congenital syphilis and other STIs on the rise

The CDC just released its 2017 surveillance report on sexually-transmitted infections on the three notifiable diseases that have federally-funded control programs: chlamydia, gonorrhea, and syphilis (see https://www.cdc.gov/nchhstp/newsroom/2018/std-surveillance-report-2017-press-release.html for the CDC news release, and see https://www.cdc.gov/std/stats17/2017-STD-Surveillance-Report_CDC-clearance-9.10.18.pdf for the 168-page report on sexually transmitted diseases 2017).

Chlamydia:  1,708,569 cases of Chlamydia trachomatis infection were reported to the CDC in 2017 (the most common notifiable condition in the US), 528.8 cases per 100,000 population.

    -- 6.9% increase over 2016

    -- increased among both males and females, in all regions, and among all racial and Hispanic ethnicity groups

    -- rates were highest among adolescent and young adults, almost two-thirds were among persons aged 15–24 years

    -- for women aged 15–24 years (the population targeted for chlamydia screening), the rate was 3,635.3 cases per 100,000, an increase of 4.9% from 2016 and 8.8% from 2013

    -- rates among men are generally lower than rates among women (probably since fewer screened), though these still increased among men by 40% during 2013– 2017

         -- this may reflect an increased number of men, including gay, bisexual and other men who have sex with men (collectively referred to as MSM) being tested and diagnosed with a chlamydial infection due to increased availability of urine testing and as well as extragenital screening. 

Gonorrhea:  555,608 cases of gonorrhea were reported to CDC in 2017 (the second most common notifiable condition in the US), 171.9 cases per 100,000 population.

    -- 18.6% increase since 2016, and 75.2% increase since the historic low in 2009

    -- rates increased among both males and females, in all regions of the US, and among all racial and Hispanic ethnicity groups

    -- 19.3% increase among men and 17.8% among women

        -- the increase among men suggests either increased transmission, increased case ascertainment (e.g., through increased extra-genital screening among MSM), or both

        -- the increase among women suggests parallel increases in heterosexual transmission, increased screening among women, or both

    -- Since 2008, the percentage of isolates with elevated ceftriaxone minimum inhibitory concentrations (MICs) has remained low at 0.2% in 2017. BUT, during 2014–2017, the percentage of isolates with elevated azithromycin MICs increased from 2.5% to 4.4%. (therapy with the combo of ceftriaxone and azithromycin is the only CDC recommended treatment for gonorrhea)

Syphilis: 30,644 cases of primary and secondary (P&S) syphilis, the most infectious stages of the disease, were reported to CDC in 2017, 9.5 cases per 100,000 population

    -- 10.5% increase during 2016–2017. Since reaching a historic low in 2000 and 2001, the rate of P&S syphilis has increased almost every year

    -- rates increased among both males and females, among all racial and Hispanic ethnicity groups, and in 72.0% of states and the District of Columbia

    -- men accounted for almost 90% of all cases of P&S syphilis and MSM accounted for 68.2% of reported P&S syphilis cases when information known about sex of sex partners

        -- the number of P&S syphilis cases increased 8.6% among MSM, 17.8% among MSW, and 24.9% among women during 2016– 2017

        -- among P&S syphilis cases with known HIV-status, 45.5% of MSM, 8.8% of MSW, and 4.5% of women were HIV-positive in 2017

    -- 918 reported cases of congenital syphilis in 2017, including 64 syphilitic stillbirths and 13 infant deaths, 23.3 cases per 100,000 live births

        -- 43.8% increase since 2016 (16.2 cases per 100,000 live births); 153.3% increase since 2013 (9.2 cases per 100,000 live births).

            -- the 2013 rate of congenital syphilis marked the first increase in congenital syphilis since 2008. Since 2013, the rate of congenital syphilis has increased each year.

        -- This increase in the congenital syphilis rate has paralleled increases in P&S syphilis among all women and reproductive-aged women during 2013–2017 (155.6% and 142.8% increases, respectively).

        -- The case rates for congenital syphilis was highest in Louisiana (93.4 per 100K live births, with 59 cases), Nevada (57.9/100K, 21 cases), California (57.5/100K, 281 cases), Texas (44.2/100K, 176 cases), Florida (41.3/100K, 93 cases). However, 37 states reported at least one case. 

Commentary:

this report is particularly troublesome: not only is there a pretty dramatic increase in the potentially awful outcomes of congenital syphilis, but there is a broad-based increase in all of the reported sexually-transmitted infections, with the following potential consequences:

    --HIV: it is notable how often the increased number of patients with syphilis have been HIV-positive (and syphilis increases the HIV transmission rate), presumably reflecting  lack of use of barrier protection. PrEP helps but is underprescribed and underutilized when prescribed. 

    --Hep B: there are universal childhood vaccinations, and many sexually-active younger people have received them, but overall this vaccine is only 90% effective even if done as recommended​. older and unvaccinated people are at risk as well. which means there is a real possibility of transmitting hep B with both its potentially very serious acute and chronic complications (see http://gmodestmedblogs.blogspot.com/2018/05/more-effective-new-hepatitis-b-vaccine.html for blog on new and improved hep b vaccine on the horizon).

     --Gonorrhea: the issue here is that it is increasingly common, and there are very real warning signs out there about increasing antibiotic resistance, with some variants insensitive to all of our currently used antibiotics (eg, see http://gmodestmedblogs.blogspot.com/2018/04/antibiotic-overuse-in-animals-and.html , and http://gmodestmedblogs.blogspot.com/2014/05/who-report-on-antimicrobial-resistance.html ​ )

-- in terms of congenital syphilis, the CDC does recommend syphilis testing for pregnant women in the 1^st prenatal visit, as well as testing at 28-32 weeks and at delivery for those who are high risk or living in high prevalence areas. Though women with inadequate access to prenatal care will continue to be at disproportionately higher risk of having infected newborns

-- and, as a broader concern, more cases of STIs lead to more use of antibiotics, which can have long lasting effects on the poor, susceptible microbiomes (eg, see https://blogs.bmj.com/bmjebmspotlight/2015/12/03/primary-care-corner-with-geoffrey-modest-md-longterm-microbiome-changes-with-antibiotics/ 

So, bottom line: all of this reinforces the increasing importance of aggressive STI screening, including syphilis as part of the mix. And, of course, reinforcing the use of barrier protection….

geoff​

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