Epidemiology Newsletter
Office of Epidemiology March 2002 Utah Department of Health
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Sexually Transmitted Diseases in Adolescent Women

Background: Sexually Transmitted Diseases (STDs) such as Chlamydia trachomatis and Neisseria gonorrhoeae are a considerable health burden in the United States. Adolescents are disproportionately impacted by STDís with close to four million new infections each year.1 Adolescent females are at highest risk due to biological, anatomical, social and behavioral factors that can dramatically increase their risk of infection.2 These infections pose significant public health concerns due to their primarily asymptomatic nature and often harmful and permanent complications associated with untreated infections. Untreated cervical infections can lead to pelvic inflammatory disease (PID), which can result in tubal scarring, infertility as well as a potentially fatal ectopic pregnancy.1,2 Infection with a STD such as chlamydia and gonorrhea also increases the likelihood of acquiring HIV if exposed.2

Among women in the United States, adolescent females had the highest reported incidence rate of both chlamydia (2,406.0 cases per 100,000 persons) and gonorrhea (715.6 cases per 100,000 persons) in 2000.3 In Utah, during 2000, the reported rates for chlamydia and gonorrhea in adolescent females was lower than the national rate, however these infections still pose a significant public health threat in this state. In 2000 the reported incidence of chlamydia in Utahís females 15-19 years in age, was 659 cases per 100,000 persons. In urban Salt Lake County, the reported incidence of chlamydia in females 15-19 years was higher at 1027.3 cases per 100,000 persons (STD-MIS data). 

The Centers for Disease Control and Prevention (CDC) has recommended that sexually active adolescents be screened for STDs at least annually. The Utah Department of Health through funding provided by CDC (Adolescent Women Reproductive Health Monitoring Project) and in partnership with Planned Parenthood Association of Utah has instituted STD and pregnancy screening along with behavioral risk assessment targeting adolescent females in high-risk settings. These settings include two juvenile detention centers, three drug treatment centers, and a clinic serving homeless youth along the Wasatch Front. These types of facilities are known to serve sexually active adolescents, many of who engage in high-risk sexual and substance abuse behavior.2,4-6 This report presents preliminary data collected during the first eight months of this study.

Methods: Urine specimens were collected from each participant. Urine samples were first tested for pregnancy (Acceava hCG urine test, Biostar, Boulder, CO) at the facility. Specimens were then tested for C. trachomatis and N. gonorrhoeae at the Utah State Public Health Laboratory, using nucleic acid amplification (BD Probe Tec, Beckton, Dickinson and Company, Sparks, MD). This test has a sensitivity and specificity for detecting chlamydia and gonorrhea in urine of over 90%. All positive results were reported to the facility from which the specimen came and treatment was coordinated. As required, local health departments provided follow-up on each positive case ensuring treatment compliance and assisting with partner notification. Care and referral for pregnancy were coordinated by the individual facility. 

Depending on the facilities monthly intake volume for adolescent females, site visits were conducted weekly, bi-monthly or monthly. The homeless youth clinic is open twice a week and study participation was conducted on these nights. At this clinic a monetary incentive was provided for participation and for returning for results and treatment, if necessary. Demographic and behavioral data were routinely collected using a standard survey, which was administered to each participant screened for chlamydia/gonorrhea and pregnancy. Participation was voluntary; subsequently not all eligible females chose to participate during site visits. STD and reproductive health education was provided to all participants, as well as anyone else who was interested, during the site visits. 

Survey and screening data were managed and analyzed using EpiInfo 2000 (CDC, Atlanta, GA). Site visits included in this analysis range from August 8, 2001 through March 21, 2002. Participants were allowed to be screened no more than once every 30 days to avoid detecting the same infection twice. Prevalence of chlamydia, gonorrhea, and pregnancy were calculated as the proportion of positive test results over the number of samples tested. Analysis is broken down by facility type: juvenile detention center, adolescent drug treatment center, and homeless youth clinic (Table 1). 

Table 1. Positivity for Chlamydia, Gonorrhea and Pregnancy by Facility Type 
 
Detention Center
Drug Treatment
Homeless Youth 
Chlamydia
11.60%
4.40%
18.00%
Gonorrhea
0.40%
0
0
Pregnancy
1.40%
3.70%
3.00%
Positivity calculated as number of positive results over total number of test results.
Preliminary Findings: There were a total of 372 participant visits included in this summary; 237 at the detention centers, 69 at the drug treatment centers and 66 at the homeless youth clinic. Urine samples that were not tested due to insufficient sample, laboratory error or were otherwise indeterminate were excluded from calculation. Every effort was made to re-collect if necessary, however this was not always possible. A total number of 345 samples were tested for C. trachomatis and N. gonorrhoeae and 202 samples were tested for pregnancy. The positivity rate for chlamydia, gonorrhea, and pregnancy by facility type is listed in Table 1. There was only one participant who tested positive for gonorrhea and this was at a detention center. Four participants had positive pregnancy tests. All four of these were unaware of their pregnancy status at the time of testing. A total of 39 participants had positive chlamydia results. 

