1. Genital chlamydia testing in general practice in Estonia

2. Project ChlamydiA Testing Training in Europe (CATTE) Participants: – Estonia – France – England (lead) – Sweden Project aims -to develop training packages for general practice staff delivering chlamydia screening; -to transfer an innovative chlamydia testing training package for GP staff http://stitraining.eu/

3. Training sessions in Estonia Department of Public Health, University of Tartu in cooperation with Department of Polyclinic and Family Medicine 5 training sessions + pilot 20 Tartu and Tartu county GP practices were randomly selected Training sessions accreditation in Centre for Continuing Medical Education, University of Tartu

4. I.Introduction II.Genital chlamydia o Microbiology, pathogenesis o Epidemiology o Clinical manifestations o Testing, diagnosis o Patient management o Prevention III.Discussion ( videos, barriers)

5. Why chlamydia? Chlamydia remains the most common STI in Europe within the young adult population, but testing rates are low EU 175 cases per 100 000 person in 2011 (ECDC) gonorrhea 12,6 cases 100 000 Left untreated chlamydia can cause serious, permanent damage to a woman's reproductive system, making it difficult or impossible for her to get pregnant later on. Chlamydia screening and treatment is an important and useful intervention to reduce the risk of PID among young women.

6. ECDC Number of reported chlamydia cases per 100,000 population, EU/EEA, 2011 Combination of the testing and reporting

7. Why to screen young adults aged 18-24? Young adults aged 18-24 are most at risk ¾ of reported cases are in age group 15-24 (ECDC) ECDC 2012

8. Why GP staff? General practices are feasible place for screening: – 71% of 16-24 years old adults in Estonia visit their GP per half a year (Uuringu raport, 2012) In case of health problems first advisor

9. Microbiology

10. Chlamydiaceae Family (species that cause disease in humans) Species (genus)Disease C. trachomatis 2 biovars, non-LGV LGV Trachoma, NGU, MPC, PID, conjunctivitis, Infant pneumonia, LGV C. pneumoniae Pharyngitis, bronchitis, pneumonia C. psittaciPsittacosis

11. Chlamydia trachomatis serovar D … K Obligatory intracellular bacteria Infect columnar epithelial cells Survive by replication that results in the death of the cell Takes on two forms in its life cycle: – Elementary body (EB) – Reticulate body (RB)

12. Chlamydia trachomatis C. trachomatis has an affinity for epithelial cells of the cervix, upper genital tract in women, urethra, rectum, and conjunctiva. C. trachomatis elementary bodies (EBs) enter cells via receptor-mediated endocytosis. Receptors for are restricted to nonciliated columnar, cuboidal, or transitional epithelium.

13. Chlamydia trachomatis Unique life cycle: 2 forms: – Elementary is the extracellular, infective form of chlamydia – Reticular reproduces by binary fission and depends on host cells for metabolism. Host cell death Incubation period 7-21 days

14. Pathogenesis Immune response: – primary immune response: PMN-neutrophils; – lymphocytes, macrophages, eosinophiles Antibodies does not eliminate risk of reinfection Chlamydia trachomatis bound to epithelial cells after neutralization by antibodies against polymorphic membrane protein D (PmpD).

15. Antimicrobial treatment C.trachomatis resistant to beta-lactam antibiotics C. trachomatis is sensitive to tetracyclines, macrolides, and some fluoroquinolones Azitromycine (suppress cell growth) Doxycyline (suppress protein synthesis)

16. Incidence (reported cases) of STI in Estonia 119/100 000 ● ● ► ► ♦ ♦ ◊ ◊

17. Incidence (reported cases) of genital C. trachomatis infections be gender, Estonia 2012

18. Chlamydia prevalence Population-based prevalence study (Tartu county 2005) 18-35 years old - 5.4% – 6.9% F – 2.7% M 18-24 years old - 6,6% – 10,2% F (Uusküla A. 2008)

19. Risk factors Age (adolescence) New or multiple sex partners History of STIs Presence of another STI Hormonal contraception use Lack of barrier contraception

20. Cervix, older female Columnar epithelium inside cervix Cervix, younger female Cervical ectopy

21. Transmission Transmission is sexual or vertical Highly transmissible Incubation period 7-21 days Significant asymptomatic reservoir exists in the population Re-infection is common

22. Clinical syndromes caused by C. trachomatis Men WomenInfants Local InfectionComplicationSequelae Conjunctivitis Urethritis Prostatitis Reiter’s syndrome Epididymitis Chronic arthritis (rare) Infertility (rare) Conjunctivitis Urethritis Cervicitis Proctitis Endometritis Salpingitis Perihepatitis Reiter’s syndrome Infertility Ectopic pregnancy Chronic pelvic pain Chronic arthritis (rare) Conjunctivitis Pneumonitis Pharyngitis Rhinitis Chronic lung disease?Rare, if any

23. C. Trachomatis infections in women Cervicitis – Majority (70%-80%) are asymptomatic – Local signs of infection, when present, include: Mucopurulent endocervical discharge Edematous cervical ectopy with erythema and friability Urethritis – Usually asymptomatic – Signs/symptoms, when present, include dysuria, frequency, pyuria