Appendix C. STD Surveillance Case Definitions

C1. Case Definitions For Nationally Notifiable Infectious Diseases

The Council of State and Territorial Epidemiologists (CSTE) recommends that state health departments report cases of selected diseases to CDC’s National Notifiable Diseases Surveillance System (NNDSS). Case definitions are periodically revised using CSTE’s Position Statements and provide uniform criteria of nationally notifiable conditions for reporting purposes. The most current surveillance case definitions for nationally notifiable STDs are listed below. Please see the NNDSS website (https://wwwn.cdc.gov/nndss/case-definitions.html) for historical case definitions.

C1.1 Chancroid (Revised 9/96)

Clinical description

A sexually transmitted disease characterized by painful genital ulceration and inflammatory inguinal adenopathy. The disease is caused by infection with Haemophilus ducreyi.

Laboratory criteria for diagnosis
  • Isolation of H. ducreyi from a clinical specimen.
Case classification

Probable: a clinically compatible case with both a) no evidence of Treponema pallidum infection by darkfield microscopic examination of ulcer exudate or by a serologic test for syphilis performed ≥7 days after onset of ulcers, and b) either a clinical presentation of the ulcer(s) not typical of disease caused by herpes simplex virus (HSV) or a culture negative for HSV.

Confirmed: a clinically compatible case that is laboratory confirmed.

C1.2 Chlamydia trachomatis Infection (Effective 1/10)

Clinical description

Infection with Chlamydia trachomatis may result in urethritis, epididymitis, cervicitis, acute salpingitis, or other syndromes when sexually transmitted; however, the infection is often asymptomatic in women. Perinatal infections may result in inclusion conjunctivitis and pneumonia in newborns. Other syndromes caused by C. trachomatis include lymphogranuloma venereum (see Lymphogranuloma Venereum) and trachoma.

Laboratory criteria for diagnosis
  • Isolation of C. trachomatis by culture, OR
  • Demonstration of C. trachomatis in a clinical specimen by detection of antigen or nucleic acid.
Case classification

Confirmed: a case that is laboratory confirmed.

C1.3 Gonorrhea (Effective 1/14)

Clinical description

A sexually transmitted infection commonly manifested by urethritis, cervicitis, proctitis, salpingitis, or pharyngitis. Infection may be asymptomatic.

Laboratory criteria for diagnosis
  • Observation of gram-negative intracellular diplococci in a urethral smear obtained from a male or an endocervical smear obtained from a female, OR
  • Isolation of typical gram-negative, oxidase-positive diplococci by culture (presumptive Neisseria gonorrhoeae) from a clinical specimen, OR
  • Demonstration of N. gonorrhoeae in a clinical specimen by detection of antigen or nucleic acid.
Case classification

Probable: demonstration of gram-negative intracellular diplococci in a urethral smear obtained from a male or an endocervical smear obtained from a female.

Confirmed: a person with laboratory isolation of typical gram-negative, oxidase-positive diplococci by culture (presumptive N. gonorrhoeae) from a clinical specimen, or demonstration of N. gonorrhoeae in a clinical specimen by detection of antigen or detection of nucleic acid via nucleic acid amplification (e.g., polymerase chain reaction [PCR]) or hybridization with a nucleic acid probe.

C1.4 Syphilis (Effective 1/18)

Syphilis is a complex sexually transmitted disease that has a highly variable clinical course. Adherence to the following surveillance case definitions will facilitate understanding the epidemiology of this disease across the US.

Syphilis, primary (Effective 1/18)

Clinical description

A stage of infection with Treponema pallidum characterized by one or more ulcerative lesions (e.g. chancre), which might differ considerably in clinical appearance.

Laboratory criteria for diagnosis

Confirmatory:

  • Demonstration of T. pallidum by darkfield microscopy in a clinical specimen that was not obtained from the oropharynx and is not potentially contaminated by stool, OR
  • Demonstration of T. pallidum by polymerase chain reaction (PCR) or equivalent direct molecular methods in any clinical specimen.

