Sexually transmitted infections: trends and updated guidelines

 - Kenny Lin, MD, MPH

An outbreak of meningococcal disease in Florida and the continuing spread of monkeypox predominantly among men who have sex with men has called attention to the role of sexual networks in facilitating outbreaks of rare diseases. The Centers for Disease Control and Prevention (CDC) released new guidance on monkeypox that advises people to be aware of the transmission risk posed by contact with genital rashes or sores at raves, parties, clubs, and festivals. Although neither meningococcal disease nor monkeypox are thought to be directly transmitted though sex, both appear to spread more easily between close personal contacts.

Unfortunately, common sexually transmitted infections (STIs) are also on the rise in the U.S. According to the CDC's 2020 Sexually Transmitted Disease Surveillance Report released earlier this year, reported cases of gonorrhea and syphilis increased from 2019 to 2020 by 10% and 7%, respectively, while an alarming 2,148 cases of congenital syphilis occurred. Although reported chlamydia cases decreased by 13%, the CDC believes that this is most likely an artifact caused by disruptions in screening from the COVID-19 pandemic, since chlamydia is often asymptomatic. Similarly, an analysis published in last week's Morbidity and Mortality Weekly Report found that HIV testing declined by up to 50% in high-risk populations from 2019 to 2020, leading to a 17% decrease in new diagnoses that probably reflects diagnostic delays rather than a true decline in HIV incidence.

In this context, the May issue of AFP summarized important updates from the CDC's 2021 STI Treatment Guidelines. In a review article, Drs. Jessica Dalby and Bradley Stoner discussed several preventive strategies including hepatitis and human papillomavirus vaccinations, HIV preexposure prophylaxis (PrEP), and expedited partner therapy. The guidelines also emphasize antibiotic stewardship by distinguishing persons with a true IgE-mediated penicillin allergy from those who can safety receive ceftriaxone and penicillins through clinical tools such as the PEN-FAST rule. A Practice Guidelines piece highlighted more key practice points: doxycycline is preferred over azithromycin for most chlamydial infections, intramuscular ceftriaxone 500 mg (or 1 gram in patients weighing 150 kg or more) is now the standard therapy for gonorrhea, and women with trichomonas should received a 7-day course of metronidazole 500 mg twice daily rather than a single 2 gram dose.

More information for clinicians and patients on sexually transmitted infections, including techniques and tips for taking a sexual history,  is available in the AFP By Topic collection on STIs and separate collections on HIV/AIDS and Hepatitis (and Other Liver Diseases).

COVID-19 vaccines arrive for under 5s

 - Jennifer Middleton, MD, MPH

This past Friday, the United States (US) Food and Drug Administration (FDA) issued updates to its COVID vaccine recommendations, extending the Pfizer COVID-19 vaccine's Emergency Use Authorization to include children aged 6 months to 4 years while also extending the Moderna COVID-19 vaccine from ages 6 months to 17 years. The next day, the US Centers for Disease Control and Prevention (CDC) authorized both vaccines for their respective age groups. Since US states have been able to preorder vaccines in the past few weeks, many locales may be ready to vaccinate children aged 6 months and older as early as this week.

The Pfizer vaccine for ages 6 months through 4 years has had a rather bumpy road to approval. The first two doses of vaccine, which were all older children and adults required to demonstrate an immune response, did not elicit a sufficient immune response in this younger age group, necessitating the addition of a 3rd dose in the series. While the 3rd dose did elicit an immune response "comparable" to that of young adults, the number of cases among enrolled children was too low to permit rigorous analysis regarding the vaccine's effectiveness against infection or hospitalization. Pfizer has touted an 80% effectiveness rate for preventing COVID-19 infection after 3 doses, "[b]ut that 80 percent estimate was based on only 10 cases in a subset of 1,678 trial participants."

Moderna's vaccine has previously only been available for adults aged 18 and older, and the FDA  approved all three of its proposed new age groups on June 17: children aged 6 months to 5 years, children aged 6-11 years, and children and teens aged 12-17 years. For these groups:

• "Among participants 6 through 23 months of age...the vaccine was 50.6% effective in preventing COVID-19. Among participants 2 through 5 years of age...the vaccine was 36.8% effective in preventing COVID-19."
• Immune response was comparable in children aged 6-11 years to young adults, but there were not enough COVID-19 cases in this cohort to determine vaccine efficacy against infection and hospitalization.
• "[A]mong participants 12 through 17 years of age, the vaccine was 93.3% effective in preventing COVID-19."

