Annual Chlamydia Screening for Women Under 25 Years Old 13
Annual Chlamydia Screening for Women Under 25 Years Old
Jessica Scharfenberg, RN
Concordia University
MPH 510 Applied Epidemiology
June 22, 2014
Background of Chlamydia:
I chose to research chlamydia screening recommendations for my capstone project as the prevalence of the sexually transmitted disease, STD, continues to rise in South Dakota (SDDOH, 2014). The five year median case number in South Dakota is 1,432 total cases within the state (SDDOH, 2014). During the first five months of 2014, 1,715 cases have already been identified; increasing the disease rate to 208.1 cases per 100,000 people (SDDOH, 2014b). Of the 1,715 cases this year, 1,152 have been identified in individuals under the age of twenty five, with 69% of the cases being identified in women (SDDOH, 2014). South Dakota’s prevalence rates are mimicking that of the United States (CDC, 2014a). As a nation, there is three times the prevalence of chlamydia in the fourteen to twenty-four age group than any other age group (CDC, 2014b). It is estimated that one in every fifteen sexually active females, fourteen to twenty four years old, have chlamydia (CDC, 2014b). Identifying a quality screening technique and promoting its use is extremely important for women’s reproductive health, as most chlamydia infections are asymptomatic (SDDOH, 2014a).
Chlamydia trachomatis, also known as chlamydia, is a sexually transmitted bacterial infection (CDC, 2014b; CDC, 2002). An estimated three million cases occur annually in the United States in young adults and adolescents, with cases in South Dakota on the rise (CDC, 2002; SDDOH 2014b). It is the most common bacterial STD in the United States, but only half of the three million cases are identified and treated annually (CDC, 2014b). Lack of identification and treatment is due to the asymptomatic nature of the infection (CDC, 2014b, SDDOH, 2014b).
Chlamydia can cause cervicitis in women and urethritis in both men and women (CDC, 2014b; CDC, 2002). Early identification in women is of utmost importance. If left untreated, chlamydia can lead to pelvic inflammatory disease, tubal factor infertility, ectopic pregnancy, and chronic pelvic pain (CDC, 2002).
The bacteria is spread through sexual contact with the penis, vagina, mouth, or anus of an infected person (CDC, 2002). Unlike other STDs, ejaculation does not need to occur for transmission of the bacteria (CDC, 2014b). Chlamydia can also be spread to neonates during the birthing process, resulting in ophthalmic neonatorum or pneumonia in exposed infants (CDC, 2014b).
Sexually active, young women are at highest risk of chlamydia for numerous reasons including behavioral, biological, and cultural reasons (CDC, 2014b). Behavioral reasons include unsafe sex practices, inconsistent condom use, and lack of monogamy (CDC, 2014b). There is a biological theory, cervical ectopy; that places younger women at higher risk of contracting chlamydia also (CDC, 2014b). Cervical ectopy is the presence of cells from the endocervix on the ectocervix-refer to figure 1 for a diagram of cervical ectopy (CDC, 2014b). The presence of the cells makes a woman more susceptible to infections. Cervical ectopy is normal in females during puberty, and decreases with age; leading to increased susceptibility of the at risk 14 to 24 year old population (CDC, 2014b). Cultural reasons for increased risk include inability to access quality sexual health care, cost, and lack of treatment related to the stigma associated with STDs (CDC, 2014b).
Figure 1: Normal Cervix vs Cervical Ectopy
Symptoms of a chlamydia infection present 7 to 28 days after exposure with the bacteria as the organism has a slow replication period (Hiatt, 2010). According to the Center for Disease Control and Prevention (CDC), an estimated 10% of males and 5-30% of females with laboratory confirmed chlamydia infection, will develop symptoms (CDC, 2002).
Symptoms is women include:
· Discharge from the vagina (Hiatt, 2010; CDC, 2014b)
· Bleeding from the vagina between periods (Hiatt, 2010; CDC, 2014b)
· Burning or pain with urination (Hiatt, 2010; CDC, 2014b)
· Urinary frequency (Hiatt, 2010; CDC, 2014b)
· Pain in the abdomen (Hiatt, 2010; CDC, 2014b)
· Occasionally fever or nausea (Hiatt, 2010; CDC, 2014b)
Symptoms in men include:
· Watery, white drip from the penis (Hiatt, 2010; CDC, 2014b)
· Burning or pain with urination (Hiatt, 2010; CDC, 2014b)
· Urinary frequency (Hiatt, 2010; CDC, 2014b)
· Swollen or tender testicles (Hiatt, 2010; CDC, 2014b)
Chlamydia can be easily treated and cured with a single dose or seven day course of antibiotics (CDC, 2014b). Those who choose the single dose antibiotic route should abstain from sex for seven days after treatment (CDC, 2014b). Those who choose the seven day course of antibiotics are asked to abstain from sex until the antibiotic is complete (CDC, 2014b). Although the bacterial infection can be cured relatively easily, damage sustained to the reproductive system is permanent (CDC 2014b; ACOG, 2010). Early identification through screening techniques can help lead to healthier female reproductive systems.
