Women and infectious disease

Definition

The most common infectious diseases that affect women in particular are pelvic infections, maternal infections, and perinatal infections. Infectious diseases are caused by exposure to viruses, bacteria, fungi, or parasites. The initial inflammation or infection caused by exposure to a pathogen can persist until a person’s health condition becomes chronic and manifests in a disease state that needs strong and specific treatments.

Women are especially susceptible to infections for a number of reasons, including social. A common role for women in most societies around the world is that of caregiver to the sick and needy, including those who have infectious diseases. Women also lack social power in most societies, including societies in impovrished, developing countries with inadequate and unhygienic living conditions and where sexually transmitted diseases (STDs) are more widespread.

Infectious Disease Types

STDs pose a great risk to women in parts of Asia, Africa, and Eastern Europe, where rape, prostitution, and arranged marriages between older men and young women (or girls) are common. Children spread infections directly to their mothers and other women in traditional roles as teachers, nurses, and caregivers. These factors make women at high risk for STDs and diseases that spread among the general population. Several diseases also can be carried by pregnant women and transmitted to her fetus during pregnancy and to her child at birth.

Pelvic infections in women lead to the following diseases:

Vaginitis. Vaginitis is usually diagnosed initially by the presence of inflammation, itching, or discharge in the area of the vagina or cervix. There are several types of vaginitis caused by infections, including yeast infections, cervicitis, lichen simplex chronicus, bacterial vaginosis, trichomoniasis, chlamydia, gonorrhea, and genital herpes. Organisms can be transmitted from person to person, leading to gynecological and other diseases because of the proximity of the vagina to the gastrointestinal tract. Once any type of viral, bacterial, or fungal pathogen enters the female gastrointestinal tract, pelvic infection is possible, including pelvic blastomycosis, schistosomiasis, actinomycosis, shigellosis, amebiasis, and listeriosis.

Listeriosis. Listeriosis is more likely to occur when a woman is pregnant or an older adult and, therefore, has decreased immunity to the Listeria monocytogenes bacterium. Most healthy adults do not present symptoms. Listeriosis is most often contracted from consuming contaminated food products. Symptoms include fever, abdominal pain, and other flu-like symptoms. Listeriosis transmitted to a fetus through the placenta can develop into granulomatosis infantiseptica, which can result in death for the infant. Newborns may have other significant findings such as breathing difficulties, fever, pneumonia, seizures, rash, jaundice, sepsis, and lethargy. Treatment of listeriosis includes a minimum of two weeks of penicillin, ampicillin, tetracycline, erythromycin, or other antibiotic.

Schistosomiasis. Schistosomiasis is a type of infection caused by the presence in the blood of flatworms of the class Trematoda and genus Schistosoma. More than 700 million people are at serious risk of contracting this type of infection annually, with over 240 million persons requiring preventative treatment in 2021. Of those, only about 75 million received treatment. The most common initial symptom is a skin rash, often called swimmer’s itch, which is visible within twenty-four hours of exposure. About one month after infection, symptoms will include fever, sweating, chills, headache, and cough. Treatment with the drugs niridazole or stibocaptate is recommended. If not treated, cervical ulcers, cervical cancer, infertility, and death may result. A fetus may become infected by the pregnant woman. Typical diagnosis includes analysis of the urine or a rectal biopsy.

Amebiasis and shigellosis. Amebiasis and shigellosis can be caused by members of the Enterobacteriaceae family, which are gram-negative organisms in contaminated water. These organisms can cause dysentery, diarrhea, abdominal pain, fever, and chills. Limiting exposure to unhealthy water is the best way to prevent the development of these infections. The most effective treatments are the tetracycline or ampicillin antibiotics. If, however, the bacteria strain proves to be resistant to these antibiotics, then trimethoprim and sulfamethoxazole can be effective.

Intrauterine-device-related infections. The gram-positive bacterium Actinomyces israelii is often associated with the usage of intrauterine devices (IUDs), which are used as contraception. A. israelii can establish a colony within the pelvis of a female, leading to gynecological infections such as actinomycosis. Initial symptoms include fever and severe abdominal pain. Diagnosis is accomplished by either examination of the IUD after it has been removed from the female, or by a Pap test. If treated with antibiotics such as penicillin, erythromycin, tetracycline, or chloramphenicol within one week of infection, the prognosis is good. Otherwise, the required treatments can involve blood transfusion. Death may result if the infection is severe.

