# Presentation: 178443

## Local STD Prevention Programs

## Topics

- Introduction
- Clinical services
- Laboratory services
- Surveillance & Epidemiology
- Education
- Policy

## Introduction

## Local STD Program Services

- Clinical services
- Laboratory services
- Partner services
- Referral services
- Dental services
- Mental health services
- Social services

- Introduction

## What are we trying to achieve with the services we offer?

- “An effective system of services and information that supports individuals, families, and communities in preventing STDs, including HIV infection, and ensures comprehensive, high-quality STD-related health services for all persons.”
- IOM Report “The Hidden Epidemic”

- Introduction

## Core Public Health Activities

- Surveillance
- Disease intervention services
- Outbreak response
- Clinical services
- Information dissemination
- Program evaluation
- Program policy

- Introduction

## Challenges

- Achieve a national goal with a variability of organizational designs and resources that exist at the state and local levels
- Each program was developed under different political and historical circumstances

- Introduction

## Clinical Services

## Access to Care

- Access can be defined as
- Strategically located geographically, so people don’t have to travel great distances
- Transportation is available regardless of availability of an auto
- Physically accessible (ADA)
- Financially accessible, regardless of patients’ ability to pay
- Culturally and linguistically accessible – meaning clinicians are sensitive to the sensibilities of their patients
- Want to assure that top quality, state-of-the-art clinical services are accessible to all

- Clinical Services

## Private Sector

- Need to ensure that private sector clinicians are completely up to date if we want to have top quality, state-of-the-art services
- Some states don’t have categorical clinics –
- They contract with private practice MDs who will agree to see STD patients and be reimbursed by the state

- Clinical Services

## Private Sector (continued)

- As HMOs continue to expand through the medical ecosystem, there is an increasing demand to work with the private sector.  Trying to manage this blend of the public and private clinical cultures is just one of the many challenges faced by STD programs.
- Incorporating viral STD clinical services, such as hepatitis, herpes simplex virus, and human papillomavirus are other challenges.

- Clinical Services

## Laboratory Services

## Types of Activities

- Diagnostic
- Screening

- Laboratory Services

## Diagnostics

- Which test system do you use to diagnose?
- Need to balance sensitivity, specificity, predictive value positive, the availability of resources, and the prevalence of disease

- Laboratory Services

## Lab Services

- Labs may be able to charge for services – others are not able to charge
- Labs may be able to do sensitivity testing to see which antibiotics are effective – others don’t have the capacity

- Laboratory Services

## Screening

- The capacity to screen in order to identify the asymptomatic infections is crucial for prevention programming
- Testing for syphilis in prisons and jails
- Testing for chlamydia in prisons and jails, in shelters, and youth detention facilities
- Places where you can reach higher risk people who would not otherwise have access to such testing is crucial

- Laboratory Services

## Challenges and Opportunities 

- Incorporating (affording and interpreting) viral testing into services
- Development of new tests that are non-invasive is very exciting
- Urine for gonorrhea and chlamydia
- These will pave the way for screening outside the walls of clinics

- Laboratory Services

## Surveillance & Epidemiology

## Public Health Surveillance

- The *ongoing* and *systematic collection*, *analysis*, *interpretation*, and *dissemination* of health data in the process of describing and monitoring disease trends
- There is a legal framework that allows this activity
- Some STDs (i.e. chlamydia, gonorrhea, syphilis) require mandatory reporting

- Surveillance & Epidemiology

**Notes:**
Surveillance is the “ongoing and systematic collection, analysis, interpretation, and dissemination of health data in the process of describing and monitoring disease trends.  

Surveillance systems operate at a variety of levels (local, state, federal, international) and involve a network of people and activities to maintain this process.

It is closely integrated with the timely dissemination of these data to those responsible for the prevention and control. 

