WELCOME! Region IX Discussion on Gonorrhea Control Hosted by CDC and Region IX IPP Coordinator

1. WELCOME! Region IX Discussion on Gonorrhea Control Hosted by CDC and Region IX IPP Coordinator The disseminated findings and conclusions in this presentation have not been formally reviewed by CDC and should not be construed to represent any agency determination or policy.

2. Regional Meetings • Smaller meeting → more discussion • Learn from peers • Emphasize program improvement • Accommodate regional similarities (morbidity, resources, infrastructure, populations)

3. Meeting Objectives Increase understanding of gonorrhea epidemiology, health disparities, and ability to develop antimicrobial resistance Increase understanding of gonorrhea control strategies Increase knowledge of gonorrhea control activities conducted in the region Develop action plans for targeted, and more robust GC control efforts

4. Gonorrhea Control: A Historical Perspective Kevin O’Connor DSTDP January 14, 2010

5. Epidemiology 101

6. Why talk about GONORRHEAnow?

7. Why now? • GC in the west • Loss of fluoroquinolones • (and GC’s ability to develop antimicrobial resistance) • Health disparities • ID populations at risk for other STDs and conditions • Opportunities: • reaching those at-risk for GC also addresses CT • learn from our historic successes • success might not be that far away

8. * * Not Anymore

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

10. This is the second MMWR in the past month that addresses gonorrhea... It is important we use this heightened awareness to reconsider what we are doing to prevent gonorrhea transmission and its sequelae and to begin new discussions about improving gonorrhea prevention. We will continue to keep you updated on developments as they occur and will work with you to address the growing urgency of this serious health concern. John M. Douglas, Jr., MD Director, Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention April 12, 2007 DCL announcing that fluoroquinolones are no longer recommended for the treatment of GC; shortly after ‘GC in the West’ MMWR article

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

12. Gonorrhea rates, U.S., 1941-2007 GC Control Program

13. Gonorrhea Control Milestones Rate (per 100,000 population) DNA probe GC Culture 500 400 D/C Fluroquinolones in HI, PI, Asia PCR 300 D/C Tetracycline Gonorrhea Control Program D/C PCN 200 Gonorrhea 100 2010 Objective 0 1970 73 76 79 82 85 88 91 94 97 2000 GISP IPP Note: The Healthy People 2010 (HP2010) objective for gonorrhea is 19.0 cases per 100,000 population

14. 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

15. Gilbert Gonorrhea - 1973

16. National Gonorrhea Control Program 1973 Female ScreeningVD clinic Screening/testing 4,356,670 582,922GC + 132,387 (3%) 109,889(19%) Partner Services3 mos.Annual est. Interviews 64,154 ~259,000 (3 mos. only: April – June 1973) Contacts 61,439 ( 0.96 CI )Ct. examined 39,409 (~2/3) Infected/treated 15,928(.40)~64,000 Epi Rx 18,063

17. Historic GC Control of Program1973 STD Clinic Targeted Screening Partner Services 109,000 females ~ 13 % 64,000 ~ 7 % 110,000 females ~ 13% 842,000 Cases reported in 1973

18. Case Finding Sources and their Contribution to Overall Morbidity STD Clinic ER JDC Private Providers Partner Services Targeted Screening Total Reported Cases

19. YourJurisdiction:Where/how are cases identified? STD Clinic ER Private Providers Partner Services Targeted Screening Total Annual Morbidity Jail

20. GONORRHEAin PITTSBURGH

22. Allegheny CountyGonorrhea Gc control strengths: 5-day full service STD clinic w/ 6 DIS Low syphilis morbidity Males come to you & receive prompt dx/Rx Straightforward, quick interviews Named contacts very likely to be infected Existing female screening program Existing partnerships: community & providers CT: No dx while in the clinic: PS more labor-intensive Contacts not likely to test positive

23. Allegheny CountyGonorrhea Gonorrhea control plan: Interview Gc+ males in the clinic Traditional contact tracing of partners Regularly audit GC screening sites; redirect screening as needed Build on local partnerships Hospitals, screening sites, JDC, community clinics, school-based clinics, MCH, healthy start Annual STD update meeting & report, letters to GSP sites, medical bulletin

24. O = Other (Previous Rx) A = Epi treat C = Infected, brought to treatment

25. Allegheny County 1993 1994 2000 # Total Cases 3,730 2,602 1,510 # F Cases 1,847 1,335 827 GC Screening Program # F Tests 70,000+ 60,000+ 38,672 # F Tests + 1,229 (66%) 856 (64%) 347 (42%) PS # Female cases ID’d by PS (partners brought to treat) 359 (20%) 235 (18%) ??

26. Allegheny CountyGonorrheaAnnual STD Progress Report (1993) The decline in Gc is likely the result of several factors: 66% female GC cases identified by Gc Screening Program (1,229 of 1847) 1,050 STD clinic males interviewed, and… 359 female sex partners are infected, ‘brought to treatment’ 20% of reported female cases ( N = 1,847) 20% of female cases ‘brought’ every year after 1990

27. Female GC Case Finding in Allegheny County, 1993 GC Screening Program 1,229 Partner Services 359 20% 66% 1847 Female GC Cases

28. Gonorrhea Morbidity Allegheny County, PA 1990-2002 New PS strategy; ongoing screening Focused PS effort ends Screening reduced

29. END