I have a power point due. I need proofreading and someone who is an expert on apa. That is where all my points are deducted from.

I have a power point due. I need proofreading and someone who is an expert on apa. That is where all my points are deducted from.
SPECIAL TOPICS IN WOMEN’S HEALTH 50 www.JAAPA.com Volume 31 Number 2 February 2018 T he CDC reports an estimated 20 million new sexually transmitted infections (STIs) in the United States each year, half in young people ages 15 to 24 years. This number is the highest ever reported. 1,2 The CDC’s director of STD prevention, Gail Bolan, MD, laments the unravelling of previously successful initiatives to reduce infection. Access to healthcare is limited in some communities and for some patients, so clinicians must make every effort to identify the often-asymptom- atic presence of STIs. Cervicitis is a common sign of STI and delay in diagnosis can have serious sequelae and add to the already heavy burden of disease. Because of better understanding of the cause and progression of cervical cancer, new guidelines recommend routine gynecologic screening examinations at less frequent intervals than previously. 3 A consequence of this may be that asymptomatic, indolent genital infections may be missed. These infections can ascend and cause seri- ous pathology as well as increase the risk of HIV transmis- sion. 4 When patients’ sexual partners also are affected, the economic and emotional burden of this condition increases. Noninfectious causes of cervicitis are usually chronic and include mechanical or chemical trauma, systemic in ammatory disease (such as Behçet syndrome), radiation therapy, and malignancy. 5 Clinicians need to appropriately and sensitively question patients on their risk factors for STI and any symptoms, and not be hesitant to perform diagnostic examinations and assessments if indicated. MYCOPLASMA GENITALIUM: AN EMERGING ISSUE M. genitalium increasingly is associated with risk of cervi- citis, pelvic in ammatory disease (PID), endometritis, sus- ceptibility to HIV, and possibly infertility and adverse birth outcomes. 6,7 Clinical presentation is similar to chlamydia— often asymptomatic and with absent or only mildly elevated systemic in ammatory markers. 5M. genitalium is very difficult to culture; however, and no diagnostic test is approved by the FDA for use in the United States. 6 Nucleic acid ampli cation testing (NAAT) with polymerase chain reaction or transcription-mediated ampli cation is used in research facilities and some laboratories, and may be avail- able for high-risk populations. 6 HISTOLOGY OF THE UTERINE CERVIX The appearance of the normal cervix varies widely, with several changes during a woman’s lifespan. Under the in uence of rising estrogen levels in puberty, columnar endocervical cells evert onto the squamous ectocervical epithelium at the squamocolumnar junction. Sometimes mistaken for infection or trauma, this area of metaplasia, the transformation zone, generally is benign but may appear red and raw and be the source of postcoital and intermen- strual bleeding ( Figure 1 ). As ovarian function diminishes during menopause and after, the squamocolumnar junction recedes into the endo- cervical canal and the cervix becomes atrophic, often strikingly pale with subepithelial point hemorrhages, and susceptible to trauma. Identifying acute cervicitis in an era of less-frequent routine gynecologic examinations Margaret Allen, PA-C, MSL, DFAAPA Margaret Allen is a former PA program director for the University of Worcester in the United Kingdom, former clinical instructor in the Stanford University primary care associate program, and practiced family medicine at Ravenswood Family Health Center in East Palo Alto, Calif. The author has disclosed no potential con icts of interest, nancial or otherwise. Roy A. Borchardt, PA-C, PhD, and Michael D. Overcash, MPAS, PA-C, department editors DOI:10.1097/01.JAA.00005 7. . Copyright © 2018 American Academy of Physician Assistants ABSTRACT Acute in ammation of the uterine cervix can lead to serious problems such as pelvic in ammatory disease (PID), endo- metritis, and complications of pregnancy and childbirth. As intervals for routine gynecologic screening examinations lengthen, cervical infections, especially if asymptomatic, may be missed. Annual wellness examinations and other patient visits outside routine gynecologic cancer screen- ing visits should include brief evaluation with sexual risk assessment and a gynecologic examination if indicated. If cervicitis persists after standard treatment for sexually trans- mitted infections (STIs), consider Mycoplasma genitalium . Clinicians should be sensitive to the fact that the unexpected presence of infection may cause distress. Keywords: acute cervicitis, pelvic in ammatory disease, sexually transmitted infections, Mycoplasma genitalium , gynecologic examination, mucopurulent 30271251 697 Copyright 251 2018 American Academy of Physician Assistants Identifying acute cervicitis in an era of less-frequent routine gynecolo gic examinations JAAPA Journal of the American Academy of Physician Assistants www.JAAPA.com 51 Nabothian cysts, epithelial cysts, and cervical broids have no pathologic signi cance. Cervical endometriosis is generally considered inoffensive despite the sometimes- alarming appearance of scattered 1- to 3-mm blue-red or blue-black lesions. Cervical polyps are friable and may wick bacteria into the endocervix; they should be curetted and sent to pathology (Figure 2). Normal cervical exudate can be scant or copious; clear or white; and thin, thick, or stringy. Reassure patients that normal discharge may vary depending on the stage of the menstrual cycle and whether the woman is ovulating, lactating, or sexually aroused. Chronic disease, increased estrogen levels from oral contraceptives, menopause, older age, or trauma all can cause alterations in color, consistency, odor, and amount of discharge. MULTIPLE CAUSES OF ACUTE CERVICITIS Chlamydia trachomatis and Neisseria gonorrhoeae produce varying degrees of acute in ammatory reaction of the glandular epithelium and are common causes of cervicitis, along with M. genitalium, Trichomonas vaginalis, and herpes simplex virus (HSV). Bacterial vaginosis is com- monly associated with cervicitis, even without concurrent vaginal ndings. Other infectious agents, such as rarer bacteria, viruses, fungi, and parasites, have been reported to cause cervicitis, with genital schistosomiasis now coen- demic with HIV in sub-Saharan Africa. 8 Most of the 79 million Americans infected with human papillomavirus (HPV) are unaware of the infection. 