Prevalence and High Rate of Asymptomatic Infection of Chlamydia trachomatis in Male College Reserve Officer Training Corps Cadets

Update on the Epidemiology, Screening, and Management of Chlamydia trachomatis Infection

Chlamydia trachomatis infection ("chlamydia") is the most commonly diagnosed bacterial sexually transmitted infection globally, occurring in the genitals (urethra or vagina/cervix), rectum, or pharynx. If left untreated in women, genital chlamydia can ascend into the upper genital tract causing pelvic inflammatory disease, increasing their risk for ectopic pregnancy, infertility, and chronic pelvic pain. In men, chlamydia can cause epididymitis and proctitis. However, chlamydia is asymptomatic in over 80% of cases. This article provides an update on the epidemiology, natural history, and clinical manifestations of chlamydia in adults and discusses the current approaches to its management and control policy.

Indifferent, ambiguous, or proactive? Young men's discourses on health service utilization for Chlamydia trachomatis detection in Stockholm, Sweden: A qualitative study

INTRODUCTION

Chlamydia trachomatis (C. trachomatis) infection is the most commonly reported sexually transmitted infection in Sweden and globally. C. trachomatis is often asymptomatic and if left untreated, could cause severe reproductive health issues. In Sweden, men test for C. trachomatis to a lesser extent than women.

AIM

To explore factors facilitating and constraining Swedish young men's health care utilization for C. trachomatis detection and treatment.

METHOD

A qualitative situational analysis study including data from 18 semi-structured interviews with men (21-30 years). Data collection took place in Stockholm County during 2018. A situational map was constructed to articulate the positions taken in the data within two continuums of variation representing men's risk perception and strategies to test for C. trachomatis.

RESULTS

Based on the informants' risk perception, strategies adopted to test and the role of social support, three different discourses and behaviours towards C. trachomatis testing were identified ranging from a) being indifferent about C. trachomatis -not testing, b) being ambivalent towards testing, to c) being proactive and testing regularly to assure disease free status. Several factors influenced young men's health care utilization for C. trachomatis detection, where the role of health services and the social support emerged as important factors to facilitate C. trachomatis testing for young men. In addition, endorsing traditional masculinity domains such as leaning on self-reliance, beliefs on invulnerability and framing men as more carefree with their sexual health than women delayed or hindered testing.

CONCLUSION

Testing must be promoted among those young men with indifferent or ambivalent discourses. Health systems aiming to increase testing among those at risk should take into consideration the positive role that young men's social support have, especially the level of social support coming from their peers. Additionally, endorsement of traditional masculinity values may delay or hinder testing.

Electronic Health Record Reminders for Chlamydia Screening in an American Indian Population

OBJECTIVES

Indian Health Service (IHS) screening rates for Chlamydia trachomatis are lower than national rates of chlamydia screening in the Southwest. We describe and evaluate the effect of a public health intervention consisting of electronic health record (EHR) reminders to alert health care providers to screen for chlamydia at an IHS facility. We also conducted an awareness presentation among health care providers on chlamydia screening.

METHODS

We conducted our intervention from November 1, 2013, through October 31, 2015, at an IHS facility in the Southwest. We implemented algorithms that queried database values to assess chlamydia screening performance in 6 clinical departments. We presented data on the screening performance of clinical departments and health care providers (de-identified) in the awareness presentations. We re-queried database values 1 and 2 years after implementation of the EHR reminder intervention to evaluate before-and-after screening rates, comparing data among all patients and among female patients only.

RESULTS

We found small, sustained relative increases in chlamydia screening rates during the 2012-2015 evaluation period: 20.8% pre-intervention to 24.9% and 24.2% one and two years postintervention, respectively, across all patients; 32.3% preintervention to 36.6% and 35.6% one and two years postintervention, respectively, among female patients. Increases in clinical department-specific screening rates varied and were most prominent in internal medicine (35.8% preintervention to peak 65.8% postintervention). The 1 clinic (obstetrics-gynecology) that did not receive an awareness presentation showed a consistent downward trend in screening rates, although absolute rates were consistently higher in that clinic than in other clinics.

CONCLUSIONS

Awareness presentations that offer feedback to health care providers on screening performance, heighten provider awareness of the importance of chlamydia screening, and promote development of novel provider-initiated screening protocols may help to increase screening rates when combined with EHR reminders.

