STD Surveillance Network Research Articles

Census Tract-Level Social Vulnerability and Gonorrhea Rates in Central Ohio: Results From the STD Surveillance Network, 2020-2021.

Gonorrhea remains a significant burden in central Ohio, particularly in socially disadvantaged communities. This study evaluates gonorrhea case rates and changes from 2020 to 2021, focusing on geographic patterns associated with social vulnerability. We analyzed gonorrhea case data from the Columbus STD Surveillance Network for 2020 and 2021. Cases were linked to census tracts and categorized into low (0-0.66) or high (0.67-1.0) vulnerability groups based on the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI). We mapped gonorrhea case rates per 100,000 population, stratified by SVI group, and compared changes using Jenks natural breaks to determine cutpoints. High case rates were defined as ≥605 (2020) and ≥532 (2021). A change in case rates was defined as <154 (decrease/no change) or ≥154 (increase). Demographic factors were summarized for both years. In 2020 and 2021, nearly half of high-SVI tracts had high gonorrhea rates, compared with about 4% to 7% of low-SVI tracts. Median rates in high-SVI tracts were approximately 5 times higher than in low-SVI tracts, with rates of 546 and 598 per 100,000 in 2020 and 2021, compared with 98 and 104 per 100,000, respectively. Gonorrhea rates increased in 23 (9%) of low-SVI tracts and 37 (25%) of high-SVI tracts. Demographic characteristics remained consistent between the 2 years. Gonorrhea rates increased in central Ohio between 2020 and 2021, with higher burdens in high-SVI census tracts. Understanding the dynamics of social vulnerability at the community level is crucial for targeting limited STD resources effectively.

Should We Be Testing for Mycoplasma genitalium on Initial Presentation? Trends in Persistent/Recurrent Urethritis Among Men Presenting for Care in STD Clinics, 2015-2019, STD Surveillance Network.

Mycoplasma genitalium is a major contributor to persistent/recurrent urethritis cases. However, there are limited published studies on recent trends of persistent/recurrent urethritis. A retrospective analysis was conducted of men presenting with symptomatic urethritis in 16 sexually transmitted disease (STD) clinics from 2015 to 2019. Poisson regression was used to assess trends in the annual proportions of urethritis episodes with follow-up (FU) characterized with persistent/recurrent urethritis symptoms. Results were also stratified by results of chlamydia (CT) and gonorrhea (NG) testing and treatment prescribed. There were 99,897 urethritis episodes, from 67,546 unique men. The proportion of episodes with persistent/recurrent symptomatic FU visits increased 50.8% over a 4-year period (annual percentage change [APC], 11.3%; 95% confidence interval [CI], 6.5-16.3). Similar trends were observed in nonchlamydial nongonococcal urethritis episodes (APC, 12.7%; 95% CI, 6.8-18.9) but increases among those positive for NG (APC, 12.1%; 95% CI, -2.3 to -28.5) or for CT (APC, 7.3%; 95% CI, -6.7 to 23.5) were not statistically significant. Among episodes who received azithromycin as first-line treatment, increases in the proportion of persistent/recurrent FU visits were observed (APC, 12.6%; 95% CI, 8.6-16.7). For episodes where first-line treatment was doxycycline, no significant increases were detected (APC, 4.3%; 95% CI, -0.3 to 9.2). We found an increase in the proportion of urethritis episodes with persistent or recurrent symptoms over time. Given these observed trends in episodes negative for NG or CT, an etiology not detectable by routine diagnostics was a likely factor in increased persistence, suggesting patients with urethritis may benefit from diagnostic testing for M. genitalium during an initial symptomatic presentation.

Trends in Patient's Use of Sexual Health Services During COVID-19 in a Network of STD Clinics, STD Surveillance Network, 2019 to 2021.

