Syphilis in Maryland: Populations at Risk

Syphilis in Maryland: Populations at Risk


[MUSIC PLAYING] MOLLY MITCHELL: Good
afternoon and welcome. My name is Molly Mitchell. I am the coordinator of the
Mid-Atlantic Public Health Training Center. And on behalf of
the training center and the Department of Health and
Mental Hygiene and the Region 3 STD-HIV Prevention
Training Center, I’d like to welcome you
all to today’s presentation on syphilis in Maryland,
populations at risk. Before we get started
with today’s presentation, for those who are watching
online, I ask that each of you please take a second and sign
into today’s presentation. That way, we’ll
have a better count of how many people
are actually watching for our federal funders. We also ask that if
you have any questions at any point during the
webcast, please just click on the link to email a
question to the presenter. And that email
will come through. I’d also like to just take
a second for those online to please take a look
at our other trainings that are coming up from the
training center, which include next month’s grand round
presentation on water safety on May 18, using social
marketing to influence decision makers, working
with interpreters, and cultural competency,
training the trainer. And with that, I’d like to go
ahead and turn the floor over to Barbara Conrad. Barbara Conrad is the
chief of the Center for Sexually
Transmitted Infection Prevention at the Maryland
Department of Health and Mental Hygiene Infectious
Disease and Environmental Health Administration. Thank you. BARBARA CONRAD: Good afternoon. I’m Barbara Conrad,
and we really welcome this opportunity
to help get the word out about syphilis,
which continues to be a very significant concern
for us here in Maryland and we know in many other
parts of the country. Today, we’ll be hearing
from Dr. Rompalo. She is a professor of medicine
at the Johns Hopkins University School of Medicine Division
of Infectious Diseases and in the Department of
Obstetrics and Gynecology. She holds a joint appointment
at the JHU Bloomberg School of Public Health in
the Division of Epidemiology and the Division of
Population, Family, and Reproductive Health. She is a noted provider in the
field of infectious disease and is an internationally
recognized expert in the field of sexually
transmitted infections, STIs. For 20 years, Dr. Rompalo
has been the medical director of the Region 3 STD-HIV
Prevention Training Center and has recently been designated
co-director of the National Training Center for Family
Planning Services for Men. Additionally, she serves
as medical consultant to the state health department’s
Center for Sexually Transmitted Infection Prevention,
co-sponsor of today’s webcast. Dr. Rompalo has
authored more than 150 peer-reviewed articles,
several chapters, is an editor and expert
reviewer for several journals, and serves on multiple national
and international advisory conference and
scientific committees. Welcome, Dr. Rompalo. ANNE ROMPALO: And welcome
everyone here and on the web. So let’s begin. Maybe we will, and
maybe we won’t. Go down. So before we start,
I’m going to talk about continuing education. The CDC is giving us
continuing education credits. I have no financial conflicts. A lot of wording here,
but basically we’re not going to talk about anything
that is unruly or illegal. And if you get
through this, you’ll get 1.0 AMA PRA
category 1 credits. And non-physicians will
also get a certificate of participation, more
information if you want it. And here is the continuing
education credit, available from the CDC. You’ll see this again. Specifically, I’ll show
this slide at the end. But this will
instruct you on how to get these valuable credits
at the end of this lecture. So let’s start. Hopefully, at the
end of this lecture, all of you here
and on the net will be able to define
populations at risk within your specific regions
and recognize the common signs and symptoms. And this is going to be
primarily of early syphilis. Choose and correctly interpret
diagnostic tests for syphilis, and describe the appropriate
steps for syphilis reporting and partner notification. So with a public
health spin, this is actually public health
and control in action, taking it from bedside to
bench and back to bedside and to the public health. So who’s at risk? And if you’re interested in more
information, go to cdc.gov/std, specifically syphilis. And you’ll get, well, a
lot of information on this. And I’m going to highlight
some of this information here. These are the most
recent data of primary and secondary syphilis. And remember, primary
and secondary syphilis are the stages of syphilis
which are infectious. And that’s why we spend
so much time on this. And these are the rates by
sex and male-to-female ratios in the United States. And what you can see
here are two things– that males are predominate
in the number of cases that are being
recently diagnosed, and that syphilis
is not going away. Where is it? These are rates by region. What we see here is the
South accounts for over 50% of the new cases are
primary and secondary infectious cases of syphilis. During 2008 to 2009, the
rates actually in the South increased by 10%. And it’s increased in
every single region, except in the West,
where there was a slow but significant decline. Looking at the rates
by state, this slide illustrates that there are
13 states with the highest rate of primary and
secondary syphilis. And this accounts for 75% of
all the cases of P&S syphilis. 10 of these states
are in the South. If you wanted to zoom
down into counties, the good news here is that over
2,000 counties in the United States, of the over 3,000
counties that we have, have no syphilis cases. But there are other counties
that are heavy with syphilis, and we have to pay attention. If any of you are
listening from these 29 counties and 2 cities– and the two cities will
remain, you know who you are– pay attention to
syphilis in your area. Who’s getting this? Well, in 2009, the rate of
primary and secondary syphilis, as shown here by
sex, was the highest among persons who were
ages 20 to 24 and 25 to 29. And you can see there’s
a discrepancy here. There’s much more males
than females being diagnosed, as I talked about. But the peak for males,
you can see, is here. I think I can show you
this, yeah, 20 to 29. But look. The rest of the ages here
are also significant. In females, we have two
areas that are high. And that’s among
the 15 to 19 year olds with a peak in
the 20 to 24 year olds. So both young men
and young women are becoming infected
with this disease. There is discrepancy
