Effectiveness of school-based chlamydia screening: a literature review by



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EFFECTIVENESS OF SCHOOL-BASED CHLAMYDIA SCREENING: A LITERATURE REVIEW

by

Katherine A. Clark



Bachelor of Arts, Bryn Mawr College, 2005

Submitted to the Graduate Faculty of

the Department of Epidemiology

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Public Health

University of Pittsburgh

2012






UNIVERSITY OF PITTSBURGH

GRADUATE SCHOOL OF PUBLIC HEALTH

This essay is submitted

by

Katherine A. Clark


on
December 14, 2012

and approved by


Essay Advisor:

Catherine Haggerty, M.P.H., Ph.D. ______________________________________

Associate Professor

Epidemiology

Graduate School of Public Health

University of Pittsburgh

Essay Reader:

Martha A.Terry, B.A., M.A., Ph.D. ______________________________________

Assistant Professor

Behavioral and Community Health Sciences

Graduate School of Public Health

University of Pittsburgh







Copyright © by Katherine A. Clark

2012





Catherine Haggerty, M.P.H., Ph.D.
EFFECTIVENESS OF SCHOOL-BASED CHLAMYDIA SCREENING: A LITERATURE REVIEW
Katherine A. Clark, MPH

University of Pittsburgh, 2012



Chlamydia trachomatis (CT) is the most commonly reported notifiable sexually transmitted disease (STD) in the United States (1). In women, chlamydia can result in serious sequelae, such as pelvic inflammatory disease (PID), chronic pelvic pain, tubal factor infertility, and ectopic pregnancy (1-3). In men, chlamydial infection can cause epididymitis, an inflammation of the epididymis, which in complicated cases can lead to scrotal abscess, testicular infarction, and infertility (1, 4). As a part of Healthy People 2020, the U.S. Department of Health and Human Services has defined a nationwide objective to reduce the number of adolescents infected with CT (5). In an effort to reduce the public health burden of CT in adolescents, school-based screening has been initiated in cities across the country. A critical review of studies reporting the results of CT screening initiatives in schools and other non-traditional settings was published in 2005 (6). Since that time, additional studies have been published reporting results of new and existing school-based screening initiatives. The purpose of this literature review is to critically assess the effectiveness of school-based chlamydia screening programs, as measured by recruitment of high-school aged males and females for screening, the detection chlamydial infection, and reinfection/rescreening rates. The majority of the studies available for review are cross-sectional prevalence reports of the screening uptake and CT prevalence detected in specific programs or specific SBHCs over different periods of time. This makes comparison of the effectiveness of programs and SBHCs difficult. SBHC screening had a lower average screening uptake then did school-based programs, though only one study reviewed provided screening coverage information for SBHCs. This study saw screening uptake ranging from 17%-56% in SBHCs, while the screening uptake in school-based programs ranged from 30.9%- 47.6% (7-9). All school-based programs had a larger screening uptake in males relative to females. All urban screening programs showed higher rates of CT positivity in females versus males, despite males having a higher screening uptake. In the two, reinfection studies evaluated, reinfection rates were high, ranging from 13.6% in a SBHC to 26.3% in a school-based program. Strengths and limitations of all reviewed studies are reported, as well as directions for future research.


