HomeMy WebLinkAboutGrant-Health Dept for elimination of Syphilis 10-19-1999 - 9eORANGE COUNTY
BOARD OF COMMISSIONERS
ACTION AGENDA ITEM ABSTRACT
Meeting Date: October 19, 1999
Action Agenda
Item No. q _ ~,
SUBJECT: Accept Continuation of Grant Funds for the Syphilis Elimination Project and Establish a
New Public Health Educator Position
DEPARTMENT: Health PUBLIC HEARING: (Y/l~ zNo-=
ATTACHMENT(S):
Continuation Letter from NC DHHS
1998 Grant Application from NC DHHS
Syphilis Elimination Project Scope of Work
INFOF:MATION CONTACT:
Rosemary Summers, Health Director
TELEPHONE NUMBERS: Extension 2411
Hillsborough 732-8181
Chapel Hill 968-4501
Durham 688-7331
Mebane 227-2031
PURPOSE:
To accept continuation of grant funds for the Syphilis Elimination Project and to establish a new
permanent, full-time Public Health Educator position to provide community education and outreach
to targeted populations that are at high risk for syphilis.
BACKGROUND:
In 1998 and now in 1999, North Carolina is ranked first in the nation in the number of primary and
secondary syphilis cases. Syphilis has also been identified as a precursor to higher rates of HIV
infection in localities that have high syphilis rates. In 1998, the North Carolina Department of
Health and Human. Services applied to the Centers for Disease Control and Prevention (CDC) for a
grant to reduce syphilis in the state. Five counties that were high morbidity counties were identified
for funding in that initial application; Forsyth, Guilford, Alamance, Orange and Durham. were
targeted counties with high morbidity rates. In 1998 Orange County reported 27 cases of primary
and secondary syphilis. The CDC awarded the grant for one-year to the state. Orange County
received $43,000 to implement the project which includes increasing screening and referrals
especially in identified high-risk populations. The health department at that time chose to hire a
temporary outreach worker to work on the project since the grant funding was only identified for
one year.
In the late spring of 1999, the NC Department of Health and Human Services applied for a
continuation grant from the CDC for this project. Attached is a letter that indicates that the CDC
has approved this project for four additional years of level funding. ($43,000 for Orange County).
The attachment entitled; "Syphilis Elimination Project Scope of Work" outlines the program that is
already in progress. In Orange County, the temporary outreach worker has secured agreements with
the IFC Homeless Shelter and with Freedom House for testing and education of identified
individuals at these facilities. In addition, discussions are underway to implement a plan for testing
and education at the Orange County Jail.
FROM :NC DEHNR HIV/STD 919 733 102QJ
' ~,wa ~ NOrtiB C~COIIQB •
,~' '" Department of Hcait6 and l~uaoau Ssa•vtces
•'~ = s Division of Publie ~Ieaith
~ 1902 Mel Sorviee Ceate~r • Rslei~b, North Carola~a 27699-1902
•o.,,.,..• 22S North Mcbowall Street • Courior 56-32 21
Ann R V4+olfc, M.D., M,P.H., Director
October 13, I999
1999.10^13 13:36 #S78 P.(di/{dl
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Dr. Rosemary Summers
Health Direc~ar
Orange County Health Deparnneat •
add West TYyon Street
Hillsborough, NC 27278
Dear bz_ Sunsmess:
• X am pleased to iufonn you that the HIt~/STD Prevention and Care Branch has received
fitnding from Centezs fer Disease Control and Prevention xa contsnue your. SypltiXis
Elimination Pzoject. Youx county will ba awarded 543,000 farthis project for January
thmttgh December 2()UO contingent upon the availability of funding.
These ftmds are to hire an outreach ararker, travel and pas diem. aperathsg expenses,
condoms anal outreach supplies. Complete details of tba sward will be mailed within the
next three weeks.
Please call Judy Owen O'Dowd at (919} 733.9553 if you have questions regarding this
award.
Sincerely, .
Evelyn Foust, CPM, MPH
Head, HI1~/S'FA Preve~on dnd Care Branch
cc: John. Peebles
Judy Owen-O'Dawd .
Diane Taw
Jthondra McMillan
EveryF~hm+e. EveryDay. EvoryBor{j:
.4n Eg:rat Qpportwttry /,4fJ3rmptive,~4ctiors Employer
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^: remaining cases. Consistent with these similarities between the syphilis and HIV epidemics in
North Carolina, the five-county target azea accounted for 21 % of the state's 1997 HIV cases,
with Guilford, Forsyth and Durham Counties ranking 3rd, 4th and 6th, respectively, among the '
' 100 counties.
