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2002 National STD Conference - Poster Abstracts 151-175


STD Clinic Samples and High-Risk Community Samples: A Comparison

P Du1, LA McNutt1, R Thomas2, FB Coles2

1Department of Epidemiology, University at Albany, Rensselaer, NY; 2Bureau of STD Control, New York State Department of Health, Albany, NY

Background: Telephone surveys response rates are declining, resulting in greater opportunity for selection bias and increased cost.

Objective: To assess the comparability of results from a study on health care preferences and STD-related knowledge, attitudes, and behaviors conducted in STD clinics with a study conducted in the same communities among high-risk individuals.

Methods: An STD clinic and community sample was selected from each of two urban areas in New York State. At each STD clinic, 100 individuals were interviewed in Fall 1997. In each community, 400 individuals were selected using random-digit dialing during the same period. Community sample subjects were defined as having high-risk profiles based on four items related to their sexual behaviors (e.g., multiple partners) (n = 139, 125).

Results: The STD clinic samples were younger and had a larger proportion of men (mean age 28, 63% males) compared to the high-risk community samples (mean age 32, 43% males). High-risk community subjects were more likely to perceive seeking health care in private physician's offices (52%) than at STD clinics (28%) or family planning clinics (11%) for sexually transmitted infections. Overall STD-related attitudes, knowledge, and behaviors were similar between STD clinic and high-risk community samples (e.g., use of condom consistently with main partner, perceived HIV knowledge), however, sporadic inconsistency for a few items occurred (e.g., perceived knowledge about specific STDs).

Conclusion and Implication for Future Research:

Estimates of general population's STD-related knowledge, attitudes, and behaviors are needed to develop relevant prevention and intervention programs. The results from our study indicate that STD clinic samples may provide similar results as more costly telephone surveys of high-risk individuals conducted in the community on assessing STD knowledge, attitudes, and behaviors. However, studies with larger sample sizes are needed to confirm these findings.


An Exploration into Geographic Clustering Using STD Surveillance System Information

JJ Jennings1,2, F Curriero1, JM Ellen1,2

1Johns Hopkins University Bloomberg School of Public Health; 2Johns Hopkins University School of Medicine

Background: Public health and community-based organizations often consider descriptive maps of rates of sexually transmitted disease to plan interventions. It has been hypothesized that the areas with high rates represent "core" areas or clusters which are due to the presence of dense sexual networks of high-risk individuals. However, the gonorrhea rates by geographic area have not been quantified nor tested for geographic clustering. We conducted a cluster detection test using SaTScan, which has been used previously in cancer research to statistically test for clusters of rates of disease.

Objectives: To determine whether there are statistically significant clusters of census block groups with high rates of gonorrhea in Baltimore City from 1995-1999.

Methods: The outcome measure was that Baltimore City reported cases of gonorrhea from 1995-99 per census block group geocoded to the reported primary address and aggregated to census block groups (n = 832) using Map Info 6.0. Spatial analysis of the case distribution was conducted using a cluster detection spatial scan statistic, SaTScan v2.1 adjusting for the underlying inhomogeneity of the background population.

Results: SaTScan identified two statistically significant areas and clusters of census block groups with high rates of gonorrhea on the east and west of Baltimore City.

Conclusions: The identified geographic clusters or core census block groups with high rates of gonorrhea indicate a non-independence of the cases of gonorrhea in these areas. The non-independence conclusion is seemingly apparent given the infectious nature of gonorrhea. However, since gonorrhea is transmissible only through sexual contact we may conclude that the core areas represent: 1) dense sexual networks with a high prevalence of disease; and 2) non-independent sexual mixing on the basis of demographic factors. Further research is warranted into local geographical heterogeneity of demographic factors.

Implications for Programs/Policy: The study provides invaluable information for public health departments as they move towards more community-based and focused intervention strategies, i.e., sexual network interventions.

Implications for Research: The research extends our understanding of the geographic distribution gonorrhea in Baltimore City and may begin to aid in our basic understanding of STD transmission and acquisition in a high-prevalence inner city. Additional research should be conducted to control for risk determinants such as selected census demographic features.

Measurable Learning Objectives: Participants will be able to describe the application of a spatial scan statistic to sexually transmitted disease research and begin to understand the implications for public health community-based organization interventions.

Contact Information: Jacky Jennings / Phone 410-502-2771 /


Increased Surveillance for Chlamydia When Adding Urine-Based Testing to a School-Based Screening System

MM Vukovich1, KA Haglund1, S Wang2, R McDonald3

1Milwaukee Adolescent Health Program, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI; 2Centers for Disease Control and Prevention, Adolescent Women Reproductive Health Surveillance Project, Atlanta, GA; 3Wisconsin State Laboratory of Hygiene, Madison, WI

Background: Many chlamydia infections are asymptomatic and go undetected. Urine-based testing is especially convenient to women, particularly high-risk adolescents.

Objective: To determine the prevalence rate of chlamydia infection among high-risk adolescent females served in school-based health centers (SBHCs), and to determine the increased number of tests performed when urine testing was made available.

Method: During 2000 urine chlamydia testing was made available, simplifying the screening process. The population included 468 adolescent females attending two SBHCs. Age ranged from 12-23 years. Sixty-three percent were African American, 29% Hispanic, 4% Caucasian, 3% Asian, and 1% Native American. Between 9/1/99 and 8/31/00, subjects were tested for chlamydia via a cervical swab, which required a pelvic exam. Between 9/1/00 and 8/31/01, either urine testing or cervical swabs (using strand displacement amplification tests (SDA)) were used to screen for chlamydia. Females seen during the first year of the study received selective screening based on symptomatology or known sexual risk factors. During the second year of the study, all sexually active adolescent females were screened for chlamydia.

Results: During year one, 175 chlamydia tests were done; 16% (28) of females were positive. In the second year, 293 tests were done; 14% (41/293) of females were positive. The prevalence rates (Year 1 vs. Year 2) were not statistically significant (p<.784).

Conclusions: The difference in the prevalence rates for the population were not statistically significant, however this study demonstrated that adding urine testing to a SBHC screening program increased the number of chlamydia tests performed by 67% and the number of identified infections by 46%. Even though screening criteria changed, the prevalence remained constant.

