We compared mpox vaccination access between urban and rural residents who received ≥1 JYNNEOS dose using immunization data in Idaho and New Mexico. Rural residents traveled five times farther and three times longer than urban residents to receive mpox vaccination. Increasing mpox vaccine availability to healthcare facilities might increase uptake.

As of November 9, 2022, a total of 28,730 cases of monkeypox (mpox) had been reported in the United States,* primarily among adult cisgender men reporting recent male-to-male sexual contact (1). Transgender and gender-diverse persons, who constitute an estimated 0.5% of the U.S. adult population,(†) face unique health disparities and barriers to care (2-4). However, data on the epidemiologic and clinical features of Monkeypox virus infections in this population are limited (5). CDC analyzed U.S. case surveillance data on mpox cases in transgender and gender-diverse adults reported during May 17-November 4, 2022. During this period, 466 mpox cases in transgender and gender-diverse adults were reported, accounting for 1.7% of reported cases among adults. Most were in transgender women (43.1%) or gender-diverse persons (42.1%); 14.8% were in transgender men. Among 374 (80.3%) mpox cases in transgender and gender-diverse adults with information available on sexual or close intimate contact, 276 (73.8%) reported sexual or close intimate contact with a cisgender male partner during the 3 weeks preceding symptom onset. During the ongoing outbreak, transgender and gender-diverse persons have been disproportionately affected by mpox. Members of this population frequently reported recent sexual or close intimate contact with cisgender men, who might be in sexual networks experiencing the highest incidence of mpox. These findings highlight the importance of tailoring public health prevention and outreach efforts to transgender and gender-diverse communities and could guide strategies to reduce mpox transmission.

As of November 14, 2022, monkeypox (mpox) cases had been reported from more than 110 countries, including 29,133 cases in the United States.* Among U.S. cases to date, 95% have occurred among males (1). After the first confirmed U.S. mpox case on May 17, 2022, limited supplies of JYNNEOS vaccine (Modified Vaccinia Ankara vaccine, Bavarian Nordic) were made available to jurisdictions for persons exposed to mpox. JYNNEOS vaccine was approved by the Food and Drug Administration (FDA) in 2019 as a 2-dose series (0.5 mL per dose, administered subcutaneously) to prevent smallpox and mpox disease.() On August 9, 2022, FDA issued an emergency use authorization to allow administration of JYNNEOS vaccine by intradermal injection (0.1 mL per dose) (2). A previous report on U.S. mpox cases during July 31-September 3, 2022, suggested that 1 dose of vaccine offers some protection against mpox (3). This report describes demographic and clinical characteristics of cases occurring 14 days after receipt of 1 dose of JYNNEOS vaccine and compares them with characteristics of cases among unvaccinated persons with mpox and with the vaccine-eligible vaccinated population in participating jurisdictions. During May 22-September 3, 2022, among 14,504 mpox cases reported from 29 participating U.S. jurisdictions,() 6,605 (45.5%) had available vaccination information and were included in the analysis. Among included cases, 276 (4.2%) were among persons who had received 1 dose of vaccine 14 days before illness onset. Mpox cases that occurred in these vaccinated persons were associated with lower percentage of hospitalization (2.1% versus 7.5%), fever, headache, malaise, myalgia, and chills, compared with cases in unvaccinated persons. Although 1 dose of JYNNEOS vaccine offers some protection from disease, mpox infection can occur after receipt of 1 dose, and the duration of protection conferred by 1 dose is unknown. Providers and public health officials should therefore encourage persons at risk for acquiring mpox to complete the 2-dose vaccination series and provide guidance and education regarding nonvaccine-related prevention strategies (4).

BACKGROUND: Syphilis can cause neurologic, ocular, or otic manifestations, possibly resulting in permanent disability or death. In 2018, CDC began collecting syphilis clinical manifestation data via the National Notifiable Diseases Surveillance System (NNDSS). We present the first reported U.S. syphilis neurologic, ocular, and otic manifestation prevalence estimates. METHODS: We reviewed 2019 NNDSS data to identify jurisdictions reporting ≥70% of syphilis cases ≥15 years old with clinical manifestation data (considered "complete reporting"). Among these jurisdictions, we determined reported neurologic, ocular, and otic manifestation prevalence, stratified by demographic, behavioral, and clinical characteristics. RESULTS: Among 41,187 syphilis cases in 16 jurisdictions with complete reporting, clinical manifestations were infrequently reported overall: neurologic (n = 445, 1.1%), ocular (n = 461, 1.1%), otic (n = 166, 0.4%), any (n = 807, 2.0%). Reported clinical manifestation prevalence was highest among cases ≥65 years old (neurologic: 5.1%; ocular: 3.5%; otic: 1.2%) and those reporting injection drug use (neurologic: 2.8%; ocular: 3.4%; otic: 1.6%). Although reported neurologic and ocular manifestation prevalence was slightly higher among HIV-infected vs. HIV-negative persons, approximately 40% of cases with manifestations were HIV-negative. Reported otic manifestation prevalence was similar regardless of HIV status. When stratifying by HIV status and syphilis stage, reported prevalence was highest among HIV-infected persons with unknown duration/late syphilis (neurologic: 3.0%; ocular: 2.3%; otic: 0.7%). CONCLUSIONS: Reported Neurologic, ocular, and otic manifestation prevalence was low among syphilis cases, but these data are likely an underestimate given potential underreporting. Reported clinical manifestation frequency, including among HIV-negative persons, emphasizes the importance of evaluating all syphilis cases for signs/symptoms of neurosyphilis, ocular syphilis, and otosyphilis.

