STD Examiner, 0897 (PDF) by Alena Amund


									                                  August 1997                                             Volume 2, Number 3

Remarks from                                      STD Program Wins
Dr. Richwald
                                                  National "Innovations
     Over a year since the
Department of Health                              in STDs" Award
Services’ 1995-96 near
fiscal meltdown led to enormous changes in             The L.A. County STD Program’s Prevention
the functions of Public Health Programs and       Connection pharmacy and hair salon outreach
Services (PHP&S), it is more important than       project was recently named a winner of the first
ever that we all play a leadership role in        national “Innovations in STDs Model Program Search”, sponsored by
assuring the high quality of STD care in Los      3M Pharmaceuticals. The project was one of four winners chosen by a
Angeles County.                                   panel of national STD/HIV experts from numerous entries submitted by
     In the past few years, we have seen: the     community-based programs for STD prevention, treatment and
downsizing of County Public Health Centers        education.
from 29 to 11; over 107 public-private                 “We’re thrilled to be honored,” says Phoebe Macon, STD Program
partnerships formed to maintain the               Health Education Assistant, who coordinates the project and was
availability of primary care services for our     instrumental in starting it seven years ago. The project received a
indigent populations; the transfers of prenatal
                                                  $2,500 award and will be highlighted in a new nationally distributed
care, family planning and the well-baby
                                                  resource guide of model programs. The award has also helped the
program from PHP&S into Personal Health
                                                  project gain considerable local media attention, including a story on
Services; and the implementation of L.A.
County’s dual managed care plan model,            KNBC news, several radio interviews, and a newspaper article.
which will enroll over 1.2 million of the              The Prevention Connection is a public/private partnership between
County’s 1.9 million Medi-Cal recipients          the L.A. County STD Program and pharmacies, hair salons and
into HMOs this year. In addition, a massive       barbershops in neighborhoods with high STD rates. STD Program
federal downsizing initiative resulted in the     health educators provide staff at participating businesses with basic
bulk of syphilis and HIV field work being         training on STDs and regularly supply each site with “prevention
transferred from STD Program federally-           packets” containing free condoms and STD information to provide to
funded Disease Intervention Specialists           customers.
(DIS) to local Public Health Investigators             “We started in 1990 with my own hairdresser,” says Macon, “and
(PHI). We estimate that County STD field          over the years we’ve just kept growing.” The project now boasts 118
services are now provided by PHI (80%),           participating businesses—62 pharmacies and 56 hair salons/
PHN (15%), and DIS (5%).                          barbershops—which distribute over 17,000 packets per year to their
     The challenges for STD control are           customers.
obviously great. There are more organizations          A 1995 evaluation of the project showed big benefits for both
and people to work with, and our work is          participating businesses and their customers. Of customers receiving
more spread out and less easily coordinated       packets, over 65% of those
and monitored. To assure success within this      surveyed said they patronize         Inside . . .
new environment, health providers must            participating businesses more
integrate core elements of STD control and                                              Clinical Corner . . . . . Page 2
                                                  often because of the project.         Impact Assessment
prevention into their services. These include:
                                                  More than 64% of clients                 Report . . . . . . . . . . Page 2
(1) routinely identifying and testing high-risk
                                                  stated that they would use            STD DataWatch . . . . Page 3
groups for STDs; (2) ensuring infected
clients receive appropriate treatment and               Please see PHARMACY,            Inservice Info . . . . . . .Insert
follow-up; Please see DIRECTOR, page 2                                     page 4
                  Clinical Corner
                  New Treatment for External Genital Warts
                   Imiquimod—an innovative treatment for                Marketed by 3M Pharmaceuticals, imiquimod is newest
 external genital warts (EGWs)—has recently been added to          in a class of drugs called immune response modifiers. In a
 the PHP&S STD formulary. Under the brand name, Aldara,            double-blind, vehicle-controlled clinical trial with 209
 Imiquimod 5% cream is the newest available treatment for          patients, 109 received imiquimod cream and 100 received
 removing external genital and perianal warts.                     vehicle cream. Females using imiquimod experienced a 72%
      “Aldara cream represents a significant breakthrough in       clearance rate of treated warts, compared to 20% for those
 the management of this common problem,” says Dr. Robert           using vehicle. In the male treatment group, 33% of males
 H. Settlage, Medical Director of the STD Program, “It greatly     using imiquimod experienced complete clearance of their
 expands our patient-applied treatment options.”                   warts, compared to 5% for those using vehicle. The median
      Among the 135 million men and women from 15 to 49            time to complete warts clearance was ten weeks.
 years of age in the U.S., an estimated 15% (20 million) are             Imiquimod cream is patient-applied prior to bedtime,
 currently infected with genital human papilloma virus             every other day, 3 times per week and left on for 6 to 10 hours.
 (HPV), which causes EGWs. Over 1.4 million individuals            The cream is then removed with soap and water. Treatment
 have EGWs, and the remainder, subclinical infection. HPV is       continues until there is a total clearance of the warts or for a
 the fastest growing sexually transmitted infection in the U.S.,   maximum of 16 weeks. Each gram of the 5% cream contains
 with 500,000 to one million new infections each year.             50 mg of imiquimod in a vanishing cream base. One month’s
      Although there is no cure for genital warts, and cases can   therapy comes in a box of 12 single-dose packets.
 have recurrent outbreaks, treatment can alleviate physical             In clinical trials, imiquimod cream has been generally
 signs and symptoms such as itching, burning, pain and             well-tolerated. Most patients experienced only mild to
 tenderness. It may also ease the embarrassment, worry, fear,      moderate skin reactions in the wart area. The most frequent
 anger and other psychological reactions to having EGWs.           reaction has been redness (erythema) at the treatment site.
      Until recently, available treatments for genital warts       Only 4% of patients reported pain and less than 2% of
 included removing them by chemical agents such as TCA,            patients discontinued use due to skin reactions.
 loop electrocautery excision (burning), excisional surgery,            There are no known contraindications to the use of
 laser ablation, cryotherapy (freezing), interferon injections,    Aldara cream. It has not been fully evaluated for the treat-
 and tissue-destructive drugs such as podofilox and                ment of internal genital/internal anal disease such as urethral,
 podophyllin--the modality most frequently used in our STD         intra-vaginal, cervical, rectal, or intra-anal HPV, however,
 clinic system. These treatments have been associated with         and is not recommended for these conditions. Treatment
 local skin reactions; pain, burning and itching are the most      guidelines for the use of imiquimod should be available in the
 commonly reported adverse effects.                                near future from the PHP&S Pharmacy Committee.

