Chlamydia Screening Among Females Aged 15–21 Years — Multiple Data Sources, United States, 1999–2010

Karen W. Hoover, MD

Jami S. Leichliter, PhD

Elizabeth A. Torrone, PhD

Penny S. Loosier, PhD

Thomas L. Gift, PhD

Guoyu Tao, PhD

Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC

Corresponding author: Karen W. Hoover, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Telephone: 404-639-8534; Email: ffw6@cdc.gov.

Introduction

Chlamydia is a sexually transmitted infection caused by the bacterium Chlamydia trachomatis. Chlamydia is the most commonly reported notifiable disease in the United States, with 1.4 million cases reported in 2012 (1). Chlamydia is usually asymptomatic in both men and women, and as a result, infections often are undiagnosed. Approximately 3 million new infections are estimated to occur each year (1). Among sexually active females aged 14–19 years, chlamydia prevalence has been estimated to be 6.8% (2). In a recent study involving approximately 1 million tests conducted among both privately insured and Medicaid-insured females aged 15–21 years, chlamydia positivity ranged from 6.9% to 10.7% among those with chlamydial symptoms and from 6.1% to 9.6% among those who were asymptomatic (3).

Chlamydial infection in females causes cervicitis, which is usually asymptomatic; however, infection sometimes can cause such symptoms as abnormal vaginal discharge, intermenstrual bleeding, dyspareunia, dysuria, or pelvic pain (4). If chlamydial cervicitis is untreated, infection can ascend to the upper genital tract along with other microorganisms that are part of the vaginal microflora (e.g., anaerobic bacteria) to cause pelvic inflammatory disease (PID) (5,6). The inflammatory and immune responses induced during PID can cause fallopian tube damage, scarring, and blockage (7), which can result in long-term adverse outcomes of tubal factor infertility, ectopic pregnancy, and chronic pelvic pain (8). Some females who have uncomplicated cervicitis have concurrent subclinical PID at the time that chlamydial cervicitis is diagnosed (9), and subclinical PID also has been associated with infertility (10). Screening for and treating chlamydial infection decreases incidence of PID (11,12). Screening for chlamydia also identifies persons at increased risk for HIV infection. Chlamydial infection has been linked to HIV transmission (13,14) because of similar sexual risk behaviors and possible increased biologic susceptibility caused by breaches in the mucosa and inflammation from the infection. Chlamydial infection is diagnosed easily by using vaginal or endocervical swab specimens or urine samples that are tested with nucleic acid amplification tests (NAATs), and treatment with oral antibiotics is simple, safe, and effective (4).

Routine annual chlamydia screening of sexually active young women is one of several important preventive reproductive health-care services. The U.S. Preventive Services Task Force (USPSTF) recommends annual chlamydia screening of all sexually active nonpregnant females aged ≤24 years. This is a USPSTF Grade A recommendation, which means that USPSTF strongly recommends the service. The certainty is high that the benefits of screening for chlamydial infection substantially outweigh the harms. USPSTF concluded that the harms of screening for chlamydia infection are no greater than small, although few studies have been published on this subject (15). USPSTF also recommends screening of pregnant females aged ≤24 years. This is a USPSTF Grade B recommendation, which means that USPSTF recommends the service. The certainty is moderate that the benefits substantially outweigh the harms of screening for chlamydia infection (15). Healthy People 2020 objectives include increasing the proportion of sexually active females aged 16–24 years who are screened each year for genital chlamydial infection (objectives STD-3 and STD-4) (16). The National Quality Forum (NQF) has endorsed as a performance measure the percentage of sexually active females aged 16–24 years who had at least one test for chlamydia in a year (NQF #0033) (17).

Public health has an essential role in monitoring adherence to recommendations for chlamydia screening and in working with the health-care sector and other stakeholders to develop and implement interventions to increase screening. Monitoring screening coverage of young women has been challenging. Screening refers to testing of asymptomatic persons, but no single available data source provides a valid, accurate, and reliable estimate of chlamydia screening coverage in sexually active asymptomatic young women. Because chlamydial infections usually are asymptomatic, chlamydia testing rates have been used to estimate screening rates.

