1. SALT Webinar STDALLIANCETEAM June 29, 2017 Strengthening U. S
SALT Webinar STDALLIANCETEAM June 29, Strengthening U.S. Response to Resistant Gonorrhea Epidemiology and Laboratory Capacity (ELC) for Infectious Disease Cooperative Agreement: SURRG Initiative
Lori Amsterdam, MPH
WI DPH STD Control Section
June 29, 2017
Epidemiology Coordinator (EC) & Program Manager for
Wisconsin SURRG Initiative

2. Outline of SURRG Overview
Purpose of ELC
Funded SURRG Sites
Some Gonorrhea Basics
CARB (Combating Antibiotic-Resistant Bacteria)
Current SURRG Activities
Long & Short Term Goals of SURRG
Structure of Wisconsin SURRG Initiative
Gonorrhea Epidemiology (John Pfister)
Milwaukee is the designated SURRG Jurisdiction in Wisconsin

3. Purpose of ELC
Build and strengthen epidemiologic, laboratory, and information systems capacity in public health departments to:
Identify and monitor occurrence of known infectious diseases
Detect new emerging infectious disease threats
Identify and respond to disease outbreaks
Develop and evaluate public health interventions

4. Funded SURRG Sites (n=9)
Wisconsin Jurisdiction = City of Milwaukee
Washington (Seattle-King County)
New York City
Wisconsin (Milwaukee)
California
(San Francisco)
North Carolina (Guilford County)
Indiana (Marion County)
Colorado (Denver County)
Georgia
(Fulton County)
Hawaii (Honolulu)

5. Gonorrhea Basics Caused by Neisseria gonorrhoeae Sexual Transmission
Gram negative diplococci (1879 Albert Neisser)
Sexual Transmission
Urogenital, rectal, and oropharyngeal infection
Vertical Transmission
Conjunctivitis
Symptoms & Sequelae
Often asymptomatic
Dysuria & discharge
PID & epididymitis
Disseminated infection
May facilitate HIV infection

6. Gonorrhea: Prevention & control
Identify
Infections
Treat
patient
partners
Population
CDC Screening recommendation
Women
Test all sexually active women age ≤24 and older women who are at increased risk for GC infection (CDC; USPSTF: Grade B)
Heterosexual men
Test if sexual history includes increased risk for GC infection (CDC; USPSTF: Grade I)
Men who have sex with men
Test at all exposed anatomic sites (CDC)

7. GC Selective Screening Criteria (SSC) WI FP Clinics: Females & Males
Level 1 GC SSC in higher GC morbidity clinics (Urban Milwaukee clinics & specified Semi-Urban area clinics)
Contact to partner with sx or dx of an STD
Symptoms
CT +
History STD
MSM
Clinician Assessment
Level 2 GC SSC in specified lower GC morbidity clinics
Contact with GC
Symptoms of GC

8. Gonorrhea Diagnostic Tests
Nucleic acid amplification tests (NAAT) recommended for men & women
Urine, vaginal, endocervical, extragenital swabs
Optimal specimen: first-catch urine in men and vaginal swabs in women
NAAT optimal for rectal and pharyngeal testing; not FDA approved but commercial validation protocols available for local labs
Limitations: no antibiotic resistance testing with NAAT
Culture: Ability to conduct antimicrobial susceptibility tests

9. GC Treatment Dual therapy recommended
Enhance treatment effectiveness
Prevent transmission of resistant organism
Azithromycin preferred over doxycycline due to high prevalence of tetracycline resistance & compliance with one dose treatment
No clinical data to support increasing dose of ceftriaxone or azithromycin as part of dual therapy
Ceftriaxone treatment failures uncommon
Azithromycin monotherapy not recommended due to ease of resistance (treatment failures)
Test of cure (TOC) not needed after treatment for urogenital or rectal infection; TOC is recommended for pharynx if treated with alternative regimen

