Epidemiology of Chlamydia Gonorrhea Syphilis and Corrections Overlapping Populations

Chlamydia and Gonorrhea

The United States has the highest rates of STIs among developed countries (Eng & Butler, 1997). Chlamydia and gonorrhea are the two most commonly reported infections with 976,445 and 339,593 cases reported in 2005 (CDC, 2006a). Chlamydia and gonorrhea are most common in persons aged 25 and younger, with peak rates among females aged 15-19 and males aged 20-24 (CDC, 2006a). Rates also are substantially elevated in some racial/ethnic minority populations. Compared with whites, chlamydia rates are more than 7 times greater among blacks, nearly 5 times greater among American Indians/Alaskan Natives, and 3 times greater among Hispanics (CDC, 2006a). Even greater disparities exist in gonorrhea rates, with the rates more than 19 times greater among blacks, more than 3 times greater among American Indians/Alaskan Natives, and more than 2 times greater among Hispanics compared with whites (CDC, 2006a). In addition to demographic characteristics, other risk markers for STIs include: multiple sex partners, drug and alcohol abuse, lower educational attainment and socioeconomic status, and poor access to medical care (Aral & Holmes, 1999).

Chlamydia and gonorrhea can lead to serious long-term sequelae in women, including chronic pelvic pain, pelvic inflammatory disease, infertility, and ectopic pregnancy (Hook & Handsfield, 1999; Stamm, 1999). Additionally, these infections increase the susceptibility and transmissibility of HIV infection (Fleming & Wasserheit, 1999). Annual chlamydia screening of sexually active women aged 25 and younger is recommended (CDC, 2006b), but there are no guidelines for screening men. Because most chlamydial and gonococcal infections in both females and males are asymptomatic (Hook & Handsfield, 1999; Stamm, 1999), screening and treatment of asymptomatic infections is essential for disease prevention and control. Large-scale screening programs that have been in place for several years have decreased both community chlamydia prevalence and disease outcomes (Addiss et al., 1993; Mertz et al., 1997). The most effective method to control chlamydia is routine screening in high- volume, high-prevalence settings (Farley et al., 2003).

Syphilis

Syphilis is a genital ulcerative disease that causes significant cardiovascular and neurological complications if untreated (Sparling, 1999). In pregnant women, 40% of untreated early syphilis results in perinatal death (Radolf et al., 1999). If syphilis was acquired during the 4 years preceding pregnancy, it could lead to infection of the fetus in over 70% of cases (Radolf et al., 1999). Like other STIs, syphilis also facilitates the transmission of HIV (Fleming & Wasserheit, 1999). Syphilis infection is staged by symptoms and likely duration of infection. Early infections of less than 1 year's duration (primary, secondary, and early latent) are the most important stages from a public health perspective, because they represent recent infections among persons and sexual networks which should be targeted for intervention to prevent further ongoing transmission within a community.

Syphilis was extremely common until the introduction of penicillin in the 1940s, with up to 25% persons of lower socioeconomic status infected (Sparling, 1999). Syphilis rates reached a nadir in the United States in 2000, and rates continued to decline among women through 2003 (CDC, 2006a). Beginning in 2001, rates increased nationally among men who have sex with men (MSM) (CDC, 2006a). During 2005, there were 33,278 reported cases of syphilis in the United States, 1/10 the number of gonorrhea cases and 1/30 the number of chlamydia cases (CDC, 2006a). The majority of counties (78%) in the United States reported no cases of syphilis, and half of syphilis cases were found in just 19 counties and two cities (CDC, 2006a). During the late 1990s, syphilis elimination in the United States was considered plausible because of the historically low rates of infection, the limited geographic distribution of infection, and the availability of effective and inexpensive diagnostic tests and treatment (St Louis & Wasserheit, 1998).

For reasons that are not totally clear, syphilis affects a slightly older population than chlamydia and gonorrhea; the peak age among women is 20-24, among heterosexual men is 25-29, and among men who have sex with men is 35-39 (CDC, 2006a). Like chlamydia and gonorrhea, there are substantial differences in rates by race/ethnicity. Among women, compared with whites, African American rates are nearly 15 times greater, American Indian/Alaskan Native rates are 5 times greater and Hispanic rates are 3 times greater (CDC, 2006a).

