11/10
New Brunswick Disease Watch Bulletin
Office of the Chief Medical Officer of Health
Introduction:
Welcome to the sixth edition of the New Brunswick Disease Watch Bulletin.
In this volume, we look at the reportable bacterial sexually transmitted infections (STIs) in New Brunswick: chlamydia,
gonorrhea and syphilis. It includes provincial epidemiology and Public Health recommendations about testing and
management of cases and contacts as well as information on the Safer Sex and Chlamydia 2010 campaign.
We welcome feedback and suggestions for topics. Please forward them to [email protected].
Chlamydia
Safer Sex and Chlamydia 2010 campaign
The Office of the Chief Medical Officer of Health (OCMOH) is planning a provincial
campaign on safer sex and chlamydia with the goal of encouraging New Brunswick youth
20 to 24 to engage in safer sexual practices. The campaign’s objectives are threefold: 1)
to increase awareness and knowledge levels about chlamydia; 2) to increase chlamydia
testing among New Brunswick youth; and 3) to promote safer sex through increased
condom usage.
In early July, eight focus groups were conducted with male and female, anglophone and
francophone youth 16 to 24 to discern their knowledge of STIs. The key research findings
informed the OCMOH that there is a lack of awareness about and understanding of STIs,
including chlamydia, among New Brunswick youth. However, participants did express
interest in learning more about the subject.
Existing knowledge about chlamydia is limited, as participants predominantly cited middle
school health education curriculum as the source of their information. Although youth
recognize chlamydia as a potentially serious health issue, they were largely unaware of its
symptoms, long-term consequences, modes of transmission, treatment, and prevention.
Furthermore, youth in the target demographic are not using condoms regularly despite
stating that they are readily accessible. Four main variables believed to contribute to this
behaviour are: a perceived lack of need, discomfort in use, embarrassment in obtaining
them, and apathy.
A Moncton-based marketing agency has been awarded a contract to develop a creative
concept and strategy for the campaign that will target youth where they live, work, study,
and socialize. This provincial campaign is a component of the New Brunswick Sexual Health
Strategy and will complement existing regional sexual health services in addition to the
clinical services delivered by key community partners, including physicians and nurse
practitioners.
Chlamydial infection, caused by an
obligate intracellular bacterium Chlamydia
trachomatis, is the most common
bacterial sexually transmitted disease.
A wide variety of genital infections are
caused by C. trachomatis serovars D
to K, including urethritis, epididymitis
and prostatitis in males and urethritis,
cervicitis, endometritis and salpingitis in
females. These infections may also cause
proctitis and proctocolitis (particularly
in homosexual men), conjunctivitis and
reactive arthritis. The mode of transmission
is mostly through vaginal, anal and oral
sex with an infected partner, and perinatal
transmission from infected mother to a
newborn baby is well described. These
latter infections lead to conjunctivitis
and pneumonia in newborns. Sexually
transmitted chlamydial infections are
asymptomatic in about 70 per cent
of females and 50 per cent of males.
Chlamydial infections of the genital tract
in adults are treated with a single dose of
Azithromycin 1g PO or with a course of
Doxycycline 100 BID PO for seven days
(consult Canadian guidelines on STIs for
detailed information). If left untreated
chlamydial infections may lead to pelvic
inflammatory disease (PID), ectopic
pregnancy, infertility and chronic pelvic
pain in females and epididymo-orchitis in
males. Worldwide C. trachomatis serovars
A-C cause ocular trachoma disease and
serovars L1, L2 and L3 – lymphogranuloma
venereum (LGV).
Gonorrhea
The incidence of sexually transmitted chlamydial infections is
increasing throughout the developed world, including Canada.
Gonorrhea is a bacterial infection caused by Neisseria gonorrhea, a
In New Brunswick the overall incidence rate of chlamydia has
non-motile, Gram-negative organism that characteristically grows
increased by 28.1 per cent during the last 10 years (Figure 1).
in pairs (diplococci). Infection is transmitted through oral, genital
This increase is higher among males (53.3 per cent) than among
antibiotic
treatment
forand
genital
gonococcal
Figure 1.(18.8 per cent). However, females remain over-represented
or anal sex
with an infected
person,
perinatal
transmission infection in
females
Incidence
rate
of
Chlamydia
infection
by
gender
and
proportion
of
female
among
from
infected
mother
to
a
newborn
baby
is
described.
Acute
adults is a single dose of Cefixime 400
mg PO with a
among all chlamydia cases, accounting for more than two cases
cases, New Brunswick, 2000-2009 (N=13 075)
urethritis
is
the
predominant
manifestation
of
gonorrhea
infection
in three
(69.2 per cent) in 2009. This latter proportion decreased
single
125
mg
IM
dose
of
Ceftriaxone
or
a
single 2ginPO
antibiotic
treatment
for
genital
gonococcal
infection
300.0
75.0%
e 1.
in men and primary site of infection in females is the endocervix.
by 4.9 per cent during the last 10 years, indicating the growing
nce rate of Chlamydia infection by gender and proportion of female among
dose
of
Azithromycin
used
as
alternatives
(consult
is perihepatitis
a treatment
single dose
of
Cefixime
mg
PO with
Urethritis,
andfor
bartholinitis
are
seen400
in females
of infected
males.
antibiotic
genital
gonococcal
infection
in a
250.0
74.0% adults
1. number
NewFigure
Brunswick,
2000-2009 (N=13
075)
and
epididymitis
in
males.
Conjunctival
infections,
proctitis,
Canadian
Guidelines
on
STIs
for
detailed
information).
Incidence300.0
rateFigure
of Chlamydia
infection
by
gender
and
proportion
of
female
among
single
125
mg
IM
dose
of
Ceftriaxone
or
a
single
2g
antibiotic
treatment
for
genital
gonococcal
infection
1.
