In May 1981, 71 (92%) of 77 patients who presented to the
Orange
County (California) Special Diseases Clinic with genital ulcers had
negative darkfield examinations, compared with 135 (69%) of 197
patients during the preceding 4 months. Haemophilus ducreyi was
isolated from 30 patients with similar lesions in December 1981.
Since then, 271 cultures from genital lesions in over 1,000 people
have grown H. ducreyi, with the peak number occurring during
January
1982 (Figure 3).
Although the CDC-recommended treatment regimen of erythromycin
or
sulfamethoxazole/trimethoprim had been uniformly used since January
1982, culture-confirmed chancroid cases continued to average 34 per
month between December 1981 and June 1982. In an effort to reduce
this number, more aggressive, nontraditional control measures were
adopted in March 1982. These included offering prophylactic
therapy
to 287 women identified as prostitutes in the county jail, in
addition
to those who voluntarily requested an examination at the clinic.
Prophylactic therapy was also offered to over 700 clinic patients
who
reported recent sexual contact with "door-to-door" prostitutes. By
July, the number of positive cultures had dropped to 14; in August,
10
were reported. Thereafter, the monthly number of cases continued to
decline, and only one culture-proven case has been reported in
1983,
despite continued, active surveillance.
The profile of chancroid patients has remained consistent
throughout this outbreak. Ninety-six percent of the culture-proven
cases occurred among Hispanic males, at least 86% of whom had
recent
sexual contact with prostitutes. One hundred forty-two of the 271
patients offered descriptions of prostitutes to whom they had been
exposed; 98 (69%) of these referred to women who solicited from
door-to-door.
There were five known prostitutes among the 271 culture-proven
chancroid patients. Two additional prostitutes from that area who
had
no chancroid symptoms were originally reported as having had H.
ducreyi recovered from cervical specimens (1). However, subsequent
microbiologic studies showed that these specimens were not H.
ducreyi,
but another species of Haemophilus. Simultaneous infection with H.
ducreyi and Treponema pallidum was documented for 15 patients. In
one
patient, herpes simplex virus was cultured along with H. ducreyi.
Thirty-seven of the 41 H. ducreyi isolates examined between
December 1981 and February 1983 shared a similar antibiogram and
contained a common 3.2 megadalton plasmid, coding for B-lactamase
production. This plasmid is identical to the gonococcal plasmid
and
is similar to one identified in a strain of H. ducreyi that has
been
epidemiologically linked to a chancroid case in Brazil (2). Over
200
B-lactamase-producing H. ducreyi strains from other geographic
areas
have been shown not to contain this particular plasmid.
Reported by JR Greenwood, PhD, TJ Prendergast, MD, LR Ehling, MD,
Orange County Health Dept, C Zavala, J Chin, MD, State
Epidemiologist,
California Dept of Health Svcs; Sexually Transmitted Diseases
Laboratory Program, Center for Infectious Diseases, Field Svcs Div,
Epidemiology Program Office, Div of Venereal Disease Control,
Center
for Prevention Svcs, CDC.
Editorial Note
Editorial Note: In 1982, Orange County, California, reported 240
cases of culture-confirmed chancroid, over seven times the number
reported by all of California the previous year. Initial efforts
to
control this outbreak by treating patients and their sexual
partners
with recommended regimens were unsuccessful. The eventual success
of
the control program was attributed to the policy of offering
prophylactic therapy to certain high-risk groups whose members were
either asymptomatic or had genital ulcers with no definitive
diagnosis. These groups included: 1) prostitutes in the county
jail,
2) clinic patients reporting prostitute contact, and 3) clinic
patients with darkfield-negative genital ulcers. Continued
surveillance and therapeutic action will be necessary if chancroid
is
to remain controlled.
Handsfield HH, Totten PA, Fennel CL, Falkow S, Holmes KK.
Molecular epidemiology of Haemophilus ducreyi infections. Ann
Intern Med 1981;95(3):315-8.
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