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Infertility Prevention Project Region I November 15, 2010 Boston, Massachusetts. Steven J. Shapiro Infertility Prevention Project Coordinator CDC/NCHHSTP/DSTDP/PTB

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Infertility prevention project region i november 15 2010 boston massachusetts
Infertility Prevention ProjectRegion I November 15, 2010Boston, Massachusetts

Steven J. Shapiro

Infertility Prevention Project Coordinator

CDC/NCHHSTP/DSTDP/PTB

Disclaimer: The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.


Topics
Topics

National Infertility Prevention Project:

  • CSPS 2011

  • DSTDP Update

  • Health Care Reform

  • Gonorrhea

  • STD Treatment Guidelines

  • “What is IPP”


Csps 2011
CSPS 2011

  • Technical Reviews

  • Additional Funds

    • 1.546 million dollars in FY 2010

      • $118K- National Chlamydia Coalition

      • $190K- Infrastructure Shortfall

      • $500K- “The Future of IPP”

      • $730K- Additional Project Area Funds

        • Expansion of CT/GC screening and treatment services

        • Supplement to CSPS 2011


Dstdp update
DSTDP Update

  • Personnel Changes

  • Agency Winnable Battles

  • Consultations

  • Guidelines

    • Laboratory and Treatment

  • 2009 STD Surveillance Report

    • Online November 22


  • Health care reform
    Health Care Reform

    What does this mean for CDC, in general, and STD Prevention specifically?


    Health care reform1
    Health Care Reform

    • Key Issues

      • Performance Improvement

      • Affordable Care Act

      • National HIV/AIDS Strategy

    • “The Future of IPP”

      • Infrastructure-driven evaluation

        • IPP in the project areas

        • Environmental Scan

        • Recommendations for the Future





    George Clooney

    accepts the

    Bob Hope

    Humanitarian Award

    For raising Awareness

    of Gonococcal

    Antimicrobial

    Resistance



    Gonorrhea case rates by sex 1999 2009
    Gonorrhea Case Rates by Sex, 1999-2009*

    Rate per 100,000

    Women

    Men

    *2009 data are preliminary


    Gonorrhea case rates by sex 2004 2009
    Gonorrhea Case Rates by Sex, 2004-2009

    Rate per 100,000

    Women

    Men

    *2009 data are preliminary


    Gonorrhea case rates by race ethnicity 2004 2009
    Gonorrhea Case Rates by Race/Ethnicity, 2004-2009

    Rate per 100,000

    Black

    American Indian

    Hispanic

    White

    Asian

    *2009 data are preliminary


    Gonorrhea case rates by age group 2004 2009
    Gonorrhea Case Rates by Age Group, 2004-2009

    Rate per 100,000

    20-24

    15-19

    25-29

    30-34

    *2009 data are preliminary


    Gonorrhea case rates among black men and women by age 2004 2009
    Gonorrhea Case Rates Among Black Men and Women by Age, 2004-2009

    Rate per 100,000

    Women15-19

    Women 20-24

    Men 20-24

    Men 25-29

    *2009 data are preliminary


    Gonorrhea is not increasing in fact gonorrhea may be decreasing
    Gonorrhea is Not Increasing… 2004-2009In Fact, Gonorrhea May Be Decreasing

    • National Job Training Program

      • Decreases 2004-2009

    • NHANES

      • Numbers too small

      • Testing discontinued in 2009 (last cycle gonorrhea included: 2007-2008)

    • Despite…

      • More people being tested for gonorrhea?

      • Targeted screening efforts?


