Chlamydia trachomatis is a common sexually transmitted infection (STI), and the most commonly diagnosed STI in genitourinary medicine (GUM) in the United Kingdom (Adams et al, 2004). The bacteria that comprises of this infection can be transmitted through vaginal, anal or oral contact, as well as from mother to child (CDC, 2007). Nearly 65% of babies born to mothers infected with Chlamydia also become infected during vaginal delivery (Black, 1997). It is due to this level of communicability that 50 million new cases of C. trachomatis infection are diagnosed annually worldwide (Black, 1997).
Chlamydia. trachomatis infection is among the sexually transmitted infections which are known to increase the risk for human immunodeficiency virus (HIV) infection (CDC, 2007). Hence, the spread of HIV is likely to delay in some high risk groups once this infection is treated (Black, 1997). Anybody who is sexually active is at risk of contracting Chlamydia, however, it is highly prevalent among woman under 25 years of age, reaching almost 30% according to some studies (Gaydos et al, 2004). It is prevalent among this age group due to the anatomical differences in the cervixes of younger women (Black, 1997).
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Older women can also be susceptible to Chlamydia infection, especially women of black decent with poor socioeconomic background, who have no children and not married (Black, 1997). Others with high susceptibility rate to the infection are people with high numbers of sexual partners, engaged in unprotected sex, and suffer concomitant gonococcal infection (Black, 1997). Some oral contraceptives maybe linked with cervical Chlamydia, however they do not cause pelvic inflammatory disease (PID), as this is thought to be a result of induced ectopy (Black, 1997, CDC, 2007).
The biggest issue with controlling Chlamydia infection is that almost 75% of women and 50% of men are unaware they have the infection, due to the asymptomatic nature of the disease, however symptoms can be present after one to three weeks of exposure (CDC, 2007). This can result, in a huge pool of individuals capable of passing on the infection to their sexual partners (Black, 1997).
Signs and symptoms of Chlamydia
Chlamydia may cause discharges, back pain, bleeding in between periods and burning sensation whiles urinating (CDC, 2007). The bacteria infect the urinary tract and the cervix, before travelling to the fallopian tubes. Infection in the cervix can also spread to the rectum. When Chlamydia goes untreated, 40% of those infected will develop pelvic inflammatory disease (PID), a condition which can cause permanent damage to the uterus and fallopian tubes (Gaydos, 2004). Such damage can lead to infertility, chronic pelvic pain and ectopic pregnancies (CDC, 2007). In pregnancy this damage can lead to premature birth, neonatal conjunctivitis and pneumonia in the infected babies. Other symptoms include cervicitis, urethritis, and endometritis, swelling of the Bartholin glands, post coital bleeding and dysuria (Black, 1997).
In a study conducted among girls infected with C. trachomatis, found 54% of girls under the age fifteen had initial infection and 30% had suffered recurrent infection between fifteen and nineteen years of age (Black, 1997). Subsequently 38% reported suffering recurrent infection after 3 years (Black, 1997). Also evidence indicates a risk of infertility and an increase in ectopic pregnancy with repeated episodes of Chlamydia (Gaydos, 2004).
Chlamydia urethritis is also prevalent among bisexual and homosexual men (CDC, 2007). Some genitourinary clinic reports a 4 and 8% increase of asymptomatic rectal Chlamydia infection among homosexual men leading to rectal discharges and discomfort whiles defecating (Black, 1997). In men the infection rarely leads to sterility, however when it infects the epididymis it may result in fever and pain (CDC, 2007). C. trachomatis infection in expectant mothers is ten times as likely to cause stillbirth, infant death and shorter Gestation age (Black, 2007).
Screening, Detection and treatment
Chlamydia qualifies for World Health Organizationâ€™s criteria for screening, The United Kingdom and other countries requires a national screening programme to be in place to offer opportunistic screening to detect Chlamydia in selected healthcare settings (Adam et al, 2004). The National Chlamydia Screening Programme (NCSP) was set up by the Department of Health in 2003, as a sexual health programme which is part of the National Health Service (NCSP, 2010). The aim of the NCSP is to ensure that all sexually active young people under age 25 are aware of Chlamydia and its effects, and have access to free and confidential testing, prevention, treatment and partner services, all designed to reduce their risk of infection or transmission (NCSP, 2010). However since 2005, The Health Protection Agency (HPA) has coordinated and supported the establishment of local Chlamydia screening programmes (NCSP, 2010).
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Because this infection can easily be treated with antibiotics, detection and treatment of individuals infected with Chlamydia is a key aspect of any control program (Gaydos et al, 2004). Data shows that Chlamydia infection among young women between the ages of 16 to 24 is very high, with over two thirds of Chlamydia infections among women in 2005 within this age group (Adam et al, 2004). The NCSP (2010), reports that in the UK one in fourteen tested young persons under the age twenty-five have Chlamydia. It is hence recommended that any sexually active adolescents and females under age twenty-five be screened for C. trachomatis infection every year (Gaydos et al, 2004).
