PID, EP, TI and E in the Context of Rising Chlamydia and Gonorrhoea Rates in Queensland

PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008 Jessie Ostermann, Elissia Canham and Ahmed Almuammar

Abstract ▸ ▸ November, 2009

The rates of Chlamydia and Gonorrhoea in Queensland have been continually increasing annually and Queensland currently reports the highest notifications for Chlamydia above all other states in Australia. This study aims to analyse the trends of the sequelae (pelvic inflammatory disease (PID), ectopic pregnancy (EP), tubal infertility (TI) and epididymitis (E)) in Queensland in relation to the increased occurrences of Chlamydia and Gonorrhoea. Interstate and overseas studies have demonstrated that the rates of sequelae have decreased or stabilized despite increases in the number of cases reported with Chlamydia. Rates of Chlamydia, Gonorrhoea, PID, EP, TI and E were calculated using data collected from the Communicable Disease Branch of Queensland Health and Queensland Health Queensland Hospital Admitted Patient Data Collection based on population data from Queensland Health District Estimated Residential Populations from Australian Standard Geographical Classification (ASGC) based on Australian Bureau of Statistics Census. Rates were matched for year, gender, age and geographical location. Overall, the results suggest that Queensland rates of EP are increasing, whereas PID, TI and E rates are decreasing in the times from 2000-2008. Chlamydia and Gonorrhoea are increasing considerably and Queensland currently reports the highest notification of these infections. It was also found that the rates of infection of Chlamydia and Gonorrhoea were drastically higher in regions with high Indigenous populations and subsequently PID, EP and E rates were also higher in these regions. TI was the only sequelae not higher in Indigenous populations. The causal link between infection with Chlamydia and Gonorrhoea and diagnosis with PID, EP, TI and E needs to be determined. This is of high public health importance because these conditions have a significant impact on fertility of both males and females, considering that at present Australia has a low fertility rate compared with global rates. This study is the first of its kind in Queensland and it is anticipated that further studies will endeavour to determine the reasons behind the higher notifications of Chlamydia and Gonorrhoea in regions with high Indigenous populations and young individuals. It is hoped that the statistics will give an insight of the current condition to Indigenous health and sexual health professionals and help guide policy makers and health care teams towards targeting these high risk groups with appropriate interventions.  PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008

Ectopic pregnancy is a complication of PID, EP, TI and E in pregnancy, frequently life threatening, where implantation of the embryo occurs outside of the context of the uterus and most commonly in the fallopian tubes and less commonly in the cervix, ovaries or abdominal cavity. It is a rising Chlamydia leading cause of pregnancy-related death in early pregnancy and often requires and Gonorrhoea emergency surgical interventions due to the risk of rupturing the fallopian tube and rates in Queensland internal bleeding (Tay, Moore and Walker, 2000 and Tenore, 2000). The known risk during 2000 and factors for ectopic pregnancy are previous PID, previous tubal surgery, previous sterilisation, previous ectopic pregnancy, 2008 IUCD in situ, IVF treatment or assisted Jessie Ostermann, Elissia Canham and fertilisation, smoking, history of sexually transmitted infection and increased age Ahmed Almuammar (Batzofin, Fielding and Friedman, 1984; Conduous, 2006; Bouyer, Coste and Shojaei, 2003; Chen, Fairly and Donovan, 2005). Introduction Tubal infertility occurs when the fallopian Pelvic Inflammatory Disease (PID) is a tube becomes occluded due to scarring and complication that arises generally from the entering sperm cannot reach the ovum. sexually transmitted infections (STI). It is a Infertility is defined as the inability to achieve ‘silent epidemic’ as it is common amongst a pregnancy after 12 months of regular sexually active women but does not always intercourse without protection (Larsen, cause symptoms. PID occurs when an 2005). Approximately 15% of couples of infection is transmitted from the vagina to the reproductive age in Australia and New cervix, endometrium and fallopian tubes. Zealand have fertility problems and the risk PID can also occur due to certain surgical factors are similar to that of ectopic procedures namely abortion and insertion of pregnancies. an intra uterine contraceptive device (IUCD). PID occurs in a 3 stage process. The cervix Epididymitis is the infection and is first infected followed by the endometrium subsequent inflammation of the epididymis. and fallopian tubes. The epididymis is a duct within the male Female infertility is a long term complication reproductive organs which receives due to PID (Centre for Disease Control and spermatozoa from the ductuli efferentes of Prevention, 2007c). Infertility occurs due to the testis and projects them to the distal vas the scarring and blockage of the fallopian deferens (Cosentino, and Cockett, 1986, tubes. Due to the scarring and blockage the 229). The epididymis’ key function is to store fertilised egg cannot pass through the tube and assist in ejaculating sperm (Cosentino, of the uterus. and Cockett, 1986, 230-232). With In Australia over 10,000 women are treated inflammation apparent in such a sensitive for PID in hospitals every year. Women in region of the body, it is usually accompanied the age group of 20-29 report the maximum by scrotal pain (Calleary, Masood and Hill, number of PID cases.

