|Year : 2016 | Volume
| Issue : 1 | Page : 31-34
Prevalence of Chlamydia trachomatis in a tertiary center in South India
Yohen Nandeibam1, Shakti Laishram2, Jessie Lionel1
1 Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||5-Feb-2016|
Department of Obstetrics and Gynaecology, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Objective: To determine the prevalence for Chlamydia trachomatis and the need for introduction of screening test for chlamydia infection in patients attending a gynaecology outpatient clinic. Materials and Methods: Ninety-nine patients had endocervical swabs taken during pelvic examination, after an informed consent and tested using the Clearview ® chlamydia test kit. Results: Overall prevalence of infection was 10%. Conclusion: There is a high prevalence of C. trachomatis which warrants introduction of screening.
Keywords: Chlamydia clearview test, Chlamydia trachomatis, Endocervical swabs, Pelvic inflammatory disease
|How to cite this article:|
Nandeibam Y, Laishram S, Lionel J. Prevalence of Chlamydia trachomatis in a tertiary center in South India. J Med Soc 2016;30:31-4
|How to cite this URL:|
Nandeibam Y, Laishram S, Lionel J. Prevalence of Chlamydia trachomatis in a tertiary center in South India. J Med Soc [serial online] 2016 [cited 2020 May 24];30:31-4. Available from: http://www.jmedsoc.org/text.asp?2016/30/1/31/175802
| Introduction|| |
Considering the multitude of patients presenting to our outpatient clinic with complications thought related to chlamydial infection, we conducted an antigen based testing to find out the prevalence of chlamydial infection. Infertility, abortions, ectopic pregnancy, preterm labor, premature rupture of membrane, and poor neonatal outcome are some of the complications associated.
| Materials and Methods|| |
Women presenting to our routine gynecological outpatient were randomly chosen and explained about the procedure. Of those who were willing to the test and follow-up 99 had an endocervical swab taken after an informed written consent. The cervix was visualized using a sterile bivalve speculum, before doing a digital examination. Excess mucus if present was removed with a swab. Endocervical swabs were then collected using Clearview ® chlamydia swab (Inverness, Houston, TX 77038). This was then sent to our Microbiology laboratory and processed on the same day. The presence of chlamydial antigen was detected using the Clearview ® chlamydia test (CCT) kit (Inverness, Houston, TX 77038) following the manufacturer's instructions. This is a rapid point of care immunochromatographic tests using the principle of enzyme immune assay. It provides result in <30 min and hence allows diagnosis and specific treatment at the same visit. The sensitivity of these tests depend on the prevalence of infection, with sensitivity of 55-85% for high prevalence setting and 25-49% for low prevalence setting. , As per manufacturer's guidelines, this test has a sensitivity ranging from 82% to 92% and specificity of 97.6-100% depending on the prevalence of the population studied.
Results were analyzed using SPSS 16.0 (Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.) and tested for significance using Fischer's exact and Pearson's Chi-square tests. The study was approved by the Institutional Review Board and Ethics Committee.
| Results|| |
Ten subjects out of 99 recruited tested positive with the CCT. Of those recruited into the study 46 had at least one of the following complaints: Lower abdominal pain, low back ache, pelvic pain, dyspareunia, and cervical discharge, and 53 were asymptomatic. Those who were asymptomatic had come for routine gynecological check-up or for interval sterilization.
Sociodemographic profiles of the asymptomatic and symptomatic groups were similar. Age ranged from 19 to 45 years (mean 32.5 years). All were married, with duration from 1 to 29 years [Table 1].
The most frequent presenting symptom was vaginal discharge (41.4%) followed by lower abdominal pain (29.2%), low back ache (13.1%), dyspareunia (11%), and chronic pelvic pain (7%) [Table 2].
Prevalence was higher among asymptomatic subjects as compared to symptomatic ones (13.2% [7/53] vs. 6.5% [3/46] [P = 0.33]). One asymptomatic patient positive for the test had history of three spontaneous abortions, one had history of infertility and one had a neonatal death. Of three of the symptomatic patients who tested positive two had all the symptoms of lower abdominal pain, low backache, chronic pelvic pain, vaginal discharge, and dyspareunia together, while one had only vaginal discharge. Only one patient among those who tested negative had all the above symptoms together (1/43).
| Discussion|| |
The overall prevalence of genital chlamydial infection in the present setting was 10%. In a prevalence study conducted on a different population group of pregnant women Vidwan et al. found a similar prevalence of 10% in the same area.  However, when these pregnant subjects were tested using nucleic acid amplification test (NAAT) (Roche, Amplicor) the prevalence was reported as 0.1%. The reason for the discrepancy between NAAT and CCT may not be explained by a lack of specificity of CCT. In recent years, a new variant of Chlamydia trachomatis with 377 bp deletion in the cryptic plasmid has been reported which cannot be detected by NAATs targeting the cryptic plasmid like the Roche Amplicor system.  This variant strain constituted 27-64% of clinical isolates in Sweden. , Such high prevalence of the variant strain has been attributed to the usage of NAATs targeting the cryptic plasmid for diagnostic testing allowing continued transmission of the undetected variant strain.  The prevalence of this variant strain is not known in a country like India where NAATs are not commonly used for diagnosis. Magbanua et al. Reported a case where a patient infected by the variant strain showed strong reactivity with the immune based chlamydia rapid test while plasmid based Roche Amplicor polymerase chain reaction remained negative.  The possibility of presence of the variant strain in our population remains and the performance of antigen detection test like CCT in detecting this strain needs further investigation. The pooled sensitivity and specificity reported for the clearview chlamydia test in a recent review was 64% (47-77%) and 97% (88-99%) respectively for cervical specimens. 
