The burden of repeat The burden of repeat Chlamydia trachomatisChlamydia trachomatis
infection in young womeninfection in young women in New York City in New York City
Klingler EKlingler E11, Pathela P, Pathela P11, Cordova D, Cordova D1,21,2, , Blank SBlank S1,21,2, Schillinger J, Schillinger J1,21,2
1. New York City Department of Health and Mental Hygiene (NYC DOHMH), USA 2. Centers for Disease Control and Prevention (CDC), USA
OBJECTIVEOBJECTIVE
To quantify the burden of repeat To quantify the burden of repeat chlamydial infection in young chlamydial infection in young women in New York Citywomen in New York City
BACKGROUNDBACKGROUND• Repeat Repeat C. trachomatisC. trachomatis ( (Ct)Ct) infections in infections in
women increase the risk for adverse women increase the risk for adverse sequelaesequelae
• CDC recommends re-screening women CDC recommends re-screening women three to four months after treatment three to four months after treatment for a for a CtCt infection infection
• Large numbers of Large numbers of Ct Ct reportedreported in in adolescentsadolescents and young adult women in NYC and young adult women in NYC• ~27,000 cases in females reported to NYC Department of ~27,000 cases in females reported to NYC Department of
Health and Mental Hygiene (DOHMH) in 2005Health and Mental Hygiene (DOHMH) in 2005
• 17,887 (67%) among women age 15 to 25 years17,887 (67%) among women age 15 to 25 years
METHODSMETHODS
• Data source: NYC DOHMH Bureau of Data source: NYC DOHMH Bureau of STD Control (BSTDC) surveillance STD Control (BSTDC) surveillance registryregistry
• Analytic sample: Women aged 10 to Analytic sample: Women aged 10 to 29 years for whom a case of 29 years for whom a case of CtCt was was reported between January 2000 and reported between January 2000 and June 2005 June 2005
•Initial infection: Initial infection: The first infection for a given The first infection for a given
woman in a yearwoman in a year•Repeat infection: Repeat infection:
A A CtCt infection infection >> 30 days after a 30 days after a woman’s initial woman’s initial CtCt report and report and
within a 12 month follow-up (f/u) within a 12 month follow-up (f/u) periodperiod
METHODSMETHODS-DEFINITIONS--DEFINITIONS-
METHODSMETHODS-DEFINITIONS--DEFINITIONS-
•Gonorrhea (GC) co-infection:Gonorrhea (GC) co-infection:Gonorrhea infection reported for a Gonorrhea infection reported for a woman within ten days of her woman within ten days of her
initial initial CtCt report report •Private Provider:Private Provider:
Any provider working outside the Any provider working outside the NYC DOHMH BSTDC clinic systemNYC DOHMH BSTDC clinic system
METHODSMETHODS-COHORT DESCRIPTION--COHORT DESCRIPTION-
• We created cohorts of women We created cohorts of women diagnosed with diagnosed with CtCt in a calendar year in a calendar year• 4 years: 2000-2003 4 years: 2000-2003
• We allowed each woman 1 year of f/u We allowed each woman 1 year of f/u time from her initial infectiontime from her initial infection
• We created a separate cohort of We created a separate cohort of women reported July 2003- June women reported July 2003- June 2004, permitting a full year of f/u2004, permitting a full year of f/u
METHODSMETHODS-ANALYSIS--ANALYSIS-
• Calculate rates of repeat infection Calculate rates of repeat infection by yearby year
• Bivariate analyses to determine predictors Bivariate analyses to determine predictors of repeat infectionof repeat infection• Covariates investigated: neighborhood of residence, Covariates investigated: neighborhood of residence,
age, provider type, gonorrhea co-infection, and age, provider type, gonorrhea co-infection, and race/ethnicityrace/ethnicity
• Multivariate analysis to identify Multivariate analysis to identify independent predictors of repeat infectionindependent predictors of repeat infection• Included all covariates examined +/- neighborhoodIncluded all covariates examined +/- neighborhood
RESULTSRESULTS
• Overall, 117,792 cases of Overall, 117,792 cases of CtCt in in females aged 10-29 years were females aged 10-29 years were reported to the NYC DOHMH BSTDC reported to the NYC DOHMH BSTDC during the 5 ½ year interval during the 5 ½ year interval
• These cases were among 91,979 These cases were among 91,979 women women
• ~ 21% of these women experienced ~ 21% of these women experienced at least one repeat infectionat least one repeat infection
2000 2001 2002 2003
July 2003-June 2004
Age (n=17,128) (n=19,283) (n=20,638) (n=21,114) (n=21,142)
Overall 14% 15% 15% 14% 13%
10 to 14 17% 19% 16% 19% 17%
