Epidemiological study on STIs in medical clinics in Mississippi during the COVID-19 pandemic

1. CHAPTER 1: INTRODUCTION Overview The purpose of this epidemiological study is to describe the incidence of gonorrhea and chlamydia in primary medical clinics in the Mississippi Delta during the COVID-19 pandemic. The present section discusses the background and significance of the present study and states the research questions the study used. Finally, the section provides a brief overview of all the sections included in the present study. Background Epidemiologists and health care providers monitor disease incidences to make informed decisions and be prepared for new infections. Sexually transmitted infections (STIs) are prevalent with increasing incidence rates worldwide (World Health Organization [WHO], 2019). More than 1 billion STIs are acquired every day worldwide, including chlamydia, gonorrhea, syphilis, trichomoniasis,herpes simplex virus, and human papillomavirus (WHO, 2019). More than 2.5 million cases of chlamydia, gonorrhea and syphilis were reported in 2019 in the US (Centers for Disease Control and Prevention [CDC], 2021). The number of STI cases in the U.S. reached an all-time high for the sixth consecutive year in 2019, which implies STIs are a growing concern for the US healthcare system (CDC, 2021). The official data for the incidence of STIs in the US during the pandemic in 2020 has not yet been published. Mississippi is one of the southern states in the U.S. The estimated population of Mississippi as of July 1, 2019, was 2,976,149, among which 59.1% were whites, 37.8% were blacks, 3.4% were Hispanics or Latinos, and 1.1% Asians (U.S. Census Bureau, 2019). The per capita income from 2014-2018 was $23,434, with a poverty rate of 19.6% (U.S. Census Bureau, 2019). Mississippi has 82 counties; 18 of these counties are located in the Mississippi Delta,

2. which lies in the northwest section of the state. Fifteen counties in the Mississippi Delta are predominantly African Americans except for Desoto county (U.S. Census Bureau, 2019). The per capita income in the Mississippi Delta ranges between $13,924 to $23,793 (U.S. Census Bureau, 2019). Gonorrhea is caused by a bacterium Neisseriagonorrhea, which grows in the reproductive tract of women and in the urinary tract in both men and women (Mississippi State Department of Health [MSDOH], 2020). Men have a burning sensation when urinating or a discharge from the urethra. Women can have a mild course but can lead to pelvic inflammatory disease, with a risk of infertility (MSDOH, 2020). Mother to the fetal transmission can occur during labor and delivery. Left untreated, gonorrhea can spread to the blood or joints and become life-threatening (MSDOH, 2020). Individuals who have gonorrhea are more likely to get HIV compared to individuals who are gonorrhea-free (CDC, 2021). This is because the same behaviors and circumstances that may put these individuals at risk for getting gonorrhea can also put them at greater risk for getting other STIs such as chlamydia and HIV (CDC, 2021). Chlamydia, caused by a bacterium ChlamydiaTrachomatis, is the most common STI in the US (CDC, 2021). The common symptoms include painful urination, discharge from the penis or vagina, painful sexual intercourse and bleeding between periods in women, and testicular pain in men (Zhou et al., 2019). Chlamydia can also infect the rectum with rectal pain, discharge, bleeding, or no signs (Zhou et al., 2019). CDC (2021) recommends chlamydia screening for sexually active women of 25 or younger, pregnant women, and women and men in risk groups. The common risk factors include having unprotected sex, multiple sexual partners, and men having sex with men (CDC, 2021). Chlamydia is more prevalent than gonorrhea (1.8 million cases against 616,392 cases in 2019 in the US); however, gonorrhea's prevalence growth is

