Chlamydia. trachomatis infection is among the sexually transmitted infections which are known to increase the risk for human immunodeficiency virus (HIV) infection (CDC, 2007). As such, treating this infection is likely to delay the spread of HIV in some high risk groups (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). Its prevalence among this age group is thought to be due to the anatomical differences in the cervixes of younger women, where there is often exposure and evertion of the squamocolumnar junction, which acts as the primary host target for C. trachomatis, in a condition known as ectopy (Black, 1997).
Older women, also tend to be highly susceptible to Chlamydia infection, especially women of black decent with poor socioeconomic background, older women who are not married and who have never had children (Black, 1997). Other groups who are also highly susceptible to this infection, includes people who have had high numbers of sexual partners, those engaging in unprotected sex, and others with 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 major challenge with controlling Chlamydia infection is that almost three quarters of women and half of men are unaware they have been infected (CDC,2007). This is typically due to the general absence of symptoms, as when symptoms are present it is usually after one to three weeks of exposure (CDC, 2007). As a result, this causes a large pool of unrecognized individuals capable of passing on the infection to subsequent sexual partners (Black, 1997). Adding to this challenge is the fact that immunity following infection is type specific, and hence can only provide partial protection, as such recurrent infections are common (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 retrospective study conducted among adolescent girls infected with C. trachomatis, 54% of subjects under the age of fifteen at initial infection and 30% of those between fifteen and nineteen suffered recurrent infections (Black, 1997). A subsequent study found that 38% of the same subjects reported a recurrent infection within 3 years (Black, 1997). There is evidence which indicates that the risk of infertility or ectopic pregnancy increases with repeated episodes of the infection (Gaydos, 2004).
The incidence of Chlamydia urethritis among bisexual and homosexual men is about one-third of that reported in heterosexual men (CDC, 2007). In genitourinary clinic populations, between 4 and 8% of homosexuals were found to suffer from asymptomatic rectal Chlamydia infection (Black, 1997). When symptoms are present, men and women who suffer from rectal infection as a result of receptive anal intercourse may have rectal discharge and pain during defecation (Black, 1997). Chlamydia infection rarely causes sterility in men but when it travels to the epididymis it may cause fever and pain (CDC, 2007). In expectant mothers, reports show that C. trachomatis infection is ten times as likely to cause stillbirth, neonatal death and considerably shorter Gestation age (Black, 2007).
Screening, Detection and treatment
Chlamydia qualifies for World Health Organization’s criteria for screening, The United Kingdom and other countries mandate that a national screening programme 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, facilitated, and supported the establishment of local Chlamydia screening programmes (NCSP, 2010).
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).
The traditional approach to laboratory diagnostic testing for C. trachomatis infections consisted of cell culture of inoculants prepared from urogenital specimens (Black, 1997). in the 1980s, antigen and nucleic acid detection technologies were developed that have found widespread application in diagnosis because they cost less, require less expertise, take less time to obtain results, and preserve infectivity during transport (Black, 1997). Nucleic acid amplification tests (NAAT) have been recently developed for diagnosing Chlamydia trachomatis infection of the genitals. Not only are the NAAT’s more sensitive than any previous test, but they are also 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). The application of these tests has brought to light the fact that culture is not as sensitive and that the prevalence of C. trachomatis infection is higher in most populations than was previously known (Black, 1997).
In women, the most common anatomic site used to obtain specimens for the isolation of C. trachomatis is the endocervix, which is sampled with a swab or cytologic brush (Black, 1997). This swab is typically inserted past the squamocolumnar junction, about 1 to 2 cm deep, rotated for 15 to 30 seconds, and removed without touching the vaginal mucosa. The preferred site of sample collection from males is the anterior urethra (Black, 1997, CDC, 2007). In this test, a dry swab is placed 3 to 4 cm into the urethra and rotated prior to removal. The individual being tested should not pass urine for an hour before the test, because urination can wash away the infected columnar cells and reduce the sensitivity of diagnostic testing (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 to typical methods of testing for Chlamydia 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 study’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
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, individual’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 STI’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.
Conclusion
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.
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