National Overview of Sexually Transmitted Diseases (STDs), 2012
All Americans should have the opportunity to make choices that lead to health and wellness. Working together, interested, committed public and private organizations, communities, and individuals can take action to prevent sexually transmitted diseases (STDs) and their related health burdens. In addition to federal, state, and local public support for STD prevention, local community leaders can promote STD prevention education. Health providers can assess their patients’ risks and talk to them about testing. Parents can better educate their children about STDs and sexual health. Individuals can use condoms consistently and correctly, and openly discuss ways to protect their health with partners and providers. As noted in the Institute of Medicine report, The Hidden Epidemic: Confronting Sexually Transmitted Diseases, surveillance is a key component of all our efforts to prevent and control these diseases.1
This overview summarizes national surveillance data for 2012 on the three notifiable diseases for which there are federally funded control programs: chlamydia, gonorrhea, and syphilis. Several observations for 2012 are worthy of note. During the mid-1990s to 2011, chlamydia and gonorrhea positivity among women screened in correctional facilities and in family planning and prenatal care clinics participating in infertility prevention activities were sent to Centers for Disease Control and Prevention (CDC) to monitor prevalence for those conditions. As the infertility prevention program expanded, trends in prevalence have become increasingly difficult to interpret2 and are no longer included in this report. For the first time, the data presented here by race and ethnicity are categorized according to the revised Office of Management and Budget standards. However, data for all jurisdictions by race/ethnicity using these categories are not available; consequently, absolute rates by race/ethnicity and comparisons between racial/ethnic groups may not match those provided in previous reports.
In 2012, a total of 1,422,976 cases of Chlamydia trachomatis infection were reported to the CDC (Table 1). This is the largest number of cases ever reported to CDC for any condition. This case count corresponds to a rate of 456.7 cases per 100,000 population, an increase of only 0.7% compared with the rate in 2011, the smallest annual increase since nationwide reporting for chlamydia began. For the first time since nationwide reporting of chlamydia began, the rate in women did not increase. The rate in men increased 3.2%.
In 2012, the overall rate of chlamydial infection in the United States among women (643.3 cases per 100,000 females) was over two times the rate among men (262.6 cases per 100,000 males), reflecting the larger number of women screened for this infection (Tables 4 and 5). However, with the increased availability of urine testing, men are increasingly being tested for chlamydial infection. During 2008–2012, the chlamydia rate in men increased 25%, compared with an 11% increase in women during this period. Rates also varied among different racial and ethnic minority populations. For example, in 2012, the chlamydia rate in blacks was 6.8 times the rate in whites.
Following a 74% decline in the rate of reported gonorrhea during 1975–1997, overall gonorrhea rates plateaued for 10 years. After the decline halted for several years, gonorrhea rates decreased further to 98.1 cases per 100,000 population in 2009, the lowest rate since recording of gonorrhea rates began. Since 2009, the gonorrhea rate has increased slightly each year to 107.5 cases per 100,000 population in 2012, a 9.6% increase overall. In 2012, there were 334,826 cases of gonorrhea reported in the United States. The 4% increase between 2011 and 2012 was observed in all regions except for the South where rates are still the highest of any region in the country. In 2012, rates increased in all age groups except those aged 15–19.
Since 2001, the rates in women have been somewhat higher than rates in men (Figure 12). In 2012, the gonorrhea rate in women was 108.7 cases per 100,000 population compared with a rate of 105.8 in men. During 2011–2012 the gonorrhea rate among women increased only 0.6% (4% since 2009) while it increased 8.3% among men (17.7% since 2009). As with chlamydia, gonorrhea rates in women were highest among those aged 15–24 years with the highest rate being in women 19 years of age (761 cases per 100,000 population, Table 23). In men, they were highest among those aged 20–24 years (Figure 16). However, the largest observed increases in 2012 were in women aged 40–44 years old and in men aged 30–34. In 2012, the gonorrhea rate in blacks was 15 times the rate in whites (Table 22B). As with chlamydia, data on gonorrhea prevalence in defined populations were available from several sources in 2012. These data showed a continuing high burden of disease in some adolescents and young adults in parts of the United States.
Antimicrobial resistance remains an important consideration in the treatment of gonorrhea. With increased resistance to the fluoroquinolones and the declining susceptibility to cefixime, dual therapy with ceftriaxone and either azithromycin or doxycycline is now the only CDC recommended treatment for gonorrhea.3 Continued monitoring of susceptibility patterns to these antibiotics is critical. One isolate with decreased susceptibility to ceftriaxone was seen in 2012 in CDC’s sentinel surveillance system, the Gonococcal Isolate Surveillance Project (GISP). No increases in Minimum Inhibitory Concentration (MIC) trends for cephalosporins were observed in 2012 (Figures 24 and 25).
The rate of primary and secondary (P&S) syphilis reported in the United States decreased during the 1990s, and in 2000, it was the lowest since reporting began in 1941. The low rate of syphilis and the concentration of most syphilis cases in a small number of geographic areas led to the development of the National Plan to Eliminate Syphilis from the United States, which was announced by the Surgeon General in 1999 and updated in 2006.4 The overall rate of P&S syphilis in the United States declined 89.7% during 1990–2000, then increased each year from 2001 through 2009. In 2010, the overall rate decreased for the first time in 10 years. But, in 2011 this rate remained unchanged, and in 2012, the rate increased 11.1% from that in 2011. This increase was solely among men in whom rates increased 14.8% overall. (Figure 31). In 33 areas where sex of partner data were available for at least 70% of cases each year during 2007-2012, cases among men who have sex with men (MSM) increased 15% between 2011 and 2012; in men who have sex with women only, cases increased 4% (Figure 30). In the US as a whole, rates in women remained unchanged between 2011 and 2012. In 2012, a total of 15,667 cases of P&S syphilis were reported to CDC, 1,697 more cases than were reported in 2011. Approximately 75% of cases were in MSM.
The 2012 rate of congenital syphilis (7.8 cases per 100,000 live births) marks the lowest rate of congenital syphilis recorded since 1988, when the case definition was changed. The rate of congenital syphilis decreased 10% between 2011 and 2012 and 26% since 2008. There were 322 cases of congenital syphilis reported in 2012.
Significant race and ethnic disparities in STD rates persist. In 2012, the P&S syphilis rate among blacks was six times the rate among whites. (Figure 38) In some subgroups, however, these disparities are much higher. The 2012 rate among blacks aged 15–19 years was 16 times the rate for whites of that age. While rates in congenital syphilis have decreased in recent years, the rates are still 14 times higher in blacks than whites and almost 4 times higher in Hispanics than whites (Table 43).
1 Eng TR, Butler WT, editors; Institute of Medicine (US). The hidden epidemic: confronting sexually transmitted diseases. Washington (DC): National Academy Press; 1997. p 43.
2 Satterwhite CL, Grier L, Patzer R, Weinstock H, Howards P, Kleinbaum D. Chlamydia positivity trends among women attending family planning clinics: United States, 2004-2008. Sex Transm Dis 2011;38 (11): 989-994.
3 Centers for Disease Control and Prevention. Update to CDC’s sexually transmitted diseases treatment guidelines, 2010. Oral cephalosporins no longer a recommended treatment for gonococcal infection. MMWR Morb Mortal Wkly Rep. 2012;61(31):590-594.
4 Centers for Disease Control and Prevention. The national plan to eliminate syphilis from the United States. Atlanta: U.S. Department of Health and Human Services; 2006.