Strategies:

Five strategies have been identified in the National Syphilis Elimination Plan as critical for eliminating syphilis in the United States. These strategies, which must be implemented at the local level,

1. Enhanced Surveillance
2. Strengthened community involvement and partnerships
3. Rapid Outbreak Response
4. Expanded Clinical and Laboratory Services

5. Enhanced Health Promotion

These strategies are directed at not only eliminating syphilis but at maintaining vigilance to assure that new cases of this subacute infectious disease are detected before transmission. What follows below is a description of the current situation in Indianapolis with regard to each of the identified strategies. This description will include an identification of barriers to fulfillment of optimal implementation for each of the strategies. The Elimination Plan will follow this description and will address each of the identified barriers as well as delineate the purpose, direction and plans for the execution of identified strategies in Marion County.

Detection of an increased number of syphilis cases was first detected in Marion County in approximately April of 1998 when there was an increase in the number of cases of infectious syphilis, that is, syphilis in its primary and secondary stages, reported to the Health Department. Because infectious syphilis accounts for the bulk of transmission, characteristics of these cases were examined. Analysis of primary and secondary cases has consistently identified four zip codes as the residence of at least 50% of cases. Figure 1 shows the location of primary and secondary cases, the location of the zip codes and an overlay of the medically underserved areas. Within these zip codes lie a total 9 of the 10 most affected census tracts. Poverty characterizes areas most affected. The three census tracts with the highest syphilis morbidity have poverty rates > 30%. Further geographic mapping has shown that within the "hot zone" zip codes, the highest concentration of cases occurs along 30^th Street, the street. 30^th Street is the major access point of a residential area within Indianapolis to I65, the interstate route that connects Chicago and Indianapolis as seen on Figure 2.

Characteristics of the individuals infected with syphilis have been derived by interview with them after diagnosis. Interviews conducted by disease intervention specialists with individuals whose disease is reported by providers and laboratories provide information on associated risk behaviors. Between 4/26/99 and 10/15/99 174 interviews were performed from the total of 189 cases of primary and secondary syphilis diagnosed. Of these 21% admitted to trading sex for drugs or money, 25% admitted to crack cocaine use, and 24% had had sex with a cocaine user. Overall 42% had traded sex, used crack or had sex with a crack user.

Table 1 shows the prevalence of positive syphilis serologies in black, white and Hispanic populations (Hispanic patient numbers are regardless of race). In each screening site, black populations have a high rate of infections compared to white and Hispanic populations.

The geographic locations of syphilis coincide with areas that are predominantly black and medically underserved (Appendix IV). A concern about reporting of white clients has been voiced. Further efforts at detecting potential biases in reporting must continue and be incorporated into the plan.

1. Enhanced Surveillance

Active surveillance or screening occurs in more than 20 sites in Marion County and passive screening i.e. reporting occurs in association with many others. Some of the sites associated with active screening are associated with the Marion County Health Department and others are public and private providers not associated with the Health Department. Appendix I lists sites where the Marion County Health Department is currently performing screening activities. Of note, in particular, is screening at the Marion County Department of Corrections Intake unit (previously referred to as Lock-up). This site is where individuals newly arrested in Marion County are received into the jail system.

Because risk behaviors for syphilis, both here and elsewhere, are associated with criminal activities, a jail-screening program was started in May of 1999. The jail-screening program was set up with the combined efforts of the Marion County Health Department, Marion County's Sheriff's office and the Indianapolis Police Department. The CDC funded a guard, a laboratory technician and a clerk for the program. Individuals are screened during non-court hours Monday through Friday from 3 PM to 11 PM. Based on the annual number of detainees and the number of unique clients screened, it is estimated that 10% of all males and 20% of all females arrested are being screened at this location. The increased percent of female screening has resulted from increased efforts to screen women, whose seroprevalence at the jail has been higher than that of men and also because of individuals with prostitution or drug related offenses have been given priority for individual counseling by a trained DIS who recommends screening. These individually counseled patients almost always agree to be screened (conversation with Kelly Adams 6/00).

Since its inception, the program has screened more than 5000 individuals have been screened for syphilis at the jail intake site. The seroprevalence in men has been 1-3% and in women approximately 6-8%. In addition to syphilis screening, Gonorrhea and Chlamydia screening is done simultaneously on urine specimens by PCR. The prevalence of GC has been about 3% whereas the Chlamydia prevalence has ranged between 7-13%. With the assistance of a jail database, we have found that more than 70% of the individuals with primary and secondary syphilis have criminal records when matching was done on the basis of name and birthdate.

The jail has been a particularly important site for screening because many syphilis patients report being in jail in the recent past. Review of the 416 cases of syphilis diagnosed in 1999 revealed that 10% of cases had names verified in a jail database associated with incarceration during the interview period. This number compares favorably with the 12% of individuals that said they were in jail during that time period. More impressive is that 38% of individuals were found in the jail database to have been in jail within 1 year of diagnosis, and 69% of infected individuals were found to have a jail record at some time. (Appendix II).

Appendix III lists the providers who reported positives RPR’s to the Marion County Health Department from 10/15/00 to 5/23/00. The distribution of individuals with reported positive tests reflects the many sites where syphilis is diagnosed. Of note is a large number of positive reports from the Bell Flower Clinic (565 which includes follow up blood work on syphilis patients) and the various Wishard Memorial Hospital sites (total 203 positive tests).

Other sites that screen for syphilis include all prenatal providers and the Wishard Memorial Hospital (WMH) Emergency Department. The WMH Emergency Department has been screening for syphilis since 5/99 according to recommendations made on the basis of discussion with the Marion County Syphilis Elimination Task Force. These recommendations included screening all patients tested for any other STD, any individual with a toxin screen which revealed cocaine and anyone brought from the jail. Although initial recommendations suggested testing sexually active individuals from the "hot zone" zip codes, this practice presented to the Stamp Out Syphilis Coalition and found to be undesirable. Silvia Teran. M.D. , an Epi Aid, Kathleen Irwin, M.D. and Cathleen Walsh , PhD. from the Health Services Branch of CDC have been working on a screening algorithm in association with the health department and the SOS coalition.

In addition to traditional screening sites associated with provision of clinical services, Marion County has developed relationships with a number of social service providers to refer potentially infected individuals. These include: Drug treatment sites, Drug Court Rehabilitation Program and Fairbanks Hospital, Prenatal care providers, Women's shelters, HIV Outreach Screening Activities, and Homeless Shelters. Screening programs have been conducted door to door screenings both on a large scale (2) and daily on a smaller scale in affected areas and at Health Fairs such as Indiana Black Expo where over 200 individuals were screened in a 5 day period. Screening continues at the time of "sting" operations to arrest Commercial Sex Workers and at "John" school, a program that defers a criminal arrest record in exchange for community service and education regarding the offense of solicitation..

