By Rebecca Bowers

EXECUTIVE SUMMARY

Nearly 2.3 million cases of chlamydia, gonorrhea, and syphilis were diagnosed in the United States in 2017, preliminary data indicate. This number surpasses the previous high level in 2016 and marks the fourth consecutive year of sharp increases in sexually transmitted infections.

  • The growth in gonorrhea diagnoses was significant, up 67% overall, from 333,004 cases in 2013 to 555,608 cases in 2017. The number of cases among men was almost doubled, jumping from 169,130 cases to 322,169 cases in the same time period.
  • New findings suggest that azithromycin resistance now is increasing in laboratory testing. If azithromycin-resistant genes cross over into gonorrhea strains that are less susceptible to ceftriaxone, someday a gonorrhea strain that is resistant to ceftriaxone could emerge.

Nearly 2.3 million cases of chlamydia, gonorrhea, and syphilis were diagnosed in the United States in 2017, according to preliminary data released at the recent National STD Prevention Conference in Washington, DC.1 This number surpasses the previous high level in 2016. This is the fourth year in a row that sexually transmitted infections have increased sharply. (Inform your practice: Use the Centers for Disease Control and Prevention’s fact sheet at https://bit.ly/2dq1S4I.)

“We are sliding backward,” states Jonathan Mermin, MD, MPH, director of the Centers for Disease Control and Prevention’s (CDC) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “It is evident the systems that identify, treat, and ultimately prevent STDs are strained to near-breaking point.”

During a press briefing on the matter, David Harvey, MSW, executive director of the National Coalition of STD Directors (NCSD), described the increases as an “absolute STD public health crisis in this country.” The STD public health challenge costs the United States more than $16 billion in preventable healthcare costs per year, he noted.2 Harvey pointed out that the large increase in STD cases comes after years of federal funding reductions.

“Federal STD funding has seen a 40% decrease in purchasing power since 2003,” Harvey observed. “That means that state and local health departments, most of which depend primarily on federal funding to support their STD programs, are working with budgets that are effectively half of what they were 15 years ago.” (See the NCSD chart at https://bit.ly/2OGx2ri, which details the decrease in the CDC’s spending power from FY2003 to FY2018.)

The National Coalition of STD Directors estimates that state and local STD programs need an additional $70 million immediately to confront the STD crisis sufficiently, said Harvey. This move would translate into Congress’ allocation of $227 million in FY19, with additional funding to support STD research activities at the National Institutes of Health, he said.

Gonorrhea Cases Increase

The number of gonorrhea diagnoses was significant, rising 67% overall, an increase from 333,004 cases in 2013 to 555,608 cases in 2017. The number of cases among men nearly doubled, jumping from 169,130 cases to 322,169 cases in the same time period. Among women, diagnoses rose for the third consecutive year, from 197,499 cases in 2013 to 232,587 cases in 2017.1

Since 2015, the CDC has recommended that healthcare providers use a two-drug combin-ation, which includes one injection of ceftriaxone and an oral azithromycin dose, to treat patients with gonorrhea, says Gail Bolan, MD, director of the CDC’s Division of STD Prevention.

“Azithromycin was added to the recommended therapy to shield ceftriaxone from resistance, and that approach seems to be working,” said Bolan at the press briefing. “Emerging resistance to ceftriaxone has not been seen since the dual therapy approach was implemented and there has not been a confirmed treatment failure in the United States when using the recommended therapy.”

Emerging resistance of azithromycin is increasing in laboratory testing, new CDC findings released at the National STD Prevention Conference suggest. Data indicate that the percentage of samples with emerging azithromycin resistance rose from 1% in 2013 to more than 4% in 2017.

Public health officials are concerned that azithromycin-resistant genes could cross over into gonorrhea strains that are less susceptible to ceftriaxone. If this should occur, someday a gonorrhea strain that is resistant to ceftriaxone could emerge.

“We expect gonorrhea will eventually wear down our last highly effective antibiotic, and additional treatment options are urgently needed,” said Bolan at the press conference. “We can’t let our defenses down — we must continue reinforcing efforts to rapidly detect and prevent resistance as long as possible.”

