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20. Sexually Transmitted Diseases
Although AIDS is the sexually transmitted disease
(STD) that has received most attention lately, the
hearings highlighted the serious health problems asso-
ciated with other STDs as well. Thirty-eight witnesses
focused on such sexually transmitted diseases as syphi-
lis, gonorrhea, herpes simplex virus, hepatitis B. hu-
man papilloma virus, and chlamydia in their testi-
mony.
Chlamydia, in particular, was cited repeatedly as a
serious public health problem. Ikrenty-five years ago
it was virtually unheard of; now it is the most preva-
lent STD in the United States. An estimated 3 to 4
million new cases occur among adults and infants
each year.t Reporting of chlamydia is incomplete, but
the condition is thought to be much more prevalent
than gonorrhea. (#591)
The incidence of STDs is rising for some condi-
tions and falling for others. For example, the inci-
dence of syphilis increased 26 percent between 1986
and 1987.2 (#177) Testimony linked the incidence
to an increase in unprotected sexual activity. (#413;
#414) Some critics have attributed it in part to
lagging public health prevention and control efforts,
as a result of transferring resources from STDs to
AIDS. (~032; #413; #~4) Albert Brunwasser of
the Allegheny County Health Department in Pennsyl-
vania summarized the concerns of many when he
stated that "AIDS should be incorporated into the
national objectives for sexually transmitted diseases,
but should not be allowed to use resources at the
expense of other parts of the program. That is,
increases in other sexually transmitted diseases should
not be allowed to occur because all time and effort is
expended on HIV infection." (#032)
As with AIDS, education and testing were viewed
as important components of any effort to reduce the
incidence of STDs. Unlike AIDS, however, some
STDs can be treated successfully. Expanded diagnosis
and treatment services, therefore, also were identified
as important means of decreasing the number of
carriers and halting the spread of these diseases.
The American Academy of Pediatrics identifies four
elements necessary to reduce STDs: public awareness
and education, access to health care, treatment by
professionals who can detect the diseases in their
early stages, and reduction in the number of carriers
in the general population. (#115)
Although STDs were a serious public health
problem long before AIDS appeared, several witnesses
made reference to some important links between
AIDS and other STDs. First, there is apparently an
increased susceptibility to HIV infection if another
STD is present; this is especially alarming in light of
the increased incidence of some STDs in certain
populations. Second, successful AIDS education pro-
grams encouraging the use of condoms also decrease
the rate of Skids. This has occurred in the gay com-
munibr, in particular. Finally, the fight against AIDS
initially drained resources from the fight against other
SIDs. Many witnesses believe that resources are still
being diverted away from SIDs, which poorly serves
both causes. (i¢032, #413, #695)
Another important issue raised again and again in
the testimony on STDs is the urgency of the problem
among teenagers and young adults. C. M. G. Buttery,
Commissioner of the Virginia Department of Health,
points out that "sexually transmitted diseases predomi-
nantly affect the young, therefore this age group must
be educated about preventive measures before they
become sexually active. (~034J Much of the testi-
mony noted the importance of developing effective
education, screening, diagnosis, treatment, and follow-
up services for them. A final point from the hearings
worth emphasizing is concern about congenital STDs.
Infected mothers can pass on disease to their
offspring; reducing the rate of infection in newborns
was a goal identified by several witnesses.
TARGETING YOUTH
Every year 2.5 million teenagers become infected with
an STD, according to testimony from the American
School Health Association (ASHA).3 It is estimated
that a teen's risk of contracting an STD is two or
three times higher than that of someone age 20 or
older.4 (~232J
The ASHA cites a 1983 national survey which
found that only one-third of adolescents consider
themselves "very informed" about STDs.5 Education
and prevention programs must be expanded, according
to the ASHA, and community health and social ser-
vice agencies, as well as schools, should be part of
the effort. As models, the AS HA points to school-
linked clinics, school-based clinics, and school or
Sexually Transmitted Diseases 159
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community-based education programs that have been
effective in preventing teenage pregnancy: For an
STD education program to have an impact, more than
one lesson that may be typical at most schools is
needed. A study of various health curriculums de-
monstrated that behavior change occurred after 40-50
hours of instruction. (#232)
The ASHA recommends that STD instruction be
part of the health education curriculum from kinder-
garten through the twelfth grade in 90 percent of all
school districts by the year 2000. It argued that to
wait until the junior or senior year for such
instructions called for in the 1990 Objectives-is not
prudent because many adolescents become sexually
active before that time. Others propose similar goals.
