Objectives: To provide chlamydia and gonorrhea screening and treatment to adolescents presumed to be at high risk, school screening was conducted among the 11th and 12th graders in San Francisco.
Study Design: Two schools in neighborhoods with high chlamydia and gonorrhea rates and student populations ≥15% black were chosen. Students viewed a 10-minute presentation and received test kits. Students decided in a private bathroom stall whether to test. All students were encouraged to return a test kit (whether they returned a urine specimen).
Results: Of 967 eligible students, 853 (88%) were in attendance. Of these, 21 (2%) declined to participate and 537 (63%) returned a specimen for testing. Students who tested were predominately heterosexual (93%) and nonwhite (99%). No students tested positive for gonorrhea; 7 (1.3%) tested positive for chlamydia. Positivity was 2.2% (5 of 227) for female students and 0.6% (2 of 310) for male students. Positivity by race/ethnicity was 5.4% (4 of 74) for blacks, 2.0% (2 of 98) for Hispanics, 0.3% (1 of 342) for Asian/Pacific Islanders, and 0% (0 of 4) for whites. The highest positivity was among black female students: 9.3% (4 of 43). Not including planning and follow-up, each case identified used 63 staff hours.
Conclusions: Despite high participation among students attending school in high morbidity neighborhoods, few infections were identified. This is likely because students have low rates of sexual activity and do not necessarily attend neighborhood schools. Screening used substantial resources. Sexually transmitted disease control programs considering school screening should consider local epidemiology and whether schools have substantial proportions of students likely at high risk for sexually transmitted diseases.
This report of a school-based screening program in San Francisco identified few chlamydial infections and no gonococcal infections, despite high participation of adolescents attending school in a neighborhood with high adolescent sexually transmitted disease rates.
From the *Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, Georgia; †San Francisco Department of Public Health; ‡San Francisco Unified School District; and §University of California, San Francisco, California
We thank all those involved in this program at San Francisco Unified School District (SFUSD) and in the STD Section of SFDPH; at SFDPH, especially the San Francisco GC Team, Rebecca Dawson, Alonzo Gallaread, Damen Herrera, and Nora Macias, and at SFUSD, Susan Kitchell, Jessie Bunn, Kevin Gogin, Phang Pham, Meyla Ruwin, Miki Cisterna, Eric Marshall, Paul Cheng, the main office, security staff, English teachers, and students at participating high schools. We also thank the members of the San Francisco GC Team and the San Francisco Community Adolescent STD Partners Group.
Presented in part at the 17th International Society for Sexually Transmitted Diseases Research, Seattle, Washington, August, 2007 [Latebreaker Poster 22].
In the past 12 months, J.D.K. has received research support from Gen-Probe, Inc.
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Copyright statement: As an employee of the United States Centers for Disease Control and Prevention, I have no authority to transfer ownership of copyright. I have been advised that any report, article, or other paper prepared by employees of the Federal Government as part of their official duties is, under the Copyrights Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. Accordingly, there is no copyright; thus ownership cannot be transferred. You should note also that the copyright notice in your publication must advise the reader that the copyright does not extend to this article. I assure you, however, that the substance of this report has not already been published and that the manuscript is not under consideration for publication elsewhere.
Correspondence: Pennan M. Barry, MD, MPH, 1360 Mission Street, Suite 401, San Francisco, CA 94103. E-mail: firstname.lastname@example.org.
Received for publication July 17, 2007, and accepted December 26, 2007.
IN THE UNITED STATES, CHLAMYDIA and gonorrhea rates are highest among persons aged 15 to 19 years, many of whom attend high school.1 Chlamydia and gonorrhea screening in high schools has been used successfully to identify substantial numbers of infections among adolescents in other cities.2–4 In San Francisco, previous efforts at high school-based screening did not efficiently identify chlamydial nor gonococcal infections.5 However, these previous efforts did not target schools in high-morbidity neighborhoods and did not systematically offer screening to all students. In addition, in 2005 the San Francisco Department of Public Health (SFDPH) identified increases in gonorrhea among black heterosexuals aged 15 to 19 years.6,7 In response to this increase in gonorrhea, and by using a new screening model developed in Philadelphia3 to increase participation, SFDPH conducted school-based screening among 11th and 12th graders at 2 high schools located in neighborhoods with high rates of chlamydia and gonorrhea among adolescents.
Planning at SFDPH and approval by school district administrators took place during an 8-month period (September 2006 to May 2007). Two high schools with total enrollment >500 students located in neighborhoods with high adolescent chlamydia (2945–7598 per 100,000 population) and gonorrhea rates (491–2669 per 100,000)8 and with student populations ≥15% black (San Francisco is 7% black)9 were selected for chlamydia and gonorrhea screening. The selected schools were academic schools and did not have specific admission criteria; they were not charter, magnet, or alternative/disciplinary schools. After approval was obtained at the school district level, we met with school nurses, teachers, principals, students, and parents to inform them and to obtain their input on the screening program. Parents were also informed by mailed letter. By California law, parents can opt their child out of sexually transmitted disease (STD) education sessions but not screening.
