1. Gonorrhea Christine Wigen, MD, MPH Assistant Medical Director
Los Angeles County Department of Pubic Health
Sexually Transmitted Diseases Program
April 1, 2009

2. Overview Description of gonorrhea and Transmission Epidemiology
Types of Infections
Diagnosis, Screening, and Treatment
Reporting
Partner Management & Patient Delivered Partner Therapy
Re-testing

3. Gonorrhea (GC) Gram-negative diplococcus
Second most common bacterial STD
Causes a range of clinical syndromes
Usually symptomatic in males, often asymptomatic in women
Can cause pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and complications in pregnancy in women

4. Gonorrhea – How do people get it?
Transmitted through sexual contact (vaginal, anal, or oral)
Ejaculation does not have to occur for GC to be transmitted or acquired
Can also be transmitted from mother to baby during delivery
People who have been treated for GC can get re-infected if they have sexual contact with a person with GC

5. Epidemiology of Gonorrhea

6. Gonorrhea — Rates: United States, 1941–2007 and the Healthy People 2010 target
Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population.

7. Gonorrhea — Rates by state: United States and outlying areas, 2007
Note: The total rate of gonorrhea for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was per 100,000 population. The Healthy People 2010 target is 19.0 cases per 100,000 population.

8. Gonorrhea — Rates: Total & by sex: United States, 1988-2007 & the Healthy People 2010 target
Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000
population.

9. Gonorrhea Rates per 100,000 Population, US, CA, LA County, 2001 - 2007

10. Reported STD Cases in US, CA and LA, 2006 and 20071,2
Year
Chlamydia
Gonorrhea
P&S Syphilis
EL Syphilis
2006[1] US
1,030,911
358,366
9,756
9,186 CA
135,827
33,740
1,835
1,369 LA
42,943
11,162
866
851
% CA
31.6%
33.1%
47.2%
62.1%
% US
4.2%
3.1%
8.9%
9.3%
2007[2]
1,108,374
355,991
11,466
10,768
141,928
31,294
2,038
1,460
LA**
44,030
10,063
919
714
31%
32.2%
45.1%
49% 4%
2.8% 8% 7%
LAC accounts for slightly more than 1/3 of the state’s STD morbidity and 44% of the early latent syphilis cases.
LA County
38,294 cases reported in 2004
CT accounts for 74% of all reported STDs
GC accounts for 19%
All syphilis accounts for 1.6%
[1] Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, Atlanta, GA: U.S. Department of Health and Human Services, November
[2] Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, Atlanta, GA: U.S. Department of Health and Human Services, January 2009

11. Distribution of Reported STD in Los Angeles County, 2008

13. Gonorrhea — Rates by race/ethnicity: United States, 1998–2007

14. Race/Ethnicity Disparity in Reported Gonorrhea Rates per 100,000 Population, LA County 2008
Los Angles Department of Public Health, STD Program

16. Gonorrhea – Rates by Gender, Los Angeles County, 2003–2007
Male
Female
2/2006 Provisional Data - CA DHS STD Control Branch

17. Gonorrhea — Age- and sex-specific rates: United States, 2007

18. Males Rate (per 100,000 population) Females
Reported Gonorrhea Rates per 100,000 Population, by Gender & Age Group, 2007
Males Rate (per 100,000 population) Females
Age
15-19
21-29
35-44
55-64

19. Gonorrhea Rates, Females, by Race/Ethnicity and Age Group, California, 2007
23 times white rate
13 times white rate
8 times white rate
2/2006 Provisional Data - CA DHS STD Control Branch

20. Infections Caused by Gonorrhea

21. Gonococcal Infections in Women
Cervicitis
Urethritis
Proctitis (rectal infection)
Pharyngitis (throat infection)
Accessory gland infection (Skene, Bartholin)
PID/Peri-hepatitis (Fitz-Hugh-Curtis)
Conjunctivitis (eye infection)
Disseminated Gonococcal Infection (DGI)
Many infections asymptomatic

22. Gonococcal Cervicitis
Incubation 3-10 days
Symptoms:
Vaginal discharge
Dysuria (burning pain upon urination)
Vaginal bleeding
Cervical signs :
Redness
Friability
Purulent discharge
STD Atlas, 1997

