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Discordant prevalence of Chlamydia trachomatis in asymptomatic couples screened by two screening approaches Evelin L Corbeto, Victoria Gonzalez, R Lugo, Ma Rosa Almirall, Ramon Espelt, Angels Avecilla, Isabel González, Imma Campo, Estrella Arranz, Jordi Casabona and CT/NG study group Int J STD AIDS published online 2 April 2014 DOI: 10.1177/0956462414528686 The online version of this article can be found at: http://std.sagepub.com/content/early/2014/03/27/0956462414528686

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Int J STD AIDS OnlineFirst, published on April 2, 2014 as doi:10.1177/0956462414528686

Original research article

Discordant prevalence of Chlamydia trachomatis in asymptomatic couples screened by two screening approaches

International Journal of STD & AIDS 0(0) 1–6 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414528686 std.sagepub.com

Evelin L Corbeto1,2,3, Victoria Gonzalez1,2,4, R Lugo1,2, Ma Rosa Almirall5, Ramon Espelt6, Angels Avecilla7, Isabel Gonza´lez8, Imma Campo9, Estrella Arranz10, Jordi Casabona1,2,11 and CT/NG study group

Abstract Background: This study was carried out to observe the effect of screening in asymptomatic couple members on the Chlamydia trachomatis prevalence. Methods: First void urine samples were collected from 105 women and their male sex partners. Women were recruited for screening at sexual health clinical setting (age 16–25 years), and home sampling screening options were used for men. Results: PCR detected seven positive C. trachomatis samples in women (6.6%) and five in men (4.6%). The concordant infection rate was 33% (3/9) (95% CI 13–182%). Conclusions: Routine urine screening of only female partner results in substantial underestimation of the C. trachomatis prevalence, where probably 56% of the couples with at least one partner tested positive would not be unnoticed. Screening both partners compared with women- or men-only screening increases the detection rate of positive couples. Furthermore, the use of alternative screening approaches against clinical setting increases the accessibility to test at risk populations.

Keywords Chlamydia trachomatis, sexual partnerships, prevalence, discordant, home screening Date received: 11 October 2013; accepted: 19 February 2014

Background Chlamydia trachomatis (CT) is the most common bacterial sexually transmitted infection (STI) in many developed countries1 and the most prevalent among sexually active young adults. Most infections are asymptomatic leading to undiagnosed infection,2 and those diagnosed 1

infections present increased chance of re-infection due to continuous exposure to untreated sexual partners or due to sexual contacts with high-risk partners. Recurrent infections, especially among women, increase

7

Sexual and Reproductive Health Centre, BSA, Badalona, Spain Sexual and Reproductive Health Centre Mataro´-Maresme, Mataro´, Spain 9 Youth Health Centre for Contraception and Sexuality (CJAS), Barcelona, Spain 10 Youth Health Centre Hospitalet del LLobregat, Spain 11 Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine, Univ Autonoma Barcelona, Bellaterra, Cerdanyola, Spain 8

Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Institut Catala d’Oncologia (ICO), Agencia de Salut Publica de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain 2 CIBER Epidemiologı´a y Salud Pu´blica (CIBERESP), Spain 3 Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine, Univ Autonoma Barcelona, Bellaterra, Cerdanyola, Spain 4 Microbiology Service, Fundacio Institut d’Investigacio en Ciencies de la Salut Germans Trias i Pujol, Hospital Universitari Germans Trias i Pujol, Univ Autonoma Barcelona, Badalona, Spain 5 Sexual and Reproductive Health Centre, ASSIR Esquerre, Barcelona, Spain 6 Sexual and Reproductive Health Centre, CAP Sant Fe`lix, Sabadell, Spain

Corresponding author: Evelin L Corbeto, Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Institut Catala d’Oncologia (ICO), Agencia de Salut Publica de Catalunya (ASPC), Generalitat de Catalunya, Badalona 08916, Spain. Email: [email protected]

