Reporting of laboratory-confirmed chlamydial infection and gonorrhea by providers affiliated with three large managed care organizations--United States, 1995-1 999

Surveillance for sexually transmitted diseases (STDs) depends on health departments receiving reports of positive STD test results from laboratories or of STD cases by clinicians. The completeness and timeliness of reporting can affect prompt sex partner notification and outbreak detection. In 1998, approximately 70% of chlamydia cases and 55% of gonorrhea cases were reported by private clinicians, including many affiliated with managed care organizations (MCOs). However, little is known about the completeness and timeliness of MCOs' STD case reporting practices. Three MCOs, three state health departments, and CDC evaluated reporting practices for chlamydial infection and gonorrhea by three large staff or group model MCOs that used different reporting procedures. The findings indicate that state health departments were notified of 78%-98% of chlamydia cases and of 64%-80% of gonorrhea cases identified in these MCOs; the median interval between specimen collection and state health department receipt of a case report was < or = 19 days. To improve surveillance quality, other MCOs, including network model MCOs, which provide most STD care in the United States, should evaluate surveillance quality and identify interventions for improvement.     

A Low-Cost Partner Notification Strategy for the Control of Sexually Transmitted Diseases: A Case Study From Louisiana

Objectives. We estimated the costs and effectiveness of implementing a partner notification (PN) strategy for highly prevalent sexually transmitted diseases (STDs) within the Louisiana STD/HIV Program.Methods. We carried out a telephone-based PN approach on an experimental basis in 2 public STD clinics in Louisiana from June 2010 to May 2012. We monitored data on the resources used for identifying, tracing, treating, and managing the infected cases and their partners to estimate the intervention costs.Results. Our results indicated that implementation of telephone-based PN should not increase the STD control program’s expenses by more than 4.5%. This low-cost PN approach could successfully identify and treat 1 additional infected case at a cost of only $171. We found that the cost per disability-adjusted life year averted (a health outcome measure), because of the adoption of selective screening with partner tracing, was $4499. This was significantly lower than the gross domestic product per capita of the United States, a threshold used for defining highly cost-effective health interventions.Conclusions. Adoption of PN for gonorrhea and chlamydia should be considered a national strategy for prevention and control of these diseases.Although partner notification (PN) is considered one of the most effective means of controlling sexually transmitted diseases (STDs), a majority of states in the United States focus their PN resources on one STD only, namely, syphilis. The PN process generally involves interviewing infected persons to obtain information about exposed sex partners, and then locating and notifying partners for medical evaluation and treatment. Other STDs, like gonorrhea and chlamydia, are treated when people visit clinics. Most STD control programs in the United States do not make any attempt to identify the partners of gonorrhea and chlamydia cases.1 Although it is important to continue partner-tracing and notification for syphilis, the practice of not tracing the partner for other high-prevalent STDs needs careful evaluation. In 2012, the number of chlamydia and gonorrhea cases reported in the United States exceeded 1.4 million and 334 000, respectively, whereas syphilis cases were less than 50 000.2 Because of the high incidence of chlamydia and gonorrhea, it is assumed that intensive PN simply will not be affordable.3,4 We attempted to estimate the incremental cost and cost-effectiveness of tracing the partner in relatively high STD incident regions of the country. As part of this study, we implemented an experimental approach of partner-tracing and notification within the Louisiana STD control program.PN is usually done by using 4 different methods—patient referral, provider referral, expedited partner therapy, and contract referral.1 Provider referral is the most commonly used PN strategy, and a number of studies have reported strong evidence for the high effectiveness of the method in increasing proportions of partners presenting for care.5–7 By implementing a simple telephone-based PN approach, we estimated the additional costs and effectiveness of the experimental strategy. The a priori hypothesis was that the telephone-based PN strategy would be highly cost-effective, and the additional resources needed for implementing the intervention would be relatively low. Quantification of costs and cost-effectiveness of a PN strategy might encourage re-evaluation of current practice of not doing any type of PN for gonorrhea and chlamydia cases.     

