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National STD Prevention Conference Philadelphia, PA March 2004

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National STD Prevention Conference Philadelphia, PA March 2004

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  1. “Gonorrhea Screening Strategies and Guideline Development for Non-Pregnant Female Patients in the California Family Planning Clinic Setting”Holly Howard, MPH1Joan Chow1, Heidi Bauer1, Melanie Deal2, Renee Gindi2, Romni Neiman1, Gail Bolan11 STD Control Branch, California DHS 2 California Family Health Council National STD Prevention ConferencePhiladelphia, PAMarch 2004

  2. Background • Lack of current GC screening guidelines • Most recent national GC screening guidelines: • USPSTF 1996 • CDC 1985 • Overall low GC prevalence, < 1%, among women attending CA family planning clinics • High volume of GC screening continues • Screening in a low GC prevalence pop may compromise predictive value of tests • Low positive predictive value • Increase in false positive results

  3. Research Objectives • Determine predictors of GC within the CA family planning population • Develop targeted screening strategies that more efficiently identify GC infection

  4. Study Methods - I Design: • Retrospective medical record chart review • Case-control study Sites: • 5 Title X family planning clinics • Geographic diversity • Urban, rural, & suburban populations • Universal GC screening

  5. Study Methods - II Study Participants: • Non-pregnant female clients seen at clinics January-December 2001: • All GC positives (“cases”) • Random sample of GC negatives (“controls”) Data: • Patient characteristics abstracted: Demographics Symptoms Sexual History Behavioral Factors Clinical Signs Test Results Diagnoses

  6. Analytic Methods - I Estimates: • Prevalence determined by test positivity • Weighting used to estimate the patient characteristics in the overall GC-negative population from the proportions in the sample Statistical Analyses: • Crude and adjusted odds ratios measured association of patient characteristics with GC positivity: • Chi square tests • Unconditional logistic regression

  7. Analytic Methods - II Exclusion Criteria Applied to Screening Analysis: • Patients diagnostically tested for GC: • Contact to an STD • GC-associated clinical syndrome: • Cervicitis • Endocervical discharge • Cervical friability, or • Cervical inflammation • Pelvic inflammatory disease (PID) • Lower abdominal tenderness • Adnexal/uterine tenderness, or • Cervical motion tenderness (CMT) • Patients with CT, trichomoniasis (or other STDs)

  8. Results: Chart Review Sample

  9. Overall GC Tested * GC Positives Cases * Weighted Total Sample N=12,739Results: DemographicsAge (Years)

  10. Overall GC Tested * GC Positives Cases * Weighted Total SampleN=12,739Results: DemographicsRace/Ethnicity

  11. Results: Clinical Presentation Total GC-Tested Clients N=12,739 (nGC+ = 138) 1.1% GC+ 54% of GC Cases (75/138) Contact-to-STD n=414 (16) 3.9% NO Contact-to-STD n = 12,325 (122) 1.0% Key = Diagnostic Testing Screening for Co-infections 18% of Pop Tested Cervicitis or PID n=948 (20) 2.1% NO Contact, Cervicitis or PID n = 11,377 (102) 0.9% Screening Analysis 46% of GC Cases (63/138) CT + n=606 (31) 5.1% NO Contact, Cervicitis, PID or CT n = 10,771 (71) 0.7% 82% of Pop Remaining Trich + n=362 (8) 2.2% NO Contact, Cervicitis, PID, CT or Trich n=10,409(63) 0.6%

  12. <=20 Yes 2 * Weighted § P-value <.05 21-25 26-30 Yes 1.5 >30 White Yes Yes Latina 1 Yes No AA Yes No No No No Other No 0.5 0 Ptr requests STD check§ Age§ Race§ Vag d/c BV Yeast >1 ptr in Ptr has other (years) (sign) 12 mos§ ptrs§ Screening AnalysisN = 10,409Results: Univariate AnalysisGC Prevalence* by Patient Characteristic

  13. Screening AnalysisN = 10,409Results: Multivariate Analysis** **Behavioral characteristics could not be included in the multivariate analysis due to the small sample size of these variables

  14. Screening AnalysisResults: Performance of Selective Screening Algorithms

  15. Study Limitations • Chart review: poorly documented behavioral and historical data • Study sites: convenience sample • Estimates may include duplicate clients in the # of clients tested • Weighting techniques provide approximate results only and are limited when assessing rare exposures and outcomes

  16. Policy Implications Development of targeted GC screening guidelines: • Recommendations for targeted screening: Definite • Adolescents (age < 20) Probable • Clients age 21-25 with risk factors(e.g., multiple partners or partner has other partners), under consideration, or • All clients age 21-25 • Include definitions of clinical indications for GC testing • Support screening for co-infections

  17. Acknowledgements Thank you! CADHS-STD Joan Chow, Heidi Bauer, Gail Bolan CFHC Melanie Deal, Renée Gindi Region IX IPP Charlotte Kent, Pat Blackburn CA FP Clinics The teams at Delta Health Care Stockton & Lodi clinics, San Bernardino County’s SB & Ontario clinics, and Planned Parenthood’s Eastmont clinic For further information, please contact: Holly Howard at hhoward@dhs.ca.gov

  18. Summary of GC Screening Guidelines for Non-Pregnant Females as Delineated by Various Recommending Bodies

  19. Univariate and multivariate analyses of patient characteristics and positive GC test results on subgroup of screened1 patients. 1 – Screened patients are defined as those who did not report contact to an STD, did not show signs of cervicitis or PID on exam, and were not diagnosed with chlamydia or trichomoniasis. 2 - Vaginal DC on exam / No STAT Diagnosis of Yeast = patient has sign of vaginal discharge on clinical exam but STAT tests performed during the visit (i.e. wet mount) did not indicate yeast. 3 – GC+ and/or CT+ within Previous Year = According to lab records located in her medical chart only, patient has a history of GC or CT within the 12 months prior to her current clinic visit. *** = not included in model

  20. Univariate analysis of behavioral patient characteristics1 and positive GC test results on subgroup of screened2 patients. 1 – Behavioral data available for a very limited number of patients only: New Sex Partner in Past 2 Months: Cases = 12, Controls = 63 >1 Sex Partner in Past 12 Months: Cases = 17, Controls = 71 Age 21-25 AND >1 Sex Partner in Past 12 Months: Cases = 4, Controls = 23 – category limited to those patients within age 21-25 only Patient indicated that Partner has or may have other Partner(s) : Cases = 23, Controls = 91 Patient indicated Monogamous Relationship: Cases = 19, Controls = 80 Married: Cases = 11, Controls = 81 Inconsistent Condom Use: Cases = 29, Controls = 89 2 – Screened patients are defined as those who did not report contact to an STD, did not show signs of cervicitis or PID on exam, and did not have a diagnosis of chlamydia or trichomoniasis.

  21. Screening AnalysisResults: Performance Selective Screening Criteria

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