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STDs: Hepatitis, Proctitis, and Ectoparasitic Infections

Our courses fulfill continuing nursing education requirements in all 50 states. For more accreditation information, click here. Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptive authorization.

This course is recommended for advanced practitioners and others who treat or counsel clients about STDs.

Wild Iris Medical Education has adapted the material for this course from the 2006 guidelines published by the Centers for Disease Control and Prevention (CDC). The original material was published by the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Division of STD Prevention. The post test and learning objectives were prepared by Sharon A. Sanders, RN.

Sexually Transmitted Diseases Treatment Guidelines, 2006 was prepared for the CDC by Kimberly A. Workowski, MD, and Stuart M. Berman, MD. References may be viewed at http://www.cdc.gov/std/treatment/2006/rr5511.pdf.

These guidelines for the treatment of people who have sexually transmitted diseases (STDs) were developed by Centers for Disease Control and Prevention (CDC) after consultation with professionals knowledgeable in the field who met in Atlanta April 19–21, 2005. The information in this report updates the 2002 Sexually Transmitted Diseases Treatment Guidelines (CDC, 2002).

Included in these updated guidelines are:

• An expanded diagnostic evaluation for cervicitis and trichomoniasis
• New antimicrobial recommendations for trichomoniasis
• Additional data on the clinical effectiveness of azithromycin for chlamydial infections in pregnancy
• Discussion of the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis with treatment-related implications
• Emergence of lymphogranuloma venereum proctocolitis among men who have sex with men (MSM)
• Expanded discussion of the criteria for spinal fluid examination to evaluate for neurosyphilis
• The emergence of azithromycin-resistant Treponema pallidum
• Increasing prevalence of quinolone-resistant Neisseria gonorrhoeae in MSM
• Revised discussion concerning the sexual transmission of hepatitis C
• Postexposure prophylaxis after sexual assault
• An expanded discussion of STD prevention approaches

Wild Iris Medical Education has divided this material into four courses: (1) STDs: detection, referral, and counseling; (2) STDs affecting the reproductive system; (3) STDs: hepatitis, proctitis, and ectoparasitic infections; and (4) STDs related to sexual assault.

VACCINE PREVENTABLE STDS

Some STDs can be effectively prevented through pre-exposure vaccination. Vaccines are under development or are undergoing clinical trials for certain STDs, including HIV and HSV. However, the only vaccines currently available are for prevention of HAV, HBV, and HPV infection (for information about HPV, see STDs of the Reproductive System). Vaccination efforts focus largely on integrating the use of these available vaccines into STD prevention and treatment activities. Every person being evaluated or treated for an STD, who is not already vaccinated, should receive hepatitis B vaccination. In addition, some individuals (MSM, illegal-drug users) should receive hepatitis A vaccination.

HEPATITIS A

Hepatitis A, caused by infection with HAV, has an incubation period of approximately 28 days (range, 15–50 days). HAV replicates in the liver and is shed in high concentrations in feces from 2 weeks before to 1 week after the onset of clinical illness. HAV infection produces a self-limited disease that does not result in chronic infection or chronic liver disease. However, 10% to 15% of patients might experience a relapse of symptoms during the 6 months after acute illness.

Acute liver failure from hepatitis A is rare (overall case-fatality rate, 0.5%). The risk for symptomatic infection is directly related to age, with >80% of adults having symptoms compatible with acute viral hepatitis and the majority of children having either asymptomatic or unrecognized infection. Antibody produced in response to HAV infection persists for life and confers protection against re-infection.

Hepatitis A infection is primarily transmitted by the fecal-oral route, by either person-to-person contact, or through consumption of contaminated food or water. Although viremia occurs early in infection and can persist for several weeks after onset of symptoms, bloodborne transmission of HAV is uncommon. Hepatitis A occasionally might be detected in saliva in experimentally infected animals, but transmission by saliva has not been demonstrated.

In the United States, nearly half of all reported hepatitis A cases have no specific risk factor identified. Among adults with identified risk factors, the majority of cases are among MSM, individuals who use illegal drugs, and international travelers. Because transmission of HAV during sexual activity probably occurs because of fecal-oral contact, measures typically used to prevent the transmission of other STDs (use of condoms) do not prevent HAV transmission.

In addition, efforts to promote good personal hygiene have not been successful in interrupting outbreaks of hepatitis A. Vaccination is the most effective means of preventing HAV transmission among individuals at risk for infection, many of whom might seek services in STD clinics.

DIAGNOSIS

The diagnosis of hepatitis A cannot be made on clinical grounds alone and requires serologic testing. The presence of IgM antibody to HAV is diagnostic of acute HAV infection. A positive test for total anti-HAV indicates immunity to HAV infection but does not differentiate current from previous HAV infection. Although usually not sensitive enough to detect the low level of protective antibody after vaccination, anti-HAV tests might be positive after hepatitis A vaccination.

TREATMENT

Patients with acute hepatitis A usually require only supportive care, with no restrictions in diet or activity. Hospitalization might be necessary for patients who become dehydrated because of nausea and vomiting and is critical for patients with signs or symptoms of acute liver failure. Medications that might cause liver damage or are metabolized by the liver should be used with caution among individuals with hepatitis A.

PREVENTION

Two products are available for the prevention of HAV infection: hepatitis A vaccine (see table below) and immune globulin (Ig) for IM administration. Hepatitis A vaccines are prepared from formalin-inactivated, cell culture–derived HAV and have been available in the United States since 1995, initially for individuals aged >2 years.

In 2005 the vaccines were approved by the FDA for individuals aged >12 months. Administered IM in a two-dose series, these vaccines induce protective antibody levels in virtually all adults. By 1 month after the first dose, 94% to 100% of adults have protective antibody levels; 100% of adults develop protective antibody after a second dose. In randomized controlled trials, the equivalent of one dose of hepatitis A vaccine administered before exposure has been 94% to 100% effective in preventing clinical hepatitis A. Kinetic models of antibody decline indicate that protective levels of antibody persist for at least 20 years.

