Chlamydia in Boston - Boston Public Health Commission

The Boston Public Health Commission has a
goal to reduce Chlamydia rates overall among
Boston residents 15 through 24 years of age
and to reduce the gap in Chlamydia rates
between Black, Latino, and White residents 15
through 24 years of age by 25% over the next
five years.
Chlamydia in Boston
A Public Health Briefing
Understanding all of the factors
that affect our health
Dr. Barbara Ferrer
Executive Director
Boston Public Health Commission
"Today there are groups of residents
in Boston that have not benefited
equally from our progress and who
bear a severe and disproportionate
burden of diseases."
In Boston, we have made significant progress improving the health status for many of our residents.
Mortality rates have dropped steadily for the past 10 years, there are significantly fewer teen pregnancies,
a near disappearance of lead-poisoned children, and fewer people are smoking tobacco. Our success is
a result of improved surveillance; advances in medical research; increased access to prevention,
screening, diagnosis, and treatment; and policy changes that reduced exposure to harmful substances.
Nevertheless, today there are groups of residents in Boston that have not benefited equally from our
progress and who bear a severe and disproportionate burden of diseases. To tackle this imbalance, we
must understand and address the many issues that influence our health, paying particular attention to
finding approaches that allow all residents to have equal access to the conditions that promote the best
possible health.
In the recent past, many of our programs have focused on individual-level interventions, intended to
influence knowledge, attitudes, and behaviors. As we move forward, we will need to prioritize strategies
that address the interpersonal, community, and societal influences of disease transmission and health.
We will need to understand how racism and poverty limit the opportunity for many Boston residents to
make healthy choices and have led in particular, to significantly worse health outcomes for many Black
residents in the city. Our health is influenced by where we live, the jobs we hold, our knowledge of risk,
our access to resources, and our support systems, making it critically important that our public health
programs acknowledge and address these broader realities and contexts.
This briefing paper describes a significant racial inequity in Chlamydia rates in Boston and offers
information to help us identify opportunities for reducing the gap. The purpose of the briefing paper is to
allow our entire health department to work together through our practices, policies and research activities
to advance the health of our communities and eliminate persistent racial inequities in health outcomes.
Executive Summary
Key Points in Efforts to Reduce Chlamydia Rates in Boston
High Chlamydia rates have costly impact:
•
Chlamydia is the most frequently reported
Sexually Transmitted Infection (STI) in the
United States, with a 62% increase in rates
nationally since 2000 (CDC, 2008a).
•
In 2009, 4,148 Chlamydia cases were reported
in Boston residents.
BPHC will build on existing efforts:
Left untreated, Chlamydia infection can cause
pelvic inflammatory disease and infertility in
women.
The Commission will build on the prevention,
screening, treatment and policy work underway at
BPHC. A few examples are:
•
Groups in Boston are affected at substantially
different rates:
•
Boston residents ages 15 through 24 are almost
four times more likely to have Chlamydia than
residents overall.
•
Among that age group, 70% of those diagnosed
are female.
•
Blacks and Latinos of all ages had case rates
seven to 11 times higher than Whites in Boston.
•
Black adolescents and young adults (ages
15-24) had a case rate 20 times that of White
adolescents and young adults.
•
The BPHC is releasing the Sexual Health of
Boston Teens. The report includes data on
Chlamydia and other sexual health risk
factors, a snapshot of the knowledge and
attitudes of students and parents, and
recommendations to address risk factors
based on best practices.
•
Entre Familia and other programs in the
Addictions Bureau screen for sexual risk
factors and offer educational groups for
clients to learn about safer sex practices.
•
The Commissionʼs School Based Health
Centers provide STI screening for all
sexually active patients, following best
practice guidelines, and improving early
diagnosis. They also offer sexual health
education for individuals and groups.
•
The Infectious Disease Bureau has surveyed
Boston providers to determine current
screening and treatment practices and to
identify areas for improvement.
A multifaceted approach is called for to reduce
Chlamydia rates, including:
2
Examining factors that might contribute to
early onset of sexual activity like access to
high quality education, the availability of
after-school programs, and life and work
opportunities.
•
•
Efforts to improve overall sexual knowledge and
health.
•
Skills building to change behavior and reduce
unprotected sex.
•
Examining and improving practices related to
screening for and treating STIs.
•
Changing policies related to sex education in
schools, funding for prevention, and the
treatment of the partners of STI cases.
Find Out More
Visit the Commission-wide goals page on
the BPHC Intranet for more information and
to view an online presentation on this topic.
