Evaluation of Surveillance System Changes to Improve Detection of Disseminated Gonococcal Infections in Virginia, 2018 to 2021.

BACKGROUND: Disseminated gonococcal infection (DGI), a complication of untreated gonorrhea, is rarely reported through routine surveillance. We sought to improve local surveillance system capacity to estimate and monitor the incidence of DGI in Virginia. METHODS: We modified surveillance protocols to identify possible DGI cases using information extracted from gonorrhea case reports and performed provider follow-up using standardized case report forms to confirm DGI diagnosis and collect clinical information. Suspect cases included those with a laboratory report indicating sterile site of specimen collection (e.g., blood, synovial fluid) and/or intravenous (IV) treatment. We performed descriptive analyses to summarize the characteristics of suspect and confirmed DGIs and estimated incidence. RESULTS: After piloting protocols in 2018 to 2019, we identified 405 suspect DGI cases from 29,294 gonorrhea cases reported in 2020 to 2021 (1.4%). We initiated investigations for 298 (73.6%) of the suspect cases, received provider responses for 105 (25.9%), and confirmed 19 DGI cases (4.7%). Positive laboratory reports from nonmucosal sites were the most reliable predictor of confirmed DGI status, but most were not confirmed as DGI even when provider follow-up was successful. The confirmed and estimated incidence of DGI were 0.06% and 0.22%, respectively. Sixteen (84%) of the confirmed cases were older than 25 years, 3 (16%) were HIV positive, and approximately half were male and non-Hispanic Black. Most (15 [74%]) were hospitalized, and common manifestations included septic arthritis and bacteremia. CONCLUSIONS: We improved surveillance for DGI in Virginia while incurring minor programmatic costs. Additional efforts to improve the completeness and quality of surveillance data for DGI are needed.

Effectiveness of Syphilis Partner Notification After Adjusting for Treatment Dates, 7 Jurisdictions.

BACKGROUND: Disease intervention specialists (DIS) prevent syphilis by ensuring treatment for patients' sex partners through partner notification (PN). Different interpretations of how to measure partners treated due to DIS efforts complicates PN evaluation. We measured PN impact by counting partners treated for syphilis after DIS interviewed the patient. METHODS: We reviewed data from early syphilis cases reported during the 2015-2017 period in 7 jurisdictions. We compared infected partners brought to treatment using the following: (1) DIS-assigned disposition codes or (2) all infected partners treated 0 to 90 days after the patient's interview (adjusted treatment estimate). Stratified analyses assessed patient characteristics associated with the adjusted treatment estimate. RESULTS: Disease intervention specialists interviewed 23,613 patients who reported 20,890 partners with locating information. Many of the 3569 (17.1%) partners classified by DIS as brought to treatment were treated before the patient was interviewed. There were 2359 (11.3%) partners treated 0 to 90 days after the patient's interview. Treatment estimates were more consistent between programs when measured using our adjusted estimates (range, 6.1%-14.8% per patient interviewed) compared with DIS-assigned disposition (range, 6.1%-28.3%). Treatment for ≥1 partner occurred after 9.0% of interviews and was more likely if the patient was a woman (17.9%), younger than 25 years (12.6%), interviewed ≤7 days from diagnosis (13.9%), HIV negative (12.6%), or had no reported history of syphilis (9.8%). CONCLUSIONS: Counting infected partners treated 0 to 90 days after interview reduced variability in reporting and facilitates quality assurance. Identifying programs and DIS who are particularly good at finding and treating partners could improve program impact.

Shigellosis Cases With Bacterial Sexually Transmitted Infections: Population-Based Data From 6 US Jurisdictions, 2007 to 2016.