Gonorrhea and chlamydia infection among women visiting family planning clinics: racial variation in prevalence and predictors

CONTEXT: Black women are disproportionately infected with gonorrhea and chlamydia. Because of the potential impact of these infections on women's reproductive health, it is important to determine whether different factors are predictive of infection in women of different races. METHODS: Data from 31,762 women aged 15-24 who were tested for gonorrhea and chlamydia at Missouri family planning clinics in 2001 were used to calculate the prevalence of each infection by selected variables. Logistic regression analysis was used to assess factors associated with the risk of infection. RESULTS:Overall, 0.7% of women had gonorrhea, and 4% had chlamydia. The gonorrhea rate was 4% for blacks and 0.4% for whites; the chlamydia rate, 9% and 4%, respectively. Independent predictors of gonorrhea in both races were symptoms, recent sexual contact with a partner who had STD symptoms, and chlamydia infection. Predictors specific to whites were visiting the clinic for STD care and having a new partner or multiple partners in the past year. Being aged 15-21 was associated with an elevated risk of gonorrhea for blacks only. In both racial groups, chlamydia infection was associated with younger age, contact with a symptomatic partner, cervicitis, cervical friability and gonorrhea positivity. Additional predictors among whites were having a new partner, having multiple partners and having pelvic inflammatory disease; no other factors were significant for blacks. CONCLUSIONS: The prevalence and predictors of gonorrhea and chlamydia infection differ significantly between blacks and whites. Until these disparities are better understood, it will be difficult to establish screening criteria for gonorrhea.     

Epidemiologic differences between chlamydia and gonorrhea.

To assess the prevalence, demographics, and transmission patterns of genital chlamydia infection, we screened 3,078 patients, and compared identified cases (N = 511) to gonorrhea cases (N = 291) diagnosed in the same setting. Chlamydia cases were younger and more likely to be White than their gonorrhea counterparts. Chlamydia cases were distributed diffusely; geographic overlap between the two diseases was only about 40 percent. Gonococcal coinfection was noted in less than 10 percent of patients with chlamydia. Nearly half of men with chlamydia and four-fifths of women were asymptomatic and most cases were identified through screening or contact tracing. Populations at high risk for chlamydia are seemingly different from those for gonorrhea. Differences may be due to control interventions (active for gonorrhea, passive for chlamydia). Chlamydia case reporting and control initiatives are recommended.     

Sexually transmitted diseases among young heterosexual urban adults.

A self-administered, confidential survey of respondents'' history of selected sexually transmitted disease (STD) was conducted in 1987-88 among adults enrolled in a multicenter study of cardiovascular disease. Respondents (and response rates) included 535 white men (78 percent), 694 white women (89 percent), 262 black men (48 percent), and 472 black women (64 percent), ages 21 to 40 years at the time of the survey. Among those who were heterosexually active, 43 percent of black women, 37 percent of black men, 33 percent of white women, and 21 percent of white men reported ever having had at least one STD in the survey. A history of syphilis or gonorrhea was more commonly reported by blacks than whites; a history of genital herpes, chlamydia, or genital warts was more commonly reported by women than men. Independent risk factors for having had at least one STD in the survey included female sex; use of cocaine, amphetamines, or opiates; and lifetime number of sex partners. The number of sex partners was the most predictive risk factor. Black race was a significant marker for other, unidentified STD risk factors. The data show a high prevalence of a lifetime history of STD among young heterosexual urban U.S. adults with possible implications for the future spread of human immunodeficiency virus infection.     

