We use cookies to improve your experience. By continuing to browse this site, you accept our cookie policy.×
Skip main navigation
Aging Health
Bioelectronics in Medicine
Biomarkers in Medicine
Breast Cancer Management
CNS Oncology
Colorectal Cancer
Concussion
Epigenomics
Future Cardiology
Future Medicine AI
Future Microbiology
Future Neurology
Future Oncology
Future Rare Diseases
Future Virology
Hepatic Oncology
HIV Therapy
Immunotherapy
International Journal of Endocrine Oncology
International Journal of Hematologic Oncology
Journal of 3D Printing in Medicine
Lung Cancer Management
Melanoma Management
Nanomedicine
Neurodegenerative Disease Management
Pain Management
Pediatric Health
Personalized Medicine
Pharmacogenomics
Regenerative Medicine

Advances in sampling and screening for chlamydia

    Jane S Hocking

    Centre for Women’s Health, Gender & Society, University of Melbourne, Victoria, Australia

    ,
    Rebecca Guy

    Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia

    ,
    Jennifer Walker

    Centre for Excellence in Rural Sexual Health, Rural Health Academic Centre, University of Melbourne, Victoria, Australia

    &
    Sepehr N Tabrizi

    * Author for correspondence

    Department of Molecular Microbiology, Royal Women’s Hospital; Department of Obstetrics & Gynecology, University of Melbourne & Murdoch Children’s Research Institute, Victoria, Australia.

    Published Online:https://doi.org/10.2217/fmb.13.3

    Chlamydia is the most commonly diagnosed bacterial sexually transmitted infection in the developed world, with diagnosis rates continuing to increase each year. As chlamydia is largely asymptomatic, screening and treatment is the main way to detect cases and reduce transmission. Recent advances in self-collected specimens and laboratory tests has made chlamydia screening easier to implement as well as possible in nonclinical settings. This review will discuss new approaches to specimen collection and how these have expanded opportunities for reaching target populations for chlamydia screening. Furthermore, it will discuss how advanced molecular microbiological methods can be used with self-collected specimens to further our knowledge of the epidemiology of chlamydia and the dynamics of transmission.

    References

    • Schachter J, Stephens RS. Biology of Chlamydia trachomatis. In: Sexually Transmitted Disease (4th Edition). Holmes KK, Sparling PF, Stamm WE et al. (Eds). McGraw-Hill, NY, USA, 555–574 (2008).
    • WHO. Global Incidence and Prevalence of Selected Curable Sexually Transmitted Infections. WHO, Switzerland (2012).
    • CDC. CDC Grand Rounds: chlamydia prevention: challenges and strategies for reducing disease burden and sequelae. MMWR Morb. Mortal. Wkly Rep.60(12),370–373 (2011).
    • Vickers DM, Osgood ND. Current crisis or artifact of surveillance: insights into rebound chlamydia rates from dynamic modelling. BMC Infect. Dis.10,70 (2010).
    • O’Rouke K, Fairley C, Samaranayake A, Collingnon P, Hocking J. Trends in chlamydia positivity over time among women in Melbourne Australia, 2003–2007. Sex. Transm. Dis.36(12),763–767 (2009).
    • Vodstrcil LA, Fairley CK, Fehler G et al. Trends in chlamydia and gonorrhea positivity among heterosexual men and men who have sex with men attending a large urban sexual health service in Australia, 2002–2009. BMC Infect. Dis.11,158 (2011).
    • Goetz H, Lindbaèck J, Ripa T, Malin Arneborn, Ramstedt K, Ekdahl K. Is the increase in notifications of Chlamydia trachomatis infections in Sweden the result of changes in prevalence, sampling frequency or diagnostic methods? Scand. J. Infect. Dis.34(1),28–34 (2002).
    • Eggleston E, Rogers SM, Turner CF et al.Chlamydia trachomatis infection among 15–35-year-olds in Baltimore, MD. Sex. Transm. Dis.38(8),743–749 (2011).
    • Fenton K, Copas A, Mitchell K et al. The acceptability of urinary LCR testing for Chlamydia trachomatis among participants in a probability sample survey of sexual attitudes and lifestyles. Sex. Transm. Infect.77(3),194–198 (2001).
    • 10  Hocking J, Willis J, Tabrizi S, Hellard M, Garland S, Fairley CK. A chlamydia prevalence survey of young women living in Melbourne, Victoria. Sex. Health3,235–240 (2006).
    • 11  Goulet V, de Barbeyrac B, Raherison S et al. Prevalence of Chlamydia trachomatis : results from the first national population-based survey in France. Sex. Transm. Infect.86(4),263–270 (2010).
    • 12  Klovstad H, Grjibovski A, Aavitsland P. Population based study of genital Chlamydia trachomatis prevalence and associated factors in Norway: a cross sectional study. BMC Infect. Dis.12,150 (2012).
    • 13  Datta SD, Torrone E, Kruszon-Moran D et al.Chlamydia trachomatis trends in the United States among persons 14 to 39 years of age, 1999–2008. Sex. Transm. Dis.39(2),92–96 (2012).
    • 14  Fine D, Thomas KK, Nakatsukasa-Ono W, Marrazzo J. Chlamydia positivity in women screened in family planning clinics: racial/ethnic differences and trends in the northwest U.S., 1997–2006. Public Health Rep.127(1),38–51 (2012).
    • 15  Rao GG, Bacon L, Evans J et al. Prevalence of Neisseria gonorrhoeae infection in young subjects attending community clinics in South London. Sex. Transm. Infect.84(2),117–121 (2008).
    • 16  Low N, Sterne JAC, Barlow D. Inequalities in rates of gonorrhoea and chlamydia between black ethnic groups in south east London: cross sectional study. Sex. Transm. Infect.77,15–20 (2001).
    • 17  Gotz HM, Veldhuijzen IK, Ossewaarde JM, de Zwart O, Richardus JH. Chlamydia trachomatis infections in multi-ethnic urban youth: a pilot combining STI health education and outreach testing in Rotterdam, Netherlands. Sex. Transm. Infect.82(2),148–152; discussion 152–143 (2006).
    • 18  Lewis D, Newton D, Guy R et al. The prevalence of Chlamydia trachomatis infection in Australia: a systematic review and meta-analysis. BMC Infect. Dis.12,113 (2012).
    • 19  Annan NT, Sullivan AK, Nori A et al. Rectal chlamydia – a reservoir of undiagnosed infection in men who have sex with men. Sex. Transm. Infect.85(3),176–179 (2009).
