High Prevalence of Chlamydial and Gonococcal Infection in Women Entering Jails and Juvenile Detention Centers -- Chicago, Birmingham, and San Francisco, 1998

The prevalence of sexually transmitted diseases (STDs) is high among women entering corrections facilities (1). Screening for STDs in these facilities, however, is difficult because of the large number of persons admitted each day and the frequent shortage of medical staff and examination space (1). New, sensitive urine tests for gonorrhea and chlamydia have made screening practical outside of medical settings. To assess the feasibility of screening women in corrections facilities for chlamydial and gonococcal infection using urine tests and to determine the prevalences* of these infections, the Chicago Department of Public Health and the University of Alabama at Birmingham (UAB) began testing women and adolescent females entering the Cook County Jail and the Cook County Juvenile Temporary Detention Center in Chicago and the Jefferson County Jail and the Jefferson County Youth Detention Center in Birmingham, respectively, in 1998. The San Francisco Department of Public Health has been testing women at the San Francisco County jails for chlamydial and gonococcal infections using urine tests since 1996 and adolescent females at the San Francisco Youth Guidance Center since 1997. This report summarizes the findings for testing incarcerated women in 1998 in the three cities; preliminary results indicate that, in these facilities, testing for chlamydial and gonococcal infections is feasible and that a high percentage of women test positive for these infections.

In Chicago and Birmingham, STD screening was offered as a component of a research study, and written informed consent was obtained from all participants. Age groups eligible for testing varied by facility (all ages at the Jefferson County Jail, aged 18-30 years at the Cook County Jail, and aged greater than or equal to 12 years at the juvenile facilities). Urine was tested for chlamydial and gonococcal DNA using the ligase chain reaction (LCR) assay at the Illinois Department of Public Health and UAB laboratories. In San Francisco, STD screening was offered routinely to women aged 18-29 years entering the adult facility and all adolescent females at the youth facility, and LCR testing was performed at the San Francisco Department of Public Health Laboratory. In the three cities, women with positive tests were treated by the facility's medical staff if they were still incarcerated when results became available; local health department staff attempted to locate infected women who were released untreated.

During July-December 1998 at the Cook County Jail, 845 (98%) of 862 women agreed to participate; of these, 772 (91%) provided a specimen. Of 772 specimens, 103 (13%) were positive for chlamydial infection, and 66 (9%) were positive for gonococcal infection, including seven (1%) that were positive for both. During August- December 1998, of 310 women asked to participate at the Jefferson County Jail, 308 (99%) consented. Of the 308 women, 34 (11%) were positive for chlamydial infection and 25 (8%) for gonococcal infection, including five (2%) positive for both. Of 124 women aged 18-29 years, 21 (17%) were positive for chlamydial infection and eight (6%) positive for gonococcal infection. During January-December 1998 at the San Francisco County Jail, 113 (10%) of 1149 women tested for chlamydial infection were positive, and 55 (5%) of 1142 women tested for gonococcal infection were positive, including 10 (1%) positive for both. Prevalence of chlamydial infection was higher among women aged 18-19 years and aged 20-24 years than among women aged greater than or equal to 25 years at all three county jails (Table 1).

At each juvenile facility, overall positivity for both chlamydial and gonococcal infection in 1998 was higher than at the adult facility in the same city (Table 1). In Chicago during April-December, 27% of adolescent females were positive for chlamydial infection, and 11% were positive for gonococcal infection. In Birmingham during March-December, 22% and 17% were positive for chlamydial and gonococcal infections, respectively, and in San Francisco during January-December, 16% and 6% were positive, respectively.

Reported by: A Evens, MS, R Kee, MD, D Broussard, K Anderson, S Mier, J Johnson, Chicago Dept of Public Health; C Mennella, MD, Cermak Health Svcs; V Vallury, MD, Cook County Juvenile Detention Center, Chicago; C Rabins, MPH, G Dizikes, PhD, Illinois Dept of Public Health. J Schwebke, MD, E Hook, MD, R Meriwether, MK Oh, MD, Univ of Alabama, Birmingham; S Clark, Jefferson County Dept of Health, Birmingham; N Whitehead, Jefferson County Sheriff's Office, Birmingham, Alabama. C Kent, MPH, M Hernandez, MPH, J Klausner, MD, J Goldenson, MD, San Francisco Dept of Public Health, California. Div of Sexually Transmitted Diseases Prevention, National Center for HIV, STD, and TB Prevention; Div of AIDS, STD, and TB Laboratory Research, National Center for Infectious Diseases, CDC.

Editorial Note:

Genital chlamydial and gonococcal infections can lead to pelvic inflammatory disease, ectopic pregnancy, infertility, or chronic pelvic pain in women (2,3). These infections are associated with increased risk for human immunodeficiency virus infection (4,5). Screening and treating women for chlamydia and gonorrhea may prevent some of these complications (6). Treating infected women in jail also may prevent transmission to the community because approximately half of arrestees are released within 48 hours of incarceration (7). The findings in this report indicate that a high percentage of women entering corrections facilities test positive for chlamydial and gonococcal infections.

