Preference among female Army recruits for use of self-administrated vaginal swabs or urine to screen for Chlamydia trachomatis genital infections.

BACKGROUND: Use of self-administered vaginal swabs (SAS) for the detection of Chlamydia trachomatis by nucleic acid amplification tests simplifies specimen collection and transport, especially for women in nonclinical settings. GOAL: We investigated the preference and comfort level of military women for the collection of SAS, compared with urine, for the diagnosis of genital chlamydial infections. STUDY DESIGN: During March through August 1999, female Army recruits in basic training at Fort Jackson, South Carolina, were invited to participate in the study. Participants were requested to complete a questionnaire after providing both first-void urine (FVU) and SAS specimens. Participant characteristics, preferences, and comfort levels were assessed using multivariate logistic regression. RESULTS: From 4496 eligible female recruits, 1403 (31%) completed questionnaires and 1382 provided both specimens; 11.8% (166 of 1403) of participants were infected with chlamydia. The relative sensitivity and specificity of the C. trachomatis Ligase Chain Reaction test on SAS in 1382 matched pairs was 81.1% and 98.6%, respectively, using the test result on urine specimens as the comparison standard. Most of the participants (90.8%) reported that they felt comfortable collecting the FVU specimen, and 69.6% indicated that they felt comfortable collecting SAS. Either specimen collection type received high acceptability at home and in the field, and more women reported that they would collect FVU than reported they would collect SAS in the future (in the field: FVU: 79.4%, SAS: 68.8%, P <0.001); at home: FVU: 90.9%, SAS: 82.9%, P <0.001). When questioned about ease of use, 60.4% of women reported that urine was the easier method. Preferences for SAS were associated with being white and having had sexual risk behaviors in the past 3 months. CONCLUSION: A study of preferences for urine versus self-administered vaginal swabs for the detection of C. trachomatis in military women showed that women generally found SAS acceptable. SAS should be a feasible alternative to urine collection in situations in which specimen storage or transport is an issue.

Features of Chlamydia trachomatis and Neisseria gonorrhoeae infection in male Army recruits.

Non-health care-seeking male United States Army recruits were tested for Chlamydia trachomatis (n=2245) and Neisseria gonorrhoeae (n=884), using a urine ligase chain reaction test to determine prevalence and potential risk factors for infection. The prevalence of chlamydial infection was 5.3%. Black race, a new sex partner, a history of trichomonas, and the presence of symptoms were associated with chlamydial infection. The prevalence of N. gonorrhoeae infection was 0.6%. Only a reported history of or positive test for C. trachomatis was associated with gonorrheal infection. Of those testing positive for chlamydia, 14% reported symptoms versus 40% of those with gonorrhea. Younger age was not a predictor of either infection, as has been shown for women. A substantial number of male army recruits are infected with C. trachomatis, but few are infected with N. gonorrhoeae. Screening on the basis of symptoms alone would miss the majority of both infections.

Predictors of repeat Chlamydia trachomatis infections diagnosed by DNA amplification testing among inner city females.

OBJECTIVE: To describe the epidemiology of prevalent and incident chlamydia infection in order to assess the appropriate interval for chlamydia screening; and to identify risk factors predictive of infection and repeat infections. DESIGN: Prospective longitudinal study of a consecutive sample of 3860 sexually active females aged 12-60 years tested for C. trachomatis by polymerase chain reaction in Baltimore City clinics during 11,904 patient visits over a 33 month period. RESULTS: Chlamydia prevalence, incidence, and frequency to diagnosis of infection varied by age. Among 2073 females < 25 years, chlamydia infection was found in 31.2%. The median times to first and repeat incident infections were 7.0 months and 7.6 months, respectively. Among 1787 females > or = 25 years, chlamydia infection was found in 9.6%. Median times to first and repeat incident infections were 13.8 months and 11.0 months, respectively. Age < 25 years yielded the highest risk of infection. CONCLUSIONS: Since a high burden of chlamydia was found among mostly asymptomatic females < 25 years in a spectrum of clinical settings, we recommend chlamydia screening for all sexually active females < 25 years at least twice yearly.

Point-of-entry screening for C. trachomatis In female army recruits. Who derives the cost savings?