There are several questions you could ask yourself about specific aspects of this definition:

*** Why should you plan your analysis?
To assure that the data source and collection process are consistent and adequate

*** Why interpret and disseminate information?
Help decision makers understand the implications of information
Facilitate consequent implementation of public health action

*** Interpretation of information
Present information clearly
Know your audience

*** Considerations for dissemination
Balance access with privacy constraints
Provide analyses and recommendations
Use clear and concise materials
Use communications media

***These are all areas will discuss throughout this course.

## Purposes of Public Health Surveillance

- Assess public health status
- Define public health priorities
- Evaluate programs
- Conduct research

- Surveillance & Epidemiology

**Notes:**
Throughout the course you will need to keep in mind the purposes and uses of public health surveillance.

1. Assess public health status 
* ex. Status of chlamydia project or the newly adopted hepatitis B requirements

2. Define public health priorities at the local/state/federal level
* ex. Use the data to target populations, diseases, e.g., syphilis elimination plan

3. Evaluate programs (how effective are the programs)
* ex. Syphilis elimination program

4. Conduct research 
* ex. Analysis of public health data enables researchers to identify where the interventions are not working

## Types of Surveillance Systems

- Active surveillance – contacting providers to ask if they’ve seen cases
- Passive surveillance – wait for case reports to come in
- Electronic reporting, particularly w/ labs – have lab reports electronically delivered to the program
- Sentinel

- Surveillance & Epidemiology

## Passive Surveillance

- Relies on reporting of cases from health care providers based on a list of conditions
- Sit and wait for case reports or test results to come in
- Provider-initiated
- Advantage: Simple and inexpensive to implement
- Limitation: Incomplete case reports and variability in quality and timeliness

- Surveillance & Epidemiology

**Notes:**
*** Passive surveillance is different insofar as the health department receives disease reports from health care providers as mandated by state law.

*** The health department takes a ‘sit and wait’ approach while they wait to receive case reports.

*** Most states have comprehensive passive infectious disease surveillance systems.

*** The most common method used for reporting.

*** The advantage to this system is that it is less costly to operate than an active system, is simple, and less burdensome 

*** The disadvantages to this system are the incomplete case reports, data may lack representativeness and timeliness, and may fail to identify outbreaks.

## Active Surveillance

- Public health officers actively collect data to complete case reports
- Health department-initiated
- Advantage: Often, cases are more complete and accurate
- Limitation: Time consuming and costly

- Surveillance & Epidemiology

**Notes:**
*** Active surveillance is a type of surveillance in which the health department regularly contacts reporting sources to elicit reports.  This can be accomplished by going to the medical facility and initiating the case report.

*** This method provides more complete reporting, but is more labor intensive, and more costly to operate. 

*** Active surveillance allows you to validate representativeness and assure more complete reporting for specific providers.

*** Active surveillance can be used to:
--- Evaluate quality assurance (timeliness, completeness, and validity)
--- Evaluate or improve the current system or disease control initiatives

Limitation: “Is the juice worth the squeeze?”

## Sentinel Surveillance

- An early warning system that may represent the “tip of the iceberg”
- Monitoring of key “sentinel” sites or populations for health events that are generalizable to the whole population
- Useful for uncommon conditions that are not monitored via active or passive surveillance
- Useful for common conditions where complete case counting is not important and action is not taken in response to a single case

- Surveillance & Epidemiology

**Notes:**
*** Sentinel surveillance can be either active or passive.  

*** Sentinel events may spark sentinel surveillance activities.
	--- Example 1: MSM cases with oral, anal, and pharyngeal GC is an unusual event that may initiate sentinel surveillance.
	--- Example 2: Only select 25 GC lab specimens and test for GC resistance.  Looking for changes in resistance of the organism.

*** Sentinel surveillance serves as an early warning system or represents the ‘tip of the iceberg’ to clinics or other sites where health events are monitored, or to networks of health-care providers who agree to report information on one or more health events.  

*** A sentinel health event has been describes as “a preventable disease, disability, or untimely death whose occurrence serves as a warning signal that the quality of preventative and/or therapeutic medical care may need to be improved”

*** It monitors key health events through sentinel: sites, events, providers, or vectors/animals (e.g., schools, labs, jails).

