Gonorrhea Decline Reverses:

Increasing for the First Time in 25 Years

David Brown / Washington Post 6dec00

The incidence of gonorrhea, a sexually transmitted disease that can lead to infertility in women and increases both sexes' risk of acquiring the AIDS virus, is rising in the United States for the first time in 25 years.

The increase in gonorrhea, first noted two years ago among high-risk homosexual men, appears to be extending into the general population, according to data released yesterday by the federal Centers for Disease Control and Prevention (CDC). Nevertheless, the disease remains highly concentrated by age, region and race.

The gonorrhea trend, described yesterday at a conference in Milwaukee, is part of new report that paints the most complete picture ever of venereal disease in the United States.

Among other findings are that syphilis cases continue to decline as they have for 10 years; chlamydia is more common than both gonorrhea and syphilis combined; and that infection with human papilloma virus (HPV) is the most common sexually transmitted disease overall.

The gonorrhea rate in the United States fell by nearly 75 percent between 1975 and 1996. After briefly staying level, it rose 9 percent from 1997 to 1999. Some, but not all, of the increase is attributable to more sensitive tests and more widespread testing, said Ronald O. Valdiserri, a CDC epidemiologist.

Health officials are uncertain why the gonorrhea rate is increasing. Part of the rise is clearly due to the jump among young gay men, which may be occurring because the advent of better treatment for AIDS is making them less likely to practice safer sex.

"There's the perception that high-risk sexual behavior no longer carries the extreme consequences it once did because of the advances in HIV treatment," said Valdiserri.

Overall, he called the trend "alarming" because the disease can have long-term health consequences if not properly treated.

Nationally, the rate of gonorrhea infection is 133 cases per 100,000 people. For blacks, it is 849 cases per 100,000; for Hispanics, 75 per 100,000; and for whites, 28 per 100,000. The rates are especially high in cities of the mid-Atlantic and the South; Baltimore leads the country with 949 cases per 100,000 people. Richmond was second with 941, and Washington sixth with 676.

The group with the highest rate was black teenagers, about 3 percent of whom contracted gonorrhea last year, according to the report.

"The data . . . suggest that while there are certainly differences in sexual risk behavior and other factors by race and ethnicity, those are tremendously overshadowed by differences in access to care," said Judith Wasserheit, another CDC epidemiologist.

The syphilis rate, at 2.5 cases per 100,000 people, is just a fraction of the gonorrhea rate, and is even more geographically cloistered. Of the country's 3,115 counties, 79 percent reported not a single case of syphilis last year, according to the report.

Indianapolis led American cities in 1999 with 50 cases per 100,000, a more than five-fold increase from 1997. Baltimore, in third place with 38 cases per 100,000, showed an equally dramatic trend in the opposite direction. In 1997, Baltimore had 102 syphilis cases per 100,000, a rate that was among the highest in the industrialized world. Washington is 14th. Unlike gonorrhea, the syphilis rate among blacks nationally fell between 1997 and 1999.

In October 1999, the CDC launched a national effort to "eliminate" syphilis as a public health problem. (In epidemiological parlance, "elimination" means scattered cases of the disease continue to be found, while "eradication" means that no cases of the disease exist.) The national syphilis rate has fallen nearly 90 percent in the last decade.

Both gonorrhea and syphilis affect the transmission of human immunodeficiency virus (HIV) infection. People with HIV and either of the other diseases are more likely to infect their sexual partners. Similarly, people with gonorrhea or syphilis are more likely to become infected by a sexual partner with HIV.

The rate of chlamydia last year was 254 cases per 100,000, an incidence that Wasserheit said "grossly underestimates the true burden of [the disease] in this country." Experts believe there are about 3 million cases each year, most of them in adolescents and young adults.

In one study, family planning clinics in 12 states found chlamydial infection in more than 7 percent of women aged 15 to 24 years. Mississippi had the highest prevalence, at 15 percent. About 40 percent of women infected with the microbe go on to develop pelvic inflammatory disease, which greatly increases the risk they will become infertile.

Although chlamydia--like gonorrhea and syphilis--is easily cured with antibiotics, it causes no symptoms in about half the men it infects. Consequently, it is hard to find and treat in the population without widespread screening.

"If we care about the health of our adolescents, we clearly have to do a better job about chlamydia prevention," Wasserheit said.

The most prevalent sexually transmitted disease, according to the CDC report, is HPV, of which about 30 types can infect the genitals. Usually, the immune system controls the infection, but sometimes it can become chronic and cause diseases ranging from genital warts to cancer of the cervix, penis or anus.

One type, HPV-16, accounts for about 50 percent of cervical cancers.

CDC epidemiologists looked for antibodies to HPV-16 in blood samples collected from 1991 to 1994 as part of the federal government's National Health and Nutrition Examination Survey.

The study found that 18 percent of women and 8 percent of men had antibodies, which show they'd been infected by the virus at some point in their lives. The rate was 19 percent among blacks, 13 percent among whites, and 9 percent among Mexican Americans.

Transmission of HPV can be reduced by use of condoms. It can't be entirely prevented, however, because the virus can colonize the external parts of the genitals not covered by a condom.