9 In a 2013 study by Shen and Liu, patients with mucopurulent cervicitis had high rates (over 50%) of predominantly oncogenic HPV strains 16 and 58, indicating a clear need for close follow-up. 10 Abnormality of vaginal ora (for example, absence of hydrogen peroxide–producing lactobacilli), allergens, or idiopathic in ammation should be considered as causes of cervicitis. Unfortunately, many women are led to believe that menstrual blood and the normal amine odor of vagi- nal discharge is unhealthful and may resort to deodorants, perfumes, or douches. 11,12 Exposure to these irritant chem- icals can disrupt the normal balance of vaginal ora and cause cervicitis. CLINICAL PRESENTATION Although cervicitis often is asymptomatic, women may present with a change in vaginal discharge, intermenstrual or postcoital bleeding, dyspareunia, pelvic or abdominal pain, and vulvovaginal irritation. Urinary symptoms may be present with concomitant urethral infection. Pain and fever are unlikely in the absence of PID or HSV. FIGURE 1. Some diseases caused by Chlamydia Copyright 251 2018 American Academy of Physician Assistants SPECIAL TOPICS IN WOMEN’S HEALTH 52 www.JAAPA.com Volume 31 Number 2 February 2018 Mucopurulent discharge may be present, and the cervix may be friable, with sustained easy bleeding when gently palpated or swabbed. Diffuse vesicular lesions or ulcer- ations suggest HSV; punctate hemorrhages are character- istic of T. vaginalis. Condyloma lesions may have a at, raised, or cauli ower appearance. On bimanual examina- tion, cervical motion tenderness, caused by in ammation of the pelvic ligaments, is a clear indication of PID. Clinicians also should look for associated, noninfectious causes such as abrasions or ecchymoses. TESTING AND TREATMENT Subjective and physical ndings usually suggest the cause of acute cervicitis. NAAT assays for gonorrhea and chla- mydia usually con rm diagnosis. 6 Vaginal pH testing for bacterial vaginosis, and the microscopic presence of tricho- monads or the “clue” cells of bacterial vaginosis may be useful. Leukorrhea (more than 10 white blood cells per high-power eld) is highly suspicious for cervicitis. 5 The CDC advises annual STI testing for women under age 25 years and older women with risk factors. 13 Goals of treatment are to relieve symptoms, prevent infection of the upper genital tract, and limit transmission to others. If clinical suspicion is suggestive of C. trachoma- tis or N. gonorrhoeae, initiate empiric therapy. 14 The CDC recommends cover for chlamydia at a minimum.13 If risk or local prevalence is high, or if the patient is pregnant, initiate presumptive treatment for chlamydia and gonor- rhea. 13 PID therapy is usually targeted toward chlamydia (with a macrolide) and gonorrhea (with a cephalosporin). If PID symptoms persist despite treatment attempts, consider eradicating M. genitalium. Because of the diagnostic challenge, and recent reports of 40% macrolide resistance, empiric treatment with moxi oxacin 400 mg daily for 14 days is suggested. 13,15 Tell patients to avoid sexual intercourse until treatment is complete and for 7 days after completing any single-dose regimen. Removal or discontinuation of chemical or mechanical causes should be suf cient for resolution of noninfectious cervicitis. If the condition persists, and tests for malignancy are negative, refer the patient to gynecology. Testing for HIV and syphilis, along with risk reduction counseling, should be part of the visit for any patient presenting with cervicitis. FOLLOW-UP Tests of cure for chlamydia and gonorrhea are not needed unless symptoms persist or the patient is pregnant. However, because of high rates of reinfection, repeat testing 3 to 6 months after laboratory con rmation of these infections is recommended. 16 This presents an opportunity for further counseling and risk reduction. Liu and colleagues recom- mend regular follow-up for patients with mucopurulent cervicitis, given the predominance of oncogenic strains of HPV in their study. 8 Follow-up should occur at more frequent intervals than those recommended for routine cervical cancer screening. CONCLUSION Current recommendations for reduced frequency of routine gynecologic screening examinations may increase the risk of missing pathogens such as chlamydia, gonorrhea, or M. genitalium. Incidence of STI in the United States is again rising, and clinicians should take advantage of any oppor- tunity to screen for infection, while being sensitive to the possibility of a patient’s alarm at an unexpected, and sometimes serious, diagnosis. JAAPA REFERENCES 1. Centers for Disease Control and Prevention. Sexually Transmit- ted Disease Surveillance 2016. Atlanta, GA: US Department of Health and Human Services; 2017. 2. Woods JL, Bailey SL, Hensel DJ, Scurlock AM. Cervicitis in adolescents: do clinicians understand diagnosis and treatment? J Pediatr Adolesc Gynecol. 2011;24(6):359-364. FIGURE 2. Nabothian cyst (left) and cervical polyp (right) Copyright 251 2018 American Academy of Physician Assistants Identifying acute cervicitis in an era of less-frequent routine gynecologic examinations JAAPA Journal of the American Academy of Physician Assistants www.JAAPA.com 53 3. US Preventive Services Task Force. Cervical cancer: screening. https://www.uspreventiveservicestaskforce.org/Page/Document/ UpdateSummaryFinal/cervical-cancer-screening. Accessed October 26, 2017. 4. Johnson LF, Lewis DA. The effect of genital tract infections on HIV-1 shedding in the genital tract: a systematic review and meta-analysis. Sex Transm Dis. 2008;35(11):946-959. 5. Centers for Disease Control and Prevention. Diseases character- ized by urethritis and cervicitis. https://www.cdc.gov/std/tg2015/urethritis-and-cervicitis.htm. Accessed October 26, 2017. 6. Ona S, Molina RL, Diouf K. Mycoplasma genitalium: an overlooked sexually transmitted pathogen in women? Infect Dis Obstet Gynecol . 2016;2016:4513089. 7. Lis R, Rowhani-Rahbar A, Manhart LE. Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis. Clin Infect Dis . 2015;61(3):418-426. 8. Holmen SD, Kleppa E, Lillebø K, et al. The rst step toward diagnosing female genital schistosomiasis by computer image analysis. Am J Trop Med Hyg . 2015;93(1):80-86. 9. Centers for Disease Control and Prevention. Genital HPV infection—fact sheet. https://www.cdc.gov/std/hpv/stdfact-hpv.htm. Accessed October 26, 2017. 10. Shen XH, Liu SH. Human papillomavirus genotypes associated with mucopurulent cervicitis and cervical cancer in Hangzhou, China. Asian Pac J Cancer Prev . 2013;14(6):3603-3606. 11. Mosher WD, Deang LP, Bramlett MD. Community environment and women’s health outcomes: contextual data. Vital Health Stat 23. 2003;(23):1-72. 12. Branch F, Woodruff TJ, Mitro SD, Zota AR. Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001-2004. Environ Health . 2015;14:57. 13. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137. 14. US Department of Health and Human Services. Of ce of Disease Prevention and Health Promotion. Healthy People 2020. https:// www.healthypeople.gov/2020/topics-objectives/topic/sexually-transmitted-diseases. Accessed October 26, 2017. 15. Salado-Rasmussen K, Jensen JS. Mycoplasma genitalium testing pattern and macrolide resistance: a Danish nationwide retrospec-tive survey. Clin Infect Dis . 2014;59(1):24-30. 16. Hosenfeld CB, Workowski KA, Berman S, et al. Repeat infection with chlamydia and gonorrhea among females: a systematic review of the literature. Sex Transm Dis. 2009;36(8):478-489. Copyright 251 2018 American Academy of Physician Assistants