10. Suspect Treatment Failures
Reinfection is common, and most treatment failure likely due to reinfection
If treatment failure suspect, obtain culture/ susceptibility test + ensure partner treatment
If received recommended treatment (ceftriaxone/AZ), first treat as a reinfection:
ceftriaxone 250 mg +azithromycin 1gram
If received alternative recommended treatment (400 mg cefixime/AZ 1 gram), first treat as a reinfection: ceftriaxone 250 mg + azithromycin 2 gram
If treatment failure suspected/supported by history and laboratory AST, treat with oral gemifloxacin 320 mg +azithromycin 2 g OR gentamicin 240 IM + azithromycin 2g (Kirkaldy CID 2014)
Report to local or state health department
Test of cure 7-14 days after retreatment/ (culture & AST test with simultaneous NAAT)

11. Gonococcal Isolate Surveillance Program (GISP)
Established in 1986 to monitor trends in N. gonorrhoeae susceptibility to antimicrobials
Collaboration between CDC, clinical sites, and laboratories
Directly inform CDC STD Treatment Guidelines
Data disseminated through routine surveillance reports
MHD Laboratory is not a GISP site, but has conducted AST on GC isolates for many years

13. Antimicrobial Resistance (AMR) gonorrhea
Undermines treatment success
Heightens risk of complications
Facilitates transmission

14. Timeline of Introduction of Antimicrobials and Emergence of Resistance
Cephalosporin's??
Ciprofloxacin
(Fluoroquinolones)
Tetracycline
PPNG
Penicillin (chromosomal)
Sulphonamides
1940
1950
1960
1970
1980
1990
2000
2010
2020
PPNG = penicillinase-producing N. gonorrhoeae
Adapted from: Goire N et al. Molecular approaches to enhance surveillance of gonococcal antimicrobial resistance. Nature Reviews Microbiology 2012

15. Antibiotic Resistance
I don’t need to go over too much about how AR occurs but this graphic and the Get Smart website is a great resource to send to public health professionals and patients for more easy to digest information.
Phenotypic assays measure the drug susceptibility of the bacteria by determining the concentration of drug that inhibits replication (AST/Etest). Genotypic assays determine the presence of mutations that are known to confer decreased drug susceptibility (WGS= whole genome sequencing).
Source: Image:

16. Global Warning Signs
1st cephalosporin treatment failure reported in Japan (2001)
Additional treatment failures reported throughout Asia and Western Pacific ( )
All reported increasing cephalosporin MICs  early warning for potential resistance
First highly ceftriaxone-resistant strain identified in Japan (2009)
Associated with ceftriaxone treatment failure (pharyngeal); ceftriaxone MIC 2 µg/ml, cefixime MIC 8 µg/ml
Over time, Europe & U.S. have been reporting increasing cephalosporin MICs ( )
Cefixime (oral cephalosporin) treatment failures noted in Europe & Canada
Second high-level ceftriaxone resistant strain reported in France & Spain (2011)
Ceftriaxone MIC 1-2 µg/ml

17. GC Resistance Found in the U.S.
A cluster of antibiotic-resistant gonorrhea cases was found in Hawaii
in late 2016, which highlighted the growing need for
antimicrobial resistant GC intervention.
So why do we want to expand? This was late 2016 and a big warning for the rest of the country. 7 cases all with RS AZ and 5 with RS Ceftriaxone.
I was at a conference and only just made aware of the new SURRG project when this story was released; quite timely.
Source:

18. Conclusions Gonorrhea is common in the U.S.
Rates of reported cases are increasing
Screening and prompt, effective dual treatment can help prevent sequelae
Resistance is urgent threat
Dual therapy still highly effective
Declining cephalosporin and azithromycin susceptibility threatens last recommended gonorrhea treatment
National and global AR GC surveillance is critical
Epidemiological and laboratory data help to better understand the populations at highest risk
Standardized global surveillance of AR gonorrhea will help better monitor trends
New antimicrobials & innovative prevention and control strategies are urgently needed

