1. National STD Prevention Conference
Monitoring genital wart disease in STD clinics through the STD Surveillance Network (SSuN)
L Newman; D Datta; K Ahrens; J Bissette; R Kerani; E Klingler; R Kohn; S Martins; K Rietmeijer; H Weinstock
National STD Prevention Conference
March 11, 2008

2. STD Surveillance Network (SSuN)
Purpose: to improve national capacity to detect, monitor, and respond to emerging trends in STDs and related behaviors
Initial activities – Fall 2005
Enhanced gonorrhea surveillance in STD clinics
Population-based enhanced gonorrhea surveillance
New activity – Fall 2006
Genital wart surveillance in STD clinics
GW is the “new activity”

3. Genital Wart Monitoring - Rationale
Licensure of quadrivalent HPV vaccine in June 2006
Genital warts became a vaccine-preventable disease
Quadrivalent vaccine >99% efficacy for genital wart prevention
Limited information on burden of disease
National survey: seroprevalence of HPV-11 = 4.7%
HMO: Patients required an average of 3.1 visits per genital wart diagnosis, $436
Seattle: Approximately 10% of STD clinic visits related to HPV

4. Genital Wart Monitoring – Objectives
Develop standardized methodology for genital wart surveillance in STD clinics
Monitor trends over time
% of STD clinic visits due to genital warts
Demographic and clinical characteristics of patients with genital warts
Proportion of patients with genital warts who received HPV vaccine
Impact of genital wart diagnosis and treatment on STD clinic resources

5. STD Surveillance Network (SSuN) Project Areas (n=6) & Participating STD Clinics (n=17), 2005-2008
Washington
Seattle and King
County Clinic
Minnesota
Red Door Clinic
New York City 10 clinics
San Francisco San Francisco City Clinic
Virginia
Richmond City Clinic
Henrico County Clinic
Chesterfield County Clinic
Colorado
Denver Metro Health Clinic
You can see that we have fairly good geographic representation.
SSuN project areas
Participating STD clinics

6. Genital Wart Monitoring - Methodology
Data collected routinely on ALL patients
At registration OR
During clinical encounter
Data transmitted to CDC
Diagnosis OR treatment for genital warts
Analysis of Aug 1, Dec 31, 2007*
*MN initiated data collection as of Nov 1, 2007

7. Data Elements Age, race/ethnicity, sex Sex of sex partners HIV status
First vs. recurrent/subsequent episode
Self-report, provider-report, chart review x 1 year
Treatment
HPV vaccine history (ever, # doses, provider type, age at first dose)
Other: census tract, education, employment, age at first sex, anonymous sex, internet, exchange of sex, incarceration, drug use

8. Results

9. Proportion of STD Clinic Visits Related to Genital Warts (N=10,050) and Gonorrhea (N=7,612)
GW = 3.9%
Average % for GW = 3.9%
In western sites especially, GW is more common than gonorrhea in STD clinics.
Average % for GC = 3.0%
n=219
GC = 3.0%
n=3,019

10. Number of Visits for Patients with Genital Warts (N=4,073 Unique Patients), Aug 2006-July 2007
Range: 1 – 30 visits
33% of patients had more than one visit
Note: only included patients through July 2007 so that all patients had at least 6 months for possible subsequent visits
Median = 1, Mean = 1.81, range 1 – 30
33% of patients had more than one visit)

11. Proportion of Genital Wart Visits (N=9,957) Due to Follow-up Visit, Aug 2006-Dec 2007
57%
“Follow-up visit” is defined as either self-reported recurrent disease, provider-reported repeat visit, or previous visit upon review of medical record in past 12 months.
Average % of visits due to subsequent dz = 57%

12. Reported Sex and Sexual Orientation of Patients with Genital Warts (N=5,399)*
Range: 3 – 30% of genital wart patients MSM
The proportion of patients with genital warts who are MSM, seen in yellow, varies by site, with a range of 3 – 30% of patients.
Women, seen in purple, account for an average of 21% of patients with genital warts (range = 13.2 – 25.7%)
Largest proportion of disease seen in MSWs.
The differences between sites seen here and in several of the following slides clearly reflect the underlying composition of the STD clinic population.
*Sexual orientation unknown for 665 patients.

