Kristen J. Mertz

Findings from STD screening of adolescents and adults entering corrections facilities: implications for STD control strategies.

Background Persons entering corrections facilities are at high risk for sexually transmitted diseases (STDs) because of risky sexual behavior and lack of access to routine screening. Goal The goal of the study was to develop a national picture of STD prevalence in this population. Study Design We analyzed information on age, race/ethnicity, urethral symptoms (men only), and test results for approximately 85,000 chlamydia, 157,000 gonorrhea, and 293,000 syphilis tests for persons entering 23 jails and 12 juvenile detention centers in 13 US counties from 1996 through 1999. Results At adult jails in nine counties, the median percentage of persons with reactive syphilis tests by county was 8.2% (range, 0.3–23.8%) for women and 2.5% (range, 1.0–7.8%) for men. At juvenile detention facilities in five counties, the median positivity for chlamydial infection was 15.6% (range, 8.0–19.5%) for adolescent girls and 7.6% (range, 2.8–8.9%) for adolescent boys; the median positivity for gonorrhea was 5.2% (range, 3.4–10.0%) for adolescent girls and 0.9% (range, 0.7–2.6%) for adolescent boys. Of adolescent boys testing positive for chlamydial infection at three juvenile facilities, approximately 97% did not report symptoms; of adolescent boys positive for gonorrhea, 93% did not report symptoms. Conclusion STD positivity among persons entering corrections facilities is high. Most chlamydial and gonococcal infections are asymptomatic and would not be detected without routine screening. Monitoring the prevalence of STDs in this population is useful for planning STD prevention activities in corrections facilities and elsewhere in the community.

Etiology of Genital Ulcers and Prevalence of Human Immunodeficiency Virus Coinfection in 10 US Cities

To determine the etiology of genital ulcers and to assess the prevalence of human immunodeficiency virus (HIV) infection in ulcer patients in 10 US cities, ulcer and serum specimens were collected from approximately 50 ulcer patients at a sexually transmitted disease clinic in each city. Ulcer specimens were tested using a multiplex polymerase chain reaction assay to detect Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV); sera were tested for antibody to HIV. H. ducreyi was detected in ulcer specimens from patients in Memphis (20% of specimens) and Chicago (12%). T. pallidum was detected in ulcer specimens from every city except Los Angeles (median, 9% of specimens; range, 0%-46%). HSV was detected in >/=50% of specimens from all cities except Memphis (42%). HIV seroprevalence in ulcer patients was 6% (range by city, 0%-18%). These data suggest that chancroid is prevalent in some US cities and that persons with genital ulcers should be a focus of HIV prevention activities.

Trends in the prevalence of chlamydial infections. The impact of community-wide testing.

Background: Evaluation of existing testing programs should guide the national effort to expand programs for the prevention of chlamydial infections. The Columbus (Ohio) Health Department instituted community‐wide testing for Chlamydia trachomatis in 1988. Goals: To assess trends in the prevalence of chlamydial infection, the coverage of screening, and concurrent trends in the prevalence of gonorrhea. Study Design: This was a cross‐sectional study of women 15 to 44 years of age tested for C. trachomatis at over 50 provider sites in Columbus, Ohio, from 1989 to 1992. Results: The prevalence of chlamydial infection among all women tested decreased by 33% from 1989 to 1992. Prevalence decreased least (19%) among black women 15 to 19 years of age, the group with the highest initial prevalence (20.2%), even though 42% of this population in the city was tested. Prevalence did not decrease at all among prenatal patients 15 to 19 years of age. For women tested for both gonorrhea and chlamydia, gonorrhea decreased by 39% during the 4‐year period. Conclusions: Screening appeared to have limited effect on the prevalence of chlamydial infection for groups with highest initial prevalence, despite the relatively high percentage of the population tested. Expanding screening programs to include men and instituting behavioral interventions may be necessary to reduce more rapidly the prevalence of chlamydia among these women.

