Download 2013-2015 Cuyahoga County Sexually Transmitted Diseases Report

2013-2015 Cuyahoga County Sexually Transmitted Diseases Report:
Chlamydia and Gonorrhea—
Executive Summary
Chlamydia cases and rates for Cuyahoga County (left) and Cleveland (right). Cases are denoted as lines, while rates
per 100,000 in population are denoted as vertical bars. Trends have shown a decrease in the rates and number of
cases in recent years, with a 12% decrease in rates from 2015* compared to rates from 2012 for the county, and an
18% decrease in rates from 2015* compared to rates from 2012 for Cleveland.
Gonorrhea cases and rates for Cuyahoga County (left) and Cleveland (right). Cases are denoted as lines, while rates
per 100,000 in population are denoted as vertical bars. Trends have also shown a decrease in the rates and number
of cases in recent years, with an 18% decrease in rates from 2015* compared to rates from 2012 for the county, and
a 20% decrease in rates from 2015* compared to rates from 2012 for Cleveland.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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2013-2015 City of Cleveland and Cuyahoga County Sexually
Transmitted Diseases Report: Chlamydia and Gonorrhea—
Executive Summary continued...
Co-infection of Chlamydia and Gonorrhea cases and rates for Cuyahoga County (left) and Cleveland (right). Cases
are denoted as lines, while rates per 100,000 in population are denoted as vertical bars. Trends have shown a
decrease in the rates and number of cases in recent years, with a 26% decrease in rates from 2015* compared to
rates from 2012 for the county, and a 29% decrease in rates from 2015* compared to rates from 2013 for Cleveland.
Cases and rates were not available before 2012 for the county and before 2013 for Cleveland.
*2015 data is preliminary.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Cleveland Department of Public Health
Office of Communicable Disease Surveillance and Epidemiology
2013
2013--2015 Cuyahoga County Sexually Transmitted
Diseases Report:
Chlamydia and Gonorrhea
Cleveland Department of Public Health
75 Erieview Plaza
Cleveland, OH 44114
Phone: 216-664-3747
Fax: 216-664-6159
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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2013-2015 Cuyahoga County Sexually
Transmitted Diseases Report:
Chlamydia and Gonorrhea
Cleveland Department of Public Health
Office of Communicable Disease Surveillance and
Epidemiology
The Cleveland Department of Public Health would like to thank the following for their
contributions to this report:
Cleveland Department of Public Health
Alisha Cassady, MPH Candidate
Vinothini Sundaram, MPH
Office of Communicable Disease Surveillance and Epidemiology
Jackie Tomer, MPH
Office of Communicable Disease Surveillance and Epidemiology
Data prepared by Ohio Department of Public Health ODRS (Ohio Disease Reporting System). Surveillance performed
in cooperation with the Cuyahoga County Board of Health.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Table of Contents
Sexually Transmitted Diseases Introduction…………………………………………………………………….……………………………………pg. 7
Chlamydia…………………………………………………………………………………………………………………………………….……………………….pg. 8
Chlamydia Introduction………………………………………………………………………………………………………………...………….pg. 9
Chlamydia Statistics……………………………………………………………………………………………………..………………………...pg. 10
Chlamydia by Municipality……………………………………………………………………….……………………………………………..pg. 11
Chlamydia by Sex………………………………………………………………………………………………….………………………………...pg. 12
Chlamydia by Age…………………………………………………………………………………………………………….…………..………...pg. 13
Chlamydia by Age and Sex…………………………………………………………………………………………………………….…………pg. 14
Chlamydia by Race……………………………………………………………………………………………….………………………………….pg. 15
Chlamydia by Ethnicity………………………………………………………………………………………………………………..………….pg. 16
Gonorrhea………………………………………………………………………………………….………………………………………………….…………..pg. 17
Gonorrhea Introduction……………………………………………………………………………………………………………………….….pg. 18
Gonorrhea Statistics………………………………………………………………………..………………………………………….…………..pg. 19
Gonorrhea by Municipality………………………………………………………………………………..………………………….………..pg. 20
Gonorrhea by Sex………………………………………………………………………………………………………….………………………..pg. 21
Gonorrhea by Age……………………………………………………………………………………………………………………..…………….pg. 22
Gonorrhea by Age and Sex………………………………………………………………………..…………………………………………....pg. 23
Gonorrhea by Race…………………………………………………………………………………………………………………….…………...pg. 24
Gonorrhea by Ethnicity……………………………………………………………………………………………..…………………………....pg. 25
Co-Infections of Chlamydia and Gonorrhea………………………………………………………………………………………………….……..pg. 26
Co-Infections Introduction………………………………………………………………………………………………………………………pg. 27
Co-Infections by Municipality………………………………………………..…………………………….………………………………….pg. 28
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Co-Infections by Sex………………………………………………………………………………………………………..………………………pg. 29
Co-Infections by Age………………………………………………………………………………………………………………………………..pg. 30
Co-Infections by Age and Sex…………………………………………………………………………………………………………………..pg. 31
Co-Infections by Race………………………………………………………………………………………………………………………………pg. 32
Co-Infections by Ethnicity………………………………………………………………………………………………………………………..pg. 33
Populations of Special Interest………………………………………………………………………………………………………..………………….pg. 34
Recommendations………………………………………………………………………………………………………………………………………………pg. 37
Future Directions…………………………………………………………………………………………………………………………………………………pg. 38
Testing Centers……………………………………………………………………..…………………………………………………………………………….pg. 39
Appendix…………………………………………………………………………………………….………………………………………………………………pg. 41
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Sexually Transmitted Diseases Introduction

Sexually transmitted diseases (STDs) are infections that are spread through sexual contact.

