Interpreting STD Surveillance Data

Sexually Transmitted Disease Surveillance 2012 presents surveillance information derived from the official statistics for the reported occurrence of nationally notifiable sexually transmitted diseases (STDs) in the United States, test positivity and prevalence data from numerous prevalence monitoring initiatives, sentinel surveillance, and national health care services surveys.

Nationally Notifiable STD Surveillance

Nationally notifiable STD surveillance data are collected and compiled from reports sent by the STD control programs and health departments in all 50 states, the District of Columbia, selected cities, U.S. dependencies and possessions, and independent nations in free association with the United States to the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC). Included among the dependencies, possessions, and independent nations are Guam, Puerto Rico, and the Virgin Islands. These entities are identified as "outlying areas" of the United States in selected figures and tables.

Reporting Formats

STD morbidity data presented in this report are compiled from a combination of data reported on standardized hard copy reporting forms and electronic data received through the National Electronic Telecommunications System for Surveillance (NETSS).

Summary Report Forms

The following hard copy forms were used to report national STD morbidity data:

1. FORM CDC 73.998: Monthly Surveillance Report of Early Syphilis. This monthly hard copy reporting form was used during 1984–2002 to report summary data for primary and secondary syphilis and early latent syphilis by county and state.
2. FORM CDC 73.688: Sexually Transmitted Disease Morbidity Report. This quarterly hard copy reporting form was used during 1963–2002 to report summary data for all stages of syphilis, congenital syphilis, gonorrhea, chancroid, chlamydia, and other STDs by sex and source of report (private versus public) for all 50 states, the District of Columbia, 64 selected cities (including San Juan, Puerto Rico), and outlying areas of the United States.

   Note: Chlamydial infection became a nationally notifiable condition in 1996, and the form was modified to support reporting of chlamydia that year. Congenital syphilis was dropped from this aggregate form in 1995 and replaced by the case-specific CDC 73.126 form described later in this section.

3. FORM CDC 73.2638: Report of Civilian Cases of Primary & Secondary Syphilis, Gonorrhea, and Chlamydia by Reporting Source, Sex, Race/Ethnicity, and Age Group. This annual hard copy form was used during 1981–2002 to report summary data for P&S syphilis, gonorrhea, and chlamydia by age, race, sex, and source (public versus private) for all 50 states, seven large cities (Baltimore, Chicago, New York City, Los Angeles, Philadelphia, San Francisco, and the District of Columbia), and outlying areas of the United States. Note: Chlamydial infection became a nationally notifiable condition in 1996, and the form was modified to support reporting of chlamydia that year.
4. FORM CDC 73.126: Congenital Syphilis (CS) Case Investigation and Reporting. This case- specific hard copy form was first used in 1983 and continued to be used through 2012 to report detailed case-specific data for congenital syphilis in some areas.

National Electronic Telecommunications System for Surveillance

Notifiable STD data reported electronically through NETSS make up the nationally notifiable disease information published in CDC’s Morbidity and Mortality Weekly Report.

As of December 31, 2003, all 50 states and the District of Columbia had converted from summary hard copy reporting to electronic submission of line-listed (i.e., case-specific) STD data through NETSS (43 reporting areas submit congenital syphilis surveillance data through NETSS). Puerto Rico converted to electronic reporting in 2006 for all STDs excluding congenital syphilis. Guam and the Virgin Islands continue to report STD data through summary hard copy forms.

Surveillance data and updates sent to CDC through NETSS and on hard copy forms through May 29, 2013, are included in this report. Data received after this date will appear in subsequent STD surveillance reports. The data presented in the figures and tables in this report supersede those in all earlier publications.

