Infertility Prevention ProjectInfertility Prevention ProjectRegion I Region I

June 14-15, 2010June 14-15, 2010Wells Beach, MaineWells Beach, Maine

Steven J. ShapiroSteven J. ShapiroInfertility Prevention Project CoordinatorInfertility Prevention Project Coordinator

CDC/NCHHSTP/DSTDP/PTBCDC/NCHHSTP/DSTDP/PTB

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

TopicsTopics

National Infertility Prevention Project:National Infertility Prevention Project:

Budget and FundingBudget and FundingDivision UpdatesDivision UpdatesPSCIPSCIHealth Care ReformHealth Care ReformChlamydiaChlamydia

National Chlamydia CoalitionNational Chlamydia Coalition

Gonorrhea Gonorrhea Performance MeasuresPerformance Measures

13.7

16.617.9

23.1

27.4 27.5 27.329

28.1 28.1 27.6 27.6

0

5

10

15

20

25

30

35

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

Mill

ion

s (D

olla

rs)

National IPP Funding Allocations 1998-2009

Funding ApplicationsFunding Applications

CSPS 2011CSPS 2011» Guidance under developmentGuidance under development» IPPIPP

Progress on 3% CT PositivityProgress on 3% CT Positivity Targeted GC Burden Calculation and plansTargeted GC Burden Calculation and plans Progress on general objectivesProgress on general objectives Progress on GC meeting action itemsProgress on GC meeting action items

IPP-OPA IAA 2010-2011IPP-OPA IAA 2010-2011» IPP Regional Infrastructure ObjectivesIPP Regional Infrastructure Objectives

Pregnancy-test OnlyPregnancy-test Only AI/AN Health Care Delivery SystemsAI/AN Health Care Delivery Systems

DSTDP UpdateDSTDP Update

STD Treatment GuidelinesSTD Treatment Guidelines» Recommended treatment for uncomplicated GC will be Recommended treatment for uncomplicated GC will be

increased to 250 mg Ceftriaxone.increased to 250 mg Ceftriaxone.» Cefixime 400 mg will remain as a recommended therapyCefixime 400 mg will remain as a recommended therapy» Combination therapy for GC+Combination therapy for GC+

STD Laboratory GuidelinesSTD Laboratory Guidelines» CT GC and syphilisCT GC and syphilis» Re-testing/Supplemental TestingRe-testing/Supplemental Testing

GYTGYT» 190K Unique visitors; average time 3 minutes190K Unique visitors; average time 3 minutes» Just under 40K Toolkit DownloadsJust under 40K Toolkit Downloads

PCSIPCSI

Funding Opportunity AnnouncementFunding Opportunity Announcement» Grants.gov CDC-PS10-10175Grants.gov CDC-PS10-10175

» ““To plan, scale-up, and support the implementation of a To plan, scale-up, and support the implementation of a syndemic approach to the prevention of HIV/AIDS, viral syndemic approach to the prevention of HIV/AIDS, viral hepatitis, STD and TB through PCSI activities as hepatitis, STD and TB through PCSI activities as described……”Enhancing the Prevention and Control of described……”Enhancing the Prevention and Control of HIV/AIDS, viral hepatitis, STD and TB in the United States”HIV/AIDS, viral hepatitis, STD and TB in the United States”

Eligibility (2007 Surveillance Data)Eligibility (2007 Surveillance Data)» 630 AIDS Cases630 AIDS Cases» 225 TB Cases225 TB Cases» 900 Syphilis (all stages) Cases900 Syphilis (all stages) Cases» 6760 Gonorrhea Cases6760 Gonorrhea Cases» 82 HBV Cases82 HBV Cases

Webinar May 10thWebinar May 10th

Health Care ReformHealth Care Reform

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

Patient Protection and Patient Protection and Affordable Care ActAffordable Care Act

Mandatory ProgramsMandatory Programs– Prevention and Public Health FundPrevention and Public Health Fund

» Up to 2 Billion dollars annually by 2015Up to 2 Billion dollars annually by 2015» Can be spent on any prevention, wellness or public health Can be spent on any prevention, wellness or public health

activities authorized in the Public Health Services Act. activities authorized in the Public Health Services Act. Section 318 of the PHSA authorizes STD prevention Section 318 of the PHSA authorizes STD prevention (CSPS); section 318A authorizes IPP.(CSPS); section 318A authorizes IPP.