13. Race/ethnicity of Patients with Genital Warts (N=5,991)*
Diverse….good system for surveillance since all three major races and ethnicities are represented. Trend towards greater proportion of white patients seen in the grey bar in Western sites (CLICK), and greater proportion of blacks, seen in the blue bars (CLICK), in the Eastern sites.
IS THIS COLLECTED AS SELF REPORTED OR PROVIDER ASCERTAINED RACE/ETHNICITY? Varies by site – Seattle = provider-ascertained, VA = patient reported
*Race/ethnicity unknown for 73 patients.

14. Age of Patients with Genital Warts (N=6,064)
~ 2/3rds < 30 years old
Here we see the age of patients with genital warts. We found that over half of all patients were between the ages of 20 and 29,
Range for 20 – 29 year olds by site: 48.0 – 60.3%

15. Reported HIV Status of Patients with Genital Warts Stratified by Sex & Sexual Orientation (N=5,121)*
Here we see that a much greater proportion MSM with GW are more likely to be HIV positive than heterosexual men and women.
Note: Data for MN should be considered preliminary, since only two months of surveillance at the time these data were extracted.

16. Provider-administered Treatment of Genital Warts (N=9,957)
13%
Approximately 2/3rds of visits involved provider-administered treatments, which can be an incredibly time-consuming activity.
Clearly GW has an impact on STD clinic provider workload.
(Only 1.5% of visits involved prescriptions to patients (podofilox & imiquimod)
2/3 of visits involved
provider-administered
treatments

17. HPV Vaccination Monitoring
Variables not fully implemented by all sites yet
Eventually plan to assess what proportion of all eligible women have received HPV vaccine
WA began offering vaccine as of May 2007.

18. Uses of SSuN Genital Wart Data
Monitor burden of disease in STD clinics
Genital wart visits accounted for an average of 4% (range 2.2 – 12.8%) of STD clinic visits in
How will this change over time?
Monitor characteristics of patients with warts
2/3rds of patients with genital warts in were under 29 years of age
Over half of genital wart visits were follow-up visits in
Describe the HPV vaccine status of STD clinic patients
__% of eligible women attending STD clinics had been vaccinated
Monitor burden of GW disease in STD clinics over time
GW visits accounted for an average of 4% of all STD clinic visits in
How will this change over time?
How will this affect provision of STD services? (use in conjunction with time motion studies)
Monitor changes in characteristics of patients with GW
Ex: Over 60% of patients with GW in were under 29 years of age
Ex: 30-60% of GW visits due to recurrent/subsequent disease in
Describe the HPV vaccine status of STD clinic patients
Ex: __% of women attending STD clinics had been vaccinated
Are eligible populations being covered?
Use of vaccine by other populations?

19. Limitations Surveillance of only STD clinic population
Limited number of participating clinics
Slight variability in methodology since integrated into routine activities
No trends over time available yet

20. Summary Findings Implications
Genital wart visits are as common as gonorrhea visits in STD clinics
Over half of genital wart visits are due to recurrent/subsequent disease
Approximately 2/3 of genital wart visits involved provider-administered treatment
Implications
Genital wart disease poses a significant burden on STD clinic workload
Widespread uptake of quadrivalent HPV vaccine may have an important impact on STD clinic workload

21. Acknowledgements SSuN Collaborating Sites and Clinics CDC
Colorado Department of Public Health
Denver Metro Health Clinic
Minnesota Department of Health
The Red Door Clinic
New York City Department of Health and Mental Hygiene
10 public STD clinics in 5 boroughs
San Francisco Department of Public Health
San Francisco City Clinic
Virginia Department of Health
3 public STD clinics in 2 counties and Richmond City
Washington State Department of Health
Public Health – Seattle & King County STD clinic
CDC
Darlene Davis
Lauri Markowitz
The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the CDC.
Thank You.