Population Denominators and Rate Calculations

2000–2012 Rates and Population

CDC’s National Center for Health Statistics (NCHS) released bridged-race population counts for the 2000–2011 U.S. resident populations that are based on counts from the 2000 U.S. Census. These estimates resulted from bridging the 31 race categories used in the 2000 census, as specified in the 1997 Office of Management and Budget (OMB) standards, to the five race/ethnicity groups specified in the 1977 OMB standards. This report uses the first published population estimate for a given year. The latest available year for bridged-race population estimates at the time this report was written was 2011. Thus 2011 population estimates were used to calculate 2011 and 2012 rates. Once published, the 2012 population estimates will be used to calculate rates in the upcoming 2013 STD Surveillance Report.

Population estimates for Guam, Puerto Rico, and the Virgin Islands were obtained from the U.S. Census Bureau Web site at https://www.census.gov/programs-surveys/popest.html . The 2010–2011 rates for outlying areas were calculated by using the 2011 population estimates.

Because of the use of the updated population data, rates for 2000–2011 may be different from those presented in previous STD surveillance reports.

1990–1999 Rates and Population

The population counts for 1990 through 1999 incorporated the bridged single-race estimates of the April 1, 2000, U.S. resident population. These files were prepared by the U.S. Census Bureau with support from the National Cancer Institute.

1981–1989 Rates and Population

Rates were calculated by using U.S. Census Bureau population estimates for 1981 through 1989.^1,2

1941–1980 Rates and Population

Rates for 1941 through 1980 were based on population estimates from the U.S. Census Bureau and are currently maintained by CDC’s Division of STD Prevention.

1941–2012 Congenital Syphilis Rates and Live Births

The congenital syphilis data in Table 1 of this report represent the number of congenital syphilis cases per 100,000 live births for all years during 1941–2012. Previous publications presented congenital syphilis rates per 100,000 population during 1941–1994 and rates for cases diagnosed at younger than 1 year of age per 100,000 live births during 1995–2005. To allow for trends in congenital syphilis rates to be compared for the period 1941 through 2012, live births now are used as the denominator for congenital syphilis, and case counts are no longer limited to those diagnosed within the first year of life. Congenital syphilis morbidity is assigned by year of birth. Rates of congenital syphilis for 1963 through 1988 were calculated by using published live birth data.³ Congenital syphilis rates for 1989 through 2006 were calculated by using live birth data based on information coded by the states and provided to the NCHS through the Vital Statistics Cooperative Program. Rates for 2007 through 2012 were calculated by using live birth data for 2009.

Reporting Practices

Although most state and local STD programs generally adhere to the national notifiable STD case definitions collaboratively developed by the Council of State and Territorial Epidemiologists and CDC, differences in policies and systems for collecting surveillance data may exist. Thus, comparisons of case numbers and rates between jurisdictions should be interpreted with caution.

However, because case definitions and surveillance activities within a given area remain relatively stable over time, trends should be minimally affected by these differences.

Reporting of Surveillance Data by Metropolitan Statistical Area

Sexually Transmitted Disease Surveillance 2012 continues the presentation of STD incidence data and rates for the 50 metropolitan statistical areas (MSAs) with the largest populations according to 2000 census data. STD surveillance reports published before 2005 presented data by selected cities; these data were derived from county data, which were used to estimate city-specific disease rates. Because county data were used to estimate city-specific morbidity and because current STD project areas’ reporting practices do not support direct identification of city-specific morbidity reports, MSAs were chosen as a geographic unit smaller than a state or territory for presentation of STD morbidity data.

MSAs are defined by the OMB to provide nationally consistent definitions for collecting, tabulating, and publishing federal statistics for a set of geographic areas.⁴ An MSA is associated with at least one urbanized area that has a population of at least 50,000. The MSA comprises the central county or counties containing the central county, plus adjacent, outlying counties that have a high degree of social and economic integration with the central county as measured through commuting.

The title of an MSA includes the name of the principal city with the largest 2000 census population. If there are multiple principal cities, the names of the second largest and third largest principal cities appear in the title in order of descending population size.

The MSA concept has been used as a statistical representation of the social and economic links between urban cores and outlying, integrated areas. However, MSAs do not equate to an urban-rural classification; all counties included in MSAs and many other counties contain both urban and rural territory and populations. STD programs that treat all parts of an MSA as if they were as urban as the densely settled core ignore the rural conditions that may exist in some parts of the area. In short, MSAs are not intended to be a general purpose geographic framework for nonstatistical activities or for use in program funding formulas.

