Syphilis serologic prevalence monitoring among STD clinic clients: correlation with reported syphilis incidence, San Diego, CA, 1985-2004

OBJECTIVE

To describe the serologic test for syphilis (STS) prevalence among STD clinic clients, determine the correlation between STS prevalence trends and reported community-diagnosed primary and secondary (P&S) case incidence, and evaluate the usefulness of STS prevalence monitoring as a component of syphilis surveillance.

STUDY

During the period 1985-2004, 21,4336 STS were done among STD clinic clients and a variety of STS prevalence measures were evaluated.

RESULTS

From 1985-1991, 10.2% of STS were positive, which declined to 5.6% during 1992-2004. Overall, STS positivity (>or=1:8) and male positivity (>or=1:8) trends were correlated with reported community-diagnosed P&S case incidence and case incidence in men (r = 0.58 and r = 0.81, respectively). Male STS positivity (>or=1:8) began increasing in 2001, 1 year before the increase in syphilis incidence in men, which began in the latter half of 2002 and occurred mostly among men who have sex with men.

CONCLUSION

In a syphilis outbreak in men who have sex with men, STS prevalence (>or=1:8) among male STD clinic clients was a useful measure of syphilis case incidence trends and may provide an early warning for a subsequent increase in community-diagnosed case incidence.

Hepatitis B vaccination of men who have sex with men attending an urban STD clinic: impact of an ongoing vaccination program, 1998-2003

OBJECTIVE

To evaluate the impact of an ongoing hepatitis B vaccination service offered in an urban sexually transmitted disease (STD) clinic.

STUDY DESIGN

During the period 1998-2003, hepatitis B vaccine acceptance, series completion, and vaccine coverage rates were evaluated among men who have sex with men (MSM) and other clients attending the main STD clinic in San Diego County, California.

RESULTS

Among 21,631 STD clinic attendees, 81% were eligible to start and 69% accepted hepatitis B vaccination. Among a cohort of MSM starting vaccination in 1998, 76% and 55% received 2 doses and 3 doses, respectively, after 1 year follow-up and coverage then increased 1-2 percentage points annually to a final 2-dose and 3-dose coverage of 80% and 62%, respectively. Vaccine coverage (>=1 prior vaccine dose) among STD clinic attendees in 2003 was 45% compared to only 11% in 1998, the first year of the program.

CONCLUSIONS

Hepatitis B vaccination can be integrated into STD clinic services with reasonable levels of vaccine acceptance and series completion. The increase in vaccination coverage over time indicates that a sustained hepatitis B immunization program can achieve acceptable vaccine coverage in high-risk populations.

Low prevalence of hepatitis C virus antibody in men who have sex with men who do not inject drugs

OBJECTIVE

It is well documented that injection drug users (IDUs) have a high prevalence of antibodies to hepatitis C virus (HCV). Sexual transmission of HCV can occur, but studies have shown that men who have sex with men (MSM) without a history of injection drug use are not at increased risk for infection. Still, some health-care providers believe that all MSM should be routinely tested for HCV infection. To better understand the potential role of MSM in risk for HCV infection, we compared the prevalence of antibody to HCV (anti-HCV) in non-IDU MSM with that among other non-IDU men at sexually transmitted disease (STD) clinics and human immunodeficiency virus (HIV) counseling and testing sites in three cities.

METHODS

During 1999-2003, public health STD clinics or HIV testing programs in Seattle, San Diego, and New York City offered counseling and testing for anti-HCV for varying periods to all clients. Sera were tested using enzyme immunoassays, and final results reported using either the signal-to-cutoff ratio or recombinant immunoblot assay results. Age, sex, and risk information were collected. Prevalence ratios and 95% confidence intervals were calculated.

RESULTS

Anti-HCV prevalence among IDUs (men and women) was between 47% and 57% at each site, with an overall prevalence of 51% (451/887). Of 1,699 non-IDU MSM, 26 (1.5%) tested anti-HCV positive, compared with 126 (3.6%) of 3,455 other non-IDU men (prevalence ratio 0.42, 95% confidence interval 0.28, 0.64).

CONCLUSION

The low prevalence of anti-HCV among non-IDU MSM in urban public health clinics does not support routine HCV testing of all MSM.

Medical care and alcohol use after testing hepatitis C antibody positive at STD clinic and HIV test site screening programs

OBJECTIVES

The Centers for Disease Control and Prevention recommend screening individuals at risk for hepatitis C virus (HCV) infection. However, few published data describe outcomes of individuals with antibody to HCV (anti-HCV) identified through screening programs. The purpose of this study was to assess rates of medical evaluation and HCV treatment, change in alcohol consumption, and barriers to medical care after testing anti-HCV positive through a public screening program.

METHODS

Anti-HCV positive individuals identified through San Diego sexually transmitted disease (STD) clinics and an HIV test site screening program were informed of positive test results, provided education and referral, and contacted by telephone three, six, and > or =12 months later.

RESULTS

From September 1, 1999, to December 31, 2001, 411 anti-HCV positive individuals were newly identified, of whom 286 (70%) could be contacted > or = three months after receipt of test results (median length [range] of follow-up 14 [3-35] months). Of these 286, 156 (55%) reported having received a medical evaluation, of whom 19 (12%) began HCV treatment. Of 132 who reported drinking alcohol before diagnosis, 100 (76%) reported drinking less after diagnosis. Individuals with medical insurance at diagnosis were more likely than those without insurance to obtain a medical evaluation during follow-up (75 [68%] of 111 vs. 70 [45%] of 155; p < 0.001). Among those who did not obtain an evaluation, the most commonly reported reason was lack of insurance.

CONCLUSIONS

Only about half of newly identified anti-HCV positive individuals received a medical evaluation, although 76% reported drinking less alcohol. Identifying ways to improve medical access for those who are anti-HCV positive could improve the effectiveness of screening programs.

