Why Are Gonorrhea Case Rates Declining in the United States? A Research Agenda

After nearly a decade of rising gonorrhea rates, the United States CDC reported a decline in infection rates for two years in a row in 2022 and 2023, especially among young adults. While this warrants cautious optimism that control measures have been successful, the reasons for the decline are unknown. We do not know what lessons can be learned about the 4CMenB vaccine with partial protection against gonorrhea, doxycycline postexposure prophylaxis (doxy-PEP), asymptomatic screening, sexual behavior, or other possible drivers. Here, we enumerate potential drivers of the decline in gonorrhea, the evidence that argues for or against each one, and the data needed to clarify their roles. We hope to encourage those with suitable data to perform the analyses we outline, for surveillance systems to provide more detailed data where possible, and for existing and new surveillance and research studies to collect additional data.