TRACKING THE 

Magnitude 

of STD 

Epidemics 

STDs at a 

Glance 

Trends by 

Disease 

A Closer 

Look by Race/ 

Ethnicity, 

Gender 

and Age 

Status of 

STDs by City 

and State 

EPIDEMICS 

Trends in STDs in the United States

HIDDEN EPIDEMICS

2000

Trends in STDs in the United States 
TRACKING THE 

HIDDEN EPIDEMICS
 EPIDEMICS 

TrendsinSTDsintheUnitedStates

Introduction....................................1
 

Magnitude of the Epidemics
 

Overall..................................................2
 

Answers to the Most Frequently
 

Asked Questions..............................3
 

TRENDS BY DISEASE
 

Chlamydia........................................................6
 

Gonorrhea......................................................9
 

Syphilis...........................................................14
 

Human Papillomavirus (HPV)..............18
 

Herpes..........................................................20
 

Hepatitis B...................................................22
 

Trichomoniasis and
 

Bacterial Vaginosis.................................24
 

Chancroid.....................................................25
 

Status of STDs by City 


And State..........................................26
 

Bibliography....................................30
 

Notes...................................................32
 

2000
 
In the United States, more than 65 million people are 

currently living with an incurable sexually transmitted 

disease (std). An additional 15 million people become 

infected with one or more stds each year, roughly half 

of whom contract lifelong infections (Cates, 1999). Yet, 

stds are one of the most under-recognized health problems in the country today. Despite the fact that stds are 

extremely widespread, have severe and sometimes 

deadly consequences, and add billions of dollars to the 

nation’s healthcare costs each year, most people in the 

United States remain unaware of the risks and consequences of all but the most prominent std—the human 

immunodeficiency virus or hiv. 

While extremely common, stds are difficult to track. 

Many people with these infections do not have symptoms and remain undiagnosed. Even diseases that are 

diagnosed are frequently not reported and counted. 

These “hidden” epidemics are magnified with each new 

infection that goes unrecognized and untreated. 

This document presents the latest available data on the 

status of the std epidemics in the United States. By combining data on reported cases of disease with various 

studies of the level of infection in specific populations, 

researchers can compile a more complete picture of the 

magnitude of these diseases. 

1 
Magnitude of t Magnitude of the


Epidemics Over Epidemics Overall


More than 25 diseases are spread primarily through Because there is no single std epidemic, but rather 

sexual activity, and the trends for each disease multiple epidemics, discussions about trends over 

vary considerably, but together these infections time and populations affected must focus on each 

comprise a significant public health problem. specific std. More is known about the frequency 

and trends of some stds than others, since many of 

The latest estimates indicate that there are 15 the diseases are difficult to track. Not including 

million new std cases in the United States each hiv, the most common stds in the U.S. are chlamyyear (Cates, 1999). Approximately one-fourth of dia, gonorrhea, syphilis, genital herpes, human 

these new infections are in teenagers. And while papillomavirus, hepatitis B, trichomoniasis and 

some stds, such as syphilis, have been brought to bacterial vaginosis. The latest estimates of inciall time lows, others, like genital herpes, gonorrhea, dence and prevalence are provided below. 

and chlamydia, continue to resurge and spread 

through the population. 

std Incidence 

(Estimated number of 

new cases every year) 

Prevalence*

(Estimated number of 

people currently infected) 

Chlamydia 3 million 2 million 

Gonorrhea 650,000 Not Available

Syphilis 70,000 Not Available

Herpes 1 million 45 million 

Human 

Papillomavirus (hpv) 5.5 million 20 million 

Hepatitis B 120,000 417,000 

Trichomoniasis 5 million Not Available

Bacterial Vaginosis** Not Available Not Available 

*No recent surveys on national prevalence for gonorrhea, syphilis, trichomoniasis or 

bacterial vaginosis have been conducted. 

**Bacterial vaginosis is a genital infection that is not sexually transmitted but is associated 

with sexual intercourse. 

Source: cates, 1999 

2 
Answers to the Most

Frequently Asked 

he Mos

Frequently Asked QuestionsNote: More detailed answers and 

supporting data are provided in

the Trends by Disease section. 

Are stds increasing or decreasing in with gonorrhea and chlamydia develop one of the 

the United States? most serious complications, pelvic inflammatory 

It depends on the disease. The latest scientific data disease (pid). pid can lead to chronic pelvic pain, 

suggest that chlamydia has declined in areas with infertility, and potentially fatal ectopic pregnancy. 

screening and treatment programs, but remains Many different organisms can cause pid, but most 

at very high levels. For the first time in nearly two cases are associated with gonorrhea and chlamydia. 

decades, gonorrhea is on the rise, increasing more 

than nine percent from 1997 to 1999, after a 72 hpv also can result in severe consequences for 

percent decline from 1975 to 1997. An increase in women. Infection with certain types of hpv place 

drug-resistant gonorrhea has been seen in Hawaii women at increased risk for cervical cancer. 

and in small clusters in other states. Syphilis, in 

both adults and infants, has declined overall and is In addition, women who are infected with an std 

now at an all time low, presenting an opportunity while pregnant can have early onset of labor, prefor elimination of the disease. In October 1999, cdc mature rupture of the membranes, or uterine infeclaunched the National Plan to Eliminate Syphilis in tion before and after delivery. std-related synthe United States. Chancroid also has declined dromes—like bacterial vaginosis—may cause harm 

steadily since 1987 (dstdp, cdc, 2000). to infants through their association with premature 

birth. Preterm birth is the leading cause of infant 

Genital herpes continues to increase, spreading death and disability in the United States, and there 

across all social, economic, racial and ethnic has been no reduction in more than 20 years. It is 

boundaries, but most dramatically affecting teens estimated that 30 to 40 percent of excess preterm 

and young adults (Fleming, 1997). With an esti­ births and infant deaths are due to stds and bacmated 20 million people in the United States cur­ terial vaginosis (Goldenberg, 1996). 

rently infected with human papillomavirus (hpv), 

this viral std also continues to spread. An estimated 5.5 million people become newly infected 

with hpv each year (Cates, 1999). Can the most serious stds infect babies? 

Many stds can be passed from an infected woman 

to fetus, newborn, or infant, before, during or after 

birth. Some stds—like syphilis—cross the placenta 

What are the most serious stds in and infect the fetus during its development. Other 

women? stds—like gonorrhea, chlamydia, genital herpes, 

By far, women bear the greatest burden of stds, and genital hpv infection—are transmitted from 

suffering more frequent and more serious com­ mother to child as the infant passes through the 

plications than men. Ten to 20 percent of women birth canal. hiv infection can cross the placenta 

3 
FREQUENTLY ASKED QUESTIONS FREQUENTLY ASKED QUESTIONS

during pregnancy, can infect the newborn during the 

birth process, or unlike other std

s, can infect a child 

as a result of breast feeding. 

If an std in a pregnant woman is detected soon 

enough, precautions can often be taken so that 

the disease is not spread to the baby. Newborns 

infected with syphilis and herpes may suffer severe 

consequences not completely relieved by treatment, including neurologic damage and death. 

Gonorrhea and chlamydia can cause prematurity, 

eye disease, and pneumonia in infants. 

What are the most common stds 

among teens? 

Teens are at high behavioral risk for acquiring most 

std

s. Teenagers and young adults are more likely 

than other age groups to have multiple sex partners, to engage in unprotected sex, and, for young 

women, to choose sexual partners older than themselves. Moreover, young women are biologically 

more susceptible to chlamydia, gonorrhea and hiv. 

Chlamydia and gonorrhea are the most common 

curable stds among teens. Curable stds are typically 

caused by bacteria that can be killed with antibiotics. However, if these diseases remain undetected 

and untreated, they can result in severe health consequences later in life. Among teens, it is not 

uncommon to see more than five percent of young 

men and five to 10 percent of young women infected with chlamydia (Mertz, cdc, 1998). Rates of gonorrhea are highest in females 15 to 19 years of age 

and in males 20 to 24 years of age. 

The prevalence of herpes increases with age. Since 

this disease stays within the body once acquired, 

the older people are, the more likely they have 

been infected. The rate of new infections for herpes 

and hpv—both viral std

s—is typically highest during the late teens and early twenties. Among 

women under the age of 25, studies have found 

that 28 to 46 percent are typically infected with 

hpv. Between 15 to 20 percent of young men and 

women have become infected with herpes by the 

time they reach adulthood. 

4 

What are std trends in teens? 

