2020 STD Prevention Conference
September 14-24, 2020 – 2020 STD Prevention Conference: Roundtable Discussion for Journalists
The biennial STD Prevention Conference will be held virtually from Sept. 14-24, 2020, under the theme, “2020 Vision: Disrupting Epidemics and Dismantling Disparities.” As part of the roundtable, STD prevention experts presented research and innovation in STD control and prevention amid COVID-19. These experts included:
- Gail Bolan, M.D., Director
Centers for Disease Control and Prevention, Division of STD Prevention
- Hillard Weinstock, M.D., M.P.H, Chief of Surveillance and Data
Centers for Disease Control and Prevention, Division of STD Prevention
- David Harvey, M.S.W., Executive Director
National Coalition of STD Directors
- Hilary Reno, M.D., PhD, Associate Professor; Medical Consultant
Washington University School of Medicine; Centers for Disease Control and Prevention, Division of STD Prevention
For your stories about the STD Prevention Conference, please find below a full transcript and audio recording of the roundtable discussion.
2020 STD Prevention Conference Roundtable for Journalists
September 14, 2020
Operator: Please stand by. Good afternoon and welcome to the 2020 STD Prevention Conference Media Round Table discussion. We’re glad you could join us. We want to remind you that today’s call is being recorded, and after the presentations, we will open the lines for a question and answer session. Now I’d like to turn it over to the opening speaker, Dr. Gail Bolan, from CDC’s Division of STD Prevention. Dr. Bolan?
Gail Bolan: Thank you and good afternoon, everyone. And welcome to the COVID-19 and STD Prevention Conference Round Table. I’d like to thank you all for joining us today to hear how the COVID-19 pandemic has transformed the state of STD prevention in the United States, both the challenges and the opportunities.
Before I introduce today’s round tables speakers, I’d like to take a moment to acknowledge that, as you’re experiencing right now, this year’s STD Prevention Conference is unlike any other. COVID-19 has upended so many aspects of our lives, and this conference is no exception with our move to a virtual format.
This year’s conference theme is “2020 Vision: Disrupting Epidemics and Dismantling Disparities.” These words feel more urgent and more relevant than ever before. The pandemic has exacerbated numerous disparities in health and in health care. Today, STD prevention colleagues from across the country have gathered to chart the way forward to discuss how we adapt to a rapidly changing public health and health care landscape and find new, better ways of working during the pandemic and beyond.
I want to thank them and you for participating today and for helping us take stock of where we are, what this moment means for STD prevention and public health, and how best to move forward together. For today’s round table, I’m joined by three experts and partners who will share research and innovations in STD control and prevention amid COVID-19.
Dr. Hillard Weinstock, from CDC’s Division of STD Prevention will discuss substantial declines in national STD reporting and testing during COVID-19. Dr. Hilary Reno, from Washington University in St. Louis and the St. Louis County Sexual Health Clinic, and who is a medical consultant with CDC, will discuss on-the-ground work and infrastructure needs of state and local health departments delivering STD prevention services.
And David Harvey, from the National Coalition of STD Directors, which helped organized this conference, will discuss survey data on the impact of COVID-19 on STD programs and efforts to increase STD testing and treatment services.
I think it’s important to note that today’s conversation will look beyond COVID-19 to address how current trends and efforts are shaping STD prevention now and will continue for years and decades to come. Even before COVID-19, the U.S. was already battling steep, sustained increases in STD cases.
Combined cases of syphilis, gonorrhea and chlamydia have been at record highs in the U.S. for the past five years, and CDC’s preliminary 2019 surveillance data shows us that this trend is expected to continue.
Many factors may have contributed to overall STD increases before COVID-19 including social, cultural, and economic circumstances such as poverty, unstable housing, drug use, stigma, lack of medical insurance, or steady medical care; discrimination or mistrust of health systems; decreased condom use among vulnerable groups including young people and gay men; and cuts to STD prevention programs and services at the state and local level.
COVID-19 compounded several of these factors, and it shows signs of exacerbating pre-existing racial and ethnic disparities in health care. Later in this call, my colleagues will present new data on how COVID-19 has impacted testing, treatment, reporting, and STD services around the country. Despite our challenges, I believe it is possible to mitigate the current STD increases, even in the midst of a pandemic. It will require new commitments and continued innovation on the ground.
