Chlamydia Screening and Treatment in Philadelphia Prison: Did it Impact Community Chlamydia Rates?

1. Chlamydia Screening and Treatment in Philadelphia Prison: Did it Impact Community Chlamydia Rates? Martin Goldberg1, Daniel R. Newman2, TA Peterman2, M Salmon1, G Anschuetz1, CL Satterwhite2, CV Spain1, A Zaidi2, L Grier2, S Berman2 1 Philadelphia Department of Public Health, Philadelphia, PA 2 CDC, Atlanta, GA National STD Conference 2008 Chicago, IL

2. Background • Screening sexually-active women aged <25 years for chlamydia is recommended, but no similar recommendation exists for males. • June 2007: “... the USPSTF noted that screening for chlamydial infection in men may be beneficial if it were to lead to a decreased incidence of chlamydial infection in women. The USPSTF did not, however, find evidence to support this outcome... benefits of screening men are unknown... a critical gap in the evidence.” • Since 2000, Philadelphia has expanded screening programs to include high-risk males.

3. 2000 – 2004 New surveillance programs Citywide HS screening & 5 HRC Data analysis: High re-infection rates in women Adult prisons Youth Study Center Family Court Increasingly sensitive laboratory technologies 2 HRC (HS) Infertility Prevention Project (IPP) Number of cases * *Chlamydia reportable as of October 1991 Year Reported Cases of Chlamydia: Philadelphia, 1991-2007

4. Temporal Association between Increased City-wide CT Screening and Changes in Rates, by Gender, Philadelphia, PA Number Tested Percent Positive Year

5. Background • From 1999-2004, Chlamydia positivity in females seen in Family Planning Clinics (FPCs) declined. • Can this decline be associated with the expansion of screening to incarcerated males in the Philadelphia prison?

6. Objective • To determine if screening and treating men aged 20-24 years in prison has affected FPC chlamydia positivity rates in females aged 20-24 years residing in the prisoners’ home ZIP codes.

7. Methods • Using census and screening data, we created a ratio for each ZIP code in Philadelphia County. • From 2002-2004 among those males aged 20-24, the ratio was computed as follows: Average annual # treated for Chlamydia [prison screening program] # males residing in each ZIP code • Three groups formed: • “High-positivity” (18 ZIPs) • “Average-positivity” – DISCARDED FOR ANALYSIS • “Low-positivity” (18 ZIPs) • We compared changes in chlamydia positivity for women aged 20-24 years attending FPCs city-wide from these two ZIP code groups.

8. Methods • We measured positivity changes for females in FPCs before (1999-2001) and after (2002-2004) the prison screening program began from the “High” and “Low” areas. • Prison screening began during the 2nd Quarter, 2002.

10. Results • Of 23,203 males aged 20-24 years residing in the 18 identified “High-positivity” ZIP codes, 1,054 (4.54%) were treated for chlamydia from 2002-2004 through the prison screening program ~1.5% (351/23,203) per year • Of 21,057 males aged 20-24 years residing in the 18 “Low-positivity” ZIP codes, 98 (0.47%) were treated for chlamydia from 2002-2004 through the prison screening program ~0.16% (33/21,057) per year.

11. ResultsFemales Aged 20-24 FPC Data • Chlamydia screening remained relatively stable from 1999 through 2004 for this population (~ 11,500 tests per year). In the 18 “High-Positivity” ZIP codes: • Prior to screening males in prison, chlamydia positivity in FPCs declined 18.2% from 10.6% in 1999 to 8.7% in 2001. • By 2004, positivity had fallen to 7.4%, a 14.6% (~total of 90 cases) decline from the start of the men’s prison screening program. In the 18 “Low-Positivity” ZIP codes: • Prior to screening males in prison, chlamydia positivity in FPCs declined 26.5% from 7.3%in 1999 to 5.4% in 2001. • By 2004, positivity had fallen to 4.2%, a 22.5% (~total of 15 cases) decline from the start of the men’s prison screening program.

12. Chlamydia positivity among “High/Low Positivity” ZIP codes for females aged 20-24 attending Family Planning Clinics Chlamydia positivity (%) 5th yr IPP YSC Adult Prison HS Family Court Year screening programs began Year

13. Conclusions • Largest female chlamydia positivity reductions occurred PRIOR to the implementation of the prison screening program • Despite a large number of males in prison being tested and treated for Chlamydia, we were unable to directly associate the continued decline in female positivity in FPCs for this age group to the prison screening program. • However, prisons remain as institutions where large numbers of infections can be found and treated • During this study period, 4,318 males were tested and treated through the prison program - 29.9% (4,318/ 14,434) of city-wide male reported morbidity came from our prisons (2002-2004)!

14. Limitations • By limiting this analysis to 20-24 year old males, we included only 26.7% (1,152) of the 4,318 males testing positive (2002-2004) in adult prison. • Men aged 20-24 years may not be having sex with women of the same age and/or women from their home ZIP codes. • Female partners of incarcerated men may not be seeking health care in FPCs. • The methods used for analysis may not have been robust enough to detect a difference.

15. DO NOT DESPAIR! • Prison screening is a good thing! • Our inability to detect an association between screening males in prison and a decrease in female positivity should not be viewed as a reason not to screen! • Prison testing is a significant part of our citywide screening program • Represents 50% of our annual male screening • Testing of males in Philadelphia has been associated with a reduction in hospitalized PID; ectopic pregnancy cases have also declined.

16. Temporal Association Between Increased CT Screening and Hospitalized PID in Philadelphia, 1996-2006 # PID Cases # Screening Tests Performed Year • Multivariable Regression Analysis (R2=0.93) • For every 10,000 females tested, we prevent 35.8 cases of hosp. PID • For every 10,000 females and 10,000 males tested, we prevent 59.3 cases of hosp. PID • p-value <0.001

17. Implications for Programs, Policy and/or Research • Serious research on the impact of screening and treating high-risk males on the community, including long term sequelae for females, needs to be done!

18. THANK YOU! Email: greta.anschuetz@phila.gov Disclaimer The findings and conclusion in this presentation have not formally been disseminated by the Centers for Disease Control and Prevention. It does not represent and should not be construed to represent any agency determination and policy.