Archive for May, 2020

A brief review of CDC recommendations for prevention, screening, and treatment of sexually transmitted diseases in the primary care setting for Georgia physicians

Alida Maria Gertz, MD, MPH, MSc, DTM&H

Core Faculty, Wellstar Atlanta Medical Center Family Medicine Residency Program

Georgia has high rates of STDs. In 2018, by rate per 100,000 population, Georgia ranked #7 in chlamydia cases, #15 in gonorrhea, #4 in primary and secondary syphilis, and #10 in congenital syphilis U[1]U. In 2015, Georgia ranked #5 in number of HIV diagnoses [2]. From 2014-2018, adolescents and youth (15-24 years old) made up 58-64% of all STD cases in Georgia. African American youth make up 35% of these cases. From 2014-2018, females made up 72% of chlamydia cases in the 15-24 years old age group and over 53% of gonorrhea cases.  It is thus important for family physicians in Georgia to be aware of updated guidelines for STD prevention, screening, and treatment, and to remember to focus on at risk populations including importantly, adolescents and young adults when seeing patients in the primary care setting.

The most recent CDC treatment guidelines for STDs came out in 2015 [3]. The CDC created PDFs summarizing these guidelines, which are easily and freely downloadable as a pocket guide [4], a wall chart [5], and even apps for iPhones or Androids [6]. More recently, in January 2020, the CDC created a companion guideline to the 2015 STD treatment guidelines, which outlines additional services that primary care clinics should be offering, to ensure quality comprehensive clinical services are provided for STD prevention, screening, and treatment [7]. Eight sections, summarized below, are included in this new guideline: 1) sexual history and physical examination, 2) prevention, 3) screening, 4) partner services, 5) evaluation of STD-related conditions, 6) laboratory, 7) treatment, and 8) referral to a specialist for complex STD or STD-related conditions.

Sexual History and Physical Examination

Taking a good sexual history is key. The five Ps of a thorough sexual history should include questions about: 1) partners, 2) practices, 3) protection, 4) past STDs, and 5) pregnancy prevention (contraception). It is notable that in Georgia, contraception can be prescribed to minors without parental consent. A freely downloadable pocket guide with example questions and step by step instructions on sexual history taking can be found 24There24T 24T[8]24T. The STD physical exam should include inspection of skin, throat, lymph nodes, anogenital area, and a neurologic exam. Notably, the CDC estimates that about half of all new STD infections each year are in people aged 15-24 years old, and Georgia is no exception as noted above 24T[9]24T. For this reason, it is particularly important for providers to ensure they speak to adolescents alone when taking a sexual history 24T[10]24T. Another important group to consider is LGBTQ patients. Men who have sex with men are at increased risk of STDs particularly HIV, and practices should make an effort to include LGBTQ friendly signage in clinics, and staff and providers should have specific training on LGBTQ terminology and how to provide culturally competent care for this vulnerable population 24T[11]24T.

Prevention

Services that should be offered in the primary care setting include: 1) providing condoms, 2) offering hepatitis A, B, and HPV vaccinations, 3) providing emergency contraception pills, 4) offering STD counseling services, and 5) HIV pre-exposure prophylaxis (PrEP) and nonoccupational postexposure prophylaxis (nPEP) services. PrEP usually consists of a single daily dose of tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg, however, a full guideline for PrEP prescribing can be found here [12], with a summary on page 11. A supplement with additional information on PrEP for patients who inject drugs, primary care practice protocols for prescribing PrEP, and other special situations also exists [13]. Providers should take note that unlike STD treatment, PrEP and nPEP are NOT allowed to be prescribed to minors without parental consent in Georgia [14].

Screening

Screening and assessment should be available in the primary care setting for: gonorrhea, chlamydia, syphilis, hepatitis B, hepatitis C, HIV, cervical cancer, and trichomoniasis. Screening for STIs is notably allowed in minors without parental consent in Georgia [14].

Partner Services

Strategies should be employed by clinics to identify, test, and treat exposed partners, and should consist of: 1) guidance to patients on notification and treatment of partners, 2) counseling of patients on partner notification, 3) expedited partner treatment (EPT) [15], which is permissible in Georgia (a link to the full Georgia prescribing rules and regulations can be found here [16]), and 4) information on gathering of partner information by health department specialists (disease intervention specialist [DIS]). It is notable that cefixime is no longer recommended for treatment of gonorrhea and therefore also not for EPT; however, it can be used in certain situations [17].

