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STDs
in Women and Infants
Public Health Impact
Women and infants disproportionately bear the long
term consequences of STDs. Women infected with Neisseria gonorrhoeae or Chlamydia
trachomatis can develop pelvic inflammatory disease (PID),
which, in turn, may lead to adverse effects on the reproductive
system such as ectopic pregnancy and tubal factor infertility.
If not adequately treated, 20% to 40% of women infected with chlamydia1 and
10% to 40% of women infected with gonorrhea2 may develop PID.
Among women with PID, scarring sequelae will cause involuntary
infertility in 20%, ectopic pregnancy in 9%, and chronic pelvic
pain in 18%.3 Approximately
70% of chlamydial infections and 50% of gonococcal infections in
women are asymptomatic.4-6 These infections
are detected primarily through screening programs. The vague symptoms
associated with chlamydial and gonococcal PID cause 85% of women
to delay seeking medical care, thereby increasing the risk of infertility
and ectopic pregnancy.7 Data from a randomized
controlled trial of chlamydia screening in a managed care setting
suggest that such screening programs can reduce the incidence of
PID by as much as 60%.8
Gonorrhea
and chlamydia can also result in adverse outcomes of pregnancy, including
neonatal ophthalmia and, in the case of chlamydia, neonatal pneumonia.
Although topical prophylaxis at delivery is effective for prevention
of ophthalmia neonatorum, prevention of neonatal pneumonia requires
antenatal detection and treatment.
Genital
infections with human papillomavirus (HPV) in women are a major concern
because persistent infection with specific types (e.g., types 16,
18, 31, 33, 35, and 45), are causally related to cervical cancer;
these types also cause Pap smear abnormalities. Other types (e.g.,
types 6 and 11) cause genital warts, Pap smear abnormalities and,
rarely, recurrent respiratory papillomatosis in infants born to infected
mothers.9
When
a woman has a syphilis infection during pregnancy, she may transmit
the infection to the fetus in utero. This may result in fetal death
or an infant born with physical and mental developmental disabilities.
Most cases of congenital syphilis are preventable if women are screened
for syphilis and treated early during prenatal care.10
Observations
- Between 1999 and
2000, the reported case rate of chlamydial infections in women
increased slightly from 400.8 to 404.0 per 100,000 females (Figure 5, Table 5).
Chlamydia rates exceed gonorrhea rates among women in all states
(Figures
A and B, Tables 5 and 14).
- In 2000, the median
state-specific chlamydia test positivity among 15- to 24-year-old
women screened in selected prenatal clinics in 23 states and Puerto
Rico was 5.9% (range, 2.2% to 14.5%) (Figure
F).
- Gonorrhea rates
among women were higher than the overall HP 2010 objective of 19.0
cases per 100,000 persons11 in 42 states
and two outlying areas in 2000 (Figure B, Table 14).
As in previous years, the highest rates of gonorrhea among women
in 2000 occurred in the South (Figure
B).
- Like chlamydia,
gonorrhea is often asymptomatic in women and can only be identified
through screening. Large-scale screening programs for gonorrhea
in women began in the late 1970s. After an initial increase in
cases detected through screening, gonorrhea rates for both women
and men declined steadily throughout the 1980s and early 1990s
(Figure 12, Tables
14 and 15).
The gonorrhea rate for women in 2000 (128.3 per 100,000 females)
was similar to the 1999 rate of 128.7 cases per 100,000 females.
The gonorrhea rate among men in 2000 (134.6 cases per 100,000 males)
was also similar to the 1999 rate of 134.7 cases per 100,000 males
(Table 15).
Men with gonorrhea are usually symptomatic and may seek care; therefore,
trends in men may be a relatively good indicator of trends in incidence
of disease. As with chlamydia, trends in reported gonorrhea rates
among women are more likely to reflect screening practices as well
as the actual burden of disease.
- In 2000, the median
state-specific gonorrhea test positivity among 15- to 24-year-old
women screened in selected prenatal clinics in 15 states was 0.9%
(range, 0.0% to 3.7%) (Figure
G).
- The HP2010 objective
for primary and secondary (P&S) syphilis is 0.2 case per 100,000
persons. Primary and secondary syphilis rates for women exceeded
the HP2010 objective in 32 states and two outlying areas (Table 26).
For congenital syphilis, the HP2010 objective is 1.0 case per 100,000
live births. Twenty-seven states and one outlying area had reported
rates higher than this objective in 2000 (Figure
D, Table
38).
- The rate of congenital
syphilis closely follows the trend of P&S syphilis in women
(Figure
29). Peaks in congenital syphilis usually occur one year after
peaks in P&S syphilis in women. The congenital syphilis rate
peaked in 1991 at 107.3 cases per 100,000 live births and has declined
by 87.5% to 13.4 cases per 100,000 live births in 2000 (Figure 30, Table
37). The rate of P&S syphilis in women peaked at 17.3 cases
per 100,000 females in 1990 and declined 89.6% to 1.8 cases per
100,000 females in 2000 (Figure 29). During 1991-2000, the average
yearly percentage decrease in the rate of congenital syphilis was
22.0% (Table
37), while the average yearly decline in the rate of P&S
syphilis reported among women during this period was 21.0%.
- The 2000 reported
rate of congenital syphilis for the United States is now well above
the HP2010 objective of 1.0 case per 100,000 live births. This
objective is many times greater than the rate of congenital syphilis
of most industrialized countries where syphilis and congenital
syphilis have nearly been eliminated.12
- While most cases
of congenital syphilis occur in infants whose mothers have had
some prenatal care (Figure E), late or limited prenatal care
has been associated with congenital syphilis. Lack of health care
provider adherence to congenital syphilis screening recommendations
also may result in congenital syphilis.13
- Accurate estimates
of pelvic inflammatory disease (PID) and tubal factor infertility
from gonococcal and chlamydial infections are difficult to obtain.
