Syphilis Elimination: Reasons for Hope?
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Transcript of Syphilis Elimination: Reasons for Hope?
Syphilis Elimination:Syphilis Elimination:
Reasons for Hope?Reasons for Hope?
Kevin O’ConnorKevin O’Connor
DSTDPDSTDP
October 7, 2010October 7, 2010
Topics
Syphilis in the South CSPS DSTDP efforts with health departments Reasons for hope
2003
Rate per 100,000population
Guam 1.2
Puerto Rico 5.8
Virgin Is. 0.9
<=0.2
0.21-4.0
>4.0
(n= 6)
(n= 39)
(n= 8)
VT 0.2NH 1.2MA 1.9RI 2.2CT 1.7NJ 1.5DE 1.3MD 5.6
3.7
1.4
3.0 1.9
4.4 1.0
4.2
7.3
0.9
1.4
4.1 1.0
0.3
0.71.3
6.2
0.1
1.0
1.4
1.7
2.6
0.8
0.24.7
2.9
3.7
3.2
0.2
1.8
1.2
1.1
1.6
2.0
0.3
3.7
3.9
0.41.9
2.5
0.2
0.7
0.0
Rate per 100,000population
<=0.20.21-4.0>4.0
VT 0.2 NH 1.5 MA 2.1 RI 3.1 CT 0.9 NJ 2.0 DE 0.9 MD 5.7
Guam 0.6
Puerto Rico 5.2 Virgin Is. 2.7
(n= 5)(n= 44)(n= 4)
2.5
0.2
3.4 1.9
3.7 0.9
3.9
6.8
1.1
1.1
3.0 0.8
0.4
0.9 0.8
4.1
0.6
2.5
0.9
1.4
1.1
0.0
0.6 0.6
3.8
3.0
1.8
0.3
1.7
1.8
1.4
1.3
2.3
0.3
2.3
3.0
0.6
1.1
1.4
0.1
0.3
0.0
2008
2005
>4/100K
.21-4/100K
<.2/100K
Rates per 100K Pop
2000
Charting the US P&S Syphilis Epidemic
Rate per 100,000population
<=.2.21-4>4
VT 0.0 NH 0.2 MA 1.1 RI 0.4 CT 0.5 NJ 0.9 DE 1.2 MD 5.8
Guam 0.6
Puerto Rico 4.5 Virgin Is. 2.7
(n=14)(n=29)(n=10)
2.8
0.0
4.0 4.1
1.0 0.3
2.7
5.2
0.2
0.1
3.4 5.9
0.4
0.2 2.1
4.8
0.1
3.3
0.3
4.9
0.5
0.0
0.1 0.3
0.9
0.7
6.3
0.0
0.6
3.5
0.4
0.6
5.9
0.0
9.7
2.0
0.1
1.8
1.1
0.2
0.9
0.2
Rate per 100,000population
Guam 3.5
Puerto Rico 4.2
Virgin Is. 0.0
<=0.2
0.21-2.2
>2.2
(n= 4)
(n= 23)
(n= 27)
VT 1.8NH 1.5MA 3.3RI 1.7CT 1.0NJ 2.6DE 1.9MD 6.7DC 24.8
9.7
0.1
5.0 7.3
6.0 2.6
5.7
9.6
2.3
0.5
4.3 2.2
0.5
1.12.2
16.5
0.8
2.1
2.2
6.3
3.8
0.7
0.83.0
2.2
6.3
3.2
0.0
3.1
2.4
0.7
2.2
2.2
0.1
6.7
5.9
0.93.4
2.8
0.7
1.2
0.6
N Carolina:N Carolina:Syphilis Rates by Gender, 2005-Syphilis Rates by Gender, 2005-
20092009
7.6
9.5 9.3 8.7
16
3.1 3.7 3.1 2.4
4.5
0
2
4
6
8
10
12
14
16
18
2005 2006 2007 2008 2009
Ra
te p
er
10
0,0
00
Male Female
Rate ratios: 2.4 2.6 3.0 3.6 3.6
84%↑
88%↑
Communicable Disease Surveillance Unit
N Carolina:N Carolina:Co-morbidity (early syphilis & Co-morbidity (early syphilis &
HIV)HIV)
0
10
20
30
40
50%
of
Sy
ph
ilis
ca
se
s w
/ HIV
males
females
Georgia P&S Syphilis by Georgia P&S Syphilis by Race 2005-2009Race 2005-2009
0
100
200
300
400
500
600
700
800
900
2005 2006 2007 2008 2009
White
Black
Others
Cases
Tennessee: Tennessee: HIV Co-Infection in Syphilis HIV Co-Infection in Syphilis
CasesCases
0%
10%
20%
30%
40%
50%
60%
MSM Hetero males Females
Percent of HIV Co-Infection
2008 2009 thru 5/31/2010
Southern Syphilis Summary Southern Syphilis Summary
Significant changes in syphilis epidemiology:
Shift from heterosexual to MSM Rapid increase in HIV co-infection among MSM Increasing among young African American
MSM
Conclusion – SE should be part of a comprehensive STD/HIV prevention effort for MSM
CSPS New Directions
Use data to drive program Identify, then address health disparities Added emphasis on program evaluation →
improvement Performance Measures (PM) Program Improvement Plans (PIP) Evidence Based Action Plans (EBAP)