The initial years of the COVID-19 pandemic disrupted sexual health care clinic's services. We describe use patterns by patient characteristics, and the use of telehealth (TH) services among a network of sexually transmitted disease (STD) clinics. Data were collected using a survey to assess the impact of COVID-19 from March to December 2020 among 7 jurisdictions who contribute STD visit-level data as part of the STD Surveillance Network. As a complement to the survey, retrospective data from January 2019 to December 2021 from these 7 STD clinics in the same 7 jurisdictions were examined for monthly utilization trends by overall visits, patient characteristics, and TH visits. Survey results indicated 7 clinics prioritized patients for in-person visits and 4 jurisdictions reported urgent care centers were the most common referral location. In April 2020 (relative to April 2019) clinic visits and unique patients decreased by 68.0% and 75.8%, respectively. Telehealth were documented in 4 clinics, beginning in March 2020, peaking in December 2020, and tapering until December 2021. We observed the number of clinic visits (-12.2%) and unique patients presenting for care (-27.2%) in December 2021 had yet to return to levels to that seen in December 2019. Sexually transmitted disease clinics showed fragility and resiliency in their adjustment to the pandemic; allowing for the continuation of services. Overall patient census has been slow to return to prepandemic levels, and many patients may still not be seeking timely care. This could result in missed opportunities to screen and treat STIs and increasing the possibility of harmful sequelae.

Presumptive and Follow-Up Treatment Associated With Gonorrhea and Chlamydia Testing Episodes in Sexually Transmitted Disease Clinics: Impact of Changing Treatment Guidelines for Gonorrhea, Sexually Transmitted Disease Surveillance Network, 2015-2018.

Background Centers for Disease Control and Prevention recommendation for treatment of uncomplicated gonorrhea (NG) were revised in December 2020 and include ceftriaxone monotherapy when chlamydial infection was excluded. We evaluated the impact of these revised treatment recommendations using data from a network of sexually transmitted disease (STD) clinics before the change in guidelines. Methods We performed a cross-sectional analysis from 8 STD clinics participating in the STD Surveillance Network from January 2015 to June 2018 assessing NG/chlamydia (CT) testing episodes, nucleic acid amplification test results, CT only and NG/CT treatment records, and timing of treatment. We describe the frequency of NG and CT treatment practices and what proportion of patients treated would not have had to receive an antichlamydial agent. Results Of 190,589 episodes that occurred during the study period, 67,895 (35.6%) episodes were associated with a treatment record consistent with NG or chlamydia (CT only [n = 37,530] or NG/CT [n = 30,365]), most (~86%) were prescribed on the same-day as initial testing. Of the 67,895 episodes with corresponding treatment record(s), 42.1% were positive for either NG or CT compared with 3.7% were positive for NG or CT for those not associated with treatment records (n = 122,694 episodes). Among 30,365 episodes associated with NG/CT treatment records, monotherapy would only have been indicated for 10.1% (3081/30,365) of the episodes as they were treated on follow-up and were NG positive and CT negative. Conclusions Treatment was prescribed in one-third of NG/CT testing episodes, with the majority provided same day. Despite changes in NG treatment guidelines to ceftriaxone monotherapy, majority of patients would continue to receive an antichlamydia agent when treated for NG in these settings.

Trends in HIV prevalence by self-report among MSM diagnosed and reported with gonorrhea in six United States jurisdictions from 2010 to 2019.

HIV co-infection among persons diagnosed with gonorrhea is not well characterized. Trends in HIV prevalence among persons diagnosed with gonorrhea may have significant implications for HIV prevention interventions, especially for MSM. MSM are increasingly and disproportionately represented among incident gonorrhea cases reported in a multistate sentinel surveillance network. Using data from this network, we estimated HIV prevalence among MSM by self-report and explored trends in co-infection by key demographics. Observational study using enhanced surveillance data. Six geographically diverse jurisdictions in the STD Surveillance Network (SSuN) 2010-2019 randomly sampled laboratory-confirmed gonorrhea cases. Enhanced investigations on sampled cases included patient interviews eliciting demographic, behavioral and HIV testing history. These data were weighted to adjust for study design and nonresponse to estimate trends in HIV prevalence. Of 653 522 reported cases, 28 979 were sampled and investigated. The proportion of cases reporting living with diagnosed HIV at the time of their gonorrhea diagnosis increased 61% across the study period from 6.6% in 2010 to 10.8% in 2019. The observed increase in HIV prevalence is concurrent with an increase in the proportion of gonorrhea cases attributable to MSM. HIV prevalence among MSM decreased in two jurisdictions and increasing trends were observed among non-Hispanic Black and Hispanic MSM. HIV prevalence decreased among non-Hispanic white MSM, MSM under 20 and those 40 years of age or older. Diagnosis with gonorrhea, especially among MSM, should be a sentinel event triggering screening for HIV, referral to high-impact HIV prevention interventions or to HIV primary care.

