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Infertility Prevention Project Region I Wells, Maine June 6-7, 2011

Infertility Prevention Project Region I Wells, Maine June 6-7, 2011. Steven J Shapiro. Infertility Prevention Project Coordinator Program and Training Branch. National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention. Division of STD Prevention.

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Infertility Prevention Project Region I Wells, Maine June 6-7, 2011

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  1. Infertility Prevention ProjectRegion IWells, MaineJune 6-7, 2011 Steven J Shapiro Infertility Prevention Project Coordinator Program and Training Branch National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Division of STD Prevention

  2. TopicsNational Infertility Prevention Project • CSPS 2011 and 2012 • DSTDP Update • Health Care Reform • Gonorrhea

  3. CSPS 2011 • 2011 • @2010 levels -70/30 Awards • A 0.2% Rescission • Additional Funds -1.546 million dollars in FY 2010 • $118K National Chlamydia Coalition • $190K Infrastructure Shortfall • $500K “The Future of IPP” • $730K Supplemental IPP Project Area Funds • Expansion of CT/GC screening and treatment services

  4. CSPS 2012 • 2012 • @2010 levels • Application Due August 2, 2011 • Streamlined Application • All requirements from FOA 09-902 remain in force • Title X grantee Letter(s) • 3% Chlamydia Positivity • Targeted Gonorrhea Plans with Burden Calculation • Progress on General IPP Objectives • Performance Measures • Additional Guidance • National Conference • Regional IPP Meetings • IPP Program Plans

  5. GC Burden Calculation - Example • Project Area X • Total IPP Funds = $500,000 • Among women 25 and younger [ALL] • 500 Gonorrhea and 10,000 Chlamydia • GC Burden = [500/(10000+500)] X 100 = 4.76% • IPP Funds to be used • $500,000 X 4.76% = $23,800 • @ $10/test = 2380 tests available for targeting

  6. DSTDP Update • Personnel Changes • Current Activities • PCSI • Data Security and Confidentiality Guidelines • Antibiotic-resistant Gonorrhea Outbreak response plan • Publications • GISP Profiles • Community Approaches to Reducing STD • CDC Grand Rounds- Chlamydia Prevention • NG with Reduced Susceptibility to Azithromycin- San Diego • DCL- Azithromycin Resistance in Hawaii

  7. Health Care Reform

  8. Health Care Reform • Key Issues • Affordable Care Act and Performance Improvement • National HIV/AIDS Strategy • Agency Winnable Battles (HIV, Teen Pregnancy Prevention) • “The Future of IPP” • An Infrastructure-driven Evaluation • IPP in the Project Areas • Environmental Scan • Recommendations for the Future

  9. “The Future of STD Prevention”2012 and Beyond • Assurance • Functioning Surveillance Systems • Local Epidemiology Support • PCSI • Policy Development • Plan Programs using Data- all sorts of data • Assessment and Accountability • Monitoring • Evaluation • Safety Net Coverage

  10. DRIP, DRIP, DRIP……

  11. Gonorrhea—Rates by Age Among Women Aged 15–44 Years, United States, 2000–2009 Rate (per 100,000 population) Age Group 1,000 30–34 15–19 35–39 20–24 40–44 800 25–29 600 400 200 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year

  12. Gonorrhea—Rates by Age Among Men Aged 15–44 Years, United States, 2000–2009 Rate (per 100,000 population) Age Group 750 30–34 15–19 35–39 20–24 40–44 25–29 600 450 300 150 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year

  13. Gonorrhea—Rates by Race/Ethnicity, United States, 2000–2009 Rate (per 100,000 population) 800 700 600 500 American Indians/Alaska Natives Asians/Pacific Islanders 400 Blacks 300 Hispanics Whites 200 100 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year

  14. Gonorrhea—Rates by County, United States, 2009 Rate per 100,000 population <19.0 (n = 1,405) 19.1–100.0 (n = 1,129) >100.0 (n = 607)

  15. Is gonorrhea decreasing?

  16. National job training program screening data

  17. National Job Training Screening Program • National Job Training Program (NJTP) • Federally funded job preparatory program • Economically disadvantaged men and women aged 16–24 years • 48 states and Washington, DC • Gonorrhea screening required at entry • Contract laboratory performs tests • Laboratory data shared with CDC • Includes information on both positive and negative tests • Available information • Sex, age, race/ethnicity • Test technology • Place and date tested

  18. Why use NJTP data ? • Information is available on all GC tests • Prevalence = XXX – number of people testing positive XXX – all people tested upon entry to NJTP • Large, “stable” population • 95,184 men tested for GC from 2004-2009 • 91,697 women tested for GC from 2004-2009 • Consistent demographic each year • NJTP entrants have higher GC risk than U.S. population • >70% < 19 years old • >60% black • >50% from South

  19. Gonorrhea prevalence among men screened in the National Job Training Program

  20. Gonorrhea prevalence among women screened in the National Job Training Program

  21. Racial disparities among women in the National Job Training Program and NETSS

  22. NETSS data-trends

  23. Gonorrhea trends by project area, 2005–2010* Large decrease Moderate decrease Moderate increase Large increase Flat

  24. BUT*…………. • Significant Increases • L.A. 14% • San Francisco 10% • CPA 16% • Hawaii 15% • New Mexico 16% • Massachusetts 26% • Washington 25% • Puerto Rico 35% • NYC 15% • New Jersey 21% • Philadelphia 40% • Pennsylvania 20% • Maryland 20% • Baltimore 10% Maine 13% Massachusetts 26% New Hampshire 36% Vermont 14% Connecticut <1% Rhode Island 9% *NETSS DATA April 28 2011 (CY 2009-CY 2010)

