Publications by authors named "Elizabeth A Torrone"

54 Publications

Can diagnostic codes in health-care claims data identify confirmed chlamydial and gonococcal infections? A retrospective cohort study, 2003-2017.

Sex Transm Dis 2021 May 6. Epub 2021 May 6.

Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia OptumLabs® Visiting Fellow, Eden Prairie, Minnesota.

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.
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http://dx.doi.org/10.1097/OLQ.0000000000001454DOI Listing
May 2021

Estimates of the Prevalence and Incidence of Genital Herpes, United States, 2018.

Sex Transm Dis 2021 04;48(4):260-265

From the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA.

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 to 49 years. We estimated prevalence using 2015-2018 National Health and Nutrition Examination Survey herpes simplex virus type 2 (HSV-2) seroprevalence data among the noninstitutionalized civilian population and extrapolated this prevalence to the full US population using 2018 American Community Survey data. We estimated incidence using 2011 to 2018 National Health and Nutrition Examination Survey 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- to 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- to 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.
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http://dx.doi.org/10.1097/OLQ.0000000000001375DOI Listing
April 2021

Genital Mycoplasma, Shigellosis, Zika, Pubic Lice, and Other Sexually Transmitted Infections: Neither Gone Nor Forgotten.

Sex Transm Dis 2021 04;48(4):310-314

From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA.

Abstract: Most estimates of the combined burden and cost of sexually transmitted infections (STIs) in the United States have focused on 8 common STIs with established national surveillance strategies (chlamydia, gonorrhea, syphilis, trichomoniasis, genital herpes, human papillomavirus, and sexually transmitted human immunodeficiency virus and hepatitis B). However, over 30 STIs are primarily sexually transmitted or sexually transmissible. In this article, we review what is known about the burden of "other STIs" in the United States, including those where sexual transmission is not the primary transmission route of infection. Although the combined burden of these other STIs may be substantial, accurately estimating their burden due to sexual transmission is difficult due to diagnostic and surveillance challenges. Developing better estimates will require innovative strategies, such as leveraging existing surveillance systems, partnering with public health and academic researchers outside of the STI field, and developing methodology to estimate the frequency of sexual transmission, particularly for new and emerging STIs.
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http://dx.doi.org/10.1097/OLQ.0000000000001367DOI Listing
April 2021

Sexually Transmitted Infections Among US Women and Men: Prevalence and Incidence Estimates, 2018.

Sex Transm Dis 2021 04;48(4):208-214

From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

Background: The most recent estimates of the number of prevalent and incident sexually transmitted infections (STIs) in the United States 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 United States for 8 STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus, 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 sex 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 United States. Chlamydia, trichomoniasis, genital herpes, and human papillomavirus comprised 97.6% of all prevalent and 93.1% of all incident STIs. Persons aged 15 to 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 United States is high. Almost half of incident STIs occurred in persons aged 15 to 24 years in 2018. Focusing on this population should be considered essential for national STI prevention efforts.
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http://dx.doi.org/10.1097/OLQ.0000000000001355DOI Listing
April 2021

Extragenital Gonorrhea and Chlamydia Positivity and the Potential for Missed Extragenital Gonorrhea With Concurrent Urethral Chlamydia Among Men Who Have Sex With Men Attending Sexually Transmitted Disease Clinics-Sexually Transmitted Disease Surveillance Network, 2015-2019.

Sex Transm Dis 2020 06;47(6):361-368

From the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA.

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 clinics.

Methods: We included visit data for MSM tested for GC and CT at 30 sexually transmitted disease clinics in 10 jurisdictions during January 1, 2015, and June 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 4566 urethral CT-positive/GC-negative test visits with extragenital testing, extragenital GC positivity was 12.5% (95% CI, 10.9-14.1).

Conclusions: 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 approximately 13% of these men. Undertreatment could potentially select for antimicrobial resistance. These findings underscore the importance of extragenital screening in MSM.
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http://dx.doi.org/10.1097/OLQ.0000000000001170DOI Listing
June 2020

Gonorrhea Prevalence Among Young Women and Men Entering the National Job Training Program, 2000-2017.

