1. Wake
County
Syphilis
Outbreak
Health
Advisory
And the proper
reporting of STD’s
Luke Keeler, WCHS DIS

2. Why this advisory?
 Wake County current syphilis case
numbers are higher than previous 15 years
 Stop further transmission and prevent
disease shift to vulnerable populations
 All data in this presentation is from NCEDSS
unless otherwise noted

3. 89
51 43 37 44
65 60
39 37
115
79 70
81
102
178
245
14
7.7
6.3
5.3
6.1
8.6
7.6
4.7
4.3
13.3
8.7
7.5
8.5
10.7
17.8
23.9
0
5
10
15
20
25
30
0
50
100
150
200
250
300
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Rate
Case
Count
Early Syphilis Case Counts and Rates per 100,000 pop.,
Wake County, 2000-2015
Number of Cases Case Rate
CASES AND RATES ARE AT 15-YEAR HIGH!
Source: For 2014 and 2015 source is NCEDSS. Case counts for 2014 and 2015 obtained via different
method than cases in all other years. 2000-2013 source: http://epi.publichealth.nc.gov/cd/stds/

4. Why are we here?
 Reach out to providers and the public
with information to:
 Find & treat those who are infected
 Prevent future transmission
 Identify collaborative strategies to stop
the transmission and help prevent future
outbreaks
 Provide outbreak data (All data in this presentation is from NCEDSS
unless otherwise noted)
 Identify current resources

5. 226, 92%
19,
8%
2015 Wake Syphilis Cases,
by Gender
Male
Female

6. 7
43 43
36
26
23
50
17
0
10
20
30
40
50
60
15-19 20-24 25-29 30-34 35-39 40-44 45-54 55-64
Cases
2015 Wake Syphilis Cases, by Age Group

7. 138
81
22
2 2 1
0
20
40
60
80
100
120
140
160
Cases
Wake Syphilis Cases,
by Race/Ethnicity, 2015

8. 126,
52%79, 32%
40, 16%
Wake Syphilis Cases, HIV Status, 2015
HIV Positive HIV Negative Status Unknown

9. 1
1
1
1
1
2
2
2
2
4
6
7
9
10
18
32
65
81
0 10 20 30 40 50 60 70 80 90
Plasma Donation Center
Hospital unspecified
Mental Health Inpatient
Blood Donation Center
Labor/Delivery
Health Dept--outlying
Ob/Gyn
Correctional Facility
Laboratory
Military Hospital
Specialty Care
FQHC
Urgent Care
Non-traditional site
Emergency Dept
Primary Care
Health Dept--STD clinic
ID Clinic
Wake, # of Syphilis Cases Diagnosed by Provider Type, 2015

10. 2
2
2
2
2
2
2
2
2
2
3
3
3
4
5
6
7
12
14
14
42
61
0 10 20 30 40 50 60 70
Avance Care-Leesville Rd
Boylan Medical Associates
Analyte Physicians Group
Central Dermatology
NCCIW
Duke Raleigh ED
Cary Medical Group
Duke Rheumatology Clinic
Duke Urgent Care-Morrisville
NextCare Urgent Care-Raleigh
Durham VA Medical Center
HD-Durham County
WCHS NTS HPM
WCHS NTS LGBT
North Hills Integrative Medicine
Raleigh ID Clinic
Triangle Family Care
Duke ID Clinic
WakeMed Main ED
UNC ID Clinic
WCHS HIP
WCHS Clinic A
Wake, # of Cases Diagnosed by Provider, 2015
(Min. 2 cases per provider)

11. 0
10
20
30
40
50
60
70
80
35
54
45 44
66 66
74
39
Cases
Wake Syphilis Cases by Stage, Last 8 Quarters
Primary Secondary Early Latent All Stages

12.  Secondary is by far the most common
stage at diagnosis (46%, vs. 21% for
primary and 32% for EL) – the take-home
message here is all places of care, from
NTS to hospitals to dermatologists to
primary care doctors, need to be
suspicious of rashes on hands/feet/all over
the body.

