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Community Collaboration to Enhance STD Testing at Juvenile Assessment Center in Pinellas County
JoAnne Lamb
Surveillance and Hepatitis Programs Manager
JoAnne.Lamb@flhealth.gov
727-568-8194
St. Petersburg
Florida
33701
Your summary must address all the questions below:
Description of LHD: Pinellas County has a population of approximately 970,637 residents as of 2017, with 52% female and 82.7% White, 11.1% Black, and 9.7% Hispanic [1]. Situated on 608 square miles, only 274 of which are land, Pinellas County is the most densely populated county in Florida, with a density of 3,292/sq mi [2]. While Pinellas County residents aged 65 and older represent 24.2% of the population [3], the county still has a substantial adolescent population, with approximately 91,000 residents between the ages of 10-19 years old [4]. The Florida Department of Health in Pinellas County (DOH-Pinellas) is one of 67 County Health Departments operating under the Florida Department of Health (DOH). DOH-Pinellas serves Pinellas County with more than 600 employees in six health department locations throughout the county. DOH-Pinellas is divided into six divisions that provide a wide range of public health services including infectious disease control, health promotion, chronic disease prevention, environmental health monitoring, disaster preparedness and response, as well as personal health services, including home visiting and clinic services.
Public health issue: Many residents, particularly adolescents between the ages of 13 to 17 years old, do not get tested for STDs. Reasons for not being tested vary, but asymptomatic infections and a lack of knowledge on STDs can impact individuals’ decision to pursue testing [5-8]. STD testing gaps are a major public health issue, especially among those who are incarcerated in juvenile detention centers, as they have shown an overall high rate of STDs compared to the general population [8]. In Pinellas County, the Juvenile Detention Center provided STD testing to all adolescents detained for longer than 24 hours as part of a routine health assessment. However, those who are detained for less than 24 hours (referred to as “nonincarcerated juveniles”) were not offered this testing and missed the opportunity to learn their chlamydia and gonorrhea status and receive treatment.
Goal: The goals of the Pinellas Juvenile Assessment Center (PJAC) STD program were to implement proactive STD testing in a high-risk juvenile population and to identify and treat both asymptomatic and symptomatic clients with chlamydia and gonorrhea infections to prevent further spread of STDs in the county.
Objectives: The objectives were to 1) work with community partners to implement a coordinated STD testing program for the nonincarcerated juvenile population of Pinellas County; 2) perform ongoing gonorrhea and chlamydia testing for consenting nonincarcerated juveniles prior to their release from PJAC; 3) to refer those testing positive to treatment; and 4) longitudinally analyze epidemiologic risk factors and geographic case distribution for future, targeted interventions.
Implementation: In June 2017, the DOH-Pinellas partnered with Operation PAR, and PJAC to initiate testing for chlamydia and gonorrhea in all consenting nonincarcerated juveniles aged 13 to 17 years old. Organization-specific roles were designated in a formal written agreement and STD education was provided. Laboratory testing was completed at the DOH, Bureau of Public Health Laboratories (BPHL). The DOH-Pinellas STD Program and Surveillance Program designed a tracking log and employed surveillance strategies to analyze results and infection trends.
Results: All specified objectives were met. A coordinated PJAC STD testing program was successfully implemented by collaborating partners. Testing was offered between July 2017 and October 2018 to 1,709 nonincarcerated juveniles and of those, 1,053 consented to testing. All juveniles with a positive gonorrhea and chlamydia result were referred to treatment by a Disease Intervention Specialist. Monthly surveillance reports have and continue to inform stakeholders of longitudinal trends in testing and case distribution.
Public health impact: By forming a collaborative partnership between DOH-Pinellas, PJAC, and Operation PAR, active and ongoing STD testing and treatment for nonincarcerated juveniles in Pinellas County has increased. By incorporating a tracking system into the program, DOH-Pinellas is building on the current understanding of STD trends in the juvenile population, thus expanding our capacity for targeted, empirically-based interventions.
