SEXUALLY TRANSMITTED DISEASES CDC REPORT IS SHOCKING

CDC Jaw-Dropping News: “Across the nation, at any given time, there are more than 110 million total, 34% of U.S. population, (new and existing) Sexually Transmitted Diseases (STDs) in the U.S.” Making this ‘hidden epidemic’ even worse, some STDs are now “antimicrobial-resistant”.

Historic low case rates, up until recently, have now resurged with extremely dangerous epidemic vengeance.

“It is estimated that there are 20 million new Sexually Transmitted Diseases in the U.S. each year. Half of these are among young people ages 15 to 24 years.

110 million ST Diseased people /(divided by) 323.1 million U.S. population = 34% of U.S. population has new and existing STDs. (CDC) The 2016 population of the U.S. 323.1 million….Flabbergasting!

The above statistics and the following entire report is completely copied from the follwoing CDC reference: [Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2016. Atlanta: U.S. Department of Health and Human Services; 2017. Copyright Information All material contained in this report is in the public domain and may be used and reprinted without special permission; however, citation as to source is appreciated]

“Sexually Transmitted Diseases (STDs) 2016 Sexually Transmitted Diseases Surveillance

Foreword

Sexually transmitted diseases (STDs) have long been an underestimated opponent in the public health battle. A 1997 Institute of Medicine (IOM) report described STDs as, “hidden epidemics of tremendous health and economic consequence in the United States,” and stated that the “scope, impact, and consequences of STDs are under recognized by the public and healthcare professionals.”1 Since well before this report was published, and nearly two decades later, those facts remain unchanged.

It is estimated that there are 20 million new STDs in the U.S. each year, and half of these are among young people ages 15 to 24 years. Across the nation, at any given time, there are more than 110 million total (new and existing) infections.2 These infections can lead to long-term health consequences, such as infertility; they can facilitate HIV transmission; and they have stigmatized entire subgroups of Americans.

Yet not that long ago, gonorrhea rates were at historic lows, syphilis was close to elimination, and we were able to point to advances in STD prevention, such as better chlamydia diagnostic tests and more screening, contributing to increases in detection and treatment of chlamydial infections. That progress has since unraveled. The number of reported syphilis cases is climbing after being largely on the decline since 1941, and gonorrhea rates are now increasing. This is especially concerning given that we are slowly running out of treatment options to cure Neisseria gonorrhoeae. Many young women continue to have undiagnosed chlamydial infections, putting them at risk for infertility.

Beyond the impact on an individual’s health, STDs are also an economic drain on the U.S. healthcare system. Data suggest the direct cost of treating STDs in the U.S. is nearly $16 billion annually.3 STD public health programs are increasingly facing challenges and barriers in achieving their mission. In 2012, 52% of state and local STD programs experienced budget cuts. This amounts to reductions in clinic hours, contact tracing, and screening for common STDs. CDC estimates that 21 local health department STD clinics closed that year.

It is imperative that federal, state, and local programs employ strategies that maximize long-term population impact by reducing STD incidence and promoting sexual, reproductive, maternal, and infant health. The resurgence of syphilis, and particularly congenital syphilis, is not an arbitrary event, but rather a symptom of a deteriorating public health infrastructure and lack of access to health care. It is exposing hidden, fragile populations in need that are not getting the health care and preventive services they deserve. This points to our need for public health and health care action for each of the cases in this report, as they represent real people, not just numbers.

We also need to modernize surveillance to move beyond counting only those cases in persons who have access to diagnosis and treatment, to develop innovative strategies to understand the burden of disease in those who may not access care, and to improve our surveillance systems to collect the information needed to target prevention activities. Further, it will be important for us to measure and monitor the adverse health consequences of STDs, such as ocular and neurosyphilis, pelvic inflammatory disease, ectopic pregnancy, infertility, HIV, congenital syphilis, and neonatal herpes.

It is my hope that a decade from now, we will be reporting on progress, instead of more health inequity in our society. This is our challenge and our call to effectively respond to the information shared in this report.