Today, I would like to highlight three innovative strategies that can increase cost – access to cost-effective quality STD prevention and treatment that will enable us to reach more people in need of critical STD prevention services both during COVID-19 and beyond. The strategies are utilizing and strengthening STD express visits, partnerships with pharmacies and retail health clinics, and expanding telemedicine services to provide STD testing and prevention services outside the clinic setting.
I’d like to unpack specifics related to each of these strategies. Let me begin with the STD express visits. Simply put, these clinical visits offer a way to dramatically ramp up testing in the U.S. at a time when infections may otherwise go undetected and untreated. STD express visits allow for a walk-in STD assessment and testing and treatment without an appointment or a full clinical exam.
Express visits can double the number of patients a clinic can see in a day. Many clinics serving patients vulnerable to STDs, especially STD clinics, were operating at capacity that was – at high capacity even before COVID. Clearly, there’s strong demand for timely STD clinic services. Most of the people we can test for STDs, the more we can connect those infected to treatment and stop the spread. Utilizing and strengthening the network of STD express visits and the important services they provide is a critical way to move the field of STD prevention forward.
Next, I want to highlight the importance of continuing to form partnerships with pharmacies and retail clinics. Pharmacies and retail clinics can provide new access points for STD services such as onsite testing and treatment. For example, if someone comes in to pick up a prescription or other pharmacy service, they could also be able to receive STD testing. If the STD test comes back positive, then the pharmacy could also dispense treatment for them, and in some areas, for their partners.
Pharmacies and retail health clinics are ubiquitous across the United States and could become important safety net providers. Retail health clinics offer flexibility and convenience for appointments. Their costs are lower than emergency department visits, and they provide evidence-based quality care under rigorous physician oversight. These health providers are often trusted community members. They could provide timely and accessible STD testing and treatment locations for millions of Americans. They also offer the potential to increase access to a variety of sexual health services including STD/HIV testing, PrEP, and contraception.
The last strategy I want to highlight is telemedicine. Telemedicine can close gaps in STD testing and treatment, facilitate support for self-testing, and ensure access to health care providers for those needing treatment, HIV prevention services, and other health care and social service needs. This strategy can help to ensure that we test the right people and reduce STD disparities.
As COVID-19 hit the United States, more Americans than ever embraced telemedicine in lieu of physically visiting a health care provider. And, for STDs, telemedicine allows patients to still receive timely care even as clinics are closed or services are reduced. Patients who had no STD concerns were given a number to call and were connected to a nurse to help them with the next steps.
Those who had symptoms were then referred to a clinic for testing and treatment. Those without symptoms were mailed self-collection testing kits that they could later return by mail to a laboratory for processing the test result, or patients could be referred to a nearby lab for self-collection testing and blood collections.
For Americans who live in rural areas without easy access to an STD clinic, telemedicine has been a way to deliver crucial STD care even before COVID-19 was in some areas.
If we want to ensure that all communities across the United States have long-term, reliable access to STD prevention and treatment services, we need to expand our telehealth and telemedicine including self-collection testing outside the clinical setting.
By expanding these three strategies I’ve just laid out, not only can we reduce STDs but we can also address the challenges of health care access that existed before and have been magnified by COVID-19. But let me be clear, these strategies cannot succeed without strong public health infrastructure.
For our part, CDC provides ongoing support for core STD prevention infrastructure including things like funding state and local health; STD prevention and surveillance programs as well as STD/HIV clinical training centers and disease intervention training centers to support health care providers seeing populations vulnerable to STDs; supporting public health disease intervention specialists at the community level; providing crucial disease intervention resources to guide health department responses to rapidly changing health threats such as STDs, HIV, TB and other emerging infectious diseases like COVID.
Prior to COVID, over half of health departments experienced budget cuts leading to reduced screening, treatment, prevention, and partner services. Later in this call, my colleagues will share more on what’s needed to improve the public health infrastructure across the country.
