STD Program Director -- Dept. of Health

STD Program Director -- Dept. of Health
STD’s In South Dakota Amanda Gill M.S. STD Program Director -- Dept. of Health

Objectives Describe the epidemiology of STD’s in the US and SD.
Describe the pathogenesis and clinical manifestations of STD’s. Understand current STD trends and morbidity in SD. Understand the importance of the emergence of GC resistance, and appropriate follow up. Understand the current STD treatment guidelines. Define current STD testing recommendations.

Call us for STD Help !

Treat Patient Treat Partners
Prevention & Control Strategy Identify Infections Treat Patient Treat Partners

CDC Encourages all Providers To:
Decrease the STD burden by scaling up STD screening by private providers. Have the “sex talk”– symptoms, prior STD history, risk, anatomic sites, partners. Make the most of your urine. Treat – according to CDC’s updated treatment guidelines. Evaluate and treat all patients’ sex partners from the previous 60 days. Suspected GC treatment failure – obtain cultures and call state STD program Provide sexual health education, counseling, and condoms to patients. Report STD’s, treatment, and partner information to the state STD program

STDs of Concern “Drips” (discharges) Gonorrhea Chlamydia
Background STDs of Concern “Drips” (discharges) Gonorrhea Chlamydia Nongonococcal urethritis / mucopurulent cervicitis Trichomonas vaginitis / urethritis Candidiasis (not an STD) Bacterial vaginosis (sexually associated)

STDs of Concern Other major concerns “Sores” (ulcers) Syphilis
Background “Sores” (ulcers) Syphilis Genital herpes (HSV-2, HSV-1) Others uncommon in the U.S. Lymphogranuloma venereum Chancroid Other major concerns Genital HPV (especially type 16, 18) and Cervical/Anal/Oral Cancer HIV/AIDS

Chlamydia trachomatis

Clinical Syndromes Caused by C. trachomatis
Local Infection Complication Sequelae Urethritis Proctitis Conjunctivitis Epididymitis Reactive arthritis (rare) Infertility (rare) Chronic arthritis (rare) Cervicitis Endometritis Salpingitis Perihepatitis Infertility Ectopic pregnancy Chronic pelvic pain Pneumonitis Pharyngitis Rhinitis Chronic lung disease? Rare, if any Men Women Infants

Chlamydia Diagnostics
Preferred Nucleic acid amplification tests (NAATs) Acceptable in limited circumstances Culture Not recommended Non-amplification tests Serology

Screening Recommendations
Pregnant Women Non-pregnant Women Men Men who have sex with Men Persons with HIV All pregnant women < 25 yrs of age Screen if >25 yrs and at inscreased risk Repeat test in the 3rd trimester for those at continued risk Retest 3 months after treatment Sexually-active women < age 25 years should be screened annually Women ≥25 years old should be screened if risk factors are present. Screening of sexually-active young men should be considered in clinical settings with a high prevalence of chlamydia and when resources permit. Screening at least annually at all anatomic sites of exposure Every 3 to 6 months if at increased risk Screen at first HIV eval, and at least annually after Every 3 to 6 months if at increased risk, and local epidemiology

Treatment of Uncomplicated Genital Chlamydial Infections
CDC-recommended regimens Azithromycin 1 g orally in a single dose, or Doxycycline 100 mg orally twice daily for 7 days Alternative regimens Erythromycin base 500 mg orally 4 times a day for 7 days, or Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days, or Ofloxacin 300 mg orally twice a day for 7 days, or Levofloxacin 500 mg orally once a day for 7 days

EPT Script called into pharmacy
“ Expedited Partner Therapy is the practice of treating the sex partners of persons with STD’s without an intervening medical evaluation or professional prevention counseling.” Script called into pharmacy Pick up meds at providers office – “quick visit” No need for exam or the expense Dept. of Health – DIS office walk-in’s Patient Delivered Therapy (PDT) Given EPT pack

EPT IS OK! (and it works!) Randomized control trials have evaluated EPT vs. traditional partner management for CT and GC More likely to report that all of their sexual partners were treated than those who were told to refer their partners for treatment EPT associated with: Increased frequency of patient-reported partner notification & treatment Fewer re-infections Less likely to be diagnosed with a repeat infection at a follow up visit No evidence of serious adverse events Golden, Matthew R., et al. “Effects of Expedited Treatment of Sex Partners on Recurrence of Persistent Gonorrhea or Chlamydia Infections.” New England Journal of Medicine. 2005; 352:7,

