1 00:00:00,000 --> 00:00:12,480 Thanks for meeting us again at the Canadian Breakpoint, a Canadian infectious disease 2 00:00:12,480 --> 00:00:16,320 podcast by infectious disease physicians. 3 00:00:16,320 --> 00:00:21,920 I'm Summer Stewart, back again with Rupeena Purewal, paediatric infectious disease specialist, 4 00:00:21,920 --> 00:00:27,460 and for this episode, we welcome special guest Dr. Amita Singh, an infectious disease specialist 5 00:00:27,460 --> 00:00:33,280 from Edmonton, Alberta for discussion regarding the rising cases of syphilis in Canada. 6 00:00:33,280 --> 00:00:35,800 Dr. Purewal. 7 00:00:35,800 --> 00:00:39,320 Welcome to another episode of our podcast, the Canadian Breakpoint. 8 00:00:39,320 --> 00:00:43,680 Today we'll be discussing a very important topic, syphilis and the current situation 9 00:00:43,680 --> 00:00:46,400 in many provinces in Canada. 10 00:00:46,400 --> 00:00:50,920 As you may all be aware, syphilis is a reportable sexually transmitted infection that's caused 11 00:00:50,920 --> 00:00:54,160 by the organism tropenia pallidum. 12 00:00:54,160 --> 00:00:58,440 Living on the stage of syphilis in an individual, they are treated with a certain regimen and 13 00:00:58,440 --> 00:01:03,560 the first line of treatment, especially in pregnancy and in pediatrics is penicillin. 14 00:01:03,560 --> 00:01:09,360 Notably, if left untreated, syphilis has many complications and in all age groups. 15 00:01:09,360 --> 00:01:13,280 The risk factors are very similar to other sexually transmitted infections, but the alarming 16 00:01:13,280 --> 00:01:18,320 factor with syphilis is that we're seeing a steep increase in the number of cases in 17 00:01:18,320 --> 00:01:21,000 many provinces in Canada since 2014. 18 00:01:21,000 --> 00:01:25,120 Specifically, Alberta has shown us the greatest rise. 19 00:01:25,120 --> 00:01:29,840 Here in Saskatchewan, we've had an exponential increase in the last few years and specifically 20 00:01:29,840 --> 00:01:34,740 concerning that congenital syphilis has also increased and caused a rise in the number 21 00:01:34,740 --> 00:01:41,000 of stillbirths, hydroxpitalis and other preventable complications in neonates. 22 00:01:41,000 --> 00:01:46,220 So today we have a very special guest with us from Alberta who specializes in this area. 23 00:01:46,220 --> 00:01:49,240 So please join me in welcoming Dr. Amita Singh. 24 00:01:49,240 --> 00:01:54,440 Dr. Singh is an infectious diseases specialist and clinical professor with the University 25 00:01:54,440 --> 00:01:56,440 of Alberta in Edmonton. 26 00:01:56,440 --> 00:02:01,760 Her clinical practice and research areas of interest include bacterial sexually transmitted 27 00:02:01,760 --> 00:02:08,960 infections, HIV, biomedical prevention and rapid diagnostic tests for syphilis and HIV. 28 00:02:08,960 --> 00:02:10,400 So thank you, Dr. Singh. 29 00:02:10,400 --> 00:02:14,900 We look forward to hearing from you about your thoughts on this topic. 30 00:02:14,900 --> 00:02:16,320 Thank you for having me. 31 00:02:16,320 --> 00:02:17,320 Perfect. 32 00:02:17,320 --> 00:02:22,840 So why don't we start with just discussing the situation currently in Alberta in regards 33 00:02:22,840 --> 00:02:24,560 to the syphilis outbreak. 34 00:02:24,560 --> 00:02:26,000 Sure. 35 00:02:26,000 --> 00:02:33,160 So you're probably aware that in 2019, our chief medical officer of health declared a 36 00:02:33,160 --> 00:02:42,440 syphilis outbreak in Alberta after seeing syphilis rates in the province rising manyfold 37 00:02:42,440 --> 00:02:46,880 and the highest rates seen since 1948. 38 00:02:46,880 --> 00:02:54,440 And despite the COVID pandemic, that trend continued in 2020, even though I understand 39 00:02:54,440 --> 00:03:00,000 that there has been decreased testing following the onset of the pandemic. 40 00:03:00,000 --> 00:03:06,800 We had a record number of cases, 2,500 infectious syphilis cases in the province in 2020. 41 00:03:06,800 --> 00:03:15,920 And sadly, 135 infants born with congenital syphilis with about 30 infants who died as 42 00:03:15,920 --> 00:03:18,400 a result of congenital syphilis. 43 00:03:18,400 --> 00:03:28,680 So very alarming to see that happen here in Alberta and of course, appearing to continue 44 00:03:28,680 --> 00:03:30,160 into 2020. 45 00:03:30,160 --> 00:03:32,600 Yeah, for sure. 46 00:03:32,600 --> 00:03:34,240 Definitely seeing an increase there. 47 00:03:34,240 --> 00:03:39,160 So why do you think this is an issue in the Prairie provinces specifically or in Alberta? 48 00:03:39,160 --> 00:03:43,880 Or do you think it is limited to that? 49 00:03:43,880 --> 00:03:49,840 We do seem to be seeing the highest rates of infectious syphilis in the Prairie provinces. 50 00:03:49,840 --> 00:03:58,880 And if we look at the cases to try to understand why that is happening, it is very clear that 51 00:03:58,880 --> 00:04:04,960 Indigenous persons, particularly those of First Nations ethnicity are disproportionately 52 00:04:04,960 --> 00:04:06,560 affected. 53 00:04:06,560 --> 00:04:16,920 And we know that Edmonton, for example, which has the highest number of cases in Alberta, 54 00:04:16,920 --> 00:04:25,120 has the second highest urban population of First Nations and Métis persons. 55 00:04:25,120 --> 00:04:32,840 And so that's definitely, unfortunately, the individuals who are being affected. 56 00:04:32,840 --> 00:04:39,520 If we look at the breakdown of the cases, we see that about half of the cases are among 57 00:04:39,520 --> 00:04:45,560 females and usually of childbearing age. 58 00:04:45,560 --> 00:04:53,440 And many of those women are affected by multiple social determinants of health, including homelessness, 59 00:04:53,440 --> 00:04:59,160 poverty, addictions and mental health problems. 