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are under way. There has been a gradual transition to acceptance and even support for the program. The coordination of postrelease care is a challenge. Individuals going to correctional facilities not offering MAT (federal or out of state) have to be weaned off MAT. Release to the community is often un- predictable. However, individuals can immediately continue treat- ment because they are already en- rolled as CODAC patients. VIABILITY The Rhode Island state bud- get for 2017 officially contained $2 million for the implementa- tion of the MAT expansion program and has been funded again through 2018. Governor Raimondo has highlighted the program’s efforts as a significant component of her statewide overdose and addiction pre- vention plan. 4 System-wide changes also ensure that the program willbecome a part of RIDOC’s standard health care services. Provider time has been increased and additional providers have been hired. To facilitate com- munication between adminis- tration, security, rehabilitative services, and medical staff, pro- gram leaders established an MAT process team. Members serving on the Governor’s Overdose Prevention and Intervention Task Force provide the public insight on program challenges and changes. CONCLUSIONS The increase in illicit use of heroin and other illicit opioids is a serious public health concern. Despite justice-involved persons being especially vulnerable to overdose and relapse upon re- lease, prisons and jails have been slow to allow this population access to MAT. Rhode Island’s statewide comprehensive pro- gram expansion at the RIDOCshows that MAT is feasible in correctional settings, and pre- liminary outcomes suggest strong rates of treatment retention after release. In the face of a severe public health crisis related to illicit opioid use, continuing and initi- ating MAT in correctional facili- ties with seamless linkage to care in the community should be a top priority for any community con- cerned about illicit opioid use and overdose deaths. Jennifer G. Clarke, MD, MPH Rosemarie A. Martin, PhD Shelley A. Gresko, BA Josiah D. Rich, MD, MPH CONTRIBUTORSJ. G. Clarke requested and obtained the funding. J. G. Clarke, R. A. Martin, and J. D. Rich designed the study and meth- odologies. J. G. Clarke and J. D. Rich provided input on subsequent drafts. R. A. Martin and S. A. Gresko wrote thefirst draft of the editorial. All authors con- tributed to and approved thefinal version. REFERENCES1. Green TC, Clarke JG, Brinkley- Rubinstein L, et al. Postincarceration fatal overdoses after implementing medicationsfor addiction treatment in a statewide correctional system.JAMA Psychiatry. 2018;75(4):405–407. 2. Degenhardt L, Bucello C, Mathers B, et al. Mortality among regular or de- pendent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies.Addiction. 2011;106(1): 32–51. 3. Merrall EL, Kariminia A, Binswanger IA, et al. Meta-analysis of drug-related deaths soon after release from prison. Addiction. 2010;105(9):1545–1554. 4. Prevent Overdose RI. The task force. Available at: http://preventoverdoseri. org/the-task-force. Accessed June 11, 2018. 5. Schuckit MA. Treatment of opioid-use disorders.N Engl J Med. 2016;375(4): 357–368. 6. Sharma A, O’Grady KE, Kelly SM, Gryczynski J, Mitchell SG, Schwartz RP. Pharmacotherapy for opioid dependence in jails and prisons: research review update and future directions.Subst Abuse Rehabil. 2016;7:27–40. 7. Deck D, Wiitala W, McFarland B, et al. Medicaid coverage, methadone mainte- nance, and felony arrests: outcomes of opiate treatment in two states.J Addict Dis. 2009;28(2):89–102. Expedited Partner Therapy: Combating Record High Sexually Transmitted Infection Rates Expedited partner therapy (EPT) is an underused practice to address the record high rates of sexually transmitted infections (STIs) in the United States. There were more than 1.59 million re- ported cases of chlamydia in 2016, the highest number of annual cases of any condition ever re- ported to the Centers for Disease Control and Prevention (CDC). 1 The continued increase in rates of chlamydia, gonorrhea, and syphilis is particularly sur- prising in light of the numerous gainsthathavebeenmadeinotherareas of reproductive health. Ac- cess to contraception has in- creased, unintended pregnancy rates have decreased, age atfirst sexual activity has increased, and access to online health information has continued to improve; so why are STI rates worsening? 2The answer is not simple, although the lack of partner treatment plays an important role. The transmission of un- diagnosed STIs may result in persistent or recurrent infections and can cause serious health complications. Women are atincreased risk for pelvic inflam- matory disease, chronic pelvic pain, and infertility. 3Untreated STIs also increase the risk of HIV acquisition. 4Adolescent women aged 15 to 24 years accounted for46% of reported chlamydia cases in 2016. 1Increasing rates among adolescents have the potential to diminish the reproductive health of future generations, as women with undiagnosed infections face serious health conquences. 1In addition to this epidemiological burden, STIs also carry a significant economic burden. The total direct cost of chlamydia and gonorrhea in 2008 was $516.7 million and $162.1 million, respectively (on the basis of 2010 US dollars). 