Chlamydia trachomatis Prevalence and Risk ... - Semantic Scholar

ORIGINAL STUDY

Chlamydia trachomatis Prevalence and Risk Behaviors in Parturient Women Aged 15 to 24 in Brazil Valdir Monteiro Pinto, MD, MSc,*† Ce´lia Landmann Szwarcwald, PhD,‡ Carla Baroni, BSc,† Lorenzo Lyrio Stringari, BSc,† Lilian Amaral Inoceˆncio, BSc,* and Ange´lica Espinosa Miranda, MD, PhD†

Background: Chlamydia trachomatis (CT) is a sexually transmitted infection having repercussions on reproductive health and impact on the fotus. Our goal was to estimate the prevalence of and risk factors for CT in young parturient women in Brazil. Methods: A national cross-sectional study of parturient women, aged 15 to 24 years, attending Brazilian public hospitals was performed in 2009. Participants answered a questionnaire including demographic, behavioral, and clinical data. A sample of urine was collected and screened for CT and Neisseria gonorrhoeae (NG), using polymerase chain reaction COBAS Amplicor CT/NG (Roche Molecular Systems, Branchburg, NJ). Results: A total of 2400 women were selected and 2071 (86.3%) participated in the study. Mean age was 20.2 years (standard deviation ! 2.7). Prevalence rates of CT and NG were 9.8% (95% confidence interval [CI]: 8.5–11.1) and 1.0% (95% CI: 0.6%–1.4%), respectively. Four percent of women infected with CT also had NG infection. CT associated factors were: being younger (15–19 years old) (odds ratio [OR] ! 1.6 [95% CI: 1.15–2.17]); first sexual intercourse before 15 years of age (OR ! 1.4 [95% CI: 1.04–6.24]); having more than 1 sexual partner in lifetime (OR ! 1.6 [95% CI: 1.13–2.26]); Pap smear screening more than 1 year (OR ! 1.5 [95% CI: 1.08–2.05]); and NG infection (OR ! 7.6 [95% CI: 3.05–19.08]). Conclusions: This study shows a high prevalence of CT infection among young pregnant women in Brazil. We suggest that CT screening should be included as part of antenatal care routine in this group in Brazil.

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hlamydia trachomatis (CT) is one of the sexually transmitted infections (STI), and has great effect on sexual and reproductive health.1,2 CT and Neisseria gonorrhoeae (NG) are responsible for genitourinary infections, pelvic inflammatory From the *Departamento de DST/AIDS e hepatites virais, Ministe´rio da Sau´de, Brasília, Brazil; †Nućleo de Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitoria, Brazil; and ‡Instituto de Comunicaçaõ e Informaçaõ Científica e Tecnolo´gica em Sau´de, Fiocruz, Brazil The authors thank regional health professionals that were very important to the conclusion of this study: Adelaide Setubal, Alvaro Koenig, Ana Cristina Alcantara, Ana Katherine Gonçalves, Ana Paula Guimara˜es, Ernesto Figueiro´ Filho, Helaine Milanez, Ivete Cristina Canti, Jorge Oliveira Vaz, Juan Jose´ Rivas, Kenia Zimmerer Vieira, Marcelino Santos Neto, Marcus Takimura, Maria Alix Leite Arau´jo, Patricia Leite Rodrigues, Renylena Schmidt, Silvana Maria Quintana, Terezinha Teno´rio da Silva, Vale´ria Aparecida da Silva, Weslane Almeida Magalhaes. They also thank Andressa Bolzan from Ministry of Health who helped with logistics. MCT/CNPq/MS-SCTIE-DECIT/CT-Sau´de number 550580/2007-7 and UNODC-Ministe´rio da Sau´de, Termo de Cooperaçaõ number 133/08. Correspondence: Ange´lica Espinosa Miranda, MD, Av. Marechal Campos, 1468–Vitoria–ES–29100-240, Brazil. E-mail: [email protected]. Received for publication February 18, 2011, and accepted April 18, 2011. DOI: 10.1097/OLQ.0b013e31822037fc Copyright © 2011 American Sexually Transmitted Diseases Association All rights reserved.