Correctional Populations

Many persons housed temporarily in jails and juvenile detention facilities have risk factors for STIs: unprotected sex with multiple partners before incarceration, poor access to medical care, lack of education, a personal or family history of drug and alcohol abuse, a history of physical and sexual abuse, young age, and racial or ethnic minority status (Beltrami et al., 1997; Aral & Holmes, 1999; James, 2004; Bureau of Justice Statistics, 2004; Margolis et al., 2006). More than 60% of detained persons are racial or ethnic minorities, more than 40% are younger than 30, and more than 85% are male (National Center for Juvenile Justice, 2004; Bureau of Justice Statistics, 2005; Harrison & Beck, 2006). More specifically, 10% of young African-American males, aged 18 to 29, currently are incarcerated (Harrison & Beck, 2006), and a higher proportion have been incarcerated in the past year. The U.S. Bureau of Justice estimates that with current rates of first incarcerations, 32% of African-American males will enter long-term state or federal prisons during their lifetimes, compared to 17% of Hispanic males and 6% of white males (Bureau of Justice Statistics, 2004). A much higher proportion of men will spend at least some time in short-term juvenile detention or jail settings. Most individuals detained in jails and juvenile detention facilities are released and return to their communities within only a few days or weeks, and many subsequently have unprotected sex (Skolnick, 1998; MacGowan et al., 2003). Thus, the cycle of STI transmission can continue once persons are released from periods of short-term incarceration.

Overlapping Populations—Corrections and STIs

The epidemiology of chlamydia, gonorrhea, syphilis, and correctional populations suggest that some of the persons at greatest risk for STIs are those who pass through correctional settings. Figure 12.1 is illustrative of this point. The San Francisco Department of Public Health (SFDPH) has performed targeted chlamydia and gonorrhea screening of women and

(A) Average Annual Jail Testing Density Number of persons tested in jail/1,000 population/year

(B) Female Chlamydia Rate Per 100,000 Population

(A) Average Annual Jail Testing Density Number of persons tested in jail/1,000 population/year

(B) Female Chlamydia Rate Per 100,000 Population

Figure 12.1 (A) Average annual jail testing density, 1997-2004 and (B) female chlamydia rate, 2004 by neighbourhood — San Francisco.

men in the county jails since the fall of 1996. Screening is targeted by age, not by residence. To compare screening in jail by neighborhood, SFDPH calculated jail testing density, which was defined as the average number of persons in the age and sex groups targeted for jail screening who were tested during 1997-2004, divided by the year 2000 census population for these same age and sex groups. In Figure 12.1, the San Francisco map on the left represents jail testing density. It is apparent that the greatest density of testing in jails occurred among residents of the southeastern portion of the city. The map on the right shows 2004 chlamydia rates among women, with the highest rates in the southeast. In San Francisco, there is a significant correlation between the neighborhoods with the greatest jail testing density and the highest rates of chlamydia.

During the second half of 2004, the City of New York Department of Correction began screening men aged 35 and younger for chlamydia at Rikers Island Jail. Prior to this time only men with symptoms were tested (personal communication from Julie Schillinger, New York City Department of Health and Mental Hygiene). Figure 12.2 demonstrates the remarkable number of infections that were detected after this asymptomatic screening program was implemented. The number of infections detected among males in corrections increased 12-fold between the first half of 2004 and 2005. During 2005, there were 40% more infections detected at Rikers Island Jail than in the 10 New York City STD Clinics, and jail screening increased the total number of reported cases of chlamydia among men in the entire city by 60%. The New York City public health surveillance data suggest that there is a tremendous reservoir of asymptomatic chlamydial infection among young adult men in jail.

While incarcerated males are at high risk for chlamydia, the prevalence of infections varied substantially in published studies, from 3% to 25% (Brady et al., 1988; Beltrami et al., 1998; Cromwell et al., 2002; Mertz, Voight, et al., 2002; Chen et al., 2003; Hardick et al., 2003; Bauer et al., 2004; CDC, 2005, 2006a; de Ravello et al., 2005; Kahn et al., 2005; Robertson et al., 2005; Trick

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