CHLAMYDIA (Screening)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 8/05/11

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians routinely screen all sexually active non-pregnant young women aged 24 years and younger for chlamydia.1 Older non-pregnant women at increased risk should also be screened for chlamydial infection.

Evidence Rating: A (Strongly Recommended/Good Evidence)
The USPSTF found good evidence that screening women at risk for chlamydial infection can reduce the incidence of pelvic inflammatory disease (PID).1 The USPSTF concluded that the benefits of screening women at increased risk are substantial.

The USPSTF recommends screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk.

Evidence Rating: B (Recommended/Moderate Certainty)
The USPSTF found fair evidence that screening identifies infection in asymptomatic pregnant women and treatment for chlamydial infection improves pregnancy and birth outcomes.

CDC Recommendation
CDC recommends screening all sexually active women aged 25 years and younger and older women with risk factors (e.g., those who have a new sex partner or multiple sex partners).2 All pregnant women should be routinely tested at the first prenatal visit. Pregnant women aged 25 years and younger and those at increased risk should be re-tested during the third trimester to prevent maternal postnatal complications and chlamydial infection in the infant.2

Evidence Rating:
Not Specified

NOTE:
The USPSTF recommends against routinely providing screening for chlamydial infection for women in certain age groups. For more information, see C recommendations.
The USPSTF found insufficient evidence for screening for chlamydial infection in men. For more information, see I recommendations.





The Value of Prevention

Economic Burden of Condition/Disease
The most recent estimate of the annual cost of chlamydial infection and its sequelae is $647 million (in year 2008 dollars).11-12 The lifetime medical cost of chlamydia has been estimated at $26 per case for men and $315 per case for women (in year 2006 dollars).11

Chlamydia can progress to pelvic inflammatory disease (PID), a serious condition that is expensive to treat. It is estimated that treatment for a single case of PID costs between $1,060 and $3,180 in 2000 dollars.13

Workplace Burden of Condition/Disease
The reproductive and other health problems of chlamydia impose a significant cost to employers by way of health and disability insurance costs. The lifetime productivity losses for young working-age adults suffering from the long-term health effects of chlamydial infection are high. An acute case of PID is estimated to result in $649 in lost productivity costs, which is equivalent to an average of $130 in lost productivity costs per untreated case of chlamydia (in year 2001 dollars).14

Economic Benefit of Preventive Intervention
Because screening allows for the early recognition of disease and subsequently an earlier initiation of treatment, it can prevent the costly complications of late-stage disease such as PID and infertility.

Estimated Cost of Preventive Intervention
In 2007, the median private-sector cost of chlamydia screening was $41.15 Approximately 95% of all paid claims fell within the range of $18 to $89.15

In 2008, the Centers for Medicare & Medicaid Services (CMS) allowable fees for the CPT codes shown above ranged from $17.52-$102.49.16 The cost per case of chlamydia treated through screening will depend on population prevalence and other factors.

Estimated Cost of Treatment
The estimated lifetime direct medical cost per case of chlamydia is $26 in men and $315 in women (in 2006 dollars).11

Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
Annual screening among women 15 to 29 years of age followed by semiannual screening for those with a history of infection was estimated to cost less than $25,000 per quality-adjusted life year (QALY) compared with the annual screening only.17

A review of 10 cost-effectiveness studies found that screening was more cost-effective than simply testing symptomatic women. The models showed that in some instances, screening was cost-saving (compared to testing symptomatic women) even at prevalence rates as low 1.1%.18




Condition / Disease Specific Information

Epidemiology of Condition/Disease
Chlamydia is the most commonly reported bacterial sexually transmitted infection (STI) in the United States. In 2008, 1,210,523 cases of chlamydia were reported by state health departments in the United States, an increase from 1,108,374 reported in 2007.3 If untreated, chlamydia can result in significant complications in both men and women.

Among women, an untreated chlamydial infection may progress to pelvic inflammatory disease (PID), a serious condition that can result in chronic pelvic pain, an increased risk of ectopic pregnancy due to scarring of the fallopian tubes, and infertility.4 Approximately 8% of U.S. women report being diagnosed with PID in their lifetime, and over 1 million women are treated for PID each year.5 Chlamydia infection has been associated with approximately one-third of all cases of PID.6

Among pregnant women, chlamydial infection increases the risk of pregnancy complications including premature rupture of the membranes, pre-term delivery, low-birth-weight infants, and postpartum endometritis. A chlamydial infection can be transmitted to an infant by an infected mother during labor and delivery and may cause neonatal conjunctivitis and/or pneumonia.7-9 Infection with chlamydia may increase an individual's susceptibility to HIV.

