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). After a small increase in 1998, the gonorrhea
rate has decreased each year since 1999 (Figure
10 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 2003, 335,104 cases of gonorrhea were reported in the United States.
The rate of reported gonorrhea in the United States was 116.2 cases
per 100,000 population in 2003 (Figure
10 and Table
1), which was the
lowest rate of reported gonorrhea ever.
In 2003, 29.9% 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 11). In 2003, similar to previous years, a higher
proportion of male gonorrhea cases were reported from STD clinics than
were female cases (43.3% and 17.7% respectively).
As in 2002, in 2003 only 8 states and 1 outlying area had gonorrhea
rates below the Healthy People 2010 (HP2010) national target of 19
cases per 100,000 population (Figure
12 and Table 12).5
In 2003, 1,319 (42.0%) of 3,140 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 1,112 counties (35.4%), and greater than 100 in 709 counties
(22.6%). The majority of counties with greater than 100 cases per 100,000
population were located in the South (Figure
13).
As in previous years, in 2003 the South had the highest gonorrhea
rate among the four regions of the country. However, the gonorrhea
rate in the South has declined by 23% from a rate of 195.1 per 100,000
population in 1999 to 149.8 in 2003. In contrast, the gonorrhea rate
in the West has increased by 25% from 51.3 cases per 100,000 population
in 1999 to 64.0 in 2003. Rates in the Northeast (91.1 in 2003) and
the Midwest (136.3 in 2003) have shown minimal change since 1999 (Figure
14 and Table 13).
Prior to 1996, rates of gonorrhea among men were higher than rates
among women. Since then, rates among women and men have remained similar
(Figure 15). In 2003 the gonorrhea rate among women was 118.8 and the
rate among men was 113.0 cases per 100,000 population (Tables
14 and
15).
The overall gonorrhea rate in selected large cities was 208.1 cases
per 100,000 population in 2003. This rate has decreased slightly each
year 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. In 2003, 44.1% of gonorrhea cases were reported
by these selected cities (Table 17). Similar to previous years, in
2003 the total gonorrhea rate among males in these selected large cities
(215.9) remained higher than that among females (199.9) (Tables
18 and 19).
Changes in gonorrhea rates from 1999 through 2003 differed by racial/ethnic
group. Gonorrhea rates decreased by 18.9% during this time period for
African-Americans from 808.4 to 655.8 cases per 100,000 population.
Since 1999, the gonorrhea rate among whites increased 22.5% (32.7 per
100,000 in 2003), Asian/Pacific Islanders increased 17.5% (22.8 per
100,000 in 2003), Hispanics increased 11.0% (71.7 per 100,000 in 2003),
and American Indian/Alaska Natives increased 5.5% (103.5 per 100,000
in 2003) (Figure 16 and Table
21B). In 2003, the gonorrhea rate among
African-Americans was 20 times greater than the rate for whites, down
from 30 times greater in 1999. The 2003 gonorrhea rates for all racial/ethnic
groups were above the HP2010 target of 19 per 100,000 population.
In 2003 the gonorrhea rate was highest for 20- to 24-year-olds (529.0).
Among females in 2003, 15- to 19- and 20- to 24-year-olds had the highest
rates of gonorrhea (634.7 and 595.2, respectively); among males, 20-
to 24-year-olds had the highest rate (465.9) (Figure
17 and Table 20).
Since 1999 there has been a 14.7% decrease in the rate of gonorrhea
among 15- to 19-year-olds, 11.7% among females and 21.0% among males.
The decrease during this time period was greater for the 15- to 19-year-olds
than any other age group (Table 20).
Increases in gonorrhea rates were largest among white men aged 35-54
years old between 1999 and 2003. For white men, rates increased 42.0%
among 35- to 39-year-olds, 56.8% among 40- to 44-year-olds, and 46.0%
among 45- to 54-year-olds (Table 21B).
As in recent years, the highest rates of gonorrhea were seen among
15- to 19-year-old African-American women (2,947.8 per 100,000), 20-
to 24-year-old African-American women (2,715.5 per 100,000), and 20-
to 24-year-old African-American men (2,649.8 per 100,000). However,
decreases in gonorrhea rates were seen among African-Americans of both
sexes and all age groups (Table 21B).
