STDs in Women and Infants
Complications of sexually transmitted infections disproportionately affect women of all ages, with important implications for women of reproductive age. Undiagnosed and untreated STDs can lead to pelvic inflammatory disease (PID), ectopic pregnancy, as well as adverse fetal and neonatal outcomes. STD-related morbidity disproportionately occurs in women for a number of reasons. Women are biologically more susceptible than men to the acquisition of some STDs and more likely to suffer from complications. It is also important to note that STDs are often asymptomatic in women, delaying diagnosis and treatment until there is a symptomatic complication. A female’s sexual and reproductive health can also be interrelated to her particular social, cultural, and economic environment, creating conditions for risky sexual behaviors. Several factors, including the use of alcohol or recreational drugs inhibiting the ability to negotiate safer sexual practices, diminished gender power, high-levels of concurrency, poverty, homelessness or unstable housing, and partner violence may contribute to the challenges women face in protecting their sexual well-being.1-5 In some circumstances, maintaining the relationship with a partner may take a higher priority than STD risk reduction, affecting her reproductive health, as well as the health of her unborn baby.6 A woman can also be placed at risk for STDs through her partner’s sexual encounter with an infected partner. Consequently, even a female who has only one partner may be obliged to practice safer sex, such as using condoms.7
Impact on Women and Fertility
Human papillomavirus (HPV) is a common sexually transmitted infection in the United States.8,9 Although most HPV infections in women appear to be transient and may not result in clinically significant sequelae,10 high-risk HPV-type infections can cause abnormal changes in the uterine cervical epithelium,10,11 which are detected by cytological examination of Papanicolaou (Pap) smears.12 Persistent high-risk HPV-type infections may lead to cervical cancer precursors, which if undetected can result in cancer,11 and excisional treatment of cervical lesions can increase risk for future preterm delivery.13 Other low-risk HPV-type infections can cause genital warts,11,14 low-grade Pap smear abnormalities,11,15 laryngeal papillomas,16 and, rarely, recurrent respiratory papillomatosis in children born to infected mothers.17,18
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 26.19,20 HPV vaccination also has been recommended for routine use in males since 2011.20-23 In October 2018, the Food and Drug Administration (FDA) extended licensing approval of the vaccine for women and men aged 27–45 years,24 and in June 2019 the CDC’s Advisory Committee on Immunization Practices (ACIP) recommended that unvaccinated adults aged 27–45 years discuss receiving the HPV vaccine with their health care providers.23 For more information on HPV vaccination, see Other STDs.
A recent meta-analysis that included data from over 60 million individuals from 14 high-income countries, including the United States, showed a substantial impact of HPV vaccination on genital HPV infections and anogenital warts among adolescent girls and young women, and high-grade cervical lesions among young women.25 Cervicovaginal prevalence of any quadrivalent HPV vaccine type has been estimated for civilian, non-institutionalized, females aged 14–34 years using data from the National Health and Nutrition Examination Survey (NHANES).26 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. For more information on HPV infections, see Other STDs.
Chlamydial infections in women are usually asymptomatic and screening is necessary to identify most infections. Routine chlamydia screening of sexually-active young women has been recommended by the CDC since 1993.27 Rates of reported cases of chlamydia among women increased steadily from the early 1990s, likely reflecting expanded screening coverage and use of more sensitive diagnostic tests (Table 1). During 2011–2013, chlamydia case rates decreased from 643.4 to 619.0 cases per 100,000 females and then increased 11.9% over the next five years, resulting in a rate of 692.7 cases per 100,000 females in 2018 (Figure 1, Table 4).
Chlamydia rates are highest among young women, the population targeted for screening (Figures 5 and 6, Table 10). During 2017–2018, rates of reported chlamydia cases increased 1.3% and 0.8% among females aged 15–19 and 20–24 years, respectively (Figure 6). Regionally, among all women, chlamydia case rates were highest among women in the South, with a rate of 744.2 cases per 100,000 females in 2018 (Table 4). Rates of reported chlamydia cases exceeded gonorrhea case rates among women in all regions (Figures A and C, Tables 4 and 15).
