High-School Based Screening for Chlamydia and Gonorrhea

State: PA Type: Model Practice Year: 2005

The High School-Based Screening for Chlamydia and Gonorrhea program targets Philadelphia public high school students in Grades 9-12. The goal of the program is to educated high school students regarding the risks of STDs, prevention methods, and the need for testing if sexually active. Approximately 30,000 students have been provided with Sexually Transmitted Disease educational presentations annually (2002-2003 & 2003-2004 school years) and approximately 60% have been tested. Outcomes of the program include: In the 2002-2003 school year: 19,713 students tested; 1,052 were found to be infected and 1,051 (99.9%) were treated.  In the 2003-2004 school year: 17,019 students tested; 813 infected and 807 (99.3%) treated.  In the 2004-2005 school year: testing is in progress with more than 10,000 students tested mid-way through the school year.   In summary, the Philadelphia Department of Public Health STD Control Program, in collaboration with the School District of Philadelphia, implemented a citywide high-school based screening program to address epidemic levels of chlamydia and gonorrhea infections in this age group. In its third year of operation, this program has demonstrated that a large scale initiative such as this can be implemented and sustained, with substantial impact on the problem.
In calendar year 2000, the case rate for reported Chlamydia infections among 15-19 year old females was 8,224/100,000, more than 6 times the rate among females (all ages) citywide and 3.5 times the national rate for females this age group. In addition, the case rate among males in Philadelphia in this age group was 1,645/100,000, only 20% of the rate among females in this age group. This screening program was implemented in high schools to reach these affected populations; testing of females was designed to identify infected individuals so that treatment could be provided and Pelvic Inflammatory Disease (PID) prevented. Testing of males was designed to identify asymptomatic individuals and to provide treatment to avoid sequelae and reduce infection/reinfection of females. Testing of both groups was also intended to reduce the reservoir of infection with asymptomatic infection in the community. Educational presentations were provided in an effort to educate students regarding the asymptomatic nature of many STDs, encourage those who were already sexually active to modify their behavior and to reinforce decisions to abstain from sex among other students. This program was innovative in its scope and in its effort to test males. It was implemented on a citywide basis and included 54 high schools with an overall enrollment of more than 50,000 students. Each year, it successfully reached more than 30,000 students in small groups (approx. 60 students) with an STD presentation and the offer of urine-based, non-invasive screening immediately following the presentation; more than 60% of the students offered testing volunteered to be tested. It represents an unprecedented collaboration between a Public Health Department and a Major School District to address the epidemic of sexually transmitted diseases prevalent among adolescents in major cities in the United States. It demonstrated that such a program could be implemented and would be accepted by parents, students and school faculty, and could be done while protecting the confidentiality of those seeking testing and those who tested positive. In addition, this program targeted males as well as females in an effort to reduce the reservoir of asymptomatic infection among males in this at risk population.
Agency Community RolesThe Philadelphia Department of Public Health initiated this program with the full collaboration of the School District of Philadelphia. The Health Department has provided the programmatic elements of this project while the School District has coordinated the scheduling of students for testing, the availability of space within the schools and access to students after testing, as necessary. During 2004, the Medicaid Managed Care Providers in Philadelphia agreed to reimburse the Department of Health for tests provided to students who were enrolled as members in their plans. To date, they have provided over $100,000 in reimbursements for this program. Costs and ExpendituresThis program costs approximately $900,000/year for all Health Department and laboratory costs. It is funded through a combination of Federal STD Grant, City of Philadelphia Department of Public Health and Medicaid Managed Care reimbursement programs. Approximately 70% of the cost is attributable to staff, the balance is associated with laboratory testing and treatment costs. Sustainability relies on continued support from these sources. ImplementationSpecific tasks to implement this program included the following: Identification of need, based upon reported chlamydia and gonorrhea morbidity among adolescents, and successful initiation of a pilot project in two schools; Development of a plan to educate and screen students in all Philadelphia Public High Schools; Identification of Health Department staff and laboratory capacity to implement the plan; Acquisition of support from the CEO of the Philadelphia School District; Involvement and support of the Home and School Council (parent’s association); Assistance of staff in each high school to assist with publicity and to assure participation of students; Assistance of the School Nursing Staff to facilitate locating students requiring follow-up (treatment of infected students was provided confidentially by Health Department staff, most often in the Nurses’ offices).
During calendar year 2004, Philadelphia achieved an overall reduction in reported Chlamydia morbidity of 5.8%, the first significant decrease in eight years; among adolescents, the reduction was 8.4%. This occurred in spite of continued screening in the high schools and other venues citywide (approximately 150,000 tests per year). These reductions have been attributed to the impact of the high school screening program and screening efforts in other venues targeting adolescents including Juvenile Detention, Family Court and Adult Prisons. Process evaluation included the number of schools in which the program was presented, total school enrollment, the percentage of students participating in the educational presentations provided to small (60 students) groups of students in each school and the percentage of participating students volunteering to be tested. Overall, the program found that approximately 60% of the total school district enrollment and that more than 60% of the students participating in the presentation volunteered to be tested.
Key Elements for Replication: Collaboration and commitment by the Administrations of the School District and Health Department at the highest levels; financial support for laboratory testing; staff to implement the educational program, specimen acquisition, specimen handling and transport; administrative support staff; medication and staff to provide treatment; staff for partner notification services and to implement re-screening of positives.