Sexually transmitted infection (STI) is a broader term for STD; some STDs do not cause symptoms, but are still
considered to be an infection. An infection is considered to be a disease when it causes altered function in the
body (University of Maryland, University Health Center, 2009).

STDs can be caused by bacteria, parasites, or viruses.

STDs can be transmitted through blood, semen, vaginal fluids, and other body fluids.

There are over 20 types of STDs.

STDs affect both men and women, however, some can cause more severe complications in women.

Treatment for STDs varies depending on the type of infection.

Using latex condoms can greatly reduce the risk of contracting an STD.

A pregnant woman who is infected with an STD is at risk for transmitting the infection to her unborn baby.

Often, STDs present as asymptomatic until long-term complications occur.

Chlamydia and gonorrhea are among the most common STDs in the United States.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Chlamydia
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Chlamydia Introduction
What is Chlamydia?
How is Chlamydia transmitted?

Chlamydia is caused by the bacteria
Chlamydia trachomatis.

Chlamydia is spread through vaginal, anal, or oral sex with an
individual who is infected.

It is the most commonly reported

sexually transmitted disease (STD) in the

United States. It has comprised the
largest portion of reported STIs to the

CDC since 1994. In 2014, there were a
total of 1,441,789 chlamydia cases
reported to the CDC.
Infection can occur days to months after the initial exposure.
Chlamydial infection can facilitate the transmission of Human
Immunodeficiency Virus (HIV).
Chlamydia can also be passed from mother to child during
childbirth (congenital infection). It can also increase the likelihood
that a woman will deliver her baby early.
Diagnosis and Treatment of Chlamydia

Often, chlamydia presents with no symptoms. In some
cases, symptoms may not appear for several weeks after
infection has occurred.

In women, chlamydia can cause abnormal vaginal
discharge and a burning sensation when urinating.

In men, chlamydia can cause discharge from the penis, a
burning sensation when urinating, and pain or swelling in
one or both testicles. However, men rarely experience
health complications associated with chlamydia.

Chlamydia is often diagnosed through cultures from swabs
of either the cervix in women or the urethra in men.
Chlamydia can also be diagnosed from a urine sample.

Chlamydia is easily cured with antibiotics. However, if left
untreated, it can cause a condition called Pelvic
Inflammatory Disease (PID), which can make it difficult for
women to get pregnant.

Individuals being treated for chlamydia should abstain
from sexual activity for seven days during treatment.

Repeat infection with chlamydia is common.
Pap smear showing Chlamydia trachomatis
Prevention of Chlamydia Infection

Annual screening for chlamydia is
recommended for all sexually active
women who are less than 25 years old or
who have multiple risk factors (e.g.,
multiple new sexual partners).

Chlamydia screening for men is
recommended in areas with a high burden
of the disease.

Using latex condoms correctly can greatly
reduce the likelihood of contracting
chlamydia.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Chlamydia Statistics
www.cdc.gov

Chlamydia has the highest prevalence in individuals under 24
years old.

In 2014, Ohio was #18 in the United States for chlamydia
infections (with 54,858 cases and a rate of 474.1 per 100,000).

Cuyahoga County was #20 in the United States for chlamydia
infections in 2014 (with 9,072 cases and a rate of 718.2 per
100,000).

Trends overtime have shown that chlamydia is more common in
women than in men.

Adolescents and young adults tend to have the highest rates of
chlamydia (among 15-24 year olds).

Trends in chlamydia infections also show that the infection is
most common in Non-Hispanic African Americans.

