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Gonorrhea

Gonorrhea. Christine Wigen, MD, MPH Assistant Medical Director Los Angeles County Department of Pubic Health Sexually Transmitted Diseases Program April 1, 2009. Overview. Description of gonorrhea and Transmission Epidemiology Types of Infections Diagnosis, Screening, and Treatment

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Gonorrhea

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  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 117.4 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 [1]Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2006. Atlanta, GA: U.S. Department of Health and Human Services, November 2007. http://www.cdc.gov/std/stats/pdf/Surv2006.pdf [2] Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2007. Atlanta, GA: U.S. Department of Health and Human Services, January 2009

  11. Distribution ofReported STD in Los Angeles County, 2008

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

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

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

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

  16. 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

  17. 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

  18. Infections Caused by Gonorrhea

  19. 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

  20. 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

  21. 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

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

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

  24. 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* *Wasserheit STD 19:261; 1992

  25. Diagnosis of Gonorrhea

  26. Gonorrhea - Diagnosis • Gram stain: 95% sensitive and >99% specific in symptomatic males • Culture: 80 - 95% 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

  27. STD Atlas, 1997 Gram Stain

  28. 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

  29. Screening for Gonorrhea

  30. 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

  31. 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

  32. 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).

  33. CT & GC Infections among MSM by Anatomic Site, SF STD Clinic San Francisco 2003 Klausner et al, 11th Conf. Retroviruses, 2004

  34. Rectal Gonorrhea in MSM, SF STD Clinic(Kent CK, Chaw JK, Klausner JD, STD Conf. 2004)

  35. 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

  36. Gonorrhea Treatment

  37. 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

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

  39. for patients with gonorrhea in California… CIPRO

  40. 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 0.125 - 0.5 µg/ml. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

  41. 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 0.125 – 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)

  42. Gonococcal Isolate Surveillance Project (GISP) — Prevalence of ciprofloxacin resistant Neisseria gonorrhoeae by GISP site, 2004-2007 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

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

  44. 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)

  45. Reporting

  46. 7 Diseases Reportable to the STD Program Mandated By California State Law: • Chlamydia • Chancroid • Gonorrhea • Non Gonoccocal Urethritis • Pelvic Inflammatory Disease • Syphilis • LGV

  47. GC Reporting • Providers must report syphilis cases within sevencalendar days by completing a Confidential Morbidity Report (CMR)

  48. 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

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