Another critical component of the National Gonorrhea Control Program was partner notification, which was emphasized to find additional persons with asymptomatic gonorrhea. Health department staff focused on finding female partners of symptomatic men because infected men were thought to almost always seek care,7,8 and male partners of female patients had often already been treated.14 In 1973, the federal partner notification program interviewed 183,610 patients, which led to examination of 134,890 partners of whom 52,703 (39.1%) were brought to treatment for an infection, and a similar number of partners were treated for possible incubating infection (Table 3). The partner notification program peaked in 1980 when 390,334 patients were interviewed (38.9% of the 1,004,029 total reported cases), 230,059 partners were examined and 85,338 (37.1%) infected partners were brought to treatment. These infected partners represented 8.5% of all cases diagnosed and reported to CDC that year. The partner notification numbers were quite different for men and women, partly due to who was pursued in investigations. For example, at the Denver STD clinic, 19.4% of all infections were derived from contact investigations, 5.7% of male cases, and 47.1% of female cases.15
Partner notification efforts changed over time, largely as a result of increased understanding of the asymptomatic nature of gonorrhea. In 1974, Handsfield reported that previous estimates of the proportion of men with gonorrhea who were symptomatic were biased because the studies were based on men attending STD clinics, whereas screening in other settings identified many infected men who were (and remained) asymptomatic.16 Similarly, partner notification studies based in STD clinics were biased because the studies enrolled symptomatic men, whereas women who were enrolled had originally been brought to the clinic because of their partners. Success in finding infected partners was not so much related to gender as it was to whether the interviewed patient was discovered as a result of screening (partners often remain infected) or as a result of partner notification (partners already treated).16 Consistent with those findings, in 1976, a study of 100 women with gonococcal PID found 63 (39%) of 161 male partners had untreated gonorrhea, of whom 14 (22%) were asymptomatic.17 These data led to a revised recommendation that included partner notification for male partners of women with PID.17 A later study compared partner investigations beginning with women with PID to investigations beginning with women who had positive screening tests and found no major differences in the number of male contacts infected (22.9% vs 25.4%) or infected partners who were asymptomatic (59% vs 49%).18 The high yield of asymptomatic male partners suggested that partner notification efforts should include partners of women with PID or positive screening tests for gonorrhea.19
It is difficult to tell how many patients might have notified their own partners without the federally funded program, and what the net impact of partner notification was. Two studies showed that giving patients a card to give to their partners worked just as well as sending out a disease investigator,15,20 at a tiny fraction of the cost (US $0.65 vs US $42 per infection found).15 However, most studies have found that more partners were notified when public health workers took responsibility for notifying partners.21 For example, 1 study found partners were more likely to be brought in for testing if health department personnel went out looking for them (80/221, 36%) than if patients were counselled on how to bring their partners in (57/457, 12%).22 Between 1975 and 2004, gonorrhea partner notification efforts reported in the literature were bringing 1 infected partner in for treatment for every 4 patients interviewed.21 By 1999, the emergence or recognition of other sexually transmitted infections, including human immunodeficiency virus (HIV) and chlamydia, made systematically offering health department–based partner services beyond the reach of most large programs, and health departments were only involved with partner notification for about 17% of gonorrhea cases.23
CONTROL PROGRAM IMPACT
The impact of the National Gonorrhea Control Program on disease incidence is difficult to discern from changes in reported cases. Although reported cases reflect trends in gonorrhea incidence, that reflection is distorted by changes in testing, reporting, and test technology that are incompletely documented or understood. Infections are usually asymptomatic, especially among women, so detection often depends on screening.2 In 2008, estimates of the incidence of gonorrhea suggested that only about 40% of infections were detected and reported.25 At the beginning of the control program (1972–1975), increased screening of women led to increases in the number of reported cases among women. Three other changes were noted during this period: (1) improved diagnostics for men meant fewer cases of nongonococcal urethritis would be reported as gonorrhea, (2) the case definition was changed to stop including persons whose only evidence of infection was that they were treated because their partners had gonorrhea, and (3) reporting by private physicians increased (it was estimated to be only 11% in 1968).12 A study in 1974 used 3 methods to estimate that reporting by private physicians was 2.7%–24% complete.26 Later studies have documented the incompleteness of gonorrhea reporting.27 One study in 2001 found electronic laboratory reporting was much more complete (95%) than traditional reporting (57%),28 suggesting that reporting is likely to be better now than in the past. Gonorrhea culture has largely been replaced by nucleic acid amplification tests (NAATs) which are almost as specific (99.8% in one report)29 and more sensitive (which allows testing of urine from men or self-collected vaginal swabs).30 Further, gonorrhea and chlamydia NAATs are often combined on the same test strip and run on the same specimen so the number of women tested for gonorrhea has likely increased as testing for chlamydia increased. The number of chlamydia tests done every year is not known, however, according to the Healthcare Effectiveness Data and Information Set measure, testing of sexually active 21- to 24-year-old women attending commercial HMOs testing increased from 16.0% in 1999 to 51.6% in 2014.31 Other groups monitored by the National Committee for Quality Assurance had similar increases in chlamydia (and presumably gonorrhea) testing.31
