COST-EFFECTIVE SCREENING AND TREAMENT FOR CHLAMYDIA
CAN AVERT SEVERE HEALTH CONSEQUENCES
Chlamydia remains the most commonly reported infectious disease in the United States, yet up to
90% of women and a large percentage of men with chlamydial infection are asymptomatic.1 If
left untreated, chlamydia can cause severe health consequences, including pelvic inflammatory
disease (PID) – a leading cause of infertility. Up to 40% of women with untreated chlamydia will
develop PID.2 Of women with PID, approximately 1 in 5 will become infertile, almost 1 in 5 will
suffer from chronic pelvic pain, and nearly 1 in 10 will have an ectopic (tubal) pregnancy.3
In pregnant women, chlamydial infection is associated with adverse pregnancy outcomes,
including preterm delivery and postpartum endometritis; Chlamydia may also result in adverse
outcomes for infants including neonatal conjunctivitis and pneumonia. More than 50% of
pregnant women with chlamydial infection will deliver an infected baby.4 A woman infected with
chlamydia has up to a 5-fold increased risk of acquiring HIV infection.5 In men, chlamydial
infection can cause adverse health consequences, including infertility.
To address this significant health crisis, we call for an increase of $20 million in FY 2009 to
support the Infertility Prevention Program at the Centers for Disease Control and
Prevention (CDC).
How common is chlamydia?
In 2006, 1,030,911 chlamydia diagnoses were reported to the CDC, up from 976,445 on the
previous year. Even so, most chlamydia cases go undiagnosed, and CDC estimates that there are
almost 3 million new cases of chlamydia in the United States each year.
Chlamydia cases for females in 2006 was three times higher than for males and the long-term
consequences of untreated disease are much more severe for females.6 Women, especially those
25 and under, are hit hardest by chlamydia. The CDC’s analysis of 2003-2004 data confirms the
significant health risk to young women, finding that four percent of all 15-19 year old females
were infected.7
How can we limit the impact of chlamydia?
The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians
routinely screen all sexually active women aged 25 years and younger, and other asymptomatic
women at increased risk for infection, for chlamydial infection. One critical effort to reach this
population is the CDC’s Infertility Prevention Project (IPP), funded through the Division of
STD Prevention. Since 1993, the program has had remarkable success in developing systematic,
region-wide collaborations between sexually transmitted disease prevention programs and health
care providers who specialize in family planning and women's health care.
Despite documented success, chlamydia testing and treatment efforts continue to be hampered by
severe funding constraints. The FY 2006 funding level for infertility programs, for example, was
approximately $30 million, an insufficient amount to cover the nearly 15 million women eligible
for the program. The inability to screen eligible women will dramatically increase the long-term
costs associated with chlamydia-related infertility.
Funding Limitations
Despite success, testing and treatment is limited by funding. A systematic assessment of the
value of clinical preventive services recommended for average-risk patients by the U.S.
Preventive Services Task Force ranked chlamydia screening as one of the 8 high-impact, costeffective clinical preventive services that are currently being delivered to less than 50% of
the target population nationally.8 The CDC estimates that 14.9 million women who are eligible
for screening, treatment, and prevention counseling services authorized by the Preventive Health
Amendments of 1992 are currently not reached by CDC’s Infertility Prevention Program.
The nation spends an estimated $2.4 billion in direct and indirect costs for chlamydial infections
each year.9 Although cases of PID cost at least $1,167 per patient,10 only $3.5 million was made
available in the FY 2005 Labor-HHS Appropriations bill for the entire IPP – an amount that
supports 64 awards to 50 states, 8 territories and 6 cities. Funds are designed to prevent
transmission of STDs that result in PID, infertility, and ectopic pregnancy, especially in
adolescent girls and young adult women by linking surveillance, clinical, laboratory, and
epidemiologic activities.
Depending on the frequency and duration of the specific program, chlamydia screening – as
compared to no screening - prevents 11% to 42% of all PID and its consequences. The most
effective strategy is to screen all sexually active women between 15 and 29 years of age annually,
with follow-up screening every 6 months for those with infection.11
Infertility prevention funds may be used to support chlamydia screening and treatment of women
and their sex partners, counseling and referral services, and outreach activities. Up to 10% of the
total infertility prevention funds can be used to augment gonorrhea screening in women. Up to
20% of total infertility prevention funds can be used to support male chlamydia screening and
treatment. These funds augment state and local health department allocations for chlamydia and
gonorrhea prevention and control activities.