2. Strengthened Community Involvement and Partnerships

Syphilis is a disease with a legacy of distrust between communities and public health institutions. Elimination is critically dependent on building productive relationships between these two groups. This will require an understanding of the history of the affected communities as well as the broader context of the existence of these communities in the city. In addition, it will take recognition of the resources within these communities, strengthening them and facilitating their development. Efforts to unite the Health Department with community groups have included activities that predated the 1998 Marion County Syphilis Outbreak including:

• A community coalition created in 1997 to combat the high infant mortality rate in Indianapolis. Dr. Virginia Caine, now Marion County Health Department Medical Director, in association local hospital CEO's organized the Health Indy Partnership. A widespread health assessment was performed that involved 26 community groups to target 5 health problem areas including pediatric asthma, teen pregnancy and tobacco use. This health assessment is performed every 4 years. For a history of the Healthy Indy Partnership, see Appendix I.
• In May of 1999, a group of Community Based Organizations was brought together to address the syphilis epidemic. Headed by State Senator Billie Breaux and community leader Al Polin, the coalition, entitled Stamp Out Syphilis Keep It in Check, referred to as the SOS Coaltion, has played a major role in coordinating activities and in analyzing the impact of health department initiatives. Appendix V lists the names of members of the SOS Coalition and briefly summarizes their activities particularly as they relate to syphilis elimination. The group meets approximately every 2 weeks and continues to grow in numbers and diversity of interest.
• Health Department officials involved in syphilis elimination provided talks, appearances or information booths for syphilis to numerous community organizations. These included the Mapleton-Brightwood Community Organization, the United Northwest Neighborhood Association, the National Council of Negro Women, the Blackburn Clinic Neighborhood Advisory group, the Martindale Brightwood Clinic Neighborhood Advisory group, Community Day, Indiana Black Expo, WTLC's Medically Speaking and Willie others.
• A breakfast meeting was held to inform state senators and representatives to update them on the syphilis epidemic. The program also elicited ideas as to how to best address the problem and to identify barriers that may prevent constituents of the affected communities from obtaining the best care.

• The PRIZM has shown that the communities most affected are comprised of 2 major groups that are termed the Southside City Residents and the Urban Dwellers. One goal of future endeavors is to understand how these interrelated communities function together and how to best take advantage of that interaction.

3. Rapid Outbreak Response

The mandate of the National Syphilis Elimination Plan is to develop an outbreak response plan that includes:

• Meeting with the affected community to discuss a social and behavioral assessment to understand the behavioral, social and health services causes of the outbreak. The establishment of a mobile outbreak response team within 6 months of the beginning of the outbreak. This Outbreak Team is critical in initiating multi-pronged strategies quickly during an epidemic.
• To optimize this approach, a members of the outbreak team should be identified in advance of an outbreak, have defined roles, meet regularly in periods of control and receive specific training in activities before the onset of an outbreak. It goes without say that the mobile outbreak response team must be able to work outside standard business hours, draw field serologies, facilitate clinical and lab services, and provide technical assistance to affected communities. The proposal within the Marion County Syphilis Elimination Plan incorporates the experience of applying Intensified Services and addresses opportunities for optimizing the Outbreak Response.
• Draw up and circulate a report within 1 month after clearance of the outbreak that summarizes the possible causes and recommends strategies for preventing future epidemics. This report is to be circulated to public and private providers, to non-health organizations serving populations at risk for syphilis, to the CDC and to other areas to policymakers and to other appropriate partners.

Despite a high degree of involvement of its personnel, Marion County met the challenge of the syphilis outbreak promptly. Although the outbreak occurred during the preparation phase for Y2K, which required strong information services support, STD staff, particularly program manager Duane Wilmot, implemented the installation of CDC tracking software, integrating it with existing systems. In addition, the STD clinic increased its activities taking any contact or associate to a syphilis patient regardless of filled appointments. During the epidemic, DIS staff suspended other activities to make sure each syphilis patient was interviewed and as many secondary cases identified as soon as possible. During the epidemic a major strength was that the Medical Director of the Health Department, Dr. Caine, was an authority on STD's and was well connected within the multiple affected communities. With the help of financial support of the Centers for Disease Control, new personnel were hired to help meet the crisis.

Marion County met many of the needs for a rapid outbreak response with financial and personnel assistance from the Centers for Disease Control. In the months of April through June of 2000, 3 teams of Disease Intervention (DIS) staff recruited nationwide from a variety of local and federally funded positions came to Indianapolis. Local and Federal DIS Staff concentrated on interviewing individuals with syphilis quickly, finding their partners, screening on the street, and identifying potentially infected individuals by asking infected persons if they knew people who might be at high risk (increasing cluster interviews).

During the second year of the epidemic, syphilis cases were interviewed more quickly, rising from 66% interviewed within 7 days of diagnosis during the first 6 months of 1999 to 89% of cases in the first 6 months of 2000. The number of contacts on whom adequate information was obtained to initiate a search for the exposed individual increased from 0.6 persons/case to 2.1 persons/case. The percent of contacts tested for syphilis increased from 43 to 52%. The number of interviews of people at risk named by infected persons doubled. The percent of syphilis cases where the source identified increased from 14 to 32%. While these numbers indicate further room for improvement, the trend towards more rapid identification of potentially infected individuals, their testing and treatment promises to contribute substantially to syphilis control and elimination.

Challenges identified by the members of the Syphilis Elimination Effort included the need to optimize communication during the outbreak regarding activities and to streamline human resources procedures to balance speed of hiring with the need for security and protection of both the corporation and employees. Staff turnovers sometimes complicated implementation syphilis elimination. During the intensified efforts, both case managers, a major data entry clerk and the surveillance coordinator resigned. The major reason for the resignations of case managers was that the positions required interpretation of information that was difficult for individuals without higher education.

The epidemic underscored the need for a rapid outbreak response team. In addition, procedures and policies for compensation need to be established in the event of any catastrophic event. These must contain incentives for employees, particularly when the impact of the event develops slowly and requires involvement over a long period of time. In the words of one employee "Anyone can give up a couple of weeks, it is the months of intense activity that it is harder to accommodate."

The Rapid Outbreak Response Plan that is outlined in the second part of this document (See Page 9) summarizes the best estimate of needed personnel to accomplish an effective program.

A report summarizing the experience of the outbreak will be circulated within 1 month of clearance of the outbreak. This will be based, in part, on this plan, which is written at a time when cases appear to be decreasing (July 2000).

