Distribution and Incidence

Gonorrhea is found worldwide, but documentation of its true extent is lacking. Direct comparisons of incidence among nations are difficult to make because of the wide variation in clinical and diagnostic facilities, the extent of disease reporting, and the degree of care given to case finding. The disease is widespread in both the industrialized and the developing world, but it is likely that the burden on developing nations is greater. It is estimated that the incidence in some large African cities may be as high as 3,000 to 10,000 per 100,000 population. Because gonorrhea is, in principle, a disease of high incidence and low prevalence, it is noteworthy that surveys of women attending prenatal and family planning clinics in Africa disclose a prevalence as high as 17 percent. Among prostitutes in Latin America, Asia, and Africa, the prevalence of gonorrhea may be 30 to 50 percent. These are, of course, occasional surveys of selected populations, but, in the absence of systematic information, they provide some sense of the magnitude of the problem.

A number of industrialized nations, on the other hand, do have systematic reporting of gonorrhea. Routinely collected statistics have permitted documentation of the major epidemiological event in the history of gonorrhea: a worldwide pandemic that began in the late 1950s and peaked in the mid-1970s.

A comparison of disease rates in the United States, the United Kingdom, Sweden, and Canada (Figure VIII.62.1), all of which have advanced

Figure VIII.62.1. Gonorrhea incidence in selected countries, 1940-83. (From R. C. Barnes and K. K. Holmes. 1984. Epidemiology of gonorrhea: Current perspectives. Epidemiological Reviews 6: 1-30; 3, fig. 1, by courtesy of Epidemiological Reviews and the American Journal of Epidemiology.)

health care systems, indicates a rise in gonorrhea occurrences after World War II, with a subsequent fall to a nadir in the mid-1950s. Though varying in size and timing, an increase in gonorrhea throughout the 1960s, with termination of the accelerated rise by the mid-1970s, was experienced by each nation. The graph is representative of the situation for most industrialized countries during the interval, and conveys the disparity with which nations were apparently affected. At the peak, in the mid-1970s, rates among industrialized nations differed by as much as 10-fold. (By contrast, rates among developing nations during the interval differed even more wildly, but here the variation in reporting clearly plays an important role.)

The impact and specific features of the pandemic may be demonstrated by examining the history of the disease in the United States during this period. Between 1956 and 1985, rates of gonorrhea increased in all age groups for both men and women (Figure VIII.62.2). Rates for females are higher at younger ages, and peak at ages 15 to 19 years. Rates for males peak at ages 20 to 24, producing a crossover pattern (Figure VIII.62.3). The origin of this increase, and of the pandemic in general, is not fully understood. It is often attributed to changes in sexual mores during the 1960s and 1970s, with major increases reported in the frequency of premarital sexual experiences by both men and women, a greater availability of contraceptive technology, and an increase in the number of individuals entering the age of sexual activity (the so-called baby boom generation).

It is likely that the pandemic has not yet had its full impact on the developing world, though the peak in industrialized nations seems to have passed. If so, the burden of morbidity, long-term sequelae, and mortality will continue to have a major influence on

1956 1959 1962 1965 1968 1971 1974 1977 1980 1983 YEAR

Figure VIII.62.3. Gonorrhea: age-specific rates for men and women, United States, 1985.

1956 1959 1962 1965 1968 1971 1974 1977 1980 1983 YEAR

Figure VIII.62.2. Gonorrhea rates in men and women, aged 20-4, United States, 1956-85.

Figure VIII.62.3. Gonorrhea: age-specific rates for men and women, United States, 1985.

80 percent of the world's population in the coming years.

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