25 - Sexually Transmitted Diseases
Objectives | References
Sexually transmitted diseases (STDs) refer to the more than 25 infectious
organisms that are primarily transmitted through sexual activity. STDs
are one of many interrelated factors that affect the broad continuum of
reproductive health, agreed upon in 1994 by 180 nations at the International
Conference on Population and Development. STD prevention as an essential
primary care strategy is integral to improving reproductive health.
The proposed set of objectives for the year 2010 reflects the extensive
problem analysis and recommendations published in 1997 by the National
Academy of Sciences' Institute of Medicine (IOM) in a report entitled
The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Despite
the burden, costs, and preventable nature of STDs and their complications,
STDs remain an underrecognized health problem. The IOM report stated that
"STDs are hidden epidemics of tremendous health and economic consequences
in the United States. They are hidden from public view because many Americans
are reluctant to address sexual health issues in an open way and because
of the biological and social factors associated with these diseases."
The generally recognized symptomatic STDs that may cause only mild initial
illnesses are only part of a very large public health problem. These organisms
also cause many other harmful, often irreversible, and costly complications
such as reproductive health problems, fetal and perinatal health problems,
and cancer. In addition, studies of the HIV pandemic from all over the
world link other STDs to a causal chain of events in the sexual transmission
of HIV infection.
As West Virginia enters the new millennium, there is both good and bad
news to report with regard to STDs. Early syphilis was the initial STD
for which control measures were developed and tested in this country.
West Virginia has maintained a significant public health syphilis management
component since 1918. In the late 1940s, West Virginia reported one of
the highest early syphilis case rates in the nation. Since that period,
infectious syphilis case rates in this state have consistently been maintained
below the national average. The national Centers for Disease Control and
Prevention (CDC) recently initiated a five-year program to totally eliminate
early syphilis in the United States. The CDC currently defines syphilis
eradication as an area where there is less than 1 case per 100,000 population
of primary and secondary syphilis. West Virginia currently has an early
syphilis rate of 0.2 cases per 100,000 population, well below the national
definition. West Virginia's success with early syphilis has come about
because of excellent surveillance systems that have been in place for
many years, as well as dedicated field staff who have worked to contain
outbreak situations. The STD Program will continue to monitor syphilis
through physician and laboratory reporting, as well as continued cooperation
with the 55 county health departments that offer STD services to their
Gonorrhea continues to show a reduction in morbidity; however, there
have been fluctuations in rates in recent years. West Virginia initiated
the first statewide effort to control gonorrhea in 1972 in conjunction
with a nationwide undertaking by the federal government. The STD Program,
with the Family Planning Program, performed routine screening on all females
aged 15 through 45 who received a pelvic examination. The first full year
of screening yielded over 350,000 women nationwide who were positive for
gonorrhea; in 85% of the cases the woman was totally asymptomatic for
the disease. Screening still occurs today in STD clinics as well as some
family planning sites.
West Virginia's STD Program is attacking the chlamydia problem the same
way it did gonorrhea by cooperating with the Family Planning Program to
perform screening of asymptomatic females. West Virginia is a part of
federal Region III. The region consists of West Virginia, Virginia, Delaware,
Maryland, Pennsylvania, and Washington, D.C. with Baltimore and Philadelphia
as separate entities. These eight project areas have been conducting chlamydia
screening since 1994. Region III was the second region in the country,
behind Region X, to initiate chlamydia screening. Since then the remaining
eight regions have used our experiences to develop their screening initiatives
as part as a nationwide program. The entire activity came about as a result
of the Infertility Bill passed by Congress in 1991. For the first time
in history, money was allocated solely for the control of chlamydia, long
recognized as the most prevalent reported sexually transmitted disease.
Surveillance data show high rates of STDs for some racial or ethnic
groups (mainly African American and Hispanic populations) compared with
rates for whites. Race and ethnicity in the United States are risk markers
that correlate with other more fundamental determinants of health status
such as poverty, access to quality health care, health care-seeking behavior,
illicit drug use, and living in communities with a high prevalence of
STDs. West Virginia currently follows this national trend; African Americans
have gonorrhea rates 293 times higher than whites and chlamydia rates
100 times those of whites.
A major challenge for STD programs in West Virginia and the U.S. in
the 21st century will be confronting viral infections, most notably Herpes
Simplex and Human Papillomavirus, which causes genital warts and has a
direct link to possible cancers in both women and men. More calls are
received on the state STD hotline concerning viral infections than any
other disease. These infections, which cause lesions, increase a person's
chances of acquiring HIV by fivefold. CDC has targeted the viral infections
as the next major goal nationally after the syphilis elimination project
The STD Program continues to work with the State Department of Education
to ensure the implementation of instructional goals and objectives as
mandated by that department concerning STD/HIV. Likewise, the program
is working with the three medical schools in the state to offer assistance
with curriculum and/or instruction around STDs, as well as an overview
of the goals and objectives of public health as it relates to the physician's
responsibility to report certain diseases so that proper epidemiology
may be performed. As public health continues to build relationships with
managed care, the STD Program will encourage physicians to recognize a
consistent quality of care when diagnosing and treating sexually transmitted
diseases by calling on the program and its links to the CDC for consultation.