Gail Bolan, M.D.
Director, Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
U.S. Centers for Disease Control and Prevention

References
1. Eng TR, Butler WT, editors; Institute of Medicine (US). Summary: The hidden epidemic: confronting sexually transmitted diseases. Washington (DC): National Academy Press; 1997. p. 43.
2. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis 2013; 40(3):187–193. DOI: 10.1097/OLQ.0b013e318286bb53. Review.
3. Owusu-Edusei K Jr, Chesson HW, Gift TL, et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008. Sex Transm Dis 2013; 40(3):197–201. DOI: 10.1097/ OLQ.0b013e318285c6d2

Preface

Sexually Transmitted Disease Surveillance 2016 presents statistics and trends for sexually transmitted diseases (STDs) in the United States through 2016. This annual publication is intended as a reference document for policy makers, program managers, health planners, researchers, and others who are concerned with the public health implications of these diseases. The figures and tables in this edition supersede those in earlier publications of these data.

The surveillance information in this report is based on the following sources of data: (1) notifiable disease reporting from state and local STD programs; (2) projects that monitor STD positivity and prevalence in various settings, including the National Job Training Program, the STD Surveillance Network, and the Gonococcal Isolate Surveillance Project; and (3) other national surveys implemented by federal and private organizations.

The STD surveillance systems operated by state and local STD control programs, which provide the case report data for chlamydia, gonorrhea, syphilis, and chancroid, are the data sources of many of the figures and most of the statistical tables in this publication. These systems are an integral part of program management at all levels of STD prevention and control in the United States. Because of incomplete diagnosis and reporting, the number of STD cases reported to the Centers for Disease Control and Prevention (CDC) is less than the actual number of cases occurring in the U.S. population. National summary data of case reports for other STDs are not available because they are not nationally notifiable diseases.

The collection of information on race/ethnicity has been standardized since 1997 in the United States from the Office of Management and Budget (OMB). Following a revision in the National Electronic Telecommunication System for Surveillance (NETSS) implementation guide in April 2008, jurisdictions reporting STD data were to collect race according to the OMB standard categories: American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, Native Hawaiian or Other Pacific Islander, White, and Multirace. While all states and the District of Columbia collect and report data for all STDs in formats compliant with these standards as of 2016, some jurisdictions only recently adopted this standard and used previous standards to report their case data to CDC in past years. Consequently, historical trend and rate data by race/ethnicity displayed in figures and interpreted in this report for 2012–2016 include only those jurisdictions reporting in the current standard consistently each year from 2012 through 2016.

Sexually Transmitted Disease Surveillance 2016 consists of four sections: the National Profile, the Special Focus Profiles, the Tables, and the Appendix. The National Profile section contains figures that provide an overview of STD morbidity in the United States. The accompanying text identifies major findings and trends for selected STDs. The Special Focus Profiles section contains figures and text that describe STDs in selected populations that are a focus of national and state prevention efforts.

The Tables section provides statistical information about STDs at county, metropolitan statistical area, regional, state, and national levels. The Appendix includes information on how to interpret the STD surveillance data used to produce this report, as well as information about Healthy People 2020 STD objectives and progress toward meeting these objectives, Government Performance and Results Act goals and progress toward meeting these goals, and STD surveillance case definitions.

Any comments and suggestions that would improve future publications are appreciated and should be sent to:
Director, Division of STD Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
1600 Clifton Road NE, Mailstop E-02
Atlanta, Georgia 30329-4027
National Overview of STDs, 2016

All Americans should have the opportunity to make choices that lead to health and wellness. Working together, interested, committed public and private organizations, communities, and individuals can take action to prevent sexually transmitted diseases (STDs) and their related health consequences. In addition to federal, state, and local public support for STD prevention activities, local community leaders can promote STD prevention education. Health care providers can assess their patients’ risks and talk to them about testing. Parents can better educate their children about STDs and sexual health. Individuals can use condoms consistently and correctly, and openly discuss ways to protect their health with partners and providers. As noted in the Institute of Medicine report, The Hidden Epidemic: Confronting Sexually Transmitted Diseases, surveillance is a key component of all our efforts to prevent and control these diseases.1

This overview summarizes national surveillance data for 2016 on the three notifiable diseases for which there are federally funded control programs: chlamydia, gonorrhea, and syphilis.

Special Focus Profiles

The Special Focus Profiles highlight trends and distribution of STDs in populations of particular interest to STD and HIV prevention programs in state and local health departments: women and infants, adolescents and young adults, racial and ethnic minority groups, and gay, bisexual, and other men who have sex with men (collectively referred to as MSM).

