Acquisition of Chlamydia trachomatis by young women during their first year of military service.

OBJECTIVES: To define the acquisition rate of Chlamydia trachomatis among a cohort of young, nonhealth-care seeking, sexually active women with well-defined exposure periods over a 12-month period. GOAL: The long-term goal is to inform public health practitioners and young women of the risk of reinfection with C. trachomatis and the need for frequent active screening to eliminate asymptomatic infections over time. STUDY DESIGN: Young sexually active female Marine Corps recruits (N = 332), serving as "controls" for an intervention to prevent sexually transmitted infections, were screened for C. trachomatis using nucleic acid amplification tests (treated if positive) at entry (T1). They were rescreened and completed self-report behavioral surveys at 4 weeks (T2) and 9 to 12 months (T3) from recruit training. MAIN OUTCOME MEASURE: The rate of C. trachomatis acquisition during a contiguous 12-month period. RESULTS: Based on microbiologic laboratory testing alone, the acquisition rate for C. trachomatis was 3.6% (T2) and 9.9% (T3) yielding a total of 13.0%. The self-reported acquisition rate for the period since graduation from recruit training was 8.1% yielding a total acquisition rate of 19.9%. CONCLUSIONS: The acquisition rate among this cohort of nonhealth-care seeking young women, who have universal health care access is as high or higher than most clinic-based studies, suggesting the need for increased implementation of active screening in primary, urgent, and nonclinic settings.

Chlamydial screening in urgent care visits: adolescent-reported acceptability associated with adolescent perception of clinician communication.

OBJECTIVE: To examine the association between adolescents' perception of clinician communication and adolescents' reported acceptability of the steps involved in chlamydial screening during urgent care visits. DESIGN: Cross-sectional survey of adolescents after urgent care visits. SETTING: Four pediatric clinics in a health maintenance organization. PARTICIPANTS: Three hundred sixty-five adolescents aged 13 to 18 years. OUTCOME MEASURES: Participants' ratings of the acceptability of talking about sexual health and providing a urine sample for chlamydial testing in an urgent care visit. RESULTS: Most adolescents found sexual health discussions and urine collection for chlamydial screening acceptable in the urgent care setting (84% and 80%, respectively). Acceptability of sexual health discussion was significantly associated with adolescents' perception that the clinician explained confidentiality (adjusted odds ratio [AOR], 2.7; 95% confidence interval [CI], 1.3-5.5), knew "how to talk to teens like me" (AOR, 9.0; 95% CI, 3.5-24.2), and "listened carefully as I explained my concerns" (AOR, 14.3; 95% CI, 4.3-54.9). Acceptability of providing a urine sample for chlamydial testing was associated with the adolescents' perception that the clinician knew "how to talk to teens like me" (AOR, 3.7; 95% CI, 1.5-9.3) and "listened carefully as I explained my concerns" (AOR, 3.6; 95% CI, 1.1-11.5). CONCLUSIONS: Sexual history taking and urine collection are 2 key components of chlamydial screening and were reported as acceptable by the great majority of adolescents in the urgent care setting. Aspects of clinician communication appear to be important target areas for pediatric clinician education in supporting expansion of chlamydial screening to adolescents in urgent care visits.

Sexual behaviors after universal screening of sexually transmitted infections in healthy young women.

OBJECTIVE: To prospectively study the relationship between diagnosis of sexually transmitted infections (STIs) at entry to U.S. Marines recruit training and subsequent sexual behaviors during vacation. METHODS: Of all women entering recruit training (June 1999-June 2000), 2,157 (94%) voluntarily enrolled. At baseline, women received universal screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis and treatment and counseling for positive STIs. Recruit training (13 weeks) precluded any social activities. Unrestricted vacation followed (median 10 days). After training resumed (3 weeks), questionnaires and repeat STI screening were administered. Multivariable logistic regression examined STI diagnosis at baseline as a predictor for risky sexual behaviors at vacation and STI-positive diagnosis after vacation. RESULTS: The study was completed by 1,712 (79%) women (median age 18 years); 1,038 reported sexual activity during vacation; 71% used condoms inconsistently; 19% had casual partners. At baseline, 152 (15%) tested STI-positive. Baseline STI diagnosis was unrelated to inconsistent condom use, nonmonogamous partnerships, or multiple partnerships. However, women testing STI-positive at baseline were more likely to test STI-positive after vacation (adjusted odds ratio 3.74, 95% confidence interval 2.10-6.65). Baseline STI diagnosis predicted casual partnerships among women aged 19-21 years (adjusted odds ratio 2.48, 95% confidence interval 1.12-5.50). CONCLUSION: Substantial numbers of women engaged in risky sexual behaviors after universal STI screening and counseling. Compared with STI-negative women, STI-positive women were at increased risk for subsequent STI acquisition regardless of their similar behaviors. As universal STI screening is increasingly implemented, follow-up care will likely be required to further reduce risky behaviors and address network-level factors. LEVEL OF EVIDENCE: II.

