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Chlamydia rate declines for first time since reporting started
National data for reported sexually transmitted diseases in 2013 show that the rate of chlamydia infections has decreased for the first time since reporting for the disease began in 1994.
Other findings in the CDC’s annual report, Sexually Transmitted Disease Surveillance, include a higher rate of gonorrhea cases among men than among women, and an increased rate of syphilis that was only seen in men. The report summarizes 2013 data on these three notifiable STDs.
“All Americans should have the opportunity to make choices that lead to health and wellness,” the researchers wrote. “An approach to improve health equity can address what the health providers can do with other partners working together. Interested committed public and private organizations, communities and individuals can take action to prevent STDs.”
There were 1,401,906 reported cases of Chlamydia trachomatis infection, for a rate of 446.6 cases per 100,000 population, a 1.5% decrease from the 2012 rate. Although the rate decreased 2.4% among women and increased 0.8% among men, the rate of chlamydia among women — 623.1 cases per 100,000 — was more than double the rate among men, which was 262.6 cases per 100,000. The rate of chlamydia among blacks was 6.4 times greater than that among whites, and the rate among American Indians/Alaska Natives was almost four times that among whites.
With 333,004 reported cases, the gonorrhea rate saw a slight decrease of 0.6% from 2012. The 2013 rate was 106.1 cases per 100,000 population. The rates decreased for all people aged 15 to 19 years and in women aged 20 to 24 years. The rates increased for all other age groups. The rate of gonorrhea increased 4.3% among men, whereas the rate among women decreased by 5.1%. The rate of gonorrhea among blacks has been declining, but the rate was still 12.4 times the rate in whites. The report also highlights the increased resistance to fluoroquinolones, and reiterates the CDC recommended treatment for gonorrhea: dual therapy with ceftriaxone and azithromycin.
There were 17,375 reported cases of primary and secondary syphilis in 2013, for a rate of 5.5 cases per 100,000 people. This was a 10% increase from 2012. The increase was almost exclusively among men, who accounted for 91% of all syphilis cases. Men who have sex with men accounted for 75% of the cases, and 52% of MSM with syphilis also were coinfected with HIV. The rate of syphilis among women was unchanged, but there was a 4% increase in the rate of congenital syphilis (8.7 cases per 100,000 live births). The rate of syphilis among blacks was almost six times higher than the rate among whites.
“Many cases of chlamydia, gonorrhea and syphilis continue to go undiagnosed and unreported, and data on several additional STDs — such as HPV, herpes simplex virus and trichomoniasis — are not routinely reported to CDC,” the researchers wrote. “As a result, the annual surveillance report captures only a fraction of the true burden of STDs in America.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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The most dramatic finding is the continued rapid increase in syphilis among MSM in the US. That increase is particularly striking because we know how to control syphilis, but the resources are not available for local health departments to do what they need to do. We know there’s a direct relationship between the funding that goes into syphilis control and the cases of syphilis. Since the 1930s, we know we can control syphilis through routine screening, early treatment and partner notification. However, those increases reflect a lack of public health infrastructure. In the past 10 years, public health departments have been stripped bare of resources. Congenital syphilis also represents a failure in the public health system. The active numbers of congenital syphilis are small, so a small increase in one county can have an impact on the whole epidemiology. It doesn’t necessarily reflect an increase in heterosexual transmission over all. It suggests that there may be gaps in routine screening and treatment programs for pregnant women. Congenital syphilis is an eminently preventable condition with a good public health infrastructure.
It’s important not to over interpret changes based on one data point, so in terms of the decreased rate of chlamydia, I would like to see if the decline is sustained in the upcoming years before making any conclusion. However, it is encouraging and speaks to the potential impact of the screening and treatment programs in the United States, and also the potential impact of the guidelines from the USPSTF that recommend that all sexually-active women younger than 25 are screened for chlamydia and promptly treated, that their partners are also offered treatment, and that they are rescreened within 3 months.
The increase of gonorrhea among men is a combination of more testing among men in general and more testing in different anatomic sites. More and more clinicians are recognizing the importance of testing the oropharynx or testing the rectum, particularly among MSM and those who may have had sexual exposure at those sites. We are working with the FDA and manufacturers so that nucleic acid amplification tests to detect gonorrhea at the pharynx and the rectum may be cleared by the FDA. Most commercial laboratories have verified those tests according to Clinical Laboratory Improvement Amendment (CLIA) regulations, and they are available for clinical use. The data suggest that those tests are highly accurate, but none of the tests are currently FDA cleared for extra-genital sites.
There are two take-home messages for ID physicians. First, they need to continue to advocate for more resources at the public health level locally. Second, in their practices, they need to routinely ask about their patients’ sexual activity and sex of their partners. As they identify patients at risk, they need to screen and screen often. Sexually-active MSM should be screened every 3 to 6 months, and sexually-active HIV-positive MSM should be screened every 3 months, for syphilis, gonorrhea and chlamydia. We know that frequent screening can reduce STD rates, so it is incumbent upon ID physicians to speak with their colleagues and make sure people are screened frequently and adequately.
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