Syphilis, hepatitis B, and chancroid are declining 

among teens and other age groups. Chlamydia is 

likely going down in areas where there is screening 

and treatment among teens at family planning clinics and school-based screening programs. In areas 

where these services are not available, the disease 

may be increasing. Herpes was increasing among 

teens through the early 1990s. Currently, the data are 

not available to tell us whether hpv, trichomoniasis, 

or bacterial vaginosis are increasing, but these diseases are extremely widespread. 

What are the most common stds 

among men who have sex with men? 

Researchers estimate that men who have sex with 

men (msm) still account for 42 percent of new hiv 

infections annually in the United States and for 60 

percent of all new hiv infections among men. 

Several recent studies have pointed to high, and 

increasing, levels of other stds among msm. 

One 26-city study, the Gonococcal Isolate Surveillance Project, reported that from 1994 to 1999, 

the proportion of gonorrhea cases among msm 

more than doubled from six to 13 percent. An std 

clinic in Washington, D.C., serving a large number of gay and bisexual men reported that gonorrhea cases increased 93 percent from 1993 to 1996, 

with 82 percent of these cases among msm. 

In King County, Washington—which includes the 

city of Seattle—researchers reported marked 

increases in both gonorrhea and syphilis cases 

among msm. Most notably, while the county had no 

cases of early syphilis in 1996, 88 cases were reported between 1998 and the first half of 1999, 85 percent of which were in gay and bisexual men. These 

men reported having multiple partners and frequently engaging in unprotected anal intercourse. 

What areas of the country have the 

greatest problems with std

s? 

Herpes and hpv are widespread throughout the 

nation, showing very little regional variation. 
Chlamydia is also extremely common across geographic boundaries, but is on the decline in regions 

where effective screening and treatment programs 

are in place. Chlamydia remains most widespread 

among women in the southern region of the country. The south also faces the highest rates of both 

gonorrhea and syphilis. The high rates of stds in 

the south may be due to high rates of poverty and 

lack of access to quality health care. 

Are stds more common among racial 

and ethnic minorities? If so, why? 

Although stds like chlamydia, hpv, and herpes are 

widespread across racial and ethnic groups, std 

rates tend to be higher among African Americans 

than white Americans. Reported rates of some 

stds, like gonorrhea and syphilis, are as much as 30 

times higher for African Americans than for whites. 

This disparity is due, in part, to the fact that African 

Americans are more likely to seek care in public 

clinics that report stds more completely than private providers. However, this reporting bias does not 

fully explain these differences. Other important 

factors include the distribution of poverty, access to 

quality health care, health-seeking behaviors, the 

level of drug use, and sexual networks with high 

std prevalence. 

Moreover, the level of prevention education may 

vary widely across communities. In some areas, 

community-based efforts may be widespread across 

social, educational, and religious organizations, but 

in others, std prevention may not yet be a high priority. Efforts are underway to increase both public 

and private sector hiv and std prevention efforts in 

communities at risk throughout the nation. Yet, 

research demonstrates that some groups at very 

high risk still lack even basic information about 

std prevention (Bunnel, cdc, 1998). 

What are the economic costs of stds 

in the United States? 

stds are associated with both direct and indirect 

costs. Direct costs include expenditures for medical 

and non-medical services and materials, such as 

physician services, laboratory services, hospitalization, transportation, and medical supplies. 

Indirect costs mainly include lost wages due to 

illness or premature death. stds also result in 

intangible costs related to pain, suffering, and 

diminished quality of life. In 1994, the direct and 

indirect costs of the major stds and their complications were estimated to total almost $17 billion 

annually. 

Estimated Cost of Selected 

stds in the United States, 1994 

std 

Total cost 

($ millions) 

Chlamydia 

Gonorrhea 

pid 

Syphilis 

Chancroid 

Herpes simplex 

hpv 

Hepatitis B 

Cervical cancer 

Sexually transmitted hiv 

Total 

2,013 

1,051 

4,148 

106 

1 

237 

3,827 

156 

737 

6,683 

16,638 

Source: Institute of Medicine. The Hidden Epidemic: 

Confronting Sexually Transmitted Diseases. 

Washington, D.C.: National Academy Press, 1997. 

FREQUENTL FREQUENTLY ASKED QUESTIONS Y ASKED QUESTIONS 

5 
a

DISEASE BY TRENDS 

Chlamydia

Chlamydia is the most commonly reported infectious disease in the United States and may be one of 

the most dangerous sexually transmitted diseases 

among women today. While the disease can be easily cured with antibiotics, millions of cases go unrecognized. If left untreated, chlamydia can have severe 

consequences, particularly for women. Up to 40 

percent of women with untreated chlamydia will 

develop pelvic inflammatory disease (pid), and one 

in five women with pid becomes infertile. Chlamydia 

also can cause prematurity, eye disease, and pneumonia in infants. Moreover, women infected with 

chlamydia are three to five times more likely to 

become infected with hiv, if exposed. 

Seventy-five percent of women and 50 percent of 

men with chlamydia have no symptoms. The 

majority of cases therefore go undiagnosed and 

unreported. The number of reported cases—about 

660,000 cases in 1999—is merely the tip of the iceberg. 

p An estimated three million people contract 

chlamydia each year (Cates, 1999). 

p Chlamydia is believed to be declining overall in 

the United States, primarily because of increased 

efforts to screen and treat women for chlamydia. 

Chlamydia is estimated to have declined from 

well over four million annual infections in the 

early 1980s to the current level of three million 

annual infections (Cates, 1999). 

p Reported chlamydia rates in women greatly 

exceed those in men largely because screening 

programs have been primarily directed at 

women. True rates are probably far more similar 

for women and men. 

p Since 1994, there has been increased funding 

available for chlamydia screening in publicly 

funded family planning and std clinics. The 

percentage of women testing positive for 

chlamydia—chlamydia positivity—in family 

planning clinics by state provides a good indication of where the disease remains most wideChlamydia Positivity among 15- to 24-Year-Old Women Tested in 

Family Planning Clinics, by State, 1999 

6.1 

VT 

NH 

MA 

RI 

CT 

NJ 

DE 

MD 

DC 

2.8 

6.6 

3.8 

10.5 

3.5 

6.3 

6.3 

5.9 

5.6 

Positivity (%) 

Puerto Rico 6.8 

Virgin Islands 15.0 

4.0 

6.1 

4.2 

4.2 

4.1 

4.6 

4.6 

4.5 

5.0 

5.5 5.5 

5.5 

5.5 

8.5 

5.3 

5.2 

5.0 5.9 3.6 

7.7 

3.7 

7.2 

7.2 

7.1 

10.0 

10.9 

14.6 

9.0 

9.3 

2.6 

2.6 3.2 

3.0 3.3 

3.3 

7.2 

3.7 

6.1 

6.5 

6.4 

4.3 

6
 
spread. The highest level of infection tends to be 

seen in areas where screening and treatment 

have not been as widely implemented. The 

greatest declines have generally been in areas 

of the country with the most effective and prolonged screening programs. 

pFrom 1988 to 1999, the Pacific northwest— Washington, Oregon, Idaho, and Alaska—witnessed a 

62 percent decline in infection among women 

tested for chlamydia in family planning clinics. 

pIn the Mid-Atlantic States—Delaware, Washington, D.C., Maryland, Pennsylvania, Virginia, 

and West Virginia—similar trends are occurring, with a decline of 16 percent since 1994 

(dstdp, cdc, 2000). 

pFrom 1997 to 1999, chlamydia test positivity in 

family planning clinics actually increased in 

eight out of 10 regions. However, these reported 

increases are most likely due to changes in 

newly available and better laboratory tests and 

expanded screening programs to populations 

with higher levels of disease (dstdp, cdc, 2000). 

Reducing the level of chlamydia will require continued expansion of screening and treatment 

among women and new efforts to reach men. 

While men experience symptoms and seek treatment on their own more often than women, half of 

men with chlamydia are asymptomatic. Reaching 

these men with treatment is critical to stem the 

spread of chlamydia and its severe consequences. 

It is also critical to reach those at greatest risk, 

primarily young people, with programs to help 

reduce their risk of infection through safer sexual 

behaviors. 

