Podcast: Disseminated gonorrhea and rising rates of STIs
Transcript
Dr. Blair Bigham: I'm Blair Bigham.
Dr. Mojola Omole: I'm Mojola Omole.
Dr. Blair Bigham: Happy Valentine's Day, Jola.
Dr. Mojola Omole: Happy Valentine's Day.
Dr. Blair Bigham: Isn't it suitable that today we're talking about the rise of sexually transmitted infections in Canada?
Dr. Mojola Omole: Yes. I'm really excited about this topic because it really starts off very small in terms of focusing on gonococcal endocarditis. And basically we're able to expand that and have a fulsome discussion about public health around STIs.
Dr. Blair Bigham: Absolutely. Going from a very specific and rare case, that I've never seen in my career yet, albeit very young, to some general topics. We're even going to encroach on syphilis and a few more things.
Dr. Mojola Omole: Yes, it seems that Manitoba is higher in terms of those infections. And so I'm curious to talk to the author today about why this is.
Dr. Blair Bigham: Absolutely. And being in an urban emergency department in Downtown Toronto, we see this very, very often. And it's associated with all sorts of other concerns and social challenges. And so I'm very curious to see where we're going with these rising rates in Canada and how we can really turn this around. And I don't know about you, Jola, but I was a little bit surprised that even with the pandemic this stuff was rising. I would've thought that maybe Tinder and Grindr and apps that might help facilitate the spread of STIs might have collapsed during the pandemic. But that doesn't seem to be the case. I was surprised by that.
Dr. Mojola Omole: [groan].
Dr. Blair Bigham: Oh, come on. That's totally fair game.
Dr. Mojola Omole: That's a very true point. Part of what's not... That we can have a more fulsome conversation about is whether it's social behaviors or societal structures that are causing there to be an increase in all STIs, but especially gonorrhea, would be very interesting.
Dr. Blair Bigham: And Jola, I have a little bit of a selfish goal here. I'm super curious to learn later in the show, when we talk to someone from the BC Centers for Disease Control about exactly how we should be testing for these conditions, especially gonorrhea. In the UK, when I was there, nobody wanted to co-treat with ceftriaxone if you had suspected chlamydia. They actually would go to the trouble right in the lab of going ahead and putting your urine on a slide and looking for diplococci. And if they didn't see it, you didn't get ceftriaxone because their resistance rates are so high. Then when I went to New York City, they thought I was crazy trying to differentiate clinically an infection, and they just gave everybody ceftriaxone just in case they had a gonococcal infection. And so I'm very curious what I should be doing in the emergency room when somebody shows up either with or without symptoms, or maybe they just have risk factors. I can never keep the guidelines straight.
Dr. Mojola Omole: So this is a great point for us to start. And let's start with our first interview with the author, Dr. Carl Boodman.
Dr. Mojola Omole: Dr. Carl Boodman is an infectious disease specialist and a medical microbiology fellow at the University of Manitoba. Welcome, today. How are you doing?
Dr. Carl Boodman: I'm doing well. Thanks, Jola.
Dr. Mojola Omole: So you begin with the story of one patient. Walk us through the case.
Dr. Carl Boodman: Sure. So this is a 54-year-old man who was really referred to hospital by his family doctor who heard a new murmur. And there had been some things changing with this patient over the previous couple of weeks. He had new onset arthritis and that came on quite suddenly and was atraumatic, so no trauma before. And there were some other more subtle changes, a little bit of low grade fever before. And then, on doing a physical exam, the family doctor noticed a quite substantial new murmur. He was then referred to an acute care hospital and the cardiac center here in Winnipeg is St. Boniface Hospital. And at that point, he actually did deteriorate quite quickly afterwards, with what we later found out was endocarditis and aortic valve insufficiency and heart failure - and needed therapy, both antimicrobial supportive management, as well as surgical interventions to keep him alive. And then he made a great recovery, but it was worrisome throughout the process.
