“Stay home, save lives” and social distancing have been common slogans for the past two years, but some public health experts have added “We are back in the 80’s” to the mix, particularly with regard to the growing number of sexually transmitted infections ( STI) to levels not seen in decades.
“There are many things I would like to go back to in the 1980s, but not that: we are actually going back to the levels of sexually transmitted infections in the 1980s,” said Catherine K. Hsu, MD, is a professor of pediatrics at Boston University School of Medicine and medical director for sexually transmitted disease prevention and surveillance and HIV / AIDS surveillance at the Bureau of Infectious Diseases and Laboratory Sciences at the Massachusetts Department of Public Health.
At the height of the COVID-19 pandemic, the focus was on reducing the transmission of 1 specific virus, but new data show that the coronavirus is not the only type of infection that has grown during the pandemic.
In their first major publication since the beginning of the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) revealed that levels of almost every type of STI have increased over the past few years.
- Cases of gonorrhea have increased by 45% since 2016 with a total of 677,769 cases in 20201
- Syphilis has increased by 52% compared to 2016 with a total of 133,945 cases.1
- Congenital syphilis has increased by 235% from 2016 to 2020 by 2,148 cases.1
- Chlamydia levels alone fell by 1.2% to 1.6 million in 2020.1
An increase in syphilis may be the biggest shock and it looks like the trend will continue. Preliminary data for 2021 show an increase in syphilis cases of 34% in women, 9% in men and 6% in newborns, with 33 states across the country reporting jumps.2
Pandemic, behavior change accused of jumping
Part of the blame for these increases is the pandemic itself, according to the CDC. The tight public health system, limited resources, reduced reviews and general underreporting over the past few years are reflected in these latest data, the agency said, while warning that these trends may be just the tip of the iceberg.
Social distancing may have helped by limiting sexual activity and exposing new partners, but it may also have led to delayed care for many people, according to the CDC.3
There is also a suspicion that better treatment of HIV / AIDS has led to a freer approach to STIs in general. In the 1980s and early 1990s, people were afraid of dying of AIDS, Hsu said. As the virus no longer carries the death penalty for many, the U-shaped curve that STI cases have shown over the past few decades reflects a potential decline in anxiety.
“We didn’t have a great treatment [for AIDs at first]. That’s not the case anymore, “she said.
In the 1990s, there was a real change in sexual public health behavior and the overall rate of STIs fell, while rare STIs such as syphilis continued to travel in small groups. Groups with a higher prevalence of HIV / AIDS also had a higher rate of STIs such as syphilis, so behavioral changes aimed at reducing HIV / AIDS transmission also have a positive effect on other infections.
“It’s important to recognize that the decline is indeed due to a coincidence of STIs,” she said.
The number of STI-transmitting sexual partners has decreased since the advent of HIV / AIDS and as diseases such as syphilis have been introduced into smaller sexual networks and not completely eradicated, the chances of meeting a carrier partner are reduced. increased, says Hsu.
“Much of this has to do with math and sexual networks, not individual behavior,” she explains. Clinicians experienced a jump in more symptomatic – and usually more advanced – STIs during the COVID-19 pandemic, as patients were reluctant to seek medical attention and data now confirm these suspicions.
“We are all afraid of the consequences in a few years,” she added, explaining that the real effects of the pandemic are yet to come – especially in terms of congenital disease transmission and the effect that untreated sexually transmitted infections could have on birth rates.
Is it too early to celebrate the decline in chlamydia?
Silent infections pose a huge threat to women’s fertility, Hsu said, because chlamydia infections are often only detected during screenings – screenings that were dropped during the first months of COVID-19.
“If you can only catch the infection through screening, that should be one of the most important messages,” Hsu said. “Chlamydia has dropped because it can only be detected by screening, but we know that pelvic inflammatory disease and infertility have also decreased after large-scale chlamydia screening has resumed. Many people are afraid he will return. “
Gonorrhea will present with painful symptoms in the urethra, which causes people who become infected to be treated. Syphilis will also become symptomatic. However, chlamydia can be boiled undetected and untreated for a long time. Diagnostic and screening methods have not changed in years, Hsu says, and although chlamydia numbers appear to have fallen in recent estimates, she warns that it is likely only the detection of the infection that has decreased, not the actual infections.