Sociodemographic markers and behavioral correlates of sexually transmitted infections in a nonclinical sample of adolescent and young adult women.

BACKGROUND: We examined sociodemographic markers and 3-month behavioral correlates of sexually transmitted infections (STIs) in a nonclinical cross-section of adolescent and young adult women. METHODS: All women (N=2288) enrolled in recruit training for the US Marine Corps during a 1-year period were asked to voluntarily participate in either a cognitive-behavioral, skills-building intervention to prevent STIs and unintended pregnancies or a nutrition and fitness program. Participants (94.2%) completed a self-administered questionnaire and were screened for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis infection. The present study presents only the baseline data from the larger study. RESULTS: One or more STIs was diagnosed in 14.1% of participants. Results of a logistic-regression model indicated that the presence of an STI at screening was significantly (Por=2 years), frequency of hormonal contraceptive use (never and sometimes), perception that their sex partners had other concurrent sex partners, and the race or ethnicity of their last sex partner (African American and Native American). CONCLUSIONS: The high prevalence of STIs in this nonclinical sample of young women suggests the need for ongoing screening and prevention interventions that target young, healthy, sexually active women.

Examination of the treatment and follow-up care for adolescents who test positive for Chlamydia trachomatis infection.

OBJECTIVE: To document the comprehensive management of Chlamydia trachomatis infections in sexually active 14- to 19-year-old adolescents. DESIGN: A chart review of both paper and electronic records to examine documentation of treatment and follow-up of adolescents who tested positive for C. trachomatis infection. SETTING: Five pediatric clinics of a large northern California health maintenance organization. PARTICIPANTS: Consecutive sample of 122 adolescent girls and boys aged 14 to 19 years who tested positive for C. trachomatis infection beginning May 1, 2001, for 20-month (4 sites) or 4-month (1 site) study periods. MAIN OUTCOME MEASURES: Antibiotic treatment, counseling regarding safer sex, management of patients' partners, screening for other sexually transmitted infections, and retesting for C. trachomatis infection. RESULTS: The median age of participants was 16.9 years. All but 4 teenagers (97%) were treated with appropriate antibiotics. During follow-up, safer-sex counseling was documented for 79% of the patients. Partner management was addressed for 52% of the patients. Only 36% of the patients were tested for other sexually transmitted infections, and 10% received C. trachomatis retesting during the Centers for Disease Control and Prevention-recommended time frame of 3 to 12 months after treatment. Significantly fewer boys than girls received safer-sex counseling (P = .02) and partner management (P = .02). CONCLUSIONS: Most teenagers received appropriate antibiotics, but fewer received other recommended care. The current study highlights important "missed-opportunity" clinical encounters for counseling to address high-risk behaviors, management of partners, detection of other sexually transmitted infections, and retesting for reinfections. Systems to address these gaps in care should be incorporated into the clinical management of adolescents infected with C. trachomatis.

Screening sexually active adolescents for Chlamydia trachomatis: what about the boys?

OBJECTIVES: We sought to determine the effectiveness of a systems-based intervention designed to increase Chlamydia trachomatis (CT) screening among adolescent boys. METHODS: An intervention aimed at increasing CT screening among adolescent girls was extended to adolescent boys (14-18 years). Ten pediatric clinics in a health maintenance organization with an ethnically diverse population were randomized. Experimental clinics participated in a clinical practice improvement intervention; control clinics received traditional information on screening. RESULTS: The intervention significantly increased CT screening at the experimental sites from 0% (baseline) to 60% (18-month posttest); control sites evidenced a change only from 0% to 5%. The overall prevalence of CT was 4%. CONCLUSIONS: Although routine CT screening is currently recommended only for young sexually active women, the present results show that screening interventions can be successful in the case of adolescent boys, among whom CT is a moderate problem.

