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 in women, such as tubal infertility, ectopic pregnancy, and chronic pelvic pain. In addition, epidemiologic and biologic studies provide evidence that gonococcal infections facilitate the transmission of HIV infection.1 Together, sexual behavior and community prevalence can increase the risk of acquiring gonorrhea. Social determinants of health, such as socioeconomic status, discrimination, and access to quality health care, may contribute to the burden of gonorrhea in a community.2
N. gonorrhoeae has progressively developed resistance to each of the antimicrobials used for treatment of gonorrhea. Declining susceptibility to cefixime (an oral cephalosporin antibiotic) resulted in a change to the CDC treatment guidelines in 2015, so that dual therapy with ceftriaxone (an injectable cephalosporin) and azithromycin is now the only CDC recommended treatment regimen for gonorrhea.3 The emerging threat of cephalosporin resistance highlights the need for continued surveillance of N. gonorrhoeae antimicrobial susceptibility.
The combination of persistently high gonorrhea morbidity in some populations and the threat of cephalosporin-resistant gonorrhea reinforces the need to better understand the epidemiology of gonorrhea.
Interpreting Rates of Reported Cases of Gonorrhea
Although gonorrhea case reporting is useful for monitoring disease trends, the number of gonorrhea cases reported to CDC is affected by many factors in addition to the actual occurrence of the infection within the population. Changes in the burden of gonorrhea may be masked by changes in screening practices (e.g., screening for chlamydia with tests that also detect N. gonorrhoeae infections or increased screening at extra-genital anatomic sites), the use of diagnostic tests with different test performance (e.g., the broader use of nucleic acid amplification tests [NAATs]), and changes in reporting practices. As with other STDs, the reporting of gonorrhea cases to CDC is incomplete.4 For these reasons, supplemental data on gonorrhea prevalence in persons screened in a variety of settings are useful in assessing the burden of disease in selected populations.
Gonorrhea — United States
In 2017, a total of 555,608 cases of gonorrhea were reported in the United States, yielding a rate of 171.9 cases per 100,000 population (Figure 14, Table 1). During 2016–2017, the rate of reported gonorrhea cases increased 18.6%, and increased 75.2% since the historic low in 2009.
Gonorrhea by Region
The South had the highest rate of reported gonorrhea cases (194.0 cases per 100,000 population) among the four regions of the United States in 2017, followed by the Midwest (170.6 cases per 100,000 population), the West (169.0 cases per 100,000 population), and the Northeast (129.6 cases per 100,000 population) (Figure 15, Table 14). During 2016–2017, the gonorrhea rate increased in all four regions: 19.9% in the West, 19.5% in the Midwest, 19.0% in the Northeast, and 17.4% in the South (Figure 15, Table 14). During 2013–2017, the rate of gonorrhea in the West increased by 104.4% (82.7 to 169.0 cases per 100,000 population), while other regions had lower overall increases during this time period (i.e., 57.7% in the Midwest, 52.3% in the South, and 52.1% in the Northeast).
Gonorrhea by State
In 2017, rates of reported gonorrhea cases per 100,000 population ranged by state from 32.5 in Vermont to 309.8 in Mississippi; the gonorrhea rate in the District of Columbia was 669.9 cases per 100,000 population (Figure 16, Tables 13 and 14).
During 2016–2017, gonorrhea rates increased in 47 states and the District of Columbia (94.1%) and decreased in 3 states (5.9%) (Table 14).
Gonorrhea by Metropolitan Statistical Area
The overall rate of reported gonorrhea cases in the 50 most populous metropolitan statistical areas (MSAs) was 191.5 cases per 100,000 population in 2017, representing a 18.1% increase compared with the rate in 2016 (162.1 cases per 100,000 population) (Table 17). In 2017, 61.3% of reported gonorrhea cases were reported by these MSAs. Since 2013, the gonorrhea rate among females in the 50 most populous MSAs has been lower than the rate among males (Tables 18 and 19). In 2017, the rate among females in these MSAs was 141.0 cases per 100,000 females, while the rate among males was 243.4 cases per 100,000 males.
Gonorrhea by County
In 2017, 50.0% of reported gonorrhea cases occurred in just 70 counties or independent cities and 625 counties (19.9%) in the United States had a rate of reported gonorrhea less than or equal to 25 cases per 100,000 population (Figure 17, Table 20). The rate ranged from 26 to 53 cases per 100,000 population in 628 counties (20.0 %), ranged from 54 to 92 cases per 100,000 population in 631 counties (20.0%), ranged from 93 to 172 cases per 100,000 population in 632 counties (20.1%), and was more than 172 cases per 100,000 population in 624 counties (19.9%). As in previous years, counties with the highest gonorrhea rates were concentrated in the South.
