Sexually Transmitted Disease Surveillance 1995

Division of STD Prevention

September 1996

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,
1995. U.S. Department of Health and Human Services, Public Health Service.
Atlanta: Centers for Disease Control and Prevention, September 1996.

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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 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
chlamydial 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 American women (8). Both 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) 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).

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 quantify 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 have begun collecting chlamydia case data. In 1995, 48
    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 1994 and 1995, the reported rate of chlamydial infections in
    women increased from 260.2 per 100,000 population to 290.3
    (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 persistent
    and acute cases; and many state/local health departments are in the
    process of developing chlamydia prevention programs, including
    surveillance infrastructure to collect information from laboratories
    and providers. 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 positivity since 1988 (Figure_C). Introduction of
    large-scale screening in other areas (Wisconsin, San Francisco, and
    Columbus, Ohio) has been followed by similar declines in chlamydia
    positivity. Data from a randomized controlled trial of chlamydia
    screening in a managed care setting suggest that such screening
    programs can also reduce the incidence of PID by as much as 60% (12).

--  Based on the successful model in Region X and as part of the
    development of a national infertility prevention program, infertility
    prevention services aimed at women in three additional PHS regions
    (III, VII, VIII) were initiated in 1993 and piloted in the remaining
    PHS regions (I, II, IV, V, VI, IX) in 1995. Each region has adopted a
    model for the prevention of STD-related infertility based on
    collaboration between family planning and STD programs. In some of the
    PHS regions, public sector chlamydia screening and treatment
    supplements ongoing local and state prevention activities; in others,
    chlamydia screening was newly introduced. In 1995, state-specific
    chlamydia test positivity among 15- to 24-year-old women screened
    varied from 2.8% to 9.4% among those attending family planning clinics
    (Figure_D). These chlamydia test positivity rates are from those
    states reporting data on 3,000 or more women screened during 1995.

--  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). Gonorrhea rates
    decreased slightly for women from 150.7 cases per 100,000 population in
    1994 to 140.3 in 1995; 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
    trends in incidence of disease. However, trends in women are largely
    determined by screening patterns, similar to chlamydia.

--  The rate of congenital syphilis (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 107.3 cases per 100,000 live births and has
    declined 64% to 39.0 in 1995 (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 66% to 5.8 in 1995 (Figure_23 and Figure_26;
    Table_24). 

--  Although the 1995 rate of CS was below the revised 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 (13).

--  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 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).

--  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 currently treated on an outpatient basis
    (15). 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 (15).

Figure_A.  Chlamydia -- Number of states with reporting laws for
               Chlamydia trachomatis infections and reported rates: United
               States, 1987-1995 
Figure_B.  Chlamydia -- Rates for women by state: United States, 1995
Figure_C.  Chlamydia -- Percent positivity among women tested in family
               planning clinics by state: Region X, 1988-1995
Figure_D.  Chlamydia -- Percent positivity among 15-24 year-old women
               tested in selected family planning clinics by state, 1995
Figure_E.  Ectopic pregnancy -- Hospitalizations of women 15-44 years of
               age: United States, 1980-1993

---------------
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     Neisseria gonorrhoeae on simultaneous infections with Chlamydia
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(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
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     verified disease and 657 control women with normal laparoscopy. Sex
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(7)  Hillis SD, Joesoef R, Marchbanks PA, et al. Delayed care of pelvic
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(8)  Goldner TE, Lawson HW, Xia Z, et al. Surveillance for ectopic
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(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
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