memorandum - Cree Health

MEMORANDUM
To :
Physicians, Nurses, Lab technicians and Pharmacists in Eeyou Istchee
From :
Dr. France Morin, Consultant Physician on Sexually Transmitted Infections
Dr. Kianoush Dehghani, Coordinator of Infectious Diseases
Cree Public Health, Region 18
Date:
April 16 2013
RE:
Syphilis : Up-to-date measures to improve Regional surveillance
 STATEMENT OF PURPOSE:
The purpose of this memorandum is to recommend improved surveillance for syphilis
in our region.
 REGIONAL CONTEXT:
1) Our Region continues to be at “HIGH RISK” for sexually transmitted infections (STI), mainly
for Chlamydia and Gonorrhea with 7-11 times higher infection rates than the rest of
Quebec.
2) We have had three cases of syphilis in our Region within the last 5 years. So far, 2 cases
have been reported to the Cree Public Health in 2013. Moreover, recently we were made
aware of significantly increased rate of syphilis in other adjacent Regions.
3) Syphilis is a disease that is not always easy to diagnose, and is associated with important
morbidity & mortality, including congenital syphilis, and neurosyphilis & cardiovascular
complications of tertiary syphilis. Also, sores associated with syphilis increase the risk of
HIV transmission by 2-5 times.
 WHAT TO DO:
1) Promoting healthy sexuality in the community: e.g. consistent condom use
2) Screening of asymptomatic individuals (see new recommendations regarding syphilis
screening for our region):
a. Population screening: e.g. screening of pregnant women
b. individuals at risk screening: e.g. screening of individuals with history of high
risk sexual behavior
3) Testing of symptomatic individuals (see appendix 1)
4) Contact tracing and contact management of all individuals who test positive for syphilis
(see Appendix 3)
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5) Reporting all individuals with a positive test for syphilis (i.e. MADO) to the public
health department of Region 18 (see appendix 2)
6) Appropriate antibiotic treatment and follow-up of individuals with syphilis (please see
appendix 1).
7) Rehabilitation & long-term care of individuals affected by disabling tertiary syphilis and
congenital syphilis.
 REGIONAL NEW RECOMMENDATIONS ON SCREENING OF ASYMPTOMATIC
INDIVIDUALS USING THE “RPR” TEST:
1) POPULATION-BASED SCREENING:
a. Screening of pregnant women at the beginning (i.e. during the first prenatal
visit), AND at week 28 of pregnancy (Note: the test at 28 weeks of gestation can
be done concomitantly with the blood test for glucose tolerance, and screening
for gonorrhea and Chlamydia)
2) SCREENING OF INDIVIDUALS AT RISK:
a. All individuals who test positive for gonorrhea should be tested for syphilis
(Note: they should also be offered HIV testing with consent & counseling).
b. Other individuals with identified risk factors, including:
i. Individuals with multiple sexual partners :
1. Defined as individuals with more than 3 partners during the
past year.
ii. Individuals who have had sexual relations with a partner originating
from « endemic » regions or countries for STI and HIV (Note : Please
contact a designated public health physician** if you have a question
about disease frequencies in different jurisdictions);
iii. Men who have sex with men (MSM);
iv. Sex workers;
v. Street youths;
vi. Individuals who have contracted gonorrhea, syphilis, HIV, hepatitis B
vii.
and/ or hepatitis C infection(s) during the last year;
Individuals who have had unprotected sexual relationship with other
individual(s) with above characteristics.
3) All sexual contacts of a patient with confirmed syphilis infection have to be evaluated
based on the incubation & contagious periods (see Appendix 1), by clinical examination
and an RPR test (see Appendix 1). If the initial RPR test proves negative in an identified
sexual contact, the test should be repeated in 3 (three) weeks (see Appendix 1).
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a. All pregnant syphilis contacts have to be reported immediately to the designated
public health physicians**.
b. All symptomatic (see Appendix 1) contacts have to be reported immediately to
the designated public health physicians**.
c. Unless otherwise indicated by the designated public health physicians** or the
designated ID specialists**, the clinicians should “wait” for the results of the RPR
and the treponemal tests “prior” to treating the patient for syphilis. Attention: If
the results of the RPR are not available in 1 (one) week after the blood sample
was sent to the lab, please contact the designated public health physician** to
follow-up.
4) All individuals who ask for screening for STI, even without reporting any of the above risk
factors after pre-test counseling, should be tested.
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APPENDIX 1. CLINICAL PRESENTATION, TESTING AND TREATMENT OF SYPHILIS:
FOR
MORE INFORMATION PLEASE REFER TO THE INESS WEBSITE AT:
HTTP://WWW.INESSS.QC.CA/FILEADMIN/DOC/INESSS/OUTILS/GUIDES_ITSS/SYPHILIS_GUIDE_ITSS_17JAN.PDF
1. PRIMARY SYPHILIS : CHANCRE

The chancre lesion appears anywhere from 10 to 90 days after the infectious contact (on
average after 3 weeks).

