Diverging Neisseria gonorrhoeae Morbidity in Non-Hispanic Black and White Females: Application of Group-Based Trajectory Modeling to Trends in County-Level Morbidity 2003-2018.

National trends in gonorrhea rates may obscure informative local variations in morbidity. We used group-based trajectory models to identify groups of counties with similar gonorrhea rate trajectories among non-Hispanic White (NHW) and non-Hispanic Black (NHB) females using county-level data on gonorrhea cases in US females from 2003 to 2018. We assessed models with 1-15 groups and selected final models based on fit statistics and identification of divergent trajectory groups with distinct intercepts and/or slopes. We mapped counties by assigned trajectory group and examined the association of county characteristics with group membership. We identified 7 distinct gonorrhea trajectory groups for NHW females and 9 distinct trajectory groups for NHB females. All identified groups for NHW female morbidity experienced increasing gonorrhea rates with a limited range (11.6-183.3/100,000 NHW females in 2018); trajectories of NHB female morbidity varied widely in rates (146.6-966.0/1000 NHB females in 2018) and included 3 groups of counties that experienced a net decline in gonorrhea rates. Counties with higher NHW female morbidity had lower adult sex ratios, lower health insurance coverage, and lower marital rates among NHW adults. Counties with higher NHB female morbidity were more urban, experienced higher rates of poverty, and had lower rates of marriage among NHB adults. Morbidity patterns did not always follow geographic proximity, which could be explained by variation in social determinants of health. Our results demonstrated a highly heterogenous gonorrhea epidemic among NHW and NHB US females, which should prompt further analysis into the differential drivers of gonorrhea morbidity.

Trends in Nationally Notifiable Sexually Transmitted Disease Case Reports During the US COVID-19 Pandemic, January to December 2020.

BACKGROUND: To describe changes in reported sexually transmitted diseases (STDs) during the US coronavirus disease 2019 pandemic, we compared the weekly number of reported nationally notifiable STDs in 2020 to 2019. METHODS: We reviewed cases of chlamydia, gonorrhea, and primary and secondary (P&S) syphilis reported to the US National Notifiable Disease Surveillance System in 2020. For each STD, we compare the number of 2020 cases reported for a given Morbidity and Mortality Weekly Report (MMWR) week to the number of 2019 cases reported in the same week, expressing 2020 cases as a percentage of 2019 cases. We also calculated the percent difference between 2020 and 2019 cumulative case totals as of MMWR week 50 (week of December 9). RESULTS: During MMWR weeks 1 to 11 (week of December 29, 2019-March 11, 2020), the weekly number of cases of STDs reported in 2020 as a percentage of the cases in the same week in 2019 was similar. However, 2020 numbers were much lower than 2019 numbers in week 15 (week of April 8; chlamydia, 49.8%; gonorrhea, 71.2%; and P&S syphilis, 63.7%). As of week 50, the 2020 cumulative totals compared with 2019 were 14.0% lower for chlamydia, 7.1% higher for gonorrhea, and 0.9% lower for P&S syphilis. CONCLUSIONS: During March-April 2020, national case reporting for STDs dramatically decreased compared with 2019. However, resurgence in reported gonorrhea and syphilis cases later in the year suggests STD reporting may have increased in 2020, underscoring the importance of continued STD prevention and care activities.

Collection of Gender Identity in National Case Notifications of Chlamydia, Gonorrhea, and Primary and Secondary Syphilis, 2018.

In 2018, 21 (41%) jurisdictions had begun reporting gender identity for sexually transmitted disease case notifications sent to the Centers for Disease Control and Prevention. Among jurisdictions with ≥70% of cases with reported gender identity and sex, 1.0% of primary and secondary syphilis cases were identified as transgender and 71% of transgender women with syphilis were concurrently coded as being male sex.

Persons Evaluated for 2019 Novel Coronavirus - United States, January 2020.