Gonorrhea by Sex
As was observed during 2013–2016, the rate of reported gonorrhea cases among males was higher than the rate among females in 2017 (Figure 18, Tables 15 and 16). During 2016–2017, the gonorrhea rate among males increased 19.3% (169.7 to 202.5 cases per 100,000 males) and the rate among females increased 17.8% (120.4 to 141.8 cases per 100,000 females). During 2013–2017, the rate among males increased 86.3% (108.7 to 202.5 cases per 100,000 males) and the rate among females increased 39.4% (101.7 to 141.8 cases per 100,000 females). The magnitude of the increase among males suggest either increased transmission or increased case ascertainment (e.g., through increased extra-genital screening) among gay, bisexual, and other men who have sex with men (collectively referred to as MSM). However, most jurisdictions do not routinely report sex of sex partner or site of infection for gonorrhea cases, so trends in gonorrhea rates among MSM over time cannot be assessed.
Gonorrhea by Region and Sex
In all regions, the rate of gonorrhea increased among both males and females during 2016–2017 and during 2013–2017 (Tables 15 and 16). The rate of reported gonorrhea cases among females increased the most in the West (21.4% during 2016–2017 and 83.4% during 2013–2017) and Midwest (18.2% during 2016–2017 and 37.5% during 2013–2017) (Table 15). However, the rate of reported gonorrhea cases among males increased the most in the Northeast (21.5%) and the Midwest (20.4%) during 2016–2017 and in the West (117.8%) and Northeast (85.7%) during 2013–2017 (Table 16).
Gonorrhea by Age
In 2017, rates of reported gonorrhea cases continued to be highest among adolescents and young adults (Figure 19, Table 21). In 2017, the highest rates among females were observed among those aged 20–24 years (684.8 cases per 100,000 females) and 15–19 years (557.4 cases per 100,000 females). Among males, the rate was highest among those aged 20–24 years (705.2 cases per 100,000 males) and 25–29 years (645.9 cases per 100,000 males).
In 2017, persons aged 15–44 years accounted for 91.8% of reported gonorrhea cases with known age. Among 15–19 year olds, rates increased 15.5% during 2016–2017. The gonorrhea rate also increased among other age groups during 2016–2017: 12.8% among those aged 20–24 years, 20.3% among those aged 25–29 years, 24.2% among those aged 30–34 years, 28.6% among those aged 35–39 years, and 26.2% among those aged 40–44 years (Table 21). Among persons aged 15–44 years, increases were observed in all age groups for both men and women during 2016–2017 (Figures 20 and 21).
Gonorrhea by Race/Hispanic Ethnicity
In 2017, the rate of reported gonorrhea cases remained highest among Blacks (548.1 cases per 100,000 population) (Table 22B). The rate among Blacks was 8.3 times the rate among Whites (66.4 cases per 100,000 population). The gonorrhea rate among American Indians/Alaska Natives (AI/AN) (301.9 cases per 100,000 population) was 4.5 times that of Whites, the rate among Native Hawaiians/Other Pacific Islanders (NHOPI) (187.8 cases per 100,000 population) was 2.8 times that of Whites, the rate among Hispanics (113.7 cases per 100,000 population) was 1.7 times that of Whites, the rate among Multirace persons (76.9 cases per 100,000 population) was 1.2 times that of Whites, and the rate among Asians (34.7 cases per 100,000 population) was half the rate of Whites (Table 22B).
During 2013–2017, for all five years during that period, the gonorrhea rate increased among all race and Hispanic ethnicity groups: 176.6% among Multirace persons, 122.4% among Asians, 109.1% among NHOPI, 100.6% among Whites, 95.3% among AI/AN, 77.4% among Hispanics, and 36.2% among Blacks (Figure 22).
More information on gonorrhea rates among race/Hispanic ethnicity groups can be found in the Special Focus Profiles.
Gonorrhea by Reporting Source
In 2017, 9.3% of gonorrhea cases were reported from STD clinics, 76.7% were reported from venues outside of STD clinics, and 14.0% had an unknown reporting source (Table A2).
