BIDC Resources for Healthcare Providers
Information and resources for healthcare providers regarding infectious diseases monitored by the Bureau of Infectious Disease Control
Monthly Webinars
Monthly Webinars
The Division of Public Health Services hosts monthly webinars for healthcare providers and public health partners on the 2nd Thursday of each month from 12:00 – 1:00 PM EST to provide updates on important and timely public health issues. Access the webinar via the link below.
Please note the new meeting information:
- Join the meeting in Microsoft Teams
- Meeting ID: 278 434 186 837
- Passcode: Bvfiah
- Call-in phone number: 603-931-4944
- Call-in passcode: 902 201 066#
Future Webinar Topics
- September 12: Respiratory Virus Season Updates; Oropouche and Other Arbovirus Updates
Watch the webinar on Gonorrhea, Chlamydia, and Doxycycline PEP
Healthcare Providers and Public Health Partners Call Presentation, March 14, 2024
Healthcare Providers and Public Health Partners Call Presentation, March 14, 2024
Healthcare Providers and Public Health Partners Call Presentation, March 14, 2024
Transcript of video:
all right uh good afternoon everybody uh why don't we go ahead and get started it's just a minute after the hour um let
me first start by welcoming all of you again to our monthly uh Public Health webinar uh today's topic as you can see
on the screen is going to cover um garia chedia and doxy cyclin postexposure
prophylaxis um I am recording this webinar and it will be posted online afterwards similar to the syphilis uh
webinar that we conducted a few months ago um and we're going to start off here with uh Dr altamare from darmouth
Hitchcock Medical Center uh presenting on the national epidemiology of garia
and chlamydia and then talking um I'm giving a a brief clinical didactic on um
testing and treatment recommendations for chyia and ganara and then I will take over and talk about New Hampshire
specific epidemiology very briefly and then uh talk about doxy cyclin post
exposure um prophylaxis um just as a reminder uh the chat function is
reserved for us posting links and information to all of you uh if you have
a question please use the Q&A box um we will not be taking hand raises or verbal
questions so if you have a question or comment please use the Q&A box which can be found in the zoom toolbar um also as
a reminder these slides will be posted online on our healthcare provider website which hopefully all of you are
familiar with um would also encourage you all to um go back and watch the earlier companion webinar to this one
that uh was recorded and posted online about syphilis and congenital syphilis
that is also um on this website uh so with that why don't I hand things over
to Dr altamare and she will get us started here by talking about the national epidemiology of garia and chyia
and then be uh briefly talk about testing and treatment recommendations before I take back over Midway through
um so Antonia go ahead thank you Dr Chan and uh thank you all for signing on another one of my favorite topics garia
and chlamydia um so this kind of first um intro slide kind of gives you high
level statistics of how many people in the US have an STI um and so as of 2018
this data was one in five and of uh most significance is about almost half of the
new STI were among youth aged 15 to 24 next slide
please so just to set the stage the the newest data we have is actually from the year 2022 and as you can see um there
were 1.6 million cases of chyia and around 600,000 cases of Gonorrhea these
are new newly diagnosed cases and so for chlamydia it seemed like it was a slight
decrease compared to 2018 data um but garia has been on the rise and we've
touched on in Prior lecture syphilis so I'm going to skip over that statistic today next
slide as you know if left untreated STI can cause um an increased risk of giving
or getting HIV there are also long-term pelvic or abdominal um consequences such
as pain and infertility um so the real key is to talk about it test for it and
treat it next slide so just to give you kind of a l Escape of what STI are most prevalent
and where new infections are happening and a reminder that prevalence is the estimated number of
infections um that are that people are living with at any given time and incidence is really the estimate of new
infectious infections diagnosed or undiagnosed and you can see here um far
above many others HPV Remains the most common sexually transmitted infection followed by herpes
hsv2 um and tronus camia make up kind of the top four in fact all of these make
up around 98% of all prevalent STI and 93% of all incident STI so although we
talk a lot about syphilis and gonorrhea they are overall um less numerous than
than chlamydia and some of the other infections next
slide so just wanted to kind of give you what um these infections have been looking like over time so we're going
back really far in some of these graphs um for chyia the upper left you can see
this graphic is from the year 1984 until around 2020 and the overall
General trajectory looks a little bit like the stock market so overall has been going up um where the arrow is
that's where they um the US CDC had decided to make this a national
identifiable condition um so you can see that it was plateauing a little bit before then but once reporting had
kicked up you can see that it's been nothing but up of note there's um a few hiccups or bends in a lot of slides
between the years you know 2020 and 2022 and that actually has to do all with the
covid pandemic where um testing had actually dropped off and so we saw less
cases but that doesn't mean there were less cases um it was more of a testing um void uh so if you look over at the
top right garia that graph definitely looks different and the um year span is
really 1941 so 40 years prior to where the chyia slide starts and you can see
that there was a nice dip in in around the 60s which actually we could probably
a tribute to penicillin um back in the day that's no longer the recommended treatment for Gonorrhea but its cousin
is and then you can see how there was a spike in the 880s came back down in the early 2000s and now we're on our way
back up um just looking at some of the more specific demographics when it comes to Asian gender they are different between
chlamydia and ganaria um you can see for chlamydia the bottom left box that there
are more females um infected with chyia and if looking at goria there are more
males but the age distribution is very similar and tends to affect again that youth AED
population next Slide the other thing to point out is
for both chyia and ganaria this graphic looks exactly the same and that is the
fact that um ethnic minorities are dis disproportionately affected by these
infections so you can see on the left um white and purple that's the percent of
the population that white people make up and what percentage of infections are
made up of white people and similarly for black being the most starking kind of color that goes pretty much from
pretty low down on this graphic at 12% of the population however black africanamerican make up about 28% of all
infections next slide so the disparities so as
previously stated 50% of reported cases of STI were among adolescence and young
adults age 15 to 24 in 2022 and 31% of all cases of camag goner and syphilis
combined were among non-h Hispanic black or African-American persons although like just stated they make up the
minority of the US population and men who have sex with men are disproportionally impacted by STDs
including gonorrhea and syphilis in fact 36% of men who have sex with men who
were diagnosed with syphilis also had concurrent HIV and so the quote from the CDC is that these disparities are
unlikely explained by differences in sexual behavior and rather reflect differential access to Quality Sexual
Health Care as well as differences sexual Network characteristics next
slide I also wanted to note that not only are the absolute numbers of infections going up but we're having an
increasing problem with antibiotic resistance um so this graphic just shows
different types of antibiotic specifically used for neria gara um and
the percent um that have increasing mic's or that minimum inhibitory
concentrations which it's eventally essentially makes them less effective against the bug so half of all
infections in 2022 were estimated to be resistant or have some um elevated level
of minimum inhibitory concentrations to at least one antibiotic but almost all
the circulating strains in the US remain susceptible to sep triaxone which is the primary recommended treatment for
uncomplicated gonorrhea next slide in fact some of you may have seen this Han that came out now
a little over a year ago January 2023 where there have absolutely been reported cases of resistance or reduced
susceptible um gonorrhea in Massachusetts and so the Han really
reiterated um the importance of screening treating um and if a suspected
treatment failure to really obtain a culture which we'll talk about when we talk about Diagnostics next
slide so we can't really talk about STI without talking about sex and I may have mentioned this before but a sexual
history taking should be taken as part of routine health care and I know when I was in med school and in training this
was not a huge part of my training talking about sex is uncomfortable for a lot of reasons um but it allows you to
really provide high quality Patient Care by appropriately assessing and screening individuals for a broad range of sexual
health concerns and an opportunity to educate patients normalize those behaviors and discuss harm reduction
next Slide the CDC puts out this wonderful um booklet it's um the size of
a pocket so it can easily fit in your pocket um and it follows the five PS of sexual history taking so these are kind
of the five categories you should be addressing um when speaking to patients who are your partners what do you do
with them do you use any protection from STI what are your past history of STI and what are your pregnancy intentions
um they actually have wonderful quotes within in the booklet on how to actually frame the question um and you know be
able to risk assess that patient this is important because when it comes to screening it's really important to
screen all sites of exposure and that might not just be a urine specimen next
slide so what are the recommendations so these are the um latest uspstf screening
recommendations for garia and clamydia for all sexually active women 24 years
or younger or 25 years and older with increased risk which you'll see below it's recommended that they be screened
for Gara and chlamydia so what does it mean to have increased risk it means a
previous or coexisting STI a new or more than one sex partner a sex partner
having sex with other partners at the same time a sex partner with an STI inconsistent condom use when not in a
mutually monogamous relationship a history of exchanging sex for money or drugs or a history of
incarceration on the other hand the recommendation for men um is that the
current evidence is insufficient to assess the balance of benefits and harms of screening routinely for clidia or
ganara in men I do want to point out on the next slide please that the CDC as of
2021 had updated their screening guidelines and not only do they List It by disease but you can List It by
population so I wanted to bring your attention to um the category of men in
particular men who have sex with men next slide there actually are very specific
recommendations for screening menu of sex with men and it's recommended that this be done for both clim and ganaria
at least annually for any sexually active men who have sex with men at sites of contact so that would mean
urethra rectum um and in the case of goria the fairings and if they remain at
increased risk it's recommended to do it more frequently perhaps as frequent as every 3 to six months so you can see how