In December 2019, a cluster of cases of pneumonia emerged in Wuhan City in central China's Hubei Province. Genetic sequencing of isolates obtained from patients with pneumonia identified a novel coronavirus (2019-nCoV) as the etiology (1). As of February 4, 2020, approximately 20,000 confirmed cases had been identified in China and an additional 159 confirmed cases in 23 other countries, including 11 in the United States (2,3). On January 17, CDC and the U.S. Department of Homeland Security's Customs and Border Protection began health screenings at U.S. airports to identify ill travelers returning from Wuhan City (4). CDC activated its Emergency Operations Center on January 21 and formalized a process for inquiries regarding persons suspected of having 2019-nCoV infection (2). As of January 31, 2020, CDC had responded to clinical inquiries from public health officials and health care providers to assist in evaluating approximately 650 persons thought to be at risk for 2019-nCoV infection. Guided by CDC criteria for the evaluation of persons under investigation (PUIs) (5), 210 symptomatic persons were tested for 2019-nCoV; among these persons, 148 (70%) had travel-related risk only, 42 (20%) had close contact with an ill laboratory-confirmed 2019-nCoV patient or PUI, and 18 (9%) had both travel- and contact-related risks. Eleven of these persons had laboratory-confirmed 2019-nCoV infection. Recognizing persons at risk for 2019-nCoV is critical to identifying cases and preventing further transmission. Health care providers should remain vigilant and adhere to recommended infection prevention and control practices when evaluating patients for possible 2019-nCoV infection (6). Providers should consult with their local and state health departments when assessing not only ill travelers from 2019-nCoV-affected countries but also ill persons who have been in close contact with patients with laboratory-confirmed 2019-nCoV infection in the United States.

Narrative Review: Assessment of Neisseria gonorrhoeae Infections Among Men Who Have Sex With Men in National and Sentinel Surveillance Systems in the United States.

To assess trends in Neisseria gonorrhoeae among gay, bisexual, and other men who have sex with men (MSM), we reviewed existing and published gonorrhea surveillance data in the United States. Data identified in this review include the following: national gonorrhea case report data and data from 3 other surveillance programs, the Gonococcal Isolate Surveillance Project (GISP), the STD Surveillance Network (SSuN), and National HIV Behavioral Surveillance.Rates of reported cases of gonorrhea among men increased 54.8% in 2006 to 2015 compared with a 2.6% increase among women. Since 2012, the rate of reported gonorrhea cases among men surpassed the rate among women; the male-to-female case rate ratio increased from 0.97 in 2012 to 1.31 in 2015. The proportion of gonococcal urethral isolates collected in the Gonococcal Isolate Surveillance Project that were collected from MSM increased from 21.5% to 38.1% in 2006 to 2015. In 2009 to 2015, the percent of MSM who tested positive for rectal and oropharyngeal gonorrhea in sexually transmitted disease (STD) clinics increased by 73.4% and 12.6%, respectively. Estimated rates of gonorrhea among MSM increased by 151% in 2010 to 2015 in jurisdictions participating in the STD Surveillance Network. Data from the National HIV Behavioral Surveillance demonstrate that testing for gonorrhea among MSM increased by 23.1% between 2011 and 2014.Together, surveillance data suggest a disproportionate burden of gonorrhea among MSM in the United States and suggest increases in both screening and disease in recent years. Because each data source has inherent limitations and biases, examining these data from different systems together strengthens this conclusion.

It Is Not Just the Southeast-Geographically Pervasive Racial Disparities in Neisseria gonorrhoeae Between Non-Hispanic Black and White US Women.

Spatial analyses of gonorrhea morbidity among women often highlight the Southeastern United States but may not provide information on geographic variation in the magnitude of racial disparities; such maps also focus on geographic space, obscuring underlying population characteristics. We created a series of visualizations depicting both county-level racial disparities in female gonorrhea diagnoses and variations in population size. We calculated county- and region-level race-specific relative rates (RelR) and between-race rate differences (RDs) and rate ratios (RRs) comparing gonorrhea case rates in non-Hispanic Black (NHB) versus non-Hispanic White (NHW) women. We then created proportional symbol maps with color representing counties' RelR/RD/RR category and symbol size representing counties' female population. Gonorrhea rates among NHB women were highest in the Midwest (718.7/100,000) and West (504.8), rates among NHW women were highest in the West (74.1) and Southeast (72.1). The RDs were highest in the Midwest (654.6 excess cases/100,000) and West (430.7), whereas the RRs were highest in the Northeast (12.4) and Midwest (11.2). Nearly all US counties had NHB female rates ≥3× those in NHW women, with NHB women in most highly populated counties experiencing ≥9-fold difference in gonorrhea rates. Racial disparities in gonorrhea were not confined to the Southeast; both relative and absolute disparities were equivalent or larger in magnitude in areas of the Northeast, Midwest, and West. Our findings help counter damaging regional stereotypes, provide evidence to refocus prevention efforts to areas of highest disparities, and suggest a useful template for monitoring racial disparities as an actionable public health metric.

