Measuring the Impact of the COVID-19 Pandemic on Sexually Transmitted Diseases Public Health Surveillance and Program Operations in the State of California

Abstract

Background 

As public health personnel and resources are redirected to COVID-19, sexually transmitted diseases (STD) programs have been unable to sustain pre–COVID-19 activities.

Methods 

We used California (CA) surveillance data to describe trends in case reporting for gonorrhea, chlamydia, and syphilis of any stage in the pre– versus post–COVID-19 eras (January–June 2019 and January–June 2020). We also analyzed data from an electronic survey administered by the CA STD Control Branch to local health jurisdictions in April, June, and September of 2020, assessing the impact of COVID-19 on STD programs.

Results 

There were sharp declines in cases of all reportable bacterial STDs occurring in conjunction with the March 19, 2020 CA stay-at-home order, most of which did not return to baseline by July. Comparing January–June 2020 to January–June of 2019, there were decreases in reported cases of chlamydia (31%), late syphilis (19%), primary/secondary syphilis (15%), early nonprimary nonsecondary syphilis (14%), and gonorrhea (13%). The largest percentage declines in STD case reporting were among Hispanic, Asian/Pacific Islander, and Black persons. Seventy-eight percent of local health jurisdiction respondents indicated that half or more of their workforce had been redeployed to COVID-19 by September 2020.

Conclusions 

During the COVID-19 era, STD case reporting and programmatic functions have diminished throughout CA. Because this may contribute to decreases or delays in STD diagnosis and treatment—with resultant increases in STD transmission—providers and public health officials should prepare for potential increases in STD-related morbidity in the months and years to come.

In Brief

An assessment describing COVID-19’s impact on sexually transmitted disease public health surveillance, sexually transmitted disease testing, and clinical services throughout the state of California was conducted.

The COVID-19 global pandemic has had wide-ranging impacts on US society, economy, health care systems, and—especially—public health infrastructure.^1,2 As personnel and resources are redirected to COVID-19, state and local public health programs have been unable to sustain pre–COVID-19 levels of activity in the prevention and control of other communicable diseases. Such negative impacts have already been reported regarding HIV, viral hepatitis, and tuberculosis programs,^2,3 and are especially true within the realm of bacterial sexually transmitted diseases (STDs), which are often asymptomatic. Because case investigation and contact tracing in the form of partner services are core functions of STD programs,⁴ STD staff already adept in these skills have been frequently redeployed to the COVID-19 public health response. In one national survey, more than half (57%) of STD disease investigation specialists (DIS) reported that they or their colleagues had been reassigned to COVID-19–related work.⁵

This decrease in staffing is coupled with reduced diagnostic capability (as laboratory supplies and services are similarly repurposed for COVID-19, resulting in shortages of STD test kits⁶) and limited ability to perform in-person patient care because of social distancing requirements and/or lack of personal protective equipment.⁷ These challenges may force STD programs to eliminate or reduce core services such as routine STD screening of asymptomatic individuals,⁸ potentially resulting in decreased or delayed diagnosis and treatment of bacterial STDs, increased transmission, and increased rates of STD-related sequalae. The primary purpose of this assessment was to characterize the impact of COVID-19 on STD public health surveillance, testing, and programmatic functions throughout the large and diverse state of California (CA).

The public health system in CA is organized into 61 local health jurisdictions (LHJs) representing 58 counties. The structure is decentralized, with local health officers having the authority for local communicable disease control. Each LHJ runs its STD program differently; some have dedicated STD clinics, whereas others provide STD services (screening, testing, diagnosis, treatment, and partner services) through local public health clinics. Throughout the state, medical providers and laboratories are required to report specific STDs to public health surveillance.^9,10 Laboratories must report cases of gonorrhea (GC), chlamydia (CT), and syphilis; providers must report GC and syphilis. As of October 2019, providers are no longer required to report CT.¹¹ Confidential morbidity report forms submitted by providers include select demographic information (such as sex, age, race/ethnicity) and treatment data; laboratory reports include similar demographics if/when available, along with test type and results.

