SCREENING FOR CHLAMYDIA (CT) AND gonorrhea (GC) in correctional populations is effective in reaching a population that does not access health care services as often as the general population.1–3 Previous studies have consistently demonstrated the high prevalence of sexually transmitted diseases (STDs) such as CT and GC among incarcerated persons compared with the general public.1,2,4–6 Screening in correctional settings is effective in identifying and treating asymptomatic CT and GC among inmates that would otherwise go undetected. As a result, jail-based screening programs can improve the health of inmates and can ultimately reduce the burden of disease in the community because most inmates are quickly released and returned to the community.1,4–6 Although universal screening for CT has been shown to be cost-effective for female inmates in whom the prevalence is 8% or higher, there are few published studies that demonstrate the cost-effectiveness of screening men in jails.7,8 CT infections are commonly asymptomatic in incarcerated men.5,6,9 However, sustained support of an STD screening program in a jail setting has been associated with declines in clinic-level STD prevalence in neighborhoods with high levels of jail-based screening.10 Additionally, criteria-based screening has been shown to be feasible and effective at case finding and at reducing the costs of jail-based STD screening programs when compared with universal screening.4–6
The Cook County Jail located in Chicago serves as a predetention center for pretrial offenders in Cook County, IL, with an annual census of more than 100,000 detainees, of which more than two-thirds are Chicago residents. From 1989 to 2003, the county jail offered voluntary universal CT and GC screening at intake for both male and female inmates; acceptance rates for CT and GC screening were over 85%, resulting in over 85,000 screening tests annually among male and female detainees. In April 2003, universal CT and GC screening was suspended for male detainees, whereas the universal CT and GC screening program continued for female detainees. This change to symptom-based testing among male detainees was necessary because of reductions in the laboratory budget to support CT and GC testing.
Our objective was to evaluate the impact of the discontinuation of universal CT and GC screening in a large county jail on case detection and citywide CT and GC case reporting.
In this cross-sectional analysis, we analyzed data from the Chicago Department of Public Health's (CDPH) STD surveillance system. As required by law, all laboratories and providers are required to report STD cases confidentially to the health department. Case reports were entered into the National Electronic Telecommunications Surveillance System. CT and GC cases reported from April 2002 to March 2003, the period of universal male CT and GC screening and the second period from April 2003 to March 2004, after universal screening was discontinued and symptom-based testing began for male detainees were included in the analysis. CT and GC cases from the Cook County Jail were identified.
Male detainees were screened by urethral swab using the BDProbeTec nucleic acid amplification assay (BD Biosciences, Sparks, MD). Urine-based nucleic acid amplification tests for CT and GC were not used because of cost considerations, security concerns, and physical facility limitations. CT and GC cases were treated by Cermak Health Services of Cook County, the health care provider for detainees of the Cook County Department of Corrections. Detainees were treated before release from the jail, when possible, and if needed CDPH staff provided follow-up treatment and partner notification services. Among the detainees diagnosed with CT and GC who were released before receiving treatment, 38% of these were found and treated by CDPH staff; an additional 11% of these detainees were located in the community but refused treatment offered by CDPH staff; and 30% were unlocatable because of inaccurate locating information.
Female detainees were screened for CT and GC by cervical swab using the BDProbeTec nucleic acid amplification assay (BD Biosciences). Unlike the male screening program, the female universal screening program continued throughout the analysis period. CT and GC cases among female detainees were treated before release and managed similar to male cases.
We compared differences in the number of reported male CT and GC cases from the Cook County Jail and at the city level during the universal screening and symptom-based testing periods using SAS version 8.2 (SAS Institute, Cary, NC, 2006). We mapped reported cases at the address level using ArcGIS 9, ArcMap version 9.1 (ESRI, Redlands, CA, 2005). To protect patient confidentiality, the final mapped points were altered from the actual address maintained within a 1-mile radius. The resulting dot map was layered onto a map displaying the boundaries of Chicago's 77 community areas. This analysis was a part of routine assessment of the public health surveillance program and was exempt from human subjects review.
Overall, reported CT and GC cases from the county jail decreased by 79.2% in the 12-month period after discontinuation of universal screening. Reported male CT and GC cases from the county jail decreased more than 90% after discontinuation (Table 1). Substantial declines were noted among reported male CT cases in all racial, ethnic, and age groups. Figure 1 illustrates the substantial declines in reported CT and GC cases from the county jail after discontinuation of screening services, as shown in the reduction of the density of cases in each neighborhood. The distribution of cases remained in the southern and western regions of the city, suggesting that the distribution of symptomatic cases was similar to the distribution of symptomatic and asymptomatic cases identified before the cessation of universal male screening.
Reported cases of CT and GC among males citywide declined by 33.3% and 19.5%, respectively during the period after discontinuation of universal male CT and GC screening at the county jail (Table 1). Of all the reported CT cases among men in Chicago, the proportion of male CT cases reported from the jail decreased from 40.6% (3329 of 8205) to 5.1% (277 of 5470). Declines in reported CT cases among males citywide were similar across all age groups. Of all reported GC cases among men in Chicago, the proportion of male GC cases reported from the jail decreased from 16.3% (1133 of 6940) to 1.9% (108 of 5585). The declines in reported GC were greatest among males aged 25 years and younger (35.4%), compared with a decline among males aged 35 years and older (32.8%) and among males between 26 and 34 years of age (28.2%).