The relative proportion of cases of P&S syphilis among men who have sex with men and women reported through national case report data from 2010 through 2019 appeared stable overall and stratified by race/ethnicity, region, and age group, but case counts increased.

PROBLEM: Sexually transmitted diseases (STDs) are a major cause of morbidity in the United States, with an estimated $15.9 billion in lifetime direct medical costs. Although the majority of STDs are diagnosed in the private sector, publicly funded STD clinics have an important role in providing comprehensive sexual health care services, including STD and HIV screening, for a broad range of patients. In certain cases, STD clinics often are the only source of sexual health care for patients, particularly among gay, bisexual, and other men who have sex with men (MSM). PERIOD COVERED: 2010-2018. DESCRIPTION OF THE SYSTEM: The STD Surveillance Network (SSuN) is an ongoing sentinel surveillance system for monitoring clinical information among patients attending STD clinics. SSuN is a collaboration of competitively selected state and city health departments that conduct facility-based sentinel surveillance in STD clinics. Information routinely collected through the course of patient encounters is obtained for all patients seeking care in the participating STD clinics. This information includes demographic, behavioral, and clinical characteristics (e.g., STD and HIV tests performed and STD and HIV diagnoses). This report presents 2010-2018 SSuN data from 14 STD clinics in five cities (Baltimore, Maryland; New York City, New York; Philadelphia, Pennsylvania; San Francisco, California; and Seattle, Washington) to describe the patient populations seeking care in these STD clinics. Estimated numbers and percentages of patients receiving selected STD-related health services were calculated for each year by using an inverse variance weighted random-effects model, adjusting for heterogeneity among SSuN jurisdictions. Trends in receipt of selected STD-related health services were examined and included HIV screening after an acute STD diagnosis among persons not previously known to have HIV infection, annual chlamydia screening among adolescent and young females, and extragenital chlamydia and gonorrhea screening among MSM. RESULTS: During 2010-2018, the total number of annual visits made in the 14 participating STD clinics decreased 29.8% (from 145,728 to 102,275 visits), and the total number of unique patients examined in the clinics decreased 35.1% (from 94,281 to 61,172 patients). Decreases in the number of unique patients occurred both among men who have sex with women only (42.4%; from 37,842 in 2010 to 21,781 in 2018) and among females (51.4%; from 36,485 in 2010 to 17,721 in 2018). The decreases in the number of female patients were observed across all age groups, although they were more pronounced among females aged ≤24 years (66.4%; from 17,721 in 2010 to 5,962 in 2018). In contrast, the number of patients identified as MSM increased 44.0% (from 12,859 in 2010 to 18,512 in 2018), with the greatest increase among MSM aged ≥25 years (58.6%; from 9,918 in 2010 to 15,733 in 2018). Among visits during which an acute STD (defined as chlamydia, gonorrhea, or primary or secondary syphilis) was diagnosed, the percentage of visits during which an HIV test was performed within approximately 14 days of the STD diagnosis increased from 58.2% in 2010 to 70.2% in 2018. Among those patients tested, 1,672 HIV infections were identified, of which 84.0% were among MSM. Among females aged 15-24 years, the percentage screened for chlamydia in any calendar year increased from 88.6% in 2010 to 90.6% in 2018. However, because fewer females aged 15-24 years attended these clinics during the study period, the crude number of adolescent and young females tested for chlamydia decreased from 14,249 in 2010 to 4,507 in 2018. During 2010-2018, the percentage of females retested after their first positive chlamydia diagnosis during the same year ranged from 11.4% to 13.3%. During 2010-2018, the percentage of MSM tested for rectal chlamydia and rectal gonorrhea increased (from 54.7% to 57.8% and from 55.0% to 58.4%, respectively). During the same period, increases were noted in the percentage of MSM with diagnosed rectal chlamydia (from 15.5% in 2010 to 17.7% in 2018) and rectal gonorrhea (from 13.3% in 2010 to 17.1% in 2018). In contrast with pharyngeal chlamydia, pharyngeal gonorrhea screening was more common (from 69.5% in 2010 to 74.6% in 2018), and the percentage positive doubled during the study period (from 7.3% in 2010 to 14.8% in 2018). Pharyngeal chlamydia testing also increased (from 50.3% in 2010 to 72.9% in 2018), with concurrent decreases in positivity (from 4.2% in 2010 to 2.6% in 2018). INTERPRETATION: During 2010-2018, changes occurred in the demographic composition of patients attending STD clinics participating in SSuN. Understanding trends in the demographic profile of STD patients and services provided can help identify addressable gaps in STD control efforts and direct public health action. Overall, fewer females, especially those aged 15-24 years, accessed care in these STD clinics during the study period. Untreated STDs among adolescent and young females can have serious consequences, including pelvic inflammatory disease and infertility. Additional efforts to monitor where adolescent and young females seek care and to ensure they are receiving quality STD-related health services are needed, especially considering increases in reported cases of STDs among females. Increases in the number of MSM attending STD clinics present a unique opportunity to reach this population with STD and HIV prevention services. Although a large percentage of STD cases are diagnosed outside of STD clinics, publicly funded STD clinics are an important safety-net provider of STD-related health services and provide vital STD-related health services for patient populations at risk for the consequences of STDs and HIV infection. PUBLIC HEALTH ACTIONS: STD-related health services represent effective strategies for preventing STD and HIV transmission and acquisition or STD-related sequelae. Ensuring that all persons receive quality HIV and STD prevention and treatment services is vital for an effective public health approach to reducing STDs. STD clinics provide crucial safety-net services for preventing STD-related morbidity, including timely identification and treatment of curable STDs such as chlamydia, gonorrhea, and syphilis. Increases in the numbers of MSM attending STD clinics participating in SSuN provide additional opportunities for linking patients to high-impact HIV preventive services (e.g., pre-exposure prophylaxis), and the clinics are positioned to facilitate initiation or resumption of treatment among persons living with HIV.