BACKGROUND: Screening women for genital Chlamydia trachomatis at entry to military service provides an opportunity to reduce costs associated with sequelae of this infection. However, financial responsibility for screening may be debated. More than 50% of recruits return to civilian life within 2 years. The military and the civilian health care systems would both benefit from a screening program. OBJECTIVE: To assess the cost-effectiveness and relative cost savings to the military and civilian health sectors of three screening strategies for U.S. Army female recruits for C. trachomatis using urine ligase chain reaction: screening all recruits, screening recruits aged < or = 25 years, and no screening. METHODS: We applied a decision analytic model. Cost factors included screening, lost military training, morbid pelvic inflammatory disease, and other sequelae. Using a 5-year analytic horizon, we conducted analyses from military and civilian perspectives. RESULTS: Screening 10,000 female army recruits would cost 193,500 dollars and prevent 282 cases of sequelae, with a projected savings of 53,325 dollars to the military and 505,053 dollars to the civilian sector. From a military perspective, screening women aged < or = 25 years provided the highest cost savings. Screening all female recruits incurred an incremental cost of $1199 per sequela prevented. From a civilian perspective, screening all recruits offered the greatest cost savings. CONCLUSIONS: Screening female Army recruits for C. trachomatis offers substantial savings in health care costs for both the military and civilian health care systems. Relative financial benefit derived from recruit screening is disproportionate; greatest cost savings are enjoyed by the civilian sector.

The cost-effectiveness of varicella screening and vaccination in U.S. Army recruits.

Varicella outbreaks in the U.S. Army disrupt training, reduce readiness, and represent substantial costs. Vaccination of susceptible individuals may be cost-effective. We conducted a cost-effectiveness analysis comparing screening of all incoming recruits and vaccination of susceptible individuals at either initial entry training (IET) or medical entrance processing station (MEPS), universal vaccination at IET, and no intervention. Primary health outcomes included the number of varicella cases prevented during the 8-week initial training period. The varicella hospitalization rate was 21.6 per 10,000 per year. In 100,000 recruits, 36 cases of varicella are expected at a cost of $181,000 in the absence of an intervention. Screening at IET would prevent 4 cases but would cost an additional $3,255,000 more than no intervention. Screening at MEPS would prevent 3 cases and save $521,000 per case prevented during the IET but would cost $2,734,000 more than no intervention. Universal vaccination would prevent 2 cases but would cost $15,858,000 more than MEPS screening and $18,592,000 more than no intervention. These results are robust. Cost per case of varicella prevented ranged from $390,000 to $7.9 million. Scarce prevention resources could be more cost-effectively allocated to other prevention programs.

Cost-effectiveness analysis of reacquiring and using adenovirus types 4 and 7 vaccines in naval recruits.

Adenovirus vaccines have controlled acute respiratory disease (ARD) in military recruits since 1971. Vaccine production, however, ceased and new facilities are required. We assessed whether reacquiring and using vaccines in naval recruits is cost-effective. Three policy options were evaluated: no vaccination, seasonal vaccination, and year-round vaccination. Morbidity (outpatient and inpatient), illness costs (medical and lost training), and vaccine program costs (start-up, acquisition, and distribution) were modeled using a decision-analytic method. Results were based on a cohort of 49,079 annual trainees, a winter vaccine-preventable ARD rate of 2.6 cases per 100 person-weeks, a summer incidence rate at 10% of the winter rate, a hospitalization rate of 7.6%, and a production facility costing US$12 million. Compared to no vaccination, seasonal vaccination prevented 4,015 cases and saved $2.8 million per year. Year-round vaccination prevented 4,555 cases and saved $2.6 million. Reacquiring and using adenovirus vaccines seasonally or year-round saves money and averts suffering.

Control of Chlamydia trachomatis infections in female army recruits: cost-effective screening and treatment in training cohorts to prevent pelvic inflammatory disease.

