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ABSTRACT: In the USA, family planning clinics are primary providers of reproductive healthcare to young women and their male partners and have long provided quality sexually transmitted infection (STI) care and prevention. Chlamydia, an easily treatable STI that can lead to serious adverse outcomes if untreated, is the most common bacterial STI in the USA, and annual chlamydia screening is recommended for sexually active women aged ≤25 years. As early adopters of routine screening, family planning clinics screen >50% of all care-seeking eligible women for chlamydia, performing better than private sector healthcare plans. To achieve high levels of quality care, family planning clinics have been leaders in implementing evidence-based care delivery and developing prevention innovations. As national healthcare reform is implemented in the USA and categorical STI clinics close, public-sector demand on family planning clinics will increase.
Women s Health 01/2013; 9(1):25-38.
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ABSTRACT: Because of the rapid development of genital warts (GW) after infection, monitoring GW trends may provide early evidence of population-level human papillomavirus (HPV) vaccine effectiveness. Trends in GW diagnoses were assessed using public family planning administrative data. Between 2007 and 2010, among females younger than 21 years, these diagnoses decreased 35% from 0.94% to 0.61% (P(trend) < .001). Decreases were also observed among males younger than 21 years (19%); and among females and males ages 21-25 (10% and 11%, respectively). The diagnoses stabilized or increased among older age groups. HPV vaccine may be preventing GW among young people.
American Journal of Public Health 03/2012; 102(5):833-5. · 3.93 Impact Factor
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ABSTRACT: Treatment of sex partners is a core strategy for the control of chlamydia. Innovations such as patient-delivered partner therapy (PDPT) are effective in preventing repeat chlamydial infections, but providers' practice and perceptions of PDPT have not been adequately evaluated. This evaluation describes family planning providers' practices, knowledge, attitudes, and barriers regarding PDPT and assesses factors associated with routine use.
A cross-sectional, self-administered, Internet-based survey of a convenience sample of family planning providers in California was conducted in 2007. Multivariate logistic regression was used to determine predictors associated with routine PDPT use.
Of the 286 respondents, 73% reported routinely using PDPT for chlamydia and 77% provided medication to clients for their partner(s). Providers were more likely to offer PDPT for female versus male clients (73% vs. 53%, P < 0.0001). More than 90% agreed that PDPT helped provide better care for clients, was well-received, and protected against reinfection. Common concerns about PDPT included missed counseling opportunities (51%) and incomplete care for partners (42%). Over one-third (41%) identified lack of reimbursement for PDPT as an important barrier to routine use. Independent predictors of routine PDPT use included affiliation with an agency that received free prepackaged single-dose medication for on-site PDPT dispensing (adjusted odds ratio = 2.66, 95% confidence interval: 1.39-5.10) and support of the clinic's medical director (adjusted odds ratio = 4.85, 95% confidence interval: 1.57-14.96).
A majority of providers in this sample reported routinely using PDPT for chlamydia-infected clients; provision of prepackaged medication to clinics facilitated use of PDPT.
Sexually transmitted diseases 02/2012; 39(2):122-7. · 2.58 Impact Factor
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ABSTRACT: Routine repeat testing of specimens with a low-positive result for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) by nucleic acid amplification test (NAAT) is not recommended (5) because 1) the majority of positive specimens that are negative on confirmatory testing are true positives, and 2) infected patients will go untreated.…
Journal of clinical microbiology 11/2011; 50(2):539. · 4.16 Impact Factor
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ABSTRACT: Prompt treatment of exposed partners is critical for preventing further transmission of chlamydia, reinfection, and sequelae among females. Patient-delivered partner therapy (PDPT) has been allowable in California since 2001; however, few data are available regarding PDPT use and treatment outcomes.
Eight family planning clinics participated in a partner services evaluation from 2005 to 2006. Females aged 16 to 35 years with chlamydia were interviewed to determine the partner service received and partner treatment outcomes; a subset of partners was also interviewed. Determinants of reported partner treatment were assessed using multivariate logistic regression. Selected medical records were reviewed to assess reinfection rates.
