Indiana – Marion County
Jim Beall, Duane Wilmot, Janet Arno MD, Carol Langley MD
________________________
Submitted 02/28/01
Fourth Quarter, 2000
INTRODUCTION:
Cases of primary and secondary syphilis decreased slightly in the fourth quarter continuing the trend of decreasing morbidity for the year. The 53 cases reported in the fourth quarter represents a 57% decrease from the fourth quarter of 1999.
Major accomplishments this quarter include:
· Representatives from the Marion County Jail and the Marion County Health Department visited Chicago to observe syphilis testing activities at the Cook County Jail.
· Commitment made by Methodist Hospital Emergency Room to begin syphilis screening Jan. 1.
· Three
aspects of Marion County’s syphilis elimination efforts were presented at the
2000 National STD Conference in Milwaukee. A poster comparing syphilis patients
to others with STDs, a presentation
discussing the effects of enhanced DIS activities, and a display of media materials
developed by the SOS coalition.
· Two
grants were written to obtain funding for Substance Abuse Treatment: One aimed at increasing Demand and the other
to SAMSHA for coordinating comprehensive services for substance abuse
rehabilitation
· Representatives
from the Indiana State Department of Health (ISDH) HIV program met with members
of the Marion County Health Department (MCHD) HIV program the MCHD and ISDH STD programs, and the director
of the NIH funded AIDS Clinical Trial Group to look at ways HIV and STD groups
can work together to prevent HIV and syphilis co-transmission, increase
syphilis testing among MSM and to improve follow-up on contacts to HIV
infection.
PROJECT PROGRESS:
I. Enhanced Surveillance
A. Summary of Enhanced Surveillance
Activities:
1. Status of surveillance plan:
The Surveillance Coordinator, Emilie Bender, (working with case management staff) identified 40 laboratories and health care providers with compliance issues related to reporting. These issues were addressed through letters, phone calls and site visits. In addition to site visits made as a result of reporting problems, the Surveillance Coordinator also made site visits to 69 other providers to provide updates on current STD trends and insure continued compliance with reporting rules.
Implementation of electronic laboratory reporting continues to get closer. Procedures are being developed for electronic reporting and it expected that approval for this reporting will be ready sometime in the first quarter of 2001. When in place, electronic reporting will occur daily from Regenstrief and include all laboratory reports by the Indianapolis Network for Patient Care, a consortium of six hospitals including Clarian hospitals (University, Methodist and Riley Hospitals), St. Vincent’s Hospital, Wishard Hospital and the Community Hospital system.
Syphilis prevalence monitoring is occurring at the Bell Flower clinic and the jail. A total of 4325 tests were performed with 162 (4%) being positive. 32% of those tested were females with 79 females testing positive.
District 5 Morbidity:
There were 80 early syphilis cases reported in the fourth quarter of 2000 compared to 212 early cases for the same time period in 1999. Of the 80 early cases, 53 (66%) were primary or secondary. Below is a breakdown of the P&S cases:
Gender:
|
Male |
Female |
|
24 (45%) |
29 (55%) |
Age group:
|
Age Group |
Male |
Female |
Total |
|
10-14 |
0 |
1 |
1 |
|
15-19 |
1 |
3 |
4 |
|
20-24 |
4 |
5 |
9 |
|
25-29 |
5 |
8 |
13 |
|
30-34 |
1 |
4 |
5 |
|
35-39 |
0 |
3 |
3 |
|
40-44 |
1 |
5 |
6 |
|
45-54 |
6 |
0 |
6 |
|
55-64 |
4 |
0 |
4 |
|
65+ |
2 |
0 |
2 |
Race:
|
Black |
46 (87%) |
|
Hispanic |
2 (4%) |
|
White |
3 (6%) |
|
Unknown |
2 (4%) |
Zip codes: (*
indicates those zip codes designated as “Hot Zone” in 1999)
|
|
3rd Quarter |
4th Quarter |
|
46201 |
5 (9%) |
2 (4%) |
|
46203 |
1 (2%) |
1 (2%) |
|
46205* |
9 (16%) |
13 (25%) |
|
46208* |
1 (2%) |
6 (11%) |
|
46218* |
9 (16%) |
9 (17%) |
|
46222 |
4 (7%) |
3 (6%) |
|
46226* |
3 (5%) |
7 (13%) |
|
46236 |
7 (12%) |
2 (4%) |
|
46254 |
5 (9%) |
0 |
|
Total of top eight zip codes |
45 (78%) |
33 (62%) |
The 53 P&S cases lived in 16 different zip codes with
only 5 zip codes reporting more than 2 cases (4 of which were “Hot Zone” zip
codes).
B. Other Surveillance Activities
During the fourth quarter screenings were also held at health fairs. A total of 34 tests were conducted with no positives. Screening was also conducted by DIS at the Marion County Jail II. 33 inmates were tested and no positives were found. A total of 1327 syphilis tests were conducted at the Marion County Jail.
