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2002 National STD Conference - Poster Abstracts 1-26


Prevalence of Chlamydia trachomatis (Ct) in a Commercially Insured Population

J Armstrong, S Leeds-Richter, H Sangi-Haghpeykar

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX

Background: Few data are available on the prevalence of Chlamydia trachonmatis (Ct) infection among commercially-insured populations, who are presumed to be at low risk for infection.

Objectives: To determine the prevalence of Ct infection in a commercially insured population of women ages 15–25 using universal screening and to describe associated risk factors for infection.

Methods: Three hundred commercially insured women ages 15–25 presenting to one of seven physicians for obstetrical or gynecological care requiring a pelvic exam were screened for Ct infection by DNA strand displacement amplification assay of endocervical specimens. Patients completed a sexual behavioral questionnaire at the conclusion of the office visit. Demographic and reproductive health variables were extracted on chart review. Risk factors for infection were those described by the American College of Obstetricians and Gynecologists (ACOG) or Centers for Disease Control and Prevention (CDC) STD screening guidelines.

Results: The study population was mean age 22.5 years old (15% were less than 20 years old), white (64.9%), non-Hispanic (74.7%), unmarried (73%), and presenting for routine gynecologic care (69%). The prevalence of infection was 4.9%. The rate of infection in women less than 20 was 9.1% compared to 4.2% among women ages 20 to 25 (P=.17). Fifty-four percent of the study population had at least one risk factor for infection. Risk factors associated with infection (P<.05) included black race, obstetrical visit type, non-use of contraception, history of a STD in past 12 months, and chronic pelvic pain. Among the 15 patients with positive test results, 12 (80%) had at least one identified risk factor for infection.

Conclusions: The prevalence of Ct infection in this commercially insured population is 4.9%. Universal screening of this age band resulted in 20% more infections identified than optimal risk factor based screening alone, but this strategy required testing 47% of the population reported to have no risk factors.

Implications for Programs: Identification of risk factors and screening for Ct infection is indicated in commercially insured populations.

Implications for Research:

The cost-effectiveness of universal screening vs. risk factor based screening in commercially insured populations is required. Barriers to testing women identified at high risk for infection need to be clarified.

Learning Objectives: By the end of the session, participants will be able to describe prevalence of Ct infection in a commercially insured population and describe risk factors for infection.

Contact information: Joanne Armstrong / Phone 713-350-2725 /


Get Tested! Chlamydia Screening Projects in Non-Traditional Settings in California

M Chartier1, M Little1, M Brammeier1, HM Bauer1, R Neiman1, Get Tested! Project Managers2, G Bolan1

1STD Control Branch, California Department of Health Services, Berkeley, CA; 2Local California Health Jurisdiction Get Tested! Project Managers

Background: Screening for chlamydia in non-t raditional settings provides an opportunity to better understand the prevalence of chlamydia in high-risk groups while building local capacity to create more cohesive community awareness, outreach and screening efforts.

Objectives: To provide positivity data to inform local policy and/or funding allocation for long-term chlamydia screening projects in non-traditional settings. To foster partnerships between local STD Control Programs and community organizations.

Methods: Projects are a collaboration between the state STD Control Branch, local STD Control Programs and community partners. Beginning in Fall 2000, multi-site, non-categorical STD clinic based screening projects, using convenience sampling to screen identified high-risk youth populations, were established throughout California. Chlamydia was detected using nucleic acid amplification tests (NAATs). Demographic, sexual history and risk behavior data were collected using a standardized variable set.

Results: To date, over 80 new local partnerships in 27 California health jurisdictions have been formed. Project venues include: 27 juvenile halls, 9 colleges and universities, 13 alternative or continuation schools, and 36 innovative sites (e.g. mobile clinics, community outreach sites, pharmacy, beauty salon, and a strawberry farm that employs teen-migrant workers). As of November 2001, 9561 youth had been screened (2208 females, 1979 under 26; 7159 males, 6499 under 26). Preliminary data show an overall positivity of 8.2% among females and 5.5% among males. To date the majority of this data has been collected from juvenile halls.

Conclusions: Screening projects in non-traditional settings identify high-risk youth in need of STD care, improve access to quality STD care and education, and foster local collaborative screening efforts.

Implications for Program/Policy: Because certain high-risk groups may not be utilizing traditional STD services, outreach and screening in non-traditional settings may improve local STD control efforts. Data on CT positivity inform local policy and allocation of funds for effective long-term chlamydia screening projects.

Further research on the public health impact of chlamydia screening in non-traditional settings is needed, especially concerning the potential to reduce community prevalence and transmission, and prevent long-term complications.

Presenting Author Contact Information:

Maggie Chartier / Phone 510-883-6040 /


Chlamydia Testing in a Public Healthcare System Before and After Implementation of Screening Guidelines

G Alfonsi1,2,3, J Shlay1,2,3, T Dam1, J Douglas1,4, A Davidson1,2,3

1Denver Public Health, Denver Health (DH), Denver, CO; 2Community Health Services, DH, Denver, CO; 3Department of Family Medicine, University of Colorado Health Sciences Center, Denver, CO; 4Department of Internal Medicine, University of Colorado Health Sciences Center, Denver, CO

Background: Since 2000, HEDIS has recommended screening all sexually active women ages 15–25 years for chlamydia (CT). Polymerase chain reaction (PCR)-testing while more sensitive is more costly than EIA.

Objective: To determine CT testing practices, within a public healthcare system, prior to and after implementation of CT screening guidelines.

Methods: Computerized review of Denver Health (DH) CT testing in women seen from 7/99 to 12/99 (TP1) and from 7/00 to 12/00 (TP2) was performed. CT testing utilized EIA during TP1 and PCR testing during TP2. HEDIS consistent agency guidelines were widely introduced and promoted in 10/99. Testing patterns and CT prevalence, stratified by age, compared the two time periods using Chi-square analysis.

Results: CT testing included 4996 tests in TP1 and 5382 tests in TP2. Comparing TP1 vs. TP2, among women 15-25 years, 2506/8558 (29.3%) were tested compared to 2835/9899 (28.6%; p=.30); whereas for those >26 years, 2490/16604 (15.0%) were tested vs. 2547/17473 (14.6%; p=.27). Overall, CT prevalence increased from 5.9% in TP1 to 8.1% in TP2 (p<.001). For women £25, prevalence was 8.7% in TP1 versus 11.2 % in TP2 (p<.001) and for women >25 years, prevalence was 2.4% vs. 4.2% (p<.001).

Conclusions: Despite clear clinical guidelines, CT screening practices emphasizing younger sexually active women and targeted testing of older women were not altered. As expected, prevalence increased with use of a more sensitive test.

Implications for Programs: Appropriate CT screening guideline implementation requires further provider education to modify clinical practice. Absent guideline adherence and changing to more sensitive and costly screening measures will likely increase CT prevalence with concomitant increased program costs. Ongoing quality assurance should address guideline adherence.

Implications for Research: Future research should focus on site- or provider-specific benchmarks and feedback to improve CT screening rates in a young adult


Risk Factors for Asymptomatic

Chlamydia trachomatis Infection Among Young Women Enlisting in the US Navy

M Ryan, L Evans, J McKeehan

Department of Defense Center for Deployment Health Research, Naval Health Research Center, San Diego, CA

Background: Asymptomatic Chlamydia trachomatis infection is a critical public health challenge for young adults in both military and civilian communities. The health assessments required at the time of enlistment in the US Navy provide a unique opportunity to assess the prevalence of asymptomatic chlamydia in young woman, and factors associated with infection.

