“Stay home, save lives” and social distancing have been common slogans for the past two years, but some public health experts are adding “Let’s go back to the 80’s” to the combination, specifically in terms of increasing of cases of sexually transmitted infections. (ITS) at levels not seen in decades.
“There are a lot of things I’d like to go back to in the ’80s, but not because of that. We’re actually going back to the levels of sexually transmitted infections in the’ 80s,” says Katherine K. Hsu, MD. teacher. of Pediatrics at Boston University School of Medicine and Medical Director of STD Prevention and HIV / AIDS Surveillance with the Massachusetts Department of Public Health’s Office of Infectious Diseases and Laboratory Sciences.
At the height of the COVID-19 pandemic, the goal was to reduce the transmission of a particular virus, but new data show that a coronavirus is not the only type of infection that increased during the pandemic. .
In its first major data release since the start of the COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) revealed that rates of almost all types of STIs have risen in recent years. years.
- Cases of gonorrhea have increased by 45% since 2016 with a total of 677,769 cases in 2020.1
- Syphilis has increased by 52% compared to 2016 with a total of 133,945 cases.1
- Congenital syphilis experienced a 235% increase over 2016 in 2020 with 2,148 cases.1
- Chlamydia rates alone fell by 1.2% to 1.6 million cases in 2020.1
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 peaks.2
Pandemic, behavioral changes guilty of a peak
Part of the blame for these increases was the pandemic itself, according to the CDC. The tense public health system, limited resources, reduced screening tests and general underreporting in recent years are reflected in these newer data, the agency shares, although it warns that these trends may be just the tip. of the iceberg.
Social distancing may have helped limit sexual activity and exposure to new partners, but it may also have caused delays in care for many people, according to the CDC.3
There is also the suspicion that better treatment for HIV / AIDS has led to a more laissez-faire attitude towards STIs in general. In the 1980s and early 1990s, people were afraid of dying of AIDS, says Hsu. Because the virus no longer carries a death sentence for many, the U-shaped curve that ITS cases have shown in recent decades reflects a possible decrease in concern.
“It simply came to our notice then [for AIDs at first]. That is no longer the case, “he said.
There was a real change in behavior in the 1990s when it came to sexual public health, and overall STI rates dropped while rare STIs such as syphilis continued to travel in small groups. The groups with the highest HIV / AIDS prevalence also experienced higher rates of STIs such as syphilis, so behavioral changes aimed at decreasing HIV / AIDS transmission also had a positive effect on other infections.
“It’s important to recognize that the fall was really due to coincident STIs,” he says.
The group of sexual partners who transmitted certain STIs was reduced after the onset of HIV / AIDS, and once diseases such as syphilis were introduced into smaller sexual networks and were not completely eradicated, the chances of finding if with a partner who is carrier increased, says Hsu.
“A lot of that is about math and sexual networks, not individual behavior,” he explains. Doctors detected an increase in the most symptomatic, and usually more advanced, STIs during the COVID-19 pandemic, as patients hesitated to seek care, and the data now confirm these suspicions.
“We are all afraid of the consequences in a few years’ time,” he said, adding that the true effects of the pandemic are yet to come. they could have on fertility rates.
Is it too early to celebrate the decline in chlamydia cases?
Silent infections pose a major threat to female fertility, says Hsu, because chlamydia infections, in particular, are often only detected during screening tests, which were left out during the first months of COVID-19.
“If you can only detect the infection by detection, this should be one of the main messages,” says Hsu. “Chlamydia went down because it is only detected by screening, but we know that pelvic inflammatory disease and infertility have also gone down since large-scale chlamydia screening began again. Many people are afraid it will return.”
Gonorrhea will present with painful symptoms in the urethra, which will cause people who become infected to see treatment. Syphilis will also become symptomatic. Chlamydia, however, can occur for a long time without being detected or treated. Diagnostic and detection methods have not changed in years, says Hsu, and while chlamydia numbers appear to have dropped in recent estimates, he warns that it is likely that only the detection of this infection has decreased, not infections. reals.
Pediatricians and primary care physicians need to be vigilant when calling patients for routine exams similar to how they do it for immunization, says Hsu. Even if patients are asymptomatic now, a chlamydia infection can have long-term fertility consequences that are not realized for many years.
Major public health organizations recommend the detection of chlamydia for all sexually active people, but for pediatricians, making this detection and getting truthful answers can be a challenge. Hsu says some pediatric practices take the position of examining any patient of a certain age in order to remove conjecture from assessments of sexual activity. Screenings should continue for women up to the age of at least 25, she adds.
Hsu also stressed the importance of re-examining high-risk patients. For patients who have had a previous diagnosis of STI, Hsu says the recommendation is to call them back to re-examine them about 3 or 4 months after treatment.
“We’ve done case studies that show that repeaters account for a lot of cases,” he says.
Newer fast tests may help, but Hsu says that perhaps one of the best things that came out of COVID-19 was increasing the availability of test kits at home, even for STIs. Many swabs are FDA approved and Hsu says it sees increased use of home testing in the near future. He also says doctors realized during the restricted healthcare environment of COVID-19 that patients are more willing to leave samples for testing and detection rather than committing to a full appointment.
Other challenges in ITS 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 are emerging data that the rectum and oropharynx may be silent reservoirs for chlamydia.
This had not previously been on the CDC’s radar, he explains, as it was primarily considered a problem in male-to-male sexual activity. However, new screening from other sites in the mucosa has confirmed that the female rectum can also harbor chlamydia, leading to reinfection of the vagina even after the chlamydia has been treated.
In addition to considering self-inoculation, Hsu said the guide has changed on which antibiotics should be used to treat chlamydial infections.
The CDC updated its guideline in July 2021,4,5,6 recommending not treating these infections with a single dose of azithromycin because it does not eradicate the infection in the rectal sites. The new recommendation is to use doxycycline twice a day for a week, a change that raised some concerns about patient adherence. It is certainly easier to continue with a shorter course of antibiotics, but Hsu said the researchers found that a single dose of azithromycin eradicated about 71% to 78% of cases of rectal chlamydia, while doxycycline was effective in eliminating more than 91% to 100% of cases. . In addition, she says, about 2 out of 3 women with vaginal chlamydia are coinfected in the rectal site even when rectal penetration is denied.
There were also updates to gonorrhea treatment protocols, says Hsu, with the CDC now recommending 500 mg of ceftriaxone instead of 250 mg. The pediatric dose is 25 to 50 mg / kg ceftriaxone, not to exceed 250 mg per dose.3 A single dose of 500 mg is intended for anyone weighing less than 150 kg in adult doses, but to use 1 gram in anyone weighing more than 150 kg, says Hsu. Doctors are also advised to drop azithromycin which has usually been added as a dual drug approach, he adds.4,5,6.
“We don’t want to double down on a smart bacterium,” says Hsu. “It was a great theory, but terrible to implement. 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 doctors should not be surprised to see that guidelines for the treatment of gonorrhea change every few years as public health authorities try to keep up with this ever-changing threat.
“Now that we’re back to a single drug, people are understandably worried,” he 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 reveal.
References:
1. Centers for Disease Control and Prevention. Surveillance of sexually transmitted diseases 2020. Updated April 12, 2022. Accessed 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. Accessed May 6, 2022. https://www.cdc.gov/std/statistics/2020/preliminary2021.htm
3. Centers for Disease Control and Prevention. Impact of COVID-19 on STDs. Updated April 12, 2022. Accessed May 2, 2022 …