HomeMy WebLinkAboutAgenda - 11-03-1999 - 9ci
ORANGE COUNTY
BOARD OF COMMISSIONERS
Action Agenda
.Item No. _ 9- C,,
ACTION AGENDA ITEM ABSTRACT
Meeting Date: November 3, 1999
SUBJECT: Accept Continuation of Grant Funds for the Syphilis Elimination Project and Establish a
New Public Health Educator Position
DEPARTMENT: Health PUBLIC HEARING: (Y/1~ 1Vo~;
ATTACHMENT(S):
Continuation Letter from NC DHHS
1998 Grant Application from NC DHHS
Syphilis Elimination Project Scope of Work
INFORMATION CONTACT:
Rosemary Summers, Health Director
TELEPHONE NUMBERS: Extension 2411
Hillsborough 732-8181
Chapel I3i11 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.
Since the continuation funds are available for four additional years, the health department is
requesting that a permanent, full-time outreach worker position be established to carry out this
project, subject to progress in achieving the program objectives outlined in the attachment and
subject to the continuation of grant funds. The new position's duties will include:
• Identifying and locating individuals and communities that are at highest risk of intervention and
outreach.
• Visiting jails, drug rehabilitation centers, homeless shelters, etc. to conduct educational
presentations and one-on-one counseling on prevention, diagnosis and treatment of syphilis.
• Collaborating with other public and private agencies in an effort to share disease intervention
activities and identify areas for outreach, screenings and cluster activities in the County.
The primary outcome of this program is to decrease the rate of syphilis to .4 cases per 100,000
population. Orange County's syphilis rate for CY 98 was 24.8 per 100,000 population.
Personnel has reviewed the proposed duties for the new position and determined it should be
classified as Public Health Educator at Salary Grade 66 with a hiring range of $27,787 - $33,774.
The position will report to the Adult Health Section Nursing Supervisor.
Identification, treatment, and follow-up of sexually transmitted diseases is one of the core functions
of the Orange County Health Department. Current staff is not sufficient to be able to address this
emerging problem.
FINANCIAL IMPACT:
The continuation of grant funds in the amount of $43,000 are sufficient to cover the cost of the
Public Health Educator's salary and benefits, as well as some program costs. No County general
funds are required for this project.
RECOMMENDATION(S):
The Manager recommends the Board accept the continuation of grant funds in the amount of
$43,000 and establish a permanent, full-time Public Health Educator at Salary Grade 66, subject to
the continuation of grant funds.
FROM :NC ~NR HIV/STD 919 733 1m20 1999.10-13 13:36 it576 P. 01101
•„* ~ Nord! Carolina
Department of Hea1tl+ ,ad Hnmaus Services 3
r Division of Public Health
1902 Mss Sotvite Ceuoer • Raleigh, Noah Cerolma 27649-1902
'..., Z2S North McDnweli Street • Cvwier 56.32-21
Ann F. Wolfe, M.D., M.P.H., Director
October 13,1999
Dr. Rosemary Summers .
Health Director _
Orange County Health Depardaunt '
300 West TYyoa Street
Hillsborough, NC 27278
Dear Dr. Sutnanors:
Y am pleased to inform you that the HIVISTD Prevetltion and Cain $t~anch has received
funding from Cessters for Disease Co~ai and Preveatian to continue your Syph~is
Elimination Project. Youx county wi11 ba awarded 543,000 forThis pro}oct for January
through Deceaabez 2000 contingent upooe the availability of funding.
These lSmds are to hire as oumach vvarl0er, travel and par di>~a. opexating cXpensts,
condoms and outreach supplies. Camplcte details of the award wilt be mailed within the
next three week.
Please call 7udy Owen-O'Dowd at {9l9) 733-9553 if you have quesl4~ons rcga~cding this
award.
Sincerely,
cc: .John Peebles
Judy Owen-O'Dowd .