Evaluation of STD-Related Conditions

Clinicians should know to evaluate the following clinical diagnoses for STD etiologies: genital ulcer disease (etiologies include: syphilis, HSV, chancroid, granuloma inguinale, and lymphogranuloma venereum), urethritis (etiologies include: gonorrhea, chlamydia, mycoplasma, trichomoniasis, and HSV), vaginal discharge (etiologies include: bacterial vaginosis, trichomoniasis, and candidiasis), PID (gonorrhea and chlamydia), epididymitis, pharyngitis, genital warts (HPV), proctitis (etiologies include: gonorrhea, LGV serovars of Chlamydia trachomatis, syphilis, and HSV), ectoparasitic infections (etiologies include: pediculosis pubis and scabies), and certain systemic or dermatologic conditions (which can be caused by: disseminated gonorrhea, neurosyphilis, ocular syphilis, condylomata lata, or palmar plantar syphilitic rash). Empiric treatment should be provided when appropriate if clinical suspicion is high.

Laboratory Tests

The following diagnostic tools should be available in the primary care setting: thermometers, pH paper, and phlebotomy. If able, clinics should also consider offering testing with same day results for trichomoniasis, bacterial vaginosis, vulvovaginal candidiasis, urine dipstick, urinalysis with microscopy, pregnancy test, and rapid HIV tests. The following tests should be available via a local laboratory: urogenital NAAT for gonorrhea and chlamydia, extragenital (pharynx and rectum) NAAT for gonorrhea and chlamydia, quantitative nontreponemal serologic test for syphilis, treponemal serologic test for syphilis, HSV viral culture or PCR, HSV serology, fourth-generation antigen/antibody HIV test, oncogenic HPV NAATs with Pap smear, serologic tests for hepatitis A, B, and C, and blood test for pregnancy. Having gram stain, methylene blue, or gentian violet stain for urethritis, gonorrhea culture, gonorrhea antimicrobial susceptibility testing, and NAAT for trichomoniasis in the primary care setting, is optional.

Treatment

First line therapies for STDs and STD related conditions should be available on site or by prescription. A tracking system to ensure patients with confirmed infections fill prescriptions is also recommended. As per the 2015 treatment guideline, metronidazole (oral or vaginal), and vaginal clindamycin are first line recommended treatments for bacterial vaginosis. Azithromycin or doxycycline are first line treatment for cervicitis, chlamydia, and nongonococcal urethritis. For epididymitis, ceftriaxone plus doxycycline is recommended. Acyclovir, valacyclovir, or famciclovir can all be used for genital HSV. Patient-applied imiquimod, podofilox, or sinecatechins, or provider-applied cryotherapy, surgical excision, trichloroacetic acid, or bichloroacetic acid, can all be used for genital warts. Ceftriaxone plus azithromycin is still recommended for gonococcal infections. Permethrin cream can be used for pediculosis pubis and scabies. Penicillin is still recommended for syphilis. Oral metronidazole or tinidazole is advised for trichomoniasis. Finally doxycycline alone is recommended for lymphogranuloma venereum [5-7]. Treatment of STD is allowable for minors without parental consent in Georgia [14].

Specialist referral

Specialist referral should be considered in the situations listed in the table below.

Table 1: Situations involving STDs that should prompt specialist referrals
Complex gonorrhea ●        Resistant gonorrhea

●        Cephalosporin or IgE-mediated penicillin allergy

●        Suspected cephalosporin treatment failure

●        Gonococcal conjunctivitis

●        Disseminated gonococcal infection

●        Gonococcal endocarditis or meningitis

●        Gonococcal ophthalmia in infants

Complex chlamydial infections ●        Chlamydial ophthalmia in infants

●        Pneumonia in infants

●        Persistent or recurrent epididymitis

●        Persistent or recurrent cervicitis

●        Cephalosporin or IgE-mediated penicillin allergy

●        Suspicion of testicular torsion

Complex syphilis ●        Primary, secondary, and latent syphilis in infants and children

●        IgE-mediated penicillin allergy

●        Tertiary syphilis

●        Neurosyphilis

●        Ocular or otic syphilis

●        Syphilis during pregnancy

Complex vaginal discharge, trichomoniasis, and candidiasis ●        Persistent vaginal discharge of unclear etiology

●        Persistent or recurrent trichomoniasis

●        IgE-mediated allergy to nitroimidazoles

●        Recurrent vulvovaginal candidiasis in patients who remain culture-positive despite maintenance therapy

●        Recurrent non albicans vulvovaginal candidiasis

Complex PID ●        Cephalosporin or IgE-mediated penicillin allergy

●        PID surgical complications (e.g., tubo-ovarian abscess)