METHODS

We used state-level public health surveillance data to describe COVID-19’s impact on case reporting for GC, CT, and all stages of syphilis—as well as on testing volumes for GC/CT—in the pre– versus post–COVID-19 eras. In addition, we used survey data from CA LHJs to assess COVID-19’s effect on local STD programs.

First, we leveraged CA surveillance data to describe the total number of unique GC, CT, and syphilis cases reported to public health each week from January 2019 to July 2020, with a focus on the period before and after CA’s mid-March 2020 “stay-at-home” order (serving as the marker of the pre– versus post–COVID-19 eras). We then compared trends in demographics (sex, age group, and race/ethnicity) for bacterial STD cases reported in the time of COVID-19 (January–June 2020) compared with the same time frame in the preceding year (January–June 2019). We did not include the third quarter (Q3) of 2019 or 2020 in our assessment, as Q3 2020 surveillance data were not yet available at the time of this analysis.

Regarding race/ethnicity, we created mutually exclusive race/ethnicity categories¹² based on guidance from the Centers for Disease Control and Prevention (CDC) according to the current Office of Management and Budget standards, whereby anyone reporting Hispanic ethnicity was categorized as Hispanic, regardless of race.¹³ We used Pearson’s chi square as our statistical test of significance for each of the demographic variables. All statistical tests were performed using STATA version 16.0.

Second, to understand COVID-19’s impact on STD testing in a specific CA clinical setting, we analyzed changes in weekly GC/CT testing volumes (total number of tests sent per week) at Family Planning, Access, Care, and Treatment (PACT) clinics served by Quest Diagnostics between January 2019 and June 2020. Our goal was to assess whether any changes in testing volumes occurred around mid-March 2020. California’s Family PACT program provides free reproductive health and family planning services to low-income CA residents of reproductive age who could become pregnant or could cause pregnancy (men who have sex with women). The Family PACT network includes approximately 2300 clinicians. As of 2016 to 2017, there were 1.83 million clients enrolled in this program, 80% female and 20% male; approximately half (45%) of Family PACT patients fell between the ages of 20 and 29 years, and 67% were Hispanic/Latinx.¹⁴ The data on testing volumes at Family PACT clinics are available through a partnership between the CA Department of Public Health STD Control Branch (STDCB) and the CA Office of Family Planning.

Third, we surveyed CA LHJs with the goal of addressing the effects of COVID-19 on local STD services. We administered an electronic Qualtrics survey to state STD controllers representing the 61 CA LHJs in April, June, and September of 2020. Our survey included a series of multiple choice and free-text questions characterizing the effects of COVID-19 on LHJ STD programs, whether housed within dedicated STD clinics or within public health clinics. Local health jurisdictions were asked to report any COVID-related changes in STD workforce and/or clinic operations (e.g., reductions in hours of operation or services offered, restrictions on in-person visits, and use of telemedicine). Free-text responses were grouped into categories based on observed responses; earlier versions of the survey included more free-text responses, whereas later versions included more multiple-choice options. The survey was designed by the CA STDCB to help us understand and respond to the needs and experiences of constituent LHJs during COVID-19, as is done within the scope of routine public health work.

This study was submitted to the CA Health and Human Services Agency’s Committee for the Protection of Human Subjects and considered exempt from review.

RESULTS

CA STD Case Reporting in the COVID-19 Era

The weekly number of bacterial STDs reported to CA STD surveillance declined sharply in conjunction with the March 19, 2020 CA stay-at-home order (as shown visually in Fig. 1) and—at least for CT and syphilis of all stages—did not return to prior baseline levels by the summer of 2020. By July 2020, only case reporting for GC began to approach pre–COVID-19 levels. Reporting for CT had also increased somewhat by July yet remained below baseline levels. Reporting for primary and secondary (P&S) syphilis and early nonprimary nonsecondary (NPNS) syphilis rose by May 2020 but declined again by July. Reporting for late/unknown duration syphilis remained consistently below pre–COVID-19 levels.

