An Overview of Sexually Transmitted Infections in Canada

1
An Overview of Sexually Transmitted Infections in
Canada

• Thomas Wong, MD MPH FRCPC
• Community Acquired Infections Division
• Health Canada
• [phone]

2
Sexually Transmitted Infections (STIs) in Canada

• Chlamydia
• Gonorrhea
• Syphilis
• HSV
• HPV

3
Chlamydia

• Most prevalent bacterial STI in Canada
• Disproportionately affects adolescents and young
  adults
• Females account for over 2/3 of reported
  chlamydia cases
• PID, chronic pelvic pain, ectopic pregnancy,
  infertility

4
Reported Chlamydia Rates in Canada, by sex

• Data for 2002 are preliminary and changes are
  anticipated
• Source Sexual Health and STI Division, Health
  Canada 2004

5
Reported Male Genital Chlamydia Rates in Canada,
by age group

• Data for 2002 are preliminary and changes are
  anticipated
• Source Sexual Health and STI Division, Health
  Canada 2004

6
Reported Female Genital Chlamydia Rates in
Canada, by age group

• Data for 2002 are preliminary and changes are
  anticipated
• Source Sexual Health and STI Division, Health
  Canada 2004

7
Chlamydia

• Reported rate had been declining until the last
  few years
• Recent rate increase may be due in part to
  increased screening since the availability of new
  non-invasive NAAT (eg. PCR, LCR) but not the
  whole story

8
ChlamydiaFactors favouring control

• Effective, single-dose treatment
• Non-invasive urine testing

9
ChlamydiaHurdles and Challenges

• Lack of chlamydia awareness/knowledge
• Majority of infections are asymptomatic
• 80 of females
• 50 of males
• Hidden Epidemic lack of awareness and
  symptoms results in a lack of adequate screening,
  diagnosis, treatment and reporting.

10
Chlamydia Prevention and Control Strategies

• Increase Awareness Sexual Health Education
• Canadian Sexual Health Education Guidelines
• Targeted Prevention and Promotion
• Take advantage of non-invasive testing and
  one-dose treatment

11
Gonorrhea

• Second most commonly reported bacterial STI in
  Canada
• Males account for almost 2/3 of nationally
  reported cases
• Other STI often present with gonorrhea
  especially chlamydia

12
Reported Gonorrhea Rates in Canada, by sex

• Data for 2002 are preliminary and changes are
  anticipated
• Source Sexual Health and STI Division, Health
  Canada 2004

13
Reported Male Gonorrhea Rates in Canada, by age
group

• Data for 2002 are preliminary and changes are
  anticipated
• Source Sexual Health and STI Division, Health
  Canada 2003

14
Reported Female Gonorrhea Rates in Canada, by
age group

• Data for 2002 are preliminary and changes are
  anticipated
• Source Sexual Health and STI Division, Health
  Canada 2003

15
Gonorrhea in Canada

• Gonorrhea rates in Canada had been declining
  until the last few years
• Rates have risen by more than 50 over past 5 yrs

16
GonorrheaHurdles and Challenges

• Lack of symptoms (asymptomatic)
• Up to 80 of females
• 10-20 of males
• Even more likely to be asymptomatic if infected
  at rectal or pharyngeal sites

17
GonorrheaHurdles and Challenges

• Antimicrobial resistance
• Quinolone resistance increasing in Canada
• lt 1 in the early 90s
• 1 late 90s
• 2.4 rate for 2001
• Reduced capacity in tracking resistance because
  of increasing NAAT use

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GonorrheaFactors favouring control

• Effective, single-dose treatment
• Non-invasive urine testing continually
  improving and more available

19
Gonorrhea Prevention and Control Strategies

• Increase Awareness Sexual Health Education
• Canadian Sexual Health Education Guidelines
• Targeted Prevention and Promotion
• Take advantage of non-invasive testing and
  one-dose treatment

20
Syphilis
21
Syphilis

• The least common of the 3 bacterial STIs
• The elimination of syphilis was seen as an
  imminent goal as recently as 1996
• BUT increasing national rates since 1997

22
Reported Syphilis Rates in Canada, by sex

• Data for 2002 are preliminary and changes are
  anticipated
• Source Sexual Health and STI Division, Health
  Canada 2004

23
Reported Male Syphilis Rates in Canada, by age
group

• Data for 2002 are preliminary and changes are
  anticipated
• Source Sexual Health and STI Division, Health
  Canada 2004

