Chlamydia Screening Focus Groups of Healthcare Providers
My research focus is the study of Chlamydia trachomatis. I am interested in Chlamydia because it is the most prevalent bacterial sexually transmitted disease in the United States. Young adults have the highest rates of chlamydial infection and are at the highest risk for infection among all age groups. Yet, as a group, they do not use Chlamydia screening services. Why? Early diagnosis of Chlamydia is important, not only to minimize disease spread but also to prevent sequelae, including epididymitis, pelvic inflammatory, disease, ectopic pregnancy, infertility and chronic pelvic pain. Traditional Chlamydia testing procedures have served as another obstacle to early detection because collection of endocervical and urethral specimens is uncomfortable at best. Fortunately, the introduction of several nucleic acid amplification tests (NAATs) now makes it possible to detect Chlamydia noninvasively from male and female using a simple urine sample. My interest in increasing the participation of the gatekeepers, the medical profession in offering these screening programs to this age group by having focus groups address concerns and dispel misconceptions, and provide more information about Chlamydia to this population that is the highest risk.
REVIEW OF THE LITERATURE
Chlamydia is one of the most common sexually transmitted diseases in modern Western society. In the United States alone, there are about four million chlamydia infections annually. However, a disturbing amount of those infected with Chlamydia -- as many as fifty percent of the men infected, and three-quarters of the women infected -- are asymptomatic and do not know that they have this disease. (Dedius et al., 2005) Lack of symptoms, however, does not imply harmlessness. Complications range from infertility to blindness, and it is therefore vital that steps be taken to reduce the number of Chlamydia infections that remain undetected.
Among women infected with Chlamydia, about fifty percent of them will develop pelvic inflammatory disease; Chlamydia causes between 250,000 to 500,000 cases of pelvic inflammatory disease every year in the United States alone. (Dedius et al., 2005) Pelvic inflammatory disease, or PID, is something of a catch-all phrase referring to an infection of the uterus, fallopian tubes, or ovaries. Up to ten percent of the total cases of PID are complications of Chlamydia, and PID itself is identifies as the leading cause of infertility. Thirteen percent of women that experience pelvic inflammatory disease will become infertile, and multiple infections increase this percentage. (Icarus et al., 2005) Sometimes, PID does not show any symptoms, however some of the common symptoms are fever, tenderness of the cervix, abdominal pain, abnormal vaginal discharge, pain during intercourse, and irregular menstrual bleeding. Even without the presence of these symptoms, PID may still cause permanent damage, including scarring of the reproductive tissues, which may cause problems such as chronic pelvic pain, ectopic pregnancy, or other reproductive problems.
Women face a particular danger if they are infected with Chlamydia during pregnancy, or if they become pregnant while infected. It is estimated that half of all infants born to mothers with this disease will be affected by it. Chlamydia can cause spontaneous abortion (or miscarriage), premature birth, blindness, and pneumonia in the child. Avoiding vaginal birth can significantly reduce the risk of transmission during birth, however the child may still be affected.
While men do not (and cannot) suffer from PID, other diseases may be caused by Chlamydia that can also cause sterility and other long-term problems. One such disease is epididymitis, which is an inflammation of the epididymis, which is likely to occur if Chlamydia spreads to the testicles. Another condition which is particularly problematic for young men infected with Chlamydia is Reiter's Syndrome. Reiter's syndrome is identified by three symptoms: inflammatory arthritis of large joints, inflammation of the eyes, and arthritis. Chlamydia is among the most common bacterial infections that will cause Reiter's syndrome. (YurikBot et al., 2005) Fifty percent or more of men with Reiter's syndrome will develop eye problems and/or blindness, and up to forty percent of men will develop penile lesions. Additionally, the Chlamydia bacteria will cause Trachoma, an eye disease which causes ulceration and scarring of the cornea. This is the leading cause of blindness worldwide and afflicts as many as 400 million people, although it is rare in the United States. (Arcadian et al., 2005)
With or without the presence of pelvic inflammatory disease or other secondary diseases, Chlamydia may be with or without noticeable symptoms. If symptoms do occur, they may include, in women, vaginal discharge of an abnormal color or with an unusual smell, pain in the abdomen and reproductive regions, painful urination, and/or the urge to urinate more often than usual. In men, if symptoms do occur, chlamydia may cause painful or burning urination, unusual discharge from the penis, swollen or tender testicles, and/or fever. (Dedius et al., 2005)
The Chlamydia infection is caused by bacteria. The Chlamydia trachomatis is a species of the chlamydiae, a group of obligately intracellular bacteria. This bacteria replicates within cells, then bursts out of the cell membrane to spread the infection to other cells. This is one of the smallest bacteria, as tiny as 500nm wide. (Grosse et al., 2005) Additionally, they cannot be cultured outside of host cells because of the intracellular nature. Due to these factors regarding the Chlamydia trachomatis bacteria, research has faced many challenges.
