Chlamydia, Gonorrhea, Disparities: A National Perspective (anything else?) Catherine Lindsey Satterwhite Region IV IPP Meeting October 8, 2009

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1 Chlamydia, Gonorrhea, Disparities: A National Perspective (anything else?) Catherine Lindsey Satterwhite Region IV IPP Meeting October 8, 29

2 Outline Disease burden and disparities Morbidity data IPP data Special analysis: Gonorrhea in IPP Gonorrhea screening thoughts Chlamydia Evaluation Initiative (CEI) Data, data, data

3 Chlamydia Rates by Sex: United States, * Rate (per 1, population) 6 Men Women 48 Total CT screening project (Region X) Program expansion 583.8* 211.1* Notifiable All 5 report Total cases reported in 28*: 1,21,523 * 28 data are preliminary (as of September, 29).

4 Chlamydia Rates by Race/Ethnicity: United States, * Rate (per 1, population) American Indian/AK Native Asian/Pacific Islander Black Hispanic White * * * 28 data are preliminary (as of September, 29).

5 Chlamydia Rates by race/ethnicity and sex: United States, 27 Men Rate (per 1, population) Women Race AI/AN Asian/PI Black Hispanic White Total 544.8

6 Chlamydia Rates by Race and Sex: United States 21-28* 28* * 2, White women White men Black women Black men * 28 data are preliminary (as of September, 29)

7 Chlamydia Median State-specific Positivity Among Year-old Women Tested in Family Planning Clinics, * Median state-specific positivity rate % 28*: 7.4 ( ) 4 ( ) Note: As of 1997, all 1 Health and Human Services (HHS) regions, representing all 5 states, the District of Columbia, and outlying areas, reported chlamydia positivity data. SOURCE: Regional Infertility Prevention Projects; Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

8 Chlamydia Percent of tests that were nucleic acid amplification tests in family planning clinics among 15- to 24-year year-old women by HHS region, Percent Region I Percent Region II Percent Region III Percent Region IV Percent Region V Percent Region VI Percent Region VII Percent Region VIII Percent Region IX Percent Region X SOURCE: Chlamydia Prevalence Monitoring Project (Regional Infertility Prevention Projects); Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

9 Chlamydia Prevalence Among Women and Men Aged Years by Race/Ethnicity (NHANES), Prevalence (%) Non-Hispanic White Non-Hispanic Black Mexican-American Females Males Source: Datta, Annals 27. NHANES=National Health and Nutrition Examination Survey

10 Racial Disparity in Adjusted Chlamydia Racial Disparity in Adjusted Chlamydia Prevalence Among Women, Aged 16 Prevalence Among Women, Aged Years 24 Years % J a n 6 M a r 6 M A y 6 J u l 6 S e p 6 N o v 6 J a n 7 M a r 7 M a y 7 J u l 7 S e p 7 N o v 7 J a n 8 M a r 8 M a y 8 J u l 8 S e p 8 N o v 8 Black White Disparity

11 % J a n 4 M a r 4 M a y 4 J u l 4 S e p 4 N o v 4 J a n 5 M a r 5 M a y 5 J u l 5 S e p 5 N o v 5 J a n 6 M a r 6 M a y 6 J u l 6 S e p 6 N o v 6 J a n 7 M a r 7 M a y 7 J u l 7 S e p 7 N o v 7 J a n 8 M a r 8 M a y 8 J u l 8 S e p 4 N o v 4 Racial Disparity in Adjusted Chlamydia Racial Disparity in Adjusted Chlamydia Prevalence Among Men, Aged 16 Prevalence Among Men, Aged Years 24 Years Black White Disparity

12 Gonorrhea Positivity among Women aged years in the United States, Linda Gorgos, Lori Newman, Catherine Satterwhite, Stuart Berman, Hillard Weinstock

13 Background GC rates vary widely by geography and among populations Limitations of case reporting data Limited data on GC positivity in screened populations GC prevalence data AddHealth Wave III: 2.1% (blacks) vs.1% (whites) NHANES , women aged years: 2.2% (blacks) vs..5% (whites)

14 Background Infertility Prevention Project provides for testing of chlamydia and gonorrhea across the U.S. Data elements collected vary by region Coordinated effort by CDC to standardize the data across all 1 HHS regions

15 Objectives Describe gonorrhea positivity among women aged years attending Infertility Prevention Project family planning clinics Select a subset of these young women that most closely approximates a screened population Examine racial disparities Examine geographic distribution of disease

16 Methods Utilized standardized data across all 1 PHS Regions All gonorrhea tests among women aged years tested in IPP family planning clinics from Selected clinics where 9% of women being tested for CT also tested for GC at visit Clinic sent 5 GC tests per calendar year

17 Analysis Positivity = # of positive tests/ total # of tests Calculated gonorrhea positivity on state and county levels Compared positivity across age groups Compared positivity across race/ ethnicity Focused analysis on non-hispanic black vs. non - Hispanic white women