Objective: To assess the prevalence of asymptomatic chlamydia infection in young women joining the US military, and to evaluate demographic and behavioral risk factors associated with infection.

Methods: All young women who began Navy basic training during calendar years 1997, 1998, and 1999 were identified. Laboratory results from chlamydia DNA-probe tests were extracted from a health care database. Data on demographics and health history were obtained from other military resources.

Results: During the three years reviewed, 22,977 young women enlisted in the US Navy. Overall, 982 (4.3%) tested positive for chlamydia. Multivariable logistic regression modeling revealed the following factors as independently associated with infection: history of substance abuse, being less than 20 years of age, exercising less than five times per week, reporting race/ethnicity as African American, having a history of self-injury, and being from the southeastern US.

Conclusions: The universal screening for chlamydia performed at entrance into the US Navy reveals several risk factors for asymptomatic infection in young women, some of which have not been previously described in smaller samples or clinic populations.

Implications for Programs/Policy: Given the value of these data and the prevalence of asymptomatic infection, similar screening programs should be considered at other military entrance points.

Implications for Research: Further study may better define the value of the Navy’s screening program, especially with regard to reduction in long-term sequelae of asymptomatic chlamydia infections.

Learning Objectives: Participants will be able to describe the US Navy’s chlamydia screening program and the risk factors it has identified as associated with asymptomatic infection.

Contact Information: Margaret Ryan / Phone 619-553-8097 /


Prevalence and Correlates of Chlamydia trachomatis in Sexually Active African-American Adolescent Females

KM Williams1, GM Wingood1,3,

RJ DiClemente1,2,3, RA Crosby1,2, D Hubbard McCree1, A Liau1, S Davies4, K Harrington5, EW Hook6, MK Oh4

1Rollins School of Public Health, Department of Behavioral Sciences and Health Education, Atlanta, GA; 2Emory Center for AIDS Research, Atlanta, GA; 3Emory University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Epidemiology and Immunology, Atlanta, GA; 4School of Medicine, Department of Pediatrics, University of Alabama, Birmingham, AL; 5School of Public Health, Department of Health Behavior, University of Alabama, Birmingham, AL; 6School of Medicine, Department of Medicine, Division of Infectious Diseases, University of Alabama, Birmingham, AL

Background: Chlamydia trachomatis is the most common sexually transmitted bacterial pathogen in the United States and disproportionately affects African-American adolescents.

Objective: To determine the prevalence of C. trachomatis and to identify correlates of infection among African-American adolescent females.

Methods: Sexually active African-American adolescent females (N = 522) completed a self-administered survey, structured interview, and provided vaginal swab specimens for laboratory assessment of STDs. The relationship between selected psychosocial, behavioral and biologically confirmed STDs and C. trachomatis was assessed.

Results: The prevalence of C. trachomatis was 17.4%. Results of multiple logistic regression revealed that adolescents testing positive for C. trachomatis infection were significantly more likely to test positive for gonorrhea (OR = 5.0; p=.004); to report non-use of condoms with a steady partner (OR = 2.4; p=.01); to be in shorter relationships (OR = 2.2; p=.02); and to perceive poorer parental monitoring (OR = 2.1; p=.03).

Conclusions: Study findings emphasize the need for assessing psychosocial factors, behavioral factors and the presence of other STDs when determining risk for C. trachomatis. Several of the constructs identified are particularly amenable to behavioral interventions.

Implications for Programs: These results will be useful in informing screening approaches to more reliably detect adolescents at higher risk for infection and provide useful information for the design of behavioral intervention programs aimed at decreasing risk for infection.

Implications for Research: Results of this analysis provide further information on the risk correlates of C. trachomatis, however additional research is needed to accurately isolate, quantify, and characterize the factors that enhance risk for C. trachomatis. Careful studies of the acquisition of C. trachomatis infections in relationship to specific psychosocial, behavioral, demographic and clinical factors are necessary to further investigate the current study findings.

Learning Objectives: Participants will be able to identify factors influencing risk for C. trachomatis infections among adolescent females.


Pilot Evaluation of the Soundex Function for the Region VIII Infertility Prevention Project (IPP)

Y Hamby1, H Hughes2, E Ansara1

1JSI Research & Training Institute; 2University of Colorado Health Sciences Center, Denver, CO

Background: The Public Health Service Region VIII Infertility Prevention Project (IPP) is part of the national IPP. The IPP was funded through the Regional Infertility Prevention Projects legislation, which aims to reduce the costly and destructive sequelae of chlamydia and other sexually transmitted diseases on the reproductive health of women. The soundex system in the Region VIII IPP is used for the purpose of converting last names into a quasi-identifier that cannot be converted back into the last name directly, thereby protecting confidentiality.

Objective: To determine the effectiveness of this system within Region VIII we assessed the accuracy and uniqueness of the soundex identifier with date of birth (DOB) as well as the ability of the unique identifiers to track the utilization of services in various clinic types.

Methods: A survey was conducted with each of the eleven Region VIII IPP areas to determine how the soundex program is implemented in each of the project areas. We ran a random sample of names (n = 350) through the regional database soundex program, the standard dbase soundex program and then compared the soundex code derived from the regional program to the soundex code derived from the soundex program used by the National Archives and Records Administration (NARA). To determine the uniqueness of soundex identifiers coupled with date of birth to more accurately “identify” a person within the system, we ran cross tabs to determine how many times soundex code is correlated with the same date of birth.

Results: Ten responses were received out of the eleven surveys sent. Of the responses received there are six distinct processes in which the soundex algorithm is implemented. No differences have been seen in the validity of the soundex based on how it is implemented in the project areas. The comparison of the soundex code derived from the regional dBase program to the NARA soundex program found the regional dBase program was 100% specific and sensitive.

Conclusion: Based on these results, the system is fully capable of tracking recurrence of chlamydia infection, retesting for chlamydia infection, and movement across clinic types to obtain chlamydia testing.

Implications for Programs/Policy: The ability to track recurrence of chlamydia infection, retesting for chlamydia infection, and movement across clinic types to obtain chlamydia testing can give programs important information for program planning and outreach.

Implications for Research: Future research should further explore implications for recurrent chlamydial infection.


How Often Should Young Women Be Screened for Chlamydia trachomatis in a Moderate-Prevalence Area?

JK Chaw, CK Kent, JD Klausner

STD Prevention and Control Services, San Francisco Department of Public Health, San Francisco, CA

Background: A recently published article from Baltimore, a high-prevalence chlamydia area, found the median time to first and repeat infection among women <25 years to be 7.0 and 7.6 months, respectively. The incidence rate in Baltimore among these young women was 20.3 cases/1,000 persons per month. The authors recommended chlamydia screening twice yearly for all sexually active women <25 years.

Objective: To assess if biannual chlamydia screening of young women is appropriate in a moderate prevalence area.

Methods: Between April 1998 and December 2000, 3,856 women aged 12–60 years had at least two visits more than 30 days apart at six San Francisco sentinel sites: two detention facilities (41% of data), the municipal STD clinic (38%), a teen clinic (6%), and two family planning clinics (15%). During 9,977 clinic visits, women were tested for chlamydia by nucleic acid amplification.

