1. Chlamydia Screening and Treatment in Philadelphia Prison: Did it Impact Community Chlamydia Rates?
Martin Goldberg1, Daniel R. Newman2, TA Peterman2,
M Salmon1, G Anschuetz1, CL Satterwhite2,
CV Spain1, A Zaidi2, L Grier2, S Berman2
1 Philadelphia Department of Public Health, Philadelphia, PA
2 CDC, Atlanta, GA
National STD Conference 2008
Chicago, IL

2. Background
Screening sexually-active women aged <25 years for chlamydia is recommended, but no similar recommendation exists for males.
June 2007: “... the USPSTF noted that screening for chlamydial infection in men may be beneficial if it were to lead to a decreased incidence of chlamydial infection in women. The USPSTF did not, however, find evidence to support this outcome... benefits of screening men are unknown... a critical gap in the evidence.”
Since 2000, Philadelphia has expanded screening programs to include high-risk males.

3. Reported Cases of Chlamydia: Philadelphia, 1991-2007
Year
Number of cases
*Chlamydia reportable as of October 1991
Infertility Prevention Project (IPP)
Data analysis: High re-infection rates in women
Increasingly sensitive laboratory technologies
Youth Study Center
Adult
prisons
Citywide HS screening & 5 HRC
2000 – 2004
New surveillance programs
2 HRC (HS)
Family Court *

4. Temporal Association between Increased City-wide CT Screening and Changes in Rates, by Gender, Philadelphia, PA
Number Tested
Percent Positive
Year

5. Background
From , Chlamydia positivity in females seen in Family Planning Clinics (FPCs) declined.
Can this decline be associated with the expansion of screening to incarcerated males in the Philadelphia prison?

6. Objective
To determine if screening and treating men aged years in prison has affected FPC chlamydia positivity rates in females aged years residing in the prisoners’ home ZIP codes.

7. Methods
Using census and screening data, we created a ratio for each ZIP code in Philadelphia County.
From among those males aged 20-24, the ratio was computed as follows:
Average annual # treated for Chlamydia [prison screening program]
# males residing in each ZIP code
Three groups formed:
“High-positivity” (18 ZIPs)
“Average-positivity” – DISCARDED FOR ANALYSIS
“Low-positivity” (18 ZIPs)
We compared changes in chlamydia positivity for women aged years attending FPCs city-wide from these two ZIP code groups.

8. Methods
We measured positivity changes for females in FPCs before ( ) and after ( ) the prison screening program began from the “High” and “Low” areas.
Prison screening began during the 2nd Quarter, 2002.

10. Results
Of 23,203 males aged years residing in the 18 identified “High-positivity” ZIP codes, 1,054 (4.54%) were treated for chlamydia from through the prison screening program ~1.5% (351/23,203) per year
Of 21,057 males aged years residing in the 18 “Low-positivity” ZIP codes, 98 (0.47%) were treated for chlamydia from through the prison screening program ~0.16% (33/21,057) per year.

11. Results Females Aged 20-24 FPC Data
Chlamydia screening remained relatively stable from 1999 through 2004 for this population (~ 11,500 tests per year).
In the 18 “High-Positivity” ZIP codes:
Prior to screening males in prison, chlamydia positivity in FPCs declined 18.2% from 10.6% in 1999 to 8.7% in 2001.
By 2004, positivity had fallen to 7.4%, a 14.6% (~total of 90 cases) decline from the start of the men’s prison screening program.
In the 18 “Low-Positivity” ZIP codes:
Prior to screening males in prison, chlamydia positivity in FPCs declined 26.5% from 7.3%in 1999 to 5.4% in 2001.
By 2004, positivity had fallen to 4.2%, a 22.5% (~total of 15 cases) decline from the start of the men’s prison screening program.

12. Chlamydia positivity among “High/Low Positivity” ZIP codes for females aged attending Family Planning Clinics
Chlamydia positivity (%)
5th yr IPP
YSC
Adult Prison HS
Family Court
Year screening
programs began
Year

13. Conclusions
Largest female chlamydia positivity reductions occurred PRIOR to the implementation of the prison screening program
Despite a large number of males in prison being tested and treated for Chlamydia, we were unable to directly associate the continued decline in female positivity in FPCs for this age group to the prison screening program.
However, prisons remain as institutions where large numbers of infections can be found and treated
During this study period, 4,318 males were tested and treated through the prison program % (4,318/ 14,434) of city-wide male reported morbidity came from our prisons ( )!

14. Limitations
By limiting this analysis to year old males, we included only 26.7% (1,152) of the 4,318 males testing positive ( ) in adult prison.
Men aged years may not be having sex with women of the same age and/or women from their home ZIP codes.
Female partners of incarcerated men may not be seeking health care in FPCs.
The methods used for analysis may not have been robust enough to detect a difference.

15. DO NOT DESPAIR! Prison screening is a good thing!
Our inability to detect an association between screening males in prison and a decrease in female positivity should not be viewed as a reason not to screen!
Prison testing is a significant part of our citywide screening program
Represents 50% of our annual male screening
Testing of males in Philadelphia has been associated with a reduction in hospitalized PID; ectopic pregnancy cases have also declined.

16. Multivariable Regression Analysis (R2=0.93)
Temporal Association Between Increased CT Screening and Hospitalized PID in Philadelphia,
Year
# Screening Tests Performed
# PID Cases
Multivariable Regression Analysis (R2=0.93)
For every 10,000 females tested, we prevent 35.8 cases of hosp. PID
For every 10,000 females and 10,000 males tested, we prevent 59.3 cases of hosp. PID
p-value <0.001

17. Implications for Programs, Policy and/or Research
Serious research on the impact of screening and treating high-risk males on the community, including long term sequelae for females, needs to be done!

18. THANK YOU!
Disclaimer
The findings and conclusion in this presentation have not formally been disseminated by the Centers for Disease Control and Prevention. It does not represent and should not be construed to represent any agency determination and policy.