75.0%
adults is infections
a singleand
dose
of Cefixime
400 infections
mg PO with PO
ain
200.0
73.0%
pharyngeal
disseminated
gonococcal
cases, New Brunswick,
2000-2009
(N=13infection
075) by gender and proportion of female among
Incidence rate
of Chlamydia
adults
is
a
single
dose
of
Cefixime
400
mg
PO
with
dose
of125
Azithromycin
asgonococcal
alternatives
(consult
single
mg
IMgenders.
dose ofInused
Ceftriaxone
or a single
2g
POa
are
described
in both
neonates,
infection
300.0
75.0%
Rate
New Brunswick,
2000-2009 (N=13 075)
250.0cases,
74.0%
150.0
72.0%
Due
to
an
increase
in
quinolone
resistance,
(/100 000)
single
125
mg
IM
dose
of
Ceftriaxone
or
a
single
2g
PO
manifests
ophthalmia neonatorum
disseminated
infection.
300.0
75.0%
Canadian
on STIs
for
detailed
information).
dose ofasGuidelines
Azithromycin
usedor
as
alternatives
(consult
250.0
74.0%
Ciprofloxacin
and
Ofloxacin
are
no
longer
preferred
200.0
73.0%
Many
infected
women
are
asymptomatic,
and
some
men
do
not
dose of
Azithromycin
used
as alternatives
(consult
100.0
71.0%
Canadian
Guidelines
on STIs
for detailed
information).
250.0
74.0%
have
any
symptoms.
The
preferred
antibiotic
treatment
for genital
drugs
for
the
treatment
of
gonococcal
infection
te
Canadian
Guidelines
on
STIs
for
detailed
information).
200.0
73.0%
150.0
72.0%
50.0
70.0% Due
to infection
an increase
in dose
quinolone
resistance, in
gonococcal
in adults is a single
of Cefixime 400
000)
200.0
73.0%
Canada.
Major
sequelae
gonococcal
infection
Rate
mg
PO with
125
mg
IM dosein
ofof
Ceftriaxone
or a single
2g include
150.0
72.0%
Due
to a single
anand
increase
quinolone
resistance,
Ofloxacin
are
no longer
preferred
(/100 000)
0.0
69.0% Ciprofloxacin
100.0 Rate
71.0%
150.0
72.0%
PID,
infertility,
ectopic
pregnancy,
and
chronic
pelvic
Due
to
an
increase
in
quinolone
resistance,
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
PO
dose
of
Azithromycin
used
as
alternatives
(consult
Canadian
(/100 000)
Ciprofloxacin
and
Ofloxacin
no longer infection
preferred in
drugs
foronin
the
treatment
of are
gonococcal
100.0Rate (male)
71.0%
85.9 83.9 99.3 92.9 88.9 118.0 101.3 94.8 70.0%
107.7
131.7
Guidelines
STIs
for
detailed
information).
pain
females
and
epididymo-orchitis
in
males.
Reiters
50.0
Ciprofloxacin
and
Ofloxacin
are
no
longer
preferred
100.0
71.0%
drugs for
the sequelae
treatmentof of
gonococcal
infection
in
Rate(female)
Canada.
Major
gonococcal
infection
include
240.2 233.9 247.6 216.2 218.7 278.9 251.7 234.8 260.9 285.4
50.0
70.0%
Due to
an
increase
quinolone
resistance,
Ciprofloxacin
and
syndrome
and
disseminated
gonococcal
infection
drugs
for in
the
treatment
of gonococcal
infection
inmay
0.0
Rate(all) 50.0
163.9 159.8 174.4 155.5 154.8 199.7 177.8 166.169.0%
185.7 210.0 70.0%
Canada.
Major
sequelae
of
gonococcal
infection
include
PID,
infertility,
ectopic
pregnancy,
and infection
chronic
pelvic
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Ofloxacin
are occur.
no Major
longer
preferred
drugs
for the treatment
of
Canada.
sequelae
of gonococcal
include
also
69.2%
0.0Proportion of female 74.1% 74.0% 71.9% 70.6% 71.7% 71.0% 72.0% 72.0% 71.5%
69.0%
gonococcal
infectionand
in Canada.
Major sequelaeand
of gonococcal
PID,in
infertility,
ectopic
pregnancy,
pelvic
Rate (male)
85.9 83.9
94.8 2007
107.7 2008
131.7 2009
2000 99.3
2001 92.9
2002 88.9
2003 118.0
2004 101.3
2005 2006
0.0
69.0%
pain
females
epididymo-orchitis
inchronic
males.
Reiters
PID,
infertility,
ectopic
pregnancy,
and
chronic
pelvic
2000 2001 2002 2003
2004 2005 2006 2007 2008 2009
Figure
3.
infection
include
PID,
infertility,
ectopic
pregnancy,
and
chronicReiters
Rate(female)Rate (male)
240.2 233.9
251.7
234.8 94.8
260.9 107.7
285.4 131.7
85.9 247.6
83.9 216.2
99.3 218.7
92.9 278.9
88.9 Year
118.0 reported
101.3
pain
in
females
and
epididymo-orchitis
in
males.
Incidence
rate
of
Gonorrhea
infection
by
gender,
New
Brunswick,
Rate (male)
syndrome
and
disseminated
gonococcal
infection
may
85.9 83.9 99.3 92.9 88.9 118.0 101.3 94.8 107.7 131.7
pain
in
females
and
epididymo-orchitis
in
males.
Reiters
pelvic pain2000-2009
in females
epididymo-orchitis in males. Reiters
Source163.9
: RDSS,
NB174.4
passive
surveillance
July 2010
Rate(all) Rate(female)
240.2
233.9 155.5
247.6
216.2 199.7
218.7system,
278.9 251.7
234.8
159.8
154.8
177.8
166.1
185.7 260.9
210.0 285.4
and 20101and
(N=272)
Rate(female)
240.2 233.9 247.6 216.2 218.7 278.9 251.7 234.8 260.9 285.4
syndrome
and
disseminated
gonococcal
infection
may
syndrome
and
disseminated
gonococcal
infection
may
also
occur.
also
occur.
syndrome
and
disseminated
gonococcal
infection
may
Proportion ofRate(all)
female 74.1% 74.0%
163.971.9%
159.8 70.6%
174.4 71.7%
155.5 71.0%
154.8 72.0%
199.7 177.8
166.1
185.7
210.0
72.0% 71.5% 69.2%
9.0
occur.
Chlamydia particularly affects people 15 to 29. In 2009, also
also
occur. 8.0
Figure 3.
