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In Focus Detail

Message from the CDC STD Director, Dr. Gail Bolan

January 25, 2016

 

Dear Colleagues,

Last year was, in short, the year of outbreaks and increases in reported STDs. Although Ebola unquestionably took center stage, CDC’s Division of STD Prevention (DSTDP) was at the frontlines when outbreaks of ocular syphilis, lymphogranuloma venereum (LGV), and HIV emerged throughout the country. The 2014 Sexually Transmitted Disease Surveillance Report showcased the troubling increases that were seen in all three nationally-reported STDs, as well as congenital syphilis. These public health events demand strategic action. However, before I dive into the plans our division has to enhance STD prevention in 2016, I would like to take this opportunity to highlight some of DSTDP’s accomplishments in 2015.

2015 Highlights

Sexually Transmitted Disease Treatment Guidelines, 2015

Last summer CDC published the Sexually Transmitted Diseases Treatment Guidelines, 2015. DSTDP worked collaboratively with other parts of the Department of Health and Human Services and STD subject matter experts to revise the Guidelines. Since going live, the Treatment Guidelines web pages have been viewed more than 1.5 million times. A wall chart, a pocket guide, and a mobile app based on the Guidelines are all available on the 2015 STD Treatment Guidelines web page. The mobile app is the second most popular app on the CDC website, and its pages have already been viewed over 1.2 million times.

Disease Intervention Specialists (DIS)

Our nation’s DIS were at the frontlines of many high profile outbreak responses. In early 2015, the Indiana State Department of Health (ISDH) began investigation and control efforts for an outbreak of HIV infection after an Indiana DIS reported 11 confirmed HIV cases traced to a rural county in southeastern Indiana. Ultimately, ISDH reported a total of 49 DIS from other states to assist with the outbreak—24 were CDC field staff, 25 were state or local staff. Additionally, beginning in 2014, more than 65 public health advisor DIS from DSTDP were deployed during the Ebola response. In October, we showed our gratitude for the outstanding contributions of these public health professionals with National DIS Recognition Day .

DSTDP staff and the Ebola response

Ninety-one DSTDP staff members of the 247-person DSTDP workforce have deployed for at least 30 days—in some cases multiple times—to the Emergency Operation Center, quarantine stations throughout the country, and affected nations in West Africa to assist with CDC’s Ebola Response. 

Some of DSTDP’s work was highlighted in an article published in the October issue of New England Journal of Medicine titled, Molecular Evidence of Sexual Transmission of Ebola Virus.” The Sierra Leone Ministry of Health, CDC, and the World Health Organization are working together, conducting a viral persistence study, which includes testing body fluids of Ebola Virus Disease (EVD) survivors to determine how long the virus stays in specific fluids after recovery. In the pilot phase of this study, Ebola was found to remain in semen for up to nine months. CDC is conducting further tests to determine if the virus is live and potentially infectious after recovery. DSTDP staff have also led in the development and implementation of pretest and posttest risk reduction behavioral counseling programs for EVD survivors enrolled in testing and counseling activities in a viral persistence study (Sierra Leone) and a men’s health screening program (Liberia). 

Advanced Molecular Detection

The Office of Advanced Molecular Detection funded two DSTDP lab proposals in 2015. The first proposal, “Genomic sequencing of Neisseria gonorrhoeae to respond to the urgent threat of antimicrobial-resistant gonorrhea,” uses whole genome sequencing to develop better tests to find out if a patient’s infection is resistant to treatment. The second proposal, “Role of DNA methylation in antimicrobial resistance: Proof of concept study,” uses the Pacific Biosciences next generation whole genome sequencing platform to determine the role of DNA methylation in antimicrobial resistance.

Building STD Specimen Banks

In 2014, CDC partnered with the Association of Public Health Laboratories on a project to collect serum samples for the syphilis serum repository. Serum samples are collected from patients with syphilis, staged, and then sent to DSTDP’s Laboratory Reference and Research Branch to be used in development of new tests and/or evaluation of tests. To date, nearly 230 samples have been received. CDC also constructed a panel of Neisseria gonorrhoeaestrains collected from recent infections to share with other federal agencies and scientific researchers. These strains have been fully characterized for antimicrobial susceptibly and genetic sequences. They are available through CDC, the Food and Drug Administration, and the National Institutes of Health. International strains will be added to the panel in 2016.

Potential Gonorrhea Treatment

CDC completed testing of one new drug compound that may be useful in the treatment of Neisseria gonorrhoeae. The in vitro activity was excellent, and comparable to currently recommended chemotherapeutic agents. The drug is currently in clinical trial in the U.S.

STD outbreaks and increases

News of STD outbreaks became all too familiar to us this past year. More than 200 cases of ocular syphilis were reported over the past two years from 20 states. Ocular syphilis, a serious site of syphilis infection, can lead to permanent blindness. A 2015 Clinical Advisory and a MMWR: Notes from the Field discuss the recently reported cases and provide information for clinicians on the diagnosis and management of ocular syphilis. 