Sexually Transmitted Diseases ●

disease, chronic pelvic pain, fallopian tube infertility, ectopic pregnancy, and are also associated with cervical cancer.3,4 CT most frequently affects people "20 years of age.1 Infection during pregnancy-childbirth cycle can result in premature labor, premature rupture of the membranes, and low birth weight.5–7 CT also have repercussions for the fotus, which may be infected through the vaginal tract and suffer conjunctivitis and pneumonia.8 In women, diagnosis of CT infection is difficult in developing countries because of inadequate infrastructure laboratories to perform diagnostic tests. CT is asymptomatic in approximately 70% to 80% of cases, and remains undetected and thus untreated. This represents one of the principal difficulties for its control.9 One of the most important risk factors identified in previous studies is being young, that is, less than 25 years of age.9 –17 In Brazil, the national prevalence of CT infection has not been estimated before. Previous local studies in Brazil have shown high frequency of CT in young women.16,17 The scarcity of data is due to several factors: the lack of clinical symptoms that influences the identification of infected individuals and the problems of access to laboratory tests. These tests are expensive and rarely performed in Brazilian public health services. In private healthcare services, CT investigation is only undertaken in symptomatic cases or when a sexual partner reports the diagnosed infection. Prenatal care coverage in the country is about 96.5% and screening for STI is performed routinely only to diagnose HIV and syphilis.18 The purpose of this study was to estimate the national prevalence of CT infection and its association with NG in parturient women aged 15 to 24 years attending Brazilian public maternity units. This study provides useful information for the elaboration of public health policies on CT screening and the building of indicators for monitoring the strategies to prevent this infection in young women.

METHODOLOGY A cross-sectional study was conducted in 2009 among parturient women attending Brazilian public hospitals. Parturient women attending selected maternity units in 5 geographic macro-regions of Brazil from March to November 2009 were invited to take part in the study.

Data Collection Each participant was interviewed face-to-face by a trained health professional A face-to-face questionnaire was used for collection of sociodemographic data (age, race/color, schooling, marital status, and family income); clinical data (gestational age, number of pregnancies, number of childbirths, number of miscarriages/abortions, antenatal examinations performed); sexual data (age at first sexual intercourse, prior history of STI, gynecological complaints, number of sex part-

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ners in the last year and since their first sexual intercourse); and STI/HIV risk behavior (drug use, sex in exchange for money/ goods, and information about sex partners regarding a history of blood transfusions, injecting drug use, bisexual practices, and history of imprisonment). Family income was measured in minimum Brazilian wages (MBW); 1 MBW in 2009 was approximately US$250.

Laboratory Tests A 20-mL urine sample was obtained from the first amount of urine passed, with the recommendations of no prior genital cleansing and a minimum period of two hours without urinating before sample collection. Samples were analyzed in a semiautomated system called COBAS Amplicor CT/NG (Roche Molecular Systems, Branchburg, NJ) for qualitative in vitro detection of CT and NG, as per the manufacturer’s instructions at the Molecular Biology Laboratory of the Infectious Diseases Unit of the Federal University of Espírito Santo.

TABLE 1. Prevalence of Chlamydia trachomatis Infection in

Brazilian Parturient Women, by Geographical Region (N ! 2071)

Region North Northeast Midwest Southeast South Brazil

Sample Size

CT#

%

95% CI

269 696 159 714 233 2071

38 60 18 70 16 202

14.1 8.6 11.3 9.8 6.9 9.8

9.9–18.3 6.5–10.7 6.3–16.3 7.6–12.0 3.6–10.2 8.5–11.1

in the study and those who accepted signed a written consent form. Those who were diagnosed as being infected received treatment in accordance with the Brazilian guidelines for Sexually Transmitted Diseases Control.18

Calculation of the Sample Size The sample size was calculated to estimate the national and regional prevalence rate in parturient women aged 15 to 24 years, with a 95% confidence interval (CI) for 1.5% bilateral size. A 10% prevalence rate was taken as the basis for calculating the sample size.17 The calculated sample size was 1536 and, considering a 20% loss and a sampling design effect of 1.3, a final sample size of 2400 parturient women was obtained.

