CDC Issues Annual Report on Sexually Transmitted Diseases

Laurie Barclay, MD

January 13, 2009

January 13, 2009 — The new annual report of the US Centers for Disease Control and Prevention (CDC) on sexually transmitted diseases (STDs) for 2007 shows a high burden of STDs, especially among women and racial minorities. In the United States, reported cases of chlamydia and gonorrhea exceeded 1.4 million in 2007. These illnesses continued to be the most frequently reported infectious diseases nationwide.

These STDs may be complicated by loss or impairment of fertility. For example, pelvic inflammatory disease may result from nearly 40% of all untreated chlamydia and gonorrhea infections, causing infertility in up to 50,000 women annually. Ectopic pregnancy, chronic pelvic pain, and other complications may also result from untreated chlamydia or gonorrhea. These complications may be preventable if the disease is diagnosed and treated in a timely manner.

Diagnosis and treatment are not difficult, but asymptomatic cases often go undetected, and estimates suggest that more than half of all new infections with chlamydia and gonorrhea remain undiagnosed. The CDC therefore recommends that all sexually active women younger than 26 years be screened annually for chlamydia, and the agency supports the recommendations of the US Preventive Services Task Force for gonorrhea screening in high-risk, sexually active women.

Potentially of even greater concern than the increase in chlamydia and gonorrhea is the continued increase in syphilis. Although once nearly eliminated, syphilis resurfaced in 2001 and has increased in prevalence each year since, with a dramatic 15.2% increase from 2006 to 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," John M. Douglas, Jr, MD, director of CDC's Division of STD Prevention, said in a news release. "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."

In 2007, more than 1.1 million chlamydia cases were reported — an increase from about 1 million in 2006 — the largest number of cases ever reported to CDC for any condition. The rate among women was 3-fold that of men in 2007 (543.6 cases per 100,000 women vs 190 cases per 100,000 men).

There were more than 350,000 cases of gonorrhea reported in 2007, making it the second most commonly reported infectious disease. As with chlamydia, more cases were reported in women (123.5 per 100,000 women vs 113.7 per 100,000 men).

The CDC report also highlights continued racial disparities in prevalence of the 3 most common reportable STDs, with African Americans most heavily affected. In 2007, blacks represented 12% of the US population but accounted for 70% of reported gonorrhea cases, 48% of all chlamydia cases, and 46% of all syphilis cases.

Black women aged 15 to 19 years had the highest rates of chlamydia (9646.7 per 100,000 population) and gonorrhea (2955.7 per 100,000 population), which is especially concerning because of the potential reproductive harms associated with these diseases. Prevalence rates for these diseases was second highest among black women aged 20 to 24 years.

Socioeconomic status, which is an important predictor of sexual health, may be partly responsible for increased prevalence in this population, with higher poverty rates reported among blacks than among whites. The higher prevalence and incidence of STDs among racial and ethnic minorities may stem from socioeconomic barriers to quality healthcare and to services for STD prevention and treatment.

"The racial disparities in rates of STDs are among the worst health disparities in the nation for any health condition," Dr. Douglas said. "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."

Disparities in syphilis rates are also evident among gay and bisexual men. Of the 11,466 primary and secondary syphilis cases reported in 2007, men who have sex with men (MSM) accounted for 65%, suggesting that increased transmission of syphilis among MSM is the primary driver of increased overall US rates. In MSM, syphilis can potentiate HIV transmission, and it has been associated with strokes and other irreversible complications, especially in those who are already infected with HIV. Annual or more frequent syphilis screening is recommended by the CDC for all MSM.

Although syphilis rates are still much lower among women than among men (1.1 cases per 100,000 among women vs 6.6 cases among men), women and infants have recently had increasing syphilis rates despite declining rates in prior years. Since 2004, syphilis rates among women have increased. For the second consecutive year, the rate of congenital syphilis increased in 2007. These trends are alarming because of the risk for transmission of untreated syphilis from a pregnant woman to her infant, resulting in stillbirths, infant deaths, or severe complications in surviving children. Therefore, all women in the early stages of pregnancy should be screened for syphilis, according to the CDC.

The CDC recommends expanded prevention programs on many fronts to reduce the health burden of STDs. Of the nearly 19 million new cases of STDs annually, 15- to 24-year-olds account for almost half, with attendant risks including reduced fertility, increased risk for HIV acquisition, and other health harms. Estimated US healthcare costs related to STDs approach $15.3 billion each year, according to the CDC.

CDC recommendations for STD prevention are a comprehensive program including screening, treatment, and behavioral interventions. To reduce health disparities, these measures should particularly target racial and ethnic groups at greatest risk.

In an attempt to lower chlamydia rates, the National Chlamydia Coalition was recently established by the CDC in collaboration with the Partnership for Prevention and 8 other leading STD organizations. Although similar CDC collaborative efforts have been underway for syphilis since 1999, successes in some areas and populations continue to be offset by increases in others, requiring ongoing shifting of priorities at the federal, state, and local levels.

"Organized collaboration among interested, committed public and private organizations and communities is the key to reducing STDs and their related health burdens," the report authors conclude.

CDC. Sexually Transmitted Disease Surveillance, 2007. Atlanta, GA: US Department of Health and Human Services; December 2008.

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