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Scott Strobel, Behavioral Intervention Specialist

KSU │ Central College Health Association Conference. Kansas Department of Health and Environment | Bureau of Disease Control and Prevention. Scott Strobel, Behavioral Intervention Specialist Dominique Saunders, Viral Hepatitis Prevention Coordinator. Presentation Objectives.

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Scott Strobel, Behavioral Intervention Specialist

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  1. KSU │ Central College Health Association Conference Kansas Department of Health and Environment | Bureau of Disease Control and Prevention Scott Strobel, Behavioral Intervention Specialist Dominique Saunders, Viral Hepatitis Prevention Coordinator

  2. Presentation Objectives • Participants will understand current trends in syphilis and review symptoms of syphilis • Participants will gain an understanding of resistant gonorrhea and review treatment guidelines. • Participants will increase their understanding of the interconnections between the youth population, drug use, and hepatitis C • Participants will gain insight on the general advances in viral hepatitis for 2013 Healthy Kansans Living in Safe and Sustainable Environments

  3. Syphilis Then… Healthy Kansans Living in Safe and Sustainable Environments

  4. Syphilis │ Current Trends • Primary & Secondary Cases reported in 2012: 15,667 • Rate per 100,000 people: 5.0 = 11% increase in 2012 from 2011 • Among cases of P&S syphilis for whom sex of partner was known, MSM accounted for 75% of P&S syphilis cases • Surveillance data from major cities in the U.S. indicated that an average of 40% of MSM with syphilis also have HIV Congenital Syphilis Cases in 2012: 322 Rate per 100,000 live births: 7.8 = 10% decrease since 2011. *Data courtesy of the CDC. Healthy Kansans Living in Safe and Sustainable Environments

  5. Figure 34. Primary and Secondary Syphilis—Rates by County, United States, 2012 NOTE: In 2012, 2,123 (67.6%) of 3,142 counties in the United States reported no cases of primary and secondary syphilis. CDC figure. Healthy Kansans Living in Safe and Sustainable Environments

  6. Rural Kansas Syphilis Outbreak │ 2012 • 29 total casesof early syphilis • - 28 males (All MSM and 3 HIV positive) • - 1 pregnant female • 1 new case of HIV found • Number of individuals tested and/or preventively treated = 399 • - 382 Males • - 17 Females • Most positive cases and contacts met through social media • (Grindr app, A4A, Craigslist) Healthy Kansans Living in Safe and Sustainable Environments

  7. Symptoms of Syphilis │ Primary Stage • A painless sore called a chancre may be located on the genitals, lips, anus, or other area of direct contact. Chancres progress from papule to ulcer. The chancre is typically painless, indurated, and has a clean base. It is highly infectious. • A primary chancre will appear anywhere from 10-90 days after exposure (average of 3 weeks). • The chancre will last 1-5 weeks and heal without treatment. • When a chancre is present, an individual is highly contagious and can easily pass the infection to their sex partners. • Atypical chancres may occur and can mimic herpes. Evaluation of patients with genital ulcers should include a serologic test for syphilis and a diagnostic evaluation for genital herpes. Healthy Kansans Living in Safe and Sustainable Environments

  8. Oral Primary Syphilis Chancre Healthy Kansans Living in Safe and Sustainable Environments

  9. Primary Syphilis Chance │ Penile Healthy Kansans Living in Safe and Sustainable Environments

  10. Symptoms of Syphilis │ Secondary Stage • Skin rashes lasting 2 – 6 weeks (average of 4 weeks) on the palms of the hands (palmer), bottoms of the feet (planter), or any part of the body. Occurs in 75%-100% of cases. • Other symptoms include fever, swollen lymph glands, headache, hair loss (alopecia), and muscle ache. • Mucous Patches, present in 6-30% of cases, are flat patches involving the oral cavity, pharynx, larynx and genitals. Healthy Kansans Living in Safe and Sustainable Environments