    • 20  Centers for Disease Control and Prevention. Clinic-based testing for rectal and pharyngeal Neisseria gonorrhoeae and Chlamydia trachomatis infections by community-based organizations – five cities, United States, 2007. MMWR Morb. Mortal. Wkly Rep.58(26),716–719 (2009).
    • 21  Kent CK, Chaw JK, Wong W et al. Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003. Clin. Infect. Dis.41(1),67–74 (2005).
    • 22  Peipert JF. Genital chlamydial infections. N. Engl. J. Med.349(25),2424–2430 (2003).
    • 23  Haggerty CL, Gottlieb SL, Taylor BD, Low N, Xu F, Ness RB. Risk of sequelae after Chlamydia trachomatis genital infection in women. J. Infect. Dis.201(Suppl. 2),S134–S155 (2010).
    • 24  van Valkengoed IGM, Morre SA, van den Brule AJC, Meijer CJLM, Bouter LM, Boeke AJP. Overestimation of complication rates in evaluations of Chlamydia trachomatis screening programmes – implications for cost–effectiveness analyses. Int. J. Epidemiol.33,416–425 (2004).
    • 25  Oakeshott P, Kerry S, Aghaizu A et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ340,c1642 (2010).
    • 26  Wiesenfeld HC, Hillier SL, Krohn MA et al. Lower genital tract infection and endometritis: insight into subclinical pelvic inflammatory disease. Obstet. Gynecol.100(3),456–463 (2002).
    • 27  Walker J, Fairley C, Bradshaw C et al.Chlamydia trachomatis incidence and re-infection among young women - behavioural and microbiological characteristics. PLoS One7(5),e37778 (2012).
    • 28  LaMontagne D, Baster K, Emmett L et al. Incidence and reinfection rates of genital chlamydia infection among women aged 16 to 24 years attending general practice, family planning and genitourinary medicine clinics in England: a prospective cohort study by the Chlamydia Recall Study Advisory Group. Sex. Transm. Infect.83,282–303 (2007).
    • 29  Batteiger BE, Tu W, Ofner S et al. Repeated Chlamydia trachomatis genital infections in adolescent women. J. Infect. Dis.201(1),42–51 (2010).
    • 30  Hosenfeld CB, Workowski KA, Berman S et al. Repeat infection with chlamydia and gonorrhea among females: a systematic review of the literature. Sex. Transm. Dis.36(8),478–489 (2009).
    • 31  Handsfield HH. Questionning azithromycin for chlamydial infection. Sex. Transm. Dis.38(11),1028–1029 (2011).
    • 32  Horner P. The case for further treatment studies of uncomplicated genital Chlamydia trachomatis infection. Sex. Transm. Infect.82,340–343 (2006).
    • 33  Horner PJ. Azithromycin antimicrobial resistance and genital Chlamydia trachomatis infection: duration of therapy may be the key to improving efficacy. Sex. Transm. Infect.88(3),154–156 (2012).
    • 34  Sandoz KM, Rockey DD. Antibiotic resistance in Chlamydiae. Future Microbiol.5(9),1427–1442 (2010).
    • 35  Wang SA, Papp JR, Stamm WE, Peeling RW, Martin DH, Holmes KK. Evaluation of antimicrobial resistance and treatment failures for Chlamydia trachomatis : a meeting report. J. Infect. Dis.191(6),917–923 (2005).
    • 36  Golden MR, Whittington WL, Handsfield HH et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhoea or chlamydial infection. N. Engl. J. Med.352,676–685 (2005).
    • 37  Schwebke J, Rompalo A, Taylor S et al. Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens – a randomized clinical trial. Clin. Infect. Dis.52(2),163–170 (2011).
    • 38  Tabrizi SN, Chen S, Borg AJ et al. Patient-administered tampon-collected genital cells in the assessment of Chlamydia trachomatis infection using polymerase chain reaction. Sex. Transm. Dis.23(6),494–497 (1996).
    • 39  Goldenberg S, Shoveller J, Koehoorn M, Ostry A. Barriers to STI testing among youth in a Canadian oil and gas community. Health Place14(4),718–729 (2008).
    • 40  Kimmitt PT, Tabrizi SN, Crosatti M et al. Pilot study of the utility and acceptability of tampon sampling for the diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis infections by duplex realtime polymerase chain reaction in United Kingdom sex workers. Int. J. STD AIDS21(4),279–282 (2010).
    • 41  Bradshaw CS, Pierce LI, Tabrizi SN, Fairley CK, Garland SM. Screening injecting drug users for sexually transmitted infections and blood borne viruses using street outreach and self collected sampling. Sex. Transm. Infect.81(1),53–58 (2005).
    • 42  CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR Morb. Mortal. Wkly Rep.59(RR-12),1–110 (2010).
    • 43  European Centre for Disease Prevention and Control Guidance. Chlamydia Control in Europe. European Centre for Disease Prevention and Control, Sweden (2009).
    • 44  Harris M, Bailey L, Bridges-Webb C, Ackermann E. Guidelines for Preventive Activities in General Practice (the Red Book) (8th Edition). Royal Australian College of General Practitioners, Australia (2012).
    • 45  Low N, Cassell JA, Spencer B et al. Chlamydia control activities in Europe: cross-sectional survey. Eur. J. Pub. Health22(4),556–561 (2011).
    • 46  Low N, Egger M. What should we do about screening for genital chlamydia? Int. J. Epidemiol.31,891–893 (2002).
    • 47  Low N, Bender N, Nartey L, Shang A, Stephenson JM. Effectiveness of chlamydia screening: systematic review. Int. J. Epidemiol.38,435–448 (2009).
    • 48  van den Broek IVF, van Bergen JEAM, Brouwers EEHG et al. Effectiveness of yearly, register based screening for chlamydia in the Netherlands: controlled trial with randomised stepped wedge implementation. BMJ345,e4316 (2012).
    • 49  Jensen BL, Hoff G, Weismann K. A comparison of an enzyme immunoassay and cell culture for detection of Chlamydia trachomatis in genito-urinary specimens. Sex. Transm. Dis.15(2),123–126 (1988).
    • 50  Fletcher RH, Fletcher SW. Clinical Epidemiology: The Essentials. Lippincott, Williams and Wilkins, PA, USA (2005).
    • 51  Hadgu A, Sternberg M. Reproducibility and specificity concerns associated with nucleic acid amplification tests for detecting Chlamydia trachomatis. Eur. J. Clin. Microbiol. Infect. Dis.28(1),9–15 (2009).
