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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. (i032, #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) 1. Centers for Disease Control: Chlamydia trachomatis infections: Policy guidelines for prevention and control. Morbid Mortal Wkly Rep Supplement 34~3S):53s-74s, 1985 2. Centers for Disease Control: Summary of notifiable disease: 1987. Morbid Mortal Wkly Rep 36(54), 19% 3. U.S. Department of Health, Education and Welfare: Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (DHEW Publication No. [PHS] 79-55071), 1979 4. Children's Defense Fund: A Children's Defense Budget. Washington, D.C.: 1986 5. Parra WC, Cates W: Progress toward the 1990 objectives for sexually transmitted disease: Good news and bad. Public Health Rep 100~3~:261-269, 1985 6. Connell DB, Turner RR, Mason EF: Summary of findings of the school health education evaluation: Health promotion effectiveness, implementation and costs. J Sch Health 55~8~:316-321, 1985 7. Children's Defense Fund: Adolescent Pregnancy: Whose Problem Is It? Washington, D.C.: 1986 8. Yow MD: Congenital ~rtomegalovirus disease: A NOW problem. J Infect Dis 159:163-167, 1989 162 Healthy People 2000: Citizens Chart the Course

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9. U.S. Department of Health and Human Services: The 1990 Health Objectives for the Nation: A Midcourse Review. Washington, D.C.: U.S. Government Printing Office, 1986 10. Yorke JA, Hethcote HW, Nold A: Dynamics and control of the transmission of gonorrhea. Sex Trans Dis 5:51-56, 1978 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