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‘Everyone has a role to play’ in addressing the STD crisis
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According to the CDC, 2.3 million new cases of the three nationally notifiable sexually transmitted diseases — chlamydia, gonorrhea and syphilis — were reported by Americans in 2017. It was yet another record-breaking year for STDs in the United States, and the epidemic is showing no signs of slowing down.
Jonathan H. Mermin, MD, MPH, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, said when the statistic was released that the country was “sliding backward.”
Surveillance efforts by the agency have revealed a significant rise in all three infections across multiple age groups and demographics. For example, rates of chlamydia — the most commonly reported STD — increased 6.9% between 2016 and 2017 alone, and nearly two-thirds of all new chlamydial infections were acquired by patients aged 15 to 24 years. The second leading notifiable infection was gonorrhea, which increased 18.6% since 2016. Although rates of syphilis have increased nearly every year since 2001, a 10.5% increase was observed between 2016 and 2017. The CDC noted that the rate of congenital syphilis more than doubled since 2013, highlighting the threat to reproductive-aged women.
Elizabeth A. Torrone, PhD, an epidemiologist in the Division of STD Prevention at the CDC, told Infectious Diseases in Children that the rise in reportable STDs can be attributed, at least in part, to better surveillance.
“As a country, we are doing a better job screening, finding infections and treating patients,” she said. “This is great because we are preventing adverse complications, but it also means that we are diagnosing more infections, causing the observed case rate to increase.”
However, Torrone added that dramatic increases in STD cases among some groups, including men who have sex with men (MSM), young women, racial and ethnic minorities and those residing in the Southern U.S. — are caused by increased transmission as opposed to improved screening efforts.
Carlos del Rio, MD, FIDSA, professor of medicine and chair of the department of global health at Emory University Rollins School of Public Health, told Infectious Diseases in Children that the STD epidemic in the U.S. is a national “crisis,” and that he has yet to hear someone acknowledge just how big of a problem it is or suggest how to solve it.
“The numbers clearly show that we have not been doing enough, and we need to take them seriously,” said del Rio, who is also the co-director of the Emory Center for AIDS Research. “We need to build and appropriately fund the public health infrastructure to really address this epidemic in a serious way. This is going to require resources; it is not going to happen by itself.”
Infectious Diseases in Children spoke with epidemiologists and pediatric infectious disease experts to explore how children and adolescents are affected by the STD epidemic in the U.S. and what providers can do to combat this growing public health threat.
Consequences for adolescents, young adults
The CDC estimates that nearly half of all new STDs are acquired by adolescents and young adults aged 15 to 24 years. Both age groups that fall within this range (15 to 19 years and 20 to 24 years) are at increased risk for infection.
Infectious Diseases in Children Editorial Board member Toni Darville, MD, distinguished professor of pediatrics and microbiology and immunology and chief of the division of infectious diseases at the University of North Carolina Children’s Hospital, said in an interview that teenagers may be at increased risk for chlamydia and other STDs because of “a combination of biological and physiological reasons.”
“Because chlamydia is asymptomatic in the majority of patients, they do not seek medical attention, and it continues to spread and remains highly prevalent,” she said.
Torrone said that one of the reasons rates of STDs among youth are particularly concerning is because the consequences of untreated infection can be severe, even though many of these diseases are “easily diagnosed and cured.”
A study published in Emerging Infectious Diseases, which assessed the long-term health outcomes related to untreated STDs in women, underscored the importance of timely screening and treatment. The researchers wrote that long-term clinical sequelae of STDs include pelvic inflammatory disease, infertility, tubal or ectopic pregnancy, cervical cancer, and perinatal or congenital infections in infants born to infected mothers.
“Adolescents may not necessarily be thinking about having children, and these infections can cause damage so that when they go on to want children later in life, they may not be able to,” Torrone said. “Again, these infections are treatable and curable, but they are also preventable. I think that is why we really focus on young people. We know we can prevent these infections and help protect their fertility later in life.”
Some potentially good news in the context of the STD epidemic is that fewer adolescents are having sex.
In June 2018, results of the National Youth Risk Behavior Survey suggested that adolescents in grades 9 through 12 reported a decline in ever having sexual intercourse (47.8% in 2007 vs. 39.5% in 2017). The survey also demonstrated a reduction in the proportion of teens who had four or more sexual partners (14.9% in 2007 vs. 9.7% in 2017). Condom use was reported by more than half of respondents.
Darville said that a lower number of teens having sex is “definitely a good thing.” She added that early sex is associated with using unsafe sex practices.
“Earlier sexual debut is associated with having more sex partners, unprotected sex, STDs and teenage pregnancy,” she said. “My concern would be that this trend may not last. Federal funding for groups that work to prevent teen pregnancy have been cut substantially since the current administration took over. Additionally, 39.5% of teenagers are still having sex, so programs encouraging safe sex practices are imperative.”
Neonatal infection
Adolescents are not the only pediatric patients affected by the surge in STDs in the U.S. A recent study published in Obstetrics & Gynecology reported that the number of syphilis cases among pregnant women in the U.S. increased 61% between 2012 and 2016, from 1,561 to 2,508 cases. CDC surveillance data showed that between 2013 and 2017, the annual number of congenital syphilis infections more than doubled — from 362 to 918 cases — outpacing overall increases in STDs in the country.
