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Large Gonorrhea Outbreak in a Rural California County, 2003

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Large Gonorrhea Outbreak in a Rural California County, 2003

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    1. Large Gonorrhea Outbreak in a Rural California County, 2003 Michael Samuel, Dr.P.H. California Department of Health Services STD Control Branch Good morning. It is a pleasure to be back up here in sunny Oroville. For all of you who do not know me, I am Jan King. I am an EIS officer from the CDC. I have been assigned to the California State STD Control Branch. We want to thank the Butte County Department of Health for inviting us back to present the results of our collaborative investigation. In the spirit of our collaboration with you on this project, we want this presentation to be a dialogue, therefore we welcome questions and comments during the presentation. Good morning. It is a pleasure to be back up here in sunny Oroville. For all of you who do not know me, I am Jan King. I am an EIS officer from the CDC. I have been assigned to the California State STD Control Branch. We want to thank the Butte County Department of Health for inviting us back to present the results of our collaborative investigation. In the spirit of our collaboration with you on this project, we want this presentation to be a dialogue, therefore we welcome questions and comments during the presentation.

    2. Butte County, California Butte County is rural county located in north central California with population of 210,000. The two largest cities are Chico and Oroville. The Oroville population is about 13000, and with including surrounding communities, about 45,000. The county population is 85% white.Butte County is rural county located in north central California with population of 210,000. The two largest cities are Chico and Oroville. The Oroville population is about 13000, and with including surrounding communities, about 45,000. The county population is 85% white.

    3. Gonorrhea Rates, 1985–2002

    4. Background County Health Department detected increases in gonorrhea in early 2003 County alerted local medical community in March and May Requested assistance of State STD Control Branch in September Outbreak investigation Control measures

    5. Methods Case series Confidential Morbidity Report (CMR) Laboratory report Interviews Standardized interview record (IR) Health educators & Disease Intervention Specialists (DIS) In-person and by-phone Network analysis Ask all cases and contacts to name all sexual and social contacts in prior 3 months EIS It was decided that a case-series was the best approach for the gonorrhea investigation. A case-series would involve creating a detailed description of gonorrhea case-patients. Already compiled data from the confidential morbidity reports and or laboratory reports would be used along with new information obtained from detailed interviews with case patients. Data collection was performed using a standardized 6-page interview record designed by the investigation team. Interviews were performed by Butte County Public Health Department Health educators and state disease intervention specialist, referred to as DIS. There were four health educators from the Butte County Department of Health. 8 state DIS traveled from Sacramento, Stockton, Fresno, Bakersfield, Berkeley, Long Beach and Orange County to participate in the investigation. Interviews were performed in-person and by-phone.EIS It was decided that a case-series was the best approach for the gonorrhea investigation. A case-series would involve creating a detailed description of gonorrhea case-patients. Already compiled data from the confidential morbidity reports and or laboratory reports would be used along with new information obtained from detailed interviews with case patients. Data collection was performed using a standardized 6-page interview record designed by the investigation team. Interviews were performed by Butte County Public Health Department Health educators and state disease intervention specialist, referred to as DIS. There were four health educators from the Butte County Department of Health. 8 state DIS traveled from Sacramento, Stockton, Fresno, Bakersfield, Berkeley, Long Beach and Orange County to participate in the investigation. Interviews were performed in-person and by-phone.

    6. Methods - Software Case series and interviews Access SAS Mapping ArcView 3.1 Network analysis Ucinet 6 for windows NetDraw 1.0 Data analysis consisted of two parts. In the case series portion of the analysis Access software was used to create a relational database. SAS was used to calculate frequencies for each data element. Missing values were excluded in the final analysis. A network analysis was performed using UCI-Net/netdraw software. Michael will give additional information about the methods involved in the network analysis as well as the results of the network analysis.Data analysis consisted of two parts. In the case series portion of the analysis Access software was used to create a relational database. SAS was used to calculate frequencies for each data element. Missing values were excluded in the final analysis. A network analysis was performed using UCI-Net/netdraw software. Michael will give additional information about the methods involved in the network analysis as well as the results of the network analysis.

