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STDs in Adolescents and Young Adults

Background

Incidence and prevalence estimates suggest that young people aged 15–24 years acquire half of all new STDs1 and that one in four sexually active adolescent females has an STD, such as chlamydia or human papillomavirus (HPV).2 Compared with older adults, sexually active adolescents aged 15–19 years and young adults aged 20–24 years are at higher risk of acquiring STDs for a combination of behavioral, biological, and cultural reasons. For some STDs, such as chlamydia, adolescent females may have increased susceptibility to infection because of increased cervical ectopy. Cervical ectopy refers to columnar cells, which are typically found within the cervical canal, located on the outer surface of the cervix. Although this is a normal finding in adolescent and young women, these cells are more susceptible to infection. The higher prevalence of STDs among adolescents may also reflect multiple barriers to accessing quality STD prevention and management services, including inability to pay, lack of transportation, long waiting times, conflict between clinic hours and work and school schedules, embarrassment attached to seeking STD services, method of specimen collection, and concerns about confidentiality (e.g., Explanation of Benefits for services received mailed to parents or guardians).3

Traditionally, intervention efforts have targeted individual level factors associated with STD risk which do not address higher-level factors (e.g., peer norms and media influences) that may also influence behaviors.4 Interventions for at-risk adolescents and young adults that address underlying aspects of the social and cultural conditions affecting sexual risk-taking behaviors are needed, as are strategies designed to improve the underlying social conditions themselves.5,6 In addition, in designing STD programs, consideration should be given to the needs of adolescent and young adult populations including extended hours, optimizing privacy in waiting rooms, and urine based specimen collection.3

Chlamydia

Figure K. United States map showing rates of reported cases of chlamydia among women aged 15 to 24 years in 2017 by state and outlying areas (Guam, Puerto Rico, and Virgin Islands).

Figure K. Chlamydia — Rates of Reported Cases Among Women Aged 15–24 Years by State, United States and Outlying Areas, 2017

In 2017, there were 1,069,111 reported cases of chlamydial infection among persons aged 15–24 years, representing 62.6% of all reported chlamydia cases. Among those aged 15–19 years, the rate of reported cases of chlamydia increased 7.5% during 2016–2017 (1,927.3 to 2,072.4 cases per 100,000 population) (Table 10). Among those aged 20–24 years, the rate increased 5.0% during 2016–2017 (2,686.1 to 2,820.3 cases per 100,000 population) (Table 10).

Among women aged 15–24 years, the population targeted for chlamydia screening, the overall rate of reported cases of chlamydia was 3,635.3 cases per 100,000 females (Table 12). This was a 4.9% increase from 2016 (3,464.1 cases per 100,000 females) and an 8.8% increase from 2013 (3,341.1 cases per 100,000 females). Among men aged 15–24 years, the overall rate of reported cases of chlamydia was 1,327.0 cases per 100,000 males. This was an 8.9% increase from 2016 (1,219.0 cases per 100,000 males) and a 29.1% increase from 2013 (1,027.8 cases per 100,000 males). Rates varied by state for both males and females. The majority of states having the highest reported case rates were in the South (Figures K and L).

Figure L. United States map showing rates of reported cases of chlamydia among men aged 15 to 24 years in 2017 by state and outlying areas (Guam, Puerto Rico, and Virgin Islands).

Figure L. Chlamydia — Rates of Reported Cases Among Men Aged 15–24 Years by State, United States and Outlying Areas, 2017

15–19 Year Old Females — In 2017, the rate of reported chlamydia cases among women aged 15–19 years was 3,265.7 cases per 100,000 females, a 6.5% increase from the 2016 rate of 3,065.8 cases per 100,000 females (Figures 5 and 6, Table 10). Increases in rates of reported cases of chlamydia during 2016–2017 were largest among 19–year old and 20–year old women (8.4% and 6.8% increases, respectively) (Table 12). During 2013–2017, the overall rate of reported cases for women aged 15–19 years increased 6.4% (Table 10).