Chlamydia Positivity among 15- to 44-Year-Old Women Tested in 

Family Planning Clinics, by hhs Regions, 1999 

6.7 

4.9 4.6 4.1 

96 97 98 99 

5.7 6.2 6.2 

97 98 99 

7.4 6.0 5.3 5.6 6.0 6.2 

94 95 96 97 98 99 

8.9 10.1 9.5 

97 98 99 

5.1 5.2 5.9 6.3 

96 97 98 99 

5.6 

7.5 7.2 

97 98 99 

5.0 4.7 5.4 5.3 

96 97 98 99 

6.0 5.0 4.6 4.6 5.3 5.4 

94 95 96 97 98 99 13.0 

10.0 9.5 

8.0 6.7 

5.0 4.1 4.7 3.9 3.9 4.6 4.9 

88 89 90 91 92 93 94 95 96 97 98 99 

Region I 

Region II 

Region III 

Region IV 

Region V 

Region VIII 

Region X 

Region IX 

8.4 8.9 9.7 8.7 

96 97 98 99 

Region VI 

Region VII 

X

IX

X VIII

IX 

VIII I

II

V

VII

IV

VI

III

I 

II 

V 

VII 

IV 

VI 

III 

7
 

CHLAMYDIA CHLAMYDIA 
CHLAMYDIA CHLAMYDIA

A Closer Look at Chlam A Closer Look at Chlamydia 


Chlamydia is widespread among the sexually active p	 An innovative program in Denver screened highpopulation, regardless of race, ethnicity, age, or gen­ risk youth in the field—parking lots, parks, and 

der. It is more concentrated among adolescents homes—and in non-clinical settings—high 

than any other std with the highest rates seen schools, recreation centers. The study found a 

among female adolescents. Data on male adoles­ high prevalence of chlamydia among young 

cents also reveal an alarming level of infection. men—12 percent—screened in the field, compared to young men screened in the facilities— 

BY GENDER AND AGE 4.4 percent. The study suggests that the prevaForty percent of chlamydia cases are reported lence of chlamydia may be much higher among 

among young people, 15 to 19 years old. Reported high-risk youth, who are not likely to access std 

prevalence among sexually active women is con­ treatment in traditional health care settings 

sistently more than five percent, with prevalence (Rietmeijer, 1997). 

among teenage girls often exceeding 10 percent— 

more than one in 10. And while the data are more BY RACE/ETHNICITY 

limited for men, studies of adolescent males tested Chlamydia is common among all races and ethnic 

in high schools and other settings have found preva­ groups, but prevalence is somewhat higher among 

lence of more than five percent (Cohen, 1998; Ku, racial and ethnic minorities, most likely due to the 

1997). Recent studies and screening programs in lack of access to screening and treatment programs. 

multiple settings throughout the country come to 

the same conclusion: chlamydia continues to exact p Data from a pilot household survey of prevaa devastating toll among our nation’s young people. lence in ten U.S. counties suggests that chlamydia is widespread. And while prevalence was 

p In 1999, nearly 10 percent (9.9 percent) of 17- to higher among young minority women, high lev37-year-old women screened for stds during els of chlamydia were detected among all adotheir induction into the Army tested positive lescents (Mertz, 1999). 

for chlamydia (dstdp, cdc, 2000). 

p	 

The prevalence of chlamydia was higher in 

p In 1999, 7.2 percent of 15- to 24-year-old females women than in men among African Americans 

screened in selected prenatal clinics in 22 states (seven percent vs. six percent), Mexican Ameriwere positive for chlamydia (dstdp, cdc, 2000). cans (five percent versus two percent), and 

whites (two percent versus one percent). 

p In 1999, of adolescent women entering juvenile detention facilities where chlamydia p Among male and female teens, 15 to 19 years old, 

screening was routine, 13 percent tested positive prevalence was approximately 12 percent for 

for chlamydia (dstdp, cdc, 2000). African Americans, six percent for Mexican 

Americans, and nearly four percent for whites. 

p A 1999 school-based screening program among 

high school students—ninth to twelfth grade— BY REGION 

in New Orleans found that nearly 12 percent Chlamydia prevalence remains higher in areas withof girls and six percent of boys were infected out longstanding screening and treatment prowith chlamydia (Cohen, 1999). grams. The highest rates are reported in the southern states. In 1999, seven out of the 10 states with 

p A 1994 household sample of young men 18 to 19 the highest rates were located in the southern 

years of age in three Maryland counties found region of the United States. If the level of screening 

that six percent were infected with chlamydia and treatment continues to increase, the disease will 

(Ku, 1996). most likely decline in women across the nation. 

8 
1970 73 76 79 82 85 88 91 94 97 99 

Rate (per 100,000 population) 

500 

400 

300 

200 

100 

0 

p Cases reported to cdc are believed to represent 

about half of all annual infections. While an 

underestimate of actual cases, these reports provide a good indication of trends in the disease. 

pThe reported gonorrhea rate in the United States 

remains the highest of any industrialized country and is roughly 50 times that of Sweden and 

eight times that of Canada. 

pResearchers have seen alarming indications that 

gonorrhea may be on the rise among gay and 

bisexual men—men who have sex with men 

(msm). In the mid-1980s, reports of increased 

condom use and reduced risky sexual practices 

accompanied dramatic decreases in rectal gonorrhea among msm in several cities (Fox, cdc, 

1998). Yet, data from cities throughout the country suggest that this trend may be reversing, and 

that gonorrhea cases may be resurging with the 

prospect of facilitating the spread of hiv in the 

gay community. 

p • One 26-city study, the Gonococcal Isolate 

Surveillance Project, reported that from 1994 

to 1999, the proportion of gonorrhea cases 

among msm more than doubled from six percent to13 percent (dstdp, cdc, 2000). 

Gonorrhea is a sexually transmitted bacterial disease. Reported gonorrhea rates declined steadily 

until the late 1990s. From 1985 to 1996, rates of 

the disease decreased nearly 10 percent annually 

(Fox, cdc, 1998). However, rates stabilized between 

1996 and 1997, and between 1997 and 1999, gonorrhea rates increased by nine percent (dstdp, cdc, 

2000). This increase, combined with signs of an 

increase in gonorrhea among gay and bisexual 

men, is reason for concern. 

Rates of infection remain high among adolescents, 

young adults, and African Americans. Gonorrhea 

remains a major cause of pelvic inflammatory disease (pid) and subsequent infertility and tubal pregnancies in women. Additionally, studies have shown 

that gonorrhea can facilitate hiv transmission and 

may be contributing significantly to the spread of 

hiv in the south. There is a critical need to reach 

populations that remain at high risk for gonorrhea 

with intensified prevention and treatment efforts. 

Gonorrhea can be easily cured, if detected early, 

and the long-term consequences can be prevented. 

p An estimated 650,000 cases of gonorrhea occur 

each year in the United States (Cates, 1999). 

Gonorrhea

9 

TRENDS BY DISEASE 

Gonorrhea Reported Rates: United States, 1970–1999 
GONORRHEA GONORRHEA

p • In King County, Washington—which includes p • In San Francisco, the incidence of rectal gonthe city of Seattle—researchers reported orrhea in males increased from 21 cases per 

marked increases in both gonorrhea and 100,000 population in 1994 to 38 cases per 

syphilis cases among msm. Most notably, 100,000 population in 1997. 

while the county had no cases of early 

syphilis in 1996, 88 cases were reported This rise in gonorrhea rates should serve as a 

between 1998 and the first half of 1999, 85 wake-up call to all people at risk—including gay 

percent of which were in gay and bisexual and bisexual men—that high-risk sexual behaviors 

men. These men reported having multiple continue to have very real consequences. 

partners and frequently engaging in unprotected anal intercourse. 

A Closer Look at Gonor A Closer Look at Gonorrhea

BY GENDER pThe gonorrhea rate increased more than nine 

While reported rates of gonorrhea were once sub­ percent in women from 119.0 cases per 100,000 

stantially higher among men than among women, population to 129.9 per 100,000 population 

that gap has narrowed. This is most likely due to (dstdp, cdc, 2000). 

increased screening in women. Because women 

are more likely to be asymptomatic than men, cases 

in women are less likely to be reported. However, BY REGION 

gonorrhea rates have increased overall in both Gonorrhea rates increased or remained constant in 

males and females. From 1997 to 1999: all regions of the country between 1997 and 1999. 

The southern states continue to have the highest 

pThe gonorrhea rate increased 8.8 percent among gonorrhea rates of any region. The reasons for this 

men from 124.9 cases per 100,000 population to may include the level of poverty and access to 

136.0 cases per 100,000 population. quality health care and preventive services. 

Gonorrhea Rates by Gender, United States, 1981–1999 

1981 83 85 87 89 91 93 95 97 99 

Rate (per 100,000 population) 

Male 

Female 

600 

450 

360 

270 

180 

0 

10
 
Gonorrhea Rates by State, United States and Outlying Areas, 1999 

38.8 

VT 

NH 

MA 

RI 

CT 

NJ 

DE 

MD 

8.8 

9.7 

39.9 

60.8 

101.4 

96.8 

223.5 

203.1 

Rate per 100,000 

Population 

Puerto Rico 8.3 

Guam 36.9 

Virgin Islands 46.5 

49.2 

37.5 

101.4 

59.9 

150.5 

47.7 

162.0 

6.0 

8.9 

92.0 56.1 

153.8 

209.3 

257.4 

63.6 

120.1 

103.3 

161.8 

12.1 

278.0 

85.1 

127.5 

193.1 

127.1 

250.2 

301.9 

378.3 

166.6 

392.0 

32.2 

26.0 109.1 

6.7 

13.0 

88.5 

57.2 

27.5 

74.6 

110.8 

138.4 

7.2 

note: The total rate of gonorrhea for the United States 

and outlying areas (including Guam, Puerto Rico and 

Virgin Islands) was 131.4 per 100,000 population. 

