Sexual Health and Sexually Transmitted Blood-borne Infections

Labstract: Chlamydia trachomatis and Neisseria gonorrhoeae - Nucleic Acid Amplification Testing

Due to the threat of increasing antibiotic resistance in N. gonorrhoeae in Ontario, Hamilton Public Health Services recommends that practitioners follow Public Health Ontario’s guidelines (See Ontario Gonorrhea Testing and Treatment Guide, 2^nd Edition below) for gonorrhea treatment, and the Canadian STI Guidelines for managing all other sexually transmitted infections.

• Ontario Gonorrhea Testing and Treatment Guide, 2^nd Edition
• Labstract: Chlamydia trachomatis and Neisseria gonorrhoeae - Nucleic Acid Amplification Testing
• Gonorrhea guide: Key Information and resources

Primary Care Management of Hepatitis B – Quick Reference (HBV-QR)

• Canadian Hepatitis C Guidelines – CATIE
• 2018 Hepatitis C Guidelines – Canadian Association for the Study of the Liver

Herpes Counselling Tool 

• Ontario Guidelines for Providers Offering HIV Testing
• Canadian Guideline on HIV Pre-Exposure Prophylaxis and Non-Occupational Post-Exposure Prophylaxis
• British Columbia (BC) Guidelines for the care of HIV positive pregnant women and interventions to reduce perinatal transmission PDF
• Treating HIV, Research and Guides (CATIE): Practical guides for patients on topics, such as drug side effects and nutritional recommendations
• Treatment Update:CATIE’s digest of recent developments in research and treatment.

Syphilis

• Canadian STI Guidelines – Syphilis Management

Congenital Syphilis

What – Congenital Syphilis Overview

When a pregnant individual has a syphilis infection it can lead to miscarriage, stillbirth, or preterm birth. The infection can also be passed from the pregnant individual to the baby during pregnancy or delivery – this is called congenital syphilis. Without treatment, the baby may develop serious problems, most often in the first few weeks following birth, but sometimes years later.

Congenital syphilis is re-emerging in Hamilton and cases have risen significantly in recent years. Local data indicates that the rate of infectious syphilis has increased 4 times among females from 2019 to 2022. 74% of the female infectious syphilis cases were among those of child-bearing age. This resulted in a rise in the number of infants undergoing investigation for congenital syphilis, due to potential transmission during pregnancy. Between 2018 to 2022, a total of 7 confirmed cases of congenital syphilis were identified, highlighting a need to ensure testing during the prenatal period.

Diagnoses of congenital syphilis in babies can be difficult as antibodies can be transferred from pregnant individual to newborn through the placenta. It is advised that all babies that are suspected congenital syphilis cases should be referred to an infectious diseases or pediatric infectious diseases specialist for a full evaluation.

So What – Recommended Health Care Provider Actions

The Public Health Agency of Canada recommends the following screening during pregnancy:

• Universal screening during the first trimester or at first pre-natal visit
• Repeat screening at 28-32 weeks and again at time of delivery:
  • in areas with outbreaks of syphilis or
  • for pregnant individuals at ongoing risk of infection or reinfection
• Consider more frequent screening for those at high risk of infection
• Screen all people who deliver a stillborn infant after 20 weeks gestation
• Individuals at high risk of acquiring syphilis (underhoused, sex workers) may be less likely to receive standard prenatal care, for this reason, screening pregnant individuals in the ER is recommended

Additionally, health care providers can ensure partners of pregnant individuals with syphilis are screened and treated to reduce risk of re-infection. They can also promote the need for safer sex practices, including reducing the number of sexual partners during pregnancy.

For more information on symptoms in babies, prevention measures and the role health care providers can play, screening recommendations, and treatment, please continue to read the information provided below.

Congenital Syphilis Symptoms in Pregnant Individuals & in Babies

A pregnant individual infected with syphilis may have no symptoms. If present, symptoms can include chancres on the genitals or mouth, a rash, fever and swollen glands.

For babies born with congenital syphilis, the infection can cause:

• Incorrectly formed bones
• Severe anemia
• Enlarged liver and spleen
• Jaundice
• Brain and nerve problems, like blindness or deafness
• Meningitis
• Skin rashes

Some babies with congenital syphilis may not show any symptoms at birth. How likely a baby contracts the infection and is born with syphilis depends on the pregnant individual’s syphilis stage during pregnancy and the gestational age at the time of treatment.