Website for LHD: The official website for the Pinellas DOH is http://pinellas.floridahealth.gov/.
References
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO’s Toolbox etc.)
Is the current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)
Target population and public health issue: The target population for the PJAC STD testing program are adolescents between the ages of 13 to 17 years old entering the Pinellas juvenile justice system who are detained for less than 24 hours. STDs disproportionately affect incarcerated individuals compared to the general population. Specifically, adolescent offenders who enter juvenile assessment centers have a higher prevalence of gonorrhea and chlamydia compared to the same age cohort in the general population [1]. Given this information, failure to test individuals in the initial stage of arrest is a missed opportunity to test a substantial segment of this high-risk group. Furthermore, asymptomatic infections comprise the vast majority of gonococcal and chlamydial infections, with one study of 12 juvenile detention centers demonstrating an absence of symptoms in 97% and 93% of male infections for chlamydia and gonorrhea, respectively [2]. If left untreated, both infections can lead to further health complications in males and females such as pelvic inflammatory disease, infertility, or increased risk of acquiring HIV [3,4]. As such, most individuals infected with chlamydia or gonorrhea are unaware of their need for treatment without testing.
What has been done in the past: With the exception of routine case finding and general educational outreaches, DOH-Pinellas was not able to enact active surveillance for this population previously. The Juvenile Detention Center in Pinellas County provides STD testing to all adolescents detained for longer than 24 hours as part of a routine health assessment. However, those who are detained for less than 24 hours are not offered this testing and miss the opportunity to learn their chlamydia and gonorrhea status. Studies demonstrate that most adolescents entering the justice system are not held for more than a day and, as a result, would miss the opportunity to receive a health screening [5].
Why the current practice is better: As a high-risk subset of the adolescent population for acquiring STDs, targeted interventions to test and treat nonincarcerated juveniles are an important public health approach in Pinellas County. The current practice is an improvement upon the previous system because 1) a large portion of adolescents entering the juvenile justice system that were previously missed to STD testing are now captured and referred to treatment; 2) longitudinal tracking of monthly tests conducted, number of cases found, epidemiologic risk factors in cases 13 to 15 years of age, and geographic trends in case distribution provide ongoing surveillance and trend analysis that will facilitate future targeted interventions; and 3) proactive testing ensures asymptomatic infections are identified. An additional strength to this practice is the leveraging of existing testing structures built by community partners (PJAC and Operation PAR) and building on these practices with a collaborative approach. The resulting practice minimizes resource allocation and maximizes the public health return.
Innovation: While other health departments may have implemented a comparable practice, our program is an initiative inspired by our own analysis of STD trends observed within our county. Our enactment of PJAC STD testing for nonincarcerated juveniles is a creative approach that goes beyond the purview of our STD program’s daily operations and employs a proactive process to case finding. In addition, our approach furthers knowledge on the epidemiologic risk factors (demographic and behavioral) that increase this subpopulation’s risk for acquiring gonorrhea and chlamydia with longitudinal surveillance. Lastly, our collaboration with community partners already conducting STD testing strategically utilizes infrastructure that minimizes start-up and in-kind resource expenditure.
Evidence-based: The CDC formally recommends testing all sexually active women under 25 years of age for chlamydia and gonorrhea and informally recommends testing young men for chlamydia in high-prevalence settings [6,7]. The juvenile incarcerate population is a high-risk group for STDs [1]. Thus, testing this target population can help reduce occurrences and spread of STD in Pinellas County.
References
1. Kahn RH, Mosure DJ, Blank S, Kent CK, Chow JM, Boudov MR, Brock J, Tulloch S. Chlamydia trachomatic and Neisseria gonorrhoeae prevalence and coinfection in adolescents entering selected US juvenile detention centers, 1997-2002. Sex Transm Dis. 2005;32(4):255-259. doi: 10.1097/01.olq.0000158496.00315.04.
2. Mertz KJ, Voigt RA, Hutchins K, Levine WC. Findings from STD screening of adolescents and adults entering corrections facilities: implications for STD control strategies. Sex Transm Dis. 2002;29(12):834-839.
