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Sexually Transmitted Diseases What’s New?

Sexually Transmitted Diseases What’s New?. Linda Creegan, FNP California STD/HIV Prevention Training Center. Common STDs Estimated Annual Incidences. Humanpapilloma Virus: 5.5 million Trichomoniasis: 5 million Chlamydia: 3 million Genital herpes: 1 million Gonorrhea: 650,000

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Sexually Transmitted Diseases What’s New?

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  1. Sexually Transmitted Diseases What’s New? Linda Creegan, FNP California STD/HIV Prevention Training Center

  2. Common STDsEstimated Annual Incidences • Humanpapilloma Virus: 5.5 million • Trichomoniasis: 5 million • Chlamydia: 3 million • Genital herpes: 1 million • Gonorrhea: 650,000 • Hepatitis B: 120,000 • Syphilis: 70,000

  3. Overview of Complications ofSexually Transmitted Diseases Fetal Wastage* Low Birthweight* Congenital Infection* Upper Tract Infection Systemic Infection Infertility Ectopic Pregnancy* Chronic Pelvic Pain STDs Cervical Cancer* HIV Infection* * Potentially Fatal

  4. Increased Transmission of HIV in the Presence of Other STDs • Transmission increased 3-5 times • Increased susceptibility • Mucosal breakdown due to genital ulcer may facilitate HIV entry • Recruitment of WBCs to site of active infection (inflammation) acts as an area of increased HIV receptors • Increased infectiousness • Increase in HIV viral load in semen, genital secretions and genital ulcers

  5. Chlamydia — Reported rates: United States, 1984–2000

  6. Chlamydia — Rates by state: United States and outlying areas, 2000 Note: The total rate of chlamydia for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 254.8 per 100,000 population.

  7. ChlamydiaAge- and gender-specific rates U.S. 2000 .0 Age Gender Total 10-14 73.9 15-19 1,348.5 20-24 1,381.7 25-29 516.9 30-34 200.0 35-39 83.8 40-44 37.9 45-54 15.6 55-64 4.7 65+ 2.9 Total 256.9

  8. Chlamydia Positivity among 15-24 y.o. women tested in family planning clinics by state, 2000 Note: States reported chlamydia positivity data on at least 500 women aged 15-24 years screened during 2000 except for Minnesota and Rhode Island. SOURCE: Regional Infertility Prevention Programs; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

  9. Prevalence of Chlamydia Infections in 15–19 Year Old Adolescent Girls by Health Care Setting, California, 2000 Source: California Department of Health Services, STD Control Branch; Los Angeles Infertility Prevention Project; and San Francisco infertility Prevention Project

  10. GonorrheaReported rates: U.S. 1970–2000 and theHealthy People year 2010 objective Note: The Healthy People 2010 (HP2010) objective for gonorrhea is 19.0 cases per 100,000 population.

  11. GonorrheaRates by state: U.S. and outlying areas, 2000 Note: The total rate of gonorrhea for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 129.9 per 100,000 population. The Healthy People year 2010 objective is 19.0 per 100,000 population.

  12. GonorrheaAge- and gender-specific rates: U.S. 2000 Age Gender Total 10-14 30.3 15-19 516.3 20-24 622.5 25-29 306.9 30-34 161.1 35-39 100.1 40-44 60.7 45-54 28.9 55-64 9.8 65+ 2.6 Total 131.4

  13. GonorrheaPositivity among 15-24 y.o. women tested in family planning clinics by state, 2000 *States reported gonorrhea positivity data on less than 500 women aged 15-24 years during 2000 except for Alaska submitting data for June-December only and Ohio submitting data for August-December only.SOURCE: Regional Infertility Prevention Programs; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

  14. GonorrheaRates by gender: U.S. 1981–2000 and theHealthy People year 2010 objective

  15. Gonorrhea and Chlamydia in Hawaii, 2001 Gonorrhea • Incidence 49.9 per 100,000 • 25% increase from 2000 to 2001 Chlamydia • Incidence 333 per 100,000 • Rate doubled between 1997 and 2001 Hawaii DOH CD Report, March/April 2002

  16. Chlamydia Prevalence Rate by Year Hawaii and U.S., 1986-2001

  17. Chlamydia Morbidity by Gender and Year Hawaii, 1986 – 2002* *Jan-June, 2002 Note: The Chlamydia Screening Program/Infertility Project (active screening of females participating in family planning services) may contribute to the disproportionate number of females detected with chlamydia infection.

