1. Chief, Program and Training Branch Division of STD Prevention
Gonorrhea Prevention: Optimizing Strategies to Reduce Health Disparities
Kevin O’Connor, M.A.
Chief, Program and Training Branch
Division of STD Prevention
Virginia DIS Training
September 12,
National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention
Division of STD Prevention

2. Epidemiology 101
I’m not an epidemiologist….

3. Overview of Discussion
Why talk about gonorrhea now?
Epidemiologic trends
Health disparities
Drug resistant gonorrhea
Regional discussions on GC
GC Prevention Activities
Surveillance
Targeted Screening - public and private
Partner Services (multiple strategies)
Health promotion/risk reduction
The right strategies for your area?

4. Gonorrhea Overview Second most commonly reported STD
Profound health disparities among African Americans
Caused by a bacterium Neisseria gonorrhoeae
Asymptomatic in most women and some men
Symptoms: discharge from vagina or penis; and pain on urination. Most men have symptoms
Complications: infertility, chronic pelvic pain, ectopic pregnancy
If exposed, increased risk of HIV acquisition
Easily treated with antibiotics?

5. Why talk about Gonorrhea now?

6. HEADLINES YOU’LL NEVER SEE:
Bono Responds to Gonorrhea Outbreak

7. President Obama signs Gonorrhea Elimination Bill

8. Why talk about Gonorrhea now?
- Profound health disparities Antibiotic Resistance - Loss of fluoroquinolones and eventual emergence of cephalosporin-resistant GC Opportunity for success? GC identifies populations with multiple risks - learn from our historic successes achieving success might not be that difficult

9. Epidemiologic Trends

10. Gonorrhea—Rates, United States, 1941–2009
Rate (per 100,000 population)
2006
2001
1996
1991
1986
1981
1976
1971
1966
1961
1956
1951
1946
1941
100
200
300
400
500
Year

11. Gonorrhea case rates by sex, 1990–2010*
* 2010 data are preliminary.

12. Status Quo 1000 new infections per day ~ 300,000 cases/year
Morbidity has been basically level since 2004, and with current resources, we expect this to continue as the best case scenario.
Current infections lead to new infections, we have to decrease the level of current infection in the state.
We must remove more infections from the bucket each day than go in. Additional resources will allow us to increase the flow out of the “bucket”. Each proposed initiative will “poke a hole” in the bottom of the bucket to lower the level of annual infections.
~ 300,000 cases/year
removing 1000 infections per day

13. Gonorrhea—Rates by State, United States and Outlying Areas, 2009
34.9
29.4
63.2
66.4
8.3
144.3
Puerto Rico
5.8
Guam
33.5
23.5
10.9
87.2
81.4
185.7
120.4
7.2
12.5
54.5
13.9
42.8
77.2
44.1
92.4
246.4
160.8
141.3
113.9
150.4
100.3
139.2
147.0
107.2
127.5
109.8
128.3
204.0
156.2
154.7
89.6
26.2
57.2
50.0
55.2
89.4
<19.0
(n = 8)
Rate per 100,000
population
19.1–100.0
(n = 24)
>100.0
(n = 22)
49.0
Virgin
Islands
104.7 VT NH MA RI CT NJ DE MD DC
8.0
8.6
30.4
30.6
73.1
54.8
111.2
113.5
432.7
NOTE: The total rate of gonorrhea for the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) was 97.8 per 100,000 population.

14. Gonorrhea—Rates by County, United States, 2009
<19.0
(n = 1,405)
Rate per 100,000
population
19.1–100.0
(n = 1,129)
>100.0
(n = 607)

15. Gonorrhea— Rates by County, Virginia, 2009

16. Gonorrhea— Cases by County, Virginia, 2009

17. Gonorrhea—Rates by Age and Sex, United States, 2009
750
600
450
300
150
10–14
15–19
20–24
25–29
30–34
35–39
40–44
45–54
55–64
65+
Total
5.0
250.0
407.5
238.9
145.0
85.6
60.8
33.6
92.2
2.7
11.4
25.3
568.8
555.3
229.4
106.2
47.6
22.9
8.7
105.7
0.5
2.1
Men
Women
Rate (per 100,000 population)
Age

18. Gonorrhea—Rates by Race/Ethnicity, United States, 2000–2009
100
200
300
400
500
600
700
800
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Whites
Hispanics
Blacks
Asians/Pacific Islanders
American Indians/Alaska Natives
Rate (per 100,000 population)
Year

19. Gonorrhea—Positivity Among Women Aged 15–24 Years Tested in Family Planning Clinics, by State, Infertility Prevention Project, United States and Outlying Areas, 2009
1.0
3.4
1.1
0.2
Puerto Rico
0.1
Virgin
Islands
2.0
0.0
0.5
0.8
0.3
1.6
0.4
2.7
2.4
1.8
1.2
1.4
0.6
2.1
1.9 *
(n = 4)
Positivity (%)
<1.0
(n = 24)
1.0–1.9
(n = 16)
>2.0
(n = 9) VT NH MA RI CT NJ DE MD DC
1.3
2.5
* States/areas not meeting minimum inclusion criteria.
NOTE: Includes states and outlying areas that reported positivity data on at least 500 women aged 15–24 years who were screened during 2009.