Results: The overall prevalence at all sites was 6.6%, but varied significantly by site (p<.01). The median times to first and repeat infection among women <25 years were 8.3 and 6.5 months, respectively. Overall incidence rate among women <25 years was 9.3 cases/1,000 persons per month (95% CI: 8.1, 10.6).

Conclusions: We found a longer time to first infection and a 50% lower incidence rate than observed in young women in Baltimore. Most data came from the highest prevalent sites in San Francisco, so that our findings likely overestimate what would be found in the broader population of this moderate prevalence city. This suggests that annual chlamydia screening for sexually active women <25 years in moderate- to low-prevalence areas is adequate.

Implications for Program/Policy: Biannual chlamydia screening may be appropriate in high-prevalence areas but may be unnecessary in areas of moderate- or low-chlamydia prevalence.

Implications for Research: Further studies should assess the most effective time period for screening in varying prevalence settings.

Learning Objectives: Participants will be able to understand the role of prevalence in their population in determining chlamydia screening intervals among women <25 years.


Examining Selective Chlamydia Screening Criteria for Women over Age 25

V Loo1, E Ciemins1, J Chow1, M Brammeier1, H Bauer1, P Kerndt2, G Bolan1.

1STD Control Branch, California Department of Health Services, Berkeley, CA; 2STD Program, Los Angeles Department of Health Services, Los Angeles, CA.

Background: Clinicians receive little guidance for screening asymptomatic women over age 25 for chlamydia (CT). Current US Preventive Services Taskforce recommendations, which include non-specific behavioral risk factors such as inconsistent condom use, may result in over-testing in this age group. Cost studies suggest a threshold prevalence ranging from 2–6% for routine CT screening among family planning populations.

Objective: To develop selective CT screening criteria specific for asymptomatic, non-pregnant women over age 25.

Methods: Routinely collected behavioral risk factor data from six family planning sites participating in the California Infertility Prevention Project from 1998–2000 were used to evaluate the sensitivity of various screening criteria. Criteria were tested hierarchically, beginning with factors associated with infection through bivariate analysis.

Results: Observed prevalence of CT infection in this sample was 1.9% (65/3410). The percentage of positive tests identified through various screening criteria ranged from 14% (9/65) among women selected based only on lifetime history of CT, to 62% (40/65) among women who had any of the following characteristics: lifetime history of CT; new partners (past 2 months); non-steady partners; non-monogamous partners; recent douching (last 30 days); single marital status; not always using condoms with non-steady partners; a steady relationship<1 year; or not always using condoms in steady partnerships of less than 2 years. The percentages of women screened using these criteria were 7% and 44%, respectively. Observed prevalence of CT among women selected by the least inclusive criteria was 3.8% compared to 2.6% using the most inclusive. The most specific criteria (history of CT, new partner, or non-steady partner; observed prevalence: 4.8%) only identified 28% of women with positive tests.

Conclusions: Selective screening criteria can identify higher prevalence sub-populations among women over age 25. Only 62% of women with positive CT tests would be selected for screening using the most inclusive criteria.

Implications for Programs/Policy: Risk factors collected through usual sexual history taking practices can be used to select a sub-population of asymptomatic women over age 25 with CT prevalence high enough to warrant routine screening.

Implications for Research: Cross-sectional studies of females over age 25 including a broader range of risk factors are needed to develop more sensitive screening criteria. Cost-effectiveness prevalence thresholds are population-dependent and should be evaluated for older women.

Measurable Learning Objectives: By the end of this presentation, participants will be able to evaluate the utility of selective chlamydia screening criteria for women over age 25 who seek care in family planning clinics.

Contact Information: Virginia Loo / Phone 510-883-6641 /


Randomized Trial Comparing Different Outreach Strategies for Chlamydia Screening

L Asbel1, R Jeanette 2, M Goldberg1, P Whittaker3, K Armstrong3, D Vojta2, C Johnson1

1Philadelphia Department of Public Health (PDPH) STD Control Program; 2Health Partners of Philadelphia, Inc.; 3Family Planning Council, Philadelphia, PA

Background: Despite aggressive STD control efforts, Chlamydia trachomatis infection remains a major public health problem in Philadelphia. Reported morbidity is highest among women 15–29 years of age, particularly low-income adolescent and young adults of black or Hispanic ethnicity.

Objective: To compare different outreach strategies for increasing the rate of chlamydia screening among women enrolled in a managed care organization.

Methods: Continuously enrolled female members of Health Partners (a medical assistance managed care organization), 15–29 years of age, were randomized into either a control group (n = 5,285) or one of five enhanced outreach groups (A–E) (n = 3,791). All participants in the enhanced outreach groups received a custom-designed and targeted newsletter containing information about chlamydial infections. In addition, four of the enhancement groups received supplementary outreach efforts as follows: A) incentive gift offer; (B) case-management services; (C) gift offer plus case management; and (D) healthcare provider notification. Outcome measures included the proportion of patients having chlamydia screening or seeking STD-related services during 90 days of follow-up.

Results: A significant difference was found in the proportion of patients having a chlamydia test performed in the study vs control groups, 10% vs 8%, respectively (P=.014). A similar benefit was also seen between study and control groups when a billing claim for STD-related services was the endpoint measurement, 11% and 9%, respectively (P=.008). Black and Hispanic women were more likely to have chlamydia screening or a claim for STD-related services, irrespective of their randomization group.

Conclusions: Chlamydia screening rates for young women enrolled in a managed care organization were modestly improved using several different outreach strategies.

Implications for Programs: Working with a local managed care organization was a promising way of targeting young women at high risk of chlamydia i nfection.

Implications for Research: Further investigation is needed to determine the optimal outreach method and message for reaching young women at high risk of STDs.


Impact of Targeted Screening and Treatment of Asymptomatic Males for Chlamydia trachomatis on Female Morbidity

M Eberhart1, L Asbel1, M Goldberg1, R Small2

1Philadelphia Department of Public Health, Division of Disease Control – STD Control Program; 2Texas Department of Criminal Justice

Background: Screening for chlamydia in women has remained relatively constant over the past 5 years, yet morbidity has continued to increase. Reinfections account for a substantial number of female cases. Reported rates in young men are much lower primarily because of a lack of routine screening. Disease burden in young men is greater than represented by reported morbidity, and small-scale screenings yield positivity rates as high as 31%.

Objective: To determine if screening and treatment of asymptomatic males will have an impact on female morbidity.

Methods: In December of 1999 the Philadelphia Department of Public Health STD Control program began screening high-risk young males for Chlamydia using urine-based tests. We proposed at that time that male screening and treatment would have an impact on disease in women. From December of 1999 through June 2001 urine screens for chlamydia were done in men resulting in 492 positive test results and treatment in 333 young men. From a large computerized database we were able to identify males with a positive test result for chlamydia from urine-based testing between December 1999 and June 2001. These male cases were grouped by ZIP Code and compared to the percent change in female morbidity by ZIP Code during the same time period.

Results: An inverse correlation (Pearson r = 0.27, p=0.03) was demonstrated between the number of men treated for chlamydia, and the percent change in reported female morbidity.

