Sexually Transmitted Infection Diagnoses at Children’s Hospitals During COVID-19

Abstract

OBJECTIVES

COVID-19 mitigation strategies resulted in changes in health care access and utilization, which could negatively impact adolescents at risk for sexually transmitted infections (STIs). We evaluated changes in STI diagnoses during adolescent visits at children’s hospitals during COVID-19.

METHODS

We conducted a retrospective cohort study using the Pediatric Health Information System database comparing adolescent (11–18 years) hospital visits with an STI diagnosis by International Classification of Diseases, 10th revision, code during COVID-19 (2020) to pre-COVID-19 (2017–2019). Data were divided into spring (March 15–May 31), summer (June 1–August 31), and fall (September 1–December 31). Median weekly visits and patient characteristics were compared using median regression.

RESULTS

Of 2 747 135 adolescent encounters, there were 10 941 encounters with an STI diagnosis from 44 children’s hospitals in 2020. There was a decrease in overall median weekly visits for STIs in spring during COVID-19 (n = –18.6%, P = .001) and an increase in overall visits in summer (11%, P = .002) during COVID-19. There were significant increases in inpatient median weekly visits for STIs in summer (30%, P = .001) and fall (27%, P = .003) during COVID-19. We found increases in Neisseria gonorrhoeae (50%, P < .001) and other STI diagnoses (defined as other or unspecified STI by International Classification of Diseases, 10th revision, code; 38%, P = .040) in fall COVID-19 (2020), and a decrease in pelvic inflammatory disease (–28%, P = .032) in spring COVID-19 (2020).

CONCLUSIONS

We found increases in median weekly adolescent inpatient visits with an STI diagnosis in summer and fall COVID-19 (2020). These findings were likely partially driven by changes in behaviors or health care access. Further work is needed to improve STI care and thus potentially improve related health outcomes.

The COVID-19 pandemic led to decreased health care access in the United States because of avoidance and closure of health care settings, increasing unemployment, and loss of health insurance.^1,2 Experts warned of negative implications on sexual and reproductive health (SRH) and SRH care access for adolescents during COVID-19,³ including potential increases in sexually transmitted infections (STIs). At baseline, nearly 1 in 4 adolescent and young adult females test positive for an STI annually.^4–6 Many adolescents at highest risk for STIs have limited access to health care because of barriers including cost, transportation, and confidentiality concerns.^7–12 Even before COVID-19, more than one third of adolescents reported no primary care provider and relied on nontraditional settings such as the emergency department (ED) and inpatient (IP) settings for health care.^10,13,14 Efforts to maintain health care services during COVID-19 (eg, telehealth visits) may not meet adolescents’ need for confidential STI testing and treatment.^3,15,16 A study in the primary care setting during COVID-19 showed increased gonorrhea and Chlamydia diagnoses despite decreased STI testing.^3,17–19 National data were limited regarding changes in STI diagnoses among adolescents in the hospital setting (ie, ED, IP) during COVID-19. Our study objective was to assess changes in hospital adolescent visits with an STI diagnosis at children’s hospitals during COVID-19 compared with before COVID-19.

Methods

Design and Data Source

We conducted a retrospective cohort study of adolescents (age 11–18 years) with a hospital visit (IP or ED) using the Pediatric Health Information System (PHIS; Children’s Hospital Association, Lenexa, Kansas) database. This age range was chosen based on established definitions of adolescents.²⁰ PHIS contains up to 41 International Classification of Diseases, 10th Revision (ICD-10), diagnoses and procedure codes on discharges from 49 children’s hospitals across the United States.²¹ The 44 hospitals that contributed complete data throughout the study period were included.

Study Period Definitions

Because of different mitigation strategies over time during COVID-19 and seasonal variations in SRH behaviors,²² we defined our study periods during COVID-19 as spring 2020 (March 15–May 31, 2020), summer 2020 (June 1–August 31, 2020), and fall 2020 (September 1, 2020–December 31, 2020). We defined our comparison periods similarly as spring pre–COVID-19 (March 15–May 31, 2017–2019), summer pre–COVID-19 (June 1–August 31, 2017–2019), and fall pre–COVID-19 (September 1, 2020–December 31, 2017–2019).