November 2015 MMWR publication reported sharp increases in the number of babies born in the United States with syphilis. DSTDP has developed a new fact sheet for expectant mothers on Congenital Syphilis, and also published a Dear Colleague Letter for clinicians addressing the increase in cases, and steps public health and medical officials can take to prevent congenital syphilis. 

Finally, a health alert was issued on October 23, 2015 when two cases of confirmed, six cases of probable, and four suspect cases of LGV among African American men who have sex with men (MSM) living with HIV were reported in Michigan. LGV is a rare and poorly characterized STD in the U.S., with the last reported case in Michigan occurring in 2008. 

Assessment of STD safety net services

A November 2015 analysis about STD prevention safety net services published in the journal of Public Health Reports found that an estimated 5.8 million people ages 15 to 44 were uninsured and in need of STD services in 2015. While the Affordable Care Act (ACA) has somewhat reduced the number of uninsured people who need publicly-funded STD prevention services, an estimated 4.6–4.7 million uninsured people will continue to need STD services annually through at least 2023. Annual chlamydia services alone for these uninsured people through 2023 might cost from $150 million to $191 million. These estimates do not include the need for and cost of other STD screening, testing, and treatment for diseases such as for syphilis, gonorrhea, and HIV. 

Public Health Informatics 

We have a number of exciting informatics updates from the past year. DSTDP established one of the first clinical web services at CDC to deliver structured and automated (computerized) (.xml) CDC guidelines to electronic medical records for real-time clinical decision support. DSTDP is leading a nationwide effort to promote electronic case reporting (ECR) for STDs. The Office of National Coordinator for Health IT, the Public Health Informatics Institute, CSTE, and other state and local STD programs are participating in a DSTDP-led effort to provide clarity on content and transport of ECRs to local and state health departments. DSTDP is awaiting security approval to start using a modern relational STD morbidity data repository that will serve as the backend to many analytical and visualization applications in the coming years. In the future, the data repository design will have capability for handling HL7 and other newer data formats.

Community Approach to Reducing Sexually Transmitted Diseases (CARS)

In the first cycle of funding for the community engagement project CARS, conducted by DSTDP and four U.S. cities, DSTDP found that blending the lived experiences of community members, the experiences of representatives from service-based and practice-based organizations, and sound science resulted in sustainable interventions to promote community health.  CARS II grantees in the second cycle are implementing several strategies, including incorporation of STI prevention messages in various social media platforms to increase access to STI testing and condoms; leveraging partner resources to implement structural change and community-designed interventions; identifying and prioritizing social determinants of health impacting LGBT youth; improving cultural humility by training clinicians and providers to better understand the needs of LGBT youth; and building trust within the targeted populations and providers through a series of town hall meetings.

Four Special Interest Group Meetings Held in 2015

In collaboration with the National Coalition of STD Directors, DSTDP hosted four special interest group (SIG) meetings for STD prevention program AAPPS grantees this year.  All agendas began with a heavy focus on surveillance and data completeness and quality, and then expanded to describe other aspects of the programs represented.  The promising practice ideas from each program were collected and distributed to meeting attendees.  At the end of each SIG meeting all representatives were requested to complete a “Participant Action Plan,” documenting ideas and actions they planned on implementing when they returned home. A compilation of all promising practice ideas has been posted to the NPIN community. To view them, please sign up to join the NPIN community

Project ECHO and the Breakthrough Series Collaborative

DSTDP is partnering with the National Association of Community Health Centers (NACHC) to increase the availability of patient-centered comprehensive primary care for LGBT patients.  Implemented in partnership with The Weitzman Institute and The Fenway Institute, evidence-based strategies to transform practice concurrently in up to 10 health centers include the Project ECHO® model—a videoconferencing technology to connect multidisciplinary LGBT clinical experts with frontline health center providers around the country; and the Breakthrough Series Collaborative model. Health center teams will use quality improvement methods to drive practice transformation, system improvement, and implementation of best practices.  In 2016, the focus is on securing health center commitments to participate, finalizing the evaluation plan and curriculum, identifying Breakthrough Series faculty, and launching the ECHO and the Breakthrough Series Collaborative.

Change in DSTDP OD Structure

This past year has seen many changes within DSTDP’s Office of the Director (OD). Raul Romaguera is now serving as the Division’s Deputy Director, and continues to serve as the Director of the Office of Policy, Planning and External Relations (OPPER). Additionally, Janice Norwood has accepted the newly-created position of Deputy Director of Program and Management Operations.

