Diverging Gonorrhea and Syphilis Trends in the 1980s: Are They Real?
--------------------------
Kenneth A. Gershman, MD, MPH, and Robert T. Rolfs, MD
Introduction
sus tract for the years 1986 to 1989 in a city experiencing a large increase in syphilis.
Declines in numbers of reported cases of gonorrhea and syphilis in the first half ofthe 1980s suggested that Americans had changed their sexual behavior in response to the AIDS epidemic.3 Since 1986, however, syphilis incidence has increased4 while gonorrhea incidence has continued to decline. The recent spread of syphilis has been associated with drug use, especially cocaine.' Drug use has also been associated with the spread of gonorrhea, but this association has been less extensively
studied.1' Since syphilis and gonorrhea are transmitted in the same way, an increase in gonorrhea incidence, rather than a decrease, might be expected during the time when syphilis incidence increased. The decrease in gonorrhea incidence,
although probably real, could be the result of decreased surveillance and case detection activities. Anecdotally, reductions have occurred in sexually transmitted disease (STD) clinic visits in some cities and in gonorrhea screening programs in many states. Such decreases in gonorrhea case detection activities could result in artifactual declines in gonorrhea incidence. Altematively, an overall gonorrhea decrease might mask an increase in the same core group in which syphilis has increased. To better understand if the divergence in national trends of gonorrhea and syphilis is real and whether this divergence masks a contemporaneous increase in both diseases in a subgroup of the population, we analyzed several types of data. These included (1) reported cases of gonorrhea and primary and secondary (PS) syphilis for the years 1981 to 1989, (2) gonorrhea screening results from six states for the years 1985 to 1989, and (3) reported cases of gonorrhea and PS syphilis by cen-
Methods We used summary data from 1981 to 1989 on cases of gonorrhea and PS syphilis reported to state health departments and sent annually to the Centers for Disease Control (CDC). Annual reports included summary data by gender, racial or ethnic group, age group, and source of report (public, private, or military) for each state and six large cities (Baltimore, Chicago, Los Angeles, New York City, Philadelphia, and San Francisco). Cases reported from public and private sources were combined; military cases were not included in these analyses. Racial or ethnic group was categorized as Black (not of Hispanic origin), White (not of Hispanic origin), Hispanic, Asian or Pacific Islander, or American Indian or Alaska Native. Incidence rates for the United States were calculated using US Bureau of the Census population estimates for 19811989.12,13 Estimates of the White and Black Hispanic populations were subtracted from estimates of Whites and Blacks to calculate estimates for Whites not of Hispanic origin and Blacks not of
Hispanic origin. Five states and two cities in 1983 and two states and three cities in 1984 did not The authors are with the Division of STD/HIV Prevention, Center for Prevention Services, Centers for Disease Control. Requests for reprints should be sent to Information Services, Center for Publication Services (E06), Centers for Disease Control (E02), Atlanta, GA 30333. This paper was submitted to the journal January 2, 1991, and accepted with revisions April 23, 1991.
American Journal of Public Health 1263
Gershman and Rolfs
500
' 25
450
400
Gonorrhea 20
-
g350§ ~ ~ 300 *
250
*
200
o
150
Q
:
.. -
'
Syphilis,
I15
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:10
0
...
.
a.
500
1981
1982
1983
-
-----
1984 1985 'Vbar
-----
1986
1987
1988
T. - -
1989
FIGURE 1-Trends in Incidence of gonorrhea and primary and secondary syphilis, United Stats, 1981-1989.
WMb Wht
ftolib
Rm 200
180.
Black
lispanlo Hlspenn
Gonorrhea
(Gonorie
Elack hill
8yp
Goneonm
%-philbe
Ri
36
""
2ZS00
01
,5
160 140
.140
120
2,000
: 100
4
120
1,500.
100
3
60
1,000-
1--1985 -
1981
of PS syphilis, however, increased 59% from a rate of 11.6 to 18.4 cases per 100 000 persons. Among Whites, the incidence of gonorrhea decreased 48% from 1986 to 1989 (107.1 to 56.4 cases per 100 000), while that of syphilis decreased 11% (2.8 to 2.5 cases per 100 000) (Figure 2). Among Hispanics, the incidence of gonorrhea decreased 50% during this time (283.5 to 140.9 cases per 100 000) and syphilis incidence decreased 27% (26.0 to 19.1 cases per 100 000). However, among Blacks, a marked divergence in trends occurred: gonorrhea incidence decreased to a lesser extent than among the other groups, 13% (2197.1 to 1912.4 cases per 100 000), while syphilis incidence increased 100% (61.0 to 121.8 cases per 100 000). Sex-specific trends within each racial or ethnic group were generally similar to overall racial or ethnic trends. While syphilis incidence increased among White females from 1986 to 1989 (from 1.4 to 1.9 cases per 100 000 persons), their rates remained extremely low. Syphilis incidence among Hispanic females did not change appreciably during this time period. Only 18 states reflect the divergence in national trends of gonorrhea and syph-
-
19119
19B16 1986 99 Ya
YWr
|Gonorrhe
Syphilij , ~~~~........
