Chlamydia trachomatis reinfection rates among female adolescents seeking rescreening in school-based health centers

A Narrative Review on Spontaneous Clearance of Urogenital Chlamydia trachomatis: Host, Microbiome, and Pathogen-Related Factors

ABSTRACT

Chlamydia trachomatis (CT) is the most commonly reported sexually transmitted infection in the United States. Untreated urogenital infection in women can result in adverse sequelae such as pelvic inflammatory disease and infertility. Despite national screening and treatment guidelines, rates continue to rise; because most infections are asymptomatic, the actual prevalence of CT infection is likely significantly higher than reported. Spontaneous clearance of CT in women (in the absence of antibiotic treatment) has been described in multiple epidemiologic studies. Given the serious consequences and high prevalence of CT infection, there is growing interest in understanding this phenomenon and factors that may promote CT clearance in women. Spontaneous CT clearance is likely the result of complex interactions between CT, the host immune system, and the vaginal microbiota (i.e., the communities of bacteria inhabiting the vagina), which has been implicated in CT acquisition. Herein, we briefly review current literature regarding the role of each of these factors in spontaneous CT clearance, identify knowledge gaps, and discuss future directions and possible implications for the development of novel interventions that may protect against CT infection, facilitate clearance, and prevent reproductive sequelae.

Determinants and prediction of Chlamydia trachomatis re-testing and re-infection within 1 year among heterosexuals with chlamydia attending a sexual health clinic

Background

Chlamydia trachomatis (chlamydia) is one of the most common sexually transmitted infections (STI) globally, and re-infections are common. Current Australian guidelines recommend re-testing for chlamydia 3 months after treatment to identify possible re-infection. Patient-delivered partner therapy (PDPT) has been proposed to control chlamydia re-infection among heterosexuals. We aimed to identify determinants and the prediction of chlamydia re-testing and re-infection within 1 year among heterosexuals with chlamydia to identify potential PDPT candidates.

Methods

Our baseline data included 5,806 heterosexuals with chlamydia aged ≥18 years and 2,070 re-tested for chlamydia within 1 year of their chlamydia diagnosis at the Melbourne Sexual Health Center from January 2, 2015, to May 15, 2020. We used routinely collected electronic health record (EHR) variables and machine-learning models to predict chlamydia re-testing and re-infection events. We also used logistic regression to investigate factors associated with chlamydia re-testing and re-infection.

Results

About 2,070 (36%) of 5,806 heterosexuals with chlamydia were re-tested for chlamydia within 1 year. Among those retested, 307 (15%) were re-infected. Multivariable logistic regression analysis showed that older age (≥35 years old), female, living with HIV, being a current sex worker, patient-delivered partner therapy users, and higher numbers of sex partners were associated with an increased chlamydia re-testing within 1 year. Multivariable logistic regression analysis also showed that younger age (18-24 years), male gender, and living with HIV were associated with an increased chlamydia re-infection within 1 year. The XGBoost model was the best model for predicting chlamydia re-testing and re-infection within 1 year among heterosexuals with chlamydia; however, machine learning approaches and these self-reported answers from clients did not provide a good predictive value (AUC < 60.0%).

Conclusion

The low rate of chlamydia re-testing and high rate of chlamydia re-infection among heterosexuals with chlamydia highlights the need for further interventions. Better targeting of individuals more likely to be re-infected is needed to optimize the provision of PDPT and encourage the test of re-infection at 3 months.

Adolescents Accessing School-Based versus Family Planning Clinics: Chlamydia and Gonorrhea Testing and Treatment Outcomes

Simple Summary

Sexually Transmitted Infections, such as gonorrhea and chlamydia, are common in school-aged youths. These infections can cause significant health problems if not identified and treated early. Current estimates of how widespread these infections are among students receiving healthcare in schools, the role school-based clinics may have in gonorrhea and chlamydia testing and treatment, and information on how the COVID-19 pandemic affected testing and treatment, are lacking. This study was conducted in an urban metropolitan area in the United States, and included 2439 patients aged 13–17 years over a 2-year period. The patients were seen at four school-based and five family planning clinics. We found that 35% of those tested in school-based clinics were positive for chlamydia, and 10% were positive for gonorrhea. The rates of these infections were higher than previous reports from school settings (both pre-COVID-19 and the during COVID-19 pandemic). School-based clinics were able to treat patients with gonorrhea and chlamydia much faster (average ~6 days) than the family planning clinics (average ~18 days). This study shows us the critical role that school-based clinics play in the testing and treatment for gonorrhea and chlamydia infections, and the value of strengthening the services these clinics provide.

Abstract

The prevalence and treatment of chlamydia (CT) and gonorrhea (GC) at school-based clinics (SBCs) requires revisiting. To assess whether clinic type influences CT/GC testing and treatment for minors (individuals 13–17 years of age), our study compared four SBCs with five family planning clinics (FPCs) in the Houston, Harris County metropolitan area of Texas, USA for: (1) the prevalence of CT/GC infection (pre-COVID-19 and during COVID-19); (2) treatment rates at the last positive diagnosis; and (3) the time, in days, from testing-to-diagnosis and testing-to-treatment. Between January 2019 and December 2020, 2439 unique patients (1579 at SBCs, 860 at FPCs) were seen. Of the 1924 tests obtained, 39.2% and 15.9% were positive for CT and GC, respectively. The prevalence of CT and GC at SBCs was similar prior to COVID-19 vs. during the COVID-19 pandemic. SBCs were able to provide treatment significantly faster after diagnosis (mean, 6.07 days; 95% CI, 3.22–8.90; 94.7% were within 30 days) than FPCs (mean, 17.60 days; 95% CI, 10.15–25.12; 84.7% were within 30 days) (p = 0.0257). This comparison within our large clinic system, with consistent clinical management protocols, suggests that SBC care may be critical to ensuring optimal sexually transmitted infection management in minors.

Impact of an Electronic Medical Record Best Practice Alert on Expedited Partner Therapy for Chlamydia Infection and Reinfection

Background

Atrius Health implemented a best practice alert (BPA) to encourage clinicians to provide expedited partner therapy (EPT) in October 2014. We assessed (1) the impact of the BPA on EPT provision and chlamydial reinfection and (2) the impact of EPT on testing for chlamydia reinfection and reinfection rates.