Sampling Sampling was performed in 2 stages. In the first stage, 24 public health system maternity units were randomly chosen, with probability proportional to size, established by the number of childbirths in the year before the study. The choice of the maternity units was stratified by geographic macroregion (North, Northeast, Midwest, Southeast, and South) with proportional allocation to the number of childbirths in the year before the commencement of the study of the year 2009. A total of 100 women were selected in each health establishment. At the time of their admission for childbirth, an interview was performed with regard to filling a designed questionnaire and providing urine samples.

Statistical Analysis Data were analyzed using the SPSS— data entry statistical program (Statistical Package for the Social Sciences) version 17.0. The data collected were weighted using the number of live births in each geographical region in the year 2008. A preliminary analysis was performed using exploratory techniques on the data, to check the distribution patterns and trends of the principal variables. Bivariate analysis was then performed to check for the presence of association between the variables. !2 tests were used for proportion differences and Student t tests and variance analysis were used for testing differences between mean values. To estimate associations with the presence of CT infection, the odds ratio (OR) was used as a measure of association, estimated with a 95% CI. Multivariate analysis was performed to estimate joint effects of independent variables, through the use of logistic regression models.

Ethical Aspects This project was submitted to the Research Ethics Committee of the Health Sciences Centre of the Federal University of Espírito Santo (Committee approval number 112/07) and to the ethical committee of each maternity unit taking part in the study. All selected women were invited to take part voluntarily

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RESULTS Of the sample of 2400 parturient women, a total of 2071 (86.3%) were included in the study. No specific information was gathered about nonrespondents. Some of them presented with bleeding during sample collection and were excluded (3.7%), some declined to participate because they were in pain (2.0%), and some accepted to participate but samples were lost during transportation (unfrozen, shed, and/or mixed) (8.0%). The mean age was 20.2 years (standard deviation [SD] ! 2.69) and mean of formal education was 8 years (SD ! 2.4). The prevalence rate of CT infection was 9.8% (95% CI: 8.5%–11.1%) and NG was 1.0% (95% CI: 0.6%–1.4%). Four percent of women with CT had a positive test results for NG. Table 1 shows the distribution of CT prevalence rates in the macroregions of Brazil. The highest rate was found in the Northern region (14.1%) and the lowest rate in the Southern region (6.9%). Table 2 shows CT results by sociodemographic characteristics. Women with positive test results were younger (15–19 years) (54.0% vs. 38.1%, P ! 0.046); reported not living maritally with their partners (38.6% vs. 26.6%, P ! 0.000), and were poorer (had income less than 4 MBW) (97.0% vs. 92.9%, P ! 0.025). The age of onset of sexual activity ranged from 9 to 24 years, with the mean of 15.6 years (SD ! 2.7). As shown in Table 3, women with Chlamydia diagnosis reported to be sexually active earlier— before 15 years of age (41.6% vs. 31.9%, P ! 0.007), have more than 1 sexual partner in the last year (8.9% vs. 4.7%, P ! 0.016), and more than 1 sexual partner in their lifetime (72.8% vs. 63.1%, P ! 0.007). They also reported illicit drug use more frequently (10.4% vs. 5.6%, P ! 0.012), including injecting drug use (2.0% vs. 0.5%, P ! 0.040). No differences were found in terms of prior history of STI (P ! 0.393) or prostitution (P ! 0.665). Table 4 describes CT prevalence rate by clinical characteristics. Parturient women with a positive CT test result gave birth prematurely more frequently (21.8% vs. 16.1%, P ! 0.046) and had a higher number of positive NG tests (4.0% vs. 0.6%, P " 0.001) when compared to the women without CT. Attending to 6 or more antenatal care appointments were significantly less among women with CT (3.7% vs. 54.6%, P ! 0.016). Pap smear screening during the preceding year was also significantly less in women with CT (37.1% vs. 47.8%, P ! 0.004). The factors associated with CT in the multivariate logistic regression analysis were as follows: age ranging from 15 to