Am J Public Health 2020 05 19;110(5):710-717. Epub 2020 Mar 19.

The authors are with the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Emily R. Learner is also with the Oak Ridge Institute for Science and Education, Oak Ridge, TN.

To examine long-term gonorrhea prevalence trends from a sentinel surveillance population of young people at elevated risk for gonorrhea. 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. 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. Trends among National Job Training Program enrollees suggest that gonorrhea prevalence is rising among young women while remaining low and steady among young men.
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http://dx.doi.org/10.2105/AJPH.2019.305559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144451PMC
May 2020

The Influence of Screening, Misclassification, and Reporting Biases on Reported Chlamydia Case Rates Among Young Women in the United States, 2000 Through 2017.

Sex Transm Dis 2020 06;47(6):369-375

Division of Epidemiology, The Ohio State University, Columbus, OH.

Background: National chlamydia case rate trends are difficult to interpret because of biases from partial screening coverage, imperfect diagnostic tests, and underreporting. 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 Centers for Disease Control and Prevention'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 7900 cases per 100,000 person-years between 2000 and 2007. After 2007, adjusted case rates declined to 7500 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 underreporting.

Conclusions: Reported chlamydia case rates may be substantially lower than true chlamydia case rates because of 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 have 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.
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http://dx.doi.org/10.1097/OLQ.0000000000001157DOI Listing
June 2020

Genomic Characterization of Neisseria gonorrhoeae Strains from 2016 U.S. Sentinel Surveillance Displaying Reduced Susceptibility to Azithromycin.

Antimicrob Agents Chemother 2020 04 21;64(5). Epub 2020 Apr 21.

Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

In 2016, the proportion of isolates with reduced susceptibility to azithromycin rose to 3.6%. A phylogenetic analysis of 334 isolates collected in 2016 revealed a single, geographically diverse lineage of isolates with MICs of 2 to 16 μg/ml that carried a mosaic-like locus, whereas the majority of isolates with MICs of ≥16 μg/ml appeared sporadically and carried 23S rRNA mutations. Continued molecular surveillance of isolates will identify new resistance mechanisms.
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http://dx.doi.org/10.1128/AAC.02420-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179607PMC
April 2020

Expanding U.S. Laboratory Capacity for Neisseria gonorrhoeae Antimicrobial Susceptibility Testing and Whole-Genome Sequencing through the CDC's Antibiotic Resistance Laboratory Network.

J Clin Microbiol 2020 03 25;58(4). Epub 2020 Mar 25.

Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

U.S. gonorrhea rates are rising, and antibiotic-resistant (AR-Ng) is an urgent public health threat. Since implementation of nucleic acid amplification tests for identification, the capacity for culturing in the United States 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, the CDC established the Antibiotic Resistance Laboratory Network (AR Lab Network) to shore up the national capacity for detecting several resistance threats including AR-Ng testing, a subactivity of the CDC's AR Lab Network, is performed in a tiered network of approximately 35 local laboratories, four regional laboratories (state public health laboratories in Maryland, Tennessee, Texas, and Washington), and the 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 the program 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 isolates, respectively, and the CDC received 531 and 646 concerning isolates and 605 and 3,159 sequences, respectively. In summary, the AR Lab Network supported the laboratory capacity for AST and associated genetic marker detection, expanding preexisting notification and analysis systems for resistance detection. Continued, robust AST and genomic capacity can help inform national public health monitoring and intervention.
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http://dx.doi.org/10.1128/JCM.01461-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098741PMC
March 2020

Trends in Ectopic Pregnancy Diagnoses in United States Emergency Departments, 2006-2013.

Matern Child Health J 2020 Feb;24(2):213-221

Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA.

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.
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http://dx.doi.org/10.1007/s10995-019-02842-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6983328PMC
February 2020

Population and Individual-Level Effects of Human Immunodeficiency Virus Preexposure Prophylaxis on Sexually Transmitted Infection Epidemics Among Men Who Have Sex With Men.

Sex Transm Dis 2019 12;46(12):759-761

From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, TB, and STD Prevention, Centers for Disease Control and Prevention.

