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R E P O R T T O T H EC O M M U N I T Y 2 0 0 1 PART III: SEXUALLY TRANSMITTED DISEASES, HEPATITIS, & TUBERCULOSIS This report on sexually transmitted disease is the third in a three- from nuisance colds and respiratory infections from which people part series of reports on communicable disease in Kent County. typically recover quickly, to severe sicknesses resulting in multiple The purpose of these reports is to provide an overview and under- organ failure and almost certain death. Monitoring, controlling, standing of communicable disease generally, and also to chronicle and, where possible, preventing communicable diseases are de- current surveillance of communicable diseases and their impact finitive activities of public health departments, and towards those on the Kent County community. More importantly, these communi- ends these reports have been produced.
cable disease reports should serve as springboard to stimulate discussion among professionals, community members, and others Because any discussion of ‘communicable disease’ encompasses a who may work to reduce and prevent communicable diseases in wide range of illnesses, modes of transmission, and methods of prevention, this report has been developed in three parts. Part I examines gastrointestinal and diarrheal diseases general y asso- Communicable diseases are illnesses that are contagious — in- ciated with food or waterborne disease organisms, while Part I fections that are transmitted directly from a person or animal to explores vaccine-preventable diseases – communicable diseases another, or passed indirectly through contaminated food or water. for which there are existing vaccines – and their incidence and They can be caused by a variety of agents — bacteria, viruses, prevalence in the community. This final section, Part III, examines and other organisms — and can be transmitted a variety of ways: sexually transmitted diseases including AIDS and HIV, as well as physical contact with the body or blood of an infected person or hepatitis and tuberculosis in the community. Some final thoughts animal; through air, food, or water; and through sexual activity. on communicable disease, as well as a bibliography of selected Communicable diseases also cause a wide range of illnesses — references and web resources, appear at the end of this report.
Sexually transmitted diseases (STD’s) – also known as sexually trans- didly as necessary to give those most at risk (i.e., teens) a realistic mitted infections (STI’s) — are some of the most commonly re- understanding of STD’s, their consequences, and how to protect ported notifiable diseases in the U.S. The U.S. Centers for Disease themselves and others. While abstinence continues to be the only Control and Prevention (CDC) reports that more than 25 STD’s affect 100% effective method of preventing sexually transmitted diseases, approximately 15 million men and women in the U.S. each year.
Kent County data – included in this report – shows that teens and Chlamydia, gonorrhea, AIDS, syphilis, and STD’s. Reversing this trend will require the hepatitis B were all among the top ten most participation and collaboration of many in the community -- including parents, schools, service agencies -- to provide effective and medical care, received appropriate diagnos- tic testing, and whose test results were prop- erly reported to the public health system.
In other words, these counts very likely rep- grounds and economic levels, and are most resent only a portion of the people affected Because of the social stigma associated with reports that the direct and indirect costs of STD’s, as well as with some sexual behav- the most common STD’s (not including HIV iors associated with their transmission, STD infection) and their complications are esti- prevention is often not addressed as can- mated to be at least $10 billion annually.
Epidemiology of Sexually Transmitted DiseasesLike many adverse health conditions, sexually transmitted diseases Gonorrhea and Chlamydia Rates, Kent, disproportionately affect minority populations. Although some STD’s Muskegon, and Genesee Counties, and — chlamydia, human papilloma virus (HPV), and herpes — are Michigan, 1995-1999 widespread across all racial groups, higher rates of STD’s tend to be reported among African Americans than white Americans. While Afri- can Americans tend to be more likely to seek care in public clinics that report STD’s more completely and consistently than many pri- vate providers, there are a number of other factors that may contrib- ute to higher rates of STD’s among African Americans and other Underlying social and economic factors (such as language or cultural barriers, higher rates of poverty, limited access to health care, sub- stance abuse) may increase the risk for infection in some communi- ties. Studies have shown that higher rates of gonorrhea are reported Primary and Secondary Syphilis and Hepatitis B lation distribution. Kent, Muskegon, and Genesee Counties all have a Rates, Kent, Muskegon, and Genesee Counties, proactive public health agency presence. Disease rates that are higher in these counties than the state as a whole may be a result of larger populations at risk, greater availability of screening programs, and Interestingly, all three communities report higher rates of chlamydia and gonorrhea than the state overall, while the syphilis case rates are essentially the same for each of the counties and the state (all of these counties are included in the National Syphilis Elimination Pro- gram, which may account for the consistently low rates of syphilis).
