CHLAMYDIA
Acknowledgements  Thank you to the members of the Provider Education Committee of the National Chlamydia Coalition (NCC), ...
Outline <ul><li>Epidemiology </li></ul><ul><li>Disease outcomes </li></ul><ul><ul><li>Female sequelae </li></ul></ul><ul><...
Outline (continued) <ul><li>Provider role </li></ul><ul><ul><li>Screening guidelines </li></ul></ul><ul><ul><li>Treatment ...
The Problem: Chlamydia <ul><li>Most commonly reported nationally-notifable disease in the US </li></ul><ul><li>Highest pre...
Epidemiology
Burden of Chlamydial Infection   <ul><li>Most commonly reported nationally-notifiable disease </li></ul><ul><ul><li>Over 1...
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 ...
Burden of Infection Highest Among Sexually Active Adolescents and Young Adults NHANES, National Health and Nutrition Exami...
Large Racial Disparities In Chlamydial Infection Non-Hispanic Blacks Non-Hispanic Whites NHANES, National Health and Nutri...
Chlamydia Prevalence in Sexually Active Females Aged 14-24 in the United States Prevalence, % NHANES, National Health and ...
Chlamydia Case Rates:  United States, 1989–2008 Centers for Disease Control and Prevention. Sexually Transmitted Disease S...
National Health and Nutrition Examination Survey (NHANES): Chlamydia Prevalence by Sex*, 1999-2006 Datta et al. Presented ...
<ul><li>National Job Training Program </li></ul><ul><ul><li>High-risk women and men, aged 16-24 years </li></ul></ul><ul><...
Chlamydia Sequelae <ul><li>Females </li></ul><ul><li>Males </li></ul>
Female Sequelae <ul><li>Chlamydia can increase HIV transmission 3-5 fold </li></ul><ul><li>Up to 15% risk of pelvic inflam...
Chlamydia in Pregnancy <ul><li>Chlamydia detected in 2-13% of pregnant  females   </li></ul><ul><li>Sequelae during pregna...
Chlamydia Vertical Transmission <ul><li>May be vertically transmitted to neonates during birth </li></ul><ul><ul><li>~50% ...
Male Sequelae <ul><li>Epididymitis </li></ul><ul><li>Proctitis </li></ul><ul><li>Reiter’s Syndrome  </li></ul><ul><li>HIV ...
Why are STDs an Adolescent Health Problem?
Age of Sexual Debut Among US Adolescents Can Vary  <ul><li>Analysis of Youth Risk Behavior Surveillance System (YRBSS)1999...
Adolescent Physical STD Susceptibility <ul><li>Cervical ectopy </li></ul><ul><ul><li>Adolescent females, usually until rea...
 
Adolescent Decision Making <ul><li>Decision-making capabilities are generally not as advanced in early adolescence </li></...
Adolescents Favor Short Term Benefits  <ul><li>Adolescents may place more emphasis on short term benefits  </li></ul><ul><...
Serial Monogamy and Concurrent Partners <ul><li>Serial monogamy:  </li></ul><ul><ul><li>The act of engaging in a number of...
Estimation of risk <ul><li>Tendency for adolescents (and people) to overestimate the risk behaviors in which peers are eng...
Sexual Behaviors of US High School Students 2009 Youth Risk Behavior Survey
Adolescents with Older Partners <ul><li>Predisposes adolescents to relationship power imbalance </li></ul><ul><ul><li>Sexu...
Teens’ Challenges with Access to Confidential Care <ul><li>Lack of insurance/ability to pay  </li></ul><ul><li>Lack of “me...
Minors’ Rights to Consent for Confidential STD Care in US <ul><li>All 50 states and the District of Columbia allow minors ...
Confidentiality of Medical Information <ul><li>Numerous federal and state laws regulate confidentiality of medical informa...
Title X and Medicaid <ul><li>Both provide confidentiality protection   for family planning services provided to minors wit...
Billing for Confidential Services is a Complex Problem  <ul><li>Many commercial health plans send home to the primary insu...
HIPAA Privacy Rule <ul><li>Federal regulations issued under the federal Health Insurance Portability and Accountability Ac...
Health Care Reform <ul><li>Affordable Care Act provides full health plan coverage for U.S. Preventive Services Task Force ...
What Providers Can Do <ul><li>Can establish policy of discussing with adolescent patients when medical records and other i...
Confidential Care Resources <ul><li>CDC web site to locate STD and HIV testing and Hepatitis B virus and HPV vaccination a...
Confidential Care Resources (Con’t.) <ul><li>ACOG web site has resources on  </li></ul><ul><ul><li>Confidentiality:  http:...
Chlamydia Screening: National Guidelines
Screening Women for Chlamydia: Current Recommendations <ul><li>Recommendations  by U. S. Preventive Services Task  Force (...
Why Screen Sexually Active Females? <ul><li>Data from a randomized controlled trial of chlamydia screening in a managed ca...
Chlamydia Screening: Males No guidelines recommend for or against male screening Correctional facilities STD clinics Adole...
Why  Not  Universal Male Chlamydia Screening? <ul><li>Screening males: the cons  </li></ul><ul><ul><li>No substantial seco...
How Compliant Are Providers With Annual Chlamydia Screening? Age  Commercial  Medicaid (yrs)    (%) Health Plan Type _____...
Barriers to Primary Care  Provider STD Risk Assessment <ul><li>Limited well care and primary care, especially in adolescen...
Opportunities for STD Screening and Care <ul><li>New (time-saving) tools </li></ul><ul><li>New tests </li></ul><ul><li>Eas...
New Tools <ul><li>Resources:  </li></ul><ul><ul><li>Ensure confidentiality </li></ul></ul><ul><ul><li>Address billing and ...
Chlamydia Diagnostic Testing Culture NAAT Preferred EIA DFA DNA Probe Sensitivity:  70-75% Specificity:  100% Sensitivity:...
New Tests: Nucleic Acid Amplification Tests (NAATs)  <ul><li>Most sensitive chlamydia tests: amplify nucleic acid sequence...
Chlamydia Screening: Preferred Genitourinary Specimens <ul><li>Females </li></ul><ul><ul><li>Vaginal swab (not endocervica...
Chlamydia Screening: Rectal, but not Pharyngeal Chlamydia <ul><li>CDC recommends NAAT for detection of rectal chlamydia in...
FDA-Cleared Chlamydia NAATs <ul><li>Amplicor </li></ul><ul><ul><li>Polymerase chain reaction (PCR) </li></ul></ul><ul><ul>...
Chlamydia Treatment
Chlamydia Treatment:  2010 CDC Treatment Guidelines <ul><li>Single-dose Rx: Azithromycin 1 gm x 1 </li></ul><ul><ul><li>OR...