The drug treatment centers had the lowest chlamydia positivity rate at 4.4%. It is important to note that many of these females had previously spent time in youth correctional facilities where they could have been tested and treated (if necessary) for chlamydia and gonorrhea prior to being sent to drug treatment. The two detention centers had a combined positivity rate of 11.6%. Independently, the positivity rates were markedly different at these two sites. At the larger of the two facilities, 7.5% of the participants tested were positive for chlamydia. Conversely, 23.6% of the participants at the smaller detention center had positive chlamydia results. It is unknown why such a large discrepancy exists at these two facilities. Both centers are urban and serve adolescents with similar socio-economic, behavioral, and racial backgrounds. The homeless youth clinic had a positivity rate of 18.0% for Chlamydia. 

A number of basic demographic and behavioral risk factors were collected and findings are presented in Table 2. Over 94% of the females at each site report ever having had vaginal sex. This number may be high due to study participation being voluntary. Those who had not previously engaged in vaginal sex may have opted against participation. At the drug treatment centers, although participation was voluntary, the majority of new intakes at each site chose to participate. The median number of sexual partners in the last three months was one at all sites. Females at the homeless youth clinic had a much smaller range in the number of partners they reported having in the last three months. Here, the highest number of partners reported was three versus 11 at the detention centers and 15 at the drug treatment centers.  

Table 2. Characteristics of Study Participants
 
Detention Center
Drug Treatment
Homeless Youth
Median Age in Years
15 (12-19)
16 (13-18)
19 (15-23)
Ever had vaginal sex
222 (94%)
67 (97%)
64 (97%)
Median # of sex partners in the last three months
1 (0-11)
1 (0-15)
1 (1-3)
1 or more previous pregnancies
51 (24%)
7 (10%)
39 (59%)
Used condom during last sex
51 (22%)
25 (36%)
16 (24%)
Used alcohol/drugs during last sex
96 (41%)
39 (56%)
20 (30%)
History of sexual abuse/rape
126 (53%)
45 (65%)
40 (61%)
Previously infected with an STD
41 (17%)
11 (16%)
21 (32%)
Ever traded sex for drugs or money
28 (12%)
13(19%)
5 (8%)
Positivity calculated as number of positive results over total number of test results. 
More than 16% of females at detention centers and drug treatment centers reported being previously infected with a STD while 32% of the females at the homeless youth clinic reported a history of previous infection. A history of sexual abuse was overwhelmingly common among all participants ranging from 50% to 65%, however it was not significantly associated with having a positive chlamydia test. Drug treatment centers had the highest percentage of females to report ever trading sex for drugs or money. Only 8% of the females at the homeless youth clinic reported ever trading sex for drugs or money in the past. 

Among those using some method of birth control, the male condom was the most commonly reported method at all sites. Females at detention centers (73%), drug treatment centers (79%), and homeless youth clinic (51%) claimed to be currently using condoms. However, consistent use of condoms was not assessed. At the homeless youth clinic, 57% of the participants reported currently using Depo-Provera while fewer (16%) reported using birth control pills. Depo-Provera and birth control pills were also the most commonly reported forms of hormonal contraception at the other two facility types with between 18% and 26% reporting the use of one or the other method. A quarter of the females at the detention centers and drug treatment centers reported using the withdrawal method as a form of birth control. 

Substance abuse is often associated with high-risk sexual behavior, such as unprotected sex, due to its effect on social and cognitive skills.2 Fifty-six percent of females at drug treatment centers reported using alcohol and or drugs the last time they had sex. At the detention centers and homeless youth clinic 41% and 30%, respectively, reported using alcohol and or drugs during their last sexual encounter. Alcohol and tobacco were the most commonly used drugs at all three facility types. Between 70% and 80% of participants at all sites reported smoking tobacco in the last month. Alcohol use was slightly less common although high. Approximately 60% of all participants reported drinking in the last month. Marijuana was the most commonly used illegal narcotic. Sixty-one percent of participants at all sites reported smoking marijuana in the last month. The reported use of methamphetamines, cocaine, and the illegal use of prescription drugs in the last month was also high ranging from 15% to 30% depending on the facility type. 

Discussion: The rate in which STDs spread in a population is determined by three factors; (1) the rate of exposure of susceptible persons to infected individuals; (2) the probability that an exposed, susceptible person will acquire the infection; and (3) the length of time that newly infected persons remain infectious and are able to spread the infection to others.2,4 The females who participated in this study are at an increased risk of acquiring an STD or becoming unintentionally pregnant, evidenced by the elevated proportion of chlamydial infection identified among participants at all three facility types. Their high rate of sexual activity and substance abuse in combination with little or no reproductive health care or STD education increases the likelihood of STD transmission and untreated infections. The health care community as well as other organizations serving high-risk adolescents are in a position to significantly influence factors contributing to the spread of STDs.