Incidence
rate of Gonorrhea infection by gender, New Brunswick,
Figure 3.
the incidence rate inYear
this
age
group
was
30
times
greater
reported
Figure 3. 1
Year reported
RDSS, NB passive surveillance system, July 2010
2000-2009
and
(N=272)7.0
IncidenceIncidence
rate2010
of Gonorrhea
infection
by gender,
New Brunswick,
rate of Gonorrhea
infection
by gender,
New Brunswick,
than
in theJuly
rest
ofJulyJuly
the
population. Youth 20
Source : RDSS,
NB:that
passive
surveillance
system,
2010
2000-2009
and 2010
(N=272)
Source
passive surveillance
system,
2010
Source
RDSS,observed
NB
passive
surveillance
system,
2010
2000-2009
and
2010 6.0
(N=272)
9.0
to 24 areparticularly
the
mostaffects
affected
(Figure
2).InIn
In 2009,
thisthe
age group
mydia particularly
affects
people
15
toto29.
9.0
Rate
9.0 5.0
Chlamydia
people
15
29.15
8.0
Chlamydia
particularly
affects
people
15
to
29.2009,
2009,
(/100 000)
Chlamydia
particularly
affects
people
toIn29.
Infemales
2009,
in
2009,
almost
per
cent
of
New
Brunswick
8.0
cidenceincidence
rate
inrate
this
group
was
30times
times
greater
8.0 4.0
inage
thistwo
age
group
was 30
greater
than that
7.0
the incidence
rate
inrest
this
age
group
was
30
times
greater
the incidence
rate
in
this
age
group
was
3024
times
greater
observed
in
the
of
the
population.
Youth
20
to
are
the
most
7.0
and
one
per
cent
of
males
reported
a
chlamydial
7.0 3.0
that observed in the rest of the population. Youth 20
6.0
than that
observed
in2).the
rest
ofgroup
the
population.
Youth
20cent
affected
(Figure
Inhighest
this
in the
2009,
almost
two per
than
that
observed
in age
the
rest
of
population.
Youth
20
6.0
infection.
The
rates
were
observed
in
the
6.0 2.0
are24the
most
affected
(Figure
2).(Figure
In
this
group
of
New
Brunswick
females
and one
per
cent
ofage
males
reported
Rate
5.0
to
are
the
most
affected
(Figure
2).
In
this
age
group
to
24
are
the
most
affected
2).
In
this
age
group
Rate
5.0
Rate
5.0 1.0
(/100 000)
and
Moncton
health
regions,
butin the
aFredericton
chlamydial
infection.
The
highest
rates were
observed
the most
09,
almost
two per
cent
ofper
New
Brunswick
females
(/100 000) (/100 000)
4.0
in
2009,
almost
two
cent
of
New
Brunswick
females
in 2009,
almost
two
per
cent
of
New
Brunswick
females
4.0 0.0
4.0
important
recent
increase
was seen
in most
Saint
John and
Fredericton
and
Moncton
health
regions,
the
important
one
cent
of
males
reported
abut
chlamydial
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
3.0
and
one
per
cent
of
males
reported
a
chlamydial
and per
one
per
cent
of
males
reported
a
chlamydial
3.0
recent
increase
was
seen
in
Saint
John
and
Miramichi,
where
rates
3.0
Miramichi,
where
rates
almost
doubled in
during
the last
Rate(male)
2.7
1.9
3.5
2.4
1.6
2.2
5.7
8.5
4.9
7.4
5.6
ion.
The
highest
rates
were
observed
the
2.0
almost
doubled
duringrates
the lastrates
four years
(dataobserved
not shown).
infection.
The
were
in the
2.0
infection.
The
were
observed
in the
2.0 Rate(female)
0.3
1.1
4.5
3.7
1.1
3.7
3.2
3.7
4.5
6.6
7.7
four
yearshighest
(data highest
not shown).
ericton
and
Moncton
regions,
butbut
thethe
most
1.0 Rate(all)
Fredericton
andhealth
Moncton
health
regions,
but
the most
1.0
Fredericton
and
Moncton
health
regions,
most
1.0
1.5
1.5
4.0
3.1
1.3
2.9
4.4
6.0
4.7
7.0
6.7
Figure 2.
0.00.0
0.0
rtant
recent
increase
was
seen
in and
Saint
John
and
Year reported
important
recent
increase
was
seen
in
John
Incidence
rate of
Chlamydia
infection
by seen
gender
ageSaint
important
recent
increase
was
inselected
Saint
John
and and
2000
2001
2006
2007
20082009
20092010
2010
2000
2003
2004 2004
20052005
2006
2007
2008
2009
2010
2000 2001
2001 2002
2002 2002
2003 2003
2004
2005
2006
2007
2008
group, New
Brunswick,
2009rates
(N=1doubled
551)almost during
SourceRate(male)
: RDSS,
NB
passive
surveillance
system,
July 201 4.9 7.4
Miramichi,
where
doubled
during
the last
michi,
where
rates
almost
the
last
2.7
1.9
3.5
2.4
7.4 5.6 5.6
Rate(male)
Miramichi,
where
rates
almost
doubled
during
the
last
2.7
1.9
3.5
2.4
1.6 1.62.2
2.2 2.25.7
5.7 5.78.58.58.5 4.94.9
5.6
Rate(male)
2.7
1.9
3.5
2.4
1.6
7.4
2500.0
1Rate for 2010 is a projection based on the first 7 months of the year.
Rate(female) 1.1
0.3
1.1
4.5
3.71.1 1.13.7 3.7 3.2 3.2 3.73.7 4.5
4.5 6.6
6.6
7.7
four(data
years
(data
not shown).
Rate(female)
4.5
3.7
years
(data
not
shown).
Rate(female) 0.3
0.3
1.1
4.5
3.7
1.1
3.7
3.2
3.7
4.5
6.6
7.7 7.7
four years
not
shown).
