Disseminated gonococcal infection (DGI) is a rare but serious complication of Neisseria gonorrhoeae infection that can result in severe illness or death. In April 2024, the Alaska Section of Epidemiology (SOE) identified an increase in suspected DGI cases in Anchorage, Alaska, prompting enhanced surveillance. The state's gonorrhea surveillance system and electronic health records were used to review all likely and verified DGI cases reported to SOE during January 2023-December 2024. Thirty-five DGI cases were identified, accounting for 0.35% (eight of 2,289) of all gonorrhea cases in 2023 and 1.3% (27 of 2,079) in 2024. The median patient age was 36 years, 51% of patients were male, and 37% had a documented substance use disorder. Overall, 21 (60%) patients experienced septic arthritis, and three (9%) patients developed endocarditis; 28 (80%) patients lacked mucosal symptoms. No deaths were reported. Eighteen available isolates collected during 2020-2024, including 14 from cases reported during 2023 and 2024, underwent antimicrobial susceptibility testing and whole-genome sequencing. Laboratory analyses identified a cluster of highly related isolates with a novel multilocus sequence type (MLST-18036) and markers of increased virulence; however, no resistance to first-line therapy (ceftriaxone) was detected. Clinicians should maintain a high index of suspicion for DGI in patients at risk for gonococcal infection, even in the absence of mucosal symptoms. Prompt diagnosis and treatment, prompt case reporting, and robust partner services are critical to preventing transmission and reducing DGI morbidity.

Introduction Mpox continues to disproportionately affect gay, bisexual, and other men who have sex with men (MSM) in the United States. Mpox testing and vaccination are critical for prevention; however, few studies have examined how knowledge of mpox transmission, fear, or stigma relate to uptake of these services. Methods 1,063 sexually active MSM provided data as part of an online, cross-sectional mpox sub-study of the American Men’s Internet Survey (AMIS) from February – April 2025. Logistic regression was used to examine if mpox transmission knowledge, fear, and stigma were associated with having ever tested for mpox and or receiving an mpox vaccine. Covariates included age, region, sexual orientation, race/ethnicity, education, employment, food security, health insurance, HIV status, and recent STI testing. Results Most participants (n=606, 57%) had received at least one dose of the mpox vaccine, while only 14% (n=144) had ever been tested for mpox. Mpox transmission knowledge was low, with fewer than half of participants correctly answering most questions and approximately one-third experienced some form of fear or stigma associated with mpox. Higher knowledge scores were associated with greater odds of testing (aOR: 1.19; 95% CI: 1.04, 1.36) and having received the vaccination (aOR: 1.14; 95% CI: 1.04, 1.26). Perceived community mpox discrimination was also associated with testing (aOR: 2.14; 95% CI: 1.26, 3.63) and being afraid of having sex due to mpox acquisition risk was associated with vaccination (aOR: 2.49; 95% CI: 1.76, 3.52). Conclusion Suboptimal mpox knowledge and experiences of fear and stigma remain common and are associated with mpox vaccination and testing among MSM. Sustained mpox-specific education and awareness that directly addresses misconceptions about transmission may improve mpox vaccination and testing uptake.

Nationally, the percentage of gonorrhea and chlamydia cases diagnosed in STD clinics dropped dramatically from 1989 through 2023 for men (gonorrhea: 74% to 7%; chlamydia: 47% to 6%) and women (gonorrhea: 57% to 4%; chlamydia: 26% to 3%). Careful consideration of where STDs are diagnosed is important for public health planning.

BACKGROUND:Men who have sex with men (MSM) have a disproportionately high syphilis burden. As anal ulcers are less visible than penile ulcers, we examined whether MSM practicing receptive or versatile versus insertive anal intercourse were more likely to be diagnosed at a later syphilis stage. METHODS:Using cross-sectional data from MSM enrolled in the Network Epidemiology of Syphilis Transmission (NEST) study, we evaluated the associations between sexual positioning (exclusive bottom, versatile bottom, or versatile vs. exclusive top or versatile top) and three outcomes: 1) syphilis stage diagnosed at baseline (secondary or latent vs. primary), 2) lifetime history of syphilis, and 3) history of syphilis in the past 12 months. RESULTS:Overall, 655 MSM enrolled in NEST; 599 had complete data on sexual positioning and syphilis stage at baseline. Of these, 57 had syphilis at baseline (Analysis 1), 506 had complete data on lifetime history of syphilis (Analysis 2), and 377 had complete data on history of syphilis in the past 12 months (Analysis 3). Among MSM with syphilis at baseline, those who practiced receptive or versatile versus insertive anal intercourse had 13 (95% CI=1.4-123) times the odds of being diagnosed with secondary or latent stage syphilis. Sexual positioning was not associated with syphilis history in the lifetime or past 12 months. CONCLUSIONS:These findings suggest that differences in sexual positioning may influence the stage at which syphilis is diagnosed among MSM. Further research in larger samples is needed to better understand these differences and their underlying mechanisms and to assess potential implications for clinical detection and diagnosis.

