Steven J ShapiroInfertility Prevention Project Coordinator

Program and Training Branch

Infertility Prevention ProjectRegion I

Wells, MaineJune 6-7, 2011

National Center for HIV/AIDS, Viral Hepatitis, STD & TB PreventionDivision of STD Prevention

TopicsNational Infertility Prevention Project

CSPS 2011 and 2012 DSTDP Update Health Care Reform Gonorrhea

CSPS 2011 2011

@2010 levels -70/30 Awards• A 0.2% Rescission

Additional Funds -1.546 million dollars in FY 2010• $118K National Chlamydia Coalition• $190K Infrastructure Shortfall• $500K “The Future of IPP”• $730K Supplemental IPP Project Area Funds

o Expansion of CT/GC screening and treatment services

CSPS 2012 2012

@2010 levels Application Due August 2, 2011 Streamlined Application

• All requirements from FOA 09-902 remain in forceo Title X grantee Letter(s)o 3% Chlamydia Positivityo Targeted Gonorrhea Plans with Burden Calculationo Progress on General IPP Objectives

• Performance Measures Additional Guidance

• National Conference• Regional IPP Meetings• IPP Program Plans

GC Burden Calculation - Example Project Area X

Total IPP Funds = $500,000 Among women 25 and younger [ALL]

• 500 Gonorrhea and 10,000 Chlamydia• GC Burden = [500/(10000+500)] X 100 = 4.76%

IPP Funds to be used• $500,000 X 4.76% = $23,800• @ $10/test = 2380 tests available for targeting

DSTDP Update Personnel Changes Current Activities

PCSI Data Security and Confidentiality Guidelines Antibiotic-resistant Gonorrhea Outbreak response plan

Publications• GISP Profiles• Community Approaches to Reducing STD• CDC Grand Rounds- Chlamydia Prevention• NG with Reduced Susceptibility to Azithromycin- San Diego• DCL- Azithromycin Resistance in Hawaii

Health Care Reform

Health Care Reform Key Issues

Affordable Care Act and Performance Improvement National HIV/AIDS Strategy Agency Winnable Battles (HIV, Teen Pregnancy

Prevention)

“The Future of IPP” An Infrastructure-driven Evaluation

• IPP in the Project Areas• Environmental Scan• Recommendations for the Future

“The Future of STD Prevention”2012 and Beyond

Assurance Functioning Surveillance Systems Local Epidemiology Support PCSI

Policy Development Plan Programs using Data- all sorts of data

Assessment and Accountability Monitoring Evaluation

Safety Net Coverage

DRIP, DRIP, DRIP……

Gonorrhea—Rates by Age Among Women Aged 15–44 Years, United States, 2000–2009

Rate (per 100,000 population)

Year

0

200

400

600

800

1,000

2009200820072006200520042003200220012000

35–3940–44

30–34

25–2920–2415–19

Age Group

Gonorrhea—Rates by Age Among Men Aged 15–44 Years, United States, 2000–2009

0

150

300

450

600

750

2009200820072006200520042003200220012000

Rate (per 100,000 population)

Year

35–3940–44

30–34

25–2920–2415–19

Age Group

Gonorrhea—Rates by Race/Ethnicity, United States,

2000–2009

0

100

200

300

400

500

600

700

800

2009200820072006200520042003200220012000

WhitesHispanicsBlacks

Asians/Pacific IslandersAmerican Indians/Alaska Natives

Rate (per 100,000 population)

Year

Gonorrhea—Rates by County, United States, 2009

<19.0 (n = 1,405)

Rate per 100,000population

19.1–100.0 (n = 1,129)>100.0 (n = 607)

IS GONORRHEA DECREASING?

NATIONAL JOB TRAINING PROGRAM SCREENING DATA

National Job Training Screening Program

National Job Training Program (NJTP) Federally funded job preparatory program Economically disadvantaged men and women aged 16–

24 years 48 states and Washington, DC

Gonorrhea screening required at entry Contract laboratory performs tests Laboratory data shared with CDC Includes information on both positive and negative tests

Available information Sex, age, race/ethnicity Test technology Place and date tested

Why use NJTP data ? Information is available on all GC tests

Prevalence = XXX – number of people testing positive XXX – all people tested upon entry to

NJTP

Large, “stable” population 95,184 men tested for GC from 2004-2009 91,697 women tested for GC from 2004-2009 Consistent demographic each year

NJTP entrants have higher GC risk than U.S. population >70% < 19 years old >60% black >50% from South

