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Background. Encephalitis is a severe neurological syndrome associated with significant morbidity and mortality. The California Encephalitis Project (CEP) enrolled patients for more than a decade. A subset of patients with acute and fulminant cerebral edema was noted. Methods. All pediatric encephalitis patients with cerebral edema referred to the CEP between 1998 and 2012 were reviewed. A case definition was developed for acute fulminant cerebral edema (AFCE) that included the CEP case definition for encephalitis and progression to diffuse cerebral edema on neuroimaging and/or autopsy, and no other recognized etiology for cerebral edema (eg, organic, metabolic, toxin). Prodromic features, demographic and laboratory data, neuroimaging, and outcomes were compared with non-AFCE encephalitis cases. Results. Of 1955 pediatric cases referred to the CEP, 30 (1.5%) patients met the AFCE case definition. The median age for AFCE and non-AFCE cases was similar: 8.2 years (1-18 years) and 8.0 years (0.5-18 years), respectively. Asian-Pacific Islanders comprised a larger proportion of AFCE cases (44%) compared with non-AFCE cases (14%, P < .01). AFCE cases often had a prodrome of high fever, vomiting, and profound headache. Mortality among AFCE patients was significantly higher than among non-AFCE patients (80% vs 13%, P < .01). A confirmed etiology was identified in only 2 cases (enterovirus, human herpes virus type 6), while 10 others had evidence of a respiratory pathogen. Conclusions. AFCE is a recently recognized phenotype of encephalitis with a high mortality. AFCE may be triggered by common pediatric infections. Here, we propose a case definition.

An HIV-negative man with pharyngeal gonorrhea had a positive test-of-cure (nucleic acid amplification test) result 7 days after treatment with ceftriaxone/azithromycin. Neisseria gonorrhoeae Multi-Antigen Sequencing Type 1407 and mosaic pen A (XXXIV) gene were identified in the test-of-cure specimen, and culture was negative. Retreatment with ceftriaxone 500 mg intramuscularly plus azithromycin 2 g orally yielded a negative test-of-cure result.

BACKGROUND:The association between area-based social factors and sexually transmitted diseases has been demonstrated in numerous studies. Such associations have not previously been explored for their potential to quantify likelihood of higher transmission of gonorrhea in small geographic areas.METHODS:Aggregate census tract-level sociodemographic factors in 4 domains (demographics, educational attainment, household income, and housing characteristics) were merged with female gonorrhea incidence data from 113 counties in 10 US states. Multivariate models were constructed, and a tract-level composite gonorrhea risk index was calculated. This composite risk index was validated against gonorrhea incidence among women from 2 independent states.RESULTS:Seven tract-level factors were found to be most strongly correlated with female gonorrhea incidence: educational attainment, proportion of female headed households, annual household income below US $20,000, proportion of population non-Hispanic black, proportion of housing units currently vacant, proportion of population reporting moving in last year, and proportion of households that are nonfamily units. Composite index was highly correlated with female gonorrhea in the study area and validated with independent data.CONCLUSIONS:Social factors predict gonorrhea incidence at the census tract level and identify small areas at risk for higher morbidity. These data may be used by health departments and health care practices to develop geographically based disease prevention and control efforts. This is especially useful because gonorrhea incidence data are not routinely available below the county level in many states.

Background Declining susceptibility of Neisseria gonorrhoeae to available antimicrobial agents has prompted repeated updates of the Centers for Disease Control and Prevention (CDC) treatment guidelines. The only regimen currently recommended as first-line treatment is dual therapy consisting of an intramuscular dose of ceftriaxone together with azithromycin or doxycycline. The objective of this analysis is to identify how adherence to the CDC guidelines varies by clinical practice setting. Methods A geographically representative random sample of N. gonorrhoeae cases reported from 2009 to 2011 was analyzed. Weighted generalized linear models were fit to calculate cumulative incidence ratios for receipt of non-recommended treatment regimen in relation to clinical practice setting, adjusted for age, race, and whether or not the participant was a man who has sex with men. Results Data from 3178 participants were available for analysis. Overall, 14.9% (weighted) of participants received non-recommended treatment. Among participants with gonorrhea identified by surveillance data as having received non-recommended treatment, the largest proportions were treated at private physicians’ offices or health maintenance organizations (34.7% of participants receiving non-recommended treatment), family planning facilities (22.3%), and emergency departments/urgent care centers (12.8%). Conclusions Barriers to adherence to the CDC treatment guidelines for gonorrhea seem to be experienced in a variety of clinical practice settings. Despite only moderate rates of nonadherence, interventions targeting private physicians/health maintenance organizations and family planning facilities may produce the largest absolute reductions in guideline-discordant treatment.

