Sexually Transmitted Diseases:
Screening Women in Jails for Chlamydial and Gonococcal Infection Using Urine Tests: Feasibility, Acceptability, Prevalence, and Treatment Rates
MERTZ, KRISTEN J. MD*; SCHWEBKE, JANE R. MD†; GAYDOS, CHARLOTTE A. DrPH‡; BEIDINGER, HEIDI A. MPH§; TULLOCH, SCOTT D.∥; LEVINE, WILLIAM C. MD*
From the *Division of STD Prevention, National Center for HIV, STD, and TB Prevention, Atlanta, Georgia; †Division of Infectious Diseases, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; ‡Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland; §Chicago Department of Public Health, Chicago, Illinois; and ∥Maryland Department of Health and Mental Hygiene, Baltimore, Maryland
The authors thank Dr. Connie Mennella, of Cermak Health Services, James Dickes and Dr. Romina Kee, of the Chicago Department of Public Health (CDPH), Richard Meriwether, of the University of Alabama at Birmingham (UAB), and David Akers, of the Maryland Department of Health and Mental Hygiene (DHMH), for implementing the study; Jennifer Tawes, of Johns Hopkins University, Anne Evens and Steve Mier, of CDPH, and Margo Jones and Willa Sanders, of UAB, for compiling data; Susan Clark, of the Jefferson County Health Department, Theodius Mitchell, of DHMH, and Joan Crawford, M. L. Hunter, and Lauren MacDonald, of CDPH, for locating and treating women; Dr. Edward Hook, of UAB, and Charles Rabins, of the Illinois Department of Health, for providing laboratory services; and Dr. Carolyn Black, Billy Litchfield, and Kathleen Hutchins, of the Centers for Disease Control and Prevention (CDC), for technical assistance on laboratory, protocol, and data issues, respectively. They especially thank Richard Voigt, of the CDC, for his help in implementing the study and his untiring efforts to promote screening for STDs in jails across the country.
Supported by the Office of Women's Health, CDC.
Presented in part at the 12th Meeting of the International Society of STD Research (Denver, CO, 1999) and published in part in MMWR Morb Mortal Wkly Rep 1999; 48(Sept 17):793–796.
Correspondence: Kristen Mertz, MD, Georgia Department of Human Resources, 2 Peachtree Street NW, 14th Floor, Atlanta, GA 30303. E-mail: email@example.com
Reprints: Epidemiology and Surveillance Branch, Division of STD Prevention, CDC, MS E-02, 1600 Clifton Road NE, Atlanta, GA 30333.
Received for publication April 25, 2001,
revised August 30, 2001, and accepted September 7, 2001.
Background: Women entering jails are at high risk for sexually transmitted diseases; however, screening for chlamydial and gonococcal infection is not routinely performed in most jails. New urine tests have made it easier to screen for these infections in nonclinical settings.
Goal: The feasibility and acceptability of urine-based screening for women entering jails and the prevalence of and treatment rates for chlamydial and gonococcal infections were determined.
Study Design: Women entering jails in Chicago, Illinois; Birmingham, Alabama; and Baltimore, Maryland, who signed consent forms were tested for chlamydial and gonococcal infection by means of the urine ligase chain reaction assay. Those testing positive were treated in jail; health department staff members attempted to contact those already released.
Results: Most women who were approached agreed to be tested (range, 87–98%, depending on city), and most of these women provided a specimen (range, 92–100%). Among 5364 women aged 16 to 75 years who were tested, the prevalence of chlamydial and gonococcal infections was high, especially among those <25 years of age (range, 15.3–21.5% for chlamydial infection and 8.2–9.2% for gonorrhea, depending on city). The majority of women testing positive were treated in jail or outside of jail (61–85%).
Conclusions: Screening women in jails for chlamydial and gonococcal infection with urine tests is feasible, is acceptable to most women, and leads to detection and treatment of many infections. Routine screening should reduce medical complications in this population and should prevent transmission in the community, given that many women are soon released.
