Transcript Title of Presentation Myriad Pro, Bold, Shadow, 28pt

Infertility Prevention Project
Region I
Wells, Maine
June 6-7, 2011
Steven J Shapiro
Infertility Prevention Project Coordinator
Program and Training Branch
National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention
Division of STD Prevention
Topics
National Infertility Prevention Project




CSPS 2011 and 2012
DSTDP Update
Health Care Reform
Gonorrhea
CSPS 2011

2011
 @2010 levels -70/30 Awards
• A 0.2% Rescission
 Additional Funds -1.546 million dollars in FY 2010
•
•
•
•
$118K National Chlamydia Coalition
$190K Infrastructure Shortfall
$500K “The Future of IPP”
$730K Supplemental IPP Project Area Funds
o Expansion of CT/GC screening and treatment services
CSPS 2012

2012
 @2010 levels
 Application Due August 2, 2011
 Streamlined Application
• All requirements from FOA 09-902 remain in force
o Title X grantee Letter(s)
o 3% Chlamydia Positivity
o Targeted Gonorrhea Plans with Burden Calculation
o Progress on General IPP Objectives
• Performance Measures
 Additional Guidance
• National Conference
• Regional IPP Meetings
• IPP Program Plans
GC Burden Calculation - Example

Project Area X
 Total IPP Funds = $500,000
 Among women 25 and younger [ALL]
• 500 Gonorrhea and 10,000 Chlamydia
• GC Burden = [500/(10000+500)] X 100 = 4.76%
 IPP Funds to be used
• $500,000 X 4.76% = $23,800
• @ $10/test = 2380 tests available for targeting
DSTDP Update


Personnel Changes
Current Activities
 PCSI
 Data Security and Confidentiality Guidelines
 Antibiotic-resistant Gonorrhea Outbreak response plan

Publications
•
•
•
•
•
GISP Profiles
Community Approaches to Reducing STD
CDC Grand Rounds- Chlamydia Prevention
NG with Reduced Susceptibility to Azithromycin- San Diego
DCL- Azithromycin Resistance in Hawaii
Health Care Reform
Health Care Reform

Key Issues
 Affordable Care Act and Performance Improvement
 National HIV/AIDS Strategy
 Agency Winnable Battles (HIV, Teen Pregnancy Prevention)

“The Future of IPP”
 An Infrastructure-driven Evaluation
• IPP in the Project Areas
• Environmental Scan
• Recommendations for the Future
“The Future of STD Prevention”
2012 and Beyond

Assurance
 Functioning Surveillance Systems
 Local Epidemiology Support
 PCSI

Policy Development
 Plan Programs using Data- all sorts of data

Assessment and Accountability
 Monitoring
 Evaluation

Safety Net Coverage
DRIP, DRIP, DRIP……
Gonorrhea—Rates by Age Among Women Aged 15–44 Years,
United States, 2000–2009
Rate (per 100,000 population)
Age Group
1,000
30–34
35–39
40–44
15–19
20–24
25–29
800
600
400
200
0
2000
2001
2002
2003
2004
Year
2005
2006
2007
2008
2009
Gonorrhea—Rates by Age Among Men Aged 15–44 Years,
United States, 2000–2009
Rate (per 100,000 population)
750
600
Age Group
15–19
20–24
25–29
30–34
35–39
40–44
2006
2008
450
300
150
0
2000
2001
2002
2003
2004
Year
2005
2007
2009
Gonorrhea—Rates by Race/Ethnicity,
United States, 2000–2009
Rate (per 100,000 population)
800
700
600
500
American Indians/Alaska Natives
Asians/Pacific Islanders
Blacks
Hispanics
Whites
400
300
200
100
0
2000
2001
2002
2003
2004
Year
2005
2006
2007
2008
2009
Gonorrhea—Rates by County, United States, 2009
Rate per 100,000
population
<19.0
(n = 1,405)
19.1–100.0
>100.0
(n = 1,129)
(n = 607)
IS GONORRHEA DECREASING?
NATIONAL JOB TRAINING PROGRAM
SCREENING DATA
National Job Training Screening Program

National Job Training Program (NJTP)
 Federally funded job preparatory program
 Economically disadvantaged men and women aged 16–24 years
 48 states and Washington, DC

Gonorrhea screening required at entry
 Contract laboratory performs tests
 Laboratory data shared with CDC
 Includes information on both positive and negative tests

Available information
 Sex, age, race/ethnicity
 Test technology
 Place and date tested
Why use NJTP data ?

