Transcript Chlamydia and Adolescent Patients

Chlamydia and Adolescent
Patients

Objectives
 Describe the epidemiology, scope, and risk factors for
Chlamydial infection in adolescents
 Assess, treat, and prevent Chlamydial infection in
adolescent patients utilizing evidence-based
guidelines
 Discuss ways to improve current clinical practice
 Provide referrals for care to adolescent patients


Adolescent Sexual Behavior
Knowing which questions to ask
YRBS 2013 Condom Use
80.00%
% of HS Students Who Used a Condom at Last Intercourse
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
1991
1993
1995
1997
1999
High School Males
2001
2003
2005
2007
High School Females

YRBS 2013
2009
2011
2013
YRBS 2013: U.S. High School
Students
YRBS Question
U.S.
% students ever had sex
46.8%
% students who used a condom at last sex
59.1%
% students had sex with 4 or more persons
(in lifetime)
15.0%
% students had sex with at least 1 person in
last
3 months
34.0%

CDC YRBS Data 2013
♀ Sexual Behavior with
Opposite-Sex Partners
Age (yrs) Any sex Vaginal sex Oral sex
Anal sex
15–19
53%
46%
45%
11%
20–24
88%
85%
81%
30%

NSFG 2006-8
http://www.cdc.gov/nchs/data/nhsr/nhsr036.pdf
♂ Sexual Behavior with
Opposite-Sex Partners
Age (yrs) Any sex Vaginal sex Oral sex
Anal sex
15–19
58%
45%
48%
10%
20–24
86%
82%
80%
32%

NSFG 2006-8
http://www.cdc.gov/nchs/data/nhsr/nhsr036.pdf
♂ Sexual Behavior with Same-Sex
Partners
Age (yrs)
Any sex with Anal sex with
Oral sex with ♂
♂
♂
15–19
3%
1%
2%
20–24
6%
3%
6%

NSFG 2006-8
http://www.cdc.gov/nchs/data/nhsr/nhsr036.pdf

Adolescents Face
Increased Risk for STIs
Biological Risk Factors: Females
Adolescent cervix
Lack of immunity from prior infections
Smaller introitus
Lack of lubrication can lead to dry,
traumatic sex

Cognitive Risk Factors
for STIs in Adolescents
 Early adolescence: concrete thinking
 Often unable to plan ahead for condoms
 Serial monogamy in relationships leading to multiple
partners
 Personal fable
 Unable to judge risk for STIs
 “Other people get STIs”

Behavioral Risk Factors
Age at
First
Intercourse
Mental
Health
Substance
Use

Sexual
Activity with
New/Older
Partner
Multiple
Sexual
Partners
Risk Factor: Intimate Partner Violence
 Teen girls who are abused by male partners are 3×
more likely to become infected with an STI/HIV than
non-abused girls.
 Adolescents rarely self-report dating violence and
may not recognize their exposure to dating violence
as abuse.
 Direct questions (with yes or no answers) may not be
effective.

Elizabeth Miller & Rebecca Levenson. Hanging out or Hooking Up:
Clinical Guidelines on responding to Adolescent Relationship Abuse
Risk Factor: Social/Institutional
Lack of
Insurance/$ to
Pay
Lack of Sex Ed
Regarding Risk
and Symptoms

Lack of
Transportation
Adolescents
Not Being
Screened
and Treated
Concerns
About
Confidentiality
Stigma
STI Protective Factors
 Peer support for contraception and condoms
 Communication with parents about sex
 Connection to family
 Connection to school and future success
 Connection to community organizations


Adolescent STI Burden
Why it matters
U.S. Preventive Services Task Force:
High-Priority Evidence Gaps
 Why focus on STI care and treatment for children,
adolescents, and young adults?
 USPSTF 4th Annual Report identifies:
 Long-term harms of HIV antiretroviral therapy
 Interventions to prevent STIs in low-risk adolescents
and
high-risk adolescents
 Effectiveness of screening strategies to identify
high-risk adolescents

CDC 2013 Report: STIs and Young
People
Incidence
Prevalence
Increased
Risk
Cost

~20 million new cases/year:
50% occur in people ages 15–24
Total infections: 110 Million
# of new infections equal among
young males (49%) and females
(51%)
Direct medical costs:
~$16 billion/year
Half of New STIs: Ages 15-24

Trends in Chlamydia Infection Among
Adolescents
 Chlamydia infection increased by an average of 3.3%
per year from 2005-2012 for females aged 15-19
 Rates decreased slightly, 2012-2013, mostly among
females and males aged 15-19
 First time that overall chlamydia case rates decreased
since national reporting began
 Rate of chlamydia shows no sign of decline for
females aged 20–24

2013 CDC STD Surveillance Report
CDC National Health Report. 2005–2013.
68% of all Chlamydia Cases
Among 15- to 24-Year-Olds

