An Overview Gonorrhea and Chlamydia Metropolitan Atlanta Gonorrhea Chlamydia Cases (and Rates) by Public Health District, Georgia, 1998 Metropolitan Atlanta Cases (and Rates) by Public Health District, Georgia, 1998 Georgia DPH00.12HW This page empty intentionally 2 Table of Contents Introduction...................................................................................................P...a.gPeage4 3 Epidemiologic data Gonorrhea surveillance......................................................................P..a..g.Peag4e 3 Gonococcal Isolate Surveillance Project (GISP)................................P..aPgaege10 Chlamydia surveillance.....................................................................P..a..g..e.P1a2ge Chlamydia Project.............................................................................P..a..g..ePa1g7e Screening for gonorrhea and chlamydia........................................................P..a..g..eP2ag2e Laboratory tests for gonorrhea and chlamydia..............................................P..a..g..ePa2g2e Treatment of uncomplicated gonorrhea and chlamydia.................................P..a..g..eP2a3ge Management of sex partners.........................................................................P...a.g.Pea2g4e Case reporting...............................................................................................P..a..gPeag2e4 Conclusion....................................................................................................P...a.gPeag2e4 References.....................................................................................................P..a..gPeag2e5 An Overview of Gonorrhea and Chlamydia in Georgia: Epidemiologic data, screening, laboratory tests, treatment, management of sex partners, and case reporting. Prepared by the Georgia Department of Human Resources, Division of Public Health Department of Human Resources Division of Public Health Prevention Services Branch STD/HIV Section Epidemiology Branch HIV/STD Epidemiology Section Audrey W. Horne Commissioner Kathleen E. Toomey, M.D.,M.P.H. Director Alpha F. Bryan, M.D. Assistant Director Alpha F. Bryan, M.D. Acting Director Alpha F. Bryan, M.D. Acting Director David B. Johnson Senior Public Health Advisor Roxanne Barrow, M.D.,M.P.H. Medical Epidemiologist Teresa Edwards Chlamydia Project Coordinator Kimberly R. Taylor, M.P.H. STD Data Manager Paul A. Blake, M.D.,M.P.H. Director John F. Beltrami, M.D.,M.P.H. & T.M.Chief Acknowledgment: The idea and general framework for this document are based on an article published in the State of Alaska Epidemiology Bulletin entitled, Prevention and Control of Gonorrhea and Chlamydia in Alaska: A call to action. 3 Introduction Sexually transmitted diseases (STDs) cause a tremendous health and economic burden and are the most frequently reported infectious diseases in the United States. Each year, more than 12 million Americans, 3 million of whom are teenagers, are infected with STDs, resulting in a cost of approximately $10 billion for the treatment of STDs and resulting complications.1 STDs are primarily associated with unprotected sexual activity, but other behavioral, biological, and social factors are also known to contribute to STD transmission, including drug and alcohol use. STDs particularly affect young persons, women, minorities, and populations living in the rural South. In recent years, Georgia has ranked in the top ten among all states for reported cases of STDs, including gonorrhea and chlamydia.2 These two STDs cause pelvic inflammatory disease (PID), infertility, ectopic pregnancy, chronic pelvic pain, epididymitis, and an increased risk of human immunodeficiency virus (HIV) transmission. Further, the annual costs for chlamydia alone have been estimated to be over $50 million. In Georgia, gonorrhea and chlamydia are the