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Year : 2014 | Volume
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Prevalence of Chlamydia trachomatis in women attending sexually transmitted disease clinics in the Colombo district, Sri Lanka |
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Gunasekera Henadira Appuhamilage Kamani Mangalika1, Silva Koththigoda Cankanamge1, Dhammike Priyadarshana2, Prathapan Shamini3, Mananwatte Sujatha4, Weerasinghe Geeganage4, Abeygunasekera Nalaka5
1 Department of Microbiology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka 2 Department of Gynaecology and Obstetrics, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka 3 Department of Community Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka 4 National STD/AIDS Control Program, Colombo South Teaching Hospital, Sri Lanka 5 STD Clinic, Colombo South Teaching Hospital, Sri Lanka
Click here for correspondence address and email
Date of Web Publication | 17-Apr-2014 |
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Abstract | | |
Background: In Sri Lanka little is known about the prevalence of Chlamydia trachomatis
(CT) infection. Objective was to determine the prevalence of CT in
female patients attending sexually transmitted disease (STD) clinics in
the Colombo district. Materials and Methods: A descriptive cross-sectional study was carried out for the prevalence of CT in all female patients (n
= 168) more than 18 years of age, attending two STD clinics in the
Colombo district from January to May 2012. Endocervical swabs were
collected and tested for CT using the Amplicor CT/NG polymerase chain
reaction assay. Results: Prevalence of CT in females attending
the STD clinics in the Colombo district was 8.3%. Mean age of those
infected with CT was 32.9 years (SD ± 8.2). Majority of females with CT
infections were Sinhalese and married. There was no significant
association with age, ethnicity or being married or not. Females who did
not attend school, or had their education only up to Grade 5 were
significantly found to have six times the risk of having CT infection
(95% CI = 1.8-22.6). A significant association was found with number of
sexual partners but not with commercial sex work or past history of STD.
Conclusions: Prevalence of CT was moderately high in this population. Keywords: Chlamydia trachomatis, female, polymerase chain reaction, Sri Lanka
How to cite this article: Mangalika GK, Cankanamge SK, Priyadarshana D, Shamini P, Sujatha M, Geeganage W, Nalaka A. Prevalence of Chlamydia trachomatis
in women attending sexually transmitted disease clinics in the Colombo
district, Sri Lanka. Indian J Pathol Microbiol 2014;57:55-60 |
How to cite this URL: Mangalika GK, Cankanamge SK, Priyadarshana D, Shamini P, Sujatha M, Geeganage W, Nalaka A. Prevalence of Chlamydia trachomatis
in women attending sexually transmitted disease clinics in the Colombo
district, Sri Lanka. Indian J Pathol Microbiol [serial online] 2014
[cited 2014 Apr 23];57:55-60. Available from: http://www.ijpmonline.org/text.asp?2014/57/1/55/130898 |
Introduction | | |
Colombo,
situated on the West Coast, is the industrial, financial and commercial
capital of Sri Lanka. The central clinic of the National STD/AIDS
Control Program (NSACP) and the STD clinic of Colombo South Teaching
Hospital (CSTH) are the only centers in the Colombo district that are
funded by the Ministry of Health and provide free healthcare for STDs.
Colombo district has a population of 2,344,209 of which 52.8% are
females between the age of 15-49 years. [1]
There is limited data on chlamydial STDs in many developing countries [2] including Sri Lanka. The lack of cost-effective diagnostic kits/methods for Chlamydia trachomatis
(CT) infections has curtailed our ability to screen our population, and
prevalence studies have not been possible. Many developed countries
have established a national standard plan for screening of CT
infections, but in hospitals and clinics in Sri Lanka there is no
program for screening. Laboratory diagnosis of CT is not done routinely
in our country. Therefore, treatment for CT is done after exclusion of
other possible etiologies for cervicitis and symptoms. Both clinics
included in this study follow the same diagnostic and treatment
protocols in keeping with national guidelines.
Commercial sex is
illegal in Sri Lanka. Female sex workers and their male clients have
been identified worldwide as a core group of high-frequency transmitters
that play a dominant role in the transmission of HIV and other STDs. [3] In Sri Lanka, although studies have been done on other STDs, little is known about the prevalence of CT infections.
World
Health Organization (WHO) in 2008 estimated that 498.9 million new
cases of bacterial and protozoal STDs occur annually worldwide. 105.7
million cases of CT occurred worldwide, and 78.5 million of those new
cases occurred in South and Southeast Asia (SEA). [4]
Surveillance
of STDs is necessary to estimate the burden of disease, allocate
resources effectively, and evaluate control strategies. From 2005 to
2011, the number of reported cases of non-gonococcal
urethritis/non-gonococcal cervicitis has not changed significantly
during this period (Strategic Information Management Unit, NSACP, Sri
Lanka, personal communication, May 1, 2013).