20. Slide 2: Rates of Diagnoses of HIV Infection, 2009 - 40 States and 5 U
Slide 2: Rates of Diagnoses of HIV Infection, States and 5 U.S. Dependent Areas
In 2009, in the 40 states and 5 U.S. dependent areas with confidential name-based HIV infection reporting since at least January 2006, the estimated rate of diagnoses of HIV infection was 17.4 per 100,000 population. The estimated rates of diagnoses of HIV infection ranged from 0.0 per 100,000 in American Samoa and the Northern Mariana Islands to 33.0 per 100,000 in Florida.

22. After Cephalosporins: What Next?
Penicillin (in increasing doses) gone
Tetracyclines gone
Spectinomycin gone
Fluoroquinolones gone
Oral cephalosporins going?
Injectable cephalosporins (Ceftriaxone)

23. Searching for new Treatment Options

24. Reported gonorrhea and chlamydia test volume
Reported gonorrhea and chlamydia test volume*: Infertility Prevention Project, U.S., 2000–2010
We hypothesize that part of this increase in gonorrhea test volume may be the result of increased use of dual NAAT tests.
*Total number of valid tests (positive and negative)

25. Reported number of tests* (IPP), by year
*Gonorrhea and chlamydia; positive and negative results only.

26. What’s going on with testing and screening in the private sector???

27. MMWR, April 17, (14);
Percentage of sexually active female enrollees aged 16−25 years* who were screened for Chlamydia trachomatis infection, by health plan type and year - Healthcare Effectiveness Data and Information Set, United States,
* years during

28. Gonorrhea positivity, women 15-24, family planning clinics, by race, Washington State IPP, 2007*
Whites
Black
All
0.4% (28,710)
4.0% (3,052)
15-17
18-21
22-24
0.5%
0.4%
0.3%
5.3%
4.2%
2.4%
New Partner
Yes No
0.8% (4,005)
0.3% (23,313)
6.1% (430)
2.7% (2,393)
*Data Source: Center for Health Training, Seattle WA

29. SSuN Population-based Gonorrhea Surveillance – Reported Risks over 3 Months by Gonorrhea Patients
MSM
MSW
Women
Anonymous sex partner
37.9%
17.9%
11.1%
Met sex partner through Internet
48.6%
2.5%
2.2%
Incarceration of patient or partner
4.1%
14.7%
17.7%
How sure are you that this partner got treated? “Sure”
49.2%
48.8%
50.8%

30. “Heterosexual men and women with GC tend to be younger and African American, and to have minimal risk behaviors other than more than one partner. In contrast, MSM with GC reported a greater number of sex partners, more sex with anonymous partners, more sex with partners met on the internet, and more frequent drug use. Such data suggest two markedly different GC epidemics among heterosexuals and MSM.”
Rietmeijer, et al, ‘Here Comes the Ssun’; PH Reports 2009 Supp. 2.; V. 124

31. National Gonorrhea Control Program
Implemented in 1972
Federal funding to state and local agencies
Establish screening programs for the detection of gonorrhea in asymptomatic women
Screening facilities included public and private agencies
Partner services

32. Gonorrhea—Rates, United States, 1941–2009
Rate (per 100,000 population)
2006
2001
1996
1991
1986
1981
1976
1971
1966
1961
1956
1951
1946
1941
100
200
300
400
500
Year
I = Historic Gonorrhea Screening Program

33. National Gonorrhea Control Program
1973
Female Screening VD clinic
Screening/testing 4,356, ,922 GC ,387 (3%) 109,889 (19%)
Partner Services 3 mos. Annual est.
Interviews , ~259,000
(3 mos. only: April – June 1973)
Contacts ,439 ( CI ) Ct. examined ,409 (~2/3)
Infected/treated ,928 (.40) ~64,000
Epi Rx ,063

34. Historic GC Control Program Case Finding July 1972 – June 1973
STD
Clinic
Targeted
Screening
Partner
Services
110,000*
females
~ 13 %
64,000
~ 7 %
132,000
females
~ 15%
842,000
Cases reported in 1973
Consider the contribution of the various program elements to overall morbidity in 1973.
Consider too that increasing case finding in one area might be more costly than case finding in another. Add to that the variable of the likelihood of finding a case with a particular intervention. (e.g. with PS ~40% of new contacts are infected but what does it cost to find that case? Can you achieve the same results with less effort?)
* Includes GC contacts

36. What SHOULD we be doing about GC NOW?
Despite this nice outline. It’s not always that easy to spell out what your miracles are and make them happen. but we can have an approach of how to get from here to there. I am going to walk you through this framework as one way to approach the problem.