*** Monitoring of key (sentinel) sites or populations for health events that are generalizable to the whole population (e.g., Jail Prevalence Monitoring Project).

*** It is useful for common conditions where complete case counting is not important and action is not taken in response to a single case, e.g., lice in schools.

*** Useful for uncommon conditions that are not monitored via active or passive surveillance where one case may require a response, e.g., smallpox.

## Sentinel Surveillance (continued)

- Advantage:
- Cheaper than case-based reporting
- More timely
- Limitation:
- Not comprehensive
- Based on the experience of the provider

- Surveillance & Epidemiology

**Notes:**
*** The advantage of sentinel surveillance is that it is cheaper than case-based reporting (in other words, cheaper than reporting every case) and reporting of cases via sentinel surveillance can be timely (quick).

*** The limitation is that it is not comprehensive and is based on the experience of the labs/providers to report the event to the local or State health department.

## Examples of Sentinel Surveillance

- GISP: Gonococcal Isolate Surveillance Project
- STD Jail Prevalence Monitoring Project

- Surveillance & Epidemiology

**Notes:**
*** In STD surveillance, Gonococcal Isolate Surveillance Project (GISP) monitors the proportion of ciprofloxacin (antimicrobial) susceptible gonorrhea isolates via laboratory surveillance in the US. Ciprofloxacin is currently recommended to treat gonorrhea.  GISP is an example of sentinel surveillance.  Monitor changes in susceptibility, which may influence treatment recommendations.

*** Local jail screening for syphilis and other STDs may identify populations of untreated STDs that would have otherwise gone undetected.  Assume inmates are representative of their communities.  [FYI, these would be prevalent cases]

*** Other examples are the school nurse who reports an elevated number of lice cases in a short period of time to the local health department or the nursing home who reports an increase in the number of influenzae cases or scabies, although scabies is not reportable in many states, this is a routine problem in nursing homes 

## Electronic Surveillance

- Requires standardized format of information
- Encrypted data
- Computerized data automatically sent to the local/state health agency

- Surveillance & Epidemiology

**Notes:**
*** Electronic surveillance may be the way of the future.

*** Where laboratories and clinics automatically electronically report to the local/state health department new cases of disease, in addition to information on the case’s age, sex, county of residence, and date the specimen was collected.  Data entry is not required.
	--- Entering data in the computer is not electronic surveillance.

*** This method may detect unusual clusters of disease among reporting facilities

*** This method will require standardized reporting format of information sent electronically

*** A method to encrypt the confidential data

## Components of a STD Surveillance System

- Case-based reporting - traditional
- Prevalence monitoring
- Population-based: behavioral / social surveillance

- Surveillance & Epidemiology

## Sources of Case Reports

- Provider-based case reporting
- Laboratory-initiated findings

- Surveillance & Epidemiology

**Notes:**
*** Health departments should accept case reports of syphilis infection and reactive syphilis laboratory tests from both clinicians and laboratories.

*** Although laboratory-initiated findings are essential, clinician reporting should continue to be encouraged to report cases, especially for early syphilis cases that require immediate partner services.  

*** In addition, mandated clinician reporting is important to ensure that health departments maintain the authority to contact clinicians directly for demographic, medical, and risk information.  

## Prevalence Monitoring Purposes and Uses of  Prevalence Monitoring

- The monitoring of trends among defined populations over time
- Most commonly performed using data obtained on selected populations
- Data are systematically collected from routine screening, not from special studies
- Monitor disease burden and trends
- Identify populations with high rates of infection
- Evaluate case reporting surveillance data
- Design and target interventions
- Allocate public health resources

- Surveillance & Epidemiology

**Notes:**

*** In contrast to case reporting, which is intended to be population based, prevalence monitoring for syphilis is most commonly performed using data obtained on selected populations. 

*** These prevalence data usually are systematically collected from routine screening rather than from special studies performed for the primary purpose of assessing disease burden. 