Prevalence of Self-reported Neurologic and Ocular Symptoms in Early Syphilis Cases.

Neurosyphilis, a complication of syphilis, can occur at any stage of infection. Measuring the prevalence of neurosyphilis is challenging, and there are limited data on the prevalence of neurologic or ocular symptoms among patients with syphilis. We sought to describe the prevalence of neurologic and/or ocular symptoms among early syphilis (ES) cases and the clinical management of symptomatic cases enrolled in the STD Surveillance Network (SSuN) Neuro/Ocular Syphilis Surveillance project. Persons diagnosed with ES were selected for interviews based on current health department protocols in 5 participating SSuN jurisdictions from November 2016 through October 2017. All interviewed ES cases were screened for self-reported neurologic and/or ocular symptoms. Additional clinical information on diagnostic testing and treatment for cases concerning for neurosyphilis/ocular syphilis was obtained from providers. Among 9123 patients with ES who were interviewed, 151 (1.7%; 95% confidence interval [CI], 1.4%-1.9%) reported ≥ 1 neurologic or ocular symptom. Of the 53 (35%) who underwent lumbar puncture, 22 (42%) had documented abnormal cerebrospinal fluid, of which 21 (95%) were treated for neurosyphilis/ocular syphilis. Among the remaining 98 symptomatic patients with no documented lumbar puncture (65%), 12 (12%) were treated for and/or clinically diagnosed with neurosyphilis/ocular syphilis. We observed a low prevalence of self-reported neurologic and/or ocular symptoms in interviewed ES cases. Approximately one-third of ES cases who self-reported symptoms underwent further recommended diagnostic evaluation. Understanding barriers to appropriate clinical evaluation is important to ensuring appropriate management of patients with possible neurologic and/or ocular manifestations of syphilis.

Treatment Practices of Pelvic Inflammatory Disease at Selected STD Clinics: STD Surveillance Network, 2015–2017 [16R

INTRODUCTION: CDC recommends broad-spectrum antimicrobial therapy (ceftriaxone 250 mg and doxycycline 100 mg BID for 14 days) for women with mild to moderate acute pelvic inflammatory disease (PID). The addition of metronidazole, commonly used to treat bacterial vaginosis (BV) and trichomoniasis, can be considered. We assessed PID treatment practices in STD clinic settings. METHODS: We conducted a cross-sectional analysis of women diagnosed with PID from 2015-2017 in 26 U.S. STD clinics. For each PID episode, we reviewed treatment information within 14 days of the visit where PID was diagnosed, stratified by concomitant diagnosis of BV and/or trichomoniasis. RESULTS: A total of 1,032 PID episodes were identified over 3 years. Treatment was documented in 941 (91.2%) episodes. Of these 941 episodes, concomitant BV and/or trichomoniasis was identified in 40.0% (377/941) of episodes (31.9% BV only, 5.2% trichomoniasis only, and 3.0% both BV and trichomoniasis). CDC recommended therapy was documented for 66.7% of all PID episodes; an additional 25.7% received ceftriaxone with dosing for doxycycline <14 days. Metronidazole, in combination with PID treatment, was documented in 52.5% of episodes. Metronidazole was more frequently included in episodes associated with BV and/or trichomoniasis (72% [271/377]) compared to those without these diagnoses (39% [220/564]). CONCLUSION: Over 90% of patients diagnosed with PID in selected STD clinics were treated with the recommended ceftriaxone; however, over a quarter did not receive the recommended dose of doxycycline. Metronidazole was provided in about half of PID episodes and was more likely to be included with concurrent BV and/or trichomoniasis.

Trends in the Prevalence of Anogenital Warts Among Patients at Sexually Transmitted Disease Clinics-Sexually Transmitted Disease Surveillance Network, United States, 2010-2016.

