Gonorrhea in California Gonorrhea Control in Region IX: Optimizing Strategies to Reduce Morbidity Phoenix, AZ January 14, 2010 Michael C. Samuel, Dr.P.H. Chief, Surveillance and Epidemiology Section, STD Control Brach Gail Bolan, M.D. Chief, STD Control Branch Division of Communicable Disease Control Center for Infectious Diseases, California Department of Public Health

Gonorrhea, Rates by Gender, California, 1990–2009 CA DPH STD Control Branch (rev 1/2010) Female Male

GC Outbreaks in California Butte, 2003, 95 cases –low SES, racial mixing, meth, incarceration, casinos? Central CA, 2004/5, 700 cases –meth, incarceration Lake County, 30+ cases –2009; core social network?

Distribution of Population and Cases by Race/Ethnicity California, 2008 Note:Charts exclude cases of multi and unknown race/ethnicity which accounted for 33.1% of total gonorrhea cases, 35.1% of total chlamydia cases, 4.7% of total P&S syphilis cases, and 0.4% of living AIDS cases. Source:California Department of Public Health, STD Control Branch and Office of AIDS

Gonorrhea, Female Rates by Race/Ethnicity and Age Group California, times white rate CA DPH STD Control Branch (rev 7/2009)

Gonorrhea Rates by Single Age and Age Categories Females Ages 0-65 years, California 2007

Gonorrhea Prevalence Monitoring, Percent Positive for Female Family Planning Quest Clients by Age Group & Race/Ethnicity, California, 2007 Note:Native American/Alaskan Natives were excluded due to low test volume. Source:California Department of Public Health, STD Control Branch; Quest/Unilab at San Jose, Sacramento and West Hills/Tarzana

African American Gonorrhea Cases, California 2008 (excludes LA and SF)

African American Gonorrhea Cases, Alameda County 2008

1 2 Gail Bolan Residence African American Gonorrhea Cases, Alameda County, Northwest Zoom, 2008

African American Gonorrhea Cases, Alameda County, Zoom 2, 2008

Gonorrhea Rates by Case Race/Ethnicity and Poverty Category of Case Census Tract (percent residents living below the federal poverty line) California, Note: Rates calculated by weighting the number of cases to account for geocodable cases lacking race/ethnicity data.

Gonococcal Isolate Surveillance Project (GISP), Percent of Neisseria Gonorrhoeae Isolates with Decreased Susceptibility or Resistance to Ciprofloxacin in Five California STD Clinics, 1990–2008 Note:Resistant isolates have MICs ≥ 1 μg ciprofloxacin/mL. Isolates with decreased susceptibility have MICs of – 0.5 μg ciprofloxacin/mL. STD Clinic Sites:Long Beach (ended participation in 2007), Los Angeles (added in 2003), Orange, San Diego, San Francisco CA DPH STD Control Branch (rev 7/2009)

GISP Alert Value and Resistant Isolates, CA GISP Data, * Cefixime was dropped from the testing panel at the beginning of 2007 and reinstated in 2009 ** Cefpodoxime was introduced in 2009; 2009 data not complete *** Can be more than one per isolate

Sexual Orientation by Region California Gonorrhea Surveillance Data, 2008

Selected Risk Characteristics for by Sexual Orientation California Gonorrhea Surveillance Data, 2008 Men Who Have Sex With Men (MSM) Heterosexual Men Heterosexual Women Internet Use to Meet Sex Partners43.2%5.1%2.7% Case Incarcerated3.4%23.7%9.0% Sex Partner Incarcerated4.6%5.2%22.8% Methamphetamine Use7.5%8.9%5.5%

Other Analyses Other GC Control-Related Data/Reports Available on Request –Re-infection –Matching to HIV/AIDS data –SSuN/CGSS Surveillance Evaluation –CGSS – risk factors –CGSS – appropriate treatment of GC by provider type –GISP MIC trends –Estimates/Projections of GC rates by race/ethnicity and sexual orientation Mapping/GIS Work Planned –Race-specific census tract-level maps for all races in addition to blacks –Demographic and risk (if available) characteristics of “hot spot” census tracts –Plotting key provider location data (including race-specific) on census tract- level maps

Program Activities Evidence-based guidelines –2006 GC Screening Guidelines –2005 GC Treatment Guidelines –Developing re-testing guidelines –Developing Ceph-R GC management guidelines Quality initiatives to improve GC clinical performance –Use of HMO and Family Pact prevalence data to alter screening practices –Use of CGSS Surveillance data to improve GC treatment

Non-Recommended Treatment, by Setting of Diagnosis California Gonorrhea Surveillance System, Weighted 2008 Data San Francisco gonorrhea cases excluded from analysis on setting of diagnosis 3 “Other” setting includes HIV Clinics, Hospital Inpatient, Military/VA, School-based Clinics, and Other

Program Activities Outbreak investigation and control –Partner management –Assess networks and venues –GISP “Alert” values Program Assessment and Evaluation –Screening (e.g. Family Pact, Juvenile Detention) –EPT (Family Planning Clinics) –Community Resource Assessment Racial Disparities –Staff training –Slide Set, Fact Sheet –Trainer Guide

Acknowledgements CA STD Control Branch: Surveillance and Epidemiology Section Disease Intervention and Field Investigation Section Program Development and Evaluation Section Health Promotion and Disease Prevention Section STD Mapping/GIS Working Group Racial Disparities Working Group Gonorrhea Control Working Group Contact:

Extra Slides

Black & White Gonorrhea Rates and Rate Ratios by Gender, California, 1990–2008 CA DPH STD Control Branch (rev 7/2009) Note: Race/ethnicity “Not Specified” ranged from 21.1% to 36.1% of cases for males in any given year.

Gonorrhea Rates by Health Jurisdiction & Race/Ethnicity California, 2008 ASIAN/PI AFRICAN AMERICAN LATINOWHITE Note:Cases with unspecified race have been redistributed based on the ratio of individual races to total known races. Cases with missing gender have been excluded from the gender-specific redistribution analysis. Source:California Department of Public Health, STD Control Branch

Assessing Counties/Census Tracts with High Concentrations of African American GC Cases – California, 2008

Assessing Counties/Tracts with High Concentration of African American GC Cases – California, 2008

Cumulative Proportion of Black & Total Cases Accounted for by Cumulative Proportion of Census Tracts, Gonorrhea, California, 1990–2008

Gonorrhea, Rates by Gender and Age Group (in years) California, 2008 Note: Gender “Not Specified” accounted for less than 0.5% of all cases. CA DPH STD Control Branch (rev 7/2009)

Gonorrhea, Rates by Gender and Race/Ethnicity California, 2008 Note:Race/Ethnicity was “Not Specified” for 33.5% of female cases and 32.4% of male cases for the given year. CA DPH STD Control Branch (rev 7/2009)

GISP Cephalosporin Alert Values Resistance thresholds not established for cephalosporins Alert values have been set at: –CeftriaxoneMIC >= –CefiximeMIC >= –CefpodoximeMIC >= In 2009 to date, 8 isolates have met or exceeded this threshold for cefpodoxime, 4 for cefixime, and 3 for ceftriaxone In addition, 5 San Diego isolates have exhibited exceptionally strong resistance to azithromycin (MIC >= 8.0; resistance >= 1.0) An enhanced interview protocol has been implemented that includes test-of-cure and re-culture for the index case and testing/treatment of partners FIX FORMAT