All of these trials were conducted before omicron became the dominant COVID-19 strain, though the FDA and CDC are still encouraging parents to obtain the vaccine for their children, even if they previously had COVID-19 infection. All of these vaccine products are safe, and any level of protection against COVID-19 infection is better than none. Over 400 children under the age of 5 have died in the US from COVID-19 since the pandemic began, and Multisystem Inflammatory Syndrome in Children (MIS-C) afflicts 1 in every 3000-4000 children who get symptomatic COVID-19. Vaccination should help decrease COVID-19 outbreaks in schools and daycare centers, which have disrupted countless families' schedules over the past 2+ years.

Vaccine uptake is predicted to be low in the under-5-years age group, though, with a recent survey showing that only 18% of parents are planning to vaccinate their eligible children immediately with another 38% who are less certain and adopting a "wait and see" approach. The US state of Florida only ordered its vaccine supply for this age group late on Friday after initial statements from its governor regarding his opposition to the vaccine. Despite conflicting messages from government leaders and widespread parental concerns, family physicians can still help parents make well-informed vaccination decisions. Sharing information about COVID-19 infection's risks to children may help combat misinformation regarding a perceived "low" risk in this age group, and the US Federal Emergency Management Agency (FEMA) has a Coronavirus Rumor Control website that fact checks several common myths. This 2021 Lown Right Care article reviews "Helping Ambivalent Patients Make Healthy Decisions about COVID-19" using motivational interviewing. A recent Curbside Consultation discussed navigating when two parents disagree about vaccinating their child. Lastly, this 2016 AFP editorial provides evidence-based "Strategies for Addressing and Overcoming Vaccine Hesitancy" that ends by reminding us that "patients' ambivalence is your friend because it means that they have not closed their minds to vaccines."

Supporting transgender and gender questioning teens

 - Jennifer Middleton, MD, MPH

A new study has found that transgender and gender questioning youth are at higher risk of several serious health risks, including bullying and suicidal thoughts, compared to their cisgender peers. 

The study's researchers pulled data from the Youth Risk Behavior Survey, which is administered across most of the United States every other year. In 2017, 15 states added a question about transgender identity. The researchers looked at the survey results from 2017 and 2019 in those states and compared reported risk experiences between transgender and gender questioning youth to the reported risk experiences from cisgender youth:

[T]ransgender adolescents were more likely to report bullying at school (41.3% vs 18.0%; aPR, 1.88 [99.75% CI, 1.48-2.38]) and considering (44.8% vs 16.2%; aPR, 1.69 [99.75% CI, 1.41-2.03]), planning (41.6% vs 12.7%; aPR, 1.94 [99.75% CI, 1.57-2.41]), and attempting (30.0% vs 6.9%; aPR, 2.65 [99.75% CI, 1.87-3.74]) suicide than cisgender youths. Gender-questioning adolescents were also more likely to report bullying at school (37.1% vs 18.0%; aPR, 1.62 [99.75% CI, 1.27-2.08]) and considering (43.2% vs 16.2%; aPR, 1.54 [99.75% CI, 1.26-1.89]), planning (37.5% vs 12.7%; aPR, 1.60 [99.75% CI, 1.30-1.96]), and attempting (27.9% vs 6.9%; aPR, 2.26 [99.75% CI, 1.63-3.14]) suicide than cisgender youth.

Transgender and gender questioning youth also reported a higher rate of sexual and dating violence, high risk sexual practices, and substance use compared to their cisgender peers. 

This survey's findings are a call to action for family physicians to support our transgender and gender nonconforming adolescents, but many transgender and gender nonconforming persons avoid healthcare settings due to prior experiences with discrimination. A 2018 AFP editorial outlines strategies family physicians can take to create an equitable environment within their practices, including using inclusive language on intake forms, providing gender neutral bathrooms, and displaying transgender-affirming materials. The editorial also lists resources for family physicians interested in expanding their gender-affirming skill set.

