Appendix B Recommendation for enhanced surveillance of gonococcal infection

Appendix B Recommendation for enhanced surveillance of gonococcal infection

Enhanced gonococcal infection surveillance Recommendation for enhanced surveillance of gonorrhoea in the context of the increase in ciprofloxacin resistance of Neisseria gonorrhoeae During TCNMI meetings held on 8 and 9 April, 2005, the Groupe de travail sur le contrôle de l'infection gonococcique presented the following recommendation: Considering that the number of strains showing quinolone resistance has increased considerably since the last three months of 2003 and that the increase has affected men in particular; Number of ciprofloxacin-resistant strains and number of strains analysed at the LSPQ Women Men Total Resistant Analysed Resistant Analysed Resistant Analysed % No. ND gono % resistant ND 2003 1 70 13 278 14 349 4.0 890 1.6 2004* 3 43 43 208 46 251 18.3 585 7.8 *First nine months of 2004 The last two columns are estimates of the minimal proportion of resistant strains, using the total number of reported gonococcal infections as the denominator. the data in the literature show similar findings affecting MSM in particular; the available data (2002 gonorrhoea investigations and a report on the free prescription medication program, 2003) indicate that quinolones continue to be used to treat gonorrhoea; information on quinolone use in 2005 to treat gonorrhoea is not well known; the available data (2002 gonorrhoea investigations) reveal an increase in the proportion of cases detected using NAAT only, and therefore these strains are not tested for resistance and their current situation is not well known; the Protocole d intervention ITS recommends conducting an epidemiological investigation after a case of gonococcal infection is reported and the working group endorses this recommendation; the feasibility and usefulness of compiling provincial data collected during investigations were demonstrated but are dependent on optimal regional participation, especially that of Montréal (65% of cases); Appendix B 1

enhanced surveillance of data collected during investigations conducted following reports of gonococcal infection between 2001 and 2003 has shown that risk factors are relatively stable; it is recommended to Reinstate provincial compilation of certain clinical and epidemiological data collected during epidemiological investigations, with the following objectives: o o Clearly identifying the treatment administered and, more specifically, better documenting quinolone use: in cases for which resistance is documented in cases in which risk of resistance is higher (MSM, infection acquired in an endemic country) in cases for which resistance was not measured in the context of screening vs. diagnosis Having an indicator for the application of new guidelines on the treatment of gonococcal infection that recommend avoidance of quinolones when the proportion of resistant strains is over 3% to 5% (as is the case in Québec). Specify the proportion of cases for which culture was not used for diagnostic testing (resistance impossible to detect). Caution is required because even in cases in which culture is used, susceptibility testing is not necessarily always performed. The LSPQ is concerned about this issue and is taking steps to correct the situation: o Compiling data from investigations can help achieve this objective (question 2.5). o The LSPQ is also collecting information from laboratories about techniques used. o Therefore, it would be useful and more effective to maintain and consolidate information sharing of data collected by public health and by the LSPQ, while respecting the legislative framework and the missions of each of these bodies. To reach this goal, the variables of interest are as follows: Sex, age and age group (section 1) Date of episode and region (section 1) Date of specimen collection (question 2.1) History of symptoms (to define the context: screening or diagnosis) (question 2.3) Site/type of positive samples (question 2.4) Technique used (question 2.5) Profile of resistance (question 2.6) Treatment prescribed (question 2.7) Partner s sex (question 3.7) Sexual relation with a person who usually lives outside Québec (question 3.14) 2 Appendix B

The TCNMI agreed to follow up on this recommendation, in keeping with the following modalities: Transmission to the Bureau de surveillance et de vigie (BSV)/MSSS of a de-identified copy of the investigation forms for all reported cases of gonococcal infection Transmission of forms starting 1 June, 2005 Data entry by the BSV and analysis by INSPQ in collaboration with MSSS Duration of the process anticipated to be a minimum of a year, that is, at least until 1 June, 2006 (reassessment of the pertinence of continuing with the process in April 2006: a year will probably not be enough to follow up on application of guidelines) Compilation and summary analysis of data performed on a monthly basis (INSPQ/BSV) Summary report distributed to the regions on a quarterly basis and more detailed annual report. Additional information will be passed on as required, following monthly analyses. 3 Appendix B

