Transcript Chlamydia
CHLAMYDIA Acknowledgements Thank you to the members of the Provider Education Committee of the National Chlamydia Coalition (NCC), who provided review and comments. For more information, see www.prevent.org/ncc. Outline Epidemiology Disease outcomes Female sequelae Male sequelae Adolescent-specific concerns Social aspects Confidentiality concerns Outline (continued) Provider role Screening guidelines Treatment guidelines Partner management and EPT Concluding thoughts Putting screening into practice The Problem: Chlamydia Most commonly reported nationally-notifable disease in the US Highest prevalence among adolescent females Often asymptomatic (up to 80% of cases) Devastating sequelae Epidemiology Burden of Chlamydial Infection Most commonly reported nationally-notifiable disease Over 1.2 million cases reported in 2008 Many infections not detected Estimated 2.8 million cases occur each year Direct medical costs: $678 million/year CDC Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of Health and Human Services; November 2009 Weinstock H, Berman S, Cates W Jr. Perspect Sex Reprod Health 2004 Chesson HW, et al. Perspect Sex Reprod Health 2004 Chlamydia Case Report Rates by State, 2008 VT NH MA RI CT NJ DE MD DC CDC Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of 8 Health and Human Services; November 2009 192 160 271 314 357 258 447 439 1177 Burden of Infection Highest Among Sexually Active Adolescents and Young Adults Prevalence, % Sexually active people aged 14-24 have about 3x the chlamydia prevalence of sexually active adults aged 25-39 Age group (years) 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 9 Large Racial Disparities In Chlamydial Infection NonHispanic Blacks NonHispanic Whites NHANES, National Health and Nutrition Examination Survey, 1999-2008 10to Analysis of sexually active14-39 year-olds; Sexual activity =“yes” response “Have you ever had sex?” Sex = vaginal, anal, or oral sex Prevalence, % Chlamydia Prevalence in Sexually Active Females Aged 14-24 in the United States 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 11 Chlamydia Case Rates: United States, 1989–2008 Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 12 2008. Atlanta, GA: U.S. Department of Health and Human Services; November 2009 National Health and Nutrition Examination Survey (NHANES): Chlamydia Prevalence by Sex*, 1999-2006 5 Prevalence (%) 4 3 Women 2 Men 1 0 1999-2000 2001-2002 2003-2004 2005-2006 2-Year Interval 13 Datta et al. Presented at4 8th Annual ICAAC/IDSA 46th Annual Meeting, Washington, D.C., 10/25-28/2008. *Ages 14-39 years Other Sources for Chlamydia Prevalence Data National Job Training Program High-risk women and men, aged 16-24 years Screened for chlamydia at program entrance Prevalence decreased, 2003-2007 Women: 19% decrease Men: 8% decrease Infertility Prevention Program (IPP) Women tested in family planning clinics, aged 15-24 years No change in positivity rates, 2003-2007 Chlamydia prevalence stable or decreasing, NOT increasing NJTP Source: Satterwhite et al. Sex Transm Dis 2010;37(2):63-37 IPP Source: Satterwhite et al, unpublished data 14 Chlamydia Sequelae Females Males Female Sequelae Chlamydia can increase HIV transmission 3-5 fold Up to 15% risk of pelvic inflammatory disease (PID) with untreated chlamydia PID outcomes: Infertility (1 in 5) Ectopic pregnancy (1 in 10) Chronic pelvic pain (1 in 5) Chlamydia in Pregnancy Chlamydia detected in 2-13% of pregnant females Sequelae during pregnancy: Associated with postpartum endometritis and infertility May lead to premature delivery Chlamydia Vertical Transmission May be vertically transmitted to neonates during birth ~50% of neonates born to infected females are colonized with chlamydia Sequelae of neonatal chlamydia infection Purulent conjunctivitis in 25-50% Neonatal pneumonia in 5-20% Male Sequelae Epididymitis Proctitis Reiter’s Syndrome HIV transmission Why are STDs an Adolescent Health Problem? Age of Sexual Debut Among US Adolescents Can Vary Analysis of Youth Risk Behavior Surveillance System (YRBSS)19992007 data A cross-sectional, nationally representative survey of students in Grades 9-12 by CDC African-American males experienced sexual debut earlier than all other groups (p<.001) and Asian males and females experienced sexual debut later than all groups (p<.001). The probability for sexual debut by their 17th birthday was greatest for African American (females and males) and Hispanic males