How Good Is Your Rule of Thumb? Validating Male-to-Female Case Ratio as a Proxy for Men Who Have Sex With Men Involvement in N. gonorrhoeae Incidence at the County Level.

BACKGROUND: Lacking information on men who have sex with men (MSM) for most reported cases, sexually transmitted disease (STD) programs in the United States have used crude measures such as male-to-female case ratios (MFCR) as a rule of thumb to gauge MSM involvement at the local level, primarily with respect to syphilis cases in the past. Suitability of this measure for gonorrhea incidence has not previously been investigated. METHODS: A random sample of gonorrhea cases reported from January 2010 through June 2013 were interviewed in selected counties participating in the STD Surveillance Network to obtain gender of sex partners and history of transactional sex. Weighted estimates of proportion of cases among MSM and proportion reporting transactional sex were developed; correlation between MFCR and proportion MSM was assessed. RESULTS: Male-to-female case ratio ranged from 0.66 to 8.7, and the proportion of cases occurring among MSM varied from 2.5% to 62.3%. The MFCR was strongly correlated with proportion of cases among MSM after controlling for transactional sex (Pearson partial r = 0.754, P < 0.0001). CONCLUSIONS: Male-to-female case ratio for gonorrhea at the county level is a reliable proxy measure indicating MSM involvement in gonorrhea case incidence and should be used by STD programs to tailor their programmatic mix to include MSM-specific interventions.

Prescription of Preexposure Prophylaxis to Men Who Have Sex With Men Diagnosed and Reported With Gonorrhea, STD Surveillance Network, 2016.

Using a representative sample of gonorrhea cases in select jurisdictions, we estimated the proportion of eligible men who have sex with men reporting being prescribed preexposure prophylaxis (PrEP) to prevent HIV infection. In 2016, half (51.3%) of the estimated 33,165 eligible men who have sex with men reported being prescribed PrEP by their health care provider.

Adherence to CDC Recommendations for the Treatment of Uncomplicated Gonorrhea - STD Surveillance Network, United States, 2016.

Gonorrhea, the sexually transmitted disease (STD) caused by Neisseria gonorrhoeae, is the second most common notifiable disease in the United States after chlamydia; 468,514 cases were reported to state and local health departments in 2016, an increase of 18.5% from 2015 (1). N. gonorrhoeae has progressively developed resistance to most antimicrobials used to treat the infection (2). As a result, CDC recommends two antimicrobials (250 mg of ceftriaxone [IM] plus 1 g of azithromycin [PO]) for treating uncomplicated gonorrhea to improve treatment efficacy and, potentially, to slow the emergence and spread of antimicrobial resistance. To monitor adherence to the current CDC-recommended regimen for uncomplicated gonorrhea, CDC reviewed enhanced data collected on a random sample of reported cases of gonorrhea in seven jurisdictions participating in the STD Surveillance Network (SSuN) and estimated the proportion of patients who received the CDC-recommended regimen for uncomplicated gonorrhea, by patient characteristics and diagnosing facility type. In 2016, the majority of reported patients with gonorrhea (81%) received the recommended regimen. There were no differences in the proportion of patients receiving the recommended regimen by age or race/ethnicity; however, patients diagnosed with gonorrhea in STD (91%) or family planning/reproductive health (94%) clinics were more likely to receive this regimen than were patients diagnosed in other provider settings (80%). These data document high provider adherence to CDC gonorrhea treatment recommendations in specialty STD clinics, indicating high quality of care provided in those settings. Local and state health departments should monitor adherence with recommendations in their jurisdictions and consider implementing interventions to improve provider and patient compliance with gonorrhea treatment recommendations where indicated.

Increases in the Rate of Neisseria gonorrhoeae Among Gay, Bisexual and Other Men Who Have Sex With Men-Findings From the Sexually Transmitted Disease Surveillance Network 2010-2015.