Surveillance for sexually transmissible diseases in Victoria, 1983 to 1992

Abstract: Surveillance systems have been developed in Victoria to determine trends in sexually transmissible diseases (STDs). Notifications to the Health Department (including laboratory notification since May 1990) have been supplemented by data about strains of Nasseria gonorrhoeae and cultures for Chlamydia trachomatis processed by the Microbiological Diagnostic Unit, enhanced laboratory surveillance of syphilis, and data on genital herpes and genital warts from the Melbourne Sexual Health Centre. During the period under review the incidence of gonorrhoea declined, rapidly at first, and then more slowly. For women, this trend has continued, while gonorrhoea acquired abroad by men has become relatively more important. Since 1988, gonorrhoea in homosexual men has increased, and rectal isolates have increased concurrently, raising concerns about HIV risk behaviour. Cases of syphilis are likely to be ascertained through STD, antenatal and refugee screening, rather than because of symptoms or contact tracing. Chlamydia is a the most common notifiable STD, despite underreporting and under-diagnosis. In 1991, 832 cases were notified, increasing to 1377 in 1992. In 1992, of the 73 cases (65 per cent of notifications) where the doctor identified a risk, 15 per cent was attributed to homosexual contact, and 27.4 per cent to heterosexual exposure. Limitations in the data include inadequate standard case definitions for many STDs, changes in the statutory requirement for notifications in 1990, underreporting, changes in diagnostic and screening patterns, and lack of detailed demographic data. Education of general practitioners is needed to improve diagnosis and notification of chlamydia.     

Partner notification in the United States: an evidence-based review

INTRODUCTION: To conduct an evidence-based review of the literature on the effectiveness of partner notification strategies for syphilis, gonorrhea, chlamydia, and human immunodeficiency virus (HIV) in the United States. METHODS: Systematic literature searches of available databases yielded 212 English language articles on partner notification, 13 of which met the inclusion criteria. These 13 articles were systematically reviewed, abstracted, and rated for quality of study methods, analysis, and generalizability. RESULTS: Partner notification can newly detect HIV and other sexually transmitted diseases among partners. Of the six high-quality studies, the highest numbers of infections per infected person, 0.23 and 0.24, were detected by provider referral while the lowest number of infections per infected person, 0.03, was detected by self referral. None of the 13 studies examined the consequences of partner notification, such as infections or health consequences averted or changes in behavior and partnerships for infected persons or their partners. CONCLUSIONS: There is good evidence that partner notification is a means of newly detecting infections. In addition, there is fair evidence that provider referral generally ensures that more partners are notified and medically evaluated than does self referral. More research is needed to improve elicitation and notification procedures and tailor them to specific populations, to assess the effect of new testing technologies on partner notification, and to understand the consequences of partner notification for infected persons and their partners.     

Gender Differences in Bacterial STIs in Canada

HEALTH ISSUE: The incidence of bacterial sexually transmitted infections (STIs) is rising in Canada. If these curable infections were prevented and treated, serious long-term sequelae including infertility, and associated treatment costs, could be dramatically reduced. STIs pose a greater risk to women than men in many ways, and further gender differences exist in screening and diagnosis. KEY FINDINGS: Reported incidence rates of chlamydia, gonorrhea, and infectious syphilis declined until 1997, when the trend began to reverse. The reported rate of chlamydia is much higher among women than men, whereas the reverse is true for gonorrhea and infectious syphilis. Increases in high-risk sexual behaviour among men who have sex with men were observed after the introduction of potent HIV suppressive therapy in 1996, but behavioural changes in women await further research. DATA GAPS AND RECOMMENDATIONS: STI surveillance in Canada needs improvement. Reported rates underestimate the true incidence. Gender-specific behavioural changes must be monitored to enhance responsiveness to groups at highest risk, and more research is needed on effective strategies to promote safer sexual practices. Geographic and ethnic disparities, gaps, and needs must be addressed. Urine screening for chlamydia should be more widely available for women as well as men, particularly among high-risk men in order to prevent re-infections in their partners. As women are more likely to present for health examinations (e.g. Pap tests), these screening opportunities must be utilized. Female-controlled methods of STI prevention, such as safer topical microbicides, are urgently needed.     