Rate(all)
163.9 159.8 174.4 155.5 154.8 199.7 177.8 166.1 185.7 210.0
Proportion of female 74.1% 74.0% 71.9% 70.6% 71.7% 71.0% 72.0% 72.0% 71.5% 69.2%
Proportion of female Year
74.1%reported
74.0% 71.9% 70.6% 71.7% 71.0% 72.0% 72.0% 71.5% 69.2%
1
FigureRate(all)
4. 1.5
Rate(all)
Rate(all)
1.5
2.
e 2. Figure 2. Figure
2000.0 rate of Chlamydia infection by gender and selected age
Incidence
nce Incidence
rate of Chlamydia
infectioninfection
by gender
and selected
age age
rate of Chlamydia
by gender
and selected
group, New Brunswick, 2009 (N=1 551)
New
Brunswick,
2009 (N=1
551)
group,
New Brunswick,
2009
(N=1 551)
2500.0
1500.0
0.0 2500.0
0.0
2000.0
500.0
Rate
2000.0
1000.0
4.0
3.1
3.1
3.11.3 1.32.9 2.9 4.4 4.4 6.06.0 4.7
4.7 7.0
7.0
6.7
1.3
2.9
4.4
6.0
4.7
7.0
6.7 6.7
Figure 4.
Figure
Figure
4. 4.
Incidence rate
of Gonorrhea infection by gender and zone, 15 to 34 years old,
80.0
1 (N=156)
Incidence
rate
Gonorrhea
infection
by and
gender
zone,
Incidence
rate
of ofGonorrhea
infection
by
gender
and
zone,15
15toto3434years
yearsold,
old,
New
Brunswick,
2005-2008,
2009
2010and
New
Brunswick,
2005-2008,
2009and
and 2010
201011 (N=156)
(N=156)
New Brunswick, 2005-2008, 2009
60.0
100.0
Rate
100.0
(/100 000)
100.0
10-14
15-19
20-24
25-29
30-34
35-39
40-44
500.0
Male
0.0
367.7
965.5
356.3
212.9
77.1
21.5
Female
43.5
1584.4
1948.5
692.4
279.2
103.5
24.4
0.0
0.0
1.5
4.0
4.0
: RDSS, NB passive surveillance system, July 201
Source
: Source
RDSS,
system,July
July201
201
Source
RDSS,NB
NBpassive
passivesurveillance
surveillance system,
system,
Source
::RDSS,
NB
passive
surveillance
July
201
1Rate
for 2010
is a projection based on the first 7 months of the year.
11
1Rate
100.0
Rate
2010
projection
based
first
months
the
year.
Rate
for
2010isisis
projectionbased
based on the
forfor
2010
aaaprojection
the first
first777months
monthsofof
ofthe
theyear.
year.
0.0
0.0
1.5
1.5
1.5
Incidence rate of Gonorrhea infection by gender
and zone, 15 to 34 years old,
Year reported
Year reported
reported
Year
New Brunswick, 2005-2008, 2009 and
2010 1 (N=156)
(/100 000)
1500.0
1500.0 Rate500.0
(/100 000)
Rate
1000.0
) (/100 000)
0.0
0.0 1000.0
1
Age group
10-14
15-19
20-24
25-29
30-34
0.0
Source
:
RDSS,
NB
passive
surveillance
system,
July 2010
10-14
15-19
20-24
25-29
30-34
35-39
Male
0.0
367.7
965.5
356.3
212.9
35-39
40-44
77.1
40-44
21.5
10-14
15-19
25-29
30-34
35-39
40-44
: RDSS, NB20-24
passive
surveillance
July
2010
Male Source
0.0
965.5
356.3 system,
212.9
77.1
21.5
Female 367.7
43.5
1584.4
1948.5
692.4
279.2
103.5
24.4
ale
0.0
367.7
965.5
356.3
212.9
77.1
21.5
Female
43.5
1584.4
1948.5
692.4
279.2
103.5
24.4
Age group
male
43.5Gonorrhea
1584.4
1948.5
692.4
279.2
103.5
24.4 by Neisseria
is a bacterial
infection
caused
Source : RDSS, NB passive surveillance
Age groupsystem, July 2010
gonorrhea, a Age
non-motile,
Gram-negative organism that
group
Gonorrhea
Source : RDSS, NB passive surveillance system, July 2010
RDSS, NB passive
surveillance system,
July 2010
Gonorrhea
characteristically
grows
in pairs (diplococci). Infection is
Gonorrhea isthrough
a bacterial
Neisseria
Gonorrhea
transmitted
oral,infection
genital caused
or analbysex
with an
orrhea
gonorrhea,
a non-motile,
Gram-negative
organism
that
infected
and
perinatal
transmission
from infected
Gonorrhea
is a person,
bacterial
infection
caused
by Neisseria
80.0
80.0
40.0
80.0
20.0
60.0
Rate
60.0
(/100 000)
Rate60.0
40.0 0.0
Rate
(/100 000)
(/100 000) 40.0
40.0
20.0
2005-2008
20.0
2009
20.0
0.0
0.0
0.0
2010
Zone 1
Other zones
Zone 1
Male
Other zones
Female
18.9
8.7
20.2
9.2
41.6
Zone 145.4
13.3
Other zones
0.0
46.1
16.5
Other zones7.7
Zone 1 85.6
Male
Female
Zone 1
Other zones
Zone 1
Other zones
Zone20.2
1
Other9.2
zones
2005-2008Zone 1 18.9 Male Other zones
8.7
Female
Source
: RDSS, NB passive surveillance
system, July
201
Male
Female
2009
13.3
46.1
2005-2008
1Rate for 2010
18.9 is 41.6
9.216.5
a projection 8.7
based
on the first20.2
7 months
of the year.
2005-2008
7.7
18.9
8.7 0.0
20.285.6
2009 2010
41.6 45.4
13.3
46.1
16.59.2
2009
41.6
13.3
46.1
2010
45.4
0.0
85.6
7.716.5
Between 2000 and 2009, a four-fold increase
in the
7.7
2010
45.4
0.0
Source : RDSS,
NB passive surveillance
system, July85.6
201
Source1Rate
surveillance
system,
July7201
for NB
2010
is arate
projection
on the first
months
year.
ofbased
gonorrhea
wasof the
observed
in New
Source :incidence
:RDSS,
RDSS,
NBpassive
passive
surveillance
system,
July
201
rrhea
ismother
a bacterial
infection
byorganism
Neisseria
1
characteristically
grows
incaused
pairs
(diplococci).