Methods

We included patients ≥15 years with ≥1 positive chlamydia test between January 2013 and March 2019. Tests-of-reinfection were defined as chlamydia tests 28–120 days after initial infection, and corresponding positive results were considered evidence of reinfection. We used interrupted time series analyses to identify changes in (1) frequency of EPT, (2) tests-of-reinfection, and (3) reinfections after the BPA was released. Log-binomial regression models, with generalized estimating equation methods, assessed associations between (1) EPT and tests-of-reinfection and (2) EPT and reinfection.

Results

Among 7267 chlamydia infections, EPT was given to 1475 (20%) patients. Expedited partner therapy frequency increased from 15% to 22% of infections between January 2013 and September 2014 (β = 0.003, P = .03). After the BPA was released, EPT frequency declined to 19% of infections by March 2019 (β = −0.004, P = .008). On average, 35% of chlamydia infections received a test-of-reinfection and 7% were reinfected; there were no significant changes in these percentages after BPA implementation. Patients given EPT were more likely to receive tests-of-reinfection (prevalence ratio [PR] 1.09; 95% confidence interval [CI], 1.01–1.16) but without change in reinfections (PR 0.88; 95% CI, 0.66–1.17).

Conclusions

Best practice alerts in electronic medical record systems may not be effective at increasing EPT prescribing and decreasing chlamydial reinfection. However, patients given EPT were more likely to receive a test of chlamydia reinfection.

Fitz-Hugh-Curtis syndrome without salpingitis: Should contrast-enhanced computed tomography be a routine diagnostic procedure?

Fitz-Hugh-Curtis syndrome should be suspected in sexually active young women presenting with acute right upper quadrant pain even in the absence of lower abdominal pain. The risk of radiation exposure associated with computed tomography should also be considered while making a diagnosis of abdominal pain in young patients.

Demographic, Behavioral, and Clinical Characteristics of Persons Seeking Care at Sexually Transmitted Disease Clinics - 14 Sites, STD Surveillance Network, United States, 2010-2018

PROBLEM

Sexually transmitted diseases (STDs) are a major cause of morbidity in the United States, with an estimated $15.9 billion in lifetime direct medical costs. Although the majority of STDs are diagnosed in the private sector, publicly funded STD clinics have an important role in providing comprehensive sexual health care services, including STD and HIV screening, for a broad range of patients. In certain cases, STD clinics often are the only source of sexual health care for patients, particularly among gay, bisexual, and other men who have sex with men (MSM).

PERIOD COVERED

2010-2018.

DESCRIPTION OF THE SYSTEM

The STD Surveillance Network (SSuN) is an ongoing sentinel surveillance system for monitoring clinical information among patients attending STD clinics. SSuN is a collaboration of competitively selected state and city health departments that conduct facility-based sentinel surveillance in STD clinics. Information routinely collected through the course of patient encounters is obtained for all patients seeking care in the participating STD clinics. This information includes demographic, behavioral, and clinical characteristics (e.g., STD and HIV tests performed and STD and HIV diagnoses). This report presents 2010-2018 SSuN data from 14 STD clinics in five cities (Baltimore, Maryland; New York City, New York; Philadelphia, Pennsylvania; San Francisco, California; and Seattle, Washington) to describe the patient populations seeking care in these STD clinics. Estimated numbers and percentages of patients receiving selected STD-related health services were calculated for each year by using an inverse variance weighted random-effects model, adjusting for heterogeneity among SSuN jurisdictions. Trends in receipt of selected STD-related health services were examined and included HIV screening after an acute STD diagnosis among persons not previously known to have HIV infection, annual chlamydia screening among adolescent and young females, and extragenital chlamydia and gonorrhea screening among MSM.

RESULTS

During 2010-2018, the total number of annual visits made in the 14 participating STD clinics decreased 29.8% (from 145,728 to 102,275 visits), and the total number of unique patients examined in the clinics decreased 35.1% (from 94,281 to 61,172 patients). Decreases in the number of unique patients occurred both among men who have sex with women only (42.4%; from 37,842 in 2010 to 21,781 in 2018) and among females (51.4%; from 36,485 in 2010 to 17,721 in 2018). The decreases in the number of female patients were observed across all age groups, although they were more pronounced among females aged ≤24 years (66.4%; from 17,721 in 2010 to 5,962 in 2018). In contrast, the number of patients identified as MSM increased 44.0% (from 12,859 in 2010 to 18,512 in 2018), with the greatest increase among MSM aged ≥25 years (58.6%; from 9,918 in 2010 to 15,733 in 2018). Among visits during which an acute STD (defined as chlamydia, gonorrhea, or primary or secondary syphilis) was diagnosed, the percentage of visits during which an HIV test was performed within approximately 14 days of the STD diagnosis increased from 58.2% in 2010 to 70.2% in 2018. Among those patients tested, 1,672 HIV infections were identified, of which 84.0% were among MSM. Among females aged 15-24 years, the percentage screened for chlamydia in any calendar year increased from 88.6% in 2010 to 90.6% in 2018. However, because fewer females aged 15-24 years attended these clinics during the study period, the crude number of adolescent and young females tested for chlamydia decreased from 14,249 in 2010 to 4,507 in 2018. During 2010-2018, the percentage of females retested after their first positive chlamydia diagnosis during the same year ranged from 11.4% to 13.3%. During 2010-2018, the percentage of MSM tested for rectal chlamydia and rectal gonorrhea increased (from 54.7% to 57.8% and from 55.0% to 58.4%, respectively). During the same period, increases were noted in the percentage of MSM with diagnosed rectal chlamydia (from 15.5% in 2010 to 17.7% in 2018) and rectal gonorrhea (from 13.3% in 2010 to 17.1% in 2018). In contrast with pharyngeal chlamydia, pharyngeal gonorrhea screening was more common (from 69.5% in 2010 to 74.6% in 2018), and the percentage positive doubled during the study period (from 7.3% in 2010 to 14.8% in 2018). Pharyngeal chlamydia testing also increased (from 50.3% in 2010 to 72.9% in 2018), with concurrent decreases in positivity (from 4.2% in 2010 to 2.6% in 2018).

