Perspectives in Disease Prevention and Health Promotion Progress Toward Achieving the National 1990 Objectives for Sexually Transmitted Diseases

The health objectives for the nation, established in 1979 (1), included 11 goals relating to the control of sexually transmitted diseases (STDs). Five are considered appropriate areas for federal involvement: gonorrhea, gonococcal pelvic inflammatory disease, syphilis, provider awareness, and student awareness. A statement of each of these objectives and the progress toward their achievement follows: By 1990, reported gonorrhea incidence should be reduced to a rate of 280 cases per 100,000 population.

During the 1960s, reported gonorrhea rates increased approximately 15% per year. In 1972, a national gonorrhea control program was initiated, and, by 1975, the rapid increase had halted. The rate of decline was slow through 1979, but it accelerated from 1979 to 1984 (Figure 1). Then, in 1985, overall gonorrhea rates increased slightly, reversing the downward trend that had lasted for a decade (2). In 1986, total gonorrhea rates decreased to 372 cases per 100,00 population, returning to the 1984 level. However, all of the 1986 decline occurred among males; gonorrhea rates among females continued to increase. It now appears that the 1990 target of 280 cases per 100,000 population may not be met. One of the primary factors limiting the effective control of gonorrhea within the United States is the epidemic of organisms that are resistant to standard therapies (Figure 2). Since 1984, the number of resistant strains has been increasing rapidly. Reported numbers increased 98% in 1985 and an additional 90% in 1986 (3). By 1990, reported incidence of gonococcal pelvic inflammatory disease should be reduced to a rate of 60 cases per 100,000 females.

Based on 1984 rates, the 1990 objective addressing gonococcal pelvic inflammatory disease (GPID) is likely to be achieved. However, GPID accounts for less than half of all pelvic inflammatory disease (PID). For example, Chlamydia trachomatis infection is estimated to account for one-quarter to one-half of all PID cases occurring each year (4). Therefore, in 1985, the Public Health Service (PHS) broadened the original emphasis of this objective to include all PID. CDC has established a target of 560 PID cases per 100,000 population by 1990. Currently, data from the Hospital Discharge Survey conducted by the National Center for Health Statistics and the National Drug and Therapeutic Index indicate a trend toward a decline in the overall PID rate. By 1990, the reported incidence of primary and secondary syphilis should be reduced to 7 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.

Rates of primary and secondary syphilis decreased markedly between 1982 and 1986 (Figure 3). The majority of the decrease has occurred in males and probably reflects behavioral changes among homosexual males in response to acquired immunodeficiency syndrome (AIDS) prevention recommendations (5). Behavioral changes among populations at high risk for AIDS are likely to result in lower incidence rates for other STDs in these same groups (6,7).

Reported rates of congenital syphilis among infants reached an all-time low of 3.0 cases per 100,000 live births in 1980, but, with the exception of FY 1982, have increased steadily since then. The 1986 rate was almost 13% higher than the 1985 rate, with three-fourths of the cases occurring in California, Florida, New York, and Texas. Several factors have contributed to the apparent increase. They include improved national surveillance, increased emphasis on reporting of stillbirths attributable to syphilis, and actual increases in the rate of infectious syphilis among females of childbearing age (8). 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. . . .

Although training for health care professionals in the treatment of STDs has improved in recent years, it is still short of the necessary quality and scope. Since 1979, PHS has emphasized four approaches to improving the training of clinicians treating STD patients. First, 10 STD Prevention/Training Centers were established to improve the diagnostic, therapeutic, and patient management skills of mid-career clinicians directly involved with STD patients (9). Second, PHS has funded the development and pilot testing of STD curricula in six medical schools. A survey in 1986 found that, in these medical schools, STD training had increased to an average of 10 hours per student (CDC, unpublished data). The same survey showed that 44% of medical schools had no clinical curriculum on STDs. Third, PHS has funded an increasing number of STD Research Training centers to encourage young scientists to pursue an academic career in STD research (10). Fourth, PHS has funded the development of an instructional package for clinicians who do not frequently see STD patients in their practices. This package should be available by late fall 1987. Despite these efforts, it is unlikely that this objective will be met by 1990. Making a meaningful impact on medical school training will require more intensive marketing of the value of the STD curriculum and followup on these efforts. By 1990, every junior and senior high school student in the United States should be receiving accurate, timely education about sexually transmitted diseases.

No systematic measures of this objective are available. In 1983, the Gallup Institute Youth Survey found that only one-third of high school respondents considered themselves "very informed", and almost one-half considered themselves "somewhat informed" about STDs (Gallup Institute, unpublished data). CDC has since placed more emphasis on behavioral knowledge and attitudes related to biological facts. Principally through state STD units, CDC actively promotes adoption of STD education for junior and senior high school students. Increased attention to school-based education as a way to prevent AIDS should improve knowledge, attitudes, and behaviors affecting other STDs as well. Reported by: Office of Disease Prevention and Health Promotion, Public Health Svc, DHHS. Div of Sexually Transmitted Diseases, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note:Between the time of establishing the health objectives for the nation in 1979 and the third review of progress toward their achievement in November 1986, the national STD status has followed an irregular course. During this interval, a major new sexually transmissible agent, human immunodeficiency virus (HIV), has come to dominate the field. Moreover, the variety and burden of STDs have increased markedly. More than 50 diseases and syndromes account for over 13 million cases and 7,000 deaths annually from STDs, excluding AIDS. The costs of treating PID and its sequelae alone are estimated to exceed $2.6 billion annually.

The population at risk for STDs increased markedly between 1970 and 1980, with the coming of age of the "baby boom" cohort and the increased sexual activity among this segment of the population (11). This factor greatly influenced trends in both bacterial and viral STDs from 1979 to 1986. However, in the 1980s, as this group has become older and their sexual behaviors have stabilized, the chances for progress toward achieving the 1990 objectives have improved.

STD control for the balance of the 1980s and into the next decade will focus on the primary prevention of all sexually transmitted infections, especially the persistent viral infections for which no therapies or vaccines exist. This new emphasis will require a shifting of priorities, which have historically been focused on secondary prevention efforts. However, if current primary prevention efforts are successful, an overall reduction in all STDs will result.

References

1. Public Health Service. Promoting health/preventing disease: objectives for the nation. Washington, DC: US Department of Health and Human Services, 1980.

2. CDC. Sexually transmitted disease statistics. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service (in press).

3. Zenilman JM, Cates W Jr, Morse SA. Neisseria gonorrhoeae: an old enemy rearms. Infect Dis and Med Lett Obstet Gynecol 1986;8(suppl):2s-9s.

4. CDC. Chlamydia trachomatis infections: policy guidelines for prevention and control. MMWR 1985;34(suppl 3):53S-74S.

5. CDC. Syphilis--United States, 1983. MMWR 1984;33:433-6,441.

6. Judson FN. Fear of AIDS and gonorrhea rates in homosexual men (Letter). Lancet 1983;2:159-60.

7. CDC. Declining rates of rectal and pharyngeal gonorrhea among males--New York City. MMWR 1984;33:295-7.

8. CDC. Congenital syphilis--United States, 1983-1985. MMWR 1986;35:625-8.

9. Margolis S. Initiation of the sexually transmitted diseases prevention/training clinic program. Sex Transm Dis 1981;8:87-93.

10. Cates W Jr. Priorities for sexually transmitted diseases in the late 1980s and beyond. Sex Transm Dis 1986;13:114-7.

11. Zelnik M, Kantner JF. Sexual activity, contraceptive use, and

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