Brian Sandoval Julie Kotchevar, PhD Governor Administrator

Richard Whitley, MS Ihsan Azzam, PhD, Md Director Chief Medical Officer

EPIDEMIC OF Understanding the Clinical & Public Health Need for Action

Department of Health and Human Services Division of Public and Behavioral Health

Sandi Larson, MPH State Epidemiologist Joseph P. Iser, MD, DrPH, MSc Chief Health Officer Acknowledgments

• Syphilis Workgroup – Nevada Division of Public and Behavioral Health • Maternal Child Health • Perinatal Substance Abuse Program • WIC, Medicaid – Local Health Departments (WCHD, SNHD, CCHHS) – DHHS Office of Analytics • Kevin Dick- Washoe County District, District Health Officer • Joseph P. Iser, Southern Nevada Health District, Chief Health Officer

2 Presentation learning objectives

1. Describe the of syphilis and in Nevada. 2. Discuss clinical manifestations, diagnosis and treatment of syphilis and congenital syphilis. 3. Describe public health and clinical measures for the prevention of syphilis.

3 Syphilis Call to Action KEVIN DICK Washoe County District, District Health Officer

https://youtu.be/hff-RfpQfCM

4 5 Syphilis Overview: Definition Syphilis is a sexually transmitted disease (STD) caused by the bacterium Treponema pallidum. Syphilis can cause serious health sequelae if not adequately treated. • Causes systemic infection • Characterized by episodes of active disease during which patients have signs/symptoms of infection, interrupted by periods of latent infection – Lab testing is required to diagnose patients • The average time between acquisition of syphilis and the start of the first symptom is 21 days, but can range from 10 to 90 days.

6 Syphilis Overview: 1. Sexual: • Person to person via vaginal, anal, or oral sex through direct contact with syphilis sores or lesions, known as a chancre. Chancres occur at the primary stage of syphilis and can be found around the external genitals or anus, in the vagina or rectum, or in or around the mouth. • Sexual transmission also occurs at the secondary stage, mainly by direct contact with mucous membrane lesions such as condyloma lata and mucous patches. 2. Vertical • From infected mother to her unborn baby via the bloodstream.

7 Primary Syphilis • The appearance of a single chancre marks the primary (first) stage of syphilis symptoms, but there may be multiple sores.

• The chancre is usually (but not always) firm, round, and painless. It appears at the location where syphilis entered the body.

• These painless chancres can occur in locations that make them difficult to notice (e.g., the vagina or anus).

• The chancre lasts 3 to 6 weeks and heals regardless of whether a person is treated or not. However, if the infected person does not receive adequate treatment, the infection progresses to the secondary stage.

Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides 8 Secondary Stage • Mucocutaneous lesions (most commonly rashes) can occur as chancre(s) fade ~6 weeks after infection (range 3 wks–6 mos). – Rashes may first appear on the palms of hands or the soles of feet, but typically appear on trunk & other areas of the body. – Lesions such as condyloma lata, a moist, wart-like lesion found in the genital area & mucous patches on the tongue – Other common findings: lymphadenopathy & constitutional symptoms. Less common: patchy alopecia & neurologic symptoms

• Symptoms clear within 2–6 wks but may take up to 3 mos, even without treatment.

• Patient is highly infectious, especially if direct contact with a moist lesion.

• In utero transmission is likely in pregnant women.

Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides 9 Latent Stage

• The latent (hidden) stage of syphilis is a period of time when there are no visible signs or symptoms of syphilis. • Without treatment, the infected person will continue Late syphilis - serpiginous gummata of forearm to have syphilis in their body even though there are no signs or symptoms. • Early latent syphilis is latent syphilis where infection occurred within the past 12 months. • Late latent syphilis is latent syphilis where infection occurred more than 12 months ago. • Latent syphilis can last for years.

Late syphilis - ulcerating gumma

Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides 10 Syphilis Staging Flowchart

SIGNS OR SYMPTOMS?

YES NO

PRIMARY SECONDARY LATENT Chancer Rash, etc. Any in past year?  Negative syphilis serology  Known contact to an early case  Good history of signs/symptoms  4-fold increase in titer  Only possible exposure past 12 months

YES NO

EARLY LATENT LATE LATENT or (<1 YEAR) UNKNOWN DURATION

11 Syphilis — Rates of Reported Cases by Stage of Infection, United States, 1941–2017

NOTE: Data collection for syphilis began in 1941; however, syphilis became nationally notifiable in 1944. Refer to the National Notifiable Disease Surveillance System (NNDSS) website for more information: https://wwwn.cdc.gov/nndss/conditions/syphilis/.

