Trichomonas – Time to Know the Facts

10/16/2014
Conflicts of Interest
Trichomonas –
Time to Know the Facts
Research support and/or participation in clinical trials
from the following companies and sources that have to
do with today’s subject:


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NIH, DOH RI, APHL
Gen-Probe, BD, Cepheid
Kimberle Chapin MD DABMM, FCAP
Director of Microbiology and Infectious Diseases
Molecular Diagnostics
Lifespan Hospital, Brown Medical School
Providence, RI
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K Chapin MD 2014
The Rodney Dangerfield of STI’s
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Case
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Trichomonas vaginalis
K Chapin MD 2014
55 yo man presents to MD for routine physical exam
and minimal urogenital complaints
Previous exam, including prostate WNL
Social history: Divorced for 3 years and currently “dating”
…..alot
HPI/PE: no specific complaints other than

occasional urinary frequency and difficulty or pain urinating,
and sometimes pain during or after ejaculation
gets no respect
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K Chapin MD 2014
Case
4
Case
45 yo woman presents to MD for GYN exam
Previous exam, including PAP WNL
Social history: Divorced for 3 years and currently
“dating”…..alot
HPI/PE: no specific complaints except occasional itching in
vaginal area, GYN exam shows only some thin watery
discharge
Wet mount negative

Urine Culture negative
HIV negative
Nucleic Amplification urine test (NAATs) negative for
CT/GC
Urine NAAT positive for TV
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K. Chapin MD 2014
K. Chapin MD 2014
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K. Chapin MD 2014
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Case 3A
Presentation Outline
Urine Culture negative
HIV negative
NAAT Endocervical swab negative for CT/GC
Endocervical swab NAAT positive for TV
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Disease background in context of other STIs
Pathogenesis
Clinical Sequelae
Current TV detection methods
Comparison of methods with NAAT
Trichomonas epidemiology clarified
Treatment
Considerations for future action and Public Health
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7
Genital Infections – Basic Tenants
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Estimates of New Cases of STIs US (2008)
Satterwhite, Torrone et al, 2013 STD, 40(3) 187-193
Asymptomatic partners transmit infections
Many infections with overlapping in signs and symptoms so
clinical diagnosis not specific
Diagnostic Testing is recommended:

Appropriate RX can be focused
Specific diagnosis increases therapeutic compliance
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Complies with state PH reporting
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K8Chapin MD 2014
K. Chapin MD 2014
Hep B = 19,000
HIV= 49,000
Syphilis = 55,400
HSV-2 = 776,000
HSV-1 Genital Infections
By both patient and partner
Gonorrhea = 820,000
Trichomoniasis = 1,090,000
Alas….current available test diagnostics lacking

