Application of an Epi Profile: Application of an Epi Profile: Gonorrhea in the U.S.Gonorrhea in the U.S.

Region V Gonorrhea Control Meeting

What is an epi profile?What is an epi profile?

• Standardized way to analyze & interpret dataStandardized way to analyze & interpret data• Suggested, not requiredSuggested, not required

• Provides evidence to support public health Provides evidence to support public health decision-makingdecision-making

• Supplement to classroom & on-the-job trainingSupplement to classroom & on-the-job training• Provides a common language for Provides a common language for

communication with other public health communication with other public health programsprograms

Why do we need an STD epi profile?Why do we need an STD epi profile?

• High burden of diseaseHigh burden of disease• Insufficient funding for unlimited program Insufficient funding for unlimited program

activitiesactivities• Few opportunities for classroom or on-the-job Few opportunities for classroom or on-the-job

training experiencestraining experiences• Technological advances allowing for more Technological advances allowing for more

sophisticated analysis of datasophisticated analysis of data

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 ProfileFramework for a GC Epidemiologic Profile

Identifying What STDs are InvolvedIdentifying What STDs are Involved

What STDs are of importance?What STDs are of importance?

Overlap in STDs : co-infectionsOverlap in STDs : co-infections

Changes over timeChanges over time

Important Data ElementsImportant Data Elements Number of testsNumber of tests Test resultsTest results Date of testDate of test

What?

Trends in Chlamydia, Gonorrhea, Trends in Chlamydia, Gonorrhea, and P & S Syphilis Morbidity,and P & S Syphilis Morbidity,

United States, 1999-2008*United States, 1999-2008*

Rate (per 100,000 population)

ChlamydiaGonorrheaP&S Syphilis

0

80

160

240

320

400

1999 2000 01 02 03 04 05 06 07 08*

*Preliminary data, will possibly increase

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

0

100

200

300

400

500

1941 46 51 56 61 66 71 76 81 86 91 96 2001 06

Rate (per 100,000 population)

Gonorrhea2010 Target

National Data Sources for GonorrheaNational Data Sources for Gonorrhea

Case reportCase report IncidenceIncidence

Infertility Prevention ProgramInfertility Prevention Program PositivityPositivity

STD Surveillance Network (SSuN)STD Surveillance Network (SSuN) Interviews of patients with gonorrheaInterviews of patients with gonorrhea STD clinic surveillanceSTD clinic surveillance

GISPGISP Gonococcal susceptibility profileGonococcal susceptibility profile

APHL surveyAPHL survey Public health lab test type and volumePublic health lab test type and volume

NHANESNHANES Population prevalence (?)Population prevalence (?)

Identifying Target PopulationsIdentifying Target Populations

Characterizing affected Characterizing affected populationspopulations

Changes over time?Changes over time?

Important Data ElementsImportant Data Elements AgeAge SexSex Race/ EthnicityRace/ Ethnicity Sex of PartnersSex of Partners Date of testDate of test

Who?

Gonorrhea rates by sex, 1981-2007Gonorrhea rates by sex, 1981-2007

Rate (per 100,000 population)

MaleFemale2010 Target

0

120

240

360

480

600

1981 83 85 87 89 91 93 95 97 99 2001 03 05 07

SSuN Population-based Gonorrhea Surveillance – SSuN Population-based Gonorrhea Surveillance – Sex and Sexual Orientation of Gonorrhea Patients, Sex and Sexual Orientation of Gonorrhea Patients,

2006-2008 (N=2,400)*2006-2008 (N=2,400)*

0

10

20

30

40

50

60

SF WA CO MN VA Total

Site

% o

f p

ati

en

ts

MSM MSW Women

* Preliminary data. Sexual orientation unknown for 51 men

22.1% MSM

Men Rate (per 100,000 population) Women

Age750 600 450 300 150 0 0 150 300 450 600 750

5.9 33.110-14286.0 647.915-19

450.1 614.520-24305.1 287.125-29

181.5 125.230-34119.5 60.535-39

86.6 30.840-4450.2 12.145-54

17.7 3.055-644.0 0.465+

113.9 123.8Total

Gonorrhea rates by age and sex, Gonorrhea rates by age and sex, 20072007

69%15-24 years

48%15-24 years

0

180

360

540

720

900

1998 99 2000 01 02 03 04 05 06 07

Rate (per 100,000 population)

American Indian/AK NativeAsian/Pacific IslanderBlackHispanicWhite

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

Female gonorrhea rates for 15-19 year olds by Female gonorrhea rates for 15-19 year olds by region and race/ethnicity, 2006region and race/ethnicity, 2006

0500

10001500

20002500

30003500

40004500

5000

Black Hispanic White

West

Midwest

South

Northeast

Rate (per 100,000 population)

Male gonorrhea rates for 20-24 year olds by Male gonorrhea rates for 20-24 year olds by region and race/ethnicity, 2006region and race/ethnicity, 2006

0

500

1000

1500

2000

2500

3000

3500

4000

Black Hispanic White

West

Midwest

South

Northeast

Rate (per 100,000 population)