3. CDC Gonorrhea Fact Sheet (Detailed Version) (September 26, 2017): https://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea-detailed.htm
4. CDC Chlamydia Fact Sheet (Oct 4, 2017): https://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm
5. Belenko S, Dembo R, Rollie M, Childs K, Salvatore C. Detecting, preventing, and treating sexually transmitted diseases among adolescent arrestees: an unmet public health need. Am J Public Health. 2009;99(6):1032-41.
6. CDC Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources. 2015. https://www.cdc.gov/std/tg2015/screening-recommendations.htm
7. American Academy of Pediatrics (all women under 25) (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/adolescent-sexual-health/Pages/STI-Screening-Guidelines.aspx). Webpage: https://www.aafp.org/afp/2008/0315/p819.html. Accessed on November 2018.
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broadbased involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
Goals: The main goal was to increase STD testing in high-risk incarcerated juveniles and identify and treat both asymptomatic and symptomatic clients with chlamydia and gonorrhea infections to prevent further spread.
Objectives: The objectives were to 1) work with community partners to increase active surveillance of gonorrhea and chlamydia in the Juvenile Detention Center population; 2) test consenting adolescent prior to their release; 3) to refer all those testing positive to treatment; and 4) longitudinally monitor and analyze epidemiologic risk factors and geographic case distribution for targeted future interventions.
Implement: In order to test nonincarcerated juveniles who are released from PJAC within 24 hours of entering, DOH-Pinellas implemented the following steps: 1) DOH-Pinellas provided training and overview information about STDs to PJAC staff, 2) DOH-Pinellas provided FDA-approved Aptima Urine Test kits, collection bags, and supplies needed for specimen collection to PJAC, 3) Operation PAR collected specimens from all nonincarcerated juveniles for mandatory drug testing, 4) for those who consented to STD testing, specimens were split for STD testing by a certified practitioner at Operation PAR laboratories, 5) Operation PAR prepared specimens to be picked up by DOH-Pinellas weekly on Mondays and Wednesdays, 6) DOH-Pinellas STD staff sent specimens to BPHL for testing, 7) DOH-Pinellas STD staff entered client information into the Health Management Service (HMS) database, and 8) DOH-Pinellas STD staff followed up on positive results to ensure treatment. Testing and treatment were provided at no-cost by DOH-Pinellas. Results were reviewed monthly by Surveillance staff to identify trends.
Selection criteria: In accordance with Florida statute 384.30 all nonincarcerated juveniles aged 13 to 17 who enter PJAC are eligible for gonorrhea and chlamydia testing without parental consent, and those infected between the ages of 13 and 15 are to be interviewed by a DOH-Pinellas Disease Intervention Specialist. Thus, all nonincarcerated juveniles entering PJAC and not proceeding to detention for more than 24 hours who are 13 to 17 years old were offered STD testing; all gonorrhea and chlamydia cases 13 to 15 years old were also interviewed.
Timeframe: The PJAC STD program started in July 2017. Specimens have been collected twice a week for a total of 1,053 individuals as of October 2018. This is an ongoing program designed to continue indefinitely.
Stakeholders involved: The primary organizational stakeholders are DOH-Pinellas, specifically the STD and Surveillance programs, and PJAC. DOH-Pinellas maintains a vested interest in improving the health of the Pinellas County residents. PJAC upholds the mission to coordinate adolescents with services to improve quality of life, including early delinquency intervention, referral and linkage, and follow-up services, among others. Operation PAR and BPHL contribute as invested partners by performing laboratory services and technical assistance.
Cost: DOH-Pinellas maintains a budget for STD testing services in the community outside of regular clinic operations. By using a portion of this budget for PJAC testing and utilizing the state laboratory for specimen processing services, this project does not require additional resources or funds.
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
Practice objectives: The objectives of the PJAC STD program were to implement an STD testing program in a facility that was missing a significant segment of its population through existing STD testing practices, to coordinate follow-up care and treatment for those testing positive, and to longitudinally monitor and analyze trends to inform targeted future interventions. To achieve these objectives, DOH-Pinellas, PJAC, and Operation PAR coordinated proactive testing of adolescents detained for less than 24 hours.
