Year : 2008 | Volume
: 29 | Issue : 2 | Page : 82--85
Prevalence of Chlamydia trachomatis and its association with other sexually transmitted infections in a tertiary care center in North India
Meenakshi Malhotra, Manju Bala, Sumathi Muralidhar, Niti Khunger, Poonam Puri
Regional STD Teaching Training and Research Centre, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
Regional STD Centre, 5th Floor, New OPD Building, VMMC and Safdarjang Hospital, New Delhi
The asymptomatic nature of chlamydial genital infections coupled with the occurrence of severe sequelae in untreated patients, makes the laboratory evaluation of great importance in the diagnosis of the disease. Genital chlamydial infections are the leading cause of preventable sexually transmitted infections (STIs) worldwide, with 43 million new cases in Southeast Asia. The present study was designed to determine the prevalence of genital chlamydial infection in women attending a sexually transmitted disease (STD) outpatient department and to determine the association of the disease with other STIs. A total of 276 female patients with a complaint of genital discharge or ulcer were enrolled for the study. Genital discharge specimens (endocervical, vaginal, and urethral swabs) were collected from all the patients. The patients were investigated for the presence of antigen and antibody of Chlamydia trachomatis with the help of the Direct fluorescent Antibody test (DFA) and the Enzyme Linked Immunosorbant Assay (ELISA), respectively. Investigations for aetio-pathogens of other STIs were carried out using the standard methods. Chlamydial infection was found in 19.9% of the patients (10.1% by DFA technique and 10.9% by ELISA). Both the antigen and antibody were positive in only three (1.1%) cases. The overall incidence of other aetio-pathogens was low. In two (0.7%) cases multiple infections were seen. Chlamydia trachomatis was found to be most commonly associated with Candida albicans . However, there was no co-infection of Chlamydia trachomatis with Neisseria gonorrhoeae.
|How to cite this article:|
Malhotra M, Bala M, Muralidhar S, Khunger N, Puri P. Prevalence of Chlamydia trachomatis and its association with other sexually transmitted infections in a tertiary care center in North India.Indian J Sex Transm Dis 2008;29:82-85
|How to cite this URL:|
Malhotra M, Bala M, Muralidhar S, Khunger N, Puri P. Prevalence of Chlamydia trachomatis and its association with other sexually transmitted infections in a tertiary care center in North India. Indian J Sex Transm Dis [serial online] 2008 [cited 2022 Aug 16 ];29:82-85
Available from: https://www.ijstd.org/text.asp?2008/29/2/82/48730
Chlamydia trachomatis is the leading cause of sexually transmitted infections (STIs) with the annual detection of 92 million new cases worldwide, including 43 million from South-east Asia.  Recent studies from India have revealed the prevalence of C. Trachomatis in young females to be 43%, in the gynecology outpatient department (OPD) and 18.9% in the Sexually Transmitted Disease (STD) patients. , Chlamydial infection if undiagnosed and untreated can result in Pelvic Inflammatory Disease (PID), ectopic pregnancy, and infertility.  The role of Chlamydia trachomatis in PID has many important implications, as it is mostly asymptomatic and tubal infertility is the sole clinical manifestation. Furthermore, chlamydial infections are associated with a 3-6-fold increase in the transmission of HIV infection and are attributed to be a risk factor for the development of cervical carcinoma. , Also, infected patients, unaware of their infection, may serve as a reservoir of infection to their partners. Hence, documentation of chlamydial infections in high-risk populations can assist in designing HIV-risk reduction strategies as well. In this report, we have analyzed the infection rates of genital chlamydial infection in women attending the female STD Clinic of a tertiary care centre, and its possible association with other STIs.
MATERIALS AND METHODS
A total of 276 women, with a history of genital discharge or ulcer, attending the female STD outpatient clinic of a tertiary care hospital were enrolled for the study. The study period was from April 2005 to December 2007.
Special plastic sterile swab sticks and a cytobrush were used for the collection of an endocervical specimen for DFA staining, for chlamydial antigen detection. The Chlamydia trachomatis antigen was detected, using the commercially available DFA test (Immuno FA, Orgenics, Israel) and antibodies (IgG and IgM) by ELISA (Calbiotech Inc., CA), according to the manufacturer's guidelines.
