application of an epi profile: gonorrhea in the u.s
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Application of an Epi Profile: Gonorrhea in the U.S. Region V Gonorrhea Control Meeting. What is an epi profile?. Standardized way to analyze & interpret data Suggested, not required Provides evidence to support public health decision-making Supplement to classroom & on-the-job training - PowerPoint PPT PresentationTRANSCRIPT
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, [email protected]
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.