DOSAGE AND SCHEDULE FOR HEPATITIS A VACCINES

Vaccine	Age (yrs)	Dose*	Volume (mL)	Two-dose Schedule (mos)**
HAVRIX †	1–18	720 (EL.U.)	0.5	0, 6–12
	>18	1,440 (EL.U.)	1.0	0, 6–12
VAQTA ††	1–18	25 (U)	0.5	0, 6–18
	>18	50 (U)	1.0	0, 6–18
* EL.U. = enzyme-linked immunosorbent assay (ELISA) units. U = units. **0 months represents the timing of the initial dose; subsequent numbers represent the months after the initial dose. † Hepatitis A vaccine, inactivated, GlaxoSmithKline Biologicals. This vaccine also is licensed for a 3-dose series in children aged 1–18 years, with 360 EL.U., 0.5-mL doses at 0, 1, and 6–12 months. †† Hepatitis A vaccine, inactivated, Merck & Co., Inc.

A combined hepatitis A and hepatitis B vaccine have been developed and licensed for use as a 3-dose series in adults aged >18 years (see table below). When administered IM on a 0-, 1-, and 6-month schedule, the vaccine produces equivalent immunity to that of the monovalent vaccines.

Hepatitis A vaccine is available for eligible children and adolescents aged <19 years through the Vaccines for Children program (phone 800-232-2522).

Ig is a sterile solution of concentrated immunoglobulins prepared from pooled human plasma processed by cold ethanol fractionation. In the United States, Ig is produced only from plasma that has tested negative for hepatitis B surface antigen, antibodies to HIV and HCV, and HCV RNA. In addition, the process used to manufacture Ig inactivates viruses (HBV, HCV, HIV). When administered IM before or within 2 weeks after exposure to HAV, Ig is >85% effective in preventing HAV infections.

PRE-EXPOSURE IMMUNIZATION

Individuals in the following groups who are likely to be treated in STD clinic settings should be offered hepatitis A vaccine: (1) all MSM; (2) illegal drug users (both injecting and non-injecting drugs); and (3) individuals with chronic liver disease (CLD), including individuals with chronic HBV and HCV infection who have evidence of CLD.

PREVACCINATION SEROLOGIC TESTING FOR SUSCEPTIBILITY

Approximately one-third of the U.S. population has serologic evidence of previous HAV infection, which increases directly with age and reaches 75% among individuals aged >70 years. Screening for HAV infection might be cost-effective in populations where the prevalence of infection is likely to be high (individuals aged >40 years and individuals born in areas of high HAV endemicity). The potential cost/savings of testing should be weighed against the cost and the likelihood that testing will interfere with initiating vaccination. Vaccination of a person who is already immune is not harmful.

POSTVACCINATION SEROLOGIC TESTING

Postvaccination serologic testing is not indicated because the majority of individuals respond to the vaccine. In addition, the commercially available serologic test is not sensitive enough to detect the low but protective levels of antibody produced by vaccination.

POSTEXPOSURE PROPHYLAXIS (PEP)

Previously unvaccinated individuals exposed to HAV (through household or sexual contact or by sharing illegal drugs with a person who has hepatitis A) should be administered a single IM dose of Ig (0.02 mL/kg) as soon as possible but not >2 weeks after exposure. Individuals who have had 1 dose of hepatitis A vaccine at least 1 month before exposure to HAV do not need Ig. If hepatitis A vaccine is recommended for a person receiving Ig, it can be administered simultaneously at a separate anatomic injection site. The use of hepatitis A vaccine alone is not recommended for postexposure prophylaxis (PEP).

SPECIAL CONSIDERATIONS

Limited data indicate that vaccination of individuals with CLD and of HIV-infected individuals results in lower seroprotection rates and antibody concentrations. In HIV-infected individuals, antibody response might be directly related to CD4+ levels.

HEPATITIS B

Hepatitis B is caused by infection with hepatitis B virus (HBV). The incubation period from time of exposure to onset of symptoms is 6 weeks to 6 months. Hepatitis B virus is found in highest concentrations in blood and in lower concentrations in other body fluids (semen, vaginal secretions, wound exudates). Hepatitis B infection can be self-limited or chronic. In adults, only one-half of newly acquired HBV infections are symptomatic, and approximately 1% of reported cases result in acute liver failure and death. Risk for chronic infection is inversely related to age at infection: about 90% of infected infants and 30% of infected children under age 5 become chronically infected, compared with 2% to 6% of adults. Among individuals with chronic HBV infection, the risk for premature death from cirrhosis or hepatocellular carcinoma (HCC) is 15% to 25%.

Hepatitis B is efficiently transmitted by percutaneous or mucous membrane exposure to infectious blood or body fluids that contain blood. The primary risk factors that have been associated with infection among adolescents and adults are unprotected sex with an infected partner, unprotected sex with more than one partner, MSM, history of other STDs, and injecting-drug use (IDU).

The CDC's national strategy to eliminate transmission of HBV infection includes:

• Prevention of perinatal infection through routine screening of all pregnant women for HBsAg and immunoprophylaxis of infants born to HBsAg-positive mothers and infants born to mothers with unknown HBsAg status
• Routine infant vaccination
• Vaccination of previously unvaccinated children and adolescents through age 18 years
• Vaccination of previously unvaccinated adults at increased risk for infection

High vaccination coverage rates, with subsequent declines in acute hepatitis B incidence, have been achieved among infants and adolescents. In contrast, vaccination coverage among the majority of high-risk adult groups (individuals with more than one sex partner in the previous 6 months, MSM, and injection-drug users) have remained low, and the majority of new infections occur in these high-risk groups. The STD clinics and other settings that provide services targeted to high-risk adults are ideal sites in which to provide hepatitis B vaccination to adults at risk for HBV infection. All unvaccinated adults seeking services in these settings should be assumed to be at risk for hepatitis B and should receive hepatitis B vaccination.

DIAGNOSIS

Diagnosis of acute or chronic HBV infection requires serologic testing (see table below). HBsAg is present in both acute and chronic infection. The presence of IgM antibody to hepatitis B core antigen (IgM anti- HBc) is diagnostic of acute or recently acquired HBV infection. Antibody to HBsAg (anti- HBs) is produced after a resolved infection and is the only HBV antibody marker present after immunization. The presence of HBsAg and total anti-HBc, with a negative test for IgM anti-HBc, indicates chronic HBV infection. The presence of anti-HBc alone might indicate a false-positive result or acute, resolved, or chronic infection.

