September 29, 2021, 8:58 a.m. Michael Devitt — On Sept. 14, the U.S. Preventive Services Task Force posted a final recommendation statement, final evidence review and evidence summary on screening for chlamydia and gonorrhea.
Based on its review of the available evidence, the task force recommended screening for chlamydia and gonorrhea in all sexually active women, including pregnant people, if they are 24 years or younger or if they are 25 years or older and at increased risk for infection. These are “B” recommendations, and apply to sexually active adolescents and adults, including those who are pregnant, who do not have signs or symptoms of either infection.
At the same time, the task force concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men, resulting in an “I” statement for these patients.
“Chlamydia and gonorrhea are two of the most common sexually transmitted infections in the United States and can cause serious health problems if not treated,” said task force member Martha Kubik, Ph.D., R.N., in a press release. “Screening all sexually active women age 24 and younger, and those who are older and at increased risk, identifies infections so people can get the care they need to stay healthy.”
According to the CDC, chlamydia and gonorrhea are the most common and second most common STIs in the United States. In 2019, the last year for which data are available, more than 1.8 million cases of chlamydia and 616,000 cases of gonorrhea were reported to the agency, with most cases occurring in adolescents and young adults ages 15 to 24. While these infections often are asymptomatic, if left untreated they can cause a variety of negative health outcomes, such as infertility, chronic pelvic pain, urethritis and epididymitis.
Aside from some slight changes in wording, the final recommendation is in accordance with the task force’s September 2014 recommendation statement on the topic, which it replaces.
Whereas the 2014 statement recommended screening for chlamydia and gonorrhea in sexually active women age 24 and younger, it also recommended screening for these infections “in older women who are at increased risk for infection.” The new final recommendation clarifies the age at which screening for women at increased risk for infection should begin.
The AAFP supported the 2014 recommendation.
To update the existing recommendation, the task force commissioned a systematic review to evaluate the benefits and harms of screening for chlamydia and gonorrhea in all sexually active adolescents and adults. The review included a search of studies published between January 2014 and May 2020, with additional surveillance conducted through May 21, 2021. Twenty studies met the researchers’ inclusion criteria, including seven that were carried forward from the prior evidence review.
The task force found convincing evidence that clinicians could identify sexually active women at increased risk for chlamydial and gonococcal infections, but only adequate evidence that clinicians could identify sexually active men at increased risk for the same infections.
The USPSTF also found convincing evidence that available screening tests can accurately diagnose chlamydial and gonococcal infections in both men and women. In particular, nucleic acid amplification tests were found to have high sensitivity and specificity for detecting these infections using specimens obtained from various anatomical sites and different collection methods.
Compared with no screening, the task force concluded that screening for chlamydial and gonococcal infections was associated with reduced risk of pelvic inflammatory disease. In addition, a review of several large cohort studies of screening at the first prenatal visit in pregnant women at increased risk for infection found that compared with no treatment or treatment failure, treatment of chlamydial infection was associated with significantly lower rates of preterm delivery, early rupture of membranes and infants with low birth weight.
In terms of conducting future studies, the task force stated that research on the effectiveness of screening for gonorrhea is lacking in all population groups, as is screening for chlamydia in men, pregnant individuals and women without risk factors. As such, the task force cited a need for research to determine the effectiveness of screening for chlamydia and gonorrhea in men, optimal screening intervals and the adverse effects of screening.
“While the evidence is clear for young women and older women at increased risk, there is not enough evidence to determine whether or not screening men reduces their risk of complications or spreading infections to others,” explained task force vice chair Michael Barry, M.D. “We need more research to understand the benefits and harms of screening men for chlamydia and gonorrhea.”
Shannon Connolly, M.D., of Los Angeles, a member of the Academy’s Commission on Health of the Public and Science, and co-author of an AAFP practice manual on screening for STIs, told AAFP News that the recommendation statement provides a clear directive to FPs to continue screening for chlamydia and gonorrhea.
“We must simply do a better job of screening to identify and treat patients with asymptomatic infections,” Connolly said. “As doctors who provide whole-person care with a commitment to preventive medicine, family physicians are uniquely situated to offer and promote this screening during routine encounters with patients.”
Connolly explained that because many patients may not know they have an infection, effective screening and treatment are crucial.
“STI screening is critically important, because asymptomatic transmission is very common and is a major driver of increasing rates of chlamydia, gonorrhea, syphilis and other STIs,” said Connolly. “We are seeing tragic sequelae of these infections in the form of ectopic pregnancy, pelvic inflammatory disease and neonatal infections. We're also seeing an increase in multi-drug resistant organisms and treatment failures, which has prompted the CDC to update their treatment guidelines this year as well.”
The effect of the COVID-19 pandemic on STI screening also must be taken into consideration, and Connolly said that family physicians can make a difference by identifying and treating patients who have infections but are asymptomatic, as well as by working to make screening more accessible.
“As we all know, many people fell behind on their routine health maintenance during the pandemic, and we are just beginning to see the consequences of missed and deferred screening in a variety of areas,” Connolly said. “The incidence of sexually transmitted diseases had already been increasing for the decade prior to the pandemic, and I fear that this trend will continue unless we make a concerted effort to identify and treat patients with asymptomatic infections. Population-based screening is the solution, and family doctors can play a role by championing evidence-based screening measures and eliminating barriers to screening for their patients.”
A draft version of the recommendation statement was posted for public comment on the USPSTF website from March 2-29, 2021.
Several commenters expressed concern that the task force found insufficient evidence to screen men and did not provide separate recommendations for specific high-risk populations. In response, the task force stated that it did not find enough evidence to support that screening for chlamydia and gonorrhea in men improved health outcomes by reducing infection complications, disease transmission or disease acquisition. However, the task force did call for more research on screening in a number of patient populations, including men who have sex with men, members of the LGBTQ+ community, and racial and ethnic minorities, in the Research Needs and Gaps section of the recommendation statement. In addition, the task force clarified to whom the recommendation applies regarding sex and gender in the Practice Considerations section.
A number of commenters requested a recommendation for universal screening, rather than risk-based screening, for women 25 years older. The task force found, based on available disease prevalence data and the accuracy of risk assessment tools, that younger age was a strong predictor of disease risk and included clarifying language in the Practice Considerations section.
Finally, the task force received a number of comments asking for clarification on screening intervals. In response, the task force noted that given the lack of available evidence on optimal screening frequency, it provided a reasonable approach for rescreening in the Practice Considerations section.
In addition to the final recommendation statement, the task force posted links to several resources on its website. These include:
The AAFP’s Commission on Health of the Public and Science plans to review the task force’s final recommendation statement, final evidence summary and evidence review, and will then determine the Academy’s stance on the recommendation, up to and including a revision of the Academy’s current recommendation.
Once the review is completed, members can visit the clinical preventive services recommendations section of the AAFP website for the latest recommendations.