BACKGROUND: The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) get tested annually for urethral and rectal chlamydia (CT) and gonorrhea (NG), and pharyngeal NG. There are no national recommendations to screen women and heterosexual men at extragenital sites. We assessed extragenital CT/NG screening among men and women at Louisiana's Parish Health Units (PHU). METHODS: The Louisiana STD/HIV/Hepatitis Program piloted extragenital screening at four PHUs in February 2016 and expanded to eleven PHUs in 2017. Sexual histories were used to identify gender of sex partners and exposed sites. Due to billing restrictions, up to two anatomical sites were tested for CT/NG. RESULTS: From February 2016-June 2019, 70,895 urogenital and extragenital specimens (56,086 urogenital, 13,797 pharyngeal and 1,012 rectal) were collected from 56,086 patients. Pharyngeal CT positivity was 160/7,868 (2.0%) among women, 54/4,838 (1.1%) among MSW (men who have sex with women) and 33/1,091 (3.0%) among MSM. Rectal CT positivity was 51/439 (11.6%) among women and 95/573 (16.6%) among MSM. Pharyngeal NG positivity was 299/7,868 (3.8%) among women, 222/4,838 (4.6%) among MSW and 97/1,091 (8.9%) among MSM. Rectal NG positivity was 20/439 (4.6%) among women and 134/573 (23.4%) among MSM.Urogenital-only screening would have missed: among women,173/3,923 (4.4%) CT and 227/1,480 (15.3%) NG infections; among MSW, 26/2,667 (1%) CT and 149/1,709 (8.7%) NG infections; and among MSM, 116/336 (34.5%) CT and 127/413 (42.1%) NG infections. CONCLUSIONS: Many CT/NG infections would have been missed with urogenital-only screening. MSM had much higher extragenital infection rates than women and MSW.

BACKGROUND: Interpretation of case-based surveillance of chlamydia and gonorrhea is limited by the lack of negative tests for comparison. We sought to develop a sustainable electronic health record (EHR)-based approach to disease surveillance in a sentinel population of pregnant persons. METHODS: We conducted a one-year assessment of sexually transmitted infections (STIs) in persons receiving at least one pregnancy-related visit within our university medical center. Data were obtained using EHR analytic structured query language code (SQL). Patients were categorized by whether they had an STI test during pregnancy and if screened, by the STI test results (positive or negative). We assessed screening and positivity by demographic using bivariate analyses. Predictors of a positive STI test were determined using logistic regression. RESULTS: We identified 4,553 persons who received pregnancy care from January 1 to December 31, 2021. Seventy-six percent (n, 3483) of persons were screened for an STI during pregnancy. Those who identified as white or had private insurance were less likely to have a chlamydia test. Among persons screened, Trichomonas was the most commonly detected STI (5%, 141/2,698) followed by chlamydia (4%, 135/3,456), and gonorrhea (0.7% 24/3,468). Predictors of a positive STI test during pregnancy were Black race [adjusted odds ratio (aOR) 6.0 (95% Confidence Interval 4.2-8.7)], age 25 [aOR 2.5 (1.9-3.3)], and public insurance [aOR 1.6 (1.2-2.1)]. CONCLUSIONS: We demonstrated that EHRs can be utilized to assess gonorrhea and chlamydia positivity. These methods could potentially be applied in other jurisdictions to improve the understanding of national STI surveillance.

OBJECTIVES: As, cases of congenital syphilis (CS) and infectious syphilis among women more than doubled in Florida and across the nation during 2013-2019, we sought to understand what may be contributing to these increases in Florida. DESIGN: A two time-period observational study. SETTING: Pregnant women with reported syphilis infections and their pregnancy outcomes (2013-2014 and 2018-2019) in Florida. PARTICIPANTS: 1213 pregnant women with reported syphilis infections living in Florida and 341 infants meeting the CS case definition. OUTCOME MEASURES: We assessed what proportion of the increase in CS was from increases in maternal syphilis infections. We examined maternal demographics, infection characteristics and timing of diagnoses that could explain the increase in CS. Finally, we reviewed if changes in presentation or severity of CS cases occurred. RESULTS: During 2013-2014, 83 (21%) of 404 pregnant women with syphilis delivered babies with CS. During 2018-2019, 258 (32%) of 809 pregnant women with syphilis delivered babies with CS. Comparing CS prevention rates, it was determined that 65% of the increase in CS was due to the increases in maternal syphilis infections. The proportion of maternal cases staged as primary or secondary increased over time (7%-13%) (p<0.01) and reports of drug use became slightly more common (6%-10%) (p=0.02). During 2018-2019, women delivering CS infants were more likely to be reinfected during the same pregnancy (27 (10%) vs 5 (6%) p=0.23) and more had negative third trimester screening tests (43 (17%) vs 7 (8% p=0.07)). The percentage of infants with CS who had ≥1 sign or symptom increased from 35% to 40%, and the combined total of stillbirths and infant deaths increased from 5 to 26. CONCLUSIONS: Recently, more pregnant women are being infected with syphilis and a higher per cent are not being treated to prevent CS. The reasons for this finding are unclear.