Implications: The ease of urine-based chlamydia screening allows programs to increase the number of high-risk women tested, which leads to the identification and treatment of many chlamydia infections that otherwise would go undetected.


Integration of Separate Data Sets Within a State Health Department

B Laffoon, T Beers, R Hamm

Missouri Department of Health and Senior Services (MDHSS), Jefferson City, MO

Background: Morbidity, vital records, hospital discharge, and emergency department data collected by the Missouri Department of Health and Senior Services (MDHSS) has been managed within separate data sets housed in different departmental organizational units. Lack of integration of these different data sets has prevented full utilization of the information they contain.

Objectives: To describe the development of a mechanism for linking seven separate databases within MDHSS, and the preliminary results and initial benefits obtained from this linkage.

Methods: A data set matching program, which can link databases of different formats, has been developed, tested, and implemented. The program loads two data sets into Microsoft Access tables and executes exact and potential matching algorithms. This allows linkage of data from HIV/AIDS, sexually transmitted disease, tuberculosis, hospital discharge, emergency department, birth record, and death record databases.

Results: To date, five of the seven databases have been linked so that specific individuals who have been entered into more than one database can be identified. Initial benefits of such linkages include 1) identifying unreported cases of disease, 2) obtaining additional information on cases already reported, 3) identifying co-morbidity trends, and 4) detecting subsequent risky behavior in reported HIV/AIDS cases.

Conclusions: Linkage of morbidity, vital record, hospital discharge, and emergency department data sets has proved beneficial to public health surveillance and prevention programs within the department.

Implications for Programs/Policy: Given these benefits, public health agencies should be strongly encouraged to integrate existing stand-alone data sets.

Implications for Research: The creation of improved mechanisms which can efficiently integrate large databases, and which are practical for use by health departments of different sizes, is an important research priority.

Learning Objectives:

1. Participants will be able to describe the database-matching program being utilized by MDHSS.

2. Participants will be able to describe the public health benefits of linking morbidity, vital records, hospital discharge, and emergency department data.


Using Lorenz Curves to Evaluate Spatial Patterns in STDs

O Devine

Statistics and Data Management Branch, Division of STD Prevention, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention

Background: Lorenz curves are commonly used to graphically summarize inequality in the distribution of wealth. Recently, Lorenz curves have been increasingly used to assess geographic variations in the distribution of STD risk.

Objectives: To examine the theory supporting the use of Lorenz curves in assessing the geographic distribution of STDs. In particular, I examine implied models and assumptions, curve interpretation and present a new approach for estimating approximate confidence intervals for Lorenz curve ordinates.

Methods: I use county-specific data for chlamydia, gonorrhea, and P&S syphilis from a number of U.S. States to illustrate the use of Lorenz curves in assessing and interpreting the spatial distribution of STD incidence. In addition, I use simulations to evaluate a new approach for estimating confidence intervals associated with the curves.

Results: Lorenz curves can be informative tools for exploratory spatial analysis of STD incidence data. The derived approximate confidence intervals are shown to perform well in describing the variation expected when estimating Lorenz curves using observed STD data.

Conclusions: Examination of Lorenz curves can be helpful in assessing geographic variations in STD risk. The suggested confidence intervals provide easy to construct, yet accurate summaries of the sampling variability associated with the estimates.

Implications for Program/Policy: Lorenz curves are increasingly being used in assessments of the spatial distribution of STD rates. Such assessments have the potential to increase program impact by focusing effort in areas with elevated risk.

Implication for Research: Spatial analysis of STD incidence, for example using Lorenz curves, can lead to the development and investigation of meaningful etiologic hypotheses. The presented confidence intervals provide researchers with a measure of the uncertainty associated with the estimated Lorenz curves.


Comparative Geographic and Population Concentration of Four STDs

RP Kerani1, HH Handsfield1,2, MS Handcock1, KK Holmes1

1University of Washington, Seattle, WA; 2Public Health Seattle & King County, Seattle, WA

Background: A phase-specific model of STD epidemic evolution (Wasserheit J, Aral S. J Infect Dis.1996;174 [Suppl 2] S201-213) posits that over time, with decreasing incidence, STDs become increasingly concentrated in smaller proportions of a population.

Objectives: Syphilis, gonorrhea, chlamydial infection (CT), and genital herpes (HSV) are reportable in Washington State, allowing us to compare the concentration of these STDs, and to ascertain whether any has become more concentrated over time.

Methods: All residents of King County, WA, diagnosed with syphilis, gonorrhea, CT, or HSV and reported to public health authorities from 1986 for syphilis and gonorrhea, 1988 for CT, and 1992 for HSV, to 2000, were assigned to their census tract of residence. Concentration curves were constructed for each infection by arranging tracts in decreasing order of case frequency, and plotting the cumulative proportions of population and cases against one another for each tract. Curves were prepared comparing the four STDs using 2000 data, and for each STD over time.

Results: Syphilis exhibited the highest level of concentration, followed by gonorrhea, CT, and HSV: while 50% of the syphilis cases were found in tracts accounting for 3% of the population, 50% of gonorrhea, CT, and HSV cases were found in tracts accounting for 11%, 22%, and 25% of the population, respectively. Syphilis became more concentrated as it was gradually eliminated from 1986 through 1996, then became less concentrated as syphilis was reintroduced. Gonorrhea incidence fell by 78% from 1987 through 1996, but paradoxically, became less concentrated. CT and HSV incidence showed less dramatic changes over time.

Conclusions: In a local setting, specific characteristics of these infections, including the natural history and infectiousness of the microorganisms, and the effectiveness and duration of control efforts, interact to produce varying levels of concentration. Diffusion of more sensitive screening technologies for gonorrhea and CT may have influenced trends in concentration observed for these infections.

Implications for Programs/Policy: Analyses of geographic/population concentration of STDs complements disease mapping, but may not detect qualitative changes in patterns of transmission.

Implications for Research: Concentration analyses allow statistical comparisons in differences in concentration among STDs, and trends in concentration over time.


