This chapter reviews current strategies in the US for the control of sexually transmitted diseases (STDs) and outlines recommendations for future strategies. At present, STD control strategies are influenced by 4 basic factors: the health care system, the different levels of government, the response of medical schools, and varying media attention. The 3 tiers of government in the US have different responsibilities for STD control, necessitating a partnership at the federal, state, and local levels. In particular, state and local health officials need to cooperate to ensure an integrated STD program. Medical schools are de-emphasizing instruction in venereology, meaning that many physicians enter practice without adequated knowledge of STD diagnosis and treatment. Overall, the STD intervention program in the US is comprised of the following components: health education and promotion, disease detection, appropriate treatment, partner tracing and patient counseling, clinical services, training, and research. There is a need for epidemiologic investigations to continually estimate the population at risk, broaden the surveillance of unreported STD, re-examine program activities for more cost-effective approaches, determine key patient behaviors such as compliance with prevention, and use cost-benefit and decision analysis models for program evaluation. The US Surgeon General has designated STD as 1 of 15 priority areas for national prevention and control efforts. Target objectives for 1990 include reductions in the rates of gonorrhea (to 280/100,000), gonococcal pelvic inflammatory disease (to 60/100,000), and primary and secondary syphilis (to 7/100,000). Other 1990 objectives are the neonatal herpes rate, the nongonococcal urethritis rate, the percentage of couples using condom or barrier methods, the percentage of high school students receiving adequate STD education, and the percentage of providers able to diagnose and treat STDs. The long-term effects of sexually transmitted diseases (STD) are far worse for women than men, yet their diagnosis and treatment are not given the kind of prestige or importance in the medical-education setting that they deserve. For example, most prevention programs are directed at men, even though they are not as likely to suffer from cancer, destruction of reproduction organs or complications of pregnancy, including the threat to the unborn, resulting from an STD. It is because men are so much less effected by STD that the author claims their importance is also devalued. Other results of STD are sociological and psychological and again the effects are much more damaging for women than for men. The result of ignoring the suffering of women as a result of STD can be seen in many aspects of the medical setting. For instance, the symptoms of STD for women are often poorly defined or very similar to other diseases. The article goes into great detail about the unique effects to women from neisseria gonorrhoea, chlamydia, herpes simplex, trichomonas vaginalis, and condylomta acuminatum. In every case, if left undiagnosed or even worse, misdiagnosed, the complications are far worse for women than for men. The symbolic importance of STD are covered providing support for the differential sociological effect of STD on women. Suggestion to the health care profession about the effects of this differential treatment on patients and their treatment as well as on medical education are also addressed. This paper reviews specific types of sexually tranmitted diseases (STDs) control laws--reporting; screening, contact tracing, and treatment--in the context of a community's social and economic situation. It is noted that reporting laws can serve statistical goals or more direct objectives of disease control, and legislation should reflect this distinction. Whenever there is a choice, legislation should enable authorities to offer positive services. Law is an effective device in the control of STDs to the extent that it is part of a comprehensive prevention, diagnosis, treatment, and management strategy. Based on these considerations, a basic plan for the legal control of STDs is outlined. In Phase 1, enabling legislation stating the basic purposes, authority and limitations of public health efforts to control STDs should be enacted, and epidemiologic studies aimed at determining the incidence and prevalence of STDs in each sector of the population should be authorized. Phase II includes the establishment of public clinics, STD specialists, physician extender programs, and appropriate licensing legislation. Reporting of STDs by all professionals and paraprofessionals diagnosing or treating STDs should be required, with a particular emphasis on the reporting of STDs in children. This phase should also authorize contact tracing and health hold orders based on reasonable epidemiologic suspicion of STD exposure. In Phase III, phsicial examinations on an involuntary basis for confined cases should be authorized, as should screening of epidemiologically documented high-risk groups. Finally, if prevalence statistics indicate a need, large-scale screening to issuance of identity cards should be considered. In the US, an estimated 2 million cases of gonorrhea occur a year. There was 72.799 cases of syphilis in 1981, Chlamydia trachomatous is widespread, genital herpes affects 500,000 to 1 million people per year, and pelvic inflammatory disease (PID) afflicts more than 850,000 women annually, which makes it among the most frequent sexually transmitted diseases (STDs). The victims of hepatitis A and hepatitis B are usually homosexual men. Treatment is available for most of these diseases, although it can be expensive. Health promotion targeted at teenagers and cultural groups can be effective, since premarital sex rose from 30% of women aged 15-19 in 1971 to 50% by 1979. Counseling on STDs is vital, but moral and social prophylaxis has also brought results in China as it did during World War II in the US. The condom or other barrier methods failed to protect 9% of women among 52,000 STD clinic attenders during 1977 and 1980, while 21% of nonusers were infected with gonorrhea. Spermicides, antiseptics, and antibiotic solutions also proved effective against infections. Systemic prophylaxis including arsenicals, bismuth, sulfathiazole, benzathine