Dr. Mojola Omole: So this was a very advanced phase of the infection from what you've been describing. Why was it not detected earlier? Were there not any local symptoms of gonorrhea?
Dr. Carl Boodman: So there weren't. And this is actually common.
Dr. Mojola Omole: Really?
Dr. Carl Boodman: Yeah. In most cases of disseminated gonococcal disease... Endocarditis is a rare, a severe manifestation of disseminated gonococcal infection. But, in most cases, people don't have any symptoms at the site of sexual activity. So people assume that if you have gonorrhea - and whether it's the urethral or the vaginal mucosa cervix or the throat or rectum - that you'd have symptoms. That's actually not the case. We know that probably 60, 70 [per cent], the majority of people do not have symptoms.
Dr. Mojola Omole: Oh, wow.
Dr. Carl Boodman: And it might be even more likely in people who get disseminated gonococcal infection, maybe because people, if they have symptoms, they present to hospital, they present to care, they get treated and then the bacteria doesn't have time to disseminate. So it's actually more the rule that people with disseminated gonococcal infection will not have had symptoms of urethritis or any kind of inflammation symptoms at the site that they have sex. And I say this broadly, because people have sex in different ways.
Dr. Mojola Omole: What are some other examples of disseminating gonorrhea? We talked about endocarditis with this patient. What are some other manifestations of disseminating gonorrhea?
Dr. Carl Boodman: That's a great question. So the kind of quintessential one is this triad of polyarthralgia. So arthralgia: some pain in the joints, but not like a frank arthritis; tenosynovitis, which is inflammation around the tendons, and it's often in the wrists or the fingers or the ankles; and then also a rash. And that rash, sometimes it's pustular, it can look like different things, but quintessentially it's this triad. The other kind of manifestation of disseminated gonococcal infection is this frank septic arthritis. So one joint is really painful and swollen, people are not walking on it. But the triad, with the arthritis, people usually can still hobble in. And then there's all kinds of other manifestations. Endocarditis is severe. Meningitis is severe. And those are all rare in the post-antibiotic era. Before 1945, gonorrhea might have been historically one of the more common causes of endocarditis, but that's historical.
Dr. Mojola Omole: So, I think part of... Just to get it to wrap around my head, is that part of preventing disseminating gonorrhea is people have equal access and ready access to treating gonorrhea period, right?
Dr. Carl Boodman: Exactly. That's exactly correct, Jola. So it's a matter of treating it, but also identifying it. And as I mentioned, a lot of people are asymptomatic. So when we're talking about a disease of public health importance, it's a matter of finding ways of engaging people with primary care and a trusting relationship in primary care, and then doing screening, whether they have symptoms or not. And then providing treatment when the test is positive. Now, on a population level that will help decrease the rates of transmission. And then the cascade will be there'll also be less of these very severe manifestations that we're starting to see.
Dr. Mojola Omole: So what would a primary care physician... Who should they be screening?
Dr. Carl Boodman: Basically anybody who's sexually active. Doesn't matter.
Dr. Mojola Omole: So everybody?
Dr. Carl Boodman: Yeah, everybody who's sexually active should be screened. There are some guidelines, I think even CMAJ might have published some recently, but there are some guidelines that suggest generally younger people, but most sexually active adults should be screened once a year. I think that approach makes sense. And then for people who have multiple sexual partners, then screen them more often. And obviously, if there's any contact with a case, screening then too. And so I think just relatively routine screening. And the important part is also screening at the site of sexual activity. So having a conversation about how people have sex, and then doing a Nucleic Acid Amplification Test. So that's your standard test for gonorrhea and chlamydia. Sampling that at the site at which people have sex.
Dr. Blair Bigham: Carl, when it comes to sampling, what's the best way to do that? Can people self swab? Are we supposed to do the swab ourselves? I heard all sorts of different ideas in residency. What's the best approach that you use to make sure that you get the sample you need?
