Week 10

Question 1

STBBI’s and Public Health

Answer 1

Are a significant health issue in Canada
STBBI’s are infections that are spread through insertive and receptive sexual practices with someone who is carrying the infection
Some viral STBBI’s like genital herpes, and HPV can be transmitted by intimate skin-to skin contact
STBBIs like HIV and Hep B are carried and transmitted through the blood
People affected often encounter stigma and discrimination which may elicit reactions
such as anxiety, fear and shame

Question 2

History of STBBI’s

Answer 2

“Venereal disease” (VD) was defined as a disease
that was only transmitted by sexual intercourse
Term was used for centuries
In the 1970’s the term “VD” was viewed as
inaccurate and replaced by sexually transmitted
disease (STD)

Question 3

Sexually Transmitted Disease

Answer 3

Defined as a disease that could be transmitted from person to person through
sexual intercourse
OR intimate contact with genitals, mouth, or rectum
The term sexually transmitted infection (STI) became preferred in 2006 in
Canada
Encompassing term that includes infections that may be asymptomatic

Question 4

Blood Borne Infection

Answer 4

Used when referring to infections that could be
carried and transmitted through the blood
Sexually transmitted and blood-borne
infections (STBBI)
Used when referring to both STIs and BBIs

Question 5

Healthy Public Policy

Answer 5

Prior to discovering antibiotics, bacterial STBBI’s weren’t treatable
At one point public policy was implemented to test men and
women for syphilis prior to marriage
An anti-VD campaign emerged in the 1920’s that targeted both
education and treatment
Social stigma influenced both doctors and patients to the extent
that infections were rarely reported
To help, municipalities sent their PH nurses to Toronto to train
with the city’s VD division for 3 months

Question 6

Healthy Public Policy prt 2

Answer 6

Resulted in politicians questioning funding and
cutting back on funds
First World War STD rates: 222 per 1000 people
Second World War STD rates 92 per 1000 people
A significant catalyst for change in the 1980’s was
the appearance of AIDS

Question 7

Current Healthy Public Policy

Answer 7

Screening for HIV, syphilis, chlamydia, gonorrhoea, and hepatitis B at the first prenatal
visit
BBI screening with blood products (blood safety)
Immunization Partnership Fund
Public Health Surveillance (HIV & AIDS, Gonorrhoea, Hep B + C, Syphilis)

Question 8

Blood Safety Contribution Program

Answer 8

Supports the development and enhancement of provincial and
territorial systems to monitor errors and adverse events
associated with blood/blood product transfusions
Also includes transplantation of cells, tissues, and organs

Question 9

Canadian Blood Services

Answer 9

Mandated to provide Canada with safe, secure, and affordable
blood and blood components systems
Has been managing Canada’s blood system since 1998, and
there has not been any recorded instances of blood-borne
infections like Hep C or HIV

Question 10

STBBI

Answer 10

Categorized as bacterial, viral or ectoparasitic infections
A person who has one STBBI is at risk for others
All insertive and receptive sexual practices (oral, vaginal, anal) put people at risk for
STBBIs

Question 11

Bacterial STI’s

Answer 11

Most commonly reported are chlamydia, gonorrhea, and
syphilis
Chlamydia & gonorrhea are primarily transmitted through
unprotected vaginal and anal sex
Less often through unprotected oral intercourse
Infection can also pass from mother to newborn baby during
delivery
Very common for people to be asymptomatic

Question 12

Chlamydia

Answer 12

Cause by Chlamydia trachomatis (C.trachomatis)
Symptoms typically appear within 1-3 weeks after
having unprotected sex
Transmitted through vaginal, anal, and oral sex
Can be transmitted from mother to child during
childbirth
Women may contract chlamydia in the cervix,
rectum, and throat
Men may contract chlamydia in the urethra,
rectum, and throat

Question 13

Chlamydia In Canada

Answer 13

Rates have been rising steadily since 1997
Attributed to improved lab testing + screening
People not consistently using safer sex methods
Disproportionately affects sexually active youth and young adults, especially women ages
15-24 in Canada
Estimated 127 million cases globally in 2018
In 2018, three quarters (76.1%) of cases were among people less than 30 y/o
Females accounted for the majority of cases

Question 14

Chlamydia and Women

Answer 14

Can lead to:
Pelvic inflammatory disease (PID)
Tubal factor infertility
Ectopic pregnancy
Chronic pelvic pain

In pregnancy:
Premature birth
Eye infection + pneumonia for baby

70% of infected women have no
symptoms and are unaware of their
condition
PID effects include: abdo pain, fever,
internal abscesses, long term pelvic pain
+ scarring of the fallopian tubes

