Laboratory Issues in STD Testing From the Perspective of The Bureau of STD Control

Jennifer Baumgartner, MSPH Preeti Pathela, DrPH Julia Schillinger, MD, MSc

Today’s talk

• Fluoroquinolone Resistance (QRNG) • Anorectal NAATs for GC and Ct detection Selected results from the Bureau’s 2004 annual lab survey will be used as a context for discussion of the above key issues.

STDs Reportable to NYC DOHMH

• Syphilis

(Treponema pallidum)

• Gonorrhea

(Neisseria gonorrhoeae)

• Chlamydia

(Chlamydia trachomatis)

• Chancroid

(Haemophilus ducreyi)

• Lymphogranuloma venereum

(Chlamydia trachomatis L1, L2, L3)

• Granuloma inguinale

(Calymmatobacterium granulomatis)

• Non-gonoccocal urethritis • Neonatal Herpes (any HSV positive test for an infant =<60 days old)

Annual Clinical Laboratory Survey • Objectives

– To determine current STD diagnostic testing methods provided to NYC residents – To monitor trends in STD testing – To monitor current laboratory compliance with citywide reporting mandates

Annual Clinical Laboratory Survey

• Methods – The NYC DOHMH Bureau of Sexually Transmitted Disease Control (BSTDC) surveyed clinical laboratories that were licensed to perform sexually transmitted disease (STD) testing by NYS – Survey instrument was a self-administered mail-in questionnaire to collect information for calendar year 2004.

Laboratories Sampled in 2004 Lab Survey

528 Laboratories Licensed by NYS DOH To perform STD testing* 330 Laboratories did not perform STD Testing on NYC residents † 178 Laboratories licensed to Perform STD testing on NYS ‡ 6 Laboratories not on NYS DOH licensed list, but performed Testing on NYC residents in 2002 184 Laboratories sent 2004 Lab Survey 52 (28%) Laboratories Located Outside New York State 132 (72%) Laboratories Located In New York State 30 (23%) Laboratories Located Outside New York City 102 (77%) Laboratories Located In New York City *Clinical laboratories currently holding a New York State (NYS) Department of Health (DOH) permit in at least one of the following categories: Bacteriology-General, Bacteriology-Gram Stains, Bacteriology-Other, Bacteriology-Restricted, Diagnostic Immunology Services Serology, Diagnostic Immunology Donor Services Serology, Virology-Direct Detection, Virology General, Virology Herpes Group Viruses Only, Wet Mounts †Based on findings from 2002 Lab Survey. Includes one laboratory that had closed.

‡Includes NYS licensed laboratories that performed testing on NYC residents based on findings from 2002 lab survey or were not surveyed in 2002. 54% (96/178) Labs were surveyed in 2002, 46% (82/178) Labs were not surveyed in 2002.

Description of Respondents (n=172)

• Location: – All five New York City Boroughs • 56% (96/172) Respondents located in NYC – Other states • 57% (98/172) of 2004 respondents had responded to the 2002 survey • 89% (80/90) of the 2002 respondents who perform testing STD testing on NYC residents responded to the 2004 survey.

Reporting Methods 2002 and 2004

Method of Reporting

Electronically * Mail † Fax ‡ Other Reporting

Percent of Labs Reporting 2002 2004

26% 43% 50% 2% 10% 23% 3% 12%

* Labs reporting at least 1 STD electronically † Labs reporting at least 1 STD by mail and do not report electronically ‡ Labs reporting at least 1 STD by fax and do not report electronically or by mail

Gonorrhea Testing Results

• 58% (81/139) of laboratories indicated that they performed at least one type of gonorrhea testing in 2004: – NAATs – 17% (23/139) reported performing Nucleic Acid Amplification Tests (NAATs) – Dual gonorrhea/chlamydia probe was the most frequently performed test – Culture - 44% (61/139) of laboratories perform gonorrhea cultures – Urethral gram stain – 38% (53/139) indicated that they performed urethral gram stains (UGS)

Gonorrhea Testing Types

Test Type* †

Urethral gram stain GC culture DNA GC-only amplification DNA dual test (GC&Ct) amplification DNA GC-only hybridization DNA Dual test (GC&Ct) hybridization EIA Other

No. of labs performing test

38% (53/139) 44% (61/139) 7% (10/139) 16% (22/139) 7% (10/139) 19% (26/139) 0% (0/139) 1% (2/139) - 49% (30/61) of laboratories performing GC culture tests also perform antimicrobial susceptibility testing.

* Labs reporting performance of test, may not have provided information for each of the above categories † Laboratories could report more than 1 test type

Gonorrhea Antimicrobial Testing

Type of Antibiotic*

Cephalosporins Penicillins Fluoroquinolones Spectinomycin Tetracyclines Macrolides

Type of Testing**

Disk Diffusion Broth Microdilution E-test Agar Dilution Other (Beta-lactamase)

No. of labs performing test

77% (23/30) 77% (23/30) 77% (23/30) 23% (7/30) 50% (15/30) 13% (4/30)

No. of labs performing test

77% (24/30) 0% (0/30) 13% (4/30) 3% (1/30) 17% (5/30) *

Survey permitted labs to specify more than one class of antibiotic

**

Survey permitted labs to specify more than one method of antibiotic susceptibility testing

Anorectal and Oropharangeal Gonorrhea NAATs Testing

• Gonorrhea NAATs testing on anorectal specimens and oropharangeal specimens: – 1% (1/139) of laboratories performed NAATs testing on anorectal specimens – 1% (1/139) of laboratories performed NAATs testing on oropharangeal specimens

Fluoroquinolone-Resistant GC, NYC BSTDC Clinics, 1999-2005

Year 1999 2000 2001 2002 2003 2004 2005 No. Specimens cultured n/a* n/a 88,400 58,047 30,094 n/a* 479 † GC No.

n/a n/a 3162 2668 1026 608 479 † GC (%) (4) (5) (3) n/a n/a QRNG No.

