screening guam

1. Screening Guam’s Massage Parlor Workers: How Often Should They Be Screened? Bernadette P. Schumann, M.P.A. Guam Department Health and Social Services 2004 National STD Conference Philadelphia, PA March 8-11, 2004

2. Background Guam Massage Parlors began appearing in 1984 Rules and Regulations: Sanitary Operation of Massage Parlors, February 13, 1984 Health Certificates, December 26, 1989 Issuance of Health Certificates, March 21, 2001 Process for any revisions or changes: Triple A Administrative Adjudication Act Final Approval by Director and the Attorney General Approval Applies to all new and existing certificate holders Examination: RPR or VDRL Skin Test for TB: If positive, perform chest X-ray Culture test for gonorrhea Process for any revisions or changes: Triple A Administrative Adjudication Act Final Approval by Director and the Attorney General Approval Applies to all new and existing certificate holders Examination: RPR or VDRL Skin Test for TB: If positive, perform chest X-ray Culture test for gonorrhea

3. Sex Industry Facilities Massage Parlors New Shiatsu/Foot Reflexology Clinics Therapeutic Massages Karaoke Lounges Supplementary Aids - rubbing alcohol, liniments, antiseptic oils, powers, creams, lotions, ointments Supplementary Aids - rubbing alcohol, liniments, antiseptic oils, powers, creams, lotions, ointments

4. Current Screening Requirements STD Screening required every 3 months: Syphilis Chlamydia Gonorrhea HIV Trichomoniasis PPD Skin test for TB required every 2 years: If positive, chest x-ray is performed

5. Obtaining Health Certificates for Massage Parlor Workers (MPWs) Step 1: MPW goes to health department (HD) Gets blood test for HIV and syphilis and obtains referral to private doctor Step 2: MPW goes to private doctor Tested for gonorrhea, chlamydia and trichomoniasis Step 3: MPW returns to private doctor Picks up test results No specific list of providers-can obtain from any private doctor Lack of consistency in clearing women for clearing certificates Analaysis shows MPW pick ups are delayed; report to HD late, Screening No specific list of providers-can obtain from any private doctor Lack of consistency in clearing women for clearing certificates Analaysis shows MPW pick ups are delayed; report to HD late, Screening

6. Obtaining Health Certificates for Massage Parlor Workers (MPWs) Step 4: MPW returns to HD 2 weeks after tests Provides gonorrhea, chlamydia and trichomoniasis results to HD All results placed in chart for doctor’s review HD doctor signs clearance form Referred to TB Program for clearance Step 5: MPW reports to TB program for clearance Step 6: MPW reports to Division of Environmental Health (DEH) for health certificate No specific list of providers-can obtain from any private doctor Lack of consistency in clearing women for clearing certificates Analaysis shows MPW pick ups are delayed; report to HD late, Screening No specific list of providers-can obtain from any private doctor Lack of consistency in clearing women for clearing certificates Analaysis shows MPW pick ups are delayed; report to HD late, Screening

7. Objectives Describe characteristics of MPWs receiving health certificate Determine prevalence of STDs among MPWs Determine level of compliance with screening requirements Analyze cost of screening MPWs Data is examined to determine whether all massage parlor workers are in compliance in obtaining required health certificate vs. those who are not in compliance (ie., missed a screening). Screening data, such as number of GC, CT, Syphilis and HIV Anjtibody tests conducted and number of reactive tests, positive screenings over a 4 year period are to be presented; A Cost breakdown for screening is reviewed and analyzed. Type of analysis: Epi Information, review of data over a 4 year period Records-reflect; calculated costData is examined to determine whether all massage parlor workers are in compliance in obtaining required health certificate vs. those who are not in compliance (ie., missed a screening). Screening data, such as number of GC, CT, Syphilis and HIV Anjtibody tests conducted and number of reactive tests, positive screenings over a 4 year period are to be presented; A Cost breakdown for screening is reviewed and analyzed. Type of analysis: Epi Information, review of data over a 4 year period Records-reflect; calculated cost

8. Methods Reviewed Department of Public Health (DPH) records for MPWs receiving a certificate during 2000-2003 Reviewed data related to cost of processing health certificates for MPWs Data will be examined whether all massage parlor workers are in compliance in obtaining required health certificate versus those who are not in compliance (i.e., missed a screening). Screening data, such as number of Gonorrhea, Chlamydia, Syphilis and HIV Antibody Tests conducted and number of reactive tests, positive screenings over a 4-year period will be presented. A cost breakdown for screenings will also be reviewed and analyzed over a 4-year period. Data will be examined whether all massage parlor workers are in compliance in obtaining required health certificate versus those who are not in compliance (i.e., missed a screening). Screening data, such as number of Gonorrhea, Chlamydia, Syphilis and HIV Antibody Tests conducted and number of reactive tests, positive screenings over a 4-year period will be presented. A cost breakdown for screenings will also be reviewed and analyzed over a 4-year period.