Supportive:

  •  A reactive nontreponemal serologic test (Venereal Disease Research Laboratory [VDRL], rapid plasma reagin [RPR], or equivalent serologic methods), OR
  • A reactive treponemal serologic test (T. pallidum particle agglutination [TP-PA], enzyme immunoassay [EIA], chemiluminescence immunoassay [CIA], or equivalent serologic methods).*

* These treponemal tests supersede older testing technologies, including microhemagglutination assay for antibody to T. pallidum [MHA-TP].

Case classification

Probable: a case that meets the clinical description of primary syphilis and the supportive laboratory criteria.

Confirmed: a case that meets the clinical description of primary syphilis and the supportive confirmatory criteria.

Syphilis, secondary (Effective 1/18)

Clinical description

A stage of infection caused by T. pallidum characterized by localized or diffuse mucocutaneous lesions (e.g., rash – such as non-pruritic macular, maculopapular, popular, or pustular lesions), often with generalized lymphadenopathy. Other symptoms can include mucous patches, condyloma lata, and alopecia. The primary ulcerative lesion may still be present. Because of the wide array of symptoms possibly indicating secondary syphilis, serologic tests for syphilis and a thorough sexual history and physical examination are crucial to determining if a case should be classified as secondary syphilis.

Laboratory criteria for diagnosis

Confirmatory:

  • Demonstration of T. pallidum by darkfield microscopy in a clinical specimen that was not obtained from the oropharynx and is not potentially contaminated by stool, OR
  • Demonstration of T. pallidum by polymerase chain reaction (PCR) or equivalent direct molecular methods in any clinical specimen.

Supportive:

  • A reactive nontreponemal serologic test (VDRL, RPR, or equivalent serologic methods), AND
  • A reactive treponemal serologic test (TP-PA, EIA, CIA, or equivalent serologic methods).
Case classification

Probable: a case that meets the clinical description of secondary syphilis and the supportive laboratory criteria.

Confirmed: a case that meets the clinical description of secondary syphilis and the confirmatory laboratory criteria.

Syphilis, early non-primary non-secondary (Effective 1/18)

Clinical description

A stage of infection caused by T. pallidum in which initial infection has occurred within the previous 12 months, but there are no signs or symptoms of primary or secondary syphilis.

Laboratory criteria for diagnosis

Supportive:

  • A current nontreponemal test titer demonstrating fourfold or greater increase from the last nontreponemal test titer, unless there is evidence that this increase was not sustained for >2 weeks.
Case classification

Probable: a person with no clinical signs or symptoms of primary or secondary syphilis who has one of the following:

  • No prior history of syphilis, AND a current reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods), AND a current reactive treponemal test (e.g., TP-PA, EIA, CIA, or equivalent serologic methods), OR
  • A prior history of syphilis and meets the supportive laboratory criteria.

AND evidence of having acquired the infection within the previous 12 months based on one or more of the following criteria:

  • Documented seroconversion or fourfold or greater increase in titer of a nontreponemal test during the previous 12 months, unless there is evidence that this increase was not sustained for >2 weeks
  • Documented seroconversion of a treponemal test during the previous 12 months
  • A history of symptoms consistent with primary or secondary syphilis during the previous 12 months
  • Meets epidemiologic criteria.

Epidemiological criteria:

  • A history of sexual exposure to a partner within the previous 12 months who had primary, secondary, or early non-primary non-secondary syphilis (documented independently as duration <12 months).
  • Only sexual contact (sexual debut) was within the previous 12 months.

Syphilis, unknown duration or late (Effective 1/18)

Clinical description

A stage of infection caused by T. pallidum in which initial infection has occurred >12 months previously or in which there is insufficient evidence to conclude that infection was acquired during the previous 12 months.