two most frequently reported infections; in 1998, 20,669 cases of gonorrhea and 25,248 cases of chlamydia were reported. The actual number of persons with these STDs in Georgia, however, is much higher than has been reported because of unknown asymptomatic infection, incomplete reporting, and persons who are presumptively treated and thus not reported. Successfully preventing and controlling STDs requires an understanding of several important and related issues such as epidemiologic data, screening, tests, treatment, management of sex partners, and case reporting. This document focuses on gonorrhea and chlamydia. Data presented in this report are from the gonorrhea and chlamydia surveillance database and the Gonococcal Isolate Surveillance Project (GISP) and Chlamydia Project databases. Laboratory testing information is from recent publications,3,4 and screening, treatment, and sex partner management recommendations are from the Centers for Disease Control and Prevention (CDC) 1998 STD treatment guidelines.5 The Division of Public Healths STD/ HIV Section has previously published the Sexually Transmitted Diseases Program Manual which is an additional and thorough reference for standards, guidelines, and laws related to STDs in Georgia.6 Gonorrhea surveillance From the mid-1970s to the mid-1990s, the rate of reported gonorrhea cases in the United States has steadily decreased; however, a reversal of this trend occurred from 1997 to 1998.2 The rate was 133 cases per 100,000 population in 1998 compared to 122 cases per 100,000 population in 1997, representing a 9% increase. The number of reported cases of gonorrhea in the United States is second only to chlamydia; in 1998, 355,642 cases of gonorrhea were reported. Charts 1 to 9 help describe the epidemiology of gonorrhea in Georgia. After a gradual decline in the rate and number of reported cases in recent years, a reversal of this trend appears to be beginning. In 1998, 20,669 cases of gonorrhea were reported for a rate of 270 cases per 100,000 population. Of these, 10,056 (49%) were female; 6,095 (29%) were 10 to 19 years old; and 9,149 (44%) were 20 to 29 years old. Among females, the number of reported cases 4 was highest in the 20 to 29 year old age group (4,236 cases), but the rate was highest among those 10 to 19 years old (769 cases per 100,000 population). Among males, the number of reported cases and the rates were highest among those 20 to 29 years old (4,887 cases, rate of 887 cases per 100,000 population). The five public health districts with the highest number of reported cases were Fulton (5,599), DeKalb (2,314), Columbus (1,625), Albany (1,620), and Macon (1,293). When the districts were grouped by metropolitan statistical area (MSA), the Atlanta area (which includes the Marietta, Fulton, Clayton, Gwinnett, and DeKalb districts) had the highest number of cases (9,390) in 1998, and the districts which include a small MSA (i.e., Albany, Athens, Augusta, Columbus, Macon, and Savannah) had the highest rate (344 cases per 100,000 population). Chart 1 Gonorrhea Cases and Rates by Year of Diagnosis Georgia, 1995-1998 Number of cases (Thousands) 25 & & 20 Rate Cases & Rate* 300 & & 250 15 200 150 10 100 5 50 0 Cases Rate* 1995 21.446 302 1996 19.94 277 * Rate = cases/100,000 population 1997 18.525 253 0 1998 20.669 270 5 Chart 2 Gonorrhea Cases by Sex and Year of Diagnosis Georgia, 1995-1998 Number of cases 14,000 12,000 # 10,000 $ $# 8,000 # Male $ Female $ $# # 6,000 4,000 2,000 0 Male Female 1995 11,158 10,149 1996 10,005 9,817 1997 8,897 9,577 1998 10,525 10,056 Chart 3 Gonorrhea Cases and Rates by Sex Georgia, 1998 Number of cases (Thousands) 12 , 10 8 6 4 2 0 Cases Rate* Males 10.525 283 Rate 300 Cases , Rate* , 250 200 150 100 50 0 Females 10.056 256 * Rate = cases/100,000 population 6 Chart 4 Gonorrhea by Age Group and Year of Diagnosis