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Vodstrcil LA, McIver R, Huston WM, Tabrizi SN, Timms P, Hocking JS. The Epidemiology of Chlamydia trachomatis Organism Load During Genital Infection: A Systematic Review. J Infect Dis 2014; 211:1628-45. [PMID: 25492913 DOI: 10.1093/infdis/jiu670] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/26/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The role of organism load in Chlamydia trachomatis infection is not well understood. We conducted a systematic review to investigate the epidemiology of C. trachomatis organism load in human genital chlamydia infection. METHODS Embase, PubMed, and Medline databases were searched for literature published through August 2014. English-language publications that quantified load in humans were eligible. Participant characteristics and laboratory data were extracted. RESULTS A total of 737 records were identified, and 29 publications involving 40 883 participants were included. In women, load was highest for cervical swabs and lowest for urine specimens. In men, load was highest for rectal swabs and similar for urethral swabs and urine specimens. Evidence of any association between load and age, serovar, risk of transmission, hormone levels, and concurrent sexually transmitted infections was inconsistent. Eight of 9 culture-based studies found an association between load and signs and symptoms, in contrast with only 3 of 8 nucleic acid amplification test (NAAT)-based studies (P = .03). CONCLUSION Chlamydia organism load varies by specimen type and site of sampling, and viable chlamydia organism load may be a more important indicator of severity of infection than total load measured by NAAT.
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Affiliation(s)
- Lenka A Vodstrcil
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne Melbourne Sexual Health Centre, Carlton Murdoch Children's Research Institute, Parkville
| | - Ruthy McIver
- Sydney Sexual Health Centre, South Eastern Sydney Local Health District, Sydney
| | - Wilhelmina M Huston
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane
| | - Sepehr N Tabrizi
- Murdoch Children's Research Institute, Parkville Department of Obstetrics and Gynaecology, University of Melbourne, The Royal Women's Hospital
| | - Peter Timms
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane University of the Sunshine Coast, Sippy Downs, Australia
| | - Jane S Hocking
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne
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Abstract
In the majority of women chlamydia infections remain asymptomatic but they may increase the risk for tubal factor subfertility. Pelvic inflammatory disease (PID) and its chronic sequelae are associated with chlamydial IgG antibody formation in serum, and a correlation between the height of antibody titres and the presence of tubal factor subfertility has been established. The predictive value of chlamydia antibody testing (CAT) is limited however. Several factors affecting sensitivity and specificity of CAT have been identified. Because it is assumed that the presence of chlamydial heat shock proteins (HSPs) may be indicative of chronic inflammation, chlamydial HSP60 antibody testing has been evaluated in its prediction of tubal factor subfertility.
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Affiliation(s)
- Jolande A Land
- Department of Obstetrics and Gynaecology, Research Institute GROW, Academisch Ziekenhuis Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
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Affiliation(s)
- D Taylor-Robinson
- Imperial College School of Medicine at St Mary's, London, United Kingdom
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Taylor-Robinson D. Chlamydia diagnosis: are the advances answering the problems of clinical practice? J Eur Acad Dermatol Venereol 1995. [DOI: 10.1111/j.1468-3083.1995.tb00529.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Thomas BJ, MacLeod EJ, Taylor-Robinson D. Evaluation of a commercial polymerase chain reaction assay for Chlamydia trachomatis and suggestions for improving sensitivity. Eur J Clin Microbiol Infect Dis 1995; 14:719-23. [PMID: 8565995 DOI: 10.1007/bf01690884] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A commercial polymerase chain reaction (PCR) assay (Amplicor, Roche) for Chlamydia trachomatis was compared with a direct fluorescent antibody (DFA) test using urethral and cervical samples, many of which on the basis of prior testing by DFA contained small rather than large numbers of elementary bodies. Urine samples were collected from patients in a sequential unselected manner. Of 244 clinical specimens (138 male urethral and cervical; 106 male and female urine), 66 were positive by both DFA and PCR and 141 were negative by both tests. Nine samples were DFA negative and PCR positive, and 28 samples were DFA positive and PCR negative. However, 24 (86%) of the latter samples contained fewer than ten elementary bodies. When serial dilutions of laboratory stock strains (serovars E and H) were tested, the DFA test detected Chlamydia trachomatis at a dilution tenfold greater than the PCR. Furthermore, of five DFA-positive clinical samples, three that were PCR negative when tested according to the manufacturer's instructions were positive when they were diluted less. A modification of the PCR assay along these lines might improve sensitivity.