An increase in hepatitis B in Genesee County is thought to be related to reporting criteria being used there, rather than an actual increase in the incidence of hepatitis B infection. (Reporting criteria for hepa- titis B need to be consistently defined to identify target areas and at- in neighborhoods with deteriorated physical conditions. More re- search is needed to explore the link between social factors and dis- Sexually transmitted diseases, and all communicable ease, and to refine and target prevention efforts accordingly.
diseases, must be continually monitored to:• provide early identification and prevention of disease One method of assessing the impact of disease in our area is to compare Kent County disease rates to those found in counties that • describe the types of people at risk of disease; are nearby geographically, or are of similar size and socioeconomic • identify the causative agent of disease; population distribution. (Kent County disease rates are also com- • develop properly targeted prevention messages; and pared to disease rates for the State of Michigan as a whole.) For the • evaluate the success and cost-effectiveness of intervention purposes of this report, Muskegon County was chosen for geographic comparison, and Genesee County as a community with similar popu- PART III: SEXUALLY TRANSMITTED DISEASES, HEPATITIS, & TUBERCULOSIS Sexually Transmitted Disease Surveillance and PreventionSexually transmitted diseases can be difficult to identify and treat munity groups, schools, and at-risk audiences (e.g., teens in sub- effectively. Because of this, access to screening services, health care, stance abuse treatment programs). The Healthy Kent 2010 Sexually and prevention education, for both men and women, is critical. In Transmitted Infection Implementation Team promotes STD preven- Kent County, STD prevention programs are developed to serve the tion in the community focusing on teens and minority populations.
community as a whole while also focusing on critical target popula- tions -- those populations where most sexually transmitted disease STD surveillance in the community, but especially among at-risk popu- transmission has been identified. Ongoing surveillance allows public lations, is also an essential component of STD prevention. The Peri- health agencies to gauge the effectiveness of STD prevention efforts natal Hepatitis B Prevention Program, for example, is a state pro- and modify programs as necessary to reach target populations.
gram developed to reduce the transmission of HBV from infected mothers to newborns during delivery, and to protect household and Comprehensive STD prevention efforts must combine clinical screen- sexual contacts of those women. Programs such as this in the com- ing and prevention services with community-wide and individual edu- munity are critical to meeting the needs of those most in need of cation. The Kent County Health Department provides a variety of health care, education, and medical services.
prevention services to help individuals assess and lower their risks for STD’s. The Health Department’s Sexually Transmitted Disease The overview of sexually transmitted diseases on the following pages Clinic provides anonymous and confidential testing for HIV and other provides a compelling picture of STD’s and their effects in Kent County sexually transmitted diseases, as well as pre- and post-test counsel- and in Michigan. When reviewing these data, it should be noted that ing, risk assessment, and risk reduction education, for clients age 13 reported rates are calculated using 1990 census data. While these and over who come into the clinic. Clinic staff also assist with partner data are used to allow accurate comparisons to state rates, they are notification to reduce disease transmission in the community, and also known to have undercounted Hispanic and Asian/Pacific Islander provide linkages for infected individuals to appropriate case manage- populations. Consequently, reported rates of STD’s among Hispanics Education – both in the community at-large and targeting specific While Hispanics and other minority populations continue to bear a at-risk groups – is also critical to STD prevention. The HIV/AIDS disproportionate share of STD’s, prevention and treatment is crucial Education, Monitoring and Prevention for Women at Risk (EMPoWeR) for all populations and must be a priority for the Kent County commu- program is a prevention and early intervention program which pro- nity. The Health Department, community agencies, and citizens must vides information, education, and risk reduction for at-risk women of continue to collaborate to ensure that STD prevention, education, color. The Health Department’s Health Education Section also pro- and treatment services are universally available, cultural y relevant, vides community education programs on HIV/AIDS and STD’s to com- and readily accessible.
Overview of Sexually Transmitted Diseases AIDS/HIV (Acquired Immunodeficiency Syndrome, Human Immunodeficiency Virus) Epidemiology:
Reports of AIDS have been collected as early as 1981, however,
uniform standards for AIDS reporting were not in place until 1983.
An HIV diagnosis was not officially reportable until 1989. Between Transmission:
1983 and 1999, 538 Kent County residents have been diagnosed with AIDS, and it is estimated that 630 Kent County residents, includ- piercing instruments) or bodily fluids (i.e., ing those not yet diagnosed, are infected with HIV (500 male and through sexual contact or breast milk) of an 130 female). This translates into a rate of 126 HIV-infected persons per 100,000 population, slightly lower than the Michigan rate of child at birth; rarely in the U.S. through In general, the HIV prevalence in each age category is higher state- Symptoms:
wide than in Kent County, with the exceptions of the 20-24 year old and 30-34 year old age groups. Consistent with statewide data, the may include cough, tiredness, night sweats, highest HIV prevalence is in the 30-34 year old age group. Estimates of the number of persons living with HIV in Kent county indicate that individuals as young as 13 years of age have acquired HIV. During the past five years, the incidence of HIV (the number of new HIV infec- Possible
tions) has averaged about 40 cases per year. Although the three- Complications:
year averages shown on the next page appear to reflect a downward trend, data from both 1997 and 1998 individually, indicate an in- infections” (frequently thrush and other crease in the number of reported HIV infections in Kent County.
Statewide data, which provide a better reflection of the true trend in the epidemic, shows that there has been no change in the number of HIV infections reported in the past five years (approximately 1,100 when immune suppression has progressed.
The impact of the HIV/AIDS epidemic on minorities has been dispro- Treatment:
portionate when compared to whites. In Kent County, Hispanics have the highest AIDS case rate (545 per 100,000 population), and the treatment of “opportunistic infections”; treatment of newborns of infected women.
Sexual abstinence; safer sexual practices, and confidential HIV testing and counseling; universal precautions (i.e., using personal protective equipment when handling blood, contaminated needles, or instruments).
PART III: SEXUALLY TRANSMITTED DISEASES, HEPATITIS, & TUBERCULOSIS Overview of Sexually Transmitted Diseases third highest estimated number (80) of HIV/AIDS cases. Black males mission, are men who have sex with men (MSM), including 5% who have the second highest rate (397 per 100,000) and the second also injected drugs (IDU). This is somewhat higher than the state- highest estimated number (160) of HIV/AIDS cases. These are fol- wide percentage of 51% MSM. Of other cases with a known mode of lowed by whites who, although they account for the majority of the transmission, 18% report high-risk heterosexual sex behaviors (HRH) estimated number of HIV/AIDS cases (380), have only the third -- sexual contact with partners who are 1) injecting drug users, 2) highest case rate (80 per 100,000 population). In all, the Hispanic bisexual men and/or, 3) HIV-infected -- and 11% report injecting AIDS case rate is six times the rate for whites in Kent County, while drug use (IDU). Although the incidence of HIV is currently stable in the African American case rate is four times greater.
Kent County, HRH is the only mode of transmission that is increasing statewide among infected persons. Transmission of HIV through blood HIV Deaths and New Diagnoses, Kent County, products or during gestation or birthing have rarely been reported in Kent County; advances in blood product screening and use of antivi- ral medications in pregnant women and children have contributed to substantial declines in these areas.
A final method of measuring the impact of an epidemic is to assess the total number of deaths attributable to a disease. Between 1983 and 1999 a total of 328 Kent County residents died from AIDS, with the highest number of annual deaths, 42, reported between 1993 and 1995. However, more ef ective medical treatments and increased understanding of HIV/AIDS disease processes have contributed to a 84-86 85-87 86-88 87-89 88-90 89-91 90-92 91-93 92-94 93-95 94-96 95-97 96-98 97-99 75% decline in the number of deaths from 1993 to 1999.
Although recent medical advances in the treatment of HIV and AIDS have been substantial, prevention remains a priority. HIV testing Part of HIV/AIDS surveillance involves obtaining a thorough medical must be accessible in a variety of settings and circumstances, and as and sexual history from individuals screened for or diagnosed with an essential component of any HIV/AIDS risk reduction program.
HIV or AIDS. By understanding the high-risk behaviors that are asso- Prevention education that is age-appropriate, culturally sensitive, ciated with HIV transmission, more effective educational and pre- and tailored to the specific needs and risks of diverse communities is vention messages can be developed. In Kent County, approximately essential to reducing the transmission of HIV, and reducing the im- 58% of the people living with HIV/AIDS, with a known mode of trans- pact of AIDS on our communities, families, and health care systems.
People Living with HIV/AIDS by Race/Ethnicity, Behavior Leading to Infection, Kent County Kent County and Michigan (as of 10/1/2000) COMMUNICABLE DISEASE IN KENT COUNTY
Overview of Sexually Transmitted Diseases Epidemiology:
Chlamydia is the most frequently reported infectious disease in the
United States. While 526,653 cases were reported in 1997, up to 3 Organism:
million cases are estimated to occur annually. This vast underreporting Transmission:
Sexual intercourse; from infected mother to is largely a result of substantial numbers of asymptomatic persons whose infections are not identified.
The 5-year average case rate for chlamydia is 233 per 100,000 population in Michigan, and 306 per 100,000 in Kent County. Re- ports of chlamydia are higher among women than men (466 cases per 100,000 women vs. 135 cases per 100,000 men). Women may Possible
be more likely to receive chlamydia testing during routine gyneco- Complications:
logical exams, however, this disparity suggests that the partners of (outside the uterus), chronic pelvic pain.
women infected with chlamydia are not being tested or treated.
Men: infertility, arthritis, red swollen eyes Some of the highest rates of chlamydia in Kent County are reported among persons 15-19 years of age (1,788 per 100,000) and 20- 24 years of age (1,295 per 100,000). Increases in these age cat- Treatment:
Antibiotic therapy for infected individual, egories follow national trends, and are consistent with high rates of sexual partners, and newborns of infected other STD’s among teenagers (reinforcing the need for targeted Prevention:
Sexual abstinence; safer sexual practices, stressing condom use; screening programs.
The highest case rates of chlamydia occur in the African American and Hispanic racial/ethnic groups. While approximately 50% of the infected with chlamydia have a 3- to 5-fold reported chlamydia cases in Kent County and Michigan have no race increased risk of acquiring HIV if exposed.
or ethnicity specified, if all of the unknown cases were assumed to be white, the case rate in African Americans is still approximately three times that of whites. Reporting of race/ethnicity will need to be improved before the true impact of chlamydia on minority groups can Chlamydia Case Rate by Age, Kent County and Chlamydia Case Rate by Race/Ethnicity, Kent Kent County N=411/year (65% not specified) PART III: SEXUALLY TRANSMITTED DISEASES, HEPATITIS, & TUBERCULOSIS Overview of Sexually Transmitted Diseases Gonorrhea (Gonoccocal urethritis; Clap; Strain; GC) Epidemiology:
Gonorrhea is the second most common infectious disease reported
in the United States. In the U.S., from 1997 to 1998, the overal Organism:
gonorrhea rate increased by more than 8%. This was the first rise in Transmission:
the gonorrhea rate in 13 years. (Prior to this upswing, gonorrhea infected person, almost always as a result rates in the U.S. had declined by 64% between 1985 to 1997.) It is of sexual activity; from infected mother to estimated that 650,000 people in the U.S. are infected with gonor- rhea each year. In 1998, the national rate of reported gonorrhea Symptoms:
infections was 133 per 100,000 population. The 5-year average case rate of gonorrhea in Michigan is 174 per 100,000 population, painful urination and urethral discharge.
In contrast to chlamydia, men and women are affected by gonorrhea at approximately the same rates (248 cases per 100,000 men, and Possible
258 cases per 100,000 women). This difference in rates between Complications:
chlamydia and gonorrhea may be due in part to chlamydia screening programs that primarily target women. In addition, clinical symptoms of gonorrhea tend to be more common in men, prompting more men to seek testing and treatment for gonorrhea than chlamydia.
As with chlamydia, high rates of infection are found in individuals Treatment:
Antibiotic therapy for infected individual, ages 15-19 and 20-24, as well as in minority populations. While sexual partners, and newborns of infected racial/ethnic designation are missing in approximately 50% of re- ported cases of gonorrhea, if all of the unknown cases were assumed Prevention:
Sexual abstinence; safer sexual practices, to be white, the case rate in African Americans would be approxi- stressing condom use; screening programs.
mately 12 times higher than the case rate for whites, while the Hispanic case rate would be double that of whites. In 1998, the CDC reported that in the U.S. approximately one of every 30 African American youths age 15 to 24 had gonorrhea.
Gonorrhea Case Rate by Race/Ethnicity, Kent Kent County N=277/year (43% not specified) COMMUNICABLE DISEASE IN KENT COUNTY
Overview of Sexually Transmitted Diseases Epidemiology:
Like chlamydia and gonorrhea, syphilis is one of the most commonly
reported diseases in the United States. Nearly 38,000 cases of Organism:
syphilis were reported in the U.S. in 1998, including 7,000 cases of Transmission:
primary and secondary syphilis, and 800 cases of congenital syphilis infected person, almost always as a result in newborns. The CDC has estimated that up to 70,000 cases occur of sexual activity; from infected mother to child at birth (congenital transmission).
Characterized by four stages based on the In Michigan, the 5-year average case rate of al stages of syphilis time from initial infection to the occurrence (Primary, Secondary, Late, Latent, and Congenital) combined is 9 per 100,000 population, while in Kent County, the case rate is 7 per (1) Primary: A swollen, nonpainful ulcer (chancre) 100,000. Monitoring the number of newly-diagnosed cases of syphi- located at the site of infection that becomes evident lis (Primary and Secondary stages [P&S] only) provides a picture of from 10-90 days after exposure (usually 21 days), the rate of transmission of syphilis in the community; the 5-year often accompanied by a swollen, painless lymph node.
average case rate for P&S syphilis in both Michigan and Kent County (2) Secondary: Begins with mild flu-like symptoms is 2 per 100,000 population. Since 1993, the incidence of syphilis and includes one or more areas of the skin that (number of new infections) has decreased for both men and women develop a rash (especially on the palms of the hands in both Kent County and Michigan. The syphilis case rate for males in and soles of the feet) that usually does not itch.
Michigan (2 per 100,000) is essentially the same as the case rate (3) Latent (hidden): Begins after the signs and for females, and is consistent with the national average.
symptoms of the secondary stage disappear.
(4) Late: Internal damage including sensory Primary and Secondary Syphilis Case Rate by impairments, skin problems, abnormal blood flow and digestion, among others; may cause death.
Adults: If untreated, late manifestations can shorten life, impair health, and limit before the 34th week of pregnancy, there is Newborns: May exhibit late-stage manifes- tations of syphilis including abnormal bone structure, visual and hearing impairments.
New cases of syphilis are most commonly reported in the 20-24 and Treatment:
Antibiotic therapy for infected individuals, 25-29 year old age groups in both Kent County and Michigan, how- sexual partners, newborns of infected women.
ever, in Kent County, syphilis incidence has reached an all-time low.
As of May 31, 2001, there had been only one new case of syphilis(in Sexual abstinence; safer sexual practices, September 1999) reported in Kent County in the last 32 months.
stressing condom use; screening programs.
In contrast to case reports for chlamydia and gonorrhea, only 5% of infected with syphilis have a 2- to 5-fold syphilis case reports do not have race/ethnicity designations, making increased risk of acquiring HIV if exposed.
assessment of the impact of syphilis by race/ethnicity more reliable.
PART III: SEXUALLY TRANSMITTED DISEASES, HEPATITIS, & TUBERCULOSIS Overview of Sexually Transmitted Diseases Over the past five years, syphilis cases in Kent County had the follow- new cases — particularly in pregnant women and individuals who ing race or ethnicity distribution: African Americans 64%, whites are also infected with HIV – to ensure appropriate assessment, in- 23%, Hispanics 7%, and others 1%. As with the other STD’s, African vestigation, and effective treatment and follow-up.
Americans are significantly impacted by syphilis, with case rates seven to eight times higher than whites or other minority groups. Some Primary and Secondary Syphilis Case Rate by fundamental societal barriers, such as poverty, inadequate access to Race/Ethnicity, Kent County and Michigan, health care, and lack of (health) education, are associated with dis- 1995-1999 proportionately high levels of syphilis in certain populations. The CDC reports that syphilis is one of the most glaring examples of racial Michigan N=208/year (1% not specified)Kent County N=10/year (2% not specified) disparity in health status, with the rate for African Americans nearly 34 times the rate for whites in the U.S. By contrast, the extremely low rate of syphilis incidence in Kent County demostrates that local syphilis prevention efforts have not only been effective, but are reaching all segments of the Kent County population.
In 1999, the CDC launched the National Plan to Eliminate Syphilis, calling for aggressive surveillance, contact investigation, and prompt treatment. While infectious syphilis in Kent County and the nation remains at an all-time low, it is important to maintain surveillance for Primary and Secondary Syphilis Case Rate by Gender, Kent County and Michigan, 1995-1999 COMMUNICABLE DISEASE IN KENT COUNTY
Hepatitis B (Type B Hepatitis; Serum Hepatitis; HBV) Epidemiology:
The CDC has estimated that each year more than 200,000 people of
all ages contract hepatitis B virus (HBV) and close to 5,000 die Organism:
prematurely of sickness caused by HBV. The 5-year average number Transmission:
of acute HBV cases is 4.8 per 100,000 population in Michigan, and person (i.e., through contaminated needles, 1.2 per 100,000 population in Kent County. The relatively low rate in Kent County (when compared to Michigan as a whole) may reflect the ef ectiveness of local prevention efforts, including vaccination and education, but may also be related to different reporting procedures in other counties (i.e., some counties report both acute and chronic Symptoms:
HBV, while others, like Kent County, report only acute cases).
The majority of hepatitis B cases in Kent County have been identified tiredness, abdominal pain, joint pain, yellow in individuals 30-39 years of age (55%), and individuals 20-29 years of age (22%). Over the past five years, hepatitis B has af- fected males at more than twice the rate of females (69% male vs.
31% female). Sexually active persons of childbearing age, espe- Complications:
cially women of childbearing age, and persons exposed to contami- of adults, 20%-50% of children infected at nated objects (healthcare workers, persons receiving tattoos from unsterilized equipment, etc.) need continued prevention education and access to HBV immunization. Persons with chronic HBV need education on how to minimize the risk of transmitting the virus to develop liver cirrhosis or liver cancer.
close contacts or family members, and on lifestyle habits that reduce Treatment:
There is currently no treatment for acute the risk or slow the progression of liver disease. In addition, testing pregnant women for HBV (i.e. Perinatal Hepatitis B Prevention Pro- chronic HBV infection are able to clear the gram) must continue to be a priority so that infants born to infected virus when treated with Interferon. Treat- mothers can receive prompt and appropriate treatment at birth.
Without intervention, 80%-90% of babies born to infected mothers will become chronically infected with HBV.
(HBIG) and hepatitis B vaccine can prevent Acute Hepatitis B Case Rate, Kent County and HBV transmission after high-risk exposures; Michigan, 1995-1999 (three-year averages) vaccine within 12 hours of birth, followed by additional doses at one and six months of age, can prevent perinatal HBV transmis- PART III: SEXUALLY TRANSMITTED DISEASES, HEPATITIS, & TUBERCULOSIS Hepatitis C (HCV; Hepatitis-NANB [non-A, non-B]) Epidemiology:
Hepatitis C is regarded as an emerging disease, about which there is
growing concern. It was not until 1988 that hepatitis C virus was Organism:
discovered to be the main cause of non-A, non-B hepatitis, and it was Transmission:
not until 1992 that an adequate test for specific antibodies to the person (i.e., through contaminated needles, virus was implemented nationwide. Based on surveillance studies, it is estimated that 3.9 million Americans have been infected with HCV razors or tooth brushes); less frequently — approximately 2% of the U.S. population — and that 2.7 million are chronically infected. HCV infection is more common in minority Symptoms:
populations (3.2% of African-Americans and 2.1% of Mexican-Ameri- cans are estimated to be infected with HCV vs. 1.5% of whites).
may include nausea, fever, loss of appetite, Persons at risk of HCV infection include those who received a blood jaundice (yellowing of the skin or eyes) and transfusion or solid organ transplant (e.g., kidney, liver, heart) before dark urine occur less frequently than with 1992, or received blood products for clotting problems before 1987.
Others at risk of contracting HCV include: injecting drug users, health care workers (with exposure to blood), long-term kidney dialysis Possible
patients, persons with multiple sex partners (partner(s) infected Complications:
with HCV), persons with infected household contacts that shared infected will develop chronic HCV infection items that may be contaminated with blood (e.g., razor), and chil- (infection that does not clear within six months after the acute infection). Of those In Kent County, although there were no reports of persons newly- will develop liver cirrhosis or liver cancer infected with HCV (diagnosis at the early stage is rare), 492 cases of HCV infection were reported in 1999. Consistent with nationwide Treatment:
Success of available treatment methods for estimates, approximately 70% of cases reported in Kent County are chronic hepatitis C virus infection ranges between the ages of 30 and 49, with males reported as infected more often than females (60% male vs. 40% female). Because chronic hepatitis C infection is not an officially reportable condition and not all infected persons have been tested, it is expected that the effects that require careful monitoring.
actual prevalence of hepatitis C in Kent County is higher than the Prevention:
Sexual abstinence; safer sexual practices, Currently, hepatitis C virus is considered to be the most common chronic blood-borne infection in the U.S., and is responsible for an precautions. There is no vaccine for HCV.
estimated 8,000-10,000 deaths annually, a number that is expected to triple in the next 10 to 20 years. HCV infection is now the leading A Note on Hepatitis Viruses
reason for liver transplantation among adults in the U.S. Current Both hepatitis A and hepatitis B can be prevented with vaccina- estimates of medical and work-loss costs of HCV-related acute and tion and are discussed in that context in Part II of this report, chronic liver disease are in excess of $600 million annually. There is Vaccine-Preventable Diseases. Hepatitis A, transmitted through no effective therapy or preventive vaccine for hepatitis C virus infec- fecal-oral contact, can be associated with some sexual prac- tion, and the impact of this disease on both public and private health tices, but is primarily a food-borne pathogen. Hepatitis A is care resources will likely be substantial.
discussed in Part I of this report, Gastrointestinal Diseases.
Because people with HIV, AIDS, or other conditions that weaken the
immune system are particularly vulnerable to tuberculosis (TB), and Organism:
because the number of people infected with HIV who are also in- Transmission:
fected with TB continues to rise, tuberculosis is increasingly dis- cussed in the context of HIV – and so is included in this report.
A total of 17,531 cases of active tuberculosis (6 cases per 100,000 Symptoms:
population) were reported to CDC from the 50 states and the District of Columbia in 1999, a 5% decrease from 1998, and a 34% de- crease from 1992, when the number of cases peaked during a resur- system can stop the bacteria from growing.
gence of TB in the United States. The 5-year average number of TB TB Disease: Without treatment, TB infection cases reported in Michigan is 393 (a case rate of 4 per 100,000 population), and in Kent County, 24 (a case rate of 5 cases per disease) and can be transmitted to others.
100,000). These rates are just over half the national 5-year aver- age case rate of 8 cases per 100,000 population.
chest; weakness; fatigue; weight loss; loss of appetite; chills; fever; night sweats.
A TB skin test is used to screen people for TB infection. Review of symptoms, chest x- ray, sputum testing, and other assessments Prevention:
Treatment with antibiotics can prevent TB infection from turning into TB disease and People at increased risk for TB infection and/or disease include: close contacts of Consistent with nationwide TB statistics, tuberculosis has been re- people with TB disease; individuals born in ported more commonly in men than women in both Michigan (58% men and 42% women) and Kent County (65% men and 35% women), elderly individuals; low-income individuals in the past five years. The 5-year average case rate for tuberculosis with poor access to health care; individuals in Kent County is approximately 6 cases per 100,000 men and 3 who use illegal drugs; individuals with HIV, The TB case rate in Kent County increases by age group, from birth to age 64, then decreases for persons aged 65 and older (the TB case rate increases steadily across all age groups in Michigan and nation- al y). Earlier diagnosis and a well-established public health tubercu- health care workers and others who may be losis clinic may contribute to efficient identification of cases at ear- lier ages in Kent County. TB is most prevalent in Kent County in PART III: SEXUALLY TRANSMITTED DISEASES, HEPATITIS, & TUBERCULOSIS migrant workers, refugees, and immigrants from regions where TB is The resurgence of TB in the United States in the late 1980’s coin- endemic (i.e., Eastern Europe, Southeast Asia). Because all of these cided with the emergence of multidrug-resistant TB (MDR TB) and groups are screened for TB when entering Kent County, cases are the HIV/AIDS epidemic. Development of MDR TB is usually attributed identified and treated earlier, resulting in relatively large case rates to improper prescriptions or patient noncompliance with medical treatment, and is often a corollary to HIV infection. Because HIV so severely weakens the immune system, people infected with both HIV As with many other reportable diseases, minority populations are and TB have a 100-times greater risk of developing active TB (and affected by higher rates of tuberculosis. In Kent County, the TB case becoming infectious) than people not infected with HIV.
rate for Hispanics is 10 times that of whites, while the case rate for Asian/Pacific Islanders is 46 times the rate for whites. Although Since 1992, TB has declined in the U.S. Continued efforts to identify many individuals in these minority groups were likely exposed to TB populations at risk of transmitting TB, screening individuals at risk of in their countries of origin, treating their TB disease to prevent being exposed to TB, as well as providing prompt treatment and additional cases is a top priority of the U.S. public health system as follow-up to individuals who are infected, are essential to maintain- well as the Kent County Health Department.
Tuberculosis Case Rate by Race/Ethnicity, Tuberculosis Case Rate by Age, Kent County COMMUNICABLE DISEASE IN KENT COUNTY
A Final Word on Communicable DiseaseSince the early 20th century, infectious disease transmission has for those most at risk of disease, developing the means to prevent decreased dramatically due to improvements in personal hygiene disease without knowing the causative agent, and promoting healthy and environmental sanitation; safer food processing, storage, and living habits all help reduce the risk of communicable disease in the preparation practices; and advances in medicine and science. Vacci- community.
nations have allowed for the global eradication of smallpox, as well as the virtual elimination of many diseases in the U.S. In addition, Improving disease reporting and communication of disease occur- new and improved antibiotics decrease the severity and duration of rence at the local, state, national, and international levels is neces- illness when it does occur and, as a result, reduce the potential for sary to monitor disease and reduce transmission. Disease surveil- disease transmission and improve the quality of life while infected.
lance systems must be vigilant, yet flexible enough to adapt to the rapidly changing technology associated with disease prevention, as The three parts of this report – on gastrointestinal diseases, vac- well as to new threats to the public’s health: the emergence of new or cine-preventable diseases, and sexually transmitted disease — pro- antibiotic-resistant organisms, an influenza pandemic, or a bioterrorist vide an essential overview of some of the most common infectious event. Collaboration and cooperation between public and private diseases that, in spite of the advances outlined above, continue to health care systems to detect, treat, and most importantly, prevent infect and affect us. Existing and emerging diseases, especially those communicable disease – gastrointestinal, vaccine-preventable, and that may be ‘imported’ through international travel or non-domestic sexually transmitted — is an effective and proven means of assuring food products and supplies, continue to pose a very real threat to our the health of the community and the individuals in it, and is the health, individually and collectively. Assuring access to medical care ultimate goal of public health.
PART III: SEXUALLY TRANSMITTED DISEASES, HEPATITIS, & TUBERCULOSIS Selected BibliogrpahyAmerican Academy of Pediatrics. In: Pickering LK, ed. 2000 Red Division of TB Elimination. TB Self-Study Module, 2. US Department Book: Report of the Committee on Infectious Diseases, 25th ed. Elk of Health and Human Services, Atlanta: CDC, National Center for American Public Health Association: In:Chin, J and Ascher, M, eds. Feinken, DR, et al. Individual and Community Risks of Measles and Control of Communicable Diseases Manual. Washington, DC:APHA; Pertussis Associated with Personal Exemptions to Immunization.
American Social Health Association. In: Alexander LL, ed. Sexually Food & Dairy Division. Foodborne Illness Surveillance System De- Transmitted Diseases in America: How many cases and at What scription. Lansing, MI:Michigan Department of Agriculture; 1999:6.
Cost? Kaiser Family Foundation:Menlo Park, CA; 1998:27.
