“Go Get Tested” Gonorrhoea and Chlamydia Initiative

Report to: Chair and members of the Board of Health

Meeting Date: December 7, 2016

Report Number: BH.01.DEC0716.R24

Prepared by: Rosalyn LaRochelle Manager, Clinical Services

Approved by: Rita Sethi Director, Community Health and Wellness

Submitted by: Dr. Nicola J. Mercer, MD, MBA, MPH, FRCPC, Medical Officer of Health & CEO

Recommendations

It is recommended that the Board of Health:

1. Receive this report for information.

Key Points

Requesting testing for sexually transmitted diseases can be embarrassing. As adults re-enter the dating scene, easy access to testing and counseling is essential as rates of both chlamydia and gonorrhea are on the rise. Of particular public health concern is the detection and treatment of Gonorrhea as treatment options are becoming limited due to antibiotic resistance.
Go Get Tested is an easy, anonymous on-line option for chlamydia and gonorrhea testing. By downloading a lab requisition and providing a urine sample at a local Life Labs, testing can occur without the need for direct interaction with a family physician. Follow-up counseling and treatment to positive tests is provided by nurses specializing in sexually transmitted infections.

Discussion

Gonorrhea
Gonorrhea rates continue to rise both internationally and within Canada. Locally, rates of gonorrhea doubled from 2013 to 2014, dropped slightly in 2015 and are showing an increase over 2014 in 2016. In 2013, the Ontario testing and treatment guidelines for gonorrhea were changed due to increasing antibiotic resistance. Following the release of the guidelines there was an initial improvement across the province in resistance patterns. More recently, however, there has been an increase in the number of cases in the province with antibiotic resistance. There have been no treatment failures reported within Wellington-Dufferin-Guelph Public Health (WDGPH).
Gonorrhea is the second most commonly reported sexually transmitted disease in Ontario. It is a bacterial infection that is most commonly spread through vaginal, anal and oral sex, but can also be transmitted from an infected mother to her baby during childbirth.
If left untreated, gonorrhea can lead to a number of complications in women (eg. Pelvic inflammatory disease, infertility, ectopic pregnancy, chronic pelvic pain) and in men (eg. epididymo-orchitis, and infertility).1
A review of the local gonorrhea infections of year to date data for 2016:

  • There is an increase in cases for individuals 15 years of age and older (Table 1)
  • Increase in presence in rural areas and Dufferin County.
  • Majority of cases are male, however, the number of cases seen in women is increasing over the last year. (Table 2)

Table 1 (based on information up to November 14, 2016)

Table showing Lab-Confirmed cases of Gonnorrhea by Age Group and year.

Data Table 1:

Lab confirmed cases of Gonorrhea by age group from 2011-2016 in WDG
  2011 2012 2013 2014 2015 2016
Age 50+ 2 4 6 7 5 3
Age 25-49 24 26 14 44 43 43
Age 20-24 5 8 7 15 14 20
Age 15-19 0 0 1 1 1 8

Table 2 (based on information up to November 14, 2016)

Table showing number of conformed Gonorrhea Cases by Gender from 2011-2016

Data Table 2:

Confirmed Gonorrhea cases by Gender 2011-2016 in WDG
  2011 2012 2013 2014 2015 2016
Male 41.9% 44.7% 57.1% 63.6% 67.2% 54.8%
Female 58.1% 55.3% 42.9% 36.4% 32.8% 45.2%

Risk factors for gonorrhea continue to be:

  • Sex with opposite sex
  • No condom use
  • New partner in past 2 months

Chlamydia
Chlamydia is most common reportable sexually transmitted infection and is often asymptomatic which can result in delayed diagnosis and treatment. The number of chlamydia infections, similar to gonorrhea, also continues to rise. In WDGPH from 2013 to 2015 the number of infections increased locally by 37%. As of November 2016, WDGPH has experienced a further 17% increase in rates from 2015.
If left untreated, chlamydia can lead to epididymo-orchitis in males, and pelvic inflammatory disease, ectopic pregnancy, infertility, and chronic pelvic pain in females.2 Chlamydia is treatable with antibiotics and unlike gonorrhea is not at risk of losing treatment options due to resistance.
A review of the local chlamydia infections of year to date data for 2016:

  • Largest number of cases occur in people under the age of 30 years old. (Table 3)
  • Majority of cases are remain consistently female. (Table 4)

Table 3 (based on information up to November 14, 2016)

Table showing number of lab-Confirmed Cases of Chlamydia in WDGPH from 2011-2016

Data Table 3:

Lab confirmed cases of Chlamydia by age group from 2011-2016 in WDG
  2011 2012 2013 2014 2015 2015
Age 50+ 12 16 9 5 14 14
Age 25-49 481 377 300 281 250 206
Age 20-24 158 185 178 340 377 327
Age 15-19 0 7 21 27 62 116

Table 4 (based on information up to November 14, 2016)

Table showing percentage of confirmed Chlamydia Cases by Gender in WDGPH from 2011-2016

Data Table 4:

Confirmed Chlamydia cases by Gender 2011-2016 in WDG
  2011 2012 2013 2014 2015 2016
Male 30.7% 34.4% 38.5% 34.4% 35.9% 39.2%
Female 69.3% 65.6% 61.5% 65.6% 64.1% 60.8%

Both chlamydia and gonorrhea cases are on the rise in Wellington-Dufferin-Guelph and the exact cause for this increase is unknown. Based on the data, lack of condom use; multiple or new sexual partners within six months of diagnoses and sex with the opposite sex are the majority of risk factors associated with these infections. Despite recommendations for annual chlamydia and gonorrhea screening, far too many people are not tested, and therefore don’t know they are infected, increasing the spread of diseases. 9 Additionally, middle aged and older adults are re-entering the dating scene and may not know they should or how to get tested for sexually transmitted infections.10 Finally, diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDs) are considered a chronic and manageable disease in some populations reducing condom use in these populations. 10 Education, public awareness campaigns, increased access to testing are all strategies that public health can use to help detect and treat sexually transmitted infections such as chlamydia and gonorrhea. Additional surveillance and assessment is required to further understand the increase in these infections moving forward.

Go Get Tested
Requesting counseling and testing for sexual transmitted diseases from primary care providers may be embarrassing, particularly for adults. Adults are open to discussing sexual health issues with their primary care provider if the provider initiates the conversation, however, studies show that providers don’t initiate the conversation often enough.
Wellington-Dufferin-Guelph Public Health began an initiative, Go Get Tested, to encourage sexually active people to get tested for gonorrhea and chlamydia without first seeing a primary care provider. Go Get Tested is an easy, anonymous way to get tested for gonorrhea and chlamydia. An on-line lab requisition is available to print from the public health website and take to a local Life Labs, where an Ontario Health card and a small urine sample is all that is required for these tests. Results are available by phone 2 weeks later. If the test is positive, a nurse from public health who specializes in addressing sexually transmitted diseases will provide counseling about the infection and arrange treatment.
The Go Get Tested model was started in 2015 and is formatted after Ottawa Public Health’s “Get Tested. Why Not” campaign. Advertising of Go Get Tested has mainly been with high school and university students, but there has been no restriction as to who can be tested under this model. As of September 2016, 11% of the 89 tests performed came back positive for either gonorrhea or chlamydia. Age range of positive cases has been from age groups 15-19 years to 45-49 years. As many adults re-enter the dating scene, access to testing becomes more important. Starting late fall 2016, Wellington-Dufferin-Guelph Public Health will advertise the Go Get Tested initiative to the adult and older adult population in our areas.

As there are no LifeLab offices in North Wellington, Public Health will offer a similar service. People living in North Wellington can bring a downloaded requisition, along with their health card, to the Public Health office. They will be given a urine bottle to provide a sample which will be forwarded to a formal lab for processing on behalf of the client. Clients with positive results will be contacted by an experienced sexual health nurse who will ensure counseling and treatment are provided. Residents of North Wellington will be able to get testing without having to travel or provide personal details to their family physician, making this a more comfortable, discrete option for those who may not have transportation, or may know their local health care provider personally.

