Estimates of the direct cost per case and overall burden of trichomoniasis for the employer-sponsored privately insured women population in the United States, 2001 to 2005

Prevalence, Associated Factors, and Appropriateness of Empirical Treatment of Trichomoniasis, Bacterial Vaginosis, and Vulvovaginal Candidiasis among Women with Vaginitis

Trichomoniasis (TV), bacterial vaginosis (BV), and vulvovaginal candidiasis (VVC) are the most common causes of vaginitis. This study investigated the prevalence of these diagnoses, their associated factors, and the appropriateness of the empirical treatment. From March 25, 2019, to June 17, 2022, 429 women with symptoms or signs of vaginitis were enrolled in a hospital in northern Taiwan with 438 episodes of vaginitis. Vaginal swabs were collected for Gram's staining, in vitro cultures for Trichomonas vaginalis, bacteria, and yeasts, and multiplex PCR assay for TV, BV, and VVC. Their empirical treatments were recorded. Factors associated with different etiologies of vaginitis were sought in multivariable logistic regression models. The prevalence of TV, BV, and VVC were 2.1%, 22.8%, and 21.7%, respectively, while coinfections of BV and VVC, TV and BV, TV and VVC, and triple infection occurred in 5.0%, 0.2%, 0.2%, and 0.7%, respectively. Multivariable analyses revealed that having multiple sexual partners was associated with TV and BV (adjusted odds ratio [aOR] 9.756 and 3.246, respectively), while menopausal women were less likely to have VVC (aOR 0.184). Moreover, dysuria was associated with TV (aOR 4.981), vaginal itch and pelvic pain with VVC (aOR 3.223 and 0.425, respectively), and discharge pH > 4.5 with BV (aOR 1.767). Other clinical symptoms and pelvic examination features had limited value for differential diagnosis. Among the 78 empirical antifungal and metronidazole prescriptions, 55.2% were ineffective or unnecessary. Our study highlights the importance to integrate appropriate diagnostic tools into the clinical care of women with vaginitis. IMPORTANCE Vaginal complaints are widespread among women and are associated with emotional, physical, and economic burdens with challenges in their diagnosis and management. In this survey, we identified that 40% of vaginitis in Taiwan was caused by either trichomoniasis, bacterial vaginosis, vulvovaginal candidiasis, or a combination of these infections. Our data suggested that typical physical findings appeared infrequently among women with these infections and their empirical treatments were frequently inappropriate. Our findings highlighted the importance of integrating proper diagnostic tools into clinical practice to improve the diagnosis and management of vaginitis, as recommended by national and international guidelines.

Genital Mycoplasma, Shigellosis, Zika, Pubic Lice, and Other Sexually Transmitted Infections: Neither Gone Nor Forgotten

ABSTRACT

Most estimates of the combined burden and cost of sexually transmitted infections (STIs) in the United States have focused on 8 common STIs with established national surveillance strategies (chlamydia, gonorrhea, syphilis, trichomoniasis, genital herpes, human papillomavirus, and sexually transmitted human immunodeficiency virus and hepatitis B). However, over 30 STIs are primarily sexually transmitted or sexually transmissible. In this article, we review what is known about the burden of "other STIs" in the United States, including those where sexual transmission is not the primary transmission route of infection. Although the combined burden of these other STIs may be substantial, accurately estimating their burden due to sexual transmission is difficult due to diagnostic and surveillance challenges. Developing better estimates will require innovative strategies, such as leveraging existing surveillance systems, partnering with public health and academic researchers outside of the STI field, and developing methodology to estimate the frequency of sexual transmission, particularly for new and emerging STIs.

Estimating the Direct Medical Outpatient Costs of Diagnosis and Treatment of Trichomoniasis Among Commercially Insured Patients in the United States, 2016 to 2018

ABSTRACT

We used 2016-2018 outpatient claims data to calculate direct outpatient medical costs per case of trichomoniasis in 2019 US dollars. The outpatient, drug, and total costs per treated case of trichomoniasis were $174, $39, and $213, respectively. Total costs were higher for female patients ($220) than for male patients ($158).

The Impact of Hurricane Sandy on HIV Testing Rates: An Interrupted Time Series Analysis, January 1, 2011‒December 31, 2013

BACKGROUND

Hurricane Sandy made landfall on the eastern coast of the United States on October 29, 2012 resulting in 117 deaths and 71.4 billion dollars in damage. Persons with undiagnosed HIV infection might experience delays in diagnosis testing, status confirmation, or access to care due to service disruption in storm-affected areas. The objective of this study is to describe the impact of Hurricane Sandy on HIV testing rates in affected areas and estimate the magnitude and duration of disruption in HIV testing associated with storm damage intensity.