Overall, CT and GC morbidity in Chicago declined by 9.3% and 12.9%, respectively, in the 12-month period after discontinuation of universal male CT and GC screening in the county jail. Changes in reported CT and GC morbidity were also noted among females. Reported CT cases among females citywide increased 2.5%, with the largest increases among females aged 35 years and older (8.7%) after the discontinuation of the universal screening program among males in the county jail. Reported GC cases among females citywide declined by 5.6%. Declines were seen among females of all ages citywide; however, larger declines were noted among the older age groups of reported female cases (8.5% among women aged 26–34 years and 8.3% among women aged 35 years and older compared with 4.5% among women aged 25 years and younger). Finally, during the 12-month period after discontinuation of the universal STD screening program among males in the county jail reported male CT cases by nonjail providers increased by 6.5%, whereas reported male GC cases by nonjail providers decreased by 5.7%.
We observed a substantial decline in the number of male CT and GC cases reported to the CDPH after discontinuation of universal screening services. If we consider the level of CT and GC morbidity during the universal screening period to reflect the true burden of prevalent disease, the large decline in male cases underscores the high proportion of male CT infection that is asymptomatic and therefore missed if testing is limited to those with symptoms, and the large decline in GC cases among males demonstrates one fault of a symptom-based testing strategy. Male detainees may be unlikely to recognize or identify themselves with symptoms of GC and therefore are unlikely to be tested in the jail using this strategy. Increases in case detection by community providers did not account for the declines in case detection noted in the jail, suggesting that infected detainees did not access screening services in nonjail settings. Consistent with other studies that demonstrate effective case finding in correctional settings, discontinuation of CT and GC screening services represents a missed opportunity to screen a high-risk population for asymptomatic CT and GC.3 Symptom-based testing misses a majority of STD cases and untreated individuals end up going back to their communities and infecting others.11 Recent data suggest that sustained STD screening in correctional facilities was associated with declines in community prevalence of CT and GC.10 Untreated chlamydial and gonococcal infections among males can result in complications such as epidimytis, orchitis, and enhanced transmission of HIV.12 Among females, untreated disease can result in complications such as pelvic inflammatory disease, pelvic pain, potentially fatal ectopic pregnancies, and facilitated HIV transmission.13,14
In contrast with the observed trends in male CT and GC jail-based morbidity, overall female CT cases increased in the period after the discontinuation of universal screening among males at the jail; however, there was no corresponding increase in reported GC cases. The increase among reported female CT cases might be attributable to changes in screening practices, changes in tests used, or true increases in morbidity prevalence. However, because the public health department did not conduct any CT campaigns targeting providers to change screening practices during this time, the higher rates could be due to untreated infection among released males being transmitted to female partners. Nevertheless, the cause of these observed increases in CT morbidity among women cannot be identified in this analysis. Further study is needed to identify the impact the discontinuation of male universal STD screening in the county jail had on the morbidity of CT and GC among women in Chicago.
There are several limitations to this analysis. Reported surveillance data were available for a 12-month period after discontinuation of universal screening services and may not demonstrate the complete impact of service cessation on Chicago's morbidity. In September 2005, age-based universal screening among male detainees was initiated among men aged 35 years and under. This targeted screening criterion was then narrowed to include only men aged 25 years and younger after 3 months because of budgetary limitations for laboratory costs. In February 2007, the STD screening program for male and female detainees was discontinued because of countywide budget cuts, and a symptom-based strategy was instituted at the jail. Additional evaluations of the effectiveness of universal, symptom-based, and age-based screening are needed.
Second, this cross-sectional analysis uses case report surveillance data and is dependent on complete reporting by jail-based providers and laboratories. Although the sensitivity of case reporting is unknown, it is unlikely that there were coincident changes in reporting behavior that may be associated with these observed case report trends. Because of incomplete reporting of race and ethnicity data, a high percentage of “unknowns” were reported for these categories, making further analysis difficult. Public health departments should continue working with the different reporting providers to obtain complete race and ethnicity data on reported cases.
Third, because this is a cross-sectional analysis, causality cannot be demonstrated by the changes to morbidity we note during the period after cessation of universal STD screening services; there were no other data relating to behavioral changes in the jail or city population that would potentially account for the observed trends.
Additional review of surveillance data over time will determine whether cessation of universal screening services impacts community wide prevalence of disease. In resource-limited settings, available resources often determine the scope of screening programs and screening established on evidence-based criteria may not be feasible. As additional resources become constrained, these screening programs become less efficient because of additional missed opportunities to screen high-risk populations.
Criteria-based targeted screening is more effective at identifying cases than symptom-based testing. Gift et al. and other authors have demonstrated the cost-effectiveness of targeted screening for CT and GC in correctional settings based on specific age-based criteria, restricted to those less than 30 years of age, compared with universal screening.4 Trick et al. demonstrated the feasibility and effectiveness of targeted screening for CT and GC based on age and symptom status, which identified the majority of chlamydial and gonococcal infections among males in the Cook County Jail.5 Although targeted criteria-based screening is a compromise to the effectiveness of universal screening, it is a cost-effective option for a screening program among detainees.
STD screening in incarcerated populations serves an important role in prevalence monitoring and disease control in a vulnerable population. Public health interventions in such settings can include case detection and treatment, and partner management services including partner notification.3 Because chlamydial and gonococcal infections are frequently asymptomatic among men, targeted screening programs are an effective way to identify male cases efficiently and to link this population and their partners into the health care system.15 Entry into the health care system can further offer an opportunity to provide education on prevention of STDs and client-centered risk reduction strategies. Without a jail-based screening program that targets asymptomatic men, we will miss the majority of incarcerated males infected with CT and GC, which accounts for nearly half of all male cases in Chicago. Efforts should be made to reimplement at least targeted screening for males in correctional settings to identify a significant proportion of CT and GC cases in the community.
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