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OBJECTIVE 25.1. Reduce the incidence of chlamydia trachomatis infections
in West Virginia to 65 cases per 100,000 population. (Baseline:
134.1 cases per 100,000 in 1998)
Data Source: West Virginia Bureau for Public Health (WVBPH),
Office of Epidemiology and Health Promotion (OEHP), Division of Surveillance
and Disease Control (DSDC), STD/MIS state data
In 1998, African Americans reported a rate of chlamydia trachomatis
that was nearly 100 times higher than that among whites (8,206.8 cases
per 100,000 population vs. 87.2 cases).
OBJECTIVE 25.2. Reduce the incidence of gonorrhea infections in
West Virginia to 15 cases per 100,000 population. (Baseline: 50.2
cases per 100,000 in 1998)
Data Source: WVBPH, OEHP, DSDC, STD/MIS state data
In 1998, African Americans reported a rate of gonorrhea that was 293
times higher than that reported by whites (6,661.3 cases per 100,000 vs.
22.7 cases). The STD Program has long been aware of the disparity in case
rates among black and white populations. Since the HIV epidemic was recognized
in the mid-1980s, increased education at all levels has taken place to
emphasize safe sex prevention messages, not only for HIV exposure but
the traditional sexually transmitted diseases as well. As expected, a
drop in rates was seen for a time, only to begin rising again at a steady
increase. One constant has remained, however. The black population has
continued to have infection rates much higher than whites with regard
to gonorrhea and chlamydia. Although the black population only makes up
3% of the state population, their infection rates are 100 to nearly 300
times those of whites depending on the disease. The STD Program has been
in contact with the State Minority Health Program for assistance in developing
strategies to address the problem through community education and involvement.
OBJECTIVE 25.3. (Developmental) Reduce the prevalence of Herpes
Simplex Virus Type 2 (HSV-2) infection among persons 20-29 years old
seen in outpatient departments in 10 major hospitals in West Virginia,
which will become sentinel sites.
Data Source: Data on ICD-9 Herpes codes 054.9, 054.10,
054.11, 054.12, 054.13, 054.19 will be obtained from the West Virginia
Health Care Authority.
OBJECTIVE 25.4. (Developmental) Reduce the prevalence of Human Papillomavirus
(HPV) among persons 15-45 years old seen in outpatient departments in
10 major hospitals in West Virginia, which will become sentinel sites.
Data Source: Data on ICD-9 Human Papillomavirus code
079.4 will be obtained from the West Virginia Health Care Authority.
The viruses that cause HSV and HPV are not curable. Although outbreaks
can be topically treated, they eventually will run their course, although
the virus remains in the body. In most cases, recurrences will manifest
themselves. Much is still to be learned about these diseases, and the
CDC has targeted the viral infections for increased research and hopefully
a cure in the future. Until that time, the state will intensify sentinel
reporting to better understand the scope of the problem. These infections
are generally recognized as the most prevalent yet underreported diseases
in the sexually active community. Safe sex messages and counseling are
still the best defense to avoid or learn to live with these infections
until a cure is realized.
OBJECTIVE 25.5. Reduce to 7% the incidence of HIV infection that
is attributed to heterosexual contact. (Baseline: 15% of new HIV
reports in 1998)
Data Source: HIV/AIDS Reporting System (HARS), CDC, Division
of HIV/STD/TB Prevention
Public health is now well into the second decade of the war on HIV/AIDS.
While the first wave of infection affected the homosexual community and
IV drug users who shared needles, the second wave is affecting women,
young people, and, still, IV drug users. While there has been much success
in the development of drugs to fight the symptoms of HIV infection, there
still is no cure. Nonetheless, a false sense of security has permeated
the sexually active community, which believes there is in fact a cure
for this infection. As a result, some people are becoming careless with
the practice of safe sex, both in the homosexual as well as the heterosexual
community. The STD Program will continue to educate and reinforce the
message that HIV is still a life-threatening illness, and that all available
precautions should continue to be practiced.
OBJECTIVE 25.6. (Developmental) Develop contractual arrangements
with medical schools and private providers (e.g., managed care organizations)
to offer public health services to STD patients in 50% of the counties,
25.6a. Provider referral method used on STD contacts;
25.6b. Reimbursement to private providers for counseling around STDs
and reproductive health;
25.6c. Initial discussion on HIV/STD at first visit with females for
As public health and managed care organizations (MCOs) continue to partner,
it is essential that both understand each other's missions and goals.
