Chlamydia and Adolescent - PowerPoint Presentation

Slide1

Chlamydia and Adolescent Patients

Slide2

Objectives

Describe the

epidemiology,

scope,

and risk factors for

Chlamydial

infection in

adolescents

Assess, treat, and prevent

Chlamydial

i

nfection

in adolescent

patients utilizing evidence-based guidelines

Discuss ways to improve current clinical

practice

Provide referrals for care to adolescent patients

Slide3

Adolescent Sexual Behavior

Knowing which questions to ask

Slide4

YRBS 2013 Condom Use

%

of HS Students Who Used a Condom at Last Intercourse

YRBS 2013

Slide5

YRBS Question

U.S.

%

students

ever had sex

46.8%

% students who used a condom at last sex

59.1%

% students

had sex with 4 or more persons

(in lifetime)

15.0%

% students had sex with at least 1 person in last 3 months34.0%

CDC YRBS Data 2013

YRBS 2013:

U.S.

High School Students

Slide6

♀ Sexual Behavior with Opposite-Sex Partners

Age (

yrs

)

Any sex

Vaginal sex

Oral sex

Anal sex

15–19

53%

46%

45%

11%20–2488%85%81%30%

http://www.cdc.gov/nchs/data/nhsr/nhsr036.pdfNSFG 2006-8

Slide7

♂ Sexual Behavior with Opposite-Sex Partners

Age (

yrs

)

Any sex

Vaginal sex

Oral sex

Anal sex

15–19

58%

45%

48%

10%20–2486%82%80%32%

http://www.cdc.gov/nchs/data/nhsr/nhsr036.pdfNSFG 2006-8

Slide8

♂ Sexual Behavior with Same-Sex Partners

Age (

yrs

)

Any sex with

♂

Anal sex with

♂

Oral sex with

♂

15–19

3%

1%2%20–246%3%6%http://www.cdc.gov/nchs/data/nhsr/nhsr036.pdfNSFG 2006-8

Slide9

Adolescents Face Increased Risk for STIs

Slide10

Biological Risk Factors: Females

Adolescent cervix

Lack of immunity from prior infections

Smaller

introitus

Lack of lubrication can lead to dry, traumatic sex

Slide11

Cognitive Risk Factors for STIs in Adolescents

Early adolescence: concrete thinking

Often unable to plan ahead for condoms

Serial monogamy in relationships leading to multiple partners

Personal fable

Unable to judge risk for STIs

“Other people get STIs”

Slide12

Behavioral Risk Factors

Slide13

Risk Factor: Intimate Partner Violence

Teen girls who are abused by male partners are 3× more likely to become infected with an STI/HIV than non-abused girls.

Adolescents rarely self-report dating violence and may not recognize their exposure to dating violence as abuse.

Direct questions (with yes or no answers) may not be effective.

Elizabeth Miller & Rebecca

Levenson

. Hanging out or Hooking Up:

Clinical Guidelines on responding to Adolescent Relationship Abuse

Slide14

Risk Factor: Social/Institutional

Adolescents Not Being Screened and Treated

Lack of Insurance/$ to Pay

Lack of Sex Ed Regarding Risk and Symptoms

Lack of

Transportation

Concerns About Confidentiality

Stigma

Slide15

STI Protective Factors

Peer support for contraception and condoms

Communication with parents about sex

Connection to family

Connection to school and future success

Connection to community organizations

Slide16

Adolescent STI Burden

Why it matters

Slide17

U.S. Preventive Services Task Force: High-Priority

Evidence Gaps

Why focus on STI care and treatment for children, adolescents, and young adults?

USPSTF 4th Annual Report identifies:

Long-term harms of HIV antiretroviral therapy

Interventions to prevent STIs in low-risk adolescents and

high-risk

adolescents

Effectiveness of screening strategies to identify

high-risk adolescents

Slide18

CDC 2013 Report: STIs and Young People

# of

new infections equal among

young

males (49%) and females (51%)

~

20

million

new cases/year:

50

% occur in people ages 15–24

Total

infections

: 110

Million

Direct

medical

costs:

~

$16 billion/year

Slide19

Half of New STIs: Ages 15-24

Slide20

Trends in Chlamydia Infection Among Adolescents

Chlamydia infection increased by an average of 3.3% per year from

2005-2012

for females aged

15-19

Rates decreased slightly, 2012-2013, mostly among females and males aged 15-19

First time that overall

chlamydia

case rates decreased since national reporting began

Rate of chlamydia shows no sign of decline for females aged 20–24

CDC National Health Report. 2005–2013.