Enhanced Surveillance and Epidemiologic Trends of Syphilis in California

MC Samuel, T Lo, G Gould, R Tulloch, K Bernstein, G Bolan

California Department of Health Services, Sexually Transmitted Disease Control Branch, Berkeley, CA

Background: In 1999, because of low numbers of syphilis cases and the ease of detecting and treating cases, syphilis was slated for elimination by 2005. A key component of the elimination plan is enhanced surveillance, including collection of expanded behavioral risk-factor data and rapid analysis and dissemination of important results to target intervention.

Methods: In 2000, California enhanced data collection instruments for early syphilis by including behavioral risk factors such as specific sexual practices, self-reported HIV status, venues for meeting sex partners, and health care seeking behavior. Other variables relating to importation, source analysis, and medical history were expanded. In this presentation we report key findings related to these expanded variables and describe California's surveillance and analysis systems.

Results: After many years of decreases in syphilis, California saw an increase in 2000 and further increases in 2001. In the first half of 2001, 215 primary and secondary (P&S) syphilis cases were reported, corresponding to an annual rate of 1.2 per 100,000, an increase of 69.4% from the low of 0.72 per 100,000 in 1999. In the first half of 2001, 67% of P&S syphilis cases were among men who have sex with men (MSM), an increase from 59% in 2000 and 29% in 1999. Among MSM cases in the first half of 2001, 20% reported meeting sexual partners at bathhouses/spas and 12% over the Internet; over half (61%) reported being HIV positive. Increases in cases have been seen in all racial/ethnic groups; the 2001 rate remains much higher in African Americans (3.8 per 100,000) than other groups.

Conclusions: An enhanced syphilis surveillance system is in place in California, providing timely data on a range of risk factors useful for targeted intervention. Recent increases in syphilis have been associated with MSM. Prevention efforts have been initiated in this population and will be refined and expanded based on new case information and further epidemiologic analysis.

Learning Objectives: At the end of this presentation, participants will be able to describe key aspects of the epidemiology of syphilis in California and describe the main features of the enhanced syphilis surveillance system.


Surveillance for Repeat Gonorrhea Infection, San Diego, California, 1995-2000: Establishing Definitions and Methods

A Maroufi1, R Gunn1,2, K Fox2

1Health and Human Services Agency, San Diego, CA; 2Centers for Disease Control and Prevention, Atlanta, GA

Background: Persons in "core" transmitter networks, defined by an elevated prevalence of gonorrhea (GC) and frequent sex partner change, are often repeatedly infected with GC. Surveillance systems directed specifically to "core" group members are needed.

Objective: To describe an approach for monitoring the rate in the population of repeat GC cases and proportion of total GC cases that were repeats, and to evaluate case definitions and methods.

Methods: From 1995-2000, all GC cases reported in San Diego, CA were reviewed to identify persons with >2 infections occurring >30 but <365 days apart, using date of report. The repeat GC rate and proportion of total GC that were repeats were determined during each calendar year. For each person with only one GC infection in a calendar year, case reports going back 12 months from the date of infection into the previous trailing year were reviewed.

Results: For the 6-year period, the average annual rate of repeat GC infection, using only each calendar year, was 1.6 per 100,000; the average annual proportion of total GC that were repeats was 2.6%. Including repeat infections identified in the trailing 12-month period, the repeat GC rate and proportion of total GC that were repeats increased to 2.7 per 100,000 and 4.3%, respectively. The temporal trend in repeat GC rates and proportions of total GC were similar and showed a pattern that mirrored overall community GC rates.

Conclusion: Surveillance of repeat GC infections, using date of report and only calendar year analysis, was feasible and provided useable repeat GC rate and proportion of total GC trend data.

Implications for Programs: To develop individual-level interventions, procedures to identify persons with repeat GC using frequent trailing 12-month analyses should be evaluated.

Implications for Research: Pilot repeat GC surveillance experience could be used to develop and evaluate a national repeat GC surveillance system.

Learning Objectives: Participants will learn the definitions and methods used in conducting repeat GC surveillance and the relationship between repeat GC and overall community GC rates.

Contact Information: Azarnoush Maroufi / Phone 619-515-6620 /


Analysis of Gonorrhea Surveillance Data

AA Zaidi

Centers for Disease Control and Prevention, Atlanta, GA

Background: Gonorrhea rates in the United States after declining 74% between 1975 and 1997 increased 8% in 1998. Declines in men (78%) were sharper than the declines in women (68%).

Objective: Build time-series models to understand the dynamic relationship between male and female gonorrhea morbidity. Also use these models to predict future gonorrhea cases in these populations.

Methods: Reported cases of gonorrhea in men and women by quarter from 1975 to 1999 were used to build time-series models. First we studied the historical behavior of each of the series and identified consistent patterns embedded in them. On the basis of these patterns we built time-series models relating present observation as a function of the past data. To study the relationships between male and female gonorrhea morbidity we studied the cross-correlations between the two series. Patterns recognized through these cross-correlations were used to build transfer-function models. In these models, present observation of one series is represented as a function of the present and previous observations of the other series. Models built through these processes are used in predicting future gonorrhea cases.

Results: Both male and female quarterly gonorrhea morbidity are highly seasonal with a seasonality of four quarters, with third quarter being the highest and about 21% higher than the first quarter. In the univariate models for both men and women, present value of the observation is a function of the previous observation and the observation four quarters earlier, emphasizing the seasonality of the data. Transfer function models show that there is an instantaneous effect of the change in one series onto other.

Conclusion: Time-series models formulated give us an understanding how the male and female gonorrhea morbidity interact with each other. These models can be used in developing more efficient STD control programs by directly affecting one series to obtain a desired effect in the other.

Implications for Programs/Policy: These and similar models can help program managers in finding the relationships between different subsets of the STD populations, which will help them in formulating efficient STD control policies.

Contact Information: Akbar Zaidi / Phone 404-639-8185 / AZAIDI@CDC.GOV


Evaluating the Reality of Disease Prevention Practice: Matching HIV Surveillance and STD Databases

J Harms, R Rogers

Houston Department of Health and Human Services, Houston, TX

Background: HIV infection is reportable by name in Texas. Positive western blots done after 1998 and detectable viral loads after 1999 are reportable. Case reports must indicate who will notify and counsel the patient's partners about their HIV exposure: health department, physician/provider, patient, or unknown.