_..---
- Outbreaks of syphilis continue to occur in some localities within North Carolina, despite the
noted decline in overall morbidity. •Several counties in central North Carolina-Forsyth,
Guilford, Alamance, and Orange--recently experienced or are currently experiencing outbreaks
of syphilis. Forsyth County, the farthest west of the group, reported increasing numbers of
syphilis cases in the latter part of 1993, with the outbreak peaking in 1995. Shortly thereafrter,
syphilis morbidity began to increase in Guilford County, immediately east of Forsyth County.
Rates in Guilford County appear to have peaked in late 1997, though rates remain well above
baseline levels. In late 1997 and early 1995, small clusters of early syphilis cases began to appear
in areas of Alamance and Orange Counties--the next counties to the east--where syphilis had
previously been uncommon. East of Orange County lies Durham County, an area that has
traditionally had high levels of STDs but recently has had modest primary and secondary syphilis
rates (1 I.2 cases/100,000 in 1997). However, very recent data show that primary and secondary
syphilis.is increasing in. Durbam County, v~~ith more cases in May, 1998 than in the previous four
months combined. '~-
In response to the high syphilis morbidity in Guilford County, the North Carolina HIVISTD
Prevention and Caze Section worked with Guilford County during August 1997 to implement a
Rapid Intervention Outreach Team (R.I.O.T.) effort. The North Carolina RI.O.T. was onainaIly
developed in 1993 as an outbreak response team. The primary fiznction of the R_I.O.T. is to
coordinate efforts among local health deparim.ents, community-based organizations and the state
HTV/STD Prevention and Care Section to rapidly increase outreach education, screening,
diagnostic services, treatment, and partner notification activities in areas that have documented
exceptionally high early syphilis morbidity-. During a R,I.O.T. effort, outreach workers from
community-based organizations and disease intervention specialists (DIS) from around the state
go into an area of high. morbidity to work together as prevention partners. This enables the local
community to offer one-on-one street and community outreach, community-based risk reduction
education, HIV/STD counseling, testing, and referral during non-traditional hours to people who
are infected, exposed or have questions about HTV/AIDS and STDs. Amore detailed description
of R_I.O.T. can be found in North Carolina's 1996 and 1997 Sexually T~r~~tted Dzsease (STD)
Accelerated Prevention Campaign C~:ntinuarion applications.
_ _ During the Gruilford County RI.O.T., a statewide network of community based organizations
and DIS participated in door to-door outreach, counseling, screening and health fairs. The door-
to-door outreach allowed outreach workers, local health department staff, and DIS from across
the state to work together as partners in prevention, sharing techniques. for engaging at-risk
individuals in conversations about HIV/STDs. The RI.O.T. resulted in distribution of 1998 .
packets of syphilis risk reduction information and on-the-spot syphilis counseling and testing to
104 individuals, of wham 13 (12.~%} were positive.
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~ participant responses. The specific intervention strategies recommended for Guilford County
aze: _
1. ~ Increase S'I'D, specifically syphilis, knowledge in the community.
2. Increase awareness of health department STD services. .
;. Increase'community-level and street outreach to the, affected communities.
4. Improve public health professionals' health education skills.
~. Promote and facilitate access to drug treatment.
6. Improve access to the at-risk population by collaborating with external partners (e.Q.
family planning, V~~IC, battered women shelters, jails, housing authority, drug
treatment, parks anal recreation) to provide STD information, screening, and treatment
services:
7. Increase mutually supportive and collaborative partnerships between and among
community-based organizations and the health department.
S. Conduct evaluations of existing prevention strategies.
Although developed for fiord County, the similarities of the syphilis epidemics in the five
counties lead us to believe that~these recommendations are excellent planning tools for this five-
county syphilis elimination project.
The health services available specifically for STDs in the five-county target area include one on-
site clinic in each county health depar~nent, open five days per week. In addition, serologic
testing for syphilis is currently performed by a small number of community-based organizations
in this area. Ek-tension of serologic testing services to better reach the population at high risk is
clearly needed and is one of the goals of this project. Partner notification services are provided
by ten DIS who serve this area; these staff aze responsible for all syphilis and HIS cases in their
area, but do not perfoim any follow-up for other STD cases.. Surveillance for STDs in the five-
county azea is largely passive. Occasional reminders are sent to private physicians to encourage
reporting. In addition, laboratory reporting of positive serologic tests for syphilis is legally
mandated and provides another route for identification of cases to the State. North Carolina does
not currently have any special surveillance azrangements to identify cases in jails, emergency
rooms, drug treatment centers, or other entities which servehigh-risk populations. .
~._-.