Approximately 90% of genital warts are caused by human papillomavirus (HPV) types 6 and 11. In the United States, HPV vaccination has been recommended for girls and women aged ≤26 years, and since 2011, for boys and men aged ≤21 years and for gay, bisexual, and other men who have sex with men (MSM) aged ≤26 years. Data were obtained from 27 clinics participating in the STD Surveillance Network. Trends in the annual prevalence of anogenital warts (AGW) from 2010-2016 were described by sex and by the sex of sex partners. During 2010-2016, significant declines in the prevalence of AGW were observed in women aged <40 years, men who have sex with women only (MSW) aged <40 years, and MSM of all age categories. An inflection in trend in 2012 was noted for MSW aged 20-24 or 25-29 years and for MSM aged 20-24 years. The observed declines in the prevalence of AGW suggest that HPV morbidity is declining among populations attending STD clinics, including MSW, MSM, and women. Declines in younger age groups are consistent with what would be expected following the implementation of HPV vaccination. However, declines were also observed in older age groups and are not likely to be the result of vaccination.

New Human Immunodeficiency Virus Diagnoses Among Men Who Have Sex With Men Attending Sexually Transmitted Disease Clinics, STD Surveillance Network, January 2010 to June 2013.

Retrospective analysis using 2010 to 2013 data from the STD Surveillance Network (SSuN), a sentinel surveillance system comprised of health departments in 12 cities conducting sentinel surveillance in 40 STD clinics. We analyzed data from all MSM repeatedly (≥2 times) tested for HIV, with an initial negative HIV test required for staggered cohort entry. Follow-up time was accrued from the date of the first negative HIV test to the most recent negative test or the first positive HIV test. The STD diagnoses during the follow-up period were reviewed. We estimated HIV diagnoses rates (number of HIV diagnoses/total number of person-years [PY] at risk) by demographic and clinical characteristics with 95% confidence intervals (CI) using an inverse variance weighted random effects model, adjusting for heterogeneity between SSuN jurisdictions. Overall, 640 HIV diagnoses occurred among 14,824 individuals and 20,951.6 PY of observation, for an adjusted incidence of HIV diagnosis of 3.0 per 100 PY (95% CI, 2.6-3.4). Rates varied across race/ethnicity groups with the highest rate among Blacks (4.7/100 PY; 95% CI, 4.1-5.3) followed by Hispanics, whites, and persons of other races/ethnicities. Men who have sex with men having a diagnosis of primary or secondary (P&S) syphilis on or after the first negative HIV test had a higher new HIV diagnosis rate (7.2/100 PY; 95% CI, 5.8-9.0) compared with MSM who did not have a P&S syphilis diagnosis (2.8/100 PY; 95% CI, 2.6-3.1). Men who have sex with men who tested positive for rectal gonorrhea (6.3/100 PY; 95% CI, 5.7-6.9) or rectal chlamydia (5.6/100 PY; 95% CI, 4.6-6.6) had higher rates of new HIV diagnosis when compared to those with negative test results. Men who have sex with men attending SSuN STD clinics have high rates of new HIV diagnoses, particularly those with a previous diagnosis of P&S syphilis, rectal chlamydia, and/or gonorrhea. Sexually transmitted disease clinics continue to be important clinical setting for diagnosing HIV among MSM populations.

Prescription of Preexposure Prophylaxis to Men Who Have Sex With Men Diagnosed and Reported With Gonorrhea, STD Surveillance Network, 2016.

Using a representative sample of gonorrhea cases in select jurisdictions, we estimated the proportion of eligible men who have sex with men reporting being prescribed preexposure prophylaxis (PrEP) to prevent HIV infection. In 2016, half (51.3%) of the estimated 33,165 eligible men who have sex with men reported being prescribed PrEP by their health care provider.

4 - The prevalence of positive anorectal gonorrhea and Chlamydia NAAT testing on routine screening for all high resolution anoscopy performed at a community health center