19. Combating Antibiotic-Resistant Bacteria (CARB)
National Target:
By 2020, US will maintain prevalence of
ceftriaxone-resistant GC at <2%

20. Combatting Antibiotic Resistant Bacteria [CARB]
Epidemiology and Lab Capacity [ELC]
SURRG: Rapid Detection and Response to AR GC
ARLN: Reference Labs

21. Sites Involved in CDC STD CARB Activities
Washington
King County (WA)
New York City
Seattle
Minnesota
Buffalo
Multnomah County (OR)
Cleveland
Columbus
Boston
Portland
Minneapolis
Milwaukee
Massachusetts
Pontiac
Philadelphia
Maryland
Baltimore
Chicago
San Francisco
Marion County (IN)
Indianapolis
Las Vegas
California
Denver
Kansas City
Guilford County (NC)
Los Angeles
Tennessee
Greensboro
Orange County (CA)
Phoenix
Fulton County (GA)
San Diego
Albuquerque
Birmingham
Atlanta
Dallas
Tripler Army Medical Center (HI)
Florida
Texas
New Orleans
Honolulu
Maryland
Texas
Tennessee
Washington
New AR Lab Sites
Denver
Fulton County (GA)
Guilford County (NC)
Honolulu
King County (WA)
Marion County (IN)
Milwaukee
New York City
San Francisco
SURRG Sites
SSuN Sites
GISP Sentinel Sites
Albuquerque
Atlanta
Birmingham
Boston
Buffalo
Chicago
Cleveland
Columbus
Dallas
Greensboro
Honolulu
Indianapolis
Kansas City
Las Vegas
Los Angeles
Minneapolis
New Orleans
New York
Orange County (CA)
Philadelphia
Phoenix
Pontiac
Portland
San Diego
San Francisco
Seattle
Tripler Army Medical Center (HI)
Baltimore
California
Florida
Massachusetts
Minnesota
Multnomah County (OR)
New York City
Philadelphia
San Francisco
Washington
* New Surveillance for Resistant GC (TBD)

22. CDC Division of STD Prevention (DSTDP) SURRG Related CARB Projects
Current CDC STD projects supported by CARB:
Gonococcal Isolate Surveillance Project (GISP)
STD Surveillance Network (SSuN)
Continuing & NEW DSTDP projects funded by CARB:
Antibiotic Resistance Lab Network (ARLN)
SURRG Rapid Detection and Response Capacity
Enhanced Gonococcal Isolate Surveillance Project (eGISP)
WI DPH & MHDL submitted proposal
Enhanced GC Isolate Surveillance (eGISP)
Improve specificity of local surveillance for AR GC
Distinguish Neisseria meningitis urethritis from NGC
NM can show GNID* &/or culture positive (suggestive of NGC)
Isolates GNID positive but negative for NGC on NAAT sent to CDC for confirmatory testing
Combined HIV & STD Prevention & Care for Vulnerable Men who Have Sex with Men & Transgender Women via Network Methods
GNID*: Gram negative intracellular diplococci

23. Antibiotic Resistance Lab Network (ARLN)
Purpose
Provide infrastructure and lab capacity for regional labs to detect and support response to resistant organisms like AR GC
Responsibilities
Conduct susceptibility testing for GISP
Provide confirmatory susceptibility testing for ‘Rapid Detection and Response’ SURRG sites
Provide Whole Genome Sequencing (WGS) data by 2018
Act as regional GC labs, receiving ALL GC isolates from the 9 SURRG sites

24. Antibiotic Resistance Lab Network (ARLN)

25. Proposed ARLN designations
SURRG Site
ARLN
Denver/CO
Texas
Fulton county/GA
Tennessee
Guilford county/NC
Maryland
Honolulu/HI
UW/Washington
King county/WA
Marion county/IN
Milwaukee/WI
New York City/NY
San Francisco/CA

