Sexually Transmitted Disease Surveillance 1993

Division of STD/HIV Prevention 

December 1994

U.S. Department of Health and Human Services 
Public Health Service 
Centers for Disease Control and Prevention 
National Center for Prevention Services 
Division of STD/HIV Prevention 
Surveillance and Information Systems Branch 
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/HIV Prevention. Sexually Transmitted Disease
Surveillance, 1993.  U.S. Department of Health and Human Services, Public
Health Service.  Atlanta: Centers for Disease Control and Prevention,
December 1994.

Copies can be obtained from Information Services, National Center for
Prevention Services, Centers for Disease Control and Prevention, 1600
Clifton Road, Mailstop E-06, Atlanta, Georgia 30333.

                         
                         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
involuntarily 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).

Congenital syphilis (CS) is a devastating consequence for the infants born
to women who are infected with syphilis during pregnancy.  Most cases of CS
are preventable if women are screened and treated early through prenatal
care (9).

HIV-infected 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 1993, 44 states had implemented legislation mandating
          reporting of chlamydia and reported cases to CDC; an additional
          two states without reporting laws collected and reported cases on
          a voluntary basis (Figure_A, Table_3).

     --   Between 1989 and 1992, the reported rate of chlamydial infections
          in women increased from 162.5 per 100,000 population to 263.9 and
          declined slightly in 1993 to 243.9 (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 a mixture of prevalent
          and incident cases; and many state/local health departments have
          not yet developed chlamydia prevention programs, including
          surveillance infrastructure, to collect information from
          laboratories and providers.  Currently, despite considerable
          underreporting, it is important to note that chlamydia rates
          exceed those of any other bacterial STD in women in many states
          (Figure_B, Table_4).

     --   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 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 have declined steadily
          throughout the 1980's and early 1990's (Figure_10;
          Table_12 and Table_13).  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 1993.  In the absence of known
          outbreaks of gonorrhea in gay men (which tend to occur
          sporadically), the steadily declining M:F RR suggests that
          decreasing gonorrhea trends may be due in 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 since then to 79.0 in 1993 (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 to 9.5 in 1993
          (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 has 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.  Hospital discharge statistics
          were therefore useful for monitoring trends in ectopic pregnancy
          (Figure_D).  Beginning in 1990, hospitalizations for ectopic
          pregnancy began to decline.  However, data 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.

(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, 1987-1993
Figure_B. Chlamydia - Rates for women by state: United States, 1993    
Figure_C. Chlamydia - Percent positivity among women tested in family
              planning clinics by state: Region X, 1988-1993    
Figure_D. Ectopic pregnancy - Hospitalizations of women 15-44 years of
              age: United States, 1980-1992    

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