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http://dx.doi.org/10.1097/OLQ.0000000000001080DOI Listing
December 2019

Prevalence of Trichomonas vaginalis Among Civilian, Noninstitutionalized Male and Female Population Aged 14 to 59 Years: United States, 2013 to 2016.

Sex Transm Dis 2019 10;46(10):e93-e96

From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA.

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.
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http://dx.doi.org/10.1097/OLQ.0000000000001013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6924265PMC
October 2019

Temporal Patterns in Chlamydia Repeat Testing in Massachusetts.

Am J Prev Med 2019 03;56(3):458-463

Department of Population Medicine, Harvard Medical School, Harvard University, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts. Electronic address:

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.
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http://dx.doi.org/10.1016/j.amepre.2018.10.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6931253PMC
March 2019

Increased Methamphetamine, Injection Drug, and Heroin Use Among Women and Heterosexual Men with Primary and Secondary Syphilis - United States, 2013-2017.

MMWR Morb Mortal Wkly Rep 2019 Feb 15;68(6):144-148. Epub 2019 Feb 15.

Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

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.
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http://dx.doi.org/10.15585/mmwr.mm6806a4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375651PMC
February 2019

Trends in the Prevalence of Anogenital Warts Among Patients at Sexually Transmitted Disease Clinics-Sexually Transmitted Disease Surveillance Network, United States, 2010-2016.

J Infect Dis 2019 04;219(9):1389-1397

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB, Centers for Disease Control and Prevention, Atlanta, GA.

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.
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http://dx.doi.org/10.1093/infdis/jiy684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6910218PMC
April 2019

Increasing Syphilis Diagnoses Among Females Giving Birth in US Hospitals, 2010-2014.

Sex Transm Dis 2019 03;46(3):147-152

From the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA.

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 International Classification of Diseases, Ninth Revision, Clinical Modification 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 < 0.001) and increased afterward at 1.8% (P < 0.001). 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 < 0.001) and Medicaid recipients (15.1%; P < 0.001). 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.
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http://dx.doi.org/10.1097/OLQ.0000000000000945DOI Listing
March 2019

Azithromycin Susceptibility Among Neisseria gonorrhoeae Isolates and Seasonal Macrolide Use.

J Infect Dis 2019 01;219(4):619-623

Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

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.
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http://dx.doi.org/10.1093/infdis/jiy551DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350947PMC
January 2019

Using Search Engine Data as a Tool to Predict Syphilis.

Epidemiology 2018 07;29(4):574-578

Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA.

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.
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http://dx.doi.org/10.1097/EDE.0000000000000836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5990018PMC
July 2018

Use of National Syphilis Surveillance Data to Develop a Congenital Syphilis Prevention Cascade and Estimate the Number of Potential Congenital Syphilis Cases Averted.

Sex Transm Dis 2018 09;45(9S Suppl 1):S23-S28

From the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA.

Background: Recent increases in reported congenital syphilis have led to an urgent need to identify interventions that will have the greatest impact on congenital syphilis prevention. We sought to create a congenital syphilis prevention cascade using national syphilis surveillance data to (1) estimate the proportion of potential congenital syphilis cases averted with current prevention efforts and (2) develop a classification framework to better describe why reported cases were not averted.

Methods: We reviewed national syphilis and congenital syphilis case report data from 2016, including pregnancy status of all reported female syphilis cases and data on prenatal care, testing, and treatment status of mothers of reported congenital syphilis cases to derive estimates of the proportion of pregnant women with syphilis who received prenatal care, syphilis testing, and adequate syphilis treatment at least 30 days before delivery, as well as the proportion of potential congenital syphilis cases averted.

Results: Among the 2508 pregnant women who were reported to have syphilis, an estimated 88.0% received prenatal care at least 30 days before delivery, 89.4% were tested for syphilis at least 30 days before delivery, and 76.9% received an adequate treatment regimen that began at least 30 days before delivery. Overall, an estimated 1928 (75.0%) potential congenital syphilis cases in the United States were successfully averted. Among states that reported at least 10 syphilis cases among pregnant women, the estimated proportion of potential congenital syphilis cases averted ranged from 55.0% to 92.3%.