Dr. Carl Boodman: That's a great question. There's different ways of doing it. So there's a lot of good evidence for self-swab if someone's interested in doing that. There's also the first pass urine is one possible means of testing, which is less invasive as well. For pharyngeal stuff, usually it's harder to self swab because people don't like making themselves gag. So generally, if you're worried about pharyngeal gonorrhea, then a self swab probably wouldn't work. And then also for rectal, self swab can work, but often it's a practitioner who does it. I think, in this context, the most important thing is thinking about it and testing at the right site. And exactly how the testing happens, there are pros and cons, but at a population level, I think the big issue is just doing more screening and engaging people in the conversation and just knowing that you're screening the right area.
Dr. Blair Bigham: And then for disseminated, it would be blood cultures every time?
Dr. Carl Boodman: That's correct. Blood cultures, but also still testing asymptomatic areas where people have sex. So blood cultures, we see a lot of positive blood cultures, but actually blood cultures are not very good for Neisseria gonorrhoeae. So the neisseria is a little finicky and it sometimes dies in the lab for no reason. We catch it a fair bit, but there's a number of cases where people do have disseminated gonococcal disease and the only way you're diagnosing it is they have the clinical syndrome and you have proof of gonorrhea at the site of sexual activity. And the clinical syndrome is clearly disseminated gonococcal disease. And even with blood cultures, those are sometimes negative. But the important part is, yes, every time you consider disseminated gonococcal infection, draw blood cultures, draw them before antibiotics, so that's important, and also take a sexual history and try to sample it from the site of sexual activity.
Dr. Blair Bigham: Carl, let's go to something a little bit more common that people might see in their clinic or their emergency department or their general practice, is people who have symptoms of a sexually transmitted infection. What is the best workup at that time? In the emergency department, I never order HIV and syphilis. I don't do the whole workup. I sort of say, "Well, you should just go to a sexual health clinic and we'll just treat you now." And I feel like I'm passing the buck. I know that a lot of people probably aren't going to go to the clinic and getting their full workup, but it's just not something we tend to do in the emergency department very often.
Dr. Blair Bigham: What's the best route when you're first seeing these patients? How much testing should you do? And then what is the best treatment? Are you always giving the azithro as well? I know that in this case, the gentleman got a gram of azithromycin. Can you just refresh my memory on when to do the ceftriaxone, when to do the azithromycin, when to think about maybe other medications, and then what am I supposed to test for when I first meet these people?
Dr. Carl Boodman: Great questions. So I'll start with the first one.
Dr. Blair Bigham: Sorry, that's probably it's own podcast right there.
Dr. Carl Boodman: No, these are great. And the only reason I mentioned that they're great questions is the fact that there's actually a shifting landscape. So the US guidelines are different than the Canadian ones. But I'll go into that in a second. But first, if you're suspecting sexually transmitted infections or sexually transmitted and bloodborne infections and people have risk factors, or they just haven't been screened recently, I just do them all. And I do them also in the emerg. We've caught a lot of new HIV diagnoses, syphilis diagnoses through the emerg. And people would present for something else and they may be struggling with substance use disorders of some type, or they have some other risk factor, or they just haven't been screened in a while and we catch a lot that way. And then it's a way of also linking them into care. And there's also public health contact tracing as well.
Dr. Carl Boodman: And in some places, like where I trained in Vancouver, it's an opt-out system. So if someone presents to care, you don't actually need to get consent to test for these things. There's a big sign on the door and it's an opt-out. So you just go ahead and test, tack them onto your CBC and whatever else. And in other jurisdictions you have to have a conversation. And I know probably for emerg docs that extra minute or two will slow you down and that could be a barrier. But I would say, if you can, test right off the bat.
Dr. Blair Bigham: The other barrier in the ER, for me, I'm sure family docs feel this as well, is that you don't get your test result back right away. And as a family doctor, I guess you can call people up later. But as an emerg doc with episodic care, I feel like it's my only window to treat. Should I be treating people before I have their results, just because they have risk factors and symptoms?
