New STI Surveillance Report – It’s Not Good
In late 2021, ProPublica profiled the efforts of a local public health worker, Mai Yang, Mai Yang, as she sought to track down a pregnant client recently screened for syphilis Yang was urgent in the need to find this client and get her curative treatment, three uncomfortable injections of penicillin, completed at least 30 days before giving birth. Congenital syphilis is a killer with a near 40% chance of a newborn dying or being stillborn. Beyond death, congenital syphilis risks a range of difficulties, from disabling deformities to cognitive dysfunction. COVID-19 impacts were readily felt throughout the story as Yang’s client, Angelica, struggled with housing, a language barrier required an interpreter, and, eventually, the clinic Yang sought to link Angelica to was not able to accommodate a walk-in appointment, despite Yang having gotten assurances they could.
Last week, the Centers for Disease Control and Prevention (CDC) released its annual sexually transmitted infection (STI) surveillance report for the year 2021, and the news, while not surprising in retrospect, is not good. Both syphilis and congenital syphilis cases rose about 32%, compared to 2020. 2020, on its own saw a moderate rise in both syphilis and congenital syphilis. However, the CDC notes 2020 as the most affected year in STI surveillance with a marked decreases in screening activities in much of 2020 and higher than previous baseline diagnoses throughout much 2021 (mostly around the 150% level but a massive spike well above 200% around November 2021 – or about the time of ProPublica’s report being published).
Gonorrhea and chlamydia cases rose, though not as dramatically. Herpes, despite being a prevalent STI, is not a reportable illness and thus not tracked in the annual report.
This marks the eight consecutive year of increasing STI diagnosis, as noted by the National Coalition of STD Directors and Association of State and Territorial Health Officials. The situation is dire, going forward. Public health offices across the country are expecting to see an exodus of staff in the next 5 years. Between low pay and poor benefits relative to the private sector and displeasure with supervisors (which may be attributed to a lack of flexibility befitting the modern world or political pressures exerted at the appointment level), young and even well-established professionals are planning on leaving this space. And none of that necessarily reflects struggles with private partners or contracted clinics, which are equally struggling with securing funding and meeting ever increasing demands to do more with less.
In the ProPublica article, former CDC Director Dr. Tom Frieden reflected on how the United States has a terrible tendency to go through “a deadly cycle of panic and neglect”. And the same might be considered here. When President Biden announced in May of 2021 that his administration would be working to secure funding for “tens of thousands” of jobs to respond to COVID-19 and support local public health officials, there was an implication those dollars (secured in the American rescue Plan) would also fund positions that had been left to atrophy or were usurped by COVID-19 activities – most notably, disease intervention specialists. But COVID-19 is winding down, in so far as the Biden Administration seems prepared to invest much in the way of workforce dollars, and that promise made in 2021, was supposed to extend through 2026. If comments from federal legislators last year were any indication, there’s not much hope yet in this Congress choosing to ensure funding is secured to help these programs meet their goals.
In a recent interview, U.S Food and Drug Administration (FDA) Commissioner Dr. Robert Califf said “misinformation” was a leading cause of a decline United States life expectancy. And while that may one element of the issue, an abject failure to appropriately fund, stay competitive with the private market, and retain the talent needed to execute public health programs is core and central to this issue. The latest STI surveillance report shows us this plainly. Technology can only do so much in terms of outreach and extending capacity – in order to meet the demands of public health, the human element must be sufficiently supported.
Advocates would do well to take the long-view of their work. It is critically necessary to support existing public health programming and to address disparities being laid bare by annual surveillance data in order to reach an equitable health dynamic in this country – health justice. We cannot get there without supporting public health entities, shielding them from the politicalization of their mission work, and ensuring they’re appropriately appreciated for the life-saving work they do. We cannot represent patients when we don’t know who they are. We must participate with our partners in elevating the STI crisis for what it is – a public health emergency.
Deceptive Masks: COVID’s Threat to STI Surveillance
In April, the Centers for Disease Control and Prevention (CDC) released its annual sexually transmitted infections (STIs) surveillance report, reflecting an increase in overall rates for the sixth year in a row, with a nearly 30% increase in STIs from 2015 to 2019. While sharpest increases in incidences were of syphilis among newborns, the infection burden is not equal with young (ages 15-24) people, gay and bisexual men, and people of color facing exceedingly disproportionate diagnoses. What’s important to note is traditional CDC surveillance reports lag by about two years – these data do not account for COVID-19 impacts among screening and treatment of STIs.
In the report’s press release, the CDC acknowledged COVID-19 posed extreme threats to screening, treatment, and prevention, as public health programs and staff typically used to address STIs had largely been repurposed in response to COVID-19, citing a survey from January showing about one third of local and state health department STI staff were still deployed to COVID-19 activities. Shortages also include screening supplies, according to a September 2020 “Dear Colleague Letter” with regular updates posted on the agency’s drug and diagnostic test notices page showing marginal improvement as reported by testing kit and supplies manufacturers.
The aforementioned survey of local and state health departments was conducted by the National Coalition of STD Directors (NCSDDC), “a national public health membership organization representing health department STD directors, their support staff, and community-based partners”. While NCSDDC usually throws most of its resources into advocating for public health policy changes, funding, and offering technical assistance, throughout the COVID-19 public health emergency, NCSDDC has found itself in the unique position of reporting on the situational needs of health departments and their staff, tasked with meeting a multitude of needs in any given community. The organization summarized its Phase III survey results as follows:
“This continued diversion of staff and other resources has caused delays in providing disease intervention services, leaving some STDs completely unchecked. STD programs continue to report clinic closures, reduced clinic hours and services, STD testing kit shortages, and diminished laboratory capacity. Additionally, STD programs report severe burnout as disease intervention specialists (DIS) pivot from COVID-19 investigations and contact tracing back to STD disease intervention and partner services work.”
For context, NCSDDC, in March of 2020, initially phrased the state of local and state health departments responding to COVID-19 as a “starved public health system in distress”. An indication that despite pledges from the White House and billions in funding allocated by law makers, “on the ground” not much has yet changed for the first responders of public health.
Complicating matters, some health officials are debating the implications of initial surveillance reports for 2020 seemingly showing certain decreases in STI diagnoses, according to one news report, as either a reduction in sexual activity among at risk persons during stay at home orders or a lack of screening. Given the context of reduced capacity, staffing, and supplies, entertaining the possibility of decreased sexual activity rather than decreased access to services shifts the responsibility (and pressure) on state lawmakers and executive offices to appropriately fund and support public health programs to that of undersupported health departments, contracted service providers, their staff, and the vulnerable communities they serve.
As discussed in HEAL blog posts from earlier this year, COVID-19’s impact on public health activities is still being discovered, largely through emerging surveillance gaps (lack of screening) and, as the CDC’s STI report shows, at a lag of data rather than a decrease of incidence, leaving communities vulnerable to outbreaks.
Later this month, on June 30th, NCSDDC will be joining Community Access National Network and Community Education Group for a virtual Community Roundtable on COVID-19’s impacts on HIV, HCV, STIs, and substance use disorder, providing stakeholders and advocates a space to further explore where public health efforts have been strained and can be strengthened in light of COVID-19.