– National Prevention, Health Promotion, and National Prevention, Health Promotion, and Public Health CouncilPublic Health Council

» Advisory in Nature- must create a National Prevention and Advisory in Nature- must create a National Prevention and Health Promotion StrategyHealth Promotion Strategy

PPACA : New Prevention ProgramsPPACA : New Prevention Programs

CDC CDC – Community TransformationCommunity Transformation

– Epidemiology and Epidemiology and Laboratory Capacity Laboratory Capacity

– Healthy Aging Living Well Healthy Aging Living Well

– Prevention ResearchPrevention Research

– Improvement of vaccine Improvement of vaccine delivery systemsdelivery systems

– Office of Women’s HealthOffice of Women’s Health

HHSHHS– State access to purchase State access to purchase

vaccine at federally vaccine at federally negotiated prices negotiated prices

– Menu labeling (FDA)Menu labeling (FDA)

– Individual Wellness Plan Individual Wellness Plan evaluation at FQHCsevaluation at FQHCs

– Grants to support School-Grants to support School-based Health Centersbased Health Centers

– Evidence based teen Evidence based teen pregnancy preventionpregnancy prevention

– Evidence based Evidence based Abstinence-only programsAbstinence-only programs

PPACA: Other ProvisionsPPACA: Other Provisions Insurance (private)Insurance (private)

» Required to provide recommended clinical preventive benefits, Required to provide recommended clinical preventive benefits, including vaccinations without cost-sharingincluding vaccinations without cost-sharing

Medicaid and MedicareMedicaid and Medicare» Medicare preventative services and USPSTF recommended services Medicare preventative services and USPSTF recommended services

(“A” level, maybe “B”) become no cost-sharing; coverage and cost (“A” level, maybe “B”) become no cost-sharing; coverage and cost sharing for vaccines unchanged sharing for vaccines unchanged

» Tobacco cessation pharmaceuticals and expanded cessation services Tobacco cessation pharmaceuticals and expanded cessation services for pregnant woman are coveredfor pregnant woman are covered

» Hospitals required to report rates of healthcare-associated infections Hospitals required to report rates of healthcare-associated infections (MRSA, VRE, etc)(MRSA, VRE, etc)

Public Health WorkforcePublic Health Workforce» Loan repayment program, expand fellowship programs (EIS)Loan repayment program, expand fellowship programs (EIS)

Monitoring Key National Health IndicatorsMonitoring Key National Health Indicators» Standardizes data collection related to health disparitiesStandardizes data collection related to health disparities

ChlamydiaChlamydia

Chlamydia — Rates: Total and by sex: United States, 1989–2008Chlamydia — Rates: Total and by sex: United States, 1989–2008

Note: As of January 2000, all 50 states and the District of Columbia had regulations requiring the reporting of chlamydia cases.

0

120

240

360

480

600

1989 91 93 95 97 99 2001 03 05 07

Rate (per 100,000 population)

MenWomenTotal

Chlamydia — Rates by state: United States and outlying areas, 2008Chlamydia — Rates by state: United States and outlying areas, 2008

Note: The total rate of chlamydia for the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was 398.5 per

100,000 population.

Rate per 100,000population

Guam 396

Puerto Rico 174

Virgin Is. 535

<=300

300.1-400

>400

(n= 13)

(n= 17)

(n= 24)

VT 192NH 160MA 271RI 314CT 357NJ 258DE 447MD 439DC 1177

535

711

391499

407 395

389

447

466

280

460 349

314

332287

528

198

446

276

728

422

324

314377

470

458

414

300

411

409

287

340

597

371

455

422

228

405

331

183

375

302

Chlamydia — Age- and sex-specific rates: United States, 2008Chlamydia — Age- and sex-specific rates: United States, 2008

Men Rate (per 100,000 population) Women

Age3500 2800 2100 1400 700 0 0 700 1400 2100 2800 3500

13.9 129.910-14701.6 3275.815-19

1056.1 3179.920-24565.9 1240.625-29

271.7 498.930-34140.8 205.635-39

78.3 85.840-4434.4 30.945-5410.4 8.455-64

2.7 2.165+211.7 585.6Total

Chlamydia — Rates by race/ethnicity: United States, 1999–2008Chlamydia — Rates by race/ethnicity: United States, 1999–2008

0

340

680

1020

1360

1700

1999 2000 01 02 03 04 05 06 07 08

Rate (per 100,000 population)

American Indian/AK NativeAsian/Pacific IslanderBlackHispanicWhite

Chlamydia — Prevalence by age group and race/ethnicity fromChlamydia — Prevalence by age group and race/ethnicity froma national survey, 1999–2002a national survey, 1999–2002

Note: Error bars indicate 95% confidence intervals.

