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.

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.

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.

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.