Correspondence
Chlamydia Infections in Female Military Recruits
N Engl J Med 1999; 340:237-238January 21, 1999
- Article
To the Editor:
In their well-conducted study of the prevalence of chlamydial infections in female military recruits, Gaydos et al. (Sept. 10 issue)1 discuss possible criteria for cost-effective screening.
It is not clear whether the partners of the infected female recruits were referred for evaluation and treatment. Given the availability of new and convenient screening tests and highly effective treatments, the Centers for Disease Control and Prevention (CDC)2 and other authorities, including Dr. Gaydos herself,3 recommend referring the sexual partner of an infected person for evaluation, testing, and treatment. Not treating the sexual partner for chlamydial infection should be considered substandard care and would undermine efforts to control this disease. . . .
Finally, since the frequency of screening is an important characteristic of any screening program,4 we would like to know what the most cost-effective frequency is and for whom. Should we screen all sexually active women under the age of 20 every six months,5 or screen men and women (under a certain age) on a yearly basis? Despite the growing literature on chlamydial infections, these questions need to be addressed in order to allow one to make evidence-based statements about cost-effectiveness analyses.
5 ReferencesElpidoforos S. Soteriades, M.D.
Jo Anna Stina Coolidge, M.D., M.P.H.
Monica Zangwill, M.D., M.P.H.
Carney Hospital, Boston, MA 02124-56661
Gaydos CA ,Howell MR ,Pare B , et al. Chlamydia trachomatis infections in female military recruits. N Engl J Med 1998;339:739-744
Full Text | Web of Science | Medline2
1998 Guidelines for treatment of sexually transmitted diseases 3
Quinn TC ,Gaydos C ,Shepherd M , et al. Epidemiologic and microbiologic correlates of Chlamydia trachomatis infection in sexual partnerships. JAMA 1996;276:1737-1742
CrossRef | Web of Science | Medline4
Screening for chlamydial infection. In: Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore: Williams & Wilkins, 1996:325-34.
5
Burstein GR ,Gaydos CA ,Diener-West M ,Howell MR ,Zenilman JM ,Quinn TC . Incident Chlamydia trachomatis infections among inner-city adolescent females. JAMA 1998;280:521-526
CrossRef | Web of Science | Medline
To the Editor:
Despite the large number of female recruits in the study by Gaydos et al., the sample is nevertheless a convenience sample rather than a statistical one and therefore cannot be representative of the general population from which the subjects came. Moreover, since sexual behavior is known to be the primary mechanism through which chlamydial infection is acquired, race should be irrelevant as a variable unless there is substantial and credible evidence that sexual behavior is dissimilar among different races in the United States. The use of such variables, which unfortunately is common, is not only offensive but also misleading. Recently, some have eloquently advocated abandoning race as a variable in public health research.1,2
2 ReferencesKwabena S. Ansong, M.D., M.P.H.
Bassett Healthcare, Cooperstown, NY 133261
Fullilove MT . Comment: abandoning “race“ as a variable in public health research -- an idea whose time has come. Am J Public Health 1998;88:1297-1298
CrossRef | Web of Science | Medline2
Bhopal R ,Donaldson L . White, European, Western, Caucasian, or what? Inappropriate labeling in research on race, ethnicity, and health. Am J Public Health 1998;88:1303-1307
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Dr. Soteriades and colleagues and Dr. Ansong raise four important points about our study: the representativeness of our sample, the use of race as a variable, the need for identification of partners, and the proper frequency of and candidates for screening. We initiated our study of female Army recruits primarily to define the prevalence of Chlamydia trachomatis infections and to provide data that would lead to the development of an effective intervention program. Our sample of 13,204 subjects provided an excellent estimate of the prevalence of C. trachomatis infection in female recruits. Although our sample was one of convenience, we believe that the large size of our study provided a reliable indication of the magnitude of infection in the populations from which these subjects came. Our data were reflective of the regional surveillance data on chlamydia reported to the CDC.
We included race as a study variable because race or ethnic background has been identified as an independent variable that is important in the transmission of sexually transmitted diseases.1 Moreover, racial and ethnic differences in the reported rates of sexually transmitted diseases are independent of family income, geographic region, educational level, and sexual risk behavior.2 Ethnic background may be an important variable representative of the choice of partners and social networks, which are important in understanding the transmission of sexually transmitted diseases.3,4 However, we acknowledged in our article that it would be inequitable to use race as a screening variable for a control program. We found that young age was an effective variable on which to base screening.
We agree that referral of sexual partners for assessment and treatment is highly desirable and, in fact, forms the cornerstone of programs to control sexually transmitted diseases. The participants in our study came from all 50 states and U.S. territories, and all infections occurred before entry into basic training. The logistical and staffing resources necessary to track all the contacts of these subjects were prohibitive, and unfortunately, this could not be accomplished. The aim of our study was to develop a control program for female Army recruits and to minimize future consequences of infection.5 Cost-effectiveness analyses to identify options for screening and treating female recruits are under way.
The issue of screening frequency is an important one. Currently, the CDC recommends annual screening for women at risk for C. trachomatis infection. Our study provided information on the prevalence of infection in large military populations, and there are no recent data concerning the incidence of infections in either men or women on which to base recommendations about the frequency of screening. Determinants of the incidence of disease and information on social networks in the Army after basic training are needed to construct models to assess the relative merits of definitions of candidates for screening and to determine the frequency of screening and the most effective treatment strategies.
5 ReferencesCharlotte A. Gaydos, Dr.P.H.
Thomas C. Quinn, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21205Kelly T. McKee, Jr., M.D.
Womack Army Medical Center, Fort Bragg, NC 28307Joel C. Gaydos, M.D.
Henry M. Jackson Foundation, Rockville, MD 208521
Zenilman JM . Ethnicity and sexually transmitted infections. Curr Opin Infect Dis 1998;11:47-52
CrossRef | Web of Science | Medline2
Ellen JM ,Aral SO ,Madger LS . Do differences in sexual behaviors account for the racial/ethnic differences in adolescents' self-reported history of a sexually transmitted disease? Sex Transm Dis 1998;25:125-129
CrossRef | Web of Science | Medline3
Fullilove RE . Race and sexually transmitted diseases. Sex Transm Dis 1998;25:130-131
CrossRef | Web of Science | Medline4
Rothenberg R ,Narramore J . The relevance of social network concepts to sexually transmitted disease control. Sex Transm Dis 1996;23:24-29
CrossRef | Web of Science | Medline5
Scholes D ,Stergachis A ,Heidrich FE ,Andrilla H ,Holmes KK ,Stamm WE . Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;334:1362-1366
Full Text | Web of Science | Medline