SOURCE: National Health and Nutrition Examination Survey. Ann Intern Med 2007;Jul 17;147(2):89-96.

Prevalence

Non-Hispanic White

Non-Hispanic Black

Mexican-American

0

4

8

12

16

14-19 20-29 30-39

Chlamydia — Positivity among 15- to 24-year-old women tested in family Chlamydia — Positivity among 15- to 24-year-old women tested in family planning clinics by state: United States and outlying areas, 2008planning clinics by state: United States and outlying areas, 2008

Note: Includes states and outlying areas that reported chlamydia positivity data on at least 500 women aged 15-24 years screened during

2008.

DATA SOURCE: Prevalence Monitoring Project (Regional Infertility Prevention Projects), Office of Population Affairs, Local and State STD Control Programs, Centers for Disease Control and Prevention

Positivity (%)

Puerto Rico 7.4

Virgin Is. 15.0

<5.0

5.0-9.9

>=10.0

(n= 5)

(n= 39)

(n= 9)

VT 3.7NH 3.9MA 5.1RI 7.6CT 7.4NJ 8.4DE 8.6MD 5.8DC 9.5

11.3

5.4

8.7 10.3

5.9 7.5

9.3

10.8

9.3

5.9

7.3 8.4

6.1

7.04.7

12.3

6.2

6.9

6.5

13.8

7.4

5.9

7.17.6

8.1

5.0

7.9

8.4

7.9

6.8

4.7

6.5

11.8

6.4

6.2

12.4

12.57.3

7.2

3.1

8.5

6.9

Chlamydia — Trends in positivity among 15- to 24-year-old women tested Chlamydia — Trends in positivity among 15- to 24-year-old women tested in family planning clinics by HHS region, 2004–2008in family planning clinics by HHS region, 2004–2008

DATA SOURCE: Prevalence Monitoring Project (Regional Infertility Prevention Projects), Office of Population Affairs,

Local and State STD Control Programs, Centers for Disease Control and Prevention

Region I

Region II

Region III

Region IV

Region V

Region VIRegion VII

Region VIII

Region IX

Region X

4.6

04

4.7

05

4.7

06

4.8

07

5.2

08

7.1

04

5.7

05

5.6

06

5.9

07

6.2

08

6.0

04

5.8

05

5.4

06

5.5

07

6.3

08

8.4

04

8.8

05

9.0

06

9.6

07

9.6

08

7.5

04

7.7

05

7.6

06

7.6

07

7.6

08

7.4

04

7.4

05

7.9

06

8.8

07

10.2

08

5.8

04

5.8

05

6.5

06

6.5

07

6.8

08

6.3

04

6.3

05

7.2

06

7.3

07

7.8

08

6.7

04

6.4

05

6.8

06

7.3

07

7.5

08

5.9

04

5.6

05

5.7

06

5.8

07

6.0

08

IV

VIIIX

IIIX

III

VI

VVIII

National Chlamydia CoalitionNational Chlamydia Coalition

Annual MeetingAnnual Meeting» December 3-4, 2009 DCDecember 3-4, 2009 DC» Social MarketingSocial Marketing» Sub-Committee MeetingsSub-Committee Meetings

Research Subcommittee Research Subcommittee What can you do?What can you do?

– Chlamydia Screening Priority in Health Care Delivery Chlamydia Screening Priority in Health Care Delivery SystemsSystems

» Outreach to State Adolescent Health CoordinatorOutreach to State Adolescent Health Coordinator» Child Health Indicators for Medicaid and CHIPChild Health Indicators for Medicaid and CHIP» EMR Incentives for Medicaid and MedicareEMR Incentives for Medicaid and Medicare

National Chlamydia CoalitionNational Chlamydia CoalitionMini Grants: To fund innovative strategies to increase CT screening and Mini Grants: To fund innovative strategies to increase CT screening and

follow-up care including partner treatmentfollow-up care including partner treatment

College Health ProgramCollege Health Program» Old Dominion (VA)Old Dominion (VA)

Sports Health ScreeningsSports Health Screenings» Uplift School (IL)Uplift School (IL)

Academic DetailingAcademic Detailing» Private Providers (IL)Private Providers (IL)

CT screeningCT screening» Medicaid Managed Care Medicaid Managed Care

(MI)(MI) Awareness and ScreeningAwareness and Screening

» PP Greater Washington PP Greater Washington and North Idahoand North Idaho

CT Model ProtocolCT Model Protocol» AI/AN (Regions VIII & X)AI/AN (Regions VIII & X)