Chlamydia Treatment: Pregnant Women <ul><li>1 g azithromycin in a single dose – preferred </li></ul><ul><li>OR </li></ul><...
Chlamydia Follow-Up: Test for Reinfection! <ul><li>High prevalence of chlamydia infection in patients recently treated for...
Provider’s Role to Prevent  Repeat Infection <ul><li>Partner notification </li></ul><ul><ul><li>Patient informs partner </...
EPT: Patient-Delivered Partner Therapy <ul><li>Recommended by CDC to treat partner(s) unlikely to obtain medical care </li...
CDC Recommendations  <ul><li>Providers can consider including EPT as part of their regular STD care  </li></ul><ul><ul><li...
Example: Partner Management Strategies among NYC Providers <ul><li>94% use patient referral frequently </li></ul><ul><li>4...
Concluding Thoughts
Putting Screening into Your Practice <ul><li>Make sexual health a priority in your practice </li></ul><ul><li>Use all medi...
Putting Screening into Practice (continued) <ul><li>Put chlamydia test kits next to Pap test or pregnancy detection materi...
Thank you!  Questions?  For more information, see  www.prevent.org/ncc
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Chlamydia Slide Set

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Produced by the Provider Education Committee of the National Chlamydia Coalition (NCC).

For more information, see www.prevent.org/ncc.

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  • Chlamydia is the most commonly reported nationally-notifiable disease. Over 1.2 M cases were reported in 2008. Yet many infections are not detected’ Data reported to the CDC estimates that 2.8 M cases of chlamydia occur each year. The direct medical costs of chlamydial infection, including costs of diagnosing and treating infertility, are estimated to be 678 M dollars a year.  
  • Chlamydia case report rates are substantial across the states. In 2008, rates were greater than 400 per 100,000 in 22 states and the District of Columbia. Case report rates are determined by both the actual burden of disease and the extent of chlamydia testing, which can vary by state.
  • The burden of infection is highest among sexually active adolescents and young adults. This figure shows chlamydia prevalence by age, based on nationally representative data from the National Health and Nutrition Examination Survey, NHANES. [ CLICK ] Sexually active people aged 14-24 have about 3 times the chlamydia prevalence of sexually active adults aged 25-39.
  • There are also large racial disparities in chlamydial infection. Chlamydia prevalence in non-Hispanic blacks is about five and a half times the prevalence in non-Hispanic whites.
  • Now let’s focus just on sexually active females aged 14-24 in the US, the group currently recommended for chlamydia screening. Prevalence of chlamydia is highest among 14-19 year-old girls [ CLICK ]: 6.8% of these girls have chlamydia. In this age group, prevalence is 4.4% among non-Hispanic whites, but 16.2% among non-Hispanic blacks. Prevalence is lower in the 20-24 year-old age group [ CLICK ] although, once again, differences by race are profound.
  • Traditionally, STD trends are monitored through case reports. Chlamydia case rates have climbed steadily over the past 2 decades. However, case rates may not reflect the true burden of disease. For instance, widespread screening recommendations for young women were first made in 1993 [CLICK ]. As screening became more common, more women were tested and more cases detected that may have previously gone undiagnosed. Also, expanded use of increasingly sensitive tests has enhanced case detection over time. The artifactual nature of these data is further evidenced by differences in rates by sex. Case rates are higher in women than men because of screening recommendations for women only.
  • Clearly, national case report data are currently problematic for assessing chlamydia trends. We must rely on other data sources to assess national chlamydia trends and evaluate programs. Nationally-representative data from NHANES can be used. The first NHANES analysis of prevalence trends among women and men aged 14-39 years showed that chlamydia prevalence from 1999 to 2006 did NOT change significantly and may be decreasing.
  • Another prevalence data source is the National Job Training Program, serving young, high-risk women and men, aged 16-24 years. In this population, chlamydia prevalence decreased from 2003 to 2007. The 3rd data source is from the Infertility Prevention Program, regional groups who are funded to provide chlamydia and gonorrhea screening and treatment services for low-income, sexually active women attending family planning, STD, and other women’s healthcare clinics. This data shows us, among 15 to 24 year-old women tested in family planning clinics, positivity rates did not change from 2003 to 2007. [ CLICK ] Overall, data from these 3 sources suggest that chlamydia prevalence is stable or decreasing, NOT increasing as case report data trends might suggest .
  • Chlamydia can increase transmission of HIV and the risk of pelvic inflammatory disease, when untreated. PID can cause infertility, ectopic pregnancy and chronic pelvic pain Source: Hills SD, Wasserheit JN. Screening for Chlamydia – A Key to The Prevention of Pelvic Inflammatory Disease. New England Journal of Medicine. 1996;334(21):1399-1401. 1. Haggerty C, Gottlieb S, Taylor B, et al. Risk of sequelae after Chlamydia trachomatis genital infection in women. The journal of infectious diseases;201 Suppl 2:S134-S55. Oakeshott P, Kerry S, Aghaizu A, et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ British medical journal (Clinical research ed) 2010;340:c1642-c.
  • Chlamydia has been detected in the cervix of 2-13% of pregnant women. Chlamydial infection is associated with postpartum endometritis and infertility. There is some evidence that untreated chlamydial infections can lead to premature delivery. Infection may be transmitted from the genital tract of infected women to their neonates during birth; approximately 50% of neonates born to infected women become colonized with chlamydia. Purulent conjunctivitis develops a few days to several weeks after delivery in 25-50% of neonates who acquire chlamydia infection, and neonatal pneumonia occurs in 5-20%. Sources: American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, Sixth Edition. ACOG: Washington, DC; 2007. Centers for Disease Control and Prevention. Chlamydia: CDC fact sheet. Available at: http://www.cdc.gov/std/chlamydia/STDFact-Chlamydia.htm#pregnant. Retrieved May 12, 2010.
  • See notes on previous slide.
