Gonorrhea -- Colorado, 1985-1992

The number of reported cases of gonorrhea in Colorado increased 19.9% from 1991 to 1992 after declining steadily during the 1980s. In comparison, in the United States, reported cases of gonorrhea in 1992 continued an overall decreasing trend (1). This report summarizes an analysis of the increase in gonorrhea in Colorado in 1992 and characterizes trends in the occurrence of this disease from 1985 through 1992.

In 1992, 4679 cases of gonorrhea were reported to the Colorado Department of Health (CDH) compared with 3901 cases reported in 1991. During 1992, reported cases increased 22.7% and 17.5% among females and males, respectively (Table 1). Similar increases occurred among blacks, whites, and Hispanics (15.6%, 15.1%, and 15.9%, respectively); however, the number of reported cases with race not specified increased 88% from 1991 to 1992 and constituted 9.7% of all reported cases in 1992. Although the largest proportional increases by age groups occurred among persons aged 35-44 years (80.4%) and greater than or equal to 45 years (87.7%), these age groups accounted for only 11.0% of all reported cases in 1992. Persons in the 15-19-year age group accounted for the largest number of reported cases of gonorrhea during 1992 and the highest age group-specific rate (639 per 100,000).

Reported cases of gonorrhea increased 32.9% in the five- county Denver metropolitan area (1990 population: 1,629,466) but decreased elsewhere in the state (Table 1). Half the cases of gonorrhea in the Denver metropolitan area occurred in 8.4% (34) of the census tracts; these represent neighborhoods considered by sexually transmitted diseases (STDs)/acquired immunodeficiency syndrome (AIDS) field staff to be the focus of gang and drug activity.

When compared with 1991, the number of gonorrhea cases diagnosed among men in the Denver Metro Health Clinic (DMHC, the primary public STD clinic in the Denver metropolitan area) increased 33% in 1992, and the number of visits by males to the clinic increased 2.4%. Concurrently, the number of cases diagnosed among women increased by 1%. Among self-identified heterosexual men, the number of gonorrhea cases diagnosed at DMHC increased 33% and comprised 94% of all cases diagnosed in males, while the number of cases diagnosed among self-identified homosexual men remained low (71 and 74 in 1991 and 1992,

respectively).

Four selected laboratories in the metropolitan Denver area (i.e., HMO, university hospital, nonprofit family planning, and commercial) were contacted to determine whether gonorrhea culture-positivity rates increased. Gonorrhea culture-positivity rates in three of four laboratories contacted increased 23%-33% from 1991 to 1992, while the rate was virtually unchanged in the fourth (i.e., nonprofit family planning).

From 1985 through 1991, reported cases of gonorrhea among whites and Hispanics in Colorado decreased; in comparison, reported cases among blacks increased since 1988 (Figure 1). During 1988-1992, the population in Colorado increased 9.9% for blacks, 9.8% for Hispanics, and 4.5% for whites. In 1992, the gonorrhea rate for blacks (1935 per 100,000 persons) was 57 times that for whites (34 per 100,000) and 12 times that for Hispanics (156 per 100,000) (Table 1). Among black females, reported cases of gonorrhea increased from 1988 through 1992 in the 15-19-year age group; among black males, cases increased from 1989 through 1992 in both the 15-19-and 20-24-year age groups.

Reported by: KA Gershman, MD, JM Finn, NE Spencer, MSPH, STD/AIDS Program; RE Hoffman, MD, State Epidemiologist, Colorado Dept of Health. JM Douglas, MD, Denver Dept of Health and Hospitals. Surveillance and Information Systems Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The increase in reported gonorrhea cases in Colorado in 1992 may represent an overall increase in the occurrence of this disease or more complete reporting stimulated by visitations to laboratories by CDH surveillance staff during 1991-1992. The increases in confirmed gonorrhea cases at DMHC and in culture-positivity rates in three of four laboratories suggest a real increase in gonorrhea rather than a reporting artifact. However, the stable culture-positivity rate in the nonprofit family planning laboratory (which serves a network of clinics statewide) indicates that the gonorrhea increase did not uniformly affect all segments of the population.

One possible explanation for the increased occurrence of gonorrhea in Colorado may be gang- and drug-related sexual behavior, as implicated in a recent outbreak of drug-resistant gonorrhea and other STDs in Colorado Springs (2). Although the high morbidity census tracts in the Denver metropolitan area coincide with areas of gang and drug activity, this hypothesis requires further assessment. To examine the possible role of drug use -- implicated previously as a factor contributing to the national increase in syphilis (3-6) -- the CDH STD/AIDS program is collecting information from all persons in whom gonorrhea is diagnosed regarding drug use, exchange of sex for money or drugs, and gang affiliation.

The gonorrhea rate for blacks in Colorado substantially exceeds the national health objective for the year 2000 (1300 per 100,000) (objective 19.1a) (7). Race is likely a risk marker rather than a risk factor for gonorrhea and other STDs. Risk markers may be useful for identifying groups at greatest risk for STDs and for targeting prevention efforts. Moreover, race- specific variation in STD rates may reflect differences in factors such as socioeconomic status, access to medical care, and high-risk behaviors.

In response to the increased occurrence of gonorrhea in Colorado, interventions initiated by the CDH STD/AIDS program include 1) targeting partner notification in the Denver metropolitan area to persons in groups at increased risk (e.g., 15-19-year-old black females and 20-24-year-old black males); 2) implementing a media campaign (e.g., public service radio announcements, signs on city buses, newspaper advertisements, and posters in schools and clinics) to promote awareness of STD risk and prevention targeted primarily at high-risk groups, and 3) developing teams of peer educators to perform educational outreach in high-risk neighborhoods. The educational interventions are being developed and implemented with the assistance of members of the target groups and with input from a forum of community leaders and health-care providers.

References

1. CDC. Table II. Cases of selected notifiable diseases, United States, weeks ending December 26, 1992, and December 28, 1991 (52nd week). MMWR 1993;41:975.

2. CDC. Gang-related outbreak of penicillinase-producing Neisseria gonorrhoeae and other sexually transmitted diseases -- Colorado Springs, Colorado, 1989-1991. MMWR 1993;42:25-8.

3. CDC. Relationship of syphilis to drug use and prostitution -- Connecticut and Philadelphia, Pennsylvania. MMWR 1988;37:755-8,

5. Rolfs RT, Goldberg M, Sharrar RG. Risk factors for syphilis: cocaine use and prostitution. Am J Public Health 1990;80:853-7.

6. Andrus JK, Fleming DW, Harger DR, et al. Partner notification: can it control epidemic syphilis? Ann Intern Med 1990;112:539-43.

7. Gershman KA, Rolfs RT. Diverging gonorrhea and syphilis trends in the 1980s: are they real? Am J Public Health 1991;81:1263-7.

8. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

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