JDC ScreeningsJDC Screenings» Baltimore JDC (MD)Baltimore JDC (MD)

Targeted use of GISTargeted use of GIS» Adagio Health (PA)Adagio Health (PA)

Provider OutreachProvider Outreach» NYS providers (Region II)NYS providers (Region II)

Plan Development Plan Development » Coalition Building (MN)Coalition Building (MN)

DRIP, DRIP, DRIP

Gonorrhea — Rates: United States, 1941–2008Gonorrhea — Rates: United States, 1941–2008

0

100

200

300

400

500

1941 46 51 56 61 66 71 76 81 86 91 96 2001 06

Rate (per 100,000 population)

Gonorrhea — Rates by race/ethnicity: United States, 1999–2008Gonorrhea — Rates by race/ethnicity: United States, 1999–2008

0

180

360

540

720

900

1999 2000 01 02 03 04 05 06 07 08

Rate (per 100,000 population)

American Indian/AK NativeAsian/Pacific IslanderBlackHispanicWhite

GonorrheaGonorrhea

““Incurable gonorrhea may be next superbug”Incurable gonorrhea may be next superbug”» MSNBC 4-8-2010MSNBC 4-8-2010

““Emergence of Antibiotic-resistant gonorrheaEmergence of Antibiotic-resistant gonorrhea””» Time (blog) 3-31-2010Time (blog) 3-31-2010

““Gonorrhea mutating into superbug especially in Gonorrhea mutating into superbug especially in SEAsia”SEAsia”

» Pattaya Daily News 4-1-2010Pattaya Daily News 4-1-2010

““Sex Infection gonorrhea becoming drug-resistant”Sex Infection gonorrhea becoming drug-resistant”» BBC News 3-29-2010BBC News 3-29-2010

GonorrheaGonorrhea

AR GC Laboratory ActivitiesAR GC Laboratory Activities» GISPGISP

» Enhanced surveillance in the Far East with WHOEnhanced surveillance in the Far East with WHO Documented Clinical Cases of resistance to oral cephalosporinsDocumented Clinical Cases of resistance to oral cephalosporins WHO-WPRO Consultations (Manila in April; Bali in May)WHO-WPRO Consultations (Manila in April; Bali in May)

» Basic research to develop a molecular test that could indicate Basic research to develop a molecular test that could indicate resistance in NAAT-positive specimensresistance in NAAT-positive specimens

AR GC Outbreak response plan developmentAR GC Outbreak response plan development» Consultation Atlanta September 14-15Consultation Atlanta September 14-15

» State-level Outbreak Response Plan Development and PilotsState-level Outbreak Response Plan Development and Pilots California, Hawaii, Illinois, New York State and Washington stateCalifornia, Hawaii, Illinois, New York State and Washington state

Regional MeetingsRegional Meetings» Monitoring Action Plan progressMonitoring Action Plan progress

» Meetings Report DevelopmentMeetings Report Development

Performance MeasuresPerformance Measures

CSPS Project started 1999CSPS Project started 1999 Pilot project 2001Pilot project 2001 Set of 12 measures 2005Set of 12 measures 2005

» Timeliness of Treatment CT and GC in FP clinicsTimeliness of Treatment CT and GC in FP clinics» STD Clinics added 2007STD Clinics added 2007» GC Interviews modified 2009GC Interviews modified 2009

NCSD Survey Optional MeasuresNCSD Survey Optional Measures– Feasibility. Usefulness and Intent to UseFeasibility. Usefulness and Intent to Use– All CT male and females 15-24All CT male and females 15-24– All GonorrheaAll Gonorrhea

Performance Measure DataPerformance Measure DataTimeliness of Treatment for CT (14 Days)Timeliness of Treatment for CT (14 Days)

Prevalence Monitoring Family Planning SitesPrevalence Monitoring Family Planning Sites

20052005 20062006 20072007 20082008 20092009

Conn 0.71 0.88 0.88 0.81 0.85

Maine 0.93 0.91 0.92 0.89 0.87

Mass 0.83 0.88 0.87 0.86 0.74

NH 0.90 0.87 0.87 0.86 0.91

RI 0.80 0.71 0.75 0.73 0.84

Vermont 0.95 0.89 0.70 0.87 0.91

Region IRegion I 0.840.84 0.860.86 0.850.85 0.830.83 0.840.84

NationalNational 0.620.62 0.660.66 0.640.64 0.640.64 0.670.67

Performance Measure DataPerformance Measure DataTimeliness of Treatment for GC (14 Days)Timeliness of Treatment for GC (14 Days)

