The early discovery of Chlamydial infection amongst women in the United States, and its significance in the decrease of the general infection rates of the diseases.
The significance of the problem statement
Chlamydia diseases is an STI that is said to be the leading public health issue in both limited and resource-rich settings. In females, the infection is asymptomatic, thus not easily detectable and can result in several complications. The direct goal for screening for chlamydia is to detect and treat the diseased individuals before the complications develop. The diagnosis also aims at identifying, testing and managing the sexual partners of the infected people to avoid reinfections and transmissions. Chlamydia trachomatis is the most common reported communicable infection in the U.S (Ginocchio et al., 2014). In women, the main advantage of screening and management is to lessen the personal threats of their reproductive sequelae. In men, who are a decreased risk of prolonged sequelae and usually have symptomatic infections, the primary goal for the diagnosis and treatment is to minimise the possibility of reinfection to their spouses and lower the general transmission rates of the disease (Sutton et al., 2011). Chlamydial infections in the females are minimally symptomatic or asymptomatic, and if untreated they can cause serious problems such as infertility, chronic pelvic discomforts, pregnancy complications, and pelvic inflammatory diseases (Blas et al., 2009).
Confirmation of the study
Chlamydia trachomatis disease cases reported in the United States are said to be about 2.8 million per year with a projected rate of prevalence of approximately 467.6 reports per a hundred thousand individuals (Blas et al., 2009). The majority of the chlamydial diseases are asymptomatic, and if untreated the infections lead to severe conditions such as tubal infertility and ectopic pregnancy. Chlamydial infections during pregnancy are linked with an increase in the threats of the perinatal mortality, preterm labour and reduced birth weight. Chlamydia disease enforces a substantial burden of costs on the healthcare organisations (Sutton et al., 2011).
Multiple risk features for C. trachomatis diseases have been discovered. Many of the infections happen in sexually energetic people younger than the age of twenty-six years, especially amongst the teenagers ageing between sixteen to nineteen years. Minorities are influenced disproportionally, just like the individuals from low socioeconomic levels. Other risks that facilitate the transmission of the disease comprise of cervical ectopy, unprotected sex, multiple or new sexual partners, early coitarche and inconsistency in the application of the barrier techniques. Military men under thirty years of age, females and males under juvenile imprisonment, and men and women in prison are all at an increased threat of infection transmission (Miller et al., 2010). The risk is also noticeably inclined in females and males with Neisseria gonorrhoeae infections within the past twelve months. Therefore, screening for chlamydial infections is commended in various population segments. However, most individuals at risk are unable to attain the required testing for the disease (Ginocchio et al., 2014).
The significance of preventing the Chlamydia
The Centers for Disease control and prevention approximates that about twenty million people are affected by the STDs in the United States, and 35% of the affected are persons with chlamydial infections. The most impacted of the population are the young individuals ageing from fifteen to twenty-four years. The STD’s cost the healthcare organisation in the U.S approximately $ sixteen billion with a large percentage of the money (about 29%) going to the care for the population affected with chlamydial infections (Sutton et al., 2011). Chlamydia leads to at least twenty thousand cases on infertility in women in the United States. Despite chlamydial infections’ being complicated and costly, they are still imposing a great problem to the United States’ public health system. The burdens are unidentified by the health care specialists, public and policymakers. The disease causes various harmful, irreversible and expensive medical complications like perinatal and fetal health issues and reproductive health conditions (Ginocchio et al., 2014).
The study targets the females that are visiting hospitals in the United States with the symptoms of chlamydial infections together with their spouses. Pregnant women are also essential for the study as well as their sexual partners.
Chlamydia screening is approved in various population subdivisions. However, most of the people at the risk of being infected are unable to acquire the appropriate testing for the disease. The review focuses of the screening tests, management of the infection, present screening commendations and screening barriers (Keegan, Diedrich, and Peipert, 2014).
There has been the testing of two Randomized controlled tests (RCTs) to illustrate the advantage of screening for chlamydia. That is, women at an increased risk of chlamydia were randomised for repetitive detection and treatment or normal care. Surveys were also conducted with the respondents being females aged between eighteen to thirty-four years; the threat was confirmed based on the responses offered according to the study questions (Haggerty et al., 2010). Screening and management of disease lowered the risk of consequent PID by approximately 50% after one year of research follow-up. Founded on the tests and the scientific evidence’s strength, the US Preventive Services Task Force (USPSTF) in the year 2001 permitted the screening of chlamydia in all non-pregnant and sexually active women ageing 25 years and below as well as in older women who were not pregnant. The commendation was termed to as the grade A endorsement (Blas et al., 2009). In 2007’s update the USPSTF organisation discovered a new RCT that addressed the usefulness of chlamydial infection screening amongst non-pregnant females al the increased risk of being infected. Workowski and Bolan, (2015) described the POPI trial (Prevention of Pelvic Infections trial) which involved 2259 sexually lively females from London who answered to the study questionnaire. The intervention group women were tested immediately and treated while those in the control set were tested after one year. The investigation focused on predominant chlamydia instead of the incident of the infections. Workowski and Bolan, (2015) then concluded that the previous explorations overestimated the efficiency of chlamydial infection screening for the prevention of PID.