Conclusions: Although the majority of potential congenital syphilis cases in the United States were averted in 2016, there was substantial geographic variation, and significant gaps in delivering timely prenatal care, syphilis testing, and adequate treatment to pregnant women with syphilis were identified. The congenital syphilis prevention cascade is a useful tool to quantify programmatic successes and identify where improvements are needed.
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http://dx.doi.org/10.1097/OLQ.0000000000000838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6737534PMC
September 2018

Congenital and Heterosexual Syphilis: Still Part of the Problem.

Sex Transm Dis 2018 09;45(9S Suppl 1):S20-S22

College of Public Health, The Ohio State University, Columbus, OH.

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http://dx.doi.org/10.1097/OLQ.0000000000000837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6915834PMC
September 2018

Prevalence of sexually transmitted infections and bacterial vaginosis among women in sub-Saharan Africa: An individual participant data meta-analysis of 18 HIV prevention studies.

PLoS Med 2018 02 27;15(2):e1002511. Epub 2018 Feb 27.

Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.

Background: Estimates of sexually transmitted infection (STI) prevalence are essential for efforts to prevent and control STIs. Few large STI prevalence studies exist, especially for low- and middle-income countries (LMICs). Our primary objective was to estimate the prevalence of chlamydia, gonorrhea, trichomoniasis, syphilis, herpes simplex virus type 2 (HSV-2), and bacterial vaginosis (BV) among women in sub-Saharan Africa by age, region, and population type.

Methods And Findings: We analyzed individual-level data from 18 HIV prevention studies (cohort studies and randomized controlled trials; conducted during 1993-2011), representing >37,000 women, that tested participants for ≥1 selected STIs or BV at baseline. We used a 2-stage meta-analysis to combine data. After calculating the proportion of participants with each infection and standard error by study, we used a random-effects model to obtain a summary mean prevalence of each infection and 95% confidence interval (CI) across ages, regions, and population types. Despite substantial study heterogeneity for some STIs/populations, several patterns emerged. Across the three primary region/population groups (South Africa community-based, Southern/Eastern Africa community-based, and Eastern Africa higher-risk), prevalence was higher among 15-24-year-old than 25-49-year-old women for all STIs except HSV-2. In general, higher-risk populations had greater prevalence of gonorrhea and syphilis than clinic/community-based populations. For chlamydia, prevalence among 15-24-year-olds was 10.3% (95% CI: 7.4%, 14.1%; I2 = 75.7%) among women specifically recruited from higher-risk settings for HIV in Eastern Africa and was 15.1% (95% CI: 12.7%, 17.8%; I2 = 82.3%) in South African clinic/community-based populations. Among clinic/community-based populations, prevalence was generally greater in South Africa than in Southern/Eastern Africa for most STIs; for gonorrhea, prevalence among 15-24-year-olds was 4.6% (95% CI: 3.3%, 6.4%; I2 = 82.8%) in South Africa and was 1.7% (95% CI: 1.2%, 2.6%; I2 = 55.2%) in Southern/Eastern Africa. Across the three primary region/population groups, HSV-2 and BV prevalence was high among 25-49-year-olds (ranging from 70% to 83% and 33% to 44%, respectively). The main study limitation is that the data are not from random samples of the target populations.

Conclusions: Combining data from 18 HIV prevention studies, our findings highlight important features of STI/BV epidemiology among sub-Saharan African women. This methodology can be used where routine STI surveillance is limited and offers a new approach to obtaining critical information on STI and BV prevalence in LMICs.
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http://dx.doi.org/10.1371/journal.pmed.1002511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828349PMC
February 2018

Narrative Review: Assessment of Neisseria gonorrhoeae Infections Among Men Who Have Sex With Men in National and Sentinel Surveillance Systems in the United States.