The reported prevalence here needs to be confirmed by simultaneous testing by NAAT targeting the chlamydial genome other than the cryptic plasmid, and the rapid test needs to be further evaluated for suitability in the local conditions. Prior prevalence studies by various workers in different population groups have shown prevalence rates in India, as variable as 1.1-45% ,,,,,,,,, [Table 3].
More number of asymptomatic subjects were positive by the rapid test than symptomatic subjects (13.2% vs. 6.5%), though the difference was not statistically significant. High prevalence of chlamydial infection in up to 14.3% in asymptomatic subjects with history of primary infertility has also been observed by Mania-Pramanik.  Three of the asymptomatic positive patients had history of adverse sequelae associated with chlamydial infection, reiterating the hidden nature of infection and its potential for continued transmission.
Of the three symptomatic patients who tested positive two presented with all symptoms of pelvic inflammatory disease (PID), while one presented only with vaginal discharge. The symptoms included lower abdominal pain, low backache, chronic pelvic pain, vaginal discharge, and dyspareunia. Presence of these symptoms together in various combinations may be predictive of underlying infection. Vaginal discharge though is frequently complained of, is hardly specific for chlamydial infection and does not warrant empirical treatment.
Pettifor et al. similarly noted that presence of vaginal discharge independently is not an effective tool for screening of cervical infection.  To avoid unnecessary treatment, risk assessment was incorporated in the flowchart for the syndromic treatment of vaginal discharge. 
Common problems in our set up are the low rate of return visit and follow-up by the patients. Most patients expect diagnosis and treatment of their condition in one sitting. This may be a result of a number of factors such as financial constraints, loss of daily wage, long distance travel. In this setting point of care testing becomes relevant. Moreover, in high prevalence settings like ours, point of care testing has been found to be an effective strategy for screening. 
Prohibitive cost of testing remains another barrier to screen chlamydial infection. Highly sensitive and specific test like NAATs are neither freely available nor affordable. Measures to cut cost like pooling of samples have been tried. This has been found to reduce the number of test by 60% without significant loss of accuracy by Currie et al.  With a prevalence of around 10% more pools are likely to be positive in our set up, thus nullifying the cost effectiveness of pooling.
Finally, the advantages in having a rapid point of care testing in a high prevalence, low resources setting like ours can be numerous. Benefits to the patients include diagnosis and treatment at the same visit, thus eliminating the problem of repeat visits and loss to follow-up, no unnecessary anxiety waiting for test results, disease specific treatment and appropriate counselling. Moreover, the risk of transmission of infection and development of sequelae are reduced.
One major drawback of this study was the lack of follow-up of partner of positive cases. The patients whose rapid test results were positive informed of the need to treat their partner. Suggestion to follow-up in sexually transmitted disease (STD) clinic of the institute is given for the partner. An additional course of antibiotic meant for the partner is prescribed. Since most patients come for Out-patient Department visit with one of the female relations and hardly anyone with their partner, counselling and treatment of the partner is not a feasible option in our set up. Another issue not addressed in this study is that of reinfection and whether the recruited patients had previously been treated for chlamydial infection. Lack of health record is a major drawback in our set up. None of the patients gave a history of having had or having been treated for STD, though.
Another drawback of this study is the unavailability of testing by NAAT to confirm the CCT positives. Multicentric or population-based studies are needed further.
| Conclusion|| |
The prevalence of chlamydial infection is high in women symptomatic for PID as well as in those who are asymptomatic using the CCT. This high prevalence warrants offering screening to patients attending Gynecology Out-patient Clinic, while those with multiple symptoms may be treated empirically.
Financial support and sponsorship
Internal FLUID grant, Christian Medical College, Vellore, Tamil Nadu.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vickerman P, Watts C, Alary M, Mabey D, Peeling RW. Sensitivity requirements for the point of care diagnosis of Chlamydia trachomatis
and Neisseria gonorrhoeae
in women. Sex Transm Infect 2003;79: 363-7.
Blanding J, Hirsch L, Stranton N, Wright T, Aarnaes S, de la Maza L, et al.
Comparison of the Clearview Chlamydia, the PACE 2 assay, and culture for detection of Chlamydia trachomatis
from cervical specimens in a low-prevalence population. J Clin Microbiol 1993;31:1622-5.
