Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the most commonly reported notifiable diseases in the United States, with 1,307,893 and 309,341 cases reported in 2010, respectively, and females aged 15 to 24 years are at the highest risk for infection with either organism.1 The general population prevalence of CT is high, at 1.6% for those aged 16 to 39 years and higher for adolescents at 6.8% (those aged 14–19 years).1,2 N. gonorrhoeae prevalence data are more scarce, but a 2009 study of those aged 16 to 24 years entering the National Job Training Program reported 0.9% for males and 1.8% for females.3 The asymptomatic nature of most chlamydial infections and their widespread prevalence have contributed to the Centers for Disease Control and Prevention’s recommendation that all sexually active females aged 15–25 years be annually screened.4 Though a Healthcare Effectiveness and Data Information Set quality measure since 2000, primary care physicians screen eligible women only 41% of the time.5 This gap in care will likely be exacerbated by the predicted shortage of primary care physicians, estimated to reach 45,000 by 2020.6 The Centers for Disease Control and Prevention does not recommend routine and universal screening for GC, but it is recommended as part of the Bright Futures national health promotion initiative.7 Compounding the problem of CT/GC morbidity and intervention are the significant and widespread cuts to public health funding, with nearly half of local health departments eliminating staff and programs in the past year.8
Emergency departments (EDs) located in more than 5754 hospitals in the United States may be a resource to address the shortage of primary care access and appropriate screening for CT/GC.9 Adolescents aged 11 to 21 years comprise 15.8% of all ED visits, and emergency care accounts for 21.6% of health care visits for young adults (aged 20–29 years).10,11 Prevalence rates for ED patients have been reported at 0.9% to 8.1% for CT and 0.9% to 3.9% for GC, and studies show that EDs are already significant screening providers.12,13 Finally, most ED visits exceed 2 hours, and sexual history taking and screening are acceptable to more than 71% of adolescents in urgent care and ED settings.14–16
Previous studies have shown that it is feasible to institute routine and universal sexually transmitted infection screening in the ED.17 The use of screening algorithms and partnerships with public health departments have been shown useful in this regard.18–20 Our objective was to determine if patient responses to a survey of sexual history administered at ED admission were predictive of infection status. If so, then screening could be directed toward those at increased risk with a resultant increase in test positivity and decrease in resources expended.
From June 2011 to February 2012, female patients aged 15 to 35 years presenting to an urban ED with low-acuity complaints were approached by the study coordinator and asked to participate. Participation included the completion of an informed consent form and a sexual history survey, provision of a urine sample for CT/GC testing, and a $10 cash incentive. This research was approved by the Springfield Committee for Research Involving Human Subjects. Samples were analyzed by a nucleic acid amplification test (BD ProbeTec), and those testing positive were contacted by the study coordinator by the patient’s preferred method (e.g., telephone) and directed to either the local health department or their primary care physician for treatment. Surveys were analyzed for associations between patient demographics, sexual history question responses, and CT/GC infection status. Associations were determined using χ2 test for categorical variables, with a 2-tailed significance level of 0.05. Age was dichotomized into 15 to 24 years (younger) and 25 to 34 years (older). Numbers of partners were also dichotomized (“0–1” and “2 or more” (2+) for male partners and “none” or “any” for female partners). Presenting complaints were classified as follows: genitourinary/obstetric/vaginal bleeding, abdominal pain, and other. Statistical analyses were performed using SPSS (v19; Chicago, IL).
Of 318 female participants, the mean (SD) age was 25.6 (4.8) years (139 younger and 179 older), 59.4% were white and 39.6% were black, 65.7% were publically insured, 96.5% were sexually active in the past year, 13.5% used oral contraceptives, 79.9% had ever been pregnant, and 38.4% had ever been told that they had a sexually transmitted infection. There were a total of 29 (9.1%) individuals infected (Table 1), and all were successfully contacted and treated. For purposes of this analysis, we used infection with CT, GC, or both as our dependent variable (infection).
