1. The burden of repeat Chlamydia trachomatis infection in young women in New York City Klingler E 1, Pathela P 1, Cordova D 1,2, Blank S 1,2, Schillinger J 1,2 1. New York City Department of Health and Mental Hygiene (NYC DOHMH), USA 2. Centers for Disease Control and Prevention (CDC), USA

2. OBJECTIVE To quantify the burden of repeat chlamydial infection in young women in New York City

3. BACKGROUND Repeat C. trachomatis (Ct) infections in women increase the risk for adverse sequelaeRepeat C. trachomatis (Ct) infections in women increase the risk for adverse sequelae CDC recommends re-screening women three to four months after treatment for a Ct infectionCDC recommends re-screening women three to four months after treatment for a Ct infection Large numbers of Ct reported in adolescents and young adult women in NYCLarge numbers of Ct reported in adolescents and young adult women in NYC ~27,000 cases in females reported to NYC Department of Health and Mental Hygiene (DOHMH) in 2005~27,000 cases in females reported to NYC Department of Health and Mental Hygiene (DOHMH) in 2005 17,887 (67%) among women age 15 to 25 years17,887 (67%) among women age 15 to 25 years

4. METHODS Data source: NYC DOHMH Bureau of STD Control (BSTDC) surveillance registryData source: NYC DOHMH Bureau of STD Control (BSTDC) surveillance registry Analytic sample: Women aged 10 to 29 years for whom a case of Ct was reported between January 2000 and June 2005Analytic sample: Women aged 10 to 29 years for whom a case of Ct was reported between January 2000 and June 2005

5. Initial infection:Initial infection: The first infection for a given woman in a year Repeat infection:Repeat infection: A Ct infection > 30 days after a woman’s initial Ct report and within a 12 month follow-up (f/u) period METHODS -DEFINITIONS-

6. Gonorrhea (GC) co-infection:Gonorrhea (GC) co-infection: Gonorrhea infection reported for a woman within ten days of her initial Ct report Private Provider:Private Provider: Any provider working outside the NYC DOHMH BSTDC clinic system

7. METHODS -COHORT DESCRIPTION- We created cohorts of women diagnosed with Ct in a calendar yearWe created cohorts of women diagnosed with Ct in a calendar year 4 years: 2000-20034 years: 2000-2003 We allowed each woman 1 year of f/u time from her initial infectionWe allowed each woman 1 year of f/u time from her initial infection We created a separate cohort of women reported July 2003- June 2004, permitting a full year of f/uWe created a separate cohort of women reported July 2003- June 2004, permitting a full year of f/u

8. METHODS -ANALYSIS- Calculate rates of repeat infectionCalculate rates of repeat infection by year Bivariate analyses to determine predictors of repeat infectionBivariate analyses to determine predictors of repeat infection Covariates investigated: neighborhood of residence, age, provider type, gonorrhea co- infection, and race/ethnicityCovariates investigated: neighborhood of residence, age, provider type, gonorrhea co- infection, and race/ethnicity Multivariate analysis to identify independent predictors of repeat infectionMultivariate analysis to identify independent predictors of repeat infection Included all covariates examined +/- neighborhoodIncluded all covariates examined +/- neighborhood

9. RESULTS Overall, 117,792 cases of Ct in females aged 10-29 years were reported to the NYC DOHMH BSTDC during the 5 ½ year intervalOverall, 117,792 cases of Ct in females aged 10-29 years were reported to the NYC DOHMH BSTDC during the 5 ½ year interval These cases were among 91,979 womenThese cases were among 91,979 women ~ 21% of these women experienced at least one repeat infection~ 21% of these women experienced at least one repeat infection

10. 2000200120022003 July 2003- June 2004 Age (n=17,128)(n=19,283)(n=20,638)(n=21,114)(n=21,142) Overall14%15% 14%13% 10 to 1417%19%16%19%17% 15 to 1917%18%19%18%17% 20 to 2413% 15%12% 25 to 298% 9% 8% Proportion of women with a repeat infection, by age and year of initial Ct diagnosis