BACKGROUND: Syphilis, a sexually transmitted infection that can cause severe congenital disease when not treated during pregnancy, is on the rise in the United States. Our objective was to identify U.S. counties with elevated risk for emergence of primary and secondary (P&S) syphilis among reproductive-aged women. METHODS: Using syphilis case reports, we identified counties with no cases of P&S syphilis among reproductive-aged women in 2017 and ≥ 1 case in 2018. Using county-level syphilis and sociodemographic data, we developed a model to predict counties with emergence of P&S syphilis among women and a risk score to identify counties at elevated risk. RESULTS: Of 2,451 counties with no cases of P&S syphilis among reproductive-aged women in 2017, 345 counties (14.1%) had documented emergence of syphilis in 2018. Emergence was predicted by the county's P&S syphilis rate among men; violent crime rate; proportions of Black, White, Asian, and Hawaiian/Pacific Islander persons; urbanicity; presence of a metropolitan area; population size; and having a neighboring county with P&S syphilis among women. A risk score of ≥20 identified 75% of counties with emergence. CONCLUSIONS: Jurisdictions can identify counties at elevated risk for emergence of syphilis in women and tailor prevention efforts. Prevention of syphilis requires multidisciplinary collaboration to address underlying social factors.

Congenital syphilis, a life-threatening infection caused by the transmission of Treponema pallidum from a woman to her fetus during pregnancy, can result in miscarriage, stillbirth, preterm birth, low birth weight, and infant death.1 Whereas many infants with congenital syphilis are asymptomatic at birth,2 classic signs can appear in the first 2 years of life, including rash, copious nasal discharge (“snuffles”), hepatosplenomegaly, jaundice related to syphilitic hepatitis, bone deformities, and neurologic involvement. Although these sequelae can be prevented when maternal syphilis is diagnosed and treated 30 days or more before delivery,3 the incidence of congenital syphilis in the United States is increasing.2

BACKGROUND: Recent increases in high-risk substance use (HRSU) (i.e., injection drug use, heroin, methamphetamine, crack/cocaine) have coincided with rising primary and secondary (P&S) syphilis rates. To further understand these trends, we examined sexual risk behaviors among women, men who have sex with women only (MSW) and men who have sex with men (MSM) who were diagnosed with P&S syphilis in 2018 and reported HRSU. METHODS: Data on HRSU and sexual risk behaviors among persons with P&S syphilis were drawn from syphilis case reports in 2018 from the National Notifiable Diseases Surveillance System. Persons with P&S syphilis were asked about sexual risk behaviors in the past 12 months including exchange sex for drugs/money; sex while intoxicated and/or high on drugs; sex with a person who injects drugs (PWID); sex with an anonymous partner; and number of sex partners. We describe percentages and adjusted prevalence ratios for women, MSW and MSM reporting these behaviors by age, race/Hispanic ethnicity, type of drug used, and incarceration history (both in past 12 months). RESULTS: Among 19,634 persons diagnosed with P&S syphilis in 2018 with information on HRSU, 29.3% of women, 22.7% of MSW and 12.4% of MSM reported HRSU. Among those reporting HRSU, percentages reporting exchange sex ranged from 17%-35% (highest for women), while reports of anonymous sex ranged from 44%-71% (highest for MSM). In this population, sexual risk behaviors were more commonly reported among those with recent incarceration history than those without such history. Among those reporting injection drug use or heroin use, percentages reporting sex with a PWID ranged from 51%-77%. In adjusted models, HRSU was significantly associated with one or more sexual risk behaviors for women (aPR, 2.63 (95% CI, 2.39-2.90); MSW aPR, 1.38 (95% CI, 1.31-1.46); and MSM aPR, 1.30 (95% CI, 1.26-1.34). CONCLUSIONS: Collaborative partnerships across the US public health system could help address barriers to timely clinical care among persons diagnosed with P&S syphilis who report HRSU.