We analyzed syphilis case notifications in reproductive-aged women during 2013-2022. Late/unknown duration syphilis grew faster after 2020 (45.8% vs. 17.9% annual growth pre-2020). Increased screening, inaccurate staging, delayed diagnosis, or increased incidence following clinical and partner services gaps during 2020 may contribute to rises in late/unknown duration cases.

BACKGROUND:There is no licensed vaccine against gonorrhea, but Neisseria meningitidis serogroup B outer membrane vesicle-based vaccines, such as MenB-4C, may offer cross-protection against gonorrhea. This systematic review and meta-analysis synthesized the published literature on MenB-4C vaccine effectiveness against gonorrhea. METHODS:We conducted a literature search of electronic databases (PubMed, Medline, Embase, Global Health, Scopus, Google Scholar, CINAHL, and Cochrane Library) to identify peer-reviewed articles published in English from 1 January 2013 to 11 September 2024 that reported MenB-4C vaccine effectiveness estimates against gonorrhea and gonorrhea/chlamydia coinfection and the duration of MenB-4C vaccine-induced protection. We estimated pooled MenB-4C vaccine effectiveness (≥1 dose) against gonorrhea using the DerSimonian-Laird random effects model. RESULTS:Eight articles met our eligibility criteria. Receipt of ≥1 dose of MenB-4C vaccine was 23% to 47% effective against gonorrhea. Two doses of MenB-4C vaccine were 33% to 40% effective against gonorrhea, and 1 dose of MenB-4C vaccine was 26% effective. MenB-4C vaccine effectiveness against gonorrhea/chlamydia coinfection was mixed, with 2 studies reporting effectiveness estimates of 32% and 44% and 2 other studies showing no protective effect. MenB-4C vaccine effectiveness against gonorrhea was comparable in people with HIV (44%) and people without HIV (23%-47%). Pooled MenB-4C vaccine effectiveness (≥1 dose) against gonorrhea was 32.4%. One study concluded that MenB-4C vaccine effectiveness against gonorrhea may wane approximately 36 months postvaccination. CONCLUSIONS:MenB-4C vaccine is moderately effective against gonorrhea in various populations. Prospective clinical trials that assess the efficacy of MenB-4C against gonorrhea, gonorrhea/chlamydia coinfection, and duration of protection are warranted to strengthen this evidence.

ABSTRACT:Persons in rural communities experience barriers to preventative sexually transmitted infection services, including screening. We calculated aggregated annual national rural and urban chlamydia and gonorrhea case rates for 2016 to 2022 and found that rates were consistently higher among urban counties. Trends in both urban and rural case rates followed a similar trajectory over time.

Objectives. To examine recent trends in substance use among women with primary and secondary (P&S) syphilis in the United States. Methods. We reviewed case notifications sent to the Centers for Disease Control and Prevention via the National Notifiable Diseases Surveillance System for women and girls aged 15 years and older with P&S syphilis from 2018 to 2023. We calculated percentages of behaviors associated with substance use during the past year (having sex while intoxicated or high, having sex with a person who injects drugs, or methamphetamine use) by year, race/ethnicity, and region. Results. Our analysis included 51 209 P&S syphilis cases. Most women and girls (86%) were of reproductive age. Behaviors were stable temporally and regionally, but methamphetamine use was highest in the West (30%). All behaviors were reported more frequently among non-Hispanic White women than non-Hispanic Black or Hispanic women. Conclusions. Although substance use behaviors were frequently reported, trends were stable, indicating that the proportion of women reporting these behaviors did not scale with recent national increases in P&S syphilis among women. Universal syphilis screening of reproductive age women and girls could be evaluated as an option to reduce syphilis among them along with adverse outcomes, including congenital syphilis. (Am J Public Health. 2025;115(12): 2044-2052. https://doi.org/10.2105/AJPH.2025.308254).

