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Health Alerts

The Snohomish Health District Health Officer Dr. Gary Goldbaum sends alerts via email to local health care providers. Alerts cover current local, regional or national health threats and important updates on medical care and protocols. Alerts are written as needed to cover urgent or emergent health issues.

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PrEP, STIs, chickenpox

Today's topics:

  • HIV Pre-exposure Prophylaxis (PrEP)
  • Management of sexually transmitted infections
  • Chickenpox

 

HIV PRE-EXPOSURE PROPHYLAXIS (PrEP)

Actions requested:

  • Contact Snohomish Health District if you are willing to be added to a PrEP referral list
  • Offer PrEP to high risk patients and use the Drug Assistance Program to cover the cost of PrEP for those without insurance coverage.

Background:

New Centers for Disease Control and Prevention (CDC) guidelines recommend pre-exposure prophylaxis (PrEP) for those at substantial risk of HIV infection. PrEP consists of a daily dose of emtricitabine/tenofovir (Truvada). This new prevention tool could have significant impact on the HIV epidemic in the U.S.

To reduce financial barriers and increase utilization, the Washington State Department of Health’s Drug Assistance Program provides co-pay coverage for insured individuals and full coverage for uninsured or under-insured individuals. Currently, only medication-related costs for PrEP are covered.

Recommendations:

  1. Contact Jessica Burt (425-339-8692 or jburt@snohd.org) if you are willing to be included on a list of medical providers who will evaluate patients for PrEP and prescribe PrEP to persons at high risk for HIV infection. Public Health and our community partners will direct persons seeking PrEP to this list.
  2. Offer PrEP to uninfected patients who are at substantial risk of infection. PrEP should be delivered as part of a comprehensive package of prevention services, including:
    • Adherence to PrEP
    • Frequent HIV testing and screening for other sexually transmitted infections (STIs) that can facilitate HIV transmission
    • Safer-sex practices and risk-reduction counseling, including consistent and correct condom use
    • Suppressive antiretroviral treatment of HIV-infected partners of individuals in serodiscordant relationships
  3. Refer eligible patients to the Drug Assistance Program.  Eligibility is limited to:
    • Individuals with sex/needle sharing partners who are HIV-positive (sero-discordant couples)
    • Men who have sex with men and who have any of the following risks:
    • Diagnosis of a bacterial STI in the last year
    • Exposure to an STI through a sexual network in the last year
    • Ten or more sexual partners in the last year
    • Methamphetamine use in the last year
    • Unprotected anal intercourse with a partner whose HIV status is unknown and who has any of the factors listed above.
  4. Have eligible patients complete and sign the Washington State Drug Assistance PrEP application available at http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/HIVAIDS/HIVCareClientServices/PrEPDAP.aspxProviders need to sign the affirmation of HIV infection on the last page.  If you have questions, contact the Early Intervention Program at 877-376-9316.

For more information about PrEP, see http://www.cdc.gov/hiv/prevention/research/prep/.

For the complete PrEP guidelines, see http://www.cdc.gov/hiv/pdf/guidelines/PrEPguidelines2014.pdf

 

MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS (STI)

Actions requested:

  • Routinely provide HIV testing when screening for STIs in men who have sex with men (MSM).
  • Offer extra-genital testing for chlamydia and gonorrhea for MSM.
  • Include syphilis testing when genital, oral, and/or anal lesions are present.
  • Offer Expedited Partner Therapy (EPT) to sex partners of patients diagnosed with chlamydia and/or gonorrhea OR refer patients to Snohomish Health District for assistance with EPT.

Background:

HIV testing is strongly recommended for MSM being treated for STIs.  STI testing and control efforts can prevent HIV transmission or detect recent infection, especially among MSM, who are at greatest risk for HIV infection.