Conclusions: In the first 6 months of 2001 we saw our first decrease in reported female chlamydia morbidity since 1992. During this same period there was no active screening of asymptomatic men for gonorrhea and gonorrhea rates among women continued to rise.

Implications for Programs/Policy: Screening and treatment of asymptomatic can reduce female morbidity.

Implications for Research: Further analysis of this correlation. Evaluation on rates of reinfection.

Contact Information: Lenore Asbel / Phone 215-685-6740 /


Expanding Chlamydia Awareness and Health Care Seeking Among At-Risk Males

KL Gudgel1, S Hartman2, M Stenger1, M Aubin1, L Klopfenstein1

1Washington State Department of Health, Olympia, WA; 2APCO Worldwide

Background: There is disparity in reported Chlamydia trachomatis (CT) infections in Washington State with a reported case ratio of 3:1, females to males. Present screening strategies focus on women. To identify more male cases, non-invasive (urine) screening was offered at Infertility Prevention Project (IPP) clinics in 6 counties in Washington State in conjunction with a media awareness initiative aimed at promoting positive healthcare-seeking behaviors among young men.

Objective: To increase CT testing among males aged 15–29 through heightened public awareness.

Methods: Key content for the media campaign was determined through focus groups with young men. Messages were delivered through healthcare professionals, radio, television, newspapers, movie advertisements, posters and information cards. Success of the media campaign is being evaluated through a random telephone survey of the target population. Urine testing was offered at IPP clinics and the number and results of tests were tallied.

Results: The slogan “Got lucky, Got anything else? Get tested!” was used on the messages for the media, posters, wallet cards, and pamphlets. Spanish versions were also developed and disseminated. A public service announcement (PSA) was developed and sent to all radio stations. Several newspapers published articles on CT. Males screened at IPP sites in the 6 counties have yielded a 13.5% positivity rate in 16 months of testing.

Conclusions: The media campaign has been a qualified success. Twelve media outlets in rural counties aired interviews or published articles on testing asymptomatic males for CT. Media in urban counties were far less receptive. Posters have been widely distributed to providers outside of the IPP including the largest health maintenance organization in Washington State. Male testing is slowly increasing in the target communities, but most clinics observe that motivating males to access the clinics is challenging.

Implications for Programs: Educational materials developed are available to other programs. Screening asymptomatic males should be considered as a means to reduce CT morbidity.

Implications for Research: Future research should investigate methods to increase male screening in a variety of healthcare settings and outside the traditional healthcare system.


Gonorrhea Prevalence and Co-infection with Chlamydia in Women Seen in Family Planning Clinics

L Dicker, D Mosure, S Berman, W Levine, and Regional Infertility Prevention Program

Centers for Disease Control and Prevention, Atlanta, GA

Background: Gonorrhea (GC) is the second most commonly reported notifiable disease in the US. Data have not existed on the prevalence of GC in populations screened for both GC and chlamydia.

Objective: To describe the prevalence of gonorrhea and coinfection with chlamydia in women aged 15–24 years routinely screened in family planning clinics in 2000.

Methods: Data were analyzed on 527,818 tests on women aged 15–24 years screened for GC in 1,464 family planning clinics in 34 states in 2000. GC positivity (median and interquartile range [IQR]) and chlamydia positivity among women infected with GC were calculated by state and age group (15–19 and 20–24 years).

Results: The median state-specific GC positivity was 0.985% (IQR, 0.6–1.6%). For women 15–19 years the median GC positivity was 0.9% (IQR 0.7–2.1%); the median GC positivity in women 20–24 years was 0.8% (IQR, 0.5–1.2%). The median GC positivity was highest in the South (1.6%, IQR 0.9–2.0%) followed by the Midwest (0.9%, IQR 0.8–1.3%) and West (0.6%, IQR 0.5–0.8%), and lowest in the Northeast (0.45%, IQR 0.215–1.2%). Among the 20 states with at least 50 positive GC tests, median chlamydia positivity among those women infected with GC was 42.6% (IQR 39.1–45.2%); it was highest among those 15–19 years (45.6%. IQR 41.7–49.0%), compared with 20–24 years (36.6%, IQR 34.3–43.9%).

Conclusions: GC positivity is highest among women 15–19 years of age screened in family planning clinics; almost half of women aged 15–19 years with GC are also infected with chlamydia.

Implications for Programs: This analysis indicates the continued importance of testing for and presumptively treating chlamydia in those women infected with GC.

Implications for Research: Examination of risk factors associated with GC infection and co-infection with chlamydia is needed to assist in the development of effective gonorrhea screening criteria.

Learning Objectives: Participants should be able to describe the prevalence of GC and co-infection with chlamydia among young women screened in family planning clinics in the US.

Contact Information: Linda Dicker / Phone 978-440-9542 /


Results of a Urine-Based Gonorrhea (GC) and Chlamydia (CT) Screening Program for High-Risk Adolescents in Monroe County

K McMahon1, M Urban2, P Coury-Doniger2, M Scahill2, J Leger1

1Monroe County Department of Health, Rochester, NY; 2University of Rochester, School of Medicine, Rochester, NY

Background: The use of new diagnostic technologies for STD screening allows for expanded STD screening in non-traditional settings. School-based clinics and juvenile justice settings serve large numbers of high-risk adolescents; yet routine STD screening is rare.

Objective: To describe the enhanced adolescent STD screening program in Monroe County involving collaborations with two inner-city high school clinics and two juvenile justice centers

Methods: Urine-based screening for GC and CT (LCx, Abbott Laboratories, Chicago) was initiated for all new inmates at two juvenile justice centers and subsequently for adolescents visiting the school-based medical clinics at two high schools in Rochester, NY.

Results: From October 1999 to July 2001, 1,083 males and 575 females were screened at two juvenile justice settings. Prevalence of GC was 4.8% in males and 11.5% in females. Prevalence of CT was 4.6% in males and 19.1% in females. Mean age for males and females with GC or CT was 15 with age range of 12–17 years. Racial distribution of cases was 72% African-American, 16% Caucasian, 6% Hispanic, and 5% other. From October 2000 to July 2001, 413 students were screened in the school-based clinics. Prevalence of GC was 3.4% and CT was 13%.

Conclusions: Prevalence of CT and GC was significant at both types of facilities and suggests that expanded adolescent screening in these facilities is warranted. Collaborations with existing adolescent settings facilitate treatment and follow-up of positive cases.

Implications for Programs: STD programs can increase their impact on case-finding in hard-to-reach adolescent populations by instituting screening programs in these types of facilities.

Implications for Research: Further research is needed to define the cost-effectiveness of expanded adolescent screening and its impact on community-wide morbidity.

Learning Objectives: Participants will become familiar with the benefits of outreach programs for STD screening in adolescents.

Contact: Kelli McMahon / Phone 716-530-4379 / Fax (716)-530-4378 /


Multiple Sexually Transmitted Infections Within Sexual Dyads

B Van Der Pol1, JA Williams1, BE Batteiger1, JD Fortenberry1, DP Orr1, Julie Shilliager2

1Indiana University School of Medicine, Indianapolis, IN; 2Centers for Disease Control and Prevention, Atlanta, GA

Background: Understanding transmission of sexually transmitted infections (STI) is crucial to development of effective control strategies.

Objective: To evaluate co-infection with multiple organisms (mSTI), Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis, among sexual partnerships (dyads).

