Elizabeth Torrone

Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008.

Background Most sexually active people will be infected with a sexually transmitted infection (STI) at some point in their lives. The number of STIs in the United States was previously estimated in 2000. We updated previous estimates to reflect the number of STIs for calendar year 2008. Methods We reviewed available data and literature and conservatively estimated incident and prevalent infections nationally for 8 common STIs: chlamydia, gonorrhea, syphilis, herpes, human papillomavirus, hepatitis B, HIV, and trichomoniasis. Where available, data from nationally representative surveys such as the National Health and Nutrition Examination Survey were used to provide national estimates of STI prevalence or incidence. The strength of each estimate was rated good, fair, or poor, according to the quality of the evidence. Results In 2008, there were an estimated 110 million prevalent STIs among women and men in the United States. Of these, more than 20% of infections (22.1 million) were among women and men aged 15 to 24 years. Approximately 19.7 million incident infections occurred in the United States in 2008; nearly 50% (9.8 million) were acquired by young women and men aged 15 to 24 years. Human papillomavirus infections, many of which are asymptomatic and do not cause disease, accounted for most of both prevalent and incident infections. Conclusions Sexually transmitted infections are common in the United States, with a disproportionate burden among young adolescents and adults. Public health efforts to address STIs should focus on prevention among at-risk populations to reduce the number and impact of STIs.

Incarceration as Forced Migration: Effects on Selected Community Health Outcomes

OBJECTIVES We estimated the effects of high incarceration rates on rates of sexually transmitted infections and teenage pregnancies. METHODS We calculated correlations between rates of incarceration in state prisons and county jails and rates of sexually transmitted infections and teenage pregnancies for each of the 100 counties in North Carolina during 1995 to 2002. We also estimated increases in negative health outcomes associated with increases in incarceration rates using negative binomial regression analyses. RESULTS Rates of sexually transmitted infections and teenage pregnancies, adjusted for age, race, and poverty distributions by county, consistently increased with increasing incarceration rates. In the most extreme case, teenage pregnancies exhibited an increase of 71.61 per 100000 population (95% confidence interval [CI]=41.88, 101.35) in 1996 after an increase in the prison population rate from 223.31 to 468.58 per 100000 population in 1995. CONCLUSIONS High rates of incarceration can have the unintended consequence of destabilizing communities and contributing to adverse health outcomes.

Chlamydia trachomatis trends in the United States among persons 14 to 39 years of age, 1999-2008.

Background: We report the first population-based assessment of national trends in chlamydia prevalence in the United States. Methods: We investigated trends in chlamydia prevalence in representative samples of the US population aged 14 to 39 years using data from five 2-year survey cycles of the National Health and Nutrition Examination Survey from 1999 to 2008. Prevalence estimates and 95% confidence intervals (CI) are reported stratified by age, gender, and race/ethnicity. Percent change in prevalence over this time period was estimated from regression models. Results: In the 2007–2008 cycle, chlamydia prevalence among participants aged 14 to 39 years was 1.6% (95% CI: 1.1%–2.4%). Prevalence was higher among females (2.2%, 95% CI: 1.4%–3.4%) than males (1.1%, 95% CI: 0.7%–1.7%). Prevalence among non-Hispanic black persons was 6.7% (95% CI: 4.6%–9.9%) and was 2.5% (95% CI: 1.6%–3.8%) among adolescents aged 14 to 19 years. Over the five 2-year cycles, there was an estimated 40% reduction (95% CI: 8%–61%) in prevalence among participants aged 14 to 39 years. Decreases in prevalence were notable in men (53% reduction, 95% CI: 19%–72%), adolescents aged 14 to 19 years (48% reduction, 95% CI: 11%–70%), and adolescent non-Hispanic black persons (45%, reduction, 95% CI: 4%–70%). There was no change in prevalence among females aged 14 to 25 years, the population targeted for routine annual screening. Conclusions: On the basis of population estimates of chlamydia prevalence, the overall chlamydia burden in the United States decreased from 1999 to 2008. However, there remains a need to reduce prevalence in populations most at risk and to reduce racial disparities.

Incarceration and Sexually Transmitted Infections: A Neighborhood Perspective

The social dynamics of some communities are affected by the loss of significant numbers of people to prison and by the release of others who encounter the challenge of coping with the negative effects of the incarceration experience. The effects on communities are evident, in part, in the high rates of sexually transmitted infections (STIs) in North Carolina (NC) counties that have a high rate of incarceration. In the present study, we examined whether the same associations can be observed at the census tract level in one urban city of NC. To identify the mechanisms by which incarceration can affect the transmission of STIs, we conducted ethnographic interviews with ex-offenders and people who lost a sexual partner to prison. We found that census tract rates of incarceration were consistently associated with gonorrhea rates in the subsequent year. An increase of the percentage of census tract person-time spent in prison from 2.0% to 2.5% corresponded to a gonorrhea rate increase of 7.1 cases per 100,000 person-years. The people interviewed spoke of sexual partnership changes including those left behind finding new partners, in part for help in making financial ends meet; men having sex with men for the first time in prison; and having multiple new partners upon reentry to the community. The statistical associations and stories of the effects of incarceration on sexual relationships provide additional evidence of unintended community health consequences of high rates of incarceration.