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Affiliation(s)
- B J Thomas
- MRC Sexually Transmitted Diseases Research Group, St. Mary's Hospital
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Thejls H, Gnarpe J, Gnarpe H, Larsson PG, Platz-Christensen JJ, Ostergaard L, Victor A. Expanded gold standard in the diagnosis of Chlamydia trachomatis in a low prevalence population: diagnostic efficacy of tissue culture, direct immunofluorescence, enzyme immunoassay, PCR and serology. Genitourin Med 1994; 70:300-3. [PMID: 8001937 PMCID: PMC1195269 DOI: 10.1136/sti.70.5.300] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the diagnostic efficacy of chlamydia culture, direct immunofluorescence (DFA), direct enzyme immunoassay (EIA), polymerase chain reaction (PCR) and serology by defining positive culture or at least two positive non-culture tests as true positive. SETTING Three gynaecological departments located in separate areas of Sweden. PATIENTS AND DESIGN All pregnant women requesting abortion during a six month period were included. In cases with unconfirmed non-culture tests, reculture with multiple passage and PCR on the culture transport medium was performed for confirmation. Serum was analysed for chlamydial antibodies type IgG, IgM and IgA using microimmunofluorescence. RESULTS 18 of 419 (4.3%) patients were positive for chlamydia according to the defined criteria. Twelve of 419 (2.9%) were positive in standard culture (primary inoculation). The sensitivity of standard culture, DFA, EIA and PCR were 66.7%, 77.8%, 64.7% and 71.4% respectively. The specificity 100% (by definition), 99.5%, 100%, 100% respectively. The positive predictive value 100% (by definition), 87.5%, 100%, 100% respectively. Negative predictive value 98.5%, 99.0%, 98.5%, 98.9% respectively. Serum IgG titre of > or = 64 and > or = 1024 gave positive predictive values of 10% and 21% respectively. CONCLUSIONS When an expanded gold standard is used, the specificity and positive predictive value of the non-culture tests used are comparable with that of standard culture even in this low prevalence population. Standard culture underestimated the chlamydia prevalence by 33%. The prevalence found represents a decrease from 10 to 2.9% of culture verified chlamydia during four years in comparable populations. Chlamydial antibodies of certain immunological classes are not necessarily present in cases with chlamydia.
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Affiliation(s)
- H Thejls
- Department of Obstetrics and Gynaecology, Gävle Central Hospital, Sweden
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Vanrompay D, Van Nerom A, Ducatelle R, Haesebrouck F. Evaluation of five immunoassays for detection of Chlamydia psittaci in cloacal and conjunctival specimens from turkeys. J Clin Microbiol 1994; 32:1470-4. [PMID: 8077391 PMCID: PMC264021 DOI: 10.1128/jcm.32.6.1470-1474.1994] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Five commercially available immunoassays were evaluated for the detection of Chlamydia psittaci in cloacal and conjunctival swabs from industrially raised turkeys: IMAGEN (DAKO Diagnostics, Ely, Cambridgeshire, United Kingdom), Chlamydia CEL-VET IF (Cellabs, Brookvale, Australia), IDEIA (DAKO Diagnostics), CELISA (Cellabs), and CLEARVIEW (Unipath, Bedford, United Kingdom). Results were compared with isolation in Buffalo Green Monkey cells as a reference method. For the conjunctival samples, the sensitivities of the IMAGEN test, the Chlamydia CEL-VET IF test, the IDEIA, the CELISA, and the CLEARVIEW test were found to be 100, 66, 0, 0, and 0%, respectively, as compared to the reference test. Also for the conjunctival samples, the specificities of the IMAGEN test, the Chlamydia CEL-VET IF test, and the IDEIA were found to be 100, 11, and 92.8%, respectively. For the cloacal specimens, the sensitivities of the IMAGEN test, the Chlamydia CEL-VET IF test, the IDEIA, the CELISA, and the CLEARVIEW test were found to be 100, 93.3, 26.6, 0, and 53.3%, respectively. Also for the cloacal specimens, the specificities of the IMAGEN test, the Chlamydia CEL-VET IF test, the IDEIA, and the CLEARVIEW test were found to be 92, 12, 100, and 88%, respectively. The IMAGEN test was the most sensitive and specific direct chlamydia antigen detection test for cloacal and conjunctival samples from turkeys.
