Ellen Klingler

Population-based surveillance for neonatal herpes in New York City, April 2006-September 2010.

Background: Population-based data for neonatal herpes simplex virus (HSV) infection are needed to describe disease burden and to develop and evaluate prevention strategies. Methods: From April 2006 to September 2010, routine population-based surveillance was conducted using mandated provider and laboratory reports of neonatal HSV diagnoses and test results for New York City resident infants aged ≤60 days. Case investigations, including provider interviews and review of infant and maternal medical charts and vital records, were performed. Hospital discharge data were analyzed and compared with surveillance data findings. Results: Between April 2006 and September 2010, New York City neonatal HSV surveillance detected 76 cases, for an average incidence of 13.3/100,000 (1/7519) live births. Median annual incidence of neonatal HSV estimated from administrative data for 1997 to 2008 was 11.8/100,000. Among surveillance cases, 90.8% (69/76) were laboratory confirmed. Among these, 40.6% (28/69) were HSV-1; 39.1% (27/69) were HSV-2; and 20.3% (14/69) were untyped. The overall case-fatality rate was 17.1% (13/76). Five cases were detected among infants aged >42 days. In all, 80% (20/25) of the case-infants delivered by cesarean section were known to have obstetric interventions that could have increased risk of neonatal HSV transmission to the infant before delivery. Over half (68%, or 52/76) of all cases lacked timely or ideal diagnostics or treatment. Conclusions: Administrative data may be an adequate and relatively inexpensive source for assessing neonatal HSV burden, although they lack the detail and timeliness of surveillance. Prevention strategies should address HSV-1. Incubation periods might be longer than expected for neonatal HSV. Cesarean delivery might not be protective if preceded by invasive procedures. Provider education is needed to raise awareness of neonatal HSV and to assure appropriate testing and treatment.

Sexually transmitted infection clinics as safety net providers: exploring the role of categorical sexually transmitted infection clinics in an era of health care reform.

Background For many individuals, the implementation of the US Affordable Care Act will involve a transition from public to private health care venues for sexually transmitted infection (STI) care and prevention. To anticipate challenges primary care providers may face and to inform the future role of publicly funded STI clinics, it is useful to consider their current functions. Methods Data collected by 40 STI clinics that are a part of the Sexually Transmitted Disease Surveillance Network were used to describe patient demographic and behavioral characteristics, STI diagnoses, and laboratory testing data in 2010 and 2011. Results A total of 608,536 clinic visits were made by 363,607 unique patients. Most patients (61.9%) were male; 21.9% of men reported sex with men (MSM). Roughly half of patients were 20 to 29 years old (47.1%) and non-Hispanic black (56.2%). There were 212,765 STI diagnoses (mostly nonreportable) that required clinical examinations. A high volume of chlamydia, gonorrhea, and HIV testing was performed (>350,000 tests); the prevalence was 11.5% for chlamydia, 5.8% for gonorrhea, 0.9% for HIV, and varied greatly by sex and MSM status. Among MSM with chlamydia or gonorrhea, 40.1% (1811/4448) of chlamydial and 46.2% (3370/7300) of gonococcal infections were detected at extragenital sites. Conclusions Sexually Transmitted Disease Surveillance Network clinics served populations with high STI rates. Given experience with diagnoses of both nonreportable and reportable STIs and extragenital chlamydia and gonorrhea testing, STI clinics comprise a critical specialty network in STI diagnosis, treatment, and prevention.

The elephant never forgets; piloting a chlamydia and gonorrhea retesting reminder postcard in an STD clinic setting.

We examined the number and proportion of persons retesting and reinfected with Chlamydia and/or gonorrhea 3 to 4 months after initial infection in one New York City sexually transmitted disease clinic using a reminder postcard compared to clinics not using this reminder. Retesting increased; however, the proportion reinfected was lower during the intervention.

Prevalence of adult male circumcision in the general population and a population at increased risk for HIV/AIDS in New York City.