Diane Tcw
Rhoandra McMi13au
EveryJ~fim+e EveryDay, EveryBo~j
~~
Evelyn Foust, CPM, MPH
Head, HIV/5~'A Preven»ion and Care Bra~aeh
An Fgrra! Opporlrottt~-l~tr~tiveActiow ~-'
SYPHII.IS ELIlVIINATION
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1998 CONTIl~fTATION APPLICA.TIOl~T
STD ACC~L~RATED PR~VEI~T'TIOl~T
CAd~PAIGN GRAI~TT
I
North CarolinaHIV/STD Prevention and Care Section
Grant ~H25/CCH40433~
June 30,1998
NARRATIVE
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Despite substantial achievements in controlling syphilis during the current syphilis epidemic,
North Carolina continues to have unacceptably high syphilis morbidity, including small numbers
of congenital syphilis cases. Outbreaks of syphilis continue to appear in areas with lazge at-risk
populations. To interrupt syphilis transmission in these high risk communities, the state
proposes to develop acommunity-wide syphilis elimination plan for afive-county area in central
North Carolina where syphilis morbidity has recently intensified. This five-county target area
Forsyth; Guilford, Alamance, Orange, and Durham Counties-- accounted for 285 (39.5%) of the
721 primary and secondary syphilis cases reported from North Carolina's 100. counties in 1997.
~:4CKGROiJND
North Carolina ranks~first in the nation in the number of primazy and secondary syphilis cases,
and third in the primary and secondary syphilis rate. The current syphilis epidemic, beginn?ng in
the middle 1980s, peaked in North Carolina with a primary and secondary syphilis rate of 36.2
cases per 100,000 population in 1992, and subsequently waned, dropping to a raze of 9.7 cases
per 100,000 in 1997, a drop of 73.2% in five years. During this time, syphilis rates dropped in
all age, race, and gender groups. However, there has been substantial geographic and
demographic variability in total syphilis morbiaity and in syphilis trends. From 1992 to 1997,
primary and secondary syphilis in the five-county tazget area increased by 4.0%. Among African-
Americans in North Cazolina, the primary and secondary syphilis rate dropped 74.7% from 149.3
cases per 100,000 population in 1992 to 37.7 cases per 100,000 in 1997, yet African-Americans
.- accounted for 84.3% of primary and secondary syphilis cases in 1997 and had razes more than
25-fold higher than whites. Ten percent of 1997 cases were in whites and the remaining 5.5% in
other ethnic groups.
Persons with syphilis are older, on average, than persons with other sexually transmitted diseases
(STDs). During the current syphilis epidemic in North Carolina, the highest rates inmost years
have be°..n among 20- to 24-year-olds. and 25- to 29-year-olds, but since 1995, rates have been.
similar in all age groups 20-34 years. In 1997, the highest rate was in 30- to 34-yeaz-olds (24.1
cases/100,000). This relative aging of the population acquiring syphilis is consistent with local
observations that the disease has become foctsed in core populations of drag users, commercial
sex workers, and associated persons.
As the syphilis epidemic has waned in North Carolina., congenital syphilis rates have dropped as
well. From 1992 to 1997, cases dropped 82.1 %, from 78 to I4 annual cases. During this time,
cases in African-Americans dropped 84.9%, v~~ile cases in whites and Hispanics were stable at
low numbers.
Populations at risk for syphilis are also at risk for HN, a risk which is compounded by the
enhancement of HIV tr~n~~~sion in the presence of genital ulcers. As in other parts of the
southeastern United States, heterosexual +*a*-~i~sion is increasingly responsible for the HIV
epidemic in North Carolina. The proportion of HIV cases attributed to heterosexual contact in
1994-96 was 3 9%, up from onty 11 % in 199D-93. As with syphilis, minorities are
disproportionately impacted by HIV in North Carolina. Outing the 1990-96 period, a stable 77%
of HIV cases were in African-Americans, with whites accounting for the majority of the
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^•. remaining cases. Consistent with these similarities between the syphilis and HIV epidemics in
North Carolina, the five-county tazget area accounted for 2T% of the state's 1997 HIV cases,.
with Guilford, Forsyth and Durham Counties ranking 3rd, 4th and 6th, respectively, among the
100 counties.
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Outbreaks of syphilis continue to occur in some localities within North Cazolina, despite the
noted decline in overall morbidity. Several counties in central North Cazolina--Forsyth,
Guilford, Alamance, and Orange--recently experienced or aze 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 thereafter,
syphilis morbidity began to increase in Guilford County, immediately east of Forsyth County.
Rates in Guilford County appeaz to have peaked in late 1997, though rates remain well above
baseline levels. In late 1997 and early 1998, small clusters of early syphilis cases began to appear
in azeas 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 primazy and secondary syphilis
rates (11.2 cases/100,000 in 1997). However, very recent data show that primary and secondary
syphilis is increasing in Durham County, with more cases in May, 1998 than in the previous four
months combined.
