Some New Developments in the Case of Chlamydia
As recently as five years ago, doctors were accustomed to hearing patients they had just diagnosed as having chlamydia trachomatis say that the disease sounded like the name of a flower.
Today, the play on words is just another tired cliche and the obscurity of chlamydia is long since gone.
Chlamydia--elevated to a position just below herpes on the ranking of sexually transmitted diseases that have achieved prominence or even perverse trendiness in the 1980s--is increasingly being recognized as a major and common health problem for both men and women. But at the same time, it may already have reached its high-water mark in terms of incidence and have stabilized.
Some doctors even say it is already decreasing in frequency as a result of improved public awareness of it and other sexually transmitted diseases and growing fear of exposure through sex to not only herpes but AIDS, as well.
The New Puritanism
This fear, some experts say, has introduced what might almost be called a new puritanism in American sexual practices in some quarters, leading to greater personal restraint and care in selection of partners and, as a result, less contact with what are euphemistically called “social diseases.”
Chlamydia is a microorganism first identified about 20 years ago. Though the disease is not part of mandatory reporting programs that require notification of state health departments when a case is discovered, the federal government’s Centers for Disease Control in Atlanta has estimated there may be 4.65 million cases a year.
Chlamydia infects the reproductive tracts of both men and women and is a major cause of urinary tract infections in both sexes, and can lead to serious health problems for women, in particular, if it is not detected.
Men can also contract infections of the epididymis--the tube that carries sperm from the testis. Women can contract cervical infection, pelvic inflammatory disease and a variety of infections during pregnancy and after delivery--problems that can be passed on to a newborn child.
Health workers note, though, that the disease is comparatively easy to treat and lends itself to being discovered in screening programs that are now being advocated for women’s health facilities.
Profile of Likely Victims
Within the last few months, there have been these developments in the case of chlamydia:
--Experts at a major West Coast chlamydia research center, Seattle’s Harborview Medical Center, have developed what could be called a profile of women most likely to contract chlamydia and urge health workers to offer screening tests to women who fit. Among the criteria: The typical chlamydia-prone woman, the team says, is 24 or younger, with a statistically average age of 21.8. She has had sex with one or more new partners within the previous two months and either takes birth control pills or uses some other non-barrier method of birth control.
--New evidence has emerged buttressing the suspicion that barrier methods, like the diaphragm, offer an element of protection against chlamydia--or perhaps that the pill makes a woman more susceptible. Pill and other non-barrier method users appear at higher risk--a conclusion that represents a reversal of what doctors had previously believed. While both men and women get chlamydia, men usually do not develop symptoms and a smaller proportion of men than women develop the organism, to begin with.
--Chlamydia represents a potentially major health risk for women since, though chlamydia itself is a comparatively minor infection, it can lead to development of pelvic inflammatory disease, which itself is being recognized increasingly as a major threat to women’s health. Two new studies establish that pelvic inflammatory disease is responsible for a higher death rate than syphilis. However, death rates for both diseases are apparently on the decline, with pelvic inflammatory disease killing .29 of every 100,000 women aged 15 to 44 and syphilis taking the lives of .17.
--Pelvic inflammatory disease remains widespread, however, with 300,000 women a year hospitalized with it and 2.5 million doctor’s office visits required to treat it. PID, as pelvic inflammatory disease is called, imposed economic costs on society of $2.6 billion in 1984, with the figure expected to rise to $3.5 billion by 1990. The figures include an estimate of the costs of treating tubal pregnancy and infertility among women who have the disease.
--Treating chlamydia is comparatively simple, with the antibiotics tetracycline or erythromycin taken for seven days usually completely effective. If those two drugs don’t work, effective agents can be found among other commonly used antibiotics.
Best Approach for Women
In Seattle, Dr. H. Hunter Handsfield, director of the sexually transmitted disease control program at the King County public health department and an associate professor at the University of Washington School of Medicine, said that the best approach for many women would be to ask for a chlamydia test each year at the time of their annual reproductive health checkups.
Handsfield and the Seattle team that developed the screening criteria called for what they describe as “selective screening” of women in an article in last week’s Journal of the American Medical Assn. The team took the selective approach, Handsfield said, because in public health clinics, the costs of testing every woman who appears for chlamydia may be unacceptably high in terms of the number of cases that can be found.
What was needed to control the cost--the most reliable chlamydia assay can run as much as $35 per patient and recently developed substitutes cost $10 to $15 each--was a set of criteria that could be used to select patients who are most likely to have chlamydia and screen them.
Handsfield said his screening study focused on women because only about 5% of men seen in a clinic setting can be expected to test positively for chlamydia while 20% to 40% of women will. Because men so seldom experience symptoms, Handsfield said, they normally do not seek care for chlamydia and most male cases are discovered only after a woman who has had contact with an infected man is diagnosed.
It is not an unfair generalization, noted Handsfield and Dr. A. Eugene Washington of the Centers for Disease Control, to say that, in the vast majority of all cases, chlamydia is something women get from men.
A General Rule
For any woman who does not rely on a public health clinic for her health care, however, Handsfield said that, as a general rule, “if you are a woman who is sexually active and you go in for your annual Pap smear, ask for a chlamydia test.
“The exceptions would be a monogamous married person or a monogamous unmarried person who has had the same partner for a year or more. Any woman who has changed partners in a year should ask the doctor if he is offering the test. If not, ask why not.
“There are many factors why (chlamydia testing) is not as widely employed as it should be. One is inertia. Doctors haven’t thought much about it and one of the ways to break through that is for patients to raise the issue themselves. The other side of the coin is (doctors) don’t want to create a lot of paranoia; but on the other hand, chlamydia is very common.”
Washington said he agreed with Handsfield’s criteria for selecting women most likely to have chlamydia, but he added that teen-agers 15 to 19 seem to be at an even higher level of risk than young women in general 24 and below.
“Chlamydia should not remain the unknown sexually transmitted disease,” Washington said. “It’s an insidious organism with widespread capacity to damage very sensitive organs, particularly in a woman’s reproductive tract.”
Washington noted that when the CDC first assessed the incidence of chlamydia in 1980, there was thought to be an annual total of 3 million cases--a figure far lower than what he said are newer, more sophisticated estimates of 4.65 million. But he cautioned that the marked difference between the two numbers does not necessarily mean chlamydia has increased in incidence dramatically.
Better Surveillance
In fact, an unknown portion of the difference between the 1980 figure and the current estimate may be strictly due to better surveillance and medical census techniques today. “It may be that the procedures we used in 1980 were faulty,” said Washington.
Handsfield also urged caution in evaluating reported numbers of chlamydia cases. “My own feeling is that it (the new total) represents both better reporting and an increase in incidence,” he said. But he said that most recently, he has begun to suspect the incidence of chlamydia may have at least peaked and perhaps to have begun to decline.
“At this juncture, it could well be leveling off or starting to drop because of the changes (in society) because of AIDS and herpes fear,” Handsfield said. “We’re also in a political era where we’re seeing an increasing trend toward personal and social conservatism.
“There will be nothing like a return to the sexual life style of the 1950s but there is some change occurring. I have no doubt that, up until 1985, the incidence of chlamydia was truly rising, even though there was also increased recognition.
“In 1985, it started to drop off a little bit.”
Handsfield said that in Seattle, chlamydia cases dropped about 10% in 1985 compared to the year before. “So far in 1986,” he said, “it looks like that trend is continuing.”
