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Direct and Indirect Effects of Screening for Chlamydia trachomatis on the Prevention of Pelvic Inflammatory Disease: A Mathematical Modeling Study

Herzog, Sereina A.; Heijne, Janneke C. M.; Scott, Pippa; Althaus, Christian L.; Low, Nicola

doi: 10.1097/EDE.0b013e31829e110e
Infectious Diseases

Background: Pelvic inflammatory disease (PID) results from the ascending spread of microorganisms, including Chlamydia trachomatis, to the upper genital tract. Screening could improve outcomes by identifying and treating chlamydial infections before they progress to PID (direct effect) or by reducing chlamydia transmission (indirect effect).

Methods: We developed a compartmental model that represents a hypothetical heterosexual population and explicitly incorporates progression from chlamydia to clinical PID. Chlamydia screening was introduced, with coverage increasing each year for 10 years. We estimated the separate contributions of the direct and indirect effects of screening on PID cases prevented per 100,000 women. We explored the influence of varying the time point at which clinical PID could occur and of increasing the risk of PID after repeated chlamydial infections.

Results: The probability of PID at baseline was 3.1% by age 25 years. After 5 years, the intervention scenario had prevented 187 PID cases per 100,000 women and after 10 years 956 PID cases per 100,000 women. At the start of screening, most PID cases were prevented by the direct effect. The indirect effect produced a small net increase in PID cases, which was outweighed by the effect of reduced chlamydia transmission after 2.2 years. The later that progression to PID occurs, the greater the contribution of the direct effect. Increasing the risk of PID with repeated chlamydial infection increases the number of PID cases prevented by screening.

Conclusions: This study shows the separate roles of direct and indirect PID prevention and potential harms, which cannot be demonstrated in observational studies.

Supplemental Digital Content is available in the text.

From the Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.

This work was supported by the Epidemiology and Mathematical Modelling for Infectious disease Control (EpideMMIC) project; Swiss National Science Foundation grant numbers PDFMP3_124952 (S.A.H.) and 320030_135654 (J.C.M.H.); and Swiss National Science Foundation grant numbers 320030_138490 (P.S.) and PZ00P3_136737 (C.L.A.). N.L. and J.C.M.H. attended a GlaxoSmithKline scientific advisory board meeting about chlamydia vaccines in 2010.

Supplemental digital content is available through direct URL citations in the HTML and PDF versions of this article ( This content is not peer-reviewed or copy-edited; it is the sole responsibility of the author.

Correspondence: Nicola Low, Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland. E-mail:

Received October 24, 2012

Accepted April 23, 2013

Copyright © 2013 Wolters Kluwer Health, Inc. All rights reserved.