We examined racial differences in willingness to use doxycycline postexposure prophylaxis (doxy PEP) to prevent sexually transmitted infections (STIs) among men who have sex with men (MSM) who have not heard of and not used doxy PEP before taking this survey. Most MSM in our study were willing to use doxy PEP. Black, non-Hispanic MSM and Hispanic MSM were more willing to use doxy PEP than White, non-Hispanic MSM. Doxycycline postexposure prophylaxis is an acceptable STI prevention approach among MSM, especially among racial/ethnic minority MSM who are disproportionately affected by bacterial STIs.

Objectives. To estimate the association of state policies that define prenatal substance use as child abuse and mandate that health care professionals report prenatal substance use to child protective services with congenital syphilis case rates. Methods. We used 2018 to 2022 US data on congenital syphilis case notifications to the National Notifiable Diseases Surveillance System. We conducted linear regression with a generalized estimating equation approach to compare congenital syphilis case rates in states with a child abuse policy only, a mandated reporting policy only, and both polices to rates in states with neither policy. Results. After adjustment for confounders, the rate of congenital syphilis cases was, on average, 23.5 (95% confidence interval = 2.2, 44.8) cases per 100 000 live births higher in states with both a child abuse policy and a mandated reporting policy for prenatal substance use than in states with neither policy. Rates were similar in states with a child abuse policy only and a mandated reporting policy only compared to states with neither policy. Conclusions. The combination of state child abuse policies and mandated reporting policies for prenatal substance use potentially contributes to higher congenital syphilis case rates. ( Am J Public Health. Published online ahead of print February 13, 2025:e1–e9. https://doi.org/10.2105/AJPH.2024.307951 )

BACKGROUND:Doxycycline use in sexually transmitted infection (STI) care is changing. Concerns about antimicrobial resistance (AR) have accompanied recent recommendations for doxycycline as bacterial STI postexposure prophylaxis (doxy PEP). We describe trends in tetracycline resistance (TetR) among Neisseria gonorrhoeae (GC) isolates collected through US national surveillance in anticipation of expanded use of doxy PEP. METHODS:N. gonorrhoeae isolates were collected from men with symptomatic urethritis attending Gonococcal Isolate Surveillance Project (GISP) clinics during 1987-2022 or from patients diagnosed with gonorrhea attending GISP, enhanced GISP, and/or Strengthening the US Response to Resistant Gonorrhea clinics during 2018-2022. Antimicrobial susceptibility testing was performed using agar dilution. We describe TetR (tetracycline minimum inhibitory concentration (MIC) ≥2 μg/mL) and high-level TetR (TetHLR) (MIC ≥16 μg/mL) patterns among collected GC isolates, including by sex and sex of sex partner(s). RESULTS:A total of 183,668 urethral GC isolates were collected from men with symptomatic urethritis during 1987-2022. The proportion of isolates demonstrating TetR was stable during 1987 (19.7%) to 2022 (19.7%) though isolates demonstrating TetHLR increased from 2.8% to 14.6%. A total of 38,383 GC isolates were collected from patients with gonorrhea during 2018-2022; TetHLR increased across all sex/sex of sex partner(s) groups and was highest among men reporting male sex partner(s). CONCLUSIONS:An increasing proportion of GC isolates collected through US national surveillance are demonstrating TetHLR. As doxycycline use expands in STI care, enhanced surveillance will be needed to monitor downstream impacts of its use on antimicrobial-resistant GC.

We examined alignment between sex of sex partners and sexual orientation in syphilis case notifications among men in 2022 to inform interpretation of sexual orientation data for notifiable conditions in the National Notifiable Diseases Surveillance System. Observed partial alignment underscores the importance of analyzing appropriate variable(s) for a given intervention.

A survey of a nationally representative sample of US adults found a low prevalence of dating and sex with new partners during the first 2 years of the COVID-19 pandemic. BackgroundThe COVID-19 pandemic may have influenced partner-seeking and sexual behaviors of adults.MethodsWe examined cross-sectional survey data collected at the end of the first year (n = 1161) and second year (n = 1233) of the COVID-19 pandemic by the National Opinion Research Center's nationally representative, probability-based AmeriSpeak panel. Data were analyzed to (1) quantify behavioral changes across pandemic years, (2) examine changes of in-person dating prevalence during year 2, and (3) assess risk perception for acquiring COVID-19 or HIV/STIs through new partnerships during year 2. Weighted percentages were calculated for responses; univariate relationships between demographic characteristics and outcomes were assessed.ResultsPrevalence of new partners for dating remained stable across pandemic years (year 1: n = 1157 [10%]; year 2: n = 1225 [12%]). The prevalence of in-person sex with new partners was also stable (year 1: n = 1157 [7%], year 2: n = 1225 [6%]), marking a decline from a prepandemic estimate (2015-2016: 16%). Partner-seeking experiences varied by age and sexual identity in both years, and by race/ethnicity during year 2. Reports of in-person dating fluctuated throughout year 2, without clear relationship to viral variants. Respondents who met new partners in person during year 2 generally reported greater concern and preparedness for reducing risks associated with HIV/STIs than COVID-19.ConclusionsThe prevalence of US adults seeking new partners for dating or sex remained stable across pandemic years. During future public health emergencies, public health officials are encouraged to offer guidance for reducing disease risks in partnerships, while emphasizing sexual health and providing tailored messaging for persons more susceptible to infection.

