1. Universal Screening to Assess Chlamydia Prevalence and Risk Among Older Women Attending Family Planning Clinics in Wisconsin
Roberta (Bobbie) McDonald
Wisconsin State Laboratory of Hygiene, Madison, WI
Region V Infertility Prevention Project
STD Prevention Conference, March 12, 2008 Chicago, IL

2. WI Chlamydia Program History
CT Testing in WI Family Planning clinics since the 1980’s (culture, then EIA/DFA)
Challenges faced in implementing a cohesive screening program
Limited resources available (technology, $)
Little data, no formal recommendations
Diverse population across WI; urban vs. rural
Supporting factors included:
Good relationships between providers, lab & program
Visionary early leadership

3. History of Universal Screening Studies in WI
First ‘Universal Screening’ studies in FP
Established evidence-based screening criteria
Positivity justified continued screening in FP
Universal screening has been revisited in 5-7 year intervals to address:
Changes in test technology and costs
Epidemiology, local data, demographics
National recommendations (age-based)

4. Universal Screening Study Model
Periods of ‘universal’ testing and expanded data collection in a representative subset of family planning clinics
Test results matched with patient and clinician questionnaire data (behavioral, demographic and clinical risk factors)
Often used as an opportunity to examine other program issues (assay performance comparisons, specimen validation, etc.)
Use locally-derived data to establish/ evaluate selective screening criteria

5. History of Universal Screening Studies in WI
Universal screening studies in WI FP:
1985 (rural, CT-DFA, GC culture)
1986 (urban, GC & CT culture, EIA & DFA)
1990 (GC culture, CT EIA/DFA)
(CT-EIA, LCR & PCR)
(SDA, males & females, CT and GC)
Data analysis in these studies led to our ‘risk-first’ approach
In all studies, age was examined as a risk criterion; added as SSC selectively in 2002

6. 2001 Universal Screening Data
8,108 female patients (10 clinics, 7 mos.)
6,572 participants (81%) w/ complete data
4908 (74.7%) age 25 and under
7.7% CT positive overall
87.5% meet SSC, 8.2% CT positive
12.5% of tests outside SSC, 4.4% CT positive
1664 (25.3%) age 26 and over
2.7% CT positive overall
86.5% meet SSC, 2.8% positive
13.5% of tests outside SSC, 1.8% CT positive

7. 2001 Universal Screening Analysis
Order is by decreasing risk ratio of individual criteria, and by increasing sensitivity

8. Milwaukee vs. Non-Milwaukee
Milwaukee
Non-Milwaukee
Cumulative Selective
Patients Meeting Criteria
Chlamydia Positive
Sensitivity
Screening Criteria* # %
(% of All +) 1
STD Contact
106
3.9% 19
17.9%
8.3%
112
3.0% 22
19.6%
11.6% 2
Criterion 1 + Symptoms of STD
1,105
40.8%
137
12.4%
59.8%
1,196
31.5%
101
8.4%
53.2% 3
Criteria 2 + Partner Risk
1,575
58.2%
176
11.2%
76.9%
2,011
53.0%
142
7.1%
74.7% 4
Criteria 3 + History of STD
1,780
65.8%
189
10.6%
82.5%
2,193
57.8%
149
6.8%
78.4% 5
Criteria 4 + Age <19
2,009
74.2%
202
10.1%
88.2%
2,610
68.8%
166
6.4%
87.4% 6
Criteria 5 + Age <23
2,251
83.2%
216
9.6%
94.3%
3,133
82.6%
177
5.6%
93.2% 7
Criteria 6 + Age <26
2,406
88.9%
221
9.2%
96.5%
3,399
89.6%
183
5.4%
96.3% 8
Universal Screening
2,707
100%
229
8.5%
3,795
190
5.0%

9. “Drawing the Line” for SSC
Balance positivity, recommendations, risk factors, and various cost measures with the bottom line program budget
Consider limitations of study (sample size, participation rate, urban bias
State “politics” may also come into play!
SSC must be simple enough to use, and accurate enough that it will be used, while effectively targeting program funds
Translating universal screening study data into meaningful SSC is complex; never as simple as “test where positivity is over 3%”

