Sexually Transmitted Diseases:
Chlamydia in the United States Military: Can We Win This War?
Gaydos, Charlotte A. MS, MPH, DrPH*; Gaydos, Joel C. MD, MPH†
From the *Division of Infectious Diseases, International STD Laboratory, Johns Hopkins University, Baltimore, Maryland; and †Department of Defense Global Emerging Infections Surveillance and Response System (DoD-GEIS), Walter Reed Army Institute of Research (WRAIR), Silver Spring, Maryland
The views expressed are those of the authors and should not be construed to represent the positions of the Johns Hopkins University, the Department of the Army, or the Department of Defense.
Correspondence: Charlotte A. Gaydos, MS, MPH, DrPH, Division of Infectious Diseases, International STD Laboratory, Johns Hopkins University, 1159 Ross Bldg., 720 Rutland Ave., Baltimore, MD 21205. E-mail: firstname.lastname@example.org.
Received for publication January 2, 2008, and accepted January 8, 2008.
Chlamydia trachomatis is the most frequently reported infectious disease in the US civilian population.1 In 2006, over 1 million cases were reported to the Centers for Disease Control and Prevention (CDC), Atlanta, GA.1 Sequelae such as pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pelvic pain are devastating consequences of untreated infections in women; epididymitis and infertility can occur in men.2–8 Screening and treatment of women have been found to prevent pelvic inflammatory disease in women9 and have been associated with less-frequent hospitalization in military women.10 Because chlamydial infections are mostly asymptomatic, yearly screening of sexually active women aged 25 years and younger has been recommended by several groups.11,12 Additionally, the CDC has recommended that infected women be rescreened at 3 months after treatment to identify those who become reinfected.13,14
Historically, sexually transmitted infections (STIs) have been a problem in military forces.15–17 Recently, however, military leaders who are facing serious problems and limited budgets have not placed a high priority on STI programs. The most prevalent STIs are viewed as being mildly symptomatic or asymptomatic and are not associated with severe morbidity that would reduce performance on the job,15 but high STI rates continue to occur in uniformed populations. STIs have been consistently identified as the leading reportable medical event in the military, and chlamydial infections lead the list of reported STIs.18 Uniformed people in the forces of the United States are primarily young, healthy women and men who come into the military with the behavior patterns and infections they acquired in their civilian communities. Chlamydial infections are highly prevalent in newcomers to the military (recruits or basic trainees)16,19 and later military life may be associated with high rates of new infections, as reported by Dr. Mary-Ann Shafer and her colleagues in this issue of Sexually Transmitted Diseases.20 The United States Department of Defense medical leaders and their distinguished civilian medical advisors [the Defense Health Board (DHB), formerly known as the Armed Forces Epidemiologic Board] have developed recommendations for screening for chlamydial infections, and the different uniformed services and individual military commands have implemented chlamydia prevention and control programs. However, a single, global, coordinated Chlamydia trachomatis prevention and control program does not exist for all uniformed personnel. Military personnel processing points on entry into military service and when uniformed people report to a new assignment often provide excellent opportunities to efficiently screen young women, as well as men, at risk for chlamydia infections. The efficiency of this type of population screening is especially impressive on entry to basic (recruit or initial entry) training when very large groups of young people can be provided an educational experience and screened over a short time period. In civilian populations, the opportunities for high-efficiency, point-of-entry screening programs are rare; most civilian men and women have to individually make the effort to visit a clinic to be screened.
In this issue of Sexually Transmitted Diseases, Shafer et al.20 report on the acquisition of C. trachomatis by women who entered the US Marine Corps and were followed for a period of approximately 1 year after basic training. Within 2 weeks of beginning their 13-week recruit training program, these ethnically diverse, predominantly young (mean age of <20 years) women were universally screened and treated for STIs, to include C. trachomatis. The overall prevalence for C. trachomatis infections in this group of nonhealth-care–seeking women was 11% at baseline (time 1). A group of 332 women was studied at approximately 4 weeks after graduating from recruit training, a 13-week period when the women were segregated from men, which was typically followed by a vacation to a civilian location (time 2), and again at about 12 months after graduation (time 3). The authors found that the laboratory-confirmed acquisition rate ranged from 3.6% (time 2) to 13%, based on the combined results of laboratory screening at time 2 and time 3. When all laboratory results were combined with self-reports of chlamydial infections, the summed acquisition rate was 19.9% for the study period. This study provides evidence that chlamydial infections are highly prevalent among women coming into the military, and highly incident among apparently healthy young military women who are not seeking medical care. After screening and treatment for STIs upon entry into the Marines, about 1 in 5 women acquired a new chlamydial infection during their 12 months of military service after recruit training. The authors considered it striking that the epidemic rates observed occurred in women who had access to the very large, global US Military Health System.