this differs slightly from the blanket statement from the uspstf where they um
you know it's a it's a grade I recommendation because there's not particularly strong evidence to screen
all men but if you get down to kind of risk categories um you can see that
there may be indication to screen certain men next slide so how do we screen the gold
standard for chlamidia and ganaria is a nucleic amplification test Um this can be done on various
specimen types vaginal or cervical swabs are sufficient for um anyone with a
vagina um or a first void urine which tends to be a little more difficult because by the time you're seeing a
patient in your schedule at 2 o'clock in the afternoon they've certainly already voided um patients can collect their own
specimens and a vaginal swab collection is equivalent in sensitivity and specificity to those collect Ed by a
clinician um the same goes for urine samples being comparable to a cervical
or urethal urethal swab as long as it's um a first uh a first day collect um you
can also use these swabs for the Oro fairings the rectum um and in babies we
often use it for the conjuntiva the key here however is to test all sites of
exposure next Slide the reason being there's now two well documented studies
looking at positivity rates and incidents of STI in various populations
and in this first one you can see that extrog genital goria and chyia were common among MSM men who have sex with
men attending this particular STI clinic and More than 70% of extrog genital Gara
infections and 85% of extrog genital chlamydia infections were associated with negative urethal tests at the same
visit and hence would not have detected up to in this case 85% of infections if
only the urine or the urethra were screened this same thing is now been proven and seen in a separate study done
um in in a cohort of patients infected with HIV at a HIV Clinic um who had
multiple sight testing and in this cohort found that 96% were positive only at an extrog
genital site we have have pretty much the same experience within our HIV um
population and in our clinics whereas if we do multi-site testing almost always
the the positive tests are coming from anywhere other than the urine or
urethra so if you can't remember the words remember this image and I apologize if I've ruined ice cream
Sundays for the rest of your life but remember the triple dip you're going to test for rectal urine and Fingal Gara
and CLA with the caveat that there's actually not enough evidence to screen
for chlamidia in the ferx because the clinical significance is not well known
so it's not actually a routine recommendation to screen however if it's found because you're using the same swab
and both tests are run on the same swab then you should treat because you certainly can transmit if there's um
chyia in the fairings and then the chocolate sauce and Cherry are the HIV syphilis and in the case of rectal
receptive sex Hepatitis C serology so all of these are potential infections
that can be acquired through sexual contct the the top HIV syphilis and Heep
C are blood tests and all the others have to be done through either swabbing or urine collection using um very
specific swabs so the next slide will show you exactly what that means um so
the swab that you should have on hand is is and this is just one Manu facturer
it's a it's a collection swab for endocervical and it's it's labeled in male urethal specimens but again it can
be used and and is FDA approved for use at other sites um how do you do it is
the most common question I get and it is quite simple if you've ever done strep tests swabbing the oral fairings is very
similar you want to you want to swab both tonsils um pillars the back of the
oral fairings and all the way around so you can make one big sweep like in in an upside down U fashion and you've got
your specimen you put that right into the tube and you label that with
obviously a patient label and but label it throat because you're going to be sending down several specimens and you
do need to know which specimen is positive if there is one because treatment guidelines May differ for
rectal swabbing just as easy you take out that blue swab and you stick it
about an inch into the rectum and twirl it around for about 10 seconds both of these swabs can be done by the patient
in fact most patients opt to do the rectal swab themselves most have a little more difficulty difficulty
self-collecting the oral fial swab and finally the last picture is a picture of
a vaginal swab um which again most patients opt to self-collect same maneuver about an inch or two into the
vagina spin it around for about 10 seconds put it into a separate bile so it should be separate swab separate
vials for all specimen site collections next slide
so what are the treatments so you do all this swabbing and you get test results back 2021 guidelines have changed quite
significantly from the prior iteration for STI treatment and probably the biggest change was in the treatment of
chlamydia which AI used to be the main state of treatment has now been moved to the alternative because doxy cycl has
proven to be much more effective especially when treating um rectal mucosa for chlamydia so the newest
guideline and recommendation for treatment of chlamydia is doxycyclin 100 milligrams orally twice a day for seven
days so you might ask gosh the adherence to this is going to be a lot less than the athra 1 gr which used to be a single
dose we haven't found that to be the case most people do just fine taking it
but know that if you worry about adherence you can use the aiyin they're
just maybe lesser efficacy particularly if you're trying to treat um rectal
mucosa um advice to the patients should be that they should abstain from sexual intercourse for the first seven days of
treatment um because that's about how long it takes to be effective otherwise they could potentially still be at risk
of transmitting infection and partners have to be notified and we often leave
this up to the patient um uh and partners means anyone that they've had contact with in the last 60 days of
diagnosis should be tested and treated and anyone who receives a diagnosis of
chlamydia should certainly be tested for HIV gonor and syphilis which you're doing probably chamian gonor at the same
time but don't forget upfront if you're testing for STI it means you should be testing for all of
them great so a word of caution on a particular strain of chyia which we've
definitely seen clinically here and that is a syndrome known as lymphogranuloma
Venum which is caused by a very specific Cobar of chlamidia trus it's L1 through
three um and it it causes a very different syndrome so what I haven't mentioned so far is that most cases of
chlamydia and even gonorrhea are asymptomatic so the intent of screening
is to pick up an asymptomatic infection and screen it certainly if someone comes in with symptoms you absolutely should
be testing for uh and treating any positive test that comes back but in the
case of this particular bug and syndrome this is very symptomatic and L
symptomatic it often causes tender unilateral ininal lymphadenopathy it could cause genital ulcers but the
syndrome we see most is that of proctocolitis which for all intents and
purposes mimics and looks exactly like IBD it has um significant colonic
inflammation diarrhea maybe constipation blood mucus colonic fistulas and
strictures that could develop and this isn't over a prolonged period of time this inflammation happens very quickly
but will persist without treatment and in fact I've had patients who've been seen by um various GI coloral surgeons
and they you know just assumed it was all new diagnosis of IBD but the
diagnosis is getting a rectal swab for GC chlamydia or in this case very
specifically chlamydia the same chyia you're testing for um in the other slides that I mentioned so a simple swab
of the rectum will give you the answer if it comes back for chlamidia trus and
they have this syndrome then essentially you can say they have lymphogranuloma Venum and need treatment for that which
is as you can see different than the 7-Day course you would give for asymptomatic rectal chamia so this is a
21-day course of doxy cyclin and symptoms should completely resolve there
is no commercially available test to actually tell you the zerar of the
chlamydia so this diagnosis and treatment is really based on a combination of the clinical syndrome and
a positive rectal uh swab next slide great so moving quickly
on to gonorrhea um there were also some updates to the treatment of gonorrhea
and that mainly had to do with the dose of seph triaxone so sep triaxone has been the um main stay of treatment for
quite some time now because as you remember ciprofloxacin athro other antibiotics that used to be used are now
quite resistant um the change here to overcome some of the rising mic's is a higher dose and to
note that it's it's a one gram dose for anyone who's over 150 kilos so really
pay attention to the weight of the person in the dose needed to treat um
ganaria uh the treatment is the same regardless of the site of infection
however there's one difference and that is if you're treating oral Fingal gonorrhea a test of cure is recommended
at 7 to 14 days because the sep triaxone tends to be a little less effective in
penetrating the Oro fial tissue than it is the other sites so we are on the side of retesting around 14 days because you
are testing again with a nucleic amplification test and if you test much earlier you may pick up on um non-viable
organism and it could be a false positive what you're really looking for is failure of treatment in this case um
and if symptoms if the person's actually symptomatic in any of these sites and you're treating for gonorrhea and
symptoms persist despite treatment then you really need to repeat not only a nucleic amplification but send a
specimen for culture because this will be the only way to get antimicrobial susceptibility testing and with the rise
in in the number of resistant isolates um this is this now should be the new Norm um if you have persistent symptoms
in the setting of symptomatic infection so there are alternative
regimens but they're not great so you can see here um if someone has a true sephos borin allergy then you're looking
at gentamycin and ethy um so it's not easy and I would
make sure for all those I'm putting air quotes around this word penicillin allergic patients truly have allergies
and try to flush that out before um uh deciding that you're not going to give them first line
therapy next slide great so followup test of cure is is pretty much not
advised for non- pregant persons but what is recommended is repeat testing
for anyone who's had a positive test um at 3 months after treatment and the reason there is not because we're
looking for failure um of treatment but you're actually looking for reinfection because the reinfection rate is really
high especially if Partners don't get treatment at the same time the only caveat to that are pregnant women they
always fall in a category of themselves given the risk to baby and so in particular when it comes to cidial
infections it is recommend that they actually have a test of cure at 3 to four weeks after
treatment next slide great so here we are at the end um if you take away
nothing else STI are on the rise a detailed sexual history is really important testing all sites of exposure
are the most important remember your triple dip and the swab you need to use and treat per the updated CDC guidelines
um the link to the guidelines are on this slide and were referenced in in the previous slides and you can go to the
next next side um the other you know kind of like little logo or slogan to
remember that hersa is actually pushing out is this ask test treat repeat it's as simple as that we need to ask test
treat and repeat and there's a little YouTube video there that you can watch too here are the references and know
that um the STI guidelines are available through an app super easy on your phone