Figure 1: Impact of COVID-19 on sexually transmitted diseases (STD) case reporting in California: trends from January 2019–July 2020. A, Trends in chlamydia and gonorrhea case reporting. B, Trends in syphilis case reporting. NPNS = nonprimary nonsecondary; P&S = primary and secondary.

Comparing January–June 2020 to January–June of 2019 (Table 1), there were decreases in the number of reported cases across all bacterial STDs—deficits of 31% for CT, 19% for late syphilis, 15% for P&S syphilis, 14% for early NPNS syphilis, and 13% for GC.

TABLE 1 - Impact of COVID-19 on STD Case Reporting in California (CA)

Absolute Numbers and Characteristics of Cases Reported to CA STD Surveillance, January–June 2019 versus January–June 2020
Demographic	Jan–June 2019	Jan–June 2020	Number Change	% Change	P
Chlamydia cases
Total no.	120,003	83,319	−36,684	−30.6
Sex					0.83
Female	72,716	50,496	−22,220	−30.6
Male	46,926	32,521	−14,405	−30.7
Age group, y					0.07
0–19	21,257	14,638	−6619	−31.1
20–34	80,167	56,047	−24,120	−30.1
35+	18,322	12,464	−5858	−32.0
Race/ethnicity					<0.05
Asian/PI	5132	2295	−2837	−55.3
Black	11,634	6619	−5015	−43.1
Hispanic	29,675	11,918	−17,757	−59.8
White	17,338	9047	−8291	−47.8
Other*	14,107	9432	−4496	−32.7
Unknown†	42,117	44,008	+1891	+4.5
Gonorrhea cases
Total no.	38,798	33,713	−5085	−13.1
Sex					0.20
Female	13,220	11,629	−1591	−12.0
Male	25,416	21,911	−3505	−13.8
Age group, y					0.16
0–19	3414	2964	−450	−13.2
20–34	23,852	20,919	−2933	−12.3
35+	11,453	9730	−1723	−15.0
Race/ethnicity					<0.05
Asian/PI	1648	1152	−496	−30.1
Black	6130	5496	−634	−10.3
Hispanic	10,736	8073	−2663	−24.8
White	8743	6884	−1859	−21.3
Other*	3010	2534	−447	−15.7
Unknown†	8531	9574	+1043	+12.2
Primary and secondary syphilis cases
Total no.	4118	3513	−605	−14.7
Sex					0.39
Female	749	662	−87	−11.6
Male	3348	2812	−536	−16.0
Age group, y					0.30
0–19	151	108	−43	−28.5
20–34	2153	1822	−331	−15.4
35+	1814	1582	−232	−12.8
Race/ethnicity					<0.05
Asian/PI	214	221	+7	+3.3
Black	567	439	−128	−22.6
Hispanic	1521	1273	−248	−16.3
White	1299	1089	−210	−16.2
Other*	109	134	+28	+29.5
Unknown†	408	357	−51	−12.5
Early nonprimary nonsecondary syphilis cases
Total no.	4177	3593	−584	−14.0
Sex					0.28
Female	624	505	−119	−19.1
Male	3487	3028	−459	−13.2
Age group, y					0.89
0–19	90	79	−11	−12.2
20–34	1922	1634	−288	−15.0
35+	2165	1880	−285	−13.2
Race/ethnicity					<0.05
Asian/PI	268	215	−53	−19.8
Black	528	492	−36	−6.8
Hispanic	1869	1507	−362	−19.4
White	1148	995	−153	−13.3
Other*	94	112	14	+16.9
Unknown†	270	272	2	+0.7
Unknown duration or late syphilis cases
Total no.	5813	4700	−1113	−19.1
Sex					<0.05
Female	2021	1771	−250	−12.4
Male	3738	2885	−853	−22.8
Age group, y					<0.05
0–19	224	133	−91	−40.6
20–34	2958	2431	−527	−17.8
35+	2630	2133	−497	−18.9
Race/ethnicity					<0.05
Asian/PI	236	182	−54	−22.9
Black	773	636	−137	−17.7
Hispanic	2498	1850	−648	−25.9
White	1173	1020	−153	−13.0
Other*	289	209	−82	−30.4
Unknown†	844	803	−41	−4.9

*The “other” category includes cases identified as other/multiracial or American Indian/Alaska Native.