*** In addition, prevalence monitoring provides additional perspective on disease occurrence in the population

## Priority Populations for Prevalence Monitoring

- Correctional system
- Pregnant women
- Drug treatment facilities
- STD clinic patients
- Special populations based on local epidemiology

- Surveillance & Epidemiology

**Notes:**
*** The priority populations for prevalence monitoring are:

*** Correctional system
--- State and local STD prevention programs should conduct prevalence monitoring at intake among arrestees in city and county jails.  High levels of screening coverage are obtainable in many jail settings.

*** Pregnant women (at delivery and prenatal visits)
--- Monitoring prevalence among pregnant women at either delivery or prenatal visit should be considered, as these data are often available with minimal effort.  
--- In addition, screening among this group is mandated in most states.

*** Drug treatment facilities
---Areas with substantial morbidity should develop screening and prevalence monitoring projects in facilities specializing in drug treatment.  Research suggests an association between syphilis infection and crack cocaine use in some areas with substantial morbidity. 
--- FYI: before when 70% of infectious syphilis cases were identified in STD clinics, now ~ 30%

*** STD clinic patients (such as HIV counseling and testing sites) 
--- HIV counseling and testing sites often provide services to a variety of clients, ranging from low to high-risk.  Screening for syphilis among HIV counseling and testing site clients should be routinely offered.  

*** Special populations based on local epidemiology (e.g., emergency department patients, clinics serving MSM)

## Population-Based Behavioral / Social Surveillance

- Complements case reporting and prevalence surveillance data
- Questionnaire-based behavioral data are necessary to develop effective prevention and intervention programs

- Surveillance & Epidemiology

**Notes:**
*** Behavioral and social data can complement case-reporting and prevalence surveillance data by:
--- monitoring and anticipating changes in disease epidemiology and 
--- identifying risk factors associated with infection

*** Timely and accurate behavioral and social data are necessary to develop effective prevention and intervention programs.  

*** Questionnaire-based behavioral data related to disease prevention can be collected in a number of settings including general population surveys, behavioral surveillance systems of high-risk and infected populations, and as part of specific intervention studies. 

## Purposes and Uses of Behavioral/Social Surveillance

- To monitor and track the risk behaviors and social factors that contribute to disease acquisition and transmission
- To identify populations that are at risk of being infected by STDs
- To aid in the identification of behaviors and social factors that can lead to the prevention of STDs

- Surveillance & Epidemiology

**Notes:**
*** The purposes and uses of Behavioral/Social Surveillance are:

1. To monitor and track the risk behaviors and social factors that contribute to disease acquisition and transmission.  

2. To identify populations that are at risk of being infected by STDs.   

3. To aid in the identification of behaviors and social factors that can lead to the prevention of STDs given appropriate evidence and/or theory based interventions.

*** The development of effective behavioral interventions aimed at syphilis control and elimination must be guided by behavioral, social, and geographical [place variables] data from infected populations, at-risk populations, and from the affected communities.

## Data Sources for Behavioral/Social Surveillance

- General population surveys
- Infected population *
- At-risk population *

- * Critical for monitoring and controlling the spread of disease

- Surveillance & Epidemiology

**Notes:**
*** Behavioral and social surveillance data are generally collected at three levels: general population, infected population, and at-risk population.  

--- General population-based surveys have been used to monitor change in risk exposures in the general population over time.

--- General-population surveys are limited in their ability to monitor changes in behaviors (e.g., risky sexual behaviors), and in their ability to monitor risk exposure among infected, at-risk populations or affected communities. 

--- Therefore, behavioral surveillance among at-risk and infected populations is critical for monitoring and controlling the spread of disease. 

