UPDATE ON THE SYPHILIS EPIDEMIC IN INDIANAPOLIS

Janet Arno, MD and Jutieh Lincoln, MPH February 9, 2011 Marion County Public Health Department (MCPHD) Indianapolis, IN

Goals of this Presentation

 To inform the Community about the status of the Syphilis epidemic, and to highlight its epidemiologic trends over time  To inform the Community about current efforts to control the Syphilis epidemic  To seek the help of the Community in controlling the Syphilis epidemic

Background

 In 1999, Marion County had the highest number of Primary and Secondary (P & S) syphilis cases in the United States.

 As a result of the outbreak, community organizations partnered with the Marion County Public Health Department, the State, and CDC to organize an effective campaign to control syphilis.

 The number of P & S was decreased from 403 P & S cases per year to less than 50 cases per year.

 In 2008 we once again saw an increase in cases twice the standard deviation of our baseline.

 Now we are seeing an increase in cases superimposed on an outbreak among MSM.

 Since 2008, about 410 Indianapolis residents have been diagnosed with the disease

Early and P & S Syphilis In Indianapolis 1996-2010 Early Syphilis P & S 600 500

1999 Syphilis Outbreak

400 300 200

2008 Syphilis Outbreak

100 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Report Year

Early Syphilis Indianapolis 2007-2010

Primary and secondary Total Early Syphilis 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

2007 2008 2009 2010

Newly Diagnosed Syphilis Cases from January 1, 2010 to December 28, 2010

     District 5: 178 cases Total number of primary and secondary syphilis cases in District 5: 117 Marion County: 162 cases Total number of primary and secondary syphilis cases in Marion County: 106 Except for race and age, the demographics of the 16 cases outside of Marion County are similar to the demographics of cases within Marion County.

200 160 120 80 40 0

Early Syphilis Cases by Diagnosis: 2008-2010, Marion County, Indiana

Primary Secondary Early Latent 49 55 18 2008 27 49 20 2009 56 82 24 2010

Report Year

Consistently, most cases had primary or secondary syphilis at diagnosis.

Early Syphilis Cases by Race: 2008-2010, Marion County, Indiana

White Black Hispanic Other 180 160 140 120 100 80 60 40 20 0 39 78 41 43 106 45 2008 2009 2010

Report Year The outbreak has shifted from mostly Whites to mostly Blacks.

180 160 140 120 100 80 60 40 20 0

Early Syphilis Cases by Age of Diagnosis: 2008-2010, Marion County, Indiana

<25 years 25-34 years 35-44 years >44 years 18 47 38 19 2008 23 34 22 17 2009 23 24 55 60 2010

Report Year

The outbreak has shifted from middle-aged to younger adults.

Early Syphilis Cases by Gender: 2008-2010, Marion County, Indiana

Male Female 180 160 140 120 100 80 60 40 20 0 9 113 8 88 30 132 2008 2009 2010

Report Year

Males (esp. MSM) account for most cases, but female proportion has grown.

HIV Co-Infection Among Early Syphilis Cases: 2008-2010, Marion County, Indiana

Negative Positive Unknown 160 140 120 100 80 60 40 20 0 12 68 41 2008 14 51 31 2009 8 38 94 2010

Report Year

The HIV-infected proportion has shrunk, but many new cases do have HIV.

Early Syphilis Cases by Sexual Orientation: 2008-2010, Marion County, Indiana

MSM Bisexual Heterosexual Unknown 180 160 140 120 100 80 60 40 20 0 20 92 25 66 64 89 2008 2009 2010

Report Year Heterosexuals account for an increasing portion of diagnosed cases.

Risk Behavior of Syphilis Cases

 Cases frequently reported: o Sexual intercourse with unknown persons o Sexual intercourse without condom o Sexual intercourse while high on drugs such as: o Alcohol o Marijuana o Crack o Cocaine o Meth

Risk Behavior of Syphilis Cases

 Frequently reported sites for meeting sex partners include: o o o o o o o o Adam for Adam Gay.com

Manhunt Facebook The Ten Club Indy Talbot Gregs   Blacks were likely to meet their sex partners:    thru Family members thru Friends at social events (ex. parties) Whites were likely to use online sites to meet their sex partners.

Methods of Case Detection that are being utilized in the Syphilis Epidemic     Disease Intervention Specialist (DIS)-a staff member who is trained to treat, interview, and follow up on persons diagnosed with an STD. Patient Referral-an instance in which a person diagnosed with an STD divulges the names of partners he/she may have put at risk for that STD. Screening-an initial evaluation conducted by a provider to determine whether a person is at risk for or has an STD.

Self Referral-an instance in which a person feels that he/she may have an STD and goes to a provider for screening.

Methods of Case Detection: 2010 Syphilis Cases, Marion County, Indiana

80 70 60 50 40 30 20 10 0 13 Traditional Disease Intervention Activities 26 Patient Referral 45 Screening 75 Self Referral

Self referral and screening accounted for the bulk of the cases diagnosed.

Conclusions

Syphilis Cases so far in 2010 surpassed 2008 and 2009’s count Blacks became majority among cases MSM still disproportionately impacted Age shifting from older to younger adults Female proportion increased to nearly 1 out of 6 syphilis cases

Conclusions

Proportion with HIV decreasing, but still high Heterosexuals proportion trending upwards 3 risks commonly reported were:  Drug use during sexual intercourse  Sexual intercourse with unknown persons  Sexual intercourse without condom Cases increasingly concentrated in central Marion County and lower income areas An increase is expected with waxing and waning components

Current Efforts

 Continue to:  Screen high risk groups (e.g. MSM, the incarcerated, commercial sex workers) and hard-hit areas in Indianapolis for the disease and quickly bring cases to treatment  Partner with providers and community-based organizations around the city to quickly identify patients with the disease and bring them to treatment, and to educate their patients about the disease and risk reduction behaviors  Aggressively follow up with partners named by cases to determine if they have the disease and bring them to treatment or to educate them about risk reduction behaviors

Current Efforts

  Continue to  Periodically update providers, public health practitioners, and the community on the epidemic through mass mailing and through MCPHD website. A powerpoint presentation on the epidemic is available at:

http://www.mchd.com/syphilis_info.htm

Have set up a new website (

http://www.bellflowerclinic.org/

) to keep providers, public health practitioners, and the community informed about clinic hours, STD resources, services offered, and to answer their questions

How Can You Help?

      Spread the word about the Syphilis epidemic Encourage persons in your community to get tested for Syphilis Inform persons in your community that Bell Flower Clinic offers low cost STD screening (or free STD screening with life saver card) Share ideas for screening sites in your community Serve as an information resource for your community Offer Suggestions on how to control the epidemic

Acknowledgement

A Special thank you to Mr. David Broyles (Marion County Public Health Department Corporate Information Systems) for his excellent and timely work on the Syphilis maps, and Caitlin Gill (Epidemiology intern from the IU Department of Public Health) for assisting in the compilation and presentation of this data.