Press Briefing Transcripts
2006 Sexually Transmitted Disease Surveillance Report
November 13, 2007, 12:00 p.m. EST
OPERATOR: Thank you for standing by and welcome to this telebriefing for the release of the CDC′s 2006 Sexually Transmitted Disease Surveillance Report.
At this time, all lines are in the listen-only mode. Later, there will be an opportunity for questions and instructions will be given at that time. If you need assistance, during the call, please press star then zero.
I would now like to turn the conference over to your host, Dr. John Douglas, Director of the CDC′s Division of Sexually Transmitted Disease Prevention; Dr. Douglas, go ahead.
JOHN DOUGLAS, DIRECTOR, CDC′S DIVISION OF SEXUALLY TRANSMITTED DISEASE PREVENTION: Good afternoon and thank you for joining us on today′s telebriefing. I′m Dr. John Douglas, Director of the Division of STD Prevention at CDC′s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB prevention.
Today, we will be discussing new data on STD diagnoses in the United States, which are published today, in CDC′s Annual National STD Surveillance Report. These data include the latest trends in three nationally notifiable STD′s reported to CDC – chlamydia, gonorrhea, and syphilis. This report is available online at www.cdc.gov/std/stats; S-T-A-T-S. The findings are also summarized in a fact sheet that you should have received before this call. If you didn′t, please call our communications office at 404-639-8895.
With the start of this telebriefing, the embargo on the report′s data has lifted. I′m joined today by my colleagues, Drs. Hillard Weinstock and Stuart Berman and Sam Groseclose who will help in answering your questions a bit later.
I′d like to start by discussing the serious impact of STD′s on public health. STDs pose a serious and ongoing health threat to millions of Americans. The CDC estimates that approximately 19 million STD infections occur each year in the U.S. Young women, racial and ethnic populations, and men who have sex with men – or MSM – are particularly hard hit by these diseases. STDs can have serious health consequences, particularly, if they are undiagnosed and left untreated. In females, chlamydia and gonorrhea can cause pelvic inflammatory disease, which can lead to infertility and ectopic pregnancy. Syphilis can cause neurologic damage and fatal infections in babies and all three STDs discussed in today′s call, increase the risk of HIV transmission.
It′s important to note that the data included in the STD Surveillance Report provide us with an important but only a partial picture of the impact of STDs, in the U.S. Many cases of notifiable STDs are either never diagnosed or go unreported. In addition, some common STDs, such as HPV – human papilloma virus – and genital herpes are not nationally notifiable. Nevertheless, looking at the new data on nationally reported STDs alone, it is clear that they represent a substantial threat to the health of Americans. I′ll now briefly describe new data contained within the Surveillance Report and then we′d be happy to answer questions.
Overall, diagnoses of all three STDs increased between 2005 and 2006. While the data do not provide explanations for the changes, in and of themselves, we do have some indications of factors driving these trends, which I′ll highlight as I discuss each disease.
I turn, first, to a discussion of chlamydia, a significant threat to the reproductive health of women and also, the most common reportable infectious disease in the U.S. In 2006, 1,030,911 cases of chlamydia were reported. This represents an all-time high for reported chlamydia cases and accounts for the largest number of cases reported to CDC for any condition. It also reflects a 5.6 percent increase from the 976,445 cases reported in 2005. While this may reflect a rise in actual infections, much of this recent increase is most likely due to expanded chlamydia screening in the U.S., as well as, the increased use of more sensitive testing technologies. These developments have contributed to the steady rise in chlamydia diagnoses since the mid-1990s. Even with these improvements, however, most cases of chlamydia, in the U.S., remain undiagnosed or unreported and CDC estimates that 2.8 million infections occur each year. The impact of chlamydia continues to be felt most severely by women, particularly, young women. In 2006, the chlamydia rate for women was three times higher than that for men, although, much of the difference in rates is explained by the fact that women are more likely to be tested. Young women aged 15 to 19, had the highest chlamydia rate, 2,862.7 cases per 100,000 compared to 515.8 cases per 100,000 for women overall.
While chlamydia is widespread across all racial and ethnic groups, racial and ethnic minorities are disproportionately affected. In 2006, the chlamydia rate among African Americans was more than eight times higher than among whites and the rate among Hispanics was three times higher than among whites. Overall, 46 percent of reported cases of chlamydia were among African Americans, even though, they only account for approximately 13 percent of the population.
Because chlamydia rates are highest among young women and because the majority of cases do not have noticeable symptoms, the CDC recommends that all sexually active women under the age of 26 be screened for chlamydia annually. The CDC also encourages older women with risk factors, such as, new or multiple sex partners, to be screened as well. Unfortunately, studies show that many women continue to go untested. Screening is one of the most effective and under-utilized prevention tools and is critical to preventing the serious health consequences of chlamydia, particularly, infertility.
Next, I′ll turn to data on gonorrhea. In 2006, 358,366 cases of gonorrhea were reported in the United States, making it the second most commonly reported infectious disease in the country, after chlamydia. The gonorrhea rate, in 2006, was 120.9 per 100,000, an increase of 5.5 percent since the year before. This is the second year of increases in gonorrhea rates following relative stability since 1997. While it is too early to determine whether this represents a trend, we will need to monitor these data, in the future, to determine if these increases will continue.
For the sixth year, in a row, the gonorrhea rate among women, in 2006, was slightly higher than the rate among men. Like chlamydia, gonorrhea can also lead to pelvic inflammatory disease and infertility. The racial disparities and diagnoses of gonorrhea are stark.
In 2006, African Americans accounted for more than two thirds or 69 percent of reported cases and had a rate of gonorrhea infection 18 times higher than that of whites. American Indians and Alaskan Natives had the second highest rate followed by Hispanics.
