Selected-Lesion SRS as a Novel Strategy in Treatment of Patients with Multiple Brain Metastases

PURPOSE/OBJECTIVE(S)

With the increasing use of intracranial SRS (SRS) for treatment of patients with >10-15 brain metastases treatment; debate remains in the literature about how these patients should be treated. While many advocate for treatment of all lesions with either SRS or whole brain radiation therapy (WBRT), several groups are considering selected-lesion SRS (SL-SRS) where only a subset of intracranial lesions are treated. However, the current practice patterns of SL-SRS are not known.

MATERIALS/METHODS

A survey of 19 questions was created using open-ended and multiple-choice style questions on SL-SRS practices and indications. The survey was distributed to providers in the US and internationally who perform SRS frequently. Ten out of 50 institutions provided responses reflecting the practices of 16 providers. Descriptive statistics was used to compare answers to each question when applicable including percentages and ranges.

RESULTS

SL-SRS was performed at 8/10 institutions, (5 out of 6 US institutions and 3 out of 4 international institutions). Only 2 institutions had established clinical indications for SL-SRS (one in the US and one internationally) and one additional US institution reported clinical trials that require SL-SRS to study efficacy of CNS penetrating targeted therapies. One program reported research protocols for untreated brain metastases that would take priority over SL-SRS (program outside the US). Size of the lesion was cited as the most important factor (90%) when deciding to treat any single lesion. Next, lesion location and focal signs/symptoms were both considered moderately important. 80% ranked distance from prior SRS as the least important factor. Perilesional edema was also less important at most programs (90%). Lesion location and presence of symptoms were also considered important. There were several factors that would encourage providers to consider SL-SRS in a patient. Prior WBRT; progressing systemic disease and CNS-penetrating drug option available; and progressing systemic disease and immunotherapy option available were the most common responses. Most respondents cited "specific request by medical oncology" as well as "cooperative studies in this topic" as factors that might push them towards SL-SRS. Several institutions specified factors beyond the listed options. One institution reported that for patients with >20 lesions, they treated the largest lesions with SRS then follow with WBRT, termed the "pre-WBRT boost." Progression of untreated lesions was the most common reason why providers would bring back patients for additional treatment.

CONCLUSION

The responses to this survey demonstrate that patients with >15-20 intracranial lesions, prior WBRT, and worsening systemic disease with CNS penetrating systemic therapies available are being considered for SL-SRS.

1520. Mind the Clap: Reported Disseminated Gonococcal Infections in the United States, 2020–2022

Background

Disseminated gonococcal infections (DGI) are estimated to occur in 0.5% to 3% of untreated Neisseria gonorrhoeae (GC) infections; however, surveillance and population-based studies to estimate DGI burden and describe recent DGI epidemiology and clinical manifestations are limited. In response to increased reports of DGI cases and clusters in the U.S., the Centers for Disease Control and Prevention (CDC) developed a surveillance system in 2020. We analyzed data captured by the initial two years of surveillance.

Methods

During 1/1/2020–3/31/2022, U.S. state/local health jurisdictions reported DGI cases to CDC utilizing a standardized case report form that collects demographic, sociobehavioral, and clinical information. A confirmed case was defined as isolation or detection of GC from a disseminated site of infection by culture or nucleic acid amplification test (NAAT); a probable case was defined as clinical manifestations of DGI and isolation or detection of GC from a mucosal site by culture or NAAT.

Results

In total, 274 DGI cases were reported to CDC from 13 U.S. states (65.7% from California): 215 (78.5%) confirmed cases and 59 (21.5%) probable cases. Among DGI cases, 51.1% were cisgender male, 33.2% were ≥ 45 years old, and 26.6% reported methamphetamine use in the past 12 months. Most patients (87.6%) did not have documented underlying immunosuppression or predisposing medical conditions. Among patients with DGI, 85.8% were hospitalized, 41.2% underwent related surgeries, and 2.2% died. Among confirmed cases, the most common disseminated sites of infection were synovial fluid (50.2%) and blood (45.1%). Among 184 (67.2%) patients with DGI who were tested for GC at a mucosal site, 115 (62.5%) were diagnosed with a mucosal GC infection (69.6% urogenital, 27.0% pharyngeal, 12.2% rectal); however, 85.5% of those not diagnosed with mucosal GC were only tested at urogenital sites. Only 89 patients (32.5%) reported mucosal symptoms present at the time of or within the month prior to DGI presentation.

Conclusion

Health care providers should maintain a high degree of suspicion for patients presenting with DGI symptoms given the potential for significant associated morbidity and the low proportion of patients who present with concurrent GC mucosal symptoms.

Disclosures

Alison Ridpath, MD, MPH, 3M company: Stocks/Bonds|Abbott Laboratories: Stocks/Bonds|Abbvie Inc.: Stocks/Bonds|Allogene Theraputics: Stocks/Bonds|Amarin Corperation PLC: Stocks/Bonds|infinity Pharmaceutical Companies: Stocks/Bonds|IQVIA Holdings Inc: Stocks/Bonds|Johnson and Johnson: Stocks/Bonds|Medtronic: Stocks/Bonds|pfizer: Stocks/Bonds|Thermo Fisher Scientific: Stocks/Bonds.