^†Cases listed as having unknown race are presented here but not included in statistical calculations.

Asian/PI indicates Asian/Pacific Islander (combined because small sample sizes).

In terms of demographic characteristics, there were no statistically significant differences in the declines in reported cases by sex or age group for CT, GC, P&S syphilis, or early NPNS syphilis. For syphilis of late or unknown duration, 2020 declines in case reporting were more pronounced among males than females (23% vs. 12%, P < 0.05) and among patients in the youngest age group (41% in the 0- to 19-year age range vs. 18% and 19% in the 20- to 34-year age group and 35+-year age group, respectively; P < 0.05).

Regarding race/ethnicity, the largest percentage declines in STD reporting between the first half of 2019 and that of 2020 were seen in people of color (all with P < 0.05). For GC, the largest declines were seen in Asian/Pacific Islander and Hispanic people (with drops of 30% and 25%, respectively, versus 21% for White/non-Hispanic people). For CT, again the greatest declines in reported cases between 2020 and 2019 occurred among Hispanic people (60% vs. 48% for White people). For P&S syphilis, 2020 case reporting saw a 23% decrease among Black people compared with a 16% decrease in White people. We observed similar trends in 2020 case reporting for early NPNS syphilis cases, which dropped 20% and 19% among Asian/Pacific Islander and Hispanic people (vs. 13% in White people). Late/unknown duration syphilis cases declined 26% and 23% in Hispanic and Asian/Pacific Islander people (again vs. 13% among White people).

There were concurrent increases in reported STD cases of unknown race between January–June 2019 and 2020. These increases were greatest for CT and GC, where we respectively saw 1891 and 1043 more reported cases of unknown race in the first half of 2020 compared with 2019 (corresponding to absolute increases of 4.5% and 12.2%). Of note, when looking at the percent of CT cases with unknown race by year, the proportion of reported cases with unknown race was 35% in the first half of 2019 (42,117/120,003 cases) compared with 53% in 2020 (44,008/83,319 cases).

STD Testing at Family PACT Clinics During COVID-19

Family PACT clinics served by Quest Diagnostics had a large drop-off in GC/CT testing concurrent with the mid-March 2020 stay-at-home order, without subsequent recovery as of June 2020 (Fig. 2). Compared with January to June 2019, GC and CT testing at Family PACT clinics declined by 44% and 43%, respectively, in the January to June 2020 time frame. Testing in this clinical setting decreased more among females than males (declines of 46% versus 37% for CT [P < 0.05] and 47% vs. 27% for GC [P < 0.05]).

Figure 2: Impact of COVID-19 on sexually transmitted diseases (STD) testing at Family PACT (Planning, Access, Care, Treatment) clinics served by Quest Diagnostics in California: trends from January 2019–June 2020.

COVID-19 and CA STD Programmatic Operations

Local health jurisdiction survey response rates in April, June, and September of 2020 were 51%, 41%, and 52%, respectively (Table 2). The percentage of LHJ respondents indicating that 50% or more of their STD workforce—including clinicians at dedicated STD and/or public health clinics as well as administrative and program staff, epidemiologists, and/or DIS—had been redeployed or were otherwise unable to work on normal STD duties because of COVID-19 increased from 65% and 59% in April and June to 78% by September.

