- Sexually Transmitted Infections
- Testing for Zika Virus
- Medically Assisted Treatment for Opioid Addiction
Sexually Transmitted Infections
Action requested: Actively screen for and treat sexually transmitted infections.
The incidence of sexually transmitted infections has increased dramatically over the past five years. In Snohomish County, syphilis, gonorrhea, and chlamydia cases year-to-date have increased 109%, 276%, and 38% respectively, from 35, 119, and 1355 respectively in 2012 to 73, 447, and 1870 respectively in 2016. Similar trends have been reported elsewhere in Washington. Of particular concern is the rise in syphilis, with complications such as ocular syphilis (clusters of ocular syphilis were reported in Washington and California in 2015; see https://www.cdc.gov/mmwr/volumes/65/wr/mm6543a2.htm?s_cid=mm6543a2_e).
Patterns of infection are changing. Historically, syphilis incidence has been highest among men who have sex with men (MSM), especially HIV-infected MSM. However, King County recently reported that more than half of their syphilis cases among MSM are HIV-negative. Moreover, although MSM remain at highest risk, the number of cases of syphilis occurring in heterosexuals, including pregnant woman, has also increased recently.
- Take a sexual history with all patients.
- Test all sexually active MSM for syphilis at least annually, and those with HIV each time you order blood tests. (Patients who are not sexually active or are in mutually monogamous long-term relationships do not require testing.)
- Test all homeless persons for syphilis when presenting in emergency rooms or clinics (unless there is a test in the past 30 days with result available).
- Test at least annually heterosexuals who pay for or receive money or drugs for sex or who have anonymous partners.
- Test all pregnant women for syphilis in the first trimester, and women at high risk for syphilis again in the third trimester. Characteristics that place pregnant women at high risk for syphilis include: homelessness; methamphetamine, opioid, or cocaine (including crack) use; exchanging sex for money, drugs or other commodities; having a sex partner who is a man who has sex with men.
- Be alert to symptoms of primary syphilis—a syphilitic chancre is usually a firm and painless ulcer at the site of inoculation; there may be localized lymphadenopathy.
- Be alert to the symptoms of secondary syphilis—rash is most common and may present as a generalize maculopapular rash on the torso with or without palmar and plantar lesions, although the rash may also be pustular. Other presentations of secondary syphilis include condyloma lata, mucous patches, alopecia, generalized malaise, lymphadenopathy, sore throat, and arthralgias.
- Test all persons diagnosed with syphilis for HIV, gonorrhea and chlamydia. MSM should be tested for gonorrhea and chlamydia at all exposed anatomical sites.
- Treat persons with symptoms compatible with primary or secondary symptoms and all persons who report sexual exposure to a person with syphilis. A serological test for syphilis should be ordered for persons with symptoms comparable with the infection or sexual exposure to a person with syphilis, but treat such persons without waiting for test results.
- Treat early syphilis (primary, secondary and early latent): benzathine penicillin (bicillin) 2.4 million units intramuscularly once. Patients with late latent syphilis require three injections spaced one week apart.
- Screen all persons diagnosed with syphilis for symptoms of neurosyphilis: vision changes, floaters, flashing lights, tinnitus, hearing loss, cranial nerve palsies, and new or different headaches. Patients with new neurologic symptoms need a lumbar puncture. Treat neurosyphilis with intravenous aqueous crystalline penicillin G (APPG) 24 million units per day for 10-14 days.
- Provide (or refer for) long-acting contraception for non-contracepting women diagnosed with syphilis if pregnancy is not desired.
- Recommend HIV pre-exposure prophylaxis (PrEP) to all HIV-negative MSM diagnosed with syphilis.
- Report all cases of syphilis to the Health District using the STD Case Report Form http://www.snohd.org/Portals/0/Snohd/Provider/files/2016_STD_CaseReport.docx.
For detailed guidance on managing STIs, see CDC's 2015 STD Treatment Guidelines at http://www.cdc.gov/std/tg2015/.
Testing for Zika Virus
Action requested: Be aware of a high rate of false positive commercial tests.
Background & Recommendations
Zika test results from commercial laboratories that are IgM+/equivocal/inconclusive may note that the specimen will be forwarded to the Centers for Disease Control & Prevention (CDC) for confirmatory testing. However, CDC does not initiate testing until public health provides complete information on patient demographics, name of the commercial lab, specimen collection date, IgM result, symptoms, onset date, pregnancy status, and exposure history. Also, CDC requires that specimens meet testing criteria—specimens with IgM+/equivocal/inconclusive results from a commercial laboratory and for which patients do not otherwise meet testing criteria will be rejected for testing (e.g., CDC will not test a specimen from an asymptomatic male with an IgM+).
Additionally, information from CDC indicates that ~80% of IgM+ specimens received from LabCorp appear to be false positives that do not confirm at CDC. It is unclear at this point whether this is due to persons being tested outside of recommendations or a problem specific to LabCorp testing. Because of this very high rate of false positives, providers should understand that these commercial IgM results are very preliminary and require confirmation.
Medically Assisted Treatment for Opioid Addiction
Action requested: Be aware that nurse practitioners and physician assistants will soon be able to receive a waiver to prescribe buprenorphine to treat opioid addiction.
Background & Recommendations
The U.S. Department of Health and Human Services (HHS) is expanding access to medication-assisted treatment (MAT) for opioid use disorders by enabling nurse practitioners (NPs) and physician assistants (PAs) to immediately begin taking the 24 hours of required training to prescribe buprenorphine. NPs and PAs who complete the required training and seek to prescribe buprenorphine for up to 30 patients will be able to apply to do so beginning in early 2017. Previously, only physicians could prescribe buprenorphine. Once NPs and PAs receive their waiver, they can begin prescribing buprenorphine immediately. HHS also announced its intent to initiate rulemaking to allow NPs and PAs who have prescribed at the 30 patient limit for one year to apply for a waiver to prescribe buprenorphine for up to 100 patients.
All training will be available either at no cost through the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Provider’s Clinical Support System - Medication Assisted Treatment program or through training programs that may be offered by the American Society of Addiction Medicine, American Academy of Addiction Psychiatry, American Medical Association, American Osteopathic Association, American Nurses Credentialing Center, American Psychiatric Association, American Association of Nurse Practitioners, and American Academy of Physician Assistants. SAMHSA is working with training providers to help them adapt curricula and obtain continuing education credits for this important training. Updates on training information and the waiver application for NPs and PAs will be available soon at http://www.samhsa.gov/medication-assisted-treatment.
You can find my recent health alerts posted on the Provider pages of our website, at http://www.snohd.org/Providers/Health-Alerts.
Gary Goldbaum, MD, MPH | Health Officer & Director | Administration
3020 Rucker Avenue, Ste 306 | Everett, WA 98201 | 425.339.5210 | firstname.lastname@example.org