Health
Diagnosis and acute management of migraine
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See related review article at www.cmaj.ca/lookup/doi/10.1503/cmaj.221607 (to be published February 6, 2023) and a first-person account of the difficulty of finding migraine treatment at www.cmaj.ca/lookup/doi/10.1503/cmaj.221813
KEY POINTS
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Migraine is a leading cause of disability across all age groups.
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Routine imaging is not recommended in patients with migraine who have no red flags, atypical symptoms or abnormal findings on neurologic examination.
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A stratified approach for acute migraine treatment empowers patients to choose from different treatment options depending on attack symptoms and severity and encourages patients to combine medications from different classes.
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Effective acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs and triptans.
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Ubrogepant and rimegepant are new, effective migraine treatments, suitable for patients with cardiovascular disease in whom triptans are contraindicated.
Migraine affects about 12% of adults, with a prevalence of 18% in women and 6% in men.1–3 Globally, in 2019, migraine was the second leading cause of disability among men and women across all age groups, and the leading cause of disability in women aged 15–49 years (expressed as years lived with disability). 4 In the United States, more than 70% of all migraine-related visits are to primary care providers,5 who play a central role in diagnosing and managing migraine. Recently, several new classes of migraine-specific medications have been shown to be effective and the evidence for the effectiveness of non-pharmacologic interventions is growing. In this article, we discuss the diagnosis and acute management of migraine, based on original research evidence, reviews and clinical practice guidelines (Box 1). We discuss prevention of migraine in a second article.6
Box 1: Evidence used in this review
We conducted a targeted search of Google Scholar and PubMed to identify original research, review articles and clinical practice guidelines published through November of 2021, using search terms that included, but were not limited to, “migraine acute treatment,” “migraine preventive treatment,” “migraine CGRP monoclonal antibodies,” “migraine 5-HT1F,” “migraine behavioural treatments” and “migraine neuromodulation.” We also consulted the most recent guidelines from the Canadian Headache Society and the American Headache Society, and the International Classification of Headache Disorders, 3rd edition.
What is the current understanding of migraine pathophysiology?
Migraine is characterized by neuronal hyperexcitability. Many genetic variants have been associated with increased susceptibility for migraine, suggesting a strong genetic basis.7 Migraine attacks can be broken down into 5 phases: prodrome, aura, headache, postdrome and interictal. However, not every migraine attack progresses through all phases (e.g., only one-third of people with migraine will experience aura) and the phases do not necessarily occur in succession (e.g., aura and headache can occur simultaneously).8,9
The pathophysiology of the headache phase is widely accepted to result from activation of the trigeminovascular pathway, which consists of peripheral trigeminal afferent nerves that innervate the dura and large cerebral arteries. When these neurons are stimulated, they release vasoactive neuropeptides such as calcitonin gene-related peptide (CGRP) and transmit nociceptive signals to the trigeminal nucleus caudalis. Nociceptive signals from the trigeminal nucleus caudalis and the dorsal horn of the upper cervical roots (C1–C2) converge at the trigeminal cervical complex before being relayed to central structures involved in pain processing (brain stem, thalamus, hypothalamus, basal ganglia and cortex).8,9 Levels of CGRP increase during a migraine attack and decrease with treatment and between attacks, and CGRP infusion can trigger a migraine attack.10 Calcitonin gene-related peptide facilitates migraines through various mechanisms, including arterial vasodilation, inflammation in the dura, facilitation of neuronal signalling and modulation of nociceptive signal transmission at the trigeminal cervical complex.10 The hypothesis that migraine can be aborted or prevented by blocking the action of CGRP has been central to the development of drugs that target the CGRP ligand or receptor.11
What are the diagnostic criteria for migraine?
