ocular syphilis response: north carolina,...
TRANSCRIPT
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May 5, 2017
Anna Cope, PhD, MPH
Epidemiologist
DSTDP/NCHHSTP/CDC
North Carolina Division of Public Health
Ocular Syphilis Response: North Carolina,
2014-2015
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Ocular Syphilis
• An inflammatory eye disease
• Causes a variety of ocular signs and symptoms
- Eye redness, eye pain, blurry vision, and vision loss
• Recommended treatment is IV penicillin G for 10-14 days
• Ocular manifestations not routinely reportable to CDC
1Worksowski KA, Bolan GA, CDC. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015.
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Clinical Advisory
• Clusters of ocular syphilis cases were reported from Seattle and San Francisco in early 2015 and CDC was notified.
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The North Carolina Response
• February 2015: DIS were instructed to ask about eye symptoms during every syphilis case interview AND document reported symptoms in the North Carolina Electronic Disease Surveillance System (NC EDSS)
• March 2015: The North Carolina (NC) Division of Public Health (DPH) issued a clinical advisory.
• December 2015: Requested Epi-Aid from CDC
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Goals of Ocular Syphilis Epi-Aid
1. Describe the population of ocular syphilis cases in NC
2. Identify potential risk factors for ocular syphilis
3. Compare ocular and non-ocular syphilis cases
4. Describe the sequelae of ocular syphilis
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Case Identification
• Case Definition:
- A confirmed syphilis case reported to the NC DPH during 2014-2015 who reported symptoms of ocular disease with no other defined etiology
• Case ascertainment from NC EDSS:
- Eye/Conjunctiva check box
- Text search of DIS notes
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Data Collection
1. NC EDSS Surveillance Data Pull
- Demographics, Clinical Factors, Treatment, Risk Factors
2. Medical Chart Review and Data Abstraction
- Requested from reporting provider to supplement surveillance data
3. Follow-Up Interviews
- Describe clinical course of disease
- Identify potential risk factors not captured in surveillance
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Results: Syphilis 2014-2015
4232 Confirmed Syphilis
Cases
4169 (98.5%) Non-Ocular
Syphilis
63 (1.5%) Ocular Syphilis* 53 checkbox
* 10 text search
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Results: Syphilis 2014-2015
4232 Confirmed Syphilis
Cases
4169 (98.5%) Non-Ocular
Syphilis
63 (1.5%) Ocular Syphilis* 53 checkbox
* 10 text search
During 2014-2015: – All stages of syphilis increased by 35%
– Report of ocular syphilis increased by 115%
– Cases were reported from 33 of 100 counties
– No ocular syphilis case named another ocular syphilis case as a sex
partner
2014 2015
N=20 N=43
N=1776 N=2393
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Ocular Case Demographics (N=63)
• ≥ 40 years old (60%)
• White (49%), Black (44%)
• Male (94%)
• MSM (63% of men)
• HIV-positive (56%)
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Ocular Case Clinical Factors
• Median RPR:- 1:128 (Range 1:1-1:16,384)
• Syphilis Stage:- Primary/Secondary: 38%
- Early Latent: 14%
- Late Latent/Latent with Clinical Manifestations: 48%
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Reported Eye Symptoms
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Eye Exam Diagnoses
Eye exam verified for 49 (78%) cases
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Ocular Syphilis Treatment
Treatment Regimen N %
10-14 days of IV penicillin
(recommended treatment)
42 67
IM Benzathine penicillin only 13 21
Other treatment regimen 5 8
Unknown treatment status 3 5
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Ocular versus Non-Ocular Syphilis
Ocular Syphilis
N = 63
Non-Ocular
Syphilis
N = 4169
Prevalence Ratio
( 95% CI)
% %
Male 1.7 98.3 2.82 (1.03, 7.73)
Race
Black 1.1 99 Ref
White 2.8 97.2 2.64 (1.59, 4.37)
Other 0.5 99.5 0.45 (0.11, 1.86)
Age (years)
<40 0.9 99.1 Ref
≥40 2.8 97.2 3.27 (1.98, 5.39)
Reported MSM (among men only) 1.6 98.4 0.83 (0.49, 1.40)
Stage of syphilis
Primary/Secondary 1.4 98.6 Ref
Early Latent 0.8 99.2 0.61 (0.28, 1.30)
Late Latent/Latent w clinical manifestations 2.2 97.8 1.58 (0.93, 2.69)