CONTEXT: Chlamydia trachomatis genitourinary infections in females can lead to serious and costly sequelae. Programs such as basic (initial entry) military training with controlled points of entry offer an opportunity to screen large cohorts of women at risk for infection. OBJECTIVE: To assess the cost-effectiveness of three interventions for C. trachomatis infections in women beginning Army training: 1) screening using urine ligase chain reaction (LCR) by age, 2) unrestricted testing using urine LCR, and 3) universal antibiotic treatment with azithromycin. DESIGN: Cost-effectiveness analysis from a military perspective. SETTING AND PATIENTS: A hypothetical cohort of 10,000 women who intended to complete at least 2 years of military service was studied. Analysis was based on data from 13,204 female trainees screened for chlamydial infection at Fort Jackson, SC. OUTCOMES: Program and training costs, cost of illness averted, and pelvic inflammatory disease (PID) prevented were determined for a 1-year follow-up period. Using sensitivity analysis, outcomes over 2 years were studied. RESULTS: At a 9.2% prevalence, no screening resulted in $220,900 in training and sequelae costs and 276 cases of PID. Screening by age produced the lowest cost $217,600, over a 1-year period and prevented 222 cases of PID for a cost-savings of $15 per case of PID prevented. Universal testing prevented an additional 11 cases of PID at a cost of $226,400, or costing $800 per additional case of PID prevented over age-targeted screening. Universal treatment prevented an additional 32 cases of PID and cost $221,100, saving $167 per additional cases of PID prevented over universal screening. Over a 2-year period, universal treatment provided the highest cost-savings and prevented the most disease. CONCLUSION: Screening by age provided a cost-savings to the Army over a 1-year period. Other organizations accessing large cohorts of young women could also benefit, even in the short term, from implementation of an age-based chlamydial screening program. Universal testing or universal treatment may be warranted in which long-term societal goals, such as maximum reduction of PID, are relevant.

Cost-effective syphilis screening in military recruit applicants.

A cost-effectiveness analysis of syphilis screening was performed. Strategies included no screening, universal testing at military entrance processing stations, universal testing at basic training centers, and contracting centralized screening. Probabilities derived from data retained on recruit applicants from 1989 through 1991 (N = 1,588,143) and from the published literature were used. Cost estimates were derived from costs incurred by the military and costs projected from implementing new strategies. Sensitivity analyses were performed. Modifying the existing contract for human immunodeficiency virus screening to include syphilis screening would maximize the effectiveness of screening at a cost to the Department of Defense of $9.52 per additional year of service received. The no-screening option was significantly more cost-saving than the current method of testing. Syphilis is rare and treatable, and individuals with syphilis will be identified by other means in many cases. Syphilis screening of recruit applicants at the military entrance processing stations should cease, saving the military $2,541,000 per year.

Chlamydia trachomatis infections in female military recruits.

BACKGROUND: Asymptomatic genital Chlamydia trachomatis infections in women can lead to pelvic inflammatory disease, infertility, and ectopic pregnancy. To design a chlamydia-control program, we conducted a large survey of women in the U.S. military. METHODS: From January 1996 through December 1997, urine samples from 13,204 new female U.S. Army recruits from 50 states were screened by ligase chain reaction for C. trachomatis infection. Information on potential risk factors was obtained by questionnaire. With multivariate analysis, we identified criteria for a screening program. RESULTS: The overall prevalence of chlamydial infection was 9.2 percent, with a peak of 12.2 percent among the 17-year-old recruits. The prevalence was 15 percent or more among the recruits from five southern states. The following risk factors were independently associated with chlamydial infection: having ever had vaginal sex (odds ratio for infection, 5.9), being 25 years of age or less (odds ratio, 3.0), being black (odds ratio, 3.4), having had more than one sex partner in the previous 90 days (odds ratio, 1.4), having had a new partner in the previous 90 days (odds ratio, 1.3), having had a partner in the previous 90 days who did not always use condoms (odds ratio, 1.4), and having ever had a sexually transmitted disease (odds ratio, 1.2). A screening program for subjects 25 years of age or less (87.9 percent of our sample) would have identified 95.3 percent of the infected women. CONCLUSIONS: Among female military recruits, the prevalence of chlamydial infection is high. A control program that screens female recruits who are 25 years old or younger with urine DNA-amplification assays has the potential to reduce infection, transmission, and the sequelae of chlamydial infection.

Incident Chlamydia trachomatis infections among inner-city adolescent females.

