The Sexual Health Clinic Role in Vaccine and Treatment Access During the 2022 Mpox Outbreak in King County, Washington.

BACKGROUND: Sexual health clinics were frontline providers in the 2022 US mpox public health response, though data on clinic-based mpox vaccine scale-up, diagnoses, and treatment are limited. We describe the role of a public health sexual health clinic (SHC) in King County's mpox response, between 5/23/22-10/31/22. METHODS: In July 2022, the SHC implemented a dedicated vaccine clinic and presumptive tecovirimat treatment (prior to laboratory confirmation) with on-site dispensation. We describe SHC's vaccine scale-up and contribution to clinical care by calculating the weekly number of vaccines administered by SHC and the total number of patients diagnosed and treated for mpox within SHC, and comparing to countywide data. We calculated time from symptom onset to testing and time from testing to treatment, and assessed temporal changes in these metrics using linear regression. RESULTS: The SHC provided ≥1 vaccine doses to 7,442 individuals (10,295 doses), administering 42% of the 24,409 vaccine doses provided countywide, with the greatest contribution in the first week of August (n = 1,562, 58% of countywide vaccinations that week). Of 598 patients evaluated for mpox and tested, 178 (30%) tested positive (37% of countywide cases), and 152 (85% of SHC patients with mpox) received tecovirimat (46% of treatment countywide). Median time from symptom onset to testing decreased from 12 to 6 days (p = 0.045); time from testing to treatment decreased from 4.5 days to 0 days (p < 0.001). CONCLUSION: The SHC was central to mpox vaccination and treatment scale-up, particularly in the first months of the 2022 epidemic.

Prior Exposure to Azithromycin and Azithromycin Resistance Among Persons Diagnosed With Neisseria gonorrhoeae Infection at a Sexual Health Clinic: 2012-2019.

BACKGROUND: There is conflicting evidence on whether prior azithromycin (AZM) exposure is associated with reduced susceptibility to AZM (AZMRS) among persons infected with Neisseria gonorrhoeae (NG). METHODS: The study population included Public Health-Seattle and King County Sexual Health Clinic (SHC) patients with culture-positive NG infection at ≥1 anatomic site whose isolates were tested for AZM susceptibility in 2012-2019. We used multivariate logistic regression to examine the association of time since last AZM prescription from the SHC in ≤12 months with subsequent diagnosis with AZMRS NG (minimum inhibitory concentration [MIC], ≥2.0 µg/mL) and used linear regression to assess the association between the number of AZM prescriptions in ≤12 months and AZM MIC level, controlling for demographic, behavioral, and clinical characteristics. RESULTS: A total of 2155 unique patients had 2828 incident NG infections, 156 (6%) of which were caused by AZMRS NG. AZMRS NG was strongly associated with receipt of AZM from the SHC in the prior 29 days (adjusted odds ratio, 6.76; 95% confidence interval [CI], 1.76 to 25.90) but not with receipt of AZM in the prior 30-365 days. Log AZM MIC level was not associated with the number of AZM prescriptions within ≤12 months (adjusted correlation, 0.0004; 95% CI, -.04 to .037) but was associated with number of prescriptions within <30 days (adjusted coefficient, 0.56; 95% CI, .13 to .98). CONCLUSIONS: Recent individual-level AZM treatment is associated with subsequent AZMRS gonococcal infections. The long half-life and persistence of subtherapeutic levels of AZM may result in selection of resistant NG strains in persons with recent AZM use.

Pharyngeal Gonorrhea in Heterosexual Male and Female Sex Partners of Persons With Gonorrhea.

BACKGROUND: Current guidance from the US Centers for Disease Control and Prevention recommends empiric treatment for persons exposed to sexually transmitted infections, including Neisseria gonorrhoeae ( NG ). As an antimicrobial stewardship measure, some clinics now recommend a test and treat strategy, but reliance on urogenital testing only may miss cases. METHODS: We conducted a descriptive analysis of pharyngeal NG infection in men who have sex with women (MSW) and women seeking care at a sexual health clinic in Seattle, WA, from February 2017 to July 2021 because of sexual contact to a partner diagnosed with gonorrhea. We also explored behavioral factors associated with pharyngeal NG positivity (by culture or nucleic acid amplification test by χ2 analysis. RESULTS: Among 352 NG contacts tested for urogenital or pharyngeal infection, 34% were positive for NG at ≥1 anatomic site (27% for MSW and 40% for women). Among 161 NG contacts tested at the pharynx, 30% (n = 48) were positive: 20% of 54 MSW (n = 11) and 35% (n = 37) of 107 women. If only urogenital testing were performed, 36% of MSW NG infections (n = 5) and 19% of female NG infections (n = 9) would have remained unidentified. CONCLUSIONS: Pharyngeal NG is relatively common among MSW and women who have been exposed to NG, and likely represents an underdiagnosed reservoir of NG infection. If empiric treatment is abandoned in favor of testing and treating, testing the throats of heterosexuals will be necessary.

