Infectious Diseases Protocol
Appendix A:
Disease-Specific Chapters
Chapter: Chlamydia trachomatis infections
Revised January 2014
Chlamydia trachomatis infections
Communicable
Virulent
Health Protection and Promotion Act:
Ontario Regulation 558/91 – Specification of Communicable Diseases
Health Protection and Promotion Act:
Ontario Regulation 559/91 – Specification of Reportable Diseases
1.0 Aetiologic Agent
Chlamydia trachomatis is an obligate intracellular bacterium causing genital infections and
other forms of infections including chlamydial conjunctivitis and pneumonia.1
1.1 Surveillance Case Definition
See Appendix B
1.2 Outbreak Case Definition
The outbreak case definition varies with the outbreak under investigation.Consideration
should be given to the provincial surveillance case definition and the following criteria when
establishing an outbreak case definition:
1.
2.
3.
4.
Clinical, laboratory and/or epidemiological criteria;
The time frame for occurrence;
A geographic location(s) or place(s) where cases live or became ill/exposed; and,
Special attributes of cases (e.g., age, underlying conditions).
Outbreak cases may be classified by levels of probability (i.e., confirmed, probable and/or
suspect).
2.0 Identification
2.1 Clinical Presentation
Chlamydia infection is often asymptomatic including pharyngeal and rectal infections. If
symptoms are present in rectal infections individuals often display rectal discharge and pain.
Males may present with urethral discharge, dysuria and frequency, non-specific urethral
symptoms such as redness, itching, and swelling.1, 2
Females may present with cervical infection that includes the following signs and symptoms:
a mucopurulent endocervical discharge with edema, dysuria, dyspareuira, erythema and
easily induced endocervical bleeding.
Complications and sequelae include salpingitis pelvic inflammatory disease with subsequent
risk of infertility. Salpingitis and pelvic inflammatory disease can also be symptoms of
chlamydia requiring treatment. Up to 70% of sexually active females with chlamydia
infection are asymptomatic.1
2
Can present as chlamydial pneumonia and conjunctivitis (Ophthalmia neonatorum) in
infants.1 For more information regarding chlamydial conjunctivitis in infants, please refer to
the Ophthalmia neonatorum Disease-Specific Chapter.
2.2 Diagnosis
See Appendix B for diagnostic criteria relevant to the Case Definitions.
For further information about human diagnostic testing, contact the Public Health Ontario
Laboratories or refer to the Public Health Ontario Laboratory Services webpage:
http://www.publichealthontario.ca/en/ServicesAndTools/LaboratoryServices/Pages/default.as
px
3.0 Epidemiology
3.1 Occurrence
Common worldwide.1
In Ontario, chlamydia is the most commonly reported sexually transmitted infection (STI).
Between 2007 and 2011, an average of 29,632 chlamydia cases was reported each year. The
rate of chlamydia is higher among females, and has been rising up to the end of 2012.
Reported rates are highest among youth and young adults aged 15 to 24 years.
For more information on infectious diseases activity in Ontario, refer to the current versions
of the Ontario Annual Infectious Diseases Epidemiology Reports and the Monthly Infectious
Diseases Surveillance Report.3, 4
3.2 Reservoir
Humans1
3.3 Modes of Transmission
Sexual contact via oral, vaginal, cervical, urethral or anal routes; in children, exposure to
infected genitals (consider the possibility of sexual abuse in these cases); newborns: during
delivery from infected mother.1, 2
3.4 Incubation Period
From time of exposure to onset of symptoms is 2-3 weeks, but can be as long as 6 weeks.2
3.5 Period of Communicability
Unknown; may extend for months or longer if untreated, especially in asymptomatic persons;
re-infections are common; effective treatment ends infectivity.1 If receiving single dose
therapy, individuals should abstain from unprotected sexual activity for 7 days.2
Re-infection is common (e.g. after 28 days). For surveillance purposes, if the four factors
noted in the Provincial Case Definition for Chlamydia are met, health units may consider 28
days for re-infection
3
3.6 Host Susceptibility and Resistance
General susceptibility.1
4.0 Reporting Requirements
4.1 To local Board of Health
Individuals who have or may have chlamydia shall be reported to the medical officer of
health by persons required to do so under the Health Protection and Promotion Act, R.S.O.
1990 (HPPA).5
4.2 To the Ministry of Health and Long-Term Care (the ministry) or Public Health
Ontario (PHO), as specified by the ministry
Report only case classifications specified in the case definition.
