Evaluating Efforts to Increase Testing for Repeat Chlamydia

Infection Among Women in California Family Planning

ClinicsRenee Gindi1, Heidi Bauer2, Joan

Chow2, Melanie Deal1

1 California Family Health Council, Berkeley, CA 2 California Sexually

Transmitted Disease Control Branch, Berkeley, CA

Background

• Repeat chlamydial infection can lead to increased risk of sequelae

• Studies estimate that >10% of women with chlamydia are re-infected within 4 months

• Most repeat infections are due to re-infection from untreated partner

• CDC Guidelines– Clinicians should consider advising all [non-

pregnant] women with chlamydial infection to be re-screened 3-4 months after treatment.

Study Objectives

• Estimate the baseline re-screening rate in selected California family planning clinics

• Promote the CDC guidelines and re-screening recommendations to family planning clinic staff

• Evaluate re-screening rates before and after the release of the CDC guidelines

Methods: Data• Line-listed chlamydia test data from 1999-2003 at 13

family planning clinics• Defining “re-screening”

– Second test between 3-4 months– Second test between 1-6 months

• Excludes:– Males– Initial positive tests after July 1, 2003– Cases re-screened within 30 days

• Statistical analysis– Trends– Grouped by pre/post-guidelines release

Methods: Guideline Promotion• May 2002: CDC STD Treatment Guidelines

released• May 2002: CFHC e-mail to 250 clinics • June 2002: CIPP memo to 250 clinics• Nov 2002: guidance document distribution

to 19 agencies at conference• Apr 2003: guidance document distribution

to 31 agencies at conference

Results: Study Population64,652 tests between Jan 1999-Jun 2003

3,149 positive tests(4.8%)

2,953 (unique) women with a positive test

1,282 women with a second test (50%)

651 women with a second test between 1-6 mo(22%)

134 women with a second test between 3-4 mo(4.5%)

Rates of re-screening within 3-4 months

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Jan-Jun1999

Jul-Dec1999

Jan-Jun2000

Jul-Dec2000

Jan-Jun2001

Jul-Dec2001

Jan-Jun2002

Jul-Dec2002

Jan-Jun2003

GUIDELINES

3.65% 6.19%

3.48% 5.97%

Rates of re-screening within 1-6 months

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

May 1999-2000 May 2000-2001 May 2001-2002 May 2002-2003

GUIDELINES

19.8%

22.8%

Distribution of time to re-screen among those

re-screened within 6 months

0%

20%

40%

60%

80%

100%

Jan-Jun1999

Jul-Dec1999

Jan-Jun2000

Jul-Dec2000

Jan-Jun2001

Jul-Dec2001

Jan-Jun2002

Jul-Dec2002

Jan-Jun2003

5-6 mo

3-4 mo

1-2 mo

<1 mo

Distribution of time to re-screen among those

re-screened within 6 months

0%

20%

40%

60%

80%

100%

Jan-Jun1999

Jul-Dec1999

Jan-Jun2000

Jul-Dec2000

Jan-Jun2001

Jul-Dec2001

Jan-Jun2002

Jul-Dec2002

Jan-Jun2003

5-6 mo

3-4 mo

1-2 mo

<1 mo

14%

25%

Median time to re-screen among those re-screened

within 6 months

0102030405060708090

100

Jan-Jun1999

Jul-Dec1999

Jan-Jun2000

Jul-Dec2000

Jan-Jun2001

Jul-Dec2001

Jan-Jun2002

Jul-Dec2002

Jan-Jun2003

Med

ian

day

s to

re-

scre

en

Median=76 days

Median=90 days

Discussion• Overall rates of re-screening remain low

– 4.5% within 3-4 months – 22% within 1-6 months

• Increase in re-screening between 3-4 months– Statistical significance varied based on mode

of analysis– Guideline promotion may have lengthened

the time to re-screening

Limitations: Data• Secondary data

– Did not collect “chlamydia re-test” as reason for visit

• Test date used as approximation for treatment date

• Short observational period– 12 months after CDC guidelines released

• Data from LA and SF not included

Limitations: Intervention• Distributed entire CDC STD

Treatment Guidelines document

• Targeted guidance documents highlighted other chlamydia screening practices in addition to re-screening

Next Steps

• Performance measures for providers and clinics

• Give feedback to providers and clinics

• Eliminate financial barriers to re-screening

• Educate clients about risks of re-infection

• Make re-screening more convenient for clients

• Increase emphasis on partner management

Q&A

Additional Materials

Repeat infection rates

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

1999 2000 2001 2002 2003

Rates of select contraceptive method use

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Jul-Dec 2001 Jan-Jun2002

Jul-Dec 2002 Jan-Jun2003

Jun-Dec2003

OCPs

Depo Provera

Rates of re-screening within 1-6 months

by half-year

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Jan-Jun1999

Jul-Dec1999

Jan-Jun2000

Jul-Dec2000

Jan-Jun2001

Jul-Dec2001

Jan-Jun2002

Jul-Dec2002

Jan-Jun2003

Rates of Test of Cure

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

Jan-Jun1999

Jul-Dec1999

Jan-Jun2000

Jul-Dec2000

Jan-Jun2001

Jul-Dec2001

Jan-Jun2002

Jul-Dec2002

Jan-Jun2003