Extragenital Screening in Men Who Have Sex With Men Diagnoses More Chlamydia and Gonorrhea Cases Than Urine Testing Alone.

Data were evaluated to determine the benefit of extragenital screening among men who have sex with men in detecting chlamydia/gonorrhea infections. More than seventy percent of chlamydia infections and >80% of gonorrhea infections would have been missed with urine testing alone in the course of a year. Extragenital testing is critical for identifying sexually transmitted diseases among men who have sex with men.

Patient-Reported Expedited Partner Therapy for Gonorrhea in the United States: Findings of the STD Surveillance Network 2010-2012.

BACKGROUND: Expedited partner therapy (EPT) has been shown to prevent reinfection in persons with gonorrhea and to plausibly reduce incidence. The Centers for Disease Control and Prevention recommends EPT as an option for treating sex partners of heterosexual patients. Few studies that examine how the reported use of this valuable intervention differs by patient and provider characteristics and by geography across multiple jurisdictions in the United States are currently available. METHODS: Case and patient interview data were obtained for a random sample of reported cases from 7 geographically disparate US jurisdictions participating in the Sexually Transmitted Disease (STD) Surveillance Network. These data were weighted to be representative of all reported gonorrhea cases in the 7 study sites. Patient receipt of EPT was estimated, and multivariate models were constructed separately to examine factors associated with receipt of EPT for heterosexuals and for men who have sex with men. RESULTS: Overall, 5.4% of patients diagnosed and reported as having gonorrhea reported receiving EPT to treat their sex partners. Heterosexual patients were more likely to have received EPT than men who have sex with men at 6.6% and 2.6% of patients, respectively. Receipt of EPT did not vary significantly by race, Hispanic ethnicity, or age for either group, although significant variation was observed in different provider settings, with patients from family planning/reproductive health and STD clinic settings more likely to report receiving EPT. Jurisdiction variations were also observed with heterosexual patients in Washington State most likely (35.5%), and those in New York City, Connecticut, and Philadelphia least likely to report receiving EPT (<2%). CONCLUSIONS: With the exception of one jurisdiction in the STD Surveillance Network actively promoting EPT use, patient-reported receipt of the intervention remains suboptimal across the network. Additional efforts to promote EPT, especially for patients diagnosed in private provider and hospital settings, are needed to realize the full potential of this valuable gonorrhea control intervention.

Partner meeting place is significantly associated with gonorrhea and chlamydia in adolescents participating in a large high school sexually transmitted disease screening program.

BACKGROUND: From 2003 to 2012, the Philadelphia High School STD Screening Program screened 126,053 students, identifying 8089 Chlamydia trachomatis (CT)/Neisseria gonorrhoeae (GC) infections. We examined sociodemographic and behavioral factors associated with CT/GC diagnoses among a sample of this high-risk population. METHODS: Standardized interviews were given to infected students receiving in-school CT/GC treatment (2009-2012) and to uninfected students calling for results (2011-2012). Sex-stratified multivariable logistic models were created to examine factors independently associated with a CT/GC diagnosis. A simple risk index was developed using variables significant on multivariable analysis. RESULTS: A total of 1489 positive and 318 negative students were interviewed. Independent factors associated with a GC/CT diagnosis among females were black race (adjusted odds ratio [AOR], 2.27; confidence interval, 1.12-4.58), history of arrest (AOR, 2.26; 1.22-4.21), higher partner number (AOR, 1.75; 1.05-2.91), meeting partners in own neighborhood (AOR, 1.92; 1.29-2.86), and meeting partners in venues other than own school, neighborhood, or through friends ("all other"; AOR, 9.44; 3.70-24.09). For males, factors included early sexual debut (AOR, 1.99; 1.21-3.26) and meeting partners at "all other" venues (AOR, 2.76; 1.2-6.4); meeting through friends was protective (AOR, 0.63; 0.41-0.96). Meeting partners at own school was protective for both sexes (males: AOR, 0.33; 0.20-0.55; females: AOR, 0.65; 0.44-0.96). CONCLUSIONS: Although factors associated with a GC/CT infection differed between males and females in our sample, partner meeting place was associated with infection for both sexes. School-based screening programs could use this information to target high-risk students for effective interventions.