23. Gonococcal Infections in Men
Urethritis
Epididymitis/seminal vesiculitis
Proctitis (rectal infection)
Conjunctivitis (eye infection)
Abscess of Cowper’s/Tyson’s glands
Pharyngitis (throat infection)
Disseminated gonococcal infection
Urethral stricture
Penile edema (swelling)
Infection may be asymptomatic

24. Gonococcal Urethritis
Incubation 2-7 days
Abrupt onset of severe dysuria
Purulent urethral discharge (“drip”)
Most urethral infections symptomatic
STD Atlas, 1997

25. Complications of GC Infections
Disseminated GC infection (DGI)
Epididymitis
PID

26. Gonorrhea and HIV Transmission/Acquisition
How can syphilis or other STDs increase HIV transmission?
Reducing physical barriers
Increasing the number of receptor cells
Increasing HIV viral load in genital lesions, semen or both
Inflammatory STDs2 to 5-fold increased HIV acquisition*
Lets now move on to speak about some of the observation studies. Many of these studies were first summarized by Judy Wasserheit. She performed a metaanalysis of ---articles showing that inflammatory STDs were associated with a 2-5 fold increased in HIV acquisition and that genital ulcers were associated with a 3-11 fold increase of HIV acquisition.
*Wasserheit STD 19:261; 1992

27. Diagnosis of Gonorrhea

28. Gonorrhea - Diagnosis
Gram stain: 95% sensitive and >99% specific in symptomatic males
Culture: % sensitive and 100% specific
DNA probe: 89-97% sensitive 97-99% specific
Nucleic acid amplification tests (NAATs): includes LCR, PCR, TMA and SDA; 95-98% sensitive, >98% specific

29. Gram Stain
STD Atlas, 1997

30. Additional NAAT Capabilities
Self-collected vaginal swab
Equivalent performance with endocervical and urine specimens and with provider specimens
FDA approved for clinic-based testing only
Non-genital NAAT testing (Not FDA approved-labs need internal verification)
Rectal
Pharyngeal
Self-collected rectal NAAT

31. Screening for Gonorrhea

32. CDC GC Screening Recommendations
Women: based on US Preventive Services Task Force (no CDC-specific recommendations)
Sexually active women if at increased risk:
Women under age 25
Previous GC infection, other STD, new/multiple partners, inconsistent condom use, commercial sex, drug use
Screening not recommended in men or in women who are at low risk for infection

33. California Guidelines for GC Screening, 2005
Routine Screening:
Sexually active women <25* annually
Over 25: targeted screening based on risk factors
History of gonorrhea in past two years
>1 partner in past year
Partner with other partners
African American women up to age 30
* Unless prevalence in patient population known to be <1%
From: CA Guidelines for Gonorrhea Screening and Diagnostic Testing Among Women
In Family Planning and Primary Care Settings, Dec 2005

34. STD Screening for Men who have Sex with Men (MSM)
STD Screening Site Type of Sex
GC/CT urethra or urine oral, anal
insertive
GC/CT* rectum receptive anal
GC/CT* pharynx receptive oral
Syphilis blood oral, anal
HIV blood oral, anal
Note: availability of non-genital NAATs is limited. LAC PHL provides
rectal GC/CT and pharyngeal GC testing. CT culture should not be used for
screening (unless medico-legal case).

35. CT & GC Infections among MSM by Anatomic Site, SF STD Clinic
San Francisco Klausner et al, 11th Conf. Retroviruses, 2004

36. Rectal Gonorrhea in MSM, SF STD Clinic (Kent CK, Chaw JK, Klausner JD, STD Conf. 2004)
And 84% of MSM were asymptomatic when infected with gonorrhea.