1.5 million new
cases per year
HSV
Chlamydia = 2,860,000
25-40% of patients the entity is not clear
HPV = 14,100,000 (includes non-HR)
20 million new infections/year (incidence); 110 million total infections (prevalence)
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K. Chapin MD 2014
in the US
COST in US dollars $16 BILLION
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K. Chapin MD 2014
Trichomonas vaginalis – Healthcare
Associated Costs
Syphilis:
14,000
TV is one of the top
5 ignored infections
in the world (CDC
2014)
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Direct medical costs for TV infection alone:
HIV: 50,000
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Sequelae related to increased risk for HIV transmission:
Gonorrhea: 700,000
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Misdiagnosis and inappropriate RX of common
entity:$$?
Hepatitis B Virus:
43,000
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Chlamydia: 1.4 Million
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Herpes Simplex Virus: 1.5 Million
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Human Papilloma Virus: 6 Million
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estimated at $34.2 million
$167 million
Vaginosis,vaginitis that continues to come back over and over
No routine testing for TV unless symptomatic or high risk
Partners NOT empirically tested or treated
NOT a reportable disease
Trichomonas: 7.2 million
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K. Chapin MD 2014
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K Chapin MD 2012
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Life-cycle of T. vaginalis is simple
Presentation Outline
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Disease background in context of other STIs
Pathogenesis
Clinical Sequelae
Current TV detection methods
Comparison of methods with NAAT
Trichomonas epidemiology clarified
Treatment
Considerations for future action and Public Health
K13
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Pathogenesis of Trichomonas – Much to Learn
•
Attaches to epithelial cells
Subsequent intense local immune response mainly with:
•
Neutrophils but also
Lymphocyte recruitment including CD4+ cells
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Recruitment of inflammation-related factors:
•
•
•
Cytokines and chronic stimulation that has implications for pathology and
cancer
Phagocytosis
Vector for spread of other organisms
•
Carrying pathogens attached to their surface into fallopian
tubes, into prostate
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K Chapin MD 2014
Presentation Outline
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Disease background
Pathogenesis
Clinical Features and Sequelae
Current TV detection methods
Comparison of methods with NAAT
Trichomonas epidemiology clarified
Treatment
Considerations for future action
TV prefers an anaerobic environment and pH 6.0
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Vaginal bacteria and host cells which alters normal flora
•
•
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Micro-ulcerations
•
Can deal with 4.5 – which may be why some infections with low organism burden
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Healthy vagina pH = 3.8-4.5
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Accomplish fermentative carbohydrate metabolism and
Produces H2 gas
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Hormone levels
Coexisting vaginal flora
Strain of TV
Relative concentration of organism present
TV phagocytosing vaginal bacteria creates a more alkaline
environment (> 4.5 pH)
TVcontains structures called Hydrogenosomes (no mitochondria)
Inflammatory response to the parasite may determine severity
of symptoms
Factors that influence the host response:
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K Chapin
MD 2014
Clinical Features
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Incubation period 4-28 days
Symptoms and signs in women
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Vaginal discharge, pruritus, and irritation, dysuria
Vaginal discharge, odor, edema or erythema, pH > 4.5
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Frothy in only 10%
Colpitis macularis (strawberry cervix) specific for TV but only on
colposcopy and rarely on routine examination
Extent of inflammatory response my determine severity of SXS
50% of women are asymptomatic