Impact Assessment Team                                             overwhelmingly believe that restructuring has adversely
                                                                   affected access to STD care in Los Angeles County.”
Reports Findings                                                        Staff reported that remaining STD clinic sites were not
                                                                   located in the areas of greatest need, as the areas that lost the
      Last month the Public Health Crisis Impact Assessment        most STD clinic sessions were high STD morbidity districts.
(IA) Team, a group of researchers studying how L.A.                Existing barriers to patient access, such as transportation
County’s October 1995 fiscal crisis and health services            difficulties, were amplified by the restructuring, respondents
restructuring has affected STD prevention and control,                                             Please see IMPACT, page 4
released findings from the first phase of its research. Their
report, “Los Angeles County Public Health Crisis: Report of
the STD Clinic Provider Survey,” contains results from in-
                                                                   Continued from page 1
depth interviews conducted with staff at the Department of
Health Services’ eleven remaining STD clinics, which were          (3) promoting effective sex and needle-sharing partner
reduced from 29 clinics before the crisis.                         notification and services, and (4) assuring clients are
                                                                   supported in changing their risk behaviors for STDs.
     From July through September, 1996, the IA team
                                                                        To effectively re-engineer the management of STD
interviewed 64 STD clinic staff, including clinicians, field       control in the Department of Health Services, we need to
staff, nurses and administrators. Respondents were asked           immediately improve our assessment of STD field services.
about changes in job responsibilities, STD clinic operations,      This includes understanding available work-force, resources,
patient access to STD care, and quality of care since October      actual workload, performance levels, and training needs. STD
1995, as well as their recommendations for the future.             Program staff look forward to working closely with PHI,
     “The good news is that DHS staff have great ideas and         PHN, DIS, as well as the other Disease Control Programs, to
intense commitment to their work,” says Marjorie Sa’adah,          meet the demands of a newly unfolding public health
Director of the IA Project. “The bad news is that they             landscape.

STD Examiner                                                                                                               Page 2
Reported STDs in Los Angeles County, First Quarter 1997*. Provisional data; rates per 100,000 population**.

                           CHLAMYDIA                         GONORRHEA                   EARLY SYPHILIS'           CONGENITAL SYPHILIS

HEALTH                                  %                              %                               %                                     %
                                             H                             H                               H                          ‡           H
DISTRICT              Cases    Rates‘ Change        Cases     Rates‘ Change          Cases     Rates Change Cases            Rates         Change

Alhambra                  90     123.8        -6        12      16.5       +174            1      1.2        -51         0      0.0            ---

Bellflower               130     187.1       -17        23      33.0         +18           2      2.4        -34         0      0.0          -100

Central                  240     330.7      +54         58      79.7          +8          27     31.1        -46         6    320.8          +100

Compton                  287     508.2       +9         76     134.2          +2          19     28.2         -6         3    173.0          +200

East L.A.                119     261.8      +42          9      19.7         +79           3      5.5        -41         0      0.0          -100

East Valley              240     294.7      +14         23      28.2         -40           3      3.1        -58         0      0.0          -100

El Monte                 192     207.3        -3        18      19.4         -16           5      4.5        -29         0      0.0            ---

Foothill                  90     147.4      +13         16      26.1         +87           6      8.2       +48          0      0.0            ---

Glendale                  95     139.5       +9         13      19.0         +19           2      2.5        -51         0      0.0            ---

Harbor                   104     252.6      +18         17      41.2         +87           2      4.1        -72         0      0.0            ---

