# Presentation: 662078

## Recent Trends in Gonorrhea in the United States

**Lori M. Newman, MD**
**Division of STD Prevention**
**CDC**
**Atlanta, GA**
**March 8, 2004**

## Neisseria gonorrhoeae

- Sequelae of untreated infection include
- Pelvic inflammatory disease
- Infertility
- Chronic pelvic pain
- Increases risk of HIV transmission and acquisition
- Gonorrhea is second most common reported notifiable disease

**Notes:**
As all of you probably know, the sequelae of untreated infection by N. gonorrhoeae include pelvic inflammatory disease, infertility, and chronic pelvic pain.
N. gonorrhoeae infection also increases the risk of HIV transmission and acquisition.
Gonorrhea is the second most common reported notifiable disease through NETSS, our national electronic reporting system.

## Gonorrhea rates, U.S., 1970-2003*

- Rate (per 100,000 population)

- Gonorrhea rate

- 2010 Objective

-   0

- 100

- 200

- 300

- 400

- 500

- 1970

- 73

- 76

- 79

- 82

- 85

- 88

- 91

- 94

- 97

- 2000

- 03

- *Preliminary 2003 data

**Notes:**
Although NETSS national gonorrhea surveillance data for 2003 are not yet finalized, it appears that the 2003 rate for gonorrhea will be approximately 116 per 100,000 population.
This may be the lowest rate since gonorrhea reporting began in the 1940s, but is still far from the Healthy People 2010 goal of 19 cases per 100,000 population.
If you step back and look at the trend line, you may notice that after implementation of a national gonorrhea control program in the early 1970s, there was an impressive decline in the gonorrhea rate during the 1970s and 80s.
However, we haven’t seen much of a change in this rate for the past 7 years.
I’m going to look at this apparently flat line from 1997 through 2003 a little closer today to better characterize recent trends in gonorrhea.

## Gonorrhea rates by sex, 1981-2003*

- Rate (per 100,000 population)

- Male

- Female

- 2010 Objective

-   0

- 120

- 240

- 360

- 480

- 600

- 1981

- 83

- 85

- 87

- 89

- 91

- 93

- 95

- 97

- 99

- 2001

- 03

- *Preliminary 2003 data

**Notes:**
When you look at trends in gonorrhea by sex, you can see that historically there was more gonorrhea reported among men than women.  However, for the past 7 years, the rates among men and women have been nearly identical.

This is quite different than what is seen with syphilis, where more cases are reported among men, and chlamydia, where more cases are reported among women.

## Gonorrhea rates by age and sex, 2003*

- *Preliminary 2003 data

**Notes:**
When examined by age and sex, you can see that the highest rates for males are in 20-24 year olds, approximately 483 cases per 100,000 population in the year 2003.  
The highest rate for females were in 15-19 year olds with a rate of 626 per 100,000 population.
Reported cases of gonorrhea occur seem to concentrate among younger females, with almost 70% of reported gonorrhea morbidity among females ages 15 – 24.  
For males, only 47% of reported gonorrhea morbidity is among those same ages of 15 – 24.
There is a much wider distribution  of ages for gonorrhea morbidity among males.

## Gonorrhea rates among females by age, 1981-2003*

- 15-19

- 20-24

- 25-29

- 30-34

- Rate (per 100,000 population)

-     0

-   300

-   600

-   900

- 1,200

- 1,500

- 1981

- 83

- 85

- 87

- 89

- 91

- 93

- 95

- 97

- 99

- 2001

- 03

- *Preliminary 2003 data

**Notes:**
When you look at how this distribution has changed over time among females, you see that rates among 15-19 year olds and 20-24 year olds are converging.   Over the past 7 years there has been an 11% decrease in the gonorrhea rate for 15-19 year olds, while the rate for 20-24 year olds has increased 10%.

Of all female age groups, only 15-19 year old females demonstrate consistently declining gonorrhea rates.

(25-29 year old have seen a 9% increase.)