The lesion can be found on any inoculation site(s), but mainly involve the genital, anorectal and/ or oro-pharyngeal areas.

The chancre lesion starts as a “papule” (usually only one), and eventually develops to an
ulcer.
The superficial ulcerative lesion is often painless (unless super-infected), with
regular contour and indurated base, and measures up to 1 cm in diameter.




Pain-less local adenopathy may be present.
The lesion often regresses spontaneously in 3 to 8 weeks.
The chancre lesion can go unnoticed.
Attention : Whenever a genital, ano-rectal and/ or oro-pharyngeal ulcer-like lesion is
observed (including those that are pain-less), a viral culture has to be taken to rule out
“herpes”.
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2. SECONDARY SYPHILIS : SKIN RASH



Often appears 2 to 12 weeks, sometimes a few months, after the chancre lesion has healed.
Often is accompanied by « flu-like » symptoms.
It consists of a generalized diffuse maculo-papular and non-pruritic rash (can also affect
the palms of hands and soles of feet)



Over time, the lesions can coalesce to form flat condylomas (i.e. condyloma lata).
The rash goes away spontaneously in 3 to 12 weeks.
The rash can go unnoticed.
Note: When you observe a diffuse rash in an adult, consider« syphilis » in your differential
diagnosis!
3. LATENT (HIDDEN) SYPHILIS: ASYMPTOMATIC
Medical history and serological testing(s) help the clinician to diagnose and classify latent
syphilis :

Early latent syphilis: Less than one year after the onset of syphilis infection; the affected
person is considered contagious.
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
Late latency syphilis: More than one year after the onset of the syphilis infection. Late
latency syphilis is not considered contagious, however, infected pregnant women can still
transmit the infection vertically to their fetus.
4. TERTIARY SYPHILIS
Tertiary syphilis appears in about 40% of individuals who did not receive appropriate
treatment for syphilis, approximately 5 to 30 years after the spontaneous healing of the chancre
lesion. Tertiary (late) syphilis is slowly progressive and may affect any organ. The disease is
generally not thought to be infectious at this stage. Manifestations may include the following:


Cardiovascular: aortic aneurysm, aortic regurgitation etc.
Neurosyphilis : dementia, altered mental status, peripheral neuropathy, incontinence, focal
neurologic findings such as hearing and vision loss etc.

Other: syphilitic gumma , paroxysmal cold hemoglobinuria, irreversible end organ damage
etc.
PLEASE NOTE : Individuals who are HIV-positive can develop symptoms very different from the
symptoms described above. HIV can also increase the chances of developing syphilis with
neurological involvement. Please consult a designated ID specialist** for more information.
5. CONGENITAL SYPHILIS :
Congenital syphilis is caused by trans-placental (i.e. vertical) transmission of syphilis
infection. The transmission rate approaches 90% if the mother has untreated primary or
secondary syphilis. Fetal infection can develop at any time during gestation. Manifestations are
defined as early if they appear in the first 2 years of life and late if they develop after age 2
years. According to a Centre for Disease Control (CDC U.S.) report, untreated syphilis, especially
early syphilis, during pregnancy can lead to deafness, neurologic impairment, bone deformities,
stillbirth, and neonatal death.
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6. CONTAGIOUSNESS (INFECTIOUS PERIOD)
Primary syphilis
Secondary syphilis
Contagious Period
Early latent Syphilis
Late latency syphilis
Tertiary
Non-contagious Period
7. DIAGNOSTIC TESTING :
In our Region, the RPR (Rapid Plasma Reagin) test has replaced the VDRL as the primary
non-treponemal diagnostic test for syphilis. An RPR serological test has to be done when a
patient presents with signs and symptoms that are suggestive of syphilis. If the RPR test of a
symptomatic patient proves negative, it has to be repeated in 3 weeks, in order to reduce the
probability of a false negative result (e.g. due to “window period” of primary syphilis). All the
positive (or in doubt) RPR results are automatically sent to the laboratoire provincial de santé
publique (LSPQ) for confirmation with a treponemal test (i.e. TP-PA).
Consult a designated public health physician** and/ or a designated ID specialist** for
EVERY symptomatic case suspected of having syphilis, immediately.
Moreover, the “contacts” of a confirmed syphilis patient should also be tested by
the RPR test. Again, if the RPR test for a contact of a confirmed syphilis patient proves negative,
it should be repeated in 3 weeks to reduce the probability of a false negative result.
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7.Screening test for asymptomatic cases :
In our Region, the RPR has replaced the VDRL test as the primary non-treponemal test
for screening asymptomatic individuals for syphilis. All the positive (or in doubt) RPR results are
automatically sent to the laboratoire provincial de santé publique (LSPQ) for confirmation with
a treponemal test (i.e. TP-PA).
8. TREATMENT :
First choice: Penicillin G benzathine*, 2,4 millions units applied intramuscularly (IM). This is a
prolonged-action penicillin.
*ATTENTION : Not to be confused with penicillin G sodique, a short-acting penicillin that is
inadequate for treating syphilis.
The required number of treatments and the type of antibiotics used depend on the
patient’s stage of syphilis and other factors (e.g. HIV status, allergy to penicillin, pregnancy &
breastfeeding etc.). Please consult a designated public health physician** and/ or a designated
ID specialist** prior to treating ANY case of syphilis (including for the treatment of pregnant
women, congenital syphilis, individuals with HIV and those with known allergy to penicillin).
Treatment for syphilis is provided free charge for all qualified Cree & Inuit residents of
Region 18. For questions on medication coverage for non-qualified patients, please contact the
pharmacist in Chisasibi Hospital.
For individuals with primary and secondary syphilis a serological follow-up by
quantitative RPR test is required to evaluate the response to treatment, at 3,6 and 12 months
after the treatment (Please discuss the post-treatment monitoring of cases with latent syphilis,
tertiary syphilis, neurosyphilis, congenital syphilis and HIV infected individuals with designated
ID specialist physicians**).
Please discuss the titer values of post-treatment RPR with the
designated ID specialist at MUHC**.
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**Designated Physicians:
The designated public health physicians for sexually transmitted infections at the Cree
Public Health are:
Dr. Kianoush Dehghani:
Telephone: 514-861-2352 extension 74237
Email: kianoush.dehghani@mcgill.ca OR kianoush.dehghani@ssss.gouv.qc.ca
Fax: 514-861-5206
Dr. France Morin:
Telephone: 450-248-0686 or 514-861-2352
Email: france.morin.chb@ssss.gouv.qc.ca
Fax: 450-248-3752
The designated infectious disease specialists at the MUHC and CHB are: Dr. Vivian
Loo and Dr. Pierre Rene (Note: this assignment will change in the near future, and new ID
physicians will be assigned to this position). They can be paged through the MUHC general
operator at 514-934-1934 extension 53333 from 8:00 to 16:00 hr. Outside business hours or
when above physicians are not available, you may contact the ID specialist on-call at the Royal
Victoria Hospital.
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APPENDIX 2.
DECLARABLE DISEASES OR MALADIE À DÉCLARATION OBLIGATOIRE (MADO)
SYPHILIS IS A MADO THAT HAS TO BE DECLARED BY:

The treating physician
AND

The laboratory
 To obtain a declaration form, see the attached form and/ or refer to the website :
http://publications.msss.gouv.qc.ca/acrobat/f/documentation/preventioncontrole/AS-770.pdf
The MADO declaration form has to be faxed « immediately » to the Cree Public Health
Department (Region 18) at: (514) 862-5206
1. Note: For the « nosologique » definition of syphilis, please consult the reference document
published by the Ministère de la Santé et des Services sociaux of Quebec (MSSS), which is
available at:
http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2012/12-268-03W.pdf
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Appendix 3. Les partenaires à joindre en fonction de la période de contagiogité (Source : refernces 4 & 7-9)
Les intervalles indiqués ci-après sont ceux habituellement recommandés. Ils constituent des intervalles minimaux. Comme il est difficile de déterminer le moment précis où l’infection a été contractée et que les
périodes d’incubation sont généralement des estimations pouvant comporter une marge d’incertitude, il peut être justifié, dans certaines situations, de prolonger la période indiquée
Infectionss
Partenaire à joindre
Actions
• les partenaires qui ont eu un contact sexuel avec la personne infectée dans les 60 jours précédant le début des
Infection génitale à Chlamydia trachomatis
symptômes ou le moment du diagnostic;
et
• s’il n’y a aucun partenaire sexuel dans les 60 jours précédant le début des symptômes ou le moment du
infection gonococcique
diagnostic, le plus récent partenaire sexuel de la personne infectée;
•les
lespartenaires
partenairesqui
quiont
onteueuun
uncontact
contactsexuel
sexuelavec
aveclalapersonne
personneinfectée
infectée: avant que celle-ci ait terminé son
traitement ou moins de 7 jours après un traitement unidose;
• jusqu’à 3 mois avant le début des symptômes;
• les partenaires qui ont eu un contact sexuel avec la personne infectée qui présente des symptômes.
• pendant la durée des symptômes.
Syphilis
Primaire
Si la date du début des symptômes est inconnue ou incertaine2, les partenaires qui ont eu un contact sexuel avec la
personne infectée jusqu’à 4 mois et une semaine avant le moment du diagnostic.
Secondaire
les partenaires qui ont eu un contact sexuel avec la personne infectée :
Traitement
épidémiologique1. Évaluation
des indications de
dépistage des ITSS.
Évaluation des indications de
dépistage des a u t r e s ITSS.
Si dernier contact sexuel ≤ 90 jours :
traitement épidémiologique1.
Si dernier contact sexuel > 90 jours :
traitement selon le résultat des tests.
• jusqu’à 6 mois avant le début des symptômes;
• pendant la durée des symptômes.
Si la date du début des symptômes est inconnue ou incertaine2, les partenaires qui ont eu un contact sexuel avec la
personne infectée jusqu’à 8 mois avant le moment du diagnostic.
latente précoce
les partenaires qui ont eu un contact sexuel avec la personne infectée jusqu’à 1 an avant le moment du diagnostic.
latente tardive
les partenaires présents ou passés qui ont eu une relation de longue durée avec la personne infectée devraient être
dirigés vers les services appropriés pour un examen clinique et sérologique.
latente tardive titrage ≥1 : 32
Traitement selon le résultat des tests.
Évaluation des indications de
dépistage des ITSS.
Si le titre du test non tréponémique est élevé (1 : 32 ou plus), il est plus prudent de faire comme s’il s’agissait
Idem à la syphilis primaire,
d’une syphilis latente précoce et de rechercher tous les partenaires de la dernière année.
secondaire et latente précoce.
1.
Traitement administré d’emblée sans attendre le résultat de l’analyse de laboratoire et même si le partenaire est asymptomatique
2.
Si la date de début des symptômes est inconnue ou incertaine, mais que des symptômes de syphilis sont présents au moment ou un professionnel de la santé fait le diagnostic, on
ajoute une pérode correspondant à la durée maximale des symptômes.
Page 12 sur 13
Refernces:
1)
2)
3)
4)
5)
6)
7)
Dre V. Loo & Dr P. Rene (consultant microbiologists, CUSM & CHB), in-person consultation, March 2013.
Syphilis Memorandum prepared by the DSP of Region 08 (l’Abitibi et Temiscaminque) February 2013.
INESS: Guide ITSS – Syphilis. Website: http://www.inesss.qc.ca/fileadmin/doc/INESSS/Outils/Guides_ITSS/syphilis_GUIDE_ITSS_17jan.pdf.
INSPQ. Janvier 2012.
Canadian Guidelines on Sexually Transmitted Infections. Website: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-10-eng.php.
PHAC. Updated 2010.
Maladie d’Origine Infectieuse : Definition Nosologique, Syphilis (p. 105). MSSS QC. 9 edition. Website :
http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2012/12-268-03W.pdf. Juin 2012.
CDC – Syphilies Factsheet. Website : http://www.cdc.gov/std/syphilis/STDFact-Syphilis-detailed.htm. Last updated 13 Feb 2013.
Institut nationale de santé publique du Québec. Complément québécois. Lignes directrices canadiennes sur les infections
transmissibles sexuellement édition 2006.
8)
Ministre de la santé et des services sociaux (MSSS QC). Aide-mémoire à l’'intention des professionnels de l a santé.
Intervention préventive auprès des personnes atteintes d'une infection transmissible sexuellement et auprès de leurs partenaires,
pour briser la chaîne de transmission, traiter les partenaires. 2004 (page 8).
9)
Régie régionale de la santé et des services sociaux de Montréal-Centre, et Régie régionale de la santé et des
services sociaux de Laval. Évaluation d'un servicede soutien à la notification aux partenaires de personnes atteintes d'une
maladie transmissible sexuellement (MTS) autre que /'infection auVIH, juin 1998.
10) Euerle B, & B.A. Cunha. Syphilis. Medscape. Updated Jan 6, 2013
11) Waseem M, & R. Steele. Pediatric Syphilis. Medscape. Updated April 1 2013.
12) MC Drouin. Facteurs de risqué et ITSS : à rechercher (Mise à jour des indication de dépistage). INSPQ (CALI). 27 Février 2013.
13) Institut nationale de santé publique du Québec. Complément québécois. Lignes directrices canadiennes sur les infections transmissibles
sexuellement édition 2006, Québec, institut , 2007.
14) Ministre de la santé et des services sociaux. Aide-mémoire à l’'intention des professionnels de la santé. Intervention préventive auprès des
personnes atteintes d'une infection transmissible sexuellement et auprès de leurs partenaires, pour briser la chaîne de transmission, traiter les
partenaires, Québec, ministère de la santé et des Services sociaux, 2004, 8 p.
15) Régie régionale de la santé et des services sociaux de Montréal-Centre, et Régie régionale de la santé et des services sociaux de Laval. Évaluation
d'un service de soutien à la notification aux partenaires de personnes atteintes d'une maladie transmissible sexuellement (MTS) autre que /'infection
au VIH, juin 1998.
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