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An Overview of Sexually Transmitted Infections in Canada. Thomas Wong, MD MPH FRCPC Community Acquired Infections Division Health Canada (613) 941-7539. Sexually Transmitted Infections (STIs) in Canada. Chlamydia Gonorrhea Syphilis HSV HPV. Chlamydia. - PowerPoint PPT Presentation
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CIDPCCIDPC Division of Community Acquired Infections 04/21/23 1
An Overview of Sexually Transmitted Infections in Canada
Thomas Wong, MD MPH FRCPCCommunity Acquired Infections DivisionHealth Canada(613) 941-7539
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 2
Sexually Transmitted Infections (STIs) in Canada
Chlamydia Gonorrhea Syphilis HSV HPV
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 4
Reported Chlamydia Rates in Canada, by sex*
0.0
50.0
100.0
150.0
200.0
250.0
300.0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Rat
e pe
r 10
0,00
0
MaleFemaleTotal
•Data for 2002 are preliminary and changes are anticipated•Source: Sexual Health and STI Division, Health Canada 2004
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
0.0
100.0
200.0
300.0
400.0
500.0
600.0
700.0
Year
Ra
te p
er
10
0,0
00
15-19
20-24
25-29
30-39
40-59
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
0.0200.0400.0600.0800.0
1000.01200.01400.01600.0
Year
Rat
e pe
r 10
0,00
0 15-19
20-24
25-29
30-39
40-59
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 8
Chlamydia:Factors favouring control
Effective, single-dose treatment
Non-invasive urine testing
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 9
Chlamydia:Hurdles 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.
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
0
5
10
15
20
25
30
35
40
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Rat
e pe
r 10
0,00
0
male
female
total
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
0
20
40
60
80
100
120
140
160
Year
Ra
te p
er
10
0,0
00
15-19
20-24
25-29
30-39
40-59
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
0
20
40
60
80
100
120
140
160
180
200
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Ra
te p
er
10
0,0
00 15-19
20-24
25-29
30-39
40-59
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 16
Gonorrhea:Hurdles 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 17
Gonorrhea:Hurdles and Challenges
Antimicrobial resistance
Quinolone resistance increasing in Canada < 1% in the early 90’s = 1% late 90’s 2.4% rate for 2001
Reduced capacity in tracking resistance because of increasing NAAT use
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 18
Gonorrhea:Factors favouring control
Effective, single-dose treatment
Non-invasive urine testing – continually improving and more available
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 20
Syphilis
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
0
0.5
1
1.5
2
2.5
3
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Rat
e pe
r 10
0,00
0
male
female
total
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
0
1
2
3
4
5
6
7
8
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
Rat
e pe
r 10
0,00
0 15-19
20-24
25-29
30-39
40-59
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 24
Reported Female Syphilis Rates in Canada, by age group*
Data for 2002 are preliminary and changes are anticipatedSource: Sexual Health and STI Division, Health Canada 2004
0.00.51.01.52.02.53.0
Year
Rate
per
100,0
00
15-1920-2425-2930-3940-59
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 25
Reported Syphilis Diagnoses in the UK, by sex
Source: Public Health Laboratory Service, 2003
0
200
400
600
800
Year
Num
ber
of D
iagn
oses
(E
ngla
nd, W
hale
s &
Nor
ther
n Ir
elan
d)
Male
Female
Total
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 26
Reported Primary and Secondary syphilis rates in Canada and the United States*
0123456789
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
Canada U.S.
U.S. Source: Sexually Transmitted Disease Surveillance, 2002, CDC
* Data for 2001 and 2002 are preliminary and changes are anticipated
Rat
e p
er 1
00,0
00
Year
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 27
Syphilis Control:Factors favouring elimination
T. pallidum slow growth rate
Long incubation period
Effective treatment with benzathine penicillin
Lack of penicillin resistance
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 28
Syphilis Control:Hurdles and Challenges
Regional Outbreaks Vancouver: heterosexual, sex-trade, MSM Yukon: heterosexual Calgary: MSM Winnipeg: heterosexual Toronto: MSM Ottawa: MSM Montreal: MSM
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 29
Syphilis Control:Hurdles and Challenges
Lack of availability of treatment – Benzathine Penicillin G
Increasing Trend of Risky Sexual Behaviour
Lack of Awareness
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 30
Syphilis Prevention and Control: Strategies
Intensify targeted prevention and health promotion
Cyberprevention Enhance surveillance Enhance efforts for case finding and
management Rapid outbreak response
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 33
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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 34
Neonatal Herpes Surveillance
Partnership between Canadian Paediatric Society (CPS) and Center for Infectious Diseases Prevention and Control of Health Canada
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 37
HPV Infection: Natural History
Often transient
Peak prevalence: ages 20-24
More likely to persist in women > 30 years
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 38
Oncogenic HPV Prevalence in Ontario and Newfoundland Women*
0
5
10
15
20
25
<25 25-34 35-44 45+
Pre
vale
nce
(%)
Ontario Newfoundland
Source: Sellors JW et al. CMAJ (2000);163:503-508Ratnam S et al. Cancer Epidemiol Biomarkers Prev (2000);9:945-951
* HPV Hybrid capture assay
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 39
HPV and Cervical Cancer:New 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 41
OtherOther STIsSTIs
HIVHIVEnhance transmission of
Risky Sex
Risky Sex
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 42
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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 43
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
CIDPCCIDPC Division of Community Acquired Infections 04/21/23 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