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Steven J ShapiroInfertility Prevention Project Coordinator
Program and Training Branch
Infertility Prevention ProjectRegion I
Wells, MaineJune 6-7, 2011
National Center for HIV/AIDS, Viral Hepatitis, STD & TB PreventionDivision of STD Prevention
TopicsNational Infertility Prevention Project
CSPS 2011 and 2012 DSTDP Update Health Care Reform Gonorrhea
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
o Expansion of CT/GC screening and treatment services
CSPS 2012 2012
@2010 levels Application Due August 2, 2011 Streamlined Application
• All requirements from FOA 09-902 remain in forceo Title X grantee Letter(s)o 3% Chlamydia Positivityo Targeted Gonorrhea Plans with Burden Calculationo Progress on General IPP Objectives
• Performance Measures Additional Guidance
• National Conference• Regional IPP Meetings• IPP Program Plans
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
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
Health Care Reform
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
“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
DRIP, DRIP, DRIP……
Gonorrhea—Rates by Age Among Women Aged 15–44 Years, United States, 2000–2009
Rate (per 100,000 population)
Year
0
200
400
600
800
1,000
2009200820072006200520042003200220012000
35–3940–44
30–34
25–2920–2415–19
Age Group
Gonorrhea—Rates by Age Among Men Aged 15–44 Years, United States, 2000–2009
0
150
300
450
600
750
2009200820072006200520042003200220012000
Rate (per 100,000 population)
Year
35–3940–44
30–34
25–2920–2415–19
Age Group
Gonorrhea—Rates by Race/Ethnicity, United States,
2000–2009
0
100
200
300
400
500
600
700
800
2009200820072006200520042003200220012000
WhitesHispanicsBlacks
Asians/Pacific IslandersAmerican Indians/Alaska Natives
Rate (per 100,000 population)
Year
Gonorrhea—Rates by County, United States, 2009
<19.0 (n = 1,405)
Rate per 100,000population
19.1–100.0 (n = 1,129)>100.0 (n = 607)
IS GONORRHEA DECREASING?
NATIONAL JOB TRAINING PROGRAM SCREENING DATA
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
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
Gonorrhea prevalence among men screened in the National Job Training
Program
80
180
280
380
480
580
680
0
0.5
1
1.5
2
2.5
3
3.5
2005 2006 2007 2008 2009
Case
rate
per
100
,000
per
sons
in N
ETSS
Perc
ent G
C po
sitive
in N
JTP
N= 95,184
GC prevalence Case rates in 15-24 year olds (NETSS)
Gonorrhea prevalence among women screened in the National Job Training
Program
80
180
280
380
480
580
680
0
0.5
1
1.5
2
2.5
3
3.5
2005 2006 2007 2008 2009
Case
rate
per
100
,000
per
sons
in N
ETSS
Perc
ent G
C po
sitive
in N
JTP
N= 91,697
GC prevalence Case rates in 15-24 year olds (NETSS)
Racial disparities among women in the National Job Training Program and
NETSS
Black
HispanicWhite
00.5
11.5
22.5
33.5
44.5
5
2005 2006 2007 2008 2009
GC P
reva
lenc
e
Year
GC prevalence by race/ethnicity among women screened in the National Job Training Program
White
Black
Hispanic
0
100
200
300
400
500
600
2005 2006 2007 2008 2009
Rate
per
100
,000
per
sons
Year
GC case rates among women in NETSS by race/ethnicity
NETSS DATA-TRENDS
Gonorrhea trends by project area, 2005–2010*
Large decrease
Moderatedecrease
Flat Moderateincrease
Largeincrease
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)
Gonorrhea trends by project area, 2009–2010*
Large decrease
Moderatedecrease
Flat Moderateincrease
Largeincrease
RESISTANCE MDR GC
“The one who does not remember history is bound to live through it again.”
George Santayana
“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
GONOCOCCAL ISOLATE SURVEILLANCE PROJECT DATA
Phoenix Albuquerque
Dallas
San DiegoOrange Co.
Las Vegas
Portland
NewOrleans
Honolulu
San Francisco
Minneapolis
Philadelphia
Cincinnati BaltimoreChicago
Miami
Denver
AtlantaBirmingham
Seattle
Cleveland
BirminghamRegional Labs
AtlantaSeattleCleveland
Tripler AMC
Los Angeles Greensboro
Detroit
OklahomaCity
New YorkCity
Kansas City
Richmond
GISP sites and regional laboratories —
United States, 2010 (29 Sites)
Austin*
* Funded for FY2010 & FY2011 as regional lab, not yet functioning
Austin
Emergence of FQ Resistance: Hawaii
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
05
1015202530354045
Cipro available
Reports of FQ resistance
* CDC, MMWR 2000.