In the third edition of the International Classification of Headache Disorders (ICHD-3), migraine is subclassified into 6 categories: migraine without aura, migraine with aura, chronic migraine, complications of migraine, probable migraine and episodic syndromes that may be associated with migraine.12
Changes from ICHD-2 include modification of migraine with aura so that aura symptoms must meet 3 of 6 aura characteristics (at least 1 aura symptom spreads gradually over 5 min or more, 2 or more aura symptoms occur in succession, each individual aura symptom lasts 5–60 min, at least 1 aura symptom is unilateral, at least 1 aura symptom is positive, the aura is accompanied — or followed within 60 min — by headache), to better distinguish migraine aura from symptoms of transient ischemic attack.13 The diagnosis previously known as basilar artery migraine has been renamed “migraine with brain stem aura,” to reflect the low likelihood that the basilar artery is involved.12 Chronic migraine has been reclassified as a subtype of migraine rather than a complication of migraine, highlighting that it is a distinct entity with unique treatments. Although the diagnostic criteria for chronic migraine still require that headache be present on 15 or more days per month for more than 3 consecutive months, migraine-type headache need be present on only 8 of the headache days each month, in recognition that patients can often experience a mixture of headache phenotypes, including tension-type.12
The Visual Aura Rating Scale (VARS) has been validated for use in distinguishing migraine with visual aura from nonspecific visual symptoms and it has a 91% sensitivity and 96% specificity for diagnosis of visual aura when the score is ≥ 5. The 5 characteristics of the visual symptoms that make up the the scale are duration 6–60 minutes (3 points), develops gradually over 5 minutes or more (2 points), scotoma present (2 points), zigzag line present (2 points) and unilateral (1 point).14
The ID Migraine Screener, a tool that has been validated in primary care, screens for 3 key migraine-associated features: photophobia, functional impairment and nausea (with the mnemonic “PIN the diagnosis”). The screen is positive for migraine if the patient has 2 or more of the features, and a study of 563 patients presenting for routine primary care appointments and reporting headaches in the past 3 months found the sensitivity to be 0.81 (95% confidence interval [CI] 0.77–0.85), specificity to be 0.75 (95% CI 0.64–0.84) and the positive predictive value to be 0.93 (95% CI 0.54–0.82).15
When should imaging be ordered in patients with migraine?
For patients with stable headaches who meet criteria for migraine and have a normal neurologic examination, guidelines from the American College of Radiology and the American Headache Society strongly recommend against routine neuroimaging.16,17 A meta-analysis found that in such patients, the prevalence of important intracranial abnormalities on neuroimaging ranged from 0% to 3.1%, with a combined prevalence of 0.18% (upper 95% CI 0.59%).18 This is comparable to the prevalence of abnormalities detected on neuroimaging among the general population (neoplastic abnormalities 0.7% [95% CI 0.47%–0.98%], nonneoplastic abnormalities 2% [95% CI 1.10%–3.15%]).19 The detection of incidental findings can trigger undue patient anxiety and unnecessary investigations and procedures.16,17
Neuroimaging should be ordered in patients with an abnormal neurologic examination or red flags on history. Headache red flags consist of patient characteristics, features of the headache, and clinical symptoms or signs that should be assessed in every patient presenting with headache. The mnemonic SNOOP4 is a widely used, simple, yet comprehensive way to remember the headache red flags (Table 1).20,21 Neuroimaging should also be ordered in patients with unilateral headache that always occurs on the same side (side-locked), a feature of trigeminal autonomic cephalalgias, which can be mimicked by underlying central nervous system pathologies such as pituitary tumours, intracranial dissections or aneurysms, and infections; aura symptoms that are unusual, prolonged or persistent, a feature that could indicate an underlying lesion or seizure; and post-traumatic headache, because of the increased risk for intracranial hemorrhage or vascular injuries.17
Magnetic resonance imaging (MRI) is preferred over computed tomography (CT) as it provides better visualization of the brain parenchyma and is more sensitive in detecting subtle lesions.22 The use of contrast can further help with visualizing the brain parenchyma and meninges and should be considered when intracranial mass, infection or inflammation are suspected.16 However, CT is preferred when hemorrhages or fractures are suspected and should be performed first when there is concern for an acute abnormality and when MRI is not readily available.22 When headache is accompanied by optic disc edema, CT or MRI with venogram is suggested to rule out cerebral venous sinus thrombosis as a cause of high intracranial pressure.16 In some patients, additional investigations such as lumbar puncture, electroencephalogram and blood work may be indicated, but this is beyond the scope of this review. A comprehensive review of neuroimaging and workup of secondary causes of headache was recently published.23
What is the approach to acute treatment of a migraine attack?
