Chlamydia and Adolescent Patients

1. Chlamydia and Adolescent Patients

2. Acknowledgments Thanks 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. Outline • Epidemiology • Disease outcomes • Adolescent susceptibility • Provider role • Screening • Treating • Prevention

4. The Problem: Chlamydia Most commonly reported communicable disease in the U.S.: Chlamydiatrachomatis (CT) Highest reported rates among adolescent females Often asymptomatic (up to 80% of cases) Devastating sequelae

5. Epidemiology

6. Chlamydia in Context: U.S. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2008. • 1,210,523 cases reported in 2008 • CDC estimates 3 million cases total with less than half reported • 401.3 reported cases per 100,000 population • Increase of 9.2% from 2007

7. Chlamydia Prevalence in Adolescent Females 7% of all sexually active femaleadolescents infected 15%-29% prevalence in inner city populations 5%-10% prevalence in suburban populations High reinfection rates within 3-6 months (10%-26%)

8. Men Rateper 100,000 Population Women 3500 2800 2100 1400 700 0 0 700 1400 2100 2800 3500 Age 10-14 13.9 129.9 15-19 701.6 3275.8 20-24 1056.1 3179.9 25-29 565.9 1240.6 30-34 271.7 498.9 35-39 140.8 205.6 40-44 78.3 85.8 45-54 34.4 30.9 55-64 10.4 8.4 65+ 2.7 2.1 Total 211.7 585.6 Chlamydia: U.S. Age and Sex-specific Rates, 2008 Centers for Disease Control and Prevention, 2008.

9. Cases (in thousands) 750 600 Non-STD Clinic Male 450 Non-STD Clinic Female STD Clinic Male STD Clinic Female 300 150 0 1999 2000 ’01 ’02 ’03 ’04 ’05 ’06 ’07 ’08 Chlamydia: U.S. Cases by Reporting Source and Sex Centers for Disease Control and Prevention, 2008.

10. Chlamydia Sequelae Females Males

11. Female Sequelae • Chlamydia can increase HIV transmission 3-5 times • Up to 40% 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)

12. 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

13. 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%

14. Male Sequelae Epididymitis Proctitis Reiter’s syndrome HIV transmission

15. STIs as an Adolescent Health Problem

16. Adolescent Susceptibility to STIs Physical Cognitive Behavioral Social

17. Physical

18. Physical Cervical ectopy No immunity from prior or recently treated infection Asymptomatic nature

20. Cognitive

21. Cognitive Risk Factors for STIs in Adolescents • Early adolescence: concrete thinking • Often unable to plan ahead for condoms • Serial monogamy in relationships • Personal fable • Unable to judge risk for STIs • “Other people get STIs” • No prior experiences to modify beliefs in invulnerability

22. Behavioral

23. Behavioral Risk Factors Early sexual initiation Sexual activity with a new partner Multiple partners Substance use at last sex

24. Sexual Behaviors of U.S. High School Students Youth Risk Behavior Survey, 2009

25. 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 STIs

26. Social

27. Access to Care Confidential services Lack of “medical home” Lack of insurance/ability to pay

28. Health Services Delivery: 1999 YRBS • >50% of students reported a preventive health care visit in the past 12 months • <50% reported an STD, HIV, or pregnancy prevention discussion at those visits • 43% of ♀ students • 26% of ♂ students • Older, sexually active, hormonal contraception using-females most likely to have reproductive health dialogue Burstein GR, et al. Pediatrics. 2003;111:996-1001.

29. Chlamydia Screening:National Guidelines

30. Chlamydia Screening: Sexually Active Females • Sexually active females 25 and younger should be screened at least annually • Patients should have repeat testing 3-4 months after treatment due to high rates of reinfection • Pregnant women should be screened for CT during 1st prenatal visit • Women at increased risk (age <25 years, new or multiple sexual partners) may be tested again in third trimester

31. Chlamydia Screening: Males No guidelines recommending for or against Selective screening in high-prevalence populations may be beneficial: Correctional facilities Adolescent-serving clinics STD clinics Men who have sex with men Multiple partners

32. Why Not Universal Male Chlamydia Screening? • Screening males: the cons • No substantial secondary prevention • Fertility not affected • Epididymitis uncommon • Men difficult to reach—limited health-care seeking • Limited effect on prevalence among women • Highest risk: partners of chlamydia-infected females

33. 2008 Chlamydia Screening By Type of Insurance Commercial Age Health Plan Medicaid (yrs.) (%) (%) ________ _________________ _____________ National Center for Quality Assurance, The state of health care quality 2008. http://www.ncqa.org/Portals/0/Newsroom/SOHC/SOHC_08.pdf.

