Sexually Transmitted Infections in Child Sexual Abuse - Update on the Evidence Base Dr Deb Wardle

Medical Evidence – Forensic Evidence One piece of the jigsaw. ‘findings’ present in less than 10% (‘supportive’) ‘Conclusive’ ‘Probable’ findings less than 5% . Forensically significant STI’s are not common – important to be clear on interpretation when they are. Narrative and other evidence tends to play larger part.

British Association Sexual Health & HIV BASHH Adolescent Special interest group – current work in revising management of STI’s in children and young people

Girls and boys - NAAT testing Self /clinician taken vulvo-vaginal (‘introital’)swab- avoiding hymen in pre pubertal Urine –boys Urine option in girls if above problematic-less sensitive in girls.

Chlamydia testing kit

Diagnostic kit Gonorrhoea testing kit This lists different techniquies with swabs, NAAT and culture plates

HSV testing kit

Syphilis Testing kit

Routine testing – non -invasive Sometimes type of testing non-routine –consider reasons for testing and discuss with Gum / microbiology/ virology

Prophylaxis for STI’s – purple book Bacterial –low risk test & treat as required Gonococcal resistance patterns increasing

..one possible exception IUD insertion as emergency contraception consider prophylactic antibiotics to cover PID

FSRH – emergency contraception guidance …should be considered

Viral STIs Hep B Herpes HIV Hep C HPV

Hepatitis B Vaccination within 6 weeks of exposure- prophylaxis Global shortgage-? Link to WHO BBV reduction

Introduction of hexavalent vaccine into the routine childhood programme From 1 October 2017 all babies born on or after 1 August 2017 become eligible for a hexavalent vaccine which includes protection against hepatitis B (HepB). The hexavalent vaccine will be offered in the routine childhood immunisation schedule at 8, 12 and 16 weeks of age. The hexavalent vaccine, Infanrix hexa®, will replace the pentavalent infant vaccines, Infanrix®-IPV+Hib and Pediacel®, currently used in the routine childhood programme. This will mean babies continue to receive protection against diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilius influenzae type b (Hib) as well as protection against HepB

Hep A Increase in MSM Not noted any impact on risk in assault cases- child/adult …however if in contact with an index case hep A vax within ???3 weeks

‘’Young people, particularly women aged under 25, are the group most at risk of being diagnosed with an STI. ‘’ HPS Genital chlamydia and gonorrhoea infection in Scotland: laboratory diagnoses 2007 - 2016

Males 9-21 years (unless msm then up to 26 years) CDC recommendations for HPV vaccination following sexual assault Females 9-26 years Males 9-21 years (unless msm then up to 26 years) Vaccination over the age of 26 years not recommended as it is less effective in reducing HPV related diseases (Saslow et al 2016) 2016 Scannell CDC 2015 HPV Recommendations for sexually assaulted patients a review and update

Case example ‘s’ awaiting results of x3 biopsies from extensive warts present since early 20’s.?AIN/VIN Sexually assaulted as a teenager – now in her 50’s – bleeding from some of lesions triggered attendance. Confident warts as a result of assault as no other partners before assault or before warts first appeared. Continues , as always has, to adversely impact on self image and relationships

HPV vaccination HPV commonest STI worldwide Lifetime acquisition 80% women 90% men Risk factors:smoking, multiple partners,injuries during sex, concurrent STI, immunocompromised.

HPV Double stranded DNA virus 150 strains sexually transmitted In many, virus dormant/transient and doesn’t lead to disease 40 mucosal strains – High risk oncogenic strains 16,18 Low risk 9,11 warts

9vHPV- Gardasil 9 6,11,16,18,31,33,45,52,58 Vaccine activates an immune response against the specific strains Side effects usually local site specific reactions

Scotland Gardasil Secondary school girls – link on SCRRS that vaccine administered Since Sept 17 MSM to age 45

HIV testing HIV bloods (4th generation P24 antigen plus HIV antibody) 95% at 4 weeks 99.9% 12 weeks Point of care test limited use IF 12 WEEKS POST INCIDENT – FINGER PRICK – REPEAT WITH SEROLOGY IF POSITIVE

PEP CHIVA PEP guidelines Most not require Pep Consider in all presenting less than 72 hours and assess risk- prevalence rate considering perpetrators demographics, injuries, number of assailants,liklihood of compliance…

Case examples Chlamydia

C and chlamydia ‘c’ Mum Step dad perpetrator

Mum 6 weeks post natal

‘C’ 14 years old- same age male ‘friend’

Chain of evidence forms

C results Chlamydia positive –vulvo-vaginal sample

Let’s go over things now results back…….14 year old friend ‘friend’ more than a friend –Chlamydia positive

Peripheral Child protection issue Risk of transmission to newborn

Court orders, tests & results ‘C’ Chlamydia positive ‘friend’ more than a friend –Chlamydia positive Mum – negative (baby not reqd to test)

Step dad- result Positive

Step dad’s reaction?

Likely Transmission route

Summary- likely BASHH guidance Prophylaxis – not antibiotics Vaccine – childhood routine Hep B -HPV if not already vaccinated Continued risk assessment for PEPSE if within 72 hours- hopefully continued low level recommended use.

HSV serology

Questions?? 

Thanks for listening