Complex herpes ●        Antiviral-resistant herpes infection

●        Genital herpes contracted during third trimester of pregnancy

●        Neonatal herpes

Viral hepatitis ●        HBV

●        HCV

Complex warts ●        Cervical or intra-anal warts

●        Atypical anogenital warts with high-grade squamous intraepithelial lesion on biopsy

Cervical intraepithelial neoplasia or cervical cancer ●        High- or low-grade squamous intraepithelial lesions on Pap smear
Complex ectoparasitic infections ●        Crusted scabies in persons with HIV infection
Sexual assault ●        When HIV nPEP is being considered

●        STDs in children (if suspected possibility of sexual abuse)

HIV infection ●        For a new diagnosis or to establish a link to care

           

Family physicians are on the frontlines of STD prevention, screening, and treatment. Along with our public health colleagues, it is up to us to decrease the number of STDs in Georgia. Focusing on prevention, screening and treatment, in high risk groups, including adolescents, will help us to do this. Primary care physicians should also work with their local Georgia public health department branches to ensure all notifiable STDs are properly reported [18]. By following the strategies outlined above, we can ensure that best practice for STD prevention, screening and treatment are followed in primary care settings across the state.

References and links to CDC STD resources

  1. 2018 STD Surveillance Report: State Ranking Tables – CDC
  2. Georgia 2015 Health Profile – CDC
  3. STD Tx Guidelines 2015 – Full: https://www.cdc.gov/std/tg2015/tg-2015-print.pdf
  4. STD Tx Guidelines 2015 – Pocket Guide: https://www.cdc.gov/std/tg2015/2015-pocket-guide.pdf
  5. STD Tx Guidelines 2015 – Wall Chart: https://www.cdc.gov/std/tg2015/2015-wall-chart.pdf
  6. STD Tx Guidelines 2015 – App Links: https://www.cdc.gov/std/tg2015/default.htm
  7. STD Clinical Services 2020: https://www.cdc.gov/mmwr/volumes/68/rr/pdfs/rr6805a1-H.pdf
  8. Taking a Sexual History – https://www.cdc.gov/std/treatment/sexualhistory.pdf
  9. https://www.cdc.gov/std/life-stages-populations/adolescents-youngadults.htm
  10. 2017 MMWR on confidentiality issues and use of STD services among Adolescents
  11. CDC Page on LGBTQ Health – https://www.cdc.gov/healthyyouth/disparities/health-considerations-lgbtq-youth.htm
  12. PrEP Guideline 2017 – https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf
  13. PrEP Guideline 2017 Supplement – https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a1.htm https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-provider-supplement-2017.pdf
  14. Minors’ Consent Laws for HIV and STD Services – https://www.cdc.gov/hiv/policies/law/states/minors.html
  15. Expedited Partner Treatment – https://www.cdc.gov/std/ept/default.htm
  16. Georgia STD Screening and Treatment – https://dph.georgia.gov/STDs/screening-and-treatment
  17. EPT for Gonorrhea – https://www.cdc.gov/std/ept/gc-guidance.htm
  18. Georgia DPH reportable disease list – https://dph.georgia.gov/sites/dph.georgia.gov/files/DPH%20ND%20Reporting%20Poster_032414.2.1.2016.pdf

Member Benefit:  COVID19 Testing to Clinic Staff and Patients

To:         Georgia Academy of Family Physicians Members (Active and Life)

Bako Diagnostics is a laboratory in Alpharetta with the capacity to offer COVID19 testing to clinic staff and patients.  COVID19 testing presents an opportunity for Georgia family physicians to deliver much needed testing to their staff, patients and broader community.  Family Practice is at the forefront of health in the US and Georgia.  This testing program can support getting a family medicine practice up and running again while performing an important healthcare delivery need.  The program will be piloted with ten (10) family physician practices with plans to expand to other GAFP practices within the following three (3) weeks.

Potential COVID19 Test Offerings:

–          Screen your staff members before allowing them to treat patients and on some recurring basis to constantly assess infection occurrence

–          Screen existing patients prior to regular appointment/office visits.  Example: Patient screened on Monday; if negative, can be scheduled for regular appointment on Wednesday with appropriate precautions on exposure to others in society.

–          Offer existing patients access to COVID testing, allowing family practice physicians to be in the vanguard of caring for their patients

–          Market your practice to broader community with pre-set COVID test day / curbside testing, creating an opportunity to build your practice and deliver a much needed community healthcare service

COVID19 testing is available through Bako Diagnostics under FDA’s Emergency Use Authorization.  Bako Diagnostics is a leader in clinical, molecular, and anatomic pathology, located in Alpharetta GA. The BakoDx real-time COVID19 PCR test provides results in 24hrs from receipt to the lab.

