May 5, 2017

Anna Cope, PhD, MPH

Epidemiologist

DSTDP/NCHHSTP/CDC

North Carolina Division of Public Health

Anna.Cope@dhhs.nc.gov

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