Overall, 743 female patients disclosed 952 partners; 58% of whom were identified as steady partners. Reported partner services included concurrent patient-partner treatment visits (15% of partners), PDPT (19%), patient referral (55%), health department referral (0.1%), and no partner management (11%). On the basis of patient report, 82% of partners were notified and 54% received treatment. Of the 166 (17%) partners interviewed, 139 (84%) reported that they had received treatment, which correlated well with patient report. Reported partner treatment was higher for concurrent treatment visits and PDPT (79% and 80%, respectively) compared to patient referral (44%, P < 0.0001). Adjusted for clinic and relationship status, partners managed with concurrent treatment visits or PDPT were more likely to receive treatment compared with partners managed with patient referral (adjusted odds ratios, 3.5; 95% confidence interval, 2.1-5.8 and adjusted odds ratios, 4.3; 95% confidence interval, 2.6-7.2, respectively). Among the patients retested within 6 months after treatment, 18% were reinfected; reinfection rates did not differ by type of partner service.
Although overall rates of reported partner treatment were low, concurrent patient-partner treatment visits and PDPT were associated with significantly higher rates of partner treatment. However, these methods may be underutilized in California family planning settings.
Sexually transmitted diseases 10/2011; 38(10):913-8. · 2.58 Impact Factor
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Heidi M Bauer
Sexually transmitted diseases 08/2011; 38(8):712-4. · 2.58 Impact Factor
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ABSTRACT: Repeated genital infections with Chlamydia trachomatis are common and associated with serious adverse reproductive sequelae in women such as infertility, ectopic pregnancy, and chronic pelvic pain. Retesting for repeat chlamydial infection is recommended 3 months after treatment for an initial infection; however, retesting rates in various settings are low. In order to design interventions to increase retesting rates, understanding provider barriers and practices around retesting is crucial. Therefore, in this survey of family planning providers we sought to describe: (1) knowledge about retesting for chlamydia; (2) attitudes and barriers toward retesting; (3) practices currently utilized to ensure retesting, and predictors associated with their use.
We conducted a cross-sectional, self-administered, Internet-based survey of a convenience sample of family planning providers in California inquiring about strategies utilized to ensure retesting in their practice setting. High-intensity strategies included chart flagging, tickler (reminder) systems, follow-up appointments, and phone/mail reminders.
Of 268 respondents, 82% of providers reported at least 1 barrier to retesting, and only 44% utilized high-intensity interventions to ensure that patients returned. Predictors associated with use of high-intensity interventions included existence of clinic-level retesting policies (OR 3.95, 95% CI 1.98-7.88), and perception of a high/moderate level of clinic priority toward retesting (OR 3.75, 95% CI 2.12-.6.63).
Emphasizing the importance of retesting to providers through adoption of clinic policies will likely be an important component of a multimodal strategy to ensure that patients are retested and that provider/clinic staff take advantage of opportunities to retest patients. Innovative approaches such as home-based retesting with self-collected vaginal swabs and use of cost-effective technologies to generate patient reminders should also be considered.
Journal of Women s Health 06/2010; 19(6):1139-44. · 1.57 Impact Factor
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ABSTRACT: Determining the magnitude of chlamydia and gonorrhea reinfection is critical to inform evidence-based clinical practice guidelines related to retesting after treatment. PubMed was used to identify peer-reviewed English language studies published in the past 30 years that estimated reinfection rates among females treated for chlamydia or gonorrhea. Included in this analysis were original studies conducted in the United States and other industrialized countries that reported data on chlamydia or gonorrhea reinfection in females. Studies were stratified into 3 tiers based on study design. Reinfection rates were examined in relation to the organism, study design, length of follow-up, and population characteristics. Of the 47 studies included, 16 were active cohort (Tier 1), 15 passive cohort (Tier 2), and 16 disease registry (Tier 3) studies. The overall median proportion of females reinfected with chlamydia was 13.9% (n = 38 studies). Modeled chlamydia reinfection within 12 months demonstrated peak rates of 19% to 20% at 8 to 10 months. The overall median proportion of females reinfected with gonorrhea was 11.7% (n = 17 studies). Younger age was associated with higher rates of both chlamydia and gonorrhea reinfection. High rates of reinfection with chlamydia and gonorrhea among females, along with practical considerations, warrant retesting 3 to 6 months after treatment of the initial infection. Further research should investigate effective interventions to reduce reinfection and to increase retesting.
Sexually transmitted diseases 09/2009; 36(8):478-89. · 2.58 Impact Factor
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ABSTRACT: Antimicrobial-resistant Neisseria gonorrhoeae is an emerging public health problem as a result of the alarming limitation in treatment options. We examined an outbreak in California of fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) by evaluation of a combination of routine isolates from the Gonococcal Isolate Surveillance Project and isolates collected by expanded surveillance performed between April 2000 and June 2002. QRNG isolates were characterized by two methods: (i) determination of a combination of antibiogram, auxotype, serovar, Lip type, and patterns of amino acid alteration in the quinolone resistance-determining region of GyrA and ParC (ASLGP) and (ii) pulsed-field gel electrophoresis (PFGE). Strain typing was used to describe the QRNG outbreak strains and the associated antimicrobial resistance profiles. Among 79 isolates that were completely characterized, we identified 20 different ASLGP strain types, and 2 of the types were considered to belong to outbreak strains that comprised 65% (51/79) of the isolates. By PFGE typing, there were 24 different strain types, and 4 of these were considered outbreak types and comprised 66% (52/79) of the isolates. The overall agreement between the typing methods in distinguishing outbreak strains and non-outbreak strains was 84% (66/79). The most common QRNG ASLGP strain type had chromosomally mediated resistance to penicillin and tetracycline and an azithromycin MIC of 0.5 microg/ml. The occurrence of an outbreak caused by QRNG strains that could fail to be eradicated by most antibiotic classes reinforces the serious problem with antimicrobial resistance in Neisseria gonorrhoeae that the public health system faces. Adherence to a regimen with the recommended antibiotics at the appropriate dose is critical, and monitoring for antimicrobial susceptibility needs to be actively maintained to adapt treatment guidelines appropriately.
Journal of clinical microbiology 08/2009; 47(9):2944-9. · 4.16 Impact Factor
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ABSTRACT: In California, medical providers have the option to provide expedited partner therapy (EPT) for Chlamydia trachomatis and Neisseria gonorrhoeae. California law was amended in 2001 and 2007 to allow physicians to prescribe, and nurse practitioners, physician assistants, and certified nurse-midwives to dispense, antibiotic therapy for the sex partners of individuals infected with chlamydia and gonorrhea, even if they have not been able to perform an examination of the patient's partner(s).In collaboration with the California STD Controllers Association, the California Department of Public Health STD Control Branch developed clinical guidelines for EPT for chlamydia and gonorrhea. These guidelines are focused on EPT strategies and provide information on the most appropriate patients, medications, and counseling procedures recommended to maximize patient and public health benefit while minimizing risk to partners.
Sex Transm Dis 04/2008; 35(3):314-9. · 2.87 Impact Factor
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ABSTRACT: We investigated the initial outbreak of fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) in southern California with analysis of transmission using strain typing.
Surveillance for QRNG was conducted between 2000 and 2002 in southern California, including epidemiology and strain typing by a combination of antibiogram, auxotype, serovar, Lip type and amino acid alteration patterns in the quinolone-resistance determining region of GyrA and ParC. Combining epidemiological data with strain typing, we describe the emergence of QRNG outbreak strains using risk factor analysis and transmission networks.
Two outbreak strains accounted for 82% of isolates. Both strains required proline, were Lip type 17c, had amino acid alterations 91> Phe in GyrA and 87> Arg in ParC, but they differed by their serovar, IB-3C8 versus IB-2H7, 2G2. Outbreak strains were positively associated with men who have sex with men (MSM), adjusted odds ratio (AOR) 23.9 (95% confidence interval (CI) 2.2 to 261) and negatively associated with travel history: AOR 0.05, (95% CI 0.0 to 0.6). Network analysis demonstrated that 17 cases were connected by sexual contacts and/or public venues including bars, bathhouses/sex clubs, and internet sites.
QRNG may have become established among Californian MSM through an identified transmission network of southern Californian bars, bathhouses and internet sites.