18 Gonorrhea Tests, ALL Males and Females, Tests = 8,31,52 States = 42 plus D.C., P.R., V.I. Counties = 2145

19 Gonorrhea Tests, ALL Males and Females, Tests = 8,31,52 States = 42 plus D.C., P.R., V.I. Counties = 2145 Gonorrhea Tests, Females aged years seen in Family Planning Clinics, Tests = 2,39,837 States = 42 plus D.C., P.R., V.I. Counties = 1968

20 Gonorrhea Tests, ALL Males and Females, Tests = 8,31,52 States = 42 plus D.C., P.R., V.I. Counties = 2145 Gonorrhea Tests, Females aged years seen in Family Planning Clinics, Tests = 2,39,837 States = 42 plus D.C., P.R., V.I. Counties = 1968 Gonorrhea Tests, Females aged years seen in Family Planning Selected Clinics Only, Tests = 1,119,394 States = 26 Counties = 753

21 Distribution of Eligible Clinics Clinics =257 Tests = 423,367 Clinics = Tests = Clinics = 61 Clinics = 9 Tests = 94,55 Tests = 589,564

22 Characteristics of Participants Characteristic Number Percent Age Group (years) , % , % Race/ Ethnicity Non Hispanic White 616, % Non Hispanic Black 274, % Hispanic 14, % Asian/ PI/ NH 17, % American Indian/Alaska Native % Multirace, other, unknown 44, %

23 Gonorrhea Test Type Test Type Percent of GC Tests NAAT 8 % NA Hybridization 1 % Other 1 % Culture <.1 %

24 Characteristic Gonorrhea Positivity Year of Testing % % % Age Group years 1.94 % 2 24 years 1.32 % Race/ Ethnicity Non Hispanic Black 4.24 % AI/AN 1.25 % Asian/ PI/ NH.98 % Non Hispanic White.65 % Hispanic.59 % Total 1.59 %

25 State Specific Gonorrhea Positivity, Females aged years seen in Selected Family Planning Clinics, See * (n=24) < 1. % (n=11) % (n=8) 2. % (n=7) * Clinics that did not report gonorrhea positivity data or did not routinely screen 9% or more of the women aged years for gonorrhea and send at least 5 gonorrhea tests per year

26 State Specific Gonorrhea Positivity, Females aged years seen in Selected Family Planning Clinics, Median = 1.3 % (IQR.7 2.%) Range 3.1% * Clinics that did not report gonorrhea positivity data or did not routinely screen 9% or more of the women aged years for gonorrhea and send at least 5 gonorrhea tests per year

27 State Specific Gonorrhea Positivity Age Median GC Positivity I.Q.R. Range years 1.4% % 3.8 % 2 24 years 1.1 %.6 1.4% 2.7 % years 1.3 %.7 2. % 3.1 %

28 State Specific GC Positivity, Non Hispanic White Females aged years seen in Selected Family Planning Clinics, See * (n=24) < 1. % (n=25) % (n=1) 2. % (n=).3.4 * Clinics that did not report gonorrhea positivity data or did not routinely screen 9% or more of the women aged years for gonorrhea and send at least 5 gonorrhea tests per year

29 State Specific GC Positivity, Non Hispanic Black Females aged years seen in Selected Family Planning Clinics, See * (n=25) < 1. % (n=1) % (n=2) 2. % (n=22) * Clinics that did not report gonorrhea positivity data or did not routinely screen 9% or more of the women aged years for gonorrhea and send at least 5 gonorrhea tests per year

30 State-Specific Specific Positivity Non Hispanic White Non Hispanic Black Median.6 % 3.8 % I.Q.R..4.8 % % Range 1.2 % %

31 Concentration of GC Morbidity Non-Hispanic black women represent 25% of the study population but account for 65% of total GC cases 16 of 753 (2%) counties account for 25 % of all GC cases 57 of 753 (8%) counties account for 5 % of all GC cases

32 Gonorrhea Positivity by County, non Hispanic White Females aged years seen in selected Family Planning Clinics, See * (n=2388) < 1. % (n=626) % (n=98) 2. % (n=29) Counties that did not report gonorrhea positivity data or did not routinely screen 9% or more of the women aged years for gonorrhea and send at least 5 gonorrhea tests per year

33 Gonorrhea Positivity by County, non Hispanic Black Females aged years seen in selected family Planning Clinics, See * (n=2437) < 1. % (n=233) % (n=62) 2. % (n=49) Counties that did not report gonorrhea positivity data or did not routinely screen 9% or more of the women aged years for gonorrhea and send at least 5 gonorrhea tests per year

34 County Level Positivity GC Positivity Non Hispanic White Non Hispanic Black % of Counties % of Counties < 1.% 83 % 33 % % 13 % 9 % 2. % 4 % 58 %

