1. National STD Prevention Conference
Population-based gonorrhea surveillance through the STD Surveillance Network (SSuN)
Lori Newman; K Ahrens; J Donnelly; S Martins; M Stenger; O Vasiliu; H Weinstock
National STD Prevention Conference
March 12, 2008

2. STD Surveillance Network (SSuN)
Purpose: to improve national capacity to detect, monitor, and respond to emerging trends in STDs and related behaviors
Initial activities – 2006 to 2008
Enhanced gonorrhea surveillance in STD clinics
Genital wart surveillance in STD clinics
Population-based enhanced gonorrhea surveillance
GW is the “new activity”

3. Rationale for Population-based Gonorrhea Surveillance
Gonorrhea rates still far from Healthy People 2010 objectives, but we don’t understand why
Case report data at national level limited to sex, age, race/ethnicity, and crude provider type
Need a better understanding of gonorrhea patients outside of the STD clinic setting

4. Objectives of SSuN Population-based Gonorrhea Surveillance
Establish network of health departments working collaboratively with standardized methodology
Collect demographic, behavioral, and clinical data on patients with gonorrhea
Monitor trends over time
Use data to guide local, state, and national STD programs and policies

5. STD Surveillance Network (SSuN) project areas (n=5) & participating counties and independent cities (n=11),
Washington
King Co.
Pierce Co.
Snohomish Co.
Minnesota
Hennepin Co.
New York City
Virginia
Chesterfield Co.
Henrico Co.
Richmond City
San Francisco San Francisco Co.
Colorado
Adams Co.
Arapaho Co.
Denver Co.
You can see that SSuN sites are distributed across the U.S. New York City is a SSUN site, but does not participate in this activity.
SSuN project areas
Participating counties and independent cities

6. SSuN Methodology
Data collected on sample of patients reported with gonorrhea in selected counties
Phone or in-person interview of first reported patients each month until completed 10 male and 10 female
SF: weekly sample adjusted for non-response for target of 100 men and 100 women per year
Sample excludes patients who attend the primary STD clinic(s)
Data transmitted with morbidity data
Assessment of representativeness, contact rate, etc.
Data collection initiated between Feb 2006 and Jan 2007
Data analyzed through Dec 31, 2007

7. Collaborative Data Elements
Demographics
Sexual practices
Substance use
Partner characteristics
HIV history
STD history
Clinical history
Treatment

8. SSuN Population Size, Sample Size, and Interview Success RateSF WA CO MN VA
Total
Number of Case Reports (A)
3,088
3,192
3,512
2,492
1,640
13,924
Number of Eligible Patients (B)
1,918
2,632
2,273
1,796
1,023
9,642
Number Eligible & Selected for SSuN (C)
534
617
1,804
1,214
526
4,695
Number Eligible, Selected, and Interviewed (D)
142
319
363
349
210
1,383
Interview Success Rate (E = D/C)
26.6%
51.7%
20.1%
28.7%
39.9%
29.5%
Over the time period examined, there were nearly 14,000 patients (CLICK) reported with gonorrhea in the 11 SSuN counties.
SSuN collaborators were able to interview nearly 1400 (CLICK) patients with gonorrhea.
Only able to interview approximately 1/3 of selected patients (CLICK), since there were large numbers of patients with unknown or incorrect contact information. Response rate was slightly better for women than for men.

9. Sex and Sexual Orientation of SSuN Interviewed Gonorrhea Patients (N=1,383)*
Proportion of MSM (seen in yellow) varies widely by site, larger proportion of MSM in western U.S., but an average of 20% of gonorrhea patients are MSM. This is in contrast to what is seen with syphilis which is estimated at over ___% of syphilis patients are MSM.
<3% unknown sex & sexual orientation at every site.
*Sexual orientation unknown for 20 men

10. Race/ethnicity of SSuN Interviewed Gonorrhea Patients (N=1,336)*
Race/ethnicity also varied widely by site, you can see that the proportion of SSuN gonorrhea patients that are black (seen in the blue bars) ranged from about 35 – 85%, with an average of 55%.
*Race/ethnicity unknown for 45 patients.

11. Age of SSuN Interviewed Gonorrhea Patients (N=1,381)
These data on the age distribution of SSuN gonorrhea patients are similar to the kind of data you get with regular surveillance data.