FIGURE2-Trends in race-specffic incidence of gonorrhea and primaryand secondary syphilis, United States, 1981-1989. Rates = No. of cases per 100 000 persons.
submit annual reports of gonorrhea cases to CDC. Estimates for these areas were
projected by averaging the sex and race distributions of cases in each area from the years before and after the missing year(s). Similar methods for interpolating missing syphilis data have been described previously.4
The proportion of gonorrhea cases reported with race not specified varied from year to year (17-19% for the years 1981 and 1986-1989 and 22-26% for 1982 through 1985). No cases were reported with sex not specified. Cases with race not specified were prorated to the race and sex distribution of known cases. To assess the validity of prorating, we tested varying as-
1264 American Journal of Public Health
The incidence of both gonorrhea and syphilis decreased in the United States from 1981 to 1985 (Figure 1). From 1986 to 1989, the incidence of gonorrhea de-
40
2D 0-
National Trends
creased 22% from a rate of 370.8 to 289.1 cases per 100 000 persons. The incidence
500
1
Reml
'60
2
60
40
where these data were available. The numbers of gonorrhea cultures performed and the numbers positive by type of facility were reported. STD clinic results were excluded and overall annual positivity rates (percent positive) were calculated for all other sources combined. Cases of gonorrhea and PS syphilis by census tract for Rochester, NY, for the years 1986 to 1989 were obtained from the New York State STD program. Rochester was selected because gonorrhea and syphilis trends diverged there and census tract data were available. Census tracts were ranked by the number of PS syphilis cases reported in 1989. Core syphilis census tracts were defined as those with the highest ranking that cumulatively accounted for approximately 50% of cases.14 Incidence rates were calculated using 1980 US Bureau of the Census population estimates by census tract.15
sumptions, including the extreme assumptions that unspecified cases were all Black or all White. Gonorrhea trends were not sensitive to these extremes. Similar methods for prorating cases of syphilis with race not specified have been previously described.4 For the analysis of state trends, an increase in syphilis incidence was defined as a greater than 33% rate increase from 1986 to 1989 with both 1988 and 1989 rates higher than the 1986 rate. Only states with at lease 25 PS syphilis cases in 1989 were included. Results of gonorrhea screening in women for the years 1985 to 1989 were obtained from six state STD programs
October 1991, Vol. 81, No. 10
Diverng Gonorrhea and Sypnils Trends ilis from 1986 to 1989. Although gonorrhea incidence rates decreased or remained unchanged in 45 states, syphilis incidence rates increased in only 22 states. In 18 of these 22 states, gonorrhea incidence decreased or remained unchanged.
Gonon*ea Screening To evaluate whether changes in surveillance methods or case detection may account for the decrease in gonorrhea incidence, we compared trends in screening positivity rates in women and reported cases of gonorrhea in six states in which syphilis has increased (Figure 3). Screening and reported case trends were quite similar between 1985 and 1989 in these states. In two states (Oregon, Washington), screening positivity rates and reported cases both declined throughout the period 1985 to 1989; in three states (Alabama, Delaware, Louisiana), both trends initially declined then increased in parallel; and in one state (Michigan), both trends remained relatively unchanged. For two of the six states, the numbers of women screened decreased by 5% or less from 1986 to 1989. In the other four states, the numbers of women screened declined by 15% to 51%. Core hypothesis. To evaluate whether the overall divergence in trends of gonorrhea and syphilis masked a contemporaneous increase in both diseases in a core group, we first analyzed race-specific case totals for 1986-1989 from several metropolitan areas where these data were available. In four metropolitan areas (Seattle, Memphis, Charlotte, Los Angeles) with an overall divergence in trends, stratification by race did not identify a group in which the incidence ofboth gonorrhea and syphilis increased. To further evaluate the core concept, we analyzed census tract data from one metropolitan area. In Rochester, NY, gonorrhea incidence remained relatively constant from 1986 to 1989 (12% increase), while syphilis incidence increased 11-fold. We compared gonorrhea and syphilis incidence rates in the census tracts with approximately 50%o of the city's reported syphilis cases (the core area) in 1989 (Table 1). Core incidence rates for syphilis and gonorrhea were 7.0 and 3.5 times higher, respectively, than noncore rates in 1989. Even in the core syphilis census tracts, however, trends for the two diseases diverged as syphilis incidence rates increased 24-fold, while gonorrhea incidence rates showed little change. A similar divergence, but of lesser magnitude, also occurred in the noncore census
October 1991, Vol. 81, No. 10
ca eooo
% PosiNg
;
Ogon n
1.6
Cals 12o,o
Washington
% Positi 2.5
Ca
1,*0
10,000.
0.0
0
C_
MichlgM
% Pochg h ,40
e
40,000
3.0 2.0
20,000.