Despite 1993 recommendations from CDC that all sexually active women 15-19 years old should
be screened for chlamydia on an annual basis, national data from 2000 estimate that only 60% of
these young women were screened.
Chlamydia screening rates are well below screening rates for other preventive health
services. The National Committee for Quality Assurance (NCQA) developed a measure to
estimate the proportion of sexually active women, 15-25 years old, who are screened in managed
care settings for the Health Employer Data and Information Set (HEDIS). Health plans have
reported on the measure since 2000, and the percentage of women screened annually has
increased in both private and Medicare Managed Care Organizations since introduction of the
measure. However, the current levels of screening for Chlamydia are well below screening rates
for breast cancer (56% and 75%) and cervical cancer (64% and 82%) and even below the
screening levels for colorectal cancer (49% and 53%), a HEDIS measure that was introduced in
2003.
Partnership between Title X Family Planning Agencies and STD programs
Given that women remain the target of the screening and treatment program, it isn’t surprising
that STD programs partner with family planning programs that receive Title X family planning
funds. CDC allocates 50% of funds to support screening and treatment of women in family
planning programs. This partnership with Title X programs, which serve more than 5 million
women at more than 4,500 clinic sites, has been critical to IPP success.
Next steps
Funds are needed to develop a comprehensive program to include re-screening of young,
sexually-active women, wider screening of men, and implementation of comprehensive partner
management strategies to prevent re-infection of women. In addition, the continued high
chlamydia prevalence indicates that expanding programs in non-traditional sites as school-based
settings and juvenile detention centers is imperative.
References
1
Screening for Chlamydial Infection: Recommendations and Rationale. Article originally in Am J Prev
Med 2001;20(3S):90-4. Agency for Healthcare Research and Quality, Rockville, MD. Available at
http://www.ahrq.gov/clinic/ajpmsuppl/chlarr.htm.
2
Centers for Disease Control and Prevention (2006). Chlamydia—CDC fact sheet. Available at
http://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm.
3
Westrom L. Joesoef R. Reynolds G. Hadgu A. Thompson SE. Pelvic inflammatory disease and fertility: A
cohort study of 1,844 women with laparoscopically verified disease and 657 women with normal
laparoscopy. Sex Transm Dis 1992;19:185-192.
4
Hannerschlag M. Chlamydia infections in infants and children. In: Sexually Transmitted Diseases – 3rd
editon (Holmes K. et al., eds). New York: McGraw-Hill 1999; p 1155.
5
CDC. Press Release: New CDC treatment guidelines critical to preventing consequences of sexually
transmitted diseases. May 9, 2002. Available at: www.cdc.gov/od/oc/media/pressrel/fs020509.htm.
6
CDC 2006 STD Surveillance Report. Available at http://www.cdc.gov/STD/stats/chlamydia.htm.
7
CDC Press Release: 2008 STD Prevention Conference - Nationally Representative CDC Study Finds 1 in
4 Teenage Girls Has a Sexually Transmitted Disease. March 11, 2008. Available at
http://www.cdc.gov/STDConference/2008/media/release-11march2008.htm.
8
Coffield et al. Priorities Among Recommended Clinical Preventive Services. American Journal of
Preventive Medicine. 2001; 21(1): 1-9.
9
Tracking the Hidden Epidemic: Trends in STDs in the United States, 2000. Atlanta: Centers for Disease
Control and Prevention; 2001.
10
Rein D. Kassler W. Irwin K. Rabiee L. Direct medical cost of pelvic inflammatory disease and its
sequelae: decreasing, but still substantial. Obstetrics & Gynecology. 95(3):397-402, 2000 March
11
Hu D, Hook EW, Goldie SJ. Screening for Chlamydia trachomatis in Women 15 to 29 Years of Age: A
Cost-Effectiveness Analysis. Ann Intern Med. 2004;141:501-513.