11. 2000200120022003 July 2003 - June 2004 median time to reinfection (months)55655 % re-infected by three months32% 27%29% Median time to repeat infection and % re-infected by three months

12. 12% 14% 13% 15% 22% 15% 12% 14% 13% Number of Ct cases reported by year and provider type and proportion of cases with repeat infection

13. 2000200120022003 July 2003 - June 2004 Repeat Infection?YesNo YesNo YesNo YesNo YesNo Age Overall9% 11%9% 8%10%7%9%6% 10 to 1415%17% 16%28%14%18%13% 11% 15 to 1911% 13%11% 10%11%9%12%7% 20 to 248%7%9%8%7% 8%7% 6% 25 to 295%6% 7%5%6%4% Rates of GC co-infection at the initial Ct infection among women with and without repeat infection, by age

14. Bivariate Analysis of Repeat Ct Infections, Race/ethnicity Repeat Infection - YES Repeat Infection - NOP-Value Race/Ethnicityn%n% White26(0.9)256(1.4)<0.0001 Hispanic415(14.8)2111(11.5) Black887(31.6)3704(20.2) Asian/PI14(0.5)175(1.0) Native Am/ AK Native2(0.1)17(0.1) Other25(0.9)174(1.0) Unknown1440(51.3)11896(64.9)

15. Bivariate Analysis of Repeat Ct Infections, Age Repeat Infection - YES Repeat Infection - NOP-Value Agen%n% 10 to 1468(2.4)343(1.9) 15 to 191382(49.2)6734(36.7) 20 to 241036(36.9)7410(40.4) 25 to 29323(11.5)3846(21.0)<0.0001

16. Bivariate Analysis of Repeat Ct Infections, GC co-infection Repeat Infection - YES Repeat Infection - NOP-Value GC Co-infectionn(%)n Yes265(9.4)1135(6.2) No2544(90.6)17198(93.8)<0.0001

17. OR (95% CI)P-Value Race/Ethnicity White1.00 <0.0001 Hispanic1.70 (1.11-2.58) Black2.13 (1.41-3.22) Asian/PI0.83 (0.42-1.63) Native Am/ AK Native1.05 (0.2 -4.81) Other1.45 (0.81-2.61) Unknown1.01 (0.67-1.52) Multi-variate Analysis of Repeat Ct Infections, Race/ethnicity

18. OR (95% CI)P-Value Age 10 to 14 yrs2.15 (1.62-2.87) 15 to 19 yrs2.31 (2.03-2.62) 20 to 24 yrs1.60 (1.40-1.83) 25 to 29 yrs1.00<0.0001 Provider Type Private Provider1.78 (1.51-2.11) City STD Clinic1.00<0.0001 GC Co-infection Yes1.41 (1.22-1.62) No1.00<0.0001 Multi-variate Analysis of Repeat Ct Infections

19. LIMITATIONS We may have classified some persistent infections as repeat infectionsWe may have classified some persistent infections as repeat infections We assumed treatment was given for an initial infectionWe assumed treatment was given for an initial infection Possible bias in who providers decide to re-screenPossible bias in who providers decide to re-screen

20. CONCLUSIONS Repeat infection rates are high among young women in NYCRepeat infection rates are high among young women in NYC Age and GC co-infection at time of initial infection may be used to target women at greatest risk for re-infectionAge and GC co-infection at time of initial infection may be used to target women at greatest risk for re-infection A larger proportion of re-infected women have their initial infection reported by a private providerA larger proportion of re-infected women have their initial infection reported by a private provider

21. THANKS to our entire BSTDC staff for their work in getting this data collected, entered, and analyzed. The findings and conclusions of this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy

24. METHODS -COHORT DESCRIPTION- 2002 A 20002001 AABB

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29. METHODS -COHORT DESCRIPTION- 2002 A 20002001 AABB