The Impact of Chlamydia on the U.S. and Boston
Chlamydia is a preventable and treatable Sexually Transmitted Infection (STI).
The disease is the most frequently reported STI in the United States, and infections have increased significantly over
the past decade. The Centers for Disease Control and Prevention (CDC) reports a 62% increase in rates nationally
since 2000 (CDC, 2008). Although some of this increase is due to technological improvements in laboratory testing,
and improvements in disease reporting, it is likely that the actual case numbers have increased. In addition to the
substantial costs associated with testing and treating the infection, left untreated, Chlamydia can cause pelvic
inflammatory disease and infertility in women.
The CDC reported that in 1995, STIs were the most common reportable diseases in the United States. (CDC, 1995)
“Each year an estimated 15 million new infections occur in the United States, and nearly 4 million teenagers are
infected with an STI. (American Sexual Health Association, 1998) The direct and indirect costs of the major STIs and
their complications …are conservatively estimated at $17 billion annually.” (IOM, 1997) STI rates in the United States
are higher than in all other industrialized countries in the world. (American Social Health Association, 1998)
In 2008, 1.2 million Chlamydia cases were reported to the CDC, the most cases ever in one year of any disease with a
rate of 401.3 cases per 100,000 people. Since many asymptomatic (without symptoms) cases are not detected, the
actual number is likely to be higher.
The CDC report on Sexually Transmitted Disease Surveillance (CDC, 2008) shows the following national trends, some
of which we see replicated in Boston:
•
•
•
•
•
•
Chlamydia rates for all racial and ethnic groups increased from 2007 to 2008.
The rate of Chlamydia among Black women was nearly eight times higher than the rate among White women
(2,056.9 and 264.4 per 100,000 women, respectively).
The Chlamydia rate among Black men was almost 12 times higher than the rate among White men (928.8 and
79.4 per 100,000 men, respectively).
The rate for Latinos (519.4 per 100,000
population) was almost three times higher
than for Whites (173.6).
Young people (15-24) have Chlamydia at
five times the rate of the total population
(10-65).
Black females ages 15-19 years old had the
highest rate of any age/race subgroup at a
staggering 10,513.4 cases per 100,000.
In 2009, 4,148 Chlamydia cases were reported in
Boston residents. Rates were highest among
Blacks, females, and those under age 25 years.
The figures below show the dramatic differences in
reported Chlamydia rates for different groups.
•
Among 15 to 24 year old Boston residents,
the Chlamydia incidence rate was 2,454
per 100,000 population as compared with
the overall rate in Boston of 704 per
100,000 (Figure 1).
•
15 to 19 year old Boston residents had the
highest Chlamydia rate (3,092 per
100,000) compared to any other age
group (Figure 1).
Figure 1
Figure 2
•
74% of the cases among those 15 to 24 years of age were in females.
•
Blacks and Latinos among all ages had case rates substantially higher than Whites in Boston (1,286 per
100,000 for Blacks compared to 820 for Latinos and 110 for Whites).
3
Multifaceted Approach is Required to
Reduce Inequities in Chlamydia Infections
Why is reducing the inequities in Chlamydia rates important?
First, Chlamydia often goes undetected in both women and men.
Without treatment, women can get pelvic inflammatory disease (PID)
that can lead to pain and infertility. A high percentage of men and
women have no symptoms and can continue to infect others if they are
not screened and treated. In addition, having an STI (particularly
untreated) may leave a person more vulnerable to other STIs including
HIV. It is also a public health responsibility to decrease Chlamydia, the
infection with the largest number of cases of any reportable condition.
(CDC, 2008).
Finally, differences in infection rates between races are grounded in
inequities and should be addressed.
BPHC has taken on the challenge of trying to reduce Chlamydia rates
and to reduce the inequities between racial/ethnic groups. It is likely
that some strategies being used to reduce infection rates will result in increased screening and thus the identification of
more reported cases, at least temporarily. Reducing the differences in the rates of infection in Blacks and Latinos
compared to Whites in the 15-24 year old range by 25% over the next five years will result in approximately 230 fewer
cases in Black residents and 120 fewer cases in Latino residents in that time period.
A multifaceted approach is called for to reduce the Chlamydia rate. This includes:
•
•
•
•
Efforts to improve overall sexual knowledge and health.
Examining and improving practices related to screening for and treating STIs.
Changing policies related to sex education in schools, condom availability, funding for prevention, and partner
treatment regulations.
Systems approaches such as availability of confidential teen services and examining factors that might
contribute to early onset of sexual activity or prevalence rates like access to high quality education, the
availability of after-school programs, and life and work opportunities.