by race and ethnicity, as you can see on this slide. African Americans
accounted for half of all the primary and secondary
syphilis cases in 2009. And the rate of primary and
secondary syphilis among blacks is nine times higher than
whites and four times higher than among Hispanics. Looking at cases by sex and
sexual behavior as well as race and ethnicity,
you see on this slide that among young black
men ages 15 to 24, there continues
to be an increase. And the increase is
significant, so significant that this is becoming a
very concerning trend. Between 2005, which is not
shown here, but between 2005 and 2009, P&S syphilis
rates among young black men in that young age group,
15 to 24, increased. Actually, it tripled. And this trend is
disproportionately high among HIV-infected,
young African-American men. Remember, HIV and
syphilis go hand in hand. They potentiate each other. It’s good news if you
have syphilis and HIV for the syphilis
and for the HIV, but it’s bad news for the
individual and for society. The next slide shows
reporting by source. And although many of us feel
that syphilis is being reported and diagnosed in STD clinics
and it’s their problem, actually this slide
illustrates that among men most of the cases are being
reported from non-STD clinics. So everyone needs to be
aware of this infection. To round things off here are
the congenital syphilis rates. Overall, the rate of
congenital syphilis decreased in 2008 to 2009,
and that’s good news. However, it is still
there and among us. So we need to pay attention. Primary and secondary
syphilis and HIV, what I wanted to show here,
this is from the specific areas that follow HIV and syphilis. That is called the STD
Surveillance Network, and they report it to the CDC. And what I want to
show you here is that among the three leading
cities, Richmond, Baltimore, and Philadelphia– and these are in our region– we are the highest. The rates go from the lowest,
which I will tell you was in– let me be sure I say this right. The lowest rates
were in Birmingham, and the highest
rates, unfortunately, are here in Baltimore. So we need to be
aware, and we need to be vigilant on the diagnosis. So how can I share
these data with you? Where do we get these data? Well, we get these data because
it’s the law that we report it. Maryland law– and I think I can
speak for all of the states– require and regulate
the reporting of syphilis, gonorrhea,
and chlamydia by both the laboratories
and health care providers. This dual-reporting
system is intentional, not just one but both, because
clinical and demographic information that you– and if all you who
are listening are providers– that you provide,
the laboratory doesn’t have. And this enables the
Department of Health to better monitor
disease trends. Who’s getting it? Where are they getting it? What states need to be, as
you saw, worried about this? And even what county
and blocks need to be aware of what’s going on? So, please, if you’re
listening, complete all the demographic
information on the lab form. And I’ll show you
this toward the end. So the summary points for
this beginning section about the epidemiology
is that nationwide, the rate of infectious syphilis
increased about 4% among men during the 2008-’09 period, with
a male-to-female ratio of about 5.6. It was highest among
persons age 20 to 29. It increased in all
racial and ethnic groups, except non-Hispanic
whites and Hispanics. And most cases are reported from
sources other than STD clinics. So if we look at
special populations, as the CDC calls them–
and they are listed here– the tick marks show you who
among these special populations are at risk for syphilis,
and particularly men who have sex with men,
adolescents and young adults, racial and ethnic minorities. And I’m going to say,
we have to pay attention to women and infants
and people entering correctional facilities. So keep your eyes wide
open when it comes to screening for syphilis. So who’s at risk
here in our region? If you’re not from
our region, I’m going to say you should
find out who’s at risk in your particular region. If there’s anyone
here listening from– I don’t know– Hawaii,
California, Alaska, well, then that’s your task. Here is the Maryland national
rankings for sexually transmitted infections. I’m just going to talk
about the rankings. You can look at rates and
US rates comparatively. But for syphilis in
2008, we were 5th. Now we rank 12th. For congenital syphilis,
however, we were 3rd and now we rank 1st. For gonorrhea, 19th,
now we’re 16th. And for chlamydia, 15th,
and now we’re 17th. So there’s a shift here,
up and down, up and down. We’re not quite
out of the woods. And, you know, you can probably
superimpose your state here and find the same things. OK, all of you who are listening
from Maryland, pay attention. This is our state. And this is the incidence
rates by jurisdiction, and Baltimore City is a hotspot. But don’t get so
relaxed because there are other very, very warm
or bordering on hotspots throughout the region. So these are our most
recent 2009 data. And you will see this
again if you’re going to come to our meeting in May. We also have the primary
and secondary rates and congenital syphilis cases. Although the highest rates
again, just like nationally, are among men, with rates
relatively low among females, we are seeing this increase
in congenital syphilis rates. You know, it may
be because we’re doing a great job in
reporting the cases, and you have to pay
attention to that. But nonetheless, we all
should screen pregnant women– and I’ll talk about
that toward the end– and continue to do that. This is P&S syphilis
reported cases among males by mode of transmission
and race and ethnicity. And you can see on this slide
that for Maryland, our MSM have higher rates
than heterosexuals. But among African
Americans, they have the highest rate
among MSM in the state. So we have to look. We have to screen, and
we have to be aware. The other thing that we
also have to be aware of, as I alluded to, syphilis
and HIV go hand in hand. And these are the most
recent data on HIV diagnosis by exposure category. And although the
percentage of HIV diagnosis among heterosexuals has
stayed basically the same– and I will say, good news. It’s going down among
injection drug users. Bad news, it’s
going up among MSM. So let’s go down the Beltway. Let’s move down a
little bit, down 495, and see what’s happening
in DC because, you know, we’re Baltimore, Maryland. But DC is part of
us, too, as well as Philadelphia and anyone else
listening here in the region. Primary and secondary
syphilis rate by gender and number
