Public Health and Communicable Diseases - SA Health - SA.Gov.au

Chlamydia -closing thestable doorDr Katrina AllenShineSAThe emergence of the deadly HIV in the early 1980ssaw a large increase in attention and funding for sexuallytransmitted infection clinics and, particularly in Australia,a major expansion in sexual health education andresearch, charted by the national survey of secondaryschool students’ sexual health. 1,2,3 Through the latterit has become clear that the message about HIV as asexually transmitted disease is being effectively taughtat later secondary school level. However what hasemerged over the time, as the studies have repeated, isthat knowledge about HIV is decreasing. Though thereis some improvement in knowledge about transmissionof Sexually Transmitted Infections (STIs), youngpeople’s knowledge of Chlamydia has not improved.Symptomatic of this lack of awareness is the knowledgethat condoms are primarily being used as contraceptionrather than infection protection. 3Genital Chlamydia is emerging as a significant publichealth problem for young people in particular, as mostWestern societies are experiencing a significant increasein infections particularly in people under 25. 4 Chlamydiais a fragile organism which infects mucus membranes.In genital infections, only 50 per cent of men and 30 percent of women experience symptoms, 5 but the infectioncan ascend in the genital tract to produce major diseasesuch as pelvic inflammatory disease in women, andchronic prostatitis and urethral strictures in men. 6 Inboth women and men the end result can be obstructiveinfertility as well as chronic pain and disease.As much of the burden of infection and disease occurs inthe young there has been considerable interest in raisingawareness of chlamydia infection in this population, aswell as in the health care providers for this population.For the latter this has largely taken the form of exploringthe possibilities of increasing screening for chlamydiain various sections of the population. Clearly screeningfor chlamydia is already part of the routine work of anSTI clinic, but the issue of screening of asymptomaticpopulations in the community has also been raised. Thishas been driven by the availability of less invasive meansof testing for chlamydia. Until recently chlamydia wastested for with an endocervical swab for women anda urethral swab for men, but the development of PCRamplification with chlamydia specific DNA has meantthat a first pass urine sample now provides an adequatesample for testing chlamydia. 6 This has meant screeningacross the community is easier, significantly increasingthe numbers of men being tested.The prevalence of chlamydia in South Australia is difficultto establish as the detection of infection mostly reflectsSTI screening and/or symptomatic screening. In 2000the ratio of women to men being tested was 4:1 buttesting is now more even between the sexes. Althoughchlamydia has been a notifiable disease in SouthAustralia since 1989, uneven testing left knowledge ofinfection rates in the male population unclear. What isnow emerging about chlamydia is that males tend tohave an infection for a shorter time than females. 7 Aswomen remain infective for longer periods it may bemost effective to screen and treat women to make adent in the rising infection rate.Routine screening, including treatment and follow-up ofpartners, has been shown to decrease the developmentof problematic complications. 8 For this reason andbecause the infection may be a marker for otherdisadvantage, 9 routine screening has been advocated bypublic health bodies both in Australia and overseas. Theidentification of chlamydia infection enables treatment,notification and treatment of infected partners.However there has been debate on which populationsshould be screened. Whole population screening isnot cost effective and most authorities favour eithertargeted or opportunistic screening. Possible populationstargeted for screening are all pregnant women in thefirst trimester, women seeking an abortion, womenattending family planning clinics or even all womenusing or requesting the injectable progesterone onlycontraception (Depo). Canadian guidelines include allsexually active women less than 25 years old and theUSA guidelines include all women aged under 20. 10The recognition of the link in identifying healthinequalities by chlamydia incidence has led to moreeffort to increase screening amongst vulnerable youngpeople, in an effort to identify and treat, and also totarget education and contraceptive access to decreasethe incidence of teenage pregnancy and abortion.Thus in Britain testing for chlamydia has moved intothe pharmacies in an effort to reach those groups ofteenagers and young people who have few health careattendances at clinics where opportunistic screeningmay occur. 5 This has inevitably led to questions ofaccess to treatment and contact tracing, but given theacceptability of testing for diabetes and high bloodpressure already available in many pharmacies, it maymake a significant contribution to reducing the stigmaassociated with chlamydia infection. Reduced stigmaand more acceptance of testing in the communitymay be an important step to encouraging effectivepreventative strategies.The simplicity and acceptability of the first pass urinetest has also led to an expansion of testing in menand education campaigns to encourage young men toget tested. 12 Most chlamydia infections are detectedby General Practitioners (GPs) and a major part ofincreasing testing for chlamydia in the community is30