Let s Think About Sexual. Maureen Kelly Planned Parenthood of the Southern Finger Lakes

Transcription

1 Syphilis Brought Us Together! Alexandra Hall MD Cornell University Maureen Kelly Planned Parenthood of the Southern Finger Lakes Karen Bishop RN Tompkins County Health Department Dana Rinaldo New York State Department of Health

2 Who we are: TC-STD.INFO A collaborative work-group with members from local organizations with a stake in public health that formed in response to a cluster of syphilis cases: NYS Regional Office Dana Rinaldo Tompkins County Health Department: Karen Bishop RN, Theresa Lyczko Planned Parenthood: Maureen Kelly, Rosaire Karij Cornell University: Alexandra Hall MD, Jennifer Austin MPH, Nina Cummings MS Tompkins Cortland Community College: : Shari Shapleigh NP Ithaca College: Erin Hall-Rhoades MD

3 Let s Think About Sexual Health for a Moment Maureen Kelly Planned Parenthood of the Southern Finger Lakes

4 Why is it that Gonorrhea is the second most commonly reported infectious disease in the United States, and the U.S. adolescent rate is 28 times greater than in the Netherlands Chlamydia infection is more than 15 times more common among U.S. teens than Dutch teens.

5 Our story begins Alexandra Hall MD Gannett Health Services Cornell University

6 December 2007, a colleague shared with me that he had just diagnosed a student with syphilis.!!!!!!!?????

7 WHAT IS SYPHILIS, AGAIN?

8 SYPHILIS Treponema pallidum Spirochete bacterium The French Disease The Italian Disease The Christian Disease Great Pox Ultimately named Syphilis by the Italian poet and physician Girolamo Fracistoro The Great Imitator

9 Primary Syphilis days after exposure Firm, painless ulcer, chancre at site of innoculation Usually on penis, vagina, or rectum Resolves spontaneously in 4-6 weeks Chancre may be too small or too inaccessible to be seen 30% transmission rate

10 Secondary Syphilis 1-6 months later Rash, mucous placques, condyloma lata Possible systemic symptoms (fever, malaise, myalgia) Rash may be missed (often subtle) or misdiagnosed Highly infectious - 30% transmission rate 35-40% have asymptomatic CNS involvement

11 Latent Syphilis No signs or symptoms Still potentially infectious Early if <1-2 years Late if > 1-2 years

12 Tertiary Syphilis to 50 years after infection Gummas - soft granulomas (16%), mass effect Neurologic symptoms (7%) Dementia Generalized paresis of the insane Argyll Robertson Pupil Tabes dorsalis Cardiovascular Aortitis (de Musset s sign) Coronary Disease Can be fatal

13 Neurosyphilis Can occur at ANY stage of disease Acute meningitis - usually within first year of infection Cranial nerve involvement Meningovascular syphilis - usu 7 yrs. Focal neurologic symptoms Arterial narrowings General paralysis of the insane (dementia) Tabes dorsalis

14 Definitive Diagnosis T. pallidum cannot be cultured in the lab I don t have, nor know how to use, a dark field microscope Non-treponemal tests RPR & VDRL Non-specific (can be false-positive due to mono, measles, varicella, connective tissue d/o, etc.) Can be used to follow response to treatment Treponemal (only 1% false-positive rate) MHA-TP FTA-ABS ABS Fluorescent Treponemal Antibody TPPA

15 Time course of antibody development during syphilis A comparison of the reactivity of the VDRL and FTA-ABS ABS during the course of untreated syphilis. A substantial proportion of persons with primary syphilis may not have developed a diagnostic antibody response at the time the chancre of primary syphilis appears. Courtesy of Charles B Hicks, MD; modified from the VD Program, Centers for Disease Control, US Public Health Service.