    • 52  Hadgu A. Issues in Chlamydia trachomatis testing by nucleic acid amplification test. J. Infect. Dis.193(9),1335–1336; author reply 1338–1339 (2006).
    • 53  Hadgu A, Dendukuri N, Hilden J. Evaluation of nucleic acid amplification tests in the absence of a perfect gold-standard test: a review of the statistical and epidemiologic issues. Epidemiology16(5),604–612 (2005).
    • 54  Schachter J, Stamm WE, Quinn TC. Discrepant analysis and screening for Chlamydia trachomatis. Lancet351(9097),217–218 (1998).
    • 55  Hilden J. Discrepant analysis – or behaviour? Lancet350(9082),902 (1997).
    • 56  Miller WC. Bias in discrepant analysis: when two wrongs don’t make a right. J. Clin. Epidemiol.51(3),219–231 (1998).
    • 57  Hadgu A, Dendukuri N, Wang L. Evaluation of screening tests for detecting Chlamydia trachomatis : bias associated with the patient-infected-status algorithm. Epidemiology23(1),72–82 (2012).
    • 58  US FDA. Establishing the Performance Characteristics of In Vitro Diagnostic Devices for Chlamydia trachomatis and/or Neisseria gonorrhoea: Screening and Diagnostic Testing. US FDA, MD, USA (2011).
    • 59  Van Der Pol B, Liesenfeld O, Williams JA et al. Performance of the cobas CT/NG test compared to the Aptima AC2 and Viper CTQ/GCQ assays for detection of Chlamydia trachomatis and Neisseria gonorrhoeae. J. Clin. Microbiol.50(7),2244–2249 (2012).
    • 60  Gronowski AM, Copper S, Baorto D, Murray PR. Reproducibility problems with the Abbott laboratories LCx assay for Chlamydia trachomatis and Neisseria gonorrhoeae. J. Clin. Microbiol.38(6),2416–2418 (2000).
    • 61  Culler EE, Caliendo AM, Nolte FS. Reproducibility of positive test results in the BDProbeTec ET system for detection of Chlamydia trachomatis and Neisseria gonorrhoeae. J. Clin. Microbiol.41(8),3911–3914 (2003).
    • 62  Castriciano S, Luinstra K, Jang D et al. Accuracy of results obtained by performing a second ligase chain reaction assay and PCR analysis on urine samples with positive or near-cutoff results in the LCx test for Chlamydia trachomatis. J. Clin. Microbiol.40(7),2632–2634 (2002).
    • 63  Boel CHE, van Herk CMC, Berretty PJM, Onland GHW, van den Brule AJC. Evaluation of conventional and real-time PCR assays using two targets for confirmation of results of the COBAS AMPLICOR Chlamydia trachomatis/Neisseria gonorrhoeae test for detection of Neisseria gonorrhoeae in clinical samples. J. Clin. Microbiol.43(5),2231–2235 (2005).
    • 64  Verkooyen RP, Noordhoek GT, Klapper PE et al. Reliability of nucleic acid amplification methods for detection of Chlamydia trachomatis in urine: results of the first international collaborative quality control study among 96 laboratories. J. Clin. Microbiol.41(7),3013–3016 (2003).
    • 65  Schachter J, Chow JM, Howard H, Bolan G, Moncada J. Detection of Chlamydia trachomatis by nucleic acid amplification testing: our evaluation suggests that CDC-recommended approaches for confirmatory testing are ill-advised. J. Clin. Microbiol.44(7),2512–2517 (2006).
    • 66  Morre SA, Sillekens PT, Jacobs MV et al. Monitoring of Chlamydia trachomatis infections after antibiotic treatment using RNA detection by nucleic acid sequence based amplification. Mol. Pathol.51(3),149–154 (1998).
    • 67  Lewis N, Dube G, Carter C et al. Chlamydia and gonorrhoea contamination of clinic surfaces. Sex. Transm. Infect.88(6),418–421 (2012).
    • 68  Renault CA, Israelski DM, Levy V, Fujikawa BK, Kellogg TA, Klausner JD. Time to clearance of Chlamydia trachomatis ribosomal RNA in women treated for chlamydial infection. Sex. Health8(1),69–73 (2011).
    • 69  Dukers-Muijrers NHTM, Morre SA, Speksnijder A, van der Sande MAB, Hoebe CJPA. Chlamydia trachomatis test-of-cure cannot be based on a single highly sensitive laboratory test taken at least 3 weeks after treatment. PLoS One, 7(3),e34108 (2012).
    • 70  Ripa T, Nilsson P. A variant of Chlamydia trachomatis with deletion in cryptic plasmid: implications for use of PCR diagnostic tests. Eurosurveillance11(11),E061109.2. (2006).
    • 71  Ripa T, Nilsson P. A Chlamydia trachomatis strain with a 377-bp deletion in the cryptic plasmid causing falsenegative nucleic acid amplification tests. Sex. Transm. Dis.34,255–256 (2007).
    • 72  Soderblom T, Blaxhult A, Fredlund H, Herrmann B. Impact of a genetic variant of Chlamydia trachomatis on national detection rates in Sweden. Eurosurveillance11(12),E061207.1. (2006).
    • 73  Kangas I, Andersen B, Olsen F, Moller J, Ostergaard L. Psychosocial impact of Chlamydia trachomatis testing in general practice. Br. J. Gen. Pract.56,587–593 (2006).
    • 74  France C, Thomas K, Slack R, James N. Psychosocial impacts of chlamydia testing are important. BMJ322,1245 (2001).
    • 75  Duncan B, Hart G, Scoular A, Bigrigg A. Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis : implication for screening. BMJ322,195–199 (2001).
    • 76  Pavlin N, Gunn JM, Parker R, Fairley CK, Hocking J. Implementing chlamydia screening: what do women think? A systematic review of the literature. BMC Public Health6,221–231 (2006).
    • 77  Pasternack R, Vuorinen P, Miettinen A. Evaluation of the Gen-Probe Chlamydia trachomatis transcription-mediated amplification assay with urine specimens from women. J. Clin. Microbiol.35(3),676–678 (1997).
    • 78  Ostergaard L, Moller JK, Andersen B, Olesen F. Diagnosis of urogenital Chlamydia trachomatis infection in women based on mailed samples obtained at home: multipractice comparative study. BMJ313(7066),1186–1189 (1996).
    • 79  Chernesky MA, Lee H, Schachter J et al. Diagnosis of Chlamydia trachomatis urethral infection in symptomatic and asymptomatic men by testing first-void urine in a ligase chain reaction assay. J. Infect. Dis.170(5),1308–1311 (1994).