As I mentioned at the beginning of our talk today, STD increases are not a new issue. Even before COVID-19, the United States was already battling steep, sustained increases in syphilis, gonorrhea, and chlamydia, but STD increases are not an unsolvable or inevitable issue.
It’s time to ramp up the use of STD express visits, partnerships with pharmacy and retail health clinics, and telehealth, telemedicine, and self-collection testing programs in order to address new barriers to STD care presented by COVID as well as stamp out rising STD infections in the future.
Thanks again for joining us virtually at the 2020 STD Prevention Conference. It’s encouraging to have so many people dedicated to fighting STDs even in these uncertain times. It’s also encouraging that so many people are thinking about lessons we can learn now to help us confront the STD epidemic now and after we get through COVID.
Now, I’d like to introduce you to my colleague here at CDC Division of STD Prevention, Dr. Hillard Weinstock, who will share new data on STD testing and reporting during COVID. Hillard?
Hillard Weinstock: All right. Thanks, Gail. I’m Hillard Weinstock, the Chief of the Surveillance and Data Management Branch for CDC’s Division of STD Prevention. Today, I’ll share new data that demonstrates the striking impact that COVID-19 has had on our ability to diagnose and track STDs in the U.S. But before I do that, here’s some baseline information about the STDs in the U.S. before COVID-19.
As Gail mentioned, combined STD cases have been at record highs in the U.S. for the past five years. Based on CDC’s new preliminary data from 2019, which are still not final, Chlamydia increased to about 1.76 million reported cases. Gonorrhea increased to about 602,000 total reported cases. Syphilis increased to nearly 123,000 cases with syphilis in newborns which can have severe, sometimes fatal consequences up more than 20% from the prior year.
Then COVID-19 hit. Starting in mid-March of this year, more Americans began living under some form of stay-at-home order. This culminated in the three-week period from early April to early May when most of the U.S. population was under stay-at-home instructions. Preliminary CDC data show a clear drop in reported STD cases in the spring and early summer of 2020 compared to the same period in 2019.
At the beginning of the year, reported STD cases were above 2019 levels, but that changed in early March as more public health measures were put in place across the country. By early April, most Americans were under stay-at-home orders. We saw that, compared to the same period in 2019, weekly reported chlamydia cases were 53% below 2019 levels. Weekly reported gonorrhea cases were 33% below 2019 levels, and weekly reported primary and secondary syphilis cases were 33% below the equivalent period to 2019.
As stay-at-home orders decreased in early June, we saw corresponding increases being reported in STD cases. Reported cases of syphilis referred to and exceeded 2019 levels by mid-June. Similarly, reported cases of gonorrhea returned to 2019 levels in mid-June. However, cases of chlamydia, as of late June, have not yet returned to their 2019 levels.
It’s difficult to pinpoint exactly why STD cases decreased during COVID-19, but I will highlight the major factors at play. With the closures and renewed health services, everything’s accessed to in-person STD testing services.
My CDC colleagues recently analyzed data from a large commercial lab finding that around the week of the U.S. National Emergency Declaration of Public Health, chlamydia tests dramatically decreased and then gradually returned to near 2019 levels by the first week of July since these intervention staff, who provide STD and HIV partner services, have been diverted to work related to COVID-19 and STD case reporting capacity at local labs and health departments have been strained by the COVID, by COVID-19 reporting priorities causing delays in reporting STD cases.
But please keep in mind two limitations to our data. First, CDC’s 2019 surveillance data are not – are still not complete. Thus, the decrease in reporting in 2020 compared to 2019 may be an underestimate of what would have occurred had COVID-19 pandemic not occurred. Second, COVID-19’s impact on STD surveillance is evolving as the epidemic and the related response to it changes.
Interestingly, as the trends I’ve descried today were largely consistent across sex, age group, and diagnosing facility type. We saw only slight variations across race and ethnicity. There were major variations between geographic regions, however.
Overall, the northeastern U.S. reported a bigger drop in reported STDs compared to other parts of the country. By early April, in the Northeast, reported cases of chlamydia and gonorrhea were at 70% below 2019 levels, and reported cases of primary and secondary syphilis were about 50% of the equivalent period. These trends coincided with public health measures taken in this region during this period.
