In this analysis, we used 97,681 chlamydia tests (23,339 in females and 74,342 in males) from 141 juvenile facilities in 29 states and 52,485 chlamydia tests (22,427 in females and 30,058 in males) from 22 adult facilities (jails) in 5 states (Table 1). In juvenile facilities, for race/ethnicity analyses, 9 facilities (6%) or 19,994 tests (20%) were excluded from the analysis because race/ethnicity information was missing for ≥25% of the persons tested in these facilities. In adult facilities, no facilities were excluded from the race/ethnicity analysis. A small proportion of persons with race/ethnicity other than white, black, or Hispanics in juvenile (5%) and adult facilities (6%) were excluded from the race/ethnicity analysis.
Chlamydia prevalence in females and males varied widely by site for age group in juvenile (Fig. 1) and adult facilities (Fig. 2). Overall, median chlamydia site prevalence was high in incarcerated adolescents (14.3% in females and 6.0% in males; Fig. 1) and adults (7.5% in females and 4.6% in males; Fig. 2). The median chlamydia site prevalence was uniformly higher in incarcerated adolescent and adult females than in incarcerated adolescent and adult males for all age groups, except age group 36 to 40 years (Figs. 1 and 2). In juvenile facilities, the prevalence did not steadily increase with age in females, but in males the prevalence steadily increased with age from 2.4% at 12 to 14 years of age to 8.7% at 18 to 20 years of age (Table 1). In adult facilities, the prevalence decreased with increasing age in both sexes (Table 1).
In juvenile facilities, non-Hispanic blacks had the highest median chlamydia site prevalence (18.4% in females and 9.6% in males). In adult facilities, non-Hispanic black males had the highest prevalence, and there was no difference in prevalence by race/ethnicity for females (Table 1).
In this analysis, which incorporated a large and geographically diverse number of correctional facilities, we found high prevalence of chlamydia in adolescent and young adult females and males. Consistent with other studies of chlamydia in incarcerated adolescents, adolescent females are at substantially higher risk of chlamydial infection compared with adolescent males.30,36 In adult facilities, females aged ≤25 years are also at substantially higher risk of chlamydial infection compared with males aged ≤25 years, and have prevalence rate similar to those found among incarcerated adolescent females. Our findings support screening of all females in juvenile facilities and young females aged ≤25 years in adult facilities, consistent with CDC and US Preventive Services Task Force guidelines.12,13 Although the prevalence of chlamydia in males aged 15 to 25 years is substantial, the role of screening males for chlamydia prevention has not been fully explored. Females not only suffer most of the health consequences of untreated infection, but also have a chlamydia prevalence that exceeds the prevalence in males ≤35 years. Cost-effectiveness analyses show that screening females for chlamydia should take the first priority based on these consistently higher levels of prevalence.26,27,37,38 However, if resources are available our data support screening males aged 15 to 25 years as the second priority.39
The National Commission on Correctional Health Care recommends that all incarcerated females receive a health assessment, including laboratory testing for STD (chlamydia, gonorrhea, and syphilis).40 Given the high prevalence of chlamydia among incarcerated adolescent and young females found in this and other analyses,41,42 we believe that the National Commission on Correctional Health Care guidelines should specifically require chlamydia screening, for all females in juvenile facilities and females aged ≤25 years in adult facilities, as recommended by CDC.12,43
Although nonwhite adolescents account for 34% of the US adolescent population, nonwhite adolescents disproportionately account for 62% of incarcerated adolescents in juvenile facilities, of which 39% are black and 18% are Hispanic.44 Our analysis also found that the majority of incarcerated adolescents in juvenile facilities was nonwhite, of which 40% were black and 34% were Hispanic. Screening for chlamydial infection in incarcerated adolescents could potentially reduce chlamydia disease burden in the communities to which they return.28
There were several limitations to this analysis. First, the sensitivity of chlamydia tests used in the different correctional facilities varied. Because most chlamydia tests (82%) conducted by the facilities were NAATs, underestimation of prevalence because of decreased sensitivity was minimal. Second, chlamydia testing was conducted on a voluntary basis. Because testing was voluntary, there might be selection biases—those with STD symptoms or at additional risks might be more willing to participate in screening activities than those without symptoms or additional risks. Third, facilities that participated in this project were not randomly selected from all US juvenile and adult correctional facilities. Those facilities that participated might be different from the ones that did not and the prevalence found may not be representative of all facilities. However, the participation of such large numbers of facilities from so many states probably reduced this selection bias. Fourth, among the facilities that participated, timing of the screening, procedure and type of testing, screening coverage, resources, and policies may have varied among the facilities. Although we had little information on the above variability issues among facilities, we excluded those facilities with prevalence consistent with diagnostic testing based on symptoms. Finally, the high percentage of missing data for race/ethnicity and the exclusion of test records with missing race/ethnicity data may have introduced bias in the race/ethnicity-specific analyses of prevalence.
The strength of our analysis is that we have large sample sizes from correctional facilities from geographically diverse parts of the United States, which enables us to aggregate data from all facilities to compute age-specific prevalence by sex. Aggregate chlamydia prevalence may not be representative of local prevalence because prevalence may vary by facilities as noted in our figures.14,21,30,32 Ideally, local prevalence data should be used to support local facility screening policy rather than the aggregate prevalence data. However, most correctional facilities do not perform sufficient numbers of tests to generate stable age-specific prevalence estimates.
In summary, our findings of consistently high chlamydia prevalence in specific sex and age groups support age-based targeted chlamydia screening among incarcerated persons; females in juveniles facilities and those aged ≤25 years in adult facilities.
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