Partner Management Sex partners should be evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceding the onset of symptoms or diagnosis of chlamydia. Most recent sex partner should be evaluated and treated, even if the time of the last sexual contact was >60 days before symptom onset or diagnosis. Expedited partner therapy (EPT) - Delivery of therapy to sex partners by heterosexual male or female patients (“patient-delivered partner therapy”) is an option in some jurisdictions

Estimated that ~ 40 % of partners are not treated
Partner Follow Up For CT and GC – focus on partners in last 60 days Provider-assisted referral Provider notifies sex partners Partners go to clinic for test/treat Patient-referral Patient notifies sex partners DOH DIS-referral Patient tells DIS who their partners are DIS notifies sex partners Partners go to DOH or clinic for test/treat Estimated that ~ 40 % of partners are not treated

Neisseria gonorrhoeae
Gonorrhea Neisseria gonorrhoeae

Gonorrhea: Gram Stain of Urethral Discharge

Syndromes in Men and Women
Anorectal infection Pharyngeal infection Conjunctivitis Disseminated gonococcal infection (DGI)

Gonococcal Infection in Children
Perinatal: infections of the conjunctiva, pharynx, respiratory tract or anal canal Older children (>1 year): considered possible evidence of sexual abuse Vulvovaginitis, not cervicitis, in prepubesient girls Anorectum or pharynx more commonly infected in boys than urethra

Diagnostic Methods Culture tests Non-culture tests
Advantages: low cost, suitable for a variety of specimen sites, antimicrobial susceptibility can be performed Anatomic sites to test: in response to exposure history in persons at significant risk of gonococcal infection, complaints, or clinical findings Non-culture tests Amplified tests (NAATs) Non-amplified tests Gram-stained smear

Treatment of Uncomplicated Gonococcal Infections of Cervix, Urethra, Rectum & Pharynx
CDC-recommended regimens Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1 g orally in a single dose Alternative regimens (If Ceftriaxone is not available) Cefixime 400 mg orally in a single dose If Cephalosporin Allergy Gemifloxacin 320 mg orally in a single dose PLUS Azithromycin 2 g orally in a single dose OR Gentamicin 240 mg IM in a single dose PLUS Azithromycin 2 g orally in a single dose

Partner Management Evaluate and treat all sex partners for N. gonorrhoeae and C. trachomatis infections, if contact was within 60 days of symptoms or diagnosis If a patient’s last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient’s most recent sex partner should be treated Avoid sexual intercourse until therapy is completed and both partners no longer have symptoms

Syphilis Treponema pallidum

Treponema pallidum

Aspects of Syphilis Diagnosis
Clinical history Physical examination Laboratory diagnosis

Laboratory Diagnosis Identification of Treponema pallidum in lesion exudate or tissue Darkfield microscopy Tests to detect T. pallidum Serologic tests to allow a presumptive diagnosis Nontreponemal tests Treponemal tests

Nontreponemal Serologic Tests
Principles Measure antibody directed against a cardiolipin-lecithin-cholesterol antigen Not specific for T. pallidum Titers usually correlate with disease activity and results are reported quantitatively May be reactive for life, referred to as “serofast” Nontreponemal tests include VDRL, RPR, TRUST, USR

Treponemal Serologic Tests
Principles Measure antibody directed against T. pallidum antigens Qualitative Usually reactive for life Titers should not be used to assess treatment response Treponemal tests include TP-PA, FTA-ABS, EIA, and CIA

Pregnant Women Non-pregnant Women Men who have sex with Men Persons with HIV Screen all pregnant women at the first prenatal visit Repeat screen in 3rd trimester Repeat screen at time of delivery Any woman who delivers a stillborn infant after 20 weeks gestation should be tested for syphilis Screen based on local prevalence and the patient’s risk behaviors Screening at least annually Every 3 to 6 months if at increased risk Screen at first HIV eval, and at least annually after Every 3 to 6 months if at increased risk, and local epidemiology