The ASHA notes that very few states now mandate
that venereal disease instruction be part of the health
education program. (#232) Although the value and
importance of STD education were emphasized by
many, "the difficulty of 'educating' away our society's
ills also was underscored; teachers should not be
expected to be "agents of social controls according to
Thomas Bell of the University of Washington.
(~329)
The ASHA also proposes that a goal for the year
2000 be implementation of STD prevention programs
for adolescents in 40 percent of U.S. communities.
Funds should come from both public and private
sources. The federal government should fund STD
prevention programs through state and local education
agencies, much as it funds drug abuse and AIDS
prevention efforts. (#232)
The importance of reaching teenagers and young
adults was echoed in hearings held by the American
College Health Association. When asked to name the
top health issues on college campuses, college health
officials consistently named STDs among the top
three. Among the reasons cited for the high level of
concern were college students' inadequate health/
sexuality education in high school and at home; their
sexual inexperience, coupled with a desire to experi-
ment and explore; and their casual attitudes about sex
and life in general. At least one witness saw this as
an opportunity as well as a problem.
The young adult population in undergraduate
and graduate schools are extremely inquisitive
and eager to learn. Now that health care in our
country has shifted to health promotion, disease
prevention, and disease protection, college
health services have a unique opportunity to
help students look at their lives in a preventive
160 Healthy People 2000: Citizens Chart the Course
manner. (#759)
College administrators share the view of many
other witnesses that young people should be well
informed about STD transmission before they reach
college age, because sexual activity often already has
begun by that time. Such education must start even
before the junior or senior year in high school the
target group for some efforts~ccording to several
witnesses. For example, Diane Allensworth of ASHA
noted that in 1983 there were almost 30,000 pregnan-
cies in girls less than 15 years old.7 (~232,}
Other witnesses addressing the STD problem
among young people focus on the hard-to-reach teens.
Marlin Johnston of the Texas Department of Human
Services says that teenage runaways are at high risk
for STDs: many girls have been raped or are preg-
nant, and many boys even less than 14 years old are
sexually active. (#112) Herbert Rader, representing
the Salvation Army, reports that "children are selling
themselves for drugs without any regard to the risks
they are taking." His organization attempts to reach
these children with programs aimed at improving their
self-image. Rader also says that preventive programs
which do not pay adequate attention to moral
strength and character issues will not solve the STD
problem. (#432J
REDUCING CONGENITAL SEXUALLY
TRANSMITTED DISEASES
Reaching teenagers is all the more important because
STDs can cause disease in the infants of affected
mothers. With the high rate of teenage pregnancy,
reduction in the number of teenage carriers can
significantly decrease the number of congenital STD
cases.