Dr. Carl Boodman: It kind of depends. And I'll just mention one thing about the follow up. So there's an integrated public health laboratory and public health follow up. So even earlier today, or this afternoon, I'll be at the public health lab. All of those new HIV diagnoses are forwarded to public health, are communicated to the HIV team. So even if you were doing a locum, you tested one person and moved to a different country, there's still a structure in place to try to connect people with new -especially new HIV diagnoses - but new sexually transmitted and blood born infections to care.
Dr. Mojola Omole: Wow.
Dr. Carl Boodman: And so even if you personally don't follow up or your emerg doesn't follow up, there is a system in place to actually follow up with patients. So that's an additional reason to treat, or to test rather. Now for your question about empiric treatment. So, if they have a contact, sure. Usually public health does this independently and people don't need to present to emerg for this. I usually screen. There's issues with antimicrobial resistance and stuff like that. So if they have a clear contact, then empiric contact testing and treatment, but often empiric treatment before you get the result is fine. If they don't have a contact and they just haven't been screened in a year, I wouldn't give IM ceftriaxone to everybody who walks in the door. So I'd say screen. Don't treat, unless they have a clear contact. Usually public health does this. But go ahead and do the testing. And there is a system in place to help follow up. And so not all of that relies on your shoulders.
Dr. Blair Bigham: Even if they have symptoms, just leave it to public health?
Dr. Carl Boodman: Oh, if you have symptoms then yeah. If you have symptoms of urethritis, the kind of classical symptoms? Yeah, then I would go ahead and just treat people. Obviously testing for the mimics, like urinary tract infection, trichomoniasis, all these other things. But yes. And so, in Canada, you were talking about the treatment guidelines, for uncomplicated gonococcal disease urethritis, and often if you haven't excluded chlamydia, yet you give 250 milligrams IM, intramuscular, of ceftriaxone, once. You give one gram of azithro at the same time. That's for two reasons, one is to try to prevent some emerging gonococcal resistance and also to concomitantly treat chlamydia if it's there.
Dr. Carl Boodman: Now in the States, just in the last year, they've changed their guidelines. They do away with the azithro. They give a higher dose of ceftriaxone. It's 500 milligrams IM once. If you've excluded chlamydia, you do not need to treat it. If you haven't excluded chlamydia, then they go with doxycycline for a week. In Canada, we haven't yet. And there's different epidemiologic and resistance patterns. So I don't know if we'll follow suit. But I just want to mention that the States and Canada have different guidelines at this point. They may converge in another couple of years.
Dr. Mojola Omole: Thank you.
Dr. Carl Boodman: Oh, it's a pleasure.
Dr. Mojola Omole: That was Dr. Carl Boodman. He is an infectious disease physician at University of Manitoba and currently a medical microbiology fellow.
Dr. Blair Bigham: Jola, we had an amazing conversation with Dr. Boodman after we stopped recording. And it turns out that disseminated gonorrhea is just the tip of the iceberg. To help us understand the wider problem of rising STIs, we turn to Dr. Jason Wong, a public health and preventive medicine specialist in British Columbia. He's also the associate medical director for the Clinical Prevention Services Division at the BC Center for Disease Control. Welcome.
Dr. Jason Wong: Hi, thanks so much.
Dr. Mojola Omole: I didn't know that we had a CDC in Canada. Just FYI.
Dr. Jason Wong: BC CDC.
Dr. Blair Bigham: BC CDC.
Dr. Mojola Omole: BC CDC. I still think it's cool.
Dr. Jason Wong: Yes, we often differentiate, say CDC Atlanta so that people are clear which CDC we're talking about.
Dr. Mojola Omole: Cool.
Dr. Blair Bigham: Very exclusive. So Dr. Boodman was saying that he's seeing more cases of disseminated gonorrhea. How surprising is that to you?