  18. Gonorrhea Morbidity by Gender and YearHawaii, 1980 –2002* Jan-June, 2002

  19. Gonorrhea Morbidity: 15-19 yo By Gender Hawaii, 1994 –2001

  20. Reported Cases of Chlamydia (CT) and Gonorrhea (GC) in Hawaii, 1996-2000 N=2286 N=1184 N=10675* N=1279 • The disproportionate number of female cases may be attributed to the active screening of women participating in family planning services.

  21. Chlamydia and GC Cases(%) Among Asian/Pacific Islanders in Hawaii, 1996-2000

  22. Chlamydia incidence by county, Hawaii, 2001 Gonorrhea incidence by county, Hawaii, 2001 Hawaii DOH CD Report, March/April 2002

  23. CipR GC in Hawaii Rate now 20% resistant! Risk Factors (Chart review, N=117) • Heterosexual orientation • Travel to Asia • Commercial sex Recommendations • AVOID fluoroquinolones to treat GC CD Report May/June 2002

  24. Gonococcal Isolate Surveillance Project (GISP) Participating Clinics and Regional Laboratories Twenty-five sentinel sites across the nation monitor culture isolates of GC for antibiotic resistance

  25. (GISP) — Percent of Neisseria gonorrhoeae isolates with decreased susceptibility or resistance to ciprofloxacin, 1990–2000 Note: Resistant isolates have ciprofloxacin MICs >1 mg/mL. Isolates with decreased susceptibility have ciprofloxacin MICs of 0.125 - 0.5 mg/mL. There were sixty-one (61) resistant isolates: one in 1991, one in 1993, two in 1994, eight in 1995, two in 1996, five in 1997, four in 1998, nineteen in 1999, and nineteen in 2000. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

  26. GISP: Percent of N. gonorrhoeae isolates obtained from MSM 1998, 1999 and 2000 Note: In 2000, these 14 clinics reported 91.7% (633/690) of GISP gonorrhea cases in men who have sex with men (MSM). In 1998 ALB reported 0.0% MSM. Clinics include: ALB=Albuquerque, NM; ANC=Anchorage, AK; ATL=Atlanta, GA; CHI=Chicago, IL; DEN=Denver, CO; HON=Honolulu, HI; LBC=Long Beach, CA; MIA=Miami, FL; ORA=Orange County, CA; PHX=Phoenix, AZ; POR=Portland, OR; SDG=San Diego, CA; SEA=Seattle, WA; and SFO=San Francisco, CA.

  27. CipI/CipR Gonococcal Isolates Hawaii, 1993-2002* Jan-June, 2002

  28. SyphilisReported cases by stage of illness: U.S. 1941–2000

  29. Primary and Secondary Syphilis Reported rates: U.S. 1970–2000 and the Healthy People year 2010 objective Note: The Healthy People 2010 (HP2010) objective for primary and secondary syphilis is 0.2 case per 100,000 population.

  30. Primary and Secondary Syphilis Rates by state: U.S. & outlying areas 2000 Note: The total rate of primary and secondary syphilis for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 2.2 per 100,000 population. The Healthy People year 2010 objective is 0.2 per 100,000 population.

