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. 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-V) that highlight specific points made in the 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 involuntarily 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). Congenital syphilis (CS) is a devastating consequence for the infants born to women who are infected with syphilis during pregnancy. Most cases of CS are preventable if women are screened and treated early through prenatal care (9). HIV-infected 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 1993, 44 states had implemented legislation mandating reporting of chlamydia and reported cases to CDC; an additional two states without reporting laws collected and reported cases on a voluntary basis (Figure_A, Table_3). -- Between 1989 and 1992, the reported rate of chlamydial infections in women increased from 162.5 per 100,000 population to 263.9 and declined slightly in 1993 to 243.9 (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 a mixture of prevalent and incident cases; and many state/local health departments have not yet developed chlamydia prevention programs, including surveillance infrastructure, to collect information from laboratories and providers. Currently, despite considerable underreporting, it is important to note that chlamydia rates exceed those of any other bacterial STD in women in many states (Figure_B, Table_4). -- 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 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 have declined steadily throughout the 1980's and early 1990's (Figure_10; Table_12 and Table_13). 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 1993. In the absence of known outbreaks of gonorrhea in gay men (which tend to occur sporadically), the steadily declining M:F RR suggests that decreasing gonorrhea trends may be due in 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 since then to 79.0 in 1993 (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 to 9.5 in 1993 (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 has 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. Hospital discharge statistics were therefore useful for monitoring trends in ectopic pregnancy (Figure_D). Beginning in 1990, hospitalizations for ectopic pregnancy began to decline. However, data 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. (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, 1987-1993 Figure_B. Chlamydia - Rates for women by state: United States, 1993 Figure_C. Chlamydia - Percent positivity among women tested in family planning clinics by state: Region X, 1988-1993 Figure_D. Ectopic pregnancy - Hospitalizations of women 15-44 years of age: United States, 1980-1992 STDs in Adolescents and Young Adults Public Health Impact Adolescents (<20-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 a variety of settings in federal Region X (Alaska, Idaho, Oregon, and Washington) (4), San Francisco, California, Columbus, Ohio, and Wisconsin (5) have demonstrated that younger women have consistently higher positivity rates of chlamydia than older women (Figure_E, Figure_F, Figure_G, and Figure_H). -- Rates of gonorrhea in 15- to 19-year-old adolescent men and women have declined in the past three years, but continue to be higher than for other age groups (Figure_12, Figure_I and Figure_J; Table_9B) (6). In 1993, the overall rate of gonorrhea for 15- to 19-year-olds was 742.1 per 100,000 population. In this age group, rates for adolescents women (868.0) exceeded the rate in men (622.7). (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. (5) Addiss DG, Vaughn ML, Hillis SD, Ludka D, Amsterdam L, Davis JP. History and features of the Wisconsin Chlamydia trachomatis control program. Family Plan Perspec 1994;26:83-6. (6) Webster LA, Berman SM, Greenspan JR. Surveillance for gonorrhea and primary and secondary syphilis among adolescents, United States--1981-1991. In: CDC Surveillance Summaries, August 13, 1993. MMWR 1993;42:(No. SS-3):1-11. Figure_E. Chlamydia - Percent positivity among women tested in family planning clinics by age group: Region X, 1988-1993 Figure_F. Chlamydia - Percent positivity among women tested in 16 sentinel clinics by age group: San Francisco, California, 1988-1993 Figure_G. Chlamydia - Percent positivity among women tested in primary care settings by age group: Columbus, Ohio, 1988-1993 Figure_H. Chlamydia - Percent positivity of chlamydia laboratory tests in women by age group: Wisconsin, 1985-1994 Figure_I. Gonorrhea - Age-specific rates among women 15-44 years of age: United States, 1981-1993 Figure_J. Gonorrhea - Age-specific rates among men 15-44 years of age: United States, 1981-1993 STDs in Minorities Public Health Impact Surveillance data show high rates of STDs for some minority 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 minorities 