Last data update: May 06, 2024. (Total: 46732 publications since 2009)
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CDC laboratory recommendations for syphilis testing, United States, 2024
Papp JR , Park IU , Fakile Y , Pereira L , Pillay A , Bolan GA . MMWR Recomm Rep 2024 73 (1) 1-32 This report provides new CDC recommendations for tests that can support a diagnosis of syphilis, including serologic testing and methods for the identification of the causative agent Treponema pallidum. These comprehensive recommendations are the first published by CDC on laboratory testing for syphilis, which has traditionally been based on serologic algorithms to detect a humoral immune response to T. pallidum. These tests can be divided into nontreponemal and treponemal tests depending on whether they detect antibodies that are broadly reactive to lipoidal antigens shared by both host and T. pallidum or antibodies specific to T. pallidum, respectively. Both types of tests must be used in conjunction to help distinguish between an untreated infection or a past infection that has been successfully treated. Newer serologic tests allow for laboratory automation but must be used in an algorithm, which also can involve older manual serologic tests. Direct detection of T. pallidum continues to evolve from microscopic examination of material from lesions for visualization of T. pallidum to molecular detection of the organism. Limited point-of-care tests for syphilis are available in the United States; increased availability of point-of-care tests that are sensitive and specific could facilitate expansion of screening programs and reduce the time from test result to treatment. These recommendations are intended for use by clinical laboratory directors, laboratory staff, clinicians, and disease control personnel who must choose among the multiple available testing methods, establish standard operating procedures for collecting and processing specimens, interpret test results for laboratory reporting, and counsel and treat patients. Future revisions to these recommendations will be based on new research or technologic advancements for syphilis clinical laboratory science. |
Sexually Transmitted Infections Treatment Guidelines, 2021
Workowski KA , Bachmann LH , Chan PA , Johnston CM , Muzny CA , Park I , Reno H , Zenilman JM , Bolan GA . MMWR Recomm Rep 2021 70 (4) 1-187 These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs. |
Vaccine effectiveness on DNA prevalence of human papillomavirus infection in anal and oral specimens from men who have sex with men- United States, 2016-2018.
Meites E , Winer RL , Newcomb ME , Gorbach PM , Querec TD , Rudd J , Collins T , Lin J , Moore J , Remble T , Swanson F , Franz J , Bolan RK , Golden MR , Mustanski B , Crosby RA , Unger ER , Markowitz LE . J Infect Dis 2020 222 (12) 2052-2060 BACKGROUND: In the United States, human papillomavirus (HPV) vaccination has been recommended for young adult men who have sex with men (MSM) since 2011. METHODS: The Vaccine Impact in Men (VIM) study surveyed MSM and transgender women aged 18-26 years in 3 U.S. cities during 2016-2018. Self-collected anal swab and oral rinse specimens were assessed for 37 types of HPV DNA. We compared HPV prevalence among vaccinated and unvaccinated participants and determined adjusted prevalence ratios (aPR) and confidence intervals (CI). RESULTS: Among 1,767 participants, 704 (39.8%) self-reported receiving HPV vaccine. Median age at vaccination (18.7 years) was older than age at first sex (15.7 years). Quadrivalent vaccine-type HPV was detected in anal or oral specimens from 475 (26.9%) participants. Vaccine-type HPV prevalence was lower among vaccinated (22.9%) compared with unvaccinated (31.6%) participants; aPR for those who initiated vaccination at </=18 years was 0.41 (95% CI: 0.24-0.57) and at >18 years was 0.82 (95% CI: 0.67-0.98). Vaccine effectiveness for at least one HPV vaccine dose at age >/=18 years or >18 years was 59% and 18%, respectively. CONCLUSIONS: Findings suggest real-world effectiveness of HPV vaccination among young adult MSM. This effect was stronger with younger age at vaccination. |
Recommendations for providing quality sexually transmitted diseases clinical services, 2020
Barrow RY , Ahmed F , Bolan GA , Workowski KA . MMWR Recomm Rep 2020 68 (5) 1-20 This report (hereafter referred to as STD QCS) provides CDC recommendations to U.S. health care providers regarding quality clinical services for sexually transmitted diseases (STDs) for primary care and STD specialty care settings. These recommendations complement CDC's Sexually Transmitted Diseases Treatment Guidelines, 2015 (hereafter referred to as the STD Guidelines), a comprehensive, evidence-based reference for prevention, diagnosis, and treatment of STDs. STD QCS differs from the STD Guidelines by specifying operational determinants of quality services in different types of clinical settings, describing on-site treatment and partner services, and indicating when STD-related conditions should be managed through consultation with or referral to a specialist. These recommendations might also help in the development of clinic-level policies (e.g., standing orders, express visits, specimen panels, and reflex testing) that can facilitate implementation of the STD Guidelines. CDC organized the recommendations for STD QCS into eight sections: 1) sexual history and physical examination, 2) prevention, 3) screening, 4) partner services, 5) evaluation of STD-related conditions, 6) laboratory, 7) treatment, and 8) referral to a specialist for complex STD or STD-related conditions.CDC developed the recommendations by synthesizing relevant, evidence-based guidelines and recommendations issued by other experts; reviewing current practice in the United States; soliciting Delphi ratings by subject matter experts on STD care in primary care and STD specialty care settings; discussing the scientific evidence supporting the proposed recommendations at a consultation meeting of experts and institutional stakeholders held November 20, 2015, in Atlanta, Georgia; conducting peer reviews of draft recommendations and supporting evidence; and discussing draft recommendations and supporting evidence during meetings of the CDC/Health Resources and Services Administration Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment STD Work Group. These recommendations are intended to help health care providers in primary care or STD specialty care settings offer STD services at their clinical settings and to help the persons seeking care live safer, healthier lives by preventing and treating STDs and related complications. |