Neurosyphilis—Spirochetes in Neural Tissue
Silver stain, 950x

Latent Syphilis Host suppresses infection, but no lesions are clinically apparent Only evidence is a positive serologic test May occur between primary and secondary stages, between secondary relapses, and after secondary stage Categories: Early latent: <1 year duration Late latent: 1 year duration

Tertiary (Late) Syphilis
Approximately 30% of untreated patients progress to the tertiary stage within 1 to 20 years. Rare because of the widespread availability and use of antibiotics

Congenital Syphilis—

Congenital Syphilis & Syphilitic Stillbirth

Case #1 Mom: 21yrs, Am. Ind., Non-Hisp No regular prenatal care
1st visit Last visit presents at small hospital for L& D Dr. notices labial sore, and questions patient Patient states that the sore “had been there a while” and it wasn’t too painful. Labs Ordered and Results: – RPR was non reactive – Gonorrhea+ – Chlamydia and HIV – – RPR 1:64, TPPA reactive – CT/GC negative Treatment: mg Rocephin, 1gm Zith mU Bicillin

Case #1 Born 4-14-14 Healthy weight and length
No congenital deformities No chancres, rash, or mucosal S/S unresolved fever Baby was transferred to NICU at a larger hospital Labs Ordered and Results: Lumbar puncture – WBC, CBC, protein, glucose all within normal limits. RPR and TPPA non reactive. Blood draw (non-umbilical) RPR 1:8 TPPA reactive Long Bone Survey – Normal Treatment: IV Penicillin 150,000 units/kg/day for 10 days

Case #2 Mom: 16yrs, Am. Ind., Non-Hisp No early prenatal care
Regular 3rd trimester care No vaginal exams presents for 38 week visit. Labs Ordered and Results: Chlamydia +, GC – RPR Non-reactive Gonorrhea + Chlamydia and HIV – RPR 1:256, TPPA reactive Treatment: gm Zith mg Rocephin and 1 gm Zith mU Bicillin Dr. refers mom for C-section and NICU for baby. Vaginal exam , prior to C-section, healing lesion seen.

Case #2 Born 6-5-14 Healthy weight and length
No congenital deformities No chancres, rash, or mucosal S/S Labs Ordered and Results: Lumbar puncture – WBC, CBC, protein, glucose all within normal limits. RPR and TPPA non reactive. Blood draw (non-umbilical) RPR 1:8 TPPA reactive Long Bone Survey - Normal Treatment: IV Penicillin 150,000 units/kg/day for 10 days

Case #3 Mom: 25yrs, White, Non-Hisp Regular prenatal appointments
No current S/S No recollection of past S/S presents for 24 week care Labs Ordered and Results: RPR 1:64, no TPPA done RPR 1:128, TPPA reactive RPR 1:64, TPPA reactive RPR 1:64, TPPA reactive Treatment: mU Bicillin mU Bicillin mU Bicillin Concerns: Re-infection Treatment failure

Case #3 Born 6-5-14 via C-section Healthy weight and length
No congenital deformities No chancres, rash, or mucosal S/S Labs Ordered and Results: Blood draw (non-umbilical) RPR 1:16, TPPA reactive Lumbar puncture -- WBC, CBC, protein, glucose all within normal limits. RPR and TPPA non reactive. Long Bone Survey – consistent with Congenital Syphilis Treatment: IV Penicillin 200,000 units/kg/day for 10 days

Case #4 Mom: 22yrs, Am. Ind., Non-Hisp
, 1st prenatal appointment at 12 weeks “Kissing” lesions & alopecia Labs Ordered & Results: RPR 1:128, TPPA Reactive CT +, GC +, HIV - Treatment: mg Rocephin, 1gm Zith, 2.4 mU Bicillin Fetus: No heartbeat detected on

, 1st prenatal appointment at 10 weeks, negative RPR Regular prenatal care Household had 3 other cases Screened as associate Labs Ordered & Results: RPR 1:64, TPPA Reactive CT +, GC -, HIV - Treatment: gm Zith, 2.4 mU Bicillin Fetus: 12/19/2013 no fetal movement at 33 weeks, no RPR testing at stillbirth delivery