From 2013-2015, there were 28,121 chlamydia infections in
Cuyahoga County.
www.cdc.gov
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Chlamydia Cases by Municipality, 2013
2013--2015
Figure 2. Graph of Chlamydia cases in Cuyahoga County municipalities in 2013-2015 (above). The top five
municipalities with the most infections are indicated on the graph. Some municipalities had no Chlamydia infections
in 2013-2015. As shown, Cleveland comprises over 50% of the Chlamydia infections in 2013-2015. Rates of infection
are provided in Table 1 of the Appendix.
Figure 3. Chlamydia cases
in Cleveland compared to
other major metropolitan
areas in Ohio (right).
Numbers obtained from
the Ohio Department of
Health (ODH). As shown,
Cleveland had a
significantly larger
number of chlamydia
infections than most other
major metropolitan areas
in Ohio. Statistics for 2015
were not yet available.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Chlamydia Cases by Sex, 2013
2013--2015
Sex
Number of Cases
Female
19,518
Male
8,602
Total
28,120*
The table to the left shows the number of
Chlamydia infections in Cuyahoga County for
2013-2015 by sex. There was one individual with
no sex data. The number of females with
Chlamydia infections is two times the number of
infections in males. Rates of infection are provided
in Table 2 of the Appendix.
*: Sex unknown for one individual
Figure 4. Graph of Chlamydia cases in Cuyahoga County for 2013-2015 by sex. As also shown in the
graph above, females comprise over 50% of the Chlamydia infections in Cuyahoga County for
2013-2015.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Chlamydia Cases by Age, 2013
2013--2015
The table to the right shows the number of Chlamydia
infections in Cuyahoga County for 2013-2015 by age.
20-24 year olds and 15-19 year olds have the highest
and second highest number of infections, respectively.
20-24 year olds and 15-19 year olds have over two times
the number of infections when compared to 25-29 year
olds. Rates of infections are provided in Table 3 of the
Appendix.
Age
Number of Cases
0-9 years old
19
10-14 years old
430
15-19 years old
9,712
20-24 years old
10,783
25-29 years old
4,080
30-34 years old
1,657
35-39 years old
716
40-44 years old
348
45-54 years old
268
55-64 years old
86
65+ years old
13
Total
28,121
Figure 5. Graph of Chlamydia
infections in Cuyahoga County for
2013-2015 by age (left). Percentages
are labeled for the three age groups
with the highest number of
infections. Adolescents and young
adults (20-24 year olds and 15-19
year olds) comprise almost 75% of
the total number of infections.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Chlamydia Cases by Age & Sex, 2013
2013--2015
Age
Female Cases
Male Cases
0-9 years old
10
9
10-14 years old
378
52
15-19 years old
7,221
2,491
20-24 years old
7,682
3,100
25-29 years old
2,582
1,498
30-34 years old
941
716
35-39 years old
371
345
40-44 years old
174
174
45-54 years old
117
151
55-64 years old
35
51
65+ years old
**
10
Total*
19,514
8,597
The table to the left shows the number of Chlamydia
infections in Cuyahoga County for 2013-2015 by age and
sex. In both sexes, 20-24 year olds and 15-19 year olds have
the highest and second highest number of chlamydia
infections, respectively. Until ages 40-44, females have
higher numbers of infections. After 45, an increase in the
number of infections is noticed in males; they have higher
numbers of infections. Rates of infection are provided in
Tables 4 and 5 of the Appendix.
*: Sex was unknown for one individual
**: Rate data are suppressed when case counts are 5 or less
Figure 6. Graph of Chlamydia infections in Cuyahoga County for 2013-2015 by age and sex.
As shown in the graph above, females have two to seven times the amount of infections as
males up to ages 40-44. However, after ages 45-54, an increase in the number of infections
can be seen in males, and their numbers surpass those of females.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Chlamydia Cases by Race, 2013
2013--2015
Race
Number of Cases
American Indian/Alaskan
Native
27
Asian
97
African American
17,687
Hawaiian Native/Pacific
Islander
7
Multiracial
**
Some Other Race
914
Caucasians
4,254
Total*
22,987
The table to the left shows the number of
Chlamydia infections for Cuyahoga County for
2013-2015 by race. African Americans have
more than four times the number of
Chlamydia infections as Caucasians. African
Americans are also the minority population
who are most adversely affected with
Chlamydia infections. Rates of infection are
provided in Table 6 of the Appendix.
*: 5,134 individuals missing, had unknown, or refused to answer race data
**: Rate data are suppressed when case counts are 5 or less
Figure 7. Graph of Chlamydia
infections for Cuyahoga County in
2013-2015 by race. As shown in
the graph to the left, African
Americans comprise more than
75% of those individuals with
Chlamydia infections, while
Caucasians comprise less than
20%. Other minority populations
contribute very little to the total
number of infections.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Chlamydia Cases by Ethnicity, 2013
2013--2015
Ethnicity
Number of Cases
Hispanic or Latino
460
Non-Hispanic or
Non-Latino
17,164
Total*
17,624
The table to the left shows Chlamydia infections for Cuyahoga
County in 2013-2015 by Ethnicity. Non-Hispanics/Non-Latinos
have over 35 times the number of Chlamydia infections as
Hispanics or Latinos. There was a large number of individuals
with missing ethnicity data. Rates of infection are provided in
Table 7 of the Appendix.
*: 10,497 individuals missing, had unknown, or refused to answer
ethnicity data
Figure 8. Graph of Chlamydia infections
for Cuyahoga County in 2013-2015 by
ethnicity. As shown in the graph to the
right, Non-Hispanics/Non-Latinos comprise
almost all of the cases of Chlamydia in
Cuyahoga County during this period.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Gonorrhea
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Gonorrhea Introduction
What is Gonorrhea?

Gonorrhea, or gonococcal infection, is caused by the
bacterium Neisseria gonorrhaeae.

It is the second most commonly reported
communicable disease.

The Centers for Disease Control and Prevention (CDC)
estimate there are 820,000 new gonococcal infections
annually, but only half of these infections are reported
Image of the gonorrhea bacterium
to the CDC.
How is Gonorrhea transmitted?

Gonorrhea is transmitted through sexual contact with the
penis, vagina, mouth, or anus of an infected partner.

Infection can also spread from mother to child during
childbirth (perinatally). An infant who is infected with
Gonorrhea could experience blindness, joint infection, or
blood infection.

