Chlamydia sentinel surveillance in Aboriginal Community Controlled Health Services finds higher testing and positivity rates among younger people

Objective: To measure chlamydia testing and positivity rates among 16–39 year olds attending Aboriginal Community Controlled Health Services (ACCHSs). Methods: Retrospective non‐identifiable computerised records containing consultation and chlamydia testing data were collected for patients (16–39 years) attending eight ACCHSs during 2008–09 in urban, regional and remote settings for the Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) system. Annual chlamydia testing and positivity rates were estimated. Results: Over two years, 13,809 patients aged 16–39 years (57.8% female, 82.3% Aboriginal or Torres Strait Islander) attended. The annual overall chlamydia testing rate was 13.0% (2008) and 16.0% (2009). Testing rates were higher among females (p<0.001) and among patients aged 16–29 than 30–39 years (males: p=0.01; females: p<0.001). Chlamydia positivity was 8.5% overall; similar in females (8.7%) and males (7.8%) (p=0.46); highest among 16–19 years (females: 17.4%; males: 13.0%), declining to 1.5% among females 35–39 years (p<0.001) and 4.8% among males 30–34 years (p<0.001). Conclusions: Chlamydia testing at these ACCHSs approached recommended levels among some patient groups, however, it should increase. High positivity among younger people highlights they should be targeted. Implications: Young people should be targeted for sexual health interventions. ACCHSs are well placed to provide enhanced sexual health services if appropriately resourced.     

Demographics, sexual risk behaviours and uptake of screening for sexually transmitted infections among attendees of a weekly women-only community clinic program

OBJECTIVES: Vancouver's DTES represents a high-risk neighbourhood, in which there exist a number of community clinics and outreach programs. The purpose of this study was twofold: 1) to describe the population of women attending a weekly women's program with respect to demographics, risk behaviours and prevalence of STI, and 2) to assess the uptake of STI screening in this setting. METHODS: A cross-sectional survey was undertaken during a weekly community clinic-based women's program from October to December, 2004. Women were recruited at the start of the program each week and were invited to provide urine samples for chlamydia and gonorrhea screening. RESULTS: Among 126 respondents, the median age was 42 (36-49), more than half (52%) self-identified as White and 40% as Aboriginal ethnicity. Forty percent were currently involved in the sex trade. Two thirds reported a Pap smear in the past year, while 14% had not accessed sexual health care (Pap smear, STI or HIV testing). Among the 92/126 (74%) women providing a urine sample, the prevalence of chlamydia and gonorrhea was 2.2% and 0.0%, respectively. CONCLUSION: The majority of women accessing this program were over 35 years of age, and while nearly half were currently involved in the sex trade, cross-sectional screening did not reveal a substantial prevalence of STIs. Women who were not regular program attendees reported less sexual health care, and represented the only two cases of chlamydia found. Innovative programs that better serve the needs of populations that remain unable or unwilling to seek sexual health care in its current formats are needed.     

Provision of sexual health services to adolescent enrollees in Medicaid managed care

OBJECTIVES: This Seattle project measured sexual health services provided to 1112 Medicaid managed care enrollees aged 14 to 18 years. METHODS: Three health maintenance organizations (HMOs) that provide Medicaid services for a capitated rate agreed to participate. These included a non-profit staff-model HMO, a for-profit independent practice association (IPA), and a non-profit alliance of community clinics. Analyses used health maintenance organizations' administrative data, chart reviews, and Medicaid encounter data. RESULTS: Health maintenance organizations provided primary care to 54% and well care to 20% of Medicaid enrollees. Girls were more likely than boys to have their sexual history taken or to be given condom counseling. Only 27% of sexually active girls were tested for chlamydia, with significantly lower rates of testing among those who spoke English as a second language. The nonprofit staff-model plan outperformed the for-profit independent practice association on most measures. CONCLUSIONS: Substantial room for improvement exists in sexual health services delivery to adolescent Medicaid managed care enrollees.     