3. higher than that of Chlamydia (CDC, 2021). Significance The significance of epidemiological studies is difficult to overstate. According to CDC (n.d.), "epidemiology is the study of the origin and causes of diseases in a community" (para. 1.). Epidemiological studies help to get to the root of health problems and disease outbreaks in communities (CDC, n.d.). Epidemiological studies gather information on demographics, prevailing symptoms, healthcare use, and treatments (CDC, n.d.). Epidemiological studies help to monitor the changes in disease prevalence and prevent future outbreaks of diseases (CDC, n.d.). Today, the importance of epidemiological studies is growing due to the COVID-19 pandemic. According to Lipsitch et al. (2020), the need for epidemiological studies is growing as the coronavirus is rapidly evolving. Such studies help to understand how the symptoms and transmission patterns are changing (Lipsitch et al., 2020). Additionally, such studies help to understand how the virus affects patients of different ages and races (Lipsitch et al., 2020). Thus, epidemiological studies are crucial during the pandemic. The present study describes the incidence of gonorrhea and chlamydia during the COVID-19 pandemic in the Mississippi Delta. The study is expected to help trace the changes in the prevalence of these STIs in the community. Local authorities can use the information to understand if the epidemiology of the diseases under analysis is changing. In case there are concerning patterns in the epidemiology of gonorrhea and chlamydia, the authorities may consider creating prevention programs that would help to control the disease transmissions. Research Questions The present research was guided by two research questions listed below:

4. RQ1: What was the prevalence of gonorrhea and chlamydia among people screened for STIs between July 1, 2020, and September 1, 2020, in the Mississippi Delta? RQ2: How did the prevalence of STIs among tested individuals between July 1, 2020, and September 1, 2020, in the Mississippi Delta compare to the prevalence of these STIs among tested individuals in previous years? Paper Overview The present paper consists of dour parts. First, a brief literature review is provided concerning the epidemiology of the diseases under analysis. Second, the methods used by the study are discussed, including the sampling strategy, data collection methods, and analysis procedures. Third, the results of the analysis are presented and discussed in a comprehensive manner. Finally, the conclusions are drawn from the study with recommendations for future research. CHAPTER 2: LITERATURE REVIEW In the United States, the incidence of chlamydia increased from 2000 to 2012 but then decreased from 2012 to 2013. It increased from 708,698 cases (a rate of 251.2/100,000) in 2000 to 1,401,906 cases (443.3/100,000) in 2013 and 1,758,666 cases (a rate of 539.9 per 100,000 population) in 2018. In Mississippi, the incidence of various STIs remains extremely high. Mississippi is ranked 3rd in 2018 for chlamydia infections in terms of rate/100,000 population (CDC, 2021). In Mississippi, there were 22,086 cases reported to the CDC (a rate of 326.7 per 100,000 population) in 2018, up from 12,697 cases (a rate of 445.8/100,000 population) in 2000 (MSDH, 2020). Of these cases, 23.57% were reported from the Mississippi Delta (MSDH, 2020). CDC (2021) revealed that there were more women with chlamydia in Mississippi (15,325 cases with the rate of 996.3/100,000) compared to men with chlamydia (Mississippi: 6,723 cases,

5. with a rate of 465/100,000). Thus, women at a higher risk of having chlamydia than men. Chlamydia infections have been increasing in both men and women since 2013. Individuals within the age group 20-24 years have had the highest incidence since 2015, from 6,912 cases (a rate of 3,124.7/100,000 population) in 2015 to 8,519 cases (rate of 4,068.5/100,000 population) in 2018 (CDC, 2021). This is followed by individuals in the age group 15-19 years (7,186 cases, a rate of 3,493.3/100,000 population), then the age group 25-29 with 3,697 cases, then age group 30-34 with 1,295 cases, and then age group 35-39 with 592 cases (CDC, 2021). Cases seen in other age groups, though small in number, have also been steadily increasing since 2015 (CDC, 2021). African Americans have always had the highest reported cases both at the national and state levels compared to other races/ethnicities, and in 2018 there were 484,785 cases (rate of 1192.5/100,000 population) reported in the US and 12, 031 cases (rate of 1077.7/100,000 population) in Mississippi (MSDH, 2020). Caucasians are next with 419,627 cases (rate of 212.1/100,000 population) in the US and 2,695 cases (rate of 159.3/100,000 population) in Mississippi in 2018 (MSDH, 2020). Despite surveillance and treatment availability, the prevalence of chlamydia is still growing, which increases the financial burden on the US healthcare system in general and Mississippi's healthcare system in particular. Gonorrhea is prevalent in the US. Although reported cases decreased from 2008 to 2009 and 2012 to 2013, and despite testing and treatments, it has steadily been increasing since 2013. Mississippi was ranked the highest in 2018 for the number of newly diagnosed cases of gonorrhea, with a rate of 326.7 per 1000,000 population (or 9,749 cases), consistently increasing since 2013 (CDC, 2021). Approximately 22.57% of these infections were reported from the Mississippi Delta Region. There were 4,888 cases, at a rate of 317.8/100,000 population in