15 to 19 17% 18% 19% 18% 17%
20 to 24 13% 13% 15% 12% 12%
25 to 29 8% 8% 9% 9% 8%
Proportion of women with a repeat infection,
by age and year of initial Ct diagnosis
2000 2001 2002 2003July 2003 - June 2004
median time to reinfection (months) 5 5 6 5 5
% re-infected by three months 32% 32% 27% 29% 29%
Median time to repeat infection and % re-infected by three months
0
5000
10000
15000
20000
25000
2000 2001 2002 2003 July 2003June2004N
umbe
r of
initi
al c
ases
dia
gnos
ed
by p
rovi
der
type
Clinic Cases Private Provider Cases
12% 12%
14%
13%
15%
22%
15%
12%
14%
13%
Number of Ct cases reported by year and provider type and proportion of
cases with repeat infection
2000 2001 2002 2003
July 2003 - June
2004
Repeat Infection? Yes No Yes No Yes No Yes No Yes No
Age
Overall 9% 9% 11% 9% 9% 8% 10% 7% 9% 6%
10 to 14 15% 17% 17% 16% 28% 14% 18% 13% 13% 11%
15 to 19 11% 11% 13% 11% 11% 10% 11% 9% 12% 7%
20 to 24 8% 7% 9% 8% 7% 7% 8% 7% 7% 6%
25 to 29 5% 6% 6% 6% 6% 6% 7% 5% 6% 4%
Rates of GC co-infection at the initial Rates of GC co-infection at the initial CtCt infection among women with and infection among women with and without repeat infection, by agewithout repeat infection, by age
Bivariate Analysis Bivariate Analysis of Repeat of Repeat CtCt Infections, Infections,
Race/ethnicityRace/ethnicity Repeat Infection -
YES
Repeat Infection -
NO P-Value
Race/Ethnicity n % n %
White 26 (0.9) 256 (1.4) <0.0001
Hispanic 415 (14.8) 2111 (11.5)
Black 887 (31.6) 3704 (20.2)
Asian/PI 14 (0.5) 175 (1.0)
Native Am/ AK Native 2 (0.1) 17 (0.1)
Other 25 (0.9) 174 (1.0)
Unknown 1440 (51.3) 11896 (64.9)
Bivariate Analysis Bivariate Analysis of Repeat of Repeat CtCt Infections, Infections,
AgeAge
Repeat Infection -
YES
Repeat Infection -
NO P-Value
Age n % n %
10 to 14 68 (2.4) 343 (1.9)
15 to 19 1382 (49.2) 6734 (36.7)
20 to 24 1036 (36.9) 7410 (40.4)
25 to 29 323 (11.5) 3846 (21.0) <0.0001
Bivariate Analysis of Repeat Bivariate Analysis of Repeat CtCt Infections, Infections,
GC co-infectionGC co-infection
Repeat Infection -
YES
Repeat Infection -
NO P-Value
GC Co-infection n (%) n (%)
Yes 265 (9.4) 1135 (6.2)
No 2544 (90.6) 17198 (93.8) <0.0001
OR (95% CI) P-Value
Race/Ethnicity
White 1.00 <0.0001
Hispanic 1.70 (1.11-2.58)
Black 2.13 (1.41-3.22)
Asian/PI 0.83 (0.42-1.63)
Native Am/ AK Native 1.05 (0.2 -4.81)
Other 1.45 (0.81-2.61)
Unknown 1.01 (0.67-1.52)
Multi-variate Analysis of Multi-variate Analysis of Repeat Repeat CtCt Infections, Infections,
Race/ethnicityRace/ethnicity
OR (95% CI) P-Value
Age
10 to 14 yrs 2.15 (1.62-2.87)
15 to 19 yrs 2.31 (2.03-2.62)
20 to 24 yrs 1.60 (1.40-1.83)
25 to 29 yrs 1.00 <0.0001
Provider Type
Private Provider 1.78 (1.51-2.11)
City STD Clinic 1.00 <0.0001
GC Co-infection
Yes 1.41 (1.22-1.62)
No 1.00 <0.0001
Multi-variate Analysis of Multi-variate Analysis of Repeat Repeat CtCt Infections Infections
LIMITATIONSLIMITATIONS
• We may have classified some We may have classified some persistent infections as repeat persistent infections as repeat infectionsinfections
• We assumed treatment was given for We assumed treatment was given for an initial infectionan initial infection
• Possible bias in who providers decide Possible bias in who providers decide to re-screen to re-screen
CONCLUSIONSCONCLUSIONS
• Repeat infection rates are high among Repeat infection rates are high among young women in NYCyoung women in NYC
• Age and GC co-infection at time of initial Age and GC co-infection at time of initial infection may be used to target women at infection may be used to target women at greatest risk for re-infectiongreatest risk for re-infection
• A larger proportion of re-infected women A larger proportion of re-infected women have their initial infection reported by a have their initial infection reported by a private providerprivate provider
THANKSTHANKS
to our entire BSTDC staff to our entire BSTDC staff
for their work in getting for their work in getting this data collected, this data collected,
entered, and analyzed.entered, and analyzed.
The findings and conclusions of this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy
METHODSMETHODS-COHORT DESCRIPTION--COHORT DESCRIPTION-
2002
A
2000 2001
AA B B
METHODSMETHODS-COHORT DESCRIPTION--COHORT DESCRIPTION-
2002
A
2000 2001
AA B B
METHODSMETHODS-COHORT DESCRIPTION--COHORT DESCRIPTION-
2002
A
2000 2001
AA B B
METHODSMETHODS-COHORT DESCRIPTION--COHORT DESCRIPTION-
2002
A
2000 2001
AA B B
METHODSMETHODS-COHORT DESCRIPTION--COHORT DESCRIPTION-
2002
A
2000 2001
AA B B
METHODSMETHODS-COHORT DESCRIPTION--COHORT DESCRIPTION-
2002
A
2000 2001
AA B B