Gonorrhea′s impact also varies by region. As in previous years, the South had the highest gonorrhea rate among the four regions, of the country. Additionally, rates rose in the South for the first time in eight years, increasing 12.3 percent between 2005 and 2006 from 141.8 to 159.2 per 100,000 population. We will need to monitor future data closely to determine whether this increase is representative of an emerging trend. While the impact is greatest, in the South, we are also concerned about continued increases in the West, where the rate of reported gonorrhea cases rose 2.9 percent between 2005 and 2006 from 80.5 to 82.8 per 100,000 and increased by 31.8 percent between 2002 and 2006.
Of critical and increasing importance, one of the major challenges in preventing and treating gonorrhea is the growing number of gonorrhea cases that are resistant to antibiotics. Earlier this year, in response to preliminary 2006 data showing continued growth in drug resistance across multiple populations, the CDC announced new gonorrhea treatment guidelines, which no longer recommend fluoroquinolones, a major class of antibiotics, for treating gonorrhea in the United States. The final data on 2006 resistance, which is contained within today′s Surveillance Report, show that 13.8 percent of gonorrhea cases, overall, were resistant to fluoroquinolones in 2006 compared to 9.4 percent in 2005 and 6.8 percent in 2004. They also show that resistance among heterosexuals doubled from 3.8 to seven percent between 2005 and 2006. These data provide further confirmation that fluoroquinolones are no longer an appropriate treatment for gonorrhea leaving us with relatively few treatment options.
Finally, I′ll turn to data on primary and secondary syphilis, the early and most infectious stages of the disease. Syphilis rates decreased steadily, during the 1990′s and reached a historic low in 2000. Since that year, however, syphilis rates have been increasing, and 2006 saw a continuation of this trend. Between 2005 and 2006, the syphilis rate increased by 13.8 percent from 2.9 to 3.3 cases per 100,000. 9,756 cases of primary and secondary syphilis were diagnosed in 2006, up from 8,724 in 2005. It should be noted, from a historical perspective that rates of syphilis still remain at an extremely low level, however, the recent increases point to the need for ongoing vigilance in addressing this recent resurgence.
National increases in syphilis appear to be driven by increases among men, particularly, men who have sex with men. In 2006, almost two-thirds, 64 percent of cases were among MSM. Given that syphilis can increase HIV risk, these data are of particular concern because they could indicate increased risk for HIV transmission.
While the rate of syphilis among women remained substantially lower than the rate among men, there were increases in syphilis in women for the second year, in a row, following a decade of earlier declines. The syphilis rate among women increased 11.1 percent between 2005 and 2006 from 0.9 to 1.0 per 100,000. The most significant increase was among African American women. The reasons for these overall increases among females are not yet clear; however, CDC is currently analyzing this trend to better understand the factors driving this increase. Additionally, for the first time in 14 years, the rate of congenital syphilis that is transmission from mother to infant, increased slightly in 2006 from 8.2 to 8.5 per 100,000 live births.
While it′s too early to determine if the increases among newborns is a trend, increases in congenital syphilis have historically followed increases in women.
And finally, although racial gaps in syphilis rates are narrowing, significant disparities remain. In 2006, syphilis rates among African Americans, overall, were roughly six times higher than among whites. This represents a substantial decline since 1999 when the rate among African Americans was 29 times greater than among whites and reflects both declines in infections among African Americans, as well as, significant increases among white men in the past five years. However, the level of disparity among African Americans continues to be among the highest of all notifiable infectious diseases. Additionally, disparities in syphilis rates also continue for Hispanics, with 2006 rates that were twice those of whites.
As the data you′ve heard today demonstrate, it is clear that STD′s continue to have a significant impact on the health of millions of Americans. Increases in all three of these STD′s reported to CDC, during 2006, underscore the continued need for vigilance in prevention, screening and treatment efforts, and racial disparities across all STD′s indicate that these efforts are especially needed among racial and ethnic minorities.
I want to briefly highlight CDC′s efforts to address ongoing challenges posed by STD′s and then move on to your questions. To combat chlamydia, CDC continues to recommend annual screening for sexually active women under 26 as a critical prevention measure. Unfortunately, our best estimates indicate that as few as 40 percent of women who need such testing are receiving it. Screening for chlamydia is considered one of the most effective prevention measures and one that is relatively under-utilized. If we are going to correct this gap, it′s vital that both young sexually active women under 26, as well as, their healthcare providers, understand the importance of routine testing every year. Simple changes in the way we provide healthcare, such as coupling a chlamydia test with a Pap test, for example, can greatly increase the number of women screened. In addition, because studies indicate that women who are effectively treated can still become reinfected by their untreated sexual partners, the CDC recommends the delivery of antibiotic by patients to their partners, otherwise known as, expedited partner therapy, as an effective strategy to combat reinfection, if other efforts for reaching partners are not likely to succeed.
The CDC is also closely monitoring gonorrhea drug resistance to ensure that infected individuals are receiving effective care. As previously mentioned, in April, the CDC revised its gonorrhea guidelines. As part of those revised guidelines, CDC no longer recommends fluoroquinolones for treating gonorrhea in the U.S. This leaves only one class of antibiotics called cephalosporins as a treatment option, underscoring the urgent need for new, effective medicines to treat gonorrhea and increased vigilance in monitoring for resistance. While no resistant cases were documented, in 2006 for cephalosporins, CDC is continuing to closely monitor for emerging resistance to this class of antibiotics.