3. Expanded Clinical and Laboratory Services

Currently Indianapolis has one major public STD clinic, Bell Flower, that has approximately 14,500 visits per year and is the largest reporter of syphilis in the County, reporting 50% of the primary and secondary syphilis morbidity. It operates on a same-day appointment system with 60-70% appointment compliance. Patients identified as contacts or associates to syphilis patients are always accepted on a walk-in basis. In addition, other walk-in appointments are accepted according to clinic load and usually equal approximately the number of missed appointments. Walk-in patients not associated with syphilis are generally those with symptoms likely to receive medication on discharge. Asymptomatic patients who desire only screening for STD's are offered syphilis screening and urine PCR testing for GC and CT without an examination in an attempt to increase the volume of patients seen at the clinic.

Bell Flower is located within 1 mile of the areas most affected by syphilis and directly behind Wishard Memorial Hospital, the county's public health hospital. Wishard was the second highest source of reported cases of syphilis. Bell Flower and Wishard are located on the campus of IUPUI, a partnership campus of Indiana University and Purdue University (IUPUI) that houses the Indiana University School of Medicine.

In addition to the STD clinic, Health and Hospital Corporation offers STD Services at the Action Center, a comprehensive health center dedicated to adolescent services, at the Wishard Primary Care Center and at the 6 Wishard Community Health Centers (See Appendix IV), which also offer specialized adolescent services.

In response to the syphilis epidemic:

• Compensation was arranged for providers so that syphilis testing could be done at a number of non-health department sites. In addition, a new screening site was created within the hot zone area, at the Martin Center, an outreach health facility dedicated to minority populations and best known for its excellence in sickle cell anemia screening and health education.
• Bell Flower expanded its hours to include Saturdays from noon to 4 PM. (NB, a trial of Sunday clinic resulted in exceedingly low attendance). In addition to Saturday clinics, extended hours were offered on Monday and Wednesday evenings.

• Both urine testing and weekend clinics were initiated because clinic appointments were filled within 1-2 hours of availability, and up to 20 calls per day went without same day services.
• In addition, permanent positions were added for 1 nurse practitioner and 1 registered nurse. In addition, nurses, nurse practitioners and district health workers were recruited from within the health department to address the increased clinical load.
• A new community screening site was established. The Martin Center provides laboratory testing for syphilis on a walk-in basis Monday through Friday. Despite newspaper, radio and television announcements for the services via news programs and talk shows and flyers, utilization of services is lower than expected. Information from syphilis patients suggests that radio advertising and billboards may be the most useful in increasing awareness of testing sites.
• A letter was sent to all health care providers in Marion County informing them of the epidemic. In addition, specific letters were sent to practitioners of subspecialties likely to see syphilis patients including Dermatology, Obstetrics and Gynecology, and Urology.
• All Emergency Department Directors were contacted to inform them of the epidemic and of the Health Department recommendations for treating onsite and for clinical suspicion.
• All Emergency Departments except 2 were provided with posters summarizing the symptoms, signs and treatments for syphilis.
• Providers were given a 24 hour number to contact with questions about syphilis patients.
• Talks (Grand Rounds or specialty talks) were given to Methodist OB/GYN, Indiana University and Wishard Hospitals (Dr. Wasserheit), Methodist Family Practice, Winona Hospital, IU medical residents, Community Hospital North and East Emergency Departments.
• A Laboratory Technician was provided to Wishard Memorial Hospital with funds from the CDC to facilitate ER screening in the evening
• Recommendations for ER screening were developed for Wishard Memorial Hospital using a computer generated reminder system. The ER associate director educated ER residents each month about the epidemic.
• ER nurses were educated about syphilis by the Clinical Director at Wishard Memorial Hospital.

In summary, to meet the challenge of the syphilis epidemic in Marion County, client services were increased by changes in compensation to healthcare providers, increasing the number of sites offering testing, changing clinic procedures and increasing staff. The focus of disease elimination motivated staff from many different levels within the Health Department.

A public relations campaign for new lab and testing sites is needed, as exemplified by the difficulty Martin Center had in establishing a testing presence. This campaign needs to take into account methods by which individuals obtain their healthcare information. Most prominent among these, in the current epidemic, appears to be radio.

3. Enhanced Health Promotion

The national Syphilis Elimination Plan calls for enhanced health promotion to improve healthy behaviors in order to avoid the recurrence of syphilis through education and "environmental" supports. The design of programs to promote health and healthy behaviors requires an intimate understanding of the community and setting that has fostered unhealthy behaviors.

• Community Partners involved in the Stamp Out Syphilis Coalition expanded existing programs and created new ones to educate community members about the syphilis epidemic. These included a major media campaign including radio, television, billboards, bus placards and health fair programs (including a Jerry Springer-like talk show format at Indiana Black Expo's Summer Celebration.
• In addition, religious organizations and ministers gave sermons and community forums informing their congregations of the problem. Some of these programs were aimed directly at youth. The Rapid Ethnographic Community Assessment promises to provide even more information on healthcare seeking behaviors.
• A syphilis talk including clinical presentations of the disease and a tour of the Bell Flower Clinic was provided to Community Members involved in the SOS coalition.
• A substance abuse group was called together and later merged into a revitalized group from Drug Free Indiana. This group entitled the Drug and Prostitution Taskforce involves the Drug Free Indiana, the United Way, the Mayor's office, the Indiana Police Department, Midtown Mental Health, the Salvation Army, Kisses for Kids, the Marion County Health Department, including Dr. Caine, community members and others. The group aims to improve drug abuse treatment and in particular, is finding ways to create a setting where women with children can get adequate supportive residential treatment that will provide childcare during rehabilitation.

• Numerous educational programs were given at Drug treatment centers including Midtown Methadone Clinic, the Midtown Mental Health Center which includes Project Home, a home for pregnant teenagers often with drug dependency problems.

The following is the plan that Marion County will take to complete syphilis elimination by the goal year of 2001, to maintain a syphilis free zone and to respond to future outbreaks.

