Transcript Slide 1

Up, Up, and Away?
Trends in Chlamydial Infections in the U.S.
Steven Shapiro
Catherine Lindsey Satterwhite, MSPH, MPH
Division of STD Prevention
Centers for Disease Control and Prevention
June, 2008
Disclaimer: The findings and conclusions in this presentation are those of the author and
do not necessarily represent the views of the Centers for Disease Control and Prevention.
Outline...
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2006 Chlamydia Supplement
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Whoops.
National Chlamydia Data
Sequelae
Chlamydia Screening Coverage
Region I Chlamydia IPP Data
2006 Chlamydia Supplement
They’re Gone!!
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Warehouse ran out of stock in
early April
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Even after triple checking...
>1000 excess orders
Syphilis supplements also gone
The ‘Whoops’ Part
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Figure 10 in the 2006 CT supplement was
INCORRECT
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See Figure K in overall 2006 Surveillance
Report for correct prevalence rates
Calculations based on gonorrhea, not
chlamydia
Errata will be sent out this week
(Thanks, Canada!)
National Chlamydia Data
Interpretation Challenges
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Increases in lab test sensitivity
Underdetection, underreporting
2000 estimate: 2.8 million cases
 2000 case reports: 709,452
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Different screening rates
Application of screening criteria varies
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CDC: Screen all sexually-active women <26 years
annually
Median State-specific Chlamydia Prevalence
by Year: Women Entering the National Job
Training Program, 1998-2006
Prevalence (%))
18
16
14
12
10
8
6
Test type change (mid-2005):
2005: 27% NAAT
2006: 89% NAAT
4
2
0
1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
Testing Trends by Year: Women Entering the
National Job Training Program, 2000-2006
100
90
80
% of All Tests
70
60
GP PACE 2
50
BD ProbeTec
(urine)
BD ProbeTec
(cervix)
40
30
20
10
0
2000
2001
2002
2003
2004
2005
2006
*From 1997-1999, Gen-Probe (GP) PACE 2 tests were used.
18
16
14
12
10
8
6
4
2
0
GP PACE 2
BD ProbeTec (urine)
Year
2006
2005
2004
2003
2002
2001
2000
1999
1998
BD ProbeTec (cervix)
1997
Prevalence (%)
Median State-specific Chlamydia Prevalence by
Year by Test Type: Women Entering the
National Job Training Program, 1997-2006
National Morbidity Data
(Case Reports)
Chlamydia — Rates by Sex:
United States, 1987–2006
Rate (per 100,000 population)
600
Men
Women
Total
480
360
527.5*
515.8
↓
Program expansion
CT screening demonstration
project (Region X)
183.0*
173.0
240
↓
120
0
1987
89
91
93
95
Notifiable
97
99
2001
03
All 50 report
Total cases reported in 2006: 1,030,911
* 2007 data are preliminary (as of February 16, 2008).
1,073,699*
05
Chlamydia — Rates by Race/Ethnicity:
United States, 1997–2006
Rate (per 100,000 population)
1700
American Indian/AK Native
Asian/Pacific Islander
Black
Hispanic
White
1360
1275.0
↓
1020
680
340
153.1
0
1997
98
99
2000
01
02
03
04
05
06
Chlamydia – Rates by Race and Sex:
United States 2001-2006
2000
1800
1600
1400
1200
1000
800
600
400
200
0
1760.9
741.2
237.0
66.0
2001
White women
2002
2003
White men
2004
2005
Black women
2006
Black men
Chlamydia — Age- and Sex-specific
Rates: United States, 2006
Men
Rate (per 100,000 population)
3000 2400 1800 1200
600
0
11.6
545.1
Age
10-14
0
Women
600
1200 1800 2400 3000
121.5
15-19
856.9
2862.7
20-24
480.8
2797.0
25-29
222.2
1141.2
30-34
415.7
120.8
35-39
174.2
65.1
40-44
27.8
45-54
25.6
9.1
55-64
6.8
2.8
65+
2.2
173.4
Total
69.0
517.0
Chlamydia — Cases by Reporting Source
and Sex: United States, 1997–2006
Cases (in thousands)
750
600
non-STD Clinic Male
non-STD Clinic Female
STD Clinic Male
STD Clinic Female
450
300
150
0
1997
98
99
2000
01
02
03
04
05
06
IPP Data
Reported Chlamydia Test* Volume:
Infertility Prevention Program, 2001 - 2006
3,500,000
3,000,000
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
2001
2002
2003
2004
*Positive and negative test results only.
2005
2006
Proportion of reported chlamydia tests* occurring
among women aged 15-24 years attending family
planning clinics that were NAATs, by region, IPP 2006
100
90
80
70
60
50
40
30
20
10
0
I
II
III
IV
*Positive and negative results only.