Gonorrhea prevalence among men screened in the National Job Training

Program

80

180

280

380

480

580

680

0

0.5

1

1.5

2

2.5

3

3.5

2005 2006 2007 2008 2009

Case

rate

per

100

,000

per

sons

in N

ETSS

Perc

ent G

C po

sitive

in N

JTP

N= 95,184

GC prevalence Case rates in 15-24 year olds (NETSS)

Gonorrhea prevalence among women screened in the National Job Training

Program

80

180

280

380

480

580

680

0

0.5

1

1.5

2

2.5

3

3.5

2005 2006 2007 2008 2009

Case

rate

per

100

,000

per

sons

in N

ETSS

Perc

ent G

C po

sitive

in N

JTP

N= 91,697

GC prevalence Case rates in 15-24 year olds (NETSS)

Racial disparities among women in the National Job Training Program and

NETSS

Black

HispanicWhite

00.5

11.5

22.5

33.5

44.5

5

2005 2006 2007 2008 2009

GC P

reva

lenc

e

Year

GC prevalence by race/ethnicity among women screened in the National Job Training Program

White

Black

Hispanic

0

100

200

300

400

500

600

2005 2006 2007 2008 2009

Rate

per

100

,000

per

sons

Year

GC case rates among women in NETSS by race/ethnicity

NETSS DATA-TRENDS

Gonorrhea trends by project area, 2005–2010*

Large decrease

Moderatedecrease

Flat Moderateincrease

Largeincrease

BUT*…………. Significant Increases

L.A. 14% San Francisco 10% CPA 16% Hawaii 15% New Mexico 16% Massachusetts 26% Washington 25% Puerto Rico 35% NYC 15% New Jersey 21% Philadelphia 40% Pennsylvania 20% Maryland 20% Baltimore 10%

Maine 13%Massachusetts 26%New Hampshire 36%Vermont 14%

Connecticut <1%Rhode Island 9%

*NETSS DATA April 28 2011 (CY 2009-CY 2010)

Gonorrhea trends by project area, 2009–2010*

Large decrease

Moderatedecrease

Flat Moderateincrease

Largeincrease

RESISTANCE MDR GC

“The one who does not remember history is bound to live through it again.”

George Santayana

“The one who does not remember history is bound to live through it again.”

“Even those who remember history are still gonna be stuck living through it again.”

George Santayana

The gonococcus

GONOCOCCAL ISOLATE SURVEILLANCE PROJECT DATA

Phoenix Albuquerque

Dallas

San DiegoOrange Co.

Las Vegas

Portland

NewOrleans

Honolulu

San Francisco

Minneapolis

Philadelphia

Cincinnati BaltimoreChicago

Miami

Denver

AtlantaBirmingham

Seattle

Cleveland

BirminghamRegional Labs

AtlantaSeattleCleveland

Tripler AMC

Los Angeles Greensboro

Detroit

OklahomaCity

New YorkCity

Kansas City

Richmond

GISP sites and regional laboratories —

United States, 2010 (29 Sites)

Austin*

* Funded for FY2010 & FY2011 as regional lab, not yet functioning

Austin

Emergence of FQ Resistance: Hawaii

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

05

1015202530354045

Cipro available

Reports of FQ resistance

* CDC, MMWR 2000.

FQ not recommended for GC in Hawaii*

Perc

enta

ge o

f GIS

P is

olat

es r

esis

tant

to

cipr

oflox

acin

Hawaii

Emergence of FQ Resistance: California

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

05

1015202530354045

Hawaii*

California

Perc

enta

ge o

f GIS

P is

olat

es r

esis

tant

to

cipr

oflox

acin

* CDC, MMWR 2000; ** CDC, MMWR, 2002

FQ not recommended for GC in California**

Emergence of FQ Resistance:

MSM

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

05

1015202530354045 FQ not recommended for

MSM†

Perc

enta

ge o

f GIS

P is

olat

es r

esis

tant

to

cipr

oflox

acin

MSM

Hawaii*California**

* CDC, MMWR 2000; ** CDC, MMWR, 2002; † CDC, MMWR, 2004.

Emergence of FQ Resistance: Rest of the US (Excluding Hawaii & California)

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

05

1015202530354045

US

Hawaii* MSM†

California**

* CDC, MMWR 2000; ** CDC, MMWR, 2002; † CDC, MMWR, 2004.; ‡ CDC, MMWR, 2007.