60 00:04:59,160 --> 00:05:07,280 So I think another thing that we have observed in the last few years in the Prairie provinces 61 00:05:07,280 --> 00:05:11,600 is a significant rise in the use of methamphetamines. 62 00:05:11,600 --> 00:05:16,680 And methamphetamines, as you know, are drugs that act as stimulants and they also increase 63 00:05:16,680 --> 00:05:25,720 the sex drive and disinhibit behavior and makes it more likely for people to engage 64 00:05:25,720 --> 00:05:31,980 in unprotected sexual behavior that puts them at risk for syphilis. 65 00:05:31,980 --> 00:05:38,800 So we're actually in the process of taking a closer look at the link between stimulant 66 00:05:38,800 --> 00:05:42,280 drug use and syphilis in our province. 67 00:05:42,280 --> 00:05:50,320 But just anecdotally, I really feel that that is a very strong component of what is happening 68 00:05:50,320 --> 00:05:55,040 or part of the explanation for what is happening with infectious syphilis. 69 00:05:55,040 --> 00:06:05,920 And we have heard that many of the women are trading sex for drugs. 70 00:06:05,920 --> 00:06:08,880 And this is the unfortunate consequence. 71 00:06:08,880 --> 00:06:12,280 Yeah, it's a very difficult situation. 72 00:06:12,280 --> 00:06:16,840 I mean, it's definitely multifactorial in terms of management wise. 73 00:06:16,840 --> 00:06:18,320 And yes. 74 00:06:18,320 --> 00:06:24,560 So currently with, I mean, we're here in Saskatchewan having, I think, from 2018, we've had a six 75 00:06:24,560 --> 00:06:28,400 fold increase in our syphilis cases. 76 00:06:28,400 --> 00:06:32,260 And it goes along with other sexually transmitted infections. 77 00:06:32,260 --> 00:06:39,360 So we've seen a rise in our other sexually transmitted infections since kind of the methamphetamine 78 00:06:39,360 --> 00:06:41,840 numbers have increased as well. 79 00:06:41,840 --> 00:06:49,280 So in terms of provinces facing this obstacle, I know that you're currently involved in a 80 00:06:49,280 --> 00:06:55,000 point of care study regarding syphilis testing. 81 00:06:55,000 --> 00:06:59,880 So can you talk a little bit about kind of what brought you to kind of start this study 82 00:06:59,880 --> 00:07:05,540 in Alberta specifically and kind of the design and the model and maybe some of the other 83 00:07:05,540 --> 00:07:10,560 provinces can get some input from you in regards to that? 84 00:07:10,560 --> 00:07:12,820 Yes, for sure. 85 00:07:12,820 --> 00:07:24,320 So with the observation that many of our cases are street involved and have pretty significant 86 00:07:24,320 --> 00:07:31,460 mistrust of the traditional health care system, when we first experienced a resurgence of 87 00:07:31,460 --> 00:07:41,400 infectious syphilis in the mid 2000s, an outreach team was formed in Edmonton, which includes 88 00:07:41,400 --> 00:07:45,720 nurses and community health representatives. 89 00:07:45,720 --> 00:07:50,120 And all of those community health representatives or Aboriginal service workers, as they're 90 00:07:50,120 --> 00:07:58,360 now called, are Indigenous and have some lived experience as well. 91 00:07:58,360 --> 00:08:08,120 And that team, in my opinion, has been invaluable in going out literally onto the streets to 92 00:08:08,120 --> 00:08:12,880 reach people and to offer testing and treatment right there and then. 93 00:08:12,880 --> 00:08:18,920 Unfortunately, the COVID pandemic has put the brakes on that for now, but I'm really 94 00:08:18,920 --> 00:08:25,220 hoping that we will be able to resume those activities very soon. 95 00:08:25,220 --> 00:08:32,640 So the team is able to go out into the community and they're able to do blood draws and to 96 00:08:32,640 --> 00:08:34,680 collect urine samples. 97 00:08:34,680 --> 00:08:39,440 And if people meet certain criteria, so for example, if they're named as a sexual contact 98 00:08:39,440 --> 00:08:46,280 to a known infectious case, or if they report symptoms suggestive of infectious syphilis, 99 00:08:46,280 --> 00:08:49,740 the team are able to offer treatment right there and then. 100 00:08:49,740 --> 00:08:56,280 So it may be in a community agency, for example, or in an inner city health clinic. 101 00:08:56,280 --> 00:09:01,880 And on some occasions, it's even been done in the individual's home, or if they have 102 00:09:01,880 --> 00:09:06,760 some sort of enclosed situation. 103 00:09:06,760 --> 00:09:12,480 I remember several years ago going out with our outreach team and actually reaching people 104 00:09:12,480 --> 00:09:16,840 who are living in tents in the River Valley here in Edmonton. 105 00:09:16,840 --> 00:09:21,320 So it is possible and feasible to do this. 106 00:09:21,320 --> 00:09:26,080 One of my wish lists for many years has been for us to have a mobile van that would make 107 00:09:26,080 --> 00:09:27,080 this a lot easier. 108 00:09:27,080 --> 00:09:28,080 For sure. 109 00:09:28,080 --> 00:09:32,920 For a number of logistical reasons, we haven't been able to do that. 110 00:09:32,920 --> 00:09:40,720 All that being said, we came to realize that although we could offer blood draws and urine 111 00:09:40,720 --> 00:09:45,840 tests, it would then take up to a week for those test results to come back. 112 00:09:45,840 --> 00:09:49,720 And then it would be very difficult to find those individuals, especially if they didn't 113 00:09:49,720 --> 00:09:52,080 have a fixed address. 114 00:09:52,080 --> 00:09:56,440 And so this is where I think point of care tests are invaluable. 115 00:09:56,440 --> 00:10:05,200 Not only do we have the opportunity to test and treat right there and then, but we also 116 00:10:05,200 --> 00:10:11,080 prevent ongoing complications if you are able to test and treat immediately and prevent 117 00:10:11,080 --> 00:10:16,880 mother to child transmission, as well as prevent transmission to partners. 