Are SE interventions working? Are they effective? Consider potential strategies for program improvements How well are interventions targeted towards at risk
populations?
Current SE Activities Surveillance - ID populations at risk
Partner ServicesPartner Services Internet Partner Services (IPS)Internet Partner Services (IPS) Management and Oversight: clear standards and expectations, Management and Oversight: clear standards and expectations,
supervisory review, engagement and support by managerssupervisory review, engagement and support by managers DIS embedded in HIV Care; gay-friendly clinicsDIS embedded in HIV Care; gay-friendly clinics DIS liaisons with key agencies to DIS liaisons with key agencies to develop strong develop strong relationshipsrelationships
Community Engagement Community Engagement - community coalitions focusing - community coalitions focusing on STD/HIV, media campaigns, STD in HIV CPG, Online outreachon STD/HIV, media campaigns, STD in HIV CPG, Online outreach STDP as part of HIVP services for MSM STDP as part of HIVP services for MSM
Targeted Screening Targeted Screening - based on epi/surveillance - based on epi/surveillance ROUTINEROUTINE STD screening in HIV Care STD screening in HIV Care
Ensure access to clinical services Ensure access to clinical services - -
SE Activities
Start Stop Improve Enhance Target Collaborate
DSTDP EffortsDSTDP Efforts
DSTDP Efforts to DSTDP Efforts to Address Syphilis, 2009-Address Syphilis, 2009-
20102010 9 Program Improvement Webinars on SE topics 9 Program Improvement Webinars on SE topics “ “Syphilis in the South” webinar Syphilis in the South” webinar CDC Field team deployed to outbreak in Cincinnati, Ohio (Aug/Sept. CDC Field team deployed to outbreak in Cincinnati, Ohio (Aug/Sept.
2010); AZ (2009); Houston (2008)2010); AZ (2009); Houston (2008) Epi-Aids: Texarkana, Arkansas; Phoenix, ArizonaEpi-Aids: Texarkana, Arkansas; Phoenix, Arizona Rapid Ethnographic Assessments in Phoenix, Arizona and North Rapid Ethnographic Assessments in Phoenix, Arizona and North
CarolinaCarolina
Program Performance Site visits (PPSV): Virginia, Tennessee, Program Performance Site visits (PPSV): Virginia, Tennessee, Mississippi, New Jersey, California (San Diego). Mississippi, New Jersey, California (San Diego). Outcome – over 82 Outcome – over 82 recommendations for syphilis –related program improvement made across all recommendations for syphilis –related program improvement made across all program domains (Surveillance, PS, Medical/lab Services, Evaluation, etc.) program domains (Surveillance, PS, Medical/lab Services, Evaluation, etc.) Priority focus on HIV care providers in areas with significant MSM morbidityPriority focus on HIV care providers in areas with significant MSM morbidity
Return PPSV to Puerto Rico and Louisiana (New Orleans, Shreveport). Return PPSV to Puerto Rico and Louisiana (New Orleans, Shreveport). 20102010
DSTDP Efforts to DSTDP Efforts to Address Syphilis, 2009-Address Syphilis, 2009-
20102010 Comprehensive program review in Albuquerque, New Mexico Comprehensive program review in Albuquerque, New Mexico
– significant focus on syphilis prevention and control – significant focus on syphilis prevention and control activities.activities.
Focus on EBAPs /other PM data – are strategies implemented Focus on EBAPs /other PM data – are strategies implemented effectively ? Are at-risk targeted? Are ineffective/inefficient effectively ? Are at-risk targeted? Are ineffective/inefficient strategies modified or stopped?strategies modified or stopped?
Best Practices Initiative – over 50 potential BP related to Best Practices Initiative – over 50 potential BP related to syphilis prevention and control submitted. Goal is to link syphilis prevention and control submitted. Goal is to link those in need with those who have demonstrated success.those in need with those who have demonstrated success.
Congenital Syphilis – PTB/ESB ID HMAs; PCs assess Congenital Syphilis – PTB/ESB ID HMAs; PCs assess current status of CS efforts in HMAs with CS or high female current status of CS efforts in HMAs with CS or high female morbidity. PCs are working with project areas on CS morbidity. PCs are working with project areas on CS program improvement, where needed.program improvement, where needed.
IPS TAIPS TA Individual TA for project areasIndividual TA for project areas
Reasons for HopeReasons for Hope
Reasons for HopeReasons for Hope
EpiEpi ‘‘Signs of declines’ in provisional surveillance data from SE: TX, Signs of declines’ in provisional surveillance data from SE: TX,
NYC, AL, & SF NYC, AL, & SF …although increases are occurring in OH, …although increases are occurring in OH, Chicago, WA, and KYChicago, WA, and KY
Enhanced EffortsEnhanced Efforts
PSPS Strengthened procedures, supervisions, and oversight: KYStrengthened procedures, supervisions, and oversight: KY Relocation of DIS: L.A.Relocation of DIS: L.A. IPS: AL, AZ, SF, MA, MO, NC, & PR. IPS: AL, AZ, SF, MA, MO, NC, & PR. ManyMany other areas other areas
ScreeningScreening ROUTINE STD screening in HIV Care ROUTINE STD screening in HIV Care Epi-based TARGETED screening (inc. collaboratively w/ HIVP) Epi-based TARGETED screening (inc. collaboratively w/ HIVP)
Thoughts on STDs & HIVThoughts on STDs & HIV
STDs among MSM STDs among MSM is an is an HIV Prevention issueHIV Prevention issue
STDP should be an core element of MSM HIVP Rectal STDs are a strong predictor of HIV sero-conversion HIV-/+ MSM with an STD should receive prompt HIVP
services Sexually active MSM should be routinely screened for
STDs (blood test for syphilis, rectal screen for CT/GC) HIV Care providers should routinely screen for STDs
Distribution of 2007 & Projected 2008 Distribution of 2007 & Projected 2008 SEE Funding* by SEE Funding* by
Project Areas in Rank Order of P&S Project Areas in Rank Order of P&S Morbidity** Morbidity**
*Total 2007 SEE funding = $19,083,197. 2008 Projected SEE Funding based on $19,000,000.**P&S Morbidity is an average of P&S Cases for 2005 and 2006
$-
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
$1,400,000
$1,600,000
$1,800,000
Project Area
Actual SEE Funding 2007
Total Proposed SEE Funding 2008
2007 Mean Investment = $477,079.93
2008 Mean Investment = $463,414.63
Proposed SEE Funding FormulaProposed SEE Funding Formula
For HMAs For HMAs Funding is based on 2 components:Funding is based on 2 components:
1)1) a base of $150,000; and a base of $150,000; and 2)2) a proportion of remaining available funds based on the % of a proportion of remaining available funds based on the % of
reported P&S cases for all HMAs for the two prior years for reported P&S cases for all HMAs for the two prior years for which data are availablewhich data are available
For post-HMAs For post-HMAs Funding will include base funding for two years during the “post-Funding will include base funding for two years during the “post-
HMA” transition period.HMA” transition period.