Sex Transm Dis 2018 04;45(4):243-249

To assess trends in Neisseria gonorrhoeae among gay, bisexual, and other men who have sex with men (MSM), we reviewed existing and published gonorrhea surveillance data in the United States. Data identified in this review include the following: national gonorrhea case report data and data from 3 other surveillance programs, the Gonococcal Isolate Surveillance Project (GISP), the STD Surveillance Network (SSuN), and National HIV Behavioral Surveillance.Rates of reported cases of gonorrhea among men increased 54.8% in 2006 to 2015 compared with a 2.6% increase among women. Since 2012, the rate of reported gonorrhea cases among men surpassed the rate among women; the male-to-female case rate ratio increased from 0.97 in 2012 to 1.31 in 2015. The proportion of gonococcal urethral isolates collected in the Gonococcal Isolate Surveillance Project that were collected from MSM increased from 21.5% to 38.1% in 2006 to 2015. In 2009 to 2015, the percent of MSM who tested positive for rectal and oropharyngeal gonorrhea in sexually transmitted disease (STD) clinics increased by 73.4% and 12.6%, respectively. Estimated rates of gonorrhea among MSM increased by 151% in 2010 to 2015 in jurisdictions participating in the STD Surveillance Network. Data from the National HIV Behavioral Surveillance demonstrate that testing for gonorrhea among MSM increased by 23.1% between 2011 and 2014.Together, surveillance data suggest a disproportionate burden of gonorrhea among MSM in the United States and suggest increases in both screening and disease in recent years. Because each data source has inherent limitations and biases, examining these data from different systems together strengthens this conclusion.
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http://dx.doi.org/10.1097/OLQ.0000000000000740DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051412PMC
April 2018

Self-Reported Chlamydia and Gonorrhea Testing and Diagnosis Among Men Who Have Sex With Men-20 US Cities, 2011 and 2014.

Sex Transm Dis 2018 07;45(7):469-475

From the Division of HIV/AIDS Prevention, and.

Background: Annual screening for chlamydia and gonorrhea is recommended for sexually active men who have sex with men (MSM) at anatomical sites of contact, regardless of condom use.

Methods: We assessed differences in self-reported chlamydia and gonorrhea testing and diagnosis in the past 12 months among MSM using National HIV Behavioral Surveillance data from 2011 and 2014. Men who have sex with men who had 1 or more partners in the past 12 months were included in analyses. Analyses of chlamydia and gonorrhea diagnosis data were limited to participants who reported past 12 months chlamydia and gonorrhea testing, respectively. Differences in testing and diagnosis over time were assessed using Poisson regression models with robust standard errors separately for chlamydia and gonorrhea.

Results: Analyses included data from 18,896 MSM (2011, n = 9256; 2014, n = 9640). Testing for chlamydia was 37% in 2011 and 47% in 2014 (prevalence ratio [PR], 1.25; 95% confidence interval [CI], 1.20-1.30) and 38% and 47% for gonorrhea (PR, 1.24; 95% CI, 1.19-1.29). Testing was higher in 2014 among most demographic subgroups. Prevalence of chlamydia diagnoses was 8% in 2011 and 11% in 2014 (PR, 1.37; 95% CI, 1.18-1.59) and of gonorrhea diagnoses was 10% in 2011 and 14% in 2014 (adjusted PR: 1.40, 95% CI, 1.23-1.60). Larger changes in diagnoses were observed among MSM in the white and "other" racial categories and those who disclosed same-sex behavior to their health care provider.

Conclusions: Self-reported testing and diagnoses among MSM increased from 2011 to 2014. Increased efforts are needed to meet annual sexually transmitted disease screening recommendations among MSM at high HIV risk.
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http://dx.doi.org/10.1097/OLQ.0000000000000786DOI Listing
July 2018

Chlamydia Prevalence Trends Among Women and Men Entering the National Job Training Program From 1990 Through 2012.

Sex Transm Dis 2018 08;45(8):554-559

Division of Epidemiology, The Ohio State University, Columbus, OH.

Background: Evaluating chlamydia prevalence trends from sentinel surveillance is important for understanding population disease burden over time. However, prevalence trend estimates from surveillance data may be misleading if they do not account for changes in risk profiles of individuals who are screened (case mix) and changing performance of the screening tests used.