5 ABOUT THE AUTHORSCornelius D. Jamison is with the Department of Family Medicine, University of Michigan, Ann Arbor. Tammy Chang is with the Department of Family Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan. Okeoma Mmeje is with the Department of Obstetrics and Gynecology, University of Michigan Correspondence should be sent to Cornelius D. Jamison, University of Michigan, National Clinician Scholars Program, 2800 Plymouth Road, Bld 14-G100, Ann Arbor, MI 48105 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the“Reprints”link. This editorial was accepted May 22, 2018. doi: 10.2105/AJPH.2018.304570 AJPHPERSPECTIVES October 2018, Vol 108, No. 10AJPHJamison et al.Editorial1325 This continued increase in STIs has occurred despite several prevention and research programs and organizations dedicated to decreasing their prevalence and transmission (e.g., the Infertility Prevention Project, the CDC, HORIZONS, US Health and Human Services). The CDC recommends annual STI screen- ing for chlamydia and gonorrhea for all sexually active women younger than 25 years. 6STI screening should be considered for men who report high-risk behaviors and in communities with a high burden of infection. 6 Health care providers are expected to counsel individuals on safe sex practices, offer STI screening as indicated, and recommend the use of condoms to everyone. Despite these programs and recommen- dations, rates of STIs continue to increase—suggesting that these efforts are just not enough. There are continued concerns regarding the availability of health care and the coverage of services, including annual STI screening and treatment. At-risk individuals without health in- surance have diminished access to screening and treatment, leading to further increases in STI rates. However, EPT has the potential to reverse this trend by allowing health care providers to reach exposed individuals who would otherwise be unable to access health care services. EXPEDITED PARTNER THERAPY EPT is a health care practice that allows providers to give a prescription or medications to the heterosexual partners of pa- tients diagnosed with chlamydia or gonorrhea without testing or examining the partner. 7Al- though EPT is not a substitute fora full sexual health evaluation, partners of infected individuals often cannot or do not seek treatment. Of note, EPT is not recommended for the manage- ment of STIs in men who have sex with men because of the lack of data demonstrating EPT’sef- fectiveness and the concern of missing STI and HIV coinfections in this population. 7EPT is en- dorsed by the CDC and the following professional health organizations: American Academy of Family Physicians, American Academy of Pediatrics, Society for Adolescent Health and Medicine, and American Congress of Ob- stetricians and Gynecologists. Most importantly, EPT is a patient- centered, effective solution that is cost-effective and safe. 7,8 WHERE EXPEDITED PARTNER THERAPY IS PERMISSIBLE Several states enacted EPT legislation following the publi- cation of the CDC’s EPT guidelines on August 16, 2006. 7 Currently, EPT is permissible in 41 states and the District of Co- lumbia (a legal status of EPT map is available at https://www.cdc. gov/std/ept/legal/default.htm). With the passing vote on House Bill 360 in February 2017, Georgia became the most recent state to permit the practice of EPT. EPT is“potentially allow- able”in seven states and Puerto Rico. EPT is currently pro- hibited in South Carolina and Kentucky. IMPLEMENTATION CHALLENGES Although EPT is largely per- missible in the United States, states struggle with its implementation.On the basis of each state’s wording and varying interpretation of the law, the implementation and de- livery of EPT may be limited and contribute to the increasing STI rates. 9There are obstacles to fully realizing EPT’s potential at every level of health care (Figure A, available as a supplement to the online version of this article at http://www.ajph.org). Stigma af- fects STI screening and treatment and may limit both patients’will- ingness to divulge concerns and providers’willingness to initiate discussions regarding sexual health. 10Patients may not be aware of EPT and therefore cannot re- questitfortheirsexualpartners or may not feel comfortable pro- viding it to their partners. Partners may notfill the prescriptions (be- cause of, e.g., high out-of-pocket cost, lack of insurance coverage) or take the medication after it is given to them. 11Cost continues to be a barrier, as many insurance com- panies currently do not cover EPT. Many health care providers may notbeawareoftheavailabilityof EPT or how to provide it in the context of their current practice. 12 Providers may also be resistant to prescribing EPT, as they may prefer to physically see or contact every patient. 12Barriers in the health care infrastructure also limit EPT use, because pharmacies and electronic medical records are of- ten not equipped to implement andsupportthewidespreadprac- tice of EPT. THE FUTURE OF IMPLEMENTATION In light of rising health care costs and the increasing burden of STIs, strengthening the imple- mentation of effective STI treatment and prevention strat- egies is critical to tackle the STI epidemic. This is most importantfor high-risk individuals and communities with a high preva- lence of STIs. Health care pro- viders are at the front line of these efforts, including leading pro- grams and policies to increase knowledge and usage of EPT. Additional research is warranted to improve the implementation of EPT, including research to further the understanding of the facilitators and barriers among health care providers and within complex health care systems. Training programs for physicians, nurses, and physician assistants could include education on the effectiveness and specific pro- cesses needed to provide EPT in their communities. Electronic medical records that remind providers and automate pre- scription of treatment of sexual partners concurrently with the index patient are promising ad- vances to promote EPT uptake. In addition to clinical practice, research is needed to understand what influences patient uptake of EPT, to understand effective ways to assist patients in educat- ing their sexual partners, and to evaluate EPT implementation in high-risk populations, such as men who have sex with men and transgender individuals. In states where EPT is only potentially allowable or prohibited, clear communication of the efficacy of EPT on STI rates is needed to inform decision-making. The United States is at a crossroads. STIs are rampant, especially among youths, and access to health care services continues to be limited for many. Although health care policies often lag behind clinical practice innovations, policies related to EPT are distinctly different. With 41 EPT per- missible states in the United States, health care policies are well aligned to meet the needs of patients. EPT provides AJPHPERSPECTIVES 1326EditorialJamison et al.AJPHOctober 2018, Vol 108, No. 10 confidential and convenient treatment—two critical com- ponents of STI care. Therefore, it is time for state and local public health departments and health care providers to advance clinical processes and practice to fully realize the potential of EPT to address the worsening STI crisis. Cornelius D. Jamison, MD, MSPH Tammy Chang, MD, MPH, MS Okeoma Mmeje, MD, MPH CONTRIBUTORSThe authors contributed equally to the conceptualization, writing, and revision of the editorial, and all of the authors ap- proved thefinal version. REFERENCES1. Centers for Disease Control and Prevention.Sexually Transmitted Disease Surveillance 2016. Atlanta, GA: US Department of Health and Human Services; 2017. 