Background Our community-based clinic decided to implement routine screening for anorectal Gonorrhea (GC) and Chlamydia (CT) for patients undergoing HRA for anal cancer prevention, due to high risk for asymptomatic GC and CT among our patient population (predominantly HIV+ MSM in NYC) and the impact undiagnosed GC/CT infection may have on recovery after biopsy or ablation of HPV-related lesions. In 2016, the CDC reported a prevalence of anorectal GC and CT of 0.146% and 0.497% in the general population nationally, and 12.1% and 12.7% in MSM in NYC clinics in the STD Surveillance Network. Methods Retrospective chart review for all HRA completed in 2017 using associated CPT and testing codes. Results 839 HRA procedures were done in 2017. Of the anorectal NAATs performed, 6.6% were positive for either GC and/or CT (4% for GC and 3% for CT). Conclusions Implementing routine screening for anorectal GC/CT at every HRA for HPV-related disease revealed a prevalence of concurrent anorectal GC and/or CT infection well above national prevalence for the general population, though at a lower rate than anorectal GC/CT among MSM seeking screening or treatment in NYC DOH clinics. We were unable to make conclusions about how treating these incidental infections impacted recovery after the procedure, as this was outside the scope of this limited chart review. But the prevalence of GC/CT infection discovered in this analysis supports the importance of adding routine GC/CT screening for all patients undergoing HRA for the diagnosis or treatment of HPV-related anal neoplasia.

Electronic case reporting of STIs: Are non-existent codes the reason for missing information?

Objective: Previous research identified data gaps between traditional paper-based STI notifiable condition reporting and pilot electronic initial case reporting (eICR) relying on Continuity of Care Documents (CCDs) exported from our clinical partner’s electronic health record (EHR) software.1 Structured data capture is needed for automatic processing of eICR data imported into public health repositories and surveillance systems, similar to electronic laboratory reporting (ELR). Coding data gaps (between paper and electronic case reports) using standardized vocabularies will allow integration of additional questions into EHR or other data collection systems and may allow creation of standard Clinical Data Architecture (CDA) templates, Logical Observation Identifiers Names and Codes (LOINC) panels, or Fast Healthcare Interoperability Resources (FHIR) resources. Furthermore, identifying data gaps can inform improvements to other standards including nationwide standardization efforts for notifiable conditions.Introduction: Under the CDC STD Surveillance Network (SSuN) Part B grant, WA DOH is testing eICR of sexually transmitted infections (STI) with a clinical partner. Existing standard vocabulary codes were identified to represent previously-identified information gaps, or the need for new codes or concepts was identified.Methods: In prior work, CCDs were securely received from our clinical partner and then analyzed for gaps compared to the existing paper-based STI case reporting form.1 Now, codes associated with gap concepts were identified in standard vocabularies such as LOINC and SNOMED CT. Standards were searched using online browsers offered by the standards development organizations (SDO) to identify potential codes, which were reviewed with public health epidemiologists and clinicians. Gaps were listed, and wording and intent was compared to standard codes including accessory information found in the SDO browsers and a final table of recommended codes was produced.Results: Acceptable congruity between currently used case reporting questions and coded vocabularies was found for the majority of data gaps previously identified. Where data need was incongruous with standard coded vocabularies, new codes or concepts could be proposed to the SDO.Pregnancy status is often missing from CDA documents but is well-conceptualized in both LOINC and SNOMED CT systems under several codes, including any current laboratory tests for pregnancy. HIV status is similarly well-conceptualized in both LOINC and SNOMED CT both as a problem list item well as thru a variety of laboratory tests. However, problem list EHR models lack standard inclusion of date of last HIV test or dates of current pregnancy as an associated coded data element which is desirable for public health.Information about the case patient’s sexual partners, need for partner STI treatment, and partner treatment completed is lacking in standard CCD documents.1 Number of current sexual partners [requiring treatment] – has a SNOMED-CT code, but lacks a match in LOINC coding system. This gap identified the need for exploration of how information about sexual partners can best be represented in interoperability artifacts, including the most useful division of information content between the information model and the standard terminology. Needed concept could resemble ‘record target’ found in HL7 version 3.0 and would allow data to be provided without specifying additional codes. Exploration of information model options or new codes is recommended.Many codes are possible for site of infection and specific symptoms but the overall concepts of ‘symptomatic infection’ and ‘site of infection’ as coded elements would need to be added.Conclusions: This coded element gap analysis found that most information requested in an STI case report can be found in a CCD. Gaps can be addressed by using existing standard terms except for concepts about sexual partners that might be better addressed by exploring the information model rather than through the addition of standard codes. Standards use will facilitate complete case reporting using CDA or FIHR, for example, within a ‘blue button’ or other system with functionality for exchanging additional information about notifiable condition case patients. Collaboration with clinicians, public health practitioners, informaticians, and EHR vendors in will help determine how these concepts might best be modeled. Understanding data gaps involves working closely with a broad range of stakeholders, to understand why gaps exist and how well proposed solutions will meet stakeholder needs.

