The Minnesota Chlamydia Partnership:
Working Together to Improve Reproductive Health
R
ates of chlamydia infection are
increasing nationwide. At the same
time, state health departments—who
play a vital role in the prevention and
control of communicable diseases,
including chlamydia—receive
limited funds earmarked for sexually
transmitted infections (STIs). After
watching chlamydia rates increase year
after year, professionals at the Minnesota
Department of Health (MDH) realized
that a large response—without a high
price tag—was needed. They also knew
they couldn’t do it alone. We sat down
with Candy Hadsall, RN, STD Nurse
Specialist and Kathy Chinn, Sexual
Health Program Specialist of MDH to
discuss the formation, goals, and future
steps of the Minnesota Chlamydia
Partnership (MCP).
Healthy Generations (HG): Chlamydia
is a significant public health issue that
state and local departments of health are
trying to control. What is the situation in
Minnesota?
Kathy Chinn (KC): As most of your readers
probably know, state health departments
are charged with monitoring the incidence
of several infectious diseases, including
chlamydia. Since the late 1990s, MDH
has seen a trend of yearly increases in
the chlamydia rate that shows no signs of
abating. We had over 18,000 cases reported
in 2012—another record! Rates are highest
among young (15-24 year-old) females, but
chlamydia has affected Minnesotans of all
races/ethnicities across all geographies. This
is not just an “urban” problem. We see the
same patterns at the national level.
Candy Hadsall (CH): Because so many
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Figure
1. Rate
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(per (per
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Surveillance
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1. Rate
of chlamydia
100,000)
in the
Minnesota,
2002-2012.
Surveillance
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Department
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We simply cannot control an epidemic when so many affected people
do not get diagnosed and treated.
chlamydia infections are asymptomatic,
people don’t seek health care. In the
meantime, these “silent” infections may
be causing damage to reproductive organs
and people may unknowingly transmit
infections to their sexual partners. We simply
cannot control an epidemic when so many
affected people do not get diagnosed and
treated. Therefore, the public health response
includes: (1) screening of asymptomatic
individuals, (2) prompt treatment of those
who are infected, and (3) encouraging
prevention behaviors like abstinence and use
of condoms.
HG: What led the MDH to form the
Minnesota Chlamydia Partnership (MCP)?
CH: Like so many other public health
departments, MDH receives minimal
funding for activities related to STIs beyond
surveillance. So, every year we have been in
the uncomfortable position of highlighting
increases in chlamydia that we have very few
tools to directly address. By 2009, many local
health departments, hospitals, clinicians, and
community groups were asking us, “What
can we do?” We started to envision a role for
MDH as convener of a coordinated effort
based on the community action model.
We wanted to harness the concern and
energy while being realistic about everyone’s
limited resources. In order to maintain
the community-level focus and function
as independently as possible, we felt it was
absolutely necessary that the effort have its
own identity outside of MDH in order to
succeed.
In February 2010 we secured a $10,000 grant
from the National Chlamydia Coalition and
the MCP was born. Our external partners
include local public health, reproductive
health clinics, the Minnesota Department
of Education, academic institutions, youth
development agencies, a health plan
consortium, and concerned community
members.
Winter/Spring 2014
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by MCP?
KC: This is MCP’s most important
goal—empowering and facilitating
local action. We are thrilled to have two
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HG: How did the MCP get off the ground?
What were some of its first activities?
he Minnesota population and chlamydia cases reported to
Health in 2012 show the disproportionate chlamydia
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ion and chlamydia cases reported to
KC: Our first major activity was the
he disproportionate chlamydia
and Minnesota
Department
of
Minnesota
Summit
on Chlamydia in
August
2010, which attracted 275 participants from
across the state. We were very happy with
the diverse representation. Clearly, many
people cared about this issue and were ready
to get to work. We solicited feedback on the
essential issues that MCP should address,
forming five work groups to tackle each issue
in more depth over the next five months.
It was a remarkable amount of work. Each
work group came up with specific objectives
and strategies for the issues under their
domain. All of these recommendations
were compiled in The Minnesota Chlamydia
Strategy: An Action Plan to Prevent and
Reduce Chlamydia in Minnesota. This is a
very comprehensive document reflecting the
multi-pronged strategies needed to tackle
every angle of the chlamydia epidemic.
