Transcript Hepatitis C Virus Infections among young adults – rural Wisconsin

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
 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
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Syphilis Then…
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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.
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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.
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Rural Kansas Syphilis Outbreak │ 2012
 29 total cases of 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)
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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).
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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.
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Oral Primary Syphilis Chancre
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Primary Syphilis Chance │ Penile
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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.
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Symptoms of Syphilis │ Secondary Stage
 Condylomata Lata – 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.
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Secondary Syphilis Palmer Rash
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Secondary Syphilis Plantar Rash
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Secondary Syphilis Rash
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Mucous Patches
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Condylomata Lata
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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
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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
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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
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Resistant Gonorrhea Threat
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GC resistance to penicillin, tetracycline & fluoroquinolones
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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
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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.
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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.
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Viral Hepatitis C and Youth │Current Trends
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
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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
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MMWR, Hepatitis C Virus Infection Among Adolescents and Young Adults –Massachusetts, 2002—2009.
May 6, 2011 / 60(17); 537-541
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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.
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MMWR, Notes from the Field: Hepatitis C Virus Infections among young adults – rural Wisconsin, 2010.
May 18, 2012 / 61(19); 358-358
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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
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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
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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.
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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?
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Youth (Grades 8 and 12) and Drug Use
35
30
25
20
8th Graders
15
12th Graders
10
5
0
Monitoring the Future: National Results on Drug use, 2013 Key Findings on Adolescent Drug Use. L. Johnston, Ph.D., et al. 2013
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Connecting the Dots
Percent of college students who reported using prescription drugs that were not
prescribed to them within the last 12 months:
Percent (%) Male
Female
Total
Antidepressants
2.5
3.3
3.1
Erectile Dysfunction Medications
1.4
0.7
1.0
Pain Killers
8.3
7.2
7.6
Sedatives
4.3
4.0
4.2
Stimulants
8.9
7.1
7.8
Used 1 of More of the Above
15.7
14.4
14.9
American College Health Association: Spring 2013 Reference Group Executive Summary. 2013.
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Drawing the Lines
Reported illegal drug use for all students within the last 30 days:
Percent (%) Male
Female
Total
Used, not in last 30 days
25.5
18.4
20.8
Used 1-9 days
13.5
6.9
9.2
Used 10-29 days
3.1
1.3
1.9
Used all 30 days
3.2
0.8
1.7
Any use within last 30 days
19.8
9.0
12.9
EXCLUDES: tobacco, alcohol, hookah tobacco (shisha), and marijuana)
American College Health Association: Spring 2013 Reference Group Executive Summary. 2013.
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Further Connections
“College students who drank alcohol, reported experiencing the following in
the last 12 months when drinking alcohol:”
Percent (%) Male
Female
Did something you later regretted
35.5
34.7
Had unprotected sex
31.9
28.8
Forgot where you were or what you did
22.7
18.4
American College Health Association: Spring 2013 Reference Group Executive Summary. 2013.
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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)
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Viral Hepatitis C │ 2013 Updates
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)
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Viral Hepatitis Updates
New pipeline drugs approved (solvadi - $84,000.00, 12
weeks)—sofosbuvir and simeprevir opens the door for an alloral 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
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Resources
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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
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Contact Information
Scott Strobel
Behavioral Intervention Specialist
Kansas Department of Health and Environment
Bureau of Disease Control and Prevention, STI-HIV Section
1534 SW Clay
Topeka, KS 66604
Office: (785) 251-2433
Cellular: (785) 213-8944
E-mail: [email protected]
Dominique Saunders
Adult Viral Hepatitis Prevention Coordinator | KACHA State Co-Chair
Kansas Department of Health and Environment
Bureau of Disease Control and Prevention, STI-HIV Section
2030 Tecumseh Road
Manhattan, KS 66502
Office: 785.776.4779 ext. 7615
Cellular: 785.213.7215
Email: [email protected]
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Questions and Discussion
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