Chlamydia Prevention in the US: Update from CDC

National Chlamydia Coalition Meeting

4 December, 2009

John M. Douglas, Jr., MD

Director, Division of STD Prevention

Centers for Disease Control and Prevention

Outline

• CDC priorities • CT surveillance status report• Priorities for 2010 and beyond

– National Chlamydia Coaltion– Other efforts at CDC

CDC Under Dr. Frieden: New Priorities

• Strengthen– Surveillance and epidemiology– Ability to support state and local public health

• Provide public health leadership in– Global health– Health polices especially health reform– Better addressing leading causes of death and disability

Improve efficiency of day-to-day functioning (personnel, procurement) and save money

Organizational Improvement All Hands, 8/27/09

NCHHSTP Strategic Plan: 2009 – 2015 Goals

• Goal 1: Program Collaboration and Service Integration

• Goal 2: Health Equity• Goal 3: Global Health Protection and Systems

Strengthening• Goal 4: Partnerships• Goal 5: Workforce Development and Capacity

Building

DSTDP Strategic Plan: Goals

Reaffirmation of existing disease-focused goals1. Prevent STI related infertility2. Prevent STI-related adverse outcomes of pregnancy3. Prevent STI-related cancers4. Prevent STI-related HIV transmission and acquisition

Operational reality: declining public health infrastructure 5. Strengthen STD prevention capacity and infrastructure

Unaddressed realities6. Reduce STD health disparities across and within communities and populations7. Address the effects of social and economic determinants of specific STDs and associated sequelae among specific populations

Chlamydia — Rates: Total and by sex: United States, 1989–2008

Note: As of January 2000, all 50 states and the District of Columbia had regulations requiring the reporting of chlamydia cases.

0

120

240

360

480

600

1989 91 93 95 97 99 2001 03 05 07

Rate (per 100,000 population)

MenWomenTotal

Total Cases =1,210,523B:W ratio= 8:1% dx’d STD clinics= 15%

Chlamydia — Median state-specific positivity among 15- to 24-year-old women

tested in family planning clinics: United States, 1997–2008

Note: As of 1997, all 10 DHHS regions, representing all 50 states, the District of Columbia, and outlying areas, reported chlamydia positivity data. SOURCE: Prevalence Monitoring Project (Regional Infertility Prevention Projects); Office of Population Affairs; Local and State STD Control Programs; Centers for Disease Control and Prevention

0

2

4

6

8

10

1997 98 99 2000 01 02 03 04 05 06 07 08

Median state-specific positivity rate

CT Prevention: Evidence of Progress

• NHANES studies– Representative national sample of general population– Most recent wave indicates no evidence of increase

• National Job Training Program– High-risk population, single lab– Significant declines 2003-7 for F (19%) and M (8%)

• Sentinel surveillance for PID– NDTI surveys indicate geometric average annual

declines of 10% 2002-2008.

Annual Chlamydia Screening in Commercial and Medicaid Plans, HEDIS

2000 - 2008

0%

10%

20%

30%

40%

50%

60%

70%

16 - 20 YO Commercial 16 - 20 YO Medicaid21 - 26 YO Commercial 21 - 26 YO Medicaid

Data from State of Health Care Quality reports from NCQA,, Healthcare Effectiveness Data and Information Set.

59%

53%

43%

40%

Challenge: NCSD Survey on STD Program Capacity and Infrastructure (Wong, 2009 NCSD mtg)

• Survey of states and selected health jurisdictions (n = 79) surveyed on impact of recession on STD programs; 81% response

• Results– Salary freezes/reductions: 64%– Furloughs/shutdown days: 47%– Staff layoffs: 25%– STD clinic closures: 25% of 39 (32

nationwide)– Services cut: clinical/lab 31%, DIS 36%, STD

screening 27%– Major involvement in H1N1 (67% spring, 76%

expected fall)• Conclusion:

– severe erosion in capacity for STD and emergency response

– capacity may be difficult to recover even with restored funds

– greater need for collaboration with health care delivery system

STD Prevention in the Era of Health Reform: Priorities

• Health system reform, rather than health care or health insurance reform would have been optimal

• However, even HI reform with greater access presents new options• Scale-up of prevention interventions for population impact

– Will require a more intentional focus on “horizontal” health care delivery systems than STD prevention programs have traditionally done

– Greater focus on assessment, assurance, policy than on direct services

– This should clearly happen at national level (eg, National CT Coalition, collaboration with HRSA, CHCs)

– What is role of local/state HD in such a horizontal re-alignment? (eg, how to enhance assessment, assurance, policy roles?)