CH: We also developed a shorter version of
the Action Plan, which we call the “booklet.”
The booklet maintains a focus on youth
because of the highly disproportionate
rates of chlamydia among young people. It
provides a simple overview of chlamydia
and the broader context surrounding
it—things like health equity, youth
development, and policy. An effective
response to chlamydia requires that all these
2
Healthy Generations
The first project is in rural Kandiyohi
County, where members of an existing
coalition on teen pregnancy (the Coalition
for Healthy Adolescent Sexuality, or CHAS)
broadened their scope to tackle chlamydia
with financial and technical support from
MCP. In collaboration with Kandiyohi
County Public Health (KCPH), CHAS
held a series of community meetings and
devised a plan to address chlamydia. A key
activity in the plan is a media campaign
that uses positive messages encouraging
parents to talk with their children. This is a
great example of how we can take advantage
of existing local infrastructures to garner
support and action for chlamydia control.
CH: The second project is coordinated
by NorthPoint, Inc.—an agency in North
Minneapolis that is situated in the zip code
with the highest chlamydia rate in the
state. NorthPoint used seed money from
MDH to implement the collective impact
model and mobilize community support
for the Minnesota Chlamydia Strategy
and, more specifically, to develop a plan to
reach African American youth in culturally
sensitive ways. This North Minneapolis
coalition has since been successful in raising
funds from other sources to facilitate the
inclusion of youth in their future activities.
HG: Minnesota’s health plans have become
an important ally of MCP. Can you tell us
how this came to be?
WHAT IS CHLAMYDIA?
Chlamydia is a bacterial infection
transmitted through sex (vaginal, anal,
and oral) or from mother to infant during
childbirth. Both men and women can
become infected with chlamydia and
transmit chlamydia.
Symptoms may include discharge,
painful urination, and pain or swelling
in the testes or rectum. One of the
hallmark characteristics of chlamydia is
its lack of symptoms—especially among
women.
Diagnosis of chlamydia is confirmed
through lab tests performed on urine
samples or swabs taken from the vagina
or rectum. Primary care providers and
specialized (e.g., reproductive health)
clinics may request these tests.
Chlamydia can be treated and cured
with a brief regimen of antibiotics.
Re-infection is possible, especially if
sexual partners are not treated at the
same time.
Complications of chlamydial infection
can be severe due to its “silent” nature.
Even without symptoms, chlamydia can
spread through the reproductive tract
and cause damage. Women may develop
pelvic inflammatory disease (PID), which
increases the risk of tubal infertility,
life-threatening ectopic pregnancy,
and chronic pelvic pain. Pregnant
women infected with chlamydia may
be at higher risk of preterm delivery
and may pass the infection to their
newborn. Complications in men are less
common but also include infertility.
Untreated chlamydia also facilitates the
transmission of HIV in both men and
women.
Prevention measures include abstinence,
correct and consistent use of condoms,
mutual monogamy, getting tested when
changing sexual partners, and knowing
the infection status of one’s partner(s).
For more information about chlamydia,
go to: http://www.cdc.gov/std/chlamydia/
STDFact-Chlamydia.htm
WHAT’S IN A NUMBER? INTERPRETING CHLAMYDIA SURVEILLANCE DATA
Public health surveillance refers to continuous monitoring of
the incidence and/or prevalence of a disease or condition at
the population level. Surveillance is a powerful tool, but there
are often limitations to interpreting surveillance data. Here are
some things to keep in mind about chlamydia surveillance:
How is infectious disease surveillance conducted?
In the US, national, state, and local public health professionals
are involved in infectious disease surveillance. The Centers for
Disease Control and Prevention’s National Notifiable Diseases
Surveillance System gives public health officials capabilities to
monitor the occurrence and spread of infections and diseases.
Every state has laws that require clinicians and laboratories
to report cases of certain infections and diseases to state
and/or local health departments. The list of diseases varies
by state but typically includes tuberculosis, HIV, food-borne
diseases like salmonella, and some sexually transmitted
infections (STIs) including chlamydia. Health departments use
this information to track disease trends, often by geographic
or demographic (age, race/ethnicity, sex) subgroups. Where
there is a high threat to public health, health departments
will follow up with individuals (e.g., notifying sex partners
of their potential exposure to a reportable STI). State health
departments also support national public health surveillance by
voluntarily sharing a portion of their data with CDC. According
to the CDC, it uses such data “to monitor disease trends,
assess the effectiveness of prevention and control measures,
identify populations or geographic areas at high risk, formulate
prevention strategies, develop public health policies, and work
with the international community to identify and contain global
outbreaks.” (http://wwwn.cdc.gov/nndss/)
Who is counted in chlamydia surveillance?