STDs in Women and Infants

Public Health Impact

Women and their infants are uniquely vulnerable to the consequences of sexually transmitted infections (STI). While individual-level determinants, including high-risk behaviors, contribute to disease transmission and acquisition risk, it is widely accepted that social barriers to STD prevention and control efforts also contribute to infectious disease prevalence. A woman’s relationship status with her male partner, such as the concurrency of the relationship, may be an important predictor of her sexual health.1–3 In addition to social factors such as poverty and lack of access to quality STD services, homelessness or unstable housing may influence a woman’s sexual risk.4 For some women, maintaining the relationship with a partner may take a higher priority than STD risk reduction,5 health, as well as the health of her unborn baby.6,7 A woman can also be placed at risk for STIs through her partner’s sexual encounter with an infected partner. Consequently, even a woman who has only partner may be obliged to practice safer sex, such as using condoms.8

STDs in Adolescents and Young Adults

Public Health Impact

Incidence and prevalence estimates suggest that young people aged 15–24 years acquire half of all new STDs1 and that one in four sexually active adolescent females has an STD, such as chlamydia or human papillomavirus (HPV).2 Compared with older adults, sexually active adolescents aged 15–19 years and young adults aged 20–24 years are at higher risk of acquiring STDs for a combination of behavioral, biological, and cultural reasons. For some STDs, such as chlamydia, adolescent females may have increased susceptibility to infection because of increased cervical ectopy. Cervical ectopy refers to columnar cells, which are typically found within the cervical canal, located on the outer surface of the cervix. Although this is a normal finding in adolescent and young women, these cells are more susceptible to infection. The higher prevalence of STDs among adolescents may also reflect multiple barriers to accessing quality STD prevention and management services, including inability to pay, lack of transportation, long waiting times, conflict between clinic hours and work and school schedules, embarrassment attached to seeking STD services, method of specimen collection, and concerns about confidentiality (e.g., Explanation of Benefits for services received mailed to parents or guardians).3

STDs in Racial and Ethnic Minorities

Public Health Impact

Surveillance data show higher rates of reported STDs among some racial or ethnic minority groups when compared with rates among Whites.1,2 Race and Hispanic ethnicity in the United States are population characteristics that are correlated with other factors affecting health status such as unemployment and low educational attainment.3-5 In 2015, the overall proportion of the United States population living in poverty was 14.7% (or 48.2 million) and decreased slightly from 2014. Although the overall poverty rate is currently stable, many Americans face challenges overcoming inequalities in economic opportunity. The poverty rate in 2015 for Whites was 9.1% (17.7 million), for Blacks it was 24.1% (or 10.0 million), and for Hispanics it was 21.4% (or 13.1 million).3 Those who cannot afford basic life necessities often have trouble accessing and affording quality sexual health services.6 People who struggle financially are often experiencing life circumstances that potentially increase their risk for STDs.6

Access to quality STD prevention and treatment services is key to reducing STD disparities in the United States. Of the estimated 19 million new cases of sexually transmitted infections that occur each year, approximately half of the cases occur among people aged 15–24 years.7 Although the overall proportion of adults without health insurance decreased from 13.3% in 2013 to 9.1% (or 29.0 million) in 2015, many people in the United States continue to lack access to health care.8 Among all races and ethnicities in the United States, Hispanics had the lowest rate of health insurance coverage in 2015 at 83.8%.8

STDs in Men Who Have Sex with Men

Public Health Impact

The incidence of many STDs in gay, bisexual, and other men who have sex with men (collectively referred to as MSM) – including primary and secondary (P&S) syphilis and antimicrobial-resistant gonorrhea – is greater than that reported in women and men who have sex with women only (MSW).1-6 In addition to the negative effects of untreated STDs, elevated STD burden is of concern because it may indicate high risk for subsequent HIV infection. Annual increases in reported STD cases could reflect increased frequency of behaviors that transmit both STDs and HIV (e.g., condomless anal sex), and having an STD increases the risk of acquisition or transmission of HIV.7-14