26. Etesting in Local SURRG Labs for Antimicrobial Susceptibility
Antibiotic Susceptibility Testing (AST) allows lab technicians to monitor the Minimum Inhibitory Concentration (MIC) of specific drugs on cultured bacteria
The test currently used is the BioMerieux Etest
High MIC levels signify reduced susceptibility and require public health intervention
Already touched upon today, but we are looking for the level of medication needed to stop bacterial growth (MIC). We are expanding culturing and our informatics for this test.
-This is not GC but just an example of AST and how MIC are measured.
Standard NAAT tests, which most of you use, don’t allow for this study. A bit of a time warp to the old-school techniques. The reversal back to culturing is needed to complete the project.
Source: Pham, C. (2016). Neisseria gonorrhoeae Antimicrobial Resistant Laboratory Testing-K8. Atlanta, GA 11/2/16

27. Interpretation of N. gonorrhoeae Antimicrobial Susceptibility Testing (Minimum Inhibitory Concentrations/MICs)
CLSI:
Susceptible
Resistant
CDC/Surveillance: Reduced Susceptibility (“Alert”)
CDC/Surveillance: Reduced Susceptibility (“Quick Send Alert”)
Azithromycin — ≥2
≥16
Cefixime
≤0.25
≥0.25
≥1.0
Ceftriaxone
≥0.125
Note: MIC values in µg/ml
To ARLN
w/in 7 days
To ARLN & CDC
w/in 24 hrs
Source: Schlanger, K. (2016). Building Rapid Detection and Response Capacity to Mitigate the Threat of Antibiotic Resistant GC. CDC SURRG ELC Grantees Meeting. Atlanta, GA Updated per SOP 6/29/17

28. What is SURRG? Strengthening U.S. Response to Resistant GC
Initial activities have focused on strengthening local and community infrastructure and laboratory capacity to rapidly detect and respond to a subset of high risk patients with GC & resistant GC
Long term goals:
Better understanding of local GC sexual and social networks
Track resistant GC transmission through the population at the molecular level
Use epidemiological data to identify opportunities for targeted interventions
First, who is SURRG?
-6 individuals currently employed and training for the program
Currently, we are wrapping up the initial phases of building the data collection tools and community partnerships.
Moving towards program critique and refinement.
Source: Schlanger, K. (2016). Building Rapid Detection and Response Capacity to Mitigate the Threat of Antibiotic Resistant GC. CDC SURRG ELC Grantees Meeting. Atlanta, GA 11/2/16

29. What is a Social Network?
A group of people or a place where interactions occur and/or interrelationships develop between people
“First we argue that individually-based risk factors must be contextualized by examining what puts people at risk of risks……”
“ Second, we argue that social factors, ……..are likely "fundamental causes" of disease, that because they embody access to important resources affect multiple disease outcomes through multiple mechanisms and consequently maintain an association with disease even when intervening mechanisms change”.
“Without careful attention to [these social factors] we run the risk of imposing individually-based intervention strategies that are ineffective [in and of themselves], and will miss opportunities to adopt broad-based societal interventions that could produce substantial health benefits for our citizens”.
Source: Social Conditions as Fundamental Causes of Disease: BRUCE G. LINK Columbia University and New York State Psychiatric Institute; JO PHELAN University of California. Los Angeles; Journal of Health and Social Behavior 1995
First, who is SURRG?
-6 individuals currently employed and training for the program
Currently, we are wrapping up the initial phases of building the data collection tools and community partnerships.
Moving towards program critique and refinement.

