Trichomonas Time to Know the Facts

Trichomonas Time to Know the Facts Conflicts of Interest Research support and/or participation in clinical trials from the following companies and sources that have to do with today s subject: NIH, DOH RI, APHL Gen-Probe, BD, Cepheid Kimberle Chapin MD DABMM, FCAP Director of Microbiology and Infectious Diseases Molecular Diagnostics Lifespan Hospital, Brown Medical School Providence, RI 1 2 The Rodney Dangerfield of STI s Trichomonas vaginalis gets no respect Case 55 yo man presents to MD for routine physical exam and minimal urogenital complaints Previous exam, including prostate WNL Social history: Divorced for 3 years and currently dating..alot HPI/PE: no specific complaints other than occasional urinary frequency and difficulty or pain urinating, and sometimes pain during or after ejaculation 3 4 Case Case Urine Culture negative HIV negative Nucleic Amplification urine test (NAATs) negative for CT/GC Urine NAAT positive for TV 45 yo woman presents to MD for GYN exam Previous exam, including PAP WNL Social history: Divorced for 3 years and currently dating..alot HPI/PE: no specific complaints except occasional itching in vaginal area, GYN exam shows only some thin watery discharge Wet mount negative 5 6 1

Case 3A Urine Culture negative HIV negative NAAT Endocervical swab negative for CT/GC Endocervical swab NAAT positive for TV Disease background in context of other STIs Clinical Sequelae Treatment Considerations for future action and Public Health 7 K 8Chapin MD 2014 Genital Infections Basic Tenants Asymptomatic partners transmit infections Many infections with overlapping in signs and symptoms so clinical diagnosis not specific Diagnostic Testing is recommended: Appropriate RX can be focused Specific diagnosis increases therapeutic compliance By both patient and partner Complies with state PH reporting Alas.current available test diagnostics lacking 25-40% of patients the entity is not clear Estimates of New Cases of STIs US (2008) Satterwhite, Torrone et al, 2013 STD, 40(3) 187-193 Hep B = 19,000 HIV= 49,000 Syphilis = 55,400 HSV-2 = 776,000 1.5 million new HSV-1 Genital Infections cases per year HSV Gonorrhea = 820,000 Trichomoniasis = 1,090,000 Chlamydia = 2,860,000 HPV = 14,100,000 (includes non-hr) 9 20 million new infections/year (incidence); 110 million total infections (prevalence) 10 COST in US dollars $16 BILLION in the US TV is one of the top 5 ignored infections in the world (CDC 2014) Syphilis: 14,000 Hepatitis B Virus: 43,000 HIV: 50,000 Gonorrhea: 700,000 Chlamydia: 1.4 Million Herpes Simplex Virus: 1.5 Million Human Papilloma Virus: 6 Million Trichomonas vaginalis Healthcare Associated Costs Direct medical costs for TV infection alone: estimated at $34.2 million Sequelae related to increased risk for HIV transmission: $167 million Misdiagnosis and inappropriate RX of common entity:$$? Vaginosis,vaginitis that continues to come back over and over No routine testing for TV unless symptomatic or high risk Partners NOT empirically tested or treated NOT a reportable disease Trichomonas: 7.2 million 11 12 K Chapin MD 2012 2