 Page 2  PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008

2007). The prevalence of epididymitis is high Control and Prevention, 2007a). In both and is generally contracted through the sexes proctitis (inflammation of the anus and retrograde ascent of pathogens or sexual the lining of the rectum), pharyngitis and transmission caused by Chlamydia disseminated gonococcal infection are Trachomatis or Gonorrhoea (Kreiger, 1984). common. Acute epididymitis causes swelling of the In men, Chlamydia presents with similar scrotum, pain in the testes and can cause symptoms as Gonorrhoea with urethritis and fevers for up to 6 weeks. If not treated, urethral discharge and orchitis. In women, epididymitis can become chronic; with pain painful and frequent urination, bleeding in becoming more severe both unilaterally and between menstruation, abnormal vaginal bilaterally (Curtis, 2003). The majority of discharge, lower abdominal pain, low back patients can be treated in GP clinics and on pain, nausea, fever and pain during an out-patient basis, therefore not requiring intercourse are common symptoms hospitalisation, unless the pain is severe and (Queensland Health, 2006, 64 and Centre is accompanied by other diagnoses such as for Disease Control and Prevention. 2007b). torsion, testicular infarction, abscess or fever. The goal in treatment is to cure the The reasons that the rates are so high for underlying infection such as Chlamydia these infections is due to the fact that they and/or Gonorrhoea with antibiotics such as are easily transmitted amongst individuals Ceftriaxone, Azithromycin and Doxycycline, who do not practice safe sexual activities relieve pain, decrease the risk of infertility and they are often asymptomatic (Stamm, and reduce the transmission to other sexual 1999; Centre for Disease Control and partners (Trojian, Lishnak and Heiman, Prevention, 2007b; Malik, Jain, Hakim, 2009). Shukla and Rizvi, 2006; WHO Task Force, 1995). Age, number of sex partners, Chlamydia and Gonorrhoea are the most socioeconomic status, and sexual common sexually transmitted infections and preference are predictors of Chlamydial are required to be notified to the National infection. Notifiable Disease Surveillance System Adolescents are also thought to be at a (NNDSS) controlled by the Australian higher risk due to a higher number of sexual Government Department of Health and partners, increased frequency of sexual Ageing. Both infections are bacterial in intercourse, reluctance to seek medical nature: Gonorrhoea is caused by the attention and lower levels of protective bacterium Neisseria gonorrhoeae and antibodies (Gilbert and Weisberg, 1993). Chlamydia is caused by the bacterium Also, Chlamydial infections may be under- Chlamydia trachomatis. reported because of the high proportion of asymptomatic infections, particularly among Symptoms for both infections are very similar women. and it is common for an individual to be infected with both microorganisms. In men, For the year 2008, there were 58,514 and Gonorrhoea presents with symptoms such 7,675 Chlamydia and Gonorrhoea national as urethral discharge, epididymitis, orchitis notifications respectively (Department of (swelling of the testes) and infertility. Painful Health and Ageing, 2009a). Chlamydia and urination, increased vaginal discharge, Gonorrhoea rates throughout Australia have cervicitis, endometritis, salpingitis, pelvic been consistently rising every year since inflammatory disease, infertility, preterm 1991 (Department of Health and Ageing, rupture of membranes and perihepatitis 2009a) when the NNDSS was established. (inflammation of the serous or peritoneal Chlamydia became notifiable in New South coating of the liver) are common symptoms Wales in 1998 so that the reporting for experienced by women (Centre for Disease

