Vol. 9, No. 4 Printed in Great Britain
Family Practice © Oxford University Press 1992
Testing for Cervical Chlamydia trachomatis Infection in an Inner City Practice PIPPA OAKESHOTT.* SALLY CHIVERTON," LINDA SPEIGHT" AND JOHN BERTRAND"*
INTRODUCTION Chlamydia trachomatis is now the commonest sexually transmitted infection in Britain. The 1991 Communicable Disease Surveillance Centre figures record 17 827 cases of genital chlamydia infection in women. The infection is associated with pelvic inflammatory disease, chronic pelvic pain, tubal infertility, and ectopic pregnancy.' But most women with cervical chlamydia have no symptoms.2 In inner city general practice populations, prevalence rates of chlamydial cervicitis of 8-12% have been reported.3"3 This has led to recommendations for improved facilities for testing for chlamydia in general practice.3*4 Two approaches to screening have been suggested: routine testing of all sexually active young women in populations with high prevalence of infection,5'6 and selective screening of high-risk groups.7'8 The aims of this study were to find the prevalence of cervical chlamydia in women having a speculum examination at our inner city health centre, to examine • To whom correspondence should be addressed at Department of General Practice and Primary Care, St George's Hospital Medical School, London SW17 ORE. •• Mawbey Brough Health Centre, London SW8 2UD. • • • Department of Virology, St Thomaj's Hospital, London SE1 7EH.
421
possible risk factors and to see if we could develop a rational practice policy for screening for chlamydia infection in women. METHOD Two nurses and four doctors working in two practices based at an inner London health centre took part in the study. Between April 1990 and October 1991 women having a speculum examination for a cervical smear or gynaecological check-up were counselled and given a patient handout. Those giving informed consent were tested for chlamydia and assessed for possible risk factors. Women over the age of 45, and those who had had a course of erythromycin or tetracycline in the previous 3 months were excluded from the study. Risk Factors
Risk factors were selected from those found to be significant in other studies: age less than 25,7-9 more than one sexual partner in the previous 3 months,7"9 past history of chlamydial infection,' sexual contact with men with urethritis,8 cervicitis,3'7'8 purulent vaginal discharge3-7-8 and inflammatory cervical smears.9 Testing for chlamydia was carried out according to a standardized protocol. Cervical smear results were ex-
Downloaded from http://fampra.oxfordjournals.org/ at Weizmann Institute of Science on June 8, 2016
Oakeshott P, Chiverton S, Speight L and Bertrand J. Testing for cervical Chlamydia trachomatis in an inner city practice. Family Practice 1992; 9: 421-424. The aims of the study were to find the prevalence of cervical ChJamydia trachomatis infection in women attending for a speculum examination, to examine possible risk factors, and to see if we could develop a rational policy for testing for chlamydia in our deprived inner London practice. During 18 months 409 women aged 17-45 (mean 28) who attended for a cervical smear or vaginal examination were tested for chlamydia using the direct immunofluorescent test. They were assessed for possible risk factors: age less than 25, more than one sexual partner in the previous 3 months, sexual contact with men with urethritis, past history of chlamydia infection, purulent vaginal discharge, cervicitis and abnormal cervical cytology. Thirty-six women (8.8%) were chlamydia positive. Chlamydia infection was significantly associated with the presence of purulent vaginal discharge or an inflammatory cervical smear. In view of the prevalence of chlamydial oervicitis, the lack of symptoms and signs, and the potential consequences of untreated infection, ideally all young women in this population should be offered screening when they attend for a speculum examination. If this is not practical, chlamydia testing might be offered to women thought to be in high-risk groups including those with purulent vaginal discharge or an inflammatory cervical smear.
422
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
traded from the medical records. When possible the results of history and examination were recorded on a questionnaire (Appendix 1). Subjects were classified into four groups depending on their cervical cytology. Women with a dyskaryotic smear were put into the first group; those with an inflammatory or borderline smear were put into the second group; those with evidence of human papilloma virus or Trichomonas vaginalis infection but no inflammation were put into the third group; and those with normal smears were put into the fourth group.
