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Increase in Urgent Care Center Visits for Sexually Transmitted Infections, United States, 2010–2014 - Volume 23, Number 2—February 2017 - Emerging Infectious Disease journal - CDC

Increase in Urgent Care Center Visits for Sexually Transmitted Infections, United States, 2010–2014 - Volume 23, Number 2—February 2017 - Emerging Infectious Disease journal - CDC



Volume 23, Number 2—February 2017

Research Letter

Increase in Urgent Care Center Visits for Sexually Transmitted Infections, United States, 2010–2014

William S. PearsonComments to Author , Guoyu Tao, Karen Kroeger, and Thomas A. Peterman
Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Abstract

During 2010–2014, urgent care centers saw a ≈2-fold increase in the number of visits for chlamydia and gonorrhea testing and a >3-fold increase in visits by persons with diagnosed sexually transmitted infections. As urgent care becomes more popular, vigilance is required to ensure proper management of these diseases.
Sexually transmitted infections (STIs) are the most commonly reported nationally notifiable diseases in the United States (1), and annual medical costs for these diseases are estimated to exceed $16 billion (2). Reported rates of gonorrhea, chlamydia, and syphilis all increased from 2014 to 2015, and antimicrobial drug–resistant gonorrhea remains an important concern (3). Therefore, proper diagnosis and treatment of these diseases is essential to reduce STI-associated morbidity rates and prevent further drug resistance (4).
Urgent care centers have been identified as appropriate sources of care for nonemergency conditions that would otherwise be treated in a more costly emergency department setting (5). These centers are proliferating across the country because of public demand for convenient care and the need to contain healthcare costs (6). The Urgent Care Association of America estimates that >9,000 of these centers are currently operating in the United States and, on average, each center sees ≈14,000 visits per year (7). Additionally, STI clinics are closing across the country because of decreased funding (8); therefore, urgent care centers might increasingly be a typical setting for STI diagnosis and treatment.
We found no literature describing the frequency of diagnosis and treatment of STIs in urgent care settings. Therefore, we set out to estimate the number of visits to urgent care centers for the testing and diagnosis of chlamydia and gonorrhea.
For these analyses, we used data from the MarketScan commercially insured medical claims database for 2010, 2012, and 2014 (9). We only included claims for visits to urgent care centers and aggregated these claims to provide numbers of visits for each patient. We then searched the claims for Current Procedural Terminology (CPT) codes and codes from the International Classification of Diseases, Ninth Revision, that indicated the testing or diagnosis of chlamydia, gonorrhea, or an “unspecified venereal disease” (Table). We counted visits that involved a test or diagnosis for each of the indicated diseases for each year and stratified these results by percentage of female patients and the average age of the patients. We then used weights supplied in the dataset and calculated weighted numbers of visits. All analyses were conducted by using SAS 9.3 (SAS Institute, Cary, NC, USA).
Overall, we estimated a ≈2.5-fold increase during 2010–2014 for all visits to urgent care centers (Technical Appendix[PDF - 170 KB - 1 page]). Among these visits, we observed increases in the numbers of visits that involved STI testing or the treatment of patients with diagnosed STIs. During 2010–2014, a ≈1.5-fold increase occurred in visits that involved chlamydia testing and a ≈2-fold increase in visits involving gonorrhea testing. We observed even larger increases in visits that involved diagnosed STIs. During the same period, we observed a ≈6-fold increase in the numbers of visits that involved diagnosed chlamydia, a >3-fold increase in the numbers of visits that involved diagnosed gonorrhea, and a ≈6-fold increase in the numbers of visits that involved an unspecified diagnosed STI. Most visits that involved STI testing were made by female patients; the average age for all patients at these visits was 28.1 years. Most visits by a patient for diagnosed chlamydia were made by female patients; the average age for all patients at these visits was 27.8 years. The number of visits by patients for an unspecified diagnosed STI was nearly evenly split between male and female patients; the average age of all patients at these visit was 30.4 years. The visits for diagnosed gonorrhea were predominantly made by male patients; the average age of all patients at these visits was 29.9 years.
Visits to urgent care centers have increased over time, and our findings demonstrate that visits to urgent care centers for STI care in particular have dramatically increased. Previous work has highlighted differences in the use of antibiotics to treat chlamydia in emergency departments compared with physician offices (10) suggesting that differences might also exist in the treatment of STIs in urgent care centers compared with other healthcare settings. Given the increases in STIs, increases in antimicrobial drug resistance, and increases in use of urgent care centers for STI care, further work is needed to determine how STIs are being managed in this venue to ensure quality care.
Dr. Pearson is a health scientist in the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta. His primary research interests include the organization, financing, and delivery of healthcare services.

