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Introduction
Hawai‘i experienced declining STD rates prior to 2000. However, this trend has ended as Hawai‘i is now experiencing an increase in STD rates similar to the early 1970's.
Chlamydia
Annual increases in chlamydia cases have ranged from 12%-45% since 1998. In 1992, Hawai‘i ranked first in the US in Chlamydia case rates and in 2003, Hawai‘i ranked 3 rd in the US with 5480 cases; chlamydia case rate of 440 per 100,000 population as compared to the US chlamydia case rate of 304 per 100,000 population. For the past 10 years, Hawai‘i has maintained its ranking among the top 10 States in the US with the highest chlamydia case rates. For more information, click here
Gonorrhea
There has been a 21%-70% annual increase in gonorrhea cases reported since 2001. The number of cases increased by 70% in 2003 . The presence of emerging antibiotic-resistant strains of N. gonorrhoeae continues to be a concern in Hawai‘i particularly with the limited number of available effective therapy. For more information, click here
Syphilis
The number of primary and secondary syphilis (P&S) cases reported has gradually increased from 2 P&S cases reported in 2000 to 14 cases reported in 2003. Over these years, the epidemiological profile of the P&S cases has shown a definite shift from heterosexual cases to men who have sex with men (MSM). Ninety ( 90%) of P&S cases in 2003 were men who have sex with men of whom 60% were co-infected with HIV/AIDS. Pockets of syphilis outbreaks have continued confirming the increasing trend in syphilis and other STDs. For more information, click here
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Chlamydia
Chlamydia became a reportable disease in Hawai‘i in 1990 and nationally in 2000. C. trachomatis infections continue to be the most commonly reported communicable infection in Hawai‘i and the US . Hawai‘i was ranked 3rd in the Centers for Disease Control and Prevention, Sexually Transmitted Disease Surveillance 2003 with 5480 reported cases of chlamydia, resulting in a chlamydia case rate of 440 per 100,000 population. Hawai‘i ’s chlamydia case rate in the past six consecutive years has maintained Hawai‘i ’s ranking among the top 10 states with the highest chlamydia case rates in the US .
The increase in chlamydia cases which started in 1998 was influenced in part by the conversion of testing technology from chlamydiazyme to nucleic acid amplification test (NAAT). There was a 45% increase in the chlamydia case rate in 1998. Chlamydia case rate continued to increase by 21%, 31%, 11%, 11% and 23% over the years from 1999 to 2003. There were 5307 chlamydia cases reported in 2004 with a chlamydia case rate of 422 per 100,000 population. A 3% decrease from 2003 (Table 1).
Chlamydia Screening Program
The Chlamydia Screening Program was established as a result of a demonstration project in 1989 that indicated the high incidence of chlamydia infections in Hawai‘i . The Screening Program is designed to screen females participating in family planning services and those at-risk of STD. The goal is to reduce the incidence of pelvic inflammatory disease and infertility. Women remain asymptomatic when infected with chlamydia and if left untreated, may result in health problems. A pregnant women infected with chlamydia may pass the infection on to her baby which may result in adverse medical complication in the neonate. About 18,000 chlamydia tests are performed through the Chlamydia Screening Program annually.
Although there were some changes by gender, age, race and geography over the past 5 years, there were no major changes. In 1999, 81% of the reported cases were women compared to 2003, where 75% of the reported cases were women. There was a 129% increase in the number of men reported with chlamydia from 1999 to 2003 as compared to 61% increase in the number of women with chlamydia. Thus, the proportion of women reported with chlamydia declined due to a greater number of men being reported with chlamydia especially in the private medical sector.
In 1999, 84% of the chlamydia cases were 29 years of age and under. In 2003, 94% of the chlamydia cases were 29 years of age and under. This is probably due to the targeted screening of women 25 years and under in the Chlamydia Screening Program. Nonetheless, r ates of C. trachomatis infection continue to be the highest among adolescents and young adults especially those less than 25 years old.
The number of cases by race showed slight changes over 5 years. The proportion of chlamydia cases reported among Asian/Pacific Islanders decreased from 67% in 1999 to 62% in 2003 along with the proporton of whites decreased from 25% in 1999 to 23% in 2003. Although, the number of reported cases among African/Americans remained a small percentage, proportion of the total has increased from 6% in 1999 to 11% in 2003.
The number of chlamydia cases reported by county varied within 1% between 1999 and 2003 with Honolulu County reporting 83%, Hawai‘i County 8%, Maui County 7% and Kaua‘i County 2%.
There were 30 pelvic inflammatory disease complicated with chlamydia (CTPID) reported in 1999 and 41 CTPIDs reported in 2003. The number of chlamydia cases increased by 73% over the past 5 years while the number of reported CTPID increased by only 37%. This under reporting is probably due to the difficulty of properly diagnosing CTPID and the lack of understanding of the need to report CTPID.