Infection
is
to a newborn
baby
is described.
Acute
urethritis
gonorrhea,
a non-motile,
Gram-negative
that
Rate
for
2010
is
a
projection
based
on
the
first
7
months
of
the
year.
1
Source : RDSS,
NB passive(Figure
surveillance
July 201 of cases remains low
Brunswick.
3).system,
The number
Rate for 2010 is a projection based on the first 7 months of the year.
rrhea,
ais
non-motile,
Gram-negative
thatwith
transmitted
through
oral, (diplococci).
genitalorganism
or
anal
sex
the predominant
manifestation
of gonorrhea
infection
characteristically
grows
in pairs
Infection
is an 1Rate for
2010 is a projection
based 2009,
on the ranging
firsta 7 four-fold
months
of the
year.
Between
2000
and
increase
in the in
compared
to chlamydia,
from
22
to 52 annually
acteristically
grows
pairs
(diplococci).
infected
person,
and genital
perinatal
transmission
fromisinfected
in
men
and in
primary
site
oforinfection
in females
transmitted
through
oral,
analInfection
sex
with
an is the Between
incidence
of
gonorrhea
was
observed
in
New
the 2000
last rate
five
years.
Except
for
2007,
there
and 2009, a four-fold increase in were
the no
mother
a newborn
baby
described.
Acute
urethritis
mitted
genital
or isanal
sex
with
an
endocervix.
Urethritis,
perihepatitis
and
bartholinitis
areBetween
infectedthrough
person,tooral,
and
perinatal
transmission
from
infected
Brunswick.
(Figure
3).
The
number
of
cases
remains
low
2000
and
2009,
a
four-fold
increase
in
the
significant
between
rate differences
of gonorrhea
wasgenders.
observed in New
is
manifestation
gonorrhea
infection incidence
ed
person,
perinatal
transmission
from
infected
seen
inpredominant
females
and
in
males.
Conjunctival
mother
to the
aand
newborn
baby
isepididymitis
described.of
Acute
urethritis
compared
to
chlamydia,
ranging
from
22
to
52
annually
in
incidence rate of gonorrhea was observed in New
Globally, there were significant changes in syphilis
epidemiology recently with large increases in the syphilis
Syphilis
numbers seen in urban centres in Europe and North
Syphilis is a bacterial infection caused by the spirochete
America (mostly among men who have sex with men
Treponema pallidum . The primary mode of transmission
(MSM).
In New
Brunswick,
annual
number of cases o
forBetween
syphilis
is by
anal and
oral insexual
contact
with Globally,
2000
andvaginal,
2009, a four-fold
increase
the incidence
rate
there were
significant
changes the
in syphilis
epidemiology
syphilis
ranged
from
zero
to
four
(with
an inaverage
of
gonorrhea
was
observed
in
New
Brunswick.
(Figure 3).
The
recently
with
large
increases
in
the
syphilis
numbers
seen
urban of less
an infected partner. Newborn infants may be infected in
Globally,
there
were
significant
changes
in syphilis
number of cases remains low compared to chlamydia, ranging
centresthan
in Europe
and
North
America
(mostly
among
men count
who
two)
from
2000
to
2007.
The
annual
increased
utero,
but
by contact
with
anyears.
active
genital
lesion
from 22
to also
52 annually
in the last
five
Except
for 2007,
thereat
have sex with men
(MSM). In with
New Brunswick,
the annual in
number
of
epidemiology
recently
large increases
the syphilis
philis the
bysyphilis
50 per
centfrom
for zero
the to
two
years,ofreaching
nine
time
of delivery.
Venereal
syphilis
has several clinical numbers
were
no significant
differences
between
genders.
cases of
ranged
fourfollowing
(with
anEurope
average
less North
seen
in
urban
centres
inmonths
and
hilis isstages:
a bacterial
infection
caused
by
the
spirochete
cases
in
2009.
The
first
seven
of
2010
are
no
than
two)
from
2000
to
2007.
The
annual
count
increased
by
50
per
as chancre
at the
site those
of
As with primary,
chlamydia,manifested
gonorrhea mostly
affects young
people:
America
(mostly
among
men
who
have
sex
with
men
cent
for
the
two
following
years,
reaching
nine
cases
in
2009.
The
ponema
pallidum
.
The
primary
mode
of
transmission
showing
any
decrease
in
this
trend.
The
cumulative
15 to 34 represent
perregional
cent of cases.
A projection based on the
bacterial
invasion82.7
and
lymphadenopathy;
first sevenInmonths
of 2010 are not showing
any decrease
in this
(MSM).
New
the annual
number
ofwas
cases
of
first
seven
months
of 2010
suggests
anfever,
increase
in caseswith
among
syphilissecondary,
is by
vaginal,
anal
and
oral
sexual
contact
number
of Brunswick,
cases
reported
up to up
July
2010
already
associated
with
rash,
headaches,
trend.
The
cumulative
number
of
cases
reported
to
July
2010
females 15 to 34 in zone 1: 12 cases reported in the first seven
syphilis
ranged
from
zero
to
four
(with
an
average
of
less
higher
than
the
reported
in 2009,
with a more
nfected
partner.
Newborn
infants
be infected
was already
higher
than
thenumber
number reported
in 2009,
with a more
malaise,
lymphadenopathy
and
months
ofgeneralized
2010
versus 11
cases inmay
the preceding
yearsometimes
ofin
2009.
than
a
two-fold
increase
in
the
2010
annualized
rate.
than
two)
from
2000
to
2007.
The
annual
count
increased
than
a
two-fold
increase
in
the
2010
annualized
rate.
o, but signs
also by
contact with
an active
genital
lesion
at
of meningitis
or uveitis;
latent,
which
is usually
Figure
6.
Most
of
this
increase
is
found
in
Zone
1
which
accounts
for
most
by
50
per
cent
for
the
two
following
years,
reaching
nine
time ofasymptomatic
delivery.
syphilis
has years;
several
clinical
and lasting
several
and
tertiary,
Syphilis Venereal
Incidence
rate 2008
of syphilis
infection
bycent).
zone, Male,
New
Brunswick,
2005cases
overall
since
(78.9
per
Their
age
distribution
cases
in
2009.