For the year 2000, using data from 12,770 birth certificate records received at Marion County Health Department through August, 93.5% of pregnant women were screened at least once for syphilis. 92% of women were screened at least twice. At Wishard Hospital, compliance with at least 1 prenatal test for syphilis was 99%; 94.7% get at least 2. Three tests are recommended in Marion County but are not recorded on birth certificates.
C. Behavioral surveillance activities
An extended interview questionnaire has been
used since October 1999 to identify behavioral risk factors. The table below summarizes the behaviors
identified in patients with P & S syphilis for the third quarter of
2000. In addition, no patient admitted
to sexual contact with an HIV positive individual, an individual with AIDS or a
bisexual male in 2000 in contrast to 1999 where 5 individuals with bisexual contact
were noted.
|
|
Early syphilis cases interviewed October through December 2000 |
|||||||
|
|
Men |
34 |
Women |
43 |
|
Total |
77 |
|
|
Risk |
N |
% |
N |
% |
|
N |
Total % |
|
|
Jail
during interview period |
7 |
20.5% |
12 |
27.9% |
|
19 |
24.7% |
|
|
Drug
use - ETOH |
25 |
73.5% |
25 |
58.1% |
|
50 |
64.9% |
|
|
Drug
use - crack |
8 |
23.5% |
12 |
27.9% |
|
20 |
26% |
|
|
Drug
use - IV |
2 |
5.9% |
0 |
0% |
|
2 |
2.6% |
|
|
Drug
use - marijuana |
18 |
52.9% |
19 |
44.1% |
|
37 |
48.1% |
|
|
Hetero
sex with IDU |
1 |
2.9% |
0 |
0% |
|
1 |
1.3% |
|
|
Hot
zone linked |
23 |
67.6% |
33 |
76.7% |
|
56 |
72.7% |
|
|
Partners
>1 in last 90 days |
18 |
52.9% |
13 |
30.2% |
|
31 |
40.3% |
|
|
New
partner in last 90 days |
15 |
44.1% |
13 |
30.2% |
|
28 |
36.4% |
|
|
Partner
has been in jail |
6 |
17.6% |
9 |
20.9% |
|
15 |
19.5% |
|
|
Partner
is crack user |
13 |
38.2% |
9 |
20.9% |
|
22 |
28.6% |
|
|
Seen
other provider w/problem* |
4 |
11.8% |
16 |
37.2% |
|
20 |
26% |
|
|
Sex
for drugs/money |
13 |
38.2% |
6 |
14% |
|
19 |
24.7% |
|
|
Sex
with female |
31 |
91.2% |
3 |
7% |
|
34 |
44.2% |
|
|
Sex
with male |
0 |
0% |
40 |
93% |
|
40 |
51.9% |
|
|
|
|
|
|
|
|
|
|
|
The percent of cases being detected in the
jail decreased from 25% in the third quarter to 5% in the fourth.
The graph below shows the percent of cases in
each age group for cases of P & S syphilis over time. The fourth quarter
saw a significant drop in those between the ages of 30 and 39. The age group
with the most significant increase was the 45+ group with a four fold increase
over both of the last two quarters. Also experiencing a noticeable increase,
though not as dramatic as the 45+ group, was the 25 – 29 group with a better
than 5% increase.
Rapid Ethnographic Community Assessment Project (RECAP): All data has been gathered and will be entered into a data set during the first quarter of 2001 with initial findings to be disseminated shortly thereafter.
Focus groups: Four community focus groups were organized by Dr. Theresa Roberts, a professor at the Indiana University School of Social Work. These were conducted among individuals involved in substance abuse (one group for men, another for women); among women involved in trading sex for drugs or money; and among community members in at-risk communities (one for men, another for women).
Evaluation Survey: Like the RECAP, data is due to be evaluated during the coming quarter.
II. Community Involvement & Organizational Partnership
A. Community Member Involvement
·
Identify and describe the affected community
partners:
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.
B. Organizational Partnerships
·
Number and names of those recruited to work in
partnership to achieve syphilis elimination
Please see attached.
