Surveys of Undiagnosed STIs Bias due to Missing Biospecimens
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Surveys of Undiagnosed Surveys of Undiagnosed STIsSTIs
Bias due to Missing BiospecimensBias due to Missing Biospecimens
Charles Turner & Susan RogersCharles Turner & Susan Rogers
forfor
MSPP Research TeamMSPP Research Team
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DisclosuresDisclosures
Neither author has personal financial relationships with commercial interests relevant to this presentation
Dr. Rogers is employed by and Dr. Turner is a consultant to the Research Triangle Institute (RTI).
RTI is a non-profit research organization that conducts surveys and other research for federal, state, and commercial clients.
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Research SupportResearch Support
NIH grant R01-HD047163 from the National Institute of Child Health and Human Development
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Monitoring STIs in the Monitoring STIs in the PopulationPopulation
Research TeamResearch Team
Susan Rogers, PI, Research Triangle InstituteSusan Rogers, PI, Research Triangle InstituteCharles Turner, Co-PI, CUNYCharles Turner, Co-PI, CUNYBill Miller, UNC School of MedicineBill Miller, UNC School of MedicineEmily Erbelding, JHU School of MedicineEmily Erbelding, JHU School of MedicineMarcia Hobbs, UNC School of MedicineMarcia Hobbs, UNC School of MedicineElizabeth Eggleston, Research Triangle Institute Elizabeth Eggleston, Research Triangle Institute Anthony Roman, University of MassachusettsAnthony Roman, University of MassachusettsSylvia Tan, Research Triangle InstituteSylvia Tan, Research Triangle InstituteJames Chromy, Research Triangle InstituteJames Chromy, Research Triangle Institute
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Monitoring Monitoring Undiagnosed STIs in Undiagnosed STIs in
PopulationsPopulations
A New Paradigm for STI EpidemiologyA New Paradigm for STI Epidemiology
Focus simultaneously onFocus simultaneously on– diagnosed infections reported to DoHdiagnosed infections reported to DoH– undiagnosed infections prevalent in undiagnosed infections prevalent in
populationpopulation
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OLD PARADIGMOLD PARADIGMTrack Diagnosed STIsTrack Diagnosed STIs
0
10
20
30
40
50
60
70
80
90
2005 2006 2007 2008
Diagnosed
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NEW PARADIGMNEW PARADIGMTrack Both Diagnosed & Track Both Diagnosed &
Undiagnosed STIsUndiagnosed STIs
0
10
20
30
40
50
60
70
80
90
2005 2006 2007 2008
DiagnosedUndiagnosed
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NEW PARADIGMNEW PARADIGMTrack Diagnosed & Track Diagnosed & Undiagnosed STIsUndiagnosed STIs
0
20
40
60
80
100
120
140
2005 2006 2007 2008
DiagnosedUndiagnosed
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1998 Baltimore STD 1998 Baltimore STD and Behavior Surveyand Behavior Survey
In-person survey with biospecimens; Adults 18-35
79% biospecimen acceptance
7.9% prevalence of undiagnosed GC and/or CT; 15% among black females
Source: Turner, Rogers et al., JAMA, Feb. 13, 2002
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1998 Baltimore STD 1998 Baltimore STD and Behavior Surveyand Behavior Survey
More Undiagnosed Infections than Annual Diagnosed Infections reported to DOH
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MSPP Survey Program, MSPP Survey Program, 2006-20092006-2009 Adolescents and Adults in
Baltimore
Ages 15 to 35
Full probability sample
Fall 2006 thru Summer 2009
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Survey ExecutionSurvey Execution
73,318 Telephone Numbers dialed
20,435 Households Identified
14,199 Households Screened
4,998 Eligible Respondents Identified
2,936 (59%) of Eligibles Interviewed
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MeasurementsMeasurements
T-ACASI interviews on sexual behaviors and STI history
Biospecimens: Urine and Vaginal Swabs
NAAT testing for Chlamydia, Gonorrhea, and Trichomonas
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BiospecimensBiospecimens
Biospecimens requested from All Survey Respondents
Mail-out and Mail-Back kits via US Postal Service
Monetary Incentive, $40 to $100
NAAT assays for Ct, GC, Tv
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Biospecimen Biospecimen AcceptanceAcceptance