How Does Racism Contribute to Poor Health & STIs?
All of the different forms of racism can have a corrosive affect on a person's
health in a number of ways. Racism can cause a lack of economic
opportunity through denial of work opportunities which can lead to a person
living in areas with high poverty, violence and environmental hazards.
Racism can also limit the delivery of health services which could otherwise
help preserve and promote good health. Exposure to racism, and the
stress it causes, can affect a person's self worth which can cause an
increase in risky behavior and lifestyle choices.
There are
several different
forms of racism.
(Source: California Dept. of Public Health, Presenting on STD Racial Health Disparities)
4
Internalized
Interpersonal
A set of private beliefs,
prejudices, and ideas that
individuals have about the
superiority of Whites and the
inferiority of people of color.
Among people of color, it
manifests as internalized racial
oppression. Among Whites, it
manifests as internalized racial
superiority.
The expression of racism
between individuals. These are
interactions occurring between
individuals that often take place
in the form of harassing, racial
slurs, or telling of racial jokes.
Institutional
Discriminatory treatment,
unfair policies and practices,
inequitable opportunities and
impacts within organizations
and institutions, based on race.
Structural
Racial bias across institutions
and society. Itʼs the cumulative
and compounded effects of an
array of factors such as public
policies, institutional practices,
cultural representations, and
other norms that work in
various, often reinforcing, ways
to perpetuate racial inequity.
Chlamydia: The unequal burden of disease
The Commissionʼs framework on social determinants of
health provides an outline of the factors that lead to racial
inequities in health. As noted below, some of these
factors may contribute to the inequities in Chlamydia
rates.
“Individual sexual behaviors including age of initiation of
sexual activity, number of lifetime sexual partners,
condom use, and substance use or alcohol use during sex
are associated with the level of risk for STIs. However,
prior studies have documented that these individual risk
behaviors do not fully account for the marked racial
disparities that disproportionately affect Blacks. The social
determinants of health, namely poverty, poor physical
conditions of neighborhoods, disproportionate
incarceration, and patterns of racial segregation have
been shown to be key factors in shaping the dynamics of
STDs.”(Hogben and Leichliter, 2008)
In a study of African American teenagers and young adults in a
rural area, lack of recreational opportunities, perceived lack of
safety and few dating options were cited as factors that
contributed to early or riskier sexual activity. (Akers,
Younmans, et al, 2008). Similar data for urban areas are
lacking. However, some have suggested that greater access to
after-school programming or jobs for teens might reduce the
level of sexual activity and enhance the perception of life
opportunity, thereby reducing sexual exposure, transmission,
the prevalence of infection and Chlamydia rates.
Social Determinants of Health Framework
A 2008 national study documented that one in four
adolescent girls has an STI (Chlamydia is among the four
most common along with Human Papillomavirus - HPV,
herpes and trichomoniasis). Half of the African American
girls in the study were infected as compared with 20% of
the White teen girls. (CDC, 2008)
Specific factors that may contribute to higher rates among
teens, girls and Blacks include:
•
biological factors that make young females more
susceptible to Chlamydia;
•
sexism and lack of empowerment that might
affect the ability of women to negotiate safer sex.
One study showed that women with less
education or lower household incomes were more
likely to report starting a relationship because of
economic need or having transactional sex
(Dunkle, Wingood, et al, 2010);
•
limited education and employment
opportunities and the impact of that on sense of
possibility, and likelihood to initiate sexual activity
at a younger age;
•
a higher rate of Chlamydia in certain sexual
networks (neighborhood, communities with higher
rates of incarceration, etc.);
•
racism and its impact on sexual behavior, and
on the personal actions taken to promote oneʼs
health and wellness.
Social determinants of health are the
circumstances in which people are born, grow, live,
work, play, and age that influence access to
resources and opportunities that promote health.
The social determinants of health include housing,
education, employment, environmental exposure,
health care, public safety, food access, income,
and health and social services.
5
The Burden by Neighborhood
Chlamydia rates vary markedly among Boston
neighborhoods with higher rates in areas with
other health problems, lower income, less
access to educational opportunity and more
economic stressors. However data are lacking
on how some of these issues influence the
prevalence of infection and sexual and
protective behaviors.
6
Current Strategies & Efforts to
Reduce Chlamydia and other STIs
There is already a great deal of work going on in Boston
to lower the rates of STIs, using varied approaches. Some
examples follow:
Policy:
•
•
The BPHC established a cross-bureau committee
to reduce STIs and will release a position
statement and promote comprehensive sexual
health education in the Boston Public Schools.