PERSONS ENTERING corrections facilities have been shown to have a high prevalence of sexually transmitted diseases (STDs). 1,2 More than half of convicted jail inmates use illicit drugs in the month before entering jail, and 37% of women report a history of sexual abuse, 3 which may put them at high risk for chlamydial and gonococcal infection. If untreated, these infections can cause pelvic inflammatory disease and complications such as infertility, ectopic pregnancy, and chronic pelvic pain. 4 Most corrections facilities, however, do not routinely screen for chlamydial or gonococcal infection during the jail intake process. 5,6 Such screening is not considered part of the corrections mandate, and corrections officials are reluctant to use limited staff, space, and money to conduct screening. In addition, some corrections officials view such screening as futile, given that many persons are released before test results are available from the laboratory.
Screening for STDs in jails has become more practical, however, since the development of urine assays for Chlamydia trachomatis and Neisseria gonorrhoeae in the mid-1990s, eliminating the need for pelvic examinations to collect endocervical specimens from women. In this study of women entering jails in three counties in the United States, we assessed the feasibility and acceptability of urine screening for chlamydial and gonococcal infection, the prevalence of both infections, and treatment rates for women testing positive.
Women entering Cook County Jail in Chicago, Illinois; Jefferson County Jail and Birmingham City Jail in Birmingham, Alabama; and the Women's Detention Center in Baltimore, Maryland, were eligible to participate. Written informed consent was obtained from all women enrolled. Approval of the institutional review boards at the Centers for Disease Control and Prevention and at each local site was obtained before the study began.
At Cook County Jail, in Chicago, each weekday evening in the intake area, health department staff recruited women who had been booked during the previous 8 hours. Women 30 years of age or younger were asked to participate until 10 women per evening had been enrolled. Participants were enrolled from July 1998 to October 1999. Written consent was obtained by health department staff from each participant. All women who underwent entrance physical examinations, regardless of their participation in the study, were screened routinely for chlamydial and gonococcal infection by means of a DNA probe assay of cervical specimens.
In Birmingham, staff members from the University of Alabama at Birmingham and the county health department went to the county jail three mornings per week and to the city jail two mornings per week. At the county jail, women of all ages were asked to participate at the time of the intake physical examination (a median of 2 days after booking); at the city jail, women of all ages were approached on the intake wards (also a median of 2 days after booking). Participants were enrolled from September 1998 to January 2000 at the county jail and from February 1999 to September 2000 at the city jail, with an interruption of 3 months in early 2000. Written consent was obtained by University of Alabama at Birmingham and health department staff members.
At the Women's Detention Center in Baltimore, women of all ages were asked by the jail medical staff to participate in the study at the time of their intake physical examination, which occurred a median of 11 days after booking. Participants were enrolled from July 1999 to June 2000. Written consent was obtained by the jail medical staff members.
Urine specimens were sent by courier to the Illinois Department of Public Health Laboratory in Chicago, to the University of Alabama at Birmingham School of Medicine's STD Research Laboratory in Birmingham, and to the Johns Hopkins School of Medicine's chlamydia laboratory in Baltimore. All specimens were tested with the ligase chain reaction assay for C trachomatis and N gonorrhoeae (LCx assay; Abbott Laboratories, Abbott Park, IL). Positive laboratory results were faxed back to the jail. Women testing positive were treated by the jail medical staff if the women were still in jail. At all facilities the standard treatment for chlamydial infection was administration of a single dose of azithromycin, although a 7-day course of doxycycline was sometimes used in Birmingham; the standard single-dose treatment for gonorrhea was cefixime at Cook County Jail, ciprofloxacin at Women's Detention Center, and ofloxacin at Jefferson County Jail and Birmingham City Jail. If women testing positive were released before the results were known, health department staff members attempted to contact them either by phone or in person and refer them for treatment.
Demographic information (date of birth, date of specimen collection, race, and ethnicity) and test results for chlamydial infection and gonorrhea were recorded for each person tested and were entered in a database. For each woman testing positive, date of treatment or place of treatment was obtained from the Chicago Department of Public Health, the Jefferson County Department of Health, or the Maryland Department of Health and Mental Hygiene.
At the jails in Chicago and Baltimore, pregnancy testing was done on site. In Birmingham, pregnancy testing was done at the chlamydia laboratory. In Birmingham and Baltimore, pregnancy test results were recorded in the database and were available for analysis.