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 three demonstration projects (Region X, San Francisco, California, and Columbus, Ohio) show higher rates among minorities (Figure_K, Figure_L, and Figure_M). -- In 1993, African-Americans accounted for about 81% of total reported cases of gonorrhea (Table_9A). The overall gonorrhea rate in 1993 was 1,215.2 cases per 100,000 in blacks and 114.3 in Hispanics compared with 28.6 in non-Hispanic whites (Figure_11, Table_9B). -- Age-specific rates are very high in African-American adolescents and young adults. In 1993, black 15- to 19-year-old women had a gonorrhea rate of 4,654.8 cases per 100,000 population and black men in this age group had a gonorrhea rate of 4,099.6. These rates were more than 20-fold higher than those in white adolescents (Table_9B). -- Despite declines in gonorrhea rates for most age and race/ethnic groups during the 1980's, African-American adolescents did not show steady declining trends in rates until 1991 (black women) and 1992 (black men) (Figure_N and Figure_O). -- 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 1993, African-Americans accounted for about 86% of all reported cases of P&S syphilis (Table_21A). Although the rate among African-Americans declined from 96.9 cases per 100,000 population in 1992 to 76.5 in 1993, the latter rate remained more than 60-fold greater than the non-Hispanic white rate of 1.2. The 1993 rate of P&S syphilis in Hispanics of 6.0 was 5-fold greater than for non-Hispanic whites (Figure_24 and Table_21B). -- In 1993, the rate of congenital syphilis in African-Americans was 344.9 per 100,000 live births and 96.3 in Hispanics compared with 6.1 in whites (Figure_P). -- Minorities are also at increased risk for the long term consequences of STDs as evidenced by differences in ectopic pregnancy rates (Figure_Q). (1) Rolfs RT, Nakashima AK. Epidemiology of primary and secondary syphilis in the United States, 1981 through 1989. JAMA 1990;264:1432-7. Figure_K. Chlamydia - Percent positivity among women tested in family planning clinics by race and ethnicity: Region X, 1988-1993 Figure_L. Chlamydia - Percent positivity among women tested in 16 sentinel clinics by race and ethnicity: San Francisco, California, 1988-1993 Figure_M. Chlamydia - Percent positivity among women tested in primary care settings by race group: Columbus, Ohio, 1988-1993 Figure_N. Gonorrhea - Reported rates for 15- to 19-year-old females by race and ethnicity: United States, 1981-1993 Figure_O. Gonorrhea - Reported rates for 15- to 19-year-old males by race and ethnicity: United States, 1981-1993 Figure_P. Congenital syphilis - Rates for infants <1 year of age by race and ethnicity: United States, 1991-1993 Figure_Q. Ectopic pregnancy - Rates by race and year group: United States, 1970-1989 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 1993, nine of the ten states with the highest rates of gonorrhea were located in the South (Figure_7 and Table_10). Nine of the ten states with the highest rates of P&S syphilis were also located in the South (Figure_19 and Figure_20; Table_22). Seven of the eight states with rates of P&S syphilis that exceeded 20 cases per 100,000 population (or twice the Healthy People 2000 [HP 2000] national objective) were located in the South (Figure_19 and Table_22). -- In 1993, 424 (92%) of 461 counties with P&S syphilis rates above the HP 2000 objective were located in the South (Figure_R). -- Between 1992 and 1993, P&S syphilis rates increased in 212 (50%) of 424 counties in the South that had 1993 rates greater than 10 cases per 100,000 population (Figure_S). -- 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 are adjusted for race and ethnic composition of the population, states in the South no longer have the highest rates, and states with the highest rates are located in the Midwest (Figure_T). When P&S syphilis rates are adjusted for race and ethnicity, the differences between the South and other regions, especially the Midwest, are greatly diminished (Figure_U). However, many states in the South continue to have high rates. -- Rates of P&S syphilis in African-Americans by region show that the epidemic of the 1980's was largely an epidemic within this group regardless of region (Figure_V). Figure_R. Primary and secondary syphilis case rates by county, 1993 Figure_S. South - Increases and decreases in cases of primary and secondary syphilis in 1993 compared with 1992 cases, by county Figure_T. Gonorrhea - Rates by state, adjusted for race and ethnic distribution of the population: United States, 1993 Figure_U. Primary and secondary syphilis - Rates by state, adjusted for race and ethnic distribution of the population: United States, 1981-1993 Figure_V. Primary and secondary syphilis - Rates in African-Americans by region: 1981-1993
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