A mother with chlamydia, for example, can pass on
conjunctivitis, pneumonia, and other respiratory
infections to her baby. Congenital syphilis can cause
death. Thomas Weller of Harvard University says
that congenital cytomegalovirus (CMV) infections can
also severely damage infants; but unlike syphilis,
which can be treated with penicillin, there is no
treatment for congenital CMV.8 (#790J
Several witnesses proposed specific goals for
reducing the rate of congenital STDs. The American
Academy of Pediatrics (AAP), for example, says that
by the year 2000 the rate of congenital syphilis should
be no more than 3.5 per 100,000 live births. This
represents approximately a 50 percent reduction from
the 1985 rate of 7.1 per 100,000. The AAP also
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proposes targets for herpes (5 per 100,000 live births
compared to 16.8 per 100,000 in 1979) and chlamydial
pneumonia (250 per 100,000 live births, down from
720 per 100,000 in 1979) contracted from the moth-
er.9 (~115) Many mothers giving birth to babies
with congenital STDs have had little or no prenatal
care, and some have been involved with drugs, accor-
ding to John Parker of the Detroit Department of
Health. Programs aimed at producing healthy babies
must address all these things and more because
"everything seems to be dovetailing," he says. (#413)
IMPLEMENTATION
Much of the testimony on STDs focused on
implementation issues: the provision of high-quality
laboratory and clinical services; the need for more
surveillance systems and more research; and the
difficulty of setting quantitative objectives for STDs,
especially because of interactions with AIDS.
Improving Services
Achieving the desired reductions in STDs will require
improvements in the quality and availability of health
services, according to witnesses.
Laboratory services, in particular, were discussed by
several testifiers. Many facilities lack adequate labora-
tory services to establish the diagnosis of STDs, accor-
ding to Berttina Wentworth of the American Public
Health Association's Laboratory Section. She says
that at these places, STDs must be diagnosed on the
basis of clinical signs, which is an inadequate ap-
proach. Asymptomatic and subclinical conditions are
missed, and some symptomatic disease also goes unde-
tected; she proposes that "by the year 2000 at least 90
percent of medical facilities responsible for the diag-
nosis and treatment of STDs shall have sufficient
laboratory services available to them for the detection
of the etiologic agents or for serological diagnosis of
such diseases as gonorrhea, syphilis, herpes virus,
chlamydia, Tnchomonas vaginalis and Candida albicans
infections." (#754)
Henry Isenberg of the Long Island Jewish Medical
Center also emphasizes the importance of improving
laboratory capability to diagnose STDs.
More rapid, simple and accurate diagnostic tools
for the detection of gonorrhea, chlamydia, and
herpes virus, especially in women, directly in
specimens are required and a development of
such agents should be supported. The ability to
discern the antibiotic susceptibility, especially of
the gonococcus directly in the specimen, is also
a very desirable objective for the year 2000.
(~438J
Some witnesses also addressed the need to expand
the capacity and improve the performance of clinical
services. According to Parker, at the local level this
would mean renovating facilities to meet the de-
mands of more people per day; getting private clinics
more involved in treatment; continuing the emphasis
on follow-up; improving physician education; and
hiring additional personnel. (~413J Parker's testi-
mony illustrates the kind of commitment and resour-
ces required to aggressively combat STDs. Bell says
the STD control effort has lacked that aggressive
approach, and contrasts it with the more vigorous
campaign to eliminate smallpox. (#329)
Bell notes that gonorrhea can be treated simply,
usually with a single dose of antibiotic. Yet, he says,
incidence rates are essentially unchanged. According
to a mathematical model he describes, curing a
relatively small number of carriers could ' interrupt
transmission of the disease.~° nIf the model is cor-
rect, then we're really missing a great opportunity," he
says. Based on this, Bell calls for mass screening in
the military, adult and juvenile correctional facilities,
and perhaps in high schools, although he acknow-
ledges that the last would be controversial. (#329)
Other witnesses identified pregnant women or immi-
grants as groups that should be screened routinely.
Making sure that those with treatable conditions
complete therapy is an important goal, witnesses
agreed. Follow-up to make sure the course of thera-
py is completed is critical. However, the limitations
of relying on therapy also were underscored First,
only some diseases are treatable. Moreover, the
development of resistant strains of causative agents
poses a constant challenge to effective treatment of
conditions that have been controllable. Steven Blum
of the American College Health Association cites a
1980 outbreak of resistant strains of gonorrhea as an
example. (#759)
Expanding Research and Reporting
Several witnesses mentioned the need to expand
knowledge about STDs so that they can be more
effectively prevented. Among the topics discussed was
the need for additional research into the development
of vaccines to prevent sexually transmitted diseases.