In September 2018, the U.S. Preventive Services Task Force (USPSTF) reaffirmed its previous recommendation that all pregnant women should be screened for syphilis — an infection that can result in stillbirth, neonatal death and morbidities such as bone deformities and neurological impairment. Results of an evidence report supporting the USPSTF’s recommendation showed that as screening rates increased from 89.8% to 97.2% among pregnant women between 2002 and 2012, the incidence of congenital syphilis decreased from 109.3 to 9.4 cases per 100,000 live births. However, the rate of congenital syphilis surged 87% between 2012 and 2016.
“These numbers are relatively small, but the increase is considerable,” Edward W. Hook III, MD, endowed professor of translational research at the University of Alabama, told Infectious Diseases in Children. “These are totally preventable infections because with appropriate prenatal care and follow-up, infections are detected, and women are treated so that they don’t transmit the infection to their children.”
Syphilis screening, according to both the CDC and USPSTF, should occur as early as possible during pregnancy. The CDC said neonates have an 80% risk of acquiring the infection if their mothers do not receive treatment. Additionally, women who are at high risk for syphilis and those who live in areas with high rates of the infection should be screened again in the third trimester and at the time of delivery.
In a 2014 study published in PLoS One, researchers wrote that pregnant women who either did not receive treatment for syphilis until the third trimester or did not receive treatment at all were more likely to experience adverse pregnancy outcomes, including preterm delivery, low birth weight, stillbirth or fetal loss and miscarriage. The researchers suggested that without universally available syphilis testing and treatment, adverse outcomes could occur in more than half of all pregnancies around the world.
del Rio said the rise in congenital syphilis is a sign of “the breakdown of public health infrastructure and decreased investment in public health, health departments and STI prevention programs.”
‘A really smart bug’
Current recommended therapy for primary or secondary syphilis — a single intramuscular injection of benzathine penicillin G — continues to be effective. Darville said there is “no concern” about antibiotic-resistant chlamydia or syphilis. However, the rising rate of antimicrobial resistance observed in cases of gonorrhea requires an immediate public health response with new treatment options and strategies.
“Gonorrhea became resistant to penicillin in the past, and then it became resistant to quinolones,” she said. “Now, it is difficult to treat patients with oral agents. What is recommended is an intramuscular administration of ceftriaxone, which is a third-generation cephalosporin. And because a small percentage of isolates have reported resistance to cephalosporin, the CDC has recommended the use of azithromycin. Now, the recommended therapy is dual therapy with ceftriaxone and azithromycin.”
This dual therapy is considered first-line treatment for uncomplicated anogenital and pharyngeal gonorrhea in the U.S., Canada, Australia and Europe. Darville added that even though the addition of azithromycin has helped to combat the rise in ceftriaxone-resistant gonorrhea, breakthrough infections could occur if the bacteria become resistant to azithromycin — and recent evidence suggests they have to some extent — “so even this dual therapy may become a problem,” she said.
Both the CDC and WHO have raised concerns about the possibility of untreatable gonorrhea. According to a review published in Microbiology Spectrum by Unemo and colleagues, Neisseria gonorrhoeae can alter its DNA, which allows the bacteria to rapidly adapt and survive in hostile host environments.
In 2017, WHO reported that 97% of countries who reported data through the organization’s Global Gonococcal Antimicrobial Surveillance Program had drug-resistant strains of gonorrhea, with increasing resistance to azithromycin (81%) and cephalosporins such as oral cefixime or injectable ceftriaxone (66%).
In their review, Unemo and colleagues suggested that “antimicrobial-resistant gonococcal strains do not recognize any borders and, accordingly, international actions, collaborations and political will, advocacy, research and funding are essential” to respond to the increasing threat caused by this bacterium.
“Gonorrhea is a really smart bug,” Torrone said. “The CDC works closely with our colleagues in the field to do enhanced surveillance to look at what antimicrobials the gonorrhea strains circulating are susceptible to. We test the strains in the lab, we see which antimicrobials work, and those inform our treatment recommendations so we can be sure that we are recommending the most effective treatments.”
WHO has described the drug pipeline for gonorrhea as “relatively empty,” and the organization stressed the need for new treatments. In the meantime, del Rio said that although resistance to ceftriaxone has been reported, it is still extremely rare. He added that it is important to remember that the recommended treatment for gonorrhea is still “a helpful and a good choice.”
‘Not someone else’s problem’
Screening, treating and preventing STDs can be a difficult topic to discuss for both patients and providers. The AAP has previously stated that pediatricians play a “significant role” in improving sexual health care for young people but they need to deliver these services to their patients more frequently.
Hook said STDs should be viewed as a health care issue rather than “stigmatized diseases in people who are misconstrued as being bad people.”
“The starting point for understanding and preventing STIs has to do with knowledge, education and realizing that as young people become sexually active, sexual health is one of their health responsibilities, just like eating right and exercising, getting vaccinated and all the things that we encourage people to do to keep themselves healthy,” Hook said.
