GENITAL INFECTIONS WITH CHLAMYDIA TRACHOMATIS and Neisseria gonorrhoeae are the 2 most commonly reported bacterial sexually transmitted diseases (STDs) in the United States, and rates of infection are the highest among adolescents.1 Because both infections are frequently asymptomatic,2 most cases can be identified only through screening.
In the winter of 1996, a schoolwide screening for chlamydia using nucleic acid amplification technology in urine specimens was implemented in 3 Louisiana urban high schools, to which a gonorrhea screening was added in the fall of 1996.3 Although these schools had school-based health centers (SBHCs) on-site, the screening was offered independent of services the SBHCs provide. Among participants in grades 9 to 12, it provided documentation of a baseline chlamydia prevalence of 6.2% among males and 11.5% among females, and a baseline gonorrhea prevalence of 1.2% among males and 2.5% among females, with 93.4% of chlamydia and 90% of gonorrhea infections remaining asymptomatic.3 The high frequency of asymptomatic infections suggests that most infected students were less likely to seek care for infections they were less likely to suspect. Although the duration of their infections before detection was unknown, those who did seek health services for any reason shortly before participating in this screening did provide the healthcare system with the opportunity to detect their infections earlier.
In the school district, students are eligible to receive services at their SBHCs if they are registered in SBHCs, i.e., if their parents/guardians have signed a registration form authorizing the student to use their SBHC services. During each of the first 3 years of the chlamydia and gonorrhea screening in the school district, approximately 70% of the total school populations were registered in SBHCs in the 3 schools in which the screening was implemented.
Although for nearly a decade, a high prevalence of asymptomatic chlamydia and gonorrhea in the local school population has been well documented and the SBHCs serving the school district are equipped to provide testing and treatment for STDs,3 the extent to which students are screened for STDs in their SBHCs has not been clearly determined. Between the years 1996 and 2000, visits associated with routine gynecologic health, treatment of STDs, and pregnancy care represented together less than 3% of the more than 300,000 visits students made to SBHCs statewide.4–6 These aggregated statistics remain less informative because they include visits made in SBHCs not equipped to provide reproductive health services such as elementary SBHCs where such services are usually not needed, they combine visits made for the treatment of STDs with visits made for gynecologic health and pregnancy care, and they do not inform on the proportion of students who were screened for STDs during clinic visits. To assess the extent to which students are being screened for STDs in selected SBHCs, we determined the proportion of students who reported to have been tested or treated for STDs at their SBHCs among participants in the chlamydia and gonorrhea screening who routinely visited their SBHCs recently. We also determined the prevalence of chlamydia and gonorrhea in this subpopulation.
The chlamydia and gonorrhea screening, which has been conducted in the school district every year since its initial implementation during the 1995–1996 school year, has been described in details elsewhere.3 During the 2002–2003 and 2003–2004 school years, 2 of the 3 schools with SBHCs participated in the screening. In these schools, students for whom consent was obtained and who were willing to participate in the screening were asked in a self-administered survey whether they were registered to receive services at their SBHCs, whether in the past 90 days they have had any STD-related symptom, the number of times they had been at their SBHC to receive services, whether they had been at their SBHC because they needed testing or treatment for an STD, and whether they were tested or treated for an STD at their SBHC. The screening was approved by the Louisiana State University Health Sciences Center Institutional Review Board and the school district.
Data were obtained for 855 students, including 396 who participated in 2002–2003, 371 who participated in 2003–2004, and 88 who participated during the 2 school years. Overall, 666 respondents were registered in SBHCs and 189 were not. Of those registered in SBHCs, 179 did not visit their SBHCs in the past 3 months; they were excluded from this analysis. The 487 students registered and who visited routinely their SBHC at least once in the past 3 months (73.1% of those registered in SBHCs and 57.0% of all respondents) are the subjects of this analysis. C. trachomatis and N. gonorrhoeae laboratory test results (BDProbeTec ET System, Sparks, MD) were used to determine the prevalence of infections among eligible respondents. For students who participated the 2 school years, only data obtained during their first participation were considered for this analysis. Chi-squared tests and analysis of variance were used to assess differences for categorical and continuous variables, respectively, with statistical significance set at P <0.05.
The 487 study subjects were 99.2% black (n = 483), 49.1% males (n = 239), in grades 9 to 12, and aged between 14 and 22 years (mean, 16.78 ± 1.44 years). Overall, 261 respondents (53.6%) attended one school and 226 (46.4%) attended the other school. They reported visiting their SBHCs 1065 times (mean, 2.28 times) in the 3 months before the survey. Females visited their SBHC significantly more often (mean, 2.48 times) than males (mean, 2.06 times) (P <0.001).