Case classification

Probable: a person with no clinical signs or symptoms of primary or secondary syphilis who meets one of the following sets of criteria:

  • No prior history of syphilis, and a current reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods), and a current reactive treponemal test (e.g., TP-PA, EIA, CIA, or equivalent serologic methods), OR
  • A prior history of syphilis, and a current nontreponemal test titer demonstrating fourfold or greater increase from the last nontreponemal test titer, unless there is evidence that this increase was not sustained for >2 weeks, OR
  • Clinical signs or symptoms and laboratory results that meet the likely or verified criteria for neurologic, ocular, otic, or late clinical manifestations syphilis (see below)
  • AND who has no evidence of having acquired the disease within the preceding 12 months (see Syphilis, early non-primary non-secondary).

Comments: Although cases of syphilis of unknown duration are grouped together with late syphilis for the purposes of surveillance, the conservative clinical and public health responses to these cases will differ when there is uncertainty about the duration of infection. When faced with uncertainty, clinicians should act conservatively and treat unknown duration syphilis as if it were late infection, with three doses of benzathine penicillin. In contrast, the most conservative approach for STD control programs would be to manage cases of syphilis of unknown duration as early non-primary non-secondary infections and search for partners who may have been recently infected. Because this would not be feasible for most STD control programs, programs should consider prioritizing cases of syphilis of unknown duration with higher nontreponemal titers (e.g., 1:32 or higher) for investigation and partner services. Although nontreponemal titers cannot reliably distinguish between early infection (<12 months duration) and late infection (>12 months duration), nontreponemal titers usually are higher early in the course of syphilis infection.

Syphilis, Congenital (Effective 1/18)

Clinical description

A condition caused by infection in utero with T. pallidum. A wide spectrum of severity exists, from inapparent infection to severe cases that are clinically apparent at birth. An infant or child (aged less than 2 years) may have signs such as hepatosplenomegaly, rash, condyloma lata, snuffles, jaundice (nonviral hepatitis), pseudoparalysis, anemia, or edema (nephrotic syndrome and/or malnutrition). An older child may have stigmata (e.g., interstitial keratitis, nerve deafness, anterior bowing of shins, frontal bossing, mulberry molars, Hutchinson teeth, saddle nose, rhagades, or Clutton joints).

Laboratory criteria for diagnosis
  • Demonstration of T. pallidum by darkfield microscopy of lesions, body fluids, or neonatal nasal discharge, OR
  • PCR or other equivalent direct molecular methods of lesions, neonatal nasal discharge, placenta, umbilical cord, or autopsy material, OR
  • Immunohistochemistry (IHC), or special stains (e.g., silver staining) of specimens from lesions, placenta, umbilical cord, or autopsy material.
Case classification

Probable: a condition affecting an infant whose mother had untreated or inadequately treated* syphilis at delivery, regardless of signs in the infant, OR an infant or child who has a reactive non-treponemal test for syphilis (VDRL, RPR, or equivalent serologic methods) AND any one of the following:

  • Any evidence of congenital syphilis on physical examination (see Clinical description).
  • Any evidence of congenital syphilis on radiographs of long bones.
  • A reactive CSF VDRL test.
  • In a non-traumatic lumbar puncture, an elevated CSF leukocyte (white blood cell [WBC]) count or protein (without other cause):
    • Suggested parameters for abnormal CSF WBC and protein values:
      1. During the first 30 days of life, a CSF WBC count of >15 WBC/mm3 or a CSF protein >120 mg/dL is
        abnormal.
      2. After the first 30 days of life, a CSF WBC count of >5 WBC mm3 or a CSF protein >40 mg/dL, regardless of CSF serology.

The treating clinician should be consulted to interpret the CSF values for the specific patient.

* Adequate treatment is defined as completion of a penicillin-based regimen, in accordance with CDC treatment guidelines, appropriate for stage of infection, initiated 30 or more days before delivery.

