EPIDEMIC OF SYPHILIS

Transcription

1 Brian Sandoval Governor Richard Whitley, MS Director Julie Kotchevar, PhD Administrator Ihsan Azzam, PhD, Md Chief Medical Officer EPIDEMIC OF SYPHILIS Understanding the Clinical & Public Health Need for Action Department of Health and Human Services Division of Public and Behavioral Health Sandi Larson, MPH State Epidemiologist

2 Joseph P. Iser, MD, DrPH, MSc Chief Health Officer Acknowledgments Syphilis Workgroup Nevada Division of Public and Behavioral Health Maternal Child Health Perinatal Substance Abuse Program WIC, Medicaid Local Health Departments (WCHD, SNHD, CCHHS) DHHS Office of Analytics Kevin Dick- Washoe County District, District Health Officer Joseph P. Iser, Southern Nevada Health District, Chief Health Officer 2

3 Presentation learning objectives 1. Describe the epidemiology of syphilis and congenital syphilis in Nevada. 2. Discuss clinical manifestations, diagnosis and treatment of syphilis and congenital syphilis. 3. Describe public health and clinical measures for the prevention of syphilis. 3

4 Syphilis Call to Action KEVIN DICK Washoe County District, District Health Officer 4

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6 Syphilis Overview: Definition Syphilis is a sexually transmitted disease (STD) caused by the bacterium Treponema pallidum. Syphilis can cause serious health sequelae if not adequately treated. Causes systemic infection Characterized by episodes of active disease during which patients have signs/symptoms of infection, interrupted by periods of latent infection Lab testing is required to diagnose patients The average time between acquisition of syphilis and the start of the first symptom is 21 days, but can range from 10 to 90 days. 6

7 Syphilis Overview: Transmission 1. Sexual: Person to person via vaginal, anal, or oral sex through direct contact with syphilis sores or lesions, known as a chancre. Chancres occur at the primary stage of syphilis and can be found around the external genitals or anus, in the vagina or rectum, or in or around the mouth. Sexual transmission also occurs at the secondary stage, mainly by direct contact with mucous membrane lesions such as condyloma lata and mucous patches. 2. Vertical From infected mother to her unborn baby via the bloodstream. 7

8 Primary Syphilis The appearance of a single chancre marks the primary (first) stage of syphilis symptoms, but there may be multiple sores. The chancre is usually (but not always) firm, round, and painless. It appears at the location where syphilis entered the body. These painless chancres can occur in locations that make them difficult to notice (e.g., the vagina or anus). The chancre lasts 3 to 6 weeks and heals regardless of whether a person is treated or not. However, if the infected person does not receive adequate treatment, the infection progresses to the secondary stage. Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides 8

9 Secondary Stage Mucocutaneous lesions (most commonly rashes) can occur as chancre(s) fade ~6 weeks after infection (range 3 wks 6 mos). Rashes may first appear on the palms of hands or the soles of feet, but typically appear on trunk & other areas of the body. Lesions such as condyloma lata, a moist, wart-like lesion found in the genital area & mucous patches on the tongue Other common findings: lymphadenopathy & constitutional symptoms. Less common: patchy alopecia & neurologic symptoms Symptoms clear within 2 6 wks but may take up to 3 mos, even without treatment. Patient is highly infectious, especially if direct contact with a moist lesion. In utero transmission is likely in pregnant women. Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides 9

10 Latent Stage The latent (hidden) stage of syphilis is a period of time when there are no visible signs or symptoms of syphilis. Without treatment, the infected person will continue to have syphilis in their body even though there are no signs or symptoms. Early latent syphilis is latent syphilis where infection occurred within the past 12 months. Late latent syphilis is latent syphilis where infection occurred more than 12 months ago. Latent syphilis can last for years. Late syphilis - serpiginous gummata of forearm Late syphilis - ulcerating gumma Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides 10

11 Syphilis Staging Flowchart SIGNS OR SYMPTOMS? YES NO PRIMARY SECONDARY LATENT Chancer Rash, etc. Any in past year? Negative syphilis serology Known contact to an early case Good history of signs/symptoms 4-fold increase in titer Only possible exposure past 12 months YES EARLY LATENT (<1 YEAR) NO LATE LATENT or UNKNOWN DURATION 11

12 Syphilis Rates of Reported Cases by Stage of Infection, United States, NOTE: Data collection for syphilis began in 1941; however, syphilis became nationally notifiable in Refer to the National Notifiable Disease Surveillance System (NNDSS) website for more information: 12

13 Primary and Secondary Syphilis Rates of Reported Cases by Sex and Male-to-Female Rate Ratios, United States,

14 Primary and Secondary Syphilis Rates of Reported Cases by State, United States and Outlying Areas, 2017 NOTE: The total rate of reported cases of primary and secondary syphilis for the United States and outlying areas (including Guam, Puerto Rico, and the Virgin Islands) was 9.5 per 100,000 population. See Section A1.11 in the Appendix for more information on interpreting reported rates in the outlying areas. ACRONYMS: GU = Guam; PR = Puerto Rico; VI = Virgin Islands. 14