penicillin G, oral doxycycline, and broad spectrum antibiotics have been used as treatment for syphilis and gonorrhea. IUDs have been implicated in PID. The hepatitis B vaccine proved potent, but the gonococcal vaccine failed. Vaccines for group B streptococcal infections, genital herpes, and cytomegalovirus (CMV) are under study. STDs can cause disease, disability, and death to the fetus, thus careful history taking and aggressive use of caesareans is advised in women with STDs. Screening contact tracing, and mass treatment can allow early detection and elimination of STDs. Infectious syphilis among prostitutes and farm workers decreased by 51.3 and 26.8%, respectively, in California in the early 1970s as a result of mass treatment. Vaccines and rapid diagnostic tests can bring STDs under control and eventually eliminate them. This review considers all prominent infections associated with pregnancy, delivery, and the postpartum, explores theories of modes of infection of various tissues involved and organisms responsible, and ends with a section on each of the usual sexually transmitted diseases (STDs) in pregnancy in terms of epidemiology, clinical findings, pathogenesis, diagnosis, transmission, management and treatment for each. In pregnancy the woman's immune system is suppressed, and her anatomical relationships change so as to alter susceptibility to infections: disease-host relationships respond in a species specific manner detailed here. Generally young primiparas have more serious disease because of primary infection. Fetal and intrauterine infections, such as chorioamnionitis, may involve syphilis, cytomegalovirus and herpes as well as Group B strep, enteric and anaerobic organisms or polyinfections, are an important risk factor for prematurity miscarriage, and prolonged rupture of membranes. Possibly bacterial products activate the prostaglandin pathway initiating preterm labor. Postpartum endometritis and sepsis may also be caused by typical STD organisms, as well as vaginal, enteric or nosocomial organisms. Chlamydia is an unappreciated cause of puerperal infections. Systemic gonorrhea should be treated prophylactically in neonates at risk. Group B streptococcus should be considered a STD in this context. Several genital mycoplasmas are responsible for puerperal fever; several vaginal anaerobes are probably associated with neonatal sepsis. Cytomegalovirus is the most common cause of congenital viral infection of the fetus and the greatest infectious cause of mental retardation, yet is usually asymptomatic in both mothers and neonates. Obstetric complications of prenatal STD infection is a field needing intense research. This document contains a rationale and plan for managing sexually transmitted diseases (STDs) in basic health services of developing countries. Such services typically offer care to 80-90% of the population in the rural areas through staffs of paramedical and auxiliary workers. Although STDs are receiving higher priority than previously, control programs for them must be practical and economical considering the meager resources available for all types of health care. STDs in developing countries differ from their counterparts in developed countries in being more frequent, more likely to involve genital ulcers, and more likely to lead to complications, which may be severe. A realistic aim of STD control programs is to reduce the incidence of complications, such as pelvic inflammatory disease (PID), urethral stricture, sterility, opthalmia, neonatorum, and congenital syphilis. The 1st steps in such a program should be good management of patients and their contacts, case-finding for syphilis in antenatals, screening and case-finding for gonorrhea in high risk groups, and systematic prophylaxis for opthalmia neonatorum. A realistic approach for basic health services is a problem oriented one following flow charts. The management of urethral discharge, vaginal discharge, PID, and genital ulcers following such principles is described, including general considerations for each type of condition, suggested and alternative strategies, local background information needed to tailor a progam and treatment protocol, and suggestions for health centers with and without laboratory facilities. Examples of procedures, incidence of diseases within the caseload, and results from some STD control programs in basic health services of developing countries are provided. The etiology, differential diagnosis, and treatment of female infertility are discussed. Emphasis is given to the role of sexually transmitted diseases (STD), specifically those caused by gonococci, chlamydia, and mycoplasmas, in infertility. The effects of STD on 5 sites--vagina, cervix, endometrium, tubal and peritubal area, and ovary--are delineated. STD play an especially important role in the development of acute tubal and peritubal disease and subsequent infertility. The primary acute infection is believed to be a mucosal or epithelial process, spreading from the cervix to endometrium and then to the endosalpinx. About 50% of couples with tubal infertility have no previous history of pelvic inflammatory disease (PID). However, significant and permanent tubal disease is suspected to result from subclinical salpingitis. IUDs may contribute to this form of salpingitis. Genital mycoplasmas are thought to play a minor role in tubal infertility relative to gonococcal or chlamydial infections. Later age at marriage and delayed childbearing make it likely that the peak incidence of recognized infertility in women will be delayed beyond the peak incidence of STD. The differentiation of tubal infertility from infertility of other causes is complicated by infertility's multifactorial etiology. Determination of whether tubal or peritubal disease was caused by a STD or other organisms or is the result of an infection secondary to an IUD is considered to be of little value in determining an individual patient's prognosis after treatment. The major clinical classifications of infertility are outlined, and the diagnostic procedures and usual etiologies and therapies for each are presented. Ovulatory factors are assumed to account for 20-30% of infertility, male factors for 30-40%, cervical factors for 5-15%, and tubal factors for another 15%.
Includes bibliographical references and index.