0°
4000 4~000. 2,000
t
0
Louiabna
Cassa 25,000
1.0
2000
'1.0
0.5 0.0
0
--t0.0
% Positiv
;-40
20,000. 15,000
1965
1967
0--0.0
19im
0.5
Aiabma
Cs 25,000
% P°iv
.3.S
20,000-
&.0
15,000
, 2.0 1.S
2.0
10,000 1.0
f ~~~~2.5
.~~~~~~~~.
81000 0.5
% Positi
],
10,000
5$000 0'
'1.0 1965
--- -r--~-;°-°
Yew
1967
1969
Yea | case
Screening
1.0 ' 0.5
4000^ 0
1965
O
1967 Yew
0.0 199
|
FIGURE 3-TrendsIn reported cas of gonorrhea and gonorhea screening poslvMty rates (% postive cultures) In women, selected states, 1985-1989.
tracts. Of note, gonorrhea incidence rates for Rochester in 1987 were substantially lower than rates for all other years from 1984 to 1989.
Discussion From 1986 to 1989, national trends of gonorrhea and syphilis incidence diverged: gonorrhea declined while syphilis increased markedly. Tlis divergence occurred among Blacks, but not among Whites or Hispanics. Results from gonorrhea screening among females in a number of states support the overall decrease in gonorrhea incidence as real, rather than the result of changes in surveillance. We were unable to demonstrate a core group in which the incidence of both gonorrhea and syphilis increased. Gonorrhea screening positivity rates declined from 1985 to 1989 in five ofthe six states we assessed, as did gonorrhea incidence. In the sixth state, both gonorrhea screening and incidence trends changed
little. Screening positivity rates should be a reliable indicator of gonorrhea prevalence if the population screened remains relatively constant over time. For the two states in which the numbers of women screened changed little, parallel decreases in both screening and incidence trends strongly suggest that a real decrease in gonorrhea incidence occurred. In the other four states, however, the numbers of women screened decreased substantially from 1985 to 1989. Declines in screening positivity rates in these states may reflect real decreases in gonorrhea prevalence or may be the result of screening fewer high-risk women. Since STD programs are likely to reduce screening at clinics with the lowest yield and maintain screening among high-risk groups, these trends probably reflect true decreases in gonorrhea incidence. Geographic clustering of both gonorrhea and syphilis cases among "core" census tracts in urban areas has been demonstrated previously.'4.16'17 Differential
American Journal of Public Health 1265
Geihnan and RXs
toms.Y Crack use and related factors such as unemployment and poverty may contribute to delays in seeking health care among persons with syphilis. From 1986 to 1989, gonorrhea and syphilis trends have diverged for Blacks, among whom syphilis has increased dramatically since 1986, but not for Whites or Hispanics. An understanding of why syphilis but not gonorrhea incidence has increased in this population will better define transmission dynamics of these two diseases and, therefore, contribute to more successful control strategies. [l
Acknowledgents
LJ p(C) .Gonrha
SyphiIs (E)
RQUA4.-4cormiodsIo*dtiIbuUwiof go'owhsmini.
I bhimgpoww.
The authors wish to thank Annette Ladan for computer programmig assistance, Laurie Kamimoto for assistance with the analysis of census tract data, and Dr. Richard B. Rothenberg for his critical review of the manuscript. This paperwas presented at the 118th Annual Meeting of the American Public Health Association, New York, NY, September/ October 1990.
References changes in disease transmission for core and noncore groups might mask trends in the smaller core group (Figure 4). For example, the exchange of sex for money or drugs in a core group might lead to increases in both gonorrhea and syphilis incidence. Screening plus condom use or other behavior change, however, might decrease gonorrhea incidence in the much larger noncore group and mask the core group increase. Because the distribution of syphilis is largely confined to a core group, overall syphilis trends would be those of the core group. If transmission of both infections increased in the core group while decreasing in the general population (noncore group), an overall decrease in gonorrhea incidence and increase in syphilis incidence would occur. Neither the analysis of race-specific data in several urban areas with an overall divergence, nor the census tract analysis of another city demonstrated a group in which the incidence of both diseases increased. Race and geography are almost certainly not direct risk factors for STD; presumably they are surrogate markers for behavioral factors, which if better defined and measured would allow us to more clearly identify the core group. Race and geography alone may be inadequate to define a core group in which the incidence of both gonorrhea and syphilis increased. It seems likely, however, that transmission of Neissenagonorphoeae has not 1266 American Joumal of Public Health