But as of late June, the Northeast continued to have lower case-reporting rates. At that point, reported cases of chlamydia, gonorrhea, and primary and secondary syphilis were still far below 2019 levels even as other regions either reached or exceeded 2019 levels.
I’d like to close by saying that, while some of these trends were anticipated, the recent syphilis and gonorrhea increases are concerning. They may reflect a backlog of cases from previous months or they may also, to guess, at the increase that we observed prior to the COVID-19 pandemic may still be with us.
Gail Bolan: Thank you so much, Hillard. Next, I would like to introduce Dr. Hilary Reno from Washington University in St. Louis. Hilary has been working with the Sexual Health Clinic in St. Louis. She will share more about how telehealth and express clinics supported their approach on the ground. Hilary?
Hilary Reno: Thank you, Gail. Hi, I’m Hilary Reno, Associate Professor of Infectious Disease at Washington University and a medical consultant with the Division of STD Prevention.
Today, I’ll share some new data that demonstrates the impact of COVID-19 on STD health services and testing in the St. Louis metro region and the ways that we responded here on the ground.
Let me start by giving you a little background about the St. Louis metro region. Our region includes the City of St. Louis, St. Louis county and surrounding counties in Missouri and Illinois. The region has a population of 2.8 million people and is in the top 15 regions in the United States for per capita rates of gonorrhea and chlamydia.
Because we have a regional coalition of STD and HIV clinicians, we know that we have 128 sites that offer HIV and STI testing. These sites include health department clinics, community-based organizations, federally qualified health centers, school-based clinics, as well as our main health care systems.
Before COVID-19, one of our main health care systems, BJC HealthCare, that includes 15 hospitals and over 100 clinics throughout the metro region, on average tested 1,000 people for gonorrhea and chlamydia each week.
To describe the impact of COVID-19 on gonorrhea and chlamydia testing volume, we followed STI testing volume at BJC HealthCare from January 2020 to July 2020. We noted that testing began to decline in the St. Louis region after the first positive COVID-19 case here at the beginning of March.
On March 24, St. Louis issued stay-at-home orders for St. Louis city and county that limited movement to a central travel, kept schools closed, and closed many other businesses. That’s when we saw the most dramatic drop in testing for gonorrhea and chlamydia with testing decreasing 45%.
Testing decreases equally impacted all age groups, races, and genders. After the order was lifted, testing volumes started to increase again and since mid-August, we have returned to pre-COVID testing volumes.
We saw a similar pattern for HIV tests in that same health care system with a decrease of 43% in HIV testing during the same period. In total, over the course of the 10-week period where we have stay-at-home orders, there were approximately 4,400 missed tests for gonorrhea and chlamydia and 5,000 missed tests – HIV tests in just this one main health care system in the St. Louis metro region.
Now that I’ve gone over the impact of COVID-19 on testing for gonorrhea, chlamydia, and HIV, I would like to discuss the pandemic’s impact on sexual health clinics in the St. Louis region. As I mentioned previously, St. Louis region has 128 STI/HIV clinics and testing sites.
At the height of the stay-at-home orders in the region, 28% of those testing sites had closed completely, 63% had modified their services meaning they had decreased hours, decreased days of operation. They may have moved from walk-in clinics to appointments only, and they had other changes. Only 8% had no change in services at all.
There was also an impact on the 89 condom distribution sites across St. Louis. These sites are administered by the City of St. Louis Department of Health. And many of them are bars, clubs and other businesses that were closed and, still now, are even limiting access.
During the height of the stay-at-home orders, 43% of these prevention access points had closed. Our research shows that are patients had limited choices about where and how they could be tested and where and how they received condoms to protect against STDs.
Some of these limitations continues – continue, and it means we have to do things differently if we want to reach everyone in our region who needs a test, so we have integrated creative solutions during March and April that we continue to use.
First, we scaled up the St. Louis County Sexual Health Clinic’s use of express STI services. All patients without symptoms could still have testing while we were able to reduce the time they spent in clinic and allow for the physical distancing that is needed.