Symptoms:
Cervicitis: mucopurulent
endocervical discharge, easily
induced endocervical bleeding
Urethritis: pyuria, dysuria, urinary
frequency

Question 15

Chlamydia and Men

Answer 15

Can lead to:
Lymphogranuloma venereum (LGV) which
is caused by C.trachomatis
LGV can cause proctitis (inflammation of
the lining of the rectum)
LGV has been the recent cause of proctitis
outbreaks among gay, bisexual, and other
men who have sex with men worldwide
(CDC, 2022)
50% of infected men have no
symptoms and are unaware of
their condition

Symptoms:
Urethritis: Discharge from the penis,
typically mucoid or watery
Burning sensation when urinating (dysuria)
Burning or itching at the opening of the
penis
Epididymitis: unilateral testicular pain,
tenderness, and swelling

Question 16

Rectal Chlamydia

Answer 16

Affects both men and women
Rectal Symptoms:
Rectal pain
Bleeding
Discharge
Mucous with stools
Painful bowel movements

Question 17

Ocular Chlamydia

Answer 17

Affects both men and women
Occurs through contact with infected genital secretions
Eye Symptoms:
Appear after 2-6 weeks
Chlamydial conjunctivitis (pink/red eye)
Mucous discharge
Crusting of the lashes
Tearing
Photophobia
Foreign body sensation
Decreased vision

Question 18

Chlamydia: Recommended Treatment

Answer 18

Non-LGV Strains = 1 gram PO Azithromycin single
dose
Or Doxycycline 100mg PO BID x 7 days
LGV Strains
Doxycycline 100mg PO BID x 21 days

Question 19

Dosage Calc

Answer 19

Order: Azithromycin 1gram PO x1 now
Available: Azithromycin 250mg tabs
How many tabs will you administer?

Order: Doxycycline 100mg PO BID x 7days
Available: Doxycycline 100mg capsules
How many tabs will the client receive from
the pharmacy when they fill this script?

Question 20

Gonorrhoea

Answer 20

Caused by the bacteria Neisseria gonorrhoea
Often referred to as “the clap” or “the drip”
Can cause infection in the penis, vagina, cervix, anus, urethra, throat
and eyes
Bacteria is carried in the semen and vaginal fluids
Spread by having vaginal, anal, or oral sex with someone who has
gonorrhea
A pregnant person with gonorrhea can give the infection the baby
during childbirth
Symptoms usually develop within 2 weeks of infection
Best way of preventing is condom and dental dam use every time you
have sex

Question 21

Gonorrhea In Canada

Answer 21

Has been notifiable since 1924 and is the second most commonly reported bacterial STI in
Canada
Rates have been increasing since 2012, and have been increasing by 9.4% per year
In 2018, 30,874 cases were reported nationally = 95.8 cases per 100,000 people
Highest number of cases were reported in the most populated provinces:
Ontario 33.8%
Quebec 24.4%
Alberta 16.2%

Question 22

Gonorrhea and Women

Answer 22

Unusual vaginal discharge that may be
thin, watery and green, or yellow in
colour
Dysuria
Pain or tenderness in the lower
abdominal area
Bleeding between periods, heavier
periods, and bleeding after sex

Question 23

Gonorrhoea and Men

Answer 23

Unusual discharge from the
tip of the penis, which may
be white, yellow or green
Dysuria
Inflammation of the foreskin
Pain or tenderness in the
testicles

Question 24

Gonorrhoea in the Rectum, Throat, or Eye

Answer 24

Both men and women may develop an infection by having
unprotected anal or oral sex
If infected semen or vaginal fluid come into contact with the eyes,
you can also develop conjunctivitis
If the eyes are infected, one may experience pain, photophobia,
and purulent drainages from one or both eyes
Infection in the rectum can cause:
Discomfort, pain, itching, discharge, spots of bright red blood
on toilet tissue
Infection in the throat can cause:
Sore throat and swollen lymph nodes in the neck

Question 25

Management of Gonorrhoea

Answer 25

Recommended regime:
Ceftriaxone 250mg IM x1 +
Azithromycin 1gram PO x1
OR Doxycycline 100mg PO BID x 7
days

Question 26

Syphilis

Answer 26

Caused by the bacterium Treponema pallidum
Has been nationally notifiable since 1924
Average onset of first symptoms is 21 days, however can range from 10-90 days
If untreated, it progresses through primary, secondary, and early latent stages

Question 27

Syphilis in Canada

Answer 27

Rates are increasing in Canada
In 2018, 6,281 cases were reported nationally (16.9 cases per 100,000)
Nunavut reported the highest rate in Canada every year since 2012
Males comprise the majority of reported cases every year (85%)
Rates among women have been increasing over the past decade
Highest rates were among the 25-29 and 30-29 year old groups (49% of cases!)