INTERPRETATION

During 2010-2018, changes occurred in the demographic composition of patients attending STD clinics participating in SSuN. Understanding trends in the demographic profile of STD patients and services provided can help identify addressable gaps in STD control efforts and direct public health action. Overall, fewer females, especially those aged 15-24 years, accessed care in these STD clinics during the study period. Untreated STDs among adolescent and young females can have serious consequences, including pelvic inflammatory disease and infertility. Additional efforts to monitor where adolescent and young females seek care and to ensure they are receiving quality STD-related health services are needed, especially considering increases in reported cases of STDs among females. Increases in the number of MSM attending STD clinics present a unique opportunity to reach this population with STD and HIV prevention services. Although a large percentage of STD cases are diagnosed outside of STD clinics, publicly funded STD clinics are an important safety-net provider of STD-related health services and provide vital STD-related health services for patient populations at risk for the consequences of STDs and HIV infection.

PUBLIC HEALTH ACTIONS

STD-related health services represent effective strategies for preventing STD and HIV transmission and acquisition or STD-related sequelae. Ensuring that all persons receive quality HIV and STD prevention and treatment services is vital for an effective public health approach to reducing STDs. STD clinics provide crucial safety-net services for preventing STD-related morbidity, including timely identification and treatment of curable STDs such as chlamydia, gonorrhea, and syphilis. Increases in the numbers of MSM attending STD clinics participating in SSuN provide additional opportunities for linking patients to high-impact HIV preventive services (e.g., pre-exposure prophylaxis), and the clinics are positioned to facilitate initiation or resumption of treatment among persons living with HIV.

Expedited Partner Therapy in Female Adolescents: A Study of Acceptance and the Impact on Reinfection Rates

BACKGROUND

Given the high risk of sexually transmitted infections (STIs) in adolescents and young adults (AYAs), this study evaluated expedited partner therapy (EPT) acceptance and STI reinfection rates in female AYA before and after availability of EPT.

METHODS

The pre-EPT cohort was a 3-year (November 2012 to November 2015) retrospective chart review of female AYA positive for Chlamydia trachomatis (CT) and/or Trichomonas vaginalis (TV) before introduction of EPT. An EPT protocol for CT and TV infections was implemented after legalization in Ohio in 2016. The post-EPT cohort was a prospective review of patients positive for CT and TV for 2 years (5/2016-5/2018) after EPT introduction. We evaluated EPT acceptance and compared reinfection rates (positive test 1-6 months after initial infection) in the pre-EPT versus post-EPT cohorts and by EPT acceptance.

RESULTS

Among patients offered EPT, 28% (67/237) with CT and 25% (24/97) with TV accepted EPT. There were no significant differences in the reinfection rates for CT or TV in the pre-EPT versus post-EPT cohorts (CT: 24% (57/240) vs 20% (38/192), P = 0.42; TV: 23% (22/97) versus 14% (12/87), P = 0.11). Although lower, reinfections rates were not significantly different among patients who accepted versus did not accept EPT (CT, 13% (6/48) vs 21% (23/110), P = 0.50 and TV, 6% (1/18) vs 18% (9/49), P = 0.69).

CONCLUSIONS

Despite the implementation of an EPT protocol, STI reinfection rates among female AYA remained high, and many declined EPT. Further research is needed to identify barriers to the provision and acceptance of EPT and ways to address these factors.

A Systematic Literature Review of Reviews on the Effectiveness of Chlamydia Testing

Chlamydia trachomatis is the most common bacterial sexually transmitted infection, causing significant morbidity and economic burden. Strategies like national screening programs or home-testing kits were introduced in some developed countries, yet their effectiveness remains controversial. In this systematic review, we examined reviews of chlamydia screening interventions to assess their effectiveness and the elements that contribute to their success to guide public policy and future research. We assessed English material published after 2000 in PubMed, the Cochrane Library, the British Nursing Index, Medical Database, and Sociological Abstracts, in addition to World Health Organization Global Health Sector Strategies, the European Center for Disease Prevention and Control guidelines, and the Prospective Register of Systematic Reviews. Systematic reviews that focused on chlamydia screening interventions were included. Using the socioecological model, we examined the levels of interventions that may affect the uptake of chlamydia screening. A total of 19 systematic reviews were included. Self-collection in home-testing kits significantly increased screening among girls and women 14-50 years of age. At the organizational level, using electronic health records and not creating additional costs facilitated testing. At the community level, outreach interventions in community and parent centers and homeless shelters achieved high screening rates. At the policy level, interventions with educational and advisory elements could result in significant improvements in screening rates.

Electronic Health Record Use in Public Health Infectious Disease Surveillance, USA, 2018-2019

PURPOSE OF REVIEW

Electronic health records (EHRs) are an excellent source of data for disease symptoms, laboratory results, and medical treatments. Thus, EHR data may improve the completeness of notifiable disease case reporting and enable longitudinal collection of disease data. The purpose of this review is to examine the current state of EHR use in public health infectious disease surveillance in the USA.

RECENT FINDINGS

A wide variety of EHR data is used in infectious disease surveillance. EHR data were used to assess the incidence of Lyme disease and identify newly diagnosed HIV infections. EHR disease detection algorithms combined laboratory reports, diagnosis codes, and medication orders to identify cases and, in the case of Lyme disease, found incidence rates 4-7 times higher than those from traditional surveillance. EHR data were also used to evaluate temporal trends in sexually transmitted disease testing, positivity, and re-testing in several primary care settings. Multiple studies were also able to control for additional confounders in multivariable models, such as number of sexual partners and concurrent infections, because of the breadth of data available in EHR systems. Studies highlighted in this review demonstrate that EHR data enhance provider-based and laboratory-based disease reports and may facilitate more complete case reporting. EHR data also provides corollary patient information that enables longitudinal disease reporting and analysis of important health outcomes. As public health infrastructure and investment allow health departments to establish closer relationships with healthcare providers, EHR data use in public health surveillance activities should continue to increase.

Patient-Delivered Expedited Partner Therapy for Chlamydia trachomatis Infection Among Female Adolescents Using School-Based Health Centers

INTRODUCTION

Expedited partner therapy (EPT) may reduce Chlamydia trachomatis reinfection. This pilot study was conducted to determine if female adolescents with C. trachomatis accept and deliver EPT to male sexual partners and whether it is associated with decreased C. trachomatis reinfection rates at 3 and 6 months.