2. Finer LB, Zolna MR. Declines in un- intended pregnancy in the United States, 2008–2011.N Engl J Med. 2016;374(9): 843–852. 3. Centers for Disease Control and Pre- vention. Pelvic inflammatory disease (PID)—CDC fact sheet. Available at: https://www.cdc.gov/std/pid/stdfact- pid.htm. Accessed August 14, 2017. 4. Hayes R, Watson-Jones D, Celum C, van de Wijgert J, Wasserheit J. Treatment of sexually transmitted infections for HIV prevention: end of the road or new beginning?AIDS. 2010;24(suppl 4): S15–S26. 5. Owusu-Edusei K Jr, Chesson HW, Gift TL, et al. The estimated direct medicalcost of selected sexually transmitted in- fections in the United States, 2008.Sex Transm Dis. 2013;40(3):197–201. 6. Centers for Disease Control and Pre- vention. STD & HIV screening recom- mendations. Available at: https://www. cdc.gov/std/prevention/screeningreccs. htm. Accessed August 14, 2017. 7. Centers for Disease Control and Pre- vention. Expedited partner therapy in the management of sexually transmitted dis- eases. Available at: https://www.cdc.gov/ std/treatment/eptfinalreport2006.pdf. Accessed August 14, 2017. 8. Ferreira A, Young T, Mathews C, Zunza M, Low N. Strategies for partner notification for sexually transmitted infections, including HIV.Cochrane Database Syst Rev.2013;(10): CD002843. 9. Mmeje O, Wallett S, Kolenic G, Bell J. Impact of expedited partner therapy (EPT) implementation on chlamydiaincidence in the USA.Sex Transm Infect. 2017; Epub ahead of print. 10. Ford JV, Ivankovich MB, Douglas JM Jr, et al. The need to promote sexual health in America: a new vision for public health action.Sex Transm Dis. 2017;44(10): 579–585. 11. Schillinger JA, Gorwitz R, Rietmeijer C, Golden MR. The expedited partner therapy continuum: a conceptual frame- work to guide programmatic efforts to increase partner treatment.Sex Transm Dis. 2016;43(2 supp 1):S63–S75. 12. Rosenfeld EA, Marx J, Terry MA, Stall R, Pallatino C, Miller E. Healthcare providers’perspectives on expedited partner therapy for chlamydia: a qualita- tive study.Sex Transm Infect. 2015;91(6): 407–411. Ebola Virus Disease Preparations Do Not Protect the United States Against Other Infectious Outbreaks The 2014–2016 West African Ebola virus disease (EVD) epidemic took the world by surprise. While 11 patients were treated in the United States, it challenged public health, health care, and emergency response infrastructures. 1 The outbreak highlighted the need for robust systems of screening and care for patients with highly hazard- ous communicable diseases (HHCDs), especially because the outbreak showed how modern travel hastens in- ternational disease spread. The May 2018 EVD out- break in the Democratic Republic of Congo rein- forces this need and demon- strates the uphill battle against emerging and reemerging diseases. In the beginning of the 2014 outbreak, most health care facilities in the United Stateswere unprepared to identify, isolate, and provide care for patients who presented to their facilities with suspected EVD. 1 Responding to this deficiency, the United States, led by the Assistant Secretary for Preparedness and Response and the Centers for Disease Control and Prevention (CDC), developed a tiered EVD care system that outlined the mini- mum expected capabilities for frontline hospitals, assessment hospitals, and Ebola treatment centers. 2Designated assessment hospitals and Ebola treatment centers collectively made signif- icant modifications to their facilities to enhance infection control, purchased greater quantities of personal pro- tective equipment, and en- hanced staff training. 3In addition, the Assistant Secretary for Preparedness and Response designated and funded onehospital in each of the 10 Department of Health and Human Services regions as a regional Ebola and other special pathogens treat- ment center (RESPTC), requiring these facilities to make more upgrades than the other two tiers to receive designation asfirst-choice locations to provide care for patients with confirmed EVD. These efforts resulted in signifi- cant progress in our domestic capability to safely care for patients with EVD. 1 CURRENT STATUS After more than three years of efforts, and in light of the new EVD outbreak, policy- makers and the public likely expect that the United States will sustain the new capabilities that it has paid for and developed to care for patients with EVD. It is also likely they believe this infrastructure can safely be used to accommodate patients during future out- breaks of other HHCDs, such as Middle East Respiratory Syndrome and other viral hemorrhagic fevers, such as Lassa. It is true that the upgraded facilities, personal protective equipment, enhanced trainings, and disease surveillance, in tandem with updated federal guidance, bolstered funding, ABOUT THE AUTHORSShawn Gibbs and Aurora Le are with the Department of Environmental and Occupational Health, Indiana University School of Public Health, Bloomington. John Lowe and Jocelyn Herstein are with the Department of Environmental, Agricultural, and Occupational Health, University of Nebraska Medical Center College of Public Health, and the Nebraska Bio- containment Unit, Nebraska Medicine, Omaha. Paul Biddinger is with Massachusetts General Hospital Boston, and Harvard Medical School, Boston. Correspondence should be sent to Shawn G. Gibbs, Indiana University School of Public Health, 1025 E Seventh St, PH 111C, Bloomington, IN 47405 (e-mail: [email protected] edu). Reprints can be ordered at http://www.ajph.org by clicking the“Reprints”link. This editorial was accepted July 15, 2018. doi: 10.2105/AJPH.2018.304667 AJPHPERSPECTIVES October 2018, Vol 108, No. 10AJPHGibbs et al.Editorial1327 Copyright ofAmerican JournalofPublic Health isthe property ofAmerican PublicHealth Association anditscontent maynotbecopied oremailed tomultiple sitesorposted toa listserv without thecopyright holder’sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.
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MMWR / April 27, 2018 / Vol . 67 / No . 16 473 Adherence to CDC Recommendations for the Treatment of Uncomplicated Gonorrhea — STD Surveillance Network, United States, 2016 Emily J. Weston, MPH 1; Kimberly Workowski, MD 1,2; Elizabeth Torrone, PhD 1; Hillard Weinstock, MD 1; Mark R. Stenger, MA 1 Gonorrhea, the sexually transmitted disease (STD) caused by Neisseria gonorrhoeae, is the second most common notifi – able disease in the United States after chlamydia; 468,514 cases were reported to state and local health departments in 2016, an increase of 18.5% from 2015 ( 1). N. gonorrhoeae has progressively developed resistance to most antimicrobials used to treat the infection (2). As a result, CDC recommends two antimicrobials (250 mg of ceftriaxone [IM] plus 1 g of azithromycin [PO]) for treating uncomplicated gonorrhea to improve treatment efficacy and, potentially, to slow the emergence and spread of antimicrobial resistance. To moni – tor adherence to the current CDC-recommended regimen for uncomplicated gonorrhea, CDC reviewed enhanced data collected on a random sample of reported cases of gonorrhea in seven jurisdictions participating in the STD Surveillance Network (SSuN) and estimated the proportion of patients who received the CDC-recommended regimen for uncom – plicated gonorrhea, by patient characteristics and diagnosing facility type. In 2016, the majority of reported patients with gonorrhea (81%) received the recommended regimen. There were no differences in the proportion of patients receiving the recommended regimen by age or race/ethnicity; however, patients diagnosed with gonorrhea in STD (91%) or family planning/reproductive health (94%) clinics were more likely to receive this regimen than were patients diagnosed in other provider settings (80%). These data document high provider adherence to CDC gonorrhea treatment recommendations in specialty STD clinics, indicating high quality of care provided in those settings. Local and state health departments should monitor adherence with recommendations in their jurisdic- tions and consider implementing interventions to improve provider and patient compliance with gonorrhea treatment recommendations where indicated. SSuN is a CDC-supported, sentinel surveillance project comprised of 10 selected state and city health departments that conduct investigations to collect supplementary informa – tion on a random sample of gonorrhea cases reported from all health care providers/reporting sources in their jurisdic – tions ( https://www.cdc.gov/std/ssun/default.htm ). These investigations include contacting the diagnosing provider to verify treatment and conducting patient interviews to collect behavioral and demographic information. Case weights were developed to account for local sample fractions and adjust for nonresponse by patient sex and age group, allowing CDC to produce estimates representative of all reported gonorrhea cases in these jurisdictions (3). Analyses were restricted to seven of the 10 SSuN jurisdictions (Baltimore, Maryland; California, excluding San Francisco; Florida; Massachusetts; Multnomah County, Oregon; Minnesota; and Philadelphia, Pennsylvania) with documented treatment information (antimicrobials and dosages) for ≥90% of cases with complete investigations. Cases with missing patient treatment information (6.7%) were excluded from further analysis. Based on provider report of treatment pro- vided, patients treated with the recommended dual therapy for uncomplicated gonorrhea (i.e., 250 mg dose of ceftriaxone [IM] plus 1 g dose of azithromycin [PO]) were classified as having received the recommended regimen. All other patients were classified as having received other regimens. Weighted estimates of the number and proportion of patients treated with the recommended regimen and corresponding 95% confidence intervals (CI) were calculated. Prevalence ratios (PRs) were estimated to identify differences in documented treatment by patient characteristics and diagnosing facility type. Gay, bisexual, and other men who have sex with men (MSM) were defined as any male patient reporting male sex partners in the previous 2–3 months or reporting their sexual orientation as gay or bisexual. In 2016, a total of 91,719 gonorrhea cases were reported in the seven participating SSuN jurisdictions. Among these, 8,393 (9.2%) were randomly sampled; complete provider investiga – tions were obtained for 3,213 cases for a response rate of 38%. Overall, 93.3% of these patients had a treatment documented and were included in the analysis. Based on weighted analysis,* CDC estimated that 81.3% (95% CI = 79.2–83.4) of reported patients with gonorrhea in these SSuN jurisdictions were treated with the recommended dual therapy for uncomplicated gonorrhea (Table 1). The percentage of patients treated with this regimen varied by jurisdiction (range  =  76.7% to 92.0%). There were no dif- ferences by patient age or race/ethnicity (Table 2). Although not statistically significant, women were somewhat less likely than men to receive the recommended regimen (79.3% versus * Case weights developed based on proportion sampled in each jurisdiction; nonresponse adjustments developed by gender and age group. All analyses were conducted using statistical software with linearized Taylor-Series 95% confidence intervals. Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention 474 MMWR / A pril 27, 2018 / Vol . 67 / No . 16 TABLE 1. Estimated number of gonorrhea cases by treatment regimens received — STD Surveillance Network, United States, 2016 Treatment regimen Weighted no.*Weighted % (95% CI)* Recommended treatment for uncomplicated gonorrhea Ceftriaxone 250 mg + azithromycin 1 g 74,59981.3 (79.2–83.4) Other regimens Ceftriaxone 250 mg only 5,4305.9 (4.8–7.0) Ceftriaxone any dosage + doxycycline 4,0164.4 (3.3–5.5) Azithromycin only 2,8843.1 (2.1–4.1) Ceftriaxone + azithromycin (other or unknown dosage) 1,9362.1 (1.3–2.9) Doxycycline only 1,0551.2 (0.5–1.8) Cefixime + azithromycin or doxycycline 5990.7 (0.5–0.9) Ceftriaxone (125 mg or unknown dosage) only 5300.6 (0.2–1.0) Other antimicrobials † 420 0.5 (0,0–1.0) Cefotaxime 1 g + azithromycin 1 g or ceftizoxime 1 g + azithromycin 1 g 1150.1 (0.0–0.3) Cefixime only 830.1 (0.0–0.2) Azithromycin 2 g + gentamicin or gemifloxacin 510.1 (0–0.1) Abbreviations: CI = confidence interval, STD = sexually transmitted disease. * No., %, and 95% CI reflect weighted estimates for all reported gonorrhea cases; minor variance in weights might cause category estimates to total to slightly more or less than overall case estimate.