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Gonorrhea Increases In Washington State: Analyses for intervention planning
May 2011
Mark R. StengerInfectious Disease & Reproductive Health Assessment Unit, Washington State Department of Health
Objectives Describe GC incidence trends and recent increases
Describe gender and behavioral trends Describe treatment trends
Describe trends and changes in partner management
Describe HIV co-morbidity among GC cases
Discuss Program Response - interventions
Historical Context - Gonorrhea Cases and Incidence RateWashington State 1920 - 2010
0
50
100
150
200
250
300
350
400
450
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
1920 1940 1960 1980 2000
Cas
es p
er 1
00,0
00
Cas
es
Year of Diagnosis
Cases Rate
Gonorrhea Cases and Rate per 100,000, Washington State 1920 - 2010
Gonorrhea Cases and Incidence RateWashington State 1996 - 2010
0
10
20
30
40
50
60
70
80
0
1000
2000
3000
4000
5000
6000
7000
1996 1998 2000 2002 2004 2006 2008 2010
Cas
es p
er 1
00,0
00
Cas
es
Year of Diagnosis
GCcases Rate
Gonorrhea Incidence Rate by Race and Hispanic EthnicityWashington State 2001 - 2010
0
100
200
300
400
500
600
700
800
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Ca
ses
pe
r 1
00
,00
0
Year of Diagnosis
NH-WHITE NH-BLACK NH-AIAN
NH-API NH-MULTI
0
20
40
60
80
100
120
140
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Cas
es p
er 1
00,0
00
Year of Diagnosis
Hispanic Non-Hispanic
Gonorrhea Incidence Rate by Non-Hispanic RaceWashington State
2001 - 2010
Gonorrhea Incidence Rate by Hispanic EthnicityWashington State
2001 - 2010
Gonorrhea Incidence Rate By Census TractWashington State 2010
YAKIMA
OKANOGAN
KING
GRANT
LEWIS
CHELAN
FERRY STEVENS
ADAMS
KITTITAS
LINCOLN
SKAGIT
WHITMANPIERCE
BENTON
WHATCOM
CLALLAM
KLICKITAT
DOUGLASSPOKANE
SNOHOMISH
SKAMANIA
JEFFERSON
COWLITZ
FRANKLINPACIFIC
CLARK
WALLA WALLA
MASON
GRAYS HARBOR
PEND OREILLE
ASOTINCOLUMBIA
GARFIELD
THURSTON
WAHKIAKUM
SAN JUAN
ISLAND
KITSAP
0 40 80 120 16020Miles
¹*2010 incidence rate per 100,000 by Census Tract based on residence of patient at diagnosis. Rates smoothed by Kriging method.
Cases per 100,000 by Census Tract
GC Incidence Rate
0 - 1
7
17 -
55
55 -
170
170
- 350
350
- 735
KING
PIERCE
CLALLAM SNOHOMISH
JEFFERSON
MASON
GRAYS HARBOR
THURSTON
ISLAND
KITSAP
0 10 20 30 405Miles
¹*2010 incidence rate per 100,000 by Census Tract based on residence of patient at diagnosis. Rates smoothed by Kriging method.
Cases per 100,000 by Census Tract
GC Incidence Rate
0 - 1
7
17 -
55
55 -
170
170
- 350
350
- 735
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64
Alert Level 1 2 0 0 0 0 0 0 0 0 1 0 0 2 0 1 0 0 0 3 0 2 0 1 1 2 1 2 1 2 2 2 0 0 1 1 0 0 0 0 1 1 1 1 2 3 1 2 2 1 7 1 1 1 1 2 1 1 1 1 0 2 2 1 0
Alert Level 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 2 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0
Cases Dx 37 48 29 42 47 40 54 42 44 45 38 30 45 48 52 46 51 41 59 40 49 39 64 44 62 48 53 42 57 56 44 54 61 52 57 55 50 57 47 51 60 46 71 59 57 44 70 66 49 75 73 73 51 51 60 67 39 55 58 59 35 39 35 61
0
10
20
30
40
50
60
70
80
0
1
2
3
4
5
6
7
8
Num
ber o
f Cas
es
Num
ber o
f Cou
nties
Ale
rting
Week (November 09 - January 2011)
* Alert Level 1 indicates cases reported are > 1 Standard Deviation over 52 week moving averageAlert Level 2 indicates cases reported are > 2 Standard Deviations over 52 week moving average
Gonorrhea Aberration Reporting SystemWashington State 2009-2011
Mantel-Haenszel Chi-Square test of trend for cases by week significant at <.0001
2011
Gonorrhea Incidence Rate by GenderWashington State 1996 - 2010
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Cas
es p
er 1
00,0
00
Year of Diagnosis
Male Female
Gonorrhea Cases by Genderby Quarter, Washington State 2008 – 2011*
Cases diagnosed through the 1st quarter of 2011, reported through May 2011
0
100
200
300
400
500
60020
08-1
2008
-2
2008
-3
2008
-4
2009
-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
2010
-4
2011
-1
Ca
ses
Year-Quarter
Male Female
Male Gonorrhea Cases by Age Groupby Quarter, Washington State 2008 – 2011*
Cases diagnosed through the 1st quarter of 2011, reported through May 2011
0
20
40
60
80
100
120
140
2008
-1
2008
-2
2008
-3
2008
-4
2009
-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
2010
-4
2011
-1
Ca
ses
Year/Quarter
15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 45 45+
Percent of Male Gonorrhea Cases Reporting MSM-risk by Quarter, Washington State 2008 – 2011*
0
10
20
30
40
50
60
2008
-1
2008
-2
2008
-3
2008
-4
2009
-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
2010
-4
2011
-1
% M
SM
Year/Quarter
Cases diagnosed through the 1st quarter of 2011, reported through May 2011
Male Gonorrhea Cases by Age Group And MSM Risk Washington State 2010