Hollywood-Wilshire       297     280.8      +26        109     102.8           -9         15     11.9        -54         1     44.4              0

Inglewood                380     459.1       -10       135     162.6         -29          20     20.2        -34         1     47.5            -86

Northeast                200     273.7      +58         28      38.2         +53           2      2.3        -60         1     48.8            ---

Pomona                   178     169.1         0        27      25.6         -15           3      2.4        -63         0      0.0          -100

San Antonio              210     237.8       +1         18      20.3         -30          14     13.3        +6          0      0.0            ---

San Fernando^            195     145.4       +2         32      23.8         -48           9      5.6       +78          0      0.0          -100

South                    218     634.8       +1         85     246.8       +122           21     51.2        -42         1     92.4            -86

Southeast                162     464.7        -5        46     131.6       +169            9     21.6        -19         2    175.0            -33

Southwest                437     566.2      +19        158     204.1         +25          23     24.9        +3          1     48.8            -88

Torrance                 153     171.0      +54         29      32.3         -10           1      0.9        -75         0      0.0            ---

West                     168     138.4      +21         41      33.7         -18           5      2.4       +23          1     49.0              0

West Valley              281     184.7      +45         39      25.6         -47           8      4.4        -28         0      0.0          -100

Whittier                 126     198.4      +11          9      14.1         -21           3      4.0       +48          0      0.0            ---

DISTRICT SUM           4,592                         1,021                              203                             17

District Unknown         920                           201                                 1                             0

COUNTY TOTAL           5,512     251.9      +13      1,222      55.8         -19        204       9.3        -31        17     41.4            -58

*                                                                      ‘
. Based on the disease week calendar (12/29/96 to 3/29/97).              Rates adjusted for cases with Health District Unknown.
**Rate calculations are based on 1995 population estimates due to      † Percent change in rate from first quarter 1996 to first quarter 1997.
  the current unavailability of 1996 estimates.                        ‡ Rates expressed per 100,000 live births.
§ Early Syphilis=Primary, Secondary, and Early Latent Syphilis.        ^ Includes cases reported from Antelope Valley.

STD Examiner                                                                                                                              Page 3
Pharmacy and Salon                               Impact Study Released
Project Honored                                  Continued from page 2
Continued from page 1
                                               said, and the division between “personal” and “public” health clinics has
condoms more often because of the project,     further hindered patients’ ability to navigate the DHS system. Staff feared that
and over 15% said they would not use           patients may be deferring care altogether, or are seeking STD care at clinics
condoms if they could not get them free at the that may be less equipped to provide effective, adequate STD care.
pharmacy or salon.                                  Respondents also raised concerns about the restructuring process itself.
     Perhaps most importantly, staff at        “Staff had little access to information during the process, “ says Sa’adah, “and
participating businesses have become           patients and the community were given confusing and conflicting
community advocates for safer sex. Hair        information.” In addition, respondents felt that the personnel cascade
stylist Cherie McQueen at Designer’s Touch     negatively affected quality of patient care, as staff teams were disrupted,
Hair Salon in Compton, one of the project’s    experienced providers laid off, inexperienced staff transferred in, and the
first participating sites, says she regularly  number of bilingual staff reduced.
counsels her clients about STDs and                 “But despite lowered morale among staff and their reservations about
condoms. “I’m not shy about it,” she says, “I  restructuring, we still found respondents eager to recommend changes that
just start talking to them.”                   could influence the future,” says Sa’adah. Their top three recommendations
     Macon says the community-based            were: (1) expand the number and location of STD clinic sites; (2) improve the
approach is what makes the project work.       leadership and planning process of the L.A. County Board of Supervisors and
“People who might never have contact with      DHS administration; and (3) make clinics more user-friendly and upgrade
the health department know and trust their     clinic facilities and equipment.
pharmacist, beautician or barber,” she              “Our thanks to the DHS staff who participated,” says Sa’adah. She and
explains. “Working with people in the com-     her team are currently working on the second half of their research, a
munity is the key to spreading our message.”   quantitative study which examines differences in STD care across the
     For more information about the Prevention restructured health care system. “Together the two studies will provide a
Connection project, contact Phoebe Macon, picture of where we were and where we need to go to improve STD care in
L.A. County STD Program, at (213) 744-5955. L.A. County,” says Sa’adah. Results of the second study are scheduled to be
                                               released in fall of 1997.

STD Examiner
Los Angeles County STD Program
2615 S. Grand Avenue, Room 500
Los Angeles, CA 90007

  STD Examiner is published quarterly
  by the Los Angeles County Sexually
  Transmitted Disease (STD) Program.
  We welcome your comments and

      Gary A. Richwald, MD, MPH

           Managing Editor
      Robyn K. Davis, MPH, CHES

             Editorial Staff
            Jane Baeumler
         Karen Bernstein, MPH

           STD EXAMINER
   Los Angeles County STD Program
   2615 S. Grand Avenue, Room 500
        Phone: (213) 744-3070
        FAX: (213) 749-9606

STD Examiner                                                                                                          Page 4

To top