Dunne, Eileen F. MD, MPH*; Gift, Thomas L. PhD*; Stamm, Walter E. MD†
From the *Centers for Disease Control and Prevention, Division of STD Prevention, Atlanta, Georgia; and †University of Washington, Division of Allergy and Infectious Diseases, Seattle, Washington.
The findings and conclusions in this paper are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Correspondence: Dr. Eileen Dunne, MD, MPH, Centers for Disease Control and Prevention, Division of STD Prevention, Atlanta, GA. E-mail: EDunne@cdc.gov.
Received for publication August 4, 2008, and accepted August 18, 2008.
In March, 2006, the Centers for Disease Control and Prevention (CDC) convened an external group of consultants to address the issue of Chlamydia screening in men. The purpose of this meeting was to review the available evidence to make recommendations about which populations of men might be appropriate to target for screening to programs that already are or soon will be conducting Chlamydia trachomatis (Ct) screening among men.1 The consultation did not address whether Ct screening among men who have sex with men should be undertaken, but sought to provide guidance on screening in a variety of settings that might be considered by health departments, schools, correctional facilities, or other programs. The consultation adopted as a premise that the primary focus of Ct screening efforts should continue to be women under the age of 26 in accordance with existing guidelines issued by CDC, US Preventive Services Task Force, and professional organizations such as the American College of Obstetricians and Gynecologists, the American Association of Family Physicians, and others. Importantly, the intent of the meeting was not to address the question of whether male screening should occur, a critical question in itself, but one that requires further evaluation, including new data and mathematical models.
During the meeting, consultants reviewed surveillance data on Ct in men; the literature on effectiveness, acceptability, and behavioral and demographic characteristics that could be used to target screening; cost-effectiveness; partner management; and the relative performance of nucleic acid amplification tests (NAATs) and the leukocyte esterase test.
The Male Chlamydia Screening Consultation Meeting Report provided recommendations to guide targeted screening of men for programs that have already undertaken or are considering such an effort.1 Appropriate priority groups to screen for Ct included men <30 years of age entering jails and men attending STD clinics. Additional guidance recommended that men with Ct infection be rescreened at 3 months for repeat Ct infection, that urine is the specimen of choice for screening asymptomatic men, and that NAATs are the test method of choice. In addition, partner services should be offered to partners of men with Ct to prevent sequelae in these partners. The results of this meeting are posted on the Internet, along with the data on strength and quality of the evidence.1
Much of the data reviewed at the consultation are provided in this special issue of Sexually Transmitted Diseases. Also included are articles providing results from original research on the incidence of repeat infection in men screened for Ct, the effectiveness of screening programs in school and court settings, insights from mathematical modeling, and the cost-effectiveness of screening high-risk men.
Ct prevalences among men in the United States vary depending on the venue and geographic location. In a review of surveillance and other data sources, Satterwhite et al. note that the population-based Ct positivity in men aged 20 to 29 years was 3.2% in 1999 to 2002.2 Specific venues may allow efficient access to and permit targeting of men at high risk for infection; Satterwhite et al. identified the Ct prevalence among young men (16–24 years) participating in the National Job Training Program to be 8.1%.2 Other venues where prevalence among males is high are adult and juvenile detention facilities. The article by Rietmeijer et al., demonstrates that Ct rates among men are high in correctional settings, but prevalence depends on the demographic composition of the target population and location.3 Community-based organizations often serve men at high risk for Ct, and such men can also be found with field outreach; Rietmeijer et al. found instances of Ct prevalences as high as 12.4% in these settings.3 However, many high-risk youth can be found in clinical settings, as well.
Other settings can be promising venues for screening, also, depending on local epidemiology. Joffe et al., found that screening male students in middle- and high school-based health centers in Denver and Baltimore identified Ct infection in 6.8% of students tested, and that a majority of screened boys had had more than 1 sex partner in the last 12 months, indicating in some cities, school screening can access high-risk boys.4 Courts that deal with juveniles represent another potential setting in which to reach high-risk young men; Johnson et al. found that the prevalence in men screened through the Family Court System of Philadelphia was 7.0%.5 Of those testing positive for Ct, 93% were treated.