6. women, and 4,846 cases, a rate of 317.8/100,000 population in men (CDC, 2021). This implies that there were no significant differences in the prevalence of gonorrhea between men and women. Gonorrhea infections were reported from different age groups. Individuals in the age group 20-24 have consistently reported the highest rate per 100,000 population since 2013, a rate of 1564.1/100,000 population (MSDH, 2020). This same age group also has the highest cases in the US, with 157,708 cases (rate of 3275/100,000 population) (CDC, 2021). Age group 25-29 years has the second-highest reported cases in the US with 129,385 cases but the age group 15- 19 years has the second-highest in Mississippi with 2,202 cases (rate of 1067.4/100,000 population) (MSDH, 2020). Age group 25-29 has the 3rd highest reported cases in Mississippi, with 2,032 cases (MSDH, 2020). This trend was linked to the increasing number of young individuals who were engaging in risky sexual behaviors Advocates for Youth, 2016). Lower numbers were reported in older adults, but CDC (2021) stated that gonorrhea infections have been increasing since 2013 in all age groups. This is partly because of high rates of quinolone resistance, increasing azithromycin resistance, and emerging resistance to extended-spectrum cephalosporins (WHO, 2019). Drug resistance for gonorrhea is a major threat to reducing the impact of gonorrhea worldwide (WHO, 2019). African American women reported greater substance abuse, more sexual partners, higher concurrency levels, and more transactional sex (MacCarthy et al., 2015). Mississippi, like most states in the Deep South, has disproportionately high rates of STIs and HIV, especially among African American sexual minorities, which include individuals who identified themselves as lesbian, gay, bisexual, men who have sex with men, or women who have sex with women (Alexander et al., 2015; MacCarthy et al., 2015). Additionally, in 2010, an estimated 1,582,360

7. people were living in rural Mississippi (Rural Health Info, 2021). Rural Mississippi overall has poorer health, higher poverty rates, an insufficient supply of medical care providers, and a cultural climate that likely contributes to the spread of STIs (Reif et al., 2017). Barger et al. (2018) report that people living in the Delta Region of Mississippi face significant disparities in the incidence of chlamydia, gonorrhea and syphilis” (p. 612). The reasons for these disparities are low investments in the area and an abnormally high prevalence of risky sexual behavior among young adults (Barger et al., 2018). It is predicted that STIs will continue to increase exponentially because of the COVID-19 pandemic. This is because public resources have shifted to the COVID-19 pandemic response (Hellmann, 2020). Access to STD testing and treatment services is dwindling as the staff is reassigned or redeployed to respond to COVID-19 (Hellmann, 2020). Some clinics have closed down permanently. Clinics that remain open have reduced hours and services, limit appointments, no longer accepting walk-ins, and have suspended outreach programs for STIs prevention and treatment (Hellmann, 2020). Thus, patients will not be able to access health services, their infections will not be treated, and they will be predisposed to more transmission of STIs (Hellmann, 2020). Such concerns make it crucial to study the prevalence of STIs during the pandemic. CHAPTER 3: METHODS Study Design and Sample This retrospective review of patients with a diagnosis of Chlamydia and or Gonorrhea will be collected from three medical clinics in the heart of the agricultural Mississippi Delta in December 2020. The Mississippi Delta is among the most socioeconomically disadvantaged areas in the country (McCausland, 2020). These clinics are busy private medical clinics located

