A pair of new studies analyze screening for the sexually transmitted infections (STIs) gonorrhea and chlamydia in youth visiting pediatric emergency departments (EDs), with one suggesting that targeted or universal screening is better at detecting infection than usual care, and the other revealing racial differences in screening among males.
Need to integrate screening in emergency care
For the first study, published today in JAMA Pediatrics, University of Cincinnati-led researchers compared gonorrhea and chlamydia detections using targeted or universal screening with those of symptomatically driven testing in patients aged 15 to 21 years over 20 months at six US pediatric EDs.
"Adolescents account for almost half of the 2.5 million diagnosed sexually transmitted infections in the US annually, and the emergency department functions as the primary source of health care for many adolescents," the study authors wrote. "No recommendations exist for emergency department gonorrhea and chlamydia screening."
Adolescents who underwent screening made up 7.6% of 98,413 ED visits from January 2021 to September 2022. The average patient age was 17.0 years, and 57.9% were female.
Patients completed an online sexual health survey. During the universally offered screening intervention, gonorrhea and chlamydia screening was offered to all participants, and clinical decision support (CDS) for testing was based on the patient’s willingness to undergo testing (survey results were not available to clinicians).
Multicenter studies to assess this method with improved rates of uptake are needed to determine whether this will remain true when a larger proportion of patients participate in the screening.
During the targeted-screening intervention, a validated risk score derived from the survey based on patient-reported behavior was integrated into the electronic health record to provide CDS for gonorrhea and chlamydia testing. The usual-care phase took place before the survey was integrated into ED care.
Of all ED visits, 19% took place during the usual-care phase, 42% during the targeted-screening phase, and 39% during the universally offered screening phase.
In the usual-care phase, 1,432 patients (19.1%) had testing ordered, compared with 3,216 (42.9%) in the targeted-screening phase and 2,856 (38%) during universal screening. Compared with usual care, population-level gonorrhea and chlamydia detection rates were higher during targeted screening (adjusted difference in infections detected per 1,000 patient visits, 2.59) and universally offered screening (adjusted difference, 1.81).
"The findings indicate that developing processes to integrate broad-scale gonorrhea and chlamydia screening in emergency departments may be warranted," the researchers concluded. "Multicenter studies to assess this method with improved rates of uptake are needed to determine whether this will remain true when a larger proportion of patients participate in the screening."
Black males more likely to be screened, tested
Last week in Pediatrics, Children's National Hospital researchers in Washington, DC, conducted a cross-sectional analysis of gonorrhea and chlamydia screening during ED visits by males ages 13 to 21 years at two urban pediatric hospital campuses from January 2021 to February 2023.
"Racial differences in Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) testing and screening are well documented among adolescent females; however, data on adolescent males are limited," the investigators wrote.
Among 17,244 ED visits, 3.7% included CT/GC testing or screening. Of the 473 (2.7%) visits by symptomatic males, 39.5% included CT/GC testing. Testing rates were higher during visits by Black males than during those of their White peers (50.0% vs 11.8%; adjusted odds ratio [aOR], 3.3).
Of the 16,771 visits by males with non-STI–related reasons for visiting the ED, 456 (2.7%) included CT/GC screening. Screening rates were higher among visits by Black males compared with non-Hispanic white males (3.5% vs 0.8%; aOR 3.1).
"There were low rates of CT/GC testing overall; however, visits by non-Hispanic Black adolescent males were more likely to include both testing and screening compared with non-Hispanic white males," the study authors wrote. "More research is needed to determine possible cause [sic] of this racial difference and to identify strategies to mitigate potential racial differences in CT/GC testing in the ED."
Racialized perceptions of Black teens
In a commentary in the same journal on the second study, Daniela Brissett, MD; Angela Ellison, MD; and Nadia Dowshen, MD, of Children's Hospital of Pittsburgh, said the findings highlight an urgent need to shift from regarding risk as an individual choice to understanding that it originates in structural conditions such as poverty, racial and gender discrimination, lack of access to confidential healthcare, and community disinvestment.
This finding signals missed opportunities for early diagnosis, timely treatment, and prevention of ongoing transmission, not only for individual patients but also for adolescent public health more broadly.
"Racialized perceptions of Black adolescents as more sexually active reflect broader forms of adultification bias, in which Black youth are seen as older, less innocent, and more accountable for behaviors than their white counterparts," they wrote.
Brissett and her colleagues also noted that roughly 60% of symptomatic adolescents weren't tested.
"This finding signals missed opportunities for early diagnosis, timely treatment, and prevention of ongoing transmission, not only for individual patients but also for adolescent public health more broadly," they wrote. "Without universal, guideline-driven protocols, clinical decision-making may default to subjective assessments of perceived risk, shaped by both implicit bias and structural racism."
