Screening Deficits, Inadequate Guidance, and the Growing Chlamydia Infection Epidemic

Key words:Chlamydia trachomatis, Screening, Bacterial vaginosis, Sexually transmitted diseases

The CDC recommends that sexually active adolescent girls be screened for Chlamydia trachomatis infection at least annually and that all sexually active women aged 20 to 25 years and women aged 25 years or older who have risk factors also receive an annual screening.¹ How well are these screening practices being observed and what are the implications?

Hoover and colleagues² analyzed data from the 2005 National Ambulatory Medical Care Survey to determine the number of visits made by nonpregnant women aged 15 to 25 years and 26 to 35 years in which testing for C trachomatis infection was not implemented. A total of 5.2 million visits were made to outpatient clinics by nonpregnant women aged 15 to 25 years in 2005. Of these women, 42% were insured through the Medicaid/State Children’s Health Insurance Program. More than a third (36.5%) belonged to a racial minority (21.3% were black, non-Hispanic; 15.2% were Hispanic).

Of the 1.2 million preventive visits made by young women who were asymptomatic, the opportunity to be tested for Chlamydia infection was missed in 84.0%. Of the 0.6 million visits in which signs or symptoms suggestive of Chlamydia infection were detected, no screening was done in 78.3%. Among the 0.4 million visits made by women aged 26 to 35 years who had signs and symptoms of Chlamydia infection, screening opportunities were missed in 86.3%.

The signs and symptoms suggestive of Chlamydia infection are not clearly delineated in the study by Hoover and colleagues. One can only presume that vaginal discharge had to be the number one criteria. Diagnostic testing for sexually transmitted diseases (STDs) is recommended by the CDC for women with mucopurulent cervicitis, pelvic inflammatory disease, abnormal vaginal discharge, dyspareunia, postcoital bleeding, abnormal vaginal discharge, or dysuria.

Similar research, basically using the same data source, was published earlier in 2008 by Hoover and Tao.³ These data demonstrated that the number of missed opportunities for screening for Chlamydia infection among young women in the ambulatory care setting was significant. Of 3.8 visits to obstetricians/gynecologists in which pelvic examinations were performed, the opportunity to screen for Chlamydia infection was missed in 82.1%. Of the 2.3 million visits in which a Papanicolaou test was performed, no testing for C trachomatis infection was performed in 77.3%. Among 3 million visits to primary care physicians in which a urinalysis was performed, the opportunity to screen for C trachomatis infection was missed in 99.1%.

The data are provocative, but the studies by Hoover and coauthors do not address the reasons for the deficits in screening for Chlamydia infection. Nor do they address why, as a nation, we are in the midst of a growing Chlamydia infection epidemic.

The national prevalence of Chlamydia infection was 347.8 per 100,000 population, according to the CDC’s STD Surveillance 2006: National Profile.⁴ The burden of infection was disproportionately on women, with 515.8 per 100,000 being affected. From 1987 through 2006, the prevalence of Chlamydia infection increased from 50.8 to 347.8 cases per 100,000 population. Part of the increase in detected cases is the result of the introduction of highly sensitive diagnostic tests. However, these tests have been available for the past 5 years and do not explain the current year-to-year increase of Chlamydia infection among women.

The failure to test falls on providers; however, the current situation is also one in which a governmental agency charged with the public good has fallen short of its mission statement. The CDC has largely abandoned its advocacy of infection/disease avoidance protection. Of greater significance for women, it has laid out guidelines that potentially misdirect practitioners from instituting a proper course of investigation and, ultimately, therapeutic intervention.

The CDC has recognized bacterial vaginosis (BV) as a defined entity rather than an induced abnormality of the bacterial flora of the vaginal tract. It has recommended intravaginal metronidazole gel, clindamycin cream, or oral metronidazole as first-line regimens for treating symptoms. The problem is that BV is a result of a number of divergent causes, among which are endocervical and endometrial Chlamydia infections.

Women given a diagnosis of BV have been shown to have a sexual profile similar to that of women at risk for STDs.^5,6 When the presence of STDs is investigated, specifically in young women with BV, a positive correlation can be found between Chlamydia infection and induced abnormality of the vaginal bacterial flora, which manifests as BV.^7,8 The guidelines advocated by the CDC for the treatment of BV, which overlook the threat of associated Chlamydia infection, leave women at risk for destruction of their fallopian tube structure and function, secondary infertility, and ectopic pregnancy.

In brief, a crisis in leadership related to STD education and prevention and also funding of needed programs is upon us. Until it is addressed, women will continue to pay a disproportionately high price, in part, in the form of the C trachomatis infection epidemic.

References:

REFERENCES
1. Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006 [published correction appears in MMWR. 2006;55:997]. MMWR. 2006;55(RR-11):1-94.
2. Hoover K, Tao G, Kent C. Low rates of both asymptomatic chlamydia screening and diagnostic testing of women in US outpatient clinics. Obstet Gynecol. 2008;112:891-898.
3. Hoover K, Tao G. Missed opportunities for chlamydia screening of young women in the United States. Obstet Gynecol. 2008;111:1097-1102.
4. Centers for Disease Control and Prevention. Chlamydia. In: STD Surveillance 2006: National Profile. www.cdc.gov/std/stats/pdf/national-profile.pdf. Accessed December 17, 2008.
5. Larsson PG, Platz-Christensen JJ, Sundström E. Is bacterial vaginosis a sexually transmitted disease? Int J STD AIDS. 1991;2:362-364.
6. Nilsson U, Hellberg D, Shoubnikova M, et al. Sexual behavior risk factors associated with bacterial vaginosis and Chlamydia trachomatis infection. Sex Transm Dis. 1997;24:241-246.
7. Joesoef MR, Wiknjosastro G, Norojono W, et al. Coinfection with chlamydia and gonorrhoea among pregnant women and bacterial vaginosis. Int J STD AIDS. 1996;7:61-64.
8. Yudin MH, Hillier SL, Wiesenfeld HC, et al. Vaginal polymorphonuclear leukocytes and bacterial vaginosis as markers for histologic endometritis among women without symptoms of pelvic inflammatory disease. Am J Obstet Gynecol. 2003;188:318-323.