Numerous tests have been applied for the analysis of Chlamydia trachomatis infections. The assessments consist of the hybridisation of the nucleic acid tests, direct immunofluorescence, nucleic acid amplification tests (NAATs), and enzyme immunoassays. Initially, cell culture was thought to be an essential identification technique due to its superior ability and specificity to recognise small numbers of chlamydial microorganism. However, Torrone, Papp, and Weinstock, (2014) illustrated that NAATs are more useful for the detection of chlamydial microbes as they are specific and sensitive. Therefore, their technique is the standardised diagnostic screening technique. NAATs’ availability has permitted the expansion of the screening methods. Identification of urogenital diseases in women can be made through the collection of endocervical or vaginal swabs or by examining the urine (Wiesenfeld et al., 2011). In bulky cross-sectional investigations comparing the endocervical specimen, vaginal swabs and first-void urine, the vaginal samples have the most significant rate of detection for the positive testing at 86%, and it is usually chosen by the patients. Forhan et al., (2009) discussed the comparison of varying screening approaches, which is first-void urine, endocervical probes of DNA and vaginal swabs. The self-collected vaginal swabs had a sensitivity of 97.2% and prohibited seventeen additional scenarios per 10, 000 women as compare to the first-void urine. Extra costs (over $ 40 000 on every 10000 females) are incurred due to a decrease in the management of the infertility cases, chronic pelvic pains and PID (Keegan, Diedrich, and Peipert, 2014).
Recommendations for screening
Clifton, (2018) explains that screening commendations rely on pregnancy status and gender. The present authorisations from the American College of Obstetricians and Gynecologists (ACOG) as well as CDC are to diagnose all the sexually active females at and below twenty-five years of age. The USPSTF mention that all sexually proactive women at twenty-four years and younger need to be screened. The women older than twenty-four years need to be assessed if at the risk of being infected, for instance, non-use or inconsistency in the use of barrier techniques, multiple partners and being institutionalised. The UK’s National Chlamydia Screening Program accepts that there is a need for annual diagnosis for all individuals who are sexually proactive at the age of 24 years and younger. NAAT is the assessment technique preferred for both women and men. In females, the use of vaginal swabs is recommended by the CDC while in males the use of first-void urine or urethral swab (Papp et al., 2014).
The CDC permits that every woman who is pregnant has to be a screen for chlamydial infections. The USTPF, American Academy of Family Physicians (AAFP) and ACOG endorse screening in expectant women at the age of twenty-four and younger as well as for any females who are at an increased risk of the disease. Satterwhite et al., (2008) defined high risk as below twenty-five years of age or having multiple or new sexual partners. ACOG also approves rescreening of expecting females in their 3rd trimester. For the patients who are pregnant and are positive after screening, a trial of the cure is performed to guarantee infection clearance. Newman et al., (2015) explain that the test of treatment is different from rescreening since rescreening is usually the evaluation for the reinfection quick like ineffective or incomplete treatment. Sometimes, rescreening detects the persistent infection, however, most diseases found at rescreening are reinfections that might be from a diseased new spouse or an old partner who was untreated. The test of medicine is typically employed in two weeks, or one following accomplishment therapy as the rescreening is performed for several months.
Because of the hardships in the occurrence of the chlamydial infections in men, neither USPSTF nor the CDC permits repetitive screening of the male patients. However, just like in women below 25 and pregnant, there is the endorsement of screening practice to men at an increased rate of infection threat, particularly those under custody, juvenile protections and the younger males (below) in the military. Sexually strong men who have intercourse with men (MSM) need to receive an anorectal STI screening test which includes chlamydia screening at least once per year (Keegan, Diedrich, and Peipert, 2014).
The genitals are the organs that are most affected by chlamydia. However, other orifices are also affected by the infection. Rectal chlamydia screening needs to be enacted for the MSM who have practised anal sex in the previous year. Urethral chlamydial infection screening needs to be endorsed for the MSM with insertive sexual intercourse in the preceding year. Presently, pharyngeal analysis of chlamydia is not permitted for the MSM by the CDC (Haggerty et al., 2010).