been affected to the same extent by whatever factors have increased the spread of syphilis. Several factors might account for differences in the epidemiologic patterns of gonorrhea and syphilis in the United States. First, gonorrhea and syphilis may have different core groups. Although studies suggest that the core group involved in the recent syphilis increase is the same as the crack-using population, less evidence exists that these two groups overlap with the gonorrhea core group.18 Second, gonorrhea and syphilis may have the same core group, but the factors that have increased the spread of syphilis may not affect the spread of gonorrhea. Oral sex has been reported to be the most frequent type ofsexual activity involved in the exchange of sex for crack19 (S. K Koester, Ph.D., November 1990, written communication), and oral sex might be more effective in spreading syphilis than gonorrhea. Transmission of pharyngeal gonococcal infection to sex partners is thought to be inefficient and relatively rare2 and, therefore, would be unlikely to sustain gonorrhea spread. Third, differences in health care seeking behavior among those with gonorrhea and syphilis might also contnbute to the divergence. Males with gonococcal urethritis tend to seek treatment shortly after the onset of symptoms.21 Prompt treatment translates into a short infectious period and interrupted transmission. In contrast, a large proportion of persons with infectious syphilis do not seek medical attention despite signs and symp-
1. Centers for Disease Control. Declining rates of rectal and pharyngeal gonorrhea among males-New York City. MMWR. 1984;33:295-297. 2. Handsfield HH. Decreasing incidence of gonorrhea in homosexually active menminimal effect on risk of AIDS. West J Med. 1985;143:469-470. 3. Judson FN. Fear of AIDS and gonorrhea rates in homosexual men. Lancet. 1983;2:159-160. 4. Rolfs RT, Nakashima AK. Epidemiology of primary and secondary syphilis in the United States, 1981-89. JAMA. 1990; 264:1432-1437. 5. Rolfs RT, Goldberg M, Sharrar RG. Risk factors for syphilis: cocaine use and prostitution.AmJPubic Health. 1990;80:853857. 6. AndrusJK, FlemingDW, HargerDR, et al. Partner notification: can it control epidemic syphilis? Ann Intern Med. 1990;112:539543. 7. Centers for Disease Control. Relationship of syphilis to drug use and prostitutionConnecticut and Philadelphia, Pennsylvania. MMWR. 1988;37:755-758. 8. Centers for Disease Control. Congenital syphilis-New York City, 1986-1988. MMWR. 1989;48:825-829. 9. Hook EW, Brady WE, Reichart CA, Upchurch DM, Sherman LA, Wasserheit JN. Determinants of emergence of antibioticresistant Neiena gonoffoeae. J Infect Dis. 1989;159:900-907. 10. Handsfield HH, Rice RJ, Roberts MC, Holmes KK. Localized outbreak of penicillinase-producing Neisseria gonorrhoeae: paradigm for introduction and spread of gonorrhea in a community. JAMA4. 1989;261:2357-2361. 11. Schwarcz, SK, Bolan GA, Fullilove MT, McCright J, Kohn R. Crack cocaine as a risk factor for gonorrhea among black teenagers. Presented at the 117th Annual Meet-
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DWng Gononic and Syphs Treds
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15.
Rochester, N.Y, Standard Metrpofitan Statisical Area. (PHC80-2-306) Washington, DC: US Dept of Commerce; 1983:411. 16. Potterat JJ, Rothenberg RB, Woodhouse DE, Muth JB, Pratts CI, Fogle JS. Gonorrhea as a social disease. Sex Transm Dis. 1985;12:25-32. 17. RothenbergR. Thegeographyofsyphilis: a demonstration of epidemiologic diversity. In: Morisset R, Kurstak E, eds.Advances in Sexualty Transmited Diseases. Utrecht, The Netherlands: VNU Science Press; 1986:125-133. 18. Maix R, Aral SO, Rolfs RT, Sterk CE, Kahn JG. Crack, sex, and STD. Sex Transm Dis. 1991;18:92-101.
ing of the American Public Health Association, Chicago, October 22-26, 1989. US Bureau of the Census. United States Population Estimates by Age, Sex and Race: 1980-1988. Washington, DC: US Dept of Commerce 1990;2:55-0. Series P-25, No. 1045. US Bureau of the Census. United States Population Estimates by Age, Se, and Race: 1989. Washington, DC: US Dept of Conmerce 1990,3:12-15. Series P-25, No. 1057. Rothenberg RB. The geography of gonorrhea: empirical demonstration of core group transmission. Am J Epidemiol. 1983;117:688-694. US Bureau of the Census. 1980 Cenisw of Population and Housing census tracts,
19. Business Research Publications. Sex for crack: how the new prostitution affects drug abuse treatment. Substance Abuse Rep. 1988;19:1-3. 20. HookEW, HandsfieldHH. Gonococcalimfections in the adult. In: Holmes KK, Mardh PA, Sparling PF, Wiesner PJ, eds. Sexually Transmitted Diseases. New York, NY: McGraw-Hill; 1990:154. 21. Jacobs NF, Kraus SJ. Gonococcal and nongonococcal urethritis in men: clinical and laboratory differentiation. Ann Intem Med. 1975;82:7-12. 22. Brown WJ, Donohue JF, Axnick NW, Blount JH, Ewen NH, Jones OG. Syphi and Other Venereal Diseases. Cambridge, Mass: Harvard University Press; 1970:41.
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Kenneth A. Gershman, MD, MPH, and Robert T. Rolfs, MD
Introduction
sus tract for the years 1986 to 1989 in a city experiencing a large increase in syphilis.
Declines in numbers of reported cases of gonorrhea and syphilis in the first half ofthe 1980s suggested that Americans had changed their sexual behavior in response to the AIDS epidemic.3 Since 1986, however, syphilis incidence has increased4 while gonorrhea incidence has continued to decline. The recent spread of syphilis has been associated with drug use, especially cocaine.' Drug use has also been associated with the spread of gonorrhea, but this association has been less extensively
studied.1' Since syphilis and gonorrhea are transmitted in the same way, an increase in gonorrhea incidence, rather than a decrease, might be expected during the time when syphilis incidence increased. The decrease in gonorrhea incidence,
although probably real, could be the result of decreased surveillance and case detection activities. Anecdotally, reductions have occurred in sexually transmitted disease (STD) clinic visits in some cities and in gonorrhea screening programs in many states. Such decreases in gonorrhea case detection activities could result in artifactual declines in gonorrhea incidence. Altematively, an overall gonorrhea decrease might mask an increase in the same core group in which syphilis has increased. To better understand if the divergence in national trends of gonorrhea and syphilis is real and whether this divergence masks a contemporaneous increase in both diseases in a subgroup of the population, we analyzed several types of data. These included (1) reported cases of gonorrhea and primary and secondary (PS) syphilis for the years 1981 to 1989, (2) gonorrhea screening results from six states for the years 1985 to 1989, and (3) reported cases of gonorrhea and PS syphilis by cen-
Methods We used summary data from 1981 to 1989 on cases of gonorrhea and PS syphilis reported to state health departments and sent annually to the Centers for Disease Control (CDC). Annual reports included summary data by gender, racial or ethnic group, age group, and source of report (public, private, or military) for each state and six large cities (Baltimore, Chicago, Los Angeles, New York City, Philadelphia, and San Francisco). Cases reported from public and private sources were combined; military cases were not included in these analyses. Racial or ethnic group was categorized as Black (not of Hispanic origin), White (not of Hispanic origin), Hispanic, Asian or Pacific Islander, or American Indian or Alaska Native. Incidence rates for the United States were calculated using US Bureau of the Census population estimates for 19811989.12,13 Estimates of the White and Black Hispanic populations were subtracted from estimates of Whites and Blacks to calculate estimates for Whites not of Hispanic origin and Blacks not of
Hispanic origin. Five states and two cities in 1983 and two states and three cities in 1984 did not The authors are with the Division of STD/HIV Prevention, Center for Prevention Services, Centers for Disease Control. Requests for reprints should be sent to Information Services, Center for Publication Services (E06), Centers for Disease Control (E02), Atlanta, GA 30333. This paper was submitted to the journal January 2, 1991, and accepted with revisions April 23, 1991.
American Journal of Public Health 1263
Gershman and Rolfs
500
' 25
450
400
Gonorrhea 20
-
g350§ ~ ~ 300 *
250
*
200
o
150
Q
:
.. -
'
Syphilis,
I15
a.
:10
0
...
.
a.
500
1981
1982
1983
-
-----
1984 1985 'Vbar
-----
1986
1987
1988
T. - -
1989
FIGURE 1-Trends in Incidence of gonorrhea and primary and secondary syphilis, United Stats, 1981-1989.
WMb Wht
ftolib
Rm 200
180.
Black
lispanlo Hlspenn
Gonorrhea
(Gonorie
Elack hill
8yp
Goneonm
%-philbe
Ri
36
""
2ZS00
01
,5
160 140
.140
120
2,000
: 100
4
120
1,500.
100
3
60
1,000-
1--1985 -
1981
of PS syphilis, however, increased 59% from a rate of 11.6 to 18.4 cases per 100 000 persons. Among Whites, the incidence of gonorrhea decreased 48% from 1986 to 1989 (107.1 to 56.4 cases per 100 000), while that of syphilis decreased 11% (2.8 to 2.5 cases per 100 000) (Figure 2). Among Hispanics, the incidence of gonorrhea decreased 50% during this time (283.5 to 140.9 cases per 100 000) and syphilis incidence decreased 27% (26.0 to 19.1 cases per 100 000). However, among Blacks, a marked divergence in trends occurred: gonorrhea incidence decreased to a lesser extent than among the other groups, 13% (2197.1 to 1912.4 cases per 100 000), while syphilis incidence increased 100% (61.0 to 121.8 cases per 100 000). Sex-specific trends within each racial or ethnic group were generally similar to overall racial or ethnic trends. While syphilis incidence increased among White females from 1986 to 1989 (from 1.4 to 1.9 cases per 100 000 persons), their rates remained extremely low. Syphilis incidence among Hispanic females did not change appreciably during this time period. Only 18 states reflect the divergence in national trends of gonorrhea and syph-
-
19119
19B16 1986 99 Ya
YWr
|Gonorrhe
Syphilij , ~~~~........
