Annual CDC Report Finds High Burden of Sexually Transmitted Diseases, Especially Among Women and Racial Minorities

Reported cases of chlamydia and gonorrhea in the United States exceeded 1.4 million in 2007, according to an annual report (http://www.cdc.gov/std/stats07/) by the Centers for Disease Control and Prevention. These diseases continue to be the most commonly reported infectious diseases in the nation and pose persistent and preventable threats to fertility in the United States.

The report, Sexually Transmitted Disease Surveillance, 2007, shows persistent racial disparities across these and other sexually transmitted diseases (STD), and a particularly heavy burden of disease among women. The report also finds continued increases in syphilis. This disease, while once on the verge of elimination, began re-emerging as a threat in 2001 and increased 15.2 percent between 2006 and 2007.

"The widespread occurrence of these diseases should serve as a stark reminder that STDs remain a serious health threat in the United States, especially for women and racial and ethnic minorities," said John M. Douglas, Jr., M.D., director of CDC's Division of STD Prevention. "Left untreated, chlamydia and gonorrhea can cause infertility, affecting a woman's chance to bear children later in life. Such a severe consequence is entirely avoidable, if as a nation we work together to increase the use of proven prevention tools and make them widely available to those who need them."

Women Bear Heavy STD Burden, Including Risk of Infertility

Women continue to bear a disproportionate burden of the long-term health consequences of STDs. In 2007, the chlamydia rate among women was three times that of men (543.6 cases per 100,000 women, compared to 190 cases per 100,000 men). The gonorrhea rate was also higher among women (123.5 per 100,000 women, compared to 113.7 per 100,000 among men).

Although the two diseases can be easily diagnosed and treated, they often have no symptoms and go undetected. If left untreated, up to 40 percent of chlamydia and gonorrhea infections in women can result in pelvic inflammatory disease -- a condition that causes as many as 50,000 women to become infertile each year. Untreated chlamydia or gonorrhea can also cause ectopic pregnancy, chronic pelvic pain, and other serious health problems.

The report found that there were more than 1.1 million chlamydia cases reported in 2007, up from about one million in 2006, making it the largest number of cases ever reported to CDC for any condition. Gonorrhea, the second most commonly reported infectious disease, had more than 350,000 cases reported in 2007. However, it is estimated that more than half of all new infections with chlamydia and gonorrhea continue to go undiagnosed, underscoring the importance of increased screening. CDC recommends annual chlamydia screening for all sexually active women under 26 years old, and supports U.S. Preventive Services Task Force recommendations to screen high-risk, sexually active women for gonorrhea.

STDs Take Heaviest Toll on Racial Minorities, Especially Black Women

CDC's 2007 STD surveillance report also indicates ongoing racial disparities in the three most common reportable STDs, with African-Americans bearing the greatest burden. While representing 12 percent of the U.S. population, blacks had about 70 percent of reported gonorrhea cases and almost half of all chlamydia and syphilis cases (48 percent and 46 percent respectively) in 2007.

STDs take an especially heavy toll on black women 15 to 19 years of age, who account for the highest rates of both chlamydia (9,646.7 per 100,000 population) and gonorrhea (2,955.7 per 100,000 population) of any group. STDs in this age group are of particular concern because of the potential threat of these two diseases to a woman's fertility.

Studies have shown that one of the most important social determinants of sexual health is socioeconomic status. Higher rates of poverty among blacks than whites, and socioeconomic barriers to quality healthcare and STD prevention and treatment services have been associated with higher prevalence and incidence of STDs among racial and ethnic minorities.

"The racial disparities in rates of STDs are among the worst health disparities in the nation for any health condition," stressed Douglas. "We must intensify efforts to reach these communities with needed screening and treatment services. Testing and the knowledge of infection is a critical first step toward reducing the continued consequences of these diseases."

Growing Threat of Syphilis

Syphilis, a disease close to being eliminated as a public health threat less than a decade ago, has increased each year since 2000 and remains a serious threat to the health of gay and bisexual men.

In 2007, men who have sex with men (MSM) continued to account for the majority of primary and secondary (P&S) syphilis cases, representing 65 percent of the 11,466 P&S syphilis cases reported. Increased transmission among MSM is believed to be the primary driver of increased rates of syphilis overall in the United States. Syphilis among MSM is of particular concern because it can facilitate HIV transmission and lead to irreversible complications such as strokes, especially in those who already have HIV. CDC recommends that all MSM be tested for syphilis at least annually.

