1. Syphilis Outbreak in Southwestern Idaho — 2002 – 2003 Jared Bartschi, MHE STD/HIV Epidemiologist Idaho Dept. of Health and Welfare

2. Introduction U.S. P&S syphilis rates show an increase after a decade of decline U.S. syphilis rates increasing among men Recently reported outbreaks describe syphilis among MSMs Idaho experiencing a syphilis outbreak –22 in 2000-2001 –64 in 2002-2003

3. Objectives Determine the extent of the outbreak Describe characteristics of the affected population Follow up with patients and partners Discuss difficulties with outbreak investigation and get suggestions from peers

4. Case-finding –Passive: laboratory and physician reporting –Active: contact tracing and testing Laboratory testing –Nontreponemal (VDRL or RPR) –Treponemal (FTA-ABS or MHA-TP) –Dark-field microscopy NOT available Interviews using CDC STD forms

5. Case Definitions Standard CSTE/CDC Early syphilis –Primary syphilis (chancres) –Secondary syphilis (mucocutaneous lesions) –Early latent syphilis  Latent syphilis (no symptoms or signs)  Evidence of acquiring infection within previous 12 months

6. Early Syphilis Cases — 2002 – 2003

7. Geography of Early Syphilis

8. Patient Characteristics — Sex SexN (%) Male23 (53) Female20 (47) TOTAL43 (100)

9. Patient Characteristics — Age AGE (years) SEXnMeanMin–MaxMedian Male2327.918–4726.0 Female2025.514–5321.5 Combined4326.914–5323.5

10. Patient Characteristics — Ethnicity Ethnicityn (%) Hispanic27 (63) Non-Hispanic13 (30) Unknown/Other40 (7) TOTAL43 (100)

11. Patient Characteristics — Pregnant Trimester Stagen1 st `2 nd 3rd Early7133 Late latency 413 Unknown21 All132 (15%)7 (54%)3 (23%)

12. Patient Characteristics — Number of Partners Reported number of opposite sex partners Reported number same sex partners = 0 SexnMeanMin–Max Male151.71–31–3 Female151.51–31–3 TOTAL301.61–31–3

13. Health Care Characteristics — Provider at Diagnosis Provider typen (%) Private physician4 (9) Health dept.7 (16) Hospital8 (18) Correctional10 (23) Other clinic14 (33) TOTAL43 (100)

14. Health Care Characteristics — Days Onset to Diagnosis Days Onset to Diagnosis SexnLimitsMedian Male109–12732 Female715–20021 Both179–20029

15. Public Health Response Raising awareness –Health Alerts to area physicians –Press releases –Informational handouts / posters –Radio announcements Follow-up infants from positive mothers Visit by CDC Project Officer

16. Limitations — Individual Withholding of partner information Language barriers Illiteracy in any language

17. Limitations — Investigation Lack of timely contact follow-up Safety concerns Travel time (large jurisdictions) Incarcerated patients and partners Out-of-jurisdiction and out-of-country partners

18. Recommendations Enhance syphilis screening during prenatal care for young Hispanics in SW ID Syphilis screening for inmates upon intake at correctional facilities Improve outreach to Hispanics in SW ID Expand screening to social networks

19. Future Needs Spanish language services Educational materials for illiterate persons Interview training for syphilis investigation Permanent bridge to Hispanic community Change in cultural norms

20. Acknowledgments Southwest District Health Department Pat Harris, Epidemiology Supervisor Craig Christiansen, Epidemiologist Jennifer Tripp, Epidemiologist Central District Health Department Gladys Goodman, Epidemiologist IDHW Office of Epidemiology and Food Protection Christine Hahn, State Epidemiologist Kris Carter, CDC EIS Officer Centers for Disease Control and Prevention Gail Gould, Public Health Advisor Mary Hayes, STD Project Advisor