Objective: To validate "health department" as a response to the "Partner Notification Question" (PNQ) for newly-tested HIV positive people diagnosed and reported in Houston/Harris County, TX, from January 2000 to September 2001.

Methods: A line-list of patients, classified by public or private facility of diagnosis, with "health department" as response to the PNQ was generated from the HIV/AIDS surveillance database and manually matched to the STD database. Evidence of initiation of an STD field record validated "health department" as a response. Whether patient interviews were done and partners were elicited were recorded.

Results: Of 294 patients identified, 69% had been diagnosed publicly and 31% privately. STD field records had been initiated on 92% of public and 54% of private patients. For public patients, 92% of initiated field records had resulted in completed interviews vs. 69% for private. For public patients 75% of completed interviews yielded partners vs. 71% for private.

Conclusions: Answering the Partner Notification Question in surveillance reports is just the beginning. To validate surveillance data and evaluate the reality of disease prevention practice, two different databases can be matched with useful results.

Implications for Programs/Policy: Thoughtful consideration should be given to integrating HIV/AIDS and STD databases. More extensive linkages between surveillance and prevention activities should be explored.

Implications for Research: The basis of differences in public and private results, results of partner follow-up, and evaluation of other PNQ response categories should all be explored.


Evaluation of a Syphilis Surveillance System-San Francisco 2000

W Wong1,2, C Kent1, R Kohn1, W Wolf1, L Fischer1, J Klausner1

1STD Prevention and Control Services, San Francisco Department of Public Health (SFDPH), San Francisco, CA; 2Centers for Disease Control and Prevention (CDC), Atlanta, GA

Background: San Francisco is a high morbidity area for syphilis. Adequate surveillance and its evaluation are essential components of syphilis prevention and control.

Objective: To describe and evaluate the San Francisco Department of Public Health (SFDPH) syphilis surveillance system.

Methods: We evaluated the syphilis surveillance system using the CDC 2001 Updated Guidelines for Evaluating Surveillance Systems (MMWR July 27, 2001/Vol. 50/No. RR-13) by reviewing documents from the SFDPH syphilis program and interviewing key personnel.

Results: Surveillance depends on the assessment of reactive syphilis serologies reported by physician and laboratories, and prevalence monitoring in representative populations at clinics, HIV testing sites, and detention facilities. Multiple personnel in different units assess reported reactive serologies, investigate suspect cases, and perform monthly review of prevalence data. Laboratories reported 2,168 (91%) of 2,389 reactive serologic tests to SFDPH within 5 working days after specimen collection; and staff evaluated 1,701 (92%) of 1,841 suspected syphilis cases within 3 days of receiving a laboratory report. The surveillance system detected recent increases in syphilis rates among gay men and was flexible in adding new prevalence monitoring sites. We used an independent laboratory survey conducted by the State of California to determine completeness of laboratory reporting. Because the survey provided aggregate numbers of positive syphilis tests, completeness of laboratory reporting could not be accurately measured.

Conclusions: The foundations of syphilis surveillance were case reporting and prevalence monitoring in representative populations. Despite the system complexity, reporting and follow-up of serologic tests was timely. The system was sensitive and flexible. Since the survey did not allow the completeness of laboratory reporting to be measured, individual laboratory audits may be necessary.

Implications for Program/Policy: Audits of laboratories may be essential to evaluate the completeness of laboratory reporting for syphilis.

Implications for Research: Further studies might address improved validation methods in evaluating syphilis surveillance systems.

Learning Objectives: Participants will be able to describe the practice of syphilis surveillance evaluation and validation.


Using Automated Systems to Obtain Accurate Data, Track Behavior Change, and Identify Program Needs

E Benet

AIDS Delaware, Wilmington DE

Background: Database software commonly available to organizations who provide preventive educational programming can be configured to monitor the progress of these and the course of behavior change in individual program participants. Software can be configured to track participants through the use of anonymous unique identifiers. When used in conjunction with surveys and knowledge-based tests, these serve to provide accurate pictures of where clients are in the course of behavior change and offer a clearer view of the strengths and weaknesses of the program.

Objective: To assist participants in maximizing the potential of information systems they may already have in place allowing them to better evaluate program effectiveness and provide more targeted and appropriate preventive education for their clients.

Methods: Using software to assign unique identifiers to clients in preventive education programs that occur with repeated interventions and tracking clients' progress over time to identify program needs.

Benefits: Labor expense savings, more time for direct service; clearer picture of where clients are at in the course of behavior change; a more specific understanding of what is working in the preventive educational programming and what is not; an ability to adjust programming to conform to the needs of a participants as they progress through programming.

Results: We were able to quickly identify frequently incorrect answers to the same question on follow-up knowledge-based tests and adjust accordingly. Additionally, because participants were anonymously surveyed about their participation in specific high-risk behaviors and what leads them to such, we were able to dynamically restructure programming directed to each group during the course of intervention, reflecting their specific needs. We were subsequently able to evaluate the effectiveness of these interventions and respond accordingly.

Conclusions: Using inexpensive software to assign unique identifiers to groups to whom we provide repeated interventions is an effective way of responding to clients'.

Implications for Programs: Programs that provide repeated preventive education programs to groups can benefit greatly from implementing automated systems with unique identifiers to track behavior change and assess knowledge and programming.

Implications for Research: Researchers can obtain a more accurate picture of epidemiological trends because participants tend to answer questions more honestly when submitted in anonymous format.

Learning Objectives: Participants will learn what they can do to fully computerized tools they may already have to provide more effective and responsive programming.

Contact Information: Edward Benet / voice: 302-652-6776 /


Electronic System for Rapid Initiation, Transfer, and Tracking of Syphilis Investigations on High-Priority Reactive Serological Test Results

A Studzinski, S Holmes

Illinois Department of Public Health STD Section, Springfield, IL

Background: STD programs that conduct syphilis elimination activities need to ensure the rapid initiation of investigations on clients with high priority serological test results. Electronic reporting methods can be used to transfer investigations within one day of receipt.

Objectives: To describe a syphilis investigative management system that requires minimal staff time, ensures rapid follow-up, and creates an electronic tracking system.