FIGURE2-Trends in race-specffic incidence of gonorrhea and primaryand secondary syphilis, United States, 1981-1989. Rates = No. of cases per 100 000 persons.
submit annual reports of gonorrhea cases to CDC. Estimates for these areas were
projected by averaging the sex and race distributions of cases in each area from the years before and after the missing year(s). Similar methods for interpolating missing syphilis data have been described previously.4
The proportion of gonorrhea cases reported with race not specified varied from year to year (17-19% for the years 1981 and 1986-1989 and 22-26% for 1982 through 1985). No cases were reported with sex not specified. Cases with race not specified were prorated to the race and sex distribution of known cases. To assess the validity of prorating, we tested varying as-
1264 American Journal of Public Health
The incidence of both gonorrhea and syphilis decreased in the United States from 1981 to 1985 (Figure 1). From 1986 to 1989, the incidence of gonorrhea de-
40
2D 0-
National Trends
creased 22% from a rate of 370.8 to 289.1 cases per 100 000 persons. The incidence
500
1
Reml
'60
2
60
40
where these data were available. The numbers of gonorrhea cultures performed and the numbers positive by type of facility were reported. STD clinic results were excluded and overall annual positivity rates (percent positive) were calculated for all other sources combined. Cases of gonorrhea and PS syphilis by census tract for Rochester, NY, for the years 1986 to 1989 were obtained from the New York State STD program. Rochester was selected because gonorrhea and syphilis trends diverged there and census tract data were available. Census tracts were ranked by the number of PS syphilis cases reported in 1989. Core syphilis census tracts were defined as those with the highest ranking that cumulatively accounted for approximately 50% of cases.14 Incidence rates were calculated using 1980 US Bureau of the Census population estimates by census tract.15
sumptions, including the extreme assumptions that unspecified cases were all Black or all White. Gonorrhea trends were not sensitive to these extremes. Similar methods for prorating cases of syphilis with race not specified have been previously described.4 For the analysis of state trends, an increase in syphilis incidence was defined as a greater than 33% rate increase from 1986 to 1989 with both 1988 and 1989 rates higher than the 1986 rate. Only states with at lease 25 PS syphilis cases in 1989 were included. Results of gonorrhea screening in women for the years 1985 to 1989 were obtained from six state STD programs
October 1991, Vol. 81, No. 10
Diverng Gonorrhea and Sypnils Trends ilis from 1986 to 1989. Although gonorrhea incidence rates decreased or remained unchanged in 45 states, syphilis incidence rates increased in only 22 states. In 18 of these 22 states, gonorrhea incidence decreased or remained unchanged.
Gonon*ea Screening To evaluate whether changes in surveillance methods or case detection may account for the decrease in gonorrhea incidence, we compared trends in screening positivity rates in women and reported cases of gonorrhea in six states in which syphilis has increased (Figure 3). Screening and reported case trends were quite similar between 1985 and 1989 in these states. In two states (Oregon, Washington), screening positivity rates and reported cases both declined throughout the period 1985 to 1989; in three states (Alabama, Delaware, Louisiana), both trends initially declined then increased in parallel; and in one state (Michigan), both trends remained relatively unchanged. For two of the six states, the numbers of women screened decreased by 5% or less from 1986 to 1989. In the other four states, the numbers of women screened declined by 15% to 51%. Core hypothesis. To evaluate whether the overall divergence in trends of gonorrhea and syphilis masked a contemporaneous increase in both diseases in a core group, we first analyzed race-specific case totals for 1986-1989 from several metropolitan areas where these data were available. In four metropolitan areas (Seattle, Memphis, Charlotte, Los Angeles) with an overall divergence in trends, stratification by race did not identify a group in which the incidence ofboth gonorrhea and syphilis increased. To further evaluate the core concept, we analyzed census tract data from one metropolitan area. In Rochester, NY, gonorrhea incidence remained relatively constant from 1986 to 1989 (12% increase), while syphilis incidence increased 11-fold. We compared gonorrhea and syphilis incidence rates in the census tracts with approximately 50%o of the city's reported syphilis cases (the core area) in 1989 (Table 1). Core incidence rates for syphilis and gonorrhea were 7.0 and 3.5 times higher, respectively, than noncore rates in 1989. Even in the core syphilis census tracts, however, trends for the two diseases diverged as syphilis incidence rates increased 24-fold, while gonorrhea incidence rates showed little change. A similar divergence, but of lesser magnitude, also occurred in the noncore census
October 1991, Vol. 81, No. 10
ca eooo
% PosiNg
;
Ogon n
1.6
Cals 12o,o
Washington
% Positi 2.5
Ca
1,*0
10,000.
0.0
0
C_
MichlgM
% Pochg h ,40
e
40,000
3.0 2.0
20,000.
