Georgia Epidemiology Report The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Department of Human Resources July 1996 http://www.ph.dhr.state.ga.us Division Of Public Health Patrick J. Meehan, M.D. - Director Epidemiology and Prevention Branch State Epidemiologist Kathleen E. Toomey, M.D., M.P.H.- Director Epidemiology Section Paul A. Blake, M.D., M.P.H.-Director Surveillance Jeffrey D. Berschling, M.P.H.; Karen R. Horvat, M.P.H.; Jane E. Koehler, D.V.M, M.P.H.; Preeti Pathela, M.P.H.; Sabrina Walton, M.S.P.H. Chronic Disease Nancy E. Stroup, Ph.D.-Director Patricia M. Fox, M.P.H.; David M. Homa, Ph.D., M.P.H.; Thomas W. McKinley, M.P.H.; Edward E. Pledger, M.P.A.; D. Lee Warner, M.P.H. Tuberculosis Bharat K. Pattni, M.B.B.S., M.P.H. HIV\AIDS Awal D. Khan, Ph.D., M.A. Sexually Transmitted Diseases Stephanie Bock, M.P.H.; Andrew Margolis, M.P.H. Office of Perinatal Epidemiology Roger W. Rochat, M.D. - Director Mary D. Brantley, M.P.H.; Raymond E. Gangarosa, M.D., M.P.H.; Rebekah Hudgins, M.P.H.; Mary P. Mathis, Ph.D., M.P.H.; Florina Serbanescu, M.D.; Edward F. Tierney, M.P.H. Georgia Epidemiology Report Editorial Board Editorial Executive Committee Paul A. Blake, M.D., M.P.H.- Editor Kathleen E. Toomey, M.D., M.P.H. Mary D. Brantley, M.P.H. Jeffrey D. Berschling, M.P.H. Mailing List Edward E. Pledger, M.P.A. Volume 12 Number 7 Genital Ulcer Disease in Fulton County Primary syphilis remains an important cause of genital ulcers, especially in the southeastern United States. In Fulton County, Georgia, rates of primary and secondary syphilis have fallen considerably in the past 5 years, following a major epidemic in the late 1980's. However, per-capita rates in Fulton County still remain about five times higher than those of the United States as a whole. These continuing high rates are of great concern because of sequelae such as neurosyphilis and congenital syphilis, and because genital ulcers may facilitate transmission of HIV. In 1995, two large clusters of early syphilis were investigated by the Fulton County Department of Health, involving a total of 29 cases. In the first cluster, a bisexual male sex worker in a downtown Atlanta single-room-occupancy hotel was found to have early syphilis, and partner notification efforts uncovered 11 cases of early syphilis. In the second area, an HIV-positive female sex worker living in Union City, a semi-rural area on the outskirts of Atlanta, was found to have secondary syphilis, and partner notification efforts there uncovered 16 cases of early syphilis. In both areas, crack cocaine use and exchange of sex for drugs were identified among a large number of patients. HIV prevalence among those syphilis patients for whom HIV serostatus was known was 14% (4/29). Concern over potential resurgence of syphilis led to the initiation of a study of syphilis and other causes of genital ulcer disease at the Fulton County STD Clinic, with cooperation from the Georgia Division of Public Health and the Centers for Disease Control and Prevention (CDC). This study was recently completed, and has provided some insights into the prevalence of different etiologies of genital ulcer disease in the Atlanta area. In this preliminary report, we address two questions: 1) among patients attending STD clinics, what proportion of genital ulcers are caused by syphilis, and what proportion by herpes simplex virus (HSV) or chancroid? and 2) how can patient history and available laboratory results aid in diagnosing genital ulcers? Methods In the study, a swab was taken from every patient with a genital ulcer who came to the clinic between November 1995 and February 1996. A newly developed test, based on the polymerase chain reaction (PCR), was used to amplify and detect the DNA of the organisms which cause syphilis, chancroid, and HSV infections. This test is investigational, and not yet available commercially. Data on patients' symptoms, results of serologic tests for syphilis, darkfield examinations, and HSV cultures was also collected. Results Ninety-five patients with ulcers were seen during the study period. As shown in Figure 1, HSV was the most commonly detected organism in the study. DNA evidence of syphilis was found in 17% of ulcers, and DNA evidence of chancroid in Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186 Phone: (404) 657-2588 FAX: (404) 