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. 


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

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

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

Epidemiology and Surveillance Branch
    Michael E. St. Louis, M.D.
    Chief 

Surveillance and Special Studies Section
    William C. Levine, M.D., M.Sc.
    Chief 

Statistics and Data Management Branch
    Russell H. Roegner, Ph.D.
    Chief 

    Melinda L. Flock, M.S.P.H.
    Deputy Chief


Foreword

"STDs are hidden epidemics of enormous health and economic consequence in
the United States. They are hidden because many Americans are reluctant to
address sexual health issues in an open way and because of the biologic and
social characteristics of these diseases. All Americans have an interest in
STD prevention because all communities are impacted by STDs and all
individuals directly or indirectly pay for the costs of these diseases.
STDs are public health problems that lack easy solutions because they are
rooted in human behavior and fundamental societal problems. Indeed, there
are many obstacles to effective prevention efforts. The first hurdle will
be to confront the reluctance of American society to openly confront issues
surrounding sexuality and STDs. Despite the barriers, there are existing
individual- and community-based interventions that are effective and can be
implemented immediately. That is why a multifaceted approach is necessary
to both the individual and community levels.

To successfully prevent STDs, many stakeholders need to redefine their
mission, refocus their efforts, modify how they deliver services, and
accept new responsibilities. In this process, strong leadership, innovative
thinking, partnerships, and adequate resources will be required. The
additional investment required to effectively prevent STDs may be
considerable, but it is negligible when compared with the likely return on
the investment. The process of preventing STDs must be a collaborative one.
No one agency, organization, or sector can effectively do it alone; all
members of the community must do their part. A successful national
initiative to confront and prevent STDs requires widespread public
awareness and participation and bold national leadership from the highest
levels" (1).

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(1) Concluding Statement from the Institute of Medicine's Summary Report,
    The Hidden Epidemic: Confronting Sexually Transmitted Diseases,
    National Academy Press, 1997, p.43.


Preface

Sexually Transmitted Disease Surveillance, 1996 presents statistics and
trends of sexually transmitted diseases (STDs) in the United States through
1996. This annual publication is intended as a reference document for
policy makers, program managers, health planners, researchers, and others
who are concerned with the public health implications of these diseases.
The figures and tables in this edition supersede those in earlier
publications of these data.

The surveillance information in this report is based on the following
sources of data: (1) case reports from the STD project areas; (2)
prevalence data from the Regional Infertility Prevention Projects, STD
project areas, and the U.S. Job Corps; (3) sentinel surveillance of
gonococcal antimicrobial resistance from the Gonococcal Isolate
Surveillance Project; and (4) national sample surveys implemented by
federal and private organizations.
 
The STD surveillance systems operated by state and local STD control
programs, which provide the case report data, 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.

Sexually Transmitted Disease Surveillance, 1996 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, and contains Table_A1 which
displays progress made toward Healthy People 2000 Priority Area 19 on
Sexually Transmitted Diseases.

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 were developed in 1989 and revised in 1995. The revisions
are used as reference points in this edition of Sexually Transmitted
Disease Surveillance, 1996. 

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, Centers
for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-02,
Atlanta, Georgia, 30333.

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(1) Department of Health and Human Services. Healthy People 2000: Midcourse
    Review and 1995 Revisions. U.S. Department of Health and Human
    Services, Public Health Service, U.S. Government Printing Office,
    Washington, D.C., 1995.


Acknowledgments

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 state and local
surveillance data to the Centers for Disease Control and Prevention.

This report was prepared by the following staff members of the Division of
STD Prevention, National Center for HIV, STD, and TB Prevention, Centers
for Disease Control and Prevention: Susan Bradley, Jim Braxton, Sharon
Clanton, Darlene Davis, Kathleen B. Dry, Kimberley K. Fox, Samuel
L.Groseclose, Alesia Jester-Harvey, Debra Mosure, LuEtta Schneider, Maya
Sternberg, Emmett Swint, and Diane M. Vitro.

                     Geographic Divisions of the United States

Figure_GEO.   Geographic Divisions of the United States

West           Midwest          South                    Northeast

Alaska         Iowa             Alabama                  Connecticut
Arizona        Illinois         Arkansas                 Massachusetts
California     Indiana          Delaware                 Maine
Colorado       Kansas           District of Columbia     New Hampshire
Hawaii         Michigan         Florida                  New Jersey
Idaho          Minnesota        Georgia                  New York
Montana        Missouri         Kentucky                 Pennsylvania
New Mexico     Nebraska         Louisiana                Rhode Island
Nevada         North Dakota     Maryland                 Vermont
Oregon         Ohio             Mississippi
Utah           South Dakota     North Carolina
Washington     Wisconsin        Oklahoma
Wyoming                         South Carolina
                                Tennessee
                                Texas
                                Virginia
                                West Virginia

National Overview of Sexually Transmitted Diseases, 1996

The logo on the cover of Sexually Transmitted Disease Surveillance, 1996 is
a reminder of the multifaceted, national dimensions of the morbidity,
mortality, and costs that result from sexually transmitted diseases (STDs)
in the United States. It highlights the central role of STD prevention in
improving women's and infants' health and in promoting HIV prevention.
Organized collaboration among interested, committed public and private
organizations is the key to reducing STDs and their related health burdens
in our population. As noted in the recent report of the Institute of
Medicine, The Hidden Epidemic: Confronting Sexually Transmitted Diseases
(1), surveillance is a key component of our efforts to prevent and control
these diseases.