Approximately 70% of women and 50% of men have asymptomatic CT urogenital infections, [5]
which represents a huge population of untreated individuals who can
unknowingly transmit the organism. Untreated CT infections could lead to
pelvic inflammatory disease, ectopic pregnancies and infertility.
Cervicitis caused by CT in pregnancy may result in miscarriage or
premature delivery. Infection of the newborn during delivery may lead to
pneumonia or conjunctivitis. [5] CT has also been implicated in invasive squamous cell carcinoma of the uterine cervix [6] and as a risk factor in HIV-1 infection and transmission. [7] It also influences the development of human papillomavirus-induced adenocarcinoma. [8]
The aim of our study was to determine the prevalence of CT in all female attendees of STD clinics in the Colombo district.
Materials and Methods | | |
Design
A
descriptive cross-sectional survey was carried out among females
attending two government STD clinics in the Colombo District; namely
Central STD clinic Colombo and STD clinic CSTH. A standardized
questionnaire with close ended questions was administered by
face-to-face interview which addressed socio-demographic characteristics
and symptoms. A subsequent self-administered questionnaire (privacy was
ensured by providing a box in which questionnaires could be placed
anonymously) explored questions on history of STD and number of sexual
partners. The questionnaire was developed in English, translated to
Sinhala and Tamil and pre-tested before use.
Study population
The
study population comprised of all consenting females over the age of 18
years who had not taken any antibiotics during the last 3 weeks and in
whom a speculum examination was possible. All consecutive females
attending the above clinics during January to May 2012 were invited to
participate until the sample size of 168 was reached. Eligibility of the
potential study participants was checked and written or verbal informed
consent was obtained by the medical officers responsible for data
collection of the study.
Data and specimen collection
After
the interview, the participants were asked to provide samples for
Chlamydial testing. STDs that were detected during the examination were
immediately treated free of charge. After the results of the PCR were
known, participants who needed additional treatment were contacted and
invited to the health facility.
The definition of "sexual worker"
was those who voluntarily provided information of selling sex part time
or full time, as a means of making a living.
All study
participants received a physical and pelvic examination. A patient was
considered to have cervicitis if the clinician found: Cervical discharge
and/or cervical friability.
An endocervical swab was collected
through a speculum during pelvic examination by a medical officer.
Endocervical swabs were collected by inserting a cotton wool swab 2 to 3
cm into the cervical os and rotating for 5 to 30 seconds. The swab for
the polymerase chain reaction (PCR) was placed immediately in sucrose
phosphate glutamic acid medium (SPG).
Specimens were collected
daily from both STD clinics and transported at room temperature to the
laboratory for processing. Upon receipt, specimens were stored at –70 o C until tested.
Laboratory method
For
diagnosis of CT, endocervical specimens were tested using Amplicor
CT/NG Test (Roche Molecular Systems, Inc., Branchburg, NJ, USA) using
the Amplicor CT Detection Kit, in accordance with instructions of the
manufacturer.
As part of the routine investigations carried out
on these patients, high vaginal swabs were examined for bacterial
vaginosis (by clue cells), candida (Gram stain) and Trichomonas vaginalis (wet mount). Results of these investigations were extracted from the laboratory records.
Statistical analysis
Data
were entered in Epi-Info 3.4.3 (CDC, Atlanta, USA). The statistical
analysis was performed with SPSS 15. Descriptive statistics was
performed initially followed by Odds ratio (OR) and 95% confidence
intervals (CI). The chi-square test was used to describe the associated
factors in the categorical variables. All inferential statistics was
tested at 5% significance (P < 0.05).
Ethical considerations
Study
protocols, questionnaires and consent forms were approved by the Ethics
Review Committee of the Faculty of Medical Sciences, University of Sri
Jayewardenepura, Sri Lanka. Questionnaires and specimens were coded.
This code was written on the consent form in order to identify the
participant to whom the STD test results belonged. Only the team of
principal investigators had access to nominal information. Some provided
written consent to the study and others verbal consent. Participants
who were found to be positive for CT were traced and offered the
appropriate treatment.
Results | | |
Among the 168 sampled during January to May 2012 at the STD clinics in the Colombo district, 8.3% (n
= 14) of the female attendees were found to be positive with CT. The
internal control revealed that seven specimens were inhibitory and
required repeat testing but could not be tested except for one.
Therefore, three (1.8%) were presumptively negative for CT according to
manufacturer's guidelines on interpretation.
The age of all
females studied ranged from 18 to 57 years. The 14 females who were CT
positive ranged from 21 to 52 years with a mean age of 32.9 years (SD ±
8.2; [Table 1]).