The relatively high incidence of STD infection among MSM may be related to multiple factors, including individual behaviors and sexual network characteristics.15-17 The number of lifetime or recent sex partners, rate of partner exchange, and frequency of condomless sex each influence an individual’s probability of exposure to STDs.15 However, MSM network characteristics such as high prevalence of STDs, interconnectedness and concurrency of sex partners, and possibly limited access to health care also affect the risk of acquiring an STD.15, 18 Furthermore, experiences of stigma – verbal harassment, discrimination, or physical assault based on attraction to men – are associated with increased sexual risk behavior among MSM.19

Disparities among MSM reflect those observed in the general population, with disproportionate incidence of STDs reported among racial and ethnic minority MSM, MSM of lower socioeconomic status, and young MSM.20-24 The higher burden of STDs among MSM with these characteristics, relative to the general population of MSM, may suggest distinct mixing patterns in their sexual networks, reduced access to screening and treatment, and differential experiences of stigma and discrimination, rather than greater numbers of sexual partners or frequency of condomless sex.15, 21-22, 24-26 Disparities may also be more pronounced for racial and ethnic minority MSM who are also unemployed, young, and/or of lower socioeconomic status.26-27

With the exception of reported syphilis cases, nationally notifiable STD surveillance data do not routinely include information on sexual behaviors and these data are missing for the majority of gonorrhea and chlamydia cases reported to CDC. Therefore, trends in STDs among MSM in the United States are based on findings from sentinel and enhanced surveillance systems. Testing strategies are also evolving to include more extragenital STD screening, which may increase detection of asymptomatic infections. Until recently, testing for gonorrhea and chlamydia in MSM largely focused on detecting urethral infections, which are more likely to be symptomatic than pharyngeal or rectal infections.28

For data reported in this chapter, MSM were defined as men who either reported having one or more male sex partners or who self-reported as gay/ homosexual or bisexual. MSW were defined as men who reported having sex with women only or who did not report the sex of their sex partner, but reported that they considered themselves straight/heterosexual. Data presented in this chapter are derived from the National Notifiable Diseases Surveillance System (NNDSS), the Gonococcal Isolate Surveillance Project (GISP), and the STD Surveillance Network (SSuN), a sentinel and enhanced surveillance project established in 2005 to provide supplemental information on STDs.

Nationally Notifiable Syphilis Surveillance Data

MSM accounted for 80.6% of male P&S syphilis cases with information about sex of sex partners in 2016 (Figure 36). Of MSM P&S syphilis cases, 36.8% were White, 29.1% were Black, and 24.0% were Hispanic (Figure X). Relative to the percentage of the US population that is White (62.3%), Black (12.3%), and Hispanic (17.1%), this represents a significant inequality in the burden of disease for non-White MSM, which was also evident among MSW and women.30 In addition, among MSM P&S syphilis cases with known HIV status in 2016, 47.0% were also reported to be HIV-positive (Figure 41).

In 2016, 44 areas (43 states and the District of Columbia) provided data to classify at least 70% of cases as MSM, MSW, or women. Among these areas, estimated rates of P&S syphilis cases in MSM ranged from 0 cases per 100,000 MSM in Wyoming to 861 cases per 100,000 MSM in Mississippi, with 26 states (59%) estimated to have rates between 200 and 400 cases per 100,000 MSM (Figure Y).

When examining reported P&S syphilis cases over time, 36 states were able to classify at least 70% of reported P&S syphilis cases as MSM, MSW, or women each year during 2012–2016. In these states, cases among MSM increased 16.4% during 2015–2016 and 63.7% during 2012–2016 (Figure 35). However, the percentage of P&S syphilis cases that were attributed to MSM in those states fell slightly in 2012 to 68.6% in 2016.

A description of the methods for estimating MSM population sizes for rate denominators can be found in Section A1.2 of the Appendix. More information about syphilis can be found in the Syphilis section of the National Profile.

Gonococcal Isolate Surveillance Project

GISP is a national sentinel surveillance system designed to monitor trends in antimicrobial susceptibilities of Neisseria gonorrhoeae strains in the United States.31 Overall, the proportion of isolates collected in selected STD clinics participating in GISP that were from MSM increased steadily, from 3.9% in 1989 to 38.1% in 2015 and decreased to 37.8% in 2016 (Figure Z). The reason for this increase over time is unclear, but might reflect changes in the epidemiology of gonorrhea or in health care seeking behavior of men infected with gonorrhea. GISP has demonstrated that gonococcal isolates from MSM are more likely to exhibit antimicrobial resistance than isolates from MSW.3, 4 During 2007–2016, the proportion of isolates with elevated ceftriaxone minimum inhibitory concentrations (MICs) (≥0.125 µg/ ml) was higher in isolates from MSM than from MSW (Figure AA). Information on the antimicrobial susceptibility criteria used in GISP can be found in Section A2.3 of the Appendix. More information about GISP and additional data can be found at https://www.cdc.gov/std/GISP