The
first seven months of 2010 are not
1 (N=29)
presenting
to 45infection
years
from
initial
infection
and
ges: primary,
as
chancre
at
site
of Treponema
2008,
2009toand
2010
Syphilismanifested
is a up
bacterial
causedthe
by the
the spirochete
ranges from
25
59,
with
most cases (41.2 per cent) in the 30-39
showing
any
decrease
in this
trend.
The
cumulative
pallidum and
.mainly
The primary
mode
ofcoronary
transmission
for syphilis
is by
age group. Investigations in this region
revealed
a high
proportion
affecting
aorta
and
arteries,
central
terial invasion
regional
lymphadenopathy;
vaginal,
anal
and
oral
sexual
contact
with
an
infected
partner.
of
men
having
sex
with
men
(MSM).
This
cluster
is
still
under
nervous
system
as well as
producing
tissue destruction of number of cases reported up to July 2010 was already
ondary,
associated
with
fever,
headaches,
Newborn
infants
mayrash,
be infected
in utero,
but also by contact with
investigation, but regional prevention and control measures
Other zones
the number
reported
2009,
various
organs.
Individuals
with
primary
and secondary
an active genital
lesion at the time of and
delivery.
Venereal
syphilis has higher
aise, generalized
lymphadenopathy
sometimes
are beingthan
developed,
and some are
already inin
place
to limitwith a more
severalof
clinical
stages:
primary,
chancre
at Infants
the site
transmission
in theincrease
community.in the 2010 annualized rate.
stages
syphilis
are
most manifested
infectious
others.
than
a Health
two-fold
ns of meningitis
orinvasion
uveitis;
latent,
which
isasto
usually
of bacterial
and regionalsyphilis
lymphadenopathy;
secondary,
Figure 6. zone
and
children
with
congenital
diagnosed
before
the
mptomatic
and lasting
several
years; and
tertiary,
associated
with rash,
fever, headaches,
malaise,
generalized
Incidence rate of syphilis infection by zone, Male, New Brunswick, 2005age
of
two
(early
congenital
syphilis)
may
lymphadenopathy
and
sometimes
signs
of
meningitis
senting up to 45 years from the initial infectionbe
andor uveitis;
2008, 2009 and 2010 1 (N=29)
Zone 1
latent, which is usually
asymptomatic
and lasting severallesions,
years;
asymptomatic
or present
with mucocutaneous
cting mainly
aortapresenting
and coronary
arteries,
central
and
tertiary,
up
to
45
years
from
the
initial
infection
snuffles, hepatospemomegaly, osteochondritis or
and affecting
mainly
aorta and coronary
central nervous
vous system
as well
as producing
tissuearteries,
destruction
of
neurosyphilis.
congenital
syphilis presents
two
systemIndividuals
as well asLate
producing
tissue destruction
of variousafter
organs.
Other zones
ous organs.
with
primary
and
secondary
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Individuals
with primary
and secondary
stages
of syphilis
are
years
with keratitis,
various
bony and
teeth
abnormalities
Rate (/100 000)
ges of syphilis
are
most
infectious
to
others.
Infants
most
infectious
to
others.
Infants
and
children
with
congenital
(e.g. Hutchinson’s teeth), lymphadenopathy,
Health
Zone 1
Other zones
syphilis
before
the agediagnosed
of two (early congenital
syphilis)
children
with diagnosed
congenital
syphilis
before The
the
hepatosplenomegaly,
or neurosyphilis.
zone
2005-2008
0.8
0.6
may be asymptomatic or anemia
present with
mucocutaneous lesions,
of twodiagnosis
(early
may
be ortesting
of syphilissyphilis)
includes
serological
initially
snuffles,congenital
hepatospemomegaly,
osteochondritis
neurosyphilis.
2009
7.1
0.4
Zone 1 2010
Lateor
congenital
syphilis
years
with
keratitis,
mptomatic
present
with presents
mucocutaneous
lesions,
14.0
2.5
using
non-treponemal
tests after
(i.e.,two
RPR
and
VDRL),
various bony and teeth abnormalities (e.g. Hutchinson’s teeth),
ffles, hepatospemomegaly,
osteochondritis
or
followed
by
confirmatory
treponemal
tests
(i.e.,
TP-PA
or
lymphadenopathy, hepatosplenomegaly, anemia or neurosyphilis.
Source : RDSS, NB passive surveillance system, July 2010
rosyphilis.
congenital
syphilis
presents
afterinitially
two
FTA-ABS).
Interpretation
of serological
tests
as
well as
The Late
diagnosis
of syphilis includes
serological
testing
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
using non-treponemal
tests (i.e.,
RPR
and VDRL),
followed IgG and
about bony
newer
tests
(e.g.,
treponemal
rs withsinformation
keratitis,
various
and
teeth
abnormalities
Rate (/100 000)
by confirmatory treponemal tests (i.e., TP-PA or FTA-ABS).
Most of this increase is found in Zone 1 which accounts
IgM
EIA) frequently
requires
with about
. Hutchinson’s
teeth),
lymphadenopathy,
Interpretation
of serological
tests consultations
as well as sinformation
Zone 1
Other zones
for
most
cases
overall
since
2008
(78.9 per cent). Their
specialists.
Preferred
treatment
of
syphilis
infection
in
newer tests (e.g.,
treponemal
IgG and IgM EIA) frequently
requires
atosplenomegaly,
anemia
or neurosyphilis.
The
2005-2008
0.8
0.6
consultations
with
specialists.
Preferred
treatment
of
syphilis
age distribution7.1 ranges from 25 to 0.4
59, with most cases
and their
sexual
contacts istesting
with various
regimes of
gnosis adults
ofinfection
syphilis
includes
serological
initially
2009
in adults and their sexual contacts is with various regimes
(41.2
per
cent)
in
the
30-39
age
group.