Urethral, vaginal, and endocervical swabs were collected using sterile cotton swabs from all the patients. Standard laboratory techniques were used for the diagnosis of other STIs,  for e.g., Trichomonas vaginalis was detected by the Wet mount and culture on Whittington medium, Neisseria gonorrhoeae by direct gram stain smear and culture on chocolate agar and saponin lysed blood agar with VCNT inhibitors. For diagnosis of candidiasis, a direct gram stained smear and culture on Saborauds dextrose agar and later Candida albicans confirmation was carried out by the germ tube test. Bacterial vaginosis was diagnosed by physiological tests (ph test >4 and amine tests) and a gram stained smear, with interpretation following Nugent's criteria. For syphilis, dark field examination, VDRL (Veneral Disease and Research Laboratory) test, Treponema pallidum Haemagglutination Test (TPHA), and Fluorescent Treponemal Antibody test (FTA-Abs), for herpes progenitalis ulcer smear and IgM HSV-2 ELISA, for donovanosis, tissue smears, and for chancroid smear and culture were carried out. Two media were used for chancroid culture i.e. GC agar base with iso-vitalex, vancomycin, fetal calf serum and Mueller Hinton agar with iso-vitalex, vancomycin and fetal calf serum.
Blood samples from all the patients were collected for VDRL and other ELISA and wherever possible, after pre-test counseling and consent for HIV tests. VDRL (Serologist to Government of India, Kolkata) test results were confirmed by TPHA using a commercially available kit (Plasmatec, UK) and FTA-Abs using FTA-Abs IgG and IgM IFA, Virgo, Calbiotec, USA. HIV testing was done by National AIDS Control Organization approved kits.
Chlamydia trachomatis was detected in 55/276 (19.9%) patients. Most of the patients with chlamydial disease belonged to the 20-30 year age group. Chlamydial antigen by DFA technique was detected in 28 (10.1%) cases and the chlamydial antibody by ELISA in 30 (10.9%) cases. The gram stain of the patients with chlamydial infection revealed pus cells (++/+++) in 39/55 (70.9%) cases.
The other STIs diagnosed were candidiasis 26 (9.4%), bacterial vaginosis 22 (7.8%), syphilis 5 (1.8%), trichomoniasis 3 (1%), gonorrhoea 2 (0.7%), and chancroid 1(0.3%). The HIV test could be performed only on 50 patients, and was found to be positive in six patients. Out of the 50 patients who tested for HIV, three (6%) were seropositive for both C hlamydia trachomatis and HIV. Age-wise distribution of chlamydial infection, various STIs, coinfection of Chlamydia trachomatis with other STIs, and multiple infections are depicted in [Table 1].
The coinfection of Chlamydia trachomatis with bacterial vaginosis was seen in 7 (12.7%) cases, candidiasis in 6 (10.9%) cases, Syphilis in 2 (3.6%) along with chancroid in 1 case. Two cases having multiple infections were observed. One case had Chlamydia trachomatis with Candida albicans, HIV, and Syphilis, and the second had Chlamydia trachomatis , Candida albicans , HIV, and bacterial vaginosis. However, not even a single case of chlamydial coinfection with Neisseria gonorrhoeae was found.
Timely detection and effective management of cervical infection due to Chlamydia trachomatis, in women, provide critical intervention opportunities. Although the gold standard for the detection of Chlamydia trachomatis has been culture, several clinical and technical factors can lead to false negative results even in expert hands.  Moreover, the tissue culture setup is not available in most hospitals, hence, serological assays, which are much simpler and rapid, have been recommended as an alternative.
The prevalence of genital infection with Chlamydia varies depending upon the population studied and the sensitivity of the laboratory methods used. The present study carried out in a hospital reveals 19.9% prevalence of Chlamydia trachomatis in STD patients, in contrast to a previous study in Mumbai, in which 8.8% prevalence was observed.  Higher prevalence, i.e., 30.8% has recently been reported in Chennai, India.  A study from a UK hospital, where male partners of females with Chlamydial infection, both symptomatic as well as asymptomatic cases, were taken, have reported the prevalence as high as 44%. 
The highest rate of chlamydial infections was found to be in the 20-30 years age group. This is the sexually active group and at a higher risk of being behaviorally more vulnerable to STI acquisition, as they generally have a higher number of sexual partners and more concurrent partnerships and change partners more often than older age groups. 
Chlamydia trachomatis antigen using the DFA technique was detected in 28 (10.1%) cases in this study. This is comparable to the Thomas et al. study in PID patients, and the Dowe et al . study in high-risk group STD attendees, who have reported Chlamydia trachomatis antigen in 14.3 and 16%, respectively. ,
Chlamydia trachomatis antibodies (IgG and IgM) were detected in 10.9% cases. This is quite low in comparison with 58.7% antibodies detected by Joyee et al . in STD attendees.  This noted difference could be because of the difference in the antigen used in the two kits and also in the population studied.