The goal of treatment of migraine attacks is to provide rapid relief from pain and other migraine-related symptoms, to restore patient function and to prevent recurrence. Ideally, treatment should be self-administered, effective, well tolerated and affordable, and require minimal redosing.24 A stratified approach to treatment that empowers patients to choose from different options, depending on attack symptoms and severity, and encourages them to combine medications from different classes (e.g., nonsteroidal anti-inflammatory drugs and triptans) for severe or prolonged attacks, is preferred.25,26 Migraine attacks associated with mild disability can be treated with simple analgesics, with an additional dose of the same or a different agent in the next 2–24 hours, if needed. The Traffic Light of Headache is a tool that can help patients make acute treatment decisions using a stratified treatment plan, according to their level of functional impairment.27 All patients should be educated and screened for medication overuse, which can lead to medication-overuse headache and is a risk factor for transformation of episodic to chronic migraine.25,26
Classic pharmacologic acute treatments for migraine
Guidelines from the Canadian Headache Society and American Headache Society both indicate that acetaminophen, acetylsalicylic acid, diclofenac, ibuprofen, naproxen sodium and triptans have the highest level of evidence for treatment of migraine attacks (Table 2).26,28 Dihydroergotamine, which has been available for decades, can be useful as a first-line agent in some patients (patients with severe attacks or who do not respond well to triptans, or both). However, the Canadian Headache Society recommends against routine use of dihydroergotamine, given potential drug interactions and a high risk of vascular adverse effects, such as bradycardia and prolonged vasoconstriction (coronary, peripheral and central).26 Dihydroergotamine is contraindicated in patients who are pregnant or have a history of peripheral vascular disease, coronary artery disease, uncontrolled hypertension, stroke, sepsis, and renal or hepatic dysfunction.24 The Canadian Headache Society also strongly recommends against the routine use of combination analgesics containing codeine or tramadol, opioids, and butalbital-containing medications, owing to the high risk of sedation, dependence and the development of medication overuse headache.22,26
Table 2:
Traditional medications for acute migraine treatment26
New pharmacologic acute treatment of migraine
Two classes of orally administered small-molecule drugs have recently been approved by the US Food and Drug Administration for the treatment of migraine attacks with and without aura: ditans (lasmiditan) and gepants (ubrogepant and rimegepant) (Table 3). They can be used in patients with cardiovascular disease in whom triptans are contraindicated.29–31 The gepants are currently being considered by Health Canada, but at the present time, lasmiditan will not be marketed in Canada.
Table 3:
New pharmacologic therapies for acute treatment of migraine, with or without aura
The safety and efficacy of each class of drug has been evaluated in phase 3, randomized, placebo-controlled trials, which assessed acute treatment response during a single migraine attack.29,30,32–35 Study design and inclusion and exclusion criteria were similar across the trials. The co-primary outcomes were freedom from pain at 2 hours and resolution of the most bothersome migraine symptom at 2 hours. Inclusion criteria were a minimum 1-year history of migraine or migraine with aura, onset before age 50 years and 2–8 moderate-to-severe migraine headaches per month. Patients were excluded if they had 15 or more headache days per month, a history of medication overuse or a change in their baseline preventive treatment within the previous 3 months. Although patients with cardiovascular risk factors (e.g., obesity, diabetes, dyslipidemia, smoking) were included in all trials, patients with clinically important cardiovascular disease were excluded from all studies except 1 trial that evaluated lasmiditan.30 This is the most notable limitation of these studies, given that the greatest potential advantage of the ditans and gepants is their suitability for use in patients with clinically important cardiovascular disease in whom triptans are contraindicated.