    8. GC Cases by Month Butte County, 2001-2003 This is the epi curve for years 2001-2003 of gonorrhea cases by month in Butte County. These are all the cases. The aqua green represents Oroville cases, the light blue is Chico and the top grey is Other area. Oroville cases, represented in green, represent the majority of gonorrhea cases. For this reason we focused our investigation on Oroville case-patients.This is the epi curve for years 2001-2003 of gonorrhea cases by month in Butte County. These are all the cases. The aqua green represents Oroville cases, the light blue is Chico and the top grey is Other area. Oroville cases, represented in green, represent the majority of gonorrhea cases. For this reason we focused our investigation on Oroville case-patients.

    9. GC Cases by Month Butte County, 2001-2003 This is the epi curve for years 2001-2003 of gonorrhea cases by month in Butte County. These are all the cases. The aqua green represents Oroville cases, the light blue is Chico and the top grey is Other area. Oroville cases, represented in green, represent the majority of gonorrhea cases. For this reason we focused our investigation on Oroville case-patients.This is the epi curve for years 2001-2003 of gonorrhea cases by month in Butte County. These are all the cases. The aqua green represents Oroville cases, the light blue is Chico and the top grey is Other area. Oroville cases, represented in green, represent the majority of gonorrhea cases. For this reason we focused our investigation on Oroville case-patients.

    10. GC Cases by Month Butte County, 2001-2003 This is the epi curve for years 2001-2003 of gonorrhea cases by month in Butte County. These are all the cases. The aqua green represents Oroville cases, the light blue is Chico and the top grey is Other area. Oroville cases, represented in green, represent the majority of gonorrhea cases. For this reason we focused our investigation on Oroville case-patients.This is the epi curve for years 2001-2003 of gonorrhea cases by month in Butte County. These are all the cases. The aqua green represents Oroville cases, the light blue is Chico and the top grey is Other area. Oroville cases, represented in green, represent the majority of gonorrhea cases. For this reason we focused our investigation on Oroville case-patients.

    11. Gonorrhea GC Cases Butte County, 2003 This slide outlines the flow of Butte County gonorrhea cases. It includes the number of cases in each area of Butte County and the number interviewed. Three areas that were defined in our analysis included the Greater Oroville area, Chico and Other Butte County areas. There were 156 cases of gonorrhea in Butte County in 2003. This represents 148 adults; 6 re-infections and 2 cases under 14 were excluded. 95 cases occurred in residents of Oroville, 31 in residents of Chico, and 22 were residents of other Butte County areas. 62 Oroville cases, 12 Chico and 13 other area case-patients were interviewed.This slide outlines the flow of Butte County gonorrhea cases. It includes the number of cases in each area of Butte County and the number interviewed. Three areas that were defined in our analysis included the Greater Oroville area, Chico and Other Butte County areas. There were 156 cases of gonorrhea in Butte County in 2003. This represents 148 adults; 6 re-infections and 2 cases under 14 were excluded. 95 cases occurred in residents of Oroville, 31 in residents of Chico, and 22 were residents of other Butte County areas. 62 Oroville cases, 12 Chico and 13 other area case-patients were interviewed.

    12. GC Cases by Gender, Age and Race/Ethnicity-Oroville, 2003 This slide represents gonorrhea case-patients by gender, age and race. The large moon in the upper left corner is a pie chart, showing the distribution of female and male case-patients. Females are pink throughout this slide and males are blue. Females make up the majority of gonorrhea cases reported to the Butte County Public Health Department. Females represent 62% of all cases and males are 38% of all case-patients. (***WHAT DID WE DECIDE ON REMOVAL OF REPEAT INFECTIONS?NOT INCLUDING RE_INFECTIONS JC) The graph is divided in two; the left hand side has the age distribution while the right side represents race. On the left hand graph age is represented. The largest proportion of female and male case-patients are in the age group 20-29. On the right graph, race is represented. The largest proportion of male and female case patients are white. African males represent a disproportionate large compared to black females.This slide represents gonorrhea case-patients by gender, age and race. The large moon in the upper left corner is a pie chart, showing the distribution of female and male case-patients. Females are pink throughout this slide and males are blue. Females make up the majority of gonorrhea cases reported to the Butte County Public Health Department. Females represent 62% of all cases and males are 38% of all case-patients. (***WHAT DID WE DECIDE ON REMOVAL OF REPEAT INFECTIONS?NOT INCLUDING RE_INFECTIONS JC) The graph is divided in two; the left hand side has the age distribution while the right side represents race. On the left hand graph age is represented. The largest proportion of female and male case-patients are in the age group 20-29. On the right graph, race is represented. The largest proportion of male and female case patients are white. African males represent a disproportionate large compared to black females.

