Sexually Transmitted Disease Surveillance 1995
Division of STD Prevention September 1996 U.S. Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Center for HIV, STD, and TB Prevention Division of STD Prevention Atlanta, Georgia 30333 Copyright Information All material contained in this report is in the public domain and may be used and reprinted without special permission; citation to source, however, is appreciated. Suggested Citation Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1995. U.S. Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention, September 1996. Copies can be obtained from Information Technology and Services Office, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-06, Atlanta, Georgia 30333 or by telephone at (404) 639-1819. The reports for 1993 through 1995 are now available electronically on CDC WONDER. For information about registering for CDC WONDER, please contact CDC's Information Resource Management Office at (404) 332-4569. These reports are also available from the Internet via the CDC home page address http://www.cdc.gov. National Profile The National Profile section contains figures showing trends and distribution of sexually transmitted diseases (STDs) by age, gender, race/ethnicity, and location for the United States. Where relevant, the figures illustrate progress toward specific year 2000 goals for the nation published in Healthy People 2000: Midcourse Review and 1995 Revisions *. Chlamydia Infections due to Chlamydia trachomatis are among the most prevalent of all sexually transmitted diseases. In women, these infections often result in serious reproductive tract complications, such as pelvic inflammatory disease, infertility, and ectopic pregnancy. In addition, infected pregnant women can infect their babies during delivery. Furthermore, chlamydia facilitates HIV transmission. While surveillance of chlamydial infections is improving, it remains incomplete in many areas of the country. A combination of factors limits documentation of the incidence and prevalence of genital chlamydial infection: large numbers of asymptomatic persons who can be identified only through screening; limited resources to support screening activities; variable compliance with public health laws and regulations that require health care providers and laboratories to report cases to local health authorities; and incompletely developed information management systems for collecting, maintaining, and analyzing morbidity and prevalence data. Thus, for most areas, the number of reported chlamydia cases reported to CDC by state health departments reflects the degree of local interest in chlamydia as a public health problem and reporting limitations rather than true disease burden or trends. -- In 1995, 477,638 chlamydial infections were reported to CDC from 49 states (Table_3). This is the second consecutive year that reported cases of chlamydia exceeded reported cases of gonorrhea (392,848 gonorrhea cases in 1995, Table_1). -- From 1984 through 1995 reported rates of chlamydia increased dramatically, from 3.2 cases per 100,000 population to 182.2 (Figure_1). Trends continue to reflect primarily increased screening, recognition of asymptomatic infection (mainly in women), and improved reporting capacity rather than true trends in disease incidence. -- As in previous years, rates of chlamydia were highest in the West and the Midwest, where substantial resources have been committed for organized screening programs (e.g., in family planning clinics) (Figure_3, Table_3). In the areas where these screening programs are in place, chlamydia rates far exceed gonorrhea rates. From 1994 to 1995, reported chlamydia rates declined in the West (from 214.7 cases per 100,000 population to 191.1), and in the Midwest (from 218.4 to 206.4), but increased in the South and Northeast. -- Between 1994 and 1995 rates of chlamydia reported from large cities (>200,000 population) decreased 5% from 327.2 cases per 100,000 population to 310.5 (Figure_4, Table_6). -- Reported rates of chlamydia for women (290.3 per 100,000 population) exceed those for men (52.1 per 100,000 population) (Figure_5, Table_4, Table_5, Table_7, and Table_8). This is mainly due to increased detection of asymptomatic infection in women through screening. The low rates in men suggest that many of the sex partners of women with chlamydia are not diagnosed or reported. In addition, men diagnosed as having non-gonococcal urethritis are treated, but frequently are not tested specifically for chlamydia. A large proportion of these men are infected with chlamydia, but they are not detected by surveillance systems based on laboratory reporting of positive chlamydia tests. -- Additional information on chlamydia screening programs for women of reproductive age and chlamydia among adolescents and minority populations can be found in the Special Focus Profiles section. Figure_1. Chlamydia -- Reported rates: United States, 1984-1995 Figure_2. Chlamydia -- Rates by state: United States, 1995 Figure_3. Chlamydia -- Rates by region: United States, 1984-1995 Figure_4. Chlamydia -- Rates in U.S. cities of >200,000 population, 1984-1995 Figure_5. Chlamydia -- Rates by gender: United States, 1984-1995 Gonorrhea Infections due to Neisseria gonorrhoeae, like those due to Chlamydia trachomatis, remain a major cause of pelvic inflammatory disease, tubal infertility, ectopic pregnancy, and chronic pelvic pain in the United States. Epidemiologic studies provide strong evidence that gonococcal infections facilitate HIV transmission, and biological studies have begun to elucidate the specific mechanisms through which this facilitation may occur. Reporting of gonococcal infections has likely been biased towards reporting of infections among persons of minority race/ethnicity who attend public STD clinics. This bias may partially explain the large reported race differentials among persons with this disease. -- In 1995, 392,848 cases of gonorrhea were reported in the United States. The rate of gonorrhea has continued its overall decline since 1975. Between 1994 and 1995 the rate decreased from 165.1 cases per 100,000 population to 149.5 (Table_1 and Figure_6). -- In 1995, 27 states/areas reported gonorrhea rates below the revised Healthy People 2000 (HP2000) national objective of 100 cases per 100,000 population (Figure_7 and Table_10). Gonorrhea rates increased between 1994 and 1995 in 6 of 36 states reporting more than 1,000 cases in 1995, down from 20 of the 35 states with more than 1,000 cases in 1994 (Table_11). -- Gonorrhea rates decreased in all regions in 1995. The South continued to have a higher rate than other regions (Figure_8). -- Although the overall gonorrhea rate for large cities (selected cities with >200,000 population) continued to decline in 1995 (Figure_9), 55 (86%) of 64 large cities had rates exceeding the revised HP2000 objective (Table_14). -- The gonorrhea rate in men continued to decline in 1995, and the rate in women decreased after a one-year increase from 1993 to 1994. Rates in men remained above the HP2000 objective in 28 states and rates in women remained above the HP2000 objective in 26 states (Figure_10; Table_12 and Table_13). -- In 1995, gonorrhea rates decreased for all racial and ethnic groups except Hispanics (Figure_11 and Table_9B). However, the rates for Hispanics and all other racial and ethnic groups except non-Hispanic blacks remained below the HP2000 objective (Figure_11 and Table_9B). The gonorrhea rate for blacks decreased by 9%, from 1,200.7 cases per 100,000 population in 1994 to 1,086.9 in 1995 (Table_9B), but remained almost 40 times greater than the rate for non-Hispanic whites. -- Between 1994 and 1995, the gonorrhea rate for 15- to 19-year-old adolescents decreased by 10%, from 739.2 to 664.6 cases per 100,000 population, after increasing slightly from 1993 to 1994. Overall, 15- to 19-year-olds had higher rates than any other age group (Table_9B). In most minority populations, 20- to 24-year-olds had the highest age-specific rates. -- Antimicrobial resistance remains an important consideration in the treatment of gonorrhea. Overall, 31.6% of isolates collected in 1995 by the Gonococcal Isolate Surveillance Project (GISP) were resistant to penicillin, tetracycline, or both (Table_18). Between 1991 and 1995, the percentage of GISP isolates that were penicillinase producing Neisseria gonorrhoeae (PPNG) declined from 13.1% to 6.8% (Figure_14). In contrast, isolates with chromosomally mediated resistance to penicillin increased from 6.4% in 1991 to 7.0% in 1995 (Figure_15). Chromosomally mediated tetracycline resistance increased from 1994 (13.5%) to 1995 (15.4%) after several years of stable prevalence (Figure_15). A growing number of GISP isolates have demonstrated decreased susceptibility to ciprofloxacin, one of the currently recommended treatments for gonorrhea. Resistance to ciprofloxacin was first identified in GISP in 1991 but remains rare (Figure_16). Reduced susceptibility and resistance to ciprofloxacin correlate with reduced susceptibility and resistance to other fluoroquinolone antibiotics. -- Additional information about gonorrhea in racial and ethnic minority populations and adolescents can be found in the Special Focus Profiles section. Figure_6. Gonorrhea -- Reported rates: United States, 1970-1995 and the Healthy People year 2000 objective Figure_7. Gonorrhea -- Rates by state: United States, 1995 Figure_8. Gonorrhea -- Rates by region: United States, 1981-1995 and the Healthy People year 2000 objective Figure_9. Gonorrhea -- Rates in U.S. cities of >200,000 population, 1981-1995 and the Healthy People year 2000 objective Figure_10. Gonorrhea -- Rates by gender: United States, 1981-1995 and the Healthy People year 2000 objective Figure_11. Gonorrhea -- Rates by race and ethnicity: United States, 1981 1995 and the Healthy People year 2000 objective Figure_12. Gonorrhea -- Age- and gender-specific rates: United States, 1995 Figure_13. Gonococcal Isolate Surveillance Project (GISP) -- Location of participating clinics and regional laboratories: United States, 1995 Figure_14. Gonococcal Isolate Surveillance Project (GISP) -- Trends in plasmid-mediated resistance to penicillin and tetracycline, 1988-1995 Figure_15. Gonococcal Isolate Surveillance Project (GISP) -- Trends in chromosomally mediated resistance to penicillin and tetracycline, 1988-1995 Figure_16. Gonococcal Isolate Surveillance Project (GISP) -- Prevalence of Neisseria gonorrhoeae with decreased susceptibility or resistance to ciprofloxacin, 1990-1995 Syphilis Although the U.S. syphilis rate declined in 1995 to its lowest level in many years, this disease remains an important problem in certain geographical areas, particularly among African-Americans. Syphilis, a genital ulcerative disease, facilitates the transmission of HIV infection, and may be particularly important in contributing to HIV transmission in those parts of the country, such as the South, where rates of both infections are high. Untreated early syphilis during pregnancy results in perinatal death in up to 40% of cases, and, if acquired in the previous four years, may lead to infection of the fetus in over 70% of cases. For syphilis, as for other STDs, differential reporting of cases from public and private sectors may magnify the differences in reported rates by race/ethnicity. -- In 1995, 16,500 cases of primary and secondary (P&S) syphilis were reported to CDC. This is the fewest cases reported since 1960. Between 1994 and 1995, the incidence of P&S syphilis in the United States declined from 7.9 to 6.3 cases per 100,000 population (Figure_18 and Table_1). -- In 1995, P&S syphilis rates were below the revised Healthy People 2000 (HP2000) national objective of 4 cases per 100,000 population in 33 states (Figure_19 and Table_22). Twelve states reported no or fewer than 5 cases of P&S syphilis in 1995. -- In 1995, 2,144 (69%) of 3,116 counties in the United States reported no cases of P&S syphilis compared with 2,105 (68%) counties in 1994. Of 972 counties reporting at least one case of P&S syphilis in 1995, 384 (40%) counties reported rates of 4 cases or less per 100,000 population (Figure_20). Therefore, the rates of P&S syphilis were above the revised HP2000 objective (4.0 per 100,000) for 588 counties in 1995. These counties (19% of the total counties in the United States) accounted for 89% of all reported P&S syphilis cases. -- In 1995, the rates of P&S syphilis continued to decline for all regions of the United States. However, the rates of 12.1 and 5.6 cases per 100,000 population in the South and Midwest, respectively, were above the revised HP2000 objective (Figure_21 and Table_23). -- The overall rate of P&S syphilis in large cities (>200,000 population) declined from 12.6 cases per 100,000 population in 1994 to 10.0 in 1995 (Figure_22 and Table_27). However, rates exceeded the revised HP2000 objective in 38 (59%) of 64 large cities in the United States and outlying areas for which data were available (Table_26). -- During the period 1992-1995, the rates of P&S syphilis have generally declined regardless of racial and ethnic group (Figure_24 and Table_21B). However, the 1995 rate for non-Hispanic blacks of 46.2 cases per 100,000 population was nearly 60 times greater than the rate for non-Hispanic whites (Figure_24 and Table_21B). -- Between 1994 and 1995, the overall rate of congenital syphilis decreased from 55.6 to 39.0 cases per 100,000 live births (Figure_27, Table_34). However, compared with 1994, increases were observed in 1995 for six (California, Florida, Georgia, Maryland, Mississippi, Oklahoma) of the 25 states reporting more than five cases (Table_35). -- In 1995, 12 states (Arkansas, California, Florida, Georgia, Illinois, Louisiana, Mississippi, Missouri, New Jersey, New York, Pennsylvania, South Carolina) had congenital syphilis rates that exceeded the revised HP2000 objective of 40 cases per 100,000 live births (Table_35). -- Additional information on syphilis and congenital syphilis can be found in the Special Focus Profiles section. Figure_17. Syphilis -- Reported cases by stage of illness: United States, 1941-1995 Figure_18. Primary and secondary syphilis -- Reported rates: United States, 1970-1995 and the Healthy People year 2000 objective Figure_19. Primary and secondary syphilis -- Rates by state: United States, 1995 Figure_20. Primary and secondary syphilis -- Counties with rates above and counties with rates below the Healthy People year 2000 objective: United States, 1995 Figure_21. Primary and secondary syphilis -- Rates by region: United States, 1981-1995 and the Healthy People year 2000 objective Figure_22. Primary and secondary syphilis -- Rates in U.S. cities of >200,000 population, 1981-1995 and the Healthy People year 2000 objective Figure_23. Primary and secondary syphilis -- Rates by gender: United States, 1981-1995 and the Healthy People year 2000 objective Figure_24. Primary and secondary syphilis -- Rates by race and ethnicity: United States, 1981-1995 and the Healthy People year 2000 objective Figure_25. Primary and secondary syphilis -- Age- and gender-specific rates: United States, 1995 Figure_26. Congenital syphilis -- Reported cases in infants <1 year of age and rates of primary and secondary syphilis among women: United States, 1970-1995 Figure_27. Congenital syphilis -- Rates in infants <1 year of age: United States, 1981-1995 and the Healthy People year 2000 objective Other Sexually Transmitted Diseases -- Hospitalizations for acute and chronic pelvic inflammatory disease (PID) have declined since the early 1980's (Figure_28). Initial visits to physicians' offices for PID declined from 1993 to 1995 (Figure_29). In 1993, an estimated 313,000 women aged 15-44 years were diagnosed with PID in emergency departments (National Ambulatory Medical Care Survey, NCHS). -- Since 1987, reported cases of chancroid have declined steadily (Table_1, Figure_31). -- Comprehensive surveillance data for non-gonococcal urethritis, genital herpes simplex virus, human papillomavirus, and trichomoniasis are not available. Ongoing trend data are limited to estimates of trends in physicians' office practices provided by the National Disease and Therapeutic Index (Figure_30, Figure_32, Figure_33, Figure_34). Figure_28. Pelvic inflammatory disease -- Hospitalizations of women 15-44 years of age: United States, 1980-1993 Figure_29. Pelvic inflammatory disease -- Initial visits to physicians' offices by women 15-44 years of age: United States, 1980-1995 and the Healthy People year 2000 objective Figure_30. Nonspecific urethritis -- Initial visits to physicians' offices by men: United States, 1966-1995 Figure_31. Chancroid -- Reported cases: United States, 1981-1995 Figure_32. Human papillomavirus (genital warts) -- Initial visits to physicians' offices: United States, 1966-1995 and the Healthy People year 2000 objective Figure_33. Genital herpes simplex virus infections -- Initial visits to physicians' offices: United States, 1966-1995 and the Healthy People year 2000 objective Figure_34. Trichomonal and other vaginal infections -- Initial visits to physicians' offices: United States, 1966-1995
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