Chlamydia: A quiet epidemic  

 

Jeannie Johnson-Brooks RN

 

 

Introduction

 

 

Chlamydia is a very common sexually transmitted disease (STD) in sexually active adolescents and young adults. This illness is caused by a bacterium called Chlamydia trachomatis. Chlamydia is an intracellular organism (it grows only within cells). This organism usually affects the cervix and the fallopian tubes of the female and the urethra (opening of the penis that urine and semen passes through) in males (1). The bacteria targets the cells of the mucous membranes which are soft the soft tissues of the body not covered by skin (2). Examples of areas that could be infected by this bacteria include:

  • the surfaces of the urethra, vagina, cervix and endometruim
  • the fallopian tubes
  • anus and rectum
  • lining of the eyelid
  • and less commonly the throat

   Chlamydia can be transmitted during vaginal, anal or oral sex. Chlamydia often produces no symptoms. Symptoms can include dysuria ( pain or burning during urination), bladder infection, vaginal discharge, lower abdominal pain and inflammation of the cervix with pus.  If left untreated it can do severe damage to the female reproductive organs and is one of the leading causes of infertility.   

According to CDC, Chlamydia is the most frequently reported bacterial STD in the United States. In 2002, 834,555 Chlamydial infections were reported to CDC from 50 states and the District of Columbia (2).  The highest rates are amongst female adolescents and young women. It is estimated that 4 million Americans are infected with Chlamydia each year (3).The problem with Chlamydia is that due to the mild or absence of symptoms people are not aware that they have the illness so the numbers are probably a lot higher because of under reporting.  The health care costs of Chlamydial infections in the US are estimated to exceed $2 billion dollars annually (4).  If left untreated, Chlamydia can cause sterility in young women and can be passed from an affected mother to her baby during vaginal delivery.  Chlamydia is a major cause of newborn pneumonia and pink eye.  

 

 

Prevalence of Chlamydia

 

In the United States prevalence of chlamydial infections is highest in adolescent and young adults. A large number of studies have showed that prevalence generally exceeded 10% among sexually active adolescent girls and have exceeded 5% among young women (5). Fewer studies have been reported for men, prevalence rates range from 15% to 20% among men seen in STD clinics and 3% to 5% among men who have no symptoms that are seen in general medical settings (5). It is believed that the rates are higher for females because they exhibit symptoms for this infection more than males and that they seek medical attention sooner than males.

Per CDC the prevalence of Chlamydia also has been higher among people who live in inner cities, have a lower socioeconomic status and are black (4). Ohio ranked 8th in the nation in Chlamydia rates in 2003. In Cleveland, Ohio the Chlamydia rates among teens 15-19 years old are staggering, it has been estimated that 1 in every 14  Cleveland teens were infected during 2002 and 2003 (6). These rates for Cleveland teens are three times greater than the Ohio rates. 1 in 9 females and 1 in 37 males were reported to be infected with Chlamydia in 2003. The Cleveland rates in 2003 can be broken down by race and the numbers are follows:

·         Chlamydia rates for African American teens aged 15-19 were 64.43 per 1,000 which is equivalent to 1 in every 15 youths were infected.

                   - 1 in 10 females and 1 in 31 males were reported with Chlamydia   

·         Chlamydia rates for African American young adults aged 20-29 were 42.57 per 1000 or 1 in 23.5

             -1 in 20 females and 1 in 30 males were infected

·         Chlamydia rates for White non-Hispanic teens 15-19 were 19.3 per 1,000 or 1 in 52 were infected.

                   - 1 in 28 females and 1 in 251 males were reported with Chlamydia

·         Chlamydia rates for non-Hispanic young adults aged 20-29 were 6.73 per 1000 or 1 in 148

             -1 in 96 females and 1 in 329 males were infected

·         Chlamydia rates for Hispanic teens 15-19 were 20.68 or 1 in 48 youths were infected.

             -1 in 27 females and 1 in 177 males aged 15-19 were reported with                  Chlamydia

·         Chlamydia rates for Hispanic young adults aged 20-29 were 17.2 per 1000 or 1 in 58

             -1 in 37 females and 1 in 144 males were diagnosed with Chlamydia

This is a serious public health problem that is facing our youth locally and nationally.

Symptoms

 

Chlamydia is known as the silent disease because approximately 85% of females and 40% of males do not have any symptoms (7). With Chlamydia it is important to realize that focusing solely on signs and symptoms is not a very useful to determine if someone is infected.  Since the majority of the people do not know that they have Chlamydia, this is one of the major reasons why this can illness can spread rapidly among sexually active adolescents. Due to the high number of people who do not feel ill, this leads public health officials to believe that there are a lot more cases of Chlamydia out there. A major question in many communities is how do we reach these youth.   

 If symptoms are present they are similar to of symptoms of gonorrhea and runs the risk of being clinically misdiagnosed. Symptoms for Chlamydia usually will develop one to three weeks after someone has been exposed to Chlamydia. A person can transmit the infection until they have received treatment.

Females

·         Most women do not experience any symptoms, but if they do they may be very minor (8).