of reported cases is high among males in DC,
although they peaked in 2007. They were really
high in 2009, too. So the ratio
currently is 15 to 1. We can see that in
race and ethnicity, the number of reported
cases are highest among African Americans. But I will say, the
one thing I have highlighted there is,
like, 11% other or unknown. And I’m going to say
again, it’s up to us to report the information
to our districts so that there’s not 11% of I
don’t know what people are. The lab won’t, but we
as clinicians will. So please fill out those forms. And here is a very
interesting slide that was shared with
us from Washington. The reported cases of primary
and secondary syphilis, people come in with
co-infection with HIV. So they have HIV and syphilis
when they walk in the door. There’s about 326. The percentage of these
co-infected individuals were– and this is men who have
sex with men, among men– were African American,
54% shown here. But look. 72% of these
co-infected individuals knew they were HIV infected
and got a new case of syphilis, again, driving home
the point that if you see HIV-infected
individuals in your clinic or in your patient
population, don’t assume that they’re not having sex. Or don’t assume that they’re
not having unsafe sex. Ask the question,
how’s your sex life? If they say, great, I met
a new partner, screen. And this is according
to CDC, IDSA, the US Preventive Task Force
Services recommendations to screen HIV-infected
individuals for STDs to hopefully decrease
HIV and STD transmission. The word is prevention. So who has infectious syphilis? Well, it’s up to
us as clinicians not to miss certain things. And I’m going to focus on
primary and secondary disease. Remember, syphilis is easy
to cure in its early stages. And the signs and symptoms
of early syphilis include– and I’m going to show
you what my kids used to call the yucky pictures. And I don’t want to put you off
your lunch, those of you who are eating, but here we go. It includes a firm, round,
small, and painless sore on the genitals, anus, or mouth. Anywhere you have
sex, this can happen. And even though I say the
classic textbook presentation, I will warn you,
syphilis doesn’t always read the textbook. Therefore, you can have
unusual presentations. Watch for a rash on
the body, especially on the palms of the hands
and the soles of the feet. But remember, you can
have a rash on the trunk and not have
palmar-plantar involvement. So any rash determines
consideration. Especially if I’m pregnant,
especially if I’m HIV Infected, you should think,
maybe I should do a serologic test for syphilis. And check the results. Now why am I focusing on
primary and secondary? Because primary, secondary,
and early latent, which is defined as within the
year of acquiring syphilis, are the infectious forms,
the very infectious forms of this disease. So for prevention and
control, in this lecture, I’m going to focus on
these and what not to miss. And here we are. These are brilliant
slides by Dr. Bingham, who works in, or has retired
recently, in England. And if you’re interested, it’s
a beautiful pocket picture guide to these. And this shows two
forms of chancre. Remember, chancres
begin as macules, which soon become papular and
then erode and form the ulcer. And sometimes it has a
brilliant, nice edge, and sometimes it’s very subtle. And this gentleman has– I’m going to show you here– he has a small ulcer on
the glands of the penis, right there. So, you know, it’s not always
beautiful, punched-out lesions. It can be subtle,
so think about it. This is a woman with
the classic kissing ulcers on the labia majora. And here, I’m going to show
you, which sometimes we miss and often don’t see,
primary chancre of the cervix. The patient has no means of
knowing when a chancre appeared on her cervix. She probably doesn’t
even know it’s there. But she is very contagious. Here are two oral chancres,
beautiful, punched-out lesion on the tongue. But here’s a lesion that’s in
the back of the throat that is very reminiscent of what I
just showed you on the cervix. Let me see if I can
get this mouse to work. OK, the mouse
doesn’t want to work. But you can see in
the back of the throat that there is a
granular type of lesion. This is a chancre. Why doesn’t it have the
classic, punched-out definition? Because the
architecture of the skin is different than
the squamous versus the transitional
columnar epithelial in the back of the throat. Secondary syphilitic rashes,
syphilis can look like anything as a rash. It can be macular. It can be papular. It can be pustular. It can be any of
these combinations. It can be generalized,
or it can be pinpoint. It can fool you,
looking like psoriasis. It can look like anything. Here’s a relatively mild rash. Here’s a rash on the chest,
which is both macular, papular, and some pustules. And here is are the classic
secondary palmar-plantar manifestations on the
palms and the soles. And you can look up closely. There’s almost, like, a
desquamation piece to this. These are condylomata, which
are heaped-up, warty-looking lesions. They are not warts. They are teeming
with spirochetes. They are highly infectious. And they occur
not where you have sex, but in warm, intertriginous
areas, in warm areas, so between the scrotum
and the penis here, scrotum and the thigh. This is two women around the
gluteal folds and labia majora minora. They look like warts. They’re not. Remember, warts are dead skin. These are secondary,
oozing lesions, which are teeming with spirochetes. Mucus patches finally on the
mouth, things to look for, flat patches, that can be
on any mucosal surface. You might find this in
the vagina, in the throat, down the esophagus. But mostly, it’s in the
mouth and in the tongue, even in the rectum. So how do you diagnosis
this, what not to miss? Well, the diagnosis of
syphilis is a challenge. Clinically, I’ve been
telling you what not to miss. But clinical diagnosis
is poor because there is a wide spectrum of illness. And as I was trying
to drive home, you have to have a high
index of suspicion. Lesion-based tests, which allow
visualization of the treponeme, are great, except you need
a dark-field microscope. And you need special
antigens to do this, which have been taken off the market. So what we do, many of us
are diagnosing syphilis in the latent stage, where
there’s no signs and symptoms. And we do a blood test. And that’s fine. But again, we’re trying
to drive the more primary-secondary diagnoses
to be aware of, to report, because these are most
contagious-infectious, and these are the people we want
to find, treat, and intervene with their partners. Well, then you might