Chlamydial infections was national for the communities reporting the highest rates of first time in 1999. infection (Department of Health and Ageing, Between 2002 and 2006, Chlamydial 2005). It is reported that the national rate of infection notification rates increased from Gonorrhoea peaked at 84.4 per 100,000 124 to 228 cases per 100,000 population, an population in 1982 (Donovan, 1998). increase of 79%. These rates will continue to Overseas trends also indicate that the rise until a national or state-wide screening notification of Chlamydia and Gonorrhoea and prevention intervention is put into are increasing. In 2006 in the United States, practice. It is important to note that the the rate of reported Gonorrhoeal infections National Sexually Transmitted Infection was 120.9 per 100,000 persons (CDC, Strategy 2005-2008, the first of its kind in 2007a). Between April 2005 and March Australia, became effective in 2005. The 2006, the National Chlamydia Screening objectives of this strategy are to improve Program in the UK found a Chlamydia awareness of STIs, in particular their prevalence of 10.2% among women under economic, social and personal impacts, 25 years old, and 10.1% among men in the within the government, medical and same age group. Over the past decade there community sectors; to establish a basis for has been a substantial increase in diagnoses coordinated national action on STIs now and of most STIs in the UK. Cases of in the future; to increase access to uncomplicated Gonorrhoea increased by diagnosis, treatment and care of STIs; to 42% between 1998 and 2007, while minimise the spread and morbidity of STIs in Chlamydia increased by 150% in the same identified priority groups; and to improve time period (Health Protection Agency, surveillance and research activities in order 2008). Among men, the rate of Chlamydial to guide the development and diagnoses is highest in 20 to 24 year olds implementation of prevention initiatives. The (1,163/100,000 in 2008), with lower rates three priority areas outlined which need the seen among 16 to 19 and 25 to 34 year olds most attention are STIs in the Indigenous (602/100,000 and 492/100,000 respectively and Torres Strait Islander communities, STIs in 2008). Higher rates were observed among in gay and other homosexually active men younger women (1,406/100,000 and and Chlamydia control and prevention. 1,168/100,000) in 16-19 and 20-24 year olds, respectively in 2008. It is apparent that Chlamydia and Certain ethnic minority groups are Gonorrhoea are known to be more prevalent disproportionately affected by some STIs. In in Aboriginal and Torres Strait Islander 2005, the GRASP (Gonococcal Resistance people. Where Indigenous status is reported to Antimicrobial Surveillance Programme) for notifications of Chlamydia (approximately survey conducted in the UK by the Health 45 per cent), it is evident that Aboriginal and Protection Agency (2006) found that black Torres Strait Islander people have about an Caribbean’s accounted for 18% of eight-fold higher rate of diagnosis (per Gonorrhoea diagnoses at the clinics studied. 100,000 population) than non-Aboriginal In another similar study by Low, Sterne and people. For notifications of Gonorrhoea from Barlow (2001), the male Gonorrhoea rate Aboriginal and Torres Strait Islander people among black Caribbean 20-24 year olds was (approximately 65 per cent) there is about a 2348 (95% CI 1965 to 2831) episodes per 40-fold higher rate of diagnosis (per 100,000 100 000 compared with 931 (95% CI 690 to population) than the non-Aboriginal 1288) in black African men and 111 (95% CI population. However, rates of Gonorrhoea 100 to 124) per 100 000 in white men of the notification also vary within different same age. Among women Gonorrhoea rates Aboriginal and Torres Strait Islander were highest in black Caribbean 15-19 year communities, with more isolated