0 4 3 8 30 48 44 QRNG (%) (0.1) (0.3) (2.9) (7.9) (9.2) † *Data not available † There were 9 additional positive GC isolates that could not be AST’d.

Prevalence of NYC BSTDC Clinic QRNG, by Sex, 2005

No. QRNG Total GC (%) QRNG Anatomic Site of Infection

Males

Anal Oral Urethral

Females

Anal Oral Endocervical

Total 42

19 7 19

2

0 0 2

44 402

67 59 276

77

8 15 54

479 (10.4)

(23.9) (11.9) (6.9)

(2.6)

(0.0) (0.0) (3.7)

(9.2)

Gonorrhea

• Performing gonorrhea culture is an important surveillance tool, since it can aid the BSTDC in monitoring antibiotic resistance. • Recently the CDC has recommended that fluoroquinolones not be used to treat gonorrhea infections in MSM. • NYC DOHMH BSTDC has adopted these treatment guidelines and further recommends that providers who treat gonorrhea in non MSM men avoid fluoroquinolones, or if using fluoroquinolones, either perform culture or conduct follow-up testing to insure that the treatment given was effective 1 . • The BSTDC also recommends caution in using fluoroquinolones in women diagnosed with gonorrhea.

1 Centers for Disease Control & Prevention. Increases in Fluoroquinolone-Resistant Neisseria gonorrhoeae Among Men Who Have Sex with Men – United States, 2003 and Revised Recommendations for Gonorrhea Treatment, 2004. MMWR 2004:53:335-338.

Chlamydia Testing Results

• 37% (51/139) of labs perform at least one type of chlamydia testing: – NAATs – 19% (26/139) reported performing Nucleic Acid Amplification Tests (NAATs) – Dual chlamydia/gonorrhea probe was the most frequently performed test – 34% (47/139) labs accept male urethral/urine specimens

Chlamydia Test Types

Test Type* †

Ct culture DNA Ct-only amplification DNA dual test (Ct&GC) amplification DNA Ct-only hybridization DNA Dual test (Ct&GC) hybridization DFA Serology EIA Other

No. of labs performing test

8% (11/139) 10% (14/139) 16% (22/139) 10% (14/139) 19% (26/139) 6% (8/139) 3% (4/139) 5% (7/139) 1% (1/139)

* Labs reporting performance of test, may not have provided information for each of the above categories † Laboratories could report more than 1 test type

Chlamydia NAATs Testing at Alternative Sites • Chlamydia NAATs testing on:

– anorectal specimens: 1% (1/139) – oropharangeal specimens: 1% (1/139) – neonatal eye specimens: 2% (3/139) – pulmonary specimens: 1% (2/139)

Lymphogranuloma Venereum • 3% (4/139) of laboratories performed Lymphogranuloma Venerum (LGV) testing in 2004:

– The 4 labs reported performing tests by: • Amplification • Culture • IFA

Discussion Chlamydia anorectal NAAT

• Currently, NAAT not approved for use on anorectal or oropharyngeal specimens, however • Laboratories that have performed local validation studies may conduct testing (e.g. San Francisco PHL) • SF study using anorectal NAAT (Ct and GC) among men who have sex with men (MSM)* - 7.9% Ct NAAT positive • NYC Public Health Laboratory to validate commercial NAAT for Ct detection from anorectal specimens – Will be used routinely for STD evaluation in NYC STD clinics (~4,000 MSM/year reporting anorectal sex

)

– Detection and treatment reduces HIV transmission * Kent CK, et al., Clinical Infectious Diseases 2005;41:67-74

Discussion LGV in NYC

• LGV recognized among MSM in NYC in early 2004 – Proctitis (hemorrhagic and non-hemorrhagic) most common clinical presentation – MSM, most HIV co-infected • Need to differentiate L-serovars of chlamydia from other serovars – Treatment regimen for LGV longer than for non-L serovars of Ct – Partner follow-up more intensive – Need for timely and sensitive LGV diagnostics lent urgency to developing anorectal NAAT capability • Wadsworth Laboratory validated an in-house NAAT for anorectal testing, and developed a nested PCR to detect the L-2 serovar of

C. trachomatis

– –

>250 specimens submitted ~1/3 of anorectal specimens tested are Ct-positive, of genotyped specimens, 80% were L-2 (n=33)

–

Clinical syndrome does not differ between L-2 and non-L serovar

* Kent CK, et al., Clinical Infectious Diseases 2005;41:67-74

Discussion Monitoring antimicrobial susceptibility in GC, NYC

• Currently, NYC gonococcal AST results reported nationally come only from STD clinic patients – ‘GISP’ (Gonococcal Isolates Surveillance Project) • Substantial number of NYC laboratories have culture and AST capacity • Interest in collaborating to monitor resistance from broader sample?