In the 24th in a series of assessments
of Healthy People 2010, Acting Assistant Secretary
for Health Cristina Beato chaired a focus area Progress
Review on Sexually Transmitted Diseases (STDs). Dr. Beato
underscored the magnitude of the problem in stating that
18.9 million new STD infections, both curable and incurable,
occur each year in the United States, half of them in
persons younger than 25 years of age. More than 65 million
people in this country are currently living with an incurable
STD. The burden of STDs in direct medical costs in 2000
was estimated to be $9.3 to $15.5 billion. In conducting
the review, Dr. Beato was assisted by staff of the lead
agency for this Healthy People 2010 focus area,
the Centers for Disease Control and Prevention (CDC).
Also participating were representatives of the Office
of Population Affairs (OPA) and other U.S. Department
of Health and Human Services (HHS) offices and agencies.
The complete text for the Sexually Transmitted Diseases
focus area of Healthy People 2010 is available
at www.healthypeople.gov/document/html/volume2/25stds.htm.
The meeting agenda, tabulated data for all focus area
objectives, charts, and other materials used in the Progress
Review can be found at www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa25-std.htm.
Data Trends
Edward Sondik of the CDC National Center for Health
Statistics provided an overview of progress achieved
in meeting the targets of selected objectives in the
focus area. Since the baseline years in the late 1990s,
the objectives for primary and secondary syphilis, congenital
syphilis, genital herpes, and responsible adolescent
sexual behavior have shown improvement. The incidence
of gonorrhea is largely unchanged over the same time
period, whereas the incidence of chlamydia infections
has been increasing, for both males and females. To some
degree, this increase may reflect improved screening
methods.
Following his overview, Dr. Sondik provided additional
details about the status of objectives that were highlighted
in the Review. Among females aged 15 to 24 years who
attended family planning clinics in 2002, 6.0 percent
had chlamydia infections, compared with 5.0 percent in
1997 (Obj. 25-1a). Females in the same age group who
attended STD clinics showed a chlamydia infection rate
of 13.5 percent in 2002, compared with 12.2 percent in
1997 (Obj. 25-1b). Males in that age group who attended
STD clinics in 2002 showed a chlamydia infection rate
of 17.5 percent, compared with 15.7 percent in 1997 (Obj.
25-1c). The 2010 target for each of the three sub-objectives
is 3.0 percent. Among five racial and ethnic groups,
the reported incidence of chlamydia infections in 2002
was 1,132.5 per 100,000 population for blacks, more than
twice the rate for Hispanics in that year, and nearly
9 times the rate for whites and Asians/Pacific Islanders.
Of the five groups, American Indians/Alaska Natives had
the second highest rate of chlamydia infection in 2002
with 724.9 cases per 100,000.
After a substantial decrease beginning in the mid-1980s,
the incidence of new cases of gonorrhea among the total
population plateaued in the latter half of the 1990s.
In 2002, the incidence was 125 new cases per 100,000,
with little difference between the rates for females
and males. The rate for blacks was 742 new cases per
100,000 in 2002, or about 24 times the rate for whites.
The target is 19 new cases per 100,000 (Obj. 25-2).
The incidence of primary and secondary syphilis for
the total population showed a large decrease from around
1990, and this decline continues for females. In 2002,
the incidence was 1.1 cases per 100,000 for females,
compared with 3.8 per 100,000 for males, an increase
for the latter from 3.6 per 100,000 in 1997. Among males,
the incidence of syphilis varies greatly by age; in 2002,
the highest incidence, 9.9 cases per 100,000, occurred
among the age group 35 to 39 years. Among females, there
was little variance in incidence between ages 19 and
39. The age group 20 to 24 years had the highest rate
in 2002, 3.3 cases per 100,000. The incidence for blacks
was 9.8 cases per 100,000 in 2002, which is less than
half the rate of 22.0 cases per 100,000 recorded in 1997.