Gonorrhea Positivity

Whites Black

All 0.4% (28,710) 4.0% (3,052)

15-1718-2122-24

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 Gonorrhea positivity, women 15-24, family planning clinics, by race, Washington State IPP, 2007*clinics, by race, Washington State IPP, 2007*

Identifying Areas of High MorbidityIdentifying Areas of High Morbidity

Geospatial distributions of Geospatial distributions of diseasedisease

Venues or providers seeing high Venues or providers seeing high burden of disease burden of disease

Changes over timeChanges over time Important Data ElementsImportant Data Elements

Geographic location of casesGeographic location of cases Type of provider or venue Type of provider or venue

where cases foundwhere cases found Local districtingLocal districting Current location of STD Current location of STD

servicesservices

Where?

Rate (per 100,000 population)

WestMidwestNortheastSouth2010 Target

0

60

120

180

240

300

1998 99 2000 01 02 03 04 05 06 07

Gonorrhea rates by region, 2000-2007Gonorrhea rates by region, 2000-2007

42%

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

Rate per 100,000population

Guam 82.4

Puerto Rico 8.2

Virgin Is. 63.5

<=19.0

19.1-100.0

>100

(n= 8)

(n= 25)

(n= 21)

VT 10.3NH 10.5MA 41.9RI 37.7CT 66.4NJ 69.6DE 151.5MD 120.5DC 408.1

236.7

86.4

82.1148.3

85.8 71.0

129.0

190.5

51.3

18.3

162.2 139.2

64.7

82.682.0

259.7

8.9

153.4

66.9

285.7

169.0

12.9

81.194.4

91.9

91.7

188.2

18.2

183.5

134.9

33.4

102.1

239.0

33.4

158.4

136.4

32.282.0

57.1

51.1

121.5

15.7

Positivity (%)

Puerto Rico 0.1

Virgin Is. 3.6

See*

<1.0

1.0-1.9

>=2.0

(n= 8)

(n= 24)

(n= 12)

(n= 9)

VT 0.1NH 0.1MARICT 0.6NJ 1.4DE 1.1MDDC

3.8

0.4

0.8 2.0

1.1 0.6

1.5

2.7

0.8

0.2

1.6 1.6

0.6

0.90.7

2.2

0.1

1.7

0.5

3.3

1.3

0.8

0.90.8

0.9

0.5

1.5

1.8

0.8

0.9

2.40.9

2.8

1.11.2

0.5

4.9

0.2

Gonorrhea — Positivity among 15- to 24-year-old women Gonorrhea — Positivity among 15- to 24-year-old women tested in family planning clinics by state, 2007tested 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 forDisease Control and Prevention

Gonorrhea — Rates by county, 2007Gonorrhea — Rates by county, 2007

Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population.

Rate per 100,000population

<=19.0 (n= 1,305)

19.1-100.0 (n= 1,099)

>100.0 (n= 736)

Identifying Contextual FactorsIdentifying Contextual Factors Risk factors impacting STDsRisk factors impacting STDs

Socio-demographics of population Socio-demographics of population servedserved

Social determinants of healthSocial determinants of health

Policies and LawsPolicies and Laws

Important Data ElementsImportant Data Elements Medical infrastructureMedical infrastructure Reported sexual and behavioral Reported sexual and behavioral

risk factorsrisk factors Partner types and partner Partner types and partner

characteristicscharacteristics Population demographicsPopulation demographics

Why?

Proportion of reported gonorrhea cases from STD Proportion of reported gonorrhea cases from STD clinics by sex, 1984-2007*clinics by sex, 1984-2007*

0

10

20

30

40

50

60

70

80

90

1984 86 88 90 92 94 96 98 2000 2002 2004 2006

*Preliminary 2007 data

Males

Females

% from STD clinics

SSuN Population-based Gonorrhea Surveillance – SSuN Population-based Gonorrhea Surveillance – Provider Type of Gonorrhea Patients Provider Type of Gonorrhea Patients

by Race/Ethnicity* by Race/Ethnicity* (excluding STD clinic patients)(excluding STD clinic patients)

Primary Care40%

Other12%

ER/Urgent Care33%

Prenatal1%

Jail/Prison3%

Family Planning6%

Hospital (other)5%

Other9%

Primary Care60%

ER/Urgent Care12%

Prenatal2%

Jail/Prison2%

Family Planning11%

Hospital (other)4%

Primary Care42%

Other17%

ER/Urgent Care20%

Prenatal2%

Jail/Prison2%

Family Planning9%

Hospital (other)8%

Blacks n=985

Whitesn=623

Hispanicsn=229

*Preliminary data

Reported gonorrhea rates in the United States and Reported gonorrhea rates in the United States and Utah, 1995-2006Utah, 1995-2006

0

20

40

60

80

100

120

140

160

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Rat

e p

er 1

00,0

00 P

op

ula

tio

n

U.S.