BACKGROUND: We investigated differences in gonococcal antimicrobial susceptibility by anatomic site among cisgender men who have sex with men (MSM) using specimens collected through CDC's enhanced Gonococcal Isolate Surveillance Project (eGISP) and Strengthening the U.S. Response to Resistant Gonorrhea (SURRG). METHODS: During January 1, 2018-December 31, 2019, 12 eGISP and 8 SURRG sites collected urogenital, pharyngeal, and rectal isolates from cisgender MSM in STD clinics. Gonococcal isolates were sent to regional laboratories for antimicrobial susceptibility testing by agar dilution. To account for correlated observations, linear mixed-effects models were used to calculate geometric mean minimum inhibitory concentrations (MICs) and mixed-effects logistic regression models were used to calculate the proportion of isolates with elevated or resistant MICs; comparisons were made across anatomic sites. RESULTS: Participating clinics collected 3,974 urethral, 1,553 rectal, and 1,049 pharyngeal isolates from 5,456 unique cisgender MSM. There were no significant differences in the geometric mean MICs for azithromycin, ciprofloxacin, penicillin, and tetracycline by anatomic site. For cefixime and ceftriaxone, geometric mean MICs for pharyngeal isolates were higher compared to anogenital isolates (p < 0.05). The proportion of isolates with elevated ceftriaxone MICs (≥0.125 μg/ml) at the pharynx (0.67%) was higher than at rectal (0.13%) and urethral (0.18%) sites (p < 0.05). CONCLUSIONS: Based on data collected from multi-jurisdictional sentinel surveillance projects, antimicrobial susceptibility patterns of N. gonorrhoeae isolates may differ among MSM at extragenital sites, particularly at the pharynx. Continued investigation into gonococcal susceptibility patterns by anatomic site may be an important strategy to monitor and detect the emergence of antimicrobial resistant gonorrhea over time.

BACKGROUND: Pelvic inflammatory disease (PID) is an infection of the upper genital tract that has important reproductive consequences to women. We describe the burden of and trends in PID among reproductive-aged women in the United States during 2006-2016. METHODS: We used data from 2 nationally representative probability surveys collecting self-reported PID history (National Health and Nutrition Examination Survey, National Survey of Family Growth); 5 datasets containing International Classification of Diseases, Ninth/Tenth Revision codes indicating diagnosed PID (Healthcare Utilization Project; National Hospital Ambulatory Medical Care Survey, emergency department component; National Ambulatory Medical Care Survey; National Disease Therapeutic Index; MarketScan); and data from a network of sexually transmitted infection (STI) clinics (Sexually Transmitted Disease Surveillance Network). Trends during 2006-2016 were estimated overall, by age group and, if available, race/ethnicity, region, and prior STIs. RESULTS: An estimated 2 million reproductive-aged women self-reported a history of PID. Three of 4 nationally representative data sources showed overall declines in a self-reported PID history, and PID emergency department and physician office visits, with small increases observed in nearly all data sources starting around 2015. CONCLUSIONS: The burden of PID in the United States is high. Despite declines in burden over time, there is evidence of an increase in recent years.

BACKGROUND: Because most sources of administrative claims data do not contain laboratory result data, researchers rely on diagnosis codes to identify cases of disease. The validity of using diagnosis codes to identify chlamydial and gonococcal infections in administrative claims data remains largely uninvestigated. METHODS: We conducted a retrospective cohort analysis using OptumLabs® Data Warehouse, which includes de-identified medical (inpatient and outpatient) claims and laboratory test results. Among males and females aged 15-39 years during 2003-2017, we identified chlamydia and gonorrhea test results and corresponding diagnosis codes. Using test results as the gold standard, we calculated the sensitivity and specificity of chlamydia and gonorrhea diagnosis codes to identify laboratory confirmed infections. RESULTS: We identified 9.7 million chlamydia and gonorrhea test results among 3.1 million enrollees. Of the 176,241 positive chlamydia test results, only 11,515 had a corresponding diagnosis code, for a sensitivity of 6.5 (95% confidence interval [CI]: 6.4-6.7) and a specificity of 99.5 (95% CI: 99.5-99.5). Corresponding diagnosis codes were identified for 8,056 of the 31,766 positive gonorrhea test results for a sensitivity of 25.4 (95% CI: 24.9-25.8) and a specificity of 99.7 (95% CI: 99.7-99.7). CONCLUSIONS: Our findings indicate that using only ICD-CM diagnosis codes to identify chlamydial and gonococcal infections substantially underestimates the burden of these diseases and inaccurately classifies laboratory confirmed infections.

BACKGROUND: The most recent estimates of the number of prevalent and incident sexually transmitted infections (STIs) in the United States (US) were for 2008. We provide updated estimates for 2018 using new methods. METHODS: We estimated the total number of prevalent and incident infections in the US for eight STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus (HPV), sexually transmitted hepatitis B, and sexually transmitted HIV. Updated per capita prevalence and incidence estimates for each STI were multiplied by the 2018 full resident population estimates to calculate the number of prevalent and incident infections. STI-specific estimates were combined to generate estimates of the total number of prevalent and incident STIs overall, and by gender and age group. Primary estimates are represented by medians and uncertainty intervals are represented by the 25th (Q1) and 75th (Q3) percentiles of the empirical frequency distributions of prevalence and incidence for each STI. RESULTS: In 2018, there were an estimated 67.6 (Q1=66.6, Q3=68.7) million prevalent and 26.2 (Q1=24.0, Q3=28.7) million incident STIs in the US. Chlamydia, trichomoniasis, genital herpes, and HPV comprised 97.6% of all prevalent and 93.1% of all incident STIs. Persons aged 15-24 years comprised 18.6% (12.6 million) of all prevalent infections; however, they comprised 45.5% (11.9 million) of all incident infections. CONCLUSIONS: The burden of STIs in the US is high. Almost half of incident STIs occurred in persons aged 15-24 years in 2018. Focusing on this population should be considered essential for national STI prevention efforts.