The target is 0.2 cases per 100,000 (Obj. 25-3). The
incidence of congenital syphilis has shown even greater
improvement in recent years, decreasing from 28 cases
per 100,000 live births in the total population in 1997
to 10 cases per 100,000 live births in 2002. Of five
racial and ethnic groups, the rate for blacks in 2002
was highest, at 40 cases per 100,000 live births, in
sharp contrast with the 1997 rate of 123 cases per 100,000
live births. The target is 1 case per 100,000 live births
(Obj. 25-9).
For the total population, the prevalence of infection
with genital herpes decreased from 17 percent in the
period 1988–1994 to 11 percent in 2002. Among four
groups between the ages of 12 and 49 years, the age group
40 to 49 years had the highest infection rate, 26 percent,
in 2002. The female infection rate in 2002 was 24 percent,
more than twice the rate (11 percent) for males. In the
age group 40 to 49 years, the genital herpes infection
rate among females in 2002 was 35 percent, compared with
18 percent among males. Among blacks, the infection rate
increased from 33 percent in the period 1988–1994
to 38 percent in 2002. The target is 14 percent (Obj.
25-4).
Among students in grades 9 through 12, the proportion
that evinced responsible sexual behavior (i.e., abstention
from sexual intercourse or use of condoms if currently
sexually active) increased from 85 percent in 1999 to
88 percent in 2003. The target is 95 percent (Obj. 25-11).
Overall, the differences between genders and between
racial and ethnic groups were not large.
Key Challenges and Current Strategies
In the presentations that followed the data overview, the principal
themes were introduced by representatives of the lead
agency—Janet Collins, Acting Director of CDC’s
National Center for HIV, STD and TB Prevention, and John
Douglas, Jr., Director of that Center’s Division
of STD Prevention. Also making a presentation was Alma
Golden, Deputy Assistant Secretary for Population Affairs/OPA.
These agency/office representatives and other participants
in the review identified a number of obstacles to achieving
the objectives and discussed activities under way to
meet these challenges, including the following:
- With all STDs, reporting of cases to CDC falls
short of actual incidence. True increases or decreases
may be masked by changes in screening practices, use
of more sensitive diagnostic tests, and changes in reporting
practices.
- More than 50 percent of all preventable infertility
among women is a result of infection with chlamydia.
Without treatment, up to 40 percent of women will experience
adverse health effects, including pelvic inflammatory
disease (PID). Twenty
percent of PID diagnoses result in infertility, 9 percent
in ectopic pregnancy, and 18 percent in severe pelvic
pain.
- Gonorrhea continues to increase in certain sexual
networks. The largest increases between 1998 and 2002
were among white men aged 30 to 44 years, primarily men
who have sex with men (MSM). Continued increases in antimicrobial
resistance have
been reported among this group and others, and treatment
options are diminishing.
- Syphilis has been demonstrated to enhance HIV
transmission, and the evidence is strong that genital
herpes does so as well.
- The decline since the 1980s and early 1990s in
the use of crack cocaine was a factor in the declining
incidence of primary and secondary syphilis, inasmuch
as crack use lessens motivation to seek medical help
for symptoms that are often more
obvious with syphilis than with some other STDs.
- Tests for HSV-2 antibody cannot identify genital
herpes due to HSV-1, which may be increasing.
- The 25 to 40 percent higher rate of prevalence
of genital herpes in women than in men suggests that
male-to-female transmission is more efficient than female-to-male
transmission. The female genital tract may be more vulnerable
to infection by the virus than the male genital tract.
- CDC’s Comprehensive STD Prevention Systems
fund 65 project areas, including all 50 states, 8 territories,
and 7 cities. Concomitantly, some 250 Federal staff are
assigned to state and local departments.
- The Gonococcal Isolate Surveillance Project provides
high-quality surveillance data to monitor antimicrobial
drug resistance in different population groups.
