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Increase in STDs-CDC Reports Worrisome Trends
 
 
  CDC 2006 Sexually Transmitted Disease Surveillance Report
 
Trends in Reportable Sexually Transmitted Diseases in the United States, 2006
 
National Surveillance Data for Chlamydia, Gonorrhea, and Syphilis

 
November 13, 2007
 
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.
 
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.
 
 
 
 
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