BACKGROUND: Approximately 20% of chlamydia (CT) and gonorrhea (GC) cases in Louisiana are diagnosed at Parish Health Units (PHU). Patient notification of CT and GC test results involves nurses' phone calls and letters to positive patients, which is time consuming and inefficient. METHODS: In December 2018, electronic results notification was implemented in Caddo PHU using Chexout software to notify enrolled patients via text or email when test results are ready to view in a patient portal. We compared the timeliness of GC/CT results notification and treatment pre- (December 2017-November 2018) and post- (December 2018-November 2019) Chexout implementation. A random sample of patients were interviewed to assess acceptability. RESULTS: During December 2018 - November 2019, 5,432 patients were tested for CT/GC, 3,924 (72%) enrolled in Chexout, and notifications were sent to 3,884 (99%). Among CT positives, 472/568 (83%) viewed results in the portal compared to 2,451/3,356 (73%) CT negatives. Among GC positives, 300/353 (85%) viewed results compared to 2,657/3,571 (74%) GC negatives. Treatment success for CT improved from 493/670 (74%) to 506/568 (89%) and for GC from 332/409 (81%) to 325/353 (92%). Mean time to treatment decreased for CT (13.4 to 10.7 days) and GC (11.3 to 9.2 days). Enrolled patients found Chexout notification satisfactory 168/169 (99%) and easy to use 130/141 (92%). Reasons for declining electronic notification included lack of personal cell phone 55/86 (64%) and confidentiality concerns 42/86 (49%). CONCLUSIONS: Electronic messaging decreased time to notification and increased treatment success. Nurses spent less time notifying patients leaving more time for patient care.

Syphilis rates have continued to rise in the United States. Florida and Louisiana consistently report high numbers of cases. We evaluated rates of reinfection to see if frequent rescreening might lead to earlier treatment and prevent infections. All syphilis records of all stages for males and females aged 15-70 years from the Florida and Louisiana Departments of Health surveillance databases 2000-2018 were evaluated. The first episode of syphilis during this period was considered the initial diagnosis for each person. Demographics of cases and repeaters (individuals reported with two or more cases of syphilis) were examined. Percentages of syphilis cases from repeaters by year were calculated as were percentages from HIV+ males. During 2000-2018, 124,827 syphilis cases were reported from 107,405 individuals: 73,811 (68.7%) males; 33,594 (31.3%) females. There were 12,545 individuals (repeaters) with two or more syphilis diagnoses (n = 17,422 cases; range, 2-10). From 2010 to 2018, repeaters accounted for steadily increasing percentage of all syphilis reported: 2010 (11%), 2013 (16%), 2015 (20%), and 2018 (26%). Among HIV+ male cases the percentage from repeaters also increased: 2010 (28%), 2013 (35%), 2015 (42%), and 2018 (50%). In 2018, 19% of all cases (n = 2455) were from HIV+ males who had a previous syphilis diagnosis. Among HIV+ males diagnosed with syphilis in 2015, 34% had a repeat syphilis diagnosis within 3 years. Most syphilis diagnosed in Florida and Louisiana was among persons infected for the first time. However, some subgroups could possibly benefit from more frequent screening. Males living with HIV who had a prior syphilis diagnosis were at very high risk of repeat infection.

INTRODUCTION: Disease intervention specialists (DIS) prevent syphilis by assuring treatment for patients' sex partners through partner notification (PN). Different interpretations of how to measure partners treated due to DIS efforts complicates PN evaluation. We measured PN impact by counting partners treated for syphilis after DIS interviewed the patient. METHODS: We reviewed data from early syphilis cases reported during 2015-2017 in seven jurisdictions. We compared infected partners brought to treatment using: 1) DIS-assigned disposition codes or 2) all infected partners treated 0-90 days after the patient's interview (adjusted treatment estimate). Stratified analyses assessed patient characteristics associated with the adjusted treatment estimate. RESULTS: DIS interviewed 23,613 patients who reported 20,890 partners with locating information. Many of the 3,569 (17.1%) partners classified by DIS as brought to treatment were treated before the patient was interviewed. There were 2,359 (11.3%) partners treated 0-90 days after the patient's interview. Treatment estimates were more consistent between programs when measured using our adjusted estimates (range 6.1%-14.8% per patient interviewed) compared to DIS-assigned disposition (range 6.1%-28.3%). Treatment of >1 partner occurred after 9.0% of interviews and was more likely if the patient was a woman (17.9%), aged <25 years (12.6%), interviewed ≤7 days from diagnosis (13.9%), HIV negative (12.6%), or had no reported history of syphilis (9.8%). CONCLUSIONS: Counting infected partners treated 0-90 days after interview reduced variability in reporting and facilitates quality assurance. Identifying programs and DIS who are particularly good at finding and treating partners could improve program impact.