Neisseria gonorrhoeae Antimicrobial Susceptibility Surveillance - The Gonococcal Isolate Surveillance Project, 27 Sites, United States, 2014.

PROBLEM/CONDITION Gonorrhea is the second most commonly reported notifiable disease in the United States; 350,062 gonorrhea cases were reported in 2014. Sexually transmitted infections caused by Neisseria gonorrhoeae are a cause of pelvic inflammatory disease in women, which can lead to serious reproductive complications including tubal infertility, ectopic pregnancy, and chronic pelvic pain. Prevention of sequelae and of transmission to sexual partners relies largely on prompt detection and effective antimicrobial treatment. However, treatment has been compromised by the absence of routine antimicrobial susceptibility testing in clinical care and evolution of antimicrobial resistance to the antibiotics used to treat gonorrhea. PERIOD COVERED 2014. DESCRIPTION OF THE SYSTEM The Gonococcal Isolate Surveillance Project (GISP) was established in 1986 as a sentinel surveillance system to monitor trends in antimicrobial susceptibilities of N. gonorrhoeae strains in the United States. Each month, N. gonorrhoeae isolates are collected from up to the first 25 men with gonococcal urethritis attending each of the participating sexually transmitted disease (STD) clinics at 27 sites. The number of participating sites has varied over time (21-30 per year). Selected demographic and clinical data are abstracted from medical records. Isolates are tested for antimicrobial susceptibility using agar dilution at one of five regional laboratories. RESULTS A total of 5,093 isolates were collected in 2014. Of these, 25.3% were resistant to tetracycline, 19.2% to ciprofloxacin, and 16.2% to penicillin (plasmid-based, chromosomal, or both). Reduced azithromycin susceptibility (Azi-RS) (defined as minimum inhibitory concentration [MIC] ≥2.0 µg/mL) increased from 0.6% in 2013 to 2.5% in 2014. The increase occurred in all geographic regions, but was greatest in the Midwest, and among all categories of sex of sex partners (men who have sex with men [MSM], men who have sex with men and women [MSMW], and men who have sex with women [MSW]). No Azi-RS isolates exhibited reduced cefixime or ceftriaxone susceptibility (Cfx-RS and Cro-RS, respectively). The prevalence of Cfx-RS (MIC ≥0.25 µg/mL) increased from 0.1% in 2006 to 1.4% in both 2010 and 2011, decreased to 0.4% in 2013, and increased to 0.8% in 2014. Cro-RS (MIC ≥0.125 µg/mL) increased following a similar pattern but at lesser percentages (increased from 0.1% in 2008 to 0.4% in 2011 and decreased to 0.1% in 2013 and 2014). The percentage of isolates resistant to tetracycline, ciprofloxacin, penicillin, or all three antimicrobials, was greater in isolates from MSM than from MSW. INTERPRETATION This is the first report to present comprehensive surveillance data from GISP and summarize gonococcal susceptibility over time, as well as underscore the history and public health implications of emerging cephalosporin resistance. Antimicrobial susceptibility patterns vary by geographic region within the United States and by sex of sex partner. Because dual therapy with ceftriaxone plus azithromycin is the only recommended gonorrhea treatment, increases in azithromycin and cephalosporin MICs are cause for concern that resistance to these antimicrobial agents might be emerging. It is unclear whether increases in the percentage of isolates with Azi-RS mark the beginning of a trend. The percentage of isolates with elevated cefixime MICs increased during 2009-2010, then decreased during 2012-2013 after treatment recommendations were changed in 2010 to recommend dual therapy (with a cephalosporin and a second antibiotic) and a higher dosage of ceftriaxone. Subsequently, the treatment recommendations were changed again in 2012 to no longer recommend cefixime as part of first-line therapy (leaving ceftriaxone-based dual therapy as the only recommended therapy). Despite the MIC decrease (i.e., trend of improved cefixime susceptibility) during 2012-2013, the increase in the number of strains with Cfx-RS in 2014 underscores the potential threat of cephalosporin-resistant N. gonorrhoeae. PUBLIC HEALTH ACTION The National Strategy for Combating Antibiotic-Resistant Bacteria identifies prevention, rapid detection, and control of outbreaks of ceftriaxone-resistant N. gonorrhoeae infection as a priority for U.S. PUBLIC HEALTH ACTION Antimicrobial susceptibility surveillance is conducted to guide development of treatment recommendations for effective therapy and prevention of complications from and transmission of gonorrhea. Federal agencies can use GISP data to develop national treatment recommendations and set research and prevention priorities. Local and state health departments can use GISP data to determine allocation of STD prevention services and resources, guide prevention planning, and communicate best treatment practices to health care providers. Continued surveillance, appropriate treatment, development of new antibiotics, and prevention of transmission remain the best strategies to reduce gonorrhea incidence and morbidity.

Increase in incidence of congenital syphilis - United States, 2012-2014.

