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May 5, 2017
Anna Cope, PhD, MPH
Epidemiologist
DSTDP/NCHHSTP/CDC
North Carolina Division of Public Health
Ocular Syphilis Response: North Carolina,
2014-2015
Ocular Syphilis
• An inflammatory eye disease
• Causes a variety of ocular signs and symptoms
- Eye redness, eye pain, blurry vision, and vision loss
• Recommended treatment is IV penicillin G for 10-14 days
• Ocular manifestations not routinely reportable to CDC
1Worksowski KA, Bolan GA, CDC. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015.
Clinical Advisory
• Clusters of ocular syphilis cases were reported from Seattle and San Francisco in early 2015 and CDC was notified.
The North Carolina Response
• February 2015: DIS were instructed to ask about eye symptoms during every syphilis case interview AND document reported symptoms in the North Carolina Electronic Disease Surveillance System (NC EDSS)
• March 2015: The North Carolina (NC) Division of Public Health (DPH) issued a clinical advisory.
• December 2015: Requested Epi-Aid from CDC
Goals of Ocular Syphilis Epi-Aid
1. Describe the population of ocular syphilis cases in NC
2. Identify potential risk factors for ocular syphilis
3. Compare ocular and non-ocular syphilis cases
4. Describe the sequelae of ocular syphilis
Case Identification
• Case Definition:
- A confirmed syphilis case reported to the NC DPH during 2014-2015 who reported symptoms of ocular disease with no other defined etiology
• Case ascertainment from NC EDSS:
- Eye/Conjunctiva check box
- Text search of DIS notes
Data Collection
1. NC EDSS Surveillance Data Pull
- Demographics, Clinical Factors, Treatment, Risk Factors
2. Medical Chart Review and Data Abstraction
- Requested from reporting provider to supplement surveillance data
3. Follow-Up Interviews
- Describe clinical course of disease
- Identify potential risk factors not captured in surveillance
Results: Syphilis 2014-2015
4232 Confirmed Syphilis
Cases
4169 (98.5%) Non-Ocular
Syphilis
63 (1.5%) Ocular Syphilis* 53 checkbox
* 10 text search
Results: Syphilis 2014-2015
4232 Confirmed Syphilis
Cases
4169 (98.5%) Non-Ocular
Syphilis
63 (1.5%) Ocular Syphilis* 53 checkbox
* 10 text search
During 2014-2015: – All stages of syphilis increased by 35%
– Report of ocular syphilis increased by 115%
– Cases were reported from 33 of 100 counties
– No ocular syphilis case named another ocular syphilis case as a sex
partner
2014 2015
N=20 N=43
N=1776 N=2393
Ocular Case Demographics (N=63)
• ≥ 40 years old (60%)
• White (49%), Black (44%)
• Male (94%)
• MSM (63% of men)
• HIV-positive (56%)
Ocular Case Clinical Factors
• Median RPR:- 1:128 (Range 1:1-1:16,384)
• Syphilis Stage:- Primary/Secondary: 38%
- Early Latent: 14%
- Late Latent/Latent with Clinical Manifestations: 48%
Reported Eye Symptoms
Eye Exam Diagnoses
Eye exam verified for 49 (78%) cases
Ocular Syphilis Treatment
Treatment Regimen N %
10-14 days of IV penicillin
(recommended treatment)
42 67
IM Benzathine penicillin only 13 21
Other treatment regimen 5 8
Unknown treatment status 3 5
Ocular versus Non-Ocular Syphilis
Ocular Syphilis
N = 63
Non-Ocular
Syphilis
N = 4169
Prevalence Ratio
( 95% CI)
% %
Male 1.7 98.3 2.82 (1.03, 7.73)
Race
Black 1.1 99 Ref
White 2.8 97.2 2.64 (1.59, 4.37)
Other 0.5 99.5 0.45 (0.11, 1.86)
Age (years)
<40 0.9 99.1 Ref
≥40 2.8 97.2 3.27 (1.98, 5.39)
Reported MSM (among men only) 1.6 98.4 0.83 (0.49, 1.40)
Stage of syphilis
Primary/Secondary 1.4 98.6 Ref
Early Latent 0.8 99.2 0.61 (0.28, 1.30)
Late Latent/Latent w clinical manifestations 2.2 97.8 1.58 (0.93, 2.69)
Median (IQR) Median (IQR) Wilcoxon p-value
RPR 128 (64-256) 32 (8-128) <0.0001