2013 CDC STD Surveillance Report

Slide21

68% of all Chlamydia Cases Among 15- to 24-Year-Olds

CDC STD Surveillance Report 2013

Slide22

Chlamydia: Rates by Race/Ethnicity,

United States, 2009-2013

CDC STD Surveillance Report 2013

Slide23

Significant Racial Disparities

Chlamydia rates in 2013:The rate for

blacks

6.4 times the rate among whites

The rate for American Indians/Alaska Natives 3.9 times the rate among whites

The rate for

H

ispanics

2.1 times the rate among whites

The rate for Native Hawaiians/Other Pacific Islanders 3.5 times the rate among whitesThe rate among Asians was lower than the rate among whites

CDC STD Surveillance Report 2013

Slide24

Chlamydia: Rates by State, United States and Outlying Areas,

2013

CDC STD Surveillance Report 2013

Slide25

Who Is Caring for Adolescents?

Slide26

Clinical Care: Female Adolescents

Source: National Ambulatory Medical Care Survey,

2003–6

Hoover et al., J

Adol

Health, 2010

Slide27

Chlamydia: Cases by Reporting Source and Sex, United States, 2004-2013

CDC STD Surveillance Report 2013

Slide28

Chlamydia: Proportion of STD Clinic Patients Testing Positive, 2013

CDC STD Surveillance Report 2013

Slide29

Case: Erica

Erica is a 16-year-old female who presents with dysuria.

What is your initial differential diagnosis?

What additional information do you need?

Slide30

Approach to the Adolescent Key Strategies

Assess developmental levelDiscuss confidentiality with adolescent/parent

Appropriately ensure confidentiality, time alone

Brief risk assessment at most visits

STI screening annually if sexually active

Systems for follow-up of confidential results

Slide31

Assessing Sexual Behavior

Include questions that

direct testing

Slide32

Sexual History: The Five Ps

Partners

Gender(s), Number (three months, lifetime)

Prevention of pregnancy

Contraception, EC

Protection from STIs

Condom use

Practices

Types of sex: anal, vaginal, oral

Past history of STIswww.stdhivtraining.net

Slide33

Prevention Counseling

AAP

Patient-centered, age-appropriate anticipatory guidance

;

Integrate sex

ed

into clinical practice; can

use

educational materials;

Prevention guidance, including abstinence, safer sexual practices, and condoms

ACOG

Counseling for all sexually active individuals

AAFPHigh-intensity behavioral counseling (HIBC)CDC*HIBC; interactive counseling approaches, i.e., client-centered STD/HIV prevention counseling; motivational interviewing; videos and large group presentations to provide information USPSTFIntensive behavioral counseling for all sexually active adolescents and adults at high-STI

risk

Slide34

Erica: Sexual History Results

Several episodes of unprotected sex in the last few weeks with one male partner (her only lifetime)

Not on hormonal contraception but uses condoms most of the time

Engages in oral (giving and receiving) and vaginal sex

No known history of STIs

Slide35

Erica: History of Present Illness Results

Erica tells you she has burning with urination and a “yellowish” discharge. She reports itchiness.

She denies abdominal pain and fever and reports no bumps or lesions.

What is the differential diagnosis?

Slide36

Differential Diagnosis

You observe discharge in the vault but not in the os.

You suspect vaginitis.

What are the causes of vaginitis?

Slide37

Differential Diagnosis

Dysuria

Genital Tract Infection

Vaginitis

Trichomonas

Bacterial

Vaginitis

Candida

Vaginitis

Slide38

Additional Concerns

Because Erica is a sexually active

16-year-old

, she is also at risk for cervicitis.

What are the most common causes of cervicitis?

Chlamydia

Gonorrhea

Slide39

C.T.

Slide40

Chlamydia

Slide41

Chlamydia Symptoms

Heavy

or prolonged menses

Spotting

Dysmenorrhea

Dyspareunia

Vaginal

discharge

Females:

Up to

~80–90%

asymptomatic

Penile discharge Dysuria Males: Up to

90% asymptomatic

Slide42

Clinical Syndromes Caused by C. trachomatis

Local Infection

Complication

Sequelae

Conjunctivitis

Urethritis

Proctitis

Epididymitis

Reiter’s syndrome (rare)

HIV risk

Chronic arthritis (rare)

Conjunctivitis

Urethritis

Cervicitis

Proctitis

Endometritis

Salpingitis

Perihepatitis

Reiter’s syndrome (rare)

HIV risk

Infertility

Ectopic pregnancy

Chronic pelvic pain

Chronic

arthritis (rare)

Conjunctivitis

Pneumonitis

Pharyngitis

Rhinitis

Eye and

lung

infections

Rare

, if any

Males

Females

Infants

Slide43

Non-Gonococcal Urethritis: Mucoid Discharge

Source

: Seattle STD/HIV Prevention Training Center

at

the University of Washington/UW HSCER Slide Bank

Slide44

Swollen or Tender Testicles (epididymitis)

Source

: Seattle STD/HIV Prevention Training

Center at

the University of Washington

Slide45

Normal Cervix

Source

: STD/HIV Prevention Training Center at the

University

of Washington/Claire E.