In response to the high syphilis morbidity in Guilford County, the North Cazolina HIV/STD
Prevention. and Care Section worked with Guilford County during August 1997 to implement a
Rapid Intervention Outreach Team (R.I.O.T.) effort. The North Cazolina RI.O.T. was onQinally
developed in 1993 as an outbreak response t,.am. The primary function of the R.I.O.T. is to
coorainate efforts among local health departments, community based organizations and the state
HIV/STD Prevention and Caze Section to rapidly increase outreach education, screening,
diagnostic services, treatment, and partner notification activities in areas that have documented
exceptionally high eazly syphilis morbidity. During a R.I.O.T. effort, outreach workers from
community-based organizations and disease intervention specialists (DIS) from azound 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
aze infected, exposed or have questions about HIVIAIDS-and STDs. Amore detailed description
of RI.O.T. caa be found in North Carolina's 1996 and 1997 Sexually Transmitted Disease (STD)
Accelerated Prevention Campaign Cc:ntinuation applications.
_ During the Guilford County RI.O.T., a statewide network of community based organizations
and DIS participated in door-to-door outrcach, cotmseling, 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 whom 13 (12.5%) were positive..
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,'"~ The difficulties encountered in routine partner elicitation of those exposed to or at risk far
syphilis in Guilford County prompted DIS to screen at corner hang outs, crack houses, and liquor
houses where original patients reported sexual encounters. Clients with previous histories of
syphilis who had no current clinical signs of infection but were believed to be at high risk,
received preventive benzathine penicillin therapy. This form of "social network" clustering
resulted in 38 individuals tested for syphilis with 9 (38%) having positive tests. Although only 4
of the tests were new positives, the remaining S were serofast titers, confirming that high-risk
individuals were being reached.
A critical component of a R,I.O.T. is the follow up to maintain the decrease in morbidity that has
been achieved. In Guilford County,, staff worked to continue relationships with the community
and providers which were enhanced or strengthened during the R.I.O.T. The Guilford County
agencies continue to meet to discuss problems and have occasional projects together. However,
resources are currently insufficient to maintain an active syphilis prevention or elimination
campaign beyond usual activities.
Following the Guilford RI.O.T., CDC assisted the Section and local health department with. an
evaluation of the Guilford syphilis outbreak and a rapid community-based needs assessment to
tailor future syphilis prevention and control efforts. The outbreak evaluation revealed a strong
relationship between syphilis cases and crack cocaine, whether used by the patient or the se~.-ual
contact During 1997, interviewed Guilford syphilis cases claimed an average of 3.2 partners,
but were able to provide sufficient information to initiate locating activity for 1.7 partners per
case. Given that 38% of cases had traded sex for drugs or money--a dramatic increase from 10°~0
in 1994--the average 3? partners par case is probably understated. Consistent v~~ith disease
transmission in a setting ofnumerous--often anonymous--sexual partners, yet low numbers of
partners that could be initiated, clustering was found to be an effective technique for identifying
infected persons. The same investigation revealed that emergency rooms and ja.iLs, who also have
contact with crack users, were not screening for syphilis in the vast majority of cases. Based on
more limited information, the Forsyth County and, more recently, Alamance and Orange County
syphilis outbreaks appear to be similar in their low proportion of partners with location
information and their strong relationship with crack cocaine. During the peak of the Forsyth
County outbr°..ak in 199, cases reported an average of 3.5 partners, but provided sufficient
information to initiate locating activities for only 2.0 partners per case. Despite currently
decreasing numbers of syphilis cases in Forsyth County, an increasing proportion are in persons
who have traded sex for drugs or money, from 28% in 1994 to 4I% in 1997.
A t..am of f ve staff conducted the rapid community-based needs assessment in Guilford County
is Saauary 1998. The goals of the assessment were to: 1) determine points of access for persons
ax behavioral risk for syphilis, 2) ascertain culturally appropriaxe and acceptable syphilis
prevention messages and strategies, and 3) tailor outreach and screening efforts. The team
conducted b4 interview and one focus group with relevant service providers and those perceived
to be at behavioral risk for syphilis (key participants). The attached Guilford County Rapid
Community Assessment Report, includes the analysis and summary of data obtained from these
intervieR~s. Recommendations were developed through a comparison of the provider and key
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~~ participant responses. The specific intervention strategies recommended for Guilford County
are:
1. " Increase STD, specifically syphilis, knowledge in the community.
' 2. Increase awareness of health department STD services.