Methods: The Illinois Department of Public Health (IDPH) STD Section receives reactive syphilis test results from laboratories in three ways: a daily electronic transmission of test results from the IDPH Division of Laboratories; weekly electronic reporting from two reference laboratories; and hard copy test results from private reference laboratories. These results are imported or manually entered into a Microsoft (MS) Access database. Field records are generated from these data daily and are e-mailed to six local health departments and printed and faxed to the remaining Illinois local health departments within one day. An electronic field record is also created in the STD Section's information management system for tracking purposes.

Results: This system has increased the capacity of the STD Section to ensure rapid initiation of high-priority syphilis investigations and also to track the timeliness and productivity of those investigations without the creation of additional staff positions. Tracking reports produced monthly by the section's syphilis elimination coordinator help to monitor open investigations and analyze productivity and timeliness of local health department investigations.

Conclusions: Electronic laboratory reporting of STD test results and electronic systems for field record initiation can increase efficiency of initiation, transfer and tracking of syphilis investigations.

Implications for Programs/Policy: Systems that increase the timeliness of syphilis investigations will assist the syphilis elimination efforts by ensuring rapid treatment, counseling and partner initiation.

Implications for Research: Electronic laboratory reporting should be encouraged and systems to retrieve reactive syphilis test results and electronically transfer investigations to health departments should be developed as a tool to improve timeliness of syphilis investigations.

Presenting Author Contact Information: Alice Studzinski / Phone: 217-782-2747 /


Assessing the California Syphilis Reactor Grid from Surveillance Data, California, 2000-2001

T Lo, M Samuel, G Gould, R Tulloch, S Coulter, R Kohn, G Bolan

California Department of Health Services, Sexually Transmitted Disease Control Branch, Berkeley, CA

Background: A reactor grid is used to prioritize the follow-up of potential primary and secondary (P&S) syphilis cases having a positive serologic test for syphilis (STS). Grid rankings are established by titer, age, and gender categories and are based on the probability of identifying untreated infectious syphilis cases for follow-up. Older patients with low titers are typically assumed to be late cases and are given an "administrative closure" (AC) ranking without further investigation. Reactor grid priorities should reflect changes in local epidemiologic trends, such as the recent cases among older males, especially men who have sex with men (MSM).

Objectives: To assess the California reactor grid ranking of "administrative closure" based on current syphilis trends.

Methods: Demographic data from P&S syphilis cases reported to the California Department of Health Services from 1/1/00 to 9/30/01 were examined. We assessed the proportion of cases that would have met the criteria for an AC ranking by age, gender, and titer classification.

Results: In this time period, 599 P&S syphilis cases were reported. Forty-three (7.2%) met the criteria that would have resulted in an AC ranking. Of these 43: 17 (39.5%) were males 30-39 years with 1:1 or unknown STS titers, 15 (34.9%) males and 1 (2.3%) female were 40-49 years with titers <1:4 or unknown, 7 males (16.3%) and 2 females (4.6%) were 50-59 years with titers <1:8 or unknown, and one male (2.3%) was >60 years with a 1:8 titer. Among the 40 males that would have had an AC ranking, 23 (57.5%) were MSM. Cases were primarily from the San Francisco Bay Area (46.5%) or Southern California (41.9%).

Conclusions: Older California males with low (<1:8) titer ratios should be given higher follow-up priority. An AC reactor grid ranking may miss untreated P&S cases since a significant proportion of syphilis has been found among older males, particularly MSM.

Implications for Programs/Policy: Using past case frequencies, public health casefinders can adjust their reactor grid follow-up rankings to identify a larger number of P&S cases.

Implications for Research: Further analyses of syphilis case investigations by grid criteria are necessary to improve the identification of populations that should be given higher follow-up priority.

Learning Objectives: Conference participants will better understand the role of the reactor grid in early syphilis investigations and recognize that local transmission trends should be reflected in the priority rankings of the reactor grid.

Contact Information: Terrence Q. Lo / Phone 510 883-6653 /


Changes in the Epidemiology of Syphilis in New York City, 1999-2001

G Paz-Bailey1, A Meyers2, L Markowitz1, J Brown2, S Rubin1,2, S Blank1,2

1Centers for Disease Control and Prevention, Atlanta, GA; 2STD Control Program, Department of Health, New York City, NY

Background: Since 1990, primary and secondary syphilis (P&S) rates have declined in New York City (NYC), from 58.2 per 100,000 in 1990 to 1.67 in 2000. However, in 2000 and 2001 there was an increase in the number of P&S syphilis cases among men who have sex with men (MSM), many of whom are co-infected with HIV. Similar outbreaks among MSM have been reported in other US cities.

Objective: To describe an outbreak of P&S syphilis among MSM in New York City.

Study Methods: We reviewed case interview records and syphilis surveillance data for P&S syphilis cases reported to the NYC Department of Health from 1999 through June 2001.

Results: From January to June 2001, 132 cases of P&S syphilis were reported, compared to 130 and 117 for all 1999 and 2000, respectively. Overall, 121 (92%) were male; the mean age was 34 years. The number of cases among whites increased from 9 in 2000 to 46 cases in 2001. More than 50% of males were MSM. Of those with known HIV status (n = 24), 8 (33%) were sero-positive; 7 of these were MSM. Of MSM cases, 42% were white, 55% were from the borough of Manhattan and 54% were reported by private providers. Ten MSM cases, but no non-MSM, reported anonymous sex.

Conclusions: The current outbreak in NYC involves mainly men who have sex with men, many of whom are co-infected with HIV.

Implications for Programs/Policy: The high proportion of co-infection of syphilis with HIV is of particular importance since syphilis increases the risk of transmitting and acquiring HIV.

Implications for research: The increase in P&S syphilis among MSM might be signaling changes in sexual practices and attitudes which needs to be addressed by further prevention research.

Learning Objectives: By the end of this session, participants will be able to describe the epidemiology of a recent syphilis outbreak among MSM in New York City.

Contact Information: Gabriela Paz Bailey / 404-639-1817 / ; Andrea Meyers / 212-788-4420 /


A New Approach to Program Evaluation: Statewide Review of Early-Latent Syphilis for Diagnostic Criteria

P Moncrief, S Shiver, D Cordova, K Schmitt, D George, L Roberts, J Fletcher, M Powelson, JL Dettis

Florida Department of Health, Bureau of STD Prevention and Control, FL

Background: The STD Program observed a trend of shifting morbidity from primary and secondary (P&S) to Early-Latent over the last few years. At the same time increasing DIS staff turnover has been noted.