be thinking, well, why not just do a culture of
all those nice, juicy lesions? Because we can’t culture
Treponema pallidum. OK, you might be
thinking, well, why not just go after it with
polymerase chain reactions? We have all these
really nifty, new tests. Well, they’re only used
in research settings. And it’s not
commercially available. So we are stuck– and I mean stuck– with serology, which happens
to be right now the cornerstone of diagnosis. There are two types of
serologic tests for syphilis. This is the classic algorithm
that I’m going to talk about. And then I’ll talk
about the new– I don’t know if it’s improved–
but the new algorithm that we will be using. And I’ll talk about
why it came about. So there are two types
of serologic tests. As we talk about since I’m in
the School of Public Health now, we have a screening
test and a confirmatory test. Screening tests are cheap,
fast, and efficient. Confirmatory tests, they
confirm the diagnosis. And this is what we use. Nonspecific, non-treponemal
antibody tests which are directed
against lipoidal antigens. These are antigens that are
released from a damaged host. It’s probably caused
by the Treponeme. So the Treponeme gets in,
gets into my blood vessels, wreaks havoc, causes
leakage, and these tests pick up that lipoidal
antigen that’s oozed from the destroyed tissue. This is both qualitative,
plus, minus, and quantitative. It gives you a titer. I’ll talk about
that in a second. If this is positive, what we
usually do, or used to do, is a more specific
antibody test that’s directed against Treponema
pallidum proteins, which is spelt incorrectly. And I apologize. This is a qualitative test. It should only be
positive or negative. So the CDC says we need
both types of tests– screening tests and
confirmatory tests– to make an accurate
diagnosis of syphilis. But herein lies the rub. The sensitivity and
specificity of these serologies vary by stage. And to make matters worse,
the presence of antibodies doesn’t distinguish past
from present infection. Ah, yes, so here is what we
have, the non-treponemal tests that are in your armamentarium
to make a diagnosis. They’re nonspecific, remember. We talked about that. They all have relatively
equivalent sensitivity, positive when you
have the disease, and specificity
negative when you don’t. And it takes about three to
four weeks after exposure. So if I have sex on Friday
night with Prince or Princess Charming, and they
have syphilis, and they inoculate me,
and I come in to see you, I won’t have enough time to make
an antibody-antigen reaction. So it will be negative. Or even when I have
a primary chancre, it could be negative because
my body hasn’t caught up with the fact that I’m
infected with syphilis. But the good news is that these
tests, when they’re positive, are reported in a
reciprocal titer. And I’ll show you
that in a second. And this titer
somewhat, not always, again, correlates
with disease activity. However, we do use titer
decline to document response to therapy. Why? Because we don’t have
cultures, because we don’t have any other way around this. So this is usually,
anybody who’s listening to this
in the clinics, you know this algorithm. What we’re trying to
do is cause the titer to decrease at least four-fold. Let’s see if I can
make this work. If I start out at
1 to 32, I would like to go down times 2, 1 to
16, times 2, 1 to 16, 1 to 8. This is a little bit off here. But I would like to go
down at least four-fold after therapy, within a
reasonable frame, which is usually six months to a year
after primary and secondary syphilis. And that means that
the therapy worked. My titer has fallen
more rapidly than it would had I not been treated. And that’s the whole gist of
this, following the titers. All right, what are the
treponemal antibody tests, the specific tests? These are either fluorescent
treponemal antibody, Treponema palladum particular
agglutination, or ELISA tests. These tests are very good. False positives are possible,
but they’re uncommon. They usually become positive
before a VDRL or RPR, but not always, not so
much that, you know, we always screen for these. And they remain
positive for life. So you can follow an FTA
titer, and you don’t get one. You get positive or negative. And even if you’re
appropriately treated, this test may stay
positive for life. And this is a diagram of
how these act over time, just quickly. As you can see, this is
sensitivity of the test. This is even without therapy. So it rises from
primary syphilis over to secondary
syphilis when you’re most active, have a lot of
manifestations of the disease. And if no treatment ensues– and let’s pretend you go to an
island someplace, “Survivor,” and have no medication and
no therapy and no nothing– it will decrease over time. Whereas the FTA or the MHATP
or whatever you’re using, Treponema Pallidum
Particular Agglutination, which is also called TPPA,
stays positive for life in most cases. OK, well, many of you,
as I talked about, might have HIV-infected
individuals in your patient population. How does that affect
diagnostic tests? Well, there’s
actually little impact of HIV infection on
these diagnostic tests. You will find case reports
of false-positive RPRs, for example, where the
patient is actually infected, and rare reports of delayed
or absent serul reactivity, where you have a secondary
case of syphilis. And everything’s negative. That happens, but
it’s not the rule. You know, higher means
higher mean serologic titers, meaning that we
have the impression that HIV-infected
individuals have higher titers of their RPR. And this can be the case. Yes, this happens. Again, it’s not the rule. But I will say that
HIV-infected individuals do have a slower drop in their
serologic titers, about 25%. A study done by
[? Roffs ?] in the 1990s showed that maybe 25%,
again, decreased slower than the textbooks
said they should have. So usually with primary
and secondary syphilis in HIV-infected individuals,
you want to follow them closely, every three months with
titers, because they are a very high-risk population. And we want to make
sure that they respond. OK, so Treponema pallidum
can’t be cultured. Serologic testing is the
method most often used to diagnose syphilis. Screening is recommended for–
now I’m talking screening, not testing, screening,
doing a test– persons at high risk. We want to detect
latent infection. OK, if I come in with a
chancre or a secondary rash, you want to diagnose me. That’s really not screening. That’s a diagnostic test. But if I come in, and let’s say
I have no signs or symptoms, and I’m highly sexually active,
