From the *Division of STD Prevention, CDC; †Tennessee Department of Health; and ‡Metro Public Health Department of Nashville and Davidson County, Nashville, Tennessee
Correspondence: Jeselyn Rhodes, MSPH, Metro Public Health Department, Epidemiology and Health Monitoring, 311 23rd Avenue North, Nashville, TN 37203. E-mail: firstname.lastname@example.org.
Received for publication April 10, 2007, and accepted July 12, 2007.
THE INCIDENCE RATE OF primary and secondary syphilis (P&S) in Nashville, Davidson County, TN, increased by 99%, from 18.3 cases per 100,000 persons in 1995 to 36.1 cases per 100,000 persons in 1996. In addition, Nashville’s rank among 64 US cities with populations of 200,000 or more increased from the 11th rank in 1990 to the third rank in 1997 for P&S incidence. Furthermore, in 1998, Nashville residents accounted for an estimated 10% of Tennessee’s population but accounted for 37% of the state’s syphilis cases.1 The increase in syphilis cases prompted Sexually Transmitted Disease (STD) program staff from Metro Public Health Department (MPHD) to investigate the possibility of a syphilis epidemic. During this investigation, STD program staff found that a substantial proportion of the sexual contacts of syphilis-infected persons were addicted to crack cocaine and that those persons were exchanging sex for drugs, money, or both. This high-risk behavior made them difficult to find and treat.
Previous studies have reported that incarcerated individuals are at particularly high risk for STD infection because they frequently have multiple partners, have unprotected sex or use condoms inconsistently, engage in substance abuse, and have difficulty in getting health care.2–5 To facilitate planning for the control of the syphilis epidemic, MPHD conducted a series of studies aimed at evaluating the association between drug and illegal sex-related criminal behavior and the acquisition of syphilis in Nashville. The study found that 71.6% of those persons with primary or secondary syphilis cases reported to MPHD from 1994 through 1998 had been arrested or charged with a crime; 38.9% had been arrested for or charged with drug-related offenses; and 12.3% had been arrested for or charged with sex-related offenses.6 Based on study data, it is estimated that the risk of syphilis acquisition increased by 62.6% per each additional sex-related charge and increased by 4.9% per each additional drug charge. The study also notes that during the pre-epidemic period (1994–1995), <22.2% of reported P&S syphilis cases had criminal charge records but that >75% of those with reported P&S syphilis cases had criminal arrests or charges during the epidemic period (1996–1998).6
The Davidson County Sheriff’s Office is not a law enforcement agency but has the primary responsibility for housing inmates charged in Davidson County (since the institution of metropolitan government in 1963, the Davidson County Sheriff is no longer a law enforcement official. Currently, the Sheriff’s Office is charged with 2 major functions: the safety and security of all inmates housed in Davidson County jails and the service of all civil process. The Metropolitan Nashville Police Department functions as the primary law enforcement agency7). From 1999 to 2005, the Davidson County Sheriff’s Office’s average inmate population was 2921, of which approximately 88% (2558) were men. The Davidson County Criminal Justice Center (DCCJC) is the central point where all arrestees are taken for booking if not diverted to pretrial release or do not bond out. In light of epidemiologic evidence that suggests an association between the Nashville syphilis epidemic and criminal arrest in Davidson County, the Tennessee Department of Health (TDH) and MPHD officials met with health care management leaders from the DCCJC to discuss possible interventions, such as screening arrestees in the jails, to affect the current syphilis epidemic.
In November 1999, the DCCJC Syphilis Screening project began screening arrestees for syphilis during medical intake. The booking and medical intake process at the DCCJC would include obtaining a medical history, tuberculosis skin test, and a venipuncture blood draw. Each arrestee was informed that he or she would be tested for syphilis and each was given the opportunity to refuse syphilis screening. Blood specimens were transported twice a day to the state laboratory for testing. Quantitative, nontreponemal rapid plasma reagin (RPR) for syphilis results were telephoned to the jail. All positive RPRs were confirmed by a Treponema pallidum particle agglutination (TPPA) test.
Upon receipt of positive (reactive) RPR results, members of the nursing staff at the jail would search a registry of syphilis cases provided by TDH to find histories of syphilis or of reactive serologies. If the nursing staff determined that an arrestee might have untreated syphilis, the arrestee was taken to the jail’s medical clinic for further evaluation or treatment or both. If adequate previous treatment could not be confirmed, the arrestee was examined, treated, or both for syphilis based solely upon the RPR results, and referred to MPHD Disease Intervention Specialist (DIS) assigned to the jail for a disease intervention interview. If an arrestee with a reactive RPR was not detained (e.g., released, transferred, etc.), follow-up for examination or treatment was referred to MPHD DIS. Confirmatory treponemal test for syphilis (TPPA) were routinely performed days later on all reactive RPRs from the jail unless the laboratory had a record of a previous reactive treponemal test.