How About Syphilis and Chlamydia?

Diagnoses of primary and secondary syphilis rose 76%, climbing from 17,375 cases in 2013 to 30,644 cases in 2017, according to preliminary data. In 2017, gay, bisexual, and other men who have sex with men comprised about 70% of the cases of primary and secondary syphilis in which the gender of the sex partner was known.1 In early stages, syphilis can be cured easily. One 2.4 million unit injection of long-acting Benzathine penicillin G given intramuscularly will cure primary, secondary, or early latent syphilis.

Adolescent reproductive health clinicians should be on the lookout for chlamydia, which remains the most common condition reported to the CDC. In 2017, more than 1.7 million chlamydia cases were diagnosed, with 45% of those identified among young females ages 15 to 24.1

The CDC recommends that women younger than 25 years of age who are sexually active receive annual screening for chlamydia and gonorrhea. In addition, older women who have risk factors, such as new or multiple sex partners, or a sex partner with a sexually transmitted infection, should have chlamydia and gonorrhea screening annually, the CDC advises.3

To treat chlamydia infection, the CDC recommends either 1 g of azithromycin orally in a single dose or 100 mg of doxycycline twice daily for seven days.3 To avoid spreading the infection to partners, people with chlamydia should avoid sexual activity for seven days after receiving single-dose antibiotics or until they have completed a seven-day antibiotic course. Providers should counsel patients about the importance of taking the full amount of medication prescribed to cure the infection.

The use of expedited partner therapy (EPT) has been recommended since 2006 by the CDC for treatment of sexually transmitted infections such as gonorrhea and chlamydia. Use of EPT currently is permissible in 42 states and the District of Columbia. (Check the map maintained by the CDC at http://bit.ly/2sofAfl to see the status of EPT laws in your state.) In 2017, Georgia became the most recent state to approve EPT use. EPT is “potentially allowable” in six states and Puerto Rico. The practice currently is prohibited in South Carolina and Kentucky.

Check Your Clinical Practice

Although new cases of STDs continue to increase, results from a recent national survey of sexually active young women indicate that many times they do not discuss sex and STD risk with their clinicians. In addition, many women aren’t being tested for infection or disease as national guidance recommends.4

For the survey, sponsored by Quest Diagnostics in Secaucus, NJ, researchers looked at the perceptions of young women ages 15-24, mothers of young women in this age group, and primary care, obstetrics/gynecology, and other specialty physicians about sexual activity and health, as well as STD knowledge and STD screening. Researchers compared the results to those of 2015 research conducted by the company involving similar populations.

Results indicate that 49% of young women reported that their clinician never asked if they desired testing for STDs. Among sexually active women, less than one in four said she had requested an STD test from her healthcare provider. Fifty-one percent of young women said they did not want to discuss sex or STDs with their healthcare providers.4

Among primary care physicians, only 74% indicated they would order chlamydia testing for a sexually active female patient who did not have symptoms. Just 72% said they would order gonorrhea testing for such a patient without symptoms, according to the study. The findings of the study indicate that “key barriers” to STD testing involve patient discomfort with conversations about sexual activity and inaccurate beliefs regarding risk, states Damian Alagia III, MD, FACOG, FACS, Quest Diagnostics’ medical director of woman’s health.

“Half of all new STD cases are acquired by young people between the ages of 15-24, and one in four sexually active adolescents has a sexually transmitted disease,” said Alagia in a press statement. “Our hope in sharing this survey’s findings with clinicians and the general public is that it prompts open dialogue about reproductive health and STD risk, which is absolutely critical to reversing the trajectory of high STD rates in the United States.”

REFERENCES

  1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2017. Atlanta: U.S. Department of Health and Human Services; 2018.
  2. Owusu-Edusei K Jr, Chesson HW, Gift TL, et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008. Sex Transm Dis 2013;40:197-201.
  3. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. Atlanta, GA: Centers for Disease Control and Prevention; 2015.
  4. Quest Diagnostics. Young Women and STDs: Are Physicians Doing Enough to Empower their Patients and Protect their Health? Available at: https://bit.ly/2IUtxXR. Accessed Oct. 18, 2018.