Prevalence Monitoring Family Planning SitesPrevalence Monitoring Family Planning Sites

20052005 20062006 20072007 20082008 20092009

Conn 0.78 0.90 0.82 0.84 0.88

Maine 1.00 0.83 1.00 1.00 0.70

Mass 0.79 0.87 0.91 0.70 0.76

NH 1.00 0.91 0.92 0.75 1.00

RI 0.73 0.77 0.68 0.80 0,94

Vermont 1.00 0.89 0.90 1.00 1.00

Region IRegion I 0.850.85 0.870.87 0.850.85 0.790.79 0.860.86

NationalNational 0.620.62 0.660.66 0.640.64 0.640.64 0.670.67

Performance Measure DataPerformance Measure DataTimeliness of Treatment CT and GC (14 Days)Timeliness of Treatment CT and GC (14 Days)

STD Sites: 2007-2009STD Sites: 2007-2009

CTCT

20072007

CTCT

20082008

CTCT

20092009

GCGC

20072007

GCGC

20082008

GCGC

20092009Conn 0.91 0.88 0.81 0.83 0.81 0.82

Maine 1.00 0.94 1.00 1.00 1.00 0.67

Mass 0.93 0.94 0.90 1.00 1.00 1.00

NH 0.83 0.84 0.94 1.00 1.00 0.95

RI 1.00 0.86 0.94 0.90 1.00 1.00

Vermont 0.98 0.00 0.00 0.90 0.00 0.00

Region IRegion I 0.930.93 0.870.87 0.910.91 0.910.91 0.860.86 0.860.86

NationalNational 0.690.69 0.720.72 0.690.69 0.700.70 0.730.73 0.670.67

Performance Measure and Morbidity DataPerformance Measure and Morbidity DataChlamydia- All FemalesChlamydia- All Females

STD Sites: 2008STD Sites: 2008

Total CT CasesTotal CT Cases

NETSSNETSS

CT STD CasesCT STD Cases

NETSS NETSS

% %

CasesCases

CT STD CasesCT STD Cases

PM DataPM Data

Conn 9239 417 4.5 268

Maine 1847 41 2.2 35

Mass 12646 323 2.6 128

NH 1548 58 3.7 273

RI 2400 66 2.8 65

Vermont 896 57 6.4 0

NationalNational 893004893004 8994389943 10.0010.00 6707467074

Performance Measure and Morbidity DataPerformance Measure and Morbidity DataGonorrhea- All FemalesGonorrhea- All Females

STD Sites: 2008STD Sites: 2008

Total GC CasesTotal GC Cases

NETSSNETSS

GC STD CasesGC STD Cases

NETSS NETSS

% %

CasesCases

GC STD CasesGC STD Cases

PM DataPM Data

Conn 1686 106 6.3 73

Maine 43 3 7.0 3

Mass 1100 55 5.0 13

NH 49 0 0 4

RI 135 7 5.2 7

Vermont 19 3 16.00 0

NationalNational 182577182577 2782527825 15.0015.00 2445824458

CSPS-IPP 2009CSPS-IPP 2009

Gonorrhea Burden CalculationGonorrhea Burden Calculation» Portion of Total IPP funds to be used to target Portion of Total IPP funds to be used to target

GC screeningGC screening» Total GC women <26/Total CT GC women <26Total GC women <26/Total CT GC women <26» Up to 10% of funds availableUp to 10% of funds available» Identify venues/providers Identify venues/providers

– High morbidity with limited screening coverageHigh morbidity with limited screening coverage– In geographic catchment areas with high In geographic catchment areas with high

morbiditymorbidity

» Shift resources to those areasShift resources to those areas

GC Burden Calculation GC Burden Calculation ExampleExample

Project Area XProject Area X» Total IPP funds = $500,000Total IPP funds = $500,000» Among women 25 and youngerAmong women 25 and younger (all venues)(all venues)

500 Gonorrhea and 10,000 Chlamydia500 Gonorrhea and 10,000 Chlamydia GC Burden = [500/(10000+500)]X100= 4.76%GC Burden = [500/(10000+500)]X100= 4.76%

» IPP Funds to be usedIPP Funds to be used $500,000 X 4.76% = $23,800$500,000 X 4.76% = $23,800 @ $10/test = 2380 tests available for targeting@ $10/test = 2380 tests available for targeting

Questions?Questions?