In an effort to combat the resurgence of syphilis, CDC updated its national plan to eliminate syphilis in 2006 and has been working with partners, across the country, to both accelerate earlier progress in combating syphilis among African Americans and women and also, to fight the resurgence among MSM. New strategies include more careful targeting of public health activity to the most affected populations, as well as innovative approaches to reaching MSM in a variety of a settings, such as, through the Internet, in bath houses, bookstores, as well as, HIV testing sites to name a few.
And finally, CDC is actively working with public health leaders and groups serving affected communities across the country to identify ways to further reduce the significant racial disparities in STD rates, especially, among African Americans.
Thank you very much. Now, I′d like to open up the call for any questions.
OPERATOR: Thank you. If you would like to ask a question, please press star then one. You will hear the tone indicating you′ve been placed in the question queue. To remove yourself from this queue, press the pound key. If you are using a speakerphone, please pick up your handset before pressing the numbers and please stay on your handset while asking your question.And we′ll go to – the first question will be from Larry Altman, New York Times. Please go ahead.
LARRY ALTMAN, NEW YORK TIMES: If I read this correctly, in your fact sheet, you′re estimating that there are 19 new million infections each year of STD′s but the three reportable ones don′t add up to that so can you give a breakdown as to where that estimate comes from and I′m assuming it reflects herpes and papilloma virus and if that assumption is correct, how many to each of those?
DOUGLAS: So yes, Larry, these numbers – the 19 million does come from an estimate that we published in 2004. Dr. Weinstock, whose with me today, was the first author of that study. The missing cases between the 19 million and three that we discussed today, are represented by estimated numbers of cases of genital herpes; HSV-II infection; genital types of human papilloma virus, as well as, trichomonal infections, which cause vaginosis in women, as well as, urarthritis in men. Hillard, I don′t know whether you have the ballpark numbers for each of those in your head.
HILLARD WEINSTOCK: I don′t, though, they do, as you say, constitute the vast majority of those estimated infections that you mentioned.
DOUGLAS: That study was published in …
DOUGLAS: 2004 in Perspectives and Family Planning, is that right?
ALTMAN: But has that been updated? That′s …
DOUGLAS: We haven′t updated those estimates since that was published.
WEINSTOCK: That was published in Perspectives on Sexual and Reproductive Health 2004.
ALTMAN: OK. I hope there′s a way that you can get those figures after the press conference …
DOUGLAS: Yes, we can …
ALTMAN: … and send them along.
DOUGLAS: We′d be happy to do that.
OPERATOR: And the next question will be from Will Dunham from Reuters. Please go ahead.
WILL DUNHAM, REUTERS: Yes, hi. This is Will Dunham with Reuters in Washington. Let me ask you, did the rates of all three diseases also increase in 2005 from 2004 and if not, I′m trying to figure out when was the last year that there have been increases from year-to-year noticed in all three of them, in one single year.
DOUGLAS: Yes, they all increased last year.
DUNHAM: This is the second consecutive year in which all three, across the board, increased over the previous year?
DOUGLAS: Yes that′s right. Chlamydia has been increasing, essentially, ever since reporting became national and again, we think reflected by increased testing and use of more sensitive tests. Gonorrhea increased – has been increasing for the past two years, so last year, was the first time that both it and chlamydia were increasing and then, finally, syphilis has been increasing since 2000.
DUNHAM: So, six straight years on syphilis, correct?
DUNHAM: OK, so – I′m sorry, so how many consecutive years on chlamydia is it?
DOUGLAS: Ever since we began national reporting. We – states came online for national reporting gradually but by 2000, all 50 states were reporting chlamydia.
DUNHAM: OK and we think that the increase is there because there′s more screening for it?
DOUGLAS: We think it′s because of more screening; because of the use of more sensitive tests. Tests that are more likely to pick up infection if its there, which are becoming more and more widely practiced, although, we absolutely cannot rule out true increases in infections. That′s a major concern, although, we have no doubt that the largest part of the trajectory of increase, is testing and the type of tests used.
DUNHAM: And let me also ask, you′ve talked about individual reasons that we might be seeing increases for the three diseases, is there anything that′s going on, you know, above and beyond that that might explain why, you know, after years of decreases on some of these diseases that you know, all of a sudden, at this point, in this decade, we′re seeing, you know, trends reverse and head up in all three.
DOUGLAS: Well, it′s a really good question. I mean I think the explanations are theories, not proven but they vary disease-by-disease. For syphilis we began to increases in 2001 and that was clearly related to increased number of cases among men who had sex with men and there are a lot of other reasons for believing that at least, a certain subset of men who have sex with men, began practicing riskier sexual behavior. Some of them, in fact, a large proportion of them, are HIV infected. They, as a group, were often on anti-retroviral therapy, which improved their general health and well-being and many of them resumed sexual activity. Probably, the biggest news, although fortunately, it′s a small trend, at this point, with syphilis, in the last two years, has been the increased rates in women. So, we had, you know, really gotten down to very low rates in women and we′d achieved major reductions in African American women, in particular, so the fact that in the last two years, we′re beginning to see those rates creep up, is really cause for concern. It′s certainly not at a very high level. It′s not like a major problem across the country but that trend is quite concerning. Frankly, part of the problem is in many of our state and local health departments who work with us on the prevention programs is that as they have been responding to the growth of syphilis epidemics in men who have sex with men, there has been some potential for less attention to be paid to the originally targeted populations.
