A Sneaky Infection

What it Does

Trouble for Newborns

Screening – What Works

Intervention: A Big Difference

Conclusion

References

OTHER TOPICS

Chlamydia trachomatis is the most common reportable sexually transmitted disease in the United States. It is epidemic among sexually active adolescents and young adults. Surveys and state reports have revealed rates from 2 to 20% in this age group, with adolescent females having the highest rate of infection. The rate of infection in teens in general and among young adult males has been estimated at 4%.

A Sneaky Infection
What makes chlamydia infections so common and such a big health problem is that people who are infected often have no symptoms until they have progressed enough to cause painful conditions which can lead to lifelong gynecologic and fertility problems. Because of this, many young women are unaware that they are infected and continue to spread disease among their sexual partners. Untreated chlamydia infections in both males and females can persist for months to years, adding to the risk of unintentional spread of the infection and reinfection with this bacteria is common.

The good news is that chlamydia can be diagnosed with a urine specimen and does not require a pelvic examination or vaginal or urethral culture. So improving our ability to screen for and treat Chlamydia infections is relatively easy-to-achieve preventive health measure, if we can just find the right way to do it.

What the Infection Does
In adolescent and adult females, chlamydial infection can cause inflammation of the urethra (urine tube), the cervix, the endometrium (lining of the uterus), the fallopian tubes (passage for the egg from ovary to uterus), and the area around the liver.

Asymptomatic chlamydia infections can develop into acute or chronic inflammation of the reproductive structures in a woman’s pelvis, called pelvic inflammatory disease or PID. Chronic pelvic pain is one complication. PID can also cause tubal pregnancies because inflammation of the fallopian tubes makes it difficult or impossible for a fertilized egg to travel and implant normally in the uterus. Such pregnancies are both dangerous to the mother and unsuccessful in producing healthy newborns Similarly, it can cause infertility because a blocked, scarred, or inflamed tube makes it impossible for the egg and sperm to meet for the normal process of fertilization.

In males, chlamydial infection can cause inflammation of the urethra and the epididymis (part of the sperm storage and transport system) as well as a trio of symptoms that includes arthritis, urethritis and conjunctivitis (inflammation of the membranes around the eye).

Risks to Newborns
If a pregnant woman has chlamydia at the time of delivery, her infant has a high probability of catching the infection as she passes through the birth canal. Newborns may have no symptoms, may develop conjunctivitis or may develop pneumonia from this exposure. If the newborns are asymptomatic and do not receive treatment, they may continue to carry chlamydia in their nasal passages and pneumonia may develop as late as 15 weeks after birth. Fortunately, carrier infants do not pass infection to others.

The Limitations of Current Screening Methods
Since the consequences of chlamydial infections are significant, but infections remain asymptomatic for long periods of time, medical guidelines recommend annual screening for chlamydia among all sexually active female adolescents and young adults until age 26. Screening tests are typically performed when teens come in for preventive care visits. But this age group tends to see doctors for acute medical problems rather than routine annual physicals aimed at prevention and counseling, so they tend to fall through the cracks. A national telephone survey showed only 21% of 18-19 year olds and 16.6% of 25-29 year olds had received counseling or testing for chlamydia.

Adolescents and young adults who primarily use urgent visit/emergency room services are most likely to be sexually active and at higher risk for exposure to sexually transmitted diseases, according to one study. Another found that 8 to 9% of the girls who were screened during an urgent care visit unrelated to a gynecologic problem had positive chlamydia tests. ^1 2 3

A recent study in the June issue of Archives of Pediatrics and Adolescent Medicine ⁴ reported on an effort to increase the rate of screening for chlamydia by incorporating it into urgent care visits, rather than relying on annual check-ups. This approach is a creative and reality-based approach to providing a critically needed service to teens and young adults. The researchers were interested in whether the young women who came to urgent care for other reasons would be willing to discuss their sexual history and accept the recommendation for chlamydia screening, and whether it could be done confidentially and without disrupting the flow of patient care in a busy urgent care setting.