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Affiliation(s)
- D Vanrompay
- Department of Avian Diseases, State University of Ghent, Belgium
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Hay PE, Thomas BJ, Horner PJ, MacLeod E, Renton AM, Taylor-Robinson D. Chlamydia trachomatis in women: the more you look, the more you find. Genitourin Med 1994; 70:97-100. [PMID: 8206484 PMCID: PMC1195202 DOI: 10.1136/sti.70.2.97] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To determine the extent to which testing of multiple sites and samples is required to define whether a woman is Chlamydia trachomatis-positive. DESIGN One-hundred and fifty women attending the Genitourinary Medicine clinic at St Mary's Hospital were enrolled; they had not received antichlamydial antibiotics in the previous three months, were not in a high-risk group for HIV infection, or pregnant, or using an intrauterine contraceptive device. Thirty-two women were re-examined three months after recruitment. METHODS An urethral specimen was Gram stained (smear) and cultured for gonococci. Another urethral specimen was taken to detect C trachomatis elementary bodies (EBs) by the MicroTrak direct fluorescent antibody (DFA) test (Syva). An endocervical swab specimen was Gram stained (smear) and cultured for gonococci. One of two other endocervical swabs was used for the DFA test and was then placed in medium which was centrifuged in a MicroCentaur at 13,000 rpm for 10 min; the deposit was examined by using the DFA test. The first 15-20 ml of voided urine (first pass urine; FPU) was also centrifuged and the deposit tested similarly. RESULTS Of 182 cervical smears and/or deposits tested for C trachomatis, 38 were positive; more cervical deposits (37) than smears (26) were positive and, of these, one-fifth of the deposits and one-third of the smears contained fewer than 10 elementary bodies. Of 162 paired urethral smears and FPU deposits available, one or other specimen of 36 pairs was chlamydia-positive, that is 31 smears and 32 deposits; of these, two-fifths of the smears and half of the deposits contained fewer than 10 EBs. Of 150 sets of cervical and urinary tract samples tested, 31 were chlamydia-positive at both sites, six in the cervix alone and four in the urinary tract alone. Of 139 women for whom there were valid first visit sample results, 36 (26%) were chlamydia-positive in the cervix, 34 (25%) in the urinary tract and 41 (29%) had at least one sample from either site positive. Overall, DFA tests of deposits from centrifuged cervical specimens achieved the highest sensitivity (88%) and those of cervical smears the lowest (70%). CONCLUSIONS Deposits from centrifuged cervical specimens were C trachomatis-positive more often than were cervical smears. Testing deposits from centrifuged urines was as successful as testing urethral smears. One-fifth (cervical deposits) to one-half (urine deposits) of specimens contained fewer than 10 EBs. The urinary tract was chlamydia-positive almost as frequently as the cervix but both sites needed to be tested to define whether a woman was chlamydia-positive.