Primary and Secondary Syphilis Among Men Who Have Sex With Men and Women, 2010 to 2019

ABSTRACT

The relative proportion of cases of primary and secondary syphilis among men who have sex with men and women reported through national case report data from 2010 to 2019 seemed stable overall and were stratified by race/ethnicity, region, and age group, but case counts increased.

Effect of Screening and Treatment for Gonorrhea and Chlamydia on HIV Incidence Among Men Who Have Sex With Men in the United States: A Modeling Analysis

BACKGROUND

Previous models have estimated the total population attributable fraction of Neisseria gonorrhoeae and Chlamydia trachomatis (NG/CT) on HIV incidence among men who have sex with men (MSM), but this does not represent realistic intervention effects. We estimated the potential impact of screening for NG/CT on downstream incidence of HIV among MSM.

METHODS

Using a network model, we estimated the effects of varying coverage levels for sexually transmitted infection screening among different priority populations: all sexually active MSM regardless of HIV serostatus, MSM with multiple recent (past 6 months) sex partners regardless of serostatus, MSM without HIV, and MSM with HIV. Under the assumption that all screening events included a urethral test, we also examined the effect of increasing the proportion of screening events that include rectal screening for NG/CT on HIV incidence.

RESULTS

Increasing annual NG/CT screening among sexually active MSM by 60% averted 4.9% of HIV infections over a 10-year period (interquartile range, 2.8%-6.8%). More HIV infections were averted when screening was focused on MSM with multiple recent sex partners: 60% coverage among MSM with multiple recent sex partners averted 9.8% of HIV infections (interquartile range, 8.1%-11.6%). Increased sexually transmitted infection screening among MSM without HIV averted more new HIV infections compared with the transmissions averted because of screening MSM with HIV, but fewer NG/CT tests were needed among MSM with HIV to avert a single new HIV infection.

CONCLUSIONS

Screening of NG/CT among MSM is expected to lead to modest but clinically relevant reductions in HIV incidence among MSM.

Chlamydial Pgp3 Seropositivity and Population-Attributable Fraction Among Women With Tubal Factor Infertility

BACKGROUND

Chlamydial infection is associated with tubal factor infertility (TFI); however, assessment of prior chlamydial infection and TFI is imperfect. We previously evaluated a combination of serological assays for association with TFI. We now describe the chlamydial contribution to TFI using a newer Chlamydia trachomatis Pgp3-enhanced serological (Pgp3) assay.

METHODS

In our case-control study of women 19 to 42 years old with hysterosalpingogram-diagnosed TFI (cases) and non-TFI (controls) in 2 US infertility clinics, we assessed possible associations and effect modifiers between Pgp3 seropositivity and TFI using adjusted odds ratios with 95% confidence intervals (CIs) stratified by race. We then estimated the adjusted chlamydia population-attributable fraction with 95% CI of TFI.

RESULTS

All Black (n = 107) and 618 of 620 non-Black women had Pgp3 results. Pgp3 seropositivity was 25.9% (95% CI, 19.3%-33.8%) for non-Black cases, 15.2% (95% CI, 12.3%-18.7%) for non-Black controls, 66.0% (95% CI, 51.7%-77.8%) for Black cases, and 71.7% (95% CI, 59.2%-81.5%) for Black controls. Among 476 non-Black women without endometriosis (n = 476), Pgp3 was associated with TFI (adjusted odds ratio, 2.6 [95% CI, 1.5-4.4]), adjusting for clinic, age, and income; chlamydia TFI-adjusted population-attributable fraction was 19.8% (95% CI, 7.7%-32.2%) in these women. Pgp3 positivity was not associated with TFI among non-Black women with endometriosis or among Black women (regardless of endometriosis).

CONCLUSIONS

Among non-Black infertile women without endometriosis in these clinics, 20% of TFI was attributed to chlamydia. Better biomarkers are needed to estimate chlamydia TFI PAF, especially in Black women.

Publication and Impact of Preprints Included in the First 100 Editions of the CDC COVID-19 Science Update: Content Analysis

Background

Preprints are publicly available manuscripts posted to various servers that have not been peer reviewed. Although preprints have existed since 1961, they have gained increased popularity during the COVID-19 pandemic due to the need for immediate, relevant information.

Objective

The aim of this study is to evaluate the publication rate and impact of preprints included in the Centers for Disease Control and Prevention (CDC) COVID-19 Science Update and assess the performance of the COVID-19 Science Update team in selecting impactful preprints.

Methods

All preprints in the first 100 editions (April 1, 2020, to July 30, 2021) of the Science Update were included in the study. Preprints that were not published were categorized as “unpublished preprints.” Preprints that were subsequently published exist in 2 versions (in a peer-reviewed journal and on the original preprint server), which were analyzed separately and referred to as “peer-reviewed preprint” and “original preprint,” respectively. Time to publish was the time interval between the date on which a preprint was first posted and the date on which it was first available as a peer-reviewed article. Impact was quantified by Altmetric Attention Score and citation count for all available manuscripts on August 6, 2021. Preprints were analyzed by publication status, publication rate, preprint server, and time to publication.

