Sexually Transmitted Disease Surveillance 1996
Division of STD Prevention September 1997 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, 1996. U.S. Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention, September 1997. Copies can be obtained from the Office of Communications, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-06, Atlanta, Georgia 30333. The reports for 1993 through 1996 are available electronically on CDC WONDER. For information about registering for CDC WONDER, please contact CDC's Epidemiology Program Office at (888) 496-8347. These reports are also available from the Internet via the CDC home page address http://wonder.cdc.gov/wonder/data/Reports.html. 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. * The Appendix contains Table_A1 which displays progress made toward Healthy People 2000 Priority Area 19 on Sexually Transmitted Diseases. ---------- * See Appendix Healthy People Year 2000 Revisions. Chlamydia Infections due to Chlamydia trachomatis are among the most prevalent of all sexually transmitted diseases. In women these infections often result in pelvic inflammatory disease, which can cause infertility, ectopic pregnancy, and chronic pelvic pain. Data from a randomized controlled trial of chlamydia screening in a managed care setting suggest that such screening programs can reduce the incidence of PID by as much as 60% (1). In addition, pregnant women infected with chlamydia can infect their babies during delivery. While case reporting of chlamydial infections is improving, it remains incomplete in many areas of the country. A combination of factors limit the documentation of the incidence and prevalence of genital chlamydial infection: variable compliance with public health laws and regulations that require health care providers and laboratories to report cases to local health authorities; large numbers of asymptomatic persons who can be identified only through screening; limited resources to support screening activities; and incompletely developed information management systems for collecting, maintaining, and analyzing case reporting and prevalence data. Thus, for most areas, the number of chlamydia cases reported to CDC by state health departments reflects many factors, only one of which is number of infections in the population. For defined populations of sexually active women, data on prevalence obtained through routine screening can provide a more accurate measure of the true burden of disease. -- In 1996, 49 states and the District of Columbia required reporting of chlamydia and reported cases to CDC. Only cases from New York City were reported for the state of New York (Figure_1, Table_5). -- In 1996, 490,080 chlamydial infections were reported to CDC from 49 states, District of Columbia and New York City (Table_1). Reported cases of chlamydia far exceed reported cases of gonorrhea (325,883 gonorrhea cases in 1996, Table_1). -- From 1987 through 1996 reported rates of chlamydia increased from 47.8 cases per 100,000 persons to 194.5 (Figure_2). This trend reflects increased screening, recognition of asymptomatic infection (mainly in women), and improved reporting, as well as the continuing high burden of disease. -- In 1996, the chlamydia case rate was highest in the South, reflecting a recent expansion of screening activity in this Region. Before 1996, reported chlamydia rates were highest in the West and Midwest, where substantial resources had been committed for screening programs (e.g., in family planning clinics) (Table_5, Figure_3 and Figure_4). -- Between 1995 and 1996, rates of chlamydia reported from selected large cities (>200,000 population) increased 2% from 313.2 cases per 100,000 persons to 318.6 (Figure_5, Table_9). -- Reported rates of chlamydia for women (321.5 per 100,000 persons) exceed those for men (60.4) (Figure_6, Table_6, Table_7, Table_10, and Table_11). This is mainly due to 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 not tested. 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. -- Rates of chlamydia for women are highest in the 15- to 19- year-olds (2,068.6 per 100,000) and in the 20- to 24-year-olds (1,485.2). For men, age-specific rates are also highest in these age groups (Figure_7, Table_3B). -- Chlamydia screening and prevalence-monitoring activities were initiated in Health and Human Services (HHS) Region X in 1988 as a CDC-supported demonstration project. In 1993, chlamydia screening services for women were initiated in three additional HHS regions (III, VII, and VIII) and, in 1995, in the remaining HHS regions (I, II, IV, V, VI, and IX). In some regions, federally-funded chlamydia screening supplements local- and state-funded screening programs. -- In 1996, state-specific chlamydia test positivity among 15- to 24-year- old women screened varied from 2.5% to 10.9% among those attending family planning clinics (Figure_9). These chlamydia test positivity rates are from those states reporting data on 1,000 or more women screened during 1996. -- The effectiveness of large-scale screening programs in reducing chlamydia prevalence in women has been well documented in areas where this intervention has been in place for several years. For example, the screening programs in Health and Human Services Region X (Alaska, Idaho, Oregon, Washington) family planning clinics have demonstrated a decline in chlamydia positivity of 61% since 1988 among 15- to 44-year- old women. Introduction of large-scale screening in HHS Region III and HHS Region VIII has also been followed by similar declines in chlamydia positivity (Figure_10). -- 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 -- Number of states that require reporting of Chlamydia trachomatis infections: United States, 1987-1996 Figure_2. Chlamydia -- Reported rates: United States, 1984-1996 Figure_3. Chlamydia -- Rates by state: United States and outlying areas, 1996 Figure_4. Chlamydia -- Rates by region: United States, 1984-1996 Figure_5. Chlamydia -- Rates in selected U.S. cities of >200,000 population, 1984-1996 Figure_6. Chlamydia -- Rates by gender: United States, 1984-1996 Figure_7. Chlamydia -- Age- and gender-specific rates: United States, 1996 Figure_8. Chlamydia -- Percent positivity among women tested in family planning clinics by state: Region X, 1988-1996 Figure_9. Chlamydia -- Percent positivity among 15-24 year old women tested in selected family planning clinics by state, 1996 Figure_10. Chlamydia -- Percent positivity among 15-44 year old women tested in family planning clinics by HHS regions: 1996 ---------- (1) Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;34(21):1362-66. 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 occurs (1). Reporting of gonococcal infections has likely been biased towards reporting of infections in persons of minority race or ethnicity who attend public STD clinics. -- In 1996, 325,883 cases of gonorrhea were reported in the United States. The rate of gonorrhea has continued its overall decline since 1975. Between 1995 and 1996 the rate decreased 17% from 149.4 cases per 100,000 persons to 124.0 (Table_1 and Figure_11). -- In 1996, 30 states or outlying areas reported gonorrhea rates below the Healthy People 2000 (HP2000) national objective of 100 cases per 100,000 persons (Figure_12 and Table_13). Gonorrhea rates decreased between 1995 and 1996 in 32 of the 35 states reporting more than 1,000 cases in 1996, whereas rates in the previous year decreased in 29 of 36 states with more than 1,000 cases (Table_14). -- Gonorrhea rates decreased in all regions in 1996. The South continued to have a higher rate than other regions (Figure_13). -- Although the overall gonorrhea rate for large cities (selected cities with over 200,000 population) continued to decline in 1996 (Figure_14), 52 (81%) of the 64 cities had rates exceeding the HP2000 objective (Table_17). -- The gonorrhea rates in both men and women declined in 1996. Rates in men and in women were above the HP2000 objective in 22 states (Figure_15, Table_15 and Table_16). -- In 1996, gonorrhea rates decreased for all racial and ethnic groups except American Indian/Alaska Native (Figure_16 and Table_12B). The rates for non-Hispanic blacks and American Indians/Alaska Natives were above the HP2000 objective (Figure_16, Table_12B). The gonorrhea rate for blacks decreased by 21%, from 1,045.5 cases per 100,000 persons in 1995 to 825.5 in 1996 (Table_12B), but was almost 32 times greater than the rate for non-Hispanic whites. -- Between 1995 and 1996, the gonorrhea rate for 15- to 19-year-old adolescents decreased by 15%, from 670.7 to 570.8 cases per 100,000 persons. Among women, 15- to 19-year-olds had the highest rate, while among men, 20- to 24-year-olds had the highest rate (Table_12B). -- Antimicrobial resistance remains an important consideration in the treatment of gonorrhea. Overall, 29.0% of isolates collected in 1996 by the Gonococcal Isolate Surveillance Project (GISP) were resistant to penicillin, tetracycline, or both (Table_21). Between 1991 and 1996, the percentage of GISP isolates that were penicillinase producing Neisseria gonorrhoeae (PPNG) declined from 13.1% to 5.8% (Figure_19). In contrast, isolates with chromosomally mediated resistance to penicillin increased from 6.4% in 1991 to 9.1% in 1996 (Figure_20). The prevalence of chromosomally mediated tetracycline resistance, 14.3% in 1996, has been relatively stable since 1992 (Figure_20). The proportion of GISP isolates demonstrating decreased susceptibility to ciprofloxacin, one of the currently recommended treatments for gonorrhea, has decreased from a high of 1.3% in 1994 to 0.5% in 1996. Resistance to ciprofloxacin was first identified in GISP in 1991 but remains rare (0.04%) in 1996 (Figure_21). Reduced susceptibility and resistance to ciprofloxacin correlate with reduced susceptibility and resistance to other fluoroquinolone antibiotics. -- The percentage of men with gonorrhea who have repeat infection within a one-year period, as measured by the Gonococcal Isolate Surveillance Project, has increased from a low of 13.8% in 1994 to 15.7% in 1996 (Figure_22). Although the number of persons with repeat infections might be expected to fall as the incidence of gonorrhea declines, an increase in the percentage of all gonorrhea cases who are repeaters may nevertheless reflect a focusing of disease in the population at highest risk. -- Additional information about gonorrhea in racial and ethnic minority populations and adolescents can be found in the Special Focus Profiles section. Figure_11. Gonorrhea -- Reported rates: United States, 1970-1996 and the Healthy People year 2000 objective Figure_12. Gonorrhea -- Rates by state: United States and outlying areas, 1996 Figure_13. Gonorrhea -- Rates by region: United States, 1981-1996 and the Healthy People year 2000 objective Figure_14. Gonorrhea -- Rates in selected U.S. cities of >200,000 population, 1981-1996 and the Healthy People year 2000 objective Figure_15. Gonorrhea -- Rates by gender: United States, 1981-1996 and the Healthy People year 2000 objective Figure_16. Gonorrhea -- Rates by race and ethnicity: United States, 1981-1996 and the Healthy People year 2000 objective Figure_17. Gonorrhea -- Age- and gender-specific rates: United States, 1996 Figure_18. Gonococcal Isolate Surveillance Project (GISP) -- Location of participating clinics and regional laboratories: United States, 1996 Figure_19. Gonococcal Isolate Surveillance Project (GISP) -- Trends in plasmid-mediated resistance to penicillin and tetracycline, 1988-1996 Figure_20. Gonococcal Isolate Surveillance Project (GISP) -- Trends in chromosomally mediated resistance to penicillin and tetracycline, 1988-1996 Figure_21. Gonococcal Isolate Surveillance Project (GISP) -- Prevalence of Neisseria gonorrhoeae with decreased susceptibility or resistance to ciprofloxacin, 1990-1996 Figure_22. Gonococcal Isolate Surveillance Project (GISP) -- Proportion of men with gonorrhea who report having a previous gonorrhea infection within the past year, 1992-1996 ---------- (1) Cohen MS, Hoffman IF, Royce RA, et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1. Lancet 1997;349:1868-1873. Syphilis Although the U.S. syphilis rate declined in 1996 to its lowest level in many years, syphilis remains an important problem in certain geographic areas, particularly among African-Americans. Syphilis, a genital ulcerative disease, facilitates the transmission of HIV 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 during 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 and ethnicity. -- In 1996, 11,387 cases of primary and secondary (P&S) syphilis were reported to CDC. This is the lowest number of cases reported since 1959. Between 1995 and 1996, the incidence of primary and secondary syphilis in the United States declined from 6.3 to 4.3 cases per 100,000 persons (Figure_24, Table_1). -- In 1996, P&S syphilis rates in 33 states and 1 outlying area were below the Healthy People 2000 (HP2000) national objective of 4 cases per 100,000 persons (Figure_25, Table_25). Thirteen states and 1 outlying area reported fewer than 5 cases of P&S syphilis in 1996. -- In 1996, 2,260 (73%) of 3,116 counties in the United States reported no cases of P&S syphilis compared with 2,144 (69%) counties in 1995. Of 856 counties reporting at least one case of P&S syphilis in 1996, 374 (44%) counties reported rates of 4 cases or fewer per 100,000 persons (Figure_26). Therefore, rates of P&S syphilis were above the HP2000 objective (4.0 per 100,000) for 482 counties in 1996. These counties (15% of the total number of counties in the United States) accounted for 84% of all reported P&S syphilis cases. -- In 1996, the rates of P&S syphilis continued to decline for all regions of the United States. However, the rate of 8.7 cases per 100,000 persons in the South remained above the HP2000 objective (Figure_27, Table_26). The P&S syphilis rates of the other 3 regions were below the HP2000 objective. -- The overall rate of P&S syphilis in selected large cities (over 200,000 population) declined from 10.1 cases per 100,000 persons in 1995 to 7.6 in 1996 (Figure_28, Table_30). However, rates exceeded the HP2000 objective in 35 (55%) of 64 large cities in the United States and outlying areas for which data were available (Table_29). -- During the period 1993-1996, the rates of P&S syphilis within racial and ethnic groups have generally declined, except for American Indian/Alaska Native (Figure_30, Table_24B). However, the 1996 rate for non-Hispanic blacks of 30.2 cases per 100,000 persons was 50 times greater than the rate for non-Hispanic whites (Figure_30, Table_24B). -- Between 1995 and 1996, the overall rate of congenital syphilis decreased from 47.4 to 30.4 cases per 100,000 live births (Figure_33, Table_37). However, compared with 1995, increases were observed in 1996 for 4 (Alabama, Maryland, Massachusetts, Tennessee) of the 24 states reporting more than 5 cases (Table_38). -- In 1996, 8 states (Arkansas, Illinois, Maryland, Mississippi, New Jersey, New York, South Carolina, Tennessee) had congenital syphilis rates that exceeded the HP2000 objective of 40 cases per 100,000 live births (Table_38). -- Additional information on syphilis and congenital syphilis can be found in the Special Focus Profiles section. Figure_23. Syphilis -- Reported cases by stage of illness: United States, 1941-1996 Figure_24. Primary and secondary syphilis -- Reported rates: United States, 1970-1996 and the Healthy People year 2000 objective Figure_25. Primary and secondary syphilis -- Rates by state: United States and outlying areas, 1996 Figure_26. Primary and secondary syphilis -- Counties with rates above and counties with rates below the Healthy People year 2000 objective: United States, 1996 Figure_27. Primary and secondary syphilis -- Rates by region: United States, 1981-1996 and the Healthy People year 2000 objective Figure_28. Primary and secondary syphilis -- Rates in selected U.S. cities of >200,000 population, 1981-1996 and the Healthy People year 2000 objective Figure_29. Primary and secondary syphilis -- Rates by gender: United States, 1981-1996 and the Healthy People year 2000 objective Figure_30. Primary and secondary syphilis -- Rates by race and ethnicity: United States, 1981-1996 and the Healthy People year 2000 objective Figure_31. Primary and secondary syphilis -- Age- and gender-specific rates: United States, 1996 Figure_32. Congenital syphilis -- Reported cases for infants <1 year of age and rates of primary and secondary syphilis among women: United States, 1970-1996 Figure_33. Congenital syphilis -- Rates for infants <1 year of age: United States, 1981-1996 and the Healthy People year 2000 objective Other Sexually Transmitted Diseases -- Since 1987, reported cases of chancroid have declined steadily (Table_1, Figure_34). In 1996, a total of 386 cases of chancroid were reported from 22 states (Table_40). Five states (Illinois, Louisiana, New York, North Carolina, Texas) reported 88% of the 386 cases. -- 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_35, Figure_36, Figure_37, Figure_38). For data on PID, see the Special Focus Profile on Women and Infants. Figure_34. Chancroid -- Reported cases: United States, 1981-1996 Figure_35. Nonspecific urethritis -- Initial visits to physicians' offices by men: United States, 1966-1996 Figure_36. Human papillomavirus (genital warts) -- Initial visits to physicians' offices: United States, 1966-1996 and the Healthy People year 2000 objective Figure_37. Genital herpes simplex virus infections -- Initial visits to physicians' offices: United States, 1966-1996 and the Healthy People year 2000 objective Figure_38. Trichomonal and other vaginal infections -- Initial visits to physicians' offices: United States, 1966-1996
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