38. GC Regional Meetings Smaller meeting → more discussion
Learn from peers
Emphasize epi & program improvement
Accommodate regional similarities
Outcome: short-term Action Plans

39. Gonorrhea Control: Optimizing Strategies to Reduce Morbidity
1-day meetings held in each of the 10 HHS regions during 2009/2010

40. Public Health Service Regions

41. Gonorrhea Prevention and Control Strategies

43. What Guides the Level of Infection in a Community?
Anderson and May postulated that an STD will continue to spread in a community if the average probability of transmission per sex partner contact (times) the average duration of infection (times) the average number of sex partners per unit of time is greater than one.
R0 = (ß x D x C)
R0 -Average number of secondary cases generated in a population by a primary case
ß - Average probability of transmission per sexual contact
D – Average duration of infectiousness
C - Average number of sexual partners per unit time
Understanding transmission dynamics provides a template for design, implementation and evaluation of interventions
Ro = average # of secondary cases generated from a new infection
= the net rate at which transmission occurs within a defined population
if >1, then disease continues to spread
B = average probability of transmission per sexual contact
GC = 50%, CT= 20%, Syp = 60%, HIV = 5%
D = Average duration of infectiousness of an infected person in years
GC = .5 yrs., CT = 1.0 years; Syp. = 0.6 years, HIV = 8-12 years
C = average rate of exposure of susceptible to infected per in a population
STD prevention = identify the most cost-effective ways to decrease transmission by influencing one or more of these transmission dynamics
Source: STDs, Holmes et. al. , 3rd Ed., 1999 Chapter 3. Roy M. Anderson

44. 2001 CDC Consultation on Gonorrhea
Recommendations for Programs
Screening
Partner services
Access to care
To view the Consultation report see resources at the ‘GC Control’ group at

45. Key Health Care Providers
Key Strategies:
Surveillance
Screening
Treatment
Partner Services
Primary Prevention/risk reduction
Community Engagement
Key Health Care Providers
From that process we identified Five key strategies. These look very familiar to all of us because they are based on collective experience and knowledge gained over time from STD programs.
Testing and screening
Timely and appropriate therapy
Partner therapy and risk reduction
Community engagement
Surveillance and program evaluation
Next had to think about what key things need to happen to make these strategies a success, so let’s look at them individually and tehn we will go back and see how they might all fit together 45 45

46. Surveillance

47. Gonorrhea—Rates by County, United States, 2009
<19.0
(n = 1,405)
Rate per 100,000
population
19.1–100.0
(n = 1,129)
>100.0
(n = 607)

48. Gonorrhea Rates among African Americans – Continental United States, 2008

49. Gonorrhea Cases by WI County
2008
1-100
>1000
Wisconsin:
72 Counties
Douglas 26
Bayfield
Ashland
Washburn 2
Sawyer 1
Iron
Vilas 4
Burnett 3
Price
Oneida 3
Florence
Polk 4
Barron
Rusk 1
Marinette 8
Forest 2
Lincoln 3
Taylor
Langlade 1
Oconto 6
St. Croix 9
Dunn 5
Chippewa 3
Clark
Marathon 26
Menominee 3
Pierce 1
Eau Claire 10
Shawano 6
2 Door
Pepin
Waupaca 2
Buffalo
Wood 6
Portage 5
Kewaunee 4
Outagamie 67
Brown
294
Jackson 3 1
Trempealeau
6,062 = Total Cases
Juneau 7
Waushara 4
Winnebago 73
Manitowoc 12
Monroe 16
Calumet 11
LaCrosse 35
Adams 2
Marquette 1 1
Green Lake
Fond du Lac 44
Sheboygan 20
Vernon
Richland 1
Sauk 14
Columbia 14
Dodge 36
Ozaukee 19
Crawford 1 21
Washington
Dane
453
Milwaukee --- 4,063
Iowa 2
Jefferson 18
Waukesha 81
Grant 7
LaFayette 1
Green 3
Rock
134
Walworth 15
Racine – 277
Kenosha

