Hello and welcome to the online learning session. Center for Disease Control and World Health Organization Sexually Transmitted Infection Guidelines, an update for 2022. My name is Gail Horner. I'm a forensic nursing specialist at the IAFN. The planners, presenters, and content reviewers of this course disclose no conflicts of interest. Upon signing in and attending the course in entirety and completing the course evaluation, you will receive a certificate that documents the continuing nursing education contact hours for this activity. The International Association of Forensic Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. The learning outcomes for this session are that the learner will describe current CDC and WHO 2021 updates for sexually transmitted infection, prophylaxis, and treatment, and how it applies to the sexual assault patient population. The learner will describe and explain CDC and WHO 2021 updates for STI testing. COVID has certainly illustrated that viral and bacterial organisms have the capacity to evolve. What is being seen in sexually transmitted infections, especially gonorrhea and chlamydia, is that the bacterias are becoming resistant to our current antibiotic treatment regimens. This will allow for sexually transmitted infections to proliferate within populations, and humans will experience an increasing number of complications. Therefore, the CDC and WHO have revised sexually transmitted infection testing methods to increase our ability to detect the organisms and treatment methods to increase our ability to treat the organisms. Let's take a moment and discuss some of the sexually transmitted infections that we as forensic nurses may encounter within our patient population. We will start with chlamydia. It is estimated that there are 400 new cases of chlamydia in the United States annually. This includes estimates of asymptomatic and unreported cases. Chlamydia is the most commonly reported notifiable disease in the United States. There are sexually transmitted infections with higher annual estimated incidence. Those include HPV, or the human papillomavirus, where there's an estimated occurrence of 6.2 million, and also trichomonas at 5 million. There are also sexually transmitted infections with lower annual estimated incidence. Herpes simplex virus, or antigenital herpes, HSV2, 572,000. Gonorrhea, nearly 620,000, or syphilis, nearly 130,000. The direct and indirect annual costs of sexually transmitted infections in the United States, including costs of treating complications, total approximately 16 billion, according to the CDC in 2021. When looking at these stats, keep in mind that only chlamydia, gonorrhea, syphilis, and cancroid are required to be reported to the CDC. Sexually transmitted infections can be asymptomatic, therefore detected, symptomatic, yet undiagnosed and untreated, and can self-resolve. Therefore, the true number of all the sexually transmitted infections are much higher. On the map, locate your state of practice. It is interesting to note what the rate of infection is within your state in comparison to other locations. Take a look at the incident of chlamydia per age group. You'll see chlamydia is most prevalent among 20 to 24-year-olds, but also pretty high in 15 to 19 and 25 to 29-year-olds. Chlamydia affects females nearly three times more often than males. Transmission of chlamydia can be sexual or vertical, meaning perinatal from mother to infant, or non-sexual. Non-sexual transmission of chlamydia is very rare. I'll give you an example. A number of years ago, I was seeing a child who was three years old who gave no history of sexual abuse, but she was positive for genital chlamydia. Mother told me that she herself had chlamydia, urinated, wiped herself with toilet tissue, then the child urinated, and the mother wiped the child with the same toilet tissue. I could not say in that incident that the chlamydia was indeed not non-sexually transmitted by the toilet tissue, mom wiping herself and then wiping the child, but this is a very rare occurrence. Chlamydia is highly transmissible. Chlamydia infections occur in about more than 50% of sexual partners. The incubation period preceding symptomatic infection is thought to be 7 to 21 days. Significant asymptomatic reservoir exists in our population, meaning there are many individuals that are asymptomatic for chlamydia having sex without knowing that they have chlamydia and passing the infection on. Reinfection is also common because often sexual partners are not treated. Perinatal transmission results in neonatal conjunctivitis in about 30 to 50% of exposed babies and pneumonia in about 3 to 16% of exposed babies. Chlamydia can also be perinatally transmitted to the