Chlamydia surveillance data include infected persons (“cases”)
who seek health care and have had their infections confirmed
by a laboratory test.
be 0.00151. By multiplying that rate by 10,000, the rate
becomes easier to understand: 15.1/10,000 persons.
Notes: rates are often calculated with the total population as
the denominator. Rates can also be calculated with subgroups
(e.g., persons 15–24 years-old) or with those at risk (e.g.,
those who report having had vaginal intercourse in the past
12 months). When examining a rate (or when trying to figure
out why two rates are different) it is always important to know
what the denominator is—different denominators will produce
different rates.
The chlamydia rate is increasing. Does that mean that more
people are getting infected?
Possibly. Chlamydia surveillance paints an incomplete picture
because it only captures cases who seek care and receive
a laboratory test. In this way, reported chlamydia cases are
the tip of an iceberg—the total number of cases is unknown.
Efforts to find additional cases—the iceberg below the
surface—will cause rates to increase even if transmission rates
are stable. As health care providers improve their chlamydia
screening rates in response to public health recommendations,
we can expect rates of reported chlamydia to rise. Other
contributing, though much less significant, factors include
improved accuracy of diagnostic tests and better reporting by
clinicians and laboratories.
It’s difficult to determine exactly how much the reported
increase in chlamydia is “real” (due to increased transmission)
and how much is an artifact of more screening. Regardless,
we know that the true chlamydia rate is higher than what is
detected through surveillance—which already shows very high
rates in certain sub-groups like young women. Herein lies the
public health significance of chlamydia and the urgent call for
prevention, screening, and treatment efforts.
Who is not counted in chlamydia surveillance?
Cases who don’t seek medical care or are diagnosed without a
laboratory test are not reported to the health department and
are therefore not counted in surveillance. This includes sexual
partners who are treated presumptively (without a laboratory
diagnosis) because of known exposure to an infected partner.
What is a chlamydia rate?
To measure the population burden of a disease,
epidemiologists use rates rather than raw numbers. This allows
them to compare the impact of a disease in populations of
different sizes. For example, 100 cases of chlamydia in a small
town represent a higher disease burden than 100 cases of
chlamydia in a large city. Therefore, rate calculations provide
a relative estimate of impact by taking population size into
account. A rate is thus number of cases/total population size.
Because this calculation usually results in a small number, it
is multiplied by a larger number (1,000; 10,000; or 100,000
are most common) to make it easier to interpret. For example,
if there were 151 cases in a city of 100,000 the number would
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3
MINNESOTA CHLAMYDIA PARTNERSHIP STRATEGIC GOALS
In 2010, the Minnesota Chlamydia
Partnership’s Steering Committee
developed five strategic areas and
workgroups created 20 individual goals to
reduce and treat chlamydia on a local or
statewide level. Any individual, agency,
organization or community can use
these suggestions and recommendations
to begin making a difference in their
communities.
Funding and Policy Issues
1. Sustainable and sufficient funding
for prevention education, screening
and treatment for patients and their
partners will be available.
2. Sustainable and sufficient funding
to provide training and continuing
education for health care providers will
be available.
Raising Community Awareness
3. Increase the awareness in the general
public of the epidemic of chlamydia
and its consequences.
4. Inform 18–24 year-old young people
who are not in school about the
chlamydia epidemic and resources
available, including screening.
5. Educate non-health care staff members
who work in youth-serving organizations
about the chlamydia epidemic and
resources available.
Education in Communities
6. Increase the number of teachers
receiving basic training in, or access
to, recommended guidelines for sexual
health education and the prevention
of chlamydia and other sexually
transmitted infections (STIs).
CH: The health plans are an important piece
of the puzzle because of their influence over
how clinical procedures (like chlamydia
screening) are performed and paid for.