The reports in this supplement provide the public and stakeholders responsible for infant, child, and adolescent health (including public health practitioners, parents or guardians and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations) with easily understood and transparent information about the use of selected clinical preventive services that can improve the health of infants, children, and adolescents. The topic in this report is one of 11 topics selected on the basis of existing evidence-based clinical practice recommendations or guidelines for the preventive services and availability of data system(s) for monitoring (18). This report analyzes 1999–2010 data from multiple data sources to estimate the prevalence of chlamydia screening among U.S. females aged 15–21 years. Public health authorities and clinicians can use these data to identify population subgroups that might require additional strategies to increase access and utilization of chlamydia screening.

Methods

Multiple data sources can be used to assess chlamydia testing coverage and provide insight into chlamydia screening patterns. The National Survey of Family Growth (NSFG) and the National Ambulatory Medical Care Survey (NAMCS) can be used to estimate population-based testing coverage of adolescent females and their use of chlamydia testing at visits to physician offices. NSFG provides estimates of self-reported testing and uses the ideal denominator of an estimate of all U.S. females who reported sexual activity. NAMCS provides insight into use patterns of this reproductive health service among females who have access to health care and identifies missed opportunities for screening of U.S. females who had clinical encounters. Healthcare Effectiveness Data and Information Set (HEDIS) measures of chlamydia testing of women enrolled in commercial and Medicaid health plans, and Title X-funded family planning clinic testing data can be used to monitor temporal trends in chlamydia screening.

To estimate chlamydia screening rates of U.S. adolescent females, CDC used four data sources: the 2006–2010 NSFG, the 2005–2010 NAMCS, 1999–2010 HEDIS measure data, and 2005–2010 Title X data. The age range of 15–21 years was used for analyses with NSFG and NAMCS data; HEDIS data were available only for females aged 16–20 years and Title X data only for those aged 15–19 years.

To estimate the percentage of sexually active females aged 15–21 years who reported that they had been tested for chlamydia in the past 12 months, CDC analyzed 2006–2010 NSFG data. NSFG is a multistage national probability sample of the U.S. population aged 15–44 years residing in households (19). During 2006–2010, a total of 12,279 females were interviewed, and the response rate was 78% (20). The survey methods were similar to those described previously (21). Analyses were limited to the 1,811 sexually active females aged 15–21 years who reported that they had been tested for chlamydia in the past 12 months. Being sexually active was defined as reporting having had one or more male sex partners in the past 12 months; and having sex included having vaginal intercourse, oral sex, or anal sex. The frequency of chlamydia testing was estimated by the females' demographic characteristics, self-reported number of sexual partners in the past 12 months, and self-reported receipt of reproductive health-care services in the past 12 months. Data were weighted to provide nationally representative estimates, and analytic methods were used to account for the complex sampling procedure used by NSFG. Differences between percentages of females were compared by using the Chi-square test; a two-sided p-value <0.05 was considered statistically significant.

To estimate the mean annual percentage of nonpregnant females aged 15–21 years who were tested for chlamydia at visits to primary care physician offices, CDC analyzed NAMCS data from 2005–2010. Primary care specialties included general and family practice, internal medicine, pediatrics, and obstetrics and gynecology. NAMCS is a multistage national probability sample of visits to nonfederally employed U.S. physician offices, including private practices and other freestanding clinics (e.g., urgent care centers, public health clinics, family planning clinics, mental health centers, community health centers, and faculty practice plans) (22). The unit of analysis used was a patient visit, with extraction of data from a review of the patient's medical record. In 2007, medical records from 32,778 patient visits to 1,568 physicians were reviewed, with a response rate of 61% (22). Survey methods used were similar to those described previously (23–25); CDC estimated the frequency of chlamydia testing at visits made by nonpregnant females aged 15–21 years by their demographic characteristics, primary care provider specialty, diagnosis at visit, and receipt of reproductive health-care service. Data were weighted to provide nationally representative estimates, and analytic methods were used to account for the complex sampling procedures used by NAMCS. Differences between percentages of visits were compared by using the Chi-square test; a two-sided p-value <0.05 was considered statistically significant.

Since 1999, the National Committee for Quality Assurance (NCQA) has collected health-care claims data for HEDIS measures of annual chlamydia screening among young females. NCQA is a private nonprofit organization that monitors the quality of U.S. health plans using data that are submitted voluntarily to HEDIS annually. HEDIS is used by 90% of U.S. health plans to evaluate the quality of health-care services and to benchmark performance (26). To estimate the annual percentage of chlamydia screening among sexually active females aged 16–20 years enrolled in commercial and Medicaid health-care plans during 1999–2010, CDC used administrative data with International Classification of Diseases 9th Edition and Current Procedural Terminology (CPT) billing codes. Methods used were similar to those described previously (26). Sexually active females were defined as those who had health-care encounters for a gynecologic examination, pregnancy, contraception, sexually transmitted disease (STD) services, cervical cancer screening, or infertility evaluation or treatment. Among females who had one of these encounters, a chlamydia test was identified by using CPT codes for chlamydia testing at the health-care encounter.