Program Details:

–          Contact Fay Fulton (ffulton@gafp.org) or Angela Flanigan (aflanigan@gafp.org) for inclusion in the pilot.

–          Collection supplies will be provided by Bako Diagnostics.

–          If within the Bako courier network, a minimum of 10 samples per pickup are required. Logistics will be covered by the lab.

–          If outside the Bako courier network, a minimum of 20 samples required for shipping (if less than 20, logistics costs to be handled by healthcare provider).

–          Billing can be setup as client bill or patient/insurance bill.  Bako’s experience and understanding is that all third party payers cover the test when ordered by a family physician. The price of the test is at the federal rate.  For patients without insurance, the price of the test is $100.

–          Detailed information on testing is available at bakodx.com/services/covid-19/

Contact your current lab or reach out to Bako Diagnostics to start offering COVID19 testing in your community.

Note that the GAFP is not accepting liability in the event the test does not perform.  This is an additional member benefit that we are offering to our members but given the national demand for testing we expect Bako’s capacity to be fully placed in short order so please message promptly with you interest.

GAFP and Department of Public Health Webinar: Patient Privacy Considerations in Family Medicine

Tuesday, June 11, 2020
Time: 12:00 pm – 1:00 pm

Registration: Please follow this link to register.

Webinar Objectives:

  • Educate family physicians and staff regarding general health information and the law pertaining to minors and those transitioning to adults.
  • Learn what exceptions apply to the general rules above?
  • Discuss best practices for your medical practice.

Presenter:

David D. Mackenzie
Partner
Huff, Powell & Bailey LLC

 

CME Information:

AMA Credit: The Georgia Academy of Family Physicians is accredited by the Medical Association of Georgia to provide continuing medical education for physicians.  The GAFP designates this live educational activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.    

 

COVID – 19 and Pregnancy                                                                                                           

Daniel H. Singleton, MD, MAS, FAAFP

As the world grapples with the novel coronavirus, SARS – CoV – 2, we must consider the evidence-based care of pregnant and newborn patients.  Considerations include 1) changes in the delivery of routine prenatal care, 2) considerations of virus associated risks during pregnancy, 3) risk and mitigation around delivery and the newborn.

  • Changes to routine prenatal care – Telehealth is an important mitigation strategy for limiting community spread of COVID 19. We must recognize that social distancing guidelines will disrupt the schedule of routine prenatal care.  Telehealth is an important tool for providing access during times when community mitigation strategies are in place.  The healthcare team should consider the patient population, availability of internet connectivity, local prevalence of viral illness and availability of staff and PPE resources.  This necessitates a cooperative problem-solving approach that includes patient, clinical leadership and staff participation. Telehealth should be used for screening of contact with known positive patients and monitoring patients for development of symptoms of COVID-19.  Increased communication between patient and provider will help set expectations and allow more successful implementation while providing needed care.
  • Risks during pregnancy – Respiratory illness has been considered a risk factor for increased morbidity and mortality during pregnancy. There is yet little evidence that pregnancy and coronavirus infection together cause increased severe morbidity in comparison to the general population. For pregnant patients with comorbid conditions, their risk appears similar to those with similar comorbidities in the general population. Evidence is lacking for vertical transmission from mother to infant.
  • Assessing risk and mitigation around delivery and the newborn – An initial first step is to develop and understand facility policies toward patients under investigation (PUI) or known positive patients. Local and state public health authorities can help provide guidance to frame these policies for local and community needs. CDC recommended PPE should be made available for healthcare workers in contact with PUI and known positive patients.

Algorithmic management of mother and newborn follows different protocols for known positive mothers and PUI mothers.  The newborns of known COVID-19 positive mothers should be treated as PUI.  The infant PUI should be tested and isolated from healthy newborns.  Testing of the newborn PUI should be done at 24 hours of age and repeated at 48 hours by swabbing the mouth and then the nasopharynx with the same swab.

If found positive, then testing should be repeated every 48 hours until there are two consecutive negative tests. If the positive infant is asymptomatic, then there may be frequent outpatient follow up using telehealth when available until day-of-life 14. Discussion on the prevention of household spread from the infected infant are necessary.