† Other antimicrobials include azithromycin 1 g + doxycycline, fluoroquinolone alone, and gentamicin alone. TABLE 2. Estimated cases by patient demographics, diagnosing facility type, and treatment regimen received — STD Surveillance Network, United States, 2016 Characteristic Regimen received Prevalence ratio (95% CI) Recommended for uncomplicated gonorrhea Other Weighted no.* Weighted % (95% CI)* Weighted no.*Weighted % (95% CI)* Total 74,59981.3 (79.2–83.4) 17,12018.7 (16.6–20.8) — Gender and sex of sex partner(s) Women 26,08879.3 (75.5–83.0) 6,82220.7 (17.0–24.5) 0.96 (0.91–1.02) MSM 27,80484.8 (81.4–88.2) 4,99415.2 (11.8–18.8) 1.07 (1.01–1.13) MSW 18,64178.9 (74.8–83.0) 4,99321.1 (17.0–25.2) 0.96 (0.90–1.02) Men with unknown sex of sex partner(s) 2,06686.9 (79.7–94.1) 31113.1 (5.9–20.3) 1.07 (0.98–1.17) Age group (yrs) ≤19 10,57083.1 (77.5–88.7) 2,14816.9 (11.3–22.5) 1.03 (0.95–1.10) 20–24 19,84281.2 (77.2–85.3) 4,58618.8 (14.7–22.8) 1.00 (0.94–1.06) 25–29 17,60084.3 (80.1–88.5) 3,28315.7 (11.5–19.9) 1.05 (0.99–1.11) 30–34 9,90180.0 (74.4–85.7) 2,46820.0 (14.3–25.6) 0.98 (0.91–1.06) 35–39 5,88777.3 (69.1–85.5) 1,72922.7 (14.5–30.9) 0.95 (0.85–1.06) 40–44 3,69782.1 (72.3–91.9) 80617.9 (8.1–27.7) 1.01 (0.89–1.14) ≥45 7,09977.2 (70.2–84.1) 2,10022.8 (15.9–29.8) 0.94 (0.86–1.04) Race/Ethnicity White 16,42477.4 (72.7–82.0) 4,80822.6 (18.0–27.3) 0.94 (0.88–1.00) Black 29,17882.5 (79.5–85.6) 6,17217.5 (14.4–20.5) 1.02 (0.97–1.08) Hispanic 21,49284.8 (80.8–88.8) 3,85315.2 (11.2–19.2) 1.06 (1.00–1.12) All other races 5,21081.5 (72.4–90.6) 1,18518.5 (9.4–27.6) 1.00 (0.89–1.12) Missing/Refused 2,29467.5 (54.5–80.6) 1,10332.5 (19.4–45.5) 0.82 (0.68–1.00) Diagnosing provider/Facility type STD clinic 11,56590.8 (87.0–94.6) 1,1749.2 (5.4–13.0) 1.14 (1.08–1.20) Private provider/HMO/ PPO 19,09075.8 (70.9–80.6) 6,10424.2 (19.4–29.1) 0.91 (0.85–0.97) Hospital ED/Emergent/Urgent care 3,24974.6 (67.8−81.5) 1,10525.4 (18.5–32.2) 0.91 (0.83–1.01) Family planning/ Reproductive health clinics 11,319 93.8 (91.0–96.6) 748 6.2 (3.4–9.0)1.18 (1.13–1.23) Other HD/Public clinics or tribal clinics 4,51688.1 (80.7–95.5) 61011.9 (4.5–19.3) 1.09 (1.00–1.19) All other † 10,506 86.3 (82.2–90.5) 1,66513.7 (9.5–17.8) 1.07 (1.01–1.13) Unknown 14,35371.5 (66.0–77.1) 5,71528.5 (22.9–34.0) 0.85 (0.78–0.92) Abbreviations: CI = confidence interval; ED = emergency department; HD = health department; HIV = human immunodeficiency virus; HMO = health maintenance organization; MSM = men who have sex with men; MSW = men who have sex with women only; PPO = preferred provider organization; STD = sexually transmitted disease. * No., %, and 95% CI reflect weighted estimates for all reported gonorrhea cases; minor variance in weights might cause category estimates to total to slightly more or less than overall case estimate.† All other includes: HIV primary/specialty care or HIV testing sites, correctional facilities, school-based pediatric or adolescent care, and other provider types. Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / April 27, 2018 / Vol . 67 / No . 16 475 82.5%; PR = 0.96, 95% CI = 0.91–1.02). MSM were more likely to receive the recommended regimen compared with het – erosexual men and women (84.8% versus 79.4%; PR = 1.07, 95% CI = 1.01–1.13). Patients diagnosed with gonorrhea in family planning/reproductive health clinics were more likely to receive the recommended regimen than were patients diagnosed in other provider settings (93.8% versus 79.5%; PR = 1.18, 95% CI = 1.13–1.23). Similarly, patients diagnosed in STD clinics were more likely to receive the recommended regimen than were patients diagnosed in other provider set – tings (90.8% versus 79.8%; PR = 1.14, 95% CI = 1.08–1.20). When stratified by sexual behavior, patients whose gonorrhea was diagnosed in STD and family planning/reproductive health clinics were more likely to be treated with the recommended regimen whether or not they were MSM. Overall, 18.7% (95% CI = 16.6–20.8) of patients received other regimens (Table 1). The most frequent other regimens reported were ceftriaxone 250 mg only (5.9%), ceftriaxone any dosage and doxycycline (4.4%), and azithromycin only (3.1%). Fewer than 0.5% of patients were treated with a regimen sug – gesting treatment of a patient with a cephalosporin allergy (e.g., azithromycin plus either gentamicin or gemifloxacin) or a patient with a complicated gonococcal infection (e.g., azithromycin plus either cefotaxime or ceftizoxime). Discussion CDC’s gonorrhea treatment recommendations are periodi – cally revised based on the best available evidence of emerging trends in antimicrobial susceptibility. Provider awareness of, and adherence to current treatment recommendations helps ensure that all patients are treated with the most effective therapy and might decrease the development of antimicrobial resistance. Monitoring treatment practices across all provider and diagnostic settings helps identify opportunities for inter – ventions to increase provider adherence. The current analysis provides estimates of treatment practices among all providers diagnosing gonococcal infections in seven of 10 SSuN juris – dictions and are the first published estimates of adherence to CDC recommendations since gonorrhea treatment guidelines were revised in 2012 and in 2015 (2,4). This analysis documents high levels of compliance with CDC treatment recommendations, with 81% of patients receiving recommended dual therapy for uncomplicated gon- orrhea and substantiate high levels of compliance observed in previous analyses of gonorrhea cases reported in jurisdictions participating in SSuN during 2006–2008 and 2010–2012 (5,6). Optimally, all patients diagnosed with uncomplicated gonorrhea should be treated with the recommended regimen to ensure effective treatment and to help forestall the emergence of antimicrobial resistance. However, in practice, many factors Summary What is already known about this topic? CDC’s treatment recommendations for gonorrhea were revised in 2012 and 2015 based on emerging antimicrobial resistance. What is added by this report? In 2016, 81% of gonorrhea cases in seven jurisdictions were treated with the recommended regimen for uncomplicated gonorrhea (250 mg dose of ceftriaxone [IM] plus 1 g dose of azithromycin [PO]), but this varied by provider type. What are the implications for public health practice? Providers should be aware of the national