STDs at Unprecedented High in United States
EXECUTIVE SUMMARY
According to the CDC, the total combined cases of chlamydia, gonorrhea, and syphilis reported in 2015 reached the highest number ever.
- More than 1.5 million chlamydia cases were reported, followed by nearly 400,000 cases of gonorrhea, and about 24,000 cases of primary and secondary syphilis.
- For the first time in the United States, health officials have identified a cluster of gonorrhea infections that shows both decreased susceptibility to ceftriaxone and very high-level resistance to azithromycin.
- Although all patients were treated successfully using the recommended dual regimen, and no further cases have been identified since May 2016, both the resistance pattern and the occurrence of a cluster of cases are cause for concern.
New figures from the CDC indicate the total combined cases of chlamydia, gonorrhea, and syphilis reported in 2015 reached the highest number ever. The largest increase in STD cases reported from 2014 to 2015 occurred in primary and secondary syphilis (19%), followed by gonorrhea (12.8%) and chlamydia (5.9%).1
In looking at the numbers, more than 1.5 million chlamydia cases were reported, followed by nearly 400,000 cases of gonorrhea, and nearly 24,000 cases of primary and secondary syphilis, the most infectious stages of the disease.1
“We have reached a decisive moment for the nation,” says Jonathan Mermin, MD, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “STD rates are rising, and many of the country’s systems for preventing STDs have eroded.”
Public health STD programs face heightened challenges and barriers to achieving their mission. In 2012, 52% of state and local STD programs experienced budget cuts, resulting in reductions in clinic hours, contact tracing, and STD screening. The CDC estimates that 21 local health department STD clinics closed in that year alone.1
“We must mobilize, rebuild, and expand services, or the human and economic burden will continue to grow,” Mermin says in a statement accompanying the new report.
To prevent and control STDs, the CDC provides support to state and local health departments for disease surveillance, contact tracing and health promotion, and other critical services. The agency also issues and maintains testing and treatment guidelines for providers so patients may receive the most effective care. Maintaining and strengthening these systems will be essential to respond to the recent increases.
“STD prevention resources across the nation are stretched thin, and we’re beginning to see people slip through the public health safety net,” Mermin says. “Turning the STD epidemics around requires bolstering prevention efforts and addressing new challenges, but the payoff is substantial in terms of improving health, reducing disparities, and saving billions of dollars.”
Check The Numbers
Several sequelae can result from C. trachomatis infection in women, the most serious of which include pelvic inflammatory disease, ectopic pregnancy, and infertility.2 In the current report, the case count for chlamydia corresponds to a rate of 478.8 cases per 100,000 population, an increase of 5.9% compared with the rate in 2014. During 2014-15, the rate of reported chlamydia cases among women increased 3.8% and the rate among men increased 10.5%. Following three years of decreases in rates during 2011-2014, the chlamydia rate among women ages 15-19 increased 1.5% during 2014-2015.
The overall rate of chlamydial infection in the United States in 2015 among women (645.5 cases per 100,000 females) was more than two times the rate among men (305.2 cases per 100,000 males), reflecting the larger number of women screened for this infection. However, due to the increased availability of urine testing and extragenital testing, men, including gay, bisexual, and other men who have sex with men (MSM), are seeing an increase in testing for chlamydial infection. During 2011-15, the chlamydia rate in men increased 20.0%, compared with a 0.3% increase in women during this same period.1
How About Gonorrhea?
Both chlamydia and gonorrhea are concerns for providers who work with adolescents: The new report shows young adults ages 15-24 accounted for nearly two-thirds of chlamydia diagnoses and half of gonorrhea diagnoses.1
In 2015, 395,216 cases of gonorrhea were reported for a rate of 123.9 cases per 100,000 population. The uptick in the gonorrhea rate during 2014-15 was observed among both males and females; however, the increase was higher among males, rising from 119.0 to 140.9 cases per 100,000.1
N. gonorrhoeae has developed resistance to each of the antimicrobials used for treatment of gonorrhea, presenting a public health challenge. Due to declining susceptibility to cefixime, the latest CDC treatment guidelines now call for dual therapy with ceftriaxone (an injectable cephalosporin) and azithromycin as the sole CDC-recommended treatment regimen for gonorrhea.3
However, for the first time in the United States, health officials have identified a cluster of gonorrhea infections that shows both decreased susceptibility to ceftriaxone and very high-level resistance to azithromycin. Laboratory tests on gonorrhea isolates collected from seven individuals in Honolulu in April and May 2016 showed resistance to azithromycin at dramatically higher levels than typically seen in the United States; also, isolates from five of the individuals showed reduced susceptibility to ceftriaxone.
Although all patients were treated successfully using the recommended dual regimen, and no further cases have been identified since May, both the resistance pattern and the occurrence of a cluster of cases, which indicates the strain was able to spread, are cause for concern to public health officials.4
“Hawaii is on the front line for antibiotic-resistant gonorrhea. We’ve been one of the first states to see declining effectiveness of each drug over the years,” says Alan Katz, MD, MPH, professor of public health at the University of Hawaii, member of the Hawaii State Board of Health, and staff physician and medical consultant at the Hawaii State Department of Health’s Diamond Head STD Clinic. “That’s made us extremely vigilant, so we were able to catch this cluster early and treat everyone found who was linked to the cluster. But the future risk of gonorrhea becoming resistant to both of the recommended therapy medications in the United States is troubling.”
Rise in Syphilis in Women
According to the new report, women’s rate of syphilis diagnosis increased by more than 27% from 2014 to 2015, and reported congenital syphilis increased by 6%. However, women still account for less than 10% of new primary and secondary syphilis infections. As in recent years, MSM represented the majority of reported primary and secondary syphilis cases in 2015. Nationally, the highest rates of syphilis in 2015 were observed among men ages 25-29 and 20-24 years, among men in the West and in the South, and among black men.1
The health outcomes of syphilis, whether they be miscarriage, stillbirth, blindness, or stroke, can be “devastating,” says Gail Bolan, MD, director of CDC’s Division of STD Prevention.
“The resurgence of congenital syphilis and the increasing impact of syphilis among gay and bisexual men makes it clear that many Americans are not getting the preventive services they need,” Bolan notes in a statement accompanying the report. “Every pregnant woman should be tested for syphilis, and sexually active gay and bisexual men should be tested for syphilis at least once a year.”
Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta, suggests that condoms, and perhaps outercourse, should be emphasized far more extensively than they are now.
Twenty years ago, condoms were provided at no or low cost to women, sometimes in great numbers, Hatcher notes. Today, 12 to 24 condoms are provided in most cases. Provision of a full year of oral contraceptives leads to more consistent use and higher continuation rates, so why not provide 100 condoms to women, basing the figure on a rate of intercourse of twice a week?
“If we are going to get serious about STDs, we need to provide large numbers of condoms to people,” Hatcher says.
REFERENCES
- Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2015. Atlanta: U.S. Department of Health and Human Services; 2016.
- Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2013. Atlanta: US Department of Health and Human Services; 2014.
- Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64(No. RR-3):1-137.
- Katz A, Komeya A, Tomas J, et al. Cluster of Neisseria gonorrhoeae isolates with high-level azithromycin resistance and decreased ceftriaxone susceptibility. Presented at the 2016 National STD Prevention Conference. Atlanta; September 2016.
Public health agencies battle rise in midst of budget cuts.
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