Gonorrhea is the second most commonly reported notifiable disease in the United
States. Infections due to Neisseria gonorrhoeae, like those resulting from
Chlamydia trachomatis, are a major cause of pelvic
inflammatory disease (PID)
in the United States. PID can lead to serious outcomes such as tubal infertility,
ectopic pregnancy, and chronic pelvic pain. In addition, epidemiologic and
biologic studies provide strong evidence that gonococcal infections facilitate
the transmission of HIV infection.1
From 1975 through 1997, the national gonorrhea rate declined 74.3% following
implementation of the national gonorrhea control program in the mid-1970s (Table
1). Gonorrhea rates subsequently appeared to plateau for several years; however,
the gonorrhea rate has decreased 11.8% from 2000 to 2004. (Figure
9 and Table
1). True increases or decreases may be masked by changes in screening practices
(affected by simultaneous testing for chlamydia), use of diagnostic tests with
different sensitivities, and changes in reporting practices.2
For most areas, the number of gonorrhea cases reported to CDC is affected
by many factors, in addition to the occurrence of the infection within the
population. As with reporting of other STDs, reporting of gonorrhea cases to
CDC is incomplete.3In addition, reporting practices for gonococcal
infections may have been biased towards reporting of infections in persons
of minority race or ethnicity, who are more likely to attend public STD clinics.2,4For
such reasons, supplemental data on gonorrhea prevalence in persons screened
in a variety of different settings are useful in assessing disease burden in
selected populations.
In 2004, 330,132 cases of gonorrhea were reported in the United States.
The rate of reported gonorrhea in the United States was 113.5 cases per 100,000
population in 2004 (Figure 9 and Table
1), which was the lowest rate of reported
gonorrhea ever.
In 2004, 29.7% of gonorrhea cases were reported by STD clinics. This is
a change from 1984, when 73.6% of gonorrhea cases were reported by STD clinics
(Figure 10 and Table
A2). In 2004, similar to previous years, a higher proportion
of male gonorrhea cases were reported from STD clinics than were female cases
(42.7% and 17.9% respectively).
In 2004, only 7 states and Puerto Rico had gonorrhea rates below the Healthy
People 2010 (HP2010) national target of 19 cases per 100,000 population (Figure
11 and Table 12).5
In 2004, 1,330 (42.4%) of 3,139 counties in the United States had gonorrhea
rates at or below the HP2010 national target of 19 cases per 100,000 population.
Rates per 100,000 population were between 19 and 100 in 1,139 counties (36.3%),
and greater than 100 in 670 counties (21.3%). The majority of counties with
greater than 100 cases per 100,000 population were located in the South (Figure
12).
As in previous years, in 2004 the South had the highest gonorrhea rate
among the four regions of the country. However, the gonorrhea rate in the
South has declined by 22% from a rate of 184.0 per 100,000 population in
2000 to 143.5 in 2004. In contrast, the gonorrhea rate in the West has increased
by 27.3% from 57.2 cases per 100,000 population in 2000 to 72.8 in 2004.
Rates in the Northeast (80.6 in 2004) and the Midwest (134.3 in 2004) have
shown minimal change since 2000 (Figure 13 and Table
13).
Prior to 1996, rates of gonorrhea among men were higher than rates among
women. For the third straight year, however, gonorrhea rates in women are
slightly higher than in men (Figure 14). In 2004 the gonorrhea rate among
women was 116.5 and the rate among men was 110.0 cases per 100,000 population
(Tables 14 and 15).
From 2000 to 2004, gonorrhea rates among women increased 31.3% in the West,
and decreased 18.6% in the South. Over the same time period, gonorrhea rates
among men increased 24.1% in the West, and decreased 25.2% in the South (Figure
13 and Tables 14 and 15).
The overall gonorrhea rate in selected large cities was 196.9 cases per
100,000 population in 2004. This rate has decreased 19.5% since 2000 when
it was 244.7 cases per 100,000 population. All of these cities had rates
higher than the HP2010 target of 19 cases per 100,000 population (Table
16).