METHODS

Using MarketScan data from January 2011‒December 2013, this study examined weekly time series of HIV testing rates among privately insured enrollees not previously diagnosed with HIV; 95 weeks pre- and 58 weeks post-storm. Interrupted time series (ITS) analyses were estimated by storm impact rank (using FEMA's Final Impact Rank mapped to Core Based Statistical Areas) to determine the extent that Hurricane Sandy affected weekly rates of HIV testing immediately and the duration of that effect after the storm.

RESULTS

HIV testing rates declined significantly across storm impact rank areas. The mean decline in rates detected ranged between -5% (95% CI: -9.3, -1.5) in low impact areas and -24% (95% CI: -28.5, -18.9) in very high impact areas. We estimated at least 9,736 (95% CI: 7,540, 11,925) testing opportunities were missed among privately insured persons following Hurricane Sandy. Testing rates returned to baseline in low impact areas by 6 weeks post event (December 9, 2012); by 15 weeks post event (February 10, 2013) in moderate impact areas; and by 17 weeks after the event (February 24, 2013) in high and very high impact areas.

CONCLUSIONS

Hurricane Sandy resulted in a detectable and immediate decline in HIV testing rates across storm-affected areas. Greater storm damage was associated with greater magnitude and duration of testing disruption. Disruption of basic health services, like HIV testing and treatment, following large natural and man-made disasters is a public health concern.  Disruption in testing services availability for any length of time is detrimental to the efforts of the current HIV prevention model, where status confirmation is essential to control disease spread.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

The Annual Economic Burden of Syphilis: An Estimation of Direct, Productivity, and Intangible Costs for Syphilis in Guangdong Initiative for Comprehensive Control of Syphilis Sites

BACKGROUND

Syphilis has continuously posed a great challenge to China. However, very little data existed regarding the cost of syphilis. Taking Guangdong Initiative for Comprehensive Control of Syphilis area as the research site, we aimed to comprehensively measure the annual economic burden of syphilis from a societal perspective.

METHODS

Newly diagnosed and follow-up outpatient cases were investigated by questionnaire. Reported tertiary syphilis cases and medical institutions cost were both collected. The direct economic burden was measured by the bottom-up approach, the productivity cost by the human capital method, and the intangible burden by the contingency valuation method.

RESULTS

Three hundred five valid early syphilis cases and 13 valid tertiary syphilis cases were collected in the investigation to estimate the personal average cost. The total economic burden of syphilis was US $729,096.85 in Guangdong Initiative for Comprehensive Control of Syphilis sites in the year of 2014, with medical institutions cost accounting for 73.23% of the total. Household average direct cost of early syphilis was US $23.74. Average hospitalization cost of tertiary syphilis was US $2,749.93. Of the cost to medical institutions, screening and testing comprised the largest proportion (26%), followed by intervention and case management (22%) and operational cost (21%). Household average productivity cost of early syphilis was US $61.19. Household intangible cost of syphilis was US $15,810.54.

CONCLUSIONS

Syphilis caused a substantial economic burden on patients, their families, and society in Guangdong. Household productivity and intangible costs both shared positive relationships with local economic levels. Strengthening the prevention and effective treatment of early syphilis could greatly help to lower the economic burden of syphilis.

Giardiasis Diagnosis and Treatment Practices Among Commercially Insured Persons in the United States

Background

Giardiasis, the most common enteric parasitic infection in the United States, causes an estimated 1.2 million episodes of illness annually. Published clinical recommendations include readily available Giardia-specific diagnostic testing and antiparasitic drugs. We investigated sequences of giardiasis diagnostic and treatment events using MarketScan, a large health insurance claims database.

Methods

We created a longitudinal cohort of 2995 persons diagnosed with giardiasis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 007.1) from 2006 to 2010, and analyzed claims occurring 90 days before to 90 days after initial diagnosis. We evaluated differences in number and sequence of visits, diagnostic tests, and prescriptions by age group (children 1-17 years, adults 18-64 years) using χ2 tests and data visualization software.

