It is currently STD Awareness Week at the CDC (how do you celebrate?), and just as they are attempting to spread the word about screening, testing, and treatment of sexually transmitted infections, the latest batch of numbers has confirmed what many in the medical community had feared. Despite a noteworthy, but not unexpected, decline in reported cases of syphilis, gonorrhea, and chlamydia in the early months of the pandemic, the final tally for 2020 is significantly higher than what we saw in 2019, though there is some important nuance that I’ll discuss shortly. This includes a significant increase in cases of congenital syphilis, which I wrote about last October.
Why do the new CDC numbers focus on these three particular sexually transmitted diseases in the new report? Why not HIV or HPV? What about Hepatitis B and C? No respect for chancroid, the most common cause of genital ulcers in the world? It isn’t that the CDC doesn’t care about the others. Chlamydia, gonorrhea, and syphilis are the three notifiable sexually transmitted diseases for which there is a current 5-year-plan (2019-2023) for federally funded control programs:
This NOFO supports strategies and activities to: eliminate congenital syphilis; prevent antibiotic resistant gonorrhea; reduce primary and secondary syphilis; prevent STD-related pelvic inflammatory disease, ectopic pregnancy, and infertility; address STD-related outbreaks; and reduce STD-related health disparities. Priority populations for this NOFO include adolescents and young adults, men who have sex with men, and pregnant women.
Syphilis and gonorrhea and chlamydia, oh my!
In addition to syphilis in adults and babies, 2019 also wasn’t a great year for gonorrhea or chlamydia. In total, there were roughly 2.5 million cases of these infections reported that year. Though there were about 160,000 fewer total cases, with the difference coming from a significant drop in the total reported cases of chlamydia, the reality is that 2020 was worse across the board. The dip in chlamydia is an illusion.
Chlamydia, which is the most commonly reported STD, is not the most prevalent. That would be HPV, a vaccine-preventable viral infection linked to genital warts and cervical cancer that is not a nationally reportable diagnosis. But like HPV, chlamydia tends to be asymptomatic for long periods of time. In fact, 70% of women and 50% of men who are diagnosed with chlamydia have no symptoms at all at the time and are picked up through screening efforts. Though these asymptomatic infections can resolve without treatment, diagnosing and treating chlamydia can prevent pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pelvic pain in many patients. This also limits spread to sexual partners.
There were roughly 1.6 million cases of chlamydia reported in 2020, which was down about 13% from 2019. But this is not a cause for celebration. Rather, it’s a predictable decrease caused by a plummet in the screening of asymptomatic people during the early months of pandemic. Reported cases of chlamydia have been steadily rising for years and this is an outlier and not the start of a new trend, despite the CDC’s efforts.
In 2019, 616,000 cases of gonorrhea were reported. In 2020, this increased by about 10% to roughly 678,000 cases. Primary and secondary syphilis, which are the stages when the infection is easily spread from person to person through intimate contact, increased by about 7% in 2020 with 41,655 reported cases. Congenital syphilis, which puts children at risk for debilitating sequelae and even death, increased by 15% with 2,148 cases and 149 deaths, continuing the alarming trend I discussed in that October post.
So 2020 was not a very good year, pretty much for anybody or anything. And to make matters even worse, the 2020 numbers are absolutely a massive undercount of the actual prevalence of these sexually transmitted diseases in the United States, and not just chlamydia. Oh, and the preliminary data from 2021 is not reassuring. We continue to move in the wrong direction.
The role of the pandemic in STD diagnosis and treatment
As I mentioned above, the drop in chlamydia cases seen in 2020 almost certainly does not represent a true decrease but an interruption in typical screening practices for a variety of pandemic related reasons. Millions of people did not receive appropriate healthcare because of closures and delays while trying to limit spread of SARS-CoV-2. Adding to this, routine screening tests were often delayed even when patients were able to be seen via telemedicine.