    13. GC Cases “Socioeconomic Status” Oroville, 2003 This table represents gonorrhea case-patients employment and education level. The first column represents values for females and the second column represents values for males. For employment status both females and males had high rates of unemployment. 50% of females and 59.1 % of males were unemployed. The case-patients also had low levels of completed education. 42.9% of females and 50% of males had less than a high school degree. 8.5% of cases were under 18 years and still in school This table represents gonorrhea case-patients employment and education level. The first column represents values for females and the second column represents values for males. For employment status both females and males had high rates of unemployment. 50% of females and 59.1 % of males were unemployed. The case-patients also had low levels of completed education. 42.9% of females and 50% of males had less than a high school degree. 8.5% of cases were under 18 years and still in school

    14. Where GC Cases Met New Partners Oroville, 2003 This slide illustrates locations case-patients reported meeting sex partners. The majority of case-patients met sex partners through mutual friends. 14% met partners at Casinos; 6% at a bar or club other than those that were names (PIGGS, Gautica). Other locations included parkd 4.7% (WHICH ONES), Motels (WHICH ONES), Piggs liquor. Surprisingly no case-patients mentioned meeting partners at the Rescue Mission or Piggs Club.This slide illustrates locations case-patients reported meeting sex partners. The majority of case-patients met sex partners through mutual friends. 14% met partners at Casinos; 6% at a bar or club other than those that were names (PIGGS, Gautica). Other locations included parkd 4.7% (WHICH ONES), Motels (WHICH ONES), Piggs liquor. Surprisingly no case-patients mentioned meeting partners at the Rescue Mission or Piggs Club.

    15. GC Cases Drug Use Oroville, 2003 Now let us look at drug use reported by cases. Alcohol was the drug that was reported with the highest frequency of 46.7%, followed by marijuana at 35%, methamphetamine at 18.3%, ecstasy at 3.3. There was very little heroin 1.7% and cocaine 1.7 reported by case patients. Methamphetamine was lower than expectedNow let us look at drug use reported by cases. Alcohol was the drug that was reported with the highest frequency of 46.7%, followed by marijuana at 35%, methamphetamine at 18.3%, ecstasy at 3.3. There was very little heroin 1.7% and cocaine 1.7 reported by case patients. Methamphetamine was lower than expected

    16. GC Cases – Race/Ethnicity of Partners Oroville, 2003 This slide illustrates differences of race in case-patient’s partners. 41% of females as compared to 26.1% of males noted that their partners were generally a different race than their own. More interesting is the further breakdown by race. 73.3% of white females stated that the race of their partners was different than their own compared to 16.7 of white men. 66.7% of African American males stated that the race of their partners was generally different than their own. (HOW MANY BLACK MEN? 5) No African-American women were interviewedThis slide illustrates differences of race in case-patient’s partners. 41% of females as compared to 26.1% of males noted that their partners were generally a different race than their own. More interesting is the further breakdown by race. 73.3% of white females stated that the race of their partners was different than their own compared to 16.7 of white men. 66.7% of African American males stated that the race of their partners was generally different than their own. (HOW MANY BLACK MEN? 5) No African-American women were interviewed

    17. GC Case and Partner Incarceration History, Oroville, 2003 This slide illustrates gonorrhea case patient’s incarceration history. 51.4% of females and 50% of males stated that either they or their sex partner have ever been in jail, prison or Juvenile Hall. 18% of females had been in jail compared to 46.9% of males. No females had been in prison compared to 18.2 % of males. 5.1% of females and 15% of males had been in juvenile hall. Interesting 42.5% of women stated that their partners had been incarcerated versus a lower percentage of 21.7% of males. 13.5% females and 18.2% of males had both themselves and sex partner been incarcerated.This slide illustrates gonorrhea case patient’s incarceration history. 51.4% of females and 50% of males stated that either they or their sex partner have ever been in jail, prison or Juvenile Hall. 18% of females had been in jail compared to 46.9% of males. No females had been in prison compared to 18.2 % of males. 5.1% of females and 15% of males had been in juvenile hall. Interesting 42.5% of women stated that their partners had been incarcerated versus a lower percentage of 21.7% of males. 13.5% females and 18.2% of males had both themselves and sex partner been incarcerated.

