LOCAL EPIDEMIOLOGY AND THE ROLE OF THE HEALTH DEPARTMENT

LOCAL EPIDEMIOLOGY AND THE ROLE OF THE HEALTH DEPARTMENT M. Winston Tilghman, M.D. HIV, STD, and Hepatitis Branch Public Health Services www.stdsandiego.org LEARNING OBJECTIVE UPON COMPLETION OF THIS TRAINING, PARTICIPANTS WILL BE ABLE TO: Describe local STD epidemiology and the role of the public health department in STD control activities 1

STD SURVEILLANCE Dual reporting requirement Laboratory Provider Reportable STDs: Within 24 hours: Syphilis Within 7 days: Gonorrhea Chlamydia, including LGV Chancroid HIV & STD REPORTING 3,695 x 2 = 7,39 2

STD SURVEILLANCE SYPHILIS 3

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Number of Cases STD Update for Clinicians: San Diego Case Count by Stage of Syphilis San Diego County, 215 4 35 Total cases = 1,175 314 339 346 3 25 2 176 15 1 5 Primary Syphilis Secondary Syphilis Early Latent Late Latent Stage of Syphilis 7

Number of Cases Number of Cases Female and Congenital Syphilis Cases San Diego County, 215 18 16 Female Syphilis Congenital Syphilis 16 14 12 11 1 8 6 4 4 2 1 1 Primary Syphilis Secondary Syphlis Early Latent Syphilis Confirmed Cases Stillbirths Female Syphilis Congenital Syphilis Note: For public health purposes, congenital syphilis is defined as an infant born to a mother with untreated or inadequately treated syphilis at the time of delivery. Only cases of confirmed neonatal or infant infection are reported here. Primary & Secondary Syphilis Cases by Year San Diego County, 1988-215 5 Men who have sex with men Other 49 45 424 4 35 3 323 31 284 369 346 346 347 333 289 277 263 25 234 2 15 1 5 193 137 112 16 19 98 52 35 38 23 23 25 27 27 47 25 33 12 2 1 16 5 11 5 1 1 13 14 26 94 111 144 21 29 269 227 253 236 282 288 282 428 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 Year Note: The white-shaded numbers within the blue bars represent the number of cases in men who have sex with men per year. The numbers above the columns represents the total number of primary and secondary syphilis cases per year. 8

Number of Cases Rate Per 1, Population Rate per 1, Population Primary & Secondary Syphilis Cases and Rates by Year San Diego County, 1988-215 Cases Rate per 1, population 5 49 2. 45 4 35 424 17.8 31 323 346 346 333 347 369 15.2 18. 16. 14. 3 25 12.5 12.9 284 11.1 11.2 234 11. 289 277 263 11.6 11. 1.6 12. 1. 2 15 1 5 193 9.3 8.9 8.6 7.6 137 6.3 112 16 19 98 4.6 4.3 4.1 3.8 52 3.7 35 38 23 23 25 27 27 2. 1.3 1.3.9.9.9 1..9 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 Year 8. 6. 4. 2.. Primary & Secondary Syphilis Rates by Gender and Year San Diego County, 1997-215 Females Males 35. 3. 29.4 25. 2. 15. 1. 5..9*. 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 Year * Between 214 and 215 the female primary and secondary syphilis rate decreased by 22% and the number of cases decreased by 21%. 9

Number of Cases Rate per 1, Population Primary & Secondary Syphilis Cases by Gender and Age San Diego County, 215 14 Female Male 12 125 16 1 8 85 8 6 65 4 2 14 2 4 2 4 3 <1 1-14 15-19 2-24 25-29 3-34 35-44 45+ Age Group Primary & Secondary Syphilis Rates by Gender and Age San Diego County, 215 8 Female Male 7 69.4 66.5 6 5 4 43.7 51.4 3 2 21.7 1 11.2 3.2 1.8 1.7..... 1.9.5 <1 1-14 15-19 2-24 25-29 3-34 35-44 45+ Age Group 1

Rate per 1, Population Number of Cases Primary & Secondary Syphilis Cases by Gender and Race/Ethnicity San Diego County, 215 Female Male 2 18 19 187 16 14 12 1 8 6 4 2 24 2 1 2 4 Native American/ Alaskan Native 45 Asian/Pacific Islander Black Hispanic White Other/Mixed Race Race/Ethnicity 8 12 Note: Excludes 15 cases missing race/ethnicity information. Primary & Secondary Syphilis Rates by Gender and Race/Ethnicity San Diego County, 215 7 Female Male 6 6.6 5 4 36.1 3 26.1 24. 22.5 2 13.8 1..5 Native American/ Alaskan Native 3.1.7 1.1 Asian/Pacific Islander Black Hispanic White Other/Mixed Race Race/Ethnicity Note: Rates exclude 15 cases missing race/ethnicity information. 11