118 00:10:16,880 --> 00:10:22,400 So this began the search, I guess, for a good syphilis test. 119 00:10:22,400 --> 00:10:26,560 There are a number of syphilis tests on the global market. 120 00:10:26,560 --> 00:10:33,520 A little over 10 years ago, we did try one test in the field, but unfortunately, that 121 00:10:33,520 --> 00:10:38,040 test did not work very well for us because it took too long. 122 00:10:38,040 --> 00:10:44,960 And by too long, I mean that it took about 20 to 25 minutes, but for truly field use, 123 00:10:44,960 --> 00:10:48,560 that wasn't very practical. 124 00:10:48,560 --> 00:10:55,000 And our field staff are not supportive of that because it was also a little bit cumbersome 125 00:10:55,000 --> 00:10:57,120 to perform in the field. 126 00:10:57,120 --> 00:11:00,120 And so we never moved ahead with that. 127 00:11:00,120 --> 00:11:09,480 So fast forward now 10 to 15 years later, we're an even worse syphilis outbreak situation. 128 00:11:09,480 --> 00:11:17,160 And so I once again had a look at the available tests on the global market and came across 129 00:11:17,160 --> 00:11:22,960 two tests that could provide test results in under five minutes. 130 00:11:22,960 --> 00:11:26,880 And so of course, that was very exciting. 131 00:11:26,880 --> 00:11:32,440 Both happened to be made by Canadian companies, one in Vancouver, at BioLitical, and one in 132 00:11:32,440 --> 00:11:34,920 Halifax, Medmyra. 133 00:11:34,920 --> 00:11:43,080 And with the support from the companies, as well as the support from REACH, we were able 134 00:11:43,080 --> 00:11:47,480 to obtain funding and to develop a study. 135 00:11:47,480 --> 00:11:50,160 So we have implemented that study. 136 00:11:50,160 --> 00:11:55,240 And our goal was to enroll about 1500 participants. 137 00:11:55,240 --> 00:11:59,820 And we're currently just under halfway in terms of enrollment. 138 00:11:59,820 --> 00:12:05,200 We had actually hoped to complete enrollment within six to seven months, but then the pandemic 139 00:12:05,200 --> 00:12:06,200 hit. 140 00:12:06,200 --> 00:12:13,200 And so continuing the study has been very slow. 141 00:12:13,200 --> 00:12:18,960 But I am hoping that we will be able to complete the study by the end of the year. 142 00:12:18,960 --> 00:12:26,560 The preliminary results suggest that both test kits perform very well in the field using 143 00:12:26,560 --> 00:12:29,400 finger prick whole blood specimens. 144 00:12:29,400 --> 00:12:36,520 And we have been able to offer point of care testing as well as treatment to all individuals. 145 00:12:36,520 --> 00:12:41,120 And very interesting, we've picked up a number of new cases. 146 00:12:41,120 --> 00:12:50,560 And we have been able to offer treatment to everyone immediately if they so wish. 147 00:12:50,560 --> 00:12:54,820 And what has been interesting to me is that everyone that we've offered point of care 148 00:12:54,820 --> 00:12:58,320 treatment to has accepted that. 149 00:12:58,320 --> 00:13:06,000 So we explain the potential benefits of treatment, but also the small potential risks, which 150 00:13:06,000 --> 00:13:12,240 include, of course, anaphylaxis and providing treatment that wasn't necessary. 151 00:13:12,240 --> 00:13:17,720 And despite that, most people have gone ahead with treatment provided there and then. 152 00:13:17,720 --> 00:13:24,680 The vast majority of our testing has been done by one of our part of notification nurses 153 00:13:24,680 --> 00:13:28,640 who works at the Edmonton Remand Center. 154 00:13:28,640 --> 00:13:36,880 And so that is another setting where we have had very high rates of loss to follow up after 155 00:13:36,880 --> 00:13:39,840 standard serologic test results come back. 156 00:13:39,840 --> 00:13:45,200 In fact, we've lost about 20 to 30% of people testing positive. 157 00:13:45,200 --> 00:13:50,760 And so this has been fantastic for use in that setting. 158 00:13:50,760 --> 00:13:52,900 Perfect. 159 00:13:52,900 --> 00:14:00,600 So the primary outcome then of your study would be to compare the point of care test 160 00:14:00,600 --> 00:14:01,920 to standard testing. 161 00:14:01,920 --> 00:14:06,320 So do all these individuals then get serological testing done simultaneously? 162 00:14:06,320 --> 00:14:07,320 That's correct. 163 00:14:07,320 --> 00:14:12,280 So we are doing standard serologic testing simultaneously. 164 00:14:12,280 --> 00:14:17,960 And we also inform patients upfront that there is a chance you could have a false positive 165 00:14:17,960 --> 00:14:23,000 result and be treated unnecessarily, or you could have a false negative results because 166 00:14:23,000 --> 00:14:29,480 we do expect that finger prick whole blood specimens will be less sensitive than a serum 167 00:14:29,480 --> 00:14:32,960 specimen sent to the lab. 168 00:14:32,960 --> 00:14:42,360 And so that they may either way, we ask people to follow up after the standard test results 169 00:14:42,360 --> 00:14:43,360 are available. 170 00:14:43,360 --> 00:14:48,440 But as I mentioned, not all of those individuals will necessarily return for follow up. 171 00:14:48,440 --> 00:14:49,440 Yeah. 172 00:14:49,440 --> 00:14:54,040 And I think that's probably one of the limitations that we have with syphilis is, I mean, there's 173 00:14:54,040 --> 00:14:57,480 a number of factors like loss of follow up contact tracing. 174 00:14:57,480 --> 00:15:02,240 So if something like this is in the picture where we have a point of care test, and you've 175 00:15:02,240 --> 00:15:08,000 already treated, at least we've kind of eliminated some of the other risks of transmission then 176 00:15:08,000 --> 00:15:09,780 to partners. 