BACKGROUND: Shigella species, which cause acute diarrheal disease, are transmitted via fecal-oral and sexual contact. To better understand the overlapping populations affected by Shigella infections and sexually transmitted infections (STIs) in the United States, we examined the occurrence of reported STIs within 24 months among shigellosis case-patients. METHODS: Culture-confirmed Shigella cases diagnosed from 2007 to 2016 among residents of 6 US jurisdictions were matched to reports of STIs (chlamydia, gonorrhea, and all stages of syphilis) diagnosed 12 months before or after the shigellosis case. We examined epidemiologic characteristics and reported temporal trends of Shigella cases by sex and species. RESULTS: From 2007 to 2016, 10,430 shigellosis cases were reported. The annual number of reported shigellosis cases across jurisdictions increased 70%, from 821 cases in 2007 to 1398 cases in 2016; males saw a larger increase compared with females. Twenty percent of male shigellosis case-patients had an STI reported in the reference period versus 4% of female case-patients. The percentage of male shigellosis case-patients with an STI increased from 11% (2007) to 28% (2016); the overall percentage among females remained low. CONCLUSIONS: We highlight the substantial proportion of males with shigellosis who were diagnosed with STIs within 24 months and the benefit of matching data across programs. Sexually transmitted infection screening may be warranted for male shigellosis case-patients.

Myocarditis Cases Reported After mRNA-Based COVID-19 Vaccination in the US From December 2020 to August 2021.

Importance: Vaccination against COVID-19 provides clear public health benefits, but vaccination also carries potential risks. The risks and outcomes of myocarditis after COVID-19 vaccination are unclear. Objective: To describe reports of myocarditis and the reporting rates after mRNA-based COVID-19 vaccination in the US. Design, Setting, and Participants: Descriptive study of reports of myocarditis to the Vaccine Adverse Event Reporting System (VAERS) that occurred after mRNA-based COVID-19 vaccine administration between December 2020 and August 2021 in 192 405 448 individuals older than 12 years of age in the US; data were processed by VAERS as of September 30, 2021. Exposures: Vaccination with BNT162b2 (Pfizer-BioNTech) or mRNA-1273 (Moderna). Main Outcomes and Measures: Reports of myocarditis to VAERS were adjudicated and summarized for all age groups. Crude reporting rates were calculated across age and sex strata. Expected rates of myocarditis by age and sex were calculated using 2017-2019 claims data. For persons younger than 30 years of age, medical record reviews and clinician interviews were conducted to describe clinical presentation, diagnostic test results, treatment, and early outcomes. Results: Among 192 405 448 persons receiving a total of 354 100 845 mRNA-based COVID-19 vaccines during the study period, there were 1991 reports of myocarditis to VAERS and 1626 of these reports met the case definition of myocarditis. Of those with myocarditis, the median age was 21 years (IQR, 16-31 years) and the median time to symptom onset was 2 days (IQR, 1-3 days). Males comprised 82% of the myocarditis cases for whom sex was reported. The crude reporting rates for cases of myocarditis within 7 days after COVID-19 vaccination exceeded the expected rates of myocarditis across multiple age and sex strata. The rates of myocarditis were highest after the second vaccination dose in adolescent males aged 12 to 15 years (70.7 per million doses of the BNT162b2 vaccine), in adolescent males aged 16 to 17 years (105.9 per million doses of the BNT162b2 vaccine), and in young men aged 18 to 24 years (52.4 and 56.3 per million doses of the BNT162b2 vaccine and the mRNA-1273 vaccine, respectively). There were 826 cases of myocarditis among those younger than 30 years of age who had detailed clinical information available; of these cases, 792 of 809 (98%) had elevated troponin levels, 569 of 794 (72%) had abnormal electrocardiogram results, and 223 of 312 (72%) had abnormal cardiac magnetic resonance imaging results. Approximately 96% of persons (784/813) were hospitalized and 87% (577/661) of these had resolution of presenting symptoms by hospital discharge. The most common treatment was nonsteroidal anti-inflammatory drugs (589/676; 87%). Conclusions and Relevance: Based on passive surveillance reporting in the US, the risk of myocarditis after receiving mRNA-based COVID-19 vaccines was increased across multiple age and sex strata and was highest after the second vaccination dose in adolescent males and young men. This risk should be considered in the context of the benefits of COVID-19 vaccination.

Unnamed Partners From Syphilis Partner Services Interviews, 7 Jurisdictions.