Life-cycle of T. vaginalis is simple Disease background in context of other STIs Clinical Sequelae Treatment Considerations for future action and Public Health K 13 Chapin MD 2014 14 Single-celled protozoan Divides by binary fission Only troph stage identified Only infects humans Infection transmitted sexually Natural infection exists on the mucosa of the genital lumen 10-105 protozoa/ml Pathogenesis of Trichomonas Much to Learn Pathology of Trichomonas vaginalis Attaches to epithelial cells Releases proteins which by direct contact result in: Micro-ulcerations Subsequent intense local immune response mainly with: Neutrophils but also Lymphocyte recruitment including CD4+ cells Recruitment of inflammation-related factors: Cytokines and chronic stimulation that has implications for pathology and cancer Phagocytosis Vaginal bacteria and host cells which alters normal flora Vector for spread of other organisms Carrying pathogens attached to their surface into fallopian tubes, into prostate 15 TV prefers an anaerobic environment and ph 6.0 Can deal with 4.5 which may be why some infections with low organism burden Healthy vagina ph = 3.8-4.5 TV phagocytosing vaginal bacteria creates a more alkaline environment (> 4.5 ph) TVcontains structures called Hydrogenosomes (no mitochondria) Accomplish fermentative carbohydrate metabolism and Produces H2 gas Inflammatory response to the parasite may determine severity of symptoms Factors that influence the host response: Hormone levels Coexisting vaginal flora Strain of TV Relative concentration of organism present K Chapin 16 MD 2014 Disease background Clinical Features and Sequelae Treatment Considerations for future action Clinical Features Incubation period 4-28 days Symptoms and signs in women Vaginal discharge, pruritus, and irritation, dysuria Vaginal discharge, odor, edema or erythema, ph > 4.5 Frothy in only 10% Colpitis macularis (strawberry cervix) specific for TV but only on colposcopy and rarely on routine examination Extent of inflammatory response my determine severity of SXS 50% of women are asymptomatic Most men are asymptomatic (> 75%) Recent studies suggest TV is more common cause of NGU than previously thought TV should be considered in male that fails therapy of NGU K 17Chapin MD 2014 18 3

Associated risks and sequelae associated with trichomoniasis Prenatal Premature rupture of membranes Pre-term Delivery Low Birth Weight Intellectual Disability of Baby Women Vaginitis, cervicitis, endometritis, PID Cervical erosion Cervical dysplasia Prolonged HPV Infection Infertility/fallopian tube damage Bacterial vaginosis Increased transmission/acquisition of HIV/HSV Presence of other STIs * Increased risk of post-surgical gynecological infections Associated risks and sequelae associated with trichomoniasis Men NG/NC Urethritis Epididymitis Prostatitis/ Proctitis Infertility and Decreased sperm motility/viability Invasive Prostate Cancer *Neisseria gonorrhoeae, Chlamydia trachomatis, human immunodeficiency virus, herpes simplex virus, and human papillomavirus 19 References in appendix 20 References in K Chapin appendix MD 2014 Disease background Clinical Signs and Symptoms, Sequelae Treatment Considerations for future action Current Estimation of Diagnostic TV Testing Performed Wet mount 48% Pap Smear %? BD Affirm 13% NAAT 10% OSOM 8% Wet mount/culture InPouch 29% 21 22 Wet Mount PAP Smear Vaginal swab in symptomatic patients Place in saline tube and then onto slide Look for motile trichomonads Needs to be done within few minutes labs up to 2 hours.. Experienced reader Requires live organisms and motility 45-80% sensitive Spaghetti and meatballs Fixed preparation May find TV in association with Leptothrix bacteria Poor sensitivity and poor specificity?? If automated reading instruments pick this up since scanning for unusual cells 50% sensitive?? 23 24 4