Additionally, while P&S syphilis continues to occur at substantially lower levels among women than men (1.1 cases per 100,000 among females compared to 6.6 among males), syphilis rates have been increasing among women and infants in recent years, reversing years of decline in these populations. Syphilis rates among women have increased since 2004, and the rate of congenital syphilis increased for the second consecutive year in 2007. Because untreated syphilis can be transmitted from a pregnant woman to her infant and result in stillbirths, infant deaths, or severe complications in children who survive, CDC recommends that all women be screened for syphilis during the early stages of pregnancy.

Intensified Efforts Needed to Address Significant Gaps in STD Prevention

To reduce the toll of STDs and protect the health of millions of Americans, expanded prevention efforts are urgently needed. CDC estimates that almost 19 million new sexually transmitted infections occur each year, and almost half of those are among 15- to 24-year-olds. In addition to the threat of infertility, increased risk of HIV acquisition, and other health risks, STDs also have a substantial economic impact. CDC estimates STDs cost the U.S. health care system as much as $15.3 billion annually.

CDC supports a comprehensive approach to STD prevention through screening, treatment, and behavioral interventions, with a focus on reducing health disparities, especially those occurring among racial and ethnic groups. To further progress against the most widespread reportable STDs, CDC, along with the Partnership for Prevention and eight other leading STD organizations, recently established the National Chlamydia Coalition. CDC also has been working with partners and community leaders across the nation on syphilis elimination efforts since 1999, yet successes in some areas and populations continue to be offset by increases in others, as programs must continually shift efforts to address emerging needs. Ultimately, successful elimination of this disease will require intensified efforts at the federal, state and local level to reach the diverse and expanded populations now at risk.

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PID Diagnosis Predicts Future STI's in Teenagers

A study among Baltimore inner-city teenage girls treated for pelvic inflammatory disease shows they are highly vulnerable to subsequent sexually transmitted infections (STI) — sometimes within a few weeks or months of their treatment.

Results of the research by Johns Hopkins Children’s Center investigators, reported in the November issue of Archives of Pediatric and Adolescent Medicine, suggest that treating pelvic inflammatory disease (PID) “with a prescription and a brochure” is simply not enough to change behavior and prevent future infections, according to lead investigator Maria Trent, M.D., M.P.H., a pediatrician and adolescent medicine specialist at Hopkins Children’s.

Repeat infections can increase a teenager’s risk for chronic pelvic pain, ectopic pregnancies and infertility.

“Because our findings show that PID is not a single isolated incident, doctors should look for ways to change behaviors in these girls and not just treat the acute clinical episode,” said Trent. “We are talking counseling, we are talking strict follow-up and, most importantly, we need to develop new strategies that actually work.”

While cautioning that the study was limited to Baltimore City girls, the researchers say teenage girls across the country’s urban areas likely face similar problems linked to inner-city life and practice behaviors that put them at high risk for repeat STIs.

In the four-year study of 110 girls ages 15 to 21 and diagnosed with PID, 80 girls returned for follow-up during the 48-month study period. Under the Hopkins protocol, those with confirmed diagnosis of PID are given a course of free medication and asked to return within 72 hours and advised to follow up again at three and again in six months with a primary-care provider.

Of the 80, 27(34 percent) were diagnosed with at least one subsequent sexually transmitted infection over a six-month period. Of the 27, eight (30 percent) had two or more STIs in the six-month period.

Getting girls to come back is challenging, researchers say. An earlier study by the Hopkins Children’s group found that only 38 percent of girls diagnosed with PID could be reached, and of these only 43 percent returned for follow-up care.

The best — and narrow — window of opportunity to counsel girls, researchers say, may be at the time of diagnosis or when they return for the repeat screening in 72 hours. This counseling, moreover, must be more thorough, not just admonitions to practice safe sex or not to have sex at all.

“What we think we need is individually tailored counseling by a clinical provider that is done after an in-depth interview with each patient to determine what aspects of her behavior put her at risk and must change,” Trent says.

Researchers are currently testing a pilot program that involves showing an educational video to teenage girls coming to the ED with PID. The Hopkins team also plans to test the value of house calls to patients by a nurse within 72 hours of diagnosis.

Funding for this research came from the Thomas Wilson Sanitarium Foundation for the Children of Baltimore City, the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention.

Other investigators in the study: Jonathan Ellen, M.D.; Shang-en Chung, M.Sc.; Lynette Forrest, all of Hopkins.

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