Prevalence and treatment of sexually transmitted infections in men followed by urologists in Germany - a cross sectional study with 347,090 men

Aim: The goal of this retrospective analysis was to study the prevalence and treatment of the most common sexually transmitted infections (STI) in men followed by urologists in Germany. Methods: This study included a total of 347,090 men followed in 71 urology practices in Germany between 2013 and 2015. The first outcome was the prevalence of individuals diagnosed with STI between 2013 and 2015. The following eight types of STI infections were included in the analysis: chlamydial infection, gonococcal infection, anogenital warts, anogenital herpes infection, trichomoniasis, ulcus molle, phthiriasis, and syphilis. The second outcome was the prevalence of individuals with STI who received an appropriate therapy within 90 days of their initial STI diagnosis. Results: The most frequent STI was anogenital warts (0.64%), whereas the least frequent STI was syphilis (0.03%). The median age at diagnosis ranged from 30.3 years for chlamydia infection to 47.5 years for trichomoniasis. The proportion of individuals receiving treatment was the highest for trichomoniasis (90.6%) and the lowest for anogenital warts (49.9%). Conclusions: Overall, approximately 1.25% of men followed in urology practices in Germany between 2013 and 2015 were diagnosed with at least one STI. Further research is needed to gain a better understanding of the factors potentially associated with the risk of being diagnosed with STI in this setting in Germany. Moreover, there is a need for enabling higher rates of diagnosis and thus treatment of infected persons.

Sexually transmitted infections: challenges ahead

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

The Association between Sexually Transmitted Infections, Length of Service and Other Demographic Factors in the U.S. Military

BACKGROUND

Numerous studies have found higher rates of sexually transmitted infections (STIs) among military personnel than the general population, but the cumulative risk of acquiring STIs throughout an individual's military career has not been described.

METHODS

Using ICD-9 diagnosis codes, we analyzed the medical records of 100,005 individuals from all service branches, divided in equal cohorts (n = 6,667) between 1997 and 2011. As women receive frequent STI screening compared to men, these groups were analyzed separately. Incidence rates were calculated for pathogen-specific STIs along with syndromic diagnoses. Descriptive statistics were used to characterize the individuals within each accession year cohort; repeat infections were censored.

RESULTS

The total sample included 29,010 females and 70,995 males. The STI incidence rates (per 100 person-years) for women and men, respectively, were as follows: chlamydia (3.5 and 0.7), gonorrhea (1.1 and 0.4), HIV (0.04 and 0.07) and syphilis (0.14 and 0.15). During the study period, 22% of women and 3.3% of men received a pathogen-specific STI diagnosis; inclusion of syndromic diagnoses increased STI prevalence to 41% and 5.5%, respectively. In multivariate analyses, factors associated with etiologic and syndromic STIs among women included African American race, younger age and fewer years of education. In the overall sample, increasing number of years of service was associated with an increased likelihood of an STI diagnosis (p<0.001 for trend).

CONCLUSION

In this survey of military personnel, we found very high rates of STI acquisition throughout military service, especially among women, demonstrating that STI-related risk is significant and ongoing throughout military service. Lower STI incidence rates among men may represent under-diagnosis and demonstrate a need for enhancing male-directed screening and diagnostic interventions.

Predictors identifying those at increased risk for STDs: a theory-guided review of empirical literature and clinical guidelines

SummarySexually transmitted diseases (STDs) are leading causes of substantial morbidity worldwide. Identification of risk factors for estimating STD risk provides opportunities for optimising service delivery in clinical settings, including improving case finding accuracy and increasing cost-efficiency by limiting the testing of low-risk individuals. The current study was undertaken to synthesise the evidence supporting commonly cited chlamydia and gonorrhoea risk factors. The level of empirical support for the following predictors was strong/moderate: age, race/ethnicity, multiple lifetime sexual partners, sex with symptomatic partners and concurrent STD diagnosis. The following predictors had weak evidence: socio-economic status, transactional sex, drug/alcohol use, condom use and history of STD diagnosis. The most frequently listed predictors among nine clinical guidelines were younger age and multiple sexual partners; the least consistently listed predictor was inconsistent condom use. We found reasonably good concordance between risk factors consistently listed in the recommendations and predictors found to have strong empirical support in the literature. There is a need to continue building the evidence base to explicate the mechanisms and pathways of STD acquisition. We recommend periodic reviews of the level of support of predictors included in clinical guidelines to ensure that they are in accordance with empirical evidence.