Adolescent Physical STD Susceptibility Cervical ectopy Adolescent females, usually until reach early 20’s Area around the cervical os is lined with columnar cells Columnar cells are more susceptible to STDs if exposed Adolescent Decision Making Decision-making capabilities are generally not as advanced in early adolescence Adolescents can have very purposeful decision making process about sexual behaviors Other factors which might influence adolescents’ decision to use condoms Relationship/partner characteristics Self-efficacy Knowledge/awareness Adolescents Favor Short Term Benefits Adolescents may place more emphasis on short term benefits May choose actions that will result in a better relationship with their partner over actions that favor longer term outcomes such as STD risk or infertility Serial Monogamy and Concurrent Partners Serial monogamy: The act of engaging in a number of exclusive sexual relationships in succession Time between serially monogamous relationships can be short (e.g., 1-2 weeks as opposed to 6 months) Almost similar to concurrent partnerships and speaks more to the importance of incident infection and the spread of disease In a survey of adolescent couples, agreement between perceptions of sex-partner concurrency and partnerreported behavior was low. Estimation of risk Tendency for adolescents (and people) to overestimate the risk behaviors in which peers are engaging and to underestimate their own risk Sexual Behaviors of US High School Students 2009 Youth Risk Behavior Survey Ever Had Sexual Intercourse Did Not Used a Condom at Last Sex Had Sex Before Age 13 Used Drugs/Alcohol at Last Sex Had 4 or More Sexual Partners 46.0 38.9 21.6 13.8 5.9 US Adolescents with Older Partners Predisposes adolescents to relationship power imbalance Sexual negotiation more difficult for younger females risk of involuntary intercourse, lack of protective behavior, and exposure to STDs Teens’ Challenges with Access to Confidential Care Lack of insurance/ability to pay Lack of “medical home” Lack of confidential services Minors’ Rights to Consent for Confidential STD Care in US All 50 states and the District of Columbia allow minors to consent for STD diagnosis and treatment ~25% of states require that minors be a certain age to consent for their own STD care state requires that providers must notify parents that an adolescent minor has received STD services No Exception in limited or unusual circumstances Some states give physicians discretion to disclose to parents Confidentiality of Medical Information Numerous federal and state laws regulate confidentiality of medical information of a minor who consented for own health care Some states’ laws explicitly protect minors’ confidentiality for STD services and do NOT allow disclosure of information without minor’s consent Other states’ laws grant providers discretion to disclose information to parents Title X and Medicaid Both provide confidentiality protection for family planning services provided to minors with funding from these programs Billing for Confidential Services is a Complex Problem Many commercial health plans send home to the primary insured an explanation of benefit (EOB) listing services reimbursed by health plan An EOB documenting reproductive services rendered to an adolescent dependent often unintentionally discloses confidential services Co-payments can be a barrier for adolescents receiving care Clinical labs often send home billing statements for STD tests, which can unintentionally disclose confidential services HIPAA Privacy Rule Federal regulations issued under the federal Health Insurance Portability and Accountability Act of 1996 Defer to state and “other applicable laws” to determine whether parents have access to confidential health information for which minor gave consent If state or other laws are silent, under HIPAA the health care provider has discretion whether or not to share information with parents Health Care Reform Affordable Care Act provides full health plan coverage for U.S. Preventive Services Task Force (USPSTF) A and B graded preventive health services Chlamydia screening all sexually active females under 25 years is a USPSTF Grade A recommendation Question if EOBs need to be generated if a service is fully covered and insured has NO financial responsibility What Providers Can Do Can establish policy of discussing with adolescent patients when medical records and other information will be disclosed Can