 

Position

Name

Division Director

Gail Bolan

Division Deputy Director

Raul Romaguera

Deputy Director for Program Management and Operations

Janice Norwood

Associate Director for Administration and Operations

Stephanie Wallace

Associate Director for Global Activities

Mary Kamb

Associate Director for Health Equity

Jo Valentine

Associate Director for Policy, Planning, and External Relations

Raul Romaguera

Associate Director for Science

Sevgi Aral

Epidemiology and Statistics Branch Chief

Kyle Bernstein

Field Services Branch Chief

Norm Fikes

Health Services Research and Evaluation Branch Chief

Tom Gift

Laboratory, Reference and Research Branch Chief

Ellen Kersh

Program Development and Quality Improvement Branch Chief

Steven Shapiro (Acting)

Social and Behavioral Research and Evaluation Branch Chief

Matthew Hogben

Surveillance and Data Management Branch Chief

Hillard Weinstock

 

2016 Forecast

Syphilis Summit

DSTDP will host the Syphilis Summit January 26–28, where participants will engage in structured discussion about syphilis. The goal of the summit is to produce a set of recommendations that outline syphilis control in the United States in 2016 (The Syphilis Action Plan); a series of published papers based on the presentations and discussions; and a set of research questions based on knowledge gaps identified during discussions.

Providing quality clinical STD services 

In 2016, DSTDP will draft the recommendations for providing quality clinical STD services in primary care settings and specialized STD clinics. Last November DSTDP hosted a consultant’s meeting to discuss recommendations and review proposed levels of STD care by setting for inclusion in the recommendations document. 

2016 STD Prevention Conference

We are looking forward to welcoming the 2016 STD Prevention Conference back to Atlanta on September 20–23; a collaborative conference between the CDC, the American Sexually Transmitted Diseases Association, the National Coalition of STD Directors, the American Sexual Health Association, the Pan American Health Organization, and the Public Health Agency of Canada. The theme for this year’s conference is, Transcending Barriers. Creating Opportunities. Modern STD prevention and control requires dynamic approaches to assessment, assurance, and policy development in the face of consistent financial challenges and shifting disease priorities. The theme for this conference highlights how these challenges can be transformed into opportunities for moving STD prevention forward.  Please consider submitting an abstract before the April 25th deadline.

Disease Intervention Specialist (DIS) Certification Project

The DIS Certification Project is being coordinated by the Public Health Accreditation Board, in partnership with CDC, the National Association of County and City County Health Officials, the National Coalition of STD Directors, and with support from national consultants in certification. This is a comprehensive, inclusive effort to develop recommendations to strengthen and formalize the critical public health workforce role of DIS in areas such as STD, HIV, TB, and other communicable diseases, as well as emergency preparedness and response. Several deliverables will result from this project, including a job task analysis to provide a template DIS job description; enumeration of the DIS workforce; establishment of a national registry for DIS; and development of three potential models for DIS certification; all of which will inform a comprehensive framework for future DIS training. 

Gonococcal Isolate Surveillance Project (GISP) Data and Combating Antibiotic Resistant Bacteria (CARB) 

Due in large part to GISP data, N. gonorrhoeae is featured prominently in the White House’s Combating Antibiotic Resistant (AR) Bacteria National Strategy and Action Plan. To support implementation of the Strategy and Action Plan, DSTDP will be working to strengthen timeliness of surveillance to detect emerging AR gonorrhea threats and rapid response initiatives for AR gonorrhea prevention. Stay tuned for more information in the coming months.

DSTDP’s role in the National HIV/AIDS Strategy

The National HIV/AIDS Strategy for the United States was updated to include action steps through 2020. Included in the update are several ways that STD prevention contributes to HIV prevention. These include identifying HIV infections among persons with acute STDs; ensuring access to pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) through STD screening, especially in STD specialty clinics; disseminating medically-accurate sexual health information; and increasing the role of DIS in linkage to care through certification.

Strategic Planning

DSTDP has finalized the key components of our internal Division’s Strategic Plan and will share it with you in the next few months. The plan’s goals are a cascade of NCHHSTP’s Strategic Plan through 2020. Through an integration of science, program, and policy, we continue to focus on four priority areas: 1) adolescents and young adults, 2) gay, bisexual, and other men who have sex with men (MSM), 3) pregnant women, and 4) strengthening STD prevention systems. The plan outlines our five long-term strategic objectives developed in order to achieve our Division’s mission and vision over the next five years. A written copy of DSTDP’s Strategic Plan is nearing completion and includes examples of key activities under each of these objectives. 

This year promises to be as productive and action-packed as the last and I truly appreciate your important contributions to STD prevention. We certainly have our collective work cut out for us in 2016. We must work to reverse the concerning widespread increases in STDs and the immediate adverse outcomes that we are witnessing, such as the increases in congenital syphilis and ocular syphilis. This will require a comprehensive, innovative effort by health departments, communities, scientists, and policy makers, in addition to the federal government, and I look forward to working with you all. I will keep you informed of the Division’s activities as the year goes on, and I look forward to seeing many of you in Atlanta for the 2016 STD Prevention Conference this fall! 

Sincerely, 

Gail Bolan, M.D.
Director, Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
U.S. Centers for Disease Control and Prevention


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