50. Milwaukee City Zip Code Areas
These 12 zip codes represent 57%
of all the gonorrhea reported
in Wisconsin in 2008.
Out of 4,032 cases reported from Milwaukee County in 2008
3,443 were reported from
the 12 zip codes in the
City of Milwaukee
noted in the table –
this represents 85.4% of the
reported cases in
Milwaukee County.
(12/43 Zip Code areas in Milwaukee City)
Zip Codes with Over 100
Reported Cases of GC in 2008:
Zip Code – Number of Cases
53206 – 548
53209 – 402
53210 – 400
53212 – 390
53218 – 376
53216 – 333
53208 – 312
53225 – 175
53205 – 149
53204 – 127
53224 – 116
53233 – 115

53. Pennsylvania

56. Targeted Screening

57. PRIORITIZATION PROCESS

58. Philadelphia

59. Top ZIP codes by Case Counts:
19143: 454 cases
19121: 306 cases
19132: 297 cases
19139: 286 cases (Rate: 542.9/100,000)
19140: 277 cases (Rate: 447.9/100,000)
Top ZIP codes by Rate:
19121: 815.8/100,000
19138: 814.2/100,000 (161 cases)
19132: 779.2/100,000
19143: 693.6/100,000
19123: 598.9/100,000 (56 cases)

61. Wisconsin

62. Milwaukee School Based Clinics Update 2010
Testing in 15 SBC began Jan 2009
Low volume of testing/positivity at first
Volume and positivity picking up
Higher-risk kids more comfortable with health center presence? Staff efforts?
# Tested
#/% Pos CT
#/%Pos GC
1-2 Q ‘09
107
10/ 9.3%
0/0%
3-4 Q ‘09
169
24/14.2%
6/3.5%
1-2Q ’10*
185
38/20.5%
10/5.4%

63. GC Action Plans
Illinois: Maintain high quality systems already in place.
Review data: lab corps, IPP, FQHCs, WIC, state lab and push for greater HEDIS compliance.
Indiana: Evaluate data and concentrate on counties to focus efforts
Michigan: Promote HEDIS measure compliance, esp. in HMAs
Kentucky: Engage in a closer examination of our data. Examine screening coverage among sites we have some influence over in target area
Massachusetts: Zip code analysis of GC rates in Springfield, Boston and Brockton.

64. Michigan Identified Need – Public Sector
The plan will meet identified need in the public sector – in local health departments and clinics.
Recently the department distributed an assessment of current practices and capacity development needs to all local health jurisdictions. Based on preliminary analysis of the responses…
~ 50% of LHD requested TA on utilizing MDSS data to target surveillance activities
~ 50% of LHD requested TA on eliciting partner information from infected patients
- While 95% report that they conduct interviews and elicit partner information from clients testing positive for GC and CT in their clinics, only 1/3 conduct quality assurance of the interview techniques, and less than ¼ do quality assurance and improvement around the productivity of these interviews.
~ 25% requested training on how to conduct effective physician visits, and only 1/3 of health jurisdictions are currently visiting providers to encourage appropriate screening, treatment and reporting.
ROLE OF MDCH in meeting these needs
Identify and disseminate best practices across Michigan’s health jurisdictions
Field Delivered Therapy, Expedited Partner Therapy, Express Visits, InSPOT, Partner Counseling for non-STD staff
Expertise applied statewide with an economy of scale
Epidemiology, Evaluation, Training, Capacity Building
The ability to meet all the identified Technical assistance and training needs identified in the assessment is beyond the capacity/time of current State Program Staff.
LHD requests for training and technical assistance (from asset inventory survey)
~ 50% - utilizing MDSS data to target surveillance
~ 50% - eliciting quality partner information
~ 25% - how to conduct effective physician visits
Role of MDCH in meeting these needs
Work with LHD STD programs to respond to need for TA.
Concentration on leveraging resources in the private medical community.
Expertise applied statewide with an economy of scale
Epidemiology, evaluation, training, capacity building

65. Michigan Identified Need – Private Sector
In 2007, 53.3% of Michigan Medicaid Managed Care patients were screened for chlamydia % were not.
In 2006, only 1/3 of females 16-20, covered by commercial insurance were screened for chlamydia – 2/3 were not.
Role of MDCH in meeting these needs
Influence private providers statewide
Build on existing partnership with key provider groups
The plan will meet identified need in the private sector by increasing appropriate screening, treatment and partner management.
ROLE OF MDCH in meeting identified need in public sector
Influence private providers statewide
- Medical Associations: MSMS, MPCA
- Health Maintenance Organizations (HMO)
Build on existing partnership with key provider groups
- Juvenile Detention
- Adolescent/School Based Health Centers
- Family Planning

