Sexually transmitted diseases (STDs) have a significant health and economic impact on the US population. In 1998 a panel of experts convened by the American Social Health Association (ASHA) for the Kaiser Family Foundation calculated that approximately 15 million new STDs are acquired annually by Americans. Of the top 10 most frequently reported infections, five are STDs.
Most Americans are unaware of the extent of the STD epidemic, however, because many infections have no symptoms, and because social stigma prevents open discussion of the topic. These asymptomatic infections can be diagnosed only through testing. Unfortunately, says ASHA, routine screening programs are not widespread, and social stigma and lack of public awareness concerning STDs often prevents open discussion between health care providers and patients, leaving most STDs undiagnosed.
April of 2002 is National STD Awareness Month, and ASHA and the Centers for Disease Control and Prevention (CDC) are hoping to prevent STDs – or at least stop their increase – by informing people about the true costs of this silent epidemic.
Gonorrhea Rates Rise in 13 of 20 Most Affected Cities
Nearly two-thirds of the US cities hardest hit by gonorrhea experienced increases in gonorrhea rates between 1999 and 2000, according to the Centers for Disease Control and Prevention (CDC). While the overall national gonorrhea rate remained stable, 13 of 20 cities with the highest rates in 1999 had even higher rates in 2000, indicating ongoing challenges in controlling the disease in some communities. Data on national trends in gonorrhea and other STDs were presented recently at the National STD Prevention Conference held in San Diego, California last month.
"The increasing gonorrhea rates in some US communities highlight the need to accelerate STD prevention and treatment efforts in these areas," said Ronald O. Valdiserri, MD, MPH, deputy director of CDC's National Center for HIV, STD, and TB Prevention. "The continued health consequences from this completely preventable STD are unacceptable. That's why we must continue to support comprehensive prevention programs that promote abstinence from sexual activity among young people, encourage mutual monogamy with an uninfected partner, and consistent and correct condom use for those with multiple partners."
According to Valdiserri, while gonorrhea can be diagnosed and treated with antibiotics, it continues to exact an inordinate toll on the health of the nation. If left untreated, the disease can facilitate HIV transmission and lead to pelvic inflammatory disease, chronic pelvic pain and infertility.
Gonorrhea increased by more than 20% in 5 of the cities with the highest rates in 1999:
- Kansas City, MO – 37.4%
- Buffalo, NY – 27.5%
- Jacksonville, FL – 22.5%
- Detroit – 21.6%
- Birmingham, AL – 21.1%
Nashville, TN, which was not among the 20 most affected cities in 1999, had an increase of 34.6% and joined the list of 20 cities in 2000.
Reasons for increases likely vary by community, but may include continued gaps in available treatment and screening services, limited access to quality health care among some populations, and reported increases in risk behavior among some populations, including gay and bisexual men.
During the same period, several communities were able to reduce their rates of gonorrhea, with rates falling in 7 of the 20 cities most affected in the previous year. Atlanta, which had the fifth highest gonorrhea rate in 1999, cut infections by more than 38% in 2000. Washington, D.C. also saw a major improvement between 1999 and 2000, with rates falling more than 23%. Chicago reduced infections by 25.2% and dropped from the top 20 list.
On a national level, the overall rate of gonorrhea appears to have stabilized, following a 9% increase between 1997 and 1999. In 2000, the rate of gonorrhea was 131.6 cases per 100,000 people, compared to 132 cases per 100,000 people in 1999. Prior to that upturn, national gonorrhea rates had declined each year since 1975.
According to Valdiserri, analyzing the local trends is critical to direct efforts where they are most needed. "The battle against STDs is primarily waged locally," said Valdiserri. "Accelerating progress nationally will require assisting those communities that now face the greatest threat, while maintaining our ongoing prevention efforts."
Syphilis Rates Decline, but Local Outbreaks Remain a Concern
The CDC also released year 2000 data showing continued progress among many US cities with the highest rates of primary and secondary syphilis. Rates fell in 15 of the 20 cities that had the highest syphilis rates in 1999: Tulsa, OK, St. Louis, Richmond, VA, New Orleans and Atlanta saw the largest decreases; while significant progress was also seen in Oklahoma City, Indianapolis, Washington, DC, Dallas and Nashville.
