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Decreasing cases of chlamydia may offer false hope in light of decreased screening.
“Stay home, save lives” and social distancing have been common taglines over the last 2 years, but some public health experts are adding “We’re back to the 80s” to the mix, specifically in terms of rising cases of sexually transmitted infections (STI) to levels not seen in decades.
“There’s a lot of things I would love to go back to the 1980s for, but not for this: We are actually back, in general, to the 1980s levels of sexually transmitted infections,” says Katherine K. Hsu, MD, a professor of pediatrics at Boston University School of Medicine and medical director for STD Prevention & HIV/AIDS Surveillance with the Bureau of Infectious Disease and Laboratory Sciences at the Massachusetts Department of Public Health.
At the height of the COVID-19 pandemic, the focus was on reducing transmission of 1 particular virus, but new data show that a coronavirus isn’t the only type of infection that spiked during the pandemic.
In its first major release of data since the COVID-19 pandemic started, Centers for Disease Control and Prevention (CDC) revealed that rates of nearly every type of STI have increased over the last several years.
The 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 spikes.2
Pandemic, behavior changes blamed for spike
Part of the blame for these increases was the pandemic itself, according to CDC. The strained public health system, limited resources, reduced screenings, and general underreporting over the last few years are reflected in this newest data, the agency shares, while warning that these trends may be only the tip of the iceberg.
Social distancing may have helped by limiting sexual activity and exposure to new partners, but it may also have resulted in delayed care for many people, according to CDC.3
There is also a suspicion that better treatment of HIV/AIDs has led to a more laissez-faire attitude about STIs in general. In the 1980s and early 1990s, people were afraid of dying from AIDs, Hsu says. Since the virus no longer carries a death sentence for many, the u-shaped curve that cases of STIs have shown in the last few decades reflects a potential drop in concern.
“We didn’t have great treatment [for AIDs at first]. That’s no longer the case,” she says.
There was a real behavior change going into the 1990s in terms of sexual public health, and overall rates of STIs dropped while rare STIs like syphilis continued to travel in small groups. Groups with higher prevalence of HIV/AIDs also experienced higher rates of STIs like syphilis, so behavior changes aimed at decreasing transmission of HIV/AIDs also had a positive effect on other infections.
“It’s important to recognize that the drop was really due to coincident STIs,” she says.
The pool of sexual partners transmitting certain STIs became smaller after the emergence of HIV/AIDs, and once diseases like syphilis were introduced into smaller sexual networks and not fully eradicated, the chances of encountering a partner who is a carrier increased, Hsu says.
“A lot of this is about math and sexual networks, not individual behavior,” she explains. Clinicians sensed a spike in more symptomatic—and usually more advanced—STIs throughout the COVID-19 pandemic as patients hesitated to seek care, and now the data are confirming those suspicions.
“All of us fear the consequences a few years from now,” she adds, explaining that the true effects of the pandemic are probably yet to come—particularly in terms of congenital disease transmission and the effect untreated STIs could have on fertility rates.
Is it too soon to celebrate the drop in chlamydia cases?
Silent infections pose a huge threat to female fertility, Hsu says, because chlamydia infections in particular are often caught only during screenings—screenings that fell by the wayside during the early months of COVID-19.
“If you can only catch the infection through screening, that has to be one of the top-line messages,” Hsu says. “Chlamydia dropped because it is only caught through screening, but we know that pelvic inflammatory disease and infertility have also dropped since large-scale chlamydia screening started up again. A lot of people fear it will come back.”
Gonorrhea will present with painful symptoms at the urethra, prompting people who become infected to see treatment. Syphilis will also become symptomatic. Chlamydia, however, can brew undetected—and untreated—for a long time. Diagnostic and screening methods haven’t changed in years, Hsu says, and while chlamydia numbers appear to have dropped in the latest estimates, she cautions that it’s likely only detection of this infection that has decreased—not actual infections.
Pediatricians and primary care doctors need to be vigilant in calling patients back for routine screenings similar to the way they are for immunization, Hsu says. Even if patients are asymptomatic now, a chlamydia infection can have long-term fertility consequences that aren’t realized for many years.