Chlamydia trachomatis infection rates among a cohort of mobile soldiers stationed at Fort Bragg, North Carolina, 2005-2010

Background

Fort Bragg, a large Army installation with reported high Chlamydia trachomatis (Ct) infection rates, is characterized by a highly mobile population and a surrounding Ct-endemic community. We assessed the rates of Ct incidence and recurrence among the installation’s active component Army personnel and determined the association of soldier transience, sociodemographic factors, and history of sexually transmitted infection (STI) with these rates.

Methods

A cohort of soldiers stationed at Fort Bragg during 2005 to mid-2010 was followed for incident and recurrent Ct infection using laboratory-confirmed reportable disease data. Linkage to demographic and administrative data permitted multivariate analysis to determine association of covariates with initial or recurrent infection.

Results

Among 67,425 soldiers, 2,198 (3.3%) contracted an incident Ct infection (crude incidence, 21.7 per 1,000 person-years). Among soldiers followed for incident infection, 223 (10.6%, crude incidence 110.8 per 1,000 person-years) contracted a recurrent Ct infection. Being female, of lower rank, under 26 years of age, of non-white race, single, or with a high school diploma or less was significantly associated with incident Ct infection. Having breaks in duty or having deployments during follow-up was associated with a lower infection rate. Among women, having prior deployments was associated with a lower rate of both incident and recurrent infection. Specifically associated with recurrent infection in women was age under 21 years or no education beyond high school.

Conclusions

This analysis reaffirms risk factors for Ct infection determined in other studies. In addition, infection risk was lower for more mobile soldiers and tied to the specific location of their regular duty assignment. The findings support the STI prevention efforts at Fort Bragg and the surrounding community, regardless of how often or for how long soldiers have deployed for military operations.

Chlamydia trends in men who have sex with men attending sexual health services in Australia, 2004-2008

BACKGROUND

In most Australian settings, chlamydia notifications do not contain information on the gender of sexual partners. We assessed trends and predictors of chlamydia testing and positivity among men who have sex with men (MSM), attending sexual health services in Australia.

METHODS

The Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) program was established in 2008 to collate demographic and chlamydia testing information from 25 sexual health services. We calculated the proportion tested and chlamydia positivity among MSM and assessed trends from 2004 to 2008 using a χ2 test and predictors using logistic regression.

RESULTS

In the 5-year period, 11,777 MSM attended as new patients (first visit ever to the service) and the proportion tested for chlamydia increased significantly from 71% in 2004 to 79% in 2008 (P < 0.01). Independent predictors of chlamydia testing were younger age, residing in a metropolitan area (adjusted prevalence ratio [APR] = 1.23; 95% confidence interval [CI]: 1.19, 1.27), being Australian-born (APR = 1.03; 95% CI: 1.01, 1.06), being a traveler or migrant (APR = 1.09; 95% CI: 1.06, 1.12), and sex overseas in the past year (APR = 1.05; 95% CI: 1.03, 1.07). Overall chlamydia positivity was 8.6% (95% CI: 8.0%-9.2%). There was no significant trend in chlamydia positivity between 2004 and 2008. Independent predictors of chlamydia positivity were younger age, being a traveler or migrant (APR = 1.52; 95% CI: 1.26-1.84), and exclusive same-sex contact (APR = 1.28; 95% CI: 1.05-1.55).

CONCLUSIONS

This new national surveillance program demonstrates that the majority of MSM attending sexual health services was offered chlamydia testing and testing has increased over time. The MSM at highest risk of chlamydia were more likely to be tested. Chlamydia transmission was frequent but stable among MSM accessing clinical services.

Chlamydia trachomatis positivity rates among men tested in selected venues in the United States: a review of the recent literature

The cost-effectiveness of screening men for Chlamydia trachomatis depends in part on the prevalence of chlamydia in the screened population and the ease with which screening programs can be implemented. Screening in venues with high rates of chlamydia positivity among men may therefore be an important adjunct to chlamydia control. To evaluate the recent US literature on chlamydia positivity in chlamydia screening programs among asymptomatic men in nonsexually transmitted disease clinic settings, we reviewed published articles between 1995 and June 2007, using PubMed as the primary search tool. Articles were abstracted and positivity rates summarized by type of venue, race/ethnicity, age group, and US region. The overall median positivity rate was 5.1%. The highest rates were observed among men tested in juvenile (7.9%) and adult (6.8%) detention facilities, among blacks (6.7%), the 15 to 19 years old (6.1%) and 20 to 24 years old (6.5%) age groups, and among men screened in the southern United States (6.4%). Chlamydia rates among men are high in certain venues, particularly correctional settings, but also depend on the demographic composition of the target population and location. Programs considering male chlamydia screening programs should conduct pilot programs to assess chlamydia positivity as well as feasibility and cost in target venues.

