Syphilis Outbreak in Southwestern Idaho —
2002-2003
K Carter1,3,
J Bartschi1,
C Christiansen2,
J Tripp2,
P Harris2,
C Hahn1
1Idaho
Division of Health, Office of Epidemiology and Food Protection,
Boise, ID;
2Southwest
District Health Department, Caldwell, ID;
3Centers
for Disease Control and Prevention, EPO/DAPHT/State Branch,
Atlanta, GA
Background:
Syphilis can facilitate HIV infection and cause
stillbirth, blindness, and dementia. Recently in the United
States, syphilis outbreaks among men who have sex with men (MSM)
have been reported. We describe a syphilis outbreak in which
heterosexual men, pregnant women, and no MSMs were reported.
Methods:
Syphilis cases were defined by using CDC/CSTE case
definitions. Standard CDC interview forms were used with
case–patients and partners. Data were entered into STD*MIS and
analyzed in EpiInfo™ version 3.01.
Results:
The number of reported syphilis cases in Idaho
during 2002–2003 was 64 compared with 22 during 2000–2001.
Thirty-four (53%) of these 64 cases were early syphilis; 12 (19%)
were detected during incarceration. Characteristics of the 64
case–patients were male, 34 (53%); age (yrs) 14–83 (median:26.5);
ethnicity, 36 (54%) Hispanic, 21 (33%) non–Hispanic, 7 (11%)
unknown; known pregnant at diagnosis, 12 (40%) of 30 females;
residence in Southwest Health District, 29 (45.3%), including 21
early syphilis cases of which 17 (81%) were among Hispanics. The
most frequently reported risk factor was sex with the opposite sex
(25 (78%) of 32 responses from 24 case–patients). No sex partners
of the same sex were reported.
Conclusions:
An outbreak of syphilis predominately among
heterosexual Hispanics is ongoing in Idaho. We recommended
enhanced syphilis screening at prenatal care for young Hispanic
females in southwestern Idaho and for inmates upon intake at
correctional institutions. Follow-up of infants born to syphilis
reactors is tracked by the health department. Outreach to
Hispanics in southwestern Idaho to encourage prenatal care,
syphilis awareness and testing, and safer sex practices is
ongoing.
Implications for Programs, Policy, and Research:
Syphilis prevention programs should include
culturally and linguistically appropriate outreach to
heterosexual, Hispanic populations. Research is needed to develop
and evaluate such tools for outreach to affected communities.
Syphilis Among Men Who Have Sex With Men:
Limitations of Traditional Case and Partner Services, San Diego
County, CA
RA Gunn1,2,
A Maroufi2,
TA Peterman1
1Centers
for Disease Control and Prevention, Atlanta, GA;
2Health
and Human Services Agency, San Diego, CA
Background:
Traditional syphilis control focuses on the prompt
identification and treatment of infectious cases (primary and
secondary [P&S] stage) and preventive treatment of sex partners.
Anecdotal reports suggest this approach may not be very effective
among men who have sex with men (MSM).
Objective:
To determine the stage at diagnosis, the duration
of the infectious period, and the outcome of partner services for
MSM with P&S syphilis in San Diego County, 2002 – 2003.
Methods:
The infectious period was defined as the number of
days from onset of symptoms until treatment; for secondary stage
cases, 21 days were added to the period to account for estimated
primary stage infectious days.
Results:
During the 2 years, 147cases of P&S syphilis were
reported; 111 (76%) were MSM. Compared to heterosexual men, MSM
cases were 40% less likely to be diagnosed in the primary stage
(33% [37/111] vs. 53% [7/13], RR = 0.6, 95% CI = 0.4, 1.1, p =
0.25). Among MSM, those reporting receptive anal intercourse were
50% less likely to be diagnosed in the primary stage (26% [21/82]
vs. 55% [16/29], RR = 0.5, 95% CI = 0.3, 0.8, p < 0.01). The mean
infectious period for MSM was 36 days. MSM reported a total of
1190 sex partners (mean 11 per case) during the interview period
but provided contact locating information for only 199 (17%); 34
(31%) of MSM named no contacts. Results of partner services will
be reported.
Conclusion:
Among MSM, the long duration of infectiousness and
the low percentage of sex partners receiving partner services,
very likely limits the community level effectiveness of the
traditional approach.
Implications for Program and Research:
The effectiveness of other approaches, such as
symptom recognition (through education of MSM and clinical care
providers), frequent serologic screening, and behavioral
interventions should be evaluated.
