STDs in Women and Infants

Public Health Impact

Women and infants disproportionately bear the long term consequences of STDs. Women infected with Neisseria gonorrhoeae or Chlamydia trachomatis can develop PID, which, in turn, may lead to reproductive system morbidity such as ectopic pregnancy and tubal factor infertility. A substantial proportion of women with chlamydia or gonorrrhea may develop PID if not adequately treated, generally estimated to be from 10-20%, but ranging up to 40%.¹ Among women with PID, tubal scarring can cause involuntary infertility in 20%, ectopic pregnancy in 9%, and chronic pelvic pain in 18%.² Approximately 70% of chlamydial infections and 50% of gonococcal infections in women are asymptomatic.^3-5 These infections are detected primarily through screening. The vague symptoms associated with PID cause 85% of women to delay seeking medical care, thereby increasing the risk of infertility and ectopic pregnancy.⁶ Data from a randomized controlled trial of chlamydia screening in a managed care setting suggest that such screening programs can reduce the incidence of PID by as much as 60%.⁷

HPV infections are highly prevalent, especially among young sexually-active women. While the great majority of HPV infections in women resolve within one year, they are a major concern because persistent infection with specific types are causally related to cervical cancer; these types also cause Pap smear abnormalities. Other types cause genital warts, low grade Pap smear abnormalities and, rarely, recurrent respiratory papillomatosis in infants born to infected mothers.⁸

Direct Impact on Pregnancy

Gonorrhea and chlamydia can result in adverse outcomes of pregnancy, including neonatal ophthalmia and, in the case of chlamydia, neonatal pneumonia. Although topical prophylaxis of infants at delivery is effective for prevention of gonococcal ophthalmia neonatorum, prevention of neonatal pneumonia requires prenatal detection and treatment.
Genital infections with HSV are extremely common, may cause painful outbreaks, and may have serious consequences for pregnant women.⁹

When a woman has a syphilis infection during pregnancy, she may transmit the infection to the fetus in utero. This may result in fetal death or an infant born with physical and mental developmental disabilities. Most cases of congenital syphilis are easily preventable if women are screened for syphilis and treated early during prenatal care.¹⁰

Observations

Chlamydia—United States

Between 2007 and 2008, the rate of chlamydial infections in women increased from 539.8 to 583.8 per 100,000 females (Figure 1, Table 4). Chlamydia rates exceeded gonorrhea rates among women in all states (Figures A and C, Tables 4 and 14).

Prevalence Monitoring Project

Prenatal Clinics—In 2008, the median state-specific chlamydia test positivity among 15- to 24-year-old women screened in selected prenatal clinics in 22 states, Puerto Rico, and the Virgin Islands was 7.9% (range: 1.8% to 19.2%) (Figure B).

Family Planning Clinics—In 2008, the median state-specific chlamydia test positivity among 15- to 24-year-old women who were screened during visits to selected family planning clinics in all 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands was 7.4% (range: 3.1% to 15.0%) (Figures 9 and 10).

Gonorrhea—United States

Like chlamydia, gonorrhea is often asymptomatic in women. Gonorrhea screening, therefore, 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, gonorrhea rates for both women and men declined steadily throughout the 1980s and early 1990s, and then reached a plateau (Figure 13). The gonorrhea rate for women (119.4 per 100,000 females) decreased slightly in 2008 for the first time in four years (Figure 14, Table 14).

Although the gonorrhea rate in men has historically been higher than the rate in women, the gonorrhea rate among women has been comparable to the rate among men for eight consecutive years (Figure 14 and Tables 14 and 15).

Prevalence Monitoring

Prenatal Clinics—In 2008, the median state-specific gonorrhea test positivity among 15- to 24-year-old women screened in selected prenatal clinics in 20 states, Puerto Rico, and the Virgin Islands was 1.0% (range: 0.0% to 5.0%) (Figure D).

Family Planning Clinics—In 2008, the median state-specific gonorrhea test positivity among 15- to 24-year-old women who were screened during visits in selected family planning clinics in 43 states, the District of Columbia, Puerto Rico, and the Virgin Islands was 0.9% (range: 0.0% to 3.8%) (Figure 23).

Congenital Syphilis

Trends in congenital syphilis usually follow trends in P&S syphilis among women, with a lag of one to two years (Figure 43). The congenital syphilis rate peaked in 1991 at 107.3 cases per 100,000 live births, and declined by 92.4% to 8.2 cases per 100,000 live births in 2005 (Table 40). The rate of P&S syphilis among women declined 95.0% (from 17.3 to 0.8 cases per 100,000 females) between 1990 and 2004 (Figure 31). However, the rate in women has increased since 2004. The rate of P&S syphilis in 2008 was 1.5 cases per 100,000 women (Table 26). The highest rates of P&S syphilis in women are observed in the South (Figure E).