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.

Background Replacing oral treatments with ceftriaxone is a central component of public health efforts to slow the emergence of cephalosporin-resistant Neisseria gonorrhoeae in the United States; US gonorrhea treatment guidelines were revised accordingly in 2010. However, current US gonorrhea treatment practices have not been well characterized. Methods Six city and state health departments in Cycle II of the STD Surveillance Network (SSuN) contributed data on all gonorrhea cases reported in 101 counties and independent cities. Treatment data were obtained through local public health surveillance and interviews with a random sample of patients. Cases were weighted to adjust for site-specific sample fractions and for differential nonresponse by age, sex, and provider type. Results From 2010 to 2012, 135,984 gonorrhea cases were reported in participating areas, 15,246 (11.2%) of which were randomly sampled. Of these, 7,851 (51.5%) patients were interviewed. Among patients with complete treatment data, 76.8% received ceftriaxone, 16.4% received an oral cephalosporin, and 6.9% did not receive a cephalosporin; 51.9% of persons were treated with a regimen containing ceftriaxone and either doxycycline or azithromycin. Ceftriaxone treatment increased significantly by year (64.1% of patients in 2010, 79.3% in 2011, 85.4% in 2012; P = 0.0001). Ceftriaxone use varied widely by STD Surveillance Network site (from 44.6% to 95.1% in 2012). Conclusions Most persons diagnosed as having gonorrhea between 2010 and 2012 in the United States received ceftriaxone, and its use has increased since the release of the 2010 Centers for Disease Control and Prevention STD Treatment Guidelines.

Public health officials have cited methamphetamine control as a tool with which to decrease HIV and other sexually transmitted infections, based on previous research that finds a strong positive correlation between methamphetamine use and risky sexual behavior. However, the observed correlation may not be causal, as both methamphetamine use and risky sexual behavior could be driven by a third factor, such as a preference for risky behavior. We estimate the effect of methamphetamine use on risky sexual behavior using monthly data on syphilis diagnoses in California and quarterly data on syphilis, gonorrhea, and chlamydia diagnoses across all states. To circumvent possible endogeneity, we use a large exogenous supply shock in the US methamphetamine market that occurred in May 1995 and a later shock stemming from the Methamphetamine Control Act, which went into effect in October 1997. While the supply shocks had large negative effects on methamphetamine use, we find no evidence that they decreased syphilis, gonorrhea, or chlamydia rates. Our results have broad implications for public policies designed to decrease sexually transmitted infection rates.

This study evaluated the safety and security impact, feasibility, and cost of a program to provide condoms to inmates. A 1-year pilot study of wall-mounted condom dispensing machines in one California state prison compared preand post-intervention rates of penal code violations related to sexual misconduct, contraband, controlled substances, and violence. The rates of penal code violations were unchanged or decreased compared to the pre-pilot year. Discreetly located condom dispensers were vandalized less frequently than those in plain view (p < .05). Distributing condoms using the pilot model would cost less than $2 per inmate annually. Results suggest that the use of discreetly located dispensing machines is an acceptable, feasible, low-cost option to prevent the transmission of sexually transmitted diseases and poses no safety or security risk in a typical medium-security prison setting.

In Brief Background The association between area-based social factors and sexually transmitted diseases has been demonstrated in numerous studies. Such associations have not previously been explored for their potential to quantify likelihood of higher transmission of gonorrhea in small geographic areas. Methods Aggregate census tract-level sociodemographic factors in 4 domains (demographics, educational attainment, household income, and housing characteristics) were merged with female gonorrhea incidence data from 113 counties in 10 US states. Multivariate models were constructed, and a tract-level composite gonorrhea risk index was calculated. This composite risk index was validated against gonorrhea incidence among women from 2 independent states. Results Seven tract-level factors were found to be most strongly correlated with female gonorrhea incidence: educational attainment, proportion of female headed households, annual household income below US $20,000, proportion of population non-Hispanic black, proportion of housing units currently vacant, proportion of population reporting moving in last year, and proportion of households that are nonfamily units. Composite index was highly correlated with female gonorrhea in the study area and validated with independent data. Conclusions Social factors predict gonorrhea incidence at the census tract level and identify small areas at risk for higher morbidity. These data may be used by health departments and health care practices to develop geographically based disease prevention and control efforts. This is especially useful because gonorrhea incidence data are not routinely available below the county level in many states. Seven widely available social determinants of health were found to predict the incidence of gonorrhea among women at the census tract level. Determinants found to be correlated with gonorrhea among women at the census tract include proportion of households headed by women, proportion of the population that is non-Hispanic black, proportion of the adult female population with less than a high school education, proportion of households with less than US $20,000 annual income, proportion of persons reporting having moved in the previous year, proportion of housing units that are vacant, and proportion of households that are nonfamily households.