World Health Organization Global Gonococcal Antimicrobial Surveillance Program (WHO GASP): review of new data and evidence to inform international collaborative actions and research efforts
Unemo M , Lahra MM , Cole M , Galarza P , Ndowa F , Martin I , Dillon JR , Ramon-Pardo P , Bolan G , Wi T . Sex Health 2019 16 (5) 412-425 Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a serious public health problem, compromising the management and control of gonorrhoea globally. Resistance in N. gonorrhoeae to ceftriaxone, the last option for first-line empirical monotherapy of gonorrhoea, has been reported from many countries globally, and sporadic failures to cure especially pharyngeal gonorrhoea with ceftriaxone monotherapy and dual antimicrobial therapies (ceftriaxone plus azithromycin or doxycycline) have been confirmed in several countries. In 2018, the first gonococcal isolates with ceftriaxone resistance plus high-level azithromycin resistance were identified in England and Australia. The World Health Organization (WHO) Global Gonococcal Antimicrobial Surveillance Program (GASP) is essential to monitor AMR trends, identify emerging AMR and provide evidence for refinements of treatment guidelines and public health policy globally. Herein we describe the WHO GASP data from 67 countries in 2015-16, confirmed gonorrhoea treatment failures with ceftriaxone with or without azithromycin or doxycycline, and international collaborative actions and research efforts essential for the effective management and control of gonorrhoea. In most countries, resistance to ciprofloxacin is exceedingly high, azithromycin resistance is present and decreased susceptibility or resistance to ceftriaxone has emerged. Enhanced global collaborative actions are crucial for the control of gonorrhoea, including improved prevention, early diagnosis, treatment of index patient and partner (including test-of-cure), improved and expanded AMR surveillance (including surveillance of antimicrobial use and treatment failures), increased knowledge of correct antimicrobial use and the pharmacokinetics and pharmacodynamics of antimicrobials and effective drug regulations and prescription policies (including antimicrobial stewardship). Ultimately, rapid, accurate and affordable point-of-care diagnostic tests (ideally also predicting AMR and/or susceptibility), new therapeutic antimicrobials and, the only sustainable solution, gonococcal vaccine(s) are imperative. |
The National Network of Sexually Transmitted Disease Clinical Prevention Training Centers turns 40 - a look back, a look ahead
Stoner BP , Fraze J , Rietmeijer CA , Dyer J , Gandelman A , Hook EW 3rd , Johnston C , Neu NM , Rompalo AM , Bolan G . Sex Transm Dis 2019 46 (8) 487-492 Since 1979, the National Network of Sexually Transmitted Disease (STD) Clinical Prevention Training Centers (NNPTC) has provided state-of-the-art clinical and laboratory training for STD prevention across the United States. This article provides an overview of the history and activities of the NNPTC from its inception to present day, and emphasizes the important role the network continues to play in maintaining a high-quality STD clinical workforce. Over time, the NNPTC has responded to changing STD epidemiological patterns, technological advances, and increasing private-sector care-seeking for STDs. Its current structure of integrated regional and national training centers allows NNPTC members to provide dynamic, tailored responses to STD training needs across the country. |
Developing a topology of syphilis in the United States
Bernstein KT , Grey J , Bolan G , Aral SO . Sex Transm Dis 2018 45 S1-s6 BACKGROUND: In the United States, reported rates of syphilis continue to increase. Co-occurring epidemics of syphilis among men who have sex with men (MSM) and heterosexual populations create challenges for the prioritization of resources and the implementation of context-specific interventions. METHODS: State was the unit of analysis and was restricted to the 44 states with the most complete data of sex or sex partners for their reported adult syphilis cases. States were classified as high, medium, or low for reported congenital syphilis (CS) and MSM primary and secondary (P&S) syphilis rates. Average values of a range of ecologic state level variables were examined among the 9 categories created through the cross-tabulation of CS and MSM P&S syphilis rates. Patterns among ecologic factors were assessed across the 9 categories of states' syphilis rates. RESULTS: Among the 44 states categorized, 4 states had high rates of both CS and MSM P&S syphilis in 2015, whereas 12 states fell into the medium/medium category and 7 into the low category. Six states had high CS and medium MSM syphilis and 4 states had medium CS but high MSM syphilis. Several area-level factors, including violent crime, poverty, insurance status, household structure and income, showed qualitative patterns with higher rates of CS and MSM P&S syphilis. Higher proportions of urban population were found among states with higher CS rates; no trend was seen with respect to urbanity and MSM P&S syphilis. CONCLUSIONS: Several area-level factors were associated with CS and MSM P&S syphilis in similar ways, whereas other ecologic factors functioned differently with respect to the 2 epidemics. Explorations of community and area-level factors may shed light on novel opportunities for population specific prevention of syphilis. |