35 Ratio of Gonorrhea Positivity by County, non Hispanic Black/ non Hispanic White Females aged years seen in selected Family Planning Clinics, Positivity Ratio % of Counties 1. 3 % See * (n=2838) 1. (n=9) (n=16) > 2. (n=278) % %

36 Summary GC positivity among young women varies by age, geographic area, and race/ ethnicity Younger women and minority populations disproportionately affected Large proportion of morbidity concentrated in a relatively small number of counties Racial disparities large and present across multiple geographic regions

37 Strengths Extends previous analysis of IPP GC data Majority of testing using NAAT technology Selection of clinics demonstrating consistent GC testing practices over all 3 years First step of using standardized data base to examine national level data Reproducible method Ability to examine time trends in future

38 Limitations Source data limited to IPP May not be representative of all young women Limited geographic representation across U.S. No data on extent of coverage of screening among women Need better understanding of who is being screened No data on risk factors Potential repeat testing of the same woman

39 Future Directions Additional calendar years of data will allow examination of time trends Valuable resource for GC data Informative for IPP planning and other national initiatives Draw attention to geographic areas and populations to focus prevention and service efforts potential for an impact!

40 Selection Criteria % of Cases Found % of Women Screened Positivity in Screened Positivity in Unscreened

41 Selection Criteria % of Cases Found % of Women Screened Positivity in Screened Positivity in Unscreened Age < 2 years 53 % 43 % 1.95 % 1.32 %

42 Selection Criteria % of Cases Found % of Women Screened Positivity in Screened Positivity in Unscreened Age < 2 years 53 % 43 % 1.95 % 1.32 % Non Hispanic Black 67 % 25 % 4.24 %.71 %

43 Selection Criteria % of Cases Found % of Women Screened Positivity in Screened Positivity in Unscreened Age < 2 years 53 % 43 % 1.95 % 1.32 % Non Hispanic Black 67 % 25 % 4.24 %.71 % Non Hispanic Black OR Age < 2 years 84 % 58 % 2.32 %.6 %

44 Selection Criteria % of Cases Found % of Women Screened Positivity in Screened Positivity in Unscreened Age < 2 years 53 % 43 % 1.95 % 1.32 % Non Hispanic Black 67 % 25 % 4.24 %.71 % Non Hispanic Black OR Age < 2 years 84 % 58 % 2.32 %.6 % Facility Positivity 1 % 89 % 6 % 2.34 %.45 %

45 Selection Criteria % of Cases Found % of Women Screened Positivity in Screened Positivity in Unscreened Age < 2 years 53 % 43 % 1.95 % 1.32 % Non Hispanic Black 67 % 25 % 4.24 %.71 % Non Hispanic Black OR Age < 2 years 84 % 58 % 2.32 %.6 % Facility Positivity 1 % 89 % 6 % 2.34 %.45 % Facility Positivity 1% OR Non Hispanic Black 92 % 63 % 2.33 %.35 %

46 Chlamydia Evaluation Initiative (CEI) Optional component to CSPS (FY 29) Purpose: Develop novel methodology to estimate community levels of: 1. Chlamydia screening coverage among sexually- active women aged <26 years 2. Partner treatment coverage among partners of chlamydia-infected infected women Calculate baseline coverage rates

47 CEI Applications 19 applications received All included chlamydia screening coverage 8 applications funded (full or partially): California, Illinois, Los Angeles, Michigan, Puerto Rico, San Francisco, Washington State, New York City Funding: September 29 Partner treatment coverage activities not funded

48 CEI Activities Use existing data in novel ways to generate estimates of chlamydia screening coverage Behavioral surveys (sexual activity) Healthcare seeking/access surveys Prevalence/positivity sources Partner with labs Validate self-reported testing history Collaboration between grantees?

49 Data, Data, Data Opportunistic New methodologies for using IPP data for surveillance purposes Enhanced data availability Data release policy pending Recognized as an important component to national chlamydia surveillance portfolio Keep it coming!

50 Reported number of tests* (IPP), by year 3,6, 3,4, 3,2, 3,, 2,8, 2,6, 2,4, 2,2, 2,, *Gonorrhea and chlamydia; positive and negative results only.

51 3,, 2,5, 2,, 1,5, 1,, Reported number of tests* (IPP), 5, by year and sex Female Male *Gonorrhea and chlamydia; positive and negative results only.

52 4,, 3,5, 3,, 2,5, 2,, 1,5, 1,, Reported number of tests* (IPP), 5, by region and year I II III IV V VI VII VIII IX X *Gonorrhea and chlamydia; positive and negative results only.

53 Reported tests* (IPP), by year and age group 1% 9% 8% 7% 6% 5% 4% 3% 2% > <15 1% % *Gonorrhea and chlamydia; positive and negative results only.

54 Reported chlamydia tests* among women aged years attending family planning clinics (IPP), by year 1% 8% 6% 4% FP Women Other 2% % *Positive and negative results only.

55 Thanks!