V
VI
VII
VIII
IX
X
Chlamydia — Trends in positivity among 15- to
24-year-old women tested in family planning
clinics by HHS region, 2002–2006
6.7 7.5 7.7 7.4 7.5
8.2 8.7 8.8 9.0 9.2
02 03 04 05 06
02 03 04 05 06
02 03 04 05 06
Region X
Region V
Region I
8.0 8.5 8.5 8.1 8.6
9.1 10.2 9.7 7.8 7.5
X
02 03 04 05 06
IX
II I
V
VIII
Region IX
III
VII
7.4 7.3 7.6 7.4 8.4
02 03 04 05 06
6.1 5.5 5.4 5.5 5.5
VI
Region VIII
IV
02 03 04 05 06
Region II
6.8 6.9 7.5 7.4 6.7
02 03 04 05 06
Region III
11.8 11.7 11.7 11.5 11.3
10.1 9.6 10.9 11.0 11.0
02 03 04 05 06
02 03 04 05 06
02 03 04 05 06
Region VII
Region VI
Region IV
6.5 6.5 6.8 6.8 7.6
Note: Trends adjusted for changes in laboratory test method and associated increases
in test sensitivity.
SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for
Disease Control and Prevention
Chlamydia — Median State-specific Positivity
Among 15-24 Year-old Women Tested in Family
Planning Clinics, 1997–2006
Median state-specific positivity rate
10
6.7%
↓
8
6
4
5.1%
↓
(2.8-16.9)
(2.0-11.2)
2
0
1997
98
99
2000
01
02
03
04
05
Note: As of 1997, all 10 Health and Human Services (HHS) regions, representing all 50
states, the District of Columbia, and outlying areas, reported chlamydia positivity data.
SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for
Disease Control and Prevention
06
Other Data
Chlamydia Prevalence Among Women and Men
Aged 14-39 Years by Race/Ethnicity (NHANES),
1999-2002
Prevalence (%)x
10
7.2
8
5.3
6
4
2
3.1
1.5
3.1
1.5
0
Females
Males
Source: Datta, Annals 2007.
NHANES=National Health and Nutrition Examination Survey
Non-Hispanic White
Non-Hispanic Black
Mexican-American
Chlamydia Positivity by Age,
Adult Jails, 2006
Men
20
Positivity
16
12
8
4
0
Age
10.3
<20
9.8
20-24
0
4
8
2.5
>=35
Total
16
15.0
10.3
30-34
5.0
12
20
19.1
25-29
6.7
7.5
Women
6.2
3.8
9.3
Note: Percent positivity is presented from facilities reporting > 100 test results.
Sequelae
What’s happened with PID?
Pelvic Inflammatory Disease —
Hospitalizations of Women 15 to 44 Years of
Age: United States, 1996–2005
Hospitalizations (in thousands)
75
60
45
Acute, Unspec.
Chronic
30
15
0
1996
97
98
99
2000
01
02
03
04
Note: The relative standard error for these estimates of the total number of acute
unspecified PID cases ranges from 8% to 11%. The relative standard error for
these estimates of the total number of chronic PID cases ranges from 11% to
18%. Data only available through 2005.
SOURCE: National Hospital Discharge Survey (National Center for Health Statistics, CDC)
05
Trends in pelvic inflammatory disease hospital
discharges and ambulatory visits, United States,
1985-2001*
Hospital Discharges: PID
* Sutton, STD, 2005
Ambulatory visits: PID
Pelvic Inflammatory Disease — Initial Visits
to Physicians’ Offices by Women 15 to 44
Years of Age: United States, 1997–2006
Visits (in thousands)
300
240
180
120
60
0
1997
98
99
2000
01
02
03
04
Note: The relative standard error for these estimates ranges from 19% to 30%.
SOURCE: National Disease and Therapeutic Index (IMS Health)
05
06
Trends in 12-month infertility among
married women, aged 15-44, 1965-2002*
* Stephen, Fertility and Sterility, 2006
Chlamydia Screening Coverage
Percent .
