An Overview of Sexually Transmitted Infections in Canada

1. An Overview of Sexually Transmitted Infections in Canada Thomas Wong, MD MPH FRCPC Community Acquired Infections Division Health Canada (613) 941-7539

2. Sexually Transmitted Infections (STIs) in Canada • Chlamydia • Gonorrhea • Syphilis • HSV • HPV

3. Chlamydia • Most prevalent bacterial STI in Canada • Disproportionately affects adolescents and young adults • Females account for over 2/3 of reported chlamydia cases • PID, chronic pelvic pain, ectopic pregnancy, infertility

4. Reported Chlamydia Rates in Canada, by sex* • Data for 2002 are preliminary and changes are anticipated • Source: Sexual Health and STI Division, Health Canada 2004

5. Reported Male Genital Chlamydia Rates in Canada, by age group* • Data for 2002 are preliminary and changes are anticipated • Source: Sexual Health and STI Division, Health Canada 2004

6. Reported Female Genital Chlamydia Rates in Canada, by age group* • Data for 2002 are preliminary and changes are anticipated • Source: Sexual Health and STI Division, Health Canada 2004

7. Chlamydia • Reported rate had been declining until the last few years • Recent rate increase may be due in part to increased screening since the availability of new non-invasive NAAT (eg. PCR, LCR) – but not the whole story

8. Chlamydia:Factors favouring control • Effective, single-dose treatment • Non-invasive urine testing

9. Chlamydia:Hurdles and Challenges • Lack of chlamydia awareness/knowledge • Majority of infections are asymptomatic • 80% of females • 50% of males • “Hidden Epidemic” – lack of awareness and symptoms results in a lack of adequate screening, diagnosis, treatment and reporting.

10. Chlamydia Prevention and Control: Strategies • Increase Awareness – Sexual Health Education • Canadian Sexual Health Education Guidelines • Targeted Prevention and Promotion • Take advantage of non-invasive testing and one-dose treatment

11. Gonorrhea • Second most commonly reported bacterial STI in Canada • Males account for almost 2/3 of nationally reported cases • Other STI often present with gonorrhea – especially chlamydia

12. Reported Gonorrhea Rates in Canada, by sex* • Data for 2002 are preliminary and changes are anticipated • Source: Sexual Health and STI Division, Health Canada 2004

13. Reported Male Gonorrhea Rates in Canada, by age group* • Data for 2002 are preliminary and changes are anticipated • Source: Sexual Health and STI Division, Health Canada 2003

14. Reported Female Gonorrhea Rates in Canada, by age group* • Data for 2002 are preliminary and changes are anticipated • Source: Sexual Health and STI Division, Health Canada 2003

15. Gonorrhea in Canada • Gonorrhea rates in Canada had been declining until the last few years • Rates have risen by more than 50% over past 5 yrs

16. Gonorrhea:Hurdles and Challenges • Lack of symptoms (asymptomatic): • Up to 80% of females • 10-20% of males • Even more likely to be asymptomatic if infected at rectal or pharyngeal sites

17. Gonorrhea:Hurdles and Challenges • Antimicrobial resistance • Quinolone resistance increasing in Canada • < 1% in the early 90’s • = 1% late 90’s • 2.4% rate for 2001 • Reduced capacity in tracking resistance because of increasing NAAT use

18. Gonorrhea:Factors favouring control • Effective, single-dose treatment • Non-invasive urine testing – continually improving and more available

19. Gonorrhea Prevention and Control: Strategies • Increase Awareness – Sexual Health Education • Canadian Sexual Health Education Guidelines • Targeted Prevention and Promotion • Take advantage of non-invasive testing and one-dose treatment

20. Syphilis

21. Syphilis • The least common of the 3 bacterial STIs • The elimination of syphilis was seen as an imminent goal as recently as 1996 • BUT – increasing national rates since 1997

22. Reported Syphilis Rates in Canada, by sex* • Data for 2002 are preliminary and changes are anticipated • Source: Sexual Health and STI Division, Health Canada 2004

23. Reported Male Syphilis Rates in Canada, by age group* • Data for 2002 are preliminary and changes are anticipated • Source: Sexual Health and STI Division, Health Canada 2004

24. Reported Female Syphilis Rates in Canada, by age group* Data for 2002 are preliminary and changes are anticipated Source: Sexual Health and STI Division, Health Canada 2004