1. Enhanced Surveillance:

The goals of enhanced surveillance are outlined in the national plan. They are to:

1. Achieve complete, accurate timely and confidential reporting of serologic reactive tests for and cases of syphilis. To do this:

• Data in STD*MIS will be reviewed weekly for duplication, errors and omissions by a data manager dedicated to STD*MIS reports and maintenance.
• Line listed case extended syphilis data will be, as it is now, transmitted to the CDC through NETSS for all stages of syphilis.
• Laboratories performing syphilis tests and providers reporting syphilis cases will be reviewed annually for completeness, accuracy, sensitivity, timeliness and quality. This review will be in addition to the STD*MIS reports on timeliness. The names and addresses of laboratories, providers and contacts at reporting sites will be updated yearly.
• The time spans of physicians and laboratories reporting morbidity will be reviewed monthly. Providers will be divided into three categories: Excellent (>90% received in 24 hours); Moderate (>90% received within 3 days) and Poor (<90% received within 3 days). Those with a poor rating will be visited within 1 month of their identification. Providers with a moderate rating will be visited within 2 months of their identification or if repeatedly in the moderate range, within 1 month. As it is likely that certain providers will reappear on the list, a plan for addressing barriers to reporting will be identified and addressed together with the surveillance coordinator. Where possible, reporting will be automated and accomplished electronically. Arrangements for such transmission are currently in progress or completed for reports from Wishard Memorial Hospital and from the Richard Roudebush VA Medical Center.
• A letter reminding providers and laboratories of the reporting requirements will be sent annually and the difference of reporting requirements for syphilis.
• The surveillance coordinator will visit all reporting sites to reinforce the need for public and private providers to report within one working day of diagnosis, report presumptive or confirmed cases of early syphilis to the health department.
• During visits to laboratories and providers, the surveillance coordinator will reinforce need to quantify the titer of positive, non-treponemal tests and the report the results of positive tests within one working day.
• The Marion County STD Program Manager and Medical Director will meet with CDC program consultants every eight weeks to review syphilis elimination activities and discuss unexpected changes in morbidity both within Marion County and nationally.
• The Medical Director will monitor progress of and, whenever possible, participate in the development of reliable non-treponemal tests for point of care screening that can be classified as low complexity for use where other serologic tests for syphilis are not immediately available.

1. The Program Manager will analyze syphilis data monthly during periods of control and weekly during epidemics. He/she will monitor Syphilis and HIV co-morbidity and the occurrence of syphilis in men who have sex with men (MSM). Information will be reported to the Medical Director in summary form weekly during epidemic periods and monthly during periods of control. The Program Manager will also develop an epidemic profile, which will be updated monthly to guide case detection during outbreak periods and to be used in the evaluation of active surveillance efforts.
2. A framework for active syphilis surveillance is being developed in association with Silvia Teran, an EpiAid from CDC. Once established, the Medical Director of the STD Program, the Program Manager and the Surveillance Coordinator should review this protocol annually.

Currently, six surveillance settings are proposed for screening during control periods :

1. STD clinics: All patients at all visits will receive an RPR. The only exception to this rule will be when a patient is returning for follow-up within one week of the index visit.

2. Jail screening: This particular screening venue is absolutely critical in syphilis screening because both here and nationwide, syphilis epidemics so frequently include a large proportion of detainees. During epidemics, every person arrested should be screened until analysis of serologic patterns allows targeted screening, a measure that is likely to dramatically decrease the cost of screening. Health Department officials will need to work with Corrections officials to facilitate this task given severe limitations of space and personnel.

3. Emergency Room Screening: Because of the enormous cost associated with screening every patient who comes to an Emergency Room, targeted screening is essential. Those targeted for screening should be determined by analysis of existing databases, both from the Health Department and from hospital records to determine which patients are most at risk. At the very least, every patient tested for a sexually transmitted disease should be tested for syphilis at every emergency room and this should be incorporated into any clinical guidelines directed towards STD care.

4. Prenatal Screening: Every woman should be screened for syphilis during the early stages of pregnancy and at delivery. During epidemic periods, all women should also be screened at 28 weeks of gestation.
5. Adolescent Screening: The Health Department specifically screens sexually active adolescents at the Action Center and at the Juvenile Detention Center. (The number of negative adolescents screened at the Action Center is not listed in Appendix I because these are run at the Health Department’s main laboratory and not entered into the STD*MIS system. ) Although Job Corps Screening occurs regularly, these results are not available without a nationwide mandate from CDC. For purposes of nationwide surveillance, we will request that this information be requested of the Job Corps from CDC.
6. MSM Screening: Syphilis testing should be promoted at the time HIV testing. Syphilis screening will occur at the Marion County Counseling and testing sites including at the anonymous HIV testing site where it will be confidential and names of individuals testing positive provided to the Health Department. All HIV positive individuals should be screened at the time of diagnosis. During epidemic periods individuals who are HIV positive should be screened every three months. In addition, continued efforts will be made by the Marion County Health Department's outreach team, headed by Mike Bryson, to screen for syphilis in non-traditional screening sites such as bars in association with HIV testing. The Brothers United, a community organization with HIV prevention programs, will continue to promote syphilis screening in association with HIV screening as well.

• The Program Manager will identify, monitor analyze and evaluate the prevalence of syphilis, behavioral risk factors and other behaviors (for example emergency room visits, drug treatment enrollment or drug treatment arrests) for designing interventions and facilitating routine screening of these populations.
• The Marion County Health Department continues to work with the Department of Corrections to increase the availability of syphilis screening with the potential of making available to every inmate, particularly during epidemic periods but also during control periods in conjunction with a pre-determined protocol.
• The Health Department will continue working with the Marion County Justice Agency to map specific crimes and/or arrests in relation to syphilis. Attempts to link information to the National Drug Abuse Monitoring Program (ADAM) will be made as well.
• Public and private laboratories will promote routine syphilis screening in non-clinical settings such as drug treatment centers and jails.

1. Strengthened community involvement and partnerships

Community partners have been critical in increasing awareness of syphilis in the community. An emerging issue is education about the disease itself, where to go for diagnosis, how to get treated and how to prevent it. In addition, a major goal towards syphilis elimination will be to achieve consensus case finding and screening in vulnerable populations. The Marion County Health Department will

4. Acknowledge and respond to the effects of racism, poverty and other relevant social issues on the persistence of syphilis in the United States.

• Moral and ethical standards will be maintained in all syphilis elimination activities. To this end, all research activities conducted in relation to syphilis will be reviewed by the SOS coalition. In addition, efforts will be made in incorporate a member of the community on each of the relevant Institutional Review Boards. Lastly, a community review board will be formed from the SOS coalition to conduct exit interviews with research participants.
• Efforts will be made to examine existing datasets for evidence of racial bias in testing and reporting. Wherever possible, samples of individuals universally screened will be examined. .
• A systematic review of prenatal screening will be performed in the next 6 months to evaluate the application of screening recommendations.
• Screening programs will be reviewed with the SOS Coalition to identify potential areas of concern. Presentation of the ER screening program led to a need to eliminate geographic identification as a reason for screening. Emphasis will be on risky behaviors or associated conditions

• During epidemic periods, the SOS coalition will continue to meet every 2-4 weeks. A newsletter will be published quarterly updating allied health professionals of developments.
• The Resource Committee and Risk Identification/Access committees of the SOS coalition will continue to identify needs of priority providers and barriers to access.
• The Health Department will continue to provide laboratory support services to provide RPR's promptly to providers.
• The Health Department will continue to establish agreements with providers in non-STD clinic settings to deliver confidential syphilis screening, condoms, and STD education. Many of these are ongoing and listed in the background section in the first part of this document.
• State and local legislative bodies will be updated on syphilis elimination every 6 months until the Outbreak is over. During times of control, updates will be provided by way of a letter.
• Annually assess and report to the Medical Director of the Health Department efforts to work with partner organizations, HIV prevention programs and community organizations to include syphilis preventive and care services.
• Provide input to CDC officials to develop standards for providing accessible and available STD services utilizing state of the art testing and models for efficiency.