We’ve also used telehealth more than ever to prescribe PrEP to those who need it. Before COVID, our clinic partnered with a pharmacy for testing of our patients on PrEP. With the stay-at-home orders, our partner pharmacy had to reduce services, but we were able to assume the testing that kept our program going.
We also started using telehealth for the initial physician visit. This saved the patient extra trip to clinic to meet with the physician. Telehealth really streamlines this process, and we will continue to use it.
As Dr. Weinstock reported, we know that cases of STIs are decreased in St. Louis, and our research shows that decreased testing volume could be one explanation. By scaling up our strategies, we were able to keep our clinic open and offer screening and diagnosis of STIs.
We also shared our experience and helped other testing sites think through how they could use express visits to offer testing when they had cut back on services. These are strategies St. Louis will continue to utilize through the pandemic and beyond to test and treat those in need because they’ve been successful and well received. Thank you.
Gail Bolan: Thank you, Hilary, for sharing the important work you’re doing in St. Louis. Finally, I’d like to introduce David Harvey, the executive director of the National Coalition of STD Directors. Today, David’s going to share information from a two-part survey NCSD recently published, highlighting what local health departments are experiencing amid COVID-19. David?
David Harvey: Good afternoon. Thank you, Gail, and welcome to members of the media for joining us today. My name’s David Harvey, and I’m executive director of the National Coalition of STD Directors, which is the national public health membership organization representing health department STD directors, their teams and community-based partners across all 50 states, 7 large cities, and 8 U.S. territories.
As part of our efforts to support our members in their response to COVID-19, we surveyed our membership twice, so far, during the pandemic to determine the impact that it has had, broadly speaking, on the STD field across the United States. And similar to the other presenters today, I will be walking through some national trends in this data which largely confirms much of the information you’ve already heard.
It is clear that COVID-19 has led to ongoing mass scale disruptions to STD clinical and prevention services in the U.S. in the form of reduced services, clinical capacity, and STD outbreak response. And, in turn, this has driven innovations in our field. It is largely due to a primarily a result of staff redeployment from within health departments to assist in COVID-19 response as well as clinic closures or reduced hours and capacity based at stay-at-home orders and other restrictions.
A little background on the process that we followed. In mid-March, very early in the pandemic, we distributed the survey to STD programs across the country at the city and the U.S. territorial level. That survey also went to 1,100 disease intervention specialists, otherwise referred to a DIS or some will call them contact tracing, although that is only one component of the work that they do.
And we refer – we sent the survey to what we call our clinic-plus network of over 500 STD and sexual health clinics throughout the country. Part of a three-month follow up on June 1st, NCSD then distributed what we called Phase 2 of this survey. This was designed to gauge the ongoing impact of COVID-19 on our nation’s STD programs to see what, if anything, had changed since March. And we will be surveying the field again soon so that we’re tracking this information on an ongoing basis.
We found that the impact on those three key parts of the STD response that we measured – services, clinic capacity and outbreak control efforts was severe in March and continued unabated through June and beyond. Here are some of the most striking findings that show just how severe the impact has been.
In our March survey, 83% of STD public health programs reported deferring STD services or field visits, 66% of clinics reported a decrease in screening and testing, 62% of STD programs reported that they could not maintain their existing STD caseloads.
In the June survey, respondents reported that 78% of STD Health Department – of the STD Health Department workforce has or had been redeployed to COVID-19 response efforts. And specifically, of these, 20% of STD directors reported that their program operations were completely disrupted and that they were unable to do core STD prevention functions, 76% reported significant disruptions to their operations.
Only 2% of programs nationwide reported that they were not involved in any way in the states’ COVID-19 contact tracing efforts, which is a very significant statistic, meaning most programs within our field were contributing in some way to contact tracing efforts, which speaks to the expertise around contact tracing in our field that has been contributed more broadly to COVID-19 response.
And only 32% of DIS reported having the capability to perform field visits remotely, or virtually; 98% of STD programs reported rely on phone calls and text messaging to reach clients. So, this speaks to no in-person work happening for DIS nationwide, which continues to be – we continue to see that disruption.
Taken together, these findings lead to a very real concern about our ability as a nation to effectively respond to STD outbreaks in the wake of COVID-19. They also raise concerns about the effects of a decreased and burnt-out workforce, which the media has been covering. This is why it is more important than ever to support DIS and our national STD response infrastructure with additional resources.