For more information about chlamydia:
For data and statistics on chlamydia, click here
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Gonorrhea
Historical Trend
The changing epidemiological profile of gonorrhea morbidity in Hawai‘i may be characterized in four (4) phases (Table 2, Figure 2). The first phase was characterized by rapid increases in gonorrhea morbidity in the 1970’s to the early 1980’s. This was due to a number of factors including the baby boomers born in the late 1940’s and early 1950’s reaching sexual maturity, the sexual revolution of the 1960’s, and the initiation of gonorrhea intervention activities by the Hawai‘i Department of Health, which initially increased the number of gonorrhea cases detected and reported.
Some of the gonorrhea intervention activities initiated during this phase include:
- A Gonorrhea Screening Program. This program began in 1972. 80% of women infected with gonorrhea were without symptoms. In 1970, 74% of the gonorrhea cases reported were among men. It was estimated that there were 3 women not being treated for every male gonorrhea case reported. This screening program was highly successful in detecting asymptomatic women with gonorrhea infections. Through this program, the number of women detected with gonococcal infection peaked in 1977 with 2.6% positive among those tested. Since then, the frequency of women detected through the screening progrom has slowly decreased to 0.53% in 1998
- The Sexually Transmitted Disease (STD) Clinic - The STD Clinic provides free and confidential STD screening, evaluation, treatment, education and risk-reduction counseling for persons aged 14 years and older.
- Disease Intervention Specialists (DIS)/ Field Services. The DIS provide individualize, client-centered STD education and risk-reduction counseling and performs voluntary and confidential partner notification and counseling activities for patients infected with STD including patients referred by private healthcare provider. This unit also coordinates STD intervention activities with private health care providers and monitors trends in STD to allow immediate intervention when new outbreaks of STD occur, provides technical guidance to the medical community and provides educational information to the general public on all STD and oversees the State gonorrhea and Chlamydia Screening Programs to assure testing and treatment of patients at-risk.
The second phase reflected a plateauing of cases. After reaching a peak gonorrhea case rate in 1977 at 464 cases per 100,000 population, the case rate plateaued from 1977 to 1981. The number of gonorrhea cases in women reached its peak in 1977. The number of women found infected with gonorrhea also peaked in 1977 with 833 women detected through the Gonorrhea Screening Program. However, due to the influence of male-to-male transmission of gonorreha and the lack of specific intervention activities to reduce gonorrhea transmission among men who have sex with men (MSM), the number of gonorrhea cases in men continued to increased, reaching a peck in 1981. Evidence of the increasing number of STDs in the State among MSM were reflected in the increasing number of MSM attending the STD Clinic where 34% of the clinic patients in 1982 were MSM.
The third phase began in 1982 with the AIDS awareness campaigns directly impacting on the incidence of gonorrhea infection among MSM. The number of gonorrhea cases reported in men declined dramatically, with annual decreases of 30-60 cases over the next six (6) years while the number of cases in women decreased by an average of 100 cases per year. The number of MSM attending the STD Clinic also reflected dramatic decreases from over 4,400 patient visits made in 1982 to a little over 400 patient visits made in 1998. The aging of the baby boomers as they matured into adulthood also impacted on the STD rates.
The final phase, which reflected lower case rates started in the late 1980’s with gonorrhea case rates below 100 cases per 100,000 population per year. The male to female sex ratio is almost 1:1 during this period as compared to the male to female ratio of 3:1 in 1970.
21st Century- The Resurgence
The number of cases has continued to remain low until 2000. The increase in gonorrhea morbidity started in 2000 with a 4% increase. Then followed by increases in number of cases by 23%, 22%, and 70% in 2001, 2002 and 2003, respectively. In 2003, Hawai‘i ranked 23 rd in the US with a gonorrhea case rate of 101/100,000 population as compared with the average US gonorrhea case rate of 116 per 100,000 population. The Healthy People 2010 objective for gonorrhea is a gonorrhea case rate of 19 per 100,000 population. The increase in 2003 was in part influenced by the conversion to using a nucleic acid amplification test by the Gonorrhea Screening Program and by making available to the Chlamydia Screening Program providers the dual laboratory test for both chlamydia and gonorrhea. However, there were 1193 cases of gonorrhea reported in 2004, a 6% decrease in the number of cases of gonorrhea infections as compared to 2003.
A review of the gonorrhea cases over the past 5 years does not show any significant gender, age, race and geographical trends other than the 70% increase from 2002 to 2003. The proportion of females increased slightly from 54% of the total morbidity in 1999 to 57% in 2003 and could have resulted from the Chlamydia Screening Program’s use of a dual nucleic acid amplification test which tests for both chlamydia and gonorrhea in 2003. Among cases whose race information was reported, the proportion of Asian/Pacific Islanders with gonorrhea infection increased from 46% in 1999 as compared to 61% of the cases in 2003. The proportion of African/Americans decreased from 22% in 1999 to 13% in 2003. The proportion of Whites with gonorrhea decreased from 32% in 1999 to 24% in 2003. The proportion of cases reported by County varied by a few percentage points. O‘ahu reported 93% of the total gonorrhea cases in 1999 and 90% of the cases in 2003. The other counties varied by only 1-2 percentage in 1999 and 2003.
