Chlamydia effective prevention tactic would be routine screening of

Chlamydia
infection: Transmission, causes, risk factors and prevention

Chlamydia
infection: Transmission, causes, risk factors and prevention Chlamydia
trachomatis is a gram-negative bacterium that is often don’t show any specific
symptoms but could lead to serious conditions if left untreated like
PID aka pelvic inflammatory disease, epididymo-orchitis and infertility1
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 more likely to get Chlamydia than men
due to multiple reasons like social and anatomical vulnerability. This will be
discussed more further down 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,
substance abuse, high alcohol 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 routine screening of high-risk individuals. A National
chlamydia screening programme (NCSP) was developed in response to high
number of cases in people under 25. 

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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.

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 PID 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 Provider referral is more commonly asked for
notifying casual partners and latest studies have suggested that onward
transmission rate is higher for those partners. The results concluded that the
number of partners needed to treat to stop transmission of an STI is 1:1 for
casual partners which means every partner need to be treated for the
transmission to be stopped completely. For regular partners the ratio is 2:5
which means every two regular partners need to be treated for five contacted
for the STI transmission to be stopped. Provider referral is done by a trained
health advisor in Genito-urinary medicine clinic who anonymously contact
partners on behalf of patients. This service has been made available in most
GUM clinics

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.

On
the whole, there has been a gradual reduction in the rates of gonorrhoea within
the general population for over a decade. The decline has been less noticeable in
adolescents than in other age groups. Chlamydia not surprisingly, has been consistently
high in young adults and some studies have found up to 40 percent of sexually
active young adults to be infected with chlamydia. Studies have established
that women are more likely to be infected with STIs than men due to an abnormal
anatomical change, cervical ectopy. Cervical ectopy is a condition where the
cervical columnar cells are outside the cervix. It is not uncommon in women to
have this condition which is another why prevalence of STI is high among women
especially adolescents. Another reason why there is a high rate of STI
prevalence amount young adults might be due to trouble accessing health
clinics, clinic hours clashing with school time, stigma attached to vising a
GUM clinic, clinical examination may be too uncomfortable, confusion about confidentiality
as most young adults don’t want their peers to find out.

Impact
of STDs on women’s health

Due to
female anatomy, they are more prone to catching an STI than men to point that
data suggests that STIs are more easily transmitted from a man to woman than
vice versa. In the case of gonorrhoea, the chance of a woman transmitting her
infection to her male partner is about 20 percent while the chance of a man
infecting his female partner is anywhere between 60-90 percent.

STIs are often asymptomatic in women especially in STIs like
gonorrhoea and chlamydia. For example, in women with gonorrhoea, 30 to 80
percent of them are show no specific symptoms, while the percentage in men’s
case is considerably low: less than 5 percent.

In chlamydia’s case, 85 percent of women are asymptomatic
while only 40 percent of men show no symptoms. Due to the female genital tract,
it makes it harder for clinicians to diagnose women of any STI as it makes
clinical exam more difficult. To diagnose gonorrhoea in a man, clinicians are
only required to take a urethral swab but for a women, they need an invasive
cervical examination. All these limitations contribute to a high number of
women being not diagnosed on time and left untreated leading to serious complications
like infertility and PID.

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 in our culture, men have the freedom to have multiple sexual
partners including paying for sex without facing judgment from society while
the same can’t be said for women as they risk facing abuse if they refuse sex
or ask to use protection during sex This social norm effectively puts women at
higher risk of acquiring STIs.

 

Interrelation
between sociodemographic risk factors and geospatial mapping

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 was used to analyse their data. Results showed that young age (15–24
years), ethnicity (with a gradient of risk black >white >Asian), and living
in deprived ‘urban’ areas were all increased risk of acquiring STI
independently. Results proved there were highly significant correlations between
geospatial analysis between the four STIs they looked at.

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