Marrazzo and Scholes reported that the acceptability of Ct screening in asymptomatic men varies, with higher acceptance in settings such as schools, clinics, or corrections than in home-based screening.6 In addition to low acceptability, Rietmeijer et al. found that men screened in home-based interventions were usually low-risk.3 Hogben and Kissinger reviewed the literature about managing female partners of men with Ct. They found that 48% to 79% of partners of men with Ct infection were identified, and that fewer than that were treated; higher rates of notification and treatment were associated with various enhancements to basic referral approaches, such as offering patients medications to bring to partners.7
Regardless of setting, repeat infection with Ct is common among men, as it is among women. The study by Dunne et al. identified that 13% of men with Ct infection overall had a repeat Ct infection (range 7%–26%), and the incidence was 45.4 infections per 100 person years; infection most commonly occurred within the first 45 days after infection supporting recommendations for rescreening men within 3 months of first infection.8
The review of laboratory methodologies for screening and testing men for Ct infection by Gaydos et al. clearly identified that a NAAT is the laboratory test of choice for screening men, and that first-catch urine is the specimen of choice for this purpose.9 NAATs have sufficient sensitivity and specificity for screening men for Ct, with a high (>90%–97%) sensitivity and high specificity (99%). Since most urine specimens from men have many fewer gene copies than do (female) cervical specimens, the high analytic sensitivity of these tests is important in this specimen.
Gift et al. found the cost-effectiveness literature suggests that screening men from the general population, even if age-based, is less cost-effective than age-based screening of women.10 However, many cost-effectiveness studies that have been completed have not directly compared male screening to female screening or considered transmission effects. In addition to this, review of the literature about the cost-effectiveness of male screening, in this issue are 2 papers that address some of the limitations of previous cost-effectiveness models.
Drawing conclusions from a dynamic model of Ct screening, Fisman et al. noted that screening high school-aged males in a Ct screening program can be very cost-effective and can also enhance the effectiveness of school-based Ct prevention in women because of reduced transmission.11 In another transmission model, Gift et al. found that screening high-risk men could be a cost-effective alternative to expanded population-based screening of women, indicating there may be a role for limited screening of men when programs must decide where and how to use additional Ct screening resources if available.12
Clearly, in an idealized setting with unlimited funding and high screening rates among young women, young men would also be screened and treated for Ct as a routine public health practice to prevent transmission to partners. Indeed, some programs outside the United States operate such a universal screening program.13 In the United States, however, given the struggle for resources for virtually all STD prevention efforts, significant thought, mathematical modeling and further data are needed to ascertain the relative benefit of various STD control activities, including male Ct screening. Key activities that lead to significant reductions in morbidity are needed, and enhancing activities to identify and treat men with Ct infection might be a step to reducing Ct morbidity. In this special issue, the data on male Ct infection are reviewed to comprehensively address and provide guidance and justification for targeted screening of men for Ct infection.
2. Satterwhite CL, Joesoef R, Datta SD, et al. Estimates of Chlamydia trachomatis infections among men: United States. Sex Transm Dis 2008; In press.
3. Rietmeijer CA, Hopkins E, Geisler WA, et al. Chlamydia trachomatis positivity rates among men tested in selected venues in the United States: a review of the recent literature. Sex Transm Dis 2008; In press.
4. Joffe A, Rietmeijer CA, Chung S, et al. Screening asymptomatic adolescent males for Chlamydia trachomatis in school-based health centers using urine-based nucleic acid amplification tests. Sex Transm Dis 2008; In press.
5. Johnson CC, Jones EH, Goldberg M, et al. Screening for Chlamydia trachomatis and Neisseria gonorrhoeae among adolescents in family court, Philadelphia, PA. Sex Transm Dis 2008; In press.
6. Marrazzo JM, Scholes D. Acceptability of urine-based screening for Chlamydia trachomatis in asymptomatic young men: a systematic review. Sex Transm Dis 2008; In press.
7. Hogben M, Kissinger P. A review of partner notification for sex partners of men infected with chlamydia. Sex Transm Dis 2008; In press.
8. Dunne EF, Chapin JB, Rietmeijer CA, et al. Rate and predictors of repeat Chlamydia trachomatis infection among men. Sex Transm Dis 2008; In press.
9. Gaydos CA, Ferrero DV, Papp J. Laboratory aspects of screening men for Chlamydia trachomatis in the new millennium. Sex Transm Dis 2008; In press.
10. Gift TL, Blake DR, Gaydos CA, et al. The cost-effectiveness of screening men for Chlamydia trachomatis: a review of the literature. Sex Transm Dis 2008; In press.
11. Fisman DN, Spain CV, Salmon ME, et al. The Philadelphia high-school STD screening program: key insights from dynamic transmission modeling. Sex Transm Dis 2008; In press.
12. Gift TL, Gaydos CA, Kent CKK, et al. The program cost and cost-effectiveness of screening men for chlamydia to prevent pelvic inflammatory disease in women. Sex Transm Dis 2008; In press.
13. LaMontagne DS, Fenton KA, Randall S, et al. Establishing the national chlamydia screening programme in England: results from the first full year of screening. Sex Transm Infect 2004; 80:335–341.