177 00:15:09,780 --> 00:15:14,960 And if there is loss to follow up, then if they've received treatment, at least there's 178 00:15:14,960 --> 00:15:19,400 that safety component that you've already given them the treatment. 179 00:15:19,400 --> 00:15:23,200 So I think for some of our northern populations, even here in Saskatchewan, we're having a 180 00:15:23,200 --> 00:15:25,800 lot of difficulty with access to care. 181 00:15:25,800 --> 00:15:29,680 So I think if reaching out to them and doing the point of care, like you mentioned, or 182 00:15:29,680 --> 00:15:36,680 even doing the mobile vans and mobile clinics is probably a good stepping stone for this, 183 00:15:36,680 --> 00:15:37,680 for sure. 184 00:15:37,680 --> 00:15:38,680 Yes. 185 00:15:38,680 --> 00:15:39,680 Yes. 186 00:15:39,680 --> 00:15:44,960 And I think the trouble, one of the things that has been suggested may be a barrier to 187 00:15:44,960 --> 00:15:49,200 testing though, the mobile van, as you know, if you say it's an STI. 188 00:15:49,200 --> 00:15:50,200 Right. 189 00:15:50,200 --> 00:16:01,400 Although we found that, you know, so if it could be offered together with other measures, 190 00:16:01,400 --> 00:16:07,440 so for example, immunizations or I don't know, other kind of checks. 191 00:16:07,440 --> 00:16:15,280 Maybe doing blood pressure or glucose or something like that, then perhaps it might be more acceptable. 192 00:16:15,280 --> 00:16:19,240 So there are a number of things that would need to be taken into consideration there. 193 00:16:19,240 --> 00:16:20,240 For sure. 194 00:16:20,240 --> 00:16:21,240 Yeah. 195 00:16:21,240 --> 00:16:25,680 And I know there was, you know, there's a huge stigma behind some of the other STIs 196 00:16:25,680 --> 00:16:27,640 that we deal with such HIV. 197 00:16:27,640 --> 00:16:34,320 So I'm sure with syphilis, we kind of have similar, similar kind of feelings and emotions 198 00:16:34,320 --> 00:16:37,960 regarding the stigma behind it. 199 00:16:37,960 --> 00:16:45,840 So yes, now that's very interesting because I've personally felt that it is so incredibly 200 00:16:45,840 --> 00:16:53,320 important to do HIV testing because HIV testing not only affects how syphilis presents and 201 00:16:53,320 --> 00:17:01,120 evolves if it remains untreated, but also how we follow up after treatment that I personally 202 00:17:01,120 --> 00:17:08,440 think that HIV testing should be considered an essential component of syphilis testing. 203 00:17:08,440 --> 00:17:13,800 And we've tried to present it that way when offering testing to patients. 204 00:17:13,800 --> 00:17:18,720 You know, just say to them, you know, this is what we're testing you for, for STIs. 205 00:17:18,720 --> 00:17:24,080 We're doing syphilis, HIV, gonorrhea and chlamydia in the hopes that eventually we will start 206 00:17:24,080 --> 00:17:31,100 to normalize HIV testing in the same way and to hopefully reduce some of that stigma that 207 00:17:31,100 --> 00:17:35,200 unfortunately, as you mentioned, continues to be in place. 208 00:17:35,200 --> 00:17:36,200 Definitely. 209 00:17:36,200 --> 00:17:37,680 That's a great thing. 210 00:17:37,680 --> 00:17:38,680 Yes. 211 00:17:38,680 --> 00:17:46,600 And so, you know, I didn't mention that we did choose to do a dual testing with syphilis 212 00:17:46,600 --> 00:17:47,640 and HIV. 213 00:17:47,640 --> 00:17:53,400 And so both of our test kits offer testing for both syphilis and HIV. 214 00:17:53,400 --> 00:18:00,720 And I can tell you that that did create some concerns with our ethics board. 215 00:18:00,720 --> 00:18:02,720 And with the communities as well. 216 00:18:02,720 --> 00:18:10,520 But after I explained my rationale for doing this, and, you know, people do have the option 217 00:18:10,520 --> 00:18:13,320 to opt out completely. 218 00:18:13,320 --> 00:18:20,360 But in fact, we've not observed anyone opting out because we've had this combination of 219 00:18:20,360 --> 00:18:21,360 tests. 220 00:18:21,360 --> 00:18:22,760 Oh, that's fair. 221 00:18:22,760 --> 00:18:23,760 Yeah. 222 00:18:23,760 --> 00:18:29,400 And once they receive the point of care test, is it very similar to kind of the previous 223 00:18:29,400 --> 00:18:35,760 HIV point of care tests that we've had in place where it gives you a positive or negative? 224 00:18:35,760 --> 00:18:37,200 So it's almost identical. 225 00:18:37,200 --> 00:18:44,240 One of the companies that makes the dual syphilis HIV test has the only Health Canada approved 226 00:18:44,240 --> 00:18:47,360 HIV test in Canada. 227 00:18:47,360 --> 00:18:49,320 And it is a fantastic test. 228 00:18:49,320 --> 00:18:56,480 I was involved back in the mid 2000s when the test kit first rolled out in Canada and 229 00:18:56,480 --> 00:19:01,940 helped to set up the point of care program for HIV in Alberta at that time. 230 00:19:01,940 --> 00:19:07,560 And we were involved with the initial evaluations and it is an almost identical test kit, except 231 00:19:07,560 --> 00:19:11,000 that it also includes the syphilis component. 232 00:19:11,000 --> 00:19:15,160 And it is extremely user friendly, very fast. 233 00:19:15,160 --> 00:19:19,040 In fact, most of the test results are under a minute. 234 00:19:19,040 --> 00:19:27,600 And it is so user friendly that the company together with help from REACH has been able 235 00:19:27,600 --> 00:19:35,240 to implement HIV self testing so that the individuals can obtain test kits from various 236 00:19:35,240 --> 00:19:40,000 community organizations and perform the test on themselves. 