Dr. Jason Wong: Well, we certainly have been seeing many of our bacterial STIs rising, I would say in British Columbia, but also in Canada. Specifically for gonorrhea, we have seen some dramatic increases over the last decade. So I'll speak for British Columbia where cases have essentially doubled over the last decade. So it really has increased dramatically. And maybe just for some comparison, chlamydia, which is another bacterial sexually transmitted infection, has only been increasing about 5% per year. So you can really see a bit of a contrast between how chlamydia has been rising, but also gonorrhea.
Dr. Blair Bigham: So rising STIs has been in the media recently, but how can it get so bad that you have disseminated gonococcal infections on the rise?
Dr. Jason Wong: The disseminated gonococcal infections, I think Dr. Boodman spoke to this, and those are still quite rare occurrences of gonorrhea. So I think in his paper, he reported about 75. Most of the gonorrhea infections really are due to sexual activity. So they're typically seen in urethral sites, cervical sites, rectal sites, and pharyngeal sites. So those really make up the vast majority of the gonorrhea infections that we see in British Columbia. So disseminated gonorrhea is still fairly rare, I would say, across Canada,
Dr. Blair Bigham: You were saying that chlamydia is going up around 5% a year. What's going on the ground in British Columbia with gonorrhea, how quickly is it rising?
Dr. Jason Wong: So they've gone up from about 1,200 cases about 10 years ago to about 3,600 cases in 2020. So they have gone up quite a bit. But just to give you some more context. So chlamydia is where we still see most of the infections. So we do see about 12 to 13,000 cases of chlamydia per year. So gonorrhea is still quite a bit rarer than chlamydia. But it is just that rate of rise to note here. And the other one maybe I'll mention here at the same time or in the same breath is around syphilis, which is the third bacterial sexually transmitted infection that we often talk about. And so syphilis has increased even more dramatically than gonorrhea. And so for syphilis in BC, we've seen an eight fold increase since 2010. So for 2021, we are reporting up to almost 1,500 cases of infectious syphilis in British Columbia, up from about 154 in 2010 when it was at its trough here.
Dr. Mojola Omole: Wow.
Dr. Blair Bigham: Now those infections are on the rise, but HIV is not, it's actually declining. Why is that?
Dr. Jason Wong: Yeah. So in BC, HIV has been decreasing at about 5% per year, over the last 10 years. And I would say there's a lot of reasons for that. One, I think there were a lot of efforts around prevention. So condom use, for example, was one of the things that was touted as one of the ways that people could prevent HIV and other sexual transmitted infections. And so that was, I think, one of the reasons that we saw some HIV declines. But we also have additional strategies here to try to prevent HIV as well. So pre-exposure prophylaxis, for example, is one of the more recent technologies that have been implemented. And so in BC, we do have a publicly funded HIV pre-exposure prophylaxis program, which does enable people to access this, which we know is very effective at preventing HIV. But I would say there are a number of other strategies too.
Dr. Jason Wong: So in BC we also recommend routine testing for HIV. And so one of the goals that we have from this program was to identify people living with HIV earlier, in order to get them access to treatment. And we do know that early access to treatment, one, improves the person living with HIV their health outcomes. But secondly, it also does allow us to reduce their viral load quicker, which does also reduce transmission. So those are just some of the examples of some of the strategies that we have here. The third thing I might say, which I think is really important, is around how we try to destigmatize HIV. And so there are some efforts to try to do this proactively. But in BC, I do think one of the things that has helped destigmatize HIV is this routine screening for HIV. And so it becomes part of routine care as opposed to having to ask people for their risk factors for HIV. And so that's just, to me, a little piece of the puzzle that helps de-stigmatize or demystify HIV in the community.
Dr. Blair Bigham: You say routine screening, what does that entail? What does it mean?
Dr. Jason Wong: So in BC, our recommendations for HIV testing is that people who are 18 to 70 years old, we recommend that they get tested every five years. And maybe I should actually preface this by saying the overarching goal is that healthcare providers know the HIV status of their patients. And so in order to do that, we recommend that people 18 to 70 years old have HIV tests every five years. And populations that are disproportionately affected by HIV so gay, bisexual, men who sex with men, people who inject drugs, for examples, we recommend that they get tested for HIV routinely. But the third thing I would say is to remind clinicians, to include HIV as part of their differential diagnosis. And so if they are working up a new or worsening condition that they consider HIV infection and actually order an HIV test in order to rule out HIV infection.
