Is the clinical spectrum of gonorrhea changing?

JOURNAL OF ADOLESCENTHEALTH 1995;17:123-127

FELLOWSHIP FORUM

Is the Clinical Spectrum of Gonorrhea Changing? MEHRAN MANDEGAR,

B.S., A N D ERIC A. S C H A F F , M.D.

Purpose: The study's objective was to determine whether the high rates of gonorrhea in one inner city teen health care program were due to an increase in detection of asymptomatic cases and consequently a decrease in symptomatic gonococcal infections over a 4V2 year study period. Methods: A chart review was conducted of all females ages 11-19 years with gonorrhea during the last six months of 1988 and all of 1990 and 1992. The presenting symptoms, physical signs, diagnosis, co-infections, and history of STD contacts were analyzed. Results: Four hundred and twenty-five charts were reviewed: 104 (24%) cases in the 11-15 year old age group, 169 (40%) in the 16-17 year old age group and 152 (36%) in the 18-19 year old age group. Approximately two-thirds had physical signs consistent with a sexually transmitted disease. About 25% presented as a contact of s o m e o n e with a k n o w n STD or with symptoms suggestive of a STD. Fewer than 2 ~ had pelvic inflammatory disease. The majority of all groups had symptoms, though older teenagers provided complaints significantly more often (p < 0.01). Teenagers under 15 years that were significantly more l i k e l y to have no symptoms or signs (p < .05). Conclusions: There were no significant changes detected in the percent of symptomatic subjects over the 4 1/2 year period, i.e., the clinical spectrum of gonorrhea remained unchanged.

With the increased public awareness of sexually transmitted diseases (STDs) in recent years, mainly owing to the HIV epidemic, individuals with gonorrhea m a y be more likely to present with earlier and, therefore, milder gonorrhea infections. The reporting of gonorrhea does not distinguish between symptomatic versus asymptomatic cases. Therefore, it is difficult to assess whether the high rates of gonorrhea in the United States are d u e to a large n u m b e r of symptomatic individuals seeking treatment or an e x p a n d e d public health effort to detect asymptomatic individuals at an earlier stage in the disease. Neisseria gonorrhoeae and other STDs continue to be a major public health problem in the United States despite the availability of effective treatment, public health clinics, and contact tracing. Rochester, NY has one of the highest rates of gonorrhea per capita in the nation, 1,677 cases per 100,000; vastly exceeding the 1990 national objective of 280 cases per 100,000 (1). In this s t u d y a primary health care site was chosen to determine whether the high rate of gonorrhea in one inner city teen health care p r o g r a m was due to an increase in detection of asymptomatic cases and consequently a decrease in symptomatic gonococcal infections over a 4l/2 year s t u d y period.

KEY WORDS:

Gonorrhea Teenagers Clinical features

From the Department of Family Medicine !E.A.S.L University ~!f Rochester Sciwol of Medicine, Rochester, New York. Address correspo~dence to: Dr. Eric A. Schaff, Associate Profl'ssor of Family Medicine and Pediatrics, University of Rochester, Depart ment of Famih! Medicine, 885 South Avenue, Rochester, NY 14(~20. Manuscript accepted July 14, 1994.

Methods Patient Population

The s t u d y was p e r f o r m e d at an inner city neighborhood health center that provides comprehensive medical services to p r e d o m i n a n t l y low income, minority residents of central Rochester. The s t u d y began in the last six months of 1988 after a log was begun on all positive gonorrhea cultures. During these six months, the teen p r o g r a m p r o v i d e d health services to 810 teenagers u p to age 19 years. They

© Societyfor AdolescentMedicine,[qq5 Published bv ElsevierScienceInc, 65~ Aventleof the Americas,Ne~ ~ork, NY 1001~

123 1054-139X/95/$9.50 SSDI 1054-139X(94)00186-I

124

MANDEGARAND SCHAFF

m a d e 1,828 visits. In 1990, 2,354 teenagers m a d e 5,216 visits. In 1992, 2,745 teenagers m a d e 6,727 visits. In the census year 1990, the total 15-19 year old female population attending the teen p r o g r a m was 589, or 2% of the 23,849 15-19 year old teenagers of M o n r o e County. Although the n u m b e r of patients and visits increased over the 41/2 year study period, the sex and ethnic percentages did not change significantly. On average, 73 percent of the patients were female. Seventy-one percent were African-American and 23 percent were of Latino origin.

Data Collection This s t u d y reviewed charts for all patients age 11-19 years with a positive N. gonorrhoeae culture during 5 six-month intervals over a four-and-a-half year period from the last half of 1988 to the end of 1992. Each culture was considered to be a separate case. There were 434 cases of gonorrhea infection in females between ages 11 and 19 years identified in the teen p r o g r a m during the study period. Nine of the 434 medical records could not be located, leaving 425 records. Charts were reviewed and data were recorded on a standard form for each episode of gonorrhea, including: chief complaint, symptoms, signs, diagnosis, co-infections and presence of STD concerns or s y m p t o m s in a male partner. The following definitions were used: 1) "STD s y m p t o m s " included vaginal and urinary complaints or abdominal pain, 2) "STS signs" included abnormal vaginal discharge, cervical discharge, or cervical, uterine or abdominal tenderness determined by the provider, 3) "STD contact" reflected information that their partner had a k n o w n STD or STD symptoms, and 4) pelvic inflammatory disease determined bv the provider using clinical criteria.