Results

Among 2995 patients (212433 claims), 18% had a Giardia-specific test followed by or concurrent with an effective antiparasitic drug, without ineffective antibiotics. Almost two-thirds of patients had an antiparasitic and 27% had an antibiotic during the study window. Compared with children, adults more often had ≥3 visits before diagnosis (19% vs 15%; P = .02). Adults were also less likely to have a Giardia-specific diagnostic test (48% vs 58%; P < .001) and more likely to have an antibiotic prescription (28% vs 25%; P = .04). When Giardia-specific tests and antiparasitic and antibiotic prescriptions were examined, pediatric clinical event sequences most frequently began with a Giardia-specific test, whereas adult sequences most frequently began with an antiparasitic prescription.

Conclusions

Giardiasis care infrequently follows all aspects of clinical recommendations. Multiple differences between pediatric and adult care, despite age-agnostic recommendations, suggest opportunities for provider education or tailored guidance.

Productivity costs of nonviral sexually transmissible infections among patients who miss work to seek medical care: evidence from claims data

BACKGROUND

Productivity losses can arise when employees miss work to seek care for sexually transmissible infections (STIs). We estimated the average productivity loss per acute case of four nonviral STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis.

METHODS

We extracted outpatient claims from 2001-2005 MarketScan databases using International Classification Disease ver. 9 (ICD-9) codes. We linked claims with their absence records in the Health and Productivity Management database by matching enrolee identifiers and the service dates from the claims such that our final data included only those who were absent because they were sick and were diagnosed with an STI on the day of their visit. To ensure that the visit was for the STIs being examined, we restricted the criteria to records with the specified ICD-9 codes only, excluding claims with other codes. We estimated the average number of hours absent and multiplied it by the mean hourly wage rate including benefits ($29.72 in 2011 United States dollars) to estimate the average productivity loss per case.

RESULTS

The average productivity losses per case were: $262 for chlamydia, $197 for gonorrhoea, $419 for syphilis and $289 for trichomoniasis. There were no significant differences between males and females.

CONCLUSIONS

Among those who take sick leave to seek care, productivity losses associated with treating nonviral STIs may be higher than their estimated direct medical costs. These productivity cost estimates can help to quantify the overall STI burden, and inform cost-effectiveness analyses of prevention and control efforts.

Characteristics and predictors of women who obtain rescreening for sexually transmitted infections using the www.iwantthekit.org screening programme

Professional organizations recommend rescreening chlamydia-infected women. The iwantthekit Internet-screening programme offered rescreening opportunities by using iwantthekit. Mailed, home-collected vaginal swabs were tested for chlamydia, gonorrhoea, and trichomoniasis by nucleic acid amplification tests. Demographics and risk behaviours of repeat users were determined from questionnaires. Predictors of repeat users were measured in a matched case-control study. Of 1747 women, 304 (17%), who used iwantthekit, indicated they had used the kit previously. Mean age was 24.7 ± 5.7 years and 69% were African-American. Repeat iwantthekit users were more likely to be aged ≥ 20 years (OR=2.10); were more likely to have been treated for a sexually transmitted infection (OR=2.32); less likely to drink alcohol before sex (OR=0.63); and to never use condoms (OR=0.43). Of repeat users, 84.2% had a negative prior test and 15.8% had a positive. At current test, 13.2% were infected. Previous trichomoniasis was associated with current trichomoniasis (p<0.05). The iwantthekit may offer rescreening opportunities for previously infected women.

The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008

BACKGROUND

Millions of cases of sexually transmitted infections (STIs) occur in the United States each year, resulting in substantial medical costs to the nation. Previous estimates of the total direct cost of STIs are quite dated. We present updated direct medical cost estimates of STIs in the United States.

METHODS

We assembled recent (i.e., 2002-2011) cost estimates to determine the lifetime cost per case of 8 major STIs (chlamydia, gonorrhea, hepatitis B virus, human immunodeficiency virus (HIV), human papillomavirus, genital herpes simplex virus type 2, trichomoniasis and syphilis). The total direct cost for each STI was computed as the product of the number of new or newly diagnosed cases in 2008 and the estimated discounted lifetime cost per case. All costs were adjusted to 2010 US dollars.

RESULTS

Results indicated that the total lifetime direct medical cost of the 19.7 million cases of STIs that occurred among persons of all ages in 2008 in the United States was $15.6 (range, $11.0-$20.6) billion. Total costs were as follows: chlamydia ($516.7 [$258.3-$775.0] million), gonorrhea ($162.1 [$81.1-$243.2] million), hepatitis B virus ($50.7 [$41.3-$55.6] million), HIV ($12.6 [$9.5-$15.7] billion), human papillomavirus ($1.7 [$0.8-$2.9] billion), herpes simplex virus type 2 ($540.7 [$270.3-$811.0] million), syphilis ($39.3 [$19.6-$58.9] million), and trichomoniasis ($24.0 [$12.0-$36.0] million). Costs associated with HIV infection accounted for more than 81% of the total cost. Among the nonviral STIs, chlamydia was the most costly infection.