The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.Though approximately 1.3 million adults identify as transgender in United States (US) [1], transgender populations remain marginalized and understudied in public health.Epidemiological studies of health outcomes of transgender populations are infrequent, but available data show alarming disparities with respect to sexual health between transgender and cisgender populations [2-4].Additionally, the few studies examining health, and specifically sexual health, of transgender populations are often published in specialty journals.This highlights the important work published by Brown et al. about sexual health of transgender women in this issue of The Journal of Infectious Diseases.Brown et al. greatly advance the field of transgender sexual health research by presenting baseline findings for a multisite prospective cohort study called The Leading Innovation for Transgender Women's Health and Empowerment (LITE).Specifically, Brown et al. investigate the prevalence and factors associated with bacterial sexually transmitted infections (STIs) among a communitybased sample of adult transgender women, stratified by HIV status, in six cities across the eastern and southern US.The study highlights the high prevalence of bacterial STIs among transgender women (16%) and differences in STI prevalence by HIV status (32% among transgender with HIV versus 11% without HIV).These findings suggest unique considerations are needed for transgender women with and without HIV and may help inform tailored interventions to curtail sexual health inequities.Given the sparsity of robust epidemiologic data to inform best practices

Introduction Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (Ng) infections are often asymptomatic; screening increases early detection and prevents disease, sequelae and further spread. To increase Ct and Ng testing, several countries have implemented specimen self-collection outside a clinical setting. While specimen self-collection at home is highly acceptable to patients and as accurate as specimens collected by healthcare providers, this strategy is new or not being used in some countries. To understand how offering at home specimen self-collection will affect testing uptake, test results, diagnosis and linkage to care, when compared with collection in clinical settings, we conducted a systematic literature review and meta-analysis of peer-reviewed studies.Methods We searched Medline, Embase, Global Health, Cochrane Library, CINAHL (EBSCOHost), Scopus and Clinical Trials. Studies were included if they directly compared specimens self-collected at home or in other non-clinical settings to specimen collection at a healthcare facility (self or clinician) for Ct and/or Ng testing and evaluated the following outcomes: uptake in testing, linkage to care, and concordance (agreement) between the two settings for the same individuals. Risk of bias (RoB) was assessed using Cochrane Risk of Bias (RoB2) tool for randomised control trials (RCTs).Results 19 studies, from 1998 to 2024, comprising 15 RCTs with a total of 62 369 participants and four concordance studies with 906 participants were included. Uptake of Ct or Ng testing was 2.61 times higher at home compared with clinical settings. There was a high concordance between specimens collected at home and in clinical settings, and linkage to care was not significantly different between the two settings (prevalence ratio 0.96 (95% CI 0.91–1.01)).Conclusion Our meta-analysis and systematic literature review show that offering self-collection of specimens at home or in other non-clinical settings could be used as an additional strategy to increase sexually transmitted infection testing in countries that have not yet widely adopted this collection method.

Neisseria meningitidis (Nm) and Neisseria gonorrhoeae (Ng) are human pathogens that sometimes occupy the same anatomical niche. Ng, the causative agent of gonorrhea, infects 87 million individuals annually worldwide and is an urgent threat due to increasing drug resistance. Ng is a pathogen of the urogenital tract and may infect the oropharyngeal or rectal site, often asymptomatically. Conversely, Nm is an opportunistic pathogen. While often a commensal in the oropharyngeal tract, it is also the leading cause of bacterial meningitis with 1.2 million cases globally, causing significant morbidity and mortality. Horizontal gene transfer (HGT) is likely to occur between Ng and Nm due to their shared anatomical niches and genetic similarity, which poses challenges for accurate detection and treatment. Routine surveillance through the Gonococcal Isolate Surveillance Project and Strengthening the U.S. Response to Resistant Gonorrhea detected six concerning urogenital Neisseria isolates with contradicting species identification in Milwaukee (MIL). While all six isolates were positive for Ng using nucleic acid amplification testing (NAAT) and matrix-assisted laser desorption/ionization time of flight identified the isolates as Ng, two biochemical tests, Gonochek-II and API NH, classified them as Nm. To address this discrepancy, we performed whole-genome sequencing (WGS) using Illumina MiSeq on all isolates and employed various bioinformatics tools. Species detection analysis using BMScan, which uses WGS data, identified all isolates as Ng. Furthermore, Kraken revealed over 98% of WGS reads mapped to the Ng genome and <1% to Nm. Recombination analysis identified putative HGT in all MIL isolates within the γ-glutamyl transpeptidase (ggt) gene, a key component in the biochemical tests used to differentiate between Nm and Ng. Further analysis identified Nm as the source of HGT event. Specifically, the active Nm ggt gene replaced the Ng pseudogenes, ggt1 and ggt2. Together, this study demonstrates that closely related Neisseria species sharing a niche underwent HGT, which led to the misidentification of species following biochemical testing. Importantly, NAAT accurately detected Ng. The misidentification highlights the importance of using WGS to continually evaluate diagnostic or bacterial identification tests.