 Page 4  PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008 olds (2612, 95% CI 2161 to 3190 per 100 The socioeconomic costs of these infections 000). and their complications are substantial, Miller and others (2004) conducted a study ranking among the top 10 reasons for health- involving a nationally representative sample care visits in most developing countries of 14,322 young adults aged 18 to 26 years (WHO, 2007, 3). The costs of screening in the United States. Urine specimens were programs, investigations of infertility and available for 12,548 (87.6%) of the treatment of sequelae of Chlamydia and participants and were tested for evidence of Gonorrhoea account for a large percentage Chlamydial and Gonococcal infections. The of health care funding and this is significant researchers found that the overall as Chlamydia and Gonorrhoea in women are prevalence of Chlamydial infection in this some of the main preventable causative sample of young adults was 4.19%. agents of infertility and reproductive tract Prevalence varied little by age, but was more problems. common among women (4.74%) than men (3.67%). Prevalence was also more than two times higher in the south (5.39%) than in the Treatment of Chlamydia and Gonorrhoea northeast (2.39%) region. Results showed that the prevalence of Chlamydial infection Both infections can be easily treated with a varied significantly by race/ethnicity. Among single dose of Azithromycin or combined white young adults, prevalence was lowest with Ceftriaxone or other preferred (1.94%) and more than six times higher in antibiotics/antimicrobials; however the black young adults (12.54%). Latino young biggest problem which is the reason why adult’s prevalence was in between these two these infections spread so rapidly, is ranges (5.89%). The highest prevalence in because in a number of cases the infection any group was among black women is asymptomatic and individuals are not (13.95%), followed by black men (11.12%). aware they are infected and continue to The lowest prevalence’s were among Asian participate in unprotected sexual activities. American men (1.14%), white men (1.38%), Due to this reason, infection rates are much and white women (2.52%). Overall higher in adolescents and young adults due prevalence of Gonorrhoea was 0.43%. to their high-risk sexual behaviours. While Among black men and women, the the spontaneous cure rate for Chlamydia has prevalence was 2.13% and among white been estimated at 7.4%, immunity following young adults, 0.10%. Overall, the prevalence infection is thought to be type-specific and of co-infection with both Chlamydial and only partially protective. As a result recurrent Gonococcal infections was 0.03%. infections are common (Victorian Department of Human Services, 2005). Infection with Chlamydia trachomatis and However it is encouraging that studies have Neisseria gonorrhoeae has become a major shown that timely treatment with antibiotics public health problem because of the long may greatly prevent some of the long-term term consequences and sequelae of complications such as infertility (Haggerty et infection experienced predominantly by al, 2003; Hillis et al, 1993; Heinonen and women and the higher rates in Indigenous Leinonen, 2003). In Sweden, declining rates and remote populations. of Chlamydial infections, attributed to Globally, sexually transmitted infections preventive policies, have been accompanied represent a huge health and economic by a fall in the risk of ectopic pregnancy burden, especially in developing countries (Egger et al., 1998). where they account for 17% of economic There are increasing concerns about the losses caused by ill-health (UNAIDS/WHO, presence in Australia of Gonococcal isolates 2000). showing resistance to multiple antibiotics including to the third generation