The US military is aware of the cost and effort that goes into recruiting, training, and retaining volunteer military service members who will be productive and not excessively hampered by morbid episodes.21 Because recruits bring with them the behavior and infections acquired in their hometown communities before their entry into military service, more effective civilian STI screening, treatment, and educational programs would be a welcome improvement. Shafer and her colleagues pointed out that in 2001, only 26% and 38% of 16- to 26-year-old sexually active women were screened by commercial and Medicaid health care plans, respectively.22
There are also many opportunities for improvements within the Military Health System. At the DHB meeting on December 12, 2007, in Arlington, VA, chlamydial screening was discussed (http://www.ha.osd.mil/DHB/meetings/2007-12/default.cfm, accessed on December 31, 2007). Programs that provide for screening, treatment, and an educational experience early in recruit training can be economical23,24 and effective25–27 because large numbers of recruits can be cared for in a short time period. This intervention early in a military career could have a positive impact on future behavior and future infections and prevent morbid sequelae. The Navy, Marines, Air Force, and Coast Guard have female recruit screening programs for chlamydia. The Army, a service in which female recruits have been found to have a prevalence of chlamydial infections of approximately 10%, and 5% in male Army recruits, does not.19,26,28,29 The Army attempts to screen female newcomers within their first year of military service, a policy under which an infected soldier could go 12 months without detection and treatment. The completeness of screening of sexually active military women aged 17 to 25 years, who had been continuously enrolled in a military medical treatment facility for the preceding year, was reported at the December DHB meeting to exceed the percentages similarly screened in civilian health care organizations.30 Overall, 72% of women in the Navy, Air Force, and Army were screened (76% in the Navy, 73% in the Air Force, and 68% in the Army).30 Even though the overall 72% screened has increased from 35% in 200116 and is considerably higher than the 90th percentile level reported for civilian health care organizations by the Healthcare Effectiveness Data and Information Set evaluations,22 it still represents a failure to test 28% of continuously enrolled sexually active military women aged 17 to 25 years. These 28% could be stationed in areas without easy access to medical care needed in the event sequelae of chlamydial infections occur, thus necessitating costly medical evacuation. Additionally, many military people move frequently, and an unknown number of at-risk women were not enrolled in a single facility for a continuous year and were not counted. These more transient women may represent a higher risk group for STIs.
Shafer and colleagues recommend that intervention programs that have been successfully implemented elsewhere be considered for military populations. They also point out that based on their data and the work of others, annual screening may be inadequate because reinfection rates may be high and reinfection may occur within a short time after treatment.23,31 It is also necessary to consider that success with female-only screening programs will be limited.29,32–34 The CDC recently published guidance for STI programs that are considering screening men for chlamydial infections.35 This CDC document identifies military men as a population that should be considered for screening.35 Chlamydia screening programs for men in the military must be evaluated and implemented where they will have a positive impact. In the 2006 textbook entitled Recruit Medicine, Niebuhr and colleagues18 called for a structured, programmatic approach to interventions for STIs in the Military Health System, to include the following:
* Education programs that are interactive, targeted to risk behaviors of military people, and implemented by trained educators.
* Strengthening of STI intervention programs at recruit training centers.
* Having all Military Health System facilities jointly negotiate STI laboratory supply, equipment, and testing contracts to control costs.
* Joint military-civilian program collaborations that include cost sharing.
The recommendations of Niebuhr and his colleagues are in concert with similar recommendations made by Brodine and Shafer in 2003.16 All of the Military Health System interventions mentioned above deserve serious consideration. Discussions with representatives from the CDC on developing meaningful collaborative programs may be a good first step to assist both civilian and military public health officials in making improvements that could help us in the war against chlamydial infections. A comprehensive, global, Department of Defense chlamydia control program that is implemented by all the uniformed services and closely coordinated with National and State programs is a worthy goal. The inclusion of meaningful, measurable goals will facilitate assessments regarding success and failure. We have excellent tools and new noninvasive sample types36,37 at our disposal, to include molecular tests38,39 to accurately and easily screen sexually active young adults, as well as effective single-dose therapy.40 The important question is, “Can we develop and implement a plan that will effectively use these tools to achieve significant improvements in our war against chlamydial infections and their sequelae?”
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