National Overview of Sexually Transmitted Diseases (STDs), 2014

All Americans should have the opportunity to make choices that lead to health and wellness. Working together, interested, committed public and private organizations, communities, and individuals can take action to prevent sexually transmitted diseases (STDs) and their related health consequences. In addition to federal, state, and local public support for STD prevention activities, local community leaders can promote STD prevention education. Health care 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.¹

This overview summarizes national surveillance data for 2014 on the three notifiable diseases for which there are federally funded control programs: chlamydia, gonorrhea, and syphilis.

Chlamydia

In 2014, a total of 1,441,789 cases of Chlamydia trachomatis infection were reported to the CDC (Table 1). This case count corresponds to a rate of 456.1 cases per 100,000 population, an increase of 2.8% compared with the rate in 2013. This overall increase follows the first time since nationwide reporting for chlamydia began that the overall rate of reported cases of chlamydia decreased from 2011 to 2013. While the rate in women from 2013–2014 increased 1.3% and the rate in men increased 6.8%, the rate among women aged 15-19 years decreased 4.2%, continuing a decline in that group since 2011.

In 2014, the overall rate of chlamydial infection in the United States among women (627.2 cases per 100,000 females) based on reported cases was over two times the rate among men (278.4 cases per 100,000 males) (Tables 4 and 5), reflecting the larger number of women screened for this infection. However, with the increased availability of urine testing, men are increasingly being tested for chlamydial infection. During 2010–2014, the chlamydia rate in men increased 22%, compared with a 6% increase in women during this period.

Rates varied among different racial and ethnic minority populations. In 2014, the chlamydia rate in blacks was 6 times the rate in whites, and the rate among American Indians/Alaska Natives was almost 4 times the rate among whites.

Gonorrhea

In 2009, the national rate of reported gonorrhea cases reached an historic low of 98.1 cases per 100,000 population (Figure 12 and Table 1). However, during 2009–2012, the rate increased slightly each year, to 106.7 cases per 100,000 population in 2012. In 2013, the rate decreased to 105.3 cases per 100,000 population. But in 2014, a total of 350,062 gonorrhea cases were reported, and the national gonorrhea rate increased to 110.7 cases per 100,000 population.

The increase in gonorrhea rate during 2013–2014 was observed primarily among men (Figure 13). Gonorrhea rates among men increased in every region of the United States, while gonorrhea rates among women increased in the South and West but decreased in the Northeast and Midwest (Tables 15 and 16).

In 2014, the rate of reported gonorrhea cases remained highest among blacks (405.4 cases per 100,000 population) (Table 22B). The rate among blacks was 10.6 times the rate among whites (38.3 cases per 100,000 population). The gonorrhea rate among American Indians/Alaska Natives (159.4 cases per 100,000 population) was 4.2 times that of whites. While rates of gonorrhea during 2010-2014 have been declining among blacks, they have increased in all other racial/ethnic groups. In American Indian/Alaska Natives, they have increased 104% during this time period.

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.² In 2014, increases in minimum inhibitory concentrations (MICs) of cephalosporins (cefixime and ceftriaxone) were observed after decreases in 2012 and 2013 (Figures 26 and 27). While the percentage of isolates with reduced azithromycin susceptibility has remained stable (between 0.3% and 0.6% of all isolates tested) in previous years, between 2013 and 2014, this percentage jumped up to 2.5% (Figure 28). Continued monitoring of susceptibility patterns to these antibiotics is critical.

Syphilis

In 2000 and 2001, the national rate of reported primary and secondary (P&S) syphilis cases was 2.1 cases per 100,000 population, the lowest rate since reporting began in 1941 (Figure 31, Table 1). However, the P&S syphilis rate has increased almost every year since 2000–2001. In 2014, a total of 19,999 P&S syphilis cases were reported, and the national P&S syphilis rate increased to 6.3 cases per 100,000 population, the highest rate since 1994.

During 2000–2014, the rise in the P&S syphilis rate was primarily attributable to increased cases among men and, specifically, among gay, bisexual, and other men who have sex with men (collectively referred to as MSM) (Figures 32 and 33). However, during 2013–2014, the rate increased both among men (14.4%) and among women (22.7%) (Tables 28 and 29). This increase among women is of particular concern because congenital syphilis cases tend to increase as the rate of P&S syphilis among women increases (Figure 46).

During 2013–2014, the overall male and female P&S syphilis rates increased in every region of the country (Figure 34, Tables 27–29). Nationally, P&S syphilis rates increased in every 5-year age group of those 15–44 years of age (Table 35) and in every race/ethnicity group except for Native Hawaiians/Other Pacific Islanders during 2013–2014 (Figure 40).

In 2014, men accounted for 91% of all cases of P&S syphilis. And, of those male cases for whom sex of sex partner was known, 83% were MSM. Reported cases of P&S syphilis continued to be characterized by a high rate of HIV co-infection, particularly among MSM. In 2014, 26 states reported both sex of sex partner and HIV status (HIV-positive or HIV-negative) for at least 70% of P&S syphilis cases (Figure 43). Among P&S syphilis cases with known HIV-status in these states, 51% of cases among MSM were HIV-positive, compared with 11% of cases among MSW, and 6% of cases among women.

Rates in women remained unchanged between 2011 and 2013 but increased 22% between 2013 and 2014. In 2014, 1,840 cases of P&S syphilis were reported in women compared with 1,500 in 2013. The 2013 rate of congenital syphilis (9.1 cases per 100,000 live births) marked the first increase in congenital syphilis since 2008. During 2013–2014, the rate increased 27.5%. There were 458 cases of congenital syphilis reported in 2014 compared with 359 in 2013 (Figure 46).

Significant racial and ethnic disparities in STD rates persist. In 2014, the P&S syphilis rate among blacks was 5.4 times the rate among whites (Figure 40). In some subgroups, however, disparities were even higher. The 2014 P&S syphilis rates among black and American Indian/Alaska Native women were between 9-10 times the rates for whites. (Table 36B). While rates of congenital syphilis increased in most race/ethnicity groups during 2013-2014, they were 10 times higher in blacks than in whites and over 3 times higher in Hispanics and in American Indian/Alaska Natives than in whites (Table 43).

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

2 Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Morb Mortal Wkly Rep 2015; 64(No. RR-3): 1–137.

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