Results

Of the 275 preprints included in the CDC COVID-19 Science Update during the study period, most came from three servers: medRxiv (n=201, 73.1%), bioRxiv (n=41, 14.9%), and SSRN (n=25, 9.1%), with 8 (2.9%) coming from other sources. Additionally, 152 (55.3%) were eventually published. The median time to publish was 2.3 (IQR 1.4-3.7). When preprints posted in the last 2.3 months were excluded (to account for the time to publish), the publication rate was 67.8%. Moreover, 76 journals published at least one preprint from the CDC COVID-19 Science Update, and 18 journals published at least three. The median Altmetric Attention Score for unpublished preprints (n=123, 44.7%) was 146 (IQR 22-552) with a median citation count of 2 (IQR 0-8); for original preprints (n=152, 55.2%), these values were 212 (IQR 22-1164) and 14 (IQR 2-40), respectively; for peer-review preprints, these values were 265 (IQR 29-1896) and 19 (IQR 3-101), respectively.

Conclusions

Prior studies of COVID-19 preprints found publication rates between 5.4% and 21.1%. Preprints included in the CDC COVID-19 Science Update were published at a higher rate than overall COVID-19 preprints, and those that were ultimately published were published within months and received higher attention scores than unpublished preprints. These findings indicate that the Science Update process for selecting preprints had a high fidelity in terms of their likelihood to be published and their impact. The incorporation of high-quality preprints into the CDC COVID-19 Science Update improves this activity’s capacity to inform meaningful public health decision-making.

Exploring and Comparing the Structure of Sexual Networks Affected by Neisseria gonorrhoeae Using Sexual Partner Services Investigation and Genomic Data

BACKGROUND

Sexual networks are difficult to construct because of incomplete sexual partner data. The proximity of people within a network may be inferred from genetically similar infections. We explored genomic data combined with partner services investigation (PSI) data to extend our understanding of sexual networks affected by Neisseria gonorrhoeae (NG).

METHODS

We used 2017-2019 PSI and whole-genome sequencing (WGS) data from 8 jurisdictions participating in Centers for Disease Control and Prevention's Strengthening the US Response to Resistant Gonorrhea (SURRG) project. Clusters were identified from sexual contacts and through genetically similar NG isolates. Sexual mixing patterns were characterized by describing the clusters by the individual's gender and gender of their sex partners.

RESULTS

Our study included 4627 diagnoses of NG infection (81% sequenced), 2455 people received a PSI, 393 people were negative contacts of cases, and 495 were contacts with an unknown NG status. We identified 823 distinct clusters using PSI data combined with WGS data. Of cases that were not linked to any other case using PSI data, 37% were linked when using WGS data. Overall, 40% of PSI cases were allocated to a larger cluster when PSI and WGS data were combined compared with PSI data alone. Mixed clusters containing women, men who report sex with women, and men who report sex with men were common when using the WGS data either alone or in combination with the PSI data.

CONCLUSIONS

Combining PSI and WGS data improves our understanding of sexual network connectivity.

Sexually Transmitted Infection Testing Among Transgender Women Living with Human Immunodeficiency Virus in the United States: Medical Monitoring Project, 2015-2019

National guidelines recommend annual sexually transmitted infection testing for sexually active people living with human immunodeficiency virus, including transgender women. Using data from the US Medical Monitoring Project during 2015-2019, in the previous 12 months, 63.3% of sexually active transgender women who were human immunodeficiency virus positive were tested for syphilis, 56.6% for chlamydia, and 54.4% for gonorrhea.

Genital Mycoplasma, Shigellosis, Zika, Pubic Lice, and Other Sexually Transmitted Infections: Neither Gone Nor Forgotten

ABSTRACT

Most estimates of the combined burden and cost of sexually transmitted infections (STIs) in the United States have focused on 8 common STIs with established national surveillance strategies (chlamydia, gonorrhea, syphilis, trichomoniasis, genital herpes, human papillomavirus, and sexually transmitted human immunodeficiency virus and hepatitis B). However, over 30 STIs are primarily sexually transmitted or sexually transmissible. In this article, we review what is known about the burden of "other STIs" in the United States, including those where sexual transmission is not the primary transmission route of infection. Although the combined burden of these other STIs may be substantial, accurately estimating their burden due to sexual transmission is difficult due to diagnostic and surveillance challenges. Developing better estimates will require innovative strategies, such as leveraging existing surveillance systems, partnering with public health and academic researchers outside of the STI field, and developing methodology to estimate the frequency of sexual transmission, particularly for new and emerging STIs.