    18. Variables with Low Frequencies Exchange of money or drugs for sex Specific venues (e.g., X Bar) Men, sex with men There were several variables with lower frequencies than initially projected during our first discussions. There very few cases that reported exchange of money or drugs for sex. Additional several venues that were though to be important were not reported by cases. This does not mean that these links were incorrect only that we were unable to substantiate them in our surveys.There were several variables with lower frequencies than initially projected during our first discussions. There very few cases that reported exchange of money or drugs for sex. Additional several venues that were though to be important were not reported by cases. This does not mean that these links were incorrect only that we were unable to substantiate them in our surveys.

    20. Visual Analysis Geographical Determine geographic distributions EIS A large proportion of GC cases were white, female and were from a low socioeconomic level. Cases frequently were unemployed, covered by publicly funded insurance and had a history of incarceration in self or partner. The only venue of note was casinos. There was some association with methamphetamine use. Gonorrhea re-infection occurred among African-American males with characteristics of core transmitters. Those characteristics included drug-use, prostitution patronage, and long duration of symptoms.EIS A large proportion of GC cases were white, female and were from a low socioeconomic level. Cases frequently were unemployed, covered by publicly funded insurance and had a history of incarceration in self or partner. The only venue of note was casinos. There was some association with methamphetamine use. Gonorrhea re-infection occurred among African-American males with characteristics of core transmitters. Those characteristics included drug-use, prostitution patronage, and long duration of symptoms.

    22. Oroville Gonorrhea Cases January, 2003

    23. Oroville Gonorrhea Cases January–February, 2003

    24. Oroville Gonorrhea Cases January–March, 2003

    25. Oroville Gonorrhea Cases January–April, 2003

    26. Oroville Gonorrhea Cases January–May, 2003

    27. Oroville Gonorrhea Cases January–June, 2003

    28. Oroville Gonorrhea Cases January–July, 2003

    29. Oroville Gonorrhea Cases January–August, 2003

    30. Oroville Gonorrhea Cases January–September, 2003

    31. Oroville Gonorrhea Cases January–October, 2003

    32. Oroville Gonorrhea Cases January–November, 2003

    33. Oroville Gonorrhea Cases January–December, 2003 Only two cases in 2002Only two cases in 2002

    34. Original DIS Network Diagram

    35. Butte County Gonorrhea Outbreak, 2003 Sexual and Social Network Diagram

    36. Butte County Gonorrhea Outbreak, 2003 Sexual and Social Network Diagram

    37. Butte County Gonorrhea Outbreak, 2003 Sexual and Social Network Diagram

    38. Characteristics of Core Cases

    39. Butte Gonorrhea Outbreak Network Cluster Cases

    40. “Network” Diagram Month of Diagnosis and Age

    41. Conclusions Large gonorrhea outbreak in rural California County Large proportion GC cases: White, female Unemployed, uneducated Lacked private health insurance Incarceration history Only venue of note was casinos Re-infection among African-American males Delay in initiating investigation was problematic EIS A large proportion of GC cases were white, female and were from a low socioeconomic level. Cases frequently were unemployed, covered by publicly funded insurance and had a history of incarceration in self or partner. The only venue of note was casinos. There was some association with methamphetamine use. Gonorrhea re-infection occurred among African-American males with characteristics of core transmitters. Those characteristics included drug-use, prostitution patronage, and long duration of symptoms.EIS A large proportion of GC cases were white, female and were from a low socioeconomic level. Cases frequently were unemployed, covered by publicly funded insurance and had a history of incarceration in self or partner. The only venue of note was casinos. There was some association with methamphetamine use. Gonorrhea re-infection occurred among African-American males with characteristics of core transmitters. Those characteristics included drug-use, prostitution patronage, and long duration of symptoms.