Performance of treponemal tests for the diagnosis of syphilis
Park IU , Fakile YF , Chow JM , Gustafson KJ , Jost H , Schapiro JM , Novak-Weekley S , Tran A , Nomura JH , Chen V , Beheshti M , Tsai T , Hoover K , Bolan G . Clin Infect Dis 2018 68 (6) 913-918 Background: Treponemal immunoassays are increasingly used for syphilis screening with the reverse sequence algorithm. There are little data describing performance of treponemal immunoassays compared to traditional treponemal tests in patients with and without syphilis. Methods: We calculated sensitivity and specificity of seven treponemal assays: 1) ADVIA Centaur (chemiluminescence immunoassay-CIA), 2) Bioplex 2200 (microbead immunoassay-MBIA), 3) fluorescent treponemal antibody absorption test (FTA-ABS), 4) INNO-LIA (line immunoassay), 5) LIAISON CIA, 6) TP-PA (Treponema pallidum particle agglutination assay), and 7) Trep-Sure (enzyme immunoassay-EIA), using a reference standard combining clinical diagnosis and serology results. Sera were collected between May 2012-January 2013. Cases were characterized as: 1) current clinical diagnosis of syphilis: primary, secondary, early latent, late latent 2) prior treated syphilis only, 3) no evidence of current syphilis, no prior history of syphilis and at least 4/7 treponemal tests negative. Results: Among 959 participants, 262 had current syphilis, 294 had prior syphilis, and 403 did not have syphilis. FTA-ABS was less sensitive for primary syphilis [78.2% (65.0-88.2%)], than the immunoassays or TP-PA (94.5-96.4%) (all p</=0.01). All immunoassays were 100% sensitive for secondary syphilis, 95.2-100% sensitive for early latent disease, and 86.8-98.5% sensitive in late latent disease. TP-PA had 100% specificity (99.0-100%). Conclusion: Treponemal immunoassays demonstrated excellent sensitivity for secondary, early latent, and seropositive primary syphilis. Sensitivity of FTA-ABS in primary syphilis was poor compared to the immunoassays and TP-PA. Given its high specificity and superior sensitivity, TP-PA is a better test to adjudicate discordant results with the reverse sequence algorithm than the FTA-ABS. |
Syphilis elimination: Lessons learned again
Valentine JA , Bolan GA . Sex Transm Dis 2018 45 S80-S85 It is estimated that approximately 20 million new sexually transmitted infections (STIs) occur each year in the United States. The federally-funded STD prevention program implemented by CDC is primarily focused on the prevention and control of the three most common bacterial STIs: syphilis, gonorrhea, and chlamydia. A range of factors facilitate the transmission and acquisition of sexually transmitted infections, including syphilis. In 1999 CDC launched the National Campaign to Eliminate Syphilis from the United States. The strategies were familiar to public health in general and to STD control in particular: 1) enhanced surveillance, 2) expanded clinical and laboratory services, 3) enhanced health promotion, 4) strengthened community involvement and partnerships, and 5) rapid outbreak response. This national commitment to syphilis elimination was not the first effort, and like others before it too did not succeed. However, the lessons learned from this most recent campaign can inform the way forward to a more comprehensive approach to the prevention and control of STIs and improvement in the nation's health. |
Use of national syphilis surveillance data to develop a congenital syphilis prevention cascade and estimate the number of potential congenital syphilis cases averted
Kidd S , Bowen VB , Torrone EA , Bolan G . Sex Transm Dis 2018 45 S23-S28 BACKGROUND: Recent increases in reported congenital syphilis have led to an urgent need to identify interventions that will have the greatest impact on congenital syphilis prevention. We sought to create a congenital syphilis prevention cascade using national syphilis surveillance data to (1) estimate the proportion of potential congenital syphilis cases averted with current prevention efforts, and (2) develop a classification framework to better describe why reported cases were not averted. METHODS: We reviewed national syphilis and congenital syphilis case report data from 2016, including pregnancy status of all reported female syphilis cases and data on prenatal care, testing, and treatment status of mothers of reported congenital syphilis cases to derive estimates of the proportion of pregnant women with syphilis who received prenatal care, syphilis testing, and adequate syphilis treatment at least 30 days prior to delivery, as well as the proportion of potential congenital syphilis cases averted. RESULTS: Among the 2,508 pregnant women who were reported to have syphilis, an estimated 88.0% received prenatal care at least 30 days prior to delivery, 89.4% were tested for syphilis at least 30 days prior to delivery, and 76.9% received an adequate treatment regimen that began at least 30 days prior to delivery. Overall, an estimated 1,928 (75.0%) potential congenital syphilis cases in the United States were successfully averted. Among states that reported at least 10 syphilis cases among pregnant women, the estimated proportion of potential congenital syphilis cases averted ranged from 55.0% to 92.3%. CONCLUSIONS: While the majority of potential congenital syphilis cases in the United States were averted in 2016, there was substantial geographic variation, and significant gaps in delivering timely prenatal care, syphilis testing, and adequate treatment to pregnant women with syphilis were identified. The congenital syphilis prevention cascade is a useful tool to quantify programmatic successes and identify where improvements are needed. |
Re-emerging and newly recognized sexually transmitted infections: Can prior experiences shed light on future identification and control
Bernstein K , Bowen VB , Kim CR , Counotte MJ , Kirkcaldy RD , Kara E , Bolan G , Low N , Broutet N . PLoS Med 2017 14 (12) e1002474 How do we spot the next sexually transmitted infection? Kyle Bernstein and colleagues look for lessons from past discovery. |