Outcome Measures and Covariates

The primary outcome was the median number and interquartile range of adolescent visits with a diagnosis (primary or secondary based on ICD-10 codes [Supplemental Table 4]) of an STI during COVID-19 (in 2020) compared with pre–COVID-19. Given changes in health care utilization during COVID-19 that impacted overall visits, we chose to compare percent change in median weekly adolescent visits to ensure consistent comparison using median regression. We also used median regression on subpopulations, including those with an underlying mental health disorder because mental health and/or substance use disorders are independently associated with high-risk sexual behaviors (eg, unprotected intercourse).^6,23 We assessed racial/ethnic outcome differences because previous literature demonstrates varied STI diagnoses by race/ethnicity.^24,25 All models were adjusted for the following covariates: age, sex, clinical setting (ED/IP), payer type, median household income quartile, disposition, and hospital census region.

Statistical Analysis

We summarized the percent change in median number of visits and interquartile range by categorical characteristics and compared between the 2 study periods (eg, spring pre–COVID-19 [March 15–May 31, 2017–2019] versus spring COVID-19 [March 15–May 31, 2020]) using median regression, based on methods similar to a recent study.²⁶ P values < .05 were considered statistically significant. The institutional review board deemed this nonhuman subject research.

Results

There was a total of 2 747 135 adolescent visits during the study periods (pre- and during COVID-19 [2020]) from 44 hospitals, of which 10 941 visits resulted in an STI diagnosis (Table 1). Overall, the majority (54.5%) of STI diagnoses were the primary diagnosis. By clinical setting, an STI was the primary diagnosis for 36% (n = 161) of IP visits (n = 4069) and 66% (n = 4536) of ED visits (n = 6872). For visits with an STI as a secondary diagnosis, the most common primary diagnoses were urinary tract infection (n = 304; 6%), sepsis (n = 108; 2%), tubulo-interstitial nephritis (n = 108; 2%), acute vaginitis (n = 98; 2%), and unspecified abdominal pain (n = 93; 2%).

TABLE 1.

Demographics of Adolescent Visits at Pediatric Hospitals With an STI Diagnosis

Characteristic	Hospital STI Visits, N (%)
Visits, N	10 941
Age, y, N (col%)
11–13	686 (6.3)
14–15	2381 (21.8)
16–18	7874 (72)
Sex, N (col%)
Male	1409 (12.9)
Female	9527 (87.1)
Race, N (col%)
Non-Hispanic white	2358 (21.6)
Non-Hispanic Black	6260 (57.2)
Hispanic	1726 (15.8)
Asian	88 (0.8)
Other	509 (4.7)
Insurance type, N (col%)
Government	7821 (71.5)
Private	1985 (18.1)
Other	1135 (10.4)
Visit type, N (col%)
Inpatient	4069 (37.2)
Emergency department	6872 (62.8)
Diagnosis position, N (col%)
Primary	5965 (54.5)
Secondary	4976 (45.5)
Census region, N (col%)
Midwest	4099 (37.5)
Northeast	1254 (11.5)
South	4121 (37.7)
West	1467 (13.4)
STI type, N (col%)
Chlamydia trachomatis	3076 (28.1)
HIV	299 (2.7)
Neisseria gonorrhoeae	1092 (10)
Other	1528 (14)
Pelvic inflammatory disease	4264 (39)
Syphilis	150 (1.4)
Trichomonas	532 (4.9)

STI, sexually transmitted infection.

Compared with pre–COVID-19, there was a decrease in median weekly adolescent visits with an STI in spring of 2020 (COVID-19) overall (–18.6%; 95% confidence interval [CI], –29.7 to –7.6%; P = .001) and in the ED (–26.7%; 95% CI, –38.8 to –14.5; P < .001). Table 2 demonstrates median weekly volume changes in adolescent visits with an STI by setting.

TABLE 2.

Percent Change in Median Weekly Adolescent Visits to Children’s Hospitals for an STI Diagnosis by Diagnosis and Clinical Setting

	Spring COVID: March 15 - May 31, 2020		Summer COVID: Jun 1 - Aug 31, 2020		Fall COVID: Sep 1 - Dec 31, 2020
	Percent Change in Median Weekly Visits (95% CI)	P	Percent Change in Median Weekly Visits (95% CI)	P	Percent Change in Median Weekly Visits (95% CI)	P
STI (all encounters)	–18.6 (–29.7 to –7.6)	.001	10.9 (4.2–17.7)	.002	12.8 (–2.6 to 28.2)	.101
Emergency department	–26.7 (–38.8 to –14.5)	<.001	0 (–13.2 to 13.2)	1.000	7.5 (–4.8 to 19.8)	.227
Inpatient	0 (–25.1 to 25.1)	1.000	30.4 (12.5–48.4)	.001	27.3 (9.6–44.9)	.003

Bold type indicates statistically significant (P < .05). Median weekly visits were calculated and compared using median regression. CI, confidence interval; STI, sexually transmitted infection.