·         Symptoms may include:

-          vaginal discharge

-          burning sensation during urination

-          proctitis

-          urethritis

-          soreness and redness in the throat or mouth

-          conjunctivitis( inflamed eyelid)

-          If the infection spreads to the fallopian tubes (PID) women may experience; lower abdominal and lower back pain, pain during intercourse, bleeding between periods or nausea or fever (8).

          Males

  • Men also may not experience symptoms like females, but if symptoms are present they may be minor (8)
  • Symptoms may include:

-          pus ( thick yellow-white fluid) or watery or milky discharge from the penis

-          pain or burning during urination

-          soreness and redness in the throat or mouth

-          conjunctivitis

-          proctitis

-          Urethritis

          Infants

  • Nearly two-thirds of the infants born vaginally to mothers with Chlamydia become infected during delivery (3). The most common complication in newborns are conjunctivitis and pneumonia

 

Complications of untreated Chlamydia

 

In females untreated Chlamydia can spread to the uterus and fallopian tubes and cause a serious condition called pelvic inflammatory disease (PID). PID happens in up to 40% of women with untreated Chlamydia (2). PID can cause permanent damage to the fallopian tubes, uterus and surrounding tissues. This can lead to chronic pain, infertility and potentially fatal ectopic pregnancy (3).  PID is estimated to cause more than 200,000 cases of infertility in the United States every year and is responsible for 2.5 million outpatient visits to physicians, more than 275,000 hospitalizations and 100,000 surgical procedures every year(3). The untreated infection in pregnant females can cause premature births, and it can be passed to the baby during childbirth, causing an eye infection, blindness or pneumonia in the newborn (9). In males untreated Chlamydia can lead to a condition called urethritis (inflammation of the urethra) and proctitis (inflammation of the rectum).

Testing/Treatment   

 

 The most reliable way to find out if a person has Chlamydia is through laboratory testing. The main methods are testing are the fluorescent antibody(FA) examination of a direct smear, the enzyme immunoassay test (EIA) and polymerase chain reaction on either a genital swab or a urine specimen. In men an urethral swab is inserted the urethra and is gently rotated so that cells can be collected and sent to the lab. Men find this procedure very uncomfortable and painful procedure especially with urethral inflammation. Some men will have to be persuaded to have this done and others simply will refuse this procedure. In women a swab is inserted into the cervix (uterus opening), and gently rotated (10).    

The urine based testing is gaining popularity in many clinic settings because it is a non invasive but yet effective test. There are no swabs needed just urine is collected in an appropriated container and sent to the lab for analysis.

Instituting the urine based test helps providers catch the hard to reach population. This testing can be offered in innovative places such as juvenile detention sites, correctional facilities , adolescent clinics, school based clinics, health fairs just to name a few.  

Recommended Treatment

 Azithromycin 1 gram orally in a single dose

Or

 Doxycycline 100 gm orally twice a day for 7 days.

Both antibiotics are equally effective. Azithromycin is more costly and is often used with adolescents. It should always be available to health care providers to treat patients for whom compliance is in question (10).

To minimize the risk for re-infection, patients should be instructed to avoid sexual intercourse until they have completed their antibiotics and all their sexual partners are treated.   

 

Public Heath interventions that make a difference

 

The main goals of Chlamydia prevention strategies are to:

  • Reduce the number of Chlamydia cases
  • Reduce the complications of chlamydial infections including inflammation of the fallopian tubes which can lead to infertility, prevent perinatal and postpartum infection and other adverse consequences of chlamydial infection.

Therefore, Chlamydia prevention efforts should be directed toward young women since a lot of women are asymptomatic and the infection may persist for extended periods of time (3).  

Since all sexually active adolescents and young adults are at risk for Chlamydia all private and public health care-providers have been very involved in fighting the spread of this treatable infection. They have increased screening efforts to identity those are not exhibiting any symptoms. Private health care has joined public health to incorporate screening and treatment for Chlamydia as a standard of preventative care. Public Health officials have found that patients and their partners are looking for and finding care that is confidential, accessible and at a reasonable cost (11). Public health has taken the lead to effectively address the barriers to adolescents and young adults accessing chlamydial services. Screenings are conducted in many mobile units using the new urine based Chlamydia test which is less invasive than the traditional culture which a sample is collected by inserting a swab into the urethra in males and cervix in females. Teens often shy away from this procedure because it can be very uncomfortable especially in males. Many state health departments have developed teen STD clinics to increase testing efforts. These clinics have been very successful because adolescents normally will not go to their primary care providers for the fear that their parents would have to be involved in there treatment. At community based teen STD clinics adolescents can be treated and tested for all STDs without parental consent and information obtained by the adolescent during their visit to the clinic is confidential.