  31. Primary and Secondary Syphilis Rates by race and ethnicity: U.S. 1981–2000 and the Healthy People year 2010 objective

  32. P&S SyphilisCounties with rates above the Healthy People year 2010 objective, U.S. 2000

  33. Primary and Secondary Syphilis Age- and gender-specific rates: U.S. 2000 Age Gender Total 10-14 0.115-19 2.320-24 4.925-29 4.930-34 4.935-39 4.540-44 3.545-54 2.055-64 0.865+ 0.2 Total 2.2

  34. P&S Syphilis in Hawaii, 2001 • Incidence: 1.0 per 100,000 • Increase from 2 cases in 2000 to 12 cases in 2001 • 10 from Honolulu county, 2 from Hawaii county • 7 of 12, 60% are MSM • Of MSM, 40% are HIV-infected Hawaii DOH CD Report, March/April 2002

  35. Genital Herpes Initial visits to physicians’ offices: U.S. 1966–2000 SOURCE: National Disease and Therapeutic Index (IMS America, Ltd.)

  36. Herpes simplex virus type 2 - Percent seroprevalence according to age in NHANES* II (1976-1980) and NHANES III (1988-1994) Note: Bars indicate 95% confidence intervals. *National Health and Nutrition Examination Survey

  37. Genital Warts Initial visits to physicians’ offices: U.S. 1966–2000 SOURCE: National Disease and Therapeutic Index (IMS America, Ltd.)

  38. STD Services in Hawaii • Oahu: Diamond Head Health Center 808-733-9281 • Hawaii: Chester Wakida 808-933-0912 • Maui: Kris Mills 808-984-8313 • Kauai: Jo Manea 808-241-3563

  39. What’s New with Chlamydia Infection? • New diagnostic tests • Single dose treatment options • Screening recommendation • Partner management options

  40. Chlamydia Infection • Most common reportable disease in the U.S. • Estimated > 3 million cases annually • Incidence is highest among sexually active adolescents and young adults • Most infections are asymptomatic • Leading cause of preventable infertility in women • Direct and indirect costs estimated at $1.7 billion annually

  41. Chlamydia Infection in Men • Urethritis • Epididymitis • Proctitis • Conjunctivitis • Reiter’s Syndrome >50% ASYMPTOMATIC

  42. Cervicitis Urethritis Conjunctivitis Proctitis Peri-hepatitis (Fitz-Hugh-Curtis syndrome) 70-80% ASYMPTOMATIC Conjunctivitis Pneumonia Chlamydia Infections in Women and Neonates

  43. Acute PID Silent PID Genital Chlamydia in Women:Complications Ectopic pregnancy 9% Untreated genital CT infection 20-50% 18% Chronic pelvic pain Infertility 14-20%

  44. Chlamydia InfectionsEstimated Complications, U.S. • PID: 400,000 cases/year • Ectopic pregnancy: 14,000 cases/year • Infertility: 8,000 cases/year • Neonatal pneumonia: 37,000 cases/year

  45. Risk Factors for Genital CT • Age < 25 years • Female gender • Black race (proxy) • New or multiple sex partners • Inconsistent use of barrier methods

  46. Public Health Approaches to Chlamydia Control • Health promotion & education • Condom availability & use • Early detection through screening high risk populations • Increase in case finding • Decrease in community prevalence and complications (PID) • Health policy

  47. Chlamydia Screening & Treatment • Decreases community prevalence • Prevents pelvic inflammatory disease • Cost effective • Opportunity to increase awareness and provide risk reduction counseling

  48. Chlamydia prevalence among women tested in FP clinics by age: Region X, 1988-1998

  49. CT Screening Prevents PIDClinical trial, Seattle HMO, 1990-1992 • Randomized controlled trial • 1009 high risk women 18-34 assigned to intervention (invitation to get tested) and 1598 to usual care • Among intervention group, 64% were tested and 7% were positive and treated • Outcome of PID within 1-year follow-up: • 9 cases among screening group compared to 33 cases among usual care group • RR = 0.44 (0.20-0.90), less than half as many cases of PID among screening group Scholes et al., NEJM, 1996; 334:1362-6

  50. CT Screening Cost-Effective • CDC estimated that “for every dollar spent on chlamydia screening, we could save $12” • Outcomes of cost effectiveness analyses most sensitive to prevalence, costs of diagnostic tests, and costs of complications • In general, screening can be cost effective if the prevalence is greater than 3%

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