METHOD

Forty-six female adolescents, aged 13 to 19years and diagnosed with C. trachomatis at two urban school-based health centers, participated in four visits over 6 months. Participants completed a self-administered self-efficacy scale and a sexual risk behavior and EPT questionnaire and were retested for C. trachomatis 3 and 6 months after treatment.

RESULTS

Overall, 65% accepted EPT, and 73% of those who accepted EPT delivered EPT to their partners. Eighty percent completed the 3-month visit, of these, 30% tested positive for C. trachomatis; 57% completed the 6-month visit, and of these, 15% tested positive for C. trachomatis. Acceptance of EPT was associated with reductions in C.trachomatis reinfection at 3 months (p = .04) but not at 6 months (p = .10). Delivery of EPT was not associated with reductions in C. trachomatis reinfection at 3 or 6 months (p = .08 and p = .44, respectively). Self-efficacy scales did not predict acceptance and delivery of EPT.

DISCUSSION

Although two-thirds of participants accepted EPT and acceptance of EPT was associated with reductions in C. trachomatis reinfection at 3 months, rates of reinfection were high. Implications of these findings are limited by the small sample size. Larger studies are needed to understand potential barriers to delivery of EPT.

Sexually Transmitted Infection Review for the Acute Care Pharmacist

PURPOSE

Review selected sexually transmitted infections (STIs) and treatment recommendations for pharmacists and providers practicing in the acute care setting.

SUMMARY

In 2015, the Centers for Disease Control and Prevention (CDC) published an updated guideline on the treatment of STIs with an emphasis on prevention and new diagnostic strategies to combat the growing problem of STIs in the United States. Despite this guidance, the incidence of infection has continued to grow. In October 2016, an in-depth analysis reported that 20 million new infections occur annually in the United States. With this growing burden of disease, it is pertinent that health-care providers optimize their treatment strategies to improve upon the management of STIs. Focusing on identification of asymptomatic- and symptomatic-infected persons, treatment, education, effective follow-up, and counseling for patients and sexual partners, emergency medicine pharmacists and providers can help minimize the negative long-term health consequences of STIs.

CONCLUSION

In the emergency department setting, clinical pharmacists and providers can play a crucial role in preventing and treating STIs and should continue to expand and keep current their knowledge of this topic.

Oral Chlamydia vaccination induces transmucosal protection in the airway

Although Chlamydia has been frequently detected in the gastrointestinal tracts of both humans and animals, it is not associated with any gastrointestinal pathology. We have recently shown that gastrointestinal Chlamydiamuridarum is not only non-pathogenic but also induces protective immunity in the genital tract. We now report that the transmucosal immunity induced by a single oral immunization with C.muridarum protected the mouse airway from a subsequent challenge infection. The oral immunization significantly reduced chlamydial burden in the airway as early as day 3 after intranasal challenge. As a result, the airway chlamydial spreading to extra-airway tissues was completely prevented on day 3 and significantly reduced on day 9. The immunized mice were protected from any significant systemic toxicity caused by the intranasal challenge since there was no significant bodyweight drop in the immunized mice. This robust protection correlated well with Chlamydia-specific antibodies that recognize chlamydial organism surface antigens and T cell responses that are dominated with a Th1 phenotype. The immunized mice developed high ratios of IgG2b/c over IgG1 levels and IFNγ-producing over IL-5- or IL-13-producing lymphocytes. Thus, we have demonstrated that oral vaccination with C. muridarum can induce Th1-dominant transmucosal immunity in the airway. Together with previous studies, we propose that non-pathogenic colonization of Chlamydia in the gastrointestinal tract be explored as an oral delivery system for inducing protection against infections and pathologies in extra-gastrointestinal tissues.

Nonpathogenic Colonization with Chlamydia in the Gastrointestinal Tract as Oral Vaccination for Inducing Transmucosal Protection

Chlamydia has been detected in the gastrointestinal tracts of humans and animals. We now report that gastrointestinal Chlamydia muridarum is able to induce robust transmucosal protection in mice. C. muridarum colonization in the gastrointestinal tract correlated with both a shortened course of C. muridarum genital tract infection and stronger protection against subsequent genital tract challenge infection. Mice preinoculated intragastrically with C. muridarum became highly resistant to subsequent C. muridarum infection in the genital tract, resulting in prevention of pathology in the upper genital tract. The transmucosal protection in the genital tract was rapidly induced, durable, and dependent on major histocompatibility complex (MHC) class II antigen presentation but not MHC class I antigen presentation. Although a deficiency in CD4⁺ T cells only partially reduced the transmucosal protection, depletion of CD4⁺ T cells from B cell-deficient mice completely abolished the protection, suggesting a synergistic role of both CD4⁺ T and B cells in the gastrointestinal C. muridarum-induced transmucosal immunity. However, the same protective immunity did not significantly affect C. muridarum colonization in the gastrointestinal tract. The long-lasting colonization with C. muridarum was restricted to the gastrointestinal tract and was nonpathogenic to either gastrointestinal or extragastrointestinal tissues. Furthermore, gastrointestinal C. muridarum did not alter the gut microbiota or the development of gut mucosal resident memory T cell responses to a nonchlamydial infection. Thus, Chlamydia may be developed into a safe and orally deliverable replicating vaccine for inducing transmucosal protection.

Chlamydia and gonorrhea screening and expedited partner therapy (EPT) practices of college student health centers

OBJECTIVE

To examine college student health centers' (SHCs) practices related to sexually transmitted disease (STD) screening and treatment over a 5-year period.

PARTICIPANTS

College SHCs that completed the ACHA Pap and STI Survey between 2010 and 2014.

METHODS

Chi-square tests were conducted with Cramer's V providing a measure of association.

RESULTS

Chlamydia screening of women under 25 years of age was a well-established practice. Almost one-third of SHCs did not report screening practices of men who have sex with men (MSM) consistent with current chlamydia and gonorrhea guidelines; however, there was improvement over time. Few college SHCs utilized expedited partner therapy (EPT), though fewer had blanket restrictions prohibiting its use in 2014 compared to 2010.