Partner notification for persons with chronic hepatitis B virus infection: use of a syphilis model service

BACKGROUND

Adults with chronic hepatitis B virus (HBV) infection are usually the source of infection for persons who acquire sexually transmitted HBV infection. Vaccinating sex- and needle-sharing partners is recommended.

GOAL

To evaluate the usefulness of a syphilis model partner notification (PN) service for high-risk persons with chronic HBV infection.

STUDY DESIGN

Locatable partners were offered serologic testing and HBV vaccination.

RESULTS

Of 190 eligible case patients, 129 (68%) were interviewed, which included 47 men who have sex with men (MSM), 26 who reported injecting drug use (IDU), and 12 who were MSM and injected drugs. Among the 129 interviewed, 85 (66%) reported having =1 recent sex partner, 46 (36%) provided locating information for 47 partners, 38 partners accepted PN services, 15 were not immune, and 14 (7% of total eligible case patients) started and 9 completed the HBV vaccine series. Overall, 15% of case patients were also hepatitis C positive, and 29% were HIV infected. PN services cost was estimated at 1472 US dollars per vaccinee.

CONCLUSION

High-risk persons with chronic HBV infection provided few names or locating information for their partners, and the proportion eligible for vaccination was low. An integrated approach that provides hepatitis C screening, human immunodeficiency virus testing, and referral might be more useful and should be evaluated.

Prevalence of and Associated Risk Factors for Fluoroquinolone-Resistant Neisseria gonorrhoeae in California, 2000-2003

BACKGROUND

Rates of fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) are increasing worldwide and in California.

METHODS

As a supplement to established surveillance, the investigation of QRNG in California included expanded surveillance in southern California, with in-depth interviews of patients (who had QRNG during the period of January 2001-June 2002) and a cross-sectional study of patients at 4 sexually transmitted diseases clinics with gonococcal isolates that underwent susceptibility testing (for the period of July 2001-June 2002).

RESULTS

The rate of QRNG increased from <1% in 1999 to 20.2% in the second half of 2003. The 2001-2002 expanded surveillance demonstrated that 66 (4.9%) of 1355 isolates were resistant to fluoroquinolones; the majority of these infections occurred after August 2001. Cross-sectional analysis of 952 patients with gonorrhea revealed that the prevalence of QRNG varied geographically during 2001-2002, with the highest rate being in southern California (8.9%) and the lowest being in San Francisco (3.6%). The QRNG prevalence was 8.6% among men who have sex with men (MSM), 5.1% among heterosexual men, and 4.3% among women. Although risk factors for QRNG varied by clinic, multivariate analysis demonstrated independent associations with race/ethnicity, recent antibiotic use, and MSM.

CONCLUSIONS

The emergence and spread of QRNG in California appeared to evolve from sporadic importation to endemic transmission among both MSM and heterosexuals. Monitoring of both the prevalence of and risk factors for QRNG infections is critical for making treatment recommendations and for developing interventions to interrupt transmission.

Integrating hepatitis, STD, and HIV services into a drug rehabilitation program

BACKGROUND

Considering the difficulties in providing screening and vaccination services for inmates in short-stay incarceration facilities, an evaluation was conducted of the integration of prevention services in an alternative sentencing drug rehabilitation program (alternative to incarceration) in San Diego CA.

METHODS

During the period April 1999 to December 2002, clients were asked to complete a brief risk-assessment questionnaire, and were offered hepatitis B virus (HBV) vaccination, HBV and hepatitis C virus (HCV) serologic testing, STD screening, and HIV counseling and testing.

RESULTS

Of the estimated 1125 rehabilitation program enrollees, 930 (83%) participated in the integration program services. Most clients were male (64%), were aged >30 years (64%), and few (7%) reported previous HBV vaccination. Of the 854 clients eligible for hepatitis B vaccination, 98% received the first dose, 69% the second dose, and 42% completed the series. Eleven percent of clients had prior HBV infection, and 14.7% had HCV infection, with positivity rates being highest among those with a history of injection drug use-HBV, 19%, and HCV, 36%. HIV infection was rare (prevalence, 0.3%), and STDs were uncommon (chlamydia prevalence, 2%, and gonorrhea prevalence, 0.6%). Total annual cost of integration services (excluding HIV testing) was dollar 31,994 equating to dollar 122 per client served.

CONCLUSIONS

Alternative sentencing drug rehabilitation programs provide a venue to efficiently deliver integrated hepatitis and other prevention services. Considering the vast number of high-risk persons in drug rehabilitation, probation, parole, and inmate release programs, an opportunity exists to greatly expand hepatitis services.

Misclassification of the stages of syphilis: implications for surveillance

SHORT SUMMARY

Syphilis cases were reviewed to see if reported stages met the Centers for Disease Control and Prevention case definition. Classification was excellent for primary and secondary and good for late latent, but half of early latent and unknown duration were misclassified. New surveillance definitions are suggested, comments requested.

BACKGROUND

Uncertainty when staging latent syphilis should lead clinicians to call it late latent (requires more treatment) and disease investigators to call it early latent (priority for partner investigation). Accurate surveillance requires consistent case definitions.

OBJECTIVE

Assess validity of reported syphilis stages.

METHODS

Record reviews in 6 jurisdictions to determine if reported cases met the Centers for Disease Control and Prevention case definitions.

RESULTS

Nine hundred seventy-three records from 6 jurisdictions in 2002 showed excellent agreement for reported primary (94.0%) and secondary (95.4%), good agreement for late latent (80.2%), and poor agreement for early latent (48.4%) and unknown duration (49.7%). Unknown duration (age < or =35 and nontreponemal test titer > or =32) was often misinterpreted to mean "not known." Early latent (within the past year, documented: seroconversion, fourfold titer increase, symptoms, or contact with an independently documented early syphilis case) was often misinterpreted to include patients with risky behavior, young age, or high nontreponemal test titers.