20–24 Year Old Females — In 2017, women aged 20–24 years had the highest rate of reported chlamydia cases (3,985.8 cases per 100,000 females) compared with any other age group for either sex (Figures 5 and 6, Table 10). The overall increase in the rate of reported chlamydia cases among females aged 20–24 years during 2016–2017 was 3.7%, with the largest increase (4.1%) observed among females aged 20 years. During 2013–2017, the rate of reported chlamydia cases in this population increased 10.9% (Table 10).

15–19 Year Old Males — In 2017, the rate of reported chlamydia cases among men aged 15–19 years was 924.5 cases per 100,000 males, an 11.1% increase from 2016. During 2013–2017, the rate of reported chlamydia cases for men aged 15–19 years increased 27.9% (Figures 5 and 7, Table 10).

20–24 Year Old Males — In 2017, as in previous years, men aged 20–24 years had the highest rate of reported chlamydia cases among all men (1,705.4 cases per 100,000 males). The rate for men in this age group increased 7.8% during 2016–2017 (Figures 5 and 7, Table 10). Similarly, during 2013–2017, the rate for men aged 20–24 years increased 30.1% (Table 10).

Gonorrhea

Figure M. United States map showing rates of reported cases of gonorrhea among women aged 15 to 24 years in 2017 by state and outlying areas (Guam, Puerto Rico, and Virgin Islands).

Figure M. Gonorrhea — Rates of Reported Cases Among Women Aged 15–24 Years by State, United States and Outlying Areas, 2017

During 2016–2017, the rate of reported gonorrhea cases increased 15.5% for persons aged 15–19 years and 12.8% for persons aged 20–24 years (Table 21). In 2017, among women aged 15–24 years, the rate was 622.8 cases per 100,000 females (Table 23). This was a 14.3% increase from 2016 (545.0 cases per 100,000 females) and a 24.1% increase from 2013 (501.7 cases per 100,000 females). Among men aged 15–24 years, the rate was 520.1 cases per 100,000 males. This was a 13.4% increase from 2016 (458.8 cases per 100,000 males) and a 51.6% increase from 2013 (343.0 cases per 100,000 males). For both women and men, rates varied by state. The majority of states with the highest reported case rates were in the South (Figures M and N).

Figure N. United States map showing rates of reported cases of gonorrhea among men aged 15 to 24 years in 2017 by state and outlying areas (Guam, Puerto Rico, and Virgin Islands).

Figure N. Gonorrhea — Rates of Reported Cases Among Men Aged 15–24 Years by State, United States and Outlying Areas, 2017

15–19 Year Old Females — In 2017, women aged 15–19 years had the second highest rate of reported gonorrhea cases (557.4 cases per 100,000 females) compared with other age groups among women (Figures 19 and 20, Table 21). During 2016–2017, the rate of reported gonorrhea cases for women in this age group increased 15.8% and 20.4% during 2013–2017 (Table 21).

20–24 Year Old Females — In 2017, women aged 20–24 years had the highest rate of reported gonorrhea cases (684.8 cases per 100,000 females) compared with other age groups among women (Figures 19 and 20, Table 21). During 2016–2017, the rate of reported gonorrhea for women in this age group increased 13.1% and 27.4% during 2013–2017 (Table 21).

15–19 Year Old Males — In 2017, the rate of reported gonorrhea cases among men aged 15–19 years was 323.3 cases per 100,000 males (Figures 19 and 21, Table 21). During 2016–2017, the rate of reported gonorrhea cases for men in this age group increased 15.2% and 44.8% during 2013–2017 (Table 21).

20–24 Year Old Males — In 2017, as in previous years, men aged 20–24 years had the highest rate of reported gonorrhea cases (705.2 cases per 100,000 males) compared with any other age group for either sex (Figures 19 and 21, Table 21). During 2016–2017, the rate of reported gonorrhea for men in this age group increased 12.6% and 55.2% during 2013–2017 (Table 21).

