Gonorrhea in San Francisco

Kyle T BernsteinChief, Epidemiology, Research and Surveillance

STD Prevention and Control ServicesSan Francisco Department of Public Health

Gonorrhea Control in Region XI: Optimizing Strategies to Reduce Morbidity

Phoenix, AZJanuary 14, 2010

GC Diagnoses, San Francisco City Clinic 2008

Female MSM MSW

N 37 550 94

White 32.4% 60.5% 15.9%

Hispanic 8.1% 22.0% 11.7%

Black 56.7% 8.3% 63.8%

API 2.7% 7.4% 8.5%

Median age 26 34 34

Mean/Median partners (3 months) 13 / 2 7 / 4 3 / 2

HIV infected 2.7% 35.8% 0%

History of GC (3 years) 8.1% 40.0% 12.7%

Symptomatic 67.5% 54.9% 95.7%

CT co-infx 13.5% 21.6% 13.8%

Non-STD Clinic GC, SSuN

Female MSM MSW

N 100 98 17

White 17.0% 65.3% 52.9%

Hispanic 10.0% 15.3% 0%

Black 60.0% 4.1% 32.3%

API 11.0% 12.2% 11.8%

College or more 16.0% 51.2% 27.3%

Median age 24 39 40

Incarcerated in past year 8.0% 1.0% 5.9%

Symptomatic 29.0% 18.4% 41.2%

Partner incarcerated 8.0% 1.0% 5.9%

Mean age difference (last partner) -2 +3 +7

Non-STD Clinic GC, SSuN

Female MSM MSW

N 100 98 17

Been to STD clinic in past year 98.0% 98.0% 70.6%

Mean/Median partners (3 months) 2.6 / 1 5.3/ 3 2.8/ 2

HIV infected 0% 42.9% 11.8%

Internet partners (3mo) 2.0% 41.8% 5.9%

Anonymous sex (3 mo) 19.0% 45.9% 35.3%

Cocaine (1 year) 12.0% 10.2% 11.8%

Crack (1 year) 8.0% 4.1% 5.9%

Meth (1 year) 4.0% 17.4% 5.9%

Poppers (1 year) 0% 26.5% 0%

Number of cases

8 to 134 to 83 to 41 to 30 to 1

Gonorrhea Among FemalesBy Census TractSan Francisco, 2008

Number of cases

41 to 5324 to 4113 to 24

6 to 130 to 6

Gonorrhea Among Men Who Have Sex with MenBy Census TractSan Francisco, 2008

Number of cases

8 to 206 to 83 to 62 to 30 to 2

Gonorrhea Among Heterosexual MenBy Census TractSan Francisco, 2008

Approach

Screen, Treat, Treat, Screen

• Screening for MSM and adolescents• Quick and appropriate treatment of index

patient• Quick and appropriate treatment of partners• Rescreening in 3-6 months

Screening for MSM and Adolescents

• SFSTD supports dual GC/CT screening at STD clinic, jails, Magnet, sex worker clinic, and primary care clinics– Annual urogenital screening for females

• <26 years old• Pregnant• IUD insertion

– Rectal and pharyngeal screening for MSM/transmen/transwomen every 3-6 months

• Diagnostic testing supported for patients with symptoms or who are contacts to GC

• Sexual Health Promotion Team targets MSM and adolescents geographically to promote screening

Quick and Appropriate Treatment of Index

• Surveillance staff verify treatment of reported GC cases

• Cefpodoxime 400mg + azithromycin 1 gram PO x 1

• Mosaic penA PCR for GC

• Review of current treatment protocols– Transition to Ceftriaxone

Quick and Appropriate Treatment of Partners

• Patient-delivered partner therapy (PDPT)– Available to all patients tested at STD-supported

clinical sites– Also available through InSpot– Evaluation of PDPT at STD clinic

Exposed Re-infection Crude RR 95% CI All Patients

PDPT 921 123 (13.4%) 0.89 0.72-1.10 No PDPT 1194 180 (15.1%) 1.0 --

MSM PDPT 724 114 (15.75%) 0.89 0.72-1.11 No PDPT 959 169 (17.62%) 1.0 --

MSW PDPT 144 6 (4.17%) 0.71 0.26-1.93 No PDPT 152 9 (5.92%) 1.0 --

Females PDPT 52 3 (5.77%) 2.39 0.41-13.85 No PDPT 83 2 (2.41%) 1.0 --

Rescreening in 3-6 months• All patients with GC encouraged to re-

screen

• Reminder Phone Call Pilot– Pre-pilot 29.6% of women rescreened– Pilot 56.5% of women rescreened

• Two sided exact test p=0.085

– No difference for CT

Acknowledgments

• Julia Marcus

• Robert Kohn

• Sally Stephens

• Ameera Snell

• Monica Lee

• Andrew Reynolds

• Susan Philip