In the 3 months preceding the survey, 32 of 479 respondents (6.7%) reported that they visited the SBHC because they needed testing or treatment for an STD, 47 of 482 (9.8%) reported having been tested or treated for an STD at the SBHC, and 29 of 481 (6.0%) reported to have had STD-related symptoms with no statistically significant gender differences (Table 1). Of the 32 students who visited the SBHC because they needed testing or treatment for an STD, 11 (34.4%) (females, 9 of 18 [50.0%]; males, 2 of 14 [14.3%]; P = 0.08) reported having been tested or treated for an STD at the SBHC. Of the 29 students who reported having had STD symptoms, 23 (79.3%) stated that they did not visit the SBHC because they needed testing or treatment for an STD, one (3.5%) did not answer the question, and 5 (17.2%) stated that they visited the SBHC because they needed testing or treatment for an STD; of them, 3 reported having been tested or treated for an STD at the SBHC.
Of all 487 respondents, 65 (13.3%) tested positive for chlamydia or gonorrhea (Table 1). Of those 65 students who tested positive, 53 (81.5%) reported not to have been tested or treated for an STD at their SBHCs in the past 90 days. Among 64 students who tested positive and had symptom information, 55 (85.9%) reported not having had STD-related symptoms in the past 90 days. Of the 29 students who reported having had STD-related symptoms within the past 90 days, 24 (82.8%) tested negative for both chlamydia and gonorrhea.
In this study, approximately 10% of respondents reported having been tested or treated for an STD at the SBHCs in the 3 months before the survey. Possibly, respondents may have inaccurately reported health services they may or may not have received at their SBHC. However, adolescents have been found to be able to validly report the content of the care they received 5 to 7 months earlier, including chlamydia and gonorrhea testing.7 With a shorter recall time in our study, inaccurate recall can be considered to be minimal.8 It can also be argued that SBHCs might adapt their screening habits to the chlamydia and gonorrhea screening routinely offered at school. In collaboration with the screening program, local SBHCs selectively collect urine specimens for chlamydia and gonorrhea testing and notify the STD screening staff to take the specimens to the laboratory regardless of students’ participation in the screening offered at school. It is therefore unlikely that screening patterns at the SBHCs were negatively affected by the chlamydia and gonorrhea screening offered at these schools. The STD testing or treatment respondents reported to have received at their SBHCs in the 3 months before the survey probably reflects the extent to which students received those services.
Students who participated in the chlamydia and gonorrhea screening outside of the clinical setting of their SBHCs yet sought routine care at their SBHCs within the previous 90 days represent opportunities for coordinated school-based efforts to control STDs among adolescents. Resources will not always permit screening students for STDs in schools with SBHCs that can provide the same services. If STD screening can be integrated into routine SBHC services, a screening program such as the one offered in these schools might be restricted to schools that do not have SBHCs. Many among the 65 infections reported here could have been detected earlier if STD testing was provided during students’ routine visits at the SBHCs. Lack of routine STD screening in these SBHCs clearly represents missed opportunities for early detection of chlamydia and gonorrhea among local teens.
The high proportion of asymptomatic chlamydia and gonorrhea infections among students who are seeking care in the 2 SBHCs is a potential source of costly complications, risk factors for acquiring other STDs, including human immunodeficiency virus, and an important reservoir for transmission to others.2 Despite high students’ utilization of SBHC services, students surveyed less frequently initiated visits to their SBHCs for STD testing or treatment, even when they developed symptoms suggestive of an STD. Furthermore, almost all students who reported having STD symptoms within the past 3 months tested negative for both chlamydia and gonorrhea. Meeting the challenges of adolescents’ reproductive health would require SBHCs to go beyond services adolescents seek and provide them with services they need. Screening for chlamydia and gonorrhea is a clear specific need of teens seeking care in these facilities. For SBHCs to adequately respond to the current STD epidemic as it affects adolescents in the United States,2 local STD prevalence, and not management of STD symptoms, should guide provision of STD-related services to adolescents served in these facilities.
1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2003. Atlanta: US Department of Health and Human Services, September 2004.
2. Institute of Medicine. The hidden epidemic: Confronting sexually transmitted diseases. In: Eng TR, Butler WT, eds. Washington, DC: National Academy Press, 1997.
3. Cohen DA, Nsuami M, Martin DH, Farley TA. Repeated school-based screening for sexually transmitted diseases: A feasible strategy for reaching adolescents. Pediatrics 1999; 104:1281–1285.
4. Louisiana’s Office of Public Health, Adolescent School Health Initiative. Louisiana School-Based Health Centers Annual Services Report 1996–1997. Office of Public Health, Department of Health and Hospitals, State of Louisiana, 1997.
5. Louisiana’s Office of Public Health, Adolescent School Health Initiative. Louisiana School-Based Health Centers Annual Service Report 1997–1998. Office of Public Health, Department of Health and Hospitals, State of Louisiana, 1999.
6. Louisiana’s Office of Public Health, Adolescent School Health Initiative. Louisiana School-Based Health Centers 1999–2000 Annual Services Report. Office of Public Health, Department of Health and Hospitals, State of Louisiana, 2001.
7. Klein JD, Graff CA, Santelli JS, et al. Developing quality measures for adolescent care: Validity of adolescents’ self-reported receipt of preventive services. Health Serv Res 1999; 34:391–404.
8. Coughlin SS. Recall bias in epidemiologic studies. J Clin Epidemiol 1990; 43:87–91.