Developing a public health response to Mycoplasma genitalium
Golden MR , Workowski KA , Bolan G . J Infect Dis 2017 216 S420-s426 Although Mycoplasma genitalium is increasingly recognized as a sexually transmitted pathogen, at present there is no defined public health response to this relatively newly identified sexually transmitted infection. Currently available data are insufficient to justify routinely screening any defined population for M. genitalium infection. More effective therapies, data on acceptability of screening and its impact on clinical outcomes, and better information on the natural history of infection will likely be required before the value of potential screening programs can be adequately assessed. Insofar as diagnostic tests are available or become available in the near future, clinicians and public health agencies should consider integrating M. genitalium testing into the management of persons with sexually transmitted infection (STI) syndromes associated with the infection (ie urethritis, cervicitis, and pelvic inflammatory disease) and their sex partners. Antimicrobial-resistant M. genitalium is a significant problem and may require clinicians and public health authorities to reconsider the management of STI syndromes in an effort to prevent the emergence of ever more resistant M. genitalium infections. |
Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action
Wi T , Lahra MM , Ndowa F , Bala M , Dillon JR , Ramon-Pardo P , Eremin SR , Bolan G , Unemo M . PLoS Med 2017 14 (7) e1002344 In a Policy Forum, Teodora Wi and colleagues discuss the challenges of antimicrobial resistance in gonococci. |
Screening for syphilis and other sexually transmitted infections in pregnant women - Guam, 2014
Cha S , Malik T , Abara WE , DeSimone MS , Schumann B , Mallada E , Klemme M , Aguon V , Santos AM , Peterman TA , Bolan G , Kamb ML . MMWR Morb Mortal Wkly Rep 2017 66 (24) 644-648 Prenatal screening and treatment for sexually transmitted infections (STIs) can prevent adverse perinatal outcomes. In Guam, the largest of the three U.S. territories in the Pacific, primary and secondary syphilis rates among women increased 473%, from 1.1 to 6.3 per 100,000 during 2009-2013 (1). In 2013, the first congenital syphilis case after no cases since 2008 was reported (1,2). Little is known about STI screening coverage and factors associated with inadequate screening among pregnant women in Guam. This study evaluated the prevalence of screening for syphilis, human immunodeficiency virus (HIV), chlamydia, and gonorrhea, and examined correlates of inadequate screening among pregnant women in Guam. Data came from the medical records of a randomly selected sample of mothers with live births in 2014 at a large public hospital. Bivariate analyses and multivariable models using Poisson regression were conducted to determine factors associated with inadequate screening for syphilis and other STIs. Although most (93.5%) women received syphilis screening during pregnancy, 26.8% were not screened sufficiently early to prevent adverse pregnancy outcomes. Many women were not screened for HIV infection (31.1%), chlamydia (25.3%), or gonorrhea (25.7%). Prenatal care and insurance were important factors affecting STI screening during pregnancy. Prenatal care providers play an important role in preventing congenital infections. Policies and programs increasing STI and HIV services for pregnant women and improved access to and use of prenatal care are essential for promoting healthy mothers and infants. |
The global roadmap for advancing development of vaccines against sexually transmitted infections: Update and next steps
Gottlieb SL , Deal CD , Giersing B , Rees H , Bolan G , Johnston C , Timms P , Gray-Owen SD , Jerse AE , Cameron CE , Moorthy VS , Kiarie J , Broutet N . Vaccine 2016 34 (26) 2939-2947 In 2014, the World Health Organization, the US National Institutes of Health, and global technical partners published a comprehensive roadmap for development of new vaccines against sexually transmitted infections (STIs). Since its publication, progress has been made in several roadmap activities: obtaining better epidemiologic data to establish the public health rationale for STI vaccines, modeling the theoretical impact of future vaccines, advancing basic science research, defining preferred product characteristics for first-generation vaccines, and encouraging investment in STI vaccine development. This article reviews these overarching roadmap activities, provides updates on research and development of individual vaccines against herpes simplex virus, Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum, and discusses important next steps to advance the global roadmap for STI vaccine development. |
Sexually transmitted diseases treatment guidelines, 2015
Workowski KA , Bolan GA . MMWR Recomm Rep 2015 64 1-137 These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs. |
Cost-effectiveness of chlamydia vaccination programs for young women
Owusu-Edusei K Jr , Chesson HW , Gift TL , Brunham RC , Bolan G . Emerg Infect Dis 2015 21 (6) 960-8 We explored potential cost-effectiveness of a chlamydia vaccine for young women in the United States by using a compartmental heterosexual transmission model. We tracked health outcomes (acute infections and sequelae measured in quality-adjusted life-years [QALYs]) and determined incremental cost-effectiveness ratios (ICERs) over a 50-year analytic horizon. We assessed vaccination of 14-year-old girls and catch-up vaccination for 15-24-year-old women in the context of an existing chlamydia screening program and assumed 2 prevaccination prevalences of 3.2% by main analysis and 3.7% by additional analysis. Estimated ICERs of vaccinating 14-year-old girls were $35,300/QALY by main analysis and $16,200/QALY by additional analysis compared with only screening. Catch-up vaccination for 15-24-year-old women resulted in estimated ICERs of $53,200/QALY by main analysis and $26,300/QALY by additional analysis. The ICER was most sensitive to prevaccination prevalence for women, followed by cost of vaccination, duration of vaccine-conferred immunity, and vaccine efficacy. Our results suggest that a successful chlamydia vaccine could be cost-effective. |
