Chlamydial Infections in the U.S.

Steven J Shapiro

CCID/NCSHHSTP/DSTDP/PTB

Region I Infertility Prevention Project Wells Beach, Maine

June 2, 2009

Disclaimer: The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Outline...

2007 Surveillance Report and Chlamydia Supplement

NHANES Behavioral Risk Data

2007 Surveillance Report and Chlamydia Supplement

Interpretation Challenges

Increases in lab test sensitivity Underdetection, underreporting

2000 estimate: 2.8 million cases 2000 case reports: 709,452

Different screening rates Application of screening criteria varies

CDC: Screen all sexually-active women <26 years annually

Rate (per 100,000 population)

MenWomenTotal

0

120

240

360

480

600

1988 90 92 94 96 98 2000 02 04 06

Chlamydia — Rates by Sex: United States, 1988–2007

543.6

190.0

Total cases reported in 2007: 1,108,374

CT screening demonstrationproject (Region X)

Program expansion

All 50 reportNotifiable

Rate (per 100,000 population)

American Indian/AK NativeAsian/Pacific IslanderBlackHispanicWhite

0

340

680

1020

1360

1700

1998 99 2000 01 02 03 04 05 06 07

Chlamydia — Rates by Race/Ethnicity: United States, 1998–2007

1398.7

162.3

Men Rate (per 100,000 population) Women

Age3250 2600 1950 1300 650 0 0 650 1300 1950 2600 3250

11.8 123.010-14615.0 3004.715-19

932.9 2948.820-24518.6 1184.525-29

246.8 460.530-34129.9 188.135-3971.4 76.540-4432.3 28.545-5410.1 8.055-642.7 1.865+

190.4 544.8Total

Chlamydia — Age- and Sex-specific Rates: United States, 2007

Chlamydia — Cases by Reporting Source and Sex: United States, 1998–2007

Cases (in thousands)

non-STD Clinic Malenon-STD Clinic FemaleSTD Clinic MaleSTD Clinic Female

0

150

300

450

600

750

1998 99 2000 01 02 03 04 05 06 07

IPP Data

Reported Chlamydia Test* Volume: Infertility Prevention Program, 2001 - 2006

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

2001 2002 2003 2004 2005 2006 2007

*Positive and negative test results only.

Chlamydia — Trends in nucleic acid amplification test (NAAT) usage among 15- to 24-year-old women tested in family planning clinics

by HHS region, 2003–2007

SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

Region I

Percent

020406080

100

03 04 05 06 07Region II

Percent

020406080

100

03 04 05 06 07Region III

Percent

020406080

100

03 04 05 06 07Region IV

Percent

020406080

100

03 04 05 06 07

Region V

Percent

020406080

100

03 04 05 06 07Region VI

Percent

020406080

100

03 04 05 06 07Region VII

Percent

020406080

100

03 04 05 06 07Region VIII

Percent

020406080

100

03 04 05 06 07

Region IX

Percent

020406080

100

03 04 05 06 07Region X

Percent

020406080

100

03 04 05 06 07

Chlamydia — Positivity among 15- to 24-year-old women tested in family planning clinics by state:

United States and outlying areas, 2007

*Data not available in 2007.Note: Includes states and outlying areas that reported chlamydia positivity data on at least 500 women aged 15-24 years screened during 2007.

SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

Positivity (%)

Puerto Rico 7.7

Virgin Is. 16.8

See*

<5.0

5.0-9.9

>=10.0

(n= 1)

(n= 6)

(n= 39)

(n= 7)

VT 3.5NH 3.8MA 4.5RI 5.7CT 6.8NJ 7.7DE 6.4MD 5.7DC

12.7

5.2

8.3 8.2

6.2 6.9

8.3

12.3

8.4

5.4

7.2 8.0

5.8

6.45.0

8.1

6.1

7.2

6.1

13.8

7.2

5.7

6.96.9

8.3

4.8

7.8

8.0

8.0

6.9

4.7

5.3

11.3

6.5

6.5

13.8

12.87.5

7.1

2.9

8.26.1

Chlamydia — Trends in positivity among 15- to 24-year-old women tested in family planning