Chlamydia Positivity in Selected Populations
The STD Surveillance Network (SSuN) is an ongoing collaboration of state, county, and city health departments from 10 participating jurisdictions where demographic, clinical, and laboratory data are collected from women aged 15–44 years attending facilities that provide family planning and reproductive health services (See Section A2.2 of the Appendix). However, in the summer of 2018, data collection in these clinic settings ended and the results presented here only include data obtained from January through June 2018. Figure B shows chlamydia testing and positivity reported only among facilities that tested more than 100 females and more than 60% of young females aged 14–24 years. In 2018, the overall positivity of chlamydia among females aged 14–24 years was 9.8%, but for females 14–19 years of age, chlamydia positivity was 10.5%. For females between the ages of 14–24 years, chlamydia positivity among non-Hispanic Blacks was about 1.5 times those of non-Hispanic Whites or Hispanics.
Like chlamydia, gonorrhea is often asymptomatic in women. Therefore, 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, rates of reported gonorrhea cases 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. However, more recently, there have been increases in overall cases (Figure 14, Table 1).
After reaching a 40-year low in 2009 (104.5 cases per 100,000 females), the rate of reported cases of gonorrhea for females increased slightly each year during 2009–2011, and then decreased during 2012–2014 (Figure 18). During 2015–2018, the gonorrhea rate among women increased 37.2% to 145.8 cases per 100,000 females (Figure 18, Table 15).
The gonorrhea case rate among females was slightly higher than the rate among males during 2009–2012; however, the rate among males was higher than the rate among females during 2013–2018 (Figure 18, Tables 15 and 16). During 2014–2018, gonorrhea rates among females were highest among those aged 15–24 years (Figure 20, Table 21). For women in this age group, rates were highest among 19-year olds in 2018 (877.3 cases per 100,000 females) (Table 23A).
Pelvic Inflammatory Disease
Data from studies suggest that as much as 10% of untreated chlamydial infections progress to clinically diagnosed PID and the risk with untreated gonococcal infection may be even higher.28-30 PID is a major concern because it can result in inflammation and damage to the fallopian tubes, elevating the risk of infertility and ectopic pregnancy. Tubal factor infertility ranks among the most common causes of infertility, accounting for 30% of female infertility in the United States,31 and much of this damage results from previous episodes of PID.32 An important public health measure for preventing PID, and ultimately tubal factor infertility, is through the prevention and control of Chlamydia trachomatis and Neisseria gonorrhoeae. Strategies to improve the early detection and treatment of chlamydia, as demonstrated in randomized controlled trials,29,33 has been shown to reduce a woman’s risk for PID and ultimately protect the fertility of women.
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. The National Disease and Therapeutic Index (NDTI; see Section A2.5 in the Appendix) provides estimates of initial visits to office-based, private physicians for PID. NDTI estimated that during 2007–2016 the number of initial visits to such physicians for PID among women aged 15–44 years decreased by 38.3% from 146,000 to 90,000 visits (Figure D). Similar declines have been observed in nationally representative data of emergency department (ED) visits from the Healthcare Cost and Utilization Project (HCUP), the largest collection of all-payer encounter level inpatient, ED, and ambulatory services data in the United States. According to an analysis using HCUP’s Nationwide Emergency Department Sample (NEDS), the percentage of ED visits with a PID diagnosis decreased during 2006–2013 among females aged 15–44 years, with the largest decreases among females aged 15–19 years (Figure E).34 It is not entirely clear what may be driving these declines, though several factors have been suggested, including earlier identification and treatment of chlamydia and gonorrhea infection and availability of single-dose therapies that increase adherence to treatment.35-37 While PID is declining nationally, it is still a major cause of morbidity in women.
Differences in self-reported lifetime diagnosis of PID by race/Hispanic ethnicity in reproductive age women have been observed in earlier research.38 Data from the 2013–2014 cycle of NHANES indicates that non-Hispanic Black and non-Hispanic White women reporting a previous STI diagnosis had nearly equal self-reported lifetime PID prevalence (10.3% vs. 10.0%) (Figure F).39 However, the lifetime prevalence of PID among non-Hispanic Black women was 2.2 times that among non-Hispanic White women if no previous STI was diagnosed (6.0% vs. 2.7%). These findings suggest that PID is associated with previous STI diagnoses and it is therefore important for physicians to screen female patients for chlamydia and gonorrhea to reduce the incidence of PID. The racial disparities observed in PID diagnoses 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.
Impact on Pregnancy and Fetal Outcomes
The sexually transmitted infections implicated in adverse pregnancy outcomes are broad and include viral, bacterial and protozoal infections. The spectrum of reproductive outcomes following STIs not only threatens the health of women and their ability to reproduce but can extend to detrimental effects on the fetus and neonates of infected individuals. Access to care and the provider’s ability to assess risk, screen, and treat STIs are critical factors in improving obstetrical outcomes.