3. Increase community-level and street outreach to the affected communities.
4. Improve public health professionals' health education skills.
S. Promote and facilitate access to drug treatment.
6. Improve access to the at-risk population by collaborating with exrternal partners (e.g.
family planning, WIC, battered women shelters, jails, housing authority, drug
' treatment, parks and 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..
. 8. Conduct evaluations of e3asting prevention strategies.
Although developed for Guilford County, the similarities of the syphilis epidemics in the fzve
counties lead us to believe that these recommendations are excellent planning tools for this five-
county syphilis elimination project.
The health sen~ices available specifically for STDs in the five-county tazget area include one on-
site clinic in each county health department, open five days per week. In addition, serologic
testing for syphilis is currently performed by a small number of community-based organizations
in this azea. Extension 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 are responsible for all syphilis and H1V cases in tizeir
azea, but do not perform any follow-up for other STD cases. Surveillance for STDs in the five-
". county area 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 arrangements to identify cases in jails, emergency
rooms, drug treatment centers, or other entities which serve higiz-risk populations.
The local county health directors from this five-county area met in September, 1997 to discuss
the escalaxing syphilis epidemic in the ar-„a.. In addition to providing accessible and prompt STD
diagnosis and treatment, the group agreed to: I) designate an outbreakresponsetenm of 1-2
people from each county to assist other counties in syphilis intervention when indicated by
morbidity, incluaing working 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 3) 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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'~. QBJECTIVES
1. Assess populations at high risk for syphilis, factors which promote syphilis ir~nsmission, and
barriers to syphilis u~eatment and prevention in high morbidity areas of Forsyth, .P: amance,
Orange and Durham Counties, by December 31, 1998.
a) Conduct and analyze rapid community assessments using the tool developed for the.
Guilford County Rapid Community Assessment.
b) Assess the availability of syphilis diagnostic and treatment services in Forsyth,
Alamance, Orange and Durham Counties, including services provided by county health
departments and services provided by other public and private providers by December 31,
1998.
c) Assess the surveillance system for syphilis in the five-county area by December 31,
1998.
d) Characterize the moleculaz epidemiology of Treponema pallidum in the five-county
azea during 1998-99.
2. Develop a targeted syphilis elimination plan for the five-county area with individualized plans
for each county based on the rapid community assessments by March 31, 1999. _
a) Assist each county in hiring an outreach worker for the project by December 31, 1998.
b) Assist each county in developing a syphilis awazeness task force which will provide
local monitoring of the syphilis elimination activities.
c) With the participation of the Tocal syphilis awareness task forces and. Local DIS, project
staff will develop a syphilis elimination plan for the five-county area.
3. Implement syphilis elitninaxion plan beginning April 1, 1999. Specifics of the plan will
depend on results of community assessments. However, each plan is expected to include the
following components: outreach worker educational and sazeening activities, clustering
techniques by local DIS, screening fir syphilis in jails and community based organizations
performing HIV counseling and testing, and contribution to the outbreak response team.
4. Evaluate and document the appropriateness of the syphilis elimination plan targeting through
quarterly assessment of the popuiaxion aiiected by syphilis and their utilization of health services
for syphilis, and revise specinc targeting of plan as indicated by this assessment.
S. Evaluate the achievements of the syphilis elimination project through process objectives,
includi~ all those given above and:
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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 RI.O.T. team led by the project coordinator will be ready to
mobilize when needed for new outbreaks.
d) By September, 1999, 7~% of indi~riduals who are in local jails more than 24 hours will
receive a serologic test for syphilis.
6. Evaluate the achievements of the syphilis~elimination praject through its impact on reported
primary and secondary syphilis morbidity, with a goal of s I ~ cases/100,000 population in the
five-county target area in the year 2000 (rates in 1997 were 26.2 cases/100,000}, and on
prevalences of syphilis in local jails, health department prenatal~clinics, and health department.
STD clinics. Specinc goals will depend on baseline prevalences, which are not currently known.
METHODS
1. Community Assessment
North Carolina will request that CDC allow a federal employee (GS-12) who is currently
assigned to the state to become a special projects of"ncer 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 arras of Forsyth, Alamance, Orange, and Durham
Counties. The rapid community assessment tool developed by Jo 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 County. Information on syphilis
clinical services available in each county v~~ill be collected by the coordinator, assisted by local
DIS. This information 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
syphilis clia Gnosis, treatment, and prevention. Data analysis will be assisted by state and federal
start familiar with 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 system by contacting local clinical service providers that serve high-risk populations and
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:'~ determTnt*+g the syphilis cases seen in the last quarter and comparing these to cases reported.. In
• ~ addition, procedures for screening and reporting cases will be reviewed at each local jail, drug
treatment center, emergency room, and other clinics which serve the high-risk population.