FYI to the instructor:

*** General population surveys
--- National Health Interview Survey (NHIS)
--- Behavioral Risk Factor Surveillance System (BRFSS)
--- Youth Risk Behavior Survey (YRBS)
--- National Household Survey on Drug Abuse (NHSDA)
--- National Survey of Family Growth (NSFG)
--- National Health and Nutrition Examination Survey (NHANES)
--- General Social Survey (GSS)

*** Infected population 
--- State and Local Area Integrated Telephone Survey (SLAITS)
--- HIV/AIDS Reporting System (HARS)
--- Sexually Transmitted Disease Management Information System (STD-MIS)
--- Supplement to HIV/AIDS Surveillance (SHAS)
--- Locally developed information management systems

*** At-risk population 
--- Arrestee Drug Abuse Monitoring HIV addendum (ADAM)
--- HIV Testing Survey (HITS)
--- Drug Abuse Warning Network (DAWN)

## Surveillance and Communication(A process that provides “information for action”)

- _Surveillance data_ should be presented in a manner that facilitates their ultimate use for public health action
- _Effective communication_ of public health surveillance results represents the critical link in the translation of scientific information into public health practice

- Surveillance & Epidemiology

**Notes:**
*** Information is the primary tool of public health practices.  Surveillance is the primary means of obtaining the data that are analyzed and translated into action; hence “information for action”.  

*** When translating surveillance data, we should present it in a manner that facilitates their ultimate use for public health action

*** This information is translated into messages, units of communication science that tell their audiences how to respond to particular pieces of information.

*** Effective communication of public health surveillance results represents the critical link in the translation of scientific information into public health practice

*** We must be able to distinguish between dissemination of information and communication of information.

## Dissemination and Communication

- _Dissemination _
- is a one-way process through which information is conveyed from one point to another

- _Communication_
- is a collaborative process involving at least two people in an effort to convey, receive, interpret, and agree upon the meaning

- Surveillance & Epidemiology

**Notes:**
*** In public health practice, there is a time-honored practice that has involved a great deal of dissemination of information (a one way process) but very little communication, a two-way process involving dissemination of information, followed by feedback.  This is the communication feedback loop that distinguishes between the two.

*** The distinction between communication and dissemination is critical to understanding what actually happens with public health information versus what public health workers think happens with it.  

*** This distinction is also key to planning, implementing, and evaluating programs that involve communication in public health practice. 

*** In today’s world, we must think globally because diseases that affect one county are likely to affect another country through air travel (e.g., Ebola, and West Nile, etc.).

Effective communication of health data is critical in the prevention of disease.

## Surveillance Data

- Data management today means using computers and having access to technical resources that can manage the hardware and software
- Surveillance is of little value unless it is used – this requires communicating the information to all stakeholders
- If the surveillance is conducted but not communicated, then the value of the activity is unclear

- Surveillance & Epidemiology

## Ethical Considerations: Surveillance Activities  

- Surveillance must respect and protect the people on whom information is collected
- If these objectives cannot be accomplished, then data collection is pointless and it is inappropriate to conduct these surveillance activities

- Surveillance & Epidemiology

## Public Health Surveillance Challenges

- Assurance of usefulness
- Computer technology
- Ethical and legal concerns
- Application to new areas
- Educate public and policy makers
- Flexibility
- Cost effective
- Incomplete cases

- Surveillance & Epidemiology

**Notes:**
[Public health clinics do the most complete reporting, leaving some wondering if there is a propensity of reporting of those with STDs of lower socioeconomic status, and minorities, as those use the PH clinics more often (discussed in module 2 – reporting bias).]

*** Assurance that public health surveillance is useful

*** Computer technology
--- lack of available resources

*** Ethical and legal concerns
--- Confidentiality

*** Application to new areas
--- Expansion of reportable disease list

*** Educate public and policy makers

*** Flexibility

*** Cost-effective

*** How to handle incomplete cases

## Epidemiology

- The study of the *distribution* and *determinants* of disease *frequency*
- Epidemiological elements are described in terms of person, place, and time

- Surveillance & Epidemiology

**Notes:**
Epidemiology is the study of the distribution and determinants of disease frequency, but for the purposes of this course we will be discussing human populations only. Distribution, determinants, and frequency are each described by person place and time elements.