• Syphilis is most likely to pass to the baby if the individual is in the primary or secondary stage of infection when they become pregnant or if they get syphilis while pregnant
• Nearly all transmissions to babies are prevented if the pregnant individual receives treatment during the first 28 weeks of pregnancy. The chance of passing syphilis to a baby increased with increasing gestational age – the risk becomes higher if treatment is received later in the pregnancy or if the individual is not treated at all

Preventing Congenital Syphilis

Addressing syphilis among individuals of reproductive age will have a downstream effect of helping to prevent congenital syphilis. Using condoms or dental dams during anal, oral, and vaginal sex helps to prevent the spread of syphilis. However, these measures do not completely eliminate the risk, as syphilis can still pass through skin-to-skin contact if the individual with syphilis has a chancre that’s not covered by a condom or dental dam.

Anyone who may be at risk for syphilis should be tested regularly and treated is necessary. Prompt treatment is important for the individual’s health and prevents syphilis from passing to others, including their baby if the individual is pregnant.

Health Care Providers Role in Preventing Congenital Syphilis

Provide education to your patients about syphilis – how it’s transmitted, the increasing risk of syphilis locally and provincially, how it can be prevented, how it’s diagnosed, and how it’s treated. You can also promote the message that syphilis is easily treated if it’s diagnosed early.

Support access to syphilis prevention, testing, and treatment. This can include direct supports, like the provision of condoms and dental dams as well as information about where individuals can access testing and treatment locally. It can also include offering services or providing referrals to services that address broader issues that impact a person’s health, such as support with housing, food security, substance use services, or mental health services.

Encourage individuals who are pregnant or planning on becoming pregnant to get tested for syphilis and treated if necessary. Educate individuals about the need for retesting during pregnancy if they are at ongoing for syphilis.

Screening Recommendations

The Public Health Agency of Canada recommends the following screening during pregnancy:

• Universal screening during the first trimester or at first pre-natal visit
• Repeat screening at 28-32 weeks and again at time of delivery:
  • in areas with outbreaks of syphilis or
  • for pregnant individuals at ongoing risk of infection or reinfection
• Consider more frequent screening for those at high risk of infection
• Screen all people who deliver a stillborn infant after 20 weeks gestation
• Individuals at high risk of acquiring syphilis (underhoused, sex workers) may be less likely to receive standard prenatal care, for this reason, screening pregnant individuals in the ER is recommended

Babies born to individuals who have been diagnosed with syphilis during pregnancy should be assessed for syphilis at birth and followed by an infectious disease or pediatric infectious diseases specialist.

The Public Health Agency of Canada recommends all pregnant individuals get tested for syphilis in their first trimester or their first prenatal visit. For individuals at ongoing risk of syphilis infection and/or those who live in areas where there is a syphilis outbreak among heterosexual individuals, additional screening should take place at 28-32 weeks of pregnancy and again at delivery

• For more information, please see the Canadian Guidelines on Sexually Transmitted Infections

Treatment

Syphilis infection in both pregnant individual and baby can be treated and cured with antibiotics. In both cases, treatment needs to be started as soon as possible, which is why testing is so important. Pregnant individuals diagnosed with infectious syphilis and suspect congenital syphilis cases should be managed in consultation with an infectious disease or pediatric infectious disease specialist. It is important to ensure that referral does not delay treatment.

Benzathine penicillin G (Bicillin-LA) is the preferred treatment for pregnant individuals with syphilis. There are no satisfactory alternatives to penicillin for the treatment of syphilis during pregnancy. Bicillin LA can be ordered from Hamilton Public Health Services for pregnant individuals for free at www.hamilton.ca/hcp-sti. Treatment for newborns with congenital syphilis tends to occur in hospitals and is guided by an infectious diseases or pediatric infectious diseases specialist.

Health care providers may want to consider follow-up testing for both the pregnant individual and/or baby to ensure the treatment has worked. Additionally, providers can advise all individuals who are treated to abstain from condomless sexual contact until treatment has been completed and ideally for seven days after completion of treatment.

• For more information, please see:
  • The Canadian Guidelines on Sexually Transmitted Infections
  • Public Health Agency of Canada – Syphilis Treatment & Follow-up Guide