PAP Smear Rapid Antigen Detection Spaghetti and meatballs Fixed preparation May find TV in association with Leptothrix bacteria Poor sensitivity and poor specificity?? If automated reading instruments pick this up since scanning for unusual cells 50% sensitive?? Rapid Antigen Test Point of care test - minutes Benefits: Relatively inexpensive No live organism needed Transit time not an issue Acceptable sensitivity in symptomatic patients Disadvantages: Vaginal swab only Symptomatic patients only Single test format No BV or candida No other STIs Poor sensitivity for a screening test/asymptomatic 25 26 27 BD Affirm VP III Detection of Bacterial vaginosis/vaginitis Hybridization probe for 3 organisms: Candida albicans Gardnerella vaginalis (BV) Trichomonas vaginalis Benefits: Stable transport/no live organisms Can be done as near patient testing (usually batched) Disadvantages Subjective color endpoint Expensive (reagent, techtime) Hybridization not as sensitive for TV as NAAT May be too sensitive for normal flora? (G. vaginalis, candida) Vaginal swab only Symptomatic patients only 28 InPouch TV by BioMed Wet mount/culture Reference Standard (2009) Slide/culture media pouch Incubation 37 C Reviewed days 1,3,5,7 Advantage Specificity and Sensitivity? Disadvantage Inconvenient for collector/lab Expensive 2 to tech time Time to detection long Single Test system Not paired with other common STIs APTIMA TV Assay (FDA-cleared April, 2011) Hologic APTIMA technology (Combo GC/CT) 29 Nucleic Acid Amplification testing (NAAT) Single specimen collection (same tube as for other STIs GC/CT) FDA-cleared for Symptomatic and Asymptomatic women Screening and Diagnostics Urine, vaginal swab, endocervical swab in Gen-Probe transport collection device, Thin Prep liquid cytology specimen Tigris Instrument fully automated Disadvantages No men, self-collection or alternate sites pharyngeal, rectal Validation has been done by labs for these purposes Tigris instrument large space and volume, cost TIGRIS HOLOGIC FDA-Cleared 2013 for TV A small footprint with a width of 48", a depth of 32", and a height of 69 275-1000 samples per 8 hour shift multiple assays planned 30 5

The BD Viper System : FDA Cleared for TV in 2012 Strand displacement Amplification Efficiency Up to 736 results per 8.5 hour shift 20 minutes of hands on time per run On-board sample DNA extraction Flexibility Runs up to five STI assays simultaneously GC, CT, TV, HSV 1 and 2 Accuracy Automated sample processing and ready to use reagents Automatic system checks BD Viper XTR Disease background Clinical Sequelae Considerations for future action 31 32 K. Chapin MD 2011. Comparison of commercially available diagnostic tests for TV detection in women *,^ % of Positive TV Tests by Wet Mount vs. APTIMA TV (n=1,086) Test OSOM Rapid Test BD Affirm VPIII APTIMA BD Viper TV Target TV antigen TV DNA TV rrna TV DN A Assay methodology Immunological (antibodies) Hybridization Probe TMA SDA Time to Result (range) Near Patient Testing Cost <1 hour Yes $12/test 1 hour batched daily 3.5 hoursdaily Possible; Typically Batched No Analytical sensitivity 2,500 org/ml of sample 500,000 org/ml of sample 0.1 org/ml of sample BD assay# % 25 20 15 10 5 0 4.3 11 Outpatient Phys. Grp 10.4 21.6 Emergency Dept Emergency Dept B A 7 9 5 6 Urgent Care facility Wet Mount APTIMA TV *P<0.0002 *Data are from respective manufacturers An analytical sensitivity of less than 1 organism per ml is due to the abundance of rrna target per organism (1 3 million copies) and the TMA amplification of the target rrna molecule # BD assay analytical sensitivity? 33 34 Munson, et al. J Clin Microbiol 2008;46:3368. % 35 Comparison of Wet Mount, Culture, Antigen OSOM and APTIMA for TV 100 90 80 70 60 50 40 30 20 10 0 50.8 75.4 82.0 98.4 Wet mount Culture OSOM APTIMA Huppert, et al. Clin Inf Dis 2007; 45:194-198. 100 90 80 70 60 % 50 40 30 20 10 0 36 50.8 Diagnostic Test Performance Side by Side Same Results 54.6 75.4 75 82.0 Wet mount Culture OSOM PCR APTIMA Huppert Nye 83 98.4 96.6 6