Trial participants had a mean age between 40 and 42 years, 84.0%–88.0% were women and 75.0%–82.5% were white. All 3 drugs met the co-primary outcomes (freedom from pain at 2 h and resolution of the most bothersome migraine symptom at 2 h) compared with placebo, and treatment-related adverse effects were mild and transient (Table 3).29,30,32–35 The most common adverse effects with the gepants were nausea, dizziness, dry mouth and dyspepsia.32,34 Open-label extension trials have not identified any long-term safety or tolerability concerns for up to 1 year.36,37 Dizziness and sedation were the most common adverse effects seen with lasmiditan, resulting in a label warning patients not to drive within 8 hours of its use (Table 3). Ongoing collection of real-world data is needed to monitor for emergence of additional potential adverse effects with use beyond 1 year.
No head-to-head studies have compared ditans or gepants with triptans. However, a recent systematic review and meta-analysis quantified the effect of lasmiditan, rimegepant and ubrogepant compared with triptans in treatment of migraine attacks.38 In terms of efficacy, triptans (except naratriptan 2.5 mg and almotriptan 6.25 mg) were more strongly associated with freedom from pain at 2 hours than lasmiditan (50 mg, 100 mg), rimegepant 75 mg and ubrogepant (50 mg, 100 mg). Patients treated with rizatriptan, sumatriptan and zolmitriptan had more adverse events than patients treated with rimegepant and ubrogepant.38 Patients treated with lasmiditan had more adverse events than most other treatments (triptans and gepants) at all doses, owing to a high incidence of dizziness and sedation. In summary, most triptans are more efficacious than the new drugs, but with similar or poorer tolerability than gepants. Lasmiditan appears to be associated with the most adverse events.
According to current evidence, triptans should remain the mainstay of acute treatment of migraines, while ditans and gepants can be alternatives for patients who cannot tolerate or do not respond well to triptans, as well as patients with cardiovascular disease in whom triptans are contraindicated. As of May 2021, rimegepant was also approved in the US for prevention for episodic migraine, making it the first oral medication with indications for both acute and preventive treatment, the latter being the subject of a subsequent article.6,33,35,39
What are the device- and procedure-related treatment options for migraine?
Neuromodulation devices and peripheral nerve blocks have a role in the management of a small number of patients with migraine. Evidence to support these is discussed in Appendix 1 (available at www.cmaj.ca/lookup/doi/10.1503/cmaj.211969/tab-related-content). Neuromodulation devices, of which 2 are available in Canada, can be used alone or together with pharmacotherapy for the acute treatment of migraine. They are noninvasive and have minimal adverse effects. Peripheral nerve blockade with local anesthetic injection can be performed at various nerve branches of the trigeminocervical system and it is covered by most provincial public health plans in Canada.
Conclusion
Migraine is a leading cause of disability. Treatment of migraine attacks should aim to provide rapid relief from headache pain and related symptoms, restore patient functioning and prevent recurrence. Older medications remain effective, although newer medications may be preferred for certain groups of patients. In Box 2, we provide a practical clinical approach to management of the patient with migraine. Nonpharmacologic and pharmacologic approaches to the prevention of migraine will be discussed in a separate article.6
Box 2: A clinical approach to managing migraine
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Identify that the primary headache type is migraine.
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Order brain imaging to exclude secondary causes of headache if red flags or abnormalities on physical examination are present.
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Categorize the disorder (episodic v. chronic migraine).
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Identify comorbidities and exacerbating factors.
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Assess disability and attack characteristics.
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Review previous treatments, unmet needs and patient’s treatment goals.
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Formulate a treatment plan.
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Take a stratified approach to acute migraine treatment.
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Individualized drugs: choose the medication best suited for the patient; with oral prevention drugs, start low and go slow.
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Consider comorbidities and coverage for migraine prevention (e.g., consider an antidepressant if patient has comorbid psychological symptoms, avoid divalproex acid in people of childbearing age, be aware that calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) and onabotulinumtoxinA require a trial of at least 2 oral preventatives before they can be covered by public or private funding and that CGRP mAbs are approved for both episodic and chronic migraine, while onabotulinumtoxinA is approved only for chronic migraine).
