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Shigella in Gay and Bisexual men
Shigella in Gay and Bisexual men
by Robert W. Wood, MD - SGN Contributing Writer

This is the first of a series of articles I hope will be of interest and use to Seattle and King County men who have sex with men (MSM), regardless of whether they identify as Gay, Bisexual, straight, Queer, Transgender, or whatever. I began writing articles in the Seattle Gay News in 1987-'89, which provided my perspective as an openly Gay physician, and the new director for the HIV/AIDS Program for Public Health - Seattle & King County, when an AIDS diagnosis virtually always led to death within a couple of years. Again in 1997-'98 and in 2001, I contributed two additional series of articles to SGN readers to share the latest developments in preventing and treating HIV and STD, especially among men who have sex with men (MSM). This new series of articles will be my last for the Seattle Gay News as director of the HIV/AIDS Program of Public Health - Seattle & King County, as I'm planning to retire after 23 years in this position. Before I leave, I would like to share my perspective with regard to HIV/AIDS and other continuing health sexual disease threats to MSM, and what's needed to create a healthier MSM community, a goal of Public Health's strategic plan for HIV prevention, adopted in 2007.

A new resurgence of Shigella
First, let me update the situation regarding Shigella, one of the local recent concerns for the health of homosexually active men. Many Gay men today are unaware they are at risk for serious stomach cramps and diarrhea caused by a microscopic bug called Shigella, the cause of another sometimes sexually transmitted disease. When this bug is present, the disease can easily be spread from one person to another through rimming (oral-anal contact) and from oral contact with contaminated skin, including skin in the groin area, the testicles, and the penis. Increased numbers of people infected with Shigella are currently being reported locally among homosexually active men. People with HIV who are immuno-suppressed (those with T4/CD4 cell counts below 200) are more likely to have serious complications from infections with Shigella.

Shigella is often spread through fecally contaminated food and water, but can also be spread person-to-person through sexual activity. Many cities with sizeable Gay/Bi populations worldwide have experienced outbreaks of shigellosis within their homosexually active communities. The last time I provided an article on this topic to the SGN (2001) in addition to cases in Seattle, San Francisco was also experiencing an outbreak of Shigella in MSM. Sexual practices more common in Gay and Bi men facilitate fecal-oral spread of the infection. For example, 50% of the sexually active men with Shigella questioned in San Francisco answered "yes" to the question: "in the week before your illness did you put your tongue in a partner's anus?" Also, oral-penile sex is a very common sexual practice among MSM and rarely is oral sex protected by condoms.

Ingestion of Shigella bacteria indirectly, through touching or licking contaminated skin can transmit infection; that is, it is not necessary for one's tongue or mouth to touch an infected anus. A penis or testicles that are less than perfectly clean can easily transmit infection. A very small amount of Shigella can cause infection, resulting in serious stomach cramps, fever, sometimes bloody diarrhea, and sometimes nausea and vomiting. Symptoms can occur 4-7 days after contact and may last up to a week. In San Francisco, about three out of four infected men surveyed had performed fellatio (oral-genital contact) the week before they became ill.

Locally, many Gay and Bisexual men with shigellosis are surprised when they learn that sexual behaviors can put them at risk of contracting diarrheal illnesses such as Shigella. This is not earth-shattering news, nor is Shigella the only gastrointestinal infection that MSM are more likely to get. Other bugs commonly acquired through sex that can cause stomach pain and diarrhea are Giardia, Amebiasis, and Cryptosporidium, three kinds of intestinal parasites. Also, in 2000, public health investigators reported the first case of sexually transmitted typhoid fever between men, another disease transmitted through fecal contamination. Finally, hepatitis A, caused by a virus, has long been known to be spread sexually between Gay and Bi men, through the fecal-oral route.

What to do if you think you have Shigella
If you think you may have Shigella and have a regular health care provider, contact that person and make an appointment as early as possible so you and your stool can be evaluated. Make sure your provider is aware that you have sex with men (being "out" to care providers is always important for your health) and disclose the kinds of sex you engage in, so he or she will understand how you might be at risk. If you have no regular provider, Public Health's STD Clinic at Harborview can provide evaluation and care. These infections are all diagnosable and most are relatively easily treatable with antibiotics if the right ones are chosen after stool testing and antibiotic susceptibility testing. Remind doctors to request antibiotic sensitivity testing; based on sensitivity test results, they might need to change antibiotics.

Shigella prevention
To prevent spread of shigellosis and other diarrhea-causing agents from the butt to the mouth, MSM need to be aware of the increased risk of transmission of these bugs from oral-genital (fellatio) and especially oral-anal (anilingus) contact. Using gloves for hand-anal contact, and latex and other barriers like condoms, dental dams, and plastic wrap may help to reduce risks for anal intercourse, blowjobs, and rimming. Still, avoiding oral contact with fecally contaminated body parts or objects, along with very thorough genital and hand washing before and after sex, remain critically important defenses against infection.

Homosexually active men with active shigellosis or any diarrhea that may have an infectious origin should avoid sexual contact with others while symptoms are present, and not resume partnerships until at least three days after beginning an appropriate course of antibiotics. People with Shigella should wait until a repeat stool culture shows them to be free of infection, since antibiotic resistance is common. People who work in the food industry, health care workers, and child care workers with acute vomiting or diarrhea should stay out of work while they have symptoms, and should be especially quick to contact their health care provider about diagnosis and treatment. These people, and all homosexually active men always need to use careful and basic hand washing and food hygiene to prevent disease transmission by non-sexual routes

Shigella infections among homosexually active men remind us that there are diseases out there not usually thought of as sexually transmitted infections that can be spread by risky sexual activity. I also want to point out to the Gay community that sexual risk taking by homosexually active men has increased significantly since effective treatment for HIV reduced the threat of dying from AIDS. We now have the highest rates of syphilis locally that we've had since before AIDS, and cases of gonorrhea and chlamydia are also remaining at very high levels.

In future articles of this series, I want to share updates about the ongoing problems of sexually transmitted diseases and HIV in our community. I'll give you my views about why this is happening, how these affect the health of MSM, and what we are and should be doing about these serious and ongoing threats to our community and to the broader one. To protect and value our personal health and the health of our community, we must increase the emphasis on safer sex. Ultimately, our actions need to be rooted in our caring and deep commitment to one another now and for the future.

If you think you may have symptoms of shigellosis, contact your health care provider. If you have no regular provider, Public Health's STD Clinic at Harborview (206-744-3590) can provide evaluation and care. If your health care provider diagnoses shigellosis, ask him or her to notify the Public Health - Seattle & King County Communicable Disease Epidemiology & Immunization program at (206) 296-4774. Citizens may also call this number for general questions on shigellosis.

For the Public Health - Seattle King County Shigellosis Fact Sheet in multiple languages please visit http://www.kingcounty.gov/health/cd - click "S" then "Shigellosis." The same site has information on other conditions mentioned in this article (giardiasis, amebiasis, typhoid fever, hepatitis A) - just click on the first letter of the condition.

Information on sexually transmitted infections can be found on the Public Health STD Program website at www.kingcounty.gov/health/std. For CDC Shigellosis information visit www.cdc.gov/nczved/dfbmd/disease_listing/shigellosis_gi.html.

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