Adherence to CDC Recommendations for the Treatment of Uncomplicated Gonorrhea - STD Surveillance Network, United States, 2016.

Gonorrhea, the sexually transmitted disease (STD) caused by Neisseria gonorrhoeae, is the second most common notifiable disease in the United States after chlamydia; 468,514 cases were reported to state and local health departments in 2016, an increase of 18.5% from 2015 (1). N. gonorrhoeae has progressively developed resistance to most antimicrobials used to treat the infection (2). As a result, CDC recommends two antimicrobials (250 mg of ceftriaxone [IM] plus 1 g of azithromycin [PO]) for treating uncomplicated gonorrhea to improve treatment efficacy and, potentially, to slow the emergence and spread of antimicrobial resistance. To monitor adherence to the current CDC-recommended regimen for uncomplicated gonorrhea, CDC reviewed enhanced data collected on a random sample of reported cases of gonorrhea in seven jurisdictions participating in the STD Surveillance Network (SSuN) and estimated the proportion of patients who received the CDC-recommended regimen for uncomplicated gonorrhea, by patient characteristics and diagnosing facility type. In 2016, the majority of reported patients with gonorrhea (81%) received the recommended regimen. There were no differences in the proportion of patients receiving the recommended regimen by age or race/ethnicity; however, patients diagnosed with gonorrhea in STD (91%) or family planning/reproductive health (94%) clinics were more likely to receive this regimen than were patients diagnosed in other provider settings (80%). These data document high provider adherence to CDC gonorrhea treatment recommendations in specialty STD clinics, indicating high quality of care provided in those settings. Local and state health departments should monitor adherence with recommendations in their jurisdictions and consider implementing interventions to improve provider and patient compliance with gonorrhea treatment recommendations where indicated.

Narrative Review: Assessment of Neisseria gonorrhoeae Infections Among Men Who Have Sex With Men in National and Sentinel Surveillance Systems in the United States.

To assess trends in Neisseria gonorrhoeae among gay, bisexual, and other men who have sex with men (MSM), we reviewed existing and published gonorrhea surveillance data in the United States. Data identified in this review include the following: national gonorrhea case report data and data from 3 other surveillance programs, the Gonococcal Isolate Surveillance Project (GISP), the STD Surveillance Network (SSuN), and National HIV Behavioral Surveillance.Rates of reported cases of gonorrhea among men increased 54.8% in 2006 to 2015 compared with a 2.6% increase among women. Since 2012, the rate of reported gonorrhea cases among men surpassed the rate among women; the male-to-female case rate ratio increased from 0.97 in 2012 to 1.31 in 2015. The proportion of gonococcal urethral isolates collected in the Gonococcal Isolate Surveillance Project that were collected from MSM increased from 21.5% to 38.1% in 2006 to 2015. In 2009 to 2015, the percent of MSM who tested positive for rectal and oropharyngeal gonorrhea in sexually transmitted disease (STD) clinics increased by 73.4% and 12.6%, respectively. Estimated rates of gonorrhea among MSM increased by 151% in 2010 to 2015 in jurisdictions participating in the STD Surveillance Network. Data from the National HIV Behavioral Surveillance demonstrate that testing for gonorrhea among MSM increased by 23.1% between 2011 and 2014.Together, surveillance data suggest a disproportionate burden of gonorrhea among MSM in the United States and suggest increases in both screening and disease in recent years. Because each data source has inherent limitations and biases, examining these data from different systems together strengthens this conclusion.

How Good Is Your Rule of Thumb? Validating Male-to-Female Case Ratio as a Proxy for Men Who Have Sex With Men Involvement in N. gonorrhoeae Incidence at the County Level.

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. 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. 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). 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.

Increases in the Rate of Neisseria gonorrhoeae Among Gay, Bisexual and Other Men Who Have Sex With Men-Findings From the Sexually Transmitted Disease Surveillance Network 2010-2015.