The percentage of chlamydia cases diagnosed in symptomatic people likely rose dramatically in 2020, because that’s who was more likely to seek care despite COVID fears. Many of these people, most of them women, were likely at the point of severe symptoms and may have even needed surgical management by the time they went to the emergency department. These delays likely will result in an ultimate diagnosis of infertility in some of them.
The pandemic wouldn’t have only made it more difficulty to diagnose and manage patients with chlamydia. In fact, prior to when efforts to curb the spread of SARS-CoV-2 began ramping up in the Spring of 2020, the numbers of reported cases of gonorrhea, syphilis, and chlamydia were all on track to surpass 2019. And they all plummeted during March and April. The CDC lists three primary factors in the Spring reduction in reported cases:
Reduced screening: Many healthcare clinics either closed entirely or limited in-person visits to symptomatic patients only…Additionally, decreased routine healthcare visits, increased unemployment and loss of health insurance, as well as STD test kit and laboratory supply shortages, may have reduced screening during the pandemic.
Limited resources: STD program resources shifted to help control the spread of COVID-19. Many jurisdictions redirected staff from routine STD surveillance and control efforts to COVID-19 activities. The observed drop in reported cases may reflect challenges in maintaining key STD activities, including case investigation, partner services, and case reporting.
Social distancing measures: Because COVID-19 can spread during sexual contact, social distancing measures were used to mitigate disease. These measures may have influenced sexual behaviors by limiting sexual activity or the number of new sexual partners, thus reducing the spread of STDs. The fear of being exposed to COVID-19 and limited access to public transportation also may have affected sexual behaviors and led to people with STD symptoms delaying care.
These issues didn’t suddenly resolve later in 2020, though the initial fear to varying degrees across the country despite continued outbreaks and records for cases being set left and right. Some parts of the country, particularly the Northeast, were more focused on pandemic precautions than others. This is a complex problem with many variables, in particular the fact that states less likely to have taken the pandemic seriously also tend to be states that already had more problems with poverty, education, healthcare disparities, social safety nets, and so on. I’m talking about the South, of course, and I’m fighting hard against my nature to not make any comments about competent political leadership, or the lack thereof. Oops, I guess I lost that battle. The food is good though.
I don’t think it’s a significant stretch to expect to see less of a decrease in STD cases in areas that in general were less likely to have experienced widespread and intense limitations in services and public fear of COVID-19. Again, I’m not making any bold claims about what these numbers mean, but the Northeast did have a 20% decrease in chlamydia cases in 2020 compared to a drop of only 7% in the South. In addition to this, the Northeast had an increase in gonorrhea cases of 5% compared to the South’s 15%. To finish this little experiment up, I found that the Northeast had an increase in primary and secondary syphilis cases of 7% while the South increased by 9%.
So it is certainly true that the South had more STD cases reported than the Northeast in 2020. The South also saw larger increases in gonorrhea and syphilis cases, and a smaller decrease in chlamydia cases, than the Northeast compared to 2019 numbers. But the South has pretty much always had a bigger problem with STDs. One could argue though, in this specific situation, that in 2020 the Northeast ended up with a higher percentage of untreated people who would have normally been diagnosed had it not been for a raging pandemic. Also that the food is terrible.
Not surprisingly, healthcare disparities were evident in the STD data from 2020, with just over half of all reported cases being diagnosed in people ages 15 to 24. Also not unexpected, sadly, were racial disparities. For example, a third of cases involved non-Hispanic Black people, which is wildly disproportionate to their 12% of the total population. In their report, the CDC focuses on social and economic factors like poverty and access to adequate healthcare as the cause for worse health outcomes in these populations. As with COVID-19, a lot of people are being ignored and are shouldering an unfair percentage of the burden.
Conclusion: The worst is probably yet to come
As I mentioned above, the data from 2021 looks bad. Things are going to get worse before they get better. If they get better. It’s great that the CDC is throwing money at this problem, but it will take more than that. Much of the underlying issue comes down to weaknesses and biases inherent in the healthcare system. Hell, in the very fabric of American society. This crap has been baked into it from the very beginning so it will take a lot of work and time to set things right.