BACKGROUND: Inequalities in Neisseria gonorrhoeae (gonorrhea) burden by sexual minority status in the United States are difficult to quantify. Sex of sex partner is not routinely collected for reported cases. Population estimates of men who have sex with men (MSM) necessary to calculate case rates have not been available until recently. For these reasons, trends in reported gonorrhea rates among MSM have not been described across multiple jurisdictions. METHODS: We estimated of the number of MSM cases reported in 6 jurisdictions continuously participating in the STD Surveillance Network 2010-2015 based on interviews with a random sample of cases. Data were obtained for Baltimore, Philadelphia, New York City, San Francisco, California (excluding San Francisco), and Washington State. Estimates of the MSM, heterosexual male (MSW) and female populations were obtained from recently published estimates and census data. Case rates and rate-ratios were calculated comparing trends in reported cases among MSM, heterosexual males and women. RESULTS: The proportion of male gonorrhea cases among MSM varied by jurisdiction (range: 20% to 98%). Estimated MSM rate increased from 1369 cases per 100,000 in 2010 to 3435 cases per 100,000 in 2015. Between 2010 and 2015, the MSM-to-Women gonorrhea rate ratio increased from 13:1 to 24:1, and the MSM-to-MSW gonorrhea rate ratio increased from 16:1 to 31:1. CONCLUSIONS: Estimated gonorrhea rate among MSM increased in a network of 6 geographically diverse US jurisdictions. Estimating the size of this population, determining MSM among reported cases and estimating rates are essential first steps for better understanding the changing epidemiology of gonorrhea.

US Public Sexually Transmitted Disease Clinical Services in an Era of Declining Public Health Funding: 2013-14.

BACKGROUND: We examined the infrastructure for US public sexually transmitted disease (STD) clinical services. METHODS: In 2013 to 2014, we surveyed 331 of 1225 local health departments (LHDs) who either reported providing STD testing/treatment in the 2010 National Profile of Local Health Departments survey or were the 50 local areas with the highest STD cases or rates. The sample was stratified by jurisdiction population size. We examined the primary referral clinics for STDs, the services offered and the impact of budget cuts (limited to government funding only). Data were analyzed using SAS, and analyses were weighted for nonresponse. RESULTS: Twenty-two percent of LHDs cited a specialty STD clinic as their primary referral for STD services; this increased to 53.5% of LHDs when combination STD-family planning clinics were included. The majority of LHDs (62.8%) referred to clinics providing same-day services. Sexually transmitted disease clinics more frequently offered extragenital testing for chlamydia and/or gonorrhea (74.7%) and gonorrhea culture (68.5%) than other clinics (52.9%, 46.2%, respectively; P < 0.05). The majority of LHDs (61.5%) reported recent budget cuts. Of those with decreased budgets, the most common impacts were fewer clinic hours (42.8%; 95% confidence interval [CI], 24.4-61.2), reduced routine screening (40.2%; 95% CI, 21.7-58.8) and reductions in partner services (42.1%; 95% CI, 23.6-60.7). One quarter of those with reduced STD budgets increased fees or copays for clients. CONCLUSIONS: Findings demonstrate gaps and reductions in US public STD services including clinical services that play an important role in reducing disease transmission. Furthermore, STD clinics tended to offer more specialized STD services than other public clinics.

Uptake and population-level impact of expedited partner therapy (EPT) on Chlamydia trachomatis and Neisseria gonorrhoeae: the Washington State community-level randomized trial of EPT.