***Two fundamental assumptions in epidemiology:
1. Disease does not occur at random
2. Disease has causal and preventive factors that can be identified through systematic investigation of different populations in different places or at different times.

***Three components of epidemiologic principle and methods: Frequency, Distribution, and Determinants
1. Measurement of disease frequency (number of cases / population size) involves quantification of the existence (“prevalent”) or new cases (“incident cases”) of disease.

2. Distribution of disease considers such questions as who is getting the disease within a population, as well as where and when the disease is occurring, in other words, person, place, and time.  Knowledge of distribution is essential to describe patterns of disease as well as to formulate hypotheses concerning possible causal or preventative factors.

3. Determinants of disease (risk factors) are derived from frequency and distribution of disease since knowledge of the two is necessary to test an epidemiologic hypothesis

FYI: there are more complex definitions of epidemiology, but for this course we are using a simpler definition 

## Measures of Frequency

- Prevalence
- Incidence

- Surveillance & Epidemiology

**Notes:**
Remind the participants that the components of epidemiology are distribution, determinants, and frequency of disease as described by person, place, and time elements.

## Definition: Prevalence

- Number of existing cases (includes both previously and newly diagnosed cases) in a population at a specific point in time
- Snapshot of disease in a specific population at a specific point in time

- Surveillance & Epidemiology

**Notes:**
*** Number of existing cases (old+new cases) in a population at a specific point in time

*** Snapshot of disease in a specific population at a specific point in time.

*** STD Example: In June 2001 at the Columbus City Health Department, of the 350 patients seen in the STD clinic, 10% (n=35/350)had chlamydia.  Therefore, the prevalence in the patients was 10%.

[FYI: more specifically, this definition of prevalence is point prevalence because it is a snap-shot of disease at a specific point in time]

## Definition: Incidence

- Number of newly diagnosed cases in a population of at-risk individuals during a specified time period

- Surveillance & Epidemiology

**Notes:**
Ideally, incidence is defined as the number of newly developed or diagnosed cases in a population of at risk individuals during a specified time period.

We say ideally because newly diagnosed cases are relative to the timeliness and accuracy of reporting.  Many providers do not report cases; therefore incidence in surveillance is really newly “reported” cases.

Another issue is the time between infection and symptoms and/or visit to the STD clinic; the incidence is based on diagnosis, however, it is possible that some patients had been infected for a long time.

## Prevalence versus Incidence

- Pre-existing cases;
- people that leave
- the case population,
- e.g., by death, recovery

- Incident (new) cases

- Surveillance & Epidemiology

**Notes:**
Here is a depiction of the relationship between incidence and prevalence.

Incidence, as we previously described, are newly diagnosed/reported cases.  Each newly diagnosed/reported case adds to the prevalence pool of cases, e.g. incident cases flow into or add to the prevalent case pool. The only way to leave the prevalent pool is to recover (receive treatment/cured) or die.

Example of HIV, where the only way to exit the prevalence pool is to die, compared to gonorrhea, where most cases leave the prevalence pool by receiving treatment.

## Education

## Education

- Extremely important; need to ensure that it is available to all stakeholders
- Types of education – lectures, interviews, posters, plays, brochures, etc.
- Audience:
- One-on-one to patients in the clinics and MD offices and outreach
- Professional education for clinicians and microbiologists
- Education to students in schools and colleges
- Community organizations
- Requires lots of resources and alliances – train the trainer

## Individual Education

- STD interventions are traditionally at the individual level
- STD interventions grew up within a clinical model, so they are focused on infected individuals and their partners
- It is necessary to work at the individual level as well as at the community level
- Individuals do not live in a vacuum – we all live within a social context – this social environment must support efforts at the individual level, and vice-versa
- This is new turf for STD, and we have much to learn from the community-oriented prevention approaches of HIV programs

- Education

## Education into Behavior Change

- The big challenge is to figure out ways to turn education into an engine for behavior change
- Knowledge in itself does not necessarily translate into behavior modification

- Education