Dr. Blair Bigham: So does every 18 to 70 year old who gets admitted to hospital in BC who doesn't have an HIV record on file in the last five years get an HIV test as part of their admission blood work?
Dr. Jason Wong: Well, those are the recommendations. And so how that translates in practice, it may vary. But certainly there has been investments and education to try to encourage people to, again, think about HIV infection and to routinely order HIV tests for individuals. And so we do know that has had an impact. And so in BC, we do monitor for HIV testing volumes and we have substantial increases in HIV testing since this program was implemented.
Dr. Mojola Omole: And primary care physicians have access to this also, correct?
Dr. Jason Wong: Well, yes. It is part of our routine lab requisition form. So primary care providers and other clinicians can all order HIV testing.
Dr. Blair Bigham: Jason, during the pandemic, I would think that the type of encounters that lead to STI prevalence would go down. Why do you think STIs are on the rise?
Dr. Jason Wong: Well, so I think there's two pieces to that. So I think part of the question is, "What is happening with STIs overall?" And so I think there are a number of theories that we have around this. But I think one of the reasons is increased testing. So we do know that many STIs don't have symptoms. And so people may not know that they actually have an STI unless they get tested. And so changes in recommendations or how often people get tested, it does lead to more diagnoses of STIs. So I think that's one component of it. And so maybe just as an example, so one of the things that we recommend for people who are on HIV pre-exposure prophylaxis is that they routinely get screened for STIs. And so that would be one example of how screening may actually be increasing diagnoses for sexual transmitted infections.
Dr. Jason Wong: But there's other pieces as well as to why STIs may be rising. So the other piece is whether there may be some changes to behaviors. And so I spoke in the beginning around condom use is one of the preventions that we can have for sexual transmitted infections, but we know that not everybody likes using condoms. And so some of the ways in which HIV pre-exposure prophylaxis has reduced risk of HIV transmission, and so some people are feeling more comfortable with having sex without a condom. And so there are these changes that may be happening as well that may also be increasing sexually transmitted infections. So these are all really important theories that we're all still continuing to contemplate. At the end of the day, it probably is a mixture of all of these different factors that are contributing to the increases in sexual transmitted infections.
Dr. Blair Bigham: Can we use any of the lessons from the success of prep and the HIV decline to other STIs?
Dr. Jason Wong: Mm-hmm . We have seen that HIV pre-exposure prophylaxis has been a very acceptable and feasible strategy that people are very willing to use. So taking a pill a day. And so one of the ideas that we've had is whether or not a similar approach could be used to prevent sexually transmitted infections, like bacterial sexually transmitted infections. And so there was a pilot study that was done in Los Angeles several years now, which did find that daily doxycycline was effective. It was statistically significant in reducing overall bacterial sexually transmitted infections. It was not statistically significant for syphilis, which is one of the ones that we're most concerned about because of its rapid rise as of late. But also because of the complications due to syphilis.
Dr. Jason Wong: And so one of the things that we've launched here is a research study trying to look at pre- as well as post-exposure prophylaxis using doxycycline to see if that may actually prevent bacterial sexually transmitted infections, so chlamydia, gonorrhea, and syphilis. But we are particularly interested to see if that might be another tool in our toolbox to prevent sexually transmitted infections. So there are some of these learnings that we've had from HIV and trying to transfer those into other sexually transmitted infections in order to see if those same strategies might work as well.
Dr. Blair Bigham: That's so interesting.
Dr. Mojola Omole: Would daily doxycycline not lead to antibiotic resistance?