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the risk of serious sequelae such as pelvic inflammatory disease, infertility and chronic pelvic pain.3–5 Several studies suggest that repeated CT infection occurs in 7–30% of women within four to six months after first diagnosis. According to the European Centre for Disease Prevention and Control (ECDC), CT is the most frequently reported STI, with over 340,000 cases reported in 2010 and doubled over the past 10 years.6,7 Moreover, increasing trends among youth has been observed with prevalence rates between 5% and 10%. In Catalonia, CT infection is a mandatory reported disease, based on weekly numerical reporting, showing incidence rates of 12.4 per 100,000 population. Epidemiological characteristics of the affected population are monitored through sentinel and microbiological reporting. In order to estimate and monitor prevalence rates, bi-annual cross-sectional studies have been carried out since 2007 among vulnerable populations, such as young people attending Sexual and Reproductive Health centres (ASSIR) and specific youth attention centres.8,9 These centres offer care to gynaecological issues, family planning, sexual education and STI-related control and prevention services.10 Poor men’s access to sexual health centres is a limitation for an accurate CT prevalence estimation. The introduction of screening programmes and new detection strategies addressed to engage young people will help to better estimate population prevalence and to decrease infection rates. Treatment of sexual partners is essential as a prevention of re-infection. Previous studies have found that the use of different screening strategies contributes to engage vulnerable population, which would not be detected otherwise.11 One of these strategies introduced the home sampling screening, considered as a useful method to identify infected sexual partners and to control transmission of infection.11–13 This study was carried out to observe the effect of screening in asymptomatic couples on the CT prevalence.

Methods The study started in fall 2010 after the approval of the Ethics Committee of the University Hospital Germans Trias i Pujol. Signed informed consent form was obtained from each participant. A total of 105 first void urine samples from sexual partners were collected for CT detection by polymerase real-time chain reaction (PCR) technique (Abbott Real Time Chlamydia trachomatis/Neisseria gonorrhoeae Assay, Abbott Molecular IL, USA) and were analysed following the manufacturer’s specifications.

Women were recruited for screening at sexual health clinical setting (age 16–25 years), and home sampling screening options was used for men. The inclusion criteria were: being sexually active during the last 12 months before baseline, no menstruation and no antibiotics use during the two weeks before sampling. Women distributed home sampling screening kit to their partners. The kit included: study information, coded sterile urine collection containers with instructions, a brief behavioural questionnaire and instructions for results notifications via the Internet. Once the urine sample was taken, it was returned by regular mail (prestamped envelope) to the coordinator centre project. Epidemiological data were obtained by standardised data collection form, including socio-demographic and behavioural variables such as age, country of origin, number of sexual partners in last year, new sexual partner in the last three months, condom use, drug use, HIV status and sexual encounter in different venues like saunas, internet chats. The results of men were communicated 15 days after their urine sample was taken through a website, created ad hoc. Positive results were recommended to arrange for a medical visit for STI assessment and control. Physicians from clinical setting notified the results to their women patients within 15 days. Data analysis was performed using the SPSS statistical package (version 18.0, SPSS Ibe´rica, SLU). CT prevalence was calculated as the number of positive samples for all samples analysed. Comparison of proportions performed using Pearson’s 2 tests.

Results Population characteristics Hundred-and-five matched-sexual pairs were recruited, 105 women from a clinical setting screening, average age 21.5 years (SD 2.2) by range of 16–25 years and their male sexual partners in the last three months from home screening with a mean age of 24.1 years (SD ¼ 4.2) by range of 16–35 years. Of these, 21% were foreign, mostly from Latin America. In all, 78% had less than two sexual partners last year; 17% of the cases had a new sexual partner in the last three months. Half of the participants (54%) did not use a condom during their last sexual intercourse and high drug consumption was observed in 82%, mostly alcohol (67%) and cannabis (39.5%); 9.5% had sex at sexual meeting places and 58% had unknown HIV status (Table 1).