    • 80  Chernesky MA, Jang D, Lee H et al. Diagnosis of Chlamydia trachomatis infections in men and women by testing first-void urine by ligase chain reaction. J. Clin. Microbiol.32(11),2682–2685 (1994).
    • 81  Bianchi A, Scieux C, Brunat N et al. An evaluation of the polymerase chain reaction amplicor Chlamydia trachomatis in male urine and female urogenital specimens. Sex. Transm. Dis.21(4),196–200 (1994).
    • 82  Williams J, van der Pol B, Rosenberger J, Ott M. Evaluation of the UriSwab sponge collection device for the detection of Chlamydia trachomatis in urine. Presented at: International Society of STD Research. London, UK, July 2009.
    • 83  Garrow SC, Smith DW, Harnett GB. The diagnosis of chlamydia, gonorrhoea and trichomonas infections by self obtained low vaginal swabs , in remote northern Australian clinical practice. Sex. Transm. Infect.78(4),278–281 (2002).
    • 84  Knox J, Tabrizi SN, Miller P et al. Evaluation of self-collected samples in contrast to practitioner-collected samples for detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis by polymerase chain reaction among women living in remote areas. Sex. Transm. Dis.29(11),647–654 (2002).
    • 85  Schachter J, McCormack WM, Chernesky MA et al. Vaginal swabs are appropriate specimens for diagnosis of genital chlamydia tract infection with Chlamydia trachomatis. J. Clin. Microbiol.41(8),3784–3789 (2003).
    • 86  Hsieh Y-H, Howell MR, Gaydos JC, McKee KT, Quinn TC, Gaydos CA. Preference among female army recruits for use of self-administered vaginal swabs or urine to screen for Chlamydia trachomatis genital infections. Sex. Transm. Dis.30(10),769–773 (2003).
    • 87  Chernesky MA, Hook EW, 3rd, Martin DH et al. Women find it easy and prefer to collect their own vaginal swabs to diagnose Chlamydia trachomatis or Neisseria gonorrhoeae infections. Sex. Transm. Dis.32(12),729–733 (2005).
    • 88  Schachter J, Chernesky MA, Willis DE et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae : results from a multicenter evaluation of the APTIMA assays for both infections. Sex. Transm. Dis.32(12),725–728 (2005).
    • 89  Chandeying V, Lamlertkittikul S, Skov S. A comparison of first-void urine, self-administered low vaginal swab, self-inserted tampon, and endocervical swab using PCR tests for the detection of infection with Chlamydia trachomatis. Sex. Health1(1),51–54 (2004).
    • 90  Wiesenfeld HC, Lowry DL, Heine RP et al. Self-collection of vaginal swabs for the detection of chlamydia, gonorrhea, and trichomoniasis: opportunity to encourage sexually transmitted disease testing among adolescents. Sex. Transm. Dis.28(6),321–325 (2001).
    • 91  Doshi JS, Power J, Allen E. Acceptability of chlamydia screening using self-taken vaginal swabs. Int. J. STD AIDS19(8),507–509 (2008).
    • 92  Hoebe CJPA, Rademaker CW, Brouwers EEHG, ter Waarbeek HLG, van Bergen JEAM. Acceptability of self-taken vaginal swabs and first-catch urine samples for the diagnosis of urogenital Chlamydia trachomatis and Neisseria gonorrhoeae with an amplified DNA assay in young women attending a public health sexually transmitted disease clinic. Sex. Transm. Dis.33(8),491–495 (2006).
    • 93  Alary M, Poulin C, Bouchard C et al. Evaluation of a modified sanitary napkin as a sample self-collection device for the detection of genital chlamydial infection in women. J. Clin. Microbiol.39(7),2508–2512 (2001).
    • 94  Tabrizi SN, Paterson B, Fairley CK, Bowden FJ, Garland SM. A self-administered technique for the detection of sexually transmitted diseases in remote communities. J. Infect. Dis.176(1),289–292 (1997).
    • 95  Bowden FJ, Paterson BA, Tabrizi SN, Fairley CK, Garland SM. Using self-administered tampons to diagnose STDs. AIDS Patient Care STDs12(1),29–32 (1998).
    • 96  Tabrizi SN, Paterson BA, Fairley CK, Bowden FJ, Garland SM. Comparison of tampon and urine as self-administered methods of specimen collection in the detection of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis in women. Int. J. STD AIDS9(6),347–349 (1998).
    • 97  Tabrizi SN, Fairley CK, Cehn S et al. Evaluation of patient-administered tampon specimens for Chlamydia trachomatis and Neisseria gonorrhoeae. Sex. Transm. Dis.27(3),133–137 (2000).
    • 98  Garland SM, Tabrizi SN. Diagnosis of sexually transmitted infections (STI) using self-collected non-invasive specimens. Sex. Health1(2),121–126 (2004).
    • 99  Tabrizi S, Chen S, Fairley C et al. Tampon-collected genital cells in the detection of Chlamydia trachomatis by polymerase chain reaction. J. Infect. Dis.168(3),796–797 (1993).
    • 100  Smith BL, Cummings MC, Benes S, McCormack WM. Evaluation of vaginal tampons for collection of specimens for detection of chlamydial infection. Sex. Transm. Dis.23(2),127–130 (1996).
    • 101  Chai SJ, Aumakhan B, Barnes M et al. Internet-based screening for sexually transmitted infections to reach nonclinic populations in the community: risk factors for infection in men. Sex. Transm. Dis.37(12),756–763 (2010).
    • 102  Alexander S, Ison C, Parry J et al. Self-taken pharyngeal and rectal swabs are appropriate for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae in asymptomatic men who have sex with men. Sex. Transm. Infect.84(6),488–492 (2008).
    • 103  Moncada J, Schachter J, Liska S, Shayevich C, Klausner JD. Evaluation of self-collected glans and rectal swabs from men who have sex with men for detection of Chlamydia trachomatis and Neisseria gonorrhoeae by use of nucleic acid amplification tests. J. Clin. Microbiol.47(6),1657–1662 (2009).
    • 104  van der Helm JJ, Hoebe CJPA, van Rooijen MS et al. High performance and acceptability of self-collected rectal swabs for diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in men who have sex with men and women. Sex. Transm. Dis.36(8),493–497 (2009).
    • 105  Twin J, Moore EE, Garland SM et al.Chlamydia trachomatis genotypes among men who have sex with men in Australia. Sex. Transm. Dis.38(4),279–285 (2011).
