Sheela Lahoti

Collection of Forensic Evidence From Pediatric Victims of Sexual Assault

OBJECTIVE: To determine the time period after sexual assault of a child that specimens may yield evidence using DNA amplification. Secondary questions included the comparative laboratory yields of body swabs versus other specimens, and the correlation between physical findings and laboratory results. PATIENTS AND METHODS: Data from evidence-collection kits from children 13 years and younger were reviewed. Kits were screened for evidence using traditional methods, and DNA testing was performed for positive specimens. Laboratory data were compared with historical information. RESULTS: There were 277 evidence-collection kits analyzed; 151 were collected from children younger than 10; 222 kits (80%) had 1 or more positive laboratory screening test, of which 56 (20%) tested positive by DNA. The time interval to collection was <24 hours for 30 of the 56 positive kits (68% positives with a documented time interval), and 24 (43% of all positive kits) were positive only by nonbody specimens. The majority of children with DNA were aged 10 or older, but kits from 14 children younger than 10 also had a positive DNA result, of which 5 were positive by a body swab collected between 7 and 95 hours after assault. Although body swabs were important sources of evidence for older children, they were significantly less likely than nonbody specimens to yield DNA among children younger than 10 (P = .002). There was no correlation between physical findings and laboratory evidence. CONCLUSIONS: Body samples should be considered for children beyond 24 hours after assault, although the yield is limited. Physical examination findings do not predict yield of forensic laboratory tests.

Comparison of the urine-based ligase chain reaction test to culture for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in pediatric sexual abuse victims.

BACKGROUND The urine-based ligase chain reaction (LCR) assay for Chlamydia trachomatis and Neisseria gonorrhoeae is an attractive alternative to culture because of the relative ease with which specimens may be collected, transported and processed. In addition LCR offers superior sensitivity while maintaining high specificity when compared with culture in various studies of adolescents and adults. A study comparing LCR to culture has not been published concerning children. METHODS We conducted a prospective, comparison trial of the urine-based LCR test for Chlamydia trachomatis and Neisseria gonorrhoeae as compared with culture among children at a specialized referral center for evaluation for alleged sexual assault. Of the 1,010 children presenting to the center during the study period, 164 met the study requirements for risk of a sexually transmissible disease and collection of both culture and urine LCR specimens. RESULTS Eight specimens tested positive by both methods for C. trachomatis. Another 10 specimens tested positive for C. trachomatis by LCR but were negative by culture. No patient with a negative LCR for C. trachomatis had a positive culture. For N. gonorrhoeae 2 specimens tested positive by both methods, and 3 specimens tested positive by LCR but negative by culture. No patient with a negative LCR for N. gonorrhoeae had a positive culture. CONCLUSIONS The low prevalence of disease in the study population precluded statistical analysis. LCR may prove to be as specific and more sensitive than culture for the detection of C. trachomatis and N. gonorrhoeae in children. Further studies are needed.

HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault

BACKGROUND The appropriate use of antiretroviral medications to protect against infection with human immunodeficiency virus (HIV) is unclear in cases of sexual assault of children, for whom the perpetrators risk of HIV is often unknown, and physical proof of sexual contact is usually absent. OBJECTIVE In an effort to clarify prescribing practices for HIV post-exposure prophylaxis (PEP) at our institution, we examined records of all children tested for HIV for prevalence of infection, our experience with prescribing PEP, and follow-up rates. DESIGN/METHODS Medical records at a sexual abuse clinic of all children tested for HIV during a 38-month period were reviewed for information concerning risk factors for HIV acquisition, STI test results, and PEP experience. Children were defined as PEP-eligible if they were within 96 hours of assault, and there was a report of sexual contact with the potential to transmit HIV. RESULTS One thousand seven hundred and fifty children were tested for HIV during the study period. Five children had a positive HIV ELISA, but only one child was confirmed HIV-positive. Three hundred and three children were eligible to receive HIV-PEP, but it was only offered to 16 (5.3%), of whom 15 accepted the medications. None of the children prescribed PEP completed follow-up, but 11 children had limited follow-up. CONCLUSIONS Our results indicate that the prevalence of HIV infection among sexually abused children in our population is low, and follow-up rates are poor. Intensive efforts to try to ensure follow-up are warranted whenever PEP is prescribed. Further research may help better define the efficacy of PEP in sexually abused children and adolescents.

Evaluation of sexual abuse in the pediatric patient.

Evaluating a patient for suspected child sexual abuse can be daunting for many pediatric primary care practitioners. The consequences of misdiagnosis can be devastating. Knowledge of common clinical presentations, both physical signs and symptoms and behavioral changes, is paramount. Sexual abuse allegations must be reported and investigated by child protection agencies or law enforcement. Practitioners must be aware of when and how to report suspected child sexual abuse, in addition to having a basic understanding of the medical examination and findings. With a caring, knowledgeable, and sensitive approach to allegations of sexual abuse, the practitioner can assist the child and his or her family through this very difficult process.

Screening and treatment of sexually transmitted diseases. Part 1: Chlamydia, gonorrhea, and bacterial vaginosis.

Despite increased public awareness sexually transmitted diseases (STDs) remain a major cause of morbidity and an important public health issue for adolescents. Each year more than 2.5 million teenagers are diagnosed with STDs and many more are infected subclinically. Whereas effective treatment regimens exist for many STDs others can only be treated symptomatically and patients must be counseled regarding transmission. The scope of this guideline includes evaluation of sexually active adolescents and treatment of common STDs other than human immunodeficiency virus (HIV) and syphilis. Sexually active adolescents may benefit from scheduled medical visits every 6 to 12 months (or more frequently if they are at higher risk or symptomatic). Serologic testing for syphilis and HIV is offered and is recommended for high-risk adolescents. If not previously administered the hepatitis B immunization series should be started and in male homosexual patients administering the hepatitis A vaccine should also be considered. Counseling about STDs and pregnancy as well as abstinence should take place at every visit. (excerpt)

Practice guidelines: Screening and treatment of sexually transmitted diseases part 2: Trichomonas, human papillomavirus infection, and genital herpes simplex virus

This article is Part 2 of a practice guideline on the screening and treatment of sexually transmitted diseases (Part 1 appeared in the January/February 2000 issue of the Journal). GENERAL SEXUAL HISTORY: Number of partners; Infected or symptomatic partners; Sexual orientation and characteristics of partners (ie age homosexuality/ bisexuality); Type of sexual activity (anal oral vaginal intercourse); Condom use; and Alcohol and drug use. (excerpt)