genital and the anal sites, and one would expect genital or anal perinatal transmission of chlamydia to clear by three years of age. The exact transmission rates are unknown. Transmission of chlamydia is thought to be more effective from men to women. This visualization provides a summary of common clinical syndromes caused by chlamydia. You see that chlamydia causes urogenital infection in both males and females, adults and children. Chlamydia can cause conjunctivitis in adults, children, and neonates, and pneumonia in infants. Note why we provide chlamydia prophylaxis following sexual assault. Look at the risk of ascending infection and infertility among adolescent and adult women. However, the reason why we don't provide prophylaxis to children is that you don't have to worry about the ascending infection, that you are not going to have complications like infertility happen to children. Gonorrhea remains a common sexually transmitted infection, one for which antibody resistance is growing. Hence, the prophylaxis and treatment guidelines have recently changed. Again, note the prevalence of gonorrhea in your state of practice. Note the prevalence of gonorrhea by age group. It's pretty similar to the age distribution that we saw for chlamydia. You see that gonorrhea is slightly more prevalent among males than females, probably due to transmission by male-on-male sex. Gonorrhea is effectively transmitted by male-to-female via semen, vagina-to-male urethra, rectal intercourse, fellatio, can cause oral infection, perinatal transmission from mother to child. Gonorrhea is also associated with increased transmission by male-to-female sex. Gonorrhea is also associated with increased transmission of and susceptibility to HIV infection, and the incubation period for gonorrhea is typically 1 to 14 days. Perinatal transmission of oral, anal, and genital gonorrhea typically clears by the end of the neonatal period, even if untreated. Beyond that, gonorrhea is transmitted to children by sexual contact. Although gonorrhea frequently results in a vaginitis in prepubescent girls and urethritis in boys, it can be asymptomatic. Although among sexually abused children, anorectal and pharyngeal infections with gonorrhea are frequently asymptomatic. Therefore, when concerned regarding genital-to-genital, oral-genital, or anogenital contact in children or adults, include gonorrhea testing in your plan of care. Adolescent and adult males with gonorrhea will often, but not always, be symptomatic. Note that many adolescent and adult females with gonorrhea may be asymptomatic. It is important to test even if asymptomatic. Note the possible complications to gonorrhea infection in the post-pubertal female, illustrating why we offer prophylaxis to adolescent and adult victims of acute sexual assault. Pelvic inflammatory disease is the most common complication. Trichomonas is a very prevalent sexually transmitted infection. Reporting of trichomonas to health departments and then the CDC is not required. Therefore, there are no CDC maps or graphs of prevalence by state or age group. Trichomonas is almost always sexually transmitted. Perinatal transmission is rare, and the persistence of perinatal infection is basically unknown, but would not be expected to persist beyond two to three years of age. Females and males with trichomonas may be asymptomatic. Transmission between female partners has been documented. Adult and adolescent males and females with trichomonas may be asymptomatic. Pre-pubertal girls most often have vaginal discharge and vaginitis, and boys are often asymptomatic. It is important to test for trichomonas when there is a concern for genital-to-genital contact. The incidence of syphilis declined for years after penicillin treatment was introduced in the 1940s. Syphilis now appears to be on the rise, especially among men having sex with men. It is a public health problem in the United States. Note the prevalence of syphilis per state. Different pattern than for chlamydia and gonorrhea. Note the age group distribution for primary syphilis. Note that it extends more widely into older populations. Note male-to-female ratio of disease. There's a striking difference. Males greatly outnumber females when it comes to primary and secondary syphilis. It is interesting to note that congenital syphilis is on a significant rise in the United States. Syphilis can be transmitted sexually or vertically from mother to child. Syphilis is most contagious to sex partners during the primary and secondary stages. In primary syphilis, a canker sore develops at the site of inoculation. Canker sores are initially macules and become ulcers. They can be mistaken for herpes. However, canker sores are painless and will