April 2006 Syphilis Epidemic in Los Angeles County S EXUALLY T RANSMITTED D ISEASE P ROGRAM.

April 2006

Syphilis Epidemic in Los Angeles County

SEXUALLY TRANSMITTED DISEASE PROGRAM

2

Primary and Secondary Syphilis Rates in the

United States, 1981–2004*

0

5

10

15

20

25

Rate (per 100,000 population)

Source: Tom Peterman, Division of STD Prevention, National Center for HIV, STD, and TB Prevention. Centers for Disease Control and Prevention

3

P&S Syphilis Rates by Sex in the United

States, 1981–2004

0

5

10

15

20

25

Men

Women



4

P & S Syphilis: Rates by Race and Ethnicity,

1981–2003

0

30

60

90

120

150

White

African-American

Hispanic

Asian/PI

Am. Indian



5

P&S Syphilis Rates by Sex and Race, United

States,1998-2004

0

2

4

6

8

10

12

14

16

18

1998 1999 2000 2001 2002 2003 2004

Black men

Black women

White men

White women



6

National Plan to Eliminate Syphilis: Definitions

National Level: The absence of sustained transmission in the United States.– Healthy People 2010 Objective

(per 100,000 population): National Target = 0.2 National (2004) = 2.7

Local Level: The absence of transmission of new cases within the jurisdiction except within 90 days of report of an imported index case.

Source: CDC Syphilis Elimination Executive Summary

7

Syphilis Elimination

“It is anticipated that these definitions will translate to <1,000 cases (0.4/100,000 population) of primary and secondary (P&S) syphilis reported nationally each year.

“The national goal, therefore, is to reduce Primary & Secondary syphilis cases to 1,000 or fewer and to increase the number of syphilis-free counties to 90% by 2005”


8

Cross Cutting Strategies

Enhanced surveillance :– includes complete, accurate, and timely reporting of

positive syphilis tests; effective, timely, and regular data analyses; development of a framework for and implementation of syphilis surveillance; and ongoing evaluation of the amount of syphilis in a community by monitoring positive syphilis tests.

Strengthened community involvement and partnerships:– acknowledges and responds to the effects of racism,

poverty, and other relevant social issues on the persistence of syphilis in the U.S.; develops and maintains partnerships to increase the availability of and accessibility to preventive and care services; and assures that affected communities are collaborative partners in developing, delivering, and evaluating syphilis elimination interventions.


9

Intervention Strategies

Rapid outbreak response :– includes both the development of an outbreak response

plan and establishment of area-specific criteria that determine when the outbreak response plan should be implemented.

Expanded clinical and laboratory services:– provides accessible and timely client-centered

counseling, screening, and treatment services in sites frequented by populations at risk for syphilis; and ensures high quality syphilis preventive and care services.

Enhanced health promotion:– includes implementation and evaluation of appropriate

and effective health promotion interventions; and timely delivery of high quality, confidential, and comprehensive client-centered partner services to patients, partners, and other identified high-risk individuals.


10

National Plan to Eliminate Syphilis

While national in scope, the NPES focuses on two area categories:

1. areas with high syphilis morbidity;

2. those areas with potential for syphilis

re-emergence.

High Morbidity Areas (HMAs): areas with continuing syphilis transmission; HMAs must address all five of the syphilis elimination strategies.


11

National Plan to Eliminate Syphilis

Potential re-emergence areas (PRAs): areas that currently experience little or no syphilis transmission but that are at significant risk for syphilis reintroduction because – 1. History f high syphilis rates in the 90s or more

recently.– 2. A port or border jurisdiction or are located along

migrant streams– 3. Located along drug corridors – 4. They include groups that are disproportionately

affected by syphilis PRAs should focus primarily on enhanced surveillance

and rapid outbreak response, including the involvement of affected communities in implementing these strategies.


