10/8/2014
SEXUALLY TRANSMITTED
INFECTIONS & TEENS
Nancy N. Fajman, MD, MPH
Associate Professor of Pediatrics
Emory School of Medicine
nfajman@emory.edu
Objectives
• At the end of the session participants will be
able to:
• Differentiate between the evaluation and treatment
of sexually transmitted infections (STIs) in preadolescents and adolescents who have been
sexually abused.
• State the mechanisms of transmission for
Gonorrhea, Chlamydia trachomatis, Syphilis, HIV,
Herpes Simplex Virus and Human Papillomavirus.
• Discuss the concept of transmissibility of STIs and
why not every contact with an infected person
results in disease.
Proper Language
• Teen vs. Adolescent
• Sexually Transmitted Infection (STI) vs.
Sexually Transmitted Disease (STD)
• Posterior vs. Butt
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Anatomy Preadolescent
Adolescent
Adolescent Physiological Changes
• Leukorrhea
• Small amount of normal,
white/mucoid discharge
• Changes in vaginal
environment (pH, types of
cells) make some infections
more likely to spread internally
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Youth Risk Behavior Survey, 2013
• ______% of high school students have had sexual
intercourse at least once.
• ______% used a condom during the last episode of
sexual intercourse
Evaluation for STIs
Adolescents
• ↑ risk for pre-existing STI
• ↑ risk for acquired STI
from assault
• ↓ likelihood for follow-up
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Evaluation for STIs
Adolescents
Preadolescents
• ↑ risk for pre-existing STI
• Less likely to have pre-
• ↑ risk for acquired STI
existing STI unless there
is a history of prior or
chronic abuse
• ↓ risk for acquired STD
from abuse, unless
penetrating injury
• ↑ likelihood for follow-up
from assault
• ↓ likelihood for follow-up
STI Concerns after Sexual Abuse
• Preadolescent
• Assess at baseline for sexually transmitted
diseases
• Reassess at:
• 2 weeks to assess for interim change from
infections such as gonorrhea or chlamydia
• 1.5, 3 and 6 months to assess for development of
antibodies to HIV and syphilis as a sign of new
infection
STI Concerns after Sexual Abuse
• Adolescent
• ?Assess at baseline for sexually transmitted diseases
• May treat presumptively for gonorrhea, chlamydia
and/or Trichomonas
• Consider need for HIV prophylaxis and provide it as
indicated
• Reassess at:
• 2 weeks to assess for interim change from infections
such as gonorrhea or chlamydia (esp. if presumptive Rx
not given)
• 1.5, 3 and 6 months to assess for development of
antibodies to HIV and syphilis as a sign of new infection
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HOW DO YOU GET AN
INFECTIOUS DISEASE?
Direct vs. Indirect (Fomite) transmission
Direct Transmission
Direct Transmission
Vertical Transmission
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Direct Transmission
Indirect (Fomite) Transmission
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WARNING!
NEISSERIA
GONORRHEA
Neisseria gonorrhea
• The Organism
• Gram negative diplococcus (gonococcus = GC)
• Looks similar to other Neisseria species under
the microscope
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Neisseria gonorrhea - Incubation
Incubation: 2-7 days
Gonorrhea
• Human – Human Transmission
• Direct Contact with infected secretions
• The organism adheres to mucus
membranes (inside mouth/throat,
conjunctivae, urethra, vagina, cervix, anal
canal) and penetrates to deeper tissues
• Can disseminate to the blood and other
body parts
Vertical Transmission of Gonorrhea
• Conjunctivitis
• Scalp abscess
• Widespread disease (blood, joints, brain)
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Gonorrhea: Clinical Presentation
• Gonorrhea in adolescents is often
asymptomatic
• Females may have infection of the urethra,
cervix (cervicitis) or Fallopian tubes
(salpingitis)
• Pelvic inflammatory disease (PID)
• Anorectal, tonsillar infection
Gonorrhea: Clinical Presentation
Gonorrhea: Clinical Presentation
 Men may have urethritis,
often with painful
urination +/- discharge
 May progress to infect
the epididymis
 Anorectal, tonsillar
infection
 May be without signs or
symptoms
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Gonorrhea: Clinical Presentation
Gonorrhea
• Male and Female: anorectal infection +/or
infection of tonsils/throat
Gonorrhea Diagnosis - Culture
• Culture Technique as the gold
standard
• For genital, anorectal or throat
(pharyngeal) infections
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Gonorrhea Diagnosis - NAAT
• Culture Technique
• Nucleic Acid Amplification Test
(NAAT)
• Requires a “dirty” urine specimen
• The test may remain + for a few
weeks after treatment although the
patient is no longer infectious
Gonorrhea – Risk of Transmission
• The risk for transmission of N. gonorrhoeae from an
infected woman to the urethra of her male partner is
approximately 20% per episode of unprotected vaginal
intercourse and increases to 60% to 80% after four or
more exposures.[Hooper]
• The risk for male-to-female transmission has been less
well studied but probably approximates 50% to 70% per
contact.[Lin]
• Transmission by anal intercourse is efficient, but the risk
per episode has not been quantified.