CONCLUSIONS

Over the 5-year period, more SHCs followed current best practices. Improvement in compliance with guidelines related to MSM STD screening as well as increased usage of EPT is needed to best address the needs of the diverse college student population.

Perceived risk of reinfection among individuals treated for sexually transmitted infections in Northern Ethiopia: implication for use in clinical practice

INTRODUCTION

The prevention of reinfection of sexually transmitted infections (STIs) is highly dependent on the level of risk perception and the subsequent adoption of preventive behaviors. While perceived risk is assumed to be key to adoption of preventive measures, the evidence regarding the predictors of perceived risk to STI reinfection are limited.

METHODS

This paper is based on a cross sectional facility based survey conducted in North Ethiopia from January to June; 2015. Patients attending public health facilities for STI care responded to a structured questionnaire at clinic exist. Ordinal logistic regression was employed to identify factors associated with risk perception.

RESULTS

Of the 1082 STI patients who participated in the study, 843(77.91%) indicated a high perceived risk of STI reinfection. The major factor associated with low perceived risk of reinfection was willingness to notify partner; the odds of being willing to notify partner was greater among those who perceived low risk (AOR=3.01, 95% CI: 2.13-4.25). In addition, low perceived risk was associated with female index cases (AOR=1.49, 95% CI: 1.07-2.08), those who had high school education and above (AOR=1.68, 95% CI: 1.07-2.65), those aged 25 years and above (AOR=1.52, 95% CI: 1.09-2.12), those who had a single partner (AOR=1.82, 95% CI: 1.20-2.74), and those who had low perceived stigma (AOR=1.42, 95% CI: 1.04-1.95).

CONCLUSION

The perceived risk of STI reinfection is high and strongly associated with willing to notify partner. Efforts to prevent STI reinfection need to consider interventions that enhance partner notification.

A Review of Expedited Partner Therapy for the Management of Sexually Transmitted Infections in Adolescents

Adolescents are at high risk of acquiring and becoming reinfected with sexually transmitted infections. Partner notification and treatment are essential to preventing the spread of sexually transmitted infections. Expedited partner therapy (EPT) is a method of partner treatment used by medical providers to treat patients' sexual partners without direct medical evaluation or counseling. The objective of this article is to review the current literature regarding EPT effectiveness, patients' attitudes and acceptance of EPT, and providers' views and practices surrounding the use of this method of partner treatment. In this article potential concerns associated with EPT use, current policy statements, and the legal status of EPT are discussed. EPT results in improved or equivalent rates of reinfection in adolescents and adults with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Overall, patients are accepting of this method of partner treatment, however, providers continue to have concerns that limit its routine use. Additional studies in adolescents will help providers better understand if EPT is a useful method to prevent reinfection in this population.

Striking ethnic variations in the epidemiology of Chlamydia trachomatis in Haifa District, Israel, throughout the years 2001-2015

Our objectives were to examine trends in the incidence of chlamydia over an extended period and compare the epidemiology of the infection between two distinct ethnic groups in Israel: Jews and Arabs. We examined the incidence rate of Chlamydia trachomatis infection among residents of Haifa District, northern Israel from 2001 to 2015, by reviewing archives of the Department of Epidemiology, Ministry of Health. Notified cases were stratified by age group, gender, and ethnic group. The overall incidence rate of Chlamydia was 10.8 cases per 100,000 population per year. The annual rate increased dramatically from 5.1 per 100,000 population in 2001, to an all-time high of 18.5 cases per 100,000 population in 2015 (P < 0.001), representing an increase of 362.7%. The most affected age group was 25-34 years of age. The estimated rate among Jewish inhabitants was ninefold higher than among Arabs. Only 3% recurrent episodes of Chlamydia were registered. The prevalence of HIV positivity among Chlamydia-infected patients was similar to that of the general population. In conclusion, Chlamydia in Haifa has been continuously increasing since 2001 and the infection is much more prevalent among patients of Jewish ethnicity, mainly due to more hazardous sexual practices in this population.

Lactobacillus plantarum producing a Chlamydia trachomatis antigen induces a specific IgA response after mucosal booster immunization

Mucosal immunity is important for the protection against a wide variety of pathogens. Traditional vaccines administered via parenteral routes induce strong systemic immunity, but they often fail to generate mucosal IgA. In contrast, bacteria-based vaccines comprise an appealing strategy for antigen delivery to mucosal sites. Vaginal infection with Chlamydia trachomatis can develop into upper genital tract infections that can lead to infertility. Therefore, the development of an effective vaccine against Chlamydia is a high priority. In the present study, we have explored the use of a common lactic acid bacterium, Lactobacillus plantarum, as a vector for delivery of a C. trachomatis antigen to mucosal sites. The antigen, referred as Hirep2 (H2), was anchored to the surface of L. plantarum cells using an N-terminal lipoprotein anchor. After characterization, the constructed strain was used as an immunogenic agent in mice. We explored a heterologous prime-boost strategy, consisting of subcutaneous priming with soluble H2 antigen co-administered with CAF01 adjuvant, followed by an intranasal boost with H2-displaying L. plantarum. The results show that, when used as a booster, the recombinant L. plantarum strain was able to evoke cellular responses. Most importantly, booster immunization with the Lactobacillus-based vaccine induced generation of antigen-specific IgA in the vaginal cavity.

Genital Chlamydia trachomatis: understanding the roles of innate and adaptive immunity in vaccine research

Chlamydia trachomatis is the leading cause of bacterial sexually transmitted disease worldwide, and despite significant advances in chlamydial research, a prophylactic vaccine has yet to be developed. This Gram-negative obligate intracellular bacterium, which often causes asymptomatic infection, may cause pelvic inflammatory disease (PID), ectopic pregnancies, scarring of the fallopian tubes, miscarriage, and infertility when left untreated. In the genital tract, Chlamydia trachomatis infects primarily epithelial cells and requires Th1 immunity for optimal clearance. This review first focuses on the immune cells important in a chlamydial infection. Second, we summarize the research and challenges associated with developing a chlamydial vaccine that elicits a protective Th1-mediated immune response without inducing adverse immunopathologies.