Condition/Disease Risk Factors
Sexually active adolescents (of both sexes) are at the highest risk for chlamydial infection.10 Prevalence of chlamydial infection is also high among women and men aged 20 to 25 years.10 The prevalence of chlamydia is higher among African-American populations and among individuals who are unmarried, have a prior history of STIs, have multiple sexual partners, and/or who use barrier contraceptives incorrectly or inconsistently.10




Preventive Intervention Information

Preventive Intervention: Purpose of Screening
Screening for chlamydia allows clinicians to identify infected patients and begin treatment earlier in the course of disease, thereby improving outcomes and avoiding the health and economic consequences of latent disease such as PID and infertility. In fact, a randomized trial provides further support that screening women at risk for chlamydia reduces the incidence of PID.19

Routine screening for chlamydia is especially important because of its asymptomatic nature. It is estimated that 75% to 85% of women (and a substantial percentage of men) with chlamydia do not have symptoms.19

Benefits and Risks of Intervention
Few studies have documented the risks associated with screening for chlamydia. Potential risks include partner discord, stigma, and side effects of treatment. As with all types of screening, false-positive results may cause undue anxiety or unnecessary treatment. Among high-risk patients, the benefits of screening for chlamydia substantially outweigh the harms. Screening allows for early recognition and treatment, reducing PID and long-term effects. Screening programs can also lead to reduced person-to-person transmission of infection, which could substantially lower infection rates at the population level. Reducing the rate of chlamydia within a population would have substantial positive health effects including lower rates of PID.19

Initiation, Cessation, and Interval of Screening
Average-risk women should be screened annually from the onset of sexual activity through age 25. Women with known risk factors and women who have experienced a previous infection should continue screening beyond the age of 25. The CDC recommends women with chlamydial infection be retested 3 months post-treatment or at their first medical encounter within the following 3-12 months post-treatment.1-2 Sex partners of individuals infected with chlamydia should also be evaluated and treated.2

Intervention Process
Several effective methods of screening for chlamydia are currently available6:
  • Nucleic acid amplification tests (NAATs) on endocervical, male urethral or vaginal swab specimens or first-catch urine specimens.
  • Non-amplified nucleic acid hybridization tests on endocervical or male urethral swab specimens.
  • Antigen detection tests on endocervical and urethral swab specimens.
  • Culture of swab specimens from the, endocervix or urethra.
Treatment Information
Health benefits should include provisions for diagnostic and treatment services. Treatment, usually a 7-day course of oral antibiotics or a single dose of azithromycin, is easy, inexpensive, and noninvasive. Side effects of treatment (gastrointestinal distress, nausea) occur infrequently. Moreover, treatment is highly effective (97% of nonpregnant women and men treated for chlamydia are cured).19




Strength of Evidence

The level of evidence supporting the recommendation in this section is described below.
Evidence-Based Research:
U.S. Preventive Services Task Force (USPSTF)
Strength of Evidence: A (Strongly Recommended/Good Evidence)
  • The USPSTF recommends routine screening of all sexually active women age 24 years and younger and other asymptomatic women at increased risk for infection.1
Strength of Evidence: B (Recommended/Moderate Certainty)
  • The USPSTF recommends routine screening of all pregnant women age 24 years and younger, and of older pregnant women at increased risk.1
Other Research
Centers for Disease Control and Prevention (CDC)
Strength of Evidence: Not Specified
  • CDC recommends screening annually all sexually active women aged 25 years and younger and older women with risk factors (e.g., those who have a new sex partner or multiple sex partners).2



Summary Plan Description

Covered Screening
Chlamydia screening is a covered benefit. The following tests are covered:
  • Antigen detection tests
  • Culture analysis of a endocervical or urethral swab
  • Culture of swab specimens from exposed sites
  • Non-amplified nucleic acid hybridization tests
  • Nucleic acid amplification assays
Initiation, Cessation, and Interval
Annual screening is a covered benefit for all women aged 25 years and younger, regardless of pregnancy. Coverage is provided for women over age 25, regardless of pregnancy, if medically indicated.