JOURNAL OF ADOLESCENTHEALTH Vol. 17, No. 2

inflammatorv disease over the 41/2 year s t u d y period of subjects with gonorrhea but no k n o w n history of an STD contact.

Results Incidence of Gonorrhea During the last six months of 1988, there were 176 cases of gonococcal infection reported in this p o p u lation, giving an incidence of 22 cases per 100 teenagers. In 1990, there were 345 gonorrhea cases, or 15 cases per 100 teenagers. In 1992, there were 276 gonorrhea cases, or 10 cases per 100 teenagers. During the same period, the n u m b e r of gonococcal infections for all ages in Monroe C o u n t y was 3,959, 3,782, and 3,532 for 1988, 1990, and 1992, respectively. In the census year 1990, the teen p r o g r a m had 162 gonorrhea cases reported in the 15-19 year old age group, which represents 25% of the 656 gonorrhea cases in M o n r o e C o u n t y in this age group.

Descriptive Analysis Of the 425 cases, there were 104 (24%) in the 11-15 year old age group, 169 (40%) in the 16-17 year old age group, and 152 (36%) in the 18-19 year old age group. There were 299 (70%) cases with STD symptoms (the rest were detected on routine examination), 280 (66%) cases with signs consistent with STD infections, and 120 (28%) cases with k n o w n STD contacts. Eighteen (4%) cases of pelvic inflammatory disease were diagnosed. O n e - h u n d r e d fifty-two (36%) cases had at least one co-infection: 100 with chlamydia, 62 with trichomonas, 7 with venereal warts, and 1 with syphilis. Of these, 18 cases had more than one co-infection: 16 cases had chlamydia and trichomonas and 2 cases had venereal warts and trichomonas.

Chi-square Analysis Analysis The study population was divided into three age groups corresponding to early (11-15 years old), mid (16-17 years old), and late (18-19 years old) adolescence. A descriptive analysis of the population was performed. Chi-square analyses were used to assess: 1) differences in symptoms, signs, k n o w n STD contact, incidence of pelvic inflammatory disease, and co-infections by the three age groups and whether the subject had an STD contact, and 2) changes in the percent of symptoms, signs, or pelvic

Table 1 summarizes the differences a m o n g the three age groups in terms of symptoms, signs of cervicitis, k n o w n STD contact, incidence of pelvic inflammatory disease, and co-infection. The majority of all groups had symptoms, though older teenagers p r o v i d e d STD complaints significantly more often (p < 0.0l). Teenagers under 15 years were significantly less likely to have s y m p t o m s or signs. Table 2 summarizes the experience of those w o m e n who reported a symptomatic male contact. The only significant difference was in symptoms,

A u g u s t 1995

CLINICAL SPECTRUM OF G O N O R R H E A

125

Table 1. Characteristics of Female Teenagers with Gonorrhea by Age Groups, N = 425 Age Groups (Years)

N

11-15 104 16-17 169 18-19 152 Chi-Sq (2~) Probability PID

No STD signs or symptoms

STD symptoms

STD signs

STD contacts

Co-infections

Dx of PID

21 (20%) 26 (15%) 14 (9%) 6.3 < 0.05

61 (59%) 123 (73%) 115 (76c;'~) 9.35 < 0.01

64 (62%) 107 (63%) 109 (72%) 3.7 0.16

22% (23) 27% (45) 34% (52) 4.8 0.09

47 (31%) 54 (36%) 51 (34%) 5.4 0.06

t (1%) 8 (5%) 9 (6%) 3.9 0.14

pelvic inflammatory disease

with 96% of women with known contact reporting symptoms versus 60% in the group without known exposure (P < 0.001). T i m e Trends

There were 305 (72%) subjects who presented with no history of STD contact during the study. Figure 1 summarizes the proportion of these subjects presenting with symptoms, sign, or the diagnosis of pelvic inflammatory disease during the 5 six-month intervals over the 4~A year study period. A Chisquare analysis revealed no significant differences in proportion of subjects with symptoms (chi-square with 4 degrees of freedom = 3.25, p = 0.51), signs (chi-square, 4 degrees of freedom = 1.9, p = .75), or incidence of pelvic inflammatory disease (chisquare, 4 degrees of freedom = 6.78, p = .1).

