Sexually Transmitted Disease Surveillance 1994

Division of STD Prevention

September 1995

U.S. Department of Health and Human Services
Public Health Service
Centers for Disease Control and Prevention 
National Center for HIV, STD, and TB Prevention (proposed)
Division of STD Prevention
Atlanta, Georgia 30333

                         Copyright Information 

All material contained in this report is in the public domain and may be
used and reprinted without special permission; citation to source, however,
is appreciated.

                           Suggested Citation

Division of STD Prevention. Sexually Transmitted Disease Surveillance,
1994. U.S. Department of Health and Human Services, Public Health Service.
Atlanta: Centers for Disease Control and Prevention, September 1995.

Copies can be obtained from Information Technology and Services Office,
National Center for HIV, STD, and TB Prevention (proposed), Centers for
Disease Control and Prevention, 1600 Clifton Road, Mailstop E-06, Atlanta,
Georgia 30333 or by telephone at (404) 639-1819.

Both the 1993 and 1994 reports are now available electronically on CDC
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CDC's Information Resource Management Office at (404) 332-4569.

                        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 reproductive consequences, e.g., ectopic pregnancy and tubal factor
infertility. If not adequately treated, 20 to 40 percent of women infected
with chlamydia (1) and 10 to 40 percent of women infected with gonorrhea
(2) develop PID. Among women with PID, scarring sequelae will cause
involuntary infertility in 20 percent, ectopic pregnancy in 9 percent, and
chronic pelvic pain in 18 percent (3). Approximately 70 percent of
chlamydia infections and 50 percent 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). Ectopic
pregnancy is the leading cause of first-trimester, pregnancy-related deaths
in African-American women (8).

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 (CS) are preventable if women are screened for
syphilis and treated early through prenatal care (9).

HIV-infected pregnant women can pass this fatal infection to their unborn
infants. Treatment with zidovudine during pregnancy can prevent as much as
two-thirds of these infections (10,11).

Observations

 --  Since 1988, CDC has supported screening programs for Chlamydia
     trachomatis infections in women to define the prevalence of these
     infections and determine the impact of screening programs on
     prevention of long term consequences. Due to increasing interest in
     chlamydial infections, many states have implemented reporting
     procedures for chlamydia and begun collecting chlamydia case data. In
     1994, 46 states had implemented legislation mandating reporting of
     chlamydia and reported cases to CDC; an additional state without
     reporting laws collected and reported cases on a voluntary basis
     (Figure_A, Table_3).

 --  Between 1993 and 1994, the reported rate of chlamydial infections in
     women increased from 249.7 per 100,000 population to 265.3
     (Figure_5, Table_4). These rates reflect trends in screening
     rather than trends in disease incidence for the following reasons:
     chlamydia infections in women are largely asymptomatic and can only be
     identified through screening; reported cases include both prevalent
     and incident cases; many state/local health departments are in the
     process of developing chlamydia prevention programs, including
     surveillance infrastructure to collect information from laboratories
     and providers. Currently, despite considerable under reporting, it is
     important to note that chlamydia rates exceed gonorrhea rates in women
     in many states (Figure_B, Table_4 and Table_12).

 --  The ability of large-scale screening programs to reduce chlamydia
     prevalence in women has been documented in areas where this
     intervention has been in place for several years. For example, the
     screening programs in federal Region X (Alaska, Idaho, Oregon,
     Washington) family planning clinics have demonstrated steady declines
     in chlamydia prevalence since 1988 (Figure_C).

 --  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 1970's. After an initial increase
     in cases detected through screening, gonorrhea rates for both women
     and men declined steadily throughout the 1980's and early 1990's
     (Figure_10; Table_12 and Table_13). Compared with 1993, in
     1994, gonorrhea rates increased slightly for women from 147.1 cases
     per 100,000 population in 1993 to 153.7; rates in men continued to
     decline during this period. Men with gonorrhea are usually symptomatic
     and seek care; therefore, trends in men are considered a relatively
     good indicator of incidence trends in disease. However, trends in
     women are largely determined by screening patterns, similar to
     chlamydia. An indication that the declining trends in gonorrhea may be
     attributed in part to the screening programs is the pattern of the
     gonorrhea male-to-female rate ratio (M:F RR). In 1980, the M:F RR was
     1.5 and has declined steadily to 1.2 in 1994. In the absence of known
     outbreaks of gonorrhea in men who have sex with men (which tend to
     occur sporadically), the steadily declining M:F RR suggests that
     decreasing gonorrhea trends may be due in large part to many infected
     women being identified and treated through screening programs.