CONCLUSIONS

The unknown duration stage should be dropped. Surveillance of latent syphilis would be more consistent if cases were reported as having high or low titers on nontreponemal test. Alternative approaches are solicited from readers.

Time to treatment for women with chlamydial or gonococcal infections: a comparative evaluation of sexually transmitted disease clinics in 3 US cities

BACKGROUND

Many women with positive screening tests for chlamydia or gonorrhea are not promptly treated and are at risk for complications and further disease transmission. Improved methods for notifying infected patients might increase timely treatment in this population.

GOAL

Describe notification procedures at STD clinics in Washington, DC; Los Angeles; and San Diego and compare timeliness of treatment during 2000 to 2002.

STUDY

Interviews were conducted to determine methods for notifying infected patients. Data were abstracted from 327 medical records of women with chlamydia or gonorrhea who had not been treated presumptively. The interval between specimen collection and treatment ("time to treatment") was calculated.

RESULTS

Each clinic had different procedures for notifying untreated infected women. Among those treated, the median time to treatment was 18 days in Washington, DC, and 8 days in Los Angeles. In San Diego, the median time to treatment was initially 14 days, which improved to 7 days after patient-notification procedures were changed.

CONCLUSION

Simple changes in patient notification procedures can decrease time to treatment at STD clinics. STD programs should evaluate time to treatment and institute methods for efficient patient follow-up.

Surveillance for Repeat Gonorrhea Infection, San Diego, California, 1995???2001

BACKGROUND

Persons with repeat gonorrhea (GC) infection often participate in sexual networks that maintain and spread GC throughout the community. However, there are no established methods for collecting repeat GC surveillance data that are needed to monitor trends and risk factors for repeat infection.

GOAL

The goal of this study was to evaluate definitions and methods for establishing surveillance for repeat gonorrhea infection.

STUDY DESIGN

During a 7-year period (1995-2001), all reported GC cases in San Diego County, California, were reviewed to identify persons with >2 GC infections that occurred >30 but <365 days apart. Various matching criteria and definitions of repeat infection were evaluated.

RESULTS

Overall, 12,287 GC infections were reported; 509 persons accounted for 551 episodes of repeat infection and 9.7% of all GC infections. The mean annual repeat GC case rate was 2.8 per 100,000 population (range, 1.5-4.1) and repeat cases were 4.5% of total GC (range, 2.7-5.5%). Temporal trends in both repeat measures mirrored the overall county reported GC case rate. Young, inner-city males were more likely to have reported repeat GC infection.

CONCLUSION

Simple, uniform repeat GC measures can be used to establish a surveillance system for monitoring trends, risk factors, and the impact of interventions directed toward preventing repeat GC infections.

Gonorrhea Surveillance

BACKGROUND

Little is known about the epidemiology of gonorrhea in the United States, except for basic demographics of reported cases. Knowing the proportion of reported gonorrhea cases identified through screening, the diagnostic test used, and patient behavioral risk factors might help to better explain changes in gonorrhea rates over time.

GOAL

The goal of this study was to implement and evaluate a gonorrhea sample survey surveillance methodology in San Diego, California.

STUDY DESIGN

Healthcare providers caring for a representative sample of all gonorrhea patients reported during August 16 through October 18, 2001 were interviewed by telephone about patient demographics, risk factors, and management.

RESULTS

The healthcare providers of 248 gonorrhea patients were contacted; data were obtained on 224 (90%) patients. Major reasons for testing included symptoms (68%), partner referral (14%), and screening (12%). Gonococcal culture, DNA probe tests, and nucleic acid amplification tests were used to diagnose 40%, 34%, and 21% of patients, respectively. At minimum, 36% of male gonorrhea patients were men who have sex with men (MSM); MSM with gonorrhea were rarely diagnosed with rectal or pharyngeal gonorrhea outside of sexually transmitted disease (STD) clinics. Estimated local resources required to conduct this survey were $12 per completed interview.

CONCLUSION

Healthcare provider telephone interviews regarding recently reported gonorrhea patients are feasible and can provide important additional information to STD programs, which could be used to direct intervention strategies and monitor trends. Ultimately, a national sampling approach could be explored and incorporated into ongoing gonorrhea surveillance.

Bacterial vaginosis in pregnancy: diagnosis and treatment practices of physicians in San Diego, California, 1999

BACKGROUND

Treating symptomatic bacterial vaginosis (BV) early in pregnancy may decrease preterm birth (PTB). Understanding how physicians manage BV is important for the development of interventions.

GOAL

The goal was to determine the extent of knowledge and behaviors of physicians related to the diagnosis, treatment, and medical effects of BV in pregnant and nonpregnant patients.

STUDY DESIGN

This was a cross-sectional survey.

RESULTS

The study group consisted of 208 physicians who provided gynecologic care, including 102 (49%) who provided care to pregnant patients. Only 65% believed that there was a strong causal association between BV and PTB. Physicians who believed that BV causes PTB were much more likely to optimally manage vaginal infections (43% versus 7%). Only 12% of physicians prescribed oral metronidazole or clindamycin during the first trimester of pregnancy to treat BV.

CONCLUSION

Physicians should be aware of the relation between symptomatic BV and PTB, seek a specific diagnosis for symptoms of vaginitis, use standard criteria to diagnose BV, and treat BV with effective regimens early in pregnancy.

Evaluation of screening criteria to identify persons with hepatitis C virus infection among sexually transmitted disease clinic clients: results from the San Diego Viral Hepatitis Integration Project

BACKGROUND

The Centers for Disease Control and Prevention estimates that 1.8% of the US population is infected with hepatitis C virus (HCV), and most are unaware of their infection.