• A RECAP will be performed every 4 years (alternating every 2 years with the health assessment survey performed by the Healthy Indy Partnership). The results of this survey will be used to identify new key community members who must be involved in syphilis elimination efforts. The target for the RECAP will be those most affected by syphilis during epidemic periods and to those with the highest incidence of STD's such as gonorrhea, Chlamydia, herpes and/or HPV in periods of relative control.
• The SOS coalition will need continued funding to continue long term participation in syphilis elimination activities. Within six months of resolution of the outbreak, the Health Department will assist the coalition in identifying ways to maintain activities during periods of control.
• Attempt to incorporate a community leader on relevant IRB's.
• Establish a committee in the SOS coalition to interview participants in syphilis research to make sure rights are protected and participation is truly informed.
• Present plans for all activities to the SOS coalition and where a particular neighborhood is targeted , to the appropriate neighborhood association.
• Annually assess and report on coalition activities, information sharing and infrastructure in the community to achieve syphilis elimination. The report should be a joint venture of SOS coalition members and Health Department Representatives, particularly the Response coordinator. This report should draw on the quarterly reports required by coalition members who receive syphilis elimination funding.

1. Rapid Outbreak Response

Clearly, the faster intervention takes place in an epidemic, the faster the outbreak will come under control. There is no standardized definition of when to initiate a rapid response outbreak or when to declare that an outbreak is over. The National Syphilis Elimination Plan calls on State and Local Health Departments to

1. Develop an Outbreak Response Plan

Definition of Outbreak: Throughout the epidemic period, which should be defined as the period during which the case rate exceeds the mean + 2 times the standard deviation of the baseline based on the past 3 years prior to an outbreak. For Marion County the average monthly number of cases was 6.3 + 1.8 from 1994 to 1996. (Because there was a small increase in 1997 and the outbreak began in 1998, the monthly numbers for these years were not used in deriving the baseline) Thus the occurrence of 10 cases in any given month would prompt analysis of cases for the possibility of an outbreak and examination of standard control strategies. A sustained number of cases > 10 for a second month would prompt a Rapid Outbreak Response. Resolution of an epidemic will require sustaining a monthly case rate > 2 for a period of 6 months (the Mean minus 2 times the standard deviation). This rigid definition defines cessation of the outbreak. The deployment of various syphilis elimination activities should be tailored to the individual circumstances of the outbreak.

As syphilis elimination becomes established this will result in every case being examined because the mean and the standard deviation will approach zero.

Case detection is detailed in expanded Clinical and Laboratory Services section. Screening sites that were critical to control of the 1998 epidemic included: the jail, emergency departments of local hospital, prenatal clinics and STD clinic(s). Other potentially useful sites would have been crack houses or any place where individuals with high numbers of sexual partners are likely to occur. Particular attention should be paid to populations at high risk for HIV infection given the association of syphilis with increased HIV transmission. Given the importance of rapid turnaround of test results, quality assurance reports should be run each week and providers whose reporting is suboptimal should be visited in person by the surveillance coordinator and barriers to reporting identified. (During epidemic times, results must be reported in <24 hours; during control periods, < 72 hours). Some form of sanction should be instituted for providers or laboratories that repeatedly have unacceptable delays in reporting. The definition of unacceptable delays should established by the surveillance team (STD surveillance coordinator and the STD Program Manager).

In order to respond to outbreaks in the future we propose to have a rapid outbreak response team that should be composed of an executive committee, an advisory board and a response team. The executive committee should be composed of a director, a community leader, an epidemiologist, a public relations expert, a representative of the mayor's office and a computer information specialist.

Leadership

The Executive Committee:

Director will coordinate other members and issue comprehensive plan based on the Epidemiology of the epidemic. The director will also establish a system of accountability for accomplishing these goals.

In addition, the Rapid Outbreak Response Director will report to the Medical Director of the Health Department and seek recommendations for partnership and activities not yet incorporated into response activities.

Response Coordinator will act as a liaison between community leaders and groups, the Medical Director of the STD Clinic, and public relations expert, the epidemiologist and others involved in syphilis elimination. This person must be well rounded, a self-motivated professional with health issues background who is willing to work irregular hours and take on many tasks.

Community Leader will initiate meetings with the affected community to coordinate an assessment within the affected community to determine what behavioral and social influences have contributed to the occurrence of the outbreak.

Medical Director will communicate with the medical community, identify a comprehensive network for providing services, identify barriers to providing the services,

An epidemiologist will use database information to characterize the epidemic. He or she will also identify areas where more information is needed including the design of methods to acquire that information. This information will be used to establish estimates of disease burden, examine and reexamine disease activity on a weekly basis and identify weaknesses in surveillance systems (as opposed to weaknesses in the performance of existing surveillance activities).

Public Relations Expert: to communicate effectively and honestly to the community to facilitate their participation in control without causing panic.

The Assistant Deputy Mayor of Policy will serve on the executive committee and will be responsible for coordinating communication with the mayor and with local, state and federal government officials when necessary.

The Information Services Expert should provide information to the epidemiologist, perform regular quality assessment of the databases, should implement necessary changes to data input required by the epidemic, such as incorporation of additional risk information. In addition, he or she should make available individual(s) to fix problems immediately in working systems as they occur.

The Action Team

Heading up intervention activities should be an action team composed of several focussed groups of individuals. These groups should be made up of flexible individuals who can go out into the field to do whatever needs to be done to see that progress is made. The Action Team will be directed by the STD Program Manager, an organized leader who participates in the executive committee and who designs interventions in conjunction with the executive committee. The members of the action team should include all eleven county DIS, both first line DIS supervisors, 2 laboratory technicians, several health educators and outreach workers. Activities would include visiting sentinel surveillance sites, collecting blood samples, and identifying affected individuals, setting up new programs, going to community meetings and working with community leaders, provide transportation for samples or people, make recommendations for ongoing services. At least 20 individuals are recommended for this team. They should be made available for a period of at least 6 months in the event of an epidemic. The team should be trained in advance and if necessary, their absences should be filled by temporary employees.