TABLE 2 - COVID-19’s Impact on California STD Programs—Survey Responses from CA Local Health Jurisdictions (LHJs)

	April 2020 (34 Responders Representing 31 LHJs)		June 2020 (27 Responders Representing 25 LHJs)		September 2020 (33 Responders Representing 32 LHJs)
	No.	%	No.	%	No.	%
Percentage of STD staff redeployed* to COVID†
>75%	16	47	10	37	13	39
50%–75%	6	18	6	22	13	39
25%–50%	3	9	6	22	1	3
10%–25%	5	15	3	11	2	6
0%–10%	4	12	2	7	4	12
Closure of STD services‡	5	16	7	26	5	15
Limitations on in-person visits to priority patients only	9	29	14	52	9	28
Use of telemedicine	7	23	9	33	4	13
Decreased capacity to perform case investigations	4	13	10	41	13	41

*Or otherwise unable to work because of illness, quarantine, childcare, and so on.

^†In this first row, we report the number/percent of individual survey responders who reported that their staff had been redeployed to COVID. In the rest of the rows, we report the number/percent of LHJs affected by COVID-19 (combining responses from individual responders when they were from the same LHJ).

^‡STD services refer to STD screening, testing, diagnosis, treatment, and partner services.

The percentage of LHJs reporting decreased capacity to perform disease investigation was 13% in April 2020 but increased to 41% in both June and September. Closures of some or all STD services—such as screening, testing, diagnosis, treatment, and partner services, whether housed within dedicated STD clinics or public health clinics—were most pronounced in June 2020 (affecting 26% of LHJs at that time, up from 16% in April). These closures had started to ease somewhat by September 2020 (affecting 15% of LHJs). Limitations on in-person clinic visits for STD care followed a similar pattern, affecting 29% of LHJs in April, peaking at 52% in June, and trending down to 28% in September. The use of telemedicine also peaked in June 2020 (reported by 33% of LHJs), in line with the height of STD service closures and limitations on in-person visits. Telemedicine use declined by September (reported by 13% of LHJs).

DISCUSSION

This large retrospective assessment demonstrates the substantial impact of the COVID-19 pandemic on bacterial STD prevention and control throughout CA in terms of overall STD surveillance, STD testing in a subset of Family PACT clinics, and local STD program operations.

The state saw sharp declines in case reporting for all bacterial STDs concurrent with the March 19, 2020, statewide stay-at-home order. Although reporting for GC—perhaps because urethral infection is often symptomatic—came closer to approaching pre–COVID-19 levels by July, the same cannot be said for CT. Similarly, P&S syphilis (which is also symptomatic, although perhaps less likely to cause someone to seek care than gonococcal urethritis) had less of a decline in case reporting compared with asymptomatic late/unknown duration syphilis. Another factor affecting syphilis reporting was that, whereas GC and CT cases are imported directly from laboratories into the state public health reporting system, syphilis cases must be adjudicated at the local level to determine the appropriate stage. There have been COVID-19–related delays in this adjudication process, likely contributing specifically to delays in syphilis reporting during our study interval. However, for all STDs, case reporting remained below 2019 levels: compared with the same period in 2019, far fewer STDs were reported to public health between January and June 2020, with percentage declines reaching more than 30% for CT and between 13% and 19% for GC and syphilis of any stage.

Our findings mirror what has been reported at the national level, where case reporting for GC/CT and P&S syphilis dropped suddenly in March 2020—despite having increased steadily throughout the preceding decade—resulting in an estimated deficit of more than 27,000 GC cases in April of this year.¹⁵ Local studies in individual cities and counties in the United States have described similar trends. King County in Washington State, for example, reported 13% fewer GC cases and 34% fewer early NPNS syphilis cases between January and July of 2020 versus 2019.¹⁶

The reductions we observed in reported CA STD cases have several potential explanations. First, the incidence of bacterial STDs may have truly decreased in the era of COVID-19, as social distancing measures may have engendered changes in sexual behavior.¹⁷ However, a recent review on this topic, including 20 articles from 12 countries, found that a sizeable portion of patients (25%–60%) have not decreased their numbers of sexual partners during the pandemic.¹⁷ Similar findings have been demonstrated in US studies of men who have sex with men (MSM).^18,19 In one US-based survey, MSM instead endorsed increased sexual activity in the era of COVID-19, including mean increases of 2.1 anal sex partners and 2.3 sex partners overall.²⁰ Outside of true reductions in sexual activity, plausible explanations for our observed decline in STD reporting lie in structural challenges affecting the continuum of sexual health services during the COVID-19 pandemic.