Screening women in jails for chlamydial and gonococcal infection using urine tests feasibility, acceptability, prevalence, and treatment rates

Background Women entering jails are at high risk for sexually transmitted diseases; however, screening for chlamydial and gonococcal infection is not routinely performed in most jails. New urine tests have made it easier to screen for these infections in nonclinical settings. Goal The feasibility and acceptability of urine-based screening for women entering jails and the prevalence of and treatment rates for chlamydial and gonococcal infections were determined. Study Design Women entering jails in Chicago, Illinois; Birmingham, Alabama; and Baltimore, Maryland, who signed consent forms were tested for chlamydial and gonococcal infection by means of the urine ligase chain reaction assay. Those testing positive were treated in jail; health department staff members attempted to contact those already released. Results Most women who were approached agreed to be tested (range, 87–98%, depending on city), and most of these women provided a specimen (range, 92–100%). Among 5364 women aged 16 to 75 years who were tested, the prevalence of chlamydial and gonococcal infections was high, especially among those <25 years of age (range, 15.3–21.5% for chlamydial infection and 8.2–9.2% for gonorrhea, depending on city). The majority of women testing positive were treated in jail or outside of jail (61–85%). Conclusions Screening women in jails for chlamydial and gonococcal infection with urine tests is feasible, is acceptable to most women, and leads to detection and treatment of many infections. Routine screening should reduce medical complications in this population and should prevent transmission in the community, given that many women are soon released.

A pilot study of the prevalence of chlamydial infection in a national household survey

Background: The prevalence of Chlamydia trachomatis genital infection in the United States population is unknown. Using a new urine test for C. trachomatis, we conducted a pilot survey as part of the National Health and Nutrition Examination Survey III (NHANES III). Goal: To determine whether the prevalence of chlamydial infection in a convenience sample of NHANES participants was high enough to justify testing for C. trachomatis in a national survey. Study Design: NHANES III, conducted from 1988 to 1994, was based on a stratified multistage probability sample of the United States population. Non‐Hispanic blacks and Mexican‐Americans were oversampled. Using the ligase chain reaction assay for C. trachomatis, we tested urine from participants 12 to 39 years of age from 10 of the 89 sites of NHANES III. The prevalence of infection was calculated by racial or ethnic group. Results: We tested 1,144 study participants, of whom 65% were female, 30% were non‐Hispanic blacks, and 30% were Mexican‐American. Prevalence was higher for non‐Hispanic blacks (7%) than for Mexican‐Americans (3%) and non‐Hispanic whites (2%). Prevalence was higher for women than men in non‐Hispanic blacks (7% vs. 6%), Mexican‐Americans (5% vs. 2%), and non‐Hispanic whites (2% vs. 1%). In 15‐ to 19‐year‐old women, prevalence was 13% in non‐Hispanic blacks, 11% in Mexican‐Americans, and 5% in non‐Hispanic whites. Conclusion: The prevalence of C. trachomatis genital infection was high enough to suggest that a reliable national prevalence estimate could be obtained in a national probability sample survey.

An Investigation of Genital Ulcers in Jackson, Mississippi, with Use of a Multiplex Polymerase Chain Reaction Assay: High Prevalence of Chancroid and Human Immunodeficiency Virus Infection

In 1994, an apparent outbreak of atypical genital ulcers was noted by clinicians at the sexually transmitted disease clinic in Jackson, Mississippi. Of 143 patients with ulcers tested with a multiplex polymerase chain reaction (PCR) assay, 56 (39%) were positive for Haemophilus ducreyi, 44 (31%) for herpes simplex virus, and 27 (19%) for Treponema pallidum; 12 (8%) were positive for > 1 organism. Of 136 patients tested for human immunodeficiency virus (HIV) by serology, 14 (10%) were HIV-seropositive, compared with none of 200 patients without ulcers (P < .001). HIV-1 DNA was detected by PCR in ulcers of 6 (50%) of 12 HIV-positive patients. Multivariate analysis indicated that men with chancroid were significantly more likely than male patients without ulcers to report sex with a crack cocaine user, exchange of money or drugs for sex, and multiple sex partners. The strong association between genital ulcers and HIV infection in this population highlights the urgency of preventing genital ulcers in the southern United States.

Gonorrhea in male adolescents and young adults in Newark, New Jersey: implications of risk factors and patient preferences for prevention strategies.