Blastomycosis and coccidioidomycosis. Blastomycosis and coccidioidomycosis are fungal infections that gain entry to the female body either through inhalation or through a skin abrasion. These infections are especially dangerous to pregnant women because they can quickly spread to many organs throughout the body. Symptoms of the two infections are similar and include coughing, chest pain, and wart-like skin lesions that continue to spread. Blastomycosis is caused by the Blastomyces (Ajellomyces) dermatitidis fungus, which can be found in the Ohio, Mississippi, and St. Lawrence River systems. If not treated, blastomycosis will be fatal.

Coccidioidomycosis, however, is not fatal, is usually self-limiting, and is without a progressive nature. The fungus Coccidiodes immitis causes this infection. This fungus is found in the soil of the southwestern United States and in some areas of South America and Central America.

Both infections can be diagnosed by testing body fluids or antigen-based skin tests and can be treated with the medication Amphotericin B. Because blastomycosis can be fatal if not treated, the drug 1-hydroxystilbamidine can also be used if necessary.

Pelvic inflammatory disease. Pelvic inflammatory disease (PID) is caused by the Chlamydia trachomatis bacterium and transmitted through sexual intercourse. Colonies of these bacteria can gain strength and grow in size when a pregnant woman has a cesarean section, leading to severe PID. Antibiotics that include tetracycline, doxycycline, and erythromycin are effective treatments after a definitive diagnosis. Diagnosis has become much more efficient since the development of the tissue culture technique in 1965. The C. trachomatis bacterium also can cause several other diseases, including urethritis, salpingitis, neonatal pneumonia, and endemic trachoma. Also, pregnant women are susceptible to stillbirth and abortion because of these bacteria.

Cytomagalic inclusion disease. Cytomagalic inclusion disease (CID) occurs in the fetus of a pregnant woman who is infected by a cytomegalovirus. The results can be pneumonia, hepatitis, seizure disorders, deafness, retardation, and anemia. The woman may have very few symptoms other than fever or malaise. Therefore, diagnosis of a pregnant woman is made after seeing the results of blood tests, urinalysis, or immunofluorescent tests on the blood of an infant’s umbilical cord.

Chancroid. Hemophilus ducreyi is a bacterium that causes the sexually transmitted disease chancroid. The first symptoms include fever and malaise, followed by pain in the lymph nodes. Tissue cultures and gram staining are definitive methods of diagnosis. Although this type of bacteria is resistant to penicillin, other antibiotics, such as tetracycline, erythromycin, and streptomycin, are effective. Washing with soaps and disinfectants after exposure does not help to prevent infection, but condom usage does.

Group B Streptococcus infection. Group B Streptococcus (GBS) infections are those infections caused by the Streptococcus agalactiae bacterium. Infection by this bacterium can lead to a variety of diseases, including skin infections, arthritis, meningitis, urinary tract infection, and pneumonia. Colonies of these bacteria can cause death in pregnant women following a cesarean section. Affected women often pass the bacterium during childbirth, infecting the infant in 1 to 2 percent of cases, and 16 percent of infected newborns die. To detect the presence of GBS, a doctor will order urine, blood, or cerebral-spinal fluid tests, followed by a bacterial culture. Ampicillin and penicillin G are effective antibiotics, but the tetracycline antibiotics are not effective.

Maternal infections. Maternal infections include puerperal and intra-amniotic infections. Several terms are used to describe intra-amniotic infection, including “chorioamnionitis,” “clinical chorioamnionitis,” and “amniotic fluid infection.” Regardless of the name used, the primary risk factors for acquiring these types of infections are a complicated pregnancy involving prelabor rupture of membranes, excessive internal fetal monitoring, prolonged labor lasting more than twelve hours, and abortions. These complications make a pregnant woman more susceptible to group B Streptococcus growth and colonization. Additional risk factors include the presence of bacterial vaginosis and the occurrence of preterm births. Bacterial vaginosis, which is present in about 20 percent of all pregnant women, can be caused by exposure to Mycoplasma hominis and Gardnerella vaginalis during sexual intercourse.