 Page 5  PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008 cephalosporin Ceftriaxone, which is used deaths (Turner et al, 2002; Murray, Baakdah, extensively in Australia (Tapsall, Limnios and Bardell and Tulandi, 2005). Murphy, 2008 and Australian Gonococal In Australia the incidence of ectopic Surveillance Programme, 2007). In contrast, pregnancy decreased slightly in the 1990s, in remote regions of Australia, traditional from a rate of 17.4 per 1000 births in 1990 to penicillin-based regimens retain their 16.2 per 1000 in 1998 (Boufous, Quartararo, efficacy. Moshin and Parker, 2001). In a study similar to this one conducted in New South Wales, Chen, Fairley and Epidemiology and association of PID, EP, Donovan (2005) found that admission rates TI, E and Chlamydia and Gonorrhoea for PID among women aged 15-34 years fell from 165 per 100 000 in 1992 to 64 per 100 During the 1970s and early 1980s, the 000 in 2001. Over the study period, the incidence of ectopic pregnancy doubled or incidence of ectopic pregnancy among tripled in most industrialized countries to women aged 15-44 years remained relatively reach annual incidence rates of between 100 constant, with 1521 admissions for ectopic and 175 per 100 000 women aged 15-44 pregnancy in 1992 and 1321 in 2001. Eighty (Coste et al, 1994; Centers for Disease five per cent of ectopic pregnancies were Control and Prevention, 1995; Thorburn, specified as being tubal. For each ectopic 1995; Makinen, 1996; Storeide et al., 1997). pregnancy in Australia there is a death rate In England, ectopic pregnancies occurred at of 1.8 per 1000 (Fox and Creinin, 2002). a rate of 3.45 per 1000 live births in 1966 A stabilization or even a decrease in the and in 1996 the rate had increased to 15.5 ectopic pregnancy rates has since been per 1000 live births (Rajkhowa et al, 2000). observed in Sweden and Finland (Thorburn, In a study in France, the rate of ectopic 1995; Makinen, 1996; Egger, Low, Smith, pregnancy was 20.2 per 1000 live births, Lindblom and Hermann, 1998), Australia 15.8 per 1000 reported pregnancies and 9.5 (Boufous et al., 2001), France (Coste et al., per 10 000 women aged 15-44 years. The 2000) and the UK (Rajkhowa et al., 2000; ectopic pregnancy rate per 1000 live births Irvine and Setchell, 2001) giving the increased steeply after the age of 30 years impression that the ‘epidemic is over’ and especially after the age of 35 years, (Thorburn, 1995). whereas rates per 10 000 women of reproductive age steadily increased until the The association between Chlamydial and age of 35 years and decreased thereafter Gonorrhoeal infections and ectopic (Coste et al, 1994). pregnancy, PID and tubal infertility has been The incidence in the United States has supported in several studies with different increased greatly in the last few decades, designs (Westrom, Joesoef, Reynolds, from 4.5 per 1000 pregnancies in 1970 to an Hagdu and Thompson, 1992; WHO Task estimated 19.7 per 1000 pregnancies in Force, 1995; Malik et al, 2006; Honey and 1992 (Murray, Baakdah, Bardell and Tulandi, Templeton, 2002). 2005). In the United States, roughly 40-50 Infections of the upper female genital tract women die each year from an ectopic are almost entirely caused by microbiological pregnancy and the death rate is 0.5 per 1000 organisms which ascend from the vagina ectopic pregnancies, which is much lower and cervix to the upper genital tract. In most than Australia. cases of PID, infection by Chlamydia In Canada, ectopic pregnancies account for trachomatis and Neisseria gonorrhoeae are about 2% of pregnancies and 4% of the the predominant causes (Wang and Fraser, approximately 20 annual pregnancy-related 1997). PID caused by Chlamydia can result in tubal scarring which can cause partial or

