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. 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 chlamydial 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 American women (8). Both gonorrhea and chlamydia also result in adverse outcomes of pregnancy, including neonatal ophthalmia and, in the case of chlamydia, neonatal pneumonia. Although topical prophylaxis at delivery is effective for prevention of ophthalmia neonatorum, prevention of neonatal pneumonia requires antenatal detection and treatment. Infections with human papillomavirus (HPV) are a major concern because specific HPV subtypes (e.g., types 16, 18, 31, 33, and 35) have been associated epidemiologically with cervical dysplasia and cervical cancer. HPV types 6 and 11 in child bearing women can cause laryngeal papillomatosis in infants. 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 quantify 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 have begun collecting chlamydia case data. In 1995, 48 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 1994 and 1995, the reported rate of chlamydial infections in women increased from 260.2 per 100,000 population to 290.3 (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 persistent and acute cases; and many state/local health departments are in the process of developing chlamydia prevention programs, including surveillance infrastructure to collect information from laboratories and providers. 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 positivity since 1988 (Figure_C). Introduction of large-scale screening in other areas (Wisconsin, San Francisco, and Columbus, Ohio) has been followed by similar declines in chlamydia positivity. Data from a randomized controlled trial of chlamydia screening in a managed care setting suggest that such screening programs can also reduce the incidence of PID by as much as 60% (12). -- Based on the successful model in Region X and as part of the development of a national infertility prevention program, infertility prevention services aimed at women in three additional PHS regions (III, VII, VIII) were initiated in 1993 and piloted in the remaining PHS regions (I, II, IV, V, VI, IX) in 1995. Each region has adopted a model for the prevention of STD-related infertility based on collaboration between family planning and STD programs. In some of the PHS regions, public sector chlamydia screening and treatment supplements ongoing local and state prevention activities; in others, chlamydia screening was newly introduced. In 1995, state-specific chlamydia test positivity among 15- to 24-year-old women screened varied from 2.8% to 9.4% among those attending family planning clinics (Figure_D). These chlamydia test positivity rates are from those states reporting data on 3,000 or more women screened during 1995. -- 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). Gonorrhea rates decreased slightly for women from 150.7 cases per 100,000 population in 1994 to 140.3 in 1995; 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 trends in incidence of disease. However, trends in women are largely determined by screening patterns, similar to chlamydia. -- The rate of congenital syphilis (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 107.3 cases per 100,000 live births and has declined 64% to 39.0 in 1995 (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 66% to 5.8 in 1995 (Figure_23 and Figure_26; Table_24). -- Although the 1995 rate of CS was below the revised Healthy People 2000 Objective of 40 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 (13). -- 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 the etiologic spectrum (with increasing proportions of more indolent chlamydial infection) and clinical management of PID (from inpatient to outpatient) rather than true trends in disease (14). -- 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_E). Beginning in 1990, hospitalizations for ectopic pregnancy began to decline. Data from out-patient care surveys suggest that nearly half of all ectopic pregnancies are currently treated on an outpatient basis (15). 