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.

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

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

Congenital hearing loss occurs in 1-3 out of 1000 infants in the United States and often found in babies whose parents have normal hearing.  There is well-established evidence that early identification of hearing loss and appropriate early intervention can mitigate the potential for poor language acquisition. The Joint Committee on Infant Hearing’s Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs, and their statement entitled, “Newborn and Infant Hearing Loss: Detection and Intervention” supports universal newborn hearing screening and outlines best practices in the timing and methods for follow up hearing screening and participation in early intervention. Early detection of hearing loss facilitates language acquisition and future opportunities for educational success.

Pediatricians and others in pediatric primary care providers play a vital role in mitigating developmental delays in infants and young children who are deaf and hard of hearing.   Those providing a medical home for children can ensure appropriate and timely referrals to providers that can perform evaluations and are knowledgeable about congenital hearing loss.  DPH provides an Early Hearing, Detection, and Intervention (EHDI) coordinator for each county to assist in follow-up services for families of infants who do not pass the initial hearing screening.  You can find your local EHDI Coordinator online at https://sendss.state.ga.us/sendss/!mch.coord_search.

Since its release, the EHDI program adopted the AAP Guidelines for Pediatric Medical Home Providers, available online at https://pediatrics.aappublications.org/content/120/4/898/tab-figures-data. This algorithm maps the 1 – 3 – 6 follow-up guidelines for newborn hearing screening as shown in Figure 1.   Outlined below are the key components of the physicians’ role in this process:

1. For all newborns, obtain written results of newborn hearing screening from the birthing facility. Results are available via a web portal through the Georgia Department of Public Health’s State Electronic Notifiable Disease Surveillance System (SendSS) or eReports. Physicians can register for SendSS and eReports by following these links  https://sendss.state.ga.us/sendss/login.screen; https://ereports.ga.gov/dph/eReports/weblogin.aspx?MsgNum=0&Locale=1033
2. By one month of age, ensure that all newborns receive a hearing screening. Infants who “refer” on their initial screening, in one or both ears, must receive a follow-up hearing screen.  Infants that pass their initial screening do not need additional testing unless concerns arise.  If the initial hearing screen uses an automated auditory brainstem response (a-ABR) screener, then the same test must be performed during the outpatient, follow-up hearing screen.
3. By three months of age, infants that refer on their outpatient follow-up screen, send for a diagnostic evaluation. Complete only one outpatient screening, as repeated screenings do not provide enough information to determine appropriate follow-up recommendations.  Repeated screenings delay the identification of hearing loss.  After three months of age, sedation may be required for testing, which can be a deterrent for parents.  EHDI coordinators can assist in locating appropriate providers, as needed.
4. By six months of age, support referrals to early intervention, otolaryngology, ophthalmology, and genetics, after diagnosis of permanent hearing loss. A suspected or confirmed case of hearing loss in children from birth to age 5 is a notifiable disease and requires a report to the Georgia Department of Public Health.  Therefore, it is important to notify the EHDI program upon confirmation of permanent childhood hearing loss.  Send a copy of the diagnostic report to the EHDI Program or a surveillance form for reporting hearing loss for children five and under, located on the GA Chapter of the American Academy of Pediatrics website.  EHDI Coordinators will work with the child’s physician and family to assist in linking infants with early intervention services.
5. Otitis media with effusion can lead to permanent hearing loss. Infants and children must be referred to an otolaryngologist and audiologist.
6. Hearing loss may develop at any age; therefore, it is important to monitor all infants for progressive or late-onset hearing loss. Referral for audiological evaluation is recommended at least once before age 30 months for infants who have risk indicators for late-onset hearing loss, such as family history of permanent childhood hearing loss, neonatal intensive care unit stay of more than five days duration, and parental concern. Included is a list of risk indicators in the attached algorithm.

For more information on the Georgia EHDI Program, please visit https://dph.georgia.gov/EHDI

or call 404-651-5482