Transcript Overview of STD Epidemiologic Trends and STD Control

STD and HIV Emerging Issues
Gail Bolan MD
Chief, STD Control Branch
CA Department of Health Services
Assistant Clinical Professor
Department of Medicine, UCSF
Overview of Complications of
Sexually Transmitted Diseases
Fetal Wastage*
Low Birthweight*
Congenital Infection*
Upper Tract
Infection
Infertility
Ectopic Pregnancy*
Chronic Pelvic Pain
Systemic Infection
STDs
Cervical Cancer*
HIV Infection*
* Potentially Fatal
STD Morbidity
California and United States 2002
California
reported
cases
US
reported
cases
US
estimated
incidence
(millions)
US
estimated
prevalence
(millions)
CT
GC
Syphilis
Congenital
syphilis
HPV
HSV
Trichomoniasis
AIDS
HIV
Hepatitis B
109,619
24,282
1029
33
754,858
318,796
6,240
349
3
0.65
0.07
NA
NA
NA
NA
NA
NA
NA
NA
2,973
NA
852
NA
NA
NA
38,878
NA
6,660
5.5
1
5
0.02
NA
0.077
20
45
NA
.56
1
.75
Total
138,788
1,125,781
15.3
10 Core Public Health Functions
and STD Activities
Public Health Functions
STD Prevention Activities
Monitor health status
Surveillance
Diagnosis and investigate health Screening and DIS follow-up
problems
Inform and empower people
about health issues
Health Education
Mobilize community
partnerships and action
Develop policies and plans that
support efforts
Community mobilization
Advocacy, strategic planning and
guidelines
10 Core Public Health Functions and
STD Activities
Public Health Functions
STD Prevention Activities
Enforce laws and regulations
Legislation and Regulations
Link people to services and
ensure provision of care when
unavailable
Access to and provision of quality
care
Ensure competent workforce
Staffing and staff development
Evaluate the effectiveness,
accessibility, and quality of
services
Research new insights and
innovative solutions
Evaluation
Research
STD Prevention and Control Strategies
• Education and counseling (primary prevention)
– Project Respect
• Identification of asymptomatic persons (secondary prevention)
– Screening
– HEDIS
• Identification of symptomatic persons (secondary prevention)
• Effective diagnosis and treatment (secondary prevention)
– Test Performance Characteristics
– Empiric Treatment
• Partner Management (primary and secondary prevention)
• Vaccination ( ideally primary prevention)
Syphilis — Reported cases: US,
1941–2001
Thousands of cases
600
P&S
Early Latent
Total Syphilis
480
360
240
120
0
1941
46
51
56
61
66
71
76
81
86
91
96
2001
Primary and secondary syphilis County rates, 1998
Rates per 100,000
Population
<=4 (n=2,803)
>4 (n=312)
Syphilis: Overview of Stages
1º
2º
Early Syphilis
Latent
30%
5-50 years
Late Syphilis
3º
Epidemiologic Vulnerability of Syphilis
•
•
•
•
•
•
No animal reservoir
Long incubation period
Limited infectiousness
Low cost and widely available diagnostic tests
Single dose therapy
No antimicrobial resistance
Syphilis Elimination:
Public Health Importance
• Important, measurable health outcomes
• Substantial cost savings
– Annual cost savings of ~1 billion
• Supports multiple public health goals
–
–
–
–
–
Reduction of racial disparities
Infectious disease control, including HIV prevention
Bio-terrorism preparedness
Reproductive health and infant health
Identifies opportunities to improve public health infrastructure
• Focus for critical collaboration between communities & health
departments
• Addresses unfinished history & broken trust
Primary & Secondary Syphilis Cases by Gender,
California, 1996–2002
Syphilis Rates 1940-2000, California
75
Rate per 100,000
1,100
50
Rate
1,000
25
900
Number of Cases
ALL MALE
0
1940
800
1950
1960
1970
1980
1990
2000
Year
700
600
500
known MSM
400
300
200
FEMALE
100
0
1996
1997
1998
1999
2000
2001
2002
5/03 Provisional Data - CA DHS STD Control Branch
Risk Characteristics of MSM P&S Syphilis
Cases, California 1999-2002
1999
2000
2001
2002
28%
56%
76%
88%
34
36
36
37
Diagnosed at EIP/HIV Care
16%
12%
15%
8%
Diagnosed at STD Clinic
4%
7%
16%
15%
Diagnosed at Private
MD/HMO
46%
43%
49%
36%
Diagnosed at Other Provider
32%
38%
20%
26%
Anonymous sex partners1
na
70%
81%
77%
Self-reported HIV+ 1
na
53%
63%
66%
Methamphetamine use
na
12%
12%
19%
na
na
na
na
23%
5%
27%
11%
20%
11%
35%
17%
23%
8%
27%
27%
%MSM1
Median Age
Meet partners at:
bathhouse/resort
sexclub
bars/clubs
Internet
1
Percentage excludes unknown
5/03 Provisional Data - CA DHS STD Control Branch
Gonorrhea Rates by Gender, California,
1993–2002
Rate per 100,000
150
100
50
0
1993
1994
1995
1996
1997
Male
Source:
1998
1999
2000
2001
2002
Female
California Department of Health Services, STD Control Branch
Provisional Data 05/16/2003
Percent
Gonococcal Isolate Surveillance Project (GISP), Percent of
Neisseria Gonorrhoeae Isolates with Decreased
Susceptibility or Resistance to Ciprofloxacin, California
Sites, 1991–2002
16.0
15.0
14.0
13.0
12.0
11.0
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
Decreased Susceptibility
Resistant
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002*
Year
Note: Resistant isolates have MICs ≥ 1 μg ciprofloxacin/mL. Isolates with decreased susceptibility
have MICs of 0.125 – 0.5 μg ciprofloxacin/mL.
STD Clinic Sites: Long Beach, Orange, San Diego, San Francisco
Source: California Department of Health Services, STD Control Branch
Gonococcal Isolate Surveillance Project (GISP) - Location of
participating clinics and regional laboratories: United States,
1998
Gonorrhea Treatment
Genital & Rectal Infections in Adults
Recommended regimens:





Cefixime 400 mg PO x 1 or
Ceftriaxone 125 mg IM x 1 or
Ciprofloxacin 500 mg PO x 1 or
Ofloxacin 400 mg PO x 1 or
Levofloxacin 250 mg PO x 1
PLUS if chlamydia is not ruled out:


Azithromycin 1 g PO x 1 or
Doxycycline 100 mg PO BID x 7 d
Why Chlamydia & Why Now?
• Most common communicable disease
reported disease in California
– Over 100,000 reported cases in 2001
– Over 75% of cases are seen in the private sector
• Significant health consequences
– Most common cause of preventable infertility
– Facilitates sexual transmission of HIV
• New technology = new opportunity
– Urine tests & single dose treatment = easier to reach,
treat & cure at-risk populations
• HEDIS increases private sector interest
– Potential public/private partnership
Chlamydia Action Coalition
A State-Wide Public/Private Partnership
funded by the
California HealthCare Foundation
www.ucsf.edu/castd
Chlamydia Screening HEDIS
Measure
• The Measure: the percentage of Medicaid and commercially
enrolled women 15 through 25 who were identified as sexually
active, who were continuously enrolled during the reporting
year, and who have at least one test for chlamydia during the
reporting year.
Number tested
Number of sexually active *
* Denominator may exclude plan employees to protect confidentiality
Source: CDC, NCHSTP, DSTDP
Chlamydia HEDIS Data Warehouse
• Centralized Data Warehouse with Electronic
Transmission of Chlamydia Screening Data
– Collection of HEDIS numerator data
– Prevalence Monitoring
• Coordinate with ELR of communicable
diseases
HIPAA Basics
• What is HIPAA?
– Health Insurance Portability and Accountability
Act
– Provides the first national standards for protecting
the privacy of health information
– HIPAA Privacy Rule regulates how certain entities,
called covered entities, use and disclose certain
protected health information (PHI)
Who is Covered?
• Three types of covered entities
– health plans, (e.g., Medicaid, Medicare, and the
Veterans Health Administration)
– health-care clearinghouses, (billing service,
repricing company, or community health
information system)
– health-care providers who transmit health
information in electronic form in connection with
certain transactions (e.g., physicians, hospitals, and
clinics)
Impact on Public Health
• Public health uses PHI to identify, monitor,
and respond to disease, death, and disability
among populations
• Privacy Rule expressly permits PHI to be
shared by covered entities for specified public
health purposes
• Public health authority may also be a covered
entity in some cases
Permitted PHI Disclosures Without
Authorization
• Where required by law
• PHI can be disclosed to public health authorities and
their authorized agents for public health purposes
• Health research
• Abuse, neglect, or domestic violence
• Law enforcement
• Judicial and administrative proceedings.
• Cadaveric organ, eye, or tissue donation purposes
• For oversight activities authorized by law
• Worker's compensation
Included Public Health Activities
• reporting of disease or injury
• reporting vital events (e.g., births or deaths)
• conducting public health surveillance,
investigations, or interventions
• reporting child abuse and neglect
• monitoring adverse outcomes related to food
(including dietary supplements), drugs,
biological products, and medical devices
Requirements for Covered Entities
• Accounting for Public Health Disclosures
– Covered entity must be able to provide a patient an
accounting of disclosure even for disclosures permitted or
required by law
• Notice of Privacy Practices
– individuals have the right to adequate notice of the uses and
disclosures of PHI that may be made by the covered entity,
as well as their rights and the covered entity's legal
obligations
• Minimum Necessary Standard
– directs covered entities to limit the amount of information
disclosed to the minimum necessary to achieve the
specified goal
Rapid HIV Testing
A key strategy of the Advancing HIV
Prevention Initiative is to use rapid HIV tests to
expand HIV testing outside clinical settings.
Reactive
Control
Positive
HIV-1
Positive Negative
Read results
STD Resources for Clinicians
California STD/HIV Prevention Training Center
www.stdhivtraining.org
CDC Treatment Guidelines
www.cdc.gov/std/treatment
California Chlamydia Action Coalition
www.ucsf.edu/castd
CA STD Control Branch
www.dhs.ca.gov/ps/dcdc/STD/stdindex.htm