<19 20-24 25-29 30-34 35-39 40-44 45+
Age Group
0
50
100
150
200
250
300
350Male GC Cases
0
10
20
30
40
50
60
70Percent MSM
MSM* NON-MSM Percent MSM
*Self-reported MSM status; cases missing sex partner gender presumed to be NON-MSM
Gonorrhea Cases by MSM, MSW & FemaleBy Quarter, Washington State 2008 – 2011*
Cases diagnosed through the 1st quarter of 2011, reported through May 2011
050
100150200250300350400450500
MSM Cases MSW Cases FEMALE Cases
MSM Gonorrhea Cases by Age Groupby Quarter, Washington State 2008 – 2011*
0
10
20
30
40
50
60
70
2008
-1
2008
-2
2008
-3
2008
-4
2009
-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
2010
-4
2011
-1
Ca
ses
Year/Quarter
15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 45 45+
Cases diagnosed through the 1st quarter of 2011, reported through May 2011
0
50
100
150
200
250
300
2008
-1
2008
-2
2008
-3
2008
-4
2009
-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
2010
-4
2011
-1
MS
M C
ase
s
Year/Quarter
Presumed HIV- MSM Reported HIV+ MSM
MSM Gonorrhea Cases by Reported HIV Statusby Quarter, Washington State
2008 – 2011*
*Cases diagnosed through the 1st quarter of 2011, reported through May 2011
0
400
800
1200
1600
2000
2400
2800
0
50
100
150
200
250
300
350
400
1994 1996 1998 2000 2002 2004 2006 2008 2010
Rat
e pe
r 10
0,00
0
Cas
es
Year
HIV+ GC Cases
Rate per 100,000 among HIV+
Incidence of Gonorrhea among PLWHA, Washington State
1994 – 2010
HIV Status of MSM Diagnosed with GC and Incidence of GC among HIV+
92
93
94
95
96
97
98
99
100
2008
-1
2008
-2
2008
-3
2008
-4
2009
-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
2010
-4
2011
-1
Pe
rce
nt w
ith T
rea
tme
nt R
ep
ort
ed
Year/Quarter
Percent of Cases with Treatment Reported by Quarter for All Cases
2009 – 2011*
Cases diagnosed through the 1st quarter of 2011, reported through May 2011
Treatment Reported 1992 – 2010
0%
20%
40%
60%
80%
100%19
92
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Ceftriaxone Doxycycline CefpodoximeLevofloxicin Azithromycin CiprofloxacinCefixime Other
Proportion of MSM Treated with CeftriaxoneBy Quarter, 1992 – 2011*
0
10
20
30
40
50
60
70
80
90
100
2008
-1
2008
-2
2008
-3
2008
-4
2009
-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
2010
-4
2011
-1
Pe
rce
nt
tre
ate
d w
ith C
eft
riaxo
ne
Year/Quarter
Cases diagnosed through the 1st quarter of 2011, reported through May 2011
Percent of All GC Cases InterviewedBy Quarter 2008 – 2011*
0
10
20
30
40
50
60
70
80
90
10020
08-1
2008
-2
2008
-3
2008
-4
2009
-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
2010
-4
2011
-1
Pe
rce
nt
of C
ase
s In
ete
rvie
we
d
Year/Quarter
Cases diagnosed through the 1st quarter of 2011, reported through May 2011
Programmatic Response:
State Level
GC ‘Summit’ in November 2010 Four counties in Puget Sound metropolitan area GISP STD clinic staff
Provider Advisory – Revised Treatment Guidelines Pro-active identification of repeaters (<120 days from previous infection)
Referral to local staff for partner management
Public Health - Seattle & King County, Harborview STD Clinic
Provider Advisory – Revised Treatment Guidelines
Culturing all MSM at all anatomic sites in the clinic
SSuN GC treatment failure surveillance
Susceptibility testing and follow-up with patients with elevated alert values
Renewed partner management focus on MSM GC
Acknowledgements
Roxanne Kerani, PhDPublic Health – Seattle & King CountySTD Control Program
Mark AubinManager, STD Services SectionWashington State Department of Health
0
1
2
3
4
5
6
7
8
920
08-1
2008
-2
2008
-3
2008
-4
2009
-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
Mea
n N
umbe
r of
Per
iod
Par
tner
s
Year/Quarter
Mean Number of Period Partners* Reported byMSM Cases by Quarter,
2008 - 2010
Number of partners reported in previous 2 months,Includes only cases completing interviews
0
5
10
15
20
2520
09-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
Per
cent
of
MS
M C
ases
with
His
tory
of
GC
in
Pre
viou
s Y
ear
Year/Quarter
Rectal GC Infections Reported by QuarterWashington State, 2008 – 2011*
Cases diagnosed through the 1st quarter of 2011, reported through May 2011
0
10
20
30
40
50
6020
08-1
2008
-2
2008
-3
2008
-4
2009
-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3Per
cent
Rep
ortin
g V
enue
Use
in L
ast
Yea
r
Year/Quarter
Bars Bath Internet
Selected Venues Reported by Quarter for MSM Cases
2008 - 2010
Percent reporting having met sex partner in venue in last year,Includes only cases completing interviews
0
5
10
15
20
2520
09-1
2009
-2
2009
-3
2009
-4
2010
-1
2010
-2
2010
-3
Per
cent
of
MS
M C
ases
with
His
tory
of
GC
in
Pre
viou
s Y
ear
Year/Quarter
Percent of MSM Cases with History of GCIn Previous Year, by Quarter
2009 - 2010
