Mark R. Stenger

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 &khgr;2 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 &khgr;2 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.

Here comes the SSuN: early experiences with the STD surveillance network.

In 2005, the Centers for Disease Control and Prevention established the STD Surveillance Network (SSuN), a sentinel surveillance system comprising local, enhanced sexually transmitted disease (STD) surveillance systems that follow common protocols. The purpose of SSuN is to improve the capacity of national, state, and local STD programs to detect, monitor, and respond rapidly to trends in STDs through enhanced collection, reporting, analysis, visualization, and interpretation of clinical, behavioral, and geographic information obtained from a geographically diverse sample of individuals diagnosed with STDs. To demonstrate the utility of a national sentinel surveillance network, this article reviews the lessons learned from the first three years of SSuN, which, through its enhanced gonorrhea and genital warts sentinel surveillance projects, has proved to be a useful adjunct to routine STD surveillance in the U.S. that can be expanded into other areas of STD public health interest.

Practical Considerations for Matching STD and HIV Surveillance Data with Data from Other Sources

Data to guide programmatic decisions in public health are needed, but frequently epidemiologists are limited to routine case report data for notifiable conditions such as sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). However, case report data are frequently incomplete or provide limited information on comorbidity or risk factors. Supplemental data often exist but are not easily accessible, due to a variety of real and perceived obstacles. Data matching, defined as the linkage of records across two or more data sources, can be a useful method to obtain better or additional data, using existing resources. This article reviews the practical considerations for matching STD and HIV surveillance data with other data sources, including examples of how STD and HIV programs have used data matching.

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.

Trends in Neisseria gonorrhoeae incidence among HIV-negative and HIV-positive men in Washington State, 1996-2007.

Objectives. We assessed population-level trends in human immunodeficiency virus (HIV) and Neisseria gonorrhoeae co-infection among adult males in Washington State between 1996 and 2007. Methods. Population-based categorical disease surveillance registries for gonorrhea and for HIV were electronically matched and merged at the record level and incidence rates were calculated for reported HIV-positive and presumed HIV-negative men. Results. The incidence of gonorrhea infection increased significantly among both HIV-positive and presumed HIV-negative men from 1996 to 2005, and this trend has recently reversed for both groups. The annual incidence rate of gonorrhea among HIV-positive men was found to be higher in all years than among men presumed to be HIV-negative. Conclusions. Inequality in the burden of gonorrhea by HIV-infection status suggests continuing sexual risk-taking among HIV-positive men as well as possible barriers to diagnosis, treatment, and partner services. This inequality may also reflect significant differences in gonorrhea burden among men who have sex with men as well as by HIV status. Monitoring emergent secular trends in population-level HIV/sexually transmitted infection comorbidity through registry matching is an achievable strategy for developing an evidence base to inform program collaboration and service integration efforts aimed at providing more comprehensive disease prevention services.

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.

The OASIS Project: Novel Approaches to Using STD Surveillance Data

This supplemental issue of Public Health Reports presents a selection of innovative strategies designed and implemented between 1998 and 2005 to enhance the ability of public health officials to use surveillance data to monitor and respond to the epidemic of sexually transmitted diseases (STDs) in the United States. These strategies reflect the collaborative efforts of the Outcome Assessment through Systems of Integrated Surveillance (OASIS) Project workgroup, a group of public health STD epidemiologists from local and state health departments and the Centers for Disease Control and Prevention (CDC). Many of the challenges encountered in the surveillance of STDs are similar to those encountered in the surveillance and investigation of other diseases, and many of the solutions presented in this supplemental issue are generalizable to the public health practice of epidemiologists working with other diseases.

Management of Pelvic Inflammatory Disease in Selected US 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.

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