Utah

261% increase

Reported cases of gonorrhea by provider type, Utah, Reported cases of gonorrhea by provider type, Utah,

2000-20062000-2006

0

50

100

150

200

250

300

350

400

2000 2001 2002 2003 2004 2005 2006Year of Diagnosis

Nu

mb

er

of

Go

no

rrh

ea

Ca

se

s

HIV Test Site

STD Clinic

Family Planning

Other Clinic

Private Provider/HMO

Hospital (Inpatient)

Correctional Facility

667% increase

67% increase

Number of positive gonorrhea tests by test type by one Number of positive gonorrhea tests by test type by one private reference laboratory, Utah, 2001-2006private reference laboratory, Utah, 2001-2006

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2001 2002 2003 2004 2005 2006

Year

Num

ber

of G

onor

rhea

Tes

ts O

rder

ed

Culture DNA probe

DNA probe (combo) Amplified Detection APTIMA®

Amplified Detection APTIMA® (combo) Amplified Detection APTIMA®, ThinPrep™ (combo)

424% increase

Reported gonorrhea and chlamydia test* volume: Reported gonorrhea and chlamydia test* volume: Infertility Prevention Program, U.S., 2001 - 2006Infertility Prevention Program, U.S., 2001 - 2006

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

2001 2002 2003 2004 2005 2006

Gonorrhea

Chlamydia

*Positive and negative test results only.

32% increase

76% increase

Gonococcal Isolate Surveillance Project (GISP) — Gonococcal Isolate Surveillance Project (GISP) — Percent of Percent of Neisseria gonorrhoeaeNeisseria gonorrhoeae isolates with isolates with

resistance or intermediate resistance to ciprofloxacin, resistance or intermediate resistance to ciprofloxacin, 1990–2007*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

Percent

ResistanceIntermediate resistance

0

4

8

12

16

1990 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05 06 07

Gonococcal Isolate Surveillance Project (GISP) — Gonococcal Isolate Surveillance Project (GISP) — Prevalence of ciprofloxacin-resistant Prevalence of ciprofloxacin-resistant Neisseria Neisseria

gonorrhoeaegonorrhoeae by GISP site, 2004-2007* by GISP site, 2004-2007*

*Preliminary 2007 data

0%

25%

50%

'04 '05 '06 '07

QRNG Prevalence

BHM PHX

LBC LAX

ORA

SDG

SFO DEN

MIA

ATL

HON TRP

CHI

NOR

BAL

DTR MIN

KCY LVG

ALB

NYC

GRB

CIN

CLE

OKC

POR

PHI

DAL

RIC

SEA

SSuN Population-based Gonorrhea Surveillance – SSuN Population-based Gonorrhea Surveillance – Fluoroquinolone Use by Provider Type, Fluoroquinolone Use by Provider Type,

Colorado and Virginia, 2007Colorado and Virginia, 2007

0

10

20

30

40

50

60

70

80

90

100

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

STD clinics

ERs, Urgent Care, and Hospitals

Primary Care

Flu

oro

qu

ino

lon

es p

resc

rib

ed,

%

Family Planning

CDC recommendations changed Source: D. Dowell, preliminary data

n (cases)=1048

n (cases)=127

n (cases) =515

n (cases) =507

SSuN Population-based Gonorrhea Surveillance SSuN Population-based Gonorrhea Surveillance – Reported Risks over Past 3 Months* – Reported Risks over Past 3 Months*

by Gonorrhea Patientsby Gonorrhea Patients

   MSMMSM MSWMSW WomenWomen

Anonymous sex partner*Anonymous sex partner* 37.9%37.9% 17.9%17.9% 11.1%11.1%

Met sex partner through Met sex partner through InternetInternet 48.6%48.6% 2.5%2.5% 2.2%2.2%

Incarceration of patient or Incarceration of patient or partnerpartner 4.1%4.1% 14.7%14.7% 17.7%17.7%

How sure are you that this How sure are you that this partner got treated? partner got treated? ““SureSure”” 49.2%49.2% 48.8%48.8% 50.8%50.8%

*Preliminary data. Data not available for WA

Summary: Gonorrhea from a National PerspectiveSummary: Gonorrhea from a National Perspective

Who ?

Where?

What?

Why? •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

“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

AcknowledgementsAcknowledgements

STD Surveillance Network (SSuN) CollaboratorsSTD Surveillance Network (SSuN) Collaborators

Washington, Oregon, Idaho, Alaska & Utah Departments of Washington, Oregon, Idaho, Alaska & Utah Departments of HealthHealth

Statistics and Data Management Branch, DSTD, CDCStatistics and Data Management Branch, DSTD, CDC Darlene DavisDarlene Davis Rob NelsonRob Nelson

Epidemiology and Surveillance Branch, DSTD, CDCEpidemiology and Surveillance Branch, DSTD, CDC Lori NewmanLori Newman Deborah DowellDeborah Dowell Nandini SelvamNandini Selvam Hillard WeinstockHillard Weinstock Eileen YeeEileen Yee

Contact informationContact information

Melanie Taylor, MD, MPHTaylorm@azdhs.gov

602-364-4565

The findings and conclusions in this presentation havenot been formally disseminated by the CDC and should not

be construed to represent any agency determination or policy.