Retesting young STI clinic visitors with urogenital Chlamydia trachomatis infection in the Netherlands; response to a text message reminder and reinfection rates: a prospective study with historical controls

OBJECTIVES

The objective of this study is to assess the effect of reminder text messages 6 months after the initial treatment on retest and chlamydia reinfection rates in young heterosexuals compared with a historical control group and to assess factors associated with both outcomes.

METHODS

Heterosexual people (aged 16-23 years), testing positive for urogenital chlamydia, were offered a retest after 6 months. Participants received a text message reminder at 6 months after the initial chlamydia diagnosis. Rates of retest uptake and the result of the retest were analysed using Cox regression. Prevalence ratios (PRs) were calculated to identify factors associated with these outcomes. Furthermore, the retest rate was compared with the retest rate of a historical control group.

RESULTS

30.6% (253/838) of the study group returned within 5-8 months compared with 9.2% (140/1530) in the historical control group. Women and persons who were not notified for a sexually transmitted infection (STI) at inclusion were more likely to return for a retest. 20.4% (56/275) of participants had a chlamydia reinfection upon retesting. Reinfection was higher in participants reporting STI-related symptoms (PR 3.2, 95% CI 1.8 to 5.6) and in participants who were notified for an STI at retest (PR 5.3, 95% CI 2.4 to 11.5).

CONCLUSIONS

A text message reminder appeared to have a clear, positive impact on the resulting retest rate. These results also indicate that retesting is necessary to identify chlamydia reinfections.

The Role of Federally Qualified Health Centers in Delivering Family Planning Services to Adolescents

PURPOSE

The purpose of this article was to examine the role of community health centers (CHCs) in providing comprehensive family planning services to adolescents, looking at the range of services offered and factors associated with provision of these services.

METHODS

This study employed a mixed methods approach comprising a national survey of CHCs and six in-depth case studies of health centers to examine the organization and delivery of family planning services. We developed an adolescent family planning index comprising nine family planning services specifically tailored to adolescents. We analyzed the influence of state-level family planning policies, funding for adolescents, and organizational characteristics on the provision of these services in CHCs. The case studies identified barriers to the provision of family planning to adolescent patients.

RESULTS

The survey found substantial variation in the provision of family planning services at CHCs, with a mean of 6.33 out of a maximum score of 13 on the family planning adolescent services index. Title X funding and location within a favorable state policy environment were significantly associated with higher scores on the family planning adolescent services index (p value < .001 and .002, respectively). Case studies revealed barriers to adolescent family planning, including lack of funding, lack of knowledge, and limitations on school-based clinical services.

CONCLUSIONS

CHCs have the opportunity to play a significant role in providing high-quality family planning to low-income, medically underserved adolescents. Additional funding, resources, and a favorable policy climate would further improve CHCs' ability to serve the family planning needs of this special patient population.

[Genitourethral infections caused by D-K serotypes of Chlamydia trachomatis]

Sexually transmitted infections of the urogenital tract are most commonly caused by the intracellular bacteria Chlamydia trachomatis worldwide, resulting the clinical picture of acute urethritis in men as well as urethritis and endocervicitis in women. As women often present with few symptoms only or a completely symptom-free disease course, one of the most important long-term complications is chronic pelvic inflammatory disease often followed by the development of infertility caused by chronic scar formation. Well-organized screening programs are considered to have a leading role in the prevention of disease spreading and long lasting unwanted complications. Antibiotic treatment options are often influenced by special circumstances, such as pregnancy and several complicated clinical forms. The aims of the authors are to give a concise review on the current knowledge regarding Chlamydia trachomatis infections and summarize typical clinical signs, modern diagnostic techniques as well as accepted treatment protocols and basic aspects of screening.

Recent advances in understanding and managing Chlamydia trachomatis infections

Worldwide, Chlamydia trachomatis infections rank among the most common sexually transmitted infections (STI), and cause notable reproductive morbidity in women. Although advances in highly accurate and non-invasive diagnostic testing have allowed for better estimation of the burden of disease—especially the asymptomatic state—we still lack a true point-of-care test, and many infections go undetected and untreated. Moreover, limited resources and effort for managing sexual partners of those in whom infection is actually identified comprise a major challenge to control. Here, we review the current state of understanding of this common infection, and efforts to control it.

Chlamydia screening strategies and outcomes in educational settings: a systematic review

Chlamydia trachomatis (CT) screening programs have been established in educational settings in many countries during the past 2 decades. However, recent evidence suggests that high uptake of screening and management (treatment, partner notification, and retesting for reinfection) improves program effectiveness. We conducted a systematic review to understand the screening strategies, the extent of screening conducted, and uptake of management strategies in educational settings. Screening studies in educational settings were identified through a systematic search of published literature from 2005 to 2011. We identified 27 studies describing 30 screening programs in the United States/Canada (n = 10), Europe (n = 8), Australia/New Zealand (n = 5), and Asia (n = 4). Most studies targeted both male and female students (74%). Classroom-based strategies resulted in 21,117 testes overall (4 programs), followed by opportunistic screening during routine health examination (n = 13,470; 5 programs) and opportunistic screening at school-based health centers (n = 13,006; 5 programs). The overall median CT positivity was 4.7% (range, 1.3%-18.1%). Only 5 programs reported treatment rates (median, 100%; range, 86%-100%), 1 partner notification rate (71%), 1 retesting rate within a year of an initial CT diagnosis (47%), and 2 reported repeat positivity rates (21.1% and 26.3%). In conclusion, this systematic review shows that a variety of strategies have been used to screen large numbers of students in educational settings; however, only a few studies have reported CT management outcomes.

Testing and treatment for sexually transmitted infections in adolescents--what's new?

BACKGROUND

Significant changes are taking place in the diagnosis and management of sexually transmitted infections (STI) in adolescents and young adults.

FINDINGS

In this review article, we provide an update of STIs in adolescents and young adults including: (1) Adolescent risk; (2) Screening guidelines; (3) Clinical manifestations; (4) Diagnostic testing; (5) Treatment; and (6) Prevention; with an emphasis on "what's new" in the field.

CONCLUSIONS/SIGNIFICANCE

While the impacts of STI epidemiology and health care access are leading to new recommendations for screening and prevention, changes in technology and drug resistance are promoting new methods of STI testing and ongoing revisions of STI treatment recommendations.