Confirmed: a case that is laboratory confirmed.

Comments: Congenital and acquired syphilis may be difficult to distinguish when a child is seropositive after infancy. Signs of congenital syphilis may not be obvious, and stigmata may not yet have developed. Abnormal values for CSF VDRL, WBC count, and protein may be found in either congenital or acquired syphilis. Findings on radiographs of long bones may help because radiographic changes in the metaphysis and epiphysis are considered classic signs of congenitally acquired syphilis. While maternal antibodies can complicate interpretation of serologic tests in an infant, reactive tests past 18 months of age are considered to reflect the status of the child. The decision may ultimately be based on maternal history and clinical judgment. In a young child, the possibility of sexual abuse should be considered as a cause of acquired rather than congenital syphilis, depending on the clinical picture. For reporting purposes, congenital syphilis includes cases of congenitally acquired syphilis among infants and children as well as syphilitic stillbirths.

Syphilitic Stillbirth (Effective 1/18)

Clinical description

A fetal death that occurs after a 20-week gestation or in which the fetus weighs greater than 500g and the mother had untreated or inadequately treated* syphilis at delivery.

* Adequate treatment is defined as completion of a penicillin-based regimen, in accordance with CDC treatment guidelines, appropriate for stage of infection, initiated 30 or more days before delivery.

Comments: For reporting purposes, congenital syphilis includes cases of congenitally acquired syphilis among infants and children as well as syphilitic stillbirths.

Comments: Additional information to be collected on clinical manifestations of reported syphilis cases (Effective 1/18)

Syphilis is a systemic infection that, if untreated, can cause a variety of clinical manifestations, including:

  • Signs and symptoms of primary and secondary syphilis (see above case definitions).
  • Latent infections (i.e., those lacking any signs or symptoms).
  • Neurologic, ocular, or otic manifestations (neurosyphilis, ocular syphilis, or otosyphilis), which can occur at any stage of syphilis.
  • Late clinical manifestations (tertiary syphilis), which generally occur after 15–30 years of untreated infection.

The following provides guidance for reporting neurologic, ocular, otic, and late clinical manifestations of syphilis. Cases should be reported according to stage of infection, as defined above (e.g., primary syphilis; secondary syphilis; early non-primary, non-secondary syphilis; or unknown duration or late syphilis) and the clinical manifestations should be reported in the case report data, as defined below.

Neurologic manifestations:

Neurologic manifestations (neurosyphilis) can occur at any stage of syphilis. If the patient has neurologic manifestations of syphilis, the case should be reported with the appropriate stage of infection (as if neurologic manifestations were not present) and neurologic manifestations should be noted in the case report data.

Clinical description

Infection of the central nervous system with T. pallidum, as evidenced by manifestations including syphilitic meningitis, meningovascular syphilis, general paresis, including dementia, and tabes dorsalis.

Classification of neurologic manifestations (neurosyphilis)

Possible: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) and clinical symptoms or signs that are consistent with neurosyphilis without other known causes for these clinical abnormalities.

Likely: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) with both of the following:

  • Clinical symptoms or signs that are consistent with neurosyphilis without other known causes for these clinical abnormalities, AND
  • Elevated CSF protein (>50 mg/dL2) or leukocyte count (>5 WBC/mm3 CSF) in the absence of other known causes of these abnormalities.

Verified: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) with both of the following:

  • Clinical symptoms or signs that are consistent with neurosyphilis without other known causes for these clinical abnormalities, AND
  • A reactive VDRL in CSF in the absence of grossly bloody contamination of the CSF.
Ocular Manifestations:

Ocular manifestations (ocular syphilis) can occur at any stage of syphilis. If the patient has ocular manifestations of syphilis, the case should be reported with the appropriate stage of infection (as if ocular manifestations were not present) and ocular manifestations should be noted in the case report data.