test negative for HSV. They are highly infectious and heal spontaneously in three to six weeks. There may be multiple lesions. Regional lymphadenopathy accompanies and serologic tests for syphilis may not be positive during early primary syphilis. Note visuals of canker lesions. They can be mistaken for herpes, but of course will test negative for herpes. Secondary lesions of syphilis occur several weeks after primary canker appears and may persist for weeks or months. Note the clinical manifestations. Serologic tests are positive and usually highest and tighter during this stage. Note syphilis lesions can also be confused for genital warts. When concerned regarding anogenital warts, it is important to test for other sexually transmitted infections, especially syphilis. Syphilis can also become blatant. The infection is suppressed by the host and no lesions are present. Serologic testing will be positive. This highlights the importance of testing for syphilis regardless of whether or not lesions are present. Syphilis is a complex infection. It can affect the central nervous system. Consultation with an infectious disease specialist regarding treatment and ongoing testing and monitoring needs is important. Hopefully you will never see a patient with tertiary syphilis. That patient would need infectious disease involvement. Syphilis can be transmitted to a woman's fetus. It can result in fetal and neonatal death and various infant disorders. Transmission can occur during any stage of syphilis and any trimester of pregnancy. There is a wide spectrum of severity, regarding congenital syphilis, and only severe cases are clinically apparent at birth. Early lesions, which are the most common, develop in infants less than two years of age and they're usually inflammatory. Late lesions develop in children greater than two years of age and need tend to be destructive. These patients need to be followed by infectious disease specialists. HIV is another disease that can be transmitted sexually that is reportable to the CDC. Note the prevalence of HIV within your state. Note prevalence of HIV diagnosis per age group. And you'll see that it is more evenly distributed among the age group, although peaks in age 25 to 34. Note that the rate of HIV diagnosis is on a slight but steady decline since 2007, and it is projected that the decrease in numbers will also be slightly greater in 2020. Note the HIV prevalence per gender. Males greatly outnumber females. This is reflective of transmission risk in male-on-male sex. You can see the risk of HIV transmission is greatest in a blood transfusion, 95%. Next, perinatal transmission, 13 to 45%. However, with the antivirals that we have now, if mothers consistently take medications, the risk is lower. Note the risk for unprotected anal intercourse and vaginal intercourse, relatively low. Hepatitis B can also be sexually transmitted. Note the prevalence of acute hepatitis B infection per state. Note the prevalence of hepatitis B is highest among a slightly older age group, 35 to 55-year-olds. Looking at trends from 1999 to 2020, you can see a decrease in acute viral hepatitis B in the United States until about 2009, and now we seem to have plateaued. Again, hepatitis B is more common in males than females. Hepatitis B can be sexually transmitted. However, it is more frequently non-sexually transmitted. It can also be perinatally transmitted. It is blood-borne, so can be transmitted from IV drug use. Most hepatitis B infections in children result from living in households with persons who have chronic hepatitis B infection rather than sexual abuse. Hepatitis C is the most common blood-borne virus in the United States. It can also be sexually transmitted. Probably the highest incident of transmission is via IV drug use. Most infants who acquire hepatitis C perinatally are due to mother's IV drug use. Note viral hepatitis C infection prevalence per state. Note that viral hepatitis C is most prevalent in the 25 to 34 age group, still pretty high in the 35 to 44 age group as well. Hepatitis C prevalence is on the rise. Again, hepatitis C is more common in males than females. Note the hepatitis C prevalence among 0 to 14-year-olds in the United States. Most of these numbers reflect perinatal transmission. It spiked in 2017 but is decreasing since then. Despite the HPV vaccine, HPV infections, including antigenital warts, continue to be very common in the United States, and HPV remains a source of cancer and death within our society. Transmission of HPV can be sexual but can also be non-sexually transmitted. HPV can be perinatally transmitted from mother to baby in children delivered via vaginal or C-section mode. Mothers can have cervical HPV and not know that