15 Rate per 100,000 Population of Primary & Secondary Syphilis Cases in Nevada by Report Year Rate per 100,000 Population % Increase % Increase Clark Washoe Carson/Douglas/Lyon All Other Counties* *All other counties: Churchill, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Mineral, Nye, Pershing, Storey, and White Pine 15

16 Percent of P&S Syphilis Cases in Nevada by Sex, 2017 Percent of P&S Syphilis Cases in Nevada by Race/Ethnicity, 2017 Female, 13% Asian/Pacific Islander, 6.8% American Indian/Alaska n Native, 7.0% Unknown/Other, 5.1% White, 35.1% Hispanic, 26.7% Male, 87% Black, 25.6% 16

17 Percent of P&S Syphilis Cases in Nevada by Sex and Age, % 45.0% 40.0% 35.0% More than half of cases for both male and female are between % 25.0% 23.8% 22.7% 20.0% 15.0% 10.0% 5.0% 0.0% 17.3% 17.8% 17.3% 16.8% 14.7% 12.3% 11.9% 10.7% 9.3% 9.2% 5.5% 4.0% 1.8% 2.7% 1.0% 0.0% Male Female 17

18 We know that doctors are not doing enough screening for STDs, said David Harvey, executive director at the National Coalition of STD Directors. The failure to screen routinely is leading to an explosion in STD rates, he said, adding that cutbacks in funding and a lack of patient awareness about the risks make it worse. 18

19 REPORT Report cases to local health departments. 19

20 The Centers for Disease Control and Prevention (CDC) has developed a simple categorization of sexual history questions that may help providers, or other members of the clinical care team, remember which topics to cover. These are called the Five P s: 20

21 In the past 12 months, how many sexual partners have you had? Men? Women? Both? Transgender? Number and gender of partners over a given time 21

22 In the past 12 months, have you had vaginal sex? Oral sex? Anal sex? For men who have sex with men Are you the receptive partner ( the bottom )? Types of sexual practices oral, vaginal, anal 22

23 Have you even been diagnosed with an STI, such as HIV, herpes, gonorrhea, chlamydia, syphilis, HPV or trichomoniasis? When? Have you had any recurring symptoms or diagnosis? When was your last HIV test? Establish risk of repeat infections, HIV status and hepatitis risk 23

24 How do you keep yourself from getting infected? Do you use condoms consistently? If not, in which situations are you more likely to use a condom? Use of condoms and other methods 24

25 Are you trying to conceive or father a child? Do you want to avoid pregnancy? Are you using contraception or practicing any form of birth control? Do you need any information on birth control or a referral? Desire of pregnancy and use of prevention methods 25

26 : WHO TO TEST? During routine visits MSM and HIV + Pregnant women Any person with signs or symptoms suggestive of syphilis should be tested for syphilis. Anyone with an oral, anal, or vaginal sex partner who has been recently diagnosed. Sexually active men who have sex with men *Annually or every 3-6 months if at increased risk*) For HIV+ sexually active individuals, screen at first HIV evaluation, and at least annually thereafter Pregnant women *At the first prenatal visit *At the beginning of the third trimester *AND, at delivery if at risk * Risk is described in the CDC STD Treatment Guidelines at treatment. 26

27 : HOW TO TEST? 27

28 Primary, Secondary, or Early Latent (1 year) Benzathine penicillin G 2.4 million units IM in a single dose Latent Syphilis of Unknown Duration, or Tertiary Syphilis with Normal CSF Examination Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals 28

29 Pregnant Women Pregnant women should be treated with the penicillin regimen appropriate for their stage of infection. PRIMARY, SECONDARY, and EARLY LATENT (<1 YEAR) Benzathine penicillin G 2.4 million units IM in a single dose CDC tx guide suggests potential benefit with a second dose of Benzathine penicillin G 2.4 million units IM administered 1 week after initial dose. LATE LATENT or UNKNOWN DURATION Benzathine penicillin G 2.4 million units IM each at 1-week intervals ONCE PER WEEK FOR 3 WEEKS** ** In pregnancy should adhere to 7 days between doses. Missed doses are NOT acceptable for pregnant women receiving therapy for late latent syphilis. Pregnant women who miss any dose of therapy must repeat the entire course of therapy. 29

30 REPORT NAC 441A.225 Requires cases of Syphilis to be reported to the health department on the first working day following the identification of the case or suspected case. Healthcare Providers (NAC 441A.230) Laboratories (NAC 441A.235) Others (NAC 441A ): Director healthcare facility, parole probation officer, principle, blood bank, insurer, person. 441A.695 The health care provider for a person with infectious syphilis shall notify the health authority immediately if the person fails to submit to medical treatment or fails to complete the prescribed course of medical treatment. 30

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32 Syphilis Call to Action JOSEPH P. ISER, MD, DrPH, MSc Southern Nevada Health District, Chief Health Officer 32