There were only three patients in whom both antigen and antibodies were detected. Therefore, the use of both antigen and antibody detection tests are mandatory, as by using only one technique, many cases would have been missed. Seventy one percent of the patients having chlamydial infection showed the presence of pus cells (++/+++). This is in accordance with the earlier studies. ,
Among the other STIs, the most common infection was candidiasis (9.4%) followed by bacterial vaginosis (7.8%), Syphilis 5 (1.8%), trichomoniasis 3 (1%), and gonorrhoea 2 (0.7%). In a study in patients with genital discharge the incidence of candidiasis (26%), trichomoniasis (13%), gonococcus (1%), and bacterial vaginosis (48%) was reported from India. 
In our study six of the 50 patients studied were HIV positive. This figure could be misleading because all the patients could not be tested due to the inability to get consent.
Coinfection of Chlamydia with other STIs, especially bacterial vaginosis, highlights the importance of early laboratory diagnosis and specific treatment of the condition as they increase the risk many folds when the infections exist together. 
There are limitations in our study. First, the prevalence of (19.9%) of Chlamydia in our study of STD clinic attendees is not representative of the true prevalence of all the community, as it is a regional reference center and most of the patients come here after preliminary treatment from one center or another. Secondly, the HIV status of all the patients cannot be done. A strong correlation between chlamydial infection and HIV infection has been observed earlier, as both have common sexual/behavioral risk factors. 
The observations of the current study reinforce the importance of routine screening for Chlamydia trachomatis as a necessary intervention to decrease the burden of chlamydial disease and to reduce the risk of HIV and its spread.
The authors thank the Medical Superintendent, VMMC & Safdarjang Hospital for permitting them to carry out this study and Smt. Renu Mehta for her excellent technical assistance.
|1||Global Prevalence and Incidence of selected curable Sexually Transmitted Infections-Overviews and estimates. Geneva: World Health Organization; 1 st February, 2001.|
|2||Singh V, Rastogi S, Garg S, Kapur S, Kumar A, Salhan S, et al . Polymerase Chain reaction for the detection of endocervical Chlamydia trachomatis infection in women attending a Gynaecology Outpatient Department in India: The International Academy of Cytology. Acta Cytol 2002;46:540-4.|
|3||Joyee AG, Thyagarajan SP, Sowmya B, Venkatesan C, Ganapathy M. Need for specific and routine strategy for the diagnosis of genital chlamydial infection among patients with sexually transmitted diseases in India. Indian J Med Res 2003;118:152-7.|
|4||Black CM. Current methods of laboratory diagnosis of Chlamydia trachomatis . Clin Microbiol Rev 1997;10:160-84.|
|5||Fleming DT, Wasserheit JN. From epidemiological synergy to Public health policy and Practice: the contribution of other sexually transmitted disease to sexual transmission of HIV Infection. Sex Transm Infect 1999;75:3-17.|
|6||Paavonen J, Eggert-Kruse W. Chlamydia trachomatis : Impact on human reproduction. Hum Reprod Update 1999;5:433-47.|
|7||Van Dyck E, Meheus AZ, Piot P. In: Laboratory diagnosis of sexually transmitted diseases. Geneva: World Health Organisation; 1999.|
|8||Gaonkar A Trupti, Gogate A, Gogate S. Chlamydia trachomatis in lower genital tract of women in child bearing age. Indian J Sex Transm Dis 2002;23:31-7.|
|9||Manavi K, Mc Millan A, Young H. Genital infection in male partners of women with chlamydial infection. Int J STD AIDS 2006;17:34-6.|
|10||Wellings K, Nanchahal K, Macdowall W, McManus S, Erens B, Mercer CH, et al . Sexual behaviour in Britain early heterosexual experience. Lancet 2001;358:1843-50.|
|11||Thomas BJ, Evans RT, Hawkins DA, Taylor-Robinson D. Sensitivity of detecting Chlamydia trachomatis elementary bodies in smears by use of fluorescein labeled monoclonal antibody comparison with conventional Chlamydia isolation. J Clin Path 1984;37:812-6.|
|12||Dowe G, King SD, Brathwaite AR, Wynter Z, Chout R. Genital Chlamydia trachomatis (serotypes D-K) infection in Jamaican street Sex Workers. Genitourin Med 1997;73:362-4.|
|13||Makhija M, Malhotra V, Puri M, Jain M, Lakshmi A, Dhali TK, et al . Comparison of Direct Immunofluorescence and ELISA for the detection of Chlamydia trachomatis antigen in patients of pelvic inflammatory disease. J Commun Dis 2003;35:32-5.|
|14||Chopra A, Mittal, Kanta S, Kaur R. Vaginitis and vaginal flora: Study of 100 cases. Indian J Sex Transm Dis 1993;14:52-4.|
|15||Eschenbach DA, Hillier S, Critchlow C, Stevens C, DeRouen T, Holmes KK. Diagnosis and clinical manifestations of bacterial vaginosis. Am J Obstet Gynecol 1998;158:819-28.|