Surveillance for Gonorrhea and Primary and Secondary Syphilis Among Adolescents, United States -- 1981-1991

Linda A. Webster, Ph.D. Stuart M. Berman, M.D. Joel R. Greenspan, M.D., M.P.H. Division of Sexually Transmitted Diseases and HIV Prevention National Center for Prevention Services

Abstract

Problem/Condition: During the 1980s, an increasing proportion of adolescent women reported having had premarital sexual intercourse, thus potentially placing an increasing number of young persons at higher risk of acquiring a sexually transmitted infection.

Reporting Period Covered: To determine rates and examine trends of sexually transmitted infections among adolescents, we analyzed data for reported cases of gonorrhea and primary and secondary syphilis among 10- to 19-year-olds for 1981 through 1991.

Description of System: Summary data for cases of gonorrhea and primary and secondary syphilis that were identified and reported to state health departments were sent annually to CDC. These data included total number of cases by disease (gonorrhea, primary and secondary syphilis), sex, racial/ethnic group (white, not of Hispanic origin; black, not of Hispanic origin; Hispanic; Asian/Pacific Islander; or American Indian/Alaskan Native), 5-year age group, and source of report (public, private).

Results: From 1981 through 1991, 24%-30% of the reported morbidity from gonorrhea and 10%-12% of the reported morbidity from primary and secondary syphilis in the United States affected the adolescent age groups. Some of the highest rates of gonorrhea during that time period were among 15- to 19-year-olds. Gonorrhea rates among adolescents increased or remained unchanged from 1981 through 1991, while the rates among older age groups decreased. Although primary and secondary syphilis rates were lower among adolescents than older age groups, adolescents contributed to the epidemic of syphilis that occurred from 1987 through 1990. Differences in reported rates of both syphilis and gonorrhea among white, black, and Hispanic adolescents increased during the latter half of the 1980s.

Interpretation: Reporting biases could account for some the differences among rates for white, black, and Hispanic adolescents. However, if gonorrhea has been underreported for any racial group, the high rates of gonorrhea among 15- to 19-year-olds represented an underestimate of the true infection rate. Increases in sexual activity among adolescents and a lack of clinical services in settings convenient to adolescents could have contributed to the increasing rates of gonorrhea and syphilis among these young persons during this time period.

Actions Taken: If gonorrhea and other sexually transmitted infections are cofactors for facilitating the transmission of human immunodeficiency virus (HIV), the high incidence of gonorrhea in some locales among some populations of adolescents could result in dramatic increases in HIV acquisition, a situation that demands attention from public health organizations.

INTRODUCTION

During the 1980s, an increasing proportion of adolescent women reported that they engaged in premarital sexual intercourse (1). Consequently, an increasing number of adolescents were at a higher risk of acquiring a sexually transmitted infection during that time period. To determine rates and examine trends of sexually transmitted infections among adolescents, we analyzed data for reported cases of gonorrhea and primary and secondary syphilis among 10- to 19-year-olds for 1981 through 1991.

METHODS

Summary data for cases of gonorrhea and primary and secondary syphilis that were identified and reported to state and local health departments from 1981 through 1991 were sent annually to CDC. These data included total number of cases by disease (gonorrhea, primary and secondary syphilis), sex, racial/ethnic group (white, not of Hispanic origin; black, not of Hispanic origin; Hispanic; Asian/Pacific Islander; or American Indian/Alaskan Native), 5-year age group, and source of report (public or private). The data were analyzed by race/ethnicity so that specific groups can be targeted for prevention efforts. The data were reported from all 50 states and the District of Columbia and from six large metropolitan areas in the United States (New York City, Philadelphia, Baltimore, Chicago, San Francisco, and Los Angeles).

Age-, race/ethnicity-, and sex-specific rates were calculated by using estimates of the population for 1981-1989 and data from the 1990 census for 1990 and 1991 (2,3). For calculation of regional rates of gonorrhea, states were grouped into four regions of the United States as defined by the Bureau of the Census: Northeast (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont); South (Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia); Midwest (Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin); and West (Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming).

For the purposes of this analysis, any persons in the 10- to 14-year-old and the 15- to 19-year-old age groups were considered adolescents.

RESULTS Gonorrhea

From 1981 through 1991 (and previously), gonorrhea was the most frequently reported sexually transmitted disease in the United States. Approximately 24%-30% of the reported morbidity from gonorrhea during that time period was in the adolescent age groups. In 1991, some of the highest reported rates of gonorrhea were among 15- to 19-year-olds (Table 1). Specifically, the gonorrhea rate among 15- to 19-year-old females in 1991 was 1,043.6 cases per 100,000 population, and the rate among 15- to 19-year-old males was 882.6. Gonorrhea rates among adolescent females were consistently higher than the rates for adolescent males during the 11-year period.