Chlamydia trachomatis in Brazil

TABLE 2. Sociodemographic Characteristics of Parturient Women Attending Brazilian Public Maternity Units and Association With C. trachomatis (N ! 2071)

Variables Age (yr) 15–19 20–24 Schooling (yr) Up to 8 9 and over Marital status Does not live with partner Married or living together Income Up to 4 minimum wages "4 minimum wages Geographical region North Northeast Midwest Southeast South

Sample Size

CT#

CT$

OR (95% CI)

822 (39.7) 1249 (60.3)

109 (54.0) 93 (46.0)

713 (38.1) 1156 (61.9)

1.9 (1.42–2.46) 1

1224 (59.1) 847 (40.9)

124 (61.4) 78 (38.6)

1100 (58.9) 769 (41.1)

1.1 (0.83–1.50) 1

575 (27.8) 1496 (72.2)

78 (38.6) 124 (61.4)

497 (26.6) 1372 (73.4)

1.7 (1.29–2.35) 1

1933 (93.3) 138 (6.7)

196 (97.0) 6 (3.0)

1737 (92.9) 132 (7.1)

2.5 (1.08–5.70) 1

269 (13.0) 696 (33.6) 159 (7.7) 714 (34.5) 233 (11.3)

38 (18.8) 60 (29.7) 18 (8.9) 70 (34.7) 16 (7.9)

231 (12.4) 636 (34.0) 141 (7.5) 644 (34.5) 217 (11.6)

2.2 (1.21–4.130) 1.3 (0.73–2.31) 1.8 (0.88–3.61) 1.5 (0.85–2.64) 1

19 years (OR ! 1.6 [95% CI: 1.15–2.17]); onset of sexual activity before 15 years old (OR ! 1.4 [95% CI: 1.04 – 6.24]); more than 1 sexual partner in their lifetime (OR ! 1.6 [95% CI: 1.13–2.26]); Pap smear screening more than 1 year ago (OR ! 1.5 [95% CI: 1.08 –2.05]); and NG coinfection (OR ! 7.6 [95% CI: 3.05–19.08]) (Table 5).

DISCUSSION This is the first population-based study at the national level in Brazil to determine the prevalence of CT in young pregnant women. We identified a prevalence rate of 9.8%. Previous local studies in Brazil have shown similar results regarding the prevalence of CT in pregnant and adoles-

cent women. A study performed in the city of Vito´ria, Espírito Santo, identified CT in 12.2% of sexually active female adolescents.19 Menezes et al.20 found 7.8% of CT in pregnant women in Recife, Pernambuco, and a study of female adolescents in Goiaˆnia, Goia´s, reported a 19.6% of CT.16 A study performed in 6 cities using a convenience sample reported a 9.4% of CT among pregnant women.17 Our findings are also in agreement with other studies performed among asymptomatic young women in other countries. Rates from 1.7% to 17% were described in different European countries12,13 and from 4.4% to 15.5% in United States.9,21 Other studies reported 10.1% of CT in pregnant women in China,22 8% in Botswana,14 and 7.7% in Venezuela.15

TABLE 3.

Behavioral Characteristics of Parturient Women Attending Brazilian Public Maternity Units and Association With C. trachomatis (N ! 2071)

Variables Age at first sexual intercourse Under 15 yr 15 yr or over No. partners/life 1 %1 No. partners/yr 1 %1 Prior STI Yes No Sex worker Yes No Illicit drug use Yes No Injecting drug use Yes No


Sample Size

CT#

CT$

OR (95% CI)

680 (32.8) 1391 (67.2)

84 (41.6) 118 (58.4)

596 (31.9) 1273 (68.1)

1.5 (1.13–2.05) 1

744 (35.9) 1327 (64.1)

55 (27.2) 147 (72.8)

689 (36.9) 1180 (63.1)

1 1.6 (1.13–2.16)

1966 (94.9) 105 (5.1)

184 (91.1) 18 (8.9)

1782 (95.3) 87 (4.7)

1 2.0 (1.18–3.40)

103 (5.0) 1968 (95.0)

7 (3.5) 195 (96.5)

96 (5.1) 1773 (94.9)

0.7 (0.30–1.45) 1

16 (0.8) 2055 (99.2)

2 (1.0) 200 (99.0)

14 (0.7) 1855 (99.3)

1.3 (0.30–5.88) 1

125 (6.0) 1946 (94.0)

21 (10.4) 181 (89.6)

104 (5.6) 1765 (94.4)

2.0 (1.20–3.22) 1

14 (0.7) 2057 (99.3)

4 (2.0) 198 (98.0)

10 (0.5) 1859 (99.5)

3.8 (1.17–12.05) 1


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TABLE 4.

Clinical Characteristics of Parturient Women Attending Brazilian Public Maternity Units and Association With C. trachomatis (N ! 2071)

Variables Gestational age Under 36 wk "36 wk Antenatal care Yes No Antenatal sessions* Up to 5 6 or more Gynecological complaints Yes No Last cytology Last year More than 1 yr ago Gonorrhoea test Positive Negative

Sample Size

CT#

CT$

OR (95% CI)

344 (16.6) 1727 (83.4)

44 (21.8) 158 (78.2)

300 (16.1) 1569 (83.9)

1.5 (1.02–2.08) 1

1974 (95.3) 97 (4.7)

185 (91.6) 17 (8.4)

1789 (95.7) 80 (4.3)

1 2.1 (1.19–3.54)

733 (37.1) 1241 (62.9)

84 (45.4) 101 (54.6)

649 (36.3) 1140 (63.7)

1.5 (1.08–1.98) 1

511 (24.7) 1560 (75.3)

58 (28.7) 144 (71.3)

453 (24.2) 1416 (75.8)

1.3 (0.91–1.74) 1

969 (46.8) 1102 (53.2)

75 (37.1) 127 (62.9)

894 (47.8) 975 (52.2)

1 1.6 (1.15–2.10)

20 (1.0) 2051 (99.0)

8 (4.0) 194 (96.0)

12 (0.6) 1857 (90.4)

6.4 (2.58–15.80) 1

*Total number of women attending antenatal sessions (1974 cases).

In agreement with other authors, our results also showed an association between CT and age, with higher frequency among the youngest group of women,9,10,13–17,23–25 as well as among women who reported having had more than 1 sex partner in their lifetimes,10,16,17 and in those with NG coinfection.9,24 These observations highlight that a systematic evaluation needs to be performed concerning risk factors related to sexual behavior in this group. Clinical studies of behavioral interventions, services for sex partners, and treatment services have shown promising results in reducing the risk of bacterial infection, duration of infection, and number of sexual partners.25 We found that Chlamydia infection showed an association with lack of yearly Pap smear screening. This may be explained by the fact that women who take care of their own health have a greater chance of having infections diagnosed and treated earlier, as suggested by Wilson et al.,12 than women who do not seek healthcare. Although a cross-sectional study is not ideal for determining risk factors, its application is justified. CT prevalence and risk factors in young women at child-bearing age is important to demonstrate the susceptibility of this population

TABLE 5. Multivariate Analysis of Factors Associated With C. trachomatis Infection in Parturient Women Attending Brazilian Public Maternity Units, 2009 Variables Age (15–19 vs. 20–24 yr) Age at first sexual intercourse (Under 15 vs. 15 yr or over) No. partners/life (more than 1 vs. 1) Last cytology (more than 1 yr vs. up to 1 yr ago) Gonorrhoea test (positive vs. negative)

OR (95% CI)

P

1.6 (1.15–2.17) 1.4 (1.04–6.24)

0.005 0.029

1.6 (1.13–2.26) 1.5 (1.08–2.05)

0.008 0.015

7.6 (3.05–19.08)

0.000

Variables included in the model are as follows: age, marital status, income, geographical region, age at first sexual intercourse, number of sex partners/yr, number of sex partners/life, drug use, gestational age, antenatal sessions, last cytology, and gonorrhoea testing.

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group to complications caused by this infection during the pregnancy-childbirth cycle and puerperium. Given the low prevalence of some risk factors in this sample, it is possible that the number of women studied was not sufficient to find statistical association between some independent variables and Chlamydia infection. The possibility of biased answers cannot be rule out because of the general tendency to give socially acceptable replies in face-to-face interviews. Also, we only included public hospitals and therefore cannot draw conclusions on private ones; however, it is important to say that about 70% of the childbirths take place in public hospitals. Bacterial STI have been neglected in recent times due to an increase of viral STI epidemic, especially HIV, which can lead to the misguided suggestion that these agents are diseases of the past, of less importance, and of limited interest to professionals providing healthcare. On the contrary, as demonstrated recently, these infections are a huge burden for health and the economy accounting for 17% of economic losses, mainly in developing countries, caused by the health-disease binomium.26 Nevertheless, great progress has been achieved in STI prevention by using, in the majority of cases, multiple approaches such as, for example, adding a screening program to prevention strategies for risk populations, which has been shown to be cost effective.27 Thus enabling early diagnosis and timely treatment and, therefore, reducing morbidity caused by highly asymptomatic diseases such as Chlamydia infections. Given the well-established association between Chlamydia infection and pelvic inflammatory disease, fallopian tube damage and scarring, infertility, ectopic pregnancy, as well as conjunctivitis and pneumonia in newborn babies, efforts to reduce this infection among teenagers and young adults can produce an important effect on morbidity arising from this disease. A recent US Preventive Services Task Force publication on measures to prevent STIs emphasized the importance of introducing the investigation of Chlamydia infection in all pregnant women aged "24 years.28 Our results show high CT prevalence in young parturient women in Brazil. This suggests that diagnostic tests for this



Chlamydia trachomatis in Brazil

infection should be included in screening programs for young pregnant women. Timely diagnosis and treatment could provide peace of mind to women worried about the outcome of their current pregnancy and the future of their sexual and reproductive health. As most cases are asymptomatic, a screening program is one of the important means for identifying undiagnosed infection and to provide earlier treatment to these women and their sexual partners.

REFERENCES 1. 2. 3. 4. 5.

6.

7. 8. 9. 10. 11.

12. 13.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines. Morb Mortal Wkly Rep 2010; 59:44 – 48. World Health Organization. Global Strategy for Intervention and Control of Sexually Transmitted Infections: 2006 –2015. Geneva, Switzerland: World Health Organization, 2007:61. Bakken IJ, Ghaderi S. Incidence of pelvic inflammatory disease in a large cohort of women tested for Chlamydia trachomatis: A historical follow-up study. BMC Infect Dis 2009; 9:130. Wallin KL, Wiklund F, Luostarinen T, et al. A population-based prospective study of Chlamydia trachomatis infection and cervical carcinoma. Int J Cancer 2002; 101:371–374. Andrews WW, Goldenberg RL, Mercer B, et al. The preterm prediction study: Association of second-trimester genitourinary Chlamydia infection with subsequent spontaneous preterm birth. Am J Obstet Gynecol 2000; 183:662– 668. Blas MM, Canchihuaman FA, Alva IE, et al. Pregnancy outcomes in women infected with Chlamydia trachomatis: A populationbased cohort study in Washington State. Sex Transm Infect 2007; 83:314 –318. Wilkowska-Trojniel M, Zdrodowska-Stefanow B, OstaszewskaPuchalska I, et al. The influence of Chlamydia trachomatis infection on spontaneous abortions. Adv Med Sci 2009; 28:1–5. Peipert JF. Genital chlamydial infections. N Engl J Med 2003; 349:2424 –2430. Miller WC, Ford CA, Morris M, et al. Prevalence of chlamydial and gonococcal infections among young adults in the United States. JAMA 2004; 291:2229 –2236. Skjeldestad FE, Marsico MA, Sings HL, et al. Incidence and risk factors for genital Chlamydia trachomatis infection: A 4-year prospective cohort study. Sex Transm Dis 2009; 36:273–279. Norman JE, Wu O, Twaddle S, et al. An evaluation of economics and acceptability of screening for Chlamydia trachomatis infection, in women attending antenatal, abortion, colposcopy and family planning clinics in Scotland, UK. BJOG 2004; 111:1261– 1268. Wilson JS, Honey E, Templeton A, et al. A systematic review of the prevalence of Chlamydia trachomatis among European women. Hum Reprod Update 2002; 8:385–394. Adams EJ, Charlett A, Edmunds WJ, et al. Chlamydia trachomatis in the UK: A systematic review and analysis of prevalence studies. Sex Transm Infect 2004; 80:354 –362.


14. 15. 16.

17. 18.

19.

20. 21.

22. 23.

24.

25.

26. 27. 28.

Romoren M, Sundby J, Velauthapillai M, et al. Chlamydia and gonorrhoea in pregnant Batswana women: Time to discard the syndromic approach? BMC Infect Dis 2007; 7:27. Arraiz N, Marcucci R, Colina S, et al. Infeccioń por Chlamydia trachomatis em mujeres consultantes em Maracaíbo, Venezuela. Rev Salud Publica 2008; 10:615– 624. Arau´jo RS, Guimara˜es EM, Alves MF, et al. Prevalence and risk factors for Chlamydia trachomatis infection in adolescent females and young women in central Brazil. Eur J Clin Microbiol Infect Dis 2006; 25:397– 400. Jalil EM, Pinto VM, Benzaken AS, et al. Prevaleˆncia da infecçaõ por clamídia e gonococo em gestantes de seis cidades brasileiras. Rev Bras Ginecol Obstet 2008; 30:614 – 619. Brasil. Ministe´rio da Sau´de. Secretaria de Vigilaˆncia em Sau´de. Programa Nacional de DST e Aids. Manual de Controle das Doenças Sexualmente Transmissíveis. Secretaria de Vigilaˆncia em Sau´de, Programa Nacional de DST e Aids. Brasília: Ministe´rio da Sau´de, 2006. Miranda AE, Szwarcwald CL, Peres RL, et al. Prevalence and risk behaviors for chlamydial infection in a population-based study of female adolescents in Brazil. Sex Transm Dis 2004; 31:542–546. Menezes ML, Fauńdes AE. Validaçaõ do fluxograma de corrimento vaginal em gestantes. J Bras Doenças Sex Transm 2004; 16:38 – 44. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Disease Surveillance 2009. Atlanta, GA: US Department of Health and Human Services, 2010. Available at: http:// www.cdc.gov/std/stats09/surv2009-Complete.pdf. Chen XS, Yin YP, Chen LP, et al. Sexually transmitted infections among pregnant women attending an antenatal clinic in Fuzhou, China. Sex Transm Dis 2006; 33:296 –301. Marrazzo JM, Johnson RE, Green TA, et al. Impact of patient characteristics on performance of nucleic acid amplification tests and DNA probe for detection of Chlamydia trachomatis in women with genital infections. J Clin Microbiol 2005; 43:577– 584. Silveira MF, Erbelding EJ, Ghanem KG, et al. Risk of Chlamydia trachomatis infection during pregnancy: effectiveness of guidelines-based screening in identifying cases. Int J STD AIDS 2010; 21:367–370. Wetmore CM, Manhart LE, Wasserheit JN. Randomized controlled trials of interventions to prevent sexually transmitted infections: Learning from the past to plan for the future. Epidemiol Ver 2010; 32:121–136. Mayaud P, Mabey D. Approaches to the control of sexually transmitted infections in developing countries: Old problems and modern challenges. Sex Transm Infect 2004; 80:174 –182. Hu D, Hook EW III, Goldie SJ. Screening for Chlamydia trachomatis in women 15 to 29 years of age: A cost-effectiveness analysis. Ann Intern Med 2004; 141:501–513. US Preventive Services Task Force. Screening for chlamydial infection: US Preventive Services Task Force Recommendation Statement. Ann Intern Med 2007; 147:128 –134.


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