Health plans already have a lot of reasons
to care about chlamydia. First, annual
chlamydia screening for all sexually active
women under age 26 is endorsed by the US
Centers for Disease Control and Prevention
(CDC) and US Preventative Services Task
Force (USPSTF) as cost effective and
evidence based. Relatedly, it’s one of several
health indicators—“HEDIS” performance
measures—used to gauge the quality of care
4
Healthy Generations
7. Reduce chlamydia rates in Minnesota
students by educating middle and
high school students about chlamydia
and other STIs, as well as other topics
related to sexual health.
8. Train parents and caregivers to be the
primary sexuality educators for youth
by providing sexual health education
guidelines and resources, including
information on chlamydia, its potential
consequences, and information on
screening and treatment.
9. Increase the number of community
members who are informed of the
education that is provided to teachers,
students, and parents.
10. University/college campuses will
participate in chlamydia and
gonorrhea awareness activities during
the school year, including screening.
Clinical Issues: Screening, Treating and
Reporting
11. Every 15–25-year-old female in
Minnesota will have a chlamydia
test annually.
12. Health care providers will treat
every person who tests positive for
chlamydia within 14 days.
13. Health care providers will treat all
partners of patients who have positive
chlamydia test results.
14. Increase clinician use of—and comfort
with—Expedited Partner Therapy to
increase partner treatment and reduce
numbers of infections.
15. Minnesota Department of Health
Partner Services staff will provide
field-delivered medications to
provided under health plans nationwide
(see page 23 for more information about
HEDIS measures). By increasing chlamydia
screening among young women, health
plans can improve their standing in this
performance measure. Lastly, increasing
the proportion of members who receive
annual chlamydia screening is a realistic
and achievable goal. For example, electronic
medical systems could trigger a “pop-up”
reminder for patients who meet eligibility
criteria for screening.
KC: Our collaboration with Minnesota’s
individuals positive for chlamydia who
do not return for treatment.
Affordable and Accessible
STI/STD Services
16. The state of Minnesota will prioritize
its public health care responsibility to
assure affordable chlamydia screening
and treatment is available for all
at-risk youth.
17. Assure that low- or no-cost screening
and testing is available for at-risk
youth in all communities.
18. Assure that low- or no-cost treatment
for chlamydial infections is available
for at-risk youth in all communities.
19. Increase access to chlamydia
screening outside of traditional
clinical settings.
20. Promote availability of school-based
clinics in school districts and colleges
across the state to increase easier
access to screening and treatment for
all at-risk populations.
For More Information
The full Minnesota Chlamydia Strategy:
Action Plan to Reduce Chlamydia in
Minnesota can be found at: http://www.
health.state.mn.us/divs/idepc/diseases/
chlamydia/mcp/strategy/index.html
To see ideas for how schools, youth,
parents and caregivers, businesses,
medical professionals, youth-serving
organizations, and health plans can
work with the Strategy to improve
the sexual health of youth, see:
www.mnchlamydiapartnership.org
health plans is an example of how fruitful
a coalition can be when expertise and
resources are shared. Independent of the
MCP, a consortium of four health plans had
chosen to focus on chlamydia screening for
many of the above reasons. By tapping into
the MCP, the health plans gained access to
experts and clinicians who advised them
on their provider screening toolkit and a
series of web-based trainings on chlamydia
screening. Because of this partnership, the
health plans were able to create additional
and more robust resources. This was
mutually beneficial for the MCP—we got
some great resources that we could promote
to all our stakeholders.
HG: What advice do you have for people
who want to adapt the MCP approach
outside of Minnesota?
CH: One of the key realizations we’ve had
is that chlamydia has to be framed as more
than a medical issue. There’s a lot of value in
the traditional disease model, which focuses
on things like screening and treatment.
Clinicians are at the front lines filling these
very important needs. However, screening
and treatment alone are not sufficient if we
want to curb this runaway epidemic. This
is why MCP is looking more upstream at
how chlamydia infection may be prevented
by addressing social and structural
determinants of health.
KC: Seeing how these bigger forces shape a
public health problem like chlamydia is a big
“aha” moment that inspires people to take
action. And because the roots of chlamydia
extend beyond the sphere of medicine, you
need to engage a wide base of stakeholders
in addition to health department
professionals and clinicians—people from
faith communities, businesses, education—it
really does take a village! That being said,
you still need a backbone organization
to maintain momentum and tend to the
coalition’s administrative needs. MDH has
filled that role for the MCP.
CH: We would also challenge people to
think of what can be done without money.