Over the surveillance period, gonorrhea rates decreased among all age and sex groups except 10- to 14-year-old males, 10- to 14-year-old females, and 15- to 19-year-old males. The rates for these groups in 1991 were, respectively, 41%, 51.2%, and 1.6% higher than in 1981. Although overall increases in gonorrhea rates were observed for these groups, different patterns of reported disease morbidity were observed for whites, blacks, and Hispanics. Specifically, gonorrhea rates decreased slightly among 10- to 14-year-old white and Hispanic males from 1987 through 1991, but increased among black males during that time period (Figure 1). Similarly, the gonorrhea rate among 15- to 19-year-old white and Hispanic males decreased steadily from 1985 through 1991, but the rate increased among black males (Figure 2). Among 10- to 14-year-old females, gonorrhea rates increased for both black and Hispanic females from 1987 through 1991, while the rates decreased for white females during that same time period (Figure 3). In addition, even though the overall rates of gonorrhea among 15- to 19-year-old females decreased during the decade, race/ethnicity-specific analyses indicated that the decrease occurred only among white and Hispanic females (Figure 4). Gonorrhea rates among 15- to 19-year-old black females remained relatively unchanged during the 11-year period.

In all regions of the United States in 1991, some of the highest rates of gonorrhea were among 15- to 19-year-olds. Gonorrhea rates among 15- to 19-year-old whites were highest in the South (325.0 cases per 100,000 population for white females and 124.4 cases per 100,000 population for white males) (Table 2). Rates among Hispanic 15- to 19-year-olds were highest in the Northeast. Specifically, in the Northeast the rates for Hispanics were reported as 749.3 cases per 100,000 population for females and 720.7 per 100,000 population for males. The reported gonorrhea rate for blacks was high in all regions of the country. In 1991, depending on the region, the proportions with infections were approximately 3.5%-7.3% among 15- to 19-year-old black females and 4.0%-7.0% among 15- to 19-year-old black males.

Primary and Secondary Syphilis

From 1981 through 1991, approximately 10%-12% of the reported primary and secondary syphilis morbidity was from the adolescent age groups. The rates for 10- to 14-year-old males were the lowest among all age groups (Table 3). Specifically, the rates ranged from 0.3 to 0.6 cases per 100,000 population during this 11-year period. From 1981 through 1991, rates of primary and secondary syphilis among 15- to 19-year-old males were similar to the rates among males greater than or equal to 30 years of age. For example, the rate among 15- to 19-year-olds in 1991 was 18.1 cases per 100,000 population, compared with the rate of 19.6 for males greater than or equal to 30 years of age. Although rates of primary and secondary syphilis were highest among 20- to 29-year-old males throughout this period, rates among 15- to 19-year-old males rose 41% in the last half of the decade, contributing to the overall 21% increase in syphilis rates among males that occurred from 1987 through 1990.

Primary and secondary syphilis rates among 15- to 19-year-old females were lower than the rates among 15- to 19-year-old males from 1981 through 1983. However, rates among females increased 112% from 1984 through 1991. By 1991, the primary and secondary syphilis rate for 15- to 19-year-old females (35 cases per 100,000 population) was almost twice the rate for 15- to 19-year-old males. Similarly, the primary and secondary syphilis rate among 10- to 14-year-old females increased 108% from 1984 through 1991. The rates for 10- to 14-year-old females were approximately 2-3 times those for 10- to 14-year-old males from 1981 through 1986, but were more than 5.5 times the rates for males from 1987 through 1991. Primary and secondary syphilis rates for adolescent females were much higher in 1991 than 1981, reflecting the dramatic increase in syphilis among females of all ages in the latter half of the 1980s.

Differences in race/ethnicity-specific primary and secondary syphilis rates among 15- to 19-year-olds increased steadily from 1986 through 1991 (Figure 5). For example, in 1985 the primary and secondary syphilis rate for 15- to 19-year-old black males was almost twice the rate for Hispanic males and 20 times higher than the comparable rate for white males. By 1991, the rate for 15- to 19-year-old black males was 11 times higher than the rate for Hispanic males and 85 times higher than the rate for white males. The increase in these ratios resulted from a decrease in rates for 15- to 19-year-old white and Hispanic males from 1986 through 1991 and an increase in rates for 15- to 19-year-old black males during this time period.

Similarly, although primary and secondary syphilis rates increased from 1986 through 1990 for white, black, and Hispanic 15- to 19-year-old females, differences in race/ethnicity-specific rates also increased during this time period (Figure 6). Specifically, rates for black females increased more than 150% from 1986 through 1990 compared with increases of less than 50% in the other racial/ethnic groups.