Differences in test sensitivity stratified by the presence or absence of vaginal symptoms Comparison of TV Detection Methods Low Prevalence - RI Sensitivity % (95% CI) Test Method All Patients (n=330) Vaginal Symptoms Present (n=210) Vaginal Symptoms Absent (n=120) 100.0% 90.0% 80.0% 70.0% 60.0% Sensitivity Wet Mount 50.8 (37.7 63.9) 57.5 (40.8 72.9) 38.1 (18.1 61.5) 50.0% 40.0% 30.0% Specificity Culture 75.4 (62.7 85.5) 77.5 (61.5 89.1) 71.4 (47.8 88.7) OSOM 82.0 (70.0 90.6) 92.5 (79.6 98.4) 61.9 (38.4 81.9) 20.0% 10.0% 0.0% Specificity Sensitivity ATV 98.4 (91.2 99.9) 97.5 (86.9 99.9) 100 (83.8 100) Huppert, et al. Clin Inf Dis 2007; 45:194-198. Affirm (n=781) Cx (n=446) PCR (n=766) TMA (n=1993) Sensitivity 63.4% 68.5% 88.5% 100.0% Specificity 99.9% 100.0% 100.0% 100.0% 37 38 Overall reported sensitivity and specificity averages (ranges)* of TV detection methods in vaginal specimens Test Avg Sensitivity (range) Avg Specificity (range) Wet mount 60.7(43.0-83.3) 100 Culture 74.3 (57.3-94.3) 100 OSOM 84.4 (61.9-94.7) 99.8 (97.1-100) BD Affirm VPIII 63.8 (44.0-83.3) 100 (99.9-100) PCR 89.1 (83.0-100) 98.6 (96.3-100) Disease background Clinical Sequelae Considerations for future action APTIMA TV 98.1 (96.6-100) 98.9 (96.4-100) *Ranges are broad due to the different gold standard tests used in the literature to interpret true positive infections Expert Review in Molecular Diagnostics, 2011, Chapin and Andrea 39 40 K. Chapin MD 2011 Trichomonas in Men Age Breakdown of TV Infections in Women presenting with vaginitis/vaginosis Infection common in men Missed diagnosis in men due to lack of testing and/or symptoms Non-reportable disease Revolving infection in partners 72% of male partners of women with TV were also positive for the infection 75% were asymptomatic 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% T. vaginalis C. trachomatis N. Gonorrhea 0.0% 15 (n=13) 16 to 20 21 to 25 26 to 30 31 to 35 36 to 40 41 to 45 46 to 50 51 to 55 56 to 60 61 (n=4) (n=119) (n=150) (n=92) (n=64) (n=50) (n=36) (n=40) (n=14) (n=9) Age in Years Hobbs et al, JCM, 2006 Andrea and Chapin, JCM, 2010 K 41 Chapin MD 2014 42 7

