UPDATE ON THE SYPHILIS
EPIDEMIC IN INDIANAPOLIS
Janet Arno, MD and Jutieh Lincoln, MPH
February 9, 2011
Marion County Public Health Department
(MCPHD)
Indianapolis, IN
Goals of this Presentation

To inform the Community about the status of the Syphilis
epidemic, and to highlight its epidemiologic trends over
time

To inform the Community about current efforts to control
the Syphilis epidemic

To seek the help of the Community in controlling the
Syphilis epidemic
Background






In 1999, Marion County had the highest number of Primary and
Secondary (P & S) syphilis cases in the United States.
As a result of the outbreak, community organizations partnered with the
Marion County Public Health Department, the State, and CDC to
organize an effective campaign to control syphilis.
The number of P & S was decreased from 403 P & S cases per year to
less than 50 cases per year.
In 2008 we once again saw an increase in cases twice the standard
deviation of our baseline.
Now we are seeing an increase in cases superimposed on an outbreak
among MSM.
Since 2008, about 410 Indianapolis residents have been diagnosed
with the disease
Early and P & S Syphilis In Indianapolis
1996-2010
Early Syphilis
P&S
600
1999 Syphilis
Outbreak
500
400
300
2008 Syphilis
Outbreak
200
# of Cases
100
0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Report Year
Early Syphilis Indianapolis
2007-2010
Primary and secondary
Total Early Syphilis
60
50
40
30
20
10
0
Q1
Q2
Q3
2007
Q4
Q1
Q2
Q3
Q4
2008
Q1
Q2
Q3
Q4
2009
Q1
Q2
Q3
2010
Newly Diagnosed Syphilis Cases from
January 1, 2010 to December 28, 2010





District 5: 178 cases
Total number of primary and secondary syphilis
cases in District 5: 117
Marion County: 162 cases
Total number of primary and secondary syphilis
cases in Marion County: 106
Except for race and age, the demographics of the
16 cases outside of Marion County are similar to
the demographics of cases within Marion County.
Early Syphilis Cases by Diagnosis:
2008-2010, Marion County, Indiana
# of Cases
Primary
200
160
120
80
40
0
Secondary
Early Latent
56
49
55
18
27
49
20
82
24
2008
2009
2010
Report Year
Consistently, most cases had primary or secondary syphilis at diagnosis.
Early Syphilis Cases by Race: 2008-2010, Marion
County, Indiana
White
Black
Hispanic
Other
180
160
140
120
100
106
39
80
41
60
40
78
20
43
45
2009
2010
# of Cases
0
2008
Report Year
The outbreak has shifted from mostly Whites to mostly Blacks.
Early Syphilis Cases by Age of Diagnosis:
2008-2010, Marion County, Indiana
<25 years
# of Cases
180
160
140
120
100
80
60
40
20
0
25-34 years
35-44 years
>44 years
23
24
18
47
23
55
34
38
60
19
22
17
2008
2009
2010
The outbreak has shifted from middle-aged to younger adults.
Report Year
Early Syphilis Cases by Gender: 2008-2010,
Marion County, Indiana
Male
Female
180
160
30
140
120
9
100
8
80
60
132
113
88
40
20
# of Cases
0
2008
2009
2010
Report Year
Males (esp. MSM) account for most cases, but female proportion has grown.
HIV Co-Infection Among Early Syphilis Cases:
2008-2010, Marion County, Indiana
Negative
Positive
Unknown
160
140
120
8
12
38
100
14
80
68
60
51
94
40
20
41
31
# of Cases
0
2008
2009
2010
Report Year
The HIV-infected proportion has shrunk, but many new cases do have HIV.
Early Syphilis Cases by Sexual Orientation:
2008-2010, Marion County, Indiana
MSM
# of Cases
180
160
140
120
100
80
60
40
20
0
Bisexual
Heterosexual
Unknown
64
20
25
92
66
2008
2009
89
2010
Report Year
Heterosexuals account for an increasing portion of diagnosed cases.
Risk Behavior of Syphilis Cases

Cases frequently reported:
o Sexual intercourse with unknown persons
o Sexual intercourse without condom
o Sexual intercourse while high on drugs such as:
o Alcohol
o Marijuana
o Crack
o Cocaine
o Meth
Risk Behavior of Syphilis Cases

Frequently reported sites for meeting sex partners include:
Adam for Adam
o Gay.com
o Manhunt
o Facebook
o The Ten
o Club Indy
o Talbot
o Gregs
Blacks were likely to meet their sex partners:
o





thru Family members
thru Friends
at social events (ex. parties)
Whites were likely to use online sites to meet their sex partners.
Methods of Case Detection that are being
utilized in the Syphilis Epidemic

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Disease Intervention Specialist (DIS)-a staff member who is
trained to treat, interview, and follow up on persons diagnosed
with an STD.
Patient Referral-an instance in which a person diagnosed with
an STD divulges the names of partners he/she may have put at
risk for that STD.
Screening-an initial evaluation conducted by a provider to
determine whether a person is at risk for or has an STD.
Self Referral-an instance in which a person feels that he/she
may have an STD and goes to a provider for screening.
# of cases
80
70
60
50
40
30
20
10
0
Methods of Case Detection: 2010 Syphilis
Cases, Marion County, Indiana
75
45
13
Traditional Disease
Intervention Activities
26
Patient Referral
Screening
Self Referral
Self referral and screening accounted for the bulk of the cases diagnosed.
Conclusions
Syphilis Cases so far in 2010
surpassed 2008 and 2009’s count
Blacks became majority among cases
MSM still disproportionately impacted
Age shifting from older to younger adults
Female proportion increased to nearly 1 out of 6
syphilis cases
Conclusions
Proportion with HIV decreasing, but still high
Heterosexuals proportion trending upwards
3 risks commonly reported were:
Drug use during sexual intercourse
 Sexual intercourse with unknown persons
 Sexual intercourse without condom

Cases increasingly concentrated in central
Marion County and lower income areas
An increase is expected with waxing and waning
components
Current Efforts

Continue to:
Screen high risk groups (e.g. MSM, the incarcerated, commercial
sex workers) and hard-hit areas in Indianapolis for the disease
and quickly bring cases to treatment
 Partner with providers and community-based organizations
around the city to quickly identify patients with the disease and
bring them to treatment, and to educate their patients about the
disease and risk reduction behaviors
 Aggressively follow up with partners named by cases to
determine if they have the disease and bring them to treatment or
to educate them about risk reduction behaviors

Current Efforts

Continue to


Periodically update providers, public health practitioners, and the
community on the epidemic through mass mailing and through
MCPHD website. A powerpoint presentation on the epidemic is
available at: http://www.mchd.com/syphilis_info.htm
Have set up a new website
(http://www.bellflowerclinic.org/) to keep providers,
public health practitioners, and the community informed
about clinic hours, STD resources, services offered, and to
answer their questions
How Can You Help?
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Spread the word about the Syphilis epidemic
Encourage persons in your community to get tested for
Syphilis
Inform persons in your community that Bell Flower
Clinic offers low cost STD screening (or free STD
screening with life saver card)
Share ideas for screening sites in your community
Serve as an information resource for your community
Offer Suggestions on how to control the epidemic
Acknowledgement
A Special thank you to Mr. David Broyles
(Marion County Public Health Department
Corporate Information Systems) for his
excellent and timely work on the Syphilis
maps, and Caitlin Gill (Epidemiology intern
from the IU Department of Public Health) for
assisting in the compilation and presentation
of this data.