    • 106  Freeman A, Bernstein K, Kohn R, Philip S, Rauch L, Klausner J. Evaluation of self-collected versus clinician-collected swabs for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae pharyngeal infection among men who have sex with men. Sex. Transm. Dis.38(11),1036–1039 (2011).
    • 107  Tabrizi S. Diagnosis of Chlamydia trachomatis using self collected non-invasive specimens – the Australian experience. Microbiol. Aust.28(1),10–12 (2007).
    • 108  Cook RL, Hutchison SL, Ostergaard L, Braithwaite RS, Ness RB. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann. Intern. Med.142(11),914–925 (2005).
    • 109  Marrazzo JM, Scholes D. Acceptability of urine-based screening for Chlamydia trachomatis in asymptomatic young men: a systematic review. Sex. Transm. Dis.35(11 Suppl.),S28–S33 (2008).
    • 110  Serlin M, Shafer M-A, Tebb K et al. What sexually transmitted disease screening method does the adolescent prefer? Adolescents’ attitudes toward first-void urine, self-collected vaginal swab, and pelvic examination. Arch. Pediatr. Adolesc. Med.156(6),588–591 (2002).
    • 111  Morre SA, van Valkengoed IG, de Jong A et al. Mailed, home-obtained urine specimens: a reliable screening approach for detecting asymptomatic Chlamydia trachomatis infections. J. Clin. Microbiol.37(4),976–980 (1999).
    • 112  van Dommelen L, Dukers-Muijrers N, van Tiel FH, Brouwers EEHG, Hoebe CJPA. Evaluation of one-sample testing of self-obtained vaginal swabs and first catch urine samples separately and in combination for the detection of Chlamydia trachomatis by two amplified DNA assays in women visiting a sexually transmitted disease clinic. Sex. Transm. Dis.38(6),533–535 (2011).
    • 113  Skidmore S, Horner P, Herring A et al. Vulvovaginal-swab or first-catch urine specimen to detect Chlamydia trachomatis in women in a community setting? J. Clin. Microbiol.44(12),4389–4394 (2006).
    • 114  Hook EW 3rd, Smith K, Mullen C et al. Diagnosis of genitourinary Chlamydia trachomatis infections by using the ligase chain reaction on patient-obtained vaginal swabs. J. Clin. Microbiol.35(8),2133–2135 (1997).
    • 115  Geisler WM. Diagnosis and management of uncomplicated Chlamydia trachomatis infections in adolescents and adults: summary of evidence reviewed for the 2010 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin. Infect. Dis.53(Suppl. 3),S92–S98 (2011).
    • 116  Gaydos CA, Farshy C, Barnes M et al. Can mailed swab samples be dry-shipped for the detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis by nucleic acid amplification tests? Diagn. Microbiol. Infect. Dis.73(1),16–20 (2012).
    • 117  Alexander S, Martin I, Ison C. Confirming the Chlamydia trachomatis status of referred rectal specimens. Sex. Transm. Infect.83(4),327–329 (2007).
    • 118  Schachter J, Moncada J, Liska S, Shayevich C, Klausner JD. Nucleic acid amplification tests in the diagnosis of chlamydial and gonococcal infections of the oropharynx and rectum in men who have sex with men. Sex. Transm. Dis.35(7),637–642 (2008).
    • 119  Tipple C, Hill SC, Smith A. Is screening for pharyngeal Chlamydia trachomatis warranted in high-risk groups? Int. J. STD AIDS21(11),770–771 (2010).
    • 120  Peters RPH, Nijsten N, Mutsaers J, Jansen CL, Morre SA, van Leeuwen AP. Screening of oropharynx and anorectum increases prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infection in female STD clinic visitors. Sex. Transm. Dis.38(9),783–787 (2011).
    • 121  Royal Australasian College of Physicians. Sexually Transmitted Infection Testing Guidelines for Men Who Have Sex With Men 2010. Royal Australasian College of Physicians, New Zealand (2010).
    • 122  Ostergaard L, Andersen B, Olesen F, Moller JK. Efficacy of home sampling for screening of Chlamydia trachomatis : randomised study. BMJ317(7150),26–27 (1998).
    • 123  Pannekoek Y, Westenberg SM, de Vries J et al. PCR assessment of Chlamydia trachomatis infection of semen specimens processed for artificial insemination. J. Clin. Microbiol.38(10),3763–3767 (2000).
    • 124  Rodger A, Hocking J, Warren R, Snow J, Aboagye-Kwarteng T, Crofts N. Prevalence of genital Chlamydia trachomatis in male clients of female sex workers in Melbourne. Venereology12(4),129–132 (1999).
    • 125  Tabrizi S, Skov S, Chandeying V, Norpech J, Garland S. Prevalence of sexually transmitted infections among clients of female commercial sex workers in Thailand. Sex. Transm. Dis.27(6),358–362 (2000).
    • 126  Shafer M-A, Moncada J, Boyer CB, Betsinger K, Flinn SD, Schachter J. Comparing first-void urine specimens, self-collected vaginal swabs, and endocervical specimens to detect Chlamydia trachomatis and Neisseria gonorrhoeae by a nucleic acid amplification test. J. Clin. Microbiol.41(9),4395–4399 (2003).
    • 127  Richardson E, Sellors JW, Mackinnon S et al. Prevalence of Chlamydia trachomatis infections and specimen collection preference among women, using self-collected vaginal swabs in community settings. Sex. Transm. Dis.30(12),880–885 (2003).
    • 128  Tilson EC, Sanchez V, Ford CL et al. Barriers to asymptomatic screening and other STD services for adolescents and young adults: focus group discussions. BMC Public Health4,21 (2004).
    • 129  Warr D, Hillier L. “That’s the problem with living in a small town”: privacy and sexual health issues for young rural people. Aust. J. Rural Health5(3),132–139 (1997).
    • 130  Wang LY, Burstein GR, Cohen DA. An economic evaluation of a school-based sexually transmitted disease screening program. Sex. Transm. Dis.29(12),737–745 (2002).
    • 131  Nsuami M, Cohen DA. Participation in a school-based sexually transmitted disease screening program. Sex. Transm. Dis.27(8),473–479 (2000).
    • 132  Burstein GR, Waterfield G, Joffe A, Zenilman JM, Quinn TC, Gaydos CA. Screening for gonorrhea and chlamydia by DNA amplification in adolescents attending middle school health centers. Opportunity for early intervention. Sex. Transm. Dis.25(8),395–402 (1998).
    • 133  Braun RA, Provost JM. Bridging the gap: using school-based health services to improve chlamydia screening among young women. Am. J. Public Health100(9),1624–1629 (2010).