For more information on the MSA definitions used in this report, go to: https://www.census.gov/programs-surveys/metro-micro.html.

Reporting of Data for Race/Ethnicity

In April 2008, the NETSS record layout was updated to conform to the OMB’s current government-wide standard for race/ethnicity data.⁵ The OMB standards were first issued in 1997. Beginning with this publication, Sexually Transmitted Disease Surveillance 2012, the race/ethnicity data are presented according to the current standard categories: American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, Native Hawaiian or Other Pacific Islander, White and multirace. As of reporting year 2012, there are 47 states (Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming) and the District of Columbia compliant with the current OMB race/ethnicity standards. In figures where trends are shown for 2008- 2012, the data are presented for 38 states (Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Missouri, Indiana, Iowa, Kansas, Kentucky, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Vermont, Virginia, Washington, West Virginia, Wyoming) and the District of Columbia since these areas consistently reported race/ethnicity data according to the current standard categories for the five consecutive years.

Management of Unknown, Missing, or Invalid Data for Age Group, Race/ Ethnicity, and Sex

The percentage of unknown, missing, or invalid data for age group, race/ethnicity, and sex varies from year to year, state to state, and by disease for reported STDs (Table A1).

Prior to the publication of Sexually Transmitted Disease Surveillance 2010, when the percentage of unknown, missing, or invalid values for age group, race/ethnicity, and sex exceeded 50% for any state, the state’s incidence and population data were excluded from the tables that presented data stratified by one or more of these variables. For the states for which 50% or more of their data were valid for age group, race/ethnicity, and sex, the values for unknown, missing, or invalid data were redistributed on the basis of the state’s distribution of known age group, race/ethnicity, and sex data. Beginning with the publication of Sexually Transmitted Disease Surveillance 2010, redistribution methodology is not applied to any of the data. The counts presented in this report are summations of all valid data reported in reporting year 2012.

As a result, rate data that are stratified by one or more of these variables reflect rates based on reported data only.

Classification of STD Morbidity Reporting Sources

Before 1996, states classified the source of case reports as either private source (including private physicians, hospitals, and institutions) or public source (primarily STD clinics). As states began reporting morbidity data electronically in 1996, the classification categories for source of case reports expanded to include the following data sources: STD clinics, HIV counseling and testing sites, drug treatment clinics, family planning clinics, prenatal/obstetrics clinics, tuberculosis clinics, private physicians/health maintenance organizations, hospitals (inpatient), emergency rooms, correctional facilities, laboratories, blood banks, the National Job Training Program (NJTP), school-based clinics, mental health providers, the military, the Indian Health Service, and other unspecified sources.

Analysis of the data reported electronically after 1996 confirmed that the new STD clinic source of report data corresponded to the earlier public source category. Therefore, source of case report data during 1984–2012 are presented as STD clinic or non-STD clinic only (Table A2).

Chlamydia Case Reporting

Trends in chlamydia case reporting from many state and local jurisdictions are likely reflective of changes in diagnostic, screening, and reporting practices than of actual trends in disease incidence. In particular, morbidity trends are likely to be influenced by changes in test technology as laboratories expand their use of more sensitive tests (e.g., nucleic acid amplification tests).

Syphilis Morbidity Reporting

The category of “total syphilis” or “all stages of syphilis” includes primary, secondary, latent (including early latent, late latent, and latent syphilis of unknown duration), neurosyphilis, late (including late syphilis with clinical manifestations other than neurosyphilis), and congenital syphilis.

In 1996, the syphilis stage “late syphilis with clinical manifestations other than neurosyphilis (late benign and cardiovascular syphilis)” was added to the syphilis case definition (see STD Surveillance Case Definitions in the Appendix). Although neurosyphilis can occur at almost any stage of syphilis, during 1996–2005, it was classified and reported as one of several mutually exclusive stages of syphilis. Beginning in 2005, neurosyphilis was no longer classified or reported as a distinct stage of syphilis.