CONTEXT: Adolescents are at highest risk for infection with Chlamydia trachomatis, an important preventable cause of pelvic inflammatory disease and subsequent tubal factor infertility in US women. Current guidelines for delivery of adolescent primary care services recommend yearly chlamydia screening for those adolescent females considered to be at risk. OBJECTIVES: To describe the epidemiology of prevalent and incident chlamydia infection among adolescent females to assess the appropriate interval for chlamydia screening and to define risk factors that would identify adolescent females to target for screening. DESIGN: Prospective longitudinal study. PATIENTS: A consecutive sample of 3202 sexually active females 12 through 19 years old making 5360 patient visits over a 33-month period, January 1994 through September 1996. SETTING: Baltimore, Md, family planning, sexually transmitted disease, and school-based clinics. INTERVENTION: Testing for C trachomatis by polymerase chain reaction. MAIN OUTCOME MEASURES: Prevalence and incidence of C trachomatis infections; predictors of positive test result for C trachomatis. RESULTS: Chlamydia infection was found in 771 first visits (24.1%) and 299 repeat visits (13.9%); 933 adolescent females (29.1%) had at least 1 positive test result. Females who were 14 years old had the highest age-specific chlamydia prevalence rate (63 [27.5%] of 229 cases; P=.01). The chlamydia incidence rate was 28.0 cases per 1000 person-months (95% confidence interval, 24.9-31.5 cases). The median time was 7.2 months to a first positive chlamydia test result and 6.3 months to a repeat positive test result among those with repeat visits. Independent predictors of chlamydia infection--reason for clinic visit, clinic type, prior sexually transmitted diseases, multiple or new partners, or inconsistent condom use-failed to identify a subset of adolescent females with the majority of infections. CONCLUSIONS: A high prevalence and incidence of C trachomatis infection were found among adolescent females. We, therefore, recommend screening all sexually active adolescent females for chlamydia infection every 6 months, regardless of symptoms, prior infections, condom use, or multiple partner risks.

Prevention of adenoviral acute respiratory disease in Army recruits: cost-effectiveness of a military vaccination policy.

INTRODUCTION: Since 1971 widespread vaccination has limited the number of adenoviral acute respiratory disease (ARD) outbreaks in Army recruits. Increased vaccine costs have recently threatened the continuation of the vaccination program. METHODS: We conducted a cost-effectiveness analysis to assess the consequences of changing the year-round Army adenovirus vaccination program to (1) seasonally targeted vaccine administration (only during the high-risk period) or (2) complete discontinuation of the program from the perspective of total cost to the Army. Costs included vaccination costs and direct and indirect medical and military training costs. Health outcomes were estimated as the number of hospitalizations for ARD prevented. In the reference case, the incidence rate among unvaccinated and vaccinated individuals was 4.06 and 1.5 per 100 person weeks, respectively. Results are expressed for a cohort of 76,171 recruits. RESULTS: In the absence of adenoviral vaccination, a projected 12,370 cases of ARD hospitalization would occur, costing $26.4 million annually. A seasonally targeted program would prevent 7,800 cases of ARD and save $16.1 million over no vaccination. Year-round immunization would not prevent any additional cases but would save $15.5 million over no vaccination. Year-round vaccination would become the cost-effective strategy if ARD incidence during the low-risk months were to increase. CONCLUSION: Vaccination of Army recruits by any schedule was cost-saving due to the high level of prevented disease and averted hospitalizations. Even though a seasonally targeted program provided the greatest cost-savings, year-round vaccination must remain an option due to the potential for adenoviral ARD outbreaks in the low-risk period.

Use of ligase chain reaction with urine versus cervical culture for detection of Chlamydia trachomatis in an asymptomatic military population of pregnant and nonpregnant females attending Papanicolaou smear clinics.

Ligase chain reaction (LCR) (Abbott Laboratories, Abbott Park, Ill.) with first-catch urine specimens was used to detect Chlamydia trachomatis infections in 465 asymptomatic military women attending clinics for routine Papanicolaou smear tests. Results were compared to results of cervical culture to determine the sensitivity of the urine LCR and the possible presence of inhibitors of amplification in pregnant and nonpregnant women. Discrepant results for LCR and culture were resolved by direct fluorescent antibody staining of culture sediments, two different PCR assays, and LCR for the outer membrane protein 1 gene. The prevalence of Chlamydia in specimens by urine LCR was 7.3% compared to 5% by culture. For 434 women with matching specimens, there were 11 more specimens positive by LCR than were positive by culture, of which all but one were determined to be true positives. There were four culture-positive, LCR-negative specimens, all from nonpregnant women. The sensitivity, specificity, and positive and negative predictive values of urine LCR after discrepant results were resolved were 88.6, 99.7, 96.9, and 99.0%, respectively. The sensitivity of culture was 71.4%. From the 148 pregnant women (prevalence by LCR, 6.8%), there were no patients who were cervical culture positive and urine LCR negative to indicate the presence in pregnant women of inhibitors of LCR. Additionally, a subset of 55 of the LCR-negative frozen urine specimens from pregnant women that had been previously processed in LCR buffer were inoculated with 5 cell culture inclusion forming units of C. trachomatis each and retested by LCR; all tested positive, indicating the absence of inhibitors of LCR in urine from these pregnant women. The use of LCR testing of urine specimens from asymptomatic women, whether pregnant or not, offers a sensitive and easy method to detect C. trachomatis infection in women.