In 2004, 42.5% of gonorrhea cases were reported by these selected cities
(Table 17). Similar to previous years, in 2004 the total gonorrhea rate among
males in these selected large cities (204.0) remained higher than that among
females (189.4) (Tables 18 and 19).
Changes in gonorrhea rates from 2000 through 2004 differed by racial/ethnic
group. Gonorrhea rates decreased by 19.1% during this time period for African-Americans
from 778.1 to 629.6 cases per 100,000 population. Gonorrhea rates also decreased
by 19.9% among Asian/Pacific Islanders from 26.7 to 21.4 cases per 100,000
population. Since 2000, the gonorrhea rate among whites increased 19.8% (33.3
per 100,000 in 2004), American Indian/Alaska Natives increased 19.4% (117.7
per 100,000 in 2004), and Hispanics increased 3.8% (71.3 per 100,000 in 2004)
(Figure 15 and Table
21B). In 2004, the gonorrhea rate among African-Americans
was 19 times greater than the rate for whites, down from 28 times greater
in 2000.
In 2004, the overall gonorrhea rate was highest for 20- to 24-year-olds
(497.8). Among females in 2004, 15- to 19- and 20- to 24-year-olds had the
highest rates of gonorrhea (610.9 and 569.1, respectively); among males,
20- to 24-year-olds had the highest rate (430.6) (Figure
16 and Table 20).
Since 2000 there has been a 15.4% decrease in the rate of gonorrhea among
15- to 19-year-olds, and a 15.2% decrease among 20- to 24-year olds, greater
than in any other age group. Decreases over this time period were greater
among male 15- to 19-year olds and 20- to 24-year olds (21.1% and 22.3% respectively)
than among female 15- to 19-year olds and 20- to 24-year olds (12.7% and
18.4%, respectively) (Table 20).
The overall rate in African-American men decreased 22.2% from 862.0 per
100,000 population in 2000 to 670.3 in 2004. Decreases were seen in all age
groups of African-American men in this time period. The overall rate in white
males increased 20.2% from 21.8 per 100,000 population in 2000 to 26.2 in
2004. Rates among Hispanic, Asian/Pacific Islander, and American Indian/
Alaska Native men showed no consistent trends over this time period (Table
21B).
The overall rate among African-American women decreased 15.6% from 702.1
per 100,000 population in 2000 to 592.5 in 2004. Decreases were noted in
15- to 19-year-old African-American women (19.7% from 2000 through 2004).
However, 15- to 19-year-old African-American women still have the highest
gonorrhea rate of any group (2,790.5 per 100,000 population). Rates among
white women increased 19% from 33.6 per 100,000 population in 2000 to 40.0
in 2004. Increases among white women were seen in nearly all age groups (Table
21B).
In summary, in those populations where rates are highest, African-Americans
and adolescents, significant decreases were observed. Increases were observed
in whites; other groups showed no change.
Gonorrhea Prevalence Monitoring Projects
Gonorrhea test positivity data are available from a variety of settings.
In 2004, the median state-specific gonorrhea test positivity among 15- to
24-year-old women screened in selected family planning clinics in 38 states,
Puerto Rico, the District of Columbia, and the Virgin Islands was 0.88% (range
0.1% to 4.2%) (Figure 19).
For women in this age group attending selected prenatal clinics in 19 states,
Puerto Rico, and the Virgin Islands, the median positivity was 1% (range
0% to 3.5%) (Figure F).
For 16- to 24-year-old women entering the National Job Training Program
in 33 states in 2004, the median state-specific gonorrhea prevalence was
2.4% (range 0% to 6.4%) in 2004 (Figure N). Among men entering the program
from 8 states in 2004, the median state-specific gonorrhea positivity was
3.7% (range 1% to 5.5%) (Figure O).
The median positivity for gonorrhea in women entering 34 juvenile corrections
facilities was 4.5% (range 0% to 16.6%), and in men entering 49 juvenile
corrections facilities was 0.8% (range 0% to 18.2%) (Table CC).