Gonorrhea infects the mucous membranes of the cervix,
uterus, and fallopian tubes in women, and the urethra in men
and women. It also can infect the mucous membranes of the
mouth, eyes, throat, and rectum.
www.cdc.gov
Diagnosis and Treatment of Gonorrhea

Men and women are often asymptomatic.

Symptoms usually include dysuria (painful or
difficult urination), discharge from the urethra
in men or vagina in women, or bleeding

between periods in women; these symptoms
may appear up to five days after exposure.

Women with gonorrhea are at a high risk of
developing complications, such as PID.

If left untreated, gonococcal infection can
increase the risk for HIV and arthritis.

Some strains of N. gonorrhaeae have developed resistance to
the drugs used to treat them. This has created a problem
because now very few antibiotics can be used to treat it.
Some risk factors for gonococcal infection include
inconsistent condom use, previous or coexisting STDs, and
exchanging sex for money or drugs.
Prevention of Gonococcal Infection

Gonococcal infection is treated with a dual
antibiotic therapy.

Re-infection can occur, even after treatment.

Gonorrhea is normally diagnosed through
urine testing.

The CDC recommends yearly screening for sexually active
women younger than 25 years old, or older women who have
many risk factors.

Using latex condoms correctly can greatly reduce the
likelihood of contracting gonorrhea.

Sexual contact should be avoided until treatment is
complete.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Gonorrhea Statistics

In 2014, there were 350,062 cases of gonorrhea reported to the CDC.

In the United States, the highest rates of infection are among teens, young adults, and African Americans.

Gonorrhea tends to concentrate in specific geographic locations and within communities.

Certain subgroups of men who have sex with men (MSM) are at a high risk for gonococcal infection.

In 2014, Ohio was #9 in the United States for gonorrhea, with 16,237 infections and a rate of 140.3 per 100,000.

Cuyahoga County was #13 in the United States for gonococcal infections in 2014 (with 3,213 infections and a rate
of 254.4 per 100,000).

Similar to chlamydia, gonorrhea tends to have higher rates in individuals aged 15-24 years old. It also tends to be
higher in Non-Hispanic African Americans.

From 2013-2015, there were 9,904 gonococcal infections in Cuyahoga County.
www.cdc.gov
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Gonorrhea Cases by Municipality, 2013
2013--2015
Figure 10. Graph of gonococcal
infections in Cuyahoga County
municipalities in 2013-2015 (left). The
top five municipalities with the most
infections are indicated on the graph to
the left. Some municipalities had no
gonococcal infections in 2013-2015. As
shown, Cleveland comprises over 60% of
the gonococcal infections in 2013-2015.
Figure 11. Gonorrhea
cases in Cleveland
compared to other major
metropolitan areas in
Ohio (right). Numbers
obtained from ODH. As
shown, Cleveland had a
significantly higher
number of gonococcal
infections than most
other major metropolitan
areas in Ohio. Statistics
for 2015 were not yet
available.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Gonorrhea Cases by Sex, 2013
2013--2015
Sex
Number of Cases
Female
5,319
Male
4,585
Total
9,904
The table to the left gives the total number of gonococcal
infections in Cuyahoga County for 2013-2015. Sex data was
available for all individuals infected. Females out-number
males in the number of infection. However, their rates of
infection between males and females are similar. Rates of
infection are supplied in Table 9 in the Appendix.
Figure 12. Graph of gonococcal
infections in Cuyahoga County for 20132015 by sex (right). As also illustrated in
the table above, women out-number men
in regards to numbers of gonococcal
infections. However, their rates of
infection are relatively similar.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Gonorrhea Cases by Age, 2013
2013--2015
The table to the right shows the number of gonococcal
infections in Cuyahoga County for 2013-2015 by age.
20-24 year olds had the largest number of infections,
followed by 15-19 year olds. 15-19 year olds had almost