Leading public health organizations recommend chlamydia screening for all sexually active persons, but for pediatricians, doing this screening—and getting truthful answers—can be a challenge. Hsu says some pediatric practices take the stance of screening any patient over a particular age in order to take the guesswork out of assessments of sexual activity. Screenings should continue for women until at least aged 25 years, she adds.
Hsu also stressed the importance of rescreening high-risk patients. For patients who have had a prior STI diagnosis, Hsu says the recommendation is to call them back for rescreening about 3 to 4 months after treatment.
“We’ve done case studies that prove that repeaters account for a tremendous amount of cases,” she says.
Newer rapid tests can help, but Hsu says maybe one of the best things that came out of COVID-19 was the increase in availability of at-home test kits—even for STIs. Many self-swabs are FDA-approved, and Hsu says she sees the use of home screenings increasing in the near future. She also says clinicians realized during the restricted health care environment of COVID-19 that patients are more willing to drop off samples for testing and screening rather than committing to a full appointment.
Other challenges in managing STIs
Another challenge of 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 are emerging data that the rectum and oropharynx can be silent reservoirs for chlamydia.
This previously hasn’t been on CDC’s radar, she explains, as it was considered mostly an issue in male-to-male sexual activity. However, new screening of other mucosal sites has confirmed that the female rectum can also harbor chlamydia, leading to reinfection of the vagina even after chlamydia has been treated.
In addition to considering autoinoculation, Hsu said guidance has changed on what antibiotics should be used to treat chlamydia infections.
CDC updated its guidance in July 2021,4,5,6 recommending against treating these infections with a single dose of azithromycin because it does not eradicate the infection at rectal sites. The new recommendation is to use doxycycline twice a day for a week—a change that raised some concerns about patient adherence. A shorter course of antibiotics is certainly easier to follow through with, but Hsu said researchers found that a single dose of azithromycin eradicated about 71% to 78% of rectal chlamydia cases while doxycycline was effective in clearing more than 91% to 100% of cases. To add to that, she says, about 2 in 3 women with vaginal chlamydia are coinfected at the rectal site even when rectal penetration is denied.
There were also updates to gonorrhea treatment protocols, Hsu says, with CDC now recommending 500 mg of ceftriaxone instead of 250 mg. Pediatric dosing is 25 to 50 mg/kg of ceftriaxone, not to exceed 250 mg per dose.3 A 500-mg single dose is intended for anyone less than 150 kg in adult dosing, but 1 gram should be used in anyone weighing more than 150 kg, Hsu says. Clinicians are also advised to drop the azithromycin that has typically been added as a dual drug approach, she adds.4,5,6
“We don’t want to double team against a clever bacteria,” Hsu says. “It was a great theory, but terrible to implement. We don’t have 2 good options against gonorrhea anymore. Gonorrhea is becoming more resistant to azithromycin, so a stronger dose of ceftriaxone is now preferred.”
Hsu says clinicians should not be surprised to see 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 a single drug again, people are understandably concerned,” she says. “If it mutates beyond cephalosporins, there really are no more options.”
Rachael Zimlich, BSN, RN, is a freelance medical writer in Cleveland, Ohio. She has nothing to disclose.
1. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2020. Updated April 12, 2022. Accessed May 4, 2022.
2. Centers for Disease Control and Prevention. Preliminary 2021 data: syphilis. Updated April 12, 2022. Accessed May 6, 2022.
3. Centers for Disease Control and Prevention. Impact of COVID-19 on STDs. Updated April 12, 2022. Accessed May 2, 2022.
4. Centers for Disease Control and Prevention. STI treatment guidelines. Updated July 22, 2021. Accessed May 2, 2022.
5. Silverberg B, Moyers A, Hinkle T, Kessler R, Russell NG. 2021 CDC update: treatment and complications of sexually transmitted infections (STIs). Venereology. 2022; 1(1):23-46. doi:10.3390/venereology1010004
6. Tuddenham S, Hamill MM, Ghanem KG. Diagnosis and treatment of sexually transmitted infections: a review. JAMA. 2022;327(2):161-172. doi:10.1001/jama.2021.23487