GOAL

The goal was to evaluate risk-based HCV screening criteria for clients attending an urban sexually transmitted disease (STD) clinic.

STUDY DESIGN

This was a cross-sectional study of HCV prevalence among all STD clinic clients during an 8-month period (September 1999 through April 2000) in San Diego, California.

RESULTS

HCV prevalence was 4.9% (165/3367). Clients who reported that they were injecting drug users (IDUs) were much more likely to be HCV-positive than other clients (51% versus 2%; P < 0.001). Selective screening of IDUs, sex partners of IDUs, and persons having received a blood transfusion before 1992 would have identified 70% of HCV-infected clients while screening only 12% of the clinic's attendees. The HCV prevalence among clients with a history of a bacterial STD (in the past 5 years) and no other major risk factors was only 2.5%.

CONCLUSION

In STD clinics, integrating risk-based screening into routine clinic services is an efficient way to identify HCV-infected persons.

Preventing transmission of hepatitis B virus from people with chronic infection

BACKGROUND

People with chronic hepatitis B virus (HBV) infection are the major source of HBV transmission in the United States. The Public Health Service recommends prevention counseling for HBV-infected people and vaccination of their household contacts and sexual partners.

OBJECTIVES

To describe the implementation of these recommendations by community physicians.

METHODS

Telephone survey of 69 people with chronic HBV infection and their healthcare providers, October 1997 through November 1997, in San Diego, California.

MAIN OUTCOME MEASURES

Counseling of people with chronic HBV infection and vaccination of their household contacts and sexual partners.

RESULTS

Forty-three percent of providers reported providing prevention counseling to their HBV-infected patients to reduce transmission; 16% of patients reported receiving counseling. For the 32 pairs for which both the patient and provider could be reached and the patients were aware of their HBV infection, 20 (63%) providers reported counseling patients, and 10 (50%) of these providers' patients reported receiving counseling. Fifty-five percent of providers recommended vaccination of contacts; 13% of eligible adult household contacts and sexual partners and 20% of eligible child household contacts had begun hepatitis B vaccination.

CONCLUSIONS

Prevention counseling of people with chronic HBV infection and vaccination of their contacts occur infrequently despite guidelines and an effective vaccine. Collaborative efforts between providers and people involved in public health are needed to improve delivery of these preventive health services.

Screening for chronic hepatitis B and C virus infections in an urban sexually transmitted disease clinic: rationale for integrating services

BACKGROUND AND OBJECTIVES

Clients attending sexually transmitted disease (STD) clinics are at risk for multiple infections (e.g., STDs, HIV, and infectious viral hepatitis). Risk assessment and serosurveys can document the need for hepatitis screening and vaccination services.

GOAL

To determine hepatitis C and B virus seroprevalence, identify predictive risk factors, and provide a rationale for integrating hepatitis services in an STD clinic.

METHODS

During various periods in 1998, consecutive clients completed a self-administered risk assessment and were offered screening for markers of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection (HBV core antibody and anti-HCV [enzyme-linked immunosorbent assay 3.0, confirmed by recombinant immunoblot assay 2.0]).

RESULTS

Sixteen percent of 300 clients tested for an anti-HBV core were positive, with injecting-drug users (IDUs) and men who have sex with men (MSM) having higher prevalences (50% and 37%, respectively). Of 615 clients tested for anti-HCV, 21 (3.4%) were positive. Injecting-drug users (n = 34) had a 38% anti-HCV prevalence compared with 1.1% for non-IDUs. Of 66 non-IDU MSM tested, none was HCV infected. IDUs had a high prevalence of past STDs (> 50%) and unsafe sexual behavior.

CONCLUSIONS

Injecting drug users and MSM are at high risk for STDs, HIV, and hepatitis infections and could benefit from a "one-stop" STD clinic that included hepatitis prevention services.

Implementing a syphilis elimination and importation control strategy in a low-incidence urban area: San Diego County, California, 1997-1998

OBJECTIVES

This study assessed a strategy designed to contain imported cases of syphilis and prevent reestablishment of ongoing transmission.

METHODS

Reported syphilis cases during an endemic period (1990-1992) and an elimination period (1997-1998) were compared in San Diego, Calif. The elimination strategy, which focuses on rapid reporting of infectious syphilis cases by clinicians, prompt partner and sexual network management, outreach to marginalized populations, and implementation of an outbreak containment plan, was evaluated.

RESULTS

Infectious syphilis incidence rates declined from 18.3 per 100,000 in 1998 to 1.0 per 100,000 in 1998. Of the 46 cases involving probable infection during 1997-1998, 19 (41%) were imported, mostly (79%) from Mexico. Outbreak containment procedures were implemented successfully for 2 small clusters. Outreach workers provided sexually transmitted disease information to a large number of individuals; however, no cases of infectious syphilis were identified, suggesting that syphilis transmission was not occurring among marginalized groups.

CONCLUSIONS

This syphilis elimination and importation control strategy will require monitoring and adjustments. Controlling syphilis along the US-Mexico border is a necessary component of syphilis elimination in the United States.

Sexually transmitted disease clinic clients at risk for subsequent gonorrhea and chlamydia infections: possible 'core' transmitters

BACKGROUND

From an sexually transmitted disease (STD) intervention perspective, developing a practical way to identify persons in core transmitter groups has been difficult. However, persons who have repeated STD infections may be in such groups.

GOAL

To evaluate a self-administered risk assessment approach that would identify STD clinic clients who were at an increased risk of being involved in gonorrhea (GC) or chlamydia (CT) transmission in the subsequent year.

STUDY DESIGN

Prospective cohort of consecutive STD clinic clients with a 1-year follow-up period.