In our study population patients under the age of 18 years were not
included and there were only eight patients under the age of 20 in the
study group. There was no significant association between age and CT
infection [Table 1]. | Table 1: Association between Chlamydia trachomatis infection and demographic characteristics
Click here to view |
Majority
of the females with CT infections were Sinhalese and married. There was
no significant association with being Sinhalese or married. Nearly 30%
of the females who did not attend school, or had their education only up
to Grade five were found positive for CT and were significantly found
to have six times the risk of having CT infection (95% CI = 1.8-22.6; [Table 1]).
Among
the 26 females who claimed to be commercial sex workers (CSWs), 15%
were found to be positive with CT infection but there was no significant
association with being a CSW [Table 2].
Fourteen percent of those who had more than two sexual partners were
infected with CT and they were significantly found to have three times
the risk (OR = 3.2; 95% CI = 1.03-10.14) of having the infection than
those with a single partner in a lifetime [Table 2].
One
of 13 (7.7%) CT positives (information was missing for one CT positive
patients) had an STD in the past, but past history of STD was not
significantly associated with CT infection in this population [Table 2]. | Table 2: Association between Chlamydia trachomatis infections and sexual behaviour
Click here to view |
The
most frequent reason given for visiting the STD clinic was being
symptomatic (55.4%). Other reasons given were 13.1% for a medical
check-up, 11.9% because the partner was infected and 4.2% for follow up.
Among other reasons given for visit (14.9%) most were court referrals.
The main physical complaint was vaginal discharge among the female attendees (n = 55) and among those with CT infection (n
= 7). Only 17.2% (5/29) of patients found to have a cervical discharge
by the physician were positive for CT (information about discharge was
missing for one CT positive patient). A complaint of discharge as well
as the physical finding of a cervical discharge were significantly
associated (P = 0.001 and P = 0.01, respectively) with CT positivity [Table 3]. In our study 35.7% of females found positive for CT were asymptomatic. | Table 3: Association between Chlamydia trachomatis infections and signs and symptoms
Click here to view |
If
the definition for cervicitis is considered as cervical discharge
and/or cervical friability 14.7% of patients with cervicitis were
infected with CT and this was statistically significant (P = 0.03).
The rate of co-infection of CT with Candida based on routine clinical investigations and available reports was 4.5% [Table 4].
There was no co-infection detected with trichomoniasis or bacterial
vaginosis. Patients diagnosed with other STDs apart from CT based on
available laboratory reports were gonorrhea (1.2%), syphilis (7.7%),
trichomoniasis (0.6%), vulvo-vaginal candidiasis (13.1%) and bacterial
vaginosis (4.1%).
Discussion | | |
Prevalence
of CT was moderately high (8.3%) in this population of female STD
clinic attendees. Prevalence rates of CT from studies carried out during
2000-2012 in female STD clinic attendees have been summarized in [Table 5].
As can be seen from the table, prevalence of CT in our population is
comparable with prevalence in Sweden but is much lower than those in
other Asian countries. | Table 5: Chlamydia trachomatis prevalence studies* among sexually transmitted disease clinic attendees, 2000-2012
Click here to view |
Based
on an estimated CT infection rate of 5% among American women of
reproductive age, the Centre for Disease Control recommends that
pregnant women be screened for CT during their first prenatal visit; and
women at increased risk for infection (those with new or multiple sex
partners and those under 25 years of age) be screened again during the
third trimester. [15]
The prevalence of curable STDs is considered a biological marker of
sexual behavior in that community. Considering the high prevalence in
our study population, screening at STD clinics may be of value. However,
the high cost of commercially available diagnostic tests is likely to
make this difficult to implement.
Because of the stigma
associated with STDs, some individuals with symptomatic STDs are
reluctant to seek treatment from government clinics. One of the
limitations of our study was that it was conducted in two government
clinics and did not include the several private clinics in the district.
It was noted that 35.7% of females found positive for CT were
asymptomatic in this study. The majority of patients in our study
visited the clinics because they were symptomatic but it is a well-known
fact that up to 70% of CT-infected females are asymptomatic. [5]
Those who are asymptomatic are unlikely to seek any kind of treatment
and repeatedly expose their partners to infection. A study among the
general population including asymptomatic women although desirable would
have been difficult to conduct due to social, ethical and religious
issues in our country. Despite these two limitations that might have
lead to an underestimation of the true burden of infection in our
community we have shown for the first time that the prevalence of CT
infection is quite high among women of our community.
In our
study only 14.7% cases of cervicitis were due to CT. This raises the
question as to the etiology of the rest of the cases of cervicitis. Mycoplasma genitalium (MG) has been found to be an increasingly important cause of cervicitis in other countries, [3]
but we have no information on how much it is responsible for cervicitis
in our patients. Recent limited data indicate that antibiotics used to
treat CT and NG may not be effective in all cases of MG. [3] Surveillance data indicates that Herpes simplex virus (HSV), a known causative agent of cervicitis, is the leading cause of STDs [16]
in Sri Lanka. However, we do not have any data regarding the prevalence
of HSV or other pathogens like ureaplasma in women with cervicitis.
