In 2012, 1,422,976 cases of infection with Chlamydia trachomatis (CT) and 334,826 cases of infection with Neisseria gonorrhoeae (GC) were reported to the Centers for Disease Control and Prevention (CDC), representing 456.7 and 107.5 cases per 100,000 persons, respectively.1 As in previous years, adolescents and persons of color were disproportionately affected, with adolescent girls aged 15 to 19 years demonstrating a CT rate of 3291.5 per 100,000 persons and a GC rate of 521.2 per 100,000.1 Strategies to interrupt transmission of CT and GC in these populations have long been sought; however, as a population, adolescents can be difficult to reach2 and existing CT screening recommendations are not well followed.3–5
After the introduction of noninvasive urine-based nucleic acid amplification techniques (NAATs) in the early 1990s,6 it became feasible to perform large-scale screenings for CT/GC in nonclinical venues such as health fairs and schools. Mass school-based screening for sexually transmitted diseases (STDs) was designed as a strategy to overcome some of the difficulties of reaching adolescents, normalize and increase uptake of testing, and curtail transmission, and it was hoped perhaps to even decrease prevalence of infection in adolescent cohorts.7 This method of screening is usually performed by an outside entity, mostly the local health department8–11 or, in some cases, a school-based health center (SBHC)12 operating in close partnership with the schools or school district where it is performed. Currently in the United States, an estimated 5 jurisdictions are performing school-based STD screening (SBSS) on a large scale.
The basic SBSS model that is currently used, and that will be discussed below, was developed in 1995 in New Orleans7 and has been described in detail by several jurisdictions.8,9,11 This mass screening method is different from ongoing STD screening that may take place at SBHC, which are clinical entities present in only approximately 2% of US schools, and where the availability of services and the methods used to deliver them vary widely.13,14 An excellent literature review on the topic of school-based screening, including some SBSS programs and routine STD screening in SBHC, both in the United States and abroad, is provided by Jamil et al.15 However, the studies in the review by Jamil et al. were implemented in a variety of ways in countries with very different health systems than the United States; thus, we have chosen to focus our current review on US classroom-based high school programs to more closely examine and compare their programmatic components.
In the basic SBSS model, students are called down by classroom to hear a brief educational presentation on STDs and screening (the content of which varies by site), including that testing is voluntary and most appropriate for sexually active students. Subsequently, all students are given a testing kit in a brown paper bag, including a demographic form to be completed by the student and a urine collection cup. All students are then escorted to the rest rooms, where they are free to provide (or not to provide) a urine sample for testing. Urine samples are tested for CT and GC through NAAT. Students who test positive are offered in-school counseling and treatment and, depending on the jurisdiction, may be offered other services such as partner services, condoms, emergency contraception, expedited partner therapy (EPT), or HIV testing (A. Peterson, personal communication, 2014; J. Schillinger, personal communication, 2014).7–11,16 Depending on capacity, SBSS programs either offer rescreening17 or will instruct students to be rescreened appropriately.18
Public health planners initially hoped that this screening model might be able to forward several public health goals, among them increasing community screening and treatment of CT in girls and women 15 to 24 years old, as recommended by CDC.19 Other goals could include increasing community and provider knowledge of STD-related prevention, treatment, and epidemiology; reducing reinfection; reducing incidence of CT/GC; treating asymptomatic CT to prevent progression to PID20,21; and increasing access to care. In addition, SBSS may have utility for those outside formal public health settings, including for schools themselves, community hospitals, or other organizations that may be interested in the large-scale, community-based provision of STD screening among adolescents.
As informed by the principles of Program Science22 and to inform STD control programs, state and local educational agencies, and other entities on decision making about implementing or not implementing SBSS, we present a literature review and guidance regarding programmatic decisions. Although many gaps in research exist, this article compiles metrics for decision making informed both by existing literature, gray literature, and the opinions of public health program officials who currently operate SBSS programs.
The electronic databases EMBASE and PubMed were searched (January–March 2014) for any published English-language articles from all available years using search terms such as school-based screening, high school screening, chlamydia screening, gonorrhea screening, and mass screening. Ancestry searches using the references from selected articles were also performed. Studies that presented findings or original research from programs that conducted mass screening in American junior or senior high schools were selected. In addition, public health program areas without any published data that authors knew either had performed or were performing SBSS as described were approached for unpublished data, information on programmatic operations, history of the program, and lessons learned.
