Chlamydia chlamydia cases and transmission but prevalence of

Chlamydia
infection: Transmission, causes, risk factors and prevention

Chlamydia
trachomatis is a gram-negative bacterium that is often asymptomatic but could lead to pelvic
inflammatory disease, epididymo-orchitis and infertility if left untreated.1 Genital chlamydia is the most common sexually
transmitted infection in men and women accounting for 46.1 percent of all STIs diagnosed in 2015.1 Women are far more likely to get Chlamydia
than men. Current studies suggest factors that increase the risk of a person
contracting Chlamydia are young age (under 25), multiple partners, previous
sexually transmitted infection (STI), socioeconomic status, incorrect use of
condoms, excessive alcohol or illegal drug intake (as marker of risk taking
behaviour) and men who have sex with men. Since many
chlamydial infections are asymptomatic, the most effective prevention tactic
would be periodic screening of individual at risk. A National chlamydia
screening programme (NCSP) was developed in response to high number of cases in
people under 25. NCSP reduced untreated chlamydia cases and transmission but
prevalence of chlamydia managed to stay high due to number of reasons, one of
them being partners not being correctly notified.

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Gonorrhoea
and the rise of antibiotics resistance

Gonorrhoea
is an STI caused by Neisseria gonorrhoeae bacterium and for most people it’s an
asymptomatic infection. The primary mode of
transmission is through unprotected vaginal, oral or anal sex. It could
eventually lead to infertility if left untreated. It also causes
complications like pelvic inflammatory disease in women and inflammation of the
epididymis, prostate gland, and urethra in men. It is treated with antibiotics
but current research has shown strains of this bacteria has acquired resistance
to several antibiotics over the last 10 years. Gonorrhoea is most commonly seen
in age group 24-25 with a rate of 269.5 per
100,000 population in 2015. It is also the second most common STI after
chlamydia in the United Kingdom. These statistics raise serious concern as
‘super-gonorrhoea’ spread across the country. According to World Health
Organisation (WHO), we need better prevention, treatment, early diagnosis and
complete tracking of new infections.

Gonorrhoea has a social stigma attached to it like any other
STI so patients are reluctant to inform their partners themselves and rely on provider
referral services by health advisors.

 

Syphilis

Syphilis is caused by the bacterium
Treponema pallidum.5 The primary mode of
transmission is by sexual contact, and the next most common is from mother to
foetus in-utero.(5,6)  Syphilis is
divided into several stages according to its different signs and symptoms.5 Primary
syphilis is associated with sores around mouth or genitals whilst secondary
stage is associated with rash, swollen lymph nodes and fever.7 The early stages
(primary, secondary, and early latent) are the most infectious and the tertiary
stage is the most harmful as it causes multiple organ damage.7 Although the
number of diagnosis were not as big as for other STIs, it did represent the
highest increase of any STI in 2015. (5,6) Men aged 25-34 (45 per 100,000
population) and 35-44 (39.1 per 100,000 population) represented the highest
rate of diagnoses in 2015. Males accounted for 94 percent of all syphilis
diagnoses and men who have sex with men accounted for 79.4 percent.(5,6)

Partner notification
studies have shown that the rate of transmission of primary, secondary, and
early latent syphilis is around 60 percent.5

Partner
notification: Provider referral and patient referral

Partner notification (PN) if done
correctly treats infection on time, reduces recurrent infection and may
eventually contribute to an overall reduction of that infection in the
community. Patient are offered a few choices when it comes to partner notification.
A lot of times, patient take the task of informing their partners themselves
rather than giving their partners’ details to health advisors. This approach of
PN is called patient referral. Patient referral is the most common approach to
PN but results show less than half the patients actually notify their partners
according to a study done on ‘Anticipated versus
actual partner notification following STI diagnosis among men who have sex with
men and/or with transgender women in Lima, Peru’.9 The study showed among all
sexual partners, 35 percent were notified of the STI diagnosis, though only 51
percent of predicted PN occurred and 26 percent of actual notifications were
unanticipated. 47 percent of participants notified no partners, while 24
percent notified all partners. Patient referral is more common in stable
relationship than casual.9 There have
been studies done which shows that patient referral (where patient takes on the
task of telling their partners themselves) could be more effective if clinicians
give patients some kind of written information, sampling kits or medication to
take it to their partner(s) with them. This is known as expedited partner
therapy or EPT.13 Since prescribing drugs with patient consultation is not
allowed in UK, accelerated partner therapy (APT) is being used where after a
telephone consultation, partners can have access to treatment or sampling kits
from either GUM clinic or pharmacy.13

There has been evidence
that PN done via APT or EPT has managed to reduce re-infection in cases by
almost 30 percent according to a systematic review done recently. Although this
is a good increase, it wasn’t significantly better than EPR aka enhanced
partner referral. Men who have sex with men have further web-based help where
their partners are informed anonymously.13 The systematic review also confirmed
that a pre-planned follow-up call to the patient also help as then the
clinician can provide them with the option of provider referral again if
patient was unsure during their face-to-face meeting.13

The stigma behind contracting an STI
could make the experience of informing the partners rather traumatic for
patients. Due to this, patients often don’t notify their partners out of fear
for their safety or reputation.  This
where provider referral comes into play. Provider referral is another approach
to partner notification. It is a service provided to patients where health
advisers contact their past or present partner(s) for them without revealing
the patient’s identity and inform them of their possible exposure so they could
seek medical care.13 Latest studies
have found that provider referral is more frequently requested for casual
partners, for whom the onward transmission rate is higher. The results
show that number of partners of who need to be treated to stop transmission of
an STI is 1:1 for casual partners, compared with 2:5 for regular partners. Provider
referral is usually undertaken by a specialist sexual health adviser based in a
sexual health clinic, and recent guidelines recommend that this approach is
made available wherever STIs are diagnosed through the development of a
community-based partner notification service.8

Timely partner notification is key to
reducing the spread of infection in the community. It also protects
unsuspecting partners from long-term tissue damage from an untreated infection.

Does
partner notification work?

Studies have shown that new
interventions like APT, EPT and EPR works more effectively if patiets are given
written information and sampling kits for their partners. PN is more likely to
more better for those in long term relationship so it only reaches a proportion
of contacts often missing casual partners. Mathematical
models suggest that improving partner notification could be highly
cost-effective in terms of cost per infection diagnosed when compared with
expanding coverage of screening, for example.8

British
association for sexual health and HIV and history taking

In 2013, the British Association of
Sexual Health and HIV (BASHH) published guidelines to outline the minimum
requirements of practice during a routine sexual history consultation.1 This
included specific guidance for information obtained regarding recent sexual
partners to aid risk assessment. It is recommend that all patients should be
asked the following: gender of partner, sites of exposure, use of barrier
methods, relationship to partner and symptoms or high risk behaviour of this partner.1
At a minimum, the number of partners within the past 3 months should be
recorded, with specific details for a minimum of the last 2 partners if these
are within the past 3 months.1 When considering high risk behaviours it is
known that the circumstance or site at which partners are met can incur higher
risk for acquisition of sexually transmitted infection. This information has
previously been utilised by public health to guide health promotion activities
and condom distribution.2 NICE guidance highlights specific high-risk premises
for sexually transmitted infection include commercial venues including sex on
premises venues, public sex environments and other places where people are most
at risk of STI. It is important as part of routine sexual history taking that
this information is obtained to inform initial testing and any health promotion
activities.

Prevalence
of Sexually transmitted infections in young adults

Men and women under 25 years old are at
the greatest risk of acquiring an STI for several reasons. The main one being
that they are more likely to have unprotected sex with multiple partners. In addition, young people are at greater
risk for substance abuse and other contributing factors that may increase risk
for STIs.

Although
overall rates of gonorrhoea have been declining in the general population for
over a decade, this decline has been less pronounced among adolescents than in
other age groups. Chlamydial infection has been consistently high among young
adults; in some studies, up to 30-40 percent of sexually active adolescent
females have been infected. Women are more likely to be infected than men
because of their increased cervical ectopy. Cervical ectopy
refers to columnar cells, being located on the outer surface of the cervix. Although
this is a normal finding in adolescent and young women, these cells are more
susceptible to infection. The higher prevalence of STIs among adolescents may
also be due to having trouble accessing STI prevention and management services
like lack of transportation, long waiting times, clinic hours clashing with school
time, embarrassment attached to seeking STI services, method of specimen
collection, and concerns about confidentiality.

Impact
of STDs on women’s health

Women are biologically more likely to become infected than men
if exposed to a sexually transmitted pathogen.

Many STIs are transmitted more easily from man to woman than
from woman to man. For example, the risk to a
woman of getting Gonorrhoea from a single act of intercourse with an infected
male partner could as high as 60 to 90 percent, while transmission from an
infected woman to man is about 20 to 30 percent.

STIs are often asymptomatic in women especially
in gonorrhoea and chlamydia. For example, in women with gonorrhoea, 30 to 80
percent of them are asymptomatic, while less than 5 percent of men are
asymptomatic. Similarly, as many as 85 percent of women with chlamydial
infection are asymptomatic compared to 40 percent of infected. When an STI is
suspected, it is often more difficult to diagnose in a woman because the
anatomy of the female genital tract makes clinical examination more difficult.
For example, a urethral swab and a Gram stain are sufficient to evaluate the
possibility of gonorrhoea in men, but a speculum examination of the cervix and
a specific culture for gonorrhoea have been required for women. Thus, women
with gonorrhoea or chlamydial infection are often not diagnosed with an STI
until complications, such as pelvic inflammatory disease, occur. 

According to the article ‘Disproportionate Impact of Sexually
Transmitted Diseases on Women’ published by CDC, women have a higher risk of
acquiring STI due to social norms and constructs. It says culturally, men are expected to have
multiple sexual partners including sex workers without risking judgement from
their social peers while women may feel they would face abuse if they refuse
sex or ask for protection. This behaviour effectively puts women at higher risk
of acquiring STIs.

 

Interrelation
between sociodemographic and geospatial risk factors

The main goal of marrying geographical
mapping and epidemiological data is to see if there’s any relation between health issues that impact a large
population, and the trends by which these populations are affected. If we find
certain high-risk locations due to these techniques, then better prevention
strategies could be made. Using geographic information systems (GIS) in public
health provides a strong foundation to monitor any outbreaks and find the
source of infection.

A study by
Charles lacey looked at four most common clinically diagnosed sexually
transmitted infections (STIs) which included gonorrhoea and chlamydia to
examine the degree of demographic and geospatial correlation between these
STIs. They used details of patients aged 15-25 who attended STI clinic with
confirmed diagnosis of either of the four STIs they were studying. Data was
collected from 1994-1995 from Leeds Healthcare commissioning area.

They
compared aged, sex, socioeconomic status and geospatial distribution of these
STIs. Regression
analysis showed that young age (15–24 years), ethnicity (with a gradient of
risk black >white >Asian), and residence in inner city areas of
deprivation were independent risk factors for all STDs. There were highly
significant correlations in the geospatial distribution of incidence rates
between the four infections.

Population based studies are needed to
clarify whether ethnicity is associated with differing sexual behavioural or
mixing patterns. Their data
suggested that chlamydia screening in women

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