APTIMA Amp versus Affirm VPIII Hybridization for TV APTIMA Trichomonas vaginalis Assay Clinical trial Clinical Evaluation of the APTIMA Trichomonas vaginalis Assay on the TIGRIS DTS System in Asymptomatic and Symptomatic Female Subjects P3 S7.08 ISSDTR 2010 Schwebke, Hobbs, Chapin, Taylor, Catania, Weinbaum, Getman, Gaydos Clinical assay performance was demonstrated in a prospective, multicenter clinical trial 1,025 symptomatic and asymptomatic women were enrolled from 9 U.S. clinical sites, including obstetric and gynecology, family planning, and STD clinics Performance characteristics were estimated by comparing results to a patient infected status algorithm using vaginal swab specimens tested by culture and/or wet mount microscopic examination as reference methods Published in: Schwebke, J.R. et. al. J. Clin. Microbiol. 49:4106-4111 43 APTIMA Trichomonas vaginalis Assay Clinical performance data Conclusions from Validation Study For each specimen type, performance was similar in symptomatic and asymptomatic women and across collection sites Specimen Type Clinician-collected vaginal swab Endocervical swab PreservCyt solution Urine Sensitivity % (95% CI)* 100.0 (96.7 100.0) 100.0 (96.7 100.0) 100.0 (96.0 100.0) 95.2 (88.4 98.1) Specificity % (95% CI)* 99.0 (97.9 99.5) 99.4 (98.6 99.7) 99.6 (98.8 99.9) 98.9 (97.8-99.5) Study provided clinical validation of the ATV assay for the intended uses in the United States: Asymptomatic Screening and Diagnostic Testing in women for Trichomonas FDA cleared highly accurate and fully automated amplified test system with ease of use specimens such as urine and vaginal swab should enhance testing for this pathogen Testing for men FDA-cleared as well would be optimal Any Amplifcation method is likely to have similar performance compared to other TV detection methods (Viper) *Sensitivity and Specificity measured at 95% CI Published in: Schwebke, J.R. et. al. J. Clin. Microbiol. 49:4106-4111 46K Chapin MD 2014 Prevalence of Trichomonas vaginalis and Co-Infection with Chlamydia trachomatis and Neisseria gonorrhoea in the United States as Determined by the APTIMA Trichomonas vaginalis Nucleic Acid Amplification Assay C. Ginocchio 1, K. Chapin 2, J. Smith 3, J. Aslanzadeh 4, J. Snook 5, C. Hill 5, C. Gaydos 6 1 North Shore-LIJ Health System Laboratories, Lake Success, NY, USA; 2 Rhode Island Hospital, Providence, RI, USA; 3 University of North Carolina, Chapel Hill, NC, USA; 4 Hartford Hospital and Clinical Laboratory Partners, Hartford, CT, USA; 5 Gen-Probe Incorporated, San Diego, CA, USA; 6 Johns Hopkins University School of Medicine, Baltimore, MD, USA Determine the prevalence of Trichomonas vaginalis (TV) using the APTIMA Trichomonas vaginalis (ATV) assay among women being screened for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in the United States Determine the co-infection rates of TV, CT and NG Methods Samples were obtained from 7,593 women aged 18 to 89 years undergoing routine screening for CT and GC by the APTIMA Combo 2 Assay Samples were obtained from 30 laboratories in 21 states Clinic types included: OB/Gyn clinics Emergency room Hospital in-patient Family practice Family planning Internal medicine Jail STD clinics 47 48 8

Geographic Prevalence of TV, CT and GC Infections Prevalence of TV, CT, and GC Infections by Age N* TV+ CT+ GC+ Overall Prevalence 7593 8.70% 6.70% 1.70% % (n/n*) (663/7593) (508/7588) (129/7579) Age Mean (SD) 29.82 (10.62) 23.4 (6.0) 24.0 (6.9) Median (min-max) 26 (18-82) 22 (18-65) 22 (18-53) Prevalence (%)* by Age Group 18-19 907 8.50% 14.40% 3.30% 20-29 3972 8.30% 8.00% 2.00% 30-39 1667 7.90% 2.50% 0.80% 40-49 720 11.30% 1.90% 0.10% 50+ 324 13.00% 0.90% 1.20% 49 50 K Chapin MD 2014 * In the calculations of prevalence, the denominator may be less than that the N shown due to missing or invalid assay data. Prevalence of TV, CT, and GC Infections by Age Prevalence of TV, CT, and GC Co-infections by Age N* CT+GC+TV+ CT+TV+ CT+GC+ GC+TV+ % prevalence Overall Prevalence 7593 0.24% 1.30% 0.61% 0.61% % (n/n*) (18/7577) (97/7588) (46/7577) (46/7579) Age Mean (SD) 22.00 (2.35) 23.41 (5.49) 21.89 (3.78) 23.15 (5.53) Median (min-max) 21.5 (18-26) 22 (18-46) 21 (18-37) 21.5 (18-50) Prevalence (%)* by Age Group 18-19 907 0.20% 2.10% 1.30% 0.90% 20-29 3972 0.40% 1.70% 0.83% 0.90% 30-39 1667 0.00% 0.40% 0.10% 0.20% 40-49 720 0.00% 0.40% 0.00% 0.00% 50+ 324 0.00% 0.00% 0.00% 0.30% 51 age K 52Chapin MD 2014 * In the calculations of prevalence, the denominator may be less than that the N shown due to missing or invalid assay data. Prevalence of TV, CT, and GC Infections by Race Prevalence of TV, CT, and GC Infections by Collection Site % prevalence K 53 Chapin MD 2014 54 9