Cases shall be reported using the integrated Public Health Information System (iPHIS), or
any other method specified by the Ministry within five (5) business days of receipt of
initial notification as per iPHIS Bulletin Number 17: Timely Entry of Cases and Outbreaks.6
The minimum data elements to be reported for each case is specified in the following:
•
•
•
Ontario Regulation 569 (Reports) under the HPPA;7
The iPHIS User Guides published by PHO; and,
Bulletins and directives issued by PHO.
5.0 Prevention and Control Measures
5.1 Personal Prevention Measures
Preventive measures include education about safer sex practices including use of condoms
and early detection of infection by screening those at risk.2
Screening should be offered to all sexually active persons as per the Sexual Health and
Sexually Transmitted Infections Prevention and Control Protocol, 2008 (or as current).
5.2 Infection Prevention and Control Strategies
Refer to Public Health Ontario’s website at www.publichealthontario.ca to search for the
most up-to-date Provincial Infectious Diseases Advisory Committee (PIDAC) best practices
on Infection Prevention and Control (IPAC). PIDAC best practice documents can be found
at:
http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/PIDAC/Pages/PID
AC_Documents.aspx.
5.3 Management of Cases
Case management should consider the PIDAC Sexually Transmitted Infections Case
Management and Contact Tracing Best Practice Recommendations, April 2009 (or as
current).8
4
Treatment determined as per attending health care provider; refer to the Sexual Health and
Sexually Transmitted Infections Prevention and Control Protocol, 2008 (or as current) for a
list of publicly funded STI medications, and the Canadian Guidelines on Sexually
Transmitted Infections, 2008 edition (or as current),2 for treatment recommendations.
5.4 Management of Contacts
For recommendations on contact management refer to PIDAC Sexually Transmitted
Infections Case Management and Contact Tracing Best Practice Recommendations, April
2009 (or as current)8 and the Canadian Guidelines on Sexually Transmitted Infections, 2008
edition (or as current).2
Contact management of cases should be guided by the Sexual Health and Sexually
Transmitted Infections Prevention and Control Protocol, 2008 (or as current).
5.5 Management of Outbreaks
Consult Public Health Ontario if an outbreak is suspected.
Provide public health management of outbreaks or clusters in order to identify the source of
illness and stop the outbreak. As per the Infectious Diseases Protocol, 2008 (or as current)
outbreak management shall comprise of but not be limited to the following general steps:
•
•
•
•
•
•
•
•
•
•
Confirm diagnosis and verify the outbreak;
Establish an outbreak team;
Develop an outbreak case definition;
Implement prevention and control measures;
Implement and tailor communication and notification plans depending on the scope of the
outbreak;
Conduct epidemiological analysis on data collected;
Conduct environmental inspections of implicated premise where applicable;
Coordinate and collect appropriate clinical specimens where applicable;
Prepare a written report; and,
Declare the outbreak over in collaboration with the outbreak team currently reviewing
them.
6.0 References
1. Heymann DL, editor. Control of communicable diseases manual. 19th ed. Washington,
DC: American Public Health Association; 2008.
2. Expert Working Group on the Canadian Guidelines on Sexually Transmitted Infections;
Public Health Agency of Canada. Canadian guidelines on sexually transmitted infections.
Evergreen ed. Ottawa, ON: Her Majesty the Queen in Right of Canada; 2013 [cited 2013
Aug 27]. Available from:
http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/index-eng.php
3. Ontario. Ministry of Health and Long-Term Care. Ontario annual infectious diseases
epidemiology report, 2009. Toronto, ON: Queen’s Printer for Ontario; 2009 (or as
current). Available from:
5
4.
5.
6.
7.
8.
http://www.health.gov.on.ca/en/common/ministry/publications/reports/epi_reports/epi_re
port_2009.pdf
Ontario Agency for Health Protection and Promotion (Public Health Ontario). Monthly
infectious diseases surveillance report. Toronto, ON: Queen’s Printer for Ontario; 2013.
Available from:
http://www.publichealthontario.ca/en/ServicesAndTools/SurveillanceServices/Pages/Mo
nthly-Infectious-Diseases-Surveillance-Report.aspx
Health Protection and Promotion Act, R.S.O. 1990, c. H.7. Available from”
http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90h07_e.htm
Ontario. Ministry of Health and Long-Term Care. Timely entry of cases and outbreaks.
iPHIS bulletin. Toronto, ON: Queen’s Printer for Ontario; 2012:17 (or as current).
Reports, R.R.O. 1990, Reg. 569. Available from: http://www.elaws.gov.on.ca/html/regs/english/elaws_regs_900569_e.htm
Provincial Infectious Diseases Advisory committee (PIDAC), Ontario. Ministry of Health
and Long-Term Care. Sexually transmitted infections case management and contact
tracing best practice recommendations. Toronto, ON: Queen’s Printer for Ontario; 2009.