The BPHC is releasing the Sexual Health of
Boston Teens. The report includes data on
Chlamydia and on sexual health risk factors. It is a
snapshot of the knowledge and attitudes of
students and parents, and contains
recommendations to address risk factors based
on best practices of condom availability, sexuality
education focused on behavior change and skills,
confidential teen services, etc.
•
The creation of BPHC Comprehensive
Reproductive and Sexuality Education Position
Statement that ensures consistency of message
and services across BPHC programs, and ideally
citywide.
•
Various groups are working to improve after
school programs and jobs for teenagers to provide
them with meaningful opportunities for learning
and skills development.
•
Screening (testing of asymptomatic patients):
•
The Infectious Disease Bureau funds community
agencies to provide integrated education and
outreach for HIV, STIs and viral hepatitis.
•
The Commission runs School Based Health
Centers (SBHCs) that provide STI screening for
all sexually active patients, following best practice
guidelines, and improving early diagnosis. They
also offer sexual health education for individuals
and groups.
Data Collection:
•
The Infectious Disease Bureau is working with
MDPH to improve data collection and the accurate
reporting of race, ethnicity and neighborhood data
in order to better define groups at highest risk so
resources can be effectively targeted.
•
The BPHC collects and analyzes data on sexual
behavior and health through various surveys
including the Behavioral Risk Factor Surveillance
System and Youth Risk Behavior Survey to better
target prevention and intervention.
Prevention:
•
•
•
Entre Familia and other programs in the
Addictions Bureau both screen for sexual risk
factors and offer educational support for clients to
learn about safer sex practices.
The Infectious Disease Bureau collaborated with
the Communications Office and with local
teenagers on an STI campaign for teenagers,
raising awareness through Facebook and PSAs.
BeSafe, a citywide collaborative seeking to
improve sexual health education in teen
leadership and sports programs around the city of
Boston, offers staff training and policy suggestions
to organizations.
Child and Adolescent Health Education in the
Division of Adolescent Health provides peer led
sexual health education in schools and other
community settings.
Treatment:
•
The School Based Health Centers treat and retest all patients they screen with positive
diagnosis for STIs lowering the re-infection rate
among the students they see who have
Chlamydia or Gonorrhea.
•
The Infectious Disease Bureau has surveyed
Boston providers to determine current screening
and treatment practices to identify areas for
improvement.
7
Promising or Best Practices
STIs are “hidden epidemics of tremendous health and economic consequence in the United States” (IOM, 1997). The
Institute of Medicine recommends that the “United States needs to establish a much more effective national system for
STI prevention, which takes into account the complex interaction between biological and social factors that sustain STI
transmission in populations; focuses on preventing the disproportionate effect that STIs have on some population
groups; applies proven, cost-effective behavioral and biomedical interventions; and recognizes that education, mass
communication media, financing, and health care infrastructure policies must foster change in personal behaviors and
in health care services.” (CDC, 2000, page 25-3).
Evidence-based practices provide the best chances to successfully intervene, although data showing which practices
actually lower STI rates are limited. However, a systematic review of the literature by the Agency for Healthcare
Research and Quality (AHRQ) identified promising practices in behavioral counseling to prevent STIs. (Lin, Whitlock, et
al, 2008) Two interventions that have demonstrated success in lowering STI rates include:
1.
Safe in the City is a 23-minute HIV/STI prevention video developed for STI clinics. A study of three clinics in
different urban areas found that patients (n= 38,635) assigned to the intervention (video watching as compared
to regular waiting room environment) showed a nearly 10% reduction in new infections. This is impressive for a
relatively low impact intervention. (Warner, Klausner, et al, 2008)
2.
A study comparing three workshop models (in depth sex education and skills building workshops, general sex
education or health education workshops) each delivered in three, four-hour sessions in an adolescent medicine
clinic in an urban, low-income area, demonstrated some success. Sexually experienced African American and
Latino adolescents (n=682) were assigned to receive one of the 3 interventions. The girls in the skillsintervention reported less unprotected sexual intercourse than the other two groups at the 12-month follow-up
and reported fewer sexual partners and were less likely to test positive for STI than were the participants in the
general health education group. (Jemmott, Jemmott, et al, 2005)
Getting Involved: What you and your program can do
to reduce Chlamydia rates in Boston
How can your program or bureau be a part of this mission
to reduce Chlamydia rates in 15 through 24 year olds in
Boston, particularly Black and Latino residents? Some of
the ideas submitted by bureaus may help you get started.
Policy
Policy work addresses the systems level components,
taking broad steps to address this epidemic from a public
health vantage point.