Food & Dairy Division. 1998 Year-End Summary Foodborne Illness Centers for Disease Control and Prevention. In: Atkinson, W, ed. Epi- Surveillance. Lansing, MI:Michigan Department of Agriculture; demiology and Prevention of Vaccine-Preventable Diseases, 6th ed. National Immunization Program, CDC; 2000:276.
Hepatitis Foundation International. Your Miraculous Liver. Hepatitis Cohen, D, et al. “Broken Windows” and the Risk of Gonorrhea. AJPH Foundation International, Cedar Grove, NJ: 15.
Hennekens, C. and Buring, J. Epidemiology in Medicine. Boston, Communicable Disease Division. Michigan Lyme Disease Report, MA:Little, Brown and Company; 1987:383.
1999. Bureau of Epidemiology, Michigan Department of Commu- HIV/AIDS Surveillance Section. 2000 Epidemiologic Profiles of HIV/ AIDS in Michigan. Bureau of Epidemiology, Michigan Department Communicable Disease Division. Guidelines for Animal Bites and Ra- bies, 1999. Bureau of Epidemiology, Michigan Department of Com- International Association of Milk, Food and Environmental Sanitar- ians, Inc. In: Bryan, FL, ed. Procedures to Investigate Foodborne Division of STD Prevention. News from the 2000 National STD Pre- Illness. Des Moines, IA:International Association of Milk, Food and vention Conference: Milwaukee, WI: Key Facts and Figures. US De- Environmental Sanitarians, Inc.;1999:142.
partment of Health and Human Services, CDC and ASHA, 2000.
International Association of Milk, Food and Environmental Sanitar- Division of STD Prevention. Sexually Transmitted Disease Surveil- ians, Inc. In:Bryan, FL, ed. Procedures to Investigate Waterborne lance, 1999. US Department of Health and Human Services, Illness. Des Moines, IA:International Association of Milk, Food and Atlanta: CDC, National Center for HIV, STD and TB Prevention; Environmental Sanitarians, Inc.;1996:125.
McCarthy, P. and Fear, J., eds. Foodborne Illness Investigations Train- Division of STD Prevention. Tracking the Hidden Epidemics: Trends in ing Manual. Food & Drug Administration Satellite Course: March Sexually Transmitted Diseases in the United States, 2000. US Department of Health and Human Services, Atlanta: CDC, Na- tional Center for HIV, STD and TB Prevention; 2000:31.
National Association of County and City Health Officials (NACCHO).
Local Health Departments and Private Clinicians: Working Together Division of TB Elimination. Reported Tuberculosis in the United States, to Improve Communicable Disease Reporting. NACCHO/CDC:Westat 1999. US Department of Health and Human Services, Atlanta: CDC, National Center for HIV, STD and TB Prevention; 2000:95.
US Department of Health and Human Services: Public Health Ser- Hutin, Y. et al. A Multistate, Foodborne Outbreak of Hepatitis A.
vice. Principles of Epidemiology, 2nd ed. Atlanta, COMMUNICABLE DISEASE IN KENT COUNTY
Selected Web ResourcesCenters for Disease Control and Prevention. www.cdc.govHealth Facts/Links. Illness. Mortality Weekly Report—Online. Immunization Program. Center for Infectious Diseases. of Bacterial and Mycotic Diseases. of Parasitic of AIDS, STD, and Tuberculosis Laboratory Research. of Viral and Rickettsial Diseases. Infectious Diseases Journal—Online. Center for HIV, STD, and TB Prevention. of HIV/AIDS of TB Elimination. of STD Prevention. Health Training Network. Food Safety and Inspection Service, United States Department of Department of Health and Human Services. American Medical Kent County Health Department. Michigan Department of Community Health.www.mdch.state.mi.usHealth Statistics/Vital Records. of Epidemiology, Communicable Disease Epidemiology U.S. Government Food Safety Information Gateway. PART III: SEXUALLY TRANSMITTED DISEASES, HEPATITIS, & TUBERCULOSIS Reducing sexually transmitted diseases, hepatitis, and tuberculosisrequires appropriate prevention education, accessible screening andtreatment services, timely disease reporting, and individual responsibility.
Communicable Disease in Kent County
Notes on this PDF publication
Part III: Sexually Transmitted Diseases,
Hepatitis and Tuberculosis

The report contained in this PDF file was published in print by the Kent County Health Department in June 2001. The colors used in this PDF file vary slightly from the colors used in the printed version, however the content is identical, with the exception of this paragraph. This page is the inside of the back cover.
The content of this report is public information and may be downloaded, stored, printed, copied, and distributed, in print or via e-mail or other electronic means, without permission.
Communicable Disease in Kent County, Part III: Sexually Transmitted Diseases, Hepatitis and Tuberculosis printed and electronic versions 2001 Kent County Health Department, Grand Rapids, MI.
whole or in part, without permission.


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