FQ not recommended in US‡

Perc

enta

ge o

f GIS

P is

olat

es r

esis

tant

to

cipr

oflox

acin

GISP TRENDS

Distribution of MICs to Cefixime, 2005–2010*

0.015 0.03 0.06 0.125 0.25 0.50

102030405060708090

20052006

Perc

enta

ge o

f iso

late

s

Minimum Inhibitory Concentrations (MICs), µg/ml* Preliminary (Jan-Sept)

Distribution of MICs to Cefixime, 2005–2010*

0.06 0.125 0.25 0.50

1

2

3

4

5

6

7

20052006

Perc

enta

ge o

f iso

late

s

Minimum Inhibitory Concentrations (MICs), µg/ml

1.3%

(n=58)

0.2%

(n=8)

* Preliminary (Jan-Sept)

GISP Surveillance

“alerts”“Decreased

Susceptibility”

Distribution of MICs to Ceftriaxone, 2006–2010*

0.06 0.125 0.25 0.50

0.5

1

1.5

2

2.5

320062007200820092010*

Perc

enta

ge o

f iso

late

s

Minimum Inhibitory Concentrations (MICs), µg/ml* Preliminary (Jan-Sept)

Distribution of MICs to Ceftriaxone, 2006–2010*

0.06 0.125 0.25 0.50

0.5

1

1.5

2

2.5

320062007200820092010*

Perc

enta

ge o

f iso

late

s

Minimum Inhibitory Concentrations (MICs), µg/ml* Preliminary (Jan-Sept)

GISP Surveillance “Alerts”

Decreased Susceptibility

Geographic Distribution of Cephalosporin* Alerts , 2005

*Cefixime or Ceftriaxone

Geographic Distribution of Cephalosporin* Alerts, 2006

*Cefixime or Ceftriaxone

Geographic Distribution of Cephalosporin* Alerts, 2009

*Cefixime or Ceftriaxone

San DiegoOrange Co.

Geographic Distribution of Cephalosporin* Alerts, 2010

*Cefixime or Ceftriaxone

Proportion of GISP Participants Identified as Men who Have Sex with

Men (MSM), 1988–2010*

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

*05

101520253035

* Preliminary 2010 (Jan-Sept)Note: Among men with available sex of sex partner data

Percentage

Year

Distribution of MICs to Azithromycin, 2006–2010*

≤0.03 0.06 0.125 0.25 0.5 1 2 4 8 1605

1015202530354045

20062007200820092010*

Perc

enta

ge o

f iso

late

s

Minimum Inhibitory Concentrations (MICs), µg/ml* Preliminary (Jan-Sept)

Distribution of MICs to Azithromycin, 2006–2010*

2 4 8 160

0.05

0.1

0.15

0.2

0.25

0.3

0.35 20062007200820092010*

Perc

enta

ge o

f iso

late

s

Minimum Inhibitory Concentrations (MICs), µg/ml* Preliminary (Jan-Sept)

INTERNATIONAL TRENDS

Distribution of MIC for ceftriaxone, EURO-GASP, 2004–2009

European Center for Disease Prevention and Control (ECDC)http://www.ecdc.europa.eu/en/publications/Publications/1101_SUR_Gonococcal_susceptibility_2009.pdf

Recent Timeline• Japan

– 2000: Possible treatment failure with cefdinir (oral) (MIC 1=µg/ml)

– Decreased susceptibility to cefixime (oral) in Japan -- 0% (1999) to 30% (2002)

– 2002–2003: 4 possible treatment failures with cefixime (oral)

– 2009: isolate with ceftriaxone MIC of 2 µg/ml (CSW)

• China – (2001–2009): ~30-40% isolates have MICs to

ceftriaxone of ≥ 0.06 µg/ml (~3% in US in 2010)• Europe

– 2009: Increases in ceftriaxone MICs from Europe – 2010:

• 2 treatment failures with cefixime (Norway)• 1 pharyngeal treatment failure with ceftriaxone (Norway)• 2 possible treatment failures with cefixime (England)

Summary• “Alert” doesn’t mean resistance• Increasing MICs to cephalosporins (esp.

cefixime)– West– MSM

• Significance of higher MICs not yet known, but very concerning

• No treatment failures reported yet in US – Will be asking clinicians and HDs to

report treatment failures

Response to Treatment Failures• Collect culture specimen for

susceptibility testing• Re-treat with at least 250 mg

ceftriaxone and 1-2 g azithromycin• Ensure partner treatment• Consider infectious disease

consultation• Report case to local health

department

ITS NOT JUST GONORRHEA……

Chlamydia—Rates by County, United States, 2009

<300.0 (n = 2,052)

Rate per 100,000population

300.1–400.0 (n = 379)>400.0 (n = 710)

Questions?Thank you

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for HIV/AIDS, Viral Hepatitis, STD , and TB PreventionDivision of STD Prevention