STDs in Women and Infants
Public Health Impact
Women and infants bear significant long-term consequences of STDs. In addition to biological and social factors such as poverty and access to quality STD services, a woman’s inability to negotiate safer sexual practices, such as condom use, can significantly affect her sexual health and subsequently the health of her unborn baby.1,2 A woman’s relationship status with her male partner, in particular, has been identified as an important predictor of her sexual health.3 For example, a perceived shortage of available men in a community, can cause women to be more accepting of their partners’ concurrent sexual relationships, and partner concurrency is a factor associated with increased risk for STDs.4 A number of studies have found significant associations between condom use and socio-demographic characteristics, including age, income, education, and acculturation.5 Because it may be the behavior of her male partner, rather than the woman’s own behavior, that increases a woman’s risk for STDs, even a woman who has only one partner may be obliged to practice safer sex such as using condoms.6
Women infected with C. trachomatis or N. gonorrhoeae can develop PID, which, in turn, can lead to reproductive system morbidity such as ectopic pregnancy and tubal factor infertility. An estimated 10%–20% of women with chlamydia or gonorrhea may develop PID if they do not receive adequate treatment.7,8 Among women with PID, tubal scarring can cause infertility in 8% of women, ectopic pregnancy in 9%, and chronic pelvic pain in 18%.9
About 80%–90% of chlamydial infections10 and up to 80% of gonococcal infections11 in women are asymptomatic. These infections are detected primarily through screening. The symptoms associated with PID are vague so 85% of women with PID delay seeking medical care, thereby increasing the risk for infertility and ectopic pregnancy.12 Data from two randomized controlled trials of chlamydia screening suggest that such screening programs reduce PID incidence. 13,14
HPV infections are highly prevalent in the United States, especially among young sexually active women. Although most HPV infections in women resolve within 1 year, they are a major concern because persistent infection with specific types of the virus are causally related to cervical cancer; these types also cause Papanicolaou (Pap) smear abnormalities. Other types cause genital warts, low-grade Pap smear abnormalities, and, rarely, recurrent respiratory papillomatosis in infants born to infected mothers.15
Chlamydia and gonorrhea can result in adverse outcomes of pregnancy, including neonatal ophthalmia and, in the case of chlamydia, neonatal pneumonia. Although topical prophylaxis of infants at delivery is effective for prevention of gonococcal ophthalmia neonatorum, prevention of neonatal pneumonia requires prenatal detection and treatment.
Genital infections with HSV are extremely common, can cause painful outbreaks, and can have serious consequences for pregnant women and their infants.16
When a woman has a syphilis infection during pregnancy, she can transmit the infection to the fetus in utero. Transmission can result in fetal death or an infant born with physical and mental developmental disabilities. Most cases of congenital syphilis are easily preventable if women are screened for syphilis and treated early during prenatal care.17
Chlamydial infections in women are usually asymptomatic and screening is necessary to identify most infections.18 Routine chlamydia screening of sexually-active young women has been recommended by CDC since 1993.19 Increases in reported cases among women since the early 1990s likely reflect expanded screening coverage (Figure 1). In 2012, there were 1,018,272 cases reported among women for a rate of 643.3 per 100,000 females. This rate is similar to the rate of 643.4 per 100,000 females in 2011.
Chlamydia rates are highest among young women, the population targeted for screening (Figure 5, Table 10). Within the young age group, rates were highest in 2012 among 19 year old females (4,921.1 per 100,000 females) although this was a slight decrease from the 2011 rate of 5,122.1 per 100,000 females (Table 12). Regionally, chlamydia case rates are highest among women in the South, with a rate of 715.4 per 100,000 females in 2012 (Table 4). Chlamydia rates exceeded gonorrhea rates among women in all states (Figures A and B, Tables 4 and 15).