Screening women for chlamydia trachomatis in family planning clinics: the cost-effectiveness of DNA amplification assays.

BACKGROUND: Highly sensitive and specific DNA amplification assays are available for use on cervical and urine specimens. These new tests have the potential to identify more chlamydial infections than the commonly used enzyme immunoassay and DNA probe tests, yet they are more expensive. This study sought to assess the cost effectiveness of cell culture, enzyme immunoassay (EIA), DNA probe (Pace 2), polymerase chain reaction (PCR) of cervical and urine specimens, and ligase chain reaction (LCR) of cervical and urine specimens as screening tools for Chlamydia trachomatis in asymptomatic women younger than 30 years of age attending family planning clinics. STUDY DESIGN: Program costs; medical cost savings of prevented sequelae in women, male sex partners, and infant; and number of prevented cases of pelvic inflammatory disease (PID), neonatal infections, and male sex partner urethritis and epididymitis were modeled in a decision analysis conducted from a health care system perspective. Results are expressed for a cohort of 18,000 women. RESULTS: If no screening for C. trachomatis were conducted in Maryland, 497 cases of PID would develop, costing $2.2 million in future medical costs. Use of EIA to detect chlamydial infection would prevent 240 cases of PID and save $887,000 over no screening. Alternatively, use of DNA amplification assays on urine specimens would prevent up to an additional 66 cases and save $287,100 over EIA. Use of LCR on cervical specimens would prevent at least 13 additional cases of PID over the urine-based assays, but would cost $3,005 for each additional case prevented. In women receiving routine pelvic examinations, LCR of cervical specimens would prevent the most disease and provide the highest cost savings. In women not receiving routine pelvic examinations, use of LCR on cervical specimens would prevent the most disease but would cost approximately $28,000 per additional case of PID prevented over DNA amplification of urine. CONCLUSIONS: Compared with EIA screening, the strategy with the lowest program costs, a screening strategy that combines use of DNA amplification on cervical specimens in women receiving pelvic examinations, and DNA amplification of urine in women with no medical indications necessitating a pelvic examination, prevents the most cases of PID and provides the highest cost savings. With enhanced sensitivity over the other diagnostic assays and with the use of noninvasive specimen collection, DNA amplification assays should be implemented as cost-effective components of a screening program for C. trachomatis.

Pooling urine samples for ligase chain reaction screening for genital Chlamydia trachomatis infection in asymptomatic women.

The accuracy of pooling urine samples for the detection of genital Chlamydia trachomatis infection by ligase chain reaction (LCR) was examined. A model was also developed to determine the number of samples to be pooled for optimal cost savings at various population prevalences. Estimated costs included technician time, laboratory consumables, and assay costs of testing pooled samples and retesting individual specimens from presumptive positive pools. Estimation of population prevalence based on the pooled LCR results was also applied. After individual urine specimens were processed, 568 specimens were pooled by 4 into 142 pools and another 520 specimens were pooled by 10 into 52 pools. For comparison, all 1,088 urine specimens were tested individually. The sample-to-cut-off ratio was lowered from 1.0 to 0.2 for pooled samples, after a pilot study which tested 148 samples pooled by 4 was conducted. The pooling algorithm was 100% (48 of 48) sensitive when samples were pooled by 4 and 98.4% (61 of 62) sensitive when samples were pooled by 10. Although 2.0% (2 of 99) of the negative pools of 4 and 7.1% (1 of 14) of the negative pools of 10 tested presumptive positive, all samples in these presumptive-positive pools were negative when retested individually, making the pooling algorithm 100% specific. In a population with 8% genital C. trachomatis prevalence, pooling by four would reduce costs by 39%. The model demonstrated that with a lower prevalence of 2%, pooling eight samples would reduce costs by 59%. Pooling urine samples for detection of C. trachomatis by LCR is sensitive, specific, and cost saving compared to testing individual samples.

Screening for Chlamydia trachomatis in asymptomatic women attending family planning clinics. A cost-effectiveness analysis of three strategies.

