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Objective: To compare vulvovaginal swabs with endocervical swabs as optimal diagnostic sample for detection of Chlamydia trachomatis infection., Design: A diagnostic test study., Setting: An urban sexual health centre., Participants: 3973 women aged ≥ 16 years requesting testing for sexually transmitted infections., Interventions: Participants took a vulvovaginal swab before routine examination, and clinicians took an endocervical swab during examination., Main Outcome Measure: Diagnosis of chlamydia infection with samples analysed using the Aptima Combo-2 assay; positive results confirmed with the Aptima CT assay., Results: Of the 3973 participants, 410 (10.3%) were infected with C trachomatis. Infected women were significantly younger (22 v 25 years, P<0.0001) and more likely to have symptoms suggestive of a bacterial sexually transmitted infection (53% v 41%, odds ratio 1.63 (95% CI 1.30 to 2.04)), be a contact of someone with a sexually transmitted infection (25% v 5%, odds ratio 6.18 (4.61 to 8.30)), clinically diagnosed with cervicitis (17% v 4%, odds ratio 4.92 (3.50 to 6.91)), and have pelvic inflammatory disease (9% v 3%, odds ratio 2.85 (1.87 to 4.33)). When women co-infected with gonorrhoea were included in the analysis, there was an association with mixed ethnicity (10% v 7%, odds ratio 1.53 (1.07 to 2.17)); but when those with gonorrhoea were removed, women of white ethnicity were significantly more likely to have chlamydia (85% v 80%, odds ratio 1.40 (1.03 to 1.91)). On analysis of complete paired results, vulvovaginal swabs were significantly more sensitive than endocervical swabs (97% (95% CI 95% to 98%) v 88% (85% to 91%), P<0.00001); corresponding specificities were 99.9% and 100%. In women with symptoms suggestive of a bacterial sexually transmitted infection, vulvovaginal swabs were significantly more sensitive than endocervical swabs (97% (93% to 98%) v 88% (83% to 92%), P=0.0008), as they were in women without symptoms (97% (94% to 99%) v 89% (84% to 93%), P=0.002)., Conclusions: Vulvovaginal swabs are significantly better than endocervical swabs at detecting chlamydia in women with and without symptoms suggestive of sexually transmitted infections. In those with symptoms, using endocervical samples rather than vulvovaginal swabs would have missed 9% of infections, or 1 in every 11 cases of chlamydia., Trial Registration: ISRCTN42867448.

Objective: To evaluate the effectiveness of register based, yearly chlamydia screening., Design: Controlled trial with randomised stepped wedge implementation in three blocks., Setting: Three regions of the Netherlands: Amsterdam, Rotterdam, and South Limburg., Participants: 317 304 women and men aged 16-29 years listed on municipal registers at start of trial., Intervention: From March 2008 to February 2011, the Chlamydia Screening Implementation programme offered yearly chlamydia screening tests. Postal invitations asked people to use an internet site to request a kit for self collection of samples, which would then be sent to regional laboratories for testing. Treatment and partner notification were done by the general practitioner or at a sexually transmitted infection clinic., Main Outcome Measures: Primary outcomes were the percentage of chlamydia tests positive (positivity), percentage of invitees returning a specimen (uptake), and estimated chlamydia prevalence. Secondary outcomes were positivity according to sex, age, region, and sociodemographic factors; adherence to screening invitations; and incidence of self reported pelvic inflammatory disease., Results: The participation rate was 16.1% (43 358/269 273) after the first invitation, 10.8% after the second, and 9.5% after the third, compared with 13.0% (6223/48 031) in the control block invited at the end of round two of the intervention. Chlamydia positivity in the intervention blocks at the first invitation was the same as in the control block (4.3%) and 0.2% lower at the third invitation (odds ratio 0.96 (95% confidence interval 0.83 to 1.10)). No substantial decreases in positivity were seen after three screening rounds in any region or sociodemographic group. Among the people who participated three times (2.8% of all invitees), positivity fell from 5.9% to 2.9% (odds ratio 0.49 (0.47 to 0.50))., Conclusions: There was no statistical evidence of an impact on chlamydia positivity rates or estimated population prevalence from the Chlamydia Screening Implementation programme after three years at the participation levels obtained. The current evidence does not support a national roll out of this register based chlamydia screening programme., Trial Registration: NTR 3071 (Netherlands Trial Register, www.trialregister.nl).

Objective: To investigate frequency and risk factors for prevalent, incident, and persistent carcinogenic human papillomavirus (HPV) in young women before the introduction of immunisation against HPV types 16 and 18 for schoolgirls., Design: Cohort study, Setting: 20 London universities and further education colleges., Participants: 2185 sexually active female students, mean age 21 years (range 16-27), 38% from ethnic minorities, who took part in the POPI (prevention of pelvic infection) chlamydia screening trial in 2004-08 and who provided duplicate, self taken vaginal swabs and completed questionnaires at baseline. At follow-up, a median of 16 months later, 821 women (38%) returned repeat vaginal swabs by post. In 2009-10, stored samples were tested for HPV., Results: Samples from 404/2185 (18.5% (95% CI 16.9% to 20.2%)) of the cohort were positive for carcinogenic HPV at baseline, including 15.0% (327) positive for non-vaccine carcinogenic genotypes. Reporting two or more sexual partners in the previous year and concurrent Chlamydia trachomatis or bacterial vaginosis were independent risk factors for prevalent vaginal HPV infection. Infection with one or more new HPV types was found in 17.7% (145/821) of follow-up samples, giving an estimated annual incidence of carcinogenic HPV infection of 12.9% (95% CI 11.0% to 15.0%). Incident infection was more common in women reporting two or more partners in the previous year, aged<20, of black ethnicity, or with C trachomatis vaginosis at baseline. Multiple partners was the only independent risk factor for incident infection (adjusted relative risk 1.99 (95% CI 1.46 to 2.72)). Of 143 women with baseline carcinogenic HPV infection, 20 (14% (8.3% to 19.7%) had infection with the same carcinogenic HPV type(s) detected after 12-28 months. Of these women, 13 (65%) had redetected infection with HPV 16 or 18, and nine (45%) with non-vaccine carcinogenic HPV genotypes., Conclusion: In the first UK cohort study of carcinogenic HPV in young women in the community, multiple sexual partners was an independent predictor of both prevalent and incident infection. Infection with non-vaccine carcinogenic genotypes was common. Although current HPV vaccines offer partial cross protection against some non-vaccine carcinogenic HPV types, immunised women will still need cervical screening.