66. Update on GC Action Plan Progress Tennessee
An analysis of the past 10 years of GC data indicated that the number of cases
in women exceeded the number of cases in men starting in 2005 in Memphis
and approached the number of cases in men in 2008 in Nashville.
In reviewing what changes occurred that could account for the shift,
the only thing identified was a change that occurred in TennCare,
Tennessee’s Medicaid Program. Since the proportion of young women tested
for chlamydia annually is a HEDIS measure, TennCare began requiring
chlamydia testing for females ages 15 to 25 in their contracts with
Managed Care Organizations (MCOS) around Most MCOs are using
the dual test for GC/CT so the result was an increase in GC testing in young
women in this age group also. Because both the number of young women who are on TennCare and the amount of disease is significantly larger in Memphis than Nashville, the impact was seen in Memphis earlier..”

67. GC Action Plans
New York City: High school screening in HMA. Laboratory validation of NAAT for rectal and pharyngeal samples.
New York State: Expand screening in SBHC. Laboratory validation of NAAT for rectal and pharyngeal samples.
Ohio: Expand screening in two schools in Cleveland
Oklahoma: Look at ER data to see how that’s being utilized for screening.
Oregon: Develop a memo encouraging providers serving higher risk persons and communities.

68. Partner Services

69. Gonorrhea Control Strategies
Partner Services
Who should you interview???
pregnant?
PID?
core area?
‘repeaters’?
MSM?
STD clinic patients?
symptomatic men?
women?
15 and under?

70. Who should you interview???
pregnant?
PID?
core area?
‘repeaters’?
MSM?
STD clinic patients?
symptomatic men?
women?
15 and under?
Other

71. Who should you interview???
Rationale
pregnant? Prevent complications
PID? Prevent reinfection/ ID asymptomatic males
core area? Reach ‘core transmitter’ →→
‘repeaters’? Reach ‘core transmitter’ →→
MSM? HIV prevention/AR GC
STD clinic patients? Max. scale & timeliness
symptomatic men? Prevent PID/reach asymptomatic
Less work – they come to you
women? Reach asymptomatic men
15 and under? Child abuse/complications
Can you reasonably expect your PS strategy to have an impact on your local morbidity?

72. Partner Services 2008 Recommendations for Partner Services (MMWR):
“Prioritizing gonorrhea infected persons from core areas might offer an opportunity to reduce transmission on the community level”
“… an example of a core area is a zip code in which >50% of GC cases in the county are identified.”
View the Recommendations at:

73. Gonorrhea Control Strategies Partner Services
Essentially, you have to do enough to make a difference; but…
How much is enough???
5 %
25%
50%
100% of cases ??

74. Partner Services How much is enough??? 100% 50% 70% 25%
Proportion of Cases interviewed
5 %
25%
50%
70%
100%

76. 2008 Illinois Gonorrhea Rates
Rate per 100,000
Population
>300
>
> 76

77. Illinois Reported Gonorrhea Cases in Six LHDs Selected for the GC PS
Illinois Reported Gonorrhea Cases in Six LHDs Selected for the GC PS* Project in 2007
Health
Department
# GC
Cases
# Target Zipcodes
# GC Cases in Target Zipcodes
% Cases in Target Zipcodes
CUPHD
436 5
395
91%
ESHD
714 6
690
97%
JCHD
135 1
118
87%
PCHD
904 3
762
84%
WCHD
865
722
VCHD
300
275
92%
Total
3,354 21
2,962
88%
These 6 Project Site Counties Accounted for 26% of Reported GC Cases in 2007 in Illinois Excluding Chicago. * PS = Partner Services

78. Targeted GC Counseling and Sex Partner Services All Outcomes – 2: February – December 2009# %
Critical Period Sex Partners Identified by Infected Persons
1,042
N/A
Critical Period Sex Partners Initiated for Follow-up
466
44.7%
Critical Period Sex Partners that were Newly Examined
308
29.6%
Initiated Sex Partners Newly Examined
66.1%
Rates
Critical Period Sex Partners Examined per Case Counseled
0.41
CP Sex Partners Newly Examined per Reported Case with Cx Record
0.29
Newly Examined Sex Partners Infected Brought to Rx per Case Cx
0.25
Newly Examined Sex Partners Infected Brought to Rx per Reported Case with Cx Record
0.18
CP = Critical Period (60 Days Prior to Positive GC Test
Cx = Counseled, Rx = Treatment