During 2008–2017, the percent of gonorrhea cases reported by STD clinics declined 64.4% among males and 57.9% among females; however, the percent of gonorrhea cases with missing/unknown reporting source increased 50.5% among males and 46.9% among females (Figures 23 and 24). During 2016–2017, the percent of gonorrhea cases reported by STD clinics decreased 12.2% among males and 8.4% among females.
In 2017, the largest proportion of cases among men were reported by private physicians/health maintenance organizations (HMOs) (21.8%), followed by other hospital clinics/facilities (12.3%), STD clinics (11.5%), emergency rooms (6.6%), and other health department clinics (6.2%) (Figure 23). Among females, private physicians/HMOs (24.8%) were the most common reporting source, followed by other hospital clinics/facilities (13.5%), laboratories (7.8%), STD clinics (6.4%), and family planning clinics (6.3%) (Figure 24).
STD Surveillance Network
The STD Surveillance Network (SSuN) is an ongoing collaboration of states and independently funded cities collecting enhanced information on a representative sample of gonorrhea case reports received from all reporting sources in their jurisdiction. Enhanced gonorrhea case report data for 2017 were obtained from Cycle 3 of SSuN, which includes 10 jurisdictions randomly sampling cases reported in their jurisdictions. In 2017, SSuN collaborators interviewed 6,409 gonorrhea cases, representing 4.1% of all cases reported from participating jurisdictions. The estimated burden of disease represented by men who have sex with men (MSM; including men who have sex with both men and women), men who have sex with women only (MSW), and women varied substantially across collaborating sites based on weighted analysis (Figure 25). San Francisco had the highest proportion of cases estimated to be MSM (86.0%), while Florida had the lowest proportion of MSM cases (20.6%). In total, across all SSuN sites, 41.7% of gonorrhea cases were estimated to be among MSM, 25.5% among MSW, and 32.9% among women.
Among six jurisdictions participating in SSuN continuously for the period 2010–2017, estimated rates of gonorrhea among MSM, MSW, and women were calculated by extending published estimates of the MSM population and are presented in Figure 26.5,6 The estimated gonorrhea case rate among MSM increased 283% during 2010–2017 from 1,368.6 cases per 100,000 MSM in 2010 to 5,241.8 cases per 100,000 MSM in 2017. Over the same time period, case rates among MSW and women also increased by 53.9% and 88.3%, respectively.
Collaborating SSuN jurisdictions also conduct sentinel surveillance on all patients seeking care in selected STD clinics. Sentinel facility data for this report include information from patients attending STD clinics during 2017 in 10 funded jurisdictions. In 2017, the proportion of STD clinic patients who tested positive for gonorrhea varied by age group, sex, and sexual behavior (Figure 27). The overall prevalence, represented by the average of the mean value by the 10 SSuN jurisdictions, was 26.5% for MSM, 14.6% for MSW, and 7.4% for women. Among those attending these clinics, MSM disproportionately had higher positivity rates when compared to MSW and women in all age groups. While positivity rates declined with increasing age in women, rates in MSW and MSM showed less consistent declines across age groups.
Additional information about SSuN methodology can be found in Section A2.2 of the Appendix.
Gonococcal Isolate Surveillance Project
Antimicrobial resistance remains an important consideration in the treatment of gonorrhea.3,7–9 In 1986, the Gonococcal Isolate Surveillance Project (GISP), a national sentinel surveillance system, was established to monitor trends in antimicrobial susceptibilities of urethral N. gonorrhoeae strains in the United States.7 Data are collected from selected STD clinic sentinel sites and from regional laboratories (Figure 28).
Antimicrobial susceptibility is measured by the minimum inhibitory concentration (MIC), the lowest antimicrobial concentration that inhibits bacterial growth in the laboratory. Increases in MICs demonstrate that the bacteria can survive at higher antimicrobial concentrations in the laboratory. Monitoring of MIC trends is useful because increasing MICs can oftentimes be an early indicator of the emergence of antimicrobial resistance.
Information on the antimicrobial susceptibility criteria used in GISP can be found in Section A2.3 in the Appendix. More information about GISP and additional data can be found at https://www.cdc.gov/std/GISP.
Susceptibility testing for ceftriaxone began in 1987. During 2008–2017, the percentage of GISP isolates that exhibited elevated ceftriaxone MICs, defined as ≥0.125 µg/ml, fluctuated between 0.05% and 0.4% (Figure 29). In 2017, 0.2% of isolates had elevated ceftriaxone MICs. Five isolates with decreased ceftriaxone susceptibility (MIC = 0.5 µg/ml) have been previously identified in GISP: one from San Diego, California (1987), two from Cincinnati, Ohio (1992 and 1993), one from Philadelphia, Pennsylvania (1997), and one from Oklahoma City, Oklahoma (2012).
