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Chlamydia

Chlamydia. Acknowledgements . Thank you to the members of the Provider Education Committee of the National Chlamydia Coalition (NCC), who provided review and comments. For more information, see www.prevent.org/ncc . . Outline. Epidemiology Disease outcomes Female sequelae

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Chlamydia

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  1. Chlamydia

  2. Acknowledgements Thank you to the members of the Provider Education Committee of the National Chlamydia Coalition (NCC), who provided review and comments. For more information, see www.prevent.org/ncc.

  3. Outline • Epidemiology • Disease outcomes • Female sequelae • Male sequelae • Adolescent-specific concerns • Social aspects • Confidentiality concerns

  4. Outline (continued) • Provider role • Screening guidelines • Treatment guidelines • Partner management and EPT • Concluding thoughts • Putting screening into practice

  5. The Problem: Chlamydia • Most commonly reported nationally-notifable disease in the US • Highest prevalence among adolescent females • Often asymptomatic (up to 80% of cases) • Devastating sequelae

  6. Epidemiology

  7. Burden of Chlamydial Infection • Most commonly reported nationally-notifiable disease • Over 1.2 million cases reported in 2008 • Many infections not detected • Estimated 2.8 million cases occur each year • Direct medical costs: $678 million/year CDC Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of Health and Human Services; November 2009 Weinstock H, Berman S, Cates W Jr. Perspect Sex Reprod Health 2004 Chesson HW, et al. Perspect Sex Reprod Health 2004

  8. Chlamydia Case Report Rates by State, 2008 VT 192 NH 160 MA 271 RI 314 CT 357 NJ 258 DE 447 MD 439 DC 1177 CDC Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of Health and Human Services; November 2009 8

  9. Burden of Infection Highest Among Sexually Active Adolescents and Young Adults Sexually active people aged 14-24 have about 3x the chlamydia prevalence of sexually active adults aged 25-39 Prevalence, % Age group (years) NHANES, National Health and Nutrition Examination Survey, 1999-2008 Sexual activity =“yes” response to “Have you ever had sex?” Sex = vaginal, anal, or oral sex 9

  10. Large Racial Disparities In Chlamydial Infection Non-Hispanic Blacks Non-Hispanic Whites NHANES, National Health and Nutrition Examination Survey, 1999-2008 Analysis of sexually active14-39 year-olds; Sexual activity =“yes” response to “Have you ever had sex?” Sex = vaginal, anal, or oral sex 10

  11. Chlamydia Prevalence in Sexually Active Females Aged 14-24 in the United States Prevalence, % NHANES, National Health and Nutrition Examination Survey, 1999-2008 Sexual activity =“yes” response to “Have you ever had sex?” Sex = vaginal, anal, or oral sex 11

  12. Chlamydia Case Rates: United States, 1989–2008 Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of Health and Human Services; November 2009 12

  13. National Health and Nutrition Examination Survey (NHANES): Chlamydia Prevalence by Sex*, 1999-2006 Women Men Datta et al. Presented at4 8th Annual ICAAC/IDSA 46th Annual Meeting, Washington, D.C., 10/25-28/2008. *Ages 14-39 years 13

  14. Other Sources for Chlamydia Prevalence Data • National Job Training Program • High-risk women and men, aged 16-24 years • Screened for chlamydia at program entrance • Prevalence decreased, 2003-2007 • Women: 19% decrease • Men: 8% decrease • Infertility Prevention Program (IPP) • Women tested in family planning clinics, aged 15-24 years • No change in positivity rates, 2003-2007 Chlamydia prevalence stable or decreasing, NOT increasing NJTP Source: Satterwhite et al. Sex Transm Dis 2010;37(2):63-37 IPP Source: Satterwhite et al, unpublished data 14

  15. Chlamydia Sequelae • Females • Males

  16. Female Sequelae • Chlamydia can increase HIV transmission 3-5 fold • Up to 15% risk of pelvic inflammatory disease (PID) with untreated chlamydia • PID outcomes: • Infertility (1 in 5) • Ectopic pregnancy (1 in 10) • Chronic pelvic pain (1 in 5)

  17. Chlamydia in Pregnancy • Chlamydia detected in 2-13% of pregnant females • Sequelae during pregnancy: • Associated with postpartum endometritis and infertility • May lead to premature delivery