Inequalities in Neisseria gonorrhoeae (gonorrhea) burden by sexual minority status in the United States are difficult to quantify. Sex of sex partner is not routinely collected for reported cases. Population estimates of men who have sex with men (MSM) necessary to calculate case rates have not been available until recently. For these reasons, trends in reported gonorrhea rates among MSM have not been described across multiple jurisdictions. We estimated of the number of MSM cases reported in 6 jurisdictions continuously participating in the STD Surveillance Network 2010-2015 based on interviews with a random sample of cases. Data were obtained for Baltimore, Philadelphia, New York City, San Francisco, California (excluding San Francisco), and Washington State. Estimates of the MSM, heterosexual male (MSW) and female populations were obtained from recently published estimates and census data. Case rates and rate-ratios were calculated comparing trends in reported cases among MSM, heterosexual males and women. The proportion of male gonorrhea cases among MSM varied by jurisdiction (range: 20% to 98%). Estimated MSM rate increased from 1369 cases per 100,000 in 2010 to 3435 cases per 100,000 in 2015. Between 2010 and 2015, the MSM-to-Women gonorrhea rate ratio increased from 13:1 to 24:1, and the MSM-to-MSW gonorrhea rate ratio increased from 16:1 to 31:1. Estimated gonorrhea rate among MSM increased in a network of 6 geographically diverse US jurisdictions. Estimating the size of this population, determining MSM among reported cases and estimating rates are essential first steps for better understanding the changing epidemiology of gonorrhea.

Electronic Case Reporting of STIs: Assessing EHR Generated CCDs

ObjectiveWe reviewed CCDs (a type of consolidated clinical dataarchitecture (C-CDA) document) shared by our clinical partner,Planned Parenthood of the Great Northwest and Hawaiian Islands(PPGNHI) since October, 2015. Analyses focuses on:-Completeness-Degree to which the CCD matches program area informationneeds-Differences in EHR generation methods-Presence and location of triggers (based on the ReportableConditions Trigger Codes) that would initiate CCD generation.IntroductionUnder the CDC STD Surveillance Network (SSuN) Part B grant,WA DOH is testing electronic case reporting (eCR) of sexuallytransmitted infections (STI) from a clinical partner.MethodsTwo methods of CCD generation, based on existing EHRcapabilities, were used to create CCDs that were delivered to WADOH using secure file transport protocol (SFTP). PPGNHI uses theNextGen EHR system.The first batch received was extracted using the Medical SummaryUtility. Random selection of cases (25) from lab positive Chlamydia(CT), Gonorrhea (GC) or Syphilis encounters with a follow-up planin the EHR (1/1/2015-3/31/2015). Each CCD contained manuallyselected encounters (related to STI case).Cases are now extracted directly from a patient chart(File--&gt;Generate CCD). Two types of CCDs can be created: singleencounter CCDs and longitudinal encounter CCDs.The CCDs were analyzed for completeness, crossover with theexisting paper case report, and with relevant CDA and C-CDAImplementation Guide (IG) standards.ResultsThis analysis includes four reportable events across 6 CCDs.One event is represented by both a longitudinal CCD and 2 singleencounter CCDs.The CCDs contained most of the basic demographic informationrequested in the paper case report with the exception of “middleinitial”.Information on the important paper case report components“gender of sex partner” and “partner management plan” are not foundin the CCD.The CCD Results section contained lab tests and results that includesite of infection and could confirm diagnosis. The ordered test (panel)is not coded, though the individual tests performed are LOINC coded.The CCD Medications section meets STI program needs forinformation about treatment in a case report. Information isrepresented using RxNorm codes as specified by the C-CDA IG.The CCD Problems section was not present in documents generatedusing the MSU but was present in documents created using File --&gt;Generate CCD from the patient chart. The Problems section andcoded entries (ICD-9-CM and ICD-10) are required for CCDs. TheProblems do not include effective dates, which are not required bythe IG.Pregnancy status, and information about HIV testing (includingprevious positive), are present in the CCD Problems section only ifthe encounter during which testing occurred is included in the CCDsubmitted.Using the CCD in place of the paper case report requiresunderstanding of the clinical workflow and use of EHR. Twoinstances that require specific attention are the “exposure” status ofthe case (known/possibly exposed vs. not shared/not known), andthe “presentation” of the diagnosis (symptomatic vs asymptomatic).For example, the ICD-10 code Z11.3 (encounter for screening forinfections with a predominantly sexual mode of transmission), cannotbe interpreted as a true “screening”, as this diagnosis is recorded forall visits that include STI testing. Similarly, a code for exposureto STIs is sometimes used, but not consistently enough to allowreliable identification of cases in which the patient was tested due toan exposure or possible exposure. Work with our clinical partner tounderstand what inferences can and should be made is an importantpart of evaluating the CCD as a replacement to the paper case report.ConclusionsThe CCDs submitted to DOH show that most information requestedin an STI case report can be found in a CCD with some exceptions,notably “gender of sex partners” and “partner management plan”.Some information is only inconsistently present, for example,exposure status and presentation.Understanding how the CCD could replace the paper case reportrequires working with the reporter to insure that the information isinterpreted on the receiving end in the same way that it is interpretedin the clinical workflow and entered in the EHR.