Like chlamydia, gonorrhea is often asymptomatic in women. Thus, gonorrhea screening is an important strategy for the identification of gonorrhea among women. Large-scale screening programs for gonorrhea in women began in the 1970s. After an initial increase in cases detected through screening, gonorrhea rates for both women and men declined steadily throughout the 1980s and early 1990s and then declined more gradually in the late 1990s and the 2000s (Figure 11). After reaching an all-time low in 2009 (104.5 cases per 100,000 females), the gonorrhea rate for women has increased slightly each year, and was 108.7 cases per 100,000 females in 2012 (Figure 12, Table 15).
The gonorrhea rate among women has been slightly higher than the rate among men since 2001 (Figure 12, Tables 15 and 16).Gonorrhea rates are highest among young women (Figure 16, Table 21). Within the young age group, rates were highest in 2012 among 19 year old females (761.3 per 100,000 females) (Table 23).
Positivity in Selected Populations
During the mid-1990s to 2011, chlamydia and gonorrhea positivity among young women screened in prenatal care clinics participating in infertility prevention activities were reported to CDC to monitor chlamydia and gonorrhea prevalence in women. As the national infertility prevention program expanded, these data became difficult to interpret as trends were influenced by changes in screening coverage, screening criteria, and test technologies, as well as demographic changes in patients attending clinics reporting data to CDC. These issues could not be addressed with the limited variables that were collected at the national level.
Positivity data continue to be useful locally to inform clinic-based screening recommendations and to identify at-risk populations in need of prevention interventions, but are no longer collected to monitor national trends in chlamydia and gonorrhea.
Trends in congenital syphilis usually follow trends in P&S syphilis among women, with a lag of 1–2 years (Figure 43). The rate of P&S syphilis among women declined 95.4% (from 17.3 to 0.8 cases per 100,000 females) during 1990–2004 (Figure 31). The rate of congenital syphilis declined by 92.4% (from a peak of 107.6 cases to 8.2 cases per 100,000 live births) during 1991–2005 (Table 1). Rates of both female P&S and congenital syphilis increased during 2005–2008. During 2009-2012, rates of both female P&S and congenital syphilis declined (from 1.4 to 1.1 cases per 100,000 population and from 10.4 to 7.8 cases per 100,000 live births, respectively) (Tables 28 and 42). The rate of congenital syphilis was 7.8 cases per 100,000 live births in 2012, the lowest rate since 1988, when the case definition was changed (Table 42).
Although most cases of congenital syphilis occur among infants whose mothers have had some prenatal care, late or limited prenatal care has been associated with congenital syphilis. Failure of health care providers to adhere to maternal syphilis screening recommendations also contributes to the occurrence of congenital syphilis.20
Accurate estimates of PID and tubal factor infertility resulting from chlamydial and gonococcal infections are difficult to obtain, in part because definitive diagnoses of these conditions can be complex. Published data suggest overall declining rates of women diagnosed with PID in the United States in both hospital and ambulatory settings.21-23
During 2001-2010, hospitalizations for acute PID overall have shown modest declines, although hospitalizations for acute PID increased by 44.3% (from 36.3 to 52.4 per 100,000) between 2009 and 2010 (Figure E). Hospitalizations for chronic PID have also shown modest declines, remaining relatively stable between 2007 and 2010 (Figure E). The National Hospital Discharge Survey (NHDS) was discontinued in 2010. In 2011, a new survey, the National Hospital Care Survey (NHCS), was launched that integrates inpatient data formerly collected by the NHDS with emergency department, outpatient department, and ambulatory surgery center data previously collected by the National Hospital Ambulatory Medical Care Survey.
Racial disparities in diagnosed PID have been observed in both ambulatory and hospitalized settings. 21 Using data from three nationally representative surveys conducted by the National Center for Health Statistics (NCHS), disease rates were two to three times higher among black women than among white women. These disparities are consistent with the marked racial disparities observed for chlamydia and gonorrhea. However, because of the subjective methods by which PID is diagnosed, racial disparity data should be interpreted with caution.