237 00:19:40,000 --> 00:19:47,440 So it is a fantastic kit and I'm really hopeful that it will work well for syphilis as well. 238 00:19:47,440 --> 00:19:50,280 Wow, that's really good to hear. 239 00:19:50,280 --> 00:19:55,280 In terms of sensitivity and specificity for the assays that we're currently testing in 240 00:19:55,280 --> 00:20:01,840 your study, are there certain variables that the companies themselves have released or 241 00:20:01,840 --> 00:20:06,080 is that something that you're also then kind of comparing and is that one of your outcomes 242 00:20:06,080 --> 00:20:07,080 that you're measuring? 243 00:20:07,080 --> 00:20:13,080 Yeah, so there is some preliminary data for both test kits and for the biological test 244 00:20:13,080 --> 00:20:21,200 kit, the preliminary data suggests that the sensitivity is lower with infectious syphilis 245 00:20:21,200 --> 00:20:29,040 cases where the RPR titer is less than or equal to one in eight dilutions. 246 00:20:29,040 --> 00:20:36,340 But it seems to perform very well with high titer RPR cases. 247 00:20:36,340 --> 00:20:44,040 So with that in mind, prior to rolling out the study, I had a look at all of the cases, 248 00:20:44,040 --> 00:20:50,680 the infectious syphilis cases in the province and about 70% of the cases at diagnosis had 249 00:20:50,680 --> 00:20:56,100 an RPR titer which was reactive at one in eight dilutions or higher. 250 00:20:56,100 --> 00:21:02,440 So we anticipate that the vast majority of cases would be picked up on the point of care 251 00:21:02,440 --> 00:21:03,440 test. 252 00:21:03,440 --> 00:21:12,560 The MedMirror test has even less data, but the sensitivity does look pretty reasonable 253 00:21:12,560 --> 00:21:15,200 from finger prick whole blood specimens. 254 00:21:15,200 --> 00:21:21,240 But yes, that is the primary objective of this particular study, which we've coined 255 00:21:21,240 --> 00:21:26,200 the acronym POSH for point of care tests for syphilis and HIV. 256 00:21:26,200 --> 00:21:32,960 So for the POSH study, the primary objective is to look at the performance, primarily the 257 00:21:32,960 --> 00:21:39,280 sensitivity, specificity and negative and positive predictive values as compared to 258 00:21:39,280 --> 00:21:41,400 standard serologic tests. 259 00:21:41,400 --> 00:21:42,400 Perfect. 260 00:21:42,400 --> 00:21:43,400 All right. 261 00:21:43,400 --> 00:21:49,080 Well, I think that's a great initiative because I think one of the biggest drawbacks with 262 00:21:49,080 --> 00:21:54,360 syphilis testing is the turnaround time that we're having with the serological testing. 263 00:21:54,360 --> 00:22:00,600 And a lot of centers that are dealing with outbreaks, I think, have the initiative to 264 00:22:00,600 --> 00:22:05,560 kind of test and treat and then await results kind of similar to our other STIs such as 265 00:22:05,560 --> 00:22:08,080 gonorrhea or chlamydia. 266 00:22:08,080 --> 00:22:16,640 But again, for the patient as well and for the provider who's administering the therapy, 267 00:22:16,640 --> 00:22:23,960 if we can have a point of care test that can weigh in on that decision, I think, and if 268 00:22:23,960 --> 00:22:27,560 you're saying it's less than five minutes or even less than a minute, you can get those 269 00:22:27,560 --> 00:22:28,680 results back. 270 00:22:28,680 --> 00:22:33,960 I think that's definitely something that would be helpful for decision-making, clinical decision-making 271 00:22:33,960 --> 00:22:34,960 as well. 272 00:22:34,960 --> 00:22:35,960 Yes, absolutely. 273 00:22:35,960 --> 00:22:36,960 Yeah. 274 00:22:36,960 --> 00:22:37,960 So what obstacles? 275 00:22:37,960 --> 00:22:42,080 I know COVID's been probably the biggest obstacle in all of... 276 00:22:42,080 --> 00:22:43,080 Yes. 277 00:22:43,080 --> 00:22:44,080 Basically in all of medicine. 278 00:22:44,080 --> 00:22:45,080 In all time. 279 00:22:45,080 --> 00:22:46,080 In all life. 280 00:22:46,080 --> 00:22:47,240 Yeah, exactly. 281 00:22:47,240 --> 00:22:51,680 So definitely none of us have gone through kind of something similar in our lives. 282 00:22:51,680 --> 00:22:57,120 So I think it's definitely brought in a lot of obstacles for access to care, even in just 283 00:22:57,120 --> 00:23:04,120 general day-to-day care, and definitely with our sexually transmitted infections. 284 00:23:04,120 --> 00:23:09,760 But what other obstacles do you feel that we face right now to manage this syphilis 285 00:23:09,760 --> 00:23:11,560 outbreak at this time? 286 00:23:11,560 --> 00:23:12,560 Yes. 287 00:23:12,560 --> 00:23:19,280 Well, maybe I'll discuss a little bit some of the obstacles with the point of care study. 288 00:23:19,280 --> 00:23:20,440 Sure. 289 00:23:20,440 --> 00:23:27,280 So yes, indeed, the pandemic was an issue and we won't go there. 290 00:23:27,280 --> 00:23:35,880 But in terms of the actual test kits, I think that one of the challenges that we experienced 291 00:23:35,880 --> 00:23:42,720 initially when training the staff is that people had the notion or preconceived notion 292 00:23:42,720 --> 00:23:49,600 that these test kits, it's just like buying a pregnancy test over the counter and you 293 00:23:49,600 --> 00:23:51,960 just dip it in the urine and away you go. 294 00:23:51,960 --> 00:23:58,080 But unfortunately, there is a little bit more to it with these particular test kits. 295 00:23:58,080 --> 00:24:05,200 And not in least part because the quality assurance of the test kits is absolutely critical. 296 00:24:05,200 --> 00:24:14,960 So for example, to make sure that when the test kits are received from the company, we 297 00:24:14,960 --> 00:24:20,600 have had each batch of test kits evaluated by our provincial lab. 298 00:24:20,600 --> 00:24:25,520 And they will test sort of randomly test a few kits just to make sure that they're performing 299 00:24:25,520 --> 00:24:28,480 as expected. 300 00:24:28,480 --> 00:24:34,240 And only then do we have them distributed to the sites. 