Assessment of Sexually Transmitted Diseases Services in City and County Jails -- United States, 1997

Approximately 15 million arrests were made in the United States in 1995, and the number of persons incarcerated has increased 72% since 1990 (1). At any given time, approximately 567,000 persons are incarcerated in local jails (i.e., county or city correctional facilities housing persons serving short-term sentences or awaiting trial) (1). The prevalence of sexually transmitted diseases (STDs) among incarcerated women is high: syphilis, 35%; chlamydia, 27%; and gonorrhea, 8% (2,3). However, limited information is available about the extent of STD diagnosis and treatment services in correctional facilities. During July-August 1997, CDC conducted a survey of STD testing and treatment policies and practices in jails. This report summarizes the results of the survey, which indicates that most facilities treat for STDs based on symptoms or by arrestee request and do not routinely screen asymptomatic persons.

Counties were selected on the basis of the following criteria: 1) counties reporting greater than 40 cases of primary and secondary syphilis in 1996; or 2) counties containing cities with populations greater than 200,000 persons, regardless of STD morbidity. STD program managers, in collaboration with county health department officials and administrative personnel at the main jail facilities in the sampled counties, completed the survey. STD testing policy was classified as routine (provided to all arrestees), symptomatic (provided to arrestees who indicate signs or symptoms of an STD), by request (provided to arrestees who request STD testing), or not provided. STD testing rates were calculated using reported monthly testing and admission data.

Of the 92 counties surveyed, 88 (96%) completed the assessment, representing 115 city and county jails. Of these 115 facilities, 94 (82%) housed both men and women, 13 (11%) housed men only, and eight (7%) housed women only.

Less than half (range: 12%-47%) of the facilities had a policy of offering routine STD testing to arrestees for chlamydia, gonorrhea, or syphilis (Table_1). However, in jails with routine testing policies, less than half (range: 3%-48%) of arrestees were tested for any of the three diseases (Table_2). More than half (52%-77%) of the facilities offered STD testing to symptomatic arrestees or to arrestees who requested testing for chlamydia, gonorrhea, or syphilis (Table_1). In these facilities, less than 8% of women and less than 3% of men were tested for any of the three diseases. Ten (9%) facilities had a policy of offering routine syphilis screening using rapid plasma reagin (Stat RPR) (a 15-minute on-site test using venipuncture blood). In these facilities, syphilis testing rates for women (70%) and men (72%) were higher than rates for facilities where no Stat RPR was available. Twenty-nine facilities (28%) had a policy of routinely offering both pregnancy and syphilis testing. In these facilities, 47% of women were tested for syphilis and 40% were tested for pregnancy.

Approximately half of arrestees were released within 48 hours after incarceration. Approximately 45% of facilities received STD test results greater than 48 hours after testing.

Most facilities used protocols to guide STD treatment (92%) and screening (73%). Fifty-six percent of facilities used the 1993 CDC STD treatment guidelines (4), and 19% used the 1993 CDC Chlamydia screening guidelines (5).

Reported by: Div of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that most facilities had a policy of STD screening based on symptoms or arrestee request. Less than half of the facilities had a policy of offering routine testing. In those facilities with a policy of routine testing, less than half of the arrestees were actually tested. Many STDs, including chlamydia, gonorrhea, and syphilis, can be asymptomatic and can only be detected through routine screening activities (6). Therefore, routine testing policies and greater implementation of existing routine testing policies in jails can increase STD diagnosis and treatment. Previous studies support the use of rapid syphilis testing and document its effectiveness in increasing diagnosis and treatment of syphilis in jail populations (2,7). Routinely offering women pregnancy and Stat RPR testing at incarceration can prevent congenital syphilis (2).

Although most facilities reported using STD treatment and screening guidelines from some source, the CDC guidelines were not widely used. To increase the number of arrestees diagnosed and treated for STDs and to improve the quality of the services delivered, CDC STD treatment guidelines or other evidence-based guidelines should be used. This can be achieved by the continued communication between health departments and jail facilities and by increasing the number of jail personnel attending STD training.