16 Difficulties in Diagnosis 20-30% of patients with primary syphilis will have a negative serologic test! 20-30% of patients with primary syphilis will have a negative serologic test! Window period of up to 90 days after infection before tests become positive 25% of patients with late neurosyphilis have negative non-treponemal serologies (i.e. RPR)

17 Treatments for Syphilis? Guaiacum Mercury A night in the arms of Venus leads to a lifetime on Mercury Arsenic (Salvarsan) Malaria infection

18 Treatment: Penicillin - Sir Alexander Fleming - Howard Walter Florey - Mass produced in 45

19 Treatment Primary, Secondary, early Latent (<1 year): - Benzathine Penicillin G 2.4 million units IM Late Latent, Tertiary, or HIV: - Benzathine Penicillin G 2.4 million units IM once a week for three weeks (total 7.2 million units) Treatment for Penicillin-allergic patients: -Primary, secondary, early latent: Doxycycline 100mg PO BID for 2 weeks OR Tetracycline 500 mg PO QID for 2 weeks. -Latent syphilis of more than 1 year: Doxycycline 100 mg PO BID for 4 weeks OR Tetracycline 500mg PO QID for 4 weeks.

20 Who needs to be tested?

21 My previous line Oh, gosh, I haven t seen syphilis since med school, working with WWII vets in NYC public hospitals, so I don t really think you need to get tested for that.

22 Syphilis Over the Years

23 Syphilis

24 Syphilis on the rise in MSM

25 CDC Recommendations for Syphilis Screening of Asymptomatic Patients All MSM (Men who have sex with men) (this is based on prevalence in population, need to take patient s circumstances into account) All Pregnant Women People who have been incarcerated and their partners Those who have had sex for drugs or money and their partners

26 Who else should be tested? (Our Recommendations) Any patient with a genital lesion Any patient with a rash of unclear etiology Any patient who engages in anonymous sexual activity

27 Evaluation & Treatment of Syphilis Contacts RPR and FTA-ABS ABS (LabCorp # ) If contact within 90 days or unknown time period, empirically treat with IM PCN If contact > 90 days prior, await serologies before treatment OR treat empirically Evaluate for signs and symptoms Screen for other STI s (HIV, CT, GC) Strongly consider evaluating/treating contacts of contacts Remember 20-30% false-negative rate in the first 90 days after infection

28 Yikes it s positive Treat according to stage if haven t already Call the Health Department Follow RPR at 3, 6, 12, 16, and 24 months should see a 4-fold decline by 6 mo and 8-fold decline by 12mo in P&S Syphilis Evaluate CSF if any neurologic symptoms Test for other STI s if you haven t already

29 Screening Guidelines for MSM Annual testing for monogamous MSM, every 3-6 months for non-monogamous HIV RPR Chlamydia - urethral and rectal Gonorrhea - urethral, rectal, and pharyngeal Hepatitis A Vaccination Hepatitis B Vaccination Consider anal pap smear every 2-3 years? HPV vaccine - studies underway

30 Screen everywhere! Figure 3. Proportion of chlamydial and gonococcal infections not identified if only urine/urethral screening was performed among men who have sex with men, San Francisco, California, 2003.

31 Back to our story

32 January diagnoses of syphilis at Cornell Both in MSM sent to LGBT List-servserv alerting community to presence of syphilis on campus and resources for info and testing Lots of conversations with LGBT community on how best to reach the population and get the word out Started developing health information materials for MSM

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34 January diagnoses of syphilis at Cornell Started conversations with the health department is this just us? Just a blip or something meaningful? Directed to Dana Rinaldo, DIS

35 Dana Rinaldo Central New York (CNY) Regional Supervisor Bureau of Sexually Transmitted Disease (STD) Control New York State Department of Health

36 CNY Staff Five Public Health Representatives AKA: Disease Intervention Specialists (DIS) Responsible for a 14 county area in CNY