when you click into it you can click on the disease entity it gives you all the treatment recommendations right there so if you don't happen to be you know
someplace where you're on a computer or they also have Wall um Graphics uh
pocket cards things like that um super important information to keep handy and
that's it thank you great thanks so much uh Dr alari for that excellent uh review
I am going to um take just about five seconds here to switch slides uh we
weren't able to combine them into one single deck my apologies for that that um and then I will pick up and take over
here and Antonia can you just confirm that you can see my slides now yep in
the correct presentation mode Perfect all right so thank you again Dr alari for that excellent clinical review I'm
going to talk very briefly about um the epidemiology of chlamydia and garia in New Hampshire although I'm going to move
fairly quickly through these slides because the patterns and the trends are very similar to what Dr Almar showed um
with the national Epi so this uh is a graph of the total number of cedia
infections diagnosed each year in New Hampshire going back to about 23 years
uh to the year 2000 so not quite as far back as some of the national graphs that uh Dr alar showed but you can see that
the trend here is um very similar where for a good decade plus we saw um gradual
and continual increase in the number of cidial infections each year that peaked
uh at just over 4,000 infections um before it has uh slowly down trended
when last year in 2023 we were almost at 2,800 chamia
infections um but the trend here is very similar to the National picture and if we stay on um chial infections this is a
graph looking at the total number of infections in New Hampshire by age and this is actually looking at the last
three years of data combined so 202 1 through 23 data is combined here and
again you can see that the majority of chlamydia infections are occurring um in older adolescents and people in their
20s um and 30s which is consistent also with the national picture and it's not surprising given that this is um partly
where the the screening recommendations uh Focus um and this contrasts with what I'll
show you in a few slides around ganaria um where there is a higher number of um infections in older age groups groups um
this is looking at the number of infections in New Hampshire by County again uh the 2021 to 23 data is combined
here uh and you can see that the the um burden of infection really is focused
around the Southern and uh Central parts of the states with uh Hillsboro County
having the highest number of chlamidia infections followed by Rockingham and then straford and Marram counties um
when we look at uh risk factors or reported sexual risk factors um you can
see that the vast majority we don't have information on so more than twoth thirds of uh people diagnosed with chlamydia uh
we don't know what their sexual risk factor is and then another quarter plus uh report um heterosexual uh contact the
the one of the main reasons for the large unknown category is simply the fact that we have um so many cidial
infections uh that many if not most of them don't get the uh full Public Health
investigation to determine risk factors and um sexual partners uh it has just
become um a a burden that is unable to be sustained um when doing Public Health
contact tracing hence we don't have a lot of information on on uh the people who are diagnosed with
chlamydia uh when we look at um ganara Trends this is a graph um looking at the
total number of Gonorrhea infections in New Hampshire East each year going back to 2000 the year 2000 um you can see
that this uh is very similar to the National trend for uh a good decade plus
we had a relatively stable um level of ganara infections at about 130 or so per
year um and then began to see a dramatic increase um around 2015 2016 where we
actually did um healthcare provider messaging at that time so some of you on this webinar may remember that messaging
back then about the dram increase in gonorrhea that had continued to go up and has not come down uh
2022 uh saw the most number of gonner infections at just over
670 uh last year U about 591 gonorrhea
infections were diagnosed in New Hampshire so we saw that dramatic increase back in 2015 2016 uh and the
numbers have remained High um since then in terms of age groups you can see that
you know still people their late teens 20s and 30s are largely impacted uh but we do see a shift to um older age groups
which is also consistent with um National ganaria trends that Dr Almar showed earlier uh in terms of uh the
geographic area impacted in New Hampshire this is um similar to the prior graph I showed for chyia looking
at the total number of goria infections now in New Hampshire by county and you can see similarly that um Hillsboro
County uh has had the most number of infections diagnosed followed by um
Rockingham and then straford and marrat counties and then similarly uh with
reported sexual risk factors there's about half of people diagnosed uh we don't have um or don't know the sexual
risk um about or on uh a little over uh a quarter report heter heterosexual
sexual contact almost a quarter report um uh men who have being uh men who have
sex with men um and so this is also not a uh surprising uh Trend
here so what are the strategies that we have to prevent the spread specifically of chlamydia in ganaria and I'm
specifically calling out climan ganara because with some other sexually transmitted infections for example HPV
we have a vaccine um Hepatitis B virus we have a vaccine um HIV you know there are
strategies like hi pre-exposure prophylaxis or prep that is utilized but with Clan Gario there is no
vaccine um and so a lot of our control methods Focus first on behavior
modification and risk reduction strategies so you know asking patients
uh or recommending patients reduce the number of sex partners have you know lower risk sexual encounters wear
condoms Etc um and that frequently is not um a successful or long-term
successful strategy and so then we look to healthcare providers and the healthcare system for secondary
prevention right early detection of infection through screening and testing um as highlighted by Dr almare you know
appropriate treatment retesting if appropriate um as I alluded to contact
tracing to identify exposed and susceptible persons often times uh is is
not successful either due to the burden of infections and reports coming in or
the simple fact that many people um do not want to or are unwilling uh to share
very personal information about um their sexual contacts uh and then there are
strategies that have been talked about previously around expedited partner therapy that's where providers um treat
Partners without necessarily having a clinic visit to assess them um but that is also difficult to implement from a u
clinical um perspective so there are a number of different strategies that uh
are used to prevent the spread of chlamy and ganara um and yet over the years we have continued to see uh rates of these
infections um overall continue to Rise um and so new strategies need to be
employed and investigated and that's where uh transitioning now to doxycyclin
postexposure prophylaxis uh comes in as an a potentially important tool uh for
controlling the spread of specifically bacter material STI this is a table from uh a from some
draft guidelines that CDC put out um a number of months ago
um this is coming but this is not yet formally released by the CDC and so you
may have heard about this in the media you may have seen um stories about this
you may have even seen um the draft guidelines eles when they were released a few months ago you can still find them
online but here is a highlevel summary of what we expect is likely coming from
the CDC in their doxycyclin postexposure prophylaxis or pep guidelines uh where
there's a recommendation based on um a highquality evidence that doxycycl 200
milligrams taken once orally within 72 hours of sex um can be considered for
gay bisexual and other men who have sex with men including transgender women uh
who are at higher risk for STI uh or as defined by having a history
of at least one bacterial STI in the prior 12 months so a lot of information
there but that is the population that CDC is looking at recommending doxycyclin pep for um based on studies
that I will be showing you here in the subsequent slides there is no recommendation they have the second uh
row here we expect that they will release guidance that there is no recommendation given at this time for
the use of doxy cyclin pep in cisgender women cisgender heterosexual men
transgender men other queer and non-binary individuals if this intervention is offered it should be
implemented with considerations for ancillary Services as detailed Below in their guidance so this is not a
recommendation against using doxy cyclin pepep for these other groups just
acknowledging that there is insufficient evidence for a strong recommendation for docy cyclin pep in these groups so this
is again draft doxy cyclin pep guidance which we expect is coming from CDC very
soon uh in the next month or two months or three months hopefully um and what I
wanted to do was just take a little bit of time and walk through three studies um which uh published studies which um
this guidance is largely I think being based off of and so first let me apologize that the the next few slides
are going to be a little bit text heavy and data heavy um but I think it's important um information so the first
study to really look at this and be published was a randomized study published back in I think it was 2017
2018 in the lanet um where they did a subgroup study so it was an amended
study um of high-risk menual of sex with men that were originally studied to
conduct that was originally conducted to study the efficacy of HIV prep that's
you know prevention of HIV with the use of tenopir and emtricitabine which many people know as
under the Brin name travada but they took a subgroup of this larger study uh
and looked at the efficacy of doxy cyclin pep um in France at preventing
bacterial STI so this was a a study conducted in France it was an open label
study meaning participants knew if they received doxic cyclin or not um and
participants had to be adults either um men who have sex with men or transgender
women having sex with men uh they were HIV negative right because they were all initially being studied for HIV prep and
they had to be at high risk for HIV acquisition um and so they were randomized to doxy cyclin versus a
standard of care and with the doxy cycl pep group uh that group was instructed
to take 200 milligrams of doxic cyclin um in a uh once within 24 hours but no
later than 72 hours after each high-risk sexual event and the they instructed
participants to take no more than three doses per week um they studied the
occurrence of a first bacterial STI and they combined chlamidia gonorrhea or
syphilis into one primary outcome measure they followed up these patients every two months with testing for
chlamydia gonorrhea and syphilis uh testing for chlamydia and gonorrhea was conducted through throat and rectal
swabs and urine um and they also assessed doicy adherence and in the
table at the bottom uh you can see uh the followup that they had the numbers of people and the proportion that
followed up um every couple of months for the different groups and you can see that followup was uh pretty high across
the study and so what they found uh and what I'm showing here are the camplan Meyer
curves from their analysis uh in the upper left you have chlamidia Gara or
syphilis combined as a single metric in the upper right goria and then in the bottom chlamydia and syphilis and so the
blue lines are those who were on doxy cycl pep the red lines in each graph are
uh the participants that did not receive pep and the graphs show the cumulative
probability of the STI that's being analyzed and in each graph I've and in
