Original ContributionsSexually Transmitted Infection History among Adolescents Presenting to the Emergency Department
Introduction
In the United States, it is estimated that there are nearly 20 million new sexually transmitted infections (STI) diagnosed annually and adolescents and young adults aged 15–24 years account for half of these cases, despite being only 25% of the sexually experienced population 1, 2, 3, 4, 5. Furthermore, women, African Americans, and Hispanics are disproportionately affected 6, 7, 8. Additionally, STIs result in approximately $16 billion in direct and indirect health-care expenses 9, 10. Among women, STIs, such as chlamydia, can cause long-term health consequences, such as pelvic inflammatory disease, infertility, and perinatal complications 11, 12, 13, 14. Among males, STIs, particularly chlamydia, have been implicated in chronic and acute infections (e.g., urethritis, epididymitis, epididymo-orchitis), as well as infertility (15).
Prior STI during adolescence or emerging adulthood predicts risk for future STI and human immunodeficiency virus (HIV) infection and recurrence rates are concerning 16, 17. For example, a cohort study found that when comparing adolescents who never had an STI to those who had (where chlamydia was most common), HIV risk doubled among those with any past STI (16). In addition, research with emerging adults suggests that a past-year diagnosis of herpes is associated with increased odds of past-year diagnoses of chlamydia, gonorrhea, and genital warts (18). Further, a recent review found recurrence rates for genital warts of up to 110 per 100,000 among females and up to 163 per 100,000 among males, in addition to a peak in incidence during emerging adulthood (19). Thus, identifying individuals with a prior STI may be clinically important to health-care providers in identifying those at future risk.
Several factors put adolescents at risk for STIs, including multiple and concurrent sexual partners, lack of consistent and proper use of barrier protection, and increased biologic susceptibility to infection 1, 5, 20, 21. For many adolescents, engaging in sexual risk behaviors increases from adolescence into emerging adulthood 22, 23, 24. In addition, high-risk behaviors, including alcohol and other substance abuse, tend to occur with or precede sexual risk behaviors among young people 24, 25, 26, 27, 28, 29. Protective factors have also been identified, such as parental disapproval of sex and high grade-point average 30, 31, 32.
Adolescents are frequently without a primary care physician and they often present to the emergency department (ED) for their medical care 2, 20, 33, 34. Also, many older adolescents do not receive health maintenance examinations, limiting the opportunity for screening and preventive medicine (35). Research also demonstrates that adolescents receiving care in the ED are more likely to engage in risky behaviors compared to those presenting in primary care (36). Further, female adolescents frequently present to the ED with gynecologic symptoms contributing to the estimated 171,000 patients who present to the ED yearly for evaluation for STIs 20, 37, 38. However, as many STIs are asymptomatic and under-diagnosed, this is likely an underestimate of the disease burden, especially among male adolescents who are less likely to seek ED care for nonurgent problems and are less likely to undergo health maintenance screening 7, 35, 39. For example, studies involving point-of-care testing have shown that about 11% of youth in EDs tested positive for chlamydia or gonorrhea 39, 40.
Although the Centers for Disease Control and Prevention (CDC) recommend routine STI screening for sexually active youth, particularly for females < 26 years, this screening occurs about half of the time 2, 5, 41. A national survey that included adolescents and adults showed that emergency physicians are less likely than other physicians to screen for STIs and suggested lack of time, follow-up, appropriate counseling, and reimbursement as primary barriers 42, 43. ED practitioner compliance with CDC guidelines for treatment of STIs and related clinical presentations, such as pelvic inflammatory disease (PID), is poor in samples of adolescents and adults 20, 44. For example, among adolescent women attending EDs for STIs or PID, full compliance with guidelines occurred in around one-third of cases 20, 45. Despite this low compliance with recommendations, research has shown that sexually active youth, compared to non–sexually active peers, are willing to engage in discussions of STIs with providers (46).