Pediatric residents' knowledge, use, and comfort with expedited partner therapy for STIs

OBJECTIVE

We examined California pediatric residents' knowledge, practices, and comfort of providing expedited partner therapy (EPT) for sexually transmitted infections, by postgraduate year of training and presence of an adolescent medicine fellowship. We hypothesized that few residents are aware of EPT, and fewer are comfortable providing it; knowledge, practices, and comfort increase during residency; and presence of an adolescent medicine fellowship increases knowledge, practices, and comfort.

METHODS

Online anonymous questionnaires were completed by pediatric residents from 14 California programs.

RESULTS

Two hundred eighty-nine pediatric residents (41% response; mean age, 29.4 ± 2.7 years; 78% female) responded. Twenty-two percent reported being moderately or very familiar with EPT. Most correctly identified several EPT methods. Incorrectly identified as EPT included patient (55%), health department (42%), and provider (37%) referrals. Only 8% were aware of California's legal status regarding EPT. Sixty-nine percent knew that California law allows EPT for chlamydia and gonorrhea, but 38% incorrectly stated that EPT can be used to treat trichomoniasis. Fifty-two percent reported ever providing EPT, but 30% of them were uncomfortable doing so. Postgraduate year 1 residents were significantly more likely to report lack of experience as a barrier to prescribing EPT. Residents in programs with the presence of an adolescent medicine fellowship had significantly higher global knowledge scores and were more likely to practice EPT with fewer concerns.

CONCLUSIONS

California pediatric residents have knowledge gaps and discomfort providing EPT, and the presence of adolescent medicine fellowship is associated with increased EPT knowledge, use, and comfort among residents. Our findings demonstrate a need to improve EPT education in pediatric residencies.

Chlamydia trachomatis infections of the female genital tract: state of the art

Chlamydia trachomatis (CT) is the most common bacterial cause of sexually transmitted infections. CT infections are strongly associated with risk-taking behavior. Recommendations for testing have been implemented in many countries. The effectiveness of the screening programs has been questioned since chlamydia rates have increased. However, the complication rates including pelvic inflammatory disease, tubal factor infertility, and tubal pregnancy have been decreasing, which is good news. The complication rates associated with CT infection have clearly been over-estimated. Genetic predisposition and host immune response play important roles in the pathogenesis of long-term complications. CT plays a co-factor role in the development of cervical neoplasia caused by high-risk human papillomavirus (HPV) types. The evidence linking CT and other adverse pregnancy outcomes is weak. The current nucleic acid amplification tests perform well. A new genetic variant of CT was discovered in Sweden but has only rarely been detected elsewhere. Single-dose azithromycin remains effective against CT. Secondary prevention by screening is still the most important intervention to limit the adverse effects of CT on reproductive health.

Interventions to prevent sexually transmitted infections, including HIV infection

The Centers for Disease Control and Prevention (CDC) Sexually Transmitted Disease (STD) Treatment Guidelines were last updated in 2006. To update the "Clinical Guide to Prevention Services" section of the 2010 CDC STD Treatment Guidelines, we reviewed the recent science with reference to interventions designed to prevent acquisition of STDs, including human immunodeficiency virus (HIV) infection. Major interval developments include (1) licensure and uptake of immunization against genital human papillomavirus, (2) validation of male circumcision as a potent prevention tool against acquisition of HIV and some other sexually transmitted infections (STIs), (3) failure of a promising HIV vaccine candidate to afford protection against HIV acquisition, (4) encouragement about the use of antiretroviral agents as preexposure prophylaxis to reduce risk of HIV and herpes simplex virus acquisition, (5) enhanced emphasis on expedited partner management and rescreening for persons infected with Chlamydia trachomatis and Neisseria gonorrhoeae, (6) recognition that behavioral interventions will be needed to address a new trend of sexually transmitted hepatitis C among men who have sex with men, and (7) the availability of a modified female condom. A range of preventive interventions is needed to reduce the risks of acquiring STI, including HIV infection, among sexually active people, and a flexible approach targeted to specific populations should integrate combinations of biomedical, behavioral, and structural interventions. These would ideally involve an array of prevention contexts, including (1) communications and practices among sexual partners, (2) transactions between individual clients and their healthcare providers, and (3) comprehensive population-level strategies for prioritizing prevention research, ensuring accurate outcome assessment, and formulating health policy.

Chlamydia trachomatis genotypes and the Swedish new variant among urogenital Chlamydia trachomatis strains in Finland

Our aims were to genotype Chlamydia trachomatis strains present in urogenital samples and to investigate the occurrence of the Swedish new variant of C. trachomatis in Finland. We genotyped 160 C. trachomatis positive samples with ompA real-time PCR and analyzed 495 samples for the new variant. The three most prevalent genotypes were E (40%), F (28%), and G (13%). Only two specimens containing bacteria with the variant plasmid were detected. It seems that in Finland the percentage of infections due to genotypes F and G has slightly increased during the last 20 years. Genotypes E and G appear to be more common, and genotypes J/Ja and I/Ia appear to be less common in Europe than in the USA. Although the genotype E was the most common genotype among C. trachomatis strains, the new variant was rarely found in Finland.

Upsurge of chlamydial reinfection in a large Canadian city: an indication of suboptimal chlamydia screening practices?

OBJECTIVES

Given the limited knowledge on chlamydial reinfection (CR) in Canada, we examined the extent and predictors of CR in Montréal, a large Canadian city.

METHODS

We retrospectively studied all Montréal residents aged > or =10 years for whom > or =1 laboratory-confirmed chlamydial infection was reported to the public health department between 1988 and 2007 (n = 44,580). Each person was passively followed for two years after baseline infection or until reinfection. Socio-demographic factors and histories of other notifiable diseases were examined as potential predictors. Cox multivariate regression was used to model the time to CR. Survival analyses were stratified by age group (<25 vs. > or =25 years).

RESULTS

We estimated an overall two-year CR rate of 6.4%, an incidence density of 3.5 per 100 person-years, and a median time to reinfection of nine months. CR significantly increased over time. Among persons <25 years, reinfection was significantly more likely among females [adjusted hazard ratio (AHR): 1.58] and younger participants (10-14 years: AHR: 2.98; 15-19 years: AHR: 1.81). Residing within the South Central sector was deleterious for six months following initial infection after which it became protective. Among persons > or =25 years, a history of sexually transmitted infections increased the risk of reinfection (AHR: 1.79).