INTERPRETING TEST RESULTS* FOR HEPATITIS B INFECTION

Serologic Marker
The symbol for negative test results is a minus and the symbol for positive test results is plus.
HBsAg*	Total anti- HBc **	IgM† anti-HBc	Anti-HBc††	Interpretation
−	−	−	−	Never infected
+§	−	−	−	Early acute infection; transient (up to 18 days) after vaccination
+	+	+	−	Acute infection
−	+	+	−	Acute resolving infection
−	+	−	+	Recovered from previous infection and immune
+	+	−	−	Chronic infection
−	+	−	−	False-positive (susceptible); previous infection; low-level chronic infection,§§ passive transfer to infant born to HBsAg-positive mother
−	−	−	+	Immune if concentration is >10 mIU/mL¶; passive transfer after HBIG¶¶ administration
* Hepatitis B surface antigen ** Antibody to hepatitis B core antigen † Immunoglobulin M †† Antibody to HBsAg § To ensure that an HBsAg-positive test result is not a false-positive, samples with repeatedly reactive HBsAg results should be tested with a licensed (and, if appropriate, neutralizing confirmatory) test. §§ Individuals positive for only anti-HBs are unlikely to be infectious except under unusual circumstances involving direct percutaneous exposure to large quantities of blood (blood transfusion, organ transplantation). ¶ Milli-international units per milliliter ¶¶ Hepatitis B immune globulin

TREATMENT

No specific therapy is available for individuals with acute hepatitis B; treatment is supportive. Individuals with chronic HBV infection should be referred for evaluation to a physician experienced in the management of CLD. Therapeutic agents approved by FDA for treatment of chronic hepatitis B can achieve sustained suppression of HBV replication and remission of liver disease in some individuals. In addition, patients with chronic hepatitis B might benefit from screening to detect HCC at an early stage.

PREVENTION

Two products have been approved for hepatitis B prevention: hepatitis B immune globulin (HBIG) and hepatitis B vaccine. HBIG provides temporary (3–6 months) protection from HBV infection and is typically used as postexposure prophylaxis (PEP) either as an adjunct to hepatitis B vaccination in previously unvaccinated individuals or alone in individuals who have not responded to vaccination. HBIG is prepared from plasma known to contain high concentrations of anti-HBs. The recommended dose of HBIG is 0.06 mL/kg.

Hepatitis B vaccine contains HBsAg produced in yeast by recombinant DNA technology and provides protection from HBV infection when used for both pre-exposure immunization and PEP. The two available monovalent hepatitis B vaccines for use in adolescents and adults are Recombivax HB (Merck and Co., Inc., Whitehouse Station, New Jersey) and Engerix-B (GlaxoSmithKline Biologicals, Pittsburgh, Pennsylvania). Twinrix (GlaxoSmithKline Biologicals, Pittsburgh, Pennsylvania) a combination vaccine (hepatitis A/ hepatitis B) for use in adults, is also available (see table below). The recommended HBV dose varies by product and age of recipient.

When selecting a hepatitis B vaccination schedule, clinicians need to consider the importance of completing the vaccine series. Approved adolescent and adult schedules for both monovalent hepatitis B vaccines (Engerix-B and Recombivax HB) include the following: 0, 1, and 6 months; 0, 1, and 4 months; and 0, 2, and 4 months. A four-dose schedule of Engerix-B at 0, 1, 2, and 12 months is licensed for all age groups.

A two-dose schedule of Recombivax HB adult formulation (10 μg) is licensed for adolescents aged 11 to 15 years. When scheduled to receive the second dose, adolescents aged >15 years should be switched to a three-dose series, with doses 2 and 3 consisting of the pediatric formulation (5 μg) administered on an appropriate schedule. Twinrix may be administered to individuals aged >18 years at risk for both HAV and HBV infections at 0, 1, and 6 months.

RECOMMENDED DOSES OF ADOLESCENT AND ADULT HEPATITIS B VACCINES

Group	Single-antigen vaccine				Combination vaccine
	Recombivax HB		Engerix-B		Twinrix*
	Dose (μg )**	Volume (mL)	Dose (μg )**	Volume (mL)	Dose (μg )**	Volume (mL)
Adolescents aged 11–19 yrs †	5	0.5	10	0.5	NA ††	NA
Adolescents aged 11–15 yrs §	10	1.0	NA	NA	NA	NA
Adults aged >20 yrs	10	1.0	20	1.0	20	1.0
Hemodialysis patients and other immunocompromised individuals aged <20 yrs †	5	0.5	10	0.5	NA	NA
Hemodialysis patients and other immunocompromised individuals aged >20 yrs	40 §§	1.0	40 ‡	2.0	NA	NA
* Combined hepatitis A and hepatitis B vaccine. This vaccine is recommended for individuals aged >18 years who are at increased risk for both hepatitis B and hepatitis A virus infections. ** Recombinant hepatitis B surface antigen protein dose in micrograms. † Pediatric formulation administered on a 3-dose schedule; higher doses might be more immunogenic, but no specific recommendations have been made. †† Not applicable. § Adult formulation administered on a 2-dose schedule. §§ Dialysis formulation administered on a 3-dose schedule at 0, 1, and 6 months. ‡ Two 1.0-mL doses of the adult formulation administered at one site on a 4-dose schedule at 0, 1, 2, and 6 months.

Hepatitis B vaccine should be administered intramuscularly (IM) in the deltoid muscle and may be administered simultaneously with other vaccines. For adolescents and adults, the needle length should be 1 to 2 inches, depending on the recipient's weight (1 inch for females weighing <70 kg), 1.5 inches for males weighing <120 kg; and 2 inches for males weighing >120 kg and females >100 kg). A 22- to 25-gauge needle is recommended. If the vaccine series is interrupted after the first or second dose of vaccine, the missed dose should be administered as soon as possible. The series does not need to be restarted after a missed dose.

In adolescents and healthy adults aged <40 years, 30% to 55% acquire a protective antibody response (anti-HBs >10 mIU/mL) after the first vaccine dose, 75% after the second, and >90% after the third. Vaccine-induced immune memory has been demonstrated to persist for at least 15 to 20 years. Periodic testing to determine antibody levels in immunocompetent individuals is not necessary, and booster doses of vaccine are not recommended.