or an injection drug user who is exchanging sex
for drug, or someone who is a commercial sex worker,
yeah, you want to screen them. You want to screen
pregnant women, whether they have signs
or symptoms or not– I’ll talk about
this in the end– to prevent congenital syphilis. And we always screen blood
donors to prevent transmission through transfusion. And thank God, that’s a
rare event these days, because we’re so
good at screening. But here’s the problem. Traditional testing to
do this RPR and this FTA takes one technologist. And they have to do one test. And this is time,
and this is labor. So this leads to the adoption
of a new reversed sequence screening in which
the sera that I send is tested by a
treponemal EIA or CIA. What does that mean? It’s an enzyme and/or
chemilluminescent immunoassay. So instead of one
tech, one test, you can run 100 sera on a
card through this machine and get an automated,
high-throughput means of testing. That, for the lab, is great. It’s fast. It’s efficient. It’s less costly,
less tech time. They can do something else. If that’s positive, then
you do the RPR or the VDRL or whatever your test is,
the non-treponemal test. All right, so why do we do this? This is the new screening. All patients have a screening. These are all ELISAs. EIA, CIA, another way to
call it is an ELISA test. And they’re all IGG,
meaning that they’re late antibody reactions. If the ELISA is
positive, then you do your non-treponemal
test, which is an RPR. And if you have to, if
there is discrepancy– and I know some of
you are thinking, oh, my God, well,
OK, you’re right. If I have an ELISA positive
and an RPR negative, there is discrepancy. Then I have to do another
specific test, an FTA or a TPPA. In some clinical
situations, an RPR or an FTA is also ordered just regularly. And these are in patients
with genital ulcers. And you just want to be
sure, so you send the order all together, or patients
needing follow up of a previously diagnosed case. Remember, I told you,
serology is not going to tell you if it’s old or new. Here are the advantages. I’m not going to spend time. We talked about this. They’re faster. They’re automated. It’s less expensive. And this is the algorithm. So here you go. I’m going to spend
a second on this because it’s worth mentioning. Let me get my
little mouse working for all of those that are
out in web land, if it works. You do an EIA or a CIA. Here you go. If it’s negative, stop, done. You’re finished. If it’s positive, then you
go on to do an RPR or a VDRL, if that’s what you have. If you have a positive
EIA and a positive RPR, OK, syphilis is there. The clinician has to decide. Is it current, or is
it a past infection? Now here’s where you
get into trouble. If the EIA is positive,
but that RPR is negative, then you’re supposed to do a
TPPA or another test, an FTA, whatever you have. If that’s positive, OK,
you have an EIA positive, an RPR negative,
a TPPA positive. Remember that slide I showed
you with the declining RPR titers over time? Well, you might be
in that situation. So you have to decide. Is it past? Is it current? Is it present. The clinician has to
look at the patient and figure out what’s going
on, talk to the patient. And if it’s negative,
syphilis is unlikely. And that disturbs many
people, that unlikely, because no one likes
to say, oh, well, you probably don’t
have syphilis. That’s not a good sentence. So anyway, the CDC said, OK. Let us look. And if you’re
interested in this MMWR article that came out
February 11 of this year– and I’m going to just
read the outcome, the data from five laboratories
throughout the United States that tested over
140,000 serum specimens with this reverse sequence
syphilis screening algorithm indicated that among
patients with a reactive EIA, 57% had let’s say non-treponemal
tests, nonreactive RPRs. And among these discordant
sera, anywhere from 12% to 60% were non-reactive with
another treponemal test. So it suggests that they
were false positive. And this was not a happy
place for anyone to be. Now this has been debated
many times on the webs and in the literature. But I’m just going to say
what the CDC is now saying. CDC continues to recommend
traditional screening, using a non-treponemal
test if it’s reactive, followed by a treponemal test. And you can read this. This will be up. You can read all the specifics. Here’s what we do in Maryland. We do an RPR. If it’s non-reactive, we stop. It’s qualitative, positive,
negative, on the serum, done. If it’s reactive, we
start to quantitate. If we start to quantitate
and it’s completely negative, we stop. If the quantitation,
however, the one to two, one to four, one to eight,
et cetera, is positive, then we go on then to an EIA. And that’s how we stand here. So your local health department,
and syphilis diagnosis is coming up, who’s
your best friend? Your local health department,
this came up wrong, backwards. But, hey, we’re talking
about reverse diagnosis, so this makes total sense. Really, if you’re in a quandary,
you don’t know what’s going on. You don’t know what
these tests mean. Find the number
and call them up. This is their job. They’re highly interested. I can tell you the State of
Maryland and Baltimore City is. I can’t imagine why DC
wouldn’t be, et cetera. So find that number and call up. It’s the law. This is the same thing
that I was talking about. So it’s not only– if you’re a clinician, you
say, oh, the lab reports, all that stuff, I don’t need to. Think again. Pay attention. You’re the one that’s
filling out the lab form. You have to have the
right information because if we have an
outbreak in a certain area or region of the state,
whatever state you’re in, the Health Department wants
to know where the person is. What’s the characteristics? How do we stop it? How do we find people
to stop the spread? This is what our State of
Maryland confidentiality morbidity report looks like. The web address is on the top. It may look laborious,
but actually if you read through
this it’s pretty simple. And this is the second part. We have HIV. We have sexually transmitted
disease, tuberculosis. It’s all there. So this is the
reportable diseases form. You can access it on the web. Please, do, and fill it out
to the best of your knowledge. It makes our job easier. What about preventing
congenital syphilis in Maryland? Well, this is the general health
and COMAR recommendations. All pregnant women shall
be screened serologically for syphilis a
minimum of two times during their prenatal visit–
at the first prenatal visit and the third trimester
at 28 weeks of gestation, or as soon as
possible thereafter. Now when you read the
