STDs in Racial and Ethnic Minorities
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Public Health Impact
Surveillance data show higher rates of reported STDs among some minority racial or ethnic groups when compared with rates among whites. Race and ethnicity in the United States are risk markers that correlate with other more fundamental determinants of health status such as poverty, access to quality health care, health care seeking behavior, illicit drug use, and living in communities with high prevalence of STDs. Acknowledging the disparity in STD rates by race or ethnicity is one of the first steps in empowering affected communities to organize and focus on this problem.
STD Reporting Practices
Surveillance data are based on cases of STDs reported to state and local health departments (see Appendix (Interpreting STD Surveillance Data)). In many state and local health jurisdictions, reporting from public sources, (for example, STD clinics) is thought to be more complete than reporting from private sources. Since minority populations may utilize public clinics more than whites, differences in rates between minorities and whites may be increased by this reporting bias. However, prevalence data from population-based surveys such as NHANES and Add Health confirm the existence of marked STD disparities.1,2
Completeness of Race/Ethnicity Data
To adjust for missing case report data, cases for which information is unknown are redistributed according to the distribution of cases in which race or ethnicity is known. This process may exacerbate any reporting bias.
Chlamydia—In 2008, 26.4% of reports on chlamydia cases were missing race or ethnicity data ranging by state from 0.0% to 59.7% (Table A1).
Gonorrhea—In 2008, 20.3% of reports on gonorrhea cases were missing information on race or ethnicity data ranging by state from 0.0% to 39.8%.
Syphilis—In 2008, only 3.2% of reports on syphilis cases were missing information on race or ethnicity data ranging from 0.0% to 18.2% among states with 10 or more cases of P&S syphilis.
All racial and ethnic groups reported increases in chlamydia rates from 2007 to 2008 (Table 11B). From 2004 to 2008, chlamydia rates increased by 27.0% among blacks, 15.6% among American Indian/Alaska Natives, 21.1% among Hispanics, 8.7% among Asian/Pacific Islanders, and 20.9% among whites.
Blacks—In 2008, approximately 49% of all reported chlamydia cases occurred among blacks (Table 11A). Overall, the rate of chlamydia among blacks in the United States was more than eight times that among whites. The rate of chlamydia among black women was nearly eight times higher than the rate among white women (2,056.9 and 264.4 per 100,000 women, respectively) (Figure O, Table 11B). The chlamydia rate among black men was almost 12 times as high as the rate among white men (928.8 and 79.4 per 100,000 men, respectively).
American Indian/Alaska Natives—In 2008, the chlamydia rate among American Indian/Alaska Natives was 808.8 cases per 100,000 population, an increase of 11.5% from the 2007 rate of 725.7. In the most recent data available (2007), the chlamydia positivity rate among females aged 15–24 years screened in Indian Health Service (IHS) clinics ranged from 8.1% in DHHS region V to 11.6% in region VIII.
Asian/Pacific Islanders—In 2008, the chlamydia rate among Asian/Pacific Islanders was 151.9 cases per 100,000 population, a slight increase from the 2007 rate of 137.1.
Hispanics—In 2008, the chlamydia rate among Hispanics was 510.4 cases per 100,000 population, nearly three times higher than the rate among whites (173.6).
Between 2007 and 2008 decreases in gonorrhea rates were seen in whites, blacks, and Hispanics (decreases of 10.7%, 4.7%, and 0.9%, respectively). Increases were seen in Asian/Pacific Islanders and American Indian/Alaska Natives (8.1% and 4.0%, respectively) (Table 21B and Figure 21).
Blacks—In 2008, approximately 71% of the total number of reported cases of gonorrhea occurred among blacks (Table 21A). In 2008, the rate of gonorrhea among blacks was 625.0 cases per 100,000 population. Overall, the rate of gonorrhea among blacks in the United States was 20 times greater than that among whites. This disparity has changed little in recent years (20 times higher in 2003, 19 times in 2007) (Figure P, Table 21B ). This disparity was higher for black men (27.6 times higher) than for black women (16.0 times higher) (Figure Q). As in 2007, the disparity in gonorrhea rates for blacks in 2008 was higher in the Midwest and Northeast (28.4 and 28.1 times higher, respectively) than in the South or the West (15.6 and 14.0 times higher, respectively) (Figure R).
In 2008, gonorrhea rates were highest for blacks 15 to 19 and 20 to 24 years of age considering all racial, ethnic, and age categories. Black women 15 to 19 years of age had a gonorrhea rate of 2,934.6 cases per 100,000 women. This rate was 16.2 times greater than the rate among white women in the same age category (181.3). Black men in the 15- to 19-year-old age category had a 2008 gonorrhea rate of 1,488.6 cases per 100,000 men, which was 40.7 times higher than the rate among 15- to 19-year-old white men of 36.6 per 100,000 men. Among men and women aged 20 to 24 years, the gonorrhea rate among blacks was 17.1 times greater than that among whites (2,556.0 and 149.1 cases per 100,000 population, respectively) (Table 21B ).
