Attachment 2c - IL Dept. of Public Health Letter.pdf

January 25, 2023

Dear Colleague, In partnership with the Illinois State Police, this letter accompanies the evidence collection kit for your assistance in the diagnosis and treatment of the patient reporting sexual assault or abuse. These guidelines are based on recommendations from the Centers for Disease Control and Prevention input from physicians experienced in the treatment of sexual assault patients. Additionally, the Illinois Department of Public Health reiterates the following considerations: 1) inclusion of a trauma informed approach, such as consent for examination; 2) provision of emergency contraception for reproductive age patients at risk for pregnancy; 3) empiric treatment of chlamydia, gonorrhea, and trichomoniasis; and 4) consideration of HBV and HPV vaccine, as well as HIV post-exposure prophylaxis. We appreciate your thoughtful care for these vulnerable patients.

Medical diagnostic specimens should be collected sequentially at various points during the medical forensic examination. It is important to note that specimens taken for diagnosis and treatment (as distinguished from forensic specimens) must be retained at the hospital and not included with this kit.

The medical diagnostic procedures that are recommended include, but are not limited, to the following: History including drug allergies and gynecologic and obstetric history (when appropriate). General physical examination.

Genital or other specimens to conduct an STI evaluation must be made on an individual basis.

Recommended Testing/ Evaluation, including STI, during Forensic Evidence Collection

Adult/Adolescent Pediatric (Pre-pubescent)

Gonorrhea

(N. gonorrhoeae) *

NAATs at site of penetration or attempted penetration (genital/urine, oral, anal)

Standard culture procedures (gram stain inadequate):

Boys: Pharynx, anus and urethra (meatal specimen if urethral discharge is present) Girls: Pharynx, anus and vagina (Cervical specimens NOT recommended)

NAATs** are an acceptable alternative to culture and urine specimens may be collected in lieu of urethral or vaginal gonococcal cultures.

NAATs for extragenital specimens (Pharynx, anus) may be considered in addition to culture for rapid diagnoses.

All positive specimens should be retained for additional testing

Chlamydia

(C. trachomatis)*

NAATs at site of penetration or attempted penetration (genital/urine, oral, anal)

Standard culture procedures:

Boys: Pharynx, anus and urethra (meatal specimen if urethral discharge is present) Girls: Pharynx, anus and vagina (Cervical specimens NOT recommended)

NAATs** are an acceptable alternative to culture and urine specimens may be collected in lieu of urethral or vaginal chlamydia cultures.

NAATs for extragenital specimens (Pharynx, anus) may be considered in addition to culture for purposes of rapid diagnoses.

All specimens should be retained for additional testing

Trichomonas

T. vaginalis

NAATs from a urine or vaginal specimen or point-of-care testing from a vaginal specimen

Girls: Culture and wet mount of vaginal swab NAAT may be considered as an alternative to culture, in consultation with an expert. Only CLIA validated, FDA approved NAATs may be considered

BV and candidiasis

Point-of-care testing and/or wet mount especially if vaginal discharge, malodor, or itching is present

Girls: Wet mount of vaginal swab

Hepatitis B Serum sample antibody test for Hepatitis B surface antigen, surface antibody and core antigen as well as core antibody

Serum sample antibody test for Hepatitis B surface antigen, surface antibody and core antigen as well as core antibody

HPV Examine for genital warts Examine for genital warts

HIV infection* Serum sample antibody test

Also, CBC, CMP if nPEP# initiated

Serum sample antibody test

Also, CBC, CMP if nPEP# initiated

Syphilis (T. pallidum)*

Serum sample for treponemal test with reflex to RPR

Serum sample for treponemal test§ with reflex to RPR

Pregnancy Urine or serum sample for patients with a uterus of reproductive age

N/A

Additional information for pre-pubescent patients per CDC Guidelines:

o Presumptive treatment is NOT recommended o Children who received a diagnosis for one STI should be screened for all STIs o Testing all sites for all organisms is not routinely recommended unless indicated by physical exam or history o Consider screening if any of the following occurred:

Child is unable to verbalize details of the assault Child has experienced penetration or has evidence of recent or healed penetrative injury to the genitals, anus, or oropharynx

Abuse occurred by a stranger

Abuse occurred by an assailant known to be infected with or at high risk for an STIs

Child, sibling, or another person in the household has an STI

Child lives in an area with a high rate of STI in the community

Signs or symptoms of STIs (i.e., vaginal discharge or pain, genital itching or odor, urinary symptoms, and genital lesions or ulcers)

Child or parent or guardian requests STI testing Thank you for the compassionate care and service that you have provided to the sexual assault patient.

Very truly yours, Sameer Vohra, MD, JD, MA Director, Illinois Department of Public Health https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf https://www.cdc.gov/std/treatment-guidelines/STI- Guidelines-2021 .pdf American Academy of Pediatrics. STIs in children. In: Red Book: 2018 Report of the Committee on Infectious Diseases, 31st edition, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2018. p.168

.https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/04/sexual-assault

Herpes Simplex Virus (HSV)

If genital or perianal lesions are present, clinical diagnosis of herpes should be confirmed by type-specific virologic testing from the lesion by NAAT or culture.

If genital or perianal lesions are present, clinical diagnosis of herpes should be confirmed by type-specific virologic testing from the lesion by NAAT or culture.

For all above testing recommendations refer to the 2021 CDC Guidelines for additional information including confirmatory testing procedures. Note that when a specimen is positive, the result should be confirmed either by retesting the original specimen or obtaining another.

* Identification beyond neonatal period strongly suggests sexual abuse.

**Data on use of NAATs for detection of N. gonorrhoeae and C. trachomatis infection in children is limited. Only CLIA-validated FDA-cleared NAAT assays should be used for extragenital specimens and expert consultation should be considered prior to using NAAT for extra-genital testing # NPEP: Non-occupational- post exposure prophylaxis for HIV

§ There are over 18 FDA approved treponemal tests such as T. pallidum passive particle agglutination [TP-PA] assay, various EIAs, chemiluminescence immunoassays [CIAs] and immunoblots, or rapid treponemal assays)