However, several major cities faced dramatic increases in infection rates between 1999 and 2000. Of the cities with the highest rates in 1999, the largest increase occurred in Norfolk, VA, where the number of cases per 100,000 people rose from 8.9 to 16.4, an increase of 84.3%. Other cities with significant increases included Detroit (45%) and Newark, N.J. (26.9%). Three cities not among the 20 most affected cities in 1999 had major increases and joined the list of hardest-hit cities in 2000: San Antonio, TX (113%), San Francisco (82.1%) and Miami (52.6%).
"Despite significant progress across much of the nation, the increases in some areas remind us that continued vigilance is required in every community if we truly hope to eliminate this disease," said Valdiserri.
These data come on the heels of national syphilis data released by CDC in November 2001, which indicated continued progress toward eliminating the disease from the United States. The national syphilis rate declined from 2.4 cases in 1999 to an all-time low of 2.2 cases per 100,000 people in 2000. In November, the CDC also released 2000 syphilis data for US counties most affected by the disease. The majority of those counties encompass the cities included in the latest data, although several affected cities – including Norfolk, Newark, Washington, San Juan, PR and New Orleans – are not located in the 22 counties highlighted in November.
Chlamydia Remains Widespread
Along with trends in syphilis and gonorrhea, the CDC presentation also included the latest data on chlamydia, which remains the most frequently reported infectious disease in the United States. In 2000, 702,093 chlamydial infections were reported to the CDC. However, it is estimated that three million new cases of this largely asymptomatic infection occur in the United States each year.
Because case reports do not provide a complete account of the burden of disease, researchers must rely on studies of chlamydia prevalence in various groups. The percentage of women testing positive for chlamydia (chlamydia positivity) in family planning clinics, by state, provides a good indication of where the disease remains most widespread among young sexually active women.
The latest data indicate that chlamydia positivity among young women is lowest in areas with longstanding screening and treatment programs, such as the northwest region of the country, but remains high in areas where these programs are not as widely available, principally southern states.
In 2000, the 10 states with the highest level of chlamydia positivity among 15- to 24-year-old women in family planning clinics include: Mississippi (15.8%), Rhode Island (11.9%), Louisiana (9.7%), Texas (9.3%), South Carolina (8.6%), Alabama (7.9%), North Carolina (7.5%), California (7.3%), Illinois (7.4%) and Wisconsin (7.2%).
Chlamydia can easily be treated and cured, but if left untreated can lead to severe health consequences, including infertility, pelvic inflammatory disease and increased risk of HIV infection. Expanded screening and treatment efforts will be critical to reduce these severe health outcomes.
HPV-16 Among Gay and Bisexual Men
Genital human papillomavirus (HPV), of which there are multiple types, can lead to cervical, penile and anal cancer. HPV type 16 (HPV-16) is associated with 50% of all cervical cancer cases.
The CDC released new research at the conference providing the first national data indicating the prevalence of HPV-16 among men who have sex with men (MSM). CDC researchers found that 38% of MSM in the United States are infected with HPV-16, nearly 5 times the prevalence in heterosexual men and twice that in women – 8% and 19%, respectively.
The new findings are based on a representative sample of 83 MSM surveyed from 1988 to 1994 in CDC's National Health and Nutrition Examinations Survey. Although cautioning that the data are preliminary, the authors stressed the need for more research into the clinical implications of HPV-16 for MSM.
"While there is significant research on the link between HPV-16 and cervical cancer, much less is known about the impact of HPV on anal and reproductive tract cancers in gay and bisexual men," said Stuart Berman, MD, head of CDC's STD epidemiology and surveillance branch. "These new findings begin to provide information about the transmission of this STD in this population."
HPV often infects people without causing noticeable symptoms, although it sometimes causes genital warts. While genital warts can be treated, there is currently no treatment for the much more common, asymptomatic HPV infection, which may develop into cancer. Every year, about 5.5 million people acquire a genital HPV infection.
Working to Reduce the Toll
The National STD Prevention Conference brought together researchers, practitioners and public health officials from across the country to examine and address key challenges in STD prevention and treatment. New research was presented on gaps in STD counseling and care, insufficient levels of testing, and emerging resistance to common treatments. Conference participants worked to identify solutions. "The human and economic toll of STDs can be reduced in this nation," said Dr. Valdiserri. "But success will require a renewed and an expanded commitment by both the public and private sectors."
This article includes information from:
Centers for Disease Control and Prevention (CDC)
American Social Health Association
Article Created: 2002-03-28
Article Updated: 2002-03-28
Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.
