Lab Matters Spring 2020 - Page 18

FROM THE BENCH Strengthening United States Response to Resistant Gonorrhea in Wisconsin by Lori Amsterdam, MPH, epidemiology coordinator, Wisconsin Division of Public Health Bureau of Communicable Diseases; and Sanjib Bhattacharyya, PhD, laboratory director and special deputy health commissioner, City of Milwaukee Health Department Background Gonorrhea (GC) is the second most commonly reported notifiable disease in the United States, with more than 500,000 reported cases of gonorrhea per year and an estimated 1.14 million new infections that may actually occur each year. Of these infections, half are found to be resistant to at least one antibiotic. Gonorrhea control relies on jurisdictional ability to detect and treat each case of gonorrhea quickly and effectively with the right antibiotic. In 2013, the US Centers for Disease Control and Prevention (CDC) released the first report to look at the burden and threats posed by antibiotic-resistant gonorrhea (ARGC) as one of the three most urgent threats of its kind in the country. As outlined in the National Action Plan for Combating Antibiotic Resistant Bacteria (CARB), the US Centers for Disease Control and Prevention’s Division of STD Prevention (DSTDP) began supporting new and continuing multipronged activities in fiscal year 2016 to slow the development and spread of ARGC. Surveillance for Antibiotic Resistant Gonorrhea In 2016, the Wisconsin Department of Health Services, Division of Public Health, STD Control Section (WI DPH STD), in collaboration with the Milwaukee Health Department and Laboratory (MHDL), competed successfully as one of nine national sites to receive DSTDP CARB funding through the Epidemiology and Laboratory Capacity (ELC) initiative for Strengthening the United States Response to Resistant Gonorrhea (SURRG). To better understand the epidemiologic factors that contribute to resistant gonorrhea, SURRG surveillance activities have been implemented in these nine, high GC morbidity jurisdictions. Activities include collection of specimens for culture and antibiotic susceptibility testing (AST) using Etest, a rapid method for detecting non-susceptible isolates. Two of the four regional laboratories in the Antibiotic Resistant Lab Network (AR Lab Network) are assigned to receive shared SURRG GC isolates from the MHDL to perform confirmatory AST on a broad panel of antibiotics currently or previously recommended for gonorrhea treatment including but not limited to azithromycin, ceftriaxone, cefixime and gentamycin. SURRG project staff in Wisconsin also focus efforts to document additional clinical, laboratory and enhanced field investigation data elements, confirm infection resolution in patient cases, test and treat partners and identify local social networks to assess local transmission dynamics and contribute to the development of national guidance and recommendations for an effective public health response to resistant gonorrhea. MHDL also serves as a sentinel site in Wisconsin for the Gonococcal Isolate Surveillance Project (GISP). This project is limited to sharing isolates and AST data from the MHDL with CDC for the first 25 gonorrhea isolates identified each month among males attending the MHD STD clinic, which also serves as the categorical STD SURRG clinic in Milwaukee. Additional authors Raquel Gomez, M(ASCP)CM, Microbiologist, City of Milwaukee Health Department Josh Weiner, MS, laboratory data specialist, City of Milwaukee Health Department Dhana Shrestha, MPH, epidemiology analyst, STD Control Section, Wisconsin Division of Public Health Bureau of Communicable Diseases Manjeet Khubbar, M.Sc., lead microbiologist, City of Milwaukee Health Department Helen Hermus, MS, BSN, RN, public health nurse supervisor, City of Milwaukee Health Department Figure 1: Milwaukee SURRG Clinic Alert and non-Alert Isolates by Month and Specimen Type Top: Total non-alert and alert isolates by anatomical site of infection April 2017-December 2019. Darker bars: alert isolates, Lighter bars: non-alerts. Percent alert by specimen type shown alongside each bar. Bottom: Alert isolates identified in SURRG clinics by month July 2017-December 2019. AZI: Azithromycin; AZI-QS: Azithromycin Quick Send (MIC >16); CFX: Cefixime; CRO: Ceftriaxone John Pfister, MS, epidemiology consultant for Health Care Education and Training (HCET) Trivikram Dasu, PhD, D(ABMLI), deputy laboratory director, City of Milwaukee Health Department 16 LAB MATTERS Spring 2020 PublicHealthLabs @APHL APHL.org