I m Telling On You! Joseph R. Johnson, DO, FACOOG Chairman, Department of Obstetrics and Gynecology Residency Director

Transcription

1 I m Telling On You! Joseph R. Johnson, DO, FACOOG Chairman, Department of Obstetrics and Gynecology Residency Director

2 Financial Disclosure I have no financial aspects to this lecture I have no of label uses of medications Information based on current 2015 CDC and OCHA guidelines

3 Objectives Understand the require reporting to the Oklahoma State Department of Health s HIV/STD Service Understand compliance with Oklahoma Public Health Code (OAC 310: ) Understand required reporting by both labs and clinics to PHIDDO (Public Health Investigation and Disease Detection of Oklahoma) Current identification and treatment of infectious disease in pregnancy

4 STD SnapShot 20 Million new STD cases per year $16,000,000, Per year in health care costs Most young people years Increases risks for infertility, ectopic pregnancy and HIV infection Chlamydia: 456:100,000 up 2.8% Gonorrhea: 110:100,000 up 5.1% Syphilis: 6.3:100,000 up 15.1% Neonatal Syphilis 11.6:100,000 up 27.5%

5 Why Report? Mandatory by State Statue (OAC 310: ) Insures accuracy of demographic information Aids in acquiring independent morbidities Reduces transmission to citizens of Oklahoma

6 STD in Pregnancy Severe effects on pregnancy IGUR, chorioamionitits, septic abortion Intrauterine and perinatal infections increase when untreated Screening recommendation look at disease severity and sequelae Screening guidelines in pregnancy are generally broader than population at large

7 What Needs to Be Reported Chlamydia Gonorrhea Syphilis RPR +, don t need confirmatory testing HIV/AIDS Hepatitis B Hepatitis C

8 Reportable Immediately Based on Suspicion Anthrax Bioterrorism - suspected disease Botulism Diphtheria H. influenzae invasive disease Hepatitis A (Anti-HAV-IgM+) Hepatitis B during pregnancy (HBsAg+) Measles (Rubeola) Meningococcal invasive disease Novel coronavirus Novel influenza A Outbreaks of apparent infectious disease Plague Poliomyelitis Rabies Smallpox Tularemia Typhoid fever Viral hemorrhagic fever

9 How to Report Reports can be Mailed Faxed Submitted online via PHIDDO (Preferred method -= submit on the secure Public Health Investigation and Disease Detection of Oklahoma) web site

10 Reported Within One Working Day M-F Acid Fast Bacillus (AFB) positive smear indicative of Mycobacterium AIDS (Acquired Immunodeficiency Syndrome) Anaplasmosis Brucellosis California serogroup virus Campylobacteriosis Congenital rubella syndrome Cryptosporidiosis Dengue fever Eastern equine encephalitis virus Escherichia coli O157, O157:H7 or a Shiga toxin producing E. coli Ehrlichiosis Hantavirus pulmonary syndrome Hemolytic uremic syndrome, postdiarrheal

11 Reported Within One Working Day M-F Hepatitis B (HBsAg+, anti-hbc IgM+, HBeAg+ Hepatitis C virus (in persons 40 years or in persons having jaundice, ALT 400 regardless of age with laboratory confirmation) Human Immunodeficiency Virus (HIV) infection Influenza associated hospitalization or death Legionellosis Leptospirosis Listeriosis Lyme disease Malaria Mumps Pertussis Powassan virus Psittacosis

12 Reported Within One Working Day M-F Q Fever Rocky Mountain spotted fever Rubella Salmonellosis Shigellosis St. Louis encephalitis virus Staphylococcus aureus (VISA or VRSA) Streptococcus pneumoniae invasive disease, children <5 yrs. Syphilis Tetanus Trichinellosis Tuberculosis Unusual disease or syndrome Vibriosis including cholera West Nile virus Western equine encephalitis virus Yellow fever

13 Reported Within One Month CD4 cell count with cell count % (by laboratories only) Chlamydial infections (C. trachomatis) Creutzfeldt-Jakob disease Gonorrhea (N. gonorrhoeae) HIV viral load (by laboratories only)

14 Isolates Needing to Be Sent to OSHD Lab Bacillus anthracis Brucella spp. Escherichia coli O157, O157:H7, or a Shiga toxin producing E. coli Francisella tularensis Haemophilus influenzae (sterile site isolates) Listeria spp. (sterile site isolates) Mycobacterium tuberculosis Neisseria meningitidis (sterile site isolates) Plasmodium spp. Salmonella spp. Staphylococcus aureus (VISA or VRSA) Vibrionaceae family (Vibrio spp., Grimontia spp., Photobacterium spp., and other genera in the family) Yersinia spp.