Primary and Secondary Syphilis

In 2017, among women aged 15–24 years, the rate of reported primary and secondary (P&S) syphilis was 5.5 cases per 100,000 females. This was a 7.8% increase from 2016 (5.1 cases per 100,000 females) and an 83.3% increase from 2013 (3.0 cases per 100,000 females). Among men aged 15–24 years, the rate was 26.1 cases per 100,000 males. This was an 8.3% increase from 2016 (24.1 cases per 100,000 males) and a 50.9% increase from 2013 (17.3 cases per 100,000 males). During 2016–2017, the rate of reported P&S syphilis cases increased 9.8% among persons aged 15–19 years and 7.8% among persons aged 20–24 years (Table 34).

15–19 Year Old Females — The rate of reported P&S syphilis cases among women aged 15–19 years increased each year during 2013–2016 (from 1.9 to 3.3 cases per 100,000 females) (Figure 43, Table 34). However, the rate slightly decreased in 2017. During 2016–2017, the rate decreased 3.0%, from 3.3 to 3.2 cases per 100,000 females (Figure 43, Table 34). Despite this decline during 2016–2017, there was an overall increase in the rate of P&S syphilis of 68.4% during 2013–2017 in women aged 15–19 years.

20–24 Year Old Females — In 2017, women aged 20–24 years had the highest rate of P&S syphilis (7.8 cases per 100,000 females) compared with other age groups among women (Figure 42, Table 34). The P&S syphilis rate among women in this age group has increased each year since 2011 and has doubled since 2013 (Figure 43, Table 34). During 2016–2017, the rate increased 14.7%.

15–19 Year Old Males — In 2017, the rate of reported P&S syphilis cases among men aged 15–19 years was 10.1 cases per 100,000 males (Figure 42, Table 34). The P&S syphilis rate among men in this age group has increased each year since 2011, with an increase of 55.4% during 2013–2017 (Figure 44, Table 34). During 2016–2017, the rate increased 13.5%.

20–24 Year Old Males — In 2017, men aged 20–24 years had the second highest rate of reported P&S syphilis (41.1 cases per 100,000 males) compared with any other age group for either sex (Figure 42, Table 34). The P&S syphilis rate among men in this age group has increased each year since 2006, with a 50.0% increase during 2013–2017 (Figure 44, Table 34). During 2016–2017, the rate increased 7.0%.

Other STDs

Human papillomavirus

HPV is the most common sexually transmitted infection in the United States.1 Starting in 2006, HPV vaccines have been recommended for routine use in United States females aged 11–12 years, with catch-up vaccination through age 26.7,8 Since late 2011, routine use of HPV vaccine has been recommended for males aged 11–12 years, with catch-up vaccination through age 21.8-10 Vaccination through age 26 is recommended for gay, bisexual, and other men who have sex with men (collectively referred to as MSM) and persons who are immunocompromised (including those infected with HIV).8

Cervicovaginal prevalence of HPV vaccine types was examined using data from the National Health and Nutrition Examination Survey (NHANES; see Section A2.4 in the Appendix).11 Prevalence decreased significantly from 2003–2006 (the pre-vaccine era) to 2011–2014 in specimens from females aged 14–19 years and 20–24 years, the age groups most likely to benefit from HPV vaccination.

Health-care claims data from adolescents and adults with employer-provided private health insurancein the United States were used to examine the population effectiveness of HPV vaccination on two clinical sequelae of HPV infection: high-grade histologically-detected cervical intraepithelial neoplasia grades 2 and 3 (CIN2+),12 and anogenital warts.13 Prevalence of CIN2+ and of anogenital warts decreased significantly during 2007–2014 among females aged 15–19 and 20–24 years (Figures 51 and 52A); prevalence of anogenital warts also decreased significantly during 2009–2014 among women aged 25–29 years (Figure 52A). These declines provide ecologic evidence of population effectiveness of HPV vaccination in females. Anogenital wart prevalence also decreased significantly during 2009–2014 among men aged 20–24 years (Figure 52B); these declines among young men are consistent with herd protection from vaccination among females.