Ectopic pregnancy, defined as implantation of a fertilized ovum on any tissue other than the lining of the uterus, is a potentially life-threatening condition that requires prompt evaluation and treatment. The ability to ascertain the number of ectopic pregnancies occurring in the United States has been affected by a shift in clinical management from an inpatient to an outpatient event, making inpatient hospital surveillance data sources unreliable. As a result, alternative surveillance methods, including data from large administrative claims,39,40 or emergency departments have been used to evaluate trends and assess the continued public health burden of this condition. Data from MarketScan Commercial Claims and Encounters Database, a large administrative claims database of United States commercial health plans, indicate that the ratio of ectopic pregnancy diagnoses to all live births among women with live births aged 15–44 years during the period of 2006–2017 have marginally increased across all age groups (Figure G). As in previous years, in 2017, rates of ectopic pregnancy were highest among women in the 35–44 year age groups.
Maternal infection with C. trachomatis or N. gonorrhoeae can also affect the infant, leading to conjunctivitis infections (termed ophthalmia neonatorum in the first four weeks of life), and, in the case of C. trachomatis, pneumonia. Although topical prophylaxis of infants at delivery may be effective for prevention of gonococcal ophthalmia neonatorum, prevention of neonatal pneumonia requires prenatal detection and treatment. The clinical presentation of conjunctivitis can be variable and these infections are especially important to treat promptly, as they can lead to visual impairment.41
During 2014–2018, 438 chlamydia or gonorrhea cases among infants aged <1 year with a specimen source of either ‘eye’ or ‘conjunctiva’ (conjunctivitis infections) were reported to CDC. The overall reported rate of chlamydial conjunctivitis in infants was relatively stable during 2014–2018, ranging from 1.4 to 2.3 cases per 100,000 live births (Figure H). Similarly, the rate of gonococcal conjunctivitis in infants remained relatively constant and low during 2014–2018, ranging from 0.2–0.4 cases per 100,000 live births. The rate of reported cases is heavily influenced by the completeness of reported data on specimen source. Of all cases reported to CDC of chlamydia or gonorrhea in infants aged <1 year during 2014–2018 (n=2,348), 81.3% did not have a specimen source of either ‘eye’ or ‘conjunctiva’; of those, 62.3% had a specimen source of ‘unknown’ (46.6%), ‘other-not specified’ (10.6%), or was missing (5.1%). When evaluating rates including these cases, the rate of chlamydia and gonorrhea infections follows similar trends but is higher in all years, indicating potential missed cases for surveillance (Figure H).
Syphilis is an important risk factor for adverse pregnancy outcomes. The consequences of untreated maternal infection can include fetal and infant death, preterm birth, and congenital infection in a proportion of surviving infants, resulting in both physical and mental developmental disabilities. Most cases of congenital syphilis are preventable if women are screened for syphilis and treated early during prenatal care.
Trends in congenital syphilis usually mirror trends in primary and secondary (P&S) syphilis among reproductive-aged women. After plateauing at a relatively low rate (0.9 cases per 100,000 females) during 2011–2013, the rate of reported cases of P&S syphilis among all women has increased each year since then (Figure 49). During 2014–2018, the rate among women increased 172.7%, from 1.1 to 3.0 cases per 100,000 females (Table 28). During this same period, the rate among reproductive-aged women (women aged 15–44 years) increased 165.4%, from 2.6 to 6.9 cases per 100,000 females aged 15–44 years (Figure 49).
Similarly, the rate of reported congenital syphilis cases has increased each year since 2012 (Table 1). In 2018, there were 1,306 reported cases of congenital syphilis, with a rate of 33.1 cases per 100,000 live births, the highest rate reported since 1995. This increase in 2018 represents a 39.7% increase relative to 2017 and a 291.0% increase relative to 2012 (Table 41).
In 2018, the highest rates of reported P&S syphilis cases among women and the highest rates of reported congenital syphilis cases were observed in the West and in the South (Figures I and J, Tables 28 and 41). The rate of P&S syphilis among women increased in every region during 2017–2018. During 2017–2018, the largest rate increase among women occurred in the West (41.2%), followed by the Northeast (40.0%), South (30.8%), and Midwest (30.8%) (Table 28). The congenital syphilis rate increased 49.5% in the South, 44.1% in the Northeast, 30.5% in the Midwest, and 29.3% in the West during 2017–2018 (Table 41).