We need the federal government to, through Congress, to allocate, at a bare minimum, $1.6 billion for STD prevention programs in this country. A pandemic on the scale of COVID-19 also requires an army of public health workers to conduct contact tracing. However, as STD DIS are redeployed to COVID-19 contact tracing, they are unable to adequately respond to current STD caseloads and future STD outbreaks. So, this is of great concern to our field nationally
Due to years of underfunding, STD program staff are struggling to keep up. With demand of these two concurrent epidemics with STDs at their highest level ever, a limited workforce and the inability to respond to STD cases, now is the time to invest in DIS and contact tracing capacity on a long term basis to increase the number of DIS at state and local health departments to support the COVID-19 response and to invest in our ability to confront rising STD rates throughout the country.
So, in summary, we call upon Congress to allocate these additional funds and NCSD has joined in efforts with other national public health organizations to call for over $8 billion in additional funding for contact tracing, specifically within state and local public health departments. As we all know, Congress is delayed in its consideration of the most recent COVID relief legislation, but we are hopeful that some form of relief will be passed later this fall in the context of ongoing budget work. Thank you very much.
Gail Bolan: Thank you so much, David, for sharing this information with our sense of the work that you do at NCSD. And again, I would like to thank NCSD for their help in organizing this conference.
I want to thank all of you on the phone for joining us today as we work to increase testing and prevention for STDs during these unprecedented times and as we share information that can help us get through COVID-19 and come out stronger on the other side. Disrupting epidemics and dismantling disparities is exactly what we need to do at this moment, it’s time to innovate and expand as to the express visits, partnerships with pharmacies and retail health clinics and telehealth and telemedicine services and self-testing programs.
Innovation always – often comes during times of difficulty. But although we continue to see worrying trends in STD transmission, I’m encouraged by some of the ideas and creative solutions we’ve shared today.
Again, thank you for joining us. And I hope you enjoy the rest of the 2020 as STD Prevention Conference. If you’d like more detail on the data we’ve shared today, please email CDC’s NCHHSTP media team. With that, I’d like to open up the lines for questions.
Operator: Thank you. The phone lines are now open. To ask a question, please, signal by pressing “star,” “1” on your telephone keypad. If you’re using a speakerphone, please make sure your mute function is turned off to allow your signal to reach our equipment.
A voice prompt on your phone line will indicate where your line is open. Please state your name and media outlet before posing your question. Again, press “star,” “1” to ask a question. And we’ll pause for just a moment to allow everyone an opportunity to signal for questions.
Gail Bolan: I actually did want to start with a question for Hilary. And, Hilary, I’m curious if you could share any ideas you have about the work that you’ve been doing on the ground that has been so successful you think you might be able to continue beyond COVID-19?
Hilary Reno: Yes. So, definitely our telehealth use for PrEP initiation visits has been very successful. Before, like I sort of mentioned in my comments, patients often had to return to clinic because our partnership with the pharmacy that helps us with this program requires a face-to-face with an MD.
My nurse practitioners who run the clinic do an amazing job, but that face-to-face with an MD still meant that patients had to come back to clinic sometimes when an MD – when it was a day when the MD wasn’t there. So through telehealth, my nurse practitioners can just call me and I can have that visit with the patient while they’re there in clinic, saving them a visit, making them very happy that they’re getting everything done at one time and they can have their PrEP medication usually within 24 hours from that visit to our clinic.
That is something we will absolutely be continuing, largely because it’s convenient for us and super convenient for the patient.
Gail Bolan: Excellent. So, we have Hilary Brueck from The Business Insider. Please state your name and affiliation and ask your question.
Hilary Brueck: Yes, hi, thanks for taking my question. I actually had a pretty similar one to the one you just asked. I was hoping that you could just talk a little bit more on any new strategies that you’ve had to deploy during the COVID pandemic that you think you might be able to use going forward or whether or not there’s been any challenges with those that you want to like sort of finesse before you begin using them.