8. in Coahoma, Bolivar, and Quitman counties in the Mississippi Delta. The following demographics were collected for this study (age, sex, race/ethnicity). Chart of patients aged 11 and older who presented to clinics between July 1, 2020, through September 1, 2020, for STI screening were reviewed. Additionally, charts of patients aged 11 and older presenting to clinics between July 1, 2019, through September 2019 for STI screening were also reviewed. A total of 47 charts were reviewed for the analysis. Selection of Subjects Participants were identified using a search of diagnosis codes for gonorrhea (CPT code 87591) and chlamydia (CPT/diagnosis code 87491) who presented to the clinic from July 2020 through September 2020 and July 2019 to September 2019. All eligible candidates, age 11 years and over, were included regardless of race or gender. Each subject was given a unique code that will identify them for this study. Variables and Data Analysis The retrospective study included assessed eight variables, including year, site (clinic), age, race, gender, STIs tested, STI confirmed, and insurance. Additionally, the total number of patients seen in the identified periods was assessed for comparison purposes. The variables were analyzed using descriptive statistics, frequency tables, and chi-square to test if the proportion of people tested positively for STIs in 2020 was different from that in 2019. SPSS was used for data analysis results because it is recommended software for data transformation and analysis. The choice of SPSS for data analysis was informed by the ability to manage the collected data effectively (Cronk, 2019). By using SPSS, the data retrieved from patient records can be manipulated and interpreted without using additional means (Stehlik-Barry & Babinec, 2017). Confidentiality and Ethical Considerations

9. Data were stored on a password-protected computer. Subjects were de-identified via the use of a separate document correlating subjects' clinic medical record numbers with a study ID assigned for the sole purpose of this study. At the end of data collection, that key was destroyed. No social security numbers, names, addresses, or other personal information was recorded. IRB approval was received before the launch of the study. The informed consents were not needed for the retrospective chart review study. CHAPTER 4: RESULTS AND DISCUSSION Descriptive Statistics A total of 47 records were reviewed for both years, among which 15 were made in 2020 and 32 were made in 2019. The mean age of all participants was 32.5, with a standard deviation (SD) of 11.5. The minimum age of all participants was 17, while the maximum age was 67. The median age for both years was 31. In 2019, the mean age of participants was 33.6, with an SD of 12.2. In 2020, the mean age of the sample was 30.1, with an SD of 10. The descriptive statistics for the age are provided in Table 1 below. Table 1. Descriptive statistics of age by year Variable Year N Mean SE SD Minimum Median Maximum Mean 1.68 2.15 2.57 Age 2019/2020 47 32 15 32.49 33.63 30.07 11.52 12.16 9.96 17 17 19 31 31 28 67 67 49 2019 2020 In 2019, the sample included 30 females and two males, while in 2020, the sample included eight females and seven males. I total, the samples included 38 females and nine males. In 2019, the sample included 26 (81.3%) African Americans, while the number of African Americans in 2020 was 9 (60%). The number of people who did not mention their race was six in both observed periods. In 2019, only one person had Trichomonas, while all the other people

10. from the sample tested negative for STIs. In 2020, however, one out of 15 tested positive for chlamydia, two tested positive for gonorrhea, and one tested positive for trichomonas. In total, four out of 15 tested positive for STIs in 2020. As for the locations, the majority of cases were taken from Clinic 1. The detailed frequency distribution for five variables, including gender, race, confirmed STI, insurance, and site, is provided in Table 2 below. Table 2. Frequency table of gender, race, and confirmed STIs Gender Year Total 2019 2020 Female Male 30 (93.8%) 2 (6.2%) 8 (53.3%) 7 (46.7%) 38 (80.9%) 9 (19.1%) Race AA Unknown Confirmed STI Neg PA Chlamydia PA Gonorrhea PA Trichomonas Insurance Ambetter BCBS Magnolia MS Molina MS MS Medicaid MS Medicare None UHC Site Clinic1 Clinic2 Clinic3 26 (81.3%) 6 (18.7%) 9 (60%) 6 (40%) 35 (74.5%) 12 (25.5%) 31 (96.9%) 0 (0%) 0 (0%) 1 (3.1%) 11 (73.3%) 1 (6.7%) 2 (13.3%) 1 (6.7%) 42 (89.4%) 1 (2.1%) 2 (4.3%) 2 (4.3%) 1 (3.1%) 7 (21.9%) 6 (18.8%) 3 (9.4%) 2 (6.3%) 2 (6.3%) 3 (9.4%) 8 (25%) 0 (0%) 8 (53.3%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 6 (40%) 1 (6.7%) 1 (2.1%) 15 (31.9%) 6 (12.8%) 3 (6.4%) 2 (4.3%) 2 (4.3%) 9 (19.1%) 9 (19.1%) 29 (90.6%) 1 (3.1%) 2 (6.3%) 10 (66.7%) 0 (0%) 5 (33.3%) 39 (83%) 1 (2.1%) 7 (14.9%) Inferential Statistics A chi-square test was conducted to determine if the proportion of people with confirmed STIs in 2019 was different from that in 2020. In order to conduct the test, a dummy variable was created, where all participants that tested positively for any STIs were marked as "Yes," and all