15 Contacts Acute Disease Service (405) or (800) Available 24 Hours a Day HIV/STD Service (405) Fax (405) Public Health Laboratory (405) Fax (405)

16 Advantage for Electronic Filling Meet public health reporting guidelines No duplicate data entry Lab technicians no longer have to enter data manually or complete forms by hand Centralization of reporting to one data repository vs. reporting specified diseases to designated program areas (Communicable Disease Div, Tuberculosis Div, HIV/STD Service, etc.) Increased data security Fast transformation of data Transmission consistency Increased timeliness of reporting Increased sensitivity of reporting system Increase in providing public health with pertinent data

17 PHIDDO Access Web Site _Service/Disease_Reporting/PHID The preferred method of reporting diseases or conditions to the OSDH is through the secure, web-based Public Health Investigation and Disease Detection of Oklahoma (PHIDDO) system. Healthcare providers interested in learning more information about the PHIDDO system or becoming a user may contact the Acute Disease Service The Acute Disease Service Epidemiologist-on-Call is available 24 hours/7 days a week at (405) for communicable disease consultations and reporting of diseases or outbreaks Additionally, diseases and conditions may be reported to the OSDH using one of the following reportable disease forms

18 PHIDDO Forms #295

19 Infections In Pregnancy Treatment Guidelines From CDC Oklahoma State STD Treatment Guidelines 2015

20 Mandatory Testing in Pregnancy N. Gonorrhea repeat 3 rd Tri at risk individuals C. Trachomatis 1 st Tri < 25 and at risk 3 rd Tri Syphilis Group B Strep at 35 weeks Pap Test HIV OPT Out screening Hepatitis B Hepatitis C IV drug use, blood transfusion or organ donation before 1992 Bacteria vaginitis asymptomatic women with prior PT Birth or symptomatic women Urine with culture if positive findings

21 Syphilis Screen all women on 1 st prenatal visit High risk, high endemic areas repeat at 28 weeks and delivery Infants hospital release - only if maternal serology known Stillbirths require screening

22 Syphilis The Great Imitator 20 affects approximately 32,000 people each year in the U.S. 14 How is Syphilis Spread? Direct contact with a syphilis sore (chancre) during vaginal, anal, or oral sex. 20 Can be spread from an infected mother to her unborn baby. 20 Primary Syphilis Secondary Syphilis Latent/Late Syphilis

23 Primary Syphilis Chancre (ˈshaŋ-kər) the syphilis sore Appears within 2-6 weeks after exposure (could take up to 3 months) Firm, round, and painless Typically disappear after a few weeks without treatment (still progresses to next stage)

24 Primary Syphilis

25 Syphilis Screening test non-treponemal tests, RPR (rapid plasma regain) and VDRL (Venereal Disease Research Laboratory) Titers DO NOT predict treatment (serofast reaction) Confirmatory test Treponema test FTA-ABS (fluorescent Treponema antibody absorbed) TP-PA (T.pallidum passive particle agglutination), EIA (enzyme Treponema assays) False positives possible with HIV, pregnancy, autoimmunity conditions, IV drug use and older age

26 Syphilis Sign and Symptoms Primary - ulceration or chancre at infection site Secondary - skin rash, mucocutaneous lesions Tertiary - cardiac, gummatous lesions, tabes dorsalis Early Latent - detected within a year duration Late Latent - unknown duration

27 Syphilis in Pregnancy Treatment with Penicillin G Only therapy effective in pregnancy If allergic desensitize in hospital setting needed Partners are treated presumptively if contact is with previous 90 days even with serologic negative testing

28 Syphilis Dosing Primary-Secondary-Early Latent: Penicillin G 2.4 Million units IM Latent: Penicillin G 7.2 Million Units IM, administered as 2.4 Million units IM each at 1 week intervals Neurosyphilis or ocular syphilis: Aqueous cyrtaliline Pen G, Million units daily, administered as 3-4 Million units IV q 4 hours for days

29 HIV Testing in Pregnancy All screening in 1 st trimester even if previously screened in nonpregnant state Consent for screening as an OPT-out program If they decline repeat emphasis at each prenatal visit Repeat in 3 rd trimester for Illicit drugs STD s in pregnancy Multiple or new partners in pregnany Rapid HIV if status is unknown during labor

30 Human Immunodeficiency Infection Acute retroviral infection that transitions to a multi-year chronic condition Progressively depletes CD4 T-lymphocytes Median time to AIDS 11 years As of % of the 1.2 Million persons infected are UNAWARE Infected persons with Acute HIV Infection 50% asymptomatic

31 HIV Screening Screen all persons requesting STD consult CDC recommends HIV screening in years in ALL healthcare settings Consents in general population OPT-out programs in pregnancy Rapid screening in pregnancy for all unknown pregnant patient in labor Absence of antiviral therapy 30% transmission verses <2% with treatment

32 HIV Treatment Protocols in Pregnancy Preferred protease inhibitor (PI): darunavir/ritonavir has been promoted to a preferred protease Preferred non-nucleoside reverse transcriptase inhibitor (NNRTI): efavirenz remains a Preferred - when initiated after the first 8 weeks of pregnancy. Preferred integrase inhibitor: Raltegravir has been promoted to the Preferred category, providing a Preferred integrase inhibitor option for initial therapy in pregnancy.