Twenty published articles were included in the literature review (Table 1). Of these, 11 (55.0%) were written using data from the New Orleans SBSS7,23–32; among these, several overlapped in terms of content over time.7,23,29 Other jurisdictions that published findings included New York City (NYC), Philadelphia, rural Pennsylvania, Michigan, and San Francisco. Eleven articles (55.0%) presented cross-sectional percent positivity (point prevalence) and demographics of infection among those tested during a given time frame.7–12,17,23–25,29 Rescreening or repeat screening was examined in 3.17,23,32 Behavioral or knowledge associations were examined in 5.12,27,28,30,33 All articles except one presented data from large cities.34
CT/GC Positivity and Demographics
Overall CT positivity ranged from 2.2% to 13.1% in females and 0.6% to 7.0% in males; however, excluding the 2 studies from San Francisco, the lower end of the range was 8.1% in females and 2.5% in males (Table 1). Infection with GC was far less frequent in all studies. African Americans, females, and older students consistently had the highest reported positivity in all studies. Other demographic factors associated with CT/GC infection were enrollment in a disciplinary school11,17 and residing in a high-morbidity area11 or in a physically deteriorated neighborhood.26
Several articles discussed either behavioral factors or student knowledge that was associated with infection or with participation in the screening process.8,12,27,28,30,33 Philadelphia has demonstrated that the places where students met their sex partners were consistently correlated with infection on multivariable analysis: having met sex partners at their own school was protective for males and females, having met partners in the neighborhood was risky for females, and meeting partners in venues other than their own school, neighborhood, or through friends was very risky for both.33 In addition, history of arrest was associated with infection in females, and young age at first sex was associated with infection in males.33 In a Michigan high school, having ever had an STD was significantly more likely in students reporting at least 4 lifetime sex partners, not using a condom at last intercourse, and having had sex in the last 3 months; however, these factors were not significantly associated with testing positive at an SBSS event.12 Interestingly, students in NYCand Philadelphia who did not respond to the initial sexual activity question at time of screening tested positive at least as often as those who reported being sexually active.8,35
In New Orleans, participating students' knowledge about STD was assessed using a survey tool. In this study, only 31% of 12th graders knew all of the most basic facts that CT and GC are transmitted sexually, that each can be cured, and that STDs can be asymptomatic and are preventable. Advanced grade level, female sex, and having had a previous CT/GC infection were each associated with a higher knowledge score on multivariate analysis, but having simply attended a school where screening was performed in the past and being currently infected were not.27 Students' own perceptions of STD risk was also assessed in another New Orleans study28: although most students (64.5%) did not perceive themselves at high risk, those who thought themselves at high risk were no more likely to test positive for CT or GC than those who did not, and estimates of risk did not differ by age, sex, or black versus other races. Last, students in New Orleans were surveyed about their reasons for refusing SBSS testing.30 This study revealed several misconceptions among students; for example, of those who stated they had had sex and did not test, the majority refused testing because they bathed every day and therefore did not consider themselves at risk of STD.
Two studies formally analyzed the cost-effectiveness of SBSS programs. Fisman et al.36 constructed a dynamic CT transmission model using Philadelphia data and found that SBSS as practiced (assuming 35% of eligible students screened) was cost-effective, particularly if both males and females participated, resulting in a cost of $500 to $3500 per quality-adjusted life year gained. Wang et al.31 used a decision-analysis model comparing school-based versus non–school-based CT screening in New Orleans SBSS and found that the SBSS program (52.3% of eligible students screened) prevented an estimated 38 cases of pelvic inflammatory disease (PID) and $119,866 in treatment costs, resulting in a net savings of $1524 per case of PID prevented. School-based STD screening costs were presented in 1997 US dollars, with screening, treatment, and program costs estimated at $128.49 per student tested31; a base-case analysis demonstrated that, at an intervention cost of $86,449, the SBSS program detected and treated 159.8 cases of CT ($541 per infected student treated).31 Cost-effectiveness in both studies was due to the projected net reduction in incidence of PID and its sequelae; in both, untreated CT infection was assumed to result in PID approximately 30% of the time (now considered to be closer to 10%).21
Program Science (Published and Unpublished Data)
Although public health program improvement is not a primary focus of the published literature, several articles mentioned aspects of their programs that may be of use to practitioners considering school-based screening programs, including how programs were initiated, capacity of programs, and sustainability of programs. Individuals working in program areas conducting SBSS also offered insights; 3 program areas that have sustained SBSS for more than one consecutive year but have not formally published work on their programs were included in the review (Table 2). These included Washington, DC16; Chicago, IL (S. Tilmon, personal communication, 2014); and Detroit, MI (A. Peterson, personal communication, 2014).