Georgia, 1995-1998 Number of cases 10,000 $ 8,000 # 6,000 4,000 ) 2,000 ' $ $ $ # # # Age group # 10-19 $ 20-29 ) 30-39 ' 40+ ) ) ) ' ' ' 0 10-19 20-29 30-39 40+ 1995 6,798 9,077 3,427 2,127 1996 6,415 8,406 3,214 1,890 1997 5,889 7,744 3,017 1,856 1998 6,095 9,149 3,347 1,621 Chart 5 Gonorrhea Cases and Rates by Age Group Georgia, 1998 Number of cases (Thousands) 10 , 8 , 6 4 2 0 Cases Rate* 10-19 6.095 549 20-29 9.149 827 Cases , Rate* Rate 800 600 , 30-39 3.347 255 400 200 , 0 >= 40 1.621 55 * Rate = cases/100,000 population 7 Chart 6 Gonorrhea Cases and Rates by Age Group and Sex Georgia, 1998 Age Group 10 - 19 Males cases (rate*) 1913 (336) 20 - 29 4887 (887) 30 - 39 2223 (346) >= 40 1288 ( 94) * Rate = cases/100,000 population Females cases (rate*) 4157 (769) 4236 (763) 1116 (166) 326 ( 20) Chart 7 Gonorrhea Cases by Public Health District (HD) Groupings Georgia, 1995-1998 Percent of all cases 60 50 Atlanta HDs Small MSA HDs Rural HDs 40 30 20 10 0 Atlanta HDs Small MSA HDs Rural HDs 1995 50 35 15 1996 48 33 19 1997 49 34 17 1998 45 36 19 Note: 8-county metro Atlanta includes the Marietta, Fulton, Clayton, Gwinnett, and DeKalb districts. Districts with a small metropolitan statistical area (MSA) are Albany, Athens, Augusta, Columbus, Macon, and Savannah. 8 Chart 8 Gonorrhea Cases and Rates by Health District (HD) Groupings Georgia, 1998 Number of cases (Thousands) 10 , , 8 6 4 2 0 Cases Rate* Atlanta HDs 9.39 330 Small MSA HDs 7.423 344 Rate 350 Cases , Rate* 300 250 200 , 150 100 50 0 Rural HDs 3.856 146 Note: 8-county metro Atlanta includes the Marietta, Fulton, Clayton, Gwinnett, and DeKalb districts. Districts with a small metropolitan statistical area (MSA) are Albany, Athens, Augusta, Columbus, Macon, and Savannah. * Rate = cases/100,000 population Chart 9 Gonorrhea Cases (and Rates) by Public Health District Georgia, 1998 Metropolitan Atlanta N = 20,669 (270 cases/100,000 population) 9 Gonococcal Isolate Surveillance Project (GISP) Gonorrhea infections have become increasingly resistant to routine antibiotic treatment, resulting in more expensive treatment options. Since 1976, when all gonorrhea infections were curable by penicillin, antibiotic-resistant strains in the United States have steadily increased to about one-third of all gonorrhea infections. The main purpose of the Gonococcal Isolate Surveillance Project (GISP) is to monitor trends of antimicrobial susceptibilities in N. gonorrhoeae and to describe the diversity of antimicrobial resistance. GISP data are useful for determining treatment recommendations. Each month, N. gonorrhoeae specimens from the first 20 men diagnosed with gonorrhea in STD clinics are collected. The Fulton County STD clinic is one of 28 national sites which participates in GISP. Chart 10 shows the treatment given to patients at the clinic in 1998, and Chart 11 shows the percentage of isolates resistant to specific antibiotics from 1988 to 1998. In 1998, all isolates were sensitive to the antibiotics administered at the clinic. Chart 10 Gonococcal Isolate Surveillance Project Treatment for gonorrhea at a Fulton county STD clinic, 1998 Ceftriaxone 79.7% Oflaxacin 1.3% None 2.2% N = 227 males with gonorrhea Missing 13.7% Spectinomycin 3.1% 10 Chart 11 Gonococcal Isolate Surveillance Project (GISP), Fulton County STD Clinic: 1988 to 1998 Percentage of isolates resistant to specific antibiotics by year Year Number PCN1 TET2 PCN & Ciprofloxacin4 Cefixime5 Ceftriaxone Spectinomycin Tested TET3 1988 236 3% 20% 4% ____ ____ 0% 0% 1989 240 18% 21% 5% ____ ____ 0% 0% 1990 236 36% 14% 3% ____ ____ 0% 0% 1991 240 29% 13% 6% 0% ____ 0% 0% 1992 236 22% 19% 4% 0% 0% 0% 0% 1993 238 11% 17% 12% 0% 0% 0% 0% 1994 229 11% 25% 9% 0% 0% 0% 0% 1995 227 4% 35% 18% 0% 0% 0% 0% 1996 193 3% 30% 10% 0% 0% 0% 0% 1997 202 4% 20% 12% 1% 0% 0% 0% 1998 227 4% 27% 7% 0% 0% 0% 0% 1 PCN = Plasmid-mediated penicillinase-producing N. gonorrhoeae (PPNG) and chromosomallymediated resistance to penicillin (PenR) 2 TET = Plasmid-mediated tetracycline resistance (TRNG) and chromosomally-mediated resistance to tetracycline (TetR) 3 The PCN & TET category is exclusive of the PCN and TET categories. 