Pediatric Resident Academic Half Day • March 21, 2013 • Dr. A. Bates, PGY5 • Pediatric Infectious Disease Fellow
Background • World Health Organization 2005: • Sexually transmitted infections among adolescents: the need for adequate health services • Since the International Conference on Population and Development in Cairo in 1994, recognition of young people’s specific sexual and reproductive health needs has gradually increased
Background • Attempts to date to promote the sexual health of young people have tended to focus on prevention, education and counselling for those who are not yet sexually active • While the provision of health services to those who have already engaged in unprotected sexual activity and faced the consequences, including pregnancy, STIs or sexual violence, has lagged behind
Background • challenges - global and local • increasing populations • antimicrobial resistance • global travel • co-infections
Objectives • recognize common sexually transmitted infections in adolescents • create a general management plan • special circumstances: • HIV • Post exposure prophylaxis • sexual abuse
What is a sexually transmitted Infection • The term STI (Sexually Transmitted Infection) is now commonly used in the place of STD (Sexually Transmitted Disease) • it is more encompassing • it includes infections that may be asymptomatic
What is happening on the Canadian Front? • three nationally reportable STIs • chlamydia, gonorrhea and syphilis • increasing rate of all three infections since 1997
Epidemiology • 15-24 yo represent ~ 25% of the sexually experienced population • they acquire ~ half of all new STDs • Compared with older adults, sexually active adolescents aged 15–19 years and young adults aged 20–24 years are at higher risk of acquiring STDs for a combination of behavioral, biological, and cultural reasons.
Epidemiology • multiple factors involved • adolescent females have an increased susceptibility to Chlamydia trachomatis because of increased cervical ectopy • multiple barriers - • lack of transport, discomfort with the facility/service design, concerns re: confidentiality
Canadian Stats 2009 • Chlamydia • AB - 366 cases/100 000 ppl • Rates (per 100 000) • 10-14 yo - 29.1 • 15-19 1041.7 • 20-24 yo - 1373.8 • steadily increasing in Canada since 1997
Canadian Stats 2009 • Gonorrhea • AB - 42 cases/100 000 ppl • Rates (per 100 000) • 10-14 yo - 3.8; • 15-19 102.5 • 20-24 yo - 145.2 • from 1997-2004 - rate has increased by ~ 94% • resistance - quinolones (up to 15.7% in 2005)
Canadian Stats 2009 • Syphilis • 15-19 yo - 52 cases • 20-24 yo - 193 cases • previously rare - by 2006 in Canada - incrased to 1 493 cases (regional outbreaks) • risk groups - MSM (HIV positive and neg) • sex workers and their clients • acquisition in endemic regions
Further Epidemiology of Canadian STIs • HPV - very common • not reportable so true incidence not known • Most affected - adolescent and young adult woment and ment • HSV - 1 & 2 - common • not reportable but seroprevalence indicate rates of at least 20% • very common in both adolescent and adult men and women (women > men)
Why the Increase? • better diagnostics (NAATs) • suboptimal youth awareness and knowledge of risk-reduction behaviours • sex is occurring at an early age (and longer throughout life) • high rates of serially monogamous relationships • adolescents (and public in general) have a poor understanding of transmission risks • vaginal, anal and oral • “party drugs” are increasingly linked to unsafe sexual behaviours
Why the Increase? • other unique factors with adolescents • where do they get there education from? • where do they get testing/treatment from? • social factors - peer pressure, games, etc.
Approach • Primary prevention • Secondary prevention
Approach • Primary prevention • aims to prevent exposure • identify at-risk individuals • thorough assessments • patient centred counselling • education
Approach • Secondary prevention • reduction of STI prevalence • detection of infection in at-risk populations • counselling • timely partner notification and treating infected individuals and contacts • goal: preventing and/or limiting further spread
Which Statement Is True? • 1) The presence of an acute infection can increase the risk of co-infection • 2) Sequelae of women from untreated CT/GC can include infertility • 3) Persistent HPV infections plays a role in cervical dysplasia and carcinoma • 4) Chronic viral STI (i.e. HSV) can have long standing negative impacts on patient’s psychosocial well-being • 5) All the above
Which Statement Is True? • 1) The presence of an acute infection can increase the risk of co-infection (ie chancre and HIV) • 2) Sequelae of women from untreated CT/GC can include infertility (chronic pelvic pain, ectopic pregnancy, PID) • 3) Persistent HPV infections plays a role in cervical dysplasia and carcinoma (role for vaccine) • 4) Chronic viral STI (i.e. HSV) can have long standing negative impacts on patient’s psychosocial well-being • 5) All the above
Approach to Adolescents with Sexually Transmitted Infections • History • Exam • Investigations • Managements
HISTORY • think about STI risk factors ...
STI Risk Factors • sexual contact with a person with a known STI • sexually active youth under 25 yo • new sexual pertner or more than 2 in the past year • serially monogamous relationships • no contraception or SOLE use of non-barrier contraception • IVDU • substance use - ETOH, rec Rx (esp if assoc with having sex)
STI Risk Factors • engaging in unsafe sexual practices (sharing sex toys, sex with blood exchange, unprotected sex - oral/genital/anal) • sex workers • survival sex • street involvement, homelessness • anonymous sexual partnering (rave party, internet, bathhouse) • victims of sexual assault/abuse • previous STI
History • very thorough HEADDSSS history • confidentiality • empathy • non judgemental • focused sexual history
Sexual History • systemic symptoms • fever • weight loss • lymphadenopathy • prevention - immunizations, condoms • Rx treatments, allergies • Patient comfort • genital signs and symptoms • discharge • dysuria • abdominal pain • testicular pain • rashes and lesions
Sexual History • relationships: are you sexually active now or have you ever been? • incl oral, anal, and vaginal • do you have any concerns about sexual or relationship violence or abuse?
