A NEWSLETTER OF THE REGION VI INFERTILITY PREVENTION ADVISORY COMMITTEE (RIPAC) ARKANSAS, LOUISIANA, NEW MEXICO, OKLAHOMA & TEXAS

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1 Chlamydia Challenge SUMMER 2008 A NEWSLETTER OF THE REGION VI INFERTILITY PREVENTION ADVISORY COMMITTEE (RIPAC) ARKANSAS, LOUISIANA, NEW MEXICO, OKLAHOMA & TEXAS CONTENTS HEALTH DISPARITIES: THE CHALLENGES WE FACE REGION VI INFERTILITY PREVENTION PROJECT Gonorrhea (GC) is the second most notifi able disease in the Unites States. The number of GC cases reported in the United States in 2004 was 330,132 (113.5 cases per 100,000 population) REGIONAL UPDATES: TEXAS OKLAHOMA LOUISIANA ARKANSAS NEW MEMBERS CANDID CAMERA MARK YOUR CALENDAR!

2 2 HEALTH DISPARITIES: Although this is the lowest GC rate the US has ever reported, it still considerably exceeds the Healthy People 2010 target of 19 cases per 100,000 population. CHALLENGES WE FACE Despite substantial improvements in the prevention of HIV/AIDS, viral hepatitis, sexually transmitted diseases and tuberculosis in the United States, some populations continue to be disproportionately affected by these diseases. The existence of such health disparities among populations has been discussed in the literature for several years. The Department of Health and Human Services Healthy People 2010 presents a comprehensive, nationwide health promotion and disease prevention agenda that specifies that health disparities include differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation. The Centers for Disease Control and Prevention (CDC) uses surveillance data from state and local health departments to monitor disparities and other patterns in these communicable diseases. Factors contributing to health disparities include poverty, unequal access to health care, and lower educational attainment. Intertwined with these factors are dynamics such as racism and homophobia. People s physical locations e.g, urban vs. rural and living situation in addition to social networks and social stigma, also contribute. Gonorrhea (GC) is the second most notifiable disease in the Unites States. The number of GC cases reported in the United States in 2004 was 330,132 (113.5 cases per 100,000 population). Although this is the lowest GC rate the US has ever reported, it still considerably exceeds the Healthy People 2010 target of 19 cases per 100,000 population. In 2004, Blacks had the highest GC rates (629.6 cases per 100,000 population). Although rates among Blacks decreased annually since 2000, the rate is nevertheless approximately 6 times that of American Indian/Alaska Natives (AI/AN), more than 18 times that of Whites and (continued on page 3)

3 3 HEALTH DISPARITIES: Since 2000, there has been a 21% increase in the CT rate among the 20 to 24- year-old group, consistently the age group with the highest rate of infection. (HEALTH DISPARITIES continued from page 2) almost 30 times the rate of Asian/Pacific islanders. In 2004, the South was the geographic region with the highest GC rate (143.4 cases per 100,000 population), but the rate still represents a decline of 22% from a rate of 184 cases per 100,000 in Chlamydia trachomatis (CT) infection is the most commonly reported sexually transmitted disease in the United States, and increases in infection have been reported over the past ten years. The increase in reported infections reflects expansion of CT screening activities, use of increasingly sensitive diagnostic tests, increased emphasis on case reporting from providers and laboratories, and improvements in the information systems for reporting. In 2004, Blacks had the highest CT rates (1,029.4 cases per 100,000 populations), approximately two times the rate for American Indian/Alaska Natives (705.8 cases per 100,000 population) and 8.4 times that of Whites (143.6 cases per 100,000 population). Chlamydia rates have increased annually for all racial/ethnic groups, except for Asians/Pacific Islanders. The Midwest reported the highest CT rates in 2004 (340.1 cases per 100,000 population), closely followed by the South and West with rates of and cases per 100,000 population respectively. Since 2000, there has been a 21% increase in the CT rate among the 20- to 24-year-old group, consistently the age group with the highest rate of infection. The age group has maintained the second highest rate for this period of time, with an overall increase of 17.5%. Developed through a national process, the document Healthy People 2010 identifies a set of 10-year health objectives to be achieved during the first decade of the 21st century. It has two overarching goals to increase quality and years of healthy life and to eliminate health disparities. CDC has a major leadership role in carrying out the goals set forward in Healthy People 2010, including the goal to eliminate racial and ethnic disparities in health. CDC provides leadership, capacity-building assistance, and funding for programs at the state, local, and community levels for the prevention and control of HIV/AIDS, viral hepatitis, STDs and tuberculosis. (Excerpts for the article were taken from: C. Brooke Steele, Lehida Melendez-Morales, Richard Campoluci, Nickolas DeLuca and Hazel D. Dean. Health Disparities in HIV/ AIDs, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis: Issues, Burden, and Response, A Retrospective Review, Atlanta, GA: Department of Health and Human Services, Center for Disease Control and Prevention, November 2007.) REGION VI INFERTILITY PREVENTION PROJECT Over a 12 year period from 1996 through June 2007, the (continued on page 4)