  • Epididymitis, Proctitis, Reiter’s Syndrome and increased risk of HIV transmission are possible outcomes of untreated chlamydia in males, but are rare. Souces: http://digestive.NIDDK.NIH.gov http://www2a.cdc.gov/stdtraining/self-study/Chlamydia/chlamydia5.asp
  • Source: Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, Schootman M, Bucholz KK, Peipert JF, Sanders-Thompson V, Cottler LB, Bierut LJ. Age of sexual debut among US adolescents. Contraception. 2009;80(2):158-62. Methods: Data from the 1999-2007 Youth Risk Behavior Surveillance System (YRBSS), a cross-sectional, nationally representative survey of students in Grades 9-12 established by the Centers for Disease Control and Prevention was analyzed. The Kaplan-Meier method was used to compute the probability of survival (not having become sexually active) at each year (age 12 through 17), and separate estimates were produced for each level of gender and racial/ethnic group. RESULTS: African-American males experienced sexual debut earlier than all other groups (all tests of significance at p&lt;.001) and Asian males and females experienced sexual debut later than all groups (all tests of significance at p&lt;.001). By their 17th birthday, the probability for sexual debut was less than 35% for Asians (females 28%, males 33%) and less than 60% for Caucasians (58% females, 53% males) and Hispanic females (59%). The probability for sexual debut by their 17th birthday was greatest for African Americans (74% females, 82% males) and Hispanic males (69%). CONCLUSIONS: These results demonstrate a need for sexual education programs and policy to be sensitive to the roles of race and ethnicity in sexual debut.
  • In adult women , the vagina and most of the ectocervix is lined by squamous epithelial cells. In an adolescent, an area around the cervical os is covered by columnar epithelial cells, referred to as the area of ectopy. Columnar epithelial cells are more susceptible to STDs if exposed. In particular, columnar cells are more likely to be infected by chlamydia and gonorrhea if exposed. As an adolescent female matures, the columnar cells recede into the endocervix. By early 20’s the ectocervix is lined by squamous epithelium in most females. Sources: Risser WL, Bortot AT, Benjamins LJ, et al. The epidemiology of sexually transmitted infections in adolescents. Semin Pediatr Infect Dis. 2005;16:160-7.
  • Deeper red area surrounding the cervical os is covered by columnar epithelial cells and referred to as the area of ectopy. The surrounding “pink” area is covered by squamous epithelial cells. The area where columnar epithelium transforms into squamous epithelium, a process referred to as metaplasia, is referred to as the “transformation zone.” Human Papillomavirus (HPV) infects the cervix at the transformation zone.
  • Although decision-making capabilities are not as advanced in early adolescence as they are later in life, one qualitative study described the very purposeful decision making process through which adolescent females progressed when making decisions about what sorts of sexual activity to engage in with their partner, what sorts of sexual activity they were ready for, and what relationship conditions would be preferable for engaging in sexual activity. There are other factors which might influence adolescents’ decision to use condoms, including relationship/partner characteristics, self-efficacy (skills and negotiation abilities) and knowledge/awareness of the importance of using condoms. Brady SS, Tschann JM, Ellen JM, Flores E. Infidelity, trust, and condom use among Latino youth in dating relationships. Sex Transm Dis. 2009 ;36(4):227-31.
  • Adolescents tend to favor short term benefits over long term outcomes. Thus, they may place more emphasis on short term benefits, such as a better relationship with their partner, over longer term outcomes, such as STD risk or infertility.
  • Serial monogamy is characterized by a series of long- or short-term, exclusive sexual relationships entered into consecutively over the lifespan. Serial monogamy is a risk factor for adolescent STDs, especially with increasing closeness in time between partnerships. For some adolescents, given the short time between serially monogamous relationships (e.g., 1-2 weeks as opposed to 6 months). Serial monogamy is almost like concurrent partnerships. Agreement between perceptions of partner concurrency and reported behavior was low among adolescent couples. Source: Lenoir CD, Adler NE, Borzekowski DL, Tschann JM, Ellen JM. What you don&apos;t know can hurt you: perceptions of sex-partner concurrency and partner-reported behavior. J Adolesc Health. 2006;38(3):179-85.
  • Read slide.
  • According to the 2009 Youth Risk Behavior Survey, a little less than half of US high school students have had sexual intercourse. This percentage increases with increasing year in school (from 31.6% in 9 th grade to 62.3% in 12 th grade). About 6 percent of adolescents have had sex before age 13, and almost 14 percent of high school students have had 4 or more sexual partners. Almost 40 percent of the students surveyed had not used a condom during the last time they had sex. Source: CDC. Youth Risk Behavior Surveillance—United States, 2009. Morbidity &amp; Mortality Weekly Report 2010;59(SS-5):1–148.
  • Read slide.
  • The 2007 National Survey of Children’s Health estimates that adolescents (12-17 yrs) are more likely to be uninsured or underinsured compared to younger children (0-5 yrs) Uninsured and underinsured children are less likely to have a medical home or received a preventive care visit in past year; more likely to have delayed or forgone needed care in past year 2001-2004 Medical Expenditure Panel Survey (ages 10-17 yrs) estimates that few adolescents receive preventive visits and among those who receive preventive visits, less than half received recommended anticipatory guidance and had time alone with their health care provider. 38% of adolescents had a preventive care visit in the previous 12 months. Low-income and full-year uninsured status were associated with higher risk for not receiving this visit. Among those who had a preventive health visit anticipatory guidance rates were much lower, with highest proportion receiving guidance for health eating (39%); only 40% had time alone with their health care provider; Younger teens, females, and Hispanic youth are less likely to receive along time with their provider. Sources: Kogan MD, et al. Underinsurance among children in the United States. New Eng J Med 2010;363:841-51. Irwin CE, et al. Preventive Care for Adolescents: Few Get Visits and Fewer Get Services. Pediatrics 2009;123;e565-e572. Edman JC&lt; et al. Who gets confidential Care? Disparities in a national sample of adolescents. J Adol Health 2010;46:393-5.
  • Health care providers play a key role in providing confidential sexual healthcare to adolescents as part of health care maintenance. Screening for sexually transmitted infections (STDs), particularly in asymptomatic patients, is a basic, effective tool used to identify and treat unrecognized conditions to prevent symptoms or serious sequelae. All 50 states and the District of Columbia (D.C.) allow minors to consent for STD diagnosis and treatment. About one fourth 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 requires that providers notify parents that an adolescent minor has received STD services, except in limited or unusual circumstances, although some states give physicians discretion to disclose the information to parents.
  • The confidentiality of medical information and records of a minor who has consented for his/her own health care is governed by numerous federal and state laws. Laws in some states explicitly protect the confidentiality of STD or contraceptive services for which minors have given their own consent and do not allow disclosure of the information without the minor’s consent. In other states, laws grant physicians 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. In many commercial health plans, an explanation of benefit (EOB) is sent home to the primary insured listing services rendered by the provider and reimbursed by the health plan. An EOB documenting that reproductive services were rendered to their adolescent dependent may disclose confidential services. In addition, co-payments automatically generated with certain billing codes for office visits and medications can be a barrier for adolescents receiving care, including treatment. Clinical laboratories may also send home billing statements for STD tests performed.