BACKGROUND: Although there are more recent estimate of genital herpes prevalence, incidence estimates in the United States (US) have not been updated since 2008. METHODS: We estimated genital herpes prevalence and incidence for 2018 among adults aged 18-49 years. We estimated prevalence using 2015-2018 NHANES herpes simplex virus (HSV) type 2 (HSV-2) seroprevalence data among the non-institutionalized civilian population and extrapolated this prevalence to the full US population using 2018 American Community Survey data. We estimated incidence using 2011-2018 NHANES HSV-2 data as inputs to a simple mathematical model. We used Monte Carlo simulation to generate 10,000 input parameter sets for age and sex subpopulations and summarized our estimates by their median; uncertainty intervals for these estimates are characterized by their first (Q1) and third (Q3) quartiles. We conducted sensitivity analyses investigating the impact of HSV type 1 (HSV-1) infection on estimates of genital herpes burden. RESULTS: In 2018, there were an estimated 18.6 (Q1=18.1, Q3=19.0) million prevalent and 572,000 (Q1=479,000, Q3=673,000) incident genital herpes infections among 18-49-year-olds. Women accounted for two-thirds of prevalent infections with an estimated 12.1 (Q1=11.9, Q3=12.5) million infections. Incidence was highest among 18-24-year-olds with an estimated 242,000 (Q1=210,000, Q3= 274,000) infections. Sensitivity analyses indicated that HSV-1 could be responsible for millions more prevalent genital herpes infections, and tens of thousands of additional incident genital herpes infections, depending on the percentage of HSV-1 infections that are genital. DISCUSSION: Genital herpes is a common sexually transmitted disease in the United States. Future research to understand the burden of genital infections attributable to HSV-1 would refine estimates of genital herpes burden.

BACKGROUND: Extragenital gonorrhea (GC) and chlamydia (CT) are usually asymptomatic and only detected through screening. Ceftriaxone plus azithromycin is the recommended GC treatment; monotherapy (azithromycin or doxycycline) is recommended for CT. In urethral CT-positive/urethral GC-negative persons who are not screened extragenitally, CT monotherapy can lead to GC undertreatment and may foster the development of gonococcal antimicrobial resistance. We assessed urethral and extragenital GC and CT positivity among men who have sex with men (MSM) attending sexually transmitted disease (STD) clinics. METHODS: We included visit data for MSM tested for GC and CT at 30 STD clinics in 10 jurisdictions during 1/1/2015-6/30/2019. Using an inverse-variance random effects model to account for heterogeneity between jurisdictions, we calculated weighted test visit positivity estimates and 95% confidence intervals (CI) for GC and CT at urethral and extragenital sites, and extragenital GC among urethral CT-positive/GC-negative test visits. RESULTS: Of 139,718 GC and CT test visits, we calculated overall positivity (GC=16.7% [95% CI=14.4-19.1]; CT=13.3% [95% CI=12.7-13.9]); urethral positivity (GC=7.5% [95% CI=5.7-9.3]; CT=5.2% [95% CI=4.6-5.8]); rectal positivity (GC=11.8% [95% CI=10.4-13.2]; CT=12.6% [95% CI=11.8-13.4]); and pharyngeal positivity (GC=9.1% [95% CI=7.9-10.3]; CT=1.8% [95% CI=1.6-2.0]). Of 4,566 urethral CT-positive/GC-negative test visits with extragenital testing, extragenital GC positivity was 12.5% (95% CI=10.9-14.1). CONCLUSION: Extragenital GC and CT were common among MSM. Without extragenital screening of MSM with urethral CT, extragenital GC would have been undetected and undertreated in ~13% of these men. Undertreatment could potentially select for antimicrobial resistance. These findings underscore the importance of extragenital screening in MSM.

Objectives. To examine long-term gonorrhea prevalence trends from a sentinel surveillance population of young people at elevated risk for gonorrhea.Methods. We analyzed annual cross-sectional urogenital gonorrhea screening data from 191 991 women (2000-2017) and 224 348 men (2003-2017) 16 to 24 years of age entering the National Job Training Program, a US vocational training program. We estimated prevalence among women using an expectation-maximization algorithm incorporated into a logistic regression to account for increases in screening test sensitivity; log-binomial regression was used to estimate prevalence among men.Results. The adjusted gonorrhea prevalence among women followed a U-shaped curve, falling from 2.9% to 1.6% from 2000 through 2011 before rising to 2.7% in 2017. The prevalence among men declined from 1.4% to 0.8% from 2003 through 2017. In the case of both women and men, the prevalence was highest across all study years among those who were Black or American Indian/Alaska Native and those who resided in the South or Midwest.Conclusions. Trends among National Job Training Program enrollees suggest that gonorrhea prevalence is rising among young women while remaining low and steady among young men. (Am J Public Health. Published online ahead of print March 19, 2020: e1-e8. doi:10.2105/AJPH.2019.305559).