Systematic monitoring of STD prevalence and reproductive health in adolescents in facilities serving high-risk adolescents is of critical importance and provides many benefits. STD screening will identify individuals who are in need of treatment, thus reducing the pool of infected persons able to transmit a STD. Screening also offers the benefit of reducing the incidence of future PID and other STD associated health consequences among screened females. Importantly, it provides an excellent opportunity for identifying females known to be sexually active and offer reproductive health and STD education as well as risk reduction information in order to reduce the risk of re-infection. Identifying and understanding specific high-risk sexual and substance abuse behavior among females in these facilities can also provide valuable information for developing more effective and culturally appropriate educational intervention programs for these populations. It is important for adolescents to become conscious of their own behavior and consider the personal consequences associated with high-risk sexual and substance abuse behaviors when making decisions. The purpose of STD and reproductive health monitoring and educational interventions in these settings is to reduce the exposure of susceptible persons to infected individuals thus reducing the incidence of new and untreated STDs.

This report provides preliminary data to support the importance of systematic monitoring of STD prevalence, reproductive health, and high-risk behavior in adolescent females in special settings. By doing so, we expect to observe a long-term reduction in the incidence of chlamydia, gonorrhea, and unintended pregnancy, as well sequelae such as PID in high-risk adolescent females. It is also important to highlight the necessity of collaboration between all sectors of the community providing reproductive health services and education to these females. Acknowledging the disparities in the reproductive health services and information available to adolescent females, especially those in drug treatment centers, detention centers or who are homeless, is the first step towards reducing the rate of STDs and unintended pregnancies in this population. 

References

1. Centers for Disease Control and Prevention. Tracking the Hidden Epidemic; Trends in STDs in the United States: 2000. http://www.cdc.gov/nchstp/dstd/stats_Trends/Trends2000.pdf

2. Eng TR, Butler WD, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Committee on Prevention and Control of Sexually Transmitted Diseases, Institute of Medicine, Division of Health Promotion and Diseases Prevention. Washington DC: National Academy Press, 1997.

3. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2000. September 2001

4. Department of Health and Human Services: Healthy People 2010: Sexually Transmitted Diseases. http://www.cdc.gov/nchs/nphome.htm

5. Risser JM, Risser WL, Gefter LR, Brandstetter DM, Cromwell PF. Implementation of a Screening Program for Chlamydial Infection in Incarcerated Adolescents. Sex Transm Dis. January 2001; 43-466.

6. Noel J, Rohde P, Ochs L, Yovanoff P, Alter M, Schmid S, Bullard J, Black C. Incidence and Prevalence of Chlamydia, Herpes, and Viral Hepatitis in a Homeless Adolescent Population. Sex Transm Dis. January 2001; 4-10

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Resistant Gonorrhea in Utah

During the 1980ís, gonorrhea first became resistant to penicillin and tetracycline rendering them ineffective treatments. As a result, the Centers for Disease Control and Prevention (CDC) recommended in 1989 that fluoroquinolone antibiotics like ciprofloxacin be used as treatment for gonorrhea. In the September 22, 2000 issue of the MMWR, there was a report of increased fluoroquinolone resistant gonorrhea in Hawaii. A increase of 1.4% in 1997 to 9.5% in 1999. In 2001, Utah had four cases of gonorrhea resistant to ciprofloxacin and ofloxacin. At least one case has been reported in 2002 to date. Because of this emergence of resistant gonorrhea cases, all specimens of gonorrhea should be sent to the Utah State Lab for susceptibility testing. If specimens prove to be resistant, they will be sent to CDC for further testing. If left untreated, gonorrhea can have serous health consequences such as pelvic inflammatory disease, disseminated gonococcal infection, infertility, ectopic pregnancy, and chronic pelvic pain. For more information, please call the Utah Department of Health, STD Program staff at (801) 538-6096.

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Important Information

When Reporting a Communicable Disease:

Call (801)-538-6191 or 

Call toll free 1-(888)-EPI UTAH (374-8824) 

Or you can Fax it to (801) 538-9923

AND AFTER HOURS 

In a Public Health emergency call 
(801)-241-1172 or 1-(888)-EPI-UTAH

The March 2002 Epidemiology Newsletter is the most current Newsletter online. 

For Information on Fact Sheets for Diseases or Annual Report Information, as well as The Epidemiology Newsletter, you can browse our website:

http://health.utah.gov/epi/

 

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Utah Department of Health, Office of Epidemiology
Monthly Morbidity Summary - March 2002 - Provisional Data

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The Epidemiology Newsletter is published monthly by the Utah Department of Health, Division of Epidemiology and Laboratory Services, Office of Epidemiology, to disseminate epidemiologic information to the health care professional and the general public.

Send comments to:
The Office of Epidemiology, Box 142104, Salt Lake City, UT 84114-2104 or call (801) 538-6191 

Approval 8000008: Appropriation 3705

Rod Betit, Executive Director, Utah Department of Health
Charles Brokopp, Dr.P.H., Director, Division of Epidemiology and Laboratory Services
Gerrie Dowdle, MSPH, Manager, Surveillance and Disease Control Program, Managing Editor
Connie Dean, Community Health Technician, Surveillance and Disease Control Program, Production Assistant

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