Neighborhoods at risk: estimating risk of higher Neisseria gonorrhoeae incidence among women at the census tract level.

BACKGROUND: The association between area-based social factors and sexually transmitted diseases has been demonstrated in numerous studies. Such associations have not previously been explored for their potential to quantify likelihood of higher transmission of gonorrhea in small geographic areas. METHODS: Aggregate census tract-level sociodemographic factors in 4 domains (demographics, educational attainment, household income, and housing characteristics) were merged with female gonorrhea incidence data from 113 counties in 10 US states. Multivariate models were constructed, and a tract-level composite gonorrhea risk index was calculated. This composite risk index was validated against gonorrhea incidence among women from 2 independent states. RESULTS: Seven tract-level factors were found to be most strongly correlated with female gonorrhea incidence: educational attainment, proportion of female headed households, annual household income below US $20,000, proportion of population non-Hispanic black, proportion of housing units currently vacant, proportion of population reporting moving in last year, and proportion of households that are nonfamily units. Composite index was highly correlated with female gonorrhea in the study area and validated with independent data. CONCLUSIONS: Social factors predict gonorrhea incidence at the census tract level and identify small areas at risk for higher morbidity. These data may be used by health departments and health care practices to develop geographically based disease prevention and control efforts. This is especially useful because gonorrhea incidence data are not routinely available below the county level in many states.

Adolescent sexually transmitted infections and risk for subsequent HIV.

OBJECTIVES: We estimated the risk of HIV associated with sexually transmitted infection (STI) history during adolescence. METHODS: We retrospectively studied a cohort of adolescents (n = 75 273, born in 1985-1993) who participated in the Philadelphia High School STD Screening Program between 2003 and 2010. We matched the cohort to STI and HIV surveillance data sets and death certificates and performed Poisson regression to estimate the association between adolescent STI exposures and subsequent HIV diagnosis. RESULTS: Compared with individuals reporting no STIs during adolescence, adolescents with STIs had an increased risk for subsequent HIV infection (incidence rate ratio [IRR] for adolescent girls = 2.6; 95% confidence interval [CI] = 1.5, 4.7; IRR for adolescent boys = 2.3; 95% CI = 1.7, 3.1). Risk increased with number of STIs. The risk of subsequent HIV infection was more than 3 times as high among those with multiple gonococcal infections during adolescence as among those with none. CONCLUSIONS: Effective interventions that reduce adolescent STIs are needed to avert future STI and HIV acquisition. Focusing on adolescents with gonococcal infections or multiple STIs might have the greatest impact on future HIV risk.

Practical and analytical aspects of using friend controls in case-control studies: experience from a case-control study of childhood cancer.

We report empirical data on the use of friend controls, specifically response rates, case-control concordance and analytical approaches. The data derive from a North American multi-institutional study of childhood cancer that was conducted in 2002-07 and that focused on paternal exposures. Case parents nominated friends as potential controls; up to three controls participated per case. For 137 (69%) of the 199 case families, at least one control parent participated. Of 374 potential controls contacted, 247 (66%) participated. Case fathers with controls were markedly more likely to be non-Hispanic White, college graduates and non-smokers compared with case fathers without controls. Odds ratios adjusted for demographic characteristics were generally similar but occasionally differed between analyses that included only members of matched sets and those that included all participants, i.e., controls and cases with and without controls. For demographic characteristics, simulations demonstrated that the observed concordance of cases and controls within matched sets exceeded that expected under random ascertainment, indicating probable overmatching. However, the observed concordance of smoking and other exposures was similar to the expectation under random ascertainment, suggesting little overmatching on exposures. Although not ideal, friend controls were convenient, had a reasonably high response rate and provided controls closely matched on race/ethnicity, education and age.

Needle in a haystack: the yield of syphilis outreach screening at 5 US sites-2000 to 2007.