Because the data for this survey were based on monthly testing and admission data reported to STD program managers, they may not represent true STD testing rates. However, in the absence of active STD surveillance, these data provide the most reliable estimates.

Treatment of persons after release is labor intensive, often unsuccessful (2,8), and represents a missed opportunity for STD control and prevention. Arrestees are a transient population with limited access to health care (7,9). A comprehensive STD control and prevention strategy should incorporate correctional facilities as an important setting for public health intervention (6,10). Health departments and correctional facilities can benefit from a partnership that facilitates STD testing and treatment in jails in areas with high rates of disease.

References

1. Gilliard D, Beck A. Bureau of Justice Statistics: prison and jail inmates at midyear, 1997. Washington DC: US Department of Justice, 1998.

2. Blank S, McDonnell D, Rubin S, et al. New approaches to syphilis control: finding opportunities for syphilis treatment and congenital syphilis prevention in a women's correctional setting. Sex Transm Dis 1997;24:218-28.

3. Holmes M, Safyer S, Bickell N, Vermund S, Hanff P, Phillips R. Chlamydial cervical infection in jailed women. Am J Public Health 1993;83:551-5.

4. CDC. 1993 Sexually transmitted diseases treatment guidelines. MMWR 1993;42(no. RR-14).

5. CDC. Recommendations for the prevention and management of Chlamydia trachomatis infections, 1993. MMWR 1993;42(no. RR-12).

6. Institute of Medicine. Committee on Prevention and Control of Sexually Transmitted Diseases. In: Eng TR, Butler WT, eds. The hidden epidemic: confronting sexually transmitted diseases. Washington, DC: National Academy Press, 1997.

7. Beltrami J, Cohen D, Hamrick J, Farley T. Rapid screening and treatment for sexually transmitted diseases in arrestees: a feasible control measure. Am J Public Health 1997;87:1423-6.

8. Heimberger T, Change W, Birkhead G, et al. High prevalence of syphilis detected through a jail screening program. Arch Intern Med 1993;153:1799-804.

9. Glaser J, Greifinger R. Correctional health care: a public health opportunity. Ann Intern Med 1993;118:139-45.

10. Skolnick A. Look behind bars for key to control of STDs. JAMA 1998;279:97-8.

TABLE 1. Number and percentage of jail facilities with a policy of offering sexually
transmitted disease and pregnancy testing *, by testing policy, sex, and type of test -- United
States, 1997
===================================================================================
                                             Type of test
                        ---------------------------------------------------------
                         Chlamydia      Gonorrhea       Syphilis     Pregnancy +
                        ------------   ------------   ------------   ------------
Policy/Sex              No.     (%)    No.     (%)    No.     (%)    No.     (%)
---------------------------------------------------------------------------------
Provided routine
  testing
  Women                  20    (20%)    23    (22%)    48    (47%)    34    (33%)
  Men                    13    (12%)    17    (16%)    49    (46%)   N/A

Provided testing to
  arrestees who had
  symptoms or who
  requested testing
  Women                  74    (72%)    73    (72%)    53    (52%)    64    (63%)
  Men                    76    (71%)    82    (77%)    57    (53%)   N/A

Did not test
  Women                   8    ( 8%)     6    ( 6%)     1    ( 1%)
  Men                    18    (17%)     8    ( 7%)     1    ( 1%)
---------------------------------------------------------------------------------
* 107 facilities for men and 102 facilities for women.
+ Four facilities did not provide information.
===================================================================================

TABLE 2. Percentage of arrestees tested for sexually transmitted diseases and
pregnancy, by testing policy and sex -- United States, 1997
==============================================================================
                                               Type of test
                               ---------------------------------------------
Policy/Sex                     Chlamydia   Gonorrhea   Syphilis    Pregnancy
----------------------------------------------------------------------------
Provided routine testing
  Women                           29%          35%        48%          39%
  Men                              3%          14%        48%          N/A

Provided testing to
  arrestees who had
  symptoms or who
  requested testing
  Women                            3%           4%         7%           4%
  Men                              0.4%         0.5%       2%          N/A
----------------------------------------------------------------------------
==============================================================================

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