BACKGROUND: Reducing transmission depends on the percentage of infected partners treated; if many are missed, impact on transmission will be low. Traditional partner services metrics evaluate the number of partners found and treated. We estimated the proportion of partners of syphilis patients not locatable for intervention. METHODS: We reviewed records of early syphilis cases (primary, secondary, early latent) reported in 2015 to 2017 in 7 jurisdictions (Florida, Louisiana, Michigan, North Carolina, Virginia, New York City, and San Francisco). Among interviewed syphilis patients, we determined the proportion who reported named partners (with locating information), reported unnamed partners (no locating information), and did not report partners. For patients with no reported partners, we estimated their range of unreported partners to be between one and the average number of partners for patients who reported partners. RESULTS: Among 29,719 syphilis patients, 23,613 (80%) were interviewed and 18,581 (63%) reported 84,224 sex partners (average, 4.5; 20,853 [25%] named and 63,371 [75%] unnamed). An estimated 11,138 to 54,521 partners were unreported. Thus, 74,509 to 117,892 (of 95,362-138,745) partners were not reached by partner services (78%-85%). Among interviewed patients, 71% reported ≥1 unnamed partner or reported no partners; this proportion was higher for men who reported sex with men (75%) compared with men who reported sex with women only (65%) and women (44%). CONCLUSIONS: Approximately 80% of sex partners were either unnamed or unreported. Partner services may be less successful at interrupting transmission in networks for men who reported sex with men where a higher proportion of partners are unnamed or unreported.

Presumptive and Follow-up Treatment for Gonorrhea and Chlamydia Among Patients Attending Public Health Department Clinics in Virginia, 2016.

BACKGROUND: Presumptive antibiotic treatment is common for suspected chlamydia (CT) and gonorrhea (GC) infections before laboratory confirmation to prevent complications, reduce loss-to-follow-up, and interrupt transmission. We assessed this practice in sexually transmitted disease (STD) and family planning clinics. METHODS: We performed a retrospective analysis of data from clinics in Virginia in 2016 using administrative data merged with electronic laboratory reporting data. After stratifying by patient and clinic characteristics, we calculated how often patients with positive CT/GC tests were treated presumptively or during a follow-up visit, and how many patients with negative tests were treated presumptively. RESULTS: Of 63,889 patient visits with valid laboratory results from 131 clinics, 13% tested positive for CT or GC. Overall, presumptive treatment was given to 45.2% of persons with positive tests and 10.1% of persons with negative tests. Among the 9443 patients presumptively treated, 40.7% had positive test results. Presumptive treatment was more common in STD clinics compared with family planning clinics (22% vs. 4%) and for males with positive tests compared to females (65% vs. 24%); smaller variations were observed across age, race/ethnicity, and diagnosis categories. Twenty-six percent of patients with positive tests who were not treated presumptively had no treatment recorded within 30 days. CONCLUSIONS: Presumptive treatment for CT/GC was commonly used in this clinic population. It improved treatment coverage and reduced time to treatment, though some uninfected persons were treated. The impact of presumptive treatment on partner notification and treatment requires further study.

Reactor Grids for Prioritizing Syphilis Investigations: Are Primary Syphilis Cases Being Missed?

BACKGROUND: Health departments prioritize investigations of reported reactive serologic tests based on age, gender, and titer using reactor grids. We wondered how reactor grids are used in different programs, and if administratively closing investigations of low-titer tests could lead to missed primary syphilis cases. METHODS: We obtained a convenience sample of reactor grids from 13 health departments. Interviews with staff from several jurisdictions described the role of grids in surveillance and intervention. From 5 jurisdictions, trends in reactive nontreponemal tests and syphilis cases over time (2006-2015) were assessed by gender, age, and titer. In addition, nationally-reported primary syphilis cases (2013-2015) were analyzed to determine what proportion had low titers (≤1:4) that might be administratively closed by grids without further investigation. RESULTS: Grids and follow-up approaches varied widely. Health departments in the study received a total of 48,573 to 496,503 reactive serologies over a 10-year period (3044-57,242 per year). In 2006 to 2015, the number of reactive serologies increased 37% to 169%. Increases were largely driven by tests for men although the ratios of tests per reported case remained stable over time. Almost one quarter of reported primary syphilis had low titers that would be excluded by most grids. The number of potentially missed primary syphilis cases varied by gender and age with 41- to 54-year-old men accounting for most. CONCLUSIONS: Reactor grids that close tests with low titers or from older individuals may miss some primary syphilis cases. Automatic, computerized record searches of all reactive serologic tests could help improve prioritization.

New Human Immunodeficiency Virus Diagnoses Among Men Who Have Sex With Men Attending Sexually Transmitted Disease Clinics, STD Surveillance Network, January 2010 to June 2013.