4 In 1997, there was one resistant isolate and one isolate with decreased susceptibility. In 1998, there were no resistant isolates, but there were 11 isolates with decreased susceptibility. 5 For cefixime, there has been no documented resistance for N. gonorrhoeae. In 1992, there was one isolate with decreased susceptibility at this clinic. 11 Chlamydia Surveillance In the last several years, the reporting of chlamydia has improved and become more standardized across the United States. Chlamydial genital infection is now the most common STD in the United States, and 4 million cases are estimated to occur annually. Since 1987, reported rates of chlamydia have steadily increased from 51 cases per 100,000 population to 237 cases per 100,000 population. This trend is considered to be due to high prevalence of disease, increased screening and recognition of asymptomatic infection, and improved case reporting. In 1998, 607,602 cases were reported in the United States.2 Charts 12 to 20 help describe the epidemiology of chlamydia in Georgia. Since 1995, the rate and number of reported cases in the state has increased each year. This trend is partly due to the implementation of the Chlamydia Project, which is described below. In 1998, 25,248 cases of chlamydia were reported for a rate of 330 cases per 100,000 population. Of these, 21,155 (84%) were female; 10,412 (41%) were 10 to 19 years old; and 11,565 (46%) were 20 to 29 years old. Among females, the number of reported cases and rate were highest in the 10 to 19 and 20 to 29 year old age groups. The five districts with the highest number of cases were Fulton (5,276), DeKalb (2,894), Columbus (2,123), Augusta (1,907), and Macon (1,884). When the districts were grouped by MSA, the Atlanta area (which includes the Marietta, Fulton, Clayton, Gwinnett, and DeKalb districts) had the highest number of cases (10,959) in 1998, and the districts which include a small MSA (i.e., Albany, Athens, Augusta, Columbus, Macon, and Savannah) had the highest rate (420 cases per 100,000 population). Chart 12 Chlamydia Cases and Rates by Year of Diagnosis Georgia, 1995-1998 Number of cases (Thousands) 30 25 Rate Cases & Rate* & 300 20 & 15 & 200 & 10 100 5 0 1995 1996 Cases 11.45 13.596 Rate* 161 189 * Rate = cases/100,000 population 1997 16.164 220 0 1998 25.248 330 12 Chart 13 Chlamydia Cases by Sex and Year of Diagnosis Georgia, 1995-1998 Number of cases 25,000 20,000 # Male $ Female $ 15,000 $ $ 10,000 $ 5,000 0 Male Female # 1995 983 10,417 # 1996 1,811 11,757 # 1997 1,978 14,150 # 1998 3,931 21,155 Chart 14 Chlamydia Cases and Rates by Sex Georgia, 1998 Number of cases (Thousands) 25 20 Cases , Rate* , 15 10 5 , 0 Cases Rate* Males 3.931 106 * Rate = cases/100,000 population Females 21.155 539 Rate 600 500 400 300 200 100 0 13 Chart 15 Chlamydia by Age Group and Year of Diagnosis Georgia, 1995 - 1998 Number of cases 14,000 12,000 10,000 Age group # 10-19 $ 20-29 ) 30-39 ' 40+ $ # 8,000 $# 6,000 $# $# 4,000 2,000 0 10-19 20-29 30-39 40+ )' 1995 5,103 4,790 850 693 )' 1996 6,061 5,784 1,021 724 )' 1997 7,119 6,971 1,070 979 ) ' 1998 10,412 11,565 1,896 446 Chart 16 Chlamydia Cases and Rates by Age Group Georgia, 1998 Number of cases (Thousands) 12 , , 10 8 6 4 Rate Cases , Rate* 1000 800 600 400 2 0 Cases Rate* 10-19 10.412 938 20-29 11.565 1046 , 30-39 1.896 144 200 , 0 >= 40 0.446 15 * Rate = cases/100,000 population 14 Chart 17 Chlamydia Cases and Rates by Age Group and Sex Georgia, 1998 Age Group 10 - 19 Males cases (rate*) 950 (167) 20 - 29 2037 (370) 30 - 39 591 ( 92) >= 40 175 ( 13) * Rate = cases/100,000 population Females cases (rate*) 9430 (1744) 9485 (1709) 1299 ( 193) 269 ( 17) Chart 18 Chlamydia Cases by Public Health District (HD) Groupings Georgia, 1996-1998 Percent of all cases 60 50 Atlanta HDs Small MSA HDs Rural HDs 40 30 20 10 0 Atlanta HDs Small MSA HDs Rural HDs 1996 56 26 18 1997 47 34 19 1998 43 36 21 Note: 8-county metro Atlanta includes the Marietta, Fulton, Clayton, Gwinnett, and DeKalb districts. Districts with a small metropolitan statistical area (MSA) are Albany, Athens, Augusta, Columbus, Macon, and Savannah. 