There were no associations between presenting complaint and infection, and presenting complaints did not significantly differ by age or race. Younger patients were more likely to be infected than older patients (odds ratio [OR], 2.27; confidence interval [CI], 1.04–4.38; P = 0.049), and blacks were more likely to be infected than whites (OR, 3.29; CI, 2.05–5.29; P < 0.001). Infection was also associated with the following: reporting 2+ male partners in the past 3 months (18.9% vs. 7.2% for 0–1 partners; OR, 3.01; CI, 1.31–6.92; P = 0.015) or 2+ male partners in the past year (17.2% vs. 4.5%; OR, 4.47; CI, 1.96–10.18; P < 0.001), reporting any female partners in the past 3 months (22.2% vs. 7.9% for no partners; OR, 3.33; CI, 1.22–9.07; P = 0.026) or any female partners in the past year (20.0% vs. 8.0%; OR, 2.88; CI, 1.070–7.760; P = 0.042), thinking that their current partner had other partners (CPOPs) (OR, 2.65; CI, 1.21–5.78; P = 0.023), and insurance status (positivity rates for private, public, and uninsured at 1.9%, 9.1%, and 16.1%, respectively; P = 0.037).
We examined the effect of limiting screening to those at increased risk for infection due to the following: younger age, black race, 2+ male partners at 3 and 12 months (2+ M3; 2+ M12), any female partners at 3 and 12 months, those thinking their CPOPs, and insurance status (Table 2). Three screening limitation factors resulted in a significantly increased patient prevalence (proportion of all screened individuals with positive result): only those reporting 2+ M3, only those reporting 2+ M12, or only those reporting any female partners in the past 3 months. Of these 3 factors, screening only those reporting 2+ M12 maximizes the number of infected identified (69.0%) and increases the tested patient prevalence (to 17.2%; P = 0.025) while still reducing the number of individuals screened by 63.5%. However, for each limitation strategy, the proportion of those identified as infected was significantly less than universal screening (ranging from 20.7% to 69.0%; all P < 0.050).
We then combined risk factors to see if further gains in those identified could be made without significant decreases tested population prevalence. Two strategies, combined strategy 1 (screening those reporting 2+ M12 or those reporting any female partners in the past 3 months) and combined strategy 2 (CS2; screening those reporting 2+ M12 or those reporting CPOP), retain the significant increase in tested patient prevalence compared with the reference strategy. Furthermore, the proportion of those infected identified by CS2 increased to 82.8% of those universally screened. Although the proportion of those identified between universal screening and CS2 was not significant (P = 0.052), this may be caused by the relatively small sample size.
Many of our study’s results, such as the high rates of infection (9.1% overall, all ages), infection disparities associated with race (blacks comprising 52% of all infected) and insurance status, and associations between infection and multiple male partners in the past year or any female partners are similar to that reported in other studies conducted in urban venues.19–21 To achieve our goal of identifying patient-reported factors useful in guiding screening practice, we examined refinements to universal screening based on survey responses. Screening only those reporting 2+ male partners in the past year or those who thought their sex partner had other partners (CS2) resulted in a 52% decrease in the number of tests administered and a 73% increase in screened patient prevalence and maximized the number of infected identified. Although this study focused on females because they are of known higher prevalence (for CT) and cost-effectiveness may be more easily achieved, our continuing work is expanding to include both males and oropharyngeal samples.
Although it might be reasonable to think that associations between infection and number of partners and multiple concurrent sex partners are generalizable, the predictive use of these questions will need to be validated in other locations and with differing populations. The recruitment method may be another limitation. We had a single study coordinator who could only approach those who were not otherwise occupied with clinicians or complaint-driven activities. The pool of individuals both eligible and available was somewhat fluid and conjectural, and we cannot determine what proportion of all potentially eligible individuals participated, resulting in potential participation bias.
This study showed that patient-provided information can be used to allocate screening resources to those at increased risk for infection. Further work needs to be done to investigate how to create a context in the admittance procedure whereby sexual history questions seem logical and reasonable. Furthermore, triaging patients for screening via any algorithm will result in a proportion being missed by not meeting the inclusion criteria. Logistical and financial concerns are important when considering both algorithm criteria (determining numbers screened and followed up) and implementation. Refining screening criteria such that tested patient prevalence exceeds 15% and nearly all infected are identified may still result in thousands of tests each year. In this regard and in terms of sample handling, sample analysis, result reporting, and treatment, active collaborations with local and state health departments may be key to ultimate feasibility. Such partnerships have been shown effective for assisting with patient follow-up, testing, and treatment, and their full-scale application and evaluation in this scenario will need to be determined.19,20 Ultimately, the continuing prevalence of CT and GC in ED patients, the high degree of accessibility of EDs across the United States, their use by those at increased risk for infection, and the gaps in public health funding make the ED a potentially critical venue to the screening of CT and GC.
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