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

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initi

al c

ases

dia

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ed

by p

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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