Chlamydia screening--Australia should strive to achieve what others have not

Chlamydia screening programs overseas have failed to reduce chlamydia prevalence despite screening 20%-30% of young sexually active women. The Australian federal government announced in 2005 that it would provide $12.5 million for chlamydia control. Policymakers must look to chlamydia screening programs in other countries to learn from their experience. Australia has an excellent primary health care system and a strong track record in establishing highly successful public health programs. This experience places it in a strong position to design and implement an innovative chlamydia screening program to reduce chlamydia prevalence.

A new automated method for isolation of Chlamydia trachomatis from urine eliminates inhibition and increases robustness for NAAT systems

Chlamydia trachomatis is a leading cause of sexually transmitted infection. Diagnostic methods with easy non-invasive sample collection are important to increase testing and hence to reduce the spread of this infection. To enable more use of urine samples in C. trachomatis diagnostics, automation is an absolute requirement since obtaining high-quality DNA from urine specimens involves extensive processing. Here, we present a study in which a new automated sample preparation method, BUGS'n BEADS STI (BnB STI), was used up-front of the BDProbeTec ET end point analysis and compared with the full BDProbeTec ET method to analyze C. trachomatis in 1002 urine samples. The BnB STI system represents a new concept within magnetic sample preparation in which bacteria are first isolated from the sample material followed by purification of bacterial nucleic acid using the same magnetic particles. Similar sensitivity and specificity were obtained with both methods. None of the samples processed with BnB STI inhibited the BDProbeTec ET test whereas 1.8% showed inhibition when processed according to the manual BDProbeTect ET DNA preparation method. Moreover, the average MOTA scores obtained with the BnB STI system were 48% higher for all amplification controls and 57% higher for positive samples, compared to the manual sample preparation. Based on these results and the significant reduction in hands-on-time for urine sample processing, the automated BnB STI sample preparation method was implemented for routine analysis of C. trachomatis from urine samples.

Interventions for increasing chlamydia screening in primary care: a review

Background

Despite guidelines recommending opportunistic chlamydia screening of younger women, screening rates in some countries remain low. Our aim was to review the evidence for specific interventions aimed at increasing chlamydia screening rates in primary care.

Methods

A Medline search was conducted for controlled trials that assessed the effectiveness of interventions aimed at improving chlamydia screening rates in primary health care settings. The Medline search was done for studies in English published prior to December 2005 using the following key words: chlamydia, screening, intervention, primary care and GPs. In addition, the references cited in the articles were reviewed. Studies in English published prior to December 2005 were reviewed.

Results

Four controlled studies met the inclusion criteria – 3 were randomized studies and one was not. Strategies to increase screening rates included the use of educational packages targeting primary care physicians and the correction of barriers to screening within clinic systems. In 3 studies, the intervention was associated with an increase in screening rates of between 100% and 276% (p < 0.04). In the fourth study, the intervention was associated with a significant attenuation in declining screening rates over time (4% versus 34% decline, p = 0.04).

Conclusion

There are only a limited number of randomized or controlled studies that demonstrate improved chlamydia screening of younger women in primary care.

Chlamydia trachomatis among young Norwegian men: sexual behavior and genitourinary symptoms

OBJECTIVE

The study objective was to assess Chlamydia trachomatis (CT) prevalence, risk factors, and genitourinary symptoms among young men.

METHODS

Sexually active men 18 to 30 years old were recruited during April through October 2005 at the student health services and through field work at university campuses in 2 Norwegian cities. A total of 1,032 participants completed a questionnaire on sexual behavior and provided first-void urine for CT testing.

RESULTS

The overall CT prevalence was 7.8% (81 of 1,032). In multivariable analysis, >or=5 lifetime sexual partners (adjusted odds ratio [aOR]: 2.7, 95% confidence interval [CI]: 1.4-5.2), a burning sensation on urination (aOR: 5.7, 95% CI: 3.1-10.5), and penile discharge (aOR: 2.6, 95% CI: 1.1-6.3) were significant risk factors for a positive CT test, whereas condom use (last intercourse) was preventive (aOR: 0.4, 95% CI: 0.2-0.8).

CONCLUSIONS

A CT prevalence of 7.8% was found among male students. Promotion of increased testing among men is important to prevent CT transmission.