each graph I've highlighted the hazard ratio and so essentially what these graphs show the one in the upper right
is they found a 47% reduced risk of a new bacterial STI in the doxycyclin pep
group that's you know chlamidia ganara or seis uh 47% reduced risk they found
no reduced risk um of G of Gonorrhea in the doxycyclin pep group as shown in the
upper right and then uh across the bottom with chlamidia and syphilis 70 and 73% reduced risk of chyia and
syphilis respectively um and so the the overall findings of this 47% reduced
risk of a new bacterial STI largely was driven by the reduced risk for chlamidia
or syphilis um in people who received doxic cyclin pep so pretty significant risk reduction
with the use of a single dose of doicy after a high-risk sexual event um a few
other important findings here majority of goria and chlamydia was detected from
rectal and throat swabs as previously highlighted by Dr Alamar this highlights the importance of testing and screening
at all sites of sexual contact 71% of STI that were diagnosed were
asymptomatic again consistent with Dr Al with what Dr alamari showed previously and highlights the importance of
screening and then doxic cycl adherence they measured through a number of different measures um during the clinic
visits about 83% reported taking doxy cyclin within 24 hours of a sex encounter when they measured um plasma
concentrations um they only detected doxic cyclin in about 30% of the pep
group recipients the caveat here being that the plasma test they did was only
able to detect doxycyclin use in the previous 48 hours so not a great test of
doxycyclin exposure if the test only picks up doxycycl use in the last two days um and then what's also important
of note with compliance and adherence is that um 63% of participants in the doxy
pep group and 25 % of those in the non-ep group had at least one plasma
sample with doxic cyclin detected so there were a potentially substantial number of people in the um comparison
group the non- pep group that were found to also be taking doxy cyclin which
would have um potentially watered down their results and yet they still found a statistically significant risk reduction
uh for prevention of chyia and syphilis with using doxycyclin pep
um of note the study did not assess the impact of the use of doxic cyclin on
antibiotic resistance subsequent Studies have however done that um so what I'm going to show you now is probably one of
the um main articles and studies uh that is that has been um conducted and used
to develop cdc's um draft doxy cyclin pep guidance this is a New England
Journal of Medicine article that was just published in about a year ago April of last year um it was also a randomized
open label clinical trial conducted in the US this time specifically at HIV and
sexual health clinics in San Francisco San Francisco in Seattle um the participants were very similar to the
the prior study so adults um men of sex with men or transgender women having sex
with men um people taking HIV prep one difference here is that they included
HIV positive individuals um and then uh participants
were also at high risk for HIV and high risk for STI as defined defined as a
person who was diagnosed with a bacterial STI in the previous 12 months that if that sounds familiar that's
because that's what was incorporated into cdc's draft um and potentially upcoming uh pep guidance they were
randomized 2: one people in the doxic cyclin pep group again were instructed to take doxy cycling 200 milligram by
mouth once within 24 hours but no later than 72 hours after each high-risk
sexual contact the difference this time is that they they had a maximum of once every 24 hours remember that in the
prior study they uh the maximum was three times per week in this study uh
they allowed a maximum of once every 24 hour uh use of uh or dosing of doxic
cyclin they had an number of different outcomes um again the the primary outcome here being studied was the
occurrence of at least one bacterial STI that's goria chlamidia or syphilis each
quarter so they followed these individuals for 12 months with quarterly scheduled clinic visits where they did
testing and so they did their analysis by quarter and so if a person was diagnosed with multiple STI in a single
quarter that person only contributed to the analysis once per quarter so an
important sort of caveat to keep in mind they also study tetracyclin resistance
in ganaria isolates as well as staff orius isolates we'll talk more about that um and at each Clinic visit they
did chlamidia goria and syphilis testing uh again similar to the prior study they took swabs of the throat and rectum and
uh collected urine samples for the chlamidia and ganara testing they access dox they assessed doxic cyclin adherence
um and then what was new in study is that they took swabs of um participant naras and Oro ferins uh to try and
culture staff orus so they were looking for staff orius colonization and they
did doxic cyclin resistance testing on those cultures and of note the study was
stopped early because of um the effectiveness of doxic cyclin postexposure
prophylaxis when they did the analysis they did the analysis by two different cohorts this is the prep pep cohort so
this is showing the results of um doxy cycl pep in participants who were on HIV
pre-exposure prophylaxis that's the trva andaban prep um and what you can see is
they broke it out by um any STI and then um the bottom part of the uh chart here
uh garia chlamydia and syphilis and so what you can see is on the right hand
side where I highlight the uh uh risk ratios is that the doxycyclin pep group
uh showed a approximately um 2third or 66% reduced
risk for the diagnosis of any STI as highlighted by that relative risk number
of. 34 and you can see then you know for any ganaria any chlamydia or any early early
cus infection that there were also significant risk reductions with the use of Dr cyclin pep um when you get to the
chlamydia and syphilis levels you know we're talking um 87 88% reduced risk of
chamian syphilis individually with the use of doxic cyclin Pep so pretty
substantial significant reductions in the risk of these STI both combined uh
as well as individually including with gonorrhea they also did a separate analysis for participants living with
HIV um you can see that they found very similar uh risk ratios um and risk
reductions with the use of doxic cyclin Pep um tetracyclin resistance uh they
evaluated tetracyclin resistance in ganaria cultures and staff orius cultures the graph I'm showing here on
the Le hand side is um looking at goria cultures um there's a lot of information
in these graphs um which might be a little confusing um in parenthesis at the bottom under each um you know
Baseline versus doxic Cycling group versus standard of Care Group they're showing the total number of um cultures
that were obtained and in the bars they show the percentage of and the number
and percentage um of those cultures which came back showing uh resistance
and non-resistance so they had culture growth in a minority um that uh showed
resistance in the dark blue bars and non-resistant gonorrhea in the light blue bar
um and you can do sort of simple math to uh determine that about 27% of ganara
isolates that were cultured at Baseline were resistant to
tetracyclin um and when you look at the proportion that were resistant between
the two study groups uh 38% resistant versus 12% resistant uh there was a
difference there in the proportion um of ganara results that were uh resistant
tetracyclin the clinical significance of this is a little bit unclear because as Dr alamari highlighted um tetracyclin is
not a recommended antibiotic anymore for treatment of um
Gara when they when they looked at staff orus cultures so very similar graph but
um a little more confusing here perhaps um you can see that at Baseline 12% of
Staff orius cultures showed resistance to tetracyclin and between the two study
groups at 12 months um into the study in the doxic cyclin pep group 16% of Staff
orus cultures were resistant to tetracyclin versus 8% uh in the standard of Care Group now that also is a higher
proportion that were resistant to tetracyclin but what's also of note is
that staff orus Carriage Carriage was 40% lower in the doxy pep group versus
standard Care Group at 12 months so there a little bit of a trade-off because there was less Carriage uh
detected in people uh but uh slightly higher resistance in the doxy cyclin pep
group again hard to know um the clinical significance of
this um 30% of participants had an STI
diagnosed at enrollment so high proportion who came into the study with an STI that had to be that was diagnosed
and treated um 86% of participants in the doxy pep group reported taking doxy
cyclin consistently um and they also had a number needed to treat that they calculated uh of about five so that is a
pretty low number needed to treat number so in summary um doxy cyclin pep taken
within 72 hours of condomless sex decrease Gara chlamidia and early
syphilis by about 2/3 among menu of sex with men and transgender women doxic
cyclin pep also substantially reduced the occurrence of each bacterial STI
individually including gonorrhea so when you look at syphilis it was about a 77 to 87% reduced risk with the use of doxy
cyclin pep with chlamidia 74 to 88% reduced risk with doxycyclin pep and
with goria 55 to 57% reduced risk with doxic cyclin
pep um now one of the questions is well why do they have a significant reduction
in goria in this study but not in the prior study conducted in France um and
there is some explanation behind this you know tetracyclin resistant gunara was more prevalent in France when the
prior Lancet article study was conducted um compared to Gar tetracyclin
resistance resistant ganara in the US it's about 56% versus 20% uh resistant
ganara and this may partly explain the different ganaria findings in the two studies and this becomes important
because the final and third study I'm going to show you um has that that that fact goria
resistance factors in as well so in the last few minutes let me highlight this final study um looking at doxic cyclin
postexposure prophylaxis to prevent STI in women so this is again a randomized
open label clinical trial of women 18 to 30 years of age in Kenya were not
pregnant and were receiving HIV prep therapy they were randomized one to one
to receive doxy cyclin postexposure prophylaxis or standard of care um and
similar to the last study uh the doxy pep group was instructed to take um
doxic cyclin 200 milligrams um orally once within 72 hours after each
condomless sexual encounter with a maximum of 200 milligrams or you know one dose per day
um again they tracked the occurrence of any bacterial STI each quarter so similar to the prior study a person with
multiple STI in a quarter contributed to the analysis only once they similarly
followed uh these women for 12 months with quarterly clinic visits they assess
doxic cyclin adherence um at the visits and also by weekly text messages and
interestingly they also collected hair samples to test for doxy cycl exposure
and uh each hair sample represented about a month of exposure they importantly also did molecular
resistance testing to detect doxy uh tetracyclin resistance um in ganaria and
chlamidia isolates and what they found was uh no significant risk reduction in
any STI or chlamydia or ganara individually um so the incidence of
bacterial STI was not significantly lower in the doxy pep group compared to the standard of Care Group there was
only one syphilis infection identified which prevented sort of separating it out in the analysis um and importantly
100% of ganaria isolates um showed tetracyclin resistance compared to no
chlamydia isolates had tetracyclin resistance and so this likely factored in to the ability to show um any
statistical significance um with you know Gara individually or um you know in
combined endpoint um there were also issues with um doxy cyclin compliance so
