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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
increasing the awareness of GPs of the risk groupsand the opportunities for screening young people.While some categories are fairly obvious, such asanyone who is symptomatic, young women needingcontraception, emergency contraception or requestinga termination, young men rarely attend for checks whenasymptomatic. 12 Testing may need to be consideredwhen they attend with a sports injury or other minorcondition.There is good evidence showing effective detection ofwomen under 30 years of age who need emergencycontraception (EC). 13 The infection was identified bytesting at the time of accessing the EC in all but 2 ofthe 500+ women who were recruited. 13 The loss tofollow-up is high in post EC review in primary healthcare and so waiting until then to check for chlamydiais neither clinically nor economically effective. MakingGPs and other primary health care workers aware ofthe high incidence of chlamydia in people aged under25, particularly those with multiple sexual partnersand infrequent or inconsistent use of condoms, is animportant part of the strategy of identifying chlamydiainfection in the community, treating it and preventingits spread. This should include education for workersabout sexual health history taking, risk identification andeffective screening in their own practice.In addition it is clear from the surveys of young people’ssexual knowledge that more emphasis needs to begiven to educating young people about STIs, in particularchlamydia as the most common infection. Even with thisimprovement in knowledge the incidence of chlamydia isunlikely to change unless there is effort put in to supportyoung women in particular to apply their knowledgeabout safe sex. It is clear that the discourse of diseaserather than pleasure means that though many youngwomen know the theory of safe sex they do not feelable to apply protective measures when having sexbecause of complex emotional dynamics. 14 It is alsoclear from the New Zealand research and examplesthat unless very specifically targeted and marketed sexeducation is provided for boys and young men it is verydifficult to promote safe sex behaviors. 15In Australia there have been several efforts to considera national strategy on tackling the chlamydia infectionrates and various states have put forward their ownplans. The rising incidence of chlamydia and what itreflects about sexual risk taking, especially in the faceof a rising (though still very small) HIV infection rate,demands a prompt response from health care providers.It is clear that to be effective this response needs tomove beyond the traditional expansion of screening andinclude the education of health care providers in sexualhealth history taking, risk assessment and chlamydiainfection in the community. Any policy must focus onsexual health and relationships education for secondaryschool students, emphasizing relationship dynamics,safe sex behaviours and increased knowledge of thechlamydia as the most common STI. Finally, withoutinvolving young people who are most affected by thisdisease, any policy of national screening would likely beineffective.References1. Smith A, Agius P, Dyson S, Mitchell A, Pitts M.Secondary School Students and Sexual Health. LaTrobe University: Australian Research Centre in Sex,Health and Society; 1992.2. Smith A, Agius P, Dyson S, Mitchell A, Pitts M.Secondary School Students and Sexual Health. LaTrobe University: Australian Research Centre in Sex,Health and Society; 1997.3. Smith A, Agius P, Dyson S, Mitchell A, Pitts M.Secondary School Students and Sexual Health. LaTrobe University: Australian Research Centre in Sex,Health and Society; 2002.4. Hocking J, Fairley C, Counahan M, Crofts N.The pattern of notification and testing for genitalChlamydia trachomatis infection in Victoria, 1998-2000: An ecological analysis. Australian New ZealandJournal of Public Health. 2003; 27(4): 405-408.5. Anonymous. Chlamydia - a testing issue. Lancet.2005;365:630.6. Peipert JF. Genital Chlamydial infections. New Engl.J.Med. 2003;349:2424-30.7. Males have infection for a shorter time than females(Clinic 275 ref)**.8. Scholes D, Stergachis A, Heidrich FE, Andrilla H etal. Prevention of pelvic inflammatory disease byscreening for cervical chlamydial infection. N.Engl.J.Med. 1996;334(21):1362-6.9. Macleod J et al. Coverage and uptake of systematicpostal screening for genital Chalmydia trachomatisand prevalence of infection in the United Kingdomgeneral population: cross-sectional study. BMJ.2005;330:940.10. Department of Human Services. Chlamydia strategyfor Victoria (2001-2004). Melbourne, Victoria: PublicHealth Division, Department of Human Services;2001.11. Elliott KJ, Lambourn AJ. Sex, drugs and alcohol: twopeer-led approaches in Tamaki Makaurau/Auckland,Aotearoa/New Zealand. Journal of Adolescence.1999;22:503-13.12. ShineSA. Sexual Health Awareness Week Campaign2006. [Accessed May 2006]. Available from: http://www.shinesa.org.au/go/special-projects/sexualhealth-awareness-week/campaigns.13. Kettle H, Cay S, Brown A, Glasier A. Screening forChlamydia trachomatis infection is indicated forwomen under 30 using emergency contraception.Contraception. 2002;66:251-3.14. Goldman J, Bradley G. Sexuality education acrossthe life cycle in the new millennium. Sex Education.2001;197-217.15.Bradshaw SN. Sport, arts, resiliency and sex- amix for young men. Australasian Sexual HealthConference Handbook. Australasian Chapter ofSexual Health Medicine; 2005.31
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