BACKGROUND: Screening women for Chlamydia trachomatis in family planning clinics is associated with a reduced incidence of chlamydial sequelae. However, the question of whom to screen to maintain efficient use of resources remains controversial. OBJECTIVE: To assess the cost-effectiveness of chlamydial screening done according to three sets of criteria in asymptomatic women attending family planning clinics. DESIGN: Cost-effectiveness analysis done by using a decision model with the perspective of a health care system. Model estimates were based on analysis of cohort data, clinic costs, laboratory costs, and published data. SETTING: Two family planning clinics in Baltimore, Maryland. PATIENTS: 7699 asymptomatic women who presented between April 1994 and August 1996. INTERVENTION: Three screening strategies--screening according to the criteria of the Centers for Disease Control and Prevention (CDC), screening all women younger than 30 years of age, and universal screening--were retrospectively applied and compared. All women were tested with polymerase chain reaction. MEASUREMENTS: Medical outcomes included sequelae prevented in women, men, and infants. Total costs included screening program costs and future medical costs of all sequelae. The incremental cost-effectiveness ratios of each strategy were calculated. RESULTS: Without screening, 152 cases of pelvic inflammatory disease would occur at a cost of $676,000. Screening done by using the CDC criteria would prevent 64 cases of pelvic inflammatory disease at a cost savings of $231,000. Screening all women younger than 30 years of age would prevent an additional 21 cases of pelvic inflammatory disease and save $74,000. Universal screening would prevent an additional 6 cases of pelvic inflammatory disease but would cost $19,000 more than age-based screening, or approximately $3000 more per case of pelvic inflammatory disease prevented. If the prevalence of C. trachomatis is more than 10.2% or if less than 88.5% of infections occur in women younger than 30 years of age, universal screening provides the greatest cost savings. CONCLUSIONS: These results suggest that age-based screening provides the greatest cost savings of the three strategies examined. However, universal screening is desirable in some situations. In general, screening done by using any criteria and a highly sensitive diagnostic assay should be part of any chlamydial prevention and control program or health plan.

Molecular amplification assays to detect chlamydial infections in urine specimens from high school female students and to monitor the persistence of chlamydial DNA after therapy.

Polymerase chain reaction (PCR) and ligase chain reaction (LCR) were compared for the diagnosis of Chlamydia trachomatis infections by testing urine specimens from 408 high school female students. After therapy, sequential urine specimens were tested to determine persistence of chlamydial DNA in urine. Baseline PCR of cervical specimens was positive in 53 (13.0%) students, and PCR and LCR of urine specimens were positive in 63 (15.4%) and 60 (14.7%), respectively. After discrepant analysis, 64 (15.7%) patients could be confirmed as truly infected. Follow-up urine specimens from 33 infected patients demonstrated that at 1-3 days after therapy, PCR and LCR were positive for 40% and 73.3%, respectively. Only at 15 days after therapy did all specimens test negative. Urine tests for Chlamydia organisms should not be used as a test of cure within 3 weeks after treatment. Use of urine assays for screening sexually active adolescents has the potential to significantly improve control of chlamydial infections.

Partner notification to prevent pelvic inflammatory disease in women. Cost-effectiveness of two strategies.

BACKGROUND AND OBJECTIVES: Partner notification is an important strategy for prevention of Chlamydia trachomatis infection and pelvic inflammatory disease (PID). PID can be prevented by early diagnosis and treatment of the female sex partners of men infected with C. trachomatis (strategy 1) and by preventing reinfection in women through diagnosis and treatment of their male sex partners (strategy 2). STUDY DESIGN: Using a decision model, the cost-effectiveness of strategies 1 and 2 was compared to no partner notification. Outcomes were measured by cases of PID prevented and net costs expended from a health care system perspective. RESULTS: In a hypothetical cohort of 1,000 male and 1,000 female index patients, strategy 1 prevented 64 and strategy 2 prevented 20 cases of PID. Strategy 1 saved $247,000 and strategy 2 saved $33,000 over no partner notification. Sensitivity analysis showed that strategy 1 was cost-effective across a wide range of assumptions. Strategy 2 was cost-effective at baseline, but its cost-saving ability was subject to changes in the model. CONCLUSION: Partner notification of both male and female index patients is a cost-effective public health strategy for prevention of PID. In most settings, both strategies can and should be implemented.