After 14 years of decline, the rate of congenital syphilis increased 6.1% between 2005 and 2006 (from 8.2 to 8.7 cases per 100,000 live births) (Table 40), and 16.1% between 2006 and 2007 (from 8.7 to 10.1 cases per 100,000 live births) (Table 40). The rate for 2008 remained unchanged from 2007. The highest of rates of congenital syphilis are observed in the South and West (Figure F).

While 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 maternal syphilis screening recommendations also contributes to the occurrence of congenital syphilis.¹¹

Pelvic Inflammatory Disease (PID)

Accurate estimates of PID and tubal factor infertility resulting from gonococcal and chlamydial infections are difficult to obtain. Definitive diagnoses of these conditions can be complex. Hospitalizations for PID have declined steadily throughout the 1980s and early 1990s,^12,13 but have remained relatively constant between 2000 and 2006, the most recent year for which these data are available (Figure G).

The estimated number of initial visits to physicians’ offices for PID from the NDTI has generally declined from 2000 through 2008 (Figure H and Table 43).

Racial disparities in diagnosed PID have been observed in both ambulatory and hospitalized settings. Black women had rates of disease that were two to three times those in white women. These disparities 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.¹³

Ectopic Pregnancy

Evidence suggests that health care practices associated with clinical management of ectopic pregnancy changed in the late 1980s and early 1990s. Before that time, treatment of ectopic pregnancy usually required admission to a hospital. Hospitalization statistics were therefore useful for monitoring trends in ectopic pregnancy. From 1997 to 2006, hospitalizations for ectopic pregnancy have remained generally stable (Figure I). As of the date of publication of this report, 2007 data are not available. Data suggest that nearly half of all ectopic pregnancies are treated on an outpatient basis.¹⁴

¹ Paavonen J, Westrom L, Eschenbach D. Pelvic inflammatory disease. In: Holmes KK, Sparling PF, Stamm WE et al, eds. Sex Transm Dis, 4th edition. New York City: McGraw-Hill, Inc, 2008:1017-1050.

² Westrom L, Joesoef R, Reynolds G, et al. Pelvic inflammatory disease and fertility: a cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopy. Sex Transm Dis 1992;9:185–92.

³ Hook EW III, Handsfield HH. Gonococcal infections in the adult. In: Holmes KK, Sparling PF, Mardh PA, et al, eds. Sex Transm Dis, 3rd edition. New York, New York: McGraw-Hill, 1999.

⁴ Stamm WE, Holmes KK. Chlamydia trachomatis infections in the adult. In: Holmes KK, Mardh PA, Sparling PF, et al, eds. Sex Transm Dis, 2nd edition. New York City: McGraw-Hill, Inc, 1990:181–93.

⁵ Zimmerman HL, Potterat JJ, Dukes RL, et al. Epidemiologic differences between chlamydia and gonorrhea. Am J Public Health 1990;80:1338–42.

⁶ Hillis SD, Joesoef R, Marchbanks PA, et al. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol 1993;168:1503–9.

⁷ Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;34(21):1362–6.

⁸ Division of STD Prevention. Prevention of Genital HPV Infection and Sequelae: Report of an External Consultants’ Meeting. National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, December 1999.

⁹ Kimberlin DW. Herpes simplex virus infections of the newborn. Seminars in Perinatology 2007 February;31(1):19-25.

¹⁰ Centers for Disease Control. Guidelines for prevention and control of congenital syphilis. MMWR 1988;37(No.S-1)

¹¹ Centers for Disease Control and Prevention. Congenital syphilis–United States, 2002. MMWR 2004;53:716–9.

¹² Rolfs RT, Galaid EI, Zaidi AA. Pelvic inflammatory disease: trends in hospitalization and office visits, 1979 through 1988. Am J Obstet Gynecol 1992;166:983–90.

¹³ Sutton MY, Sternberg M, Zaidi A, St. Louis ME, Markowitz LE. Trends in pelvic inflammatory disease hospital discharges and ambulatory visits, United States, 1985–2001. Sex Transm Dis 2005;32(12)778–784.

¹⁴ Centers for Disease Control and Prevention. Ectopic pregnancy in the United States, 1990–1992. MMWR 1995;44:46–8.