Transcript 3-6

CT and GC Screening:
What about the guys?!
Gale R Burstein, MD, MPH, FAAP, FSAHM
Erie County Department of Health
SUNY at Buffalo School of Medicine
Buffalo, NY
Questions
1)
What are published federal agency and medical
professional organizations’ guidelines for GC/CT
screening sexually active adolescent males
1)
What is evidence for published federal agencies
and medical professional organizations’
recommendations for ♂ GC/CT screening?
Methods

Evidence-based federal and national
professional medical organization ♂ GC/CT
screening recommendations collected and
reviewed
 Organizations:

AAP, AAFP, ACOG, CDC, USPSTF
Background papers reviewed
RESULTS
Chlamydia
♀ Routine annual chlamydia screening
AAP
ACOG
AAFP
CDC
USPSTF
all sexually active ≤25 yrs
all sexually active adolescents
all sexually active <24 yrs
all sexually active ≤25 yrs
all sexually active <24 yrs
♂ Routine annual chlamydia screening
AAP
(draft)
MSM (Q3-6 mo if ↑ risk);
Screen based on individual and population-based risk factors
(CT-exposed in past 60 days);
Consider screening if multiple partners and in clinic settings
with ↑ prevalence, e.g., jails or juvenile detention, Job Corp,
STD clinics, SBHCs, adolescent clinics
AAFP
Insufficient evidence to recommend routine screening
CDC
MSM (Q3-6 mo if ↑ risk); CT-exposed in past 60 days
Consider screening ♂<30 yrs in clinical settings with ↑
prevalence (e.g., adolescent clinics, jails or juvenile
detention, STD clinics, SBHCs, EDs, Job Corp, military
recruits);
Insufficient evidence to recommend general population
screening
USPSTF* Insufficient evidence to recommend routine screening
*Update in progress
EVIDENCE
CT Prevalence of Among Men Screened in 4 U.S. Cities*


Objective: ♂ CT Prevalence in 4 U.S. Cities
Methods: Urine CT testing offered to ♂ during 1999 -2003
in Baltimore, Denver, San Francisco, and Seattle in:



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
juvenile/adult detention
adolescent 1º care clinics
adult 1º care clinics
high school clinics
college clinics

health fairs,
 street outreach programs,
 CBOs
 drug rehabilitation program
*Schillinger JA, et al. Sex Transm Dis 2005;2: 74-77.
Results

23,507 men tested at >50 venues in 4 cities

median age = 21 yrs
 44% NH black; 25% Hisp; 19% NH white; 7%API; 10% other
 96% asymptomatic

overall ♂ CT prevalence = 7%

Location
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
Baltimore=12%
Denver=10%
San Francisco=5%
Seattle=1%
Age


15 - 19 yo=8%
20 - 24 yo=9%
Schillinger JA, et al. Sex Transm Dis 2005;2: 74-77.
Results cont’d
Prevalence by venue
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Adolescent 1º care: 16%
CBO: 12%
High school clinic: 9%
Adult 1º care: 8%
Adult detention: 7%
Juvenile detention: 6%

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

Drug rehab: 5%
Street outreach 3%
College clinics: 3%
School health fair: 1%
Schillinger JA, et al. Sex Transm Dis 2005;2: 74-77.
Program Cost and Cost-Effectiveness (CE) of Screening
Men for Chlamydia to Prevent PID*


Objective: determine if screening ♂ to prevent PID is CE
Methods:
♂
CT screening study data applied to estimate CE of CT
screening strategies:
♂ screening
 expanded ♀ screening
 combining Disease Intervention Specialists (DIS) – provided
partner notification (PN) with screening
 Cases of PID and quality-adjusted life years (QALYs) lost were
primary outcome measures

*Gift TL, et al. Sex Transm Dis 2008; 35 suppl; S66-S75.
Results:

Targeting high-risk ♂ (↑ # partners in past year and
↑ CT prevalence) for screening was cost saving vs.
expanded screening of low-risk ♀
cost savings if ♂ already receiving health
screenings
 Screening ♂ in general population not cost saving
 More

Combining PN with ♂ screening was more effective
than screening ♂ alone
Gift TL, et al. Sex Transm Dis 2008; 35 suppl; S66-S75.
RESULTS
Gonorrhea
♀ Routine gonorrhea screening
AAP
(draft)
all sexually active ♀ <25 yrs
ACOG
all sexually active ♀ adolescents
all sexually active ♀ if ↑risk for infection (all
young [<25 yrs] sexually active or persons with
other individual or population risk factors)
AAFP
all sexually active ♀ <25 yrs
all sexually active ♀ if ↑risk for infection (all
USPSTF* young [<25 yrs] sexually active or persons with
other individual or population risk factors)
CDC
*Update in Progress
USPSTF GC Risk Factors


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♀ & ♂ < 25 yrs are highest risk for GC
GC risk factors include: H/O GC, other STIs, new or multiple sexual
partners, inconsistent condom use, sex work, and drug use.
GC prevalence varies widely among communities and patient
populations.


Individual risk depends on the local epidemiology of disease.

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African Americans and MSM have higher prevalence of infection than
general population in many communities and settings.
Local public health provide guidance to clinicians to help identify
populations at ↑ risk in their communities.
In communities w/ ↑ GC prevalence, broader screening of sexually
active young people may be warranted, especially in settings
serving individuals who are ↑ risk.
Clinicians may consider other population-based risk factors, i.e.,
residence in urban communities and communities with ↑ poverty
rates
Low community GC prevalence may justify more targeted screening
♂ Routine gonorrhea screening
AAP (draft)
MSM (Q3-6 mo if ↑ risk);
Contact in past 60 days;
Consider screening on basis of individual and population
based risk factors (persons of color, ↑ community
prevalence)
AAFP
Insufficient evidence to recommend for or against routine
GC screening for in ♂ at ↑increased risk for infection
CDC
MSM, contact in past 60 days
USPSTF*
Insufficient evidence to recommend for or against routine
GC screening for in ♂ at ↑increased risk for infection
*Update in Progress
USPSTF Justification for ♂ GC
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Morbidity from undiagnosed and untreated
genital GC is lower in ♂ than in ♀
Clinical Sx more likely to lead to Dx and Rx in ♂;
 prevalence

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of Asx GC in ♂ men is lower
USPSTF judges small magnitude of potential
harms of screening ♂ for GC
Given low prevalence of Asx ♂ GC, USPSTF
could not determine the balance of benefits and
harms of GC screening in ♂ at ↑ risk for infection
QUESTIONS
DISCUSSION