13. 8
13
14
21
14
19
16
14
15
18
13 13
26
20 20
25
13
28
26
24 24
13 13 13
0
5
10
15
20
25
30
Cases
Wake Syphilis Cases, Comparison by Month, 2014 vs. 2015
2014 2015

14. 0
1
5
9
12
17
24
29
32
33
38
50
63
64
65
69
69
71
89
96
101
105
170
183
214
245
248
261
289
0 50 100 150 200 250 300 350
Gang
House
Condom Use (pickups only
IVDU
Traded sex for money/drugs
Congregate living?
Sex Assualt victim
(Female) sex with male
Penile/Vaginal sex
Sex at sex party
condom use unknown
met partner at bar
condom use always
((Male) sex with female
Ct to Syph
Jail/Prison Hx
condom use never
Sex with Alcohol/drugs
rectal sex
Travel
oral sex
NON-IVDU
met partner on internet
Multiple Partners in Ix period
HIV+
Prior STD
condom use sometimes
Alcohol
MSM
Risk Factors on Syphilis Cases, 1/1/14-12/31/15, Wake

15. Syphilis Overview
 Sexual Transmission
 Physical contact during vaginal, oral and
anal sex
 In utero
 Treatment
 Antibiotics
Treponema pallidum

16. Syphilis Pathology
 Penetration
 Treponema pallidum enters the body via skin &
mucous membranes through abrasions during
sexual contact.
 Transmitted transplacentally from mother to
fetus during pregnancy.
 Rate of transmission by infected partner is 20-
50%.
 Dissemination:
 Incubation 10-90 days (average 3 weeks,
maximum 3 months).
 Travels via the circulatory system (including the
lymphatic system and regional lymph nodes)
throughout the body.
 Invasion of the central nervous system (CNS)
can occur during any stage of syphilis.

17. Primary Syphilis
 Primary lesion or “chancre” develops at
the site of inoculation.
 Chancre
 Progresses from macule to papule to ulcer;
 Typically painless, indurated, and has a
clean base;
 Highly infectious;
 Heals spontaneously within 3 to 6 weeks;
and
 Multiple lesions can occur.
 Serologic tests for syphilis may not be
positive during early primary syphilis.

18. Primary Syphilis Lesion

19. Secondary Syphilis
 Secondary symptoms occur several weeks
after the primary lesion appears; and may
persist for weeks to months.
 Primary & secondary stages may overlap.
 Clinical Manifestations:
 Rash (75%-100%)
 Mucous patches (6%-30%)
 Condylomata lata (10%-20%)
 Alopecia (5%)
 Other symptoms include fever, swollen lymph
glands, headache, hair loss & liver/kidney
involvement.
 Serologic tests are usually highest in titer
during this stage.

20. Secondary Syphilis Rash

21. Latent Syphilis
 Asymptomatic: Host suppresses infection
and no lesions are apparent
 Only evidence is a positive serologic
blood test
 Categories:
 Early Latent <1 year duration (relapsing
secondary may occur during this time)
 Late Latent >1 year duration

22. Neurosyphilis
 Occurs when T. pallidum invades the
central nervous system (CNS).
 May occur at any stage of syphilis
 Can be asymptomatic.
 Early neurosyphilis occurs a few months to
a few years after infection.
 Ocular involvement can occur in early or
late neurosyphilis.

23. Congenital Syphilis
 Occurs when T. pallidum is transmitted
from a pregnant woman to her fetus.
 May lead to stillbirth, neonatal death, and
infant disorders such as deafness,
neurologic impairment, and bone
deformities.
 Transmission can occur during any stage
of syphilis; risk is much higher during
primary and secondary syphilis.
 Fetal infection can occur during any
trimester of pregnancy.