·
Description of activities or services provided by
the community organizations, including the respective populations
targeted/reached
C. Describe any
support provided by the health department to the community
organizations
¾ Staff
support to provide screenings and educational presentations as needed (ongoing)
¾ Assistance
with curriculum development for educational programs (ongoing)
D. Expanded STD services provided through community-based events
|
Number of Organizations |
Organization |
Number of Events |
Type of Event |
|
0 |
Migrant and Rural Health Centers |
|
|
|
3 |
Correctional Centers Central
Receiving Jail
Screening Marion County Jail 2 |
5d/wk 1 1 |
Ongoing screening Outreach Screening Quarterly Screening Event |
|
|
Substance Abuse Programs |
Weekly As needed |
Outreach Screening Intake at Methadone Clinic |
|
1 |
Family Planning/Women's Health Programs |
|
Attempt to repeat 3 month screening program failed
because of personnel layoffs |
|
0 |
Universities |
|
|
|
0 |
American Indian/Alaska Native Health Centers |
|
|
|
20 |
Community Based Organizations |
|
|
|
8 |
Community Health Centers |
|
Contracts for reimbursement for screening |
|
0 |
Radio broadcasting companies |
|
|
Gender Differences in Syphilis Awareness Among 77 Individuals Diagnosed with Early Syphilis and Interviewed
|
|
2000 cases reported
October through December |
|||||||
|
|
Men |
34 |
Women |
43 |
|
Total |
77 |
|
|
Knows of Syphilis Outbreak |
N |
% |
N |
% |
|
N |
Total % |
|
|
At
all |
23 |
67.6% |
26 |
60.5% |
|
49 |
63.6% |
|
|
From
TV |
12 |
35.3% |
10 |
23.3% |
|
22 |
28.6% |
|
|
From
Radio |
11 |
32.4% |
13 |
30.2% |
|
24 |
31.2% |
|
|
From
a Flyer or Brochure |
7 |
20.6% |
9 |
20.9% |
|
16 |
20.8% |
|
|
From
Billboards |
11 |
32.4% |
14 |
32.6% |
|
25 |
32.5% |
|
|
From
Bus Poster |
4 |
11.8% |
5 |
11.6% |
|
9 |
11.7% |
|
|
In
the Newspaper |
5 |
14.7% |
11 |
25.6 |
|
16 |
20.8% |
|
E. Physician and other health care provider visitations
See Section A: Enhanced Surveillance.
III. Biomedical and Behavioral Interventions
A.
Syphilis Screening Activities
|
Indicators
|
How many? |
Venue |
|
1. Number of
targeted syphilis screening events conducted by program staff (e.g., jails,
crack houses, apartment complexes, etc.) |
4 |
-Ongoing screening at jail’s central receiving. - Screening at Marion County Prosecutor’s program
for first-time offenders |
|
2. Number of
persons screened (Jail Screening Program) |
1787 (1327) |
Field bloods + community screenings + Outreach +
Jail |
|
3. Number of reactive STS identified |
44 |
|
|
4. Number of new early syphilis cases identified |
5 |
|
|
5. Number of
newly identified other syphilis infections |
1 |
|
B. Partner Services
|
Indicators |
3rd Qtr |
4th
Qtr |
|
1. Number of
early syphilis cases detected by/reported to the program |
84 |
80 |
|
2. Number
of cases interviewed |
80 (84 eventually) |
77 |
|
3. Number
of partners elicited |
769 |
254 |
|
4. Number
of new partners initiated |
145 |
147 |
|
5. Number
of new partners examined |
80 |
72 |
|
6. Number
of infected partners brought to treatment |
23 |
15 |
|
7. Number
of new partners preventively treated |
45 |
48 |
|
8. Number
of new clusters initiated |
76 |
66 |
|
9. Number
of new clusters examined |
48 |
43 |
|
10. Number
of clusters infected brought to treatment |
1 |
4 |
The number of period
partners given dramatically declined as few cases interviewed admitted more
than 2 or 3 partners.
C. Assessment of standard STD clinical services
|
Indicators |
How Many? |
|
1. Number of STD clinic sites |
1 |
|
2. Number of patient visits per site |
3820 |
|
3. Number of patients screened per site |
3149 |
|
4. Hours of operation |
Mon. 7:45 a.m. – 6:30 p.m. Tue. 11:30 a.m. – 3:30 p.m. Wed. 11:45 a.m. – 6:30 p.m. Thu. 7:45 a.m. – 3:30 p.m. Fri. 7:45 a.m. – 3:45 p.m. |
IV. Technical Assistance Needs and Other Issues
and Concerns/Comments
V. Administrative/Personnel Issues
DIS Staff: One DIS has been placed in the surveillance office to insure each syphilis reactor is evaluated and dispositioned in a timely and efficient manner. This DIS has also been given the responsibility of all congenital investigations and primary liaison between case management and DIS, and between case management and the surveillance office. Plans were finalized during the 4th quarter to upgrade this DIS position to a DIS II and increase the responsibilities to include supervision of the 2 case managers.
Dr. Feldmann, the medical director of the Indiana State Department of Health, resigned.
Vacant positions: Nursing Supervisor, case manager, receptionist, data manager
VI. Publications/Presentations
Abstracts:
JN
Arno, D Wilmot, J Beall, and C Langley, Comparing Syphilis Patients to Others with
STD’s: Do Differences Mark Networks?
Presented as a poster 12/00 in Milwaukee, WI at the National STD Prevention
Conference
D
Wilmot, J Arno, C Langley, N Thomas, J Beall, Intensifying DIS Efforts Through
Outside Reinforcements. Presented as a talk 12/00 in Milwaukee, WI at the
National STD Prevention Conference
VII. Appendices
Syphilis Focus Groups Component