79. Targeted GC Counseling and Sex Partner Services All Outcomes - 3: February – December 2009# %
Newly Examined Sex Partner that were Infected Brought to Treatment
192
62.3%
Newly Examined Sex Partners Testing Negative and Preventatively Treated 85
27.6%
Newly Examined Sex Partners Treated and not Tested 18
5.8%
Newly Examined Sex Partners Testing Negative and Not Treated 13
4.2%
Sex Partners Referred to Other Health Jurisdiction for Follow-up 65
6.2%
Sex Partners Infected and Previously Treated
102
9.8%
Sex Partners Unable to Locate or Refused Exam
188
18.0%
Cases Counseled with ≥ 1 Sex Partner Infected Brought to Treatment
184
24.4%

80. Targeted GC Counseling and Sex Partner Services Outcomes By Sex: February – December 2009
Sex of Case Cx
# Cases Cx
N=754
% Cases Cx
% Cases Cx in Clinic #
CP SP Per Case Cx
CP SP Exams
Per Case Cx
Infected SP Newly Rx Per Case Counseled %
Cases Cx With ≥ 1 Infected Newly Rx SP
Male
329
44%
64%
1.6
0.4
0.20
25.2%
Female
425
56%
37%
1.2
0.17
23.8%
Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated
CP = Critical Period (60 Days Prior to Positive GC Test)

81. Race and Ethnicity of Case Cx Infected SP Newly Rx Per Case CX
Targeted GC Counseling and Sex Partner Services Outcomes By Race/Ethnicity: February – December 2009
Race and Ethnicity of Case Cx
# Cases Cx
N=754
% Cases Cx #
CP SP Per Case Cx
CP SP Exams
Per Case Cx
Infected SP Newly Rx Per Case CX %
Cases Cx With
≥ 1 Infected Newly Rx SP
Race
Black
604
80%
1.4
0.41
0.18
23.8%
White 96
13%
1.5
0.46
0.21
30.2%
Ethnicity
Hispanic 22 3%
18.2%
Non-Hispanic
663
88%
0.42
0.27
25.5%
Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated
CP = Critical Period (60 Days Prior to Positive GC Test)

82. Infected SP Newly Rx Per Case CX
Targeted GC Counseling and Sex Partner Services Outcomes By Age Group: February – December 2009
Age Group of Case Cx
# Cases Cx
N=754
% Cases Cx #
CP SP Per Case Cx
CP SP Exams
Per Case Cx
Infected SP Newly Rx Per Case CX %
Cases Cx With
≥ 1 Infected Newly Rx SP
15-19
231
31%
1.36
0.35
0.20
19.9%
20-24
263
35%
1.46
0.49
0.30
27.8%
25-29
138
18%
1.35
0.41
0.32
31.9%
30-34 56 7%
1.30
0.39
0.23
21.4%
91% of clients counseled were among these 4 age groups. Young clients might be females and reluctant to identify older males.
Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated
CP = Critical Period (60 Days Prior to Positive GC Test)

83. # Infected SP Newly Rx Per Case Cx
Targeted GC Counseling and Sex Partner Services Outcomes By Cx Setting: February – December 2009
Setting Where Case Cx
# Cases Cx
N=754
% Cases Cx
# CP SP Per Case Cx
# CP SP Exams
Per Case Cx
# Infected SP Newly Rx Per Case Cx
% Cases Cx With
≥ 1 Infected Newly Rx SP
Clinic
367
49%
1.5
0.5
0.33
31.9%
Telephone
352
46%
1.2
0.3
0.18
17.3%
Field 35 4%
1.7
0.4
0.17
17.1%
Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated
CP = Critical Period (60 Days Prior to Positive GC Test)

84. Illinois Conclusions and Implications
Number of Critical Period Sex Partners per Case was very Consistent Across Data (~1.4 per case)
Counseling Males May Be More Productive Than Females
Counseling at Time of Rx is almost 2x as Productive as Counseling in Field or by Telephone; and was 2.7 times less costly to Identify Infected Newly Treated Sex Partners

85. New York State

86. Key Terms for NYS Core - Census tract with 50% of morbidity
Adjacent - Census tract with 30% of morbidity
Peripheral - Remaining Census tracts with 20% of morbidity

87. Gonorrhea Core Epidemiologic Tracts, Monroe County, NYS, 2007

88. New York State’s Approach to Gonorrhea Partner Services
For transmission purposes not all gonorrhea cases are equal, therefore:
Intensely interview core area cases
Target gonorrhea screening to facilities and providers that serve the core population

89. Reported Gonorrhea Cases and Core Epi Interventions, Monroe County: 2002-2007
Data Source: New York State Department of Health, Bureau of STD Control