For more information on HPV infections, see Other STDs.

Herpes simplex virus

Herpes simplex virus (HSV) is among the most prevalent of sexually transmitted infections.1,14 Most genital HSV infections in the United States are caused by HSV type 2 (HSV-2), while HSV type 1 (HSV-1) infections are typically orolabial and acquired during childhood.15,16 NHANES data show that among adolescents aged 14–19 years, HSV-1 seroprevalence has significantly decreased by almost 23%, from 39.0% during 1999–2004 to 30.1% during 2005–2010, indicating declining orolabial infection in this age group.16 HSV-2 seroprevalence in this age group was much lower in both time periods.16

Other studies have found that genital HSV-1 infections are increasing among young adults.17,18 This has been attributed, in part, to the decline in orolabial HSV-1 infections, because those who lack HSV-1 antibodies at sexual debut are more susceptible to genital HSV-1 infection.16,19 Increasingly common oral sex behavior among adolescents and young adults also has been suggested as a contributing factor.16,20

For more information on genital HSV infections, see Other STDs.

National Job Training Program

The National Job Training Program (NJTP) is an educational program for socioeconomically disadvantaged youth aged 16–24 years and is administered at more than 100 sites throughout the country. The NJTP screens participants for chlamydia and gonorrhea within two days of entry to the program. All of NJTP’s chlamydia screening tests and the majority of gonorrhea screening tests are conducted by a single national contract laboratory*.

To increase the stability of the 2017 estimates, chlamydia or gonorrhea prevalence data are presented when valid test results for 100 or more students per year are available for the population subgroup and state. Additional information about NJTP can be found in Section A2.1 in the Appendix.

Among women entering the program in 2017 in 44 states and Puerto Rico, the median state-specific chlamydia prevalence was 11.8% (range: 4.8% to 19.6%) (Figure O). Among men entering the program in all 50 states, the District of Columbia, and Puerto Rico, the median state-specific chlamydia prevalence was 6.6% (range: 2.1% to 14.5%) (Figure P).

Among women entering the program in 44 states and Puerto Rico, the median state-specific gonorrhea prevalence in 2017 was 2.6% (range: 0.0% to 6.3%) (Figure Q). Among men entering the program in 44 states, the District of Columbia, and Puerto Rico, the median state-specific gonorrhea prevalence was 0.8% (range: 0.0% to 2.2%) (Figure R).

* Laboratory tests are conducted by the Center for Disease Detection, LLC San Antonio, Texas.

Figure O. United States map showing prevalence of chlamydia among women aged 16 to 24 years in the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) entering the National Job Training Program (NJTP) in 2017 by state of residence.

Figure O. Chlamydia — Prevalence Among Women Aged 16–24 Years Entering the National Job Training Program (NJTP) by State of Residence, United States and Outlying Areas, 2017

Figure P. United States map showing prevalence of chlamydia among men aged 16 to 24 years in the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) entering the National Job Training Program (NJTP) in 2017 by state of residence.

Figure P. Chlamydia — Prevalence Among Men Aged 16–24 Years Entering the National Job Training Program (NJTP) by State of Residence, United States and Outlying Areas, 2017

Figure Q. United States map showing prevalence of gonorrhea among women aged 16 to 24 years in the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) entering the National Job Training Program (NJTP) in 2017 by state of residence.

Figure Q. Gonorrhea — Prevalence Among Women Aged 16–24 Years Entering the National Job Training Program (NJTP) by State of Residence, United States and Outlying Areas, 2017

Figure R. United States map showing prevalence of gonorrhea among men aged 16 to 24 years in the United States and outlying areas (Guam, Puerto Rico, and Virgin Islands) entering the National Job Training Program (NJTP) in 2017 by state of residence.