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 prenatal syphilis screening recommendations, as well as acquisition of infection during pregnancy after the initial screening test, also contribute to the occurrence of congenital syphilis.
Neonatal Herpes Simplex Virus
Herpes simplex virus (HSV) is among the most prevalent of sexually transmitted infections,8 and can have serious consequences for pregnant women and their infants.42 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.43,44 NHANES data show that HSV-1 seroprevalence has significantly decreased among adolescents, indicating declining orolabial infection;44 HSV-2 seroprevalence in this age group was much lower.44 Those who lack HSV-1 antibodies at sexual debut are more susceptible to genital HSV-1 infection,44,45 and are also at increased risk of developing symptomatic disease from newly-acquired (i.e., primary) genital HSV-2 infection.46 Young women may therefore be increasingly likely to first acquire HSV-1 infection genitally, or acquire a primary genital HSV-2 infection, during their child-bearing years;45,47 first-episode primary genital HSV infection during pregnancy increases the risk of neonatal HSV transmission,45,48 particularly if the mother acquires infection towards the end of her pregnancy.45,49 Another analysis of NHANES data found that among pregnant women with three or fewer lifetime sex partners, seronegativity for both HSV-1 and HSV-2 increased from 1999–2006 to 2007–2014,50 raising the possibility that pregnant women with fewer sex partners may have increased risk of acquiring genital HSV during pregnancy and vertically transmitting HSV to their neonates. For more information on genital HSV infections, see Other STDs.
Neonatal HSV infections, although relatively rare, cause significant morbidity and mortality.42 Neonatal herpes can be a severe illness presenting with vesicular lesions on the skin, eye, or mouth, seizures, respiratory collapse, and/or liver failure, following contact with infected cervical or vaginal secretions during delivery.42,49 Most neonatal HSV infections result from perinatal transmission from mother to neonate,49 but postnatal infection can occur.51 Although reporting of neonatal HSV infection is required in a few jurisdictions,52,53 it is not a nationally reportable disease.
An examination of inpatient records of infants aged 60 days or younger at admission using the HCUP Kid’s Inpatient Database (KID) showed an overall incidence of 9.6 cases per 100,000 live births in 2006.54 Rates did not vary significantly by region or by race/Hispanic ethnicity; however prevalence was significantly higher among cases for which the expected primary payer was Medicaid (15.1 cases per 100,000 live births) compared with private insurance or managed health care (5.4 cases per 100,000 live births). A recent study using the HCUP National Inpatient Sample (NIS) found that incidence of neonatal HSV infection per 100,000 live births significantly increased from 2003 to 2014, from 7.9 during 2003–2005 to 10.0 during 2012–2014.55
In New York City, 76 cases of neonatal HSV infection were identified through population-based surveillance during a 4.5 year period (April 2006–September 2010), for an average annual incidence of 13.3 cases per 100,000 live births.47 Forty-one percent of the confirmed cases were infected with HSV-1. A review of certificates of death or stillbirth issued in New York City during 1981–2013 identified 34 deaths due to neonatal HSV infection, or 0.82 deaths per 100,000 live births.53
STDs are an important health priority and their substantial morbidity and mortality related to sequelae can often be overlooked in women. This is particularly true for reproductive aged women and their infants. The overall rate of reported female chlamydia cases has increased 11.4% over the last four years, much of that attributed to increased screening and more complete national reporting. Gonorrhea infections among females have also increased 45.2% to 145.8 cases per 100,000 females in recent years. Surveillance data continues to show that numbers and rates of chlamydia and gonorrhea cases are highest in females between the ages of 15 and 24, and certain races/ethnicities are disproportionately impacted. Despite increases in reported cases of chlamydia and gonorrhea, available data suggest an overall decline in the incidence of PID, largely attributed to an increase in effective screening and treatment of chlamydial and gonococcal infections in adolescents and young women. In contrast to declining PID rates, data suggests rates of ectopic pregnancy have marginally increased over time.
Mother to child transmission of STDs can result in serious adverse consequences. Potential adverse neonatal outcomes include neonatal ophthalmia, neonatal pneumonia, and prematurity. The rate of congenital syphilis in the United States has increased every year since 2013. In 2018, there were 935 reported cases of congenital syphilis and the national congenital syphilis rate was 23.7 cases per 100,000 live births, the highest rate in two decades. Despite current recommended STD screening during pregnancy, some women may not have their infections treated during pregnancy because of a lack of or limited prenatal care.
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