2,936 did 13-Minute Survey Interview
2,522 (86%) agreed to biospecimen
2,120 (72%) biospecimens received
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Biospecimen Biospecimen NonResponseNonResponse 414 completed interview but
refused request for biospecimen
402 agreed but did not supply biospecimen despite repeated requests
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Performance Improved Performance Improved with Experiencewith Experience
% supplying biospecimens% supplying biospecimens(linear p < 0.05)(linear p < 0.05)
60
65
70
75
80
Y-1 Y-2 Y-3
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Equivalent Acceptance by Equivalent Acceptance by Gender, Race, Marital Gender, Race, Marital
StatusStatus% supplying biospecimens% supplying biospecimens
(all p > 0.40)(all p > 0.40)
0
10
20
30
40
50
60
70
80
Male vs.Female
Black vs.NonBlack
Marry, NvrMarry, D-W-S
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Equivalent Acceptance Equivalent Acceptance Across Age Groups Across Age Groups
(p > 0.50)(p > 0.50)
0
10
20
30
40
50
60
70
80
15-17 18-25 26-34
AGE
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Varied Slightly for Varied Slightly for Hispanics and by EducationHispanics and by Education
(HISP: p = 0.08; EDUC p = 0.02) (HISP: p = 0.08; EDUC p = 0.02)
01020
30405060
7080
Hispanic vs.Non_Hispanic
<HS, HSG, Some Coll,Coll+
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Modest Variation by Modest Variation by Number of Sex Partners in Number of Sex Partners in
Past YearPast Year(Categorical: p = 0.09; Linear p > 0.50) (Categorical: p = 0.09; Linear p > 0.50)
0
10
20
30
40
50
60
70
80
0 1 2 3 4 5-10 11+
Number of Partners, 12 mo.
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Equivalent Testing for Equivalent Testing for Respondents with Same-Respondents with Same-
Gender Sex History Gender Sex History (Male: p > 0.50; Female: p > 0.50) (Male: p > 0.50; Female: p > 0.50)
SGSSGSNo No
0
10
20
30
40
50
60
70
80
MEN WOMEN
Ever Had Same-Gender Sex
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More Likely to Test when More Likely to Test when “Don’t Know” if Partner “Don’t Know” if Partner
diagnosed with STI in past diagnosed with STI in past YearYear(p = 0.03)(p = 0.03)
0
10
20
30
40
50
60
70
80
No Don't Know Yes
Partner Diagnosed with STI, 12 mo.
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Less Likely to Test if had a Less Likely to Test if had a New Partner in Past New Partner in Past
Month !! Month !! (p = 0.01, last month vs. longer)(p = 0.01, last month vs. longer)
01020
30405060
7080
PastMonth
1-3Months
3-12Months
1+ Years
New Partner Recency
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More Likely to Test if Ever More Likely to Test if Ever Had Trichomonas but not Had Trichomonas but not
GC or CT GC or CT p = 0.37 (GC), 0.57 (CT), 0.02 (TV)p = 0.37 (GC), 0.57 (CT), 0.02 (TV)
0
10
20
30
40
50
60
70
80
GC CT TV
NoYes
Any Lifetime Infection
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LessLess Likely to Test if Had Likely to Test if Had GC in Past Year GC in Past Year
p = 0.01 (GC), > 0.50 (CT), 0.35 (TV)p = 0.01 (GC), > 0.50 (CT), 0.35 (TV)
0
10
20
30
40
50
60
70
80
GC CT TV
NoYes
Infection in Last Year
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Impact of Missing Impact of Missing BiospecimensBiospecimensJoint Impact of:
Difference in characteristics of persons who do and do not provide biospecimens; and
Association of infection likelihood with those characteristics
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Synthetic EstimatesSynthetic Estimates
2,120 biospecimens
787 imputations with full socio-demographics, sexual behaviors, STD history, and symptoms
16 imputations from socio-demographics & reduced sex and STI indicators
13 cases imputed from socio-demographics only
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Estimate of Undiagnosed Estimate of Undiagnosed Trichomonas vaginalisTrichomonas vaginalis
From Biospecimens
7.6%
Biospecimens plus Imputations
7.3%
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Estimate of Undiagnosed Estimate of Undiagnosed ChlamydiaChlamydia and/or and/or
TrichomonasTrichomonas From Biospecimens
10.6%
Biospecimens plus Imputations
10.2%
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CONCLUSIONCONCLUSION
Feasible
Important
New Paradigm for STI Epidemiology