Susceptibility testing for cefixime began in 1992, was discontinued in 2007, and was restarted in 2009. The percentage of isolates with elevated cefixime MICs (≥0.25 µg/ ml) declined from 1.4% in 2011 to 0.4% in 2017 (Figure 29).
Susceptibility testing for azithromycin began in 1992. Figure 29 displays the distribution of azithromycin MICs among GISP isolates collected during 2008–2017. Most isolates had MICs of 0.125–0.5 µg/ml. During 2012–2014, the percentage of isolates with elevated azithromycin MICs (≥2 µg/ml) ranged from 0.3% to 2.5% with a sharp increase during 2013–2014 (0.6% to 2.5%); during 2014–2017, the percentage increased from 2.5% to 4.4%. No isolates with elevated azithromycin MICs had elevated ceftriaxone MICs in 2017.
Susceptibility to Other Antimicrobials
Susceptibility testing for gentamicin began in 2015. Between 2015 and 2017, 66.7–75.3% of all tested isolates have had an MIC value of 8 µg/mL (Figure 30). None of the isolates tested in GISP have had an MIC above 16 µg/mL.
In 2017, 30.1% of isolates collected from GISP sites were resistant to ciprofloxacin, 23.1% to tetracycline, and 15.8% to penicillin (Figure 31). Although these antimicrobials are no longer recommended for treatment of gonorrhea, the resistance phenotypes remain common. Of all the isolates collected in GISP in 2017, 4.6% demonstrated resistance or elevated MICs to at least 3 antibiotics tested and 51.5% were susceptible to all antibiotics tested (Figure 32).
Antimicrobial Treatments Given for Gonorrhea
The antimicrobial agents given to GISP patients for gonorrhea therapy are shown in Figure 33. The proportion of patients treated with ceftriaxone 250 mg increased from 84.0% in 2011 to 98.1% in 2017. In 2017, 1.1% of patients were treated with gentamicin 240 mg and 0.1% were treated with cefixime 400mg.
In 2017, based on weighted analysis of SSuN jurisdictions with documented treatment information (i.e., antimicrobials and dosages) for ≥90% of cases, 82.4% (95% CI = 80.3–84.4) of reported patients with gonorrhea in SSuN jurisdictions received the recommended treatment for uncomplicated gonorrhea (Figure 34). The proportion of reported patients that received the recommended dual treatment ranged from 77.3% (95% CI = 72.5–82.1) in Massachusetts to 92.0% (95% CI = 88.9–95.2) in Multnomah County, Oregon.
Gonorrhea Among Special Populations
More information about gonorrhea in race/Hispanic ethnicity groups, females of reproductive age, adolescents, and MSM can be found in the Special Focus Profiles.
The national rate of reported gonorrhea cases reached a historic low in 2009, but increased each year during 2009–2012. After a temporary decrease in 2013, the gonorrhea rate increased again during 2014–2017. This increase was largely attributable to increases among men. Enhanced surveillance data suggest the largest increases are among MSM. However, high gonorrhea rates persist in certain geographic areas, among adolescents and young adults, and in some racial/Hispanic ethnicity groups. Additionally, continued surveillance for antimicrobial resistant gonorrhea is critical to monitor for the emergence of reduced susceptibility and resistance to cephalosporins and azithromycin.
1. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 75(1):3–17.
4. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: Prevalence and incidence estimates, 2008. Sex Transm Dis 2013; 40(3): 187–193. DOI: 10.1097/OLQ.0b013e318286bb53. Review.
5. Grey JA, Bernstein KT, Sullivan PS, et al. Estimating the population sizes of men who have sex with men in US states and counties using data from the American Community Survey. JMIR Public Health Surveill 2016;2(1) :e14.
6. Stenger M, Pathela P, Anschuetz G, et al. Increases in the rate of Neisseria gonorrhoeae among gay, bisexual and other men who have sex with men (MSM) — findings from the STD Surveillance Network 2010–2015. Sex Transm Dis 2017; 44(7): 393–397.
7. Centers for Disease Control and Prevention. Update to CDC’s sexually transmitted diseases treatment guidelines, 2006: Fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep 2007; 56(14): 332–336.