Worldwide,
As the rate of CT around the world has been climbing over the last decade [
In India, no national data source contains information about the prevalence of CT. Though many studies of STIs have been done throughout the country, most of this piece of information has focused on high risk populations, mainly HIV positive women and female sex workers [
This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [
Studies were included in our review if they were published between January 1, 2003, and December 31, 2013. Date restrictions were used to ensure that studies were comparable in terms of available diagnostic technology, cultural norms during the study period, and overall population living in India and centered on women of childbearing age (15–40 years). Studies were excluded if they focused exclusively on sex workers, HIV positive women, or men. Studies of both men and women were included if data were stratified by sex.
We searched PubMed and Ovid Medline for articles pertaining to CT prevalence in India. Search terms included “
Information from articles that met the inclusion criteria was extracted by two readers (Kalpana Betha and Jamie M. Robertson) and compared for agreement. Any discrepancies were solved through discussion. Information extracted included the following: author(s), journal, year of publication, study design, participant demographics, sample size, setting, CT testing method, and prevalence findings.
Our database search yielded a total of 132 studies (see Figure
Characteristics of the studies addressing
Author | Year | Setting | Location | Population | | Age | Diagnostic method | Sample source | Prevalence (95% CI)1 | Validity |
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Vidwan et al. [ | 2012 | ANC clinic | Tamil Nadu | Pregnant (≥28 weeks’ gestation) | 784 | Mean: 25.8 | NAA | Endocervical | 0.1% (0–0.38%) | This is the largest study on CT prevalence among healthy pregnant mothers in South India. But project sample population may not represent local delivering female population. |
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Patel et al. [ | 2010 | GYN clinic | New Delhi | Symptomatic, nonpregnant | 335 | Median: 29 | PCR | Endocervical | 23.0% | Used in-house PCR method which was cost-effective; included only symptomatic patients. |
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Becker et al. [ | 2010 | GYN clinics | Karnataka | Symptomatic | 335 | Mean: 30.7 | PCR | Endocervical | 2.7% | It has good sample size;women were recruited from gynecology clinics; itmay lead to enrollment of low risk women. |
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Dwibedi et al. [ | 2009 | OB/GYN clinic | Orissa | Symptomatic | 71 | Mean: 31.5 | PCR | Endocervical | 7.0% | It has small sample size. It is the first report from the region. It may help clinicians of the region in treating cases with similar symptoms. |
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Singh et al. [ | 2003 | GYN clinic | New Delhi | Symptomatic and asymptomatic | 280 | 18–25 | PCR | Endocervical | 28.5% | Studied age-wise prevalence rate and determined most prevalent serovars of CT. |
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Joyce et al. [ | 2004 | Community3 | Tamil Nadu | Symptomatic and asymptomatic | 1066 | Range: 15–45 | PCR | Urine | 1.1% (0.5–1.7%) | It is the first population based study in India. It has the largest sample size. It used two methods to determine prevalence. |
2Reported only as age groups; no measure of central tendency available.
95% CI: 95% confidence interval; ANC: antenatal care; OB/GYN: obstetrics and gynecology; GYN: gynecology; SD: standard deviation; NAA: nucleic acid amplification; PCR: polymerase chain reaction; ELISA: enzyme-linked immunosorbent assay; DFA: direct fluorescent antibody; STI: sexually transmitted infection.
3Representative sample taken from 3 randomly selected districts by using the probable proportional to size cluster survey method.
Three studies [
All 6 studies employed polymerase chain reaction (PCR) testing as a method of CT diagnosis [
The prevalence of active chlamydial infection assessed by PCR or NAAT was greatest among populations considered to be at a generally higher risk for sexually transmitted infection, including symptomatic and asymptomatic women presenting to obstetrics and gynecology, gynecology, or STI clinics. In four studies, the rate of CT ranged from 2.7% to 23% [
This is the first systematic review of CT prevalence among childbearing age women in India which does not focus on women who are not part of a high risk group, such as those who are HIV positive or are sex workers. We found the reported prevalence of active CT infection detected using molecular techniques among lower risk groups including pregnant women presenting for antenatal care and a general population based study to be lowest, ranging from 0.1% (95% CI 0–0.38%) to 1.1% (95% CI 0.5%–1.7%). Prevalence of current infection among populations considered to be of higher risk including symptomatic and asymptomatic women presenting to obstetrics and gynecology, gynecology, or sexually transmitted disease clinics was higher, ranging from 2.7% to 28.5%. Variation in this higher risk group was largely explained by age, with the highest rates among younger women.
Though we did not include studies of known high risk populations, the majority of studies included in this review were done among women presenting to either gynecologic or STI clinics, the majority of whom reported symptoms of sexually transmitted and reproductive tract infections. This may bias our review toward reporting a higher prevalence of CT. However, studies including symptomatic and asymptomatic women taken from other clinic settings, such as antenatal clinics, and population based studies mostly found results similar to what has been seen in population based studies in the United States and other countries. In the United States, the prevalence of CT among women aged 14–39 years is 2.2% (95% CI: 1.4–3.4%) [
The current practice in India is to conduct opportunistic screening among symptomatic women. As asymptomatic infection is common, it would be optimal to offer screening for both symptomatic and asymptomatic women, including pregnant women who present to antenatal clinics, in order to provide treatment, prevent sequelae, and decrease the chances of CT being spread throughout the community. Additionally, it would be optimal to test, treat, and counsel partners. If partners are unwilling or unable to access medical services, expedited partner therapy should be advocated and women should be instructed to abstain from sexual intercourse for 7 days until partners have completed treatment. The current practice for partner management in India is client-initiated partner notification [
We found that the majority of published information related to the prevalence of CT among women comes from obstetrics and gynecologic clinics. Most symptomatic women in India present to such facilities instead of STI specific clinics [
This focus is especially important given the changing cultural climate in India. Increasingly, adolescents, especially males, are engaging in premarital sexual activity [
Increased screening efforts can prevent a variety of sequelae associated with CT. In the United States, the Centers for Disease Control and Prevention (CDC) recommends annual CT screening for all women aged 25 years and younger. In addition, it recommends screening all pregnant women at the first prenatal visit and second screening during the third trimester for women ≤25 years of age and those identified to be of high risk [
Finally, in order to better understand the true burden of CT on the population, more community-based studies of asymptomatic individuals are needed. In addition, identification of risk factors unique to populations in India may help identify targets for ongoing community-based studies that would provide an important way to identify CT in nonpregnant populations and prevent additional infections.
The authors declare that there are no competing interests regarding the publication of this paper.
The authors would like to thank Dr. Clareann Bunker, Associate Professor, Department of Epidemiology, Graduate School of Public Health at the University of Pittsburgh, and Dr. P. S. Reddy, Professor, Division of Cardiology, School of Medicine at the University of Pittsburgh, Chairman, SHARE India, for their guidance and support. This work was funded by Fogarty International Center 5D43TW009078.