There’s so much talk about constrained
budgets and “What we could do if only we
had money.” But there are a lot of things
that individuals and communities can do
without funding. For example, changing
social norms. Think about recent changes in
attitudes toward smoking in public places.
They occurred not only because programs
to help smokers quit smoking were funded
and implemented, but because individuals,
businesses and communities decided that
it was in everyone’s best interest to breathe
clean air. This sea change influenced policy
makers to legislate healthier environments.
Finally, we would urge the engagement of
health plans. Minnesota has a somewhat
unique situation in that all health
maintenance organizations (HMOs) are
required to be not-for-profit entities. Our
sense is that these insurers are community
health-oriented and therefore more open
to addressing a public health issue like
chlamydia than for-profit companies. And
as we described earlier, health plans have
a strong impetus to improve chlamydia
screening and reminding them of that might
help get one’s foot in the door.
HG: The MCP is about to embark on its
fourth year. Congratulations! What is on
the horizon for MCP in 2014 and beyond?
CH: We will be examining how the
Minnesota Chlamydia Strategy is being
implemented at the local level. The
demonstration projects we’re supporting
will advance this effort. For example, the
group in Kandiyohi County is charged
with creating an “Organizer’s Toolkit” that
documents their process of local adaptation
(available Spring 2014). We hope that will
be a road map for others to follow. We’ll
be focusing a lot on communications,
including improvements to the website, to
promote awareness of chlamydia and uptake
of our resources. Beyond that, we want to
stay nimble in order to take advantage of
whatever opportunities present themselves.
Figure
3. Conceptual
community
Figure
3. Conceptualmodel
model for
for community
engagement
in the Minnesota
engagement
in the Chlamydia
MinnesotaPartnership.
ChlamydiaSource:
4
MinnesotaSource:
Chlamydia
Partnership.
Partnership.
Minnesota
Chlamydia
4
Partnership.
KC: While the focus of the MCP is on
Minnesota, we’re also plugged into the
national community of public health
professionals and advocates who are
concerned about this epidemic and the
sexual health of young people. We have
been contacted by people working in health
departments in other states and in Canada
who want to know more about what we have
done so that they can implement something
similar. We’ve shared our experiences with
national-level organizations that participate
in the National Chlamydia Coalition as well
as groups in Minnesota. We will continue to
tell MCP’s story.
5. STI surveillance statistics are available
for Minnesota. Available from: http://www.
health.state.mn.us/divs/idepc/dtopics/stds/
stats/stdsurvrpts.html as well as the United
States http://www.cdc.gov/std/stats12/.
For More Information
1. Minnesota Department of Health. 2012 STD Surveillance
Statistics. Available from: http://www.health.state.
mn.us/divs/idepc/dtopics/stds/stats/stdsurvrpts.html
1. Minnesota Chlamydia Partnership.
Available from: http://www.health.
state.mn.us/mcp and http://www.
mnchlamydiapartnership.org
2. Minnesota Chlamydia Strategy. Available
from: http://www.health.state.mn.us/divs/
idepc/diseases/chlamydia/mcp/strategy/
MNChlamydiaStrategy.pdf
3. A Special Report: Chlamydia Prevention
(the “booklet”). Available from: http://www.
mnchlamydiapartnership.org/wp-content/
uploads/2012/10/MCP-Report-2012.pdf
4. National Chlamydia Coalition. Available
from: http://www.ncc.prevent.org
6. Basic information about chlamydia
infection (symptoms, treatment, etc.).
Available from: http://www.cdc.gov/std/
Chlamydia/
7. For more information about MCP,
including how to join, contact Candy
Hadsall, RN at [email protected]
or (651) 201-4015.
REFERENCES
2. US Centers for Disease Control. Sexually Transmitted
Disease Surveillance 2012. Available from: http://www.
cdc.gov/std/stats12/default.htm
3. US Census Bureau. Available from:
http://factfinder2.census.gov/
4. Minnesota Chlamydia Partnership. A Special Report:
Chlamydia Prevention. Available from: http://
www.mnchlamydiapartnership.org/wp-content/
uploads/2012/10/MCP-Report-2012.pdf
Summer Martins, MPH, is a student in the PhD
program in epidemiology, Division of Epidemiology
& Community Health, School of Public Health,
University of Minnesota.
Winter/Spring 2014
5