Hepatitis B vaccination is generally well-tolerated by the majority of recipients. Pain at the injection site and low-grade fever are reported by a minority of recipients. Evidence for a causal association between receipt of hepatitis B vaccination and anaphylaxis exists, which is estimated to occur in 1 of 1.1 million doses of vaccine administered among children and adolescents; no deaths have been reported after anaphylaxis.

Vaccine is contraindicated in individuals with a history of anaphylaxis after a previous dose of hepatitis B vaccine and in individuals with a known anaphylactic reaction to any vaccine component. No evidence for a causal association has been demonstrated for other adverse events reported after administration of hepatitis B vaccine.

Pre-Exposure Vaccination

Hepatitis B vaccination is recommended for all unvaccinated adolescents, all unvaccinated adults at risk for HBV infection, and all adults seeking protection from HBV infection. For adults, acknowledgement of a specific risk factor is not a requirement for vaccination. Hepatitis B vaccine should be routinely offered to all unvaccinated individuals attending STD clinics and to all unvaccinated individuals seeking treatment for STDs in other settings.

Other settings where all unvaccinated adults should be assumed to be at risk for hepatitis B and should receive hepatitis B vaccination include correctional facilities, facilities providing drug abuse treatment and prevention services, healthcare settings serving MSM, and HIV testing and treatment facilities. All individuals who receive clinical services in these settings should be offered hepatitis B vaccine unless they have a reliable vaccination history (a written, dated record of each dose of a complete series). In all settings, vaccination should be initiated even though completion of the vaccine series might not be ensured.

Prevaccination Antibody Screening

Prevaccination serologic testing for susceptibility may be considered to reduce the cost of vaccinating adult populations that have an expected high prevalence of HBV infection (>20%–30% in IDUs and MSM [especially in older age groups]). In addition, prevaccination testing for susceptibility is recommended for unvaccinated household, sexual, and needle-sharing contacts of HBsAg-positive individuals.

Anti-HBc (core antigen) is the test of choice for prevaccination testing; individuals who are anti-HBc–positive should be tested for HBsAg. If individuals are determined to be HBsAg-negative, no further action is required. If individuals are determined to be HBsAg-positive, the individual should be referred for medical followup, including counseling and evaluation for antiviral treatment. In addition, all household members, sex partners, and needle-sharing partners of HBsAg-positive individuals should be vaccinated.

Serologic testing should not be a barrier to vaccination of susceptible individuals, especially in populations that are difficult to reach. In the majority of situations, the first vaccine dose is administered immediately after collection of the blood sample for serologic testing. Vaccination of individuals who are immune to HBV infection because of current or previous infection or vaccination does not increase the risk for adverse events.

The following table provides guidelines for PEP of hepatitis B in unvaccinated individuals who have a discrete identifiable exposure to blood or body fluids that contain blood.

PEP GUIDELINES FOR INDIVIDUALS UNVACCINATED FOR HEPATITIS B

Cause of exposure	Suggested action
Discrete exposure to an HBsAg*-positive source
Percutaneous (bite or needlestick) or mucosal exposure to HBsAg-positive blood or body fluids that contain blood	Administer hepatitis B vaccine and hepatitis B immune globulin (HBIG)**
Sexual or needle-sharing contact of an HBsAg-positive individual	Administer hepatitis B vaccine and HBIG**
Victim of sexual assault/abuse by a perpetrator who is HBsAg-positive	Administer hepatitis B vaccine and HBIG**
Discrete exposure to a source with unknown HBsAg status
Victim of sexual assault/abuse by a perpetrator with unknown HBsAg status	Administer hepatitis B vaccine**
Percutaneous (bite or needlestick) or mucosal exposure to blood or body fluids that contain blood from a source with unknown HBsAg status	Administer hepatitis B vaccine**
* Hepatitis B surface antigen. ** Immunoprophylaxis should be administered as soon as possible, preferably within <24 hours. Studies are limited on the maximum interval after exposure during which postexposure prophylaxis is effective, but the interval is unlikely to exceed 7 days for percutaneous exposures and 14 days for sexual exposures. The hepatitis B vaccine series should be completed.

Postvaccination Testing for Serologic Response

Serologic testing for immunity is not necessary after routine vaccination of adolescents or adults. Testing after vaccination is recommended for individuals whose subsequent clinical management depends on knowledge of their immune status (healthcare workers or public safety workers at high risk for continued percutaneous or mucosal exposure to blood or body fluids). In addition, testing is recommended for (1) HIV-infected individuals and other immunocompromised individuals to determine the need for revaccination and the type of followup testing, and (2) sex and needle-sharing partners of HBsAg-positive individuals to determine the need for revaccination and for other methods to protect themselves from HBV infection.

If indicated, testing should be performed 1 to 2 months after administration of the last dose of the vaccine series using a method that allows determination of a protective level of anti-HBs (>10 mIU/mL). Individuals determined to have anti-HBs levels of <10 mIU/mL after the primary vaccine series should be revaccinated with a three-dose series, followed by anti-HBs testing 1 to 2 months after the third dose.

Individuals who do not respond to revaccination should be tested for HBsAg. If HBsAg-positive, the individual should receive appropriate management; if HBsAg negative, the individual should be considered susceptible to HBV infection and taught precautions to prevent HBV infection as well as the need for HBIG PEP for any known exposure.

Postexposure Prophylaxis (PEP)

Both passive-active PEP with HBIG and hepatitis B vaccination, and active PEP with hepatitis B vaccination alone, have been demonstrated to be highly effective in preventing transmission after exposure to HBV. HBIG alone has been demonstrated to be effective in preventing HBV transmission but, with the availability of hepatitis B vaccine, HBIG is typically used as an adjunct to vaccination.

Exposure to HBsAg-Positive Source

Unvaccinated individuals or individuals known not to have responded to a complete hepatitis B vaccine series should receive both HBIG and hepatitis vaccine as soon as possible (preferably within 24 hours) after a discrete, identifiable exposure to blood or body fluids that contain blood from an HBsAg-positive source (refer to table above). Hepatitis B vaccine should be administered simultaneously with HBIG in a separate injection site, and the vaccine series completed by using the age-appropriate vaccine dose and schedule Exposed individuals who are in the process of being vaccinated but who have not completed the vaccine series should receive the appropriate dose of HBIG (0.06 mL/kg) and should complete the vaccine series.

Exposed individuals who are known to have responded to vaccination are considered protected and need no further vaccine doses. Individuals who have written documentation of a complete hepatitis B vaccine series and who did not receive postvaccination testing should receive a single vaccine booster dose. Alternately, these individuals can be managed according to guidelines for individuals with occupational exposure to blood or body fluids that contain blood.

Exposure to Source with Unknown HBsAg Status

Unvaccinated individuals who have a discrete, identifiable exposure to blood or body fluids containing blood from a source with unknown HBsAg status should receive the hepatitis B vaccine series, with the first dose initiated as soon as possible after exposure (preferably within 24 hours) and the series completed by using the age-appropriate dose and schedule. Exposed individuals who are not fully vaccinated should complete the vaccine series. Exposed individuals with written documentation of a complete hepatitis B vaccine series require no further treatment.

Pregnancy

All pregnant women receiving STD services should be tested for HBsAg, whether or not they were tested or vaccinated earlier. All HBsAg-positive pregnant women are to be reported to state and local perinatal hepatitis B prevention programs. HBsAg-negative pregnant women seeking STD treatment who have not been previously vaccinated should receive hepatitis B vaccination. Additional information regarding management of HBsAg-positive pregnant women and their infants is available at http://www.cdc.gov/mmwr/PDF/rr/rr5416.pdf.

HIV-Infection

HIV-infection can impair the response to hepatitis B vaccination. HIV-infected individuals should be tested for anti-HBs 1 to 2 months after the third vaccine dose. Modified dosing regimens, including a doubling of the standard antigen dose and administration of additional doses, might increase the response rate.

HBsAg-Positive Individuals

This section provides recommendations for management of all HBsAg-positive individuals. Recommendations for HBsAg-positive individuals who are co-infected with HIV are available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5315a1.htm.

All individuals with HBsAg-positive laboratory results should be reported to the state or local health department.

To verify the presence of chronic HBV infection, HBsAg-positive individuals should be retested. The absence of IgM anti-HBc or the persistence of HBsAg for 6 months indicates chronic HBV infection.

Individuals with chronic HBV infection should be referred for evaluation to a physician experienced in the management of chronic liver disease (CLD). Some patients with chronic hepatitis B will benefit from early intervention with antiviral treatment or screening to detect hepatocellular carcinoma (HCC) at an early stage.

Household, sexual, and needle-sharing contacts of chronically infected individuals should be identified. Unvaccinated sex partners and household and needle-sharing contacts should be tested for susceptibility to HBV infection (see Prevaccination Antibody Screening) and should receive the first dose of hepatitis B vaccine immediately after collection of the blood sample for serologic testing. Susceptible individuals should complete the vaccine series by using an age-appropriate vaccine dose and schedule. Individuals who are fully vaccinated should complete the vaccine series.

Sex partners of HBsAg-positive individuals should be counseled to use methods (eg, condoms) to protect themselves from sexual exposure to infectious body fluids (semen and vaginal secretions), unless they have been demonstrated to be immune after vaccination (anti-HBs >10mIU/mL) or previous infection (anti-HBc positive).

To prevent or reduce the risk for transmission to others, HBsAg-positive individuals should be advised concerning the risk for transmission to household, sexual, and needle-sharing contacts and the need for such contacts to receive hepatitis B vaccination.

HBsAg-positive individuals also should be advised to:

• Use methods (eg, condoms) to protect nonimmune sex partners from acquiring HBV infection from sexual activity until the partner can be vaccinated and immunity documented
• Cover cuts and skin lesions to prevent the spread of infectious secretions or blood
• Refrain from donating blood, plasma, body organs, other tissue, or semen
• Refrain from sharing household articles (toothbrushes, razors, or individual injection equipment) that could become contaminated with blood

To protect the liver from further harm, HBsAg-positive individuals should be advised to:

• Avoid or limit alcohol consumption because of the effects of alcohol on the liver
• Refrain from starting any new medicines, including OTC and herbal medicines, without checking with their healthcare provider
• Obtain vaccination against hepatitis A if liver disease is determined to be present

When seeking medical or dental care, HBsAg-positive individuals should be advised to inform those responsible for their care of their HBsAg status so that they can be appropriately evaluated and managed. Information regarding HBsAg-positive women who are pregnant is available in this report (see Pregnant Women).

Other counseling messages to be considered:

• HBV is not spread by hugging, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact
• Individuals should not be excluded from work, school, play, childcare, or other settings because they are infected with HBV
• Involvement with a support group my help patients cope with chronic HBV infection.

HEPATITIS C

Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States; approximately 2.7 million individuals are chronically infected. Although HCV is not efficiently transmitted sexually, individuals at risk for infection through injection-drug use may seek care in STD treatment facilities, HIV counseling and testing facilities, correctional facilities, drug treatment facilities, and other public health settings where STD and HIV prevention and control services are available.

Individuals newly infected with HCV typically are either asymptomatic or have a mild clinical illness. HCV RNA can be detected in blood within 1 to 3 weeks after exposure. The average time from exposure to antibody to HCV (anti-HCV) seroconversion is 8 to 9 weeks, and anti-HCV can be detected in >97% of individuals by 6 months after exposure. Chronic HCV infection develops in 60% to 85% of HCV-infected individuals; 60% to 70% of chronically infected individuals have evidence of active liver disease.

The majority of HCV-infected individuals may be unaware of their infection because they are not clinically ill. However, infected individuals serve as a source of transmission to others and are at risk for CLD or other HCV-related chronic diseases for decades after infection.

Hepatitis C is most efficiently transmitted through large or repeated percutaneous exposure to infected blood (transfusion of blood from unscreened donors or use of injecting-drugs), although less efficient, occupational, perinatal, and sexual exposures also can result in transmission of HCV.