12

Chlamydia76%

NGU/PID3%

Early Latent Syphilis

1%P&S Syphilis1%

Gonorrhea19%

Source: LAC DHS STD Program; N=51,749

Reported Sexually Transmitted Diseases,

Los Angeles County (n=51,759), 2004

13

Reported Primary and Secondary Syphilis Rates by Year, United States, California, and Los Angeles County, 2000 - 2005

1.5

2.1

3.9

4.9 4.9

6.5

1.0

1.6

3.0

3.7

0.2 0.2 0.2 0.2 0.2 0.2

3.6

2.72.22.1 2.4 2.5

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

1999 2000 2001 2002 2003 2004 2005Year

Rat

es p

er 1

00,0

00 p

opul

atio

n

LA County (1)

California (2)

United States (3)

Target

Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005

14

Reported Early Latent Syphilis by Year, United States, California, and Los Angeles County, 2000-2005

2.2 2.3

3.84.0 4.0

5.9

1.01.2

2.02.3 2.4

3.43.1 3.0 2.9

2.7

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

1999 2000 2001 2002 2003 2004 2005

Year

Rat

es p

er 1

00,0

00 p

opul

atio

n

LA County (1)

California (2)

United States (3)


15

Reported Primary, Secondary and Early Latent Syphilis Cases,

Los Angeles, California, United States, 2000-2005

Year Los Angeles(1)

California (2)

United States(3)

P&S EL P&S EL P&S EL

2000 151 203 326 355 5,979 9,465

2001 199 224 546 413 6,103 8,701

2002 369 356 1,046 720 6,862 8,429

2003 456 377 1,293 818 7,177 8,361

2004 461 388 1,359 873 7,980 7,768

2005 623 563 N/A N/A N/A N/A

16

Reported Primary and Secondary Syphilis by Age Group and Sexual Orientation, Los Angeles County, 2001-2005 (N=2108)

050

100150

200250

300350

400450

500

<15 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+

Age

Cas

es

MSM Others


17Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005

Reported Early Latent Syphilis Cases by Age Group and Sexual Orientation, Los Angeles County, 2001-2005 (N=1910)

0

50

100

150

200

250

300

350

400

450

500

<15 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+

Age

Case

s

MSM Others


Reported Primary and Secondary Syphilis by Race/Ethnicity and Sexual Orientation, Los Angeles County, 2001-2005 (N=2108)

0

100

200

300

400

500

600

700

800

900

1000

White AfricanAmerican

Latino/a Asian/Pac.Is.

Amer.Ind/Alas. Nat.

Other/Mixed Unknown

Race/Ethnicity

Cas

es

MSM Others

19

Reported Early Latent Syphilis Cases by Race/Ethnicity and Sexual Orientation, Los Angeles County, 2001-2005 (N=1910)

0

100

200

300

400

500

600

700

800

900

1000

White AfricanAmerican

Latino/a Asian/Pac.Is.

Amer.Ind/Alas. Nat.

Other/Mixed Unknown

Race/Ethnicity

Cas

es

MSM Others



Reported Early Syphilis by HIV Status and Sexual Orientation, Los Angeles County, 2001-2005 (N=4016)

0

10

20

30

40

50

60

70

80

90

100

MSM & MSM/W MSW All Females

Sexual Orientation

Perc

ent

Yes No Unknown

21Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2005SPAs with less than 6% included in “Other”

Reported Early Syphilis Cases by SPA of Residence, Los Angeles County, 2001-2005 (N=4016)

Other15%

SPA 214%

SPA 447%

SPA 611% SPA 7

7%SPA 8

6%

22

Trends in Early Syphilis in Los Angeles County, Women

Female incidence has increased 97% between 2001 (69) and 2005 (136).

– African American and Hispanic women each comprised 41% of 136 ES cases reported for women in 2005

– 17% of these cases were pregnant

91% of pregnant cases were either African American or Hispanic

Nearly one-third of female ES cases in 2005 were from SPA 6, followed by SPA 4 at 18%, SPA 8 at 15%, and SPA 7 at 12%.

1.5% syphilis cases were co-infected with HIV


Reported Early Syphilis Cases Amongst Women, Los Angeles County, 2005 (N=136)

0%

5%

10%

15%

20%

25%

15-19 20-24 25-29 30-34 40-44 45-49 50-54 55-59 60+ Unknown

Age

Pe

rce

nta

ge

24

Trends in Early Syphilis in Los Angeles County, Men

The Syphilis epidemic has been concentrated in the Hollywood-Wilshire Health District (SPA 4, Metro)

Epidemic is centered around the MSM and MSM/W populations

– Primarily amongst White and Latino MSM

Approximately 60% of MSM were co-infected with HIV

Behavioral Risk Factors for MSM Syphilis Cases

26

CSVs

Frequent17%

Don't Frequent83%

Frequent17%

Don't Frequent

83%

Sexual Encounter Venues Among MSM Early

Syphilis Cases, Los Angeles County, 2001-2005

Use19%

Don't Use81%

Bars/Clubs (n=846) Internet (n=512)

CSVs (n=429)

Source: Epidemiology Unit, STD Program, 2006.

