By Marie Rosenthal, MS

The nation saw a concerning increase in sexually transmitted diseases (STDs) during the COVID-19 pandemic, according to a new report by the CDC. Reported cases of gonorrhea and primary and secondary syphilis were up 10% and 7% in 2020, respectively, compared with 2019; and congenital syphilis increased by almost 15%.

 

 

In hard numbers, there were 677,769 cases of gonorrhea; 133,945 cases of syphilis; 2,148 cases of congenital syphilis; and 1.6 million cases of chlamydia.

Resistant gonorrhea is also a concern. However, most circulating strains in the United States remain susceptible to ceftriaxone, the primary treatment for gonorrhea; only 0.1% of isolates displayed elevated ceftriaxone minimum inhibitory concentrations (MICs) in 2020. In 2020, 5.8% of isolates had elevated azithromycin MICs; the proportion was higher among MSM compared with men who have sex with women only (9.2% vs 4.3%).  Continued monitoring of susceptibility patterns to antibiotics is critical to inform gonorrhea treatment guidelines, the CDC said.

“In 2020, the COVID-19 pandemic dramatically disrupted life as we knew it, and while there were moments in 2020 when it felt like the world was standing still, sexually transmitted diseases were not,” said Jonathan Mermin, MD, MPH, the director of the CDC’s National Center for HIV, Viral Hepatitis, STD, and TB Prevention. “The unrelenting momentum of STDs continued, even as prevention and treatment services were disrupted. New data CDC data suggests STDs increased during the first year of the pandemic.”

The trend is looking like it continued into 2021, he added. “We already know some STDs continued to increase in 2021 as well,” and are expected to surpass the 2020 numbers.

Several factors likely contributed to the initial decline in reported STD cases during the first part of 2020, including:

  • reduced frequency of in-person healthcare services as routine visits decreased, resulting in less frequent STD screening;
  • diversion of public health staff from STD work to respond to the pandemic;
  • STD test and laboratory supply shortages;
  • lapses in health insurance coverage due to unemployment; and
  • telemedicine practices that led to some infections not being captured in national data.

Even a statistic that appears to be a silver lining—a decrease in chlamydia by 13%—is probably not good news, Dr. Mermin said, because it is likely underreported. 

Infections caused by Chlamydia trachomatis historically account for the largest proportion of reported STDs in the United States. The decline in reported chlamydia cases is likely due to decreased STD screening and underdiagnosis during the pandemic, rather than a reduction in new infections. This also contributed to an overall decrease in the number of reported STDs in 2020 (from 2.5 million reported cases in 2019 to 2.4 million in 2020).

Because chlamydial infection is often asymptomatic, it is often identified during in-person screening, such as during a PAP smear. “However, in 2020, clinics reduced routine screening due to disruptions from the COVID-19 pandemic, and many people deferred nonurgent issues to avoid visiting a healthcare center,” Dr. Mermin said.

Disparities and Inequities Seen

Although STDs are increasing across many groups, the 2020 STD data show that some racial and ethnic minority groups, men who have sex with men (MSM), and young people continue to experience higher rates of STDs. 
For instance, 43% of primary and secondary syphilis cases in 2020 occurred in MSM, and more than half of reported STDs occurred among those who are 15 to 24 years of age.

“The COVID-19 pandemic increased awareness of something we have long known about STDs—that long-standing social and economic factors, such as poverty and health insurance status, create barriers, increase health risks and often results in worse health outcomes,” said Leandro Mena, MD, MPH, the director of the CDC’s Division of STD Prevention. 

“Disproportional STD rates continue among many racial and ethnic minority groups,” he said, including Blacks, Hispanics, American Indians, Alaska Natives and Pacific Islanders, as well as MSM and young people.

“These data illustrate the factors such as lack of access to regular medical care and discrimination and stigma continue to stand in the way of quality sexual healthcare for everyone who needs it,” Dr. Mena said. “If we are to make lasting progress against STDs in this country, we have to understand the symptoms that create inequities and work with partners to change them.” 

Both physicians said STD prevention, treatment and surveillance must be prioritized to regain the lost ground against STDs, and there is plenty of work for everyone from community organizations and health systems to public health workers. 

“The COVID-19 pandemic strained our nation’s already crumbling public health infrastructure, and we will be working for some time to document the impact of these disruptions on our nation’s STI [sexually transmitted infection] epidemics, but we cannot wait for full understanding to act. STDs threaten the health of too many people in America, and our collective obligation is to change that,” Dr. Mermin said.

A new emphasis must be placed on field support for prevention and surveillance programs at the state and local levels, including the investigation, contact tracing, training, community engagement and partnerships with the private sector, according to Dr. Mena. 

It is also “critical to expand access to quality and stigma-free STD services. People need to receive care in places that are more accessible and go beyond traditional STD clinics, for example, retail pharmacy clinics, LGBTQ centers and outreach services, and substance use treatment programs,” Dr. Mena said. “These groups can play a critical role in promoting STD prevention and the local level and empower people to prioritize their sexual health.”