37 NYSDOH NYSDOH REGIONAL REGIONAL MAP MAP WASHINGTON Clinton Franklin Essex Hamilton Warren Saratoga Fulton Schenectady Washington Niagara Orleans Erie Genesee Monroe Wayne Ontario Sen St. Lawrence Jefferson Oswego Cayu a Lewis Oneida Madison WESTERN WESTERN REGION REGION CNYRO CNYRO REGION REGION CAPITAL CAPITAL DISTRICT DISTRICT REGION REGION Delaware RENSSELAER Albany Greene Columbia Otsego Ulster Erie Chautauqua Cattaraugus Wyoming Allegany Ontario neca Yates Steuben Schuyler ug Tompkins Tioga Madison Chenango Broome Sullivan Dutchess Orange Putnam Rockland Westchest er New York Richmond Bronx METROPOLITAN METROPOLITAN AREA AREA REGION REGION

38 Disease Intervention Specialist (DIS) The role of the DIS is to ensure prompt examination and treatment of those infected or at risk of being infected with any of the three reportable STD s (Syphilis, Gonorrhea & Chlamydia) They also perform Partner Notification Assistance Program (PNAP) activities for those with HIV/AIDS.

39 Disease Intervention Interview Prior to the interview, the DIS assesses the positive case report. This includes contacting the medical provider to review pertinent information such as symptoms, treatment, medical history and demographic information. All of which will assist the DIS with the investigative process.

40 Disease Intervention Interview The DIS attempts to interview all patients who test positive for a reportable STD in order to prevent further transmission & complications of the disease. The interview includes: * Reassurance of patient confidentiality * Referral of patient for appropriate treatment * Education of patient on disease & transmission * Elicitation of partner information * Referral of sex partners

41 December 3, 2007 Case #1 Case #1 Male Cornell student Male sexual partners Provider: Gannett Health Services (Cornell) Sx: plantar & faint torso rash Stage: Secondary Results: RPR 1:512 FTA-R Diagnosed with HIV

42 * * R *? 12/3/07 1 *? * I 12/20/07 * * * R-refused follow up (f/u)?-could not verify f/u id only * -tested neg/treated

43 Case #2 12/3/07 12/20/07 December 20, 2007 Case #2 Male Community leader/ business owner Notified via Internet Male & Female Sexual Partners Resistant to come to care Provider: PPSFL Stage: Secondary Sx: Rash on torso/arms Results: RPR 1:32 FTA-R

44 I 12/20/07 2 R-refused f/u N-negative/no tx?-could not verify f/u I-infected * I 1/31/08 *-tested id Represents approx 10 unknown partners

45 What do you mean, there were 100 sexual contacts who couldn t be traced?

46 Craigslist, Men Seeking Men, Tue Oct 14 Want to get to know somebody (Cornell) LOOKING FOR HOT FUN (ITHACA) looking for fun today/tonight..interested.? (ithaca/tburg area) calling all twinks! (IC) I need to get off NOW (ithaca) Visitor looking for fun with young hot jocks (Ithaca/CU) Hot mouth available for guys needing to nut (campus) looking for well hung top (enfield) pic Some Quiet Affection/Tenderness (Ithaca) Wednesday night traveler (Ithaca hotel) Morning cock sucker available (Ithaca U host) head (ithaca) DRNK HORNY FRAT GUY WANT TO EXPERIMENT WITH ANOTHER JOCK (CORNELL NORTHHHHH) tight ass (cornell univ.) pic any 1 still up and looking for fun (Ithaca) Looking to meet on Cornell campus now (Cornell) lookin for clean dick (cornell) pic young looking for young to chill (west campus) Looking for fun and maybe something more (Cornell) now!!!!!!!! (IC commons) <<<< needs cum (ithaca)

47 /3/07 Case #3 12/20/07 12/3/07 12/20/07 1/31/08 January 31, 2008 Case #3 Male Cornell Staff Notified via Internet Male & Female Sexual Partners Provider: PPSFL Sx: None present Stage: Early Latent Results: RPR 1:16 FTA-R