Evidence of Recent Genomic Evolution in Gonococcal Strains With Decreased Susceptibility to Cephalosporins or Azithromycin in the United States, 2014-2016

BACKGROUND

Given the lack of new antimicrobials or a vaccine, understanding the evolutionary dynamics of Neisseria gonorrhoeae is a significant public and global health priority. We investigated the emergence and spread of gonococcal strains with decreased susceptibility to cephalosporins and azithromycin using detailed genomic analyses of gonococcal isolates collected in the United States, 2014-2016.

METHODS

We sequenced genomes of 649 isolates collected through the Gonococcal Isolate Surveillance Project. We examined the genetic relatedness of isolates and assessed associations between clades and various genotypic and phenotypic combinations.

RESULTS

We identified a large and clonal lineage of strains (MLST ST9363) associated with elevated azithromycin minimum inhibitory concentration (AZIem), characterized by a mosaic mtr locus (C substitution in the mtrR promoter, mosaic mtrR and mtrD). Mutations in 23S rRNA were sporadically distributed among AZIem strains. Another clonal group (MLST ST1901) possessed 7 unique PBP2 patterns, and it shared common mutations in other genes associated with cephalosporin resistance.

CONCLUSIONS

Whole-genome sequencing methods can enhance monitoring of antimicrobial resistant gonococcal strains by identifying gonococcal populations containing mutations of concern. These methods could inform the development of point-of-care diagnostic tests designed to determine the specific antibiotic susceptibility profile of a gonococcal infection in a patient.

Optimizing Coverage vs Frequency for Sexually Transmitted Infection Screening of Men Who Have Sex With Men

Background

The incidence of bacterial sexually transmitted infections (STIs) in men who have sex with men (MSM) has increased substantially despite availability of effective antibiotics. The US Centers for Disease Control and Prevention (CDC) recommends annual screening for all sexually active (SA) MSM and more frequent screening for high-risk (HR) MSM. The population-level benefits of improved coverage vs increased frequency of STI screening among SA vs HR MSM are unknown.

Methods

We used a network transmission model of gonorrhea (NG) and chlamydia (CT) among MSM to simulate the implementation of STI screening across different scenarios, starting with the CDC guidelines at current coverage levels. Counterfactual model scenarios varied screening coverage and frequency for SA MSM and HR MSM (MSM with multiple recent partners). We estimated infections averted and the number needed to screen to prevent 1 new infection.

Results

Compared with current recommendations, increasing the frequency of screening to biannually for all SA MSM and adding some HR screening could avert 72% of NG and 78% of CT infections over 10 years. Biannual screening of 30% of HR MSM at empirical coverage levels for annual SA screening could avert 76% of NG and 84% of CT infections. Other scenarios, including higher coverage among SA MSM and increasing frequency for HR MSM, averted fewer infections but did so at a lower number needed to screen.

Conclusions

The optimal screening scenarios in this model to reduce STI incidence among MSM included more frequent screening for all sexually active MSM and higher coverage of screening for HR men with multiple partners.

Kissing, saliva exchange, and transmission of Neisseria gonorrhoeae

Data from mathematical models suggest that kissing and saliva exchange during sexual activity might be major contributors to community gonorrhoea morbidity. Although there is little evidence to support this, it provokes discussion of the potential role of the oropharynx in gonorrhoea control. Improved sensitivity and ease of diagnostic testing, as well as increased screening for extragenital infections among men who have sex with men, have increased awareness of the high frequency of oropharyngeal gonorrhoea. However, there are insufficient data to determine the mechanisms of transmission for these infections. Innovative studies that use quantitative microbiological techniques are needed to accurately assess how oral gonorrhoea or saliva exchange in infected people contribute to the morbidity of gonorrhoea in the community. More empirical data on pharyngeal gonorrhoea infections, and the role of transmission to and from the oropharynx, are needed to inform prevention planning.

2020, sexually transmissible infections and HIV in gay, bisexual and other men who have sex with men

This editorial accompanies a series of papers dealing with this watershed period for HIV and sexually transmissible infections (STI) infections in gay, bisexual and other men who have sex with men (GBM). We are delighted to share with you the views of some international opinion leaders on what the future may hold and what challenges lie ahead. In this issue of the Journal, authors describe current HIV and STI incidence among GBM and predict the future.

Seroprevalence of Herpes Simplex Virus Types 1 and 2 Among Pregnant Women and Sexually Active, Nonpregnant Women in the United States

Background

Neonatal herpes is a rare, devastating consequence of herpes simplex virus type 1 (HSV-1) or 2 (HSV-2) infection during pregnancy. The risk of neonatal infection is higher among pregnant women seronegative for HSV-1 or HSV-2 who acquire their first HSV infection near delivery.

Methods

We estimated HSV-1 and HSV-2 seroprevalence among pregnant women aged 20-39 years in 1999-2014, assessed HSV seroprevalence changes between 1999-2006 and 2007-2014, and compared HSV seroprevalence between pregnant women and sexually active, nonpregnant women aged 20-39 years in 2007-2014 using National Health and Nutrition Examination Survey data.