657-2586 7% of ulcers. Note that syphilis and chancroid were often present in ulcers in combination with HSV. Importantly, patients with syphilis alone and with HSV alone by PCR did not differ significantly in complaints of painful or painless ulcer, itching, dysuria, rash, or lymphadenopathy. Bacterial causes of ulcers were not uncommon in this population of STD Clinic patients: DNA of syphilis was detected in 17% of ulcers, and DNA of chancroid was detected in 7% of ulcers. In total, one of every four patients with an ulcer had syphilis or chancroid. In a number of cases, syphilis or chancroid was detected together with HSV. Figure 1. Genital Ulcer Disease at Fulton County STD Clinic, November 1995 - February 1996 These data emphasize the importance of looking carefully for evidence of syphilis and chancroid, even in a patient with lesions typical for HSV infection. For diagnosing syphilis, darkfield examination and non-treponemal tests for syphilis (such as RPR or VDRL) are very useful, though both may still be negative in primary syphilis. For diagnosing chancroid, culture is not available in most settings, though chancroid can be suspected in a patient with a painful ulcer with undermined edges, and tender inguinal adenopathy. Both syphilis and chancroid are associated with HIV, and with risk factors such as crack cocaine use and commercial sex work. However, lack of risk factors does not ensure that syphilis and chancroid are absent. n=95 Note:Detection of organisms by polymerase chain reaction. As noted in the 1993 CDC STD Treatment Guidelines, physicians must often decide on a treatment for a genital ulcer before a final diagnosis is available. In that circumstance, the physician should treat for the diagnosis considered most likely. Many experts recommend "presumptive" treatment for both syphilis and chancroid if the diagnosis is unclear, and if the patient resides in a community in which chancroid morbidity is notable, which appears to be the case for many patients in the Atlanta area. In addition, the study found that standard laboratory tests for genital ulcer disease miss some cases. For example, only 69% (11/16) of the patients with syphilis DNA detected had a positive serologic test for syphilis (RPR) at the time of examination, and only 53% (7/13) had a positive darkfield exam. Similarly, only 59% (35/59) of patients with HSV DNA detected had a positive HSV culture result. It is important to remember that these test results may be affected by partial self-treatment by the patient with oral antibiotics, the use of creams or ointments, or bacterial superinfection. In addition, in some cases the lesions may have scabbed over, so that no serous fluid was available for darkfield or HSV culture. Conclusions Appropriate treatment of genital ulcers is an important element in public-health efforts to control syphilis and its sequelae, such as congenital syphilis, and to reduce the likelihood of HIV transmission. However, a physician who has found a genital ulcer on examination may not easily be able to distinguish between the three most likely pathogens, which are herpes simplex virus (HSV), syphilis, and chancroid. Other possible causes of genital ulcers, such as lymphogranuloma venereum (LGV) and granuloma inquinale, are very rare in the United States. This study, which used very sensitive investigational methods to detect possible causative organisms, revealed that patient history and standard laboratory testing were imperfect in establishing a diagnosis. For example, in contrast to the textbook description, we found that syphilitic ulcers did not usually appear to be "painless". In fact, patients with syphilis alone and with HSV alone by PCR did not differ significantly in complaints of painful or painless ulcer, itching, dysuria, rash, or lymphadenopathy, perhaps because both herpetic and syphilitic ulcers were often superinfected by the time medical care was sought. One possible CDC-recommended regimen to treat both primary syphilis and chancroid is penicillin G 2.4 Million Units IM in a single dose (for primary syphilis), and azithromycin 1 gram PO in a single dose (for chancroid). Other recommended treatments for chancroid include ceftriaxone 250 mg IM in a single dose, or erythromycin base 500 mg PO 4 times per day for 7 days. In addition, it is pivotal to confidentially