Recent Trends in Gonorrhea in the United States Lori M. Newman, MD Division of STD Prevention CDC Jacksonville, FL May 9, 2006

Neisseria gonorrhoeae Sequelae of untreated infection include Pelvic inflammatory disease Infertility Chronic pelvic pain Increases risk of HIV transmission and acquisition Gonorrhea is second most common reported notifiable disease

Gonorrhea rates, U.S., * *Preliminary 2005 data

Gonorrhea rates by sex, * *Preliminary 2005 data

Gonorrhea rates by age and sex, 2005* *Preliminary 2005 data

Proportion of reported gonorrhea cases from STD clinics by sex, * *Preliminary 2005 data Males Females % from STD clinics

Gonorrhea rates by race/ethnicity, * *Preliminary 2005 data

Gonorrhea rates by state, United States and outlying territories, 2004

Gonorrhea rates by county: United States, 2004

Gonorrhea rates by region, * *Preliminary 2005 data

Female gonorrhea rates for year olds by region and race/ethnicity, 2005* *Preliminary 2005 data Rate (per 100,000 population)

Male gonorrhea rates for year olds by region and race/ethnicity, 2005* *Preliminary 2005 data Rate (per 100,000 population)

A closer look at increases in gonorrhea in the West……..

How to define the area of interest? States with increases in number of reported gonorrhea cases of >= 25% from 2000 to 2005 AND States with at least 500 cases in 2005

States with >25% increase in reported gonorrhea cases from 2000 to 2005* and > 500 cases in 2005* Cases 2000 Cases 2005* 2000 to 2005 Utah % Hawaii4831,002107% California21,59533,55555% Washington2,4183,69753% Oregon1,0381,55950% Alaska % Nevada1,5532,16940% *Preliminary 2005 data, as of Jan 2006

Gonorrhea rates by sex, 7 western states, * *Preliminary 2005 data for AK, CA, HI, NV, OR, UT, WA +48% +58%

Gonorrhea rates by age, 7 western states, * *Preliminary 2005 data for AK, CA, HI, NV, OR, UT, WA +71% +58% +47% +39% +49% +69%

Gonorrhea rates by race/ethnicity, 7 western states, * *Preliminary 2005 data for AK, CA, HI, NV, OR, UT, WA +18% +61% +89% +80% +45%

Have providers in the West adopted more sensitive, less specific, gonorrhea test technology than other states? AND/OR Are providers in the West screening more than in other states?

Comparison states with greatest number of gonorrhea cases in 2005* Cases 2000 Cases 2005* 2000 to 2005 Texas32,91924,527-25% Florida22,78119,702-14% Ohio19,30319,3560% Illinois20,67118,711-9% New York20,06717,099-15% North Carolina17,82314,578-18% Georgia20,26513,987-31% *Preliminary 2005 data, as of Jan 2006

Proportion of gonorrhea tested by nucleic acid amplification tests (NAATs), and gonorrhea test volume, American Public Health Laboratory Survey, 2000 and 2004 (N=30 labs) West* (n=20) Comparison** (n=10) % of gonorrhea tested by NAATs % 8% % 73% Gonorrhea test volume ,6031,222, ,1921,088,608 *West: AK, CA, NI, NV, OR, UT, WA **Comparison: FL, GA, IL, NY, NC, OH, TX Source: APHL laboratory survey, unpublished data, CDC, 2001 & Methods published in: Webster Dicker L et al. Laboratory Tests Used in U.S. Public Health Laboratories for STDs, STD 2004; 31:

Hypotheses  Artifactual increases  Use of more sensitive and less specific test technology  Gonorrhea screening  Increased dual gonorrhea/chlamydia testing  Outreach and screening efforts

Hypotheses, cont.  Real increases due to  Increased risk behavior  Reduced disease control efforts  Increases in resistant gonorrhea  Predominance of a more transmissible or more virulent gonococcal strain

Other analyses Local in-depth analyses of case report data Enhanced gonorrhea surveillance Evaluation of laboratory test volume and positivity Case control study Review of other data sources (DIS interviews, STD clinics, HMOs)

Summary National rate remains stable, but still far from HP 2010 goal of 19 per 100,000 Concerning racial disparities for gonorrhea High burden of disease among black adolescents and young adults in all regions Large increases in West, unclear cause, further investigation is underway

Current activities Working with project areas to investigate AND respond to increases in the West STD Surveillance Network (SSuN) 6 collaborating sites Enhanced gonorrhea surveillance STD clinics Sample of cases in neighboring counties Expanded behavioral, clinical, and lab data NEDSS and STD Program Area Module Translation of data into action

Acknowledgements Statistics and Data Management Branch, Division of STD Prevention, CDC Rob Nelson Epidemiology and Surveillance Branch, Division of STD Prevention, CDC Katrina Park Hillard Weinstock The many participants in the “GC in the West” working group

Contact information Lori Newman, MD Epidemiology and Surveillance Branch Division of STD Prevention Centers for Disease Control and Prevention Atlanta, GA (404) For more information: The findings and conclusions in this presentation have not been formally disseminated by the CDC and should not be construed to represent any agency determination or policy.