301 00:24:34,240 --> 00:24:38,880 Now, the reason that this is important and we haven't experienced any problems in this 302 00:24:38,880 --> 00:24:46,400 particular study, but another study that I'm involved with in Nunavut, there was an issue 303 00:24:46,400 --> 00:24:53,680 when the test kits were shipped out in the wintertime and they did not perform as well. 304 00:24:53,680 --> 00:24:58,240 And we were having some concerns about some of the results. 305 00:24:58,240 --> 00:25:01,600 There were in fact, were a number of false positives. 306 00:25:01,600 --> 00:25:07,040 And it turned out that the issue there was that the test kits had frozen in transport 307 00:25:07,040 --> 00:25:10,720 and had stopped working as expected. 308 00:25:10,720 --> 00:25:15,920 And so that's just kind of one very important piece. 309 00:25:15,920 --> 00:25:22,320 But even after the, with our particular study, we experienced a bit of an issue after receiving 310 00:25:22,320 --> 00:25:27,320 the test kits and distributing them because a small proportion of one of the company's 311 00:25:27,320 --> 00:25:36,520 test kits had inadequate offer in one of the bottles that you mix the blood specimen into. 312 00:25:36,520 --> 00:25:44,640 And so we actually had to return that batch of test kits and receive a new supply, but 313 00:25:44,640 --> 00:25:50,680 that was only identified after the first few tests were done. 314 00:25:50,680 --> 00:25:53,760 And we were able to identify that as an issue. 315 00:25:53,760 --> 00:26:03,000 And then the third big problem that we experienced is that we were not aware that, so we spent 316 00:26:03,000 --> 00:26:09,000 a lot of time focusing on the training about syphilis and the study protocols and how to 317 00:26:09,000 --> 00:26:10,980 actually perform the test kits. 318 00:26:10,980 --> 00:26:17,560 And when we did the training with the test kits, we mostly did that with stored sera 319 00:26:17,560 --> 00:26:21,880 so that people could see what the positive test results look like and the negative test 320 00:26:21,880 --> 00:26:23,580 results look like. 321 00:26:23,580 --> 00:26:29,760 But we had not spent much time focusing on how to actually do and collect the finger 322 00:26:29,760 --> 00:26:31,800 stick whole blood specimens. 323 00:26:31,800 --> 00:26:35,040 So that was a bit of a learning curve for us. 324 00:26:35,040 --> 00:26:43,280 And we actually had to go back and seek some additional training, not only for ourselves 325 00:26:43,280 --> 00:26:49,660 as the investigators, but then to make sure that all of our study staff were retrained 326 00:26:49,660 --> 00:26:54,400 in that finger stick whole blood collection process. 327 00:26:54,400 --> 00:26:56,960 So those were just some learnings. 328 00:26:56,960 --> 00:27:03,640 And I wish that we had known all this before we started, I guess, just to try to make it 329 00:27:03,640 --> 00:27:05,760 a bit smoother with the rollout. 330 00:27:05,760 --> 00:27:11,320 But I think now that we're up and running, we have a well-oiled machine. 331 00:27:11,320 --> 00:27:12,320 Nice. 332 00:27:12,320 --> 00:27:13,320 That's great to hear. 333 00:27:13,320 --> 00:27:14,320 That's great. 334 00:27:14,320 --> 00:27:18,860 So we've talked a little bit about the limitations and I think the strengths of your study is 335 00:27:18,860 --> 00:27:20,760 something that we also want to touch on. 336 00:27:20,760 --> 00:27:26,900 So how do you feel with the strengths of the study and how this information that we gather 337 00:27:26,900 --> 00:27:32,680 from this POSH study, how it will help your list of lists outbreak in Alberta? 338 00:27:32,680 --> 00:27:33,720 Yeah. 339 00:27:33,720 --> 00:27:42,280 So in terms of the strengths of the study, we have managed to include a number of sites 340 00:27:42,280 --> 00:27:48,120 in the Ebbinton zone, as well as in some of our northern communities. 341 00:27:48,120 --> 00:27:55,760 So I think we have fairly good distribution in terms of use of the test kits or potential 342 00:27:55,760 --> 00:27:57,840 for use of the test kits. 343 00:27:57,840 --> 00:28:05,000 And then also, you know, different settings too, because one of the things we will also 344 00:28:05,000 --> 00:28:10,840 be assessing is the test user experience with this. 345 00:28:10,840 --> 00:28:16,760 And we'll be able to take a look at how the user experience in terms of the volume that 346 00:28:16,760 --> 00:28:20,440 they've done affects their experience. 347 00:28:20,440 --> 00:28:25,000 And so I think that that is one of the strengths of our study though, that we tried to identify 348 00:28:25,000 --> 00:28:29,360 sites based on where the problem was happening. 349 00:28:29,360 --> 00:28:33,000 And so that is continuing. 350 00:28:33,000 --> 00:28:39,440 In terms of where we're hoping to go with this, I am really hoping that our study data 351 00:28:39,440 --> 00:28:47,600 will be used by both companies, assuming that the data shows or confirms that both test 352 00:28:47,600 --> 00:28:55,320 kits do have value for point of care testing for syphilis, that they will then apply for 353 00:28:55,320 --> 00:29:03,240 Health Canada approval so that we no longer have to go through a research type of process 354 00:29:03,240 --> 00:29:08,680 to use these test kits in Canada or to use it in an off-label capacity. 355 00:29:08,680 --> 00:29:13,200 Because that does pose additional challenges, as you know, it would be nice if we could 356 00:29:13,200 --> 00:29:19,640 simply buy the test kits, do all of the quality assurance and training, and away we go and 357 00:29:19,640 --> 00:29:20,640 use them. 358 00:29:20,640 --> 00:29:26,480 But the companies, neither of the companies has sufficient data on the performance of 359 00:29:26,480 --> 00:29:30,720 the test kits currently to apply for Health Canada approval. 