BACKGROUND: Screening for syphilis has been performed for decades, but it is unclear if the practice yields many cases at acceptable cost, and if so, at which venues. We attempted a retrospective study to determine the costs, yield, and feasibility of analyzing health department-funded syphilis outreach screening in 5 diverse US sites with significant disease burdens. METHODS: Data (venue, costs, number of tests, reactive tests, new diagnoses) from 2000 to 2007 were collected for screening efforts funded by public health departments from Philadelphia; New York City; Washington, District of Columbia; Maricopa County, Arizona (Phoenix); and the state of Florida. Crude cost per new case was calculated. RESULTS: Screening was conducted in multiple venues including jails, shelters, clubs, bars, and mobile vans. Over the study period, approximately 926 258 tests were performed and 4671 new syphilis cases were confirmed, of which 225 were primary and secondary, and 688 were early latent or high-titer late latent. Jail intake screening consistently identified the largest numbers of new cases (including 67.6% of early and high-titer late-latent cases) at a cost per case ranging from $144 to $3454. Data quality from other venues varied greatly between sites and was often poor. CONCLUSIONS: Though the yield of jail intake screening was good, poor data quality, particularly cost data, precluded accurate cost/yield comparisons at other venues. Few cases of infectious syphilis were identified through outreach screening at any venue. Health departments should routinely collect all cost and testing data for screening efforts so that their yield can be evaluated.

COVID-19 Case Investigation and Contact Tracing in the US, 2020.

Importance: Contact tracing is a multistep process to limit SARS-CoV-2 transmission. Gaps in the process result in missed opportunities to prevent COVID-19. Objective: To quantify proportions of cases and their contacts reached by public health authorities and the amount of time needed to reach them and to compare the risk of a positive COVID-19 test result between contacts and the general public during 4-week assessment periods. Design, Setting, and Participants: This cross-sectional study took place at 13 health departments and 1 Indian Health Service Unit in 11 states and 1 tribal nation. Participants included all individuals with laboratory-confirmed COVID-19 and their named contacts. Local COVID-19 surveillance data were used to determine the numbers of persons reported to have laboratory-confirmed COVID-19 who were interviewed and named contacts between June and October 2020. Main Outcomes and Measures: For contacts, the numbers who were identified, notified of their exposure, and agreed to monitoring were calculated. The median time from index case specimen collection to contact notification was calculated, as were numbers of named contacts subsequently notified of their exposure and monitored. The prevalence of a positive SARS-CoV-2 test among named and tested contacts was compared with that jurisdiction's general population during the same 4 weeks. Results: The total number of cases reported was 74 185. Of these, 43 931 (59%) were interviewed, and 24 705 (33%) named any contacts. Among the 74 839 named contacts, 53 314 (71%) were notified of their exposure, and 34 345 (46%) agreed to monitoring. A mean of 0.7 contacts were reached by telephone by public health authorities, and only 0.5 contacts per case were monitored. In general, health departments reporting large case counts during the assessment (≥5000) conducted smaller proportions of case interviews and contact notifications. In 9 locations, the median time from specimen collection to contact notification was 6 days or less. In 6 of 8 locations with population comparison data, positive test prevalence was higher among named contacts than the general population. Conclusions and Relevance: In this cross-sectional study of US local COVID-19 surveillance data, testing named contacts was a high-yield activity for case finding. However, this assessment suggests that contact tracing had suboptimal impact on SARS-CoV-2 transmission, largely because 2 of 3 cases were either not reached for interview or named no contacts when interviewed. These findings are relevant to decisions regarding the allocation of public health resources among the various prevention strategies and for the prioritization of case investigations and contact tracing efforts.

Determining risk markers for gonorrhea and chlamydial infection and reinfection among adolescents in public high schools.