TABLE OF CONTENTS



1.0 Methods 11

2.0 Results 15

1.1Screening Coverage 16



1.1.1Screening coverage in SBHCs 17

1.1.2Screening coverage of school-based programs 20

1.2Detected Prevalence of CT Infections 25



1.2.1Prevalence of CT detected in SBHCs 26

1.2.2Prevalence of CT detected in school-based programs 27

1.3reinfection/rescreening rate in SBHCS and school-based programs 29



3.0 Discussion 32

1.4Screening coverage 33

1.5Detected CT Prevalence 36

1.6Rescreening/Reinfection 38



4.0 Conclusion 39

Chlamydia trachomatis (CT) is the most commonly reported notifiable sexually transmitted disease (STD) in the United States (1). In women, chlamydia can result in serious sequelae, such as pelvic inflammatory disease (PID), chronic pelvic pain, tubal factor infertility, and ectopic pregnancy (1-3). PID is an inflammation of the uterus, fallopian tubes, and ovaries (3). Symptoms range from non-existent to severe, and can include fever, pelvic pain, and abnormal vaginal discharge (10). PID will affect 8% of US women in their lifetime (3). In men, chlamydial infection can cause epididymitis, an inflammation of the epididymis, the tube connecting the testicle to the vas deferens (1, 4). In complicated cases, epididymitis can lead to scrotal abscess, testicular infarction, and infertility (1, 4). In 2009, 1,244,180 CT cases were reported in the US, with an estimated 2.8 million remaining undetected (1). Yearly, approximately $701 million is spent covering the direct medical costs of CT and CT-related infertility (1).

Adolescents and young adults carry the largest burden of CT in the United States. The Centers for Disease Control and Prevention (CDC) estimate CT prevalence in 14-19 year old sexually active females at 6.8% (2). In 2010, the highest rates of chlamydia were reported among 15-19 and 20-24 year old women (3,378.2 cases and 3,407.9 cases per 100,000, respectively) (2). For males, CT rates were highest among those aged 20-24 years at 1,187.0 cases per 100,000 individuals (2). CT rates also vary substantially by race/ethnicity. African-American (AA) women had the highest rates of CT relative to whites, American Indians/Alaska Natives, and Hispanics in 2010 (1,167.5 cases per 100,000 versus 138.7, 592.8, and 369.6 cases per 100,000, respectively) (2).

Infection with CT is usually asymptomatic. Because most infections are asymptomatic and the consequences of untreated infections can be severe, especially in women, the CDC currently recommend screening of all sexually active women aged 25 years or younger, as well as older women with risk factors such as new or multiple sexual partners (11). Currently, the routine screening of sexually active men is recommended only in clinical settings with high CT prevalence, such as adolescent clinics and correctional facilities (11). Despite clear recommendations, current evidence suggests that young women are not being screened as is recommended (12). The National Survey of Family Growth’s 2006-2008 cycle found that 38% of sexually active women aged 15-25 reported a chlamydia test in the past year, substantially fewer than should be tested based on current guidelines (12). Chlamydia screening and effective follow-up treatment are essential to preventing the spread of chlamydia and the development of chlamydia-related sequelae (13).

Clinical testing for CT has never been easier. Nucleic acid amplification tests (NAATs) are extremely sensitive and can be run using urine samples, which can be easily and quickly collected with minimal discomfort to those being screened (1). Urine chlamydia testing has been shown to be the preferred screening method of both young men and young women (14, 15). The U.S. Preventive Services Task Force recommends CT screening to reduce the incidence of PID (13).

The U.S. Department of Health and Human Services has defined the need to reduce the number of adolescents and young adults with CT as a Healthy People 2020 objective (5). Healthy People 2020 defines a separate objective to specifically reduce the rate of chlamydia infection in females 15-44 years of age (5). In the past 20 years, high schools, particularly in urban areas, have been targeted as sites for chlamydia screening (7-9, 16-34). These sites offer unique access to a relatively contained, well-defined population of adolescents, making large-scale screening, treatment, rescreening, and partner treatment theoretically more feasible and effective. These sites also afford the opportunity to provide STD-prevention education in conjunction with screening services.

A critical review of studies reporting the results of CT screening initiatives in schools and other non-traditional settings was published in 2005 (6). Since that time, additional studies have been published reporting results of new and existing school-based screening initiatives. The purpose of this literature review is to critically assess the effectiveness of school-based chlamydia screening programs, as measured by recruitment of high-school aged males and females for screening, the detection chlamydial infection, the provision of treatment/partner treatment, and reinfection rates. Strengths and limitations of all reviewed studies are reported, as well as directions for future research.




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