360 00:29:30,720 --> 00:29:31,720 Right. 361 00:29:31,720 --> 00:29:39,960 It's definitely going through an ethics approval approach for every centre is usually challenging. 362 00:29:39,960 --> 00:29:41,720 So I agree if we have kind of... 363 00:29:41,720 --> 00:29:49,360 It is challenging and I will be the first to say that I did try to persuade our ethics 364 00:29:49,360 --> 00:29:56,420 board that having a four-page consent form was really not practical nor necessary. 365 00:29:56,420 --> 00:29:58,680 But that is what we have. 366 00:29:58,680 --> 00:30:03,580 We were able to make some progress though with the ethics board at the request of one 367 00:30:03,580 --> 00:30:09,360 First Nations community to allow for verbal consent. 368 00:30:09,360 --> 00:30:15,920 So allowing the testing provider to obtain consent from the person. 369 00:30:15,920 --> 00:30:18,320 So that was a little bit of progress. 370 00:30:18,320 --> 00:30:19,320 For sure. 371 00:30:19,320 --> 00:30:20,320 I think there's... 372 00:30:20,320 --> 00:30:21,320 Yeah. 373 00:30:21,320 --> 00:30:26,880 We do provide everyone with a copy of the consent form should they wish to read it. 374 00:30:26,880 --> 00:30:27,880 Perfect. 375 00:30:27,880 --> 00:30:28,880 Yeah. 376 00:30:28,880 --> 00:30:35,560 I think if there's anything that we can do to kind of limit the barriers to testing with 377 00:30:35,560 --> 00:30:40,640 syphilis, I mean, that's always something that I think all provinces and all places 378 00:30:40,640 --> 00:30:43,120 are having clinicians are having challenges with. 379 00:30:43,120 --> 00:30:48,520 So definitely if you can have a streamlined process like you have in place, that would 380 00:30:48,520 --> 00:30:49,700 be great. 381 00:30:49,700 --> 00:30:57,360 So currently in our provinces in Saskatchewan, we've introduced kind of the point of care 382 00:30:57,360 --> 00:31:04,200 testing as well, similar to, as you're aware of as part of the study as well. 383 00:31:04,200 --> 00:31:11,880 And so if a province would like to be involved in the study, is that something that you guys 384 00:31:11,880 --> 00:31:20,560 are currently still offering in terms of needing eligibility and where you guys are with enrollment? 385 00:31:20,560 --> 00:31:23,160 Well, that's an excellent question. 386 00:31:23,160 --> 00:31:30,600 So I did discuss this with our study team here, and unfortunately we don't have the 387 00:31:30,600 --> 00:31:36,240 capacity to support all of the paperwork requirements. 388 00:31:36,240 --> 00:31:41,680 So the Health Canada applications, as well as the ethics board requirements, particularly 389 00:31:41,680 --> 00:31:44,360 if there are study modifications. 390 00:31:44,360 --> 00:31:52,800 So what I have done instead, I guess, is that I've offered up all of our documents for people 391 00:31:52,800 --> 00:31:55,000 to use. 392 00:31:55,000 --> 00:32:00,560 And the fact that we have Health Canada approval will just make it easier for anyone else. 393 00:32:00,560 --> 00:32:06,080 Wishing to do this to obtain Health Canada approval, as well as we're happy to provide 394 00:32:06,080 --> 00:32:10,680 our ethics board approval, which could be used as well. 395 00:32:10,680 --> 00:32:17,400 And the other thing that I have offered is my time, I guess, I'm happy to help to support 396 00:32:17,400 --> 00:32:21,840 training in any way, if that would be helpful. 397 00:32:21,840 --> 00:32:23,320 That's perfect. 398 00:32:23,320 --> 00:32:25,480 Thank you so much, Dr. Singh. 399 00:32:25,480 --> 00:32:29,200 So I guess kind of ending off on the topic of advice. 400 00:32:29,200 --> 00:32:35,120 I mean, you're the expert and the specialist in this area. 401 00:32:35,120 --> 00:32:41,400 Also being a clinician myself, I definitely kind of advocate always STI testing and including 402 00:32:41,400 --> 00:32:48,040 syphilis because we know that we're seeing these numbers and we always advocate for testing 403 00:32:48,040 --> 00:32:54,080 for all of the STIs and not picking and choosing because we know that they usually have a similar 404 00:32:54,080 --> 00:32:55,120 risk factors. 405 00:32:55,120 --> 00:33:01,680 So what advice can you give to let's say family doctors out there or any clinicians really 406 00:33:01,680 --> 00:33:08,120 having first access in terms of testing and even if they don't have access right now to 407 00:33:08,120 --> 00:33:12,800 the point of care test, how they should go about the syphilis outbreak or any kind of 408 00:33:12,800 --> 00:33:17,600 expertise that you can give us because definitely the other provinces we're drowning in our 409 00:33:17,600 --> 00:33:18,640 numbers as well. 410 00:33:18,640 --> 00:33:22,840 And it's becoming quite an exponential increase here. 411 00:33:22,840 --> 00:33:26,360 Yes, no, I mean, that's an excellent question. 412 00:33:26,360 --> 00:33:32,320 Of course, it's always challenging because people have competing priorities. 413 00:33:32,320 --> 00:33:38,080 But given what is happening with syphilis right now, particularly in the Prairie provinces, 414 00:33:38,080 --> 00:33:43,200 I think it is really important that all providers have a heightened awareness. 415 00:33:43,200 --> 00:33:47,400 Of course, as you've mentioned, you know, you do and I do, but that's not good enough. 416 00:33:47,400 --> 00:33:54,240 I need everyone to be thinking about this possibility and to consider offering STI testing 417 00:33:54,240 --> 00:33:57,320 as part of routine care. 418 00:33:57,320 --> 00:34:03,440 And I am a strong advocate for normalizing this testing. 419 00:34:03,440 --> 00:34:10,040 You know, most people are having sex, don't necessarily need to know the details. 420 00:34:10,040 --> 00:34:16,120 You're offering it in the same way that you would offer testing for diabetes or hypertension. 