    42. Conclusions - Network Analysis Detected one large network with very diverse race/ethnicity, age, and geography Included casino and travel history Beyond traditional field investigation, comprehensive network analysis requires systematic collection of data using uniform procedures

    43. Limitations – General Study Design No comparison group Incomplete data Not provided Not recorded consistently Limited Local Health Department resource Rotating State staff EIS The study design, the case series, limited our ability to make an association between risk factors and gonorrhea. Given that there was no comparison group like what is used in a case-control study, we were only able to describe characteristics of our cases but not make a statement that they differed from another population. There was inconsistent completion of interview forms. The interview form was long and detailed requiring a case to commit to a 20 minute interview. Some case patients were unwilling to complete the interview. The interview form training was inadequate. As a result there were many errors and mistakes in the form completion and several variables are unreliable such as condom use. Many cases were unwilling to provide information on contacts and we know that some cases were untruthful about their number of sex partners. Network analysis was not timely due to software availability and our training on its use. In the future, the network analysis should be used in a timely fashion to illustrate to field staff investigation progress on a daily basis.EIS The study design, the case series, limited our ability to make an association between risk factors and gonorrhea. Given that there was no comparison group like what is used in a case-control study, we were only able to describe characteristics of our cases but not make a statement that they differed from another population. There was inconsistent completion of interview forms. The interview form was long and detailed requiring a case to commit to a 20 minute interview. Some case patients were unwilling to complete the interview. The interview form training was inadequate. As a result there were many errors and mistakes in the form completion and several variables are unreliable such as condom use. Many cases were unwilling to provide information on contacts and we know that some cases were untruthful about their number of sex partners. Network analysis was not timely due to software availability and our training on its use. In the future, the network analysis should be used in a timely fashion to illustrate to field staff investigation progress on a daily basis.

    44. Limitations Network Analysis Lack of experience with formal network analysis Incomplete data Connections Infection status

    45. Potential Value of Network Analysis Nature of individuals in specific clusters Nature of network structure May help control future outbreak

    46. Acknowledgements California Department of Health Services, STD Control Branch Roxanne Aguirre Gail Bolan George Camarillo Jennifer Chase Stewart Coulter Juan Cruz Denise Gilson Brian Hughes Jan King Marcella Lemus Terry Lo Manny Olivas Shaheed Salahudin Butte County Health Department Sherry Bloker Charlotte Freer Mark Lundberg Alice Kienzle Carmen Ochoa Eric Sawtelle Lorna Andreatta Jim Gamez University of California Berkeley Ben Bellows Zurab Koberidze CDC David Callahan Stu Burman

    47. GC Cases in by Month Butte County, 2001-2004 This is the epi curve for years 2001-2003. A graph of gonorrhea cases by month in Butte County. These are all the cases. The aqua green represents Oroville cases, the light blue is Chico and the top grey is the Other area. Oroville cases, represented in green, represent the majority of gonorrhea cases. For this reason we focused our investigation on Oroville.This is the epi curve for years 2001-2003. A graph of gonorrhea cases by month in Butte County. These are all the cases. The aqua green represents Oroville cases, the light blue is Chico and the top grey is the Other area. Oroville cases, represented in green, represent the majority of gonorrhea cases. For this reason we focused our investigation on Oroville.

    48. For more information contact: Michael C. Samuel msamuel@dhs.ca.gov 510-540-2311 or Jan King jking@dhs.ca.gov 510-883-6643

    50. GC Cases Partner Characteristics Oroville, 2003 Cases were asked whether their partner had sex with others and the age of their partners. Similar percentages 63.2% for females and 63.6% for males believed that their partners were having sex with others. The next characteristic was the age of partners. We asked cases whether their sex partners were older younger or the same age. 55.6% of females reported that their partners were older versus 4.8% of males. 5.6% of females versus 52.4% of males reported that their partner was younger. This is consistent with cultural norms of women dating older men and men dating younger women. Cases were asked whether their partner had sex with others and the age of their partners. Similar percentages 63.2% for females and 63.6% for males believed that their partners were having sex with others. The next characteristic was the age of partners. We asked cases whether their sex partners were older younger or the same age. 55.6% of females reported that their partners were older versus 4.8% of males. 5.6% of females versus 52.4% of males reported that their partner was younger. This is consistent with cultural norms of women dating older men and men dating younger women.

