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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