DISCUSSION

During the period 1981 through 1991, 24%-30% of the reported morbidity from gonorrhea and 10%-12% of the reported morbidity from primary and secondary syphilis in the United States were from the adolescent age groups. Although gonorrhea rates among older age groups decreased during this 11-year period, gonorrhea rates among adolescents increased or remained unchanged, with rates among adolescent females consistently higher than rates among adolescent males. In 1991, some of the highest rates of gonorrhea were among 15- to 19-year-olds, specifically, 882.6 cases per 100,000 population for males and 1,043.6 cases per 100,000 population for females. Although primary and secondary syphilis rates were lower in adolescents than in older age groups, adolescents contributed to the epidemic of syphilis that occurred from 1987 through 1990. Differences in reported rates of both syphilis and gonorrhea among white and Hispanic and black adolescents increased during the latter half of the 1980s.

Reporting biases could account for some of these results. Specifically, reporting from public clinics is more comprehensive than reporting from private health-care sources (4). Thus, syphilis and gonorrhea rates may have been underestimated for persons more likely to use private clinics. Such underreporting could explain some, but probably not all of the differences among rates for white, black, and Hispanic adolescents. Such differences in risk among racial/ethnic groups may reflect social, economic, behavioral, or other factors, rather than race/ethnicity directly. If gonorrhea has been underreported for any race/ethnicity-sex group, the already high rates of gonorrhea for 15- to 19-year-olds would represent an underestimate of the true infection rate in the total population.

The increasing rates of gonorrhea and syphilis among adolescents from 1981 through 1991 are consistent with findings of an increase in the proportion of adolescent women who reported having had premarital sex during the 1980s (1). Furthermore, first sexual experiences occurred at younger ages during this time period. Early initiation of sexual intercourse is associated with an increased number of sex partners and thus, a greater risk of sexually transmitted infections. However, the increase in the proportion of adolescent women having premarital sex and the decrease in the age at first sexual experience occurred to a greater extent in white women, while the increases in gonorrhea and syphilis rates occurred to a greater extent in black women.

In some studies condom use was shown to increase among sexually active adolescents during the 1980s. Those studies also indicated that fewer than half of the adolescents who used condoms did so all the time (5). Inconsistent use of condoms in high-risk settings could have increased the risk of acquiring a sexually transmitted infection and could have accounted for some of the increasing rates among adolescents.

A lack of available clinical services in settings that are convenient to adolescents could have hindered secondary prevention of sexually transmitted infections during the 1980s (5). More specifically, care is particularly fragmented for adolescents, and a lack of readily accessible services could have resulted in increases in the amount of time between exposure to an infection, awareness of the symptoms, and diagnosis and treatment. Furthermore, health professionals may not be likely to address issues of sexually transmitted infections or sexuality among adolescents. All these factors could have led to longer periods of untreated infection and consequently to increased transmission of sexually transmitted diseases among adolescents.

If left untreated, gonorrhea will lead to pelvic inflammatory disease (PID). However, many of the other consequences of sexually transmitted infections in adolescent women occur later in life (5). Acute PID increases a woman's risk of recurrent PID, chronic pelvic pain, infertility, and ectopic pregnancy. Thus, strategies to prevent these adverse reproductive outcomes must address the health-care, educational, and risk-reduction needs of adolescents. Such strategies require an understanding of how to influence sexual and health-care-seeking behavior. In addition, prevention programs must ensure that those providing health care to adolescents are adequately trained and that they sufficiently appreciate the need to recognize, diagnose, and treat sexually transmitted infections among these young patients and their partners. The high rates of gonorrhea and other sexually transmitted infections among adolescents can be decreased through prevention program activities that promote greater awareness, proper diagnosis and treatment, and follow-up of sex partners. Better measures of PID and other adverse consequences of sexually transmitted infections should be developed and monitored to further ensure that these prevention program activities successfully decrease complications from sexually transmitted infections in adolescents.

Finally, some studies suggest that infection with gonorrhea -- and possibly other sexually transmitted infections -- may be a cofactor for facilitating the heterosexual transmission of human immunodeficiency virus (HIV) (6). If this is the case, the incidence of gonorrhea in some locales among some populations of young adults may result in dramatic increases in HIV acquisition, a possibility that demands attention from public health organizations and other providers of health care.

References

1. CDC. Premarital sexual experience among adolescent women -- United States, 1970-1988. MMWR 1991;39:929-32.

2. Bureau of the Census. United States population estimates by age, sex, and state: 1981-1989. Current Population Reports (Series P-25). In press.

3. Bureau of the Census. Census of population and housing, 1990: summary tape file 1 {machine-readable file}. Washington: Bureau of the Census, 1991.

4. Aral SO, Holmes KK. Epidemiology of sexual behavior and sexually transmitted diseases. In: Holmes KK, Mardh PA, Sparling PF, et al., eds. Sexually transmitted diseases. 2nd ed. New York: McGraw-Hill, 1990:19-36.

5. Cates W. The epidemiology and control of sexually transmitted diseases in adolescents. In: Schydlower M, Shafer MA, eds. AIDS and other sexually transmitted diseases. Philadelphia: Hanley & Belfus, Inc., 1990:409-27.

6. Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Trans Dis 1992;19:61-77.

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