48 12/3/07 2 * * * * * 3 *? R-refused f/u?-could not verify f/u * * * 1/31/08 id * -tested neg/treated Represents approx 10 unknown partners

49 2 Case #4 12/3/ /20/07 12/3/ /20/07 2 1/31/ /3/ /20/07 3 1/31/08 4 March 6, 2008 Male Cornell Faculty Notified via Internet Male Sexual Partners Provider: PPSFL Sx: Raised rash-soles soles feet, back, face, trunk Stage: Secondary Results: RPR 1:128 FTA-R Diagnosed with HIV Case #4

50 R 1/31/08 3/6/08 4 * * R-refused f/u?-could not verify id only at start * -tested neg/treated

51 In Tompkins County pieces of the puzzle begin to come together.. 12/3/ early syphilis cases within 4 months connected to each other all with connections to Cornell 12/20/ /20/07 3 3/6/08 4

52 5 known HIV positives Over 150 anonymous partners who cannot be notified of their exposure!

53 EEK!

54 Public Health Response Karen Bishop, RN, BS Tompkins County Health Department

55 Syphilis Surveillance Track disease incidence (typical is 0-1 cases per year in Tompkins County) Facilitate quarterly Communicable Disease meeting Key players include hospital infection control, college health center staff, Environmental Health, and CD staff

56 Call to Action Facilitated the formation of the Syphilis Workgroup, now tc-std.info Members included Gannett Health Center/ Cornell University, Hammond Health Center/Ithaca College, Tompkins-Cortland Community College Health Center, Planned Parenthood, Tompkins County Health Dept., NYSDOH CNY Regional Office

57 Call to Action Syphilis Workgroup met regularly Put everything out on the table Reviewed new clinical cases Strategized possible outreach efforts to improve case-finding and intercept transmission Community at large Community Providers Campus

58 Community at Large Press release Article in Ithaca Journal Article in Syracuse Sunday paper Posters

59 Community Providers Blast fax regarding recent cases to all MDs Mass Mailing: Letter regarding recent increase in incidence MMWR Aug. 4, 2006 edition on STD Treatment Guidelines Pocket guide to STD treatments by CDC An Update and Review of the Diagnosis and Management of Syphilis by NYC Health & Region II STD HIV Prevention Training Center Poster for exam or waiting rooms CD Report - Newsletter

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62 Campus April 08 to entire Cornell community to entire Ithaca College community to entire TC3 community Negotiated free testing at Cornell via Wadsworth for a finite period of time and held special evening testing clinics, with patient information materials distributed Publicized free testing services available at either Gannett Health Center or Planned Parenthood Media interviews, both radio and print

63 Did it work?

64 Results of our Efforts Over 200 Syphilis and HIV tests performed at Cornell About 200 syphilis tests performed at Planned Parenthood, twice the normal monthly rate Letter to editor of Cornell Daily Sun from student group charging heterosexism by Gannett Health Center on LGBT listserv decrying Dr. Hall for not trying to promote testing for straight women and for not responding to the situation sooner Substantially increased awareness of syphilis on campus and in the community And

65 Case #5 April 15, 2008 Case#5 Male Not a student, but lives with Cornell student Male Sexual Partners Provider: PPSFL Sx: Penile Lesion Stage: Primary Results: RPR 1:32 FTA-R

66 4/15/08 #5 I? 5/8/08 #6?-unknown outcome I-infected *-tested id only at start

67 * Case #6 4/15/08? #5 I 5/8/08 #6 May 5, 2008 Case #6 Male Cornell student Male sexual partners Provider: PPSFL Sx: wart-like area on top of penis (condyloma lata) Stage: Secondary Results: RPR 1:32 FTA-R