Prevalences of chlamydial and gonococcal infection and pregnancy were calculated by age group (16–24 years, 25–34 years, and 35 years and older) and race/ethnicity (white, black, or Hispanic) for each county. The chi-square test was used to compare prevalence by group for each infection. Differences in prevalence were considered statistically significant at P < 0.05.
In the three counties, most of the women entering jails who were asked to participate signed consent forms (range, 87–98%;Table 1). Of those consenting, almost all provided a specimen (range, 92–100%;Table 1). The exact participation rate could not be determined in Baltimore because during the first 6 months of the study, the number of women refusing to participate was not recorded. From February 15 to June 2000, of 713 women asked to participate in Baltimore, 634 (89%) consented.
Of the specimens provided, 0.1% to 4% were considered unsatisfactory. In Chicago, 41 specimens were considered unsatisfactory because of prolonged transit time (>4 days) and were not tested; in Birmingham, only 2 were considered unsatisfactory; in Baltimore, of the 73 considered unsatisfactory, 36 were in transit too long, 24 had mismatched identifiers, and 13 leaked.
The characteristics of women tested are shown in Table 2. In Birmingham and Baltimore, the majority of women were >30 years old, as was true for the general population of women in jail; in Chicago, where the study was limited to women aged 30 years or younger, approximately half the women were 16 to 24 years of age and half were 25 to 30 years of age. At all sites, at least two thirds of women tested were black. Only in Chicago was the Hispanic population large enough to include in our analysis of racial/ethnic differences.
The overall prevalence of chlamydial and gonococcal infection was significantly higher among women younger than age 25 years than among women aged 25 to 30 years or women older than age 30 years at all three sites, except for the prevalence of gonococcal infection in Jefferson County, Alabama, which did not differ significantly by age group (Figure 1). Among women aged 16 to 24 years, prevalence ranged by city from 15.3% to 21.5% for chlamydial infection and from 8.2% to 9.2% for gonorrhea.
Racial/ethnic differences in prevalence of chlamydial and gonococcal infection varied by city (Figure 2). In Cook County, Illinois, there was a significantly higher prevalence of both infections among blacks than among whites, but in Baltimore the opposite was true (Figure 2). In Jefferson County, Alabama, there was no significant difference in the prevalence of chlamydial or gonococcal infection among blacks and whites.
The percentage of women coinfected with chlamydial infection and gonorrhea varied by jail. Among women with gonorrhea, the percentage who also had chlamydial infection was 21% in Jefferson County, 33% in Baltimore, and 40% in Cook County. Among women with chlamydial infection, the percentage who also had gonorrhea was 17% in Jefferson County, 19% in Baltimore, and 25% in Cook County.
Most women testing positive for chlamydial or gonococcal infection were contacted and treated. In Cook County, where testing took place within 8 hours of booking, many infected women had already been released when results were returned. Of women testing positive, 35% had documented treatment in jail, and 26% were treated outside jail, for a total of 61% with documented treatment; 3% were still in jail but there was no documentation of treatment (Table 3). Of those released before treatment, 42% were located by a city health department staff member. In Jefferson County, Alabama, where testing took place a median of 2 days after booking, 57% were treated in jail and 29% were treated outside of jail, for a total of 85% infected women who received documented treatment (Table 3). Of those released before treatment, 66% were contacted and treated. In Baltimore, where testing took place a median of 11 days after booking, most (72%) of the women testing positive were still in jail and were treated there; 5% were treated outside jail, for a total of 77% who received documented treatment (Table 3). Of those released before treatment, 15% were contacted and treated.
Of women enrolled who underwent pregnancy testing, 4.7% (69 of 1453) in Jefferson County and 3.4% (65 of 1909) in Baltimore had positive pregnancy tests (data on pregnancy were not available for Chicago). The prevalence of pregnancy varied by age group. Of women younger than 25 years of age in Jefferson County, Alabama, 13.4% were pregnant; in Baltimore, the prevalence of pregnancy among women younger than 25 years of age was 7.2%. Pregnancy rates were much lower for women older than 30 years of age in both Jefferson County, Alabama, and Baltimore (2.4% and 2.0%, respectively). The percentage of all pregnant women with chlamydial infection, gonorrhea, or both was 16% in Baltimore and 17% in Jefferson County.