BACKGROUND: Extragenital gonorrhea (GC) and chlamydia (CT) are usually asymptomatic and only detected through screening. Ceftriaxone plus azithromycin is the recommended GC treatment; monotherapy (azithromycin or doxycycline) is recommended for CT. In urethral CT-positive/urethral GC-negative persons who are not screened extragenitally, CT monotherapy can lead to GC undertreatment and may foster the development of gonococcal antimicrobial resistance. We assessed urethral and extragenital GC and CT positivity among men who have sex with men (MSM) attending sexually transmitted disease (STD) clinics. METHODS: We included visit data for MSM tested for GC and CT at 30 STD clinics in 10 jurisdictions during 1/1/2015-6/30/2019. Using an inverse-variance random effects model to account for heterogeneity between jurisdictions, we calculated weighted test visit positivity estimates and 95% confidence intervals (CI) for GC and CT at urethral and extragenital sites, and extragenital GC among urethral CT-positive/GC-negative test visits. RESULTS: Of 139,718 GC and CT test visits, we calculated overall positivity (GC=16.7% [95% CI=14.4-19.1]; CT=13.3% [95% CI=12.7-13.9]); urethral positivity (GC=7.5% [95% CI=5.7-9.3]; CT=5.2% [95% CI=4.6-5.8]); rectal positivity (GC=11.8% [95% CI=10.4-13.2]; CT=12.6% [95% CI=11.8-13.4]); and pharyngeal positivity (GC=9.1% [95% CI=7.9-10.3]; CT=1.8% [95% CI=1.6-2.0]). Of 4,566 urethral CT-positive/GC-negative test visits with extragenital testing, extragenital GC positivity was 12.5% (95% CI=10.9-14.1). CONCLUSION: Extragenital GC and CT were common among MSM. Without extragenital screening of MSM with urethral CT, extragenital GC would have been undetected and undertreated in ~13% of these men. Undertreatment could potentially select for antimicrobial resistance. These findings underscore the importance of extragenital screening in MSM.

BACKGROUND: National chlamydia case rate trends are difficult to interpret due to biases from partial screening coverage, imperfect diagnostic tests, and under-reporting. We examined the extent to which these time-varying biases could influence reported annual chlamydia case rates. METHODS: Annual reported case rates among women aged 15 through 24 years from 2000 through 2017 were obtained from the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention AtlasPlus tool. Estimates of reporting completeness, diagnostic test sensitivity and specificity, and screening coverage were derived from literature review and expert opinion. We adjusted annual reported case rates for incomplete reporting, imperfect diagnostic tests, and partial screening coverage through a series of corrections, and calculated annual adjusted case rates of correctly diagnosed chlamydia. RESULTS: Adjusted chlamydia case rates among young women were higher than reported case rates throughout the study period. Reported case rates increased over the study period, but adjusted rates declined from 12,900 to 7,900 cases per 100,000 person-years between 2000 and 2007. After 2007, adjusted case rates declined to 7,500 cases per 100,000 person-years in 2017. Bias from partial screening coverage had a larger impact on case rate magnitude and trend shape than bias from imperfect diagnostic tests or under-reporting. CONCLUSIONS: Reported chlamydia case rates may be substantially lower than true chlamydia case rates due to incomplete reporting, imperfect diagnostic tests, and partial screening coverage. Because the magnitude of these biases has declined over time, the differences between reported and adjusted case rates has narrowed, revealing a sharp decline in adjusted case rates even as reported case rates have risen. The decline in adjusted case rates suggests that the rise in reported case rates should not be interpreted strictly as increasing chlamydia incidence, as the observed rise can be explained by improvements in screening coverage, diagnostic tests, and reporting.

In 2016, the proportion of Neisseria gonorrhoeae isolates with reduced susceptibility to azithromycin rose to 3.6%. A phylogenetic analysis of 334 N. gonorrhoeae isolates collected in 2016 revealed a single, geographically diverse lineage of isolates with MICs of 2-16 mug/mL that carried a mosaic-like mtr locus, whereas the majority of isolates with MICs >/= 16 mug/mL appeared sporadically and carried 23S rRNA mutations. Continued molecular surveillance of N. gonorrheae will identify new resistance mechanisms.

US gonorrhea rates are rising, and antibiotic-resistant Neisseria gonorrhoeae (AR-Ng) is an urgent public health threat. Since implementation of nucleic acid amplification tests for Ng identification, capacity for culturing Ng in the US has declined, along with the ability to perform culture-based antimicrobial susceptibility testing (AST). Yet, AST is critical for detecting and monitoring AR-Ng. In 2016, CDC established the Antibiotic Resistance Laboratory Network (AR Lab Network) to shore up national capacity for detecting several resistance threats including Ng. AR-Ng testing, a sub-activity of CDC's AR Lab Network, is performed in a tiered network of approximately 35 local laboratories, four regional laboratories (state public health laboratories in MD, TN, TX, WA), and CDC's national reference laboratory. Local laboratories receive specimens from approximately 60 clinics associated with the Gonococcal Isolate Surveillance Project (GISP), enhanced GISP (eGISP), and Strengthening the U.S. Response to Resistant Gonorrhea (SURRG). They isolate and ship up to 20,000 isolates to regional laboratories for culture-based agar dilution AST with seven antibiotics and for whole genome sequencing of up to 5,000 isolates. The CDC further examines concerning isolates and monitors genetic AR markers. During 2017 and 2018, the network tested 8,214 and 8,628 Ng isolates, and CDC received 531 and 646 concerning isolates, and 605 and 3,159 sequences, respectively. In summary, the AR Lab Network supported laboratory capacity for Ng-AST and associated genetic marker detection, expanding pre-existing notification and analysis systems for resistance detection. Continued, robust AST and genomic capacity can help inform national public health monitoring and intervention.