notify, counsel and treat partners of patients, and to report suspected cases of syphilis and chancroid to local health departments. Local health departments can offer assistance in partner notification, counseling and treatment, with strict attention to issues of confidentiality. This will prevent further spread of disease in the patient's community, and ensure that he or she will not become re-infected. It is important to note that syphilis and chancroid (like other STDs such as gonorrhea, chlamydia and LGV) are reportable by law in Georgia to state or local public health (State Law OCGA 31-12-2). Finally, all patients and their partners should strongly consider being tested for HIV. For other possible treatment regimens and more complete treatment guidelines, physicians and other providers may consult the "1993 Sexually Transmitted Diseases Treatment Guidelines", available without cost from the CDC at (404) 639-8063. For more information contact Douglas T. Fleming, MD, Centers for Disease Control and Prevention, Division of STD Prevention, Mailstop E-02, 1600 Clifton Rd. Atlanta GA 30333. This report was contributed by Douglas T. Fleming, MD, William Levine, MD, Michael St. Louis, MD , National Center for HIV/ STD/TB Prevention, CDC; David Trees, PhD, National Center for Infectious Diseases,CDC; and Pradnya Tambe, MD,Fulton County STD Clinic - 2 - Domestic Violence and Pregnancy Position Statement from the Council On Maternal and Infant Health Domestic violence, partner abuse and battering, which includes physical, emotional and sexual abuse, is very costly on both a personal and societal level. It is a leading cause of injury and death in women, and is a prominent cause of suicide and suicide attempts 1,2. Medical costs arise from these injuries and the psychological symptoms of depression, anxiety, sleep and eating disorders are also expensive to treat. Domestic violence during pregnancy is a serious public health problem that can negatively affect both the mother and the fetus. National studies have found that the prevalence of abuse among pregnant women ranges from 4-20% . 3,4,5 In terms of pregnancy outcomes, studies have shown that physical abuse is associated with a delay in entry to prenatal care 6. Women who do not receive comprehensive, timely prenatal care are more likely to have poor pregnancy outcomes such as prematurity and low birthweight 7. A study of women in Georgia that have had a live birth showed that women who are physically abused by their partners, were more likely to delay entry into prenatal care until the third trimester than non-abused women 6. The Council on Maternal and Infant Health recommends that physical violence be considered a risk factor for late entry into prenatal care. The Georgia Pregnancy Risk Assessment Monitoring System estimates that at least 10% of women are physically hurt by a husband or partner, or involved in a physical fight in the twelve months before they deliver a live infant; the equivalent of 10,930 Georgians per year9. In a representative sample of 3,130 women interviewed throughout Georgia in the 1995 Georgia Women's Health Survey, 28% had ever been physically abused by partner or ex-partner. Approximately 8% of women reported abuse on a standard intake history, and 29% reported abuse when asked by a health care provider in a 1991 study10. For these reasons, health care practitioners who come in contact with pregnant women need to screen for domestic violence routinely and refer the patient to the appropriate services. The opportunity to intervene on behalf of the battered pregnant woman may arise in such settings as family planning clinics, emergency rooms, and WIC offices. In addition, because obstetrician-gynecologists are the primary care providers for many women, they also play a vital role in identifying women who are the victims of abuse and in offering them appropriate care. The Council on Maternal and Infant Health recommends that all women be screened for domestic violence/physical abuse. The Council also recommends that health care and social service providers be trained to enhance their skills in conducting physical abuse screenings. The Council supports the American College of Obstetricians and Gynecologists (ACOG) care standard of screening all women for physical abuse during prenatal care, which is