Enhancing Surveillance Through the STD Surveillance Network (SSuN)

1. Enhancing Surveillance Through the STD Surveillance Network (SSuN) Lori Newman & Kristen Mahle Division of STD Prevention, CDC October 16, 2008

2. Overview SSuN Cycle 1 - Proof of concept • Population-based • STD clinics MSM Prevalence Monitoring Project • STD clinics and gay men’s health centers SSuN Cycle 2 - Creating a robust platform • Population-based • STD clinics • Laboratory

3. Example of the Problem What’s going on here?

4. The Response - Enhanced Surveillance Projects 2002 1998 1999 2000 2001 2003 2004 2005 2006 2007 2008 2009 GISP MSM Adolescent Jail OASIS SSuN Cycle 1 Cycle 2 SSuN is the product of multiple years ofexperience!

5. STD Surveillance Network (SSuN) Cycle 1 – Proof of concept • Goal: to improve national and local capacity to detect, monitor, and respond to emerging trends in STDs and related behaviors • Cycle 1: 2006 - 2008 • STD clinic and population-based surveillance • Initial activities • Enhanced gonorrhea surveillance in STD clinics • Enhanced gonorrhea surveillance in counties • Genital wart surveillance in STD clinics

6. SSuN Cycle 1 Population-based and STD clinic surveillance 2006 - 2008 Washington King Co. Pierce Co. Snohomish Co. Minnesota Hennepin Co. New York City Virginia Chesterfield Co. Henrico Co. Richmond City San Francisco San Francisco Co. Colorado Adams Co. Arapaho Co. Denver Co. SSuN project areas (6) Counties (11) STD clinics (17, not shown)

7. SSuN Population-based Gonorrhea Surveillance - Objectives • To understand factors that influence gonorrhea transmission • Usually not available • If available, single geographic area or STD clinic only • Use data to guide local, state, and national STD programs and policies

8. SSuN Population-based Gonorrhea Surveillance - Methodology • Sample of patients reported with gonorrhea in selected counties • Phone or in-person interviews • Interviewed >2,000 patients to date • Data transmitted with morbidity data • Assessment of representativeness, contact rate, etc. • Morbidity data on >20,000 patients to date

9. SSuN Data Processes • Sites (monthly/quarterly) • Quality check • Transmit data to CDC • Review of data quality • Local analysis and dissemination • CDC (monthly/quarterly) • Review of data quality • Multisite datasets • Data summary reports • CDC and sites • Analysis & dissemination *Preliminary data

10. SSuN Population-based Gonorrhea Surveillance – Provider Type of Gonorrhea Patients by Race/Ethnicity* (excludes patients seen at STD clinics) Hispanics n=229 Whites n=623 Blacks n=985 *Preliminary data

11. STD Clinic Surveillance - Methodology • Data collected on ALL STD clinic patients • At registration OR • During clinical encounter • Extract data from electronic medical record • For SSuN cycle 1: only data on gonorrhea and genital wart patients transmitted to CDC

12. STD Clinic Surveillance - Genital Warts • Monitor impact of the HPV vaccine • Impact of genital wart diagnosis and treatment on STD clinic resources • Demographic and clinical characteristics of patients with genital warts • Populations not receiving the vaccine

13. STD Clinic Surveillance – Proportion of STD Clinic Visits Related to Genital Warts (N=12,001)* n=2,503 n=2,244 n=427 n=3,068 4.1% n=246 n=3,513 *Preliminary data

14. MSM Prevalence Monitoring Project • Objectives: • Assess prevalence of and trends in STDs, HIV, and risk behaviors among MSM • Enhance prevention and control efforts for MSM • Brief History: • Sexual behavior data usually not available • Implemented in 1999 in state and local health departments and community clinics • Unfunded since 2004 • 8 project areas currently participating

15. Test positivity for gonorrhea, chlamydia, and syphilis seroreactivity among MSM, by HIV status, STD clinics, 2007 *Seroreactivity

16. SSuN and MSM Project: Examples of Programmatic Impact • Need for increased HIV testing of patients diagnosed with gonorrhea in ERs • Identification of populations needing improved access to STD care • Highlighted the importance of increased STD screening among HIV positive patients • Need for increased rectal and pharyngeal gonorrhea and chlamydia screening in asymptomatic MSM

17. SSuN and MSM Project - Limitations • Insufficient geographic representation • Duplication of efforts and resources • Data limited to specific diseases or populations • MSM Prevalence Monitoring: • Not currently funded • Lack of data standardization and completeness

18. SSuN Cycle 2 - Vision • Integrated processes • Surveillance projects (SSuN, MSM Prevalence Monitoring Project, future projects) • Surveillance and program • Program service areas (e.g., STD, HIV, Hepatitis) • Robust platform • Access to high quality, informative data at the local and national level • Database that can be queried • Flexible and timely • Strong data management and analytic capacity

19. SSuN Cycle 2 How do we get there? • Expand range of activities • STD clinic surveillance • STD clinic laboratory surveillance • Population-based surveillance • Program service evaluation • Expand data management and analytical capacity • Increase local data management resources • Encourage analyses at local level • Identify additional ways to disseminate and use data • Improve geographic representativeness • Bring 7 new sites on board

20. SSuN Cycle 2: Participating project areas (n=12) and labs (n=6), 2009 – 2013 Washington . Connecticut* Chicago* Philadelphia* New York City Baltimore* San Francisco Colorado Virginia Los Angeles/CA* Alabama* Louisiana* SSuN Laboratory Sites ~ 100 counties ~ 40 STD clinics * New Sites

21. SSuN Cycle 2 – Activities STD Clinic - Genital warts - Syphilis, GC, CT in MSM - HIV testing coverage - Monitor Hepatitis B vaccine coverage? STD Clinic Lab - T. vaginalis resistance monitoring - Monitor etiology of STD syndromes? Population-based -Gonorrhea - Treatment of PID in private sector?