24
Reported Female Syphilis Rates in Canada, by age
group
Data for 2002 are preliminary and changes are
anticipated Source Sexual Health and STI
Division, Health Canada 2004
25
Reported Syphilis Diagnoses in the UK, by sex
Source Public Health Laboratory Service, 2003
26
Reported Primary and Secondary syphilis rates in
Canada and the United States
Rate per 100,000
Year
U.S. Source Sexually Transmitted Disease
Surveillance, 2002, CDC Data for 2001 and 2002
are preliminary and changes are anticipated
27
Syphilis ControlFactors favouring elimination

• T. pallidum slow growth rate
• Long incubation period
• Effective treatment with benzathine penicillin
• Lack of penicillin resistance

28
Syphilis ControlHurdles and Challenges

• Regional Outbreaks
• Vancouver heterosexual, sex-trade, MSM
• Yukon heterosexual
• Calgary MSM
• Winnipeg heterosexual
• Toronto MSM
• Ottawa MSM
• Montreal MSM

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Syphilis ControlHurdles and Challenges

• Lack of availability of treatment Benzathine
  Penicillin G
• Increasing Trend of Risky Sexual Behaviour
• Lack of Awareness

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Syphilis Prevention and Control Strategies

• Intensify targeted prevention and health
  promotion
• Cyberprevention
• Enhance surveillance
• Enhance efforts for case finding and management
• Rapid outbreak response

31
Reportable Bacterial STI

• National rates of Chlamydia, Gonorrhea and
  Syphilis all rising
• WHY?
• Safe-sex burnout
• HAART and post-exposure prophylaxis
• Younger generation did not witness AIDS
  devastation
• Internet facilitating high risk partnering

32
Genital Herpes (HSV)

• Not reportable at the federal level
• Prevalence in Canada not well known (therefore a
  priority)
• Caused by HSV types 1 and 2
• Infection is life-long
• Predominantly asymptomatic
• Asymptomatic viral shedding leads to transmission

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Neonatal Herpes

• Most serious direct consequence of genital HSV
  infection
• Not reportable at Federal level (passively
  reported in many prov/terr information
  collected is limited and case definitions vary)
• Incidence per 100,000 live births
• United States 20-50 cases
• United Kingdom Australia 2-3 cases
• Canada 5.9 cases

34
Neonatal Herpes Surveillance

• Partnership between Canadian Paediatric Society
  (CPS) and Center for Infectious Diseases
  Prevention and Control of Health Canada

35
Neonatal Herpes Surveillance

• Two phase project
• Phase I surveillance of neonatal herpes
• Canadian pediatricians report every new observed
  neonatal case
• Maternal HSV infection
• Neonatal morbidity and lab results
• Immediate sequelae in neonatal period
• Phase II follow-up of neonatal cases
• 3 year follow up of neonatal cases RE longer term
  sequelae of neonatal infection

36
Human Papillomavirus (HPV)

• Estimated to be the most common STI
• Not reportable at federal level
• High risk types (oncogenic)
• Genital cancers (cervical, anal, penile)
• Low risk types (non-oncogenic)
• Genital warts

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HPV Infection Natural History

• Often transient
• Peak prevalence ages 20-24
• More likely to persist in women gt 30 years

38
Oncogenic HPV Prevalence in Ontario and
Newfoundland Women
HPV Hybrid capture assay
Source Sellors JW et al. CMAJ
(2000)163503-508 Ratnam S et al. Cancer
Epidemiol Biomarkers Prev (2000)9945-951
39
HPV and Cervical CancerNew Horizons

• HPV-DNA testing
• Primary screening
• Triage
• HPV Vaccine
• Liquid Based Cytology
• Implications for HPV testing and testing for
  other STIs
• Awareness of HPV Cervical Cancer link

40
STI Testing Issues

• Culture vs. NAAT (PCR, LCR)
• NAAT Urine vs. Swab
• Order of Swabs/Pap Test
• Menstruation and testing
• New and emerging tests

41
Other STIs
HIV
Enhance transmission of
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STI HIV Synergy

• STI increases HIV transmission acquisition
• STI morbidity can be worse, and infection more
  difficult to treat, for HIV-infected individuals
• Rise in syphilis indicative of unsafe sexual
  practices implications for rates of HIV
• STI incidence in HIV-infected individuals
• Can use as marker of unsafe sexual behaviors in
  HIV-positive population

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Conclusion

• Reportable STIs continue to rise
• Behavioural surveillance gap exists hindering
  targeted awareness, prevention and promotion
• Lack of data on viral STIs, however efforts to
  address viral STIs are underway

44
Acknowledgements

• Provincial and Territorial Partners
• Toronto Public Health Department
• AIDS Committee of Ottawa
• National Microbiology Lab
• Lai King Ng
• Janice Mann
• Rhonda Kropp
• Maureen Perrin