4 4 HEALTH DISPARITIES: For Black women aged years CT+ went from 14.3% to 18.3% over the 12 year period. INTERESTING WEBSITES: preventiononline.org WAITING ROOM VIDEO REDUCES STI S profilevideos?user= SafeintheCityVideo (HEALTH DISPARITIES continued from page 3) Region VI IPP assessed chlamydia (CT) and gonorrhea (GC) test records for women aged years seen at family planning (FP), and sexually transmitted disease (STD) clinics across the five Region VI states (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas). Over 500 clinics provided test records to IPP during the study period. These clinic types and client age ranges were selected because they represent a higher priority population identified by the CDC s Division of STD Prevention and screening criteria approximate universal testing. Statespecific data collection forms and procedures were implemented. However, each state collects core data elements, including client test date, date of birth, race/ethnicity, provider type, and CT and GC test results. Over 1,300,000 CT/GC test records were analyzed. For chlamydia and gonnorrhea, observed positivity was calculated by dividing the number of positive tests by the total number of tests that were either positive or negative and multiplying by 100. CT and GC tests were stratified by age categories (15-19/20-24 years), race/ethnicity (non-hispanic White and Black), and clinic type (FP/STD). Test results were not adjusted for test type. For most of the study period, Region VI states relied on various non-amplified CT/CG tests. Incorporating selected racial/ethnic data, FP and STD age comparisons were further stratified by White and Black tests. CT trends in FP clinics clearly showed age and racial/ethnic differences. The lowest positivities were for White women ages years (4.1% to 4.4%), followed by White women ages years (continued on page 5)

5 5 HEALTH DISPARITIES: White women ages GC ranged from 0.3% in 1996 to 0.5% in White women ages GC was 0.6% in 1996 and 0.7% in (HEALTH DISPARITIES continued from page 4) (6.4% to 5.8%). For Blacks, women aged years had CT+ of 8.1% in 1996 that increased to 11.0% in 2007; for Black women aged years CT+ went from 14.3% to 18.3% over the 12 year period. For STD clinics, the CT trends by age and race/ethnicity were slightly less consistent. White women aged years had CT positivities from 1996 to 2007 of 8.5% to 12.8%, respectively. White adolescent CT+ was stable at 14.7% at these study endpoints. Black CT+ for women aged years increased from 11.3% to 15.3%. Paralleling that trend, Black adolescent women showed the highest CT+ that also increased over time from 19.6% in 1996 to 23.7% in In FP clinics, Whites had very low levels of gonorrhea regardless of age. For White women ages GC ranged from 0.3% in 1996 to 0.5% in 2007; for White women ages GC was 0.6% in 1996 and 0.7% in Among Black patients, GC positivities were higher and varied by age. Black women aged years showed GC levels of 2.2% in 1996 and 3.4% in Black adolescent women had the highest GC positivity, 4.9% in 1996 and it increased to 6.2% in In STD clinics, White adolescents and those ages years had comparable GC positivities over time (6.2% to 4.1% for teens and 5.6% to 4.0% for the older age group). Among Blacks GC positivity trended down from high levels. Adolescent GC levels went from 16.7% in 1996 to 15.5% in 2007 while for women ages GC went from 11.9% down to 10.1% over the study period.