OBJECTIVES: Ectopic pregnancy is an important adverse pregnancy outcome that is under-surveilled. Emergency department (ED) data can help provide insight on the trends of ectopic pregnancy incidence in the United States (US). METHODS: Data from the largest US all-payer ED database, the Healthcare Cost and Utilization Project Nationwide ED Sample, were used to identify trends in the annual ratio of ED ectopic pregnancy diagnoses to live births during 2006-2013, and the annual rate of diagnoses among all pregnancies during 2006-2010. Diagnoses were identified through International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes and CPT codes. RESULTS: The overall ratio of weighted ED visits with an ectopic pregnancy diagnosis during 2006-2013 was 12.3 per 1000 live births. This ratio increased significantly from 2006 to 2013, from 11.0 to 13.7 ectopic pregnancies per 1000 live births, with no inflections in trend. The rate of ectopic pregnancy diagnoses per 1000 pregnancies increased during 2006-2010, from 7.0 to 8.3, with no inflections in trend. Females of all age groups experienced increases, though increases were less pronounced with increasing age. All geographic regions experienced increases, with increases being most pronounced in the Northeast. CONCLUSIONS: Our study suggests that ED ectopic pregnancy diagnoses may be increasing in the US, although the drivers of these increases are not clear. Our results highlight the need for national measures of total pregnancies, stratified by pertinent demographic variables, to evaluate trends in pregnancy-related conditions among key populations.

Human immunodeficiency virus (HIV) preexposure prophylaxis (HIV PrEP)1 provides substantial individual-level HIV risk reduction and may confer a population-level decrease in HIV incidence among gay, bisexual, and other men who have sex with men (MSM) when high HIV PrEP coverage is obtained.2 Unfortunately, the effect of HIV PrEP on sexually transmitted infection (STI) epidemics among MSM is less clear. We review recent trends in reported STIs among MSM in the United States, discuss the mechanisms by which HIV PrEP may impact STI rates, and consider the resulting population and individual-level effects of HIV PrEP on STI epidemics.

Rising azithromycin nonsusceptibility among Neisseria gonorrhoeae isolates threatens current treatment recommendations, but the cause of this rise is not well understood. We performed an ecological study of seasonal patterns in macrolide use and azithromycin resistance in N. gonorrhoeae, finding that population-wide macrolide use is associated with increased azithromycin nonsusceptibility. These results, indicative of bystander selection, have implications for antibiotic prescribing guidelines.

Among the US civilian noninstitutionalized population aged 14 to 59 years in 2013 to 2016, prevalence of Trichomonas vaginalis infection in urine was 1.3% overall. Prevalence was 2.1% among females, 0.5% among males, and highest at 9.6% among non-Hispanic black females. Estimate instability limited analysis of factors beyond sex, age, and race/Hispanic ethnicity.

BACKGROUND: Approximately 90% of genital warts are caused by human papillomavirus (HPV) types 6 and 11. In the United States, HPV vaccination has been recommended for girls and women aged </=26 years, and since 2011, for boys and men aged </=21 years and for gay, bisexual, and other men who have sex with men (MSM) aged </=26 years. METHODS: Data were obtained from 27 clinics participating in the STD Surveillance Network. Trends in the annual prevalence of anogenital warts (AGW) from 2010-2016 were described by sex and by the sex of sex partners. RESULTS: During 2010-2016, significant declines in the prevalence of AGW were observed in women aged <40 years, men who have sex with women only (MSW) aged <40 years, and MSM of all age categories. An inflection in trend in 2012 was noted for MSW aged 20-24 or 25-29 years and for MSM aged 20-24 years. CONCLUSIONS: The observed declines in the prevalence of AGW suggest that HPV morbidity is declining among populations attending STD clinics, including MSW, MSM, and women. Declines in younger age groups are consistent with what would be expected following the implementation of HPV vaccination. However, declines were also observed in older age groups and are not likely to be the result of vaccination.

Introduction: National guidelines recommend test-of-cure for pregnant women and test-of-reinfection for all patients with chlamydia infections in order to interrupt transmission and prevent adverse sequelae for patients, partners, and newborns. Little is known about retesting and positivity rates, and whether they are changing over time, particularly in private sector practices. Methods: Electronic health record data on patients with chlamydia tests were extracted from three independent clinical practice groups serving ≅20% of the Massachusetts population. Records were extracted using the Electronic medical record Support for Public Health platform (esphealth.org). These data were analyzed for temporal trends in annual repeat testing rates by using generalized estimating equations after index positive chlamydia tests between 2010 and 2015 and for differences in intervals to first repeat tests among pregnant females, non-pregnant females, and males. Data extraction and analysis were performed during calendar years 2017 and 2018. Results: An index positive C. trachomatis result was identified for 972 pregnant female cases, 10,309 non-pregnant female cases, and 4,973 male cases. Test-of-cure 3–5 weeks after an index positive test occurred in 37% of pregnant females. Test-of-reinfection 8–16 weeks after an index positive test occurred in 39% of pregnant females, 18% of non-pregnant females, and 9% of males. There were no significant increases in test-of-cure or test-of-reinfection rates from 2010 to 2015. Among cases with repeat tests, 16% of pregnant females, 15% of non-pregnant females, and 16% of males had positive results. Conclusions: Chlamydia test-of-cure and test-of-reinfection rates are low, with no evidence of improvement over time. There are substantial opportunities to improve adherence to chlamydia repeat testing recommendations.