Median (IQR) Median (IQR) Wilcoxon p-value
RPR 128 (64-256) 32 (8-128) <0.0001
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Ocular versus Non-Ocular Syphilis
Ocular Syphilis
N = 63
Non-Ocular
Syphilis
N = 4169
Prevalence Ratio
( 95% CI)
% %
Male 1.7 98.3 2.82 (1.03, 7.73)
Race
Black 1.1 99 Ref
White 2.8 97.2 2.64 (1.59, 4.37)
Other 0.5 99.5 0.45 (0.11, 1.86)
Age (years)
<40 0.9 99.1 Ref
≥40 2.8 97.2 3.27 (1.98, 5.39)
Reported MSM (among men only) 1.6 98.4 0.83 (0.49, 1.40)
Stage of syphilis
Primary/Secondary 1.4 98.6 Ref
Early Latent 0.8 99.2 0.61 (0.28, 1.30)
Late Latent/Latent w clinical manifestations 2.2 97.8 1.58 (0.93, 2.69)
Median (IQR) Median (IQR) Wilcoxon p-value
RPR 128 (64-256) 32 (8-128) <0.0001
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HIV and Ocular Syphilis
• The prevalence of ocular syphilis was higher among HIV-infected
syphilis patients
Prevalenceof OS
PR 95% CI
HIV Status
Positive 2.0% 1.8 1.1, 2.9
Negative/Unknown 1.1% REF
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HIV and Ocular Syphilis
• The prevalence of ocular syphilis was higher among HIV-infected
syphilis patients
• Considering only HIV-infected syphilis patients, the prevalence of ocular
syphilis was highest among those diagnosed with HIV and ocular
syphilis at the SAME TIME
Prevalenceof OS
PR 95% CI
HIV Status
Positive 2.0% 1.8 1.1, 2.9
Negative/Unknown 1.1% REF
Prevalenceof OS
PR 95% CI
Timing of HIV Diagnosis
Concurrently Diagnosed 4.2% 2.5 1.2, 5.0
Previously Diagnosed 1.7% REF
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Follow-Up Interviews
63
Ocular Syphilis Cases
39 (62%) Completed Follow-Up Interview
7 (11%)
Refused Follow-Up Interview
17 (27%)
Could not be located
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Timing of symptoms, seeking care, and treatment
Patient First Seeks Care
Onset of Symptoms
Initiation of Treatment
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Timing of symptoms, seeking care, and treatment
Emergency Department: 7 days
Eye doctor: 14 days
Primary care physician: 18 days
STD clinic: 18 days
Infectious Disease physician: 30 days
Patient First Seeks Care
Onset of Symptoms
Initiation of Treatment
Overall Median= 14 days
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Timing of symptoms, seeking care, and treatment
Emergency Department: 7 days
Eye doctor: 14 days
Primary care physician: 18 days
STD clinic: 18 days
Infectious Disease physician: 30 days
Patient First Seeks Care
Onset of Symptoms
Initiation of Treatment
Overall Median= 14 days Overall Median= 10 days
Emergency Department: 8 days
Eye doctor: 13 days
Primary care physician: 9 days
STD clinic: 8 days
Infectious Disease physician: 8 days
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Reported Visual Function
2. When OS Symptoms were the worst
1. Before OS Symptoms
3. At the time of the Interview
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Reported Visual Function
2. When OS Symptoms were the worst
1. Before OS Symptoms
3. At the time of the Interview
85%
Excellent or
Good
Vision
6%
Excellent or
Good
Vision
80%
Excellent or
Good
Vision
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Summary
• Detection of syphilis patients reporting eye symptoms was possible using existing surveillance infrastructure
• Reports of OS increased between 2014 to 2015, possibly due to increased awareness
• OS was diagnosed in all stages of syphilis and among HIV-positive and HIV-negative patients
- However, OS was more common among HIV-infected patients,
particularly those diagnosed with HIV and syphilis concurrently
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Summary
• No common exposure or reported risk factor was identified among cases in NC
• OS can result in severe visual impairment
- Most patients improved after treatment
• Providers should be alerted about the potential for ocular manifestations of syphilis and appropriate treatment/care
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Acknowledgements
NC DPH
– Erika Samoff
– Victoria Mobley
– Jessica Rinsky
– Mara Larson
– Nicole Dzialowy
– Aaron Fleischauer
– Evelyn Foust
– Public Health
Epidemiologists
CDC
– Sara Oliver
– Charnetta
Williams
– Gui Liu
– Tom Peterman
– Lauri Markowitz
NC DIS
– Miraida Gipson
– Samantha Greene
– Jason Hall
– Stephanie Hawks
– Victor Hough
– Andre Ivey
– Mike Mercurio
– Dishonda Taylor