Private business: the uptake of confidential HIV testing in remote Aboriginal communities on the Ananau Pitiantiatiara Lands

Background and methods: Despite a concentration of risk factors for HIV transmission, many remote Aboriginal communities in central Australia have a low uptake of HIV testing. We studied, the uptake of HIV testing in six clinics in remote Aboriginal communities following the introduction of voluntary confidential testing to assess the impact of the intervention and to determine if the program was reaching people most at risk of HIV infection and transmission.
Setting: The study was conducted by Nganampa Health Council, an Aboriginal-controlled health service on the A n angu Pitjantjatjara Lands in the far north-west of South Australia.
Results: Since the introduction of confidential coded testing in August 1994 the number of HIV tests provided through the remote clinics has increased from 83 tests/year to 592 tests/year. In the 12-month audit period (August 1, 1995, to July 31, 1996) 62.7% of women aged 20–24 years, 44.6% of people aged 12–40 years and 24% of the total population had an HIV test. Fifty per cent of tests were accounted for by the 15–25 year age groups and 60% of tests related to an STD consult.
Discussion: This study shows that a high uptake of HIV testing in high-risk groups can be achieved in remote Aboriginal communities where a high level of confidentiality is maintained.     

Higher Yet Suboptimal Chlamydia Testing Rates at Community Health Centers and Outpatient Clinics Compared With Physician Offices

To assess chlamydia testing in women in community health centers, we analyzed data from national surveys of ambulatory health care. Women with chlamydial symptoms were tested at 16% of visits, and 65% of symptomatic women were tested if another reproductive health care service (pelvic examination, Papanicolaou test, or urinalysis) was performed. Community health centers serve populations with high sexually transmitted disease rates and fill gaps in the provision of sexual and reproductive health care services as health departments face budget cuts that threaten support of sexually transmitted disease clinics.Community health centers can serve as a key health care venue for the provision of quality sexual and reproductive health care services for persons in medically underserved communities. They are public or nonprofit, community-directed health care facilities that increase access to care for persons who experience barriers to quality health care, such as their inability to pay, geographic location, or language or cultural differences.1With increasing closure of sexually transmitted disease (STD) clinics throughout the United States,2 greater provision of STD services in community settings will be important for protecting the sexual and reproductive health of men and women in minority populations with high prevalence of STDs and limited access to care.3,4 An important STD service is chlamydia testing for persons with symptoms or signs of infection and also for all asymptomatic sexually active women aged 25 years or younger annually, as recommended by the Centers for Disease Control and Prevention and other organizations.5–7 An untreated chlamydial infection can result in serious complications, including pelvic inflammatory disease, infertility, or ectopic pregnancy.8–10 We estimated the proportion of visits made by women to community health centers, physician offices, and outpatient clinics with a chlamydia screening or diagnostic test.     

Implementation of chlamydia screening in a general practice setting: a 6-month pilot study

OBJECTIVE: To determine whether screening for asymptomatic Chlamydia trachomatis infection could be undertaken in the context of a smear clinic or other sexual health consultation in general practice. METHODS: A prospective, opportunistic, cohort study was undertaken in a general practice setting. The participants were asymptomatic women aged 16-24 years and men aged 16-34 years who were screened for Chlamydia trachomatis by testing endocervical swabs or first-voided urine samples. The main outcome measure was the uptake of the screening offer and the presence or absence of chlamydia infection as indicated by the test result. RESULTS: A total of 115 patients (109 women and six men) were offered screening. Eighty-one (70%) patients accepted, with five positive results, giving an overall prevalence of 6.2% (5/81, 95% CI 1-11%). Of those offered screening when having a smear, 8.3% (3/36, 95% CI 0-17%) were positive. CONCLUSION: Screening for chlamydia can be undertaken in the context of existing services offered in general practice (e.g. a smear clinic or consultation) where contraception/sexual health is discussed.     

Provision of contraceptive and related services by publicly funded family planning clinics, 2003