During 2013-2017, the national annual rate of reported primary and secondary (P&S) syphilis cases in the United States increased 72.7%, from 5.5 to 9.5 cases per 100,000 population (1). The highest rates of P&S syphilis are seen among gay, bisexual, and other men who have sex with men (collectively referred to as MSM) (2), and MSM continued to account for the majority of cases in 2017 (1). However, during 2013-2017, the P&S syphilis rate among women increased 155.6% (from 0.9 to 2.3 cases per 100,000 women), and the rate among all men increased 65.7% (from 10.2 to 16.9 cases per 100,000 men), indicating increasing transmission between men and women in addition to increasing transmission between men (1). To further understand these trends, CDC analyzed national P&S syphilis surveillance data for 2013-2017 and assessed the percentage of cases among women, men who have sex with women only (MSW), and MSM who reported drug-related risk behaviors during the past 12 months. Among women and MSW with P&S syphilis, reported use of methamphetamine, injection drugs, and heroin more than doubled during 2013-2017. In 2017, 16.6% of women with P&S syphilis used methamphetamine, 10.5% used injection drugs, and 5.8% used heroin during the preceding 12 months. Similar trends were seen among MSW, but not among MSM. These findings indicate that a substantial percentage of heterosexual syphilis transmission is occurring among persons who use these drugs, particularly methamphetamine. Collaboration between sexually transmitted disease (STD) control programs and partners that provide substance use disorder services will be important to address recent increases in heterosexual syphilis.

Although the U.S. syphilis epidemic is concentrated among men who have sex with men, the number of congenital syphilis cases and the primary and secondary syphilis rate among women both doubled in recent years.

BACKGROUND: National trends in syphilis rates among females delivering newborns are not well characterized. We assessed 2010-2014 trends in syphilis diagnoses documented on discharge records and associated factors among females who have given birth in US hospitals. METHODS: We calculated quarterly trends in syphilis rates (per 100,000 deliveries) by using ICD-9 codes on delivery discharge records from the National Inpatient Sample. Changes in trends were determined by using Joinpoint software. We estimated relative risks (RR) to assess the association of syphilis diagnoses with race/ethnicity, age, insurance status, household income, and census region. RESULTS: Overall, estimated syphilis rates decreased during 2010-2012 at 1.0% per quarter (P < .001) and increased afterwards at 1.8% (P < .001). The syphilis rate increase was statistically significant across all sociodemographic groups and all US regions, with substantial increases identified among whites (35.2% per quarter; P < .001) and Medicaid recipients (15.1%; P < .001). In 2014, the risk of syphilis diagnosis was greater among blacks (RR, 13.02; 95% confidence interval [CI], 9.46-17.92) or Hispanics (RR, 4.53; 95% CI, 3.19-6.42), compared with whites; Medicaid recipients (RR, 4.63; 95% CI, 3.38-6.33) or uninsured persons (RR, 2.84; 95% CI, 1.74-4.63), compared with privately insured patients; females with the lowest household income (RR, 5.32; 95% CI, 3.55-7.97), compared with the highest income; and females in the South (RR, 2.42; 95% CI, 1.66-3.53), compared with the West. CONCLUSIONS: Increasing syphilis rates among pregnant females of all backgrounds reinforce the importance of prenatal screening and treatment.

BACKGROUND: Researchers have suggested that social media and online search data might be used to monitor and predict syphilis and other sexually transmitted diseases. Because people at risk for syphilis might seek sexual health and risk-related information on the internet, we investigated associations between internet state-level search query data (e.g., Google Trends) and reported weekly syphilis cases. METHODS: We obtained weekly counts of reported primary and secondary syphilis for 50 states from 2012 to 2014 from the US Centers for Disease Control and Prevention. We collected weekly internet search query data regarding 25 risk-related keywords from 2012 to 2014 for 50 states using Google Trends. We joined 155 weeks of Google Trends data with 1-week lag to weekly syphilis data for a total of 7750 data points. Using the least absolute shrinkage and selection operator, we trained three linear mixed models on the first 10 weeks of each year. We validated models for 2012 and 2014 for the following 52 weeks and the 2014 model for the following 42 weeks. RESULTS: The models, consisting of different sets of keyword predictors for each year, accurately predicted 144 weeks of primary and secondary syphilis counts for each state, with an overall average R of 0.9 and overall average root mean squared error of 4.9. CONCLUSIONS: We used Google Trends search data from the prior week to predict cases of syphilis in the following weeks for each state. Further research could explore how search data could be integrated into public health monitoring systems.