Screening Methods:
There are four commonly used screening tests for chlamydia (CDC, 2002). Culture testing is the reference standard in which all other testing methods are compared (CDC, 2002; ACOG 2010). Although culture testing is the reference, other testing options are needed due to the difficult standardization, technically demanding, and expensive characteristics of cultures (CDC, 2002). Other testing methods include nucleic acid amplification tests-NAATs, enzyme immunoassays-EIAs, and direct fluorescent antibody-DFA tests (CDC, 2002;Watson, Templeton, Russel et. al, 2002).
Culture tests begin by collecting a cervical cell test sample via pelvic exam and swab collection (CDC, 2002). The culture is then inoculated with susceptible cells (CDC, 2002). The specimen is set aside for 48-72 hours to allow growth (CDC, 2002). After the growth period, samples are stained with an antibody specific to the outer membrane protein of chlamydia (CDC, 2002). A down fall of culture testing is methods vary among laboratories, leading to variation in performance within the lab (CDC, 2002).
Detection of chlamydia is highly specific with cell cultures if outer membrane protein stain is used because of the unique appearance of the chlamydia inclusions (CDC, 2002). Some laboratories use less specific methods while culture testing, which are not recommended by the CDC (CDC, 2002). The high specificity of cell cultures, if executed properly, are the first choice when results will be used as evidence or in legal situations (CDC, 2002). Disadvantages of the culture technique include low sensitivity, long turnaround time, standardization difficulty, labor intensity, complexity, transportation requirements, and high cost (CDC, 2002).
NAATs amplify nucleic acid sequences specific to the organism being tested (CDC, 2002). NAATs are non-culture, testing methods that uses dirty urine or cervical swabs as the specimen collection technique (CDC, 2002; ACOG, 2010). NAAT testing is highly sensitive, and can produce a positive signal with as little as one coy of target DNA or RNA (CDC, 2002, ACOG, 2010). The largest advantage of NAATs is that a pelvic examination and cervical swab are not needed to perform the test; leading to increased testing ability in non-traditional settings (ACOG, 2010). They also allow for detection of non-living bacteria, expanding transit, handling, and storage time and options (ACOG, 2010). Although the tests are highly sensitive, false-negatives are possible if the specimen contains amplification inhibitors (CDC, 2002). Several NAATs manufacture companies have created amplification controls to help detect inhibitors in the sample (CDC, 2002).
Numerous EIA cervical swab tests exist and detect chlamydia with a monoclonal or polyclonal antibody that has been labeled with an enzyme (CDC, 2002). The enzyme works by converting a colorless substrate into a colored substrate, detected only by spectrophotometer (CDC, 2002). An advantage of EIA testing is specimens do not require refrigeration leading to ease of transport and storage (CDC, 2002). Although cross-reaction can lead to false-positives, manufacturers of EIA test have developed blocking assays to verify positive results (Watson et. al, 2002).
DFA tests work by detecting antigens of the chlamydia antibody (CDC, 2002). Specimens for DFA tests are collected by cervical swabs (CDC, 2002). The specimen is then applied to the well of a slide, allowed to dry, and fixated to the slide (CDC, 2002). Once this process has occurred, the slide can be stored without refrigeration until the slide can be processed with fluorescent microscopy (CDC, 2002). DFA testing is considered highly specific, if the test is performed by an experienced microscopist (CDC, 2002). Disadvantages to DFA testing include need for laboratories competent in fluorescent microscopy, time consumption, and need for dedicated staff due to the tiring DFA testing process (CDC, 2002). Figure 2 summarizes the advantages, disadvantages, sensitivity, specificity, and positive predictive value (PPV) of the four screening methods. Figure 3 is the CDC’s PPV predictor used for chlamydia.
