Revision of Region II IPP Screening Criteria May 16, 2007 Region II IPP Advisory Committee Meeting Cicatelli Associates Inc. New York City

Revision of Region II IPP Revision of Region II IPP Screening CriteriaScreening Criteria

May 16, 2007May 16, 2007Region II IPP Advisory Committee MeetingRegion II IPP Advisory Committee Meeting

Cicatelli Associates Inc.Cicatelli Associates Inc.New York CityNew York City

Region II IPPRegion II IPPStrategic Plan 2005-2009Strategic Plan 2005-2009

PRIORITY 1: Target/Expand Chlamydia PRIORITY 1: Target/Expand Chlamydia Screening to Young Sexually Active Screening to Young Sexually Active Women and Men at Risk for Infection in Women and Men at Risk for Infection in Public and Private Settings.Public and Private Settings. GOAL: All at risk men and women under the GOAL: All at risk men and women under the

age of 25 will be screened at least annually.age of 25 will be screened at least annually.• OBJECTIVE 1A: Revise regional screening criteria OBJECTIVE 1A: Revise regional screening criteria

for females so that screening is targeted to the for females so that screening is targeted to the most at-risk populations by October 2007.most at-risk populations by October 2007.

Screening WorkgroupScreening Workgroup

MembersMembers Eileen Crayne (NJ DHSS STD)Eileen Crayne (NJ DHSS STD) Debbie Polacek (NJFPL)Debbie Polacek (NJFPL) Jennifer Howard (PPGNNJ)Jennifer Howard (PPGNNJ) Steve Rubin, Preeti Pathela, and Julie Steve Rubin, Preeti Pathela, and Julie

Schillinger (NYC DOHMH STD)Schillinger (NYC DOHMH STD) Alison Muse (NYS DOH STD)Alison Muse (NYS DOH STD) Gale Burstein (Erie County DOH)Gale Burstein (Erie County DOH)

FacilitatorFacilitator Kelly Opdyke (CAI - Infrastructure)Kelly Opdyke (CAI - Infrastructure)

Region II Minimum Selective Region II Minimum Selective Screening Criteria*Screening Criteria*

Title X ClinicsTitle X Clinics All women All women ≤≤ 24 years of age attending the clinic 24 years of age attending the clinic

for an initial or annual visit will be screened for for an initial or annual visit will be screened for chlamydiachlamydia

STD ClinicsSTD Clinics All women All women ≤≤ 29 years of age attending the STD 29 years of age attending the STD

clinic will be screened for chlamydiaclinic will be screened for chlamydia

*Region II IPP, 2003 Protocols & Guidelines*Region II IPP, 2003 Protocols & Guidelines

Current Limitations of Screening Current Limitations of Screening Criteria & Proposed RevisionsCriteria & Proposed Revisions

Areas of Consideration:Areas of Consideration: Client AgeClient Age Clinic Site TypeClinic Site Type Pelvic ExamPelvic Exam Re-ScreeningRe-Screening MalesMales Local PrevalenceLocal Prevalence Test TechnologyTest Technology Females Females ≥≥26 years26 years

Criteria: Client AgeCriteria: Client Age

Current LimitationCurrent Limitation Criteria do not Criteria do not

address screening address screening among females age among females age 25 years25 years age bracket does not age bracket does not

correspond with correspond with USPSTF or CDC USPSTF or CDC criteria (<26 yrs); criteria (<26 yrs); clients age 25 omittedclients age 25 omitted

Proposed RevisionProposed Revision Criteria based on Criteria based on

national standardsnational standards all sexually active all sexually active

females age females age ≤≤25 yrs 25 yrs (i.e. <26 yrs)(i.e. <26 yrs)

Includes expanding Includes expanding screening to females screening to females age 25 in Family age 25 in Family PlanningPlanning

Criteria: Clinic Site TypeCriteria: Clinic Site Type


address screening in address screening in sites other than STD sites other than STD or FPor FP

Proposed RevisionProposed Revision Criteria no longer Criteria no longer

specific to site type, specific to site type, but should consider but should consider local prevalence datalocal prevalence data