guidelines for the treatment of sexually transmitted infections. Monitoring of treatment practices is a critical public health priority to help assure that patients receive the highest quality of care, and to address the emerging threat of antimicrobial-resistant gonorrhea. might influence provider’s adherence to the recommended regimen, including the availability of injectable medications at the time of treatment and patient-reported allergies. In the current analysis, patients diagnosed with gonorrhea in STD and family planning/reproductive health clinics were more likely to be treated with the recommended regimen than were patients diagnosed in other provider settings, similar to obser – vations from earlier studies ( 7,8). Across all provider settings, MSM were more likely to be treated with the recommended regimen, and MSM were more likely than non-MSM to receive a diagnosis in STD clinics. However, in stratified analyses by sexual behavior and diagnosing facility type, STD clinics were still more likely to treat with the recommended regimen than were other provider types. Implementation of guidelines in other provider settings might be influenced by a smaller volume of patients with gonorrhea seeking care and services, as providers diagnosing fewer cases might be less familiar with current recommendations. The majority of patients treated with other regimens were treated with only one antimicrobial, including 3% of all patients treated with azithromycin only and 1.2% with doxy – cycline alone. Azithromycin monotherapy is not recommended for treatment of gonococcal infections because of concerns about emerging resistance and case reports of treatment failures (1,2,9). In addition, tetracycline has not been recommended as treatment regimen for gonorrhea since the 1980s because of established chromosomally and plasmid-mediated resistance in the United States ( 10). These findings reinforce the imperative for state and local jurisdictions to identify provider settings where patients are receiving inadequate treatment. Additional training and education on the importance of adherence to treatment recommendations might increase the proportion of patients adequately treated and further delay the emergence of antimicrobial-resistant gonorrhea. Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention 476 MMWR / Apr il 27, 2018 / Vol. 67 / No. 16 The findings in this report are subject to at least four limi- tations. First, findings are based on enhanced investigations conducted for a random sample of gonorrhea cases in seven jurisdictions; SSuN is not designed to be nationally repre – sentative although these jurisdictions reported approximately 20% of all gonorrhea cases in the United States in 2016. Second, although case weights were calculated to account for differing sample fractions across SSuN jurisdictions and for nonresponse, it is possible that unmeasured bias exists. CDC is unable to adjust these data for nonresponse by provider type because the complete distribution by provider type in the underlying population of cases is unknown. If providers who were less likely to treat patients with a recommended therapy were also less likely to respond to investigators, this analysis might overestimate the proportion of patients treated with the recommended regimen. Third, a small number of patients might have had allergies or other clinical scenarios that would have been appropriately treated with an alternative regimen; however, allergies and complications are not documented during SSuN investigations. Consequently, findings might underestimate the proportion of appropriately treated patients with gonorrhea. Finally, treatment information was missing for 6.7% of sampled cases; it is plausible that these patients were treated with the recommended regimen, but investigators were unable to document treatment at the time of the investigation. Despite the high level of treatment adherence documented in this analysis, improving provider adherence to treatment recommendations for antibiotic use across the full spectrum of health care settings is an integral part of a comprehensive approach to combating the emergence of antimicrobial- resistant gonorrhea. State and local health departments should continue to work with the providers and patients to assure timely detection and treatment of gonorrhea according to current CDC treatment recommendations (2). Acknowledgments Christina Schumacher, Baltimore City Health Department; Heidi Bauer, Joan Chow, Emily Han, California Department of Public Health; Craig Wilson, Sonya du Bernard, Lisa Thompson, Florida Department of Health; Kathleen Hsu, Heather Elder, Massachusetts Department of Public Health; Krissie Guerard, Dawn Ginzl, Laura Tourdot, Minnesota Department of Health; Lenore Asbel, Greta Anschuetz, Robbie Madera, Philadelphia Department of Public Health; Gail Bolan, Jim Braxton, Brian Emerson, LaZetta Grier, Eloisa Llata, Tremeka Sanders, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Conflict of Interest No conflicts of interest were reported. 1Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, CDC; 2Department of Medicine, Emory University, Atlanta, GA. Corresponding author: Emily J. Weston, [email protected] , 404-639-3603. References 1.CDC. Sexually transmitted diseases surveillance, 2016. Atlanta: USDepartment of Health and Human Services, 2017. https://www.cdc.gov/ std/stats16/CDC_2016_STDS_Report-for508WebSep21_2017_1644.pdf 2.Workowski KA, Bolan GA. Sexually transmitted diseases treatmentguidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3).3.Stenger MR, Pathela P, Anschuetz G, et al. Increases in the rate of Neisseria gonorrhoeae among gay, bisexual and other men who have sex with men—findings from the Sexually Transmitted Disease Surveillance Network 2010–2015. Sex Transm Dis 2017;44:393–7. https://doi. org/10.1097/OLQ.0000000000000623 4.CDC. Update to CDC’s sexually transmitted diseases tr eatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal Wkly Rep 2012;61:590–4. 5.Kerani RP, Stenger MR, Weinstock H, et al. Gonorrhea treatmentpractices in the STD Surveillance Network, 2010-2012. 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Sex Transm Dis 2012;39:877–9. https://doi.org/10.1097/OLQ.0b013e3182685d2b 10. Unemo M, Shafer WM. Antimicrobial resistance in Neisseria gonorrhoeae in the 21st century: past, evolution, and future. Clin Microbiol Rev 2014;27:587–613. https://doi.org/10.1128/CMR.00010-14 Morbidity and Mortality Weekly Report US Department of Health and Human Services/Centers for Disease Control and Prevention This content isin the Public Domain.