2. Establish area specific criteria that determine when the outbreak response plan is to be implemented. These criteria are given in the summary of the Outbreak Response Plan given above. These criteria were developed to be dynamically generated over time as syphilis elimination is accomplished. They will be reviewed annually to determine their relevance and achievability. Within 1 week of surpassing the established threshold of 10 for 2 consecutive months, the Rapid Outbreak Response will be initiated.

4. Expanded Clinical and Laboratory Services

• The number of patients who are not seen the same day they are seeking services in the STD clinic will continue to be monitored and recorded on the triage sheets.
• New programs such as "Fast Track" which aim to streamline testing and treatment will be developed.
• Recommendations for improving clinic flow should be derived from health care efficiency specialists in addition to STD clinic experts and CDC consultants. This analysis should include analysis of cost.
• An instrument has been developed to assess provision of services in eight hot zone priority clinics by the Resource Committee of the SOS coalition. Expansion of this instrument will be discussed to possible application to all clinics and providers throughout Marion County.
• Clinics and providers throughout the city should be compensated for visits associated with the epidemic including screening. A team of providers in association with health department officials should determine the dollar amount of compensation. The method of collection should be prompt and easy and should be included as a part of this plan so that it may be implemented quickly. No patient requesting STD services should be turned away.
• The Health Department will organize a set of seminars for providers at all levels including physicians, nurses and nurse practitioners and social workers that is accompanied by a brochure that explains what it wants each of those providers to do. Recommendations should include reporting within 24 hours any suspected case of syphilis, treatment with penicillin, what to do with a penicillin allergic patient and on the spot testing of individuals at risk (which should be summarized and updated yearly in the brochure). The delivery of these seminars should be telescoped within a 2-week period and updates should be sent to providers every 6 months during epidemic periods. The Health Department may wish to incorporate this information with other vital public health information, which they would like to provide annually to providers.

The National Syphilis Elimination Plan calls for enhanced health promotion to improve healthy behaviors in order to avoid the recurrence of syphilis through education and "environmental" supports. The design of programs to promote health and healthy behaviors requires an intimate understanding of the community and setting that has fostered unhealthy behaviors. Community Partners involved in the Stamp Out Syphilis Coalition expanded existing programs and created new ones to educate community members about the syphilis epidemic. In addition, religious organizations and ministers gave sermons and community forums informing their congregations of the problem. Some of these programs were aimed directly at youth. The Rapid Ethnographic Community Assessment promises to provide even more information on healthcare seeking behaviors.

Increased educational efforts related to sexually transmitted diseases, specifically syphilis, will continue. The staff in the Health Department who works in the community will give provide education during their other scheduled activities. Staff making home visits to clients for health related reasons, i.e., prenatal care, well child care, immunizations, children at risk, tuberculosis and other communicable disease, have discussed syphilis and have taken pamphlets to educate clients, and refer clients for testing when appropriate.

When the Public Health Nurses do health education programs with youth groups in the community and in schools, syphilis/STD education will be included as a standard. Public Health Nurses assigned to schools will include discussion about syphilis in the conference with the Principal and at meetings with faculty.

Staff offering services in the district offices has literature available to give to clients and do education about syphilis.

These enhanced efforts will become part of the health promotion efforts and will be ongoing.

10/15/99 to 5/23/00 QUALITATIVE RESULTS

---------------------+-------------------------------+------

000 COMMUNITY SCREEN | 0 331 0 9 0 | 340

113 JUVENILE CTR | 0 884 0 2 0 | 886

114 SHALOM ROBRTS PK | 0 7 0 0 0 | 7

115 BROADWAY SHALOM | 0 38 0 0 0 | 38

123 BUTLER HLT CTR | 0 4 0 0 0 | 4

124 RAPHAEL HLTH CTR | 0 20 0 0 0 | 20

125 PEOPLES HC | 0 4 0 2 0 | 6

126 PP MIDTOWN | 0 11 0 0 0 | 11

127 PP CASTLETON | 0 193 0 2 0 | 195

128 PP SOUTH | 0 25 0 0 0 | 25

148 PP EAST | 0 99 1 0 0 | 100

155 PP NORTHWEST | 0 50 0 0 0 | 50

157 IPD LOCK UP | 95 3336 0 76 0 | 3507

160 MARION CTY JAIL | 0 16 0 3 0 | 19

BELL FLOWER CTS | 1 265 0 44** 0 | 310

CONCORD CENTER | 0 44 0 0 10 | 54

FIELD | 0 160 0 21 0 | 181

HARBOR LIGHT | 0 8 0 1 0 | 9

MARION CO HLTH DEPT | 0 6 0 0 0 | 6

MARION CO JAIL 2 | 0 97 0 1 0 | 98

OUTREACH | 0 212 0 5 8 | 225

OUTREACH SUSAN FAYE | 0 151 0 1 1 | 153

S05 BELL FLOWER CL | 158 6676 0 521 7 | 7362

SHALOM ROBERTS PARK | 0 4 0 0 0 | 4

SHELTER HEALTH FAIR | 0 54 0 0 0 | 54

---------------------+-------------------------------+------

* This number represent number of tests rather than number of individuals screened. In many cases, individuals are tested more than once, since patients return for follow-up testing.