Conclusion

Chlamydia and gonorrhea are both sexually transmitted infections that continue to be on the rise. While chlamydia is easily treated, gonorrhea is showing antibiotic resistance and has limited treatment options. Preventing the spread of infection of these sexually transmitted diseases is a primary role of public health in Ontario.
Requesting sexual health counseling and treatment by a family physician may be embarrassing, particularly for an adult population who may be re-entering the dating scene. Providing the public with discrete access to testing for the most common sexually transmitted infections helps to diagnose and treat infections while reducing the spread of disease. Easy access to testing and treatment by downloading a lab requisition and providing a urine sample at a local lab make the Go Get Tested initiative an attractive alternative to the traditional approach to testing and treatment.

Ontario Public Health Standards

Sexual Health, Sexually Transmitted Infections, and Blood-borne Infections (including HIV):

  • To prevent or reduce the burden of sexually transmitted infections and blood-borne infections

WDGPH Strategic Directions

Strategic Directions
DIRECTION(s) APPLIES? (YES/NO)
Health Equity: We will provide programs and services that integrate health equity principles to reduce or eliminate health differences between population groups.              YES
Organizational Capacity: We will improve our capacity to effectively deliver public health programs and services.                NO
Service Centred Approach: We are committed to providing excellent service to anyone interacting with Public Health.              YES
Building Healthy Communities: We will work with communities to support the health and well-being of everyone.               NO

 

Health Equity

Go Get Tested opens options for the detection and treatment of both chlamydia and gonorrhea to people who are uncomfortable speaking about their sexual health to a family physician. Providing an alternative formation of the Go Get Tested option in the Mt Forest area ensures that people living in all areas of WDG public health area have access to this service.

Appendices

None.

References

1. Public Health Agency of Canada: Canadian Guideline for Sexually Transmitted Diseases, July 2013: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/assets/pdf/secti…
2. Public Health Agency of Canada: Canadian Guideline for Sexually Transmitted Diseases, July 2013: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-5-2-eng.php
3. Tillman JL, Mark HD. HIV and STI testing in older adults: an integrative review. Journal of Clinical Nursing.2015; 24: 2074-2095.
4. Nusbaum MRH, Singh AR, Pyles AA. Sexual Healthcare Needs of Women Aged 65 and Older. J Am Geriatr Soc. 2004; 52; 117-122.
5. Morton CR, Kim H, Treise D. Safe Sex After 50 and Mature Women’s Belief of Sexual Health. The Journal of Consumers Affairs.2011; Fall: 372-390.
6. Gott CM. Sexual activity and risk-taking in later life. Health and Social Care in the Community. 2001; 9(2): 72-78.
7. Balfe M, Brugha, O’Donovan D, O’Connell EO, Vaughn D. Triggers of self-conscious emotions in the sexually transmitted infection testing process. BMC Research Notes. 2010; 3:229. Available from: http://bmcresnotes.biomedcentral.com/articles/10.1186/1756-0500-3-229
8. Baker JR, Arnold-Reed DE, Brett T, Hince DA, O’Ferrall I, Bulsara MK. Perceptions of barriers to discussing and testing for sexually transmitted infections in a convenience sample of general practice patients. Australian Journal of Primary Health. 2013; 19; 98-101.
9. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2014. Atlanta: U.S. Department of Health and Human Services; 2015. Available from: http://www.cdc.gov/nchhstp/newsroom/2015/std-surveillance-report-press-r…
10. Relich S, Taylor M, Konkin K. Chlamydia, gonorrhea and syphilis on the rise: Is Tinder to blame? Healthy Debate; June 9, 2016. Available from: http://healthydebate.ca/2016/06/topic/chlamydia-gonorrhea-rise-tinder-blame