Stevens

Slide46

Chlamydial Cervicitis

Source

: STD/HIV Prevention Training Center at the

University

of Washington/Connie

Celum

and Walter

Stamm

Slide47

Normal Human Fallopian Tube Tissue

Source

:

Patton, D.L. University of Washington, Seattle, Washington

Slide48

C. trachomatis Infection (PID)

Source

:

Patton, D.L. University of Washington, Seattle, Washington

Slide49

Chlamydia Screening

Slide50

♀ Routine Annual Chlamydia Screening

AAP

all sexually active ≤25 yrs

ACOG

all sexually active adolescents

AAFP

all sexually active

<

24 yrs

CDC*

all sexually active <25 yrs

USPSTF

all sexually active <24 yrs*Draft

Slide51

Chlamydia Screening: Males

Routine Screening NOT recommended for men

Correctional facilities

STI

clinics

Adolescent-serving clinics

MSM

Multiple partners

Selective screening in high-prevalence populations

should be considered

AAFP, CDC, USPSTF, AAP Recommendations

Slide52

USPSTF CT Risk Factors

Age ♀ ages

15-24

years,

♂ ages

20-24

years

New sex partner, >1 sex partner, sex partner w/ STI infection

Inconsistent condom use

H/O or coexisting STIsExchanging sex for money or drugs. Incarcerated populations, military recruits, and patients receiving care at public STI clinics. Racial Disparities:

Blacks and Hispanics higher CT rates vs. whites

Slide53

USPSTF Justification for ♂ CT

♂ CT may cause nongonoccal urethritis, epididymitis, and rarely urethral structures and reactive arthritis

asymptomatic urethritis uncommon

Slide54

MSM Screening: Chlamydia and Gonorrhea

CDC recommends at least yearly urethral and rectal screening for MSMs who, in the last year, have participated in:

Insertive

anal intercourse

Receptive anal intercourse

Receptive oral intercourse (GC only)

Screening is recommended regardless of condom use

For high risk sex behavior, should screen every

3-6

months

Slide55

Women Who Have Sex with Women

Regardless of reported same-sex behavior, providers should consider:

Screening all females for chlamydia and gonorrhea as per recommendations

Offering routine cervical cancer screening and HPV vaccine in accordance with current guidelines.

Slide56

Confidentiality and Billing

Slide57

Confidentiality and Billing

Cannot guarantee confidentiality in many cases

Explanation of benefits (EOB) may be sent by insurance company

Teen patient may request for EOB to be sent to alternative address by health plan

Need to know the “paper trail issues” in your health system

Need to have Plan B for confidential services

www.itsyoursexlife.com/gyt/

Slide58

Explanation of Benefits (EOBs) Medicaid vs. Commercial Insurance

EOBs sent to policyholder or insured in most commercial plans

Some health plans NOT sending EOBs if only copayment due

Medicaid does not routinely send EOBs

EOBs do not disclose service/diagnosis

Parent can obtain that info from health plan

No control over lab bills/statements

Slide59

Chlamydia Tests and Treatment

Slide60

Case: Evaluating Cervicitis

How do you evaluate Erica for cervicitis?

Slide61

Chlamydia Diagnosis

Culture

Sensitivity: 70%

Specificity: 85%–95%

NAAT

Sensitivity: 85%–90%

Specificity: >98%

Preferred

EIA

Sensitivity: 50%–65%

Specificity: >95%

DFA

DNA Probe

Sensitivity: 65%–70%

Specificity: 95%

Sensitivity: 65%–70%

Specificity: 95%

Slide62

NAAT vs. Culture

Schachter

J,et

al.

Sex

Transm

Dis

. 2008;35:

637–42

.

Slide63

Chlamydia NAAT Screening:Preferred Noninvasive Genitourinary Specimens

♀: Vaginal swab

Vaginal swab samples are as sensitive as endocervical swab specimens

Urine samples acceptable

♀urine may have ↓ performance compared to cervical swab samples

♂: Urine

Urethral swab samples may be ↓ sensitive than urine

www.cdc.gov/std/laboratory/2014LabRec/default.htm

Slide64

FDA Clearance

All NAATsUrethral swabs from males

Cervical swabs

Urine from males and females

Certain NAATs

Vaginal swabs

Non-FDA cleared for:

Rectal

Pharyngeal

(Many laboratories have met regulatory CLIA requirements)

Slide65

How to Order Screen

Gen-Probe APTIMA

testing

QUEST diagnostics test codes

LabCorp

diagnostics test

codes

Pharyngeal

70051X

188698

Rectal

16506X

188672Urine/Urethral13363X183194Non-genital GC/CT NAATs can be done by clinical laboratory with CLIA approval

Relevant CPT Billing Codes:CT detection by NAAT: 87491GC detection by NAAT: 87591

Slide66

Chlamydia Treatment

Recommended RegimensAzithromycin 1 g PO single dose

Doxycycline 100 mg PO BID x 7 days

CDC STD Treatment Guidelines. 2010.