CONTEXT: In addition to contraceptive services, publicly funded family planning clinics provide low-income women with a range of reproductive diagnostic, treatment and educational services. Nationally representative information about the scope of services available from clinics is needed to formulate policy and programmatic recommendations. METHODS: In 2003, more than 1,000 U.S. clinics responded to an eight-page survey on service availability and clinic policies. Differences in the proportions of clinics reporting each service or policy were examined by clinic type and receipt of Title X funding. RESULTS: Nearly all clinics offer pills, injectables and condoms; 75% offer the patch; and 80% offer emergency contraception. Most clinics (73%) typically use a conventional Pap smear for initial cervical cancer screenings; 27% use liquid-based Pap tests. For follow-up, 68% of clinics use liquid-based or other advanced testing. Virtually all clinics screen at least some clients for chlamydia; Planned Parenthood and Title X-funded clinics, more than others, tend to focus screening efforts on sexually active women aged 25 and younger. Single-dose treatments are provided by 58% of clinics. Nine in 10 clinics offer HIV testing on-site, most of them to any client who requests it. Services targeted to specific populations include counseling about abstinence for minors (91%); non-reproductive health services for men (36%); and availability of staff such as translators (81%) and bilingual administrative (59%) or clinical personnel (57%) for non-English-speaking clients. CONCLUSIONS: More public funding is imperative for clinics to keep up with the demands of new technologies and a diverse client base.     

A pilot project for chlamydia screening in adolescent females using self-testing: characteristics of participants and non-participants

OBJECTIVES: A self-test screening program for genital C. trachomatis infection in female students attending high school in rural Nova Scotia was introduced. The objectives of this pilot study were to determine the extent of uptake, reasons for being/not being screened, and whether students at risk would be more likely to be screened. METHODS: The screening program was carried out between September 2005 and May 2006. Test kits were accessed through the school's health centre without first seeing the school nurse for counselling. Tests were processed non-nominally at the laboratory. A cross-sectional survey was offered to all students in the school to assess factors related to participation or non-participation. Univariate analysis was carried out for young women's sexual activity and risk taking, reasons for being participants or non-participants, risk behaviours, and knowledge about chlamydia. RESULTS: One hundred and sixty-three women (58%) had had vaginal intercourse at least once. Twenty-four of these used the self-test kit. Though 83% of those not using the self-test knew that females with chlamydia are very often asymptomatic, 54% indicated lack of symptoms as a reason for not doing so. Many (49%) gave low probability of infection as a reason for not using the kit, but high-risk sexual activity was frequent in these young DISCUSSION: Uptake of self-testing for C. trachomatis was lower than anticipated. This may be due to lack of counselling meant to encourage testing to overcome a dissonance of knowledge and behaviour. Self-testing should be further explored to better understand its potential to increase chlamydia screening among Canadian adolescents.     

Indirect estimation of Chlamydia screening coverage using public health surveillance data

Although routine screening of all sexually active adolescent females for Chlamydia trachomatis infection is recommended at least annually in the United States, no national or state-specific population-based estimates of chlamydia screening coverage are known to exist. Conclusions regarding screening coverage have often been based on surveys of health care provider or facility screening practices, but such surveys do not consider persons who do not seek care at these facilities or who seek care at more than one facility. The authors developed a method to estimate the proportion of sexually active females aged 15-19 years screened for chlamydia in 45 states and the District of Columbia by using national data on chlamydia positivity, estimates of sexual activity from the National Survey of Family Growth, and chlamydial infections reported to the Centers for Disease Control and Prevention. Because of uncertainty regarding these values and related assumptions, credibility intervals were calculated by using a Monte Carlo model. When this model was used, the median state-specific proportion of sexually active females aged 15-19 years screened in 2000 was 60% (90% credibility interval: 55, 66). These results and this method should be evaluated for their utility in guiding implementation of national and state chlamydia control programs.     

Male adolescent use of health care services: where are the boys?