Results

Among pregnant women in 1999-2014, HSV-1 seroprevalence was 59.3%, HSV-2 seroprevalence was 21.1%, and HSV seronegativity was 30.6%. Between 1999-2006 and 2007-2014, HSV-1 and HSV-2 seroprevalence among pregnant women remained stable. However, among pregnant women with ≤3 sex partners (approximately 40% of all pregnant women), seronegativity for both HSV-1 and HSV-2 increased from 35.6% to 51.4% (P < .05). In 2007-2014, nonpregnant women who were (1) unmarried, (2) living below poverty level, or (3) had ≥4 sex partners were more likely than pregnant women to be seronegative for both HSV-1 and HSV-2 (P < .05).

Conclusions

HSV-1 and HSV-2 seroprevalence among US pregnant women remained stable between 1999 and 2014. However, pregnant women with fewer sex partners were increasingly seronegative for both HSV-1 and HSV-2, indicating an increasing proportion of pregnant women who are vulnerable to primary HSV acquisition in pregnancy, which confers an increased risk of transmitting HSV to their neonates.

Laboratory Evaluation of a Commercially Available Rapid Syphilis Test

Serological diagnosis of syphilis depends on assays that detect treponemal and nontreponemal antibodies. Laboratory certification and trained personnel are needed to perform most of these tests, while high costs and long turnaround time can hinder treatment initiation or linkage to care. A rapid treponemal syphilis test (RST) that is simple to perform, accessible, and inexpensive would be ideal. The Syphilis Health Check (SHC) assay is the only Food and Drug Administration (FDA)-cleared and Clinical Laboratory Improvement Amendments (CLIA)-waived RST in the United States. In this study, 1,406 archived human serum samples were tested using SHC and traditional treponemal and nontreponemal assays. Rapid test results were compared with treponemal data alone and with a laboratory test panel consensus defined as being reactive by both treponemal and nontreponemal assays for a given specimen, or nonreactive by both types of assays. The sensitivity and specificity of the SHC assay compared with treponemal tests alone were 88.7% (95% confidence interval [CI], 86.2 to 90.0%) and 93.1% (95% CI, 90.0 to 94.9%), respectively, while comparison with the laboratory test panel consensus showed 95.7% (95% CI, 93.6 to 97.2%) sensitivity and 93.2% (95% CI, 91.0 to 95.1%) specificity. The data were further stratified based on age, sex, pregnancy, and HIV status. The sensitivity and specificity of the SHC assay ranged from 66.7% (95% CI, 46.0 to 83.5%) to 91.7% (95% CI, 87.7 to 94.7%) and 88% (95% CI, 68.8 to 97.5%) to 100% (95% CI, 47.8 to 100%), respectively, across groups compared to traditional treponemal assays, generally increasing for all groups except the HIV-positive (HIV+) population when factoring in the laboratory test panel consensus. These data contribute to current knowledge of the SHC assay performance for distinct populations and may guide use in various settings.

Advancing the public health applications of Chlamydia trachomatis serology

Genital Chlamydia trachomatis infection is the most commonly diagnosed sexually transmitted infection. Trachoma is caused by ocular infection with C trachomatis and is the leading infectious cause of blindness worldwide. New serological assays for C trachomatis could facilitate improved understanding of C trachomatis epidemiology and prevention. C trachomatis serology offers a means of investigating the incidence of chlamydia infection and might be developed as a biomarker of scarring sequelae, such as pelvic inflammatory disease. Therefore, serological assays have potential as epidemiological tools to quantify unmet need, inform service planning, evaluate interventions including screening and treatment, and to assess new vaccine candidates. However, questions about the performance characteristics and interpretation of C trachomatis serological assays remain, which must be addressed to advance development within this field. In this Personal View, we explore the available information about C trachomatis serology and propose several priority actions. These actions involve development of target product profiles to guide assay selection and assessment across multiple applications and populations, establishment of a serum bank to facilitate assay development and evaluation, and development of technical and statistical methods for assay evaluation and analysis of serological findings. The field of C trachomatis serology will benefit from collaboration across the public health community to align technological developments with their potential applications.

Sexual transmission of Zika virus and other flaviviruses: A living systematic review

BACKGROUND

Health authorities in the United States and Europe reported an increasing number of travel-associated episodes of sexual transmission of Zika virus (ZIKV) following the 2015-2017 ZIKV outbreak. This, and other scientific evidence, suggests that ZIKV is sexually transmissible in addition to having its primary mosquito-borne route. The objective of this systematic review and evidence synthesis was to clarify the epidemiology of sexually transmitted ZIKV.