Rapid Emergence of Gonococcal
Fluoroquinolone Resistance in Men Who Have Sex With Men in King
County, Washington
WLH Whittington1,
MR Golden1,2,
KK Winterscheid1,
SA Wang3,
KK Holmes1,
HH Handsfield1,2
1Department
of Medicine, University of Washington,
2Public
Health—Seattle & King County, Seattle, WA;
3Centers
for Disease Control and Prevention, Atlanta, GA
Background:
Fluoroquinolone resistance in Neisseria gonorrhoeae
is prevalent in many parts of the Pacific Rim. From 1995-2001,
fluoroquinolone resistant gonococci caused <1% of reported cases
of gonorrhea in King County. Sporadic cases (1.6% of 506 isolates
tested) were identified during 2002, but rates rose in 2003.
Objectives:
To describe prevalence and trends in gonococcal
fluoroquinolone resistance in 2003.
Methods:
Ciprofloxacin susceptibilities were determined by
disk diffusion and agar dilution susceptibility tests on gonococci
recovered by public and private clinical laboratories.
Ciprofloxacin resistance was defined by a minimum inhibitory
concentration (MIC) of >1 mg/ml.
Results:
Throughout January-April 2003, 0/110 gonococcal
isolates were ciprofloxacin resistant. During May-June, 4
infections in men (3 heterosexual) were caused by ciprofloxacin
resistant gonococci and routine susceptibility testing of all
isolates was implemented July 1. During July-September and
October-December, 3.8% (6/159) and 16.5% (22/133) of isolates were
ciprofloxacin resistant, respectively (P<0.05). All isolates with
disk diffusion zone diameters <21 mm yielded MICs >1 mg/ml. From
July through December, prevalence was similar among persons
attending the Public Health STD Clinic (12%) and other facilities
(10%). Three distinct phenotypes were identified and ciprofloxacin
MICs were 4-16 mg/ml for 86% of isolates from these 28 infections.
Decreased susceptibility to tetracycline and azithromycin was
observed in 80% of ciprofloxacin resistant isolates. Almost all
(27/28) infected persons were male. Among persons attending the
STD Clinic, resistance was more common among men who have sex with
men (MSM, 22%) than among heterosexual men and women (3%, OR 8.6,
95% CI 1.8-80.6).
Conclusions:
Fluoroquinolone resistance emerged rapidly among
persons with gonorrhea in Seattle during 2003; cases have been
predominately identified in MSM. Local gonorrhea treatment
recommendations were modified and fluoroquinolones are no longer
recommended.
Implications for Programs, Policy and/or Research:
Timely use of susceptibility tests permits
appropriate local tailoring of gonorrhea treatment
recommendations.
Partner Impairment of Safe Sex Behavior by
Women Participating in a Randomized, Controlled STD/HIV Prevention
Trial
A Holden1,
R Shain1,
J Piper1,
J Korte1,
S Perdue2,
J Champion3
1University
of Texas Health Science Center at San Antonio, OB Gyn;
2University
of Texas Health Science Center at San Antonio, Microbiology;
3University
of Texas Health Science Center at San Antonio, School of Nursing
Background:
A controlled, randomized trial of a
cognitive/behavioral intervention significantly reduced STD
reinfection for one year among 477 participating women by reducing
high-risk sexual behavior. Using detailed information about each
woman’s sexual partners, we identified 78 men (8.7%), referred to
as “players”, who had sex with more than one participant; 46 women
(9.6%) were involved. Significantly, women partnered to these men
experienced 34% of all infections during follow-up.
Objective:
To determine if and the extent to which sexual
contact with these men impacted the practice of safer sex.
Methods:
We
conducted chi-square and logistic regression analysis to assess
the relationship between having sex with these men and the failure
to practice safe sex. We also utilized chi-square analysis to
identify those elements of the safer sex variable (no condom use
with a casual partner, or problematic condom use in conjunction
with 5 or more unprotected acts in the past 3 months) that were
most affected.
Results:
Women
partnered to “players” were significantly more likely to practice
unsafe sex (OR = 2.3, C.I. 1.6 - 3.5, p < .02). Specifically, they
were more likely to never use condoms with him during sex (OR =
1.8, C.I. 1.0 - 3.5, p < .08). Of those who used condoms, more
were likely to experience problems (OR = 2.9, C.I. 1.6-5.5, p <
.01). These problems included, for example, slippage, breakage,
improper coverage of the penis, and his removal of the condom
prior to coitus. Finally, women partnered to these men were more
likely than other women to report that their partners had “a lot”
of influence over them (51.2% vs 38.5%, p=.07).