Congenital syphilis (CS) occurs when a mother infected with syphilis transmits the infection to her child during pregnancy. CS can cause severe illness, miscarriage, stillbirth, and early infant death. However, among pregnant women with syphilis who deliver after 20 weeks gestation, maternal treatment with penicillin is 98% effective at preventing CS (1). In the United States, the rate of CS decreased during 1991–2005 but increased slightly during 2005–2008 (2). To assess recent trends in CS, CDC analyzed national surveillance data reported during 2008–2014, calculated rates, and described selected characteristics of infants with CS and their mothers. The overall rate of reported CS decreased from 10.5 to 8.4 cases per 100,000 live births during 2008–2012, and then increased to 11.6 cases per 100,000 live births in 2014, the highest CS rate reported since 2001. From 2012 to 2014, reported cases and rates of CS increased across all regions of the United States. To reduce CS, the timely identification of and response to increases in syphilis among women of reproductive age and men who have sex with women are essential. All women should have access to quality prenatal care, including syphilis screening and adequate treatment, during pregnancy (3).

HIV stigma experienced by young men who have sex with men (MSM) living with HIV infection.

Stigma can compromise the health of persons living with HIV. Although HIV is increasingly affecting young men who have sex with men (MSM), little is known about their experiences with HIV stigma. We used narrative data to examine HIV stigma experienced by young MSM living with HIV. Data came from 28 qualitative interviews with young MSM. We used inductive content analysis to identify themes across these interviews. Participants commonly discussed negative perceptions and treatment of persons living with HIV. Stigma could result in nondisclosure of HIV status, internalized stigma, and avoidance of HIV-related things. Some men discussed strategies that might combat stigma. Findings suggest that HIV stigma might challenge young MSMs health by undermining health-conducive resources (e.g., social support) and contributing to HIV vulnerability. Interventions that counteract HIV stigma may help to create environments that promote well-being among young MSM living with HIV.

Neighborhood factors affecting rates of sexually transmitted diseases in Chicago.

High rates of gonorrhea have been shown to be associated with high rates of incarceration in the prior year. One hypothesized chain of events is that there is a negative effect of incarceration on neighborhood social characteristics, which in turn affect behaviors facilitating transmission of sexually transmitted diseases (STDs). This study examined whether neighborhood characteristics were associated with the incidence of STDs and homicide rates as a proxy for incarceration rates. Data were from the 1995 Program on Human Development in Chicago Neighborhoods, the Chicago Health Department, and the Chicago Police Department. Neighborhood gonorrhea rates increased by 192.2 (95% confidence interval (CI) 131.6, 252.9) cases per 100,000 population with a change from the 25th to the 75th percentile of social disorder. This rate difference was a value greater than the median neighborhood gonorrhea rate. Similar increases were observed for other neighborhood measures and for Chlamydia infection. We hypothesize that high rates of incarceration may play a role in undermining neighborhood social cohesion and control. Using homicide rates as a proxy for incarceration, a change from the 25th to the 75th percentile of 1995 neighborhood homicide rates yielded a gonorrhea rate increase of 164.6 (95% CI 124.4, 204.7) cases per 100,000. Factors that undermine the social fabric of a community can become manifest in health outcomes such as STDs. The effects of high rates of incarceration on neighborhoods merit further exploration.

A Trich-y question: should Trichomonas vaginalis infection be reportable?

Trichomonas vaginalis (TV) infection is the most common curable sexually transmitted infection (STI).1 In the United States, a population-based survey of females aged 14 to 49 years in 2001 to 2004 estimated that there were 2.3 million women with prevalent TV infections.2 Most infections are asymptomatic.3 In those with symptoms of disease, or trichomoniasis, the most common symptoms are vaginitis in women and urethritis in men.3 T. vaginalis infection is not currently reportable in any US state.

Endemic early syphilis among young newly diagnosed HIV-positive men in a southeastern U.S. state

An epidemic of HIV infections among college students who are primarily men who have sex with men (MSM) have been reported from North Carolina, a state with one of the highest syphilis rates in the southeastern United States. We assessed the proportion of early syphilis coinfections among young HIV-infected individuals statewide and associated risk factors. From January 2002 to July 2006, chart abstractions were performed from North Carolina surveillance records for newly diagnosed HIV-positive men 18-30 years of age reported between 2000-2005, and a subset of women in the same age group. Bivariable and multivariable analyses were conducted to assess early syphilis risk factors among HIV-infected persons. During the 6-year period, there were 1460 HIV-positive men aged 18-30 years reported in North Carolina; 90 (6.2%) were coinfected with early syphilis without a significant change over time. Data were available for 551 HIV-positive women diagnosed from 2002-2005; only 6 (1.1%) were coinfected. Fifty-five percent of coinfected men were diagnosed with both infections on the same date of evaluation. Young HIV-infected men who are black (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI], 1.3, 4.1), MSM (aOR 3.8; 95% CI, 1.8, 7.8), or reported sex with both genders (aOR 5.1; 95% CI, 2.2, 11.5), or anonymous sex (aOR 2.1; 95% CI, 1.3, 3.3) were more likely to have early syphilis. Although male coinfections have not increased over time, early syphilis has become endemic among young HIV-positive men statewide, emphasizing the need to provide screening for both infections among high-risk individuals.