CDC treatment guidelines, they say, no infant
should leave the hospital without that maternal
serologic status having been determined at
least once during pregnancy. And any woman who delivers a
stillborn infant after 20 weeks gestation should be
tested for syphilis. And the fetus should
be tested for syphilis using a confirmatory
test, if we have it. Serologic testing should
be performed at delivery in areas where the prevalence
of syphilis is high or for patients at risk. We are doing this here. We rank number 1. We are doing it
here in Baltimore. But I’m telling
you, pay attention to how much syphilis
is in your community. And don’t assume if
you haven’t looked. Ask questions of your patient. Congenital syphilis we should
not have, so be careful. All right, let’s talk
about prevention. Who should be screened? All pregnant women
should be tested at their first prenatal visit
for women in high-risk area groups. And I’m telling you,
you know who you are or where you live, the
clinicians that are listening. If you don’t, find out. Repeat serologic
testing may be necessary in the third trimester
and at delivery. Populations at increased risk
for syphilis as determined by incidence rates,
who are they? OK, men who have sex
with men who engage in high-risk sexual behavior. If I’m a man who has
sex with other men, MSN, and I come in to see you,
and I’m not having sex at all, OK. But if I come in to see you,
and you say, you know, Andrew– I’ll be Andrew. How’s your sex life? I say, it’s great. I just met somebody new. Screen me. And if you say, OK, where did
you meet him, on the internet? Screen me. OK, commercial sex
workers, persons who exchange sex for drugs,
and those in adult correctional facilities, usually
high risk takers, it’s an opportunity to screen. Hopefully, that will be easy. And these are the US
Preventive Services Task Force recommendations. You can look them up. These were July 2004. I haven’t found any more
up to date than these. But if you find some,
please, send them to me. And this is what the Prevention
and Partner Services– now that’s screening. But let me spend a second
on this, prevention. We talked about prevention. Screening is prevention. Treatment is prevention. Talking to partners
about sexual activity and treating them before they
become contagious if you can, this partner services, and that
is rudimentary to prevention. Well, what are partner services? What is this? Partner notification, it’s
a process through which infected persons are interviewed
to elicit information about their partners, who
can then be confidentially– and that’s the key– confidentially notified
of their possible exposure or potential risk. So let’s pretend that
I come to see you. And I have secondary syphilis. And you say, Anne,
how many partners have you had in the past six months? And I say, 10. And you say, well, can
you remember who they are or where they are? And I can give you
some information. Let’s say I specifically
know Joe and Pete and Sally and Luis. And you know where they are
or about where they are. You’re not going
to say, OK, Luis, Anne named you as syphilis. No, you’re going to hopefully
find these people and say, we have reason to believe
that you’ve come in contact with someone who has syphilis. And we would like you to come
in and get screened and get treated. Now usually, people
are very, you know, open and willing to
take care of themselves. And if you are the person
that’s delivering this message, and they start screaming
at you, who told you this, say, you know, this
is confidential. I don’t have any
names here, but we do know that you’re among those
people that need to come in. So there are ways to do this. We can do it. We as clinicians can do it. But I’ll talk about the disease
intervention specialists who are your best friend,
the Health Department, who will help you do this. We want to offer a range of
medical, prevention, and even psycho-social services. We do this for HIV, and
it makes total sense. Why? To promote positive
behavior change, reduce infectiousness, decrease
STD and HIV transmission, and reduce, hopefully,
STD and HIV incidence. This is why we do. This is why this is important. Well, beyond you and
me, who else does this? The disease
intervention specialist, your best friends, who sit
at the Health Department, waiting for your call. And I’m sure there
are some of you guys that are DIS listening. And you want to take out a knife
and stab me, but that’s OK. These people are trained
to interview persons with HIV and other STDs. They know how to do this– we
call this the index person– and to elicit information
about their partners and their associates
and to notify the partners of their
possible exposure, ensuring that the
partners are offered or know where to get
appropriate services, which includes examination,
treatment, and other referrals. So if I’m an injection drug
user and I’m a partner, hopefully you’ll go
to the right place where they’ll say, OK, Anne. We need to get you
screened for syphilis. We need to get you
treated for syphilis. And how about your
drug problems? Do you want to go someplace to
talk to somebody about this? You need to have all of this. This is healthy people. This is prevention. And also provide prevention
counseling to index patients’ partners’ social
contacts and associates. You know the social network? I didn’t have sex with
John, but John and I are really good friends. And we both had sex with Mary. That’s a social contact. So maybe they need
to come in, too, to hear some of these messages. And we are moving toward
social networking for disease intervention of many types. So remember, lab reporting does
not negate our responsibility as providers to report STIs
to the local state government because labs, they
provide what we give them. So they have
minimal information. So let’s say you send it off,
and the Health Department calls you. Please, don’t take
this as an offense. The Health Department is trying
to figure out what’s going on. Was the patient treated? Do I have to find them? And so please respond, to avoid
the Health Department ensuring that treatment is not delayed. The faster we learn about
primary and secondary syphilis, the faster we can intervene
and stop transmission. You might say, well, HIPAA
doesn’t allow me to do this. Yes, it does. HIPAA allows release of patient
information for public health purposes. This is a public
health intervention. Please, cooperate. I am finished. I hopefully finished early,
and we can take some questions. There are many
references that are peppered throughout the slides. But the main reference is the