Methods: We analyzed chlamydia screening data from a sentinel surveillance population of 389,555 young women (1990-2012) and 303,699 young men (2003-2012) entering the US National Job Training Program. This period follows the introduction of national chlamydia screening programs designed to prevent transmission and reduce population disease burden. After ruling out bias due to case mix, we used an expectation-maximization-based maximum likelihood approach to account for measurement error from changing screening tests, and generated minimally biased long-term chlamydia prevalence trend estimates among youth and young adults in this sentinel surveillance population.

Results: Adjusted chlamydia prevalence among women was high throughout the study period, but fell from 20% in 1990 to 12% in 2003, and remained between 12% and 14% through 2012. Adjusted prevalence among men was steady throughout the study period at approximately 7%. For both women and men, adjusted prevalence was highest among Black and American Indian youth and young adults, and in the Southern and Midwestern regions of the United States throughout the study period.

Conclusions: Our minimally biased trend estimates provide support for an initial decrease in chlamydia prevalence among women soon after the introduction of national chlamydia screening programs. Constant chlamydia prevalence in more recent years suggests that screening may not be sufficient to further reduce chlamydia prevalence among high-risk youth and young adults.
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http://dx.doi.org/10.1097/OLQ.0000000000000798DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6043365PMC
August 2018

Rapid Increase in Gonorrhea Cases With Reduced Susceptibility to Azithromycin in Columbus, Ohio.

Sex Transm Dis 2018 02;45(2):e5-e6

Sexual Health Clinic Columbus Public Health Columbus, OH Division of Infectious Diseases The Ohio State University College of Medicine Columbus, OH Sexual Health Clinic Columbus Public Health Columbus, OH Neisseria Reference Laboratory Harborview Medical Center University of Washington Seattle, WA Division of STD Prevention Centers for Disease Control and Prevention Atlanta, GA Ohio Department of Health Columbus, OH Sexual Health Clinic Columbus Public Health Columbus, OH Antimicrobial Resistance Regional Laboratory Washington State Department of Health Public Health Laboratories Shoreline, WA Sexual Health Clinic Columbus Public Health Columbus, OH Division of Infectious Diseases The Ohio State University College of Medicine Columbus, OH.

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http://dx.doi.org/10.1097/OLQ.0000000000000765DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6895544PMC
February 2018

Susceptibility of Neisseria gonorrhoeae to Gentamicin-Gonococcal Isolate Surveillance Project, 2015-2016.

Sex Transm Dis 2018 02;45(2):96-98

From the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA.

The gentamicin minimum inhibitory concentrations (MICs) of Neisseria gonorrhoeae isolates were determined. Seventy-three percent of isolates demonstrated an MIC range of 8 to 16 μg/mL, and 27% demonstrated an MIC of 4 μg/mL or less. Significant associations between gentamicin MIC and resistance or reduced susceptibility to other antimicrobials were found.
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http://dx.doi.org/10.1097/OLQ.0000000000000693DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5861718PMC
February 2018

Using social media as a tool to predict syphilis.

Prev Med 2018 04 24;109:58-61. Epub 2017 Dec 24.

Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA. Electronic address:

Syphilis rates have been rapidly rising in the United States. New technologies, such as social media, might be used to anticipate and prevent the spread of disease. Because social media data collection is easy and inexpensive, integration of social media data into syphilis surveillance may be a cost-effective surveillance strategy, especially in low-resource regions. People are increasingly using social media to discuss health-related issues, such as sexual risk behaviors, allowing social media to be a potential tool for public health and medical research. This study mined Twitter data to assess whether social media could be used to predict syphilis cases in 2013 based on 2012 data. We collected 2012 and 2013 county-level primary and secondary (P&S) and early latent syphilis cases reported to the Center for Disease Control and Prevention, along with >8500 geolocated tweets in the United States that were filtered to include sexual risk-related keywords, including colloquial terms for intercourse. We assessed the relationship between syphilis-related tweets and actual case reports by county, controlling for socioeconomic indicators and prior year syphilis cases. We found a significant positive relationship between tweets and cases of P&S and early latent syphilis. This study shows that social media may be an additional tool to enhance syphilis prediction and surveillance.
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http://dx.doi.org/10.1016/j.ypmed.2017.12.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5843531PMC
April 2018