12 Primary and Secondary Syphilis — Rates of Reported Cases by Sex and Male-to-Female Rate Ratios, United States, 1990–2017

13 Primary and Secondary Syphilis — Rates of Reported Cases by State, United States and Outlying Areas, 2017

NOTE: The total rate of reported cases of primary and secondary syphilis for the United States and outlying areas (including Guam, Puerto Rico, and the Virgin Islands) was 9.5 per 100,000 population. See Section A1.11 in the Appendix for more information on interpreting reported rates in the outlying areas. ACRONYMS: GU = Guam; PR = Puerto Rico; VI = Virgin Islands.

14 Rate per 100,000 Population of Primary & Secondary Syphilis Cases in Nevada by Report Year

50.0

45.0

40.0

35.0 30.4% Increase 30.0

25.0 23.7 72.7% Increase 20.0 18.4

Rate per 100,000 Population 100,000 per Rate 15.0 12.6

10.0 7.4 5.0 3.2 3.8 5.0 1.6 0.0 Clark Washoe Carson/Douglas/Lyon All Other Counties* 2016 2017

*All other counties: Churchill, Elko, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Mineral, Nye, Pershing, Storey, and White Pine

15 Percent of P&S Syphilis Cases Percent of P&S Syphilis Cases in in Nevada by Sex, 2017 Nevada by Race/Ethnicity, 2017

Asian/Pacific Unknown/Other, Islander, 6.8% 5.1% American Female, Indian/Alaska 13% n Native, 7.0%

White, 35.1%

Hispanic, 26.7%

Male , Black, 25.6% 87%

16 Percent of P&S Syphilis Cases in Nevada by Sex and Age, 2017

50.0%

45.0%

40.0% More than half of cases for both male and female are between 25-39 35.0%

30.0%

23.8% 25.0% 22.7%

20.0% 17.3% 17.8% 17.3% 16.8% 14.7% 15.0% 12.3% 11.9% 10.7% 9.3% 9.2% 10.0% 5.5% 5.0% 4.0% 1.8% 2.7% 1.0%0.0% 0.0% 15-19 20-24 25-29 30-34 35-39 40-44 45-54 55-64 65+ Male Female

17 “We know that doctors are not doing enough screening for STDs,” said David Harvey, executive director at the National Coalition of STD Directors. The failure to screen routinely “is leading to an explosion in STD rates,” he said, adding that cutbacks in funding and a lack of patient awareness about the risks make it worse.

18 REPORT Report cases to local health departments.

19 The Centers for Disease Control and Prevention (CDC) has developed a simple categorization of sexual history questions that may help providers, or other members of the clinical care team, remember which topics to cover. These are called the Five P’s:

20 In the past 12 months, how many sexual partners have you had? Men? Women? Both? Transgender?

• Number and gender of partners over a given time 21 In the past 12 months, have you had vaginal sex? Oral sex? Anal sex?

For men who have sex with men—Are you the receptive partner (“the bottom”)?

• Types of sexual practices – oral, vaginal, anal 22 Have you even been diagnosed with an STI, such as HIV, herpes, gonorrhea, chlamydia, syphilis, HPV or trichomoniasis? When? Have you had any recurring symptoms or diagnosis? When was your last HIV test?

• Establish risk of repeat infections, HIV status and hepatitis risk 23 How do you keep yourself from getting infected?

Do you use condoms consistently? If not, in which situations are you more likely to use a condom?

• Use of condoms and other methods 24 Are you trying to conceive or father a child? Do you want to avoid pregnancy? Are you using contraception or practicing any form of birth control? Do you need any information on birth control or a referral?

• Desire of pregnancy and use of prevention methods 25 : WHO TO TEST?

During routine MSM and HIV + visits Pregnant women

•Any person with signs or •Sexually active men who symptoms suggestive of have sex with men Pregnant women syphilis should be tested •*Annually or every 3-6 *At the first for syphilis. months if at increased prenatal visit risk*) *At the beginning of the third trimester •Anyone with an oral, anal, •For HIV+ sexually active or vaginal sex partner who individuals, screen at first *AND, at delivery if has been recently at risk diagnosed. HIV evaluation, and at least annually thereafter

* Risk is described in the CDC STD Treatment Guidelines at www.cdc.gov/std/ treatment.