they do. They have no external warts. And also remember that the HPV virus typically clears spontaneously between one to two years, so many women may not know that they ever had the virus. The incubation period for the HPV virus is unknown. HPV can be also transmitted via auto-inoculation. An individual with a wart on their hand or elsewhere on the body can touch the wart and then touch their genitals and transmit the HPV virus in that mode. And also, inoculation can also come from a caregiver who has a wart on their hand and then changes a child's diaper or helps them bathe and transmits the virus in that manner. Antigenital herpes is a chronic, lifelong illness. There are two HSV serotypes. HSV-1 is typically thought of as the oral infection, HSV-2 as antigenital infection. However, antigenital herpes can be either HSV-1 or HSV-2. According to the CDC, seroprevalence of HSV increases with age, HSV-1 at a greater rate than HSV-2. Blacks are affected more often than whites, and antigenital herpes increases the risk for contracting HIV. Antigenital herpes can be transmitted sexually and perinatally. A person can also auto-inoculate themselves. A person with oral herpes can auto-inoculate themselves by touching their hand to their mouth and then touching their genitals. This is the most common mode of transmission in children. And a caregiver with oral herpes could touch their mouth and then touch the child's genitals, like in diapering or toileting or helping them bathe. Note the first clinical episode of antigenital herpes can be the primary infection or the non-primary infection with the virus. Primary infection is the patient's first-ever infection with HSV-1 or HSV-2. No antibody is present when symptoms appear, and the disease is more severe than recurrent disease. The first clinical episode can also be a non-primary infection, a newly acquired HSV-1 or HSV-2 infection in an individual previously seropositive to the other strain of the virus. Symptoms are usually milder than in the primary infection. Recurrent symptomatic infections typically are mild and of short duration. Antibodies are present when symptoms appear. Asymptomatic infections, the serum antibody is present without a known history of clinical outbreaks. In primary infection, lesions are typically very painful and systemic symptoms may be present. Note as the lesion progresses, especially as the ulcer dries and crusts, testing is less sensitive. So the typical lesion progression is that of a papule to a vesicle, then the vesicle ruptures and becomes a pustule and forms an ulcer and crusts. And once the lesion begins to crust, testing is less sensitive, especially culture testing. Recurrent infection tends to be less severe than primary infection. And typically, there are no systemic symptoms. Recurrent infection is more common with HSV-2 than HSV-1 infection. Now we'll talk about the CDC recommendations for sexually transmitted infection testing. Remember that in adults and children, the culture method of testing is no longer the gold standard. NAT testing is more sensitive and less likely to have false negatives. There is also an increased ease of specimen collection with collecting a dirty urine or a vaginal swab and an increased ease of specimen transmission. These are the latest guidelines by the CDC for adolescent and adult testing for sexually transmitted infections following acute sexual assault. Trichomonas, bacteriovaginosis, gonorrhea, and chlamydia are the most frequently diagnosed infections among women who have been sexually assaulted. Such conditions are prevalent among the population, and detection of these infections after a sexual assault does not necessarily imply acquisition during the assault. However, post-assault exam presents an important opportunity for identifying or preventing a sexually transmitted infection. Chlamydia and gonorrhea infection among adolescent and adult females are of particular concern due to the risk of ascending infection. And that being said, of course, if you have an adolescent patient or an adult patient who is not sexually active and test positive for chlamydia and gonorrhea, then certainly there's a concern that those infections were acquired during the sexual assault. Females should be offered NAT testing for trichomonas from urine or vaginal specimen. Regarding bacteriovaginosis and candidiasis, testing should be offered if symptomatic, especially if there's vaginal discharge, mild odor, or itching present. And the testing should be in the form of a point-of-care test or a wet mount. Culture testing for chlamydia, gonorrhea, and trichomonas is no longer the gold standard. NAT testing is more sensitive and less likely to have a false negative result. Men