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Footnotes
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Competing interests: Werner Becker reports receiving consulting fees from AbbView, Novartis, Lundbeck, Eli Lilly, Teva and McKesson, and honoraria for lectures, presentations, manuscript writing and educational events from AbbVie, Novartis, Weber and Weber, Lundbeck and Teva. Dr. Becker serves as a volunteer member on the board of Migraine Canada and on the board of the Pain Society of Alberta. In the past, he has served on the boards of the Canadian Headache Society and the American Headache Society. Tommy Lik Hang Chan reports receiving unrestricted education grants from AbbVie, Teva and Novartis; honoraria from AbbVie, Eli Lilly, Miravo and Novartis; and travel stipends for attending conferences and meetings from AbbVie. Dr. Chan is on the advisory board for AbbVie, Eli Lilly, Teva, Lundbeck, Miravo and Novartis. No other competing interests were declared.
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This article was solicited and has been peer reviewed.
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Contributors: All of the authors contributed to the conception and design of the work, drafted the manuscript, revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
Health
'Pandora's Box': Doctors Warn of Rising Plant Fungus Infections in People After 'First of Its Kind' Case – VICE
A man in India is the first human known to be infected by a fungus called Chondrostereum purpureum, a pathogen that is most well-known for causing a disease called silver leaf in plants, reports a new study.
The patient, who was 61 at the time of the diagnosis, made a full recovery and has not experienced any recurrence of the infection after two years of follow-up observations. However, this “first of its kind” case study exemplifies the risks that fungal pathogens pose for humans, especially now that climate change and other human activities like rampant urbanization, have opened a “Pandora’s Box for newer fungal diseases” by contributing to their spread, according to the study.
Fungal pathogens are having a pop culture moment because they are the source of a fictional disease depicted in apocalyptic game The Last of Us, which was recently adapted into the acclaimed HBO series of the same name. But these microbes are also a real-life scourge that infect about 150 million people every year, resulting in about 1.7 million deaths.
Though millions of fungal species exist, only a very small fraction of them are able to infect animals, including humans, because our bodies present challenges to these invaders such as high temperatures and sophisticated immune systems.
Soma Dutta and Ujjwayini Ray, doctors at Apollo Multispecialty Hospitals in Kolkata, India, have now added one more fungus to that small list of human invaders with their unprecedented report of a C. purpureum infection. The patient, a plant mycologist, had suffered from cough, fatigue, anorexia, and a throat abscess for months before his hospital visit, and was probably exposed to the fungus as a result of his profession.
When conventional techniques failed to diagnose the disease, the pathogen was sent to a World Health Organization center based in India where it was finally identified using DNA sequencing. The case “highlights the potential of environmental plant fungi to cause disease in humans and stresses the importance of molecular techniques to identify the causative fungal species,” according to their recent study in the journal Medical Mycology Case Reports.
“This is a first of its kind of a case wherein this plant fungus caused disease in a human,” Dutta and Ray said in the study. “This case report demonstrates the crossover of plant pathogens into humans when working in close contact with plant fungi. The cross-kingdom pathogenicity demands much work to be done in order to explore insights of the mechanisms involved, thus leading to possible recommendations to control and contain these infections.”
C. purpureum can infect a variety of different plants with silver leaf disease, an often fatal condition that is named after the color that the pathogen induces on the leaves on the hosts. It is the latest in a growing number of fungal pathogens that have infected humans, which are buoyed on in part by human activities, such as urbanization, travel, and commerce.
Human-driven climate change is also accelerating the spread of infectious diseases, including fungal pathogens, by allowing microbes to adapt to higher temperatures (like those in mammal bodies), expand their range, and interact with new hosts in the aftermath of extreme weather events. And though fungal diseases have maintained a lower profile in epidemiology compared to other pathogens, they may be more dangerous than viruses or bacteria in some contexts.
“While viral and bacterial diseases receive most attention as the potential cause of plagues and pandemics, fungi can arguably pose equal or even greater threats,” according to a 2021 study in PLoS Pathogens. “There are no vaccines available yet for fungal pathogens, the arsenal of antifungal agents is extremely limited, and fungi can live saprotrophically, producing large quantities of infectious spores and do not require host-to-host contact to establish infection. Indeed, fungi seem to be uniquely capable of causing complete host extinction.”