Prevalence Hundred-and-five first void urine samples from women and 105 from men were obtained. PCR technique

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Table 1. Behavioural characteristics of 105 couples. Women Variables

Frequency

Origin Foreign 24 Spanish 81 Na sexual partners 2 87 >2 18 New sexual partner last 3 months Yes 21 No 84 Condom use last sexual intercourse Yes 53 No 52 Drug use Yes 80 No 25 Cannabis Yes 36 No 67 Alcohol Yes 52 No 53 Non injected drugs Yes 11 No 94 Injected drugs Yes 1 No 104 Sexual meeting places Yes 5 No 93 Internet Yes 1 No 102 Bar/disco Yes 3 No 101 Sauna Yes 1 No 102 HIV status Known 49 Unknown 56

Men %

Frequency

Total %

Frequency

%

22.9 77.1

20 85

19.0 81.0

44 166

21.0 79.0

82.9 17.1

77 28

73.3 26.7

164 46

78.1 21.9

20.0 80.0

16 89

15.2 84.8

37 173

17.6 82.4

50.5 49.5

44 61

41.9 58.1

97 113

46.2 53.8

76.2 23.8

92 13

87.6 12.4

172 38

81.9 18.1

34.3 63.8

47 58

44.8 55.2

83 125

39.5 59.5

49.5 50.5

89 16

84.8 15.2

141 69

67.1 32.9

10.5 89.5

15 90

14.3 85.7

26 184

12.4 87.6

1.0 99.0

2 103

1.9 98.1

3 207

1.4 98.6

4.8 88.6

15 90

14.3 85.7

20 183

9.5 87.1

1.0 97.1

3 102

2.9 97.1

4 204

1.9 97.1

2.9 96.2

13 92

12.4 87.6

16 193

7.6 91.9

1.0 97.1

2 103

1.9 98.1

3 205

1.4 97.6

46.7 53.3

38 67

36.2 63.8

87 123

41.4 58.6

detected seven positive CT samples in women (6.6%) and five in men (4.6%), women had higher prevalence than men but these differences were not statistically significant (p ¼ 0.55). Also, prevalence values did not differ

by age group (Figure 1). CT prevalence was statistically higher in those of foreign origin, 18.18% vs. 2.41% (p ¼ 0.004) – foreign men (15%) and foreign women (2.4%) (p < 0.001).

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0,1

p Women=0,579 p Men=0,987

Prevalence

0,09 0,08

Women Men

0,07 0,06 0,05 0,04 0,03 0,02 0,01 0 16-18

19-21

22-24

25-27

28,00

Age group (years)

Figure 1. Sex and age group Chlamydia trachomatis prevalence.

50 9/105 couples, at least one of the partners were CT positive

45 40

Concordance rate

35 30 25 20 15

3 couples (both partners positive)

4 couples (female partner positive only)

3/9= 33%

4/9= 44%

10

2 couples (male partner positive only) 2/9= 22%

5 0

Figure 2. Concordant and discordant Chlamydia trachomatis infection rates among couples.

Concordant infections The detection rate was different between couples. At least one partner was positive in nine (8.5%) of the 105 couples tested (95% CI 4–18%). Among these nine couples, in four cases female partners tested positive (4/9 ¼ 44%) (95% CI 23–275%) and male partners tested positive in two cases (2/9 ¼ 22%) (95% CI 6–120%). Of the nine couples with at least one member tested positive, both members of the couple tested positive in three pairs, so the concordant infection rate was 33% (3/9) (95% CI 13–182%) (Figure 2). According to these results, if only female urine specimens had undergone screening, 56% of all couples with at least one positive partner would have gone undetected.

