Adolescent Chlamydia Infection Defining the Problem Provider Role in Chlamydia Control Gale R Burstein, MD, MPH, FAAP Erie County Department of Health Women and Children s Hospital of Buffalo January 4, 2008 Outline The Problem Epidemiology Disease outcomes Adolescent susceptibility Provider role Screening Treating prevention Chlamydia is most common reportable communicable disease 3 million cases per year common Highest reported rates among adolescent females Usually asymptomatic Devastating sequela Epidemiology What is the population with the highest chlamydia rates? Age Gender Race Location 1
Chlamydia Prevalence in Adolescent Females 15%-29% prevalence in inner-city populations highest rates in younger teens 5%-10% prevalence in suburban populations High reinfection rates within 3-6 months (10%- 26%) 80% of infections asymptomatic Chlamydia Prevalence by Age Females Tested by PCR in Baltimore City Clinics,1994-1996 Reported FEMALE Chlamydia Cases by Age, Erie County, 2006 % CT+ 30 25 20 15 10 5 0 % CT+ 13 14 15 16 16 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 2% 10% 12% 35% 40% N =3,131 <15 yrs 15-19 yrs 20-24 yrs 25-29 yrs 30+ yrs Burstein JAMA 1998;280:521-6 Age Chlamydia Rates by state: United States and outlying areas, 2005 Chlamydia Rates by race/ethnicity: United States, 1996 2005 Guam 485.9 300.1 258.9 250.9 200.9 231.6 313.6 192.6 364.2 335.4 370.2 444.3 VT 154.0 262.8 171.1 NH 141.7 MA 224.6 239.0 RI 302.5 350.4 371.4 332.7 CT 315.1 383.0 NJ 220.2 250.1 300.3 291.8 DE 408.5 382.3 397.7 321.6 MD 329.1 271.2 162.2 303.9 388.7 201.4 365.1 391.2 Rate per 100,000 380.5 309.1 435.8 population Rate (per 100,000 population) 1600 White Black Hispanic 1280 Asian/Pac Isl Am Ind/AK Nat 960 664.4 434.7 319.5 381.5 732.6 377.7 380.1 249.3 <=150.0 (n= 2) 150.1-300.0 (n= 18) >300.0 (n= 33) 640 320 Puerto Rico 95.4 Virgin Is. 216.0 Note: The total rate of chlamydia for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 329.5 per 100,000 population. 0 1996 97 98 99 2000 01 02 03 04 05 2
Chlamydia Sequela Females Males Female Sequela Pelvic inflammatory disease Sx and Asx Up to 40% risk Infertility (1 in 5) Ectopic pregnancy (1 in 10) Chronic pelvic pain (1 in 5) HIV transmission 3-5 fold risk Male Sequela Not much Epididymitis Reiter s Syndrome HIV transmission Why are STIs an Adolescent Health Problem? Youth Risk Behavior Surveillance Survey (YRBSS) Nationally representative sample of high school students Ask about 6 categories of risk behaviors Implemented every 2 years Most recent published data from 2005 2005 YRBSS Results Sexual Risk Behaviors, New York State (excluding NYC) 39% of all students have had sexual intercourse during their lifetime 3% of all students initiated sexual intercourse before 13 years of age 10% of all students had >4 lifetime sex partners 3
2005 YRBSS Results Currently Sexually Active Students Behaviors New York State (excluding NYC) 71% reported condom use during their last sexual intercourse Adolescent Susceptibility to STIs 17% reported either they or their partner had used birth control pills before last sex 20% had used drugs or alcohol at last sexual intercourse Physical Cervical ectopy Smaller introitus - more trauma Forced sexual contact - dry/traumatic sex No immunity from prior chlamydia infection Asymptomatic nature Early Adolescence Behavioral Cognitive Stage of Development Concrete thinkers more likely to have unprotected sex serial monogamous relationships 4