Resistance to ciprofloxacin (a fluoroquinolone) was first identified in
GISP in 1991. From 1991 through 1998, fewer than nine ciprofloxacin-resistant
isolates were identified each year and such isolates were identified in only
a few GISP clinics. In 2000, similar to 1999, 19 (0.4%) ciprofloxacin-resistant
GISP isolates were identified in 7 GISP clinics. In 2001, 38 (0.7%) ciprofloxacin-resistant
GISP isolates were identified in 6 clinics; in 2002, 116 (2.2%) such isolates
were identified in 13 clinics (Figure 22) and in 2003, 270 (4.1%) were identified
in 21 clinics. In 2004, 429 (6.8%) isolates submitted to GISP demonstrated
resistance to ciprofloxacin.
In Honolulu, the prevalence of ciprofloxacin-resistance identified remained
high. In 2004, 21 (22.8%) of 92 isolates submitted from Honolulu demonstrated
ciprofloxacin-resistance, up from 16 (13.3%) of 120 isolates in 2003. At
Tripler Army Medical Center, in Hawaii, 2 (28.6%) of 7 isolates tested in
2004 demonstrated resistance to ciprofloxacin. This high proportion of ciprofloxacin-resistant
isolates in Hawaii continues to reinforce the recommendation made by CDC
in 2000 that fluoroquinolones not be used to treat gonococcal infections
acquired in Hawaii.6
In California, increases in the number of isolates resistant to ciprofloxacin
were identified in 4 of 5 GISP sites, while one site, Orange County, experienced
a decrease from 31.5% in 2003 to 20.5% in 2004. In Long Beach, 25% of isolates
were ciprofloxacin-resistant compared with 19.4% in 2003; in San Francisco,
24.3% were resistant in 2004 compared to 19.2% in 2003; in San Diego, 20.6%
were resistant in 2004 compared to 13.2% in 2003; in Los Angeles, 13.8% were
resistant compared to 12.4% in 2003. The high prevalence in California reinforces
the CDC and California STD Program recommendations that fluoroquinolones
no longer be used for gonorrhea treatment in California.
In other west coast states, GISP sites experienced large increases in ciprofloxacin-resistance.
In Seattle the prevalence of resistant isolates submitted to GISP doubled
from 18 (7%) of 258 in 2003 to 38 (16.2%) of 235 in 2004, while in Portland
the prevalence nearly quadrupled, from 4 (3%) of 132 in 2003 to 22 (11.5%)
of 191 in 2004.
Prevalence of ciprofloxacin-resistance also increased in many GISP sites
outside California, Hawaii, Washington and Oregon in 2004. Substantial increases
occurred in Denver, Miami, Minneapolis and Phoenix, while smaller increases
occurred in 8 other GISP sites. In Denver, ciprofloxacin-resistance increased
from 0.7% in 2003 to 8.3% in 2004. In Miami resistance increased from 2.1%
in 2003 to 6.8% in 2004; in Minneapolis it increased from 2.3% in 2003 to
9.3% in 2004; in Phoenix it increased from 2.6% in 2003 to 6.6% in 2004.
Atlanta, Baltimore, Chicago, Dallas, Greensboro, New Orleans, Oklahoma City
and Philadelphia saw increases in fluoroquinolone-resistant Neisseria
gonorrhoeae (QRNG) prevalence, but to a lesser extent. Sites that saw ciprofloxacin-resistant
isolates for the first time in 2004 included Atlanta, Greensboro, and Oklahoma
City.
The prevalence of ciprofloxacin-resistance did not change from 2003 in
several GISP sites: Cincinnati – 0.3%, Cleveland – 0.4%, and Las
Vegas – 2.4%. Only Albuquerque, Birmingham, Detroit and St. Louis did
not identify ciprofloxacin-resistant isolates during 2004.
Overall, outside of Hawaii and California, 3.6% of isolates were ciprofloxacin-resistant
in 2004. Looking at sites outside Hawaii, California and Washington, areas
where fluoroquinolones are no longer recommended for treatment of any gonococcal
cases, 3% of isolates were resistant. Additional information on antimicrobial
susceptibility data and treatment recommendations from state and local health
departments may be found in the 2004 GISP report7or
the GISP website.
