Laboratory Issues in STD Testing From the Perspective

Laboratory Issues in STD Testing From the Perspective of The Bureau of STD Control Jennifer Baumgartner, MSPH Preeti Pathela, Dr. PH Julia Schillinger, MD, MSc

Today’s talk • Fluoroquinolone Resistance (QRNG) • Anorectal NAATs for GC and Ct detection Selected results from the Bureau’s 2004 annual lab survey will be used as a context for discussion of the above key issues.

STDs Reportable to NYC DOHMH • • • Syphilis (Treponema pallidum) Gonorrhea (Neisseria gonorrhoeae) Chlamydia (Chlamydia trachomatis) Chancroid (Haemophilus ducreyi) Lymphogranuloma venereum (Chlamydia trachomatis L 1, L 2, L 3) • Granuloma inguinale (Calymmatobacterium granulomatis) • Non-gonoccocal urethritis • Neonatal Herpes (any HSV positive test for an infant =<60 days old)

Annual Clinical Laboratory Survey • Objectives – To determine current STD diagnostic testing methods provided to NYC residents – To monitor trends in STD testing – To monitor current laboratory compliance with citywide reporting mandates

Annual Clinical Laboratory Survey • Methods – The NYC DOHMH Bureau of Sexually Transmitted Disease Control (BSTDC) surveyed clinical laboratories that were licensed to perform sexually transmitted disease (STD) testing by NYS – Survey instrument was a self-administered mail-in questionnaire to collect information for calendar year 2004.

Laboratories Sampled in 2004 Lab Survey 528 Laboratories Licensed by NYS DOH To perform STD testing* 330 Laboratories did not perform STD Testing on NYC residents† 178 Laboratories licensed to Perform STD testing on NYS‡ 6 Laboratories not on NYS DOH licensed list, but performed Testing on NYC residents in 2002 184 Laboratories sent 2004 Lab Survey 52 (28%) Laboratories Located Outside New York State 132 (72%) Laboratories Located In New York State 30 (23%) Laboratories Located Outside New York City 102 (77%) Laboratories Located In New York City *Clinical laboratories currently holding a New York State (NYS) Department of Health (DOH) permit in at least one of the following categories: Bacteriology-General, Bacteriology-Gram Stains, Bacteriology-Other, Bacteriology-Restricted, Diagnostic Immunology. Services Serology, Diagnostic Immunology Donor Services Serology, Virology-Direct Detection, Virology General, Virology Herpes Group Viruses Only, Wet Mounts †Based on findings from 2002 Lab Survey. Includes one laboratory that had closed. ‡Includes NYS licensed laboratories that performed testing on NYC residents based on findings from 2002 lab survey or were not surveyed in 2002. 54% (96/178) Labs were surveyed in 2002, 46% (82/178) Labs were not surveyed in 2002.

Description of Respondents (n=172) • Location: – All five New York City Boroughs • 56% (96/172) Respondents located in NYC – Other states • 57% (98/172) of 2004 respondents had responded to the 2002 survey • 89% (80/90) of the 2002 respondents who perform testing STD testing on NYC residents responded to the 2004 survey.

Reporting Methods 2002 and 2004 Method of Reporting Percent of Labs Reporting 2002 2004 Electronically* 26% 43% Mail† 50% 23% Fax‡ 2% 3% Other Reporting 10% 12% * Labs reporting at least 1 STD electronically † Labs reporting at least 1 STD by mail and do not report electronically ‡ Labs reporting at least 1 STD by fax and do not report electronically or by mail

Gonorrhea Testing Results • 58% (81/139) of laboratories indicated that they performed at least one type of gonorrhea testing in 2004: – NAATs – 17% (23/139) reported performing Nucleic Acid Amplification Tests (NAATs) – Dual gonorrhea/chlamydia probe was the most frequently performed test – Culture - 44% (61/139) of laboratories perform gonorrhea cultures – Urethral gram stain – 38% (53/139) indicated that they performed urethral gram stains (UGS)

Gonorrhea Testing Types Test Type*† No. of labs performing test Urethral gram stain 38% (53/139) GC culture 44% (61/139) DNA GC-only amplification 7% (10/139) DNA dual test (GC&Ct) amplification 16% (22/139) DNA GC-only hybridization 7% (10/139) DNA Dual test (GC&Ct) hybridization 19% (26/139) EIA 0% (0/139) Other 1% (2/139) - 49% (30/61) of laboratories performing GC culture tests also perform antimicrobial susceptibility testing. * Labs reporting performance of test, may not have provided information for each of the above categories † Laboratories could report more than 1 test type

Gonorrhea Antimicrobial Testing Type of Antibiotic* No. of labs performing test Cephalosporins 77% (23/30) Penicillins 77% (23/30) Fluoroquinolones 77% (23/30) Spectinomycin 23% (7/30) Tetracyclines 50% (15/30) Macrolides 13% (4/30) Type of Testing** No. of labs performing test Disk Diffusion 77% (24/30) Broth Microdilution 0% (0/30) E-test 13% (4/30) Agar Dilution 3% (1/30) Other (Beta-lactamase) 17% (5/30) *Survey permitted labs to specify more than one class of antibiotic **Survey permitted labs to specify more than one method of antibiotic susceptibility testing

Anorectal and Oropharangeal Gonorrhea NAATs Testing • Gonorrhea NAATs testing on anorectal specimens and oropharangeal specimens: – 1% (1/139) of laboratories performed NAATs testing on anorectal specimens – 1% (1/139) of laboratories performed NAATs testing on oropharangeal specimens

Fluoroquinolone-Resistant GC, NYC BSTDC Clinics, 1999 -2005 Year No. Specimens cultured GC No. GC (%) QRNG No. QRNG (%) 1999 n/a* n/a 0 2000 n/a 4 2001 88, 400 3162 (4) 3 (0. 1) 2002 58, 047 2668 (5) 8 (0. 3) 2003 30, 094 1026 (3) 30 (2. 9) 2004 n/a* 608 n/a 48 (7. 9) 2005 479† n/a 44 (9. 2)† *Data not available †There were 9 additional positive GC isolates that could not be AST’d.

