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

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

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

Chlamydia Rates by Sex: United States, 1988 28* Rate (per 1, population) 6 Men Women 48 Total 36 24 CT screening project (Region X) Program expansion 583.8* 211.1* 12 1988 9 92 94 96 98 2 2 4 6 Notifiable All 5 report Total cases reported in 28*: 1,21,523 * 28 data are preliminary (as of September, 29).

Chlamydia Rates by Race/Ethnicity: United States, 1998 28* Rate (per 1, population) 17 136 American Indian/AK Native Asian/Pacific Islander Black Hispanic White 1519.3* 12 68 34 173.6* 1998 99 2 1 2 3 4 5 6 7 * 28 data are preliminary (as of September, 29).

Chlamydia Rates by race/ethnicity and sex: United States, 27 Men Rate (per 1, population) Women 2 16 12 8 4 Race 4 8 12 16 2 293.8 AI/AN 1158.2 66.3 Asian/PI 28.8 841.3 Black 196. 211.7 Hispanic 753.3 71.9 White 249.3 19.4 Total 544.8

22 2 18 16 14 12 1 8 6 4 2 Chlamydia Rates by Race and Sex: United States 21-28* 28* 21 22 23 24 25 26 27 28* 2,56.9 928.8 264.4 79.4 White women White men Black women Black men * 28 data are preliminary (as of September, 29)

Chlamydia Median State-specific Positivity Among 15-24 Year-old Women Tested in Family Planning Clinics, 1997 28* Median state-specific positivity rate 1 8 6 5.1% 28*: 7.4 (3.1-15.) 4 (2.-11.2) 2 1997 98 99 2 1 2 3 4 5 6 7 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

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, 23 27 27 Percent 1 8 6 4 2 3 4 5 6 7 Region I Percent 1 8 6 4 2 3 4 5 6 7 Region II Percent 1 8 6 4 2 3 4 5 6 7 Region III Percent 1 8 6 4 2 3 4 5 6 7 Region IV Percent 1 8 6 4 2 3 4 5 6 7 Region V Percent 1 8 6 4 2 3 4 5 6 7 Region VI Percent 1 8 6 4 2 3 4 5 6 7 Region VII Percent 1 8 6 4 2 3 4 5 6 7 Region VIII Percent 1 8 6 4 2 3 4 5 6 7 Region IX Percent 1 8 6 4 2 3 4 5 6 7 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

Chlamydia Prevalence Among Women and Men Aged 14-39 Years by Race/Ethnicity (NHANES), 1999-22 1 Prevalence (%) 8 6 4 2 7.2 5.3 3.1 3.1 1.5 1.5 Non-Hispanic White Non-Hispanic Black Mexican-American Females Males Source: Datta, Annals 27. NHANES=National Health and Nutrition Examination Survey

Racial Disparity in Adjusted Chlamydia Racial Disparity in Adjusted Chlamydia Prevalence Among Women, Aged 16 Prevalence Among Women, Aged 16-24 Years 24 Years % 7 8 9 1 11 12 13 14 15 16 17 18 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

% 2 3 4 5 6 7 8 9 1 11 12 13 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 16-24 Years 24 Years Black White Disparity

Gonorrhea Positivity among Women aged 15-24 years in the United States, 25-27 27 Linda Gorgos, Lori Newman, Catherine Satterwhite, Stuart Berman, Hillard Weinstock

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 1999-26, women aged 14-25 years: 2.2% (blacks) vs..5% (whites)

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

Objectives Describe gonorrhea positivity among women aged 15-24 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

Methods Utilized standardized data across all 1 PHS Regions All gonorrhea tests among women aged 15-24 years tested in IPP family planning clinics from 25-27 27 Selected clinics where 9% of women being tested for CT also tested for GC at visit Clinic sent 5 GC tests per calendar year

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

Gonorrhea Tests, ALL Males and Females, 25 27 Tests = 8,31,52 States = 42 plus D.C., P.R., V.I. Counties = 2145

Gonorrhea Tests, ALL Males and Females, 25 27 Tests = 8,31,52 States = 42 plus D.C., P.R., V.I. Counties = 2145 Gonorrhea Tests, Females aged 15 24 years seen in Family Planning Clinics, 25 27 Tests = 2,39,837 States = 42 plus D.C., P.R., V.I. Counties = 1968

Gonorrhea Tests, ALL Males and Females, 25 27 Tests = 8,31,52 States = 42 plus D.C., P.R., V.I. Counties = 2145 Gonorrhea Tests, Females aged 15 24 years seen in Family Planning Clinics, 25 27 Tests = 2,39,837 States = 42 plus D.C., P.R., V.I. Counties = 1968 Gonorrhea Tests, Females aged 15 24 years seen in Family Planning Selected Clinics Only, 25 27 Tests = 1,119,394 States = 26 Counties = 753

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

Characteristics of Participants Characteristic Number Percent Age Group (years) 15 19 487,121 44 % 2 24 632,273 56 % Race/ Ethnicity Non Hispanic White 616,879 56 % Non Hispanic Black 274,699 25 % Hispanic 14,593 13 % Asian/ PI/ NH 17,758 1.7 % American Indian/Alaska Native 2722.3 % Multirace, other, unknown 44,789 4.1 %

