large
DESCRIPTION
EARNING. BOUT. (SYPHILIS). EACTOR. LARGE. RID. VALUATION. Schaffzin JK, Koumans EH, Kahn RH, Markowitz LE. Evaluation of syphilis reactor grids: optimizing impact. Sexually Transmitted Diseases 2003;30(9):700-706. LARGE. Reactor grids Methods for reactor grid evaluation Results - PowerPoint PPT PresentationTRANSCRIPT
EARNING
BOUT
EACTOR
RID
VALUATION
(SYPHILIS)
Schaffzin JK, Koumans EH, Kahn RH, Markowitz LE. Evaluation of syphilis reactor grids: optimizing impact.Sexually Transmitted Diseases 2003;30(9):700-706.
LARGE
• Reactor grids
• Methods for reactor grid evaluation
• Results
• Conclusions
Syphilis reactor grids
40
50
60
70
20
32168421WR
30
STS Lab ResultsA
ge
Gro
up
s
CLOSED
OPEN
Syphilis reactor grids
40
50
60
70
20
32168421WR
30
STS Lab ResultsA
ge
Gro
up
s
CLOSED
Syphilis reactor grids
40
50
60
70
20
32168421WR
30
STS Lab ResultsA
ge
Gro
up
s
70
60
50
40
20
32168421WR
30
VARIABLE AREA
Objectives
1. Evaluate the effect different grids and different prevalences have on:
2. Identify characteristics of cases not investigated by grid design
- Missed cases
- Investigations that yield no cases
Reactor grid evaluation
1. Identify population groups of reactors with different prevalence of syphilis, all of whom were investigated with known outcome and none of whom were applied to any grids
2. Select five grids representing the range of currently used grids
3. Apply groups of reactors to these five grids
Methods for grid evaluationsteps
• 5 jail surveillance projects (1999-2001)
• 1 mobile screening site (1999-2001)
• All people with reactive confirmed serologies had follow-up and staging
Selection of different population groups
Groups
Group D(SF + MA)
13,012 screened347 reactors
Group C*(Baton Rouge) 3,375 screened
196 reactors
Group B(Nashville)
10,754 screened846 reactors
Group A(Milwaukee)
11,007 screened260 reactors
New cases of syphilis
5
36
234
143
Prevalence among
reactors
1%
18%
28%
55%
Prevalence of syphilis by group
Reactor grids selected
Grid 5Grid 1
OPEN
CLOSED
NA
Age Trep R WR 1:1 1:2 1:4 1:8 1:16 ≥1:320-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74>74No Age
Age Trep R WR 1:1 1:2 1:4 1:8 1:16 ≥1:320-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74>74No Age
Age Trep R WR 1:1 1:2 1:4 1:8 1:16 ≥1:320-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74>74No Age
Grid 2
Age Trep R WR 1:1 1:2 1:4 1:8 1:16 ≥1:320-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74>74No Age
Grid 3
Age Trep R WR 1:1 1:2 1:4 1:8 1:16 ≥1:320-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74>74No Age
Grid 4
Age Trep R WR 1:1 1:2 1:4 1:8 1:16 ≥1:320-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74>74No Age
Grid 2
Age Trep R WR 1:1 1:2 1:4 1:8 1:16 ≥1:320-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74>74No Age
Grid 3
Age Trep R WR 1:1 1:2 1:4 1:8 1:16 ≥1:320-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74>74No Age
Grid 4
Applied to
Grids
Group A(Milwaukee)
55%
Group B(Nashville)
28%
Group C (Baton Rouge)
18%
Group D(SF + MA)
1%
Groups
Grid outcomeReactors closed
Grid 1
Grid 2
Grid 3
Grid 4
Grid 5
OPEN
CLOSED
Grid outcome
Most inclusive
Most exclusive
Percent of reactors closed
Groups A-D
0
10
20
30
40
50
60
70
80
90
100
A (55%) B (28%) C (18%) D (1%)
Group (prevalence)
% o
f re
acto
rs c
lose
d
Grid 1
Grid 2
Grid 3
Grid 4
Grid 5
Group A(Milwaukee)
55%
Group B(Nashville)
28%
Group C (Baton Rouge)