two times the number of gonococcal infections
compared to 25-29 year olds. Rates of infection are
supplied in Table 10 in the Appendix.
Age
Number of Cases
0-9 years old
**
10-14 years old
168
15-19 years old
2,991
20-24 years old
3,442
25-29 years old
1,576
30-34 years old
774
35-39 years old
377
40-44 years old
209
45-54 years old
246
55-64 years old
94
65+ years old
20
Total*
9,902
*: 2 individuals missing age data
**: Rate data are suppressed when case counts are 5 or less
Figure 13. Graph of gonococcal
infections in Cuyahoga County for 20132015 by age (left). As also illustrated in
the table above, 20-24 year olds and 1519 year olds comprise most of the
gonococcal cases for 2013-2015.
Combined, they comprise 65% of the
cases.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Gonorrhea Cases by Age & Sex, 2013
2013--2015
Age
Female Cases
Male Cases
0-9 years old
**
**
10-14 years old
134
34
15-19 years old
1,928
1,063
20-24 years old
1,964
1,478
25-29 years old
720
856
30-34 years old
303
471
35-39 years old
127
250
40-44 years old
64
145
45-54 years old
52
194
55-64 years old
19
75
65+ years old
**
18
Total*
5,317
4,585
The table to the left shows the number of
gonococcal infections in Cuyahoga County for
2013-2015 by age and sex. In both sexes, 20-24
year olds and 15-19 year olds have the highest and
second highest number of gonococcal infections,
respectively. After 24 years old, the number of
infections greatly increases in males, with the male
sex comprising most of the number of infections
after the age of 24. Rates for infections are supplied
in Tables 11 and 12 in the Appendix.
*: 2 individuals missing age data
**: Rate data are suppressed when case counts are 5 or less
Figure 14. Graph of gonococcal
infections in Cuyahoga County
for 2013-2015 by age and sex.
As shown in the graph to the
right, females who are 20-24
and 15-19 years old have the
highest number of gonococcal
infections. However, after 24
years old, there is an upward
trend in the number of
infections in males, and their
number surpasses that of
females.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Gonorrhea Cases by Race, 2013
2013--2015
Race
Number of
American Indian/Alaskan Native
13
Asian
22
African American
7,325
Hawaiian Native/Pacific Islander
**
Other
243
Caucasian
907
Total*
8,511
The table to the left shows the number of
gonococcal infections in Cuyahoga County for
2013-2015 by race. Similar to Chlamydia,
African Americans had the highest number of
infections. African Americans had eight times
the number of gonococcal infections as
Caucasians. Rates of infection are provided in
Table 13 of the Appendix.
*: 1,393 individuals missing, had unknown, or refused to answer race data
**: Rate data are suppressed when case counts are 5 or less
Figure 15. Graph of gonococcal infections
in Cuyahoga County for 2013-2015 by
race. As shown in the graph to the right,
African Americans comprise more than
75% of the number of gonococcal
infections in Cuyahoga County for this
period, while Caucasians only comprise
only about 10%. Again, other minority
populations contribute very little to the
total number of infections.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Gonorrhea Cases by Ethnicity, 2013
2013--2015
Ethnicity
Number of
Cases
Hispanic or Latino
157
Non-Hispanic or Non-Latino
6,500
Total*
6,657
The table to the left shows the number of gonococcal infections
for Cuyahoga County in 2013-2015 by ethnicity. Similar to
Chlamydia, Non-Hispanic/Non-Latinos had 41 times the number
of infections as Hispanic/Latinos. There were also a large
number of individuals with missing ethnicity data. Rates of
infection are provided in Table 14 of the Appendix.
*: 3,247 individuals missing, had unknown, or refused to answer
ethnicity data
Figure 16. Graph of gonococcal infections for
Cuyahoga County in 2013-2015 by ethnicity
(right). As also shown in Chlamydia cases in
2013-2015, Non-Hispanic/Non-Latinos comprise
almost all of this population with gonococcal
infections in Cuyahoga County during this period.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Co
Co--Infections of
Chlamydia &
Gonorrhea
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Co
Co--Infections Introduction
What is co-infection?