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 (15). Figure_A. Chlamydia -- Number of states with reporting laws for Chlamydia trachomatis infections and reported rates: United States, 1987-1995 Figure_B. Chlamydia -- Rates for women by state: United States, 1995 Figure_C. Chlamydia -- Percent positivity among women tested in family planning clinics by state: Region X, 1988-1995 Figure_D. Chlamydia -- Percent positivity among 15-24 year-old women tested in selected family planning clinics by state, 1995 Figure_E. Ectopic pregnancy -- Hospitalizations of women 15-44 years of age: United States, 1980-1993 --------------- (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) 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. (13) Division of STD/HIV Prevention. Healthy People 2000: National Health Promotion and Disease Objectives. Progress Review: Sexually Transmitted Diseases, October 26, 1994. (14) 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. (15) CDC. Ectopic pregnancy -- United States, 1990-1992. MMWR 1995;44:46-8. STDs in Adolescents and Young Adults Public Health Impact Compared with older adults, 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, the age of initiation of sexual activity has steadily decreased and age at first marriage has increased, resulting in increases in premarital sexual experience among adolescent women and in an enlarging pool of young women at risk (1,2,3). In addition, the higher prevalence of STDs among adolescents reflects multiple barriers to quality STD prevention services, including lack of insurance or other ability to pay, lack of transportation, discomfort with facilities and services designed for adults, and concerns about confidentiality. Observations -- Numerous prevalence studies in various clinic populations have shown that sexually active adolescents have high rates of chlamydial infection (4). Large-scale screening demonstration projects in federal Region X (Alaska, Idaho, Oregon, and Washington) (5) have demonstrated that younger women have consistently higher positivity rates of chlamydia than older women (Figure_F). -- Rates of gonorrhea among male adolescents have steadily decreased during the four year period 1992-95 (Table_9B). In the 10- to 14-year-old group, the rate for males decreased from 26.2 per 100,000 in 1992 to 12.6 in 1995, a decrease of 52%. In the 15- to 19-year-old group, the rate declined from 770.3 in 1992 to 498.4 in 1995, a 35% decrease. Among young adult men in the 20- to 24-year-old group, the rate of gonorrhea fell from 896.1 in 1992 to 666.4 in 1995, a decrease of 26%. -- Rates of gonorrhea among female adolescents also generally decreased over the four year period 1992-95 (Table_9B). However, both adolescent age groups exhibited an increase between 1993 and 1994, which was followed by a decrease in 1995. This pattern also occurred among young adult women. In the 10- to 14-year-old group, the rate for females decreased from 91.2 per 100,000 in 1992 to 72.8 in 1995, a decrease of 20%. In the 15- to 19-year-old group, the rate declined from 973.8 in 1992 to 839.7 in 1995, a 14% decrease. Among young adult women in the 20- to 24-year-old group, the rate of gonorrhea fell from 766.5 in 1992 to 624.6 in 1995, a decrease of 19%. -- In 1995, the highest age-specific gonorrhea rates among women and the second highest rates among men were in the 15- to 19-year-old group (Figure_12). -- Increases in gonorrhea between 1994 and 1995 were noted among Hispanic adolescents and young adults (Table_9B). -- Since 1990, approximately 20,000 female Job Corps entrants have been screened each year for chlamydia. The Job Corps, administered by the U.S. Department of Labor at 108 sites throughout the country, is a residential occupational training program for urban and rural disadvantaged youth aged 16-24 years. Among women entering the Job Corps in 1995, based on their place of residence just before program entry, state-specific chlamydia test positivity ranged from 4.2% to 17.1% (Figure_I). Chlamydia infection is widespread geographically and highly prevalent among these economically disadvantaged young women. Figure_F. Chlamydia -- Percent positivity among women tested in family planning clinics by age group: Region X, 1988-1995 Figure_G. Gonorrhea -- Age-specific rates among women 10-44 years of age: United States, 1981-1995 Figure_H. Gonorrhea -- Age-specific rates among men 10-44 years of age: United States, 1981-1995 Figure_I. Chlamydia -- Percent positivity among 16-24 year-old women entering the U.S. Job Corps by state of residence, 1995 --------------- (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) Forrest JD. Timing of reproductive life stages. Obstet Gynecol 1993; 82(1):105-11. (4) CDC. Recommendations for the prevention and management of Chlamydia trachomatis infections, 1993. MMWR 1993;42(No. RR-12). (5) 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. 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 increased by this reporting bias. 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_J). -- In 1995, African-Americans accounted for about 79% of total reported cases of gonorrhea (Table_9A). The overall gonorrhea rates in 1995 were 1,086.9 cases per 100,000 for African-Americans and 90.6 for Hispanics compared with 29.1 for non-Hispanic whites (Figure_11, Table_9B). Compared with 1994, 1995 rates decreased for all race/ethnic groups except Hispanics. -- Gonorrhea rates are very high for African-American adolescents and young adults. In 1995, black 15- to 19-year-old women had a gonorrhea rate of 4,432.6 cases per 100,000 population. Black men in this age group had a gonorrhea rate of 3,267.3. These rates were on average more than 27 times higher than those of white adolescents 15- to 19-years-old (Table_9B). Among 20- to 24-year-olds in 1995, the gonorrhea rate among blacks was 35 times greater than that of whites (4,238.9 vs. 121.1, 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 1994 and 1995 gonorrhea rates for black 15- to 19-year-old women declined by 7.1%, and for black men in this age group, by 16.1% (Table_9B and Figure_K and Figure_L). -- The most recent epidemic of syphilis was largely an epidemic in heterosexual, minority populations (1). Since 1990, rates of primary and secondary (P&S) syphilis have declined among all racial and ethnic groups except American Indian/Alaska Native. However, rates among African-Americans and Hispanics continued to be higher than for non-Hispanic whites. In 1995, African-Americans accounted for about 86% of all reported cases of P&S syphilis (Table_21A). Although the rate among African-Americans declined from 58.6 cases per 100,000 population in 1994 to 46.2 in 1995, the latter rate was nearly 60-fold greater than the non-Hispanic white rate of 0.8 per 100,000. The 1995 rate of P&S syphilis in Hispanics was 3.0 (Figure_24 and Table_21B). -- In 1995, the rate of congenital syphilis in African-Americans was 162.2 per 100,000 live births and 49.7 in Hispanics compared with 3.9 in whites (Figure_M). Compared with 1994, this represented a 30% decrease among blacks and a 35% decrease among Hispanics. Figure_J. Chlamydia -- Percent positivity among women tested in family planning clinics by race and ethnicity: Region X, 1988-1995 Figure_K. Gonorrhea -- Reported rates for 15- to 19-year-old females by race and ethnicity: United States, 1981-1995 Figure_L. Gonorrhea -- Reported rates for 15- to 19-year-old males by race and ethnicity: United States, 1981-1995 Figure_M. Congenital syphilis -- Rates for infants <1 year of age by race and ethnicity: United States, 1991-1995 and the Healthy People year 2000 objective --------------- (1) Rolfs RT, Nakashima AK. Epidemiology of primary and secondary syphilis in the United States, 1981 through 1989. JAMA 1990;264:1432-7. 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. These racial and ethnic differentials in STD rates are particularly disturbing in light of the fact that STDs facilitate HIV transmission at least two to five fold. High HIV prevalence among childbearing women living in the South may be due, in part, to the high rates of these others STDs. Data from a randomized controlled trial of STD treatment to prevent HIV infection suggest that as much as a 40% reduction in HIV incidence might be achieved in areas with high STD rates (1). 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, Table_11 and Table_23). -- In 1995, the 10 states with the highest rates of gonorrhea were all located in the South (Figure_7 and Table_10). Thirteen of the 17 states with rates of P&S syphilis above the revised HP2000 objective of 4 per 100,000 population were located in the South (Figure_19 and Figure_20; Table_22). All 8 states with rates of P&S syphilis that exceeded 12 cases per 100,000 population (or three times the revised HP2000 national objective) were located in the South (Figure_19 and Table_22). -- In 1995, 492 (84%) of 588 counties with P&S syphilis rates above the revised HP2000 objective were located in the South (Figure_20 and Figure_N). -- Between 1994 and 1995, P&S syphilis rates increased in 244 (54%) of 449 counties in the South that had 1995 rates greater than 4 cases per 100,000 population (Figure_O). -- 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_N. South -- Primary and secondary syphilis case rates by county, 1995 Figure_O. South -- Increases and decreases in cases of primary and secondary syphilis in 1995 compared with 1994 cases, by county Figure_P. Primary and secondary syphilis -- Rates in African-Americans by region: 1981-1995 --------------- (1) Grosskurth H, Mosha F, Todd J, Mwijarubi E, Klokke A, Senkoro K, Mayaud P, Changalucha J, Nicoll A, ka-Gina G, Newell J, Mugeye K, Mabey D, Hayes R. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet 1995;346:530-6.
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