STD Surveillance Network

SSuN is an ongoing collaboration of state, county and city health departments collecting enhanced provider- and patient-based information among a random sample of reported gonorrhea cases, as well as clinical and behavioral information among all patients attending STD clinics in collaborating jurisdictions.29 Data for 2016 were obtained from 29 STD clinics in SSuN jurisdictions.

Additional information about SSuN found in Section A2.2 of the Appendix.

Gonorrhea, 2010–2015

The number of diagnosed and reported gonorrhea cases among MSM was estimated at the county level based on patient interviews conducted among a random sample of all cases reported to six health departments continuously collaborating in the STD Surveillance Network between January 2010 and June 2013, and again July through December 2015. Estimates of the size of the MSM population in each county were obtained from published estimates and used to estimate the incidence of reported gonorrhea by year among MSM in the six collaborating SSuN sites.32, 33 Estimated gonorrhea incidence among MSM increased 151.0% across the study period from 1,368.6 cases per 100,000 MSM in 2010 to 3,434.7 cases per 100,000 MSM in 2015 (Figure BB). Over the same time period, estimated gonorrhea rates among women and MSW also increased, but by a significantly smaller proportion (39.8% and 31.7%, respectively).33

Gonorrhea and Chlamydia in STD Clinics, 2016

In 2016, 25,880 unique MSM presented for care in the 29 STD clinics in nine SSuN jurisdictions. In total, 22,418 unique MSM were tested for urogenital gonorrhea and/ or chlamydia (22,404 for gonorrhea, 22,152 for chlamydia). The proportion of men tested for urogenital infections was similar across SSuN jurisdictions, though the proportion who tested positive (positivity) varied by SSuN jurisdiction (Figure CC). In general, urogenital gonorrhea positivity was higher than urogenital chlamydia positivity (except in Massachusetts and Multnomah County); median site-specific positivity for gonorrhea was 8.8% (range by jurisdiction: 2.8%–15.3%) and for chlamydia was 6.3% (range: 4.8%–10.3%).

A total of 17,489 unique MSM were tested for rectal gonorrhea and/or chlamydia in 2016 (17,467 for gonorrhea, 17,445 for chlamydia) (Figure DD). In most jurisdictions, similar proportions of MSM were tested for rectal gonorrhea and chlamydia, likely reflecting use of dual diagnostic tests. Compared to urogenital testing, a lower proportion of MSM were tested for rectal infection. The median site-specific positivity for rectal gonorrhea was 15.9% (range: 9.9%–30.3%) and for rectal chlamydia was 17.2% (range: 12.3%–20.0%).

During 2016, 15,680 MSM were tested at the oropharyngeal site for gonorrhea (Figure EE). The median site-specific positivity for oropharyngeal gonorrhea was 8.8% (range by jurisdiction: 1.0%–16.1%). Oropharyngeal chlamydia data are not shown as some of the SSuN jurisdictions do not offer routine testing for oropharyngeal chlamydia infections.

HIV Status and STDs in STD Clinics, 2016

Among HIV-positive MSM visiting SSuN STD clinics in 2016, urogenital chlamydia positivity was 8.6% and urogenital gonorrhea positivity was 14.0% (compared to 6.7% and 9.0%, respectively, among HIV-negative MSM) (Figure FF). Among HIV- positive MSM, 7.4% were diagnosed with P&S syphilis compared to 3.1% of HIV-negative MSM. Percentages represent the overall average of the mean value by jurisdiction.

Summary

The number of reported P&S syphilis cases among MSM continued to rise in 2016 and the majority of P&S syphilis cases remained among MSM. Estimated rates of reported gonorrhea incidence increased among MSM in SSuN jurisdictions in recent years. Furthermore, the proportion of GISP isolates with elevated MICs to antimicrobials currently used to treat gonorrhea was higher among MSM than among MSW.

