Chlamydia screening of adolescent and young adult women by general practice physicians in Toronto, Canada: Baseline survey data from a physician education campaign.(Report)

Abstract: The current study surveyed primary care physicians to gather information on their testing practices for Chlamydia trachomatis among 15- to 24-year-old young women and to identify factors associated with their likelihood of doing such testing. The Canadian Guidelines on Sexually Transmitted Infections (PHAC, 2006) recommend routine testing of all sexually active women in this age group and some prior sexual health assessment interviewing is therefore needed as well. Respondents were 251 physicians (52% male; 48% female) practicing in Toronto who worked predominantly in general/family practice and/or walk-in clinics. When asked about their likelihood of recommending Chlamydia testing for 15- to 24-years-olds in different contexts or types of visit, over 90% said they would do so if the patient asked, about half would do so in annual checkups or as an add on to a Pap test, but only 3% said they would do so in visits for other reasons. This suggests situational rather than routine assessment and testing, which was also reflected in actual self-reported practices in the past month. Female physicians did sexual health assessment and Chlamydia testing in a greater percentage of visits than male physicians. Physicians endorsed few barriers to offering Chlamydia testing except for "not having enough time" (31.5% of respondents). Possible explanations of the findings and applications to professional education and support are discussed.

Introduction

Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI) in Canada. The highest reported rates of infection are among adolescent and young adult women. In 2004, the Chlamydia rate was 1443.6 per 100,000 among women aged 15-19 and 1489.4 among women aged 20-24 (Public Health Agency of Canada, 2006a). There have been no large scale Chlamydia prevalence studies conducted in Canada. In a review of existing Canadian studies, Davies and Wang (1996) noted Chlamydia prevalence rates among sexually active adolescents, college students, women attending community clinics, family planning units, and abortion clinics ranging from 7% to 25% and Richardson, Sellors, Mackinnon et al. (2003) found a prevalence of 6% among women aged 16-30 years in Hamilton, Ontario. These prevalence rates are in line with the results of the much larger, geographically diverse prevalence studies conducted by the Centers for Disease Control and Prevention (2006) in the United States that have found a Chlamydia prevalence rate of 6.3% among 15- to 24-year-old women attending family planning clinics. Chacko, Wiemann, and Smith (2004) report that asymptomatic Chlamydia infection is highly prevalent among economically disadvantaged females in the United States. In the city of Toronto, it has been shown that living in areas characterized by socio-economic disadvantage is associated with higher rates of STI, including Chlamydia (Hardwick & Patychuk, 1999).

Most Chlamydia infections are asymptomatic and, if left untreated, may lead to pelvic inflammatory disease (PID) and its sequelae, most notably infertility, chronic pelvic pain, and ectopic pregnancy (Banikarin & Chacko, 2005; Hills, Owens, Marchbanks et al., 1997; Kelver & Nagamani, 1989). According to the Public Health Agency of Canada (2005), ectopic pregnancy is a leading cause of maternal death in the first trimester. In 20% to 60% of cases, ectopic pregnancy leads to permanent sterility.

Using a randomized control design, Scholes et al. (1996) demonstrated that a screening strategy that identified, tested, and treated women at increased risk for Chlamydia reduced the incidence of PID by 56% in one year of follow-up. Additional case studies have shown that screening programs significantly reduce the prevalence of genital tract infections and PID (Pimenta, et al., 2002).