24. Aspects of Syphilis Diagnosis
 Clinical History
 Physical Examination
 Laboratory Diagnosis

25. Clinical History
 Assess
 History of syphilis
 Known contact to an early case of syphilis
 Typical signs or symptoms of syphilis in the
past 12 months
 Most recent serologic test for syphilis

26. Physical Examination
 Oral cavity
 Lymph nodes
 Skin of toros
 Palms and soles
 Genitalia and anal area
 Abdomen
 Neurologic examination

27. Laboratory Diagnosis
 Identification of Treponema pallidum in lesion
or tissue
 Darkfield microscopy
 Tests to detect T. pallidum
 Serologic tests to allow a presumptive
diagnosis
 Nontreponemal Tests (RPR, TRUST, USR, VDRL)
 Treponemal Tests (TP-PA, EIA, CIA, FTA, MHATP)
 The use of only one type of serologic test is
insufficient for diagnosis (You must have one
of each)

28. Causes of False-Positive Reactions in
Serologic Tests for Syphilis
 Public health laws require that all cases of syphilis be reported to the
state/local health department & DIS will help to stage diagnosis.
Disease RPR/VDRL FTA-ABS TP-PA
Age Yes
Autoimmune Diseases Yes Yes
Cardiovascular Disease Yes Yes
Dermatologic Diseases Yes Yes --
Drug Abuse Yes Yes
Febrile Illness Yes
Glucosamine/chondroitin sulfate Possibly
Leprosy Yes No --
Lyme disease Yes
Malaria Yes No
Pinta, Yaws Yes Yes Yes
Recent Immunizations Yes -- --
STD other than Syphilis Yes

29. Screenings
 All HIV positive
people
 All sexually active
men having sex with
men (MSM)
 All those seeking
care/treatment for a
sexually transmitted
infection (STI)
 All those seeking
care for a rash or
hair loss
 All pregnant
women (at least 3
times)
 At initial visit
 At 28-32 weeks
 At delivery
 Any women
delivering a
stillborn infant after
20 weeks gestation

30. Treatment for Adults
 Presumptive treatment
 Primary, Secondary and Early Latent Syphilis
 Benzathine Penicillin G 2.4 mu IM x 1
 Doxycycline 100 mg BID x 14 days (PCN allergy)
 Late Latent Syphilis
 Benzathine Penicillin G 2.4 mu IM x 3 (weekly)
 Doxycycline 100 mg BID x 28 days (PCN allergy)
 Neurosyphilis and Congenital Syphilis
 Infectious Disease consult recommended!

31. Follow-Up
 Primary or secondary syphilis
 Re-examine at 3, 6 and 12 months
 Follow-up titers should be compared to the
maximum or baseline nontreponemal titer
obtained on day of treatment and make sure
there has been a 4 fold decrease in titer
 Latent syphilis
 Re-examine at 6, 12 and 24 months
 HIV-infected patients
 3, 6, 9, 12 and 24 months for primary or
secondary syphilis
 6, 12, 18 and 24 months for latent syphilis
 Neurosyphilis
 Serologic testing as above
 Repeat CSF examination at 6-month intervals
until normal.

32. Treatment Failure
 Indications of probable treatment failure
or reinfection include:
 Persistent or recurring clinical signs or
symptoms
 Sustained 4-fold increase in titer
 Titer fails to show a 4-fold decrease within 6-
12 months
 Retreat and re-evaluate for HIV infection.
 CSF examination can be considered.

33. Reporting
 Laws & regulations in all states require that
persons diagnosed with syphilis are
reported to public health authorities.
 Reporting must be completed by provider
& laboratory.
 The follow-up of patients with early syphilis
is a public health priority.

34. NC Public Health Law
 Physicians, and other medical facilities
(G.S. § 130A-135 through 130A-139) must
report cases or suspected cases of
reportable diseases to their local health
department, which in turn reports this
information to the N.C. Division of Public
Health (G.S. § 103A-140).