Clinical description

Infection of any eye structure with T. pallidum, as evidenced by manifestations including posterior uveitis, panuveitis, anterior uveitis, optic neuropathy, and retinal vasculitis. Ocular syphilis may lead to decreased visual acuity including permanent blindness.

Classification of ocular manifestations (ocular syphilis)

Possible: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) and clinical symptoms or signs consistent with ocular syphilis without other known causes for these clinical abnormalities.

Likely: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) and both of the following:

  • Clinical symptoms or signs consistent with ocular syphilis without other known causes for these clinical abnormalities, AND
  • Findings on exam by an ophthalmologist that are consistent with ocular syphilis in the absence of other known causes for these abnormalities.

Verified: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) and both of the following:

  • Clinical symptoms or signs consistent with ocular syphilis without other known causes for these clinical abnormalities, AND
  • Demonstration of T. pallidum in aqueous or vitreous fluid by darkfield microscopy, or by PCR or equivalent direct molecular methods.
Otic Manifestations:

Otic manifestations can occur at any stage of syphilis. If the patient has otic manifestations of syphilis, the case should be reported with the appropriate stage of infection (as if otic manifestations were not present) and otic manifestations should be noted in the case report data.

Clinical description

Infection of the cochleovestibular system with T. pallidum, as evidenced by manifestations including sensorineural hearing loss, tinnitus, and vertigo.

Classification of otic manifestations (otosyphilis)

Possible: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) and clinical symptoms or signs consistent with otosyphilis without other known causes for these clinical abnormalities.

Likely: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) and both of the following:

  • Clinical symptoms or signs consistent with otosyphilis without other known causes for these clinical abnormalities, AND
  • Findings on exam by an otolaryngologist that are consistent with otosyphilis in the absence of other known causes for these abnormalities.

Verified: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) and both of the following:

  • Clinical symptoms or signs consistent with otosyphilis without other known causes for these clinical abnormalities, AND
  • Demonstration of T. pallidum in inner ear fluid by darkfield microscopy, or by PCR or equivalent directmolecular detection methods.
Late Clinical Manifestations:

Late clinical manifestations of syphilis usually develop only after a period of 15–30 years of untreated infection. Therefore, if the patient has late clinical manifestations of syphilis, the case should be reported with the appropriate stage of infection (for the vast majority of cases, unknown duration or late syphilis) and late clinical manifestations should be noted in the case report data.

Clinical description

Late clinical manifestations of syphilis (tertiary syphilis) may include inflammatory lesions of the cardiovascular system (e.g., aortitis, coronary vessel disease), skin (e.g., gummatous lesions), bone (e.g., osteitis), or other tissue. Rarely, other structures (e.g., the upper and lower respiratory tracts, mouth, eye, abdominal organs, reproductive organs, lymph nodes, and skeletal muscle) may be involved. In addition, certain neurologic manifestations (e.g., general paresis and tabes dorsalis) are also late clinical manifestations of syphilis.

Classification of late clinical manifestations of syphilis (tertiary syphilis)

Likely: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) with either of the following:

  • Characteristic abnormalities or lesions of the cardiovascular system (e.g., aortitis, coronary vessel disease), skin (e.g., gummatous lesions), bone (e.g., osteitis), or other tissue, in the absence of other known causes of these abnormalities, OR
  • Clinical signs and symptoms consistent with late neurologic manifestations of syphilis (e.g., general paresis, including dementia, or tabes dorsalis) in a case that meets the criteria for likely neurologic manifestations of syphilis (see above).