Methods: Subjects were recruited at an STD clinic regardless of infection status. Partners of enrolled subjects were recruited from the clinic, or sought using DIS. Samples were obtained for polymerase chain reaction (PCR) for all three organisms.

Results: Among 76 dyads, 54 (71.1%) had at least one infected person. Twenty-eight (51.9%) dyads had only one infected person. In the remaining 26, both persons had STI. Twenty-one (38.9%) dyads included at least one person with mSTI. In four, the same mSTI were detected in both persons, in 7, one person had mSTI while the other had the same STI plus an additional organism, in 8 one member was negative and in the remaining two dyads each person was infected with different organisms. In 6/21 (28.6%) dyads with mSTI, the first person evaluated had only one of the STI which were subsequently found in their partner.

Conclusions: Pathogens diagnosed in persons attending an STD clinic cannot be considered fully representative of the pathogens which may be found in their partners.

Implications for Programs/Policy: Lacking predictable transmission patterns, especially in high-risk patients who may have mSTI, contact tracing is clearly warranted. Tracing should be aimed at bringing partners into clinics for testing, as well as treatment, in order to detect any additional STI that may be present in a substantial number of sexual dyads.

Implications for Research: Transmission of STI, especially when mSTI are involved, remains a complex, poorly understood process. Further research is needed to improve our understanding of both the biological and behavioral factors involved.


Ciprofloxacin-Resistant Neisseria gonorrhoeae in Southern California, 2000–2001: Are Men Who Have Sex with Men at Greater Risk?

HM Bauer1, A Vannier2, D Moore3,

P Weismuller4, N DeAugustine5, B Fujikawa5, H Calvet5, R Gunn6, C Peter6, R Nachum7, P Kerndt8, S Coulter1, SA Wang9, J Knapp9, G Bolan1

1California Department of Health Services STD Control Branch, Berkeley, CA; 2Kaiser Permanente Southern California, Los Angeles, CA; 3Orange County Public Health Laboratory, Santa Ana, CA; 4County of Orange Health Care Agency, Santa Ana, CA; 5City of Long Beach Health Department, Long Beach, CA; 6San Diego County Health and Human Services Agency, San Diego, CA; 7King-Drew Medical Center, Los Angeles, CA; 8Los Angeles Health Department, Los Angeles, CA; 9Centers for Disease Control and Prevention (CDC), Atlanta, GA

Background: During the summer of 2000 (July–September), six cases of ciprofloxacin-resistant gonorrhea (CipR GC) were reported in Orange County, California. These cases were identified through the national Gonococcal Isolate Surveillance Project (GISP), which provides antibiotic susceptibility testing on gonococcal isolates from male patients with urethral infections seen in sentinel clinics. These six cases represented a substantial increase for southern California GISP sites over previous years.

Objectives: To investigate the increase in CipR GC in Orange County and surrounding health jurisdictions in southern California, identify additional cases, and characterize their risk factors.

Methods: Beginning January 2001, five Southern California laboratories prospectively tested all GC isolates for ciprofloxacin susceptibility using disk diffusion and e-test methods. Isolates included urethral, cervical, rectal, and pharyngeal specimens from patients seen in seven southern California health jurisdictions: three STD clinics, one 1 managed care organization, one public clinic, and one jail setting. For CipR GC cases, medical records were reviewed and patients were interviewed.

Results: During a 15 month period (July 2000–September 2001), 15 CipR cases were identified: seven isolates from GISP patients and eight from other patients (< 1% of the 900 GC isolates tested). The occurrence of CipR GC varied by health jurisdiction and clinical setting. Two women (2/2) reported a male partner who had traveled to SE Asia. Of the 13 males, six reported exposure to male sex partners (MSM), and two of these were linked. All four of the cases since May 2001 were MSM with multiple sex partners.

Conclusion: Although the current rate of CipR GC in southern California is low, these data support that ongoing transmission of CipR GC strains is occurring among MSM and if such transmission continues, it may warrant using cephalosporins to treat GC in southern California. Travel to areas with high endemic levels of CipR GC is an important risk and clinicians should obtain a travel history for GC patients and their partners.

Implications for Program/Policy: Monitoring levels of antibiotic resistance in local health jurisdictions can inform evidence-based recommendations regarding treatment regimens. Providers must assess patients’ risk of having CipR and treat accordingly.

Implications for Research: Further epidemiologic investigations are necessary to characterize the sources of resistant strains and reduce further spread in the US.

Learning Objectives: Participants will be able to describe the methods and outcomes of the CipR GC investigation in southern California.

Contact information: Heidi Bauer / Phone 510-883-6617 /


Characteristics of Patients Infected with Ciprofloxacin-Resistant Neisseria gonorrhoeae, in the Continental United States, 1994-2000

S Conner, S Wang

Centers for Disease Control and Prevention, Atlanta, GA

Background: Ciprofloxacin is a widely used, inexpensive treatment for Neisseria gonorrhoeae (GC), but ciprofloxacin-resistant (CipR) GC is becoming more common.

Objectives: To describe characteristics of male patients with CipR GC in the continental United States (U.S.).

Methods: CipR GC isolates in the continental U.S. were identified from 1991-2000 through the Gonococcal Isolate Surveillance Project (GISP), the national sentinel surveillance system monitoring GC. Clinical and demographic data from these male patients with CipR GC were examined.

Results: Forty-one GC isolates from GISP (1991-2000) were identified as CipR within the continental U.S. The first resistant isolate appeared in 1994, followed by a substantial increase in CipR isolates in 1999. These patients with CipR were concentrated within four areas on the west coast: Seattle, WA (24%, 10/41); Orange County, CA (17%, 7/41); San Diego, CA (12%, 5/41); and San Francisco, CA (12%, 5/41). Twenty percent (8/40) were Asian. For those patients with additional data, 84% (33/39) were heterosexual. Forty-five percent (10/22) had taken antibiotics within the previous 30 days. Four of seven patients had sex work exposure within the previous 30 days. Either patients or their sex partners were likely to have had foreign exposure, defined as travel to or residence in a foreign country within the previous 30 days [patients or sex partners combined, (50%, 11/22)].

Conclusions: Foreign exposure or geographic residence on the west coast appeared to be an important characteristic of patients with CipR GC.

Implications for Programs/ Policy: Travel history should be routinely obtained in patients with GC as it may help guide selection of appropriate GC treatment.

Implications for Research: More data on patients with CipR GC are needed in order to better characterize the risk factors for acquisition and spread of CipR GC.

Measurable Learning Objectives: By the end of this session, participants will be able to describe characteristics of some male patients with CipR GC and discuss the implications of antimicrobial resistance on GC treatment.


Gonorrhea Screening Practices, Strategies, and Guideline Development for Non-Pregnant Female Patients in a Managed Care Setting

H Chaney1, M Chartier1, H Bauer1, R Neiman1, N Kang1, R Baxter2, G Bolan1

1STD Control Branch, California Department of Health Services, Berkeley, CA; 2Kaiser Permanente Northern California, Oakland, CA

Background: Over the past few decades, the overall prevalence of gonorrhea (GC) in the US has declined to the extent that general-population-based screening may no longer be an appropriate or cost-effective control strategy. In 2000, the prevalence of GC in a large managed care organization (MCO) in northern California with a high GC test volume was <1%, leading to the suspicion of over-screening.