NEWBORN MALE CIRCUMCISION IS the most common surgical procedure in the United States (US); approximately 80% of US men are circumcised.1 Male circumcision (MC) is associated with a decreased risk of infant urinary tract infections, penile cancer, and some sexually transmitted diseases (STDs) including HIV in adult men.2–8 However, citing the rarity of these conditions, potential complications of the newborn circumcision procedure, and inconclusive evidence linking MC to common STDs, current policy statements of the American Academy of Pediatrics and other professional bodies do not endorse newborn circumcision as medically indicated.8,9 Others oppose MC considering it genital mutilation.10 Since the latest (1999) American Academy of Pediatrics policy statement, 3 randomized controlled trials conducted in Africa3–5 have demonstrated that adult MC reduces HIV transmission in heterosexual men by more than half. Because of these trials, adult MC is now a recommended HIV prevention strategy by UNAIDS and the World Health Organization in settings where the heterosexual HIV incidence is high and MC prevalence is low.11 The implications of these findings for adult MC as an HIV prevention strategy in the US are currently being considered.12,13 In theory, at least, populations in the US with a high incidence of HIV and a low MC prevalence could potentially benefit from adult MC. However, in the US, male-to-male sexual exposure accounts for a substantial proportion of male HIV/AIDS cases (61%)14 and the protective effect of adult MC for transmission during anal sex is not yet confirmed. In New York City (NYC), the epicenter of the US HIV epidemic, HIV prevalence in MSM in the general population is 8.4%,15 which is slightly higher than HIV prevalence in the general adult population in Uganda (7.0%)16 and Kenya (7.4%).17 If MC proves protective against HIV transmission during anal sex, MC could be of value as an intervention among the MSM population in NYC and elsewhere. The potential value of MC for heterosexual men in this country will also be a function of MC prevalence and HIV incidence in population subgroups at increased risk for HIV. STD clinic patients often have STDs that increase their risk for HIV.18 In NYC the HIV prevalence among male STD clinic patients is 2.1% (Klingler to McKinney, July. 25, 2007, personal communication), however little is known about MC prevalence in these populations. To provide data which could be used to elucidate the potential value of MC as an HIV prevention strategy in a city with both heterosexually transmitted HIV cases and high rates of HIV infection among MSM, we estimated MC prevalence in a populationbased sample of men in the general population; in men presenting to publicly-funded STD clinics; and in MSM from both of these populations. The NYC Health and Nutrition Examination Survey (HANES) was a 2004 population-based cross-sectional survey of the NYC noninstitutionalized population 20 years of age. Detailed information about the survey is published elsewhere.19 Briefly, NYC HANES included a personal interview that elicited health and demographic information. A private Audio Computer-Assisted Self-Interview collected self-reported data on sexual behavior and circumcision status. The Audio Computer-Assisted Self-Interview was administered in English or Spanish; those who did not understand either language were unable to respond and were not included in these analyses. To address this limitation, we adjusted our weights to account for nonresponse for foreign born status in addition to age and race/ethnicity. The household response was 84%; 64% of invited males participated.19 Of the 831 men who took part, we included the 661 study participants who responded definitively to the question, “Are you circumcised or uncircumcised?” A medical drawing of a circumcised and uncircumcised penis was made available to assist the respondent in determining his status.1 Race/ ethnicity was self-reported and categorized as follows: first, persons reporting Hispanic ethnicity were classified as Hispanic of Correspondence: Christy M. McKinney, PhD, MPH, Faculty Associate, University of Texas School of Public Health, Dallas Regional Campus, 5323 Harry Hines Blvd, V8.112, Dallas, TX 75390-9128. E-mail: christy.mckinney@utsouthwestern.edu. Received for publication December 17 2007, and accepted March 18, 2008. From the *Houston School of Public Health, University of Texas, Dallas, Texas; †New York City Department of Health and Mental Hygiene, New York, New York; ‡Division of STD Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia; and §Columbia University, New York, New York Sexually Transmitted Diseases, September 2008, Vol. 35, No. 9, p.814–817 DOI: 10.1097/OLQ.0b013e318175d899 Copyright

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.

