Health Objectives for the Nation Progress Toward Achieving the 1990 Objectives for the Nation for Sexually Transmitted Diseases
Eleven of the 1990 Objectives for the Nation (1) addressed sexually transmitted diseases (STDs). When the objectives were established in 1979, five involved national priority areas: syphilis, gonorrhea, gonococcal pelvic inflammatory disease, provider proficiency, and student awareness. The other six objectives addressed nongonococcal urethritis, chlamydial pneumonia, neonatal herpes, condom use, STD screening in the workplace, and STD reporting levels; however, because of data limitations in 1979, these objectives were considered lower priority. This article summarizes progress through December 1988 toward the five priority objectives. By 1990, reported incidence of primary and secondary syphilis should be reduced to a rate of seven cases per 100,000 population per year, with a reduction in congenital syphilis to 1.5 cases per 100,000 children under 1 year of age.
This objective is unlikely to be met. Although crude rates of primary and secondary syphilis decreased markedly between 1982 and 1986, they subsequently increased and, by 1988, reached their highest level in 40 years (Figure 1). However, trends differed among races and genders. In white males, reported cases decreased during the 1980s; for black males and females, rates increased. Reported rates of congenital syphilis also increased (Figure 2), as did the number of states reporting cases during the 1980s. By 1990, reported gonorrhea incidence should be reduced to a rate of 280 cases per 100,000 population.
This objective is likely to be met (Figure 3). However, two concerns are that: 1) al though overall gonorrhea rates decreased substantially from 1980 to 1988, rates remained stable among blacks and declined more slowly among teenagers than among persons in older age groups (2); and 2) the number and percentage of gonococcal strains resistant to standard therapies, primarily penicillin, increased substantially (3). By 1990, reported incidence of gonococcal pelvic inflammatory disease should be reduced to a rate of 60 cases per 100,000 females.
This objective is likely to be met. Nationwide, however, gonococcal pelvic inflammatory disease accounts for less than 50% of all pelvic inflammatory disease (PID). Therefore, in 1985, CDC began to monitor all diagnosed cases of PID. Using a more complete measure of PID, CDC added a target of 560 PID cases per 100,000 females by 1990 (1985 incidence was approximately 680 per 100,000). This goal is also likely to be achieved (Figure 4). By 1990, at least 95% of health care providers seeing patients with suspected cases of sexually transmitted diseases should be capable of diagnosing and treating all currently recognized sexually transmitted diseases.
This objective is unlikely to be met. In 1985, nearly two thirds of 407 physicians presented with a typical case profile for gonorrhea would not have implemented traditional spousal notification (4). Only 10% of primary-care providers regularly assessed the sexual behaviors of their patients (5), and 70% of clinicians did not prescribe the combinations of antibiotics recommended to treat polymicrobial PID (6). In 1985, nearly half of U.S. medical schools offered no clinical curricula on STDs (CDC, unpublished data). By 1990, every junior and senior high school student in the United States should be receiving accurate, timely education about sexually transmitted diseases.
This objective is unlikely to be met. Although 95% of schools reported offering at least one class on STDs as part of their standard curricula (7), only 77% of teenagers surveyed in 1988 reported receiving STD education by age 18 (CDC, unpublished data). In addition, awareness by students of STD symptoms, signs, and approaches to prevention is low. Reported by: Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service, US Department of Health and Human Services. Div of STD/HIV Prevention, Center for Prevention Svcs, CDC.
Editorial Note: Since the development of the 1990 objectives, a new sexually transmitted agent, human immunodeficiency virus (HIV), has become a major contributor to STD. Counseling and testing for HIV is routinely recommended as part of STD services in the United States. In addition, the variety and burden of STDs have increased markedly. The incidence of genital-ulcer diseases--including syphilis, genital herpes, and chancroid--has increased. Genital chlamydial infection has become the most common bacterial sexually transmitted infection; its relatively mild symptoms, higher screening and diagnostic costs, and longer course of therapy make chlamydia especially difficult to control. For example, many women with serologic evidence of past chlamydial infection and current infertility due to fallopian-tube occlusion report having no prior history of PID. Finally, specific strains of the human papillomavirus have been strongly associated with the development of cervical cancer (8,9).
Sexual behaviors have also changed during the 1980s. Homosexual men have apparently adopted safer sexual behaviors in response to HIV prevention recommendations; these changes, in turn, have lowered the level of other STDs in this population. However, in 1988, a larger percentage of teenagers were initiating sexual intercourse at younger ages than in 1982 (CDC, unpublished data).
In the 1980s, crack cocaine became an important contributor to high-risk sexual activity, such as the exchange of sex for drugs (10). Cocaine use has been associated with high rates of syphilis in childbearing women (11).
Those circumstances have contributed to the failure to meet some of the 1990 objectives for STDs. As a result, the level of morbidity from STDs and their sequelae remains high. Objectives for the year 2000 for the prevention and control of STDs and HIV infection are currently being established (12). These objectives will be broader than those formulated in 1979 and closely linked to other priority areas such as sexual behavior, immunization and infectious diseases, substance abuse, and surveillance.
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4. Novack DH, Detering BJ, Arnold R, Forrow L, Ladinsky M, Pezzullo JC. Physicians' attitudes toward using deception to resolve difficult ethical problems. JAMA 1989;261:2980-5.
5. Lewis CE, Freeman HE. The sexual history-taking and counseling practices of primary care physicians. West J Med 1987;147:165-7.
6. Grimes DA, Blount JH, Patrick J, Washington AE. Antibiotic treatment of pelvic inflammatory disease: trends among private physicians in the United States, 1966 through 1983. JAMA 1986;256:3223-6.
7. Forrest JD, Silverman J. What public school teachers teach about preventing pregnancy, AIDS, and sexually transmitted diseases. Fam Plann Perspect 1989;21:65-72.
8. Koutsky LA, Galloway DA, Holmes KK. Epidemiology of genital human papillomavirus in fection. Epidemiol Rev 1988;10:122-63.
9. Reeves WC, Rawls WE, Brinton LA. Epidemiology of genital papillomaviruses and cervical cancer. Rev Infect Dis 1989;11:426-39. 10. des Jarlais DC, Friedman SR. Intravenous cocaine, crack, and HIV infection. JAMA 1988;259:1945-6. 11. CDC. Congenital syphilis--New York City, 1986-1988. MMWR 1989;38:825-9. 12. CDC. Year 2000 national health objectives. MMWR 1989;38:629-33.
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