Encourage clients (especially teens and young adults) to get risk assessment and be tested Encourage sexual health goal on client treatment plans Tell clients to be truthful on risk assessments Reinforce information is confidential Tell clients urine specimen for CT/GC test is NOT a test for drugs Help infected persons and partners deal with shame, denial, anger, blame, avoidance Inform of syringe exchange locations, overdose prevention

81 Discussion Questions: How do you address sexuality with clients in your settings? Where are you referring your clients for sexual health needs (including STD testing)??

82 Contact Information Candy Hadsall, RN, MA Prevention Nurse Specialist

83 RESOURCES

84 Examples of Risk Assessments MDH: ment/hivstdhepriskassessmenttool.pdf RAAPS: : info@raaps.org HEADSS: EADSS.pdf California Adolescent Sexual Health Toolkit: STD-Sexual-risk-assessment-and-STD-risk-factors.pdf

85 SYPHILIS TESTING AND TREATMENT

86 Syphilis : Diagnosis Evaluation for syphilis includes multiple factors: Serologic evaluation: Reactive screening and confirmatory serologies, with quantitative values to monitor treatment response History: History of prior infection & treatment Signs or symptoms recently or in the past? Clinical presentation: Complete examination for signs of disease- don t miss subtle findings that could misclassify stage of infection Identifying T. pallidum in lesions or tissue

87 Screening Tests Traditional (RPR/VDRL - still recommended by CDC): Nontreponemal test followed by testing of reactive sera w/treponemal test Reverse sequence: Treponemal test (EIA/CIA) first, followed by nontreponemal testing of reactive specimens. Can result in ID of discordant sera reactive w/treponemal but non-reactive with nontreponemal test Always confirm the initial screening test. 2 out of 3 reactive tests needed to rule out false positive.

88 8 8 Serologic Evaluation: Tests done? RPR, VDRL = non-treponemal tests used for initial screening, or to confirm EIA screening tests. Testing required to rule out biological false positive. TP-PA = most common second treponemal test used in the new testing algorithm. EIA: treponemal test now used for screening, but needs to be confirmed with a non-treponemal test. Always confirm the initial screening test. 2 out of 3 reactive tests needed to rule out false positive.

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90 9 0 Managing Reactive Serologic Tests If confirmatory test is positive, establish whether patient has a history of prior infection/ treatment If H/O prior tx, and low titer, no treatment should be required. If NO H/O prior dx and tx, no clinical findings indicating new disease, and no negative serology in the preceding 12 months, rule out neurological symptoms and treat for late latent disease. Check with DIS staff to locate prior documentation of tx; help with staging disease

91 9 1 Staging of Latent Syphilis- New or Old? Early Latent: Infected less than one year - NEW Negative syphilis serology in past year Known contact to an early case of syphilis Good history of typical signs/symptoms Late Latent duration) (infected > 1 year or unknown No syphilis serology in past year No contact to syphilis case or history of signs/symptoms in past year

92 THE COURSE OF SYPHILIS STS T I T E R Effective Contact Transmission is a lesion to skin affair. Incubation Days (Average 21 days) Incubation: No signs or symptoms, STS nonreactive. Primary Duration 1 5 Weeks (Average 21 days) STS may be nonreactive for a week or longer after appearance of chancre, then becoming reactive. Period of Latency 0 10 weeks (Average 4 weeks) Period of latency. No signs or symptoms. STS reactive. 1/3 of patients have no period of latency. Secondary Duration 2 6 weeks (Average 4 weeks) Secondary eruption may vary greatly in appearance and may or may not be conspicuous 20-25% of patients will have minimal or atypical lesions. STS reactive. Early Latent Early latency: for purposes of epidemiology, under one year s duration. History of probable primary or secondary manifestations. STS reactive. Secondary Relapse Secondary relapse: up to 1/3 patients will relapse, most within the first year of infection. 5-10% will have a second relapse. 1% a third relapse. RPR EXPOSURE INCUBATION PRIMARY LATENCY SECONDARY LATENCY SECONDARY RELAPSE Late Latent (1 year +) No signs or symptoms. Spinal fluid is negative. Rarely communicable, except in pregnant women. STS reactive. Over 2 years duration. Late (years later) Signs and symptoms range from none apparent to those indicating severe damage to one or more body systems. STS usually reactive, but may be nonreactive.

93 Treatment for Syphilis Early Syphilis (primary, secondary, early-latent) Benzathine PCN G 2.4 million units IM, 2 injections at same time Alternative Therapies: Tetracycline 500 mg po QID x 14 days Ceftriaxone 1 gm IM/IV QD x 8-10 days Late Syphilis or unknown duration Benzathine PCN G 7.2 million units, administered as 3 doses of 2.4 million units IM, at 1 week intervals Neurological involvement million units daily, administered as 3-4 million units IV q 4 hours x days

94 Managing Patients Allergic to Penicillin No proven alternatives to penicillin available to treat neurosyphilis, congenital syphilis, syphilis in pregnant women. Non-Pregnant: Doxycycline 100 mg po BID x 14 days or Tetracycline 500 mg po QID x 14 days Pregnant women: must be desensitized first Then: Benzathine PCN G 2.4 million units IM once