421 00:34:16,120 --> 00:34:19,680 Screening, I should say. 422 00:34:19,680 --> 00:34:24,160 And you know, and if you're going to offer STI testing, do it as a package. 423 00:34:24,160 --> 00:34:28,920 So definitely do HIV syphilis blood tests. 424 00:34:28,920 --> 00:34:35,720 And for certainly for males and females, if you offer urine for gonorrhea and chlamydia, 425 00:34:35,720 --> 00:34:39,000 that is a pretty good basic STI screen. 426 00:34:39,000 --> 00:34:40,960 So you know, it's just thinking about it. 427 00:34:40,960 --> 00:34:46,320 And then if people are presenting with weird symptoms that don't make sense, just about 428 00:34:46,320 --> 00:34:52,480 absolutely every, any clinical manifestation you can ever think of or possibly conceive 429 00:34:52,480 --> 00:34:56,320 of has been caused by syphilis as far as I can tell. 430 00:34:56,320 --> 00:35:00,160 Think about syphilis and do a test. 431 00:35:00,160 --> 00:35:06,680 So particularly patients presenting with changes in vision or neurological symptoms, including 432 00:35:06,680 --> 00:35:07,840 acute psychosis. 433 00:35:07,840 --> 00:35:14,400 We've seen a number of cases like that where there've been delays in diagnoses. 434 00:35:14,400 --> 00:35:19,840 You know, if individuals presenting with stroke-like symptoms or trouble walking that you wouldn't 435 00:35:19,840 --> 00:35:24,920 expect to have had a stroke, think about syphilis. 436 00:35:24,920 --> 00:35:28,160 You know, and offer the testing. 437 00:35:28,160 --> 00:35:30,680 No, that's great advice for sure. 438 00:35:30,680 --> 00:35:37,560 Yeah, I think definitely the name for syphilis is the mimicker of all other diseases. 439 00:35:37,560 --> 00:35:41,680 So I think it's done. 440 00:35:41,680 --> 00:35:43,520 It stood by its name for sure. 441 00:35:43,520 --> 00:35:45,160 Yeah, till today. 442 00:35:45,160 --> 00:35:46,640 Yeah, no, definitely. 443 00:35:46,640 --> 00:35:48,080 Well, that's really great. 444 00:35:48,080 --> 00:35:53,720 Thank you so much for giving us some input regarding your point of care tests, the POSH 445 00:35:53,720 --> 00:35:57,320 study, your expertise is invaluable. 446 00:35:57,320 --> 00:36:03,680 Honestly, like in terms of what we're experiencing right now, even with congenital syphilis is 447 00:36:03,680 --> 00:36:06,280 kind of what I'm seeing more of. 448 00:36:06,280 --> 00:36:10,280 We're seeing two to three cases a week of presumed congenital syphilis. 449 00:36:10,280 --> 00:36:16,840 And there's, you know, these are preventable complications that, you know, it's almost 450 00:36:16,840 --> 00:36:23,640 as a clinician, it's always, always difficult when you know, something could have been prevented 451 00:36:23,640 --> 00:36:25,320 and you're at the treatment phase. 452 00:36:25,320 --> 00:36:32,680 So I think awareness for sure regarding syphilis testing, and if we can kind of limit the barriers 453 00:36:32,680 --> 00:36:39,600 to testing with the point of care tests in place in the near future, I think we'll be 454 00:36:39,600 --> 00:36:44,640 better on track to manage these syphilis outbreaks for sure. 455 00:36:44,640 --> 00:36:45,640 Definitely. 456 00:36:45,640 --> 00:36:52,680 And I guess last but not least is continuing to pay attention to the social determinants 457 00:36:52,680 --> 00:37:01,880 of health because until we fix the roots or attempt to address the root problems that 458 00:37:01,880 --> 00:37:08,560 is the syphilis is just the tip of the iceberg of so many things that are happening right 459 00:37:08,560 --> 00:37:16,080 now that we need to address, particularly in our First Nations population and to work 460 00:37:16,080 --> 00:37:20,920 with those populations to figure out how best we can support their needs. 461 00:37:20,920 --> 00:37:22,280 Oh, definitely. 462 00:37:22,280 --> 00:37:25,000 And thank you so much for all your help with this. 463 00:37:25,000 --> 00:37:30,640 And I think clinicians like yourself and your expertise have definitely revolutionized a 464 00:37:30,640 --> 00:37:34,640 lot of sexually transmitted infection diseases. 465 00:37:34,640 --> 00:37:40,440 And there's been a lot of changes that have occurred in the last decade or more. 466 00:37:40,440 --> 00:37:46,280 And so hopefully we'll see some new revolutionary changes with syphilis and its management. 467 00:37:46,280 --> 00:37:47,280 Yes. 468 00:37:47,280 --> 00:37:49,240 Thanks so much, Rapina. 469 00:37:49,240 --> 00:37:50,240 Yeah. 470 00:37:50,240 --> 00:37:51,240 Thanks a lot. 471 00:37:51,240 --> 00:37:52,240 Nice chatting with you. 472 00:37:52,240 --> 00:37:54,360 Yes, you too. 473 00:37:54,360 --> 00:37:59,160 Thank you for joining us on another episode of our podcast, the Canadian Breakpoint. 474 00:37:59,160 --> 00:38:04,000 Today we discussed an important issue regarding the ongoing syphilis outbreak in Canada. 475 00:38:04,000 --> 00:38:06,200 I hope you enjoyed this episode. 476 00:38:06,200 --> 00:38:10,380 I would like to thank Dr. Singh for taking the time to discuss the current situation 477 00:38:10,380 --> 00:38:16,360 in Alberta and other provinces and for providing guidance and expertise with preventing and 478 00:38:16,360 --> 00:38:18,840 managing syphilis. 479 00:38:18,840 --> 00:38:23,280 Thank you to Dr. Purwall and Dr. Singh, as well as Verity Pharmaceuticals, their kind 480 00:38:23,280 --> 00:38:24,720 sponsorship. 481 00:38:24,720 --> 00:38:31,240 Follow us on Twitter at CABreakpoint and email us at thecanadianbreakpoint at gmail.com to 482 00:38:31,240 --> 00:38:35,240 suggest infectious disease topics or discussions you'd like to hear. 483 00:38:35,240 --> 00:38:59,080 We look forward to seeing you again at the Canadian Breakpoint.