Transcript www.ssstdi.ie

Outbreak of Lymphogranuloma Venereum
(LGV) in the greater Dublin area
Presentation at SSSTDI meeting
29th November 2014
Dr. Fionnuala Cooney
Chair LGV Outbreak Control Team
Specialist in Public Health Medicine, HSE East
Presentation on behalf of the LGV OCT
GUIDE, St James’s Hospital
Prof Fiona Mulcahy
Dr Fiona Lyons
Dr Almida Lynam
Dr Shay Keating
HSE Health Promotion & Improvement
Ms Roisin Guiry
Ms Moira Germaine
Dublin Aids Alliance
Ms Susan Donlon
GUIDE and GMHS
Dr Susie Clarke
Dr Grainne Courtney
Ms Sile Dooley,
Mr MICK Quinlan, Manager
GMHS
HPSC
Dr Derval Igoe
Dept Public Health HSE East
Dr Coilín ÓhAiseadha
Microbiology St James’ Hospital
Dr Phil Downes,
Dr Brendan Crowley
Dr Fionnuala Cooney
Ms Mary Kelleher
Introduction

There have been 28 cases of LGV notified in the
greater Dublin area since May 2014 to date

An outbreak of LGV has been declared and an
Outbreak Control Team has been convened

This presentation will describe
–
–
–
Public Health importance of LGV
Investigation of the outbreak
Development and implementation of control measures
LGV : an infection of Public Health
importance

Causative pathogen: Chlamydia trachomatis types L1, L2, and L3.
The L2b strain is currently found in MSM

In contrast to serovars A-K which remain confined to the mucosa, serovar
Lstrains are invasive organisms that disseminate via underlying connective
tissue and spread to regional lymph nodes.

LGV is thought to account for 2 to 10% of genital ulcerative diseases in areas
such as India and Africa.

Outbreaks of LGV have been reported amongst MSM in Europe since 2003,
mainly in HIV positive men. In the UK there was a large increase in
diagnosed cases in 2009, peaking in mid-2010 – 75% in London, Brighton
and Manchester. Other Western countries reporting outbreaks include
Belgium, France, Germany, Sweden, USA and Canada.
Clinical features of LGV

Depending on the site of inoculation LGV can cause
– inguinal disease (usually after inoculation of the genitalia), or
– the anorectal syndrome (usually after inoculation via the rectum).

The disease course usually follows three separate stages.
– primary (transient papules and or ulceration) [1-3 weeks]
– secondary (inguinal lymphadenopathy and/or anorectal manifestations
[weeks to months]
– tertiary chronic stage characterised by fibrosis, strictures, fissures
lymphatic obstruction and genital elephantiasis [months to years]
2013 European Guideline on the
Management of LGV

In particular, HIV-positive MSM should be made aware of
recent trends in hepatitis C epidemiology

Recommend warning about the risks of unprotected anal sex,
serosorting, recreational drug use and mucosally-traumatic
sexual practices such as fisting

Also prudent to advise against sharing any equipment and to
wash equipment thoroughly after use. . . .also, enema use may
be implicated in transmission of LGV
http://www.iusti.org/regions/Europe/pdf/2013/LGV_IUSTI_gu
ideline_2013.pdf
Recognition of the problem

In September 2014 the Department of Public Health noted an
increase in lymphogranuloma venereum (LGV) notifications

Eight notifications of LGV had been received in the year up to
Sept, compared to between one and five notifications per year
for the previous four years

True increase or increased ascertainment, or both?

Clinicians and labs were consulted –they confirmed that there
was an increase in clinical cases presenting at GUIDE and
GMHS and that there had been no recent change in testing
process or practices in either clinics or in laboratories
Formation of OCT

Multidisciplinary OCT formed at meeting on 3rd Oct 2014

OCT is using the national STI Outbreak guidelines that are
currently under development

OCT has agreed plans to investigate and control the outbreak

Database has been developed in Dept of Public Health and this
has been prioritised for updating as the data comes through
from labs and clinics

Communication and co-ordination plans are in place as
management components of the work of the OCT
Distribution of LGV cases by week of notification
on CIDR, week 1-44
4.5
4
3
2.5
Week of notification
2
1.5
1
0.5
Week
44
43
42
41
40
39
38
37
36
35
34
33
32
31
29
28
27
26
25
24
23
22
0
21
No. of notifications
3.5
Distribution of time intervals for each LGV case displaying
week of onset of symptoms, week of laboratory confirmation and date of notification
on CIDR, week 1- 44, 2014
47
45
43
41
39
35
33
31
29
27
25
Week of LGV lab confirmation
23
Week of onset of symptoms
21
19
Week of notification on CIDR
17
Case Number
27
26
25
24
23
22CF
21
20
19CF
18
17CF
16CF
15CF
14CF
13CF
12
11CF
10CF
9CF
8
7
6
5CF
4
3
2
15
1
Week Number
37
Age distribution of LGV cases
Age distribution of LGV cases, week 1- 44, 2014
8
Years
Mean age
36.1
Mode
Median
35
35
7
6
No. of notifications
Summary
5
4
3
2
Range
26-55
1
0
<19
20-24
25-29
30-34
35-39
40-44
Age (years)
45-49
50-54
55-59
60-64
>64
Nationality and area of residence of LGV cases
Distribution of LGV cases by postcode, week 1-41
Count
10
Not specified
15
9
Ireland
7
7
Postcode
USA
Kildare
27
0
Dublin 24
Total
1
Dublin 16
1
2
Dublin 14
USA
3
Dublin 12
1
4
Dublin 7
Lithuania
Post Code
Dublin 1
1
5
Dublin 8
Brazil
6
Dublin 2
2
No. of notifications
France
8
Not specified
Nationality
Clinical presentation and sexual contacts
Symptoms & Signs
(avail. on 10 cases)
Sexual Contacts
Yes
No
Proctitis symptoms
9
1
Rectal pain
8
2