Objective: To determine the risks of short term adverse events in adolescent and older women undergoing medical abortion., Design: Population based retrospective cohort study., Setting: Finnish abortion register 2000-6., Participants: All women (n = 27,030) undergoing medical abortion during 2000-6, with only the first induced abortion analysed for each woman., Main Outcome Measures: Incidence of adverse events (haemorrhage, infection, incomplete abortion, surgical evacuation, psychiatric morbidity, injury, thromboembolic disease, and death) among adolescent (<18 years) and older (≥ 18 years) women through record linkage of Finnish registries and genital Chlamydia trachomatis infections detected concomitantly with abortion and linked with data from the abortion register for 2004-6., Results: During 2000-6, 3024 adolescents and 24,006 adults underwent at least one medical abortion. The rate of chlamydia infections was higher in the adolescent cohort (5.7% v 3.7%, P < 0.001). The incidence of adverse events among adolescents was similar or lower than that among the adults. The risks of haemorrhage (adjusted odds ratio 0.87, 95% confidence interval 0.77 to 0.99), incomplete abortion (0.69, 0.59 to 0.82), and surgical evacuation (0.78, 0.67 to 0.90) were lower in the adolescent cohort. In subgroup analysis of primigravid women, the risks of incomplete abortion (0.68, 0.56 to 0.81) and surgical evacuation (0.75, 0.64 to 0.88) were lower in the adolescent cohort. In logistic regression, duration of gestation was the most important risk factor for infection, incomplete abortion, and surgical evacuation., Conclusions: The incidence of adverse events after medical abortion was similar or lower among adolescents than among older women. Thus, medical abortion seems to be at least as safe in adolescents as it is in adults.

Objectives: To compare the cost, cost effectiveness, and sex equity of different intervention strategies within the English National Chlamydia Screening Programme. To develop a tool for calculating cost effectiveness of chlamydia control programmes at a local, national, or international level., Design: An economic and mathematical modelling study with cost effectiveness analysis. Costs were restricted to those of screening and partner notification from the perspective of the NHS and excluded patient costs, the costs of reinfection, and costs of complications arising from initial infection., Setting: England. Population Individuals eligible for the National Chlamydia Screening Programme., Main Outcome Measures: Cost effectiveness of National Chlamydia Screening Programme in 2008-9 (as cost per individual tested, cost per positive diagnosis, total cost of screening, number screened, number infected, sex ratio of those tested and treated). Comparison of baseline programme with two different interventions-(i) increased coverage of primary screening in men and (ii) increased efficacy of partner notification., Results: In 2008-9 screening was estimated to cost about £46.3m in total and £506 per infection treated. Provision for partner notification within the screening programme cost between £9 and £27 per index case, excluding treatment and testing. The model results suggest that increasing male screening coverage from 8% (baseline value) to 24% (to match female coverage) would cost an extra £22.9m and increase the cost per infection treated to £528. In contrast, increasing partner notification efficacy from 0.4 (baseline value) to 0.8 partners per index case would cost an extra £3.3m and would reduce the cost per infection diagnosed to £449. Increasing screening coverage to 24% in men would cost over six times as much as increasing partner notification to 0.8 but only treat twice as many additional infections., Conclusions: In the English National Chlamydia Screening Programme increasing the effectiveness of partner notification is likely to cost less than increasing male coverage but also improve the ratio of women to men diagnosed. Further evaluation of the cost effectiveness of partner notification and screening is urgently needed. The spreadsheet tool developed in this study can be easily modified for use in other settings to evaluate chlamydia control programmes.

Objective: To determine whether screening and treating women for chlamydial infection reduces the incidence of pelvic inflammatory disease over the subsequent 12 months., Design: Randomised controlled trial., Setting: Common rooms, lecture theatres, and student bars at universities and further education colleges in London., Participants: 2529 sexually active female students, mean age 21 years (range 16-27)., Intervention: Participants completed a questionnaire and provided self taken vaginal swabs, with follow-up after one year. Samples were randomly allocated to immediate testing and treatment for chlamydial infection, or storage and analysis after a year (deferred screening controls)., Main Outcome Measure: Incidence of clinical pelvic inflammatory disease over 12 months., Results: Baseline prevalence of chlamydia was 5.4% (68/1254) in screened women and 5.9% (75/1265) in controls. 94% (2377/2529) of women were followed up after 12 months. The incidence of pelvic inflammatory disease was 1.3% (15/1191) in screened women compared with 1.9% (23/1186) in controls (relative risk 0.65, 95% confidence interval 0.34 to 1.22). Seven of 74 control women (9.5%, 95% confidence interval 4.7% to 18.3%) who tested positive for chlamydial infection at baseline developed pelvic inflammatory disease over 12 months compared with one of 63 (1.6%) screened women (relative risk 0.17, 0.03 to 1.01). However, most episodes of pelvic inflammatory disease occurred in women who tested negative for chlamydia at baseline (79%, 30/38). 22% (527/2377) of women reported being tested independently for chlamydia during the trial., Conclusion: Although some evidence suggests that screening for chlamydia reduces rates of pelvic inflammatory disease, especially in women with chlamydial infection at baseline, the effectiveness of a single chlamydia test in preventing pelvic inflammatory disease over 12 months may have been overestimated. Trial registration ClinicalTrials.gov NCT00115388.