Percent Percent of Interviewed MSM Cases MSM* Primary & Secondary Syphilis Cases Co-Infected with HIV by Year San Diego County, 2-215 1 9 8 7 6 5 48% 4 3 2 1 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 Year *MSM: Men Who Have Sex With Men. Meeting Venues Among Interviewed MSM* Primary & Secondary Syphilis Cases San Diego County, 21-215 6 Internet Bathhouses/Sex Clubs Parties Bars/Clubs 55 55% 5 45 4 35 3 25 2 23% 15 1 5 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 8% 4% Year Note: Reported use of venues is not mutually exclusive. *MSM: Men Who Have Sex With Men. 12

Number of Interviewed Cases Reporting Use of Site Percent of Interviewed MSM Cases Reported Use of Internet-Based Services** Among Primary & Secondary MSM* Syphilis Cases San Diego County, 214 215 14 214 215 126 12 1 8 6 48 52 63 4 2 13 25 21 21 15 1 1 8 4 6 5 1 3 4 1 2 2 1 2 Note: Reported use of sites is not mutually exclusive. *MSM: Men who have sex with men. ** Included websites have been used by at least 2 MSM cases per year in 213 or 214. Reported Substance Use of Interviewed MSM* Primary & Secondary Syphilis Cases by Year San Diego County, 24-215 4 Methamphetamine Cocaine Alkyl Nitrites (Poppers) Impotence Drugs MDMA (Ecstasy) 35 3 25 2 15 16% 1 5 9% 6% 5% 5% 24 25 26 27 28 29 21 211 212 213 214 215 Year Note: Reported substances are not mutually exclusive. *MSM: Men Who Have Sex With Men. 13

Primary & Secondary Syphilis Cases by Reporting Facility Type San Diego County, 215 Planned Parenthood 4% Military 2% HIV Care/EIP Facility Other 12% 2% County STD Clinics 39% Student Health 2% Community Health Clinics 13% Correctional Facilities <1% Hospital/Emergency Room/Urgent Care 3% Private MD/HMO 24% 14

WHAT IS DRIVING THE CURRENT SYPHILIS EPIDEMIC? SOME POSSIBILITIES INCLUDE: Advances in HIV prevention and treatment Methamphetamine and other substance use Internet sites/hook-up apps Lack of effective biomedical prevention Low funding for STD control Stigma Poverty, access to quality healthcare GONORRHEA 15

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Number of Cases Rate per 1, Population Rate per 1, Population Gonorrhea Cases and Rates by Year San Diego County, 1996-215 Cases Rate per 1, population 4 3695 16 35 3391 14 3 25 2 15 1815 69.2 155 56.7 1587 156 58.7 56.7 1875 1797 63.9 65.5 2128 72.9 1972 66.4 2376 78.9 266 85.7 2767 9.3 2385 77. 216 64.2 1843 6.1 219 65.2 2166 69.5 2597 83. 2865 114.5 16.2 9.9 12 1 8 6 1 4 5 2 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 Year Gonorrhea Rates by Gender and Year San Diego County, 1996-215 Females Males 2 175 165.9 15 125 1 75 5 62.7 25 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 Year 17

Number of Male Cases Number of cases Rectal or Pharyngeal Gonorrhea Infections in Males San Diego County, 1997-215 1 9 931 8 7 645 715 762 786 6 558 5 4 393 373 427 3 2 1 22 16 143 12 98 142 18 38 41 5 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 Year Gonorrhea Cases by Gender and Age San Diego County, 215 Female Male 7 626 639 6 5 449 4 345 49 412 3 214 2 1 161 129 121 18 54 1 5 1 <1 1-14 15-19 2-24 25-29 3-34 35-44 45+ Age Group Note: Excludes 5 cases missing gender information and 16 cases missing age information. 18

Number of Cases Rate per 1, Population Gonorrhea Rates by Gender and Age San Diego County, 215 6 Female Male 5 521.7 4 421.1 34.1 3 278.9 217.7 2 182.2 144.3 1 12.8 15.2 52.6 71.4.5. 5.3 1. 8.4 <1 1-14 15-19 2-24 25-29 3-34 35-44 45+ Age Group Note: Rates exclude 21 cases missing gender or age information. Gonorrhea Cases by Gender and Race/Ethnicity San Diego County, 215 8 Female Male 7 72 6 5 443 4 3 272 2 164 175 19 1 3 3 11 Native American/ Alaskan Native 85 99 Asian/Pacific Islander Black Hispanic White Other/Mixed Race Race/Ethnicity Note: 44.7% of cases are missing race/ethnicity data and are not included in counts above. 41 19