Prevalence of NYC BSTDC Clinic QRNG, by Sex, 2005 Anatomic Site of Infection No. QRNG Total GC (%) QRNG Males 42 402 (10. 4) Anal 19 67 (23. 9) Oral 7 59 (11. 9) Urethral 19 276 (6. 9) Females 2 77 (2. 6) Anal 0 8 (0. 0) Oral 0 15 (0. 0) Endocervical 2 54 (3. 7) Total 44 479 (9. 2)

Gonorrhea • Performing gonorrhea culture is an important surveillance tool, since it can aid the BSTDC in monitoring antibiotic resistance. • Recently the CDC has recommended that fluoroquinolones not be used to treat gonorrhea infections in MSM. • NYC DOHMH BSTDC has adopted these treatment guidelines and further recommends that providers who treat gonorrhea in non MSM men avoid fluoroquinolones, or if using fluoroquinolones, either perform culture or conduct follow-up testing to insure that the treatment given was effective 1. • The BSTDC also recommends caution in using fluoroquinolones in women diagnosed with gonorrhea. 1 Centers for Disease Control & Prevention. Increases in Fluoroquinolone-Resistant Neisseria gonorrhoeae Among Men Who Have Sex with Men – United States, 2003 and Revised Recommendations for Gonorrhea Treatment, 2004. MMWR 2004: 53: 335 -338.

Chlamydia Testing Results • 37% (51/139) of labs perform at least one type of chlamydia testing: – NAATs – 19% (26/139) reported performing Nucleic Acid Amplification Tests (NAATs) – Dual chlamydia/gonorrhea probe was the most frequently performed test – 34% (47/139) labs accept male urethral/urine specimens

Chlamydia Test Types Test Type*† No. of labs performing test Ct culture 8% (11/139) DNA Ct-only amplification 10% (14/139) DNA dual test (Ct&GC) amplification 16% (22/139) DNA Ct-only hybridization 10% (14/139) DNA Dual test (Ct&GC) hybridization 19% (26/139) DFA 6% (8/139) Serology 3% (4/139) EIA 5% (7/139) Other 1% (1/139) * Labs reporting performance of test, may not have provided information for each of the above categories † Laboratories could report more than 1 test type

Chlamydia NAATs Testing at Alternative Sites • Chlamydia NAATs testing on: – anorectal specimens: 1% (1/139) – oropharangeal specimens: 1% (1/139) – neonatal eye specimens: 2% (3/139) – pulmonary specimens: 1% (2/139)

Lymphogranuloma Venereum • 3% (4/139) of laboratories performed Lymphogranuloma Venerum (LGV) testing in 2004: – The 4 labs reported performing tests by: • Amplification • Culture • IFA

Discussion Chlamydia anorectal NAAT • Currently, NAAT not approved for use on anorectal or oropharyngeal specimens, however • Laboratories that have performed local validation studies may conduct testing (e. g. San Francisco PHL) • SF study using anorectal NAAT (Ct and GC) among men who have sex with men (MSM)* - 7. 9% Ct NAATpositive • NYC Public Health Laboratory to validate commercial NAAT for Ct detection from anorectal specimens – Will be used routinely for STD evaluation in NYC STD clinics (~4, 000 MSM/year reporting anorectal sex) – Detection and treatment reduces HIV transmission * Kent CK, et al. , Clinical Infectious Diseases 2005; 41: 67 -74

Discussion LGV in NYC • LGV recognized among MSM in NYC in early 2004 – Proctitis (hemorrhagic and non-hemorrhagic) most common clinical presentation – MSM, most HIV co-infected • Need to differentiate L-serovars of chlamydia from other serovars – Treatment regimen for LGV longer than for non-L serovars of Ct – Partner follow-up more intensive – Need for timely and sensitive LGV diagnostics lent urgency to developing anorectal NAAT capability • Wadsworth Laboratory validated an in-house NAAT for anorectal testing, and developed a nested PCR to detect the L-2 serovar of C. trachomatis – >250 specimens submitted – ~1/3 of anorectal specimens tested are Ct-positive, of genotyped specimens, 80% were L-2 (n=33) – Clinical syndrome does not differ between L-2 and non-L serovar * Kent CK, et al. , Clinical Infectious Diseases 2005; 41: 67 -74

Discussion Monitoring antimicrobial susceptibility in GC, NYC • Currently, NYC gonococcal AST results reported nationally come only from STD clinic patients – ‘GISP’ (Gonococcal Isolates Surveillance Project) • Substantial number of NYC laboratories have culture and AST capacity • Interest in collaborating to monitor resistance from broader sample?