  • Federal regulations issued under the federal Health Insurance Portability and Accountability Act of 1996, known as the HIPAA Privacy Rule, defer to state and “other applicable laws” with respect to the question of whether parents have access to information about care for which a minor has given consent. Thus the confidentiality and disclosure provisions in minor consent laws, the provisions of other state medical records and medical information laws, and the federal confidentiality protections for family planning programs all affect whether parents have access to such information.
  • As of Sep 23, 2010, preventive services with A or B grades and immunizations recommended by ACIP are covered services in all new commercial health plans with no deductibles or co-payments for patients. Between now and 2014, these provisions will gradually extend to all group and individual plans during the process of reissuing insurance or as the insurer and purchaser choose that provision. If a service is fully covered, therefore, there is no financial responsibility, will an EOB still need to be generated?
  • Providers may elect to establish a policy of discussing with their adolescent patients when medical records and other information will be disclosed and develop a mechanism to alert office staff as to what information in the chart is confidential. As electronic medical records become more widely used, development of systems to protect confidentiality of electronic adolescent health information is critical. Providers should become familiar with local low- or no-cost family planning and STD clinical services in the case where parental disclosure of sexual health care services through billing is an unacceptable option for the adolescent patient.
  • The Centers for Disease Control and Prevention supports a web site to locate STD and HIV testing and Hepatitis B virus and Human Papillomavirus vaccination at: http://www.hivtest.org/std_testing.cfm . AAP Section on Adolescent Health web site ( www.aap.org/Sections/adolescenthealth/default.cfm ) has many resources and tools for pediatricians to assist with delivery of confidential health care, including tips for protecting youth confidentiality, screening tools, information for parents, and billing and coding guidance. Other resources for understanding minors’ rights to consent for health care can be found on the Guttmacher Institute’s web site at: http://www.guttmacher.org/sections/adolescents.php and in the Center for Adolescent Health &amp; the Law publication, State Minor Consent Laws: A Summary, 3rd ed , available to purchase at: www.cahl.org .
  • ACOG has a document on confidentiality and billing guidance online at http://www.acog.org/departments/adolescentHealthCare/TeenCareToolKit/ACOGConfidentiality.pdf and http://www.acog.org/departments/dept_notice.cfm?recno=7&amp;bulletin=4799, respectively.
  • Currently, there are recommendations by U.S. Preventive Services Task Force (USPSTF) to screen all sexually active females aged &lt;25 annually, and to screen women aged 25 or older if they’re at increased risk. CDC and many medical associations also recommend routine screening for women who are 25 years of age. Increased risk is defined as having new or multiple sex partners; history of chlamydial or other sexually transmitted infection; inconsistent condom use; exchanging sex for money or drugs Certain demographics also have a higher prevalence of infection than the general population in many communities and settings: African-American and Hispanic women; incarcerated populations; military recruits; patients at public sexually transmitted infection clinics. Chlamydia screening in non-pregnant women is an A-rated recommended preventive service. All pregnant women should be screening for chlamydia at 1 st prenatal visit; pregnant women who are 25 years of age and younger and those at increased risk, should be tested again in the 3 rd trimester .
  • Read slide.
  • In March 2006, CDC convened an external consultation addressing male chlamydia screening to review evidence and develop recommendations for male chlamydia screening, available at http://www.cdc.gov/std/chlamydia/ChlamydiaScreening-males.pdf . The US Preventive Services Task Force cites “insufficient evidence” to recommend routine screening for ALL males.
  • Read slide.
  • The data speak for themselves – not very well. Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America&apos;s health plans to measure performance on important dimensions of care and service.  Altogether, HEDIS consists of 71 measures across 8 domains of care. As of July 2010, chlamydia screening among females is included in the smaller set of measures used to accredit health plans. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an &amp;quot;apples-to-apples&amp;quot; basis. Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts. Many health plans report HEDIS data to employers or use their results to make improvements in their quality of care and service. Employers, consultants, and consumers use HEDIS data, along with accreditation information, to help them select the best health plan for their needs. To ensure the validity of HEDIS results, all data are rigorously audited by certified auditors using a process designed by NCQA.
  • The bullets on this slide summarize known barriers to primary care provider STD risk assessment. This training addresses knowledge and training barriers, and provides some tips for time-saving strategies for easy annual chlamydia screening. Regarding the final bullet point: as previously discussed, commercial health plans usually provide an explanation of benefits (EOB) to the primary policy holder each time services are rendered. The EOB that indicates reproductive health or testing was delivered may alert parents to what would otherwise be confidential services, thereby potentially creating a barrier for minors seeking STD services. This barrier likely requires system-wide reform for removal, but in the meantime, developing referrals for access to confidential STD screening for minors in your local area would be key.
  • The following slides will review New time saving tools New tests Easy treatment And some newer prevention strategies for incorporating chlamydia screening into your practice
  • Read Slide.
  • What is currently available in terms of chlamydia diagnostics? Culture of urethral or endocervical specimens has long been the gold standard for diagnosis and is still used for medico-legal purposes because of its high, near perfect specificity; however, compared to Nucleic Acid Amplification Technology (NAAT), its sensitivity is approximately 70-75% depending on the laboratory expertise, adequacy of specimen collection and transport conditions. For screening purposes it is impractical for reasons of cost, low sensitivity, complexity, limited availability and long turnaround time. NAAT first became available in 1993. Sensitivities of all these tests are approximately 90-95% and specificities are greater than 98%. Sensitivity and specificity of NAATs are clearly the highest of any of the test platforms for the diagnosis of chlamydial infections. Since accurate diagnosis is the goal, there is no justification for the ongoing use of other technologies. Non-amplified tests such as enzyme immunoassays (EIA), direct fluorescent antibody (DFA), and DNA probe assays are inferior to NAATs with respect to performance. Sources: California Chlamydia Action Coalition: Screening Test Information for Medical Directors. http://www.ucsf.edu/castd/toolbox/07v2-ScreenTestForDirectors.pdf Centers for Disease Control and Prevention. Screening Tests To Detect Chlamydia trachomatis and Neisseria gonorrhoeae Infections--2002. MMWR 2002; 51 (No. RR-15):1-38. Crotchfelt KA, Pare B, Gaydos C, Quinn TC. Detection of Chlamydia trachomatis by the Gen-Probe AMPLIFIED Chlamydia trachomatis assay (AMP-CT) in urine specimens from men and women and endocervical specimens from women. J Clin Microbiol 1998; 36:391-94.