Prolonged labor and sexual intercourse are just two of the risk factors that contribute to the incidence of infectious diseases in women because the vagina itself has a huge supply of organisms that have the potential to become virulent. There are millions of these microbial organisms within the vagina of the average woman. Thus, the rupture of any number of membranes of the placenta, uterus, or vagina, and also cesarean delivery and multiple cervical examinations, can lead to these severe infections. The most prevalent of these infections that become severe after childbirth is endometritis. As with most of these infections, the best treatment is the use of antibiotics.

Perinatal infections. Perinatal infections can occur in pregnant women with few symptoms, and they can be transmitted to the fetus, often resulting in severe illness or in death for the fetus. The most common of these infectious diseases are toxoplasmosis; “other” diseases, specifically syphilis, hepatitis, and zoster; rubella; cytomegalovirus; and herpes simplex. They are usually referred to by the acronym TORCH.

The protozoan parasite Toxoplasma gondii, which is transmitted by rodents and cats, is the cause of toxoplasmosis. Most infected humans show only nonspecific, mononucleosis symptoms. Thus, the relatively high incidence of infection that ranges from 10 to 80 percent worldwide is generally overlooked. However, as many as 5 percent of pregnancies infected with toxoplasmosis in the first or second trimester are lost. Approximately 60 percent of pregnant women who become infected in their third trimester will transmit this disease to their fetuses. Those fetuses who do survive may endure permanent visual and neurological disabilities after birth. If diagnosed early, treatment with the drugs sulfadiazine and pyrimethamine is effective, although medical treatment in pregnant patients should be undertaken with specialist consultation. Diagnostic methods include immunofluorescent antibody tests, enzyme-linked immunosorbent assay (ELISA) tests, and the polymerase chain reaction (PCR) method.

Although the rubella vaccine has been a factor in lowering the incidence rate of rubella in the general population, pregnant women who acquire rubella during the first trimester of pregnancy are at a higher risk of having a spontaneous abortion, stillbirth, or preterm birth. Also, a surviving infant may develop deafness, cataracts, heart defects, pneumonitis, neurodevelopmental impairment, or other severe disorders. The most common diagnostic tools are hemagglutination inhibition (HI) titer, which is an antibody test, and reverse transcriptase-polymerase chain reaction.

Of the TORCH infections, cytomegalovirus (CMV) is the most common in the developed world. The mode of transmission is contact with infected saliva, urine, or blood. Generally, adults have very few symptoms, and the symptoms that do occur are fever, muscle aches, and malaise, which certainly are not diagnostic because they could easily indicate many other conditions. Therefore, although definitive diagnosis is usually made using ELISA, antibody tests, or virus isolation methods, many children are born with this infection. Typical health problems include developmental delay, visual and hearing losses, and seizures; the death rate is up to 5 percent but often higher in those with neurological complications. The drugs in use are ganciclovir and valganciclovir, but they may have side effects.

Other Infectious Diseases

Human immunodeficiency virus (HIV). In 2010, 1.3 million people died from HIV-related causes, but by 2023, only 630,000 deaths occurred. Between 2010 and 2023, the death rate among girls and women from HIV-related illnesses decreased by 56 percent. In 2023, 39.9 million people worldwide were living with HIV (53 percent were girls and women), up from 29 million in 2001. Improvements in treatments in the first decades of the twenty-first century decreased the mortality rate of the disease and allowed people with HIV to live relatively healthy lives. Antiretroviral therapy (ART) often involves a combination of several types of medications depending on the patient's needs, including Nucleoside Reverse Transcriptase Inhibitors (NRTIs), Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs), and Protease Inhibitors (PIs). The drugs Zidovudine (Retrovir) or atazanavir (Reyataz) are sometimes prescribed to pregnant women in combination with other antiretroviral drugs to avoid transmission of the virus to their fetus. Many rapid, easy-to-use tests, such as OraQuick and Reveal, are available, along with ELISA and Western blot analysis of antibodies to HIV. It is imperative for women to receive early treatment and diagnosis of HIV because several other dangerous conditions may develop following an HIV diagnosis, such as cervical cancer.

Gram-negative bacteria cause an increase in the growth of cytokines and prostaglandin E2 because of the products of an endotoxin called lipopolysaccharide. Eventually, the gums and bones that support a person’s teeth become damaged, leading to periodontal disease. Extended periodontal disease causes diabetes and cardiovascular and pulmonary diseases in both women and men. Pregnant women are even more severely affected because preterm birth or spontaneous abortions may occur. As a result, further bacterial growth can lead to additional infections.