35. Public Health Law
 NC Has a general statute (GS 130A) and specific
rules (10A NCAC 41A) regarding PH law
 HIV and STDs covered in the rules section
 Bottom line: if diagnosed with, or exposed to, STDs in NC,
you must be treated (.0204(b)&(c))
 Syphilis cases additionally must give names to a DIS
(.0204(c)(3))
 If you test for GC and CH, you must test for syphilis
(.0204(d))
 HIV control measures require:
 100% condom use by HIV+ persons (.0202(1)(a))
 Notification of partners (.0202(1)(f,g))
 Patient’s attending physician must give control measures
(.0202(2)(a))
 Pre-test counseling not required; individual post-test
counseling required for HIV+ (.0202(10))
 State DPH has HIV partner notification program – DIS
(.0202(13))
 No specific consent required for HIV testing – general
consent can be used, as long as pts are given the
chance to refuse testing (.0202(16))

36. NCEDSS Reporting Requirements
 North Carolina General Statute:
 130A-135 – Physicians to Report
 A physician licensed to practice medicine
who has reason to suspect that a person
about whom the physician has been
consulted professionally has a communicable
disease or communicable condition declared
by the Commission to be reported, shall
report information required by the
Commission to the local health director of the
county of district in which the physician is
consulted.
 North Carolina Administrative Code
 10A NCAC 41A.0101 – Reportable Diseases
and Conditions

37. NCEDSS Reporting Requirements
 GC/CH/NGU/PID – Part 1 information is
entered in NCEDSS and reported to the
state surveillance unit.
 HIV/Syphilis – Positive lab is obtained and
entered into NCEDSS. Partners/contacts
are linked, risk history, treatment, referrals
and plan for follow-up are submitted to
state for review.
 Feedback and suggestions for next steps
are exchanged in a back and forth
process until all opportunities for disease
intervention have been exhausted.

38. Confidential
Communication
Disease Report –
Part 1
 Confidential
Communication
Disease Report – Part 1
 Epi.public.nc/gov/cd/
docs/dhhs_2124.pdf

39. Role of DIS
 DIS are trained professionals in the public health STD field.
Informed about causes and spread of STDs, skilled in taking
sexual histories, identifying and locating people who may
have been exposed or tested positive for a STD.
 4 Person Team in Wake County Human Services
Communicable Disease Program
 3 Disease Intervention Specialists
 1 DIS supervisor
 2 Primary Functions
 STD Investigations
 Client interviews and notifications
 “Overview” of a DIS:
 Talking with index cases and partners and other high-risk
contacts, wherever it may be
 Trying to locate hard-to-reach clients
 NCEDSS

40. Mission of DIS
 STOP THE SPREAD OF DISEASE!
 Primary Intervention: getting contacts to STDs
notified and/or tested/treated as quickly as
possible
 Secondary Intervention: getting lab-diagnosed
cases treated
 Daily work: Follow up on cases until all
opportunities for disease intervention are
exhausted
 HIV/Syphilis Case Management in NCEDSS
 GC/CH Disease Reporting in NCEDSS
 DIS provide counseling about behaviors that put a
person at risk for STDs, including HIV and syphilis
infections to patients.
 DIS offer STD educational sessions one on one with
patients and also provide education outreach to
audiences, such as colleges, correctional facilities,
health care providers, community organizations
and the general public.

41. Priority Cases for DIS
 Pregnant Females (Infected or Exposed)
 STAT+ Cases (Symptomatic Syphilis Cases
or Contacts who are Preliminarily Positive)
 Contacts to early Syphilis or HIV
 HIV+ clients unaware of their diagnosis
 Young Clients (<15 years old)
 Control Measures Violations (can lead to
legal prosecution by Health Director)

42. DIS conduct Interviews
 Partners: sexual or needle sharing
contacts from possible infections period
until the time of index case interview
 Suspects: sex or needle sharing partners
prior to infectious period, or other
individuals named by the index as being
at high risk
 Associates: members of the index case’s
social or sexual network felt by DIS to be
at high risk of HIV/Syphilis
 Also includes locations/venues where
individuals meet partners
(online/internet/apps)