## Gonorrhea rates among males by age, 1981-2003*

- Rate (per 100,000 population)

-     0

-   400

-   800

- 1,200

- 1,600

- 2,000

- 1981

- 83

- 85

- 87

- 89

- 91

- 93

- 95

- 97

- 99

- 2001

- 03

- 20-24

- 15-19

- 25-29

- 30-34

- *Preliminary 2003 data

- 35-39

- 40-44

- 10-14

**Notes:**
Gonorrhea rates among males from 1997 – 2003 showed an approximately 25% decline in the 15-19 year old age group, similar to what we’ve seen in women. 
Rates declined between 5-10% in the other age groups shown here during this time period.        (10, 6, 5%)

The trend in declining gonorrhea rates for adolescents of both sexes is similar to what is has been seen recently in syphilis and pregnancy rates.

(National Survey of Family Growth)

## Gonorrhea rates by state: U.S., 2003*

**Gonorrhea rates by state: U.S., 2003***

- *Preliminary 2003 data

- Note: The Healthy People 2010 objective for gonorrhea
-  is 19 cases per 100,000 population

**Notes:**
Let’s look at gonorrhea rates by state.  
Similar to the past 3 years, only 8 states, or 15% of states, had gonorrhea rates in 2002 below the Healthy People 2010 national objective of 19 cases per 100,000 population.  These states are located in the Northwestern and the Northeastern U.S.

(Categories: <= 19.0 (n=8)							
		19.1-100.0 (n=19)
		>100.0 (n=24))

## Gonorrhea rates by county: U. S., 2003*

**Gonorrhea rates by county: U. S., 2003***

- Note: The Healthy People 2010 objective for gonorrhea is 19 cases per 100,000 population

- *Preliminary 2003 data

**Notes:**
There is a remarkable amount of heterogeneity of the gonorrhea rate within states, however.
In 2003, 43% of 3,139 counties in the U.S. had GC rates at or below the HP2010 national objective.
Only 22% of counties had rates greater than 100, the majority of these counties clustered in the southeastern U.S.. 

(33% in mid-range)

## Gonorrhea rates by region, 1981-2003*

- South

- Midwest

- Northeast

- West

- 2010 Objective

- *Preliminary 2003 data

- Rate (per 100,000 population)

-   0

- 120

- 240

- 360

- 480

- 600

- 1981

- 83

- 85

- 87

- 89

- 91

- 93

- 95

- 97

- 99

- 2001

- 03

**Notes:**
When you examine gonorrhea rates by region, you see that the South traditionally has had the highest rates.  In 2003 this meant that the South accounted for 43% of reported gonorrhea morbidity.
However, if you look at what has happened regionally since 1997, you see that from 1997 to 2003, the South actually had a 20% decrease in their gonorrhea rate.
During the same time period the other three regions experienced increases ranging from 8% in the NE to 29% in the West.
Increasingly the South is accounting for a smaller proportion of gonorrhea morbidity.

(the MW had an 11% increase)

## Gonorrhea rates by race/ethnicity, 1981-2003*

- Rate (per 100,000 population)

-     0

-   500

- 1,000

- 1,500

- 2,000

- 2,500

- 1981

- 83

- 85

- 87

- 89

- 91

- 93

- 95

- 97

- 99

- 2001

- 03

- Black

- American Indian/Alaska Native

- Hispanic

- White

- *Preliminary 2003 data

**Notes:**
If you look at gonorrhea rates by race and ethnicity, you see that non-Hispanic blacks account overwhelmingly for the majority of reported gonorrhea cases at any point in time.
However, from 1997 to 2003, the gonorrhea rate among blacks decreased by 18%.

## Gonorrhea rates by race/ethnicity, 1981-2003, excluding blacks*

- *Preliminary 2003 data

- American Indian/Alaska Native

- Hispanic

- White

- Asian/Pacific Islander

- Rates (per 100,000 population)

**Notes:**
In order to understand trends among other races and ethnicities during the past 7 years, I have removed the trend line for blacks. 
Now you can see that in contrast to blacks where rates decreased over the past 7 years, reported gonorrhea rates have increased in all other race/ethnicities.
For example, rates among American Indians increased 19%, Hispanics 20%, Whites 28%, and American Indians/Alaska Native 32% over this 7 year time period.

## Ratios of minority gonorrhea rates to white rates,1981-2003*

- Black

- American Indian/Alaska Native

- Hispanic

- Asian/Pacific Islander

- *Preliminary 2003 data

- Rate ratio

**Notes:**
This slide shows the trend over time of the ratio of minority gonorrhea rates to white gonorrhea rates.
You can see that the racial disparity between blacks and whites has decreased over the past 7 years.  However, in 2003, the rate for blacks in the U.S. was still 21 times higher than that for whites.