BACKGROUND: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) case surveillance relies on reported positive laboratory results. Changes in reported cases may represent changes in testing practice or infection prevalence. This study evaluated changes over time for CT and NG positivity and testing rates of pregnant persons. METHODS: Prenatal testing results from persons ages 16-40 years tested by a national reference clinical laboratory were analyzed for CT and NG testing and positivity during 2010-2018 (n = 3,270,610). RESULTS: Testing rates increased among pregnant persons for CT (from 56.3% in 2010 to 64.1% in 2018, p < 0.001) and NG (from 55.6% to 63.2%, p < 0.001). Higher CT testing rates were found in Black non-Hispanic (adjusted odds ratio [AOR] 1.58, 95% CI 1.57-1.60) and Hispanic (AOR 1.19, 95% CI 1.18-1.20) persons. NG and CT testing rates were virtually identical. Significant increasing trends in CT positivity were observed for each age group studied (p < 0.001 for all): 16-19 (from 11.7% to 13.0%); 20-24 (from 6.4% to 6.7%); 25-30 (from 1.9% to 2.4%); 31-40 years (from 0.76% to 0.92%). Black non-Hispanic persons had the highest positivity for CT (AOR 2.52, 95% CI 2.46-2.57) and NG (AOR 5.42, 95% CI 5.05-5.82). CONCLUSIONS: Testing and adjusted positivity for both CT and NG among pregnant persons increased from 2010 to 2018. Higher testing rates were observed in Black non-Hispanic and Hispanic persons (even in persons under 25 years) suggesting some testing decisions may have been based on perceived risk, in contrast to many guidelines recommending screening all pregnant persons under 25 years.

BACKGROUND: Reactive syphilis serologies are investigated by health departments to determine if they represent new infection, reinfection, or treatment failure. Serologies prioritized for investigation based on nontreponemal test titer and age (using a 'reactor grid') undergo manual record search and review. We developed a computerized algorithm that automates the record search and review. METHODS: We developed and tested the algorithm using a Florida Department of Health dataset containing serologies reported January 2016-December 2018 and previous records linked to each individual. The algorithm was based on the syphilis case definition, which requires (except primary cases with signs and symptoms) 1) a positive treponemal test and a newly positive nontreponemal test or, 2) a 4-fold increase in nontreponemal test titer. Two additional steps were added to avoid missing cases. New York City Department of Health and Mental Hygiene validated this algorithm. RESULTS: The algorithm closed more investigations (49.9%) than the reactor grid (27.0%). The algorithm opened 99.4% of the individuals investigated and labeled as cases by the health department; it missed 75 cases. Many investigations opened by the algorithm were closed by the 'reactor grid'; we could not assess how many would have been cases. In New York City, the algorithm closed 70.9% of investigations, likely because more individuals had previous test in the database (88.2%) compared to Florida (56.5%). CONCLUSIONS: The automated algorithm successfully searched and reviewed records to help identify cases of syphilis. We estimate the algorithm would have saved Florida 590 workdays over 3 years.

BACKGROUND: The purpose of this study was to estimate the cost of syphilis in the United States, in terms of the average lifetime direct medical cost per infection. METHODS: We used a decision tree model of the natural history of syphilis. The model allowed for numerous possible outcomes of infection, including treatment for syphilis at various stages, inadvertent treatment, and late syphilis outcomes in those who are alive and still infected 30 years after acquisition. Future costs were discounted at 3% annually. Model inputs such as the cost and probability of each outcome were based on published sources. The probabilities we applied yielded outcomes consistent with reported cases of syphilis by stage from national surveillance data and number of deaths due to late syphilis from national mortality data. RESULTS: The estimated, discounted lifetime cost per infection was $1,190 under base case assumptions (2019 dollars). Treatment costs associated with late syphilis outcomes such as cardiovascular syphilis accounted for only $26 of the average lifetime cost per infection. Results were most sensitive to assumptions regarding the treatment cost per case of unknown duration or late syphilis. In the probabilistic sensitivity analyses, the 2.5th and 97.5th percentiles of the 10,000 simulations of the lifetime cost per infection were $729 and $1,884, respectively. CONCLUSIONS: Our estimate of the lifetime cost per infection is about 50% higher than in a previous study, a difference due in large part to our higher cost assumptions for benzathine penicillin G.s.

BACKGROUND: We estimated the lifetime medical costs attributable to STIs acquired in 2018, including sexually acquired HIV. METHODS: We estimated the lifetime medical costs of infections acquired in 2018 in the United States for eight STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, and HIV. We limited our analysis to lifetime medical costs incurred for treatment of STIs and for treatment of related sequelae; we did not include other costs such as STI prevention. For each STI except HPV, we calculated the lifetime medical cost by multiplying the estimated number of incident infections in 2018 by the estimated lifetime cost per infection. For HPV, we calculated the lifetime cost based on the projected lifetime incidence of health outcomes attributed to HPV infections acquired in 2018. Future costs were discounted at 3% annually. RESULTS: Incident STIs in 2018 imposed an estimated $15.9 billion (25th-75th percentile: $14.9-16.9 billion) in discounted, lifetime direct medical costs (2019 U.S. dollars). Most of this cost was due to sexually acquired HIV ($13.7 billion) and HPV ($0.8 billion). STIs in women accounted for about one-fourth of the cost of incident STIs when including HIV, but about three-fourths when excluding HIV. STIs among 15-24-year-olds accounted for $4.2 billion (26%) of the cost of incident STIs. CONCLUSIONS: Incident STIs continue to impose a considerable lifetime medical cost burden in the United States. These results can inform health economic analyses to promote the use of cost-effective STI prevention interventions to reduce this burden.