The local county health directors from this five-county area met in September, 1997 to discuss
the escalating syphilis epidemic in the area. In addition to pro~nding accessible and prompt STD
diaQn.asis and treatment, the group agreed ta: 1) designate an outbreak response team of 1-2
. _ people from each county to assist other. counties in syphilis intervention when indicated by
morbidity, including worlan.g with the Section in RI.O.T. preparations and efforts when needed;
2) work with the Section to continue to facilitate communication and collaboration between local
health departments, CBOs and private providers; and ~) discuss syphilis and other STDs at the
regional health directors conference every quarter. The health directors have subsequently given
the syphilis elimination project, as outlined here, their full support.
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a) By January, 1999, all community-based organizations offering HIV counseling and
- testing in the five-county area will offer and encourage syphilis serologic testing to
clients requesting HIV tests. ~ -
b) By May, 1999, each outreach worker will provide: weekly risk-reduction sessions at the
local jail, provide one-on-one outreach to individuals. at risk for syphilis in the
community for 8 hours per week and document the establishment of condom distribution
sites which are accessible to at-risk persons.
c) By June, 1999, the new RLO.T. team led by the project coordinator will be ready to
mobilize when needed for new outbreak-s. ~ .
d) By September, 1999, 7~% of individuals who are in local jails more than 24 hours will
receive a serologic test for syphilis.
6. Evaluate the achievements of the syphilis~elimination project through its impact on reported
primary and secondary syphilis morbidity, with a goal of _< 1 ~ cases/I00,000 population in the
five-county target area in the year 2000 (rates in 1997 were 26:? cases/100,000), and on
prevalences of syphilis in local jails, health department prenatal~clinies, and health department
STD clinics. Specific goals will depend on baseline prevalences, which are not currently Imown.
METHOI?S
1. Community Assessment
North Cazalina. will request that CDC allow a federal employee (GS-12) who is currently
assi~ied to the state to become a special projects ofncer for the project. This individual will
coorainate and provide direct oversight to the project, and develop and implement data collection
for project evaluation. The community assessment teams will be comprised of the project
coordinator, a county health educator and a local DIS in each county; teams will conduct rapid
community assessments in the high morbiaity azeas of Forsyth, Alamance, Orange, and Durham
Counties. The rapid community assessment tool developed by 3o Valentine (CDC) and
implemented recently in Guilford County will be used. State and local DIS have demonstrated
their ability to successfully perform this assessment in Guilford Count3~. Information on syphilis
clinical services available in each county ~nll be collected by the coordinator, assisted by local
DIS. This infaimation will include availability and utilization of syphilis screening in local jails
and drug treatment centers. These assessments will allow characterization of the local population
at high risk for syphilis, local factors promoting syphilis transmission, and local barriers to
s~~philis dia.`~nosis, treatment, anal prevention. Data analysis will be assisted by state and federal
staff familiar u*ith epidemiologic analyses.
Each county's surveillance system for syphilis will be evaluated by the project coordinator and
local DIS, assisted by state staff.. This evaluation will include assessing the sensitivity of the
current s3>stem by contacting local clinical service providers that serve high-risk populations and
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!"'~ a) Outreach worker activities--The outreach workers will be liaisons among the health
department, community-based organizations, and other local agencies which serve populations at
high risk for syphilis. These agencies will include drug treatment centers, county and city j ails,
Local housing authorities, and the parks and recreation departments. Outreach workers will focus
attention on the diagnosis, treatment and prevention of syphilis. They will work with the
agencies to insure that clinical and prevention services are provided to those at highest risk.. For
example, they may work with the housing authority and the parks and recreation departments to
provide educational sessions and periodic serologic testing. A housing office may agree to
become a distribution point for condoms. Routine testing and educational sessions may be set up
at the jails and drug treatment centers. The outreach worker will provide transportation to those
who need syphilis clinical services and are otherwise unable to access them.
The syphilis outreach workers will also provide direct outreach services to the at-risk population.
The workers will coordinate with other community-based health outreach workers in the county
to provide group outreach at least tvG~ice per month to high risk areas in each county. The
outreach worker will provide one-on-one syphilis risk reduction education in the at-risk
communities several times per week. Condoms will be distributed during each outreach. One-
on-one or small group demonstrations on how to properly use a condom will be standard. Blood
samples will be collected by the outreach worker when desired by the clients to allow for
serologic testing far syphilis without a clinic visit. In order to reach persons at highest risk for
acquiring syphilis, the outreach worker will work flexible hours, since persons at greatest risk
.may be most accessible during the evening hours.
The outreach worker will establish a close working relationship with state and local DIS. The
outreach worker will attend twice monthly `=chalk talks" u~zth the DIS and other HIV/STD
regional staff . This -will keep both the outreach worker and DIS informed of each others'
activities. This will also assure that "hot spots" are identified immediately and plans made to
provide screening and cltistering~in the area. The outreach worker will also assist DIS with
identiuication and location of high risk individuals, such as marginal partners, suspects, or.
assbci:ates who may not otherwise be found. However, the outreach worker will not replace any
ead.sting DI5 activities; this project will be used only to enhance current activities. The regional
and local DIS will continue to provide disease intervention services as outlined in the 1998
Continuation Application STD Accelerated Prevention Campaign Grant.
The outreach worker will also work with local health department staff to insure that providers are
educated about those individuals at risk and how to best provide them services. This may
include cultural sensitivity training, STD treatment information, STD diagnostic techniques and
client-centered counseling. Vdhen needed, state resources for providing such training will be
used. The Local health departments will provide STD clinics that are accessible and convenient
to those at risk. Evening andlor weekend hours may need to be considered for infected persons
to access treatment.
b) Clustering techniques--Local DIS will use clustering. techniques when inter~newing syphilis
cases in the target area. These techniques have proven effective at identifying cases in Guilford
County, where trading sex for drugs was a common activity in syphilis patients. Since this risk
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• ~ EVALUATION
1 Evaluation of ongoing appropriateness of elan '
To gather information on how we can best target prevention anal screening activities on an
ongoing basis, several sources. of data will be examined quarterly. First, DIS v~nll include the
following questions ~ their interviews of syphilis infected individuals in the five-county area:
1. Has the patient been to an emergency room within the last month? three months?
2. Has the patient been in a drug treatment program in the last month? three months?
3. Has the patient been in jail or prison in the last month?three months?
. 4. Has the patient been to a health department clinic in the last month? three months?
5. If yes to 4,-which clinic? (STD, Family Planning, Adult Health, Prenatal, etc.)
6. Has the patient received health care in other settings in the last month? three months?
7. If yes to 6, where? (Specify which private physician, community health center, etc.)
Responses to these questions will suggest locations where screening would be an effective case-
finding tool Second, early syphilis case data will be analyzed to monitor the demographics of
case patients, the routes through which cases are identified (partner notification,.clustering, jail
screening, community-based organization screening, etc.), and the behavioral risk factors of
cases. Third, DIS activity will be analyzed to assess the effectiveness of partner notification
activities and the ongoing need for alternative methods such as clustering. Examination of these
data will allow us to promptly identify changes in the local epidemiology of syphilis, including
new outbreaks, and to provide a response appropriate to the specific sociocultural setting of the
cases.
?. Evaluation through Process Objectives
Achievement of objectives TI-3 will be monitored and documented by the project coordinator,
and achievement of specific objectives under objective n~ will be monitored and documented
once implementation of the syphilis elimination plan has be„wn. These achievements will be
reported quarterly to all participating organizations, the Regional Health Director's Group, and
the Section.
3. Evaluation through Outcomes
Reported primary and secondary syphilis morbidity in the five-county area will be monitored and
documented. Cases are expected to increase initially as case-finding efforts are intensified and as
• active surveillance increases reports from some agencies. Cases should then decline as
transmission is interrupted by prompt identification and treatment of infectious cases. Due to the
uncertain. impact of reporting changes on morbiairy trends, prevalence monitoring will provide a
_ more rigorous evaluation of the impact of this project. Prevalence monitoring ~dll be undertaken
" in several setdngs, including local jails, health department prenatal clinics, and health department
STD clinics. Prevalence data will be collected from the beginning of jail screening, and is
available from health departrnent clinics. ~ Project staff will compile data quarterly and report it to
all participating organizations, the Regional Health Director's Crrotip, and the Section.
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The new R.I.O.T. team led by the project coordinator will be ready to mobilize when
needed for new outbreaks.
75% of individuals who are in local jails more than 24 hours will receive a serologic test
for syphilis.
The syphilis elimination project will be evaluated through its impact on reported primary
and secondary syphilis morbidity, with a goal of s 15 cases/100,000 population in the five-
county target area in the year 2000 (rates in 1997 were 26.2 casesl100,000), and on
prevalences of syphilis in local jails, health department prenatal clinics, and health
department STD clinics. Specific goals will depend on baseline prevalences, which aze
not currently known.
Each county will be awazded $43,000 for calendar year 1999.. Funds will be used to either hire an
outreach worker, or contract with a Section approved community based organization to hire an
outreach worker. Funds are also~provided for~travel and per diem, pager cellular phone and other
operating expenses. Additional funding has been provided for the purchase ~of patient acceptable
condoms and other outreach supplies. The proposed funding breakdown which was submitted to
CDC is: -
Outreach Worker Salary and Fringe $27,500
Travel and Per Diem $ 3,000
Phone, pager, and office expenses $ ~ 1,000
Condoms and Outreach Supplies ~ $11,500