Parallel observation of four methods for screening women under 25 years of age for genital infection with Chlamydia trachomatis

Young pregnant women's views on the acceptability of screening for chlamydia as part of routine antenatal care

Background

In pregnancy, untreated chlamydia infection has been associated with adverse outcomes for both mother and infant. Like most women, pregnant women infected with chlamydia do not report genital symptoms, and are therefore unlikely to be aware of their infection. The aim of this study was to determine the acceptability of screening pregnant women aged 16-25 years for chlamydia as part of routine antenatal care.

Methods

As part of a larger prospective, cross-sectional study of pregnant women aged 16-25 years attending antenatal services across Melbourne, Australia, 100 women were invited to participate in a face-to-face, semi structured interview on the acceptability of screening for chlamydia during pregnancy. Women infected with chlamydia were oversampled (n = 31).

Results

Women had low levels of awareness of chlamydia before the test, retained relatively little knowledge after the test and commonly had misconceptions around chlamydia transmission, testing and sequelae. Women indicated a high level of acceptance and support for chlamydia screening, expressing their willingness to undertake whatever care was necessary to ensure the health of their baby. There was a strong preference for urine testing over other methods of specimen collection. Women questioned why testing was not already conducted alongside other antenatal STI screening tests, particularly in view of the risks chlamydia poses to the baby. Women who tested positive for chlamydia had mixed reactions, however, most felt relief and gratitude at having had chlamydia detected and reported high levels of partner support.

Conclusions

Chlamydia screening as part of routine antenatal care was considered highly acceptable among young pregnant women who recognized the benefits of screening and strongly supported its implementation as part of routine antenatal care. The acceptability of screening is important to the uptake of chlamydia screening in future antenatal screening strategies.

A study of young peoples' attitudes to opportunistic Chlamydia testing in UK general practice

Objective

The objective of this study was to assess young people's perceptions of being offered a chlamydia screening test in United Kingdom (UK) general practice.

Methods

This is qualitative study that uses focus groups and individual interviews with young adults (age 16 – 18) to assess their views.

Results

These young adults were a difficult group to gain access to. Two focus groups, one in a school, the other in a general practice (family practice), and 2 individual interviews were undertaken (total sample 18). Respondents were unfamiliar with Chlamydia, but broadly aware of sexually transmitted infections. General practice (family practice) was perceived as an acceptable place to deliver opportunistic screening, but participants felt that tests should not be initiated by GP receptionists. Novel delivery routes such as schools and "Pub"/Bar dispensing machines were discussed. Issues around stigma and confidentiality were also raised.

Conclusion

Opportunistic Chlamydia screening in UK general practice (family practic seems acceptable to young adults. While this is a difficult group to gain access to for research, attempts need to made to ensure acceptability to users of this programme.

Prevalence of Chlamydia trachomatis in a public colposcopy clinic population

BACKGROUND

Chlamydia trachomatis is a major public health issue, with notifications of this sexually transmitted disease continuing to rise in Australia. Women attending colposcopy clinics are referred for treatment of cervical abnormalities often associated with human papilloma virus (HPV) infection. There is evidence that women who have acquired one sexually transmitted infection, such as HPV, are at higher risk of acquiring another. Women attending colposcopy clinics may therefore be at risk of undiagnosed infection with C. trachomatis.

AIM

To determine the prevalence of C. trachomatis in women attending a public metropolitan colposcopy clinic in Victoria.

METHODS

A cross-sectional study was performed. Institutional ethics committee approval and informed consent were obtained. Consecutive women attending the colposcopy clinic completed a questionnaire and had a swab collected from the endocervix for analysis by polymerase chain reaction for C. trachomatis. Positive screens were treated in accordance with best practice. Data were analysed with Minitab Version 2004 (Minitab Inc, State College, PA, USA).

RESULTS

Of 581 women approached to participate in the trial, consent was obtained from 568 women (98%) and final outcome data was available on 560 women (99%). The overall rate of chlamydial infection was 2.1% (95% CI 1.5-2.7%). However, in women aged 25 years or less the rate was 5.8% (95% CI 3.8-7.8%) and in women over 25 years it was only 0.9% (95% CI 0.4-1.4%). Apart from age, no other demographic factor was significantly associated with chlamydial infection.

CONCLUSION

Although the prevalence of chlamydial infection in the colposcopy clinic population as a whole does not warrant a policy for routine screening, screening directed at women aged 25 years or less would gain the greatest yields in terms of cost efficacy. Such a policy should be implemented as standard practice.