Risk and prevalence of treatable sexually transmitted diseases at a Birmingham substance abuse treatment facility

OBJECTIVES: We evaluated the prevalence of gonorrhea, chlamydia, trichomoniasis, and syphilis in patients entering residential drug treatment. METHODS: Data on sexual and substance abuse histories were collected. Participants provided specimens for chlamydia and gonorrhea ligase chain reaction testing. Trichomonas vaginalis culture, and syphilis serologic testing. RESULTS: Of 311 patients, crack cocaine use was reported by 67% and multisubstance use was reported by 71%. Sexually transmitted disease (STD) risk behaviors were common. The prevalence of infection was as follows: Chlamydia trachomatis, 2.3%; Neisseria gonorrhoeae, 1.6%; trichomoniasis, 43%; and syphilis, 6%. CONCLUSIONS: STD counseling and screening may be a useful adjunct to inpatient drug treatment.     

Assessment of sexually transmitted diseases as risk factors for HIV seroconversion in a New Orleans sexually transmitted disease clinic, 1990-1998

PURPOSE: This investigation examined the role of ulcerative and non-ulcerative sexually transmitted diseases (STDs) in increasing susceptibility to HIV seroconversion in a large population of uninfected and predominantly heterosexual persons attending a New Orleans STD clinic. METHODS: A retrospective cohort of clients with repeat HIV tests between January 1990 and April 1998 was constructed using three independent sources of information. Multivariate Cox regression was used to identify risk factors for HIV seroconversion while controlling for the effects of behavioral risk factors. A time-dependent covariate for STD allowed HIV seroconversion to be examined in relation to the timing of STD diagnosis. RESULTS: Having a recent syphilis or GUD diagnosis was associated with significantly increased hazards of seroconversion (among men: hazard ratio [HR], 4.2 [2.4-7.2]; among women: 5.0 [1.9-13.0]). Among men with no history of GUD or syphilis, those with recent gonorrhea within 1 year prior to seroconversion were 2.8 (1.5-5.2) times as likely to seroconvert. CONCLUSIONS: This study suggests that both ulcerative and non-ulcerative STD may be associated with increased risk of HIV transmission and therefore comprehensive STD control strategies may be particularly effective tools for HIV prevention.     

Screening of sexually transmitted diseases in clinical and non-clinical settings in Salvador, Bahia, Brazil

The objectives were to study: (1) acceptance of STD screening in non-clinical settings for asymptomatic individuals; (2) risk factors and STD prevalence among individuals in non-clinical and clinical settings; and (3) non-clinical screening of asymptomatic populations as a feasible method for STD control. We recruited 139 males and 486 females between 18 and 30 years of age from a family planning clinic, schools, and community centers in low-income neighborhoods. We asked about STD symptoms and STD/HIV risk behaviors and tested the individuals for gonorrhea, Chlamydia, syphilis, and HIV. Except for HIV, women recruited directly from the community had higher STD rates than those who came in for care at the clinic. Screening in non-clinical settings in Brazil is feasible and has a high yield among young adults in low-income communities. Infected participants would likely never have otherwise sought care or been tested or treated. STD control efforts could be implemented in any site that can reach populations at risk and become a routine procedure in health care settings where people report for problems unrelated to STDs.     

2004-2009年全州县性病／艾滋病疫情分析

[目的]探讨全州县性病／艾滋病流行情况,为政府制定相关控制措施提供依据。[方法]对全州县2004～2009年淋病、梅毒、艾滋病疫情资料进行分析。[结果]2004～2009年累计报告淋病、梅毒、艾滋病病人／艾滋病病毒感染者（以下简称艾滋病）1009例,年均发病率为21．68／10万,年发病率分别为2004年14．79／10万、2005年为10．39／10万、2006年为17．58／10万、2007年为21．39／10万、2008年为26．65／10万、2009年为38．51／10万。年均发病率,淋病为5．31／lo万,梅毒为13．26／10万,艾滋病为3．12／10万。1009例中,男性590例,女性419例;梅毒、淋病、艾滋病,男性分别为311、179、100例,女性分别为306、68、45例。发病率最高的年龄组,艾滋病、梅毒、淋病均为25～34岁。[结论]全州县梅毒、淋病、艾滋病发病率偏高。     

Screening for sexually transmitted infections among economically disadvantaged youth in a national job training program.