Discussion Although there has been an aggressive effort to identify and treat cases of gonorrhea for the past decade, the incidence of gonorrhea remain quite high. Clinical aspects of gonorrhea have been studied primarily on selected populations attending STD clinics. Epidemiologic studies performed at these sites have shown that men predominately attend these clinics for symptom evaluation while women's reasons are less uniform (2). Gonococcal infection in

men and w o m e n m a y be asymptomatic and therefore may easily be overlooked in routine examinations (3,4). Recent studies suggest that the prevalence of gonorrhea in some private practices and ambulatory clinic settings m a y be as high as 1 to 2 percent (5). This study attempted to determine if the high number resulted from increased detection of asymptomatic cases. Results of this study must be interpreted with caution because of its retrospective nature using medical records. This study relied on multiple providers, each of whom may have had different degrees of completeness in charting and different criteria for diagnosing illnesses such as pelvic inflammatory disease. In addition, women with severe symptoms may have presented to hospitals or emergency departments. A primary care setting that routinely screens women for gonorrhea and chlamydia as part of its family planning services was chosen, to avoid the bias of studying STD populations who likely knew they were infected. However, owing to its location and the population that it serves, this site cares for a relatively high risk group of adolescents when compared with the general population. This is substantiated by the finding that one-fourth of all female teenagers in Monroe County with gonorrhea were diagnosed at this site. The study found that teenagers under 15 years of age were significantly less likely to report no STD symptoms or have STD signs compared with older teenagers. Young teenagers may be 1) less aware of

Table 2. Characteristics of Female Teenagers with Gonorrhea by History of STD Contacts, N = 425 N With STD contacts W i t h o u t STD contacts Chi-sq (1 ~ freedom) Probability

120 ( 100'Yc) 305 ( 100~;'c)

Positive symptoms

Positive signs

Co-infections

Dx of PID

115 (96'~)

83 (69%)

46 (38%)

2 (2%)

184 (00'if)

197 (65%)

106 (35%)

16 (5%)

52.04 < .001

0.80 0.37

0.48 0.48

2.7 0.09

126

MANDEGAR AND SCHAFF

JOURNAL OF ADOLESCENT HEALTH Vol. 17, No. 2

% CASES OF GONORRHEA WITH: 60 50 4O SYMPTOMS* - - CERVICITIS

30

-~- PID DX 20 10

0~

JUL-DEC 88

JAN-JUN 90

JUL-DEC 90

JAN-JUN 92

JUL-DEC 92

TIME INTERVALS Symptoms=vaginal discharge, abdominal or vaginal pain Figure 1. Percent of female teenagers w~th ,~,onorrhea presenting with vaginal swmptoms, si~,ns ot cervicitis and PID over 4V2 years (STD contacts excluded), N = 305.

b o d y changes or STD s y m p t o m s or 2) unwilling to mention STD concerns owing to embarrassment. Clinicians must maintain a high degree of suspicion of STDs w h e n providing care to y o u n g e r sexually active teenagers. The high percent of teen females who had STD contacts and also had STD symptoms or signs may reflect a more advanced infection or the patient/ provider bias of knowing they were exposed to a STD. Fewer than one-third of our patients claimed to have a partner with STD concerns or symptoms. This may suggest either a large asymptomatic male pool or a reluctance of males to acknowledge their symptoms. It is difficult to screen males directly because they do not routinely come for health care or receive routine reproductive check-ups. Therefore most asymptomatic males with gonorrhea can go undiagnosed for a long time. This delay in recognition of gonococcal infection is an important factor leading to persistence or increased transmission of gonorrhea in the general population (6). More aggressive screening programs and methods to seek out asymptomatic males with gonorrhea are needed.

This study was unable to detect a decrease in symptomatic gonorrhea infections over the 41/2 year study period. Possibly a longer s t u d y period or comparisons with studies from the past m a y answer this question more definitively. Because we were unable to detect any time trends, we are unable to resolve the question of w h e t h e r the increasing reported rates of gonorrhea reflect a large n u m b e r of symptomatic individuals seeking treatment or an expended public health effort to detect asymptomatic individuals at an earlier stage in their infection. We thank Judy Engerman, Sally Rousseau, Peter Franks, M.D., and Nancy Campbell-Heider, Ph.D. for their technical assistance, Sue Cowell from the Monroe County Department of Health, and the Anthony L. Jordan Health Center's Medical Record staff. The project was partially supported from a grant for predoctoral training in Family Medicine from the U.S. Department of Health and Human Services.

References i. Monroe County Department of Health. Defining the STD core population: Implications for HIV/STD education and prevention. The epidemiology of syphilis and gonorrhea in Monroe County; 1986-1991.

August 1995

2. Pabst KM, Reichort CA. Disease prevalence among women attending a sexually transmitted disease clinic varies with reason for visit. Sex Trans Dis 1992;19(2):88-91. 3. Barlow D, Phillips I. Gonorrhea in women: diagnostic, clinical and laboratory aspects. Lancet 1987;1:761-4. 4. Handsfield HH, Lipman TO, Harnich JP, et al. Asymptomatic gonorrhea in men: diagnosis, natural course, prevalence and significance. N Engl J Med 1974;290:117-23.

CLINICAL SPECTRUM OF GONORRHEA

127

5. Bronken TP, Dyke JW, Andruszewski MH. A solid-phase enzyme immunoassay in detection of cervical gonorrhea in a low prevalence population. J Fam Pract 1985;20:43-8. 6. Rice RJ, Roberts PL, Holmes KK, et al. Sociodemographic distribution of gonorrhea incidence: Implications for prevention and behavioral research. Am J Public Health 1991;81(10):1252-8.