develop mechanism to alert office staff as to what information in the chart is confidential Can refer to local low- or no-cost family planning and STD clinic if disclosure of confidential services through EOBs is unacceptable for teen patient Confidential Care Resources CDC web site to locate STD and HIV testing and Hepatitis B virus and HPV vaccination at: http://www.findstdtest.org AAP Section on Adolescent Health web site has many resources and tools for providers to assist with delivery of confidential health care at: www.aap.org/Sections/adolescenthealth/default.cfm Guttmacher Institute web site at: http://www.guttmacher.org/sections/adolescents.php Center for Adolescent Health & the Law publication, State Minor Consent Laws: A Summary, 3rd ed, available to purchase at: www.cahl.org. Confidential Care Resources (Con’t.) The American College of Obstetricians and Gynecologists web site has resources on Confidentiality: http://www.acog.org/departments/adolescentHealthCare/Teen CareToolKit/ACOGConfidentiality.pdf Billing guidance: http://www.acog.org/departments/dept_notice.cfm?recn o=7&bulletin=4799 Chlamydia Screening: National Guidelines Screening Women for Chlamydia: Current Recommendations Recommendations by U. S. Preventive Services Task Force (USPSTF) for non-pregnant women: Screen all sexually-active females aged <25 years Screen women aged ≥25 years if at increased risk USPSTF: A-rated recommended preventive service http://www.ahrq.gov/clinic/uspstf/uspschlm.htm 41 Screening Pregnant Women for Chlamydia Recommendations by U. S. Preventive Services Task Force (USPSTF) for pregnant women: Screen all pregnant women for chlamydia at first prenatal visit Pregnant women aged ≤25 years and those at increased risk should be screened again in the 3rd trimester http://www.ahrq.gov/clinic/uspstf/uspschlm.htm 42 Why Screen Sexually Active Females? Data from a randomized controlled trial of chlamydia screening in a managed care setting suggest that screening programs can lead to a reduction in the incidence of PID by as much as 60% Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;34(21): 1362-66. Chlamydia Screening: Males No guidelines recommend for or against male screening Correctional facilities Selective screening in high-prevalence populations may be beneficial: STD clinics Adolescent-serving clinics MSM Multiple partners Why Not Universal Male Chlamydia Screening? Screening males: the cons No substantial secondary prevention Fertility not affected Epididymitis uncommon Men difficult to reach due to limited health care seeking In modeling and cost effectiveness studies: limited effect on prevalence among women Highest risk: Partners of chlamydia-infected females Partner notification and treatment is critical!!! How Compliant Are Providers With Annual Chlamydia Screening? 2008 Chlamydia Screening HEDIS Rates Health Plan Type Age _____ Commercial Medicaid (yrs) (%) ________________ ____________ 16-20 36.4 48.8 21-26 39.2 54.2 The State of Health Care Quality, 2008 National Center for Quality Assurance at: http://www.ncqa.org/Portals/0/Newsroom/SOHC/SOHC_08.pdf Barriers to Primary Care Provider STD Risk Assessment Limited well care and primary care, especially in adolescents Competing priorities/lack of time Lack of reimbursement Belief that patient population’s STD prevalence is low Lack of provider training Lack of provider and patient comfort In commercial health plans, billing statements may break confidentiality Opportunities for STD Screening and Care New (time-saving) tools New tests Easy treatment New prevention strategies New Tools Resources: Ensure confidentiality Address billing and EOBs Simplify risk assessment Available at: National Chlamydia Coalition: http://ncc.prevent.org/ AAP: www.aap.org/moc/AdolHandouts_AAPMbrs/ProviderHandout s.htm SAHM: www.adolescenthealth.org/Clinical_Care_Resources/2721.htm ACOG: www.acog.org/goto/teens Chlamydia Diagnostic Testing Culture NAAT EIA DFA Sensitivity: 70-75% Specificity: 100% Sensitivity: 90-95% Specificity: >98% Sensitivity: 53-76% Specificity: 95% Sensitivity: 80-85% Specificity: >99% Preferred DNA Probe Sensitivity: 65-70% Specificity: 95% New Tests: Nucleic Acid Amplification Tests (NAATs) Most sensitive chlamydia tests: amplify nucleic acid sequences specific to C. trachomatis Do not require viable organisms Either swab (vaginal, endocervical, urethral) or urine specimens are FDA-cleared for use Can detect GC and CT in single specimen Now