Letter to the Editor
To the Editors
The US Preventive Services Task Force recommends screening all sexually active women for gonorrhea if they are young or have other individual or population risk factors for infection.1 Individual risk factors depend on the local epidemiology of gonorrhea, and population risk factors include residence in urban communities and communities with high rates of poverty.1,2 Gonorrhea rates are higher among adolescents. In 2011, the US rates of reported cases of gonorrhea per 100,000 populations were 98.7 in men and 108.9 in women; among individuals aged 15 to 19 years, these rates were 248.6 in men and 556.5 in women.3 The state of Louisiana reported 545.4 and 1242.0 gonorrhea cases per 100,000 populations in men and women aged 15 to 19 years.3
In 2010, 97% of adolescents aged 14 to 17 years were enrolled in US schools.4 Although the US Preventive Services Task Force does not recommend screening men for gonorrhea for insufficient evidence,1 available evidence clearly makes Louisiana adolescent boys and girls candidates for gonorrhea screening,2,3 and schools are an ideal place to find adolescents.4 From school years 1996 to 1997 to 2004 to 2005, between 1545 (1996–1997) and 6078 (1999–2000) 9th through 12th grade students in New Orleans public schools (age, 14–24 years; mean, 16.7 years; median, 17.0 years) provided urine specimens that were tested for both chlamydia and gonorrhea (LCx Chlamydia trachomatis Assay and LCx Neisseria gonorrhoeae Assay [Abbott Park, IL] until 1999–2000; BDProbeTec ET C. trachomatis and N. gonorrhoeae Amplified DNA Assays [Sparks, MD] thereafter) in a school-wide chlamydia screening program.5
The average 9-year gonorrhea positivity was 1.2% (184/14,988; 95% confidence interval [CI], 1.1%–1.4%) in men and 3.3% (478/14,343; 95% CI, 3.0%–3.6%) in women (P < 0.001). Positivity ranged between 0.8% (24/3084; 1999–2000) and 2.0% (23/1179; 2002–2003) in men and between 2.2% (42/1944; 1997–1998) and 4.8% (67/1399; 2000–2001) in women. In sex-specific multivariate logistic regression analyses with age, race, laboratory assay, school year, and chlamydia test results as covariates (Table 1), gonorrhea positivity in men was significantly associated with age (P = 0.01) and with chlamydia positivity (P < 0.001). In women, gonorrhea positivity was associated significantly only with chlamydia positivity (P < 0.001). The odds of gonorrhea positivity increased in aging women (adjusted odds ratio [AOR], 1.08; 95% CI, 1.00–1.16; P = 0.05) and in African American men (AOR, 2.55; 95% CI, 0.35–18.45; P = 0.36) and women (AOR, 5.59; 95% CI, 0.78–40.14; P = 0.09), although the increases did not achieve significance levels of P < 0.05, partly because of the relatively lower baseline gonorrhea positivity among students who were tested. Gonorrhea positivity did not vary significantly over time (P > 0.16).
The lack of significant differences in gonorrhea positivity between 1996 and 2005 reflected endemic and stable prevalence of gonorrhea among New Orleans school-aged adolescents. The morbidity associated with N. gonorrhoeae,6 its role in facilitating sexual transmission of HIV,7 and emerging resistance to antibiotics used against it8 dictate that its public health impact and population distributions be continuously monitored. Diagnostic tests that simultaneously detect C. trachomatis and N. gonorrhoeae in the same specimen9 would allow chlamydia screening programs to detect N. gonorrhoeae in populations that otherwise would not be tested for gonorrhea for lack of clear gonorrhea screening guidelines.
Musheni Nsa, MD
Department of Pediatrics
Our Lady of the Lake Regional
Baton Rouge, LA
Ngozi C. Mezu-Patel, MD
David H. Martin, MD
Stephanie N. Taylor, MD
M. Jacques Nsuami, MD, MPH
Department of Medicine
Louisiana State University Health
New Orleans, LA
1. U.S. Preventive Services Task Force. Screening for gonorrhea: Recommendation statement. Ann Fam Med 2005; 3: 263–267.
2. Cohen D, Spear S, Scribner R, et al. “Broken windows” and the risk of gonorrhea. Am J Public Health 2000; 90: 230–236.
3. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta: U.S. Department of Health and Human Services, 2012.
4. Snyder TD, Dillow SA. Digest of Education Statistics 2011 (NCES 2012–001). Washington, DC: National Center for Education Statistics, Institute of Education Sciences, U.S. Department of Education, 2012.
5. Nsuami MJ, Nsa M, Brennan C, et al. Chlamydia positivity in New Orleans public high schools, 1996–2005: Implications for clinical and public health practices. Acad Pediatr. In press.
6. Litt IF, Edberg SC, Finberg L. Gonorrhea in children and adolescents: A current review. J Pediatr 1974; 85: 595–607.
7. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 75: 3–17.
8. Lewis DA. The gonococcus fights back: Is this time a knock out? Sex Transm Infect 2010; 86: 415–421.
9. van der Pol B, Ferrero DV, Buck-Barrington L, et al. Multicenter evaluation of the BDProbeTec ET system for detection of Chlamydia trachomatis
and Neisseria gonorrhoeae
in urine specimens, female endocervical swabs, and male urethral swabs. J Clin Microbiol 2001; 39: 1008–1016.