Objective: To investigate the cost effectiveness of screening for Chlamydia trachomatis compared with a policy of no organised screening in the United Kingdom., Design: Economic evaluation using a transmission dynamic mathematical model., Setting: Central and southwest England., Participants: Hypothetical population of 50,000 men and women, in which all those aged 16-24 years were invited to be screened each year., Main Outcome Measures: Cost effectiveness based on major outcomes averted, defined as pelvic inflammatory disease, ectopic pregnancy, infertility, or neonatal complications., Results: The incremental cost per major outcome averted for a programme of screening women only (assuming eight years of screening) was 22,300 pounds (33,000 euros; $45,000) compared with no organised screening. For a programme screening both men and women, the incremental cost effectiveness ratio was approximately 28,900 pounds. Pelvic inflammatory disease leading to hospital admission was the most frequently averted major outcome. The model was highly sensitive to the incidence of major outcomes and to uptake of screening. When both were increased the cost effectiveness ratio fell to 6200 pound per major outcome averted for screening women only., Conclusions: Proactive register based screening for chlamydia is not cost effective if the uptake of screening and incidence of complications are based on contemporary empirical studies, which show lower rates than commonly assumed. These data are relevant to discussions about the cost effectiveness of the opportunistic model of chlamydia screening being introduced in England.

Objective: To evaluate the effectiveness of a practice nurse led strategy to improve the notification and treatment of partners of people with chlamydia infection., Design: Randomised controlled trial., Setting: 27 general practices in the Bristol and Birmingham areas., Participants: 140 men and women with chlamydia (index cases) diagnosed by screening of a home collected urine sample or vulval swab specimen., Interventions: Partner notification at the general practice immediately after diagnosis by trained practice nurses, with telephone follow up by a health adviser; or referral to a specialist health adviser at a genitourinary medicine clinic., Main Outcome Measures: Primary outcome was the proportion of index cases with at least one treated sexual partner. Specified secondary outcomes included the number of sexual contacts elicited during a sexual history, positive test result for chlamydia six weeks after treatment, and the cost of each strategy in 2003 sterling prices., Results: 65.3% (47/72) of participants receiving practice nurse led partner notification had at least one partner treated compared with 52.9% (39/68) of those referred to a genitourinary medicine clinic (risk difference 12.4%, 95% confidence interval -1.8% to 26.5%). Of 68 participants referred to the clinic, 21 (31%) did not attend. The costs per index case were 32.55 pounds sterling for the practice nurse led strategy and 32.62 pounds sterling for the specialist referral strategy., Conclusion: Practice based partner notification by trained nurses with telephone follow up by health advisers is at least as effective as referral to a specialist health adviser at a genitourinary medicine clinic, and costs the same. Trial registration Clinical trials: NCT00112255.

Objective: To measure the coverage and uptake of systematic postal screening for genital Chlamydia trachomatis and the prevalence of infection in the general population in the United Kingdom. To investigate factors associated with these measures., Design: Cross sectional survey of people randomly selected from general practice registers. Invitation to provide a specimen collected at home., Setting: England., Participants: 19,773 men and women aged 16-39 years invited to participate in screening., Main Outcome Measures: Coverage and uptake of screening; prevalence of chlamydia., Results: Coverage of chlamydia screening was 73% and was lower in areas with a higher proportion of non-white residents. Uptake in 16-24 year olds was 31.5% and was lower in men, younger adults, and practices in disadvantaged areas. Overall prevalence of chlamydia was 2.8% (95%confidence interval 2.2% to 3.4%) in men and 3.6% (3.1% to 4.9%) in women, but it was higher in people younger than 25 years (men 5.1%; 4.0% to 6.3%; women 6.2%; 5.2% to 7.8%). Prevalence was higher in the subgroup of younger women who were harder to engage in screening. The strongest determinant of chlamydial infection was having one or more new sexual partners in the past year., Conclusions: Postal chlamydia screening was feasible, but coverage was incomplete and uptake was modest. Lower coverage of postal screening in areas with more non-white residents along with poorer uptake in more deprived areas and among women at higher risk of infection could mean that screening leads to wider inequalities in sexual health.

Objectives: To assess whether bacterial vaginosis or chlamydial infection before 10 weeks' gestation is associated with miscarriage before 16 weeks., Design: Prospective cohort study., Setting: 32 general practices and five family planning clinics in south London., Participants: 1216 pregnant women, mean age 31, presenting before 10 weeks' gestation., Main Outcome Measure: Prevalence of miscarriage before 16 weeks' gestation., Results: 121 of 1214 women (10.0%, 95% confidence interval 8.3% to 11.7%) miscarried before 16 weeks. 174 of 1201 women (14.5%, 12.5% to 16.5%) had bacterial vaginosis. Compared with women who were negative for bacterial vaginosis those who were positive had a relative risk of miscarriage before 16 weeks' gestation of 1.2 (0.7 to 1.9). Bacterial vaginosis was, however, associated with miscarriage in the second trimester at 13-15 weeks (3.5, 1.2 to 10.3). Only 29 women (2.4%, 1.5% to 3.3%) had chlamydial infection, of whom one miscarried (0.32, 0.04 to 2.30)., Conclusion: Bacterial vaginosis is not strongly predictive of early miscarriage but may be a predictor after 13 weeks' gestation. The prevalence of Chlamydia was too low to assess the risk, but it is unlikely to be a major risk factor in pregnant women.