## Gonorrhea rates for 15-19 year old females by region and race/ethnicity, 2003*

- *Preliminary 2003 data

- Rate (per 100,000 population)

**Notes:**
What if we put these data together?
Let’s look at the females in the age group with the highest rates, those ages 15-19 years old.
If you stratify by race/ethnicity and region, you can see that the highest rates are among black adolescents, in every region of the U.S.
Let me translate what this means....
This bar chart shows that nearly 2% of black adolescent females in the U.S. had a reported case of gonorrhea in 2003.

## Gonorrhea rates for 20-24 year old males by region and race/ethnicity, 2003*

- *Preliminary 2003 data

- Rate (per 100,000 population)

**Notes:**
Now let’s look at those males with the highest rates, those ages 20-24 years old.
Again, if you stratify by race/ethnicity and region, you can see that the highest rates are among black 20-24 year olds, IRRESPECTIVE of region.
Let me put this in simpler terms...
This bar chart shows that over 2% of black males ages 20-24 in the Midwest had a reported case of gonorrhea in 2003.
These are very concerning rates.

## Gonorrhea — Positivity among 15-24 year old females tested in family planning clinics by state, 2002

-    VT

-   0.2

-    NH

-   0.1

-    MA

-    RI

-    CT

-   0.8

-    NJ

-   1.3

-    DE

-    MD

-    DC

-   1.2

- (n= 15)

- (n= 21)

- (n= 10)

- (n=  7)

-   2.3

-   0.6

-   1.5

-   0.9

-   0.5

-   0.6

-   2.4

-   0.1

-   1.8

-   1.2

-   0.7

-   0.7

-   0.7

-   2.4

- 1.0

-   2.8

-   0.9

-   0.6

-   0.6

-   1.2

-   0.7

-   1.5

-   0.7

-   0.9

-   1.4

-   0.7

- 1.0

-   0.2

-   2.8

-   2.7

-   0.4

*****Less than 500 females tested

**Notes:**
Such high rates of gonorrhea among young Americans are supported by another type of data that we collect nationally through the Regional Infertility Prevention Projects, that of gonorrhea positivity.  Gonorrhea positivity is the number of positive gonorrhea tests divided by the total number of gonorrhea tests.  Measures of positivity are a way of roughly estimating the prevalence of gonorrhea in a population.
This map shows the median gonorrhea test positivity among 15-24 year old females tested in family planning clinics by state in 2002. The nation MEDIAN gonorrhea positivity for this age group in 2002 was 0.9%, with a range from 0.1% - 2.8%.
These positivity data are consistent with our national morbidity reporting data.  The map shows a similar pattern of disease, with highest rates among adolescent and young women in Southern states.

## Proportion of reported gonorrhea cases from STD clinics by sex,1984-2003*

- *Preliminary 2003 data

- Males

- Females

- % from STD clinics

**Notes:**
This graph shows the proportion of reported gonorrhea cases from STD clinics over time.  The top line shows this proportion for males, and the bottom line shows the proportion for females. 
As you can see, for both males and females, the proportion of all reported gonorrhea cases coming from STD clinics has declined over time.  The inverse of this statement is that an increasing proportion of gonorrhea is being reported from other sources.
This graph also shows that a higher proportion of males tend to be diagnosed with gonorrhea in STD clinics than are females.

## Proportion of reported gonorrhea cases by source and sex, 2003*

- *Preliminary 2003 data

**Notes:**
We can look at this in greater detail with our NETSS national surveillance data.  This is a barchart of the proportion of reported gonorrhea cases coming from different reporting sources.  Going from left to right we see STD clinics, Private physicians, Hospitals and Emergency Room, other clinics, family planning clinics, prenatal clinics, jails, other sources, and unknown.  

This barchart shows that for females, private physicians report the highest proportion of gonorrhea cases.
It also shows that private physicians are also an important source of gonorrhea reporting for male, though to a lesser extent than for females.

