Chlamydia Slide Set

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
Male sequelae
Adolescent-specific concerns
Social aspects
Confidentiality concerns

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

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

Epidemiology

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

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

Burden of Infection Highest Among Sexually Active Adolescents and Young Adults 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 Prevalence, % Age group (years) Sexually active people aged 14-24 have about 3x the chlamydia prevalence of sexually active adults aged 25-39

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

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

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

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

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
NJTP Source: Satterwhite et al. Sex Transm Dis 2010;37(2):63-37 IPP Source: Satterwhite et al, unpublished data Other Sources for Chlamydia Prevalence Data Chlamydia prevalence stable or decreasing, NOT increasing

Chlamydia Sequelae
Females
Males

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)

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

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%

Male Sequelae
Epididymitis
Proctitis
Reiter’s Syndrome
HIV transmission

Why are STDs an Adolescent Health Problem?

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).

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

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

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

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.

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

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

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

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

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 parental consent for STD care or that providers notify parents that an adolescent minor has received STD service
Exception in limited or unusual circumstances
Some states give physicians discretion to disclose to parents

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 or contraceptive services and do NOT allow disclosure of information without minor’s consent
Other states’ laws grant providers discretion to disclose information to parents

Title X and Medicaid
Both provide confidentiality protection for family planning services provided to minors with funding from these programs

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
EOB documenting reproductive services rendered to an adolescent dependent may disclose confidential services
Co-payments can be a barrier for adolescents receiving care
Clinical lab may also send home billing statements for STD tests

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

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

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

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 .

Confidential Care Resources (Con’t.)
ACOG web site has resources on
Confidentiality: http://www.acog.org/departments/adolescentHealthCare/TeenCareToolKit/ACOGConfidentiality.pdf
A nd billing guidance: http://www.acog.org/departments/dept_notice.cfm?recno=7&bulletin=4799

Chlamydia Screening: National Guidelines

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

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 as 60%
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.

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

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

How Compliant Are Providers With Annual Chlamydia Screening? Age Commercial Medicaid (yrs) (%) Health Plan Type _____ ________________ ____________ The State of Health Care Quality, 2008 National Center for Quality Assurance at: http://www.ncqa.org/Portals/0/Newsroom/SOHC/SOHC_08.pdf 2008 Chlamydia Screening HEDIS Rates 16-20 36.4 48.8 21-26 39.2 54.2

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

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

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

Chlamydia Diagnostic Testing Culture NAAT Preferred 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%

New Tests: Nucleic Acid Amplification Tests (NAATs)
Most sensitive chlamydia tests: amplify nucleic acid sequences specific to C. trachomatis
Do not require viable organisms
Either swab (vaginal, endocervical, urethral) or urine specimens are FDA-cleared for use
Can detect GC and CT in single specimen
Now widely available

Chlamydia Screening: Preferred Genitourinary Specimens
Females
Vaginal swab (not endocervical swab or urine sample)
Vaginal swab samples are as sensitive as endocervical swab specimens, with no difference in specificity
Endocervical swab and urine samples are acceptable, but female urine may have reduced performance when compared to genital swab samples
Males
First catch urine (not urethral swab)
In some studies, urethral swab samples are less sensitive than urine, though equivalently specific
http://www.aphl.org/aphlprograms/infectious/std/Documents/CTGCLabGuidelinesMeetingReport.pdf

Chlamydia Screening: Rectal, but not Pharyngeal Chlamydia
CDC recommends NAAT for detection of rectal chlamydia infection, in persons engaging in receptive anal intercourse
Rectal specimen types not been cleared by the FDA for use with NAATs
Labs encouraged to establish their own specifications
Quest and LabCorp now offer commercial NAAT for rectal CT
Pharyngeal chlamydia screening not recommended
Unclear clinical significance and transmissibility of C. trachomatis detected at oropharyngeal sites
http://www.aphl.org/aphlprograms/infectious/std/Documents/CTGCLabGuidelinesMeetingReport.pdf CDC STD Treatment Guidelines, 2010

FDA-Cleared Chlamydia NAATs
Amplicor
Polymerase chain reaction (PCR)
Roche Molecular Systems (Branchburg, NJ)
Aptima
Transcription mediated amplification (TMA)
Gen-Probe (San Diego, CA)
BD ProbeTec Q X
Strand displacement amplification (SDA)
Becton Dickinson (Franklin Lakes, NJ)
RealTime CT/NG assay
Real-Time polymerase chain reaction (RT PCR)
Abbott Laboratories (Abbott Park, IL)

Chlamydia Treatment

Chlamydia Treatment: 2010 CDC Treatment Guidelines
Single-dose Rx: Azithromycin 1 gm x 1
OR
Doxycycline 100 mg BID x 7 days
Contraindicated during pregnancy
Effectiveness equivalent
Alternatives (erythromycin, levofloxacin, ofloxacin) exist, but are not preferred

Chlamydia Treatment: Pregnant Women
1 g azithromycin in a single dose – preferred
OR
Amoxicillin 500 mg, orally, three times daily for 7 days
Repeat testing (NAAT preferred) 3 weeks after completion of treatment, to document chlamydial eradication
Prophylactic cesarean delivery not warranted
Neonates born to women known to have untreated chlamydia should be evaluated and monitored

Chlamydia Follow-Up: Test for Reinfection!
High prevalence of chlamydia infection in patients recently treated for chlamydial infection
Usually from reinfection
Confers elevated risk for PID and other complications
CDC therefore recommends test for reinfection:
3 months after Rx or whenever patient next presents to clinic in the 12 months following initial treatment
Except in pregnant women, test-of-cure (i.e. repeat testing 3-4 weeks after completing therapy) not advised
CDC STD Treatment Guidelines, 2010

Provider’s Role to Prevent Repeat Infection
Partner notification
Patient informs partner
Provider counsels patient about informing partner
Provider informs partner
Expedited partner therapy (EPT)
LIMITED health department resources to notify chlamydia-infected partners

EPT: Patient-Delivered Partner Therapy
Recommended by CDC to treat partner(s) unlikely to obtain medical care
Provider gives patients medication intended for the partners, OR
Provider writes partners prescriptions for medication
http://www.cdc.gov/std/ept/default.htm

CDC Recommendations
Providers can consider including EPT as part of their regular STD care
EPT “useful option” to further partner treatment
Especially for male partners of chlamydia-infected females
CDC STD Treatment Guidelines 2010 recommend EPT as option for partner treatment among heterosexual persons with chlamydia
Not routinely recommended for MSM because of high risk for co-existing infections, especially undiagnosed HIV, in partners
http://www.cdc.gov/std/ept/default.htm

Example: Partner Management Strategies among NYC Providers
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.

Concluding Thoughts

Putting Screening into Your Practice
Make sexual health a priority in your practice
Use all medical visits to update recommended preventive care
Implement practice-wide systems and reminders for screening
Make behavioral/sexual risk assessment routine
“ We screen all our patients your age.”
Use urine-based screening

Putting Screening into Practice (continued)
Put chlamydia test kits next to Pap test or pregnancy detection materials
Provide patient information materials
Encourage continuing education for providers

Thank you! Questions? For more information, see www.prevent.org/ncc

Chlamydia Slide Set

by National Chlamydia Coalition

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