References

  1. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2014. Atlanta: US Department of Health and Human Services; 2015 [cited 2016 Sep 7]. https://www.cdc.gov/std/stats14
  2. Owusu-Edusei K JrChesson HWGift TLTao GMahajan ROcfemia MCet al. The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008. Sex Transm Dis2013;40:197201DOIPubMed
  3. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2015. Atlanta: US Department of Health and Human Services; 2016 [cited 2016 Oct 7]. https://www.cdc.gov/std/stats15
  4. Workowski KABolan GACenters for Disease Control and PreventionSexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep2015;64(RR-03):1137.PubMed
  5. Weinick RMBurns RMMehrotra AMany emergency department visits could be managed at urgent care centers and retail clinics. Health Aff (Millwood)2010;29:16306DOIPubMed
  6. Yee TLechner AEBoukus ERThe surge in urgent care centers: emergency department alternative or costly convenience? Res Brief2013;26:16.PubMed
  7. American Association of Urgent Care Centers2015 Urgent Care Industry Headlines [cited 2016 Aug 21]. http://c.ymcdn.com/sites/www.ucaoa.org/resource/resmgr/Infographics/2015_BM_Survey_Headlines_Sum.pdf
  8. Golden MRKerndt PRImproving clinical operations: can we and should we save our STD clinics? Sex Transm Dis2010;37:2645https://dx.doi.org/10.1097/OLQ.0b013e3181d5e01ePubMed
  9. Truven Health Analytics. MarketScan database [cited 2016 Sep 7]. https://marketscan.truvenhealth.com/marketscanportal
  10. Pearson WSGift TLLeichliter JSJenkins WDDifferences in the treatment of Chlamydia trachomatis by ambulatory care setting. J Community Health2015;40:111521DOIPubMed

Table

Technical Appendix

Cite This Article

DOI: 10.3201/eid2302.161707

Reoccurrence of Avian Influenza A(H5N2) Virus Clade 2.3.4.4 in Wild Birds, Alaska, USA, 2016 - Volume 23, Number 2—February 2017 - Emerging Infectious Disease journal - CDC

Reoccurrence of Avian Influenza A(H5N2) Virus Clade 2.3.4.4 in Wild Birds, Alaska, USA, 2016 - Volume 23, Number 2—February 2017 - Emerging Infectious Disease journal - CDC



Volume 23, Number 2—February 2017

Research Letter

Reoccurrence of Avian Influenza A(H5N2) Virus Clade 2.3.4.4 in Wild Birds, Alaska, USA, 2016

Figures

Technical Appendices

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Dong-Hun Lee, Mia K. TorchettiComments to Author , Mary Lea Killian, Thomas J. DeLiberto, and David E. Swayne
Author affiliations: US Department of Agriculture, Athens, Georgia, USA (D.-H. Lee, D.E. Swayne)US Department of Agriculture, Ames, Iowa, USA (M.K. Torchetti, M.L. Killian)US Department of Agriculture, Fort Collins, Colorado, USA (T.J. DeLiberto)