Objectives: To better understand current testing practices and characterize GC-infected, non-pregnant female patients in a managed care setting. To develop clinical practice GC screening guidelines for MCO providers.

Methods: A case-control study design reviewed the administrative data and medical record charts for non-pregnant females who were tested for GC at any Northern California Kaiser Permanente facility July 1, 1999, to June 30, 2000. All eligible GC-positive cases and a facility-specific proportion of randomly sampled GC-negative cases were reviewed. Each case was characterized according to age, facility location, county morbidity, symptoms, signs, STD co-infection, contact to disease, sexual behavior risk factors, and STD history.

Results: Preliminary data analysis of positive cases indicated that, in a managed-care setting, GC testing based on symptomatic presentation, contact to disease, and/or recent STD history may capture up to 90% of positive cases. Further results concerning test volume, specificity, and cost-effectiveness of screening criteria are pending following completion of data collection.

Conclusions: Universal or routine age-based screening for GC may not be indicated in low prevalence populations. In addition to diagnostic testing of symptomatic patients and contacts, GC screening guidelines should target those factors associated with increased risk for infection within a specific population.

Implications for Program/Policy: A better knowledge of the managed care patient population, and the characteristics in this population associated with increased risk for GC infection, will aid in the development of evidence-based GC screening guidelines that are sensitive, specific, and cost-efficient within the managed care setting.

Implications for Research: Prospective universal screening studies collecting thorough sexual history information is needed to understand the specific associated risks for gonococcal infection within managed care’s asymptomatic patient population.

Presenting Author Contact Information:

Holly Chaney / Phone 510-883-6610 /


Gonorrhea Surveillance: Estimating Epidemiologic and Clinical Characteristics of Reported Cases Using a Sample Survey Methodology, San Diego County, 2001

K Mark1,2, A Arroyo2, R Gunn1,2

1Centers for Disease Control and Prevention, Atlanta, GA; 2Health and Human Services Agency, San Diego County, CA

Background: San Diego County has experienced a 30% increase in reported gonorrhea cases over the past two years. Information about reported cases is limited to basic demographic data, which are often incomplete.

Objective: To evaluate the feasibility of surveying clinical providers of a sample of reported cases to estimate characteristics of all reported cases.

Methods: The providers caring for a sample (n = 200, ~10%) of reported gonorrhea cases (projected 1,956 cases in 2001) are being telephoned and asked about patient demographics, risk factors, and management. Cases included are all those reported during a report week (starting August 16, 2001) and then every other week thereafter.

Results: The providers of all 35 cases reported during the first report week were contacted, and 33 (94%) completed the survey which took an average of 20 minutes (setting up and conducting the interview). Providers responded that 49% of cases were male of whom 19% were men who have sex with men. The reasons why cases were tested for gonorrhea included symptoms (61%), partner referral (18%), and screening (18%). Of all tests performed, 46% were DNA probe, 31% amplified methods, and 23% culture. Treatments included cephalosporins (58%), fluoroquinolones (35%), and azithromycin alone (7%). Partner treatment was documented in only 18%. Analysis of data from the completed sample will be presented.

Conclusions: Collecting information from providers about recently reported gonorrhea cases is feasible and provides important information that is not available to the STD program under current surveillance practices.

Implications for Programs: Surveying providers of a sample of reported gonorrhea cases provides information about cases that can be used to direct intervention strategies and monitor trends.

Implications for Research: Studies comparing the data obtained and time involved in provider surveys compared with case-patient surveys should be conducted in a variety of jurisdictions, and ultimately, a national sampling approach could be explored.

Learning Objectives: Participants will be able to describe the population affected by gonorrhea and describe clinician practices regarding gonorrhea testing, screening, treatment, and partner notification in San Diego County in 2001.

Contact Information: Karen Mark / Phone 619-692-8664 /


Trends in Gonorrhea in Canada, 1994–2001

L Hansen, T Wong

Centre for Infectious Disease Prevention and Control, Health Canada, Ottawa, Canada

Background and Objectives: The Canadian goal for gonorrhea control is to eliminate locally transmitted infection by 2010. As in other western nations, the incidence of gonorrheal infection in Canada has recently increased. We evaluated national data to describe the changing epidemiology of gonorrhea.

Methods: National gonorrhea surveillance data on reported cases in Canada were analyzed.

Results: The reported gonorrhea rate declined from over 200/100,000 in 1980 to its nadir of 14.9/100,000 in 1997. In 2000, the preliminary rate was 20.1/100,000. Projections based on data from the first quarter of 2001 indicate that case numbers are continuing an upward trend in both men and women. Ethnicity information is unavailable. In females, the highest rate and the largest increase are occurring in the 15–24 age group, in contrast to the 20–39 age group in males. Since 1997, the rate for men in their 30s has surpassed that for teens. Over 1/3 of nationally reported gonorrhea infections among males lack any marker of sexual orientation, although the number of cases among men who have sex with men (MSM) has been rising with the general trend.

Conclusions: In the past 4 years, reported gonorrhea rates reversed their long decline. The disease control target will not be reached by 2010.

Implications for Programs/Policy: Evidence-based behavioral interventions, and the development of new approaches, are needed to reach those at highest risk. Gonorrheal infection is a potential marker of high-risk behavior, and the relatively dramatic resurgence of this disease is of public health concern.

Implications for Surveillance/Research: The addition of valuable surveillance indicators will permit more detailed analysis of populations at risk, as well as the design and implementation of preventive programs.

Learning Objectives: Participants will be able to describe recent changes in STD epidemiology in Canada and their public health implications.

Contact information: Lisa Hansen / Phone 613-941-8051 /


Increases in Gonorrhea Among Vulnerable Populations: Obstacles to Disease Intervention

SJ Shapiro1,2, S Downes1

1Maine Bureau of Health; 2Centers for Disease Control and Prevention, Atlanta, GA

Background and Rationale: Gonorrhea in the state of Maine, until recently, had been characterized as isolated occurrences of disease with little or no evidence of transmission within social networks. An outbreak in Waterville in 1999 has been previously described. Ongoing outbreaks among men who have sex with men (MSM) and young women have provided additional opportunities to describe current prevention infrastructure and intervention methods.

Objective: Describe two ongoing outbreaks among vulnerable populations and identify obstacles to disease intervention activities.

Methods: Traditional STD partner notification methods were used to identify, locate, examine, treat, and counsel persons at risk for gonococcal infection during these outbreaks. Recommendations and instructions for use of diagnostic tools were distributed to medical providers statewide. Community outreach activities occurred in partnership with local HIV service organizations.

Results: Gonorrhea among MSM, up 45% in 2001, is concentrated in the largest urban area in the state. Gonorrhea among women aged 15–19, up 200%, is evenly distributed throughout the state. Culture methods for the detection of gonorrhea are generally unavailable. Lack of insurance coverage or disposable income can lead to treatment of partners without diagnostic evaluation.

Conclusions: Traditional disease intervention activities are increasingly more difficult among vulnerable populations. Income status, as well as diagnostic test availability, impacts partner notification activities.

Implications for Programs/Policy: Community-based organizations and state/local health departments can successfully partner to provide accurate and timely information to affected populations and their healthcare providers. Additional mechanisms for financial support for diagnostic testing and therapy are necessary.

Implications for Research: Development of non-culture gonorrhea diagnostic methods for pharyngeal and rectal infections would aid in the epidemiologic analysis of outbreaks, especially among MSM.


Patterns of Sexually Transmitted Diseases (STD) and Neisseria gonorrhoeae (Ng) Antimicrobial Susceptibility Among Female Sex Workers in Manado, Indonesia

MR Joesoef1, JS Moran1, A Karundeng2, C Runtupalit2, M Lesmana3, JS Lewis1, CA Ryan1

1Division of STD Prevention and Laboratory, Centers for Disease Control and Prevention, Atlanta, GA; 2Bahagia Harapan Kita Foundation, Indonesia; 3US Naval Medical Research Unit 2, Jakarta, Indonesia

Background: Little is known about the prevalence of STD and Neisseria gonorrhoeae (Ng) antimicrobial susceptibility among female sex workers in Manado, Indonesia. Manado is close to the Philippines where Ng resistance to ciprofloxacin, the current drug of choice for gonorrhea in Manado, has emerged. Thus, monitoring the Ng susceptibility is important for providing adequate gonorrhea treatment.

Objectives: To determine the patterns of STD and Ng antimicrobial susceptibility among female sex workers in Manado, Indonesia.

Methods: We conducted an STD prevalence survey from June 1998 to April 1999. We recruited informal female sex workers to participate in this survey. We detected cervical infections of Ng and Chlamydia trachomatis (Ct) by DNA probe (GenProbe PACE 2). We also evaluated in vitro susceptibilities of 39 Ng isolates to commonly used antibiotics in Manado.

Results: A total of 474 female sex workers participated in this study. The results of DNA probe testing showed a 19.0% prevalence of gonorrhea, a 13.1% prevalence of chlamydia, a 25.9% prevalence of either infection, and a 6.1% prevalence of dual infections. The prevalence rates of gonorrhea and chlamydia increased by declining age and age at first sexual intercourse. The prevalence rates of gonorrhea and chlamydia were similar by sex workers’ education, condom use at the last sexual intercourse, use of antibiotics in the previous month, and STD symptoms at examination. Condom use at the last sexual intercourse was low (34%). The prevalence rates of gonorrhea and chlamydia were the lowest among sex workers who sought STD treatment at public clinics (13% and 7%, respectively). The most cited reason for the use of condom at the last sexual intercourse was for the prevention of STD/HIV. Of the 45 Ng isolates collected, 39 were successfully re-cultured for antimicrobial susceptibility testing. All isolates were resistant to tetracycline and penicillin and all were susceptible to ciprofloxacin, ceftriaxone, azithromycin, and erythromycin. A total of 12 isolates (31%) were resistant to kanamycin.

Conclusions: We found high rates of gonorrhea and chlamydia infections and low rate of condom use among informal female sex workers. We also found no Ng resistance for ciprofloxacin and universal resistance to tetracycline and penicillin.

Implications for Programs: Campaign efforts for consistent and correct use of condoms should be improved. Ciprofloxacin should be continued as the drug of choice for the treatment of gonorrhea and periodic monitoring should be implemented.

Learning Objectives: Participants will be able to describe patterns of STD prevalence and Ng antimicrobial susceptibility among female sex workers and its program implications.


High Rate of Bacterial Vaginosis (BV) Among Women with Intrauterine Devices (IUD) in Manado, Indonesia

MR Joesoef1, A Karundeng2, C Runtupalit2, JS Moran1, JS Lewis1, CA Ryan1

1Division of STD Prevention and Laboratory, Centers for Disease Control and Prevention, Atlanta, GA; 2Bahagia Harapan Kita Foundation, Indonesia

Background: Recent research reported that bacterial vaginosis (BV) might enhance the acquisition and transmission of HIV. BV is also associated with an increased risk of pelvic inflammatory disease, a disease also associated with IUD insertion.

Objective: To measure the prevalence of BV, sexually transmitted diseases (STD), and their associations with IUD.

Methods: We conducted a prevalence survey of BV and STD (sexually transmitted diseases; defined as current infections with Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis) among all patients attending a family planning clinic in Manado from May–July 1999. BV was diagnosed by Gram stain using Nugent’s criteria and vaginal trichom oniasis by wet mount or culture. Cervical infections with Chlamydia trachomatis and Neisseria gonorrhoeae were diagnosed by DNA probe (GenProbe PACE II).

Results: Of 357 patients, 116 (32.5%) had BV, 83 (23.3%) had trichomoniasis, 9 (2.5%) had chlamydia, and 8 (2.2%) had gonorrhea. The prevalence of STD was similar among users of all types of contraception. However, BV was more common among IUD users (47.2%) than among non-IUD users (29.9%). This association persisted after controlling for age, education, ever had douching, and any STD (odds ratio 2.0, 95% CI 1.1-3.8). BV was also associated with STD (41.3% in women with STD vs. 29.4% in women without). This association remained significant after adjusting for age, education, ever had douching, and IUD use (odds ratio 1.7, 95% CI 1.1-2.9).

Conclusions: Because we found that BV was associated with IUD and other studies reported that both BV and IUD were associated with PID, a Gram stain evaluation of BV should be considered prior to IUD insertion.

Implications for Programs: BV screening and treatment program should be considered prior to IUD insertion.

Learning Objectives: Participants will be able to describe the association between BV and IUD and its implication on BV screening and treatment prior to IUD insertion.


Characteristics Associated with Vaginal Douching Among Young Women: Results from the 2000 California Women’s Health Survey

R Gindi1, MS Kang1 , JM Chow1 , B Davis2 , G Bolan1

1California Department of Health Services, Sexually Transmitted Diseases Control Branch, Berkeley, CA 2Public Health Institute, Survey Research Group, Sacramento, CA

Background: Douching has been associated with lower genital tract infections (bacterial vaginosis and chlamydia) and their sequelae (pelvic inflammatory disease, ectopic pregnancy, and infertility).

Objective: To examine the association of douching with sexual risk behaviors among young women in California.

Methods: The 2000 California Women’s Health Survey is a random-digit-dialed population-based survey administered to women 18 years of age or older. Participants 18–44 years old were asked about douching practices and sexual behavior during the previous 12 months. Analyses were limited to young women age 18–24, the group with the highest STD risk. Data were weighted to the age and race distribution of the 1990 California population.

Results: From January to December 2000, 2402 interviews were completed (74% response rate). Of the young women (N = 580), 20% reported douching in the past 12 months. Thirty-eight percent of young African-American women, 20% of young white women, and 19% of young Hispanic women reported douching. Among all of those who reported douching, 21% reported douching more than once a month. Young African-American women were more likely to report douching more than once a month (40%) than Hispanic (21%) or white (20%) young women. Among young women who reported douching more than once a month, 31% reported having a new male sex partner within the past 12 months. Of these, 45% reported not using a condom during the first sexual encounter with that new partner.

Conclusions: Douching is common among young women overall and may be of particular concern among those with new partners and/or lack of condom use with new partners.

Implications for Program/Policy: Targeted education around douching and its association with reproductive health should be made available for young women. Providers doing STD risk assessment should be aware of douching history as a possible risk factor.

Implications for Research: Research is needed to understand the possible synergistic effect of douching on STD acquisition, particularly regarding the relationship between douching and other sexual risk behaviors.

Learning Objectives: Participants will be able to recognize the population-based prevalence of douching and to identify sexual behavioral risk factors associated with douching.

Contact Information: Renee Gindi / Phone 510-883-6640 /


Vaginal Douching Behaviors Then and Now: Has Anything Changed?

JS Merchant, MK Oh, P Brown, E Funkhouser, M Boschulte1, E Beatty1, S Howard2

1University of Alabama at Birmingham, Birmingham, AL; 2Columbus Health Dept, Columbus, OH; 3Howard University, Washington, DC

Background: Although an association between vaginal douching and a variety of adverse reproductive health outcomes has been known for many years, many women continue to douche.

Purpose: To determine any changes in douching behavior of U.S. women across time.

Methods: A confidential survey was self-administered to a convenience sample of women (n = 571, 14–63 years of age, median 25 years) attending public health clinics between August 2000 and August 2001. Included were questions regarding beliefs about d ouching, douching practices and gynecologic events. Characteristics of those who were >30 years of age (n = 202; median age 22) at survey were compared with those who were £ 30 years old (n = 369; median age 39) by use of the chi-square test and t-test.

Results: Those >30 were more likely to believe that douching kills germs that cause STDs (28% vs.18%; P=.003), and to agree that some women believe douching prevents pregnancy (35% vs. 23%; P=.006). Age of menarche, sexual debut, and initial douching age were younger in £30 group than >30 group (P=.02; 12.2 vs.12.6 yrs; P<.0001; 15.5 vs. 16.9 yrs; P<.0001; 16.7 vs. 18.7 yrs, respectively). Overall, 90% (n = 182) of those >30 and 70% (n = 258) of those £30 had “ever douched” before. Older women were more likely to douche to get rid of vaginal symptoms, such as itching and irritation (P=.001) and vaginal discharge (P=.0001), whereas those £30 were more likely to douche after menstruation (P=.04). Those >30 tended to douche more frequently (P=.01), to have douched recently (P=.006), and were more likely to use homemade products (P=.0004). No significant differences were found between the two groups regarding the likelihood of douching after sex, before sex, before going to a doctor, douching to please their partners, or beginning vaginal douching before sexual debut.

Conclusion: Younger women differ from older counterparts. They have better knowledge about douching, may douche for different reasons, and begin sex at a younger age.

Implications for Programs/Policy: Researchers and clinicians should take into account differences in motivation and belief with regard to douching between younger and older women.

Implications for Research: When investigating douching behavior, more attention should be paid to these generational differences, as they may have real effects on willingness and ability to stop douching.

Presenting author contact information: Jeanne S. Merchant / Phone 205-939-5277 /


Why Do Adolescent Women Start and Continue to Douche?

JS Merchant, MK Oh, PR Brown

University of Alabama at Birmingham School of Medicine, Birmingham, AL

Background: Vaginal douching, with questionable benefits and safety records, is a complex and poorly understood behavior. In light of published dangers of douching, understanding reasons that women douche is important.

Objective: To ascertain in-depth information about reasons for starting vaginal douching behavior and to explore the role of male sexual partners and mothers.

Methods: A convenience sample of 21 adolescent women who douche (age range = 15–20; mean = 18), were asked to answer five open-ended questions about their douching behavior.

Results: Regarding the reason to begin douching, ten said that an older relative influenced them and 11 decided to do it on their own. When asked, “Have you ever talked with a boyfriend about douching?” ten answered yes, and 11, no. Of those who said yes, all said that the boyfriend initiated the conversation. Two said that their boyfriends requested that they douche, and one allowed her boyfriend to douche for her for sexual purposes. Most (16) said that they had heard that douching causes tightness or dryness in the vagina affecting sexual pleasure (most from friends and some from mass media). One said that she thought this was why most teens douche, one said that her partner approved because her “vagina was very tight,” and one described a friend who used douching “to cover up an affair.” When asked about douche brand selection (all used commercial solutions), many described being swayed by advertising on TV and in magazines, and one said she chose the most expensive brand, believing that it “is the best.” When asked how they learned to douche the first time, nine said their mother or another female relative showed them, and nine read the instructions in the box.

Conclusions: This small qualitative study shows that douching in adolescents is influenced by family and friends, and also by sexual partners and mass media.

Implications for Programs: Women’s reproductive health programs that want their clients to stop douching should tailor initiatives to the specific needs of the individual clientele, including reasons for and perceived benefits of douching.

Implications for Research: This subject needs a great deal more exploration, including qualitative studies to explore the complicated reasons women have for douching. As most women who douche begin this behavior during adolescent years and adolescents are the most high-risk group of women with regard to acquisition of STDs, focusing on them makes sense.

Learning Objectives: Participants should gain a general understanding of the myriad of reasons women have for douching.

Contact Information: Jeanne S Merchant / Phone 205-939-5277 /,


Early Onset of Douching is Associated With False Beliefs and High-Risk Behaviors

MK Oh1, J Merchant1, P Brown1, E Funkhouser1, E Beatty2, M Boschulte2, S Howard3, T Simpson1

1University of Alabama at Birmingham, Birmingham, AL; 2Columbus Health Dept, Columbus, OH; 3Howard University, Washington, D.C.

Background: Vaginal douching, particularly frequent douching over a long period of time has been linked to a variety of adverse health consequences including STDs.

Purpose: To determine factors associated with early onset (£15 years old) of douching. Methods: A confidential survey was self-administered to a convenience sample of women (n = 571, 14–63 years of age, median 25 years) attending public health clinics in Alabama and Ohio. The questionnaire included questions regarding beliefs about douching, douching practices, and gynecologic events. Those who began douching at £15 years of age were compared with those who began at 16 or older using t-test and chi-square analysis.

Results: The mean menarchal age of the 571 participants was 12.4 ± 1.7 yrs, mean age at sexual debut was 16.0 ± 2.5 yrs., 22% believed douching kills germs that cause STDs, 27% agreed that “women believe douching prevents pregnancy,” and 29% agreed that “men believe douching prevents pregnancy.” The mean age of first douching was 17.5 ± 3.3 (range 9–35) years. Eighteen percent began douching before their sexual debut; 66% douched monthly or more often. The timing of douching included after sexual intercourse 39%, before sex 18%, and before going to a doctor 11%. Of those who had ever douched, 22% began the practice at age £15 years. Compared with those who began at a later age, those that began at age £15 yrs were more likely to believe that douching kills germs that cause STDs (OR = 10.5; p=0.005), to douche at least monthly (OR = 2.5; p=0.002), douche after (OR = 1.8; p=0.01) and before sexual intercourse (OR = 1.9; p=0.02), and to have begun sexual intercourse at a younger age (14.6 vs. 16.2 yrs; p<.0001).

Conclusion: This study indicates that early onset of vaginal douching is associated with frequent douching and other high-risk behavior. Future research should address both biological and behavioral implications of douching.

Implications for Programs/Policy: STD risk-reduction programs must target very young adolescents and address myths associated with vaginal douching.

Implications for Research: Studies examining the effects of vaginal douching should account for confounding sexual risk behaviors.

Measurable Learning Objectives: Participants will be able to describe the association of vaginal douching in young girls and the existence of sexual risk behavior.

Contact Information: Phone 205-934-8770 /


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