BACKGROUND: Reducing transmission depends on the percentage of infected partners treated; if many are missed, impact on transmission will be low. Traditional partner services metrics evaluate the number of partners found and treated. We estimated the proportion of partners of syphilis patients not locatable for intervention. METHODS: We reviewed records of early syphilis cases (primary, secondary, early latent) reported during 2015-2017 in seven jurisdictions (Florida, Louisiana, Michigan, North Carolina, Virginia, New York City, and San Francisco). Among interviewed syphilis patients, we determined the proportion who reported named partners (with locating information), reported unnamed partners (no locating information), and did not report partners. For patients with no reported partners, we estimated their range of unreported partners to be between one and the average number of partners for patients who reported partners. RESULTS: Among 29,719 syphilis patients, 23,613 (80%) were interviewed and 18,581 (63%) reported 84,224 sex partners (average=4.5; 20,853 (25%) named and 63,371 (75%) unnamed). An estimated 11,138 to 54,521 partners were unreported. Thus, 74,509 to 117,892 (of 95,362 to 138,745) partners were not reached by partner services (78-85%). Among interviewed patients, 71% reported ≥1 unnamed partner or reported no partners; this proportion was higher for men who reported sex with men [MSM] (75%), compared to men who reported sex with women only (65%), and women (44%). CONCLUSION: Approximately 80% of sex partners were either unnamed or unreported. Partner services may be less successful at interrupting transmission in MSM networks where a higher proportion of partners are unnamed or unreported.

BACKGROUND: Reported U.S. cases of chlamydia and gonorrhea have increased since 2000, while studies in select populations suggest the prevalence of these diseases has decreased. We sought to determine if these diagnoses are increasing among pregnant women delivering at our center. METHODS: This is a retrospective study of women delivering at least one infant > 18 weeks gestation at the Medical University of South Carolina over eleven years (2008-2018). Using the perinatal information system, we collected maternal race, age, insurer, and chlamydia and gonorrhea screening results during the pregnancy of record. Cochran-Armitage trend analyses were performed to evaluate trends in these diagnoses by delivery year for all women and for age/race subgroups. RESULTS: During the study period, there were 24,807 deliveries. The median age of women was 28 years (IQR 23-32). Five percent (5.0%) of women were diagnosed with chlamydia and 1.2% with gonorrhea. The percent of women diagnosed decreased for both chlamydia (9.6% to 3.4%) and gonorrhea (2.5% to 1.1%) (p <0.001 trend analyses for both). A higher percentage of Black women had chlamydia and gonorrhea and both diagnoses declined over time, chlamydia 17.4% to 6.9%, p<0.0001 and gonorrhea 5.8% to 2.1%, p< 0.0001. In a sub-analysis of race and age, Black women < 25 experienced the most significant decline in chlamydia diagnoses (p<0.0001). CONCLUSIONS: We observed declining diagnoses of chlamydia and gonorrhea among pregnant women in our center. Although Black women delivering were more likely to have either diagnoses, they experienced a significant decline in both chlamydia and gonorrhea over time.

We reviewed all cases of syphilis reported among pregnant women in Florida during 2018 for syphilitic reinfection. Nineteen (7.3%) of 261 pregnant women with syphilis were reported as reinfected during the same pregnancy. Timely rescreening and treatment prevented six (31.6%) of nineteen reinfected women from delivering infants with congenital syphilis.

BACKGROUND: Neonatal herpes simplex virus infection (nHSV) leads to severe morbidity and mortality, but national incidence is uncertain. Florida regulations require that healthcare providers report cases, and clinical laboratories report test results when herpes simplex virus (HSV) is detected. We estimated nHSV incidence using laboratory-confirmed provider-reported cases and electronic laboratory reports (ELR) stored separately from provider-reported cases. Mortality was estimated using provider-reported cases, ELR, and vital statistics death records. METHODS: For 2011-2017, we reviewed: provider-reported cases (infants <60 days of age with HSV infection confirmed by culture or polymerase chain reaction (PCR)), ELR of HSV-positive culture or PCR results in the same age group, and death certificates containing International Classification of Disease, Tenth Revision, codes for herpes infection: P35.2, B00.0-B00.9, and A60.0-A60.9. Provider-reported cases were matched against ELR reports. Death certificates were matched with provider and ELR reports. Chapman's capture-recapture method was used to estimate nHSV incidence and mortality. Mortality from all three sources was estimated using log-linear modelling. RESULTS: Providers reported 114 nHSV cases and ELR identified 197 nHSV cases. Forty-six cases were common to both datasets, leaving 265 unique nHSV reports. Chapman's estimate suggests 483 (95% C.I. 383-634) nHSV cases occurred (31.5 infections per 100,000 live births). nHSV deaths were reported by providers (n=9), ELR (n=18), and vital statistics (n=31), totaling 34 unique reports. Log-linear modeling estimates 35.8 fatal cases occurred (95% CI 34-40). CONCLUSIONS: Chapman's estimates using data collected over 7 years in Florida, conclude nHSV infections occurred at a rate of 1 per 3000 live births.