26 : HOW TO TEST?

27 Latent Syphilis of Unknown Primary, Secondary, or Early Duration, or Tertiary Syphilis Latent (1 year) with Normal CSF Examination • Benzathine penicillin G 2.4 • Benzathine penicillin G 7.2 million units IM in a single million units total, dose administered as 3 doses of 2.4 million units IM each at 1-week intervals

28 PRIMARY, SECONDARY, and EARLY LATENT (<1 YEAR) • Benzathine penicillin G 2.4 million units IM in a single dose Pregnant women should • CDC tx guide suggests potential benefit with a second dose of Pregnant be treated with the Benzathine penicillin G 2.4 million units IM administered 1 week Women penicillin regimen after initial dose. appropriate for their stage of infection. LATE LATENT or UNKNOWN DURATION

• Benzathine penicillin G 2.4 million units IM each at 1-week intervals ONCE PER WEEK FOR 3

** In pregnancyWEEKS** should adhere to 7 days between doses. Missed doses are NOT acceptable for pregnant women receiving therapy for late latent syphilis. Pregnant women who miss any dose of therapy must repeat the entire course of therapy.

29 REPORT

• NAC 441A.225 Requires cases of Syphilis to be reported to the health department on the first working day following the identification of the case or suspected case. – Healthcare Providers (NAC 441A.230) – Laboratories (NAC 441A.235) – Others (NAC 441A.240-255): Director healthcare facility, parole probation officer, principle, blood bank, insurer, person.

• 441A.695 The health care provider for a person with infectious syphilis shall notify the health authority immediately if the person fails to submit to medical treatment or fails to complete the prescribed course of medical treatment.

30 31 Syphilis Call to Action JOSEPH P. ISER, MD, DrPH, MSc Southern Nevada Health District, Chief Health Officer

https://youtu.be/uqoFUPHD1_c

32 Congenital Syphilis Definition and Affects

Congenital syphilis (CS) is a disease that occurs when a mother with syphilis passes the infection on to her baby during pregnancy

• CS can have major health impacts on your baby. How CS affects your baby’s health depends on how long you had syphilis and if — or when — you got treatment for the infection.

• Up to 40% of babies born to women with untreated syphilis may be stillborn, or die from the infection as a newborn.

For babies born with CS, CS can cause: CS can cause: • Deformed bones, • (losing the baby during • Severe anemia (low blood count), pregnancy), • Enlarged liver and spleen, • (a baby born dead), • Jaundice (yellowing of the skin or eyes), • Prematurity (a baby born early), • Brain and nerve problems, like blindness or • Low birth weight, or deafness, • Death shortly after birth. • Meningitis, and • Skin rashes.

https://www.cdc.gov/std/syphilis/stdfact-congenital-syphilis.htm 33 Congenital Syphilis — Rates of Reported Cases Among Infants by Year of Birth and State, United States and Outlying Areas, 2017

NOTE: The total rate of reported cases of congenital syphilis for infants by year of birth for the United States and outlying areas (including Guam, Puerto Rico, and the Virgin Islands) was 23.2 per 100,000 live births. See Section A1.2 in the Appendix for more information on estimating rates for outlying areas. ACRONYMS: GU = Guam; PR = Puerto Rico; VI = Virgin Islands.

34 Rate of Reported Cases of P&S Syphilis among Women & Congenital Syphilis Cases, United States vs. Nevada, 2012-2017

10 100

9 90

8 80

7 70

6 60

5 50

4 40

3 30

2 20

1 10 Rate of cases CS per 100,000 live births

0 0 Rate P&S cases among women per 100,000 population 2012 2013 2014 2015 2016 2017 NV- P&S Syphilis cases in women 0.3 1 1.6 1.6 3.4 5.1 US- P&S Syphilis cases in women 0.9 0.9 1.1 1.4 1.9 2.3 US- CS cases 8.4 9.2 11.5 12.4 16.2 23.3 NV- CS cases 2.9 5.7 13.9 22 33.1 57.9

