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.46  Many adolescents at highest risk for STIs have limited access to health care because of barriers including cost, transportation, and confidentiality concerns.712  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.3,1719  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.

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.

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).

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.

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.

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%).

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.

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).

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.

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)2830  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.30,3133  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.

Drs Masonbrink, Abella, Hall, and Goyal conceptualized and designed the study, critically reviewed the study data and conducted data analyses, drafted sections of the initial manuscript, and reviewed and revised the manuscript; Drs Gooding and Burger participated in study design, critically reviewed the study data, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of this study.

FUNDING: Research reported in this publication was in part supported by the National Institute On Drug Abuse of the National Institutes of Health under award K23DA055736 (principal investigator A.R.M.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

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Supplementary data