Personal Fable New skill of hypothetical thinking & belief of uniqueness Teens believe are invulnerable Those things only happen to others - never to me. Believe only others can get infected with STIs Minimize perceived risk of behaviors Access to Care Confidential services Lack of Medical Home Poverty major determinant for lack of insurance and access to 1 care (Newacheck Pediatrics 1999;104:195-202) 20% adolescents forgone health care within past year (Ford JAMA1999;282:2227-2234) Adolescent Females with Older Male Partners Predisposes adolescent females to relationship power imbalance sexual negotiation more difficult for younger females risk of involuntary intercourse, lack of protective behavior, and exposure to STIs Benefits of Early Sexual Activity Gaining peer acceptance and respect Establishing autonomy from parents Repudiating conventional authority norms and values Coping with anxiety, frustration, and anticipation of failure Affirming maturity Transitioning from childhood to adulthood Chlamydia Screening National Guidelines U.S. Chlamydia trachomatis Screening Recommendations Universal annual screening of all sexually active females <25 years old CDC, USPSTF, AAP, AMA, ACOG, AAFP Universal screening sexually active females <25 years old with NAATs is cost effective if prevalence 2.3%* No clear recommendations for male chlamydia screening *Howell MR, et al. Sex Transm Dis 1997 5
2006 Chlamydia Screening HEDIS Rates Age Commercial Medicaid (yrs) (%) (%) 16-20 21-26 Health Plan Type 36 38 The State of Health Care Quality, 2007 National Center for Quality Assurance at: http://web.ncqa.org/portals/0/publications/resource%20library/sohc/sohc_07.pdf 51 55 1999 YRBSS: Health Services Delivery >50% of students reported a preventive health care visit in the past 12 months <50% reported an STD, HIV, or pregnancy prevention discussion at those visits 43% of students 26% of students older, sexually active, hormonal contraception using - females most likely to have reproductive health dialogue Burstein GR, et al. Pediatrics 2003;111:996-1001. Burstein GR, et al. Pediatrics 2003;111:996-1001 Barriers to Primary Care Provider STI Risk Assessment Barriers to Primary Care Provider STI Risk Assessment Limited well care and primary care, especially in adolescents Competing priorities / lack of time Lack of reimbursement Belief that patient population s STI prevalence is low Lack of provider training Lack of provider and patient comfort No available confidential health care services in commercial health plans Information Sources for Reported Chlamydia Cases: United States, 2000 Chlamydia Cases by reporting source and sex: United States, 1996 2005 23% 18% STD Clinic Other Corrections Facility 2% 10% FP Clinic ER 6% Cases (in thousands) 750 600 450 300 non-std Clinic Male non-std Clinic Female STD Clinic Male STD Clinic Female Hospital 10% 31% Private Clinic/HMO 150 0 1996 97 98 99 2000 01 02 03 04 05 6
Nucleic Acid Amplification Test (NAAT) Chlamydia Test Performance Amplify nucleic acid sequences specific to organism being detected Do not require viable organisms Most sensitive chlamydia tests Endocervical, urethral, urine, (self collected vaginal swab for Aptima) specimens Can detect GC and CT in single specimen Test NAAT Culture Nonamplified Sensitivity (%) 85-95 70 65 Specificity (%) 97-99.5 100 98-99 Expensive Amplicor FDA-Cleared CT/GC NAATs Polymerase chain reaction (PCR) Roche Molecular Systems (Branchburg, NJ) Aptima Transcription mediated amplification (TMA) Gen-Probe (San Diego, CA) BD ProbeTec Strand displacement amplification (SDA) Becton Dickinson (Franklin Lakes, NJ) Chlamydia Rx Chlamydia Rx Chlamydia F/U Single-dose Rx: Azithromycin 1 gm x 1 Preferred Rx during pregnancy OR Doxycyclin 100 mg BID x 7 days Very high reinfection risk No health dept partner notification resources Effectiveness equivocal 7