Available from:
http://www.publichealthontario.ca/en/eRepository/STIs%20Case%20Management%20C
ontact%20Tracing.pdf
7.0 Additional Resources
Ontario. Ministry of Health and Long-Term Care. Sexual health and sexually transmitted
infections prevention and control protocol, 2013 (revised). Toronto, ON: Queen’s Printer for
Ontario; 2013 Available from:
http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/sexual_health
_sti.pdf
Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial
Infectious Diseases Advisory Committee. Routine practices and additional precautions in all
health care settings. 3rd ed. Toronto, ON: Queen’s Printer for Ontario; 2012. Available from:
http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012
.pdf
8.0 Document History
Table 1: History of Revisions
Revision Date
January 2014
Document Section
General
Description of Revisions
New template.
Title of Section 3.6 changed from
“Susceptibility and Resistance” to “Host
Susceptibility and Resistance”
Title of Section 4.2 changed from “To Public
Health Division (PHD)” to “To the Ministry of
Health and Long-Term Care (the ministry) or
Public Health Ontario (PHO), as specified by the
6
Revision Date
Document Section
Description of Revisions
ministry”
Section 8.0 Document History added.
1.2 Outbreak Case
Definition
Entire section revised.
2.1 Clinical
Presentation
First paragraph changed from “Chlamydia
infection is frequently asymptomatic.” to
“Chlamydia infection is often asymptomatic
including pharyngeal and rectal infections. If
symptoms are present in rectal infections
individuals often display rectal discharge and
pain.”
Addition of fourth paragraph “Complications…”
Final paragraph changed from “Can present as
Chlamydia pneumonia in infants.” to “Can
present as chlamydial pneumonia and
conjunctivitis (Ophthalmia neonatorum) in
infants. For more information regarding
chlamydial conjunctivitis in infants, please refer
to the Ophthalmia neonatorum Disease-Specific
Chapter.”
2.2 Diagnosis
Addition of the second paragraph:
“For further information…”
3.1 Occurrence
First paragraph changed from “Common
worldwide; high rates of infection among
sexually active persons.” to “Common
worldwide.”
Second paragraph changed from “In Ontario,
Chlamydia is the most commonly reported STI.
The rate of Chlamydia is higher among females,
and has been rising. Reported rates are highest
among youth and young adults aged 15 to 24
years.” to “In Ontario, chlamydia is the most
commonly reported sexually transmitted
infection (STI). Between 2007 and 2011, an
average of 29,632 chlamydia cases was reported
each year. The rate of chlamydia is higher
among females, and has been rising up to the
end of 2012. Reported rates are highest among
youth and young adults aged 15 to 24 years.”
Addition of third paragraph “For more
7
Revision Date
Document Section
Description of Revisions
information…”
3.4 Incubation Period
First sentence changed from “….onset of
infection…” to “…onset of symptoms…”
3.5 Period of
Communicability
First paragraph, addition of second sentence “If
receiving…”
Addition of second paragraph “Re-infection is
common…”
3.6 Host Susceptibility First and second paragraph replaced with
and Resistance
“General susceptibility.”
5.2 Infection
Prevention and
Control Strategies
Entire section revised.
5.3 Management of
Cases
First two paragraphs were deleted:
“Refer to Ontario Regulation 569 for relevant
data to collect and ensure to inquire about the
following: history of exposure; contact history
and assess for risk factors” and
“Provide education about and promote safer sex
practices and advise about the need to test for
HIV infection and other STIs if indicated (2).”
Reference to “PIDAC Sexually Transmitted
Infections Case Management and Contract
Tracing Best Practice Recommendations, April
2009” added.
Final paragraph changed from “Treatment
determined as per attending health care provider;
refer to the Sexual Health and Sexually
Transmitted Infections Prevention and Control
Protocol, 2008 (or as current) for the following
sections, and the Canadian Guidelines on
Sexually Transmitted Infections, Public Health
Agency of Canada, 2008 edition.” to “Treatment
determined as per attending health care provider;
refer to the Sexual Health and Sexually
Transmitted Infections Prevention and Control
Protocol, 2008 (or as current) for a list of
publicly funded STI medications, and the
8
Revision Date
Document Section
Description of Revisions
Canadian Guidelines on Sexually Transmitted
Infections, 2008 edition (or as current),2 for
treatment recommendations.”
5.4 Management of
Contacts
Entire section revised.
5.5 Management of
Outbreaks
Entire section revised.
6.0 References
Updated.
7.0 Additional
Resources
Updated.
9
© 2014 Queen’s Printer for Ontario