Bixby Center Lecture "Think Syphilis" - Innovative Strategies for Targeting LA Women Melissa Papp-Green January 23, 2020

1. “Think Syphilis”
Innovative Strategies for Targeting Women at
Risk in Los Angeles County
UCLA
The Bixby Center on Population and Reproductive
Health
January 23, 2020
Melissa Papp-Green, MPH, CHES
Division of HIV & STD Programs

2. Congenital Syphilis, California versus United States
Incidence Rates, 1963–2017
Note: The Modified Kaufman Criteria were used through 1989. The CDC Case
Definition (MMWR 1989; 48: 828) was used effective January 1, 1990.
California data prior to 1985 include all cases of congenital syphilis, regardless of age.
Rev. 9/2018
https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/STD-
Data.aspx

3. Congenital Syphilis Number of Cases –LAC 2018
Rev. 6/2018
Los Angeles 55

4. Number of Female Syphilis Cases and Congenital Syphilis Cases,
Los Angeles County, 2006-20181
1 Data are from STD Casewatch as of 06/16/2019 and excludes cases from Long Beach and Pasadena
2 2017-2018 data are provisional due to reporting delay.
3 Syphilis among females of reproductive age (ages 15-44) including all cases staged as primary, secondary, early latent and late latent
4 Congenital Syphilis includes syphilitic stillbirths 4
94 80 70 48 65 56 33 58 80 88 106 164 186
387
338
242
187 197 145 139
203
268 307
379
549
735
29 28
22
14 7
15
6
8
32
21
33
44
55
0
10
20
30
40
50
60
0
100
200
300
400
500
600
700
800
900
1000
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017² 2018²
Pregnant Women³ Non-Pregnant Women³ Congenital Syphilis⁴
Source: Division of HIV and STD Programs
CasesofSyphilisamongFemales(n)
CaseofCongenitalSyphilis(n)

5. Key Findings of Case Reviews
• 60% of women received late (20%) or no prenatal care (40%)
• Almost 50% of the cases were identified by syphilis screening at delivery
– Of these, often women are discharged prior to their syphilis test results returning
• Most cases occur primarily
– among Latina (60%) and African American (25%) women
– >2/3rds report active SUD during pregnancy, with methamphetamine use most
common
– History of arrest or incarceration (up to 25%)
– Experiencing unstable housing or homelessness (10-20%)
• 35-70% of infants placed into custody of child protective services after birth

6. % Methamphetamine Use among P&S Syphilis Cases by MSM, MSMW and
Women, Los Angeles County, 2010-20171
Source: Division of HIV and STD Programs
1. Primary & Secondary Syphilis cases with data on substance use in past 12 months. Excludes injection drug users. Data as of September 9, 2018.
2. 2016-2017 data are provisional due to reporting delay.
Percent
0
2
4
6
8
10
12
14
16
18
2010 2011 2012 2013 2014 2015 2016² 2017²
MSM
MSW
Women

7. LAC Congenital Syphilis Elimination Goals and Strategies
All persons at highest risk of
syphilis aware of risk and offered
education and testing.
All pregnant women and women
of reproductive age screened and
treated for syphilis.
All syphilis cases identified and
investigated in timely manner to
disrupt disease transmission.
• High quality surveillance to identify
cases and monitor trends
• Effective syphilis partner services
activities for women and men
• Community medical providers to screen
and treat
• Accessible, welcoming clinical services
for women with co-morbidities
• Awareness of rising rates of syphilis
among women and community
• Syphilis education, testing, and
referrals in non-clinical settings
Eliminating Congenital Syphilis in Los Angeles County: A Call to Action, Draft July 2019.