clinics by HHS region, 2003–2007

SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

Region I

Region II

Region III

Region IV

Region V

Region VIRegion VII

Region VIII

Region IX

Region X

4.7

03

4.6

04

4.7

05

4.7

06

4.8

07

7.4

03

7.1

04

5.7

05

5.6

06

5.9

07

5.6

03

6.0

04

5.8

05

5.4

06

5.5

07

6.2

03

8.4

04

8.8

05

9.0

06

9.6

07

7.3

03

7.5

04

7.7

05

7.6

06

7.6

07

7.3

03

7.4

04

7.4

05

7.9

06

8.8

07

5.5

03

5.8

04

5.8

05

6.5

06

6.5

07

5.9

03

6.3

04

6.3

05

7.2

06

7.3

07

6.5

03

6.7

04

6.4

05

6.8

06

7.3

07

5.8

03

5.9

04

5.6

05

5.7

06

5.8

07

IV

VIIIX

IIIX

III

VI

VVIII

Median state-specific positivity rate

0

2

4

6

8

10

1997 98 99 2000 01 02 03 04 05 06 07

Chlamydia — Median State-specific Positivity Among 15-24 Year-old Women Tested in Family

Planning Clinics, 1997–2007

Note: As of 1997, all 10 Health and Human Services (HHS) regions, representing all 50 states, the District of Columbia, and outlying areas, reported chlamydia positivity data.

SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

6.9%↓

(2.9-16.8)5.1%

↓

(2.0-11.2)

Trends in Chlamydia Population Prevalence in the US, 1999-2006

Results from the National Health and Nutrition Examination Survey (NHANES)

Datta, S. Deblina; Sternberg M, Satterwhite CL, Johnson R, Papp J, McQuillan G, Berman S, Weinstock H

Introduction

First analysis of national CT trend data from 1999-2006 using population based data collected from participants aged 14-39 years of the National Health and Nutrition Examination Survey (NHANES), a representative sample of the U.S civilian, non-institutionalized population

Figure 1. Chlamydia trachomatis Prevalence Estimates and 95% CI in 2 Year Intervals, NHANES 1999-2006

0

1

2

3

1999-2000 (n=3145) 2001-2002 (n=3487) 2003-2004 (n=3211) 2005-2006 (n=3375)

Years Sampled

Pre

vale

nce

(%)

p value for overall homogeneity=0.05

1999-2002 (n=6632) 2003-2006 (n=6586)Prevalence (95%CI) Prevalence (95%CI) p-value

Total 2.2 (1.8-2.8) 1.7 (1.3-2.2) 0.11

Gender Male 2.0 (1.6-2.5) 1.4 (1.0-2.0) 0.08 Female 2.5 (1.8-3.4) 2.0(1.5-2.8) 0.37

Age Group (years) 14-19 3.4 (2.8-4.2) 2.3 (1.6-3.3) 0.04 20-29 2.5 (1.9-3.4) 2.2 (1.4-3.3) 0.55 30-39 1.3 (0.7-2.4) 0.9 (0.6-1.3) 0.36

Racial/Ethnic Group Non-Hispanic White 1.5 (1.0-2.4) 1.0 (0.7-1.5) 0.17 Non-Hispanic Black 6.3 (5.4-7.5) 5.2 (3.6-7.3) 0.26 Mexican-Americans 3.1 (2.3-4.2) 1.7 (1.0-2.9) 0.03

Table 1. Chlamydia Prevalence Estimates and Chi-squre Test by 4-Year Intervals in NHANES, 1999-2006

Summary

Decreases observed in overall CT prevalence during this time period but not at a statistically significant level

Statistically significant decreasing trends observed in some subgroups

14-19 year olds experienced decreasing trend in CT; this is a group that has previously been identified as the age group with highest CT prevalence; it is also a group targeted for routine CT screening

Mexican-Americans experienced decreasing trend in CT Non-Hispanic Blacks had highest prevalence of any

racial/ethnic group over this period and did not experience statistically significant declines

Regional Behavioral Risk Data

Who collects What?

How is it Used?

Behavioral Risk Factor Regions

Condom at last sex I and X

Consistent Condom Use- 12 months I

Douching last 30 days IX

New Sex Partner 60 or 90 days All but II, III, V

Number of Sex Partners last 30 days IX

No Sex I

Multiple Sex Partners NS, 60 or 90 All but II, III, V

Exposed to Chlamydia IX

Risk History II

Symptomatic Sex Partner VI and X

Monogomous Sex Partner VI

Partner with other Partners IX and X

Uses of Behavioral Risk Data

Limited regional uses Region IX

establish screening criteria and notable risk factors

Region X Informed development of the

selective screening criteria No other regional uses; if used at

individual state level

Questions?