The number of people with sexually transmitted diseases in Maryland is growing rapidly and many might not even know they are infected, fueling the spread.
The rise in STDs is happening across the state and not just in trouble spots such as Baltimore, which has a history of high rates.
The spread of syphilis, gonorrhea and chlamydia are of particular concern to public health officials and doctors, who say they are treating many more cases.
The STDs can be asymptomatic, which means they produce no symptoms in early stages, making it challenging to capture everyone who is infected and increasing the chances of passing it on to others.
There were 44,967 cases of the three diseases in the state in 2017, a 10.5 percent increase from the year before, according to the Maryland Health Department. Cases of gonorrhea increased 15 percent, syphilis by 12.3 percent and chlamydia by 9 percent.
“We definitely have seen drastic increases,” said Dr. Sebastian Ruhs, director of the infectious disease center of excellence at Chase Brexton Health Services, a Baltimore-based system of health clinics. “We are diagnosing new cases every day.”
What is happening in Maryland reflects a national trend.
The Centers for Disease Control reported last month a record number of nearly 2.3 million cases of the three diseases diagnosed in the United States in 2017, 200,000 more than in 2016.
Officials with the federal health agency said the country seemed to be sliding backward in preventing the spread of these diseases.
"It is evident the systems that identify, treat and ultimately prevent STDs are strained to near-breaking point," said Dr. Jonathan Mermin, director of the CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, in a statement last month.
A myriad of factors are likely leading to the jump in cases, public health officials believe, including cuts to STD screening and marketing campaigns, which means people are hearing fewer messages about safe sex and condom use.
Funding to the CDC’s Division of STD Prevention has dropped from $168.5 million in 2003 to $148 million this year, according to the National Coalition of STD Directors. Adjusted for inflation, that is a 40 percent decrease in purchasing power for the federal health agency and the local health departments it funds. As a result, STD prevention programs have had to lay people off, close clinics and reduce hours, the coalition has found.
Public health campaigns and messages have to be constant and consistent to be most effective, providers said.
“The CDC is doing a good job, but they need more money,” said Dr. Anne Rompalo, a professor of medicine at Johns Hopkins School of Medicine. “You have to keep your finger on the pulse and that is not cheap.”
Women who may have received STD testing with their pap smears — now done every three years instead of annually — also might be getting screened less often, doctors said.
The introduction of PREP, a drug that prevents HIV contraction, may have made people less fearful of getting the disease and also made them less vigilant about using condoms.
The opioid epidemic is likely a contributing factor, too. In some cases, substance users may trade sex for drugs. Others might not protect themselves when they are under the influence and their inhibitions are down. Sharing needles also can spread infection.
“I think when there is more drug use, people are more promiscuous,” said Dr. Nicola London, associate chair of the obstetrics and gynecology department at MedStar Franklin Square Medical Center. “We need to bring awareness back to STDs because they are still really prevalent.”
Young people and men who have sex with men are a particularly vulnerable population, said Onyeka Anaedozie, acting director of the Infectious Disease Prevention and Health Services Bureau at the state department of health. Women anatomically are also more prone to infection. In 2017, people ages 15 to 24 made up 13 percent of Maryland’s population but accounted for 65 of chlamydia cases, 48 percent of gonorrhea cases and 23 percent of syphilis cases.
Complications from these STDs are preventable and can be treated with antibiotics if caught early.
Left untreated, gonorrhea in women can cause pelvic inflammatory disease which can lead to chronic pain, infertility and ectopic pregnancy. It can cause testicle pain in men. Chlamydia, the most common of the diseases, also can cause infertility problems and moms can pass the disease on to their babies causing problems with their eyesight. Syphillis can cause neurological problems.
Doctors and public health officials worry the diseases could become more dangerous if the problem is not better controlled.
Cases of antibiotic-resistant gonorrhea have been reported in other countries and some worry it could show up in the United States as well.
Gonorrhea has become resistant to nearly every class of antibiotic except ceftriaxone, according to the CDC. In 2015, the federal agency began recommending health care providers prescribe a single shot of the antibiotic with an oral dose of a second antibiotic, azithromycin, to people diagnosed with gonorrhea.
Azithromycin was added to help delay the development of resistance to ceftriaxone. More than 4 percent of gonorrhea samples were resistant to azithromycin in 2017, up from 1 percent in 2013, and the CDC worries that ceftriaxone could become resistant as well.
Dr. Gregory Taylor, a family medicine doctor who sees patients at the University of Maryland Medical Center for Infectious Disease, said some of the STDs are being diagnosed in nontraditional sites, such as the rectum and mouth.
Amid cuts to STD prevention programs, Taylor and other area doctors said they are trying to be more vigilant about encouraging their patients to get tested for STDs and to use protection. Condoms are “free flowing” at the facility where he works.
“I think it is important to be aware that they are at risk,” Taylor said. “If they have an inkling that they may have been exposed they need to be tested and treated right away.”
There are other efforts across the state to get more people tested and treated. Chase Brexton has a walk-in STD clinic where people can come twice a week to get tested.
Baltimore health officials recently increased hours at two of its STD clinics where people can get free testing. There is also a mobile van that travels the city offering free testing.
The health department is working with the CDC to get more information from people who test positive for an STD to help better understand how they spread.
City residents also can sign up to get free condoms mailed to them monthly.
By law every pregnant woman in the state must be tested for syphilis two or three times during pregnancy depending on where she lives and her risk. Syphilis is the most severe of the three diseases and can lead to neurological problems in mom and birth defects to the baby.
To better find “hot spots,” or pockets where infections are rising, the state has increased its tracking and data collecting around the state. It will increase resources when it sees potential problem areas.
Five counties — Anne Arundel, Baltimore, Montgomery, Prince George’s and St. Mary's — were recently given additional state funds to combat gonorrhea.
“The rapid spread of these STDs is a serious concern for us,” Anaedozie said. “And we are doing what we can to address it.”