Fortunately, this very common sexually transmitted disease can be effectively treated and cured with simple antibiotics, which is not the case with some common STDs. Unfortunately, large numbers of infected patients do not realize they have Chlamydia, and screening for this disease is lacking in many ways. People do not realize how important it is to get tested for Chlamydia, and there are a vast array of misconceptions and misunderstandings about this infection. Doctors are limited by patient concerns, financial issues, lack of education, and many other unfortunate factors. Education, screening, and proper treatment are vital in curbing the occurrences of Chlamydia.
According to the U.S. Preventitive Services Task Force (USPSTF), sexually active women up to twenty-five years of age should be routinely screened for Chlamydia trachomatis. The American Family Physician article "Recommendations on screening for Chlamydia" (Morantz, 2003), rates of infection vary greatly among different communities and populations. Infection is the most common among females under twenty-one years of age, however it is also extremely prevalent among women up to twenty-five years of age. Women over the age of twenty-five are also at risk, however some sources such as this one recommend screening only if particular risk factors occur, such as not using condoms all of the time, having new or many sexual partners, or a history of sexually transmitted diseases. Screening pregnant women is also necessary, because of the danger posed to the unborn child. This article reveals that the optimal timing for screening pregnant women is not known, and that early screening may help improve outcomes such as low birth weight and premature delivery, while screening in the third trimester may be more effective in preventing the transmission of the infection to the child during childbirth. Additionally, this article reveals that the ideal time between screenings (which have negative results) is not known, and that risk factors such as age and sexual behavior should be taken into consideration. This article is clear that screening is recommended and that Chlamydia is a threat, however in this source several of the problematic attitudes which may be interfering with proper screening practices. Automatic screening for Chlamydia is not recommended by the USPSTF, but rather many risk factors are recommended for consideration before deciding to screen for the infection. Additionally, if there are benefits to both early and late screening during pregnancy, it would be logical to recommend screening twice during pregnancy as an automatic part of prenatal care.
According to the British Medical Journal article "Screening for genital chlamydial infection - Evidence-Based Health Policy Report" (Pimenta, 2000), there are serious consequences for an inadequate sexual and reproductive health care system. The United Kingdom developed an integrated strategy on sexual health in response to these concerns. This report found that in the 1990's, there was a significant rise in the occurrence of Chlamydia infections among females between sixteen and nineteen years of age, and among males between twenty and twenty-four years of age. Women attending clinics to have an abortion were also found to have higher rates of infection than samples from the general public. Professional awareness of the disease is rising, however it is not sufficient to curb the danger, and vast quantities of infected individuals remain untreated. This article additionally addresses the questions of whether screening itself is effective, and how to determine the costs and benefits of different screening procedures. A study conducted in Wisconsin from 1986 to 1990 confirmed that screening for Chlamydia lowered the incidents of pelvic inflammatory disease. (Pimenta, 2000) The proposal discussed in this article suggested a focus on opportunistic screening, such as screening females only when they are attending certain types of clinics. Again, the concern of keeping cost low is…