The role of sexual activity in the transmission of HCV has been controversial. Case-control studies have reported an association between acquiring HCV infection and exposure to a sex contact with HCV infection or exposure to multiple sex partners. Surveillance data also indicate that 15% to 20% of individuals reported with acute HCV infection have a history of sexual exposure in the absence of other risk factors.

Case reports of acute HCV infection among HIV-positive MSM who deny injecting-drug use have indicated that this occurrence is frequently associated with other STDs (eg, syphilis). In contrast, a low prevalence (average, 1.5%) of HCV infection has been demonstrated in studies of longterm spouses of patients with chronic HCV infection who had no other risk factors for infection, and multiple published studies have demonstrated the prevalence of HCV infection among MSM who have not reported a history of injecting-drug use to be no higher than that of heterosexuals.

Because sexual transmission of bloodborne viruses is more efficient between homosexual men when compared to heterosexual men and women, it is unclear why HCV infection rates are not substantially higher among MSM compared with heterosexuals. Overall, these findings indicate that sexual transmission of HCV is possible but inefficient. Additional data are needed to determine whether sexual transmission of HCV might be increased in the context of HIV infection or other STDs.

DIAGNOSIS AND TREATMENT

Anti-HCV testing is recommended for routine screening of asymptomatic individuals based on their risk for infection or based on a recognized exposure (see Hepatitis C, Prevention). For such individuals, testing for HCV infection should include the use of an FDA-cleared test for antibody to HCV (immunoassay, EIA, or enhanced chemiluminescence assay and, if recommended, a supplemental antibody test).

Individuals counseled and tested for HCV infection and determined to be anti-HCV positive should be evaluated (by referral or consultation, if appropriate) for presence of active infection, presence or development of CLD, and for possible treatment. Reverse transcriptase polymerase chain reaction to detect HCV RNA may be used to confirm the diagnosis of current HCV infection, and an elevated alanine aminotransferase (ALT) level is biochemical evidence of CLD. Combination therapy with pegylated interferon and ribavirin is the treatment of choice for patients with chronic hepatitis C. Because of advances in the field of antiviral therapy for acute and chronic hepatitis C, clinicians should consult with specialists knowledgeable about management of hepatitis C infection.

PREVENTION

No vaccine for hepatitis C is available, and prophylaxis with immune globulin is not effective in preventing HCV infection after exposure. Reducing the burden of HCV infection and disease in the United States requires implementation of both primary and secondary prevention activities. Primary prevention reduces or eliminates HCV transmission; secondary prevention activities reduce liver and other chronic diseases in HCV-infected individuals by identifying them and providing appropriate medical management and antiviral therapy, if appropriate.

Individuals seeking care in STD clinics or other primary-care settings should be screened to identify those who should be offered HCV counseling and testing. In STD clinics and other settings that serve large numbers of individuals at high risk for bloodborne infections (eg, correctional), the major risk factor for which to screen for HCV infection is injection of illegal drugs. In addition, for clinical management issues, all individuals with HIV infection should also be offered HCV counseling and testing.

Other risk factors for which routine HCV testing is recommended include individuals who:

• Had a blood transfusion or solid organ transplant before July 1992
• Received clotting factor concentrates produced before 1987
• Have been on long-term dialysis
• Have signs and symptoms of liver disease (eg, abnormal ALT)

Individuals who test positive for anti-HCV (see Diagnosis and Treatment) should be provided information regarding (1) how to protect their liver from further harm, (2) how to prevent transmission to others, and (3) the need for medical evaluation for CLD and possible treatment.

To protect their liver from further harm, HCV-positive individuals should be advised to avoid alcohol and to avoid any new medicines (including OTC and herbals) without checking with their doctor.

To reduce the risk for transmission to others, HCV-positive individuals should be advised:

• Not donate blood, body organs, other tissue, or semen
• Not share any individual items that might have blood on them (toothbrushes, razors)
• Cover cuts and sores on the skin to keep from spreading infectious blood or secretions

HCV-positive individuals with one longterm, steady sex partner do not need to change their sexual practices. They should discuss the low but present risk for transmission with their partner and discuss the need for counseling and testing. HCV-positive women do not need to avoid pregnancy or breastfeeding.

HCV-positive individuals should be evaluated (by referral or consultation, if appropriate) for presence of development of CLD, including assessment of liver function tests, assessment for severity of liver disease and possible treatment, and determination of the need for hepatitis A and B vaccination. Individuals who test negative for anti-HCV who had an exposure previously should be reassured that they are not infected.

Regardless of test results, individuals who use or inject illegal drugs should be counseled to:

• Stop using and injecting-drugs
• enter and complete substance abuse treatment, including relapse prevention
• take the following steps to reduce individual and public health risks, if they continue to inject drugs:
• Never reuse or share syringes, water, or drug preparation equipment
• Use only syringes obtained from a reliable source (eg, pharmacies)
• Use a new, sterile syringe to prepare and inject drugs
• If possible, use sterile water to prepare drugs; otherwise, use clean water from a reliable source (eg, fresh tap water)
• Use a new or disinfected container ("cooker") and a new filter ("cotton") to prepare drugs
• Clean the injection site before injection with a new alcohol swab
• Safely dispose of syringes after one use
• Get vaccinated for hepatitis A and B

Postexposure Followup

No PEP has been demonstrated to be effective against HCV. Testing to determine whether HCV infection has developed is recommended for healthcare workers after percutaneous or permucosal exposures to HCV-positive blood and for children born to HCV-positive women.

Pregnancy

Routine testing for HCV infection is not recommended for all pregnant women. Pregnant women with a known risk factor for HCV infection should be offered counseling and testing. Patients should be advised that 5 of every 100 infants born to HCV-infected woman become infected. This infection occurs predominantly during or near delivery, and no treatment or delivery method is known to decrease this risk. The risk is increased by the presence of maternal HCV viremia at delivery and also is greater (2–3 times) if the woman is co-infected with HIV.

Breastfeeding does not appear to transmit HCV, although HCV-positive mothers should consider abstaining from breastfeeding if their nipples are cracked or bleeding. Infants born to HCV-positive mothers should be tested for HCV infection and, if positive, evaluated for the presence of CLD.