0°
4000 4~000. 2,000
t
0
Louiabna
Cassa 25,000
1.0
2000
'1.0
0.5 0.0
0
--t0.0
% Positiv
;-40
20,000. 15,000
1965
1967
0--0.0
19im
0.5
Aiabma
Cs 25,000
% P°iv
.3.S
20,000-
&.0
15,000
, 2.0 1.S
2.0
10,000 1.0
f ~~~~2.5
.~~~~~~~~.
81000 0.5
% Positi
],
10,000
5$000 0'
'1.0 1965
--- -r--~-;°-°
Yew
1967
1969
Yea | case
Screening
1.0 ' 0.5
4000^ 0
1965
O
1967 Yew
0.0 199
|
FIGURE 3-TrendsIn reported cas of gonorrhea and gonorhea screening poslvMty rates (% postive cultures) In women, selected states, 1985-1989.
tracts. Of note, gonorrhea incidence rates for Rochester in 1987 were substantially lower than rates for all other years from 1984 to 1989.
Discussion From 1986 to 1989, national trends of gonorrhea and syphilis incidence diverged: gonorrhea declined while syphilis increased markedly. Tlis divergence occurred among Blacks, but not among Whites or Hispanics. Results from gonorrhea screening among females in a number of states support the overall decrease in gonorrhea incidence as real, rather than the result of changes in surveillance. We were unable to demonstrate a core group in which the incidence of both gonorrhea and syphilis increased. Gonorrhea screening positivity rates declined from 1985 to 1989 in five ofthe six states we assessed, as did gonorrhea incidence. In the sixth state, both gonorrhea screening and incidence trends changed
little. Screening positivity rates should be a reliable indicator of gonorrhea prevalence if the population screened remains relatively constant over time. For the two states in which the numbers of women screened changed little, parallel decreases in both screening and incidence trends strongly suggest that a real decrease in gonorrhea incidence occurred. In the other four states, however, the numbers of women screened decreased substantially from 1985 to 1989. Declines in screening positivity rates in these states may reflect real decreases in gonorrhea prevalence or may be the result of screening fewer high-risk women. Since STD programs are likely to reduce screening at clinics with the lowest yield and maintain screening among high-risk groups, these trends probably reflect true decreases in gonorrhea incidence. Geographic clustering of both gonorrhea and syphilis cases among "core" census tracts in urban areas has been demonstrated previously.'4.16'17 Differential
American Journal of Public Health 1265
Geihnan and RXs
toms.Y Crack use and related factors such as unemployment and poverty may contribute to delays in seeking health care among persons with syphilis. From 1986 to 1989, gonorrhea and syphilis trends have diverged for Blacks, among whom syphilis has increased dramatically since 1986, but not for Whites or Hispanics. An understanding of why syphilis but not gonorrhea incidence has increased in this population will better define transmission dynamics of these two diseases and, therefore, contribute to more successful control strategies. [l
Acknowledgents
LJ p(C) .Gonrha
SyphiIs (E)
RQUA4.-4cormiodsIo*dtiIbuUwiof go'owhsmini.
I bhimgpoww.
The authors wish to thank Annette Ladan for computer programmig assistance, Laurie Kamimoto for assistance with the analysis of census tract data, and Dr. Richard B. Rothenberg for his critical review of the manuscript. This paperwas presented at the 118th Annual Meeting of the American Public Health Association, New York, NY, September/ October 1990.
References changes in disease transmission for core and noncore groups might mask trends in the smaller core group (Figure 4). For example, the exchange of sex for money or drugs in a core group might lead to increases in both gonorrhea and syphilis incidence. Screening plus condom use or other behavior change, however, might decrease gonorrhea incidence in the much larger noncore group and mask the core group increase. Because the distribution of syphilis is largely confined to a core group, overall syphilis trends would be those of the core group. If transmission of both infections increased in the core group while decreasing in the general population (noncore group), an overall decrease in gonorrhea incidence and increase in syphilis incidence would occur. Neither the analysis of race-specific data in several urban areas with an overall divergence, nor the census tract analysis of another city demonstrated a group in which the incidence of both diseases increased. Race and geography are almost certainly not direct risk factors for STD; presumably they are surrogate markers for behavioral factors, which if better defined and measured would allow us to more clearly identify the core group. Race and geography alone may be inadequate to define a core group in which the incidence of both gonorrhea and syphilis increased. It seems likely, however, that transmission of Neissenagonorphoeae has not 1266 American Joumal of Public Health