8
•
The Commission can work with BPS, MDPH and
others to get sexual health education into the
Boston Public Schools and passed at the
statewide level. As of August, 2010, 35 states and
Washington DC require the provision of STI/HIV
education, and 21 states and DC mandate sex
education in public schools.
•
Policy work can be integrated with the training and
awareness efforts of the Center for Health Equity
and Social Justice that focus on underlying social
determinants, including racism, to address health
inequities.
•
BPHC can issue screening and treatment
protocols for healthcare providers.
•
BPHC can provide education related to the
importance of consistent use of condoms. The
Healthy People 2010 objective is to increase from
85% (1999) to 95% the percentage of adolescents
in grades 9-12 who were not sexually active or
who used condoms when sexually active.
(Dailard, 2001; Health of Boston, 2010; CDC,
2000) Schools, after-school programs and parent
groups can be offered curriculum and training to
effectively teach teenagers about sexual health
and safe sex practices and skills.
•
More programming and jobs for teenagers,
particularly in highly affected neighborhoods,
creates opportunities and may motivate behavior
change.
•
Mass media campaigns have been effective in
changing awareness, attitudes and behaviors
around other health issues such as smoking and
driving under the influence.
Prevention/Education:
Effective STI prevention requires effective population-level
and individual-level interventions. The IOM issued an
optimistic and clarion call; we can “have a rapid and
dramatic impact on the incidence and prevalence of STIs
in the United States. Many effective and efficient
behavioral and biomedical interventions are
available.” (IOM, 2007)
Prevention is critical in significantly reducing the number
of Chlamydia cases. Having fewer sexual partners and
engaging in safer sex to reduce the risk of exposure and
possible transmission (e.g. use of condoms prevents
exposure that is likely to lead to infection) are two critical
factors related to lowering the disease rate. Many
programs are already providing group and individual
education and screening for HIV & STIs. What other
opportunities are there to educate about healthy
relationships and sexual health, to teach about condom
use and to support effective safer sex negotiation skills?
•
•
Screening/Testing:
Since infection with Chlamydia is usually asymptomatic
(without symptoms), screening is important. Data has
shown that Chlamydia screening can reduce the
incidence of pelvic inflammatory disease (PID, a principal
cause of infertility) by as much as 60 percent (Scholes,
Stergachis et al, 1996). Annual screening for sexually
active females and males younger than 26 years of age
is widely recommended as a means to detect and treat
Chlamydia. (CDC, 2008; CDC, 2000)
•
The Community Initiatives Bureau is considering
training oral health providers to identify oral
symptoms for STIs and to test during these
appointments.
Homeless Services offered the possibility of
increasing condom distribution and safe sex
education in their outreach efforts.
•
Schools are the main source of STI information for
most teenagers. Parents locally and nationally
report the need to learn how to talk to their
children about STIs as well as their desire to have
schools offer comprehensive sexuality education.
CAFHB uses a health questionnaire to alert
providers to the need to counsel and test women
for all STIs, focusing on Black women in 7 high
priority neighborhoods.
•
EMS suggested training staff to be able to offer
counseling and referrals.
Treatment:
Rapid diagnosis and treatment of cases and their partners
results in a shorter time when the case is contagious.
Duration of infectivity is an important contributor to
disease spread.
•
New guidelines for expedited treatment for cases
and their partners can be explored.
•
Public campaigns targeted to teens to increase
testing and treatment might be effective.
9
Notes:
10
Reference List & Resources:
Akers AY, Younmans S, Lloyd SW, Banks B, Smith DM, Adimora ASA, Corbie-Smith G. When there is
nothing to do, you do somebody: environmental factors affecting HIV risk in rural North Carolina.
(Presentation) 2008 National STD Prevention Conference, March 10-13, 2008. Available at:
http://cdc.confex.com/cdc/std2008/webprogram/Paper14566.html. Accessed August 11, 2010
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11
Reference List & Resources (cont.):
Dailard, Cynthia. Sex Education: Politicians, Parents, Teachers and Teens. The Guttmacher Report
on Public Policy. February 2001: Vol 4, n 1.
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The Authors:
For the Boston Public Health Commission:
Dr. Anita Barry
Rhoda Johnson Tuckett
Eno Mondesir
Greg Lanza
Cindy Engler
Pam Jones
Phyllis Sims
Michael SooHoo
Catherine Cairns
Miriam Messinger (Consultant)
Thomas M. Menino
Mayor
Barbara Ferrer, Ph.D, MPH, M.Ed.
Executive Director