CONCLUSION

CR is a significant and growing problem in Montreal. The current recommendation for a single repeat screening six months posttreatment might be usefully complemented with additional screenings. Our results also underscore the importance of screening high-risk populations, particularly young women.

Bridging the gap: using school-based health services to improve chlamydia screening among young women

OBJECTIVES

We implemented a chlamydia screening program targeted at young women accessing reproductive health care services in a school-based setting, and we assessed racial/ethnic factors associated with infection.

METHODS

The California Family Health Council partnered with 9 health care agencies receiving federal Title X family planning funding and 19 educational institutions to implement the Educational Partnerships to Increase Chlamydia Screening (EPICS) program from January 2008 through December 2008.

RESULTS

EPICS agencies provided reproductive health services to 3396 unique sexually active females, 85% of whom self-reported no other source for reproductive health care. Chlamydia screening was provided to 3026 clients (89.1% chlamydia screening coverage). Of those screened for chlamydia, 5.6% tested positive. Clients who were African American (odds ratio [OR]=7.5; 95% confidence interval [CI]=3.9, 14.3), Pacific Islander (OR=4.1; 95% CI=1.1, 15.5), or Asian (OR=3.3; 95% CI=1.4, 8.1) were more likely to have a positive test than were White clients.

CONCLUSIONS

Chlamydia screening programs implemented in school-based settings have the capacity to identify and treat a significant amount of asymptomatic infection in a population that otherwise may not be reached. To facilitate screening, school-based clinics should implement outreach strategies that target their school population and clinical strategies that maximize opportunities for screening.

Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial

OBJECTIVE

To determine whether screening and treating women for chlamydial infection reduces the incidence of pelvic inflammatory disease over the subsequent 12 months.

DESIGN

Randomised controlled trial.

SETTING

Common rooms, lecture theatres, and student bars at universities and further education colleges in London.

PARTICIPANTS

2529 sexually active female students, mean age 21 years (range 16-27).

INTERVENTION

Participants completed a questionnaire and provided self taken vaginal swabs, with follow-up after one year. Samples were randomly allocated to immediate testing and treatment for chlamydial infection, or storage and analysis after a year (deferred screening controls).

MAIN OUTCOME MEASURE

Incidence of clinical pelvic inflammatory disease over 12 months.

RESULTS

Baseline prevalence of chlamydia was 5.4% (68/1254) in screened women and 5.9% (75/1265) in controls. 94% (2377/2529) of women were followed up after 12 months. The incidence of pelvic inflammatory disease was 1.3% (15/1191) in screened women compared with 1.9% (23/1186) in controls (relative risk 0.65, 95% confidence interval 0.34 to 1.22). Seven of 74 control women (9.5%, 95% confidence interval 4.7% to 18.3%) who tested positive for chlamydial infection at baseline developed pelvic inflammatory disease over 12 months compared with one of 63 (1.6%) screened women (relative risk 0.17, 0.03 to 1.01). However, most episodes of pelvic inflammatory disease occurred in women who tested negative for chlamydia at baseline (79%, 30/38). 22% (527/2377) of women reported being tested independently for chlamydia during the trial.

CONCLUSION

Although some evidence suggests that screening for chlamydia reduces rates of pelvic inflammatory disease, especially in women with chlamydial infection at baseline, the effectiveness of a single chlamydia test in preventing pelvic inflammatory disease over 12 months may have been overestimated. Trial registration ClinicalTrials.gov NCT00115388.

High-risk sexual behaviours and genital chlamydial infections in high school students in Southern Taiwan

Summary

The objective of this study was to determine the prevalence of high-risk sexual behaviours and sexually transmitted infections (STIs) and associated risk factors in Taiwanese high school students. Students in grades 10 and 11 (mean age: 15.9 ± 0.9; range: 13–20 years) at two schools were recruited. An anonymous online real-time computer-assisted self-interviewing questionnaire was designed to assess demographic factors and sexual behaviours. Urine specimens were tested for genital chlamydial and gonococcal infections. The same survey and screening was conducted one year later on the same group of students. Overall, 670 individual students (993 visits) were enrolled with 323 students in both surveys. Twenty-seven percent had had sexual intercourse, and more than three quarters (79%) of them had engaged in high-risk sexual behaviours. Having friends using drugs increased the odds of practicing high-risk sexual behaviours (odds ratio [OR] 1.99, 95% CI: 1.13 to 3.50). Among 182 sexually active students, 8.8% had chlamydial (female: 12.5%; male: 5.3%) and 1.1% had gonococcal infections. Having sex with someone met on the Internet was the most significant risk factor for acquiring chlamydia (OR 8.14, 95% CI: 2.82 to 23.51). In conclusion, this adolescent population reported high prevalence of high-risk sexual behaviours and had a high prevalence of chlamydia supportive of a potential epidemic of STIs and HIV.

Repeat infection with Chlamydia and gonorrhea among females: a systematic review of the literature

Determining the magnitude of chlamydia and gonorrhea reinfection is critical to inform evidence-based clinical practice guidelines related to retesting after treatment. PubMed was used to identify peer-reviewed English language studies published in the past 30 years that estimated reinfection rates among females treated for chlamydia or gonorrhea. Included in this analysis were original studies conducted in the United States and other industrialized countries that reported data on chlamydia or gonorrhea reinfection in females. Studies were stratified into 3 tiers based on study design. Reinfection rates were examined in relation to the organism, study design, length of follow-up, and population characteristics. Of the 47 studies included, 16 were active cohort (Tier 1), 15 passive cohort (Tier 2), and 16 disease registry (Tier 3) studies. The overall median proportion of females reinfected with chlamydia was 13.9% (n = 38 studies). Modeled chlamydia reinfection within 12 months demonstrated peak rates of 19% to 20% at 8 to 10 months. The overall median proportion of females reinfected with gonorrhea was 11.7% (n = 17 studies). Younger age was associated with higher rates of both chlamydia and gonorrhea reinfection. High rates of reinfection with chlamydia and gonorrhea among females, along with practical considerations, warrant retesting 3 to 6 months after treatment of the initial infection. Further research should investigate effective interventions to reduce reinfection and to increase retesting.