Abstract Background Doxycycline, a tetracycline analog, is being considered for use as post-exposure prophylaxis (PEP) to reduce bacterial sexually transmitted infections (STIs) among gay, bisexual, and other men who have sex with men (MSM) and transgender women. Pre-existing tetracycline resistance may contribute to the varied effectiveness of doxycycline in preventing Neisseria gonorrhoeae (GC). We examined trends in tetracycline resistance (TetR) and tetM plasmid-mediated high-level tetracycline resistance (TetHLR) among GC isolates collected from MSM and transgender women through national sentinel surveillance. Methods Genital (urethral, urine, vaginal or endocervical), pharyngeal and rectal GC isolates were collected from MSM and transgender women during 2018–2021 at 12 Enhanced Gonococcal Isolate Surveillance Project (eGISP) and 8 Strengthening the U.S. Response to Resistant Gonorrhea (SURRG) sites. We determined overall prevalence of TetR and TetHLR (minimum inhibitory concentration, MIC ≥2 µg/mL and MIC ≥16 µg/mL, respectively) among MSM and transgender women by anatomic site of infection and described annual trends among MSM. Results Among 10,853 isolates collected from 8,667 MSM, overall TetR prevalence was 31% (genital: 31%, pharyngeal: 32%, rectal: 29%), and annual TetR prevalence decreased during 2018–2021 (Table 1). Overall TetHLR prevalence among MSM was 13% (genital: 13%, pharyngeal: 12%, rectal: 12%) and annual TetHLR prevalence for genital and pharyngeal infections increased during 2018–2021. Among 108 isolates collected from 89 transgender women, overall TetR prevalence was 23% (genital: 19%, pharyngeal: 23%, rectal: 25%) and TetHLR prevalence was 9% (genital: 0%, pharyngeal: 10%, rectal: 12%), though numbers were small. Conclusion Approximately 1/3 of GC isolates collected from MSM and 1/4 of GC isolates collected from transgender women were tetracycline resistant. Prevalence of tetracycline resistance was similar across anatomic sites. Providers should continue to follow recommended screening and treatment guidelines for gonorrhea among persons using doxycycline as STI PEP. Additionally, given high levels of TetHLR, enhanced tetracycline resistance surveillance is needed with implementation of doxycycline as STI PEP. Disclosures All Authors: No reported disclosures

Background Syphilis, a sexually transmitted infection that can cause severe congenital disease when not treated during pregnancy, is on the rise in the United States. Our objective was to identify US counties with elevated risk for emergence of primary and secondary (P&S) syphilis among women of reproductive age. Methods Using syphilis case reports, we identified counties with no cases of P&S syphilis among women of reproductive age in 2017 and 1 case or more in 2018. Using county-level syphilis and sociodemographic data, we developed a model to predict counties with emergence of P&S syphilis among women and a risk score to identify counties at elevated risk. Results Of 2451 counties with no cases of P&S syphilis among women of reproductive age in 2017, 345 counties (14.1%) had documented emergence of syphilis in 2018. Emergence was predicted by the county's P&S syphilis rate among men; violent crime rate; proportions of Black, White, Asian, and Hawaiian/Pacific Islander persons; urbanicity; presence of a metropolitan area; population size; and having a neighboring county with P&S syphilis among women. A risk score of 20 or more identified 75% of counties with emergence. Conclusions Jurisdictions can identify counties at elevated risk for emergence of syphilis in women and tailor prevention efforts. Prevention of syphilis requires multidisciplinary collaboration to address underlying social factors.