6 6 TEXAS NEWS SO LONG AND HAPPY TRAILS A fond farewell to Marcia Sims, Texas Department of State Health Services, Family Planning Program Representative retired June The entire membership wishes to thank Marcia for her commitment to RIPAC. TEXAS IPP WELCOMES NEW PARTNER The Texas IPP would like to welcome a new member to the partnership, El Buen Samaritano Health Clinic. El Buen Samaritano, located in Austin is a new Federal Title X grantee. The clinic provides primary, maternity and preventive healthcare, social work services and educational programs by a bilingual staff in a homelike, relaxed environment. The services are designed for individuals and families who are not covered by health insurance and are offered without regard to immigration status. The clinic works in collaboration with local hospitals and clinics such as University Medical Center at Brackenridge, the Seton Neighborhood Clinic system, People's Community Clinic, Planned Parenthood and many other community organizations to meet the healthcare needs of the community they serve. El Buen Samaritano offers a wide range of birth control options, including the birth control pill, injection, and IUDs. They also provide pregnancy testing and basic infertility consultations. CHARTER SCHOOL PROJECT AUSTIN, TX On February 5th and February 11th 2008 the Texas IPP along with a team of partners and volunteers held mass screening events on two campuses of a local charter high school. A total of 104 (54 male; 50 female) students were tested over two days. There were 11 Chlamydia positive cases (10.6% positivity), including one co-infected with Gonorrhea (GC). All positive cases were treated and referred for full exams and STD screening. For many of the students, including the positives, this was their first time testing for a sexually transmitted disease (STD). The Texas Infertility Prevention Program would like to thank all of those that made this screening event possible: People s Community Clinic, the charter school staff, Texas Department of State Health Services, Women s Health Laboratory and our volunteer counselors.

7 7 OKLAHOMA NEWS CHLAMYDIA CHALLENGE Oklahoma will be focusing more attention toward health disparities and redirect some of its resources toward the African American Population in HEALTH DISPARITIES Oklahoma has identified an overall state rate of Chlamydia among the African American population to be thirty-three percent of all positive tests. With such high Gonorrhea /Chlamydia rates identified in our African American population consenting for testing, Oklahoma will be focusing more attention toward health disparities and redirect some of its resources toward the African American Population in We are also showing higher percentages of low birth weight babies in Oklahoma in the African American Population which could be related. The agency plans to explore further how best to address this issue via collaborations with health care providers. These findings are in populations concentrated in our larger metro areas of Tulsa and Oklahoma County. Oklahoma has recently added Suprax back to its formulary; in most cases this provides a one-dose treatment for GC instead of a painful injection. The service hopes to increase the number of patients screening visits and compliance.

8 8 LOUISIANA NEWS Although African Americans only represent 32% of the state population, 64% of Chlamydia cases, 68% of gonorrhea cases and 80% of syphilis cases for 2007 were in the African American population. STD HEALTH DISPARITIES IN LOUISIANA Louisiana continues to carry the dubious distinction of being ranked as the least healthy state in which to live. Rates of sexually transmitted diseases in Louisiana are among the highest in the nation. There are significant health disparities or "population-specific differences in the presence of disease for sexually transmitted diseases in Louisiana. Although African Americans only represent 32% of the state population, 64% of Chlamydia cases, 68% of gonorrhea cases and 80% of syphilis cases for 2007 were in African American population. According to a 2003 report by the Louisiana Department of Health and Hospitals Bureau of Minority Health Access, barriers that prevent racial and ethnic minorities from obtaining adequate health care are: Language & communications. Lack of culturally sensitive staff or personnel at hospitals and/or clinics. Transportation. Lack of awareness and education. While the existing health status data on populations of color is troubling, what is not known is equally troubling. Much more needs to be learned about minority populations in order to assess their health needs and, in turn, develop effective and appropriate health related policies and programs. To achieve better health outcomes we must intervene earlier in the disease process, preferably prior to illness. The Louisiana Office of Public Health ensures availability of quality, culturally competent services for sexually transmitted diseases through STD and Family Planning clinics throughout the state. In addition, the STD Program has partnered with LSU Health Care Services Division (LSU HCSD) to decrease rates of STDs in Louisiana. LSU HCSD operates seven of the ten public hospitals in Louisiana. The STD and Family Planning Programs will conduct Health Education and Outreach activities in assisting with achieving better health outcomes. The programs will also look into the possibility of collaborating with the Bureau of Minority Health Access. RACE/ETHNICITY DISTRIBUTION OF STDS IN LOUISIANA 2007