Evaluation of gonorrhea test of cure at 1 week in a Los Angeles community-based clinic serving men who have sex with men
Beymer MR , Llata E , Stirland AM , Weinstock HS , Wigen CL , Guerry SL , Mejia E , Bolan RK . Sex Transm Dis 2014 41 (10) 595-600 BACKGROUND: Because of the decreasing susceptibility of Neisseria gonorrhoeae to cephalosporin therapy, the Centers for Disease Control and Prevention recommends test of cure (TOC) 1 week after gonorrhea (GC) treatment if therapies other than ceftriaxone are used. In addition, the Centers for Disease Control and Prevention asks clinicians, particularly those caring for men who have sex with men (MSM) on the west coast, to consider retesting all MSM at 1 week. However, it is unclear if this is acceptable to providers and patients or if nucleic acid amplification tests (NAATs) are useful for TOC at 7 days. METHODS: Between January and July 2012, MSM with GC were advised to return 1 week after treatment for TOC using NAAT. A multivariate logistic regression model was used to determine demographic and behavioral differences between MSM who returned for follow-up and MSM who did not. RESULTS: Of 737 men with GC, 194 (26.3%) returned between 3 and 21 days of treatment. Individuals who returned were more likely to have no GC history (P = 0.0001) and to report no initial symptoms (P = 0.02) when compared with individuals who did not return for TOC. Of those who returned, 0% of urethral samples, 7.4% of rectal samples, and 5.3% of pharyngeal samples were NAAT positive at TOC. CONCLUSIONS: Although TOC may be an important strategy in reducing complications and the spread of GC, low return rates may make implementation challenging. If implemented, extra efforts should be considered to enhance return rates among individuals with a history of GC. If TOCs are recommended at 1 week and NAATs are used, the interpretation of positive results, particularly those from extragenital sites, may be difficult. |
Dual contraceptive use among adolescents and young adults: correlates and implications for condom use and sexually transmitted infection outcomes
Hood JE , Hogben M , Chartier M , Bolan G , Bauer H . J Fam Plann Reprod Health Care 2014 40 (3) 200-7 BACKGROUND: Simultaneous condom and hormonal contraception usage ('dual method use') maximises protection against pregnancy and sexually transmitted infection (STI), although there is concern that promotion of this strategy could result in diminished condom use and inadvertently increase STI risk. In this study, we (1) assessed how the use of dual methods, versus condoms alone, related to STI and consistency of condom use and (2) described the correlates of dual use. METHODS: A sample of 1450 young people aged 12-25 years were surveyed and screened for chlamydia and gonorrhoea at non-clinical sites in two high morbidity Californian counties in 2002-2003. Differences in STI prevalence and reported consistency of condom use were assessed for 'condom only' and 'dual method' users. Correlates of dual use were analysed via multivariate polytomous logistic regression. RESULTS: Condom only and dual method users did not significantly differ in terms of STI prevalence or reported consistency of condom use. Sex, age, race and relationship tenure were significant correlates of dual use. DISCUSSION: In these observational data, dual method use did not detrimentally affect STI risk. If interpreted alongside each subgroups' risk patterns for STI and unplanned pregnancy, the correlates of dual use can inform STI and pregnancy prevention interventions. |
Toward global prevention of sexually transmitted infections (STIs): The need for STI vaccines
Gottlieb SL , Low N , Newman LM , Bolan G , Kamb M , Broutet N . Vaccine 2014 32 (14) 1527-35 An estimated 499 million curable sexually transmitted infections (STIs; gonorrhea, chlamydia, syphilis, and trichomoniasis) occurred globally in 2008. In addition, well over 500 million people are estimated to have a viral STI such as herpes simplex virus type 2 (HSV-2) or human papillomavirus (HPV) at any point in time. STIs result in a large global burden of sexual, reproductive, and maternal-child health consequences, including genital symptoms, pregnancy complications, cancer, infertility, and enhanced HIV transmission, as well as important psychosocial consequences and financial costs. STI control strategies based primarily on behavioral primary prevention and STI case management have had clear successes, but gains have not been universal. Current STI control is hampered or threatened by several behavioral, biological, and implementation challenges, including a large proportion of asymptomatic infections, lack of feasible diagnostic tests globally, antimicrobial resistance, repeat infections, and barriers to intervention access, availability, and scale-up. Vaccines against HPV and hepatitis B virus offer a new paradigm for STI control. Challenges to existing STI prevention efforts provide important reasons for working toward additional STI vaccines. We summarize the global epidemiology of STIs and STI-associated complications, examine challenges to existing STI prevention efforts, and discuss the need for new STI vaccines for future prevention efforts. |
Trends in antimicrobial resistance in Neisseria gonorrhoeae in the USA: the Gonococcal Isolate Surveillance Project (GISP), January 2006-June 2012