Chlamydia infection among pregnant women and those seeking termination

A total of 60 women tested positive for chlamydia during the study period. Of these, 75% (n = 45) were pregnant and were divided into those seeking termination (38%) and the antenatal group (62%). Of all pregnant chlamydia-positive women, 35% were teenagers. Most were aged <25 years, but if all test-positive women up to 30 years were included, 100% infections among the termination group and 92% infection among the antenatal group were detected. Of all chlamydia-positive pregnant women, 69% were nulliparous and 15.6% had multiple sexual partners. While 28.6% of the women in the antenatal group were married, in the termination group, none were married (p = 0.02). All women in the termination group were asymptomatic, while 75% of the antenatal chlamydia-positive women were emergency admissions (p < 0.0001). To conclude, opportunistic screening should be offered to pregnant women aged 25 - 29 years, to enhance detection. Testing strategies should focus on testing pregnant women of <19 years.

Vulvovaginal-swab or first-catch urine specimen to detect Chlamydia trachomatis in women in a community setting?

Screening for chlamydia in women is widely recommended. We evaluated the performance of two nucleic acid amplification tests for detecting Chlamydia trachomatis in self-collected vulvovaginal-swab and first-catch urine specimens from women in a community setting and a strategy for optimizing the sensitivity of an amplified enzyme immunoassay on vulvovaginal-swab specimens. We tested 2,745 paired vulvovaginal-swab and urine specimens by PCR (Roche Cobas) or strand displacement amplification (SDA; Becton Dickinson). There were 146 women infected with chlamydia. The assays detected 97.3% (95% confidence interval [CI], 93.1 to 99.2%) of infected patients with vulvovaginal-swab specimens and 91.8% (86.1 to 95.7%) with urine specimens. We tested 2,749 vulvovaginal-swab specimens with both a nucleic acid amplification test and a polymer conjugate-enhanced enzyme immunoassay with negative-gray-zone testing. The relative sensitivities obtained after retesting specimens in the negative gray zone were 74.3% (95% CI, 62.8 to 83.8%) with PCR and 58.3% (95% CI, 46.1 to 69.8%) with SDA. In community settings, both vulvovaginal-swab and first-catch urine specimens from women are suitable substrates for nucleic acid amplification tests, but enzyme immunoassays, even after negative-gray-zone testing, should not be used in screening programs.

Chlamydia in gynecologic practice

The focus on Chlamydia trachomatis in gynecologic practice 20 years ago was in treating its potential consequences: pelvic inflammatory disease, infertility and ectopic pregnancy. Although these conditions are still important, the current focus of C. trachomatis management for the obstetrician and gynecologist is early detection and treatment. The majority of women with C. trachomatis are asymptomatic, therefore, screening programs are being devised so that C. trachomatis can be treated prior to the occurence of any adverse consequences. Novel tests have allowed the use of urine samples and self-collected vulvovaginal swabs in the detection of C. trachomatis. This article will review the consequences of C. trachomatis infection in women, methods of identification of the organism, the prevalence in various populations, and treatment and screening strategies.

Evaluation of endocervical, first-void urine and self-administered vulval swabs for the detection of Chlamydia trachomatis in a miscarriage population

OBJECTIVE

To compare, in parallel, different approaches of opportunistically screening women with bleeding in early pregnancy for Chlamydia trachomatis.

DESIGN

Prospective observational [corrected] study.

SETTING

Early pregnancy assessment unit, University hospital, Scotland, UK.

POPULATION

Over 200 consecutive women admitted to an early pregnancy assessment unit were recruited. All had a positive pregnancy test, a history of vaginal bleeding and were less than 24 weeks of gestation. Women with recent antibiotic use, heavy vaginal bleeding and cervical shock excluded.

METHODS

Each women provided two or more of the following specimens: a self-administered vulval swab, first-void urine and/or endocervical swab. Following screening, each completed a semi-structured questionnaire assessing the acceptability of each method undertaken.

MAIN OUTCOME MEASURE

Subjective rating of the screening methods; prevalence; method performance, including proportion requiring repeat testing.

RESULTS

The majority accepted screening, with moderate prevalence rates (95% CI) 3.9% (2.0-7.4%) identified. All positive women were less than 30 years of age. Parallel screening exposed the potential of reduced test performance with urine. Non-invasive sampling was more acceptable, but more likely to require repeat testing.

CONCLUSION

Both acceptability and the effect of bleeding on test performance need further assessment before a particular specimen can be recommended for screening this population of women for C. trachomatis.