Although the prevalence of chlamydial and gonococcal infection is high among incarcerated women, most corrections facilities do not routinely screen for these infections but test only those who have symptoms or who request testing (7). Most women with gonorrhea or chlamydia, however, are asymptomatic. At city and county jails surveyed during 1997 that tested arrestees because of symptoms or by request, less than 5% of women were tested for chlamydia and gonorrhea (7).

The cost of testing for chlamydia and gonorrhea remains a barrier to routine screening. If resources are scarce, corrections facilities may choose to screen only persons at highest risk. The data described in this report and in previously published reports indicate that the prevalence of chlamydia and gonorrhea is higher among adolescent females entering juvenile facilities than among women entering adult facilities (8). In the three county jails described in this report, the prevalence of chlamydial infection was higher among women aged less than or equal to 24 years than among women aged greater than or equal to 25 years. In addition, women aged less than or equal to 24 years may be at higher risk than older women for complications from chlamydial and gonococcal infections (9).

The findings in this report are subject to at least two limitations. First, the findings are from corrections facilities in three cities, and the prevalence of STDs varies across facilities and may be substantially different in other U.S. cities. Second, although the nucleic acid amplification tests used at all of these facilities have greater sensitivity than previous testing methods, they are imperfect (10).

Each city and county in the United States should assess the feasibility of screening persons entering corrections facilities for STDs and compare the yield of screening this population with other screening activities. Local STD-control programs and corrections officials should collaborate to assess the contribution of STD screening in corrections facilities toward identifying and treating infections that would not be detected otherwise and, if appropriate, implement screening to interrupt transmission of gonorrhea and chlamydia in communities.

References

1. Puisis M, Levine WC, Mertz KJ. Overview of sexually transmitted diseases. In: Puisis M, ed. Clinical practice in correctional medicine. St. Louis, Missouri: Mosby, 1998:127-33.
2. Stamm WE. Chlamydia trachomatis infections of the adult. In: Holmes KK, Sparling PF, Mardh PA, et al, eds. Sexually transmitted diseases. 3rd ed. New York, New York: McGraw-Hill, 1999.
3. Hook EW, Handsfield HH. Gonococcal infections in the adult. In: Holmes KK, Sparling PF, Mardh PA, et al, eds. Sexually transmitted diseases. 3rd ed. New York, New York: McGraw-Hill, 1999.
4. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999;75:3-17.
5. Royce RA, Sena A, Cates W, Cohen MS. Sexual transmission of HIV. N Engl J Med 1997;336:1072-8.
6. Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;334:1362-6.
7. CDC. Assessment of sexually transmitted diseases services in city and county jails--United States, 1997. MMWR 1998;47:429-31.
8. Division of Sexually Transmitted Diseases Prevention. Sexually transmitted disease surveillance, 1997. Atlanta, Georgia: US Department of Health and Human Services, CDC, National Center for HIV, STD, and TB Prevention, September 1998.
9. Westrom L, Svensson L, Wolner-Hansen P, Mardh PA. Chlamydial and gonococcal infections in a defined population of women. Scand J Infect Dis 1982;32(suppl):157-62.
10. Black CM. Current methods of laboratory diagnosis of Chlamydia trachomatis infections. Clin Microbiol Rev 1997;10:160-84.

* In this report, the terms "prevalence" and "positivity" are used interchangeably although some women may be tested more than once; because of the short length of the study period, the difference between positivity and true prevalence is small.

TABLE 1. Percentage of positive tests for chlamydial and gonococcal infection in
women entering jails, by age group and facility -- Cook County, Illinois; Jefferson
County, Alabama; and San Francisco, California, 1998
===============================================================================================
                                                   Chlamydia                 Gonorrhea
                                             ----------------------     --------------------
                                    Age                  Positive                  Positive
                        Testing    group       No.     ------------       No.     ----------
Facility                period     (yrs)     tests*    No.     (%)      tests*   No.    (%)
--------------------------------------------------------------------------------------------
Cook County
  Juvenile detention     Apr-Dec    12-17      452     124    (27%)      449     50    (11%)
   center
  Jail                   Jul-Dec    18-19      112      24    (22%)      112     15    (14%)
                                    20-24      264      34    (13%)      264     23    ( 9%)
                                    25-30      396      45    (11%)      396     28    ( 7%)

Jefferson County
  Youth detention        Mar-Dec    12-17       98      22    (22%)       98     17    (17%)
   center
  Jail                   Aug-Dec    18-19       15       5    (33%)       15      0    ( 0%)
                                    20-24       46       7    (15%)       46      3    ( 7%)
                                    25-29       63       9    (14%)       63      5    ( 8%)
                                     >=30      184      13    ( 7%)      184     17    ( 9%)

San Francisco County
  Youth guidance         Jan-Dec     9-17      585      92    (16%)      579     36    ( 6%)
   center
  Jail                   Jan-Dec    18-19      232      40    (17%)      232      7    ( 3%)
                                    20-24      509      47    ( 9%)      505     24    ( 5%)
                                    25-29      408      26    ( 6%)      405     24    ( 6%)
--------------------------------------------------------------------------------------------
* Unsatisfactory tests were excluded.
===============================================================================================

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