Congenital Syphilis Morbidity Reporting

In 1988, the surveillance case definition for congenital syphilis was changed. This case definition has greater sensitivity than the former definition.⁶ In addition, many state and local STD programs have greatly enhanced active case finding for congenital syphilis since 1988. For these reasons, as well as because of increasing morbidity, the number of reported cases increased dramatically during 1989–1991. All reporting areas had implemented the new case definition for reporting congenital syphilis by January 1, 1992.

In addition to changing the case definition for congenital syphilis, CDC introduced a new data collection form (CDC 73.126) in 1990 (revised April 2010). Since 1995, the data collected on this form have been used for reporting congenital syphilis cases and associated rates. This form is used to collect individual case information, which allows more thorough analysis of case characteristics. For the purpose of analyzing race/ethnicity, cases are classified by the race/ethnicity of the mother. Congenital syphilis cases were reported by state and city of residence of the mother during 1995–2012.

Congenital syphilis reporting may be delayed as a result of case investigation and validation. Cases for previous years are added to CDC’s surveillance databases throughout the year. Congenital syphilis data reported after publication of the current annual STD surveillance report will appear in subsequent reports and are assigned by the case patient’s year of birth.

Chlamydia and Gonorrhea Positivity and Prevalence Monitoring

Chlamydia and gonorrhea prevalence was calculated for men and women entering the NJTP. To increase the stability of the estimates, chlamydia or gonorrhea prevalence data are presented when valid test results for 100 or more students per year are available for the population subgroup and state. The majority of NJTP’s chlamydia screening tests are conducted by a single national contract laboratory, which provides these data to CDC. Gonorrhea screening tests for male and female students in many training centers are conducted by local laboratories; these data are not available to CDC. Test results for students at centers that submit specimens to the national contract laboratory are included only if the number of gonorrhea tests submitted is greater than 90% of the number of chlamydia tests submitted from the same center for the same period. Prevalence data for state- specific figures were published with permission from the NJTP.

During the mid-1990s to 2011, chlamydia and gonorrhea positivity among women screened in correctional facilities, family planning clinics, and prenatal care clinics participating in infertility prevention activities were reported to CDC to monitor chlamydia and gonorrhea prevalence. As the national infertility prevention program expanded, these data became difficult to interpret as trends were influenced by changes in screening coverage, screening criteria, and test technologies, as well as demographic changes in patients attending clinics reporting data to CDC. These issues could not be addressed with the limited variables that were collected at the national level. Positivity data continue to be useful locally to inform clinic-based screening recommendations and to identify at-risk populations in need of prevention interventions, but are no longer collected to monitor national trends in chlamydia and gonorrhea.

STD Surveillance Network (SSuN)

In 2005, CDC established the STD Surveillance Network (SSuN) as a dynamic network comprised of local enhanced STD surveillance systems that follow common protocols. The purpose of SSuN is to improve the capacity of national, state, and local STD programs to detect, monitor, and respond rapidly to trends in STDs through enhanced collection, reporting, analysis, visualization, and interpretation of disease information.

Twelve collaborating local or state health departments participated in SSuN in 2012: Alabama Department of Public Health, Baltimore City Health Department, Chicago Department of Public Health, Colorado Department of Public Health and Environment, Connecticut Department of Public Health, County of Los Angeles Department of Public Health (in collaboration with California State Department of Public Health), Louisiana Office of Public Health, New York City Department of Health and Mental Hygiene, Philadelphia Department of Public Health, San Francisco Department of Public Health, Virginia Department of Health, and Washington State Department of Health.