30. SURRG Year 1 Activities
Scale up collection of specimens for GC culture
From both genital and extra-genital sites in males and females
From patients attending Non-STD partner clinics
From contacts identified through DIS investigations with 1st and 2nd generation sexual partners and 1st generation social contacts, to better understand local GC sexual and social networks
Design and upgrade local informatics systems
To develop data systems for metrics collection and program evaluation
To coordinate data flow between SURRG entities in WI (STD Clinics, non-STD partner clinics, MHD Laboratory, KHC & DIS, WI DPH, & CDC)
To collect, prepare, and send isolates and key data to our partner ARLN laboratory in Texas, & CDC (May 2017 from WI)
To share and communicate with other SURRG sites in order to develop best practices for public health GC response activities
Not only expand outside of the STD clinic but also expanding testing (expand GISP).
-The collection sites for males AND females. As well as extra genital.
Data collection tools are being finalized so all sites across the country are standardized.
Indiana SURRG Site EC: Justin Holderman, MPH

31. Structure of SURRG in Wisconsin
Epidemiology Coordinator (EC)
Jurisdiction (> 200 GC cases reported) Contractual Partner Agency in Milwaukee
Milwaukee City Health Department Laboratory (MHDL)
Milwaukee City Health Department (MHD) Keenan STD Clinic
Contractual Partner Agency
Health Care Education & Training (HCET)
GC Antibiotic Resistance Prevention (GARP) Teams & Workgroups
GARP Subcommittee Co-chairs meet monthly with EC
Administrative/Contractual SURRG partners & EC meet monthly with CDC SURRG Team
Full GARP team members meet Face to Face (F2F) biannually
First F2F meeting December 15th, 2016: Zilber School of Public Health, Milwaukee
Second F2F meeting July 13, 2017

32. Meet our WI GARP Team! Gonorrhea Antibiotic Resistance Prevention
WI DPH STD Section in Madison, WI
STD Control Section Director: Anthony Wade, Federal Assignee
SURRG Project Manager & EC: Lori Amsterdam
Epi Analyst: John Pfister
DIS Trainer: Loriann Wunder
WEDSS Unit Supervisor: Amy Bittrich
WSLH in Madison, WI
Data Management & ELR Coordinator/Surveillance Reporting: Mary Wedig
MHDL in Milwaukee, WI
Laboratory Director: Sanjib Bhattacharyya
Lead Microbiologist: Manjeet Khubbar
Laboratory Information Systems (LIS) Specialist: Noah Leigh
SURRG Surveillance Coordinator (IT/Data Manager), SURRG LIS Consultant, SURRG Microbiologist II:

33. Meet our WI GARP Team! MHD Keenan STD Clinic
MHD Associate Medical Director: Paul Hunter, MD
Communicable and Infectious Disease STD Clinic & SURRG Team Manager: Julie Katrichis, RN
Keenan STD Public Health Nurse: Tim Maher
CDC Special Projects Coordinator: Darlene Turner-Harper
CDC Field Operations Manager: Otilio Oyervides (OT)
SURRG-DIS Epi Investigation Team x 2: Hired April 2017
Partner Agency HCET Offices in Madison, WI & Indianapolis, IN
STD Project Manager: Jeremy Roseberry
Facilitation & coordination of GARP communications, monthly, quarterly, bi-annual meetings, webinar and technical support
Consultant Epi Analyst: John Pfister

34. Wisconsin GARP Workgroups Planning of Activities, Knowledge Base and Co-chair(s)
Laboratory- Sanjib Bhattacharyya
Performs & plans sampling for GC testing, culturing & transport methodology, AST using Etest, collection of laboratory, clinical and epi-investigation data elements from STD and non-STD clinical partner agencies and transport of isolates and accompanying data to ARLN & CDC
Clinical- Julie Katrichis
Performs & plans sampling & transport of GC culture specimens, performs risk assessment & collection of clinical data elements at STD & non-STD clinics
Disease Intervention Specialists- Loriann Wunder, Vanessa Vann
Plan and prepare protocols and perform DIS training for GC index patient and partner f/u & other DIS activities, and training to ensure collection of all required epi-investigation data elements
Data Infrastructure & Data Management- Amy Bittrich, Mary Wedig
Implement plans to integrate rapid electronic communication of test results and reporting to providers, field, health departments, ARLN & CDC
Epi Analytic- Brandon Kufalk, Marisa Stanley
Merging & data compilation from local LIMS/surveillance systems of collected data elements to complete performance metrics reporting, and data transmission to CDC. Coordinates the collection and analysis of clinical, laboratory and epi- case investigation data elements, including social/neighborhood network data and subtyping & genome sequencing data to identify high risk transmitter factors
Community Outreach- Chairs not yet identified
Purpose of this workgroup is to promote provider & patient awareness of GC morbidity/SURRG activities, in the Milwaukee jurisdiction community