  • NAATs have several advantages when compared to older tests for chlamydia: NAATs are the most sensitive assays Since they don’t require viable organisms, NAATs are less susceptible to adequacy of specimen collection and transport conditions Multiple sample types, many of which are not invasive, offer greater clinician-patient choice and ease of patient screening Most test platforms can simultaneously screen for multiple STIs at once They are now widely available
  • While there is a great deal of choice in terms of sample type, the preferred specimens for chlamydia screening for females and males, and why they are preferred, are listed on this slide. These preferred samples types were delineated in a CT GC Lab Guidelines document developed by the American Public Health Laboratories in conjunction with the CDC, and will form the basis of an MMWR update that will be published on this subject.
  • While the specimen types used for rectal CT diagnostics have not yet been cleared by the FDA, CDC has acknowledged that NAATs are the most sensitive and specific tests and should be used for diagnosis in these sites. They recommend labs establish their own protocols for using NAATs to screen for rectal CT. All Quest and LabCorp sites already use NAATs for this purpose, and multiple public health labs have also validated NAATs for screening as well. Check with your laboratory for access to these screening tests. Pharyngeal chlamydia screening, unlike rectal chlamydia screening, is not recommended, because of unclear clinical significance and transmissibility of CT detected at oropharyngeal sites.
  • Current commercially available NAATs include: Roche Amplicor , which is based on polymerase chain reaction technology GenProbe APTIMA based on transcription mediated amplification Becton-Dickinson BD ProbeTec based on strand displacement amplification New NAAT licensed: Abbott RealTime CT/NG assay is real time polymerase chain reaction http://www.abbottmolecular.com/NewRealTimePCRTestForChlamydiaAndGonorrheaReceivesCEMarkCertification_3827.aspx
  • When available, on-site single dose treatments should be used for teens. Directly observed therapy is likely to have greater compliance. Source: Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12).
  • Treatment should be administered to women who have known chlamydial infections or whose neonates are infected. Doxycycline and ofloxacin are contraindicated in pregnancy. Limited data on azithromycin in pregnant women suggests that it is safe and efficacious. Recommended regimens for treating chlamydia in pregnant women include 1 g azithromycin in a single dose or amoxicillin 500 mg, orally, three times daily for 7 days. Repeat testing should be done 3 weeks after completion of treatment regimens to confirm successful treatment. Neonates born to women known to have untreated chlamydial infection should be evaluated and monitored for development of disease. Chlamydial infections in the neonate generally are mild and responsive to antimicrobial therapy. Prophylactic cesarean delivery is not warranted. Source: American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, Sixth Edition. ACOG: Washington, DC; 2007.
  • High prevalence of chlamydia infection has been reported in multiple studies, in patients recently treated for chlamydia infection. Reinfection confers elevated risk for complications stemming from chlamydia infection Reinfection usually results from: Failure of sex partners to receiver treatment, or Initiation of sexual activity with a new infected partner CDC therefore recommends test of reinfection approximately 3 months after treatment, REGARDLESS of whether the index patient believes their sex partners were treated
  • Providers counsel patient about notifying all partners who had sexual contact with infected patient in preceding 60 days: Inform patient that if partners are not treated s/he may be infected again Explain that untreated infections can cause health complications To avoid reinfection, patient must avoid all sexual contact for 7 days after patient and partner begin treatment Some hints for discussion: “ How would you like to let your partner/s know s/he needs to be tested for chlamydia?” Partners can be notified in-person, by email or text, or letter. Resources and examples are available in the Why Screen for Chlamydia? To view the resources, go to www.prevent.org/NCC . Click “for healthcare providers” tab. “Resources” can be clicked below the picture and description of Why Screen for Chlamydia? You can click on each resource and go directly to that item. “ Would you like to do this yourself or would you like me or someone from the office to help?” “ You may feel embarrassed or angry. If you do, let’s talk about those feelings.” “ Key things to tell your partner are: You have been exposed to chlamydia. You need to seek medical care as soon as possible to be tested and treated. And no sex until 7 days after you start treatment.” Health departments do not typically conduct partner notification about chlamydia or gonorrhea infections (resources tend to be limited to HIV and syphilis cases). Check with your local health department – chlamydia partner notification is provided in some states upon patient or provider request. EPT, providing treatment to partner/s without prior medical evaluation, may be an option. (next slide)
  • What about patients whose sexual partners are unlikely to seek medical care, for example, they may be uninsured, have mental health or addiction issues, be known to patient only by street name or casually, or many other issues. Expedited partner therapy, often partner-delivered therapy may be appropriate. As of November 2010, EPT is judged to be “permissible” in a little over half of US states. In most instances, public health officials are permitted to deliver EPT; in some jurisdictions it is also permissible for other providers to do so. For guidance on EPT, see http://www.cdc.gov/std/ept/default.htm. To find up-to-date information about the legal status of EPT in a particular state or locality, contact the state health department. Both the health department’s legal counsel and STD specialists may have specific information for you.
  • Read Slide.
  • This information shows that providers are often already using patient-delivered partner therapy, even before it became explicitly legal within New York. A survey of New York City Healthcare providers was conducted. Frequent patient referral was reported by about 94 percent of healthcare providers. Overall, about 49% of healthcare providers reported ever using PDPT and 27% reported using PDPT frequently. The study conclusions found that PDPT use is common and is being used in conjunction with other partner management strategies. Source: Rogers ME , Opdyke KM , Blank S , Schillinger JA . Patient-delivered partner treatment and other partner management strategies for sexually transmitted diseases used by New York City healthcare providers. Sex Transm Dis. 2007;34(2):88-92.
  • Chlamydia and gonorrhea are common, easily detected and treated. Consequences of not treating can be lifelong—infertility. Screening for, diagnosing and treating STDs should be integrated into high-quality preventive care.
  • Read slide. For additional ideas on how to put screening into practice, see pages 9-10 of Why Screen for Chlamydia? An Implementation Guide for Healthcare Providers, which is available at www.prevent.org/NCC.