Emerging strains of antibiotic-resistant Neiserria gonorrhoeae
The presence of antibiotic-resistant Neiserria gonorrhoeae continues to be a public health concern in the management of the infection. Hawai‘i is in a unique position in the Pacific because of its diverse population of not only residents but also tourists and immigrants from the South Pacific and South East Asia . Hawai‘i serves as the portal of entry into the mainland US from the east and the South Pacific and Asia to the west. The ability for Hawai‘i to monitor emerging strains of antibiotic-resistant N. gonorrhoeae arising from Asia and the Pacific region provides an early warning sign for the continental United States.
Hawai‘i was the first state to identify penicillinase producing N. gonorrhoeae (PPNG) (1976), and N. gonorrhoeae resistant-strains to spectinomycin (1989), tetracycline (1993), and ciprofloxacin (1993). Cluster of gonorrhoeae cases with reduced-sensitivity to azithromycin (1999) and cefixime (2001) have been reported.
Public Health Implications: In 1980’s, Penicillin- and Tetracycline-resistant strains became endemic in Hawai‘i . Now, Ciprofloxacin-resistant N. gonorrhoeae is endemic in Hawai‘i. In 2000, the increase percentage of Ciprofloxacin-resistant N. gonorrhoeae identified through the antibiotic sensitivity testing of gonococcal isolates has prompted the DOH to recommend Flouroquinolones not to be used for the treatment of gonorrhea cases in Hawai‘i . This treatment recommendation was adopted by the CDC and published in the CDC STD Treatment Guidelines, 2002.
The SPP will continue to monitor gonorrhea antibiotic resistance in Hawai‘i through the Gonorrhea Screening Program. Since antibiotic sensitivity testing can only be performed on live gonorrhea cultures, Hawai‘i has continued the Gonorrhea Screening Program using the culture method.
The State Laboratory has implemented routine antibiotic sensitivity testing on all gonorrhea isolates received from all sources, which accounts for about half of the state’s total gonorrhea morbidity. The number of antibiotics screened for antibiotic sensitivity has increased to seven antibiotics since June 2000. They include Azithromycin, Ciprofloxacin, Ceftriaxone, Spectinomycin, Cefixime, Tetracycline and Penicillin. About 23,000 gonorrhea cultures are submitted annually through the Gonorrhea Screening Program.
Effective therapy for gonorrhoeae infections has become limited as resistant strains of gonorrhea become established in Hawai‘i . This may become a major public health concern in the medical management of this disease. The STD Prevention Program (SPP) has intensified gonorrhea prevention activities including case management services to all patients diagnosed with antibiotic-resistant gonorrhea and referral of sex partners for examination and treatment.
Because Hawai‘i is a crossroad to mainland US, the Pacific, and Asia, the threat of emerging resistant strains of gonorrhea and the limited number of effective therapy for these resistant-strain gonorrhea continue to be a public health concern.
For more information about gonorrhea:
For data and statistics on gonorrhea, click here
Additional information on antibiotic-resistant N. gonorrhoeae
Gonoccocal Isolate Surveillance Project (GISP)
GISP was established in 1986 to monitor trends in antimicrobial susceptibilities of strains of N. gonorrhoeae in the United States in order to establish a rational basis for the selection of gonococcal therapies. GISP is a collaborative project between selected sexually transmitted diseases (STD) clinics, five regional laboratories, and the Centers for Disease Control and Prevention (CDC).
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Syphilis
The epidemiology of syphilis in Hawai‘i is changing. The number of primary and secondary syphilis (P&S) syphilis cases has gradually increased from 2 cases reported in 2000 to a high of 14 cases (all men) reported in 2003 (Table 3). In 2003, Hawai‘i ranked 30th state in the US; Hawai‘i P&S syphilis case rate was 1.1/100,000 poulation as compared to the US P&S case rate of 2.5 per 100,000 population. The Healthy People 2010 objective for P&S is 0.2 cases per 100,000 population.
Prior to 2000, most of the P&S syphilis cases were heterosexuals who acquired their infection from Asia. From 2001 through 2004, 96% (43/45) of reported P&S syphilis cases were males. Seventy-seven percent (77%) (33/43) of these cases were men who have sex with men of whom 75% (24/32) acquired their infection locally. The median age is 42 years (age range 22 years old - 63 years old) and of those whose HIV status is known, 41% (11/27) were HIV positive/AIDS.
HIV and syphilis co-infection
Syphilis infection increases the risk of HIV transmission. It may also increase viral load and decrease CD4 count thereby taxing the immune system. Syphilis infection, if left untreated, may cause serious long term health problems such as neurologic problems, vision and hearing loss, and heart disease.
Pockets of syphilis outbreaks occur, confirming the increasing trend in STDs in Hawai‘i and potentially increasing the number of HIV/AIDS cases.
For more information about syphilis:
For data and statistics on syphilis, click here
For diagnostic tools, clinical courses on syphilis, and primary and secondary syphilis algorithms, visit the California STD/HIV Prevention Training Center
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