CDC STD Surveillance Report 2013
Chlamydia: Rates by Race/Ethnicity,
United States, 2009-2013

CDC STD Surveillance Report 2013
Significant Racial Disparities
 Chlamydia rates in 2013:
 The rate for blacks 6.4 times the rate among whites
 The rate for American Indians/Alaska Natives 3.9 times
the rate among whites
 The rate for Hispanics 2.1 times the rate among whites
 The rate for Native Hawaiians/Other Pacific Islanders
3.5 times the rate among whites
 The rate among Asians was lower than the rate among
whites

CDC STD Surveillance Report 2013
Chlamydia: Rates by State, United States
and Outlying Areas, 2013

CDC STD Surveillance Report 2013

Who Is Caring for Adolescents?
Clinical Care: Female Adolescents
Source: National Ambulatory Medical Care Survey, 2003–6

Hoover et al., J Adol Health, 2010
Chlamydia: Cases by Reporting Source and
Sex, United States, 2004-2013

CDC STD Surveillance Report 2013
Chlamydia: Proportion of STD Clinic
Patients Testing Positive, 2013

CDC STD Surveillance Report 2013
Case: Erica
 Erica is a 16-year-old
female who presents
with dysuria.
 What is your initial
differential diagnosis?
 What additional
information do you
need?

Approach to the Adolescent Key
Strategies
 Assess developmental level
 Discuss confidentiality with adolescent/parent
 Appropriately ensure confidentiality, time alone
 Brief risk assessment at most visits
 STI screening annually if sexually active
 Systems for follow-up of confidential results


Assessing Sexual Behavior
Include questions that direct
testing
Sexual History: The Five Ps
 Partners
 Gender(s), Number (three months, lifetime)
 Prevention of pregnancy
 Contraception, EC
 Protection from STIs
 Condom use
 Practices
 Types of sex: anal, vaginal, oral
 Past history of STIs

www.stdhivtraining.net
Prevention Counseling
AAP
Patient-centered, age-appropriate anticipatory guidance;
Integrate sex ed into clinical practice; can use educational
materials;
Prevention guidance, including abstinence, safer sexual practices,
and condoms
ACOG
Counseling for all sexually active individuals
AAFP
High-intensity behavioral counseling (HIBC)
CDC*
HIBC; interactive counseling approaches, i.e., client-centered
STD/HIV prevention counseling; motivational interviewing; videos
and large group presentations to provide information
USPSTF
Intensive behavioral counseling for all sexually active adolescents
and adults at high-STI risk

Erica: Sexual History Results
 Several episodes of unprotected sex in the last few
weeks with one male partner (her only lifetime)
 Not on hormonal contraception but uses condoms
most of the time
 Engages in oral (giving and receiving) and vaginal
sex
 No known history of STIs

Erica: History of Present Illness Results
 Erica tells you she has burning with urination and a
“yellowish” discharge. She reports itchiness.
 She denies abdominal pain and fever and reports no
bumps or lesions.
 What is the differential diagnosis?

Differential Diagnosis
 You observe discharge in the vault but not in the os.
 You suspect vaginitis.
 What are the causes of vaginitis?

Differential Diagnosis
Dysuria
Genital Tract
Infection
Vaginitis

Trichomonas
Bacterial
Vaginitis
Candida
Vaginitis
Additional Concerns
 Because Erica is a sexually
active
16-year-old, she is also at risk for
cervicitis.
 What are the most common
causes of cervicitis?
 Chlamydia
 Gonorrhea

C.T.

Chlamydia
Curable bacterial STI
Most common reportable communicable disease
Highest-reported rates among adolescent and young
adult females (Aged 15–24)
Usually asymptomatic

Chlamydia Symptoms
Females:
Up to ~80–90%
asymptomatic
Males:
Up to 90%
asymptomatic

• Heavy or prolonged menses
• Spotting
• Dysmenorrhea
• Dyspareunia
• Vaginal discharge
• Penile discharge
• Dysuria
Clinical Syndromes Caused by C.
trachomatis
Males
Females
Infants

Local
Infection
Complication
Sequelae
Conjunctivitis
Urethritis
Proctitis
Epididymitis
Reiter’s syndrome
(rare)
HIV risk
Chronic arthritis
(rare)
Conjunctivitis
Urethritis
Cervicitis
Proctitis
Endometritis
Salpingitis
Perihepatitis
Reiter’s syndrome
(rare)
HIV risk
Infertility
Ectopic pregnancy
Chronic pelvic pain
Chronic arthritis
(rare)
Conjunctivitis
Pneumonitis
Pharyngitis
Rhinitis
Eye and lung
infections
Rare, if any
Non-Gonococcal Urethritis:
Mucoid Discharge

Source: Seattle STD/HIV Prevention Training Center
at the University of Washington/UW HSCER Slide Bank
Swollen or Tender Testicles
(epididymitis)