The results of this study indicate that screening for chlamydial and gonococcal infection with urine tests is feasible and acceptable to most women. The development of assays that can be done with urine specimens instead of cervical specimens has facilitated mass screening by jail staff members or by health department staff members stationed in jails. Our results show that screening leads to detection and treatment of many infections. A urine screening program at the juvenile detention center in Birmingham showed similar success for adolescents. 7 Our findings suggest that local health and corrections officials should collaborate to assess the yield of such screening in local jails across the country. In facilities where prevalence of infection is significant, routine screening and treatment should prevent medical complications and prevent transmission in the community, given that many women are quickly released back into the community. In addition to preventing complications in women, screening and treatment in jails should also prevent infections in newborns, given that approximately 16% of pregnant women in the study tested positive for chlamydial or gonococcal infection or both.
The feasibility of screening depends on the willingness of corrections officials to conduct screening or to work with local health department staff members. The jails in this study relied on health department or university staff members to collect specimens or to conduct the laboratory tests. Local health, university, and corrections officials should discuss the most efficient system for providing services.
In the three participating cities, a small percentage of women declined to participate in the study. If screening for chlamydial infection and gonorrhea were implemented as routine care for women entering jails and not done as a research study, the refusal rate at all sites may have been even lower. The reason for the relatively high percentage of women who did not produce a specimen in Chicago (7.5%) is not clear. Women coming into the Cook County Jail often are held in local holding areas for several hours and may become dehydrated. The toilets in the intake area are not private, and women may not want to give a specimen in the open. Finally, it is possible that they did not want to participate in the study but did not want to refuse overtly.
The prevalence of both chlamydial and gonococcal infection was especially high among women 30 years of age or younger. The highest prevalence was among women younger than 25 years of age. This finding is consistent with data from most studies of chlamydial infection and gonorrhea, which show the highest prevalence is among adolescent women, who are biologically more susceptible to infection because of increased cervical ectopy. 8–10 Jails with limited resources may choose to limit screening to younger women to identify the most infections per test done; however, the prevalence of infection among older women (older than 30 years of age) in this study would justify routine screening in most settings.
Prevalence by race/ethnicity varied by site. Although most studies show that the prevalence of gonorrhea is higher among blacks than among whites, that was true for only one of our participating jails. Race does not appear to be a consistent predictor of infection in women in jail.
The majority of women who tested positive were treated, either in jail or in outside facilities if they were released from jail before test results were available. The percentage treated in jail varied by site. The timing of testing during the intake process affects the percentage of those testing positive who are treated in jail. In general, jails performing testing within 24 hours of booking will release a higher percentage of women by the time test results come back and will therefore be able to treat a smaller percentage in jail. However, timing also affects the percentage of women booked who are tested. Those jails that test within 24 hours of booking will test a higher percentage of women booked and detect a higher percentage of total infections. If the local health department is willing to contact women testing positive who have been released, many more infections can be detected and treated with an early screening policy.
Our study was limited to women. However, studies have shown that men entering jails have chlamydial infection at high rates. 1,2 Inclusion of both sexes in routine screening programs should be considered. One important issue to consider is whether men are as easily located as women in a particular geographic area.
Our study did not include all women entering the participating jails. In Chicago and Birmingham, health department and university staff members did not work during all shifts and could not test all incoming women. In Baltimore, women were not tested until a median of 11 days after booking, so the majority of women booked into the jail were released without being asked to participate. Therefore, bias may have occurred in our acceptability, prevalence, and treatment rates if the women tested were not representative of the whole population of women entering jails. Nonetheless, our estimates indicate that routine screening for chlamydial and gonococcal infection can detect many infections and result in a high treatment rate under a wide variety of circumstances.
In summary, urine-based screening for chlamydial and gonococcal infection in women entering jails is feasible, acceptable, and productive in terms of identifying and treating infections. Local corrections and health officials should decide whom to test and when to test on the basis of local prevalence and the availability of jail or health department staff members, laboratory services, and funding for test kits. STD screening programs in corrections facilities may lead to treatment for large numbers of infected persons, leading to a reduction of disease transmission in the community.
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