The story for gonorrhea, I would say and I′ll actually invite my colleagues here to join me on this because this is, I think, really a – I think we′ve got (inaudible) well worked out, is almost certainly due, in part, to increased testing. Many women, who are tested for chlamydia, are tested as – with what are called dual tests, which also packaged gonorrhea tests with it and so, as we have been increasing chlamydia testing, we′ve been increasing gonorrhea testing. Those same tests that make chlamydia diagnoses more sensitive, also, probably, enhance gonorrhea detection and so both the factors for chlamydia are probably going on with gonorrhea but there probably are true increases. We published in an MMWR report, in March, the observation that gonorrhea rates have been going up in eight Western states since 2002, and when we dug in for the explanation, on that it looked like it was, probably, all three factors, meaning, more testing; more sensitive tests being used and probably, some real increase, as well. The increases in the South that we′re describing in today′s Surveillance Report, almost certainly, reflect this same combination, although, we′ve analyzed that in a little less detail.
Why are we seeing true increases in infection? Now, we get into, you know, honestly speculative territory. It′s true that STD prevention programs and – in local and state health departments have been stretched from an infrastructure point of view and frankly, I think that some of this may reflect, you know, attention to lots of different problems with the same amount of resources. It′s hard to know whether or not what we all recognize as an issue with national healthcare, which is an increasing number of individuals who do not have health insurance and don′t have ready access to healthcare, may be affecting sexually transmitted diseases. These individuals, with these infections, have historically, often, sought care in the public sector but we′re seeing an increasing number of infections reported out of non-STD clinic settings and so that loss of access to healthcare is sort of a population phenomenon and certainly, could contribute to whether or not infections are being well-controlled.
Dr. Berman, any other reflections?
STUART BERMAN: Well, you know, there′s always the question, is there something going on nationally in terms of risk taking behavior and its really pretty hard to have specific enough data to understand all the factors that could be behind, you know, what are reasonably modest increases of 10 to 20 percent but I would say, there is in the last couple years, reassuring data coming from, for example, the Division Adolescent School of Health collect data on high school students that show that there has been an ongoing decrease in risky sexual behavior, so as an overlay to this, you know, its reassuring that we′re not seeing those kinds of changes but exactly what′s underlying some of the other rate increases, I don′t think we can go beyond what the Dr. Douglas (ph) had described.
DOUGLAS: Thanks Dr. Berman.
OPERATOR: And your next question comes from Mike Stobbe, Associated Press.
MIKE STOBBE, ASSOCIATED PRESS: Hi, thank you for taking the question. In the historical charts, going back to ′41, there are numbers and rates for each of the diseases, except, chlamydia. That starts around ′84 and you just explained that most states didn′t come on until 2000, do you mind, I don′t have a history, why didn′t we see full chlamydia reporting until much later?
DOUGLAS: Well, again, a brief history of sexually transmitted disease control, in the U.S., is as follows. We began addressing STDs as sort of an organized process in the early 1940s and it was entirely a syphilis program. Once penicillin became available, we aggressively attacked syphilis with better screening and treatment. Gonorrhea was certainly known to be a sexually transmitted infection but not really addressed with formal public health programs until the 1970′s when we developed antibiotic – rather bacteriologic media that allowed us to do reasonably easy culture testing and so, by the 70s, we had a two-pronged program addressing both syphilis and gonorrhea. Chlamydia had been known to be transmitted by sex but it was not clear until the late 70s and early 80s that it, in fact, was responsible for a number of conditions that had been previously unexplained, most importantly, urethral infection in men and even more importantly, pelvic infection in women and so, in the late 1980′s, we began to do pilot demonstration projects looking at whether chlamydia screening could impact infection, in the population. It appeared that it could and so, we and others began to both support public screening programs, as well as, to make recommendations, so it wasn′t until we began to get that somewhat gradually increasing recognition of the importance of chlamydia that it began to be reported and we didn′t begin to collate those data nationally until the early 1980s.
BERMAN: I also want to mention that its every state′s decision about what to collect and make reportable and it took a little while for each of the states to gear up and decide, yes, we – it is indeed going to be reportable in states and we′ll pass on that information, so it was – it took a number of years for that process.
WEINSTOCK: I believe …
DOUGLAS: That was Dr. Berman and Dr. Weinstock also has a comment.
WEINSTOCK: I′ll just add that I believe it was around 1995 that chlamydia was recommended as a nationally reportable disease and it really wasn′t until about the year 2000 when all states actually reported it.
DOUGLAS: Thank you Dr. Hillard Weinstock
OPERATOR: And your next question comes from Miriam Falco, CNN.
MIRIAM FALCO, CNN: Hi, I′m sorry. I was actually on the phone with one of your other press officers about another STD-related story. My question is, why only recommend screening for women under age 26. Are these other minorities, the racial and ethnic minorities, men under – men having sex with men, where do they fall into it with your recommendations?
DOUGLAS: Well …
FALCO: I know you said the majority of cases were in young women, age 15 to 19 and my question to that is how many of those get regular gynecological exams at that age, so I′ve got two questions.
DOUGLAS: Yes, well, a couple of thoughts or a couple of comments. First of all, just to clarify, its – the highest rates of chlamydia infection are seen in adolescent females, although, it′s not the majority of cases because they only comprise a small minority of adult women. They don′t comprise the majority of reported cases. Secondly and most really importantly, I think, your question about who do we recommend screening for; we′ve recommended screening for young sexually active women because we′ve determined after a number of years that there were no reasonable other proxies for determining who had a relatively high risk of infection than the simply age and so, chlamydia prevalence in young women peaks in late adolescence and the early 20s and so, even, young women that have been relatively careful about their sexual activity, have some risk of being infected.
Clearly the risk is higher if you have multiple partners and don′t use condoms. But even women who have been relatively careful, because partners are often asymptomatic, can be infected as well.