In addition to avoiding the spread of new fungal pathogens that can directly infect humans, researchers also point to the damage these diseases can deal to crops and ecosystems that people depend on. For this reason, Dutta and Ray recommend more research into the nature of these infections and strategies to mitigate their spread.
“Cross-kingdom human pathogens, and their potential plant reservoirs, have important implications for the emergence of infectious diseases,” Dutta and Ray said. “Fungi are also responsible for various infections in plants that cause destruction of millions of plants and crops” and “produce toxins that contaminate food and cause acute toxicity.”
“Over the past several decades multiple new pathogenic fungi have emerged,” they concluded. “A notable emergence of the multidrug resistant fungus Candida auris has spread all over the world and has become a significant threat. The worsening of global warming and other civilization activities opens Pandora’s Box for newer fungal diseases.”
Health
Staff reassigned to children’s ICU in Winnipeg, some surgeries postponed: Shared Health – Global News
An influx of kids sick with respiratory illness at the children’s pediatric intensive care unit (PICU) in Winnipeg has forced a staff shakeup that may result in the postponement of some non-urgent surgeries, health officials say.
Shared Health says roughly 10 staff — including some from pediatric surgical and recovery units — are being temporarily reassigned to help at Health Sciences Centre Children’s ICU.
Read more:
Children’s ER seeing ‘unprecedented’ patient levels in Winnipeg as feds secure more pain medications
Officials say a resurgence in respiratory illness circulating in the province is to blame for an uptick in kids ending up in the hospital’s ICU.
There were 17 kids receiving intensive care in the PICU as of Thursday morning. The PICU’s normal baseline capacity is nine.
“A significant number of these patients were experiencing medically complex cases that were further complicated by respiratory illness, including infants and young children,” Shared Health said in an online statement.
There were 51 patients in the hospital’s neonatal ICU Thursday morning. The normal baseline capacity there is 50.
Meanwhile, Shared Health says the number of kids visiting the ER with influenza-like symptoms has increased from a low of 22 on March 18 to 47 on Wednesday.
Read more:
Children’s ER seeing ‘unprecedented’ patient levels in Winnipeg as feds secure more pain medications
Shared Health didn’t say how long it expects the latest staff reassignments will be in place.
While all urgent and life-threatening surgeries will continue to be performed, Shared Health said some non-urgent procedures will be postponed.
Families of affected patients will be contacted, officials said.
© 2023 Global News, a division of Corus Entertainment Inc.
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Toronto:
The numbers of babies born with syphilis in Canada are rising at a far faster rate than recorded in the United States or Europe, an increase public health experts said is driven by increased methamphetamine use and lack of access to the public health system for Indigenous people.
While syphilis has made a global resurgence over the last five years, Canada is an outlier among wealthy nations in its rate of increase: 13-fold over five years, according to Health Canada. The incidence of babies born with syphilis reached 26 per 100,000 live births in 2021, the most recent year available, up from 2 in 2017, according to the Health Canada data.
That total is on track to increase further in 2022, according to the preliminary government data obtained by Reuters.
Babies with congenital syphilis are at higher risk of low birthweight, bone malformations and sensory difficulties, according to the World Health Organization (WHO).
Syphilis in pregnancy is the second-leading cause of stillbirth worldwide, the WHO said.
Yet congenital syphilis is easily preventable if an infected person gets access to penicillin during their pregnancy.
Among the G7 group of wealthier nations for which data is available, only the United States had a higher incidence of syphilis at birth: 74 per 100,000 live births in 2021, triple the rate in 2017, according to preliminary figures from the U.S. Centers for Disease Control and Prevention (CDC).
There were 2,677 cases of congenital syphilis in the U.S. in 2021 for a population of 332 million, according to preliminary CDC data. Canada had 96 cases for a population of 38 million, according to Health Canada.
People experiencing poverty, homelessness and drug use, and those with inadequate access to the health system, are more likely to contract syphilis through unsafe sex and pass it to their babies, public health researchers said.
“In high-income countries you see it in pockets of disadvantaged populations,” said Teodora Elvira Wi, who works in the WHO’s HIV, Hepatitis and sexually transmitted infection program.
“It’s a marker of inequality. It’s a marker of low-quality prenatal care.”