Rate per 1, Population Gonorrhea Rates by Gender and Race/Ethnicity San Diego County, 215 4 Female Male 35 35.4 3 25 2 178.2 15 1 14.5 94.1 71.9 91.9 5 41.7 Native American/ Alaskan Native 34.4 3.4 43.1 23.2 11.6 Asian/Pacific Islander Black Hispanic White Other/Mixed Race Race/Ethnicity Note: 44.7% of cases are missing race/ethnicity data and are not included in rates above. Gonorrhea Cases by Reporting Facility Type San Diego County, 215 Other 8% County STD Clinics 22% Planned Parenthood 22% Private MD/HMO 23% Military 7% Student Health 1% Community Health Clinics 9% Correctional Facilities 2% Hospital/Emergency Room/Urgent Care 6% 2

CHLAMYDIA 21

Number of Cases Rate per 1, Population STD Update for Clinicians: San Diego Chlamydia Cases and Rates by Year San Diego County, 1996-215 2 Cases Rate per 1, Population 8 18 16538 1642 15626 17418 7 16 15336 15349 14 12 1 8 6 4 12692 1198 1473 14266 1822 111 495.5 492.6 1225 1249 447.9 465.5 9168 8637 39.8 49.9 7576 35.1 359.5 361.9 76 344.9 636 36.9 32.1 5642 275.4 259.2 239.7 215.3 528.6 59.2 489.2 539.7 6 5 4 3 2 2 1 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 Year 22

Number of Cases Rate per 1, Population STD Update for Clinicians: San Diego Chlamydia Rates by Gender and Year San Diego County, 1996-215 Females Males 8 7 693.3 6 5 4 384.2 3 2 1 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 21 211 212 213 214 215 Year Rectal or Pharyngeal Chlamydia Infections in Males San Diego County, 26-215 8 7 688 6 61 63 589 522 5 424 4 345 365 3 295 2 1 63 26 27 28 29 21 211 212 213 214 215 Year 23

Rate per 1, Population Number of Cases Chlamydia Cases by Gender and Age San Diego County, 215 55 5 45 4 Female 4789 Male 35 3 25 2 233 28 217 15 1 5 1444 894 818 675 723 591 51 237 8 7 58 6 <1 1-14 15-19 2-24 25-29 3-34 35-44 45+ Age Group Note: Excludes 34 cases missing gender information and 8 cases missing age information. Chlamydia Rates by Gender and Age San Diego County, 215 44 4 Female 3872.1 Male 36 32 28 24 2 263.7 1847.4 16 12 8 4 1399. 1178.9 777.5 68.2 399.3 328.6 35.5 3.9 3.3 61.2 12.5 6. 37.1 <1 1-14 15-19 2-24 25-29 3-34 35-44 45+ Age Group Note: Rates exclude 114 cases missing gender or age information 24

Chlamydia Cases by Reporting Facility Type San Diego County, 215 Planned Parenthood 35% Other 3% County STD Clinics 6% Private MD/HMO 24% Hospital/Emergency Room/Urgent Care 6% Military 12% Student Health 1% Community Health Clinics 12% Correctional Facilities 1% 25

PUBLIC HEALTH RESPONSE CASE INVESTIGATIONS/PARTNER SERVICES 26

LOW- TO NO-COST STD CLINICAL SERVICES GC/CT HOME TESTING PROGRAM www.dontthinkknow.org 27

GONOCOCCAL ISOLATE SURVEILLANCE PROJECT (GISP) Sentinel Sites and Regional Laboratories, 211 CHLAMYDIA SCREENING PROJECT (CLASP) Chlamydia and gonorrhea screening in juvenile detention facility Typical female CT positivity rate of 1-15% Typical female GC positivity rate of 1-3% Treatment provided to those who are released prior to diagnosis 28

EDUCATION AND TRAINING DATA AND STATISTICS http://www.sandiegocounty.gov/hhsa/programs/phs/hiv_std_hepatitis_branch/reports_and_statistics.html 29

OTHER SERVICES STD Clinical Consultation Pager: (877) 217-1816 Syphilis Histories (619) 692-851 THANK YOU! ACKNOWLEDGEMENTS Heidi Aiem Tara Beeston Lawrence Wang California Department of Public Health STD Control Branch STD Clinic and Field Services Staff 3