widely available Chlamydia Screening: Preferred Genitourinary Specimens Females Vaginal swab (not endocervical swab or urine sample) Vaginal swab samples are as sensitive as endocervical swab specimens, with no difference in specificity Endocervical swab and urine samples are acceptable, but female urine may have reduced performance when compared to genital swab samples Males First catch urine (not urethral swab) In some studies, urethral swab samples are less sensitive than urine, though equivalently specific http://www.aphl.org/aphlprograms/infectious/std/Documents/CTGCLabGuidelinesMeetingReport.pdf Chlamydia Screening: Rectal, but not Pharyngeal Chlamydia CDC recommends NAAT for detection of rectal chlamydia infection, in persons engaging in receptive anal intercourse Rectal specimen types not been cleared by the FDA for use with NAATs Labs encouraged to establish their own specifications Quest and LabCorp now offer commercial NAAT for rectal CT Pharyngeal chlamydia screening not recommended Unclear clinical significance and transmissibility of C. trachomatis detected at oropharyngeal sites http://www.aphl.org/aphlprograms/infectious/std/Documents/CTGCLabGuidelinesMeetingReport.pdf CDC STD Treatment Guidelines, 2010 FDA-Cleared Chlamydia NAATs Amplicor Polymerase chain reaction (PCR) Roche Molecular Systems (Branchburg, NJ) Aptima Transcription mediated amplification (TMA) Gen-Probe (San Diego, CA) BD ProbeTec 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) Chlamydia Treatment Chlamydia Treatment: 2010 CDC Treatment Guidelines Single-dose Rx: Azithromycin 1 gm x 1 OR Doxycycline 100 mg BID x 7 days Contraindicated during pregnancy Effectiveness equivalent Alternatives (erythromycin, levofloxacin, ofloxacin) exist, but are not preferred Chlamydia Treatment: Pregnant Women 1 g azithromycin in a single dose – preferred OR Amoxicillin 500 mg, orally, three times daily for 7 days Repeat testing (NAAT preferred) 3 weeks after completion of treatment, to document chlamydial eradication Prophylactic cesarean delivery not warranted Neonates born to women known to have untreated chlamydia should be evaluated and monitored Chlamydia Follow-Up: Test for Reinfection! High prevalence of chlamydia infection in patients recently treated for chlamydial infection Usually from reinfection Confers elevated risk for PID and other complications CDC therefore recommends test for reinfection: 3 months after Rx or whenever patient next presents to clinic in the 12 months following initial treatment Except in pregnant women, test-of-cure (i.e. repeat testing 3-4 weeks after completing therapy) not advised CDC STD Treatment Guidelines, 2010 Provider’s Role to Prevent Repeat Infection Partner notification Patient informs partner Provider counsels patient about informing partner Provider informs partner Expedited partner therapy (EPT) LIMITED health department resources to notify chlamydia-infected partners EPT: Patient-Delivered Partner Therapy Recommended by CDC to treat partner(s) unlikely to obtain medical care Provider gives patients medication intended for the partners, OR Provider writes partners prescriptions for medication http://www.cdc.gov/std/ept/default.htm CDC Recommendations Providers can consider including EPT as part of their regular STD care EPT “useful option” to further partner treatment Especially for male partners of chlamydiainfected females CDC STD Treatment Guidelines 2010 recommend EPT as option for partner treatment among heterosexual persons with chlamydia Not routinely recommended for MSM because of high risk for co-existing infections, especially undiagnosed HIV, in partners http://www.cdc.gov/std/ept/default.htm Example: Partner Management Strategies among NYC Providers 94% use patient referral frequently 49% ever used PDPT 27% use PDPT frequently Rogers ME, et al. Sex Transm Dis. 2007;34(2):88-92. Concluding Thoughts Putting Screening into Your Practice Make sexual health a priority in your practice Use all medical visits to update recommended preventive care Implement practice-wide systems and reminders for screening Make behavioral/sexual risk assessment routine “We screen all our patients your age.” Use urine-based screening Putting Screening into Practice (continued) Put chlamydia test kits next to Pap test or pregnancy detection materials Provide patient information materials Encourage continuing education for providers Thank you! Questions? For more information, see www.prevent.org/ncc