Sexually Transmitted Disease Surveillance 1993

Division of STD/HIV Prevention 

December 1994

U.S. Department of Health and Human Services 
Public Health Service 
Centers for Disease Control and Prevention 
National Center for Prevention Services 
Division of STD/HIV Prevention 
Surveillance and Information Systems Branch 
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/HIV Prevention. Sexually Transmitted Disease
Surveillance, 1993.  U.S. Department of Health and Human Services, Public
Health Service.  Atlanta: Centers for Disease Control and Prevention,
December 1994.

Copies can be obtained from Information Services, National Center for
Prevention Services, Centers for Disease Control and Prevention, 1600
Clifton Road, Mailstop E-06, Atlanta, Georgia 30333.


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

National Center for Prevention Services      
     Alan R. Hinman, M.D., M.P.H.
     Director

Division of STD/HIV Prevention      
     Judith N. Wasserheit, M.D., M.P.H.
     Director
 
     Joel R. Greenspan, M.D., M.P.H.  
     Chief, Surveillance and Information Systems Branch (SISB)

     Allyn K. Nakashima, M.D. 
     Chief, Surveillance Section, SISB


                                 Preface

Sexually Transmitted Disease Surveillance, 1993 presents current
statistics and trends of sexually transmitted diseases (STDs) in the
United States through 1993.  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, 1993 is an annual publication,
and figures and tables in this edition supersede those in earlier
publications of these data.

In this year's edition, a new section entitled Special Focus Profiles has
been added.  This section contains figures and text describing the STDs
in selected subgroups and populations.  Three other sections are updated
from previous editions and include:  National Profile consisting of
figures that provide an overview of the STD situation in the United
States; Tables providing detailed statistical information about STDs at
the state, city, and national levels; and Appendix providing information
about the sources and limitations of the data used to produce this
report.

In response to a user's survey included in last year's report, the
Regional Profiles and State Profiles sections have been eliminated from
this edition.  Updated Regional Profiles and State Profiles figures are
available upon request from the Surveillance and Information Systems
Branch, Division of STD/HIV Prevention, National Center for Prevention
Services, Centers for Disease Control and Prevention, 1600 Clifton Road,
Mailstop E-63, Atlanta, Georgia 30333.

Any comments and suggestions that would improve the usefulness of future
publications are appreciated and should be sent to the above address.

                             Acknowledgments

This report was prepared by the following staff members of the
Surveillance and Information Systems Branch and the Graphics Imaging
Center, Division of STD/HIV Prevention, National Center for Prevention
Services, Centers for Disease Control and Prevention:  Susan Bradley,
Sharon Clanton, Martha R. Cowart, Kathleen B. Dry, Alesia Jester, Joel R.
Greenspan, Melinda L. Flock, William E. Johns, 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.


                               Dedication

We dedicate this volume to the memory of our colleague and friend, David
Burleson, whose skills, optimism, and commitment to service will be
greatly missed
                     
                     Geographic Divisions of the United States

Figure_GEO.   Geographic Divisions of the United States
         
         STD Prevention: A stategic common element in HIV prevention 
              and promotion of health among women and infants


Figure_STD.   STD Prevention: A stategic common element in HIV 
                  prevention and promotion of health among women and
                  infants
        
        National Overview of Sexually Transmitted Diseases, 1993
                                    
Sexually transmitted disease (STD) prevention is linked to several
important public health goals including prevention of human
immunodeficiency virus (HIV) infection; prevention of infertility in women;
prevention of low birth weight, prematurity, congenital infections, ectopic
pregnancy and other adverse outcomes of pregnancy; and prevention of
cervical cancer (1).  The figure Figure_STD on the facing page
illustrates the critical overlap between prevention of STDs and the
prevention of these outcomes.  STDs are a result of high risk behaviors
that also promote the spread of HIV.  Recent AIDS surveillance data
indicate that for the majority of AIDS cases, transmission was most likely
related to unsafe sexual practices (2).  Multiple studies strongly suggest
that the presence of STDs enhances the transmission of HIV (3).  Although
many of the bacterial STDs are easily treated with currently available
antimicrobial therapies, they continue to disproportionately affect certain
disadvantaged populations.  Compared with other industrialized countries,
the United States continues to have very high rates of STDs (1).

