Patterns of chlamydia/gonorrhea positivity among voluntarily screened New York City public high school students

Epidemiology of Chlamydia trachomatis and Repeat Positivity Following Detection in New York State

BACKGROUND

In New York State, excluding New York City, chlamydia remains a persistent health concern. Our aim was to characterize chlamydia epidemiology and identify groups at higher risk of repeat positivity to inform targeted public health interventions.

METHODS

We analyzed demographic and clinical data of laboratory-confirmed chlamydia cases in New York State from 2015 to 2019. Repeat positivity was defined as a second positive chlamydia test within 31 to 365 days of the initial positive test. We compared characteristics of individuals with single and repeat positivity and evaluated associations with repeat positivity using multivariable logistic regression models.

RESULTS

During the study period, 176 273 individuals were diagnosed with chlamydia, with 17 253 experiencing repeat positivity. Repeat positivity was more common among individuals assigned female at birth. Key predictors of repeat positivity among females included non-Hispanic Black (adjusted odds ratio [aOR]: 1.33; 95% confidence interval [CI], 1.27-1.40) race/ethnicity, ages 13 to 19 (aOR: 1.62; 95% CI, 1.55-1.69), prior sexually transmitted infection (STI) diagnosis (aOR: 1.24; 95% CI, 1.18-1.31), symptomatic examination (aOR: 1.07; 95% CI, 1.02-1.13), and county/community (aOR: 1.10; 95% CI, 1.05-1.15) or private/public (aOR: 1.18; 95% CI, 1.11-1.25) provider. Among males, predictors included non-Hispanic Black (aOR: 1.57; 95% CI, 1.45-1.70) race/ethnicity, ages 13 to 19 (aOR: 1.27; 95% CI, 1.17-1.38), HIV coinfection (aOR: 1.30; 95% CI, 1.10-1.54), prior STI diagnosis (aOR: 1.31; 95% CI, 1.20-1.43), extragenital infection site (aOR: 2.59; 95% CI, 2.27-2.95), symptomatic examination (aOR: 1.21; 95% CI, 1.12-1.31), and county/community health (aOR: 1.09; 95% CI, 1.02-1.17) provider.

CONCLUSIONS

Our findings provide valuable insights for sexual health interventions to prevent chlamydia transmission and recurrence. Prioritizing resources for prevention interventions and tailored sexual health promotion among non-Hispanic Black individuals is crucial. Additionally, targeted STI prevention efforts are needed for males who have sex with men and those initially diagnosed with extragenital infection. Research is warranted on STI prevention among people living with HIV or at high risk of HIV infection. Strengthening prevention strategies through Expedited Partner Therapy and sexual health education for individuals at risk of repeat positivity could enhance prevention efforts.

Cost-Effectiveness Analysis of Michigan's School-Wide Sexually Transmitted Disease Screening Program in Four Detroit High Schools

PURPOSE

The Michigan Department of Health and Human Services, in collaboration with St. John Providence Health System, initiated voluntary school-wide sexually transmitted disease (STD) screenings in four Detroit public high schools. We sought to assess the cost-effectiveness of the STD screening program from 2010 to 2015, with a focus on chlamydia.

METHODS

The costs and effectiveness of the school-based screening were compared with those of a "no school screening" scenario using a healthcare system perspective. A decision tree model was constructed to project cases of chlamydia, epididymitis, and pelvic inflammatory disease (PID) in each of the two scenarios among students tested positive and their partners. Health effects were measured as cases of PID prevented, and quality-adjusted life-years (QALYs) gained. Cost estimates included program costs, chlamydia testing/treatment costs in the absence of school screening, and treatment costs for epididymitis, PID, and PID sequelae. The incremental cost-effectiveness ratio (ICER) was measured as cost/QALY gained. Multivariate sensitivity analyses were conducted on key parameter estimates and assumptions used.

RESULTS

Under base-case assumptions, at a total program cost of $333,848 over 5 years, the program prevented an estimated 1.9 cases of epididymitis and 17.3 cases of PID, resulting in an ICER of $38,235/QALY gained (yearly ICER ranging from $27,417 to $50,945/QALY). Of 10,000 Monte Carlo simulation runs, the yearly ICER remained ≤$50,000/QALY in 64%-98% of the simulation runs.

