Background: Chlamydia trachomatis infections can lead to serious and costly sequelae. Because chlamydia is most often asymptomatic, many infected youth do not seek testing. Entry to a detention system provides an opportunity to screen and treat many at-risk youth.
Goal: The goal of this study was to determine the cost-effectiveness of screening male youth for chlamydia on entry to detention.
Study Design: Incremental cost-effectiveness of 3 chlamydia screening strategies was compared for a hypothetical cohort of 4000 male youth per year: 1) universal chlamydia screening using a urine-based nucleic acid amplification test (NAAT), 2) selective NAAT screening of urine leukocyte esterase (LE)-positive urines, and 3) no screening. The model incorporated programmatic costs of screening and treatment and medical cost savings from sequelae prevented in infected males and female partners. The analysis was conducted from the healthcare system perspective.
Results: Chlamydia prevalence in the sampled population of 594 was 4.8%, and the average number of female sexual partners/infected male was 1.6. Universal NAAT screening was the most cost-effective strategy, preventing 37 more cases of pelvic inflammatory disease (PID) and 3 more cases of epididymitis than selective screening and saving an additional $24,000. The analysis was sensitive to NAAT cost, LE sensitivity, rate of PID development, PID sequelae cost, and number of female partners. Universal screening remained the most cost saving for prevalence as low as 2.8% or higher.
Conclusions: Universal chlamydia screening of adolescent males on entry to detention was the most cost-effective strategy. Savings are primarily the result of the prevention of PID in recent and future partners of index males. Screening detained male youth using a urine-based NAAT provides a public health opportunity to significantly reduce chlamydia infections in youth at risk for sexually transmitted diseases.
CHLAMYDIA TRACHOMATIS, THE MOST prevalent bacterial sexually transmitted disease (STD) in the United States, infects adolescents and young adults at higher rates than any other age group. 1 Early diagnosis of this STD is important, not only to minimize disease spread, but also to prevent untreated infections from progressing to pelvic inflammatory disease (PID) in young women and epididymitis in young men. PID can have serious long-term sequelae, including ectopic pregnancy, infertility, and chronic pelvic pain. 1 The total cost to society for treatment of PID and its sequelae has been estimated at $4.2 billion annually. 2
Until recently, evaluation for chlamydia has required that males submit to urethral swabs. However, several urine-based nucleic acid amplification tests (NAATs) are now available. Not only are these tests noninvasive, but they have been shown to perform better than urethral culture for detection of chlamydia. 3–8 Availability of noninvasive chlamydia testing could pave the way for more widespread screening of asymptomatic males. Most chlamydia screening programs have not targeted young men because the burden of untreated infection falls largely on young women. Nevertheless, untreated infected males continue to serve as a reservoir for new and recurrent infection among women. In fact, the Centers for Disease Control and Prevention Jail STD Prevalence Monitoring Group demonstrated a substantial proportion of chlamydia infections (3.1–10.4%) among 15- to 19-year-old male detainees in 5 jurisdictions. 9
Several economic analyses have been conducted to evaluate various chlamydial screening strategies. Thus far, the majority of those that included a NAAT arm were applied to populations of women and have demonstrated that screening asymptomatic young women for chlamydia is cost-effective. 10–17 Fewer cost-effectiveness analyses (CEAs) have been applied to men and not all included a NAAT arm. 10,17–21 The analyses that incorporated use of urine leukocyte esterase (LE), a nonspecific, yet inexpensive, means of screening males for urethral infections, 22 concluded that confirmatory NAAT testing of LE-positive males was the most cost-effective strategy. 18–20 Most of the cost savings resulted from prevention of sequelae among infected female partners of the screened males.
Most chlamydia-screening CEAs have been applied to hypothetical cohorts of patients who are already seeking care in some type of medical setting, and several have been applied to students in school-based settings. However, high-risk youth often do not attend school or access any source of regular health care. 23–25 Urine-based chlamydia screening of adolescent males on entry to a juvenile justice detention facility is a feasible method for detecting infection in otherwise unscreened youth. 26,27 Yet, the cost-effectiveness of this approach remains unknown.
We have performed a cost-effectiveness analysis of urine-based chlamydial screening using a decision model based on a hypothetical cohort of 4000 adolescent males detained by the Massachusetts Department of Youth Services each year. Incremental cost-effectiveness of the following strategies was compared: 1) universal screening with urine-based NAAT, 2) selective screening (with urine-based NAAT) of males with a positive urine LE test, and 3) no screening (current standard).