15 Chart 19 Chlamydia Cases and Rates by Health District (HD) Groupings Georgia, 1998 Number of cases (Thousands) 12 , 10 , 8 6 4 2 0 Cases Rate* Atlanta HDs 10.959 385 Small MSA HDs 9.061 420 Rate Cases , Rate* 400 300 , 200 100 0 Rural HDs 5.228 198 Note: 8-county metro Atlanta includes the Marietta, Fulton, Clayton, Gwinnett, and DeKalb districts. Districts with a small metropolitan statistical area (MSA) are Albany, Athens, Augusta, Columbus, Macon, and Savannah. * Rate = cases/100,000 population Chart 20 Chlamydia Cases (and Rates) by Public Health District Georgia, 1998 Metropolitan Atlanta N = 25,248 (330 cases/100,000 population) 16 Chlamydia Project Of the estimated 4 million cases of chlamydia each year, 2.6 million occur in women. As many as 85% of infections in women and 40% of infections in men may be asymptomatic and will not be identified without screening. Uncomplicated chlamydial infections can be easily treated with antibiotics; however, more than one million women each year develop PID, primarily as a result of unrecognized and untreated cervical infections. In parts of the country where large-scale chlamydia programs have been implemented, the prevalence of disease has steadily declined. For example, in family planning clinics in Region X (Alaska, Idaho, Oregon, Washington), chlamydia positivity declined 60% from 1988 (9.3%) to 1998 (3.7%).2 Furthermore, statewide declines were observed in prevalence, incidence, and complications of chlamydia after a comprehensive chlamydia prevention program was implemented in Wisconsin.7 vaginal discharge or bleeding, abdominal pain, and pain with urination or intercourse. The data presented in this text and Charts 21 to 29 focus on women and 265 sites that were involved with collecting and submitting the data to the Division of Public Health in 1998. In 1998, 59,850 women were screened in this project. Of women with results, 7.6% (4,466/ 59,106) were infected with chlamydia and 2.9% (1,666/57,316) were infected with gonorrhea. By age group, the chlamydia positivity was 12% (2,226/18,448) in women 10 to 19 years old, 6.3% (1,814/28,761) in women 20 to 29 years old, 2.0% (145/7,251) in women 30 to 39 years old, and 1.0% (16/1,529) in women 40 to 49 years old. By race/ethnicity, the chlamydia positivity was 11% (3,459/32,525) among African Americans, 3.6% (744/20,859) among Whites, and 3.3% (127/3,895) among Hispanics. Since 1994, the Georgia Division of Public Health has participated in the Region IV Chlamydia Project, whose main goals include determining the prevalence of chlamydia and preventing and controlling chlamydia and its complications, particularly in women. Since the implementation of the project, the number of sites in Georgia that screen and provide treatment for chlamydia has expanded. In 1998, the project expanded to 446 sites, nearly all of which were family planning (FP), STD, teen, or college-based clinics. In general, women who had a pelvic exam during their clinic visit were screened for chlamydia and gonorrhea, and symptoms were defined as Of chlamydia positive women with documented information on symptoms, 65% (2,698/4,131) were asymptomatic, and of the women who were pregnant, 17% (110/645) were infected with chlamydia. The chlamydia positivity was 6.9% (3,158/45,881) at the FP sites, 10% (965/9,760) at the STD sites, 11% (276/2,458) at the teen clinics, and 6.6% (49/ 743) at the college sites. The five districts with the highest chlamydia positivity rates were Albany (11%), Augusta (10%), Columbus (9.9%), Macon (9.4%), and Valdosta (8.9%). 