BACKGROUND: Expedited partner therapy (EPT), the practice of treating the sex partners of persons with sexually transmitted infections without their medical evaluation, increases partner treatment and decreases gonorrhea and chlamydia reinfection rates. We conducted a stepped-wedge, community-level randomized trial to determine whether a public health intervention promoting EPT could increase its use and decrease chlamydia test positivity and gonorrhea incidence in women. METHODS AND FINDINGS: The trial randomly assigned local health jurisdictions (LHJs) in Washington State, US, into four study waves. Waves instituted the intervention in randomly assigned order at intervals of 6-8 mo. Of the state's 25 LHJs, 24 were eligible and 23 participated. Heterosexual individuals with gonorrhea or chlamydial infection were eligible for the intervention. The study made free patient-delivered partner therapy (PDPT) available to clinicians, and provided public health partner services based on clinician referral. The main study outcomes were chlamydia test positivity among women ages 14-25 y in 219 sentinel clinics, and incidence of reported gonorrhea in women, both measured at the community level. Receipt of PDPT from clinicians was evaluated among randomly selected patients. 23 and 22 LHJs provided data on gonorrhea and chlamydia outcomes, respectively. The intervention increased the percentage of persons receiving PDPT from clinicians (from 18% to 34%, p < 0.001) and the percentage receiving partner services (from 25% to 45%, p < 0.001). Chlamydia test positivity and gonorrhea incidence in women decreased over the study period, from 8.2% to 6.5% and from 59.6 to 26.4 per 100,000, respectively. After adjusting for temporal trends, the intervention was associated with an approximately 10% reduction in both chlamydia positivity and gonorrhea incidence, though the confidence bounds on these outcomes both crossed one (chlamydia positivity prevalence ratio = 0.89, 95% CI 0.77-1.04, p = 0.15; gonorrhea incidence rate ratio = 0.91, 95% CI .71-1.16, p = 0.45). Study findings were potentially limited by inadequate statistical power, by the institution of some aspects of the study intervention outside of the research randomization sequence, and by the fact that LHJs did not constitute truly isolated sexual networks. CONCLUSIONS: A public health intervention promoting the use of free PDPT substantially increased its use and may have resulted in decreased chlamydial and gonococcal infections at the population level. TRIAL REGISTRATION: ClinicalTrials.gov NCT01665690.

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.

Management of Pelvic Inflammatory Disease in Selected U.S. Sexually Transmitted Disease Clinics: Sexually Transmitted Disease Surveillance Network, January 2010-December 2011.

BACKGROUND: Pelvic inflammatory disease (PID) remains an important source of preventable reproductive morbidity, but no recent studies have singularly focused on US sexually transmitted disease (STD) clinics in relationship to established guidelines for diagnosis and treatment. METHODS: Of the 83,076 female patients seen in 14 STD clinics participating in the STD Surveillance Network, 1080 (1.3%) were diagnosed as having PID from 2010 to 2011. A random sample of 219 (20%) women were selected, and medical records were reviewed for clinical history, examination findings, treatment, and diagnostic testing. Our primary outcomes were to evaluate how well PID diagnosis and treatment practices in STD clinic settings follow the Centers for Disease Control and Prevention (CDC) treatment guidelines and to describe age group-specific rates of laboratory-confirmed Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in patients clinically diagnosed as having PID in the last 12 months, inclusive of the PID visit. RESULTS: Among the 219 women, 70.3% of the cases met the CDC treatment case definition for PID, 90.4% had testing for CT and GC on the PID visit, and 68.0% were treated with a CDC-recommended outpatient regimen. In the last 12 months, 95.4% were tested for CT or GC, and positivity for either organism was 43.9% in women aged 25 years or younger with PID, compared with 19.4% of women older than 25 years with PID. CONCLUSIONS: Compliance with CDC guidelines was documented for many of the women with PID, though not all. Our findings underscore the need for continued efforts to optimize quality of care and adherence to current guidance for PID management given the anticipated expertise of providers in these settings.

Gonorrhea treatment practices in the STD Surveillance Network, 2010-2012.

BACKGROUND: Replacing oral treatments with ceftriaxone is a central component of public health efforts to slow the emergence of cephalosporin-resistant Neisseria gonorrhoeae in the United States; US gonorrhea treatment guidelines were revised accordingly in 2010. However, current US gonorrhea treatment practices have not been well characterized. METHODS: Six city and state health departments in Cycle II of the STD Surveillance Network (SSuN) contributed data on all gonorrhea cases reported in 101 counties and independent cities. Treatment data were obtained through local public health surveillance and interviews with a random sample of patients. Cases were weighted to adjust for site-specific sample fractions and for differential nonresponse by age, sex, and provider type. RESULTS: From 2010 to 2012, 135,984 gonorrhea cases were reported in participating areas, 15,246 (11.2%) of which were randomly sampled. Of these, 7,851 (51.5%) patients were interviewed. Among patients with complete treatment data, 76.8% received ceftriaxone, 16.4% received an oral cephalosporin, and 6.9% did not receive a cephalosporin; 51.9% of persons were treated with a regimen containing ceftriaxone and either doxycycline or azithromycin. Ceftriaxone treatment increased significantly by year (64.1% of patients in 2010, 79.3% in 2011, 85.4% in 2012; P = 0.0001). Ceftriaxone use varied widely by STD Surveillance Network site (from 44.6% to 95.1% in 2012). CONCLUSIONS: Most persons diagnosed as having gonorrhea between 2010 and 2012 in the United States received ceftriaxone, and its use has increased since the release of the 2010 Centers for Disease Control and Prevention STD Treatment Guidelines.

