BURNING & SQUIRMING WHAT S NEW IN SEXUALLY TRANSMITTED INFECTIONS

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1 BURNING & SQUIRMING WHAT S NEW IN SEXUALLY TRANSMITTED INFECTIONS Dr. Joss Reimer MD MPH FRCPC Medical Officer of Health, WRHA & Manitoba Health Assistant Professor, Departments of Community Health Sciences and Family Medicine, University of Manitoba

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3 None to declare Conflict of Interest

4 Syphilis Treponema Pallidum s.p.p. pallidum

5 Syphilis the Basics Direct (sexual) contact; blood transfusion; perinatal Stages Primary Secondary Incubating Early latent Late latent Tertiary Congenital

6 Primary Syphilis ID 2353 S Lindsley CDC Public Health Image Library Painless Chancre ID 3499 CDC Public Health Image Library ID 6739 G Hart; NJ. Fiumara CDC Public Health Image Library

7 Secondary Syphilis Rash: Anything except vesicular Self-Learning Module on Sexually Transmitted Diseases, Public Health Agency of Canada Boehringer-Ingelheim

8 Secondary Syphilis Alopecia Rash: Often on palms/soles Picture courtesy of John Embil

9 Secondary Syphilis Condylomata lata (Syphilis) Condylomata acuminata (HPV) ID S Lindsley 1971 CDC Public Health Image Library

10 Adapted from: Peeling, R. Diagnostic tolls for preventing and managing maternal and congenital syphilis: an overview Bull World Health Org vol.82 n Serology CMIA TPPA Specific Abs Nonspecific Abs

11 Problems with RPR/VDRL as a Screen 102 Biologic False Positives Mycoplasma Relapsing fever Leptospirosis Rickettsia Lyme disease Tuberculosis Subacute bacterial endocarditis Syphilis Protocol CDC Protocols Manitoba Health Healthy Living and Seniors, 2010

12 Serology Testing Algorithm Treponemal Test (CMIA) No current or previous treponemal infection Nonreactive Reactive Non Treponemal Test (VDRL/RPR) RPR + TPPA + RPR - TPPA + RPR + TPPA - RPR - TPPA - Most likely diagnosis Active treponemal infection Old treated treponemal infection Biologic false positive False positive Other diagnoses Treated after many years of infection Latent active treponemal infection Early active treponemal infection Early active treponemal infection Adapted from: CPHLN Laboratory Guidelines Can J Infect Dis Med Microbiol Vol 26 Supp A 2015

13 Treatment free from MB Health

14 Background - Canada Since 1999, outbreaks in Vancouver, Calgary, Edmonton, Toronto, Ottawa, Montreal, Halifax Count Rate / 100,000 Notifiable Diseases On-Line ( ), Syphilis. Public Health Agency of Canada:

15 Number Infectious Syphilis Cases WHR* N=274 Q1Q2Q3 Q4 Q1Q2Q3Q4 Q1Q2Q3Q4 Q1Q2 Q3Q4 Q1Q3 Q1Q2 Q3Q4 Q1Q2Q3Q4 Q1Q2Q3Q4 Q1 Q2Q3Q4 Q1Q2Q3 Q4 Q Heterosexual Bisexual MSM only Source: Syphilis Surveillance Database, Population and Public Health Program, Winnipeg Regional Health Authority, March 2015 *Has postal code in WHR or is identified as resident in WHR (excludes cases not resident in WHR)

16 Demographics (WHR* cases ) >150 Infectious Cases 93% male (65% MSM + 17% bisexual) Downtown (29%), River Heights (11%) and Point Douglas (9%) 47% meeting on social media

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18 Network Diagram: Meeting Places

19 Gonorrhea Neisseria Gonorrhoeae

20 Gonorrhea The Basics Gram-negative diplococci Transmission Sexual Perinatal MB Rates: 1220 cases (96/100,000) Triple the Canadian average! Most occur in youth (age 15-24)

21 Non-Genital Gonorrhea Pharynx mild symptoms: erythema, cervical lymphadenopathy. Goal of therapy reduce spread Conjunctiva - autoinnoculation ID 3764 J Miller CDC Public Health Image Library

22 Non-Genital Gonorrhea Disseminated (DGI) (2% of GC infections) Septic emboli cause polyarthritis & dermatitis + fever Severity variable Usually no urogenital symptoms Diagnosis joint aspiration (gram stain) Blood culture may or may not be + Watch for meningitis, endocarditis, myocarditis Consider concurrent urogenital infection ID 5178 SE Thompson CDC Public Health Image Library

23 Anti-Microbial Resistance World Europe/Parts of Asia Cefixime/Ceftriaxone resistance Everywhere Cipro resistance Variable Azithro resistance Canada Cipro resistant Cefixime/Ceftriaxone resistance growing Manitoba based on only 24 samples Cipro resistance growing Cefixime/Ceftriaxone remains sensitive BUT minimum inhibitory concentrations increasing AND saw our first isolates with beta lactamase

24 Distribution of Cefixime Minimum Inhibitory Concentrations (MICs) for Gonorrhea Isolates USA Susceptible Increasing Resistance CDC GISP Profiles 2013, Figure 1. Distribution of Cefixime MICs

25 Treatment USA Ceftriaxone 250mg IM and Azithro 1g PO (or doxy) Canada Ceftriaxone 250mg IM and Azithro 1g PO Cefixime acceptable alternative Manitoba Cefixime 800mg PO and Azithro 1g PO Ceftriaxone also considered 1 st line Cefixime not 1 st line for non-genital infections nor for MSM Note: New Provincial Protocol Coming This Summer! Includes updated treatment recommendations.

26 A Note on Hepatitis C US CDC one time screening for baby boomers Canada considering similar guideline

27 A Note on Collecting Information Public Health Act Health Care Provider responsible to collect contact information Public Health can help with: Gonorrhea Syphilis HIV HCV Chlamydia in youth (or high-risk if notified)

28 What do we need from you? Test, Test, Test MSM, casual/anonymous partners, condomless sex Never assume you know someone s risk Culture is very suspicious of gonorrhea (or failed tx) If results Positive Treat Collect partner info Repeat syphilis q3 months (while outbreak ongoing) Call Public Health with Questions

29 Thank you