25. Reported Syphilis Diagnoses in the UK, by sex Source: Public Health Laboratory Service, 2003

26. Reported Primary and Secondary syphilis ratesin Canada and the United States* Rate per 100,000 Year U.S. Source: Sexually Transmitted Disease Surveillance, 2002, CDC * Data for 2001 and 2002 are preliminary and changes are anticipated

27. Syphilis Control:Factors favouring elimination • T. pallidum slow growth rate • Long incubation period • Effective treatment with benzathine penicillin • Lack of penicillin resistance

28. Syphilis Control:Hurdles and Challenges • Regional Outbreaks • Vancouver: heterosexual, sex-trade, MSM • Yukon: heterosexual • Calgary: MSM • Winnipeg: heterosexual • Toronto: MSM • Ottawa: MSM • Montreal: MSM

29. Syphilis Control:Hurdles and Challenges • Lack of availability of treatment – Benzathine Penicillin G • Increasing Trend of Risky Sexual Behaviour • Lack of Awareness

30. Syphilis Prevention and Control: Strategies • Intensify targeted prevention and health promotion • Cyberprevention • Enhance surveillance • Enhance efforts for case finding and management • Rapid outbreak response

31. Reportable Bacterial STI • National rates of Chlamydia, Gonorrhea and Syphilis all rising • WHY? • Safe-sex burnout • HAART and post-exposure prophylaxis • Younger generation did not witness AIDS devastation • Internet facilitating high risk partnering

32. Genital Herpes (HSV) • Not reportable at the federal level • Prevalence in Canada not well known (therefore a priority) • Caused by HSV types 1 and 2 • Infection is life-long • Predominantly asymptomatic • Asymptomatic viral shedding leads to transmission

33. Neonatal Herpes • Most serious direct consequence of genital HSV infection • Not reportable at Federal level (passively reported in many prov/terr – information collected is limited and case definitions vary) • Incidence per 100,000 live births: • United States : 20-50 cases • United Kingdom & Australia : 2-3 cases • Canada : 5.9 cases

34. Neonatal Herpes Surveillance • Partnership between Canadian Paediatric Society (CPS) and Center for Infectious Diseases Prevention and Control of Health Canada

35. Neonatal Herpes Surveillance • Two phase project: • Phase I: surveillance of neonatal herpes • Canadian pediatricians report every new observed neonatal case • Maternal HSV infection • Neonatal morbidity and lab results • Immediate sequelae in neonatal period • Phase II: follow-up of neonatal cases • 3 year follow up of neonatal cases RE longer term sequelae of neonatal infection

36. Human Papillomavirus (HPV) • Estimated to be the most common STI • Not reportable at federal level • High risk types (oncogenic) • Genital cancers (cervical, anal, penile) • Low risk types (non-oncogenic) • Genital warts

37. HPV Infection: Natural History • Often transient • Peak prevalence: ages 20-24 • More likely to persist in women > 30 years

38. Oncogenic HPV Prevalence in Ontario and Newfoundland Women* * HPV Hybrid capture assay Source: Sellors JW et al. CMAJ (2000);163:503-508 Ratnam S et al. Cancer Epidemiol Biomarkers Prev (2000);9:945-951

39. HPV and Cervical Cancer:New Horizons • HPV-DNA testing • Primary screening • Triage • HPV Vaccine • Liquid Based Cytology • Implications for HPV testing and testing for other STIs • Awareness of HPV – Cervical Cancer link

40. STI Testing Issues • Culture vs. NAAT (PCR, LCR) • NAAT: Urine vs. Swab • Order of Swabs/Pap Test • Menstruation and testing • New and emerging tests

41. Risky Sex Risky Sex Other STIs HIV Enhance transmission of

42. STI & HIV Synergy • STI increases HIV transmission & acquisition • STI morbidity can be worse, and infection more difficult to treat, for HIV-infected individuals • Rise in syphilis indicative of unsafe sexual practices; implications for rates of HIV • STI incidence in HIV-infected individuals • Can use as marker of unsafe sexual behaviors in HIV-positive population

43. Conclusion • Reportable STIs continue to rise • Behavioural surveillance gap exists – hindering targeted awareness, prevention and promotion • Lack of data on viral STIs, however efforts to address viral STIs are underway

44. Acknowledgements • Provincial and Territorial Partners • Toronto Public Health Department • AIDS Committee of Ottawa • National Microbiology Lab • Lai King Ng • Janice Mann • Rhonda Kropp • Maureen Perrin