Compared with pre–COVID-19, there was a 30.4% (95% CI, 12.5–48.4) increase in median IP weekly visits overall with an STI diagnosis in summer of 2020 (COVID-19; Table 2, Fig 1). Characteristics associated with increased median weekly STI visits in summer 2020 (COVID-19) compared with pre–COVID-19 included female sex (P = .040) and being aged 14 to 15 years (P = .047).

FIGURE 1.

This figure demonstrates the overall median weekly volume of adolescent hospital visits for STIs delineated by spring COVID-19 (March 15–May 31, 2020), summer COVID-19 (June 1–August 31), and fall COVID-19 (September 1–December 31, 2020). There was an increase in the median weekly hospital visits in summer 2020 during COVID-19 for an STI (summer: 11%, P = .002) compared with pre–COVID-19. STI, sexually transmitted infection.

There were increased visits in fall 2020 during COVID-19 (27.3%; 95% CI, 9.6–44.9; P = .003). Characteristics associated with increased visits in the fall COVID-19 period compared with pre–COVID-19 included being aged 16 to 18 years (P = .014), non-Hispanic Black race/ethnicity (P = .005), having a secondary mental health diagnosis (P = .002), and having governmental insurance (P = .007).

By specific STI diagnosis (Supplemental Table 4), there were increases during COVID-19 in Neisseria gonorrhoeae (50.0%; 95% CI, 28.1–71.9; P < .001; Supplemental Table 3) and other STI diagnoses (37.5%; 95% CI, 1.7–73.3; P = .040) in fall 2020 and a decrease in PID (–28.0%; 95% CI, –53.5 to –2.5; P = .032) in spring 2020.

Discussion

In this retrospective cohort study, we found a decrease in median weekly adolescent hospital visits during all periods in 2020 (COVID-19), yet an increase in the median weekly adolescent visits for an STI diagnosis in summer and fall COVID-19 of 2020, specifically in the inpatient setting. Additionally, there were increased visits noted in the fall for N. gonorrhoeae. Recent studies have shown decreased STI testing and increased STI diagnoses in various clinical settings during COVID-19 periods of 2020.^17,27 Our findings may be partially driven by changes in health care utilization (eg, loss of primary care access and school-based sexual education)^28–30 and increased reliance on nontraditional settings for SRH care, including hospital-based care. Additionally, there may have been changes in health care provider behavior (ie, increased SRH screening and empirical treatment) in hospital settings because of decreased health care access related to COVID-19, particularly in those with underlying mental and behavioral health conditions.^30,31–33 These changes may also partially explain the decrease in STI visits noted in the early pandemic (spring), followed by a subsequent rebound effect during summer and fall 2020. Further study is warranted to better understand underlying risks among subpopulations and drivers that can then inform efforts to improve equitable SRH access and outcomes for adolescents.

Because of use of administrative data, potential limitations include data incompleteness, limited precision, and possible misclassification bias. Based on similar previous literature using the PHIS database, we relied on diagnosis codes (rather than clinical or laboratory information) to categorize our outcome measures, which may result in underestimation.^34,35 Our findings may be partially driven by fluctuations in hospital visits for nonurgent diagnoses. Declines in overall patient volumes are similar to those noted in recent literature.^36,37 The PHIS database only includes information from pediatric hospitals limiting generalizability to outpatient and community hospital settings.

Given our findings and recent literature on SRH care for adolescents during COVID-19, efforts are needed to optimize SRH care and offset risk for increased STIs as the pandemic evolves and to prepare for future pandemics. To optimize STI testing and treatment, innovative efforts are needed, including virtual and in-person outreach, to increase adolescent access to SRH education and care. Screening adolescents for SRH needs, including STI prevention, testing, and treatment, at every clinical encounter, including hospital visits, is even more critical during COVID-19. These efforts are instrumental to reduce the risk for STIs among adolescents cared for in the hospital with the potential to improve related health outcomes in adolescents during COVID-19 and in future health care crises.