Hilary Reno: This is Hillary again. I can also talk about the express visits we’ve used. We’ve used express visits in our clinic since probably 2012. But it was really with the pandemic, with the requirement of keeping patients spaced out in clinic that expresses it, since they’re so much faster because we don’t have a clinician component.
Patients come in, get their test results, get some prevention messaging, exit materials, and then leave the clinic. That allows us to bring more patients into clinic, but still keep them spaced out as well. So, we’re using express visits at a higher volume now. We’ve talked to other clinics in the area that are doing the same thing. They had initially – we talked to a couple of clinics that initially shut down entirely.
But when they realized that express clinics allow patients to come in and get out quickly but still get the testing done, they realized that was a strategy they could use to meet their need. And specifically, there was one adolescent clinic here that does a really high volume of STD Care and other sexual health care for adolescents, which is a high-risk group and really need the access to sexual health care.
So, they had shut down, but then they realized they could do express visits and they were able to reopen at least most days of the week to express visits. So – and that happened even before the stay-at-home orders ended, so really key to that clinic.
Hilary Brueck: Great. And if I could just follow up on that, do you have any sort of numbers of like how many business they were having a day before the pandemic and then how many visits with the express visits, just to kind of see the contrast?
Hilary Reno: I don’t have their numbers. I know with our clinic we had at the sexual health clinic, which sees people from, you know, 13 years up – we had, before the pandemic, we were seen probably 25 to 30 people a day. Initially, our patient volume dropped dramatically, and we were seeing, at times, single digits a day. And then as we got into the stay-at-home orders, revved-up express visits, we were able to increase.
We’re not back to pre-COVID times. I think patients are still having trouble. Either they’re needing to go to work or they’re still they’ve got their kids at home and it’s harder to get out and get testing, but we’re at least back to two-thirds of that volume.
And what I would say is that, before, our express visits were probably 5% or less of our visits. Now they’re more like more like 30 or 40% of our visits. So, we still have room to see more patients and express visits are going to be able to allow us to open up those visits even more.
Gail Bolan: And this is Gail. I can add, from CDC, that we’ve been very interested in express visits for a number of years before COVID. And we actually were able to support some demonstration projects at seven sites. So, we’re in the process of analyzing those data to see sort of pre and post what happened with these express visits.
And the other additions that we’re doing as well is we’re also looking at cost. I think that people who work in clinics, we’ve heard, feel this is a very cost-effective strategy. But, obviously, we at CDC need to have the data and the evidence before we can come up with our recommendations.
Operator: And as a reminder, press “star,” “1” if you have a question. We’ll pause for a moment.
Gail Bolan: And I was going to ask Hillard the question, if his team has been thinking about any alternative ways of reporting STD cases that can shed more light on transmission trends or adverse outcomes during COVID given our challenges with delayed reporting or no reporting from states that are very busy with COVID work.
Hillard Weinstock: Yes, I think we have that, and it is a challenge. I think it will be important to look at adverse outcomes of STIs, not just cases reported. Just because cases aren’t reported or diagnosed doesn’t need a force that they aren’t occurring. And this could very well be manifested in sequelae that occur later after effect.
For example, I think we want to look closely at congenital syphilis in 2020, which is a good indicator of syphilis in women of reproductive age. I didn’t discuss 2020 congenital syphilis numbers because reported congenital syphilis cases are generally delayed every year. But it will be important to examine later in this year and I think early next, whether congenial syphilis is still increasing, as it was pre-COVID.
I also think it’s important that we look at other sequelae of STIs that are not reportable to CDC but can be examined through other sources of data like pelvic inflammatory disease which can result from untreated chlamydia or gonorrhea and also neurosyphilis and ocular syphilis which can, of course, be complications of syphilis.
So, those are a few of the approaches and other conditions that I think we need to look at as we see decreases in co-reported cases to CDC.
Gail Bolan: Okay. I believe our next caller is Alice Ollstein at POLITICO.
Alice Ollstein: Yes. Thank you. I wanted to ask – I saw CDC put out guidance earlier this month on testing supply shortages for STDs. And I wondered if folks are concerned about that, restricting testing going forward, even as things normalize more in terms of a pandemic.