Sexually transmitted infections 03/2008; 84(4):290-1. · 2.18 Impact Factor
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ABSTRACT: Neonatal herpes infections can have serious consequences. Methods for monitoring the incidence of neonatal herpes have not been standardized.
To use existing data to examine neonatal herpes-related morbidity in California.
California hospital discharge and mortality data were used to identify neonatal herpes cases, defined as a herpes-related discharge diagnosis with an admitting age of 42 days or less, and neonatal herpes-related deaths. California birth data were used to identify pregnancies complicated by herpes and to determine cesarean section rates.
The overall incidence of neonatal herpes was 12.1 per 100,000 live births per year, with no observable change from 1995 to 2003. Neonatal herpes-related mortality, which was estimated to be 0.8 deaths per 100,000 live births, also did not show significant change over time. Between 1995 and 2002, herpes complication in labor declined steadily from 0.23% to 0.09% of all labors (P <0.0001). Among pregnancies with herpes as a complication of labor, cesarean section rates increased from 72.2% to 78.3% (P = 0.01), whereas overall cesarean rates increased from 20.0% to 26.0% (P <0.0001).
Existing data can be used to monitor the morbidity and mortality of neonatal herpes. Because the rate of neonatal herpes cases and deaths was stable from 1995 to 2003 despite a decrease in herpes complications in labor and an increase in cesarean rates, new interventions are needed to prevent neonatal herpes.
Sex Transm Dis 02/2008; 35(1):14-8. · 2.87 Impact Factor
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ABSTRACT: Because definitive methods for diagnosing primary syphilis are limited, it is important to optimize the sensitivity of serodiagnosis.
To determine the most sensitive testing approach to the diagnosis of primary syphilis, using the commonly available serologic tests: the Venereal Disease Research Laboratory (VDRL) test and the Treponema pallidum particle agglutination (TP-PA) test.
Sensitivities of 2 serologic testing strategies for primary syphilis were compared among 106 darkfield-confirmed cases treated in San Francisco from January 2002 through December 2004.
The sensitivity of the diagnostic strategy using VDRL confirmed by TP-PA was 71% (95% CI, 61%-79%). Substituting Rapid Plasma Reagin test for VDRL in a subset of 51 patients produced the same sensitivity (71%; 95% CI, 56%-83%). The sensitivity of TP-PA as the first-line diagnostic test was 86% (95% CI, 78%-92%). The sensitivity of the former approach was significantly lower among HIV-positive patients, compared with HIV-negative patients (55% vs. 77%, P = 0.05).
The TP-PA test as the first-line diagnostic test yielded higher sensitivity for primary syphilis than did the use of the currently recommended strategy.
Sex Transm Dis 01/2008; 34(12):1016-1018. · 2.87 Impact Factor
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ABSTRACT: To describe trends in STD diagnostic test volume and test technology in California from 1996 to 2003.
A self-administered survey was mailed annually to licensed clinical laboratories in California that performed STD testing. Data were collected on volume and diagnostic test type for chlamydia, gonorrhea, syphilis, chancroid, HIV, hepatitis B, herpes simplex virus (HSV), and human papilloma virus (HPV). Data were analyzed for trends over time.
Response rates ranged from 77% to 99% per survey year. The total number of chlamydia, gonorrhea, and syphilis tests increased from 8.1 to 9.3 million annually. The proportion of chlamydia and gonorrhea tests performed using nucleic acid amplification testing increased from 5% to 66% and from 1% to 59%, respectively. Gonorrhea culture testing decreased from 42% to 10% of all gonorrhea tests. HIV test volume increased from 2.4 to 3.1 million tests. Newer technology tests for HSV and HPV were less common but increased in use. Non-public health laboratories conducted over 90% of all STD testing.
Analyzing trends in diagnostic technologies enhances our understanding of the epidemiology of STDs and monitoring laboratory capacity and practices facilitates implementation of STD control activities.
Sex Transm Dis 08/2007; 34(7):513-8. · 2.87 Impact Factor
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ABSTRACT: The objective of this study was to examine California clinicians' use of and attitudes toward patient-delivered partner therapy (PDPT) to treat sexual partners of patients infected with chlamydia.