Abstract

We report reoccurrence of highly pathogenic avian influenza A(H5N2) virus clade 2.3.4.4 in a wild mallard in Alaska, USA, in August 2016. Identification of this virus in a migratory species confirms low-frequency persistence in North America and the potential for re-dissemination of the virus during the 2016 fall migration.
Historically, apparently effective geographic barriers (Bering and Chukchi Seas of the North Pacific Ocean) appeared to limit dissemination of Asian-origin, highly pathogenic avian influenza virus (HPAIV), such as influenza A(H5N1) virus A/goose/Guangdong/1/1996 (Gs/GD), between the Old and New Worlds (1). However, such barriers are incomplete; occasional spillovers of virus genes move from 1 gene pool to another (2). Asian-origin HPAIV H5N8 was identified in North America at the end of 2014 (3).
Novel HPAIVs H5N1, H5N2, and H5N8 emerged in late 2014 by reassortment with North American low pathogenicity avian influenza viruses (4). A novel reassortant H5N2 virus originating from Asian-origin H5N8 virus clade 2.3.4.4 and containing Eurasian polymerase basic 2, polymerase acidic, hemagglutinin, matrix, and nonstructural protein genes and North American lineage neuraminidase (NA), polymerase basic 1 (PB1), and nucleoprotein genes was identified on poultry farms in British Columbia, Canada, and in wild waterfowl in the northwestern United States. This virus subsequently predominated during influenza outbreaks in the United States in 2015.
During the boreal summer, birds from 6 continents (North America, South America, Asia, Africa, Australia, and Antarctica) fly to Alaska, USA, to breed. Thus, Alaska is a potentially major location for intercontinental virus transmission (1,2). Recent data provide direct evidence for viral dispersal through Beringia (5,6). Genetic evidence and waterfowl migratory patterns support the hypothesis that H5 virus clade 2.3.4.4 was introduced into North America through the Beringian Crucible by intercontinental associations with waterfowl (3). In addition, low pathogenicity avian influenza viruses were collected in Alaska before initial detection of H5 HPAIV clade 2.3.4.4, which contained genes that had recent common ancestry with reassortant H5N2 virus PB1, nucleoprotein, and NA (N2 subtype) genes and H5N1 virus PB1, polymerase acidic, NA (N1 subtype), and nonstructural protein genes of HPAIVs (7).
We report detection of an HPAIV H5N2 subtype from wild mallard sampled in Alaska during August 2016. Influenza A virus was detected in 48/188 dabbling duck samples collected during a live bird banding effort near Fairbanks, Alaska, during August 6–15, 2016. One sample of H5 virus from an adult mallard was identified as an HPAIV H5N2 on the basis of complete genome sequencing. We conducted comparative phylogenetic analysis of A/mallard/Alaska/AH0008887/2016(H5N2) virus, hereafter known as 8887/2016(H5N2) virus, to trace its origin and understand its genetic relationship to HPAIV H5N2 isolated in 2014–2015 (Technical Appendix[PDF - 2.18 MB - 8 pages]).
We considered 8887/2016(H5N2) virus an HPAIV on the basis of amino acid sequence at the hemagglutinin proteolytic cleavage site (PLRERRRKR/G), as shown for other Gs/GD HPAIV H5Nx subtypes in subclade 2.3.4 (http://www.offlu.net/fileadmin/home/en/resource-centre/pdf/Influenza_A_Cleavage_Sites.pdf). Homology BLAST searches showed that all genes had >99.2% nucleotide similarity with genes of H5N2 virus outbreak strains collected during late February–March 2015 (Technical Appendix[PDF - 2.18 MB - 8 pages] Table).
Thumbnail of Maximum clade credibility phylogeny of concatenated complete genome sequences of avian influenza A(H5N2) virus clade 2.3.4.4 in wild birds, Alaska, USA, 2016. Horizontal bars indicate 95% Bayesian credible intervals for estimates of common ancestry. Bold indicates a genetic cluster that includes A/mallard/Alaska/AH00088535/2016/08/12(H5N2) virus and related viruses. Scale bar indicates years.
Figure. Maximum clade credibility phylogeny of concatenated complete genome sequences of avian influenza A(H5N2) virus clade 2.3.4.4 in wild birds, Alaska, USA, 2016. Horizontal bars indicate 95% Bayesian credible intervals for estimates...
Phylogenetic analysis showed that the concatenated genome of 8887/2016(H5N2) virus formed a cluster with viruses from initial detections in the midwestern United States, including a snow goose in Missouri, a backyard poultry farm in Kansas, and a turkey farm in Minnesota (Figure). Our epidemiologic investigation data suggested that point-source introductions by indirect contact with wild waterfowl were the most probable source of infection for these backyard poultry in Kansas and a turkey farm in Minnesota (8). This genetic cluster was supported by a maximum-likelihood bootstrap value of 80 and a Bayesian posterior probability of 1.00.
The mean time to most recent common ancestry of viruses in this genetic cluster was estimated to be the end of January 2015 (mean time to most recent common ancestry January 27, 2015, 95% Bayesian credible interval January 11–February 10, 2015). Consistent clustering of 8887/2016(H5N2) virus with other H5N2 outbreak viruses in phylogenies for each gene suggests that the 8887/2016(H5N2) virus probably evolved through genetic drift from common ancestors of outbreak viruses in the absence of further reassortment (Technical Appendix[PDF - 2.18 MB - 8 pages] Figure 2). The mean rate of the nucleotide substitution obtained by Bayesian analysis was 6.064 × 10–3 (95% Bayesian credible interval 4.43–7.82 × 10–3) substitutions/site/year. In the root-to-tip regression plot of maximum-likelihood phylogeny, we found that 8887/2016(H5N2) virus fell below the regression line, which indicated sequences that are slightly less divergent than average of 2014–2015 H5N2 outbreak viruses (Technical Appendix[PDF - 2.18 MB - 8 pages] Figure 3).
The last reported detection during the influenza outbreak in the United States in 2015 was from a Canada goose in Michigan on June 17. There were 2 detections by PCR (3 assays, 2 gene targets, no virus recovered, no sequence obtained) from mallards in July (bird banding effort in Utah) and November (hunter harvest in Oregon) during surveillance in 2015–2016. Sequence of the HPAIV H5N2 from a wild mallard during surveillance in 2016–2017, evidence for continued evolution of this virus lineage, widespread detections of HPAIV H5N2 in healthy wild birds (9), and lack of pathobiological effects in experimentally infected waterfowl (10) collectively provide strong evidence for maintenance of HPAIV H5N2 in wild birds in North America. Detection of HPAIV in a mallard might imply the potential for dissemination of HPAIV H5N2 during the southward fall migration of waterfowl in 2016.
Dr. Lee is postdoctoral researcher at the US Department of Agriculture, Athens, GA. His research interests include molecular epidemiology and host–pathogen interactions for avian influenza viruses.

Acknowledgment

We thank Michael J. Petrula and David Sinnett for collecting samples; Kerrie Franzen, Meredith Grady, Andrew Hubble for providing technical assistance; the Washington State Animal Disease Diagnostic Laboratory for their participation in wild bird surveillance activities, and the originating and submitting institution (Kagoshima University, Kagoshima, Japan) for A/crane/Kagoshima/KU1/2014(H5N8) sequences (accession no. EPI169390] from the GISAID EpiFlu Database (http://platform.gisaid.org).

References

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  2. Koehler AVPearce JMFlint PLFranson JCIp HSGenetic evidence of intercontinental movement of avian influenza in a migratory bird: the northern pintail (Anas acuta). Mol Ecol2008;17:475462DOIPubMed
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  6. Lee DHPark JKYuk SSErdene-Ochir TOKwon JHLee JBet al. Complete genome sequence of a natural reassortant H9N2 avian influenza virus found in bean goose (Anser fabalis): direct evidence for virus exchange between Korea and China via wild birds. Infect Genet Evol2014;26:2504DOIPubMed
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  8. Animal and Plant Health Inspection Service, US Department of Agriculture. Epidemiologic and other analyses of HPAI-affected poultry flocks: September 9, 2015 Report [cited 2016 Oct 28]. https://www.aphis.usda.gov/animal_health/animal_dis_spec/poultry/downloads/Epidemiologic-Analysis-Sept-2015.pdf
  9. Bevins SNDusek RJWhite CLGidlewski TBodenstein BMansfield KGet al. Widespread detection of highly pathogenic H5 influenza viruses in wild birds from the Pacific Flyway of the United States. Sci Rep2016;6:28980DOIPubMed
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Figure

Technical Appendix

Cite This Article

DOI: 10.3201/eid2302.161616