The absence of screening is accredited to both the provider and patient barriers. In an exploration conducted by Zakher et al., (2014) on the primary health care professionals, only 31% of the participants reported that they could screen sexually active asymptomatic woman ageing between 15 to 25 years. The physicians that are less likely to perform screening practices are male, who have the opinion that chlamydia incidences are low. Other individuals who are not open to screening exercises are the practitioners in rural areas, solo experts and doctors with scarce minority patients. The infected individuals are also unlikely to follow screening especially when they have limited understanding or lack of information of the chlamydia’s asymptomatic state and the potential of prolonged morbidity of the chlamydial infections. However, some patients evade screening because of the shame of detection and the stigma of acquiring positive diagnostic results. Other obstacles comprise of the incapability to pay for the costs of testing and the period related to the discovery (Wiesenfeld et al., 2011).
St. Lawrence et al., (2012) conducted two studies on the partakers of the Contraceptive CHOICE Venture. The project offered free contraceptives to 8500 females at a hospital together with STI assessment at the period of their yearly follow-up. The first investigation was on home-based or clinic-based vaginal swabs that were self-collected. The females who selected the home-based diagnosis were more expected to finish their testing as compared to those who picked the clinical-based assessment. Lack of medical cover, minority ethnicity and limited socio-economic status were linked with the decrease in the probability of screening completion even though the tests were free. The second exploration consisted of women agreeing to the STD screening who were then randomly picked for self-collected vaginal swabs at the clinic or homes. Females in the home-based setting indicated greater potentiality of completing the testing than the clinical-based group. Amongst the ones who failed to finish, claimed that there was no enough time or they forgot to visit the medical centres (Wiesenfeld et al., 2011).
Intrusions to overcome the obstacles to screening include enlightenment of patients and providers about chlamydia (educational outreach). Provision of financial encouragement to clinical centres where free tests are conducted optimise the whole practice’s involvement in the screening of chlamydia thus increasing the number of testing enactment. Motivation of the home-based testing practices as they increase the likelihood of the patient completing their screening process. Internet involvement, whereby the vaginal swabs that are self-collected are mailed to the labs for testing (Papp et al., 2014).
The morbidity of the infection can be minimised through swift treatment of people whose test results are positive together with their partners; the step also prevents the transmission of the disease (Marrazzo, and Suchland, 2014). The CDC approved the oral provision of 1g of azithromycin per dose or 100mg of doxycycline twice in a day for seven days. Lin et al., (2008), debated whether azithromycin or doxycycline is desirable as an effective treatment where comparable curing rates were recognised. Recently, Hocking et al., (2013) revealed the important advantage of doxycycline over the other treatment (azithromycin).
Hosenfeld et al., (2009) discusses that treatment needs to be offered to all the sexual contacts the infected person had been with up to sixty days before the diagnosis or onset of the symptoms. If the patient’s sexual contact occurred more than sixty days before the signs, then their last sex partner need to be treated. The test of medicine is unnecessary in males and non-expectant females because doxycycline or azithromycin treatment is still beneficial. However, reinfection cases are common. Thus, the NCSP and CDC sanctioned that people who test positive should undergo repeated testing in three months to guarantee that they are not reinfected. The step is usually significant in cases where the patient’s companion is not yet cured. Expectant women need to go through the test of cure after the treatment process because of the severe threats linked to recent CT infection. To avoid reinfection persons are required to abstain from sex until one week after the treatment by azithromycin or upon accomplishment of the seven-day regimen of doxycycline. Sexual partners should use protection during intercourse until they are both healed (Lin et al., 2008).
Due to the increased occurrence of chlamydia in the U.S and the under application of the screening practices, there has been an increase in the efforts that promote screening procedures for the improvement of the public health. With the increased potential to lessen the adverse effects of infertility, PID and chronic pelvic discomfort, it is recommended that screening should be done to every sexually proactive female ageing from twenty-five years and below. Yearly testing should also be endorse in sexually vigorous women of twenty-six years or older who are at risk of chlamydial infection or during the screening process in a particular geographical place associated with the high percentage of chlamydia occurrence. Females need to be offered a choice of home-based testing with vaginal swabs that are self-collected to ensure screening compliance and the possibility of saving costs (Wiesenfeld et al., 2011). Expecting women usually require screening upon the commencement of the prenatal health care and rescreened during their 3rd trimester of pregnancy. MSM should also be yearly screened. Other interventions can be a reduction of the obstacles to care, patient and provider enlightenment and encouragement of repetitive screening. Increased acquisition of effective treatments and advancements in the screening rates will result in a vast net enhancement regarding reduced medical costs, pain and suffering (Marrazzo, and Suchland, 2014).
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