Appendix C Epidemiological surveillance of gonococcal infection

Epidemiological surveillance of gonococcal infection The epidemiological surveillance of infectious diseases provides direction to public health activities designed to prevent the greatest possible number of infections. This document describes how epidemiological surveillance of N. gonorrhoeae is conducted and managed in Québec. It explains how the notifiable disease system (MADO system) works, what is involved in an epidemiological investigation that is conducted once a case has been reported, including the attendant preventive interventions, the place given to enhanced surveillance, as well as the structure of the LSPQ's Programme de surveillance des souches de N. gonorrhoeae résistantes aux antibiotiques dans la province de Québec. 1. Notifiable disease surveillance Basic surveillance of certain diseases is performed by means of the notifiable disease system. This system stems from certain obligations provided for in the Public Health Act and the Minister s Regulation under the Act: The Minister shall, by regulation, draw up a list of intoxications, infections and diseases that must be reported to the appropriate public health director and, in certain cases provided for in the regulation, to the Minister or to both the public health director and the national public health director (sec. 79). The list may include only intoxications, infections or diseases that are medically recognized as capable of constituting a threat to the health of a population and as requiring vigilance on the part of public health authorities or an epidemiological investigation (sec. 80). The report must indicate the name and address of the person affected and contain any other personal or non-personal information prescribed by regulation of the Minister. The report must be transmitted in the manner, in the form and within the time prescribed in the regulation (sec. 81). Persons required to report (sec. 82): Any physician who diagnoses an STBI included in the list or who observes the presence of clinical manifestations characteristic of any of those STBIs in a living or deceased person, and any chief executive officer of a private or public laboratory or of a medical biology department, where a laboratory analysis conducted in the laboratory or department under his or her authority shows the presence of any STBI. In accordance with the Minister s Regulation under the Public Health Act, STBIs that must be reported are the following: Chancroid Granuloma inguinale Viral hepatitis Chlamydia trachomatis infection Gonococcal infection Lymphogranuloma venereum Appendix C 1

Syphilis HIV infection (reported by the physician only if the infected person has donated blood, organs or tissues, or received blood, blood products, organs or tissues) AIDS (reported by the physician only if the infected person has donated blood, organs or tissues, or received blood, blood products, organs or tissues) A written report must be transmitted to the public health director in the territory within 48 hours. The following information must be provided: Name of the infection or disease Name, sex, occupation, date of birth, address with postal code, telephone number and health insurance number of the person affected Date of onset of the disease The date on which the samples were taken and the name of the laboratory (or laboratories) that will analyse them, if needed In the case of viral hepatitis, syphilis, HIV infection and AIDS, all information pertaining to blood, organ or tissue donations made by the person affected and all information pertaining to blood, blood products, organs and tissues received by the person affected In the case of syphilis, information on the stage of the disease (primary, secondary, latent of less than or more than a year, congenital, tertiary or any other form) Information on the reporting physician (name, permit number, telephone numbers at which he or she can be reached) Signature and date of the report Reported cases of gonococcal infection must meet the definitions listed below. 1 Genitourinary gonococcal infection Confirmed case: Isolation of N. gonorrhoeae in a urogenital specimen or detection of N. gonorrhoeae by appropriate laboratory technique in a urethral or endocervical specimen or nucleic acid detection of N. gonorrhoeae in a urethral, endocervical or urinary specimen. Gonococcal eye infection Confirmed case: Isolation of N. gonorrhoeae from an ocular specimen. Other gonococcal infection Confirmed case: Isolation of N. gonorrhoeae from a clinical specimen other than ocular or urogenital. Data on reported cases are managed with a computerized system implemented in 1989 1990 that links all 18 health regions to a common platform located at the LSPQ, where reported 2 Appendix C

notifiable disease cases are recorded. The aggregation of de-identified data allows description of the epidemiology of infections reported in Québec. The data are used to classify cases according to certain basic variables, such as sex, age and region of residence. 2. Epidemiological investigations and preventive interventions Interventions designed to prevent complications, reduce the duration of the infectious period and reduce the risk of transmission can be introduced after reception of an STI report. In accordance with the Public Health Act, the Protocole d intervention sur les infections transmissibles sexuellement à déclaration obligatoire 2 defines the recommended public health intervention to conduct after an STI has been reported. The protocol lists the infections that should, depending on the current epidemiological context, be the object of a high-priority public health intervention, that is, an epidemiological investigation that includes preventive interventions with people who have contracted an STI and with their partners (PIPSP). Gonococcal infections are among the infections identified as a priority. The intervention protocol describes the parameters of an epidemiological investigation, the contents of preventive advice to give an index case following a report, and the PIPSP. The epidemiological investigation to conduct after a report of a notifiable STI and the ensuing interventions meet surveillance, prevention and public health protection objectives. Surveillance and prevention objectives a) Validation Collect the required information to verify that case classification conforms to case definitions. b) Planning of preventive interventions Establish an overview of the epidemiological situation (age, sex, region and risk factors) that allows targets to be set for preventive interventions. Establish indicators to enable direct or indirect evaluation of the preventive intervention (e.g. screening programs, treatment guidelines). Public health protection objectives a) Reduce the rate of exposure to an STI. b) Reduce the effectiveness of STI transmission. c) Reduce the duration of infectiousness of an STI. As a complement to data collection for surveillance purposes, the following interventions can also be conducted in the context of an epidemiological investigation: Counsel the index case to prevent him or her from transmitting the infection and to prevent future exposures or reinfections: reduction in number of partners, use of barrier methods, safe sexual practices, advice concerning harm reduction related to addiction. Facilitate access to appropriate treatment. 3 Appendix C

