STDs in Women and Infants

Public Health Impact

Women and infants bear significant long-term consequences of STDs. In addition to biological and social factors such as poverty and access to quality STD services, a woman’s inability to negotiate safer sexual practices, such as condom use, can significantly affect her sexual health and subsequently the health of her unborn baby.^1,2 A woman’s relationship status with her male partner, in particular, has been identified as an important predictor of her sexual health.³ For example, a perceived shortage of available men in a community, can cause women to be more accepting of their partners’ concurrent sexual relationships, and partner concurrency is a factor associated with increased risk for STDs.⁴ A number of studies have found significant associations between condom use and socio-demographic characteristics, including age, income, education, and acculturation.⁵ Because it may be the behavior of her male partner, rather than the woman’s own behavior, that increases a woman’s risk for STDs, even a woman who has only one partner may be obliged to practice safer sex such as using condoms.⁶

Women infected with C. trachomatis or N. gonorrhoeae can develop PID, which, in turn, can lead to reproductive system morbidity such as ectopic pregnancy and tubal factor infertility. An estimated 10%–20% of women with chlamydia or gonorrhea may develop PID if they do not receive adequate treatment.^7,8 Among women with PID, tubal scarring can cause infertility in 20% of women, ectopic pregnancy in 9%, and chronic pelvic pain in 18%.⁹

About 80%–90% of chlamydial infections¹⁰ and up to 80% of gonococcal infections¹¹ in women are asymptomatic. These infections are detected primarily through screening. The symptoms associated with PID are vague so 85% of women with PID delay seeking medical care, thereby increasing the risk for infertility and ectopic pregnancy.¹² 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%.¹³

HPV infections are highly prevalent in the United States, especially among young sexually active women. Although most HPV infections in women resolve within 1 year, they are a major concern because persistent infection with specific types of the virus are causally related to cervical cancer; these types also cause Papanicolaou (Pap) smear abnormalities. Other types cause genital warts, low-grade Pap smear abnormalities, and, rarely, recurrent respiratory papillomatosis in infants born to infected mothers.¹⁴

Direct Impact on Pregnancy

Chlamydia and gonorrhea 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, can cause painful outbreaks, and can have serious consequences for pregnant women.¹⁵

When a woman has a syphilis infection during pregnancy, she can transmit the infection to the fetus in utero. Transmission can 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.¹⁶

Observations

Chlamydia—United States

During 2010-2011, the rate of reported chlamydial infections in women increased from 605.1 to 648.9 cases 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 15).

Positivity in Selected Populations

Prenatal Clinics—In 2011, the median state-specific chlamydia test positivity among women aged 15–24 years who were screened in selected prenatal clinics in 15 states, Puerto Rico, and the Virgin Islands was 7.7% (range: 2.8% to 16.3%) (Figure B). In a multivariate-regression analysis accounting for individual-level and clinic-level factors, chlamydia positivity among women aged 14-25 years who were screened in prenatal care clinics decreased from 2004-2009.¹⁷

Family Planning Clinics—In 2011, the median state-specific chlamydia test positivity among women aged 15–24 years who were screened during visits to selected family planning clinics in all 50 states, Puerto Rico, and the Virgin Islands was 8.3% (range: 3.8% to 15.9%) (Figure 13). In a multivariate-regression analysis accounting for individual-level and clinic-level factors, chlamydia positivity among women aged 14-25 years who were screened in family planning clinics remained stable from 2004-2008.¹⁸

Gonorrhea—United States

Like chlamydia, gonorrhea is often asymptomatic in women. Thus, 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, gonorrhea rates for both women and men declined steadily throughout the 1980s and early 1990s and then reached a plateau (Figure 16). After reaching an all-time low in 2009 (104.5 cases per 100,000 females), the gonorrhea rate for women increased slightly in 2010 and 2011 to 108.9 cases per 100,000 females (Figure 17, Table 15).

Although the gonorrhea rate in men has historically been higher than the rate in women, the gonorrhea rate among women has been slightly higher than the rate among men for 10 consecutive years (Figure 17, Tables 15 and 16).

Positivity in Selected Populations

Prenatal Clinics—In 2011, the median state-specific gonorrhea test positivity among women aged 15–24 years who were screened in selected prenatal clinics in 15 states, Puerto Rico, and the Virgin Islands was 0.8% (range: 0.0% to 3.8%) (Figure D).

Family Planning Clinics—In 2011, the median state-specific gonorrhea test positivity among women aged 15–24 years who were screened during visits to selected family planning clinics in 48 states, Puerto Rico, and the Virgin Islands was 0.7% (range 0.0% to 3.5%) (Figure 28).

Congenital Syphilis

Trends in congenital syphilis usually follow trends in P&S syphilis among women, with a lag of 1–2 years (Figure 50). The rate of P&S syphilis among women declined 95.4% (from 17.3 to 0.8 cases per 100,000 females) during 1990–2004 (Figure 38). The rate of congenital syphilis declined by 92.4% (from a peak of 107.6 cases to 8.2 cases per 100,000 live births) during 1991–2005 (Table 1). Rates of both female and congenital syphilis increased during 2005–2008, and have since declined.