Previous Sexually Transmitted Infections and Partner Services Interviews as Predictors of Subsequent Interview Completion Among Cisgender MSM: Partner Services Fatigue?

BACKGROUND: Anecdotal reports suggest that partner services (PS) are less successful among people with repeat sexually transmitted infection (STI) diagnoses and/or previous PS interactions. We examine whether having repeated STI diagnoses and/or PS interactions is associated with PS outcomes among men who have sex with men (MSM). METHODS: With STI surveillance and PS data for MSM diagnosed with gonorrhea, chlamydia, and/or syphilis from 2007 to 2018, in King County, WA, we used Poisson regression models to examine the relationships between PS outcomes (e.g., completing a PS interview and providing identifying information for a contact) with (1) number of previous STI case episodes and (2) number of previous PS interviews completed. RESULTS: Of the 18,501 MSM STI case patients initiated for interview in the analytic period (2011-2018), 13,232 (72%) completed a PS interview, and 8,030 (43%) had at least 1 prior PS interview. The proportion of initiated cases successfully interviewed declined from 71% among those with no previous PS interview to 66% among those with ≥3 prior interviews. Similarly, the proportion of interviews with ≥1 partner identified declined with greater numbers of previous PS interviews (from 46% [0 interviews] to 35% [≥3 interviews]). In multivariate models, having ≥1 prior PS interview was negatively associated with completing a subsequent interview and providing partner locating information. CONCLUSIONS: Having a history of STI PS interviews is associated with less PS engagement among MSM. New approaches to PS should be explored to address the growing epidemic of STIs among MSM.

A Multifaceted Evaluation of a COVID-19 Contact Tracing Program in King County, Washington.

CONTEXT: Despite the massive scale of COVID-19 case investigation and contact tracing (CI/CT) programs operating worldwide, the evidence supporting the intervention's public health impact is limited. OBJECTIVE: To evaluate the Public Health-Seattle & King County (PHSKC) CI/CT program, including its reach, timeliness, effect on isolation and quarantine (I&Q) adherence, and potential to mitigate pandemic-related hardships. DESIGN: This program evaluation used descriptive statistics to analyze surveillance records, case and contact interviews, referral records, and survey data provided by a sample of cases who had recently ended isolation. SETTING: The PHSKC is one of the largest governmental local health departments in the United States. It serves more than 2.2 million people who reside in Seattle and 38 other municipalities. PARTICIPANTS: King County residents who were diagnosed with COVID-19 between July 2020 and June 2021. INTERVENTION: The PHSKC integrated COVID-19 CI/CT with prevention education and service provision. RESULTS: The PHSKC CI/CT team interviewed 42 900 cases (82% of cases eligible for CI/CT), a mean of 6.1 days after symptom onset and 3.4 days after SARS-CoV-2 testing. Cases disclosed the names and addresses of 10 817 unique worksites (mean = 0.8/interview) and 11 432 other recently visited locations (mean = 0.5/interview) and provided contact information for 62 987 household members (mean = 2.7/interview) and 14 398 nonhousehold contacts (mean = 0.3/interview). The CI/CT team helped arrange COVID-19 testing for 5650 contacts, facilitated grocery delivery for 7253 households, and referred 9127 households for financial assistance. End of I&Q Survey participants (n = 304, 54% of sampled) reported self-notifying an average of 4 nonhousehold contacts and 69% agreed that the information and referrals provided by the CI/CT team helped them stay in isolation. CONCLUSIONS: In the 12-month evaluation period, CI/CT reached 42 611 households and identified thousands of exposure venues. The timing of CI/CT relative to infectiousness and difficulty eliciting nonhousehold contacts may have attenuated the intervention's effect. Through promotion of I&Q guidance and services, CI/CT can help mitigate pandemic-related hardships.

Performance of Patient-collected Specimens for Neisseria gonorrhoeae Culture.