    • 134  Bowden FJ, O’Keefe EJ, Primrose R, Currie MJ. Sexually transmitted infections, blood-borne viruses and risk behaviour in an Australian senior high school population – the SHLiRP study. Sex. Health2(4),229–236 (2005).
    • 135  Debattista J, Martin P, Jamieson J et al. Detection of Chlamydia trachomatis in an Australian high school student population. Sex. Transm. Infect.78(3),194–197 (2002).
    • 136  Barry PM, Scott KC, McCright J et al. Stay in school? Results of a sexually transmitted diseases screening program in San Francisco high schools-2007. Sex. Transm. Dis.35(6),550–552 (2008).
    • 137  Kent CK, Branzuela A, Fischer L, Bascom T, Klausner JD. Chlamydia and gonorrhea screening in San Francisco high schools. Sex. Transm. Dis.29(7),373–375 (2002).
    • 138  Asbel LE, Newbern EC, Salmon M, Spain CV, Goldberg M. School-based screening for Chlamydia trachomatis and Neisseria gonorrhoeae among Philadelphia public high school students. Sex. Transm. Dis.33(10),614–620 (2006).
    • 139  Cohen DA, Nsuami M, Etame RB et al. A school-based chlamydia control program using DNA amplification technology. Pediatrics101(1),E1 (1998).
    • 140  Joffe A, Rietmeijer CA, Chung S-E et al. Screening asymptomatic adolescent men for Chlamydia trachomatis in school-based health centers using urine-based nucleic acid amplification tests. Sex. Transm. Dis.35(Suppl. 11),S19–s23 (2008).
    • 141  Gaydos CA, Hsieh YH, Galbraith JS, Barnes M, Waterfield G, Stanton B. Focus-on-Teens, sexual risk-reduction intervention for high-school adolescents: impact on knowledge, change of risk-behaviours, and prevalence of sexually transmitted diseases. Int. J. STD AIDS19(10),704–710 (2008).
    • 142  Gold J, Hocking J, Hellard M. The feasibility of recruiting young men in rural areas from community football clubs for STI screening. Aust. NZ J. Public Health31(3),243–246 (2007).
    • 143  Kong FYS, Hocking JS, Link CK, Chen MY, Hellard ME. Sex and sport: chlamydia screening in rural sporting clubs. BMC Infect. Dis.9,73 (2009).
    • 144  Debattista J, Clementson C, Mason D et al. Screening for Neisseria gonorrhoeae and Chlamydia trachomatis at entertainment venues among men who have sex with men. Sex. Transm. Dis.29(4),216–221 (2002).
    • 145  Debattista J, Dwyer J, Orth D, Lister G, Patten J. Community screening for Neisseria gonorrhoeae and Chlamydia trachomatis among patrons of sex-on-premises venues: two years later. Venereology13(3),105–109 (2000).
    • 146  Lister N, Smith A, Tabrizi S et al. Screening for Neisseria gonorrhoeae and Chlamydia trachomatis in men who have sex with men at male-only saunas. Sex. Transm. Dis.30(12),886–889 (2003).
    • 147  Lambert NL, Fisher M, Imrie J et al. Community based syphilis screening: feasibility, acceptability, and effectiveness in case finding. Sex. Transm. Infect.81(3),213–216 (2005).
    • 148  Mayer KH, Ducharme R, Zaller ND et al. Unprotected sex, underestimated risk, undiagnosed HIV and sexually transmitted diseases among men who have sex with men accessing testing services in a New England bathhouse. J. Acquir. Immune Defic. Syndr.59(2),194–198 (2012).
    • 149  Buhrer-Skinner M, Muller R, Menon A, Gordon R. Novel approach to an effective community-based chlamydia screening program within the routine operation of a primary healthcare service. Sex. Health6(1),51–56 (2009).
    • 150  Martin L, Freedman E, Burton L et al. The C-project: use of self-collection kits to screen for Chlamydia trachomatis in young people in a community-based health promotion project. Sex. Health6(2),157–162 (2009).
    • 151  Cwikel JG, Lazer T, Press F, Lazer S. Sexually transmissible infections among female sex workers: an international review with an emphasis on hard-to-access populations. Sex. Health5(1),9–16 (2008).
    • 152  Morton AN, Wakefield T, Tabrizi SN, Garland SM, Fairley CK. An outreach programme for sexually transmitted infection screening in street sex workers using self-administered samples. Int. J. STD AIDS10(11),741–743 (1999).
    • 153  Mak RP, Van Renterghem L, Traen A. Chlamydia trachomatis in female sex workers in Belgium: 1998–2003. Sex. Transm. Infect.81(1),89–90 (2005).
    • 154  Macauley S, Creighton S. Testing commercial sex workers for chlamydia and gonorrhoea on outreach. Sex. Transm. Infect.85(3),231–232 (2009).
    • 155  Van Leeuwen JM, Rietmeijer CA, LeRoux T, White R, Petersen J. Reaching homeless youths for Chlamydia trachomatis and Neisseria gonorrhoeae screening in Denver, Colorado. Sex. Transm. Infect.78(5),357–359 (2002).
    • 156  Auerswald CL, Sugano E, Ellen JM, Klausner JD. Street-based STD testing and treatment of homeless youth are feasible, acceptable and effective. J. Adolesc. Health38(3),208–212 (2006).
    • 157  Grimley DM, Annang L, Lewis I et al. Sexually transmitted infections among urban shelter clients. Sex. Transm. Dis.33(11),666–669 (2006).
    • 158  Bradshaw CS, Pierce LI, Tabrizi SN, Fairley CK, Garland SM. Screening injecting drug users for sexually transmitted infections and blood borne viruses using street outreach and self collected sampling. Sex. Transm. Infect.81(1),53–58 (2005).
    • 159  Peterman TA, Newman DR, Goldberg M et al. Screening male prisoners for Chlamydia trachomatis : impact on test positivity among women from their neighborhoods who were tested in family planning clinics. Sex. Transm. Dis.36(7),425–429 (2009).
    • 160  Mertz KJ, Schwebke JR, Gaydos CA, Beidinger HA, Tulloch SD, Levine WC. Screening women in jails for chlamydial and gonococcal infection using urine tests: feasibility, acceptability, prevalence, and treatment rates. Sex. Transm. Dis.29(5),271–276 (2002).
    • 161  Davies SC, Karagiannis T, Headon V, Wiig R, Duffy J. Prevalence of genital chlamydial infection among a community sample of young international backpackers in Sydney, Australia. Int. J. STD AIDS22(3),160–164 (2011).