Figure R. Gonorrhea — Prevalence Among Men Aged 16–24 Years Entering the National Job Training Program (NJTP) by State of Residence, United States and Outlying Areas, 2017

Summary

The rate of reported cases of chlamydia, gonorrhea, and P&S syphilis increased for both sexes in 15–24 year olds during 2016–2017. For chlamydia, rates of reported cases are consistently highest among women aged 15–24 years, likely reflecting targeted screening of young women; however, the rate of reported chlamydia in males aged 15–24 years increased 29.1% during 2013–2017, while the rate in females increased 8.8%. Similarly, in 2017, the rate of reported cases of gonorrhea in females aged 15–24 years was higher than in men of the same age group; however, during 2013–2017, the rate of reported gonorrhea in males aged 15–24 years increased 51.6%, while the rate in females increased 24.1%. Increases in chlamydia and gonorrhea diagnoses among men likely reflect a combination of increased screening among young men, including extragenital screening, and increased incidence. Conversely, rates of reported cases of P&S syphilis have been consistently higher among adolescent and young adult men compared to women; however, the largest increase in P&S syphilis rates during 2013–2017 was among women of this age group. During 2013–2017, rates of reported P&S syphilis cases increased 83.3% and 50.9% in 15–24 year old females and males, respectively.

References

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2. Forhan SE, Gottlieb SL, Sternberg MR, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics 2009; 124(6):1505–1512.

3. Tilson EC, Sanchez V, Ford CL, et al. Barriers to asymptomatic screening and other STD services for adolescents and young adults: Focus group discussions. BMC Public Health 2004;4(1):21.

4. DiClemente RJ, Salazar LF, Crosby RA. A review of STD/HIV preventive interventions for adolescents: Sustaining effects using an ecological approach. J Pediatr Psychol 2007;32(8):888–906.

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9. Centers for Disease Control and Prevention. Recommendations on the use of quadrivalent human papillomavirus vaccine in males — Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep 2011; 60(50):1705–1708.

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12. Flagg EW, Torrone EA, Weinstock H. Ecological association of human papillomavirus vaccination with cervical dysplasia prevalence in the United States, 2007–2014. Am J Public Health 2016; 106(12):2211–2218.

13. Flagg EW, Torrone EA. Declines in anogenital warts among age groups most likely to be impacted by human papillomavirus vaccination, United States, 2006–2014. Am J Public Health 2018; 108(1):112–119.

14. Smith JS, Robinson NJ. Age-specific prevalence of infection with herpes simplex virus types 2 and 1: A global review. J Infect Dis 2002; 186(Suppl 1):S3–S28.

15. Corey L, Wald A. Genital Herpes. In: Holmes KK, Sparling FP, Stamm WE, et al., eds. Sexually Transmitted Diseases. 4th ed. New York, NY: McGraw-Hill; 2008:399–437.

16. Bradley H, Markowitz LE, Gibson T, et al. Seroprevalence of herpes simplex virus types 1 and 2 — United States, 1999–2010. J Infect Dis 2014; 209(3):325–333.

17. Bernstein DI, Bellamy AR, Hook EW III, et. al. Epidemiology, clinical presentation, and antibody response to primary infection with herpes simplex virus type 1 and type 2 in young women. Clin Infect Dis 2013; 56:344–351.

18. Roberts CM, Pfister JR, Spear SJ. Increasing proportion of herpes simplex virus type 1 as a cause of genital herpes infection in college students. Sex Transm Dis 2003; 30(10):797–800.

19. Kimberlin DW. The scarlet H. J Infect Dis 2014; 209(3):315–317.

20. Copen CE, Chandra A, Martinez G. Prevalence and timing of oral sex with opposite-sex partners among females and males aged 15–24 years: United States, 2007–2010. National Health Statistics Reports, No. 56. Hyattsville, MD: National Center for Health Statistics; 2012.

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