Kenneth A. Katz

Azithromycin resistance in Treponema pallidum.

Purpose of review Although the recommended treatment for syphilis is penicillin, azithromycin has been used as an alternative. We discuss azithromycin-related treatment failures and resistance in Treponema pallidum, and propose ways to meet the resulting clinical and public health challenges. Recent findings Azithromycin treatment failures in syphilis were first noted in San Francisco in 2002 and result from an A→G mutation at position 2058 of the 23S rRNA gene of T. pallidum. This mutation confers resistance by precluding macrolide binding to the bacterial 50S ribosomal subunit, of which 23S rRNA is a structural component. Azithromycin resistance has also been identified in T. pallidum specimens from elsewhere in the United States, Ireland, and Canada, and the amount of resistant specimens has increased with time. Treatment with azithromycin or other macrolides appears to be a risk factor for presenting with a resistant T. pallidum strain. Summary Although T. pallidum remains sensitive to penicillin and certain other antibiotics, azithromycin resistance in T. pallidum has emerged and is increasing in the United States, Canada, and Ireland. This poses clinical and public health challenges, and indicates a need for further antibiotic drug development and surveillance for resistance in T. pallidum. If azithromycin is used to treat syphilis, clinicians and public health practitioners should remain vigilant for treatment failures.

Repeat syphilis among men who have sex with men in California, 2002-2006: implications for syphilis elimination efforts.

OBJECTIVES We examined rates of and risk factors for repeat syphilis infection among men who have sex with men (MSM) in California. METHODS We analyzed 2002 to 2006 California syphilis surveillance system data. RESULTS During the study period, a mean of 5.9% (range: 4.9%-7.1% per year) of MSM had a repeat primary or secondary (PS) syphilis infection within 2 years of an initial infection. There was no significant increase in the annual proportion of MSM with a repeat syphilis infection (P = .42). In a multivariable model, factors associated with repeat syphilis infection were HIV infection (odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.14, 2.37), Black race (OR = 1.84; 95% CI = 1.12, 3.04), and 10 or more recent sex partners (OR = 1.99; 95% CI = 1.12, 3.50). CONCLUSIONS Approximately 6% of MSM in California have a repeat PS syphilis infection within 2 years of an initial infection. HIV infection, Black race, and having multiple sex partners are associated with increased odds of repeat infection. Syphilis elimination efforts should include messages about the risk for repeat infection and the importance of follow-up testing. Public health attention to individuals repeatedly infected with syphilis may help reduce local disease burdens.

Molecular Epidemiology of Syphilis-San Francisco, 2004-2007

We describe the molecular epidemiology of syphilis in San Francisco (SF) using Treponema pallidum specimens obtained from patients examined at the SF municipal sexually transmitted diseases clinic during 2004-2007. Of 69 specimens, 52 (75%) were subtype 14d9. Single subtype predominance might reflect a closely linked sexual network in SF.

Prevalence and correlates of Trichomonas vaginalis among incarcerated persons assessed using a highly sensitive molecular assay.

We describe the epidemiology of Trichomonas vaginalis (TV) among San Francisco County Jail inmates using APTIMA TV analyte-specific reagents on remnant urine. We detected TV in 15/713 (2.1%) men and 95/297 (32.0%) women. Among women, increased age was significantly associated with TV. The benefits of TV screening should be determined.

Sentinel surveillance for influenza-like illness, severe acute respiratory illness, and laboratory-confirmed influenza in Kinshasa, Democratic Republic of Congo, 2009-2011.

Little is known about influenza in central Africa. We conducted sentinel surveillance for influenza-like illness, severe acute respiratory illness, and laboratory-confirmed influenza at 5 sites in Kinshasa, Democratic Republic of Congo, from January 2009 through April 2011. We obtained samples from 4156 patients, of whom 605 (15%) had specimens containing laboratory-confirmed influenza virus. Apart from the period of pandemic influenza due to influenza A virus subtype H1N1, which occurred during August-December 2009, influenza activity peaked at least once each year from January through March, predominantly among children. These data can guide interventions to reduce the burden of influenza in the Democratic Republic of Congo and central Africa.