RESULTS

During a 6-month period in 1995, 2576 STD clinic clients in San Diego completed a risk assessment. Of those clients, 204 (7.9%) had a subsequent STD and 79 (3.1%) had a subsequent GC or CT infection during the 1-year follow-up period. The strongest predictor of a subsequent GC/CT was having a recent history or current clinic visit diagnosis of GC or CT (6.1% subsequent GC/CT rate). The more past episodes of GC or CT, the higher the subsequent GC/CT rate. Unsafe sexual behavior had little effect on further increasing subsequent GC/CT risk.

CONCLUSION

STD clinic clients with a recent history of GC or CT and a high risk of subsequent GC/CT may be core transmitters who could likely benefit from risk reduction, periodic screening for GC/CT, symptom recognition counseling, and preventive treatment-the essential elements of STD-prevention case management.

The changing paradigm of sexually transmitted disease control in the era of managed health care

Several trends in sexually transmitted diseases (STDs) have laid the foundation for a new paradigm for STD treatment and prevention that encompasses a community-wide, population-oriented approach. Public health STD programs, in partnership with a wide variety of community collaborators, will need to carry out the essential functions of public health-assessment, policy development, and assurance-by developing resources for community organizing and planning, enhanced information systems, and comprehensive training programs for professional staff and community partners. Community providers (particularly practicing clinicians and community and hospital clinics) will need to deliver primary prevention (community health promotion and clinical preventive services) and secondary prevention (screening and treatment) services while categorical STD clinics focus on providing care for high-risk, high-frequency STD transmitters who serve as the reservoir for much of a community's bacterial STDs. Managed care organizations and public health STD programs will need to formalize collaborative arrangements and capitalize on the strengths of each organization in order to have a population-level impact on STD transmission.

Epidemiologic support to state and local sexually transmitted disease control programs. Perceived need and availability. The Field Epidemiology Network for STDs (FENS)

BACKGROUND AND OBJECTIVES

Sexually transmitted diseases (STDs) comprise the majority of national infectious disease morbidity reported, yet the number of epidemiologists working in state and local STD programs is estimated to be small. Even less is known about the training and activities of those epidemiologists.

GOALS

To determine the number, training, and affiliation of epidemiologists working with STD programs and the level of satisfaction with epidemiologic support available.

STUDY DESIGN

Survey of 65 program managers in state and local health departments.

RESULTS

Program managers named 146 people working on epidemiologic activities, and 84 of those people were classified as "epidemiologist" by the criteria we applied. The median number of full-time equivalent (FTE) epidemiologists working in or with STD programs was 0.5; one quarter of all STD program had no epidemiologists. There was a significant association between number of FTE epidemiologist and population, with most programs with more than 0.5 epidemiologists located in areas with at least 1,000,000 population. State Epidemiologists do not provide technical support to most state STD programs. Almost half (45%) of all program managers indicated that they have inadequate epidemiologic support for routine program activities.

CONCLUSIONS

The current level of epidemiologic support available to most STD programs is inadequate to perform surveillance and data analyses, interpret data to develop program objectives, and perform program evaluation. An essential next step is the delineation of a set of critical, analytic STD field epidemiology functions to define appropriate standards against which epidemiologic capacity can be more precisely measured.

Screening high-risk adolescent males for Chlamydia trachomatis infection. Obtaining urine specimens in the field

BACKGROUND AND OBJECTIVES

Reported case data suggest that few men are being tested for Chlamydia trachomatis (CT) infection (female:male reported case ratio is > 5:1) partially because men seek preventive health services less frequently than women and, until recently, obtaining a CT specimen from men required a urethral swab, which has low patient acceptability. A study was conducted in San Diego, CA, to determine whether urine specimens could be obtained from high-risk teen males in the field using a peer teen outreach approach.

GOALS

Identify teen males infected with CT and provide treatment and partner management services.

STUDY DESIGN

Prevalence survey of 261 teen males and a program cost evaluation.

RESULTS

During the 6.5-month study period (Dec 15, 1995 to June 30, 1996) an estimated 1,860 teen males were approached and 261 submitted a urine specimen; 16 (6.1%) were positive by polymerase chain reaction. All positive males were treated with azithromycin, 1 gm, in the field, and 9 female sex partners were treated, 7 of whom were CT positive. The cost per specimen obtained and per CT infection identified was $103 and $1,677, respectively. The annual cost for adding a peer teen outreach service to an existing STD program using existing staff and adding 1.2 full-time equivalents of outreach time is approximately $25,000.

CONCLUSION

Peer teen outreach and in-field collection of urine specimens appear to be an acceptable alternative for screening teen males for CT and should be further evaluated in other communities.

The role of young children in a community-wide outbreak of hepatitis A

An Hasidic Jewish community has experienced recurrent hepatitis A outbreaks since 1980. To assess risk factors for illness during a 1985-6 outbreak, the authors reviewed case records and randomly selected 93 households for an interview and serologic survey. In the outbreak, 117 cases of hepatitis A were identified, with the highest attack rate (4.2%) among 3-5 year olds. Among the survey households, the presence of 3-5 year olds was the only risk factor that increased a household's risk of hepatitis A (indeterminant relative risk, P = 0.02). Furthermore, case households from the outbreak were more likely to have 3-5 years olds than were control households from the survey (odds ratio = 16.4, P < 0.001). Children 3-5 years old were more likely to have hepatitis A and may have been the most frequent transmitters of hepatitis A in this community. Hepatitis A vaccination of 3-5 year olds can protect this age group and might prevent future outbreaks in the community.

Staphylococcal food poisoning caused by imported canned mushrooms

From February through April 1989, four outbreaks of staphylococcal food poisoning in the United States were associated with eating mushrooms canned in the People's Republic of China (PRC). In the four outbreaks, 99 persons who ate at a suspect facility developed gastrointestinal symptoms within 24 h, including 18 who were hospitalized. Illness was associated with eating mushrooms at a university cafeteria (relative risk [RR] = 53.0), a hospital cafeteria (RR = 13.8), a pizzeria (odds ratio [OR] = infinity), and a restaurant (OR = infinity) (all P < .0001). Staphylococcal enterotoxin A was found by ELISA in mushrooms at the sites of two outbreaks and in unopened cans from the three plants thought to have produced mushrooms implicated in outbreaks. These investigations led to multistate recalls and a US Food and Drug Administration order to restrict entry into the United States of all mushrooms produced in the PRC; until this action, the United States imported approximately 50 million pounds yearly.