PURPOSE: To evaluate results of screening for syphilis, gonorrhea, and chlamydia among youth in a federally funded job training program. METHODS: Data were evaluated from medical records of 12,881 randomly selected students in 54 U.S. job training centers during 1996. The intake medical evaluation includes serologic testing for syphilis. The policy was for females to receive a pelvic examination with gonorrhea and chlamydia testing and for males to be first screened with a urine leukocyte esterase (LE) assay, with follow-up gonorrhea and chlamydia testing for those with positive LE results. RESULTS: Adjusting for our sampling strategy, among females, an estimated 9.2% had a positive chlamydia test, 2.7% a positive gonorrhea test, and 0.4% had a positive syphilis test. Gonorrhea and chlamydia rates among females were highest in African-American followed by Native American students. Chlamydia infection was most common in younger women < or = 17 years of age. An estimated 0.1% of males had a positive syphilis test, and 4.8% of males a positive urine LE test. Of 103 LE-positive males tested for gonorrhea and chlamydia, only 27 (26%) had a positive test for one of these STDs. CONCLUSIONS: Our study supports routine screening of adolescents for gonorrhea and chlamydia, including those youth from socioeconomically disadvantaged backgrounds. Because individuals from such backgrounds may not regularly interact with traditional clinical health care systems, screening and treatment should be offered in alternative settings, such as the job training program described in this study.     

2010年福建省梅毒、淋病病例报告准确性评价

目的了解福建省医疗机构梅毒、淋病病例报告现状和准确程度,为性病疫情管理和疫情估计提供依据。方法下载被调查地区2010年1-6月所有梅毒与淋病病例的网络直报数据与医疗机构门诊日志、实验室检测结果进行核对并进行准确性评价。结果共核查梅毒病例1 158例,其中后天性梅毒1 067例,先天性梅毒425例;淋病病例425例,淋病病例报告准确性高于梅毒病例。淋病病例报告的准确率为84.71%,梅毒为54.89%。在各期/类梅毒病例报告中,I期、Ⅱ期梅毒和Ⅲ期梅毒的准确率分别为63.37%、78.05%和54.55%,隐性梅毒仅52.27%,胎传梅毒的准确率最低仅有27.47%。结论福建省隐性梅毒和胎传梅毒的准确率偏低,影响了性病疫情的准确性,应进一步加强性病疫情的管理,强化性病诊断的培训,提高性病报告质量。     

Syphilis testing in association with gonorrhea/chlamydia testing during a syphilis outbreak

We used an electronic medical records system retrospectively to evaluate how frequently, in a public hospital and its clinics, combined gonorrhea/chlamydia tests were accompanied by a syphilis test before and during a syphilis outbreak. Among 70,330 gonorrhea/chlamydia tests (1996-2000), the proportion with a syphilis test increased from 13% (preoutbreak) to 50% (intervention period) for men and from 6% to 13% for nonpregnant women. The increased syphilis testing coincided with a multifaceted public health intervention.     

兰州市某女子劳教所劳教人员性病流行病学调查

目的了解和掌握女性劳教人员梅毒、淋病、衣原体、支原体和HIV感染状况及流行特征。方法 2008年12月对兰州市某女子劳教所劳教人员进行整群抽样,调查其高危行为史,并抽取血标本进行HIV抗体和梅毒检测,采用阴道拭子采集标本,送实验室进行淋球菌和支原体培养,并用立明快速试剂盒进行衣原体检测。结果梅毒检出率为27.78%,淋病的检出率为3.70%,衣原体的检出率为22.20%,支原体的检出率为45.40%,HIV抗体阳性率为0。结论应加强宣传教育和行为干预,并注重劳教和监管人员的性病诊治,防止性病进一步传播蔓延。     

Problems with condom use among patients attending sexually transmitted disease clinics: prevalence, predictors, and relation to incident gonorrhea and chlamydia