CONCLUSIONS

Sexually transmitted infections continue to impose a substantial cost burden on the payers of medical care in the United States. The burden of STIs would be even greater in the absence of STI prevention and control efforts.

A brief review of the estimated economic burden of sexually transmitted diseases in the United States: inflation-adjusted updates of previously published cost studies

We conducted a literature review of studies of the economic burden of sexually transmitted diseases in the United States. The annual direct medical cost of sexually transmitted diseases (including human immunodeficiency virus) has been estimated to be $16.9 billion (range: $13.9-$23.0 billion) in 2010 US dollars.

Trichomonas vaginalis infection in women who submit self-obtained vaginal samples after internet recruitment

BACKGROUND

Submission of self-obtained vaginal samples (SOVs) collected at home could remove barriers that women face in getting tested for sexually transmitted infections (STIs). Internet recruitment of SOVs is highly acceptable.

METHODS

Sexually active women ≥14 years were recruited by an educational Internet program, available at: www.iwantthekit.org (IWTK), which offered free testing for trichomonas as part of a panel, which also offered testing for chlamydia and gonorrhea. Kits were ordered online, SOVs were sent through US mail to the laboratory, and tested by nucleic acid amplification tests. Demographics and sexual risk factors were accessed by questionnaires. Women called or were contacted to receive their results.

RESULTS

Of women requesting kits, 1525 (43%) returned swabs by mail. In all, 61% were <25 years, 52% were black, and 80% were single. Vaginal discharge was reported by 44%, prevalence for trichomonas was 10% (10% for chlamydia, 1% for gonorrhea), and 18% had at least one prevalent STI. Multivariate logistic regression demonstrated several significantly associated risks factors as follows: adjusted odds ratio for black race was 2.69; for residence of Illinois, 3.85; for not having health insurance, 1.57; for lack of a bachelor's degree, 5.53; for having 2 to 15 partners, 1.60; for having ≥16 partners in previous year, 3.51; for being bisexual, 2.0; for not always using condoms, 3.04; and for having a partner who had a previous STI, 1.71. Age was not associated with trichomonas infection. All infected women were treated.

CONCLUSIONS

A high prevalence of trichomonas and high sexual risk factors were demonstrated. Internet recruitment was a useful method of screening women for trichomonas infection.

Costs and effectiveness of neonatal male circumcision

OBJECTIVE

To evaluate the expected change in the prevalence of male circumcision (MC)-reduced infections and resulting health care costs associated with continued decreases in MC rates. During the past 20 years, MC rates have declined from 79% to 55%, alongside reduced insurance coverage.

DESIGN

We used Markov-based Monte Carlo simulations to track men and women throughout their lifetimes as they experienced MC procedure-related events and MC-reduced infections and accumulated associated costs. One-way and probabilistic sensitivity analyses were used to evaluate the impact of uncertainty.

SETTING

United States.

PARTICIPANTS

Birth cohort of men and women.

INTERVENTION

Decreased MC rates (10% reflects the MC rate in Europe, where insurance coverage is limited).

OUTCOMES MEASURED

Lifetime direct medical cost (2011 US$) and prevalence of MC-reduced infections.

RESULTS

Reducing the MC rate to 10% will increase lifetime health care costs by $407 per male and $43 per female. Net expenditure per annual birth cohort (including procedure and complication costs) is expected to increase by $505 million, reflecting an increase of $313 per forgone MC. Over 10 annual cohorts, net present value of additional costs would exceed $4.4 billion. Lifetime prevalence of human immunodeficiency virus infection among males is expected to increase by 12.2% (4843 cases), high- and low-risk human papillomavirus by 29.1% (57 124 cases), herpes simplex virus type 2 by 19.8% (124 767 cases), and infant urinary tract infections by 211.8% (26 876 cases). Among females, lifetime prevalence of bacterial vaginosis is expected to increase by 51.2% (538 865 cases), trichomoniasis by 51.2% (64 585 cases), high-risk human papillomavirus by 18.3% (33 148 cases), and low-risk human papillomavirus by 12.9% (25 837 cases). Increased prevalence of human immunodeficiency virus infection among males represents 78.9% of increased expenses.

CONCLUSION

Continued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women.