METHODS AND FINDINGS

We performed a living (i.e., continually updated) systematic review of evidence published up to 15 April 2018 about sexual transmission of ZIKV and other arthropod-borne flaviviruses in humans and other animals. We defined 7 key elements of ZIKV sexual transmission for which we extracted data: (1) rectal and vaginal susceptibility to infection, (2) incubation period following sexual transmission, (3) serial interval between the onset of symptoms in a primary and secondary infected individuals, (4) duration of infectiousness, (5) reproduction number, (6) probability of transmission per sex act, and (7) transmission rate. We identified 1,227 unique publications and included 128, of which 77 presented data on humans and 51 presented data on animals. Laboratory experiments confirm that rectal and vaginal mucosae are susceptible to infection with ZIKV and that the testis serves as a reservoir for the virus in animal models. Sexual transmission was reported in 36 human couples: 34/36 of these involved male-to-female sexual transmission. The median serial symptom onset interval in 15 couples was 12 days (interquartile range: 10-14.5); the maximum was 44 days. We found evidence from 2 prospective cohorts that ZIKV RNA is present in human semen with a median duration of 34 days (95% CI: 28-41 days) and 35 days (no CI given) (low certainty of evidence, according to GRADE). Aggregated data about detection of ZIKV RNA from 37 case reports and case series indicate a median duration of detection of ZIKV of 40 days (95% CI: 30-49 days) and maximum duration of 370 days in semen. In human vaginal fluid, median duration was 14 days (95% CI: 7-20 days) and maximum duration was 37 days (very low certainty). Infectious virus in human semen was detected for a median duration of 12 days (95% CI: 1-21 days) and maximum of 69 days. Modelling studies indicate that the reproduction number is below 1 (very low certainty). Evidence was lacking to estimate the incubation period or the transmission rate. Evidence on sexual transmission of other flaviviruses was scarce. The certainty of the evidence is limited because of uncontrolled residual bias.

CONCLUSIONS

The living systematic review and sexual transmission framework allowed us to assess evidence about the risk of sexual transmission of ZIKV. ZIKV is more likely transmitted from men to women than from women to men. For other flaviviruses, evidence of sexual transmissibility is still absent. Taking into account all available data about the duration of detection of ZIKV in culture and from the serial interval, our findings suggest that the infectious period for sexual transmission of ZIKV is shorter than estimates from the earliest post-outbreak studies, which were based on reverse transcription PCR alone.

Ebola RNA Persistence in Semen of Ebola Virus Disease Survivors - Final Report

BACKGROUND

Ebola virus has been detected in the semen of men after their recovery from Ebola virus disease (EVD). We report the presence of Ebola virus RNA in semen in a cohort of survivors of EVD in Sierra Leone.

METHODS

We enrolled a convenience sample of 220 adult male survivors of EVD in Sierra Leone, at various times after discharge from an Ebola treatment unit (ETU), in two phases (100 participants were in phase 1, and 120 in phase 2). Semen specimens obtained at baseline were tested by means of a quantitative reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay with the use of the target sequences of NP and VP40 (in phase 1) or NP and GP (in phase 2). This study did not evaluate directly the risk of sexual transmission of EVD.

RESULTS

Of 210 participants who provided an initial semen specimen for analysis, 57 (27%) had positive results on quantitative RT-PCR. Ebola virus RNA was detected in the semen of all 7 men with a specimen obtained within 3 months after ETU discharge, in 26 of 42 (62%) with a specimen obtained at 4 to 6 months, in 15 of 60 (25%) with a specimen obtained at 7 to 9 months, in 4 of 26 (15%) with a specimen obtained at 10 to 12 months, in 4 of 38 (11%) with a specimen obtained at 13 to 15 months, in 1 of 25 (4%) with a specimen obtained at 16 to 18 months, and in no men with a specimen obtained at 19 months or later. Among the 46 participants with a positive result in phase 1, the median baseline cycle-threshold values (higher values indicate lower RNA values) for the NP and VP40 targets were lower within 3 months after ETU discharge (32.4 and 31.3, respectively; in 7 men) than at 4 to 6 months (34.3 and 33.1; in 25), at 7 to 9 months (37.4 and 36.6; in 13), and at 10 to 12 months (37.7 and 36.9; in 1). In phase 2, a total of 11 participants had positive results for NP and GP targets (samples obtained at 4.1 to 15.7 months after ETU discharge); cycle-threshold values ranged from 32.7 to 38.0 for NP and from 31.1 to 37.7 for GP.

CONCLUSIONS

These data showed the long-term presence of Ebola virus RNA in semen and declining persistence with increasing time after ETU discharge. (Funded by the World Health Organization and others.).

Development of risk reduction behavioral counseling for Ebola virus disease survivors enrolled in the Sierra Leone Ebola Virus Persistence Study, 2015-2016

Background

During the 2014–2016 West Africa Ebola Virus Disease (EVD) epidemic, the public health community had concerns that sexual transmission of the Ebola virus (EBOV) from EVD survivors was a risk, due to EBOV persistence in body fluids of EVD survivors, particularly semen. The Sierra Leone Ebola Virus Persistence Study was initiated to investigate this risk by assessing EBOV persistence in numerous body fluids of EVD survivors and providing risk reduction counseling based on test results for semen, vaginal fluid, menstrual blood, urine, rectal fluid, sweat, tears, saliva, and breast milk. This publication describes implementation of the counseling protocol and the key lessons learned.

