Syphilis on the Rise in MN: Who Should Be Concerned and Why MARRCH Conference, 10/31/2017 Candy Hadsall, RN, MA STD Prevention Nurse Specialist Minnesota Department of Health STD/HIV and TB Section STD/HIV and TB Section What We’ll Cover Sexual Health STD Facts, Categories Epidemiology of syphilis, chlamydia, gonorrhea in MN Syphilis Basics Messages to Give Clients Risk Assessments Referrals What is Sexual Health? “Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” World Health Organization 2002 Context of Sexuality in Life Sexuality influences all parts of life Sex is important for continuation of species Desire for sex: unique to humans Sex feels good so people will do it Talking about sex: personal, intimate, and difficult to talk about – especially in sex- negative society Context (cont) . Disease prevention is only one part of sexual health . Discuss positives aspects, don’t focus on negatives only . Remember to acknowledge pleasure . Clients may remember what you say years later and you won’t know Determinants of Sexual Health Socioeconomic, political, and cultural context e.g. Policy, gender norms, faith, culture, ethnicity, norms and values Distal social environment e.g. Neighborhood, community, school, work, faith group Health Care Proximal social and sexual networks e.g. Sexual partner(s), family, peers, teachers Individual characteristics e.g. Biology, social skills, cognitive ability, knowledge, attitudes, confidence, competence Sexual Health and Wellbeing Characteristics Outcomes Physical Emotional Cognitive Reproduction Behavioral Disease (avoidance) Emotional Violence (avoidance) Social Conception Adulthood Source: Amended from Zubrick et al (2008), Solar & Irwin (2007), Scottish Executive (2003) Sex, Sexuality, Silence, Treatment and Recovery Do you talk with clients about sexuality and sexual health during treatment and/or recovery? Sexually Transmitted Diseases STD Basic Facts • Are almost always spread from person to person by sexual intercourse, and • Are spread most commonly by anal or vaginal intercourse but also through oral sex. • Some STDs, such as hepatitis B or HIV infection, are also transmitted through blood-to-blood contact, sharing of needles or equipment to inject drugs, body piercing or tattoo. • Pregnant women may pass infections to infants during pregnancy/birth or through breast feeding. STDs Discriminate • Transmission easier male to female than reverse • More women asymptomatic or with atypical, nonspecific symptoms: delayed care – CT=75% asymp (F), 40% asymp (M) • Diagnosis more difficult in women – no symptoms, don’t seek care, don’t get treated • Complications more frequent in women, often severe/permanent Categories of STDs • Bacterial - cured with antibiotics – Chlamydia – Gonorrhea – Syphilis – Chancroid – NGU - Nongonoccal urethritis (various organisms other than CT or GC) Categories (cont) • Viral - no cure for most, treat symptoms – Herpes – HPV (Genital warts) – HIV – Hepatitis • Hepatitis C – now curable Categories (cont) • Other: – Pubic lice (“crabs”) - by crab louse – Scabies - by mite – Vaginitis - • Trichomonas • Yeast • Bacterial vaginosis (usually gardenerella) Screening and Treatment for STDs Screening for STDs • Screening = test performed based on risk behaviors, not symptoms, to check to see if disease is present • Tests are disease-specific • Not all diseases are included in “Routine” testing/screening UNLESS client specifically requests or risk assessment warrants – Examples: herpes, warts viruses, syphilis • No publicly funded programs in MN offer herpes, HPV blood testing Rates of Screening are Low • Shame, stigma, secrecy • Believe STD symptoms should be severe • May attribute symptoms to other causes • May wait for symptoms to disappear • Fear/distrust of medical system • Embarrassed/afraid to talk to partners • Reluctant to discuss drug use/history (part of risk assessment) Treatment • Bacterial – Antibiotics - oral and IM • Viral – No cure for any disease other than Hep C, treat symptoms – Vaccinations for Hep A & B, HPV • Other – Oral, topical, intravaginal meds STDs in Minnesota Surveillance Data 2016 STDs in Minnesota: Number of Cases Reported . Total of 28,631 STD cases reported to MDH in 2016: . 22,675 Chlamydia cases . 14,451 cases in 15-24 year olds . 5,104 Gonorrhea cases . 852 Syphilis cases (all stages) . 