Question 28

Syphilis Staging: Primary Most Infectious

Answer 28

Chancre sore or proctitis
Single sore or multiple are common
Sores appear where the syphilis entered the body, are usually firm, round small and
painless
Chancres last 3-6 weeks and will heal without treatment

Question 29

Syphilis Staging: Secondary Infectious

Answer 29

Begins with skin rash and mucous membrane lesions
Rash is rough, red or reddish brown spots on palms of hands, soles of feet, and/or
torso extremities, not usually itchy
Can also include fever, swollen lymph glands, sore throat, patchy hair loss, muscle
aches, fatigue, flu-like symptoms

Question 30

Syphilis Staging: Late stage not infectious

Answer 30

No symptoms identified at the time of medical visit
Infection has been identified to have occurred after the last 12 months (ie, no evidence of
any of the above stages in the past year)

Question 31

Syphilis S+S Primary

Answer 31

Chancre sores - are usually firm, round
and painless. On occasion are open
and wet
Chancres can show up on your vulva,
vagina, anus, penis, scrotum, lips or
mouth
They can be easy to mistake for an
ingrown hair

Question 32

Syphilis S+S Secondary

Answer 32

Secondary Stage
Rashes on the palms of your hands, soles of
your feet or other body parts
Not usually itchy
May develop mild flu-like symptoms (slight
fever, tired, sore throat, swollen glands,
headache, muscle aches)
Can also have sores in your mouth, vagina, or
anus
May note hair or weight loss
Can last 2-6 weeks at a time
and come and go for up to 2
years

Question 33

Syphilis S+S Late Stage

Answer 33

Late stages
Tumors
Blindness
Paralysis
Damage the nervous system, brain
and other organs
May result in death

Question 34

Management of Syphilis

Answer 34

Recommended regime:
Primary or Secondary syphilis: Penicillin G
benzathine 2.4 million units IM x1
Neurosyphilis: 2.4 million units IM qWeek
x3
Doxycycline, tetracycline, and possibly
ceftriaxone can be used in patients with
PCN allergy
Pregnant women should only be treated
with penicillin

Question 35

Dosage Calc

Answer 35

Order: 2.4 million units of Penicillin G IM X1 now
Available: 5 million units, to be diluted in 3.1 mL of
sterile water for injection, yielding an approximate
volume of 5mL total
How many mL will you administer IM?
Which IM site is the most appropriate + why?

Question 36

Viral STI’s

Answer 36

Genital herpes simples virus (HSV)
Human papilloma virus (HPV)
Both are non-reportable
Genital HSV and HPV are transmitted through intimate skin-skin sexual contact, can also be spread from mother to baby through childbirth (resulting in serious complications such as abnormal
development or death)
Untreated HSV 1 or 2 in the second half of pregnancy, carries a 30-50% risk of vertical transmission
Neonatal herpes can cause serious morbidity (including long-term neurological damage ie
cognitive dysfunction and learning disabilities) and high mortality

Question 37

HSV

Answer 37

HSV type 1 and 2 (2 is most common)
Either can cause genital infections, however HSV-2 rarely causes oral herpes
Often appear as one or a group of painful, itchy, fluid filled blisters in or around the genitals, buttocks, and/or thighs
May experiences burning while voiding, fever and flu-like symptoms, and swollen glands
Transmission occurs when both symptomatic and asymptomatic

Question 38

HSV Diagnostics

Answer 38

Viral identification “Nucleic Acid Amplification Test” (NAAT) or viral culture
HSV serology may be useful if testing isn’t available

Question 39

HSV Treatment

Answer 39

Oral acyclovir, famciclovir, valacyclovir within the first 3-4 days of
symptom onset for maximum benefit
Caesarean delivery is strongly recommended if a first episode of genital herpes occurs in the third trimester
Suppressive therapy is recommended for those with frequent (>6/year) or
highly symptomatic recurrences

Question 40

HSV Partner Notification

Answer 40

Not required as a public health measure
People are encouraged to inform their partners so that partners are aware of risk of infection

Question 41

HPV

Answer 41

HPV is one of the most common STI’s in Canada + worldwide
There are many types of HPV, some lead to cancer and others to skin lesions
It is estimated that as many as 75% of sexually active people will have at least one HPV
infection in their lifetime
Most peoples immune systems will eventually clear the infection
Only a small proportion of people will go on to develop cancer

Question 42

What Is HPV?