  18. Chlamydia Vertical Transmission • May be vertically transmitted to neonates during birth • ~50% of neonates born to infected females are colonized with chlamydia • Sequelae of neonatal chlamydia infection • Purulent conjunctivitis in 25-50% • Neonatal pneumonia in 5-20%

  19. Male Sequelae • Epididymitis • Proctitis • Reiter’s Syndrome • HIV transmission

  20. Why are STDs an Adolescent Health Problem?

  21. Age of Sexual Debut Among US Adolescents Can Vary • Analysis of Youth Risk Behavior Surveillance System (YRBSS)1999-2007 data • A cross-sectional, nationally representative survey of students in Grades 9-12 by CDC • African-American males experienced sexual debut earlier than all other groups (p<.001) and Asian males and females experienced sexual debut later than all groups (p<.001). • The probability for sexual debut by their 17th birthday was greatest for African American (females and males) and Hispanic males

  22. Adolescent Physical STD Susceptibility • Cervical ectopy • Adolescent females, usually until reach early 20’s • Area around the cervical os is lined with columnar cells • Columnar cells are more susceptible to STDs if exposed

  23. Adolescent Decision Making • Decision-making capabilities are generally not as advanced in early adolescence • Adolescents can have very purposeful decision making process about sexual behaviors • Other factors which might influence adolescents’ decision to use condoms • Relationship/partner characteristics • Self-efficacy • Knowledge/awareness

  24. Adolescents Favor Short Term Benefits • Adolescents may place more emphasis on short term benefits • May choose actions that will result in a better relationship with their partner over actions that favor longer term outcomes such as STD risk or infertility

  25. Serial Monogamy and Concurrent Partners • Serial monogamy: • The act of engaging in a number of exclusive sexual relationships in succession • Time between serially monogamous relationships can be short (e.g., 1-2 weeks as opposed to 6 months) • Almost similar to concurrent partnerships and speaks more to the importance of incident infection and the spread of disease • In a survey of adolescent couples, agreement between perceptions of sex-partner concurrency and partner-reported behavior was low.

  26. Estimation of risk • Tendency for adolescents (and people) to overestimate the risk behaviors in which peers are engaging and to underestimate their own risk

  27. Sexual Behaviors of US High School Students 2009 Youth Risk Behavior Survey

  28. Adolescents with Older Partners • Predisposes adolescents to relationship power imbalance • Sexual negotiation more difficult for younger females •  risk of involuntary intercourse, lack of protective behavior, and exposure to STDs

  29. Teens’ Challenges with Access to Confidential Care • Lack of insurance/ability to pay • Lack of “medical home” • Lack of confidential services

  30. Minors’ Rights to Consent for Confidential STD Care in US • All 50 states and the District of Columbia allow minors to consent for STD diagnosis and treatment • ~25% of states require that minors be a certain age to consent for their own STD care • No state requires that providers mustnotify parents that an adolescent minor has received STD services • Exception in limited or unusual circumstances • Some states give physicians discretion to disclose to parents

  31. Confidentiality of Medical Information • Numerous federal and state laws regulate confidentiality of medical information of a minor who consented for own health care • Some states’ laws explicitly protect minors’ confidentiality for STD services and do NOT allow disclosure of information without minor’s consent • Other states’ laws grant providers discretion to disclose information to parents

  32. Title X and Medicaid • Both provide confidentiality protectionfor family planning services provided to minors with funding from these programs

  33. Billing for Confidential Services is a Complex Problem • Many commercial health plans send home to the primary insured an explanation of benefit (EOB) listing services reimbursed by health plan • An EOB documenting reproductive services rendered to an adolescent dependent often unintentionally discloses confidential services • Co-payments can be a barrier for adolescents receiving care • Clinical labs often send home billing statements for STD tests, which can unintentionally disclose confidential services

  34. HIPAA Privacy Rule • Federal regulations issued under the federal Health Insurance Portability and Accountability Act of 1996 • Defer to state and “other applicable laws” to determine whether parents have access to confidential health information for which minor gave consent • If state or other laws are silent, under HIPAA the health care provider has discretion whether or not to share information with parents

  35. Health Care Reform • Affordable Care Act provides full health plan coverage for U.S. Preventive Services Task Force (USPSTF) A and B graded preventive health services • Chlamydia screening all sexually active females under 25 years is a USPSTF Grade A recommendation • Question if EOBs need to be generated if a service is fully covered and insured has NO financial responsibility