35 Number of Reported Cases of P&S Syphilis among Women & Congenital Syphilis Cases, Nevada, 2012-2018*

100

90

80

70 63 60 50 50 47

40 Number of Cases 30 23 23

20 14

10 4 0 2012 2013 2014 2015 2016 2017 2018*

P&S Syphilis cases in women CS cases

*2018 data is preliminary reported from January to June 30, 2018

36 Percent of Congenital Syphilis Cases by Maternal Age at Delivery in Nevada, 2016-2018*

100% 90% 80% 70% 60% 56%

50% 42% 40% 28% 28% 30% 22% 22% 25% 20% 17% 17% 17% 11% 11% 10% 6% 0% 0% 0% < 20 20-24 25-29 30-34 35-39

2016 2017 2018*

• Nevada seeing an increase in cases 30-34 years of age

*2018 data is preliminary reported from January to June 30, 2018

37 Percent of Congenital Syphilis Cases by Maternal Race/Ethnicity in Nevada, 2016-2018*

100% 90% 80% 70% 60% 50% 42% 42% 40% 33% 33% 33% 33% 28% 30% 22% 20% 17% 11% 10% 6% 0% 0% 0% 0% 0% White Black Hispanic Pacific Islander Unknown 2016 2017 2018* • Whites and Blacks consistently make up a majority of the reported cases

*2018 data is preliminary reported from January to June 30, 2018

38 Percent Mothers who received Prenatal Care Among Congenital Syphilis Cases in Nevada, 2016-2018*

100% 90% 80% 70% 56% 56% 60% 52% 50% 44% 44% 39% 40% 30% 20% 10% 6% 4% 0% 0% Yes No Unknown 2016 2017 2018*

• Among those cases who received prenatal care the detection of syphilis was too late to prevent congenital syphilis

*2018 data is preliminary reported from January to June 30, 2018

39 Congenital Syphilis Cases by Other Maternal Demographics in Nevada, 2016-2017 (N=27)

Sex Behaviors Past 12 Month Drug Use 100%

90% 85% 85% unknown 4% 80% 70%

60% Yes 44% 50% No 40% 30% 52% 22% 20% 11% 7% 10% 4% 0% Sex with male Sex with female Sex with MSM Sex while high Had anonymous Sex without sex condom

Had another STD at time More than 1/3 of cases had more than 1 sexual 18% of Syphilis dx partner past 12 months

40 Public Health Response: Points of Intervention to Prevent CS

• Data match was completed with Medicaid, SNAP, TANF, WIC, and Child Welfare and the 2016/2017 (N=27) reported congenital syphilis cases • 21 had involvement in Child Welfare • 17 had involvement WIC • 22 enrolled in Medicaid and/or SNAP What does this tell us? Case reviews also show: Prevention efforts need • Cases access ER for care and services to be community wide during pregnancy and involve not only • Cases access substance use and mental public health and health facilities medical providers but • Homeless shelters non-traditional service providers.

41 Public Health Response: Points of Intervention to Prevent CS Pre- During Birth pregnancy Pregnancy

• Screening • Linkage to prenatal • Evaluation and Screening/dx/tx care treatment of baby • Timely partner • Screening/dx services • Timely treatment • Accessible highly appropriate for effective stage contraception • Timely partner services • Case management • Prevent and detect new infection

Source: http://www.acphd.org/media/490618/syphilis-pediatric-stoltey_01242018.pdf 42 Congenital Syphilis Take Home Points

• Female syphilis and congenital syphilis cases are increasing in Nevada. • Most congenital syphilis cases can and should be prevented. • Confirm maternal syphilis testing at delivery; infants should not be discharged without this information. • Ensure exposed infants are evaluated and treated according to guidelines; this is an opportunity to prevent morbidity associated with untreated syphilis. • Follow infants until RPRs become nonreactive. • Report to local health department.

43 Statewide Congenital Syphilis Campaign Clinical Guidelines and Consultation

STD Clinical Consultation Network Enter your consult online at: www.stdccn.org

https://www.cdc.gov/std/tg2015/default.htm CDC STD Treatment Guidelines App Available now, free

45 Resources

46 Training • https://nnptc.org/ • https://depts.washington.edu/ptcstd/NSTDC% 20Launch%20Slides.pdf

47 48 Sandi Larson, MPH Office of Public Health Informatics and Epidemiology Nevada Division of Public and Behavioral Health [email protected]