Co-infection is contracting a second STD while already
infected with a different STD.

Being infected with one STD increased the likelihood
of being infected with a second STD.

Chlamydia and gonorrhea are the two most commonly
reported bacterial STDs, which increases the likelihood
of co-infection.

If caught early, only a single dose of antibiotics is
required to treat both infections.
Transmission electron micrograph of Chlamydia trachomatis
Similarities between Chlamydia and Gonorrhea

Chlamydia and Gonorrhea have similar symptoms of
infection.

These two organisms also infect similar mucosal
membranes.

Because of these similarities, an individual can easily
become infected with both infections.

This also suggests that individuals should be tested
for both STDs simultaneously, especially if they
exhibit risk factors.
Chlamydia and Gonorrhea Co-Infection Statistics

Data from the Virginia Department of Health suggests
that 40-50% of 15-24 year olds who have tested
positive for Gonorrhea are co-infected with
Chlamydia.

This same data also suggested that women and African
Americans are more likely to have a co-infection.

Women are also more likely to develop complications
from co-infections, such as PID.

In 2013-2015, there were 3,325 co-infections of
Chlamydia and Gonorrhea in Cuyahoga County.
Scanning electron micrograph of Neisseria gonorrhoeae
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
27
Co
Co--Infections Cases by Municipality, 2013
2013--2015
Figure 18. Graph of Co-Infection Cases
in Cuyahoga County Municipalities in
2013-2015 (left). The top five
municipalities with the most
co-infections are indicated on the graph.
Some municipalities had no
co-infections infections in 2013-2015. As
shown, Cleveland comprises over 60% of
the co-infections in 2013-2015.
Figure 19. Graph of co-infection
cases for Cleveland, Ohio in 20122015. As shown, the number of
co-infections of Chlamydia and
Gonorrhea has steadily decreased
since 2013. Unfortunately, data
was not available to compare to
other cities in Ohio.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
28
Co
Co--Infection Cases by Sex, 2013
2013--2015
The table to the right shows the number of co-infection cases in
Cuyahoga County for 2013-2015 by sex. Sex data was available for
all individuals. The number of females with co-infections
out-numbers that of males by more than 50%. Rates for infection
are supplied in Table 16 in the Appendix.
Sex
Number of
Cases
Female
1,981
Male
1,344
Total
3,325
Figure 20. Graph of the number of co-infection
cases in Cuyahoga County for 2013-2015 by sex
(left). As also shown in the table above, females
out-number males in regards to number of
co-infection cases. Because of this, women also
have a higher rate of co-infection cases.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
29
Co
Co--Infection Cases by Age, 2013
2013--2015
Age
Number of Cases
0-9 years old
**
10-14 years old
88
15-19 years old
1,394
20-24 years old
1,180
25-29 years old
379
30-34 years old
139
35-39 years old
65
40-44 years old
32
45-54 years old
32
55-64 years old
14
65+ years old
**
Total
3,325
The table to the left shows the number of
co-infection cases in Cuyahoga County for
2013-2015 by age. 15-19 year olds have the
highest number of co-infections, followed closely
behind by 20-24 year olds. 15-19 year olds had
almost four times the number of co-infections
cases compared 25-29 year olds. Rates of infection
are supplied in Table 17 in the Appendix.
**: Rate data are suppressed when case counts are 5 or less
Figure 21. Graph of co-Infection cases in
Cuyahoga County for 2013-2015 by Age
(right). As also illustrated in the table
above, 15-19 year olds and 20-24 year olds
comprise most of the co-infection cases for
2013-2015. Combined, they comprise over
75% of the cases.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
30
Co
Co--Infection Cases by Age & Sex, 2013
2013--2015
The table to the right shows the number of co-infection
cases in Cuyahoga County for 2013-2015 by age and sex.
In females, 15-19 year olds had the highest number of
infections, while in males, 20-24 year olds had the
highest number of infections. 15-19 year old females
also have two times the number of co-infection cases
when compared to 15-19 year old males. After 24 years
old, the number of infections increases rapidly in males,
with the male sex comprising most of the number of
infections after this age. Numbers and rates of infection
are supplied in Tables 18 and 19 in the Appendix.
Age
0-9 years old
10-14 years old
15-19 years old
20-24 years old
25-29 years old
30-34 years old
35-39 years old
40-44 years old
45-54 years old
55-64 years old
65+ years old
Total
Female Cases
**
73
943
691
178
59
19
7
7
**
**
1,981
Male Cases
**
15
451
489
201
80
46
25
25
11
**
1,344
**: Rate data are suppressed when case counts are 5 or less
Figure 22. Graph of co-infection cases in Cuyahoga County for 2013-2015 by age and sex. As shown
also shown in the table above, women have a significantly higher number of infections until 25 years
old; at this point, males have a much higher number of infections. 15-24 year old females and males
also comprise the largest number of co-infection cases.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
31
Co
Co--Infection Cases by Race, 2013
2013--2015
Race
Number of Cases
American Indian/Alaskan Native
**
Asian
8
African American
2,508
Other
69
Caucasian
264
Total*
2,854
The table to the left shows the number of
co-infection cases by race. African Americans have
the largest number of infections. The number of
co-infection cases in African Americans is almost
ten times the number of co-infection cases in
Caucasians. There were very few co-infection cases
in minority populations (excluding African
Americans); the number of co-infections in
minorities only comprises about 3% of the total
number of co-infections. Numbers and rates of
infection are provided in Table 20 in the Appendix.
*: 471 individuals missing or had unknown race data
**: Rate data are suppressed when case counts are 5 or less
Figure 23. Graph of co-infection cases in
Cuyahoga County for 2013-2015 by race
(right). As also shown in the table above,
African Americans comprise most of the coinfection cases in Cuyahoga County during
this time period, making up 88% of the total
number of co-infection cases. As also stated
above, minority populations other than
African Americans contribute very little to the
total number of cases.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
32
Co
Co--Infection Cases by Ethnicity, 2013
2013--2015
The table to the right shows the number of
co-infection cases in Cuyahoga County for
2013-2015 by ethnicity. Similar to both chlamydia
and gonorrhea, Non-Hispanic/Non-Latinos comprise
the vast majority of the population with
co-infections. However, about one-third of