Now 25 and below is – there is nothing magic about it. It is simply a relatively helpful epidemiologic cut point. Certainly women above the age of 25 have chlamydia infection. We do think that the using other criteria for determining who ought to be infected. And those criteria including having new partners, or having multiple partners, or having symptoms of chlamydia infections such as vaginal discharge, abdominal pain, or abnormal findings on physical examination do constitute reasons for testing.
But that blanket recommendation for women appears to be reasonable or practical to do only for women below that certain age group. Now there have been a lot of questions about men, because men obviously contribute to the transmission dynamics of chlamydia. And we recently put out some guidance about screening for chlamydia in men who are in settings where it is know that there is a high prevalence of infection.
Those for example include men in detention centers and jails, and in certain adolescent clinics. We don′t yet know at the population level whether or not testing and treating men will impact infection in women to a significant enough degree that it′s -- warrants a wide recommendation. And so we have got honestly frankly a little bit of a gray area in terms of that.
For men who have sex with men, we do in fact – because their rates of all sexually transmitted infections, including chlamydia are higher – recommend annual testing for chlamydia, gonorrhea, and syphilis. And if they are not yet – if they are not HIV infected, HIV as well. Dr. Berman?
DR. BERMAN: You mentioned something about young women having or not having a gynecological exam. One of the important things to know at this point is that the tests that are available do not require a pelvic gynecological exam. They can be done very easily on urine. And so that is a means by which young girls who are not undergoing pelvic exam can be tested, and tested regularly without necessarily seeing a gynecologist or having such an exam.
UNIDENTIFIED: Thank you.
OPERATOR: And your next question comes from the line of John Lauerman, Bloomberg News. Please go ahead.
JOHN LAUERMAN: Hi. Can somebody tell me when the last time was that we had an increase in syphilis this big? Is it recent or how long has it been?
DOUGLAS: This is – John, this is not a lot bigger than it has been in the last several years.
DOUGLAS: I′m looking at my colleagues to see if anybody has got those numbers in their pocket. So this increase of 13.8 percent is a little bigger than last year. Let me see if any of us can pull those numbers together. But I think the message is, the magnitude of the increase is not a lot bigger than what we have been seeing for the past several years.
LAUERMAN: Yes. And I was wondering if you could – I could expand on this idea that you were talking about earlier about whether disparities and access to healthcare play much of a role in whether people are screening for these diseases or treated for them?
DOUGLAS: There are data that uninsured young women are less likely to receive preventative services such as pap smears and chlamydia screening. We don′t have data like that for gonorrhea testing or screening. We also frankly don′t have any direct analysis that are able to say that in counties where rates have gone up in the south or in the west, access to healthcare or the proportion of the uninsured has increased.
So that is why I think I really do have to frame it as a hypothesis that is certainly plausible based on experiences with other prevention measures, including chlamydia screening, but not proven by any means for gonorrhea.
LAUERMAN: OK. Well what about I mean across the board? Is it something – is it something that could at least the data would suggest a (inaudible) for all three diseases?
DOUGLAS: I don′t think the data would suggest that for syphilis so much. One of the challenges as we have turned from dealing with syphilis in largely minority populations, who in fact were often poor, often lived in sections of the city or rural areas where access to healthcare was difficult, to becoming much more of an epidemic in MSM, many of these men are in fact receiving care, especially those that are HIV infected.And so the real challenge there has not been so much access to healthcare, it′s beginning what is really a fairly uncommon disease recognized by healthcare providers who aren′t used to seeing it, as well as encouraging those healthcare providers to remember testing.
You know I guess to allude to the earlier point, not to overplay this. That proportion of cases of all STDs that are being reported to us out of non-STD clinic settings would be indirect evidence that that reduction in access to healthcare could play a role. But again, I would have to emphasize the could part of it.
I would like to point out though that one of the strategies that is important that I mentioned in passing is affected by access to healthcare, and that is partner treatment. Up to 25 percent of women who are treated for chlamydia or gonorrhea become re-infected within the next three to six months. There is often the perception among physicians that once they report a case of a notifiable disease such as chlamydia or gonorrhea to the health department that disease will be followed up upon with formal partner notification activities by public health personnel.
And while that is largely true for uncommon infections such as syphilis, it is absolutely not true for these really high volume diseases like chlamydia and gonorrhea. And therefore these recommendations of using this other process expedited partner therapy which is basically the phenomenon of a partner receiving treatment without going through a formal medical evaluation has been determined to be so important.
We have three large clinical studies now that have shown that we can reduce rates of re-infection in infected women if they deliver medication to their partners, or their partners are otherwise assisted in receiving therapy. We have just completed a legal analysis in the U.S. to determine the legality of this practice, which we believe to be such a potentially useful adjunct.
There are now 11 states in the U.S. where it has been formally determined to be legal. Among the other 39 states, statutes and regulations are either explicitly not in support of this, or they are ambiguous. And so from a prevention opportunity point-of-view, especially given the fact that we deal with a healthier system where not everybody has access to cure, we think this is a relatively important prevention approach to try to propagate.
LAUERMAN: If I am still on the line, one more question. Are you concerned about the increased opportunity for HIV infection to gonorrhea and syphilis, and I don′t know whether chlamydia is an issue there as well.
DOUGLAS: Yes, I didn′t emphasize that in detail, although I mentioned it in passing at the beginning. Absolutely we are concerned about that. The observational studies carried out in a lot of different settings in the world have indicated that all of the sexually transmitted diseases that either cause ulcerations in the genital skin such as syphilis where inflammation of mucosal sites such as the urethra or the cervix can enhance HIV transmission.T
hey probably can enhance both getting HIV, because your tissues are more susceptible. The almost certainly can enhance transmitting HIV, because their presence in your genital tract increases the infectivity of HIV. So there is absolutely no question that these increases, especially in minority populations where HIV is also a disparate problem, is really a cause for concern.