Objectives: To analyse trends in rates of genital chlamydial infection and ectopic pregnancy between 1985 and 1995 in a county in Sweden., Setting: Uppsala county where screening for chlamydial infection, treatment, and contact tracing has been widespread and where ectopic pregnancies are recorded., Methods: Rates of chlamydial infections and ectopic pregnancy between 1985 and 1995 were calculated for women aged 20-39 years. Poisson and linear regression were used to examine the association between the risk of ectopic pregnancy and the current rates of chlamydial infection and rates of chlamydial infection from up to 5 years earlier., Main Outcome Measures: Rates of chlamydial infection per 100 examinations, rates of ectopic pregnancy per 1000 pregnancies, rate ratios and 95% confidence intervals for an increase in chlamydial infections of 5 new cases per 100 examinations., Results: 103 870 cervical samples from women aged 15-39 years were analysed; 5648 (5.4%) were positive for chlamydia. 51 630 pregnancies were analysed; 930 (1.8%) were ectopic. Both rates declined over time. For women aged 20-24 years there was a strong correlation between the rate of ectopic pregnancy and the rate of chlamydial infection in the same year (r=0.93, P<0. 001); among older women correlations were stronger with rates of chlamydial infection occurring 1 or 2 years earlier. In Poisson regression ectopic pregnancy was most strongly associated with the current rate of chlamydial infection among women aged 20-24 (rate ratio 1.85, 95% confidence interval 1.44 to 2.38), with the rate of infection 1 year earlier among 25-29 year olds (rate ratio 1.72, 1. 33 to 2.22) and 30-34 year olds (rate ratio 2.27, 1.53 to 3.37); and with the rate 2 years earlier among 35 to 39 year olds (rate ratio 2. 58, 1.45 to 4.60)., Conclusions: Declining rates of genital chlamydial infections have probably led to a fall in the rate of ectopic pregnancies. The timing of the decline in the rate of ectopic pregnancies varies with age. Among young women falling rates of chlamydial infection have been accompanied by an immediate reduction in the rate of ectopic pregnancy.

Objective: To determine the prevalence of the different Chlamydia trachomatis genotypes in Portuguese patients., Methods: Urogenital isolates (n = 240) derived from attenders of various clinics in the Lisbon area were differentiated into genovars by genotyping with restriction fragment length polymorphism (RFLP) analysis of the PCR amplified omp1 gene., Results: Genotype E was the most common for both men (47.9%) and women (43.8%). Genotypes D and F were the second most prevalent for men (11.3%) and genotype H was the second most prevalent for women (19.5%). Genotypes F, G, D, in women and H, G, I, in men, were found in a lower percentage of cases. Genotypes B, Ba, J, K, L1 and L2 were very rarely detected., Conclusions: With one exception, the overall distribution of Chlamydia trachomatis genotypes in our study is similar to what has been observed in other western countries. The only exception is the unusual prevalence of genotype H among women. The clinical manifestations associated with this and other genotypes were similar.

Objectives: The aetiology of non-gonococcal urethritis (NGU) in a considerable proportion of men remains unaccounted for. We wished to investigate the possible aetiological role of bacterial vaginosis (BV), the commonest cause of abnormal discharge in women, in this condition., Methods: We carried out two studies. In the first, case-control, study, we recruited men with and without NGU and examined their female partners for evidence of BV. The second, cohort design, study which ran concurrently with the first study involved recruiting women with and without BV and examining their male partners for evidence of NGU. The diagnoses of both NGU and BV were made microscopically to include symptomatic and asymptomatic individuals in both disease categories., Results: In the case-control study 51 couples were recruited. Of these 39 men had NGU and 12 (31%) of their female contacts had BV. In contrast, of 12 men without NGU, only one (8%) of the female partners had BV (odds ratio 4.89, 95% CI: 0.51-42.27). When only Chlamydia trachomatis negative patients were considered, the odds ratio for an association between BV and NGU was increased to 6.77, 95% CI: 0.73-62.68). Thirty eight couples were recruited to the cohort design study. Of 17 women with BV, 12 (71%) of their male partners had NGU. In contrast, of 21 women without BV, seven (33%) of their male partners had NGU (p = 0.049, odds ratio 4.8). When only C trachomatis negative patients were considered, the significance of the association was increased (p = 0.037; odds ratio 5.42)., Conclusions: An association exists between NGU and BV, and vice versa. If BV arises de novo the findings could help to explain the development of urethritis in stable sexual relationships.

Objectives: To determine the prevalence of genital Chlamydia trachomatis infections in commercial street sex workers (CSSW) in Jamaica., Methods: The prevalence of C trachomatis infection was determined in 129 Jamaican CSSW using the direct fluorescent antibody (DFA) method and the isolation techniques which utilise fluorescent and iodine staining of endocervical cytobrush specimens cultured in McCoy cells. The seroprevalence of C trachomatis in the CSSW was also compared with that in blood donors (n = 435), using the microimmunofluorescence (MIF) test., Results: The DFA detected C trachomatis in 16% (21/129) of the specimens. The prevalence as determined by the iodine and fluorescein stained cultures was 24% (31/129) and 25% (33/129) respectively. The overall prevalence of current chlamydial infection detected by the isolation techniques used was 25% (33/129). As determined by the MIF test, a statistically significantly higher seroprevalence rate of C trachomatis (95%, 61/64) was found in CSSW compared with blood donors (53%, 229/435; OR 22.6; chi 2 = 49.8; p < 0.001). The prevalence of current infection in CSSW as indicated by the isolation of C trachomatis was not influenced by history of previous pelvic inflammatory disease (PID), sexually transmitted disease, or condom use. N gonorrhoeae (9%) and Candida albicans (7%) were found in comparatively low frequencies, while Trichomonas vaginalis (0%) was not found in specimens from the CSSW., Conclusions: A high seroprevalence rate and a high rate of current infection with C trachomatis occur in Jamaican CSSW. In order to control the spread and prevent the severe clinical complications and sequelae of C trachomatis infection, the diagnosis and treatment in such high risk groups such as CSSW should be optimised.