The AAFP actively supports transgender and gender nonconforming persons, affirming that "diversity in gender identity and expression is a normal part of the human existence and does not represent pathology." Unfortunately, legislative initiatives in several US states threaten access to gender-affirming care for over 50,000 transgender youth. This AFP article on "Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know" provides guidance on both care within the office and simple ways to advocate in our communities. This 2019 Community Blog guest post contains additional advocacy tips. And, the AFP By Topic on Special Populations contains a Lesbian, Gay, Bisexual, and Transgender category if you'd like to read more.

Supervised injection sites prevent opioid overdose deaths, improve public safety

 - Kenny Lin, MD, MPH

In a fortuitous alignment, each of the medical journals with the three largest print circulations (JAMA, American Family Physician, and The New England Journal of Medicine) recently published editorials or features making the case for opening supervised sites for injection drug use in the United States as a form of harm reduction for patients with substance use disorders.

A news feature in JAMA observed that these sites come in many varieties depending on agency resources and patient needs: 

Supervised consumption sites can be as modest as a social service agency restroom stall, the door shortened at the bottom to make it easier to spot an unconscious person, or as expansive as Vancouver’s trailblazing Insite, which averaged 312 injection room visits per day in 2019 and offers detox rooms with private bathrooms, transitional housing for people in recovery, and other wraparound services.

In the U.S., a legal statue forbidding the operation of establishments where illicit drugs are consumed has generally forced these sites underground. Nonetheless, a research report on the outcomes an unsanctioned site located in an undisclosed U.S. city reported that over 5 years, 33 overdoses were successfully treated with naloxone administered by trained staff, with no patients requiring transfer to an outside medical institution. Advocates of supervised consumption sites argue that they do not "enable" substance use; rather, they relocate use that otherwise occur without medical supervision, often in public places, and prevent deaths from overdoses. The JAMA article quoted Sam Rivera, executive director of a nonprofit organization that operates two sites in New York City, as saying: “Every person who walks in has tried treatment and detox. We want them to be able to try again when they're ready, and in order to do that they have to be alive.”

An editorial in AFP by Drs. Jorge Finke and Jie Chan cited abundant evidence demonstrating that supervised injection sites improve health outcomes for persons who use illicit drugs and the surrounding community:

One study found a 26% net reduction in overdose deaths in the area surrounding a supervised injection site in Vancouver, Canada, compared with the rest of the city. A supervised injection site in Barcelona, Spain, was associated with a 50% reduction in overdose mortality from 1991 to 2008. People who inject drugs are significantly less likely to share needles if they regularly use supervised injection sites. ... Supervised injection sites can also reduce the number of publicly discarded syringes, and they improve public safety. ... One study in Vancouver, Canada, observed an abrupt, persistent decrease in crime after the opening of a supervised injection site.

In addition, modeling studies predict that opening supervised injection sites could be cost-saving "by preventing HIV, hepatitis C, hospitalizations for skin and soft-tissue infections, overdose deaths, ambulance calls, and emergency department visits and by increasing uptake of addiction treatment."

A NEJM Perspective article asserted that the Biden administration should take action to "[make] it clear that the federal government won't stand in the way of organizations or state or local governments that want to establish overdose-prevention centers," given that the Department of Justice under the Trump administration asked courts to block the opening of a sanctioned site in Philadelphia in 2019. Arguably, Section 856 of the Controlled Substances Act (also known as the "crack house statute") was not intended to limit the operations of public health facilities, but continued legal ambiguity makes it difficult for state health officials to gain support for supervised injection sites. In a related NEJM Perspective, two clinicians at a primary care and buprenorphine clinic in Chicago emphasized that these sites are desperately needed to save people's lives:

We hand out naloxone, distribute cookers and syringes, and counsel our patients on safer injection practices — such as not injecting alone — but this work isn’t enough to keep them safe. In the clinic, we use a low-threshold model for prescribing buprenorphine to reduce harm and increase access to lifesaving medications for opioid use disorder, offering same-day buprenorphine initiation, van-based outreach, telehealth appointments, and recovery-support services. It still isn’t enough. Our patients continue to die in the largest numbers we’ve ever seen.

The largest numbers we’ve ever seen. The Centers of Disease Control and Prevention reported that in 2021, more than 107,000 people died of a drug overdose, a 15% increase over the previous record high in 2020 and "roughly one U.S. overdose death every 5 minutes." By publishing pieces that provide compelling rationales for opening supervised injection sites, the top three journals in medicine have made a statement that these effective public health interventions should be employed widely to reverse this terrible trend.