9. Characteristics of MPWs Obtaining Health Certificate, 2000-2003

10. Reported Number of Employers by MPWs, 2000-2003 Bernie – These numbers are updated from the last version. 28 employers are listed in the MPW database. Several employers may be repeats. In addition, one employer was listed as unknown and one individual did not provide a n employer.Bernie – These numbers are updated from the last version. 28 employers are listed in the MPW database. Several employers may be repeats. In addition, one employer was listed as unknown and one individual did not provide a n employer.

11. *Compliance With 3-month Screening Requirement, 2000-2003 Among the 68 women with at least 2 screening visits: 28% were never compliant* 54% were compliant at least 50% of the time 26% were compliant at least 75% of the time 12% were compliant 100% of the time Compliancy is defined as 2.5 to 3.5 months between screening visits.Compliancy is defined as 2.5 to 3.5 months between screening visits.

12. Number of Cases of Reportable STDs Among Women, Guam, 2000-2003 Bernie – for this slide, you could talk about numbers of reportable STDs among the general population, compared to numbers among the screened MPWs (which are shown on the next slide).Bernie – for this slide, you could talk about numbers of reportable STDs among the general population, compared to numbers among the screened MPWs (which are shown on the next slide).

13. Each line represents a visit; Not coming in at all; illustration demonstrates: what is it showing Talk about the compliance Over time, only 1 infection Client 1-4 Screening visit? Never came by after infection What part of screening hsitory Repeat infection Syphilis Case: was this a new or old infection? Time period between screening visits: 0-75 days=1-2.5 months 66-106 days=2.5-3.5 months 107-183 days=3.5-6 months 184-365 days=7-12 months Over 365 days=Over 1 yearEach line represents a visit; Not coming in at all; illustration demonstrates: what is it showing Talk about the compliance Over time, only 1 infection Client 1-4 Screening visit? Never came by after infection What part of screening hsitory Repeat infection Syphilis Case: was this a new or old infection? Time period between screening visits: 0-75 days=1-2.5 months 66-106 days=2.5-3.5 months 107-183 days=3.5-6 months 184-365 days=7-12 months Over 365 days=Over 1 year

14. Screening Costs Screening cost per visit DPH provides free blood test-uses CDC 6 step HIV Prevention Counseling/integrates STD information and referral for syphilis testing, referral form to private doctor MPW-out of pocket costs-refer to private doctor’s clinicScreening cost per visit DPH provides free blood test-uses CDC 6 step HIV Prevention Counseling/integrates STD information and referral for syphilis testing, referral form to private doctor MPW-out of pocket costs-refer to private doctor’s clinic

15. Summary Majority of MPWs over the age of 35 Low STD infection rate among MPWs who are screened MPW screening visits are not consistent with regulations Costly screening Another bullet-number of visits-important to highlight! Not a whole lot of morbidities Point: When they are inspected Delay in Pick ups; screening and evaluation; documented differently by Program Staff; inconsistent documentation Compliant or not? Cost IssueAnother bullet-number of visits-important to highlight! Not a whole lot of morbidities Point: When they are inspected Delay in Pick ups; screening and evaluation; documented differently by Program Staff; inconsistent documentation Compliant or not? Cost Issue

16. Limitations Lack of standard documentation of screening visits Limited staff dedicated to certificate issuance Certificates issued by DPH but enforcement by DEH DEH does not enforce regulation on parlors that are non-compliant

17. Limitations Inconsistent screening practices for MPWs by clinicians Not all MPWs in establishment are screened Not all sex industry workers are screened

18. Recommendations Modify screening requirements Revise rules and regulations for determining the establishments whose employees are required to have health certificates Reassess and adjust screening intervals Standardize screening practices among all providers Younger CSW going to other industries-not seeing in MPWs: Mamasan/Manager are older CSW Expand the type of “CSW” definition, not just MPW What intervals need to be determined/every six-eight months?? Pin point what interval should be? Needs to be further evaluated Reassess screening intervals STD CHC: Reduce Cost; coordinate CHC’s making providers aware of rules and regulations’ Explore Service providersYounger CSW going to other industries-not seeing in MPWs: Mamasan/Manager are older CSW Expand the type of “CSW” definition, not just MPW What intervals need to be determined/every six-eight months?? Pin point what interval should be? Needs to be further evaluated Reassess screening intervals STD CHC: Reduce Cost; coordinate CHC’s making providers aware of rules and regulations’ Explore Service providers

19. Recommendations Provide listing of providers to MPWs Standardize documentation for screening process Enforce regulations Providers from Community Health Centers or private doctors-set rules and regulations for screening; Improve standards for screening DEH-work closely with DEH; regulations not enforced due to limited DEH inspectors- Want to increase compliance rateProviders from Community Health Centers or private doctors-set rules and regulations for screening; Improve standards for screening DEH-work closely with DEH; regulations not enforced due to limited DEH inspectors- Want to increase compliance rate

20. Acknowledgements Guam Department of Public Health & Social Services Robert Haddock, D.V.M., M.P.H. Tom Nadau Rosanne Rabago Centers for Disease Control and Prevention Roxanne Barrow, M.D., M.P.H. Thom Cylar Dianna Frick, M.P.H. John Glover

21. Acknowledgements Guam Community College Medical Assistant Students Julie Cruz Celeste Leon Guerrero George Prudente Maria Urbino Portland State University Trina M.P. Pacheco, Graduate Student