17 Chart 21 Georgia Chlamydia Project 265 sites, 1998 Of women with chlamydia (CT) results, 7.6% (4,466/59,106) were positive Of women with CT, 96% (4,287/4,466) were known to be treated Of women with gonorrhea (GC) results, 2.9% (1,666/57,316) were positive Of women with CT and GC results, 1.0% (543/56,824) were positive for both Chart 22 Georgia Chlamydia Project Chlamydia positivity by age group, 1998 Age Group 10 - 19 20 - 29 30 - 39 40 - 49 Percent Positive 12% (2,226/18,448) 6% (1,814/28,761) 2% (145/7,251) 1% (16/1,529) Total 8% (4,201/55,989) Chart 23 Georgia Chlamydia Project Chlamydia positivity by race/ethnicity, 1998 Race/ethnicity Percent Positive Black 11% (3,459/32,525) White 4% (744/20,859) Hispanic 3% (127/3,895) Other 6% (33/544) Total 8% (4,363/57,823) 18 Chart 24 Georgia Chlamydia Project Chlamydia positivity by age group and race/ethnicity, 1998 Age Group Black White Hispanic 10 - 19 17% (1,697/9,737) 5% (419/7,730) 7% (32/439) 20 - 29 9% (1,411/15,311) 3% (298/10,514) 3% (54/1,989) 30 - 39 3% (115/4,483) 1% (22/2,133) 1% (5/385) 40 - 49 1% (12/999) 1% (4/420) 0% (0/57) Total 11% (3,235/30,530) 4% (743/20,797) 3% (91/2,870) Chart 25 Georgia Chlamydia Project Chlamydia positivity by age group and symptoms, 1998 Age Group Symptomatic Asymptomatic 10 - 19 18% (728/3,997) 10% (1,470/14,228) 20 - 29 8% (620/7,609) 6% (1,157/20,655) 30 - 39 2% (73/2,997) 2% (67/4,072) 40 - 49 2% (12/722) 0.5% (4/757) Total 9% (1,433/15,325) 7% (2,698/39,712) 19 Chart 26 Georgia Chlamydia Project Chlamydia positivity by age group and pregnancy status, 1998 Age Group 10 - 19 20 - 29 30 - 39 40 - 49 Total Pregnant 29% (67/230) 12% (40/346) 5% (3/66) 0% (0/3) 17% (110/645) Not Pregnant 11% (1,985/17,414) 6% (1,661/27,083) 2% (125/6,621) 1% (14/1,365) 7% (3,785/52,483) Chart 27 Georgia Chlamydia Project Chlamydia positivity by clinic type, 1998 Clinic type Percent Positive Family Planning 7% (3,158/45,881) STD 10% (965/9,760) Teen 11% (276/2,458) College 7% (49/743) 20 Chart 28 Georgia Chlamydia Project Chlamydia positivity by reason for visit, 1998 Reason for visit STD problem or volunteer Family planning Referred by sex partner Percent Positive 9% (1,441/15,506) 7% (2,867/42,073) 13% (92/694) Chart 29 Chlamydia Positivity by Location of Clinic Georgia, 1998 Metropolitan Atlanta Dalton 4.6% Gainesville Rome 5.1% 3.5% Atlanta Athens 6.7% LaGrange 8.8% Macon 9.4% Augusta 10% Columbus 9.9% Albany 11% Dublin 8.4% Waycross 6.6% Valdosta 8.9% Marietta 3.6% Gwinnett 3.7% DeKalb 7.3% Fulton 8.3% Clayton 6.8% Savannah Brunswick 7.0% Note: Information presented is based on data processed as of May, 1999 21 Screening for gonorrhea and chlamydia Early diagnosis and treatment for a specific infection is a primary goal of screening. Several organizations have published guidelines for the screening of gonorrhea and chlamydia, and most recommendations are for young persons, women, and persons at high-risk for acquiring infection. Furthermore, state legislation in Georgia requires that health insurance plans pay for the cost of an annual chlamydia screening for all women less than 30 years old. For pregnant women, CDC recommends testing for gonorrhea at the first prenatal visit for women at risk or for women living in an area in which the prevalence is high.5 Repeat testing for gonorrhea should be done during the third trimester for those at continued risk. Testing for chlamydia should be done in the third trimester for women at increased risk, i.e., women aged less than 25 years and women who have a new or more than one sex partner or whose partner has