Chlamydia Screening and Positivity in Juvenile Detention Centers,United States, 2009–2011

An estimated 2.9 million new chlamydia infections occur in the United States each year. Among women, chlamydia can lead to serious adverse outcomes, including pelvic inflammatory disease and infertility. Chlamydia prevalence is highest among females aged 15–19 years. Despite long-standing recommendations directed at young, sexually active females, screening remains sub-optimal. Juvenile detention centers (JDCs) are uniquely situated to screen and treat high-risk adolescents. From 2009–2011, performance measure data on chlamydia screening coverage (proportion of eligible females screened) and positivity (proportion of females tested who were positive) were available from 126 geographically-dispersed JDCs in the United States. These facilities reported screening 55.2% of females entering the facilities (149,923), with a facility-specific median of 66.4% (range: 0–100%). Almost half (44.4%) of facilities had screening coverage levels of 75–100%. This screening resulted in the detection of 12,305 chlamydial infections, for an overall positivity of 14.7% (facility-specific median = 14.9%, range: 0–36.9%). In linear regression analysis, chlamydia positivity was inversely associated with screening coverage: as coverage increased, positivity decreased. The burden of chlamydia in JDCs is substantial; facilities should continue to deliver recommended chlamydia screening and treatment to females and identify mechanisms to increase coverage.     

Chlamydia screening among sexually active young female enrollees of health plans--United States, 1999-2001

Chlamydia trachomatis infection is the most commonly reported sexually transmitted disease (STD) in the United States, with the highest rates among adolescent females and young women. Approximately 5%-14% of routinely screened females aged 16-20 years and 3%-12% of women aged 20-24 years are infected with chlamydia. Because up to 70% of chlamydial infections in women are asymptomatic, routine screening and treatment of infected persons is essential to prevent pelvic inflammatory disease, infertility, ectopic pregnancy, and perinatal infections. Since the 1990s, CDC, the U.S. Preventive Services Task Force, and several clinical organizations have recommended routine screening for chlamydial infection for all sexually active women aged <26 years and for pregnant women of all ages. To evaluate rates of chlamydia screening among sexually active young females, CDC analyzed 1999-2001 data from the Health Plan Employer Data and Information Set (HEDIS) reported by commercial and Medicaid health insurance plans. This report summarizes the results of that analysis, which determined that screening rates were low despite slight increases in screening covered both by commercial and Medicaid plans during 1999-2001. Increased screening by health-care providers and coverage of screening by health plans will be necessary to reduce substantially the burden of chlamydial infection in the United States.     

Barriers to screening sexually active adolescent women for chlamydia: a survey of primary care physicians.

PURPOSE: To determine the proportion of primary care physicians who screen sexually active teenage women for chlamydia and to determine demographic factors, practice characteristics, and attitudes associated with chlamydia screening. METHODS: We obtained a random sample of 1600 Pennsylvania physicians from the American Medical Association masterfile, stratified to include at least 40% women and equal numbers of family physicians, internists, obstetricians/gynecologists, and pediatricians. In January 1998, physicians received mailed questionnaires; nonrespondents received two follow-up mailings. Physician characteristics associated with chlamydia screening were determined using bivariate and logistic regression analyses. RESULTS: Only one-third of physicians responded that they would screen asymptomatic, sexually active teenage women for chlamydia during a routine gynecologic examination. In multivariate analysis, physicians were significantly (p <.05) more likely to screen if they were female (43% vs. 24%), worked in a clinic versus solo practice (60% vs. 18%), worked in a metropolitan location (46% vs. 26%), or had a patient population > or = 20% African-American (54% vs. 25%). Attitudes associated with screening included the belief that most 18-year-old women in their practice were sexually active (36% vs. 12%), feeling responsible for providing information about the prevention of sexually transmitted diseases to their patients (42% vs. 21%), or knowing that screening for chlamydia prevents pelvic inflammatory disease (37% vs. 13%). Physicians were less likely to screen if they believed that the prevalence of chlamydia was low (10% vs. 41%). CONCLUSIONS: A majority of physicians do not adhere to recommended chlamydia screening practices for teenage women. Interventions to improve chlamydia screening might target physicians who are male, in private practice, or who practice in rural areas, and should focus on increasing awareness of the prevalence of chlamydia and benefits of screening.     

