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. 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-U) 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% of women infected with chlamydia (1) and 10% to 40% of women infected with gonorrhea (2) develop PID. Among women with PID, scarring sequelae will cause involuntary infertility in 20%, ectopic pregnancy in 9%, and chronic pelvic pain in 18% (3). Approximately 70% of chlamydial infections and 50% 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). Data from a randomized controlled trial of chlamydia screening in a managed care setting suggest that such screening programs can reduce the incidence of PID by as much as 60%. (8) 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) in women 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). Observations -- Between 1995 and 1996, the reported rate of chlamydial infections in women increased from 316.2 per 100,000 population to 321.5 (Figure_6, Table_6). This increase most likely reflects an increase in screening rather than an increase in number of cases in women; even as reported cases have increased, prevalence among women screened in the U.S. has declined (see section on Chlamydia). Despite considerable under-reporting, it is important to note that chlamydia rates exceed gonorrhea rates in women in many states (Figure_A and Figure_B, Table_6 and Table_15). -- For gonorrhea, the Healthy People year 2000 objective is 100 cases per 100,000 persons. Gonorrhea rates for women alone exceeded this HP2000 objective in 22 states (Figure_B, Table_15). The highest rates of gonorrhea for women were concentrated in the South. -- 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_15, Table_15 and Table_16). Gonorrhea rates decreased for women from 140.2 cases per 100,000 population in 1995 to 119.5 in 1996; rates in men also declined from 158.7 to 128.5 from 1995 to 1996. Men with gonorrhea are usually symptomatic and may seek care; therefore, trends in men may be a relatively good indicator of trends in incidence of disease. However, trends in women are determined more by screening practices, similar to chlamydia. -- The Healthy People year 2000 objective for primary and secondary syphilis is 4.0 per 100,000 persons. Primary and secondary syphilis rates for women alone exceeded the HP2000 objective in 15 states and 2 outlying areas (Figure_C, Table_27). Five southern states (Louisianna, Maryland, Mississippi, North Carolina, Tennessee) had rates for women that were at least 3 times greater than the HP2000 objective for primary and secondary syphilis. For congenital syphilis, the Healthy People year 2000 objective is 40 per 100,000 live births. Five (Arkansas, Maryland, Mississippi, South Carolina, Tennessee) of 8 states that exceeded the HP2000 objective were in the South (Figure_D, Table_38). -- The rate of congenital syphilis (CS) closely follows the trend of primary and secondary (P&S) syphilis in women (Figure_32). 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 72% to 30.4 in 1996 (Figure_33, Table_37). The rate of P&S syphilis in women peaked at 17.3 per 100,000 persons in 1990 and declined 77% to 4.0 in 1996 (Figure_29 and Figure_32, Table_27). -- Although the 1996 rate of CS was below the 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 (10). -- Accurate estimates of pelvic inflammatory disease (PID) and tubal factor infertility from gonococcal and chlamydial infections are difficult to obtain. Definitive diagnosis of these conditions can be complex, requiring for example, laparoscopy or laparotomy, while tubal patency studies may be needed 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 the 1990's. Trends in hospitalized PID have declined steadily throughout the 1980's and early 1990's (Figure_F). 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 in-patient to out-patient) rather than true trends in disease (11). -- 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 treated on an out-patient basis (12). The total number of ectopic pregnancies in the U.S. in 1992 was estimated to be 108,800 (or 19.7 cases per 1,000 pregnancies), the highest level in more than two decades (12). -- Initial visits to physicians' offices for PID declined from 1993 to 1995, but increased in 1996 (Figure_G). In 1994, an estimated 397,000 women aged 15-44 years were diagnosed with PID in emergency departments (National Hospital Ambulatory Medical Care Survey, NCHS). Figure_A. Chlamydia -- Rates for women by state: United States and outlying areas, 1996 Figure_B. Gonorrhea -- Rates for women by state: United States and outlying areas, 1996 Figure_C. Primary and secondary syphilis -- Rates for women by state: United States and outlying areas, 1996 Figure_D. Congenital syphilis -- Rates for infants <1 year of age by state: United States and outlying areas, 1996 Figure_E. Ectopic pregnancy -- Hospitalizations of women 15-44 years of age: United States, 1980-1994 Figure_F. Pelvic inflammatory disease -- Hospitalizations of women 15-44 years of age: United States, 1980-1994 Figure_G. Pelvic inflammatory disease -- Initial visits to physicians' offices by women 15-44 years of age: United States, 1980-1996 and Healthy People year 2000 objective ---------- (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, Handsfield 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) 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. (9) CDC. Guidelines for prevention and control of congenital syphilis. MMWR 1988;37(No.S-1). (10) Division of STD/HIV Prevention. Healthy People 2000: National Health Promotion and Disease Objectives. Progress Review: Sexually Transmitted Diseases, October 26, 1994. (11) 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. (12) CDC. Ectopic pregnancy -- United States, 1990-1992. MMWR 1995;44:46-8. STDs in Adolescents and Young Adults Public Health Impact Compared to 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). The Chlamydia Regional Projects that perform large-scale screening among women attending family planning clinics demonstrate that younger women consistently have higher positivity rates of chlamydia than older women, even as prevalence declines. An example is the Region X Project, which has screened women since 1988 (5) (Figure_H). -- Among women, 15- to 19-year-olds had the highest rate of gonorrhea (Figure_J, Table_12B), and 20- to 24-year-olds had the highest rate of primary and secondary syphilis (Figure_L, Table_24B). Among men, 20- to 24-year-olds had the highest rate of gonorrhea and second highest rate of primary and secondary syphilis (Figure_K and Figure_M, Table_12B and Table_24B). -- Rates of gonorrhea among male adolescents have steadily decreased during the 4 year period 1993-96 (Table_12B). In the 10- to 14-year-old group, the rate for males decreased from 20.4 per 100,000 in 1993 to 9.1 in 1996, a decrease of 55%. In the 15- to 19-year-old group, the rate declined from 611.4 in 1993 to 394.3 in 1996, a 36% decrease. Among young adult men in the 20- to 24-year-old group, the rate of gonorrhea fell from 729.9 in 1993 to 522.5 in 1996, a decrease of 28%. -- Rates of gonorrhea among female adolescents also generally decreased over the 4 year period 1993-96 (Table_12B). However, both adolescent age groups exhibited an increase between 1993 and 1994, which was followed by decreases in 1995 and in 1996. This pattern also occurred among young adult women. In the 10- to 14-year-old group, the rate for females decreased from 78.0 per 100,000 in 1993 to 57.9 in 1996, a decrease of 26%. In the 15- to 19-year-old group, the rate declined from 851.6 in 1993 to 756.8 in 1996, an 11% decrease. Among young adult women in the 20- to 24-year-old group, the rate of gonorrhea fell from 629.2 in 1993 to 522.9 in 1996, a decrease of 17%. -- In 1996, 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_17). -- From 1995 to 1996, gonorrhea rates increased among American Indian/Alaska Native adolescents and young adults (Table_12B). -- 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 1996, based on their place of residence just before program entry, state-specific chlamydia test positivity ranged from 1.7% to 17.9% (Figure_I). Chlamydia infection is widespread geographically and highly prevalent among these economically disadvantaged young women. Figure_H. Chlamydia -- Percent positivity among women tested in family planning clinics by age group: Region X, 1988-1996 Figure_I. Chlamydia -- Percent positivity among 16-24 year-old women entering the U.S. Job Corps by state of residence, 1996 Figure_J. Gonorrhea -- Age-specific rates among women 10-44 years of age: United States, 1981-1996 Figure_K. Gonorrhea -- Age-specific rates among men 10-44 years of age: United States, 1981-1996 Figure_L. Primary and secondary syphilis -- Age-specific rates among women 10-44 years of age: United States, 1981-1996 Figure_M. Primary and secondary syphilis -- Age-specific rates among men 10-44 years of age: United States, 1981-1996 ---------- (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 or ethnic groups when compared with rates for whites. 