  11. Symptoms of Syphilis │ Secondary Stage • CondylomataLata – Occurs in 10-20% of cases are moist, heaped, wart-like papules that occur genitally. These lesions are very infectious. • Signs of symptoms of secondary syphilis are often first observed clinical manifestation of syphilis because primary lesions may occur in the anus or vagina and may not be recognized by the patient. • Symptoms will go away without treatment. • The patient may be able to pass it on to sex partners. Healthy Kansans Living in Safe and Sustainable Environments

  12. Secondary Syphilis Palmer Rash Healthy Kansans Living in Safe and Sustainable Environments

  13. Secondary Syphilis Plantar Rash Healthy Kansans Living in Safe and Sustainable Environments

  14. Secondary Syphilis Rash Healthy Kansans Living in Safe and Sustainable Environments

  15. Mucous Patches Healthy Kansans Living in Safe and Sustainable Environments

  16. Condylomata Lata Healthy Kansans Living in Safe and Sustainable Environments

  17. Congenital Syphilis • Vertical transmission from mother to child • Untreated syphilis during pregnancy may lead to stillbirth and neonatal death. It may also cause deafness, neurologic impairment and bone deformities • Transmission to fetus can occur during any stage of syphilis, but the risk is much higher during primary and secondary stages of syphilis • Can occur at any trimester of pregnancy Healthy Kansans Living in Safe and Sustainable Environments

  18. Syphilis Treatment Guidelines Primary, Secondary, and Early Latent Syphilis Treatment (adults only): Benzathine penicillin G (Bicillin) 2.4 MU IM in a single dose Alternative: Doxycycline 100 mg BID for 14 days Late Latent Syphilis or Syphilis of an Unknown Duration (adults only): Benzathine penicillin G (Bicllin) 7.2 MU IM Total, administered as 3 doses of 2.4 MU IM each at 1-week intervals Alternative:Doxycycline 100 mg BIS for 28 days Neurosyphilis: Aqueous Crystalline Penicillin G 18-24 MU per day, administered as 3-4 MU IV every 4 hours or continuous infusion for 10-14 days **Pregnant women should be treated with the penicillin regimen appropriate for their stage of infection. Doxycycline is contraindicated during pregnancy Healthy Kansans Living in Safe and Sustainable Environments

  19. Gonorrhea • Nationally: • Cases Reported in 2012: 334, 826 • Rate per 100,000 people: 107.5 = 4.1% increase since 2011 • 34% of GC infections are in 15-24 year olds • Kansas: • Cases in 2012 = 2237 • 38% of GC infections in 15-24 year olds Healthy Kansans Living in Safe and Sustainable Environments

  20. Resistant Gonorrhea Threat • GC resistance to penicillin, tetracycline & fluoroquinolones • Kansas staff follow up on all GC positives • Current CDC Treatment Guidelines (Aug 2012): - 250 mg IM Ceftriaxone - 1 G Azithromycin - Oral Cephalosporins no longer recommended Healthy Kansans Living in Safe and Sustainable Environments

  21. Gonoccal Isolate Surveillance Project (GISP) GISP has routinely monitored gonorrhea drug susceptibility since 1986. Providers should remain vigilant regarding cephalosporin treatment failures, and report treatment failures to their state health department. Healthy Kansans Living in Safe and Sustainable Environments

  22. CDC Screening Recommendations • Screening for men who are MSM and sexually active at least once per year for syphilis, chlamydia, gonorrhea and HIV. For MSM who are more sexually active, have anonymous partners, or sex in conjunction with illicit drug use should be screened more frequent testing is recommended (3-6 month intervals). • Annual chlamydia screening for all sexually active women age 25 & under, as well as older women with risk factors such as a new or multiple sexual partners. • Yearly gonorrhea screening for at-risk sexually active women (i.e. those with new partners or who live in a community with a high burden of disease.) • Syphilis, HIV, chlamydia, gonorrhea and hepatitis B screening for all pregnant women, with repeat testing as needed to protect the health of mothers and their infants. Healthy Kansans Living in Safe and Sustainable Environments