Methodology/Principal findings

The Ebola Virus Persistence Risk Reduction Behavioral Counseling Protocol was developed from a framework used to prevent transmission of HIV and other sexually transmitted infections. The framework helped to identify barriers to risk reduction and facilitated the development of a personalized risk-reduction plan, particularly around condom use and abstinence. Pre-test and post-test counseling sessions included risk reduction guidance, and post-test counseling was based on the participants’ individual test results. The behavioral counseling protocol enabled study staff to translate the study’s body fluid test results into individualized information for study participants.

Conclusions/Significance

The Ebola Virus Persistence Risk Reduction Behavioral Counseling Protocol provided guidance to mitigate the risk of EBOV transmission from EVD survivors. It has since been shared with and adapted by other EVD survivor body fluid testing programs and studies in Ebola-affected countries.

The 2014–2016 West Africa Ebola Virus Disease (EVD) epidemic was large and widespread, affecting thousands of people across Guinea, Liberia, and Sierra Leone. Prior to this epidemic, there were limited data on persistence of Ebola virus in body fluids of EVD survivors and the potential risk that viral persistence may pose for Ebola virus transmission, including possible sexual transmission. This paper documents the development and implementation of a behavioral counseling protocol to facilitate adoption of risk reduction behaviors among male and female EVD survivors enrolled in the Sierra Leone Ebola Virus Persistence Study. This behavioral counseling protocol, composed of pre-test, delivery of results, and post-test counseling, enabled study staff to translate the study’s body fluid test results into individualized information and preventive action for study participants. Risk reduction behavioral counseling became an important EVD epidemic control measure.

Network-Centric Interventions to Contain the Syphilis Epidemic in San Francisco

The number of reported early syphilis cases in San Francisco has increased steadily since 2005. It is not yet clear what factors are responsible for such an increase. A recent analysis of the sexual contact network of men who have sex with men with syphilis in San Francisco has discovered a large connected component, members of which have a significantly higher chance of syphilis and HIV compared to non-member individuals. This study investigates whether it is possible to exploit the existence of the largest connected component to design new notification strategies that can potentially contribute to reducing the number of cases. We develop a model capable of incorporating multiple types of notification strategies and compare the corresponding incidence of syphilis. Through extensive simulations, we show that notifying the community of the infection state of few central nodes appears to be the most effective approach, balancing the cost of notification and the reduction of syphilis incidence. Additionally, among the different measures of centrality, the eigenvector centrality reveals to be the best to reduce the incidence in the long term as long as the number of missing links (non-disclosed contacts) is not very large.

Prevalence of Pelvic Inflammatory Disease in Sexually Experienced Women of Reproductive Age - United States, 2013-2014

Pelvic inflammatory disease (PID) is a clinical syndrome of the female reproductive tract characterized by inflammation of the endometrium, fallopian tubes, or peritoneum (1). PID occurs when microorganisms ascend from the vagina or cervix to the fallopian tubes and other upper genital tract structures (1). PID can result from untreated bacterial infections, including chlamydia and gonorrhea, and can lead to infertility, ectopic pregnancy, and chronic pelvic pain (1). Because there is no single diagnostic test for PID, clinicians rely on nonspecific signs and symptoms for diagnosis. The purpose of these analyses was to assess the burden of self-reported PID in a nationally representative sample using data from the National Health and Nutrition Examination Survey (NHANES) 2013-2014 cycle. Starting in 2013, NHANES female participants aged 18-44 years were asked about a lifetime history of PID diagnosis. Based on these data, the estimated prevalence of self-reported lifetime PID was 4.4% in sexually experienced women of reproductive age (18-44 years). The prevalence of self-reported lifetime PID was highest in women at increased risk, such as women reporting a previous sexually transmitted infection (STI) diagnosis. Stratified by race/ethnicity and having a previous STI diagnosis, non-Hispanic black (black) and non-Hispanic white (white) women reporting a previous STI diagnosis had nearly equal self-reported lifetime PID prevalence (10.0% versus 10.3%). However, the lifetime prevalence of PID among black women was 2.2 times that among white women if no previous STI was diagnosed (6.0% versus 2.7%). These findings suggest that PID is prevalent and associated with previous STI diagnoses; therefore, it is important for clinicians to screen female patients for chlamydia and gonorrhea to reduce the incidence of PID.

Neisseria gonorrhoeae strain with reduced susceptibilities to extended-spectrum cephalosporins

The spread of Neisseria gonorrhoeae strains with reduced susceptibility to extended-spectrum cephalosporins is an increasing public health threat. Using Etest and multiantigen sequence typing, we detected sequence type 1407, which is associated with reduced susceptibilities to extended-spectrum cephalosporins, in 4 major populated regions in California, USA, in 2012.