The presenting symptoms in the LHF group were more severe than those in the LP group. Within the LHF group there was a greater proportion of symptoms indicating haemodynamic compromise, including collapse and cardiac arrest. This suggests that the passengers presenting to Hillingdon hospital with PE following a long haul flight may only be the “tip of the iceberg” in terms of total flight associated PE. Patients with less severe symptoms or those with delayed onset of symptoms may present later to their local hospitals.

Surveillance is, by definition, information intensive, in that its essential function is to gather information about the health of the public. Increasingly sophisticated and user-friendly information technology tools are becoming more widely available for use in surveillance. This chapter focuses on the most widely used statistical software packages for analysis of epidemiologic data. It includes discussions of selected data analysis software packages that are available to the end-users at no cost including Epi Info and R. In addition, the chapter provides selected examples of data resources that are available for infectious disease surveillance.

Twenty of 37 gonorrhea cases identified during an outbreak were diagnosed at one health care organization that used an out-of-state laboratory. The results were transmitted into electronic medical records without provider notification. Delays in treatment and reporting were identified. Systems should be implemented to ensure provider notification of electronic laboratory results.

We evaluated Neisseria gonorrhoeae Etest minimum inhibitory concentrations (MICs) relative to agar dilution MICs for 664 urethral isolates for ceftriaxone (CRO) and azithromycin (AZM), 351 isolates for cefpodoxime (CPD) and 315 isolates for cefixime (CFM). Etest accurately determined CPD, CFM and AZM MICs, but resulted in higher CRO MICs.

We used data from the STD Surveillance Network to estimate HIV testing among patients being tested or treated for gonorrhea. Of 1,845 gonorrhea-infected patients identified through nationally notifiable disease data, only 51% were tested for HIV when they were tested or treated for gonorrhea. Among the 10 geographic sites in this analysis, the percentage of patients tested for HIV ranged from 22–63% for men and 20–79% for women. Nearly 33% of the un-tested patients had never been previously HIV-tested. STD clinic patients were more likely to be HIV-tested than those in other practice settings.

Background Associations between social factors and health outcomes have been established for many diseases, including gonorrhoea. Inequalities in gonorrhoea are particularly pronounced; the incidence for non-Hispanic Blacks is 17 times the incidence for non-Hispanic Whites. A gap exists in the literature on how social determinants for this population can be used to target STD interventions. Methods Health departments from 10 diverse states geocoded female gonorrhoea case reports from 2009–2011 to the census tract. We calculated three-year gonorrhoea incidence rates among females for 11,832 tracts in the study area. Tract-level social determinants were obtained from the American Community Survey. Female rates were used to preclude confounding by the unknown proportion of men-who-have-sex-with-men among male cases. Tracts were stratified as above or below the county-level mean proportion of non-Hispanic Black residents to minimise interactions between race and other factors, and subsequent analyses were limited to the stratum with a higher proportion of blacks (N = 4,345). Using hierarchical models and logistic regression, associations between female gonorrhoea incidence, household income, education and housing characteristics were examined. Factors found to be associated with gonorrhoea incidence were used to construct tract-level gonorrhoea risk indices. Results The mean tract-level female incidence rate was 194/100,000 (range, 0–2,836) in this stratum. Gonorrhea incidence was correlated with: proportion of households with annual income below $20,000 (β = 0.7089, P < 0.0001), housing vacancy rate (β = 0.5519, p < 0.0001) and proportion of population with less than high school education (β = 0.3206, p < 0.0001). Risk indices based on these factors correctly predicted 77.3% of tracts with incidence in the highest quartile in this stratum while excluding 58.9% of tracts with lowest incidence. Conclusions Area-based social factors provide more specific criteria than race alone and may be useful for better targeting disease prevention activities to areas at highest risk for gonorrhoea incidence, especially where street-level address information on reported cases is unavailable.