Objectives: Determine if new staff members have been adhering to programmatic standards for diagnostic criteria. Establish baseline information on completeness of data entered into STD*MIS.

Methods: Year 2000 early syphilis case reports were assigned to Headquarters Bureau of STD staff for in-depth review. A desktop review was conducted through statewide area network in STD*MIS. Reviewers accessed from the system: morbidity, interview, field records, notes, signs/symptoms/history and clinic visit. If a case did not meet diagnostic criteria based on the information within the system, gaps were identified. Staff met to discuss findings, and morbidity was corrected. Reports were disseminated to area managers.

Results: We reviewed 1407 records. Thirty-eight percent failed to meet diagnostic criteria based on the information available within the STD*MIS system files. From area to area of the state the range went from 1.56% to 81.3%. The final segment is ongoing and will compare the rates of failure to rates of staff turnover.

Conclusions: The review identified a clear need to develop staff capacity to correctly report and enter data, to document completely within all files of the system and to develop knowledge regarding the diagnostic criteria among less experienced DIS and Front Line Supervisors.

Implications for Programs: The review established baseline failure rates from which to set a new programmatic process objective goal for year 2002.

Implications for Research: The process provided management staff the opportunity to experience first hand the value of systematic examination of surveillance and morbidity data. Future research and programmatic evaluation should monitor DIS competencies. Strategies for staff development should be explored.

Learning Objectives: Participants will be able to describe a methodology for statewide review of record using current technology. Participants will be able to identify the benefits and limitation of the desk audit methodology applied to conduct programmatic evaluation.

Contact Information: Karla Schmitt / Phone 850-245-4326 /


"Take It to the Streets": Syphilis Screening in Non-Traditional Venues

J Scott1, M Eisenberg1, A Muriera2, E Spender-Smith2, L Carnicom2

1NC HIV/STD Prevention and Care Branch, Raleigh, NC; 2Wake County Human Services, Raleigh, NC

Background: In 1999 and 2000, North Carolina conducted the Rapid Ethnographic Community Assessment Process (RECAP) in six high morbidity area (HMA) counties. One common sentiment voiced by community members was the desire to "take it (testing and counseling) to the streets." Collaboration between the North Carolina Syphilis Elimination Project (NCSEP) and the Non-Traditional Counseling, Testing and Referral Site Program (NTS) has resulted in an increase in syphilis screening outside of traditional settings. Of all persons testing for HIV at NTS sites in 2000, 81% also tested for syphilis with a prevalence rate of 1.9. Screening in non-traditional settings is a productive means of identifying prevalence of syphilis and an opportunity for collection of risk behavior data.

Objective: To identify opportunities and means for syphilis screening and risk behavior data collection outside of traditional settings.

Methods: The following venues are used for taking syphilis screening to the streets: 1) NTS mobile and fixed site testing through contracts with community-based organizations and health departments; 2) county-based Intensive Community Education Efforts (ICEEs); and 3) state-sponsored Rapid Intervention Outreach Teams (RIOTs). The collection of risk behavior data through syphilis prevalence monitoring and its' implication for guiding and garnering support for new intervention programs will be discussed.

Contact Information: NCSEP: Jan Scott / 919-715-3688 / NTS: Marti Eisenberg Nicolaysen / 919-733-9547 /


Silently Stressing Syphilis-Community Partnership of SEP Poster Dissemination in Cleveland, OH

T Chrestoff1, G Nowels1, H Scaife2

1Ohio Department of Health; 2Cuyahoga County Department of Health

Background: Syphilis morbidity rates in Cuyahoga County had been ranked among the highest in Ohio, yet these rates have consistently dropped since 1996. This caused not only a decrease in routine syphilis screening within the medical community, but also a possible gap in educational outreach interventions. Results of a survey distributed throughout the community indicated that at-risk populations are not currently receiving education regarding syphilis and STDs in general.

Objectives: To develop and disseminate an effective and innovative tool to increase both community and individual awareness of syphilis and current potential for its elimination.

Methods: A poster was developed using the theme, "It's Bad. It's Silent. It's Syphilis. Get Tested. Get Treated. Get Well." The poster includes the addresses and numbers of two CBOs involved with SEP activities in Cuyahoga County that provide testing and treatment for syphilis. Data analysis identified key providers for poster distribution.

Results: A total of 300 posters were developed and distributed throughout Cuyahoga County. Establishments who agreed to display the posters were: drug/alcohol rehab centers (100); city jails (50); adult entertainment center and bookstores (50); planned parenthood and women's health clinics (50); STD clinics (35); and college universities (15).

Conclusions: Unanimous acceptance of this poster and expressed interest from the medical community necessitated the development of a second poster. This poster focuses on long-term complications of syphilis and is currently being distributed.

Implications for Program Policy: This can be both a cost-effective means to mass educate populations who were previously viewed as difficult to reach and a way to stimulate awareness and screening increases within the medical community.

Implications for Research: Research through surveys, referral tracking, or comparison of case rates can be used to determine the effectiveness of this approach.


Potential Impact of the National Plan to Eliminate Syphilis on HIV Incidence Rates Among African-Americans

HW Chesson1, SD Pinkerton2, R Voigt1, GW Counts1

1Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA; 2Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI

Background: African-Americans are disproportionately affected by syphilis and HIV/AIDS. Because syphilis can facilitate the transmission of HIV (through increased infectiousness of HIV-infected persons and/or increased susceptibility of HIV-uninfected persons), an effective syphilis elimination program in the United States could decrease HIV incidence.

Objective: To estimate the number and cost of new, syphilis-attributable HIV cases in African-Americans in 1999.

Methods: We used a simplified model of HIV transmission. Based on the number of reported syphilis cases and estimates of HIV and syphilis co-infection rates, we estimated the number of partnerships consisting of HIV-discordant African-Americans in which at least one partner had infectious syphilis. Using estimates of the probability of HIV transmission in such partnerships, we estimated how many new cases of HIV resulted from these partnerships as compared with how many new HIV cases would have been expected had syphilis not been present. We calculated the cost of these syphilis-attributable cases using published estimates of the discounted lifetime direct medical treatment cost per case of HIV ($195,000 in 1996 dollars).