other partners. Laboratory tests for gonorrhea and chlamydia Several tests are available for detecting gonococcal and chlamydial infections, and advances in diagnostic tests are continually occurring.3,4 Table 1 briefly describes some of the tests that are currently available and common sources of specimen collection. The DNA probe (e.g., GenProbe Pace 2), polymerase chain reaction (PCR), and ligase chain reaction (LCR) tests offer an advantage because one specimen can be tested for both gonorrhea and chlamydia. Table 1 Organism N. gonorrhoeae C. trachomatis Test Technology Common specimen sources Grams stain Microscopy Urethra Culture Culture Urethra, endocervix, rectum, pharynx DNA Probe Nucleic acid hybidization Urethra, endocervix Polymerase or ligase chain reaction (PCR or LCR) Nucleic acid amplification Urethra, endocervix, urine DFA (direct fluorescent- Microscopy antibody) Urethra, endocervix, rectum EIA (enzyme immunoassay) Immunohistochemistry Urethra, endocervix, urine DNA Probe Nucleic acid hybridization Urethra, endocervix Polymerase or ligase chain reaction (PCR or LCR) Nucleic acid amplication Urethra, endocervix, urine 22 Treatment of uncomplicated gonorrhea and chlamydia Tables 2 and 3 show the CDC recommended treatment regimens for uncomplicated gonococcal and chlamydial infections in adolescents and adults. The CDC guidelines should be read for alternative regimens and special considerations.5 Table 2 Recommended regimens for uncomplicated gonococcal infections of the urethra, cervix, and rectum in adolescents and adults a) Cefixime 400 mg orally in a single dose plus Azithromycin 1 g orally in a single dose b) Cefixime 400 mg orally in a single dose plus Doxycycline 100 mg orally twice a day for 7 days c) Ceftriaxone 125 mg IM in a single dose plus Azithromycin 1 g orally in a single dose d) Ceftriaxone 125 mg IM in a single dose plus Doxycycline 100 mg orally twice a day for 7 days e) Ciprofloxacin 500 mg orally in a single dose plus Azithromycin 1 g orally in a single dose f) Ciprofloxacin 500 mg orally in a single dose plus Doxycycline 100 mg orally twice a day for 7 days g) Ofloxacin 400 mg orally in a single dose plus Azithromycin 1 g orally in a single dose h) Ofloxacin 400 mg orally in a single dose plus Doxycycline 100 mg orally twice a day for 7 days Note: Because persons infected with gonorrhea are often coinfected with chlamydia, dual therapy is recommended. Table 3 Recommended regimens for uncomplicated chlamydial infections in adolescents and adults a) Azithromycin 1 g orally in a single dose b) Doxycycline 100 mg orally twice a day for 7 days 23 Management of sex partners Persons infected with gonorrhea or chlamydia STDs. Surveillance data show that gonorrhea should refer their sex partners for evaluation and appears to be increasing for the first time in several treatment. Sex partners should be evaluated and years, and GISP results show that therapeutic treated if they had sexual contact with the index regimens are currently available to successfully patient during the 60 days preceding the onset of treat all gonococcal strains at a Fulton county STD symptoms or diagnosis of chlamydia.5 If the time clinic, despite a substantial proportion of gonorrhea of the last sexual contact was more than 60 days isolates being resistant to some medications. The before the onset of symptoms or diagnosis, then expansion of the Chlamydia Project throughout the most recent sex partner should be treated. Sex Georgia has resulted in the screening and treatment partners, as well as the index patient, should be of chlamydia and gonorrhea in increasingly large instructed to abstain from sex until all treatment is numbers of women, many of whom otherwise may completed and any symptoms have resolved. not have been diagnosed and treated. This project Timely treatment of sex partners can prevent