Conclusions from Prevalence Study Ginnochio et al TV prevalence (8.7%) is higher than CT (6.7%) and GC (1.7%) TV prevalence is highest in women >40 years (>11%), while CT and GC prevalence is lowest in that age group (<2%) TV prevalence is highest among black women (20.2%) Co-infection of TV with CT and/or GC was relatively low and highest in women <20 years TV prevalence was highest in jail (22.3%) and emergency room (17.0%) collection sites The high TV prevalence in all age groups suggests that all women being screened for CT/GC should also be screened for TV 55K Chapin MD 2014 56 J. Clin. Microbiol. 51: 101-104; 2013 Disease background Clinical Sequelae Treatment Considerations for future action Treatment of TV Single 2 g oral metronidazole Vaginal gel not as effective (most commonly used for BV) Tinidazole Twice the ½ life of metro (12-14 hrs) Better tolerated True resistance < 10%; can be overcome with higher dosing Therapy is ineffective if partner is not treated! Treating for BV is not the same as treating for TV 57 58 Diagnostic Problem with TV What is it? A vaginal nuisance or an STI? Disease background Clinical Sequelae Treatment Considerations for future action 59 60 10

Getting TV on the Map Educate the healthcare providers Don t know the prevalence or the sequelae Trichomoniasis is not always associated with symptoms, age or obvious sexual risk behaviors Educate the public/patient (Chapin s PR campaign?) Did you know the most common treatable STI is one that your physician may not be testing for?? What STD is a college student s MOM more likely to have then their college student? Educate the Laboratory Know the benefits/disadvantages of current tests methods Many labs/providers do wet mount and think it is OK 61 K 62 Chapin MD 2012 Implementation of Trichomonas Testing Combined Concerted Effort PUBLIC HEALTH HEALTHCARE PROVIDERS LABS PATIENT Insurance 63 64 The STD you have heard of and are going to do something about it.. 65 66 11

References Hobbs MM, Lapple DM, Lawing LF et al. Methods for Detection of Trichomonas vaginalis in the Male Partners of Infected Women: Implications for Control of Trichomoniasis. Journal of Clinical Microbiology, 44(11), 3994-3999 (2006). Nye MB, Schwebke JR, Body BA. Comparison of APTIMA Trichomonas vaginalis transcription-mediated amplification to wet mount microscopy, culture, and polymerase chain reaction for diagnosis of trichomoniasis in men and women. American Journal of Obstetrics and Gynecology, 200(2), 188.e181-188.e187 (2009). Andrea SB, Chapin KC. Comparison of APTIMA Trichomonas vaginalis transcription-mediated amplification assay and BD Affirm VPIII for detection of Trichomonas vaginalis in symptomatic women: Performance parameters and epidemiologic implications. Journal of Clinical Microbiology, 49(3), 866-869 (2011). Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases Treatment Guidelines, 2010. Morbidity and Mortality Weekly Report, 59(RR-12) (2010). CID, 2013 Baron et al, A guide to Utilization of the Microbiology Laboratory for the Diagnosis of Infectious Diseases CAP today Jan 2013 Huppert J, Mortensen J, Reed J et al. Rapid antigen testing compares favorably with transcription-mediated amplification assay for the detection of Trichomonas vaginalis in young women. Clinical Infectious Disease, 45(2), 194-198 (2007). Munson E, Napierala M, Olson R et al. Impact of Trichomonas vaginalis Transcription-Mediated Amplification-Based Analyte- Specific-Reagent Testing in a Metropolitan Setting of High Sexually Transmitted Disease Prevalence. Journal of Clinical Microbiology, 46(10), 3368-3374 (2008). Chapin K, Andrea, S. APTIMA Trichomonas vaginalis, a transcription-mediated amplification assay for detection of Trichomonas vaginalis in urogenital specimens. Expert Review in Molecular Diagnostics. Sept. 2011. Schwebke, J. Mandell s 7 th edition. Trichomonas vaginalis online text 67 12