68 Boston 5/8/08 #6 *?-unknown outcome *-tested neg/treated id only at start Represents approx 10 unknown partners?

69 Now Tompkins County Early Syphilis Cases look like this:

70 Cornell associated C C C C C C C C C 5 of 6 cases & at least 5 partners C

71 Still 5 known HIV positives

72 Early Syphilis (ES) can occur in any county on any campus

73 Broome County ES Broome County had 5 cases of ES during the same time frame (1st 6 months of 2008) 4 had ties to BU, naming partners from BU and BCC BU BU BU BCC BU BU BU

74 Broome County ES & HIV 3 known HIV positives BU BU BCC BU BU BU BU

75 Other CNY Counties with ES during same time frame Oneida Oneida Oneida Onondaga Madison

76 Other Counties with ES & HIV 2 known to be co-infected with HIV Oneida Oneida Oneida Onondaga Madison

77 The BIG Picture in the CNY Region

78 * C C C IC C BU BU BCC BU IC C C C BU IC BU BU C C SUNY Cortland 16 ES cases in 1 st half of known HIV + in the picture 22 known to have a college connection C Rochester area college

79 NYSDOH REGIONAL SUPERVISORS Dee Daniels Buffalo Region Chautauqua WESTERN REGION Niagara Erie Cattaraugus Orleans Genesee Wyoming Allegany Monroe Ontario Steuben Wayne CNYRO REGION Dana Rinaldo Yates Sen neca Schuyler Cayu ug a Tompkins Tioga Oswego Jefferson Broome Lewis Oneida Madison Chenango St. Lawrence Otsego Delaware Franklin Hamilton Fulton Clinton Essex Warren WASHINGTON Saratoga Schenectady Washington Albany RENSSELAER Greene Columbia CAPITAL DISTRICT REGION Kim Mosteller Lorraine Urbanski Rochester Region METROPOLITAN AREA REGION Sean Moore Sullivan Ulster Orange Rockland Richmond Bronx New York Dutchess Putnam Westchest er Julie Helberg-HirschHirsch (Nassau & Suffolk Co s)

80 Where are we now? No new cases since May yet Received a grant from NYS to further our outreach and community education

81 Ongoing Projects Website: TC-STD.INFO Info on how/where to get tested STD information (links) Birth control information (links) Safer sex, including on-line, information Advertising buses, posters, coasters, java jackets, print, radio, Facebook

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83 What have we learned? Our many roles in improving the health of our communities The importance and benefit of collaboration Working in sexual health outreach presents unique challenges Remember not to confuse identity and behavior

84 we have seen a very high level of anonymous sexual contacts found through the Internet getting contact info for testing and treatment of partners has been difficult to access due to the anonymous/internet connections. this cuts across campus and community boundaries...there are students, staff, faculty and community members involved. Some patients bring fear, reluctance and concerns to their care regarding past discrimination or bias behavior and identity are not the same! Don't let assumptions based on how someone identifies (straight, gay...) intervene in care...we must talk about behaviors and sex partners not just identity labels. we have to talk to each other...campus, community, county...we are ALL involved in public health and we all hold vita pieces of the puzzle that makes a lot more sense when we're all around one table talking! Be aware of, and provide education about, Internet hook ups. STDs are preventable!! We can stem the tide!

85 Things to Remember

86 It s back!

87 It s sneaky. Chancre may be undetectable. Blood tests can be negative for up to 90 days after infection. Rash of secondary syphilis may be very subtle. Symptoms can often mimic other diseases and conditions (the Great Imitator)

88 It s easier than ever for students to find partners, and it s trickier than ever to trace contacts. craigslist

89 Sexual health outreach, especially that of minority populations, can be a minefield. Privacy Tuskegee Mistrust The Man Racism Anger Misogyny Homophobia Fear

90 So

91 We need to band together Share information Share resources Learn from each other Coordinate our efforts To Improve the health of our students and our communities! Please take 2 minutes to fill out your So What, Now What sheet, so that you can make the most of this presentation! (we ll take questions afterward)

92 QUESTIONS AND COMMENTS