Sexually transmitted infection related stigma and shame among African American male youth: implications for testing practices, partner notification, and treatment

A self-administered, street intercept survey was conducted in order to examine the relation of stigma and shame associated with sexually transmitted infections (STI) to STI testing practices, partner notification, and partner-delivered treatment among young African American men (n=108) in a low-income, urban community in San Francisco with high STI burden. Multivariate logistic regression revealed that increasing STI-related stigma was significantly associated with a decreased odds of STI testing, such that every standard deviation increase in stigma score was associated with 0.62 decreased odds of having been tested (aOR: 0.62, 95% CI: 0.38-1.00), controlling for age. STI stigma was also significantly associated with a decreased willingness to notify non-main partners of an STI (aOR: 0.64 95% CI: 0.41-0.99). Participants with higher levels of stigma and shame were also significantly less likely to be willing to deliver STI medication to a partner (stigma aOR: 0.57, 95% CI: 0.37-0.88; shame aOR 0.53 95% CI: 0.34-0.83). Findings suggest that STI-related stigma and shame, common in this population, could undermine STI testing, treatment, and partner notification programs. The medical establishment, one of the institutional factors to have reinforced this culture of stigma, must aid efforts to reduce its effects through providing integrated services, reframing sexual health in campaigns, educating clients, and providing wider options to aid disclosure and partner notification practices.

Extragenital gonorrhea and chlamydia testing and infection among men who have sex with men--STD Surveillance Network, United States, 2010-2012

BACKGROUND

Gonorrhea (GC) and chlamydia (CT) are the most commonly reported notifiable diseases in the United States. The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) be screened for urogenital GC/CT, rectal GC/CT, and pharyngeal GC. We describe extragenital GC/CT testing and infections among MSM attending sexually transmitted disease (STD) clinics.

METHODS

The STD Surveillance Network collects patient data from 42 STD clinics. We assessed the proportion of MSM attending these clinics during July 2011-June 2012 who were tested and positive for extragenital GC/CT at their most recent visit or in the preceding 12 months and the number of extragenital infections that would have remained undetected with urethral screening alone.

RESULTS

Of 21 994 MSM, 83.9% were tested for urogenital GC, 65.9% for pharyngeal GC, 50.4% for rectal GC, 81.4% for urogenital CT, 31.7% for pharyngeal CT, and 45.9% for rectal CT. Of MSM tested, 11.1% tested positive for urogenital GC, 7.9% for pharyngeal GC, 10.2% for rectal GC, 8.4% for urogenital CT, 2.9% for pharyngeal CT, and 14.1% for rectal CT. More than 70% of extragenital GC infections and 85% of extragenital CT infections were associated with negative urethral tests at the same visit and would not have been detected with urethral screening alone.

CONCLUSIONS

Extragenital GC/CT was common among MSM attending STD clinics, but many MSM were not tested. Most extragenital infections would not have been identified, and likely would have remained untreated, with urethral screening alone. Efforts are needed to facilitate implementation of extragenital GC/CT screening recommendations for MSM.

Using the Neisseria gonorrhoeae multiantigen sequence-typing method to assess strain diversity and antibiotic resistance in San Francisco, California

Urogenital Neisseria gonorrhoeae isolates (266) collected in San Francisco, CA, in 2009 were analyzed for antimicrobial susceptibility and were subsequently genotyped by N. gonorrhoeae multiantigen sequence typing (NG-MAST). Isolates of identical or closely related sequence types were found to possess highly similar phenotypes with regard to drug susceptibility. Isolates containing decreased susceptibility to oral cephalosporins were detected in 2009 and were found to contain the mosaic penA allele (XXXIV) found previously to be associated with decreased susceptibility to cephalosporins. A better understanding of the relationships between phenotypic and genotypic markers for antimicrobial resistance may be helpful to the development of effective surveillance systems for drug-resistant N. gonorrhoeae.

A tale of two gonorrhea epidemics: results from the STD surveillance network

OBJECTIVE

An increasing proportion of gonorrhea in the United States is diagnosed in the private sector, posing a challenge to existing national surveillance systems. We described gonorrhea epidemiology outside sexually transmitted disease (STD) clinic settings.

METHODS

Through the STD Surveillance Network (SSuN), health departments in the San Francisco, Seattle, Denver, Minneapolis, and Richmond, Virginia, metropolitan areas interviewed systematic samples of men and women reported with gonorrhea by non-STD clinic providers from 2006 through 2008.

RESULTS

Of 2,138 interviews, 10.0% were from San Francisco, 26.4% were from Seattle, 25.2% were from Denver, 22.9% were from Minneapolis, and 15.5% were from Richmond. A total of 1,165 women were interviewed; 70.1% (815/1,163) were ≤24 years of age, 51.3% (598/1,165) were non-Hispanic black, and 19.0% (213/1,121) reported recent incarceration of self or sex partner. Among 610 men who have sex with only women, 50.9% were ≤24 years of age, 65.1% were non-Hispanic black, 14.1% reported incarceration of self or sex partner, and 16.7% reported anonymous sex. Among 363 men who have sex with men (MSM), 20.9% were ≤24 years of age, 61.6% were non-Hispanic white, 39.8% reported anonymous sex, 35.7% reported using the Internet to meet sex partners, and 12.1% reported methamphetamine use.

CONCLUSIONS

These data identified two concurrent gonorrhea epidemics in minority populations: a young, black, heterosexual epidemic with frequently reported recent incarceration, and an older, mostly white MSM epidemic with more frequently reported anonymous sex, Internet use to meet sex partners, and methamphetamine use.