In all jurisdictions, setting up SBSS required lengthy planning and a great deal of community input, both from participating schools and parents. In addition, planners had to take into account the existing local public health laws to structure their programs. Areas of particular concern for the jurisdictions in which SBSS programs were initiated included the legal issues of adolescents' ability to consent for testing without parental consent, adolescents' ability to consent for sexual activity and statutory rape laws, and laws regarding confidentiality of medical information and reporting to the Health Departments. For example, in New Orleans and Michigan, planners had to take into account that written or verbal parental consent was necessary for students younger than 18 years to participate in the program (A. Peterson, personal communication, 2014).7 An excellent overview of necessary steps to consider when deciding whether or not to initiate an SBSS program is informed by several of the reviewed programs and described in a 2005 manual by ETR Associates,37 as well as in guidance for starting such a program in Indian country.38
School-based STD screening program capacity varied by local legal restrictions, financial considerations, and program goals. All programs screened both males and females, ranging from 1201 to 112,228 persons from program initiation to June 2013 (Table 2). All programs except San Francisco were able to find substantial numbers of infected students, with total positivity ranging from 5.4% to 11.2% compared with San Francisco's 1.9%. Health departments in New Orleans, NYC, Philadelphia, San Francisco, and Washington, DC, directly provided treatment teams for in-school treatment, whereas Chicago, Detroit, and New Orleans used SBHC or health department clinics for treatment. Jurisdictions that provided treatment teams for in-school treatment seemed to have slightly higher treatment rates (92.9%–100%) when compared with jurisdictions that used SBHC or a combination of treatment strategies (83.1%–99.0%). NYC, Philadelphia, and Washington, DC, were able to directly provide condoms to students. In NYC and San Francisco, planners took advantage of the explicit legality of EPT for CT in their state and were able to provide adolescents with treatment for their sex partners in this manner (J. Schillinger, personal communication, 2014).10 Washington, DC, was able to offer in-school HIV testing for infected students,16 whereas Philadelphia's agreement with their school district expressly forbade similar testing (M. E. Salmon, personal communication, 2014).
Although by definition, only programs able to sustain themselves for more than 1 school year were included in this review, none of the participating programs were able to completely pay for itself. Funding streams for staff salary, medication, and testing at all locations depended on local and national sources that varied from year to year (J. Schillinger, personal communication, 2014; S. Tilmon, personal communication, 2014; M. E. Salmon, personal communication, 2014).10,16,29 This variability greatly affected the number of schools SBSS programs were able to access at a given time (New Orleans, NYC, Michigan, Chicago) and at times threatened the existence of the program (NYC, Chicago). Alone among programs, Philadelphia, through a data exchange agreement with local Medicaid providers, was able to pay for the cost of testing for most students it tested; however, staffing, medication, and program support were not included in the agreement (M. E. Salmon, personal communication, 2014). In Washington, DC, active and ongoing community involvement proved crucial for implementing and sustaining SBSS.39
What SBSS Programs Can Do: Increase Access to Screening, Cost-Effective Case Finding and Treatment
Although they are work-intensive to establish, SBSS programs are a feasible way to screen large numbers of adolescent girls for CT on an annual basis, as recommended by CDC.19 Moreover, New Orleans SBSS data showed that, in a group of students for whom any programmatic barriers to participation were removed, a majority were shown to test annually.32 School-based STD screening results in substantial case finding in both males and females in most jurisdictions where it has been attempted. In addition, in all SBSS programs that screened males and females, more males than females chose to test, which may be notable given the difficulty of accessing male adolescents for screening outside STD clinics. In the published literature, San Francisco was an exception, with overall CT positivity ranging from only 1.3% to 2.1%9,10 as was rural Pennsylvania, where only 2 CT cases were detected among 51 adolescent girls tested.34 The cause of this is not entirely clear; the authors of the San Francisco studies attribute the difficulty in case finding in their jurisdiction to multiple factors, including low prevalence of lifetime sexual intercourse in their youth.10 In addition, most SBSS programs are able to treat or ensure treatment of most CT/GC cases that are found8,10,11,15,26 and, consequently, may reduce PID and other sequelae of untreated CT/GC infection.40 Due, in large part, to this reduction, available data indicate that SBSS programs are cost-effective.31,36 However, only 2 cost-effectiveness studies specifically focusing on SBSS have been performed, and both assumed that approximately 30% of untreated CT infections will progress to PID. More recent work has demonstrated that a 10% progression to PID might be more appropriate.21,41 Other cost-effectiveness studies of CT screening performed in family planning clinic settings (where screening costs are lower than in SBSS) have demonstrated that CT rates lower than 1.1% to 1.2% were no longer cost-effective,6,42 but notably showed that when age was used to select women and NAATs were used on urine samples, screening was still cost-saving at a prevalence at or greater than 1.1%.6,43 Furthermore, one of these studies suggests that CT screening programs using NAAT only require a treatment rate of more than 11% of infected females to remain cost-saving.6 Given that the age group of those screened in SBSS has the highest CT prevalence and NAA-based testing is always used, it seems reasonable for areas with CT prevalence lower than the 3% threshold suggested by CDC,44 but greater than approximately 1.5%, to consider SBSS as an effective strategy for case finding and treatment, whether or not they have the ability to treat students themselves (Table 3).