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

Characteristic Gonorrhea Positivity Year of Testing 25 1.45 % 26 1.66 % 27 1.67 % Age Group 15 19 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 %

State Specific Gonorrhea Positivity, Females aged 15 24 years seen in Selected Family Planning Clinics, 25 27 1.6. 1.9 1.3.6.8 1.3 1.4 1.3.7 2..2.4.8.8 1.2 2.2.7 2. 3.1.9 2.8 2.8 2.1.7 1.5 See * (n=24) < 1. % (n=11) 1. 1.9 % (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 15 24 years for gonorrhea and send at least 5 gonorrhea tests per year

State Specific Gonorrhea Positivity, Females aged 15 24 years seen in Selected Family Planning Clinics, 25 27 1.6. 1.9 1.3.6.8 1.3 1.4 1.3.7 2..2.8 1.2.7.9 2.1 1.5 3.1 2.8 2.8.4.8 2.2 2..7 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 15 24 years for gonorrhea and send at least 5 gonorrhea tests per year

State Specific Gonorrhea Positivity Age Median GC Positivity I.Q.R. Range 15 19 years 1.4%.9 2.6 % 3.8 % 2 24 years 1.1 %.6 1.4% 2.7 % 15 24 years 1.3 %.7 2. % 3.1 %

State Specific GC Positivity, Non Hispanic White Females aged 15 24 years seen in Selected Family Planning Clinics, 25 27.8..9.9.4.6.8.6.6.4.8.2.3.6.9.8.5.6.9.4 1.2.8.8.6 See * (n=24) < 1. % (n=25) 1. 1.9 % (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 15 24 years for gonorrhea and send at least 5 gonorrhea tests per year

State Specific GC Positivity, Non Hispanic Black Females aged 15 24 years seen in Selected Family Planning Clinics, 25 27 2.4 4.9 3.8 3.3 3.6 4.2 4.3 4.6 3.2 4.7 1.4.3 2.2 1.9 5.4 6.9 8.7 3.4 4.5 3.7 4.4 4.7 3.9 3.1 3.8 See * (n=25) < 1. % (n=1) 1. 1.9 % (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 15 24 years for gonorrhea and send at least 5 gonorrhea tests per year

State-Specific Specific Positivity.8. 2.4.9 4.9.9.4.6.8.6.6.8.4.2 3.8 3.3 3.6 4.2 4.3 4.6 4.7 3.2 1.4.3.6.3.9.8.5.6.9.4 1.2.8.6.8.4.3 2.2 1.9 5.4 6.9 8.7 3.4 4.5 3.7 4.4 4.7 3.8 3.9 3.1 Non Hispanic White Non Hispanic Black Median.6 % 3.8 % I.Q.R..4.8 % 3.2 4.6 % Range 1.2 %.3 8.7 %

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

Gonorrhea Positivity by County, non Hispanic White Females aged 15 24 years seen in selected Family Planning Clinics, 25 27 See * (n=2388) < 1. % (n=626) 1. 1.9% (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 15 24 years for gonorrhea and send at least 5 gonorrhea tests per year

Gonorrhea Positivity by County, non Hispanic Black Females aged 15 24 years seen in selected family Planning Clinics, 25 27 See * (n=2437) < 1. % (n=233) 1. 1.9% (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 15 24 years for gonorrhea and send at least 5 gonorrhea tests per year

County Level Positivity GC Positivity Non Hispanic White Non Hispanic Black % of Counties % of Counties < 1.% 83 % 33 % 1. 1.9 % 13 % 9 % 2. % 4 % 58 %

Ratio of Gonorrhea Positivity by County, non Hispanic Black/ non Hispanic White Females aged 15 24 years seen in selected Family Planning Clinics, 25 27 Positivity Ratio % of Counties 1. 3 % See * (n=2838) 1. (n=9) 1.1 2. (n=16) > 2. (n=278) 1.1 2. 5 % 2. 92 %

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

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

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

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!

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

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

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 %

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 %

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 %

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 %

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

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

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?

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!

Reported number of tests* (IPP), by year 3,6, 3,4, 3,2, 3,, 2,8, 2,6, 2,4, 2,2, 2,, 21 22 23 24 25 26 27 28 *Gonorrhea and chlamydia; positive and negative results only.

3,, 2,5, 2,, 1,5, 1,, Reported number of tests* (IPP), 5, by year and sex 25 26 27 28 Female Male *Gonorrhea and chlamydia; positive and negative results only.

4,, 3,5, 3,, 2,5, 2,, 1,5, 1,, Reported number of tests* (IPP), 5, by region and year 25 26 27 28 I II III IV V VI VII VIII IX X *Gonorrhea and chlamydia; positive and negative results only.

Reported tests* (IPP), by year and age group 1% 9% 8% 7% 6% 5% 4% 3% 2% >39 3-39 26-29 2-25 15-19 <15 1% % 22 23 24 25 *Gonorrhea and chlamydia; positive and negative results only.

Reported chlamydia tests* among women aged 15-24 years attending family planning clinics (IPP), by year 1% 8% 6% 4% 15-24 FP Women Other 2% % 25 26 27 28 *Positive and negative results only.

Thanks!