At the individual level, patients may be hesitant to seek health care—inclusive of sexual health services—because of fears of COVID-19 exposure,^21,22 resulting in underdiagnosis of STDs. At the systems level, as shown in our LHJ survey and elsewhere, STD programs face COVID-19–related staffing and operational challenges that likely contribute to decreased STD screening and testing, again leading to underdiagnosis. Regarding staffing challenges, COVID-19 has resulted in the mass redeployment of STD DIS, epidemiologists, and clinical staff to COVID-19 activities. This was clearly seen in our LHJ survey, in which more than three-quarters of LHJs reported that half or more of their STD staff was redeployed to COVID-19 by September 2020. Similar trends have been observed nationally; a National Coalition of STD Directors survey, for example, found that 78% of the health department–affiliated STD workforce had been reassigned to COVID-19.⁵

Likely due in part to these staffing shortages—potentially compounded by social distancing requirements and/or personal protective equipment shortages—more than a quarter of responding CA LHJs reported complete closure of some or all STD services by June of 2020, whereas more than 50% had been forced to limit in-person STD care to priority patients only, with concurrent increases in the use of telemedicine. Nearly half of LHJs (41%) reported decreased ability to perform case investigations, including in-person case interviews. Particularly in regions experiencing COVID-related shortages in STD test kits and/or laboratory supplies/resources, some STD programs in CA and elsewhere are: (1) using syndromic treatment (treating patients empirically based on signs/symptoms without confirmatory testing), (2) providing empiric treatment to known contacts to STDs and/or using expedited partner therapy without confirmatory testing, (3) reducing clinic hours or reserving in-person visits for symptomatic individuals, (4) deferring routine STD screening for asymptomatic patients, and/or (5) extending STD screening intervals even for patient populations with a high incidence of STDs—including MSM on HIV preexposure prophylaxis.^6,8 For all of these reasons, it is unsurprising that STD screening/testing would be depressed in the era of COVID-19—as we observed for GC/CT among CA Family PACT clinics—again contributing to the decreases in STD diagnosis and case reporting seen in our CA study as well as nationally.¹⁵

California STD programs are not alone in facing significant operational challenges in the time of COVID-19. On the contrary, STD programs face similar difficulties elsewhere throughout the United States.^22,23 Following stay-at-home orders, New York City closed 7 of their 8 sexual health clinic(s) and scaled down in-person sexual health services in favor of telehealth, electronic prescribing, syndromic management, and the use of oral (rather than intramuscular [IM]) STD treatment regimens.²³ Although such adaptations likely increase access to sexual health services—particularly for well-resourced patients with access to telemedicine, less so for more vulnerable populations including persons experiencing homelessness—these approaches also have downsides. From a surveillance standpoint, patients treated syndromically without confirmatory testing are not reported to public health surveillance or included in case counts. From a clinical standpoint, the use of oral rather than IM treatments is also suboptimal, risking treatment failures due to antibiotic resistance in cases of GC²⁴ and presenting greater adherence challenges in cases of syphilis (which, depending on stage, require 2–4 weeks of daily doxycycline if oral therapy is prescribed instead of IM penicillin).²⁵

Regarding specific bacterial STDs, declines in case reporting for late/unknown duration syphilis in our CA study were more pronounced among males than females, perhaps because pregnant people may still receive some amount of syphilis screening concurrent with prenatal health care even in the era of COVID-19 (particularly because CDC and CA guidance specifically recommends syphilis screening for all patients during pregnancy^26,27), whereas screening among MSM decreased. At least in CA Family PACT clinics served by Quest Diagnostics, however, decreases in testing for other STDs—namely GC/CT—were still more pronounced in women than in men, likely because of the cessation of routine practices that generally prioritize screening women in this clinical setting. In terms of other demographic characteristics—aligning with national data¹⁵—we otherwise did not observe consistent differences in CA case reporting across STDs by age or sex in the first half of 2020 compared with 2019.