- One study showed that closer personal involvement
by parents in the lives of their adolescent children
reduced the risk of gonorrheal and chlamydial infection
by 94 percent.
- CDC’s National Plan to Eliminate Syphilis
in the United States has among its goals increasing the
number of syphilis-free counties to 90 percent by 2005.
Among the Plan’s key strategies are expanded clinic
and lab services, rapid outbreak response, and partnering
with communities and organizations.
- After first successfully testing it as a regional
model in HHS Region X, CDC has conducted the National
Infertility Prevention Program in partnership with
OPA since 1993. Today, the Program provides $27.8 million
to screen and treat women and their sex partners in
all 10 HHS Regions in a variety of healthcare settings,
including family planning and STD clinics, migrant
health centers, women’s detention facilities,
and Indian Health Service (IHS) sites.
- CDC will undertake a 5-year evaluation project
to test the efficacy of an abstinence-only sexual risk
reduction program for adolescents of middle school age.
In Alabama, an abstinence-only program was shown to have
a significant impact in reducing STD transmission among
adolescents.
Approaches for Consideration
Participants in the review made the following suggestions
for steps to enable further progress toward achievement
of the objectives for Sexually Transmitted Diseases:
- Expand screening for chlamydia and gonorrhea to identify
and treat these diseases before they lead to PID. Expansion
is needed in a number of areas—additional STD
and family planning clinics; more women served within
the existing network of STD and family planning clinics;
and additional public screening locations, such as
community health clinics, detention facilities, IHS
clinics, and school-based clinics. Work with the private
sector, which reports the majority of STDs, to increase
the number of sexually active women aged 16 to 27 years
who are screened for chlamydia. Also, expand screening
and treatment to male partners to decrease reinfection
of women.
- Develop multilevel strategies for addressing
increasing rates of STDs in MSM. Recent increases in
syphilis cases in men are attributable to MSM and affect
the ability to achieve the syphilis elimination goal.
Strategies must address issues such as
arranging to meet sexual partners via Internet communication
and related difficulties in partner notification/treatment,
the impact of methamphetamine use on sexual risk-taking
and STD incidence, and the challenge of syphilis/HIV
coinfection.
The multilevel approach should include integrated, cooperative
activities among public health practitioners, healthcare
providers, and members of the community.
- Implement human papilloma virus (HPV) education
programs for the public and healthcare providers.
- Increase use of the highly sensitive nucleic acid amplification
tests, which are 20 to 30 percent more sensitive than
standard methods for diagnosing chlamydia.
- In view of the increase in antimicrobial resistance
against most treatment options, increase cooperative
efforts with the Food and Drug Administration and private
industry to encourage the development and testing of
new drugs for gonorrhea.
- Expand outreach of STD prevention programs to
people in military service, a population that is significantly
affected by these diseases but has in the past been relatively
neglected in national surveillance and control activities.
- Take steps leading to the creation of a national
system for reporting on infertility, including a sentinel
system that would allow cases of infertility to be systematically
linked to prior STDs.
- To reduce risky practices and inculcate responsible
sexual behavior, promote the establishment of STD and
family planning clinics where couples are encouraged
to receive counseling together.
- Integrate HIV/STD prevention education with
other topics taught in schools that address interrelated
high-risk behaviors, such as drug use.
- Seek to maximize the involvement of parents
in school programs aimed at reducing the incidence of
adolescent pregnancy and transmission of STDs. Assist
school districts in producing guidance materials to help
parents to take up this role.
Contacts for information about Healthy People
2010 focus area 25Sexually Transmitted Diseases:
- Centers for Disease Control and Prevention—Gena
Hill, ghill@cdc.gov
- Office of Disease Prevention and Health Promotion
(coordinator of the Progress Reviews)—Miryam
Granthon (liaison to the focus area 25 workgroup),
mgranthon@osophs.dhhs.gov
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Cristina V. Beato, M.D.
Acting Assistant Secretary for Health
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