Pathela, Preeti DrPH, MPH*; Hennessy, Robin R. MPH*†; Blank, Susan MD, MPH*†; Parvez, Farah MD, MPH*†; Franklin, Woodman BA*; Schillinger, Julia A. MD, MSc*†
ALTHOUGH NEISSERIA GONORRHOEAE HAS been a notifiable condition for decades, mandatory reporting of Chlamydia trachomatis to the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) was introduced only in 1993.1 At that time, urethral culture, an invasive genitourinary specimen type, was the only available test type for men. With the advent of noninvasive specimen types, such as urine, it has become much more feasible to screen males for chlamydial and gonococcal infections.
The NYC DOHMH runs a large public sexually transmitted disease (STD) program, with 10 STD clinics serving the most populated metropolitan area in the United States. The STD clinics have approximately 58,000 male patient visits annually. Of 4477 male chlamydia cases reported to the NYC DOHMH from all providers in 2001, 16% were reported from NYC DOHMH STD clinics. In late 2002, routine screening for chlamydia and gonorrhea using dual nucleic acid amplification tests (NAATs) (a dual assay applied to a single specimen) was introduced for all male patients seeking an STD evaluation at NYC DOHMH STD clinics. By the end of 2002, 5876 male chlamydia cases were reported citywide and, as a result of routine male screening at the STD clinics, the contribution of the STD clinics to male chlamydia reports doubled to 34%. In mid-2006, NYC DOHMH STD clinic screening was further augmented by the introduction of “express visits,” whereby even patients who do not receive a full STD evaluation, such as those seeking human immunodeficiency virus testing only, are encouraged to submit a urine sample for chlamydia and gonorrhea testing.
Even before routine screening of males was introduced in NYC DOHMH STD clinics, STD screening was implemented in NYC juvenile detention facilities. In 2000, through a partnership with the NYC DOHMH, the NYC Department of Juvenile Justice expanded health services to youth to include universal screening for chlamydia and gonorrhea, within 72 hours of admission to detention. From mid-2005 to mid-2006, the average daily population in NYC Department of Juvenile Justice facilities was 4492; approximately 3200 remanded male youth are screened for chlamydia and gonorrhea annually (NYC DOHMH, unpublished data, 2006).
NYC has the second largest jail jurisdiction in the nation. In 2005, STD screening in the NYC correctional setting was extended to adult males when the NYC DOHMH Bureau of Correctional Health Services implemented urine-based chlamydia and gonorrhea screening using NAATs for all incarcerated males aged ≤35 years upon intake to 6 NYC jails. Before implementation of the screening program, diagnostic testing and treatment were performed for men with complaints consistent with STD. Males aged ≥16 years make approximately 100,000 entries to the adult jail system annually through 4 intake facilities on Rikers Island and 2 additional intake facilities in Manhattan and the Bronx; from mid-2005 to mid-2006, the average daily male population in jails was 13,497, a census larger than many state prisons.3
This article describes citywide chlamydia and gonorrhea case reporting from 2002 through 2006 and quantifies the contribution of male screening in adult jails to citywide surveillance for these diseases.
Materials and Methods
Laboratory Survey Data
Since 2003, the Bureau of STD Control (BSTDC) at the NYC DOHMH has conducted biennial surveys of commercial and reference laboratories that are licensed by New York State to perform STD testing on specimens from NYC residents. Data from surveys of clinical laboratories were used to evaluate changes in STD laboratory testing practices. Survey questions sought to measure compliance with citywide reporting mandates, laboratory practices (specimen volume and test types used) for the full year before survey, and timeliness of laboratory reporting activities. We compared chlamydia testing practices reported by laboratories responding in 2002 (n = 90) and 2004 (n = 139).
NYC Surveillance Data
In NYC, reporting is mandated for 7 sexually transmitted infections. Of these, chlamydia and gonorrhea are the most commonly reported infections. The NYC Health Code requires that chlamydia and gonorrhea case reports be sent by physicians and positive laboratory results be sent by clinical laboratories via mail, fax, or electronic transmission within 24 hours of diagnosis. Information from received reports is entered by BSTDC staff into a surveillance database. For each case, the reporting provider is recorded, and providers are categorized as one of the following types: NYC DOHMH STD clinics, correctional facilities, hospitals, laboratories, and other private sector providers.
Surveillance data were used to quantify changes in the number and types of NYC providers who reported male chlamydia cases to the BSTDC in 2004 and 2006. Data were analyzed to determine numbers of chlamydia and gonorrhea cases reported by gender, age, report year, and provider type (e.g., STD clinics, correctional facilities, hospitals, laboratories, private doctors, and other clinics) from 2004 through 2006.
Laboratory Survey Data
Surveys of laboratories performing STD testing for NYC residents showed that the number of laboratories accepting male genitourinary specimens for chlamydia testing increased over time. In 2002, 68% (34 of 50) of laboratories that conducted chlamydia testing accepted male specimens for testing; by 2004, this had increased to 92% (47 of 51) of laboratories.
NYC Surveillance Data
In 2004, approximately 890 providers reported male chlamydia cases to the BSTDC; this number rose to roughly 1125 providers in 2006. In each year, >90% of reporting providers were in the private sector (i.e., neither city-operated STD clinics nor correctional facilities). Increasing numbers of reports of male chlamydia from both clinical laboratories and providers in NYC have led to a steadily increasing male chlamydia case rate (Fig. 1).
Of 6542 citywide chlamydia cases among males ≤35 years old reported to the BSTDC in 2004, 2643 (40%) were reported from NYC DOHMH STD clinics, 222 (3%) cases were reported from adult jails, and 138 (2%) from juvenile detention facilities. The contribution of different provider types to 2004 citywide gonorrhea case counts followed similar patterns, with 1606 (39%) of 4080 gonorrhea reports from NYC DOHMH STD clinics, 68 (2%) from adult jails, and 18 (<1%) from juvenile detention facilities.
In 2005, the first year of the adult jail screening program, the number of chlamydia cases among males ≤35 years old reported from the jails increased from 222 (in 2004) to 3854 (in 2005), an increase of 1636% (Fig. 2). These increases translated into a 59% increase in the number of male chlamydia case reports citywide, and an increase in the male citywide case rate from 203.0 cases per 100,000 males (in 2004) to 322.7 cases per 100,000 males (in 2005). In 2005, jails surpassed all other providers, including all 10 public STD clinics combined, in reported chlamydia cases among males aged ≤35 years. Jails reported 35% of cases, compared with 25% of cases reported from STD clinics, thereby eclipsing STD clinics with 40% more case detection. Routine jail screening has also identified additional gonorrhea cases. Gonorrhea case detection in NYC jails increased from 68 cases (in 2004) to 670 (in 2005), an increase of 885% (Fig. 3) that resulted in a 4% increase in the number of citywide gonorrhea case reports.
In 2006, the contribution of NYC DOHMH STD clinics to citywide male chlamydia cases was roughly similar to that of adult jails (each contributed approximately 30% of citywide case reports), likely as a result of the introduction of express visits and the resulting screening of more male patients in STD clinics that year.
In NYC, in recent years, there has been a gradual rise in the number of male chlamydia cases reported from all provider sources, as highly sensitive, noninvasive tests have become available and utilized to detect this common, but often asymptomatic, infection. Although there is evidence that male chlamydia reporting has been increasing in all segments of the health care provider community in NYC, a marked effect on reported case numbers and rates followed the introduction of universal screening for chlamydia and gonorrhea by the small number of providers making up the public sector, that is, STD clinics and correctional facilities. Although adolescents and young adult males comprise the age groups with the highest rates of chlamydia, the long-standing screening program in NYC juvenile detention facilities contributes only 2% of citywide male chlamydia cases every year. Case detection increased substantially when universal screening was introduced in NYC DOHMH STD clinics, but there was an even more dramatic impact on disease detection when screening was introduced among males admitted to NYC jails. In the year after the introduction of chlamydia and gonorrhea screening of young men in adult jails, jails reported 40% more chlamydia cases than 10 STD clinics and 13 times more cases than juvenile detention facilities.
Screening in NYC jails using the dual NAATs has shown a differential impact on case reporting for chlamydia versus gonorrhea. This is likely because gonorrhea is a substantially less common infection than chlamydia and in men is largely symptomatic; therefore would be diagnosed even in the absence of screening programs. However, given that some proportion of gonococcal infections is asymptomatic,4 universal screening for gonorrhea in jails using a dual NAAT can detect a reservoir of infection among high-risk men.
The large number of cases contributed to our surveillance data by correctional facilities is not entirely surprising, as arrestees report risk behaviors before their arrest that place them at risk for STDs, such as multiple sexual partners, prior history of STDs, lack of condom use, and illicit drug use.5 Moreover, reports from short-term cross-sectional studies have shown that STD screening in correctional facilities yields a high prevalence of chlamydial infections among those tested.6–8
In 2002, the National Commission on Correctional Health Care commissioned a report, The Health Status of Soon-To-Be-Released Inmates, which included nationwide policy recommendations to improve the health of inmates, protect the public from communicable disease, and reduce the cost to society of inmate illnesses that go untreated or undertreated. Recommendations included screening inmates for syphilis, gonorrhea, and chlamydia upon reception at prisons and jails, and treating inmates who test positive for these infections.9 Despite this, STD screening is still not routine at most city and county jails across the nation.10 Challenges to screening and/or treatment in correctional facilities include unavailability of arrestees because of their rapid release or frequent court appearances and difficulty in locating released, infected persons for necessary treatment. Additionally, there are security and logistical issues such as movement of incarcerated persons to and from clinics to jail cells and lack of space, staff, and monetary resources for screening and treatment.10 These challenges are somewhat balanced by advances that make screening and treatment programs in nontraditional settings more practical, such as the relative ease of specimen collection for urine-based dual chlamydia/gonorrhea tests and inexpensive, single-dose antibiotic therapy.
An important next step in establishing the value of male chlamydia screening in the jails is to measure the impact of male case detection and treatment on chlamydia rates among women in the communities to which incarcerated males return. The baseline burden of disease among women in the NYC population is currently high; in 2006, 28,288 female chlamydia cases were reported to the Bureau of STD Control, yielding a case rate of 671.3 cases per 100,000 females. Because women with chlamydia have an increased risk of adverse pregnancy outcomes and infertility, screening programs for females should be sustained and even augmented. However, because males factor importantly in the chain of transmission, screening and treatment of high-risk males are crucial to disease control.
Our data show that a large number of chlamydia and gonorrhea cases can be detected by screening young men in adult jails. Screening in this setting contributes approximately one-third of all male chlamydia cases in NYC, a number even higher than the number of infections detected in traditional settings for screening high-risk men, such as STD clinics. There are large numbers of individuals brought into the criminal justice system in the United States each year; approximately 650,000 men experience a stay at a local jail annually.11 These men may be unlikely to access health care at traditional healthcare venues or may not get screened for STD even if seeking care from a community provider. The costs of a jail-based screening and treatment program are borne at the level of the correctional health system, whereas the benefits are reaped at the societal level. Therefore, partnerships between correctional health and public health authorities are critical to the successful execution of programs.
1. New York City Health Code. Article 11. Section §11.03(a).
4. Gaydos CA, Kent CK, Rietmeijer CA, et al. Prevalence of Neisseria gonorrhoeae
among men screened for Chlamydia trachomatis
in four United States cities, 1999–2003. Sex Transm Dis 2006; 33:314–319.
5. Beltrami JF, Cohen DA, Hamrick JT, et al. Rapid screening and treatment for sexually transmitted diseases in arrestees: A feasible control measure. Am J Public Health 1997; 87:1423–1426.
6. Bernstein KT, Chow JM, Ruiz J, et al. Chlamydia trachomatis
and Neisseria gonorrhoeae
infections among men and women entering California prisons. Am J Public Health 2006; 96:1862–1866.
7. Mertz KJ, Schwebke JR, Gaydos CA, et al. Screening women in jails for chlamydial and gonococcal infection using urine tests: Feasibility, acceptability, prevalence, and treatment rates. Sex Transm Dis 2002; 29:271–276.
8. Cohen DA, Kanouse DE, Iguchi MY, et al. Screening for sexually transmitted diseases in non-traditional settings: A personal view. Int J STD AIDS 2005; 16:521–527.
10. Parece MS, Herrera GA, Voigt RF, et al. STD testing policies and practices in U.S. city and county jails. Sex Transm Dis 1999; 26:431–437.