FQ not recommended for GC in Hawaii*
Perc
enta
ge o
f GIS
P is
olat
es r
esis
tant
to
cipr
oflox
acin
Hawaii
Emergence of FQ Resistance: California
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
05
1015202530354045
Hawaii*
California
Perc
enta
ge o
f GIS
P is
olat
es r
esis
tant
to
cipr
oflox
acin
* CDC, MMWR 2000; ** CDC, MMWR, 2002
FQ not recommended for GC in California**
Emergence of FQ Resistance:
MSM
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
05
1015202530354045 FQ not recommended for
MSM†
Perc
enta
ge o
f GIS
P is
olat
es r
esis
tant
to
cipr
oflox
acin
MSM
Hawaii*California**
* CDC, MMWR 2000; ** CDC, MMWR, 2002; † CDC, MMWR, 2004.
Emergence of FQ Resistance: Rest of the US (Excluding Hawaii & California)
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
05
1015202530354045
US
Hawaii* MSM†
California**
* CDC, MMWR 2000; ** CDC, MMWR, 2002; † CDC, MMWR, 2004.; ‡ CDC, MMWR, 2007.
FQ not recommended in US‡
Perc
enta
ge o
f GIS
P is
olat
es r
esis
tant
to
cipr
oflox
acin
GISP TRENDS
Distribution of MICs to Cefixime, 2005–2010*
0.015 0.03 0.06 0.125 0.25 0.50
102030405060708090
20052006
Perc
enta
ge o
f iso
late
s
Minimum Inhibitory Concentrations (MICs), µg/ml* Preliminary (Jan-Sept)
Distribution of MICs to Cefixime, 2005–2010*
0.06 0.125 0.25 0.50
1
2
3
4
5
6
7
20052006
Perc
enta
ge o
f iso
late
s
Minimum Inhibitory Concentrations (MICs), µg/ml
1.3%
(n=58)
0.2%
(n=8)
* Preliminary (Jan-Sept)
GISP Surveillance
“alerts”“Decreased
Susceptibility”
Distribution of MICs to Ceftriaxone, 2006–2010*
0.06 0.125 0.25 0.50
0.5
1
1.5
2
2.5
320062007200820092010*
Perc
enta
ge o
f iso
late
s
Minimum Inhibitory Concentrations (MICs), µg/ml* Preliminary (Jan-Sept)
Distribution of MICs to Ceftriaxone, 2006–2010*
0.06 0.125 0.25 0.50
0.5
1
1.5
2
2.5
320062007200820092010*
Perc
enta
ge o
f iso
late
s
Minimum Inhibitory Concentrations (MICs), µg/ml* Preliminary (Jan-Sept)
GISP Surveillance “Alerts”
Decreased Susceptibility
Geographic Distribution of Cephalosporin* Alerts , 2005
*Cefixime or Ceftriaxone
Geographic Distribution of Cephalosporin* Alerts, 2006
*Cefixime or Ceftriaxone
Geographic Distribution of Cephalosporin* Alerts, 2009
*Cefixime or Ceftriaxone
San DiegoOrange Co.
Geographic Distribution of Cephalosporin* Alerts, 2010
*Cefixime or Ceftriaxone
Proportion of GISP Participants Identified as Men who Have Sex with
Men (MSM), 1988–2010*
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
*05
101520253035
* Preliminary 2010 (Jan-Sept)Note: Among men with available sex of sex partner data
Percentage
Year
Distribution of MICs to Azithromycin, 2006–2010*
≤0.03 0.06 0.125 0.25 0.5 1 2 4 8 1605
1015202530354045
20062007200820092010*
Perc
enta
ge o
f iso
late
s
Minimum Inhibitory Concentrations (MICs), µg/ml* Preliminary (Jan-Sept)
Distribution of MICs to Azithromycin, 2006–2010*
2 4 8 160
0.05
0.1
0.15
0.2
0.25
0.3
0.35 20062007200820092010*
Perc
enta
ge o
f iso
late
s
Minimum Inhibitory Concentrations (MICs), µg/ml* Preliminary (Jan-Sept)
INTERNATIONAL TRENDS
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
Recent Timeline• 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)
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
Response to Treatment Failures• Collect culture specimen for
susceptibility testing• Re-treat with at least 250 mg
ceftriaxone and 1-2 g azithromycin• Ensure partner treatment• Consider infectious disease
consultation• Report case to local health
department
ITS NOT JUST GONORRHEA……
Chlamydia—Rates by County, United States, 2009
<300.0 (n = 2,052)
Rate per 100,000population
300.1–400.0 (n = 379)>400.0 (n = 710)
Questions?Thank you
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
National Center for HIV/AIDS, Viral Hepatitis, STD , and TB PreventionDivision of STD Prevention