HIV-Infection

Because of the high prevalence of HIV/HCV co-infection and because of critical clinical management issues for co-infected individuals, all HIV-infected individuals should be tested for HCV. Because a small percentage of co-infected individuals fail to acquire HCV antibodies, HCV RNA should be tested in HIV-positive individuals with unexplained liver disease who are anti-HCV negative. The course of liver disease is more rapid in HIV/HCV co-infected individuals, and the risk for cirrhosis is nearly twice that in individuals with HCV infection alone.

Treatment of HCV in co-infected individuals might improve tolerance to highly active antiretroviral therapy (HAART) for HIV infection because of the increased risk for hepatotoxicity from HAART with HCV infection. However, anti-HCV treatment in co-infected individuals is still investigational, and based on ongoing clinical trials, more data are needed to determine the best regimens.

PROCTITIS, PROCTOCOLITIS, AND ENTERITIS

Sexually transmitted gastrointestinal syndromes include proctitis, proctocolitis, and enteritis. Evaluation for these syndromes should include appropriate diagnostic procedures (anoscopy or sigmoidoscopy, stool examination, and culture). Proctitis is inflammation of the rectum (the distal 10–12 cm) that might be associated with anorectal pain, tenesmus, or rectal discharge. N. gonorrhoeae, C. trachomatis(including lymphogranuloma venereum, or LGV, serovars), T. pallidum, and HSV are the most common sexually transmitted pathogens involved. In patients co-infected with HIV, herpes proctitis might be especially severe. Proctitis occurs predominantly among individuals who participate in receptive anal intercourse.

Proctocolitis is associated with symptoms of proctitis and diarrhea or abdominal cramps and inflammation of the colonic mucosa, extending to 12 cm above the anus. Fecal leukocytes might be detected on stool examination, depending on the pathogen. Pathogenic organisms include Campylobacter sp., Shigella sp., Entamoeba histolytica, and, rarely, LGV serovars of C. trachomatis. Cytomegalovirus (CMV) or other opportunistic agents might be involved in immunosuppressed HIV-infected patients. Proctocolitis can be acquired by the oral route or by oral-anal contact, depending on the pathogen.

Enteritis usually results in diarrhea and abdominal cramping without signs of proctitis or proctocolitis; it occurs among individuals whose sexual practices include oral-anal contact. In otherwise healthy individuals, Giardia lamblia is most frequently implicated. When outbreaks of gastrointestinal illness occur among social or sexual networks of MSM, clinicians should consider sexual transmission as a mode of spread and provide counseling accordingly.

Among HIV-infected patients, gastrointestinal illness can be caused by other infections that usually are not sexually transmitted, including CMV, Mycobacterium avium-intracellulare, Salmonella sp., Campylobacter sp., Shigella sp., Cryptosporidium, Microsporidium , and Isospora. Multiple stool examinations might be necessary to detect Giardia, and special stool preparations are required to diagnose cryptosporidiosis and microsporidiosis. In addition, enteritis might be directly caused by HIV infection. When laboratory diagnostic capabilities are available, treatment decisions should be based on the specific diagnosis. Diagnostic and treatment recommendations for all enteric infections are beyond the scope of this course.

TREATMENT

Acute proctitis of recent onset among individuals who have recently practiced receptive anal intercourse is usually sexually acquired. Such patients should be examined by anoscopy and should be evaluated for infection with HSV, N. gonorrhoeae, C. trachomatis, and T. pallidum. If an anorectal exudate is detected on examination or if polymorphonuclear leukocytes are detected on a Gram-stained smear of anorectal secretions, the following therapy may be prescribed while awaiting additional laboratory tests.

Patients with suspected or documented herpes proctitis should be managed the same as those with genital herpes. If painful perianal ulcers are present or mucosal ulcers are detected on anoscopy, presumptive therapy should include a regimen for treating genital herpes. In addition, LGV proctitis and proctocolitis also should be considered. Appropriate diagnostic testing for LGV should be conducted in accordance with state or federal guidelines, and doxycycline therapy should be administered 100 mg orally twice daily for 3 weeks.

Followup

Followup is based on the specific etiology and the severity of clinical symptoms. Re-infection might be difficult to distinguish from treatment failure.

Management of Sex Partners

Partners of patients with sexually transmitted enteric infections should be evaluated for any diseases diagnosed in the original (index) patient.

ECTOPARASITIC INFECTIONS

Pediculosis Pubis

Patients who have pediculosis pubis (pubic lice) usually seek medical attention because of pruritus or because they notice lice or nits on their pubic hair. Pediculosis pubis is usually transmitted by sexual contact.

Reported resistance to pediculicides has been increasing and is widespread. Malathion may be used when treatment failure is believed to have occurred because of resistance. The odor and long duration of application for Malathion make it a less attractive alternative than the recommended pediculicides. Ivermectin has been successfully used to treat lice but has only been evaluated in small studies.

Lindane is not recommended as first-line therapy because of toxicity. It should only be used as an alternative because of inability to tolerate other therapies or if other therapies have failed. Lindane toxicity, as indicated by seizure and aplastic anemia, has not been reported when treatment was limited to the recommended 4-minute period. Permethrin has less potential for toxicity than lindane.

OTHER CONSIDERATIONS

The recommended regimens should not be applied to the eyes. Pediculosis of the eyelashes should be treated by applying occlusive ophthalmic ointment to the eyelid margins twice a day for 10 days. Bedding and clothing should be decontaminated (machine-washed, machine-dried using the heat cycle, or dry-cleaned) or removed from body contact for at least 72 hours. Fumigation of living areas is not necessary. Patients with pediculosis pubis should be evaluated for other STDs.

Followup

Patients should be evaluated after 1 week if symptoms persist. Re-treatment might be necessary if lice are found or if eggs are observed at the hair-skin junction. Patients who do not respond to one of the recommended regimens should be re-treated with an alternative regimen.

Management of Sex Partners

Sex partners within the previous month should be treated. Patients should avoid sexual contact with their sex partner(s) until patients and partners have been treated and re-evaluated to rule out persistent disease.

Pregnancy

Pregnant and lactating women should be treated with either permethrin or pyrethrins with piperonyl butoxide; lindane is contraindicated in pregnancy.

