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.

Centers for Disease Control and Prevention 
     David Satcher, M.D., Ph.D.
     Director

National Center for HIV, STD, and TB Prevention (proposed)
     Helene D. Gayle, M.D., M.P.H.
     Acting Director

Division of STD Prevention
     Judith N. Wasserheit, M.D., M.P.H.
     Director

                                 Preface

Sexually Transmitted Disease Surveillance, 1994 presents current statistics
and trends of sexually transmitted diseases (STDs) in the United States
through 1994. It is intended as a reference document for program managers,
health planners, researchers, investigators, policy makers, and others who
are concerned with the public health implications of these diseases.

The STD surveillance systems operated by state and local STD control
programs are the sources of most of the information in this publication.
These systems are an integral part of program management at all levels of
STD prevention and control in the United States. The role of these
surveillance systems is to provide program managers with the disease burden
and trend information necessary for problem definition, priority setting,
resource allocation, and program evaluation.

Sexually Transmitted Disease Surveillance, 1994 is an annual publication,
and figures and tables in this edition supersede those in earlier
publications of these data.

Sexually Transmitted Disease Surveillance, 1994 consists of four parts. The
National Profile contains figures that provide an overview of the STD
situation in the United States. The accompanying text identifies major
findings and trends for selected STDs. The Special Focus Profiles contain
figures and text describing STDs in selected subgroups and populations that
are a focus of national and State prevention efforts. The Detailed Tables
provide statistical information about STDs at the state, city, and national
levels. The Appendix provides information about the sources and limitations
of the data used to produce this report.

Selected figures and tables in this document include a reference point that
is used to monitor progress toward some of the Healthy People 2000 (HP2000)
national health status objectives for STDs (1). The original HP2000 health
status objectives that were developed in 1989 are used as reference points
in this edition of Sexually Transmitted Disease Surveillance, 1994. During
1995 a midcourse reappraisal of the original HP2000 objectives was
completed. As a result, several of the STD health status objectives were
changed. The revised health status objectives will be used as reference
points next year beginning with the publication of 1995 STD data.

Any comments and suggestions that would improve the usefulness of future
publications are appreciated and should be sent to Director, Division of
STD Prevention, National Center for HIV, STD, and TB Prevention (proposed),
Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop
E-02, Atlanta, Georgia, 30333.

(1) Department of Health and Human Services. Healthy People 2000: National
Health Promotion and Disease Prevention Objectives. U.S. Department of
Health and Human Services, Public Health Service. DHHS Publication No.
(PHS) 81-50213. U.S. Government Printing Office, Washington, D.C.,
September 1990.

Acknowledgments

This report was prepared by the following staff members of the Division of
STD Prevention, National Center for HIV, STD, and TB Prevention (proposed),
Centers for Disease Control and Prevention:  Susan Bradley, Sharon Clanton,
Martha R. Cowart, Kathleen B. Dry, Alesia Jester, Joel R. Greenspan,
Melinda L. Flock, Tamara Kicera, Allyn K. Nakashima, Margaret B. VanNorden,
and Diane M. Vitro.

Publication of this report would not have been possible without the
contributions of the State and Territorial Health Departments and the
Sexually Transmitted Disease Control Programs, who provided morbidity data
to the Centers for Disease Control and Prevention.
                     
                     Geographic Divisions of the United States

Figure_GEO.   Geographic Divisions of the United States

        National Overview of Sexually Transmitted Diseases, 1994

The new logo on the cover of this year's edition of Sexually Transmitted
Disease Surveillance, 1994, is a reminder of the national dimensions of the
morbidity, mortality, and costs that result from sexually transmitted
diseases (STDs) in this country. Organized, collaborative efforts among
interested and committed public and private organizations are the keys to
reducing STDs and their related health burdens in our population. Several
observations for 1994 are worthy of note. 

States have recognized the programmatic importance of collecting and
sharing reliable information on efforts to reduce the number of genital
Chlamydia trachomatis infections in the population. In 1994, through the
efforts of the Council of State and Territorial Epidemiologists (CSTE),
chlamydia became a nationally reportable condition. The development of
improved state and federal data bases will ultimately result in better
planning, priority setting, and evaluation of chlamydia control efforts.
Despite the absence of chlamydia data from several states in 1994, this was
the first year in which the reported number of cases of chlamydia infection
(448,984) exceeded the reported number of cases of gonorrhea (418,068) in
the United States. This occurred amid growth in chlamydia control programs
nationwide, together with continuing commitments to sustain gonorrhea
prevention programs that began in the 1970s.  In 1994, for every chlamydia
case detected and reported in males, more than five cases were detected in
females. This discrepancy is attributable to screening strategies that
focus on women because they are asymptomatic in the majority of cases. Male
sex partners can be treated prophylactically for chlamydia without a
diagnostic laboratory test, but current surveillance systems limit the
ability to document the treatment of male partners. Given that chlamydia
prevention programs are just beginning in most areas of the country, and
that the initial focus usually is on detecting infection in asymptomatic
females, the current level of morbidity suggests that an enormous reservoir
of infection in both women and men remains to be detected, treated, and
documented.

Data on gonorrhea for 1994 suggest that the annual decreases that have been
evident since the mid-1970s are continuing, but at a slower rate of
decline. The 1994 gonorrhea rate of 168.4 remains below the HP2000
objective of 225, and is the lowest rate in the past 30 years. However, the
average annual decreases in gonorrhea over the previous 10 years have been
about 20 cases per 100,000 population per year. The decrease in reported
cases between 1993 (173.8 per 100,000) and 1994 was 5.4 cases per 100,000.
A slowing of decrease also occurred between 1983-84 and 1988-89, followed
soon after by a return to rapidly falling rates. Whether rates will
continue to decline or level off in the coming years remains to be seen. 

A closer look at gonorrhea statistics reveals divergence in the recent
trends between males and females. When compared to 1993 rates, 1994
gonorrhea rates among men continued to decrease. However, the rate among
women rose from 147.1 in 1993 to 153.7 in 1994, an increase of 4.5%.
Increases were even higher among the youngest groups of females: 10- to
14-year-old females had a 7.0% increase, and 15- to 19-year-olds had a 6.8%
increase. Because men with gonorrhea are usually symptomatic and seek
medical care, trends among males are a good measure of disease incidence.
Trends in women are largely determined by screening practices. It is
possible that expansion of chlamydia screening programs for women
(especially for younger women) is having an indirect beneficial effect on
gonorrhea detection and treatment as well.

The 20,627 cases of primary and secondary (P&S) syphilis reported in 1994
were the fewest cases reported in the United States since 1977. The P&S
syphilis rate of 8.1 per 100,000 population fell below the HP2000 objective
of 10 per 100,00 for the first time. Syphilis remains a problem only in
selected areas of the country. In 1994, 68% of U.S. counties did not report
any syphilis cases. This is an increase from 64% of counties in 1993. In
1994, P&S syphilis rates exceeded 10 per 100,000 in 396 counties (13% of
total counties). These counties accounted for 77% of all reported P&S
syphilis cases. Most notably, 92% (364 of 396) of these counties were
located in the South. In addition, 10 of the 12 states with P&S syphilis
rates greater than 10 per 100,000 were located in the South. These data
suggest that comprehensive syphilis prevention efforts focused in the South
may dramatically reduce the number of U.S. syphilis cases by the end of the
decade.

When we examine STD statistics by race/ethnicity, we continue to see very
wide discrepancies among racial/ethnic groups. For example, gonorrhea rates
among black adolescents (15-19 years of age) are more than 28 times greater
than the rate among white adolescents. The rate of P&S syphilis among
blacks is nearly 60 times that in whites; P&S syphilis among Hispanics is
3.5 times that in whites. Congenital syphilis has also decreased nationally
in recent years. However, of the 1,934 reported cases with known
race/ethnicity of the mother, blacks and Hispanics accounted for 92% of all
reported cases while accounting for only 21% of the female population.
Although there are no known biologic reasons to explain why racial or
ethnic factors alone should alter STD risk, race and ethnicity in the
United States serve as risk markers that correlate with other more
fundamental determinants of health status such as poverty, access to
quality care, and health-care-seeking behavior. 

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