8. Goal 1: All syphilis cases identified and investigated in timely manner to
disrupt disease transmission.
• High quality surveillance activities to identify cases
and monitor trends
• Effective syphilis partner services activities for
women and men

9. Goal 2: All pregnant women and women of reproductive age will be
appropriately screened and treated for syphilis in LAC.
• Community medical providers servicing this population to screen and treat
– Increase collaboration with key medical provider groups
• OB, birthing hospitals, Title X, primary care, ED providers
– Birthing hospital survey on syphilis screening procedures
– Public health detailing

10. Public Health Detailing Campaign and Action Kit
Four public health detailers conducted a brief syphilis tutorial and
assessment at initial visit and follow-up sessions with medical
providers in LAC during an approximately 8-week period.
1st round between May and July 2018
2nd round between September and December 2018
• Access kit:
http://publichealth.lacounty.gov/dhsp/SyphilisInWomen-
ActionKit.htm
10

11. Public Health Detailing Campaign and Action Kit
• 4 public health detailers conducted a brief syphilis tutorial
and assessment at initial visit
• Follow-up sessions conducted with medical providers
during an 8-week period
• Key messages
1. Screen all women of reproductive age
2. Screen all pregnant women for syphilis during the first trimester
or at their initial prenatal visit.
3. Re-screen pregnant women for syphilis early in the third
trimester (28-32 weeks) and at delivery.
4. Stage syphilis correctly in order to treat correctly.
Call the Clinical STD Consultation Warmline for help (213) 368-7441
http://publichealth.lacounty.gov/dhsp/SyphilisInWomen-
ActionKit.htm 11

12. Taking a sexual history, syphilis screening, staging and treatment
12

13. Patient Posters (couple and pregnant women)
13

14. Patient Brochures in Syphilis in Women Action Kit
14

15. Patient Resources: Syphilis and Congenital Syphilis FAQ in English, Spanish and Mandarin
15
http://www.publichealth.lacounty.gov/hea/library/topics/std/

16. STD Clinical Consultation warmline
16

17. 17

18. 11 STD CLINICS IN LOS ANGELES COUNTY
http://publichealth.lacounty.gov/dhsp/S
yphilisInWomen/22_2019_DPH_SexualH
ealthClinic(w-address)_v9.24.19.jpg

19. Number and types of visits in detailing campaign
· · 1186 total visits (includes providers and
19
1st ROUND 2nd ROUND
798 total visits (providers only) 936 total visits (providers only)
432 initial visits 588 initial visits
366 follow-up visits 348 follow-up visits

20. Identifying Providers to Detail in 1st Round
• PRIORITY I: Providers that diagnosed a case of syphilis in the mother of a baby born
with congenital syphilis 2014-2016
• PRIORITY II: Providers that diagnosed a case of syphilis in a females of child bearing
age 2016
• PRIORITY III: CPSP-Comprehensive Perinatal Service Program providers in 2016
Identifying Providers to Detail in 2nd Round
• PRIORITY I: New providers at new sites that diagnosed a case of syphilis in female in
2017-2018
• PRIORITY II: New providers at old sites that diagnosed a case of syphilis in female in
2017-2018
• PRIORITY III: Urgent care providers in zip codes with high female syphilis morbidity 20

21. Standardized Provider Assessment 1st Round
• Demographic information
• Self-reporting knowledge of syphilis trends and screening guidelines
• Self-report of taking a sexual history
• Proportion of pregnant patients that receive third trimester
screening
Categorized Qualitative Boxes on the back for reps post call 21

22. 46
82
0
10
20
30
40
50
60
70
80
90
100
Moderately/Extremely Knowledgeable
Percentage
Initial Visit Follow-Up Visit
35
63
0
10
20
30
40
50
60
70
Moderately/Extremely Knowledgeable
Percentage
Initial Visit Follow-Up Visit
Figure 2A: 1st Round :CPSP†/Surveillance*
n=363
Figure 2B: 2nd Round: High Morbidity Zip
Codes††/Surveillance** n=349
Provider Reported Knowledge of Syphilis Trends in Los Angeles County1
1.Data from PHD Field Reports ; † Comprehensive Perinatal Service Program Providers; *Dx a case of syphilis in a female in 2016 or mother of CS case 2014-2016; †† Purchased
list of health care providers in high syphilis morbidity zip codes; **Dx a case of syphilis in a female in 2017-2018 and providers not reached in 1st round

