1. Creating a Screening Algorithm for
Sexually Transmitted Infections:
Baiye N. Orock, MPH, U of S School of
Public Health
Dr. Mark Vooght, MHO, FHHR
April 2015

2. 2009 2010 2011 2012 2013 2014
FHHR 28.5 22.9 28.0 26.0 19.7 29.5
SK 46.8 48.8 52.1 52.4 53.5
Target 24.5 24.5 24.5 24.5 24.5 24.5
0
10
20
30
40
50
60
Rateper10,000
Chlamydia Rates (All Ages) per 10,000 Population for FHHR and SK,
2009-2014, Target 2013/14
Target is based
on average rate
for 2009-14,
and a 5%
Updated: Feb 2, 2015
Senior Leader Chart Maintenance Chart Developer
Dr. Vooght Epidemiologist Epidemiologist

3. Q3
2012/13
Q4
2012/13
Q1
2013/14
Q2
2013/14
Q3
2013/14
Q4
2013/14
Q1
2014/15
Q2
2014/15
Q3
2014/15
Number tests done 752 679 665 710 782 858 842 891 810
Positivity rate (%) 3.3 4.6 4.2 3.5 3.3 2.9 5.0 4.9 6.9
Target (%) 3.3 3.3 3.3 3.3 3.3 3.3 3.3 3.3 3.3
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
0
100
200
300
400
500
600
700
800
900
1000
Positivityrate(%)
NumberofTests
FHHR Chlamydia Positivity Rate (%) - Tests Done,
Q3 2012/13 to Q3 2014/15
Updated: Jan 6, 2015
Senior Leader Chart Maintenance
Dr. Vooght T. Schellenberg
Target is based on average rate
for Q1 2012/13 to Q4 2013/14,
and a 20% decrease

4. 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
FHHR HIV Rate 1.8 0 1.9 1.9 1.8 3.7 3.6 9 5.5 1.8 1.8
SK HIV Rate 4 2.6 4 5.5 8.1 10.2 12.7 17.1 19.4 16.2 17.2 16.2 12 9.6
0
5
10
15
20
25Rateper100,000
HIV Rates per 100,000 Population for FHHR and SK, 2001 to 2014 Updated: Feb 12, 2015
Sponsor Owner
Dr. Vooght C. Ward

5. Issue: Develop an Evidence-based STI
Screening Decision Tool
• The development of an STI screening decision
tool to be used by healthcare providers
• Screening to be risk-based ?
• This to be informed by conducting a literature
review

6. RESEARCH QUESTIONS:
• 1. What are the evidence-based algorithms for
identifying sexually transmitted infection risk
factors and testing requirements in adult patients
presenting to primary care?
• 2. What are the evidence-based guidelines
regarding optimal risk grouping, age cohorts, risk
categories, and timing of screening for sexually
transmitted infections in adult patients?

8. Asymptomatic Patients:

9. Symptomatic Patients

10. Utilizing the Evidence:
• We predominantly used 6 STI Guidelines, to
create a screening algorithm
• Risk-based

11. Offer routine screening (Chlamydia, Gonorrhea, HIV & Syphilis) to ALL sexually active clients.
Yes
No
Syndromic
management1 .
Routine
screening plus2
HBV, HCV.
As part of investigation,
consider routine screening
plus risk based screening
below
Are there any STI-related
Signs & Symptoms?
Female Male
Is client pregnant?
Yes No
ALL < 25 &/or at high risk* ?
< 30 & sexually active?
Yes No
Routine
screening
plus3 HBV
Routine
screening
plus4 HBV, HCV.
Routine
screening
Risk - based
screening
Yes
SEXUALLY TRANSMITTED INFECTION/BLOOD BORNE PARTHOGEN (STI/BBP) SCREENING ALGORITHM
Is this visit related to a sexual health concern?