  • Chlamydia Slide Set

    1. 1. CHLAMYDIA
    2. 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. 3. Outline <ul><li>Epidemiology </li></ul><ul><li>Disease outcomes </li></ul><ul><ul><li>Female sequelae </li></ul></ul><ul><ul><li>Male sequelae </li></ul></ul><ul><li>Adolescent-specific concerns </li></ul><ul><ul><li>Social aspects </li></ul></ul><ul><ul><li>Confidentiality concerns </li></ul></ul>
    4. 4. Outline (continued) <ul><li>Provider role </li></ul><ul><ul><li>Screening guidelines </li></ul></ul><ul><ul><li>Treatment guidelines </li></ul></ul><ul><ul><li>Partner management and EPT </li></ul></ul><ul><li>Concluding thoughts </li></ul><ul><ul><li>Putting screening into practice </li></ul></ul>
    5. 5. The Problem: Chlamydia <ul><li>Most commonly reported nationally-notifable disease in the US </li></ul><ul><li>Highest prevalence among adolescent females </li></ul><ul><li>Often asymptomatic (up to 80% of cases) </li></ul><ul><li>Devastating sequelae </li></ul>
    6. 6. Epidemiology
    7. 7. Burden of Chlamydial Infection <ul><li>Most commonly reported nationally-notifiable disease </li></ul><ul><ul><li>Over 1.2 million cases reported in 2008 </li></ul></ul><ul><ul><li>Many infections not detected </li></ul></ul><ul><li>Estimated 2.8 million cases occur each year </li></ul><ul><li>Direct medical costs: $678 million/year </li></ul>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. 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
    9. 9. 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
    10. 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
    11. 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
    12. 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
    13. 13. 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
    14. 14. <ul><li>National Job Training Program </li></ul><ul><ul><li>High-risk women and men, aged 16-24 years </li></ul></ul><ul><ul><li>Screened for chlamydia at program entrance </li></ul></ul><ul><ul><li>Prevalence decreased, 2003-2007 </li></ul></ul><ul><ul><ul><li>Women: 19% decrease </li></ul></ul></ul><ul><ul><ul><li>Men: 8% decrease </li></ul></ul></ul><ul><li>Infertility Prevention Program (IPP) </li></ul><ul><ul><li>Women tested in family planning clinics, aged 15-24 years </li></ul></ul><ul><ul><li>No change in positivity rates, 2003-2007 </li></ul></ul>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
    15. 15. Chlamydia Sequelae <ul><li>Females </li></ul><ul><li>Males </li></ul>
    16. 16. Female Sequelae <ul><li>Chlamydia can increase HIV transmission 3-5 fold </li></ul><ul><li>Up to 15% risk of pelvic inflammatory disease (PID) with untreated chlamydia </li></ul><ul><li>PID outcomes: </li></ul><ul><ul><li>Infertility (1 in 5) </li></ul></ul><ul><ul><li>Ectopic pregnancy (1 in 10) </li></ul></ul><ul><ul><li>Chronic pelvic pain (1 in 5) </li></ul></ul>
    17. 17. Chlamydia in Pregnancy <ul><li>Chlamydia detected in 2-13% of pregnant females </li></ul><ul><li>Sequelae during pregnancy: </li></ul><ul><ul><li>Associated with postpartum endometritis and infertility </li></ul></ul><ul><ul><li>May lead to premature delivery </li></ul></ul>
    18. 18. Chlamydia Vertical Transmission <ul><li>May be vertically transmitted to neonates during birth </li></ul><ul><ul><li>~50% of neonates born to infected females are colonized with chlamydia </li></ul></ul><ul><ul><li>Sequelae of neonatal chlamydia infection </li></ul></ul><ul><ul><ul><li>Purulent conjunctivitis in 25-50% </li></ul></ul></ul><ul><ul><ul><li>Neonatal pneumonia in 5-20% </li></ul></ul></ul>
    19. 19. Male Sequelae <ul><li>Epididymitis </li></ul><ul><li>Proctitis </li></ul><ul><li>Reiter’s Syndrome </li></ul><ul><li>HIV transmission </li></ul>
    20. 20. Why are STDs an Adolescent Health Problem?
    21. 21. Age of Sexual Debut Among US Adolescents Can Vary <ul><li>Analysis of Youth Risk Behavior Surveillance System (YRBSS)1999-2007 data </li></ul><ul><ul><li>A cross-sectional, nationally representative survey of students in Grades 9-12 by CDC </li></ul></ul><ul><li>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). </li></ul>
    22. 22. Adolescent Physical STD Susceptibility <ul><li>Cervical ectopy </li></ul><ul><ul><li>Adolescent females, usually until reach early 20’s </li></ul></ul><ul><ul><li>Area around the cervical os is lined with columnar cells </li></ul></ul><ul><ul><li>Columnar cells are more susceptible to STDs if exposed </li></ul></ul>
    23. 24. Adolescent Decision Making <ul><li>Decision-making capabilities are generally not as advanced in early adolescence </li></ul><ul><li>Adolescents can have very purposeful decision making process about sexual behaviors </li></ul><ul><li>Other factors which might influence adolescents’ decision to use condoms </li></ul><ul><ul><li>Relationship/partner characteristics </li></ul></ul><ul><ul><li>Self-efficacy </li></ul></ul><ul><ul><li>Knowledge/awareness </li></ul></ul>
    24. 25. Adolescents Favor Short Term Benefits <ul><li>Adolescents may place more emphasis on short term benefits </li></ul><ul><ul><li>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 </li></ul></ul>
    25. 26. Serial Monogamy and Concurrent Partners <ul><li>Serial monogamy: </li></ul><ul><ul><li>The act of engaging in a number of exclusive sexual relationships in succession </li></ul></ul><ul><ul><ul><li>Time between serially monogamous relationships can be short (e.g., 1-2 weeks as opposed to 6 months) </li></ul></ul></ul><ul><ul><ul><li>Almost similar to concurrent partnerships and speaks more to the importance of incident infection and the spread of disease </li></ul></ul></ul><ul><li>In a survey of adolescent couples, agreement between perceptions of sex-partner concurrency and partner-reported behavior was low. </li></ul>
    26. 27. Estimation of risk <ul><li>Tendency for adolescents (and people) to overestimate the risk behaviors in which peers are engaging and to underestimate their own risk </li></ul>
    27. 28. Sexual Behaviors of US High School Students 2009 Youth Risk Behavior Survey
    28. 29. Adolescents with Older Partners <ul><li>Predisposes adolescents to relationship power imbalance </li></ul><ul><ul><li>Sexual negotiation more difficult for younger females </li></ul></ul><ul><ul><li> risk of involuntary intercourse, lack of protective behavior, and exposure to STDs </li></ul></ul>
    29. 30. Teens’ Challenges with Access to Confidential Care <ul><li>Lack of insurance/ability to pay </li></ul><ul><li>Lack of “medical home” </li></ul><ul><li>Lack of confidential services </li></ul>