Thus, the ED may be a crucial location for STI testing, intervention, referrals, and treatment efforts among youth, especially young men who may be asymptomatic carriers of STIs. In order to inform such efforts, research is needed to identify characteristics of those youth presenting to the ED setting who may be at highest risk for STIs to focus limited resources for point of care testing, as universal testing may not be feasible in every setting. Although youth with prior STI may have different characteristics than youth with current STI, given the relationship between past STI and future risk for STI and HIV infection and the concerning recurrence rates, information on the prevalence and characteristics of youth in the ED with prior STI is needed to identify those at risk in order to inform screening, prevention, and treatment efforts to provide an alternative to universal biologic testing 16, 17, 18, 19, 39, 40. The aims of this study are to determine the prevalence of prior STI among sexually active males and females between 14 and 20 years of age in the ED and then to determine correlates of prior STI among this cohort.
Section snippets
Study Design and Setting
The present study included secondary analysis of data from youth screened for inclusion in an ED-based randomized controlled trial (RCT) for underage drinking 47, 48. Recruitment procedures and computer-based screening took place at the University of Michigan, Department of Emergency Medicine, an academic, Level I trauma center comprising a main ED, urgent care, and a pediatric ED; all attending physicians are board-certified in emergency medicine/pediatric emergency medicine. The total annual
Sample
During recruitment, 9228 patients aged 14–20 years old presented to the ED and 6629 (70.8%) met eligibility criteria for screening, while 2696 (29.2%) were excluded. The most frequent reasons for exclusion were insufficient cognitive orientation (31.6%) or not having a parent/guardian present if the patient was a minor (15.1%). Among screening-eligible patients, 1436 (21.9%) were missed and RAs approached 5096 (78.0%) of whom 707 (13.9%) refused participation, and 4389 (86.1%) completed the
Discussion
Adolescence is a high risk time for transmission of STIs, which can lead to longstanding medical consequences. Prior research found that nearly 10% of asymptomatic 18- to 30-year-olds in the ED test positive on urine screen for gonorrhea or chlamydia 61, 62. Improved detection and screening is needed and recommended by the CDC, yet strategies are needed to focus testing and treatment reach.
To guide such strategies, this study provides practical data regarding characteristics of sexually active
Conclusions
One in 10 sexually active youths seeking care in the ED report a prior STI diagnosis, and 50% have recently engaged in high-risk sexual behaviors that warrant improved testing, diagnosis, treatment, and prevention messages. Although women are more likely to report a prior STI diagnosis, potentially due to the occurrence of symptoms or receipt of routine gynecologic care, it is important to note that men also report high rates of sexual risk behaviors associated with risk for STI. Thus, ED
Acknowledgments
The authors thank Ms. Linping Duan for statistical support in the preparation of this manuscript.
References (85)
- et al.
Emergency department management of sexually transmitted infections
Emerg Med Clin North Am
(2011) - et al.
Implementing an HIV and sexually transmitted disease screening program in an emergency department
Ann Emerg Med
(2007) Sexually transmitted chlamydial infections and subfertility
Int Cong Ser
(2004)A review on infection with Chlamydia trachomatis
Best Pract Res Clin Obstet Gynaecol
(2006)Chlamydia during pregnancy: implications and impact on perinatal and neonatal outcomes
J Obstet Gynecol Neonatal Nurs
(2002)- et al.
Emergency department management of sexually transmitted infections in US adolescents: results from the National Hospital Ambulatory Medical Care Survey
Ann Emerg Med
(2004) - et al.
Testing and treatment for sexually transmitted infections in adolescents—what's new?
J Pediatr Adolesc Gynecol
(2014) - et al.
Association of MDMA/ecstasy and other substance use with self-reported sexually transmitted diseases among college-aged adults: a national study
Public Health
(2009) - et al.
Rates and correlates of violent behaviors among adolescents treated in an urban emergency department
J Adolesc Health
(2009) - et al.
Longitudinal prediction of sexually transmitted diseases among adolescents: results from a national survey
Am J Prev Med
(2000)
Smart teens don't have sex (or kiss much either)
J Adolesc Health
Do young adults have unmet healthcare needs?
J Adolesc Health
Adolescent health care in a pediatric emergency department
Ann Emerg Med
Point-of-care testing for sexually transmitted infections increases awareness and short-term abstinence in adolescent women
J Adolesc Health
Development of adolescent self-report measures from the National Longitudinal Study of Adolescent Health
J Adolesc Health
Chart reviews in emergency medicine research: where are the methods?