34. Barriers to STI Risk Assessment By Primary Care Providers

35. Barriers to STI Risk Assessment By Primary Care Providers Limited well care and primary care, especially in adolescents Competing priorities/lack of time Lack of reimbursement Belief that patient population has low STI prevalence Lack of provider training Lack of provider and patient comfort In commercial health plans, billing statements may break confidentiality

36. Opportunities for STI Screening and Care New tools New tests Easy treatment New prevention strategies

37. Tools Available at National Chlamydia Coalition www.prevent.org/ncc American Academy of Pedoatrocs www.aap.org/moc/AdolHandouts_AAPMbrs/ProviderHandouts.htm Society for Adolescent Health and Medicine www.adolescenthealth.org/clinicalcare.htm American Congress of Obstetricians and Gynecologists www.acog.org/goto/teens Resources to • Ensure confidentiality • Address billing and EOBs (explanation of billing statements) • Simplify risk assessment

38. Tests: Nucleic Acid Amplification Test NAAT Amplified nucleic acid sequences specific to organism being detected Does not require viable organisms Most sensitive chlamydia test Endocervical, urethral, urine, and self-collected vaginal swab (for Aptima, BD ProbeTec QX, and Abbott RealTime CT assay) specimens Can detect GC (Neisseriagonorrhoeae or gonorrhea) and CT in single specimen Expensive

39. Chlamydia Diagnosis: Tests Culture NAAT EIA DFA DNA Probe Sensitivity: 60%-80% Specificity: 85-95% Sensitivity: 85-90% Specificity: >98% Sensitivity: 50-65% Specificity: >95% Sensitivity: 65-70% Specificity: 95% Sensitivity: 65-70% Specificity: 95% Preferred

40. Rectal and Pharyngeal Chlamydia and Gonorrhea • CDC recommends NAATs for detection of rectal and pharyngeal infections • FDA has not yet cleared rectal and pharyngeal specimen types for use with NAATs • Labs encouraged to establish their own specifications • Quest and LabCorps sites now offer NAAT testing for rectal and pharyngeal CT and GC

41. FDA-Cleared CT NAATs • Amplicor • Polymerase chain reaction (PCR) • Roche Molecular Systems (Pleasanton, CA) • Aptima • Transcription mediated amplification (TMA) • Gen-Probe (San Diego, CA) • BD ProbeTec QX • 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)

42. Chlamydia Rx

43. Chlamydia Treatment: 2006 CDC Guidelines • Single-dose Rx: Azithromycin 1 gm x 1 OR • Doxycycline 100 mg BID x 7 days • Contraindicated during pregnancy • Effectiveness equivalent

44. Treatment During Pregnancy 1 g azithromycin in a single dose—preferred OR Amoxicillin 500 mg, orally, 3 times daily for 7 days Repeat testing 3 weeks after completion of treatment Prophylactic cesarean delivery not warranted Neonates born to women known to have untreated chlamydia should be evaluated and monitored

45. Chlamydia Follow-up • Very high reinfection risk • Test for reinfection • 3-4 months after Rx or whenever patient presents to clinic within next 12 months

46. Provider’s Role in Preventing Repeat Infection • Partner notification • Patient informs partner • Provider counsels patient about informing partner • Provider informs partner • Expedited partner therapy (EPT) • No health department resources to notify partners

47. Patient-Delivered Partner Therapy Recommended by CDC to treat partner/s unlikely to obtain medical care Provider gives patients medication intended for their partners, or Provider writes partners prescriptions for medication, to be delivered by patient

48. CDC Recommendations • Providers consider including EPT as part of their regular STI care • EPT is “useful option” to further partner treatment • Especially for male partners of Chlamydia- or gonorrhea-infected females • CDC STD Treatment Guidelines 2006 recommend EPT as option for partner treatment among heterosexual persons with chlamydia or gonorrhea

49. Partner-Management Strategies • Among NYC providers • 94% use patient referral frequently • 49% ever used patient-delivered partner therapy (PDPT) • 27% use PDPT frequently Rogers ME, et al. Sexually Transmitted Diseases. 2007;34(2):88-92.

50. Concluding Thoughts