The Syphilis Health Check (SHC) had low estimated specificity (91.5%) in one Florida county. We investigated use of SHC by a range of Florida publicly-funded programs between 2015 and 2016 to estimate specificity, positive predictive value (PPV), field staff acceptance, and impacts on programmatic outcomes. All reported SHC results were extracted from routinely collected program data. Field staff were surveyed about SHC's utility. Analyses investigated differences between SHC and traditional syphilis testing outcomes. Of 3,630 SHC results reported, 442 were reactive; 92 (20.8%) had prior diagnoses of syphilis; 7 (1.6%) had no further testing. Of the remaining 343; 158 (46.0%) were confirmed cases, 168 (49.0%) were considered false-positive, and 17 (5.0%) were not cases but not clearly false-positive. Estimated specificity of SHC was 95.0%. Overall, 48.5% of positives became confirmed cases (PPV). PPV varied according to prevalence of syphilis in populations tested. Staff (90%) thought SHC helped identify new cases but expressed concern regarding discordance between reactive SHC and lab-based testing. Programmatic outcomes assessment showed shorter time to treatment and increased numbers of partners tested for the SHC group; these enhanced outcomes may better mitigate the spread of syphilis compared to traditional syphilis testing alone, but more research is needed.

The Centers for Disease Control and Prevention (CDC) recommends syphilis screening at least annually for sexually active men who have sex with men (MSM). The objective of this study is to assess the frequency of MSM testing for syphilis and how syphilis test results compared with results of rectal gonorrhea and chlamydia tests. In collaboration with a large US commercial laboratory, we identified men aged 15-60 years who had rectal chlamydia or gonorrhea tests during 09/01/2013-09/30/2015 as presumed MSM. We classified MSM as having current or past syphilis if during the study period they had (1) either a reactive qualitative non-treponemal test or at least a 1:1 quantitative non-treponemal test, and (2) they had a reactive treponemal test. Of 52,771 MSM, 14.3% had no syphilis testing, 4.8% had only treponemal testing (37.8% were reactive), 63.2% had only non-treponemal testing (2.0% were reactive), and 17.7% had both non-treponemal and treponemal testing (86.6% had current or past syphilis). Of those MSM who had reactive qualitative non-treponemal tests, at least 90% had no quantitative non-treponemal tests. Current or past syphilis was more common among MSM with positive rectal gonorrhea or chlamydia tests (24.1%) than MSM with negative rectal gonorrhea and chlamydia tests (13.0%, p < 0.005). Of MSM with any syphilis testing during 09/01/2013-09/30/2014, 64.8% also had annual repeat testing. Syphilis testing in general and repeat syphilis testing were frequent but suboptimal among MSM. It is important to continually monitor syphilis for MSM, especially for those MSM who had rectal chlamydia or gonorrhea infection.

BACKGROUND: Discordant syphilis test results, with a reactive non-treponemal test and non-reactive treponemal test are usually considered biological false positive test results (BFP), which can be attributed to other conditions. Syphilis surveillance laws mandate laboratory reporting of reactive syphilis tests which include many BFPs. We describe the frequency of BFP, titer distributions, and titer increases from reported test results in Florida and New York City (NYC). METHODS: Reactive non-treponemal tests for individuals with at least one non-reactive treponemal test and no reactive treponemal test, were extracted from STD surveillance systems in Florida and NYC from 2013 through 2017. Characteristics of individuals with BFPs were analyzed after selecting the observation with the highest titer from each individual. We next considered all results from individuals to characterize persons who had a four-fold titer increase between successive non-treponemal tests. RESULTS: Among 526,540 reactive non-treponemal tests, there were 57,580 BFPs (11%) from 39,920 individuals. Over 90% (n=52,330) of BFPs were low titer (</=1:4), but 654 (1%) were high-titer BFPs (>/=1:32). Very high-titer (>/=1:128) BFPs were more common among individuals over 60 years of age (OR 2.68 95%CI 1.22-5.91). A four-fold increase in titer was observed among 1,863 (14%) individuals with more than one reported BFP. CONCLUSIONS: Most BFPs detected by surveillance were low-titer but some were high-titer and some had a four-fold increase in titer. Review of patient histories might identify underlying conditions contributing to these high and rising titers.

Text or e-mail messages can provide timely notification of sexually transmitted disease (STD) results to patients. We assessed STD clinic patient opinions about text/e-mail notification via a service called Chexout. Among 113 patients who opted in, the majority found results notification via texts/e-mails to be satisfactory (99.0%) and easy (92.9%).

BACKGROUND: Presumptive antibiotic treatment is common for suspected chlamydia (CT) and gonorrhea (GC) infections before laboratory confirmation to prevent complications, reduce loss-to-follow-up, and interrupt transmission. We assessed this practice in sexually transmitted disease (STD) and family planning clinics. METHODS: We performed a retrospective analysis of data from clinics in Virginia in 2016 using administrative data merged with electronic laboratory reporting data. After stratifying by patient and clinic characteristics, we calculated how often patients with positive CT/GC tests were treated presumptively or during a follow-up visit, and how many patients with negative tests were treated presumptively. RESULTS: Of 63,889 patient visits with valid laboratory results from 131 clinics, 13% tested positive for CT or GC. Overall, presumptive treatment was given to 45.2% of persons with positive tests and 10.1% of persons with negative tests. Among the 9443 patients presumptively treated, 40.7% had positive test results. Presumptive treatment was more common in STD clinics compared with family planning clinics (22% vs. 4%) and for males with positive tests compared to females (65% vs. 24%); smaller variations were observed across age, race/ethnicity, and diagnosis categories. Twenty-six percent of patients with positive tests who were not treated presumptively had no treatment recorded within 30 days. CONCLUSIONS: Presumptive treatment for CT/GC was commonly used in this clinic population. It improved treatment coverage and reduced time to treatment, though some uninfected persons were treated. The impact of presumptive treatment on partner notification and treatment requires further study.