CPT Codes

Chlamydia (Screening)
87270 Infectious agent antigen detection by immunofluorescent technique, Chlamydia trachomatis
87320 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semi-quantitative, Chlamydia trachomatis
87110 Chlamydia, culture, any source
87810 Infectious agent detection by immunoassay with direct optical observation, Chlamydia trachomatis
87490 Infectious agent detection by nucleic acid; Chlamydia trachomatis, direct probe technique
87491 Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe technique
87492 Infectious agent detection by nucleic acid (DNA OR RNA); Chlamydia trachomatis, quantification
87800 Infectious agent detection by nucleic acid, multiple organisms; direct probe technique (also used for organisms other than Chlamydia trachomatis)
87801 Infectious agent detection by nucleic acid, multiple organisms; amplified probe technique (also used for organisms other than Chlamydia trachomatis)




Other Information and Resources

CDC Resource




Author(s)

Campbell KP, Lentine D. Sexually transmitted infections (STIs) evidence-statement: screening and counseling. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006.

Acknowledgments

The National Business Group on Health would like to thank the Centers for Disease Control and Prevention's Division of Sexually Transmitted Disease Prevention for their review and update of this statement in December 2009.




References

1 U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2007;147:128-33.
2 Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55(11).
3 Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of Health and Human Services; November 2009.
4 Kohl KS, Markowitz LE, Koumans EH. Developments in the screening for Chlamydia trachomatis: A review. Obstet Gynecol Clin North Am. 2003 Dec;30(4):637-58.
5 Haggerty CL, Ness RB. Epidemiology, pathogenesis and treatment of pelvic inflammatory disease. Expert Rev Anti Infect Ther. 2006 Apr;4(2)235-47.
6 Paavonen J, Westrom L, and Eschenbach D. Pelvic Inflammatory Disease. In Holmes KK, Sparling PF, Stamm WE et al, eds. Sexually Transmitted Diseases. New York: McGraw Hill Medical, 2008. pp 1017-50.
7 Hwang L, Shafer MA. Chlamydia trachomatis infection in adolescents. Adv Pediatr. 2004;51:379-407.
8 Nelson HD, Helfand M. Screening for chlamydial infection. Am J Prev Med. 2001;20:95-107.
9 Mårdh PA. Influence of infection with Chlamydia trachomatis on pregnancy outcome, infant health and life-long sequelae in infected offspring. Best Pract Res Clin Obstet Gynaecol. 2002;16:847-64.
10 Datta SD, Sternberg, M, Johnson, RE et al. Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002. Ann Intern Med. 2007;147:89-96.
11 Chesson HW, Blandford JM, Gift TL, Tao G, Irwin KL. The estimated direct medical cost of sexually transmitted diseases among American youth, 2000. Perspect Sex Reprod Health. 2004; 36(1):11-19.
12 Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health. 2004;36:6-10.
13 Yeh JM, Hook EW, Goldie SJ. A refined estimate of the average lifetime cost of pelvic inflammatory disease. Sex Transm Dis. 2003;30(5):369-78.
14 Blandford JM, Gift TL. Productivity losses attributable to untreated chlamydial infection and associated pelvic inflammatory disease in reproductive-aged women. Sex Transm Dis. Oct 2006;33(10 Suppl):S117-121.
15 Thomson Reuters. 2007 MarketScan® Commercial Claims and Encounters Database. 2009.
16 Center for Medicare and Medicaid Services (CMS). Clinical Laboratory Fee Schedule 2009 [Internet]. CMS, Washington, DC.[modified January, 2009; cited 2009 Mar 17]. Available from: http://www.cms.hhs.gov/ClinicalLabFeeSched/02_clinlab.asp.
17 Hu D, Hook EW, Goldie SJ. Screening for chlamydia trachomatis in women 15 to 29 years of age: A cost-effectiveness analysis. Ann Intern Med. 2004;141(7):501-513.
18 Honey E, Augood C, Templeton A, Russell I, Paavonen J, Mardh P-A, Stary A, Stray-Pedersen B. Cost effectiveness of screening for Chlamydia trachomatis: a review of published studies. Sex Transm Infect. 2002;78:406-412.
19 Meyers D, Halvorson H, Luckhaupt S. Screening for chlamydial infection: A focused evidence update for the U.S.Preventive Services Task Force. Evidence Synthesis No. 48. Rockville, MD: Agency for Healthcare Research and Quality; June 2007. AHRQ Publication No. 07-15101-EF-1. Available at http://www.uspreventiveservicestaskforce.org/uspstf07/chlamydia/chlamydiaup.htm. Accessed July 24, 2011.