Verified: a person with a reactive nontreponemal test (e.g., VDRL, RPR, or equivalent serologic methods) and a reactive treponemal test (e.g., TP-PA, EIA, CIA or equivalent serologic methods) and either of the following:

  • Characteristic abnormalities or lesions of the cardiovascular system (e.g., aortitis, coronary vessel disease), skin (e.g., gummatous lesions), bone (e.g., osteitis), or other tissue in the absence of other known causes of these abnormalities, in combination with either demonstration of T. pallidum in late lesions by special stains or equivalent methods, or by PCR or equivalent direct molecular methods, or demonstration of pathologic changes that are consistent with T. pallidum infection on histologic examination of late lesions, OR
  • Clinical signs and symptoms consistent with late neurologic manifestations of syphilis (e.g., general paresis, including dementia, or tabes dorsalis) in a case that meets the criteria for verified neurologic manifestations of syphilis (see
    above).

C2. Case Definitions For Non-Notifiable Infectious Diseases

Although the conditions below are not currently nationally notifiable, they may be reportable in some jurisdictions. To provide uniform criteria for those jurisdictions, case definitions are provided by CSTE. Case definitions are periodically revised. The most current surveillance case definitions for non-notifiable STDs are listed below. Please see the NNDSS website (https://wwwn.cdc.gov/nndss/case-definitions.html) for historical case definitions.

C2.1 Genital Herpes (Herpes Simplex Virus) (Revised 9/96)

Clinical description

A condition characterized by visible, painful genital or anal lesions.

Laboratory criteria for diagnosis
  • Isolation of herpes simplex virus from cervix, urethra, or anogenital lesion, OR
  • Demonstration of virus by antigen detection technique in clinical specimens from cervix, urethra, or anogenital lesion, OR
  • Demonstration of multinucleated giant cells on a Tzanck smear of scrapings from an anogenital lesion.
Case classification

Probable: a clinically compatible case (in which primary and secondary syphilis have been excluded by appropriate serologic tests and darkfield microscopy, when available) with either a diagnosis of genital herpes based on clinical presentation (without laboratory confirmation) or a history of one or more previous episodes of similar genital lesions.

Confirmed: a clinically compatible case that is laboratory confirmed.

Comment

Genital herpes should be reported only once per patient. The first diagnosis for a patient with no previous diagnosis should be reported.

C2.2 Genital Warts (Revised 9/96)

Clinical description

An infection characterized by the presence of visible, exophytic (raised) growths on the internal or external genitalia, perineum, or perianal region.

Laboratory criteria for diagnosis
  • Histopathologic changes characteristic of human papillomavirus infection in specimens obtained by biopsy or exfoliative cytology, OR
  • Demonstration of virus by antigen or nucleic acid detection in a lesion biopsy.
Case classification

Probable: a clinically compatible case without histopathologic diagnosis and without microscopic or serologic evidence that the growth is the result of secondary syphilis.

Confirmed: a clinically compatible case that is laboratory confirmed.

Comment

Genital warts should be reported only once per patient. The first diagnosis for a patient with no previous diagnosis should be reported.

C2.3 Granuloma Inguinale

Clinical description

A slowly progressive ulcerative disease of the skin and lymphatics of the genital and perianal area caused by infection with Calymmatobacterium granulomatis. A clinically compatible case would have one or more painless or minimally painful granulomatous lesions in the anogenital area.

Laboratory criteria for diagnosis
  • Demonstration of intracytoplasmic Donovan bodies in Wright or Giemsa-stained smears or biopsies of granulation tissue.
Case classification

Confirmed: a clinically compatible case that is laboratory confirmed.

C2.4 Lymphogranuloma Venereum

Clinical description

Infection with L1, L2, or, L3 serovars of C. trachomatis may result in a disease characterized by genital lesions, suppurative regional lymphadenopathy, or hemorrhagic proctitis. The infection is usually sexually transmitted.

Laboratory criteria for diagnosis
  • Isolation of C. trachomatis, serotype L1, L2, or L3 from clinical specimen, OR
  • Demonstration by immunofluorescence of inclusion bodies in leukocytes of an inguinal lymph node (bubo) aspirate, OR
  • Positive microimmunofluorescent serologic test for a lymphogranuloma venereum strain of C. trachomatis.
Case classification

Probable: a clinically compatible case with one or more tender fluctuant inguinal lymph nodes or characteristic proctogenital lesions with supportive laboratory findings of a single C. trachomatis complement fixation titer of >64.