PURPOSE: To describe patterns of health care use by adolescent males in the United States and clinical practice characteristics associated with their use of adolescent-specific programs. METHODS: Secondary analysis of three national data sets to determine health care use by male adolescents: the National Ambulatory Medical Care Survey [NAMCS (1994): pediatric, family physician, internal medicine, and obstetric/gynecologic outpatient visits]; National Hospital Ambulatory Medical Care Survey [NHAMCS (1994): outpatient department (OPD) and emergency department (ED) visits]; and Comprehensive Adolescent Health Services Survey [CAHSS (1995)]. Both NAMCS and NHAMCS are representative national probability samples. Total visit estimates by adolescents in 1994 to NAMCS sites were 387,076,630, to OPD sites were 6,511,244, and to ED sites were 13,161,824. For CAHSS, 468 programs (60% of eligible) participated. Data analyses were performed using two-tailed Student's t-tests and correlation testing. RESULTS: Older male adolescents, aged 16-20 years, account for a lower percentage of total visits to NAMCS sites combined compared to younger males, aged 11-15 years (15.8% vs. 25.1%, p <.001), mainly owing to a significant decline in visits to pediatricians (3.2% vs. 14.9%, p <.001), despite significant increases in female health care use during the same time period. Younger males were seen at similar rates compared to females at NAMCS, NHAMCS-OPD and NHAMCS-ED sites, but older males account for a significantly lower percentage of total visits than females to all NAMCS sites combined (15.8% vs. 34.7%, p <.001), the NHAMCS-ED (26.4% vs. 31.5%, p <.05), and the NHAMCS-OPD (15.0% vs. 41.2%, p =.001). Among specialized adolescent sites (CAHSS), 13-19-year-old males account for fewer visits than females to all programs types: schools (40% vs. 60%), hospitals (33% vs. 67%), and community/health departments (25% vs. 75%) (all p's < or =.001). Clinical practice characteristics correlated with having a greater proportion of male adolescent visit varied depending on the types of adolescent program examined. CONCLUSIONS: Younger male adolescents make health care visits in relatively equal proportions to females at all NAMCS and NHAMCS locations and visits by older males are significantly reduced. Male adolescent visits are lower than females at all adolescent-specific programs; school-based clinics see the highest proportion of males. Greater understanding of male adolescents' transition between providers from adolescence to adulthood is needed to improve care to male adolescents who under-use health services.     

Is provider continuity associated with chlamydia screening for adolescent and young adult women?

BACKGROUND: Longitudinal patient-provider relationships are a cornerstone of primary care. For many prevention services, better continuity of provider has been associated with better adherence to recommended practice. Our objective was to examine the relationship between continuity of care and chlamydia screening in adolescent and young women, a preventive service where large performance gaps exist. METHODS: The study population included 4117 sexually active women aged 14-25 years continuously enrolled at a large U.S. HMO. Administrative data from 2000 to 2002 were used to document chlamydia testing, provider continuity, and selected covariates. We used logistic regression to examine the relationship between provider continuity and chlamydia testing after controlling for potential confounders. RESULTS: 57.2% of eligible young women received a chlamydia test over the 2-year period. After controlling for utilization and other confounders, we found women in the lowest continuity of care quartile had 41% greater odds of being tested than those in the highest quartile (OR 1.41, 95% CI 1.14-1.76). CONCLUSIONS: For adolescents and young women, the likelihood of testing for chlamydia was reduced when care was concentrated with a usual provider. Potential implications for health service delivery are discussed.     

Exploration of testing practices and population characteristics support an increase in chlamydia positivity in Tasmania between 2001 and 2010

Objective : The proportion of positive chlamydia tests in young people in Tasmania increased significantly between 2001 and 2010. While female positivity rates increased steadily, male positivity rose steeply to 2005 then stabilised. Crude positivity rates can be influenced by a variety of factors making interpretation difficult. Unique Tasmanian datasets were used to explore whether symptom status, reason for testing or sexual exposure could explain the observed positivity trends. Methods : Population‐level chlamydia positivity rates in Tasmania over a 10‐year period were compared with surveillance data collected on people aged 15 to 29 years notified with chlamydia. Results : The proportion of asymptomatic chlamydia cases increased, with the largest increase in males aged 15 to 19 years (28%). Opportunistic testing of cases increased (greatest in males, range 17–32%). Sexual exposure remained consistent. Conclusions : After allowing for any changes in sexual exposure, symptom status and reason for testing, an increase in chlamydia positivity occurred over the 10 years. Healthcare providers have increased chlamydia testing in high‐risk groups. Implications : Monitoring chlamydia testing patterns and positivity rates at a population level is a step forward in surveillance practices. Targeted surveys provide valuable information to supplement routine surveillance data.     

