STD Prevention Conference 2012

Summaries of Highlighted Research

Self-Reported Chlamydia Testing of Women in the United States, 2006-2008
Authors: Hoover, Tao, Leichliter, Peterman
Presentation: Oral D6.4 (Thursday, March 15, 8:30 a.m. CDT)

Trends in Chlamydia Retesting Rates Among Males and Females, Region II Infertility Prevention Project, CY2007-CY2009
Authors: Opdyke, Ologhobo
Presentation: Oral C7.4 (Wednesday, March 14, 10:30 a.m. CDT)

The Power of the Pop-Up: How One Simple Clinic Systems-Level Intervention Increased Overall Chlamydia/Gonorrhea Retesting Rates
Authors: Howard, Barandas, Chow, Bauer
Presentation: Oral D3.4 (Thursday, March 15, 8:30 a.m. CDT)

Increasing Chlamydia and Gonorrhea Retesting Rates in a Student Health Center Using a Quality Improvement Approach
Authors: Burstein, Mancuso, Opdyke, et al.
Presentation: Poster Session 2 (Wednesday, March 14, 3:45 p.m. CDT)

Most Young Women Not Receiving Recommended Chlamydia Screening

Chlamydia often has no symptoms, and when left undiagnosed and untreated can cause serious health consequences, including infertility. Because of the heavy burden of chlamydia among young women, CDC recommends annual screening for sexually active women aged 25 and under. According to this most recent nationally representative estimate of chlamydia screening among this group, however, just over a third were tested in the previous year.

The analysis, led by CDC’s Karen Hoover, used data from the 2006-2008 cycle of the National Survey of Family Growth, a nationally representative household survey. It shows that only 38 percent of sexually active young women aged 15-25 reported having had a chlamydia test within the past year, indicating that 62 percent – more than nine million young women – were not screened as recommended.

Testing rates were low across all sub-groups of young women, but some groups were more likely to report having been tested than others:

Researchers found that women in the older age group (42 percent among those aged 20-25) were more likely to have been tested compared to those in the younger age group (30 percent among those aged 15-19).

African-American women (55 percent tested), those who had multiple sex partners (47 percent tested), and those who received public insurance (50 percent tested) or were uninsured (41 percent tested) were most likely to report having been tested.

Women who accessed reproductive health care in the past year (i.e., contraception, a Pap test, pelvic examination or pregnancy test) were also more likely to report having been tested (45 percent) compared to those who did not access reproductive health care (4 percent).

Although it is encouraging that testing was highest among some of the groups at greatest risk for chlamydia, testing rates were still low across all sub-groups of young women, underscoring the need to develop better screening strategies.

While these data are based on self-reports and may be subject to recall bias or misunderstanding of tests received, they will allow CDC to monitor trends in annual chlamydia testing over time among a nationally representative group of young women. Because it is difficult to measure chlamydia screening on a national level, experts must look at a variety of data sources (including data from health plans, insurance claims, hospitals, clinics, etc.) to understand who is being screened and how often. All of these sources point to the fact that far too few young women are being screened as CDC recommends.

Many Chlamydia Patients Not Receiving Follow-Up Retesting

Chlamydia reinfection is common even when individuals are properly diagnosed and treated, because of untreated infection in their sexual partners. To prevent the health consequences of reinfection, CDC recommends retesting approximately three months after initial chlamydia treatment or during the person’s next health care visit (within 12 months). Despite these recommendations, a new analysis of laboratory data from publicly funded STD and family planning clinics in four areas (New York State, New York City, New Jersey, U.S. Virgin Islands) participating in one region of CDC’s Infertility Prevention Project indicates that only a small proportion of those diagnosed with chlamydia were retested.

The analysis, led by Kelly Morrison Opdyke of Cicatelli Associates, Inc. – a nonprofit organization that provides training and technical assistance to health and social service providers – included 63,774 men and women who tested positive for chlamydia between 2007 and 2009. Just 14 percent of men and 22 percent of women were retested within one to six months. Younger people were more likely to be retested within one to six months of their initial diagnosis (19 percent of those 25 and under) compared with older patients (15 percent of those over 25). Retesting rates were lower among clients attending STD clinics (15 percent) compared with family planning clinics (23 percent), community health centers (35 percent) or university/college health centers (36 percent).

Of those who were retested, 25 percent of men and 16 percent of women again tested positive for chlamydia. Given low retesting rates, this suggests that a substantial number of reinfections are being missed. The retrospective analysis also indicated a decline in retesting during the period studied, although it did not examine reasons for the decline. The authors recommend that clinics establish systems to routinely monitor retesting rates and take steps as needed to improve patient follow-up.

Simple Steps Can Help Improve Chlamydia Retesting Rates

Two studies presented at the conference demonstrate that clinics can successfully boost chlamydia retesting rates by making basic changes to their procedures.

Because CDC recommendations for retesting are the same for both chlamydia and gonorrhea, researchers looked at steps that could be taken to increase retesting rates for both diseases.

In California, researchers previously documented that even when women diagnosed with and treated for chlamydia and gonorrhea made another health care visit between one and six months after receiving treatment, clinics often failed to retest them. To remind providers when retesting was needed, Holly Howard of the California Department of Public Health and colleagues adapted electronic records systems to provide a pop-up flag upon check-in when patients returned to the clinic for any reason.

Following the implementation of pop-up reminders at six large family planning clinics, retesting rates for chlamydia and gonorrhea among those patients who returned to the clinic increased by 23 percent, from 70 percent to 86 percent. Retesting among returning patients improved to at least 80 percent and as much as 90 percent across all sites, with the clinic that began with the lowest retesting rates seeing the most dramatic improvement. Chlamydia was much more common than gonorrhea among patients and accounted for the majority of the retests.

Because the intervention focused on automating existing clinic systems, researchers note that it achieved significant impact at a low cost and without relying on the memories of either patients or providers.

In western New York, staff with the University at Buffalo student health clinic also sought to improve chlamydia and gonorrhea retesting rates among students, which was just 17 percent at baseline. Led by Gale Burstein in the University’s medical school, they implemented a three-step Treatment-Letter-Reminder process. Each student initially testing positive for chlamydia or gonorrhea returned to the clinic to receive treatment (at no cost). The provider offered counseling about retesting and gave the student a standard letter with details about treatment and retesting. Staff also obtained up-to-date contact information from each student, to help ensure they received follow-up messages. Four to five weeks following the initial visit, the student received an automated email reminder, followed by a personal email and telephone call as needed, about the need to return for retesting. The new process was introduced in August 2011, and by the end of December 2011, retesting rates had increased to 86 percent. Chlamydia cases accounted for most of the initial diagnoses and subsequent retests, with retesting rates for chlamydia increasing from 16 percent to 89 percent.

The authors recommend that other student health clinics and private providers investigate similar, inexpensive ways to follow up with chlamydia patients to encourage retesting.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES