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Recommendation for your practice: Screen all young women every year for Chlamydia, CDC urges

With a rising rate of infection, comprehensive screening of the most vulnerable population is a vital undertaking

January 2008 · Vol. 20, No. 01

IN THIS ARTICLE

All sexually active women younger than 26 years should be screened annually for Chlamydia trachomatis, according to the Centers for Disease Control and Prevention (CDC). although that recommendation isn’t new, it remains a critical component of efforts to reduce the number of new cases, said John M. Douglas, Jr, MD, Director of the CDC’s Division of Sexually transmitted Disease Prevention, during a telebriefing november 13.

Almost 50% of all sexually transmitted infections (STIs) occur among people 15 to 24 years—and young women 15 to 19 years have the highest rate of C. trachomatis infection, followed closely by women 19 to 241.

Chlamydia diagnoses increased in 2006, as they have every year since 2000, the first year all states reported new cases of this StI. Just over 1 million cases were reported in 2006, although the CDC estimates the real number at nearly 2.8 million new cases, most of which go undiagnosed.2

For every 100 women aged 15 to 24 years who are screened, 5.65 cases of Chlamydia will be detected, based on the reported case rate. However, because the actual number of cases is thought to be higher, the screen-positive rate may exceed 6%.

Annual screening of young women is a “critical prevention measure,” said Douglas, as is repeat testing approximately 3 months after treatment. Older women who have a risk factor for StI, such as a new partner or multiple partners, or symptoms of Chlamydia infection, such as vaginal discharge, abdominal pain, or abnormal findings on physical examination, also should be screened, he said.“

Unfortunately, our best estimates indicate that as few as 40% of women who need such testing are receiving it,” Douglas said. “Simple changes in the way we provide health care, such as couplinga Chlamydia test with a Pap test, for example, can greatly increase the number of women screened.”

“In addition, because studies indicate that women who are effectively treated can still become reinfected by their untreated sexual partners, the CDC recommends the delivery of antibiotic treatment by patients to their partners—otherwise known as expedited partner therapy—as an effective strategy to combat reinfection if other efforts for reaching partners are not likely to succeed,” Douglas said.

Also on the rise…

Gonorrhea and syphilis diagnoses also increased in 2006, with 358,366 and 9,756 new cases, respectively, according to the CDC.1

“Probably the biggest news with syphilis in the last 2 years—although, fortunately, it’s a small trend at this point—has been the increased rate in women,” said Douglas. “We had really gotten down to very low rates in women, and achieved major reductions in African American women in particular, so the fact that in the last 2 years we’re beginning to see those rates creep up is really cause for concern.”

As for gonorrhea, the rising rate maybe attributed, in part, to the use of “dual” tests, which include gonorrhea and Chlamydia tests in a single package. “So, as we have been increasing Chlamydia testing, we have been increasing gonorrhea testing,” said Douglas. “Those same tests that make Chlamydia diagnoses more sensitive also probably enhance gonorrhea detection,” he added. “But there probably are true increases” in the rate of gonorrhea, too.

Like Chlamydia, gonorrhea is under diagnosed, and the rate of new infectionis likely twice the number reported, accordingto the CDC.1

Fluoroquinolone resistance is rising

Once widely recommended as first-line treatment for gonorrhea, fluoroquinolones have fallen out of favor in recent years but are still sometimes prescribed. The Centers for Disease Control and Prevention (CDC) discourages their use, noting that 13.8%of gonorrhea isolates tested positive for resistance to fluoroquinolones in 2006.2 Cephalosporins are now recommended, said John M. Douglas Jr, MD, Director of the CDC’s Division of Sexually Transmitted Disease Prevention.

“Antibiotic resistance monitoring that we’ve done in the US, and that the World Health Organization and others have done in other parts of the world, has not demonstrated emergence of resistance to this class of antibiotics at all,” Douglas said. “There are a handful of strains that show intermediate levels of resistance, which are concerning, but those have not increased over time, so, at least at this point, we think they are sporadic.”

The three reportable diseases, representinga total of 1,399,033 new cases, account for only a small percentage of all STIs diagnosed in 2006. When herpes simplex virus 2, genital types of human papillomavirus, and trichomonal infectionsare included in the count, approximately19 million new STIs occur every year, the CDC estimates.1

African Americans are hardest hit

African Americans accounted for 46% of all Chlamydia infection cases in 2006, 69% of cases of gonorrhea, and 43.2% of all reported cases of primary and seconddary syphilis.

In 2006, the number of new cases of Chlamydia infection in African Americans was 1,760.9 for every 100,000 people, compared with 237.0 new cases among Caucasians. In Hispanics, the rate was 761.3 new cases for every 100,000people. American Indians and alaska natives also were hit hard, with 1,262.3 cases for every 100,000 people.

The rate of Chlamydia infection did not increase in Asians and Pacific islanders.

The disparity in statistics between whites and members of minorities probably has several causes. First, racial and ethnic minorities may be more likely to seek health care in a public clinic—and such clinics tend to report StI rates more completely than do private practitioners. Second, members of minorities may have limited access to quality health care, a higher rate of poverty, and a higher prevalence of disease overall, Douglas noted.

Reference

1. Trends in reportable sexually transmitted diseases in the United States, 2006. National surveillance data for Chlamydia, gonorrhea, and syphilis [press release]. Centers for Disease Control and Prevention; November 13, 2007.

2. Weinstock H, Berman S, Cates W, Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004;36:6-10.

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