Dr. Jason Wong: So I think that's definitely one of the big concerns that we have using a daily antibiotic like doxycycline. We do know that doxycycline is used for prevention of other types of infections, so malaria, for example. So there is some history and precedent to using doxycycline daily. But I think the concern for antimicrobial resistance is a very important issue. But the other aspect I think I would mention is we are not talking about broad use of doxycycline. We are trying to identify people who are at highest risk for sexually transmitted infections or reinfection of sexually transmitted infections. And so wanting to ensure that we are targeting our interventions for people who are most likely to benefit and least likely to confer these types of population level impacts like antimicrobial resistance that we might be worried about.
Dr. Blair Bigham: I want to bring this down to the front lines. If you're a busy emergency doctor or a very busy primary care doctor running a clinic, what should you be doing? Who should you be looking out for? Who should you be screening? And then who should you be treating?
Dr. Jason Wong: Yeah, so I would say one of the things that I would encourage people in primary care, for example, and family medicine to do is to have some of these conversations with your patients. So ask them about their sexual activities, whether they've had new sexual partners, the type of sexual activity that they participate in. Because that does transfer to the risk of having sexually transmitted infections. So broadly speaking, people who have new partners or who have multiple sexual partners or people who have symptoms that are consistent with sexual transmitted infections, we do recommend that they get screened or tested for sexually transmitted infections.
Dr. Jason Wong: And so I think we do know that many people, possibly the majority of people, don't actually have symptoms of sexually transmitted infections. And so the only way really to know is to have testing. And so the biggest piece, I would say, is to have those conversations and to try to normalize those types of conversations with your patients so that they feel comfortable speaking to you as their healthcare provider and to make informed decisions as to how often they should be screened for sexually transmitted infections.
Dr. Blair Bigham: And so screening is really the key. These are sneaky organisms.
Dr. Jason Wong: Yeah, well screening definitely is one of the key pillars that we have. But social context and stigma are also a part of that conversation, part of those drivers of sexually transmitted infections. So I really do think that frontline care providers like family doctors really play a really critical role in understanding sexual health and sexual wellbeing, and also trying to meet some of those other social needs that people have. So things like social supports, and housing, and these types of aspects that really do support the overall wellbeing of an individual.
Dr. Mojola Omole: So a family doctor should screen everybody in terms of at least screening questions or tests in terms of sexual activity and for STIs. Is that correct?
Dr. Jason Wong: Yeah. So family physicians should be speaking to their clients and their patients about sexual health and their sexual activities and recommending screening as appropriate. So somebody who is in a monogamous relationship may not need screening as often as somebody who may be having multiple partners or sequential partners or ...
Dr. Mojola Omole: Sometimes you think you're monogamous, but you're not.
Dr. Jason Wong: I think this comes down to having that trusting relationship with your provider. Certainly, I think we do know that things happen and people may have or believe some things, and they may not actually be true. But I think for the most part, most people do know their partners quite well, and their risk is aligned with their knowledge of their partners.
Dr. Blair Bigham: Jola is trying to ruin Valentine's Day for us.
Dr. Jason Wong: Yes.
Dr. Mojola Omole: I just feel like Jason has young love in his heart because I'm like, "You don't know people. They're horrible." Just joking.
Dr. Blair Bigham: Jason, any last thoughts on how we can protect vulnerable populations from these rising infections?
Dr. Jason Wong: Well, I would say, one of the things that we're trying to work towards is having more patient centric care. And so I think what that means for us is thinking about... My work is in primarily sexually transmitted and bloodborne infections, but fully recognize that this is not the only thing that people are thinking about and that there is, one, multiple infections, but also like there are other aspects to life and their wellness. And so this is what we're talking about when we talk about things like syndemic based care. So syndemics is a theory in which multiple epidemics can be exacerbated or reinforcing one another.
Dr. Jason Wong: So thinking, for example, of how mental health and substance use might also intersect with sexually transmitted infections. And so I think one of the things that we will want to move towards is thinking about the whole patient type kind of a care, and that sexual health and STI care is just a piece of that. And so wanting to make sure that there are other supports, like social supports, and care for other coexisting conditions that are also part of that wellbeing and approach to the patient. So I think that is the type of movement that we're trying to move towards. And I think one of the reasons why collaborations, engagement with primary care and other clinicians and healthcare providers but also allied healthcare providers are really important for patients.