Kirkcaldy RD , Kidd S , Weinstock HS , Papp JR , Bolan GA . Sex Transm Infect 2013 89 Suppl 4 iv5-iv10 BACKGROUND: Neisseria gonorrhoeae has progressively developed resistance to sulfonamides, penicillin, tetracycline and fluoroquinolones, and gonococcal susceptibility to cephalosporins has been declining worldwide. METHODS: We described trends in gonococcal antimicrobial susceptibility in the USA from January 2006 through June 2012. Susceptibility data for cefixime, ceftriaxone, azithromycin, penicillin, tetracycline and ciprofloxacin were obtained from the Gonococcal Isolate Surveillance Project (GISP), a sentinel surveillance system that monitors antimicrobial susceptibility in urethral gonococcal isolates collected from symptomatic men at 25-30 sexually transmitted disease clinics throughout the USA. RESULTS: The percentage of isolates with elevated cefixime minimum inhibitory concentrations (MICs) (≥0.25 microg/mL) increased from 0.1% in 2006 to 1.4% in 2010-2011 and was 1.1% in the first 6 months of 2012. The percentage with elevated ceftriaxone MICs (≥0.125 microg/mL) increased from 0.1% in 2006 to 0.3%-0.4% during 2009 through the first 6 months of 2012. There were no temporal trends in the prevalence of elevated azithromycin MICs (≥2 microg/mL) (0.2%-0.5%). The prevalence of resistance remained high for penicillin (11.2%-13.2%), tetracycline (16.7%-22.8%) and ciprofloxacin (9.6%-14.8%). CONCLUSIONS: The proportion of gonococcal isolates with elevated cephalosporin MICs increased from 2006 to 2010, but plateaued during 2011 and the first 6 months of 2012. Resistance to previously recommended antimicrobials has persisted. As the number of antimicrobials available for gonorrhoea treatment dwindles, surveillance systems such as GISP will be critical to detect emerging resistance trends and guide treatment decisions. |
Neisseria gonorrhoeae antimicrobial resistance among men who have sex with men and men who have sex exclusively with women: the Gonococcal Isolate Surveillance Project, 2005-2010
Kirkcaldy RD , Zaidi A , Hook EW 3rd , Holmes KH , Soge O , del Rio C , Hall G , Papp J , Bolan G , Weinstock HS . Ann Intern Med 2013 158 321-8 BACKGROUND: Gonorrhea treatment has been complicated by antimicrobial resistance in Neisseria gonorrhoeae. Gonococcal fluoroquinolone resistance emerged more rapidly among men who have sex with men (MSM) than men who have sex exclusively with women (MSW). OBJECTIVE: To determine whether N. gonorrhoeae urethral isolates from MSM were more likely than isolates from MSW to exhibit resistance to or elevated minimum inhibitory concentrations (MICs) of antimicrobials used to treat gonorrhea. DESIGN: 6 years of surveillance data from the Gonococcal Isolate Surveillance Project. SETTING: Publicly funded sexually transmitted disease clinics in 30 U.S. cities. PATIENTS: Men with a total of 34,600 episodes of symptomatic urethral gonorrhea. MEASUREMENTS: Percentage of isolates exhibiting resistance or elevated MICs and adjusted odds ratios for resistance or elevated MICs among isolates from MSM compared with isolates from MSW. RESULTS: In all U.S. regions except the West, isolates from MSM were significantly more likely to exhibit elevated MICs of ceftriaxone and azithromycin than isolates from MSW (P < 0.050). Isolates from MSM had a high prevalence of resistance to ciprofloxacin, penicillin, and tetracycline and were significantly more likely to exhibit antimicrobial resistance than isolates from MSW (P < 0.001). LIMITATIONS: Sentinel surveillance may not be representative of all patients with gonorrhea. HIV status, travel history, and antimicrobial use data were missing for some patients. CONCLUSION: Men who have sex with men are vulnerable to the emerging threat of antimicrobial-resistant N. gonorrhoeae. Because antimicrobial susceptibility testing is not routinely done in clinical practice, clinicians should monitor for treatment failures among MSM diagnosed with gonorrhea. Strengthened prevention strategies for MSM and new antimicrobial treatment options are needed. |
Cephalosporin-resistant gonorrhea in North America
Kirkcaldy RD , Bolan GA , Wasserheit JN . JAMA 2013 309 (2) 185-7 Gonorrhea has affected humans for centuries and remains common. Worldwide, an estimated 106.1 million cases occur annually.1 In 2011, gonorrhea again was the second most commonly reported notifiable infection in the United States with 321 849 cases reported.2 Because gonorrhea often can be asymptomatic, the true disease burden may be closer to 700 000.3 Gonorrhea disproportionately affects racial, ethnic, and sexual minorities. Untreated gonococcal infection can lead to pelvic inflammatory disease, ectopic pregnancy, and infertility in women and can facilitate transmission of human immunodeficiency virus.4 Childhood blindness still affects infants born to mothers infected with gonorrhea, particularly in resource-limited countries. | For years, gonorrhea has been easily treated with a single oral dose of antibiotics. However, Neisseria gonorrhoeae has progressively acquired resistance to each new agent: sulfonamides in the 1940s, penicillins and tetracyclines in the 1970s and 1980s, and fluoroquinolones by 2007 in the United States. Since then, cephalosporins have been the only antibiotics recommended for gonorrhea treatment.5 However, gonococcal susceptibility to oral cephalosporins is declining, and the effectiveness of these drugs is threatened. | Increasing cephalosporin minimum inhibitory concentrations (MICs), an early warning of impending resistance, and treatment failures with cephalosporins have been reported from east Asia since the early 2000s and recently have been reported from Europe.6,7 In the United States, the Gonococcal Isolate Surveillance Project (GISP), a national surveillance system that monitors trends in antibiotic susceptibility, has documented increasing cefixime MICs since 2009.8 The steepest cefixime MIC increases have been reported in the western United States and among individuals who have had male-to-male sexual contact, the region and population in which fluoroquinolone resistance initially emerged. However, data are lacking on the cefixime MICs at which clinical effectiveness wanes. |
A trich-y question: should Trichomonas vaginalis infection be reportable?
