LA County Recommendations for Preventing Communicable Diseases in Men Who Have Sex with Men February 7, 2018 LA County Dept of Public Health, LA Public Health, Public Health 1185 Men who have sex with men (MSM) are at increased risk for certain health conditions. Over the past fourteen months, the Los Angeles County Department of Public Health (LAC DPH) has notified clinicians about a variety of outbreaks that have disproportionately impacted MSM. This article summarizes six steps providers can take to decrease their MSM patients' risk of these preventable communicable diseases. 1. Vaccinate to prevent invasive meningococcal disease The outbreak of invasive meningococcal disease (IMD) primarily among MSM continues in Southern California. In LA County, it is recommended that all MSM, regardless of HIV status or risk factors, be vaccinated to prevent IMD. Vaccinate all HIV-uninfected MSM patients with a single dose of the MenACWY vaccine (Menveo® or Menactra®) or provide a booster if it has been ≥5 years since the last vaccine dose. Vaccinate all HIV-infected MSM patients with 2 doses of MenACWY vaccine at least 8 weeks apart and a booster 5 years later and every 5 years thereafter throughout life. For the complete recommendations, vaccine schedule, and information on how to access vaccine, view the July 2017 Los Angeles Health Alert Network (LAHAN) advisory. Prevention messages including FAQs for MSM are available in English and Spanish on the LAC DPH meningococcal disease website. 2. Vaccinate to prevent hepatitis A A health alert was released on November 2, 2017, about a concerning increase in hepatitis A cases among MSM in LA County in 2017 compared with 2016. In addition, there are large outbreaks of hepatitis A among MSM nationally and internationally. In order to prevent a local outbreak, LAC DPH requests that clinicians: Follow the current Centers for Disease Control and Prevention (CDC) guidelines and vaccinate unvaccinated MSM to prevent hepatitis A. Consider vaccinating with the combined hepatitis A and hepatitis B vaccine (Twinrix®) to protect against both hepatitis A and B infections if not previously vaccinated for either infection. The CDC recommends vaccination against hepatitis A and B for all MSM in whom previous infection or vaccination cannot be documented.1 For detailed information on the prevention, recognition, and management of hepatitis A, view the November 2017 Rx for Prevention CME article, "Clinical Recognition and Management of Hepatitis A in the Context of an Ongoing Outbreak in Los Angeles County." Prevention messages including FAQs for MSM, a hepatitis A infographic, a handwashing infographic, and other patient materials are available in English and Spanish on the LAC DPH hepatitis A website. 3. Vaccinate to prevent mumps The LA County mumps outbreak, which spanned January to December 2017, predominately affected MSM and their close contacts. Clinicians are reminded that sporadic mumps cases continue to occur and to keep mumps in their differential when evaluating patients with acute orchitis, parotitis, or other salivary gland swellings. The CDC recommends that all adults without proof of immunity to mumps be vaccinated unless they have a medical contraindication like pregnancy or severe immunodeficiency: Single dose MMR recommended for most adults. Two MMR doses recommended for HIV-infected persons with CD4+T-lymphocyte count >200 cells/ul for at least 6 months. More information on the prevention of mumps can be found in the September 2017 Rx for Prevention CME article, "Recognizing and Managing Mumps in Adults". 4. Prevent multidrug-resistant Shigella by ordering antimicrobial susceptibility tests and limiting use of antibiotics In Los Angeles and other southern California counties in 2016, there was an outbreak of a rare strain of Shigella among MSM that was resistant to numerous antibiotics, which made it hard to treat and led to severe outcomes. Since 2016 in LA County, there has been an increase in annual Shigella cases reported among MSM. In April 2017, LAC DPH disseminated a Health Advisory regarding the CDC's identification of emerging Shigella strains with decreased susceptibility to fluoroquinolones and providing new recommendations for diagnosing and managing Shigella in MSM. Key points in the new guidance from the CDC and LAC DPH are related to identifying resistant cases (ordering stool samples with antimicrobial susceptibility testing whenShigella is suspected) and reducing unnecessary use of antibiotics (antibiotic therapy for Shigella is only recommended for patients who are immunocompromised or who develop severe illness). Local guidance for clinicians can be found on the LAC DPH Shigella website. Providers should help educate their MSM patients on how to prevent Shigella infections through hand washing and other infection control practices before, during, and after sex. Prevention messages for MSM, including FAQs and palm cards in English and Spanish, are available on the LAC DPH Shigella website. 5. Screen for sexually transmitted infections, including HIV Rates of HIV infection, early syphilis (primary, secondary, or early latent), gonorrhea, and chlamydia continue to rise among MSM in LA County and nationally. Among MSM, new HIV infections are associated with recent or concurrent STDs, particularly early syphilis. In LA County, 80% of early syphilis cases occurred among MSM. MSM in LA County remains at disproportionate risk for HIV acquisition and transmission, accounting for 85% of all new HIV diagnoses. LAC DPH estimates that the high rates of HIV infections among MSM are a result of the high rates of HIV infection among young (ages 18 – 29) black/African-American MSM. Clinicians should routinely ask male patients about STD-related risks, including the gender of their sex partners. MSM, including those with HIV infection, should be asked about risky sexual behaviors and offered STD and HIV testing and risk reduction counseling. As many infections are asymptomatic and substantial numbers of MSM remain unaware of their HIV serostatus (up to 44% in one recent survey of young men in minority populations),5 routine STD and HIV screening is important. The LAC DPH STD Screening Recommendations provide population screening recommendations, guidance on how to perform a brief sexual risk assessment, and information on risk factors that indicate the need for more frequent screening among MSM and other groups. The following is adapted from these recommendations LAC DPH STD and HIV Screening Recommendations for MSM STD Screening Recommendations Frequency Comments CT and GC (urine) CT and GC (rectal) GC (pharyngeal) Annually or more frequently if high-risk behavior As patients may underreport receptive anal and/or oral sex, consider an opt-out approach to testing e.g. say "for men who have sex with men, I routinely collect a mouth, rectal, and urine specimen." Syphilis Annually or more frequently if high-risk behavior HIV (if uninfected) Repeat screening every 3-12 months, as indicated by risk Hepatitis B Surface Antigen (HBsAg) At least once Hepatitis C At least annually if HIV-positive or injection drug user A fact sheet for MSM about STDs, including HIV, is available from the CDC. 6. Offer HIV pre-exposure prophylaxis (PrEP) to men at high risk of HIV acquisition Primary care providers should consider routinely offering PrEP to patients at increased risk of HIV infection. PrEP has been shown to decrease the risk of HIV acquisition by up to 99% when taken daily as prescribed. In order to decrease HIV acquisition in LA County, LAC DPH launched the Get PrEP LA campaign which provides information for both patients and clinicians. To learn more about PrEP, priority populations for PrEP, and how to obtain free CME, read the Rx for Prevention article, "HIV Prevention with PrEP" or view the LAC DPHwebinar. A fact sheet for patients about PrEP is available from the CDC. Detailed online information for patients can be found on the Get PrEP LA website. Conclusions These six communicable disease-related recommendations were selected as they relate to recent and/or ongoing outbreaks in LA County and reflect evidence-based clinical recommendations. By implementing these steps, clinicians can improve the health of their patients as well as the community. The complex factors that contribute to disparities in the rates of these communicable diseases, as well as other conditions among MSM (e.g. depression, substance use, injury), will be discussed in future issues of Rx for Prevention.