Conclusion:
Women partnered with men who have proven sexual
relationships with other women are less likely to practice safe
sex, primarily absence of or incorrect condom use. They are also
more vulnerable to his control.
Implications for Programs, Policy, and/or Research:
Intervention attempts to reduce risky sexual
behavior among women who interact with extremely high-risk men may
need to address issues involving how to identify these men, how to
avoid involvement with them, or increased acquisition of
communication and related skills by program participants. Further,
programs may need to incorporate specialized components to
increase efficacy of identification and treatment of male partners
of women at risk for disease transmission.
Remnants of the Tuskegee Syphilis Study
Effects on University Freshmen: Yet a Possible Barrier to Research
Participation?
CB Spivey, T Simpson, MK Oh, T Vazin1,
K Gunn1
Univ Alabama at Birmingham and
1Alabama
State Univ, Montgomery, AL
Background:
African Americans’ distrust of the biomedical
community has been attributed to the Tuskegee Study. Assessing
perceived barriers to participation in biomedical research will
illuminate the impact of the Tuskegee Study.
Methods:
A cross-sectional survey was administered during
freshmen orientation at a Historically Black University Sept-Oct
2003.
Results:
A total of 691 students participated in the survey
(57% female, 95% AA). When asked about the impact of the Tuskegee
Study as a possible barrier to participation in biomedical
research, 35% reported that it was very important, 33% reported
that it was somewhat important, 14% reported it was unimportant,
and 17% of those surveyed “never heard of it”. Alabama students
were more likely than non-Alabama students to report the study as
being very important to participation in research (X = 11.0;
p-value = .01). Females were more likely to report the study as
being very important than males (X= 22.42; p-value = .001),
whereas males were more likely to cite the study as not being
important. Students citing confidentiality as being highly
important were significantly more likely to report the Tuskegee
Study as being very important in their decision to participate in
research (X= 34.39; p-value= .000). Likewise, those students in
which confidentiality was not of concern were less likely to have
heard of the Tuskegee Study. Students reporting mistrust of
researchers were more likely to report the Tuskegee Study as being
very important in their decision to participate in research (X=
62.1; p-value= .000). Trusting researchers were less likely to be
an issue among students unfamiliar with the Tuskegee Study.
Students citing lack of interest as a very important barrier were
more likely to report the Tuskegee Study as being very important
(X= 51.65; p-value= .000).
Conclusion:
Study findings indicate that the Tuskegee Study
still continues to be one of the pervading factors, within the
African American community, influencing individual interest in
participating in biomedical research.
A.11 Philadelphia, Pennsylvania March 8-11, 2004
2004 National STD Prevention Conference
Implications for Programs, Policy, and/or Research:
This study brought into focus the correlation of
possible barriers precluding students’ willingness to participate
in biomedical research. Programs seeking to increase minority
participation in biomedical research should address these and
related barriers.
Parental Receptiveness to a Hypothetical HPV
Vaccine
AJ Lenar, EL Anderson, A Carpico, M Wentworth, K Connolly
Merck & Company, Inc., West Point, PA
Background:
Human Papillomavirus (HPV) infection is the most
common sexually-transmitted viral diseases worldwide. Overall,
50%-75% of sexually active men and women contract genital HPV
infection at some point in their lives.1
Objective:
To assess quantitatively parental acceptance of an
HPV vaccine for adolescents if one were available.
Methods:
An internet-based survey was administered to 2,050
parents of female adolescents, 9-17 years of age. In order to
obtain a representative sample, quotas were set for Hispanic and
African-American parents. Data were analyzed using cumulative
logistic regression to examine factors influencing parental
acceptance.
Results:
Data demonstrated a majority (71%) of parents were
generally unaware of a relationship between HPV and cervical
cancer. Despite an initial lack of knowledge, when presented with
epidemiological data regarding the disease, 62% percent of all
parents said they would get their daughters vaccinated before
their 18th birthday if a vaccine were available. Most of the
remainder was unsure, rather than opposed to vaccination. Fewer
than five percent of parents said that they would leave the
decision up to their daughters, upon turning 18. The receptiveness
hierarchy was most closely associated with protective attitudes
towards children (OR = 9.70, p<.0001). Social values and
perceptions regarding sexual debut influenced parental
receptiveness, but to a lesser extent. In addition, a strong
physician recommendation increases overall parental receptiveness
to 79%, a change of 17%.
Conclusions:
Most parents were unaware of a relationship between
HPV and cervical cancer. Once they received information regarding
the disease, parents of adolescent girls were receptive to
vaccinating their daughters if a vaccine became available.
Receptiveness increases with a strong physician recommendation.