33 HIV Delivery Protocols HIV RNA levels assessed at approximately 34 to 36 weeks gestation Informed decisions about mode of delivery are also used to inform decisions about optimal treatment of the newborn Viral loads in then indictable range no increased transmission with a vaginal delivery Avoid breast feeding is still a strong recommendation

34 Chlamydia trachomatis in Pregnancy Chlamydia is the highest reportable disease in persons < 24 years Serious sequelae includes, PID, Infertility and ectopic pregnancy Asymptomatic infection is common Annual screening of all sexually active women < 25 recommended Also those at increased risk New partner or more than one sexual partner

35 Chlamydia Rates by Age and Sex, United States,

36 Chlamydia Testing Swabs from the endocervix or vagina NAAT testing - nucleic acid amplification testing CDC recommend but not FDA approved for anal or oral specimen First catch urine and self collected specimens are equal in efficacy

37 Chlamydia Treatment Treat patient and partner decreases relapse Azithromycin 1 gram PO Meta-analysis of 12 studies show 97-98% equally efficacious to doxycline Erythromycin shown to be less effective d/t GI side effects No advantage with Levofloxacin and ofloxacin (more expensive) Obtain NAAT TOC in 3-4 weeks, retest in 3 rd trimester

38 Gonorrhea in Pregnancy ALL pregnant women should be screened at their initial visit Women < 25 years old and high risk behaviors Prior risk factors, infection, multiple partners, inconsistent use of condoms or IV drug use Retest all positive patients in the 3 rd trimester

39 Gonorrhea Rates of Reported Cases by Age and Sex, United States, 2013

40 Gonorrhea Testing Second most common reportable disease in US 820,000 Cases Annually CDC recommends NAAT method for detection Women often asymptomatic until late squelae present, PID or infertility Annual screen for all sexually active women < 25 years Increased risk with multiple sex partners, concurrent p[artners or prior STI

41 Gonorrhea Treatment Gonococcal Isolate Surveillance Project monitored strains for antimicrobial effectiveness 2007 Fluoroquinolone resistance 2010 CDC - Recommendations started for dual therapy as increasing resistant strains noted Minimum drug concentrations needed to obtain MIC levels

42 Gonorrhea Treatment in Pregnancy Dual Therapy Ceftriaxone 250 mg IM plus Azithromycin 1 gram PO Recommendations are to follow the CDC guidelines If IgE mediated PCN allergy or cephalosporin allergy contact the STD Control Branch for recommendations or

43 Hepatitis in Pregnancy All pregnant women should be screened for Hepatitis during their first prenatal visit High risk women include IV drug users, transfusions, persons infected with HIV and children born of Hep positive mothers Incidence is 1.2 Million Hep B positive in US 350 Million worldwide Transmission can occur during vaginal or C Section HBIG given within 12 hours of birth decreases neonatal transmission

44 Hepatitis

45 Hepatitis Screening Screen all pregnant women during their 1 st prenatal visit Consider high risk if Household with Hepatitis positive individual Sexual contacts with Hepatitis positive individual More than one sexual contact in past 6 months Treatment of an STD during pregnancy HIV infection Chronic liver disease End stage renal disease Travel to region with a prevalence > 2%

46 Test for Hepatitis Surface Antigen Negative If high risk may vaccinate during pregnancy or postpartum Re-check surface antigen when admitted for labor Positive Recommend all household family and sexual contacts Obtain additional testing and referrals Check HbeAg(+), ALT (>19 IU/L) HBV DNA load (>20,000 IU/mL) all need hepatologist referral immediately

47 Hepatitis Transmission Prevention Review testing and make sure that HBsAg was positive Retest high risk moms prior to delivery Alert that infant needs Hepatitis B immune globulin (HBIG within 12 hours of birth) and hepatitis B vaccine (series of three)

48 Prevention of Perinatal Transmission

49 Trichomoniasis in Pregnancy Diagnosis by wet mount, pap smear or cultures (95%) Metronidazole 2 grams orally in single dose Partner should be treated (use your judgement) Tindidazole 2 grams oral in single dose is secondary med safety unknown in pregnancy Breast feeding withhold meds for hours

50 Bacterial Vaginosis Symtomatic pregnancy patients should be treated especially if history or symptoms associated with preterm delivery/labor Screening for BV not well established Treatment by vaginal preparations not well established Metronidazole 250 mg po TID x 7 days Metronidazole 500 mg po BID x 7 days Clindamycin 300 mg po BID x 7 days

51 Group B Strep All screened at 35 weeks An urine positive in pregnancy considered positive at delivery History on neonatal sepsis considered positive at delivery Unknown status at delivery treat risk factors Gestation < 37 Intrapartum temp > F Membrane rupture greater than 18 hours

52 GBS Treatment PCN G 5 million units IV load then 2.5 million q 4 hours till delivered Amoxicillin 2 grams load IV then 1 gram every 4 hours till delivered PCN Allergy may give: Clindamycin 900 mg IV q 8 hours if sensitivity is known, otherwise Vancomycin 1 gram IV q 12 hours

53 Herpes Virus Diagnosis by serology showing Glycoprotien G Symptomatic females may show classic ulcerations Women with known Herpes or known partners with herpes should: Take Acyclovir 400 mg po BID starting at 35 weeks until delivery Reduces C-section rates at term Decreased perinatal transmission rate

54 Questions