Rural gonorrhea in the southeastern United States: a neglected epidemic?

Some rural counties in the southeastern United States are experiencing high rates of gonorrhea; however, existing knowledge of epidemiologic patterns of gonorrhea within communities is from urban areas. This paper describes the epidemiology of gonorrhea within a rural county of North Carolina and compares it with the patterns described for large cities. Data include gonorrhea reports from private physicians and the county health department from August 11, 1992, to August 10, 1993, and ethnographic interviews. The rate among males (1,602 cases per 100,000 person-years) was twice that among females. The risk of reinfection within 6 months of an initial infection (12.9%) was high compared with risks in urban settings. Although case numbers did not cluster by geographical area as described for some cities, case rates did. Factors favoring transmission in rural communities include greater poverty and fewer health care resources than in urban settings, the exchange of sex for crack cocaine, and a lack of anonymity that may cause some people to avoid seeking treatment or acknowledging risky sexual behaviors in a clinical setting. Addressing high rural rates will entail improving access to care, taking extra measures to ensure confidentiality, and dispelling the myth that high rates are limited to cities.