1. Syphilis in Bexar County: Developing a Criterion for Prophylactic Treatment in a City Clinic
Cameron Warner
Public Health Associate
Centers for Disease Control and Prevention
Office for State, Tribal, Local and Territorial Support
2015 PHAP / PHPS Summer Seminar
June 3, 2015
Centers for Disease Control and Prevention
Office for State, Tribal, Local and Territorial Support

2. Syphilis in Bexar County, Texas
An Overview
Syphilis in Bexar County, Texas 2

3. Background: Syphilis Epidemiology
Caused by a bacteria, Treponema Pallidum
Sexually and vertically transmitted
Consequences can include: death, blindness, paralysis
Treatment with penicillin
Progresses in stages
Primary, Secondary, Early and Late Latent
Congenital
Primary: chancre on tongue
Primary: chancre on penis
Secondary: rash on back
Secondary: rash on palms 3

4. Elevated Syphilis Rates in Bexar County, Texas
P&S syphilis rates in Bexar County (16.0/100,000) are 3.0 times higher than both the statewide rate (5.4/100,000) and the national rate (5.3/100,000).
P&S = Primary and Secondary Stages of Syphilis
Source: Data extracted from SAMHD’s STD*MIS database, Texas and CDC reports, using ACS population estimates 4

5. Challenges Associated with Syphilis Diagnosis
Knowledge of Exposure
Patient may not realize exposure
Exposure or risk may not be disclosed to clinician
Laboratory Testing
Screening test, Nontreponemal (e.g. RPR), may not test positive during both
The incubation period
Up to 90 days after exposure
Early primary syphilis stage
Image retrieved by CDC website and Public Health Image Library
Photomicrograph of T. Pallidum 5

6. Targeted Prophylactic Syphilis Treatment
Prophylactic treatment - an additional clinical tool
“The institution of measures to protect a person from a disease to which he or she has been, or may be, exposed.”*
Example 1 (commonly utilized in STD clinic)
Treating a client for syphilis when an exposure is known to have occurred and
No signs or symptoms and a negative STAT lab test
Example 2 (used in some city STD clinics)
Treating a client for syphilis when no exposure is known to have occurred and
With an epidemiologic risk factor high locally
Could be used to address the high rates of syphilis in Bexar County, Texas
Need to identify local epidemiologic risk factors
*The American Heritage® Stedman's Medical Dictionary, 2002 6

7. Syphilis in Bexar County, Texas
Methods and Results
Syphilis in Bexar County, Texas 7

8. Methods Data extracted from the local database, STD*MIS
Early syphilis cases
Early syphilis (primary, secondary and early latent stages) represents an infection identified with a year of exposure
City STD clinic visit information
Timeframe utilized
Past 14 months: January 1, 2014 to February 28, 2015
Analysis conducted
Using Microsoft Excel
By zip code, gender, race and ethnicity, and the risk factor, men that have sex with men (MSM) 8

9. Results: Early Syphilis Cases
Early Syphilis Cases, Bexar County (N=603)
77% male (465)
68.7% (414) were Hispanic
27.2% (164) came from 6 zip codes
One zip code, 78207, had the most cases 7.6% (46)
78207 also had the highest case count by:
Males, females, and Hispanics (total and by sex)
Source: STD*MIS, San Antonio Metropolitan Health District 9

10. Results: STD Clinic Visits
SAMHD STD Clinic Visits (N=12,149)
25.4% (3,087) were from the six zip codes with the highest case counts
Zip code had the most clinic visits, 6% (735)
The highest case count by males, females, and Hispanics (total and by sex)
A case count in the top five by non-Hispanic Whites and non-Hispanic African Americans (total and by sex)
Source: STD*MIS, San Antonio Metropolitan Health District 10

11. Early Syphilis by Zip Code, Bexar County, Texas January 2014 – February 2015
Cases*
Counts & % of Total (n=603)
7.6% % % % %
Mapped: %
* Zip Codes with < 20 cases were not included
Source: STD*MIS, San Antonio Metropolitan Health District, exported 11

12. Results: Early Syphilis Case Research – Men who have Sex with Men (MSM)
Syphilis Cases, Bexar County, Texas
MSM
49% (309) of early syphilis cases in 2013 reported MSM as a risk factor
Doubled from 2005 (21%)
44% (470) of all syphilis cases in 2013 reported a MSM risk factor
Doubled from 2005 (22%)
Research* showed higher risk of infection for MSMs who:
>1 sex partner within previous 6 months
Use Grindr, or similar application
Have anonymous sex
*Texas DSHS Syphilis Elimination Coordinator
Source: STD*MIS, San Antonio Metropolitan Health District 12

13. Syphilis in Bexar County, Texas
Implications for Practice
Syphilis in Bexar County, Texas 13

14. Use of Data: Informing Criterion for Prophylactic Syphilis Treatment
Treatment offered to
Any MSM who:
>1 sex partner within previous 6 months
Uses Grindr, or similar application
Has anonymous sex
Emphasis placed if they live in 78207
Expanded prophylactic treatment began in April 2015
City STD Clinic is implementing 14

15. Acknowledgments SAMHD Epidemiology Analysis Cara Hausler*
John Berlanga*
SAMHD STD/HIV Branch
Management Staff
Disease Intervention Services Staff
Clinical Staff
SAMHD Executive Leadership
Dr. Anil Mangla
Dr. Junda Woo
CDC / OSTLTS / PHAP
Linda Kirk
PHAP Training and Education Team
PHAP Leadership
*Directly contributed to this project 15

16. Cameron Warner, ype4@cdc.gov
Thank you!
Cameron Warner,
(210)
Centers for Disease Control and Prevention
Office for State, Tribal, Local and Territorial Support