Steven J Shapiro Infertility Prevention Project Coordinator Program and Training Branch Infertility Prevention Project Region I Wells, Maine June 6-7, 2011 National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Division of STD Prevention

Topics National Infertility Prevention Project  CSPS 2011 and 2012  DSTDP Update  Health Care Reform  Gonorrhea

CSPS 2011  2011 levels -70/30 Awards A 0.2% Rescission  Additional Funds 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 levels  Application Due August 2, 2011  Streamlined Application All requirements from FOA remain in force o Title X grantee Letter(s) o 3% Chlamydia Positivity o Targeted Gonorrhea Plans with Burden Calculation o 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/( )] X 100 = 4.76%  IPP Funds to be used $500,000 X 4.76% = $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

 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

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

Gonorrhea—Rates by Race/Ethnicity, United States, 2000– Whites Hispanics Blacks Asians/Pacific Islanders American Indians/Alaska Natives Rate (per 100,000 population) Year

Gonorrhea—Rates by County, United States, 2009 <19.0(n = 1,405) Rate per 100,000 population 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  91,697 women tested for GC from  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

Gonorrhea prevalence among women screened in the National Job Training Program

Racial disparities among women in the National Job Training Program and NETSS

NETSS DATA-TRENDS

Gonorrhea trends by project area, 2005–2010* Large decrease Moderate decrease Flat Moderate increase Large increase

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 (CY 2009-CY 2010)

Gonorrhea trends by project area, 2009–2010* Large decrease Moderate decrease Flat Moderate increase Large increase

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 Diego Orange Co. Las Vegas Portland New Orleans Honolulu San Francisco Minneapolis Philadelphia Cincinnati Baltimore Chicago Miami Denver Atlanta Birmingham Seattle Cleveland Birmingham Regional Labs Atlanta Seattle Cleveland Tripler AMC Los Angeles Greensboro Detroit Oklahoma City New York City 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 Cipro available Reports of FQ resistance * CDC, MMWR FQ not recommended for GC in Hawaii* Percentage of GISP isolates resistant to ciprofloxacin Hawaii

Emergence of FQ Resistance: California Hawaii* California Percentage of GISP isolates resistant to ciprofloxacin * CDC, MMWR 2000; ** CDC, MMWR, 2002 FQ not recommended for GC in California**

Emergence of FQ Resistance: MSM FQ not recommended for MSM † Percentage of GISP isolates resistant to ciprofloxacin MSM Hawaii* California** * CDC, MMWR 2000; ** CDC, MMWR, 2002; † CDC, MMWR, 2004.

Emergence of FQ Resistance: Rest of the US (Excluding Hawaii & California) US Hawaii*MSM † California** * CDC, MMWR 2000; ** CDC, MMWR, 2002; † CDC, MMWR, 2004.; ‡ CDC, MMWR, FQ not recommended in US ‡ Percentage of GISP isolates resistant to ciprofloxacin

GISP TRENDS

Distribution of MICs to Cefixime, 2005–2010* Percentage of isolates Minimum Inhibitory Concentrations (MICs), µg/ml * Preliminary (Jan-Sept)

Distribution of MICs to Cefixime, 2005–2010* Percentage of isolates 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* Percentage of isolates Minimum Inhibitory Concentrations (MICs), µg/ml * Preliminary (Jan-Sept)

Distribution of MICs to Ceftriaxone, 2006–2010* Percentage of isolates 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 Diego Orange 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* * Preliminary 2010 (Jan-Sept) Note: Among men with available sex of sex partner data Percentage Year

Distribution of MICs to Azithromycin, 2006–2010* Percentage of isolates Minimum Inhibitory Concentrations (MICs), µg/ml * Preliminary (Jan-Sept)

Distribution of MICs to Azithromycin, 2006–2010* Percentage of isolates 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)

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 100,000 population 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 Telephone: CDC-INFO ( )/TTY: Web: 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 Prevention Division of STD Prevention