OPERATOR: And we need to move on to the next question.
UNIDENTIFIED: I have got the statistics that were asked for in terms of syphilis increases. From ′04 to ′05 it was 7.4 percent, ′03 to ′04 was 8.0 percent, and ′02 to ′03 4.1 percent.
OPERATOR: And we will go to our next question. That will be from Jia-Rui Chong from the LA Times.
JIA-RUI CHONG: Hi. I was wondering if you could help me a bit I guess with the tone of this report. How worried should we be about these increases? Especially if you have talked about how some of the increases might be due to screenings, and we have seen some increases over the past couple of years.
DOUGLAS: It is a really good question. You know I don′t think that the increases per se are major causes for alarm as much as first the absolute magnitude of chlamydia and gonorrhea infection, number one. And the enormous disparities in these infections number two. I think the syphilis trends are real and are concerning.
They are concerning, again not so much at the level of massive population impact, as they are at the level of a disease that was really knocked on its feet – knocked off its feet. It was really prime for being eliminated. And we have seen reversals in what really ought to be a preventable problem. So it is at the level of the canary in the mind, if you will.
Nobody is – you know a few minors being infected. But certainly trends in syphilis going in what appear to be clearly the wrong direction.
CHONG: Well I was going to follow that up with which of these diseases you were more worried about. But that sounds like maybe that it is syphilis that is more worrisome than the others?
DOUGLAS: Well you know we are more worried about the trends in syphilis. Because we think it represents a real true honest to God reversal. I would say we are more worried about the magnitude of chlamydia especially just because there is you know twice as much of it reported as gonorrhea. Really three times as much. And we believe since it is under reported it probably represents a much bigger iceberg.
So from a population worry point-of-view, you know chlamydia is first and gonorrhea is second. And syphilis is not from a population perspective as much as it is from a missed opportunity and a potentially lost progress perspective. Dr. Berman.
DR. BERMAN: You know I don′t think the message is that you know the forest is burning. And the huge epidemic is out of control as much as these are large numbers of infections that are out there. And as highlighted in an “Institute of Medicine” report a decade ago, this is a hidden epidemic that most people are not aware of how many STDs are out there, the risks that they run, and the need for getting regular testing for some of these, and treatment and having partners treated.
We′d like to see these rates going down. That they′re not going down says there should be greater awareness of the public and maybe a little more attention to them both among the public and their providers. And that′s, I think, the message.
CHONG: OK. And the other question I had was about when you were talking about syphilis you mentioned that perhaps, you know, better treatment for HIV has made some people more sexually active. How does that, I guess, reflect on chlamydia and gonorrhea, which are also sexually transmitted diseases? I mean, does that HIV thing have anything to do with those diseases?
DOUGLAS: Well, there′s pretty clear evidence that having HIV infection and then getting syphilis modifies the natural history of syphilis. You′re more likely to get complications such as strokes and blindness, neurosyphilis. This was reported a couple of months ago in another MMWR report. You′re also likely to be more infectious from a syphilis and an HIV perspective. So we believe that populations that have a lot of HIV and syphilis are going to spread syphilis more readily.
We′ve also been able to see this phenomena more for syphilis because frankly, the rates are so low that a blip in sexually active MSM can be more readily detected. We′re absolutely concerned about it at the level – for gonorrhea and chlamydia as well, frankly, simply because there′s so much more infection, and it′s got more potential to increase rates of heterosexual HIV, although, we′ve been less able to document rises among MSM because the numbers are so much larger.
CHONG: OK. Thank you very much.
OPERATOR: Your next question is from Bob Roehr, the “Bay Area Reporter.”
Please go ahead.
BOB ROEHR, BAY AREA REPORTER: Thank you. Two very different questions. First, why is the rate of chlamydia decline – why does it decline in older women? Is it simply limited sexual activity, or is there any biological reason?
DOUGLAS: Likely a couple of things, mostly biological – well, both biological and behavioral. The behavioral, of course, is they′re less likely to be exposed to partners who have chlamydia, because male prevalence of chlamydia drops with age as well. So even if the older female was as susceptible if here partners were older she′ll be less likely to get exposed.
But it does appear that the cervix of the young woman, especially the young to middle adolescent woman, has got a cell type on the outside of the cervix that′s more susceptible to getting chlamydia infected. And as women age, those cell types become a smaller portion of the covering of the cervix, so basically reducing target tissue.
It also appears that chlamydia has the potential for establishing some form of immunity, probably not permanent and probably not complete, but if you′ve been exposed to chlamydia once or twice you may have some residual protection. So that would be more operative in younger women who′ve never seen it than in older women.
BOB ROEHR: The other question has to do with there certainly are great disparities within communities of color and whites. How much of this reflects the collection of data in that minority communities are more likely to use public health facilities where that data is, you know, much better collected than from private practice?
DOUGLAS: Well, that′s a really good question, too, and we′ve been concerned over the years that the phenomenon you′ve just described would bias the statistics towards giving us a perceived higher rate in African Americans or Hispanic population.
I think there are a couple of lines of evidence that would suggest that′s probably not playing a major role, although it could be part of the explanation. One is that as STDs are increasingly diagnosed at non-STD clinic settings, we′ve continued to see those disparities.
Secondly, we now – excuse me – we now have data collected from what we consider to be reasonably good samples of the general population. A study published by our group several months ago in the “Annals of Internal Medicine” from a national survey called “NHANES,” the National Health and Nutrition Examination Survey, where STD testing is carried out as part of a battery of nutritional assessments and behavioral questions, showed disparity levels that are actually quite similar to what we see in reported data. And given that that′s not biased by either healthcare seeking or by the type of facility that you′re being seen in, we think that′s pretty cooberative of true disparities actually existing.