37. MSM and GC/CT
Rectal CT/GC infections often overlooked due to asymptomatic nature and lack of sensitive test
Emerging evidence re: high prevalence
Anatomic site-specific screening needed

38. Gonorrhea Treatment

39. Gonorrhea Treatment in California
Recommended regimens:
Ceftriaxone 125 mg IM x 1*
Cefixime 400 mg PO x 1†
Alternative regimens:
Spectinomycin 2 g IM x 1**
Cefpodoxime 400 mg po x 1
Co-treat for chlamydia unless ruled out by NAAT
*Preferred and only recommended regimen for pharyngeal infection
† suspension may be available
** currently not manufactured

40. Gonorrhea Treatment in Cephalosporin-allergic Patients
Urogenital infections
Azithromycin 2 g po x 1 with TOC
Spectinomycin 2 g IM x 1 *
Pharyngeal infections
*No longer manufactured!

41. for patients with gonorrhea in California…
CIPRO

42. Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2007
Note: Resistant isolates have ciprofloxacin MICs ≥ 1 µg/ml. Isolates with intermediate resistance have ciprofloxacin MICs of µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

43. Gonococcal Isolate Surveillance Project (GISP), Percent of Neisseria Gonorrhoeae Isolates with Decreased Susceptibility or Resistance to Ciprofloxacin in Five California STD Clinics, 1990–2006
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, Los Angeles (added in 2003), Orange, San Diego, San Francisco
CA DPH STD Control Branch (rev 7/2007)

44. Gonococcal Isolate Surveillance Project (GISP) — Prevalence of ciprofloxacin resistant Neisseria gonorrhoeae by GISP site,
Note: Not all clinics participated in GISP for the last 4 years. Sites include: ALB=Albuquerque, NM; ATL=Atlanta, GA; BAL=Baltimore, MD; BHM=Birmingham, AL; CHI=Chicago, IL; CIN=Cincinnati, OH; CLE=Cleveland, OH; DAL=Dallas, TX; DEN=Denver, CO; DTR=Detroit, MI; GRB=Greensboro, NC; HON=Honolulu, HI; KCY=Kansas City, MO; LAX=Los Angeles, CA; LBC=Long Beach, CA; LVG=Las Vegas, NV; MIA=Miami, FL; MIN=Minneapolis, MN; NOR=New Orleans, LA; NYC=New York City, NY; OKC=Oklahoma City, OK; ORA=Orange County, CA; PHI=Philadelphia, PA; PHX=Phoenix, AZ; POR=Portland, OR; SDG=San Diego, CA; SEA=Seattle, WA; SFO=San Francisco, CA; and TRP=Tripler Army Medical Center, HI

45. Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance to ciprofloxacin by sexual behavior, 2001–2007

46. Gonococcal Isolate Surveillance Project (GISP), Percent of Neisseria Gonorrhoeae Isolates Obtained from Men who Have Sex with Men in Five California STD Clinics, 1990–2006
Note: This project began in 1991 for the Orange County STD Clinic, and in 2003 for the
Los Angeles County STD Clinic.
CA DPH STD Control Branch (rev 7/2007)

47. Reporting

48. Non Gonoccocal Urethritis Pelvic Inflammatory Disease Syphilis LGV
7 Diseases Reportable to the STD Program Mandated By California State Law:
Chlamydia
Chancroid
Gonorrhea
Non Gonoccocal Urethritis
Pelvic Inflammatory Disease
Syphilis
LGV
And now that I’ve discussed the program & it’s activities, let’s discuss the diseases that are reportable to the STD Program which are:
The 4 most common in your practice are: CT, GC, PID & Syphilis.
These are all bacterial infections which are curable with the appropriate antibiotic therapy and you can refer to your treatment guidelines for those.
CT & GC are characterized by discharge ( cervical or urethral); chancroid & syphilis are both characterized by genital lesions however the chancroid lesion is painful whereas the syphilis chancre is painless. PID is an ascending infection of the lower genital tract due to untreated CT, GC or other organism. And NGU or non-gonococcal urethritis is an infection characterized by an abnormal discharge in the absence of CT.
AIDS is reportable to the HIV Epidemiology Program.
HIV just recently became reportable to the state of California in July of 2002.
Other reportable STD’s that can be transmitted sexually are for ex. Hep B & C, and salmonella. These infections are reportable to ACD.

