More than 2 million cases of chlamydial infection, gonorrhea and syphilis were reported in the United States in 2016 -- the highest number ever -- according to the CDC's annual Sexually Transmitted Disease Surveillance Report(www.cdc.gov) released Sept. 26.
Chlamydia trachomatis infections were the biggest offender, with about 1.6 million cases diagnosed last year. The CDC said almost 470,000 cases of gonorrhea also were reported, along with nearly 28,000 cases of primary and secondary syphilis.
These record levels of STDs in the United States have CDC leadership concerned about how best to curb this trend.
"Increases in STDs are a clear warning of a growing threat," said Jonathan Mermin, M.D., M.P.H., director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, in a news release(www.cdc.gov). "STDs are a persistent enemy, growing in number and outpacing our ability to respond."
- More than 2 million cases of chlamydial infection, gonorrhea and syphilis were reported in the United States in 2016, according to the CDC's annual Sexually Transmitted Disease Surveillance Report.
- Chlamydia trachomatis infections were the biggest offender, with about 1.6 million cases diagnosed last year; almost 470,000 cases of gonorrhea also were reported, along with nearly 28,000 cases of primary and secondary syphilis.
- Chlamydial infection rates were highest in 2016 among adolescent and young adult females, who are traditionally targeted for routine chlamydia screening.
STD Rates Accelerate in Multiple Populations
Chlamydial infection rates were highest among adolescent and young adult females -- populations traditionally targeted for routine chlamydia screening. However, spikes in syphilis and gonorrhea cases that were seen among certain patient populations in 2016 were not anticipated.
Although the number of newly diagnosed cases of gonorrhea rose in both men and women last year, men saw the steepest increase, at 22.2 percent. The CDC said research indicates a large portion of these new cases occurred among men who have sex with men (MSM). This trend is particularly alarming, the agency noted, considering the growing threat of drug resistance to the only remaining treatment regimen recommended for gonorrhea: dual therapy with ceftriaxone and azithromycin.
Syphilis rates increased by 17.6 percent overall from 2015 to 2016, with most of these primary and secondary cases occurring among men (almost 90 percent) -- especially gay, bisexual and other MSM. Also, half of MSM diagnosed with syphilis were also living with HIV infection, which presents an opportunity for health care professionals to integrate HIV and other STD prevention and care services for these patients.
Additionally, there was a 35.7 percent increase in the rate of syphilis among women and a 27.6 percent increase in congenital syphilis during this period. There were 628 cases of congenital syphilis reported in 2016, including 41 syphilitic stillbirths.
Those figures are especially lamentable given that congenital syphilis is readily preventable through routine screening and timely treatment of pregnant women, the CDC said.
"Every baby born with syphilis represents a tragic systems failure," said Gail Bolan, M.D., director of the CDC's Division of STD Prevention. "All it takes is a simple STD test and antibiotic treatment to prevent this enormous heartache and help assure a healthy start for the next generation of Americans."
Discussing STDs With Young Adults, Adolescents
Family physician Shannon Dowler, M.D., associate chief quality officer for Mission Health in Asheville, N.C., told AAFP News that one of the challenges with chlamydial infection is that it's often asymptomatic, so patients can carry and share the infection without knowing it.
"Young adults have more extensive sexual networks, so the proliferation of infection is more rapid," said Dowler, who is a staunch advocate of STD prevention. "Also, young women are particularly susceptible to infection because of physiologic differences during adolescence."
Dowler, who serves on the AAFP's Commission on Health of the Public and Science, said health departments currently are overrun with cases of chlamydial infection and don't have the resources to contact partners of patients to ensure treatment has been provided (although most still do so for gonorrhea and syphilis).
Despite making up only a quarter of the sexually active population, young adults account for half of all STD cases. Therefore, screening is critical in this population, Dowler said.
"Also, adolescents and young adults face barriers to accessing care that adults do not; confidentiality concerns, cost of health care, transportation and developing health literacy make it particularly challenging," she said.
Dowler recommended family physicians set aside at least a minute or two with every adolescent patient to discuss topics -- such as sex -- that these patients may not feel comfortable discussing in front of their parents.
"Many studies show that (gay, lesbian, bisexual, transgender and queer) youth are particularly vulnerable to dating violence and sexually transmitted infections, so knowing where a patient's risk lies is important," she said.
Dowler also suggested family physicians familiarize themselves with pop culture -- how social media impacts sexual networks, colloquial expressions they might not have heard before -- and which of their patients are part of vulnerable populations.
Addressing STDs With Older Adults
It's also important to talk about sexual behavior with older adult patients, a population that's seen a steady upward trend in STDs, Dowler noted.
To educate her patients about this growing health concern, Dowler has created and used unique communication tools, including a humorous rap video for older adult patients titled "STDs Never Get Old."(www.youtube.com)
"We have seen a dramatic rise in STDs in the elderly due to several factors; the ability to maintain sexual function longer with pharmaceutical assistance, changes in immunity and weakening mucosal tissue, and accessibility in community living are just a few factors," she said.
Working With MSM Patients on STDs
Condoms prevent the spread of gonorrhea, HIV and several other STDs, but many patients, particularly young MSM, can have a fatalistic view about their lifetime risk and actively choose not to use protection, Dowler said.
"Family doctors have to remember to screen all sites as appropriate; understanding if a patient has had oral, anal or penile exposure and checking all sites will help identify and treat STDs," she said. "But patients have to be part of the dialogue and be willing to be open with their doctor about their risks."
Family physicians also are critically important in stopping the spread of HIV by discussing pre-exposure prophylaxis with their patients.
"This is a great tool to help combat the spread of HIV, particularly when patients have been clear that they are not going to use barrier methods with sexual contacts or if they are IV drug users," Dowler said.
Discussing Congenital Syphilis With Pregnant Patients
Family physicians should be aware of the general rise in syphilis and familiarize themselves with the clinical presentation of primary and secondary disease, as well as with congenital syphilis, Dowler said.
"If you have not seen syphilis a lot in your career, learning about the clinical presentation will help with early diagnosis and treatment," she noted.
Most, if not all, states mandate syphilis testing in early pregnancy and during the third trimester, Dowler said.
"The challenge comes with women who are late-entry into prenatal care or who have exposures late in pregnancy," she said. "Encouraging early prenatal care and having family doctors caring for pregnant women, particularly in underserved and rural communities, allows more women access."
In general, Dowler said family physicians have to be comfortable talking about sex with patients and having open, nonjudgmental dialogue about individual risk factors.
Family physicians also can be incredibly important community partners in offering sexual education to school and church groups.
"Just last weekend, I presented to 60 10th-grade boys at a local Episcopal school, and I regularly make myself available to church youth groups and private schools," Dowler said.
The HPV vaccine is still not being given to enough young teens, so Dowler said family physicians should continue to create a dialogue with these patients and their families about the safety and efficacy of the vaccine.
"The increase in head and neck cancers in younger men and women from HPV infection is critically important in the message of HPV vaccine uptake," she said.
"When I meet with teens, I try to tell stories about real people and how STDs impacted their lives and I have a few main points: you need to have an adult dialogue partner to talk about these things with -- and in a perfect world, it's your parent; you can get many infections from oral and anal sex (which a lot of teens don't seem to understand); and be open and honest with your family doctor, no matter what the topic.
"All of these things will help you stay healthy."
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