STD Prevention & Control in a Time of Changing ResourcesThe Need for Stronger Partnerships

George Walton, MPH, CPH, MLS(ASCP)CM

STD Program Manager

Bureau of HIV, STD, and Hepatitis

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Objectives Discuss the epidemiology of chlamydia, gonorrhea, syphilis, and

HIV in Iowa.

Explain current STD prevention activities conducted by IDPH,

including partner services.

Describe recent changes in Iowa’s STD morbidity & resources and

how they relate to changing priorities and prevention strategies.

Explore options for increased collaboration among the various

health professionals in Iowa whose work includes sexual health,

emphasizing STDs with high incidence like chlamydia.

Discuss Iowa’s ongoing syphilis epidemic and the impact of various

prevention and control strategies.

Numerous STDs have been identified 25+

All STDs are treatable, many are curable Certain STDs are reportable to state or

local public health agencies Follow up is performed

Varying degrees Goal – reduce incidence and mitigate deleterious

effects upon the population’s health

STDs – A diverse group

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Reportable STDs

Disease Causative Agent Type of microbe

Chlamydia

Chlamydia trachomatis bacterium

Gonorrhea

Neisseria gonorrhoeae bacterium

Syphilis Treponema pallidum subsp pallidum bacterium

HIV Human Immunodeficiency Virus virus

Hepatitis B Hepatitis B Virus virus

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Epidemiology and Surveillance Data

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2013 surveillance data: Greatest number of cases of any reportable

disease (STD or otherwise) in Iowa and U.S. 11,006 cases reported in Iowa

70% of cases <25 years of age 72% of cases among women

Greater number screened Certain racial and ethnic groups

disproportionately impacted 18% of cases among black, non-Hispanic populations 7% among Hispanic populations

1,422,976 reported nationally (2012 data)

Chlamydia

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2013 surveillance data: Second most commonly reported infection in

Iowa and U.S. 1,471 cases reported

55% of cases <25 years of age 76% under 30 years of age 55% of cases among women Black, non-Hispanic persons highly

disproportionately impacted, 31% of reported cases

Hispanic populations account for 6% of reported cases

334,826 cases reported nationally (2012 data)

Gonorrhea

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2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

1,000

3,000

5,000

7,000

9,000

11,000

13,000

Gonorrhea

Year

# of cases

Chlamydia and Gonorrhea in Iowa, 2000-2013

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Gonorrhea in 2012    

Rank County Cases Rate

1 Scott 271 164

2 Black Hawk 181 138

2 Polk 593 138

4 Linn 230 109

5 Pottawattamie 92 99

6 Webster 35 92

7 Johnson 109 83

8 Decatur 6 71

9 Des Moines 27 67

10 Clinton 31 63

Gonorrhea in 2013    

Rank County Cases Rate

1 Webster 82 216

2 Wapello 35 98

3 Pottawattamie 85 91

4 Polk 387 90

5 Scott 146 88

6 Woodbury 89 87

7 Des Moines 32 79

8 Black Hawk 89 68

9 Johnson 85 65

10 Calhoun 6 62

Gonorrhea – top 10 counties by rate per 100,000 population

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2013 surveillance data (early syphilis only): 171 cases of early syphilis reported in

IowaMore evenly distributed among age

groupsMen accounted for 91% of casesMen who have sex with men (MSM)

disproportionately impactedOf males diagnosed in 2013, more than 80%

were MSM 30,170 reported nationally (2012 data)

Syphilis

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0

20

40

60

80

100

120

140

160

180

1911

18 15 17 1525 27 27 32

2331

81

171

Year

# of cases

Early Syphilis in Iowa, 2000-2013

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2013 surveillance data: 122 new diagnoses in Iowa

72% of cases were men MSM are highly impacted

84% of the male cases (60% overall)

Disparities among racial and ethnic minorities Black, non-Hispanic persons, 23% of cases Hispanic persons, 7% of cases

46% of new diagnoses among 25-44 year olds Foreign born: 27 (22% of total) in 2013

49,273 new HIV cases nationally (2011 data)

HIV Infection

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2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

140

Diagnoses of HIV Infection in Iowans: 2004 through 2013

Year of HIV Diagnosis

Num

ber o

f Per

sons

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STD Prevention Activities

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Examples of IDPH Activities Surveillance and Epidemiology

Ultimate goal – inform other prevention activities and raise awareness among medical providers, other health professionals, and the public.