Treatment and Contact Tracing Women found to have chlamydia infection were recalled, counselled and given appropriate treatment. They were advised that it was essential that their partners should seek treatment, and encouraged to return for follow up.3-4 RESULTS Four-hundred and nine women aged 17-45 (mean 28) were tested for chlamydia of whom 36 (8.8%) were positive. Three-hundred and ninety women (95%) had cervical smear results in their medical notes (Table 1). The relative risk of chlamydia infection with an inflammatory smear as opposed to a normal smear was 2.4 (95% confidence interval 1.22-4.77). Three-hundred and eighteen patients (78%) had completed questionnaires (Table 2). The relative risk
TABLE 1 Chlamydia trachomatis and cervical cytology in 390 women
Chlamydia positive Chlamydia negative Total
Dyskaryotic smear
Inflammatory or borderline smear
W
(%)
Trichomonas vaginalis or wart virus infection (%)
Normal smear
1 Total
(%)
W
36 (85.8)
61 (83.6)
11 (100)
246 (93.2)
354 (90.8)
42
73
11
264
390
TABLE
(0)
(6.8)
(9.2)
12 (16.4)
0
18
36
6 (14.2)
2 Risk factors in 318 women with completed questionnaires
Risk factor
Chlamydia positive 23 women (
Family Practice © Oxford University Press 1992
Testing for Cervical Chlamydia trachomatis Infection in an Inner City Practice PIPPA OAKESHOTT.* SALLY CHIVERTON," LINDA SPEIGHT" AND JOHN BERTRAND"*
INTRODUCTION Chlamydia trachomatis is now the commonest sexually transmitted infection in Britain. The 1991 Communicable Disease Surveillance Centre figures record 17 827 cases of genital chlamydia infection in women. The infection is associated with pelvic inflammatory disease, chronic pelvic pain, tubal infertility, and ectopic pregnancy.' But most women with cervical chlamydia have no symptoms.2 In inner city general practice populations, prevalence rates of chlamydial cervicitis of 8-12% have been reported.3"3 This has led to recommendations for improved facilities for testing for chlamydia in general practice.3*4 Two approaches to screening have been suggested: routine testing of all sexually active young women in populations with high prevalence of infection,5'6 and selective screening of high-risk groups.7'8 The aims of this study were to find the prevalence of cervical chlamydia in women having a speculum examination at our inner city health centre, to examine • To whom correspondence should be addressed at Department of General Practice and Primary Care, St George's Hospital Medical School, London SW17 ORE. •• Mawbey Brough Health Centre, London SW8 2UD. • • • Department of Virology, St Thomaj's Hospital, London SE1 7EH.
421
possible risk factors and to see if we could develop a rational practice policy for screening for chlamydia infection in women. METHOD Two nurses and four doctors working in two practices based at an inner London health centre took part in the study. Between April 1990 and October 1991 women having a speculum examination for a cervical smear or gynaecological check-up were counselled and given a patient handout. Those giving informed consent were tested for chlamydia and assessed for possible risk factors. Women over the age of 45, and those who had had a course of erythromycin or tetracycline in the previous 3 months were excluded from the study. Risk Factors
Risk factors were selected from those found to be significant in other studies: age less than 25,7-9 more than one sexual partner in the previous 3 months,7"9 past history of chlamydial infection,' sexual contact with men with urethritis,8 cervicitis,3'7'8 purulent vaginal discharge3-7-8 and inflammatory cervical smears.9 Testing for chlamydia was carried out according to a standardized protocol. Cervical smear results were ex-
Downloaded from http://fampra.oxfordjournals.org/ at Weizmann Institute of Science on June 8, 2016
Oakeshott P, Chiverton S, Speight L and Bertrand J. Testing for cervical Chlamydia trachomatis in an inner city practice. Family Practice 1992; 9: 421-424. The aims of the study were to find the prevalence of cervical ChJamydia trachomatis infection in women attending for a speculum examination, to examine possible risk factors, and to see if we could develop a rational policy for testing for chlamydia in our deprived inner London practice. During 18 months 409 women aged 17-45 (mean 28) who attended for a cervical smear or vaginal examination were tested for chlamydia using the direct immunofluorescent test. They were assessed for possible risk factors: age less than 25, more than one sexual partner in the previous 3 months, sexual contact with men with urethritis, past history of chlamydia infection, purulent vaginal discharge, cervicitis and abnormal cervical cytology. Thirty-six women (8.8%) were chlamydia positive. Chlamydia infection was significantly associated with the presence of purulent vaginal discharge or an inflammatory cervical smear. In view of the prevalence of chlamydial oervicitis, the lack of symptoms and signs, and the potential consequences of untreated infection, ideally all young women in this population should be offered screening when they attend for a speculum examination. If this is not practical, chlamydia testing might be offered to women thought to be in high-risk groups including those with purulent vaginal discharge or an inflammatory cervical smear.
422
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
traded from the medical records. When possible the results of history and examination were recorded on a questionnaire (Appendix 1). Subjects were classified into four groups depending on their cervical cytology. Women with a dyskaryotic smear were put into the first group; those with an inflammatory or borderline smear were put into the second group; those with evidence of human papilloma virus or Trichomonas vaginalis infection but no inflammation were put into the third group; and those with normal smears were put into the fourth group.
Treatment and Contact Tracing Women found to have chlamydia infection were recalled, counselled and given appropriate treatment. They were advised that it was essential that their partners should seek treatment, and encouraged to return for follow up.3-4 RESULTS Four-hundred and nine women aged 17-45 (mean 28) were tested for chlamydia of whom 36 (8.8%) were positive. Three-hundred and ninety women (95%) had cervical smear results in their medical notes (Table 1). The relative risk of chlamydia infection with an inflammatory smear as opposed to a normal smear was 2.4 (95% confidence interval 1.22-4.77). Three-hundred and eighteen patients (78%) had completed questionnaires (Table 2). The relative risk
TABLE 1 Chlamydia trachomatis and cervical cytology in 390 women
Chlamydia positive Chlamydia negative Total
Dyskaryotic smear
Inflammatory or borderline smear
W
(%)
Trichomonas vaginalis or wart virus infection (%)
Normal smear
1 Total
(%)
W
36 (85.8)
61 (83.6)
11 (100)
246 (93.2)
354 (90.8)
42
73
11
264
390
TABLE
(0)
(6.8)
(9.2)
12 (16.4)
0
18
36
6 (14.2)
2 Risk factors in 318 women with completed questionnaires
Risk factor
Chlamydia positive 23 women (