Testing and follow-up procedures were modeled after a similar program used successfully in Philadelphia3 and were designed to maximize student privacy and participation. Screening activities (except specimen collection) took place in students’ English classroom. Students attending English class viewed a 10-minute presentation about chlamydia and gonorrhea and describing testing procedures. Each student received a form to collect demographic and locating information, a paper bag, urine cup, STD fact sheets, and referral cards to local clinics. Students indicated their desire to test by returning a urine specimen in the cup provided and enclosed in a paper bag; those students declining testing returned a paper bag containing an empty cup. Nonsexually active students were discouraged from testing. To ensure confidentiality, students decided whether to test in a private bathroom stall. All students were encouraged to fill out a demographic form and to visit the bathroom, and all students returning a bag (whether they returned a urine specimen) and the demographic form were eligible for a prize drawing. There were 12 prizes available ranging in value from $10 to $80. To minimize disruption to school and maximize efficiency of program procedures, 11 SFDPH staff were used per day. Specimens were tested for Chlamydia trachomatis and Neisseria gonorrhoeae by using transcription-mediated amplification (Aptima, Gen-Probe, Inc., San Diego, CA).
A single SFDPH staff member used the students’ preferred contact information supplied on the demographic form to contact students who tested positive or who won a prize. Students who tested positive were supplied with field-delivered therapy at a time and location convenient for the student. They were also given treatment to take to their sex partners (patient-delivered partner treatment) according to routine SFDPH practice.10,11 Test results were available to students only; not parents or teachers.
Screening occurred during 5 days in May 2007. A total of 967 students were eligible for testing on the basis of student enrollment rosters; 114 were absent from school on testing days, leaving 853 students (88%) who viewed the presentation (Table 1). Of these, 21 students (2%) declined to participate, 295 (35%) did not return a urine specimen, and 537 (63%) returned a urine specimen for testing. Students who returned a urine specimen were predominately heterosexual (93%) and nonwhite (65% Asian/Pacific Islander; 14% black; 19% Hispanic). Participation was highest among our primary target population of black adolescents; participation was 80% (74 of 93) among blacks, 74% (98 of 132) among Hispanics, and 59% (342 of 581) among Asian/Pacific Islanders. Participation increased with increasing age.
No students tested positive for gonorrhea; 7 (1.3%) tested positive for chlamydia (Table 1). Chlamydia positivity by sex was 2.2% (5 of 227) for female students and 0.6% (2 of 310) for male students. Chlamydia positivity by race/ethnicity was 5.4% (4 of 74) for blacks, 2.0% (2 of 98) for Hispanics, 0.3% (1 of 342) for Asian/Pacific Islanders, and 0% (0 of 4) for whites. The subgroup with the highest positivity was black female students: 9.3% (4 of 43). All students testing positive were provided treatment and patient-delivered partner therapy. Not including planning, follow-up, and school district staff time, the 5 test days expended 440 hours of SFDPH staff time; each case identified used 63 SFDPH staff hours.
As has been previously demonstrated in San Francisco and elsewhere, we determined that high school-based STD screening in San Francisco was feasible. However, despite high participation rates among students attending school in high-morbidity neighborhoods, only a limited number of chlamydial infections and no gonococcal infections were identified.
Published reports from school screening programs in other cities have demonstrated positivity to be higher than identified in this program. In Philadelphia and New Orleans, chlamydia positivity was 8.1% and 9.7% among female students and 2.5% and 4.0% among male students, respectively.3,4 The reasons for low numbers of infections identified are likely multiple. First, among 61 states and cities participating in the 2005 Youth Risk Behavior Surveillance Survey, San Francisco high school students in 9th to 12th grades had the lowest prevalence of lifetime sexual intercourse (29.9% among female students and 32.6% among male students; 32% among 11th graders and 42% among 12th graders).12,13 Second, although attendance was high, adolescents who are at highest risk for STDs might not be enrolled in school,14 they might be incarcerated, or they might attend an alternative/disciplinary school.3 Third, public school students in San Francisco do not necessarily attend neighborhood schools but can be assigned to schools throughout the city for multiple reasons, including parent choice, academic achievement, and student diversity. This might have diminished the impact of selecting schools on the basis of neighborhood STD rates. An additional reason for the low prevalence of infection identified might, in part, be explained by nonsexually experienced students submitting a specimen for testing. Although the brief presentation and individual staff discouraged nonsexually active students from testing, the participation rate (63%) was approximately double the rate of sexual experience among San Francisco high school students participating in the 2005 Youth Risk Behavior Surveillance Survey. However, participation increased with increasing age, a pattern expected if only sexually experienced students participated.
Positivity (and participation) was highest among black students as was demonstrated in Philadelphia.3 Positivity was substantially higher among female students compared with male students. This was also demonstrated in other cities3,4 and settings (e.g., youth detention centers).15 The positivity among black female students in our program approached the positivity found in other successful screening programs.3,4 This might justify targeting screening to female students only if such a policy were determined to be acceptable to students, parents, administrators, and public health officials.
School screening did have substantial benefits. The program provided evidence that STD rates are low in this population, information that is important for future program planning. It once again facilitated important collaboration between SFDPH and the school district, and it reminded approximately 1000 students of the importance of maintaining their reproductive health through regular STD screening and condom use. Nevertheless, school screening involved a substantial investment of resources.
Although other school screening programs have successfully identified a high prevalence of infection in geographic regions with high chlamydia and gonorrhea rates,2–4 the yield from screening in high schools in San Francisco has been consistently low.5 Screening in high schools might not be an efficient use of limited resources in jurisdictions with moderate to low prevalence of chlamydia and gonorrhea. STD control programs considering screening in schools should consider local epidemiology and whether schools have substantial proportions of students likely to be at high risk for STDs. If found to be locally acceptable, control programs might consider screening female students only. Finally, SFDPH is considering other methods for reaching black adolescents including using fewer DPH staff to screen students at nontraditional high schools (e.g., charter schools or alternative/disciplinary schools) that have a higher proportion of black students and through social network interventions.
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