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RESEARCH |
Kristen J. Mertz, Raymond L. Ransom, Michael E. St. Louis, Samuel L. Groseclose, Alula Hadgu, and William C. Levine are with the Division of STD Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Ga. Charles Hayman is with the Employment and Training Administration, Department of Labor, Washington, DC.
Correspondence: Requests for reprints should be sent to William C. Levine, MD, Centers for Disease Control and Prevention, Mail Stop E-02, 1600 Clifton Rd NE, Atlanta, GA 30333.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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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 
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.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The job-training program for economically disadvantaged youths administered by the US Department of Labor enrolls more than 60 000 young men and women aged 16 to 24 years each year at approximately 100 centers across the country.7 In 1997, approximately 40% of the enrollees were women, 72% were minorities, 33% came from families on public assistance, 78% were high school dropouts, and 63% had never held a full-time job.7 Because prevalence of chlamydial infection is usually high in adolescents, minorities, and persons of low socioeconomic status,8 women entering the program are routinely screened for chlamydia.9 We assessed trends in the prevalence of chlamydial infection in this population from May 1990 through June 1997.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We included women aged 16 to 24 years (>99% of women tested) in the analysis. We restricted our analysis to specimens labeled as "entrance examination" tests that had a new patient code number. Using the US Postal Service's computerized zip code files, we derived state of home residence before enrollment from the zip code of residence. States of residence were grouped into 4 US Census Bureau regions (South, Northeast, Midwest, and West).
The percentage of women enrolled in the program who were tested for chlamydial infection at entrance was calculated by dividing the number of entrance examination test results by the number of women enrolled in the program. Enrollment numbers and the age and state of residence of enrollees were obtained from the program's Data Center.
Prevalence of infection was calculated by individual age, age group (16–19 years, 20–24 years), race/ethnicity (White, Black, Hispanic, American Indian/Alaskan native, Asian/Pacific Islander), geographic region of residence, presence or absence of symptoms, and time period (1990–1993, 1994–1997). Adjusted odds ratios were calculated by logistic regression analysis to determine independent predictors of chlamydial infection.
The relative change in prevalence from 1990 to 1997 was calculated for all women tested and for each age group, race/ethnicity, and geographic region in which at least 200 women per year were tested. Confidence intervals for the relative decrease in prevalence in each group were obtained by Taylor series approximation.11 We evaluated the significance of trends with the 2 test for trend by using calendar-year periods.12
We adjusted annual prevalence for age (16–17, 18–19, 20–21, 22–24 years) and race/ethnicity (White, Black, Hispanic, other), using the 1990 female program population as the "standard" population. Because the demographic characteristics of the female program population were stable over time, age- and race/ethnicity-adjusted prevalence was similar to unadjusted prevalence; therefore, we chose to present only unadjusted prevalence.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Of the specimens submitted, 577 (0.4%) were unsatisfactory and were excluded from the analysis. Of the remaining 141 336 tests, 17 597 (12.5%) were positive. Prevalence was significantly higher for adolescents; minorities; those living in the South, Midwest, and Northeast compared with those in the West; and those with symptoms of infection (Table 1
). As age increased, prevalence of chlamydial infection decreased (Table 2). Prevalence was significantly higher for adolescents aged 16 through 19 than for women aged 20 through 24 years in all regions and for all racial/ethnic groups (data not shown). Prevalence was significantly higher for Blacks than for Whites in all 4 regions (data not shown). Similarly, prevalence for Hispanic women was significantly higher than that for Whites in all regions except the South, where prevalence for Hispanic women (10.0%) was the same as that for White women.
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). The early time period (1990–1993) was independently associated with increased risk for chlamydial infection.
The prevalence of chlamydial infection decreased 32.9% (95% confidence interval [CI] = 27.4%, 37.5%) during the study period, from 14.9% in 1990 to 10.0% in 1997 (P < .001) (Figure 1). After age and race/ethnicity were adjusted for, the relative change in prevalence was not significantly different from the unadjusted decrease (data not shown). The decrease in the prevalence of chlamydial infection from 1990 to 1997 was statistically significant for all age, racial/ethnic, and geographic groups (P < .05). The relative decrease in prevalence was 28.8% (95% CI = 22.9%, 34.6%) for women aged 16 to 19 years and 39.7% (95% CI = 28.7%, 50.6%) for women aged 20 through 24 years. By region, the relative decrease was 40.4% (95% CI = 29.7%, 51.2%) for the Midwest, 37.0% (95% CI = 25.1%, 49.0%) for the West, 36.6% (95% CI = 25.3%, 47.9%) for the Northeast, and 24.1% (95% CI = 15.9%, 32.3%) for the South. The relative decrease was larger for Whites (41.5%; 95% CI = 30.0%, 52.9%) and Blacks (33.6%; 95% CI = 27.5%, 39.6%) than for Hispanics (6.3%; 95% CI = –14.0%, 26.5%).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Although screening programs for chlamydia were instituted in the 1980s in some sexually transmitted disease (STD) clinics, family planning clinics, and private physicians' offices,13,16,17 many medical care providers did not implement chlamydia screening until the mid-1990s, if at all.14,18 Federal funding for infertility prevention that supported screening and treatment services was limited until the mid-1990s.4 It was not until 1993 that the CDC issued a recommendation for health care providers to screen all sexually active adolescent women for chlamydia.8 Given the lack of screening in the early 1990s in many communities, screening programs are probably only 1 of several factors contributing to the decrease in the prevalence of chlamydia in this population. Other factors, such as increased condom use and decreased sexual experience in adolescents, may have contributed to the nationwide decline in the prevalence of C trachomatis in female enrollees.19,20 AIDS prevention activities, introduced in the 1980s, may have contributed to the increase in safe sex or delayed sex and thus to the decline in the incidence of STDs. Concurrent with the decrease in the prevalence of chlamydial infection in program enrollees, the prevalence of HIV infection in program enrollees declined 50% from 1990 to 1996.21
Possible reasons for a smaller decline in the prevalence of chlamydial infection in Hispanics than in other racial/ethnic groups include less access to medical care in the 1990s and less access to safe sex messages. Data from the National Survey of Family Growth in 1995 indicated that Hispanic women were less likely than non-Hispanic White or Black women to have health insurance, to have received a pelvic examination during the preceding 12 months, or to have received any formal sex education before the age of 18 years.20
There are several limitations or potential biases in these prevalence estimates. First, chlamydia test results are available for only 81% of all female entrants. Some women may have dropped out of the program before getting tested, some may not have been tested because they denied being sexually active,22 and some were tested by a noncontract laboratory. If most of those not tested were not sexually active, our prevalence estimates are too high for the entire population. On the other hand, the prevalence data shown here may underestimate prevalence in female entrants, because the sensitivity of the enzyme immunoassay used throughout the study period is estimated to be 77%.10 Trends should not be affected by either of these potential biases.
Despite the marked decline in the prevalence of chlamydial infection in female program entrants documented here, prevalence was still very high in 1997, especially in adolescent women. The program is providing a much-needed service by testing and treating this population for chlamydial infection, thus preventing medical complications of C trachomatis infection and transmission to sex partners. In the communities where these out-of-school, unemployed, economically disadvantaged young women live before entering the program, it is necessary to strengthen prevention and control efforts. Health care providers should be encouraged to implement routine chlamydia screening and treatment for young women, encourage treatment for sex partners of women testing positive, and provide education and counseling about safe sex practices. Screening and education in nontraditional settings, such as schools, juvenile detention facilities, and drug treatment centers, may help to further reduce chlamydial infection in sexually active adolescents.23
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Acknowledgments |
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Footnotes |
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Accepted for publication September 26, 2000.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. 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.[Abstract]
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Royce RA, Sena A, Cates W, Cohen MS. Sexual transmission of HIV. N Engl J Med.1997;336:1072–1078.
4. Hillis S, Black C, Newhall J, Walsh C, Groseclose SL. New opportunities for chlamydia prevention: applications of science to public health practice. Sex Transm Dis.1995;22:197–202.[Medline]
5. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1994. Atlanta, Ga: Centers for Disease Control and Prevention; September 1995.
6. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1997. Atlanta, Ga: Centers for Disease Control and Prevention; September 1998.
7. Job Corps Annual Report, Program Year 1997. Washington, DC: US Dept of Labor; 1998.
8. Centers for Disease Control and Prevention. Recommendations for the prevention and management of Chlamydia trachomatis infections, 1993. MMWR Morb Mortal Wkly Rep.1993;42(RR–12):2.
9. Policy and Requirements Handbook. Washington, DC: US Dept of Labor; 1998.
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11. Casella T, Berger RL. Statistical Inference. Pacific Grove, Calif: Wadsworth & Brooks/Cole Advanced Books and Software; 1990.
12. Schlesselman JJ. Case–Control Studies. New York, NY: Oxford University Press; 1982.
13. Mertz KJ, Levine WC, Mosure DJ, Berman SM, Dorian KJ. Trends in the prevalence of chlamydial infections: the impact of community-wide testing. Sex Transm Dis.1997;24:169–175.[Medline]
14. Centers for Disease Control and Prevention. Chlamydia prevalence and screening practices—San Diego County, California, 1993. MMWR Morb Mortal Wkly Rep.1994;43:366–369, 375.[Medline]
15. Groseclose SL, Zaidi AA, DeLisle SJ, Levine WC, St. Louis ME. Estimated incidence and prevalence of genital Chlamydia trachomatis infections in the United States, 1996. Sex Transm Dis.1999;26:339–344.[Medline]
16. Britton TF, DeLisle S, Fine D. STDs and family planning clinics: a regional program for chlamydia control that works. Am J Gynecol Health. 1992;6:24–31.
17. Addiss DG, Vaughn ML, Hillis SD, Ludka D, Amsterdam L, Davis JP. History and features of the Wisconsin Chlamydia trachomatis control program. Fam Plann Perspect.1994;26:83–87.[Medline]
18. Centers for Disease Control and Prevention. Chlamydia screening practices of primary-care providers—Wake County, North Carolina, 1996. MMWR Morb Mortal Wkly Rep.1997;46:819–822.[Medline]
19. Centers for Disease Control and Prevention. Trends in sexual risk behaviors among high school students—United States, 1991–1997. MMWR Morb Mortal Wkly Rep.1998;47:749–752.[Medline]
20. Abma J, Chandra A, Mosher W, Peterson L, Piccinino L. Fertility, family planning, and women's health: new data from the 1995 Survey of Family Growth. Vital Health Stat 23. 1997;No. 19.
21. Valleroy LA, MacKellar DA, Karon JM, Janssen RS, Hayman CR. HIV infection in disadvantaged out-of-school youth: prevalence for US Job Corps entrants, 1990 through 1996. J Acquir Immune Defic Syndr Hum Retrovirol.1998;19:67–73.[Medline]
22. Lifson AR, Halcon LL, Hannan P, St. Louis ME, Hayman CR. Screening for sexually transmitted infections among economically disadvantaged youth in a national job training program. J Adolesc Health.2001;28:190–196.[Medline]
23. Institute of Medicine. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Eng TR, Butler WT, eds. Washington, DC: National Academy Press; 1997.
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