BY AGE BY RACE/ETHNICITY 

Gonorrhea most dramatically affects teens and Gonorrhea has been increasing in all races and ethyoung adults. Gonorrhea rates are highest among nic groups since 1997 after declining in all races 

females between the ages of 15 and 19 and males and ethnic groups over the past few decades (Fox, 

between the ages of 20 and 24. This is true regard­ cdc, 1998). Reported rates of gonorrhea among 

less of race or ethnicity. African Americans remain more than 30 times highGonorrhea, White Non-Hispanic Race/Ethnicity, Age and Gender Specific, 

United States, 1999 

 

11
 

GONORRHEA GONORRHEA 

Age 

10–14 

15–19 

20–24 

25–29 

30–34 

35–39 

40–44 

45–54 

55–64 

65+ 

Total 

Men Rate (per 100,000 population) Women

250 200 150 100 50 0 0 50 100 150 200 250 

9.1 

3.3 

0.8 

0.2 

33.9 

0.9 12.7

38.6 

76.6 

58.6 

44.9 

33.9 

21.9 

11.3 

5.3 

1.3 

21.7 

198.3 

178.4 

72.1 

36.4 

21.8 
GONORRHEA GONORRHEA

Age 

10–14 

15–19 

20–24 

25–29 

30–34 

35–39 

40–44 

45–54 

55–64 

65+ 

Total 

Men Rate (per 100,000 population) Women

4,000 3,200 2,400 1,600 800 0 0 800 1,600 2,400 3,200 4,000 

169.6 

54.1 

10.3 

6.9 

763.5 

48.6 282.4

1,996.5 

3,582.4 

2,225.7 

1,323.8 

970.0 

701.8 

416.6 

163.8 

46.7 

943.7 

3,691.0 

3,273.1 

1,304.6 

585.5 

332.2 

Gonorrhea, Black Non-Hispanic Race/Ethnicity, Age and Gender Specific, 

United States, 1999 

Age 

10–14 

15–19 

20–24 

25–29 

30–34 

35–39 

40–44 

45–54 

55–64 

65+ 

Total 

Men Rate (per 100,000 population) Women

400 320 240 160 80 0 0 80 160 240 320 400 

23.4 

8.8 

3.0 

1.5 

77.0 

4.6 24.6

160.9 

255.0 

170.3 

103.5 

68.6 

42.6 

24.6 

12.1 

7.7 

73.7 

331.8 

279.6 

137.6 

66.6 

38.4 

Gonorrhea, Hispanic Race/Ethnicity, Age and Gender Specific, United States, 1999 

er than rates among whites and more than 11 times pThe gonorrhea rate among Hispanics increased 

higher than rates among Hispanics.This trend most from 67.4 to 75.3 cases per 100,000 people. 

likely reflects differences in access to prevention 

and treatment services. From 1997 to 1999: pThe gonorrhea rate increased for American 

Indian/Alaska Natives from 99.4 to 110.7 cases 

pThe gonorrhea rate among African Americans per 100,000 people.
 

increased from 802.4 to 848.8 cases per 100,000
 

people.
 pThe gonorrhea rate increased for Asian and 

Pacific Islanders from 19.5 to 22.1 cases per 

pThe gonorrhea rate among whites increased 100,000 people.
 

slightly from 26.2 to 27.9 cases per 100,000 people.
 

12 
Gonorrhea Reported Rates for 15- to 19-year-old Females

By Race/Ethnicity: United States, 1981–1999 

1981 83 85 87 89 91 93 95 97 99 

7,000 

5,600 

4,200 

2,800 

1,400 

0 

Rate (per 100,000 population) 

White 

Black 

Hispanic 

Other 

Gonorrhea Reported Rates for 15- to 19-year-old Males 

By Race/Ethnicity: United States, 1981–1999 

1981 83 85 87 89 91 93 95 97 99 

7,000 

5,600 

4,200 

2,800 

1,400 

0 

Rate (per 100,000 population) 

White 

Black 

Hispanic 

Other 

AMONG ADOLESCENTS 

p Among adolescents, gonorrhea increased 13


percent between 1997 and 1999, although 1999


rates were slightly lower than those in 1998.


Young African-American women and men


remain at extremely high risk.
 

13
 

GONORRHEA GONORRHEA 
TRENDS BY
 DISEASE

Syphilis Syphilis

Syphilis is a bacterial sexually transmitted disease
 

that progresses in stages. The disease is curable
 

and progression of disease is preventable, but if
 

untreated, it can cause cardiovascular and neurological diseases and blindness. Syphilis causes genital ulcers, which increase the likelihood of sexual
 

hiv transmission two- to five-fold. Untreated,
 

syphilis can be transmitted from a pregnant woman
 

to her fetus.
 

In the United States, the reported rate of syphilis is
 

at the lowest level since reporting began in 1941. In
 

1999, 79 percent of the 3,115 counties in the United
 

States reported no cases of primary and secondary
 

syphilis (p&s syphilis). The unprecedented low rate
 

of syphilis overall, combined with cases concentrated in only 20 percent of U.S. counties, has created a unique but narrow window of opportunity to
 

eliminate syphilis in the United States. In October
 

1999, cdc launched the National Plan to Eliminate
 

Syphilis in the United States.
 

Since the introduction of penicillin and the organization of a national std control program in the
 

1940s, the initial near elimination of syphilis in
 

1957 has been followed by cyclic national epidemics
 

every seven to 10 years (St. Louis, cdc, 1998).
 

The most recent epidemic peaked in 1990 at 20.3 

per 100,000 people. Since 1990, syphilis rates have 

declined 88 percent to 2.5 cases per 100,000 people 

in 1999 (cdc, 2000). 

In 1999, 6,657 cases of p&s syphilis were reported to 

cdc, a decline of 22.2 percent from 1997 when 

8,556 cases were reported. Cases of p&s syphilis 

reported to cdc are believed to represent about 80 

percent of all recently acquired cases (Cates, 1999). 

Congenital Syphilis 

In 1999, 556 cases of congenital syphilis—infants 

acquiring infection from their mothers during pregnancy or delivery—were reported. Rates of congenital syphilis closely follow trends in p&s syphilis 

in women. Peaks in congenital syphilis usually 

occur one year after peaks in p&s syphilis in 

women. The congenital syphilis rate in the United 

States peaked in 1991 at 107.3 cases per 100,000 

live births and declined 87 percent to 14.3 cases 

per 100,000 live births in 1999. 

Primary & Secondary Syphilis Reported Rates, United States, 1970–1999 

1970 73 76 79 82 85 88 91 94 97 99 

Rate (per 100,000 population) 

p&s Syphilis 

25 

20 

15 

10 

5 

0 

14 
A Closer Look at Syphilis A Closer Look at Syphilis

BY GENDER From 1997 to 1999, rates of p&s syphilis were stable 

In 1999, the overall male-to-female ratio of p&s for white Americans, declined 29 percent in African 

syphilis was 1.5, with 50 percent more cases among Americans and increased 20 percent in Hispanics. 

men than women. Increases in the male-to-female The increase in Hispanic rates occurred among 

rate ratio in 1999 were observed in certain cities cor­ males. 

responding to an increase in syphilis among men 

who have sex with men (msm). Recently, outbreaks In 1999, the rate of congenital syphilis among 

of syphilis among msm have been reported, possi­ African Americans was 57.9 cases per 100,000 live 

bly reflecting an increase in risk behavior in this births and among Hispanics, 20.4 cases per 100,000 

population associated with the availability of high­ live births. While these rates reflect a 52.7 percent 

ly active antiretroviral therapy for hiv infection. decline for African Americans and a 38.9 percent 

decline for Hispanics from 1997 to 1999, they 

BY RACE/ETHNICITY remain considerably higher than the rate for 

Syphilis continues to disproportionately affect whites, which was two cases per 100,000 live births. 

African Americans. Syphilis has been cited as one 

of the most glaring examples of existing gaps in 

minority health status. Despite the fact that the BY AGE 

disease can be easily treated and cured with basic p&s syphilis rates in 1999 were highest among 

medical care, reported rates of p&s syphilis are 30 women ages 20 to 29 years old and among men 

times higher for African Americans than for white ages 35 to 39 years old. However, the age groups at 

Americans (cdc, 2000). With increased awareness highest risk vary by race and ethnicity. 

and access to acceptable health care, this health 

disparity could be largely eliminated. 