BACKGROUND: Interventions to prevent HIV in women include screening, partner notification, promoting condoms, and pre-exposure prophylaxis (PrEP). Identifying a woman's risk of acquiring HIV can help guide intervention recommendations. METHODS: We used data from Louisiana's STI and HIV registries to study 13- to 59-year-old women following their first diagnosis of syphilis, (or if none) gonorrhea, or (if none) chlamydia during 2000-2015. We measured rates of HIV reported subsequent to their STI (through 2016). Rates for women without STI were estimated by subtracting women with STI from reported cases and from Census estimates for the population. PrEP cost was estimated as $11,000 per year, and effectiveness was estimated as 100%. RESULTS: First STI were: syphilis (6,574), gonorrhea (64,995), or chlamydia (140,034). These 211,603 women had 1,865,488 person-years of follow-up and 969 HIV diagnoses. Women with no STI had 5,186 HIV diagnoses over 24,359,397 person-years. Rates of HIV diagnosis (per 100,000 person-years) were higher for women after syphilis (177.3), gonorrhea (73.2), or chlamydia (35.4) compared to women with no STI (22.4). Providing PrEP to all women diagnosed with syphilis or gonorrhea would cost $7,371,111,000 and could have prevented 546 HIV diagnoses. Limiting PrEP to one year after syphilis or gonorrhea diagnosis would cost $963,847,334 but only 143 HIV diagnoses were within 2 years after a syphilis or gonorrhea diagnosis. CONCLUSIONS: Rates of HIV diagnosis were high after women had STI, but not high enough to make PrEP cost-effective for them. Most women diagnosed with HIV did not have previously reported STI.

For decades, disease intervention specialists have worked on the front lines of public health, defending against the spread of sexually transmitted diseases (STDs), including HIV. The transmission of STDs can be interrupted when a disease intervention specialist contacts recently diagnosed persons, ensures that they are treated, identifies their sexual partners, and ensures that the partners are tested and treated. The success of this work depends on the ability and willingness of patients to name their sexual partners; the ability of the disease intervention specialist to promptly interview infected persons, find their sexual partners by using available resources, and maintain patient confidentiality; and the cooperation of local providers and community stakeholders in coordinating prevention messaging. With proper training and resources, disease intervention specialists provide an effective, albeit costly, service for health departments to control the spread of STDs and HIV.1

BACKGROUND: Congenital syphilis can be prevented if syphilis is treated early in pregnancy. Identifying women with syphilis who are pregnant facilitates prioritization for follow-up. In 2016, Florida reported 1,062 female syphilis cases, aged 15-44 years, and 160 (15%) cases were missing pregnancy status. The Florida Department of Health developed a system-generated weekly email notification sent to local program staff for all female syphilis investigations with unknown pregnancy status. We describe the outcome of these efforts to reduce unknown pregnancy status among women with syphilis. METHODS: Review of the frequency and outcomes (reduction in investigations flagged and change in pregnancy status variable) of the first email notification (10/2/2017) were compared to subsequent notifications through 6/25/2018. In addition, we reviewed pregnancy status of reported female syphilis cases (aged 15-44 years) from 2013-2018. RESULTS: The first email notification listed 76 investigations with unknown pregnancy status. This number decreased to 40 in one week and to 22 by one month. The decreased volume continued through June 2018 (n=13). Of the original 76 investigations, 3 women were pregnant and 38 (50%) were determined to meet the syphilis case definition (including 1 who was pregnant). In 2017, pregnancy ascertainment for female syphilis cases reached 98%. CONCLUSIONS: Focused efforts using email notification to obtain pregnancy status improved ascertainment in large STD programs with minimal effort. Most but not all women with unknown pregnancy status were identified as not pregnant.

BACKGROUND: Health departments prioritize investigations of reported reactive serologic tests based on age, gender, and titer using reactor grids. We wondered how reactor grids are used in different programs, and if administratively closing investigations of low-titer tests could lead to missed primary syphilis cases. METHODS: We obtained a convenience sample of reactor grids from 13 health departments. Interviews with staff from several jurisdictions described the role of grids in surveillance and intervention. From 5 jurisdictions, trends in reactive nontreponemal tests and syphilis cases over time (2006-2015) were assessed by gender, age, and titer. In addition, nationally-reported primary syphilis cases (2013-2015) were analyzed to determine what proportion had low titers (</=1:4) that might be administratively closed by grids without further investigation. RESULTS: Grids and follow-up approaches varied widely. Health departments in the study received a total of 48,573 to 496,503 reactive serologies over a 10-year period (3044-57,242 per year). In 2006 to 2015, the number of reactive serologies increased 37% to 169%. Increases were largely driven by tests for men although the ratios of tests per reported case remained stable over time. Almost one quarter of reported primary syphilis had low titers that would be excluded by most grids. The number of potentially missed primary syphilis cases varied by gender and age with 41- to 54-year-old men accounting for most. CONCLUSIONS: Reactor grids that close tests with low titers or from older individuals may miss some primary syphilis cases. Automatic, computerized record searches of all reactive serologic tests could help improve prioritization.