P11.16 Denominators matter: trends inneisseria gonorrhoeaeincidence among gay, bisexual and other men who have sex with men (gbmsm) in the us – findings from the std surveillance network (ssun) 2010–2013

Introduction Inequalities in Neisseria gonorrhoeae burden by sexual minority status have been observed in the United States but are difficult to characterise. GBMSM status of gonorrhoea cases is not routinely collected for reported cases and GBMSM population estimates at the level of geography necessary to most usefully inform public health responses are not readily available. Incidence trends and inequalities among GBMSM have not been described across multiple jurisdictions. Methods A random sample of reported gonorrhoea cases was interviewed and weighted to estimate GBMSM status of all cases reported in 12 geographically disparate states and/or cities collaborating in SSuN. Census and Gallup opinion polling data were used to estimate size of GBMSM, heterosexual male and female populations by age group at the state, county and city level for 2010–2013. Incidence rates and rate-ratios were calculated comparing incidence trends among GBMSM, heterosexual males and females. Results The estimated size of GBMSM population varied across SSuN jurisdictions from 2.8% of males in Alabama to 15.4% in San Francisco. The proportion of male gonorrhoea cases attributable to GBMSM also varied by jurisdiction (range: 13.6% to 92.4%). GBMSM incidence increased in SSuN sites from 1,169.7 cases per 100,000 in 2010 to 1,474.4 in 2013, increased modestly among heterosexual men and remained stable among females at 106 cases per 100,000. The rate-ratio of GBMSM to females and to heterosexual men during the study period ranged from 10.7 to 13.9. The highest incidence among GBMSM across all sites was observed for those aged 25–29 years with estimated annual incidence exceeding 3,400 cases per 100,000 across the study period. Conclusion Gonorrhoea incidence among GBMSM is increasing in a sentinel network of US jurisdictions. Estimates of the size of this population and ascertainment of GBMSM status for reported cases are essential first steps for better understanding the changing epidemiology of gonorrhoea. Disclosure of interest statement The STD Surveillance Network (SSuN) is funded by the US Centres for Disease Control and Prevention (CDC). No pharmaceutical grants were received in the development of this study.

Management of Pelvic Inflammatory Disease in Selected U.S. Sexually Transmitted Disease Clinics: Sexually Transmitted Disease Surveillance Network, January 2010-December 2011.

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. 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. 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. 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.

Meeting sex partners through the Internet, risky sexual behavior, and HIV testing among sexually transmitted infections clinic patients.

The Internet has now become a popular venue to meet sex partners. People who use the Internet to meet sex partners may be at a higher risk for contracting HIV and STIs. This study examined the association between meeting sex partners from the Internet, and HIV testing, STI history, and risky sexual behavior. Data were obtained from the Virginia Department of Health STD Surveillance Network. Logistic regression models were used to obtain crude and adjusted odds ratios, and 95% confidence intervals for the associations between meeting sex partners through the Internet and ever tested for HIV, HIV testing in the past 12months, STI history, and risky sexual behavior. Logistic regression was also used to determine if gender and men who have sex with men interaction terms significantly improved the model. Women who met a sex partner from the Internet were more likely to have had an HIV test in the past 12months than women who did not meet a partner in this way. On the other hand, men who met a sex partner through the Internet were more likely to have ever had an HIV test than other men, but this was only seen for heterosexual men. All populations who met a sex partner from the Internet were more likely to take part in risky sexual behavior. HIV prevention strategies should emphasize annual testing for all populations.