Criteria: Pelvic ExamCriteria: Pelvic Exam

Current LimitationCurrent Limitation Screening contingent Screening contingent

on pelvic examon pelvic exam

Proposed RevisionProposed Revision Expanded to include Expanded to include

limited service clients limited service clients (no pelvic exam) (no pelvic exam) using urine-based using urine-based NAATNAAT

Criteria: Re-ScreeningCriteria: Re-Screening


address re-screening address re-screening of positives (as per of positives (as per national guidelines)national guidelines)

Proposed RevisionProposed Revision Expanded to include Expanded to include

recommendation for recommendation for re-screening positive re-screening positive females within 3-12 females within 3-12 months as per CDC months as per CDC guidelinesguidelines

Criteria: MalesCriteria: Males


address screening of address screening of malesmales

Proposed RevisionProposed Revision Provision for Provision for

screening sexually screening sexually active young males in active young males in high-prevalence high-prevalence settingssettings

Criteria: Local PrevalenceCriteria: Local Prevalence


address targeted address targeted screening based on screening based on local prevalencelocal prevalence

Proposed RevisionProposed Revision Recommendation for Recommendation for

sites to adjust age sites to adjust age criteria based on local criteria based on local age-specific age-specific prevalence (≥2%)prevalence (≥2%)

Criteria: Test TechnologyCriteria: Test Technology

Current LimitationCurrent Limitation No mention of No mention of

preferred diagnostic preferred diagnostic test methodologytest methodology

Proposed RevisionProposed Revision Recommendation to Recommendation to

use NAAT, as per use NAAT, as per CDC lab guidelinesCDC lab guidelines

Criteria: Females Criteria: Females ≥≥26 Yrs26 Yrs

Current LimitationCurrent Limitation No guidance on No guidance on

testing in females testing in females outside of age criteriaoutside of age criteria

Proposed RevisionProposed Revision Recommendation for Recommendation for

clinical considerations clinical considerations for testing females for testing females age 26 and overage 26 and over

Region II Minimum Selective Region II Minimum Selective Screening Criteria - Screening Criteria - ProposedProposed

The Region II Infertility Prevention Project The Region II Infertility Prevention Project Chlamydia Screening Workgroup has developed Chlamydia Screening Workgroup has developed selective screening criteria for chlamydia based selective screening criteria for chlamydia based on on national recommendationsnational recommendations provided by the provided by the CDC in the 2006 STD Treatment Guidelines (CDC in the 2006 STD Treatment Guidelines (http://www.cdc.gov/std/treatment/2006/urethritis-http://www.cdc.gov/std/treatment/2006/urethritis-and-cervicitis.htm#uc4and-cervicitis.htm#uc4). ).

Providers should follow CDC guidelines for Providers should follow CDC guidelines for screening and treating screening and treating pregnant womenpregnant women..


FEMALESFEMALES

ScreeningScreening Annually screen all sexually active females Annually screen all sexually active females ≤≤ 25 years of 25 years of

age for chlamydia.age for chlamydia.

Re-ScreeningRe-Screening All females, regardless of age, should be retested for All females, regardless of age, should be retested for

chlamydia 3 months after being treated for a positive chlamydia 3 months after being treated for a positive chlamydia test, or when they next present for care within chlamydia test, or when they next present for care within the following 3-12 months.the following 3-12 months.


MALESMALES

Screening of sexually active young males should Screening of sexually active young males should be considered in clinical settings with a high be considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent prevalence of chlamydia (e.g., adolescent clinics, job corps, correctional facilities, and STD clinics, job corps, correctional facilities, and STD clinics).clinics).

Recommendations for Implementation:Recommendations for Implementation:Use of Limited ResourcesUse of Limited Resources

Programs must consider implementation of Programs must consider implementation of these recommendations these recommendations in relation to program in relation to program resourcesresources, including fiscal, personnel, and , including fiscal, personnel, and technological.technological.

The program’s aim should be to achieve the The program’s aim should be to achieve the highest level of disease identificationhighest level of disease identification within this within this context.context.

Recommendations for Implementation: Recommendations for Implementation: Test TechnologyTest Technology

Use of highly sensitive and specific NAAT Use of highly sensitive and specific NAAT (nucleic acid amplification tests) is strongly (nucleic acid amplification tests) is strongly recommended (recommended (http://www.cdc.gov/std/labguidelineshttp://www.cdc.gov/std/labguidelines).).

Use of urine-based NAAT can facilitate non-Use of urine-based NAAT can facilitate non-invasive screening of females who do not invasive screening of females who do not require a pelvic exam, as well as males. require a pelvic exam, as well as males.

Recommendations for Implementation: Recommendations for Implementation: Local Age-Specific PrevalenceLocal Age-Specific Prevalence

Sites with an age-specific chlamydia prevalence Sites with an age-specific chlamydia prevalence rate of rate of less than 2%less than 2% * should consider * should consider further further targeting screeningtargeting screening criteria based on local criteria based on local prevalence data.prevalence data.

Conversely, sites with an age-specific chlamydia Conversely, sites with an age-specific chlamydia prevalence rate of prevalence rate of greater than 2%greater than 2% * may * may consider consider expanding criteriaexpanding criteria..

*Adjusted for laboratory test type.*Adjusted for laboratory test type.

Recommendations for Implementation:Recommendations for Implementation:Clinical ConsiderationsClinical Considerations

Risk HistoryRisk History Multiple sex partners in Multiple sex partners in

last 90 dayslast 90 days New sex partner in last New sex partner in last

90 days90 days STD infection in past yearSTD infection in past year Contact to STDContact to STD Possible non-Possible non-

monogamous partnermonogamous partner

Clinical FindingsClinical Findings Friable CervixFriable Cervix Mucopurulent CervicitisMucopurulent Cervicitis Cervical Cervical

motion/Tendernessmotion/Tenderness Pelvic Inflammatory Pelvic Inflammatory

Disease (PID)Disease (PID) UrethritisUrethritis New STD diagnosisNew STD diagnosis Bacterial Vaginosis Bacterial Vaginosis

Testing of females ≥26 years of age with one or more of the following documented risk factors or clinical findings may be clinically indicated:

Recommendations for Implementation:Recommendations for Implementation:Test of CureTest of Cure

Except in pregnancyExcept in pregnancy, test-of-cure (repeat testing 3–4 , test-of-cure (repeat testing 3–4 weeks after completing therapy) is not recommended for weeks after completing therapy) is not recommended for persons treated with the recommended or alterative persons treated with the recommended or alterative regimens, unless therapeutic compliance is in question, regimens, unless therapeutic compliance is in question, symptoms persist, or re-infection is suspected.symptoms persist, or re-infection is suspected.

RationaleRationale

CDC STD Tx and Lab GuidelinesCDC STD Tx and Lab Guidelines USPSTF Ct screening recommendationsUSPSTF Ct screening recommendations NCQA HEDIS measure for Ct screeningNCQA HEDIS measure for Ct screening ACOG Pap guidelines for females <21 yrsACOG Pap guidelines for females <21 yrs California Over 20 Study preliminary findingsCalifornia Over 20 Study preliminary findings Regional IPP data on high Ct prevalence among Regional IPP data on high Ct prevalence among

walk-in pregnancy test clientswalk-in pregnancy test clients CDC Males Screening Consultation outcomesCDC Males Screening Consultation outcomes

Breakout GroupsBreakout Groups

Pro’s – Con’sPro’s – Con’s

ScienceScience

Promotes Targeted Use of Limited Promotes Targeted Use of Limited ResourcesResources

Ease of ImplementationEase of Implementation

Next StepsNext Steps

Which of the proposed revisions should be Which of the proposed revisions should be adopted?adopted?

What are the pros and cons to consider?What are the pros and cons to consider? What other information do we need to What other information do we need to

move forward?move forward? Region II IPP Screening Workgroup.Region II IPP Screening Workgroup.

Documents

Revision of Region II IPP Screening Criteria May 16, 2007 Region II IPP Advisory Committee Meeting Cicatelli Associates Inc. New York City