Discussion CT prevalence and CT concordant infection rate were determined by two screening strategies in sexual matched-pairs. This study was performed for the first time in Catalonia, a home sampling screening strategy, where couples of women (less than 25 years) previously tested in clinical setting were tested. Screening programmes are cost-effective if they tested the population at risk14,15; therefore, screening in clinical settings at centres for young people is essential. Also, another important factor is the increased coverage to reduce the prevalence and the incidence of infection.16 This study has been pioneer, in our European region, to test sexual partners following the

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home sampling method, regardless of infection status. This strategy shows common benefit for youth, which probably leads to an increase in participation rates, and therefore, increases the population coverage. Young people, especially men, rarely go to health services because they perceive of good health and were asymptomatic in mostly cases.2,10 Screening in a non-clinical setting as a home sampling screening performance increases test coverage and tests people who would otherwise be difficult to be tested.17–19 There is a controversy that carrying out diagnosis on couples by home sampling can delay treatment for them.20 In this sense, some studies showed that expedited partner therapy (EPT) is a good alternative. Several randomised trials were designed to compare EPT with standard uptake sexual pairs approaches and suggest that EPT is a cost-effective strategy. EPT evidences to be useful to ensure partner treatment and reduces sex rates with untreated partners.20,21 Despite these advantages, an EPT faces problem related to STI assessment and control, further contact tracing and other STI/HIV screening. Furthermore, although some studies observed home sampling screening providing an equal number of partners treated versus conventional tracking partner or EPT, other studies found more infected partners with home sampling screening.22 To enhance home sampling participation rate in our study, we incorporate the Internet tool for communication of results. So any barriers were not set up for young men due to the anonymous status they had with this tool instead of going to health centres to pick up their results. Although it was not possible to count the total web entries, usefulness, high viability and acceptability among young people had been highlighted by other studies using the same method.11,23,24 The concordant infection rate of 33% (three of nine) obtained in our study was similar than that reported by others.25 This rate shows that both men and women partners should be included in the routine CT screening. According to our data, urine screening of only women partners results in substantial underestimation of the CT prevalence, where probably 56% of the couples with at least one partner tested positive would not be unnoticed. Screening both partners compared with women-only or men-only screening increases the detection rate of positive couples.25,26 Furthermore, the use of alternative screening approaches against clinical setting increases the accessibility to test at-risk populations.16,25 The main limitation of this study includes, social desirability response bias related to drug use or sexual behaviour questions. In order to reduce this bias, participants were informed about strict confidentiality of data use.

Despite the limitation, the use of two complementary screening approaches provides an opportunity to act on promoting preventing sexual health and increases accessibility of young people who otherwise would not be attended at health services. In turn, it is feasible and contributes to increase the population coverage (especially in the male population), helps to get better knowledge of CT prevalence in the population and additionally, the test between sexual partners avoids possible re infections. CT prevalence and concordant infection rate obtained and the young STI vulnerability,26,27 make the systematic screening among young population relevant in our setting. Acknowledgment The authors gratefully acknowledge the following study group: Clinical staff: A. Molins, A. Payaro´, A. Rodas, A. Giugni, A. de Castro, A. Molins, A. Villalo´n, A. Dı´ ez, A. Rodas, C. Piorno, E. Grau, E. Lopez-Grado, M. Trujillo, R. Escriche, E. Crespo, E. Picola, I. Escribano, I. Ferre´, J. Xandri, J. Cid, L. Zamora, L. Esteve, MA. Villalo´n, M. Teixido´, A. Molins, N. Dominguez, A. Yus. CEEISCAT staff: A. Montoliu, N. Romero. Laboratory HUGTIP staff: E. Bascun˜ana.

Conflict of interest The authors declare no conflict of interest.

Funding This study was funded by Health Department, Generalitat de Catalunya, Spain, and partially funded by CIBER de Epidemiologı´ a y Salud Pu´blica (CIBERESP).

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Discordant prevalence of Chlamydia trachomatis in asymptomatic couples screened by two screening approaches.

This study was carried out to observe the effect of screening both members of an asymptomatic couple for Chlamydia trachomatis. First void urine sampl...
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