Information on number of
sexual contacts available on
eight cases to date:
– number of contacts ranged
from 1 to 15.
Rectal discharge
6
4
Bloody stools
4
6
Tenemus
2
8
Swollen lymph glands
1
9

Information on meeting
places available on 5 cases:
– Bar/Club 3
– Sauna
2
Other STI infections: current and past
HIV status:
HIV Pos 26
HIV Neg 2
Current co-infections reported as present in 12/27
Gonorrhoea 4
Syphilis 2
Previous STIs
Notifications of STIs in
HSE East, are being
checked on CIDR on
each LGV cases, back to
January 2013
HCV 1
Previous notification of STI on 15 out of 27 LGV cases
Gonorrhoea, 2
Syphilis, 8
Chlamydia, 9
Molecular Virology laboratory at St James’s
Hospital: sequence analysis of LGV isolates

Sequence analysis of outer membrane protein A (ompA) gene
including variable segment regions VS1 – VS4, has been
carried out on 10 of the isolates to date

Of these, 8 had sequences identical to Chlamydia trachomatis
strain L2, GenBank DQ 064295.1

This is a different variant to the L2b variant identified
previously in 2013 on LGV isolates

Results must be interpreted in conjunction with
epidemiological data

Sequencing of other isolates is in-progress
Enhanced surveillance

New enhanced surveillance form close to being devised to
investigate this outbreak.

It is building on existing enhanced surveillance form with
additional questions on
– clinical presentation and treatment
– HIV viral load
– acquisition of LGV - questions on sexual practices, use of protection,
serosorting behaviour etc
– use of alcohol & recreational drugs
– knowledge and information about LGV
National alert to clinicians and
laboratory personnel

A national alert was been sent to STI and HIV clinicians, clinical
microbiologists, gastroenterologists, and colorectal surgeons
advising:
– consideration of the possibility of LGV in HIV positive MSM with
proctitis or other lower GIT symptoms;
– urgent referral of all LGV cases to a STI specialist service;
– and reporting of LGV cases to local Director of Public Health.

In addition, Faculty of Pathology informed:
– LGV can mimic inflammatory bowel disease.
– LGV has no pathognomic histopathological features
Public Health Alert: National and Europe




All Directors of Public Health,
Director of Health & Wellbeing and
Dept of Health
HPSC sent alert to Epidemic Intelligence Information System
for Sexually Transmitted Infections (EPIS STI) which is a
surveillance system implemented to facilitate rapid reporting
and dissemination of unusual events related to STI
transmission across Europe.
Information sub-group:
information for men at risk

Leaflet for distribution to men at risk - new leaflet on LGV in
the LUV Bugs series. Also a poster has been developed to be
available to download and print

Advert placed in Gay Community News, Dec 2014 issue

New page on LGV on Man2Man website, available since 20th
Nov at: http://www.man2man.ie/lgv.html

Article planned for Jan 2015 edition of Gay community News to be written by PLHIV from Positive Now, with input and
support from information sub-group

Develop resource for personnel in clinics with recommended
acceptable terminology and language on sexual issues for MSM
New leaflet and poster on LGV in the LUV Bugs
series.
.
Other on-going work and planned reports

Sequence analysis of LGV isolates to continue to assist the
investigation

Work in progress to assess the proportion of HIV positive
MSM with LGV and assess burden of asymptomatic
infection– sample of 300 consecutive rectal chlamydia isolates
to be tested for LGV

Planned review of the cases of LGV in which there was a TOC
following one week of treatment with doxycline – to explore if
can be reported as a case series.

Epidemiological report from OCT once sufficient data on
cases available

Outbreak Control Team Report.
Conclusion

This is the first outbreak of LGV notified in Ireland

Investigation underway to identify risk groups and
risk activities - outbreak enhanced surveillance form

Laboratory work on sequencing of significant
assistance

Control measures include informing men at risk as
well as updating HIV/STI health service providers

STI/HIV clinic to play important role in raising
awareness and offering clinical assessment
Many Thanks
on behalf of LGV Outbreak
Control Team
Trends in Ireland
Table 1 Number of LGV
notification of 2010-2014*
Region
2010
2011
2012
2013
2014
HSE-E
2
2
1
5
28
N/A
N/A
N/A
0
0
5
28
National other
than HSE-E
Total