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Affiliation(s)
- P E Hay
- Division of Sexually Transmitted Diseases, Clinical Research Centre, Harrow, Middlesex, UK
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Thomas BJ, MacLeod EJ, Taylor-Robinson D. Evaluation of sensitivity of 10 diagnostic assays for Chlamydia trachomatis by use of a simple laboratory procedure. J Clin Pathol 1993; 46:912-4. [PMID: 8227407 PMCID: PMC501617 DOI: 10.1136/jcp.46.10.912] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AIMS To determine the sensitivity of commercially available diagnostic assays for Chlamydia trachomatis using a simple method. METHODS Nine commercial assays and an "in-house" polymerase chain reaction (PCR) were evaluated using serial dilutions of a laboratory grown H serovar--four of them using a laboratory grown E serovar. Seven of the assays were further tested using dilutions of several cervical samples known to contain chlamydiae. RESULTS The most sensitive assays were the MicroTrak direct fluorescent antibody (DFA) test (Syva) and the PCR which detected C trachomatis at a 10(-8) dilution of the H serovar, while the two least sensitive, Clearview (Unipath) and TestPack (Abbott), were positive only at 10(-4) and 10(-3) dilutions, respectively. A range of enzyme immunoassays (EIAs) and a nucleic acid hybridisation test were of intermediate sensitivity. The results with serovar E were consistent with these. When clinical samples were examined, the DFA test detected C trachomatis in dilutions at least 10-fold greater than any other assay. CONCLUSIONS The range of sensitivity of diagnostic assays determined by the laboratory dilution procedure is very wide. Sensitivity assessed in this way, however, reflects the ability of the assays to detect C trachomatis in large scale clinical trials. The dilution procedure, which is simple to undertake, could therefore be applied by any laboratory before a new diagnostic method is considered for routine use.
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Affiliation(s)
- B J Thomas
- Division of Sexually Transmitted Diseases, Clinical Research Centre, Harrow, Middlesex
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Thomas BJ, MacLeod EJ, Taylor-Robinson D. Evaluation of sensitivity of 10 diagnostic assays for Chlamydia trachomatis by use of a simple laboratory procedure. J Clin Pathol 1993; 46:408-10. [PMID: 8320320 PMCID: PMC501247 DOI: 10.1136/jcp.46.5.408] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AIMS To determine the sensitivity of commercially available diagnostic assays for Chlamydia trachomatis using a simple method. METHODS Nine commercial assays and an "in-house" polymerase chain reaction (PCR) were evaluated using serial dilutions of a laboratory grown H serovar--four of them using a laboratory grown E serovar. Seven of the assays were further tested using dilutions of several cervical samples known to contain chlamydiae. RESULTS The most sensitive assays were the MicroTrak direct fluorescent antibody (DFA) test (Syva) and the PCR which detected C trachomatis at a 10(-8) dilution of the H serovar, while the two least sensitive, Clearview (Unipath) and TestPack (Abbott), were positive only at 10(-4) and-3 dilutions, respectively. A range of enzyme immunoassays (EIAs) and a nucleic acid hybridisation test were of intermediate sensitivity. The results with serovar E were consistent with these. When clinical samples were examined, the DFA test detected C trachomatis in dilutions at least 10-fold greater than any other assay. CONCLUSIONS The range of sensitivity of diagnostic assays determined by the laboratory dilution procedure is very wide. Sensitivity assessed in this way, however, reflects the ability of the assays to detect C trachomatis in large scale clinical trials. The dilution procedure, which is simple to undertake, could therefore be applied by any laboratory before a new diagnostic method is considered for routine use.