Source: Seattle STD/HIV Prevention Training
Center at the University of Washington
Normal Cervix

Source: STD/HIV Prevention Training Center at the
University of Washington/Claire E. Stevens
Chlamydial Cervicitis

Source: STD/HIV Prevention Training Center at the
University of Washington/Connie Celum and Walter Stamm
Normal Human Fallopian Tube Tissue

Source: Patton, D.L. University of Washington, Seattle, Washington
C. trachomatis Infection (PID)

Source: Patton, D.L. University of Washington, Seattle, Washington

Chlamydia Screening
♀ Routine Annual Chlamydia Screening
AAP
all sexually active ≤25 yrs
ACOG
all sexually active adolescents
AAFP
all sexually active <24 yrs
CDC*
all sexually active <25 yrs
USPSTF
all sexually active <24 yrs
*Draft

Chlamydia Screening: Males
Routine Screening NOT
recommended for men
Correctional facilities
STI clinics
Selective screening in
high-prevalence
populations should be
considered
Adolescent-serving clinics
MSM
Multiple partners

AAFP, CDC, USPSTF, AAP Recommendations
USPSTF CT Risk Factors
 Age
 ♀ ages 15-24 years,
 ♂ ages 20-24 years
 New sex partner, >1 sex
partner, sex partner w/
STI infection
 Inconsistent condom use
 H/O or coexisting STIs
 Exchanging sex for
money or drugs.

 Incarcerated populations,
military recruits, and
patients receiving care at
public STI clinics.
 Racial Disparities:
 Blacks and Hispanics
higher CT rates vs.
whites
USPSTF Justification for ♂ CT
 ♂ CT may cause
nongonoccal urethritis,
epididymitis, and rarely
urethral structures and
reactive arthritis
 asymptomatic urethritis
uncommon

MSM Screening:
Chlamydia and Gonorrhea
 CDC recommends at least yearly urethral and rectal
screening for MSMs who, in the last year, have
participated in:
 Insertive anal intercourse
 Receptive anal intercourse
 Receptive oral intercourse (GC only)
 Screening is recommended regardless of condom use
 For high risk sex behavior, should screen every 3-6
months

Women Who Have Sex with Women
 Regardless of reported same-sex behavior, providers
should consider:
 Screening all females for chlamydia and gonorrhea as
per recommendations
 Offering routine cervical cancer screening and HPV
vaccine in accordance with current guidelines.


Confidentiality and Billing
Confidentiality and Billing
 Cannot guarantee confidentiality in many cases
 Explanation of benefits (EOB) may be sent by
insurance company
 Teen patient may request for EOB to be sent to
alternative address by health plan
 Need to know the “paper trail issues” in your health
system
 Need to have Plan B for confidential services
 www.itsyoursexlife.com/gyt/

Explanation of Benefits (EOBs)
Medicaid vs. Commercial Insurance
 EOBs sent to policyholder or insured in most
commercial plans
Some health plans NOT sending EOBs if only
copayment due
 Medicaid does not routinely send EOBs
 EOBs do not disclose service/diagnosis
Parent can obtain that info from health plan
 No control over lab bills/statements


Chlamydia Tests and Treatment
Case: Evaluating Cervicitis
 How do you evaluate Erica for
cervicitis?

Chlamydia Diagnosis
Culture
NAAT
EIA
DFA
Sensitivity:
70%
Specificity:
85%–95%
Sensitivity:
85%–90%
Specificity:
>98%
Sensitivity:
50%–65%
Specificity:
>95%
Sensitivity:
65%–70%
Specificity:
95%
Preferred

DNA
Probe
Sensitivity:
65%–70%
Specificity:
95%
NAAT vs. Culture

Schachter J,et al. Sex Transm Dis. 2008;35:637–42.
Chlamydia NAAT Screening:
Preferred Noninvasive Genitourinary Specimens
 ♀: Vaginal swab
• Vaginal swab samples are as sensitive as endocervical
swab specimens
• Urine samples acceptable
– ♀urine may have ↓ performance compared to cervical
swab samples
 ♂: Urine
 Urethral swab samples may be ↓ sensitive than urine

www.cdc.gov/std/laboratory/2014LabRec/default.htm
FDA Clearance
 All NAATs
 Urethral swabs from males
 Cervical swabs
 Urine from males and females
 Certain NAATs
 Vaginal swabs
 Non-FDA cleared for:
 Rectal
 Pharyngeal
 (Many laboratories have met regulatory CLIA
requirements)

How to Order Screen
Non-genital GC/CT NAATs can be done by
clinical laboratory with CLIA approval
Gen-Probe APTIMA
testing
QUEST diagnostics test LabCorp diagnostics
codes
test codes
Pharyngeal
70051X
188698
Rectal
16506X
188672
Urine/Urethral
13363X
183194
Relevant CPT Billing Codes:
CT detection by NAAT: 87491
GC detection by NAAT:

87591
Chlamydia Treatment
 Recommended
Regimens
 Azithromycin 1 g PO
single dose
 Doxycycline 100 mg PO
BID x 7 days

CDC STD Treatment Guidelines. 2010.
Hey! There’s an App for That!

www.cdc.gov/std/STD-Tx-app.htm
STI Partner Management Strategies
Provider
Referral
• Partners contacted by index
patient’s provider or by a disease
intervention specialist
Patient
Referral
• Index patient assumes primary
responsibility to notify and refer
his/her partners at risk
Expedited
Partner
Therapy
(EPT)

• Providers (1) give patient medication
intended for the partners (2) write
partners’ prescriptions for medication
CDC Recommends EPT
 EPT: Delivery of medications or prescriptions by
persons infected with an STD to their sex partners
without clinical assessment of the partners.
 EPT laws vary by state:
 Permitted in 35 states and the city of Baltimore, MD
 Prohibited in 6 states (FL, KY, MI, OH, OK, WV)
 www.cdc.gov/sTd/ept/legal/default.htm
 Heterosexual sex partners should be evaluated,
tested, and treated if:
 Had sexual contact with patient during or >60 days of
symptom onset/diagnosis of chlamydia or gonorrhea

Behaviors Affecting EPT Effectiveness
Patient-delivered
specific
Patient did not give Rx to
any/all partners
Partners noncompliant with Rx
General
noncompliance
Patients did not contact partners
Patients noncompliant with Rx
Resumed sex <7 days after
case and partner treatment
Sex with new partner(s)

EPT Barriers
 General theoretical
liability issues
 Rx without an exam
 Medical records for
treated partner?
 Legal issues with minors
 Consent to care
 Obligation to report sex
in minors with older
partners

 Financial: who pays for
partner Rx?
 Adverse drug effects
 Partner may not seek
complete STI assessment
 Potential to miss
partners’ other STIs,
including HIV
 Missed counseling
opportunities for partners
Repeat Testing After Treatment
 Pregnant females
 Repeat testing, preferably by NAAT, 3 weeks after
completion of recommended therapy
 Non-pregnant females
 Test of cure not recommended unless:
• Compliance is in question, symptoms persist, or
reinfection is suspected
 Repeat testing recommended 3-4 months after
treatment
• Especially adolescents; high prevalence of repeat
infection

Erica: Wrap-Up
 Administer EC and write advanced prescription
 HIV test
 HPV vaccine
 Give appointment to return in 3 months

Red Book STI Chapters

http://aapredbook.aappublications.org/
Provider Resources:
Sexually Transmitted Infections
 National Chlamydia Coalition: ncc.prevent.org
 U.S. Centers for Disease Control and Prevention
 Statistics and Surveillance Reports:
www.cdc.gov/std/stats/default.htm
 Expedited Partner Therapy: www.cdc.gov/STD/ept/default.htm
 Screening & Treatment Guidelines:
www.cdc.gov/std/treatment/2010/default.htm
 American Social Health Association:
 www.ashastd.org/std-sti/hpv.html
 U.S. Department of Health and Human Services
womenshealth.gov/faq/stdhpv.htm
 USPSTF: www.uspreventiveservicestaskforce.org/uspstopics.htm
 ACOG: www.acog.org/Resources-And-Publications

Provider Resources and Organizational
Partners
 www.advocatesforyouth.org—Advocates for Youth
 www.aap.org—American Academy of Pediatricians
 www.aclu.org/reproductive-freedom American Civil Liberties
Union Reproductive Freedom Project
 www.acog.org—American College of Obstetricians and
Gynecologists
 www.arhp.org—Association of Reproductive Health
Professionals
 www.cahl.org—Center for Adolescent Health and the Law
 www.glma.org Gay and Lesbian Medical Association

Provider Resources and Organizational
Partners
 www.guttmacher.org—Guttmacher Institute
 janefondacenter.emory.edu Jane Fonda Center at Emory
University
 www.msm.edu Morehouse School of Medicine
 www.prochoiceny.org/projects-campaigns/torch.shtml NARAL
Pro-Choice New York Teen Outreach Reproductive Challenge
(TORCH)
 www.naspag.org North American Society of Pediatric and
Adolescent Gynecology
 www.prh.org Physicians for Reproductive Health

Provider Resources and Organizational
Partners
 www.siecus.org—Sexuality Information and Education Council
of the United States
 www.adolescenthealth.org—Society for Adolescent Health and
Medicine
 www.plannedparenthood.org Planned Parenthood Federation of
America
 www.reproductiveaccess.org Reproductive Health Access
Project
 www.spence-chapin.org Spence-Chapin Adoption Services

Please Complete Your Evaluations Now