35. Community Outreach New tools from CDC
Dear Partners in Prevention, Concerning developments reported last year suggest that gonorrhea may be beginning to outsmart our last recommended treatment. Keeping an eye on antibiotic resistance has never been more important. CDC has developed these new tools to assist in your efforts to make sure your communities are aware of the emerging threat of drug-resistant gonorrhea and to help them better understand the issue:
A  NEW video animation was developed to help raise awareness about drug-resistant gonorrhea. It illustrates gonorrhea’s history of overpowering almost every drug ever used to treat it, the current battles we face as the bacterium evolve, and the dangers of this common infection becoming untreatable. Please share with your memberships and those who seek to educate community leaders and others about this topic.
The 2015 Gonococcal Isolate Surveillance Project (GISP) Profiles are also now available. In addition to the national antimicrobial susceptibility results included in the 2015 STD Surveillance Report, the GISP Profiles provide a one-stop resource to assure you have the most up-to-date national and local CDC antimicrobial susceptibility data. For more than 30 years, these data have helped those of us in public health ensure gonorrhea is successfully treated with the right drugs.
Thank you for your continued commitment to prevention and your efforts to keep drug-resistant gonorrhea a top public health priority.
Sincerely, Gail Bolan, M.D. Director, Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention U.S. Centers for Disease Control and Prevention

36. Workgroup Implementation Planning 5 Key Strategic Directions January-June 2017
Increase the number of GC culture specimens collected for isolation of GC to increase AST E-testing of isolates
Identify high risk criteria for selection/prioritization of GC positive index patients to receive follow-up and partner services in addition to “Alert MIC/High Alert MIC” cases
Risk profile might include GC patient who self-reports as MSM, & repeat GC infection, & from highest morbidity Milwaukee zip code
Increase the # of high risk GC index patients followed up and partner services initiated
Identify and prioritize data infrastructure upgrades to enable efficient collection and rapid transmission of clinical, laboratory and DIS data elements on GC positive patients and their partners
LIMS in MHDL
EMR in KHC
Improve current manual methods (upgrade to electronic interface/transmission) to merge clinical, laboratory and DIS data elements into one database for analytic and reporting purposes

37. Data Flow & the Intersection of Data Streams for SURRG
Clinical isolate submission
Laboratory data
Epidemiologic data
Core clinical index patient data (EHR/EMR)
Expanded DIS field investigation data

38. Data Sources & Key Personnel Involved
EC & Epi Analyst
Local STD Clinics (KHC; STDMIS; WEDSS)
Local PHL
GC Surveillance Data Manager (MHDL; LIMS)
Other Healthcare Partner Clinics (BEST; PPW; WEDSS & e-data extractions )

39. High Alert isolates w/in 24 hrs
Milwaukee KHC STD Clinic
CDC
High Alert isolates w/in 24 hrs
Local MHDL PHL
ARLN Lab
Etest AST
All GC isolates monthly
Alert and High Alert isolates w/in 24 hrs
Agar dilution AST
Next generation sequencing
SURRG Isolate and Data Flow Pathways
Non-STD Partner Clinic
WI DPH STD Program