Sexual History • sexual risk behaviour • number of partners • sexual preference, orientation • sexual activities - give or receive oral sex? anal sex? • personal risk - sex with people from other countries, bathhouses, travelling • use of condoms?
Sexual History • STI history • have you ever been tested for an STI/HIV? last screening date? • have you ever had an STI in the past? if yes, what and when? • how long have symptoms been on going
Sexual History • Reproductive health history • use of contraception? frequency? problems? • ever been pregnant? used emergency contraception?
Other High Risk Behaviors • Substance use • ETOH, IVDU, sex while intoxicated • tattoos or piercings • Psychosocial history • traded sex for money, drugs, shelter? paid for sex? forced to have sex? • sexually abused (mentally, physically) • have a home? live with anyone other than family? • Encounters with the law
Exam • Common to both sexes • systemic signs - weight loss, fever, enlarged LNs • mucocutaneous regions (incl pharynx) • external genitalia - lesions, inflammations, genital d/c, anatomical irreg • perianal inspection
Exam • adolescent males • palpate scrotal contents (attn to epididymis) • retract foreskin to inspect the glans • “milk” the urethra - discharge • adolescent females • separate labia - visualize vaginal orifice • speculum exam - cervix, vaginal walls • bimanual exam - uterine or adnexal masses or tenderness
Investigations • Urine - first void - CT/GC (NAATs) • Serum - Syphilis EIA/RPR • anti-HIV 1/2 antibodies • HepBs Ag, HepBs Ab • HepC Ab • HepA Ab • Cervix: • Endocervical canal - swab for CT and GC culture/NAAT (1-2 cm - columnar epithelial cells); direct inoculate for N. gonorrhoeae onto culture plate or transport medium • Exocervical samples - HSV, HPV
Investigations • Lesions • vesicles - deroof and swab - HSV PCR • ulcers - HSV PCR; Syphilis - dark field microscopy, PCR, DFA/IFA • Pharynx - posterior pharynx and tonsillar crypts (culture) • Rectum - CT, GC, HSV
Investigations • Urethra • thin, dry flex swab, moistened (3-4 cm males; 1-2 cm females) rotate slowly -> prepare a slide; inoculate on culture/transport medium • “milking” penis 3-4x helps • Vaginal • collect pooled vaginal secretions; or swab in posterior fornix (usually done during speculum exam) • Warts/Other HPV infections • scrape exocervical for superficial epithelial cells; use cytobrushes to collect from squamo-columnar junction • HPV DNA
Post Test Counselling • organism/syndrome specific advise • education about transmission, safer sex practices • case reporting requirements • partner notification • use of motivational interviewing strategies (both primary and secondary prevention)
Which of the Statements are True? • 1) patients with organisms causing urethritis almost always have symptoms • 2) patients should abstain from unprotected sex until 7 days after starting treatment • 3) when collecting urine for NAAT for CT/GC, collection of mid-stream urine is recommended • 4) if abuse is suspected, NAAT testing is sufficient
Which of the Statements are True? • 1) patients with organisms causing urethritis almost always have symptoms - up to 25% are asymptomatic (esp NGU) • 2) patients should abstain from unprotected sex until 7 days after starting treatment • 3) when collecting urine for NAAT for CT/GC, collection of mid-stream urine is recommended - first-catch urine • 4) if abuse is suspected, NAAT testing is sufficient - need a culture
Asymptomatic • Neisseria gonorrhoaea • Chlamydia trachomatis • Syphilis • HSV 1 & 2 • HPV • HIV • Viral hepatitis
Urethritis • urethral discharge • burning on urination • irritation of the distal urethra or meatus • meatal erythema • Gonococcal urethritis - urethritis develops 2 to 6 days • NGU urethritis - 1 to 5 wks (avg 2-3) after acquisition
Urethritis Pathogens • N. gonorrhea • C. trachomatis • Trichomonas vaginalis • HSV • Mycoplasma genitalium • Ureaplasma urealyticum • * Adenovirus • * Candida albicans
Chlamydia Background • caused by Chlamydia trachomatis serovars D to K • under diagnosed • usual incubation is 2 to 3 wks (up to 6 wks) • without treatment, infection can persist for many months • individuals with N. gonorrhea are usually co-infected with C. trachomatis • Screen sexually active females under 25 years
Chlamydia Signs/Symptoms • females - most often asymptomatic; cervicitis, vaginal discharge, dysuria, conjunctivitis • males - often asymptomatic; urethral discharge, urethritis, dysuria, conjunctivitis, proctitis • neonates/infants - conjunctivitis in neonates; pneumonia in infants < 6 months
Chlamydia Testing • NAATs are the most sensitive and specific • done on urine, urethral and cervical (blood and mucus can affect test) • culture preferred for medico-legal purposes and recommended for throat specimens • serology not useful for acute genital chlamydial infections • conjunctival swab for culture, DFA
Chlamydia Treatment • Preferred: • Azithromycin 1g PO x 1 or Doxy 100mg PO BID x 7/7 • Infants with conjunctivitis: • need systemic treatment - Erythromycin x 14 d (can use Azithro once > 1 mo)
Chlamydia Aftermath • Major sequelae: • female - PID, ectopic pregnancy, chronic pelvic pain, reactive arthritis, infertility • males - epididymo-orchitis, reactive arthritis