Contrary to national statistics, however, we did observe significant differences in STD case reporting by race/ethnicity in CA, with the largest decreases occurring among Hispanic, Asian/Pacific Islander, and/or Black Californians depending on the bacterial STD in question. These racial/ethnic differences may be explained in part by increases in reported 2020 STD cases of unknown race, which we observed for CT, GC, and early NPNS syphilis. These increases in cases of unknown race are likely driven by a shift toward laboratory-based reporting as providers’ ability to submit confidential morbidity report forms with more detailed race/ethnicity information is limited in the time of COVID-19. As of October 2019,¹¹ providers (unlike laboratories) are also no longer required to report CT cases to public health surveillance, another change that could drive a shift toward laboratory-based reporting for CT. That said, our observed absolute and percentage decreases in 2020 STD case reporting among people of color cannot be fully explained by the increases in cases of unknown race. Particularly given the disproportionate impact of COVID-19 on racial and ethnic minorities in the United States,^28,29 declining STD case reports by race/ethnicity may also reflect exacerbations of existing inequities in health care access, inclusive of sexual health services.

Our assessment has several limitations. First, because patients may have been treated empirically for suspected bacterial STDs without confirmatory testing, our surveillance data likely underestimate true STD incidence during our time frame of interest. In addition, jurisdictions, providers, and/or laboratories may have lacked capacity to report all STDs in a timely fashion during the COVID-19 era, even when diagnosed and treated appropriately. The STDCB has received requests from LHJs for support with data entry and disease investigations, supporting this possibility. However, because our data mirror national trends, we doubt such missed diagnoses fully explain the decreases we observed in STD reporting throughout CA.

Second, our ability to measure testing volumes applied only to GC/CT testing within a subset of Family PACT clinics, although these settings are of particular interest given they primarily serve low-income clients—especially women of reproductive age³⁰ who could be at risk of significant STD-related morbidity such pelvic inflammatory disease, associated infertility, and the risk of birthing infants with congenital syphilis. Third, because our LHJ survey was distributed to health-department affiliated personnel, we were unable to measure COVID-19’s impact on STD services in other settings such as private practice. Fourth and finally, although we received consistent responses from some of the larger LHJs in CA, our survey suffered from limited response rates (only 41%–52% of LHJs were represented depending on the month of survey administration, and the exact combination of LHJ responders was not entirely consistent across April, June, and September of 2020). We suspect, however, that the challenges faced by LHJs in the era of COVID-19 were likely underestimated by our assessment, given that the LHJs most impacted by COVID-19 may have been least likely to respond.

The CDC has issued guidance for STD programs experiencing service disruptions during COVID-19,³¹ including recommendations to (1) expand the use of telehealth, (2) consider home-based STD testing, (3) develop self-collection protocols for STD swabs, and (4) continue to provide first-line STD treatment by referring to open clinics and/or pharmacies when needed. Despite such adaptations, our assessment highlights COVID-19’s negative impact on STD surveillance and services in the state of CA. The deficits we observed in STD testing, diagnosis, case reporting, routine sexual health care, and partner services may soon contribute to increased STD transmission and sequalae. Particularly because the downstream consequences of undiagnosed and untreated STDs can be as severe as disseminated GC infection (cases of which are already on the rise in CA as of November 2020³²), pelvic inflammatory disease, infertility, neurosyphilis, and even congenital syphilis, it is imperative that STD providers and public health professionals be aware of the COVID-19 pandemic’s impact on STD care and prepared for potential increases in STD-related morbidity in the months and years to come. On the other hand, urgent interventions—including efforts to raise patient/provider awareness of COVID-19’s effect on sexual health services and to reinstate routine STD screening, diagnosis, treatment, and public health reporting to the full extent possible—could help mitigate the pandemic’s negative consequences on STD prevention and control.