Information is available on all GC tests
 Prevalence = XXX – number of people testing positive
XXX – all people tested upon entry to NJTP

Large, “stable” population
 95,184 men tested for GC from 2004-2009
 91,697 women tested for GC from 2004-2009
 Consistent demographic each year

NJTP entrants have higher GC risk than U.S. population
 >70% < 19 years old
 >60% black
 >50% from South
Gonorrhea prevalence among men screened in
the National Job Training Program
3.5
680
3
580
2.5
480
2
380
1.5
280
1
180
0.5
0
80
2005
2006
GC prevalence
2007
2008
2009
Case rates in 15-24 year olds (NETSS)
Case rate per 100,000 persons in NETSS
Percent GC positive in NJTP
N= 95,184
Gonorrhea prevalence among women screened in
the National Job Training Program
3.5
680
3
580
2.5
480
2
380
1.5
280
1
180
0.5
0
80
2005
2006
GC prevalence
2007
2008
2009
Case rates in 15-24 year olds (NETSS)
Case rate per 100,000 persons in NETSS
Percent GC positive in NJTP
N= 91,697
Racial disparities among women in the
National Job Training Program and NETSS
4.5
GC prevalence by race/ethnicity among women screened in the
National Job Training Program
GC Prevalence
4
3.5
3
2.5
Black
2
1.5
1
Hispanic
White
0.5
0
600
Rate per 100,000 persons
5
GC case rates among women in NETSS by race/ethnicity
500
Black
400
300
200
100
Hispanic
White
0
2005
2006
2007
Year
2008
2009
2005
2006
2007
Year
2008
2009
NETSS DATA-TRENDS
Gonorrhea trends by project area, 2005–2010*
Large
decrease
Moderate
decrease
Flat
Moderate
increase
Large
increase

BUT*………….
Maine 13%
Massachusetts 26%
New Hampshire 36%
Vermont 14%
Connecticut <1%
Rhode Island 9%
•
Significant Increases











L.A. 14%
San Francisco 10%
CPA 16%
Hawaii 15%
New Mexico 16%
Massachusetts 26%
Washington 25%
Puerto Rico 35%
NYC 15%
New Jersey 21%
Philadelphia 40%
 Pennsylvania 20%
 Maryland 20%
 Baltimore 10%
*NETSS DATA April 28 2011 (CY 2009-CY 2010)
Gonorrhea trends by project area, 2009–2010*
Large
decrease
Moderate
decrease
Flat
Moderate
increase
Large
increase
RESISTANCE
MDR GC

“The one who does not remember history is bound to
live through it again.”
George Santayana

“The one who does not remember history is bound to
live through it again.”
George Santayana