  23. Viral Hepatitis C and Youth │Current Trends

  24. Hepatitis C and IDU │ Data • Injection drug use (IDU) is the principle “driver” of HCV incidence 1 • HCV antibody (anti-HCV) prevalence among persons who inject drugs/substances (PWID) between 30% and 70% 2 • Anti-HCV incidence among persons who inject drugs/substances (PWID) between 16% and 42% per year 3 • Anti-HCV prevalence among younger injectors(18—29 yo) between 10% and 36% 4 1Hagan et al. 2010; Garfein et al. 1998; 2Armstrong et al. 2006, Amon et al. 2008; 3 Klevens et al. 2013 Daniels et al. 2007; 4 Amon et al. 2008 Healthy Kansans Living in Safe and Sustainable Environments

  25. Hepatitis C (HCV) │ Current Trends Increasing reports of injection-related HCV infections among persons under 30 States reporting increases in HCV cases: Upstate New York, Alabama, Colorado, Connecticut, Georgia, Indiana, New Mexico, Kentucky, Maine, Maryland, Montana, Rural Wisconsin, North Carolina, Oregon, Tennessee, Washington, Massachusetts,Wisconsin, and West Virginia • MMWR, Hepatitis C Virus Infection Among Adolescents and Young Adults –Massachusetts, 2002—2009. May 6, 2011 / 60(17); 537-541 • MMWR. Use of enhanced surveillance for hepatitis C virus infection to detect a cluster among young injection drug users---New York, November 2004—April 2007. 2008; 57:517—21. • MMWR, Notes from the Field: Hepatitis C Virus Infections among young adults – rural Wisconsin, 2010. May 18, 2012 / 61(19); 358-358 Healthy Kansans Living in Safe and Sustainable Environments

  26. Quick Review │ Prevalence and Viral Characteristics • Why is there such a high HCV prevalence among PWID (30-70%)? • Higher HCV prevalence contributes to higher HCV incidence • 30-70% of IDUs will acquire HCV within 1-3 years of injecting (CDC) • The probability of injecting with someone who is HCV-infected is now greater than the probability of injecting with someone who is HIV-infected • Differences in viral infectivity and stability • HCV is more concentrated (i.e. replicates faster) in blood than HIV • HCV is more stable outside the body than another virus like HIV • HCV can survive longer on inanimate objects than another virus like HIV Healthy Kansans Living in Safe and Sustainable Environments

  27. HCV’s Behavioral Risk Profile • Viral Infectivity of HCV persists for: • Up to 63 days in syringe barrel and dead space • Up to 21 days in H2O (in plastic container) • Up to 14 days on inanimate faces (cookers and injection surfaces) • Paintsil et al. Survival of Hepatitis C Virus in Syringes: Implication for Transmission among Injection Drug Users. JID, 2010 • Doerrbecker et al. Inactivation and survival of hepatitis C virus on inanimate surfaces. J ID, 2011 • Doerrbecker et al. Transmission of Hepatitis C Virus Among PWID: Viral Stability and Association With Drug Preparation Equipment, JID, 2012 The space between the tip of the syringe —i.e. the hub of the needle and the needle itself contains small amounts of solution when the plunger is fully depressed Healthy Kansans Living in Safe and Sustainable Environments

  28. HCV’s Behavioral Risk Profile Considered These vital characteristics transform every piece of injecting equipment into a primary transmission vector. HCV’s protracted infectivity and environmental stability has the potential to transform the entire injection episode into a substantial risk factor since the setting itself contains a plethora of mandatory equipment that can harbor and transmit HCV. Healthy Kansans Living in Safe and Sustainable Environments

  29. Relevant Considerations But WAIT…where does this risk begin and are our college students truly the students that are injecting drugs or other substances? Are they really at risk for HCV? Healthy Kansans Living in Safe and Sustainable Environments

  30. Youth (Grades 8 and 12) and Drug Use Monitoring the Future: National Results on Drug use, 2013 Key Findings on Adolescent Drug Use. L. Johnston, Ph.D., et al. 2013 Healthy Kansans Living in Safe and Sustainable Environments

