Original Study
Prevalence of Sexually Transmitted Infections Among Adolescents Entering Child Protective Services

Material from this work was presented as a poster at the Southern Regional Meetings held in New Orleans in February 2014. Abstracts from this meeting were published in the Journal of Investigative Medicine; however, the manuscript in its entirety has not been published.
https://doi.org/10.1016/j.jpag.2014.09.011Get rights and content

Abstract

Study Objective

Persons aged 15-24 years have the highest rates of sexually transmitted infections (STIs). Adolescents in protective services custody may be at even greater risk of acquiring STIs, but little is known about the prevalence of STIs among this population. We therefore set out to assess the prevalence of STIs among adolescents seen in the Harris County Child Protective Services Clinic.

Design

A retrospective chart review from January 2009 to December 2011 was conducted.

Setting and Participants

Patients aged 12-18 years seen for their intake physical examination at the Harris County Child Protective Services Clinic in Houston, Texas.

Main Outcome Measures

Main outcome measures included the number of positive tests for chlamydia, gonorrhea, syphilis, and HIV. Secondary measures included sexual history, use of condoms and contraception, and reports of drug and alcohol use.

Results

Among 437 patients, 60% were female, their mean age was 15 years, and nearly half were African American. There were 27 cases of chlamydia, 12 of gonorrhea, 3 of syphilis, and none of HIV. Three of the teenagers who reported never having sex were positive for an STI. Being female, being older than 15 years, and having had sexual intercourse at least once were significant risk factors.

Conclusion

The prevalence of STIs in adolescents entering foster care was comparable to national averages. Recommending routine screening of all adolescents in this population is important to ensure better detection and treatment.

Introduction

Each year, thousands of children are referred to the Harris County Child Protective Services (CPS) in Houston, Texas.1 In 2011, approximately 16% of these children were between the ages of 10 and 13 years, with an additional 16% being 14-17 years old.1 Many of these adolescents entered protective services because of family conflicts, juvenile delinquent behaviors, and/or physical or sexual abuse. After entering CPS care, some of the youth are placed in emergency shelters, while others end up residing in group or foster homes. Understanding the specific health needs of adolescents presenting to protective services is crucial to provide efficient and appropriate care for this high-risk population. The Centers for Disease Control and Prevention (CDC) has reported that, in the United States, the prevalence of chlamydia was 6.8% among sexually active females aged 14-19 from 1999 to 2008.2 In 2011, the highest rates of gonorrhea were observed among adolescent females, with a reported 556.5 cases per 100,000 among 15- to 19-year-olds.3, 4 Also in 2011, the rate of HIV diagnosis among 13- to 19-year-olds was 11 per 100,000, with adolescents accounting for nearly 1 of every 4 new HIV diagnoses in the United States.5 Last, while rates of syphilis in the United States decreased among females aged 15-19 years to 2.3 cases per 100,000 in 2012, rates increased among males in that age group to 5.8 per 100,000 in that same year.6 In Houston, Harris County, in 2010, 11.26 females and 20.17 males per 100,000 aged 15-19 had syphilis; Harris County consistently ranks among the top 5 counties nationwide for this disease.7

While rates of sexually transmitted infections (STIs) among adolescents nationwide have been well studied, little is known about the prevalence of STIs among adolescents in foster care. Girardet et al found that among sexually victimized children, the prevalence of each STI was less than 10%.8 However, these were children 13 years of age and younger; furthermore, most children with an STI had normal or nonspecific findings on examination. Steele et al examined the medical and mental health of children entering the foster care system in Utah9; while 54% of these children had 1 or more acute or chronic medical condition, STIs were not specifically addressed. A study by Lambert et al described sexual risk factors and STIs of adolescents entering Youth Protection Centres in Quebec, but rates of HIV and syphilis were not determined.10 In 2002, the American Academy of Pediatrics published their recommendations for the health care of children in foster care.11 For STIs, their recommendation is that “laboratory tests should be performed for HIV and other sexually transmitted diseases when indicated clinically or by history (p. 538).” However, without first understanding the prevalence of STIs among this population, deciding who should be tested or not may be difficult, especially given that the physical examination results are likely to be normal. Therefore, we assessed the prevalence of chlamydia, gonorrhea, syphilis, and HIV among adolescents in foster placement entering care at a child protective services clinic.

Section snippets

Methods

We conducted a retrospective review of medical charts from the Harris County Protective Services Clinic in Houston, Texas, from January 2009 to December 2011. According to Harris County CPS data, 576 adolescents aged 12-18 years entered CPS custody during our study period; of these youth, 437 presented to our clinic for their intake physical examination. Two of the authors are primary providers at this clinic and performed more than 90% of the physical examinations.

All adolescents presenting to

Results

We reviewed 437 charts. The mean age (SD) of the patients was 15.0 (1.5) years, and 63% were female (Table 1). Nearly half of the patients were African American and living in a shelter when evaluated. Of the adolescents seen, 422 (97%) were screened for chlamydia and gonorrhea, 191 (44%) were screened for syphilis, and 170 (39%) were screened for HIV. Chlamydia was the most prevalent STI, with gonorrhea being the second most common (Table 1); 6 patients were infected with both. There were 3

Discussion

Chlamydia trachomatis is the most commonly reported sexually transmitted infection among adolescents, and a majority of infected individuals are asymptomatic.12 Current American Academy of Pediatrics recommendations for children in foster care suggest screening adolescents for STIs when clinically indicated by history or symptoms.12 Among our patients, the prevalence of chlamydia and gonorrhea was 6.4% and 2.8%, respectively, which is comparable to the CDC national data. Lambert et al found a

Conclusion

In our study population of adolescents entering foster care, the prevalence of sexually transmitted infections was comparable to national averages. We therefore recommend routine screening of all adolescents in this population for STIs, including HIV, regardless of symptoms or reported history. Routine screening will help to ensure better detection and treatment as well as prevention of complications and transmission to others.

Acknowledgments

We thank Maria Reyes, MD, who initially reviewed a portion of the data. We also appreciate Dr Kim Connelly-Smith for her review of the manuscript.

References (14)

  • CPS in Harris County annual report, 2011 statistics. Available: http://www.hc-ps.org/pdf_files/2012CPSAnnRep.pdf....
  • Centers for Disease Control and Prevention

    CDC grand rounds: chlamydia prevention: challenges and strategies for reducing disease burden and sequelae

    Morb Mortal Wkly Rep

    (2011)
  • Centers for Disease Control and Prevention: Gonorrhea—fact sheet. Sexually transmitted diseases (STDs). Available:...
  • Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention,...
  • Centers for Disease Control and Prevention. HIV surveillance report, 2011. Available:...
  • Centers for Disease Control and Prevention: 2012 Sexually transmitted diseases surveillance: STDs in adolescents and...
  • Bureau of Epidemiology, Houston Department of Health and Human Services: Houston/Harris County STD trends, 2000-2010....
There are more references available in the full text version of this article.

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    A foster care assessment and referral center recently described high rates of screening and low prevalence of infectious diseases such as tuberculosis and HIV (Greiner et al., 2017). A Child Welfare Clinic screening adolescents entering foster care found less than 1% positive for syphilis; almost 5% had chlamydia (Cheung, Montgomery, & Benjamins, 2015). Primary care clinics may be ideal venues for screening children in foster care for infectious diseases, but little is known about practices for screening children entering foster care in a primary care setting.

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Preparation of this manuscript was partially supported by an NIH K12-5KL2RR024149-05 (Dr. Benjamins); No external funding was secured for this study. The authors indicate no conflicts of interest.

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