Objectives: To estimate the prevalence of Chlamydia trachomatis in asymptomatic women attending general practice: to assess the potential of the ligase chain reaction as a screening tool; and to evaluate selective screening criteria., Design: Cross sectional survey., Setting: Four general practices in northeast London., Subjects: 890 women aged 18-35 years attending general practice for a cervical smear or a "young well woman" check between October 1994 and January 1996. The women were tested for C trachomatis with confirmed enzyme immunoassay (endocervical specimens) and ligase chain reaction assay on urine specimens., Main Outcome Measures: Prevalence of C trachomatis infection in women aged 18-35 on the basis of each test; sensitivity and specificity of both tests in this population., Results: Prevalence of confirmed infection was 2.6% (95% confidence interval 1.6% to 3.6%) in all women. Prevalence on the basis of enzyme immunoassay was 1.6% (0.8% to 2.7%), with a sensitivity of 60% and a specificity of 100%. Prevalence on the basis of ligase chain reaction was 2.5% (1.5% to 3.9%), with 90% sensitivity and 99.8% specificity. Screening all women aged < or = 25 and all women who had had two or more partners in the past year would have detected 87% (20/23) of infections., Conclusion: Ligase chain reaction on urine samples performs at least as well as enzyme immunoassay on cervical specimens in this low prevalence population. It offers potential as a non-invasive screening tool. A simple selective screening strategy might be appropriate and would be able to detect most cases of infection. However, a rigorous economic evaluation of possible screening strategies is needed first.

Purpose: To evaluate the use of the Amplicor PCR assay in two European centres (Amsterdam and Vienna) as a standard for amplification assays in comparative studies., Study Design: Both centres used the Amplicor PCR assay and their own standard diagnostic methods as the reference assay. Discrepant results were further analysed by an Omp1-PCR assay. In total 805 female patients and 614 male patients were included in the studies., Results: The prevalence of Chlamydia trachomatis infections in female patients was 10.0% in Amsterdam and 2.5% in Vienna and in male patients 13.7% and 10.8%, respectively. The mean sensitivity of the Amplicor PCR assay with cervical specimens from female patients was 92.5% and the mean specificity was 99.2%. For the reference assays the mean values were 87.5% and 100.0% respectively. The mean sensitivity of the Amplicor PCR assay with urine specimens from male patients was 70.3% and the mean specificity was 97.6%. For the reference assays these values were 64.9% and 100.0% respectively. The mean sensitivity of the Amplicor PCR assay with urethral specimens from male patients was 67.6% and the mean specificity was 98.5%. For the reference assays these values were 62.2% and 100.0% respectively. Of all specimens together, 1.0% showed an OD value between 0.25 and 0.5 in the Amplicor PCR assay and had to be retested. The sensitivity of the Amplicor PCR assay was less than could be expected from previous studies comparing amplification assays under similar conditions. Also, the sensitivity of the Amplicor PCR assay varied considerably between study centres using urine specimens from male patients-45.9% and 94.6%, respectively., Conclusion: The Amplicor PCR assay cannot be considered as a standard for amplification assays in comparative studies.

Objective: To describe the recent epidemiology of genital Chlamydia trachomatis infection in England and Wales., Design: Retrospective study of routinely available surveillance datasets and ad hoc prevalence studies., Methods: Numbers of new cases of genital C trachomatis infection, obtained from the Department of Health and Welsh Office, were combined with the estimated mid-year resident population of England and Wales. Rates were analysed for trend over time using a log linear age period model in GLIM4. Ad hoc prevalence and case finding studies carried out over the past 20 years were critically assessed in terms of study design and testing methodologies., Results: Attendance rates at genitourinary medicine (GUM) clinics were higher for women than men over the period 1989 to 1994 as were the number of laboratory reports. The highest rate of attendance (GUM clinic data) was for women aged 16 to 19 years. There was an overall significant linear decrease in the attendance rates over time for both men (p = 0.0172) and women (p = 0.0000) between 1989 and 1994. There was considerable variation in the prevalence of genital C trachomatis infection detected within different clinical settings, together with a substantial level of asymptomatic infection., Conclusions: Genital C trachomatis infection is broadly distributed throughout the sexually active population, with a substantial reservoir of asymptomatic infection among those generally perceived to be at low risk of a sexually transmitted infection. Young people, particularly women aged 16 to 19 years, are at highest risk of genital C trachomatis infection. This is of concern since younger women are more susceptible than older women to developing complications of chlamydial infection, such as pelvic inflammatory disease. The broad distribution of infection across all sexually active health service attenders and the high level of asymptomatic infection suggest that a new, screening based, approach to the control of genital C trachomatis infection is required. Recommendations are made as to the epidemiological research required to guide such work.

Aims: To evaluate demographic characteristics of women terminating their pregnancy for sentinel surveillance of Chlamydia trachomatis infection and to report changing prevalences of C trachomatis over time within this study population., Design: Screening for C trachomatis in women seeking induced abortion was introduced in 1984 at the Department of Gynecology, Regional Hospital, Trondheim, Norway. Over the study years our department has used a precoded medical record covering sociodemographic, medically relevant data, also recording outcome of the C trachomatis test. Throughout the study the Department of Microbiology applied cell culture, enzyme immunoassay, and, during the most recent years a nucleic acid test to identify C trachomatis., Statistical Methods: Chi square test for linear trend and unconditional logistic regression., Results: Over the study period, women having induced abortion were characterised by being most often single and more often at younger age. The overall age-adjusted prevalence of C trachomatis declined from 9.2% in 1985 to 3.6% in 1995, the major decline occurring from 1987 to 1991, and affected all age-groups simultaneously. There was a 60% decrease in odds ratio of having a C trachomatis infection from 1985 to 1991, and the crude and the adjusted odds ratios did not differ for any year examined., Conclusion: Women deciding on pregnancy termination have demographic characteristics that identify high-risk groups for C trachomatis infection. Despite these characteristics, which were relatively constant over the study period, the study population changed from being a high- to a low-prevalence population of C trachomatis.