10. Current SSC in WI FP (2002) SEX PARTNER RISK: All within past 90 days
Patient had more than one partner
Patient had a partner who had more than one partner
Patient had a new partner
CONTACT: within past 90 days
Partner w/ symptoms or diagnosis of CT, GC, NGU, epididymitis, or other STD
SYMPTOMATIC
Current diagnosis of (or evaluation for) gonorrhea
Current diagnosis of or symptoms of PID
Cervicitis - mucopurulent discharge or friable cervix
Cervical erythema greater than 50%
Purulent vaginal discharge
HISTORY of STD (note: NOT “Test of Cure”)
Confirmed or self-reported CT infection in past 5 years
OTHER
Protocol testing: Prior to an IUD insertion
Pregnancy - prenatal visit
SPECIAL AGE CRITERIA
Patients not meeting above criteria, but under a specified age may be tested using contract funds in selected clinics. (<19 semi-urban, <23 Milwaukee)

11. Universal Screening Studies: Impact on Routine
CHLAMYDIA (CT)
*See complete definitions on reverse of last page*
Females
 Sex Partner Risk
 Contact
 Symptomatic
 History of STD (NOT “Test of Cure”)
 Protocol (pre-IUD) Testing
 Prenatal
For AUTHORIZED clinics only:
 Special Age Criteria
Routine testing data re SSC is gathered on the lab form
Contract (IPP) funds available only for tests meeting SSC
Age criteria is assigned to each clinic based on data
Patients tested outside of SSC are selected by clinician for various reasons

12. Universal vs. Routine Screening
2001 Universal Screening Study Females
2001 Universal Screening Study Females
Age distribution quite similar
Reduction in tests over age 25 in 2006 compared to universal (20% of tests vs. 25%)
Alternate funding sources for CT testing play a role
Age
2006 Routine Screening, Females, by Age
2006 Routine Screening, Females, by Age
Age

13. 2006 Routine Testing Data 39,107 female patients (~70 clinics)
31,110 (79.6%) age 25 and under
7.9% CT positive overall
85.8% meet SSC, 8.6% CT positive
14.2% of tests outside SSC, 4.3% CT positive
7997 (20.4%) age 26 and over
3.3% CT positive overall
84.6% meet SSC, 3.6% positive
15.4% of tests outside SSC, 1.9% CT positive

14. 2006 Routine Testing by Age

15. 2006 Routine Screening, Age >25

16. In general, positivity on SSC is about double the off-SSC rate
2006 CT Positivity by Location, Age
In general, positivity on SSC is about double the off-SSC rate
CT positivity in Milwaukee has always been strikingly higher than the rest of WI
Off-SSC CT rates are uniformly low in women over 25 across all of WI!
2006 Positivity by Location, Age, SSC

17. 2008 Universal Screening Study Current Critical Challenges
Always needing to do more with less!
Impact of FP MA waiver (free testing w/o requirement of meeting SSC)
Convince clinicians not to test low-risk older women when there is funding they can access?
Increased emphasis on reducing screening in older women (>25? >30?)
Reducing low-yield off-SSC testing in all age groups

18. 2008 Universal Screening Goals
Increase participation towards “Universal”
Clinic-based (NP) Study Coordinator
Better training for clinic staff, more follow-up
Streamline clinic procedures
Improve questionnaire, simplify questions
Clinicians provided input into potential new criteria questions
Assess specific reasons for off-SSC testing…

19. “Clinician Impression” Questions
Does patient meet current screening criteria?  Yes  No
If NO, would you be inclined to test patient outside criteria?
 Yes  No
If yes, Why? (mark any/all that apply)
risks outside the 3-month timeframe
reliability of history information provided
other reason (specify)______________________________________________
_________________________________________________________
Rate your impression of patient’s overall STD risk from 1 (very low) to 5 (very high):
Rate your impression of patient’s overall health from 1 (very good) to 5 (very poor):

20. Summary: CT Screening in WI Women > 25
Universal screening studies can provide data needed to support use of SSC
WI’s locally-derived SSC identifies women over age 25 at increased risk of CT infection in WI FP
Women over 25 without risk criteria are a small portion of CT tests, with low positivity (=/< 2%), even in high-prevalence areas

21. Lessons from The WI Experience
Using local data to determine SSC may require different criteria for different areas
More complex for the program, more effective
Each clinic has only one set of SSC to follow
Financial incentives can help compliance
Alternate sources of funding can complicate SSC use and the ability to monitor
Provider behavior can be changed, slowly