The number of fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) isolates
from men who have sex with men (MSM) continued to increase in 2004 to 286
(23.8%). During the same time period, the number of these isolates from heterosexuals
increased from 79 (1.5%) in 2003 to 136 (2.9%) (Figure
23). In 2004, CDC
recommended that fluoroquinolones no longer be used to treat gonorrhea among
MSM.9
To date, cephalosporin resistance has not been identified in GISP and the
proportion of GISP isolates demonstrating decreased susceptibility to ceftriaxone
or cefixime has remained very low over time. In 2001, three GISP isolates
with decreased susceptibility to cefixime were also found to be resistant
to penicillin, tetracycline, and ciprofloxacin; such multi-drug resistance
in combination with decreased susceptibility to cefixime had not previously
been identified in the United States.10In 2004, two GISP isolates
had decreased susceptibility to cefixime; one of those isolates demonstrated
the same resistance pattern as the 2001 isolates described above. In 2004,
no GISP isolates had decreased susceptibility to ceftriaxone.
The proportion of GISP isolates demonstrating elevated minimum inhibitory
concentrations (MICs) to azithromycin has been increasing since GISP began
monitoring azithromycin susceptibility in 1992. In 1992, there were no isolates
with azithromycin MIC ≥ 1.0 µg/ml but in 2004 there were 57 (0.9%) such isolates,
compared with 26 (0.4%) in 2003.
Additional information about gonorrhea in racial and ethnic minority populations,
adolescents, men who have sex with men, and other at risk populations can
be found in the Special Focus Profiles.
1 Cohen MS, Hoffman IF, Royce RA, et al. Reduction of concentration
of HIV-1 in semen after treatment of urethritis: implications for prevention
of sexual transmission of HIV-1. Lancet 1997;349:1868-73.
2 Centers for Disease Control and Prevention. Gonorrhea – United
States, 1998. MMWR 2000;49:538-42.
3 Sexually Transmitted Diseases in America: How Many Cases
and At What Cost? Prepared for the Kaiser Family Foundation by: American Social
Health Association, December 1998, ASHA: Research Triangle Park, NC, Kaiser
Family Foundation: Menlo Park, CA 94025.
4 Fox KK, Whittington W, Levine WC, Moran JS, Zaidi AA, Nakashima AN. Gonorrhea in the United States, 1981-1996: demographic and geographic trends.
Sexually Transmitted Diseases 1998;25(7):386-93.
5 U.S. Department of Health and Human Services. Healthy
People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving
Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.
6 Centers for Disease Control and Prevention. Fluoroquinolone-resistance
in Neisseria gonorrhoeae, Hawaii, 1999, and decreased susceptibility to azithromycin
in N. gonorrhoeae, Missouri, 1999. MMWR 2000;49:833-837.
7 Centers for Disease Control and Prevention. Sexually
Transmitted Disease Surveillance 2004 Supplement: Gonococcal Isolate Surveillance
Project
(GISP) Annual Report 2004. Atlanta, GA: U.S. Department of Health and Human
Services (available first quarter 2006).
8 Centers for Disease Control and Prevention. Increases in
fluoroquinolone-resistant Neisseria gonorrhoeae – Hawaii and California,
2001 MMWR 2002;51:1041-1044.
9 Centers for Disease Control and Prevention. Increases in
fluoroquinolone-resistant Neisseria gonorrhoeae among men who have sex with
men – United States, 2003, and revised recommendations for gonorrhea treatment,
2004. MMWR 2004;53:335-338.
10 Wang SA, Lee MV, Iverson CJ, Ohye RG, Whiticar PM, Hale
JA, Trees DL, Knapp JS, Effler PV, Weinstock HS. Multi-drug resistant Neisseria
gonorrhoeae with decreased susceptibility to cefixime, Hawaii, 2001. CID 2003;37:849-52.
Gonorrhea 1 
