Sexually Transmitted Diseases:
Sex and Age Correlates of Chlamydia Prevalence in Adolescents and Adults Entering Correctional Facilities, 2005: Implications for Screening Policy
Joesoef, M Riduan MD, PhD*; Weinstock, Hillard S. MD, MPH*; Kent, Charlotte K. PhD*; Chow, Joan M. PhD†; Boudov, Melina R. MA‡; Parvez, Farah M. MD, MPH§; Cox, Tamara MPA*; Lincoln, Thomas MD∥; Miller, Jamie L. MPH*†; Sternberg, Maya PhD*; the Corrections STD Prevalence Monitoring Group
From the *Division of Sexually Transmitted Diseases Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia; †California Department of Health Services, Richmond, Virginia; ‡Los Angeles County Department of Health Services, Los Angeles, California; §Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia; and ∥Baystate Medical Center, Springfield, Massachusetts
The authors thank Dr. Michael Samuel of the California Department of Health Services; Kathleen Hutchins, Donna Helms, and LaZetta Grier of the Centers for Disease Control and Prevention; and Regional Coordinators of the Infertility Prevention Project.
The findings and conclusions in this report have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.
The Corrections STD Prevalence Monitoring Group (listed in alphabetical order) includes Melina Boudov of the Los Angeles County Department of Health Services; Dr. Joan Chow and Jamie Miller of the California Department of Health Services; Dr. Barbara Conrad of the Maryland Department of Health and Mental Hygiene; Tamara Cox of the Chicago Department of Health; Patrick Dwyer of the New York Department of Health; Darlene Harper of the Milwaukee Department of Health; Patrick Harris of the Texas Department of Health and Services; Kathleen Hutchins, Dr. M. Riduan Joesoef, Dr. Charlotte Kent, and Dr. Hillard Weinstock of the Centers for Disease Control and Prevention; Dr. Thomas Lincoln of the Hampden County Correctional Center, Massachusetts; David Novak of the Department of Public Health, Massachusetts; Dr. Farah Parvez of the New York City Department of Health and Mental Hygiene; and Melinda Salmon of the Philadelphia Department of Health.
Correspondence: Division of Sexually Transmitted Diseases Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333. E-mail: email@example.com.
Received for publication June 12, 2007, and accepted September 24, 2007.
Objectives: To evaluate sex and age correlates of chlamydia prevalence in incarcerated populations.
Methods: Cross-sectional analysis of chlamydia prevalence by demographic characteristics from incarcerated females and males entering selected juvenile and adult correctional facilities (jails) in the United States in 2005.
Results: A total of 97,681 and 52,485 incarcerated persons aged ≥12 years were screened for chlamydia in 141 juvenile and 22 adult correctional facilities, respectively. Overall, chlamydia prevalence was high in females (14.3% and 7.5%) in both juvenile and adult facilities when compared with that in males (6.0% and 4.6%). The chlamydia prevalence was higher in incarcerated females than in incarcerated males for persons ≤35 years, and prevalence was highest among females aged ≤25 years (range, 11.3%–15.6%). In juvenile facilities, prevalence did not steadily increase with age in females (12.8% in 12–14 years, 15.1% in 15–17 years, and 14.3% in 18–20 years) whereas in males prevalence steadily increased with age (2.4% in 12–14 years to 8.7% in 18–20 years). In females and males the highest prevalence in juvenile facilities was in incarcerated blacks (18.4% and 9.6%, respectively). In adult facilities, the prevalence was consistently highest in younger detainees: in females it was 15.6% in 18- to 20-year olds compared with 1.5% in those >40 years; in males it was 8.8% in 18- to 20-year olds compared with 1.4% in those >40 years.
Conclusions: The consistently high chlamydia prevalence among females in juvenile facilities and females (≤25 years) in adult facilities supports a screening policy in correctional settings consistent with Centers for Disease Control and Prevention and US Preventive Services Task Force guidelines. Although the prevalence of chlamydia in males is substantial, chlamydia prevalence in females exceeds that of males ≤35 years, and thus screening females for chlamydia in these facilities should take priority over screening males.
CHLAMYDIA TRACHOMATIS IS THE MOST commonly reported bacterial sexually transmitted disease (STD) in the United States. Genital chlamydial infections in females may cause pelvic inflammatory disease, tubal infertility, ectopic pregnancy, and chronic pelvic pain,1,2 and has been associated with cervical carcinoma.3,4 In males untreated chlamydial infections may cause urethritis, epididymitis, prostatitis,5 and infertility.6,7 Additionally, the infection may increase the risk for human immunodeficiency virus infection acquisition and transmission.8–10 Two-thirds of females with chlamydial infection in the cervix have no signs or symptoms of the infection.5 In males about 60% of chlamydial infections are asymptomatic,5 and thus, males may also serve as an important reservoir for chlamydia resulting in repeated transmissions of the infection to sex partners.11
Because of the asymptomatic nature of the disease, screening and treatment programs for chlamydial infections constitute an important component of prevention efforts to reduce population disease burden. Because chlamydia prevalence and incidence are consistently highest in young females, annual chlamydia screening for young females (≤25 years old) has been recommended by Centers for Disease Control and Prevention (CDC)12 and the US Preventive Services Task Force.13 In the general population, chlamydia screening has been implemented in many family planning, prenatal care clinics, and managed care plans where young women seek care. With the introduction of noninvasive, highly sensitive nucleic acid amplification tests (NAATs) expansion of widespread chlamydia screening to nonclinical settings is also feasible.14,15
Incarcerated persons are at particularly high risk for STD infection because they are more likely to report multiple partners, unprotected sex or inconsistent condom use, history of substance abuse, commercial sex work, and difficulty accessing health care.16–20 National prevalence monitoring in incarcerated populations, especially juvenile detention sites, has documented a high prevalence of chlamydia in females (15.9%) and in males (6.1%),21 which is generally higher than that seen in family planning clinics and the general population.21–23 Because incarcerated persons may have limited access to health care,24,25 many correctional facilities include screening for chlamydia as part of their routine medical assessment. Treatment of chlamydial infections in this population is cost-effective26,27 and may have a major impact on disease burden and transmission in the general community.28
State-run or state-directed correctional facilities are divided into 2 type of institutions—local (city/county) and state. The number of persons entering the correctional system at the local level, either as adults or adolescents, is far greater than those that enter the state-level institutions. Persons entering jails or juvenile detention facilities at the local level are usually waiting for trials, charged with lesser crimes, or persons sentenced for shorter durations, generally less than a year. Adults or adolescents that have committed more serious offenses are housed in the prison or youth authority—usually under federal control. Under prison or youth authority, inmates often serve much longer sentences than those in the jail or juvenile detention facility. The majority of persons in the state systems are placed there after having been adjudicated at the local level. Because of the high volume of persons entering the correctional systems at the local level and the greater likelihood of a faster return to the community, these correctional facilities are the logical first line of STD prevention activities for incarcerated population. This analysis reflects state data mostly from the local institutions—jails for adults and juvenile detentions for adolescents.
Although many prevalence studies in incarcerated populations have been conducted, these studies have been limited in their generalizability because of lack of geographical scope and small sample sizes.29–34 Our analysis evaluated chlamydial infections in incarcerated population by sex and age using data collected in 2005 from a large national prevalence monitoring project in geographically diverse correctional facilities. This evaluation may assist local policy makers in setting priorities for chlamydia screening in females and males in these populations where resources are limited.
In 1996, the CDC, through the Corrections STD Prevalence Monitoring Project, began collecting information on STD prevalence and demographic characteristics from persons entering correctional facilities in the United States.14,30,32 The goal of this project was to monitor the STD prevalence in incarcerated adolescents and adults at entry to juvenile detentions and adult correctional facilities (jails) in geographically diverse areas of the United States. Local and state health departments collaborated with correctional facilities and laboratories to compile the demographic and laboratory test results and to send the line-listed data electronically (without personal identifiers) to the CDC on a quarterly and yearly basis. Starting in 2002, screening data from juvenile and adult facilities participating in the CDC's Infertility Prevention Project were also included. Core line listed data elements include age, sex, race/ethnicity, location of the facility, chlamydia test result and type, year of laboratory test, and other informations if available (e.g., presence of STD symptoms). We used data collected in 2005 for our analysis. Because these surveillance activities were part of public health program evaluation, the activities were exempted from institutional review board clearance.
The facilities participating in the project conducted testing for STD at the time the person entered the facility, or at the first physical examination. This testing was conducted on a voluntary basis using urine, urethral, or cervical specimens. A variety of commercially available NAATs were used, including the Becton Dickinson ProbeTec ET assay (Becton Dickinson Co., Franklin Lakes, NJ), Gen-Probe Transcription-Mediated Amplification and Aptima Combo-2 test (Gen-Probe, Inc., San Diego, CA), and Roche Amplicor PCR (Roche Diagnostics Corp., Basel, Switzerland). A small proportion (12%) of urethral and cervical specimens were tested using other test types, including Gen-Probe PACE2 (Gen-Probe, Inc.) and direct immunofluorescence antibody. We excluded inconclusive and unsatisfactory test results from the analysis. We were not able to exclude duplicate tests from an individual.
We categorized demographic characteristics as follows: (a) age according to adolescent developmental stages for juveniles and 5-year grouping for adults: 12 to 14 years, 15 to 17 years, 18 to 20 years, 21 to 25 years, 26 to 30 years, 31 to 35 years, 36 to 40 years, and >40 years; (b) race/ethnicity: Hispanic, non-Hispanic black, and non-Hispanic white. Because very small numbers reported belonging to other race/ethnicities (e.g., Asians, Pacific Islanders, and American Indians) we excluded persons of other race/ethnicity groups from the analysis. For race/ethnicity analyses, we also excluded facilities that submitted data with ≥25% missing values for race/ethnicity. We excluded facilities submitted ≤100 test results in a year because these facilities might not have stable prevalence estimates. We also excluded facilities with chlamydia prevalence >40% in any specific age group or race/ethnicity; these facilities were likely to have tested only individuals with STD symptoms (diagnostic testing) rather than testing all individuals regardless of symptoms (screening). We only included adult facilities that we confirmed conducted screening regardless of symptoms. In age group and race/ethnicity analyses, we further excluded facilities when the number of tests was <10.
To estimate chlamydia prevalence, we used positivity rates computed as the total number of positive tests divided by the total number of positive and negative tests.35 We used SAS version 9.1 (SAS Institute, Inc., Cary, NC) for data analyses. We charted the distribution of chlamydia prevalence by age group for each facility for females and males using R software (http://www.r-project.org/). In this chart (Figs. 1 and 2), the prevalence for each facility was depicted as the center of a circle with the areas of the circles proportionate to the number of tests. Each age group was represented within a box and showed female and male prevalence. The relative area of each circle was comparable only within each box. Prevalence for each sex was summarized by the median site prevalence.
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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