Partner Services Includes interviewing patient for risk reduction

counseling and contact tracing/confidential partner notification to interrupt the chain of infection.

Screening for certain STDs Many are asymptomatic. Screening the most affected

populations is a key prevention strategy. Assuring adequate treatment Increasing condom availability

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Partner Services Conducted by Disease Prevention Specialists (DPS)

A broad array of services offered to: Persons with HIV, syphilis, gonorrhea, or chlamydia.

Examples: prevention counseling, assuring adequate treatment and linkage to medical care, referral to other services.

Identified partners of persons with these infections. Confidential partner notification is a core component.

Data show that notification by DPS is more effective than by patients themselves at reducing infection rates.

Others who are at increased risk and may benefit from screening or other prevention services.

All conducted while adhering to strict confidentiality standards.

Participation strongly encouraged but is voluntary.

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A closer look at chlamydia prevention activities

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How do we respond to chlamydia cases? IDPH now performs partner services for very

few cases. Only when specifically requested.

Obtain verification of adequate treatment from clinician.

If patient was adequately treated, that’s it! Interview criteria have been cut back over the

years due to growing numbers of cases of other STDs. Syphilis, gonorrhea, and HIV are deemed “higher

priority” than chlamydia cases. Numbers of cases increases every year, number of

staff stays the same.

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Waving the white

flag or calling for

backup?

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Maybe it is a good time to rethink chlamydia prevention activities… Partner Services is a tried and true method.

It’s been used successfully for many decades – “gold standard” intervention for syphilis.

But…syphilis has different characteristics than chlamydia. Syphilis has a very predictable symptomatology

pattern. Relatively easy to determine when someone was

infected. Effective investigation/partner services will reveal

whether you’ve found the “source”. More likely to follow distinctive disease patterns –

it has a lower incidence so increases in cases more easily noticed.

Thus you can more readily associate clusters of cases with one another.

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Maybe it is a good time to rethink chlamydia prevention activities… On the other hand, chlamydia…

Is much more prevalent. It has the highest incidence of any reportable condition!

It is often asymptomatic, making it difficult to determine when the infection was acquired.

Thus, it can be nearly impossible to identify the “source.”

Are partner services really the most efficient use of our limited resources?

If not partner services, then what?

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Chlamydia is highly concentrated in a specific population (adolescents and young adults).

If we were to select 100 sexually active teens at random vs those selected via partner services referral… Where would we find more positives per time spent?

Public Health is calling for backup! We need our partners in medicine and other health

professionals to help. “Free” clinics are constantly closing or cutting back hours. Public Health does not have the capacity to screen

everyone who should be. Tests with high sensitivity and specificity are now much

more widely available.

Screening!

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Screening! A lot of support already in place for chlamydia

screening Grade A recommended service from the United

States Preventive Services Task Force (USPSTF) for sexually active females 24 years of age and younger. Covered at no cost sharing as a result of Affordable Care

Act. It’s a measure for Healthcare Effectiveness Data

and Information Set (HEDIS). Many plans offer incentives to patients and providers for

this service. We still have safety net providers

Community-Based Screening Services (CBSS).

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Additional options Expedited Partner Therapy (EPT)

Clinical practice of treating the sex partners of patients diagnosed with chlamydia and/or gonorrhea by providing prescriptions or medications to the patient to take to his or her partner(s) without the health care provider first examining the partner(s).

Data show this practice reduces re-infection rates. Approx. 20% reduction for CT; 50% for GC (compared to

patient referral) Supported by several national organizations –

CDC, AAFP, ACOG It is legal in Iowa!

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Expedited Partner Therapy139A.41 CHLAMYDIA AND GONORRHEA TREATMENT.Notwithstanding any other provision of law to the contrary, aphysician, physician assistant, or advanced registered nursepractitioner who diagnoses a sexually transmitted chlamydia orgonorrhea infection in an individual patient may prescribe, dispense,furnish, or otherwise provide prescription oral antibiotic drugs tothat patient's sexual partner or partners without examination of thatpatient's partner or partners. If the infected individual patient isunwilling or unable to deliver such prescription drugs to a sexualpartner or partners, a physician, physician assistant, or advancedregistered nurse practitioner may dispense, furnish, or otherwiseprovide the prescription drugs to the department or local diseaseprevention investigation staff for delivery to the partner orpartners.

