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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 STI Burden Why it matters CDC STI Estimates 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: ~$16 billion/year Adolescents Face Increased Risk for STIs Biological Behavioral Social/Institutional Chlamydia — Rates of Reported Cases by Age and Sex, United States, 2014 CDC STD Surveillance Report 2014 Chlamydia — Rates of Reported Cases by State, United States and Outlying Areas, 2014 CDC STD Surveillance Report 2014 Chlamydia — Rates of Reported Cases by Race/Ethnicity, United States, 2010– 2014 CDC STD Surveillance Report 2014 STD Disparities: Meeting the Challenges Multiple factors contribute to STD disparities in African-Americans: Racial inequality High levels of uninsured Low educational attainment High incarceration rates To address STD disparities, involvement of affected communities at all steps in the process is required Source: Valentine, J. “Addressing STD Disparities Among Adoles Health Impact Pyramid with STD Prevention Examples Smallest Impact Behavioral counseling to reduce STD/HIV Counseling & Education Clinical Interventions Long-lasting Protective Interventions Changing the Context To Make Individuals’ Default Decisions Healthy Largest Impact Socioeconomic Factors Frieden T. AJPH 2010 STD Testing and Treatment Immunization, male circumcision Ubiquitous condom availability, alcohol tax Decrease poverty & inequality and improve education & housing Social Determinants Affecting Individual Health Social environment can determine the availability of healthy sexual partners Challenging economic circumstances can increase risk for STDs if affordable quality health care is not accessible Community mistrust/miscommunication between providers and patients negatively affects health care-setting interactions & may lead to barriers to care-seeking Source: Valentine, J. “Addressing STD Disparities Among Adolescents” Social/Institutional Risk Factors Lack of Insurance/$ to Pay Lack of Transportation Lack of Sex Ed Regarding Risk and Symptoms Adolescent s 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 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 — Percentage of Reported Cases by Sex and Selected Reporting Sources, United States, 2014 CDC STD Surveillance Report 2014 Chlamydia — Proportion of STD Clinic Patients* Testing Positive by Age, Sex, and Sexual Behavior, STD Surveillance Network (SSuN), 2014 CDC STD Surveillance Report 2014 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? 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 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 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 Men Who Have Sex With Men (MSM) 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 http://www.cdc.gov/std/tg2015/specialpops.htm#MS M Women Who Have Sex with Women (WSW) 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. http://www.cdc.gov/std/tg2015/specialpops.htm# WSW Transgender Males and Females Assess STD- and HIV-related risks based on current anatomy and sexual behaviors diversity of transgender persons regarding surgical affirming procedures, hormone use, and their patterns of sexual behavior providers must remain aware of common STD Sx and screen for STDs on basis of behavior and sexual practices 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 www.cdc.gov/std/tg2015/default.htm Chlamydia Treatment Azithromycin 1g Orally Single Dose Alternatives: Erythromycin or Levofloxacin or Ofloxacin O R Doxycycline 100mg orally Twice a day x 7 days Pregnancy Alternative Regimens: • Amoxicillin • Erythromycins http://www.cdc.gov/std/tg2015/chlamydia.htm Azithromycin vs Doxy for urogenital CT 567 youth detention (12 - 21 yo ♀&♂) participants receiving directly observed therapy Doxy group: no treatment failures Azithromycin group: 5 (3.2%) failures Overall efficacy: Doxycycline 100% Azithromycin 97% Did not establish non-inferiority of azithro Geisler, et al. NEJM. 2015; 373: 2512-21. Chlamydia Treatment Doxycycline delayed release 200 mg tabs (Doryx) GI upset Qday x 7 days $ Oropharyngeal Chlamydia Clinical significance unclear Routine oropharyngeal CT screening not recommended Can be sexually transmitted to genital sites Treat oropharyngeal chlamydia with Azithromycin or doxy 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 40 states and Washington, D.C. Potentially Allowable in 8 states (AL, GA, DE, KS, OK, SD, VA, NJ and Puerto Rico) Prohibited in 2 states (Kentucky & West Virginia) 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 https://www.cdc.gov/std/ept/legal/default.htm Updated July 2016 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 www.cdc.gov/std/tg2015/default.htm www.cdc.gov/std/tg2015/screening-recommendations.htm Want to know more about STDs? There’s an app for that. CDC Treatment Guidelines App for Apple and Android http://www.cdc.gov/std/tg2015/ STD Clinical Questions Plan A: call health department STD Clinical Consultation Network (STDCCN) 8 Regional PTCs STD Clinical Consultation Network www.STDCCN.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