To better understand the epidemiology of syphilis cases, we plan a pilot project to characterize
strains of Treponema pallidum. With the collaboration of the Division of AIDS, STD, and T13
Laboratory Research, Center for Infectious Diseases, we will assess T. pallidum strains within
our five-county target area in 1998-99. These data will allow us to evaluate the hypothesis that
the syphilis epidemic is moving across the central part of the state, presumably facilitated by the
movement of core transmitters. Empiric demonstration of strain movement from county to
county, or demonstration that local epidemics are not linked, will help direct future prevention
efforts. •
2. Plan Development
Each county will be given funds to hire an outreach worker. The county will either hire the
outreach worker or contract with a community based organizaxion to hire the worker. The
outreach workers will need to be street smart, nonjudgmental, and respected by the communities
and individuals at risk. The outreach workers will also be trained in phelobotomy so that they
can obtain blood specimens outside of clinic settings. The outreach workers should be in place by
December 31,1998. Regardless of the employer, the outreach worker will work closely with the
county health department, the community-based organizations, other county agencies and the
Section. These relationships will be established through a memorandum of understanding.
A syphilis awareness task force will be formed in each county. by inviting representatives from
(at a minimum) health-related CBOs, the county jail, the housing authority, and the Iocal health
department, as well as the syphilis outreach worker. The task forces will meet at Ieast quarterly
to assess the impact of syphilis intervention and plan intervention activities for the following
quarter in the county.
A syphilis elimination plan, customized for each county, will be developed through the joint
efforts of the project coordinator, local DIS, local CBO representatives, other members of the
syphilis awareness task force, and Section star'fi Results of the community and clinical ser traces
assessments as described above will be used to determine the details of each county's plan.
Because of similarities among the syphilis. outbreaks in this area of North Carolina, it is e~.-pected
that the plans will have many common components, but local #leaibility is critical.
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~. Plan Implementation
Although the specifics of the plan will vary.from county to county, and will not be determined
until after the community assessments are performed, same basic components are expected: to be
included based on previous work done in Guilford County. These components are outlined
below.
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~~ a) Outreach worker activities--The outreach workers will be liaisons among the. health
department, community-based organisations, and other local agencies which serve populations at
high risk for syphilis. These agencies will include drug treatment centers, county. and :city jails,
local housing authorities, and the parks and recreation depar~ments. 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 pazks 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 tR~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 for syphilis without a clinic visit. In order to reach persons at highest risk for
acquiring syphilis, the outreach worker will work flexible hour, 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" with the DIS and other HIVISTD
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 clustering~in the area, The outreach worker will also assist DIS with
identincation and location of high risk individuals, such as marginal partners, suspects, or
associates who may not otherwise be found. However, the outreach worker will not replace any
eadsting DIS 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 Grrant.
The outreach worker will also work with local health department stair 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. When 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 and/or weekend hours may need to be considered for infected persons
to access treatment.
b) Clustering techniques--Local DIS will use clustering. techniques when interviewing syphilis
cases in the target ar-.,a. These techniques have proven effective ax identifying cases in Guilford
County, where trading sex for drugs w•as a Gammon activity in syphilis patients. Since this risk
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!~ factor is likewise common in the entire five-county area, clustering can be expected to be more
eliectil=e than strict pa~-txter elicitatioIl and notification. __
c) Enhanced surveillance activities--Surveillance for syphilis will be enhanced in the five-county
tazget azea through screening in jails and non-health department HN counseling and testing sites,
and through implementation of active surveillance of jails, emergency rooms, and providers
serving high-risk populations. The outreach worker will establish a relationship with the county
jails. Several of the local jails currently provide limited syphilis screening, but none provide
screening to all individuals as they enter the jail. Routine syphilis testing should be provided in
each county jail. A mechanism will be established to facilitate testing of the blood within 24
hours. The outreach worker will assure that at least weekly educational sessions aze presented to
inmates in each jail ~on syphilis, HIV and other STDs. Jail health staff will be trained to
recognize symptoms of syphilis and immediately refer anyone with suspicious symptoms to
testing (if not already done) and treatment.
