1. Screening Protocols and Education Charlotte A. Gaydos, MS, MPH, DrPH
Associate Professor
Johns Hopkins University, Baltimore, MD

2. BALTIMORE CHLAMYDIA PREVALENCE HIGH AND MIDDLE SCHOOL FEMALES
BY YEAR:
HIGH AND MIDDLE SCHOOL FEMALES

3. BALTIMORE CHLAMYDIA PREVALENCE UNDUPLICATED SCHOOL FEMALES
BY YEAR:
UNDUPLICATED SCHOOL FEMALES

4. Reinfection in Females
10,609 unique females in schools were tested for CT by NAATs between either by cervical swabs or urine samples w/ prevalence 18.1% ( % by yr)
Of 1920 CT positives, 897 (46.7%) females had at least one subsequent test between 30 and 365 days later
Female CT Reinfection (cumulative incidence): 26.3% (236/897)
By School site: %
By age: 38.9% age 13 yr to 12.7% for age 18 yr
Gaydos et al. STD 2008;35:

5. Results: Urine vs. Vaginal (n=364 paired specimens)
Chlamydia
AC2 Vaginal 55 1 12
296 + -
AC2
Urine
Urine CT prevalence: 15.4% (56/364)
Vaginal CT prevalence: 18.4% (67/364)
Urine CT: sensitivity 82.4% (56/68)
Vaginal CT: sensitivity 98.5% (67/68)

6. Screening Protocols and Education
Baltimore:
Current protocol involves screening any adolescent who attends SBHCs in 8 high and 3 middle schools if they are sexually active upon questioning from nurse practitioner
Education is personalized on an individual basis for each patient
For more extensive “whole school” screening there is a need to get “buy in” from school health educators and develop a plan as to how to approach screening & education in the schools, from the Health Department, and SBHCs

7. Screening Protocols and Education
Baltimore:
Testing is by APTIMA Combo2 NAAT: vaginal swabs for females and urine for males
Prevalence for Females: 15.5% (2242 tested)
Males: 9.1% (929 tested)
Education is personalized on an individual basis for each patient
Partner Notification: By health staff if another student, if non student, patient asked to notify PN

8. Screening Protocols and Education
New York City:
STD education and screening program offered to pubic high school students grades 9-12
Target schools in neighborhoods w/ high STD rates among adolescents
STD staff go to schools conduct the program:

9. Screening Protocols and Education
New York City:
Within each 45 min period, class is conducted:
Education: 25-minute presentation focused on STD prevention, CT/GC testing, other available sexual and reproductive health
services
Everyone participates in education program
Voluntary, confidential testing:

10. Screening Protocols and Education
New York City:
Students receive brown paper bag with urine cup, contact info sheet, and call-back card
All students complete paperwork
Instructions for obtaining test results are explained during the presentation and on the call-back card
All students are brought to bathrooms (to protect privacy) where they can choose whether or not they want to test
Students return brown paper bags either with or without a urine specimen

11. Screening Protocols and Education
New York City:
Students given a number to call back for test results
Students must give secret code to obtain results over phone
Test results not given to anyone but the individual student
Urine tested using ProbeTec NAAT testing at the Public Health Lab
Approximately 50% of students decide to be tested w/ urine test
Prevalence : Female: 10.4%; Male: 4.6%

12. Screening Protocols and Education
Indian Health Service:
For each site, site-specific protocol and approach to education are developed
Every project is individual and every aspect of the project is a case-by-case endeavor
There are approximately 4 sites we have worked/are working with - some sites have done some screening and some have not

13. Screening Protocols and Education
Indian Health Service:
Each project develops it's own site specific protocol. We have issued guidance for schools last year website: (STD tab). The type of test varies by site - some are NAAT, some are not, some are BD and some Gen Probe. Not generalizable for IHS.
Positivity has varied from percent
In one school 67% of 600 students attended the assembly, 95% accepted a specimen cup, 73% of these provided a urine: prevalence: Females 6%; Males 4%

14. Screening Protocols and Education
Philadelphia:
Who is offered screening?
STD education and screening program is offered to all 9-12th graders in Philadelphia public schools
With the exception of special education students who are not able to be mainstreamed for any classes
(often these students have severe physical handicaps as well)
With the exception of students attending the high school operated by the Philadelphia prison system – of note all persons entering the prison system are screened upon intake.

15. Screening Protocols and Education
Philadelphia:
PDPH trained staff go to each school and present an educational program to 60 students at a time during a typical class period
Initially a power point presentation was used
Beginning in 2006 a video developed to be used for the STD education piece using popular city radio personalities as speakers
Education brief on all STDs, focusing on reasons to test (risk factors; how to protect oneself)
Where to get tested if one does not want to take the test in school

16. Screening Protocols and Education
Philadelphia:
All students are sent to the restroom with a testing kit after the educational portion of the program is completed
All students are to return the testing kit
Students volunteer to be tested by returning urine specimens
PDPH staff typically aliquot urine on site
Urine is tested in the PDPH public health laboratory using Aptima combo 2
Prevalence last year: Females: 7.2% Males: 2.8%
Students are given a number to call to get their test results (ask for “Zelda”)

17. Screening Protocols and Education
New Orleans:
Screening program administration contacts schools to seek their interest in conducting screening each school year.
Initial contact always begins with the school official the most receptive to the screening program while being influential (mostly the school nurse)
In schools with a school-based health center (SBHC), it is always the Director of the Health Center
This contact ultimately always leads to a tripartite meeting between the Screening Program Administration, the school principal, and the School Nurse/SBHC Director

18. Screening Protocols and Education
New Orleans:
The screening program representative gives a detailed description of the program and discusses details related to how the screening will be conducted, how students will be notified about their test results, and how infected students will obtain counseling and treatment
Date and time scheduled for students to receive an oral presentation of the program by program staff. This orientation session is arranged according to what fits the school best and can be either in a class subject (such as English classes), or through assemblies in an auditorium or at the cafeteria (such as by grade levels).

19. Screening Protocols and Education
New Orleans:
At the end of each orientation session, consent forms are distributed to all students in attendance. Students aged 18 years or older are asked to sign and return their consent forms. Students younger than 18 are asked to take the forms to their parents/guardians for their signature and are encouraged to return signed consents to the school the following school day.
Screening program staffs return to schools during the following days to collect signed consent forms, to replace lost forms, or to give forms to those who had not received ones
Screening staffs schedule a screening date that is mutually agreeable with the school and the school nurse.

20. Screening Protocols and Education
New Orleans:
Screening Program Coordinator and the school nurse locate within the school an appropriate place for screening with restroom accessibility (a hallway nearby restrooms, an empty classroom, the gym, an auditorium, an area within a school health center).
On screening days, scheduled classes are brought to the testing area and each student is received individually to discuss their participation in the screening.
Those who do not have consent and those who have consent but are not willing to be screened are sent back to their classrooms.

21. Screening Protocols and Education
New Orleans:
Those who have consent and willing to be screened provide a urine specimen in a urine collection cup.
Strand displacement (Becton Dickinson ProbeTec) has been used since 2000 for CT testing
Prevalence for last screening: Females: 15%, Males: 9.3% (approximately 2000 screened)

22. Screening Protocols and Education
Summary:
Schools provide an excellent venue for educational opportunities for teaching adolescents about STIs
Screening of adolescents for chlamydia in school settings is feasible and provides easy access to large numbers of at-risk individuals, when non-invasive specimens are collected for use with NAAT assays
Prevalence detected is usually higher than in family planning settings
Schools also provide excellent locations for treatment of infected students
Opportunities abound!

23. School Nurse Practitioners
Acknowledgements
Mathilda Barnes, BS
Bulbul Aumakhan, MD
Nicole Quinn, BS
Patricia Agreda
Pamela Whittle, BS
Terry Hogan, MPH
Catherine Wright
Sharon Hobson
Gerry Waterfield
School Nurse Practitioners
1159 Ross Bldg
720 Rutland Ave.
Baltimore, MD 21205 PH
FAX