HIV-Infection

Patients who have pediculosis pubis and also are infected with HIV should receive the same treatment regimen as those who are HIV-negative.

Scabies

The predominant symptom of scabies is pruritus. Sensitization to Sarcoptes scabiei occurs before pruritus begins. The first time a individual is infested with S. scabiei, sensitization takes up to several weeks to develop. However, pruritus might occur within 24 hours after a subsequent re-infestation. Scabies in adults frequently is sexually acquired, although scabies in children usually is not.

Lindane is not recommended as first-line therapy because of toxicity. It should only be used as an alternative if the patient cannot tolerate other therapies or if other therapies have failed. Lindane should not be used immediately after a bath or shower, and it should not be used by individuals who have extensive dermatitis, women who are pregnant or lactating, or children under 2 years of age. Lindane resistance has been reported in some areas of the world, including parts of the United States.

Seizures have occurred when lindane was applied after a bath or used by patients who had extensive dermatitis. Aplastic anemia after lindane use has been reported. Permethrin is effective and safe and less expensive than ivermectin. One study demonstrated increased mortality among elderly, debilitated individuals who received ivermectin, but this observation has not been confirmed in subsequent reports.

OTHER CONSIDERATIONS

Bedding and clothing should be decontaminated (either machine-washed, machine-dried using the hot cycle, or dry cleaned) or removed from body contact for at least 72 hours. Fumigation of living areas is unnecessary.

CRUSTED SCABIES

Crusted scabies (Norwegian scabies) is an aggressive infestation that usually occurs in immunodeficient, debilitated, or malnourished individuals. Patients who are receiving systemic or potent topical glucocorticoids, organ transplant recipients, mentally retarded or physically incapacitated individuals, HIV-infected or human T-lymphotrophic virus-1-infected individuals, and individuals with various hematologic malignancies are at risk for developing crusted scabies. Crusted scabies is associated with greater transmissibility than scabies. No controlled therapeutic studies for crusted scabies have been conducted, and the appropriate treatment remains unclear.

Substantial treatment failure might occur with a single topical scabicide or with oral ivermectin treatment. Some specialists recommend combined treatment with a topical scabicide and oral ivermectin or repeated treatments with ivermectin 200 μg/kg on days 1, 15, and 29. Lindane should be avoided because of the risks for neurotoxicity with heavy applications or denuded skin. Patient's fingernails should be closely trimmed to reduce injury from excessive scratching.

Followup

Patients should be informed that the rash and pruritus of scabies might persist for up to 2 weeks after treatment. Symptoms or signs that persist for more than 2 weeks can be attributed to several factors. Treatment failure might be caused by resistance to medication or by faulty application of topical scabicides. Patients with crusted scabies might have poor penetration into thick scaly skin and harbor mites in these difficult-to-penetrate layers. Particular attention must be given to the fingernails of these patients. Re-infection from family members or fomites (infected inanimate objects) might occur in the absence of appropriate contact treatment and washing of bedding and clothing. Even when treatment is successful and reinfection is avoided, symptoms can persist or worsen as a result of allergic dermatitis.

Finally, household mites can cause symptoms to persist as a result of cross-reactivity between antigens. Some specialists recommend re-treatment after 1 to 2 weeks for patients who are still symptomatic; others recommend re-treatment only if live mites are observed. Patients who do not respond to the recommended treatment should be re-treated with an alternative regimen.

Management of Sex Partners and Household Contacts

Both sexual partners and close individual or household contacts within the preceding month should be examined and treated.

Managing Epidemics

Scabies epidemics frequently occur in nursing homes, hospitals, residential facilities, and other communities. Control of an epidemic can only be achieved by treatment of the entire population at risk. Ivermectin can be considered in this setting, especially if treatment with topical scabicides fails. Epidemics should be managed in consultation with a specialist.

Infants, Young Children, and Pregnant or Lactating Women

Infants, young children, and pregnant or lactating women should not be treated with lindane. They can be treated with permethrin. Ivermectin is not recommended for pregnant or lactating patients. The safety of ivermectin in children who weigh <15 kg has not been determined.

HIV-Infection

Patients who have uncomplicated scabies and also are infected with HIV should receive the same treatment regimens as those who are HIV-negative. HIV-infected patients and others who are immunosuppressed are at increased risk for crusted scabies. Ivermectin has been reported to be useful in small, noncontrolled studies. Such patients should be managed in consultation with a specialist.

ILLITERACY AND HEALTH

Illiteracy is often silent, yet it is a potentially deadly problem in healthcare. In a field where vocabulary is unfamiliar to many and information is often presented at the college level (despite the fact that the average American reads at the eighth-grade level!) a client who has difficulty reading or calculating numbers is at a terrible disadvantage when it comes to understanding what they need to be healthy (Marcus, 2006).

A client's language difficulties, which may range from poor skills to no skills, may be the result of:

• Never having acquired reading and calculating skills
• Having had them but lost them due to an illness or accident
• Possessing them only in another language

The problem is frequently made worse by the shame and embarrassment that research has shown often accompanies illiteracy. It is a situation requiring tact and understanding on the part of healthcare staff (Marcus, 2006).

All clients benefit when healthcare providers:

• Develop an awareness of signs that may indicate a patient cannot read
• Learn simple tests to quietly confirm that suspicion
• Work out alternative methods to convey medical information

The lack of reading or calculating skills should be considered in when a client is noncompliant, and staff should be alert when clients repeatedly say they cannot fill out a form because they "forgot their reading glasses" or "have a headache." Once aware of a possible problem, diagnostic techniques can be as simple as handing a client an instruction sheet upside down and asking them to read it out loud, watching to see if they turn it right side up before they begin (Ratnayake, 2006).

Alternative methods for delivering information requires adapting the information to the needs of clients. Be aware that even simple pictures do not always have shared meanings. Healthcare providers need to familiarize themselves with the literature on the subject and the resources that are currently available. For example, Medlineplus, an online medical information provider, includes over 160 strictly audio/video presentations on common illnesses, tests, and procedures (Doyle, 2003).

Remember too that office staff are often in a position to notice any problems clients may have with forms (Marcus, 2006). Be sure to share your knowledge!

Posted November 10, 2006

Expires December 1, 2008

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