22. SSuN Cycle 2 - Initial Steps • Revisit objectives, data management, analysis, and dissemination plans • Develop/update protocols • STD clinic: genital warts, MSM, HIV testing coverage • Collect data on all STD clinic patients • Denominator = person-event (not visit!) • STD Clinic Lab: Trich resistance • Population-based: GC • Develop/update data dictionary • Merge SSuN Cycle 1 and MSM data elements • Identify elements to keep, add, or remove for core data sets

23. SSuN Cycle 2 - Logistics • Weekly SSuN conference calls • Every Thursday, 2-3 pm EST • SSuN collaborator’s meeting in Atlanta • Book hotel rooms by Nov. 10 • Dec 2 – STD clinic surveillance (8:30 – 5:00 PM) • Dec 3 – GC county surveillance (8:30 – 5:00 PM) • Dec 4 – Lab/trich surveillance (8:30 – 1:00 PM)

24. Alabama Jane Schwebke Elizabeth Turnipseed Edward Hook Baltimore Charlene Brown Emily Erbelding Chicago William Wong Nanette Benbow Irina Tabidze Beau Gratzer Colorado Jennifer Donnelly Cornelis Rietmeijer Ralph Wilmoth Melanie Mattson Doug Robinson Christie Mettenbrink Laura Gillim Ross Andrea Smith SSuN Local Collaborators Philadelphia Caroline Johnson Meilnda Salmon Lenore Asbel Felicia Lewis Greta Ansuetz San Francisco Kyle Bernstein Julia Marcus Robert Kohn Jeff Klausner Virginia Jeff Stover Jennifer Bissette Oana Vasiliu Washington State Mark Stenger Roxanne Kerani Matthew Golden Connecticut Heidi Jenkins Lynn Sosa Los Angeles/California Peter Kerndt SF Sabet Rain Mocello Gail Bolan Michael Samuel Louisiana Lisa Longfellow Mohammad Rahman Joy Ewell Megan Jespersen William Robinson Dielda Robertson Stephanie Taylor New York City Preeti Pathela Susan Blank Julie Schillinger Ellen Klinger Tom Cherneskie

25. ESB Hillard Weinstock (Team Lead) Lori Newman (Project Officer) Kristen Mahle (Co-Project Officer) Shalini Parekh (Project Coordinator) Stuart Berman Deblina Datta Emily Koumans Debbie Dowell Robert Kirkcaldy SDMB Rob Nelson Darlene Davis(Data manager) Jim Braxton(Data manager) Sam Groseclose Donna Helms Fred Rivers Delicia Carey BIRB Jami Leichliter HSREB Charlotte Kent PTB David Johnson Kevin O’Connor Steve Shapiro LRRB Ron Ballard DPD Evan Secor DHAP Kim Elmore To be determined DVH To be determined SSuN Cycle 2 CDC Collaborators

26. Thank you!

27. SSuN Cycle 2 – Data Management Updates Darlene Davis and Rob Nelson Statistics and Data Management Branch (SDMB)

28. SSuN Cycle 2 – Data Management • CDC data managers: • Darlene Davis and Jim Braxton • Contact: SSuNDataManagement@cdc.gov. • Current SSuN Cycle 1 and MSM Prevalence Monitoring sites: • Continue to transmit data per current protocols until SSuN Cycle 2 guidelines are finalized • New SSuN Cycle 2 sites: • Each project area should identify a primary point of contact FOR DATA MANAGEMENT at the state/city health department • Even STD clinic data should pass through this contact before being sent to CDC • Plan to use the File Transfer Protocol (FTP) site for non-data related files (e.g., edit check programs and data dictionaries)

29. FTP Site Guidance

30. SSuN Cycle 2 – Data Transfer • CDC’s Information Security Office has proposed requiring the Secure Data Network (SDN) for all data transfers to CDC • Secure Data Network (SDN): • CDC’s web-based mechanism for user authentication and secure file transfer • Digital certificates issued to ensure access for authorized persons only • All data are encrypted, thus protecting data from unauthorized eavesdropping while in transit • SSuN Cycle 2 data will be transferred to CDC via the SDN in anticipation of these guidelines

31. SSuN Cycle 2 – Data Transfer • Transfer of data via the SDN requires an additional data encryption tool • SEAL • Available at no cost from CDC • Reportedly troublesome with some datasets • PGP • Commercially available (not expensive) • SSuN funds can be used to purchase • Statistics and Data Management Branch is in process of setting up SDN • Written guidance and telephone support will be provided to grantees

32. Questions?