To estimate new human immunodeficiency virus (HIV) diagnosis rates among HIV negative men who have sex with men (MSM) who are repeatedly tested for HIV in sexually transmitted disease (STD) clinics and assess the impact of demographic and disease-specific characteristics that are associated with higher HIV diagnosis rates. STUDY DESIGN: Retrospective analysis using 2010 to 2013 data from the STD Surveillance Network (SSuN), a sentinel surveillance system comprised of health departments in 12 cities conducting sentinel surveillance in 40 STD clinics. We analyzed data from all MSM repeatedly (≥2 times) tested for HIV, with an initial negative HIV test required for staggered cohort entry. Follow-up time was accrued from the date of the first negative HIV test to the most recent negative test or the first positive HIV test. The STD diagnoses during the follow-up period were reviewed. We estimated HIV diagnoses rates (number of HIV diagnoses/total number of person-years [PY] at risk) by demographic and clinical characteristics with 95% confidence intervals (CI) using an inverse variance weighted random effects model, adjusting for heterogeneity between SSuN jurisdictions. RESULTS: Overall, 640 HIV diagnoses occurred among 14,824 individuals and 20,951.6 PY of observation, for an adjusted incidence of HIV diagnosis of 3.0 per 100 PY (95% CI, 2.6-3.4). Rates varied across race/ethnicity groups with the highest rate among Blacks (4.7/100 PY; 95% CI, 4.1-5.3) followed by Hispanics, whites, and persons of other races/ethnicities. Men who have sex with men having a diagnosis of primary or secondary (P&S) syphilis on or after the first negative HIV test had a higher new HIV diagnosis rate (7.2/100 PY; 95% CI, 5.8-9.0) compared with MSM who did not have a P&S syphilis diagnosis (2.8/100 PY; 95% CI, 2.6-3.1). Men who have sex with men who tested positive for rectal gonorrhea (6.3/100 PY; 95% CI, 5.7-6.9) or rectal chlamydia (5.6/100 PY; 95% CI, 4.6-6.6) had higher rates of new HIV diagnosis when compared to those with negative test results. CONCLUSIONS: Men who have sex with men attending SSuN STD clinics have high rates of new HIV diagnoses, particularly those with a previous diagnosis of P&S syphilis, rectal chlamydia, and/or gonorrhea. Sexually transmitted disease clinics continue to be important clinical setting for diagnosing HIV among MSM populations.

Sex Disparities in Adverse Childhood Experiences and HIV/STIs: Mediation of Psychopathology and Sexual Behaviors.

HIV and other sexually transmitted infections (STIs) are important public health challenges in the US. Adverse childhood experiences (ACEs), including abuse (emotional, physical or sexual), witnessing violence among household members, may have an effect on sexual behaviors, which increase the risk of HIV/STIs. The aim of this study was to examine the sex differences in the role of posttraumatic stress disorder (PTSD), major depression (MD), substance use disorders (SUDs), early sexual debut, and intimate partner violence (IPV) perpetration as mediators in the association between ACEs and HIV/STIs. Data were obtained from Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions. Structural equation modeling was used to determine the role of PTSD, MD, SUDs, early sexual debut, and IPV perpetration as mediators in the relationships between ACEs and HIV/STIs. Differences and similarities existed in the mediational roles of psychopathology and sexual behaviors. For example, among men, MD fully mediated physical/psychological abuse (ß = 0.0002; p = 0.012) and sexual abuse (ß = 0.0002; p = 0.006), and HIV/STIs while among women, MD fully mediated physical/psychological abuse (ß = 0.0005; p < 0.001) and parental violence (ß = -0.0002; p = 0.012). Among men, IPV perpetration fully mediated sexual abuse (ß = -0.0005; p = 0.012) and HIV/STIs while among women, IPV perpetration was not a statistically significant mediator. HIV/STI prevention and intervention programs should use a life course approach by addressing adverse childhood events among men and women and consider the sex differences in the roles of psychopathology and sexual behaviors.

Meeting sex partners through the Internet, risky sexual behavior, and HIV testing among sexually transmitted infections clinic patients.