  36. What Providers Can Do • Can establish policy of discussing with adolescent patients when medical records and other information will be disclosed • Can develop mechanism to alert office staff as to what information in the chart is confidential • Can refer to local low- or no-cost family planning and STD clinic if disclosure of confidential services through EOBs is unacceptable for teen patient

  37. Confidential Care Resources • CDC web site to locate STD and HIV testing and Hepatitis B virus and HPV vaccination at: http://www.findstdtest.org • AAP Section on Adolescent Health web site has many resources and tools for providers to assist with delivery of confidential health care at: www.aap.org/Sections/adolescenthealth/default.cfm • Guttmacher Institute web site at: http://www.guttmacher.org/sections/adolescents.php • Center for Adolescent Health & the Law publication, State Minor Consent Laws: A Summary, 3rd ed, available to purchase at: www.cahl.org.

  38. Confidential Care Resources (Con’t.) • The American College of Obstetricians and Gynecologists web site has resources on • Confidentiality: http://www.acog.org/departments/adolescentHealthCare/TeenCareToolKit/ACOGConfidentiality.pdf • Billing guidance: http://www.acog.org/departments/dept_notice.cfm?recno=7&bulletin=4799

  39. Chlamydia Screening: National Guidelines

  40. Screening Women for Chlamydia:Current Recommendations • Recommendations by U. S. Preventive Services Task Force (USPSTF) for non-pregnant women: • Screen all sexually-active females aged <25 years • Screen women aged ≥25 years if at increased risk • USPSTF: A-rated recommended preventive service http://www.ahrq.gov/clinic/uspstf/uspschlm.htm 41

  41. Screening Pregnant Women for Chlamydia • Recommendations by U. S. Preventive Services Task Force (USPSTF) for pregnant women: • Screen all pregnant women for chlamydia at first prenatal visit • Pregnant women aged ≤25 years and those at increased risk should be screened again in the 3rd trimester http://www.ahrq.gov/clinic/uspstf/uspschlm.htm 42

  42. Why Screen Sexually Active Females? • Data from a randomized controlled trial of chlamydia screening in a managed care setting suggest that screening programs can lead to a reduction in the incidence of PID by as much as60% Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;34(21): 1362-66.

  43. Chlamydia Screening: Males No guidelines recommend for or against male screening Correctional facilities Selective screening in high-prevalence populations may be beneficial: STD clinics Adolescent-serving clinics MSM Multiple partners

  44. Why Not Universal Male Chlamydia Screening? • Screening males: the cons • No substantial secondary prevention • Fertility not affected • Epididymitis uncommon • Men difficult to reach due to limited health care seeking • In modeling and cost effectiveness studies: limited effect on prevalence among women • Highest risk: Partners of chlamydia-infected females

  45. How Compliant Are Providers With Annual Chlamydia Screening? 2008 Chlamydia Screening HEDIS Rates Health Plan Type Age Commercial Medicaid (yrs) (%) _____ ________________ ____________ The State of Health Care Quality, 2008 National Center for Quality Assurance at: http://www.ncqa.org/Portals/0/Newsroom/SOHC/SOHC_08.pdf

  46. Barriers to Primary Care Provider STD Risk Assessment • Limited well care and primary care, especially in adolescents • Competing priorities/lack of time • Lack of reimbursement • Belief that patient population’s STD prevalence is low • Lack of provider training • Lack of provider and patient comfort • In commercial health plans, billing statements may break confidentiality

  47. Opportunities for STD Screening and Care • New (time-saving) tools • New tests • Easy treatment • New prevention strategies

  48. New Tools • Resources: • Ensure confidentiality • Address billing and EOBs • Simplify risk assessment • Available at: • National Chlamydia Coalition: http://ncc.prevent.org/ • AAP: www.aap.org/moc/AdolHandouts_AAPMbrs/ProviderHandouts.htm • SAHM: www.adolescenthealth.org/Clinical_Care_Resources/2721.htm • ACOG: www.acog.org/goto/teens

  49. Chlamydia Diagnostic Testing Culture NAAT EIA DFA DNA Probe Sensitivity: 70-75% Specificity: 100% Sensitivity: 90-95% Specificity: >98% Sensitivity: 53-76% Specificity: 95% Sensitivity: 80-85% Specificity: >99% Sensitivity: 65-70% Specificity: 95% Preferred

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