Hoots BE , Peterman TA , Torrone EA , Weinstock H , Meites E , Bolan GA . Sex Transm Dis 2013 40 (2) 113-6 Trichomonas vaginalis (TV) infection is the most common curable sexually transmitted infection (STI).1 In the United States, a population-based survey of females aged 14 to 49 years in 2001 to 2004 estimated that there were 2.3 million women with prevalent TV infections.2 Most infections are asymptomatic.3 In those with symptoms of disease, or trichomoniasis, the most common symptoms are vaginitis in women and urethritis in men.3 T. vaginalis infection is not currently reportable in any US state. | Recently, interest in making TV infection reportable has increased.4 Potential reasons for doing so include monitoring epidemiologic trends and stimulating public health research. The introduction of highly sensitive and specific nucleic acid amplification tests offers new options for making the diagnosis. In addition, researchers have cited associations of TV infection with adverse health events such as HIV acquisition, as reasons to make it reportable. | In the United States, the Council of State and Territorial Epidemiologists (CSTE) determines which conditions should be nationally notifiable by states to the Centers for Disease Control and Prevention. However, the authority to require reporting of cases of certain conditions resides in the states. Neither CSTE nor individual states have a published set of criteria to determine whether a condition should be reportable, although there are public health surveillance principles that are used by states and CSTE. |
Tackling multidrug-resistant gonorrhea: how should we prepare for the untreatable?
Kidd S , Kirkcaldy R , Weinstock H , Bolan G . Expert Rev Anti Infect Ther 2012 10 (8) 831-3 If cephalosporin resistance develops and spreads, successful treatment of gonorrhea will be extremely challenging, especially in settings without access to antimicrobial susceptibility testing to guide treatment decisions. | Control of Neisseria gonorrhoeae infection continues to represent a significant public health challenge worldwide. Globally, an estimated 88 million new cases of gonorrhea occur annually [1]. In addition to causing urethritis and cervicitis, N. gonorrhoeae infection can result in serious complications such as pelvic inflammatory disease, chronic pelvic pain, tubal infertility and ectopic pregnancy in women, and can facilitate HIV transmission [2]. Timely and effective treatment for gonorrhea prevents severe complications in the individual and limits transmission of the disease in the community by shortening the duration of infection. However, N. gonorrhoeae has progressively acquired resistance to each of the antimicrobial agents that have been recommended for treatment over the past 70 years, and the remaining treatment options are dwindling. | Since gonorrhea was first treated with sulfalinamide at the beginning of the antimicrobial era, N. gonorrhoeae has systematically developed resistance to sulfonamides, penicillins, tetracyclines and, most recently, the fluoroquinolones [3]. Third-generation cephalosporins are one of the last classes of antimicrobials that remain highly effective against gonorrhea. They are the recommended first-line treatment for gonorrhea in many countries, including the USA; however, there is evidence that cephalosporin-resistant N. gonorrhoeae may be on the horizon. The first reports of possible cephalosporin treatment failures associated with decreased in vitro susceptibility came from Japan during 2001–2003, and decreasing susceptibility of N. gonorrhoeae to third-generation cephalosporins has been observed in east Asia for more than 10 years [4]. Recently, cases of possible cefixime treatment failures in Europe were reported in 2010–2011 [5–9], and decreasing susceptibility to third-generation cephalosporins has been observed in Europe, Canada and the USA [10–12]. |
Neisseria gonorrhoeae with high-level resistance to azithromycin: case report of the first isolate identified in the United States
Katz AR , Komeya AY , Soge OO , Kiaha MI , Lee MV , Wasserman GM , Maningas EV , Whelen AC , Kirkcaldy RD , Shapiro SJ , Bolan GA , Holmes KK . Clin Infect Dis 2012 54 (6) 841-3 We report on the first Neisseria gonorrhoeae isolate in the United States identified with high-level resistance to azithromycin. This report discusses the epidemiologic case investigation, the molecular studies of resistance-associated mutations and N. gonorrhoeae multiantigen sequence typing, and challenges posed by emerging gonococcal antimicrobial resistance. |
The emerging threat of untreatable gonococcal infection
Bolan GA , Sparling PF , Wasserheit JN . N Engl J Med 2012 366 (6) 485-7 It is time to sound the alarm. During the past 3 years, the wily gonococcus has become less susceptible to our last line of antimicrobial defense, threatening our ability to cure gonorrhea and prevent severe sequelae. | Gonorrhea is the second most commonly reported communicable disease in the United States, with an estimated incidence of more than 600,000 cases annually. It disproportionately affects vulnerable populations such as minorities who are marginalized because of race, ethnic group, or sexual orientation. Unfortunately, Neisseria gonorrhoeae has always readily developed resistance to antimicrobial agents: it became resistant to sulfanilamide in the 1940s, penicillins and tetracyclines in the 1980s, and fluoroquinolones by 2007.1 When the prevalence of antimicrobial resistance in the Gonococcal Isolate Surveillance Project (GISP) exceeds 5%, national treatment recommendations are changed to focus on other effective drugs. However, the treatment options recommended by the Centers for Disease Control and Prevention (CDC) are now limited to third-generation cephalosporins.2 |
Chlamydia partner services for females in California family planning clinics