Objective: To describe the epidemiology and associated clinical features of gonorrhoea and chlamydial infection and to develop a profile of sexually transmitted diseases (STDs) in an outer London health district., Design: Hospital-based retrospective study., Setting: Genitourinary medicine clinic, Northwick Park Hospital, Harrow and Brent Health Authority., Subjects: 70 male and female individuals with gonorrhoea and 129 with chlamydial infection, diagnosed consecutively over 28 months in 1992-94., Results: More men than women had gonorrhoea (43 versus 27) but more women than men had chlamydial infection (84 versus 45), p < 0.001. There was a clear tendency for cases with either infection to locate along major road and rail transport routes. Foci of gonococcal infection were concentrated mainly in the densely populated areas, whereas chlamydial cases were more evenly spread. There was no significant effect of gender or type of STD on the odds ratio for residence in Harrow, single marital status or attendance for test of cure. However, the odds ratios for women having sexual intercourse with a regular partner only or previous STD were 5 (95% CI 2.4 to 10.2), p < 0.001 and 0.3 (95% CI 0.18 to 0.69), p = 0.002 times the odds for men, respectively. The odds ratios for patients with gonococcal infection being employed or having sex with a regular partner only were 0.5 (95% CI 0.27 to 0.98), p = 0.04 and 0.30 (95% CI 0.15 to 0.60), p < 0.001 times the odds for patients with chlamydial infection, respectively. Of the women with gonorrhoea and previous pregnancy, 68% gave a history of abortion compared with 44% of those with chlamydial infection (p = 0.03)., Conclusion: The identification of foci gonococcal and chlamydial infection and apparent location of these infections along the major transport routes in our health district require further study. That chlamydial infection, unlike gonorrhoea, is evenly distributed irrespective of population concentration and deprivation, suggests urgent need for a comprehensive local effort to control both STDs.

Objective: To investigate trends in sexually transmitted diseases (STDs) among female commercial sex workers and in their condom use patterns during the period from 1990 to 1993 in Fukuoka, Japan., Methods: The study group consisted of a total of 824 commercial sex workers who attended an STD clinic to undergo screening for STDs including chlamydia, gonorrhoea, syphilis, hepatitis B and HIV-1 infection during the period from 1990 to 1993. For detection of Chlamydia trachomatis and Neisseria gonorrhoeae, endocervical smear specimens were taken from the women. Blood samples were obtained for serological diagnosis of syphilis, hepatitis B and HIV-1. Commercial sex workers who visited the clinic during the period from November to December of 1993 were interviewed concerning past (1990 and 1991) and recent (1992 and 1993) condom use patterns., Results: The annual detection rates of C trachomatis and N gonorrhoeae declined significantly from 16.3% in 1990 to 12.2% in 1993 (P < 0.0001) and from 1.5% in 1990 to 0.8% in 1993 (P = 0.0096), respectively. There was a remarkable reduction in the annual syphilis infection rate, from 7.5% in 1990 to 0.5% in 1993 (P = 0.0011). The positive rate for the hepatitis B surface antigen in the women ranged from only 0.6% to 1.9% and none were found to be positive for HIV-1 during the 4-year period. During the same period, there was a significant increase in the proportion of commercial sex workers always using condoms from 6.3% in 1990-91 to 25.3% in 1992-93 (P = 0.0023)., Conclusion: The prevalences of chlamydia, gonorrhoea, and syphilis infections decreased significantly among commercial sex workers in Fukuoka from 1990 through 1993, and no commercial sex workers were HIV-1 seropositive. The reductions in the prevalence of major STDs may be related to the increased use of condoms.

Objectives: To evaluate and compare the range of genital infections diagnosed in a group of lesbians attending an inner city genitourinary clinic with a control group of heterosexual women attending the same clinic., Setting: The Ambrose King Centre, the Royal London Hospital, a genitourinary clinic within which the Audre Lorde Clinic, a specialist sexual health clinic for women identifying as lesbians, is operated., Subjects: Two hundred and forty one women attending the specialist clinic between October 1993 and September 1994. Heterosexual controls matched for age and ethnicity were selected from the same time period., Methods: A retrospective case note analysis was made of 241 lesbians and 241 matched heterosexual controls. Data were collected on age, ethnicity, symptoms, diagnoses and services used., Results: An infection was diagnosed in 129 (65%) of the lesbians and 126 (62%) of the heterosexual women. Only 23 (10%) of the lesbians exclusively practised same gender sexual contact. Genital herpes (p = 0.05) and genital warts (p = 0.005) were more common in the heterosexual women. Gonorrhoea and chlamydia infection were infrequent diagnoses in both groups, occurring in four (2%) lesbians and 14 (7%) heterosexuals (p = 0.05). Bacterial vaginosis occurred in 65 (33%) of the lesbians and 27 (13%) of the heterosexuals (p < 0.0001). Cervical cytology abnormalities were uncommon but only found in the lesbians., Conclusions: Screening for genital infections in lesbians is appropriate. The high prevalence of bacterial vaginosis in this group is unexplained but suggests a possible sexual transmission. Lesbians should be included within the cervical cytology screening programme.

Objectives: To study the association of serovars of Chlamydia trachomatis with clinical manifestations of genital tract infection and socio-demographic characteristics., Methods: In 1986-88 the C trachomatis isolates from 159 heterosexual men and 116 women attending a sexually transmitted disease (STD) clinic were collected and typed accordingly. A medical history was recorded, a physical examination took place and samples were taken for laboratory diagnostics., Results: Serovars E, F and D were the most common for both men (75%) and women (67%). Men infected with serovars of the C-complex had more often a history of STD (p = 0.06). The opposite was demonstrated in women (p = 0.07). In addition, women younger than 18 years at first intercourse were more often infected with C-complex serovars (p = 0.05). For men, the serovars F/G less often produced symptoms of urethral discharge (p = 0.01) than the serovars of the B-complex and C-complex and were less often associated with the presence of 10 or more leukocytes in a Gram-stained smear (p = 0.04)., Conclusions: In this study, infections with serovars F and G caused less obvious symptoms and signs of inflammation in men; in women no differences were found in the clinical manifestation of infections with different serovars.