Chlamydia trachomatis infection among Hispanic women in the California-Mexico border area, 1993: establishing screening criteria in a primary care setting

BACKGROUND

Chlamydia prevalence and transmission patterns in California-Mexico border communities are unknown, and selective screening strategies for Hispanic populations have not been evaluated.

GOAL OF THIS STUDY

To determine chlamydia prevalence among Hispanic women in the California-Mexico border area and established screening criteria.

STUDY DESIGN

This was a cross-sectional prevalence survey of family planning/prenatal Hispanic clients (n = 2378) in San Diego and Imperial Counties, California, and Tijuana, Mexico.

RESULTS

Overall, chlamydia prevalence was 3.2% (3.3% in California; 2.1% in Mexico). Women born in Mexico or those who visited Mexico for at least 1 week in the recent past had a prevalence rate similar to women without those characteristics. Multivariate analysis showed that young age (less than 25 years old), unmarried status, or having clinical signs of a chlamydia syndrome (primarily cervicitis) or vaginosis independently predicted chlamydia infection. Applying minimum screening criteria recommended by the Centers for Disease Control would require screening less than half of the clients. However, only 69% of infections would be identified. Using survey-based criteria (less than 25 years old, unmarried, and clinical signs of a chlamydia syndrome) would require screening 64% of clients, but would identify 92% of those infected.

CONCLUSION

Chlamydia prevalence among Hispanic women seeking reproductive healthcare was similar (< 5%) on both sides of the California-Mexico border. Among Hispanic women, using easily obtained demographic data (age and marital status) and clinical signs (primarily cervicitis), an effective selective screening strategy can be implemented.

Syphilis in San Diego County 1983-1992: crack cocaine, prostitution, and the limitations of partner notification

BACKGROUND AND OBJECTIVES

Recent epidemics of syphilis have been associated with crack cocaine use and anonymous sex for drugs, suggesting a potential limitation of sex partner notification as a disease control strategy. To assess these factors in an inner city epidemic of syphilis in San Diego County, California, we performed a descriptive epidemiologic analysis.

STUDY DESIGN

Descriptive epidemiologic data were obtained from case investigation reports of primary and secondary syphilis.

RESULTS

In the middle and late phases of the epidemic (1990-1992), the incidence of syphilis in the inner city area was more than six times that in remainder of the county. Illegal drug use was reported by 30% of patients. Drug use, especially crack cocaine, was related to prostitution. The estimated total number of sex partners per patient ratio was 4.2, whereas the named sex partners per patient ratio was only 1.5. Twenty-two percent of patients did not report any named partners. Overall, only 26% of the estimated total number of sex partners received treatment.

CONCLUSIONS

Expanding partner notification to include more high-risk persons identified through social networks and increasing screening among high-risk populations may improve control of inner city drug/prostitution-related syphilis epidemics.

Epidemiologic aspects of a St. Louis encephalitis outbreak in Fort Walton Beach, Florida in 1980

From July 10 through August 4, 1980, five cases of St. Louis encephalitis (SLE) occurred in and near Fort Walton Beach on the Gulf Coast of northwest Florida. These were the first cases of SLE ever reported from the Florida panhandle. To determine the extent of SLE infection in the community, sera (n = 968) were collected from patients at the local hospital and county public health unit and tested for SLE virus antibody. The SLE attack rate was highest in a centrally located impoverished census tract. There was a trend toward decreasing seroprevalence with distance from the central area of the city. Overall, seroprevalence was higher in males (prevalence ratio = 2.7) and in all areas, seroprevalence increased with age. The serosurvey results suggest that SLE has been endemic in the Fort Walton Beach area.

HIV seroprevalence and reasons for refusing and accepting HIV testing

BACKGROUND AND OBJECTIVES

We sought to evaluate the HIV seropositivity of patients who refused or accepted human immunodeficiency virus (HIV) testing in a South Carolina sexually transmitted diseases (STD) clinic, and the patients' reasons for refusing or accepting testing.

STUDY DESIGN

A serologic and self-administered survey done Jan. 9 through June 1, 1989. For those who refused HIV testing, a routine syphilis serology sample was tested blindly for HIV.

RESULTS

Of 1,929 patients in the study, 398 (21%) refused HIV testing. HIV test refusers were 2.2 times more likely to be HIV antibody positive than HIV test acceptors (3.0% versus 1.4%, prevalence ratio = 2.2, CI95 1.1-4.4), with this difference mainly occurring among males. Seven of eight patients reporting that they refused testing because they were HIV positive were found to be HIV negative. The principal reason indicated for test refusal was not feeling at risk for HIV infection. The principal reasons indicated for test acceptance were wanting to know the results for their own health status and wishing to prevent spread of the virus to partners.

CONCLUSION

We conclude that: (1) a higher seropositivity exists among HIV test refusers than acceptors; (2) patient reporting HIV seropositivity should be viewed with caution; (3) many STD patients deny their risk for HIV; and (4) STD patients are concerned about transmission of HIV to their partners.