Syphilis, White Non-Hispanic Race/Ethnicity, Age and Gender Specific, 

United States, 1999 

Age 

10–14 

15–19 

20–24 

25–29 

30–34 

35–39 

40–44 

45–54 

55–64 

65+ 

Total 

Men Rate (per 100,000 population) Women

2.0 1.6 1.2 0.8 0.4 0 0 0.4 0.8 1.2 1.6 2.0 

0.5 

0.3 

0.1 

0.0 

0.4 

0.0 

0.5 

0.0 

0.2 

0.8 

1.1 

1.4 

1.4 

1.2 

0.7 

0.5 

0.2 

0.6 

1.3 

1.1 

1.0 

0.9 

15
 

SYPHILIS SYPHILIS 
SYPHILIS SYPHILIS

Men Rate (per 100,000 population) Women

50 40 30 20 10 0 0 10 20 30 40 50 

15.6 

6.7 

1.8 

0.4 

12.6 

0.1 1.4

9.5 

31.1 

30.7 

34.6 

39.2 

32.9 

26.6 

13.6 

3.6 

18.1 

20.1 

26.6 

29.2 

28.6 

26.4 

Age 

10–14 

15–19 

20–24 

25–29 

30–34 

35–39 

40–44 

45–54 

55–64 

65+ 

Total 

Syphilis, Black Non-Hispanic Race/Ethnicity, Age and Gender Specific, 

United States, 1999 

Age 

10–14 

15–19 

20–24 

25–29 

30–34 

35–39 

40–44 

45–54 

55–64 

65+ 

Total 

Men Rate (per 100,000 population) Women

7.5 6.0 4.5 3.0 1.5 0 0 1.5 3.0 4.5 6.0 7.5 

0.9 

0.4 

0.6 

0.0 

0.9 

0.0 0.1

1.7 

5.6 

5.1 

5.3 

4.5 

4.4 

2.7 

2.2 

0.5 

2.6 

1.5 

2.7 

2.1 

1.9 

1.1 

Syphilis, Hispanic Race/Ethnicity, Age and Gender Specific, United States, 1999 

BY REGION In 1999, three independent cities—Baltimore, Md.; 

Syphilis continues to be concentrated in the Danville, Va.; and St. Louis, Mo.—and 22 counties 

southern region of the United States. In 1999, the accounted for half of the total number of p&s 

rate of syphilis in the south—4.5 cases per 100,000 syphilis cases reported. 

people—was higher than any other region in the 

country. 

16 
Primary & Secondary Syphilis Counties with Rates Above and Counties with Rates 

Below the Healthy People Year 2000 Objective, United States, 1999 

Rate per 100,000 

Population 

Primary & Secondary Syphilis Rates by State: United States and Outlying Areas, 1999 

 

0.3 

VT 

NH 

MA 

RI 

CT 

NJ 

DE 

MD 

0.5 

0.1 

0.6 

0.3 

0.5 

0.8 

1.3 

6.7 

Rate per 100,000 

Population 

Puerto Rico 3.8 

Guam 1.3 

Virgin Islands 0.9 

0.2 

1.4 

0.5 

0.2 

1.8 

0.3 

2.5 

0.1 

0.0 

4.5 0.7 

2.6 

11.8 6.1 

0.2 

5.6 

7.6 0.8 0.1 

5.6 

2.6 

0.8 

3.5 

3.4 

4.6 

7.0 

7.0 

2.4 

7.0 

0.3 

0.0 0.8 

0.0 0.0 

0.4 

0.9 

0.2 

0.3 

0.8 

2.3 

0.1 

note: The total rate of syphilis for the United States and 

outlying areas (including Guam, Puerto Rico and Virgin 

Islands) was 2.5 per 100,000 population. 

17
 

SYPHILIS SYPHILIS 
Human P Human Papillomavir apillomavirus


TRENDS BY
 DISEASE

(HPV)

Human papillomavirus (hpv) is a virus that sometimes causes genital warts but in many cases 

infects people without causing noticeable symptoms. Concern about hpv has increased in recent 

years after studies showed that some types of hpv 

infection cause cervical cancer. hpv is likely the 

most common std among young, sexually active 

people and is of increasing public health importance. At any one time, an estimated 20 million 

people in the United States have genital hpv infections that can be transmitted to others. Every year, 

about 5.5 million people acquire a genital hpv 

infection. 

While there is no way to know for sure if hpv is 

increasing, there are no signs of a significant 

decline. With improved testing technology, 

researchers have been able to get a much clearer 

picture of the true extent of hpv in certain groups 

in recent years, and the infection is even more 

common than originally believed. 

There are 30 distinct types of hpv that can infect 

the genital area. Of these, some types cause genital warts, and others cause subclinical infections, 

noted as such because they are invisible or cannot 

be seen. Genital warts are extremely common, but 

can be treated and cured. Subclinical hpv infection 

is much more common than genital warts, and 

there is currently no treatment. The disease can 

lead to cervical, penile and anal cancer. 

Most hpv infections appear to be temporary and 

are probably cleared up by the body’s immune system. One study in college students showed that in 

91 percent of women with new hpv infections, hpv 

became undetectable within two years (Ho, 1998). 

However, reactivation or reinfection is possible. 

Persistent cervical infection with certain types of 

hpv is the single most important risk factor for 

cervical cancer. hpv type 16 accounts for more 

than 50 percent of cervical cancers and high-grade 

dysplasia—abnormal cell growth. hpv type 16, 

along with types 18, 31, and 45 account for 80 percent of cervical cancers (Bosch, 1995; Shah, 1997). 

A Closer Look at A Closer Look at HPVInfection
 Infection

p An estimated 5.5 million people become infected with hpv each year in the United States, and 

an estimated 20 million Americans are currently infected (Cates, 1999). 

p An estimated 75 percent of the reproductive-age 

population has been infected with sexually 

transmitted hpv (Koutsky, 1997). 

p An estimated 15 percent of Americans ages 15 

to 49 are currently infected (Koutsky, 1997). 

p Studies repeatedly show high levels of hpv infection in women, with the highest levels among 

young women. 

p A recent U.S. study among female college students found that an average of 14 percent 

became infected with genital hpv each year. 

About 43 percent of the women in the study 

were infected with hpv during the three-year 

study period (Ho, 1998). 

p	 

Typical prevalence of hpv for women under the 

age of 25 is between 28 and 46 percent (Burk, 

1996; Bauer, 1991). 

p Although less data are available on hpv among 

men, levels of current infection in men appear 

to be similar to those in women (dstdp hpv 

Report, cdc, 1999). 

18 
p

p hpv may be an even greater problem for hiv­ p

positive men and women. hiv-positive individuals have a higher prevalence of hpv infection 

and precancerous lesions on the cervix and 

anus than hiv-negative individuals. Co-infection with hiv and hpv is most likely due to 

shared risk behaviors for both diseases, as well 

as an increased susceptibility to hpv because 

of a compromised immune system. 

• A San Francisco study of gay and bisexual 

men found that 60 percent of hiv-negative 

men had hpv, with almost universal hpv 

infection among hiv-positive individuals with 

severely compromised immune systems 

(Palefsky, unpublished data). 

19 

• Similarly, a six-city study among high risk 

and hiv-infected women found that 26 percent of hiv-negative women were infected 

with hpv, but 70 percent of hiv-positive 

women with severely comprised immune systems were infected with hpv (Palefsky, 1998). 

Genital Warts 

Research indicates that approximately one percent of sexually active adults in the United States 

have genital warts. These estimates are based on 

select studies demonstrating levels of infection 

ranging from 1.5 percent among female college 

students treated in student health centers to 13 

percent in some std clinics (Koutsky, 1997). 

HUMAN PAPILLOMAVIRUS HUMAN PAPILLOMAVIRUS 
TRENDS BY
 DISEASE Herpes


Genital herpes—herpes simplex virus type two 

(hsv-2)—is one of the most common sexually 

transmitted diseases in the United States, with as 

many as one million people in the United States 

becoming infected each year. While genital herpes 

continues to spread across all social, economic, 

racial and ethnic boundaries, prevalence of infection increased most dramatically in teens and 

young adults in the late 1980s and early 1990s 

(Fleming, 1997). The disease is potentially fatal in 

newborns and can be particularly severe in people 

with hiv infection. 

Symptoms of herpes—recurrent painful ulcers— 

can be treated, but the infection cannot be cured. 