Title X is a federal program administered by the U.S. Department of Health and Human Services' Office of Population Affairs (OPA). Title X provides family planning and related preventive health-care services, with priority given to low-income persons; services include chlamydia testing. Since 2005, the program has monitored chlamydia testing, with service grantees reporting testing data to OPA annually (27,28). For purposes of this analysis, family planning clinic users were assumed to be sexually active and therefore should have been screened according to recommendations. For each year during 2005–2010, the percentage of users who were tested for chlamydia was calculated as the number of unduplicated female users aged 15–19 years who were tested among all family planning users in this age group.

Results

On the basis of NSFG data, a weighted estimate of 8.2 million (56.6%) U.S. females aged 15–21 years reported that they were sexually active, of whom 3.30 million (40.0%) reported that they had been tested for chlamydia in the past 12 months (Table). A chlamydia test was reported by a significantly larger proportion of sexually active women aged 20–21 years (50.0%) than by adolescents aged 18–19 years (38.2%) or those aged 15–17 years (25.2%) (p<0.001). Non-Hispanic black adolescent females had the highest testing rates (56.1%) compared with members of other racial and ethnic groups (p<0.001). Females who had Medicaid insurance or were uninsured had higher testing rates (48.4% and 43.8%, respectively) than those who had private insurance (33.8%) (p<0.001). Females with an income-to-poverty ratio of ≤138% had higher testing rates (42.7%) than those with a ratio of >138% (38.0) (p<0.05). Females who had two or more sexual partners had higher testing rates (45.8%) than those who had only one partner (36.3%) (p<0.001). A larger proportion of sexually active females who had received other reproductive health services (e.g., family planning or contraception, a pregnancy test, pelvic examination, or a Papanicolaou test) in the past 12 months reported having had a chlamydia test compared with females who did not receive these services.

On the basis of NAMCS data, among a weighted estimate of 20.9 million visits to primary care physician offices made by females aged 15–21 years, a chlamydia test was performed at only 4.3% of visits (Table). Testing was performed more often at visits to obstetrics and gynecology offices (11.1%) than at visits to other primary care specialties (2.3%; p<0.001). A chlamydia test was very rare at visits to pediatricians, with no chlamydia test performed at most visits (99.1% [standard error: 0.48]). Females who made visits with symptoms or signs of chlamydial infection were tested at 9.9% of these visits, but only at 3.2% of visits for other reasons (p<0.001). Screening was performed at 8.4% of visits for preventive care compared with other visits (2.5%; p<0.001) and more frequently at visits for reproductive health services than at visits for other services. A chlamydia test was performed at 28.1% of visits with a Pap test compared with 1.7% of visits without Pap testing (p<0.001).

During 1999–2010, the HEDIS measure of chlamydia testing of commercially insured females aged 16–20 years increased from 18.5% to 40.8% (Figure). During 2001–2010, the HEDIS measure of chlamydia testing of Medicaid-insured females aged 16–21 years increased from 39.6% to 54.6%. During 2005–2010, Title X service providers tested 3.4 million female family planning users aged 15–19 years for chlamydia, and the percentage of females tested for chlamydia increased from 49.8% in 2005 to 56.7% in 2010 (Figure). Over all years, the annual rates of chlamydia testing of Medicaid-insured females and Title X female family planning clinic users were both higher compared with rates of commercially insured females.

Discussion

In this report, nationally representative rates of chlamydia screening of U.S. adolescent females were estimated by using NSFG data to generate self-reported testing rates and by using NAMCS data to generate testing rates at visits on the basis of medical record review. HEDIS measure data and Title X data were used to estimate temporal trends in the annual chlamydia testing rate. Although the methods, age groups, and units of measure varied, all the findings support the conclusion that many sexually active adolescent females in the United States were not tested as recommended, even when they visited a physician with symptoms and signs consistent with chlamydial infection.

