Sexually Transmitted Disease Surveillance 1996

Division of STD Prevention September 1997

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 
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,
1996. U.S. Department of Health and Human Services, Public Health Service.
Atlanta: Centers for Disease Control and Prevention, September 1997.

Copies can be obtained from the Office of Communications, National Center
for HIV, STD, and TB Prevention, Centers for Disease Control and
Prevention, 1600 Clifton Road, Mailstop E-06, Atlanta, Georgia 30333.

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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 reproductive consequences, e.g., ectopic pregnancy and tubal factor
infertility. If not adequately treated, 20% to 40% of women infected with
chlamydia (1) and 10% to 40% of women infected with gonorrhea (2) 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 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.

Infections with human papillomavirus (HPV) in women are a major concern
because specific HPV subtypes (e.g., types 16, 18, 31, 33, and 35) have
been associated epidemiologically with cervical dysplasia and cervical
cancer. HPV types 6 and 11 in child bearing women can cause laryngeal
papillomatosis in infants.

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).

Observations

--   Between 1995 and 1996, the reported rate of chlamydial infections in
     women increased from 316.2 per 100,000 population to 321.5
     (Figure_6, Table_6). This increase most likely reflects an
     increase in screening rather than an increase in number of cases in
     women; even as reported cases have increased, prevalence among women
     screened in the U.S. has declined (see section on Chlamydia). Despite
     considerable under-reporting, it is important to note that chlamydia
     rates exceed gonorrhea rates in women in many states (Figure_A and
     Figure_B, Table_6 and Table_15).

--   For gonorrhea, the Healthy People year 2000 objective is 100 cases per
     100,000 persons. Gonorrhea rates for women alone exceeded this HP2000
     objective in 22 states (Figure_B, Table_15). The highest rates
     of gonorrhea for women were concentrated in the South.

--   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_15, Table_15 and Table_16). Gonorrhea rates
     decreased for women from 140.2 cases per 100,000 population in 1995 to
     119.5 in 1996; rates in men also declined from 158.7 to 128.5 from
     1995 to 1996. 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. However, trends in women are
     determined more by screening practices, similar to chlamydia.

--   The Healthy People year 2000 objective for primary and secondary
     syphilis is 4.0 per 100,000 persons. Primary and secondary syphilis
     rates for women alone exceeded the HP2000 objective in 15 states and 2
     outlying areas (Figure_C, Table_27). Five southern states
     (Louisianna, Maryland, Mississippi, North Carolina, Tennessee) had
     rates for women that were at least 3 times greater than the HP2000
     objective for primary and secondary syphilis. For congenital syphilis,
     the Healthy People year 2000 objective is 40 per 100,000 live births.
     Five (Arkansas, Maryland, Mississippi, South Carolina, Tennessee) of 8
     states that exceeded the HP2000 objective were in the South
     (Figure_D, Table_38). 

--   The rate of congenital syphilis (CS) closely follows the trend of
     primary and secondary (P&S) syphilis in women (Figure_32). Peaks
     in CS usually occur one year after peaks in P&S syphilis in women. The
     CS rate peaked in 1991 at 107.3 cases per 100,000 live births and has
     declined 72% to 30.4 in 1996 (Figure_33, Table_37). The rate
     of P&S syphilis in women peaked at 17.3 per 100,000 persons in 1990
     and declined 77% to 4.0 in 1996 (Figure_29 and Figure_32,
     Table_27). 

--   Although the 1996 rate of CS was below the Healthy People 2000
     Objective of 40 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 (10).

--   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 1980's may be treated in out-patient facilities
     during the 1990's. Trends in hospitalized PID have declined steadily
     throughout the 1980's and early 1990's (Figure_F). However, 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 in-patient to out-patient) rather
     than true trends in disease (11).

--   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_E).
     Beginning in 1990, hospitalizations for ectopic pregnancy began to
     decline. Data from out-patient care surveys suggest that nearly half
     of all ectopic pregnancies are treated on an out-patient basis (12).
     The total number of ectopic pregnancies in the U.S. in 1992 was
     estimated to be 108,800 (or 19.7 cases per 1,000 pregnancies), the
     highest level in more than two decades (12).

--   Initial visits to physicians' offices for PID declined from 1993 to
     1995, but increased in 1996 (Figure_G). In 1994, an estimated
     397,000 women aged 15-44 years were diagnosed with PID in emergency
     departments (National Hospital Ambulatory Medical Care Survey, NCHS). 

Figure_A.  Chlamydia -- Rates for women by state: United States and 
               outlying areas, 1996
Figure_B.  Gonorrhea -- Rates for women by state: United States and 
               outlying areas, 1996
Figure_C.  Primary and secondary syphilis -- Rates for women by state: 
               United States and outlying areas, 1996
Figure_D.  Congenital syphilis -- Rates for infants <1 year of age by 
               state: United States and outlying areas, 1996
Figure_E.  Ectopic pregnancy -- Hospitalizations of women 15-44 years 
               of age: United States, 1980-1994
Figure_F.  Pelvic inflammatory disease -- Hospitalizations of women 
               15-44 years of age: United States, 1980-1994
Figure_G.  Pelvic inflammatory disease -- Initial visits to physicians' 
               offices by women 15-44 years of age: United States,
               1980-1996 and Healthy People year 2000 objective


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(9)   CDC. Guidelines for prevention and control of congenital syphilis.
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(10)  Division of STD/HIV Prevention. Healthy People 2000: National Health
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