Most people with herpes have no symptoms and 

are unaware of their infection. In a national household survey, less than 10 percent of people who 

tested positive with herpes knew they were infected (Fleming, 1997). With or without visible symptoms, the disease can be transmitted between sex 

partners, from mothers to newborns, and can 

increase a person’s risk of becoming infected with 

hiv. Genital herpes can also make hiv-infected 

individuals more infectious and is believed to play 

a role in the heterosexual spread of hiv in the 

United States. Preventing the spread of herpes may 

help slow both epidemics. 

p More than one in five Americans—45 million 

people—are infected with genital herpes 

(Fleming, 1997). 

p From the late 1970s to the early 1990s, herpes 

prevalence increased 30 percent (Fleming, 1997). 

p Preliminary 1999 data from the National Health 

and Nutrition Examination Survey (nhanes) suggest that the prevalence of hsv-2 has remained 

relatively stable over the 1990s. In 1999, the estimated prevalence was 19 percent among the 

general U.S. population ages 14 to 49 years old 

(McQuillan, 2000). 

A Closer Look at Her A Closer Look at Herpes


BY GENDER 

Herpes is more common in women than men, 

infecting approximately one out of four women, 

versus one out of five men. This difference in gender may be because male-to-female transmission 

is more efficient than transmission from females 

to males. 

BY REGION 

Herpes is common in all regions of the country 

and in both urban and rural areas.There are no significant differences in prevalence by geographic 

location. 

BY AGE 

The percent of people infected with herpes increases with age because, once infected, people remain 

infected with this incurable disease throughout 

their lives. Herpes infection is believed to be 

acquired most commonly during adolescence and 

young adulthood, as individuals become sexually 

active and may have multiple partners. 

According to two national surveys between the 

1970s and the 1990s, genital herpes increased fastest 

among white teens ages 12 to 19 years old (Fleming, 

1997). Herpes prevalence among white teens ages 12 

to 19 years old in the 1990s was five times greater 

than the prevalence in the 1970s. Among young 

white adults 20 to 29 years of age, herpes prevalence 

increased two-fold over that period. 

20 
 

BY RACE/ETHNICITY 

Although genital herpes is increasing among young 

whites, the infection is more common among 

African Americans, who have a seroprevalence of 

more than 45 percent, as compared to whites, who 

have a seroprevalence of approximately 17 percent (Fleming, 1997). 

Herpes Seroprevalence Race/Ethnicity 

and Age Specific, United States 

nhanes ii nhanes iii 

(1976-1980)* (1988-1994)* 

Percent Percent 

Seroprevalence**Seroprevalence** 

Whites 12-19 1.0 4.5 

20-29 7.7 14.7 

Blacks 12-19 5.7 8.8 

20-29 19.5 33.3 

Mexican 12-19 not available 5.4 

Americans 20-29 not available 14.8 

*Seroprevalence has been adjusted to the 1980 census. 

**Rounded to the nearest tenth. 

Herpes Seroprevalence Race/Ethnicity and Gender Specific,
 

United States
 

Category of Subjects 

nhanes ii 

(1976-1980)* 

Age-Adjusted 

Percent 

Seroprevalence 

nhanes iii 

(1988-1994)* 

Age-Adjusted 

Percent 

Seroprevalence 

Percent 

Relative 

Increase 

All Races and Ethnic Groups** 

Both sexes 

Men 

Women 

Whites 

Both sexes 

Men 

Women 

Blacks 

Both sexes 

Men 

Women 

16.0 

13.4 

18.4 

12.7 

10.7 

14.5 

43.6 

34.1 

51.4 

20.8 

17.1 

24.2 

16.5 

14.1 

18.7 

47.6 

37.5 

55.7 

30 

27 

32 

30 

32 

29 

9 

10 

8 

*Seroprevalence has been adjusted to the 1980 census. The age range is ≥ 12 years. 

**Totals differ from the numbers for whites and blacks because other races and ethnic 

groups are included in the category of all races and ethnic groups. 

21 

HERPES 

nhanes ii nhanes iii 

(1976-1980)* (1988-1994)* 

Age-Adjusted Age-Adjusted Percent 

Percent Percent Relative 

Category of Subjects Seroprevalence Seroprevalence Increase 

All Races and Ethnic Groups** 

Both sexes 16.0 20.8 30 

Men 13.4 17.1 27 

Women 18.4 24.2 32 

Whites 

Both sexes 12.7 16.5 30 

Men 10.7 14.1 32 

Women 14.5 18.7 29 

Blacks 

Both sexes 43.6 47.6 9 

Men 34.1 37.5 10 

Women 51.4 55.7 8 

*Seroprevalence has been adjusted to the 1980 census. The age range is ≥ 12 years. 

**Totals differ from the numbers for whites and blacks because other races and ethnic 

groups are included in the category of all races and ethnic groups. 
TRENDS BY
 DISEASE Hepatitis B
 Hepatitis B

Hepatitis B (hbv) virus is a serious viral disease 

that attacks the liver, and can cause extreme illness 

and even death. An acute hbv infection is a newly 

acquired, symptomatic infection. In some people, 

the infection resolves and the virus is cleared. 

However, many will remain chronically infected 

with the virus after the symptoms associated with 

their new infection have subsided. People chronically infected with hbv face an increased risk of 

developing chronic liver disease, including cirrhosis (scarring) and liver cancer, and for transmitting 

hbv infection to others. 

p According to the Third National Health and 

Nutrition Examination Survey (nhanes iii), about 

five percent of the U.S. population has ever been 

infected with hepatitis B, with an estimated 

200,000 infections occurring each year (Coleman, 

1998). Of these, it is believed that 120,000 infections are acquired through sexual transmission 

annually, mostly among young adults. An estimated 417,000 people are currently living with 

chronic sexually acquired hbv infection. 

p Infants and young children have the highest 

risk of chronic infection. 

p An estimated 5,000 to 6,000 deaths occur each 

year from chronic hepatitis B-related liver disease. 

p Hepatitis B vaccinations have been recommended for people with risk factors for hbv 

infection since the vaccine became available in 

1981. However, many teens and young adults at 

risk through sexual or drug-related behavior 

have not been vaccinated for hbv. Intensified 

efforts to vaccinate high-risk groups are urgently needed. 

p In 1997, 10,416 cases of acute hepatitis B were 

reported to cdc. However, reported cases dramatically underestimate the actual number of 

people who are infected with hepatitis B virus 

each year—an estimated 200,000. 

p A recent study demonstrates the high degree of 

under-vaccination among those at high risk. 

Among acute hepatitis B cases reported by sentinel counties in 1996, 70 percent had a missed 

opportunity for vaccination in the past. Of these, 

42 percent had been treated for an std in the 

past, 31 percent had been in prison or jail at 

some time in their lifetime, and 25 percent 

reported sexual or household contact with an 

hbv-infected person (Mast, cdc, 1998). 

22 
A Closer Look at Hepatitis B
 A Closer Look at Hepatitis B

BY GENDER 

The incidence of acute hepatitis B is higher among 

men than women. This difference is believed to 

reflect a higher prevalence of behavioral risk factors 

among males. 

BY AGE 

In the United States, adults and adolescents 

account for the majority of reported cases of acute 

hepatitis B, with the highest incidence rates 

observed among 25 to 39 year olds. Sexual transmission is the most common mode of transmission 

of hbv among adults and adolescents. According to 

data reported by sentinel counties in 1996, 40 percent of acute hepatitis B were attributed to high-risk 

heterosexual practices—more than one partner in 

the prior six months, history of other stds—and 18 

percent were associated with homosexual activity. 

Other risk factors associated with acute hepatitis B 

include injecting drug use (15 percent), household 

contact with another person infected with hbv 

(three percent), and health care employment (two 

percent) (Mast, cdc, 1998). 

An estimated 20,000 infants are born to mothers 

infected with hepatitis B each year. Providing the 

infant with treatment immediately after birth can 

prevent infection in 90 to 95 percent of cases. 

Pregnant women should be screened for hbv to 

detect infection and ensure the best treatment for 

themselves and their infants. 

BY RACE/ETHNICITY 

According to seroprevalence data for the general 

U.S. population from nhanes iii, the prevalence of 

Hepatitis B is higher among African Americans—12 

percent—than among whites—three percent— or 

Mexican Americans—4.4 percent. 