OPERATOR: And your next question comes from Duncan Osborne, “Gay City News.”
Please go ahead.
DUNCAN OSBORNE: Hi. Thank you.Dr. Douglas, you know, this must be the, I don′t know, fourth or fifth such telebriefing that I′ve been on in which you′ve reported increases in syphilis and other infections among MSM. But what is not working here? I mean, this is clear evidence of failure on the part of public health and private agencies that deal with this population. Where is the failure?
DOUGLAS: Well, let me point out, Duncan, that this has been an extraordinarily frustrating problem for those of us at the federal level as well as folks at state and local health departments. And I think the answer′s complicated. There are clearly examples of situations where rates of syphilis have fallen among MSM.
Almost certainly in response to public health efforts and what is in part sustaining the national numbers at the level they are with the increases we′ve seen is both resurgences of syphilis in places it was somewhat controlled as well as cases of syphilis or outbreaks of syphilis occurring in MSM in new locations. So that′s one aspect of a complicated story.
A second aspect is that as you′re probably aware, some of the traditional public health approaches such as partner notification where we either try to use providers or patients to inform their sexual partners, that worked a lot less well among at least men in certain cities where the proportion of partners that are not easily locatable, they′re either purely anonymous or they don′t have sufficient locating information, has been problematic.
As you′re aware, there have been attempts to try to use technology such as the Internet to both e-inform individuals as well as to announce in chat rooms that there have been syphilis outbreaks occurring. So, you know, I think the honest truth is that we′re on an early part of the learning curve with populations that – for which our traditional approaches aren′t working as effectively.
Dr. Berman, anything to add to that?
We′re as, you know, tired of reporting this every year as you are of hearing it, let me assure you.
OSBORNE: Well, but let me sort of quickly follow-up on that. Is it possible – I mean, the exchange that you just had with the reporter from the “L.A. Times” was interesting in its tone, I thought. Is it possible that–and I don′t mean to single out CDC here, so I′ll just public health in general feels less urgency about responding to these problems because they are seen among men who have sex with men, and that if we were seeing the same increases among sort of the general population that we would be getting a different response. Is that possible?
DOUGLAS: You know, any scenario like that, Duncan, is possible. I think it′s unlikely, and I think it′s unlikely because the cities in which we′ve seen the largest increases have paradoxically been those cities that I think are, you know, for want of a better term, most gay-friendly in terms of their health department policies. I mean, two of the biggest increases have been in New York and San Francisco.
Now, you know, could public health have been more culturally sensitive or – maybe, although I′m not – I don′t see any evidence of that in either of those locations. If this was happening in a fairly homophobic or relatively more homophobic region of the country, I think your concern might have great plausibility to it. But, you know, I don′t want to appear to be whitewashing public health, but I think when we look at it pretty hard there′s, you know, not a lot of evidence with that happening.
Now, there has been, as you′re probably also aware, some pushback about certain social marketing campaign efforts. So San Francisco and L.A. were both relatively edgy in terms of getting social marketing with healthy penises and feel the sore, campaigns that probably wouldn′t work very well in certain other cities. Could they have done more? Maybe. But so I′m not rejecting outright your observation, but I don′t see a lot of evidence of that in the places that we′ve seen the most syphilis and MSM.
BERMAN: Well, I think there are some other, you know, (INAUDIBLE) dynamics going on within the population. You know, the greatest threat that syphilis poses in the heterosexual community is what it does in terms of adverse pregnancy outcome. You know, it is a killer of babies, and that′s – and the prevalence of syphilis in MSM community is highest among those men who are already HIV infected. And so it could be the case that there′s less issue of urgency in dealing with syphilis in the MSM community than it would be in some heterosexual populations.
So there′s some other challenges. I don′t think it′s a question of the public health approach as, you know, when you′re also talking about some of the other diseases. There′s less structure in chlamydia screening in MSM than there is among women, and the sites, the actual anatomic sites of infection for MSM are far less likely to be symptomatic then among heterosexual men.
So it′s harder to pick up the infection, harder to control. There are just epidemiologic challenges that are independent of any sort of public health will. You know, there are fewer tools, and I think some of that contributes.
OPERATOR: And your next question comes from Dan DeNoon, “WebMD.”
DAN DENOON, WEBMD: Thank you.
I′d like to go to the question of antibiotic resistance in gonorrhea. So we′re down to the syphilis foreigns. Is there any sense of how rapidly the epidemic might start including syphilis foreign resistant strains? And were that to arise, are you talking about this as the last ditch effort, or what would be – what would be around after that?
DOUGLAS: Your question is really an excellent one. So how much longer can we project syphilis foreigns being infected before resistance cracks through?
I think it′s hard to predict, although a couple of somewhat reassuring observations – syphilis foreigns have been – the syphilis foreign class that we use – second and third generation syphilis foreigns have been used and in reasonably widespread use for the treatment of gonorrhea and other infectious diseases for over 20 years now. And antibiotic resistance monitoring that we′ve done in the U.S. and WHO and other have done in other parts of the world have not demonstrated emergence of resistance to this class of antibiotics at all.
There are a handful of strains that show intermediate levels of resistance, which are concerning, but those have not increased over time. So at least at this point we think that they are sporadic; however, there are unquestionably resistance mechanisms to this class of antibiotics in other bacteria. And when those resistance mechanisms become operative in a bacteria you can get a fairly sudden and abrupt change in susceptibility from being very susceptible to not susceptible at all. So it′s – the past is quasi-reassuring, but it certainly doesn′t say not to worry for the future.
What would happen if we lost this class of antibiotics? One of the problems we have with dealing with bacterial infections in general is that the production of new classes of antibiotics and types of antibiotics has slowed down in recent years. One of the reasons that MRSA, Methicillin-resistant staph, is a problem is that Methicillin is an old drug and there are relatively fewer new drugs that have been developed since then that can deal with this. In some ways, the same is true for gonorrhea.
So what we would probably do is turn to other classes of antibiotics that have not ever been systematically explored for gonorrhea that would have some challenges in their utilization such as the fact that they might need to be given in multiple doses rather than a single dose or they might need to be given in combinations rather than as a single treatment, approaches that we don′t see – as Dr. Berman, used, the metaphor of the forest burning down, the forest burning down were this to happen, but it would clearly created challenges about the effective control of gonorrhea.
DENOON: And if I might just switch tracks to another subject, the astonishing rates of chlamydia among the very youngest group of women, what does that say about the epidemiology of disease? Are women starting to catch it and just recatching it over and over? Or are we seeing a spectrum across the 15 to 24-year-old age group? Do you have anymore of a close-up look of what′s happening in this very important population?
DOUGLAS: Well, we do think that the – they are exposed to sexual partners, late adolescent and early 20′s men, who have higher rates of infection. They do appear to – they do appear to have higher incidence. That is, rates of new infection. And especially since in places where partner therapy is incompletely provided, which is most of the U.S., their rates of reinfection are quite high.
Now, those were all kind of general observations about young sexually active women in general. We don′t have particular insights about a particular population, so I think beyond those sort of general comments.
Dr. Berman or Dr. Weinstock, anything to add to that?
UNIDENTIFIED: I think that′s our best way of responding to your question.
UNIDENTIFIED: But let me say, I think one of the things that have struck all of us that have been looking at chlamydia epidemiology is how consistent that finding is of prevalence being highest in young women. You know, in very study, every study in every locale the prevalence is highest in those young women. It may – I′m not saying it′s the same every place but is always the highest, suggesting – reiterating that statement I think that Dr. Douglas made before that there has to be some biologic component to this.
And exactly how high the prevalence is in any one population, then there′s a function of, you know, how much access to care, risk behavior, what their partners are doing. But I think that notion that it′s high and highest in young women is almost a universal observation and speaks to the importance of having young sexually active women and their providers aware of this. And so they have regular care and regular testing for chlamydia because very few of them are actually aware that they do – that that care is recommended and the close connection between that infection and compromises infertility.
There′s very – you know, that′s an awareness that really needs to be sort of increased.
OPERATOR: And thank you. We have time for one last question. That′ll be from Heidi Splete, Internal Med News. Please go ahead.
HEIDI SPLETE, INTERNAL MED NEWS: Hi. Thank you for taking my question.
Could you elaborate a little bit on the point that was just made about providers being aware of the consequences of infection?
And also, do you have a couple of pearls for health care providers about maybe red flags and what to look for, and how they might be able to work in trying to test both men and women for any of those three diseases?Thank you.
DOUGLAS: Provider awareness.You know, I think one of the biggest problems we see is settings of relatively more affluent populations where the assumption is that these young women can′t possibly be infected.
And so, when we look at our measurements of coverage or compliance with that annual screening recommendation, it′s been pretty interesting that we always see higher rates of coverage in Medicaid managed care than we do in other commercial managed care organizations.
Even though when you carefully look at prevalence in the population served by those slightly better-off populations, the prevalence is, in fact, definitely high enough to warrant screening. And so, I think one of the things we′re dealing with as providers who know sort of vaguely the recommendations, but just assume it doesn′t apply to the populations they′re dealing with.
And really underscores that point Dr. Berman made, is that the vast majority of chlamydia infections in women – and frankly, in men, as well – are asymptomatic. People just don′t have either symptomatic findings, nor do they have physical findings.
There′s been a lot of effort to try to predict, based on physical examination – speaking of pearls – as to who′s going to have chlamydia infection. And there are clearly associations between having inflammatory cervicitis, or inflammatory urethritis and having chlamydia infection. But those who don′t have that in the age groups that we′ve been discussing, also have high rates of infection.
BERMAN: If there was a message, I would say, if there are providers that think the young women in their practice don′t have Chlamydia, they should think again.
SPLETE: OK, thank you. That was Dr. Berman, right?
BERMAN: Yes, I think …
DOUGLAS: Yes, that was Dr. Berman.
DOUGLAS: The inimitable voice of Dr. Berman.
SPLETE: Thank you.
DOUGLAS: If I could, two other pearls.
One is this really high predilection in every population that′s been looked at for re-infection after treatment. And so, providers who have identified an infection and offer treatment, really need to preemptively and proactively suggest to their patients that they come back in three to six months for follow-up testing. And that′s for both chlamydia and gonorrhea.
And then finally, maybe most importantly as a pearl to providers, is that the buck sort of stops with you in terms of trying to work with your patient to get their partners treated, because the public health infrastructure to do that on a routine basis is simply not there.
SPLETE: OK. Thank you.
OPERATOR: And that does conclude the call for today. Thank you for your participation and for using the AT&T executive teleconference service.
This call is being recorded, and it will be available for replay beginning at 5:15 p.m. today, through 11:59 p.m. on November 20th.
You may access the recording by dialing 1-800-475-6701, and entering the access code 893065.
A transcript of today′s briefing will be available online later today.Once again, thank you for your participation. You may now disconnect.
DOUGLAS: Thank you very much.
- Historical Document: November 13, 2007
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