    BUT….. 2004-2009

    • New England

      • Maine 18%

      • Mass 20%

      • NH 47%

      • VT 24%

      • CT 3%

      • RI 11%

    • Others

      • NJ 12%

      • NYC 12%

      • PA 23%

      • MD 9%

      • AK 26%

      • CA 14%

      • HI 8.5%

      • Guam 58%

      • PR 24%


    2010 std treatment guidelines

    Up and coming (preliminary language only—final language pending):

    2010 STD Treatment guidelines


    Gonorrhea treatment uncomplicated infections of the cervix urethra and rectum
    Gonorrhea Treatment: pending):Uncomplicated Infections of the Cervix, Urethra, and Rectum

    Cefixime (400mg PO) OR

    Ceftriaxone (250mg IM)

    PLUS

    Azithromycin (1g PO) OR

    Doxycycline (100mg PO, 2x/day, 7 days)

    (Regardless of whether or not chlamydia is ruled out)


    Screening among pregnant women chlamydia
    Screening Among Pregnant Women: Chlamydia pending):

    • 2010: All pregnant women should be routinely screened for chlamydia during the first prenatal visit.

      • Retest during 3rd trimester: Women aged ≤25 years and those at increased risk

      • If diagnosed with chlamydia in 1st trimester, retest within 3-6 months (preferably 3rd trimester)

    • Changes from 2006: Strengthened and clarified retesting language


    Screening among pregnant women gonorrhea
    Screening Among Pregnant Women: Gonorrhea pending):

    • 2010: All pregnant women at risk for gonorrhea or living in a high-prevalence area should be screened for gonorrhea during the first prenatal visit.

      • Retest during 3rd trimester: Women at continued risk

      • If diagnosed with chlamydia in 1st trimester, retest within 3-6 months (preferably 3rd trimester)

    • Changes from 2006: Strengthened and clarified retesting language


    Chlamydia screening among young women 2010
    Chlamydia Screening Among Young Women: 2010 pending):

    • Annual screening of all sexually active women aged ≤25 years is recommended, as is screening of older women with risk factors (e.g., those who have a new sex partner or multiple sex partners). ..USPSTF updated their chlamydia screening guidance and found that the epidemiology of chlamydial infection in the U.S. has not changed since the last review. In issuing recommendations, USPSTF made the decision to alter the age groups used to demonstrate disease incidence (i.e., from persons ≤25 years of age to those aged ≤24 years). CDC has not changed its age cutoff, and thus continues to recommend annual chlamydia screening of sexually active women aged ≤25 years.


    Chlamydia screening among young women changes from 2006
    Chlamydia Screening Among Young Women: Changes from 2006 pending):

    • Age cut-off remains the same

    • Addresses USPSTF age change

    • No change to risk factors

    • Added language: Among women, the primary focus of chlamydia screening efforts should be to detect chlamydia and prevent complications, whereas targeted chlamydia screening in men should only be considered when resources permit and do not hinder chlamydia screening efforts in women.


    Chlamydia screening among men
    Chlamydia Screening Among Men pending):

    • 2010: Although evidence is insufficient to recommend routine chlamydia screening in sexually active young men because of several factors (feasibility, efficacy, cost), the screening of sexually active young men should be considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent clinics, correctional facilities, STD clinics).

    • Changes from 2006: Expansion to allow for venue-based male screening


    Chlamydia retesting women and men
    Chlamydia Retesting: Women and Men pending):

    • 2010: Chlamydia-infected women and men should be retested approximately 3 months after treatment…If retesting at 3 months is not possible, clinicians should retest whenever persons next present for medical care in the 12 months following initial treatment.

    • Changed from 2006: Strengthened language


    Gonorrhea screening among young women
    Gonorrhea Screening Among Young Women pending):

    • 2010: The prevalence of gonorrhea varies widely among communities and populations; providers should consider local gonorrhea epidemiology when making screening decisions. Widespread screening is not recommended. However, because infections among women are frequently asymptomatic, targeted screening of young women (i.e., those aged <25 years) at increased risk for infection is a primary component of gonorrhea control in the U.S.

    • Changes from 2006: Emphasis on targeted screening and use of local data, no change in risk factors


    Gonorrhea retesting women and men
    Gonorrhea Retesting: Women and Men pending):

    • 2010: Clinicians should retest patients 3 months after treatment…If patients do not seek medical care for retesting in 3 months, providers are encouraged to test these patients whenever they next seek medical care within the following 12 months.