 --  The rate of CS closely follows the trend of primary and secondary
     (P&S) syphilis in women (Figure_26). Peaks in CS usually occur one
     year after peaks in P&S syphilis in women. The CS rate peaked in 1991
     at 107.6 cases per 100,000 live births and has declined 48% to 55.6 in
     1994 (Figure_27 and Table_34). The rate of P&S syphilis in
     women peaked at 17.3 per 100,000 population in 1990 and declined 56%
     to 7.6 in 1994 (Figure_23 and Figure_26; Table_24).
     Although the rate of CS is approaching the Healthy People 2000
     national objective of 50 cases per 100,000 live births, this objective
     is many times greater than the rate of CS of most industrialized
     countries where syphilis and CS have nearly been eliminated (12).

 --  Accurate estimates of pelvic inflammatory disease (PID) and tubal
     factor infertility from gonococcal and chlamydial infections are
     difficult to obtain largely due to the requirement for complex and
     invasive procedures (e.g., laparoscopy or laparotomy, and tubal
     patency studies) 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 1980's may be treated in out-patient facilities during 1990's.
     These factors make surveillance for PID difficult. Trends in
     hospitalized PID have declined steadily throughout the 1980's and
     early 1990's (Figure_28). However, these trends may be more
     reflective of changes in hospitalization rates rather than true trends
     in disease (13).

 --  Recent evidence suggests that health care practices associated with
     ectopic pregnancy also changed in the late 1980's and early 1990's.
     Before that time, treatment of ectopic pregnancy usually required
     admission to a hospital. Hospitalization statistics were therefore
     useful for monitoring trends in ectopic pregnancy (Figure_D).
     Beginning in 1990, hospitalizations for ectopic pregnancy began to
     decline. Data from outpatient care surveys suggest that nearly half of
     all ectopic pregnancies are currently treated on an outpatient basis
     (14). The total number of ectopic pregnancies in the U.S. in 1992 was
     estimated at 108,800 (or 19.7 cases per 1,000 pregnancies), the
     highest level in more than two decades (14).

(1) Stamm 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.

(2) Platt 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.

(3)Westrom 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;19:185-92.

(4) Hook EW III, Hansfield 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.

(5) Stamm 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.

(6) Zimmerman HL, Potterat JJ, Dukes RL, et al. Epidemiologic differences
between chlamydia and gonorrhea. Am J Public Health 1990;80:1338-42.

(7) Hillis 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.

(8) Goldner TE, Lawson HW, Xia Z, et al. Surveillance for ectopic pregnancy
-- United States, 1970-1989. In: CDC Surveillance Summaries, December 17,
1993.MMWR 1993;42(No.SS-6):73-85.

(9) CDC. Guidelines for prevention and control of congenital syphilis. MMWR
1988;37(No.S-1).

(10) CDC. Recommendations of the U.S. Public Health Service task force on
the use of zidovudine to reduce perinatal transmission of human
immunodeficiency virus. MMWR 1994;43(No.RR-11).

(11) Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant
transmission of human immunodeficiency virus type I with zidovudine
treatment. N Engl J Med 1994;331:1173-80.

(12) Division of STD/HIV Prevention. Healthy People 2000: National Health
Promotion and Disease Objectives. Progress Review: Sexually Transmitted
Diseases, October 26, 1994.

(13) 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.

(14) CDC. Ectopic pregnancy -- United States, 1990-1992. MMWR 1995;44:46-8.

Figure_A. Chlamydia - Number of states with reporting laws for
              Chlamydia trachomatis infections and reported rates: United
              States, 1987-1994
Figure_B. Chlamydia - Rates for women by state: United States, 1994    
Figure_C. Chlamydia - Percent positivity among women tested in family
              planning clinics by state: Region X, 1988-1994    
Figure_D. Ectopic pregnancy - Hospitalizations of women 15-44 years of
              age: United States, 1980-1993

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