Case #6 Mom: 33yrs, Am. Ind., Non-Hisp Preg contact in April 2014
Regular prenatal care Labs Ordered & Results: RPR non reactive RPR non reactive RPR 1:64, TPPA Reactive CT -, GC -, HIV - Treatment: mU Bicillin Fetus: no fetal movement at 31 weeks, no RPR testing at stillbirth delivery

came in for ingrown toenail, requesting pregnancy test Provider did STD screen 25 weeks Labs Ordered & Results: RPR 1:32, TPPA Reactive (secondary) RPR 1:16 RPR 1:64, TPPA Reactive CT, GC, HIV negative Treatment: As of , patient is untreated Fetus: no fetal movement stillbirth 2lb, 3 oz, 13.5 inches

Therapy for Primary, Secondary, and Early Latent Syphilis
CDC-recommended regimens Benzathine penicillin G 2.4 million units intramuscularly in a single dose (Bicillin L-A®) If PenicillinAllergy Doxycycline 100 mg orally twice daily for 14 days OR Tetracycline 500 mg orally 4 times daily for 14 days

Therapy for Late Latent Syphilis
CDC-recommended regimens Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units intramuscularly each at 1-week intervals If PenicillinAllergy Doxycycline 100 mg orally twice daily for 28 days OR Tetracycline 500 mg orally 4 times daily for 28 days

Follow-Up Primary or secondary syphilis Latent syphilis
Reexamine at 6 and 12 months. Follow-up titers should be compared to the maximum or baseline nontreponemal titer obtained on day of treatment. Latent syphilis Reexamine at 6, 12, and 24 months. HIV-infected patients 3, 6, 9, 12 and 24 months for primary or secondary syphilis 6, 12, 18, and 24 months for latent syphilis Neurosyphilis Serologic testing as above Repeat CSF examination at 6-month intervals until normal

Management of Sex Partners
For sex partners of patients with syphilis in any stage Draw syphilis serology Perform physical exam For sex partners of patients with primary, secondary, or early latent syphilis Treat presumptively as for early syphilis at the time of examination, unless The nontreponemal test result is known and negative and The last sexual contact with the patient is > 90 days prior to examination.

Syphilis Case Study

History Stan Carter is a 19-year-old male who presents to the STD clinic. Chief complaint is a penile lesion for 1 week Last sexual exposure was 3 weeks prior, without a condom. No history of recent travel Predominantly female partners (3 in the last 6 months), and occasional male partners (2 in the past year) Last HIV antibody test (2 months prior) was negative

Physical Exam No oral, perianal, or extra-genital lesions
Genital exam discloses a lesion on the ventral side near/at the frenulum. Lesion is red, indurated, clean-based, and non- tender. Two enlarged tender right inguinal nodes, 1.5 cm x 1 cm Scrotal contents without masses or tenderness No urethral discharge No rashes on torso, palms, or soles. No alopecia. Neurologic exam with normal limits.

Questions What are the possible etiologic agents that should be considered in the differential diagnosis? What is the most likely diagnosis? Which laboratory tests would be appropriate to order or perform?

Stat Lab Results The results of stat laboratory tests showed the following: RPR: Nonreactive Darkfield examination of penile lesion: Positive for T. pallidum What is the diagnosis? What is the appropriate treatment?

Reference Lab Results RPR: Nonreactive FTA-ABS: Reactive
HSV culture: Negative Gonorrhea NAAT: Negative Chlamydia NAAT: Negative HIV antibody test: Negative Do the reference laboratory results change the diagnosis? Who is responsible for reporting this case to the local health department?

Stan’s Sex Partners Tracy – last sexual exposure 3 weeks ago
Danielle – last sexual exposure 6 weeks ago Jonathan – last sexual exposure 1 month ago Tony – last sexual exposure 8 months ago Carrie – last sexual exposure 6 months ago Which of Stan’s partners should be evaluated and treated prophylactically, even if their test results are negative?

Sex Partner Follow-Up Stan’s partner, Tracy, is found to be infected and is diagnosed with primary syphilis. She is also in her second trimester of pregnancy and is allergic to penicillin. 9. What is the appropriate treatment for Tracy?

Follow-Up Stan returned to the clinic for a follow-up exam 1 week later. Results were as follows His penile lesion was almost completely healed. He had not experienced a Jarisch-Herxheimer reaction. The RPR (repeated at the follow-up visit because the initial one was negative) was 1:2. 10. What type of follow-up evaluation will Stan need? 11. What are appropriate prevention counseling messages for patients with syphilis?

Chlamydia Case Study

History Suzy Jones: 17-year-old college student who presents to the Student Health Center seeking advice about contraception Shy talking about her sexual practices Has never had a pelvic exam Has had 2 sex partners in past 6 months Does not use condoms or any other contraceptives Her periods have been regular, but she has recently noted some spotting between periods. Last menstrual period was 4 weeks ago. Denies vaginal discharge, dyspareunia, genital lesions, or sores

Physical Exam Vital signs: blood pressure 118/68, pulse 74, respiration 18, temperature 37.1° C Breast, thyroid, and abdominal exam within normal limits Genital exam reveals normal vulva and vagina The cervix appears inflamed, bleeds easily, with a purulent discharge coming from the cervical os. Bimanual exam is normal without cervical motion pain, uterine or adnexal tenderness.

Questions What is the initial clinical diagnosis?
What is the most likely microbiologic diagnosis? Which laboratory tests should be ordered or performed? What is the appropriate treatment at the initial visit?

Laboratory Results NAAT for Chlamydia trachomatis: positive
NAAT for Neisseria gonorrhoeae: negative Wet mount: pH 4.2, no clue cells or trichomonads but numerous WBCs KOH preparation: negative for “whiff test” HIV antibody test: negative Pregnancy test: negative

Questions 5. What is the final diagnosis?
What are the appropriate prevention and counseling messages for Suzy? Who is responsible for reporting this case to the local health department?

Partner Management Suzy’s sex partners from the past year:
John – Last sexual exposure 5 weeks ago Tom – Last sexual exposure 7 months ago Michael – Last sexual exposure 2 weeks ago 8. Which sex partners should be evaluated, tested, and treated?

Follow-Up Suzy returned for a follow-up visit at 3 months
Her repeat chlamydia test returned positive Suzy stated that her partner, Michael, went to get tested, but the test result was negative so he was not treated 9. What is the appropriate treatment at the 3-month follow- up visit?

Gonorrhea Case Study

History: Robert Forbes
33-year-old male who presents to his doctor reporting a purulent urethral discharge and dysuria for 3 days. Lives in Dallas with history of travel to Las Vegas 3 weeks ago. New female sex partner (Laura) for 2 months. They have unprotected vaginal intercourse 4 times/week, the last time being 2 days ago. No oral or rectal sex. Also had a one-time sexual encounter with a woman he met in Las Vegas 3 weeks ago (Monica). They had oral and vaginal sex. No condoms used. No history of urethral discharge or STDs, no sore throat or rectal discomfort. Negative HIV test 1 year ago.

Physical Exam Vital signs: blood pressure 98/72, pulse 68, respiration 14, temperature 37.2° C Cooperative, good historian Chest, heart, musculoskeletal, and abdominal exams within normal limits No flank pain on percussion, normal rectal exam, no sores or rashes The genital exam reveals a reddened urethral meatus with a purulent discharge, without lesions or lymphadenopathy

Questions What should be included in the differential diagnosis?
Which laboratory tests are appropriate to order or perform? What is the appropriate treatment regimen?

Laboratory Results Results of laboratory tests:
Urethral and pharyngeal culture: showed growth of a Gram- negative diplococcus that was oxidase-positive. Biochemical and FA conjugate testing confirmed this isolate to be N. gonorrhoeae. NAAT for chlamydia: negative RPR: nonreactive HIV antibody test: negative 4) What is the diagnosis, based on all available information? 5) Who is responsible for reporting this case to the local health department?

Partner Management Robert’s sex partners within the past 3 months:
Laura: Last exposure - Unprotected vaginal sex 2 days ago Monica: Last exposure - Unprotected oral (Monica performed fellatio) and vaginal sex 3 weeks ago while he was in Las Vegas Jerilyn: Last exposure - Unprotected vaginal sex 3 months ago 6) Laura was examined and her lab results came back negative for gonorrhea and chlamydia. How should Laura be managed? 7) What tests should Jerilyn and Monica have?

Follow-Up Robert returns 4 months later for an employer-sponsored flu shot. He took his medications as directed, is asymptomatic, and has had no sex partners since his office visit to you. 8) Does Robert need repeat testing for gonorrhea? 9) What are appropriate prevention counseling messages for Robert?

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