• Transmission occurs less readily by fellatio, especially
from the oropharynx to the urethra, and transmission in
either direction by cunnilingus is believed to be rare.
Fomite Transmission of Gonorrhea
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Fomite Transmission of Gonorrhea
• Case reports
• Contaminated facemask strap  eye inoculation
• Ingested chocolate agar
• Recovery of gonorrhea organism from inanimate
objects
• Epidemics of conjunctivitis
• Epidemics of vulvovaginitis and rectal gonorrhea
Goodyear-Smith, F, What is the evidence for non-sexual transmission of gonorrhea in children after the
neonatal period? A systemic review. J Forensic and Legal Med, 2007. 14:489-502
CHLAMYDIA
TRACHOMATIS
Chlamydia trachomatis
• The Organism
• Obligate intracellular bacteria
• Incubation: variable, but usually at least 1 week
• Human – Human Transmission
• Direct Contact with infected secretions
• The organism adheres to mucosal surfaces (inside mouth,
conjunctivae, urethra, vagina, cervix, anal canal) and penetrates
the epithelial (superficial) cells.
• Disease manifestations are largely mediated by the patient’s
immune response to the infection.
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Vertical Transmission
• ~20-50% of women with
Chlamydia infection at time of
delivery will pass the infection
to their newborn
• These infections are usually
asymptomatic but may persist
in the body for up to 3 years
• If there is disease, it most
frequently affects the eyes or
lungs
Chlamydia: Clinical Presentation
• Chlamydia in adolescents
is often asymptomatic
• Infection of the urethra,
cervix (cervicitis) or
Fallopian tubes
(salpingitis)
• Pelvic inflammatory disease
(PID)
• Anorectal infection
Chlamydia: Clinical Presentation
• Inflammation of the urethra (urethritis) may
extend to the scrotum (epididymitis);
anorectal infection
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?Fomite Transmission of Chlamydia
• Recovery of Chlamydia from a nonporous
plastic surface
• Ambient conditions
• 50% of the samples were positive after 5 minutes
• Humid conditions
• 50% of samples positive after 52.5 minutes
• Complete desiccation at >3 hours
Novak et. al., Chlamydia trachomatis can be transmitted by a nonporous plastic surface in
vitro. Cornea. 1995 14(5):523-6
Chlamydia Diagnosis
• Culture method possible but may
have false negative results; must
use culture for anal detection
• Non-culture, NAAT, method is
acceptable
• Requires a “dirty” urine specimen
• The test may remain + for a few
weeks after treatment although the
patient is no longer infectious
SYPHILIS
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Syphilis
• The organism: Treponema pallidum,
a spirochete bacteria
• Transmission
• From infected mother through the
placenta to fetus
• Direct contact with ulcer or mucous
membranes of infected individual
• Incubation Period
• 10 - 90 days
• average of 3 weeks
Primary Syphilis: Chancre
Secondary Syphilis
• Generalized Rash
• Begins @ 1-2 months
after infection
• Condyloma lata
• Flat, thickened lesions in
the anogenital region
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Secondary Syphilis
Secondary Syphilis - Condyloma lata
Tertiary Syphilis
• @ 15-30 years after initial infection
• Usually associated by involvement of the aorta or
“gumma” changes of the skin, bone or internal organs
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HIV
Human
Immunodeficiency
Virus
HIV
• The organism: an RNA retrovirus that
attacks cells in our immune system
• Transmission: three primary methods
• sexual contact
• exposure to blood, largely through injection
drug use and occasionally through transfusion
• perinatal transmission from infected mothers to
their infants
Sexual Transmission of HIV
• Although HIV has been isolated from a variety
of body fluids, only blood, semen, other genital
secretions, and breast milk have been
implicated as sources of infection.
• Transmission of HIV infection through a single
sexual contact is directly related to:
• the infectiousness of the source partner,
• the susceptibility of the exposed individual,
• the number of partners, and
• the prevalence of HIV infection in the population.
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Exposure Risk
• High
• Traumatic skin wound
• Bleeding in donor
and recipient
• Traumatic sex with
blood
• Receptive anal
intercourse
• Intermediate
• Receptive vaginal
sex without trauma
• Low-Intermediate
• Skin with
compromised
integrity
Within 2 – 6 weeks of HIV exposure
HIV Testing
• Antibody Presence
• usually @ > 6 wks after infection
• Newborn will have antibody from
infected mother at time of birth
• lasts up to approximately 1 year
• DNA/RNA Polymerase
Chain Reaction (PCR)
• Usually positive within 1-2 weeks
of exposure
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Post Exposure Prophylaxis (PEP) for HIV
• Must start within 72 hours of exposure
• Take multiple drugs for 28 days
• National HIV/AIDS Clinicians'
Consultation Center (UCSF)
• Warmline: 800-933-3413, M-F, 8am – 8 pm EST
• PEPline 1-888-448-4911
• 24 hours / 7 days a week
HERPES SIMPLEX VIRUS
(HSV)
Herpes Simplex Virus (HSV)
• The Organism: HSV is a DNA virus
• There are 2 forms of Herpes Simplex Virus
• HSV-1 infections usually affect the face
and skin above the waist
• HSV-2 infections usually affect the
genitalia and skin below the waist
• BUT - Either virus can be found at either
place on the body.