Investigations in
IM
Benzathine
penicillin
G
(depending
on
the
stage)
2010
14.0
2.5
ng non-treponemal
tests
(i.e.,GRPR
and VDRL),
of IM Benzathine
penicillin
(depending
on the stage) and
this
region
revealed
a
high
proportion
of
men having sex
and
penicillin
G
for
neurosyphilis
(consult
Canadian
G for neurosyphilis
(consult
Canadian
Guidelines
owed bypenicillin
confirmatory
treponemal
tests
(i.e., TP-PA
oron STIs
Source
:
RDSS,
NB
passive
surveillance
system,
July
2010
for
detailed
information).
with
men
(MSM).
This
cluster
is
still
under
investigation
on STIs for detailed information).
Source : RDSS, NB passive surveillance system, July 2010
A-ABS).Guidelines
Interpretation
of serological tests as well as
1
prevention
and
control
measures
are being
Rate forbut
2010regional
is a projection
based on the first
7 months
of the
year.
5.
ormation Figure
about
tests
(e.g.,
treponemal
Incidence
ratenewer
of syphilis infection
by gender
and proportion
of male among IgG
cases, and
developed,
and
some
are
already
in
place
to limi
1 (N=43)
New Brunswick,requires
2000-2009 and 2010
Most of
this increase
is community.
found in Zone 1 which accounts
EIA) frequently
consultations
with
6.0
100.0%
transmission
in the
cialists. Preferred treatment of syphilis infection in
5.0
lts and their sexual contacts is with various regimes of
4.0
Benzathine penicillin
G (depending on the stage)
Rate
3.0
penicillin (/100
G000)
for neurosyphilis
(consult Canadian
delines on STIs for
2.0 detailed information).
5.0
4.0
Rate
(/100 000)
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
2010
100.0%
Rate(male)
0.0
0.0
0.3
0.8
0.8
0.3
0.0
0.8
1.4
2.2
Rate(female)
0.0
0.0
0.3
0.3
0.3
0.0
0.0
0.3
0.3
Rate(all)
0.0
0.0
0.3
0.5
0.5
0.1
0.0
0.5
0.8
0.3 0.5
80.0%
1.2
5.6
3.0
Proportion of male 0.0% 0.0% 50.0% 75.0% 75.0%100.0% 0.0% 75.0% 83.3% 88.9%
60.0%92.3%
Year reported
3.0
Source : RDSS, NB passive surveillance system, July 2010
40.0%
Source: RDSS, NB passive surveillance system, July 2010
2.0
1
Rate for 2010 is a projection based on the first 7 months of the year.
20.0%
1.0
0.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Rate(male)
0.0
0.0
0.3
0.8
0.8
0.3
0.0
0.8
1.4
2.2
5.6
Rate(female)
0.0
0.0
0.3
0.3
0.3
0.0
0.0
0.3
0.3
0.3
0.5
Rate(all)
0.0
0.0
0.3
0.5
0.5
0.1
0.0
0.5
0.8
1.2
3.0
Proportion of male 0.0% 0.0% 50.0% 75.0% 75.0%100.0% 0.0% 75.0% 83.3% 88.9% 92.3%
Year reported
rce : RDSS, NB passive surveillance system, July 2010
60.0%
40.0%
20.0%
gure 5.
1.0
cidence rate of syphilis infection by gender and proportion of male among cases,
ew Brunswick, 2000-2009 and 2010
0.01 (N=43)
6.0
80.0%
0.0%
0.0%
for most cases overall since 2008 (78.9 per cent). Their
age distribution ranges from 25 to 59, with most cases
(41.2 per cent) in the 30-39 age group. Investigations in
this region revealed a high proportion of men having sex
with men (MSM). This cluster is still under investigation,
but regional prevention and control measures are being
developed, and some are already in place to limit
transmission in the community.
The table below includes STIs regional epidemiology highlights in New Brunswick, risk factors for STIs, at-risk groups targeted for testing
and summary of available tests and specimens sites
STI
NB epidemiology
Risk factors
Target groups
for testing
Available tests and
specimen sites*
Chlamydia
Higher rates in
zones 1,2,3 and 7.
Rate in females is
double compared
to males.
Males are
forgotten reservoir.
• Those who have had sex with an
infected partner.
• New sex partner or more than two sex
partners in the past year.
• Those with previously diagnosed STI.
• Vulnerable populations: intravenous
drug users, incarcerated, sex trade
worker, street youth.
Sexually active
males and
females (including
asymptomatic)
younger than 25.
Pregnant women.
Nuclear acid amplification
tests (NAATs): PCR,TMA.
Cultures (preferred method
for medico-legal purposes);
DFA, EIA.
Specimen sites: urine,
urethral, cervical, vaginal,
rectal, pharyngeal swabs.
Gonorrhea
Highest rates in
males 20 to 24, and
females, 15 to 19.
Higher rates in
zones 1 and 2.
• Those who have had sex with an
infected partner.
• Men who have sex with men.
• Sex trade workers and their sex
partners.
• Individuals younger than 25 with
multiple sex partners.
• Street youth.
• Those with previously diagnosed STI.
• Those originating from or who have had
sex with someone from a country with a
high prevalence.
Symptomatic or
at-risk males and
females.
Pregnant women.
Nuclear acid amplification
tests (NAATs): PCR,TMA.
Cultures (allows for
antimicrobial sensitivity
testing and preferred
method for medico-legal
purposes).
Specimen sites: urine,
urethral, cervical, vaginal,
rectal, pharyngeal swabs.
Syphilis
Highest rate in
Zone 1.
Most cases are in
MSM.
• Those who have had sex with an
infected partner.
• Men who have sex with men.
• Sex trade workers and their sex
partners.
• Street youth and homeless.
• Injection drug users.
• Those with multiple sex partners.
• Those with previously diagnosed STI.
• Those originating from or having sex
with someone from a country with a
high prevalence.
Pregnant women.
Immigrants older
than 15 (screened as
a part of immigration
application).
At-risk males
(i.e., MSM )
Primary and secondary
syphilis lesions, placenta:
dark-field microscopy, DFA/
IFA, PCR.
Serology (blood specimen).
-non-treponemal tests
(RPR, VDRL);
-treponemal tests (TP-PA,
MHA-TP, FTA-ABS, IgG and
IgM EIA, INNO-LIA);
CSF: VDRL, FTA-ABS, PCR.