## Average completeness of  gonorrhea reporting, U.S., 2002

**99.8%**

**98.3%**

**96.5%**

**75.9%**

**71.5%**

**32.6%**

**19.5%**

- *Proportion calculated for women only

**Notes:**
So, what are the quality of our surveillance data?
One way of measuring the quality of surveillance data is to assess the completeness of reporting for each data element.
You can see here that states do an excellent job obtaining data on sex, age, and reporting source.  
Completeness of reporting tapers off to about 75% for race/ethnicity and specimen site, the anatomic site from which the gonorrhea was diagnosed.
If you look just at women, you see that although NETSS, our national electronic reporting system, allows for the reporting of the presence of pelvic inflammatory disease and being pregnant at the time of gonorrhea diagnosis, these data are not reported frequently enough among women to provide reliable information.
What I do not show you here is how the completeness of reporting varies by state.  This can be important for variables such as race/ethnicity, where the completeness of reporting varies by state from 55 to 100%.

## Data limitations

- Incomplete reporting
- Reporting bias towards STD clinics
- Limited type of data available
- Difficult to distinguish between changes in screening & reporting practices versus changes in burden of disease

**Notes:**
What are the limitations of these surveillance data?
Due to incomplete reporting, it is calculated that these rates underestimate true gonorrhea rates by approximately 50%. 
We also know that there is a reporting bias towards STD clinics since STD clinics tend to report more reliably than does the private sector.  This can result in two different types of problems.  
	One, this may overemphasize disease among STD clinic populations, which are frequently minorities. 
	Two, as STD clinics account for a decreasing proportion of gonorrhea morbidity, the quality of our gonorrhea surveillance data may decrease as well.
Another data limitation is that there are only a few types of data available through NETSS.  
For example, having information on sexual orientation would be extremely useful in understanding trends in gonorrhea.  
Also, with the current national surveillance system, if we see a noteworthy trend in gonorrhea, it is difficult to determine if the trend is due to difference between changes in screening and reporting practices as opposed to true changes in the burden of disease.  Knowing the presence or absence of symptoms for gonorrhea cases, for example, might assist in answering such a question.

## Summary

- Males = females
- High rates among adolescents & young adults
- Decreases in South
- Decreases among blacks
- Increased reporting by private sector
- Insufficient information on risk behavior at a national level

**Notes:**
Let me summarize what we do know about gonorrhea at the national level in 2003.
Gonorrhea rates among males and females are approximately the same.
The highest national rates continue to be among adolescents and young adults, although rates for 15-19 year olds do appear to be decreasing.
Gonorrhea rates have decreased in the South, but gonorrhea rates in all other regions have increased.
Gonorrhea rates have decreased among blacks, but gonorrhea rates in all other races/ethnicities have increased.
A decreasing proportion of gonorrhea is being reported by STD clinics, with increased reporting by the private sector.
Insufficient information on risk behavior at a national level means that it is very difficult to identify changes in disease in important populations such as men who have sex with men.

## Future data improvements

- NEDSS and STD Program Area Module
- NETSS collection of sex of partner info
- OASIS Project

**Notes:**
CDC is taking steps to improve national gonorrhea surveillance.
CDC is piloting the new National Electronic Disease Surveillance System, otherwise known as NEDSS, and the STD Program Area Module which may have radical implications for gonorrhea surveillance.
In the meantime, CDC is also piloting changes to NETSS to collect information on sex of sex partner in several states.
CDC is also funding a demonstration project called OASIS, Outcome Assessment through Systems of Integrated Surveillance.  The OASIS project is working with 9 sites to improve STD surveillance.  I encourage anyone interested in STD surveillance to attend our symposium on Wednesday at 10:00 AM entitled “Turning STD Surveillance Data into Action”.
This leads to my final point which is no matter how much we improve gonorrhea surveillance data, however, the most important step is to translate these data into action.

## Acknowledgements

- Data and Statistics Management, Division of STD Prevention, CDC
- Sharon Clanton
- Michael Phillips
- Emmett Swint
- Epidemiology and Statistics Branch, Division of STD Prevention, CDC
- Hillard Weinstock

## Contact information

**Lori Newman, MD**
**Epidemiology and Surveillance Branch**
**Division of STD Prevention**
**Centers for Disease Control and Prevention**
**Atlanta, GA  30307**
**(404) 639-6183**
**len4@cdc.gov**