The infant testing negative, but whose mother is positive, should be discharged into the care of a healthy caregiver.  The mother should maintain social distancing of 6 feet and use hand hygiene and mask for care of infant until one of two things occur.  1) she is afebrile without antipyretics for 72 yours and she is at least 10 days past the onset of symptoms OR 2) she has two consecutive negative COVID-19 tests done at least 24 hours apart. Similar guidelines should be used for visitation to the NICU for by positive mothers.

In the case of mothers that are PUI, the infant is not considered PUI but temporary separation from the mother should be considered until negative resolution of the mother’s pending results. If the mother becomes a known positive, then the infant gains PUI status and should be treated as such.

There are aspects of breastfeeding that should be considered for care of the mother-newborn dyad.  There is no evidence to date that is SARS-CoV-2 transmitted through breastmilk. For a mother that is known positive or PUI mothers may express breast milk using appropriate breast and hand hygiene and the milk may be feed by a non-infected caregiver.  Direct breastfeeding must be accompanied by strict hand and breast hygiene along with the use of a mask.

Providers must work diligently to adapt to changes in access as the pandemic develops and changes in each locality.  This will require greater flexibility in how access to needed care is provided while maintaining appropriate safety for healthcare workers and patients. The increased rates of infection, morbidity, and mortality in communities of color who also represent increased risk of peripartum morbidity and mortality requires that every effort to be made to address access and patient education around risks during the current viral pandemic.

Resources:

The American Academy of Pediatrics (AAP) issues guidance on breastfeeding during COVID-19 pandemic. https://www.aappublications.org/news/2020/04/23/covid19breastfeeding042320

The American Academy of Pediatrics (AAP) issued guidance on infants born to mothers with suspected or confirmed COVID-19. https://www.aappublications.org/news/2020/04/02/infantcovidguidance040220

Coronavirus, A. N. (2019). Practice Advisory [https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019

Discontinuation of Isolation for Persons with COVID -19 Not in Healthcare Settings: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html  5/3/2020

Call for Nominations: 2021 GAFP Board of Directors

To:       All Active and Life GAFP Members in All Districts

From:   Jeff Stone, MD, MBA, MHA, FAAFP – Chair, Nominating Committee

The Nominating Committee is working to compile a slate of candidates for the 2021 GAFP Board of Directors.  GAFP leadership has a history of excelling at both the state and national levels and far outpaces other physician groups in innovative and new initiatives.

The Congress of Delegates will vote on the slate for the 2021 Board in late summer.  (Residents and Medical Students will hold their own elections in the fall.)

If you are interested in becoming more active in the Georgia Academy, please consider applying.  Your time commitment is 4 meetings a year (typically March, June, August and November) and being available to GAFP leaders, staff, and your district colleagues should issues emerge that require your leadership input and participation.

All Board members receive one free registration per year for either our Summer CME or Annual Meeting as a token of our appreciation for your hard work.

Board members are asked to be the eyes and ears of your community and bring to the leadership issues important to family physicians from your hometown.  Please click this link, https://www.surveymonkey.com/r/23GDV2P and respond by May 20th  if you are interested in applying for the 2021 Board.

Potential vacancies are listed below:

Officers

*President-Elect (automatically becomes President in November 2020 and Board Chair in November 2021)

*Vice President (1-year term)

*Treasurer (3-year term)

*COD Speaker (1-year term)

COD Vice Speaker (1-year term)

*Member of the Executive Committee and must be available for monthly conference calls and four face-to-face meetings in addition to attending the GAFP Board of Directors meetings.

AAFP Delegates- (must be eligible to attend AAFP Congress of Delegates)

AAFP Delegate (2-year term)

AAFP Alternate Delegate (2-year term)

District Director and Alternate Director Available Positions

Director – District 1 (3-year term) – (Counties: Baldwin; Bryan; Bulloch; Burke; Chatham; Effingham; Evans;  Glascock;  Greene;  Hancock;  Jefferson;  Jenkins;  Johnson;  Liberty;  Long;  McDuffie;  McIntosh; Screven; Taliaferro; Warren; Washington and Wilkinson)

Director – District 6 (3-year term) – (Counties: Bibb; Butts; Crawford; Houston; Jasper; Jones; Lamar; Macon; Monroe; Peach; Pike; Pulaski; Putnam; Spalding; Twiggs and Upson)

Director – District 7 (3-year term) – (Counties: Bartow; Catoosa; Chattooga; Dade; Floyd; Gordon; Polk; Walker and Whitfield)

Alternate Director – District 6 (3-year term) – (Counties: Bibb; Butts; Crawford; Houston; Jasper; Jones; Lamar; Macon; Monroe; Peach; Pike; Pulaski; Putnam; Spalding; Twiggs and Upson)