The SSuN data contained in this report include demographic, behavioral, clinical, and laboratory information collected from all patients at 42 STD clinics within the jurisdictions of SSuN health departments. These clinics are located in San Francisco, CA (San Francisco City Clinic); Los Angeles, CA (12 STD clinics in Los Angeles County); Seattle, WA (Seattle-King County Clinic); Denver, CO (Denver Metro Health Clinic); Chicago, IL (7 public STD clinics in Cook County); New Orleans, LA (Delgado Personal Health Center); Birmingham, AL (Jefferson County STD Clinic); Richmond, VA (Richmond City, Henrico County and Chesterfield County Clinics); Baltimore, MD (Druid STD Clinic and Eastern STD Clinic); Philadelphia, PA (Philadelphia STD Clinics 1 and 5); New York City, NY (9 public STD clinics in 5 boroughs); Hartford, CT (Hartford STD Clinic); and New Haven, CT (New Haven STD Clinic).

Men who have sex with men (MSM) were defined as men who either reported having sex with another man ever before STD testing (asked at all SSuN sites) or who did not report sex with men but reported that they considered themselves gay/homosexual or bisexual (asked at 10 of the 12 sites). Men who have sex with women (MSW) were defined as men who reported having sex with women only before STD testing or who did not report the sex of their sex partner, but reported that they considered themselves straight/heterosexual (asked at 10 of the 12 sites).

Gonococcal Isolate Surveillance Project

Data on antimicrobial susceptibility in Neisseria gonorrhoeae were collected through the Gonococcal Isolate Surveillance Project (GISP), a sentinel system of selected STD clinics located at 25–30 GISP sentinel sites and 4–5 regional laboratories in the United States. For more details on findings from GISP, go to: http://www.cdc.gov/std/GISP.

For 2012, the antimicrobial agents tested by GISP were ceftriaxone, cefixime, cefpodoxime, azithromycin, spectinomycin, ciprofloxacin, penicillin, and tetracycline.

The antimicrobial susceptibility criteria used in GISP for 2012 are as follows:

• Ceftriaxone, minimum inhibitory concentration (MIC) ≥0.5 µg/ml (decreased susceptibility).*
• Cefixime, MIC ≥0.5 µg/ml (decreased susceptibility).*
• Cefpodoxime, MIC ≥1.0 µg/ml (decreased susceptibility).*
• Azithromycin, MIC ≥2.0 µg/ml (decreased susceptibility).*
• Spectinomycin, MIC ≥128.0 µg/ml (resistance).
• Ciprofloxacin, MIC 0.125–0.5 µg/ml (intermediate resistance).
• Ciprofloxacin, MIC ≥1.0 µg/ml (resistance).
• Penicillin, MIC ≥2.0 µg/ml (resistance).
• Tetracycline, MIC ≥2.0 µg/ml (resistance).

The majority of these criteria are also recommended by the Clinical and Laboratory Standards Institute (CLSI).⁷

* The Clinical Laboratory Standards Institute criteria for decreased susceptibility and resistance to ceftriaxone, cefixime, cefpodoxime, and azithromycin and for susceptibility to azithromycin have not been established for N. gonorrhoeae.

Other Surveillance Data Sources

National Health and Nutrition Examination Survey

The National Health and Nutrition Examination Survey (NHANES) is a series of cross-sectional surveys designed to provide national statistics on the health and nutritional status of the general household population in the United States. Data are collected through household interviews, standardized physical examinations, and the collection of biological samples in special mobile examination centers. In 1999, NHANES became a continuous survey with data released every 2 years. The sampling plan of the survey is a stratified, multistage, probability cluster design that selects a sample representative of the U.S. civilian, non-institutionalized population. For more information, see: http://www.cdc.gov/nchs/nhanes.htm.

National Disease and Therapeutic Index

The information on the number of initial visits to private physicians’ offices for STDs was based on analysis of data from the National Disease and Therapeutic Index (NDTI) (machine-readable files or summary statistics for 1966 through 2012). NDTI is a probability sample survey of private physicians’ clinical management practices. For more information on this database, contact IMS Health, e-mail: ServiceCenter@us.imshealth.com; Telephone: (800) 523-5334.