Objective: To test the diagnostic validity of clinical algorithms for the detection of Chlamydia trachomatis in an urban population of married women in Turkey., Design: Cross-sectional population-based survey., Subjects: A systematic sample of 867 women who reported the use of contraceptive methods., Main Outcome Measures: Sensitivity, specificity and positive predictive value of clinical algorithms for the diagnosis of C trachomatis., Results: C trachomatis was diagnosed in 4.89% of the women. The WHO algorithm for use in settings where no vaginal examination could be performed had a sensitivity of 9% and a specificity of 96%. The corresponding figures for the WHO algorithm incorporating the findings of a speculum examination were 47% and 56% respectively. Algorithms incorporating symptoms or signs other than those suggested by the WHO did not yield satisfactory standards of validity., Conclusions: The findings of this study do not support the widespread introduction of the use of clinical decision models for screening of women for chlamydia infection in primary health care settings such as family planning or antenatal clinics. The large number of false positive results with the use of the clinical algorithms tested in this study would cause unnecessary costs to the health system and unnecessary interventions to the women treated.

Aim: To review the epidemiology of and data collection for sexually transmitted diseases (STDs) in South Africa., Methods: Literature published since 1980 on STDs in South Africa were complied and evaluated. Historical reports and salient unpublished literature were also used in the literature review. Studies were critically reviewed in the light of sample populations and study methods, and a baseline picture of the patterns of STD burden was developed., Results: The STD burden in apparently asymptomatic study populations is significant. Ulcerative infections, primarily caused by syphilis and chancroid, are present in 5-15% of asymptomatic clinic attenders; prevalence rates of gonorrhoea average 8%, with up to 13% of gonococcal isolates resistant to penicillin antibiotics. In addition, on average, chlamydia and vaginal infections are detected in 16% and 20-49%, respectively, of antenatal and family planning clinic attenders. HIV seroprevalence rates have reached 7.6% in antenatal clinic attenders. Most South African STD data are derived from ad hoc surveys which have traditionally focused only on several major infections and particular urban centres. Almost all STD studies have been facility-based, with many studies based at STD clinics, thus reporting only relative frequencies and not population-based prevalences of STDs. With the possible exception of HIV, systematic surveillance data for STDs are conspicuously lacking., Conclusion: The disease burden of classic sexually transmitted infections has historically been heavy, and continues to be a serious public health problem in South Africa. Morbidity from both ulcerative and non-ulcerative infections, particularly in women, is significant. The body of STD data, although mostly sound, remains incomplete, and with the rapid emergence of HIV in South Africa, surveillance of STDs and focused STD policies will be critical.

Objective: To determine how often chlamydial conjunctivitis is accompanied by a genital chlamydial infection and if there is a correlation between the dominant hand and the eye first infected., Methods: We retrospectively studied the records of 65 patients with chlamydial conjunctivitis who were referred to the Outpatient Department of Sexually Transmitted Diseases (STD) of the University Hospital Rotterdam by ophthalmologists of the Eye Hospital Rotterdam. The patients have recently been asked by letter if they were left- or right-handed., Results: Twenty of the 37 men (54%) had a positive chlamydial urethral culture. Seventy per cent of these men had no genital symptoms. Eight of the 37 men (22%) had a non-specific urethritis (NSU). Twenty of the 27 women examined (74%) had a positive chlamydial cervical culture. Sixty per cent of these women had no genital symptoms. Eight women with a genital chlamydial infection also had another genital infection. Five women without a genital chlamydial infection had another genital infection. Two women had no genital infection at all. A correlation between the eye infected and left- or right-handedness of the patient could not be found., Conclusions: A considerable percentage of the patients with a chlamydial conjunctivitis had a concomitant genital chlamydial infection. The majority of them had no genital symptoms. Since patients with chlamydial conjunctivitis and/or their partners possibly have a concomitant genital chlamydial infection, we recommend referral of both patients and sexual partners to an STD clinic for routine examination and systemic treatment when indicated.

Objective: To test the hypothesis that minor chronic insults such as smoking, chronic bronchitis, and two persistent bacterial infections may be associated with increases in C reactive protein concentration within the normal range and that variations in the C reactive protein concentration in turn may be associated with levels of cardiovascular risk factors and chronic coronary heart disease., Design: Population based cross sectional study., Setting: General practices in Merton, Sutton, and Wandsworth., Subjects: A random sample of 388 men aged 50-69 years from general practice registers. 612 men were invited to attend and 413 attended, of whom 25 non-white men were excluded. The first 303 of the remaining 388 men had full risk factor profiles determined., Interventions: Measurements of serum C reactive protein concentrations by in house enzyme linked immunosorbent assay (ELISA); other determinations by standard methods. Coronary heart disease was sought by the Rose angina questionnaire and Minnesota coded electrocardiograms., Main Outcome Measures: Serum C reactive protein concentrations, cardiovascular risk factor levels, and the presence of coronary heart disease., Results: Increasing age, smoking, symptoms of chronic bronchitis, Helicobacter pylori and Chlamydia pneumoniae infections, and body mass index were all associated with raised concentrations of C reactive protein. C Reactive protein concentration was associated with raised serum fibrinogen, sialic acid, total cholesterol, triglyceride, glucose, and apolipoprotein B values. C Reactive protein concentration was negatively associated with high density lipoprotein cholesterol concentration. There was a weaker positive relation with low density lipoprotein cholesterol concentration and no relation with apolipoprotein A I value. C Reactive protein concentration was also strongly associated with coronary heart disease., Conclusion: The body's response to inflammation may play an important part in influencing the progression of atherosclerosis. The association of C reactive protein concentration with coronary heart disease needs testing in prospective studies.