12. Routine screening & Other2
Add HAV5, HBV5, HCV.
Add HBV5 .
Add HBV5 ; consider Chancroid#, LGV#, Granuloma inguinale #
Add HBV5, HCV.
consider Parasitic7 STI
Using IV drugs or other addictive substances?
Same-sex partner( MSM6/WSW) or bisexual?
Sex trade workers and/or their clients?
Recently in an STI endemic area8?
Are there any other risk factors9?
Client requests STI screening
Risk-Based Screening:
Important: Go through ALL questions as the
client may be in more than one risk
category:

13. SUPERSCRIPT:
1 - Focused primary and secondary prevention counselling; treatment as necessary and partner follow up .
2 – Offer routine screening and/or screening based on institutional or local prevalence of STI.
3 – For all pregnant women, Chlamydia and Gonorrhea screening recommended for first prenatal visit. If positive, re-test within 3
– 6 months.
4 – For all pregnant women at high risk, Chlamydia and Gonorrhea screening recommended for first and third trimesters. Also
repeat HIV serology during labour for those at high-risk.
5 - Offer serological screening and immunize accordingly following Hepatitis A and B immunization recommendations as per the
Saskatchewan Immunization Manual, available at: http://www.health.gov.sk.ca/sim-chapter10
6 – Sample collection for MSM should be at site of receptive/penetrative oral or anal sex (Pharyngeal, urethral and/or rectal).
7 – Examples of a parasitic STI include trichomoniasis, pubic lice and scabies. Screening may be necessary only for trichomoniasis.
8 – For a list/map of STI endemic regions/countries, refer to:
http://www.who.int/gho/hiv/hiv_013.jpg --- HIV -endemic regions
http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/sexually-transmitted-diseases.html -- Syphilis- endemic
regions (see Table 3).
NB: “The largest number of new infections occurs in the region of South and Southeast Asia, followed by sub-Saharan Africa,
Latin America, and the Caribbean” CDC, 2011.
SEXUALLY TRANSMITTED INFECTION/BLOOD BORNE PARTHOGEN (STI/BBP) SCREENING ALGORITHM
STI /BBP Screening Algorithm

14. STI /BBP Screening Algorithm
9 - OTHER RISK FACTORS:
-Sexual contact with person(s) with a known STI.
-A new sexual partner or more than two sexual partners in the past year.
-Serially monogamous individuals.
-No contraception or the use of only non-barrier methods of contraception
(i.e. no condoms).
-Any individual engaging in unsafe (i.e. Unprotected) sexual practices
-“Survival sex”: exchanging sex for money, drugs, shelter or food.
-Anonymous or internet sexual partnering.
-Victims of sexual abuse.
-Previous history of STI
-Living in an area with high prevalence of STI.
HAV = Hepatitis A Virus.
HBV = Hepatitis B Virus.
HCV = Hepatitis C Virus.
HIV = Human Immunodeficiency Virus.
LGV = Lymphogranuloma venerum.
#- Use professional discretion (i.e. screen based
on prevalence of STIs in the countries recently
visited).
*- presence of one or more risk factors for
STI/BBP.
ABBREVIATIONS

15. Utility of the Screening Tool:
• Used in concert with the STI Syndromic-based
risk-assessment tool

16. Sexual health-related visit
Presence of No symptoms
signs/symptoms but
concerns
Non-Sexual health-related visit
Brief risk assessment (See back of page)
Risk identified No risk identified
*Routine Asymptomatic screening
Minimal prevention counseling
Maintenance of safer practices
Discussion of future risk avoidance
Focused risk assessment
Focused prevention counseling
Syndromic management
Testing/screening
Treatment and partner follow-up
STI Risk Assessment in Primary Care Settings

17. Testing Code Key

18. Survey Conclusion & Recommendations:
Recommendations
 Development of an accompanying STI risk-based client questionnaire
 Creation of a partnership with eHealth to develop a province wide format for the Electronic
Medical Records (EMR) system.
 Have strategically located patient-specific posters or monitor displays, with appropriate STI
prevention and control messages (especially risk factors), at waiting areas in physician offices
and health clinics
 Of the Physicians, NPs and PHNs who participated in an implementation survey of the
developed tools, (screening algorithm and clinical assessment tool):
- 92% found them easy to use,
- 46% found the algorithm cluttered
- 100% rated the content as good to excellent, and