The Section and local health departments cuaently work with at least seven community-based
organizations in these five counties: Step One, Community Connection, CAARE, Inc., Mount
Sinai AIDS Education Project, Triad Health Project, Sickle Cell Disease Association of the
Piedmont, and Alamance Cares. Many of these community based organizations provide HIV
counseling and testing as part of their prevention services. Several months ago the Section began
work with all community-based organizations in the state who were providing HIV counseling
and testing ser~~ices to also include syphilis testing services. This will become a prerequisite for
Section-funded community-based organizations providing HIV counseling and testing services
on January 1,1999. Staff are currently working with community-based organizations in the f ve-
county azea to assure that syphilis testing is .strongly encouraged for everyone tested for HIV.
These community-based organizations also include syphilis prevention messages in all of their
HN prevention efforts. Through this pmject the community and health department relationships
will be further enhanced and STD prevention will become a more prominent part of all HN
prevention messages.
The local health department staff DIS, and outreach workers will work together to ensure that all
cases aze promptly reported, int,-rviewed and counseled. These activities will include active
surveillance of emergency rooms, county jails and providers serving communities at high risk.
d} Outbreak response team North Carolina developed an outbreak response team, R.I.O.T., in
1993. Due to R.I.O.T.'s success, the state will .continue to use the R.I.O.T. model for rapid
aisease intervention and outreach in outbreak situations. As stated earlier in this report, the
outreach tazQe*s and identifies individuals at high risk for infection, the DIS are able to
concentrate efforts to identify and bring to treatment those at highest risk for syphilis and those
who are infected, and this effort prepares the health department and community based
organizations for the type of cooperation and collaboration needed to interrupt syphilis
transmission. The plan will be revised to .include the syphilis elimination project coordinator as
the RI.O.T. team leader, and the five syphilis outreach workers as team members. With these
_ ~ changes, implementation of a RI.O.T. effort should require a very limited amount of time and
the t..am should be exceedingly mobile.
9
15
• ~ EVALUATION
1 Evaluation of oneoin ag~Tnpropriateness ofplan
To gather information on how we can best target prevention and screening activities on an
ongoing basis, several sources of data will be examined quarterly. First, DIS will include the
following questions iu their interviev~~s 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 proeram 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 5, 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
nevv outbreaks, and to provide a response appropriate to the specific sociocultural setting of the
cases. '
~ Evaluation through Process Obiectives
Achievement of objectives ~1-3 will be monitored and documented by the project coordinator,
. and achievement of specific objectives under objective ~~ will be monitored and documented
once implementation of the syphilis elimination plan has b Amin. These achievements will be
reported quarterly to all participating organizations, the Regional Health Director's Group, and
the Section.
Evaluation through Outcomes
Reported primary and secondary syphilis morbiaity in the five-county area will be monitored and
documented. Cases are ekpected to increase initially as case-Ending efforts are intensified and as
• active surveillance increases reports from some agencies. Cases should then decline as
~n~ission is interrupted by prompt identification and treatment of infectious cases. Due to the
uncertain impact of reporting changes on morbiaity trends; prevalence monitoring will provide a
_ more rigorous evaluation of the impact of this project. Prevalence monitoring Kill be undertaken
in several settings, including local jails, health department prenatal clinics, and health department
STD clinics. Prevalence data will be collected from the be;~'inning of jail screening,. and is
available from health department clinics. Project staff will compile data quarterly and report it to
all participating organizations, the Regional Health Director's Group, and the Section.
14
16
SYPHILIS ELINIINATION PROJECT
SCOPE OF WORK
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 thereafter,
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 1998, 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 (11.2 cases/100,000 in 1997). However, very recent data show that primary and secondary
syphilis is increasing in Durham County, with more cases in May, 1998 than in the previous four
months combined. . -
The first year of this project, the Project Coordinator and the local Syphilis Elimination staff will
Assess populations at high risk for syphilis, factors which promote syphilis transmission,
and barriers to syphilis treatment and prevention in high morbidity areas of Forsyth,
Alamance, Orange and Durham Counties.
Develop and implement a~targeted syphilis elimination plan for the five-county area with
individualized plans for each county based on the rapid community assessments. Each
plan will. include the following components: outreach worker. educational and screening
activities, clustering techniques by local DIS, screening for syphilis in jails and
community-based organizations performing HIV counseling and testing, and contribution
to the outbreak response team.
Evaluate and document the appropriateness of the syphilis elimination plan targeting
through quarterly assessment of the population affected by syphilis and their utilization of
health services for syphilis, and revise specific targeting of plan as indicated by this
assessment.
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.
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.
17
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 cases/100,000), 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 are
not currently known.
Each county will be awarded $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