Gonorrhea reports have been collected at CDC since 1941. The variables collected and formatting have changed over time; however, anatomic site of infection and sex-of-sex-partner have not been routinely collected. Reported cases of gonorrhea began increasing in about 1963 when there were 278,289 (Fig. 1). In 1963, most cases were symptomatic men diagnosed by clinical examination or gram stain; the male-female rate ratio was 3.1. The male-female rate ratio decreased as women were screened in the screening program, it stabilized at about 1.6 between 1973 and 1982, then decreased gradually to 1.0 in 1997. Since the program began, 15- to 24-year-olds have accounted for 66% to 76% of cases among women and 45% to 61% of cases among men. Gonorrhea has also consistently been more commonly reported among black persons compared to white persons. Although race is missing from many cases reported to CDC, the black-white rate ratio nationally was 10.3 in 1981, increased to 40.2 in 1993 (associated with an increase in use of crack cocaine),32 and then decreased to 10.3 in 2014. In 1975, the rates of reported gonorrhea for 20-24-year-olds were: for men, 14.0% among nonwhites and 1.1% among whites; and for women, 6.6% among nonwhites and 0.8% among whites.33 By 2014, the overall reported rate of gonorrhea in the United States had fallen to 0.11%, 0.24 times what it had been in 1975. Annual rates among 20- to 24-year-olds in 2014 were: for men, 1.7% among blacks and 0.16% among whites; and for women, 1.8% among blacks and 0.19% among whites (race was missing for 18.6%).1
Population-Based Surveys and Sentinel Surveillance
In 2001 to 2002, the National Longitudinal Study of Adolescent Health found the prevalence of gonorrhea among 18- to 26-year-olds was 0.43% (95% confidence interval, 0.29%–0.63%). It was higher in black men (2.4%) than white men (0.07%), and higher in black women (1.9%) than white women (0.13%).34 In a nationally representative sample of 14- to 25-year-olds in the United States (NHANES), the prevalence of gonorrhea was 0.40% (95% confidence interval, 0.20%–0.72%) in 1999 to 2008.35 Subsequently, the gonorrhea prevalence was too low to permit precise tracking of changes over time in NHANES.35 Sentinel surveillance can provide an alternative to case reports for monitoring changes in the prevalence of gonorrhea. Sentinel surveillance often has the advantage of providing information about the number of persons tested, which allows the calculation of positivity or prevalence among those tested. A study of the prevalence among 16- to 24-year-old men and women entering the National Job Training Program found a 40% to 50% decrease in prevalence between 2004 and 2009, whereas rates of reported gonorrhea in the United States decreased by only 12.7%36 during that period, suggesting that trends in reported infections might be partially due to increases in testing.
Among women with untreated gonococcal cervicitis, 10% to 40% will develop symptomatic PID.37 These are rough estimates because there is no ethical way to observe a group of women with untreated infections to determine the incidence of PID among women with gonorrhea. Among women with PID, sequelae include involuntary infertility in 16% to 18%, ectopic pregnancy in 0.6% to 9%, and chronic pelvic pain in 18% to 29%.3 Pelvic inflammatory disease is difficult to measure precisely because it is usually a clinical diagnosis. Furthermore, asymptomatic PID can damage the tubes of women who never knew they had an infection. Despite the measurement issues, it is clear that there have been very large decreases in symptomatic PID.3 Estimated visits to physicians for PID decreased from 407,000 in 1993 to 88,000 in 2013.1 Hospitalizations for PID decreased by 68%, between 1985 and 2001, which may be partially explained by a shift toward outpatient treatment; however, there was also a (harder to quantify) decrease in PID diagnosed in ambulatory settings.38 Other studies found PID was decreasing at rates of 3.4% to 6.5% per year between 1996 and 2007 using a variety of methods.39–42
Contextual Factors That May Have Influenced Gonorrhea Trends
Trends in demographics and sexual behavior have likely influenced trends in gonorrhea. The sexual revolution of the 1960s to 1970s (the pill, increased numbers of sexual partners) likely played a role in the increase in gonorrhea.43 The baby boom changed the structure of the US population;33 15- to 24-year-olds (the group with highest rates of gonorrhea) were 6.8% of the population in 1960 and 9.5% in 1975.44 The acquired immune deficiency syndrome (AIDS) epidemic (identified in 1981) likely contributed to decreases in gonorrhea, by increasing condom use, decreasing sexual behavior that would lead to exposure to gonorrhea, and reducing the pool of highly sexually active gay men, because many became ill or died from AIDS. Condom use increased among heterosexuals between 1982 and 1995, especially among young blacks who were at highest risk for gonorrhea (from 6% to 33% among 20- to 24-year-olds),45 only to stabilize or decrease since 199646 when the effectiveness of highly active antiretroviral therapy was announced in Vancouver and concern about acquiring HIV decreased.47 These trends in condom use since 1982 mirror trends in gonorrhea (Fig. 1). Decreases in gonorrhea among men who have sex with men48 undoubtedly contributed to the decreases in gonorrhea among men in the 1980s, though the exact amount is difficult to estimate because sex-of-sex-partner information is not available for reported cases, and many other factors influenced changes in the male-female rate ratio.