Beyond STD burden in the general MSM population, the data indicated heterogeneity of STD prevalence among MSM according to geography, race and ethnicity, and HIV status. State-specific P&S syphilis rate estimates among MSM varied from 0 to over 800 cases per 100,000 MSM and the prevalence of diagnosed STDs among MSM differed by SSuN jurisdiction. Reported P&S syphilis was disproportionately prevalent among Black and Hispanic MSM, and data from MSM who attended SSuN clinics suggested that P&S syphilis, urogenital gonorrhea, and urogenital chlamydia may be more prevalent among MSM living with diagnosed HIV infection than among HIV-negative MSM.

Also see Sexually Transmitted Disease and HIV Screening: http://www.cappaa.com/std-and-hiv-screening

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[Unsafe oral sex is causing a rise in cases of untreatable ‘super-gonorrhoea’ by Alison Millington Jul. 7, 2017, Business Insider]

“The rate of gonorrhea is much higher in men who have sex with men (MSM) than in heterosexuals. Because of unique behavioral characteristics, asymptomatic sites of infection, mainly the pharynx, are principal drivers of gonorrhea prevalence in men who have sex with men. On the basis of this observation, we call for interventions.

‘The rates of sexually transmitted infections are rising rapidly in men who have sex with men (MSM) (1). Gonorrhea is of particular concern because rising rates will increase the probability of antimicrobial drug resistance (2). In response, the Centers for Disease Control and Prevention has recommended reducing the prevalence of gonorrhea as a key strategy to mitigate against antimicriobial resistance (2). However, reducing prevalence requires understanding why gonorrhea is so common in MSM. We suggest that specific sexual practices of MSM result in them having a high prevalence of asymptomatic infection in particular anatomic sites and that these infections are the primary drivers of transmission (3).

“In heterosexuals, the primary sites of gonorrheal infection are the urethra in men and cervix in women (4). Most heterosexual men with urethral infection become symptomatic and quickly seek healthcare (after a few days) (5). About half of women are asymptomatic, and thus they take longer to seek healthcare than men (5,6).

In MSM, 3 sites are commonly infected: pharynx, rectum, and urethra (7). In a Seattle clinic, the proportion of MSM with pharyngeal gonorrhea was 6.5%, rectal gonorrhea 9.7%, and urethral gonorrhea 5.5% (7). Almost all urethral infections were symptomatic (96%), but most pharyngeal and rectal infections were asymptomatic. Most pharyngeal or rectal infections (58%) were not associated with urethral infection (7).

“An additional factor favoring the persistence of gonorrhea-infected sites in MSM is their lower rate of partner notification compared with heterosexuals (8). This behavior creates a scenario in which men with pharyngeal or rectal gonorrhea often go untreated, even if they transmit an infection to the urethra of a sex partner. This longer duration of infectiousness translates into a higher reproductive rate for gonorrhea in MSM compared with heterosexuals, independent of the number of sexual partners.

“Determining the key drivers of the reproductive rate for gonorrhea in MSM involves characterizing transmission between anatomic sites, which requires quantifying the site-specific sexual practices of MSM. Studies assessing the most recent sexual acts among MSM show that most have kissed (75%), practiced mutual masturbation (64%), or had oral sex (77%) (9); oro-anal sex (25%) and penile-anal sex (35%) are less common (9). In contrast, in heterosexuals, penile-vaginal sex occurs in 95% of most recent sexual acts; therefore, most sexual acts between heterosexuals in which gonorrhea transmission occurs will lead to symptomatic infections that prompt them to seek treatment (9,10).

“One behavior that may be important for transmitting gonorrhea that has not been well studied is kissing (11). Kissing has not been asked about in any national sex surveys and only occasionally in clinical sexually transmitted infection studies (9). We were unable to find any published studies on kissing partners in which sex did not occur (termed kissing-only partners) either in heterosexuals or MSM, besides the data we recently presented (3).

“We surveyed 1,151 MSM attending our clinic in 2016 and found a mean of 3.7 kissing-only partners and a mean of 4.5 kissing and sex partners in the previous 3 months (3) (Technical Appendix[PDF – 331 KB – 4 pages]Figure 1). Kissing-only partners were much more common among younger MSM, who are at substantially higher risk for gonorrhea than older MSM (3,12). The reason for this preponderance of gonorrhea in young MSM is currently unknown but is consistent with and could be explained by kissing being an important transmission route.