NCC: Key Partner for the FutureNCC: Key Partner for the Future

• Health Reform offers new opportunities to support Health Reform offers new opportunities to support implementation of key strategiesimplementation of key strategies

• NCC is well positioned to support government goals and NCC is well positioned to support government goals and prioritiespriorities

• Local affiliates and chapters could partner with state and Local affiliates and chapters could partner with state and local STD programs to expand dissemination of tools local STD programs to expand dissemination of tools and reach new audiencesand reach new audiences

• With exemplary performance come high expectations for With exemplary performance come high expectations for the futurethe future

• Can engage new partners in the research community Can engage new partners in the research community and pharmaceutical and laboratory industries.and pharmaceutical and laboratory industries.

NCC Early Returns: Key NCC Early Returns: Key Accomplishments to DateAccomplishments to Date

• NCC has evolved faster than expected for most coalitionsNCC has evolved faster than expected for most coalitions

• Key outcomesKey outcomes

– Development and dissemination of Implementation GuideDevelopment and dissemination of Implementation Guide

– Publication of USPTF recommended services for Publication of USPTF recommended services for adolescentsadolescents

– Compilation of resources for providers Compilation of resources for providers

– Successful support of HEDIS accreditation measureSuccessful support of HEDIS accreditation measure

– Engagement of wide variety of partners (providers, health Engagement of wide variety of partners (providers, health plans, advocacy organizations, researchers, federal plans, advocacy organizations, researchers, federal agencies and community-based organizations)agencies and community-based organizations)

NCC: New Developments to ComeNCC: New Developments to Come

• Launching mini-grants programs to implement innovative Launching mini-grants programs to implement innovative strategies to increase CT screening and follow-up care and strategies to increase CT screening and follow-up care and partner treatmentpartner treatment

• Series of Roundtables to examine critical policy issues to Series of Roundtables to examine critical policy issues to – expand implementation of EPTexpand implementation of EPT– increase coordination across federally-funded programs increase coordination across federally-funded programs

(including Medicaid, adolescent health, maternal and (including Medicaid, adolescent health, maternal and child health, school-based clinics and community health child health, school-based clinics and community health centers)centers)

• Proactive outreach to mediaProactive outreach to media• Evaluating and documenting accomplishments of the NCC Evaluating and documenting accomplishments of the NCC

(CDC-P4P collaboration)(CDC-P4P collaboration)

Tuesday, December 1, 2009

WETZSTEIN: STD exams needed early

A prominent medical group recently suggested that American teenage girls and college-age women avoid getting gynecological exams for cervical cancer until they turn 21.

I hate to second-guess this esteemed group, but when one in four U.S. teenage girls has a sexually transmitted disease (STD), the advice seems odd to me.

I would think medical professionals would urge every American woman who is single and sexually active to run, not walk, to a doctor's office every few months for a genital checkup. This goes double for teens and college-age girls.

Getting regular genital exams is just prudent these days - and with chlamydia cases reported at a record 1.2 million, there's no time to delay.

Chlamydia is curable with antibiotics, said Susan Maloney of the National Chlamydia Coalition. The chlamydia test is easy to do (just a vaginal swab); some doctors are starting to ask women getting Pap smears whether they would like a chlamydia test too.

Sexually active young women should ask their doctors for a chlamydia test whether they "feel anything or not," Ms. Maloney said.