The prevalence of gonorrhea clearly declined between the 1970s when 1.6% to 4.2% of women had positive screening tests in various settings (Table 2) and the early 2000s when 0.43% of a representative sample of all 18- to 26-year-olds were infected.34 However, the populations tested in these periods were different, so the exact amount of the decrease remains uncertain. As with many other public health campaigns, there were no randomized controlled trials that tested the effects of the different components of the control program. The major factors contributing to the success appear to be the large size of the effort (equal to US $86 million in 2015 dollars per year), extensive screening, and widespread partner notification. Society-level trends also had an impact on infection rates. Increases in gonorrhea were likely fueled by increases in sexual activity and mixing during the sexual revolution of the 1960s and decreases were partly caused by changes in response to the AIDS epidemic in 1982 to 1997.32 The gonorrhea control program began in 1973, the year the average baby boomer was 18, and rates decreased as the baby boomers aged out of the high-risk age for acquiring infection.32 Changes in the number of reported cases have been influenced by changes in testing, sensitivity of tests, and reporting. Still, there is no doubt that the true incidence of gonorrhea is much lower now than it was in the 1970s, and there is no doubt that rates of PID have fallen.38–42
What can we learn from the gonorrhea control program? The gonorrhea control program involved substantial federal funding which covered widespread screening of women for gonorrhea. Screening rates continue to be very high, but most testing is now done by private providers. NAATs for gonorrhea are often combined with tests for chlamydia, therefore most women who are tested for chlamydia are also tested for gonorrhea. Although the numbers of chlamydia tests performed are not nationally available, there were over 1 million positive chlamydia tests among women reported in 2014.1 If the prevalence of chlamydia among females tested was, for example, 6.7% (1 of 15) then 15 million women were tested for chlamydia and gonorrhea, suggesting the testing rate was comparable to the gonorrhea testing rates of the 1970s. However, the gonorrhea control program involved a major health department effort to notify, test, and treat partners. Partner treatment is an important aspect of treating STD because reinfection is common, and reinfection is often attributable to an untreated partner.49 Partner notification is still done by some health departments, but mostly in areas where resources permit because there are few cases of syphilis or HIV. As testing shifted to the private sector, the burden of partner notification has shifted to clinicians who have many other responsibilities. However, new opportunities are also available to facilitate partner treatment, such as cell phones or e-mail for contacting partners, and patient delivered partner therapy to facilitate treatment.49 A recent study in STD clinics found partners could be effectively and confidentially notified via telephone, an approach that cost only US $171 to identify and treat a new infection.50 Further work is needed to expand this simple, effective, and low-cost approach to other settings.
Gonorrhea remains frustratingly common in the United States. When the control program began, funding for gonorrhea control exceeded funding for syphilis, the only other venereal disease that had a prevention program. Now both gonorrhea and syphilis compete for attention with HIV, herpes, human papillomavirus, and chlamydia (the most common reportable infection). The emergence of antimicrobial resistant strains further threatens gonorrhea control efforts. However, some new developments make gonorrhea control easier than ever. Urine-based testing technologies facilitate testing for gonorrhea, and the test for gonorrhea has been combined with the test for chlamydia, so testing for gonorrhea remains high. Screening for gonorrhea is recommended by the US Preventive Services Task Force for sexually active women aged 24 years or younger and in older women who are at increased risk for infection,51 and thus is covered under most insurance plans. Electronic case reporting by laboratories gives health departments the opportunity to count and follow-up on cases that may have previously gone unreported. The internet and cell phones can help providers communicate with infected persons and their partners to assure treatment and retesting. Patient delivered partner treatment is permitted in 39 states,52 and has been shown to reduce reinfection among patients compared to traditional counseling on partner treatment.49 Gonorrhea is not the national priority that it was in the 1970s, but downward trends could resume if treating partners was considered an integral part of treating patients—and it is.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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© Copyright 2016 American Sexually Transmitted Diseases Association
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