    • 162  Bloom MS, Hu Z, Gaydos JC, Brundage JF, Tobler SK. Incidence rates of pelvic inflammatory disease diagnoses among Army and Navy recruits potential impacts of chlamydia screening policies. Am. J. Prev. Med.34(6),471–477 (2008).
    • 163  Greenland KE, Op de Coul ELM, van Bergen JEAM et al. Acceptability of the internet-based chlamydia screening implementation in The Netherlands and insights into nonresponse. Sex. Transm. Dis.38(6),467–474 (2011).
    • 164  Gaydos CA, Dwyer K, Barnes M et al. Internet-based screening for Chlamydia trachomatis to reach non-clinic populations with mailed self-administered vaginal swabs. Sex. Transm. Dis.33(7),451–457 (2006).
    • 165  Masek BJ, Arora N, Quinn N et al. Performance of three nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria gonorrhoeae by use of self-collected vaginal swabs obtained via an internet-based screening program. J. Clin. Microbiol.47(6),1663–1667 (2009).
    • 166  Gaydos CA, Barnes M, Aumakhan B et al.Chlamydia trachomatis age-specific prevalence in women who used an internet-based self-screening program compared to women who were screened in family planning clinics. Sex. Transm. Dis.38(2),74–78 (2011).
    • 167  Jenkins WD, Rabins C, Barnes M, Agreda P, Gaydos C. Use of the internet and self-collected samples as a sexually transmissible infection intervention in rural Illinois communities. Sex. Health8(1),79–85 (2011).
    • 168  Novak D, Novak M. Use of the internet for home testing for Chlamydia trachomatis in Sweden: who are the users? Int. J. STD AIDS23(2),83–87 (2012).
    • 169  Shih SL, Graseck AS, Secura GM, Peipert JF. Screening for sexually transmitted infections at home or in the clinic? Curr. Opin. Infect. Dis.24(1),78–84 (2011).
    • 170  Baraitser P, Pearce V, Holmes J, Horne N, Boynton PM. Chlamydia testing in community pharmacies: evaluation of a feasibility pilot in south east London. Qual. Saf. Health Care16(4),303–307 (2007).
    • 171  Brabin L, Thomas G, Hopkins M, O’Brien K, Roberts SA. Delivery of chlamydia screening to young women requesting emergency hormonal contraception at pharmacies in Manchester, UK: a prospective study. BMC Womens Health9,7 (2009).
    • 172  Anderson C, Thornley T. A pharmacy-based private chlamydia screening programme: results from the first 2 years of screening and treatment. Int.J. Clin. Pharm.33(1),88–91 (2011).
    • 173  Health Protection Agency. Annual Report of the National Chlamydia Screening Programme in England 2006/7. National Chlamydia Screening Programme, UK (2007).
    • 174  Department of Health. Boots Selected to Provide Free Chlamydia Screening for 16–24 Year Olds Across the Capital. Department of Health, UK (2005).
    • 175  Sexual Health Society of Victoria. National Management Guidelines for Sexually Transmissible Infections. Sexual Health Society of Victoria, Australia (2008).
    • 176  Guy R, Hocking J, Low N et al. Interventions to increase rescreening for repeat chlamydial infection. Sex. Transm. Dis.39(2),136–146 (2012).
    • 177  Mukenge-Tshibaka L, Alary M, Lowndes CM et al. Syndromic versus laboratory-based diagnosis of cervical infections among female sex workers in Benin: implications of nonattendance for return visits. Sex. Transm. Dis.29(6),324–330 (2002).
    • 178  Vickerman P, Watts C, Alary M, Mabey D, Peeling RW. Sensitivity requirements for the point of care diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in women. Sex. Transm. Infect.79(5),363–367 (2003).
    • 179  Guy R, Ward JS, Smith KS et al. The impact of sexually transmissible infection programs in remote Aboriginal communities in Australia: a systematic review. Sex. Health9(3),205–212 (2012).
    • 180  Gift TL, Pate MS, Hook EW 3rd, Kassler WJ. The rapid test paradox: when fewer cases detected lead to more cases treated: a decision analysis of tests for Chlamydia trachomatis.Sex. Transm. Dis.26(4),232–240 (1999).
    • 181  Hislop J, Quayyum Z, Flett G, Boachie C, Fraser C, Mowatt G. Systematic review of the clinical effectiveness and cost–effectiveness of rapid point-of-care tests for the detection of genital chlamydia infection in women and men. Health Technol. Assess.14(29),1–97, iii–iv (2010).
    • 182  Huang W, Gaydos CA, Barnes MR, Jett-Goheen M, Blake DR. Comparative effectiveness of a rapid point-of-care test for detection of Chlamydia trachomatis among women in a clinical setting. Sex. Transm. Infect. doi:10.1136/sextrans-2011-050355 (2012) (Epub ahead of print).
    • 183  Bowden FJ. Reappraising the value of urine leukocyte esterase testing in the age of nucleic acid amplification. Sex. Transm. Dis.25(6),322–326 (1998).
    • 184  van Dommelen L, van Tiel FH, Ouburg S et al. Alarmingly poor performance in Chlamydia trachomatis point-of-care testing. Sex. Transm. Infect.86(5),355–359 (2010).
    • 185  Nadala E-C, Goh BT, Magbanua J-P et al. Performance evaluation of a new rapid urine test for chlamydia in men: prospective cohort study. BMJ339,b2655 (2009).
    • 186  GeneXpert Technology: a look to the future. Presented at: Association for Molecular Pathology Annual Meeting, Grapevine, TX, USA, 17–19 November 2011.
    • 187  Goldenberg SD, Finn J, Sedudzi E, White JA, Tong CYW. Performance of the GeneXpert CT/NG assay compared to that of the Aptima AC2 Assay for detection of rectal Chlamydia trachomatis and Neisseria gonorrhoeae by use of residual aptima samples. J. Clin. Microbiol.50(12),3867–3869 (2012).
    • 188  Peeling RW. Applying new technologies for diagnosing sexually transmitted infections in resource-poor settings. Sex. Transm. Infect.87(Suppl. 2),ii28–ii30 (2011).
    • 189  Piepenburg O, Williams CH, Stemple DL, Armes NA. DNA detection using recombination proteins. PLoS Biol.4(7),e204 (2006).
    • 190  Zhang Y, Agreda P, Kelley S, Gaydos C, Geddes CD. Development of a microwave-accelerated metal-enhanced fluorescence 40 second, <100 cfu/ml point of care assay for the detection of Chlamydia trachomatis. IEEE Trans. Biomed. Eng.58(3),781–784 (2011).