having sex with men should be offered screening for chlamydia and gonorrhea at the anatomic site of contact, even if the sexual assault did not involve oral or anal sex. But if men having sex with men have had oral or anal sex within the past year, then they should be offered testing for chlamydia and gonorrhea. A serum sample should be performed for HIV, hepatitis B, and syphilis infection. And this testing should be repeated in six weeks, three months, and six months. And a urine pregnancy test should be offered for females of reproductive age. These are the indications for sexually transmitted infection testing, specifically in children. NAT testing can be used to test for chlamydia, gonorrhea, and trichomonas in children. The CDC states that although data regarding NAT testing in children is limited and performance is test-related, no evidence demonstrates that NAT testing performance would differ in children than it does in adults. And that's true for chlamydia, gonorrhea, and trichomonas. And it's also true for extragenital sites, for the oral and anal testing as well. When the specimen is positive, results should be confirmed either by retesting the original specimen or obtaining another specimen. Only FDA-cleared NAT assays should be used. And here you see the various indications for STI testing based on the history given by the child or the injury or the concern of sexual abuse. Note the algorithm for syphilis testing. First, screen with a non-troponal test like an RPR or BDRL. If positive, confirm with a tromonal test like an EIA or a CLIA. Note the screening and confirmatory tests for HIV. When testing for hepatitis B, a hepatitis B antibody test is positive in individuals who have had the HPV vaccine. So when screening for the infection, draw a hep B surface antigen to screen for infection. And then note the screening and confirmatory testing for hepatitis C. HPV is diagnosed via visualization of the lesion. There is no diagnostic benefit to typing of the lesion. PCR is the preferred method of testing for HSV. PCR is a NAT test. It is more sensitive than culture. HSV culture is very specific but not as sensitive as PCR. You can have false negative testing. Serologies collected following acute sexual assault, as we talked about a couple of minutes ago, should be repeated in six weeks, three months, and six months. If a child tests positive for one sexually transmitted infection, they should be tested for all sexually transmitted infections. For instance, if a child tests positive for oral gonorrhea, the following testing should be completed, if not previously completed. Anal testing for chlamydia and gonorrhea, genital urine NAT testing for chlamydia, gonorrhea, trichomonas, and also HIV, RPR, hepatitis B, and C testing. And if a prepubertal sibling tests positive for a sexually transmitted infection, all children in the home should be tested for a sexually transmitted infection. And now we'll talk about adult, adolescent, and child acute sexual assault prophylaxis. There are new CDC recommendations regarding prophylaxis following acute sexual assault. As you know, ceftriaxone for gonorrhea, doxycycline is for chlamydia, and flagell for trichomonas. When providing prophylaxis for sexually transmitted infections, and this is in the adult and adolescent female, when providing prophylaxis for sexually transmitted infections, we also need to consider factors affecting a patient's ability to complete a seven-day course. Because we see, although the prophylaxis for gonorrhea remains a one-time injection, IM injection, although the dose of ceftriaxone has increased, the prophylaxis for chlamydia and trichomonas now involves a seven-day course of prophylaxis. So we need to consider factors affecting a patient's ability to complete a seven-day course. Later, we will discuss CDC-recommended treatment for a positive infection. And you'll see that one gram of zithromycin for chlamydia treatment and flagell 2 grams PO are listed as alternative treatment options. It's not ideal for prophylaxis. It's not what the CDC says is the ideal prophylaxis. But although it's not ideal, but in patients who state that they are unable to be compliant with a seven-day window of treatment, you may consider this with the caveat of counseling the patient that they need to be retested in three to four weeks to make sure that they are not indeed positive. Look at the treatment recommendations of the CDC for adolescent and adult prophylaxis. So the CDC recommends that adolescent and adult males who have experienced acute sexual assault receive prophylaxis for chlamydia and gonorrhea, but not trichomonas. In children, acute prophylaxis is not indicated for chlamydia, trichomonas, or gonorrhea because