has also contributed to an improved understanding disease transmission to others and reinfection of of STDs in Georgia, sustained health care cost the index patient. savings based on the prevention of infections and complications, and the treatment of asymptomatic Case Reporting women who might have unknowingly spread their infection to others. Timely and complete reporting of gonorrhea and chlamydia is an integral component of successful disease control and prevention and important for monitoring accurate morbidity trends and targeting limited resources for public health planning and policy. In Georgia, all physicians, laboratories, and other health care providers are required by law to report persons with gonorrhea or chlamydia to their county, district, or state health department. Both clinical and lab-confirmed diagnoses are reportable within 7 days either by phone or by mail. Persons reporting by mail should use a Notifiable Disease Report Form and mail it in an envelope marked confidential. Important information to report includes the disease; the patients complete name and address, phone number, date of birth, sex, race/ethnicity, and pregnancy status; the physicians name and phone number; and the reporting persons name, institution, and phone number. Conclusion This document has provided an overview of several important public health issues related to When interpreting surveillance data, it is important to note that there are more cases in a jurisdiction than are actually reported to the health department. Due to persons who are asymptomatic, persons who receive presumptive treatment (e.g., males with symptoms suggestive of gonorrhea), and incomplete reporting, the number of reported cases in this document represents an underestimate of the true number of persons in Georgia with gonorrhea or chlamydia. In addition to promoting widespread screening and treatment, management of sex partners, and case reporting, individual and group interventions should be considered to further prevent and control STDs. Partner notification is a cost-effective strategy to prevent PID,8 and brief, interactive HIV/ STD counseling interventions which are tailored to each individuals risks can increase condom use and prevent new STDs.9 In Georgia, much progress has been made in preventing and controlling STDs, but continued efforts are needed. Preventing STDs and overcoming their enormous impact on the citizens of Georgia requires a sustained, multifaceted approach. 24 References 1. Institute of Medicine. The neglected health and economic impact of STDs. In: Eng TR, Butler WT, eds. The hidden epidemic: confronting sexually transmitted diseases. Washington, DC: National Academy Press, 1997:28-68. 2. Division of STD Prevention. Sexually Transmitted Diseases Surveillance, 1998. Department of Health and Human Services, Atlanta: Centers for Disease Control and Prevention (CDC), September 1999. 3. Holmes KK, Sparling PF, Mardh PA, et al. eds. Sexually Transmitted Diseases. 3rd ed. New York: McGraw-Hill, 1999. 4. Black CM. Current methods of laboratory diagnosis of Chlamydia trachomatis infections. Clin Microbiol Rev 1997;10:160-184. 5. Centers for Disease Control and Prevention. 1998 Guidelines for treatment of sexually transmitted diseases. MMWR 1998;47(no. RR-1). 6. Division of Public Health. Sexually Transmitted Diseases Program Manual. Georgia Department of Human Resources, Atlanta, GA. September 1998. 7. Hillis SD, Nakashima A, Amsterdam L, et al. The impact of a comprehensive chlamydia prevention program in Wisconsin. Family Planning Perspectives 1995;27:108-111. 8. Howell MR, Kassler WJ, Haddix A. Partner notification to prevent pelvic inflammatory disease in women: cost effectiveness of two strategies. Sex Transm Dis 1997;24:287-292. 9. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. JAMA 1998;280:1161-1167. 25