Answer 42

There is no cure for HPV infections but many symptoms are
treatable
Routine Papanicolaou (Pap) exams are important screening tools
for cervical cancer
3 vaccines are available to help prevent some types of HPV,
including strains that cause 7-% of anal and genital cancers +
90% of anogenital warts
HPV causes almost all cervical cancers, and is also linked to
cancer of the throat, oral cavity, penis, anus, vagina or vulva

Question 43

HPV Symptoms

Answer 43

Many people are asymptomatic
Anogenital warts are one sign, they look like small cauliflower
or may be flat
In women, warts may appear on the vulva, thigh, any, rectum, or in the vagina or urethra with the cervix being a common HPV site
Active infection will demonstrate a change in cells and will either become normal again or the cells slowly progress to cervical cancer
HPV DNA testing is available in Canada, but is not a part of women’s regular check-ups or Pap tests.
It isn’t covered by provincial/territorial health programs

Question 44

HPV Vaccines

Answer 44

Health Canada has authorized 3 vaccines
Gardasil, Gardasil 9 (for females and males), and Cervarix (for
females only)
Studies have found the vaccines to be safe
Vaccines cannot cause disease as they contain no live
biologicals or DNA
Vaccines do not contain any preservatives, thimerosal, or
mercury
If you are infected with one type of HPV, you can still benefit
from the vaccine
None of the vaccines have an impact on existing infection

Question 45

Gardasil+Gardasil 9

Answer 45

Protects against two high risk types of HPV (16 and 18) which
cause approximately 70% of anal and genital cancers
Also covers two low risk types of HPV (6 + 11) which cause
90% of anogenital warts
Gardasil 9 prevents up to an additional 14% of anogenital
cancers cause by HPV types 31, 33, 45, 52, 58
Vaccines are approved for females age 9-45 and in males 9-26
Involves one dose initially followed by one dose two months
later, and another dose given 6 months after the first dose
Not recommended for pregnant or lactating women

Question 46

Screening for STI’s

Answer 46

In 2018, 60% of Canadians reported never having been screened for STI’s
STI screening provides an opportunity to discuss transmission, signs and symptoms, risk reduction, and preventative measures
More frequent STI screening may be appropriate for individuals:
Who have had a previous STI diagnosis
New sexual partner
Multiple or anonymous sexual partners
Sexual partner(s) having a STI
Condomless sex
Sex while under the influence of alcohol or drugs

Question 47

BBI’s

Answer 47

Includes HIV, Hepatitis B, and Hepatitis C
Need special consideration as they are not solely transmitted by sexual activity
Transmission can also occur by reusing drug, tattooing, or piercing equipment that has
residual traces of infected blood
Hep B + C can be transmitted through sharing razors or toothbrushes
Can be transmitted from mother to neonate during pregnancy or birth
HIV can be transmitted through breast milk

Question 48

HIV/AIDS

Answer 48

Virus that attacks the body’s immune system
HIV is a manageable chronic condition
If left untreated, it causes a weakened immune system or acquired immune deficiency syndrome (AIDS)
In 2018 there was an estimated 62,050 people living with HIV in Canada - 85% being diagnosed and on treatment
An estimated 2,242 new HIV infections occurred in Canada in 2018
HIV is not transmitted through:
Kissing, hugging, toilet seats, sharing foods, shaking hands, or mosquito bites

Question 49

HIV/AIDS Symptoms

Answer 49

Some people may not develop symptoms after contracting HIV, and could remain undiagnosed until symptoms of AIDS
appear (this can be up to 10 years later)
50% or more of people living with HIV may develop the following within 2-4 weeks:
Chills
Fever
Fatigue
Joint Pain
Headache
Sore throat
Muscle aches
Swollen lymph nodes

Question 50

HIV Testing

Answer 50

Blood serum testing
Some are not able to detect the virus during the first 2-4 weeks of HIV infection, however the individual is still infectious
May repeat testing if it’s negative and there’s a possibility of having HIV
Anonymous testing
Rapid HIV testing (point of care)
Online testing

Question 51

Treating HIV

Answer 51

Treatment is highly effective, and can prevent HIV transmission
Client’s can be treated with antiretroviral medications as part of antiretroviral therapy
(ART)
Lower the level of HIV in the body (suppresses the viral load)
Slows the spread of the virus in your body
Helps the immune system fight off other infections

Question 52

Prep Medication

Answer 52

Highly effective HIV prevention strategy that HIV negative people
can use to lower risk
Involves taking antiretroviral (anti-HIV) drugs and having regular
medical appointments, monitoring, and supporting
When taken as prescribed, the risk of transmission is extremely low
Generally safe and well tolerated
Available by prescription
Two PrEP pills approved by Health Canada, both contain
emtricitabine + either tenofovir disoproxil or tenofovir alafenamide
Only covered under OHIP for those 24 years or younger, otherwise
costs $250-280/month in Ontario