Sexually transmitted disease testing: evaluation of diagnostic tests and methods

Most STIs in adolescents are asymptomatic. Recent studies in adolescents have documented relatively short periods of time until reinfection occurs (median times 4.7-7.6 months), suggesting that sexually active adolescents should be screened for STI every 6 months. Evidence-based practice is exceedingly helpful in deciding when to test, whom to test, and which methodology to use. In a recent critical analysis regarding screening women for chlamydia, screening all women for chlamydia was more cost-effective than testing only symptomatic women. With the proliferation of highly sensitive and specific assays, and the usefulness of different specimen sources (such as urine or self-swabs), health care providers of adolescents should screen all patients at risk for STIs. Although these screening and diagnostic techniques provide greater accuracy than previously attainable, screening should be part of a comprehensive methodology designed to promote good health care decisions, such as encouraging abstinence, promoting safer sexual practices, and using the most appropriate methodology to detect and treat STIs.     

CDC Grand Rounds: Chlamydia prevention: challenges and strategies for reducing disease burden and sequelae

hlamydia, a sexually transmitted infection caused by the bacterium Chlamydia trachomatis, is the most commonly reported nationally notifiable disease. A total of 1,244,180 cases were reported in 2009. However, many infections are not detected, and an estimated 2.8 million infections occur each year. The burden of infection is greatest among sexually active adolescents and young adults; chlamydia prevalence among sexually active persons aged 14--24 years is nearly three times the prevalence among those aged 25--39 years (National Health and Nutrition Examination Survey 1999-2008 [NHANES], unpublished data, 2011). Substantial racial/ethnic disparities in chlamydial infection exist, with prevalence among non-Hispanic blacks approximately five times the prevalence among non-Hispanic whites. Among sexually active females aged 14--19 years, chlamydia prevalence is 6.8% overall (4.4% among non-Hispanic whites and 16.2% among non-Hispanic blacks).     

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.     

HEDIS 2000 measures zero in on women's health issues

Along with several other key changes, new HEDIS 2000 measures call for measuring "the breadth, depth, and personalization of menopause counseling" and for assessing the percentage of sexually active women aged 15 to 25 who are screened for chlamydia.     

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.     

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.

     

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.     

Valuing Experience Factors in the Provision of Chlamydia Screening: An Application to Women Attending the Family Planning Clinic

Objective:  To examine women's preferences for characteristics of chlamydia screening. Chlamydia trachomatis is the most common curable sexually transmitted disease. To design effective screening programs, it is important to fully capture the benefits of screening to patients. Thus, the value of experience factors must be considered alongside health outcomes.
Methods:  A self-complete discrete choice experiment questionnaire was administered to women attending a family planning clinic. Chlamydia screening was described by five characteristics: location of screening; type of screening test; cost of screening test; risk of developing pelvic inflammatory disease if chlamydia is untreated; and support provided when receiving results.
Results:  One hundred twenty-six women completed the questionnaire. Respondents valued characteristics of the care experience. Screening was valued at £15; less invasive screening tests increase willingness to pay by £7, and more invasive tests reduce willingness to pay by £3.50. The most preferred screening location was the family planning clinic, valued at £5. The support of a trained health-care professional when receiving results was valued at £4. Respondents under 25 years and those in a casual relationship were less likely to be screened.
Conclusions:  Women valued experience factors in the provision of chlamydia screening. To correctly value these screening programs and to predict uptake, cost-effectiveness studies should take such values into account. Failure to do this may result in incorrect policy recommendations.     

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.     

Asymptomatic sexually transmitted diseases: the case for screening

BACKGROUND: The United States has the highest prevalence of sexually transmitted diseases in the developed world. Control strategies should address the most frequent reasons why curable sexually transmitted diseases are not treated. METHODS: We approached 1,631 persons ages 18-29 in various sites and offered them screening for gonorrhea and chlamydial infection and surveys regarding past genitourinary symptoms. For those with past symptoms we abstracted medical records or conducted additional interviews. From these data we estimated the total number of persons who had gonorrhea or chlamydial infections in the previous year, the proportion treated, and the primary reasons for nontreatment. RESULTS: The prevalence of gonorrhea was 2.3% and that of chlamydial infection was 10.1%. We estimate that 45 and 77% of all cases of gonorrhea and chlamydial infection, respectively, were never symptomatic and that 86 and 95% of untreated cases of gonorrhea and chlamydial infection, respectively, were untreated because they were never symptomatic. The remaining 14 and 5% of untreated cases of gonorrhea and chlamydia, respectively, were not treated because persons did not receive medical care for symptoms. CONCLUSIONS: The primary reason that gonorrhea and chlamydial infections are untreated is that infected persons never have symptoms. The most effective method to control these sexually transmitted diseases is routine screening at high-volume sites.     