12. How do SSuN patients compare with morbidity patients?
All morbidity
SSuN Interviewed
Female
39.7%
52.2%
Age under 25
46.0%
51.9%
Non-hispanic black
48.7%
51.2%

13. Reported HIV Status of SSuN Interviewed MSM with Gonorrhea (N=247)*
Over 30% of MSM with gonorrhea are HIV positive. This is extremely concerning from an HIV prevention perspective since gonorrhea is an indicator of unprotected sex.
HIV was extremely rare among MSW and women with gonorrhea.

14. Provider Type of SSuN Interviewed Gonorrhea Patients (N = 978)
REVISE TEXT
You can see here that more gonorrhea cases were reported from the ER/Urgent care setting, than from primary care clinics (28%).
This is similar to the proportion seen STD clinic patients, not part of the SSuN sample, accounted for 36% of gonorrhea morbidity in these 11 counties.
This did not vary much by sex,
This has serious implications for partner management, for example, which may be less likely to occur in and ER or urgent care setting.

15. Provider Type of SSuN Interviewed Gonorrhea Patients by Race/Ethnicity
Whites
n=216
Blacks
n=550
This is a pretty interesting demonstration of racial differences in care seeking behavior.
Hispanics
n=129

16. Reported Drug Use over Past 3 Months by SSuN Interviewed Gonorrhea Patients
MSM*
MSW
Women
Cocaine
11.3%
5.8%
4.5%
Crack
5.3%
2.3%
1.9%
Methamphetamine
12.4%
2.8%
2.5%
Nitrates
19.2% 0%
Sexual performance-enhancing drugs
11.6%
3.7%
0.3%
High levels of drugs such as cocaine, meth, nitrates, and sexual performance-enhancing drugs among MSM, much lower levels of drug use among MSW and women.
*Note: small numbers of MSM in VA (n=3) and CO (n=12), and MSW in SF (n=3)

17. Reported Risk Behaviors over Past 3 Months by SSuN Interviewed Gonorrhea Patients
MSM
MSW
Women
Median number of sex partners (mean) 2
(4.0)
(2.2) 1
(1.7)
Given or received sex for drugs or money
3.8%
2.7%
2.0%
Anonymous sex partner*
39.9%
17.8%
10.3%
Met sex partner through Internet
47.3%
2.2%
1.6%
Incarceration of patient or partner
13.2%
15.6%
SHOW how risks vary by sex/sex orientation
*Data not available for WA

18. Reported Interactions with Last Sex Partner by SSuN Interviewed Gonorrhea Patients
MSM
MSW
Women
In the time before you were tested for gonorrhea, did you use a condom the last time you had sex? “Yes”
39.9%
33.9%
26.7%
Have you had sex with this partner since being tested? “Yes”
23.8%
26.8%
How sure are you that this partner got treated? “Sure”
48.4%
47.5%
48.3%
Both MSM and heteros could use more aggressive prevention counseling and partner management since about 1 in 4 had sex since being tested, and only ½ of patients were sure that their partner had been treated.
I DO NOT SHOW EPT data because only avail for 3 ½ sites (WA inconsistent), and varied widely by site.

19. Gonorrhea Treatment for SSuN Interviewed Patients (N= 1,224)
About 2/3rds of patients are receiving a cephalosporins.
~ 2/3 of patients
received
cephalosporins

20. Limitations
Only 5 geographic sites and 11 counties, so limited ability to generalize
Possible response bias since only able to contact about 1 in 3 patients with gonorrhea due to poor contact information
Slight variability in methodology between sites since integrated into routine activities
No trends over time available yet

21. Summary Mixed heterosexual and MSM epidemic
MSM gonorrhea patients interviewed reported high levels of risk behavior
30% co-infected with HIV
Greater numbers of sex partners, drug use, anonymous sex, & internet sex
Heterosexual gonorrhea risks
May involve incarceration, anonymous sex
Drug use and sex work infrequently reported
Aggressive counseling and partner management may be useful intervention strategies for both MSM and heterosexual gonorrhea populations
Important racial/ethnic differences in where gonorrhea is being diagnosed

22. Future Directions Trends over time
Are changes in risk behaviors associated with changes in morbidity?
Expand number of SSuN participating sites
Better geographic representativeness
Geocoding & linkage with census data & other data sources
Where & when is gonorrhea being diagnosed?
Gonorrhea association with SES and environmental factors
Racial/ethnic variation in access to care

23. Acknowledgements SSuN Collaborating Sites CDC
Colorado Department of Public Health
Minnesota Department of Health
San Francisco Department of Public Health
Virginia Department of Health
Washington State Department of Health
CDC
Darlene Davis
For more information on SSuN, contact:
The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the CDC.
Thank You.