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Herpes Virus
Herpes Virus
Herpes Simplex Virus
Herpes whitlow
Herpes gladiatorum
Eczema herpeticum
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Herpes Simplex Virus (HSV)
• Transmission: by direct contact
• Incubation Period: 2 days to 2 weeks
• Primary and Recurrent infections
• After the first infection (Primary) the Herpes virus remains
in the body (latent) and periodically “sheds”
• Shedding (during a Recurrent infection) may be silent (no
symptoms) or cause symptoms
• A person is contagious with Herpes whether the “shedding”
causes symptoms or not.
Vertical Transmission of HSV
• Up to 60% of women with a primary HSV genital
infection pass the infection to the newborn at
delivery
• <2% risk of transmission to infants born to mothers with
recurrent HSV infection
• >75% of newborns who contract HSV infection have
been born to women with no history or clinical
findings suggestive of prior genital HSV infection
Non-Vertical Transmission of HSV
• In most circumstances, transmission requires
direct contact of infected with uninfected mucus
membranes or skin during intimate contact such
as kissing or sexual contact.
• Transmission appears to be enhanced if the skin is
damaged or broken
• HSV is relatively unstable outside mammalian
cells.
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Herpes Simplex Virus Survival
• Skin: infectious virus recovered for up to 2 hrs
• Plastic: up to 4 hours
• Cloth: up to 3 hours
• Turner R, et. al., Shedding and survival of herpes simplex virus from ‘fever blisters’.
Pediatrics 1982. 70(4):547-549
?HSV Fomite Transmission
Nerurkar et. al., Survival of Herpes Simplex Virus in Water Specimens Collected From Hot Tubs in
Spa Facilities and on Plastic Surfaces. JAMA 1983;250:3081-3083
HSV Diagnosis
• Tzank smear – examine under microscope – not specific
for HSV
• Culture – rub the base of a fresh blister (vesicle) with a
cotton swab; send immediately to lab; grows in 2-5 days
• NAAT – only validated for cerebrospinal fluid in children
• Direct Fluorescent Antibody – not validated for children
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HSV Diagnosis
• Serology/Blood Assessment
• IgM antibody: indicates recent onset or recent recurrence of HSV
infection
• IgG antibody: indicates past HSV infection
• Beware:
• There is significant variability among test results
• 20-80% U.S. adults have HSV-2 antibody
• >25% U.S. children have HSV-1 antibody by 7 years
HUMAN PAPILLOMAVIRUS
(HPV)
Human Papillomavirus
• a DNA virus with >100 types
• Certain HPV types have a predilection for
dry skin or mucus membranes
• but not entirely specific
• Persistence of HPV
• Incubation: 3 months – several years?
• Latency – forever?
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HPV Transmission
• Transmission of warts
• Sexual contact
• Maternal Vertical Transmission
• Children may not show warts until 24-60 months of
life, if ever
• Autoinoculation
• Other caregivers or contacts - Heteroinoculation
• Oral reservoir of HPV
• ?Fomites
Fomite Transmission?
HPV Transmission - Direct Contact
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Ano-genital HPV – Condyloma acuminata
Condyloma acuminata - Females
Diagnosis of HPV
• Usually by observation
• Biopsy if unsure
• A variety of skin conditions have been
confused with HPV
• Antibody tests indicate whether a person has
had HPV exposure. Most people have.
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Conclusions
• Not all teens are sexually active.
• Those who are, however, are at increased risk for
sexually transmitted infections.
• The transmission of sexually transmitted agents is
dependent on multiple variables
• Age/development of the child
• Type of infectious agent and site of exposure
• Frequency of exposure
• Not everyone exposed to an STI gets the disease.
• Fomite transmission of STIs is a potential to
consider, though likely is rare.
Major References
• CDC 2010 STD Treatment Guidelines
• Mandell, Douglas, and Bennett's Principles and Practice of Infectious
Diseases, 8th ed., Saunders, 2014
• Goodyear-Smith, F, What is the evidence for non-sexual transmission
of gonorrhea in children after the neonatal period? A systemic review.
J Forensic and Legal Med, 2007. 14:489-502
• Hooper RR, Reynolds GH, Jones OG, et al: Cohort study of venereal
disease, I: The risk of gonorrhea transmission from infected women to
men. Am J Epidemiol 1978; 108:136-144.
• Lin JS, Donegan SP, Heeren TC, et al: Transmission of Chlamydia
trachomatis and Neisseria gonorrhoeae among men with urethritis
and their female sex partners. J Infect Dis 1998; 178:1707-1712
• Nerurkar et. al., Survival of Herpes Simplex Virus in Water Specimens
Collected From Hot Tubs in Spa Facilities and on Plastic Surfaces.
JAMA 1983;250:3081-3083
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