Implications for Programs, Policy, and/or Research:
Other research suggests that the physicians would
respond favorably to an HPV vaccine if one were available and
would be most likely to offer a personal recommendation to their
older adolescent patients.2 Efforts may be needed to increase
parental awareness of HPV.
1CDC,
Tracking the Hidden Epidemics 2000,
2Physician
Quantitative Study, Merck Vaccine Division, December 2003.
B2G
Physician Attitudes and Receptiveness to
STD Vaccines
A Carpico, E Anderson, AJ Lenar, M Wentworth, K Connolly
Merck & Company, Inc., West Point, PA
Background:
Human papillomavirus (HPV) is a very common
sexually transmitted disease (STD) among young, sexually active
people. An estimated 20 million people in the United States
currently have genital HPV infections.1
Objective:
To assess quantitatively the prevalence of sexual
risk discussions among physicians and their female adolescent
patients, 9-18 years of age and to assess physician’s attitudes
towards vaccines for STDs, including an HPV vaccine if one were
available.
Methods:
An internet-based survey was conducted with 642
physicians (309 pediatricians and 333 family practitioners) from
the American Medical Association (AMA) master file. Quotas were
set for physician specialty, gender, region, and type of practice,
in order to obtain a representative sample of physicians.
Results:
Over 50% of physicians reported having sexual risk
discussions with their female adolescent patients, 9- 18 years of
age. These discussions occurred more frequently with older
patients. Forty-three percent of physicians reported that they
strongly believe vaccines against STDs are important for their
9-12 year old patients; these physicians were more likely to
strongly recommend an HPV vaccine if one were available. Among
almost all physicians (73%), parental resistance to an HPV vaccine
if one were available was considered an extremely, very, or
somewhat important barrier to vaccination.
Conclusions:
Many physicians reported discussing the risks of
sexual activity with their adolescent patients; some physicians
were more proactive than others. While many physicians considered
vaccines against STDs important, parental resistance was perceived
by physicians as a significant barrier to vaccinating their
adolescent patients.
Implications for Programs, Policy, and/or Research:
Other research suggests that many parents would be
generally receptive to an HPV vaccine if one were available and a
strong physician recommendation increases their receptivity.2 In
this study, many physicians perceived parental resistance as a
large barrier. It appears that there is a knowledge gap between
physicians and parents that needs to be closed in order to reduce
misconceptions about STD vaccination.
Learning Objectives:
By the end of the session, participants will learn
about the prevalence of sexual risk discussions among physicians
and their 9-18 year old patients. In addition, participants will
be able to describe physician attitudes regarding STD vaccines for
their adolescent patients.
1CDC, Tracking the Hidden Epidemics 2000,
2Parent Quantitative Study, Merck Vaccine Division, December 2003.
C5G
Lessons
Learned: Sexual Health Social Marketing in Retail Pharmacies
S Cohen
Pharmacy Access Partnership, Public Health Institute, San
Francisco, CA
Background:
With direct pharmacy access to emergency contraception in
California, there are opportunities for pharmacies to a play
stronger role in STI prevention. Consumer awareness of the family
planning category, including condoms, is limited as products are
not actively promoted and educational materials are not widely
provided. In some pharmacies condoms are difficult to locate as
they are placed in a “feminine hygiene” aisle. Piloting
traditional pharmacy marketing strategies applied to the family
planning product category is a new direction for pharmacy
retailers.
Objectives:
Reinforce consumer’s decision to seek/use OTC
family planning products. Increase consumer educational
opportunities for STI prevention. Increase public awareness of
pharmacist services
Methods:
During 2003, Pharmacy Access Partnership worked
with pharmacies and public health stakeholders to create and pilot
educational and promotional materials for retail pharmacy
settings. Materials include signs, posters, shelf talkers, coupon
bag stuffers, and brochures. Selected pharmacies in California
including major chain stores were recruited to pilot materials.
Results:
Approximately 100 pharmacies committed to piloting
materials. This presentation highlights lessons learned in
developing materials and describes implementation challenges and
evaluation of using pharmacies to increase consumer education
around STIs.
Conclusions:
By prominently grouping OTC contraceptive supplies
with educational materials, pharmacies have the opportunity to
better meet consumer needs and play a more active role in STI
prevention.
Implications for Programs, Policy, and/or Research:
As pharmacies are part of the health care system
that people interact with most, they serve as an important place
to deliver STI prevention education.
Learning Objectives:
By the end of the session, participants will be
able to (1) recognize the role pharmacies can plan in promoting
the prevention of STIs (2) understand the implementation
challenges in promoting sexual health education in a retail store
environment.
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