90. Gonorrhea-Reported Rates: NYS Exclusive of NYC and Monroe County, 1992-2007

91. Update on GC Action Plans
Washington State
“Gonorrhea morbidity is likely quite sensitive to changes in the proportion of cases interviewed and provided partner management. The proportion of cases provided partner management by public health staff in King County decreased from 43% in the first half of 2009 to 39% for cases diagnosed year-to-date in 2010 due to budget restrictions. In contrast, in Pierce County, an urban jurisdiction directly south of King County, the proportion of cases interviewed increased from 55 to 69% in the same time period and gonorrhea morbidity decreased by 27%. These observations underscore the potential importance of maintaining sufficient capacity for disease intervention in the control and prevention of gonorrhea. ”
Oregon
“During the first 6 months of 2010 compared to the same time period in 2009 reported GC cases decreased slightly or remained steady in all counties… Every reported GC case is contacted by the health department and interviewed if they can be located. Many of the increased cases are related to case finding.
The Oregon STD Program has prioritized the following groups for enhanced gonorrhea intervention: MSM, African Americans, and males and females in the 15 – 24 year age group.”

92. Update on GC Action Plans
Connecticut
“In May 2010, a GC partner services (PS) initiative began in the cities of
Hartford and New Haven. The targeted areas of these cities were based on reported cases in specific high morbidity zip codes. These two towns were selected because many of the cases reported in the state are from these towns and DIS worksites are based in these areas, giving them easy and timely access to provide PS. Anyone reported to the Sexually Transmitted Disease (STD) Control Program within three weeks of diagnosis and <25 years of age is immediately assigned to a DIS for a PS interview. The DIS will work intensely to locate these individuals for five days to [identify] exposed partners. This effort focuses on GC health disparities among African Americans. ”

93. Health Promotion HIV, STD, and Pregnancy Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division of Adolescent and School Health

94. Percentage of secondary schools that tried to increase student knowledge on HIV prevention in a required course
53% - 86%
87% - 89%
90% - 93%
94% - 97%
This slide shows the percentage of secondary schools that tried to increase student knowledge on HIV prevention in a required course. The values range from 53% to 97%. Alabama, Alaska, Arizona, Florida, Louisiana, Massachusetts, Oklahoma, South Dakota, Tennessee, Texas, Vermont, range from 53% to 86%. California, Connecticut, Georgia, Iowa, Kansas, Kentucky, Maryland, Michigan, Mississippi, North Carolina, Ohio, Wyoming, range from 87% to 89%. Delaware, Maine, Minnesota, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Oregon, Pennsylvania, South Carolina, Virginia, range from 90% to 93%. Arkansas, Hawaii, Idaho, Indiana, Nevada, New Jersey, New York, Rhode Island, Utah, Washington, West Virginia, Wisconsin, range from 94% to 97%. Colorado, Illinois and New Mexico did not have weighted results.
No Data
School Health Profiles, see
Division of Adolescent and School Health

95. Percentage of secondary schools that tried to increase student knowledge on STD prevention in a required course
50% - 85%
86% - 88%
89% - 91%
92% - 97%
This slide shows the percentage of secondary schools that tried to increase student knowledge on STD prevention in a required course. The values range from 50% to 97%. Alaska, Arizona, Florida, Louisiana, Massachusetts, Michigan, North Dakota, Oklahoma, South Dakota, Tennessee, Vermont, range from 50% to 85%. California, Connecticut, Iowa, Kansas, Kentucky, Mississippi, Montana, New Hampshire, North Carolina, Ohio, Texas, Wyoming, range from 86% to 88%. Alabama, Georgia, Hawaii, Idaho, Maine, Maryland, Minnesota, Pennsylvania, Rhode Island, South Carolina, Virginia, West Virginia, range from 89% to 91%. Arkansas, Delaware, Indiana, Missouri, Nebraska, Nevada, New Jersey, New York, Oregon, Utah, Washington, Wisconsin, range from 92% to 97%. Colorado, Illinois and New Mexico did not have weighted results.
No Data
School Health Profiles, see
Division of Adolescent and School Health