23. 52
93
0
10
20
30
40
50
60
70
80
90
100
Moderately/Extremely Knowledgeable
Percentage
Initial Visit Follow-Up Visit
40
69
0
10
20
30
40
50
60
70
80
Moderately/Extremely Knowledgeable
Percentage
Initial Visit Follow-Up Visit
Figure 2A: 1st Round :CPSP†/Surveillance*
n=363
Figure 2B: 2nd Round: High Morbidity Zip
Codes††/Surveillance **n=349
Provider Reported Knowledge of Syphilis Screening Guidelines in Los Angeles County1
1.Data from PHD Field Reports; † Comprehensive Perinatal Service Program Providers; *Dx a case of syphilis in a female in 2016 or mother of CS case 2014-2016;
†† Purchased list of health care providers in high syphilis morbidity zip codes; **Dx a case of syphilis in a female in 2017-2018 and providers not reached in 1st
round

24. 40
74
0
10
20
30
40
50
60
70
80
90
100
Reported 90+% Screening
Percentage
Initial Visit Follow-Up Visit
Figure 3A 1st Round :CPSP†/Surveillance*
(n=220 initial; n=222 follow-up )
Providers Reporting 3rd Trimester Screening between 28-32 weeks1
23
71
0
10
20
30
40
50
60
70
80
90
100
Reported 90+% Screening
Percentage
Initial Visit Follow-Up Visit
1.Data from PHD Field Reports ; † Comprehensive Perinatal Service Program Providers; *Dx a case of syphilis in a female in 2016 or mother of CS case 2014-2016;
†† Purchased list of health care providers in high syphilis morbidity zip codes; **Dx a case of syphilis in a female in 2017-2018 and providers not reached in 1st round
Figure 3B: 2nd Round: High Morbidity Zip Codes††/Surveillance **
(n=93 initial; n=73 follow-up )

25. 34
78
0
10
20
30
40
50
60
70
80
90
100
Adopted 1 Recommendation
Percentage
Initial Visit Follow-Up Visit
15
50
0
10
20
30
40
50
60
Adopted 1 Recommendation
Percentage
Initial Visit Follow-Up Visit
Figure 2A: 1st Round :CPSP†/Surveillance*
n=363
Figure 2B: 2nd Round: High Morbidity Zip
Codes††/Surveillance** n=349
Provider Reported Adoption of 1 Recommendation1 ,2
1.Data from PHD Field Reports ; † Comprehensive Perinatal Service Program Providers; *Dx a case of syphilis in a female in 2016 or mother of CS case 2014-2016;
†† Purchased list of health care providers in high syphilis morbidity zip codes; **Dx a case of syphilis in a female in 2017-2018 and providers not reached in 1st round 2. See
“Dear Colleague Letter”

26. Barriers to Treating syphilis (initial visit n=349)
– 6% Test interpretation/diagnosis/staging
– 10% Obtaining or storing of proper medication
– 7% Cost of medication
– 5% Administering treatment in office
– 4%Completing treatment within appropriate time frame
– 13% Getting patients back into office for results and treatment
– 3% Reimbursement for treatment
– 70% No barriers
– 2% Other
26
2nd Round Treatment Question Results

27. KEY FINDINGS 1st Round
•Third trimester screening at 35 weeks vs 28-32 weeks
•Limited in-office/clinic treatment
• Medi-Cal billing uncertainty
•Medi-Cal reimbursement issues
–Screening only covered once a month
–Doxycycline on Pharmacy Formulary but not Benzathine
penicillin G which is only covered on Clinic Formulary
–patients paying out of pocket for Bicillin
27

28. FUTURE GOALS
•Following up with providers that still screen in the third
trimester at 35 weeks
•Medi-Cal billing and reimbursement clarification
•Increasing number of sites distributing Bicillin
• Sharing campaign materials with San Francisco DPH,
Louisiana DPH
28