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 or 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 Health and Human Services Region X (Alaska, Idaho, Oregon, and Washington) show consistently higher rates among minorities (Figure_N). -- In 1996, African-Americans accounted for about 78% of total reported cases of gonorrhea (Table_12A). The overall gonorrhea rates in 1996 were 825.5 cases per 100,000 for African-Americans and 69.0 for Hispanics compared with 25.9 for non-Hispanic whites (Figure_16, Table_12B). Compared with 1995, 1996 rates decreased for all race/ethnic groups except American Indian/Alaska Native. -- Gonorrhea rates are very high for African-American adolescents and young adults. In 1996, black females aged 15 to 19 years had a gonorrhea rate of 3,790.9 cases per 100,000 population. Black men in this age group had a gonorrhea rate of 2,357.2. These rates were on average about 24 times higher than those of 15- to 19-year-old white adolescents (Table_12B). Among 20- to 24-year-olds in 1996, the gonorrhea rate among blacks was almost 30 times greater than that of whites (3,015.5 vs. 103.9, respectively) (Table_12B). -- 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 1995 and 1996 gonorrhea rates for black females aged 15 to 19 years declined by 14.1%, and for black males in this age group, by 27.1% (Table_12B, Figure_O and Figure_P). -- 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 for African-Americans and Hispanics continue to be higher than for non-Hispanic whites. In 1996, African-Americans accounted for about 84% of all reported cases of P&S syphilis (Table_24A). Although the rate for African-Americans declined from 44.9 cases per 100,000 population in 1995 to 30.2 in 1996, the latter rate was nearly 50-fold greater than the non-Hispanic white rate of 0.6 per 100,000. Between 1995 and 1996, primary and secondary syphilis rates for black females aged 15 to 19 years declined by 39.8%, and for black males in this age group, by 38.7% (Figure_Q and Figure_R, Table_24B). The 1996 rate of P&S syphilis in Hispanics was 1.9 (Figure_30, Table_24B). -- In 1996, the rate of congenital syphilis in African-Americans was 127.8 per 100,000 live births and 36.4 in Hispanics compared with 3.2 in whites (Figure_S). Compared with 1995, this represented a 37% decrease for blacks and a 42% decrease for Hispanics. Figure_N. Chlamydia -- Percent positivity among women tested in family planning clinics by race and ethnicity: Region X, 1988-1996 Figure_O. Gonorrhea -- Reported rates for 15-19 year old females by race and ethnicity: United States, 1981-1996 Figure_P. Gonorrhea -- Reported rates for 15-19 year old males by race and ethnicity: United States, 1981-1996 Figure_Q. Primary and secondary syphilis -- Reported rates for 15-19 year old females by race and ethnicity: United States, 1981-1996 Figure_R. Primary and secondary syphilis -- Reported rates for 15-19 year old males by race and ethnicity: United States, 1981-1996 Figure_S. Congenital syphilis -- Rates for infants <1 year of age by race and ethnicity: United States, 1991-1996 ---------- (1) Nakashima AK, Rolfs RT, Flock ML, Kilmarx P, Greenspan JR. Epidemiology of syphilis in the United States, 1941 through 1993, Sexually Transmitted Diseases 196;23(1):16-23. STDs in the South Public Health Impact The southern region (Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, 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 other 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_12, Figure_13, Figure_25, Figure_27, Table_14 and Table_26). In 1996, the South also had the highest rate of Chlamydia (Figure_3, Table_5) compared to the other regions. -- In 1996, 6 of the 10 states with the highest chlamydia rates were in the South (Table_4). Similarly, the 10 states with the highest rates of gonorrhea were all located in the South (Figure_12, Table_13). Twelve of 16 states with rates of P&S syphilis above the HP2000 objective of 4 per 100,000 persons were located in the South (Figure_25 and Figure_26, Table_25). All 8 states with rates of P&S syphilis that exceeded 10 cases per 100,000 population (or 2.5 times the HP2000 national objective) were located in the South (Figure_25, Table_25). -- In 1996, 429 (89%) of 482 counties with P&S syphilis rates above the HP2000 objective were located in the South (Figure_26 and Figure_T). -- Of the 429 counties in the South that had a 1996 P&S syphilis rate above 4.0 per 100,000 population, 188 (44%) had an increasing rate from 1995 to 1996 (Figure_T and Figure_U). Figure_T. South -- Primary and secondary syphilis case rates by county, 1996 Figure_U. South -- Increases and decreases in cases of primary and secondary syphilis in 1996 compared with 1995 cases, by county ---------- (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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