there is no risk of ascending infection. If there's a positive lab result for chlamydia, gonorrhea, or trichomonas, this holds very strong forensic value. So have the child return to the clinic to collect another specimen, retest that specimen, treat for the infection, and then the child should return to clinic in three to four weeks for a test of cure. The next few slides will explain how to assess HIV risk because HIV prophylaxis is indicated in cases of acute sexual assault or abuse of children, adolescents, and adults. This is the CDC algorithm to assist for HIV risk assessment following acute sexual abuse assault. First of all, HIV PEP must be initiated within 72 hours of the latest incident of sexual abuse or sexual assault. If it's greater than 72 hours, HIV PEP is not recommended. Note that there is negligible risk for HIV acquisition from exposure of the vagina or the rectum to saliva, regardless of the assailant HIV status. Is the assailant HIV positive? If yes, initiate HIV PEP. If there has been any exposure of the vagina, rectum, eye, mouth, or other mucous membrane to blood, semen, vaginal secretions, rectal secretions, or any body fluid that is visibly contaminated with blood, and this is when the source is known to be HIV positive. When the HIV status of the assailant is unknown, it is a case-by-case determination. So when assessing for HIV risk following acute sexual abuse, sexual assault, consider three things. The sexual act. Is there reason to believe that unprotected receptive anal intercourse, unprotected receptive vaginal intercourse, or unprotected insertive vaginal intercourse occurred. Also look at the perpetrator. Are they a known perpetrator, and are they known to be HIV positive. Are they known to engage in male on male sex, or be an IV drug user, or certainly if they're an unknown perpetrator if it's a stranger, then they could be HIV positive, and we wouldn't know that. And certainly, in cases of an individual being known to be HIV positive, or it's an unknown perpetrator, the risk for HIV transmission may be greater. However, many of the times, the perpetrator is known to the individual, but their HIV status is not known. And there isn't really any reason to believe that they engage in male on male sex or, or an IV drug user. Now if there's anogenital, if the victim or the perpetrator had anogenital injury and there was bleeding. The risk is also increased. So consider those three elements the sexual act, the perpetrator, and whether or not there's anogenital injury. Note the initial labs that should be drawn before initiating HIV PEP. Also a referral to an HIV or infectious disease specialist is indicated. HIV PEP must be initiated within 72 hours the latest incident of sexual abuse sexual assault, and must be taken for 28 days. The CDC recommends a three drug regimen, and you see those listed at the bottom of the slide. You can also combine drugs and so there, there are drugs that are combined and then the patient only has to take two drugs such as the scoping. These are for patients weighing greater than 25 kilograms and able to swallow pills. Also, it's important to realize that HIV PEP can cause nausea and diarrhea, so the patients will need an anti emetic and also consider an anti diarrheal medication as well. Note the HIV regimen treatment regimen for children. These patients will also need an anti emetic because actually these medications are more nausea producing than the medications that older individuals can take and also consider an anti diarrheal medication. Hep B prophylaxis is indicated in children, adolescents, and adults, following acute sexual abuse sexual assault. If the survivor is vaccinated, and no post vaccine testing was completed, the survivor should receive a happy vaccine, only one dose, no further prophylaxis is indicated. If the assailant is of unknown happy status, and the survivor is unvaccinated. They should the survivor should receive a happy vaccine, and then the vaccine should be repeated at one to two months, and four to six months. If the assailant is known to be happy positive, and the survivor is unvaccinated, the survivor should receive the happy vaccine and H hepatitis B Ig. And then the vaccine should be repeated at one to two months, and four to six months. HPV prophylaxis is also recommended in survivors between the age of nine and 26. If the survivor is 15 to 26 years of age, and there was no vaccination or incomplete vaccination, they should receive the HPV vaccine, and then in one to two months should receive the second HPV vaccine, and then six months, a third vaccine. The survivor is nine to 14 years of age, and has received no HPV vaccination or incomplete vaccination, they should receive an