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Iowa’s syphilis epidemic continues

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Syphilis Overview – Stages of the Infection Primary

Characterized by painless chancres (sores) at the site of infection.

Highly infectious. Resolves with or without treatment (approx. 3 weeks).

Secondary Characterized by diffuse rash and lymphadenopathy. Resolves with or without treatment (approx. 4 weeks).

Early Latent Resolution of signs but infection acquired <1 year ago.

Late Latent Infection >1 year ago Not infectious

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First three stages of syphilis (primary, secondary, and early latent) are collectively referred to as “early syphilis” or “infectious syphilis”. Greatest interest in terms of public health.

Late syphilis important medically Severe, life-threatening complications can develop

15-30 years after untreated infection Tertiary syphilis

Neurosyphilis – not a stage; can occur at any stage

Early/Infectious Syphilis

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Syphilis in Iowa In 2013, 171 cases of early syphilis

Compared to the 31 cases in 2011, this is over a 450% increase

What’s different now than in 2011? Surge in our MSM populations

55% of cases in 2011; nearly 85% in 2012 & 2013 More who are comorbid with HIV

15% of cases in 2011 27.2% in 2012 31% in 2013

Case numbers remain high in 2014

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Syphilis Prevention and Control Strategies Partner Services

Contact tracing and partner notification are key. Find the “source” of the infection. Prevent spread and re-infection.

Is the “gold” in the gold standard fading? Challenges… Increasing number of “anonymous” partners. Often meet

online or via apps like “Grindr”. Very little identifying or locating information available.

Resistance to partner services. Clients refusing to participate.

We will expand to do “clustering” with our early syphilis cases. Others in the index patient’s social circles that may benefit

from testing besides sex partners.

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Syphilis Prevention and Control Strategies

Calling for more backup! Medical providers may have longer

relationships and better rapport with patients – encourage them to work with Public Health and participate in Partner Services. It’s worked well for others. Reduces risk of re-

infection. Done confidentially. If partner services doesn’t yield results, what

else can be done?

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Syphilis Prevention and Control Strategies

Syphilis is concentrated in a particular population. Need to find the infected and undiagnosed/untreated.

Increased screening!

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Syphilis Prevention and Control Strategies Treatment

Easily treated and cured Primary, secondary or early latent syphilis:

2.4 million units of long-acting benzathine penicillin G (Bicillin L-A), intramuscular injection.

Late latent syphilis: Three injections, spaced 1 week apart, needed

for late syphilis. Other penicillin derivatives used for neurosyphilis (most

administered intravenously).

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Syphilis Prevention and Control Strategies Presumptive treatment

Persons presenting with symptoms should be tested and treated the same day.

All sex partners to early syphilis should be presumptively. Sex partners within last 90 days should be treated even

if tests are negative. Sex partners greater than 90 days should be treated

presumptively if there is any uncertainty about follow up.

If sex partners are treated very early, their infectious period can be virtually eliminated, reducing the spread of the infection.

Presumptive treatment is a prevention strategy!

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Syphilis – addressing the epidemic Multifaceted response is required. Continued partner services, including clustering. Increased awareness among providers

Be vigilant for signs/symptoms and test and treat accordingly

Screen populations at greatest risk (e.g. MSM) Treat patients and their sex partners appropriately

(including presumptive treatment, when appropriate) Encourage participation in partner services

Increased awareness in the community Education Risk reduction Seek screening more frequently

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Future of STD Prevention & Control Governmental public health agencies to

return focus to assessment, assurance, and policy development.

Too pervasive for any one group to address on its own. Public Health, Medicine, Health Insurers,

Community-Based Organizations, Health Educators, Schools, other non-profits, etc. must collaborate, pool resources, and take advantage of each other’s expertise.

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Thank you for all that you do! Let’s continue to find ways to work

together to meet our common goals of reducing the incidence of STDs and improving the sexual health of Iowans!

Contact information:George Walton, MPH, CPH, MLS(ASCP)CM  

STD Program Manager

Bureau of HIV, STD, and Hepatitis

Iowa Department of Public Health

321 E. 12th St | Des Moines, IA 50319-0075

Office: 515-281-4936 | Fax: 515-281-0466

George.Walton@idph.iowa.gov