40. SURRG STD Clinic & Health Center Partners Reported Morbidity January-December 2016
Baseline Data:
MHD Keenan STD Clinic
521 total GC cases reported/ 4,136 patients tested (12.6% positivity)
SURRG Health Center Partners
Brady East STD Clinic (BESTD)
Among males, 108 total GC positives/1,872 tests (5.8% positivity; 2016)
45.9% of total tests were collected from extragenital sites (859/1,872 oral and rectal combined)
57 GC positives/859 extragenital specimens (6.6% positivity)
2 FP clinics in Milwaukee (WI Ave & Northwest)
580 total GC positives/12,901 tests (4.5% positivity; 2016)

41. Baseline AST Data at Keenan STD Clinic Reported Morbidity January-December 2016
MHD Keenan STD clinic
75% (389/521) of GC cases tested with NAAT, also provided specimens from multiple sites for culture, yielding a total of 480 GC culture specimens (from urethral, pharyngeal, and/or rectal swabs)
82% (392/480) of these cultures yielded positive isolates
AST was performed on 98% (384/392) of these isolates
6% (23/392) of all isolates were resistant to Cipro (so 5% (19/369) of GC+ patients were resistant to Cipro)
0% resistance or reduced susceptibility to Cefixime or Ceftriaxone

42. Plans to Increase AST of GC Isolates SURRG STD Clinics & Non-STD Partners January-December 2016
STD Clinics in Milwaukee (Keenan & BEST)
Increase cultures sent to MHDL for Etest from Females and extragenital specimen sites from STD clinics, from 392 AST isolates (2016) to 750 AST isolates using Etest in 2017
Keenan: 43.1% of NAAT testing Jan-Dec 2016 among females were from extragenital sites (6.4% +)
BESTD: 45.9% of NAAT & culture testing Jan-Dec 2016 among males were from extragenital sites (7.1% +)
Non-STD Partners
Increase cultures sent to MHDL for Etest from Females and extragenital specimen sites for an additional 250 Etest isolates from non-STD clinic settings in 2017
2 FP clinics in Milwaukee: 69% of NAAT testing (7,177 /10,450; 2016) among females were swabs from extragenital or cervical sites (3.0% +)

43. GC Testing, Culture Protocol Keenan Health Center (KHC) Increase Collection of Culture Specimens: Males, Females, Extragenital & MSM
In addition to NAATs testing, Public Health Nurses (PHNs) collecting GC cultures from patients attending KHC- STD clinic who meet the following criteria as of May 2017(unless refused by patient):
Clients exposed during sexual contact to a partner with GC:
GC cultures from all sexually exposed sites (urethral [males], cervical [females], rectal, and/or pharyngeal) are collected
Men with positive gram stain for intra/extracellular diplococci or with discharge consistent with GC:
GC culture is collected using urethral swab; PHNs collect GC cultures from other sexually exposed sites based upon patient reported risk history. If ceftriaxone is NOT used as part of the treatment regimen, cultures from all exposed sites are collected
Clients returning for treatment for NAAT positive GC test result:
GC culture is collected from all sites for which the GC test was positive
Females with mucopurulent cervical discharge:
Cervical GC culture is collected
Men who have sex with men who report pharyngeal and/or rectal sexual exposure:
GC culture of sexually exposed sites is strongly recommended to patient

44. Other Requirements/Expectations SURRG Year 1
Monthly CDC led calls with EC, Lab & Clinical Chairs, & Epi Analyst (beginning November, 2016)
Monthly performance metrics reports (due monthly after SURRG protocols implemented; April 2017)
Annual Progress Report and Continuation Application (Submitted: May, 2017 for SURRG Year 2)
CDC provides monthly CARB reports to CARB oversight office, that in turn reports directly to the White House. Grantee information from monthly performance metrics reports and grantee phone calls provide content for these CARB reports
RDR is White House-driven
Expect considerable oversight and greater than-average reporting requirements