10/15/99 to 5/23/00 QUALITATIVE RESULTS

---------------------+-------------------------------+------

000 COMMUNITY SCREEN | 0 331 0 9 0 | 340

103 BARRINGTON | 0 7 0 0 0 | 7

104 BLOOD BANK | 0 0 0 9 0 | 9

105 FARRINGTON/SHAL. | 0 3 0 0 0 | 3

105 SHALOM | 0 3 0 0 0 | 3

105 SHALOM HEALTH CT | 0 2 0 0 0 | 2

106 CITIZENS HLTH | 0 3 0 0 0 | 3

107 COMMUNITY HOSP E | 0 0 0 2 0 | 2

110 IND GIRLS SCHOOL | 0 1 0 0 0 | 1

113 JUVENILE CTR | 0 884 0 2 0 | 886

114 SHALOM ROBRTS PK | 0 7 0 0 0 | 7

115 BROADWAY SHALOM | 0 38 0 0 0 | 38

116 METH HOSP ER | 0 0 0 6 0 | 6

116 METH. HOSP-ER | 0 3 0 8 0 | 11

117 METHODIST FPC | 0 2 0 15 0 | 17

118 METH OB/GYN | 0 1 0 5 0 | 6

119 GLENDAL MED CTR | 0 1 0 0 0 | 1

123 BUTLER HLT CTR | 0 4 0 0 0 | 4

124 RAPHAEL HLTH CTR | 0 20 0 0 0 | 20

125 PEOPLES HC | 0 4 0 2 0 | 6

126 PP MIDTOWN | 0 11 0 0 0 | 11

127 PP CASTLETON | 0 193 0 2 0 | 195

128 PP SOUTH | 0 25 0 0 0 | 25

130 SOUTHEAST HC | 0 1 0 0 0 | 1

131 SOUTHWEST HC | 0 0 0 1 0 | 1

132 VA MED CTR | 0 1 0 3 0 | 4

135 WISHARD HOSP | 0 5 0 61 0 | 66

135 WISHARD HOSP-ER | 0 0 0 1 0 | 1

135 WISHARD HOSP-OB | 0 0 0 2 0 | 2

136 WINONA HOSP | 0 0 0 1 0 | 1

138 PRIVATE PHYSICIA | 0 3 0 18 0 | 21

147 OTHER | 0 1 0 0 0 | 1

148 PP EAST | 0 99 1 0 0 | 100

152 METHODIST ADOL | 0 1 0 0 0 | 1

155 PP NORTHWEST | 0 50 0 0 0 | 50

157 IPD LOCK UP | 95 3336 0 76 0 | 3507

158 IU HEALTH CARE | 0 1 0 1 0 | 2

160 MARION CTY JAIL | 0 16 0 3 0 | 19

161 WOMENS PRISON | 0 0 0 2 0 | 2

163 IU MED CTR | 0 0 0 3 0 | 3

164 WESTVIEW HOSP | 0 2 0 0 0 | 2

167 COMMUNITY HOSP | 0 0 0 5 0 | 5

167 COMMUNITY HOSP N | 0 3 0 0 0 | 3

168 ST VINC. HSP-CAR | 0 0 0 1 0 | 1

169 ST FRANCIS BG | 0 0 0 2 0 | 2

186 RDC | 0 1 0 1 0 | 2

188 ATTERBURY JOB C | 0 0 0 1 0 | 1

201 BLACKBURN | 0 1 0 14 0 | 15

202 COTTAGE CORNERS | 0 0 0 5 0 | 5

203 FOREST MANOR | 0 0 0 22 0 | 22

204 NEDHO | 0 2 0 14 0 | 16

206 WESTSIDE HC | 0 0 0 2 0 | 2

207 GRASSY CREEK | 0 0 0 1 0 | 1

303 ACTION CENTER | 0 4 0 1 0 | 5

313 MARTIN CTR | 0 6 0 1 0 | 7

ADULT REHAB | 0 2 0 0 0 | 2

AVENTIS SERVICES | 0 0 0 2 0 | 2

BELL FLOWER CTS | 1 265 0 44 0 | 310

CENTEON BLOOD PLASMA | 0 0 0 1 0 | 1

COMM HOSP FOR WOMEN | 0 0 0 2 0 | 2

COMMUNITY HOSP EAST | 0 0 0 6 0 | 6

COMMUNITY NORTH HOSP | 0 0 0 1 0 | 1

COMMUNITY SCREENING | 0 0 0 1 0 | 1

COMMUNITY SOUTH | 0 0 0 2 0 | 2

CONCORD CENTER | 0 44 0 0 10 | 54

EASTSIDE MED CTR | 0 0 0 1 0 | 1

FIELD | 0 160 0 21 0 | 181

GEIST FAMILY MED | 0 0 0 1 0 | 1

GEORGTOWN MED CTR | 0 0 0 1 0 | 1

HARBOR LIGHT | 0 8 0 1 0 | 9

HENDRICKS CO | 0 1 0 0 0 | 1

INDIANA PHYSICIANS | 0 0 0 1 0 | 1

INDIANA WOMENS PRISO | 0 0 0 1 0 | 1

INDPLS BLOOD PLASMA | 0 0 0 1 0 | 1

INDPLS DRUG TX CTR | 0 0 0 3 0 | 3

IPD LOCKUP | 0 0 0 19 0 | 19

JUVENILE DETENT CTR | 0 0 0 2 0 | 2

MARION CO HLTH DEPT | 0 6 0 0 0 | 6

MARION CO JAIL 2 | 0 97 0 1 0 | 98

MARION CO. JAIL | 0 0 0 2 0 | 2

MARTINDALE BRIGHTWOO | 0 1 0 2 0 | 3

METHODIST HOSPITAL | 0 6 0 16 0 | 22

NORTH ARLINGTON HC | 0 0 0 2 0 | 2

NORTHWEST OBGYN | 0 0 0 1 0 | 1

OTHER | 0 2 0 5 0 | 7

OUTREACH | 0 212 0 5 8 | 225

OUTREACH SUSAN FAYE | 0 151 0 1 1 | 153

PEOPLES HLTH CTR CTS | 0 0 0 2 0 | 2

PLASMA CARE CTR | 0 0 0 1 0 | 1

PMD | 0 1 0 34 0 | 35

PUBLIC SAFETY HEALTH | 0 0 0 1 0 | 1

RAPHAEL HEALTH CTR | 0 9 0 1 0 | 10

RIVERVIEW HTH CL | 0 1 0 0 0 | 1

ROBERTS PARK SHALOM | 0 2 0 0 0 | 2

S05 BELL FLOWER CL | 158 6676 0 521 7 | 7362

SHALOM ROBERTS PARK | 0 4 0 0 0 | 4

SHELTER HEALTH FAIR | 0 54 0 0 0 | 54

SOUTHEAST OBGYN | 0 0 0 1 0 | 1

SOUTHPOINT OB/GYN | 0 0 0 1 0 | 1

SOUTHSIDE OBGYN | 0 0 0 1 0 | 1

SOUTHWEST OB GYN | 0 0 0 1 0 | 1

ST FRANCIS HOSPITAL | 0 0 0 3 0 | 3

ST. FRANCIS CLINIC | 0 0 0 1 0 | 1

UNIVERSITY HOSP | 0 1 0 1 0 | 2

UNKNOWN | 0 0 0 1 0 | 1

WESTLAKE PHYS WOMEN | 0 0 0 1 0 | 1

WINONA HOSP | 0 1 0 2 0 | 3

WISHARD HOSP | 0 2 0 139 0 | 141

---------------------+-------------------------------+------

The Building Healthier Neighborhoods Partnership is the product of a unique collaboration among the major hospitals andhealth department in Marion County - a collaboration formed to fund and conduct the Marion County's first baseline community health assessment. Other partners in the assessment project were United Way/Community Services Council, Indiana University Bowen Research Center, and Indiana Hospital and Health Association.