CT prevention: Other CDC Efforts• CDC-HRSA collaboration

– Leadership meetings Nov 2009– Range of possible synergies

• Evaluation of antenatal CT prevalence to monitor impact at state/local levels

• Chlamydia Evaluation Initiative– 8 project areas funded to assess approaches to monitor

screening coverage• CT modeling

– Assesses impact of screening coverage and partner RX on prevalence

• “Chlamydia Prevention and Control” selected as a topic for new monthly CDC PH Grand Rounds

• Assessment of CT screening in high- and low-performing health plans– Public awareness/demand thought to be critical

Development of Children’s Development of Children’s Healthcare Quality Measures Healthcare Quality Measures

• Secretary will identify quality measures for Medicaid and Secretary will identify quality measures for Medicaid and CHIPCHIP– Covers 45% of those < 19Covers 45% of those < 19

• Mandated by Title IV of CHIPRAMandated by Title IV of CHIPRA• Subcommittee established by CMS and AHRQ scored Subcommittee established by CMS and AHRQ scored

over 120over 120• Submitted 25 to HHS and OMBSubmitted 25 to HHS and OMB• Chlamydia screening currently on the listChlamydia screening currently on the list• Comments will be solicited in Jan 2010Comments will be solicited in Jan 2010

– Opportunity for public input!!Opportunity for public input!!

Evolving Landscape of EPT: Evolving Landscape of EPT: Legal Status SummaryLegal Status Summary

EPT is Potentially Allowable

EPT is Likely Prohibited

EPT is Permissible

CA

OR

WA

NV

NM

UT

AZ

WY

CO

NB

KS MO

AROK

FL

GAALMS

LATX

WI

IA

MN

ID

MT ND

SD

NC

VAWV

KY

TN

OH

MI

INIL

VT

AK

HI

ME

NY

PA

RI

MA

NJ

CT

NH

SCDE

DC

MD(Baltimore only)

CA

OR

WA

NV

NM

UT

AZ

WY

CO

NB

KS MO

AROK

FL

GAALMS

LATX

WI

IA

MN

ID

MT ND

SD

NC

VAWV

KY

TN

OH

MI

INIL

VT

AK

HI

ME

NY

PA

RI

MA

NJ

CT

NH

SCDE

DC

MD

2006

2009

Legislation Pending

2006—2009: Increase of10 statesNon-EPT states with >30 k reportedcases: --FL, OH, MI, GA, NC, VA --23% all reported CT

Current CDC EPT EffortsCurrent CDC EPT Efforts• Continued technical assistance to states Continued technical assistance to states

requesting policy assistancerequesting policy assistance– Needs to be more focused on high-morbidity Needs to be more focused on high-morbidity

statesstates• New project with Centers for Law and Public’s New project with Centers for Law and Public’s

HealthHealth– Identify range of policy/legal tools needed by Identify range of policy/legal tools needed by

states to implement EPTstates to implement EPT– Develop toolbox and make available to statesDevelop toolbox and make available to states– Project to be completed by October 2010Project to be completed by October 2010

Public Outreach: Works in Progress

• GYTNOW: improving the process and extending the messagesGYTNOW: improving the process and extending the messages– though GYT09 marketing methods were appropriate for the though GYT09 marketing methods were appropriate for the

target audience, the process did not work well for our partners target audience, the process did not work well for our partners (eg, timing and availability of materials)(eg, timing and availability of materials)

– Extensive feedback being used to improve the next round of Extensive feedback being used to improve the next round of GYT, called GYTNOWGYT, called GYTNOW

– continued, constructive feedback by partners critical to produce continued, constructive feedback by partners critical to produce successful long-term effort successful long-term effort

• Infertility Prevention Social MarketingInfertility Prevention Social Marketing– OMB clearance delayed project by 1 yearOMB clearance delayed project by 1 year– Concept & Message testing (Nov-Dec 09)Concept & Message testing (Nov-Dec 09)– Next steps for campaign development, implementation & partner Next steps for campaign development, implementation & partner

engagementengagement

AcknowlegementsAmy Pulver

Raul Romaguera

Rhonda Perry

Stuart Berman

Catherine Satterwhite

The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC/ATSDR