The researchers divided several urgent care clinics into two groups. In the control group, the staff was given a one hour teaching session about chlamydia, including risks of infection, testing procedures, the specific vulnerability of the adolescent and young adult population, and the need for more widespread screening. The test clinics were asked to develop a system to identify teens at risk, provide screening, and develop a follow up and treatment system, and to communicate and follow confidentiality rules. They were asked to meet monthly to review their progress toward increasing the screening rate of adolescent females who presented with non-gynecologic complaints, and to continually refine their system as they learned from experience. Since chlamydia can be tested with a urine specimen, the screening did not involve a pelvic or gynecologic examination. If a female returned for screening within three days of her urgent care visit, she was counted in the pool of successfully screened patients.

Intervention Makes A Difference
The outcome for both the control and intervention clinics was compared to the rate of screening that had been done in the three months preceding the onset of the study, and the study period was divided into 6 three-month periods to monitor progress over the course of the 18 months study. The intervention group was a clear success in that by the fifth period of the study, the numbers of screened adolescents increased by 15.93% compared to a decrease of 2.13% in the controls. Further, the prediction for screening in the final three months was 42.19% in the intervention group compared to 29.82% in the control group.

Conclusions
The study gives important support to the concept that teens and young adults are open to discussion and screening of chlamydia at a medical visit even when it is unrelated to their active medical problem. It provides important messages for parents, and sexually active women in their teens and twenties that they must be as proactive about sexually transmitted diseases, as they are about unwanted pregnancy. Parents should be aware that even a healthy adolescent needs a visit to her doctor. Ideally, all patients would go for annual checkups that provide an opportunity for a wide variety of developmentally appropriate screening and advice on personal care and safety. This visit should include private time with the physician and patient, to provide an opportunity to raise sensitive and important health issues.

Parents who are aware that their teenagers are sexually active should be aware of the high prevalence and serious complications of chlamydia infections. In addition to talking with their sons and daughters about birth control, they should encourage them to use safe sex practices such as condoms, to decrease their risk of acquiring an infection with lifelong consequences. If parents are uncomfortable with their knowledge or ability to discuss such issues, they should arrange for an appointment with the teen’s doctor, or at an adolescent clinic or a family planning clinic.

Doctors who staff urgent visit sites, or primary care doctors whose teen and young adult patients only show up when they are sick, should consider adopting a practice of providing written information for their patients and making chlamydia screening easily and confidentially available. If the urgent care site does not provide chlamydia screening, doctors should provide referral sources to the patient to have the testing done accurately and confidentially. Similarly, patients who are seeing their doctors for other problems should feel comfortable asking their doctors for resources for chlamydia testing.

Any patient who is screened should be sure to obtain the results and to comply with full treatment recommendations. This includes letting their partners know of their infection so they can be treated as well. If a chlamydia test is positive, both patients and doctors should consider the high risk of other sexually transmitted diseases and do appropriate tests and follow up.

Currently, routine testing for chlamydia in teen and young adult males is recommended in the Guidelines of Adolescent and Preventive Services but not by other medical groups. The authors of this study propose that annual screening should be adopted for males as well as females. Young adult men who are sexually active may want to ask their doctors about screening, and parents who are aware that their teenage sons are sexually active may want to provide their sons with accurate information and encourage a medical visit to assess their sons' risk and need for testing.

1. Bachmann LH, Pigott D, Desmond R; et al. Prevalence and factors associated with gonorrhea and chlamydial infection in at-risk females presenting to an urban emergency department. Sex Transm Dis. 2003;30(4):335-339. return

2. Todd CS, Haase C, Stoner BP. Emergency department screening for asymptomatic sexually transmitted infections. Am J Public Health. 2001;91(3):461-464. return

3. Mehta SD, Rothman RE, Kelen GD, Quinn TC, Zenilman JM. Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: a critical population for STD control intervention. Sex Transm Dis. 2001;28(1):33-39. return

4. Tebb K, Wibbelsman C, et al. Screening for Asymptomatic Chlamydia Infections among Sexually Active Adolescent Girls during Pediatric Urgent Care. Archives of Pediatrics and Adolescent Medicine. 2009; 163(6): 559-654. return

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