96. Percentage of secondary schools that taught 11 key HIV, STD, and pregnancy prevention topics in a required course during grades 6, 7, or 8
13% - 39%
40% - 42%
43% - 53%
54% - 66%
This slide shows the percentage of secondary schools that taught 11 key HIV, STD, and pregnancy prevention topics in a required course during grades 6, 7, or 8. The values range from 13% to 66%. Alaska, Arizona, Connecticut, Kansas, Louisiana, Minnesota, Mississippi, Nebraska, South Dakota, Vermont, Wyoming, range from 13% to 39%. Idaho, Iowa, Maine, Massachusetts, Michigan, Montana, North Dakota, Oklahoma, Oregon, Pennsylvania, Tennessee, Utah, range from 40% to 42%. Alabama, California, Delaware, Florida, Kentucky, Missouri, New Hampshire, North Carolina, Ohio, Texas, Washington, Wisconsin, range from 43% to 53%. Arkansas, Georgia, Hawaii, Indiana, Maryland, Nevada, New Jersey, New York, Rhode Island, South Carolina, Virginia, West Virginia, range from 54% to 66%. Colorado, Illinois and New Mexico did not have weighted results.
No Data
School Health Profiles, see
Division of Adolescent and School Health

97. Percentage of secondary schools that taught 4 key topics related to condom use in a required course during grades 9, 10, 11, or 12
9% - 31%
32% - 44%
45% - 66%
67% - 88%
This slide shows the percentage of secondary schools that taught 4 key topics related to condom use in a required course during grades 9, 10, 11, or 12. The values range from 9% to 88%. Alabama, Alaska, Arizona, Georgia, North Carolina, North Dakota, Oklahoma, South Dakota, Texas, Utah, Wyoming, range from 9% to 31%. Florida, Idaho, Indiana, Kansas, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Ohio, Tennessee, range from 32% to 44%. Arkansas, Iowa, Kentucky, Minnesota, Nevada, Pennsylvania, Rhode Island, South Carolina, Virginia, Washington, West Virginia, Wisconsin, range from 45% to 66%. California, Connecticut, Delaware, Hawaii, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Oregon, Vermont, range from 67% to 88%. Colorado, Illinois and New Mexico did not have weighted results.
No Data
School Health Profiles, see
Division of Adolescent and School Health

98. Key Strategies: What’s the right mix for YOUR AREA?
Surveillance
Screening
Treatment
Partner Services
Primary Prevention/risk reduction
Community Engagement
Key Health Care Providers
From that process we identified Five key strategies. These look very familiar to all of us because they are based on collective experience and knowledge gained over time from STD programs.
Testing and screening
Timely and appropriate therapy
Partner therapy and risk reduction
Community engagement
Surveillance and program evaluation
Next had to think about what key things need to happen to make these strategies a success, so let’s look at them individually and tehn we will go back and see how they might all fit together 98 98

99. GC Prevention Continuum
Comprehensive
Sex Ed
Work with
Key Medical
Providers
Targeted
Screening
Promote
Screening
School/Jail
Screening
Media
Campaigns
Community
Level
interventions
PS Tools
Follow-up on
individual cases
Targeted
Partner
Services
Partner
Services
For all GC
High
Morbidity
Low
Morbidity

100. Gonorrhea Prevention and Control Lessons
Assess surveillance, testing data…
Target screening based on local epi:
PUBLIC – IPP/FP, corrections, CHCs, HIVP, school clinics
PRIVATE – promote screening by key private providers in HMAs (ERs, MCOs), policy (CT HEDIS)
Assess & ensure access to care/treatment
Partner with providers and communities

101. Gonorrhea Prevention and Control Lessons
Primary Prevention: Health Promotion/Risk Reduction/Condoms/Comprehensive sex ed – especially in core areas
Partner Services
Reaching partners is very important due to high positivity (…but low contact index)
What proportion of case to interview? (~ more than 25% of cases)
Time management? (minimize effort & max. impact, quick OIs, 7 – 10d follow-up)
Less intense, more effective than PS for other STDs
Offer PS tools and training to providers
Need ongoing evaluation and improvement

102. ‘Dear Colleague’ Letter on the need for Comprehensive STDP Services for MSM

103. MSM Limited Screening Need comprehensive services
Enhance & promote routine non-genital NAATs screening for MSM
Need comprehensive services
In HIV prevention and care; gay-friendly providers
Real concerns about potential spread of resistant GC
Efforts must be connected to HIV prevention and care

104. Drug Resistant GC Surveillance and detection Treatment
Case definition; elevated suspicion
Assess and enhance Culture capacity labs
Enhance surveillance to rapidly detect resistant GC
Treatment
Management of patients and partners
Enhance current GC prevention efforts

105. Thank you!
Questions?
Division of STD Prevention

106. END

107. Thanks to: State Epidemiologists and Program Directors Michael Bender
DSTDP Program Consultants
Steven Shapiro
Catherine Satterwhite
Heather Bradley
Bob Kirkcaldy
see additional materials from the GC Regional meetings at the
resources section of the ‘GC Control’ group at
National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention
Division of STD Prevention