Detect possibilities of treatment failure and notify the attending physician. Offer hepatitis A and B vaccination, in accordance with the recommendations of the MSSS s free vaccination program. Inform the index case about preventive interventions for partners and offer support that is in line with regional organization. Refer the individuals (index case and his or her partners) to services that meet their needs. Although the Act and its regulations establish obligations for physicians and public health departments, it can sometimes be difficult to complete an epidemiological investigation. Such difficulties can influence the quality of surveillance data obtained during such an investigation. 3. Health intervention to enhance surveillance of gonococcal infection in Québec Basic surveillance can be periodically enhanced when a situation requires it, as was the case when a significant increase in the number of reported cases of gonococcal infection was recorded (beginning in 1998), or when fluoroquinolone-resistant gonorrhoea started to spread in the province. Public health departments and the Direction générale de la santé publique du MSSS thought it worthwhile to collect more detailed or more specific information about certain elements. In 2001, agreement was reached with all public health departments to systematically conduct epidemiological investigations after a case of gonococcal infection has been reported and to use a common questionnaire to facilitate enhanced surveillance of the evolution of the situation. Data analysis results are presented in the Rapport d analyse Enquêtes épidémiologiques réalisées suite à une déclaration d infection gonococcique, 1 er mars 2001 31 décembre 2001. 3 In April 2005, the TCNMI decided to implement a second intervention to enhance surveillance of gonococcal infection. This decision was made on the basis of a recommendation of the working group (see Appendix B). The Final report health intervention. Enhanced surveillance of gonococcal infection in Québec, 1 June 2005 to 31 May 2006 4 presents the analysis of data collected during this year of observation. 4. Program for the surveillance of antibiotic-resistant strains of N. gonorrhoeae in the province of Québec 5 The goal of the program for the surveillance of antibiotic-resistant strains of N. gonorrhoeae in the province of Québec, implemented by the LSPQ in 1998, is to collect data on the epidemiology of gonococcal infections, rates of resistance and the emergence of new types of resistance to the antibiotics used to treat gonococcal infections. Given the increase in fluoroquinolone resistance observed beginning in 2004 and as announced to microbiology laboratories in January 2005, the LSPQ decided, after consulting its partners, to focus surveillance on ciprofloxacin-resistant strains of N. gonorrhoeae and on the possible emergence of strains that are less susceptible to ceftriaxone. 4 Appendix C

Participating laboratories contribute in two distinct ways: 1. Monthly transmission of forms indicating the total number of patient strains of N. gonorrhoeae isolates observed in the laboratory as well as the number of cases for which gonorrhoea is detected in clinical specimens using gene amplification only (e.g. PCR). 2. Sending to the LSPQ all patient strains (one strain per patient within a period of seven days) with decreased susceptibility to a fluoroquinolone (e.g. ciprofloxacin) or cephalosporin (e.g. ceftriaxone, cefotaxime or cefixime). Other strains are also forwarded: strains isolated in children ( 14 years) or those ineffectively treated, those acquired outside Canada and those with unusual characteristics. In 2005, N. gonorrhoeae strains sent to the LSPQ were characterized according to susceptibility to ceftriaxone and ciprofloxacin, as determined using an agar dilution method in accordance with the procedures recommended by the Clinical and Laboratory Standards Institute. Strains showing resistance to ciprofloxacin are sent to the National Microbiology Laboratory in Winnipeg for further characterization (plasmid profile, auxotyping, serotyping or gene amplification), as part of the Canadian Surveillance Program. This program provides access to information such as the incidence of gonococcal infections, rate of ciprofloxacin-resistant strains, fluctuations and regional distribution of these strains, as well as possible emergence of resistance to cephalosporins. The data can be informative for public health authorities that must decide on the different treatment regimens to use for gonococcal infections. 5 Appendix C

Bibliography 1. MINISTÈRE DE LA SANTÉ ET DES SERVICES SOCIAUX. Surveillance des maladies à déclaration obligatoire au Québec : Définitions nosologiques Maladies d origine infectieuse, 6 th ed, Québec, ministère de la Santé et des Services sociaux, June 2006. 2. MINISTÈRE DE LA SANTÉ ET DES SERVICES SOCIAUX. Les infections transmissibles sexuellement à déclaration obligatoire : Protocole d intervention, Québec, ministère de la Santé et des Services sociaux, March 2004, various pages. 3. Sylvie VENNE. Rapport d analyse Enquêtes épidémiologiques réalisées suite à une déclaration d infection gonococcique, 1 er mars 2001 31 décembre 2001, Québec, ministère de la Santé et des Services sociaux, September 2002. 4. Pier Raymond ALLARD et al. Final report health intervention. Enhanced surveillance of gonococcal infection in Québec, 1 June 2005 to 31 May 2006, Québec, Institut national de santé publique du Québec and Bureau de surveillance et de vigie (maladies infectieuses) du ministère de la Santé et des Services sociaux, December 2006. 5. LOUISE JETTÉ and Louise RINGUETTE. Surveillance des souches de Neisseria gonorrhoeae résistantes aux antibiotiques dans la province de Québec, Rapport 2005, Laboratoire de santé publique du Québec, Institut national de santé publique du Québec, April 2006. [On line] [http://www.inspq.qc.ca/pdf/publications/493-surveillancesouchesneisseria.pdf] 6 Appendix C