Gonorrhea in California

Gonorrhea Control in Region IX: Optimizing Strategies to Reduce MorbidityPhoenix, 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 ControlCenter for Infectious Diseases, California Department of Public Health

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Gonorrhea, Rates by Gender, California, 1990–2009

Gonorrhea Rates, 1913-2009, California

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CA DPH STD Control Branch (rev 1/2010)

Female

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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/EthnicityCalifornia, 2008

Native American/Alaskan Native

Asian/Pacific Islander

African American

Hispanic/Latino

White

Native American/Alaskan Native

Asian/Pacific Islander

African American

Hispanic/Latino

White

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, 2008

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24 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

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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

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Gail Bolan Residence

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

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

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Census Tract Poverty Category

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Gonorrhea Rates by Case Race/Ethnicity and Poverty Category of Case Census Tract (percent residents living below the federal poverty line)

California, 2004-2006

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 0.125 – 0.5 μg ciprofloxacin/mL.

STD Clinic Sites: Long Beach (ended participation in 2007), Los Angeles (added in 2003), Orange,San Diego, San Francisco

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Resistant Decreased Susceptibility

CA DPH STD Control Branch (rev 7/2009)

GISP Alert Value and Resistant Isolates, CA GISP Data, 1987 - 2009

* 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

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AZITHROMYCIN HIGH RESISTANT (>= 8.0)

AZITHROMYCIN LOW RESISTANT (>= 1.0)

CEFPODOXIME RESISTANT (>= 1.0)

CEFPODOXIME ALERT (>= .250)

CEFIXIME ALERT (>= .250)

CEFTRIAXONE ALERT (>= .125)

Sexual Orientation by RegionCalifornia Gonorrhea Surveillance Data, 2008

REGION MSMMale

Heterosexual Female

Northern CA 10.1% 30.0% 59.9%

Bay Area (excluding SF) 16.7% 29.8% 53.5%

San Francisco 75.9% 11.0% 13.0%

Central CA 11.9% 38.6% 49.4%

Southern CA (excluding LA) 24.1% 28.1% 47.8%

Los Angeles 26.4% 26.0% 47.5%

TOTAL 26.2% 27.0% 46.8%

Assumed proportion of male pop MSMWhite Black Hispanic0.05 0.05 0.05

MSMMale-HetFemale

MSM ratio to whiteMale-Het ratio to white

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MSM ratio to whiteMale-Het ratio to white

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Selected Risk Characteristics for by Sexual OrientationCalifornia Gonorrhea Surveillance Data, 2008

Men Who Have Sex With Men

(MSM)

HeterosexualMen

Heterosexual Women

Internet Use to Meet Sex Partners 43.2% 5.1% 2.7%

CaseIncarcerated 3.4% 23.7% 9.0%

Sex Partner Incarcerated 4.6% 5.2% 22.8%

Methamphetamine Use 7.5% 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 DiagnosisCalifornia 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:

Michael.Samuel@cdph.ca.gov

510-620-3198

Gail.Bolan@cdph.ca.gov

510-620-3400

Extra Slides

Black & White Gonorrhea Rates and Rate Ratiosby Gender, California, 1990–2008

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Black - Male Black - FemaleWhite - Male White - FemaleBlack:White - Male Black:White - Female

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/EthnicityCalifornia, 2008

ASIAN/PIAFRICAN

AMERICAN LATINO WHITE

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

Rates per 100,000 Population

< 5 cases 0 0.1 - 24.9 25 - 49.9 50 - 99.9 100 - 249.9 250 - 499.9 500 +

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

Year CENTRACT County Black Cases Black Cases - Weighted Rank2008 600152020 Alameda 0 0 bottom 502008 600153030 Alameda 1 1 bottom 502008 600640050 Alameda 12 21 top 5%

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.2008 600554020 Contra Costa 4 9 next 20%2008 600630011 Butte 0 0 bottom 50

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Top 5%Next 20%

(25% cumulative)Next 25%

(50% cumulative)Bottom 50%

(100% cumulative) Total

# of CPA census tracts accounty for cases

8 72 147 4757 4984

Percent including CPA tracts with no cases

0.16% 1.4% 2.9% 95.5% 100.0%

Cumulative Percent 0.16% 1.6% 4.6% 100.0% 100.0%

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

>0 >=5 >=10

# CPA tracts BlackCatZBESTYR County 1-Top 5 2-Next 20 3-Next 25 4-Bottom 50 (blank) Grand Total

2008 Alameda 6 19 40 191 256Amador 1 1Butte 25 25Colusa 1 1Contra Costa 9 10 106 125El Dorado 7 7Fresno 7 113 120Inyo 1 1Kern 8 8 97 113Kings 20 20LA (Long Beach) 2 16 65 83LA (Pasadena) 19 19Riverside 1 2 246 249Sacramento 14 28 193 235San Benito 5 5San Bernardino 2 12 18 172 204San Diego 1 6 380 387Yuba 5 5

Grand Total 8 72 147 2986 3213

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

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All CasesBlack Cases

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

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All CasesBlack Cases

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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)

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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 thegiven 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:

– Ceftriaxone MIC >= 0.125– Cefixime MIC >= 0.250– Cefpodoxime MIC >= 0.250

• 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