Most men are asymptomatic (> 75%)
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17Chapin MD
K
2014
K Chapin MD 2014
Pathology of Trichomonas vaginalis
Releases proteins which by direct contact result in:
•
•Single-celled protozoan
•Divides by binary fission
•Only troph stage identified
•Only infects humans
•Infection transmitted sexually
•Natural infection exists on the
mucosa of the genital lumen
•10 -105 protozoa/ml
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Recent studies suggest TV is more common cause of NGU than
previously thought
TV should be considered in male that fails therapy of NGU
K Chapin MD 2014
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Associated risks and sequelae
associated with trichomoniasis
Associated risks and sequelae associated
with trichomoniasis
Prenatal
Women
Premature rupture of
membranes
Pre-term Delivery
Men
NG/NC Urethritis
Epididymitis
Prostatitis/ Proctitis
Infertility and
Decreased sperm motility/viability
Invasive Prostate Cancer
Vaginitis, cervicitis, endometritis, PID
Cervical erosion
Low Birth Weight
Cervical dysplasia
Intellectual Disability of Baby
Prolonged HPV Infection
Infertility/fallopian tube damage
Bacterial vaginosis
Increased transmission/acquisition of HIV/HSV
Presence of other STIs *
Increased risk of post-surgical gynecological
infections
*Neisseria gonorrhoeae, Chlamydia trachomatis, human immunodeficiency virus, herpes simplex virus, and human papillomavirus
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K Chapin MD 2014
References in appendix
K Chapin
MD 2014
References in
appendix
20
Current Estimation of Diagnostic TV Testing Performed
Presentation Outline
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Disease background
Pathogenesis
Clinical Signs and Symptoms, Sequelae
Current TV detection methods
Comparison of methods with NAAT
Trichomonas epidemiology clarified
Treatment
Considerations for future action
Wet mount
48%
BD Affirm
13%
NAAT
10%
OSOM
8%
Wet
mount/culture
InPouch
29%
Pap Smear % ?
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K Chapin MD 2014
Wet Mount
PAP Smear
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K Chapin MD 2014
Vaginal swab in symptomatic
patients
Place in saline tube and then
onto slide
Look for motile trichomonads
Needs to be done within few
minutes – labs up to 2
hours…..
Experienced reader…
Requires live organisms and
motility
45-80% sensitive
K Chapin MD 2014
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Fixed preparation
May find TV in
association with
Leptothrix bacteria
Poor sensitivity and
poor specificity
?? If automated
reading instruments
pick this up since
scanning for unusual
cells
50% sensitive??
Spaghetti and meatballs
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K Chapin MD 2014
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10/16/2014
PAP Smear
Rapid Antigen Detection
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Rapid Antigen Test
Fixed preparation
May find TV in
association with
Leptothrix bacteria
Poor sensitivity and
poor specificity
?? If automated
reading instruments
pick this up since
scanning for unusual
cells
50% sensitive??
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K Chapin MD 2014
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BD Affirm VP III – Detection of Bacterial
vaginosis/vaginitis
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Stable transport/no live
organisms
Can be done as near patient
testing (usually batched)
Specificity and Sensitivity?
Disadvantage
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Slide/culture media pouch
Incubation 37°C
Reviewed days 1,3,5,7
Advantage
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Subjective color endpoint
Expensive (reagent, techtime)
Hybridization not as sensitive
for TV as NAAT
May be too sensitive for normal
flora? (G. vaginalis, candida)
Vaginal swab only
Symptomatic patients only
K Chapin MD 2014
Reference Standard (2009)
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Candida albicans
Gardnerella vaginalis (BV)
Trichomonas vaginalis
Disadvantages
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Poor sensitivity for a screening
test/asymptomatic
InPouch TV by BioMed – Wet mount/Culture
Benefits:
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Vaginal swab only
Symptomatic patients only
Single test format
 No BV or candida
 No other STIs
K Chapin MD 2014
Hybridization probe for 3
organisms:

Relatively inexpensive
No live organism needed
Transit time not an issue
Acceptable sensitivity in symptomatic
patients
Disadvantages:
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Spaghetti and meatballs
25
Point of care test - minutes
Benefits:
Inconvenient for collector/lab
Expensive 2° to tech time
Time to detection long
Single Test system
 Not paired with other
common STIs
K Chapin MD 2014
APTIMA TV Assay (FDA-cleared April, 2011)
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HOLOGIC
FDA-Cleared 2013 for TV
Hologic APTIMA technology (Combo GC/CT)
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Nucleic Acid Amplification testing (NAAT)
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Single specimen collection (same tube as for other STIs GC/CT)
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FDA-cleared for Symptomatic and Asymptomatic women
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Screening and Diagnostics
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Urine, vaginal swab, endocervical swab in Gen-Probe transport collection
device, Thin Prep liquid cytology specimen
Tigris Instrument – fully automated
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Disadvantages
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No men, self-collection or alternate sites
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Validation has been done by labs for these purposes
Tigris instrument
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29
A small footprint with a
width of 48", a depth of 32",
and a height of 69“
275-1000 samples per 8
hour shift – multiple assays
planned
pharyngeal, rectal
large space and volume, cost
TIGRIS
K Chapin MD 2014
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The BD Viper™ System :
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Up to 736 results per 8.5 hour shift
20 minutes of hands on time per run
On-board sample DNA extraction
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Runs up to five STI assays simultaneously
GC, CT, TV, HSV 1 and 2
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Accuracy
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Flexibility
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BD Viper XTR
Efficiency
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Presentation Outline
FDA Cleared for TV in 2012
Strand displacement Amplification
Disease background
Pathogenesis
Clinical Sequelae
Current TV detection methods
Comparison of methods with NAAT
Trichomonas epidemiology clarified
Considerations for future action
Automated sample processing and ready
to use reagents
Automatic system checks
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K. Chapin MD 2011
.
Comparison of commercially available
diagnostic tests for TV detection in women*,^
Test
OSOM Rapid
Test
BD Affirm
VPIII
TV antigen
TV DNA
Immunological
(antibodies)
Hybridization
Probe
<1 hour
1 hour –
batched
daily
Near
Patient
Testing
Yes
Cost
$12/test
Analytical
sensitivity
2,500
org/mL of
sample
500,000
org/mL of
sample
Possible;
Typically
Batched
25
21.6
20
%
Time to
Assay
Result
TV Target methodology (range)
% of Positive TV Tests by
Wet Mount vs. APTIMA TV (n=1,086)
Wet Mount
APTIMA TV
15
11
10
TV rRNA
TMA
BD Viper
TV DN A
SDA
*P<0.0002
5
of
No
sample†
0
Outpatient Phys. Emergency Dept Emergency Dept B
Grp
A
BD assay#
Urgent Care
facility
Munson, et al. J Clin Microbiol 2008;46:3368.
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K Chapin MD 2014
Comparison of Wet Mount, Culture,
Antigen OSOM and APTIMA for TV
Diagnostic Test Performance
Side by Side – Same Results
98.4 96.6
100
98.4
100
90
75.4
80
60
90
83
70
60
%
50.8
50.8 54.6
50
50
40
40
30
30
20
20
10
10
0
0
Wet mount
Culture
OSOM
Wet mount
APTIMA
K Chapin MD 2014
Culture
Huppert
Huppert, et al. Clin Inf Dis 2007; 45:194-198.
35
82.0
75.4 75
80
82.0
70
%
6
0.1 org/mL
3.5 hoursdaily
*Data are from respective manufacturers
† An analytical sensitivity of less than 1 organism per mL is due to the abundance of rRNA target per organism (1–3 million
copies) and the TMA amplification of the target rRNA molecule # BD assay analytical sensitivity?
33
9
7
4.3
5
APTIMA
10.4
36
OSOM
PCR
APTIMA
Nye
K Chapin MD 2014
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10/16/2014
Differences in test sensitivity stratified by the presence or absence of vaginal symptoms
Comparison of TV Detection Methods
Low Prevalence - RI
Sensitivity % (95% CI)
Test Method
All Patients (n=330)
Wet Mount
50.8 (37.7‐63.9)
57.5 (40.8‐72.9)
38.1 (18.1‐61.5)
Culture
75.4 (62.7‐85.5)
77.5 (61.5‐89.1)
71.4 (47.8‐88.7)
OSOM
82.0 (70.0‐90.6)
92.5 (79.6‐98.4)
61.9 (38.4‐81.9)
ATV
98.4 (91.2‐99.9)
97.5 (86.9‐99.9)
100 (83.8‐100)
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Vaginal Symptoms Vaginal Symptoms Present (n=210) Absent (n=120)
Sensitivity
Specificity
Huppert, et al. Clin Inf Dis 2007; 45:194-198.
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K Chapin MD 2014
Specificity
Sensitivity
Affirm (n=781)
63.4%
99.9%
Cx (n=446)
68.5%
100.0%
Avg Sensitivity (range) Avg Specificity (range)
PCR (n=766)
88.5%
100.0%
TMA (n=1993)
100.0%
100.0%
K Chapin MD 2014
Presentation Outline

*
Specificity
38
Overall reported sensitivity and specificity averages
(ranges)* of TV detection methods in vaginal
specimens
Test
Sensitivity

Wet mount
60.7(43.0-83.3)
100

Culture
74.3 (57.3-94.3)
100
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OSOM
84.4 (61.9-94.7)
99.8 (97.1-100)
BD Affirm VPIII
63.8 (44.0-83.3)
100 (99.9-100)
PCR
89.1 (83.0-100)
98.6 (96.3-100)
APTIMA TV
98.1 (96.6-100)
98.9 (96.4-100)
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Disease background
Pathogenesis
Clinical Sequelae
Current TV detection methods
Comparison of methods with NAAT
Trichomonas epidemiology clarified
Considerations for future action
Ranges are broad due to the different “gold standard” tests used in the literature to interpret true positive infections
Expert Review in Molecular Diagnostics , 2011, Chapin and Andrea
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Trichomonas in Men
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Infection common in men
Missed diagnosis in men due to lack of testing and/or
symptoms
Non-reportable disease
Revolving infection in partners
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72% of male partners of women with TV were also positive for
the infection
75% were asymptomatic
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K. Chapin MD 2011
Age Breakdown of TV Infections in Women
presenting with vaginitis/vaginosis
14.0%
12.0%
10.0%
8.0%
T. vaginalis
C. trachomatis
N. Gonorrhea
6.0%
4.0%
2.0%
0.0%
≤15 (n=13)
16 to 20
(n=119)
21 to 25
(n=150)
26 to 30
(n=92)
31 to 35
(n=64)
36 to 40
(n=50)
41 to 45
(n=36)
46 to 50
(n=40)
51 to 55
(n=14)
56 to 60
(n=9)
≥61 (n=4)
Age in Years
Andrea and Chapin, JCM, 2010
Hobbs et al, JCM, 2006
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APTIMA Amp versus Affirm VPIII Hybridization for TV
APTIMA Trichomonas vaginalis Assay Clinical trial
Clinical Evaluation of the APTIMA® Trichomonas vaginalis Assay on the TIGRIS® DTS® System in
Asymptomatic and Symptomatic Female Subjects P3 S7.08 ISSDTR 2010
Schwebke, Hobbs, Chapin, Taylor, Catania, Weinbaum, Getman, Gaydos
 Clinical
assay performance was demonstrated in a
prospective, multicenter clinical trial
 1,025 symptomatic and asymptomatic women were
enrolled from 9 U.S. clinical sites, including obstetric and
gynecology, family planning, and STD clinics
 Performance characteristics were estimated by
comparing results to a patient infected status algorithm
using vaginal swab specimens tested by culture and/or
wet mount microscopic examination as reference
methods
Published in: Schwebke, J.R. et. al. J. Clin. Microbiol. 49:4106-4111
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K Chapin MD 2014
APTIMA Trichomonas vaginalis Assay
Conclusions from Validation Study
Clinical performance data
 For
each specimen type, performance was similar in symptomatic
and asymptomatic women and across collection sites

Study provided clinical validation of the ATV assay for the
intended uses in the United States:
Sensitivity %
(95% CI)*
Specificity %
(95% CI)*

Clinician-collected vaginal swab
100.0
(96.7 – 100.0)
99.0
(97.9 – 99.5)

Endocervical swab
100.0
(96.7 – 100.0)
99.4
(98.6 – 99.7)
PreservCyt solution
100.0
(96.0 – 100.0)
99.6
(98.8 – 99.9)
Urine
95.2
(88.4 – 98.1)
98.9
(97.8 -99.5)
Specimen Type