available in the ACOG Patient Education pamphlet entitled "The Abused Woman." Copies may be ordered from: ACOG Distribution Center P O Box 4500 Kearneysville, WV 25430-4500 1-800-762-2264 Detailed information for physicians on the screening, referral and treatment of abused clients is available through the Medical Association of Georgia's booklet entitled "Life Preservers: A Life Line for Victims of Violence." Copies: Medical Association of Georgia 938 Peachtree Street, NE Atlanta, Georgia 30309 404-876-7535 The Council on Maternal and Infant Health Board and Membership Louis I. Levy, M.D. Chairperson - Columbus Debbie Sibley, R.N., M.S.N. Vice Chairperson - Augusta Irma Works, Ed.S. Secretary - Columbus Tee Rae Dismukes Executive Director - Atlanta Roberta M. Brown-Royston;Wilma Brown-Atlanta; Lynne Feldman, M.D.-Valdosta; Schley Gatewood, Jr., M.D.-Americus; Eugene H. Jackson, M.D.-Cuthbert; Mary Johnson, R.N., M.S.N.-Rome; Wm. P. Kanto, Jr., M.D.-Augusta; Lawrence W. Price, M.D.-Villa Rica; Hugh W. Randall, Jr., M.D.-Atlanta; William R. Sexson, M.D.-Atlanta;Charles T. Stafford, M.D.-Dahlonega; Richard A. Wherry, M.D.-Bainbridge; Nancy White-Dunwoody References 1. FBI, Uniform crime reports. Washington, DC, US Department of Justice, 1993. 2. Campbell JC, Poland ML, Waller JB, and Ager J. Correlates of battering during pregnancy. Research in Nursing & Health. 15:219-226, 1992. 3. O'Campo P, Gielen AC, Faden RR, Xue X, Kass N, and Wang M. Violence by male partners against women during the childbearing year: a contextual analysis. American Journal of Public Health. 85(8): 1092-1097, 1995. 4. Hillard PJ. Physical abuse in pregnancy. Obstetrics and Gynecology. 66: 185-190, 1985. 5. Helton AS, McFarlane J, Anderson ET. Battered and pregnant: a prevalence study. American Journal of Public Health. 77(10):1337-1339, 1987. 6. Dietz P, Rohweder C, Mathis M, Rochat R. Physical abuse and entry into prenatal care. Presented at the Maternal, Infant, and Child Health Epidemiology Workshop. Atlanta, Georgia, September 28, 1995. 7. Institute of Medicine. Preventing Low Birthweight. Washington, D.C: National Academy Press, 1994. 8. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy: Severity and frequency of injuries and associated entry into prenatal care. Journal of the American Medical Association. 267(23):3176-3178, 1992. 9. Georgia Pregnancy Risk Assessment Monitoring System, Office of Perinatal Epidemiology, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources, 1993-94. 10. McFarlane J, Christoffel K, Bateman L, Miller V, Bullock L. Assessing for abuse: Self-report vs. Nurse interview. Public Health Nursing. 8: 245-250, 1991. - 3 - The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186 July 1996 Volume 12 Number 7 Reported Cases of Selected Notifiable Diseases in Georgia Profile for April 1996 Selected Notifiable Diseases Campylobacteriosis Giardiasis H. influenzae B Meningococcal Disease Rubella Salmonellosis Shigellosis Viral Meningitis Tuberculosis Congenital Syphilis Early Syphilis Other Syphilis Cryptosporidiosis E. coli O157:H7 Legionnaires' Disease Lyme Disease Mumps Pertussis Total Reported forApril 1996 29 30 3 16 0 47 45 1 56 2 167 81 4 2 0 0 1 3 Previous 3 Months Total Ending inApril 1996 1995 1994 139 200 169 146 128 121 35 24 25 55 31 28 0 0 0 180 187 233 121 379 259 8 11 13 179 170 199 14 11 9 530 685 740 236 256 214 13 8 2 5 1 1 1 6 52 0 6 36 1 4 5 7 6 6 Previous 12 Months Total Ending inApril 1996 1995 1994 958 114 1683 610 462 398 99 60 75 148 92 91 0 7 0 1671 1560 1281 990 2098 637 101 75 147 783 742 796 62 52 78 2416 2589 3365 1098 891 923 118 26 10 33 27 16 9 64 82 8 89 78 9 14 16 31 34 55 The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office; and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia. Report Period Total Cases Reported * Percent Female AIDS Profile Update MSM Risk Group Distribution (%) IDU MSM&IDU HS Blood Unknown Race Distribution (%) White Black Other Last 12 Mos 07/95 to 06/96 5 Yrs Ago 07/90 to 06/91 Cumulative 01/80 to 06/96 2434 1344 15815 17.4 10.6 13.8 47.1 17.8 4.1 62.4 18.0 5.3 53.0 19.1 6.0 15.6 1.1 14.3 36.0 60.8 3.2 7.9 2.0 4.3 48.6 50.3 1.1 10.4 2.1 9.5 41.7 56.4 2.0 MSM - Men having sex with men IDU - Injection drug users * Case totals are accumulated by date of report to the Epidemiology Section HS - Heterosexual - 4-