Since 1995, gonorrhea has become the second most frequently reported infectious disease, after chlamydial infection, in the United States (11). The World Health Organization estimates that there are approximately 100 million gonorrheal infections each year throughout the world. The reported number of cases of gonorrhea in the United States in 2002 was roughly 362,000, although the true incidence is estimated to be twice that number. This number had been decreasing yearly after a peak of 1 million cases in 1978, until 1997 through 1998, when the rates increased over 10% in women and 7.4% in men, according to the Centers for Disease Control and Prevention.
The highest incidences occur in young (ages 15-30 years), single persons of low socioeconomic and educational attainment, in inner-city residents, and in some rural settings, especially in the Southeast. The incidence of reported gonorrhea is 30-fold higher in African Americans than in whites or persons of Asian or Pacific-Island ancestry; the rates in those of Hispanic or Native American ethnicity are three-fold and four-fold higher than in whites, respectively (12). The differences between racial and ethnic groups are reflections of differing sex-partner-network structures, socioeconomic attainment, education, and access to health care. Persons of lower socioeconomic status selectively attend public clinics, where reporting is more complete than in the private sector, but this bias accounts for only a small part of the observed differences between racial and ethnic groups. The incidence of gonorrhea is several times higher in men who have sex with men (MSM) than in heterosexuals. Rates of gonorrhea and other sexually transmitted diseases (STDs) rose dramatically among MSM in the United States and other industrialized countries from 1997 to 2002, in association with improved therapy and survival of persons with HIV infection. The risk of contracting gonorrhea via conventional intercourse is 50% for women and about 20% for men following a single exposure (12). Urethral-to-pharyngeal transmission by fellatio also occurs frequently, and pharyngeal gonococcal infection is especially common among MSM. Conflicting data exist on the efficiency of transmission of pharyngeal infection to the urethra by fellatio. Both transmission and acquisition of gonorrhea by cunnilingus appear to be very rare. Transmission by kissing is rare to nonexistent. Pharyngeal gonococcal infection is found in about 5% of heterosexual men, 5% to 10% of heterosexual women, and 10% to 20% of MSM with gonorrhea (11). Pharyngeal gonococcal infection, most often asymptomatic, may be more common in pregnant women because of altered sexual practices. Gonococci die rapidly on drying, so that transmission by fomites is rare. Perinatal transmission, with neonatal ophthalmitis or pharyngeal infection, is now rare. Gonorrhea in prepubertal children older than one year almost always results from sexual abuse.
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