ATLANTA - A study in Baltimore found a high prevalence of chlamydial and gonococcal infections among middle school-age girls, although most of the students were asymptomatic, according to Gale R. Burstein, MD, MPH.
Burstein, STD/HIV prevention fellow at the School of Hygiene and Public Health, Johns Hopkins University, said the study was undertaken because previous surveys among high school students indicated that 9% had had their first sexual encounter before the age of 13, and they wanted to determine if this at-risk group had a high rate of disease. She presented a poster here at the International Conference on Emerging Infectious Diseases.
Between November 1996 and December 1997, students who came into one of three Baltimore middle school health clinics for any reason were asked if they were sexually active. Those who admitted to being sexually active were asked by nurse practitioners to provide urine specimens. It was a casual, non-threatening question, Burstein said. "By the way, are you sexually active? Would you give a urine sample for testing?" Fewer than 5% said no. The specimens were tested by LCR (Abbott) for Chlamydia trachomatis and Neisseria gonorrhoeae.
"Urine-based screening tests are great ways to test kids, and the LCR tests were very sensitive and very specific for chlamydia and gonorrhea," she said.
In all, girls in 256 visits and boys in 47 visits were tested. Some of those tested visited the clinic more than once. Visits less than 30 days apart were excluded. These middle school clinics serve as primary care providers for many inner city children because they have no other form of health care. Therefore, the visits were for a variety of reasons, including physical exams, reproductive health visits, injuries and symptoms of STDs.
Most of the children were around 14 years old; 98% were black, Burstein said. Many exhibited high-risk behaviors for STDs: Within the past 90 days, 48.9% reported having multiple partners; 46.5% had just been involved with a new partner; and 54.6% reported inconsistent condom use.
Of those tested, 16.4% were positive for C. trachomatis; 92.8% were asymptomatic. In addition, 11.4% tested positive for gonorrhea; 86% of those had no symptoms.
Teenagers should be asked about sexual activity at every visit, and anyone who admits to being sexually active should be tested. "Ask the question and screen," Burnstein suggested. "Screening once a year doesn't really cut it." More than 15% of the girls in the study were found to be positive for C. trachomatis during the first visit; 18.6% tested positive during a repeat visit. More than 11% were found positive for gonorrhea during the first visit; 11.8% tested positive during a repeat visit.
Only 2% of the males tested were positive for gonorrhea and 2% males tested positive for chlamydia in this middle school sample.
Unfortunately, the partners of many of these girls were not found and may not have been treated. "That's a big problem. There is no support in Baltimore for contact tracing for gonorrhea and chlamydia," Burstein told Infectious Diseases in Children. "Another problem is that the girls were mostly around the age of 14, and that often their partners are older. A four-year difference between the partners can be a felony, [so the girls were reluctant to give up their partner]."
Alimitation to the study, Burstein said, was that they could ask a limited number of questions, so they did not ask about other risk factors such as drug use. However, Burstein said school-based clinics were excellent vehicles for identifying at-risk children and treating them, especially with urine-based tests. "We would have never gotten those kids to consent to pelvic exams or the boys to urethra swabs," she said. And follow-up is easier. "The great thing about middle school is you have a captive audience. You can pull them out of class for follow-up."
It is important for pediatricians to recognize that very young teenagers are sexually active, and that they need counseling and testing for STDs, she added.
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