CONCLUSIONS

We found favorable cost-effectiveness ratios for Michigan's school-wide STD screening program in Detroit. School-based STD screening programs of this type warrant careful considerations by policy makers and program planners.

Effectiveness of a Universally Offered Chlamydia and Gonorrhea Screening Intervention in the Pediatric Emergency Department

PURPOSE

Adolescents represent more than half of the newly diagnosed sexually transmitted infections in the U.S. annually. Emergency departments (EDs) may serve as an effective, nontraditional setting to screen for chlamydia/gonorrhea (CT/GC). The objective was to evaluate the effectiveness of a universally offered CT/GC screening program in two pediatric ED settings.

METHODS

This was a prospective, delayed start pragmatic study conducted over 18 months in two EDs within the same academic institution among ED adolescents aged 14-21 years with any chief complaint. Using a tablet device, adolescents were confidentially informed of CT/GC screening recommendations and were offered screening. If patients agreed to CT/GC testing, a clinical decision support tool was triggered to inform the provider and order testing. The main and key secondary outcomes were the proportion of CT/GC testing and positive CT/GC test results in each respective ED.

RESULTS

Both EDs experienced modest but statistically significant increases in CT/GC testing post- versus pre-intervention (main: 11.5% vs. 7.9%; confidence interval [CI]: 2.9-4.2; p < .0001 and satellite: 3.8% vs. 2.6%; 95% CI: .7-1.7; p < .0001). Among those tested, the positivity rate at the main ED did not significantly change post- versus pre-intervention (24.1% vs. 23.2%; 95% CI: -1.9 to 3.8; p = .71) but significantly decreased at the satellite ED (7.6% vs. 14.8%; 95% CI: -12.2 to -2.2; p = .01).

CONCLUSIONS

A universally offered screening intervention increased the proportion of adolescents who were tested at both EDs and the detection rates for CT/GC at the main ED, but patient acceptance of screening was low.

Mathematical modeling study of school-based chlamydia screening: potential impact on chlamydia prevalence in intervention schools and surrounding communities

Background

Chlamydia screening in high schools offers a way to reach adolescents outside of a traditional clinic setting. Using transmission dynamic modeling, we examined the potential impact of high-school-based chlamydia screening programs on the burden of infection within intervention schools and surrounding communities, under varying epidemiological and programmatic conditions.

Methods

A chlamydia transmission model was calibrated to epidemiological data from three different settings. Philadelphia and Chicago are two high-burden cities with existing school-based screening programs. Rural Iowa does not have an existing program but represents a low-burden setting. We modeled the effects of the two existing programs to analyze the potential influence of program coverage and student participation. All three settings were used to examine a broader set of hypothetical programs with varying coverage levels and time trends in participation.

Results

In the modeled Philadelphia program, prevalence among the intervention schools’ sexually active 15–18 years old population was 4.34% (95% credible interval 3.75–4.71%)after 12 program years compared to 5.03% (4.39–5.43%) in absence of the program. In the modeled Chicago program, prevalence was estimated as 5.97% (2.60–7.88%) after 4 program years compared to 7.00% (3.08–9.29%) without the program. In the broader hypothetical scenarios including both high-burden and low-burden settings, impact of school-based screening programs was greater in absolute terms in the higher-prevalence settings, and benefits in the community were approximately proportional to population coverage of intervention schools. Most benefits were garnered if the student participation did not decline over time.

Conclusions

Sustained high student participation in school-based screening programs and broad coverage of schools within a target community are likely needed to maximize program benefits in terms of reduced burden of chlamydia in the adolescent population.

Information Technology-Assisted Screening for Gonorrhea and Chlamydia in a Pediatric Emergency Department

PURPOSE

The aim of the study was to design and implement a novel, universally offered, computerized clinical decision support (CDS) gonorrhea and chlamydia (GC/CT) screening tool embedded in the emergency department (ED) clinical workflow and triggered by patient-entered data.

METHODS

The study consisted of the design and implementation of a tablet-based screening tool based on qualitative data of adolescent and parent/guardian acceptability of GC/CT screening in the ED and an advisory committee of ED leaders and end users. The tablet was offered to adolescents aged 14-21 years and informed patients of Centers for Disease Control and Prevention GC/CT screening recommendations, described the testing process, and assessed whether patients agreed to testing. The tool linked to CDS that streamlined the order entry process. The primary outcome was the patient capture rate (proportion of patients with tablet data recorded). The secondary outcomes included rates of patient agreement to GC/CT testing and provider acceptance of the CDS.