What SBSS Programs Cannot Do: Reduction in Prevalence, Increasing Knowledge About STDs
Very few studies examine other aspects of SBSS, but available data suggest that SBSS programs have been unable to reduce prevalence of infection in a sustained manner, either in individual schools or in the adolescents who test as a whole.17,29,35 Longitudinal data from programs (A. Peterson, personal communication, 2014)29,45 and a modeling study36 all demonstrate a temporary decline in percent positivity (proxy measure of prevalence in this cohort) among students during the first 3 to 4 years, with a subsequent rebound to preprogram levels or higher. Interestingly, this pattern of initial decline and subsequent increase in CT cases has also been seen after the implementation of CT control programs on a larger scale in settings outside the United States, such as in Sweden and British Columbia,41,46 and has been attributed to a true increase in prevalence.41 In high schools, it is hypothesized that this rebound in positivity occurs at least in part because the school environment does not exist separately from the larger community—high school students do not only choose their sex partners from their own schools.29,33 Indeed, Philadelphia data demonstrated that adolescents met their partners in their own school less than half of the time.33 Until the proportion of susceptible persons who are screened in the larger community reaches an effective screening rate32,41 and a sufficient number of partners of those who are infected are referred for treatment,47, it seems unrealistic to expect SBSS programs alone to decrease community CT/GC prevalence. Recent unpublished data from the first 4 years of the Michigan SBSS are showing a consistent yearly decline in percent positivity among students in all 5 schools included; it remains to be seen whether or not numbers rebound in this jurisdiction (A. Peterson, personal communication, 2014). Further studies are needed. In addition, SBSS programs do not seem to appreciably increase student knowledge about STDs, at least in a way that results in fewer infections; rather, in the one study that examined it, student knowledge increased most with history of prior infection, indicating that a medical encounter or personal experience with STD was a more effective way of teaching about STD than didactics27 (Table 3).
Other Potential Applications for SBSS Programs: Identification of Risk, Linkage to Care, Dissemination of Other Prevention Strategies
Because they are able to reach large numbers of students, SBSS programs can potentially be used as platforms for other public health interventions or for investigations into perceptions of risk and real risk factors. Two studies investigating student attitudes showed that students who perceived themselves to be at high risk for STD were not significantly more likely to test positive in the SBSS program,28 but that some students harbored real misinformation about their susceptibility to and actual risk of infection.30 Another study showed that a brief interview could be used to predict infection in a cohort of students testing in an SBSS program and, consequently, could be used to identify students who were at high risk for infection.33 If SBSS programs were to be used in such a manner, high-risk students could then be targeted for text message reminders about rescreening (such as in Washington, DC),18 condom use, or other effective risk-reduction interventions.
The small number of studies that have examined sustained SBSS programs across the United States substantially limited the conclusions that could be drawn in this review. In addition, the outcomes of SBSS may not be generalizable to all areas, as 11 of 20 studies were drawn from New Orleans and only 1 very small pilot study was done in a rural area.34 Another limitation of the review is that any costs studied are societal costs, rather than direct costs to public health programs: programs do not treat PID and therefore will not see cost-savings from decreased case numbers. Additional cost studies accounting for CT screening that is paid for by individuals newly insured under the Affordable Care Act should be performed. Other gaps in research include the lack of case-control or prospective cohort studies of PID to see if its incidence (as opposed to the incidence of CT/GC) is indeed affected by SBSS, validation of risk behaviors associated with infection in a jurisdiction at other geographic sites, comparison of treatment rates using different models of treatment, and prospective evaluation of the efficacy of behavioral or other interventions on rates of infection in high-risk students. In addition, other metrics of measuring the success of SBSS, such as number of partners brought to treatment or percentage of infected youth treated via SBSS (as compared with those diagnosed elsewhere), should be evaluated.
In summary, SBSSs are a feasible way of screening and treating large numbers of adolescent girls and males for CT and GC, and are probably effective at reducing PID and other sequelae of infection. Such programs are cost-effective to society as a whole, although they require substantial investment of time and resources from the jurisdictions that perform them. School-based STD screening programs do not seem to decrease prevalence or effectively increase student knowledge of STDs, but may serve as an effective platform for the identification of more high-risk adolescents and/or the dissemination of other public health prevention strategies.
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