Pediatricians and primary care physicians need to be vigilant in calling patients for routine checkups similar to the way they are for immunization, Hsu said. Even if patients are asymptomatic now, chlamydia infection can have long-term fertility effects that are unaware for many years.
Leading public health organizations recommend chlamydia screening for all sexually active people, but for pediatricians, doing this screening – and getting the right answers – can be a challenge. Hsu says some pediatric practices take the position of screening every patient over a certain age to remove speculation from assessments of sexual activity. The checks must continue for women at least until the age of 25, she added.
Hsu also stressed the importance of re-examining high-risk patients. For patients who have a previous diagnosis of STIs, Hsu says the recommendation is to call them for a re-examination about 3 to 4 months after treatment.
“We’ve done case studies that prove that repeaters are a huge number of cases,” she said.
Newer rapid tests may help, but Hsu says perhaps one of the best things about COVID-19 is increasing the availability of test kits at home – even for STIs. Many stand-alone tampons have been approved by the FDA, and Hsu says he sees the use of home screenings increasing in the near future. She also says that clinicians realized during the limited health environment of COVID-19 that patients are more likely to leave samples for testing and screening instead of committing to a full examination.
Other challenges in STI management
Another challenge in managing chlamydia based on assessments of sexual activity is that patients – especially young adults – may not “count” oral or rectal sexual activity. But Hsu says there is new evidence that the rectum and oropharynx may be silent reservoirs for chlamydia.
This was not on the CDC’s radar before, she explains, as it was considered primarily a problem in sexual activity between a man and a man. However, a new screening elsewhere in the mucosa confirmed that the female rectum may also contain chlamydia, leading to re-infection of the vagina even after chlamydia treatment.
In addition to considering autoinoculation, Hsu said guidelines have changed as to what antibiotics should be used to treat chlamydia infections.
The CDC updated its guidelines in July 2021, 4,5,6, recommending that these infections not be treated with a single dose of azithromycin, as it does not eliminate the infection in the rectal area. The new recommendation is to use doxycycline twice a day for a week – a change that has raised some concerns about the patient’s adherence. A shorter course of antibiotics is certainly easier to implement, but Hsu said the researchers found that a single dose of azithromycin killed about 71% to 78% of cases of rectal chlamydia, while doxycycline was effective in clearing more than 91% to 100% of cases. In addition, she says, about 2 out of 3 women with vaginal chlamydia are co-infected at the rectal site, even when rectal penetration is denied.
There have also been updates to gonorrhea treatment protocols, Hsu says, with the CDC now recommending 500 mg of ceftriaxone instead of 250 mg. The pediatric dose is 25 to 50 mg / kg ceftriaxone, should not exceed 250 mg per dose.3 A single dose of 500 mg is intended for each less than 150 kg for adult dosing, but 1 gram should be used for each weighing more than 150 kg, says Hsu. Clinicians are also advised to stop azithromycin, which is usually added as a dual-drug approach, she added.
“We don’t want to double the team against a smart bacterium,” Hsu said. “It was a great theory, but terrible to apply. We no longer have 2 good options against gonorrhea. Gonorrhea is becoming more resistant to azithromycin, so a stronger dose of ceftriaxone is now preferred.
Hsu says clinicians shouldn’t be surprised to see that guidelines for treating gonorrhea change every few years as public health authorities try to keep up with this ever-mutating threat.
“Now that we’re back to medicine, people are understandably worried,” she said. “If it mutates beyond the cephalosporins, there really are no more options.”
Rachel Zimlich, BSN, RN, is a freelance medical writer in Cleveland, Ohio. She has nothing to reveal.
References:
1. Centers for Disease Control and Prevention. Surveillance of Sexually Transmitted Diseases, 2020. Updated April 12, 2022. Visited May 4, 2022 https://www.cdc.gov/std/statistics/2020/default.htm
2. Centers for Disease Control and Prevention. Preliminary data for 2021: syphilis. Updated April 12, 2022. Visited May 6, 2022 https://www.cdc.gov/std/statistics/2020/preliminary2021.htm
3. Centers for Disease Control and Prevention. Effect of COVID-19 on sexually transmitted diseases. Updated April 12, 2022. Accessed May 2, …
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