“Even those who remember history are still gonna be
stuck living through it again.”
The gonococcus
GONOCOCCAL ISOLATE
SURVEILLANCE PROJECT DATA
GISP sites and regional laboratories —
United States, 2010 (29 Sites)
Seattle
Portland
Minneapolis
Detroit
Philadelphia
Cleveland
Baltimore
Cincinnati
Chicago
San Francisco
Las
Vegas
Denver
Los Angeles
Orange Co.
San Diego
Phoenix
Kansas
City
Richmond
Oklahoma
City
Greensboro
Albuquerque
Dallas
Austin
Birmingham Atlanta
New
Orleans
Tripler AMC
Honolulu
Miami
* Funded for FY2010 & FY2011 as regional lab, not yet functioning
New York
City
Regional Labs
Birmingham
Atlanta
Seattle
Cleveland
Austin*
Percentage of GISP isolates resistant to ciprofloxacin
Emergence of FQ Resistance:
Hawaii
45
40
Cipro available
35
FQ not recommended for GC in Hawaii*
Reports of FQ
resistance
30
25
20
15
10
Hawaii
5
0
1984
1989
* CDC, MMWR 2000.
1994
1999
2004
Percentage of GISP isolates resistant to ciprofloxacin
Emergence of FQ Resistance:
California
45
FQ not recommended for GC in California**
40
Hawaii*
35
30
25
20
15
10
California
5
0
1984
1989
1994
* CDC, MMWR 2000; ** CDC, MMWR, 2002
1999
2004
Percentage of GISP isolates resistant to ciprofloxacin
Emergence of FQ Resistance:
MSM
FQ not recommended for MSM
45
40
Hawaii*
California**
35
30
25
20
15
10
MSM
5
0
1984
1989
1994
1999
* CDC, MMWR 2000; ** CDC, MMWR, 2002; † CDC, MMWR, 2004.
2004
†
Emergence of FQ Resistance:
Percentage of GISP isolates resistant to ciprofloxacin
Rest of the US (Excluding Hawaii & California)
FQ not recommended in US‡
45
40
Hawaii*
MSM†
California**
35
30
25
20
15
10
US
5
0
1984
1989
1994
1999
2004
* CDC, MMWR 2000; ** CDC, MMWR, 2002; † CDC, MMWR, 2004.; ‡ CDC, MMWR, 2007.
GISP TRENDS
Distribution of MICs to Cefixime, 2005–2010*
90
80
2005
2006
2009
2010
Percentage of isolates
70
60
50
40
30
20
10
0
0.015
0.03
0.06
0.125
0.25
Minimum Inhibitory Concentrations (MICs), µg/ml
* Preliminary (Jan-Sept)
0.5
Distribution of MICs to Cefixime, 2005–2010*
7
Percentage of isolates
6
5
4
GISP Surveillance
“alerts”
3
1.3%
2
2005
2006
2009
2010
“Decreased
Susceptibility”
(n=58)
0.2%
1
(n=8)
0
0.06
0.125
0.25
Minimum Inhibitory Concentrations (MICs), µg/ml
* Preliminary (Jan-Sept)
0.5
Distribution of MICs to Ceftriaxone, 2006–2010*
3
2006
2007
2008
2009
2010*
Percentage of isolates
2.5
2
1.5
1
0.5
0
0.06
0.125
0.25
Minimum Inhibitory Concentrations (MICs), µg/ml
* Preliminary (Jan-Sept)
0.5
Distribution of MICs to Ceftriaxone, 2006–2010*
3
Percentage of isolates
2.5
2
GISP Surveillance
“Alerts”
1.5
2006
2007
2008
2009
2010*
Decreased
Susceptibility
1
0.5
0
0.06
0.125
0.25
Minimum Inhibitory Concentrations (MICs), µg/ml
* Preliminary (Jan-Sept)
0.5
Geographic Distribution of Cephalosporin* Alerts ,
2005
*Cefixime or Ceftriaxone
Geographic Distribution of Cephalosporin* Alerts,
2006
*Cefixime or Ceftriaxone
Geographic Distribution of Cephalosporin* Alerts,
2009
*Cefixime or Ceftriaxone
Geographic Distribution of Cephalosporin* Alerts,
2010
Orange Co.
San Diego
*Cefixime or Ceftriaxone
Proportion of GISP Participants Identified as Men
who Have Sex with Men (MSM), 1988–2010*
Percentage
35
30
25
20
15
10
5
0
•
•
1988
1993
1998
Year
* Preliminary 2010 (Jan-Sept)
Note: Among men with available sex of sex partner data
2003
2008
Distribution of MICs to Azithromycin, 2006–2010*
45
40
2006
2007
2008
2009
2010*
Percentage of isolates
35
30
25
20
15
10
5
0
≤0.03
0.06
0.125
0.25
0.5
1
2
4
Minimum Inhibitory Concentrations (MICs), µg/ml
* Preliminary (Jan-Sept)
8
16
Distribution of MICs to Azithromycin, 2006–2010*
2006
0.35
2007
0.3
2008
2009
Percentage of isolates
0.25
2010*
0.2
0.15
0.1
0.05
0
2
4
8
Minimum Inhibitory Concentrations (MICs), µg/ml
* Preliminary (Jan-Sept)
16
INTERNATIONAL TRENDS
Distribution of MIC for ceftriaxone, EURO-GASP,
2004–2009
European Center for Disease Prevention and Control (ECDC)
http://www.ecdc.europa.eu/en/publications/Publications/1101_SUR_Gonococcal_susceptibility_2009.pdf
Recent Timeline
• Japan
– 2000: Possible treatment failure with cefdinir (oral) (MIC
1=µg/ml)
– Decreased susceptibility to cefixime (oral) in Japan -- 0% (1999)
to 30% (2002)
– 2002–2003: 4 possible treatment failures with cefixime (oral)
– 2009: isolate with ceftriaxone MIC of 2 µg/ml (CSW)
• China
– (2001–2009): ~30-40% isolates have MICs to ceftriaxone of ≥
0.06 µg/ml (~3% in US in 2010)
• Europe
– 2009: Increases in ceftriaxone MICs from Europe
– 2010:
• 2 treatment failures with cefixime (Norway)
• 1 pharyngeal treatment failure with ceftriaxone (Norway)
• 2 possible treatment failures with cefixime (England)
Summary
• “Alert” doesn’t mean resistance
• Increasing MICs to cephalosporins (esp. cefixime)
– West
– MSM
• Significance of higher MICs not yet known, but very
concerning
• No treatment failures reported yet in US
– Will be asking clinicians and HDs to report treatment
failures
Response to Treatment Failures
• Collect culture specimen for susceptibility
testing
• Re-treat with at least 250 mg ceftriaxone
and 1-2 g azithromycin
• Ensure partner treatment
• Consider infectious disease consultation
• Report case to local health department
ITS NOT JUST GONORRHEA……
Chlamydia—Rates by County, United States, 2009
Rate per 100,000
population
<300.0
(n = 2,052)
300.1–400.0
(n = 379)
>400.0
(n = 710)
Questions?
Thank you
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: [email protected] Web: http://www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
National Center for HIV/AIDS, Viral Hepatitis, STD , and TB Prevention
Division of STD Prevention