Provider s role to prevent repeat infection sequela Test of Reinfection: 3-4 months after Rx or whenever pt presents to clinic within next 12 month Partner notification Provider Referral Patient Referral Expedited Partner Therapy Patient-Delivered Partner Therapy Providers give patients medication intended for the partners Providers prescribe extra doses of medication in the index patients names Providers write partners prescriptions for medication EPT effect on repeat CT infections Randomized controlled trial evaluating partner management strategies to prevent repeat CT infections sample of 1454 diagnosed with CT infection compared EPT vs patient referral Trend for CT infection at follow-up among in EPT arm, but infection rates in both groups were high at follow-up: 12% CT infections among in EPT arm 15% CT infections among in patient referral arm Odds Ratio = 0.80 (95% CI = 0.62 1.05; P=.102) Schillinger, et al. Sex Transm Dis 2003;30(1):49-56. Behaviors affecting EPT effectiveness EPT-specific Patients did not give Rx to any/all partners General non-compliance Patients noncompliant with Rx Patients did not contact partner(s) Partners noncompliant with Rx Resumed sex <7 days after case and partner treatment Sex with new partner(s) Effect of EPT to prevent recurrent or persistent GC or CT infections Partner Management Strategies among NYC Providers % Persistent or Recurrent Gonorrhea and Chlamydial Infection with EPT vs Patient/Provider Referral in Seattle, WA. Index Case Dx* EPT (%) Referral (%) RR (95% CI) Gonorrhea 3 11 0.32 (0.13 0.77) Chlamydia 11 13 0.82 (0.62 1.07) GC or CT 10 13 0.76 (0.59 0.98) *N=2751 Golden, et al. NEJM 2005;352:676-685. 94% use patient referral frequently 49% ever used PDPT 27% use PDPT frequently Rogers ME, et al. Sex Transm Dis. 2007;34(2):88-92. 8
EPT Legal Status Permissible in 11 states Possible is 28 states Prohibited in 13 states CDC Recommendations Providers consider including EPT as part of their regular STI care EPT is useful option to further partner treatment Especially for male partners of chlamydia- or gonorrhea-infected females CDC STD Treatment Guidelines 2006 recommend EPT as option for partner treatment among heterosexual persons with chlamydia or gonorrhea Policy makers remove systemic barriers EPT Dear Colleague letter available at: www.cdc.gov/std/dearcolleagueept5-10-05.pdf Syphilis Reported cases by stage of infection: United States, 1941 2004 Chlamydia Rates: United States, 1984 2004 Cases (in thousands) 600 480 P&S Early Latent Total Syphilis Rate (per 100,000 population) 350 280 360 210 240 140 120 70 0 0 1941 46 51 56 61 66 71 76 81 86 91 96 2001 1984 86 88 90 92 94 96 98 2000 02 04 Note: As of January 2000, all 50 states and the District of Columbia had regulations requiring the reporting of chlamydia cases. Chlamydia Reporting New York State Chlamydia Reporting Chlamydia became reportable disease in NYS in August of 2000 last state to make chlamydia reportable Who reports? How to report? 9
Who Reports in NY State? Why Report Communicable Diseases?? Labs via Electronic Clinical Laboratory Reporting System (ECLRS) Positive test data for all NYS reportable disease automatically transferred to health departments Providers via DC-103 form or calling ECDOH Physicians are required to report selected communicable diseases to the local health department under NY State Sanitary Code (10NYCRR 2.10). Mandatory laboratory reporting does not negate the physician reporting requirement. Allows ECDOH to detect outbreaks, prevent 2 transmission, identify newly emerging infections, and evaluate control measures effectiveness Labs only report positive test results to ECDOH suspected/confirmed case report may be the only notification LHD receives. ECDOH can assist physicians with accessing appropriate lab tests to confirm suspected cases. Reported Communicable Diseases, Erie County, 2006 Gonorrhea 1,791 Chlamydia 4,199 All other 49 diseases 1,700 What do we do now? Erie County Department of Health Tel: 716-858-7697 Fax: 716-858-7964 10