Asymptomatic Screening and Diagnostic Testing in women for
Trichomonas
FDA cleared highly accurate and fully automated amplified test
system with ease of use specimens such as urine and vaginal swab
should enhance testing for this pathogen
Testing for men FDA-cleared as well would be optimal
Any Amplifcation method is likely to have similar performance
compared to other TV detection methods (Viper)
*Sensitivity and Specificity measured at 95% CI
Published in: Schwebke, J.R. et. al. J. Clin. Microbiol. 49:4106-4111
46K Chapin MD
2014
Prevalence of Trichomonas vaginalis and Co-Infection with Chlamydia
trachomatis and Neisseria gonorrhoea in the United States as
Determined by the APTIMA® Trichomonas vaginalis Nucleic Acid
Amplification Assay
Methods
•
Samples were obtained from 7,593 women aged 18 to 89 years
undergoing routine screening for CT and GC by the APTIMA
Combo 2 ® Assay
•
Samples were obtained from 30 laboratories in 21 states
•
Clinic types included:
C. Ginocchio1, K. Chapin2, J. Smith3, J. Aslanzadeh4, J. Snook5, C. Hill5, C. Gaydos6
1 North Shore-LIJ Health System Laboratories, Lake Success, NY, USA; 2 Rhode Island Hospital, Providence, RI, USA; 3 University of
North Carolina, Chapel Hill, NC, USA; 4 Hartford Hospital and Clinical Laboratory Partners, Hartford, CT, USA; 5 Gen-Probe
Incorporated, San Diego, CA, USA; 6 Johns Hopkins University School of Medicine, Baltimore, MD, USA
• Determine the prevalence of Trichomonas vaginalis (TV)
using the APTIMA Trichomonas vaginalis (ATV) assay
among women being screened for Chlamydia trachomatis
(CT) and Neisseria gonorrhoeae (NG) in the United States
• Determine the co-infection rates of TV, CT and NG
•
•
•
•
•
•
•
•
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K Chapin MD 2014
OB/Gyn clinics
Emergency room
Hospital in-patient
Family practice
Family planning
Internal medicine
Jail
STD clinics
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Geographic Prevalence of
TV, CT and GC Infections
Prevalence of TV, CT, and GC
Infections by Age
Overall Prevalence
N*
TV+
7593
8.70%
(663/7593)
% (n/N*)
CT+
GC+
6.70%
1.70%
(508/7588) (129/7579)
Age
Mean (SD)
Median (min-max)
29.82 (10.62)
26 (18-82)
23.4 (6.0)
22 (18-65)
24.0 (6.9)
22 (18-53)
8.50%
8.30%
7.90%
11.30%
13.00%
14.40%
8.00%
2.50%
1.90%
0.90%
3.30%
2.00%
0.80%
0.10%
1.20%
Prevalence (%)* by Age Group
18-19
20-29
30-39
40-49
50+
907
3972
1667
720
324
* In the calculations of prevalence, the denominator may be less than that the N shown due to missing or invalid assay data.
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2014
Prevalence of TV, CT, and GC
Infections by Age
Prevalence of TV, CT, and GC
Co-infections by Age
Overall Prevalence
N*
CT+GC+TV+
CT+TV+
CT+GC+
GC+TV+
7593
0.24%
(18/7577)
1.30%
(97/7588)
0.61%
(46/7577)
0.61%
(46/7579)
% prevalence
% (n/N*)
Age
22.00 (2.35)
21.5 (18-26)
Mean (SD)
Median (min-max)
23.41 (5.49) 21.89 (3.78) 23.15 (5.53)
22 (18-46)
21 (18-37) 21.5 (18-50)
Prevalence (%)* by Age Group
907
3972
1667
720
324
18-19
20-29
30-39
40-49
50+
age
51
0.20%
0.40%
0.00%
0.00%
0.00%
2.10%
1.70%
0.40%
0.40%
0.00%
1.30%
0.83%
0.10%
0.00%
0.00%
0.90%
0.90%
0.20%
0.00%
0.30%
* In the calculations of prevalence, the denominator may be less than that the N shown due to missing or invalid assay data.
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Prevalence of TV, CT, and GC Infections by
Collection Site
% prevalence
Prevalence of TV, CT, and GC Infections
by Race
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Conclusions from Prevalence Study
Ginnochio et al
•
TV prevalence (8.7%) is higher than CT (6.7%) and GC (1.7%)
•
TV prevalence is highest in women >40 years (>11%), while CT and GC
prevalence is lowest in that age group (<2%)
•
TV prevalence is highest among black women (20.2%)
•
Co-infection of TV with CT and/or GC was relatively low and highest in
women <20 years
•
TV prevalence was highest in jail (22.3%) and emergency room (17.0%)
collection sites
•
The high TV prevalence in all age groups suggests that all women
being screened for CT/GC should also be screened for TV
J. Clin. Microbiol. 51: 101-104; 2013
Presentation Outline
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Disease background
Pathogenesis
Clinical Sequelae
Current TV detection methods
Comparison of methods with NAAT
Trichomonas epidemiology clarified
Treatment
Considerations for future action
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Presentation Outline