Results: All specified objectives for the PJAC STD program have been met. Operation PAR, PJAC and DOH-Pinellas successfully coordinated a collaborative approach to gonorrhea and chlamydia surveillance. To date, 1,709 tests have been offered and 1,053 individuals have been tested through PJAC from August 2017 to October 2018. Seventy specimens tested positive for either gonorrhea or chlamydia (4.1% prevalence of infection).
Year to date, the PJAC STD program has tested 62% of the eligible nonincarcerated adolescents (monthly range: 46%, 78%). Follow-up contact on those who tested positive has been an ongoing response by the STD Program of DOH-Pinellas, including treatment, education, and, for those 13 to 15 years of age, contact investigations and interviews. Since the program’s implementation, surveillance has been ongoing as the DOH-Pinellas surveillance analyst assesses longitudinal trends that build upon current understanding of risk factors and epidemiological trends in the juvenile population.
Evaluation: Evaluation of the PJAC STD program is continuous and ongoing. The program’s process measure of interest is the number of tests offered and performed monthly, and the approximate 10% increase in average monthly tests performed from 2017 and 2018 indicate program growth (62 tests/month, 2017; 68.1 tests/month, 2018). Tests performed are also compared to number of declinations each month. Reasons for declinations aside from reported sexual inactivity are unknown; however, will be evaluated in the 2-year program evaluation report, with the goal of decreasing declinations by 5% in the third evaluation year.
Data sources: Data on testing offered and specimens approved for testing are collected from the PJAC STD program director. BPHL provides specimen testing data, positive results, and specimens unable to be processed.
Performance measures: The outcome measure of interest is the monthly number of tests offered and conducted (those consenting), which have been 1,709 tests offered and 1,053 tests conducted for nonincarcerated juveniles who would not otherwise be tested since the program began in July 2017. The proportion of declinations each month is also an outcome measure we are closely monitoring.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)
Lessons learned overall: Public health interventions can maximize efficacy and scope in a population by having an empirically-based rationale and design. As such, a thorough understanding of disease etiology, epidemiologic trends, and existing knowledge of risk factors positions health departments to design effective and advantageous programs. Specifically, understanding the high prevalence of asymptomatic infections among gonorrhea and chlamydia cases strengthens the relevance of targeted testing. Together, research-driven approaches to public health interventions maximize the benefit derived from the energy expelled. Lessons learned from the PJAC STD program include a stronger understanding of gonorrhea and chlamydia infections among the nonincarcerated juvenile population of Pinellas County and the proportion consenting to testing.
Lessons learned (partner collaboration): Fostering collaborations among agencies and stakeholders is important to assess and target public health issues. It is essential to explore current public health practices conducted by community partners and contribute to existing structures to maximize public health benefit and resource allocation. To effectively engage with these existing structures, local health departments will benefit from a long-term strategy in building strong community partnerships. Specific to STDs in adolescents, jurisdictions looking to expand STD testing services to adolescents will benefit from building relationships with schools, local justice system authorities, and other community-specific partners that may have a stake in adolescent health. Through this partnership, DOH-Pinellas efficiently implemented a multi-faceted approach to adolescent STD detection and intervention, ensured proper management and handoff of specimens and data, and built on existing epidemiologic knowledge of STDs in a high-risk population.
Sustainability plans: Through a collaborative approach to continued STD testing and ongoing surveillance, DOH-Pinellas has created a sustainable program. DOH-Pinellas is raising awareness and disseminating education on how to prevent future infections, thus mitigating STD spread in the broader population through case follow up and education. Given the high estimated cost of the STD burden in American youth [1], the viability and importance of early STD detection cannot be overstated. The PJAC STD program is, therefore, offering valuable and long-term prevention and intervention resources to a high-risk population, ensuring an upstream strategy to decrease STD prevalence in Pinellas County.
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