National Hospital Discharge Survey

The information on patients hospitalized for pelvic inflammatory disease (PID) or ectopic pregnancy was based on analysis of data from the National Hospital Discharge Survey (NHDS) (machine-readable files for 1980 through 2010. NHDS, which is conducted by NCHS, is an ongoing, nationwide sample survey of medical records of patients discharged from acute care hospitals in the United States. For more information, see: http://www.cdc.gov/nchs/nhds.htm. The estimates generated by using NHDS data are based on statistical surveys and therefore have sampling variability associated with the estimates.

Healthy People 2020 Objectives

For three decades, Healthy People has provided a comprehensive set of national 10-year health promotion and disease prevention objectives aimed at improving the health of all Americans.⁸ It is grounded in the principle that establishing objectives and providing benchmarks to track and monitor progress over time can motivate, guide, and focus action.

Healthy People 2020 (HP2020) continues in the tradition of its ambitious, yet achievable, 10-year agenda for improving the Nation’s health. HP2020 is the result of a multiyear process that reflects input from a diverse group of individuals and organizations.

HP2020 is organized into 42 topic areas, with more than 1,200 measures designed drive action that will support its four overarching goals:

• Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
• Achieve health equity, eliminate disparities, and improve the health of all groups.
• Create social and physical environments that promote good health for all.
• Promote quality of life, healthy development, and healthy behaviors across all life stages.

The topic area, Sexually Transmitted Diseases, contains objectives and measures related to STDs. Baselines, HP2020 targets, and annual progress toward the targets are reported in Table A3. The year 2020 targets for the diseases addressed in this report are as follows: P&S syphilis (males), 6.8 cases per 100,000 population; P&S syphilis (females), 1.4 cases per 100,000 population congenital syphilis, 9.1 cases per 100,000 live births; gonorrhea (females aged 15–44 years), 257.0 cases per 100,000 population and gonorrhea (males aged 15–44 years), 198.0 cases per 100,000 population.

The majority of the STD-related HP2020 targets were set using a standard percentage improvement with a standard default of a “10 percent improvement over the baseline.”

Government Performance and Results Act of 1993

The Government Performance and Results Act (GPRA) of 1993 was enacted by Congress to increase confidence in the capability of the federal government to increase the effectiveness and accountability of federal programs, to improve service delivery, to provide federal agencies a uniform tool for internal management, and to help Congress make decisions.

GPRA requires each agency to have a performance plan with long-term outcomes and annual, measurable performance goals and to report on these plans annually, comparing results with annual goals. There are two GPRA goals for STD: reducing PID and eliminating congenital syphilis. Each of these goals has specific measures of progress, which are outlined in Table A4.

1 U.S. Census Bureau. United States population estimates by age, sex and race: 1980–1988. In: Current population reports [Series P-25, No. 1045]. Washington, DC: U.S. Government Printing Office; 1990.

2 U.S. Census Bureau. United States population estimates by age, sex and race: 1989. In: Current population reports [Series P-25, No. 1057]. Washington, DC: U.S. Government Printing Office; 1990.

3 Centers for Disease Control and Prevention. Vital statistics of the United States 1988. vol.1 - natality. Hyattsville (MD): U.S. Department of Health and Human Services; 1990.

4 Office of Management and Budget. Standards for defining metropolitan and micropolitan statistical areas. Federal Register. 2000;65(249):82228-38.

5 Office of Management and Budget. Revisions to the Standards for Classification of Federal Data on Race and Ethnicity. Federal Register Notice. October 30, 1997.

6 Kaufman RE, Jones OG, Blount JH, Wiesner PJ. Questionnaire survey of reported early congenital syphilis: problems in diagnosis, prevention, and treatment. Sex Transm Dis. 1977;4:135-9.

7 Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; twentieth informational supplement. M100-S23, 33(1). Wayne (PA): Clinical and Laboratory Standards Institute; 2013.

8 U.S. Department of Health and Human Services. Healthy People 2020 Web site. [Accessed on 10/18/2013] http://healthypeople.gov/2020/default.aspx.