Objective: To measure the prevalence of urethritis due to Neisseria gonorrhoeae and Chlamydial infection trachomatis in rural Tanzanian men, Design: About 500 men aged 15-54 years were selected from each of 12 rural communities by random cluster sampling; interviewed concerning past or present symptoms of sexually transmitted diseases; and asked to provide a first catch urine specimen, which was tested for pyuria with a leucocyte esterase dipstick test. Subjects with symptoms or with a positive result on testing were examined, and urethral swabs were taken for detection of N gonorrhoeae by gram stain and of C trachomatis by antigen detection immunoassay., Setting: Mwanza region, north western Tanzania., Subjects: 5876 men aged 15-54 years., Main Outcome Measures: Prevalence of urethral symptoms, observed urethral discharge, pyuria, urethritis ( > 4 pus cells per high power field on urethral smear), N gonorrhoeae infection (intracellular gram negative diplococci), and C trachomatis infection (IDEIA antigen detection assay)., Results: 1618 (28%) subjects reported ever having a urethral discharge. Current discharge was reported by 149 (2.5%) and observed on examination in 207 (3.5%). Gonorrhoea was found in 128 subjects (2.2%) and chlamydial infection in 39 (0.7%). Only 24 of 158 infected subjects complained of urethral discharge at the time of interview (15%)., Conclusion: Infection with N gonorrhoeae and C trachomatis is commonly asymptomatic among men in this rural African population. This has important implications for the design of control programmes for sexually transmitted disease.

Objective: To validate the performance of a direct fluorescence antibody (DFA) test and to determine the prevalence, risk factors and clinical manifestations of cervical chlamydia infection in different groups of women in Nicaragua., Study Population: 926 women, 863 routine clinic attenders (mean age 27 years) and 63 sex workers (mean age 25 years) attending health centres in León, Corinto, Matagalpa and Bluefields., Methods: Cervical specimens were examined using the Syva MicroTrak test system with a cut-off of 10 or more elementary bodies (EBs). The DFA results were validated by a one-step polymerase chain reaction (PCR) assay. Discordant results were further examined in nested PCR assays directed at two different target genes. An interviewer-administered questionnaire and a standard gynaecological examination were completed., Results: Sensitivity of DFA was 80.1%, specificity 98.3%, and positive and negative predictive values 62.5% and 99.3%, respectively. Values were lower in locations where samples thawed because of electricity breaks and higher among sex workers. The majority of discordant results was confirmed as positive in nested PCR assays. Prevalence of cervical chlamydia infection based on positivity in DFA and/or PCR ranged from 2% among routine clinic attenders aged 35 years or older, to 8% among adolescent clinic attenders, and to 14% among sex workers. Among routine clinic attenders, young age (odds ratio [OR] 3.6, 95% confidence intervals [95% CI] 1.4-8.9 for women aged 15-19 years as compared with 1 in women 25 years of age or older) and use of oral contraceptives (OR 4.0, 95% CI 1.7-9.6) were the only statistically significant risk factors identified in multivariate logistic regression analysis. Presence of mucopurulent cervical discharge (OR 5.9, 95% CI 3.0-11.5) and presence of ectropion (OR 2.6, 95% CI 1.1-6.5) were the clinical signs independently associated with infection., Conclusions: Our results indicate that the DFA test was sensitive and specific while the performance of the PCR assay depends on adequate storage of samples. Genital C trachomatis infection is a common health problem among women in Nicaragua. The wide implementation of syndromic STD management algorithms together with health education programmes aimed at young people is the most promising approach to control STD in Nicaragua.

Objectives: To identify predictors for Chlamydia trachomatis infection among visitors of an STD clinic in Amsterdam in 1986-1988. To design predictor-based screening programmes for C trachomatis. To evaluate the chosen screening strategy in 1993., Methods: In 1986-1988, 947 heterosexual men and 648 women participated in the study. A medical history was recorded, a physical examination took place and samples were taken for laboratory diagnostics. Information for 1993 was available from routine databases., Results: C trachomatis infections in heterosexual men in 1986-1988 (prevalence 15.8%) were independently associated with: age under 26 years, being an STD contact, coitarche below 13, last sexual contact with a non-prostitute, (muco)-purulent urethral discharge and ten or more leukocytes per microscopic field of urethral smear or urine. For women (prevalence 21.5%) independent predictors were age under 26, no history of STD, being an STD contact, cervical friability, (muco)purulent cervical discharge, presence of clue cells and ten or more leukocytes per field of urethral smear. Screening men with one anamnestic predictor for C trachomatis and ten or more leukocytes in smear or urine (59% of men) would detect 93% of the cases in 1986-1988. For females only universal screening proved to be suitable. After the introduction of a screening strategy in 1989 (universal for women, indicated by urethritis for men), a strong decline was found in the C trachomatis prevalence for all subgroups in 1993, excluding prostitute's clients and Turkish men., Conclusions: In 1993 the overall C trachomatis prevalence had declined among the attendants of the STD clinic. It seems likely that this fall was caused both by the screening programme and the reduction of risk behaviour.

Objective: To determine the prevalence of Chlamydia trachomatis infection in women attending a family planning clinic in Papua New Guinea, in the period between April and June 1991., Setting: The outpatient department of Obstetrics and Gynaecology of Port Moresby General Hospital, Port Moresby, Papua New Guinea, the departments of Dermato-Venereology and Clinical Microbiology of the Erasmus University, Rotterdam, The Netherlands and the National Institute of Public Health and Environmental Protection, Bilthoven, The Netherlands., Patients: A total of 254 consecutive women who attended the family planning clinic at Port Moresby General Hospital, Papua New Guinea were enrolled into this study., Methods: Cervical infections with C trachomatis were diagnosed using the direct immunofluorescent assay (DFA) and the polymerase chain reaction (PCR). Serum IgM and IgG antibodies directed against C trachomatis were detected using the enzyme-linked fluorescent assay (ELFA)., Results: The prevalence of C trachomatis was 14.6% using the PCR, 9.1% using the DFA and 17.3% when the results of the PCR and the DFA were combined. An elevated IgM titre was observed in 14.2% of the women, whereas 44.1% had an elevated IgG titre. The titres of IgM or IgG were significantly higher in women who were positive using the PCR or the DFA than in those who were negative in both the PCR and the DFA (p = 0.032 and p = 0.0046, respectively)., Conclusion: Cervical infection by C trachomatis can be considered a major health problem in at least the studied population in Papua New Guinea. The prevalence of C trachomatis infection is at least comparable with that in groups with a high prevalence in industrialized countries. Effective screening and treatment programmes are imperative to combat this problem.