  25. Gonorrhea trends by project area, 2009–2010* Large decrease Moderate decrease Moderate increase Large increase Flat

  26. Resistance MDR GC

  27. “The one who does not remember history is bound to live through it again.” George Santayana

  28. “The one who does not remember history is bound to live through it again.” • “Even those who remember history are still gonna be stuck living through it again.” George Santayana The gonococcus

  29. Gonococcal isolate surveillance project data

  30. GISP sites and regional laboratories —United States, 2010 (29 Sites) Seattle Portland Minneapolis Detroit New York City Philadelphia Chicago Cleveland San Francisco Baltimore Cincinnati Las Vegas Kansas City Regional Labs Denver Richmond Birmingham Los Angeles Atlanta Oklahoma City Greensboro Seattle Orange Co. Cleveland Albuquerque San Diego Phoenix Austin* Atlanta Birmingham Dallas New Austin Orleans Tripler AMC Honolulu Miami * Funded for FY2010 & FY2011 as regional lab, not yet functioning

  31. Emergence of FQ Resistance: Hawaii Cipro available FQ not recommended for GC in Hawaii* Reports of FQ resistance Percentage of GISP isolates resistant to ciprofloxacin Hawaii * CDC, MMWR 2000.

  32. Emergence of FQ Resistance: California FQ not recommended for GC in California** Hawaii* Percentage of GISP isolates resistant to ciprofloxacin California * CDC, MMWR 2000; ** CDC, MMWR, 2002

  33. Emergence of FQ Resistance: MSM FQ not recommended for MSM† Hawaii* California** Percentage of GISP isolates resistant to ciprofloxacin MSM * CDC, MMWR 2000; ** CDC, MMWR, 2002; † CDC, MMWR, 2004.

  34. Emergence of FQ Resistance: Rest of the US (Excluding Hawaii & California) FQ not recommended in US‡ Hawaii* MSM† California** Percentage of GISP isolates resistant to ciprofloxacin US * CDC, MMWR 2000; ** CDC, MMWR, 2002; † CDC, MMWR, 2004.; ‡ CDC, MMWR, 2007.

  35. GISP trends

  36. Distribution of MICs to Cefixime, 2005–2010* Percentage of isolates Minimum Inhibitory Concentrations (MICs), µg/ml * Preliminary (Jan-Sept)

  37. Distribution of MICs to Cefixime, 2005–2010* Percentage of isolates GISP Surveillance “alerts” “Decreased Susceptibility” 1.3% (n=58) 0.2% (n=8) Minimum Inhibitory Concentrations (MICs), µg/ml * Preliminary (Jan-Sept)

  38. Distribution of MICs to Ceftriaxone, 2006–2010* Percentage of isolates Minimum Inhibitory Concentrations (MICs), µg/ml * Preliminary (Jan-Sept)

  39. Distribution of MICs to Ceftriaxone, 2006–2010* GISP Surveillance “Alerts” Percentage of isolates Decreased Susceptibility Minimum Inhibitory Concentrations (MICs), µg/ml * Preliminary (Jan-Sept)

  40. Geographic Distribution of Cephalosporin* Alerts , 2005 *Cefixime or Ceftriaxone

  41. Geographic Distribution of Cephalosporin* Alerts, 2006 *Cefixime or Ceftriaxone

  42. Geographic Distribution of Cephalosporin* Alerts, 2009 *Cefixime or Ceftriaxone

  43. Geographic Distribution of Cephalosporin* Alerts, 2010 Orange Co. San Diego *Cefixime or Ceftriaxone

  44. Proportion of GISP Participants Identified as Men who Have Sex with Men (MSM), 1988–2010* Percentage * Preliminary 2010 (Jan-Sept) Note: Among men with available sex of sex partner data Year

  45. Distribution of MICs to Azithromycin, 2006–2010* Percentage of isolates Minimum Inhibitory Concentrations (MICs), µg/ml * Preliminary (Jan-Sept)

  46. Distribution of MICs to Azithromycin, 2006–2010* Percentage of isolates Minimum Inhibitory Concentrations (MICs), µg/ml * Preliminary (Jan-Sept)

  47. International trends

  48. Distribution of MIC for ceftriaxone, EURO-GASP, 2004–2009 European Center for Disease Prevention and Control (ECDC) http://www.ecdc.europa.eu/en/publications/Publications/1101_SUR_Gonococcal_susceptibility_2009.pdf

  49. Japan 2000: Possible treatment failure with cefdinir (oral) (MIC 1=µg/ml) Decreased susceptibility to cefixime (oral) in Japan -- 0% (1999) to 30% (2002) 2002–2003: 4 possible treatment failures with cefixime (oral) 2009: isolate with ceftriaxone MIC of 2 µg/ml (CSW) China (2001–2009): ~30-40% isolates have MICs to ceftriaxone of ≥ 0.06 µg/ml (~3% in US in 2010) Europe 2009: Increases in ceftriaxone MICs from Europe 2010: 2 treatment failures with cefixime (Norway) 1 pharyngeal treatment failure with ceftriaxone (Norway) 2 possible treatment failures with cefixime (England) Recent Timeline

  50. Summary • “Alert” doesn’t mean resistance • Increasing MICs to cephalosporins (esp. cefixime) • West • MSM • Significance of higher MICs not yet known, but very concerning • No treatment failures reported yet in US • Will be asking clinicians and HDs to report treatment failures

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