This year's edition of Sexually Transmitted Disease Surveillance, 1993
highlights certain population subgroups and geographic areas particularly
affected by STDs.  These population subgroups include women and infants,
adolescents and young adults, and minorities (especially African-
Americans).  The South, with the highest incidence rates of syphilis and
gonorrhea, is also highlighted.  In this decade, these populations provide
both the most urgent need and the greatest challenges for STD prevention
and control programs at the federal and state/local levels.

National incidence for two important bacterial sexually transmitted
diseases (gonorrhea and syphilis) continued to decline in 1993.  Overall
rates of gonorrhea declined 12 percent from 197 per 100,000 population in
1992 to 172 in 1993 and is now well below the United States Public Health
Service (USPHS) Healthy People 2000 (HP 2000) national objective of 225
cases per 100,000 population (4).  Primary and secondary (P&S) syphilis
decreased from 13.3 to 10.4 cases per 100,000 population (1992 versus
1993), the lowest rate in 15 years.  Thus, despite the epidemic of syphilis
that occurred in the late 1980's, the HP 2000 national objective of 10
cases per 100,000 population has nearly been achieved.  Syphilis is now an
infrequent and highly focal disease in all regions except the South.  In
1993, the South had a P&S syphilis rate of 18.8; these cases accounted for
more than 60% of all syphilis cases in the U.S.

Congenital syphilis rates have decreased in parallel to declining rates of
syphilis in women.  Infants at risk for congenital syphilis were most often
born to unmarried, African-American women who have received little or no
prenatal care.  While congenital syphilis cases are relatively rare
outcomes, they remain an important sentinel indicator of low prenatal care
utilization in populations of women who also face extreme poverty, illicit
drug use, lack of access to health care, and poor education.

Chlamydia trachomatis infection, for which prevention and control programs
are beginning, is the most prevalent bacterial STD in the United States. 
Although there was a slight decline in reported cases of chlamydial
infection between 1992 and 1993 (from 178 to 168 cases per 100,000
population), as additional states implement screening programs, reported
cases should continue to increase nationally over the near term.  Chlamydia
prevention and control programs are a high priority because of their
potential impact on prevention of pelvic inflammatory disease and its
sequelae, e.g., infertility and ectopic pregnancy.

Syphilis tends to be a disease of adults, but gonorrhea and chlamydia are
diseases that disproportionately affect adolescents.  In 1993, the rate of
gonorrhea in 15- to 19-year-olds was 742 cases per 100,000 population. 
Although age-specific national data for chlamydial infections are not
available, numerous prevalence studies have shown rates to be highest in
adolescents and young adults under 25 years of age (5).

The STD rates continue to be much higher for African-Americans and other
minorities than for white Americans.  The 1993 P&S syphilis rate of 76.5
cases per 100,000 population for blacks remains more than 60-fold higher
than for whites (1.2 cases per 100,000 population).  Similarly, the rate of
gonorrhea (1,215 cases per 100,000 population) for blacks was more than
40-fold higher than for whites (28.6).  For Hispanics, rates of P&S
syphilis (6.0) and gonorrhea (90.4) were 5- and 3-fold higher than for
whites, respectively.

Statistics on cases of AIDS and HIV infection are not presented in this
document.  These data are available from the Division of HIV/AIDS, National
Center for Infectious Diseases, Centers for Disease Control and Prevention,
1600 Clifton Road, Mailstop G-49, Atlanta, Georgia 30333.

(1) Centers for Disease Control and Prevention.  Healthy People 2000:
National Health Promotion and Disease Prevention Objectives.  Progress
Review:  Sexually Transmitted Diseases. Division of STD/HIV Prevention
internal report, October, 1994, p. 17.

(2) Centers for Disease Control and Prevention.  HIV/AIDS Surveillance
Report, 1994;6(no.1).

(3) Wasserheit JN. Epidemiologic synergy.  Interrelationships between human
immunodeficiency virus infection and other sexually transmitted diseases. 
Sex Transmit Dis 1992;19:66-77.

(4) 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) 91-50213.  U.S. Government Printing Office, Washington D.C.,
September 1990.

(5) Centers for Disease Control and Prevention. Recommendations for
prevention and management of Chlamydia trachomatis infections, 1993. MMWR
1993;42(No. RR-12):1-4.

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