*Availability of tests and tests offered vary by laboratories. Results are dependent on the type of test, specimen site, collection and
transport.
PCR – Polymerase chain reaction; TMA – Transcription mediated amplification; DFA – Direct antibody fluorescent assay; IFA - Indirect
antibody fluorescent assay; RPR – Rapid plasma reagin test; VDRL – Venereal Disease Research Laboratory test; TP-PA – T. pallidum particle
agglutination; MHA-TP – microhemagglutination- T. pallidum; FTA-ABS – fluorescent treponemal antibody absorbed; EIA – enzyme
immunoassay; INNO-LIA – line immunoassay, CSF – cerebrospinal fluid
Management of cases and contacts:
The management of cases and their contacts should be done
according to the Canadian Guidelines on Sexually Transmitted
Infections. If you do not already have a copy, visit the guidelines’
web page to order one:
• http://www.phac-aspc.gc.ca/std-mts/sti-its/guide-lignesdir-eng.
php
• Public Health will follow up with a clinician regarding case and
contact management
• Partner notification:
• Chlamydia and gonorrhea: All partners who had sexual
contact with the index case within the following trace-back
periods should first be tested and treated regardless of clinical
findings and without waiting for test results.
Syphilis: All sexual contacts within the following trace-back periods
need to be located, tested and treated if serology is reactive
Chlamydia
Gonorrhea
60 days prior to symptom onset
or date of specimen collection (if
asymptomatic).
Include additional time up-to-date of
treatment.
If no partners during the
recommended trace-back period,
notify last partner.
If all partners traced test negative,
notify a partner prior to the trace-back
period.
Primary syphilis
three months
Secondary syphilis
six months
Early latent syphilis
one year
Late latent / tertiary
syphilis
Requires assessment of marital or longterm partners and children, depending
on duration of infection
Congenital syphilis
Requires assessment of the mother and
her sexual partners
Counselling and prevention on safer sex
To lower the risk of contracting an STI:
• limit the number of sexual partners. The more partners one has,
the higher the risk of getting an STI;
• know the sexual partner’s history;
• have protected sex: Use condoms for vaginal and anal sex and
dental dams for oral sex;
• have regular STI check-ups;
• the only sure way to prevent chlamydia is by not having sex or
by delaying sex;
• the use of alcohol and drugs lowers the decision-making abilities
needed to say no to sex or to practise safer sex; and
• individuals with STIs and their sexual contacts should abstain
from unprotected intercourse until treatment of both partners is
complete.
Changes to the New Brunswick immunization
schedule for January 2011.
A number of improvements to the New Brunswick immunization
schedule will be introduced at the start of 2011. These changes will
address both urgent epidemiological issues as well as some of the
revised recommendations from the National Advisory Committee
on Immunization (NACI). The Office of the Chief Medical Officer of
Health intends to change the schedule only once a year, in January
whenever possible.
Alterations to adult pertussis vaccine eligibility.
A more detailed review of the epidemiology of pertussis in
NB, and the acute risks we face, will be in the next (Christmas)
edition of Disease Watch NB. Outbreaks of pertussis, with several
consequences for the very young, are being reported in a number
of North American jurisdictions, including California (6,000 cases
and 10 deaths in children younger than three months) and
Saskatchewan (five deaths in children younger than three months).
To be fully protected against pertussis, infants need at least three
doses of vaccine and probably four or five. Additionally, vaccination
with acellular pertussis vaccine likely lasts only one to two decades.
Many adults are non-immune. The cycle of recent outbreaks
every three to five years has returned, driven by circulation in
adolescents and adults.
An adolescent booster dose has been part of school programs
for many years, but the eldest recipients of this are now about 20
years old. Most pregnant women are non-immune and are at risk
of developing pertussis and passing this on to their newborns, with
tragic consequences.
To protect children from infection, we are introducing a free dose
of Tdap (tetanus-diptheria-accelular pertussis) for all postpartum
women and for their partner, the latter preferably before birth.
We are also recommending other close contacts be vaccinated,
but these are not covered under the free program. Detailed
information is being distributed to providers.
Free vaccine will also be available to health-care workers in
hospitals exposed to young children.
Second dose varicella vaccine and conversion to
combined vaccine
Free flu vaccine
for pregnant women.
Vaccin antigrippal gratuit
pour les femmes enceintes.
Get the flu shot.
Faites-vous vacciner.
A safe and effective way
to protect you and your baby.
C’est la façon sécuritaire et efficace
de vous protéger, vous et votre enfant.
Visit gnb.ca/flu
Dial 811
Visitez gnb.ca/grippe
Composez le 811
CNB 7508
Post licensure studies of varicella vaccine have confirmed that
one dose of vaccine is only 80 to 85 per cent effective against any
disease; and, that protection wanes with time although varicella
breakthrough is generally mild and less contagious than varicella
in unvaccinated persons. NACI and the United States Advisory
Committee on Immunization Practices (ACIP) have recommended
introducing a second dose of vaccine to the program. This is
despite the theoretical risks of increasing rates of herpes zoster
and of moving disease to a higher age group with more severe
morbidity.
In New Brunswick, a second dose of varicella vaccine will be
introduced Jan. 1.
The recent NACI statement also addressed the issue of excess
adverse events associated with the combined MMRV vaccine
over the two vaccines given separately. A detailed review by ACIP
suggests that there was an increased risk of febrile convulsions
when MMRV was used in the 12- to 23-month group; the extent of
this was in the order of one case per 2,500 vaccine doses.
In Canada, a different vaccine is used, and NACI have not identified
any similar data with this vaccine, so no restrictions have been
placed on the use of a combined vaccine. In Quebec, the extensive
use of this vaccine in young children has not revealed any safety
signals.
Using a combined vaccine at 12 months will enable us to reduce
the number of needles from the current four doses. While some
data suggest that the most cost effective scenario is to give
the second varicella dose at about five years of age, there are
programmatic benefits to giving this with the second dose of
measles at 18 months.
Accordingly, a two dose combined MMRV vaccine will be
introduced on Jan. 1 with doses at 12 months and 18 months.
Detailed data on transition arrangements will follow.