    • 191  Christerson L, Ruettger A, Gravningen K, Ehricht R, Sachse K, Herrmann B. High-resolution genotyping of Chlamydia trachomatis by use of a novel multilocus typing DNA microarray. J. Clin. Microbiol.49(8),2838–2843 (2011).
    • 192  Gravningen K, Christerson L, Furberg A-S et al. Multilocus sequence typing of genital Chlamydia trachomatis in Norway reveals multiple new sequence types and a large genetic diversity. PLoS One7(3),e34452 (2012).
    • 193  Stevens MP, Tabrizi SN, Muller R, Krause V, Garland SM. Characterization of Chlamydia trachomatis omp1 genotypes detected in eye swab samples from remote Australian communities. J. Clin. Microbiol.42(6),2501–2507 (2004).
    • 194  Geisler WM, Black CM, Bandea CI, Morrison SG. Chlamydia trachomatis OmpA genotyping as a tool for studying the natural history of genital chlamydial infection. Sex. Transm. Infect.84(7),541–544; discussion 544–545 (2008).
    • 195  Wylie JL, Cabral T, Jolly AM. Identification of networks of sexually transmitted infection: a molecular, geographic, and social network analysis. J. Infect. Dis.191(6),899–906 (2005).
    • 196  Eckert LO, Suchland RJ, Hawes SE, Stamm WE. Quantitative Chlamydia trachomatis cultures: correlation of chlamydial inclusion-forming units with serovar, age, sex, and race. J. Infect. Dis.182(2),540–544 (2000).
    • 197  Rogers SM, Miller WC, Turner CF et al. Concordance of Chlamydia trachomatis infections within sexual partnerships. Sex. Transm. Infect.84(1),23–28 (2007).
    • 198  Geisler WM, Suchland RJ, Whittington WL, Stamm WE. Quantitative culture of Chlamydia trachomatis : relationship of inclusion-forming units produced in culture to clinical manifestations and acute inflammation in urogenital disease. J. Infect. Dis.184(10),1350–1354 (2001).
    • 199  Batteiger BE, Xu F, Johnson RE, Rekart ML. Protective immunity to Chlamydia trachomatis genital infection: evidence from human studies. J. Infect. Dis.201(Suppl. 2),S178–S189 (2010).
    • 200  Gomes JP, Borrego MJ, Atik B et al. Correlating Chlamydia trachomatis infectious load with urogenital ecological success and disease pathogenesis. Microbes Infect.8(1),16–26 (2006).
    • 201  Molano M, Meijer CJLM, Weiderpass E et al. The natural course of Chlamydia trachomatis infection in asymptomatic Colombian women: a 5-year follow-up study. J. Infect. Dis.191,907–916 (2005).
    • 202  Gray RT, Beagley KW, Timms P, Wilson DP. Modeling the impact of potential vaccines on epidemics of sexually transmitted Chlamydia trachomatis infection. J. Infect. Dis.199(11),1680–1688 (2009).
    • 203  Jones RB, Vanderpol B, Martin DH, Shepard MK. Partial characterization of Chlamydia trachomatis isolates resistant to multiple antibiotics. J. Infect. Dis.162(6),1309–1315 (1990).
    • 204  Lefevre JC, Lepargneur JP. Comparative in vitro susceptibility of a tetracycline-resistant Chlamydia trachomatis strain isolated in Toulouse (France). Sex. Transm. Dis.25(7),350–352 (1998).
    • 205  Mourad A, Sweet RL, Sugg N, Schachter J. Relative resistance to erythromycin in Chlamydia trachomatis. Antimicrob. Agents Chemother.18(5),696–698 (1980).
    • 206  Somani J, Bhullar VB, Workowski KA, Farshy CE, Black CM. Multiple drug-resistant Chlamydia trachomatis associated with clinical treatment failure. J. Infect. Dis.181(4),1421–1427 (2000).
    • 207  Bhengraj AR, Vardhan H, Srivastava P, Salhan S, Mittal A. Decreased susceptibility to azithromycin and doxycycline in clinical isolates of Chlamydia trachomatis obtained from recurrently infected female patients in India. Chemotherapy56(5),371–377 (2010).
    • 208  Shkarupeta MM, Lazarev VN, Akopian TA, Afrikanova TS, Govorun VM. Analysis of antibiotic resistance markers in Chlamydia trachomatis clinical isolates obtained after ineffective antibiotic therapy. Bull. Exp. Biol. Med.143(6),713–717 (2007).
    • 209  Zhu H, Wang HP, Jiang Y, Hou SP, Liu YJ, Liu QZ. Mutations in 23S rRNA and ribosomal protein L4 account for resistance in Chlamydia trachomatis strains selected in vitro by macrolide passage. Andrologia42(4),274–280 (2010).
    • 210  Misyurina OY, Chipitsyna EV, Finashutina YP et al. Mutations in a 23S rRNA gene of Chlamydia trachomatis associated with resistance to macrolides. Antimicrob. Agents Chemother.48(4),1347–1349 (2004).
    • 301  NHS. National Chlamydia Screening Programme. www.chlamydiascreening.nhs.uk
    • 302  Australian Chlamydia Control Effectiveness Pilot. www.accept.org.au
    • 303  I want the Kit. John Hopkin’s University. www.iwantthekit.org
    • 304  WHO. Mapping the landscape of diagnostics for sexually transmitted infections. www.who.int/tdr/publications/documents/mapping-landscape-sti.pdf
    • 305  Cepheid Xpert® CT/NG Product Information. www.cepheid.com/product-catalog/clinical-ivd-tests/xpert-ctng
    • 306  Smittskyddsinstitutet (SMI). Chlamydia Infection. www.smittskyddsinstitutet.se/in-english/statistics/chlamydia-infection
    • 307  Statens Serum Institut. www.ssi.dk/data
    • 308  CDC WONDER Online Database. www.wonder.cdc.gov/std-v2008.html
    • 309  Public Health Agency of Canada. Reported cases and rates of chlamydia by province/territory and sex, 1991 to 2009. www.phac-aspc.gc.ca/std-mts/sti-its_tab/chlamydia_pts-eng.php
    • 310  Australian Government. Department of Health and Ageing. National Notifiable Diseases Surveillance System. www.health.gov.au/cda/source/CDA-index.cfm
    • 311  Health Protection Agency. Sexually Transmitted Infections Annual Data. www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/STIs/STIsAnnualDataTables/#2._STI_data_tables