Association of Skin Cancer and Indoor Tanning in Sexual Minority Men and Women

Importance Skin cancer, the most common cancer in the United States, is highly associated with outdoor and indoor tanning behaviors. Although indoor tanning has been suggested to be more common among sexual minority (self-reported as homosexual, gay, or bisexual) men compared with heterosexual men, whether rates of skin cancer vary by sexual orientation is unknown. Objective To investigate whether skin cancer prevalence and indoor tanning behaviors vary by sexual orientation in the general population. Design, Setting, and Participants We performed a cross-sectional study using data from the 2001, 2003, 2005, and 2009 California Health Interview Surveys (CHISs) and the 2013 National Health Interview Survey (NHIS) of population-based samples of the California and US noninstitutionalized civilian population. Participants included 192 575 men and women 18 years or older who identified as heterosexual or a sexual minority. Main Outcomes and Measures Self-reported lifetime history of skin cancer and 12-month history of indoor tanning. Results The study included 78 487 heterosexual men, 3083 sexual minority men, 107 976 heterosexual women, and 3029 sexual minority women. Sexual minority men were more likely than heterosexual men to report having skin cancer (2001-2005 CHISs: adjusted odds ratio [aOR], 1.56; 95% CI, 1.18-2.06, P < .001; 2013 NHIS: aOR, 2.13; 95% CI, 1.14-3.96, P = .02) and having tanned indoors (2009 CHIS: aOR, 5.80; 95% CI, 2.90-11.60, P < .001; 2013 NHIS: aOR, 3.16; 95% CI, 1.77-5.64, P < .001). Sexual minority women were less likely than heterosexual women to report having had nonmelanoma skin cancer (2001-2005 CHIS: aOR, 0.56; 95% CI, 0.37-0.86, P = .008) and having tanned indoors (2009 CHIS: aOR, 0.43; 95% CI, 0.20-0.92, P = .03; 2013 NHIS: aOR, 0.46; 95% CI, 0.26-0.81, P = .007). Conclusions and Relevance Sexual minority men indoor tan more frequently and report higher rates of skin cancer than heterosexual men. Primary and secondary prevention efforts targeted at sexual minority men might reduce risk factors for, and consequences of, skin cancer.

Outbreak of acute hepatitis B virus infections associated with podiatric care at a psychiatric long-term care facility

BACKGROUND Effective measures exist to prevent health care-associated hepatitis B virus (HBV) transmission, yet outbreaks continue to occur. In 2008, the Los Angeles County Department of Public Health identified an outbreak of HBV infections among psychiatric long-term care facility residents. METHODS Residents underwent HBV serologic testing and were classified as acutely infected, chronically infected, susceptible, or immune. Persons residing in the facility during 2008 were enrolled in a retrospective cohort study to identify risk factors for acute HBV infection. We assessed infection control practices at the facility. RESULTS Nine of 81 residents (11%) enrolled in the cohort study had acute HBV infection. Five of 15 residents (33%) undergoing podiatric care on a single day subsequently developed acute infection (rate ratio, 4.33; 95% confidence interval, 1.18-15.92). Infection control observations of the consulting podiatrist revealed opportunities for cross-contamination of instruments with blood. Other potential health care and behavioral modes of transmission were identified as well. Residents were offered HBV vaccination, and infection control recommendations were implemented by the podiatrist and facility. CONCLUSIONS Of the multiple potential transmission modes identified, exposure to HBV during podiatry was likely the dominant mode in this outbreak. Long-term care facilities should ensure compliance with infection control standards among staff and consulting health care providers.

Dermatologists, Imiquimod, and Treatment of Molluscum Contagiosum in Children Righting Wrongs

“Halfofwhatwe’reteachingyouiswrong,”oneofmymedical school deans would often say. “The problem,”hewouldcontinue,“isthatwedon’tknowwhichhalf.”The dean was wise. Consider the case of imi-quimod, long widely considered beneficial for treat-mentofmolluscumcontagiosum.Itactuallyisnot,as2large randomized clinical trials (RCTs) showed.

Repeat syphilis among men who have sex with men--San Diego County, 2004-2009.

Among 614 men who have sex with men in San Diego County with early syphilis during January 2004 to June 2007, 74 (11.7%; 95% confidence interval: 9.3%-14.4%) had repeat syphilis within 2 years. HIV-infected MSM were more likely to have repeat syphilis (odds ratio: 1.9; 95% confidence interval: 1.1, 3.4).

Prevalence and correlates of herpes simplex virus type-2 infection among men who have sex with men, san francisco, 2008.

Background: Most herpes simplex virus type 2 (HSV-2) infections are asymptomatic or unrecognized, so periodic serological surveys are necessary in order to measure the true prevalence of infection, track trends over time, and identify correlates of infection, including coinfection with human immunodeficiency virus (HIV). Methods: We conducted a community-based, cross-sectional, serological survey among 500 men who have sex with men (MSM) in San Francisco during 2008. Results: The seroprevalence of HSV-2 infection was 26.1% (95% confidence interval [CI], 18.3–33.9), of HIV infection was 18.6% (95% CI, 13.0–24.4), and of HSV-2/HIV coinfection was 12.0% (95% CI, 7.3–16.8; categories not mutually exclusive). HSV-2 prevalence was 3.7 (95% CI, 2.3–5.9) times as high among HIV-infected MSM as among HIV-uninfected MSM. Strong predictors of HSV-2 infection among both HIV-infected and HIV-uninfected MSM were older age and black race. Conclusions: The prevalence of HSV-2 infection among MSM in San Francisco is similar to that among MSM nationwide and is higher than that among all men nationwide. Prevalence rates are highly disparate among subpopulations of MSM in San Francisco, with the strongest predictors of infection being HIV-positive serostatus, older age, and black race. Primary prevention of HSV-2, particularly among populations at the highest risk for infection with HSV-2 or HIV, should remain a major public health goal to reduce the substantial morbidity caused by both of these infections.