Ann Emerg Med
Sexual behaviors and condom use at last vaginal intercourse: a national sample of adolescents ages 14 to 17 years
J Sex Med
Condom negotiation strategies and actual condom use among Latino youth
J Adolesc Health
Alcohol, helping young adults to have unprotected sex with casual partners: findings from a daily diary study of alcohol use and sexual behavior
J Adolesc Health
Alcohol use, partner type, and risky sexual behavior among college students: findings from an event-level study
Addict Behav
Scope of HIV risk and co-occuring psychosocial health problems among young adults: violence, victimization, and substance use
J Adolesc Health
Assessment of factors affecting the validity of self-reported health-risk behavior among adolescents: evidence from the scientific literature
J Adolesc Health
Reliability of the 1999 youth risk behavior survey questionnaire
J Adolesc Health
Comparability of a computer-assisted versus written method for collecting health behavior information from adolescent patients
J Adolesc Health
Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States
Pediatrics
Sexually transmitted disease surveillance 2009
Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008
Sex Transm Dis
Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000
Perspect Sex Reprod Health
Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010
MMWR Recomm Rep
Incidence, prevalence, and cost of sexually transmitted infections in the United States
Health disparities in HIV/AIDS, viral hepatititis, sexually transmitted diseases, and tuberculosis: issues, burden and response, a retrospective review, 2000–2004
The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008
Sex Transm Dis
STDs: screening, therapy, and long-term implications for the adolescent patient
Int J Fertil Menopausal Stud
Male genital tract chlamydial infection: implications for pathology and infertility
Biol Reprod
Adolescent sexually transmitted infections and risk for subsequent HIV
Am J Public Health
A retrospective study of recurrent chlamydia infection in men and women: is there a role for targeted screening for those at risk?
Int J STD AIDS
Characteristics associated with genital herpes testing among young adults: assessing factors from two national data sets
J Am Coll Health
Systematic review of the incidence and prevalence of genital warts
BMC Infect Dis
Disentangling adolescent pathways of sexual risk taking
J Prim Prevent
Developmental trajectory of sexual risk behaviors from adolescence to young adulthood
Youth Soc
Achieving quality health services for adolescents
Pediatrics
Prevalence and correlates of HIV risk among adolescents and young adults reporting drug use: data from an urban Emergency Department in the U.S
J HIV AIDS Soc Serv
Cited by (11)
Impact of a Training Directed to the Emergency Health Professionals on the Managements of Sexual Transmission Infection Patients
2023, Actas Dermo-SifiliograficasManagement of Urethritis: Is It Still the Time for Empirical Antibiotic Treatments?
2019, European Urology FocusCitation Excerpt :Owing to this reason, gonococcal and nongonococcal infections often coexist, generating an additional confounding factor and limiting the use of empirical treatments. Previous urethritis or other sexually transmitted diseases (STDs) occurring during adolescence or human immunodeficiency virus (HIV) infections are other significant factors that could increase the risk of recurrent urethritis episodes [18]. Newbern et al [19] conducted a cohort study comparing one group of adolescents with previous STDs with another with no previous STDs and found that the first group had double the risk of developing subsequent HIV infection.
Updates on Sexually Transmitted Urethro-cystitis
2022, Current Bladder Dysfunction ReportsPediatric and adolescent sexuality: An overview
2022, Behavioral Pediatrics II: Neuropsychiatry, Sexuality and Eating Disorders. Fifth EditionElectronic Screening for Adolescent Risk Behaviors in the Emergency Department: A Randomized Controlled Trial
2022, Western Journal of Emergency Medicine
This study was funded by National Institute on Alcohol Abuse and Alcoholism (#R01AA018122) and a portion of Dr. Bonar's work on this manuscript was supported by an NIAAA T32 training grant (#T32AA007477) and later a National Institute on Drug Abuse career development grant (#K23DA036008). Center support was also provided by Centers for Disease Control and Prevention to the University of Michigan Injury Center (#R49CE002099). The NIAAA, NIDA, CDC, and the University of Michigan had no direct role in the present study design, collection, analysis, or interpretation, writing of this manuscript, or the decision to submit this paper for publication. The authors have no other financial relationships relevant to this article to disclose.
ClinicalTrials.gov Identifier: NCT01051141.