Results: In 1999, an estimated 896 new cases of HIV in African-Americans could be attributed to the facilitative effects of syphilis. These 896 cases (602 women, 294 men) represent approximately 3 to 8 percent of all new cases of HIV in African-Americans in 1999.

Conclusions: A successful syphilis elimination program could reduce HIV incidence and the disproportionate burden of HIV/AIDS on the African-American community. This reduction in HIV incidence could save $175 million in future HIV costs, suggesting that a national syphilis elimination program likely would pay for itself.

Implications for Programs: Syphilis prevention can be a cost-effective tool for HIV prevention.

Implications for Research: More complex transmission models could be used to estimate the long-term effects of syphilis prevention on HIV incidence.

Learning Objectives: Participants will learn the basic components and methodology of this simplified transmission model, and will be able to evaluate the potential effect of syphilis elimination on HIV incidence for a wide range of populations.

Contact Information: Harrell Chesson / Phone no. 404-639-8182 /


Development and Implementation of a Syphilis Outbreak Response Plan: Houston Department of Health and Human Services and Community Partners

M Thomas

Houston Department of Health and Human Services, Bureau of STD/HIV, Houston, TX

Background: Syphilis rates in the U.S. (and in Houston) decreased each year from 1990 to 1999. While rates are low we must work towards syphilis elimination. In 1998, the CDC required local health departments to develop an outbreak response plan to investigate causes of syphilis outbreaks and to define roles and responsibilities of Houston Health Department staff and community partners.

Objective: To create a rapid response plan for syphilis outbreaks that enhances the detection of syphilis outbreaks and defines the roles of community organizations and health department staff.

Methods: A health department syphilis response work group was formed to develop an outbreak response plan for the city of Houston. An advisory committee was developed with representatives of community organizations to enhance coordinated outreach and action throughout the city during an outbreak.

Results: A rapid response plan was developed that details action to be taken by community partners and Health Department staff during a syphilis outbreak. Specific outbreak thresholds were created to facilitate the determination of when an outbreak occurs.

Conclusion: Development of a syphilis rapid response plan ensures a formalized action-plan for outbreak situations and facilitates response by delineating responsibilities.

Implications for Program/Policy: Rapid response plans are a useful tool for organizing priorities, strategies, and job responsibilities during an outbreak.

Implications for Research: Additional analysis of outbreak response plan development and implementation would aid future outbreak response efforts.

Contact Information: Mike Thomas / Phone 713-794-9272 / /


Obstacles Encountered in Syphilis Elimination Program Implementation

M Rollins, M Krempasky, K Dorian, B Radcliff, D Coleman

Columbus Health Department, Columbus, OH

Background: Franklin County is one of the 28 counties in the US accounting for 50% of total syphilis morbidity. CDC funding for syphilis education and surveillance is available for these high morbidity areas (HMA). It is mandated that 25% of total funds received be allocated to support organizations that represent/serve populations affected by syphilis.

Objectives: To increase community awareness of syphilis through education of the public and hospital ER staff, and to perform serologic surveillance to monitor the prevalence of syphilis.

Methods: Visits were made to infectious disease officers in local hospitals to assess/encourage syphilis screening of patients seen in ERs with symptoms of any STD. The Health Department offered to provide free specimen collection supplies, diagnostic tests, treatment, and medical/contact follow-up, as needed. Also, in targeted, high prevalence areas, community organizations were recruited to be partners with the Health Department in the provision of syphilis education, screening, and medical services to their constituents.

Results: All local hospitals were contacted or visited, but none have significantly increased their performance of syphilis serologies. Six community groups received Syphilis Elimination Program (SEP) subgrants, but they have been slow to fully understand their internal and external responsibilities.

Conclusions: While hospitals have voiced an interest in doing more to combat syphilis, legal, staffing, and billing concerns have been obstacles to increasing serologic surveillance in ERs. Also, community organizations may be hampered in implementing anti-syphilis programs by their lack of administrative structure and expertise in following grant requirements.

Implications for Program/Policy: In order to control syphilis, it is imperative that local health departments establish solid partnerships with many entities, including hospital ERs and community organizations representing/serving high-risk populations.

Implications for Research: How to better educate/motivate ER staff concerning the identification of patients that may be at increased risk for syphilis in an HMA. How to increase the grant management skills of community organizations.

Learning Objectives: Participants will better understand potential obstacles to partnering with community providers in the delivery of syphilis elimination services.


Year 2001 STD Training in the Pacific Island Jurisdictions of Ebeye, Chuuk and Yap: Lessons Learned

S Adler1, H Calvet1, M Little1, S Schnare2, G Bolan3

1California STD/HIV Prevention Training Center, Berkeley CA; 2 Department of Family and Child Health, University of Washington, School of Nursing, Seattle WA; 3California Department of Health Services, STD Control Branch, Berkeley CA

Background: The Pacific Island Jurisdictions face tremendous barriers to effective health care and have unique training needs. The California STD/HIV Prevention Training Center's (PTC) 1999 Pacific Training Project's evaluation identified needs for site-specific, skills-based clinical training. Ebeye (Republic of the Marshall Islands) and Chuuk and Yap (Federated States of Micronesia) were targeted because of infrequent training opportunities or no prior on-site STD training. Support for the training was obtained from the Department of Health and Human Services' Office of Pacific Health.

Objective: To provide an overview of a programmatic needs and skills-based, site-specific STD training intervention for clinicians in the Pacific Island Jurisdictions.

Methods: An October 2000 needs assessment revealed information on program resources, available medications, diagnostics, and perceived training needs. Findings were used to develop a skills-based training intervention adapting the World Health Organization's (WHO) Syndromic Approach to STD Management and existing CA PTC curriculum. Each site's training was determined after on-site meetings with local staff and included: sexual history taking, confidentiality, male and female genital exam skills, diagnosis and management, laboratory practicums, STD/HIV interactions, partner management and case studies. Faculty time observing and assisting in clinic, and meetings with laboratory staff supplemented the training.