Question 53

Post Exposure Prophylaxis

Answer 53

Can be taken after HIV exposure to help prevent infection
Should be started as soon as possible, up to a maximum of
72 hours afterwards
Very effective but will not prevent 100% of HIV
transmissions from occurring
Must have high adherence to the full course of PEP drugs
(4 weeks) and should have no further exposures to HIV
while taking PEP
PEP is a combination of three medications
Tenofovir disoproxil fumarate, emtricitbine, raltegravir
(or dolutegravir)

Question 54

Reducing Stigma About HIV

Answer 54

Reduce stigma by being respectful, compassionate and nonjudgemental
Model this behaviour for others when you witness stigmatizing
behaviours
When talking about HIV, be thoughtful of the words you use
Learn more about the facts of HIV:
Treatment lowers the viral load, making it too low to be measured in
blood tests and therefore undetectable
People on HIV treatment who maintain an undetectable viral load
have effectively no risk of transmitting HIV to their sexual
partners

Question 55

Hepatitis B

Answer 55

Is a liver disease spread by contact with infected body fluids,
including blood, semen and vaginal fluid
It is more infectious that HIV
Following infection, 50% of people are asymptomatic
50% will develop symptoms of fatigue, nausea, vomiting,
jaundice, decreased appetite, and arthralgia
Approximately 95% of healthy people will clear the virus, the
remaining will become chronic carriers
Those Hepatitis B may eventually develop liver cancer, liver
failure, or cirrhosis
Diagnosis is confirmed by blood tests and can be treated using
antiviral drugs

Question 56

Hepatitis B Vaccine

Answer 56

Four Hepatitis B-Containing Vaccines Available for Use in Canada
Engerix-B + Engerix-B Pediatric
Infanrix hexa, also contained diphtheria, tetanus toxoids, acellular
pertussis, hep B, inactivated poliomyelitis, and conjugated
Haemophilus influenza type B
Recombivax HB, Recombinvax HB - Pediatric, Recombivax-HB
Adult dialysis
Twinrix + Twinrix Junior, combined Hepatitis A and B
3 vaccine series over 6 months
Not covered under OHIP

Question 57

Hepatitis C

Answer 57

Is a liver disease caused by the hepatitis C virus (HCV)
Most commonly spread by percutaneous exposure with infected blood and
less commonly by sexual activity or perinatal exposure
Hepatitis C can progress to cause liver injury and eventually end-stage disease
Following infection, most people are asymptomatic
30% of people may experience fatigue, jaundice, or arthralgia
Approximately 45% of healthy people will spontaneously clear HCV
55-85% of people will develop chronic infection

Question 58

Hepatitis C Diagnosing

Answer 58

Diagnosis is made through serum blood testing
Treatment is highly effective and cures more than 95% of people of hepatitis C
Medications used are called “direct-acting antivirals” (DAAs), which block the ability of the HCV to
replicate
Being cured of hepatitis C, or a sustained virological response (SVR) is achieved after a negative/
undetectable HCV RNA test 12 weeks after the end of their treatment
Treatment is based on amount of liver injury, drug interactions, genotype/strain of the HCV, length of
treatment, and previous treatment experience

Question 59

Primordial Prevention STBBIs

Answer 59

Preventing STBBIs and risk factors from existing
Creation of programs and policies that keep youth off the streets, or advocating for
access to comprehensive sexual health education

Question 60

primary Prevention STBBIs

Answer 60

Refers to preventing the start of disease with the goal of decreasing incidence
Involves activities prior to any sign of disease, injury, or transmission of STBBIs
Includes the use of penile or male condoms + vaginal or female condom
*Remember condoms are not 100% effective in protecting against herpes or HPV
Vaccination is very valuable

Question 61

Secondary Prevention STBBI

Answer 61

Refers to early detection
Involves regular testing and screening for STBBIs, including blood testing, urine
samples, genital examination, and sometimes swabs

Question 62

Tertiary prevention STBBIs

Answer 62

Measures aimed at decreasing the progress of a disease and controlling long-term
negative consequences
Involves using medications to treat an infection
Manage symptoms

Question 63

Quarternary Prevention STBBIs

Answer 63

Methods to avoid results of unnecessary or excessive intervention
As new medications are developed for STBBIs, is it important to ensure patients are
not placed in any harm - ensuring consent is obtained in trials, and having the ability
to withdraw at any time