BACKGROUND: Ocular syphilis (OS) has been associated with HIV coinfection previously. We compared demographic and clinical characteristics of syphilis patients with and without HIV to identify risk factors for developing OS. METHODS: We reviewed all syphilis cases (early and late) reported to the North Carolina (NC) Division of Public Health during 2014-2016 and categorized HIV status (positive, negative, unknown) and OS status based on report of ocular symptoms with no other defined etiology. We estimated prevalence ratios (PR) and 95% confidence intervals (CI) for OS by HIV status. Among syphilis patients with HIV, we compared viral loads and CD4 cell counts by OS status. We compared symptom resolution by HIV status for a subset of OS patients. RESULTS: Among 7,123 confirmed syphilis cases, 2,846 (39.9%) were living with HIV, 109 (1.5%) had OS, and 59 (0.8%) had both. OS was more prevalent in syphilis patients with HIV compared to HIV-negative/unknown-status patients (PR: 1.8; 95% CI: 1.2, 2.6). Compared to other patients with HIV, the prevalence of OS was higher in patients with viral loads >200 copies/mL (1.7; 1.0, 2.8) and in patients with a CD4 count </=200 cells/mL (2.3; 1.3, 4.2). Among 11 patients with severe OS, 9 (81.8%) were HIV-positive. Among 39 interviewed OS patients, OS symptom resolution was similar for HIV-positive (70.0%) and HIV-negative/unknown-status (68.4%) patients. CONCLUSION: Syphilis patients with HIV were nearly twice as likely to report OS symptoms as were patients without documented HIV. HIV-related immunodeficiency possibly increases the risk of OS development in co-infected patients.

BACKGROUND: Louisiana has had the highest rates of congenital syphilis (CS) in the nation since 2012. CS Case Review Boards were established statewide in 2016 to study CS cases and identify interventions. METHODS: We summarized the findings of CS review boards, assessed which cases were preventable by prenatal care providers, reviewed recommended interventions, and assessed subsequent improvement in provider practices. RESULTS: All 79 CS cases reported January 2016-July 2017 were reviewed by boards during August 2016-August 2017.Twenty-six cases (33%) that could have been prevented by prenatal care providers had: lack of rescreening at 28-32 weeks (n=15), lack of any screening (n=5), treatment delay (n=4), or incorrect interpretation of test results (n=2).Twenty-one cases (27%) were possibly preventable by providers including: mother did not return for follow-up and treatment (n=19), late third trimester reactive test with premature delivery (n=1), or incomplete treatment and lack of follow-up by health department staff (n=1).Thirty-two cases (40%) that were unlikely to be prevented by providers had: non-reactive test at 28-32 weeks then reactive test <30 days before delivery (n=10), no prenatal care (n=9), mother adequately treated, case by infant criteria (n=8), first/second trimester non-reactive, reactive at preterm delivery (n=4), or mother adequately treated, reinfected before delivery (n=1). Providers were advised to adhere to CDC recommended syphilis screening and treatment protocols and rapidly report pregnant women with syphilis. Many providers changed their procedures. CONCLUSIONS: CS case review boards identified practices with inadequate screening, treatment, or reporting. Sharing these findings with providers changed practices and may prevent future cases.

BACKGROUND: Chlamydial infections are common among young women and can lead to serious reproductive health complications. We assessed the risk of reported repeat chlamydial infection among young women in Louisiana and time interval between infections by age and race/ethnicity. METHODS: We analyzed surveillance data on chlamydial infections reported among women in Louisiana from January 1, 2000 to December 31, 2015. Multiple reports for the same person were matched using unique codes. Chlamydial infections reported more than 30 days after a previous positive test were considered new infections. Women aged 15-34 years at first infection during 2000-2012 were censored after three years or after they had a repeat infection. Cumulative incidence and incidence rate of repeat chlamydial infection among women were determined by year of first infection. Race- and age-specific results were obtained using stratified analyses. RESULTS: One in four women diagnosed with a chlamydial infection at 15-34 years of age in Louisiana had a reported repeat infection in three years or less. Risk of repeat infection increased for younger women, racial/ethnic minorities, and women in more recent cohorts. Young black women aged 15-19 years in 2012 had the highest risk (44%). Black women also had shorter intervals between infections than white women. CONCLUSIONS: Repeat chlamydial infections were common, especially among young black women. The true number is likely higher because surveillance data only count infections that were detected and reported. Comprehensive prevention strategies are needed to address high rates of repeat chlamydial infections among women.

Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) are the most frequently reported notifiable diseases in the United States and costs for diagnosis and treatment of these two infections are approximately $700 million per year. A proposed new method for screening for these two infections is self-tests; similar to at-home pregnancy and HIV tests which do not include sending collected specimens to a laboratory for diagnosis. However, no such self-tests for sexually transmitted diseases (STD) have been approved by the Food and Drug Administration (FDA). To determine the acceptability of such a test, we used three surveys, conducted in 2017, including the American Men's Internet Survey, the SummerStyles survey, and the DocStyles survey to ask potential users about their interest in this type of test and how they might use it. Among our sampled population of men who have sex with men, 79.5% said they would prefer to take this type of test at home and 73.9% said they would be willing to pay at least $20 for the test. Among young adults (18-29years), 54.1% indicated that they would like to take this test at home and 64.5% were willing to pay more than $10 for such a test. Among sampled physicians, 85.1% were "likely" or "very likely" to use an FDA-approved STD self-test in their office to screen for CT or GC. Self-tests for STDs are on our horizon and we need to be prepared to integrate these tests into our healthcare systems.

BACKGROUND: Before penicillin, the syphilis case-fatality rate was 10% within 40 years. Late complications, such as cardiovascular syphilis, were still common in the 1950s but now seem quite rare even though some infections likely go undetected. We studied trends in syphilis mortality as an indicator of trends in severe complications of syphilis. METHODS: We assessed underlying cause of death from U.S. death certificates for 1968-2015. We examined death trends by type of syphilis (cardiovascular, neuro, congenital, other). We compared trends in deaths to trends in primary and secondary syphilis from national STD surveillance data. RESULTS: During 1968-2015 there were 6,498 deaths attributed to syphilis; 4,149 males and 2,349 females. Annual syphilis deaths decreased from 586 in 1968 to 94 in 1984, then leveled off to between 24-46 since 1998. Between 1968 and 2015, the decrease in annual cardiovascular syphilis deaths (from 338 to 3) exceeded the decrease in annual neurosyphilis deaths (from 191 to 33). Congenital syphilis deaths (which do not include stillbirths) generally decreased from 28 to 2 per year. An increase in primary and secondary syphilis among women in the late 1980s was accompanied by a 4-fold increase in congenital syphilis deaths (from 9 in 1986 to 35 in 1990) but there was no subsequent increase in syphilis deaths among women. CONCLUSION: Adults now rarely die from syphilis. Increases in infections in the late 1980s did not lead to an increase in adult syphilis deaths. Congenital syphilis deaths still increase when syphilis increases among women.

BACKGROUND: Before searching prior records, sexually transmitted disease (STD) programs use syphilis reactor grids to exclude some reactive non-treponemal test results (RNTs) based on patient age, sex, and test titer. We propose a new algorithm that starts with comparing RNTs to previous syphilis non-treponemal tests and current treponemal test results. METHODS: De-duplicated RNTs from Florida's surveillance system (2006-2015) were extracted and stratified on morbidity. An algorithm was developed to triage RNTs. Sensitivity and specificity of the algorithm and the current reactor grid were estimated using reported syphilis cases. A random sample of cases missed by the proposed algorithm, stratified by stage of disease, were reviewed to verify case classification. RESULTS: Reported RNTs increased 58% from 2006 (n=34,808) to 2015 (n=55,001) (total=372,902). The current reactor grid removed 91,518 (24.5%) RNTs and missed 1,149 potential cases. Strictly following the reactor grid would result in a sensitivity of 97.4% and a specificity of 27.5%. The proposed algorithm would remove 242,078 (64.9%) RNTs and miss 2,768 potential cases. This results in a slightly lower sensitivity of 93.8%, but nearly triples the specificity, 72.9%. A review of a random sample of the 2,768 cases estimated that 72.7% would not have met the syphilis surveillance case definition resulting in an adjusted sensitivity of 98.4%. CONCLUSIONS: In Florida, an algorithm that starts by searching previous syphilis test results vastly improved specificity and slightly improved sensitivity compared to the current reactor grid. Implementing an automated algorithm could increase case ascertainment efficiency and further prioritize likely cases for investigation.

This article summarizes a multi-state outbreak of heterosexual syphilis, including 134 cases of syphilis in adults and adolescents and at least two cases of congenital syphilis, which occurred on an American Indian reservation in the United States during 2013-2015. In addition to providing salient details about the outbreak, the article seeks to document the case-finding and treatment activities undertaken, their relative success or failure, and the lessons learned from a coordinated, multiagency response. Of 134 adult cases of syphilis, 40% were identified by enhanced, interagency contact tracing and partner services; 26% through symptomatic testing; and 16% through screening of asymptomatic individuals as the result of an electronic medical record (EMR) screening prompt. A smaller proportion of cases were identified by community screening events in high-morbidity communities; high risk venue-based screening events; other screening, including screening upon request; and prenatal screening at first trimester, third trimester, and day-of-delivery. Future heterosexual syphilis outbreak responders should act quickly to coordinate a package of high-yield case-finding and treatment activities-potentially including activities that seek to do the following: 1) increase prenatal screening, 2) improve community awareness and symptomatic test-seeking, 3) educate providers and improve general screening for syphilis; 4) implement EMR reminders for providers; 5) screen high-morbidity communities and at high-risk venues; and 6) form novel partnerships to accomplish partner services work when the context does not allow for traditional, DIS-only partner services.