In 2002, a stratified random sample of primary care physicians and nurse practitioners completed a mailed, self-administered survey. Weighted frequencies were calculated to assess partner management practices, including PDPT, and attitudes toward PDPT. Multivariate models were constructed to determine independent predictors of PDPT use.
Of 708 physicians and 895 nurse practitioners, approximately half (47% and 48%, respectively) reported that they use PDPT usually or always. Over 90% agreed that PDPT protects patients from reinfection and provides better care for patients with chlamydia. However, providers reported concerns that PDPT may result in incomplete care for the partner, may be dangerous without knowing the partner's medical or allergy history, is an activity the practice may not get paid for, and may get them sued. Obstetrics/gynecology and family practice physicians were more likely than internal medicine physicians to report routine use of PDPT. Concerns about adverse outcomes of PDPT were associated with less PDPT use.
Although the proportion of California healthcare providers routinely using PDPT is comparatively high, further study is warranted to examine the circumstances under which this partner management strategy is used.
Sex Transm Dis 08/2006; 33(7):458-63. · 2.87 Impact Factor
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ABSTRACT: Currently, azithromycin is not considered a first-line treatment for Chlamydia trachomatis in pregnant women. We evaluated the use, efficacy, and safety of azithromycin compared with erythromycin and amoxicillin in the treatment of genital chlamydial infection during pregnancy.
This was a retrospective cohort study of pregnant women with genital chlamydial infection. Data on antibiotics prescribed, test-of-cure (TOC) results, and maternal and infant complications were collected from medical records.
Of the 277 women in the study sample, 69% were initially prescribed azithromycin, 9% amoxicillin, and 19% erythromycin. Eight-one percent of subjects had a TOC 7 or more days after diagnosis and before delivery. Treatment efficacy, as defined by a negative TOC, was 97% (95% confidence interval [CI], 92.9-99.2) for azithromycin, 95% (95% CI, 76.2-99.9) for amoxicillin, and 64% (95% CI, 44.1-81.4) for erythromycin. The efficacy of azithromycin was significantly higher than erythromycin (P < 0.0001). There were no significant differences in efficacy by age, race/ethnicity, concurrent sexually transmitted disease diagnosis, partner treatment, or substance use. Furthermore, there was no difference in complications for women or infants exposed to azithromycin compared with those treated with other regimens.
Clinical outcome data from this study population of women and infants support both efficacy and safety of azithromycin for treatment of C. trachomatis in pregnancy.
Sex Transm Dis 02/2006; 33(2):106-10. · 2.87 Impact Factor
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ABSTRACT: Because sexually transmitted chlamydial infections are common among young women, it is critical that providers screen and manage these infections appropriately.
To assess the Chlamydia care practices of California primary care physicians and nurse practitioners.
Cross-sectional, self-report mail survey.
A stratified random sample of primary care physicians and a convenience sample of primary care nurse practitioners in California.
Survey content included 5 topic areas: sexual history taking, management of cervicitis, management of a nonpregnant Chlamydia-infected patient, availability of onsite STD services, and Chlamydia screening practices and attitudes. Main outcome measure was the reported frequency of Chlamydia screening of sexually active women age 25 and younger. Respondents included 708 physicians (49% response rate) and 895 nurse practitioners (63% response rate). Nearly half of physicians (47%, 95% confidence interval [CI], 42% to 51%) and a majority of nurse practitioners (79%, 95% CI, 77% to 82%) reported routine Chlamydia screening of women under age 20; similar proportions reported routinely screening women aged 20 to 25 years. Independent predictors of screening among physicians were adolescent medicine specialty, female gender, practicing in a nonprivate setting, and having a higher volume of female patients. Additional findings included the overscreening of women over age 25 by nurse practitioners and the shared concern among providers that Chlamydia screening may not be reimbursed.
The Chlamydia care practices of many California primary care providers are inconsistent with current guidelines. Targeted provider education and improved reimbursements are potential strategies for improvement.