The rate of P&S syphilis among women was 1.0 cases per 100,000 women in 2011 (Table 27), and the rate of congenital syphilis was 8.5 cases per 100,000 live births in 2011 (Table 41). The highest rates of P&S syphilis among women and congenital syphilis were observed in the South (Figures E and F, 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 maternal syphilis screening recommendations also contributes to the occurrence of congenital syphilis.¹⁹

Pelvic Inflammatory Disease

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. Hospitalizations for PID declined steadily throughout the 1980s and 1990s.^20,21 During 2001-2010, hospitalizations for acute PID overall have shown modest declines, although hospitalizations for acute PID increased by 44.3% (from 36.3 to 52.4 per 100,000) between 2009 and 2010 (Figure G). While this does not represent a trend in this data, and the explanations may not be immediately clear, continued monitoring of these data is warranted. Hospitalizations for chronic PID have also shown modest declines, remaining relatively stable between 2007 and 2010 (Figure G).

The estimated number of initial visits to physicians’ offices for PID from NDTI declined during 2002–2011 (Figure H, Table 44).

Racial disparities in diagnosed PID have been observed in both ambulatory and hospitalized settings. Disease rates were two to three times higher among black women than among 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.²¹

Ectopic Pregnancy

The incidence of ectopic pregnancy in the United States during the 1970’s and 1980’s was marked by significant increases. This surveillance relied on the National Hospital Discharge Survey (NHDS), which collects information on discharged hospital inpatients in the United States. Since the late 1980s, the ability to ascertain the number of ectopic pregnancies occurring in the United States has been affected by changing health care practices, including technological advances that permit early, accurate diagnosis of pregnancy and ectopic pregnancy, and pharmacological and technical advances in treatment of ectopic pregnancy. Data from the NHDS suggest that hospitalizations for ectopic pregnancy have decreased from 33.0 per 100,000 in 2001 to 21.6 per 100,000 in 2010 (Figure I). However, this likely does not reflect a decrease in the actual public health burden of ectopic pregnancy given that administrative data from the middle of the decade shows that the proportion of cases being treated with nonsurgical intervention is increasing.²²

1 Pulerwitz J, Amaro H, De Jong W, Gortmaker SL, Rudd R. Relationship power, condom use and HIV risk among women in the USA. AIDS Care. 2002;14(6):789-800.

2 McCree DH, Rompalo A. Biological and behavioral risk factors associated with STDs/HIV in women: implications for behavioral interventions, In: Aral SO, Douglas JM,Lipshutz JA (editors). Behavioral Interventions for Prevention and Control of Sexually Transmitted Diseases (p. 310-324). New York, NY: Springer.

3 El-Bassel N, Gilbert L, Krishnan S, Schilling R, Gaeta T, Purpura S, et al. Partner violence and sexual HIV-Risk behaviors among women in an inner-city emergency department. Violence Vict. 1998;13(4):377-393.

4 Hogben M, Leichliter JS. Social determinants and sexually transmitted disease disparities. Sex Transm Dis. 35(12) S13-S18.

5 Manderson L, Chang T, Tye LC, Rajanayagam K. Condom use in heterosexual sex: a review of research, 1985–1994. In: Catalan J, Sherr L, Hedge B (editors). The impact of AIDS: psychological and social aspects of HIV Infection. p. 1-26. The Netherlands: Harwood Academic Publishers.

6 O’Leary A. A woman’s risk for HIV from a primary partner: balancing risk and intimacy. Annu Rev Sex Res. 2000; 11:191-234.

7 Paavonen J, Westrom L, Eschenbach. Pelvic Inflammatory Disease. In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, Cohen, MS, Watts DH, (editors). Sex Transm Dis. 4th ed. New York: McGraw-Hill; 2008:1017-1050.

8 Hook EW III, Handsfield HH. Gonococcal infections in the adult. In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et al, (editors). Sex Transm Dis. 4th ed. New York: McGraw-Hill; 2008:627-45.

9 Westrom L, Joesoef R, Reynolds G, Hagdu A, Thompson SE. 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.

10 Stamm WE. Chlamydia trachomatis infections in the adult. In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et al, (editors). Sex Transm Dis. 4th ed. New York: McGraw-Hill; 2008:575-93.

11 Marrazzo JM, Handsfield HH, Sparling PF. Neisseria gonorrhoeae In: Mandell GL, Bennett JE, Dolin R (editors). Principles and practice of Infectious Diseases, 7th ed. Philadelphia, PA: Churchill Livingstone; 2010: 2753-2770.

12 Hillis SD, Joesoef R, Marchbanks PA, Wasserheit JN, Cates W Jr, Westrom L. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol. 1993;168:1503-9.

13 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.

14 Centers for Disease Control and Prevention. Prevention of genital HPV infection and sequelae: report of an external consultants’ meeting. Atlanta: U.S. Department of Health and Human Services; 1999.

15 Kimberlin DW. Herpes simplex virus infections of the newborn. Semin Perinatol. 2007;31(1):19-25.

16 Centers for Disease Control and Prevention. Guidelines for prevention and control of congenital syphilis. MMWR Morb Mortal Wkly Rep. 1988;37(No. SS-1).

17 Satterwhite CL, Gray AM, Berman S, Weinstock H, Kleinbaum D, Howards PP. Chlamydia trachomatis infections among women attending prenatal clinics: United States, 2004-2009.Sex Transm Dis. 2012 Jun;39(6):416-20.

18 Satterwhite CL, Grier L, Patzer R, Weinstock H, Howards PP, Kleinbaum D. Chlamydia positivity trends among women attending family planning clinics: United States, 2004-2008.Sex Transm Dis. 2011 Nov;38(11):989-94.

19 Centers for Disease Control and Prevention. Congenital syphilis — United States, 2003–2008. MMWR Morb Mortal Wkly Rep. 2010;59:413-17.

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21 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)778-84.

22 Hoover KW, Tao G, Kent CK. Trends in the diagnosis and treatment of ectopic pregnancy in the United States. Obstet Gynecol. 2010;3(115):495-502.