Use of multiple molecular subtyping techniques to investigate a Legionnaires' disease outbreak due to identical strains at two tourist lodges

A multistate outbreak of Legionnaires' disease occurred among nine tour groups of senior citizens returning from stays at one of two lodges in a Vermont resort in October 1987. Interviews and serologic studies of 383 (85%) of the tour members revealed 17 individuals (attack rate, 4.4%) with radiologically documented pneumonia and laboratory evidence of legionellosis. A survey of tour groups staying at four nearby lodges and of Vermont-area medical facilities revealed no additional cases. Environmental investigation of common tour stops revealed no likely aerosol source of Legionella infection outside the lodges. Legionella pneumophila serogroup 1 was isolated from water sources at both implicated lodges, and the monoclonal antibody subtype matched those of the isolates from six patients from whom clinical isolates were obtained. The cultures reacted with monoclonal antibodies MAB1, MAB2, 33G2, and 144C2 to yield a 1,2,5,7 or a Benidorm 030E pattern. The strains were also identical by alloenzyme electrophoresis and DNA ribotyping techniques. The epidemiologic and laboratory data suggest that concurrent outbreaks occurred following exposures to the same L. pneumophila serogroup 1 strain at two separate lodges. Multiple molecular subtyping techniques can provide essential information for epidemiologic investigations of Legionnaires' disease.

Risk factors for developing eosinophilia myalgia syndrome among L-tryptophan users in New York

Using a case-control study design, patients with eosinophilia myalgia syndrome (EMS) who had used L-tryptophan (LT) were compared with LT users who did not develop EMS. Of the 113 case patients and 95 controls who had used a retail brand that could be traced to a bulk LT producer, all (100%) case-patients and 69 (73%) controls used LT brands that were traced to Showa Denko K.K. (lower 95% CL = 10.0). Among the users of LT produced by Showa Denko K.K., the risk of EMS was greater for persons who used LT produced after December 1, 1988 (OR = 25.8, [95% CL = 7.1, 101.4]). The risk of developing EMS increased with increased dosage of LT, increased age, and use of LT as a sleeping aid. These epidemiologic data support the hypothesis that the etiologic agent in EMS is a contaminant introduced into LT products during production.

Fatal incident risk factors in recreational boating in Ohio

To identify risk factors predicting the involvement of boat operators in incidents resulting in at least one fatality, the authors obtained data from a mail survey of registered boat owners in the State of Ohio and from the Boating Accident Report (BAR) files for 1983-86 compiled by the Ohio Department of Natural Resources. Additionally, they reviewed Ohio death certificates for those years to identify cases missed by the BAR system. Forty percent of the fatal incidents would have been missed by a search of death certificates alone. During the period studied, 107 boating incidents resulted in 124 deaths. There were 0.9 fatal incidents per million boat-operator hours. Factors found to be associated with an increased risk of a fatal boating incident were the operator being younger than 30 years, having fewer than 20 hours of boat operating experience, and lacking formal boat safety training. Canoes, kayaks, rowboats, and inflatables were associated with a higher rate of fatal incidents per million hours of use than were motorboats. Young age and lack of experience were associated independently with increased risk, explaining some of the effects associated with types of boats and with lack of training. The findings suggest that supervised experience, safety training programs aimed at young operators, and interventions specific to certain types of boats are likely to reduce boating fatalities.

The protective effect of alcohol on the occurrence of epidemic oyster-borne hepatitis A

Limited data indicate that drinking alcoholic beverages along with eating food contaminated with Shigella or Salmonella decreases the risk and/or the severity of illness. No such study has been reported following exposure to a viral pathogen. During an oyster-borne outbreak of hepatitis A, we studied the effect of ingestion of alcoholic beverages concomitant with consumption of contaminated oysters. The analysis was restricted to 51 cases and 33 controls who had consumed the implicated raw oysters. After controlling for potential confounders, we found a protective effect for beverages that have an alcohol concentration of greater than or equal to 10% (odds ratio = 0.1, 95% confidence interval = 0.02-0.9), but not for beverages with an alcohol concentration of less than 10% (odds ratio = 0.7, 95% confidence interval = 0.2-2.9).

Vitamin A levels and severity of measles. New York City

Recent studies show that vitamin A levels decrease during measles and that vitamin A therapy can improve measles outcome in children in the developing world. Vitamin A levels of children with measles have not been studied in developed countries. We therefore measured vitamin A levels in 89 children with measles younger than 2 years and in a reference group in New York City, NY. Vitamin A levels in children with measles ranged from 0.42 to 3.0 mumol/L; 20 (22%) were low. Children with low levels were more likely to have fever at a temperature of 40 degrees C or higher (68% vs 44%), to have fever for 7 days or more (54% vs 23%), and to be hospitalized (55% vs 30%). Children with low vitamin A levels had lower measles-specific antibody levels. No child in the reference group had a low vitamin A level. Our data show that many children younger than 2 years in New York City have low vitamin A levels when ill with measles, and that such children seem to have lower measles-specific antibody levels and increased morbidity. Clinicians may wish to consider vitamin A therapy for children younger than 2 years with severe measles. Additional studies of vitamin A in measles and other infectious diseases, and in vaccine efficacy trials, should be done.

Needlestick injuries and hepatitis B immunization in Florida paramedics: a statewide survey

STUDY OBJECTIVES

To determine the incidence of needlestick injury among paramedics working in Florida during 1987, to describe the circumstances surrounding such injuries, and to assess the hepatitis B vaccination status of this group.

DESIGN

Survey of a systematic random sample of paramedics using a self-administered questionnaire.

SETTING

Florida.

TYPE OF PARTICIPANTS

Paramedics.

MAIN RESULTS

A completed questionnaire was returned by 300 of 500 paramedics (60%) who received the mailed questionnaire. Sixty-nine paramedics (23%) reported a total of 110 needlestick injuries. More than one third of injuries occurred in conjunction with recapping needles. Almost 62% of reported injuries could have been prevented had proper needle disposal technique been used. Sixty-two percent of paramedics reported having had at least one dose of the hepatitis B vaccine. Sixty-five percent of the unvaccinated paramedics said they would take the hepatitis B vaccine if it was offered free.