Vidwan NK, Regi A, Steinhoff M, Huppert JS, Staat MA, Dodd C, et al.
Low prevalence of Chlamydia trachomatis
infection in non-urban pregnant women in Vellore, S. India. PLoS One 2012;7:e34794.
Moller JK, Pedersen LN, Persson K. Comparison of Gen-probe transcription-mediated amplification, Abbott PCR, and Roche PCR assays for detection of wild-type and mutant plasmid strains of Chlamydia trachomatis
in Sweden. J Clin Microbiol 2008;46: 3892-5.
Herrmann B, Törner A, Low N, Klint M, Nilsson A, Velicko I, et al.
Emergence and spread of Chlamydia trachomatis
variant, Sweden. Emerg Infect Dis 2008;14:1462-5.
Marions L, Rotzen-Ostlund M, Grillner L, Edgardh K, Tiveljung-Lindell A, Wikstrom A, et al.
High occurrence of a new variant of Chlamydia trachomatis
escaping diagnostic tests among STI clinic patients in Stockholm, Sweden. Sex Transm Dis 2008;35:61-4.
Magbanua JP, Goh BT, Michel CE, Aguirre-Andreasen A, Alexander S, Ushiro-Lumb I, et al. Chlamydia trachomatis
variant not detected by plasmid based nucleic acid amplification tests: Molecular characterisation and failure of single dose azithromycin. Sex Transm Infect 2007;83:339-43.
Hislop J, Quayyum Z, Flett G, Boachie C, Fraser C, Mowatt G. Systematic review of the clinical effectiveness and cost-effectiveness of rapid point-of-care tests for the detection of genital chlamydia infection in women and men. Health Technol Assess 2010;14:1-97, iii-iv.
Mania-Pramanik J, Meherji PK, Gokral JS, Donde UM. Chlamydia trachomatis
infection in an urban setting. Sex Transm Infect 2001;77:141.
Pettifor A, Walsh J, Wilkins V, Raghunathan P. How effective is syndromic management of STDs?: A review of current studies. Sex Transm Dis 2000;27:371-85.
Vuylsteke B. Current status of syndromic management of sexually transmitted infections in developing countries. Sex Transm Infect 2004;80:333-4.
Peeling RW, Holmes KK, Mabey D, Ronald A. Rapid tests for sexually transmitted infections (STIs): The way forward. Sex Transm Infect 2006;82 Suppl 5:v1-6.
Currie MJ, McNiven M, Yee T, Schiemer U, Bowden FJ. Pooling of clinical specimens prior to testing for Chlamydia trachomatis
by PCR is accurate and cost saving. J Clin Microbiol 2004;42:4866-7.
Joyee AG, Thyagarajan SP, Rajendran P, Hari R, Balakrishnan P, Jeyaseelan L, et al. Chlamydia trachomatis
genital infection in apparently healthy adult population of Tamil Nadu, India: A population-based study. Int J STD AIDS 2004;15:51-5.
Gokral JS, Mania-Pramanik J, Meherji PK, Mali BN. Introital swab testing for Chlamydia trachomatis
in a resource-poor setting: An Indian perspective. Int J Fertil Womens Med 2005;50:140-3.
Brabin L, Gogate A, Gogate S, Karande A, Khanna R, Dollimore N, et al.
Reproductive tract infections, gynaecological morbidity and HIV seroprevalence among women in Mumbai, India. Bull World Health Organ 1998;76:277-87.
Sawhney MP, Batra RB. Chlamydia trachomatis
seropositivity during pregnancy. Indian J Dermatol Venereol Leprol 2003;69:394-5.
Singh V, Salhan S, Das BC, Mittal A. Predominance of Chlamydia trachomatis
serovars associated with urogenital infections in females in New Delhi, India. J Clin Microbiol 2003;41:2700-2.
Garg S, Bhalla P, Sharma N, Sahay R, Puri A, Saha R, et al.
Comparison of self-reported symptoms of gynaecological morbidity with clinical and laboratory diagnosis in a New Delhi Slum. Asia Pac Popul J 2001;16:75-92.
George JA, Panchatcharam TS, Paramasivam R, Balasubramanian S, Chakrapani V, Murugan G. Evaluation of diagnostic efficacy of PCR methods for Chlamydia trachomatis
infection in genital and urine specimens of symptomatic men and women in India. Jpn J Infect Dis 2003;56:88-92.
Sowmya B, Rajendran P, Krishnan S, Joyee AG, Hari R, Rajesh PK; Ramkumar, et al.
Prevalence of Chlamydia trachomatis
and Neisseria gonorrhoeae
genital infections in the apparently healthy population of Sringeri (Karnataka) by a coamplification PCR assay. Indian J Med Microbiol 2001;19:228-9.
Alexander R, Mathai E, Nayyar V, Mathew M, Jasper P. Low prevalence of chlamydial endocervical infection in antenatal South Indian women. Genitourin Med 1993;69:240-1.
[Table 1], [Table 2], [Table 3]