9 9 ARKANSAS NEWS INCOMING RIPAC OFFICERS FALL 2008 The incoming Chair Elizabeth Delamater, Ph.D., Texas, and Co-Chair Jan Fox, MPH, RN, Oklahoma (left to right) The incoming Sub-Committee Chair for the Clinical/ Training Alicia Nelson, NP, RN CHLAMYDIA IN ARKANSAS The Public Health Laboratory of the Arkansas Department of Health implemented Nucleic Acid Amplified Testing (NAAT), a new screening test for chlamydia, in July A significant increase in the number of chlamydia cases is noted since the implementation of the new testing procedure. The chlamydia positivity rate increased from 5.9% pre-naat to 11.7% post-naat. HEALTH DISPARITIES Factors such as age, gender, race, and geographic distribution are assessed to understand disparities of chlamydia infections in Arkansas. Disparities exist among women of different age groups and among African Americans (Figures 1-4). Analysis of geographic disparities in chlamydia shows clustering of areas with high burden of the disease (Figure 5). Among the 9,956 total chlamydia cases in 2007, the most affected age group continues to be age years (n=9,441; 95%), with the maximum number of cases seen in age years (n=3,883; 39%) and age years (n=3,724; 37%). Females are affected more by the disease (n=7,894; 79%) in most of the age groups. Reasons include a greater number of females accesing services and a greater number of tests targeted toward this population; for instance, 87.5% of chlamydia tests were targeted towards females <25 years in African Americans make up 56% (n=5,612) of the total cases compared to other racial groups, although they comprise only 16% of Arkansas population. The affected population continues to be the same during both PACE 2 System Assays (Pre-NAAT) and APTIMA COMBO 2 Assays (Post-NAAT), although the number of cases has significantly increased over time (Figure 1 Figure 4). Geographically, the counties with the highest burden of chlamydia remained the same for different time periods from January 2007 through May Arkansas is one of only 13 states with an Expedited Partner Therapy (EPT) program which could reduce the number of new cases and treat asymptomatic partners. However, a proposal for implementing the program is currently under review. Preventive measures also include chlaymdyia awareness campaigns in selected sites.

10 10 ARKANSAS NEWS FEMALES MALES FIGURE 5: CLUSTERING OF AREAS WITH HIGH MORBIDITY OF CHLAMYDIA CASES IN ARKANSAS, JANUARY 2007-MAY 2008 FIGURE 1 & 2: SCREENING TEST RESULTS BY AGE & GENDER Figure 1. Chlamydia by Age & Gender, Six Months Pre-NAAT (PACE 2 System Assays) Figure 2. Chlamydia by Age & Gender, Six Months Post-NAAT (APTIMA COMBO 2 Assays) Age (Years) Age (Years) FIGURE 3 & 4: SCREENING TEST RESULTS BY RACE & GENDER 2500 Figure 3. Chlamydia by Race & Gender, Six Months Pre-NAAT (PACE 2 System Assays) 3000 Figure 4. Chlamydia by Race & Gender, Six Months Post-NAAT (APTIMA COMBO 2 Assays) Prepared by: Binu Jacob, Kellye McCartney, and Mark Barnes Asians Blacks Hispanics A. Indian White Unknown Asians Blacks Hispanics A. Indian White Unknown SOURCE: STD*MIS