Decline in prevalence of human papillomavirus infection following vaccination among Australian Indigenous women,a population at higher risk of cervical cancer: The VIP-I study

BackgroundCervical cancer occurrence and mortality are strongly correlated with socioeconomic disadvantage, largely due to unequal access to screening and treatment. Universal human papillomavirus (HPV) vaccination provides the opportunity to greatly reduce this global health disparity. Australian Indigenous women have substantially higher rates of cervical cancer than non-Indigenous women, primarily due to under-screening. We investigated HPV infection rates in Indigenous women 7 years after implementation of the national HPV vaccination program.MethodsWe used a repeat cross-sectional design, with the baseline being provided by an HPV prevalence survey among Indigenous women attending clinics for cervical cytology screening, prior to the start of the vaccination program in 2007. We returned to clinics in four locations during 2014–15, and invited women aged 18–26 years attending for screening to provide a cervical specimen for HPV testing, as well as to complete a short questionnaire and consent to allow access of their records in the National HPV Vaccination Program Register. We used well-established laboratory methods to test specimens for specific HPV genotypes.ResultsA total of 142 women were recruited at participating sites and compared to 155 who had been recruited at the same locations in the 2007 pre-vaccine survey. The two groups were identical in regard to age, with the more recent group having a higher proportion of hormonal contraception users, and a lower proportion of smokers. The proportion found to have any HPV type fell from 58 to 36% with the decline being entirely due to reductions in vaccine types, which fell by 94% from 24 to 1.4%.ConclusionAustralia’s national HPV vaccination program appears to be successfully protecting a very high proportion of Indigenous women against vaccine targeted HPV types, who have in the past been at elevated risk of cervical cancer.     

An Ongoing Burden: Chlamydial Infections among Young American Indian Women

Objectives Studies conducted in the 1980s, when there was limited chlamydia screening, showed high positivity, 23%–30%, among American Indian women. In the 1990s, chlamydia screening and treatment programs were implemented in a variety of settings serving American Indian women including Indian Health Service (IHS) clinics. Yet, a 2000–2001 national survey documented a chlamydia prevalence of 13.3% among young American Indian women, five times higher than the prevalence among whites. The purpose of this analysis was to determine the chlamydia positivity and risk factors for chlamydia among women screened in Indian Health Service (IHS) clinics participating in the National Infertility Prevention Program in 2003. Methods Data were analyzed from 11,485 chlamydia tests performed among women universally screened in 23 IHS clinics in three states (Montana, North Dakota, South Dakota). Sexual risk history and clinical data were collected in the Montana IHS clinics and used to assess risk factors for chlamydial infection in a multivariate logistic regression model. Results Chlamydia positivity was highest among 15–19 year old women screened in IHS clinics (state range: 15.3%–18.6%). Positivity decreased with age but remained high even among women aged 30–34 years. Young age and having had multiple or new sex partners in the last 90 days were associated with an increased risk of chlamydia; however, chlamydia positivity was greater than 6.7% for women with no known risk factors. Conclusions A greater emphasis on chlamydia screening and treatment should be a component of any program whose goal is to improve the reproductive health of American Indian women.

     

Screening for sexually transmitted infections among economically disadvantaged youth in a national job training program.

PURPOSE: To evaluate results of screening for syphilis, gonorrhea, and chlamydia among youth in a federally funded job training program. METHODS: Data were evaluated from medical records of 12,881 randomly selected students in 54 U.S. job training centers during 1996. The intake medical evaluation includes serologic testing for syphilis. The policy was for females to receive a pelvic examination with gonorrhea and chlamydia testing and for males to be first screened with a urine leukocyte esterase (LE) assay, with follow-up gonorrhea and chlamydia testing for those with positive LE results. RESULTS: Adjusting for our sampling strategy, among females, an estimated 9.2% had a positive chlamydia test, 2.7% a positive gonorrhea test, and 0.4% had a positive syphilis test. Gonorrhea and chlamydia rates among females were highest in African-American followed by Native American students. Chlamydia infection was most common in younger women < or = 17 years of age. An estimated 0.1% of males had a positive syphilis test, and 4.8% of males a positive urine LE test. Of 103 LE-positive males tested for gonorrhea and chlamydia, only 27 (26%) had a positive test for one of these STDs. CONCLUSIONS: Our study supports routine screening of adolescents for gonorrhea and chlamydia, including those youth from socioeconomically disadvantaged backgrounds. Because individuals from such backgrounds may not regularly interact with traditional clinical health care systems, screening and treatment should be offered in alternative settings, such as the job training program described in this study.     