RESULTS

Outcomes at the main and satellite EDs, respectively, were as follows: 1-year patient capture rates were 64.6% and 64.5%; 9.9% and 4.4% of patients agreed to GC/CT testing, and of those, the provider ordered testing for 73% and 72%.

CONCLUSIONS

Implementation of this computerized screening tool embedded in the clinical workflow resulted in patient capture rates of almost two-thirds and clinician CDS acceptance rates >70% with limited patient agreement to testing. This screening tool is a promising method for confidential GC/CT screening among youth in an ED setting. Additional interventions are needed to increase adolescent agreement for GC/CT testing.

Cost-Effectiveness of a School-Based Chlamydia Screening Program, Duval County, FL

During the 2015-2016 school year, the Florida Department of Health in Duval County hosted Teen Health Centers (TeenHC) at five high schools of Jacksonville providing HIV/STD screening and pregnancy testing. The purpose of this study was to assess the cost-effectiveness of the TeenHC chlamydia screening program and determine at what student participation level, the program can be cost-effective. We assessed the costs and effectiveness of the chlamydia screening program compared with "no TeenHC". Cost-effectiveness was measured as cost per quality-adjusted life years (QALY) gained. At a program cost of US$61,001 and 3% participation rate, the cost/QALY gained was $124,328 in the base-case analysis and $81,014-$264,271 in 95% of the simulation trials, all greater than the frequently citied $50,000/QALY benchmark. The cost/QALY gained could be <$50,000/QALY if student participation rate was >7%. The TeenHC chlamydia screening has the potential to be cost-effective. Future program efforts should focus on improving student participation.

Condom Availability in Schools: A Practical Approach to the Prevention of Sexually Transmitted Infection/HIV and Unintended Pregnancy

Adolescents and young adults are highly impacted by sexually transmitted infections (STIs) and unplanned pregnancy in the United States and globally. Consistent and correct use of male latex condoms is associated with protection against both STIs and pregnancy. Providing adolescents and young adults with access to free condoms in schools may increase the use of condoms by improving condom availability, eliminating cost, and decreasing embarrassment associated with purchasing condoms. Studies demonstrate that condom availability in schools is associated with the increased use of condoms and improved overall sexual health. The Society for Adolescent Health and Medicine encourages schools to make condoms available to students as part of efforts to decrease rates of STIs and unplanned pregnancy in adolescents and young adults. The Society for Adolescent Health and Medicine also encourages health care providers to advocate for and support the availability of condoms in local schools.

Community-Based Assessment to Inform a Chlamydia Screening Program for Women in a Rural American Indian Community

BACKGROUND

Rates of chlamydial infection in American Indian/Alaska Native women in the United States are approximately 4-fold those in non-Hispanic white women. We conducted a community-based survey of self-identified American Indian/Alaska Native women 14 to 25 years of age on a reservation in the Northwestern United States to inform a chlamydia screening strategy.

METHODS

The anonymous survey assessed respondents' knowledge, perceptions, and preferences related to chlamydia screening, results receipt, and partner notification. We recruited women using respondent-driven sampling, school-based sampling, and direct recruitment through social media and fliers. Participants in schools completed the survey as a paper-based, self-administered survey. Other participants could complete the survey in person, by phone as an interviewer-administered survey, or online.

RESULTS

We recruited 162 participants, most in schools (n = 83; 51%) or by peer referral (n = 55; 34%). Only 1 woman completed the survey online. Thirty-one respondents (19%) reported a history of an unplanned first pregnancy, and 19 (12%) reported a history of a diagnosed sexually transmitted disease. Most women (n = 98; 63%) recognized the potential impact of Chlamydia trachomatis on fertility. The preferred site for chlamydia screening was the Indian Health Service Clinic (n = 114; 70%), but 79 women (41%) would accept a C. trachomatis test at a nonclinical testing site. Of the 56 women (35%) who would accept home testing, most preferred to get the test kit from a clinic.