Gail Bolan: Well, we actually had to put out two clinical guidances when we were learning and were hearing from our colleagues in the field that either clinical services were just closing because they didn’t have the PPE and they had to divert clinicians to COVID work or that they had reduced hours and were only providing essential services, which, in the field of STDs, is basically managing people with symptoms or people who have been a known contact to a known infected person.
So, we were very concerned about basic reduction in general testing and treatment. But then we also heard initially in the COVID response that we were having trouble with shortages of drugs like azithromycin and that some people were using for COVID treatment. So, we had to put out clinical recommendations on what drugs to use to manage STDs in the time of COVID.
I’m not aware that we’ve been having drug shortages more recently. But a more recent problem, as you mentioned, is that we’re now hearing, and it’s spotty around the country. We’re trying to understand why some places are having a significant reduction in the chlamydia, gonorrhea and nucleic acid amplification tests, which are the tests that we use to screen for chlamydia and gonorrhea in young women and in gay, bisexual and other men who have sex with men.
And it seems to be multifactorial, the problems. It can be a swab issue of supplies that go with the kits or it could actually be resources in the labs that are converting staff over to COVID testing. So, again, we had to put out a prioritization list because we always want to get the right people tested based on the U.S. Preventive Services Task Force recommendations.
And occasionally, we do know in the health care setting, some people come in for concerns about STDs and they think one of the ways of managing their concerns is getting all the tests that are available to test all STDs. But the recommendations really recommend that the tests be focused on young people, at young women, less than age 25 and then gay men.
And we focused on the most important sites of infection where infection is the most common, and that’s in the rectum and the throat. So, we have not found that much infection when we do a urine sample in gay men, so we prioritize those to other sites for testing. We’re hoping that we’re not going to have to have further prioritization of tests. But again, these are tests that we are recommending for people that have no symptoms and don’t know they’re infected.
We do have a very good old test for diagnosing gonorrhea in symptomatic men. It’s called the gram stain. So, we do know that labs can run gram stains and so we are recommending providers save their NAT testing for asymptomatic patients and to use gram stain testing in men with symptoms of gonorrhea or symptoms of urethritis. And that test can sort out whether that etiology is gonorrhea or whether it’s other causes of infection of urethra.
And then we’re also recommending if people have other sort of symptoms associated with STIs like genital l ulcers or other discharge presentations that they – they’re going to empirically treat their patients any way on that day. We don’t like people with symptoms to be leaving a clinic without treatment.
But we also generally recommend testing because it gives us more information. It also helps with follow up in and with partner services. But if we are short, we’re prioritizing that those patients mainly receive in-care treatment and again, save the other tests for the asymptomatic priority populations.
Operator: And as a reminder, press “star,” “1”, if you have a question.
Operator: There are no media questions at this time.
Gail Bolan: Great. Okay. Well, again, I know we’re all challenged by this unprecedented epidemic of COVID. But we wanted to share with you the findings today of the impact it’s also having on – a fairly significant impact on our sort of sustained and steady increases of sexually transmitted diseases that we’ve been seeing in this country.
Certainly, it’s important to recognize that, while many of these infections are asymptomatic, we do know that there are severe adverse outcomes, especially in young women, in terms of pelvic inflammatory disease and PID – PID as well as infertility. And then we also know that STDs facilitate HIV transmission.
So, we are working hard to mitigate are STD increases at the time of COVID. But I will say the silver lining is, I think, we’re looking at some of these innovations as new, cost-effective ways to provide as STD care instead of having just to go into your provider all the time to have an exam to be identified with these infections.
So, we think there’s some great opportunities we’re learning that I expect will be continuing after COVID. But, certainly, we know that we’ve been challenged by this COVID pandemic.
So, again, thank you so much for your attention today and enjoy the rest of the conference.
Operator: CDC will post a recording and transcript of today’s event within 48 hours of the online NCHHSTP newsroom. Thank you for participating in the 2020 STD Prevention Conference at Media Roundtable. We appreciate your interest and questions. If you’d like more detail on data share today, please email NCHHSTPmediateam@CDC.gov. This concludes today’s call.
Bio and Headshot: Gail Bolan, M.D., Director, CDC’s Division of STD Prevention