 Page 6  PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008 total tubal occlusion and subsequently result Risk factors for epididymitis in all men in an ectopic pregnancy or infertility (Honey include sexual activity, strenuous physical and Templeton, 2002). activity, bicycle or motorcycle riding and According to Simms and Stephenson (2000), prolonged periods of sitting (e.g., during as many as 10% to 40% of women with travel, with a sedentary job) (Trojian, Lishnak untreated Chlamydial infection develop and Heiman, 2009). symptomatic pelvic inflammatory disease The true incidence in the community and and one in four of these will result in infertility nationally in Australia is vague due to (WHO, 2007 and Department of Health and differences in reporting of the condition and Ageing, 2005). Other research suggests that lack of research in this area. There is limited there is a 6-10 time higher chance of an data relating to epididymitis in Indigenous ectopic pregnancy occurring if the individual populations. However, in New South Wales has PID and a 10% to 60% higher incidence in 2001, there were a total of 287 of tubal infertility after one to three episodes notifications (Chen, Fairley and Donovan, of PID (Westrom, 1980; Washington, Ami, 2005). Another study of epididymitis and PID Wolner-Hassen et al, 1991; Peterson, Galaid in Australia by Chen, Pan, Britt and Donovan and Cates, 1990; Ault and Faro, 1993, (2006) analysed the encounters to GPs via a Newkirk, 1996; Westrom et al, 1992). national representative study between 1998 An important aspect to consider is affirmed and 2003. An estimated 54,200 GP byWølner-Hanssen (1995) suggesting that encounters for epididymitis took place in females who have minimal symptoms may Australia during the study period. Although be at a greater risk of serious sequelae Chlamydia and Gonorrhoea rates increased because the Chlamydial infection may cause during the study period, the rate for substantial tubal destruction in the absence epididymitis did not change significantly of symptoms. (Chen, Pan, Britt and Donovan, 2006). Studies in the 1980s suggest that the The highest prevalence of epididymitis is in incidence in the United States is young men aged 19 to 35 years of age and approximately 600,000 cases per year acute epididymitis is most frequently caused (Kreiger, 1984). In 2002, epididymitis or by Chlamydia trachomatis or Neisseria orchitis accounted for 1 in 144 outpatient gonorrhoeae (Centre for Disease Control visits (0.69 percent) in men 18 to 50 years of and Prevention, 2006; Manavi, Turner, Scott age (Woodwell and Cherry, 2004). The and Stewart, 2005; Redfern, English, disorder is a major cause of hospital Baumber and McGhie, 1984). Acute admissions in the military causing epididymitis caused by sexually transmitted approximately 20% of admissions in the enteric organisms (e.g., Escherichia coli) United States (Curtis, 2003). also occurs among men who have sex with In the United States, studies have found that men. Chlamydia was responsible for it is likely that there has been a recent approximately 50% of the estimated 500,000 increase in cases of epididymitis that cases of acute epididymitis seen during the parallels the increase in reported cases of 1980s in the United States (National Institute Chlamydia infection and Gonorrhoea in the of Health, 1981). United States (increases of 5.6% and 5.5%, Historically, epididymitis was thought to be respectively, from 2005 to 2006) (Centre for caused by chemical irritation from urine Disease Control and Prevention, 2007d). reflux; however a study published in 1979 was the first to show that bacteria were As identified in the previous sections, responsible for most cases (Berger, Chlamydia and Gonorrhoea are long- Alexander, Harnisch, et al, 1979). The study established to be the common causes of also showed that the type of bacteria varied PID. Figures approximate that Chlamydia with patient age. accounts for 50% of the PID cases whilst

 Page 7  PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008 gonorrhoea accounts for 25%. Chlamydia 2008 for each age bracket, gender and accounts for one-quarter to one-half of the 1 geographical location based on the million recognized cases of PID in the United Queensland Health Health Service Districts States each year. Infections of the fallopian and determining whether there was a causal tube not clinically recognized as PID, relationship between the rates of infection contribute significantly to the increasing with Chlamydia and Gonorrhoea to the rates number of women who experience ectopic of diagnosis of PID, EP, TI and E. There was pregnancy or involuntary infertility. also a particular focus on areas with a high In the study by Chen, Pan, Britt and prevalence of Aboriginal and Torres Strait Donovan (2006), over the study period Islander people as Chlamydial and overall encounter rates did not change Gonorrhoeal infection rates are notoriously significantly for PID and a fall in encounter high in these regions. rates for PID of about 50% occurred among women aged 15-34 years (P=0.02). The epidemic of Gonorrhoeae experienced Methods by industrialised countries in the 1960s peaked in Sweden in 1970, and then Age, gender, region and year specific rates decreased. An associated PID epidemic of Chlamydia and Gonorrhoea were peaked at 11/1000 women aged 15–39 calculated from data acquired from the between 1970 and 1974 and then declined Communicable Disease Branch of as a tertiary ectopic pregnancy epidemic Queensland Health for the years 2000-2008 emerged (Westrom, 1980 and Meirik, 1981). for males and females aged 1585+ years.