American Indian/Alaska Natives—In 2008 the gonorrhea rate among American Indian/Alaska Natives was 110.2 which was 3.6 times higher than the rate among whites. This disparity was similar to that in recent years (3.5 times higher in 2004) (Figure P, Table 21B ). It was higher for American Indian/Alaska Native women (3.7 times higher) than for American Indian/Alaska Native men (3.3 times higher) (Figure Q). In 2008, the disparity in gonorrhea rates for American Indian/Alaska Natives continued to be higher in the Midwest and the Northeast (4.4 and 4.1 times higher, respectively) than in the West or the South (3.5 and 2.8 times, respectively) (Figure R).
Asian/Pacific Islanders—In 2008 the gonorrhea rate among Asian/Pacific Islanders was 20.0 cases per 100,000 population which was lower than the rate among whites (Figure P, Table 21B ). This difference is greater for Asian/Pacific Islander women than for Asian/Pacific Islander men (Figure Q). In 2008 rates among Asian/Pacific Islanders were again consistently lower than among whites in all four regions of the U.S. (Figure R).
Hispanics—In 2008, the gonorrhea rate among Hispanics was 66.8 cases per 100,000 population which was higher than the rate among whites. This disparity was similar to that in recent years (Figure P, Table 21B ) and was higher for Hispanic men than for Hispanic women (Figure Q). The disparity in gonorrhea rates for Hispanics was higher in the Northeast (4.2 times higher) than in the Midwest (2.7 times higher), the South (2.0 times higher), or the West (1.8 times higher) (Figure R).
Primary and Secondary Syphilis
The syphilis epidemic in the late 1980s occurred primarily among heterosexual and minority populations.3,4 During the 1990s, the rate of P&S syphilis declined among all racial and ethnic groups (Figure 36). Between 2004 and 2008, the rate of
P&S syphilis increased among all racial and ethnic groups except for American Indian/Alaska Natives (Table 34B).
Blacks—Between 2007 and 2008, the rate of P&S syphilis among blacks increased 25.4% (from 13.8 cases per 100,000 population to 17.3 cases per 100,000 population). In 2008, 48.9% of all cases of P&S syphilis reported to CDC were among blacks and 33.1% of all cases were among non-Hispanic whites (Table 34A). Compared to whites, the overall 2008 rate for blacks was 7.9 times higher. It was 6.9 times higher in 2007 (Table 34B). In 2008, the P&S rate among black men was 7.0 times higher than that among white men; the rate among black women was over 15 times higher than that among white women (Figure S). In some age groups, particularly 15–19 year old black men and women, disparities have increased markedly in recent years as rates of disease have increased (Figures T and U). Among black men 15-24 years old, rates increased 3-fold from 2004 to 2008, the fastest rate of increase for any age or race/ethnicity group over this time period (Table 34B). Overall, the 2008 rate among men 15-19 years of age was 22 times higher for blacks than for whites. Among black women 15-24 years of age, rates increased about two-fold between 2004 and 2008. In 2008, rates were 15 times higher for black women 15-19 years of age than for white women of the same age.
Recent trends in young black men are of particular concern given data indicating high HIV incidence in this population.5
American Indian/Alaska Natives—Between 2007 and 2008, the rate of P&S syphilis among American Indian/Alaska Natives decreased 32.4% (from 3.4 to 2.3). In 2008, 0.4% of all cases of P&S syphilis reported to CDC were among American Indian/Alaska Natives (Table 34A).
Compared to whites, the 2008 rate for American Indian/Alaska Natives was comparable (Table 34B).
Asian/Pacific Islanders—Between 2007 and 2008, the rate of P&S syphilis among Asian/Pacific Islanders increased 25.0% (from 1.2 to 1.5 per 100,000 population). In 2008, 1.6% of all cases of P&S syphilis reported to CDC were among Asian/Pacific Islanders (Table 34A). The 2008 rate for Asian/Pacific Islanders was 0.7 times the rate for whites (Table 34B).
Hispanics—Between 2007 and 2008, the rate of P&S syphilis among Hispanics increased 11.9% (from 4.2 to 4.7). In 2008, 15.9% of all cases of P&S syphilis reported to CDC were among Hispanics (Table 34A). Compared to whites, the 2008 rate for Hispanics was 2.1 times higher (Table 34B).
In 2008, the rate of congenital syphilis (based on the mother’s race/ethnicity) was 34.6 cases per 100,000 live births among blacks and 12.8 cases per 100,000 live births among Hispanics. These rates are 12.4 and 4.6 times higher, respectively, than the 2008 rate among whites (2.8 cases per 100,000 live births) (Figure V, Table 41).
1 Datta SD, Sternberg M, Johnson RE, Berman S, Papp JR, McQuillan G, et al. Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002. Ann Intern Med 2007; 147(2):89–96.
2 Miller WC, Ford CA, Morris M, Handcock MS, Schmitz JL, Hobbs MM et al. Prevalence of chlamydial and gonococcal infections among young adults in the United States. JAMA 2004; 291(18):2229–2236.
3 Nakashima AK, Rolfs RT, Flock ML, Kilmarx P, Greenspan JR. Epidemiology of syphilis in the United States, 1941 through 1993. Sex Transm Dis 1996;23:16–23.
4 Peterman TA, Heffelfinger JD, Swint EB, Groseclose SL. The changing epidemiology of syphilis. Sex Transm Dis 2005;32:S4-S10.
5 Centers for Disease Control and Prevention. Subpopulation estimates from the HIV incidence surveillance system–United States, 2006. MMWR 2008;57:985–989.