43. Patient Counseling and
Education
 Nature of the disease
 Transmission
 Treatment and follow-up
 Risk Reduction

44. Management of Sex Partners
 For sex partners of patient with syphilis in
any stage
 Draw syphilis serology
 Perform physical exam
 For sex partners of patients with primary,
secondary, or early latent syphilis
 Treat presumptively as for early syphilis at
the time of examination

45. Key Partners of DIS
 State DIS (parallel role)
 Clinic A Staff
 HIV Bridge Counselors
 HIV/STD Outreach Staff
 NCEDSS Consultants at the State
 Many external contacts who
diagnose/treat/report STDs (Hospitals,
Urgent Care Centers, Private Doctors,
OB/GYN Clinics)

46. Primary Training
 STD Module Training and Education
 Fundamentals of Disease Intervention
Course
 Interview skills training
 Field investigation
 Field work/Case management
 Socio-Sexual Network Training
 Continuing education

47. Additional Training
 Office/Unit/Branch/Section Orientations
 OSHA/Blood-borne Pathogen training
 HIV Counseling, Testing and Referral
Certification
 Phlebotomy/Oraquick/Urine Testing
 Confidentiality/Legal Issues (CMVs)
 LHD protocols and policies

48. HIV/STD Community Outreach
 DIS work closely with HIV/STD Community
outreach staff (NTS, PH educators) to
identify hotspots and then mobilize staff to
do education and testing in areas where
DIS work cases.

49. Bridge Counselors
 Short term case manager for clients newly
diagnosed with HIV
 Available to discuss feelings, questions &
concerns about HIV as well as inform about
disease progression and treatment options
 Assistance with finding a suitable HIV health
provider
 Arrange transportation for first clinic appt. and
accompany patient to the first appt. if
requested.

50. Bridge Counselors
 Assistance with obtaining housing, food,
disability, etc.
 Once medical care has been accessed
with an HIV provider, Bridge Counselor will
discharge the patient’s case or if needed,
refer to long term case management.

51. STD Contact Tracing

53. WCHS Disease Intervention
Specialists Program Contact
Information
 Darvlyn McLean, DIS Supervisor 919-250-4422
 Martha Smith, RN 919-212-9552
 Cynthia Mbaye, RN 919-212-9273
 Luke Keeler 919-250-3114

54. What is being done?
 Wake County Human Services
 Increase awareness and education
 Surveillance and monitoring
 Targeted testing
 Coordination with other health
departments in the region

55. Resources
 Screening and Treatment
 Wake County Human Services Clinic A
 Monday, Wednesday, Thursday and Friday
 Sign in 8:30 AM and 12:30 PM
 Tuesday
 Sign in 9:30 AM and 12:30 PM
 Wednesday
 Sign in at 4:30 PM
 Non-traditional Testing Sites (NTS)
 http://www.wakegov.com/humanservices/pu
blichealth/information/hiv/Pages/default.asp
x

56. Resources
 Case Management
 Disease Intervention Specialist (DIS) interview
and follow up with all newly diagnosed people
 Wake County and NC Division of Public Health
DIS serve Wake County
 Contact tracing on all those diagnosed with
early syphilis
 Rules on Testing and Reporting
 North Carolina Administrative Code (NCAC)
 Reportable Disease and Conditions
 10A NCAC 41A.0101
 Control Measures-Sexually Transmitted Diseases
 10A NCAC 4aA.0204
 http://reports.oah.state.nc.us/ncac.asp?folderNam
e=Title10A-HealthandHumanServicesChapter41-
EpidemiologyHealth

57. Resources
 Data
 Facts and Figures – NC HIV/STD Reports
http://epi/publichealth.nc.gov/cd/stds/figures.ht
ml
 Additional Information
 Centers for Disease Control and Prevention
Facts, data and treatment info
http://www.cdc.gov/std/syphilis/default.htm
 Wake County Human Services Medical
Providers web page (see handout)
http://www.wakegov.com/humanservices/public
health/providers/Pages/default.aspx

58. Questions?