Population screening for Chlamydia trachomatis infection in the UK: a qualitative study of the experiences of those screened

BACKGROUND: Screening for Chlamydia trachomatis in selected health care settings is underway in the UK despite insufficient evidence about the personal impact of screening. OBJECTIVES: To describe men and women's experiences of being screened for chlamydia as part of the Chlamydia Screening Studies (ClaSS) project, a population-based UK study of postal screening for chlamydia. METHODS: We conducted in-depth interviews with 45 purposively sampled participants in the ClaSS project using a checklist of topics relating to their experiences of the screening process. Interviews were audio-tape recorded, transcribed verbatim and analysed using the constant comparison method. RESULTS: Four main themes emerged: initial discomfort with screening arising from an unease with sexual health issues; anxiety, especially after receiving a positive test result, due to the fear of informing sexual partners, the risk of infertility and the possibility of having other undetected infections; women's concern about being stigmatised for having been infected with chlamydia, which affected how they felt about themselves and how they thought others would perceive them; and recognising the need to balance the harms of screening with the benefits. Despite some reported adverse effects, no one regretted their decision to be screened. CONCLUSIONS: Public education and discussion of sexually transmitted infections should help to increase the acceptability of chlamydia screening and destigmatise a diagnosis of chlamydia. Those working in primary care settings are likely to become increasingly involved in chlamydia screening and so must be suitably trained to inform individuals of the potential adverse effects and to deal with their consequences.     

Infrequency of sexually transmitted disease screening among sexually experienced U.S. female adolescents

CONTEXT: Since 1993, the Centers for Disease Control and Prevention and professional medical organizations have recommended that all sexually experienced female adolescents receive annual screening for Chlamydia trachomatis. Whether adolescents receive this care is largely unknown. METHODS: Reports of receipt of testing or treatment for a sexually transmitted disease (STD) in the past year, as well as sites of care, were obtained from 3,987 sexually experienced females in grades 7-12 who participated in Wave 1 of the National Longitudinal Study of Adolescent Health, conducted in 1995. Logistic regression was used to determine predictors of reporting care. RESULTS: Eighteen percent of all participants reported having received STD services in the past year. Of those who reported having had a routine physical examination in the past year, 22% reported receipt of STD services. The proportion reporting STD care increased linearly with age from 9% of 12-13-year-olds to 25% of those 19 or older. In adjusted analyses, the odds of reporting testing or treatment were elevated among participants who had had a physical examination in the past year (odds ratio, 2.1), those with Medicaid or Medicare insurance (1.9), black women (1.5) and older adolescents (1.2). Adolescents most often reported having received STD care at a community health center (44%) or a private physician's office (31%). CONCLUSIONS: Continued inadequate screening may contribute to persisting high prevalence of chlamydia infection among adolescents. Future research is needed to determine whether the proportions of adolescents receiving recommended STD screening have increased over time.     

Annals Journal Club: Impact of Cervical Cancer Screening Guidelines on Screening for Chlamydia

The highest prevalence of chlamydia infection in the United States is among people aged 15 to 24 years. We assessed the impact of not doing routine cervical cancer screening on the rates of chlamydia screening in women aged 15 to 21 years. We classified visits to family medicine ambulatory clinics according to their timing relative to the 2009 guideline change that led to more restrictive cervical cancer screening. Women had higher odds of being screened for chlamydia before vs after the guideline change (odds ratio = 13.97; 95% CI, 9.17–21.29; P <.001). Chlamydia and cervical cancer screening need to be uncoupled and new screening opportunities should be identified.     

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.     

Missed opportunities for cervical cancer prevention during prenatal care

Pregnancy constitutes an excellent opportunity for the prevention of cervical carcinoma since the gynecological examination is part of routine prenatal care. A transversal study was conducted in which a total of 445 postnatal women were interviewed using standardized questionnaires. The prevalence of an up-to-date cytopathological exam was 38.9% at the beginning of pregnancy, reaching 59.1% during the postnatal period (p>0.001). Postnatal women aged 19 years or less, non-white, with less than 11 years schooling, family income of less than one minimum wage, sexually active at 15 years of age or less, with the beginning of prenatal care after the 1st trimester, and receiving prenatal care at healthcare units of the Unified Health System had a lower prevalence of cytopathological examination. Adjusted analysis revealed that the variables under study were not significantly associated with cytopathological coverage, though the incidence of prenatal care showed a prevalence ratio of 1.18 (95% CI: 0.98-1.42). The local health service proved ineffective, recvealing the need to increase cytopathological coverage and train health professionals regarding the importance of routine prenatal procedures.