    51. GC Case and Partner Incarceration History, Oroville, 2003 This slide illustrates gonorrhea case patient’s incarceration history. 51.4% of females and 50% of males stated that either they or their sex partner have ever been in jail, prison or Juvenile Hall. 18% of females had been in jail compared to 46.9% of males. No females had been in prison compared to 18.2 % of males. 5.1% of females and 15% of males had been in juvenile hall. Interesting 42.5% of women stated that their partners had been incarcerated versus a lower percentage of 21.7% of males. 13.5% females and 18.2% of males had both themselves and sex partner been incarcerated.This slide illustrates gonorrhea case patient’s incarceration history. 51.4% of females and 50% of males stated that either they or their sex partner have ever been in jail, prison or Juvenile Hall. 18% of females had been in jail compared to 46.9% of males. No females had been in prison compared to 18.2 % of males. 5.1% of females and 15% of males had been in juvenile hall. Interesting 42.5% of women stated that their partners had been incarcerated versus a lower percentage of 21.7% of males. 13.5% females and 18.2% of males had both themselves and sex partner been incarcerated.

    52. Percentage of GC Cases by Reported Number of Partners by Gender, Oroville 2003 This is a bar graph of the reported number of partners of the gonorrhea case-patients. The overwhelming largest frequency for women was 1 sex partner, for males 1 and 2 partners were split evenly. The frequencies decrease with increasing number of partners. The highest number reported was 10. Anecdotally, we know that some of the partners had more than the number stated.This is a bar graph of the reported number of partners of the gonorrhea case-patients. The overwhelming largest frequency for women was 1 sex partner, for males 1 and 2 partners were split evenly.

    53. Reported Number of Sexual Partners

    55. Limitations – Local Two parallel STD databases, neither complete Separation between Nursing and Health Education Lack of relationship with private laboratories EIS At the beginning of the investigation, when we were streamlining the flow of gonorrhea reports, we found out that there were two parallel STD databases. One listing was maintained by nursing and another by health education. The two databases were similar but there were significant differences. There were cases that were listed on one but not the other. This situation was remedied by nursing and health education collaboratively designing one database and protocol for the flow of STD CMR and laboratory reporting in Butte County. There was also a disconnect with nursing and health education in managing cases of gonorrhea. Health education has skills in interviewing and building community rapport while nursing has clinical background needed to insure adequate treatment and contact screening. Lack of a strong relationship with the laboratories prevented us from exploring the possibilities of enrolling controls and performing a case-control study.EIS At the beginning of the investigation, when we were streamlining the flow of gonorrhea reports, we found out that there were two parallel STD databases. One listing was maintained by nursing and another by health education. The two databases were similar but there were significant differences. There were cases that were listed on one but not the other. This situation was remedied by nursing and health education collaboratively designing one database and protocol for the flow of STD CMR and laboratory reporting in Butte County. There was also a disconnect with nursing and health education in managing cases of gonorrhea. Health education has skills in interviewing and building community rapport while nursing has clinical background needed to insure adequate treatment and contact screening. Lack of a strong relationship with the laboratories prevented us from exploring the possibilities of enrolling controls and performing a case-control study.

    56. Approaches to Network Analysis Standard Case/Contact/Cluster Approach Interview cases, contacts, and clusters treat untreated persons prevents further spread Network Analysis Approach Systematic collection of all data uniform procedures formally view, study, and understand network Prevent further spread and prevent/control future outbreaks

    57. Four case-patients had repeat infections during 2003; all were African-American males. Two Refused interview; 2 were interviewed. One interviewed case-patient had three gonorrhea infections during the investigation period. He initially refused interview but was then convinced to be interviewed while incarcerated. He stated that sex partner have had an incarceration history, injected drugs and at least one of his sex partners was likely was a commercial sex work. The second interviewed case had 2 gonorrheal infections during the investigation period. He was named by many cases, named as a drug dealer by others, may have had an incarceration history and traveled frequently to Sacramento, Reno, Chico, Susanville and Oakland. Most of this information came from social contacts and not the case-patient. Four case-patients had repeat infections during 2003; all were African-American males. Two Refused interview; 2 were interviewed. One interviewed case-patient had three gonorrhea infections during the investigation period. He initially refused interview but was then convinced to be interviewed while incarcerated. He stated that sex partner have had an incarceration history, injected drugs and at least one of his sex partners was likely was a commercial sex work. The second interviewed case had 2 gonorrheal infections during the investigation period. He was named by many cases, named as a drug dealer by others, may have had an incarceration history and traveled frequently to Sacramento, Reno, Chico, Susanville and Oakland. Most of this information came from social contacts and not the case-patient.

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