11 STEPHANIE NICHOLAS TAYLOR, MD, is a native of New Orleans, LA and received an undergraduate degree in Medical Technology from the University of New Orleans. She graduated from the Louisiana State University School of Medicine with honors and was inducted into Alpha Omega Alpha Medical Honor Society. Dr. Taylor completed her Internal Medicine Residency, and Infectious Diseases Fellowship at LSU Health Sciences Center. Currently, Dr. Taylor is an Associate Professor of Medicine and JAN FOX NEW DIRECTOR, DIVISION OF SURVEILLANCE & CARE DELIVERY We are pleased to announce that Jan Fox, MPH, R.N. has accepted the position of Director, Division of Surveillance and Care Delivery, HIV/STD Service, Disease and Prevention Services effective March 15, Mrs. Fox has served in public health as a registered nurse for twenty years. Her experience, combined with her nursing degree and a Masters in Public Health, with an emphasis in epidemiology, has resulted in Microbiology at the LSUHSC and Medical Director of the Delgado STD Clinic. She has been awarded grant support from the Centers for Disease Control (CDC), LA Office of Public Health, the Robert Wood Johnson Foundation, the National Foundation of Infectious Diseases and the STI Clinical Trials Group. Her basic science and clinical research have been presented at numerous meetings. She is Board Certified in Internal Medicine and Infectious Diseases, serves on several medical center committees, and is Course Director of STD training programs in Louisiana. a valuable mix of clinical/medical knowledge and skills to assess the occurrence and determinants of disease among various populations. While her educational pursuits have focused in the general area of public health, her professional interests have long centered on infectious diseases, specifically those that are transmitted sexually or are blood borne in nature. She has had hands-on experience working as a nurse in STD clinics and providing HIV counseling, testing and referral services. Her most recent appointment was Manager, Viral Hepatitis Program. NEW MEMBERS JILL NOBLES-BOTKIN, MSN, CNM, assumed the role as Director of Women s Health for the Oklahoma State Department of Health March 1, This position provides leadership and oversight for both family planning and maternity services. She received bachelor s degrees in biology and nursing, a Master s in Nursing, and certification to practice as a Certified Nurse Midwife. Previous experience includes 22 years in Labor and TRACY BUSHONG, R.N. joined the Texas Department of State Health Services Family Planning program in July of Working as a nurse consultant in the area of Program Policy, she has worked with the many contractors who provide family planning services throughout the state. Bushong attended the University of Texas at Austin to complete her B.S.N. and R.N. and has considered Austin home ever since. Her clinical career 11 Delivery as a staff nurse, charge nurse, and nurse manager; 4 years providing clinical GYN services and developing a prenatal care program for Planned Parenthood of Central Oklahoma; and, 3 years as a Nurse Consultant for the Oklahoma State Department of Health developing policy and procedure manuals, updating orders for PHNs and Advanced Practice Providers, providing training and technical assistance to advanced practice providers, and participating in site visits to county health departments and contract agencies. began in Adult ICU and Neonatal ICU and eventually transitioned into Public Health. Bushong s public health experiences have been in the area of school health (especially adolescents), city/ county programs (disease prevention/ communicable disease/disaster prevention and preparedness), and currently Texas DSHS Family Planning. Tracy Bushong sees working with the RIPAC as a wonderful way to combine all of this background work and make the prevention of STI related infertility a priority.

12 12 CANDID CAMERA PHOTOS FROM THE RIPAC APRIL 2008 ORIENTATION SESSION & MEETING

13 13 CONTACT US STATE ADVISORY & ASSOCIATE COMMITTEE MEMBERS: ARKANSAS Randy Owens (501) Sharon Ashcraft, R.N., B.S.N. (501) Kelley McCartney (501) LOUISIANA Stephen J. Martin, Ph.D. (504) Elease Lewis, M.B.A. (504) Lisa Longfellow (504) NEW MEXICO Daryl Smith (Interim) (505) Lynn Mundt, M.B.A. (505) Lisa Onischuk, B.S. ASMT (505) OKLAHOMA Jill Nobles-Botkins, MS, CNM (405) Michael Harmon, M.A. (405) Garry McKee (405) TEXAS Elizabeth Delamater, Ph.D. (512) Alicia Nelson, M.Ed, FNP (512) Tracy Bushong, R.N., (512) x3944 EX-OFFICIO MEDICAL ADVISOR Stephanie Nicolas Taylor, MD, (504) CHAIR Lisa Longfellow (504) VICE CHAIR Lynn Mundt (505) REGION VI OFFICE OF FAMILY PLANNING Evelyn Glass (214) Liese Sherwood-Fabre (214) CENTER FOR HEALTH TRAINING Brenda Hanson (512) Florastine Mack, R.N., B.S.N., M.S.H.P. Coordinator (512) MARK YOUR CALENDAR: RIPAC Advisory Committee Meeting (RIPAC) October 27-28, 2008 Albuquerque, NM National Coalition of STD Directors October 20-24, 2008 Phoenix, AZ GIVE US YOUR INPUT AND FEEDBACK! Please call, fax or mail to: Florastine Mack, Infertility Prevention Project Center for Health Training, 1106 Clayton Lane, Suite 410 E, Austin, Texas Phone (512) Fax: (512)