CONCLUSIONS

Our results suggest that Indian Health Service efforts to increase chlamydia screening in the clinic and through outreach may be more successful than promotion of home testing in this population.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infection in adolescents in Northern Italy: an observational school-based study

BACKGROUND

We carried out a study to evaluate the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae genital infections in school-based adolescents in Northern Italy.

METHODS

Systematic screening for C. trachomatis and N. gonorrhoeae genital infection was performed in 13th grade students in the province of Brescia, an industrialized area in Northern Italy. Student filled in a questionnaire on sexual behaviour and provided a urine sample for microbiological testing.

RESULTS

A total of 2,718 students (mean age: 18.4 years; 59.1% females) provided complete data (62.2% of those eligible). Overall 2,059 students (75.8%) were sexually active (i.e. had had at least one partner), and the mean age at sexual debut was 16.1 years (SD: 1.4). Only 27.5% of the sexually active students reported regular condom use during the previous 6 months, with higher frequency in males than in females (33.8% vs 24.2%). No case of N. gonorrhoeae infection was detected, while C. trachomatis was found in 36 adolescents, with a prevalence of 1.7% (95% CI: 1.2-2.4) among sexually active students, and no statistical difference between females and males (1.9 and 1.4%, respectively). Inconsistent condom use (odds ratio, OR = 5.5) and having had more than one sexual partner during the previous 6 months (OR = 6.8) were associated with an increased risk of Chlamydia infection at multivariate analysis.

CONCLUSION

The prevalence of C. trachomatis infection among sexually active adolescents in Northern Italy was low, despite a high proportion of students who engage in risky sexual behaviour. No cases of N. gonorrhoeae infection were identified.

School-Based Sexually Transmitted Disease Screening: Review and Programmatic Guidance

School-based sexually transmitted disease (STD) screening (SBSS) was designed to provide chlamydia and gonorrhea testing, treatment, and counseling to adolescents in a school setting to overcome some of the difficulties of screening in this population. To inform STD control programs and other entities on decision making about potentially implementing this intervention, we reviewed existing published and gray literature on SBSS from 1998 to 2014. Although they are work-intensive to establish, school-based STD screening programs are a feasible and cost-effective way of testing large numbers of male and female adolescents for chlamydia and gonorrhea, and to provide counseling and treatment to almost all those who are found infected. School-based STD screening programs do not seem to reduce prevalence in either the school or the general adolescent population, although there are currently relatively few studies on large-scale SBSS. More research in this field is needed.

The project connect health systems intervention: linking sexually experienced youth to sexual and reproductive health care

PURPOSE

To evaluate a health systems intervention to increase adolescents' receipt of high-quality sexual and reproductive health care services.

METHODS

Quasi experimental design. Twelve high schools in a large public school district were matched into pairs. Within each pair, schools were assigned to condition so that no control school shared a geographic border with an intervention school. Five yearly surveys (T1, T2, …, T5) were administered from 2005 to 2009 (N = 29,823) to students in randomly selected classes in grades 9-12. Community-based providers of high-quality sexual and reproductive health care services were listed on a referral guide for use by school nurses to connect adolescents to care.

RESULTS

Statistically significant effects were found for intervention school females on three outcomes, relative to controls. Relative to T1, receipt of birth control in the past year was greater at T4 (adjusted odds ratio [AOR] = 1.85; 95% confidence interval [CI], 1.09-3.15) and T5 (AOR = 2.22; 95% CI, 1.32-3.74). Increases in sexually transmitted disease testing and/or treatment in the past year were greater in T1-T3 (AOR = 1.78; 95% CI, 1.05-3.02), T1-T4 (AOR = 1.73; 95% CI, 1.01-2.97), T1-T5 (AOR = 1.97; 95% CI, 1.17-3.31), and T2-T5 (AOR = 1.76; 95% CI, 1.06-2.91). Increases in ever receiving an HIV test were greater in T1-T4 (AOR = 2.14; 95% CI, 1.08-4.26). Among males, no intervention effects were found.

CONCLUSIONS

A school-based structural intervention can improve female adolescents' receipt of services.

Factors associated with Chlamydia trachomatis testing in a high school based screening and previously in clinical practice: a cross-sectional study in Norway

Background

High school based chlamydia screening has been shown to increase uptake and detect hidden infections among sexually active adolescents. Our study aimed to: i) examine the proportions of 15–20 year-olds tested in a high school based screening and previously in clinical practice, ii) determine chlamydia prevalence according to testing pattern, and iii) examine factors associated with testing in the two settings.