Results: Over 100 participants attended the three-day trainings conducted by PTC faculty in February 2001. Interactive role play practicums, question and answer sessions, and on-site observations revealed challenges to STD management including: cultural barriers constraining male providers from examining females, geographic remoteness affecting supplies, limited transportation impacting partner management, chronic understaffing, and infrastructure barriers.

Conclusions: On-site training in the Pacific Island Jurisdictions allowed for site-specific, flexible training based on an assessment of training needs and available resources. While STD training is integral to providing STD services, clinic observations and discussion with participants reveal larger infrastructure barriers to implementing lessons learned in training.

Implications for Programs/Policy: These site-specific, flexible trainings can be used as a model for future trainings in remote or resource poor areas.

Implications for Research: Evaluation of the effectiveness of site-specific trainings in underserved areas needs further study.

Contact Information: Sharon Adler /


To Train or Not To Train-That is the Question!

SL Harper, RB Heath, BJ Nolt, MJ Mitchell, M Scharbo-Dehaan

Centers for Disease Control and Prevention, Atlanta, GA

Background: Since the implementation of the Syphilis Elimination Plan and the completion of a number of STD program assessments, many requests for training have been received by state and local health departments, as well as the STD/HIV Prevention Training Centers (PTC) and the Training and Health Communications Branch (THCB) of the Division of STD Prevention (DSTD) at the Centers for Disease Control and Prevention (CDC). In the past, any type of employee performance problem was usually considered a training issue. However, training is not always the answer, nor is it the only answer, to employee performance issues. This is also true regarding training to address staff needs when implementing programmatic changes. It is important to know when training is appropriate and what specific training is needed.

Purpose: To assist STD program management in identifying true training needs.

Methods: We shall describe the purpose of training and when it is appropriate to address staff performance issues. We shall also describe other types of appropriate responses to performance concerns. An instrument to ask pertinent questions for identification and classification of the performance problem will be introduced. Participants will use this instrument as a tool during several case studies presented during the session. Training programs currently offered by PTCs and THCB will be reviewed, and their objectives stated. Objectives NOT covered by training will also be discussed. Participants in the workshop will have an opportunity to share lessons learned and will have the chance to ask questions of the workshop leaders.

Measurable Learning Objectives:

At the end of this workshop, participants will be able to: 1. Describe a training need as opposed to some other employee need.

2. Describe tools that can help the program manager ascertain whether the problem can be solved through training.

Contact Information: Stacy Harper / Phone no. 404.639.8536 /


Launching Leadership: The ATPM/CDC STD Prevention Fellowship Program

RB Heath, M Scharbo-DeHaan, D Anderson

Centers for Disease Control and Prevention, Atlanta, GA

Background: In an effort to address the STD prevention needs of the future public health workforce, the ATPM/CDC STD Fellowship Program was established in 1993. The program was designed to provide leadership training in public health and STD prevention practice and policy to: 1) preventive medicine or primary care residents; 2) early career professionals in the fields of public health and preventive medicine; and 3) graduate students and early career professionals from other academic disciplines with skills that are important to the field of public health. Twenty-two university-based, postdoctoral positions have been funded and include four- to six-month rotations at both the CDC in Atlanta and at a state or city health department. These fellowships provide for university-based STD research, public health department affiliation, and study of STD policy at a federal level through rotations at CDC.

Objective: To evaluate how well this ongoing fellowship program is achieving its goal to forge a strong link between STD academic research and health department environments.

Methods: Through interviews with former STD fellows and reviews of CVs, information was obtained on the fellows' activities during and after their fellowships including publications, education/training activities, grants awarded, and academic/public health affiliations.

Results: Seventy-seven percent of fellowship alumni were affiliated with universities or federal agencies and worked directly with STD prevention projects at state/local health departments. Alumni contributed to STD prevention with more than 14 book chapters, more than 64 grants, and more than 182 publications. Information was available for 13 fellows.

Conclusions: As measured by publications, grants awarded, and STD prevention activities, the fellowship program has been a successful means for developing leadership in STD prevention activities.

Implications for Programs: The ATPM/CDC STD fellowship program will continue to recruit future leaders in public health and STD prevention.

Implications for Research: The fellowship program will require constant evaluation to ensure continued success.


National Network of STD/HIV Prevention Training Centers (NNPTC) Training Activities and Student Characteristics, May 2000-April 2001

K Koski, M Scharbo-DeHaan, F Barnes, B Heath

Division of STD Prevention, National Center for HIV, STD and TB Prevention, CDC, Atlanta, GA

Background and Rationale: CDC funds the National Network of STD/HIV Prevention Training Centers (NNPTC), which consists of 18 Prevention Training Centers (PTCs) located across the United States. Ten sites provide clinical training (Part 1), four provide behavioral training (Part 2), and four provide partner services training (Part 3).

Objectives: To describe training activities conducted by the NNPTC during the first year of the current five-year grant cycle and to identify selected characteristics of the student population.

Methods: We reviewed the NNPTC Student Registration Database and PTC quarterly narratives to obtain student and course data.

Results: Part 1 (Clinical) PTCs provided 207 courses attended by 4,885 students. The students' most frequently reported occupation was registered nurse (32.3%). Students most frequently reported that they spend less than 25% of their principal occupation on STD (32.4%). The most frequently attended course was "STD Update for Clinicians" (1,639 students). Part 2 (Behavioral) PTCs sponsored 74 courses attended by 1,150 students. The students' most frequently reported occupation was health educator (21.5%). The majority (49.7%) spent 100% of their principal occupation devoted to STD. The most frequently attended course was "Bridging Theory and Practice" (346 students). Part 3 (Partner Services) PTCs provided 59 courses attended by 816 students. The students' most frequently reported occupation was disease intervention specialist (37.5%). The majority (56.0%) spent 100% of their principal occupation devoted to STD. The most frequently attended course was "Introduction to STD Intervention (ISTDI)" (227 students).

Conclusion: The NNPTC is making a vital contribution to STD/HIV prevention by providing training to targeted groups of health care providers, behavioral scientists, and prevention specialists.

Implications for Programs/Policy: Specialized training is available through the NNPTC for those providing varied STD/HIV services.

Implications for Research: Research is needed to determine whether PTCs are effectively meeting local and regional STD/HIV training needs.


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