Extragenital gonorrhea and chlamydia testing and infection among men who have sex with men--STD Surveillance Network, United States, 2010-2012.

BACKGROUND: Gonorrhea (GC) and chlamydia (CT) are the most commonly reported notifiable diseases in the United States. The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) be screened for urogenital GC/CT, rectal GC/CT, and pharyngeal GC. We describe extragenital GC/CT testing and infections among MSM attending sexually transmitted disease (STD) clinics. METHODS: The STD Surveillance Network collects patient data from 42 STD clinics. We assessed the proportion of MSM attending these clinics during July 2011-June 2012 who were tested and positive for extragenital GC/CT at their most recent visit or in the preceding 12 months and the number of extragenital infections that would have remained undetected with urethral screening alone. RESULTS: Of 21 994 MSM, 83.9% were tested for urogenital GC, 65.9% for pharyngeal GC, 50.4% for rectal GC, 81.4% for urogenital CT, 31.7% for pharyngeal CT, and 45.9% for rectal CT. Of MSM tested, 11.1% tested positive for urogenital GC, 7.9% for pharyngeal GC, 10.2% for rectal GC, 8.4% for urogenital CT, 2.9% for pharyngeal CT, and 14.1% for rectal CT. More than 70% of extragenital GC infections and 85% of extragenital CT infections were associated with negative urethral tests at the same visit and would not have been detected with urethral screening alone. CONCLUSIONS: Extragenital GC/CT was common among MSM attending STD clinics, but many MSM were not tested. Most extragenital infections would not have been identified, and likely would have remained untreated, with urethral screening alone. Efforts are needed to facilitate implementation of extragenital GC/CT screening recommendations for MSM.

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.

The legal aspects of expedited partner therapy practice: do state laws and policies really matter?

BACKGROUND: Expedited partner therapy (EPT) is a potential partner treatment strategy. Significant efforts have been devoted to policies intended to facilitate its practice. However, few studies have attempted to evaluate these policies. METHODS: We used data on interviewed gonorrhea cases from 12 sites in the STD Surveillance Network in 2010 (n = 3404). Patients reported whether they had received EPT. We coded state laws relevant to EPT for gonorrhea using Westlaw legal research database and the general legal status of EPT in STD Surveillance Network sites from Centers for Disease Control and Prevention's Web site in 2010. We also coded policy statements by medical and other boards. We used χ tests to compare receipt of EPT by legal/policy variables, patient characteristics, and provider type. Variables significant at P < 0.10 in bivariate analyses were included in a logistic regression model. RESULTS: Overall, 9.5% of 2564 interviewed patients with gonorrhea reported receiving EPT for their partners. Receipt of EPT was significantly higher where laws and policies authorizing EPT existed. Where EPT laws for gonorrhea existed and EPT was permissible, 13.3% of patients reported receiving EPT as compared with 5.4% where there were no EPT laws and EPT was permissible, and 1.0% where there were no EPT laws and EPT was potentially allowable (P < 0.01). Expedited partner therapy was higher where professional boards had policy statements supporting EPT (P < 0.01). Receipt of EPT did not differ by most patient characteristics or provider type. Policy-related findings were similar in adjusted analyses. CONCLUSIONS: Expedited partner therapy laws and policies were associated with higher reports of receipt of EPT among interviewed gonorrhea cases.

HIV testing among patients infected with Neisseria gonorrhoeae: STD Surveillance Network, United States, 2009-2010.

We used data from the STD Surveillance Network to estimate HIV testing among patients being tested or treated for gonorrhea. Of 1,845 gonorrhea-infected patients identified through nationally notifiable disease data, only 51% were tested for HIV when they were tested or treated for gonorrhea. Among the 10 geographic sites in this analysis, the percentage of patients tested for HIV ranged from 22-63% for men and 20-79% for women. Nearly 33% of the un-tested patients had never been previously HIV-tested. STD clinic patients were more likely to be HIV-tested than those in other practice settings.