Methods

A population based cross-sectional study was conducted in 5 high schools in Norway in 2009, using web-questionnaires and Chlamydia trachomatis PCR in first-void urine (800 girls/818 boys, mean age 17.2 years). Only sexually active participants at risk for chlamydia infections were included in the analyses. Crude and multivariable logistic regression models were applied with ‘clinic based testing’ and ‘school based screening’ as outcome variables.

Results

56% of girls and 21% of boys reported previous clinic based testing. In the school based screening, 93% were tested with no gender difference. 42% of girls and 74% of boys were tested for the first time at school (‘school-only test’). Both girls with clinic based testing and girls with school-only test had high chlamydia prevalence (7.3% vs 7.2%). Boys with clinic based testing had twice the prevalence of those with school-only test (6.2% vs 3.0%, p = 0.01). Half of infections were detected in participants with school-only test. One-fifth were repeat infections. In multivariable analysis of girls and boys combined, female gender, older age, early sexual debut, no condom use at first and last intercourse, steady relationship, and higher number of lifetime partners increased the odds of clinic based testing. The odds of school based screening increased with male gender, academic affiliation, later sexual debut, condom use at first intercourse, and current urogenital symptoms in multivariable analysis.

Conclusions

More than half the girls had been tested prior to the school based screening and had high prevalence independent of previous clinic based testing. School screening was mostly associated with factors unknown to increase chlamydia infection risk, while clinic based testing was associated with traditional risk factors. The unusually high and equal participation between genders and the detection of a large chlamydia reservoir confirms the value of school based screening suggesting this approach to be further explored in Norway.

Pediatric emergency department provider perceptions of universal sexually transmitted infection screening

The purpose of this study was to describe the perceptions of pediatric emergency care providers in relation to implementing a universal sexually transmitted infection screening process for adolescent female patients in a pediatric emergency department. A descriptive qualitative design was used with a convenience sample of pediatric emergency physicians and nurses working in a large urban, pediatric teaching hospital. Participants were individually interviewed using a standard interview guide. Verbatim transcripts were analyzed using a modified constant comparative analysis method. Three overriding themes were identified that describe the perceptions of providers in relation to a universal screening process in a pediatric emergency department: Attitudes, Barriers, and Solutions. Universal sexually transmitted infection screening is one strategy that may help with early identification and treatment of adolescent female patients with undiagnosed sexually transmitted infections, and the pediatric emergency department is a potential site for such screening.

Most adolescents who participate in school-based screenings for sexually transmitted infections do not perceive themselves at high risk of sexually transmitted infection

Statements of study limitations have been made in a number of reports that voluntary participants in school-based screenings for sexually transmitted infections (STIs) may be individuals who self-select for participation because they perceive themselves at high risk of STI. We surveyed 3336 students participating in the New Orleans school-based screening for chlamydia and gonorrhoea to determine their perceived personal risk of STI. Among all screening participants, 1183 (35.5%) estimated that their chances of getting an STI were pretty high or very high and 2153 (64.5%) estimated that their chances were none, not very high or medium. These findings indicate that most participants in the New Orleans school-based screening for chlamydia and gonorrhoea do not perceive themselves at high risk of STI.

Adolescent STIs for primary care providers

PURPOSE OF REVIEW

Sexually transmitted infections (STIs) remain a significant source of morbidity among adolescents, who bear a disproportionate burden of disease. Many infections are asymptomatic, but pose significant risk for long-term sequelae in this at-risk population.

RECENT FINDINGS

Recommendations published within the last 5 years from the Centers for Disease Control, United States Preventive Services Task Force, and American Academy of Pediatrics are available to aid providers in appropriate screening, treatment, and prevention of common STIs. However, recent data indicate that many adolescents at risk for STIs are not being appropriately screened. In this review, we summarize screening and treatment recommendations for chlamydia and gonorrhea; prevention and screening recommendations for human papilloma virus (HPV); and appropriate testing for HIV and syphilis.

SUMMARY

Primary care providers are in a unique position to address STIs with adolescents. Improved adherence to screening, treatment, and vaccination recommendations by primary care providers is imperative to reduce prevalence, complications, and transmission of STIs in the adolescent population.