    30. 31. Minors’ Rights to Consent for Confidential STD Care in US <ul><li>All 50 states and the District of Columbia allow minors to consent for STD diagnosis and treatment </li></ul><ul><ul><li>~25% of states require that minors be a certain age to consent for their own STD care </li></ul></ul><ul><ul><li>No state requires parental consent for STD care or that providers notify parents that an adolescent minor has received STD service </li></ul></ul><ul><ul><ul><li>Exception in limited or unusual circumstances </li></ul></ul></ul><ul><ul><ul><li>Some states give physicians discretion to disclose to parents </li></ul></ul></ul>
    31. 32. Confidentiality of Medical Information <ul><li>Numerous federal and state laws regulate confidentiality of medical information of a minor who consented for own health care </li></ul><ul><li>Some states’ laws explicitly protect minors’ confidentiality for STD or contraceptive services and do NOT allow disclosure of information without minor’s consent </li></ul><ul><li>Other states’ laws grant providers discretion to disclose information to parents </li></ul>
    32. 33. Title X and Medicaid <ul><li>Both provide confidentiality protection for family planning services provided to minors with funding from these programs </li></ul>
    33. 34. Billing for Confidential Services is a Complex Problem <ul><li>Many commercial health plans send home to the primary insured an explanation of benefit (EOB) listing services reimbursed by health plan </li></ul><ul><li>EOB documenting reproductive services rendered to an adolescent dependent may disclose confidential services </li></ul><ul><li>Co-payments can be a barrier for adolescents receiving care </li></ul><ul><li>Clinical lab may also send home billing statements for STD tests </li></ul>
    34. 35. HIPAA Privacy Rule <ul><li>Federal regulations issued under the federal Health Insurance Portability and Accountability Act of 1996 </li></ul><ul><li>Defer to state and “other applicable laws” to determine whether parents have access to confidential health information for which minor gave consent </li></ul>
    35. 36. Health Care Reform <ul><li>Affordable Care Act provides full health plan coverage for U.S. Preventive Services Task Force (USPSTF) A and B graded preventive health services </li></ul><ul><ul><li>Chlamydia screening all sexually active females under 25 years is a USPSTF Grade A recommendation </li></ul></ul><ul><ul><li>Question if EOBs need to be generated if a service is fully covered and insured has NO financial responsibility </li></ul></ul>
    36. 37. What Providers Can Do <ul><li>Can establish policy of discussing with adolescent patients when medical records and other information will be disclosed </li></ul><ul><li>Can develop mechanism to alert office staff as to what information in the chart is confidential </li></ul><ul><li>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 </li></ul>
    37. 38. Confidential Care Resources <ul><li>CDC web site to locate STD and HIV testing and Hepatitis B virus and HPV vaccination at: http://www.findstdtest.org </li></ul><ul><li>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 </li></ul><ul><li>Guttmacher Institute web site at: http://www.guttmacher.org/sections/adolescents.php </li></ul><ul><li>Center for Adolescent Health & the Law publication, State Minor Consent Laws: A Summary, 3rd ed , available to purchase at: www.cahl.org . </li></ul>
    38. 39. Confidential Care Resources (Con’t.) <ul><li>ACOG web site has resources on </li></ul><ul><ul><li>Confidentiality: http://www.acog.org/departments/adolescentHealthCare/TeenCareToolKit/ACOGConfidentiality.pdf </li></ul></ul><ul><ul><li>A nd billing guidance: http://www.acog.org/departments/dept_notice.cfm?recno=7&bulletin=4799 </li></ul></ul>
    39. 40. Chlamydia Screening: National Guidelines
    40. 41. Screening Women for Chlamydia: Current Recommendations <ul><li>Recommendations by U. S. Preventive Services Task Force (USPSTF) for non-pregnant women: </li></ul><ul><ul><li>Screen all sexually-active females aged <25 years </li></ul></ul><ul><ul><li>Screen women aged ≥25 years if at increased risk </li></ul></ul><ul><li>USPSTF: A-rated recommended preventive service </li></ul>http://www.ahrq.gov/clinic/uspstf/uspschlm.htm
    41. 42. Why Screen Sexually Active Females? <ul><li>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% </li></ul>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.
    42. 43. 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:
    43. 44. Why Not Universal Male Chlamydia Screening? <ul><li>Screening males: the cons </li></ul><ul><ul><li>No substantial secondary prevention </li></ul></ul><ul><ul><ul><li>Fertility not affected </li></ul></ul></ul><ul><ul><ul><li>Epididymitis uncommon </li></ul></ul></ul><ul><ul><li>Men difficult to reach due to limited health care seeking </li></ul></ul><ul><ul><li>In modeling and cost effectiveness studies: limited effect on prevalence among women </li></ul></ul><ul><li>Highest risk: Partners of chlamydia-infected females </li></ul>
    44. 45. 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
    45. 46. Barriers to Primary Care Provider STD Risk Assessment <ul><li>Limited well care and primary care, especially in adolescents </li></ul><ul><li>Competing priorities/lack of time </li></ul><ul><li>Lack of reimbursement </li></ul><ul><li>Belief that patient population’s STD prevalence is low </li></ul><ul><li>Lack of provider training </li></ul><ul><li>Lack of provider and patient comfort </li></ul><ul><li>In commercial health plans, billing statements may break confidentiality </li></ul>
    46. 47. Opportunities for STD Screening and Care <ul><li>New (time-saving) tools </li></ul><ul><li>New tests </li></ul><ul><li>Easy treatment </li></ul><ul><li>New prevention strategies </li></ul>
    47. 48. New Tools <ul><li>Resources: </li></ul><ul><ul><li>Ensure confidentiality </li></ul></ul><ul><ul><li>Address billing and EOBs </li></ul></ul><ul><ul><li>Simplify risk assessment </li></ul></ul><ul><li>Available at: </li></ul><ul><ul><li>National Chlamydia Coalition: http://ncc.prevent.org/ </li></ul></ul><ul><ul><li>AAP: www.aap.org/moc/AdolHandouts_AAPMbrs/ProviderHandouts.htm </li></ul></ul><ul><ul><li>SAHM: www.adolescenthealth.org/Clinical_Care_Resources/2721.htm </li></ul></ul><ul><ul><li>ACOG: www.acog.org/goto/teens </li></ul></ul>
    48. 49. 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%