The inhibition rate for the PCR reaction was 4.2% which is consistent with other studies. [17] It is interesting to note that although blood is considered as having inhibitory factors for PCR [18]
none of the seven specimens that were visibly blood stained was
inhibited. It was observed that the specimens that were inhibited were
those that had mucus in it. Wiping the cervix before collection of the
endocervical specimen as recommended by the manufacturer is important to
avoid getting inhibitory results.
Although the manufacturers
recommend using Dacron swabs with the Amplicor CT/NG kit, we had to use
commercially available cotton wool swabs with plastic handles due to
financial constraints. Soon after collection of the specimen, swabs were
placed in SPG medium. Prior testing of the positive control with cotton
wool swabs showed that there was no inhibition of the PCR and that the
required optical density readings were achieved with the positive and
negative controls.
Screening of urine is a convenient
non-invasive method for detection of these pathogens. Amplicor CT/NG kit
has sensitivities ranging from 79.2% to 90.7% for detection of CT in
female urine with specificities of 97.0-99.4%. [19]
Although the difference may be small, endocervical swab specimens are
superior in performance to urine specimens with diagnostic tests for CT.
[19] Therefore, it was decided to use endocervical swabs in this study to obtain a more accurate prevalence rate.
Infection
with CT has been shown to be associated with certain risk factors.
Younger age has been shown to be a risk factor for CT infection and age
less than 20 and 30 have been implicated as the high prevalence ages. [12],[20] In our study we could not find any association with any age groups [Table 1]. However, it must be noted that our population consisted of patients over the age of 18 years.
Some studies show that being single is a risk factor for CT infection [21],[22] whereas others could not find a significant association. [12],[17] A low level of education was a risk factor in some [21],[23] but others have found no association. [12],[2] One study linked high literacy rate as a risk factor for CT infection. [25] We did not detect an association with being single which included never married, divorced or widowed women [Table 1].
Those who had studied up to Grade five or less were more at risk of
infection indicating that in our women the level of education did have
an impact on the prevalence of CT [Table 1].
Similarly,
the number of sexual partners has also been studied as a risk factor
for CT infection. Significant associations were found in some studies [17],[23],[24] while others could not find any association. [26] In our study CT infection was more (OR = 3.2; 95% CI = 1.03-10.14) in those who had two or more partners in the past [Table 2]. Commercial sex work and a past history of STD were not associated with CT in this study [Table 2] although it has been shown to be in some. [11],[27]
Religious and social ethics discourage open discussion of sexual
matters in Sri Lanka. Although participants were assured of anonymity
and confidentiality and given a self-administered questionnaire, the
number admitting to having had more than one partner and commercial sex
may be under-reported here.
A review of studies on STD rates
around the world has emphasized that women selling sex tend to have
comparatively higher rates of STD than the general population. [28]
One recent study found that consistent condom use was low with only 38%
brothel workers and street workers in Colombo, Sri Lanka using condoms
always. [29]
This is a cause for concern as FSW are believed to be the core in
spreading infection in the community. Only 28.6% of CT-infected patients
admitted to being FSWs. Therefore, it appears that in our community
FSWs are not the only important source in spread of infection.
The
most frequent reason given for visiting the STD clinic was being
symptomatic and this is similar to findings in other studies among STD
clinic attendees. [24] A significant association with features of cervicitis and CT positivity has been shown in other studies too [Table 3]. [24]
Recommendations
In
conclusion the high CT prevalence rate in our study population is a
cause for concern. The cost effectiveness of initiating a screening
program for women of reproductive age should be considered and the
search for developing cheaper diagnostic methods for CT should be
continued.
Acknowledgements | | |
Authors
would like to thank the participants of the study. They wish to extend
their special thanks to Mrs. Hemali Attanayake, Medical Laboratory
Technologist, NSACP, for excellent technical assistance. They are
thankful for the assistance in data and specimen collection, provided by
Dr. A.T. Pinidiyapathirage, Dr. Hemantha Weerasinghe and Dr. K.G.S.
Gunasekera of the Central clinic, National STD/AIDS Control Program and
the staff of the STD Clinic, Colombo South Teaching Hospital. They also
thank Mr. Wasantha Arunasiri (Computer analyst) and Dr. Sajith
Dissanayake Dept. of Microbiology, Faculty of Medical Sciences,
University of Sri Jayewardenepura for assistance in data entry.
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Correspondence Address: Gunasekera Henadira Appuhamilage Kamani Mangalika Senior Lecturer, Department of Microbiology, Faculty of Medical Sciences, University of Sri Jayewardenepura Sri Lanka
DOI: 10.4103/0377-4929.130898
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5] |
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