Home STI testing: the adolescent female's opinion.

PURPOSE: To assess sexually active adolescent females' attitudes of home tests for sexually transmitted infections. METHODS: This study represents a follow-up to a study on adolescent attitudes toward different sampling methods for STI testing. In the initial study participants completed a pre-examination health survey, provided first void urine (FVU) and self-collected vaginal swab samples followed by a pelvic examination with STI screening by endocervical swabs. Participants' attitudes about the three collection techniques were assessed at the end of the visit. For the current study, this same group of ethnically diverse adolescents (13-20-years-old) was contacted by telephone 9 months after their initial clinic visit to re-assess their attitudes about the three specimen collection techniques and to evaluate their attitudes regarding the use of home STI testing. Friedman tests of mean ranks evaluated teens' rankings of STI sampling methods and multivariate regression analysis was used to identify predictors of home test preference. RESULTS: Home urine testing was the first choice for STI screening followed by the FVU, self-obtained vaginal swab and endocervical swab collected in a clinical setting. FVU was preferred to self-collected vaginal swabs (p = .01). Adolescents who worried about having an STI were more likely to favor home urine testing (OR 5.5, p = .01). Only 22% would seek any STI screening if asymptomatic. CONCLUSIONS: Because young women preferred home STI testing, this may be an additional option, as the foundation for such testing kits has progressed. Adolescent preferences may be heavily influenced by the pelvic examination experience. Because of the largely asymptomatic nature of CT infections, multiple screening options (clinical and home-based) need to be available to increase access to care.

Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls.

CONTEXT: Chlamydia trachomatis infection is a serious public health concern that disproportionately affects adolescent girls. Although annual C trachomatis screening of sexually active adolescent girls is recommended by health professional organizations and is a Health Employer Data and Information Set (HEDIS) performance measure, this goal is not being met. OBJECTIVE: To test the effectiveness of a system-level, clinical practice improvement intervention designed to increase C trachomatis screening by using urine-based tests for sexually active adolescent girls identified during their routine checkups at a pediatric clinic. DESIGN, SETTING, AND PARTICIPANTS: A randomized cluster of 10 pediatric clinics in the Kaiser Permanente of Northern California health maintenance organization, where adolescent girls aged 14 to 18 years had a total of 7920 routine checkup visits from April 2000 through March 2002. INTERVENTION: Five clinics were randomly assigned to provide usual care and 5 to provide the intervention, which required that leadership be engaged by showing the gap between best practice and current practice; a team be assembled to champion the project; barriers be identified and solutions developed through monthly meetings; and progress be monitored with site-specific screening proportions. MAIN OUTCOME MEASURE: Chlamydia trachomatis screening rate for sexually active 14- to 18-year-old girls during routine checkups at each participating clinic. RESULTS: The population of adolescents was ethnically diverse with an average age of 15.4 years. Twenty-four percent of girls in the experimental clinics and 23% in the control clinics were sexually active. Of the 1017 patients eligible for screening in the intervention clinic, 478 (47%) were screened; of 1194 eligible for screening in the control clinic, 203 (17%) were screened. At baseline, the proportion screened was 0.05 (95% confidence interval [CI], 0.00-0.17) in the intervention and 0.14 (95% CI, 0.01-0.26) in the control clinics. By months 16 to 18, screening rates were 0.65 (95% CI, 0.53-0.77) in the intervention and 0.21 (95% CI, 0.09-0.33) in the control clinics (time period by study group interaction, F(6,60) = 5.33; P<.001). The average infection rate for the experimental clinics was 5.8% (23 positive test results out of 393 total urine tests and a total of 3986 clinic visits) vs 7.6% in controls (12 positive test results out of 157 tests and 3934 clinic visits). CONCLUSIONS: Implementation of this clinical practice intervention in a large health maintenance organization system is feasible, and it significantly increased the C trachomatis screening rates for sexually active adolescent girls during routine checkups.