The Internet has now become a popular venue to meet sex partners. People who use the Internet to meet sex partners may be at a higher risk for contracting HIV and STIs. This study examined the association between meeting sex partners from the Internet, and HIV testing, STI history, and risky sexual behavior. Data were obtained from the Virginia Department of Health STD Surveillance Network. Logistic regression models were used to obtain crude and adjusted odds ratios, and 95 % confidence intervals for the associations between meeting sex partners through the Internet and ever tested for HIV, HIV testing in the past 12 months, STI history, and risky sexual behavior. Logistic regression was also used to determine if gender and men who have sex with men interaction terms significantly improved the model. Women who met a sex partner from the Internet were more likely to have had an HIV test in the past 12 months than women who did not meet a partner in this way. On the other hand, men who met a sex partner through the Internet were more likely to have ever had an HIV test than other men, but this was only seen for heterosexual men. All populations who met a sex partner from the Internet were more likely to take part in risky sexual behavior. HIV prevention strategies should emphasize annual testing for all populations.

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.

Prevalence of genital warts among sexually transmitted disease clinic patients-sexually transmitted disease surveillance network, United States, January 2010 to December 2011.

BACKGROUND: A quadrivalent vaccine that prevents genital warts (GWs) has been recommended by the Advisory Committee on Immunization Practices for women since 2007 and for men since 2011. National estimates of GW burden in sexually transmitted disease (STD) clinic settings are useful to provide a baseline assessment to monitor and evaluate reductions in GW and serve as an important early measure of human papillomavirus (HPV) vaccine impact in this population. METHODS: Genital wart prevalence among STD clinic patients from January 2010 to December 2011 was determined from a cross-sectional analysis of all patients attending STD clinics in the STD Surveillance Network (SSuN). We conducted bivariate analyses for women, men who have sex with women (MSW), and men who have sex with men (MSM) separately, using χ statistics for the association between GW diagnosis and demographic, behavioral, and clinical characteristics. RESULTS: Among 241,630 STD clinic patients, 13,063 (5.4%) had GWs. Wide regional differences were observed across SSuN sites. The prevalence of GW was as follows: 7.5% among MSW (range by SSuN site, 3.9-15.2), 7.5% among MSM (range, 3.3-20.6), and 2.4% among women (range, 1.2-5.4). The highest rate was among 25- to 29-year-old MSW (9.8%). Non-Hispanic black women and MSW had a lower prevalence of GWs than did women and MSW in other racial/ethnic groups. CONCLUSIONS: There is a significant burden of GW in STD clinic populations, most notably in men. Given the opportunity for prevention with a quadrivalent HPV vaccine, STD clinics may be an ideal setting for monitoring trends in GW prevalence among men (MSW and MSM). However, given the observed low GW prevalence among female STD clinic patients, STD clinics may not provide an appropriate setting to monitor the impact of HPV vaccine among women.

Residential segregation and gonorrhea rates in US metropolitan statistical areas, 2005-2009.

BACKGROUND: The residential segregation of black populations, often in areas of high-economic disadvantage and low social status, may play a crucial role in the observed racial inequities in sexually transmitted disease rates. METHODS: An ecological analysis of 2005 to 2009 average gonorrhea rates was performed across 277 US metropolitan statistical areas (MSAs). The black isolation index and Gini index of income inequality were used as proxy measures for racial and economic residential segregation respectively, derived from 2005 to 2009 US Census estimates. We used logistic regression modeling to produce estimates of odds ratios (ORs) and 95% confidence intervals (CIs) for the association between the segregation indices, both independently and in combination, on gonorrhea rates in MSAs. Effect measure modification was assessed by calculating the relative excess risk due to interaction between the 2 indices. RESULTS: Compared with MSAs with low levels of racial segregation, MSAs with high levels of racial segregation had increased odds of high gonorrhea rates (adjusted OR, 3.37; 95% CI, 1.23-9.21). Similarly, higher levels of income inequality predicted higher gonorrhea rates, although this association did not persist after adjustment for potential confounders (adjusted OR, 1.54; 95% CI, 0.74-3.24). In combined models, the influence of racial residential segregation on gonorrhea rates was stronger than that of income inequality-based segregation; there was no evidence of additivity or a multiplicative interaction. CONCLUSIONS: Residential segregation by race or income equality may be a key component in the perpetuation of high rates of gonorrhea and other sexually transmitted diseases among black populations in the United States.