    49. 50. New Tests: Nucleic Acid Amplification Tests (NAATs) <ul><li>Most sensitive chlamydia tests: amplify nucleic acid sequences specific to C. trachomatis </li></ul><ul><li>Do not require viable organisms </li></ul><ul><li>Either swab (vaginal, endocervical, urethral) or urine specimens are FDA-cleared for use </li></ul><ul><li>Can detect GC and CT in single specimen </li></ul><ul><li>Now widely available </li></ul>
    50. 51. Chlamydia Screening: Preferred Genitourinary Specimens <ul><li>Females </li></ul><ul><ul><li>Vaginal swab (not endocervical swab or urine sample) </li></ul></ul><ul><ul><ul><li>Vaginal swab samples are as sensitive as endocervical swab specimens, with no difference in specificity </li></ul></ul></ul><ul><ul><ul><li>Endocervical swab and urine samples are acceptable, but female urine may have reduced performance when compared to genital swab samples </li></ul></ul></ul><ul><li>Males </li></ul><ul><ul><li>First catch urine (not urethral swab) </li></ul></ul><ul><ul><ul><li>In some studies, urethral swab samples are less sensitive than urine, though equivalently specific </li></ul></ul></ul>http://www.aphl.org/aphlprograms/infectious/std/Documents/CTGCLabGuidelinesMeetingReport.pdf
    51. 52. Chlamydia Screening: Rectal, but not Pharyngeal Chlamydia <ul><li>CDC recommends NAAT for detection of rectal chlamydia infection, in persons engaging in receptive anal intercourse </li></ul><ul><li>Rectal specimen types not been cleared by the FDA for use with NAATs </li></ul><ul><ul><li>Labs encouraged to establish their own specifications </li></ul></ul><ul><li>Quest and LabCorp now offer commercial NAAT for rectal CT </li></ul><ul><li>Pharyngeal chlamydia screening not recommended </li></ul><ul><ul><li>Unclear clinical significance and transmissibility of C. trachomatis detected at oropharyngeal sites </li></ul></ul>http://www.aphl.org/aphlprograms/infectious/std/Documents/CTGCLabGuidelinesMeetingReport.pdf CDC STD Treatment Guidelines, 2010
    52. 53. FDA-Cleared Chlamydia NAATs <ul><li>Amplicor </li></ul><ul><ul><li>Polymerase chain reaction (PCR) </li></ul></ul><ul><ul><li>Roche Molecular Systems (Branchburg, NJ) </li></ul></ul><ul><li>Aptima </li></ul><ul><ul><li>Transcription mediated amplification (TMA) </li></ul></ul><ul><ul><li>Gen-Probe (San Diego, CA) </li></ul></ul><ul><li>BD ProbeTec Q X </li></ul><ul><ul><li>Strand displacement amplification (SDA) </li></ul></ul><ul><ul><li>Becton Dickinson (Franklin Lakes, NJ) </li></ul></ul><ul><li>RealTime CT/NG assay </li></ul><ul><ul><li>Real-Time polymerase chain reaction (RT PCR) </li></ul></ul><ul><ul><li>Abbott Laboratories (Abbott Park, IL) </li></ul></ul>
    53. 54. Chlamydia Treatment
    54. 55. Chlamydia Treatment: 2010 CDC Treatment Guidelines <ul><li>Single-dose Rx: Azithromycin 1 gm x 1 </li></ul><ul><ul><li>OR </li></ul></ul><ul><li>Doxycycline 100 mg BID x 7 days </li></ul><ul><ul><li>Contraindicated during pregnancy </li></ul></ul><ul><li>Effectiveness equivalent </li></ul><ul><li>Alternatives (erythromycin, levofloxacin, ofloxacin) exist, but are not preferred </li></ul>
    55. 56. Chlamydia Treatment: Pregnant Women <ul><li>1 g azithromycin in a single dose – preferred </li></ul><ul><li>OR </li></ul><ul><li>Amoxicillin 500 mg, orally, three times daily for 7 days </li></ul><ul><li>Repeat testing (NAAT preferred) 3 weeks after completion of treatment, to document chlamydial eradication </li></ul><ul><li>Prophylactic cesarean delivery not warranted </li></ul><ul><li>Neonates born to women known to have untreated chlamydia should be evaluated and monitored </li></ul>
    56. 57. Chlamydia Follow-Up: Test for Reinfection! <ul><li>High prevalence of chlamydia infection in patients recently treated for chlamydial infection </li></ul><ul><ul><li>Usually from reinfection </li></ul></ul><ul><ul><li>Confers elevated risk for PID and other complications </li></ul></ul><ul><li>CDC therefore recommends test for reinfection: </li></ul><ul><ul><li>3 months after Rx or whenever patient next presents to clinic in the 12 months following initial treatment </li></ul></ul><ul><li>Except in pregnant women, test-of-cure (i.e. repeat testing 3-4 weeks after completing therapy) not advised </li></ul>CDC STD Treatment Guidelines, 2010
    57. 58. Provider’s Role to Prevent Repeat Infection <ul><li>Partner notification </li></ul><ul><ul><li>Patient informs partner </li></ul></ul><ul><ul><ul><li>Provider counsels patient about informing partner </li></ul></ul></ul><ul><ul><li>Provider informs partner </li></ul></ul><ul><ul><li>Expedited partner therapy (EPT) </li></ul></ul><ul><li>LIMITED health department resources to notify chlamydia-infected partners </li></ul>
    58. 59. EPT: Patient-Delivered Partner Therapy <ul><li>Recommended by CDC to treat partner(s) unlikely to obtain medical care </li></ul><ul><ul><li>Provider gives patients medication intended for the partners, OR </li></ul></ul><ul><ul><li>Provider writes partners prescriptions for medication </li></ul></ul>http://www.cdc.gov/std/ept/default.htm
    59. 60. CDC Recommendations <ul><li>Providers can consider including EPT as part of their regular STD care </li></ul><ul><ul><li>EPT “useful option” to further partner treatment </li></ul></ul><ul><ul><ul><li>Especially for male partners of chlamydia-infected females </li></ul></ul></ul><ul><ul><li>CDC STD Treatment Guidelines 2010 recommend EPT as option for partner treatment among heterosexual persons with chlamydia </li></ul></ul><ul><ul><ul><li>Not routinely recommended for MSM because of high risk for co-existing infections, especially undiagnosed HIV, in partners </li></ul></ul></ul>http://www.cdc.gov/std/ept/default.htm
    60. 61. Example: Partner Management Strategies among NYC Providers <ul><li>94% use patient referral frequently </li></ul><ul><li>49% ever used PDPT </li></ul><ul><li>27% use PDPT frequently </li></ul>Rogers ME, et al. Sex Transm Dis . 2007;34(2):88-92.
    61. 62. Concluding Thoughts
    62. 63. Putting Screening into Your Practice <ul><li>Make sexual health a priority in your practice </li></ul><ul><li>Use all medical visits to update recommended preventive care </li></ul><ul><li>Implement practice-wide systems and reminders for screening </li></ul><ul><li>Make behavioral/sexual risk assessment routine </li></ul><ul><li>“ We screen all our patients your age.” </li></ul><ul><li>Use urine-based screening </li></ul>
    63. 64. Putting Screening into Practice (continued) <ul><li>Put chlamydia test kits next to Pap test or pregnancy detection materials </li></ul><ul><li>Provide patient information materials </li></ul><ul><li>Encourage continuing education for providers </li></ul>
    64. 65. Thank you! Questions? For more information, see www.prevent.org/ncc
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