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

Outcomes of HIV partner services for people with HIV and STD coinfection versus new HIV diagnosis: implications for HIV prevention strategies.

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.

O04.5 Comparison of the Clinical and Demographic Characteristics of Neonatal Herpes Infections Caused by Herpes Simplex Virus Type 1 and Type 2; Findings from a Population-Based Surveillance System, 2006–2012

To the Editor: W read with great interest the article by Peterman et al.1 and applaud their work in highlighting the value of implementation science and program evaluation. In their 4-year long evaluation of data in nearly 60 health jurisdictions, the implementation of STD performance measures was associated with little improvement in STD program performance. Seen as an intervention, performance measures were initially introduced in the hopes of improving performance. The authors state, “We thought that if we measured and reported programs’ performance on specific activities, then program performance would improve. We expected that the low-performing programs would identify factors that contributed to their low performance and take steps to improve.”1 Although the data presented showed that the STD performance measures were not effective, the authors insist, “...we believe it is too early to abandon performance measures.”1 But if not now, when? What is not considered in the piece by Peterman is the work necessary for the local health department. Data must be collected, cleaned, analyzed, and uploaded to Center for Disease Control and Prevention through the performance measures mechanism. As public health resources continue to be lost, maintaining a basic programmatic infrastructure is challenging.2 Continuing to participate in an “intervention” that has been shown to be unproductive not only adds stress to a fragile system without any identified benefit but also undermines the whole point of program evaluation. If data-based decision making is the goal, why are we ignoring these data?

How Good is Your Rule of Thumb? Validating Male-to-Female Case Ratio as a Proxy for MSM-involvement in N. gonorrhoeae Incidence at the County Level

Background The epidemiology of neonatal herpes infection (nHSV) is changing as herpes simplex virus type 1 (HSV-1) is an increasingly common cause of genital herpes. Few sources of population-based data for nHSV exist; nHSV has been a notifiable disease in New York City (NYC) since 2006. Methods To compare the clinical and demographic characteristics of nHSV due to HSV-1 and herpes simplex virus type 2 (HSV-2), we used standard case investigation forms to abstract infant inpatient/outpatient medical records, and maternal labour and delivery records for babies ≤ 60 days of age diagnosed with laboratory-confirmed herpes infection and reported in NYC during 2006–2012. Disease syndromes were grouped as invasive (disseminated/central nervous system infection/death) versus localised (skin/eye/mucous membrane infection,). Cases lacking liver function test results, or lumbar puncture were excluded from analyses of disease syndrome. Bivariate analyses compared clinical and demographic characteristics by viral type. Results There were 91 cases reported (HSV-1, 40; HSV-2, 36; untyped, 15). Among 76 cases with viral typing, the majority (53%; 40/76) were HSV-1. There were no statistically significant differences by viral type for any variables examined: age ≤ 7 days at presentation (HSV-1, 59% versus HSV-2, 41%), fever (HSV-1, 38% versus HSV-2, 46%), vesicles (HSV-1, 46% versus HSV-2, 53%), invasive disease (HSV-1, 53% versus HSV-2, 70%), case fatality rate (HSV-1, 18% versus HSV-2, 19%), maternal history of genital herpes (HSV-1, 20% versus HSV-2, 20%), maternal genital lesions at delivery (HSV-1, 8% versus HSV-2, 3%), vaginal delivery (HSV-1, 69% versus HSV-2, 61%), white non-Hispanic maternal race/ethnicity (HSV-1, 26% versus HSV-2, 12%), maternal age < 20 (HSV-1, 15% versus HSV-2, 27%). Conclusions Neonatal herpes infections due to HSV-1 and HSV-2 have a similar presentation, and death rate. To prevent nHSV, candidate HSV vaccines will need to protect against HSV-1, as well as HSV-2 infection in women.

P1-S1.51 Prevalence of anogenital Warts among STD clinic patients-STD surveillance network, USA, January 2010–September 2010

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.