HPV vaccine, and then in six months, receive a second vaccine, and the third vaccine is not indicated. Now we'll discuss sexually transmitted infection treatment. Note CDC recommended treatment for chlamydia and adolescents and adults. If the alternative regimen is used the CDC recommends test of cure in three to four weeks. Note the CDC recommended treatment for chlamydia and pregnant women. Note the CDC recommended treatment for chlamydia infection and children. Do confirmatory testing prior to treatment. Do the legal and psychosocial consequences as a positive for chlamydia it would be genital or anal result. You may want to run a different confirmatory test on a NAT specimen, but you will need to collect another specimen and rerun the test. Also, follow up testing in three to four weeks for test of cure, especially in cases where it is unclear who the perpetrator is, is necessary to ensure clearance of the infection. Children testing positive for chlamydia need to be tested for other sexually transmitted infections, gonorrhea, trichomonas, HIV, syphilis, hepatitis B and C, and also report to Child Protective Services and law enforcement the positive chlamydia result. Note the CDC recommended treatment for gonorrhea infection in adults and adolescents. Note that the dose of ceftriaxone has increased. If ceftriaxone is not available for a treatment option for a positive gonorrhea result, you see the alternative regimens there. Test of cure should be obtained in three to four weeks due to possible resistance. Note the gonorrhea treatment recommendations in pregnancy. Ceftriaxone is the drug of choice for gonorrhea treatment. Note gonorrhea treatment in children. Again, it is weight-based. Again, you must test for other sexually transmitted infections, obtain a secondary specimen prior to treatment, obtain a test of cure in three to four weeks, and report the positive gonorrhea result to Child Protective Services and law enforcement. Note CDC recommended treatment for trichomonas. If a seven-day course of flagell is not positive, test of cure is recommended. Trichomonas should be treated in pregnancy, regardless of the pregnancy stage. Here we see the treatment recommendations for trichomonas in children. Again, it's weight-based. Again, we need to test for other sexually transmitted infections, and we need to obtain another specimen prior to treatment, obtain a test of cure in three to four weeks, and report the positive trichomonas result to Child Protective Services and law enforcement. Here we see the CDC recommended syphilis treatment in adolescents and adults. This is for primary, secondary, and early latent syphilis. Syphilis is a complex disease. If a positive syphilis result is obtained, especially in a child, consult with an infectious disease physician to ensure proper treatment and retesting. Certainly, a positive syphilis result should be reported to Child Protective Services and law enforcement, and the child needs to be tested for other sexually transmitted infections. Note the CDC recommended treatment for anagenital herpes. This is the recommended anagenital herpes treatment in adolescents and adults for the first clinical episode. In children, the treatment dose is weight-dependent, and typically, acyclovir is used. You'll also have to consider symptomatic relief because anagenital herpes is so painful. So you need to consider over-the-counter pain relievers and also encourage sitz baths. Now we'll discuss sexually transmitted infections and child sexual abuse. This is the interpretation of positive sexually transmitted infection results in children. Gonorrhea, genital, anal, oral gonorrhea. Chlamydia, genital or anal. Trichomonas, genital. Transmitted by sexual contact unless there is evidence of perinatal transmission. Remember, we talked about in gonorrhea, perinatal transmission typically clears in the neonatal period, so it clears by one month. Chlamydia clears by three years of age. Trichomonas, it's unclear how long perinatal transmission can persist, but one would expect it to clear by two to three years. So for the most part, gonorrhea, chlamydia, trichomonas infection in children transmitted by sexual contact. Syphilis is transmitted by sexual contact unless there is evidence of perinatal transmission or clearly documented but rare non-sexual transmission. HIV, transmitted by sexual contact if perinatal or blood transfusion transmission has been ruled out. Anagenital warts or anagenital herpes both may be sexually transmitted. Molluscum contagiosum is most likely not sexually transmitted. Anagenital warts or herpes. So anagenital warts or herpes can both be sexually and non-sexually transmitted when considering anagenital warts in children. Perinatal