11. others were marked "No." The frequency distribution for the dummy variable is provided in Table 3 below. The Chi-Square test revealed that the proportion of people with confirmed STIs in 2019 was significantly lower than that in 2020 with 95% confidence (p = 0.046). Table 3. Frequency distribution of the dummy variable Year N Event Sample proportion 2019 2020 32 15 1 4 0.03125 0.26667 Discussion The results of the present answered the two research questions stated in the introduction to the present paper. First, the study revealed that the proportion of people with confirmed STIs during the pandemic was 26.7% among all screened individuals. Among all the tested individuals, 6.7% had chlamydia, and 13.3% had gonorrhea. Second, the prevalence of people with confirmed STIs among all tested individuals during the pandemic was higher than that before the pandemic in the same period. These findings are coherent with the overall growing prevalence of STIs in the US in general in Mississippi in particular (CDC, 2021, MSDH, 2020). Additionally, the findings supported the idea that the pandemic had a negative impact on the prevalence of STIs, which was mentioned by Hellmann (2020). In particular, the number of people screened for STIs in the observed clinics decreased by 53% during the pandemic, which was seen in the results of the present study. Such a tendency may be explained by the fact that clinics were overwhelmed with COVID-19 patients, which forced them to decrease the number of STI screenings (Hellmann, 2020). Lack of timely diagnosis and treatment due to inadequate screening procedures may unfavorably affect the situation with STI prevalence in the future (Hellmann, 2020). Among other important findings, it is crucial to notice that the mean age of people tested

12. for STIs decreased in 2020 in comparison with the same period in 2019. This can be explained by the recommendations made for older adults by CDC to stay at home during the pandemic. Additionally, it should be noticed that the proportion of people screened for STIs without insurance increased from 9.4% to 40%, which may demonstrate that many people lost their jobs and health insurance during the pandemic. This phenomenon can also partially explain the reduced number of people screened for STIs in 2020. While the results of the present study are significant, it is crucial to acknowledge its limitations. The primary concern associated with the results of the present paper is the sample size. According to Andrade (2020), small sample sizes negatively affect the precision of estimations. Moreover, inadequate sample sizes may be unethical (Andrade, 2020). The sample size of the present study included a total of 47 observations, among which 32 were made in 2019 and 15 were made in 2020. These sample sizes are inadequate, which implies that the reliability of findings is small (Andrade, 2020). Another concern of the present study is that it does not demonstrate the prevalence of the STIs under analysis against the population of the cities/counties. Instead, the proportions of positively diagnosed patients against all screened patients is discussed. Finally, it should be acknowledged that the results are applicable only to the Mississippi Delta, as the sample was taken from this region. Thus, the generalizability of the results is limited. CHAPTER 5: CONCLUSION The present research aimed at describing the incidence of gonorrhea and chlamydia in primary medical clinics in the Mississippi Delta during the COVID-19 pandemic. Data was collected from three clinics during the period between July and September in 2019 and 2020 and analyzed using SPSS. The results of the study revealed that there was an increased incidence of