Dr. Blair Bigham: Jason, thank you so much. That's a great place for us to pause. We really appreciate your time.
Dr. Jason Wong: Great. Thanks so much for having me.
Dr. Blair Bigham: Dr. Jason Wong is a public health and preventive medicine specialist and the associate medical director of clinical prevention services at the BC Center for Disease Control.
Dr. Blair Bigham: (silence)
Dr. Mojola Omole: So Blair, this has been a really great episode talking to both Dr. Boodman and Dr. Wong about the rise of STIs, especially syphilis and gonorrhea in Canada. What are some of your initial thoughts that you're having?
Dr. Blair Bigham: I think just reflecting on how I practice now. The emergency department is so busy right now. The pandemic has just caused complete chaos. And I know that I'm under-testing. I'm not getting the syphilis blood work done. I'm not doing HIV testing. And I actually very rarely, I think, compared to maybe what other people do, test for gonococcal infections and chlamydia. Because, at my hospital, we don't get those tests back the same day. And so I think I have this habit, we're just so busy, of saying, "Look, I'll test you for what I need to test you for. I'll treat you for what I need to treat you for. But you need to go to a sexual health clinic and get this sorted out properly."
Dr. Blair Bigham: And I think that with the pandemic, I don't know that people are actually going to that follow-up. And so I think that this is a wake up call for me to make sure that I'm offering testing at the point of interaction to make it easy for people, and considering treatment more frequently than what I'm doing now. I think I'm over relying on other parts of the healthcare system to get this right.
Dr. Mojola Omole: It seems that that's a very clear point that screening, screening, screening, testing, testing, testing, and those two areas are very important in terms of preventing disseminating forms of these sexually transmitted bacterial infections.
Dr. Blair Bigham: And testing in the right place as well.
Dr. Mojola Omole: Yeah.
Dr. Blair Bigham: I think I send off a urine NAAT, but I very rarely ask about swabbing throats and rectums. And that's a default habit of just being in a very busy place. I'm seeing patients in hallways and chairs. I can't have these private conversations. And so I just defer to public health and the sexual clinics, which I think access to those is just so hard.
Dr. Mojola Omole: Yeah. I think it's really important that, as always, our family physicians are the backbone of our healthcare system. And it seems also, when we're talking about STIs, that they're still the backbone of it in terms of having that rapport with their patients to have the sexual history. And one thing that really stood out for me from both Dr. Wong and Dr Boodman was that you just screen everybody and you test everybody. There's no stigma of, "Well only this population should be tested." The assumption is anyone who's sexually active between 18 and 70… I would argue there might be some very active over-seventies… but all of them should be screened and, if appropriate, tested. And so that was a really important point.
Dr. Mojola Omole: And one thing that Dr Boodman and Dr. Wong touched a bit about was the fact that the social determinants of health really do drive these conversations. This seems to be a continual theme with our podcast: what we're noticing is that really social determinants of health… Both of us are specialists, and my job is to cut things out and your job is to fix things and diagnose things. But really, what really makes the most impact is addressing some of the social determinants of health.
Dr. Blair Bigham: Especially, and like Jason was saying, these syndemics, these overlapping epidemics of mental health, of drug use, of crystal meth, of STIs, they all go hand in hand and affect crossover populations. If you drew a Venn diagram of who gets this infection and who gets this infection and who has mental health problems, those Venn diagrams would probably overlap an awful lot. And I think often they're overlapping in populations that we can all predict need a more robust social safety net.
Dr. Blair Bigham: That's it for this week's episode of the CMAJ Podcast. It is Valentine's Day. If you love us, we'd really appreciate you rating or sharing this podcast through whatever platform you're using. It goes a long way to helping us get out the message. I'm Blair Bigham.
Dr. Mojola Omole: I'm Mojola Omole. Stay well until next time.