The completion of the health assessment led the partners to create a unified leadership model under the "Healthy Indy Partnership" banner to implement the assessment's recommendations and, more importantly, to provide the community with a leadership structure which will continuously assess and improve the health status of the residents of Marion County.

1994 Marion County Health Director Virginia Caine, MD and hospital CEOs discuss need

for a community health assessment. Eight hospitals and health department agree to

fund the project.

March 1995

Community health assessment project kicked off; data collection and analysis

conducted by Indiana University Bowen Research Center.

Third Quarter 1995

Steering Committee made up of representatives of the funders and other partners is

formed to proved oversight and guidance; Community Advisory Committee made up

of representatives of community based organizations is formed to provide

broad-based input into the assessment.

Fourth Quarter 1995 to First Quarter 1996

Steering Committee identifies eighteen major health issues; three are selected for first

year action: (1) Pediatric Asthma, (2) Teen Pregnancy and (3)Youth Tobacco Use.

CEOs charge Steering Committee with developing a leadership structure and agree

to fund startup.

Fourth Quarter 1996

Steering Committee develops Leadership structure to move process to

implementation phase and selects Thomas Otto as the first Executive Director of

BHNP.

Community Health Assessment officially released to the community (November,

1996)

First Quarter, 1997

Several "Task Forces" developed with representatives from multiple community

sectors. Detailed Youth Tobacco Initiative developed and funding proposal

submitted to Robert Wood Johnson Foundation. Local funding agencies, five area

hospitals and the Marion County Health department agree to partner in funding this

project.

Second Quarter, 1997

Steering Committee transitions to a fully integrated Board of Directors by adding

representatives from major community stakeholders and announces Corinne A.

Wheeler as new Executive Director of BHNP.

Third Quarter, 1997

Announced the receivership of a $700,000 grant from the Robert Woods Johnson

Foundation, Indianapolis Foundation and the Health Foundation of Greater

Indianapolis for a Youth Tobacco Initiative. This initiative targets 12 IPS Middle

Schools and selected surrounding neighborhoods.

Fourth Quarter, 1997

Board of Directors develops to represent 26 Community Leaders.

First, Second Quarters, 1998

BHNP "revisions" and embraces the new vision of Indianapolis To

Be the Healthiest Community in America.

Third Quarter, 1998

The completion of the health assessment led the partners to create a unified

leadership model under the "Building Healthier Neighborhoods Partnership" banner

to implement the assessment's recommendations and, more importantly, to provide

the community with a leadership structure which will continuously asses and improve

the health status of the residents of the Marion County.

Below is a list of community organizations and businesses that were recruited to participate in the Stamp Out Syphilis Coalition. Initially, these organizations were recruited from the Healthy Babies Consortium and then expanded to include Outreach, WTLC and the Hoosier Radio Stations, Senator Billie Breaux, and Neighborhood Associations with regions located in the Hot Zone. These organizations meet every month to discuss developments in the Syphilis Epidemic and results of ongoing activities and suggestions for new approaches.

April 13, 2000

Dear Colleague:

It has been a year since we last updated you on the syphilis epidemic in Marion county. At that time, 161 cases of primary and secondary syphilis had been seen in 1998, the seventh highest of any county in the United States. In 1999 we saw 416 cases. This is occurring at a time when the national incidence is at an all time low and the CDC remains dedicated to syphilis elimination by 2005.

We continue to need your help. You can do three things to help us: screen, report and treat.

First, screen everyone at risk. At risk individuals include: anyone from a high risk area (see enclosed map) who is sexually active, anyone with another suspected sexually transmitted disease, anyone who uses cocaine or may have a sexual partner who uses cocaine or other illicit drugs, anyone who trades sex for drugs or money or who has had sex with a person who trades sex and anyone with multiple sex partners. Many recent reports have involved adolescents. If at risk, they should be screened as well.

In 1999 we saw 6 newborns with congenital syphilis, at least one in a mother negative early in her pregnancy, not felt to be at risk and asymptomatic diagnosed at delivery. All pregnant women should be screened at the time they are diagnosed as pregnant and at delivery. Women at risk should be screened a third time at 28 weeks according to CDC recommendations.

Second, we need to improve reporting. Our ability to find partners depends on prompt interviewing for partners at the time of diagnosis. Please report any cases of primary, secondary or early latent infection to our surveillance coordinator by telephone at 221-8316 or me at 221-8312 as soon as the disease is diagnosed clinically or by serology.

Lastly, many providers await syphilis test results before treatment. Twenty to 30% of patients with primary syphilis have a NEGATIVE RPR or VDRL. Up to 20% may have a negative confirmatory FTA-Abs or MHA-TP. Even with a high index of suspicion cases can be missed. We are recommending presumptive treatment of undiagnosed genital ulcers for syphilis. Unlike other areas that have had syphilis outbreaks, we have not seen chancroid in a small sample of genital ulcers tested by multiplex PCR (a highly sensitive test).

Thanks to your cooperation, many sites are calling us with their patients so that we can swiftly initiate partner notification and identify sites where individuals may be contracting the infection. You also help us by letting us know about problems you are encountering in getting patients tested and treated. Thank you for your efforts. We truly appreciate your support.

Sincerely,

Janet N. Arno, M.D.

Sexually Transmitted Disease Control

May 23, 1999

As most of you know, we are in the midst of a syphilis outbreak. In the first quarter of 1999, Marion County has diagnosed 54 cases of primary or secondary syphilis. Unfortunately, there have been cases of congenital syphilis reported as well. Like other cities that have experienced syphilis outbreaks, a substantial proportion of cases in Indianapolis are diagnosed outside of the public health STD clinic system, either by private providers or in emergency rooms. By virtue of your position as an obstetrician and gynecologist, you are in the best position to prevent congenital syphilis by prenatal screening.

The Centers for Disease recommends serologic screening for syphilis in all women during the early stages of pregnancy. For populations where prenatal care is not optimal, women should be screened and treated at the time pregnancy is diagnosed using an RPR-card test whose results are available quickly.

Specifically, because the prevalence of syphilis in our community is high, serologic testing should be performed twice during the third trimester as well, at 28 weeks of gestation and at delivery.

These recommendations are found the publication: Centers for Disease Control and Prevention. 1998 Guidelines for treatment of sexually transmitted diseases. MMWR 1998;47(no. RR-1) pp 40-41.

Please help us eliminate syphilis, particularly from newborns by completing all three recommended screening tests. If you have any questions about screening for syphilis, its clinical manifestations or its treatment, please contact me at the Bell Flower Clinic, at 221-8300.

Janet N. Arno, M.D.

Medical Director

The Bell Flower Clinic