13. STIs, including gonorrhea and chlamydia, in 2020 in comparison with the same period in 2019. However, the differences in proportions can be explained by the decreased number of screenings due to the pandemic, increased number of people without insurance, and low precision due to inadequate samples sizes. Future research should aim at addressing the weaknesses of the present study. In particular, the sample size can be increased to ensure higher reliability of results. This can be achieved by increasing the period of observations or by including information from more clinics in the analysis. Additionally, future research may focus on comparing the proportion of people diagnosed with STIs against the populations of the cities in which clinics are situated. Finally, clinics from other counties and states can be included in the analysis to increase the generalizability of findings. References IvyPanda Study Blog (2024). Sexually Transmitted Infections in Young People. https://ivypanda.com/essays/sexually-transmitted-infections-in-young-people/ Advocates for Youth. (2016). Young people in Mississippi. https://www.advocatesforyouth.org/resources/fact-sheets/young-people-in-mississippi/ Alexander, J., Rose, J., Dierker, L., Chan, P. A., MacCarthy, S., Simmons, D., Mena, L., & Nunn, A. (2015). It's complicated: Sexual partner characteristic profiles and sexually transmitted infection rates within a predominantly African American population in Mississippi. Sexually Transmitted Diseases, 42(5), 266-271. https://doi.org/10.1097/OLQ.0000000000000266. Andrade, C. (2020). Sample size and its importance in research. Indian journal of psychological medicine, 42(1), 102-103.

14. Barger, A. C., Pearson, W. S., Rodriguez, C., Crumly, D., Mueller-Luckey, G., & Jenkins, W. D. (2018). Sexually transmitted infections in the Delta Regional Authority: significant disparities in the 252 counties of the eight-state Delta Region Authority. Sexually Transmitted Infections, 94(8), 611-615. Centers for Disease Control and Prevention. (n.d.). The importance of epidemiology. CDC. https://www.cdc.gov/eis/downloads/epidemiology-factsheet.pdf Centers for Disease Control and Prevention. (2021). Sexually transmitted disease surveillance 2019. CDC. https://www.cdc.gov/std/statistics/2019/default.htm Cronk, B. C. (2019). How to use SPSS®: A step-by-step guide to analysis and interpretation. Routledge. Hellmann, J. (2020, April 23). Pandemic sparks concerns about surging STD, HIV rates. The Hill. https://thehill.com/policy/healthcare/494236-pandemic-sparks-concerns-about- surging-std-hiv-rates Lipsitch, M., Swerdlow, D. L., & Finelli, L. (2020). Defining the epidemiology of Covid-19— studies needed. New England Journal of Medicine, 382(13), 1194-1196. McCarthy, S., Mena, L., Chan, P. A., Rose, J., Simmons, D., Riggins, R., Hoffmann, M., Perez- Brumer, A., Chamberlain, N., & Nunn, A. (2015). Sexual network profiles and risk factors for STIs among African-American sexual minorities in Mississippi: A cross- sectional analysis. LGBT Health, 2(3), 276-281. https://doi.org/10.1089/lgbt.2014.0019. Mississippi State Department of Health. (2020). STD/HIV office. https://msdh.ms.gov/msdhsite/_static/14,0,150.html. Reif, S., Safley, D., McAllaster, C., Wilson, E., & Whetten, K. (2017). State of HIV in the US Deep South. Journal of Community Health, 42(5), 844-853.

15. Rural Health Info (2021). Mississippi. https://www.ruralhealthinfo.org/states/mississippi Stehlik-Barry, K., & Babinec, A. J. (2017). Data analysis with IBM SPSS statistics. Packt Publishing Ltd. U.S. Census Bureau (2019). QuickFacts: Mississippi. https://www.census.gov/quickfacts/fact/table/coahomacountymississippi,US/PST045219 World Health Organization (WHO) (2019, June 14). Key facts. https://www.who.int/news- room/fact-sheets/detail/sexually-transmitted-infections-(stis). Zhou, C., Zhang, X., Zhang, W., Duan, J., & Zhao, F. (2019). PCR detection for syphilis diagnosis: Status and prospects. Journal of clinical laboratory analysis, 33(5), e22890.