CONCLUSION

The majority of needlestick injuries among paramedics in Florida could be prevented with proper needle disposal. Offering the hepatitis B vaccine at no charge to paramedics in Florida could increase the vaccination rate substantially.

The raw oyster consumer--a risk taker? Use of the Behavioral Risk Factor Surveillance System

We used the 1988 Behavioral Risk Factor Surveillance System in Florida to determine the prevalence of consumption of raw oysters, a vehicle implicated in the transmission of several pathogens. One-third of survey respondents reported ever eating raw oysters. The prevalence was higher for persons 18-49 years old and for males, and, when controlled for age and sex, for persons who reported being cigarette smokers or acute or chronic alcohol drinkers, and driving while intoxicated.

A multistate outbreak of hepatitis A caused by the consumption of raw oysters

BACKGROUND

In August 1988 we investigated a multistate outbreak of hepatitis A caused by Panama City, Florida, raw oysters.

METHODS

Cases of hepatitis A (HA) with onset in July-August 1988 were identified among persons who ate seafoods harvested in the coastal waters of Panama City, Florida. We conducted a case-control study, using eating companions of case-patients, and calculated attack rate (AR) per 1000 dozen raw oysters served. Enzyme immunoassay (EIA) and a polymerase chain reaction (PCR) technique were performed on samples of raw shellfish obtained from Panama City coastal waters.

RESULTS

Sixty-one case-patients were identified in five states: Alabama (23), Georgia (18), Florida (18), Tennessee (1), and Hawaii (1). We found an increased risk of HA for raw oyster eaters (odds ratio = 24.0; 95% confidence interval = 5.4-215.0; P less than .001). The AR of HA in seafood establishments was 1.9/1000 dozen raw oysters served. The EIA and PCR revealed HA virus antigen and nucleic acid in oysters from both unapproved and approved oyster beds, in confiscated illegally harvested oysters, and in scallops from an approved area.

CONCLUSIONS

The monitoring of coastal waters and the enforcement of shellfish harvesting regulations were not adequate to protect raw oyster consumers. More emphasis should be placed on increasing public awareness of health hazards associated with eating raw shellfish.

Public health intervention in a cocaine-related syphilis outbreak

BACKGROUND

Cocaine users and prostitutes are at high risk for syphilis, but disease control is difficult among these populations. During a cocaine-related syphilis outbreak in Chester, Pennsylvania, in 1989, we conducted a control program at sites where sex and drugs were sold.

METHODS

During a 2-week period, investigators recruited persons from these sites for interview, serologic testing, and empiric treatment.

RESULTS

Among 136 persons screened, 25 (18%) had early syphilis and 26 others (19%) had recent sexual contact with early syphilis patients. All were treated at initial screening at a cost of $402 and 12 investigator hours per case, compared to $470 and 20 hours per case when treated during routine investigator activities. This program may have contributed to a short-term decline in syphilis incidence in Chester by reducing the period of infectivity of these patients.

CONCLUSIONS

Screening and empiric treatment of persons at sites where sex and drugs are sold can be useful in short-term control of cocaine-related syphilis outbreaks.

The syphilis epidemic in Connecticut: relationship to drug use and prostitution

Syphilis rates in Connecticut increased four-fold between 1986 and 1988. During this time there were also signs of a large increase in cocaine use in the state. We studied links between these parallel trends in drug use and syphilis by examining two sources of data: information collected during syphilis case interviews and information from the syphilis screening program at the state's prison for women. As syphilis rates rose, there were large increases in the percentage of women with syphilis who reported prostitution or illicit drug use. In 1988, 41% of women with syphilis reported cocaine use, and 19% reported prostitution; 21% of male heterosexuals with syphilis reported cocaine use, and 31% reported sexual contact with prostitutes. Among incarcerated women, syphilis infection was frequent: of 113 women incarcerated for possession of illicit drugs in 1987-88, 7% were found to be infected with Treponema pallidum, and of 187 women incarcerated for prostitution in these years, 14% were infected. In both groups of incarcerated women studied, cocaine users had the highest syphilis rates, and those who administered drugs nonintravenously had rates similar to those who administered drugs intravenously. We concluded that the syphilis epidemic in Connecticut is related to the increase in use of illicit drugs (primarily cocaine) and that female drug users are at very high risk of syphilis regardless of whether they administer drugs intravenously or nonintravenously. We recommend that syphilis control efforts focus on wider serologic screening and early treatment of drug users, prostitutes, and their sex partners.

Partner acceptance of health department notification of HIV exposure, South Carolina

To determine the acceptability of health department notification of sex and needle-sharing partners of persons infected with human immunodeficiency virus (HIV), we administered an anonymous questionnaire to partners notified of their exposure to HIV during the previous 2 years. Of the 202 partners notified, 132 (65%) were locatable and completed the questionnaire. Only 12 (9%) thought they may have been exposed to HIV before health department notification. When the 132 partners were asked if they thought the health department did the right thing in telling them about their exposure, 87% responded "yes;" when asked if the health department should keep notifying persons exposed to HIV, 92% responded "yes." Responses were similar for homosexual-bisexual men, heterosexuals, and intravenous drug users; men and women; and whites and blacks. We conclude that health department notification is acceptable to persons exposed to HIV in this rural South Carolina district.

Lyme disease in New Jersey

Lyme disease is a spirochetal infection endemic throughout New Jersey. Case reports from 1984 through 1986 suggest different high-risk groups and different disease severity than had been observed in earlier cases in the state. Both sexes now appear equally at risk, while younger age groups, particularly children less than ten years old, appear to be at increased risk. Mild disease is usual, although classic rheumatologic and neurologic complications can occur. Informal surveys suggest Lyme disease is under-reported by a factor of five- to tenfold in New Jersey. Early recognition by physician and patient is necessary for prompt treatment to reduce complications.