BACKGROUND: Neisseria gonorrhoeae culture is necessary to determine antimicrobial resistance, but typically requires specimen collection by clinicians. We sought to determine the sensitivity of patient-collected specimens for N. gonorrhoeae culture. METHODS: We performed N. gonorrhoeae cultures on paired clinician- and patient-collected specimens from the pharynx (n = 93), rectum (n = 88), endocervix/vagina (n = 89), and urethra/urine (n = 46). We calculated the percent concordance and the kappa statistics for paired-specimen results, and determined the test sensitivity for each specimen type using positivity of either specimen in a pair as a gold standard defining the presence of true infection. RESULTS: At least 1 specimen was positive in 26%, 31%, 61%, and 3% of paired samples in the pharynx, rectum, urethra/urine, and endocervix/vagina, respectively. Patient- and clinician-collected results were highly concordant at the pharynx (95%; kappa = 0.85), rectum (99%; kappa = 0.97), urethra/urine (83%; kappa = 0.87), and endocervix/vagina (100%; kappa = 1.0; P ≤ .005 for all comparisons). Patient-collected pharyngeal and rectal swabs and urine were 92%, 96%, and 96% sensitive, while clinician-collected specimens at these anatomic sites were 87.5%, 100%, and 94% sensitive (P > .05 for all comparisons). Among 24 urine specimens held for 4-22 hours after collection, 100% yielded concordant N. gonorrhoeae culture results, compared to immediate processing. CONCLUSIONS: Patient- and clinician-collected specimens are comparably sensitive for N. gonorrhoeae culture. These findings suggest that patient-collected specimens could be used to expand the availability of gonococcal antimicrobial resistance testing for both clinical and surveillance purposes.

Decreases in Reported Sexually Transmitted Infections During the Time of COVID-19 in King County, WA: Decreased Transmission or Screening?

BACKGROUND: In response to the COVID-19 pandemic, Washington State's Stay Home, Stay Healthy (SHSH) order was implemented on March 24, 2020. We hypothesized that pandemic mitigation measures might reduce sexually transmitted infection (STI) screening and/or transmission. METHODS: We used King County, WA STI surveillance and sexual health clinic (SHC) data from January 1, 2019, to July 31, 2020. We calculated mean weekly case counts for gonorrhea, primary and secondary (P&S) syphilis, male urethral gonorrhea, and early latent (EL) syphilis for 3 periods in 2020: pre-SHSH (January 1-March 23), SHSH (March 24-June 5), and reopening (June 6-July 31). Primary and secondary syphilis and male urethral gonorrhea were used as proxies for sexual behavior, and EL syphilis was used as a proxy for STI screening. We compared SHC visits (2019 vs. 2020) and SHC gonorrhea treatment practices (across 2020 periods). RESULTS: Compared with January to July 2019, from January to July 2020, reported cases of gonorrhea, male urethral gonorrhea, P&S syphilis, and EL syphilis decreased by 9%, 5%, 16%, and 22%, respectively. Mean weekly case counts of gonorrhea, male urethral gonorrhea, and EL syphilis decreased pre-SHSH to SHSH, but all returned to pre-SHSH levels during reopening. Sexual health clinic visits during SHSH were 55% lower in 2020 than in 2019. In the SHC during SHSH, ceftriaxone treatment of gonorrhea decreased, whereas cefixime/cefpodoxime treatment and gonorrhea treatment with no testing increased. CONCLUSIONS: Decreases in reported STIs concurrent with COVID-19 SHSH may reflect a true decline in STI transmission. However, the larger decreases in asymptomatic infections indicate that much of the observed decrease was likely due to decreased screening.

Partner Elicitation After Partner Services Interviews and Reinterviews Among Patients With Antimicrobial-Resistant Gonorrhea.

BACKGROUND: Partner notification services (PS) are often used to control sexually transmitted infections, but their effectiveness is limited by patients' reluctance to name sex partners. We hypothesized that being notified of having antimicrobial-resistant Neisseria gonorrhoeae (ARGC) would make patients more likely to provide named partner information. METHODS: We used King County, Washington STD surveillance and Strengthening the US Response to Resistant Gonorrhea data to identify gonorrhea cases. Using log-binomial regression, we computed unadjusted and adjusted prevalence ratios for factors associated with naming any partners during routine PS interview vs. interview after ARGC diagnosis. Among those who completed a standard PS interview and later a reinterview after ARGC diagnosis, we compared mean numbers of reported and contactable partners at initial interview and reinterview using the Wilcoxon rank sum test. RESULTS: From July 2018 to October 2020, 1588 gonorrhea cases were interviewed; 103 (6%) had ARGC. After adjusting for sexual exposure, age, year, disease intervention specialist, reinterview, and diagnosing clinic, being interviewed after ARGC diagnosis remained predictive of naming ≥1 partner relative to routine PS (prevalence ratio, 2.2; 95% confidence interval, 1.6-2.9). Among 40 cases who completed a standard PS interview and later a reinterview after ARGC diagnosis, there was a modest increase in mean partners named at initial versus reinterview (1.4 vs. 1.9 per case, P = 0.09). CONCLUSIONS: Cases interviewed after ARGC diagnosis named more contactable partners than did those undergoing routine PS. Reinterviewing patients after ARGC diagnosis provides only a modest increase in contactable partners but may be useful to limit transmission of this potentially challenging infection.