Chlamydia testing rates were lowest at visits to pediatricians, who conduct 48% of all health-care visits for adolescents aged 15–16 years and 23% of all visits for those aged 17–18 years (29), two age groups with high rates of infection (1–3). Many screening opportunities at clinical visits were missed for young females, including at preventive visits. Preventive visits are an ideal opportunity to discuss sexual and reproductive health issues, including STD and pregnancy prevention, and to perform chlamydia screening (30,31). Testing rates were higher among females who used reproductive health services, both by self-report in NSFG and by medical record review in NAMCS. However, even at visits for reproductive health care, testing was suboptimal, and many opportunities were missed. Testing coverage has not increased to a sufficient extent over the 12-year period that HEDIS data have been monitored. Although testing rates were higher for Medicaid-insured females and Title X family planning clinic users compared with commercially insured females, testing rates in all these groups were suboptimal. Chlamydia screening of young females has been demonstrated to be cost-effective compared with other common clinical preventive services (32). Nevertheless, it is relatively underutilized compared with other preventive services recommended by USPSTF (32).

Ongoing changes in the U.S. health-care system offer opportunities to improve the use of clinical preventive services among infants, children, and adolescents. The Patient Protection and Affordable Care Act of 2010 (as amended by the Health Care and Education Reconciliation Act of 2010 and referred to collectively as the Affordable Care Act [ACA]) expands insurance coverage, consumer protections, and access to care and places a greater emphasis on prevention (33). As of September 23, 2010, ACA § 1001 requires nongrandfathered private health plans to cover, with no cost-sharing, a collection of four types of clinical preventive services, including 1) recommended services of USPSTF graded A (strongly recommended) or B (recommended) (34); 2) vaccinations recommended by the Advisory Committee on Immunization Practices (35); 3) services adopted for infants, children, and adolescents under the Bright Futures guidelines supported by the Health Resources and Services Administration (HRSA) and the American Academy of Pediatrics (36) and those developed by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children (37); and 4) women's preventive services as provided in comprehensive guidelines supported by HRSA (38). USPSTF recommends chlamydia screening as a Grade A service for sexually active nonpregnant females aged ≤24 years and for older nonpregnant women at increased risk (15). Screening is recommended as a Grade B service for pregnant females aged ≤24 years (15). State Medicaid programs cover chlamydia screening as part of the Early and Periodic Screening, Diagnostic and Treatment benefit (39).

The Health Insurance Marketplace (or Health Insurance Exchange) began providing access to private health insurance for small employers and to persons and families interested in exploring their options for coverage, with policies taking effect as early as January 2014.* Federal tax credits are available on a sliding scale to assist those living at 100%–400% of the federal poverty level who purchase health insurance through the Marketplace (ACA § 1401). Insurance plans sold on the Marketplace must cover the four types of recommended clinical preventive services without cost-sharing, including chlamydia screening.

In 2010, a total of 18% of U.S. females aged 15–21 years were uninsured (40,41). Although ACA will decrease barriers to access to chlamydia screening services, it is difficult to anticipate the extent to which use of chlamydia screening will increase. Chlamydia screening has not been used fully by those who currently have access to health care, with low rates of screening at visits for preventive care and reproductive health services. Even as access to services without patient costsharing expands, the challenge of increasing use will remain. Barriers to screening adolescents include lack of provider skill and comfort in taking the sexual history that is required to identify sexually active adolescents who should be screened (42), and lack of disclosure of sexual behavior by adolescents (43). Patients might have concerns about lack of confidentiality caused by an explanation of benefits that is sent by a health plan to the policy holder, who is often the adolescent's parent or guardian (44). Adolescents might not have access to a health-care provider or venue where they think that their privacy would be maintained (45,46). Clinicians or adolescents might not be aware of the risk for infection. Many competing demands and priorities in an often brief clinical encounter also can be a barrier to chlamydia screening, especially given the sensitive discussion about sexual behaviors that is necessary to identify those who should be tested.