 

There is a widespread public support to reduce Chamydial infections. Public health was instrumental in working with policymakers so that they could understand the true impact of Chlamydia and its effects on women, young adults and their families. Through the efforts of several public officials thorough out the United States, CDC developed the Infertility Prevent Program (IPP) (12). This project developed as a result of a federal initiative that recognized that Chlamydia is a leading cause of infertility and by detecting this silent disease early health departments can prevent complications (13). Through the infertility Prevention Project, all sexually active women aged < 26 years, all pregnant women of all ages, and all patients who have had a STD in the past are tested for Chlamydia in State funded STD clinics (12).This project is a Public Health success story. This program has been largely successful in reducing the rates of Chlamydia by increasing chlamydial screening and treatment services to women who were in need of service but had little or no access to it. According to CDC, for every dollar spent on screening and treatment of Chlamydia, we save $12 dollars in complications that result from untreated Chlamydia (12). In northwestern US, Chlamydia rates have dropped by 62% over the past years since the implementation of the IPP and have declined by 30% in the Mid-Atlantic States. In Ohio, the Ohio State Health Department provides 76 sites with testing and treatment supplies for Chlamydia through the Infertility Prevention Project. The Cleveland Department of Health offers confidential and comprehensive STD screening and treatment at two community based health centers. With the support of the IPP the Cleveland Department of Public Health has increased its screening efforts and is now gearing up to offer urine based Chlamydia testing. It is apparent that the more we screen young adults the more we detect the infection. CDPH offers STD services to those 13 years and older for a very small fee. CDPH will soon provide mobile screening services to increase accessibility for individuals in high risk areas.

  To increase public awareness about the importance of Chlamydia and other STDs the Cleveland Department of Public Health (CDPH) developed a large campaign to address STD’s in adolescents. CDPH created an eye catching logo on billboards and posters in kiosks. The messages were geared toward encouraging parents to get involved and educate their children regarding STDs and encouraging youth to discuss STD’s with their medical providers. This campaign increased public awareness about the seriousness of STDs ad caught media attention regarding the problem. CDPH has seen a 15% increase in the volume of young patients since the launching of the campaign.

Public health has made great strives in tackling this very prevalent infection. There is still a lot more work that has to be done. Continued partnerships need to be formed with schools, policymakers and the private medical providers to reach the underserved population who are affected by Chlamydia. Increased public awareness about the importance of detecting this preventable infection needs to be universally applied.

 

 

 

 

Where to go for more information

 

1.       STD information and referrals to STD Clinics

         1-800-CDC- INFO (800-232-4636)

         TYY: 1-888-232-6348

         In English and Spanish

2.       Chlamydia facts myDNA.com     http://www.mynda.com/health/sexual/chlamydia             

3.      Centers for Disease Control and Prevention

                  http://cdc.gov/std/chlamydia/STDFact-Chlamyida.htm

 

4.       Web MD.com

 

                  http://www.webmd.com/content/article/46/2953_512.htm

 

 

5.       American Social Health Association.org

                  http://www.ashastd.org/learn/learn_ chlamydia .cfm         

     

6.       National Institute if Allergy and Infectious Diseases

 

                  http://www.naid.nih.gov

 

                 

 

   

 

References

 

1.      “Chlamydia Trachomatis;” 2004. Well-net.com. http://www.well-net.com/STD/Chlamydia.html

2.      “Chlamydia Fact Sheet;” 26 January 2006. Centers for Disease Control and Prevention. May 2004. www.cdc.gov/std/chlamydia /STDFact-chlamydia.htm

3.      CDC. Recommendations for the Prevention and Management of Chlamydia trachomatis Infections, 1993. MMWR 1993;42 (RR-12)

4.      Toomey K, Barnes, R. Treatment of Chlamydia trachomatis Genital Infection. Reviews of Infectious Diseases Volume 12 July-August 1990

5.      Hills S, Black C, Newhall J, Walsh, C, and Groseclose S. New opportunities for Chlamydia Prevention: Applications of Science to Public Health Practice. CDC Sexually Transmitted Diseases. May-June 1995

6.      “Chlamydia among Cleveland teens 15-19” 23 March 2006. ClevelandHealth.info. March 2004. www.clevelandhealth.info/localstats/topics/std/chlamyida/document

7.      “Sexual Health: Chlamydia. 26, January, 2006. WebMD Medical Reference. February,2005. www.webmd.com/content/article/46/2953_512.htm

8.      “Chlamydia: Learn about STIs/STDs”. 26 January, 2006. American Social Health Association. 1999-2006. www.ashastd.org/learn/learn_chlamydia

9.      “Chlamydia: Health Matters” 26 January, 2006. National Institute of Allergy and Infectious Diseases-National Institute of Health. July, 2005. www.niaid.nih.gov/factsheets/stdclam.htm

10.  CDC. Sexually Transmitted Diseases Treatment Guidelines 2002. MMWR 2002 Vol.51 RR-6

11.  Challenges and Opportunities: Action Agenda for Chlamydia, Prevention and Control in California: A Five Year Plan. January 1999. www.ucsf.edu

12.  National Coalition of STD Directors, April 23, 2002,: Testomony, submitted to the United States House Subcommittee on Labor, Health and Human Services and Education and Related Agencies, Committees on Appropriations, retrieved April 21, 2006.  http://www.ncsddc.org/