This overview summarizes national surveillance data on the three diseases
for which we have federally-funded control programs: chlamydia, gonorrhea,
and syphilis. Several observations for 1996 are worthy of note.

In 1996, the reported number of cases of genital Chlamydia trachomatis
infections was 490,080, a rate of 194.5 per 100,000 persons. This rate
exceeds that of all other notifiable infectious diseases in the United
States. In 1996, the overall reported rate for women (321.5 per 100,000)
was more than five times that in men (60.4). This difference in reported
cases is attributable to screening strategies that focus on women because
the severe sequelae of chlamydia infections accrue principally to women,
and because these infections are asymptomatic in the majority of cases
among women.

Using local, state, and federal resources, chlamydia prevention programs
for screening of asymptomatic women have been established throughout the
country. In 1996, state-specific chlamydia test positivity among women aged
15-24 years who were screened at selected family planning clinics ranged
from 2.5% to 10.9%. These screening programs have consistently shown that
the highest rates of chlamydial infection in women are in adolescents. In
addition, examination of chlamydial screening results for rural and urban
disadvantaged women aged 16-24 years entering the U.S. Job Corps shows that
chlamydia is highly prevalent in these economically disadvantaged young
women, with state-specific rates in 1996 ranging from 1.7% to 17.9%.

In parts of the United States where large-scale chlamydia programs have
been instituted, prevalence of disease has steadily declined. During
1988-1996, among 15- to 44-year-old women participating in the screening
programs in Health and Human Services (HHS) Region X family planning
clinics, the rate of chlamydia test positivity declined 61% (from 9.3% to
3.6%). During 1994-1996, among women under 45 years of age in Region III,
positivity declined 28% (from 4.7% to 3.4%), and in Region VIII, positivity
declined 21% (from 3.9% to 3.1%). See the Appendix for definition of HHS
regions.

Data on gonorrhea for 1996 show that the annual decreases that have been
evident since the national gonorrhea control program began in the mid-1970s
are continuing. The 1996 gonorrhea rate of 124.0 is the lowest rate since
national reporting began but is above the revised Healthy People 2000
(HP2000) objective of 100. The average annual decreases in gonorrhea over
the last 10 years have been about 25 cases per 100,000 persons per year.
The decrease in reported cases between 1995 (149.4 per 100,000) and 1996
was 25.4 cases per 100,000.

With respect to gender, the 1996 gonorrhea rate decreased from the 1995
rate by 19.0% in males (128.5), and by 14.8% in females (119.5). In
general, age-specific rates decreased for both sexes. Relative to 1995,
decreases in the age-specific rates ranged from approximately 10% to 27% in
males and about 1% to 19% in females. Decreases were greatest in the
youngest age group: 10- to 14-year-olds (males:26.6%; females:19.1%).
Because men with gonorrhea are usually symptomatic and seek medical care,
trends in males are a good measure of disease incidence. Trends in women
are largely determined by screening practices. As for chlamydia, rates of
gonorrhea in women are particularly high in adolescents, with the highest
rates in 15- to 19-year-olds. 

With regard to antimicrobial resistance, a growing number of Neisseria
gonorrhoeae isolates tested through the Gonococcal Isolate Surveillance
Project have demonstrated decreased susceptibility to ciprofloxacin, one of
the currently recommended treatments for gonorrhea. However in 1996,
resistance to ciprofloxacin was rare (0.04%).

The 11,387 cases of primary and secondary (P&S) syphilis reported in 1996
were the fewest cases reported in the United States since 1959. The P&S
syphilis rate of 4.3 per 100,000 persons is approaching the HP2000
objective of 4 per 100,000. Syphilis continues to be reported only in
specific areas of the country. In 1996, the percentage of U.S. counties
that did not report any syphilis cases increased to 73% compared to 69% of
the counties in 1995. In 1996, P&S syphilis rates exceeded 4 per 100,000 in
482 counties (15% of total counties). These counties accounted for 84% of
all reported P&S syphilis cases. Most notably, 89% (429 of 482) of these
counties were in the South. In addition, 12 of the 18 states or outlying
areas with P&S syphilis rates greater than 4 per 100,000 were located in
the South. These data suggest that comprehensive syphilis prevention
efforts focused in the South may markedly reduce the number of U.S.
syphilis cases by the end of the decade.

When STD statistics were examined by race or ethnicity, very wide
discrepancies continue between racial or ethnic groups. For example,
gonorrhea rates in black adolescents (15-19 years of age) are almost 25
times greater than the rate in white adolescents. The rate of P&S syphilis
in blacks is nearly 50 times that in whites; P&S syphilis in Hispanics is
about 3 times that in whites. Congenital syphilis has decreased nationally
in recent years. However, in 1996, of the 1,160 reported cases with known
race or ethnicity of the mother, blacks and Hispanics accounted for 90% of
all reported cases, while accounting for only 23% of the female population.
Race and ethnicity in the United States serve as risk markers that
correlate with other, more fundamental determinants of health status such
as socioeconomic status, access to good quality medical care, and efforts
to receive good quality medical care. Reporting biases also undoubtedly
play a role in race differentials, while not explaining them completely.

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(1) Institute of Medicine. The Hidden Epidemic: Confronting Sexually
    Transmitted Diseases, Committee on Prevention and Control of Sexually
    Transmitted Diseases, National Academy Press, Washington, D.C., 1997. 

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