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Wellington SCL Newsletter
3rd August 2018

 

Please forward this email to all clinical staff

Please find the latest information from your laboratory provider Wellington SCL.  In this newsletter we cover:

  • Syphilis update: the epidemic continues
  • Faecal occult blood testing (FOBT)
     

Syphilis update: the epidemic continues

The Wellington region is experiencing a syphilis epidemic, as are other parts of the country and the world. Men who have sex with men appear to be the “core group”, but increasing numbers of heterosexual men and women are being diagnosed with active syphilis. Three women were detected as part of antenatal screening in this region in the past 18 months, which serves as an extra reminder that syphilis is spreading to groups who don’t expect it (neither do many doctors, so they don’t test).
 
Syphilis, yaws and other treponemal infections are diagnosed serologically in this region. The first test performed in the lab is an enzyme immunoassay (EIA) which remains positive for life after infection, and usually appears around or soon after the initial infection (chancre). Activity of infection and response to treatment is determined with the RPR, which will fall (sometimes slowly) with successful treatment.
 
The graph below shows that more screens are being done, and a greater proportion are positive. These figures include repeats.

 
The graph below shows the number of new diagnoses of active syphilis (ie no repeats with an RPR of 1:4 or more).
The graph above shows that the numbers are steadily increasing over the past 12 months. Wellington Sexual Health Service data show that numbers have been increasing since 2013, but the current laboratory dataset extends only back to March 2017.
 
The graph below shows that all ages are affected, apart from those under the age of 20.
13% of active cases are female.  Not included in the current dataset is one baby with congenital syphilis born in this region recently.
 
To reiterate recent the recent alert from the Wellington Sexual Health service:
Consider syphilis:
  • For non-itchy rashes, particularly when affecting palms of hands and soles of feet
  • In MSM and their sexual partners
  • When testing for chlamydia or gonorrhoea
  • Vertigo or uveitis
  • Neurological syndromes
 
Treatment varies according to stage and extent of infection. Cases therefore need proper assessment, treatment and contact tracing.
 
Discuss any cases of suspected infectious syphilis and their sexual contacts with clinicians at Wellington Sexual Health Service, 04 3859879 or 0800 188881. Call our clinical microbiologists for any testing issues, including interpretation, although all positive results are reviewed by a microbiologist.
 
For more clinical and patient information on syphilis visit:

Faecal occult blood testing (FOBT) should be for asymptomatic screening purposes only

As you know, the National Bowel Screening Programme is being rolled out across New Zealand but is not expected to be established in the Wellington region within the next year or two. Wellington SCL currently provides FOBT although it is not funded under DHB contracts.

FOBT is not recommended for use as a diagnostic tool for patients with symptoms or signs which could be explained by acute GI infection or bowel cancer, such as unexplained anaemia or altered bowel habit. (See the 3D HealthPathways and other guidelines such as BPAC (June 2012: Appropriate use of the faecal occult blood test http://www.bpac.org.nz/BT/2012/docs/best_tests_jun2012_faecal_occult_pages_19-21.pdf
In particular, the laboratory currently rejects FOBT requests when requests for faecal pathogens are alsorequested from the same specimen. This is because the test will not be meaningful in the setting of infectious diarrhoea.
Positive FOBT results may lead to invasive or expensive investigations. Patients with “red flags” for significant bowel pathology should undergo further evaluation regardless of FOBT result. Red flags for significant bowel pathology include:
  1. Unintentional weight loss
  2. Abdominal or rectal mass
  3. Blood in stool
  4. Unexplained iron deficiency anaemia
  5. Change in bowel habit lasting longer than six weeks
These patients should be referred to gastroenterology for further evaluation.  Further information is available at the 3D HealthPathways https://3d.healthpathways.org.nz/
The currently available test at Wellington SCL is more sensitive than the test provided through the bowel screening programme, and is therefore more likely to give insignificant positive results. It is also likely that patients will be charged for the test in the future. Some patients may wish to be tested before the bowel screening programme starts because of anxieties around developing bowel cancer in the interim. Suggested criteria could be:
  1. Age 60-74 years
  2. Family history of bowel cancer
  3. Asymptomatic or minor symptoms
  4. No previous FOBT within the last 2 years
However please note that asymptomatic patients with positive FOBT results are unlikely to be accepted for further investigation in the public system as per 3D HealthPathways https://3d.healthpathways.org.nz/
If you would like to discuss this further, please contact Drs Juliet Elvy or Tim Blackmore, Clinical Microbiologist, through the WSCL switchboard.
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