individuals are missing or have unknown ethnicity
data. Numbers and rates of infection are provided in
Table 21 of the Appendix.
Ethnicity
Number of Cases
Hispanic or Latino
43
Non-Hispanic or Non-Latino
2,191
Total*
2,234
*: 1,091 individuals missing or had unknown ethnicity data
Figure 24. Graph of co-infection cases in
Cuyahoga County for 2013-2015 by ethnicity. As
also shown in the table above,
Non-Hispanic/Non-Latinos comprise the vast
majority of the population with co-infection
cases. Hispanic/Latinos only make up 2% of the
total number of individuals with a co-infection.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
33
Populations of Special Interest
Women
Women are at a higher risk for all types of STDs. Explanations
for this occurrence include her relationship status with a
male partner and social factors, such as access to healthcare
for sexual health and socioeconomic status (SES), and
inability to negotiate safe sex practices (e.g., condom use).
Women with Chlamydia and Gonorrhea in particular are at
an increased risk of developing PID, which can cause serious
www.cdc.gov
consequences to reproductive health. Often, both chlamydia
and gonorrhea are asymptomatic in women, and are often only detected through screening. It is estimated that 1020% of women will develop PID if they do not receive adequate treatment for chlamydia or gonorrhea (CDC, 2014).
Chlamydia and Gonorrhea can also result in adverse outcomes in pregnancy, including neonatal ophthalmia and
neonatal pneumonia (CDC, 2014).
Rates of both Chlamydia and Gonorrhea have been steadily increasing
in women in the United States since 1993 (CDC, 2014). This increase
could be due in part to increased screening efforts all over the United
States. However, locally rates have decreased in recent years. In
Cuyahoga County, Chlamydia rates in women in 2013 were 1,052.23
www.cdc.gov
per 100,000, however, rates decreased in 2015 to 929.31 per 100,000.
These rates are still much higher compared to men (in males rates in 2013 and 2015 were 489.49 per 100,000 and
466.61 per 100,000, respectively). These rates are similar for gonorrhea and co-infections, with women having a
higher rate than men. However, the difference between females and males is not as great when comparing
gonorrhea and co-infections. In 2015, the rate of gonorrhea in women was 229.5 per 100,000; in men, the rate of
Gonorrhea in 2015 was 244.83 per 100,000. This shows the rate of Gonorrhea is actually increasing in men, which
also coincides with national data. For co-infections, the rate in women in 2015 was 76.85 per 100,000; the same
rate in males was 68.49. (All rates of infection are available in the tables in the Appendix.)
Adolescents and Young Adults
In recent years, national STD incidence has increased in
adolescents and young adults aged 15-24 years old. It is
estimated that this age group acquires half of all new STD
cases and that 1 in 4 sexually active adolescent females have
an STD (CDC, 2014). This age group is often at an increased
risk of acquiring an STD because of differences in behavior,
www.cdc.gov
biology (i.e., immature reproductive system), or culture. This increased incidence could also be due to
many barriers to accessing healthcare, such as inability to pay for services, lack of transportation, schedule conflicts,
and stigma surrounding STD treatment.
In 2015, adolescents and young adults aged 15-24 years old comprised over 60% of all Chlamydia, Gonorrhea, and
(cont’d on next page)
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
34
Adolescents and Young Adults cont’d...
co-infections cases in Cuyahoga County. However, trends in rates show that incidence of both STDs is in both of
these age groups. For example, in 2013, the rate of Chlamydia in 15-19 year olds was 4,049.71 per 100,000, but in
2015 this rate decreased to 3,362.92 per 100,000. However, these rates are still high when compared to other
groups. In 2015, rates of co-infection in 15-19 year olds was 408.3 per 100,000, while the same rate in 25-29 year
olds was only 161 per 100,000; this means the rate of co-infection is two-and-a-half times higher in 15-19 year olds.
A similar trend has been identified in Chlamydia and Gonorrhea cases. In 2015, rates of Chlamydia in 15-19 year olds
was 3,362.92 per 100,000 compared to 1,792.99 per 100,000 in 25-29 year olds; this means the rate is almost two
times higher in 15-19 year olds. Similarly, in Gonorrhea cases in 15-19 year olds, the rate in 2015 was 906.47 per
100,000, compared to 25-29 year olds
www.cdc.gov
whose rate was 667.19 per 100,000; the
rate in 15-19 year olds is almost 50%
higher than the rate in 25-29 year olds.
(All rates of infection are available in the tables in
the Appendix.)
Racial and Ethnic Minorities
Recent surveillance has shown higher rates of STDs in
some racial and ethnic minority groups when compared to
Caucasians. These higher rates are sometimes attributed
to higher rates of poverty, low SES, differences in
education, and poor access to healthcare. Often, there is
also fear and distrust of healthcare workers among
minority groups, which also prevents these individuals
from accessing care. Even when care is accessible, the
quality of care may differ for these minority patients. All
www.cdc.gov
of these aspects are observed when examining the incidence of STDs among different races and ethnicities.
Rates of infection for Chlamydia, Gonorrhea, and co-infection are generally higher in all minority populations when
compared to Caucasians (excluding Asians). In Cuyahoga County, however, African Americans were the only well
represented minority population in Chlamydia, Gonorrhea, and co-infection cases. For all types of infections, African
Americans comprised over 60% of the total number of infections. In 2015, the rate of Chlamydia in African
Americans in Cuyahoga County was 1,414.49 per 100,000, while the same rate in Caucasians was 171.85 per
100,000; this shows that African Americans had eight times the number of Chlamydia infections compared to
Caucasians. The same trend was observed in Gonorrhea and co-infection cases. For Gonorrhea cases in Cuyahoga
County in 2015, African Americans had a rate of 559.71 per 100,000, while Caucasians only had a rate of 35.25 per
100,000; this means that African Americans had a rate almost sixteen times higher than Caucasians. For co-infection
cases in Cuyahoga County for 2015, African Americans had a rate of 175.96 per 100,000, while the rate in Caucasians
was 7.49 per 100,000; this means that the rate was almost twenty-four times higher in African Americans than
Caucasians. While rates are higher in other minority populations in Cuyahoga County, there are very few cases in
other minority populations of Chlamydia, Gonorrhea, and co-infections. (All rates of infection are available in the tables in the
