1. Outbreak of Lymphogranuloma Venereum (LGV) in the greater Dublin area Presentation at SSSTDI meeting 29 th November 2014 Dr. Fionnuala Cooney Chair LGV Outbreak Control Team Specialist in Public Health Medicine, HSE East

2. Presentation on behalf of the LGV OCT GUIDE, St James’s Hospital Prof Fiona Mulcahy Dr Fiona Lyons Dr Almida Lynam Dr Shay Keating GUIDE and GMHS Dr Susie Clarke Dr Grainne Courtney Ms Sile Dooley, Mr MICK Quinlan, Manager GMHS Microbiology St James’ Hospital Dr Brendan Crowley Ms Mary Kelleher HSE Health Promotion & Improvement Ms Roisin Guiry Ms Moira Germaine Dublin Aids Alliance Ms Susan Donlon HPSC Dr Derval Igoe Dept Public Health HSE East Dr Coilín ÓhAiseadha Dr Phil Downes, Dr Fionnuala Cooney

3. 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

4. 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.

5. 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]

6. 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

7. 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

8. Formation of OCT Multidisciplinary OCT formed at meeting on 3 rd 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

11. Age distribution of LGV cases SummaryYears Mean age36.1 Mode35 Median35 Range26-55

12. Nationality and area of residence of LGV cases NationalityCount Not specified15 Ireland7 France2 Brazil1 Lithuania1 USA1 Total27

13. Clinical presentation and sexual contacts Symptoms & Signs (avail. on 10 cases)YesNo Proctitis symptoms91 Rectal pain82 Rectal discharge64 Bloody stools46 Tenemus28 Swollen lymph glands19 Sexual Contacts Information on number of sexual contacts available on eight cases to date: – number of contacts ranged from 1 to 15. Information on meeting places available on 5 cases: – Bar/Club 3 – Sauna 2

14. Other STI infections: current and past HIV status:HIV Pos 26 HIV Neg 2 Current co-infections reported as present in 12/27 Gonorrhoea 4Syphilis 2 HCV 1 Previous STIs Notifications of STIs in HSE East, are being checked on CIDR on each LGV cases, back to January 2013

15. 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

16. 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

17. 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

18. 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.

19. 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 20 th Nov at: http://www.man2man.ie/lgv.htmlhttp://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

20. New leaflet and poster on LGV in the LUV Bugs series..

21. 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.

22. 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

23. Many Thanks on behalf of LGV Outbreak Control Team

24. Trends in Ireland Table 1 Number of LGV notification of 2010-2014* Region20102011201220132014 HSE-E221528 National other than HSE-E N/A 00 Total528