Background: Although the national rate of gonorrhea declined 68% from 1975 to 1995, rates remain high in many inner‐city areas. In 1995, the gonorrhea rate in Newark, NJ, was five times the US rate. Objective: To determine factors associated with acquisition of gonorrhea by men in Newark. Study Design: A case‐control study conducted at the sexually transmitted disease (STD) clinic in Newark, comparing males 15 to 29 years with culture‐confirmed gonorrhea to controls with no STD. Results: Compared with controls, males with gonorrhea more frequently reported at least 1 casual sex partner within the preceding month (adjusted odds ratio [OR], 3.2; 95% CI, 1.8‐5.7), sex after using marijuana during the preceding month (OR, 2.4; 95% CI, 1.1‐5.3), and a history of incarceration (OR, 2.1; 95% CI, 1.2‐3.7). Of males with casual partners, having a new casual sexual relationship (onset within the past month) was particularly risky for gonorrhea (OR, 3.9; 95% CI, 1.2‐12.7). Incorrect condom use was highly prevalent for both cases and controls. Many persons with gonorrhea reported that they were not willing to consistently use condoms or to have only one partner. Conclusions: Sex with casual partners is associated with gonorrhea in males, and may be a difficult practice to change. Condoms are often used incorrectly, if at all, in this population. Prevention strategies, in addition to the promotion of condom use and monogamy, may be necessary.

Comparison of Enzyme Immunoassays for Antibodies to Haemophilus ducreyi in a Community Outbreak of Chancroid in the United States

The performance of two EIAs (adsorption EIA and lipooligosaccharide [LOS] EIA) that detect antibodies to Haemophilus ducreyi was evaluated with serum specimens obtained from 163 patients (96 with genital ulcer disease [GUD]). Paired serum specimens (initial and follow-up) were obtained from 52 of the GUD patients. By use of initial serum specimens from 82 GUD patients whose etiologic agents for their ulcers had been identified, the adsorption EIA had a sensitivity and specificity for chancroid of 53% and 71%, while the LOS EIA had a sensitivity and specificity of 48% and 89%, respectively. Sensitivity and specificity of the adsorption EIA increased to 78% and 84%, respectively, when the results of follow-up serum specimens were used to calculate optimal performance. The proportion of patients testing positive for H. ducreyi who had anti-H. ducreyi IgG antibodies, as determined by adsorption EIA, increased with the duration of infection, thus limiting the role of EIAs in the diagnosis of chancroid.

Prevalence of genital chlamydial infection in young women entering a national job training program 1990 -1997.

OBJECTIVES This analysis describes trends in the prevalence of genital chlamydial infection in economically disadvantaged young women entering a national job training program. METHODS We examined chlamydia test data for May 1990 through June 1997 for women aged 16 to 24 years who enrolled in the program. The significance of trends was evaluated with the chi 2 test for trend. RESULTS Prevalence of chlamydial infection declined 32.9%, from 14.9% in 1990 to 10.0% in 1997 (P < .001). Prevalence decreased significantly in all age groups, racial/ethnic groups, and geographic regions. CONCLUSIONS The decrease in prevalence of chlamydial infection suggests that prevention activities have reached disadvantaged women across the United States; however, prevalence of chlamydial infection remains high, and enhanced prevention efforts in disadvantaged communities are urgently needed.

Screening women for gonorrhea: demographic screening criteria for general clinical use.

OBJECTIVES The purpose of this analysis was to derive potential gonorrhea screening criteria for women. METHODS Data corresponding to 44,366 gonorrhea cultures from women 15 through 44 years of age in Columbus, Ohio, were analyzed. RESULTS Characteristics that were associated with gonococcal infection and were suitable for screening decisions included patients age and marital status and previous prevalence of gonorrhea at provider site. Probabilities of infection ranged from .001 for married women 25 through 44 years of age at low-prevalence provider sites to .078 for unmarried women 15 through 19 years of age at high-prevalence sites. CONCLUSIONS Patients age and marital status and prevalence of gonorrhea at provider site can be used as indicators to ensure testing of high-prevalence groups.