45. Long-Range Vision for SURRG in US: Multipronged Approach
Reduction in overall GC morbidity to mitigate threat of resistance and use epidemiological network and population approaches to identify and reduce GC & AR GC outbreaks
Promote and expand GC resistance testing & surveillance with assistance from community partners, innovative DIS interviews, and social network analysis
Expanded monitoring of GC isolates with AST to ensure appropriate treatment for GC and expand investment in culture-based surveillance to detect resistance and mutations
Add whole genome sequencing(WGS)to surveillance tool box to better understand transmission dynamics
Use currently available AST tools until molecular tools are available to quickly identify GC & AR GC outbreaks
Develop new diagnostics, new treatment options and new prevention approaches
Rapid molecular assays to detect susceptible and resistant strains
GC vaccine

46. Ways to Use Molecular Data
Monitor drug resistance
Understand transmission patterns
Using molecular surveillance data to identify, investigate and intervene recent transmission events can support efforts to improve health outcomes and prevent transmission
Identify possible outbreaks and trigger investigation and intervention
Cluster data can be a powerful tool to help target the interventions we know are effective
 Monitor outbreaks over time
 Identify networks with active transmission
 Prioritize prevention efforts
The possibilities opened up by using these data for prevention planning and public health intervention are great

47. Take Away Messages
SURRG is a high-profile activity that requires regular reporting of performance metrics and monthly progress calls
Initial activities focus on strengthening infrastructure and capacity to rapidly detect and respond to GC & resistant strains of GC
SURRG funding is our “syphilis elimination” moment to reduce GC morbidity in Milwaukee
Longer term goals include using a variety of data sources (including genomic data) to:
better understand GC networks and AR GC transmission,
use data to identify opportunities for interventions,
move GC control toward population-level approaches to reduce overall GC burden
Although activities are implemented in only a sample of 9 jurisdictions, lessons learned will be applicable nationally
K8 funding is dedicated to controlling AR GC, but there is a lot that can
With great power comes great responsibility.
The stern talking to:  This is a very high profile activity, and we expect a tremendous amount of Congressional and CDC scrutiny in how the money is being spent and the impact of the funding.  I would not be surprised if there were adverse funding implications in the future if we blow this. So the epi coordinator should expect to be responsible for regular reporting to us on progress. And although the project will look a bit different in each jurisdiction, we will also be directive when needed to ensure that we have something to show for the investment in 5 years.  This money is not to backfill existing positions and disappear into thin air but needs to be dedicated to the project objectives.   This is a lot of money, and we’re going to be asking a lot of you.
We plan this as a 5 year project, and we expect all of you to cross the finish line with us in 5 years.  But you need to re-apply for each year of funding, and we will stop funding sites that are using funds in ways that are at odds with project objectives and goals.
be learned about general GC control in the process.
Funding should be dedicated to GC—and must be justifiably spent in a way that controls AR GC

48. Credits, Acknowledgements and Slide Contributions
Indiana SURRG Site EC: Justin Holderman, MPH
CDC Lead Surveillance & Special Studies Team: Elizabeth Torrone, MSPH, PhD
CDC Epidemiologist, Surveillance & Special Studies: Emily Weston, MPH
Kimberly Workowski, M.D, FACP, FIDSA, Professor of Medicine, Division of Infectious Diseases, Emory University

49. CDC DSTDP SURRG Support Staff Acknowledgements
Core Staff:
Karen Schlanger, SURRG Project Lead
Shacara Johnson, SURRG Project Officer
Cau Pham, Microbiologist/SURRG Laboratory Coordinator
Consultants:
Kyle Bernstein, Epidemiology and Statistics Branch Chief
Bob Kirkcaldy, Epidemiology Research Team Lead
Ginny Bowen, Epidemiologist
John Papp, GC Laboratory, Lead Microbiologist
Evelyn Nash, Microbiologist
Jennifer Ludovic, Policy Team Lead
Rodney Presley, Data Management Team Lead
Alesia Harvey, Surveillance
Lizzi Torrone, Surveillance Team Lead
Tremeka Sanders
Ellen Kersh
Hillard Weinstock