Research into better and more extensive screening
Sexually Transmitted Diseases 161
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tests to identitr them also was urged.
The importance of better reporting and surveillance
also arose during the testimony. More comprehensive
reporting of chlamydia was mentioned by several
witnesses. (#137; #259)
A few witnesses called for increased focus on the
human papilloma virus (HPV). Hunter Handsfield of
the Seattle-King Counter Department of Public Health
says it is probably too soon to recommend control of
the HPV; effective surveillance is needed at this stage.
(~695) However, by the year 2000, prevention and
treatment of HPV infections of the genitalia and
perineum should be an integral part of every STD
control program, according to Robert Bernstein,
Commissioner of the Texas Department of Health.
(#020) Isenberg calls for continued research into the
cause of the virus and its relationship to cancer.
(~438J
Setting Quantifiable Goals
In addition to the goals for congenital STDs identified
above, a variety of targets were suggested for specific
conditions in the general population. However,
Handsfield emphasizes that these numeric goals
should be stated for population subgroups. He notes,
for example, that the overall incidence of gonorrhea
REFERENCES
in Seattle-King County, Washington, is decreasing, but
in some groups, such as inner-city Blacks, it is
increasing. The decrease is due largely to the decline
in disease among gay meI1 who are practicing safe sex
in response to the AIDS epidemic. (#695)
Although the AIDS epidemic is associated with
some reduction in other STDs, testimony also indi-
cated that the fight against AIDS has diverted
attention from, or decreased funding for, other STDs.
Handsfield comments, "Funding for AIDS control was
initially largely taken from the coffers of sexually
transmitted disease control programs. This must not
be permitted to continue and it must in fact be
reversed. (#695)
Witnesses also cited evidence that the presence of
an STD may make transmission of AIDS more likely,
which means that a coordinated effort at combatting
AIDS and other STDs is essential. (#695) The
ASHA calls for STD prevention programs for
adolescents that "combine and coordinate the multiple
health/social services of the community with those of
the schools in 40 percent of U.S. communities."
(~232) Although some health jurisdictions may be
unable to expand, the concept of combining local
resources into a total communicable disease clinic
makes sense because, as Kizer says, "the same groups
being seen in STD facilities are those who are at high
risk for HIV, as well as other diseases." (~591)
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promotion effectiveness, implementation and costs. J Sch Health 55~8~:316-321, 1985
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OCR for page 163
9. U.S. Department of Health and Human Services: The 1990 Health Objectives for the Nation: A Midcourse
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TESTIFIERS CITED IN CHAPTER 20
020 Bernstein, Robert; Texas Department of Health
032 Brunwasser, Albert; Allegheny County Health Department (Pennsylvania)
034 Buttery, C. M. G.; Virginia Department of Health
112 Johnston, Marlin; Texas Department of Human Services
115 King, Caroler American Academy of Pediatrics
137 Mack, Douglas; Kent C:ounn,r Health Department (Michigan)
177 Randolph, Linda; New York State Department of Health
232 Allensworth, Diane; American School Health Association
259 Hunter, Katherine; Baptist Medical Center, Montclair (Alabama)
329 Bell, Thomas; University of Washington
413 Parker, John; Detroit Department of Health
414 Love, Melinda; Detroit Department of Health
432 Rader, Herbert; lithe Salvation Army in the United States
438 Isenberg, Henry; Long Island Jewish Medical Center
591 Kizer, Kenneth; California Department of Health Services
694 Hagens, William; Washington State House of Representatives
695 Handsfield, H. Hunter; Seattle-King County Department of Public Health
754 Wen~rorth, Berttina; American Public Health Association, Laboratory Section
759 Blum, Steven; American College Health Association
790 Weller, Thomas; Harvard University
Sexually Transmitted Diseases 163
Representative terms from entire chapter:
transmitted diseases