Journal of General Internal Medicine 01/2006; 20(12):1102-7. · 2.83 Impact Factor
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Heidi M Bauer,
Karen E Mark,
Michael Samuel,
Susan A Wang,
Penny Weismuller,
Douglas Moore,
Robert A Gunn,
Chris Peter,
Ann Vannier,
Nettie DeAugustine,
Jeffrey D Klausner,
Joan S Knapp,
Gail Bolan
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ABSTRACT: Rates of fluoroquinolone-resistant Neisseria gonorrhoeae (QRNG) are increasing worldwide and in California.
As a supplement to established surveillance, the investigation of QRNG in California included expanded surveillance in southern California, with in-depth interviews of patients (who had QRNG during the period of January 2001-June 2002) and a cross-sectional study of patients at 4 sexually transmitted diseases clinics with gonococcal isolates that underwent susceptibility testing (for the period of July 2001-June 2002).
The rate of QRNG increased from <1% in 1999 to 20.2% in the second half of 2003. The 2001-2002 expanded surveillance demonstrated that 66 (4.9%) of 1355 isolates were resistant to fluoroquinolones; the majority of these infections occurred after August 2001. Cross-sectional analysis of 952 patients with gonorrhea revealed that the prevalence of QRNG varied geographically during 2001-2002, with the highest rate being in southern California (8.9%) and the lowest being in San Francisco (3.6%). The QRNG prevalence was 8.6% among men who have sex with men (MSM), 5.1% among heterosexual men, and 4.3% among women. Although risk factors for QRNG varied by clinic, multivariate analysis demonstrated independent associations with race/ethnicity, recent antibiotic use, and MSM.
The emergence and spread of QRNG in California appeared to evolve from sporadic importation to endemic transmission among both MSM and heterosexuals. Monitoring of both the prevalence of and risk factors for QRNG infections is critical for making treatment recommendations and for developing interventions to interrupt transmission.
Clinical Infectious Diseases 09/2005; 41(6):795-803. · 9.15 Impact Factor
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ABSTRACT: Herpes simplex virus (HSV) type-specific serological tests are now widely available, but indications for their use have not been well defined. The California Sexually Transmitted Diseases (STD) Controllers Association convened a committee of clinicians and researchers to make recommendations for the use of type-specific HSV type 2 (HSV-2) serological tests.
By means of a systematic review of the literature, evidence to support screening in selected high-risk groups was compiled. Screening recommendations were developed by applying standard screening criteria to each specific population.
The committee concluded that, in addition to serological testing for the diagnostic evaluation of patients with symptoms, screening of asymptomatic patients is likely to be beneficial among the following groups: those at high risk for STDs and human immunodeficiency virus (HIV) infection who are motivated to reduce their sexual risk behavior, HIV-infected patients, and patients with sex partners with genital herpes. In contrast, universal screening for HSV-2 infection in pregnant women is unlikely to be beneficial.
The targeted use of HSV-2 serological tests for specific diagnostic situations and selected populations should benefit patients, providers, and the community. Until more data become available, these recommendations provide justification for selective diagnostic and screening uses of HSV-2 serological tests.
Clinical Infectious Diseases 02/2005; 40(1):38-45. · 9.15 Impact Factor
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ABSTRACT: Urine-based chlamydia tests enable screening in non-clinical settings.
The goal of this study was to determine the prevalence of chlamydia infection among high-risk youth and young adults in non-clinical settings.
County sexually transmitted disease (STD) programs implemented chlamydia screening projects in non-clinical settings using nucleic acid amplification tests. Demographic and access to care data were collected.
Overall, 16,279 female and male youth were screened for chlamydia in 24 counties throughout California. The 158 screening venues included 32 educational, 32 correctional, and 94 community-based settings. Chlamydia infection rates varied significantly by gender, age, and venue type. Among females, the highest prevalence was found in jail settings (14.6%), juvenile detention (13.0%), and alternative schools (10.0%). Among males, the highest prevalence was found in jail (7.9%) and juvenile detention (5.8%). Venue types that serve populations with poor access to care and high rates of infection were identified.
Screening projects in non-clinical settings identify high-risk youth in need of STD care, improve access to STD screening and education, and foster local collaborations.
Sex Transm Dis 08/2004; 31(7):409-14. · 2.87 Impact Factor