been affected to the same extent by whatever factors have increased the spread of syphilis. Several factors might account for differences in the epidemiologic patterns of gonorrhea and syphilis in the United States. First, gonorrhea and syphilis may have different core groups. Although studies suggest that the core group involved in the recent syphilis increase is the same as the crack-using population, less evidence exists that these two groups overlap with the gonorrhea core group.18 Second, gonorrhea and syphilis may have the same core group, but the factors that have increased the spread of syphilis may not affect the spread of gonorrhea. Oral sex has been reported to be the most frequent type ofsexual activity involved in the exchange of sex for crack19 (S. K Koester, Ph.D., November 1990, written communication), and oral sex might be more effective in spreading syphilis than gonorrhea. Transmission of pharyngeal gonococcal infection to sex partners is thought to be inefficient and relatively rare2 and, therefore, would be unlikely to sustain gonorrhea spread. Third, differences in health care seeking behavior among those with gonorrhea and syphilis might also contnbute to the divergence. Males with gonococcal urethritis tend to seek treatment shortly after the onset of symptoms.21 Prompt treatment translates into a short infectious period and interrupted transmission. In contrast, a large proportion of persons with infectious syphilis do not seek medical attention despite signs and symp-
1. Centers for Disease Control. Declining rates of rectal and pharyngeal gonorrhea among males-New York City. MMWR. 1984;33:295-297. 2. Handsfield HH. Decreasing incidence of gonorrhea in homosexually active menminimal effect on risk of AIDS. West J Med. 1985;143:469-470. 3. Judson FN. Fear of AIDS and gonorrhea rates in homosexual men. Lancet. 1983;2:159-160. 4. Rolfs RT, Nakashima AK. Epidemiology of primary and secondary syphilis in the United States, 1981-89. JAMA. 1990; 264:1432-1437. 5. Rolfs RT, Goldberg M, Sharrar RG. Risk factors for syphilis: cocaine use and prostitution.AmJPubic Health. 1990;80:853857. 6. AndrusJK, FlemingDW, HargerDR, et al. Partner notification: can it control epidemic syphilis? Ann Intern Med. 1990;112:539543. 7. Centers for Disease Control. Relationship of syphilis to drug use and prostitutionConnecticut and Philadelphia, Pennsylvania. MMWR. 1988;37:755-758. 8. Centers for Disease Control. Congenital syphilis-New York City, 1986-1988. MMWR. 1989;48:825-829. 9. Hook EW, Brady WE, Reichart CA, Upchurch DM, Sherman LA, Wasserheit JN. Determinants of emergence of antibioticresistant Neiena gonoffoeae. J Infect Dis. 1989;159:900-907. 10. Handsfield HH, Rice RJ, Roberts MC, Holmes KK. Localized outbreak of penicillinase-producing Neisseria gonorrhoeae: paradigm for introduction and spread of gonorrhea in a community. JAMA4. 1989;261:2357-2361. 11. Schwarcz, SK, Bolan GA, Fullilove MT, McCright J, Kohn R. Crack cocaine as a risk factor for gonorrhea among black teenagers. Presented at the 117th Annual Meet-
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DWng Gononic and Syphs Treds
12.
13.
14.
15.
Rochester, N.Y, Standard Metrpofitan Statisical Area. (PHC80-2-306) Washington, DC: US Dept of Commerce; 1983:411. 16. Potterat JJ, Rothenberg RB, Woodhouse DE, Muth JB, Pratts CI, Fogle JS. Gonorrhea as a social disease. Sex Transm Dis. 1985;12:25-32. 17. RothenbergR. Thegeographyofsyphilis: a demonstration of epidemiologic diversity. In: Morisset R, Kurstak E, eds.Advances in Sexualty Transmited Diseases. Utrecht, The Netherlands: VNU Science Press; 1986:125-133. 18. Maix R, Aral SO, Rolfs RT, Sterk CE, Kahn JG. Crack, sex, and STD. Sex Transm Dis. 1991;18:92-101.
ing of the American Public Health Association, Chicago, October 22-26, 1989. US Bureau of the Census. United States Population Estimates by Age, Sex and Race: 1980-1988. Washington, DC: US Dept of Commerce 1990;2:55-0. Series P-25, No. 1045. US Bureau of the Census. United States Population Estimates by Age, Se, and Race: 1989. Washington, DC: US Dept of Conmerce 1990,3:12-15. Series P-25, No. 1057. Rothenberg RB. The geography of gonorrhea: empirical demonstration of core group transmission. Am J Epidemiol. 1983;117:688-694. US Bureau of the Census. 1980 Cenisw of Population and Housing census tracts,
19. Business Research Publications. Sex for crack: how the new prostitution affects drug abuse treatment. Substance Abuse Rep. 1988;19:1-3. 20. HookEW, HandsfieldHH. Gonococcalimfections in the adult. In: Holmes KK, Mardh PA, Sparling PF, Wiesner PJ, eds. Sexually Transmitted Diseases. New York, NY: McGraw-Hill; 1990:154. 21. Jacobs NF, Kraus SJ. Gonococcal and nongonococcal urethritis in men: clinical and laboratory differentiation. Ann Intem Med. 1975;82:7-12. 22. Brown WJ, Donohue JF, Axnick NW, Blount JH, Ewen NH, Jones OG. Syphi and Other Venereal Diseases. Cambridge, Mass: Harvard University Press; 1970:41.
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