It is critical that STD patients be counseled about their infection and
the importance of referring their sexual contacts for evaluation. The
STD Program will explore the possibilities of educating medical students
as well as MCOs about the benefits of contact tracing and the entire epidemiologic
OBJECTIVE 25.7. Increase to 75% the number of county health departments
with at least one clinician who has attended formal training at an STD/HIV
Prevention Training Center in either Baltimore or Cincinnati. (Baseline:
25% of county health departments in 1999)
Data Source: WVBPH, OEHP, DSDC, STD Program
It is critical that clinicians/nurses continue to be properly trained
in the diagnostics and treatment issues surrounding sexually transmitted
diseases. The STD Program arranges to send personnel from county health
departments for training, and updates when necessary, to ensure that they
are current with the many issues surrounding these sometimes complex diseases.
OBJECTIVE 25.8. Ensure the implementation of instructional goals and
objectives as mandated by the State Department of Education concerning
Health education became required by state legislation enacted in 1988
to include age-appropriate HIV/AIDS and sexually transmitted disease education
for grades 6 through 12. The Department of Education has prepared a model
HIV/AIDS health education curricula for grades K through 12. Individual
school systems may utilize the prepared model or submit a model to the
Department of Education for approval. The Department of Education's focus
with HIV/AIDS education as well as the other sexually transmitted diseases
is to move to a more comprehensive health education program addressing
a preventative approach.
Meeting the Objectives
Health Promotion Channels for Achieving Objectives:
- Public Health Programs
- Health Care System
- Higher Education
The Director of the Division of Surveillance and Disease Control, which
houses the West Virginia STD Program, will be the contact person for policies
and procedures in addressing these objectives. In order to meet the objectives
and confine the annual incidence of sexually transmitted diseases by the
year 2010, the following strategies will be continued, using the health
promotion channels listed above:
- Support clinical services for detecting the existence of STDs.
- Sustain a statewide comprehensive surveillance system for STDs.
- Assure laboratory STD reporting, compliance, and testing follow-up.
- Maintain a confidential registry of STD cases.
- Observe trends in STD occurrences.
- Increase public awareness about the risks, symptoms, and treatment
- Implement strong early STD case intervention.
- Provide partner notification services.
- Supply appropriate medical treatment to local health departments.
- Encourage all health care providers to use CDC-recommended treatment
therapies for all diagnosed and suspected patients and their sexual
- Serve as an educational/ technical resource to the medical community
and the general public.
- Operate a statewide STD hotline.
- Collaborate with health and social service agencies in providing
educational materials and condoms to those at risk for STDs.
- Increase educational efforts to reach adolescents, young adults,
and African Americans.
- Maintain a resource base of free educational materials.
Work Group Members
Greg Moore, Work Group Leader, Supervisor of Field Operations,
West Virginia STD Program, WVBPH
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Billy Wayne Bailey, West Virginia State Senator, Ninth District,
Ronald Bryant (Retired), Former Director of the STD/AIDS Program,
Cathy Davis, RN, NP, Nurse Practitioner, Valley Health Systems,
Travis Hansbarger, MD, Medical Resident, Marshall University Family
Monica Hatfield, Representing the Faith Community, Charleston,
Catherine Hayes, DO, Osteopathic Physician practicing in Wheeling,
Shelley Humphreys, RN, NP, Nurse Practitioner/Clinic Nurse, Kanawha-Charleston
Brenda C. Issac, RN, BSN, MA, Lead School Nurse, Kanawha County
Robert Johnson, Director, WV STD Program, WVBPH
Pamela Minimah, Chair, West Virginia Coalition for Minority Health
Katie Shreve, Student, Marshall University, Huntington, WV
Kelly Shreve, Public Health Disease Investigator II, Representing
West Virginia STD Program Field Staff
Savolia Spottswood, MS, Director, Minority Health Program, WVBPH
Institute of Medicine, Committee on Prevention and Control of Sexually
Transmitted Diseases. The Hidden Epidemic: Confronting Sexually Transmitted
Diseases. Ed. by Thomas R. Eng and William T. Butler. Washington,
DC: National Academy of Sciences, 1997.
U.S. Department of Health and Human Services. Healthy People 2010
(Conference Edition, in Two Volumes). Washington, DC: January 2000.
For More Information
West Virginia STD Program
Office of Epidemiology
and Health Promotion
350 Capitol Street, Room 125
Charleston, WV 25301-3715
Phone: (304) 558-2950; Fax: (304) 558-6335