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Sexually Transmitted Disease Surveillance 1994

Division of STD Prevention

September 1995

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 (proposed)
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,
1994. U.S. Department of Health and Human Services, Public Health Service.
Atlanta: Centers for Disease Control and Prevention, September 1995.

Copies can be obtained from Information Technology and Services Office,
National Center for HIV, STD, and TB Prevention (proposed), Centers for
Disease Control and Prevention, 1600 Clifton Road, Mailstop E-06, Atlanta,
Georgia 30333 or by telephone at (404) 639-1819.

Both the 1993 and 1994 reports 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.
                                    
                         Special Focus Profiles

The Special Focus Profiles section highlights trends and distribution of
sexually transmitted diseases (STDs) in populations of particular interest
for STD and HIV prevention programs in state and local health departments.
These populations are most vulnerable to STDs and their consequences: 
women and infants; adolescents and young adults; minorities; and
populations in the southern United States. The Special Focus Profiles refer
to figures located in disease-specific sections in the National Profile. In
addition, there are figures (Figures A-P) that highlight specific points
made in the following text.

                        STDs in Women and Infants

Public Health Impact

Women and infants disproportionately bear the long term consequences of
STDs. Women infected with Neisseria gonorrhoeae or Chlamydia trachomatis
can develop pelvic inflammatory disease (PID), which, in turn, may lead to
adverse reproductive consequences, e.g., ectopic pregnancy and tubal factor
infertility. If not adequately treated, 20 to 40 percent of women infected
with chlamydia (1) and 10 to 40 percent of women infected with gonorrhea
(2) develop PID. Among women with PID, scarring sequelae will cause
involuntary infertility in 20 percent, ectopic pregnancy in 9 percent, and
chronic pelvic pain in 18 percent (3). Approximately 70 percent of
chlamydia infections and 50 percent of gonococcal infections in women are
asymptomatic (4-6). These infections are detected primarily through
screening programs. The vague symptoms associated with chlamydial and
gonococcal PID cause 85% of women to delay seeking medical care, thereby
increasing the risk of infertility and ectopic pregnancy (7). Ectopic
pregnancy is the leading cause of first-trimester, pregnancy-related deaths
in African-American women (8).

When a woman has a syphilis infection during pregnancy, she may transmit
the infection to the fetus in utero. This may result in fetal death or an
infant born with physical and mental developmental disabilities. Most cases
of congenital syphilis (CS) are preventable if women are screened for
syphilis and treated early through prenatal care (9).

HIV-infected pregnant women can pass this fatal infection to their unborn
infants. Treatment with zidovudine during pregnancy can prevent as much as
two-thirds of these infections (10,11).

Observations

 --  Since 1988, CDC has supported screening programs for Chlamydia
     trachomatis infections in women to define the prevalence of these
     infections and determine the impact of screening programs on
     prevention of long term consequences. Due to increasing interest in
     chlamydial infections, many states have implemented reporting
     procedures for chlamydia and begun collecting chlamydia case data. In
     1994, 46 states had implemented legislation mandating reporting of
     chlamydia and reported cases to CDC; an additional state without
     reporting laws collected and reported cases on a voluntary basis
     (Figure_A, Table_3).

 --  Between 1993 and 1994, the reported rate of chlamydial infections in
     women increased from 249.7 per 100,000 population to 265.3
     (Figure_5, Table_4). These rates reflect trends in screening
     rather than trends in disease incidence for the following reasons:
     chlamydia infections in women are largely asymptomatic and can only be
     identified through screening; reported cases include both prevalent
     and incident cases; many state/local health departments are in the
     process of developing chlamydia prevention programs, including
     surveillance infrastructure to collect information from laboratories
     and providers. Currently, despite considerable under reporting, it is
     important to note that chlamydia rates exceed gonorrhea rates in women
     in many states (Figure_B, Table_4 and Table_12).

 --  The ability of large-scale screening programs to reduce chlamydia
     prevalence in women has been documented in areas where this
     intervention has been in place for several years. For example, the
     screening programs in federal Region X (Alaska, Idaho, Oregon,
     Washington) family planning clinics have demonstrated steady declines
     in chlamydia prevalence since 1988 (Figure_C).

 --  Like chlamydia, gonorrhea is often asymptomatic in women and can only
     be identified through screening. Large-scale screening programs for
     gonorrhea in women began in the late 1970's. After an initial increase
     in cases detected through screening, gonorrhea rates for both women
     and men declined steadily throughout the 1980's and early 1990's
     (Figure_10; Table_12 and Table_13). Compared with 1993, in
     1994, gonorrhea rates increased slightly for women from 147.1 cases
     per 100,000 population in 1993 to 153.7; rates in men continued to
     decline during this period. Men with gonorrhea are usually symptomatic
     and seek care; therefore, trends in men are considered a relatively
     good indicator of incidence trends in disease. However, trends in
     women are largely determined by screening patterns, similar to
     chlamydia. An indication that the declining trends in gonorrhea may be
     attributed in part to the screening programs is the pattern of the
     gonorrhea male-to-female rate ratio (M:F RR). In 1980, the M:F RR was
     1.5 and has declined steadily to 1.2 in 1994. In the absence of known
     outbreaks of gonorrhea in men who have sex with men (which tend to
     occur sporadically), the steadily declining M:F RR suggests that
     decreasing gonorrhea trends may be due in large part to many infected
     women being identified and treated through screening programs.

 --  The rate of CS closely follows the trend of primary and secondary
     (P&S) syphilis in women (Figure_26). Peaks in CS usually occur one
     year after peaks in P&S syphilis in women. The CS rate peaked in 1991
     at 107.6 cases per 100,000 live births and has declined 48% to 55.6 in
     1994 (Figure_27 and Table_34). The rate of P&S syphilis in
     women peaked at 17.3 per 100,000 population in 1990 and declined 56%
     to 7.6 in 1994 (Figure_23 and Figure_26; Table_24).
     Although the rate of CS is approaching the Healthy People 2000
     national objective of 50 cases per 100,000 live births, this objective
     is many times greater than the rate of CS of most industrialized
     countries where syphilis and CS have nearly been eliminated (12).

 --  Accurate estimates of pelvic inflammatory disease (PID) and tubal
     factor infertility from gonococcal and chlamydial infections are
     difficult to obtain largely due to the requirement for complex and
     invasive procedures (e.g., laparoscopy or laparotomy, and tubal
     patency studies) to accurately document these conditions. Most cases
     of PID are treated on the basis of interpretations of clinical
     findings, which vary between individual practitioners. In addition,
     the settings in which care is provided can vary considerably over
     time. For example, women with PID who would have been hospitalized in
     the 1980's may be treated in out-patient facilities during 1990's.
     These factors make surveillance for PID difficult. Trends in
     hospitalized PID have declined steadily throughout the 1980's and
     early 1990's (Figure_28). However, these trends may be more
     reflective of changes in hospitalization rates rather than true trends
     in disease (13).

 --  Recent evidence suggests that health care practices associated with
     ectopic pregnancy also changed in the late 1980's and early 1990's.
     Before that time, treatment of ectopic pregnancy usually required
     admission to a hospital. Hospitalization statistics were therefore
     useful for monitoring trends in ectopic pregnancy (Figure_D).
     Beginning in 1990, hospitalizations for ectopic pregnancy began to
     decline. Data from outpatient care surveys suggest that nearly half of
     all ectopic pregnancies are currently treated on an outpatient basis
     (14). The total number of ectopic pregnancies in the U.S. in 1992 was
     estimated at 108,800 (or 19.7 cases per 1,000 pregnancies), the
     highest level in more than two decades (14).

(1) Stamm WE, Guinan ME, Johnson C. Effect of treatment regimens for
Neisseria gonorrhoeae on simultaneous infections with Chlamydia
trachomatis. N Engl J Med 1984;310:545-9.

(2) Platt R, Rice PA, McCormack WM. Risk of acquiring gonorrhea and
prevalence of abnormal adnexal findings among women recently exposed to
gonorrhea. JAMA 1983;250:3205-9.

(3)Westrom L, Joesoef R, Reynolds G, et al. Pelvic inflammatory disease and
fertility: a cohort study of 1,844 women with laparoscopically verified
disease and 657 control women with normal laparoscopy. Sex Transm Dis
1992;19:185-92.

(4) Hook EW III, Hansfield HH. Gonococcal infections in the adult. In:
Holmes KK, Mardh PA, Sparling PF, et al, eds. Sexually Transmitted
Diseases, 2nd edition. New York City: McGraw-Hill, Inc, 1990:149-65.

(5) Stamm WE, Holmes KK. Chlamydia trachomatis infections in the adult. In:
Holmes KK, Mardh PA, Sparling PF, et al, eds. Sexually Transmitted
Diseases, 2nd edition. New York City: McGraw-Hill, Inc, 1990:181-93.

(6) Zimmerman HL, Potterat JJ, Dukes RL, et al. Epidemiologic differences
between chlamydia and gonorrhea. Am J Public Health 1990;80:1338-42.

(7) Hillis SD, Joesoef R, Marchbanks PA, et al. Delayed care of pelvic
inflammatory disease as a risk factor for impaired fertility. Am J Obstet
Gynecol 1993;168:1503-9.

(8) Goldner TE, Lawson HW, Xia Z, et al. Surveillance for ectopic pregnancy
-- United States, 1970-1989. In: CDC Surveillance Summaries, December 17,
1993.MMWR 1993;42(No.SS-6):73-85.

(9) CDC. Guidelines for prevention and control of congenital syphilis. MMWR
1988;37(No.S-1).

(10) CDC. Recommendations of the U.S. Public Health Service task force on
the use of zidovudine to reduce perinatal transmission of human
immunodeficiency virus. MMWR 1994;43(No.RR-11).

(11) Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant
transmission of human immunodeficiency virus type I with zidovudine
treatment. N Engl J Med 1994;331:1173-80.

(12) Division of STD/HIV Prevention. Healthy People 2000: National Health
Promotion and Disease Objectives. Progress Review: Sexually Transmitted
Diseases, October 26, 1994.

(13) Rolfs RT, Galaid EI, Zaidi AA. Pelvic inflammatory disease: trends in
hospitalization and office visits, 1979 through 1988. Am J Obstet Gynecol
1992;166:983-90.

(14) CDC. Ectopic pregnancy -- United States, 1990-1992. MMWR 1995;44:46-8.

Figure_A. Chlamydia - Number of states with reporting laws for
              Chlamydia trachomatis infections and reported rates: United
              States, 1987-1994
Figure_B. Chlamydia - Rates for women by state: United States, 1994    
Figure_C. Chlamydia - Percent positivity among women tested in family
              planning clinics by state: Region X, 1988-1994    
Figure_D. Ectopic pregnancy - Hospitalizations of women 15-44 years of
              age: United States, 1980-1993
                  
                  STDs in Adolescents and Young Adults

Public Health Impact

Adolescents (10- to 19-year-olds) and young adults (20- to 24-year-olds)
are at higher risk for acquiring STDs for a number of reasons:  they may be
more likely to have multiple (sequential or concurrent) sexual partners
rather than a single, long-term relationship; they may be more likely to
engage in unprotected intercourse; and they may select partners at higher
risk. In addition, for some STDs, e.g., Chlamydia trachomatis, adolescent
women may have a physiologically increased susceptibility to infection due
to increased cervical ectopy and lack of immunity. During the past two
decades, premarital sexual experience among adolescent women has steadily
increased resulting in an enlarging pool of young women at risk (1,2). 

Observations

 --  Numerous prevalence studies in various clinic populations have shown
     sexually active adolescents have high rates of chlamydial infection
     (3). Large-scale screening demonstrations projects in federal Region X
     (Alaska, Idaho, Oregon, and Washington) (4) have demonstrated that
     younger women have consistently higher positivity rates of chlamydia
     than older women (Figure_E).

 --  Rates of gonorrhea in 10- to 14-year-old and 15- to 19-year-old
     adolescents have decreased steadily from the mid-1980s, up to 1993.
     However, this group of adolescents showed an increase in the reported
     rate of gonorrhea between 1993 and 1994. The 10- to 14-year-old group
     increased slightly from 50.0 in 1993 to 50.4 in 1994. The 15- to
     19-year-old group increased from 742.1 in 1993 to 763.4 in 1994. The
     latter represented a 2.9% increase (Table_9B). This represents the
     first increase in gonorrhea among adolescents (10- to 19-year-olds)
     since 1985-1986.

 --  The increase in gonorrhea among adolescents in both age groups is
     entirely attributed to increases among adolescent females. In these
     age groups, young females have had higher gonorrhea rates than young
     males (Table_9B). Young males continued to show decreases in
     gonorrhea from 1993 to 1994 in both age groups. However both groups of
     young females showed increases (Figure_F). Gonorrhea rates among
     10- to 14-year-old females increased from 80.3 in 1993 to 85.9 in
     1994, a 7.0% increase. Rates among 15- to 19-year-old females
     increased from 868.0 to 926.7, a 6.8% increase.

 --  Increases in gonorrhea in 1994 vs. 1993 among young females were
     demonstrated in whites, African-Americans, Hispanics (10- 14-year-olds
     only), and Asian/Pacific Islanders (Table_9B).

(1) CDC. Premarital sexual experience among adolescent women -- United
States, 1970-1988. MMWR 1991;39:929-32.

(2) CDC. Pregnancy, Sexually Transmitted Diseases and Related Risk
Behaviors Among U.S. Adolescents. Atlanta: Centers for Disease Control and
Prevention, 1994. Adolescent Health: State of the Nation monograph series,
No. 2. CDC Publication No. 099-4630.

(3) CDC. Recommendations for the prevention and management of Chlamydia
trachomatis infections, 1993. MMWR 1993;42(No. RR-12).

(4) Lossick J, Delisle S, Fine D, Mosure D, Lee V, Smith C. Regional
program for widespread screening for Chlamydia trachomatis in family
planning clinics. In: Bowie WR, Caldwell HD, Jones RP, et al., eds.
Chlamydial Infections: Proceedings of the Seventh International Symposium
of Human Chlamydial Infections, Cambridge, Cambridge, University Press,
1990, pp. 575-9.

Figure_E. Chlamydia - Percent positivity among women tested in family
              planning clinics by age group: Region X, 1988-1994    
Figure_F. Gonorrhea - Age-specific rates among women 10-44 years of
              age: United States, 1981-1994    
Figure_G. Gonorrhea - Age-specific rates among men 10-44 years of age:
              United States, 1981-1994    

                           STDs in Minorities

Public Health Impact

Surveillance data show high rates of STDs for some minority racial/ethnic
groups when compared with rates for whites. There are no known biologic
reasons to explain why racial or ethnic factors alone should alter risk for
STDs. Rather, race and ethnicity in the United States are risk markers that
correlate with other more fundamental determinants of health status such as
poverty, access to quality health care, health care seeking behavior,
illicit drug use, and living in communities with high prevalence of STDs.
Acknowledging the disparity in STD rates by race/ethnicity is one of the
first steps in empowering affected communities to organize and focus on
this problem.

Surveillance data are based on cases of STDs reported to state and local
health departments (see Appendix). In many areas, reporting from public
sources (e.g., STD clinics) is more complete than reporting from private
sources. Since minority populations may utilize public clinics more than
whites, differences in rates between minorities and whites may be biased
toward showing higher rates for minorities. However, this bias is unlikely
to account for the very large differences in rates between minorities and
whites discussed below. In areas where reporting from private sources is
known to be of high quality, the differences in rates between minorities
and whites persist (CDC, unpublished data).

Observations

 --  Although chlamydia is a widely distributed STD among all racial and
     ethnic groups, trends in positivity in women screened in federal
     Region X (Alaska, Idaho, Oregon, and Washington) show consistently
     higher rates among minorities (Figure_H).

 --  In 1994, African-Americans accounted for about 81% of total reported
     cases of gonorrhea (Table_9A). The overall gonorrhea rates in 1994
     were 1,219.3 cases per 100,000 for African-Americans and 84.5 for
     Hispanics compared with 30.1 for non-Hispanic whites (Figure_11,
     Table_9B). Compared with 1993, 1994 rates increased slightly for
     all race/ethnic groups except Hispanics.

 --  Age-specific rates are very high for African-American adolescents and
     young adults. In 1994, black 15- to 19-year-old women had a gonorrhea
     rate of 4,911.9 cases per 100,000 population, representing a 5.5%
     increase over the rate in 1993. Black men in this age group had a
     gonorrhea rate of 4,007.5, representing a 2.2% decrease over the rate
     in 1993. These rates were on average more than 28-fold higher than
     those in white adolescents 15- to 19-years-old (Table_9B). Among
     20- to 24-year-olds in 1994, the gonorrhea rate among blacks was 38
     times greater than that of whites (4,479.3 vs. 116.3, respectively)
     (Table_9B).

 --  Despite declines in gonorrhea rates for most age and race/ethnic
     groups during the 1980's, African-American adolescents did not show
     declining trends in rates until 1991 (black women) and 1992 (black
     men). Between 1993 and 1994 gonorrhea rates for black females 10- to
     24-years-old increased. Rates for black  males in this age group
     decreased (Table_9B and Figure_I and Figure_J). 

 --  The most recent epidemic of syphilis was largely an epidemic in
     heterosexual minority populations (1). Since 1990, the rates of
     primary and secondary (P&S) syphilis have declined among all racial
     and ethnic groups. However, rates among African-Americans and
     Hispanics continued to be higher than for non-Hispanic whites. In
     1994, African-Americans accounted for about 87% of all reported cases
     of P&S syphilis (Table_21A). Although the rate among African-
     Americans declined from 76.5 cases per 100,000 population in 1993 to
     59.5 in 1994, the latter rate remained about 60-fold greater than the
     non-Hispanic white rate of 1.0. The 1994 rate of P&S syphilis in
     Hispanics was 3.5 (Figure_24 and Table_21B).

 --  In 1994, the rate of congenital syphilis in African-Americans was
     202.1 per 100,000 live births and 66.9 in Hispanics compared with 4.2
     in whites (Figure_K). Compared with 1993 this represented a 43%
     decrease among blacks and a 39% decrease among Hispanics.

(1) Rolfs RT, Nakashima AK. Epidemiology of primary and secondary syphilis
in the United States, 1981 through 1989. JAMA 1990;264:1432-7.

Figure_H. Chlamydia - Percent positivity among women tested in family
              planning clinics by race and ethnicity: Region X, 1988-1994 
Figure_I. Gonorrhea - Reported rates for 15- to 19-year-old females by
              race and ethnicity: United States, 1981-1994
Figure_J. Gonorrhea - Reported rates for 15- to 19-year-old males by
              race and ethnicity: United States, 1981-1994    
Figure_K. Congenital syphilis - Rates for infants <1 year of age by
              race and ethnicity: United States, 1991-1994    

                            STDs in the South

Public Health Impact

The southern region (Alabama, Arkansas, Delaware, Florida, Georgia,
Kentucky, Louisiana, Maryland, Mississippi, Oklahoma, North Carolina, South
Carolina, Tennessee, Texas, Virginia, West Virginia) has had higher rates
of primary and secondary (P&S) syphilis and gonorrhea than other regions of
the country. The reasons for regional differences in rates are not well
understood, but may include differences in racial and ethnic distribution
of the population, poverty, and availability and quality of health care
services.

Observations

 --  The South has consistently had higher rates of both gonorrhea and P&S
     syphilis compared with other regions throughout the 1980's and 1990's
     (Figure_7, Figure_8, Figure_19, and Figure_21).

 --  In 1994, the nine states with the highest rates of gonorrhea were
     located in the South (Figure_7 and Table_10). Ten of the
     twelve states with rates of P&S syphilis above the HP2000 objective of
     10 per 100,000 population were located in the South (Figure_19 and
     Figure_20; Table_22). All five states with rates of P&S
     syphilis that exceeded 20 cases per 100,000 population (or twice the
     HP2000 national objective) were located in the South (Figure_19
     and Table_22). 

 --  In 1994, 364 (92%) of 396 counties with P&S syphilis rates above the
     HP2000 objective were located in the South (Figure_20 and
     Figure_L).

 --  Between 1993 and 1994, P&S syphilis rates increased in 198 (54%) of
     364 counties in the South that had 1994 rates greater than 10 cases
     per 100,000 population (Figure_M).

 --  Much of the difference in rates between the South and other regions of
     the country is due to the differences in distribution of the
     population by race and ethnicity. As stated above, gonorrhea and
     syphilis are largely focused in minority populations and these groups
     are disproportionately located in southern states. When gonorrhea
     rates were adjusted for the race and ethnic composition of the
     population, states in the South no longer had the highest rates, and
     states with the highest rates were located in the Midwest
     (Figure_N). When P&S syphilis rates were adjusted for race and
     ethnicity, the differences between the South and other regions,
     especially the Midwest, were greatly diminished (Figure_O).
     However, many states in the South continued to have high rates.

 --  Rates of P&S syphilis in African-Americans by region show that rates
     in this group, while decreasing, are high regardless of region
     (Figure_P).

Figure_L. Primary and secondary syphilis case rates by county, 1994    
Figure_M. South - Increases and decreases in cases of primary and
              secondary syphilis in 1994 compared with 1993 cases, by
              county    
Figure_N. Gonorrhea - Rates by state, adjusted for race and ethnic
              distribution of the population: United States, 1994    
Figure_O. Primary and secondary syphilis - Rates by state, adjusted for
              race and ethnic distribution of the population: United
              States, 1994    
Figure_P. Primary and secondary syphilis - Rates in African-Americans
              by region: 1981-1994    



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