despite about 80% of participants in the pep group reporting doxic cyclin use um
when they did hair sample testing doxy cyclin was only detected was detected in
at least one visit in only about 56% of participants and when they excluded
participants where doxy cyclin was on hold for example if a woman became pregnant
they had to hold the doxic cyclin or if there was concern for pregnancy they had to hold the doxic cyclin um well they
assessed when they excluded visits where doxic on doxy cycl was on hold uh doxic
cyclin was only detected in about 33% of visits so the this study um found that
the incidence of bacterial St eyes was not significantly lower with doxy cyclin
pep compared with standard of care in women receiving HIV prep in Kenya um and
importantly hair sample testing to assess doxic cyclin use suggested that doxic cyclin was not taken during the
majority of months and on top of that doxy cycl resistant Gara 100% of
isolates showed resistance likely impacted the ability to show efficacy so
those are the three primary studies which um are published studies um which
are um the basis for cdc's draft doxy cycl pep guidelines as shown here this
is what I highlighted previously this is why the the focus is of these guidelines
is in men who have sex with men and transgender women who are at higher risk for
STI um but this guidance um as it was last reviewed here um does not exclude
the possibility of um using doxy cyclin pep in other populations it's just that
there is insufficient data and um more study will be needed and there are
additional recommendations and ancillary Services which become important when um discussing and counseling patients
including screening for other STI as Dr Alamar highlighted risk reduction
counseling um you know having that discussion about the the risk and the benefits of doxy cyclin pep assessing
for HIV prep pre-exposure prophylaxis and vaccination for other um STi for
which there is a vaccine available um so we don't have a lot of time left um but
let me just maybe see if Dr alamari wants to make any comments I know um the
providers are already starting to use doxy cycl pep um clinically um given the
data given the draft guidance that um has been put out and we expect more formal guidance to come shortly but let
me um just see in the last minute or so if Dr uh uh Dr alar has any comments about how this has been implemented uh
clinically in her clinic or in other um provider clinics yeah thanks Dr Chan
this was a great overview of all the various studies that have supported this upcoming recommendation and I have to
say that you know the patients are also hearing about this through various
networks um and so they've been asking more like hey should I be on docy pep
and so right now we've actually been doing it on an individual kind of risk assessed basis um I have several
patients that are on it um and uh there's you know a lot of um counseling
to go with it you know this doesn't obviate the need for barrier protection
um it doesn't help all SDI so there's a lot of kind of the general counseling that you have to give no matter no
matter what including you know when prescribing HIV prep I think we talked about it again actually at our team
meeting today and the concern that was raised I think by someone else in the chat was are we worried about antibiotic
resistance and I really do think there's some hesitancy especially given the data you showed that you know we we could
create more resistant bugs if um if this was blanketly used for everyone on the
other hand we could be preventing a lot of unnecessary sexually transmitted infections so I think there's a hard um
line a fine line to walk right now and so I don't think people are universally
recommending it for sure and obviously the be guidance on strict indications but it's the word is out there and
patients are definitely asking about it great that's very helpful thanks so much for your um input thank you to all
uh participants um there's a lot of information here uh thank you very much to Dr Alamar for um her clinical review
and um comments here at the end and just as a reminder these slides and the
recorded webinar will be posted online on this website afterwards uh so you and
others can go back and review not only this webinar but also the syphilis and congenital syphilis webinar we had back
in December so we're a minute over time let me um stop and thank you all for your participation uh and we will see
you back here again uh next month thank you all very
much
Watch the webinar on Syphilis
Healthcare Provider Webinar, 12/14/2023: Syphilis & Congenital Syphilis
Healthcare Provider Webinar, 12/14/2023: Syphilis & Congenital Syphilis
Healthcare Provider Webinar, 12/14/2023: Syphilis & Congenital Syphilis
Transcript of video:
speaker here great so good afternoon everybody thank you for joining us once again on
our monthly Public Health webinar today's topic will be to discuss syphilis and congenital syphilis uh and
I am joined by my colleagues Dr Elizabeth talbet um and Dr Antonia
altamare uh Dr altamare is an infectious disease physician um up at Darth
Hitchcock Medical Center she's also an associate professor professor of medicine at the Gil school of medicine
at Dartmouth and the medical director for the New Hampshire AIDS Education and Training Center one of her areas of
expertise within infectious diseases is HIV and sexually transmitted infections
uh and so I asked her to come on today to give um some background and clinical
dactic on syphilis uh so she's going to start off by uh providing a um clinical
background on testing treatment for syphilis give a little bit of national epidemiology on what's happening with
syphilis uh and then and then at the end I'm going to take over and talk about syphilis um in New Hampshire look at
some epie slides and then a recent publication from the CDC so with that let me thank um Antonia for being on and
I will hand it over to her to uh Drive the slid set here thank you great thanks
Ben again sorry for the late start um we're gonna move right in um and to let
you know the obvious that if you haven't noticed syphilis is certainly not a disease of the past um and
you know there's updated numbers every year but the most recent kind of collection you see here is that we have
increasing um infections of all flavors of sexually transmitted infections but I really want you to focus on the number
of new syphilis cases and most importantly newborns being born with
congenital infection um this is up to date as of 2021 and I'm going to show you a little later on what the 2022
statistics looks like which are actually um much much higher um so every single
one of these cases is preventable um and you can see here that we've now had at least one reported case
in almost every state in the United States and really truly unnecessary and preventable deaths from babies infected
with syphilis and when you look at the general epidemiology of populations and
infection cases in these populations you can see a sign ific jump in cases in
women over the last several years and as you would expect as the number of cases of primary and secondary syphilis
increase in women we are seeing a dramatic increase in number of congenital syphilis cases there's been a
lot looked at in these cases and it's very surprising at the missed opportunities we see and you can see in
this graphic which I really love to show kind of where are the where is the bul of where we could have intervened so
where are those missed opportunities in that large top kind of green bar that
you see on the rise that represents no timely prenatal care and no timely
syphilis testing and so some of that may be out of a provider's hands if someone
just shows up kind of in labor and they didn't come in for treatment um but if you look down at the next purple bar
that big chunk represents no adequate maternal treatment despite the receipt
of a syphilis diagnosis and that's a real big missed opportunity um the the
next pink one down is late identification of seroc conversion during pregnancy so may have tested
negative at the beginning but actually either acquired infection or had a late seral conversion later on and this was a
missed opportunity and then a much smaller proportion are no timely syphilis testing despite the receipt of
timely prenatal care and so many of these bars and chunks of opportunities are places where we can absolutely do
better so I wanted to start with just kind of basic syphilis we call it syphilis but the organism the bacteria
that actually causes it is a Spyro called treponema padum and can be acquired sexually or hematogenously and
in this lecture we're talking a lot about vertical transmission so mother to child and as you know if left untreated
is associated with significant complications and can facil facilitate the transmission and AC I of HIV
infection so this is a great graphic that I've been using now from a recent
um report in the New England Journal about the stages of syphilis and
textbook wise it used to be that you have a primary a secondary and a latent phase and then you move on to tertiary
but this actually explains really more what happens and how much more complex infection really is because you can
actually flip-flop between stages and CNS Invasion which we always thought
about as kind of a tertiary or late manifestation of syphilis really can be the primary and sometimes the only
manifestation of early syphilis and this becomes really important when doing a really good history taking and physical
exam because staging syphilis correctly is very important on how to treat it um
so if you remember the Shanker is kind of primary that primary lesion um that
occurs at the site of inoculation and so many times this is missed both by the
patient and um providers because it may be in areas that you can't see it could be on a cervix it could be in the mouth
it could be in the rectum these are obvious places on a penis and one is um Aion on the tongue which is very often
missed for um um an AP this ulcer and so this these lesions appear
several weeks after infection um and they're self-limiting classically
painless and classically solitary however I've seen plenty of patients who've had multiple lesions and
sometimes painful lesions because it can become secondarily infected um so not always textbook in a hard stage to
identify because it's often missed and without treatment it does go away on its
own and you kind of move into what we call the secondary phase which is more of the
disseminated um speto infection that comes with just a typical
viral like illness so patients will typically have fevers chills maybe a body rash um and again they may not
think much of it and it will self-resolve without any treatment and so unless they come to attention to
someone and and get a physical exam this may again be missed and some of those Hallmark um features that you may see um
are that palms and Soles rash but it can be just a diffus macular papular rash on the torso um this left picture of the
tongue is actually a secondary um case of um lesions on the tongue which is
unusual but again um can be mistaken for a lot of different things like geographic tongue or just who knows what
that could be but it's not typically classic and then after this stage it it
sets into what we call more the asymptomatic stage it becomes latent but
that doesn't mean that people are not still infectious and this stage becomes really important for screening um
because again transmission can still happen and and it's most important in pregnant women to identify um this stage
because there is still a risk of transmission to Baby so we'll go over a little bit more but wanted to give you
very high points here and to keep this graphic in your mind as to how truly complicated syphilis can be and to just
have it in your differential for any syndrome really um and to get together with a sexual history should prompt