How reliable are Australian Childhood Immunisation Register coverage estimates for indigenous children? An assessment of data quality and coverage

Low levels of reporting indigenous status to the Australian Childhood Immunisation Register (ACIR) in the past have resulted in reduced confidence in vaccination coverage data for Aboriginal and Torres Straight Islander children. This study shows that the reporting of indigenous status has improved from 42% of the estimated national cohort of Indigenous children aged 12 to 14 months in 2002 to 95% in 2005. Over that period diphtheria-tetanus-pertussis (DTP) vaccination coverage estimates for Indigenous children increased slightly from 86.0% to 86.9%. Data by state and territory or remoteness are also presented. ACIR vaccination coverage estimates for Indigenous children can now be used with confidence for program planning at the national and jurisdictional level.     

A phase II clinical trial of a dental health education program delivered by aboriginal health workers to prevent early childhood caries

ABSTRACT: BACKGROUND: Early Childhood Caries (ECC) is a widespread problem in Australian Aboriginal communities causing severe pain and sepsis. In addition dental services are difficult to access for many Aboriginal children and trying to obtain care can be stressful for the parents. The control of dental caries has been identified as a key indictor in the reduction of Indigenous disadvantage. Thus, there is a need for new approaches to prevent ECC, which reflect the cultural norms of Aboriginal communities. METHODS: This is a Phase II single arm trial designed to gather information on the effectiveness of a dental health education program for Aboriginal children aged 6 months, followed over 2 years. The program will deliver advice from Aboriginal Health Workers on tooth brushing, diet and the use of fluoride toothpaste to Aboriginal families. Six waves of data collection will be conducted to enable estimates of change in parental knowledge and their views on the acceptability of the program. The Aboriginal Health Workers will also be interviewed to record their views on the acceptability and program feasibility. Clinical data on the child participants will be recorded when they are 30 months old and compared with a reference population of similar children when the study began. Latent variable modeling will be used to interpret the intervention effects on disease outcome. DISCUSSION: The research project will identify barriers to the implementation of a family centered Aboriginal oral health strategy, as well as the development of evidence to assist in the planning of a Phase III cluster randomized study.Trial registrationACTRN12612000712808.     

Neural correlates of pediatric obesity

Australia commenced an ongoing school based government funded human papillomaviruses (HPV) (cervical cancer prevention) vaccination program in April 2007 for adolescent females aged 12-13 years. In addition, up to December 31, 2009, a catch-up program for young females 13-26 years of age was offered: a school-based vaccination program was used to offer HPV vaccine to girls enrolled in school (14-17 years), and general practitioners or other community health provider offered vaccine to young women aged 18-26 years. To date, only the quadrivalent vaccine (HPV 6/11/16/18) has been utilized in the funded program. Acceptance of the vaccine is high with coverage of 3 doses of the HPV vaccine in the school age cohort around 70%, and just over 30% in the older age cohort. Since the vaccination program was initiated, a reduction in new cases of genital warts of 73% among vaccine eligible age females has been evidenced in STI clinics across Australia. A reduction of 44% of new cases in young males (not a part of the free program) was also documented during this same time period, suggesting significant herd immunity. Similarly, in the state of Victoria, a small but significant decrease in high grade abnormalities in Pap screening findings has been reported in young women<18 years for the period 2007-9, as compared to pre-vaccination. Challenges for the future include how we can sustain and improve HPV vaccination coverage in young Australian women, while maintaining cervical cancer screening participation and reviewing cervical cancer screening methods.     

A comparison of the population diagnosed with chlamydia in primary care with that diagnosed in sexual health clinics: implications for a national screening programme

OBJECTIVES: To compare demographic, behavioural and HIV testing characteristics of individuals diagnosed with chlamydia infection in primary care with those in genitourinary medicine clinics, in the absence of a screening programme. The aim was to explore the current and potential contribution of primary care to the control of chlamydia. STUDY DESIGN AND METHODS: We analysed data on individuals who reported one or more chlamydia diagnoses in the past 5 years in a large probability sample survey of the resident, UK general population aged 16-44 years. Estimates were weighted and odds ratios calculated. RESULTS: Women diagnosed in primary care reported fewer sexual partners, and were less likely to have had an HIV test in the past 5 years than their counterparts diagnosed in genitourinary medicine clinics. Age, ethnicity, social class, educational attainment and urbanization of area of residence did not differ between the two groups. Too few men were diagnosed in primary care to allow for such a comparison. CONCLUSIONS: Primary care already diagnoses a large number of women with chlamydia infection, who may perceive themselves as low risk through age or sexual behaviour, yet are likely to comprise a substantial proportion of all infections. Few men are diagnosed in primary care. These groups need to be strategically targeted in the context of a future chlamydia screening programme, which will focus on the screening of younger women at high risk, and in which the role of primary care is still in development.     