49. GC Reporting
Providers must report syphilis cases within seven calendar days by completing a Confidential Morbidity Report (CMR)

50. STD Confidential Morbidity Reporting (CMR)
Tool used by providers to report STD lab & treatment
STD Purpose
To determine the extent of STD morbidity in L.A. County
To evaluate disease transmission risk
Provides a mechanism to target intervention activities
Now I have placed a copy of the LA County STD CMR in your packets, which you can review at your leisure. This was recently revised by the program in March of this year with input from county clinicians.
As you can see, there is an area to specify the disease, the pt.’s pregnancy status, treatment information as well as any labs or additional tests that were done.
All providers, public and private, should use this to report morbidity to the STD Program.

51. STD CMR:
Available via
Or call

52. Gonorrhea and Chlamydia Partner Management and Patient Delivered Partner Therapy

53. Patient Delivered Partner Therapy (PDPT) for GC and CT: infection rates at follow-up
% Reinfected
RCT of expedited partner therapy vs standard
931 patients assigned to SR and 929 to EPT
Male and female index cases
Rate of reinfection lower in EPT groups
P=.02
P=.17
Golden, NEJM, 2005

54. Rate of CT Re-infection of Women According to Partner Management
None= No counseling or attempted partner rx
A=Patient counseled to refer partner
B= Patient refers partner, compliance monitored
C=Patient-delivered Partner Therapy RX
25 years of data. N
372
997
645
167
Ramstedt K, 1991

55. Gonorrhea & Chlamydia Partner Management
All sex partners from 60 days preceding the diagnosis should be evaluated, tested, and treated
If no sex partners in previous 60 days, treat the most recent partner

56. Summary of RCT PDPT Studies
Providing treatment for partners of chlamydia or gonorrhea infected heterosexual patients, without provider evaluation, is an effective partner management strategy
Decrease in reinfection rates of index cases proves effectiveness (gonorrhea > chlamydia)

57. Current Options in California for Management of Sex Partners for CT/GC
Patient self-referral
Provider/clinic referral
Patient Delivered Partner Therapy/Expedited Partner Therapy

58. Status of PDPT/EPT in California
Chlamydia PDPT
Legal since January 1, 2001(SB 648)
Gonorrhea PDPT
Became legal January 1, 2007 (AB 2280)

59. CA Guidelines for PDPT for Chlamydia (1)
Diagnosis: Uncomplicated genital chlamydia infection
First-line: Attempt to bring partners in for evaluation and treatment
Priority patients: Females with male partners
Partners: Males who are uninsured or unlikely to seek medical services
Medication: Azithromycin (Zithromax*)1 gram (250 mg tablets x 4) orally once

60. CA Guidelines for PDPT for Chlamydia (2)
Number of doses are limited to the number of sex partners in past 60 days
Education materials must accompany meds
Patient counseling: Abstinence until 7 days after treatment and until 7 days after partners have been treated
Evaluation: Recommend re-test patients for chlamydia 3-4 months after treatment
Adverse rxns: Report to

61. Guidelines for PDPT for Gonorrhea
Under-development
Recommended medication will be cefpodoxime 400mg x 1 plus azithromycin 1g

62. Re-Testing for Gonorrhea and Chlamydia

63. Recommendations for Re-testing
Recommendation: women and men infected with chlamydia and/or gonorrhea should be re-tested 3-4 months after treatment
Rationale:
High percent of rapid repeat infection
Short time to repeat positive test
Re-screening identifies highest risk patients
STD Treatment Guidelines, 2006

64. Gonorrhea Re-infection rates
Patients retested at 3-4 months:
Women 12-24% infected
Men % infected
Kjaer et al, STI 2000, Golden et al NEJM 2005.

65. Check List for the Management of Gonorrhea and Chlamydia Cases
Ensure timely and appropriate treatment
Test for other STDs
Patient counseling
Ensure that sex partners are treated
Schedule 3 month retesting follow-up
Report case to the local health department

67. Harm Reduction Use of condoms consistently and correctly
Minimize # of sex partners
Avoid sex while under the influence of alcohol or drugs to decrease risky behavior
Avoiding abusive relationships

69. Resources 2006 STD Treatment Guidelines: www.cdc.gov/std
Los Angeles County STD Program website:
California STD-HIV Prevention Center:

70. Questions? Christine Wigen, MD, MPH
Phone #: