Running Head: Chlamydia trachomatis Infections

Epidemiology Research Project

Chlamydia trachomatis Infections
April 13, 2015
HSC 387
McKenna Bireley, Briana Freeman, Julie Hayden,
Hannah Janowiak, Chaun Smith, & Quinn Wease

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Disease Profile

Chlamydia trachomatis (C. trachomatis) is the bacterial agent that causes chlamydia infections
in humans. Chlamydia infections are sexually transmitted infections (STIs), thus chlamydia infections
usually occur in the genitals, internal sexual organs, mouth, anal region, or rectum. They can also cause
eye infections, most commonly in newborns. Chlamydia infections are the most commonly reported STI
both worldwide and in the United States. Chlamydia infections are easily cured with antibiotics.
However, infections typically do not cause symptoms. Therefore, they go untreated and cause more
severe diseases, such as, pelvic inflammatory disease, Fitz-Hugh-Curtis Syndrome, lymphogranuloma
venereum (LGV). This research paper will describe the characteristics of chlamydia infections and the
impact that this highly prevalent STI has on the U.S. population (CDC, 2012a).
Symptomology
Most people infected with chlamydia experience no symptoms and are unaware they are infected
(Center for Disease Control and Prevention [CDC], 2012a). If symptoms do arise, they may begin to
occur 5 to 10 days after the onset of the infection. Common symptoms experienced by women with
chlamydia include: abdominal pain, abnormal vaginal discharge, irregular bleeding (metrorrhagia), lowgrade fever, painful sexual intercourse (dyspareunia), pain or burning while urinating, swelling of the
vagina (vaginitis), urge to urinate more than usual, vaginal bleeding after intercourse, and a yellowish
discharge from the cervix that may have a strong odor. Men infected with chlamydia may experience
symptoms including: pain or burning while urinating, pus, watery, or milky discharge from the penis,
inflammation of the testicles (orchitis), and swelling around the anus (CDC, 2012a). Due to the fact that
chlamydia has little to no symptoms, it may go undiagnosed and untreated for a long time. Undiagnosed
and untreated chlamydia can lead to several other diseases, such as, pelvic inflammatory disease (PID),
Fitz-Hugh-Curtis Syndrome, chlamydial conjunctivitis, and lymphogranuloma venereum (LGV). Pelvic
Inflammatory Disease is characterized by chronic inflammation of the uterine wall due to an untreated
infection. Symptoms of PID are similar to those of chlamydia including: pain in the lower abdomen,
fever, pain, or bleeding during sex, unusual discharge or odor from the vagina, burning during urination,
and bleeding between periods (CDC, 2014j). Fitz-Hugh-Curtis Syndrome is characterized by the
inflammation of the lining of the stomach or liver caused by an untreated chlamydia infection. A
symptom associated with Fitz-Hugh-Curtis Syndrome is acute sharp pain in the upper right part of the
abdomen. This pain may become referred to areas of right upper arm. Other symptoms include vomiting,

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nausea, fever, and night sweats (National Organization of Rare Diseases Database, 2009). The symptoms
of chlamydial conjunctivitis are inflammation, reddening, and tenderness of the eyelid. This is most
common in children born from infected mothers (CDC, 2014b). LGV is the infection of lymph glands
near the genitals. The symptoms of LGV include swelling and pustule formation near a lymphatic gland
(New York State Department of Health, 2006). Chlamydia infections do not typically display different
stages of progression unless the infection goes untreated, then it can progress to any of the above
infections (CDC, 2012a).
Incubation Period
The incubation periods of all strains of C. trachomatis are poorly defined because most people
who are infected are asymptomatic, thus are unaware that they have an infection and dont seek medical
help. It is likely that the incubation period ranges from 7 to 14 days or longer. If symptoms do arise, it
may take weeks after the initial exposure to develop into an infection or display symptoms (Heymann,
2015). Therefore, it is often difficult to track exposure, especially amongst people who are highly
sexually active.
Communicability
The period of communicability of chlamydia infections is also unknown. Any person who has a
confirmed chlamydia infection is considered to be contagious until they have finished treatments and
have had a negative test result. An untreated infection can last for months or longer, and the infection is
communicable for the duration of the infection (Heymann, 2008). Chlamydia is transmitted through
sexual contact with the penis, vagina, mouth, or anus of an infected person. Not only can C. trachomatis
be spread between sexual partners, but it can be spread from an untreated mother to her baby during
childbirth, which can result in chlamydial conjunctivitis and chlamydial pneumonia (CDC, 2012a).
Communicability is best prevented by inhibiting skin to skin contact through the proper use of a condom
or dam. A dam is a piece of plastic, similar to a condom, that is used to cover female genital during sex
(National Health Service, 2013).
Susceptibility
Susceptibility to chlamydia is described as general, meaning that anyone is susceptible to
contracting chlamydia (Heymann 2015). Everyone is susceptible to chlamydia infections; however,
young sexually active individuals are at a higher risk of contracting the disease due to behaviors and
biological factors (CDC, 2012a). Women are at a higher risk for contracting chlamydia due to their
anatomy (CDC, 2011a). Men who have sex with them (MSM) contract chlamydia at higher rates due to
tearing that occurs during anal sex and they are more likely to have multiple partners (CDC, 2014g;

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Jenness, et al., 2011). Very little is understood about the immunity induced by chlamydia infections.
However, cell mediated immune responses are specific to the strain of C. trachomatis that is present
(Heymann, 2008).
Personal Impact
Chlamydia has a personal and societal impact on those infected and potentially those around
them. Medication taken for chlamydia will stop the infection; however, it will not repair any permanent
damage already caused by the disease. Chlamydia infections can have an effect on a persons family,
finances, mental health, and interpersonal relations.
Recurrence of chlamydia infection is very common. Women who had multiple re-infections of
chlamydia have an increased risk of serious reproductive health complications. C. trachomatis infects
both genders, but it has a greater impact on the lives of women. If untreated, chlamydia can cause
problems in a womans family. A chlamydia infection in a woman can cause difficulties for her family or
an obstacle for her potential family. Chlamydia infections in a woman who has a family or is planning
on having a family can cause physical problems in two ways. The first way is that untreated chlamydia
infections can cause infertility (CDC, 2012a). The second way is that a pregnant woman with an
untreated chlamydia infection can spread the infection to her child during birth (CDC, 2014c). Both of
these physical problems can cause financial, relational, and psychological or emotional problems in a
womans family.
A chlamydia infection can cause problems with fertility when a couple is trying to conceive.
Infertility can be an emotional and financial burden on the couple. Fertility treatments can cost
thousands of dollars for one round of treatment; most women require multiple rounds of treatment. Also,
the majority of insurance plans dont cover infertility treatments, so these expenses must be paid out-ofpocket (CDC, 2012b). Unsuccessful treatments can cause the couple to lose hope and become frustrated.
If the couple decides to adopt or use a surrogate, which is also not covered by health insurance, it can be
a very expensive and long process. On its own, infertility can cause psychological issues, such as,
depression in women and sometimes in their partners. If either of the partners in the relationship cannot
handle the stress, sadness, or financial burden that comes with infertility, the relationship could end. The
loss of a relationship due to infertility could cause the woman to become depressed and hinder her from
seeking another relationship in the future, which would prevent her from having a family. However, if
the couple is able to make it through their struggle with infertility, it is likely that their relationship will
be stronger, making their family stronger.

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Due to the stigma associated with STIs, many people who contract an STI are stigmatized and
their interpersonal relations are harmed. This could be especially true if an untreated chlamydia infection
caused permanent damage to a child causing the mother to be judged. Stigmatization could also occur if
the infection causes infertility and the woman is judged for not being able to have children due to her
own presumed misconduct or ignorance.
Societal Impact
STIs can have a devastating effect on communities, especially if they occur at high rates or there
is an outbreak. Chlamydia infections are highly prevalent throughout the U.S. Since chlamydia
infections are highly and consistently prevalent and asymptomatic, they affect several areas in a
community including: healthcare, economics, education, and politics (CDC, 2012a; CDC, 2013b).
Chlamydia infections can affect a communitys healthcare system, economics, and politics is by
creating an issue of how to educate people who are at risk for an infection. The best way to prevent
chlamydia infections is through primary prevention. Primary prevention does not occur without
educating people on the risks associated with contracting an infection and the best ways to avoid
contracting an infection. Educating a community about STIs, like chlamydia, is expensive and difficult
for healthcare systems (CDC,2011b; CDC,2014j).
Educational expenses associated with chlamydia infections occur because the healthcare systems
in communities have to hire educators. This is because other healthcare professionals do not necessarily
have time nor the expertise to educate every person about chlamydia infections (CDC, 2011b). The other
option if they cannot allocate funds to pay for educational staff, then they can add more responsibility to
existing healthcare workers and have them provide chlamydia education. For example, nurses could
have to do all of their normal duties, as well as, take time to educate at risk patients about STIs. Both of
the options present a problem for healthcare systems. The first option forces a healthcare system to
spend more money to pay an educator, while the money could be spent on another health need in the
community. The second option could cause the healthcare system to pay more in overtime pay for
current employees. The second option could also cause burnout because staff would have extra
responsibilities added to their job descriptions. Burnout of healthcare employees is already a significant
problem for the healthcare system (McHugh, Kutney-Lee, Cimiotti, Sloane, Aiken, & Fagin, 2011).
Educating patients presents a problem for the healthcare system and politics because they have to
determine the best way to get at risk patients to discuss the topic of STIs. The healthcare system and
politicians also has to spend significant time determining the best and most effective methods to educate
on STIs, like chlamydia. This costs the healthcare system time and money to develop effective education

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interventions, as well as, training healthcare workers on how to successfully deliver the education
intervention. As a part of STI education, the healthcare system has to spend time and money on
developing resources, such as brochures and handouts. These materials aid in the education of at risk
patients. The printing and the time spent developing these materials can burden the healthcare
employees time and the healthcare systems finances (CDC, 2011b).
Asymptomatic STIs, like chlamydia, have an effect on a community healthcare system because
they require that regular screenings occur for at risk patients in order to detect infections and prevent
damage from untreated infections. It is often difficult for healthcare systems to get high-risk people
screened or to get those who were diagnosed with an STI to continue regular screening (CDC, 2011;
CDC, 2013b).
Being the most common STI, chlamydia places significant economic cost on the healthcare
system of a community. On average, chlamydia tests can range from as much as $28.00 to $42.00. This
is an expensive test, especially when it is used just as a screening tool when an actual infection may not
be present (Huang, Gaydos, Barnes, Jett-Goheen, & Blake, 2012). Also, most people will be tested
multiple times if they are in a high-risk group or if they previously had a chlamydia infection. This high
cost per test could adversely affect a community composed of people with low socioeconomic status or
people who lack health insurance. If the population in a community cannot afford chlamydia tests, then
it is likely that the rates of chlamydia in the community will increase. A situation like this would force
the healthcare system to attempt to respond to the need for screening, mainly through expensive
screening programs.
The estimated lifetime cost of STIs, like chlamydia on the healthcare system of the U.S. is
conservatively $742 million per year. Although this is the annual cost for STIs for the entire U.S., much
of this cost burden likely falls on the healthcare systems in smaller communities, even those with limited
budgets (CDC, 2013b).In 2008, direct medical costs of C. trachomatis infections were estimated at
516.7 million dollars (CDC, 2014i). Chlamydia infections affect community healthcare systems by
costing them significant time and money. The time and money allocated to dealing with chlamydia
infections could be spent on other health initiatives. However, since chlamydia is a highly prevalent STI,
it is beneficial to the overall health of communities that the healthcare systems spend the necessary time
and money on chlamydia prevention and treatment.
As discussed above, chlamydia infections impose a great burden on the healthcare system and
the U.S. economy. As a result of this burden, the best method for the reduction of STIs like chlamydia is
a common topic in politics. Many politicians, including President Barack Obama have included STI

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reduction plans in their platforms during elections. For example, in 2011, just prior to 2012 elections,
President Barack Obama cut funding for abstinence only sex education program in school and put the
funding to support comprehensive sex education in schools. This decision caused many political quarrels
(Walcott, Chenneville, & Tarquini, 2011).
Many leaders in the education system have also been debating about the type of sex education
program that would have the most impact to lower the rates of STIs. Many parents, for reasons dealing
primarily with religious beliefs, support abstinence only programs, while both political and educational
leaders have been pushing to change to comprehensive sex education programs (Walcott, Chenneville, &
Tarquini, 2011). Politicians and educational leader push for comprehensive sex education programs
because studies have shown that they will decrease the high rates of teen pregnancy and STIs (Hall,
2011). A push for comprehensive sex education has caused changes in the dynamics of the education
system and has fueled many political debates (Walcott, Chenneville, & Tarquini, 2011).

Etiology
Agent characteristics
Chlamydia infections are STIs caused by the agent C. trachomatis (Eschenbach, 2015).C.
trachomatis is an obligate intracellular bacteria (Albrecht, Sharma, Reinhardt, Vogel, & Rudel, 2010).
Obligate and intracellular means that it must live within a host tissue and utilize the hosts nutrients in
order to survive and reproduce (Saka et al., 2011). C. trachomatis is also non-motile for this reason it
requires a host as a vector. Both of these characteristics a C. trachomatis explain why skin-to-skin
contact for transmission and why the organism does not live long outside of a host. C. trachomatis has
several different serovars and infectious clinical manifestations. Serovars or serotypes are distinct
variations within a species of bacteria or virus, also known as different stains. Within the specie of C.
trachomatis the serovars are; A, B, Ba,& C. Theses serovars cause trachoma, which is the leading cause
of blindness. The serovars D, E, F, G, H,I, J, K, all previously stated symptoms of chlamydia infections,
inclusion conjunctivitis in adults and newborns, neonatal pneumonia and swelling of the eye
(ophthalmia),nasopharyngeal discharge, lymphogranuloma venereum, pelvic inflammatory disease and
adverse pregnancy outcome. Finally, the L1, L2, and L3 serovars can cause lymphogranuloma venereum
(LGV), an ulcerative genital infection (Eschenbach, 2015).
Reservoir

Chlamydia trachomatis Infections

C. trachomatis uses humans as its reservoir (Heymann, 2015). As mentioned above, C.

trachomatis requires a reservoir because it is a non-motile obligate intracellular bacteria. C. trachomatis
uses its human reservoirs cells as a source of nutrients and a means of mobility (Saka et al., 2011). The
moist environment and cellular structure of the human genatalia provide and excellent place for C.
trachomatis to infect and thrive (CDC, 2011a).
Mode of transmission
Chlamydia infections can be spread through contact with parts of an infected person including the
vagina, mouth, anus, and penis during sexual intercourse (Heymann, 2015). Since C. trachomatis is nonmotile and requires a host to survive, chlamydia infections are spread through skin-to-skin contact
(CDC,2013a). The most common place for transmission is to the vaginal area because the tissue is
thinner and easier to penetrate (CDC, 2011a). Chlamydia infections can also be transmitted by skin to
skin contact to a child from the mothers infected cervix during vaginal birth (Heymann, 2015). As
mentioned earlier, the best way to prevent the transmission of chlamydia is by the proper and regular use
of condoms or dams during any and all sexual activities (National Health Service, 2013).
Risk factors for exposure and high risk groups
Specific groups of people are different risks for contracting a chlamydia infection. Important risk
factors include age, gender, number of sexual partners, consistency of condom use, prior history of other
STIs, and sexual orientation, and socioeconomic status in association with race and ethnicity (CDC,
2014a; Navarro, Jolly, Nair, & Chen, 2002).
Any sexually active person can be infected with chlamydia. It is a very common STI, especially
among young people. Age is the most consistent risk factor for contracting chlamydia infections. It has
been found that the younger age of men and women has been consistently associated with the increased
risk of a chlamydia infection among those who are sexually active (Navarro, et al., 2002). People aged
25 and under are at the highest risk for a chlamydial infection, specifically, adolescents ages 15-24 years
old (CDC, 2014a). In 2013, it showed that among those 1519 years old there were 1,852.1 cases per
100,000, and the rate among 2024 year olds was 2,451.6 cases per 100,000 (CDC, 2015) (Figure 1).
Adolescents are at a high risk because they typically lack knowledge about STIs and how they are
transmitted. Adolescents are also more likely to engage in risky sexual behaviors, such as, unprotected
sex. They also frequently fail to communicate effectively about sex and sexuality due to embarrassment
or not wanting to make sex awkward (CDC, 2010a). Adolescents are also less likely to acknowledge the

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risks that are associated with engaging in sexual behavior mainly because they think they are impervious
to STIs (Newby, Wallace, & French, 2012). Also since 1970, it has been found that the proportion of
adolescent women who engage in premarital sexual intercourse has doubled, thus the number of sex
partners is much greater at an earlier age than in past years, which increases their risk for contracting C.
trachomatis (Navarro, et al., 2002).
Chlamydial infections are not found in just one gender, but they are found in both males and
females. Gender is a significant risk factor for contracting chlamydia. Studies have found that around
70% of those infected with Chlamydia trachomatis are females, while 50% of those infected are males
(Navarro, et al., 2002). Females who are sexually active are at a higher risk for C. trachomatis infections
than men. Females are more vulnerable to STIs because of certain aspects of their physical development.
The lining of the vagina is much thinner than that of the tissue on other genitalia and the columnar
epithelium cells on the cervix support the growth of C. trachomatis (CDC, 2011a; Navarro, et al., 2002).
As previously mentioned, adolescents are more likely to contract C. trachomatis but among them,
females ages 13-24 years old are at higher risk than males in the same age group. It is estimated that 1 in
15 sexually active females aged 14-19 years has chlamydia. Transmission rates are thought to be slightly
higher from men to women than from women to men, but since there is a significant reservoir of
asymptomatic carriers in the general population, the exact rate of transmission is unknown (CDC,
2011a).
Inconsistent or lack of condom use puts any sexually active individual at a greater risk for
contracting C. trachomatis, especially when the person has multiple of new partners. The number of
sexual partners a person has increases their likelihood of contracting any type of STI, especially C.
trachomatis. Most people do not discuss STIs prior to sex, and it is likely that the new partner has had
multiple other partners who could have given them chlamydia. Also, having a history of STIs is a risk
factor that greatly increases a persons likelihood of contracting C. trachomatis (CDC, 2013a).
Sexual orientation is a risk factor for contracting chlamydia or any other STI. There are
disproportionately higher rates of STIs in MSM when compared to men and women who have sex with
only women. This disparity is likely due to increased sexual risk taking amongst MSM . These risks
include high rates of unprotected sex, large number of lifetime sex partners, and changing partners
(CDC, 2014g). Also, STIs occur more frequently in MSM because anal sex is typically rougher and
causes more tearing of the skin. The tearing that occurs removes a barrier or protection against infection,
thus allowing an agent to infect the person more easily (Jenness, S. M., et al., 2011). The prevalence of
site-specific chlamydial infections for MSM is 15.2% (CDC, 2014g).

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Finally, socioeconomic status is a risk factor. People with low socioeconomic status have less
education and less ability to afford or access quality healthcare. Both of these factors increase the
likelihood of contracting an STI. Minority races and ethnicities usually have a lower socioeconomic
status than Non-Hispanic Whites; therefore, minority groups usually experience higher rates of
chlamydia. This is evident in the reporting of rates of chlamydia infections that occurred in 2012 are
compared by race and ethnicity. The rates of chlamydia infections were 8 times higher in Black men and
6 times higher in Black women than in White men and women. The rates of chlamydia were 4.1 times
higher among both genders of people who are American Indians/Alaska Natives than in Whites. Both
genders of Native Hawaiians/Other Pacific Islanders and Hispanics had rates that were higher than
Whites. Only Asians had chlamydia rates lower than that of Whites (CDC, 2014a).
Methods of Control
Preventions
The suggested ways to reduce the number of chlamydia infections is through interventions that
focus on primary and secondary prevention. The purpose of primary prevention is to prevent an
infection from occurring, while purpose secondary prevention it to detect an infection to prevent the
infection from progressing. It is suggested that both primary and secondary prevention efforts be focused
on reaching at risk groups, such as young people, females, and MSM.
Primary prevention efforts for chlamydia usually involve educational interventions and the
emphasis of condom and dam usage (Heymann, 2015). Behavior change is a key goal of primary
prevention. Examples of primary prevention that can be delivered to an individual or a community are
educating people about how having multiple partners can increase the risks of getting chlamydia,
educating on the symptoms of chlamydia, and educating about how to properly use a condom or dam.
Another example of primary prevention if providing condoms or dams for free or at a reduced price.
Primary prevention occurs in many settings. One example is in a sexual education class in schools,
which would be considered a community level intervention. Primary prevention at an individual level
can occur during routine check-ups or from educational pamphlets sitting out at clinics. Distributing
educational materials can also be used for a community level intervention. Another community level
outlet to deliver primary prevention is by using media, including social media, to deliver information
about chlamydia infections and ways to prevent infections. Different outlets are used to deliver primary

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prevention depending on the target population. For example, an intervention that utilizes social media
would likely be more effective for young adults.
Secondary prevention for chlamydia typically involves screenings. The purpose of a screening
for chlamydia is to prevent the infection from spreading or causing further damage (CDC, 2014a).
Screening for chlamydia are one of the most cost-effective ways to decrease the burden of chlamydia.
Screenings are especially important in the prevention of chlamydia because chlamydia is typically
asymptomatic and people dont know they are infected until they get screened. Screening helps to
prevent both the progression of untreated chlamydia and the spreading of chlamydia to sexual partners.
Screenings typically occur in a healthcare setting (CDC, 2011c). Mass screenings can be organized in
order to implement secondary prevention efforts for an entire community. On an individual level, a
doctor can screen people at their yearly physicals. It is recommended that all sexually active females
ages 25 and younger get tested for chlamydia infections regularly (CDC, 2014a).
The goal of tertiary prevention is to treat an infection once it has been clinically diagnosed.
Tertiary prevention for chlamydia infections on an individual level usually includes the use of antibiotics
to eliminate the infection. It can also include treatments for any other illness that was caused by an
untreated chlamydia infections, such as PID. An example of tertiary prevention that could work on both
an individual and community level is the formation of support groups for people who have had
chlamydia or other illnesses due to untreated chlamydia. Also, individual or group counseling is a
suggested form of tertiary prevention for people who have or have had chlamydia infections. It is
important that people know that people are aware of the possible effects that their chlamydia infection
could have on the rest of their body. The purpose of follow up appointments and counseling is to prevent
the reoccurrence of an infection (Heymann, 2015).
Control of Patients, Contacts, and Environment
Chlamydia infections are notifiable diseases; therefore, any confirmed case must be reported to
the department of health in the state where the infection occurred. Isolation is not necessary for the
control of chlamydia infections. Standard precautions should be used when working with an infected
person (Heymann, 2008). Standard precautions include the wearing of personal protective material,
mainly gloves, and hand washing (CDC, 2014g). Caution should be used to discard any object that came
in contact with vaginal or urethral secretions. Neither quarantine nor immunizations are necessary or
utilized for the control of chlamydia infections. To control chlamydia infections in the clinical
environment, surfaces that might have come in contact with genital areas or vaginal or urethral
secretions should be disinfected and sterilized (Heymann, 2008).

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In order to control the highly prevalent rates of chlamydia, many of types of interventions like
the examples listed in the prevention section are being done. Chlamydia is easily transmitted through
unprotected sexual contact. The only way to physically control the spread chlamydia from person to
person while allowing sexual intercourse is through condom use. However, many people report they do
not use a condom or that they improperly use condoms. Interventions for improving condom use are
mainly focused on increase condom distribution (CDC, 2014e). Another suggested way to increase
condom use is through social marketing to spread awareness and decrease awkwardness associated with
condoms (WHO, 2012). Since rates of chlamydia infections are high in young people, it is important
that schools and universities create comfortable and welcoming environments for students to learn about
STIs, openly discuss STIs, and have access to condoms and dams.
Diagnostic Tests
For Chlamydia, it is almost always hard to know that people has been infected because there are
usually no symptoms from it, but going to a doctors office and taking a diagnostic test will allow
people to know if they have been infected. This is a quick and easy procedure that helps for a less
dramatic experience when going to get checked for an STI (Geisler, 2011). Doctors will use the
knowledge of communication to find out if it is necessary to check to see if the patient has been infected
with Chlamydia. A doctor can either collect a urine sample or a swab sample from the cervix or urethra.
The doctor uses the swab to collect fluid from either the cervix or the urethra (CDC, 2014i).
There are a few laboratory tests that can be done to detect chlamydia including a cell culture,
direct fluorescent antibody test, and enzyme immunoassays. All these test require a second nucleic acid
hybridization test to confirm their results. These tests require tissues swabs, thus theyre invasive. These
tests are also not very cost effective. Due to these factors another test was developed called a NAAT,
which stands for nucleic acid amplification test. NAATs can be used to test tissue swabs.However,
NAATs are the only also the only FDA approved test for chlamydia that can be used test urine samples.
Which makes them less invasive for patients and more cost effective because the tests dont require as
much time from healthcare workers to obtain samples. With the invention of NAATs, most of the other
tests for chlamydia have become obsolete. However, NAATs and many of the other tests mentioned
above are not approved by the FDA for follow up tests for chlamydia after people completed their
antibiotic regimens (CDC, 2014h). A cell culture is the suggested way to retest people for chlamydia
infections approximately three months after their treatment with antibiotics is over (Heymann, 2015).
NAATs work by amplifying even a single ribonucleic acid (RNA) or deoxyribonucleic acid
strand from the organism they were designed to test for. This amplification process is rapid. Amplified

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RNA or DNA from a sample is then compared with known RNA or DNA of the species that is being
tested for (CDC, 2014h)
NAATS have proven to have sensitivity above 90%, which makes them be nearly 20-30% more
sensitive than other tests for chlamydia, such as, the ones mentioned above. NAATs have a high
specificity of 99% (CDC, 2014h; Heymann, 2015) This because they can have positive test results from
amplification of just a single copy of DNA or RNA from chlamydia and the specimen does not ever have
to be alive. Due to this fact a truly sensitive test result is more likely. Chlamydia infections can have
harmful effects if left untreated; therefore, the detection and treatment of chlamydia is important. Thus, a
test that is more sensitive is desired, even with possibly lower specificity results. More sensitive tests are
also accepted because the treatment for chlamydia is a non-invasive antibiotic, so anyone who might
receive a false positive result will likely not be harmed by the treatment. Typically the only issues with
being diagnosed might be the stigma of having an STI or relational problems it might cause, but still it is
more important that people get treatment. NAATs have created more opportunities for easier, cheaper,
and faster detection of chlamydia. As a result NAAT tests have enabled the implementation and the
growth of screening programs, especially for sexually active women age 25 and younger (CDC 2010a;
CDC, 2014i).
To test the how well NAATs perform, researchers have compared multiple versions of NAATs
based on test algorithms using both samples what were purified in a lab and samples that were taken
from infected persons. This type of testing is important to evaluate validity of different brands of NAATs
for identifying chlamydia and not other bacteria that could be present in a sample taken from a person.
Though this method seems to work well, and indicate that NAATs provide more sensitive results that
earlier methods used to test for chlamydia, the scientific community has not been able established a
preferred method of testing the performance of different brands of NAATs. However, since the FDA has
approved the use of NAATs, the scientific and clinical community continues to use NAATs, while being
aware that any diagnostic test has its limitations. The specific limitation associated with NAATs is that
extreme caution must be taken to not cause cross contaminate the sample because NAATs are so
sensitive. Any cross contamination would likely cause invalid test results. Another limitation of NAATs
is that they are not FDA approved to test oropharyngeal or rectal samples. However, they have been
testing NAATs to see if this is a possibility, and the results indicate that using NAATs to test these area
could be a possibility, though the give slightly lower specificity and sensitivity results. Until FDA
approval, specimens from these areas will be tested through other means, such as, cell cultures (CDC,
2014i).

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Current Treatments
Treating chlamydia is an easy process once the patient tests positive. When patients find out
they test positive for chlamydia they should get treated immediately. If treatment is not done
immediately, then complications could occur. Doctors use antibiotics to treat chlamydia infection.
Antibiotics work by interfering in the processes that infectious bacteria need to survive, such as
preventing the the bacteria from forming certain proteins or disruption cell wall formation. For example,
since C. trachomatis is a gram negative bacteria, it must be able to form its complex cell wall order to
survive, thus if an antibiotic hinders this process the bacteria will not survive.The common
recommended antibiotics are a single dose of oral of one gram of azithromycin and two doses for seven
days of 100 milligram doxycycline for adult. Alternatives for adults include: four doses per day for
seven days of 500 milligram erythromycin taken orally, four doses a day for seven days of 800
milligram erythromycin ethylsuccinate taken orally, one does a day for seven days of 500 milligram
levofloxacin taken orally, and two doses a day for seven days of 300 milligram ofloxacin taken orally.
Antibiotic treatment for pregnant women includes three doses daily for seven days of 500 milligram
amoxicillin taken orally, the same dosage of azithromycin as given to all adults, and erythromycin given
at lower doses but over a longer time span. For eye infection in infants caused by C. trachomatis the
suggestion is 50 milligrams of oral erythromycin divided into four doses per day and given for 14 days.
These treatments are most effective when the patient follows the regimen guidelines, meaning that they
finish the full course of antibiotics (CDC, 2011b). Once the patient has taken the antibiotics, usually the
infection is gone. However, in some cases it will not completely go away. Due to the likelihood that the
infection is not completely gone and the high rate of recurrence of chlamydia infections, patients are
recommended to be retested roughly three months after they finish their antibiotics (CDC, 2011b;
Heymann, 2015).
Other treatments for chlamydia, that are somewhat more of preventive measure, could be
behavioral changes, such as, increasing condom and dam use, decreasing the number of sexual partners
someone has, and encouraging regular screening for chlamydia and other STIs.
Epidemic Measures
There are not formal generalizable epidemic measures established by an organization such as the
CDC or the World Health Organization should an epidemic of chlamydia occur in the U.S. (Heymann,
2008). The CDC has referred to it a hidden epidemic, because it is so prevalent and does not typically
cause death, nor does it cause immediate noticeable harm to those infected, thus the public is not overly
concern about reporting it as an epidemic (CDC, 2009c). Since chlamydia is the most common STI in

Chlamydia trachomatis Infections

15

the U.S. and is reported at high rates, some states, such as Minnesota, have referred to it as an epidemic.
Such states have established plans to decrease the incidence and prevalence of chlamydia infections.
These plans include: screening interventions for high risk persons, such as women age 25 and younger,
screening for partners of infected persons, providing free screenings for all uninsured persons,
implementing media awareness campaigns, providing education to people who work with college
students, adolescents, or children, improving sex education in schools, and providing proper education
for health care providers (Minnesota Department of Health, 2011).
Distribution
Chlamydia trachomatis was first discovered by Halberstaedter and von Prowazek in 1907 while
they were studying samples taken from the infected eye of an orangutan (Budai, 2007). Though it was
discovered in the early in the 20th century, the U.S. did not keep formal records of chlamydia infections
until 1984 (CDC, 2014b). In 1994, chlamydia infections were added to the list of notifiable diseases in
the U.S. Chlamydia trachomatis is the most common STI reported in the United States since 1994
(CDC, 2014a). There has been a consistent increase in the prevalence of chlamydia infections over the
past thirty years. Due to the continually increasing prevalence of chlamydial infections, they are
considered an important public health concern. This concern is amplified by the fact that the majority of
cases are asymptomatic, so many people go untreated. Untreated chlamydial infections can lead to
further complication.
Morbidity
Since 1993, the number of reported cases of chlamydia infections in the U.S. has continually
increased. The number of chlamydia cases reported in the U.S. in 1993 was 405,332 (CDC, 2014l).
From 1993 to 2008, the rate of chlamydia infections per 100,000 population increased from 178.0 to
398.1. In 2008, the number of reported cases of chlamydia was 1,217,397 (CDC, 2015). The pattern of
reports of chlamydia infections continued from 2008 to 2013 with the rates increasing from 398.1 to
446.6 per 100,000 population. The most recent data on chlamydia infections reported 1,401,906 cases in
2013 (CDC, 2015) (Figure 1). This increase is likely due both to an increase of the cases of chlamydia
infections, as well as, increased screening and reporting measures.
The morbidity of chlamydia infections in Indiana over the past 20 years has closely reflected that
of the U.S. population. Chlamydia infections in Indiana have also shown an increasing trend since 1993.
In 1993, there were 10,034 cases of reported in Indiana. The rate of infections per 100,000 population in
Indiana was 177.1, this nearly matches the U.S. rate of infections at 178.0 (CDC, 2014l). In 2008, both

Chlamydia trachomatis Infections

16

the number of cases and rate per 100,000 population of infections increased to 22,085 and 347.42
respectively. The prevalence of infections continued to increase in 2013 with the total number of cases
being 28,015 and the rate per 100,000 population being 428.53 (CDC, 2015)(Figure 2).
Mortality
Chlamydia infections are not typically deadly. Untreated chlamydia infections can lead to an
ectopic pregnancy. An ectopic pregnancy is when the pregnancy occurs outside of the uterus. Since
ectopic pregnancies, only account for 4-10% of pregnancy deaths, and these deaths are not directly
caused by a chlamydia infections, they will not be considered in mortality data for chlamydia infections
(Marion & Meeks, 2012). There is no data currently available for deaths from chlamydia infections in
the U.S. or Indiana.
Person, Place, and Time Factors
The prevalence of chlamydia is highest amongst women, especially those who are 15-24 years
old. In 2013, there were 993,348 cases of chlamydia reported by females. Cases of chlamydia in females
made up 70.9% of the 1,401,906 cases reported in the U.S. in 2013.In 2013, a combined total of 719,288
cases of were reported from females ages 15-19 and 20-24 in the U.S. The rates very high at 3093.30
and 3621.12 per 100,000 population respectively. The rates of chlamydia infections are lower for men
than women, but the highest rates of infections in men occurs at the ages of 20-24. In 2013, the rate of
infections in men ages 20-24 was 1,325.6 per 100,000 males (CDC, 2015) (Figure 1). In Indiana, the
highest rates of infection also occurred in females ages 15-19 and 20-24. For males in Indiana in 2013
the highest rate of infections in males was from those ages 20-24 years old (CDC, 2015) (Table 2).
In the U.S. with regards to race, chlamydia infections are the most prevalent among African
American men and women. The prevalence of chlamydial infections from 2005-2008 in African
Americans was 5.9%. A 2013 surveillance report indicated that the rate of infections in African
American was 6.4 times greater than the rate of infections in Caucasians. In the U.S., chlamydia
infections are less prevalent in Asians than any other race (CDC, 2013b). In Indiana, chlamydia rates are
the highest in Caucasians, followed closely by African Americans (1Indiana State Department of Health,
2013).
From 2004 to 2006, the Midwestern region of the U.S. reported the highest rates of chlamydia.
From 2004-2013 the Southern region of the U.S. reported the lowest rates of chlamydia. In 2006, the
rates of chlamydia infection in the Southern region surpassed that in both the Western and Midwestern
regions. The highest rates of chlamydia, nearly 480 infection per 100,000 population, was reported by
the Southern region in 2011. Since then, the Southern region has reported significantly higher rates of

Chlamydia trachomatis Infections

17

chlamydia than the other regions of the U.S. Overall from 2004 to 2011 the rates of chlamydia increased
nearly each year. From 2012 to 2013, the rates of chlamydia have decreased in every region but the
Western region where rates continue to slightly increase. The Northeastern region reported rates per
100,000 population ranging from near 280 in 2004 to 450 in 2011. The Western region reported rates per
100,000 population ranging from 320 in 2004 to 424.9 in 2013. The Southern region reported rate per
100,000 population as low as 325 in 2004 to as high as 480 in 2011. The Midwestern region reported
rates as low as 340 in 2004 and 2006. The Midwestern region reported rate per 100,000 population as
high as 400 in 2012 (CDC, 2014c) (Figure 3). In Indiana, Marion County reported the highest number of
infections in the state from 2011-2013. Marion County, Indiana reported the highest count in the state
with 10,109 cases in 2012 (Indiana State Department of Health, 2013b).
Case Study
Being that C. trachomatis are asymptomatic it is difficult to determine if people are infected, thus it
is also difficult to document cases. The U.S. reports high rates of many strains of Chlamydia
trachomatis. Since chlamydia infections are not deadly, few outbreaks are reported in the U.S., even
though chlamydia infections are highly prevalent. The high prevalence of chlamydia also makes the
occurrence of an outbreak less likely because in order for an outbreak to occur the rate must be
significantly higher than normal. However, the strains, serovars L1-L3, of Chlamydia trachomatis that
causes lymphogranuloma venereum (LGV) is very uncommon in the U.S. LGV causes inguinal
syndrome, characterized by the formation of abscesses in the groin area where lymph nodes drain, as
well as, ulcers in the infected area (New York State Department of Health, 2006). The most recent report
any form of a chlamydia outbreak in the U.S. was an outbreak of the LGV strain in San Francisco, CA
from 1979-1989 (Sparrgaren et al., 2005).
Similar to the U.S., the LGV strain of chlamydia is also not very common in other industrialized
nations. The Netherlands typically reports less than five cases of LGV a year. However, a case study was
started after the report of an outbreak of 92 cases of the LGV strain occurred amongst MSM in the in the
Netherlands from early 2003 to September of 2004.The majority of cases were reported in 2004, which
further alerted health official that an outbreak was occurring (CDC, 2004). As a result of the outbreaks
of LGV in the Netherlands, in October 2004 a national diagnostic surveillance system was set up by the
Health Protection Agency Centre for Infections in London. The system and team was to observe the
cases of the LGV strain of C. trachomatis in the United Kingdom. To inform medical professionals
about the recent discovery of outbreaks in the Netherlands and other parts of Europe a letter was sent to

Chlamydia trachomatis Infections

18

genitourinary clinicians and microbiologist, as well as, a briefing about the surveillance protocol and the
investigation algorithm. At the same time Terrence Higgins Trust Gay Mens Prevention Team
developed and distributed a warning to gay men about LGV and its symptoms in hopes of bringing men
to get screened for chlamydia (Ward, et al., 2007).
Since there was a high number of confirmed cases of LGV, a national incidence team was
assembled. It included microbiologists, a press officer, clinicians, epidemiologists, public health
specialists, and voluntary sector representatives. Diagnostic tests were administered to any man who
reported having sex with other men. If the preliminary test came back positive, the sample was
forwarded to the Sexually Transmitted Bacterial Reference Laboratory to confirm if the chlamydia was
caused by the LGV strain.
Gay men who had anorectal symptoms, such as, rectal pain, bleeding, or discharge, had
rectal specimens tested (CDC,2014h). If they showed symptoms of swelling of the lymph nodes near the
groin (inguinal lymphadenopathy), then they would have specimens from the urethra tested. Thirteen
men had both rectal and urethral specimen collected. Rectal specimens were the most commonly
collected samples. If the man tested positive for chlamydia trachomatis, particularly the LGV strain, his
sexual associates were also contacted to be tested for the infection. A small collection of chlamydia
specimen stored in the last 12 months also tested positive for LGV and was included in the sample.
Chlamydial status of the samples was determined using an in-house real-time polymerase chain reaction
(PCR) assay (CDC, 2004). This PCR assay tested for a specific marker found only in the DNA of C.
trachomatis serovars L1-L3, which cause LGV. All cases testing positive for LGV were reported to the
microbiologist and the surveillance team. The microbiologists and the surveillance team would then
contact patients who tested positive for the LGV strain. Patients testing positive for LGV were given an
extensive questionnaire about their demographic information, relevant sexual contacts, medical history,
and detailed risk factors and sexual history. The data gathered from the men was then entered into a
secure database (Ward et al., 2007).
It is unethical to infect someone with chlamydia, so samples were taken from MSM who
were currently the primary group affected by LGV at this time. A total of 1,408, samples were taken in
eighteen months starting on October 4, 2004 until February 28, 2006 for LGV testing. Only 327 were
positive for LGV, 655 were positive for other chlamydial infections, and 101 could not be classified.
Majority, 71%, of the samples came from London, 13% were derived from Brighton, and the remaining
16% came from across the United Kingdom. Nine men out of the 1,408 samples reported to have had
LGV twice during the eighteen month period. A substantial number of men, 201 of 252, reported

Chlamydia trachomatis Infections

19

unprotected anal sex. Also, 75% reported unprotected receptive and anal intercourse, and 55% reported
insertive anal intercourse (Ward et al., 2007) (Figure 4).
Only 282 cases were accompanied with the extensive questionnaire including
demographics and sexual history. White men were the vast majority of the cases. The ages ranged from
21-65 years old. Most of the patients, 86%, with LGV sought medical help because of symptoms. A
substantial amount of men had symptoms suggestive of severe disease and eight men had no symptoms.
The report is not specific in defining the symptoms of LGV or what was defined as severe disease. There
was a great range of time in developing LGV symptoms; symptom development ranged from a day to
eighteen months. After symptoms developed, only 25% took less than a month to report to a healthcare
facility (Ward et al., 2007).
The infection seem to be contracted primarily through unprotected anal intercourse with
multiple partners and primarily from MSM. Though samples were taken from across the United
Kingdom, LGV positive samples came in clusters from areas with a high population of gay men.
Anyone who tested positive for LGV was treated immediately with the recommended type and dosage
of antibiotics. There was no information given for attack rates of the sample. Due chlamydia infections
being mainly asymptomatic, all of the sampled men were not aware they had the infection until they
were screened; therefore, there was not a clear determination of the duration of the infections nor the
incubation period (Ward et al., 2007).
Since this outbreak occurred there have been increased reporting of the LGV strain in in Europe.
This infection emerged as a common problem amongst MSM. Health officials urge for continuing
surveillance and testing for the LGV strain in the MSM population throughout industrialized Europe.
The health officials suggest that health organizations raise awareness to the general public and clinicians
about LGV and the severe repercussions that can occur if LGV is left untreated. Officials hoped that
increased surveillance, awareness, and testing for LGV would slow the outbreak and that the knowledge
obtained thus far would help prevent further outbreaks of LGV (Ward et al., 2007).
.
Conclusion
Chlamydia infections are the most prevalent STIs in the U.S. and worldwide. Chlamydia is
mainly an asymptomatic disease, which causes many issues in the understanding and diagnosis of
chlamydia infections. It is important that this infection is never left untreated because it can cause other
harmful disease including PID, LGV, and Fitz-Hugh-Curtis Syndrome. Every sexually active person is

Chlamydia trachomatis Infections

20

susceptible to contracting a chlamydia infection. The causative agent of chlamydia infections in C.

trachomatis. This bacteria uses humans as a reservoir and can be transmitted through skin to skin
contact with the penis, vagina, mouth, and/or anus during sexual intercourse. Risk factors for chlamydia
infections include: age, number of sexual partners, consistency of condom or dam use, gender, sexual
orientation, and socioeconomic status in association with race and ethnicity. High risk groups include
women, young people, MSM, and Blacks (CDC, 2014b).
Chlamydia infections can adversely affect an individuals family, interpersonal relationships,
finances, and mental health. Due to chlamydia being highly prevalent it has had a significant effect on
the society of the U.S. by effecting the healthcare system, economy, educational systems, and politics.
Chlamydia costs the U.S. nearly $517 million each year, if the prevalence of chlamydia infections was
decreased, then this money could be utilized to eliminate other significant health or economical issues
(CDC, 2014h). Chlamydia infections have sociological effects on the development social norms about
sex amongst people in the U.S. Certain groups or people have become stigmatized because of the high
prevalence of chlamydia associated with them, thus people who are not included in these stigmatized
groups will likely not engage in sex or even social acquaintance with stigmatized people. Frequently
groups that are stigmatized are minority group with lower socioeconomic status, this stigmatization
because of chlamydia further widens the gap between minority groups and majority groups in the U.S.
Chlamydia has an adverse effect on the psychological health of the U.S. population in two ways. The
first is that it can harm interpersonal relationships causing residual emotional and psychological issue.
The second way is that if untreated chlamydial infections cause infertility of other health issues for
people, then their mental health can be adversely affected as they try to cope with their physical health
issues. Chlamydia infections affect the physical domain of peoples lives by increasing their chances of
contracting another STI, or getting cancer, and by causing poor reproductive health including problems
with the delivery and development of offspring (Office of Disease Prevention and Health Promotion,
2014).
Due to the high rates of chlamydia many organizations have taken on massive prevention
campaigns. For example, the CDC and other partners recently launched the GTY: Get Yourself Tested
Campaign in 2009 and has continued this program. The program aims at lowering STI rate through
primary, secondary, and tertiary prevention. Example of each type of prevention include, education and
awareness about STIs, increased screenings for STIs, and providing access to treatment facilities
respectively (Heymann, 2015).

Chlamydia trachomatis Infections

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Identifying and controlling chlamydia infections it very important to attempts to lower the
prevalence of chlamydia. The best way to control the spread of chlamydia is through increased condom
and dam use, as well as, screenings. The most reliable and common way to test for a chlamydia infection
by a NAAT test. Once a test is positive, chlamydia can be easily treated with antibiotic (Ward, et al.,
2007).
The most current data indicates that there were 1,401,906 cases of chlamydia in the U.S. in 2013.
The District of Columbia reported 1014 cases of chlamydia per 100,000 population, the highest rate of
chlamydia infections in the U.S. in 2013. The District of Columbia was followed by Alaska that reported
a chlamydia rate of 789 per 100,000 population in 2013. The state with the lowest chlamydia rate was
New Hampshire with the rate of infection being 236 per 100,000 population (CDC, 2014f). The most
current data from Indiana indicates that the rate of chlamydia infections was per 100,000 population
being 428.53, with a total of 28,015 reported cases. Indiana was ranked 22nd state with the highest
chlamydia rates in 2012 when it reported a rate of 452.7 per 100,000 population (CDC, 2013h).
The rates of chlamydia have been steadily increasing over the past 20 years (CDC, 2014k; CDC,
2015). Since lowering rates of chlamydia requires increased screening, the short term projections for
incidence and prevalence of chlamydial infections are that the rates will continue to increase due to
increases in screening and reporting measures. In the long term, roughly in the next 20 years, it is
expected that the incidence and prevalence rates will either remain constant or decrease slightly. This
change is expected because of the many educational and awareness interventions about STIs that are
currently happening across the U.S. (CDC, 2014b). The developers of Health People 2020 suggest that
the public health response to the high rates of STIs include several types of interventions at both the
national and state levels. Such interventions include improving the epidemiological understanding of
chlamydia by improving the collection data from persons infected with chlamydia. They suggest that
legislative action are necessary to lower the rates of STIs. Improved communication and awareness
programs encourage in order to increase education about STIs, destigmatize STIs, and lessen health
disparities associated with STIs (Office of Disease Prevention and Health Promotion, 2014). They also
advocate for increased screening interventions. Decreasing the rates of chlamydia in the U.S. will
require a combined effort from individuals, healthcare workers, communities, legislators, and
government officials.

Chlamydia trachomatis Infections

22

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Chlamydia trachomatis Infections

27
Appendix

Figure 1. Chlamydial infections: Age and gender-specific reported cases and rates per 100,000
population, United States, 2008 and 2013

Gender

2008-Count

Females

13,697

45.88

11,575

38.55

Age:

340,975

3,251.38

317,724

3,043.30

0-14 years

322,054

3,153.20

401,564

3,621.12

15-19 years

126,901

1,221.05

151,510

1,428.28

20-24 years

47,757

495.47

62,737

599.15

25-29 years

21,510

206.33

26,879

273.39

30-34 years

18,107

24.76

24,815

31.90

35-39 years

2,003

**

1,310

**

893,004

579.36

993,348

623.09

40+ years

2008-Rate

2013-Count

2013-Rate

Unknown
Total:
Males

1,903

6.08

1,846

5.89

Age:

76,901

695.92

78,585

715.18

0-14 years

114,354

1,050.65

153,554

1,325.62

15-19 years

60,877

554.15

82,486

757.87

20-24 years

26,831

268.50

41,149

390.86

25-29 years

14,959

141.06

20,211

207.49

30-34 years

18,049

27.52

28,365

40.49

35-39 years

939

**

659

**

313,779

209.29

405,652

262.57

40+ years
Unknown
Total:
Total for year:
**Data not available.

1,210,523

398.12

1,401,906

446.59

Chlamydia trachomatis Infections

28

Chlamydia trachomatis Infections

29

Figure 2. Chlamydial infections: Age and gender-specific reported cases and rates per 100,000
population, Indiana, 2008 and 2013

Gender
Females

2008-Count

2008-Rate

2013-Count

2013-Rate

251

39.17

233

36.11

Age:

6,477

2,948.27

6,909

3,096.4

0-14 years

6,028

2,887.65

8,326

3,545.1

15-19 years

2,264

1,034.83

2,899

1,400.0

20-24 years

816

404.66

1,131

539.86

25-29 years

348

163.80

469

235.30

30-34 years

261

17.03

337

21.06

35-39 years

68

**

**

16,513

510.56

20,307

611.81

44

6.56

28

4.15

Age:

1,431

616.75

1,680

714.18

0-14 years

2,030

930.47

3,034

1,262.0

15-19 years

1,091

483.31

1,482

712.95

20-24 years

461

222.14

752

355.43

25-29 years

255

117.42

350

176.04

30-34 years

240

17.51

381

26.29

35-39 years

20

**

**

5,572

177.31

7,708

239.51

28,015

428.53

40+ years
Unknown
Total:
Males

40+ years
Unknown
Total:
Total for year:
**Data not available.

22,085

637.04

Chlamydia trachomatis Infections

30

Chlamydia trachomatis Infections

Figure 3. Rates of Chlamydia by Region of the U.S. 2004-2013

Breakdown of Regions by State.

31

Chlamydia trachomatis Infections

32

Figure 4. Shows the number of cases of LGV among MSM from October 2004 to February 2006. The
y-axis on the right displays the number of cases with a total of 327 cases. The y-axis on the right
displays the number of samples that were tested for LGV with a total of 1408.