BACKGROUND: In response to high adolescent rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC), Philadelphia began screening in all public high schools in 2003. METHODS: Data from 14,862 students who tested more than once in the Philadelphia High School STD Screening Program (PHSSSP) during the 2002-2006 school years were analyzed for factors associated with CT and GC infection. Multivariable Cox proportional hazards models and logistic regression models were constructed to identify characteristics associated with measured STD rates. A secondary analysis assessed short-term reinfection rates among participants retesting within the same school year. RESULTS: In the primary analysis, over multiple years, the unadjusted female CT/GC rate was more than double that in males (6.0 vs. 2.4 cases per 100 person-years, respectively). Among students with a baseline positive, males had a higher rate than females (19.9 vs. 17.7 cases per 100 person-years, respectively). Among students with a positive test result, 13.6% were reinfected within the same school year. Females with named partners not treated had a higher reinfection rate than all others (85.5 vs. 40.1-45.2 cases per 100 person-years, respectively). CONCLUSIONS: Clinicians and screening programs that offer STD testing to urban high school students, regardless of gender, should encourage those with a prior STD history to test more frequently. Clinicians should work with infected patients, especially females, to ensure their partners are treated.

Screening male prisoners for Chlamydia trachomatis: impact on test positivity among women from their neighborhoods who were tested in family planning clinics.

BACKGROUND: Chlamydia trachomatis screening test positivity among women in the United States has remained high, leading researchers to suggest that programs should also screen men. Men have been screened in Philadelphia prisons since 2002. Philadelphia prisons are similar to jails in other jurisdictions; in 2003 the median duration of incarceration was 17 days. We studied whether screening and treating men in prison influenced C. trachomatis infection among women living in their communities. METHODS: We divided the city into 2 areas: "high-treatment" (high percentage of men were treated for C. trachomatis detected in prison) and "low-treatment" (low percentage of men were treated for C. trachomatis detected in prison). We compared changes in test positivity among women from those areas, who were tested in family planning clinics during the 2 years before versus the 3 years after the male prison screening program began. RESULTS: In 2002 to 2004, prison screening led to treatment of 1054 infections among 23,203 men aged 20 to 24 years living in high-treatment areas and 98 infections among 21,057 men aged 20 to 24 years in low-treatment areas. Test positivity declined among 20- to 24-year-old women in both areas. In high-treatment areas, positivity decreased 9.1% per year from 1999 to 2001 and 4.9% per year from 2001 to 2004. In low-treatment areas, positivity decreased 13.2% per year from 1999 to 2001 and 7.5% per year from 2001 to 2004. CONCLUSION: C. trachomatis test positivity among 20- to 24-year-old women tested in family planning clinics continued to decrease after men were treated for C. trachomatis; however, we found no evidence that the continued decrease was due to the new prison screening program.

Association between enhanced screening for Chlamydia trachomatis and Neisseria gonorrhoeae and reductions in sequelae among women.

PURPOSE: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are typically asymptomatic, but, if untreated, can lead to sequelae including pelvic inflammatory disease (PID) and ectopic pregnancy. The objective was to describe trends of these sequelae in Philadelphia after implementing citywide screening in a high-morbidity population (>6% positivity). METHODS: In this ecologic study, which used data from 1996 to 2007, multivariable linear regression analysis was used to assess the association between the number of annual CT/GC screening tests by gender and the number of women aged 14-30 years hospitalized for PID or ectopic pregnancy. A standardized hospitalization database provided the number of admissions with a discharge diagnosis of PID or ectopic pregnancy. Positive CT/GC laboratory results reported by hospitals and emergency departments (EDs) were used as a proxy for outpatient PID. RESULTS: Between 1996 and 2007, CT/GC screening increased by 188%, whereas declines were noted in hospitalized PID cases (36%, -173 cases), ectopic pregnancy (38%, -119 cases), and ED-diagnosed CT/GC cases (39%, -727 cases). Screening 10,000 females for CT/GC corresponded with 26.1 fewer hospitalized PID cases (95% confidence interval 11.2-41.1), whereas screening 10,000 males corresponded to 10.4 (95% CI: 2.6-18.2) fewer cases. Although male screening was not significantly associated with ectopic pregnancy, screening 10,000 females was associated with 28.6 fewer ectopic pregnancies (95% CI: 7.4-49.8). CONCLUSIONS: This ecologic analysis found a correlation between large-scale CT/GC screening in a high-morbidity population and reductions in hospitalized PID, ectopic pregnancies, and ED-diagnosed CT/GC.