Slide67

www.cdc.gov/std/STD-Tx-app.htm

Hey! There’s an App for That!

Slide68

STI Partner Management Strategies

Partners

contacted by index

patient’s

provider or by a disease intervention specialist

Provider Referral

Index

patient assumes primary responsibility to notify and refer his/her partners at risk

Patient Referral

Providers

(1)

give

patient medication intended for the partners (2) write partners’ prescriptions for medication

Expedited Partner Therapy (EPT)

Slide69

CDC Recommends EPT

EPT: Delivery of medications or prescriptions by persons infected with an STD to their sex partners without clinical assessment of the partners.

EPT laws vary by state:

Permitted in 35 states and the city of Baltimore, MD

Prohibited in 6 states (FL, KY, MI, OH, OK, WV)

www.cdc.gov/sTd/ept/legal/default.htm

Heterosexual sex partners should be evaluated, tested, and treated if:

Had sexual contact with patient during or >60 days of symptom onset/diagnosis of chlamydia or gonorrhea

Slide70

Behaviors Affecting EPT Effectiveness

Patient-delivered specific

Patient did not give Rx to

any/all partners

General

noncompliance

Patients did not contact partners

Patients noncompliant with Rx

Resumed sex

<7

days after case and partner treatment

Sex with new partner(s)

Partners noncompliant with Rx

Slide71

EPT Barriers

General theoretical liability issues

Rx without an exam

Medical records for treated partner?

Legal issues with minors

Consent to care

Obligation to report sex in minors with older partners

Financial: who pays for partner Rx?

Adverse

drug effectsPartner may not seek complete STI assessmentPotential to miss partners’ other STIs, including HIVMissed counseling opportunities for partners

Slide72

Repeat Testing After Treatment

Pregnant females

Repeat testing, preferably by NAAT, 3 weeks after completion of recommended therapy

Non-pregnant females

Test of cure not recommended unless:

Compliance

is in question, symptoms persist, or

reinfection

is suspected

Repeat testing recommended 3-4 months after treatmentEspecially adolescents; high prevalence of repeat infection

Slide73

Erica: Wrap-Up

Administer EC and write advanced prescription

HIV test

HPV vaccine

Give appointment to return in 3 months

Slide74

Red Book STI Chapters

http://aapredbook.aappublications.org/

Slide75

Provider Resources: Sexually Transmitted Infections

National Chlamydia Coalition:

ncc.prevent.org

U.S. Centers for Disease Control and Prevention

Statistics and Surveillance Reports:

www.cdc.gov/std/stats/default.htm

Expedited Partner Therapy:

www.cdc.gov/STD/ept/default.htm

Screening & Treatment Guidelines:

www.cdc.gov/std/treatment/2010/default.htm American Social Health Association:www.ashastd.org/std-sti/hpv.html

U.S. Department of Health and Human Services

womenshealth.gov/faq/stdhpv.htmUSPSTF: www.uspreventiveservicestaskforce.org/uspstopics.htmACOG: www.acog.org/Resources-And-Publications

Slide76

Provider Resources and Organizational Partners

www.advocatesforyouth.org

—

Advocates for

Youth

www.aap.org

—

American

Academy of

Pediatricianswww.aclu.org/reproductive-freedom

American Civil Liberties Union Reproductive Freedom Projectwww.acog.org

—

American College of Obstetricians and Gynecologistswww.arhp.org—Association of Reproductive Health Professionalswww.cahl.org—Center for Adolescent Health and the Law www.glma.org Gay and Lesbian Medical Association

Slide77

www.guttmacher.org—

Guttmacher Institute

janefondacenter.emory.edu

Jane Fonda Center at Emory

University

www.msm.edu

Morehouse School of

Medicinewww.prochoiceny.org/projects-campaigns/torch.shtml

NARAL Pro-Choice New York Teen Outreach Reproductive Challenge (TORCH)www.naspag.org

North American Society of Pediatric and Adolescent Gynecologywww.prh.org Physicians for Reproductive HealthProvider Resources and Organizational Partners

Slide78

Provider Resources and Organizational Partners

www.siecus.org

—

Sexuality Information

and

Education Council of the United

States

www.adolescenthealth.org

—

Society for Adolescent Health and Medicine www.plannedparenthood.org

Planned Parenthood Federation of Americawww.reproductiveaccess.org Reproductive Health Access

Project

www.spence-chapin.org Spence-Chapin Adoption Services

Slide79

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