Diagnostic Tests for Chlamydial and Gonorrheal Infections

Chlamydia trachomatis and Neisseria gonorrhoeae are the two most prevalent bacterial sexually transmitted infections reported in the United States. The purpose of this article is to review the various tests available for diagnosing C. trachomatis and N. gonorrhoeae. The nucleic acid amplification tests are preferred owing to their high sensitivity and specificity and use on specimens obtained noninvasively. Non-amplified non-culture tests, such as the DNA probe test, remain a choice for settings in which nucleic acid amplification tests are not available or affordable. Culture is recommended for use on conjunctival, oropharyngeal, and rectal specimens and in cases of suspected abuse. In addition, for gonorrhea, culture is recommended when screening in populations with a low prevalence of infection. Point-of-care tests are limited by low sensitivity and should be used for only populations unlikely to return for follow-up.

Prevalence of Chlamydia trachomatis in Asymptomatic Brazilian Military Conscripts

BACKGROUND

Few data are available on the prevalence and risk factors for Chlamydia trachomatis infection among young men in Brazil.

OBJECTIVES

To assess prevalence and risk factors for C. trachomatis infection in male military conscripts.

METHODS

In 2000, 627 young men recruited for military service in Goiania, Goias, Brazil, were enrolled in this cross-sectional study. Participants completed a demographic and sexual risk behavior questionnaire, and urine samples were screened for C. trachomatis by polymerase chain reaction.

RESULTS

The prevalence of chlamydial infection among asymptomatic conscripts was 5.0% (95% confidence interval [CI], 3.3-7.3). In multivariate analysis, failure to use condoms (odds ratio [OR](adjusted) 5.3; 95% confidence interval [CI], 1.2-23.4; P = 0.028) and having more than 2 sexual partners in the last 2 months (OR(adjusted) 2.6; 95% CI, 1.1-6.9; P = 0.049) were significantly associated with positivity for C. trachomatis.

CONCLUSIONS

A substantial number of asymptomatic young male military recruits were infected with C. trachomatis, and risk factors for this infection were related to sexual behavior. Further research is required to determine if routine screening may be considered as a strategy to reduce prevalence among this population.

Incidence of sexually transmitted infections in asymptomatic healthy young Japanese men

The aim of this study was to estimate the incidence rates of asymptomatic sexually transmitted infections (STI) in young men in Sapporo, Japan. A survey of 204 healthy male volunteers was conducted. First-voided urine specimens were used for detection of Chlamydia trachomatis and Neisseria gonorrhoeae with polymerase chain reaction assay, and cotton swab wiping of the external genitalia was used for detection of human papillomavirus (HPV) with the Hybrid Capture method. The incidence rates were 3.4% for C. trachomatis and 5.9% for HPV. No N. gonorrhoeae was detected. In sexually active men who had regular sexual intercourse, the detection rate of C. trachomatis was 4.7% and that of HPV was 8.0%. Our study showed that the incidence rates of asymptomatic STIs were not negligible, and that we should provide screening programs for young men with a high risk for such unrecognized infections and study their natural histories.

Differences in demographics and risk factors among men attending public v non-public STD clinics in Baltimore, Maryland

OBJECTIVE

To compare the demographics and risk factors of men who utilise the services of a municipal public sexually transmitted disease (STD) clinic with those who utilise the services provided by a non-public men's STD clinic operated by a not for profit primary care clinic.

METHODS

A record based review of the characteristics and STD prevalence of men who visited a non-public STD clinic in Baltimore, Maryland, compared with those of a random sample of male attendees of a public STD clinic. Data abstracted from the records included information on age, race/ethnicity, self reported risk behaviours, and STD tests and results. We used chi2 analysis as well as bivariate and multivariate modelling to compare differences in categorical factors between clinics groups.

RESULTS

Men who utilised the services at the non-public STD clinic were more often white (71% v 3%, p<0.001), MSM (65% v 2%, p<0.001), and presented for general screening (52% v 15%, p<0.001) compared to those at the public clinic. In addition, they more frequently reported > or =3 partners (22% v 11%, p=0.005), and having an HIV positive partner (10% v 3%, p=0.005). Factors independently associated with attendance at non-public clinic in multivariate analysis were general screening as reason for visit (OR = 11.0, p<0.001), having 3+ partners in past month (OR=10.5, p=0.002), and "sometimes" using condoms (OR=3.6, p=0.033).

CONCLUSIONS

Non-public STD clinics can reach a distinct segment of the male population with high risk sexual behaviours that might not attend public STD clinics.