  31. Connecting the Dots Percent of college students who reported using prescription drugs that were not prescribed to them within the last 12 months: American College Health Association: Spring 2013 Reference Group Executive Summary. 2013. Healthy Kansans Living in Safe and Sustainable Environments

  32. Drawing the Lines Reported illegal drug use for all students within the last 30 days: EXCLUDES: tobacco, alcohol, hookah tobacco (shisha), and marijuana) American College Health Association: Spring 2013 Reference Group Executive Summary. 2013. Healthy Kansans Living in Safe and Sustainable Environments

  33. Further Connections “College students who drank alcohol, reported experiencing the following in the last 12 months when drinking alcohol:” American College Health Association: Spring 2013 Reference Group Executive Summary. 2013. Healthy Kansans Living in Safe and Sustainable Environments

  34. Relevant ‘Recap’ • National/State data indicate trend in young persons abusing prescription drugs • Growing national trend of younger IDUs • Increasing incidence of HCV among young IDUs • Prescription drugs, particularly opioid analgesics (national) and stimulants (Kansas) are highly addictive – increases likelihood of young person transitioning from “social” use to IDU • Further considerations to be had when considering the sexual health implications that recreational or regular drug use has on sexual health risk for youth (STIs, including HIV – STIs highly relevant in most academic settings) Healthy Kansans Living in Safe and Sustainable Environments

  35. Viral Hepatitis C │ 2013 Updates

  36. Viral Hepatitis Updates Second year anniversary of the Department of Health and Human Services (HHS) action plan - COMBATING THE SILENT EPIDEMIC of VIRAL HEPATITIS: Action Plan for the Prevention, Care & Treatment of Viral Hepatitis In June 2013, the USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering 1-time screening for HCV infection to adults born between 1945 and 1965(age cohort) Healthy Kansans Living in Safe and Sustainable Environments

  37. Viral Hepatitis Updates New pipeline drugs approved (solvadi - $84,000.00, 12 weeks)—sofosbuvir and simeprevir opens the door for an all-oral regimen, potentially avoiding interferon and its harsh side effects. Other direct-acting antivirals are under development Orasure Technologies develops the first FDA-approved, CLIA-waived rapid HCV test, greater than 98% accurate, tests for multiple HCV genotypes, user friendly, fingerstick and venipuncture whole blood collection Healthy Kansans Living in Safe and Sustainable Environments

  38. Resources • American College Health Association: http://www.acha.org/ • HCV Advocate: http://www.hcvadvocate.org/ • UFO Model: http://www.ufomodel.org/home • The Body: http://www.thebody.com/ • Harm Reduction Coalition: http://harmreduction.org/ • Centers for Disease Control & Prevention: http://www.cdc.gov • KDHE STD Program: http://www.kdheks.gov/std • KDHE HIV/AIDS Program: http://www.kdheks.gov/hiv • KDHE STD Department Facebook: http://www.facebook.com/AvoidTheRisk • STD Info For Youth: www.didjaknow.org • U.S. Health & Human Services AIDS Website: www.aids.gov • Teens and HIV: www.iknowhiv.org • KDHE KACHA Webpage: http://www.kdheks.gov/hiv/kacha.htm Healthy Kansans Living in Safe and Sustainable Environments

  39. Contact Information Scott Strobel Behavioral Intervention Specialist Kansas Department of Health and EnvironmentBureau of Disease Control and Prevention, STI-HIV Section 1534 SW Clay Topeka, KS 66604 Office: (785) 251-2433 Cellular: (785) 213-8944 E-mail: sstrobel@kdheks.gov Dominique Saunders Adult Viral Hepatitis Prevention Coordinator | KACHA State Co-ChairKansas Department of Health and EnvironmentBureau of Disease Control and Prevention, STI-HIV Section 2030 Tecumseh Road Manhattan, KS 66502 Office: 785.776.4779 ext. 7615Cellular: 785.213.7215 Email: dsaunders@kdheks.gov Healthy Kansans Living in Safe and Sustainable Environments

  40. Questions and Discussion Healthy Kansans Living in Safe and Sustainable Environments

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