0 Chancroid cases 290 HIV cases (not part of 28,631) Data Source: Minnesota STD Surveillance System 2016 STDs in Minnesota: Annual Review STDs in Minnesota Rate per 100,000 by Year of Diagnosis, 2006-2016 Chlamydia Gonorrhea P&S* Syphilis a 450 10 he 9 rr 400 R o a n 8 t e o 350 of G 7 d 300 P&S n a 6 ia 250 S d y y 5 ph m 200 a ilis l 4 h C 150 3 of 100 e 2 t a R 50 1 0 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Year * P&S = Primary and Secondary Summary of 2016 STD Trends in MN . Resurgence of syphilis over past decade in MN, with MSM and HIV + men especially impacted. Between 2015 and 2016, early syphilis cases increased by 29%. Number of cases in females = near record high for last decade. Epidemic of chlamydia – over 22,000 cases in 2016. Numbers evenly distributed across Twin Cities, suburbs, Gr MN . Especially impacted: females under age 24 . Gonorrhea also growing, especially in Twin Cities – concern about antibiotic resistance . Persons of color continue to be disproportionately affected by STDs CHLAMYDIA AND GONORRHEA Minnesota Department of Health STD Surveillance System STD/HIV/TBSection CT Disproportionately Impacts Youth MN Population in 2010 Chlamydia Cases in 2016 (n = 5,303,925) (n = 22,675) 25-29 yrs 25-34 yrs 35+ yrs 18% 13% 53% 30-44 yrs 15% 15-24 yrs 45+ yrs 14% 2% 15-24 <15 yrs yrs <15 yrs 20% 64% 1% GC Disproportionately Impacts Youth MN Population in 2010 Gonorrhea Cases in 2016 (n = 5,303,925) (n = 5,104) 25-29 30-44 yrs yrs 22% 25-34 yrs 35+ yrs 24% 13% 53% 45+ yrs 7% 15-24 yrs 15-24 <15 yrs 14% <15 yrs yrs 1% 20% 46% Age-Specific CT Rates by Gender, 2016 3500 3325 Males Females 3000 s 2623 n so 2500 r e p 0 2000 100,00 1485 r e 1500 1300 p e at R 1000 905 659 463 500 418 88 144101 92 8 43 24 10 0 10-14 15-19 20-24 25-29 30-39 40-44 45-49 50+ Age in Years Age-Specific Gonorrhea Rates by Gender Minnesota, 2016 Males Females 436 394 368 S 348 N O S R PE 235 100,000 202 PER 144 ATE R 94 90 53 34 22 17 17 3 1 10-14 15-19 20-24 25-29 30-39 40-44 45-49 50+ AGE IN YEARS Chlamydia Facts • 80-85% of cases in females are asymptomatic, 50- 90% of cases in males are asymptomatic • If don’t have symptoms = think “no problem” • Don’t get screened = delayed treatment • Develop serious complications • Chlamydia = leading preventable cause of tubal infertility Chlamydia Complications Untreated Genital Chlamydial Infection 70%-80% >50% Asymptomatic Asymptomatic Female Urethritis Male Urethritis 20-50% Neonatal Infection PID Epididymitis Orchitis (Acute & Silent) 9% Chronic 18% Pelvic Ectopic Pregnancy Pain 14-20% Infertility Source: CDC Chlamydia in the United States. April 2001 Chlamydia Rates in Minnesota, 2001-2013 Projected to 2018 Rate per 100,000 Year CDC Chlamydia and Gonorrhea Screening Recommendations • Sexually active women 25 years and younger yearly • Women above age 25 years if at risk: new partner or multiple partners, known contact • Re-screen women with CT infection 3-4 months after treatment to screen for reinfection (not because medication didn’t work) • Routine screening of males not recommended for CT; base on risk, special settings • Screen MSM all ages; swabs from multiple sites TREATMENT 2015 Recommended Treatment of Chlamydia • Azithromycin 1 g orally, single dose (preferred) Or • Doxycycline 100 mg bid x 7 days • No sex for 7 days after completing treatment 2015 Recommended Treatment for Gonorrhea • Ceftriaxone 250 mg IM, single dose PLUS • Azithromycin 1 g orally • No sex for 7 days after completing treatment See CDC Treatment Guidelines for treatment of oral GC PARTNER TREATMENT Expedited Partner Therapy What is Expedited Partner Therapy (EPT)? • Treatment of sexual partners without clinic visit or being seen by provider • One form of EPT = Patient Delivered Partner Therapy (PDPT): Delivery of prescription or medication by original patient to her/his partner(s) • Legal in MN in 2008 When to Use EPT • EPT should be used when: – Patient + for CT, GC and – Partner(s) unlikely to seek care – Other management options are impractical or unsuccessful • Not for MSM, pregnant partners of males Clinical evaluation of partner still #1 choice SYPHILIS oods W Kittson Roseau the 2016 Minnesota Lake of Lake Marshall Koochiching Primary & Secondary Pennington Beltrami RedLake Cook Syphilis Rates by Polk ater Lake w St.Louis ear l C Itasca Norman Mahnomen County Hubbard Clay Becker Cass CrowWing Wadena Aitkin Carlton Wilkin OtterTail Rate per 100,000 persons Pine Todd Morrison Grant Douglas Lacs e Kanabec ill 0 M raverse T Stevens Benton 0.8 – 3.0 Pope Stearns Isanti Big Stone sago i Sherburne h 3.1 – 9.2 C Swift Anoka Kandiyohi > 9.2 Wright on Chippewa Meeker t ng i Lac quiParle Hennepin Ramsey ash City of Minneapolis 33.7 (129 cases) W McLeod Carver