transmission with the high incidence of HPV infection in the adult population is a real possibility. You must ask the mother if she or her partner have anagenital warts. Has the mother ever had an abnormal pap smear? When was her last pap smear? Remember the HPV virus can spontaneously clear. So a mother with a negative pap smear could have had HPV during the pregnancy. The sexual abuse guru, Joyce Adams, states that an anagenital wart first diagnosed at age five years or older, there's a higher concern for sexual abuse. If a child or a caregiver of a young child has a wart on their hand or elsewhere on their body, they can auto-inoculate by touching the wart and then touching the genitals. Anagenital herpes, if the child has a history of oral herpes, they can touch the HSV oral lesion and then touch their genitals and auto-inoculate. Children with anagenital warts or anagenital herpes will need a forensic interview and you may need to report to Child Protective Services and law enforcement in order to obtain the forensic interview. But report with the caveat that both anagenital warts and anagenital herpes can also be non-sexually transmitted. You want to obtain a thorough medical history, talking about the other modes of transmission that we talked about earlier. Child needs an anagenital exam, child needs testing for other sexually transmitted infections, chlamydia, gonorrhea, trichomonas, HIV, syphilis, hepatitis B and C. Report to Child Protective Services and law enforcement definitely if the child gives history of sexual abuse, if the anagenital exam reveals acute or chronic trauma, or the child has another sexually transmitted infection. When considering anagenital warts, if the child was older than five when the first anagenital wart was noted, report to Child Protective Services and law enforcement with the caveat that HPV can also be non-sexually transmitted. In children with anagenital herpes and no history of oral lesions of herpes, report to Child Protective Services and law enforcement with the same caveat that anagenital herpes can also be non-sexually transmitted. Anagenital herpes can look like this. These are some examples of anagenital warts. Treatment for genital warts or anagenital warts in the adolescent adult female typically involves a referral to gynecology. Anagenital warts in the adult adolescent male treatment involves referral to dermatology or perhaps surgery if warts are near the anal opening. In pre-pubertal girls, genital warts, especially in the entritus, refer to pediatric gynecology. Like in this case, we would report to pediatric gynecology. If anagenital warts are external and not near the anagenital verge, refer to dermatology for treatment. Warts near the anal verge, such as these, may require a referral to surgery if there is a concern of internal warts. Take a look at syphilis lesions and note that the cankers can look like herpes and chondylomata lata can look like anagenital warts. This is why in children and adolescents and adults, with what looks like HSV or warts, we should also always test for syphilis. The World Health Organization has also recently released updated guidelines for diagnostic testing and treatment of sexually transmitted infections. The World Health Organization recognizes that in many low and middle income countries, laboratory testing resources may be limited. WHO recommends not testing for chlamydia, gonorrhea, and trichomonas, but also discusses the utility for rapid strip testing. Also, WHO recommends treating symptomatic individuals with urethral in a male or vaginal discharge for chlamydia, gonorrhea, or trichomonas when laboratory testing is limited. Note the World Health Organization chlamydia treatment recommendations in adolescent and adult females. Note the WHO gonorrhea treatment recommendations in adolescent and adult females, and the zithromycin and the cefoxamine are only if they had not been previously treated for chlamydia. Note the WHO recommendations in adult and adolescent females for trichomonas. Note the WHO sexually transmitted infection recommendations for treatment of gonorrhea, chlamydia, and trichomonas in adolescent and adult males. Note the WHO recommended genital herpes treatment, and these are in adolescents and adults, females and males. Note the WHO recommendations for syphilis treatment, and again, these are adult and adolescent. If you have any questions, please shoot me an email, and I will be more than glad to answer any questions. And here are the references used in this presentation. Thank you for joining in this online learning session.

2022 guidelines

STI testing

bacteria resistance

gonorrhea

chlamydia

revised methods

prevalent STIs

sexual assault

prophylaxis