What sets Canada apart are its Indigenous populations who experience discrimination and often have poor access to health and social services, said Sean Rourke, a scientist with the Li Ka Shing Knowledge Institute at St. Michael’s Hospital in Toronto, who focuses on prevention of sexually transmitted disease.
“It’s just the whole system, and all the things that we’ve done in bad ways not to support Indigenous communities,” he said.
Health Canada told Reuters it has dispatched epidemiologists to help provinces contain the increase in congenital syphilis. Spokesperson Joshua Coke said the federal government is expanding testing and treatment access in Indigenous communities.
Tessa, an Indigenous 28-year-old woman who asked to be identified only by her middle name, said she had a years-long crystal meth addiction and was homeless when she got pregnant in Saskatoon, Saskatchewan.
“I would be walking down the street just crying: ‘Why am I living like this?'” she told Reuters.
She said she received no prenatal care until she went into labor in November, which is when she tested positive for HIV and syphilis during a routine test.
Her daughter was prescribed a 10-day course of antibiotics, administered by IV, and is now healthy, Tessa said. But she still thinks about the difficulties she experienced in accessing prenatal care.
“Having transportation, maybe, and a place to live, and being sober, probably would have helped, big time,” she said.
Susanne Nicolay, nurse lead at Wellness Wheel clinic in Regina, Saskatchewan, which serves Indigenous and vulnerable populations, said providers needed to do more to expand access to health care. “The system always talks about patients that are hard to reach. But I think it’s health providers that are hard to reach,” she said.
‘MULTIPLE FAILURES’
A lot needs to go wrong for a baby to be born with syphilis, said Jared Bullard, a Manitoba pediatrician who has been researching babies born with syphilis since 2021 in an ongoing study for the Public Health Agency of Canada.
“It’s pointing at multiple failures along the path,” he said.
In Canada, the rise in babies born with syphilis is concentrated in the three prairie provinces: Manitoba, Saskatchewan and Alberta.
Prairie provinces have higher crystal meth use and remote populations and Indigenous populations who may have trouble accessing health care, Bullard said.
Manitoba recorded the highest rate, with about 371 cases per 100,000 live births in 2021.
The province said in an emailed statement that it is expanding training for health care providers in addressing sexually transmitted infections, encouraging frequent testing and early treatment. It is digitizing its records of STI infections.
Saskatchewan has launched a public awareness campaign urging people to practice safe sex and get tested, said Dale Hunter, a spokesperson for the provincial health ministry. The province had an incidence of 185 cases of congenital syphilis per 100,00 live births in 2021.
Alberta said women aged 15-29 made up more than half of what it called a “significant increase” in syphilis rates. “The reasons for the increase are not fully known, but it is likely that a variety of factors have contributed to this rise,” Alberta Health Services spokesperson James Wood said.
In preliminary results of a study of 165 infants exposed to syphilis, Bullard and fellow pediatrician Carsten Krueger found at least two-thirds were born to women reporting a history of substance abuse.
About 45% of the women identified as Indigenous and another 40% had no ethnicity recorded. Indigenous people make up about 5% of the Canadian population, according to census data.
About a quarter of the people in the study did not get tested because they got no prenatal care; about one-fifth of those who tested positive did not get treated. Bullard said he has also seen people get treated early in pregnancy and then get re-infected.
Public health researchers and clinicians said the rates of congenital syphilis began increasing before the pandemic and worsened as public health agencies diverted resources to COVID-19 testing and other pandemic-related health measures.
“All of the social circumstances that contributed to this have just gotten worse over the pandemic,” said Ameeta Singh, an infectious diseases specialist with an HIV/STI practice in Edmonton, Alberta.
This month Health Canada approved a syphilis and HIV test that can provide results in less than a minute, allowing providers to begin treatment right away.
Some public health researchers and providers are urging the Canadian government to buy and distribute the tests.
“We probably need a million tests to get out there around the country,” Rourke said. “The solution’s right in front of us.”
Health Canada did not respond when asked about purchasing test kits.
(Except for the headline, this story has not been edited by NDTV staff and is published from a syndicated feed.)
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