Yu YY , Frasure-Williams JA , Dunne EF , Bolan G , Markowitz L , Bauer HM . Sex Transm Dis 2011 38 (10) 913-8 BACKGROUND: Prompt treatment of exposed partners is critical for preventing further transmission of chlamydia, reinfection, and sequelae among females. Patient-delivered partner therapy (PDPT) has been allowable in California since 2001; however, few data are available regarding PDPT use and treatment outcomes. METHODS: Eight family planning clinics participated in a partner services evaluation from 2005 to 2006. Females aged 16 to 35 years with chlamydia were interviewed to determine the partner service received and partner treatment outcomes; a subset of partners was also interviewed. Determinants of reported partner treatment were assessed using multivariate logistic regression. Selected medical records were reviewed to assess reinfection rates. RESULTS: Overall, 743 female patients disclosed 952 partners; 58% of whom were identified as steady partners. Reported partner services included concurrent patient-partner treatment visits (15% of partners), PDPT (19%), patient referral (55%), health department referral (0.1%), and no partner management (11%). On the basis of patient report, 82% of partners were notified and 54% received treatment. Of the 166 (17%) partners interviewed, 139 (84%) reported that they had received treatment, which correlated well with patient report. Reported partner treatment was higher for concurrent treatment visits and PDPT (79% and 80%, respectively) compared to patient referral (44%, P < 0.0001). Adjusted for clinic and relationship status, partners managed with concurrent treatment visits or PDPT were more likely to receive treatment compared with partners managed with patient referral (adjusted odds ratios, 3.5; 95% confidence interval, 2.1-5.8 and adjusted odds ratios, 4.3; 95% confidence interval, 2.6-7.2, respectively). Among the patients retested within 6 months after treatment, 18% were reinfected; reinfection rates did not differ by type of partner service. CONCLUSIONS: Although overall rates of reported partner treatment were low, concurrent patient-partner treatment visits and PDPT were associated with significantly higher rates of partner treatment. However, these methods may be underutilized in California family planning settings. |
Cost-effectiveness of pooled nucleic acid amplification testing for acute HIV infection after third-generation HIV antibody screening and rapid testing in the United States: a comparison of three public health settings
Hutchinson AB , Patel P , Sansom SL , Farnham PG , Sullivan TJ , Bennett B , Kerndt PR , Bolan RK , Heffelfinger JD , Prabhu VS , Branson BM . PLoS Med 2010 7 (9) e1000342 BACKGROUND: Detection of acute HIV infection (AHI) with pooled nucleic acid amplification testing (NAAT) following HIV testing is feasible. However, cost-effectiveness analyses to guide policy around AHI screening are lacking; particularly after more sensitive third-generation antibody screening and rapid testing. METHODS AND FINDINGS: We conducted a cost-effectiveness analysis of pooled NAAT screening that assessed the prevention benefits of identification and notification of persons with AHI and cases averted compared with repeat antibody testing at different intervals. Effectiveness data were derived from a Centers for Disease Control and Prevention AHI study conducted in three settings: municipal sexually transmitted disease (STD) clinics, a community clinic serving a population of men who have sex with men, and HIV counseling and testing sites. Our analysis included a micro-costing study of NAAT and a mathematical model of HIV transmission. Cost-effectiveness ratios are reported as costs per quality-adjusted life year (QALY) gained in US dollars from the societal perspective. Sensitivity analyses were conducted on key variables, including AHI positivity rates, antibody testing frequency, symptomatic detection of AHI, and costs. Pooled NAAT for AHI screening following annual antibody testing had cost-effectiveness ratios exceeding US$200,000 per QALY gained for the municipal STD clinics and HIV counseling and testing sites and was cost saving for the community clinic. Cost-effectiveness ratios increased substantially if the antibody testing interval decreased to every 6 months and decreased to cost-saving if the testing interval increased to every 5 years. NAAT was cost saving in the community clinic in all situations. Results were particularly sensitive to AHI screening yield. CONCLUSIONS: Pooled NAAT screening for AHI following negative third-generation antibody or rapid tests is not cost-effective at recommended antibody testing intervals for high-risk persons except in very high-incidence settings. |
Repeat infection with chlamydia and gonorrhea among females: a systematic review of the literature
Hosenfeld CB , Workowski KA , Berman S , Zaidi A , Dyson J , Mosure D , Bolan G , Bauer HM . Sex Transm Dis 2009 36 (8) 478-89 Determining the magnitude of chlamydia and gonorrhea reinfection is critical to inform evidence-based clinical practice guidelines related to retesting after treatment. PubMed was used to identify peer-reviewed English language studies published in the past 30 years that estimated reinfection rates among females treated for chlamydia or gonorrhea. Included in this analysis were original studies conducted in the United States and other industrialized countries that reported data on chlamydia or gonorrhea reinfection in females. Studies were stratified into 3 tiers based on study design. Reinfection rates were examined in relation to the organism, study design, length of follow-up, and population characteristics. Of the 47 studies included, 16 were active cohort (Tier 1), 15 passive cohort (Tier 2), and 16 disease registry (Tier 3) studies. The overall median proportion of females reinfected with chlamydia was 13.9% (n = 38 studies). Modeled chlamydia reinfection within 12 months demonstrated peak rates of 19% to 20% at 8 to 10 months. The overall median proportion of females reinfected with gonorrhea was 11.7% (n = 17 studies). Younger age was associated with higher rates of both chlamydia and gonorrhea reinfection. High rates of reinfection with chlamydia and gonorrhea among females, along with practical considerations, warrant retesting 3 to 6 months after treatment of the initial infection. Further research should investigate effective interventions to reduce reinfection and to increase retesting. |
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