Tuberculosis (TB) has generally been decreasing in developed countries since the early twentieth century, but nearly two-thirds of the estimated 10.4 million cases in 2015 occurred in the developing nations of China, India, Indonesia, Nigeria, Pakistan, and South Africa. In 2021, 10.6 million people were infected with TB, and eight countries accounted for two-thirds of these infections—India (28 percent), Indonesia (9.2 percent), China (7.4 percent), the Philippines (7 percent), Pakistan (5.8 percent), Nigeria (4.4 percent), Bangladesh (3.6 percent), and the Democratic Republic of the Congo (2.9 percent). Of those infected, 6 million were men, 3.4 million were women, and 1.2 million were children. The bacterium Mycobacterium tuberculosis is the cause of TB. The lungs are the primary area infected; the second most common TB infection (an estimated 15 to 20 percent of cases) involves the female genital tract. Specifically, the Fallopian tubes are infected most of the time. From the fallopian tubes, the infection generally spreads to the uterus and ovaries, often causing infertility. Symptoms of genital tract TB include menstrual disorders with excessive bleeding and lower abdominal pain. Several antituberculous drugs are used for treatment.

Zika virus. Zika is a mosquito-borne illness that can be transmitted sexually as well. Zika in otherwise healthy women typically causes mild flu-like symptoms, as well as rash or conjunctivitis, for up to a week. Vertical transmission to a fetus can cause microcephaly (small heads and underdeveloped brains). Newborns with congenital Zika syndrome tend to exhibit signs such as partial skull collapse, lower brain mass, eye damage, and restricted body movement due to joint problems and greater-than-average muscle tone. There is no vaccine or specific treatment for Zika. Prevention consists of minimizing exposure to mosquitoes and avoiding unprotected sex with an affected partner for at least six months.

Impact

In the early 2000s, infectious disease was the leading cause of death for women worldwide, killing more than fifteen million women annually. While cardiovascular disease and cancers overtook infectious diseases as the leading cause of death in women, the number of women dying from infectious diseases each year remained at about 15 million into the 2020s. Women living in low-income areas and those who belong to marginalized populations are consistently the most vulnerable to severe infectious diseases. In the 2010s and 2020s, during the Ebola outbreaks in Africa, the Zika outbreaks in the Americas, and the global COVID-19 pandemic, women were the clear outliers in terms of vulnerability to illness or death.

The most common infectious diseases that affect women are HIV infection, which leads to acquired immunodeficiency syndrome (AIDS), and malaria. The mortality rate for women is higher in economically undeveloped nations because of the combination of poor hygiene, lack of available medical care and treatments, and restrictive cultural norms. Worldwide, 49 percent of persons infected with HIV in 2021 were women and girls. Women have also been disproportionally affected when their partners become infected by HIV. In Uganda, more than 25 percent of the women who lost their spouses to HIV/AIDS also lost their property. Children of women who die from infectious diseases also suffer economically, psychologically, and socially.

Bibliography

Binagwaho, Agnes, and Kedest Mathewos. “Infectious Disease Outbreaks Highlight Gender Inequity.” Nature Microbiology, vol. 7, no. 3, 2022, pp. 361–62, doi:10.1038/s41564-022-01075-2. Accessed 8 Jan. 2025.

Faro, Sebastian, and David Soper, editors. Infectious Diseases in Women. Saunders, 2001.

Gay, Laetitia, et al. “Sexual Dimorphism and Gender in Infectious Diseases.” Frontiers in Immunology, vol. 12, 2021, doi:10.3389/fimmu.2021.698121. Accessed 8 Jan. 2025.

“Gender Parity in Infectious Diseases.” The Lancet Infectious Diseases, vol. 19, no. 3, 2019, p. 217, doi:10.1016/S1473-3099(19)30072-6. Accessed 8 Jan. 2025.

Hollier, Lisa D., and George D. Wendel, Jr. Infectious Diseases in Women. Saunders, 2008.

Martin Richard J., et al. Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 12th ed., Elsevier, 2024.

Murthy, Padmini, and Clyde Lanford Smith. Women’s Global Health and Human Rights. Jones and Bartlett, 2010.

"Zika Virus." Centers for Disease Control and Prevention, US Dept. of Health and Human Services, 31 Mar. 2024, www.cdc.gov/zika/about/index.html. Accessed 8 Jan. 2025.