Between November 1, 1999, and August 31, 2005, 313 cases of early (primary, secondary, and early latent) syphilis were detected through the jail screening or 34.8% of Davidson County’s total reported early syphilis cases. The proportion of early syphilis cases detected range from 14.8% in 1999 to the highest level of 48.1% in 2002 and to 17.8% in 2005 (Table 1). However, in 2003 in Davidson County, a drastic shift in affected populations began to manifest itself from a heterosexual epidemic to one affecting primarily men. This is demonstrated by the change in the male-to-female ratio, which until 2003 was roughly 1:1 (Table 1). Conversely, from the beginning of 2003 through the end of 2005, the male-to-female ratio increased steadily to 4.1:1 in 2003, 5.2:1 in 2004, and 8:1 in 2005 (Table 1). However, the male-to-female ratio among the inmate population held steady at approximately 7:1 between 1999 and 2005.
An important lesson learned was that it was critical to have a public health interest on site at the jail. Once screening began, the decision was made to assign a DIS from MPHD to the jail. The jail provided an office (actually a cleaned and repainted closet that was affectionately referred to as the “cloffice”) and telephone service. The DIS facilitated screening by identifying barriers and resolving issues that hindered the screening of persons tested at the time of booking. The DIS also trained the jail nursing staff and modeled how to present the opportunity for testing to persons arrested so as to reduce the number of refusals. This public health staff person assisted the jail’s medical staff to properly evaluate the serologic results and patient history to determine the proper staging of disease and treatment. When arrested individuals were infected and required treatment on weekends or holidays, the DIS was on call for consultation and for patient interviews.
Another important lesson learned was that the program could not have been successfully implemented had it not been for the collective effort of all the project’s collaborators: the local health department (MPHD), state health department (TDH), the TDH’s Bureau of Laboratories (the Laboratory), the assistant Chief Jailer from the Sheriff’s Department (DCCJC), and the Administrator of Prison Health Services—the contracted private medical provider at the jail. Efforts to facilitate this synergistic collective included meeting monthly to identify, discuss, and immediately correct any barriers to or issues concerning operations. Unfortunately, several key personnel changes at the jail, both in the Sheriff’s Department and on the medical staff (Prison Health Services), resulted in a declining commitment to the project as demonstrated by poor monthly screening rates beginning in 2003. After significant effort, there was some rebound in screening rates during 2004; however, without constant oversight the screening rates continually declined. Although local and state health officials desired to maintain the project as a sentinel surveillance site for syphilis cases in heterosexuals, 3 factors resulted in a decision to discontinue this screening effort effective September 1, 2005: (a) relatively low number of new early syphilis cases (primary, secondary, and early latent cases) being identified since 2003; (b) the virtual elimination of heterosexual syphilis in the community; (c) high staff turnover at the jail. Although sustaining the jail screening project would have provided an excellent sentinel surveillance site for detecting a reemergence of heterosexual early syphilis, the local program had to assess if the investment required was worth the value gained. With the virtual elimination of heterosexual early syphilis, the project was primarily identifying patients that were previously adequately treated. Requirements to sustain this program would have mirrored those that were necessary to establish the effort initially. Maintaining or resurrecting a spirit of collaboration and ownership among the Sheriff’s Department staff during these times of staffing and contracting changes required a significant investment from public health leaders.
Public health officials involved with the syphilis elimination effort in Nashville believe that the jail syphilis screening project might be a major contributor to the elimination of heterosexual syphilis in Davidson County. Before the initiation of the jail screening project, the incidence of early syphilis in Nashville in 1998 was 26.1 cases per 100,000 people, but by 2005 the rate had declined to 3.5 cases per 100,000 (Table 1). The Nashville DCCJC jail syphilis screening project was unique in that it focused on testing all persons booked by concentrating screening efforts at the site where all persons arrested in Davidson County would be processed. The collaborative experience between public health and corrections officials demonstrated the positive effect on community health that resulted from the successful amalgamation of syphilis epidemiologic data, implementation of a public health program to address the precursors to the problem identified through the surveillance data, and the resulting policy changes that followed.
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5. Beltrami JF, Cohen DA, Hamrick JT, et al. Rapid screening and treatment for sexually transmitted diseases in arrestees: A feasible control measure. Am J Public Health 1997; 87:1423–1426.
6. Metro Public Health Department. Primary and Secondary Syphilis in Nashville and Davidson County, TN: 1996–1999. Epidemic Risk Factors Examined: An Investigative Report on the Current Syphilis Epidemic in Nashville and Davidson County, Tennessee, Part 3. Available at: ftp://ftpnashvillegov/web/health/web_docs/pdf_copies/syph2_pages_1-33pdf
. Accessed September 12, 2006.