27

Sociodemographic Characteristics Associated with Behavioral Risk Factors, 2004

Variables

Odds ratio (95% CI)

Univariate analysis Multivariate analysis

Demographic

Age (y) < 30 vs. > 30 0.6 (0.4 – 0.9) 0.7 (0.4 – 1.1)

Race/ethnicity White vs. Non-white 1.3 (0.9 – 1.7) 1.1 (0.8 – 1.6)

HIV Positive Yes vs. No 1.5 (1.1 – 2.1)* 1.6 (1.1 – 2.5)*

Behavioral

Anal insertive Yes vs. No 1.4 (0.9 – 2.1) 1.6 (0.9 – 2.9)

Anal receptive Yes vs. No 1.3 (0.8 – 1.9) 1.0 (0.6 – 1.7)

Oral sex Yes vs. No 2.3 (0.9 – 5.6) 0.5 (0.2 – 1.7)

Anonymous Partners Yes vs. No 4.2 (2.5 – 6.9)* 4.7 (2.4 – 9.2)*

Condom Use No vs. Yes 0.9 (0.7 – 1.3) 0.9 (0.6 – 1.4)

Incarcerated Yes vs. No 0.8 (0.4 – 1.9) 0.8 (0.3 – 2.1)

IV Drug User Yes vs. No 2.3 (0.9 – 5.6) 2.4 (0.7 – 8.6)

Non-IV drug User Yes vs. No 1.5 (1.1 – 2.0)* 1.4 (1.2 – 2.1)*

* p<0.05

28

Commercial Sex Venues Compared to those who did not, MSM diagnosed with syphilis that

frequent commercial sex venues were:– Two times as likely to be HIV infected – Five times as likely to report having sex with anonymous

partners– One and half times as likely to use non-IV drugs

The most common drug used at commercial sex venues was methamphetamine (60%).

They were also:– more likely to report condom non-use, IV drugs use than those

who do not.– less likely to have sexual encounters at other venues

(bars/clubs, motels, parks, Internet, dancehalls, streets).

29

MSM and the Internet Overall 19% MSM who were diagnosed with early

syphilis infection met their sexual partners through the Internet – 65% were HIV positive

MSM with early syphilis who do use the Internet to meet their sexual partners were:– 2.6 times more likely to be White– 3.8 times more likely to have anonymous sex– 2.6 times more likely to use injection drugs

Independent predictors of meeting sexual partners via the Internet among MSM with early syphilis were:– White race– Having anonymous sex partners

30

Conclusion

Despite national progress toward syphilis elimination syphilis remains an important problem in the South and in urban areas in other regions of the country.

In Los Angeles County syphilis rates amongst MSM populations have continued to rise since 2001. In this population, the epidemic has been characterized by high HIV-co-infection rates.

31

Conclusions (cont’d)

In 2004, syphilis rates increased for men and women in almost all racial and ethnic groups.

In 2004, half of the total number of P&S syphilis cases in the US were reported from 19 counties and 1 city

1.Los Angeles County2.San Francisco County, CA 3.Cook County, IL 4.New York County, NY 5.Fulton County, GA 6.Dade County, FL 7.Harris County, TX 8.Baltimore (City), MD 9.Dallas County, TX 10.Broward County, FL

32

Syphilis Elimination Conclusions

“Elimination of syphilis would have far-reaching public health implications because it would remove two devastating consequences of the disease –increased likelihood of HIV transmission and compromised ability to have healthy babies due to spontaneous abortions, stillbirths, and multi-system disorders caused by congenital syphilis acquired from mothers with syphilis.

In addition, more than $996 million is spent annually as a result of syphilis. Eliminating syphilis in the United States would be a landmark achievement because it would remove these direct health burdens, and it would significantly decrease one of this Nation's most glaring racial disparities in health.”


Dante’ Tolbert, MPHEpidemiology Analyst, STD [email protected](213) 744-5901

SEXUALLY TRANSMITTED DISEASE PROGRAM

April 2006 Syphilis Epidemic in Los Angeles County S EXUALLY T RANSMITTED D ISEASE P ROGRAM.

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