Definitive diagnosis of these conditions can be complex, requiring
for example, laparoscopy or laparotomy, while tubal patency studies
may be needed to accurately document these conditions. Most cases
of PID are treated on the basis of interpretations of clinical
findings, which vary between individual practitioners. In addition,
the settings in which care is provided can vary considerably over
time. For example, women with PID who would have been hospitalized
in the 1980s may be treated in outpatient facilities during the
1990s. Trends in hospitalized PID have declined steadily throughout
the 1980s and early 1990s but have remained relatively constant
from 1995 through 1999 (Figure I). These trends may be more reflective
of changes in the etiologic spectrum (with increasing proportions
of more indolent chlamydial infection) and clinical management
of PID (from inpatient to outpatient) rather than true trends in
disease.14
- The reported number
of initial visits to physicians’ offices for PID through the National
Disease and Therapeutic Index (NDTI) has generally declined from
1993 through 2000. The reported number of visits in 2000 was slightly
lower than the number of initial visits reported in 1999 (Figure J). In 1999, an estimated 268,018
cases of PID were diagnosed in emergency departments among women
15 to 44 years of age (National Hospital Ambulatory Medical Care
Survey, NCHS). This estimated number has an approximate relative
standard error of 17.5%.
- Evidence suggests
that health care practices associated with ectopic pregnancy also
changed in the late 1980s and early 1990s. Before that time, treatment
of ectopic pregnancy usually required admission to a hospital.
Hospitalization statistics were therefore useful for monitoring
trends in ectopic pregnancy. Beginning in 1989, hospitalizations
for ectopic pregnancy began to decline. The number of reported
hospitalizations for ectopic pregnancy decreased in 1999 relative
to the number reported in 1998 (Figure
H). Data from outpatient care surveys suggest that nearly half
of all ectopic pregnancies are treated on an outpatient basis.15
1Stamm WE, Guinan ME, Johnson C. Effect of
treatment regimens for Neisseria
gonorrhoeae on simultaneous
infections with Chlamydia
trachomatis. N Engl J Med 1984;310:545-9.
2Platt R, Rice PA, McCormack WM. Risk of acquiring
gonorrhea and prevalence of abnormal adnexal findings among women
recently exposed to gonorrhea. JAMA 1983;250:3205-9.
3Westrom L, Joesoef R, Reynolds G, et al.
Pelvic inflammatory disease and fertility: a cohort study of 1,844
women with laparoscopically verified disease and 657 control women
with normal laparoscopy. Sex
Transm Dis 1992;9:185-92.
4Hook EW III, Handsfield HH. Gonococcal infections
in the adult. In: Holmes KK, Mardh PA, Sparling PF, et al, eds. Sexually Transmitted Diseases, 2nd edition. New York City: McGraw-Hill,
Inc, 1990:149-65.
5Stamm WE, Holmes KK. Chlamydia trachomatis infections in the adult. In: Holmes KK, Mardh
PA, Sparling PF, et al, eds. Sexually
Transmitted Diseases,
2nd edition. New York City: McGraw-Hill, Inc, 1990:181-93.
6Zimmerman HL, Potterat
JJ, Dukes RL, et al. Epidemiologic differences between chlamydia
and gonorrhea. Am
J Public Health 1990;80:1338-42.
7Hillis SD, Joesoef R, Marchbanks PA, et al.
Delayed care of pelvic inflammatory disease as a risk factor for
impaired fertility. Am
J Obstet Gynecol 1993;168:1503-9.
8Scholes D, Stergachis A, Heidrich FE, Andrilla
H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease
by screening for cervical chlamydial infection. N Engl J Med 1996;34(21):1362-6.
9Division of STD Prevention. Prevention of Genital HPV Infection and Sequelae:
Report of an External Consultants’ Meeting. National Center for HIV, STD, and TB Prevention,
Centers for Disease Control and Prevention, Atlanta, December
1999.
10 Centers for
Disease Control. Guidelines for prevention and control of congenital
syphilis. MMWR 1988;37(No.S-1).
11 U.S. Department
of Health and Human Services. Healthy People
2010. 2nd ed. With Understanding and Improving Health and Objectives
for Improving Health. 2 vols. Washington, DC: U.S. Government Printing
Office, November 2000.
12 Division of
STD/HIV Prevention. Healthy
People 2000: National Health Promotion and Disease Objectives.
Progress Review: Sexually Transmitted Diseases, October 26, 1994.
13 Centers for
Disease Control and Prevention. Congenital Syphilis - United States, 2000. MMWR 2001;50:573-77.
14 Rolfs RT,
Galaid EI, Zaidi AA. Pelvic inflammatory disease: trends in hospitalization
and office visits, 1979 through 1988. Am J Obstet Gynecol 1992;166:983-90.
15 Centers for
Disease Control and Prevention. Ectopic pregnancy in the United States, 1990-1992. MMWR 1995;44:46-8.
Figure
A. Chlamydia — Rates for women by state: United States and
outlying areas, 2000
Note: The total rate of chlamydia
for women in the United States and outlying areas (including Guam,
Puerto Rico and Virgin Islands) was 399.8 per 100,000 population.
Figure
B. Gonorrhea — Rates for women by state: United States and
outlying areas, 2000
Note: The total rate of gonorrhea
for women in the United States and outlying areas (including Guam,
Puerto Rico and Virgin Islands) was 126.5 per 100,000 population.
The Healthy People year 2010 objective is 19.0 per 100,000 population
for women.
STDs in Women
and Infants figures continued on page 2
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