Ocular versus Non-Ocular Syphilis
Ocular Syphilis
N = 63
Non-Ocular
Syphilis
N = 4169
Prevalence Ratio
( 95% CI)
% %
Male 1.7 98.3 2.82 (1.03, 7.73)
Race
Black 1.1 99 Ref
White 2.8 97.2 2.64 (1.59, 4.37)
Other 0.5 99.5 0.45 (0.11, 1.86)
Age (years)
<40 0.9 99.1 Ref
≥40 2.8 97.2 3.27 (1.98, 5.39)
Reported MSM (among men only) 1.6 98.4 0.83 (0.49, 1.40)
Stage of syphilis
Primary/Secondary 1.4 98.6 Ref
Early Latent 0.8 99.2 0.61 (0.28, 1.30)
Late Latent/Latent w clinical manifestations 2.2 97.8 1.58 (0.93, 2.69)
Median (IQR) Median (IQR) Wilcoxon p-value
RPR 128 (64-256) 32 (8-128) <0.0001
HIV and Ocular Syphilis
• The prevalence of ocular syphilis was higher among HIV-infected
syphilis patients
Prevalenceof OS
PR 95% CI
HIV Status
Positive 2.0% 1.8 1.1, 2.9
Negative/Unknown 1.1% REF
HIV and Ocular Syphilis
• The prevalence of ocular syphilis was higher among HIV-infected
syphilis patients
• Considering only HIV-infected syphilis patients, the prevalence of ocular
syphilis was highest among those diagnosed with HIV and ocular
syphilis at the SAME TIME
Prevalenceof OS
PR 95% CI
HIV Status
Positive 2.0% 1.8 1.1, 2.9
Negative/Unknown 1.1% REF
Prevalenceof OS
PR 95% CI
Timing of HIV Diagnosis
Concurrently Diagnosed 4.2% 2.5 1.2, 5.0
Previously Diagnosed 1.7% REF
Follow-Up Interviews
63
Ocular Syphilis Cases
39 (62%) Completed Follow-Up Interview
7 (11%)
Refused Follow-Up Interview
17 (27%)
Could not be located
Timing of symptoms, seeking care, and treatment
Patient First Seeks Care
Onset of Symptoms
Initiation of Treatment
Timing of symptoms, seeking care, and treatment
Emergency Department: 7 days
Eye doctor: 14 days
Primary care physician: 18 days
STD clinic: 18 days
Infectious Disease physician: 30 days
Patient First Seeks Care
Onset of Symptoms
Initiation of Treatment
Overall Median= 14 days
Timing of symptoms, seeking care, and treatment
Emergency Department: 7 days
Eye doctor: 14 days
Primary care physician: 18 days
STD clinic: 18 days
Infectious Disease physician: 30 days
Patient First Seeks Care
Onset of Symptoms
Initiation of Treatment
Overall Median= 14 days Overall Median= 10 days
Emergency Department: 8 days
Eye doctor: 13 days
Primary care physician: 9 days
STD clinic: 8 days
Infectious Disease physician: 8 days
Reported Visual Function
2. When OS Symptoms were the worst
1. Before OS Symptoms
3. At the time of the Interview
Reported Visual Function
2. When OS Symptoms were the worst
1. Before OS Symptoms
3. At the time of the Interview
85%
Excellent or
Good
Vision
6%
Excellent or
Good
Vision
80%
Excellent or
Good
Vision
Summary
• Detection of syphilis patients reporting eye symptoms was possible using existing surveillance infrastructure
• Reports of OS increased between 2014 to 2015, possibly due to increased awareness
• OS was diagnosed in all stages of syphilis and among HIV-positive and HIV-negative patients
- However, OS was more common among HIV-infected patients,
particularly those diagnosed with HIV and syphilis concurrently
Summary
• No common exposure or reported risk factor was identified among cases in NC
• OS can result in severe visual impairment
- Most patients improved after treatment
• Providers should be alerted about the potential for ocular manifestations of syphilis and appropriate treatment/care
Acknowledgements
NC DPH
– Erika Samoff
– Victoria Mobley
– Jessica Rinsky
– Mara Larson
– Nicole Dzialowy
– Aaron Fleischauer
– Evelyn Foust
– Public Health
Epidemiologists
CDC
– Sara Oliver
– Charnetta
Williams
– Gui Liu
– Tom Peterman
– Lauri Markowitz
NC DIS
– Miraida Gipson
– Samantha Greene
– Jason Hall
– Stephanie Hawks
– Victor Hough
– Andre Ivey
– Mike Mercurio
– Dishonda Taylor