Figure 2: Screening Method Summary (CDC, 2002; ACOG, 2010; Watson et. al, 2002)
Figure 3: PPV Predictor for Chlamydia Adapted from the CDC (CDC, 2002)
Recommendations
Based on CDC recommendations all sexually active women under the age of 25 should be screened for chlamydia annually (CDC, 2014b). I would go further to recommend that NAATs be the test of choice for the screening process. NAATs are highly specific and sensitive with a high PPV (CDC, 2002; ACOG, 2010; Watson et. al, 2002). The main disadvantage to NAATs is the possibility of false negatives, but manufacturers have created amplification inhibitor detectors to counteract this (CDC, 2002). The largest benefit of the NAATs though, is the ability to use a urine sample for the test; increasing testing site flexibility.
In the spring of 2012, The American Congress of Obstetricians and Gynecologists (ACOG) released new screening guidelines that recommended against PAP smears for women younger than 21 years of age; and only every three years for women 21-29 years of age (ACOG, 2012). Historically, during PAP smears, cervical swabs were obtained during the pelvic examination part of a woman’s annual physical (ACOG, 2012). With the new ACOG guidelines, the highest risk chlamydia population is no longer having pelvic exams regardless of sexual activity status. NAATs allow for easy chlamydia testing, even though women are no longer receiving PAP smears.
There are numerous other advantages to NAATs testing. One being non-invasive, ease of collection through a urine sample (ACOG, 2010). There are four NAATs testing methods whose specificity and sensitivity is very similar through both urine and cervical specimen samples which is depicted in figure 4 (ACOG, 2010). Urine NAATs offer convenience in a variety of settings and allow for the test to be performed by health care providers other than clinicians. Screening with urine NAATs can be accomplished at schools, community events, and walk in clinics, offering savings in cost and time (CDC, 2013; Academy for Educational Development, 2007).
Figure 4: Summary of NAATs Methods (ACOG, 2010)
Ethics
In 2002, the CDC estimated that tangible costs related to chlamydia in the United States exceeded $2.4 billion annually (CDC, 2002). As chlamydia rates continue to increase, not only does the monetary cost increase, but also the intangibles. Untreated chlamydia can wreak havoc on the female reproductive system leading to psychological and emotion injury caused by pelvic inflammatory disease, infertility, and ectopic pregnancy (CDC, 2002; National Chlamydia Coalition, 2012).
Laws were enacted in all fifty states in late 2000, requiring the reporting of chlamydia and by the end of the following year it was the most commonly reported communicable infection (CDC, 2002). Although it is commonly reported, only about half of the cases in the United States are actually detected and treated (CDC, 2014b). In 2010, ACOG released screening recommendations for chlamydia. In their release they stated that only 49.9% of eligible females in commercial insurance and Medicaid programs were screened in the two previous years, identifying immense underutilization of screening programs (ACOG, 2010; Watson et. al, 2002).
The framework to increase utilization of chlamydia screening programs is in place, but resource education needs to be increased for both health care providers and high risk populations, women under twenty five years of age (Academy for Educational Development, 2007; CDC, 2013; National Chlamydia Coalition, 2012; SDDOH, 2014b). Increasing utilization and screening rates would be a cost effective means of improving women’s health and reducing chlamydia burden in the United States (Gift, 2012). The South Dakota Department of Health’s Family Planning Program is working diligently to spread the word and increase chlamydia screening in high risk populations. It is part of their policy to screen every woman under twenty five enrolled in their program annually (SDDOH, 2014a). The Family Planning Program is following both ACOG and CDC recommendations by utilizing NAATs tests. Although only a small percent of South Dakota women are enrolled in the family planning program, nurses from the program provide STD education and screening information to schools annually (SDDOH, 2014a).
Public health officials and practitioners often times operate under strict guidelines though, when it comes to STD education. Unfortunately, sexual activity is considered taboo for many people; and parents and school officials do not want the education brought into the school. It is an ever revolving battle, but public health officials continue to make slow head way. There are numerous websites, public service announcements, and printed ads sponsored by public health programs to help empower young women with protection and treatment knowledge (SDDOH, 2014a).
Key findings by the Academy for Education Development cited the following as factor that influence teenagers and young adults to seek STD screening:
· Many consider themselves knowledgeable about STDs, but research shows a lack of knowledge about asymptomatic diseases, testing options, and the connection between STDs and infertility (Academy for Educational Development, 2007)
· Many young people do not view themselves as vulnerable to STDs (Academy for Educational Development, 2007)
· Many also misunderstand infection symptoms (Academy for Educational Development, 2007)
· There is stigma associated with being screened for STDs (Academy for Educational Development, 2007)
· Confidentiality concerns (Academy for Educational Development, 2007)