Test of Cure Return Rate and Test Positivity, Strengthening the US Response to Resistant Gonorrhea, United States, 2018-2019.

BACKGROUND: Reduced antibiotic susceptibility (RS) in Neisseria gonorrhoeae (GC) may increase treatment failure. Conducting tests of cure (TOC) for patients with RS-GC may facilitate identification of treatment failures. METHODS: We examined 2018 to 2019 data from 8 jurisdictions participating in the US Centers for Disease Control and Prevention's Strengthening US Response to Resistant Gonorrhea project. Jurisdictions collected GC isolates and epidemiological data from patients and performed antimicrobial susceptibility testing. Minimum inhibitory concentrations of ceftriaxone, 0.125 µg/mL or greater; cefixime, 0.250 µg/mL or greater; or azithromycin, 2.0 µg/mL or greater were defined as RS. Patients with RS infections were asked to return for a TOC 8 to 10 days posttreatment. We calculated a weighted TOC return rate and described time to TOC and suspected reasons for any positive TOC results. RESULTS: Overall, 1165 patients were diagnosed with RS infections. Over half returned for TOC (weighted TOC, 61%; 95% confidence interval, 50.1%-72.6%; range by jurisdiction, 32%-80%). Test of cure rates were higher among asymptomatic (68%) than symptomatic patients (53%, P = 0.001), and men who have sex with men (62%) compared with men who have sex with women (50%; P < 0.001). Median time between treatment and TOC was 12 days (interquartile range, 9-16). Of the 31 (4.5%) TOC patients with positive results, 13 (42%) were suspected because of reinfection and 11 (36%) because of false-positive results. There were no treatment failures suspected to be due to RS-GC. CONCLUSIONS: Most patients with a RS infection returned for a TOC, though return rates varied by jurisdiction and patient characteristics. Test of cure can identify and facilitate treatment of reinfections, but false-positive TOC results may complicate interpretation and clinical management.

Impact of Anatomic Site, Specimen Collection Timing, and Patient Symptom Status on Neisseria gonorrhoeae Culture Recovery.

BACKGROUND: Neisseria gonorrhoeae culture is required for antimicrobial susceptibility testing, but recovering isolates from clinical specimens is challenging. Although many variables influence culture recovery, studies evaluating the impact of culture specimen collection timing and patient symptom status are limited. This study analyzed urogenital and extragenital culture recovery data from Centers for Disease Control and Prevention's Strengthening the US Response to Resistant Gonorrhea (SURRG) program, a multisite project, which enhances local N. gonorrhoeae culture and antimicrobial susceptibility testing capacity. METHODS: Eight SURRG jurisdictions collected gonococcal cultures from patients with N. gonorrhoeae-positive nucleic acid amplification test (NAAT) results attending sexually transmitted disease and community clinics. Matched NAAT and culture specimens from the same anatomic site were collected, and culture recovery was assessed. Time between NAAT and culture specimen collection was categorized as same day, 1 to 7 days, 8 to 14 days, or ≥15 days, and patient symptoms were matched to the anatomic site where culture specimens were collected. RESULTS: From 2018 to 2019, among persons with N. gonorrhoeae-positive NAAT, urethral infections resulted in the highest culture recovery (5927 of 6515 [91.0%]), followed by endocervical (222 of 363 [61.2%]), vaginal (63 of 133 [47.4%]), rectal (1117 of 2805 [39.8%]), and pharyngeal (1019 of 3678 [27.7%]) infections. Culture recovery was highest when specimens were collected on the same day as NAAT specimens and significantly decreased after 7 days. Symptoms were significantly associated with culture recovery at urethral (P = <0.0001) and rectal (P = <0.0001) sites of infection but not endocervical, vaginal, or pharyngeal sites. CONCLUSIONS: Culture specimen collection timing and patient symptomatic status can impact culture recovery. These findings can guide decisions about culture collection protocols to maximize culture recovery and strengthen detection of antimicrobial-resistant infections.

Epidemiologic Treatment for Contacts to Neisseria gonorrhoeae and Chlamydia trachomatis Infection in Sexually Transmitted Disease Clinic Patients in Seattle, WA; 1994 to 2018.

