The State of the Syphilis Outbreak in Marion County, Indiana: Two
UPDATE ON THE SYPHILIS EPIDEMIC IN INDIANAPOLIS Janet Arno, MD and Jutieh Lincoln, MPH February 9, 2011 Marion County Public Health Department (MCPHD) Indianapolis, IN Goals of this Presentation To inform the Community about the status of the Syphilis epidemic, and to highlight its epidemiologic trends over time To inform the Community about current efforts to control the Syphilis epidemic To seek the help of the Community in controlling the Syphilis epidemic Background In 1999, Marion County had the highest number of Primary and Secondary (P & S) syphilis cases in the United States. As a result of the outbreak, community organizations partnered with the Marion County Public Health Department, the State, and CDC to organize an effective campaign to control syphilis. The number of P & S was decreased from 403 P & S cases per year to less than 50 cases per year. In 2008 we once again saw an increase in cases twice the standard deviation of our baseline. Now we are seeing an increase in cases superimposed on an outbreak among MSM. Since 2008, about 410 Indianapolis residents have been diagnosed with the disease Early and P & S Syphilis In Indianapolis 1996-2010 Early Syphilis P&S 600 1999 Syphilis Outbreak 500 400 300 2008 Syphilis Outbreak 200 # of Cases 100 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Report Year Early Syphilis Indianapolis 2007-2010 Primary and secondary Total Early Syphilis 60 50 40 30 20 10 0 Q1 Q2 Q3 2007 Q4 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 2010 Newly Diagnosed Syphilis Cases from January 1, 2010 to December 28, 2010 District 5: 178 cases Total number of primary and secondary syphilis cases in District 5: 117 Marion County: 162 cases Total number of primary and secondary syphilis cases in Marion County: 106 Except for race and age, the demographics of the 16 cases outside of Marion County are similar to the demographics of cases within Marion County. Early Syphilis Cases by Diagnosis: 2008-2010, Marion County, Indiana # of Cases Primary 200 160 120 80 40 0 Secondary Early Latent 56 49 55 18 27 49 20 82 24 2008 2009 2010 Report Year Consistently, most cases had primary or secondary syphilis at diagnosis. Early Syphilis Cases by Race: 2008-2010, Marion County, Indiana White Black Hispanic Other 180 160 140 120 100 106 39 80 41 60 40 78 20 43 45 2009 2010 # of Cases 0 2008 Report Year The outbreak has shifted from mostly Whites to mostly Blacks. Early Syphilis Cases by Age of Diagnosis: 2008-2010, Marion County, Indiana <25 years # of Cases 180 160 140 120 100 80 60 40 20 0 25-34 years 35-44 years >44 years 23 24 18 47 23 55 34 38 60 19 22 17 2008 2009 2010 The outbreak has shifted from middle-aged to younger adults. Report Year Early Syphilis Cases by Gender: 2008-2010, Marion County, Indiana Male Female 180 160 30 140 120 9 100 8 80 60 132 113 88 40 20 # of Cases 0 2008 2009 2010 Report Year Males (esp. MSM) account for most cases, but female proportion has grown. HIV Co-Infection Among Early Syphilis Cases: 2008-2010, Marion County, Indiana Negative Positive Unknown 160 140 120 8 12 38 100 14 80 68 60 51 94 40 20 41 31 # of Cases 0 2008 2009 2010 Report Year The HIV-infected proportion has shrunk, but many new cases do have HIV. Early Syphilis Cases by Sexual Orientation: 2008-2010, Marion County, Indiana MSM # of Cases 180 160 140 120 100 80 60 40 20 0 Bisexual Heterosexual Unknown 64 20 25 92 66 2008 2009 89 2010 Report Year Heterosexuals account for an increasing portion of diagnosed cases. Risk Behavior of Syphilis Cases Cases frequently reported: o Sexual intercourse with unknown persons o Sexual intercourse without condom o Sexual intercourse while high on drugs such as: o Alcohol o Marijuana o Crack o Cocaine o Meth Risk Behavior of Syphilis Cases Frequently reported sites for meeting sex partners include: Adam for Adam o Gay.com o Manhunt o Facebook o The Ten o Club Indy o Talbot o Gregs Blacks were likely to meet their sex partners: o thru Family members thru Friends at social events (ex. parties) Whites were likely to use online sites to meet their sex partners. Methods of Case Detection that are being utilized in the Syphilis Epidemic Disease Intervention Specialist (DIS)-a staff member who is trained to treat, interview, and follow up on persons diagnosed with an STD. Patient Referral-an instance in which a person diagnosed with an STD divulges the names of partners he/she may have put at risk for that STD. Screening-an initial evaluation conducted by a provider to determine whether a person is at risk for or has an STD. Self Referral-an instance in which a person feels that he/she may have an STD and goes to a provider for screening. # of cases 80 70 60 50 40 30 20 10 0 Methods of Case Detection: 2010 Syphilis Cases, Marion County, Indiana 75 45 13 Traditional Disease Intervention Activities 26 Patient Referral Screening Self Referral Self referral and screening accounted for the bulk of the cases diagnosed. Conclusions Syphilis Cases so far in 2010 surpassed 2008 and 2009’s count Blacks became majority among cases MSM still disproportionately impacted Age shifting from older to younger adults Female proportion increased to nearly 1 out of 6 syphilis cases Conclusions Proportion with HIV decreasing, but still high Heterosexuals proportion trending upwards 3 risks commonly reported were: Drug use during sexual intercourse Sexual intercourse with unknown persons Sexual intercourse without condom Cases increasingly concentrated in central Marion County and lower income areas An increase is expected with waxing and waning components Current Efforts Continue to: Screen high risk groups (e.g. MSM, the incarcerated, commercial sex workers) and hard-hit areas in Indianapolis for the disease and quickly bring cases to treatment Partner with providers and community-based organizations around the city to quickly identify patients with the disease and bring them to treatment, and to educate their patients about the disease and risk reduction behaviors Aggressively follow up with partners named by cases to determine if they have the disease and bring them to treatment or to educate them about risk reduction behaviors Current Efforts Continue to Periodically update providers, public health practitioners, and the community on the epidemic through mass mailing and through MCPHD website. A powerpoint presentation on the epidemic is available at: http://www.mchd.com/syphilis_info.htm Have set up a new website (http://www.bellflowerclinic.org/) to keep providers, public health practitioners, and the community informed about clinic hours, STD resources, services offered, and to answer their questions How Can You Help? Spread the word about the Syphilis epidemic Encourage persons in your community to get tested for Syphilis Inform persons in your community that Bell Flower Clinic offers low cost STD screening (or free STD screening with life saver card) Share ideas for screening sites in your community Serve as an information resource for your community Offer Suggestions on how to control the epidemic Acknowledgement A Special thank you to Mr. David Broyles (Marion County Public Health Department Corporate Information Systems) for his excellent and timely work on the Syphilis maps, and Caitlin Gill (Epidemiology intern from the IU Department of Public Health) for assisting in the compilation and presentation of this data.