23 

HEPATITIS B HEPATITIS B 
TRENDS BY
 DISEASE Trichomoniasis and
 ichomoniasis and

Bacterial Vaginosis
 aginosis (BV)

Trichomoniasis, which affects both men and 

women, is caused by a microscopic parasite. While 

bacterial vaginosis is caused by an imbalance in 

the bacteria normally found in the vagina, and as 

such only affects women. Currently, there are no 

national surveillance data on trichomoniasis, bacterial vaginosis, and related vaginal infections, but 

these infections are among the most common 

conditions found in women in health care settings. While these diseases are treatable, untreated bacterial vaginosis is associated with pelvic 

inflammatory disease, and both trichomoniasis 

and bacterial vaginosis may increase the risk of hiv 

infection. In pregnant women, these diseases may 

also cause babies to be born prematurely or with 

low birth weights. However, the biomedical mechanisms for these outcomes are just beginning to be 

understood. 

A Closer Look at T A Closer Look at Trichomoniasis chomoniasis

And Bacter And Bacterial Vaginosis ( aginosis (BV)

p An estimated five million cases of trichomoniasis 

occur each year in the United States (Cates, 1999). 

p Scientific studies suggest bacterial vaginosis is 

common in women of reproductive age. In the 

United States, as many as 16 percent of pregnant women have bv. This varies by race and 

ethnicity from six percent in Asians and nine 

percent in whites to 16 percent in Hispanics 

and 23 percent in African Americans (cdc, 2000). 

p Diagnoses of other vaginal infections—of which 

bacterial vaginosis is the most common cause— 

increased dramatically over the decade, but now 

have begun to decline. In 1997, more than three 

million women were diagnosed with vaginitis in 

private doctors’ offices. Because these cases do 

not include women diagnosed in public health 

care settings or who are not diagnosed at all, 

these are minimum numbers of infection. 

24 
Chancroid


Chancroid is caused by a bacterial infection that 

produces genital ulcers. Reported cases of chancroid declined steadily from 4,986 cases in 1987 

to 143 reported cases in 1999. While chancroid is 

not widespread, it is believed to be substantially 

under-diagnosed and underreported. Moreover, 

chancroid has the potential to cause large outbreaks. It is difficult to diagnose without a specific laboratory test, which most health care providers 

and laboratories do not have the capability to perform (Beck-Sague, cdc, 1996). Even large outbreaks 

may go unrecognized despite a large burden of 

disease in the community. The disease causes genital ulcers and is of concern because it may contribute to increased hiv transmission in some communities (Mertz, cdc, 1998). 

A Closer Look at Chancr A Closer Look at Chancroid


pIn 1999, only 16 states and one outlying area 

reported one or more cases of chancroid and 

three of these states—New York, South Carolina, 

and Texas—accounted for nearly 72 percent of 

the 143 reported cases. 

p	 

A 1996 10-city study demonstrated substantial 

levels of unrecognized chancroid in some cities. 

In both Chicago and Memphis,Tenn., a significant 

percentage of patients with genital ulcers in std 

clinics had evidence of chancroid—12 percent 

and 20 percent, respectively. In Memphis, none of 

the patients had been diagnosed with chancroid, 

and few had received the appropriate treatment. 

In Chicago, the disease had been suspected, but 

not confirmed. Fortunately, most of these patients 

were treated appropriately for chancroid (Mertz, 

cdc, 1998). 

p In the above study, more men were found to 

be infected with chancroid than women. This 

study also found that 60 percent of chancroid 

cases were diagnosed in people 35 years of age 

or older (Mertz, cdc, 1998). 

 

5 

4 

3 

2 

1 

0 

Cases (in thousands) 

Chancroid Reported Cases, United States, 1981–1999 

1981 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 

25 

TRENDS BY DISEASE 
Status of atus of STDs by


City and S City and State,1999


Detailed national data by city and state are only than higher incidence of disease. This section will 

available for nationally notifiable stds. And while therefore present the status of gonorrhea and 

chlamydia became nationally notifiable in 1995, syphilis by city and state. To provide an indication 

the data are currently more representative of trends where chlamydia is currently the most common, 

in screening than of trends in disease. Because data on the percentage of women who tested poschlamydia often has no symptoms, cases are fre­ itive for chlamydia in family planning clinics also 

quently identified only through screening. are provided on the overview maps. Other stds, 

Therefore, high rates of chlamydia and gonorrhea like genital herpes and hpv are known to be widemay indicate more effective screening programs spread across all states and communities. 

and the introduction of more sensitive tests, rather 

Gonorrhea 

Rate per 

Syphilis 

Rate per 

100,000 100,000 

City Cases Population City Cases Population 

1. Baltimore, MD 6,124 948.6 1. Indianapolis, IN 407 50.0 

2. Richmond, VA 1,827 940.9 2. Nashville, TN 250 46.8 

3. St. Louis, MO 2,876 847.6 3. Baltimore, MD 246 38.1 

4. Rochester, NY 2,037 846.6 4. Memphis, TN 258 29.7 

5. Atlanta, GA 5,631 761.6 5. Atlanta, GA 213 28.8 

6. Washington, DC 3,536 675.9 6. Oklahoma City, OK 114 28.0 

7. Detroit, MI 7,900 626.8 7. Detroit, MI 189 15.0 

8. Newark, NJ 1,741 612.3 8. St. Louis, MO 51 15.0 

9. Norfolk, VA 1,291 599.9 9. Tulsa, OK 45 11.8 

10. Memphis, TN 5,038 579.9 10. New Orleans, LA 51 11.0 

11. New Orleans, LA 2,687 577.2 11. Louisville, KY 67 10.0 

12. Philadelphia, PA 7,775 541.3 12. Chicago, IL 282 9.5 

13. Milwaukee, WI 4,884 535.7 13. Norfolk, VA 20 9.3 

14. Chicago, IL 14,488 486.4 14. Washington, DC 45 8.6 

15. Kansas City, MO 1,956 432.8 15. Charlotte, NC 53 8.4 

16. Minneapolis, MN 1,558 427.4 16. Newark, NJ 22 7.7 

17. Jacksonville, FL 2,981 405.2 17. Dallas, TX 151 7.4 

18. Buffalo, NY 1,233 389.2 18. Phoenix, AZ 195 7.0 

19. Birmingham, AL 2,492 377.8 19. Richmond, VA 13 6.7 

20. Indianapolis, IN 3,045 374.4 20. San Juan, PR 61 5.8 

Rate for United States: 133.2 Rate for United States: 2.5 

26 
Areas Cur eas Currently Facing t y Facing the

Greatest Rates of Cur ates of CurableSTDs

While national rates of syphilis have reached alltime lows, rates remain high in many areas, mainly in the south. Following a 72 percent decline in 

gonorrhea from 1975 to 1997, reported rates of the 

disease increased about nine percent from 1997 to 

1999. Twelve cities lead the nation in reported rates 

of both diseases. When examining these data, it 

should be noted that the reported rates reflect the 

quality and completeness of surveillance data provided to cdc by state health departments, as well 

as the occurrence of disease in the community. 

Cities* on the Top 20 List for Rates of Gonorrhea and Syphilis 

Minneapolis, MN Rochester, NY 

Milwaukee, WI Buffalo, NY

Detroit, MI Newark, NJ Chicago, IL Philadelphia, PA 

Indianapolis, IN Baltimore, MD 

Kansas City, MO Washington, DC 

Richmond, VA St. Louis, MO Norfolk, VA 

Tulsa, OK 

Oklahoma City, OK Phoenix, AZ 

Dallas, TX 

= Gonorrhea 

= Syphilis 

= Both 

*over 200,000 population 

Louisville, KY
 

Nashville, TN Charlotte, NC
 

Memphis, TN
 

Birmingham, AL
 Atlanta, GA 

Jacksonville, FL 

New Orleans, LA 

San Juan, PR

Many of these communities also face a significant 

threat from chlamydia, which remains widespread 

across much of the United States. The highest levels of chlamydia remain in states where screening 

and treatment have not been widely implemented. 