INTRODUCTION: Current Centers for Disease Control and Prevention guidelines recommend that clinicians empirically treat the sex partners of persons with Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT) infection before confirming that they are infected. It is possible that this practice, known as epidemiologic treatment, results in overtreatment for uninfected persons and may contribute to development of antimicrobial resistance. We sought to quantify the number of patients who received epidemiologic treatment and the proportion of those who were overtreated. METHODS: We reviewed records from a municipal sexually transmitted disease clinic in Seattle, WA, from 1994 to 2018 to identify visits by asymptomatic patients seeking care because of sexual contact to a partner with GC and/or CT. We defined overtreatment as receipt of antibiotic(s) in the absence of a positive GC/CT test result and calculated the proportions of contacts epidemiologically treated and tested positive for GC/CT and overtreated in five 5-year periods stratified by sex and gender of sex partner. We used the Cochran-Armitage test to assess for temporal trends. RESULTS: The number of asymptomatic contacts epidemiologically treated for GC/CT increased from 949 to 3159 between the 1994-1998 and 2014-2018 periods. In 2014-2018, 55% of persons were overtreated, most (82.1%) of these were men who have sex with men (MSM). The proportion of MSM overtreated decreased from 74% to 65% (P < 0.01), but the total number of overtreated MSM increased from 172 to 1428. DISCUSSION: A high proportion of persons receiving epidemiologic treatment of GC/CT are uninfected. The current practice of routinely treating all sex partners of persons with GC/CT merits reconsideration in light of growing antimicrobial resistance.

Population-Level Effectiveness of HIV Pre-exposure Prophylaxis Among MSM and Transgender Persons With Bacterial Sexually Transmitted Infections.

BACKGROUND: Pre-exposure prophylaxis (PrEP) is highly efficacious, but its effectiveness may be limited by poor adherence or discontinuation. Our objective was to estimate the effectiveness of real-world PrEP use in a population at increased risk of HIV infection. SETTING: King County, Washington. METHODS: We conducted a retrospective cohort study using sexually transmitted infection (STI) partner services (PS) interview data collected January 2014-August 2018 in King County, Washington, USA. During PS interviews, men who have sex with men and transgender persons who have sex with men were asked if they were taking PrEP. We linked STI PS data to HIV surveillance data to estimate HIV incidence among self-reported PrEP users vs. nonusers using Cox proportional hazards regression, adjusting for age, race/ethnicity, and calendar year. RESULTS: Among 4368 individuals, 1206 (28%) were taking PrEP at the time of the PS interview. The median observation time was 14 months (interquartile range 6-23 months). Five (0.4%) of 1206 PrEP users and 97 (3%) of 2162 PrEP nonusers were subsequently diagnosed with HIV (P < 0.001). HIV incidence was lower among PrEP users than nonusers [0.17 vs. 1.86 cases per 100 person-years, adjusted hazards ratio 0.21 (95% confidence interval: 0.08 to 0.58)]. Latinx ethnicity, Native Hawaiian/Pacific Islander ethnicity, gonorrhea, and syphilis were also independently associated with higher HIV risk. CONCLUSIONS: Self-reported PrEP use was associated with a 79% reduction in HIV incidence among men who have sex with men and transgender persons who have sex with men with STIs in King County.

Primary antiretroviral drug resistance in newly human immunodeficiency virus-diagnosed individuals testing anonymously and confidentially.

The purpose of this study was to determine if anonymous and confidential testers differ in recency of human immunodeficiency virus (HIV) infection at time of testing and prevalence of antiretroviral drug (ARV) resistance. We examined data from the Centers for Disease Control and Prevention-sponsored Antiretroviral Drug Resistance Testing project, which performed genotypic testing on leftover HIV diagnostic serum specimens of confidentially and anonymously tested ARV-naïve persons newly diagnosed with HIV in Colorado (n = 365 at 11 sites) and King County, Washington (n = 492 at 44 sites). The serologic testing algorithm for recent HIV seroconversion was used to classify people as likely to have been recently infected or not. Type of testing, anonymous or confidential, was not significantly associated with either timing of HIV testing by serologic testing algorithm for recent HIV seroconversion or resistance rates. Mutations conferring any level of ARV resistance were present in 17% of testers, and high-level resistance mutations were present in 10%. Anonymous testers were significantly more likely to have CD4+ counts >500 cells per mm(3) (45% vs. 28%; p = 0.018), indicative of an early infection. This study indicates that anonymous testers have demographic differences relative to confidential HIV testers but were not more likely to exhibit drug resistance. Findings related to when in the course of disease anonymous testers are tested are inconsistent, but anonymous testers had higher CD4 counts, which indicates early testing and is consistent with other studies.