Ideally, all women with symptoms or clinical signs would be tested for C. trachomatis infection and treated, as should their sexual partners (Black, 1997). Presumptive treatment of women with mucopurulent cervicitis or other clinical signs is a reasonable approach based on the increased prevalence of C. trachomatis infection in women, but this decision should be supported by findings or estimates of prevalence by local screening programs (Black, 1997, CDC 2010).
Nucleic acid amplification tests (NAAT) have been recently developed for diagnosing Chlamydia trachomatis infection of the genitals replacing the tradition nucleic acid diagnostic testing. NAAT is more sensitive and extremely specific (Schachter et al, 2003). Low prevalence populations can be screened using these test and will provide results with high predictive value. Studies have shown that NAATs can be used to test first-catch urines (FCUs) from symptomatic and asymptomatic men (Schachter et al, 2003), The sensitivity obtained is similar to cervical swabs, which results in detection of Chlamydia bacteria in the urethra and vaginal secretions that enter the urine specimen during collection (Schachter et al, 2003).
Specimens collected in a non-invasive manner used for the diagnosis of Chlamydia infections in both men and women allows Chlamydia infection control for true population-based prevalence surveys and sophisticated screening approaches (Schachter et al, 2003). Been able to diagnose asymptomatic infections is imperative for control of bacterial sexually transmitted diseases, particularly for C. trachomatis, which is often asymptomatic (Schachter et al, 2003). These tests have brought to light the high prevalence of C. trachomatis infection among the populations than previously known (Black, 1997).
In women, specimens are obtained from the endocervix for the isolation of C. trachomatis using a swab or cytologic brush, where as men sample is collected from the anterior urethra (Black, 1997). Passing urine an hour before the test can wash the infected columnar cells away, hence reducing sensitivity of the sample (Black, 1997).
A more specific and sensitive test is the Nucleic acid amplification tests for screening Chlamydia, but they are often unaffordable for some clinics (Mahilium-Tapay et al, 2007). It takes a week or two for the results to be produced, though this does not exclude immediate initiation of treatment and partner notification (Mahilium-Tapay et al, 2007). An alternative method of testing is the rapid test (CRT), which has not yet been approved for medical use (Mahilium-Tapay et al, 2007). This could be a useful way of screening for Chlamydia A test with the characteristics of the Chlamydia Rapid Test could be a useful way of screening for Chlamydia as it is non-invasive and results are immediate and could attract more young women to come forward for the test it approved (Mahilium-Tapay et al, 2007).
Mahilium-Tapay et al (2007) assessed the performance of the CRT as a possible Chlamydia screening tool. They used a non invasive procedure, using urine specimens and vulva vaginal swabs to screen 1349 women between the ages of 16-54. These researchers reported that the Rapid Test kits were appropriate to be used in diagnosing infections because they offered a good sensitivity and specificity. It showed 83.5% and 86.7% sensitivity and predictive value respectively among the studyâ€™s participants. These researchers also found that the load of Chlamydia trachomonas in vaginal swabs was higher than that found in the urine samples. Their participants reported that they preferred the self collecting vaginal swabs to urine as they did not have to wait two hours after voiding to void again so the doctors could collect a sample. The self-collecting vagina swab was the preferred method for the rapid test kits (Mahilium-Tapay et al, 2007).
The CRT has a thirty minute turnaround time which permits treatment while the individual is still at the clinic (Mahilium-Tapay et al 2007). Given that nearly 3% of women detected with Chlamydia go on to develop PID in the space of testing positive and their return for treatment, the use of the Chlamydia Rapid Test is crucial for prompt diagnosis and treatment (Mahilium-Tapay et al 2007). Testing and treating the individual can help to prevent Chlamydia spreading too quickly. Tracing of contacts should also be started immediately, to aid in treatment of other sexual partners (Mahilium-Tapay et al 2007).
Attitudes and perceptions that can affect the uptake of screening for Chlamydia
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The manner in which a Chlamydia screening service is organised and delivered can affect its success (Low et al, 2009). In the UK, the opportunistic approach for screening is what is been used, where practitioners offer the test to individuals who are part of the target population, who uses the health service or the sexual health clinics for other reasons (Low et al, 2009). As a result high risk individuals who do not attend the clinic do not get screened whiles those at low risk are repeatedly screened (Low et al, 2009).
Pavlin et al (2006), suggest that to control the spread of Chlamydia, it is crucial to
Understand the reasons why people choose to or not to undertake Chlamydia screening. They relate this to an existing psychological theory, the Theory of Planned Behaviour (TPB) (Pavlin et al, 2006).