    • Changed from 2006: Strengthened language


    What is ipp
    What is IPP pending):

    • Public Health Services Act Section 318A

    • CSPS Project Areas (64)- approx. 28 million annually

      • Based on historical formula

        • Initial distribution (early 90’s): Need and quality

        • Current distribution: Demonstrated and estimated need

      • Within CSPS structure (through 2013)

        • DSTDP POC- Program Consultants

  • Infrastructure (10)- approx. 2.2 million annually

    • Funds awarded through OPA’s regional Family Planning Training Centers (3 year grant cycle, ending 6/30/2011).

      • DSTDP POCs- ESB, PTB, SDMB, LRRB and HSREB


  • Division priorities
    Division Priorities pending):

    • IPP

      • Prevention of STD-related infertility

      • Prevention of STD-related adverse outcomes of pregnancy

      • Strengthen STD prevention capacity and infrastructure

      • Address health disparities


    Project areas
    Project Areas pending):

    • Goal:

      • Provide CT/GC screening and treatment services for at-risk women and their sex partners

        • Use of funds varies depending on project area


    Project areas1
    Project Areas pending):

    • Accomplishments:

      • 09-0902 CSPS

        • “Use your data”

        • 3% CT positivity threshold established

        • Flexibility regarding “50% rule”

        • Continued expansion of screening and treatment services into non-FP/STD facilities

        • Increasing number of tests reported

        • Regional gonorrhea meetings: Target gonorrhea screening



    Project areas2
    Project Areas 2001-2009

    • Strengths

      • Well-established partnership between STD, FP, labs

        • Available forum to address program issues

      • Programmatic evaluations conducted at low cost

      • Leadership can look beyond categorical funding

    • Weaknesses

      • Epi support varies from non-existent to extensive

      • Lack of publication/dissemination of special projects

      • Leadership is bound by categorical funding and history

      • Disease burden is larger than available resources


    Infrastructure
    Infrastructure 2001-2009

    • Goal:

      • Support and improve the ability of public health departments to implement IPP activities and promote interventions that prevent STD-related infertility

    • Activities

      • Administration

      • Coordination

      • Communication

      • Prevalence monitoring and data management

      • Education and program promotion

      • Enhanced activities

      • Independent laboratory consultant


    Infrastructure accomplishments
    Infrastructure - Accomplishments 2001-2009

    • Establishment of infrastructure performance measures

      • Screening coverage estimates

      • Test utilization by age

  • Establishment of pan-regional grant objectives

    • Native American and Alaskan Native health care delivery systems

    • Development of pregnancy-test only epi profiles

  • Data standardization

  • De-emphasis of regional screening criteria

  • Epi-methods workgroup and process

  • Enhancement of IHS Partnership

  • Support for regional GC meetings

  • Increased submission and acceptance of conference abstracts


  • Infrastructure1
    Infrastructure 2001-2009

    • Small Projects (examples)

      • Pacific Island assessments

      • Collaboration with HMOs: Chlamydia trends and PID surveillance [ESB]

      • Provider adherence to screening criteria assessment

      • Adolescent confidentiality

      • EPT support

      • Cross-regional data analysis

      • Rescreening assessment

      • Concurrency study

      • Laboratory studies

      • Jail screenings [HSREB]


    Infrastructure2
    Infrastructure 2001-2009

    • Strengths

      • Regions provide recognized leadership on a variety of issues

      • Partner with branches other than PTB

      • Extensive representation on National Chlamydia Coalition (NCC)

      • Independence fosters flexibility and critical thinking

      • Available funding mechanism

      • Partnership recognized as a successful model

    • Weaknesses

      • Unable or unwilling to publish work

      • Ten distinct regional partners with varying levels of capacity


    Questions
    Questions? 2001-2009


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