The incidence of ectopic pregnancy in the United States during the 1970’s and 1980’s was marked by significant increases. This surveillance who also relied on the NHDS, which collected information on discharged hospital inpatients in the United States. Since the late 1980s, the ability to ascertain the number of ectopic pregnancies occurring in the United States has been affected by changing health care practices, including technological advances that permit early, accurate diagnosis of pregnancy and ectopic pregnancy, and pharmacological and technical advances in treatment of ectopic pregnancy. Data from the NHDS suggest that hospitalizations for ectopic pregnancy have decreased from 33.0 per 100,000 in 2001 to 21.6 per 100,000 in 2010 (Figure I). However, this likely does not reflect a decrease in the actual public health burden of ectopic pregnancy given that administrative data from the middle of the decade show that the proportion of cases being treated with nonsurgical intervention is increasing.24 In the future years, data on ectopic pregnancy will be available from NHCS.
2 McCree DH, Rompalo A. Biological and behavioral risk factors associated with STDs/HIV in women: implications for behavioral interventions, In: Aral SO, Douglas JM,Lipshutz JA (editors). Behavioral Interventions for Prevention and Control of Sexually Transmitted Diseases (p. 310-324). New York, NY: Springer.
3 El-Bassel N, Gilbert L, Krishnan S, Schilling R, Gaeta T, Purpura S, et al. Partner violence and sexual HIV-Risk behaviors among women in an inner-city emergency department. Violence Vict. 1998;13(4):377-393.
5 Manderson L, Chang T, Tye LC, Rajanayagam K. Condom use in heterosexual sex: a review of research, 1985–1994. In: Catalan J, Sherr L, Hedge B (editors). The impact of AIDS: psychological and social aspects of HIV Infection. p. 1-26. The Netherlands: Harwood Academic Publishers.
7 Paavonen J, Westrom L, Eschenbach. Pelvic Inflammatory Disease. In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, Cohen, MS, Watts DH, (editors). Sex Transm Dis. 4th ed. New York: McGraw-Hill; 2008:1017- 1050.
8 Hook EW III, Handsfield HH. Gonococcal infections in the adult. In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et al, (editors). Sex Transm Dis. 4th ed. New York: McGraw-Hill; 2008:627-45.
9 Westrom L, Joesoef R, Reynolds G, Hagdu A, Thompson SE. 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;9:185-92.
10 Stamm WE. Chlamydia trachomatis infections in the adult. In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et al, (editors). Sex Transm Dis. 4th ed. New York: McGraw-Hill; 2008:575-93.
11 Marrazzo JM, Handsfield HH, Sparling PF. Neisseria gonorrhoeae In: Mandell GL, Bennett JE, Dolin R (editors). Principles and practice of Infectious Diseases, 7th ed. Philadelphia, PA: Churchill Livingstone; 2010: 2753-2770.
12 Hillis SD, Joesoef R, Marchbanks PA, Wasserheit JN, Cates W Jr, Westrom L. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol. 1993;168:1503-9.
14 Oakeschott, P, Kerry S, Aghaizu A, Atherton H, Hay S, et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ. 2010;340:c1642.
15 Centers for Disease Control and Prevention. Prevention of genital HPV infection and sequelae: report of an external consultants’ meeting. Atlanta: U.S. Department of Health and Human Services; 1999.
17 Centers for Disease Control and Prevention. Guidelines for prevention and control of congenital syphilis. MMWR Morb Mortal Wkly Rep. 1988;37(No. SS-1).
18 Farley TA, Cohen DA, Elkins W. Asymptomatic sexually transmitted diseases: the case for screening. Preventive Medicine. 2003;36:502-9.
19 Centers for Disease Control and Prevention. Recommendations for the prevention and management of Chlamydia trachomatis infections. 1993 MMWR 1993,42(RR-12):1-39.
20 Centers for Disease Control and Prevention. Congenital syphilis — United States, 2003–2008. MMWR Morb Mortal Wkly Rep. 2010;59:413-17.
22 Sutton MY, Sternberg M, Zaidi A, St. Louis ME, Markowitz LE. Trends in pelvic inflammatory disease hospital discharges and ambulatory visits, United States, 1985–2001. Sex Transm Dis. 2005;32(12)778-84.