According to the TPB, individualâ€™s behaviour is affected by Attitude; this can be explained based on the kind and amount of information possessed by the individual about Chlamydia infection and screening (Pavlin et al, 2006, Adjzen, 1991). Hence, by creating awareness about Chlamydia, Women who are mostly infected, are more likely to accept screening for Chlamydia if they know about the seriousness of the condition and the long term effect of infertility, how widespread it is, and if they are aware that it can be asymptomatic. This is likely to make them see the importance and understand the testing process (Pavlin et al, 2006). Whether the person prefers the behaviour and sees it as a Subjective Norms (Adjzen, 1991), where in this case it becomes important to give individuals especially women some control over the screening process.
This is one good strategy adopted in the UK where individuals can order their testing kits online, take their own specimen and post them. This makes it possible for the individual to opt for the screening and still remain anonymous. It is important to make options available when it comes to screening; this gives the individual some sense of control. Options such as self testing urine, self-administered swabs, outreach health professionals and mobile health vans can be very useful (Pavlin et al, 2006). Also if the people see society as in favour of the behaviour, and to exercise Behavioural Control (Adjzen, 1991), in this case it is up to the society to make Chlamydia screening be seen as a responsible behaviour and also removing the stigma associated with Chlamydia screening (Pavlin et al, 2004). The level to which the person feels able to ratify the behaviour (Adjzen, 1991); this is by making people aware that the infection is treatable and testing positive is not the end, but rather there is more support and treatment is free.
Prevention and control.
Chlamydia is best prevented by abstinence from vaginal, anal, or oral sex. If this is not possible then the best sexual relationship is one with a single partner who tests negative for Chlamydia (Schoenstadt, 2006). The use of condoms for any kind of sex can also reduce the risk of Chlamydia transmission (Schoenstadt, 2006). Latex condoms have been proven through studies to provide an impermeable barrier for particles of Chlamydia and other STIâ€™s (CDC, 2010). As such, the consistent and correct use of condoms can reduce the risk of contracting and transmitting Chlamydia (CDC, 2010). It is also important for healthcare practitioners to educate clients that, birth control methods including pills, injectables, implants and diaphragms do not protect against Chlamydia. Individuals who use any of these methods should be advised to also use a latex condom (or dental dam for oral sex) correctly when they have sex (CDC, 2007). Genitourinary clinics and other health facilities will have to provide a friendly environment for individuals and their partners to talk to doctors and nurses for more information and where to seek help (Schoenstadt, 2006).
Health promotion campaigns should focus particularly on the youth and aim to educate young people about Chlamydia, its complications, provide screening advice and counselling, and also promote responsible and healthful behaviour (CCDR, 1997)
Surveillance, clinical services behavioural intervention and partner management have been used to prevent and control some sexually transmitted infections (Barrow et al, 2008) and these methods can be used to keep the rising incidence of Chlamydia under control too.
Surveillance, partner services, and behaviour intervention as a way of reducing incidence.
Surveillance involves monitoring the prevalence of Chlamydia and its complications, related sexual behaviours, anti-bacterial resistance, screening, and the coverage and quality of healthcare of patients with this infection. Surveillance is an efficient method for tackling the burden of Chlamydia (Barrow et al 2008). The indispensable mechanism for effective clinical prevention and control services involve the routine screening of individuals who are asymptomatic and at risk. The prompt diagnosis and accurate treatment for individuals who are infected with, or have been exposed to Chlamydia can aid in preventing complications (Barrow et al, 2008, Hawkes, 2003).
The provision of effective clinical services can interrupt Chlamydia transmission, through prompt screening and treatment of this infection and its sequelae. However, acceptability of care, access to care, suitability of care and affordability are key challenges that can impact even the most effective clinical service-based prevention and control (Barrow et al, 2008).
Partner services generally require identifying, interviewing and counselling the sex partners of patients to facilitate their access to care. This often causes a drop in the transmission rate and the ability of patients to avoid harmful outcomes (Barrow et al, 2008). Challenges can arise when asymptomatic individuals refuse and impede the successful execution of partner services as a valuable public health tool (Hawkes et al, 2003). However, if presented in a culturally-responsive way that complements community customs by presenting a comprehensive approach to case management, this approach can be a helpful tool for controlling the rate of Chlamydia infection (Pavlin et al, 2006).
The aim of behaviour intervention is to help individuals in reducing their risk of acquiring and passing Chlamydia on to others. This can be achieved through promotion of condom use or through the reduction of sexual partners (Barrow et al, 2008). In order for these interventions to aid in the reduction of Chlamydia rates, it is important that they are culturally competent, engage the interest of the public, and address cultural and social restrictions on behaviour (Pavlin et al, 2006). These strategies have been described in this paper separately, but these will typically function collaboratively in practice.
Chlamydia is a major public health problem owing to its asymptomatic nature, and its detrimental sequale. Traditional methods of prevention such as abstinence and condom use are both effective ways of reducing the risk of transmission. Surveillance, clinical services, behavioural intervention, and partner management are also important in controlling Chlamydia. Health promotion among young people, through awareness and information regarding treatment options are also a step in the right direction. Chlamydia screening can aid in detection of asymptomatic infection, prevent PID and prevent the infertility that can result from infection.