1. Application of an Epi Profile: Gonorrhea in the U.S. Region V Gonorrhea Control Meeting

2. What is an epi profile? Standardized way to analyze & interpret data Standardized way to analyze & interpret data Suggested, not required Suggested, not required Provides evidence to support public health decision-making Provides evidence to support public health decision-making Supplement to classroom & on-the-job training Supplement to classroom & on-the-job training Provides a common language for communication with other public health programs Provides a common language for communication with other public health programs

3. Why do we need an STD epi profile? High burden of disease High burden of disease Insufficient funding for unlimited program activities Insufficient funding for unlimited program activities Few opportunities for classroom or on-the-job training experiences Few opportunities for classroom or on-the-job training experiences Technological advances allowing for more sophisticated analysis of data Technological advances allowing for more sophisticated analysis of data

4. Who? Identifying Target Populations Where? Identifying Areas of High STD Morbidity What? Identifying What STDs are involved Why? Identifying Contextual Factors Framework for a GC Epidemiologic Profile

5. Identifying What STDs are Involved What STDs are of importance? Overlap in STDs : co-infections Changes over time Important Data Elements Number of tests Test results Date of test What?

6. Trends in Chlamydia, Gonorrhea, and P & S Syphilis Morbidity, United States, 1999-2008* * * Preliminary data, will possibly increase

7. Gonorrhea rates, U.S., 1941-2007

8. National Data Sources for Gonorrhea Case report Case report Incidence Incidence Infertility Prevention Program Infertility Prevention Program Positivity Positivity STD Surveillance Network (SSuN) STD Surveillance Network (SSuN) Interviews of patients with gonorrhea Interviews of patients with gonorrhea STD clinic surveillance STD clinic surveillance GISP GISP Gonococcal susceptibility profile Gonococcal susceptibility profile APHL survey APHL survey Public health lab test type and volume Public health lab test type and volume NHANES NHANES Population prevalence (?) Population prevalence (?)

9. Identifying Target Populations Characterizing affected populations Changes over time? Important Data Elements Age Sex Race/ Ethnicity Sex of Partners Date of test Who?

10. Gonorrhea rates by sex, 1981-2007

11. SSuN Population-based Gonorrhea Surveillance – Sex and Sexual Orientation of Gonorrhea Patients, 2006-2008 (N=2,400)* * Preliminary data. Sexual orientation unknown for 51 men 22.1% MSM

12. Gonorrhea rates by age and sex, 2007 69% 15-24 years 48% 15-24 years

13. Gonorrhea rates by race/ethnicity, 1981-2007

14. Female gonorrhea rates for 15-19 year olds by region and race/ethnicity, 2006 Rate (per 100,000 population)

15. Male gonorrhea rates for 20-24 year olds by region and race/ethnicity, 2006 Rate (per 100,000 population)

16. Gonorrhea Positivity WhitesBlack All0.4% (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 Ptner 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 Gonorrhea positivity, women 15-24, family planning clinics, by race, Washington State IPP, 2007*

17. Identifying Areas of High Morbidity Geospatial distributions of disease Venues or providers seeing high burden of disease Changes over time Important Data Elements Geographic location of cases Type of provider or venue where cases found Local districting Current location of STD services Where?

18. Gonorrhea rates by region, 2000-2007 42%

19. Gonorrhea rates by state, United States and outlying territories, 2007

20. Gonorrhea — Positivity among 15- to 24-year-old women tested in family planning clinics by state, 2007 *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 screened during 2006. SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

21. Gonorrhea — Rates by county, 2007 Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population.

22. Identifying Contextual Factors Risk factors impacting STDs Socio-demographics of population served Social determinants of health Policies and Laws Important Data Elements Medical infrastructure Reported sexual and behavioral risk factors Partner types and partner characteristics Population demographics Why?

23. Proportion of reported gonorrhea cases from STD clinics by sex, 1984-2007* *Preliminary 2007 data Males Females % from STD clinics

24. SSuN Population-based Gonorrhea Surveillance – Provider Type of Gonorrhea Patients by Race/Ethnicity* (excluding STD clinic patients) Blacks n=985 Whites n=623 Hispanics n=229 *Preliminary data

25. Reported gonorrhea rates in the United States and Utah, 1995-2006 261% increase

26. Reported cases of gonorrhea by provider type, Utah, 2000-2006 667% increase 67% increase

27. Number of positive gonorrhea tests by test type by one private reference laboratory, Utah, 2001-2006 424% increase

28. Reported gonorrhea and chlamydia test* volume: Infertility Prevention Program, U.S., 2001 - 2006 *Positive and negative test results only. 32% increase 76% increase

29. Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2007* Note: Resistant isolates have ciprofloxacin MICs ≥ 1 µg/ml. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990. * Preliminary 2007 data

30. Gonococcal Isolate Surveillance Project (GISP) — Prevalence of ciprofloxacin-resistant Neisseria gonorrhoeae by GISP site, 2004-2007* *Preliminary 2007 data

31. SSuN Population-based Gonorrhea Surveillance – Fluoroquinolone Use by Provider Type, Colorado and Virginia, 2007 STD clinics ERs, Urgent Care, and Hospitals Primary Care Fluoroquinolones prescribed, % Family Planning CDC recommendations changed Source: D. Dowell, preliminary data n (cases) =1048 n (cases)=127 n (cases) =515 n (cases) =507

32. SSuN Population-based Gonorrhea Surveillance – Reported Risks over Past 3 Months* by Gonorrhea Patients MSMMSWWomen 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% *Preliminary data. Data not available for WA

33. Summary: Gonorrhea from a National Perspective Concentrated in South Select, not all, counties Shift towards private sector Adolescents/young adults African Americans Heterosexual AND MSM Increases in test volume Persistent racial disparities Association with high risk behaviors Persistent high rates of gonorrhea

34. “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

35. Acknowledgements STD Surveillance Network (SSuN) Collaborators STD Surveillance Network (SSuN) Collaborators Washington, Oregon, Idaho, Alaska & Utah Departments of Health Washington, Oregon, Idaho, Alaska & Utah Departments of Health Statistics and Data Management Branch, DSTD, CDC Statistics and Data Management Branch, DSTD, CDC Darlene Davis Darlene Davis Rob Nelson Rob Nelson Epidemiology and Surveillance Branch, DSTD, CDC Epidemiology and Surveillance Branch, DSTD, CDC Lori Newman Lori Newman Deborah Dowell Deborah Dowell Nandini Selvam Nandini Selvam Hillard Weinstock Hillard Weinstock Eileen Yee Eileen Yee

36. Contact information Melanie Taylor, MD, MPH Taylorm@azdhs.govaylorm@azdhs.gov 602-364-4565 The findings and conclusions in this presentation have not been formally disseminated by the CDC and should not be construed to represent any agency determination or policy.