Hook said the rate of HPV among youths is an example of how “STDs are not someone else’s problem,” and why education is so important. He said the number of HPV infectious accumulate at a rate of 15% annually among monogamous women. Within 3 years of being sexually active, more than 50% of young people have HPV, and over their lifetimes, between 80% and 85% of Americans will acquire the vaccine-preventable STD.
He noted, however, that some parents are still hesitant to begin the vaccination series for their child, fearing it will promote sexual promiscuity.
“The argument of ‘If I vaccinate my child against HPV, that’s like telling them to go out and have sex’ is a little silly,” Hook said. “It’s like saying that if you’re about to travel internationally and we give you a cholera vaccine, you can go drink sewer water. It just doesn’t make any sense. We are talking about keeping people healthy.”
Educating patients about sexual health can lower rates of STDs, but it cannot be assumed that youths are getting the right message. The CDC said 37% of youths — and specifically, three-quarters of all high schoolers — received abstinence-only sex education between 2000 and 2014.
“There are studies that show that if people — especially adolescents and young adults — are educated about sex, that really does affect the rate of STDs,” Darville said. “Unfortunately, there have been some studies recently that show that no one is talking to them about sex or asking if they are having sex, even when they go to see their pediatrician.”
Torrone said patients also have a responsibility to discuss their own sexual health with their providers when the subject is broached, which she acknowledged can be uncomfortable. In fact, young patients may be concerned over whether discussions about their sexual health will remain confidential. A recent study published by the State Medical Society of Wisconsin suggested that between 20% and 50% of teenagers who discussed topics such as substance use, mood and sex believed that clinicians would inform their parents of their behaviors. A separate CDC study found that 12.7% of teens and young adults who are insured through their parents reported that they would not seek sexual and reproductive health services out of fear that their parents would learn about it.
Hook said that pediatricians “have to be willing to talk about this topic with their patients” because of these concerns.
“We have this paradoxical situation in which the patient has things they want to say and questions they have, but they are waiting to be asked,” he said. “The health care provider is hesitant about asking the questions unless someone opens the door.”
As the STD epidemic rages in the U.S., Torrone said it is the providers who see patients on a daily basis who will have to do most of the work to address it, not federal or state health agencies.
“There have been persistently high rates of chlamydia, gonorrhea and syphilis for the past decade,” she said. “This is not a problem the CDC can address alone, and that our state and local health departments can address alone. STDs are complicated, and it really will take all sectors of our community to address them.” – by Katherine Bortz
- References:
- AAP Committee on Adolescence. Pediatrics. 2017;doi:10.1542/peds-2017-2858.
- CDC. Sexually transmitted disease surveillance 2016. https://www.cdc.gov/std/stats16/CDC_2016_STDS_Report-for508WebSep21_2017_1644.pdf. Accessed January 23, 2019.
- CDC. Sexually transmitted disease surveillance 2017 - National profile. https://www.cdc.gov/std/stats17/natoverview.htm. Accessed January 15, 2019.
- CDC. Sexually transmitted disease surveillance 2017 - STDs in adolescents and young adults. https://www.cdc.gov/std/stats17/adolescents.htm. Accessed January 15, 2019.
- CDC. Sexually transmitted diseases - syphilis treatment and care. https://www.cdc.gov/std/syphilis/treatment.htm. Accessed January 15, 2019.
- Deal C, et al. Emerg Infect Dis. 2004;doi:10.3201/eid1011.040622_02.
- Kahn L, et al. MMWR Morb Mortal Wkly Rep. 2018;doi:10.15585/mmwr.ss6708a1.
- Lee EC. WMJ. 2017;116:210-214.
- Leichliter JS, et al. MMWR Morb Mortal Wkly Rep. 2017;doi:10.15585/mmwr.ss6609a1.
- Lin JS, et al. JAMA. 2018;doi:10.1001/jama.2018.7769.
- Qin J, et al. PLoS One. 2014;doi:10.1371/journal.pone.0102203.
- Trivedi S, et al. Obstet Gynecol. 2019;doi: 10.1097/AOG.0000000000003000.
- Unemo M, et al. Microbiol Spectr. 2016;doi:10.1128/microbiolspec.EI10-0009-2015.
- US Preventive Services Task Force. JAMA. 2018;doi:10.1001/jama.2018.11785.
- Weston EJ, et al. MMWR Morb Mortal Wkly Rep. 2018;doi:10.15585/mmwr.mm6716a4.
- WHO: Antibiotic-resistant gonorrhea on the rise, new drugs needed. https://www.who.int/news-room/detail/07-07-2017-antibiotic-resistant-gonorrhoea-on-the-rise-new-drugs-needed. Accessed January 16, 2019.
- For more information:
- Toni Darville, MD, can be reached at lad@email.unc.edu.
- Carlos del Rio, MD, FIDSA, can be reached at cdelrio@emory.edu.
- Edward W. Hook III, MD, can be reached at ehooks@uabmc.edu.
- Elizabeth A. Torrone, PhD, can be reached at wxq5@cdc.gov.
Disclosures: Darville, del Rio, Hook and Torrone report no relevant financial disclosures.