HEDIS: Mean Chlamydia Screening Rates
Females, Aged 16-20 Years
100
90
80
70
60
50
40
30
20
10
0
2000 2001 2002 2003 2004 2005 2006
Commercial
Medicaid
Cervical Cancer Screening
100.0
90.0
80.0
81.8
78.1
70.0
65.2
60.0
50.0
59.9
40.0
30.0
20.0
Commercial
10.0
Medicaid
0.0
2000
2001
2002
2003
2004
2005
Regional IPP Data
Chlamydia — Trends in positivity among 15- to
24-year-old women tested in family planning
clinics by HHS region, 2002–2006
6.7 7.5 7.7 7.4 7.5
8.2 8.7 8.8 9.0 9.2
02 03 04 05 06
02 03 04 05 06
02 03 04 05 06
Region X
Region V
Region I
8.0 8.5 8.5 8.1 8.6
9.1 10.2 9.7 7.8 7.5
X
02 03 04 05 06
IX
II I
V
VIII
Region IX
III
VII
7.4 7.3 7.6 7.4 8.4
02 03 04 05 06
6.1 5.5 5.4 5.5 5.5
VI
Region VIII
IV
02 03 04 05 06
Region II
6.8 6.9 7.5 7.4 6.7
02 03 04 05 06
Region III
11.8 11.7 11.7 11.5 11.3
10.1 9.6 10.9 11.0 11.0
02 03 04 05 06
02 03 04 05 06
02 03 04 05 06
Region VII
Region VI
Region IV
6.5 6.5 6.8 6.8 7.6
Note: Trends adjusted for changes in laboratory test method and associated increases
in test sensitivity.
SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for
Disease Control and Prevention
Region IV – Chlamydia positivity in 15-24 year old
women in family planning clinics, 1997-2006
P ercent P ositive
15
12.7
11.7
11.2
10.5
10.4
10
10.1
10.9
11.0
11.0
04
05
06
9.6
5
0
97
98
99
00
01
U nadjusted
02
03
A djusted
Region IV – Chlamydia positivity in 15-24 year old
women in family planning clinics, 1997-2006
16
100
14
80
10
60
8
40
6
4
20
2
0
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
NAAT Usage
Adjusted
Unadjusted
NAAT Proportion
Percent Positive
12
How best to analyze programmatic
data for surveillance purposes?
Continuously Reporting Clinics?
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Program necessitates shifting funds
Political considerations
Continous clinics
Stable, defined characteristics
 Additional information about clinic
practice
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Region I* Clinic Participation
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Clinic Type
2002
2003
2004
2005
2006
Family Planning
90
94
113
109
96
STD
17
13
12
10
11
Adult Corrections
4
4
4
3
3
Juvenile Corrections
5
10
11
12
9
Other
18
37
25
22
22
TOTAL
134
158
165
156
141
Family Planning clinics reporting:
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At least one test in each year, 2002-2006:
At least 100 tests in each year, 2002-2006:
At least 200 tests in each year, 2002-2006:
At least 500 tests in each year, 2002-2006:
*CT, MA, ME, NH only; VT not included
61
45
29
13
Region I: Chlamydia positivity in women aged
<26 years in family planning clinics, 2002-2006
10
9
Positivity (%) .
8
7
All FP
FP >0
FP >99
FP >199
FP >499
6
5
4
3
2
*CT, MA, ME, NH
VT not included
1
0
2002
2003
2004
*CT, MA, ME, NH only; VT not included
Year
2005
2006
Region I: Tests Utilized by Family Planning
Clinics Reporting >0 Tests Per Year
100
90
80
% of All Tests
70
60
GP PACE2
ABBOTT LCR
BD SDA
GP Aptima
50
40
30
20
10
0
2002
2003
*CT, MA, ME, NH only; VT not included
2004
2005
2006
Region I: Chlamydia positivity in women aged <26
years in family planning clinics reporting >99 tests
per year, by test type, 2002-2006
10
9
Positivity (%) .
8
7
GP PACE2
ABBOTT LCR
BD SDA
GP APTIMA
6
5
4
3
2
Must have >50
positives in a
single year of a
single test type to
be included.
1
0
2002
2003
2004
*CT, MA, ME, NH only; VT not included
Year
2005
2006
Division of STD Prevention Priority:
Increase Chlamydia Screening Among
Women Aged <26 Years
Vision of Success
Imagine a national chlamydia partnership:
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Comprised of a wide array of engaged, energized partners from
all sectors (private, public, non-profit, philanthropic)
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Focused on one overarching mission: high adherence to clinical
guidance on annual chlamydia screening of sexually-active
women ≤ 25 years old
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Performing a variety of interlocking, complementary activities
that each is uniquely positioned to accomplish
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Efficiently applying assets toward the overarching mission ($,
people, expertise, position, respect)
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Proactively identifying and addressing impacts of the growth of
screening
Summary
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No more CT supplements right now (but soon!)
Interpretation of chlamydia data is difficult
Chlamydia rates are
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decreasing?
flat?
increasing?
PID rates appear to be decreasing
Chlamydia screening coverage rates, while slowly
improving, are still low
Could analysis of continuously-reporting family
planning clinics be a better way to analyze IPP
data?
Thanks!

Division of STD Prevention, CDC
 Hillard Weinstock
 Deblina Datta
 Riduan Joesoef
 LaZetta Grier
 Rose Horsley
 Rob Nelson
 Lori Newman
 Jim Braxton
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Regional IPP Coordinators and Data Managers
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State and Local Health Departments