27 

ST

ATUS OF STDS BY CITY AND ST TUS OF STDS BY CITY AND ST

A

T

E
 
STATUS OF STDS BY CITY AND STATE STATUS OF STDS BY CITY AND STATE

= Gonorrhea 

= Syphilis 

= Both 

= States with Chlamydia Positivity

*over 200,000 population Levels of More Than Five Percent

Phoenix, AZ Oklahoma City, OK 

Dallas, TX 

New Orleans, LA 

Tulsa, OK 

Kansas City, MO 

St. Louis, MO 

Birmingham, AL

 Jacksonville, FL 

Nashville, TN 

Atlanta, GA 

Charlotte, NC 

Norfolk, VA 

Newark, NJ 

Indianapolis, IN 

Richmond, VA 

Buffalo, NY 

Minneapolis, MN 

Washington, DC 

Chicago, IL 

Milwaukee, WI 

Memphis, TN 

Louisville, KY 

Philadelphia, PA 

Detroit, MI 

Rochester, NY 

Baltimore, MD 

San Juan, PR 

Virgin Islands 

Cities* on the Top 20 List for Rates of Gonorrhea and Syphilis, and States with 

Chlamydia Positivity Levels of More Than Five Percent Among 15- to 24-year-old 

Women Tested in Family Planning Clinics, United States, 1999 

28
 
STATES WITH HIGHEST RATES OF Indiana (103.3), Connecticut (101.4) and Kansas 

GONORRHEA AND SYPHILIS (101.4). From 1997 to 1999, gonorrhea increased in 

Twenty-four states now have rates of gonorrhea the 18 states italicized above. 

that exceed the Healthy People 2000 goals for the 

nation, including the following states in order by p&s Syphilis now exceeds the Healthy People 2000 

rates per 100,000 people: South Carolina (392), goal for the nation in 11 states in order by rates per 

Mississippi (378.3), Louisiana (301.9), Georgia (278), 100,000 people: Tennessee (11.8), Indiana (7.6), 

North Carolina (257.4), Alabama (250.2), Delaware Louisiana (7.0), Mississippi (7.0), South Carolina 

(223.5), Tennessee (209.3), Maryland (203.1), Illinois (7.0), Maryland (6.7), North Carolina (6.1), Georgia 

(193.1), Texas (166.6), Michigan (162), Ohio (161.8), (5.6), Oklahoma (5.6), Alabama (4.6) and Arizona 

Florida (153.8), Missouri (150.5), Virginia (138.4), (4.5). From 1997 to 1999, rates increased in the 

Wisconsin (127.5), Arkansas (127.1), Oklahoma three states italicized above. 

(120.1), Pennsylvania (110.8), New York (109.1), 

Gonorrhea 

States with Rates Above 

The Healthy People 

Year 2000 Objective, 

United States, 1999 

Syphilis 

States with Rates Above 

The Healthy People 

Year 2000 Objective, 

United States, 1999 

29
 

STATUS OF STDS BY CITY AND STATE STATUS OF STDS BY CITY AND STATE 
Bibliog Bibliography


Baur HM, Ting Y, Greer CE, et al. Genital Human 

Papillomavirus Infection in Female University 

Students as Determined by a pcr-Based Method. 

jama 1991;265(4):472-7. 

Bosch FX, et al. Prevalence of Human Papillomavirus 

in Cervical Cancer: A Worldwide Perspective. J Natl 

Cancer Inst 1995;87:796-802. 

Bunnell R, Dahlberg L, Stone K, et al. Misconceptions 

about std Prevention and Associations with std 

Prevalence and Incidence in Adolescent Females 

in a Southeastern City [abstract]. In: Program and 

Abstracts of the 1998 National std Prevention 

Conference; December 1998. 

Burk RD, Ho GY, Beardsely L, Lempa M, et al. 

Sexual Behavior and Partner Characteristics are 

the Predominant Risk Factors for Genital Human 

Papillomavirus Infection in Young Women. J Infect 

Dis 1996;174(4):679-89. 

Cates W et al. Estimates of the Incidence and 

Prevalence of Sexually Transmitted Diseases in the 

United States. Sex Trans Dis 1999;26(suppl):S2-S7. 

cdc. Increases in Unsafe Sex and Rectal Gonorrhea 

Among Men Who Have Sex with Men—San Francisco, 1994-1997. mmwr 1999;48(No. 35);773-777. 

cdc. Resurgent Bacterial Sexually Transmitted 

Disease Among Men Who Have Sex With Men — 

King County, Washington, 1997-1999. mmwr 1999; 

48(No. 3):773-777 

cdc. Gonorrhea—United States, 1998. mmwr 2000; 

49(No. 24):538-42. 

cdc. Fluoroquinolone-Resistance in Neisseria gonorrhoeae, Hawaii, 1999, and Decreased Susceptibility 

to Azithromycin in N. gonorrhoeae, Missouri, 1999, 

mmwr. 2000;49(No. 37):833-7. 

cdc. 1998 Guidelines for Treatment of Sexually 

Transmitted Diseases. mmwr 1998;47(No:RR-1): 

[inclusive page numbers]. 

Coleman PJ, McQuillan GM, Moyer LA, et al. 

Incidence of Hepatitis B Virus Infection in the 

United States, 1976-1994: Estimates from the 

National Health and Nutrition Examination 

Surveys. J Infect Dis 1998;178:954-60. 

Cohen DA et al. Repeated School-based Screening 

for Sexually Transmitted Diseases: A Feasible 

Strategy for Reaching Adolescents. Pediatrics 

1999;104(6):1281-5. 

Division of std Prevention. The National Plan to 

Eliminate Syphilis from the United States, National 

Center for hiv, std, and tb Prevention, Atlanta: 

Centers for Disease Control and Prevention (cdc), 

October 1999. 

Division of std Prevention. Prevention of Genital 

hpv Infection and Sequelae: Report of an External 

Consultants Meeting, Department of Health and 

Human Services, Atlanta: Centers for Disease 

Control and Prevention (cdc), December 1999. 

Division of std Prevention. Sexually Transmitted 

Disease Surveillance, 1999. U.S. Department of 

Health and Human Services, Atlanta: Centers of 

Disease Control and Prevention (cdc), September 

2000. 

Fleming DT, McQuillian GM, Johnson RE, et al. 

Herpes Simplex Virus Type 2 in the United States, 

1976 to 1994. N Engl J Med 1997;337(16):1105-11. 

Fox KK, Whittington WL, Levine WC, et al. 

Gonorrhea in the United States, 1981-1996. Demographic and Geographic Trends. Sex Trans Dis 

1998;26(7):386-93. 

30 
Ho GYF, Bierman R, Beardsley L, et al. Natural 

History of Cervicovaginal Papillomavirus Infection 

in Young Women. N Engl J Med 1998;338(7):423-8. 

Goldenberg RL, Andrews WW, Yuan AC, et al. Sexually Transmitted Diseases and Adverse Outcomes 

of Pregnancy. Clin Perinatal 1997;March;2491:23-41. 

Holmes KK, Sparling PF, Mardh PA, Lemon SM, 

Stamm WE, Piot P, Wasserheit JN eds. Sexually 

Transmitted Diseases. New York, McGraw Hill, 1999. 

Klausner, JD et al. Tracing a Syphilis Outbreak 

Through Cyberspace. jama 2000;284:447-449. 

Koutsky L. Epidemiology of Genital Human 

Papillomavirus Infection. Am J Med 1997;102(suppl 

5A):3-8. 

Ku L, Sonenstein FL,Turner CF, et al.The Promise of 

Integrated Representative Surveys About Sexually 

Transmitted Diseases and Behavior. Sex Transm Dis 

1997;May:299-309. 

Martinez J, Smith R, Farmer M, et al. High Prevalence of Genital Tract Papillomavirus Infection in 

Female Adolescents. Pediatrics 1988;82:604-8. 

Mast EE, Mahony FJ, Alter MJ, Margolis HS. Progress 

Toward Elimination of Hepatitis B Virus Transmission in the United States. Vaccine 1998;(suppl): 

S48-S51. 

Mertz KJ, McQuillan GM, Levine WC, et al. A pilot 

study of the prevalence of Chlamydial infection in 

a National household survey. Sex Trans Dis 1998; 

May:225-228. 

31 

McQuillan GM. Implications of a National Survey for 

stds: Results from the nhanes Survey. Presentation 

at 2000 Infectious Disease Society of America 

Conference. September 7-10, 2000, New Orleans. 

Mertz KJ, Trees D, Levine WC, et al. Etiology of 

Genital Ulcers and Prevalence of Human Immunodeficiency Virus Coinfection in 10 U.S. Cities. J Infect 

Dis 1998;178. 

National Committee for Quality Assurance (ncqa). 

hedis 2000: Technical Specifications, Washington, 

DC, 1999, pp. 68-70, 285-286. 

Palefsky JM. Human Papillomavirus Infection and 

Anogenital Neoplasia in Human Immunodeficiency Virus-Positive Men and Women. Monogr 

Natl Cancer Inst 1998;23:15-20. 

Reitmeijer CA, Yamaguchi KJ, Ortiz CG, et al. 

Feasibility and Yield of Screening Urine for 

Chlamydia trachomatis by Polymerase Chain 

Reaction Among High-Risk Male Youth in FieldBased and Other Nonclinic Settings. A New Strategy 

for Sexually Transmitted Disease Control. Sex 

Transm Dis 1997;24(7):429-35. 

Shah KV. Human Papillomaviruses and Genital 

Cancers. N Engl J Med 1997;337:1386-8. 

St. Louis ME and Wasserheit JN. Elimination of 

Syphilis in the United States. Science 1998;281:353-4. 

BIBLIOGRAPHY BIBLIOGRAPHY 
Notes