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K. Chapin MD 2014
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Treatment of TV
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Single 2 g oral metronidazole
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Vaginal gel not as effective (most commonly used for BV)
Tinidazole
Twice the ½ life of metro (12-14 hrs)
Better tolerated
True resistance < 10%; can be overcome with higher
dosing
Therapy is ineffective if partner is not treated!
Treating for BV is not the same as treating for TV
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Diagnostic Problem with TV…
What is it? A vaginal nuisance or an STI?
Disease background
Pathogenesis
Clinical Sequelae
Current TV detection methods
Comparison of methods with NAAT
Trichomonas epidemiology clarified
Treatment
Considerations for future action
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Getting TV on the Map
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Educate the healthcare providers
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Educate the public/patient (Chapin’s PR campaign?)
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K Chapin MD 2014
Did you know the most common treatable STI is one that your physician may
not be testing for??
What STD is a college student’s MOM more likely to have then their
college student?
Educate the Laboratory
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Don’t know the prevalence or the sequelae
Trichomoniasis is not always associated with symptoms, age or
obvious sexual risk behaviors
Know the benefits/disadvantages of current tests methods
Many labs/providers do wet mount and think it is OK
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Implementation of Trichomonas Testing
Combined Concerted Effort
PUBLIC
HEALTH
LABS
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HEALTHCARE
PROVIDERS
Insurance
PATIENT
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The STD you have heard of…and
are going to do something about it…..
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References
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Hobbs MM, Lapple DM, Lawing LF et al. Methods for Detection of Trichomonas vaginalis in the Male Partners of Infected Women:
Implications for Control of Trichomoniasis. Journal of Clinical Microbiology, 44(11), 3994-3999 (2006).
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Nye MB, Schwebke JR, Body BA. Comparison of APTIMA Trichomonas vaginalis transcription-mediated amplification to wet
mount microscopy, culture, and polymerase chain reaction for diagnosis of trichomoniasis in men and women. American Journal of
Obstetrics and Gynecology, 200(2), 188.e181-188.e187 (2009).
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Andrea SB, Chapin KC. Comparison of APTIMA® Trichomonas vaginalis transcription-mediated amplification assay and BD Affirm
VPIII for detection of Trichomonas vaginalis in symptomatic women: Performance parameters and epidemiologic implications.
Journal of Clinical Microbiology, 49(3), 866-869 (2011).
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Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases Treatment Guidelines, 2010. Morbidity and
Mortality Weekly Report, 59(RR-12) (2010).

CID, 2013 Baron et al, A guide to Utilization of the Microbiology Laboratory for the Diagnosis of Infectious Diseases
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CAP today Jan 2013
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Huppert J, Mortensen J, Reed J et al. Rapid antigen testing compares favorably with transcription-mediated amplification assay for
the detection of Trichomonas vaginalis in young women. Clinical Infectious Disease, 45(2), 194-198 (2007).

Munson E, Napierala M, Olson R et al. Impact of Trichomonas vaginalis Transcription-Mediated Amplification-Based AnalyteSpecific-Reagent Testing in a Metropolitan Setting of High Sexually Transmitted Disease Prevalence. Journal of Clinical Microbiology,
46(10), 3368-3374 (2008).
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Chapin K, Andrea, S. APTIMA Trichomonas vaginalis, a transcription-mediated amplification assay for detection of Trichomonas
vaginalis in urogenital specimens. Expert Review in Molecular Diagnostics. Sept. 2011.

Schwebke, J. Mandell’s 7th edition. Trichomonas vaginalis online text
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