“We determined what we consider to be the accepted transmission routes for gonorrhea by anatomic site in MSM (Figure, panel A), although one should acknowledge that no studies have reported site-specific gonorrhea transmission between MSM partners. Major textbooks and published studies indicate the penis is key to gonorrhea transmission between men (Figure, panel A) (4). Studies suggest that urethral infection is largely acquired from unprotected anal sex, with perhaps one third of cases acquired by receiving oral sex (Technical Appendix[PDF – 331 KB – 4 pages] Table).

“Relatively little research has been done on gonorrhea transmission not involving the penis. Some observational studies support the potential transmission of gonorrhea between the pharynx and rectum, although this is not consistently described as a route of transmission in major textbooks (4). Studies have shown that receptive oro-anal sex has been associated with rectal infection, and oro-anal sex has been associated with pharyngeal gonorrhea (Technical Appendix[PDF – 331 KB – 4 pages] Table).

“We propose new models of gonorrhea transmission: throat-to-throat transmission through kissing and throat-to-anus transmission (and vice versa) through oro-anal sex (Figure, panel B). We propose that transmission to the penis occurs but contributes little to the reproductive rate because it is present there a short time relative to the other anatomic sites.

“Unfortunately, there are few studies on gonorrhea transmission between the throats of sex partners to support or refute our suggestion. We did, however, find case reports of transmission through kissing from >40 years ago, and kissing is a well-recognized transmission route for other Neisseria species (11,13). In a matched, case–control study of 15- to 19-year-olds, intimate kissing with multiple partners was associated with an odds ratio of 3.7 for meningococcal disease (13). One of the few cohort studies in MSM to ask about kissing showed it to be significantly associated with pharyngeal gonorrhea (Technical Appendix[PDF – 331 KB – 4 pages] Table), but few studies have examined kissing behavior.

“The frequent detection of gonorrhea in the saliva of men with pharyngeal infection suggests saliva likely plays a role in gonorrhea transmission (14). Saliva is central to oral sex, oro-anal sex, and even penile-anal sex; saliva is commonly used as lubricant (14).

“Transmission models for gonorrhea in MSM should be consistent with current site-specific prevalence and incidence. We estimated prevalence and incidence of pharyngeal and anal gonorrhea from 3,034 MSM attending a Seattle clinic on the basis of site-specific duration data (Technical Appendix[PDF – 331 KB – 4 pages] Figure 2) (7,15). The incidence of urethral gonorrhea was ≈5.5/100 person-years, and we estimated the prevalence among MSM to be low (0.24%) because the infections are often of short duration due to their treatable and symptomatic nature. It is difficult to see how, even with frequent changes in sex partners, the estimated incidence of pharyngeal infection (26/100 person-years) could arise from urethral infection, given its low prevalence.

“There are several implications if our model of transmission is correct. First, a preventive approach using condoms will not work because, unlike heterosexuals, the penis is not responsible for most gonorrhea transmission among MSM. Second, the screening that is advocated annually for MSM would need to be much more frequent to reduce the disease reproductive rate. MSM taking pre-exposure prophylaxis for HIV are screened every 3 months; this screening frequency might be sufficient to reduce gonorrhea prevalence. Third, our model suggests reducing pharyngeal duration and transmissibility is needed for gonorrhea control, and we call for suggestions of interventions that might achieve this. One approach we are investigating is an antibacterial mouthwash (clinical trial no. ACTRN12616000247471), following up some of our earlier data.

“Finally, it is possible that the rapidly rising rates of syphilis in MSM may share similarities with gonorrhea transmission. Syphilis is also uncommon in heterosexuals and more likely to be asymptomatic in MSM with anal infection. When interventions are being tested for their effects on gonorrhea transmission, investigators might consider including syphilis as an outcome.
Dr. Fairley is a professor of public health and Director of the Melbourne Sexual Health Centre. His research interest is the control of sexually transmitted infections.

[CDC>EID journal>Past Issues>January 2017, Volume 23, Number 1—January 2017, Frequent Transmission of Gonorrhea in Men Who Have Sex with Men, Christopher K. Fairley et al Health Centre, Melbourne, Victoria, Australia (C.K. Fairley, J.S. Hocking, et al); Monash University, Melbourne (J.S. Hocking)]

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