Sexually transmitted diseases

de King K. Holmes, P. Frederick Sparling, Per-Anders Mardh, Stanley M. Lemon, Walter E. Stamm, Peter Piot, Judith N. Wasserheit

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 a