Gonorrhea test positivity data are available from a variety of settings.
In 2003, the median state-specific gonorrhea test positivity among
15- to 24-year-old women screened in selected family planning clinics
in 39 states, Puerto Rico, District of Columbia, and the Virgin Islands
was 0.8% (range 0.1% to 4.0%) (Figure
18). For women in this age group
attending selected prenatal clinics in 23 states, Puerto Rico, and
the Virgin Islands, the median positivity was 1.0% (range 0.0% to 3.7%)
(Figure G). For 16- to 24-year-old women entering the National Job
Training Program in 34 states and Puerto Rico in 2003, the median state-specific
gonorrhea prevalence was 2.1% (range 0.0% to 6.3%) in 2003 (Figure
Q). Among men entering the program from 10 states from July through
December 2003, the median state-specific gonorrhea positivity was 2.8%
(range 1.4% to 6.3%) (Figure R). The median positivity for gonorrhea
in women entering 28 juvenile corrections facilities was 5.7% (range
0.5% to 15.9%), and in men entering 35 juvenile corrections facilities
was 1.3% (range 0.3% to 4.5%) (Figures
LL and MM). See Special
Focus Profiles.
Antimicrobial resistance remains an important consideration in the
treatment of gonorrhea.6-8 Overall, 16.4% of isolates collected in
2003 in 30 STD clinics by the Gonococcal Isolate Surveillance Project
(GISP) were resistant to penicillin, tetracycline, or both (Figure
20).
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
21) and in 2003, 270 (4.1%) were identified in 21 clinics.
In Honolulu, the proportion of GISP isolates that were resistant
to ciprofloxacin remained high in 2003 at 13.3%. This was higher than
in 2002 (11.7%), but lower than in previous years (20.3% in 2001 and
14.3% in 2000). At Tripler Army Medical Center, in Hawaii, 4.2% of
isolates tested 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, significant increases in the proportions of GISP isolates
resistant to ciprofloxacin were identified in 3 out of 5 California
GISP sites (for Long Beach, 19.4% in 2003 compared with 7.2% in 2002;
for Orange County, 31.5% for 2003 compared with 11.4% in 2002; for
San Francisco, 19.2% in 2003 compared with 6.7% in 2002). San Diego
saw a slight decrease in ciprofloxacin-resistant isolates, down to
13.2% in 2003 from 16.5% in 2002. In 2003, Los Angeles reported to
GISP for the first time and 12.4% of isolates from that location were
resistant to ciprofloxacin. In 2002, the California STD Program recommended
that fluoroquinolones no longer be used for gonorrhea treatment in
California.
The proportion of GISP isolates that were ciprofloxacin-resistant
at other GISP clinics where such isolates were identified in 2003 were:
Baltimore – 0.4%, Chicago– 2.1%,
Cincinnati – 0.4%, Cleveland – 0.3%, Dallas – 2.0%,
Denver - 0.7%, Las Vegas 2.5%, Miami – 2.1%, Minneapolis – 2.3%,
New Orleans – 0.4%, Philadelphia – 1.3%, Phoenix – 2.6%,
Portland – 3.0%, and Seattle 7.0%. Overall, outside of Hawaii
and California, 1.2% of isolates were ciprofloxacin-resistant. Additional
information on antimicrobial susceptibility data and treatment recommendations
from state and local health departments may be found in the 2003 GISP
report7or the GISP
website.
The number of fluoroquinolone resistant Neisseria gonorrhoeae (QRNG)
isolates from MSM more than doubled from 77 (7.2%) in 2002 to 188 (15%)
in 2003. During the same time period, the number of QRNG isolates from
heterosexuals doubled, from 38 (0.9%) in 2002 to 79 (1.5%) in 2003
(Figure
22). 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.10 In
2003, 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 2003 there were
26 (0.4%) such isolates.
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. Sex Transm Dis 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 2003 Supplement: Gonococcal Isolate
Surveillance Project (GISP) Annual Report 2003. Atlanta, GA: U.S.
Department of Health and Human Services (in press).
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.