CDC, in collaboration with its public health partners, can develop and implement simple, affordable, and sustainable interventions to overcome barriers and facilitate screening of adolescents. These interventions are needed to ensure that as barriers to health care are decreased by ACA, chlamydia screening services are accessible to all sexually active females. Although toolkits and other resources have been developed (31,47,48) and widely disseminated to primary care providers including pediatricians (48,49), screening rates have been low. Possible interventions to increase screening include the use of electronic health record prompts to increase screening and retesting of those who are found positive. Prompts have been demonstrated to be most effective when used as part of a more comprehensive effort that includes additional interventions including implementation teams, training of providers, provider feedback, and panel management (50–52). Structural interventions (e.g., clinic protocols and procedures) can facilitate adherence to recommendations for screening and improve health-care system performance. The structural intervention of placing a chlamydia collection swab beside a cervical cytology kit has been demonstrated to be successful in ensuring that a chlamydia test also was performed (53). However, because cervical cancer screening guidelines no longer recommend cervical cytologic screening for females aged <21 years (54), alternative interventions need to be developed as fewer adolescents are screened for cervical cancer and thus for chlamydia (55). Providers and patients will need to use other existing opportunities to test for chlamydia, such as at visits for preventive care, contraception, and pregnancy testing (56). In addition, the implementation of patient-centered interventions that facilitate self-collection of specimens can be effective to increase screening. Primary care providers might perform chlamydia screening more often if they were to be made aware that a test can be performed easily without a pelvic exam by using a self-collected vaginal swab specimen or urine (4). Finally, social marketing campaigns for young females, such as the Get Yourself Tested (GYT) campaign, have been demonstrated to increase patient demand for screening (57,58).

Limitations

The findings in this report are subject to at least nine limitations. First, although NSFG data are representative of all sexually active U.S. females and accurately identify females who should have been tested on the basis of their self-reported sexual activity, testing rates might be either overestimated or underestimated because females who had a chlamydia test were identified by self-report of the test. Many females who have a gynecologic examination or Pap test might incorrectly assume that a chlamydia test also was performed (59), resulting in an overestimate of testing. Females might not know that a chlamydia test was performed, and this also might lead to an underestimate of testing. Second, with NAMCS data, chlamydia tests are more accurately identified by a review of the patient's medical record, but the unit of analysis is a visit rather than a person. Young females might have had more than one visit in a year and other opportunities for testing besides the reviewed visit, possibly leading to an underestimate of testing rates. In contrast, NSFG captures testing performed in venues in addition to physician offices. Third, NAMCS data do not distinguish whether females are sexually active or not, and nonsexually active females would not require a test. This would result in an underestimate of the testing rate. However, reproductive health visits probably were made by sexually active adolescents, and rates of testing rates at these visits were also very low. Fourth, among the data sources analyzed, only NAMCS included variables to distinguish symptomatic and asymptomatic screening. In contrast, NSFG does not collect data on whether females were symptomatic or asymptomatic for chlamydial infection, so it was not possible to distinguish screening of asymptomatic females from testing of symptomatic females. Fifth, the HEDIS measure of chlamydia screening includes only females who utilize reproductive health-care services, likely resulting in inclusion of too few females in the denominator and an overestimate of testing rates. Sixth, all female family planning clinic users were included in the analysis of Title X data on the assumption that they were all sexually active. Some users might not have been sexually active, and their inclusion in the denominator would result in an underestimate of screening rates. However, it is likely that most adolescents seeking reproductive health care at a Title X service site are sexually active. Seventh, with both HEDIS measures and Title X data, service providers might change over time, and trends in testing might reflect changes in the service providers participating in the program rather than changes within clinics. Eighth, rates calculated using HEDIS and Title X data were made on the basis of convenience samples, so the findings cannot be generalized to the U.S. population. Finally, Medicaid and Title X family planning clinic users might be at increased risk for chlamydial infection (60,61), and this might have led clinicians who care for these populations to be more likely to test for chlamydia, resulting in an overestimate of testing rates compared with the general population of U.S. adolescents.

Conclusion

In the United States, chlamydia screening rates have been suboptimal with fewer than half of sexually active females aged 15–21 years screened annually. Although testing and screening rates varied by demographic characteristics, insurance type, screening venue, and type of health-care services used, suboptimal rates indicate that improvement in screening coverage is needed. Provision of this simple, affordable, effective, and cost-effective service can protect the reproductive health of adolescents and prevent infertility and ectopic pregnancy. Interventions are needed to increase patient and provider adherence to the recommendation for annual chlamydia screening of all sexually active females aged ≤24 years.

CDC will continue to use the four data sources described in this report to monitor chlamydia screening trends. The usefulness of surveys would be enhanced by adding additional questions to ascertain whether a female was symptomatic or sexually active. Together, these data can be used to track trends in chlamydia screening and to provide valuable information for improving access and use of this important preventive service by adolescent females. Access to chlamydia screening will likely be increased with implementation of ACA, and CDC and its public health partners will use the chlamydia testing data provided in this report to develop focused interventions for at-risk groups and to identify missed opportunities for screening and testing of those who access care.

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