Epidemiologic Notes and Reports Penicillinase-producing Neisseria gonorrhoeae--Los Angeles

An intensified prevention program has controlled the first outbreak of penicillinase-producing Neisseria gonorrhoeae (PPNG) infections in a major U.S. metropolitan area. The outbreak in Los Angeles County, California, was initially identified in August 1980 and reached an average of 50 cases per month through March 1981 (Figure 1). Most cases were reported in residents of the central-southwestern part of the county, where rates of reported cases of non-PPNG gonococcal infection have historically been the highest.

In March 1981, the County of Los Angeles Department of Health Services implemented an expanded prevention program with special emphasis in those health districts reporting the greatest numbers of PPNG cases. The strategy included: 1) using spectinomycin as initial treatment for all patients (in health districts reporting the greatest number of PPNG cases) who had or were suspected of having uncomplicated gonococcal urethritis or cervicitis; 2) testing all N. gonorrhoeae isolates for B-lactamase production; 3) referring all identified sexual partners of patients with PPNG for prompt examination and treatment; 4) culturing high-risk groups, particularly prostitutes, for N. gonorrhoeae; 5) publicizing the outbreak through the media, targeting educational programs for high-risk groups, and educating health care providers through medical alerts, letters, and seminars.

Between March and December 1981, more than 16,000 doses of spectinomycin were administered. At least 19,520 N. gonorrhoeae isolates were tested for B-lactamase production. Contact interviews and reinterviews of persons with PPNG resulted in the examination of 924 sexual partners and other suspects. In addition, 8,147 persons were cultured at a county jail (where persons arrested for prostitution are usually sent). Public health personnel spent an estimated 14,700 person-hours on this effort during the first 10 months (March-December 1981).

All these prevention activities were designed to improve the timeliness of the appropriate treatment given to persons with PPNG. The average interval between the infected patient's first visit to a health care facility and the administration of spectinomycin or other appropriate therapy, was reduced from 8.5 days (January-February 1981) to 3.3 days (March-December 1981).

During the first 4 months of the intervention program (April-July 1981), the average number of cases reported monthly remained stable. Thereafter, cases decreased and leveled off through 1982 and into 1983, averaging less than 15 cases reported monthly from October 1981 through March 1983. From October 1981 through December 1982, the proportion of all cases attributed to persons returning to Los Angeles from high-incidence PPNG areas increased from less than 5% to approximately 40% (Figure 1). All six patients reported in March 1983 had either histories of foreign travel or exposures to partners with histories of foreign travel or residence. Reported by S Sidhu, MD, Venereal Disease Control Program, County of Los Angeles; R Barnes, PhD, Public Health Laboratories, County of Los Angeles Dept of Health Svcs; Venereal Disease Control Div, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The control of PPNG infections in Los Angeles and the virtual end of endemic transmission are attributable to the comprehensive control effort, including targeted use of spectinomycin therapy, laboratory surveillance, testing and treating sexual partners, screening and educating high-risk populations, and educating high-risk community and professional groups. These measures appreciably reduced the time that the average patient remained able to transmit the disease. However, cases continue to be imported into Los Angeles, and high-quality surveillance and appropriate control measures are being maintained to ensure that endemic transmission does not occur.

In many other areas of the United States, the incidence of PPNG infection is increasing. For the entire United States, 3,424 cases were reported during the first 9 months of 1982, an increase of 1,491 cases (77%) over the same period in 1981. Sustained, endemic transmission continues in New York City and Florida. For the first 9 months of 1982, these areas accounted for 47% of all U.S. cases (1); comprehensive control efforts in these areas are being directed toward eliminating endemic disease.

Control of the spread of PPNG in other areas is threatened by the pressure of continued importation. During 1981, 27% of all cases reported by areas other than Los Angeles, Florida, and New York City were in persons returning from high-incidence PPNG areas overseas (1). For these locations, CDC continues to recommend timely and appropriate therapy for the maximum number of infected persons. This prevention strategy includes: 1) using spectinomycin, 2 g intramuscularly, for confirmed cases, sexual partners of persons with confirmed cases, and persons with suspected gonococcal infections who have returned from high-incidence PPNG areas; 2) prompt referral and treatment of sexual partners; 3) testing all gonococcal isolates for B-lactamase production; and 4) screening high-risk persons for gonococcal infections (2,3,4).

References

1. CDC. Penicillinase-producing Neisseria gonorrhoeae surveillance. Atlanta: Venereal Disease Control Division, Center for Prevention Services, CDC, 1981-1982.

2. CDC. Penicillinase-producing Neisseria gonorrhoeae--New Mexico, California. MMWR 1980;29(32):381-2.

3. Jaffe HW, Biddle JW, Johnson SR, Wiesner PJ. Infections due to penicillinase-producing Neisseria gonorrhoeae in the United States: 1976-1980. J Infect Dis 1981;144(2):191-7.

4. CDC. Global distribution of penicillinase-producing Neisseria gonorrhoeae (PPNG). MMWR 1982;31(1-2):1-3.

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