33 Congenital Syphilis Definition and Affects Congenital syphilis (CS) is a disease that occurs when a mother with syphilis passes the infection on to her baby during pregnancy CS can have major health impacts on your baby. How CS affects your baby s health depends on how long you had syphilis and if or when you got treatment for the infection. Up to 40% of babies born to women with untreated syphilis may be stillborn, or die from the infection as a newborn. CS can cause: Miscarriage (losing the baby during pregnancy), Stillbirth (a baby born dead), Prematurity (a baby born early), Low birth weight, or Death shortly after birth. For babies born with CS, CS can cause: Deformed bones, Severe anemia (low blood count), Enlarged liver and spleen, Jaundice (yellowing of the skin or eyes), Brain and nerve problems, like blindness or deafness, Meningitis, and Skin rashes. 33

34 Congenital Syphilis Rates of Reported Cases Among Infants by Year of Birth and State, United States and Outlying Areas, 2017 NOTE: The total rate of reported cases of congenital syphilis for infants by year of birth for the United States and outlying areas (including Guam, Puerto Rico, and the Virgin Islands) was 23.2 per 100,000 live births. See Section A1.2 in the Appendix for more information on estimating rates for outlying areas. ACRONYMS: GU = Guam; PR = Puerto Rico; VI = Virgin Islands. 34

35 Rate of Reported Cases of P&S Syphilis among Women & Congenital Syphilis Cases, United States vs. Nevada, Rate P&S cases among women per 100,000 population NV- P&S Syphilis cases in women US- P&S Syphilis cases in women US- CS cases NV- CS cases Rate of CS cases per 100,000 live births 35

36 Number of Reported Cases of P&S Syphilis among Women & Congenital Syphilis Cases, Nevada, * Number of Cases * P&S Syphilis cases in women CS cases *2018 data is preliminary reported from January to June 30,

37 Percent of Congenital Syphilis Cases by Maternal Age at Delivery in Nevada, * 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0% 56% 42% 28% 22% 22% 25% 28% 17% 11% 6% 0% 11% 17% 17% < * Nevada seeing an increase in cases years of age *2018 data is preliminary reported from January to June 30,

38 Percent of Congenital Syphilis Cases by Maternal Race/Ethnicity in Nevada, * 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 42% 42% 33% 33% 33% 33% 28% 22% 17% 11% 6% 0% 0% 0% 0% White Black Hispanic Pacific Islander Unknown * Whites and Blacks consistently make up a majority of the reported cases *2018 data is preliminary reported from January to June 30,

39 Percent Mothers who received Prenatal Care Among Congenital Syphilis Cases in Nevada, * 100% 90% 80% 70% 60% 50% 40% 56% 39% 44% 44% 56% 52% 30% 20% 10% 0% 6% 0% Yes No Unknown 4% * Among those cases who received prenatal care the detection of syphilis was too late to prevent congenital syphilis *2018 data is preliminary reported from January to June 30,

40 Congenital Syphilis Cases by Other Maternal Demographics in Nevada, (N=27) Drug Use 100% Sex Behaviors Past 12 Month unknown 4% 90% 80% 70% 85% 85% Yes 44% 60% 50% No 52% 40% 30% 20% 10% 7% 4% 22% 11% 0% Sex with male Sex with female Sex with MSM Sex while high Had anonymous sex Sex without condom 18% Had another STD at time of Syphilis dx More than 1/3 of cases had more than 1 sexual partner past 12 months 40

41 Public Health Response: Points of Intervention to Prevent CS Data match was completed with Medicaid, SNAP, TANF, WIC, and Child Welfare and the 2016/2017 (N=27) reported congenital syphilis cases 21 had involvement in Child Welfare 17 had involvement WIC 22 enrolled in Medicaid and/or SNAP Case reviews also show: Cases access ER for care and services during pregnancy Cases access substance use and mental health facilities Homeless shelters What does this tell us? Prevention efforts need to be community wide and involve not only public health and medical providers but non-traditional service providers. 41

42 Public Health Response: Points of Intervention to Prevent CS Prepregnancy Screening Screening/dx/tx Timely partner services Accessible highly effective contraception During Pregnancy Linkage to prenatal care Screening/dx Timely treatment appropriate for stage Timely partner services Case management Prevent and detect new infection Birth Evaluation and treatment of baby Source: 42

43 Congenital Syphilis Take Home Points Female syphilis and congenital syphilis cases are increasing in Nevada. Most congenital syphilis cases can and should be prevented. Confirm maternal syphilis testing at delivery; infants should not be discharged without this information. Ensure exposed infants are evaluated and treated according to guidelines; this is an opportunity to prevent morbidity associated with untreated syphilis. Follow infants until RPRs become nonreactive. Report to local health department. 43

44 Statewide Congenital Syphilis Campaign

45 Clinical Guidelines and Consultation STD Clinical Consultation Network Enter your consult online at: CDC STD Treatment Guidelines App Available now, free 45

46 Resources 46

47 Training 20Launch%20Slides.pdf 47

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49 Sandi Larson, MPH Office of Public Health Informatics and Epidemiology Nevada Division of Public and Behavioral Health