Appendix.)
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
35
Populations of Special Interest cont’d...
The table to the left shows the
number of co-infections in females,
by age and race, for 2013-2015.
African American females who are
15-19 years old have the highest
number of co-infections ; the
number of cases in this group
comprises 21.14% of the total
number of co-infections for this
time period. This data suggests that
African American adolescent girls
should be a target of education
about STDs; increased screening
efforts for STDs would also be
beneficial to this population.
The table to the right shows the
number of co-infections in males,
by age and race, for 2013-2015.
African American males who are
15-19 years old have the second
highest number of co-infections; the
number of cases in this group
comprises 10.59% of the total
number of co-infections for this
time period. This data suggests that
African American adolescent boys
should also be the target of
education about STDs; increased
screening efforts for STDs would also
be beneficial to this population.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
36
Recommendations
In order to further prevent the spread of STDs, it is vital that anyone
who is sexually active is screened and tested. Per the CDC’s
guidelines, screening and testing for Chlamydia and Gonorrhea are
recommended for all sexually active women 25 years old and
younger once a year; it is also recommended that women who are
older but have many risk factors (such as new or multiple sex
partners) should also be screened annually. Pregnant women 25
years old and younger should also be screened for both Chlamydia
and Gonorrhea in order to protect the health of the child. Screening
is also recommended annually for sexually active gay, bisexual, or any men who have sex with men
(MSM); MSM who have multiple or anonymous sex partners are recommended to be screened more
often (CDC 2016). For those who have been treated for an STD, it is recommended that they be
rescreened three months after treatment.
Screening and testing of sexual partners is also critical in order to stop the spread of infection.
Recently, Ohio joined 47 other states who are participating in Expedited Partner Therapy (EPT). EPT is the
practice of treating the partners of patients who have been diagnosed with Chlamydia or Gonorrhea
without a healthcare provider seeing the partner first. The healthcare provider will give the patient
medications that can be given to their sexual partner(s), making treatment of STDs much easier. However,
the preferred method of partner treatment is partner referral through the patient.
Chlamydia and Gonorrhea can also be prevented through other methods. Abstinence is the most
reliable way to prevent any STD infection (i.e., not having anal, vaginal, or oral sex). Reducing the number
of sexual partners, or participating in mutual monogamy will also greatly reduce the risk of STD infection.
When male latex condoms are used correctly, they can be very effective at reducing the transmission of
STDs. In order to reduce risk, latex condoms must be worn throughout the entirety of anal, oral, or vaginal
intercourse.
As stated earlier, adolescents and young adults have the highest risk of acquiring Chlamydia and
Gonorrhea. Therefore, it is imperative that STD testing and treatment be increased among this
population. The CDC has recommended several approaches to teen STD testing and treatment. There are
several public school systems in the United States that have implemented education, testing, and
treatment programs for STDs in adolescents (e.g., School
District of Philadelphia, Chicago Public Schools, and San
Diego Unified School District) (CDC 2016). It would be
advantageous to consider a program like the ones listed in
the Cleveland Municipal School District in attempts to lower
the number of adolescents and young adults who are
infected with Chlamydia and Gonorrhea.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
37
Future Directions
Currently, the Cleveland Department of Public Health (CDPH) is collaborating with the Cleveland
Metropolitan School District to provide health education in schools and to promote reproductive health
services offered. Reproductive health clinic nurses from CDPH have met with high school principals and
school nurses in order to increase awareness among students of the services offered at reproductive health
clinics. Recently, CDPH has employed adolescent peer educators to assist in the reproductive health clinics,
promote services offered by the clinics, and offer peer-to-peer education in structured settings. Peer-to-peer
education has occurred in forums such as after school programs, Halloween parties, HIV testing days, and a
Reproductive Health Summit. Staff at the Reproductive Health Clinic have also worked with the CDPH
program MomsFirst mobile unit in order to provide urine-based Gonorrhea and Chlamydia screening, health
education outreach within the community, and the distribution of condoms one afternoon a week at various
locations throughout the city. It is hoped that these programs can continue and expand in order to continue
to service the need in this community.
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
38
Testing Centers
Your risk of getting HIV from an infected partner is much higher if you already
have an STD. HIV positive persons put their partner at risk when safe sex practices
aren’t followed.
Get smart. Get checked. Get treated.
To find a testing center near you, visit https://
gettested.cdc.gov
Local testing centers include:
Cleveland Department of Public Health
Cuyahoga County Board of Health
McCafferty Health Center
Health Center
4242 Lorain Ave.
5550 Venture Dr.
Cleveland, OH 44113
Parma, OH 44130
(216) 651-5005
(216) 201-2001
J. Glen Smith Health Center
11100 St. Clair Ave.
Northeast Ohio Neighborhood
Health Services (NEON)
Cleveland, OH 44108
8300 Hough Ave.
(216) 249-4100
Cleveland, OH 44103
(216) 231-7700
Care Alliance
Free Clinic of Greater Cleveland
Downtown
12201 Euclid Ave.
1530 St. Clair Ave.
Cleveland, OH 44106
Cleveland, OH 44114
(216) 721-4010
(216) 781-6724
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
39
2013
2013--2015 Cuyahoga County Sexually
Transmitted Diseases Report: Chlamydia
and Gonorrhea
Created by: CDPH Office of Communicable Disease Surveillance and Epidemiology
Data Source: Ohio Department of Health ODRS (Ohio Disease Reporting System)
Date: July 8, 2016
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
40
Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
41
Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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Appendix
2013-2015 Cuyahoga County Chlamydia and Gonorrhea Surveillance Report
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