29. Goal 2: All pregnant women and women of reproductive age will be
appropriately screened and treated for syphilis in LAC.
• Increasing number of providers treating
with Bicillin
– Planned Parenthood clinics in LAC
• Increasing number of pregnant women
treated with Bicillin
– Bicillin delivery to providers
– Transportation via UberHealth
– Incentivized treatment with gift cards

30. Goal 2: All pregnant women and women of reproductive age will be
appropriately screened and treated for syphilis in LAC.
• Accessible and welcoming clinical services
for women with co-morbidities
– Explore new models of care for clinical
services
• More flexible perinatal case management
• Consider roving OB team model
• Express STD clinics to increase # patients
seen and treated for syphilis

31. Goal 3: All persons at highest risk of syphilis will be aware of the risk and
be offered education and testing in non-clinical settings.
• Awareness of rising rates of syphilis to
women and their community
– Social marketing, reports, website,
outreach
– Expand partnerships

32. THINK SYPHILIS Social Marketing Campaign Focus Groups
• Conducted three focus groups
– English-speaking, Spanish-speaking,
Women recovering from SUD
• Resonant messages and images chosen
– That Rash or Sore Might be Syphilis
– Man, Pregnant Woman, Hand, Foot
– “It’s their health too”
– Man, Pregnant Woman
• Images were accessible regardless of literacy level
32

33. THINK SYPHILIS METRO BUS ADS
• 98 Buses
• Routes serving the areas of highest syphilis morbidity
• Bi-lingual buses with English/Spanish on either side
• Running for 6 months beginning in October 2019
33

34. THINK SYPHILIS GetProtectedLA.com
34

35. THINK SYPHILIS Social Marketing Campaign Preliminary Results
35
Users and Pageviews on GetProtectedLA.com
MONTH USERS PAGEVIEWS
MAY 96 1,450
JUNE 47 264
JULY 44 133
AUGUST 36 77
SEPTEMBER 43 134
OCTOBER 85 417
NOVEMBER 61 147
DECEMBER 761 1,260
TOTAL 1,173 3,882

36. THINK SYPHILIS Social Marketing Campaign Preliminary Results
36
OCT
18
NOV
18
DEC
18
JAN
19
FEB 19 MAR
19
APR
19
MAY
19
JUNE
19
JULY
19
AUG
19
SEP 19 OCT
19
NOV
19
DEC
19
702 586 573 668 590 483 646 792 792 752 727 683 882 893 755
Hits on DHSP STD Clinic Services Page: http://publichealth.lacounty.gov/dhsp/STDClinics.htm

37. THINK SYPHILIS Social Marketing Campaign Preliminary Results
37
Calls to the DHSP STD Hotline: 1-800-758-0880
152 calls answered by a health educator or nurse from March 3rd, 2019 to September 30th, 2019-6 callers referenced “syphilis”
112 calls answered by a health educator or nurse since October 1st, 2019- 3 callers referenced “syphilis”
264 calls answered to date-54 callers referenced “condoms”

38. Goal 3: All persons at highest risk of syphilis will be aware of the risk and
be offered education and testing in non-clinical settings.
• Increase syphilis education, testing, and referrals in non-clinical
settings and field
• Correctional health – women’s jail rapid screening program
• Substance use disorder treatment providers and syringe
exchange providers
• Homeless services healthcare providers and street medicine
teams

39. Goal 3: All persons at highest risk of syphilis will be aware of the risk and
be offered education and testing in non-clinical settings.
• Enhance field outreach capacity targeted to persons experiencing
homelessness
– Partner with existing homeless medical services
• Street medicine teams
• Mobile units/vans
• Brick and mortar clinics serving the homeless
– Public Health outreach
• Syringe exchange, wound care, vaccines, and HIV/STD testing

40. Questions?
THANK YOU!
Melissa Papp-Green, MPH
Mpapp-green@ph.lacounty.gov
(2130 351-8065
California Health Report Article: In Los Angeles, a Novel Plan to End Congenital Syphilis:
http://www.calhealthreport.org/2019/02/19/in-los-angeles-a-novel-plan-to-end-
congenital-syphilis/
40