Bridging the Gap: Using School-Based Health Services to Improve Chlamydia Screening Among Young Women

Objectives. We implemented a chlamydia screening program targeted at young women accessing reproductive health care services in a school-based setting, and we assessed racial/ethnic factors associated with infection.Methods. The California Family Health Council partnered with 9 health care agencies receiving federal Title X family planning funding and 19 educational institutions to implement the Educational Partnerships to Increase Chlamydia Screening (EPICS) program from January 2008 through December 2008.Results. EPICS agencies provided reproductive health services to 3396 unique sexually active females, 85% of whom self-reported no other source for reproductive health care. Chlamydia screening was provided to 3026 clients (89.1% chlamydia screening coverage). Of those screened for chlamydia, 5.6% tested positive. Clients who were African American (odds ratio [OR] = 7.5; 95% confidence interval [CI] = 3.9, 14.3), Pacific Islander (OR = 4.1; 95% CI = 1.1, 15.5), or Asian (OR = 3.3; 95% CI = 1.4, 8.1) were more likely to have a positive test than were White clients.Conclusions. Chlamydia screening programs implemented in school-based settings have the capacity to identify and treat a significant amount of asymptomatic infection in a population that otherwise may not be reached. To facilitate screening, school-based clinics should implement outreach strategies that target their school population and clinical strategies that maximize opportunities for screening.Chlamydia trachomatis infection is the most commonly reported sexually transmitted disease (STD) in the United States, with more than 1.2 million reported chlamydia infections in 2008.¹ Young women aged 15 to 19 years and 20 to 24 years had the highest chlamydia rates of all age groups in 2008, accounting for more than half of all reported cases.¹ The chlamydia rate among African Americans was more than 8 times higher than was the rate among Whites in 2008, and the rates among American Indians/Alaska Natives and Hispanics/Latinos were also higher than that of Whites (4.7 times higher and 2.9 times higher, respectively).¹ Most chlamydia infections are asymptomatic, yet they can lead to serious health sequelae, particularly among women. When left untreated, 20% to 50% of chlamydia infections will cause pelvic inflammatory disease, which can lead to tubal scarring, ectopic pregnancy, chronic pelvic pain, and infertility.² Chlamydia infection also facilitates the transmission of HIV and can increase risk of complications during and after pregnancy.^3,4The Centers for Disease Control and Prevention (CDC) recommends that all sexually active females aged 25 years and younger be screened annually for chlamydia.⁵ Despite strong support for this recommendation, less than half of all sexually active young women receive an annual chlamydia screening, and many women at high risk are not receiving necessary chlamydia prevention services.^6,7 Improving chlamydia screening rates could lead to significant cost savings for individuals and for the US health care system as a whole.^8,9It is well documented that adolescents and young adults face significant barriers in accessing care and prevention services for STDs.^10–16 The provision of STD services in school-based settings overcomes many of these obstacles because service providers have direct access to the student population, can provide services at little to no cost, and can provide youth-focused counseling.^17–19 Studies have further demonstrated that school-based STD programs are widely supported and cost-effective, and that they have the capacity to identify and treat a significant amount of asymptomatic infection.^20–22Previous school-based efforts have primarily focused on providing chlamydia tests through “wall-to-wall” screening, in which a large group of students are offered screening during a limited time period. For schools without a school-based health center that provides reproductive health services, this may be an appropriate chlamydia control strategy. However, studies of these wall-to-wall screening projects have shown wide variation in chlamydia positivity.^23–26 One study suggests that for schools that do provide reproductive health services in a school-based health center, students may not be receiving chlamydia screening often enough during routine visits.²⁷ Although there are many benefits of providing services in the school-based setting, previous studies have failed to highlight ways to increase student use of school-based chlamydia screening services, to increase screening coverage, or to integrate chlamydia screening as part of routine reproductive health care.We implemented a chlamydia screening program targeted at young women accessing reproductive health care services in a school-based setting, and we assessed racial/ethnic factors associated with infection.