Condom use remains important for sexually transmitted disease (STD) prevention. This analysis examined the prevalence of problems with condoms among 1,152 participants who completed a supplemental questionnaire as part of Project RESPECT, a counseling intervention trial conducted at five publicly funded STD clinics between 1993 and 1997. Altogether, 336 participants (41%, 95% confidence interval: 38, 45) reporting condom use indicated that condoms broke, slipped off, leaked, or were not used throughout intercourse in the previous 3 months. Correspondingly, 8.9% (95% confidence interval: 7.0, 9.5) of uses resulted in STD exposure if partners were infected because of delayed application of condoms (4.3% of uses), breakage (2.0%), early removal (1.4%), slippage (1.3%), or leakage (0.4%). Use problems were significantly associated with reporting inconsistent condom use, multiple partners, and other condom problems. One-hundred thirty participants completing the questionnaire were tested for gonorrhea and chlamydia at this time and also 3 months earlier. Twenty-one (16.2%) were infected with incident gonorrhea and chlamydia, with no infections among consistent users reporting no use problems. Exact logistic regression revealed a significant dose-response relation between increased protection from condom use and reduced gonorrhea and chlamydia risk (p(trend) = 0.032). Both consistency of use and use problems must be considered in studies of highly infectious STD to avoid underestimating condom effectiveness.     

Where do people go for treatment of sexually transmitted diseases?

CONTEXT: Major public health resources are devoted to the prevention of sexually transmitted diseases (STDs) through public STD clinics. However, little is known about where people actually receive treatment for STDs. METHODS: As part of the National Health and Social Life Survey, household interviews were performed from February to September 1992 with 3,432 persons aged 18-59. Weighted population estimates and multinomial response methods were used to describe the prevalence of self-reported STDs and patterns of treatment utilization by persons who ever had a bacterial or viral STD. RESULTS: An estimated two million STDs were self-reported in the previous year, and 22 million 18-59-year-olds self-reported lifetime STDs. Bacterial STDs (gonorrhea, chlamydia, nongonococcal urethritis, pelvic inflammatory disease and syphilis) were more common than viral STDs (genital herpes, genital warts, hepatitis and HIV). Genital warts were the most commonly reported STD in the past year, while gonorrhea was the most common ever-reported STD. Almost half of all respondents who had ever had an STD had gone to a private practice for treatment (49%); in comparison, only 5% of respondents had sought treatment at an STD clinic. Respondents with a bacterial STD were seven times more likely to report going to an STD clinic than were respondents with a viral STD--except for chlamydia, which was more likely to be treated at family planning clinics. Men were significantly more likely than women to go to an STD clinic. Young, poor or black respondents were all more likely to use a family planning clinic for STD treatment than older, relatively wealthy or white respondents. Age, sexual history and geographic location did not predict particular types of treatment-seeking. CONCLUSIONS: The health care utilization patterns for STD treatment in the United States are complex. Specific disease diagnosis, gender, race and income status all affect where people will seek treatment. These factors need to be taken into account when STD prevention strategies are being developed.     

Integrating routine HIV testing into a public health STD clinic

OBJECTIVE: To integrate routine HIV testing into the services offered at a public health department STD clinic and document the rate of acceptance and rate of test positivity during the first 18 months. METHODS: Testing for HIV was added to the array of tests offered to all patients at the Maricopa County STD clinic. Patients were informed of this new option at registration and were provided with a consent form and instructions to read the form and sign it, unless they did not desire testing. STD clinicians were responsible for insuring that questions regarding testing were answered and that consent forms were signed. HIV prevention was integrated into the general STD preventive messages during the clinical encounter. RESULTS: Sixty-eight percent of patients accepted testing (12,176 of 17,875). Of these, 68 were HIV-positive, for a rate of 5.6 per 1,000. The positive rate for men was 8.6/1000 and for women 1.2/1,000. The rate for men who reported having sex with men (MSM) was 63.8/1,000. Fourteen of the HIV-positive MSM were co-infected with syphilis. Of the 68 who were HIV-positive, 58 (85.3%) were successfully located, informed of their test results, and referred for HIV treatment and support services. CONCLUSIONS: HIV testing can be included in the routine battery of tests offered at an STD clinic with high patient acceptance. Routine testing can discover those who are unaware of their HIV-positive status, providing an opportunity for early referral for treatment, counseling to avoid disease transmission, and notification of sexual contacts.