testing so I wanted to move on to what the current screening recommendations are and and these are the uspstf
screening recommendations for asymptomatic non-- pregant adolescent adults um at increased risk of
infection um and they recommend a a one-time screen and the risk category
that they Define is highest in menu of sex with men persons with HIV or sexually transmitted infections persons
with illicit drug use and a history of incarceration sex work or military
service additionally regardless of any of those risk factors it's universally
recommended that all pregnant women be screened for syphilis early in pregnancy
so as early as them coming into care and if there's more questions about
that the CDC had updated their STI um treatment guidelines and have um developed a new section on screening
which is both divided by disease and population which is great um so if we
for example look at syphilis you'll see this entire table um and who should be
screened and at what interval based on potential category or population and so
just looking at pregnant women for example it says all pregnant women at the first prenatal visit should have a
screening test and retesting at 28 weeks and delivery if at high risk um because
we're finding that we're missing that opportunity and someone who was potentially infected during the early
pregnancy and may seroc convert later in pregnancy so a little bit more specifics
about syphilis and pregnancy and why this is so important um transplacental
transmission of the treponem can occur at any time during gestation but really occurs with increased frequency as
gestation advances and women with untreated primary and secondary syphilis
are more likely to transmit to their fetuses than those with latent disease however if you look at the first even
four years after infection you could pass on that infection to a fetus in 80%
of the cases um and the result there could be up to 40% of P of the babies
will um result in infant death or still birth the risk of transmission Beyond
those four years after infection really starts to go down and it's about 2% but
it's not perfect and it's not zero and so essentially what this is saying is
even if a woman has been infected with syphilis you know three years prior to when they conceive they're still at risk
during that pregnancy to transmit infection to BB and hence the reason it's so incredibly important to screen
all pregnant women um for syphilis interestingly the chupones are
not transferred in breast milk milk however if that that is the point of inoculation and there happens to be a
Shanker on the breath that is absolutely um a vehicle from which uh the
treponemes can be transmitted to Baby during breastfeeding so again being very alert to physical exam findings or
complaints of any kind of skin lesions so why is this so important well
the complications are real um and you can see here what the adverse pregnancy outcomes are um in untreated maternal
syphilis so pretty significant risk of adverse outcomes almost 80% of pregnancies will have something
unexpectedly go wrong including congenital infection pre-term birth low
birth weight miscarriage still birth uh and Fetal loss and so this is really
what we're trying to prevent drilling down to what the screening guidance really is as I've
said and hopefully you will get this by the end all pregnant women should be screened and tested for syphilis at
their first prenatal visit and for women at high risk you should really be performing additional testing in the
third trimester and perhaps again at delivery and we'll go over um the
details in that high risk for infection any woman who's had a fetal
death after 20 weeks gestation should be tested for syphilis this is really important because 20 weeks is really
when the immune system has developed and it's really the immune reaction to the treponemal infection that causes the
congenital anomalies and so any death in a fetus that H that happens after 20
weeks should spark a High um pre-test probability for syphilis infection and
therefore those women should actually be um screened at that point and essentially the teaching is no
mother or neonate should leave the hospital without a serologic test documented at least once during that
pregnancy or if um high- risk documented at the time of delivery and just circling back to the
fact that syphilis can actually increase the risk of transmission or acquisition of HIV every time you test for syphilis
you should also be testing for HIV so women at high risk here it is if
they've ever been diagnosed with an STI during pregnancy they fall into a high-risk category if they exchange sex
for drugs or money have multiple sex partners have late entry into care no preal care reside in an area of high
syphilis prevalence which you'll get a better sense of where we live in Hampshire with this later on um have me
methamphetamine or heroin use are incarcerated or the partners incarcerated or have unstable housing or
homelessness just to highlight there's actually laws in several States requiring testing in pregnancy um and
you can see there's very few that don't require it by law um I did double check
with Ben and he can correct me if anything has changed but New Hampshire does not have a law for any time um um
basically mandating uh a cist testing in pregnancy but you can see Most states do
at least for entry into care and several states have requirements by law to
retest in the third trimester Andor again at delivery so let's talk about testing
because this seems to be what is completely overwhelming when um providers test and then get a result and
they're so totally confused and it's so totally not your fault we just don't have better tests and so this is what we
have to deal with we have non-treponemal tests and we have treponemal tests and
depending on your laboratory it can be any combination of those that you see listed
here and the testing algorithm consists of a combination of these two because we
just don't have a Magic Bullet test that we can do that'll give us a straight answer the differen is in the way the
tests are performed and why Labs um choose what tests to have really comes
down to to um Personnel Resources and training as well as cost um so some Labs
have an rpr others have a vdrl for their non-treponemal as far as treponemal are
concerned there's all these different variations and I'm going to show you why it's important to know what you're
reading and looking at when a test result comes back what I want to start with not to
confuse you but to understand when you would expect these tests to become positive because that is really
important in trying to Stage syphilis um and the other piece
that you're going to need to know for that in you know to inform treatment is
whether or not the patient has had a prior history of syphilis and whether that's been treated and when um because
all of this is really important in trying to interpret your test result you have at hand so what you can see as you
probably know with most other serologic testing the IG turns positive before the
IGG and both of those actually turn positive before any non-treponemal test
so you see here the lines of vdrl um or rpr go up after you start to
see IGG and then actually come down at a pretty slow and steady rate even if the
disease is left untreated so it's possible that you can have someone who is infected with syphilis maybe 10 20
years earlier who never got treated and their rpr at some point may be reported
as non-reactive and that's just because it does Wan with time we expect it to
WAN and get to non-reactive with treatment and that's one of the key features to follow in treating patients
um but know that very very early in infection and very very late in infection you could have a falsely
negative nontreponemal test just to add more more confusion
there's different algorithms that can be used and it's really important to know what your particular lab uses uh to
diagnose and um do these these tests for syphilis um there's a traditional
algorithm which actually starts with a non-treponemal assay so for example that rpr and if it's reactive it has to be
confirmed and so that second test is usually a treponemal specific test um
and if it confirms Ms reactive then you have confirmed an infection with syphilis the problem is you don't know
whether it's current or past and that's where history taking is really important if that treponemal test ends
up being non-reactive in the setting of a non-treponemal test being positive then it's quite possible that first
non-treponemal was a false positive most places I find are actually
using the reverse algorithm but again know what your lab uses to help you try to interpret the final test result but
that just starts with a treponemal test instead of a non-treponemal and then it
moves on to a treponemal and if there's discordant results you just kind of need a tiebreaker so that's where the third
test comes into play Labs often do this Cascade automatically so all you would
have to do is grab one specimen sample from a patient send it off for syphilis testing in the lab should Cascade
through this um but obviously call the lab ask them to help you interpret if there's any
questions um about the algorithm they're using or um whether or not you need to
get further blood so I do have some sample um uh
test results I just wanted to run through quickly to highlight um how this
might be confusing these are all patients of mine they're screenshots from our medical record and this is
simply because we use the reverse algorithm this is what the test result came back for a patient who was screened
for syphilis syphilis IGG IGM negative it would be safe to assume that this
person does not have syphilis at this time of course if they have continued exposure or rest you'd want to repeat
testing at some interval depending on that risk but it would be safe to tell the patient at this point they do not
have syphilis infection looking at this this is again reverse algorithm the first syphil test
actually came back positive so it reflects to an rpr and the rpr was positive with a tighter of 1 to eight
that is confirmed syphilis infection again whether this is old or even
recently treated infection is unclear without more history um or this could be
new infection with a you know uptrending rpr that would need treatment but this is syphilis
infection looking at this one this had an initial IGG posit positive and the
results unfortunately don't always result in the order that the Cascade is done but if you look at it R PR was done
that was negative and so it it reflexed to a third treponemal test which was
positive so that confirms that this patient had a history of syphilis at
some point because they have two treponemal tests that are positive but an rpr that's negative or non-reactive
so may not represent active early infection
this particular example is one where syphilis iggm was positive but rpr was
non-reactive again being that it's discordant it has to reflect to a tiebreaker which in this um example was
the T palad of and body at the bottom and that was nonreactive so you can actually say in
this case I think that first test was a false positive and you don't have
syphilis and I'll go over what conditions can actually cause false positive tests and this is just an
example of sometimes we get patients getting tests done where there's the traditional algorithm that's used and if
an rpr comes back negative um it's likely safe to assume that they do not
have active current syphilis infection although it gets a little tricky again if this is latent disease and it's
untreated untreated disease um and in particular if it's a pregnant patient
where you become worried could you be missing something um but again if they're that far out and rpr is negative
they're unlikely to transmit beyond that kind of four years of latency all right hopefully that helps
but you can mul over this uh the slides will be posted I know this is confusing
so I wanted to go over what can actually cause a false positive non-treponemal so this is an rpr test unfortunately this
is common and it's real common in pregnant women to have a false positive rpr for example and this study they were
looking at vdls again it's the non-treponemal tests but here are some other conditions that can actually cause
a false positive nontreponemal acute febrile illness recent immunization autoimmune disorders IV drug use chronic
liver disease and HIV and hence the reason that we say all positive tests should be confirmed with additional
testing what about the treponemal test well that's even more common to be positive in pregnant women and falsely
positive other um trigger for this would be Advanced age tumor dialysis
autoimmune disease and other spiroketal infections like malaria or leprosy and again the reason why we really need to
confirm a positive test when it comes to the nontreponemal
tests there are instances where I've kind of already eluded you can have a false negative and so that's when the
rpr is non-reactive really early infection um can have a non-reactive rpr so if you
catch that patient with that primary Shanker it is possible that about 20 to
30% of patients with that Shanker might have a negative treponemal non-treponemal test but if you have um
if you go through the algorithm the treponemal test is likely to be positive that early in
disease I'm going to skip and go down to late infection because we talked about that a little earlier if it's really
late infection non-real tests can become non-reactive over time
and then similar to the theory behind early treatment of Lyme disease for example you may um uh prevent seroc
conversion the same can happen in early treatment of syphilis so that's a third scenario where you might have a positive
treponemal but never seroconvert the non-treponemal and that's if you receive um really early
treatment and the fourth scenario is the prozone effect or the prozone reaction which I'm probably taking you back to
med school years um where these are such such high tighters of antibody that they
Clump and they don't allow um the antigen antibody complexes to become app
parent some Labs automatically check for this um but if you have a patient who
has especially secondary syphilis or even primary where you expect that rpr
to be really high they have a lot of spirro load that would be the place where if you got a negative rpr you
would ask that lab to please dilute that specimen and check again because you have a high pre-test probability given
how they're presenting whether that be with a diffused skin rash or primary Shanker that you're really worried about
syphilis and you need them to recheck that with some dilution it also occurs in pregnancy HIV
and Neurosis so um those things are higher probability of having this
prozone reaction happen I do want to touch on and I'm not
going to read this word for word but want to reference you to the STI treatment guidelines again that CNS
infection can happen at any point in infection even with early primary
syphilis and we are seeing more and more patients actually present with isolated
ocular syphilis or odic symptoms including hearing loss or Idis and these
abnormalities can become permanent and result in hearing loss or vision loss if
it's not identified and early and treated early and so these excerpts are taking you
through what you should do and consider as far as CNS evaluation and in what circumstances for CNS at the top uiis or
ocular in the middle and odic symptoms below again we see these patients often and it does not you cannot miss it
because this could have devastating outcomes in the interest of time I might
gloss over um the neurosyphilis testing it's probably going to be be rare that
you have to go down this line but in the event that you do know that again testing is not perfect um so even if you
have a negative vdrl with a high suspicion for neuros syphilis and an elevated protein in white count that
negative vdrl does not rule out neuros syphilis but the importance of making
the diagnosis is treatment absolutely differs for neurosifilis and it's actually the same for CNS disease ocular
disease or odic disease requiring IV antibiotics as opposed to traditional IM
IM penicillin so what are the treatment
guidelines so anyone with primary secondary or early latent which we Define as a positive test we think with
infection acquired in the past year and the only know the way to know that would be if they had had prior testing and you
have that test result as clearly negative within the prior year then that person can be classified as early latent
if you have no prior history of testing or testing was more than a year ago they fall into late latent disease so for
primary secondary and early late T syphilis treatment is quite easy it's
one dose of IM benzine penicillin alternatively for nonpregnant
patients if and I'll show you why this is going to become important if there's either an allergy or a shortage of the
above medication you can actually use doxycyclin but it's two week weeks of B doxy
cyclin if someone has late Laten so asymptomatic just screen positive it's
been more than a year the recommendation is for three once weekly injections of
Ben benzathine penicillin alternative again for non-pregnant patients is doxy
cyclin but this time for 28 days and as stated previously any and all neuros
syphilis including even isolated ocular OIC syphilis requires IV penicillin
there is an alternative option for imrane penicillin but it needs to be
given with probenicid um for 10 to 14 days in case you didn't catch it the
only treatment in pregnancy for Syphilis is penicillin even if the patient has
known anaphylaxis to penicillin you admit them desensitize them and give
them penicillin why because this is the only known antibiotic with treatment efficacy and no
contraindications um and that we know Works uh to treat both mom and baby
because other non-penicillin antibiotics such as tetracycline or doxy cycling are contraindicated in pregnancy um other
drugs May lack sufficient data on efficacy and or don't cross the placental barrier there's really strict
guidelines as to the dosing regimen and if if you're treating someone with late
Laten so just asymptomatic test positive syphilis and you're trying to give those
three once weekly doses you cannot miss more than nine days in between dose so
if that patient gets first dose day you know one and doesn't come in until day
11 for the second you have to start the series all over again um so remember
nine days is a key interval it should be seven um but you can stretch it to 9ine
after which if it's beyond that you have to start over so here's the ringer um there's a
national shortage of buy selling um and so there is a very clear alert that is
in the guidelines and available through the CDC that this be reserved to treat
pregnant people with syphilis and babies with congenital syphilis because penicillin is the only recommended
treatment for these populations as I said doxy cycl is an alternative for all others and staging p patients
appropriately is really important in conserving um the supply that we have early syphilis only requires one dose um
so don't feel the need to give three if you can accurately um uh stage
disease so one last thing you should know about is the jerk Herkimer reaction
which is quite common in the treatment of early syphilis infection and this
Tempo um manifest as an acute systemic reaction but it's to the rapid killing
of the spyit and it can cause worsening of the symptoms they already have including skin rash fevers chills teoc
cardia arthas headache fitis
Al a 95% of people who are treated for primary or secondary syphilis in
pregnancy however this can be quite problematic because this reaction alone can precipitate pre-term labor labor and
Fetal distress um so it's actually recommended that if you have a pregnant person who actually has signs or
symptoms of primary or secondary syphilis that the first dose of treatment be given under continuous
fetal monitoring um to make sure that there isn't any evidence of Al distress due to the jerk's herxheimer
reaction so what are outcomes maternal treatment is Curative for both mom and
fetus in most cases so the risk of congenital infection in a mom who's been treated is one to 2% however if you
leave that person untreated then it's almost guaranteed that their baby may become
infected predictors of treatment failure in pregnancy are are a high
non-treponemal type tighter at the time of treatment or delivery ultrasound abnormality suggestive of congenital
syphilis early stage infection treatment that happens less than 30 days before
delivery again early identification and early treatment is key and delivery um
less than 36 weeks gestation so to wrap it up wanted to let
you know that syphilis can have very serious complications when left untreated there's big initiatives out
there now one of my favorite is this ask test treat repeat it's as simple as that
this website is really great there's a great little um video that you can watch and some toolkits available through
hersa um at this link here and additionally I wanted to leave you with the links that you can bookmark
or apps you can download for quick reference on how to treat all STI um and most importantly the center
the national network of STD clinical prevention training centers has a hotline that's available 247 that you
can call for expert consultation I've used this hotline before for complex HIV
patients the people on the other end are incredibly nice and helpful and so if there's ever any questions about test
interpretation or whether you should treat and what to treat with please visit um the national Consultation
Services they're great Additionally the national STD curriculum um available for
the University of Washington has also really great um updated um educational
material um so that is it and happy to take questions at the end great thank you Antonia for that
excellent uh clinical dactic on syphilis I'm going to move ahead here and talk a
little bit about um syphilis and what's happening in New Hampshire with syphilis
and unfortunately because we were having some technical difficulties earlier um I'm not able to drive my slides so I'm
going to um let Dr alamari continue to navigate here so this first slide here
is looking at the total number of syphilis infections that have occurred in New Hampshire each year going back to
2000 uh this represents all stages of syphilis um and again is showing data
from 2000 up through 2022 when we have um completed data you can see that you
know over two decades ago we were at about you know 20 infections identified
each year in New Hampshire uh that has progressively and steadily increased
over the last two decades um and we are now at as of last year 176 people in New
Hampshire uh diagnosed with syphilis um the 2023 numbers are still
preliminary and are still um coming in so we'll see if this trend continues but this trend as it's shown here on this
graph for New Hampshire also mirrors the national Trend and while the overall burden of syphilis in New Hampshire is
much much lower than some other sexually transmitted infections like ganara like
chlamidia um the trajectory is very concerning and as I'll show you in a few slides there are some really very
unfortunate consequences um for syphilis increasing in our state uh next
slide so this next slide is looking um at the total number of syphilis
infections in our state by age group uh this is combining the last three years
of data together so 2021 to 2023 data combined that's 2023 data that we have
so far to date again um this year's data is obviously incomplete and includes uh
cases that have been reported to us through the end of November um but uh mostly three years of data here that has
been combined um and you can see that uh uh thankfully no syphilis infections in
people under the age of 18 um but beginning in the teens and early 20s uh
the number of infections starts to increase um the majority of infections
are occurring in people in their mid 20s to mid-30s um and you can see that still
also a substantial number of people um being diagnosed with syphilis into their 30s 40s 50s and even um Beyond uh Beyond
60s um next slide this is um a graph showing the
total number of syphilis infections by County again this is uh combining 2021
to 2023 data um and you can see that there is geographic difference in our
state um with Hillsboro County having the majority of the syphilis infections and in fact um I think the city of
Manchester which is in Hillsboro County accounts for about 40 to 45% of the
syphilis infections that are um occurring in Hillsboro County um but then we also have maram and Rockingham
counties which have higher um numbers of syphilis infections next
slide in terms of reported sexual risk factors um you can see here that almost
half of uh people diagnosed with syphilis um are in men who have sex with
men um but still about a quarter um report uh heterosexual sexual activity
next slide um we can also look at syphilis um
by different categories this is a graph looking at the number of infectious syphilis infections in our state each
year going back again to the year 2000 infectious syphilis is not a clinical
category um but it's a term we oftentimes use in public health to indicate early syphilis infection so the
category of infectious syphilis includes people with primary syphilis secondary syphilis and other early syphilis
infections that were determined to have occurred in the previous 12 months essentially includes early Laten
syphilis um this is when people we believe are most infectious and able to
transmit the infection to other people hence the term infectious syphilis um but still even people with later um or
more delayed diagnosis um or later stages of infection can still transmit their infection as um Dr Alamar already
mentioned uh but when you look at um earlier in infectious syphilis infections you can see that the trend
here uh very similarly mirrors um the overall trend for all syphus cases um in
New Hampshire next slide um concerningly we're also seeing
that the number of syphilis cases in females in New Hampshire um has been
increasing it was at zero or very very low for um many many years and you can
see that in the last decade or so that the number of um early syphilis
infections in females in New Hampshire um has been increasing now the overall
number is still relatively low so if you look at the y- AIS for example um the highest um number in a year that we had
was you know below 14 cases in females
um but this has um unintended and important consequences that we need to
be aware of and if you go to the next slide uh this is a graph looking at the number of congenital syphilis infections that
have been occurring each year in New Hampshire again going back to the year 2000 uh you can see that there was a
good you know 12 years where we had no congenital syphilis infections um and
then more recently um the number of congenital syphilis infections um has been increasing so that in the last five
or six years um there have been you know six congenital syphilis infections
identified thankfully none so far this year um but the trend is concerning uh
and if you go to the next slide um it's important to recognize that as syphilis increases in females particularly women
of childbearing age um next slide that congenital syphilis will also increase
and so when you overlay the graphs of um infectious syphilis that's occurred in females in New Hampshire um and you o
and you overlay that with the curve or the graph for congenital syphilis um you
can very clearly see that as syphilis has increased in women of childbearing age that congenital syphilis has also
increased um and all of the consequences of that that Dr altamare um has
mentioned next slide CDC put out this mmwr publication
about a month ago um highlighting nationally the missed
opportunities for preventing congenital syphilis in our country um and what they
found was that over the last decade um there were 10 times as many babies born
with syphilis in 2022 compared to um
2012 nine in 10 um cases in nine out of
10 cases timely testing and treatment um during pregnancy might have prevented um
the episodes of congenital syphilis um and many people you can see the graph in
the or the pie chart in the lower rightand corner that um about 37% of um
cases had no timely testing testing another 40% had inadequate treatment and these were really missed opportunities
for preventing um conal syphilis um next
slide so with this publication um the CDC has
started to expand their recommendations for testing and preventing congenital
syphilis in particular uh to suggest that providers consider Geographic risk
in addition to individual behaviors when determining um the need to screen for
syphilis infection um they included in this publication a recommendation to make any healthc care encounter during
pregnancy an opportunity to test and treat for syphilis this can include um
emergency department visits or um visits to syringe service programs or other um
health care or um Health Service need visits um they have in here a
recommendation that different settings could consider implementing rapid syphilis testing with immediate
treatment of pregnant persons who are positive obviously while awaiting full confirmatory testing in that Cascade of
care that um Antonia mentioned um but rapid syphilis testing with immediate treatment of pregnant persons um may
have a place for controlling spread of syphilis and then obviously to ensure appropriate treatment and as Dr alamari
mentioned penicilin G is the only effective and recommended treatment for syphilis during pregnancy next
slide um now a threshold for high levels of syphilis um is not currently defined
um in any of the STI treatment guidelines um and it's still obviously
recommended that everybody should be assessing individual risk factors per existing STI screening recommendations
to determine whether or not a patient might need screening for syphilis or any other sexually transmitted infection um
but there is this healthy people 2030 goal um that has been out there um
highlighting the need or the goal to reduce the rate of primary and secondary syphilis among women aged 15 to 44 years
to this rate of 4.6 cases per 100,000 or less um and so because of this healthy
people 2030 goal because of the national trends of increasing syphilis and in particular increasing congenital
syphilis uh CDC with this publication um in the mmwr um has made this
recommendation that counties with syphilis rates in women above this
target rate this above this healthy people 2030 goal um that providers should offer syphilis screening to all
sexually active persons aged 15 to 44 years to diagnose and treat syphilis
before pregnancy might occur next slide and so with this publication they
put out this graph um looking at the county level about Which counties across the country um have rates of primary
plus secondary syphilis in females 15 to 44 years of age Above This healthy
people 2030 goal uh next slide and you can see that most of New Hampshire um is
grayed out except for this one County uh where CDC is suggesting that um
providers working um and practicing in that county begin to offer syphilis
testing to all sexually active people uh between the ages of 15 and 44 next slide
um and so you can see the numbers here next slide uh that Rockingham County is specifically called out um in New
Hampshire as having a higher rate of primary and secondary syphilis among women aged 15 to 44 years um and so are
recommending that providers offer syphilis testing to all sexually active people in this age group Next
slide um now obviously numbers and rates fluctuate year toe so making clinical
decisions um based on one year of data has limitations uh and so what we've
done is we've um done this alternative analysis of syphilis rates still in females aged 15 to 44 years um but we
went and looked at the rates of infectious syphilis by New Hampshire County and combined not one year of data
but combined um data from 2021 through 2023 and again infectious syphilis is a
category that we use to look at primary and secondary and early Laten syphilis
um so this is really expanding sort of the data analysis beyond what CDC has done and you can see here that meramac
um had a rate of 5.9 cases of infectious syphilis per 100,000 um persons again
that's the that's the group of females aged 50 to 44 years Hillsboro and Rockingham counties had very similar
rates over the the last three years of 3.7 cases of infe syphilis per 100,000
um persons in this population um the other New Hampshire counties had too few infections to calculate a reliable rate
for this population but at the end of the day compared to Rockingham County which again CDC is um suggesting and
recommending that providers start to offer syphilis screening um for all sexually active persons in this in these
um in this age group compared to Rockingham County the higher three-year rate in marac county and the similar
three-year rate in Hillsboro County suggests that providers could also consider expanding screening um in these
counties as well um and thinking back to um the data slides that I just showed
again Hillsboro Rockingham and Marat counties were the three counties in New
Hampshire that had the highest rates of syphilis um overall um and on this slide
have the highest rate of infectious syphilis in um females aged 15 to 44
years of age um and so I I just want to next next and final slide really um
acknowledge that syphilis has steadily increased in New Hampshire and is continuing to increase in New Hampshire
and regionally and nationally um and that an increasing number of infections in females has translated to an increase
in congenital syphilis um and so as STI rates increase there will be a need for
expanded testing and screening to control transmission and there are steps that uh CDC is already beginning to take
in their recommendations for trying to expand testing geographically based on rates of um syphilis or early syphilis
infections and in New Hampshire the rate of um syphilis particularly early syphilis um are highest in the counties
of Hillsboro marac and um Rockingham counties now is it a formal recommendation that all providers should
go out there and start testing all sexually active people um you know in these three counties no that's not a
necessarily a formal part of ours or cdc's recommendations uh but just be aware that as again as STI rates
increase as syphilis increases um our
populations particularly you know sexually active populations you know
would benefit from expanded screening and testing and so factor that into your clinical decision-making when you're
assessing um patients and their health um it's also important to ensure that
there is appropriate And Timely treatment um to prevent transmission and avoid adverse Health outcomes like
congenital syphilis uh and again penicilin G is the only effective and recommended treatment for syphilis um
during pregnancy um go ahead two more slides one more let me also just at the
end here um mention that these webinar slides will be posted on our healthcare provider resource website which is
linked here um we also will um make an attempt to announce the topic of the
next webinar on that same website we'll try and post an update to this website um a week or so before the next webinar
and our next healthc care provider and public health webinar will be occurring um January 11th from noon to 1 um we are
also going to look at taking on the topics of garia and clamidia um and
changes that are coming around doxy cycl postexposure prophylaxis in the future
hopefully either in January or February so stay tuned and check the website again um
for the the topic when we get closer to the next webinar so with that let me stop and we have um just a a couple
minutes here for questions