CDC Prevention and Control. This is the national plan
to eliminate syphilis. But also go to the
cdc.gov/std website. And you can look for
syphilis specifically. And it’ll have a lot of handouts
and a lot of great information. And the new treatment
guidelines are there. So, please, do. Now we’re open to questions. Do you want to start here? We’ll start in the
audience first. Yes? AUDIENCE: About three
weeks ago, there was a patient treated at
the Hopkins ER for a rash. And it was treated
with prednisone. My question is,
what do you think are the possibilities of funding
and having stat labs in the ER? ANNE ROMPALO: The
question is, what is the possibility
of funding and having stat labs in the
emergency rooms, in the emergency department. AUDIENCE: Secondary syphilis. ANNE ROMPALO: Oh, yeah, so this
was based on the fact that one of our HIV-infected individuals
came in with a rash and– no? AUDIENCE: No. ANNE ROMPALO: No, no, just
walked in with a rash, and they were treated with
steroids because, you know. All right, again, one of the
reasons why I’m preaching here– and maybe many of
you are among the choir– but hopefully this will get
out to emergency departments and to places which are thinking
about many, many things. You know, when you’re in
the emergency department, you do see a lot of rashes. But what we want people to do is
think beyond the box right now, thinking rashes, syphilis. Ask some questions. Is it a man who
has sex with men? Is it a commercial sex worker? Is it an IV drug user? Or is it someone
who is connecting with high-risk populations? Maybe I’m not a man
who has sex with men. But maybe I’m someone who has
run across that social network where syphilis is. The easiest thing
to do, if you see a rash, which
dermatologists always do, send off an RPR or a VDRL or
whatever the screening test is. Would it be brilliant
to have that stat? I mean, STD clinics
have stat RPR tests. Yeah, it would. I don’t know if we’re going
to go there right now. I think what we’re
trying to do is come up with better point-of-care
tests that do not require special microscopes
or a long time, in other words, point of care,
which they have in Africa. Take a little stab of blood. Put it on the magic card. Add the elixir,
positive, negative, just like a urine
pregnancy test. And that’s what we’re
trying to evolve toward. Dr. Charlotte Gaydos
is here, looking for people who are interested
in doing this to contact her. Any good ideas,
please, let us know. Thank you for the question. Yes? AUDIENCE: The first
part of your talk, and I don’t know if you
addressed this population at risk that a lot of
us are concerned about, which is minority men
who have sex with men, particularly in Baltimore City. ANNE ROMPALO: Indeed, I did. I drove that home. So you’ll be very happy
when you see my slides. We have to pay attention. You know, minority men
who have sex with men also may be incredibly
hard-to-reach populations because of discrimination not
only within their community, but in the community as a whole. And we have to be aware of that. And actually, if there’s anyone
working with minority MSM, our health departments are very
interested in collaborating with you all to get a better
I’m going to say conversation going so that minority
MSM don’t feel as stigmatized to come in and
get treatment and be aware. So, yeah, good point, thank you. Yes? AUDIENCE: What is
your recommendation given the delay of conversion
from negative to positive on the RPR of a
person who presents with a chancre or
something, recent exposure, hasn’t been the 21 days? ANNE ROMPALO: So
the question is, for those of you on
the web, what do we do, what is my opinion, on someone
who may come in to see you– let’s pretend you’re in the
emergency department or the STD clinic or the HIV
clinic, wherever– with an ulcer or a
chancre, what looks like a chancre and,
you know, there’s not enough time for the RPR or
the VDRL to become positive, or for that matter
even the EIA, if you’re doing reverse testing? You know, what I was
taught in Seattle is treat and sort it out later. And I think that is
a great thing to do. Now, OK, it’s shots, 2.4
million units of bicillin. But it’s also doxycycline. If they say, I
don’t want a shot, don’t give me a shot, you can
still do doxycycline for two weeks, 100 milligrams
twice a day. Don’t use azithromycin. Africa can you azithromycin. We have too many cases that have
been reported with resistance to azithromycin by DNA probing. So, yeah, treat and
figure it out later. And you will have
sent the serology. But if you have somebody in
the emergency department, and they have an ulcer
or chancre or a zipper cut or a bite, and you’re
thinking, mm, treat. OK, thank you. Any other– yeah, we do. AUDIENCE: So I know the city
health department immediately reports to the state. And you showed the graph
with a large, large number of the cases being
non-STD clinics. So what would be the difference
in the reporting lab from, say, a private clinic compared
to an STD clinic? ANNE ROMPALO: That’s
a great question. And I’m actually going to
defer to Barb to answer that. But I tell you, it’s an issue. It’s an issue if you
don’t report quickly. I know the labs have
algorithms for reporting, correct, Barbara? And they try to
report as quickly as the tests come up positive. The lag is when there’s
not enough information that the laboratory can
report to the health departments about the case. So, for example, I did a review
for HERSA and sundry cities throughout the United States. And there was this one hospital. It’s not Johns Hopkins, so
you don’t stone me here. But I’m not going to
say which hospital. There was one
hospital that said, the lab sends directly
to the Health Department. And the question was, well, how
did the Health Department get back to you? Because although
they were saying, you know, Ms. Anne from
such and such place, the Health Department couldn’t
get back to the clinic. There was, like,
12 OB-GYN clinics within this institution. And they didn’t write
down enough information as to what clinic. Who’s the doctor? So therein is the lag. So me preaching to the
choir about, please, fill out the forms,
please, fill out the forms, because that cuts
down on the time. Because if we don’t
have enough information, somebody has to
be aware of that. They have to say,
OK, Ms. Terry, you’re the disease
intervention specialist who’s assigned to this case. She has to get her case. She has to find the person. She has to call on the phone. They have to return the call. Therein is the lag. And one other thing I will
say, if you have somebody in the hospital, in
the hospital, who has secondary syphilis, please