Chlamydia (CT) and gonorrhea (GC) are among the most commonly reported notifiable conditions in Washington State and MSM are disproportionately affected.  The CDC recommends screening MSM for urogenital, rectal and pharyngeal CT and GC.  Most rectal and pharyngeal infections are asymptomatic and providers generally limit screening to urine-based tests, which fail to detect non-genital infections. Studies have found that more than 60% of gonorrhea infections and more than 50% of chlamydia infections are extra- genital, serving as reservoirs of infection and increasing the likelihood of further transmission.

Primary and secondary syphilis rates have been steadily increasing in Washington State as well as Snohomish County over the last several years.  Syphilis is a genital ulcerative disease that facilitates HIV transmission and if untreated during pregnancy may lead to fetal infection or perinatal death.  Symptoms of infection are often subtle and easily confused with other sexually transmitted infections, such as genital herpes infection. Syphilitic rashes can be highly variable and are often mistaken for drug reactions, pityriasis rosea, psoriasis, and tinea versicolor. Conversely, very few other medical illnesses cause a rash on the palms and soles.

To reduce the continued transmission of STIs in the community, all sex partners of infected individuals should be treated.  Expedited Partner Therapy (EPT) provides for the treatment of sex partners of infected individuals without requiring partners to be tested or seen by health care providers. 

Recommendations:

  1. For men who have had insertive oral or anal intercourse with another man during the preceding year (regardless of history of condom use), test for N. gonorrhoeae (GC) and C. trachomatis (CT) in urine using nucleic acid amplification testing (NAAT).
  2. For men who have had receptive anal intercourse during the preceding year, test for rectal infection with GC and CT (NAAT of a rectal swab).
  3. For men who have performed oral intercourse on another man during the preceding year, test for pharyngeal GC infection (NAAT of an oral swab). Testing for C. trachomatis pharyngeal infection is not recommended. (Note: The APTIMA Combo test automatically tests for both infections.)
  4. Consider syphilis in the differential diagnosis of all genital ulcers and body rashes.
  5. Assure that patients get their results.  If you are unable to assure that a patient will get his/her results, contact Jordan Bower or Lisa Roberts at 425-339-5261 for assistance.
  6. Treat all partners of patients who test positive for chlamydia or gonorrhea as if they are infected. It is best to examine and treat all sexual partners exposed within the 60 days prior to the date the patient was tested.  If this is not possible, patients may be given Expedited Partner Therapy (EPT) medication to give to their sex partners. EPT medication is also available at pharmacies across the county.  Detailed information about EPT is at http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/SexuallyTransmittedDisease/ExpeditedPartnerTherapy.aspx. For assistance in assuring that partners are treated, contact Jordan Bower or Lisa Roberts at 425-339-5261.

For more information about screening and treatment for CT, GC, and syphilis, see http://www.cdc.gov/STI/treatment/default.htm.

 

CHICKENPOX (VARICELLA)

Action requested: Test when considering the diagnosis of varicella.

Background:

An outbreak of varicella is occurring in the Arlington School District. Cases have been laboratory-confirmed at three elementary schools; providers have reported rash illness consistent with varicella among students at another elementary school.

Chickenpox can cause serious complications, including pneumonia, septicemia, and encephalitis.  Infants, adolescents, adults, pregnant women, and immunocompromised persons are at highest risk.  Shingles is a late (and very painful) complication of varicella infection.

Vaccination is essential to prevent infection. Keeping infectious persons out of school, worksites, or other congregate settings is key to preventing transmission.  To determine when exclusion measures are indicated, public health relies on providers to confirm cases, particularly early in an outbreak.  The presentation of varicella can mimic other conditions, especially if the person has been vaccinated (usually only with a single dose), so we urge providers to obtain laboratory confirmation when varicella is suspected.

Recommendations:

  1. To test for varicella, the crust of a lesion can be lifted off the skin (a glass slide is useful), transferred directly into a break-resistant, snap-cap or screw-top tube, and submitted for PCR testing.
  2. To report varicella or for assistance with testing, contact the Communicable Disease team at 425-339-5278.
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Health alerts include information about diseases or other health risks or issues that affect Snohomish County.