Confirmed: a clinically compatible case that is laboratory confirmed.

C2.5 Mucopurulent Cervicitis (Revised 9/96)

Clinical description

Cervical inflammation that is not the result of infection with N. gonorrhoeae or Trichomonas vaginalis. Cervical inflammation is defined by the presence of one of the following criteria:

  • Mucopurulent secretion (from the endocervix) that is yellow or green when viewed on a white, cotton-tipped swab (positive swab test), OR
  • Induced endocervical bleeding (bleeding when the first swab is placed in the endocervix).
Laboratory criteria for diagnosis
  • No evidence of N. gonorrhoeae by culture, Gram stain, or antigen or nucleic acid detection, and no evidence of T. vaginalis on wet mount.
Case classification

Confirmed: a clinically compatible case in a female who does not have either gonorrhea or trichomoniasis.

Comment

Mucopurulent cervicitis (MPC) is a clinical diagnosis of exclusion. The syndrome may result from infection with any of several agents (see C. trachomatis). If gonorrhea, trichomoniasis, and chlamydia are excluded, a clinically compatible illness should be classified as MPC. An illness in a female that meets the case definition of MPC and C. trachomatis infection should be classified as chlamydia.

C2.6 Nongonococcal Urethritis (Revised 9/96)

Clinical description

Urethral inflammation that is not the result of infection with N. gonorrhoeae. Urethral inflammation may be diagnosed by the presence of one of the following criteria:

  • A visible abnormal urethral discharge, OR
  • A positive leukocyte esterase test from a male aged <60 years who does not have a history of kidney disease or bladder infection, prostate enlargement, urogenital anatomic anomaly, or recent urinary tract instrumentation, OR
  • Microscopic evidence of urethritis (≥5 white blood cells per high-power field) on a Gram stain of a urethral smear.
Laboratory criteria for diagnosis
  • No evidence of N. gonorrhoeae infection by culture, Gram stain, or antigen or nucleic acid detection.
Case classification

Confirmed: a clinically compatible case in a male in whom gonorrhea is not found, either by culture, Gram stain, or antigen or nucleic acid detection.

Comment

Nongonococcal urethritis (NGU) is a clinical diagnosis of exclusion. The syndrome may result from infection with any of several agents (see C. trachomatis). If gonorrhea and chlamydia are excluded, a clinically compatible illness should be classified as NGU. An illness in a male that meets the case definition of NGU and C. trachomatis infection should be classified as chlamydia.

C2.7 Pelvic Inflammatory Disease (Revised 9/96)

Clinical case definition

A clinical syndrome resulting from the ascending spread of microorganisms from the vagina and endocervix to the endometrium, fallopian tubes, and/or contiguous structures. In a female who has lower abdominal pain and who has not been diagnosed as having an established cause other than pelvic inflammatory disease (PID) (e.g., ectopic pregnancy, acute appendicitis, and functional pain), all the following clinical criteria must be present:

  • Lower abdominal tenderness, AND
  • Tenderness with motion of the cervix, AND
  • Adnexal tenderness.

In addition to the preceding criteria, at least one of the following findings must also be present:

  • Meets the surveillance case definition of C. trachomatis infection or gonorrhea
  • Temperature >100.4 F (>38.0 C)
  • Leukocytosis >10,000 WBC/mm3
  • Purulent material in the peritoneal cavity obtained by culdocentesis or laparoscopy
  • Pelvic abscess or inflammatory complex detected by bimanual examination or by sonography
  • Patient is a sexual contact of a person known to have gonorrhea, chlamydia, or nongonococcal urethritis.
Case classification

Confirmed: a case that meets the clinical case definition.

Comment

For reporting purposes, a clinician’s report of PID should be counted as a case.