call your health department and tell them, you
know, Anne is here. She’s HIV infected, and
she has secondary syphilis. That really speeds it up
because you, the DIS officer, can come to the hospital
and interview me, Anne, who has this HIV-syphilis
co-infection. It really speeds things
up because if I leave, the DIS officer has to find me. And I may not want to be found. So that really helps. Yes, do we have any
questions from the web? You want to come here? Oh, no, we have
another question here. Yes? AUDIENCE: I’m sorry I missed
the first part of the talk. But I work with adolescents. From what I understand, it
doesn’t affect them as much as the other STIs. I just wanted to double check. My thought is MSMs who might
happen to be adolescent. ANNE ROMPALO: You know, right
now, we are seeing increases among adolescents,
meaning, like, the 15 to 19 to 20 to 24 year olds. These are the ones that are
increasing most aggressively, especially among,
you know, minority. And they may be MSM,
but also in the girls. I mean, and that’s disturbing,
so we have to be aware of that. You missed it because I had my
tick off list on who to target. And adolescent and young adults
are right in there with MSM. And we have to be aware. So, yeah, please, keep that
in mind because, you know, adolescents don’t think
they can get anything. Unfortunately, they do. Yes? No more in-house? Can we go to the web? Do we have any questions? BARBARA CONRAD: One comment. ANNE ROMPALO: We have one
comment, which we shall– “just want to say thank you for
the last comment about HIPAA. I’m in California.” Yay, California. “And here, providers
say they can’t release that info due to HIPAA.” No, this is on the CDC website. This is a public health concern. HIPAA does not apply. Are we good? Yes, another question
here in the audience. AUDIENCE: What brought about
the change from STD to STI? ANNE ROMPALO: The
question is what brought about the change from
sexually transmitted diseases to sexually
transmitted infections? I think it was around stigma. People don’t want to be
told they have a disease. Whereas if you have an
infection, it can be cured, and you can move on. So I think that was the whole
politically-correct move, and it’s not a bad one. I trip up on all of them
because I’m an old timer, and I was taught disease. So sometimes, I can’t
remember infections. OK, well, you know, I think
we’re right on time, 1:00. Hopefully everyone
in the hinterlands has had a good lunch. And thank you for listening. And thank you all for
being here today with me. All right, remember. It’s STD Awareness Month. Get yourself tested. BARBARA CONRAD: Thank
you, Anne, informative and stimulating as ever. I’d like to do a few
wrap-up comments here. And this is kind of like
the post-game summary of what did we just see. What did we just hear? And I will say,
Anne, every time you said your best friend, the local
health department, I smiled. I was like, yay, because
that’s very true. But also it’s a
relationship that I know that we work very hard
at the state and local level to work with private providers
to promote that relationship because that relationship is
what makes it so that we can intervene in a timely basis
with our public health actions to try to reduce transmission. But a few highlights
from Anne, most cases are reported from
non-STD clinics. So the private-sector
testing and screening are extremely important to us. And we really want to
encourage additional screening and testing in private sector. STD clinic, we know,
hey, you walk in. You’ve self-selected. We’re going to test you. But sexually active
youth and adults who go for other kinds
of health care services, it takes being proactive
by the health care provider to ask that challenging
question, how’s your sex life, and open the whole
conversation so that it can be determined
if there is a need to do screening. There are some
good tips on that, how to ask the question,
on the website www.gyt.org. And that’s to get yourself
it used to be just tested. But now it’s get
yourself tested. Get yourself talking. And the get yourself
talking part of that is for youth to
talk with their partners, or anybody to talk
with their partners, for people to talk with
their health care providers, and providers to talk
with their clients. So it’s just the whole
thing of, you know, can we talk about this and
make it something that’s easier to identify and to test for? Reporting, of course,
a very, very key part, and I definitely appreciated
the emphasis there on it’s OK under HIPAA. And I would suggest
that providers also tell their staff,
because I know that they are the front line between
the local health department and the provider’s office. That’s who our DIS call. That’s who they interact
with, is your staff. So you can tell your staff, hey. The local health
department will call, and it’s OK to talk with them. And here’s the information
it’s OK to provide them so that they can do
their public health work. And then a final area
of great interest and always lots of intrigue
is the test analysis and the recognition
that there might need to be multiple protocols
or sequences out there in recognition of things
like economic reality. But it can sometimes make
it harder for the provider. You know, you don’t
get to choose. You don’t get to tell
your private sector lab, oh, I want you to
run it this way. They’re going to do
what they gotta do. But if they’re using the
traditional sequence, great. If they have switched
to the new sequence, there might be some things
that you as a provider have to pay attention to. You might have to order the
confirmatory test specifically. Some labs aren’t doing
that automatically anymore. And you might need to
follow up with your lab to make sure that they’re
doing the confirmatory in a timely basis. So it just gets
interesting as we go through all these changes. So, again, I’d
like to thank Anne for her wonderful presentation
today and thank you for your participation. Please, be sure to fill
out those forms so that we know who’s been with us today. And if you want to mark
your calendars in advance, next year, Wednesday,
April 18, 2012, that will be our next
cooperative effort here with the
Mid-Atlantic Public Health Center and Region 3 PTC. Thank you. Click a slide, they’re saying. Arrow key, no, not
that one, there we go. OK, on to continuing
education credit. So there’s your information
for getting your continuing education credits. And there are several
slides about that. And that’s it. So thank you. Oh, that’s our friend,
the treponeme right here. Thank you. [APPLAUSE]

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