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Affiliation(s)
- B J Thomas
- Division of Sexually Transmitted Diseases, Clinical Research Centre, Harrow, Middlesex
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Affiliation(s)
- D Taylor-Robinson
- Division of Sexually Transmitted Diseases, Clinical Research Centre, Harrow, Middlesex, U.K
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Taylor-Robinson D. The value of non-culture techniques for diagnosis of Chlamydia trachomatis infections: making the best of a bad job. Eur J Clin Microbiol Infect Dis 1992; 11:499-503. [PMID: 1526232 DOI: 10.1007/bf01960803] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- D Taylor-Robinson
- Division of Sexually Transmitted Diseases, Clinical Research Centre, Harrow, Middlesex, UK
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Byrne MA, Turner MJ, Griffiths M, Taylor-Robinson D, Soutter WP. Evidence that patients presenting with dyskaryotic cervical smears should be screened for genital-tract infections other than human papillomavirus infection. Eur J Obstet Gynecol Reprod Biol 1991; 41:129-33. [PMID: 1657654 DOI: 10.1016/0028-2243(91)90090-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
One hundred and fifty-four women with dyskaryotic cervical smears were referred for colposcopy from two distinct population groups, namely those who initially had attended a sexually transmitted disease (STD) clinic, and those who came from general practitioners and family planning and gynaecology clinics (non-STD group). They were investigated to determine the prevalence and pattern of concomitant lower genital-tract infections. The mean age in each group was 25 years. Microbiological studies revealed that 79 (51%) of the women were infected, more than one infection occurring in 16 (10%) of them. Infection was present in 40% of the non-STD group and 66% of the STD group. The pattern of infection was remarkably similar in each group. Bacterial vaginosis was the most common disease in each group and accounted for more than one-third of all infections detected. Six patients had genital warts, 15 harboured Chlamydia trachomatis and 4 had gonorrhoea. Two-thirds of those with C. trachomatis and half of those with gonorrhoea were asymptomatic. We conclude that an abnormal cervical smear is frequently a marker of concomitant lower genital tract infection. Comprehensive microbiological investigations in order to effect appropriate treatment are easily achieved on women in the STD group, but the cost may be seen as prohibitive for those in the non-STD group. For these women we suggest a less comprehensive microbiological approach that provides a compromise strategy of management.
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Affiliation(s)
- M A Byrne
- Department of Genito-urinary Medicine, St Mary's Hospital, London, U.K
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Taylor-Robinson D, Thomas BJ. Laboratory techniques for the diagnosis of chlamydial infections. Genitourin Med 1991; 67:256-66. [PMID: 2071132 PMCID: PMC1194684 DOI: 10.1136/sti.67.3.256] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Yolk-sac inoculation of embryonated eggs was superseded 25 years ago by the use of cell cultures (often McCoy) for the isolation of Chlamydia trachomatis. Centrifugation of specimens onto the cell monolayers was shown to increase sensitivity, but little of late has further improved sensitivity which is at least ten-fold greater than that of eggs. However, culture is slow and labour intensive so that non-cultural techniques without these drawbacks have come to dominate. Direct fluorescent antibody (DFA) tests are rapid and have sensitivities that range from 70% to 100% for men and 68% to 100% for women, and specificities that range from 87% to 99% for men and 82% to 100% for women; if the tests are read by competent observers the values are at the top end of the ranges. The detection rate may be enhanced even further by relatively low-speed centrifugation of specimens before staining. Skilled reading is not a feature of enzyme immunoassays (EIAs) which according to the literature have sensitivities that range from 62% to 97% for men and 64% to 100% for women, and specificities that range from 92% to 100% for men and 89% to 100% for women. However, comparison against poor reference tests is responsible for most of the higher values and the clinician should not be misled into believing that EIAs have excellent sensitivity; the lower values in the ranges are closer to reality. Furthermore, EIAs that are being designed for use by general practitioners should be regarded with the greatest caution since lack of sensitivity means that chlamydia-positive patients will go undetected. The polymerase chain reaction (PCR) is not bedevilled by insensitivity but it is no more sensitive than the most sensitive cell culture or DFA tests. PCR is unsuitable for routine diagnosis but has a place as a research tool. For men, examination of "first-catch" urine samples by the best of the non-cultural procedures provides an acceptable non-invasive approach to diagnosis; for women, the value of examining urine may be less, but needs to be thoroughly tested. However, there is little doubt that a Cytobrush used to obtain cervical specimens holds no practical advantage over a swab. Serological tests are reliant on the provision of paired sera for making a diagnosis; high antibody titres in single sera may be suggestive of an aetiological association in deep-seated chlamydial infections (epididymitis, arthritis, salpingitis, etc), but unequivocal interpretation is unusual, particularly in an individual case, since the distinction between a current and past infection is problematical.
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Affiliation(s)
- D Taylor-Robinson
- Division of Sexually Transmitted Diseases, Clinical Research Centre, Middlesex, UK
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