Epidemiology of Chlamydia in the United States Debra J. Mosure, Ph.D. Division of STD Prevention Centers for Disease Control and Prevention March 8, 2004

Genital Chlamydia trachomatis Infections Tremendous burden of infection Estimated annual incidence in 2000: 2.8 million Estimated annual incidence in year olds in 2000 : 1.5 million Estimate annual medical cost: $374.6 million Over 70% of infections asymptomatic Major cause of reproductive health consequences in women

Devastating Consequences Infectious complications Neonatal pneumonia or eye infections in 60-70% of infants born to untreated mothers At least 2-5 fold increased risk of HIV infection chlamydia gonorrhea pelvic inflammatory disease infertility ectopic pregnancy chronic pelvic pain 20-50% 10-40% 20% 9% 18%

Two Components of Chlamydia Surveillance Case Reporting Prevalence Monitoring

Chlamydia — Number of states that require reporting of Chlamydia trachomatis infections: United States, 1987–2002

Chlamydia — Rates by sex: United States, 1984–2002

Chlamydia — Age- and sex-specific rates: United States, 2002

Chlamydia Surveillance Systems Case Reporting Chlamydia Prevalence Monitoring Regional Infertility Prevention Projects Jail Prevalence Monitoring Project

Chlamydia — Trends in positivity among year old women tested in family planning clinics by HHS regions, 1988–2002 Note: Trends adjusted for changes in laboratory test method and associated increases in test sensitivity. No data on laboratory test method available for Region VII in 1995 and Regions IV and V in 1996.

Chlamydia — Positivity among women tested in family planning clinics by age group: Region X, 1988–2002 Note: Women who met screening criteria were tested. Trends not adjusted for changes in laboratory test method and associated increases in test sensitivity in 1994 and 1999–2002.

Chlamydia — Positivity among women tested in family planning clinics by race and ethnicity: Region X, 1988–2002 Note: Women who met screening criteria were tested. Trends not adjusted for changes in laboratory test method and associated increases in test sensitivity in 1994, and 1999–2002.

Chlamydia — Positivity among year old women tested in Indian Health Service Clinics by IHS areas, 2002 *IHS areas not reporting chlamydia positivity data during SOURCE: Indian Health Service

Chlamydia — Positivity in women entering juvenile and adult corrections facilities, 2002 Note: The median positivity is presented from facilities reporting >100 test results. California, Pennsylvania, Massachusetts, and Texas submitted data from more than one adult corrections facility. Arizona, California, Massachusetts, Texas and Washington submitted data from more than one juvenile corrections facility.

Chlamydia — Positivity in men entering juvenile and adult corrections facilities, 2002 Note: The median positivity is presented from facilities reporting >100 test results. Massachusetts submitted data from more than one adult corrections facility. Arizona, California, Illinois, Maryland, Massachusetts, Texas, Utah, Washington and Wisconsin submitted data from more than one juvenile corrections facility.

Chlamydia Surveillance “True” Prevalence

Chlamydia — Prevalence among year-old women entering the National Job Training Program by state of residence, 2002 *Fewer than 100 women residing in these states and entering the National Job Training Program were screened for chlamydia in SOURCE: U.S. Department of Labor

Chlamydia — Prevalence among women and men by age group (NHANES), Females Males

Sexually Transmitted Diseases Laboratory Test Survey Collaboration between the Association of Public Health Laboratories and the Centers for Disease Control and Prevention To collect information about the volume and type of testing for STDs in the U.S.

Laboratory Survey Results Type of Chlamydia Tests in 2000 Type of Test# Tests Done% of all Tests Done DNA Probe - Pace 2C1,382, % DNA Probe - Pace 2808, % LCR749, % EIA430, % TMA190,7224.9% PCR147,6303.8% SDA94,2782.4% DFA56,3441.5% Culture16,9790.4% TOTAL3,877, % Reference: Dicker LW, Mosure DJ, Steece R, Stone K. Laboratory tests used in U.S. Public Health Laboratories for Sexually Transmitted Diseases, Sexually Transmitted Diseases 2004 (in press).

Manufacturer* Survey Results Chlamydia Tests Sold in 2001 Type of TestNo. Sold% of Total Non-NAAT16,815, % NAAT7,258, % TOTAL24,074,068100% *Abbott Laboratories, Becton, Dickinson and Company, Gen-Probe, Incorporated, Roche Diagnostics Corporation, and Wampole Laboratories

Chlamydia Screening Recommendations Centers for Disease Control and U.S. Preventive Services Task Force recommend screening all sexually active females aged years at least annually all sexually active females aged years annually sexually active females > 25 years with risk factors (e.g., new sex partner or multiple sex partners)

What is HEDIS? Health Plan Employer Data and Information Set HEDIS Report Card Performance measurement to assess quality in managed care organizations (MCO’s) 90% of MCO’s report on HEDIS measures

HEDIS Chlamydia* Screening Rates 2002 Private Medicaid * Chlamydia measure: number eligible women receiving chlamydia screening number sexually active women, aged 15 through 25

Chlamydia Screening Coverage for Year Old Women by U.S. Census Region*, 2000 Overall60%55%-66% Midwest70%63%-77% South61%55%-66% West54%48%-60% Northeast49%44%-54% % Coverage90% Credibility Interval Estimates exclude 4 states with >100% coverage Reference: Levine WE, Dicker LW, Devine O, Mosure DJ. Indirect estimation of chlamydia screening coverage using public health surveillance data. American Journal of Epidemiology (in press).

Summary Two components of chlamydia surveillance: case reporting and prevalence monitoring Increase in case reports in men and women from 1984 to 2002 Limitations of case reports to monitor trends in chlamydia: reporting laws and amount of screening Prevalence has declined in areas of the U.S. where large scale screening programs have been implemented Prevalence remains high among persons at risk: women < 20 years and persons entering correctional facilities

Summary Estimated 24 million chlamydia tests sold in % were non-NAATs, 77% sold to private labs Most common types of chlamydia performed in 2000 were DNA probes Managed care plans participating in HEDIS indicate that < 25% of private insured and <40% of women with Medicaid screened 55%-66% of sexually active women years of age in the U.S. were screened in 2000

Chlamydia in the U.S.