National Overview of Sexually Transmitted Diseases (STDs), 2013

All Americans should have the opportunity to make choices that lead to health and wellness. An approach to improve health equity can address what the health providers can do with other partners working together.¹ Interested committed public and private organizations, communities, and individuals can take action to prevent sexually transmitted diseases (STDs) and their related health burdens. In addition to federal, state, and local public support for STD prevention, local community leaders can promote STD prevention education. Health providers can assess their patients’ risks and talk to them about testing. Parents can better educate their children about STDs and sexual health. Individuals can use condoms consistently and correctly, and openly discuss ways to protect their health with partners and providers. As noted in the Institute of Medicine report, The Hidden Epidemic: Confronting Sexually Transmitted Diseases, surveillance is a key component of all our efforts to prevent and control these diseases.²

This overview summarizes national surveillance data for 2013 on the three notifiable diseases for which there are federally funded control programs: chlamydia, gonorrhea, and syphilis. The data presented here by race and ethnicity are categorized according to the Office of Management and Budget standards. However, data for all jurisdictions by race/ethnicity using these categories are not available; consequently, absolute rates by race/ethnicity and comparisons among racial/ethnic groups may not match those provided in previous reports.

Chlamydia

In 2013, a total of 1,401,906 cases of Chlamydia trachomatis infection were reported to the CDC (Table 1). This case count corresponds to a rate of 446.6 cases per 100,000 population, a decrease of 1.5% compared with the rate in 2012. This is the first time since nationwide reporting for chlamydia began that the overall rate of reported cases of chlamydia has decreased. The rate in women decreased 2.4% while rate in men increased 0.8%.

In 2013, the overall rate of chlamydial infection in the United States among women (623.1 cases per 100,000 females) was over two times the rate among men (262.6 cases per 100,000 males), reflecting the larger number of women screened for this infection (Tables 4 and 5). However, with the increased availability of urine testing, men are increasingly being tested for chlamydial infection. During 2009–2013, the chlamydia rate in men increased 21%, compared with an 6.2% increase in women during this period. Rates also varied among different racial and ethnic minority populations. For example, in 2013, the chlamydia rate in blacks was 6.4 times the rate in whites and the rate among American Indians/Alaska Natives was almost 4 times that rate among whites.

Gonorrhea

Following a 74% decline in the rate of reported gonorrhea during 1975–1997, overall gonorrhea rates plateaued for 10 years. After the decline halted for several years, gonorrhea rates decreased further to 98.1 cases per 100,000 population in 2009, the lowest rate since recording of gonorrhea rates began. Between 2009 and 2012, the gonorrhea rate increased slightly each year to 106.7 cases per 100,000 population in 2012. In 2013, there were 333,004 cases of gonorrhea reported and the national gonorrhea rate decreased slightly to 106.1 cases per 100,000 population. In 2013, rates decreased among all persons aged 15–19 years and in women 20–24 years; rates increased in other age groups.  

In 2013, for the first time since 2000, the rate of reported gonorrhea cases among men was higher than the rate among women. During 2012–2013, the gonorrhea rate among men increased 4.3% and the rate among women decreased 5.1%. The increase among men compared with a decrease among women suggests either increased transmission or increased case ascertainment (e.g., through increased extra-genital screening) among gay, bisexual and other men who have sex with men.

In 2013, the gonorrhea rate in blacks was 12.4 times the rate in whites (Table 22B); while rates among blacks have been declining, even greater increases in whites have contributed to lessening of the apparent disparities in rates between blacks and whites. As with chlamydia, data on gonorrhea prevalence in defined populations were available from several sources in 2013. These data showed a continuing high burden of disease in some adolescents and young adults in parts of the United States.

Antimicrobial resistance remains an important consideration in the treatment of gonorrhea. With increased resistance to the fluoroquinolones and declining susceptibility to cefixime, dual therapy with ceftriaxone and  azithromycin is now the only CDC recommended treatment for gonorrhea.³ In 2013, decreases in minimum inhibitory concentrations (MICs) of cephalosporins (cefixime and ceftriaxone) were observed. Continued monitoring of susceptibility patterns to these antibiotics is critical. (Figures 25 and 26).

Syphilis

The rate of primary and secondary (P&S) syphilis reported in the United States decreased during the 1990s, and in 2000, it was the lowest since reporting began in 1941. The low rate of syphilis and the concentration of most syphilis cases in a small number of geographic areas led to the development of the National Plan to Eliminate Syphilis from the United States, which was announced by the Surgeon General in 1999 and updated in 2006.4 The overall rate of P&S syphilis in the United States declined 89.7% during 1990–2000, then increased each year from 2001 through 2009. In 2010, the overall rate decreased for the first time in 10 years. While the rate remained unchanged in 2011, the rate increased 22% during 2011–2013.

In 2013, 1,708 more cases were reported than in 2012. This increase was almost solely among men (Figure 31). In 2013, men accounted for 91% of all P&S cases; in the 49 states and the District of Columbia that provided information about sex of sex partners of patients with syphilis, MSM accounted for 75% of all P&S cases. In areas where information for both sex of partner and HIV status was relatively complete (70% or greater for all cases), 52% of MSM with P&S syphilis were also co-infected with HIV; co-infection in MSW and women was 9.9% and 5.2%, respectively (Figure 42).

Rates in women remained unchanged between 2011 and 2013. In 2013, 1,500 cases of P&S syphilis were reported in women. The 2013 rate of congenital syphilis (8.7 cases per 100,000 live births) marks the first increase in congenital syphilis since 2008 and was largely driven by increases in the West, coinciding with increases in P&S syphilis among women in the West. There were 348 cases of congenital syphilis reported in 2013.

Significant racial and ethnic disparities in STD rates persist. In 2013, the P&S syphilis rate among blacks was almost six times the rate among whites (Figure 39). In some subgroups, however, these disparities are much higher. The 2013 rate among blacks aged 15–19 years was approximately 13 times the rate for whites in that age group (Table 36B). While rates in congenital syphilis have decreased in recent years, the rates are still 10 times higher in blacks than in whites and almost 3.5 times higher in Hispanics than in whites (Table 43).

1 Sadana R, Blas E. What can public programs do to improve health equity? Public Health Reports. 2013;Vol 128:12-20.

2 Eng TR, Butler WT, editors; Institute of Medicine (US). The hidden epidemic: confronting sexually transmitted diseases. Washington (DC): National Academy Press; 1997. p 43.

3 Centers for Disease Control and Prevention. CDC’s sexually transmitted diseases treatment guidelines, 2015. MMWR Morb Mortal Wkly Rep. 2015 (in press).

4 Centers for Disease Control and Prevention. The national plan to eliminate syphilis from the United States. Atlanta: U.S. Department of Health and Human Services; 2006.

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