18%
Group D(SF + MA)
1%
Groups
Grid outcome, cases missed
OPEN
CLOSED
Grid outcome
Grid 1
Grid 2
Grid 3
Grid 4
Grid 5
Most inclusive
Most exclusive
“Cases Missed”
Cases
Non-Cases
Cases
Non-Cases
Case classification
Percent of syphilis cases not investigated
0
10
20
30
40
50
60
70
A (55%) B (28%) C (18%) D (1%)
Group (prevalence)
% o
f ca
ses
no
t in
vest
igat
ed
Grid 1
Grid 2
Grid 3
Grid 4
Grid 5
Groups A-D
Conclusions 1
Cases missed
• Percent of cases missed depends on grid design
“Non-cases investigated”
“Cases missed”
Open
Closed
Grid 1
Grid 2
Grid 3
Grid 4
Grid 5
Group A(Milwaukee)
55%
Group B(Nashville)
28%
Group C(Baton Rouge)
18%
Group D(SF & MA)
1%
Groups
Cases
Non-cases
Cases
Non-cases
Grid outcome
Case classification
Grid outcomes, non-cases investigated
Percent of non cases investigated
0
10
20
30
40
50
60
70
80
90
100
A (55%) B (28%) C (18%) D (1%)
Group
% o
f re
acto
rs in
vest
igat
ed w
ho
wer
e n
ot
case
s
Grid 1
Grid 2
Grid 3
Grid 4
Grid 5
Groups A-D
Conclusions 2
Investigations of non-cases
• Proportion of investigations that are not cases depends on prevalence of syphilis among reactors
• Investigations of non-cases are virtually independent of grid design
• Use of a grid doesn’t increase concentration of syphilis among investigated reactors
1111
86
255
14
1
54321Grid
1
222
2016
12
7
1
5421
Age Group
60-69
50-59
40-49
30-39
20-29
10-19
Grid
Female
2
7
3
Male
Age distribution of early cases missed
1
5
54
56
43
5
Total Cases
4912110421920Total 9164 145
0
2
16
83
42
2
Total Cases
• Cases excluded by age tend to be:
- Men ages 30-50
- Women ages 20-40
54321Grid
5421Grid
Female
3
Male
Titer distribution of early cases missed
31
1
1451
18101
31
32Titer
1:16
1:8
1:4
1:1-1:2
Trep only
WR
4
4
1
117
9
14
18
3
3
Total Cases
4912110421920Total 9164 145
1
1
19111
153
72
66
81
17
19
15
7
6
Total Cases
• Cases excluded tend to have:
- RPR titer 1:1 – 1:4
Overall conclusions
The percentage of cases missed by a grid is dependent on grid design.
The percentage of investigations that are not cases is dependent on prevalence of syphilis among reactors.
In areas with moderate to high prevalence (>10%), use of certain grids will lead to missed cases, whereas in low prevalence areas (<10%) grids can reduce the percentage of unnecessary investigations.
Implications
• Grid evaluation should include the following:
• Grids should be designed to minimize cases missed
• Percent of non-productive investigations should not be a focus of grid design
• Limited resources driving grid design can lead to missed cases
• As yet no guidance on what percentage of cases missed is “acceptable”
- Determination of grid design (inclusive vs. exclusive)
- Calculation of syphilis prevalence among reactors
Acknowledgements
CDC ATPM
Josh SchaffzinEmily Koumans Richard Kahn Lauri Markowitz
Catherine McLean Jim Braxton
Gabriela Paz-Bailey
Vera Schomer
Thanks to Charlotte Kent, Robert Kohn, Anne Spalding, Elizabeth Mangiamelli, Chris Freeman, Dacid Lundberg,
Josephine Ford Michael Whelan, Kathy Middleton, Mary Kay Schuknecht, John Thilges, Jim Braxton
Reactor Grid Evaluation
Late (%)
Early (%)Dx
Female (%)
Male (%)Gender
Mean
RangeAge
Reactors
0.6
0.9
101 (29)
246 (71)
23.1
18-62
347
Group E
NA
7
74 (58)
54 (42)
34.9
12-52
124
Group D
10
9
134 (68)
62 (32)
36.9
13-76
196
Group C
9
19
270 (32)
576 (68)
34.9
9-75
846
Group B
8
47
134 (51)
126 (49)
36.0
18-64
260
Group A
Group Demographics