Rates for pelvic inflammatory disease, tubal infertility, epididymitis and ectopic Aim pregnancies were ascertained from The overall aim of the study was to compare Queensland Health Queensland Hospital and analyse the Queensland rate trend of Admitted Patient Data Collection for public Chlamydia and Gonorrhoea, PID, EP, TI and and private hospital admissions in E. Queensland for the years 2000-2008. PID As the rate of Chlamydia and Gonorrhoea rates were calculated for females aged 15- has been rising in the last couple of decades 85+ years. Epididymitis rates were in Queensland, it would be assumed that the calculated for males aged 15-85+ years. sequelae of these infections (PID, EP, TI and Ectopic pregnancy and tubal infertility rates E) would be on the increase as well, were calculated for women aged 15-50 however studies suggest that this may not years, on the assumption that female be the case and in fact there may be reproductive activity is greatly reduced discordance. above the age of 50. The data age groups Due to the lack of significant data and range from 15-20, 21-30, 31-40 and 41+ and research in the area of STIs and their the inclusion of population data above the relationship to ectopic pregnancies, tubal age of 50 would show an incorrect infertility, pelvic inflammatory disease and underestimation of the rate. epididymitis in Queensland, the aim was to Repeat admissions were not able to be fill this gap and to mirror the similar study recognized from this data. The diagnoses conducted in New South Wales by Chen, were grouped by means of the ICD10 Fairley and Donovan in 2005. classification system, which was introduced This was achieved by means of gathering for 1999/2000 data. The ICD9 codes were and analysing epidemiological data of all the used in the years prior. An outline of this can diseases/infections ranging from 2000 and

 Page 8  PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008 be seen in the Table of codes of Diagnoses 100,000 and therefore almost 0.1% of on page 19 of the appendices. Queensland females experienced an ectopic pregnancy in 2000. Rates of diagnosis of PID, EP, TI and E were calculated using figures from Queensland Again in 2008, the highest rate of ectopic Health District Estimated Residential pregnancies was in the Torres Strait- Populations from Australian Standard Northern Peninsula region with a rate of 183. Geographical Classification (ASGC) based The second highest was Mackay with 170.1 on Australian Bureau of Statistics Census and third highest was Darling Downs-West counts and were completely matched by Moreton with 123. The region with the lowest year, age, gender and regions of prevalence was Cape York with a rate of Queensland. The rates are represented in 60.5. cases per 100,000 population. In 2008 the rate for the total population was 62.6 for the age bracket 15-20, 163 for ages Due to the change in Health Service District 21-30, 164 for ages 31-40 and 7.7 for ages boundaries over time, population estimates 41-50. The average rate for the female by current HSD boundaries go back as far as population of Queensland aged 15-50 was 2000, so rates prior to that date are not 104 per 100,000, which is 4.6 per 100,000 possible. Current HSD boundaries can be up from 2000. seen on page 17 of the appendices. The highest total Queensland rate was 106 in 2007 and the lowest rate was in 2002 with a rate of 96. In the years 2005-2007 there Results was a significant increase in the rates, with the highest being 333 in Central West in A vast amount of information relating to the 2007, followed by 310 in 2006 in Mt Isa and results can be seen in the tables and graphs 302 in Torres Strait-Northern Peninsula in in appendix 1. 2007. The fourth highest rate was in 2003 in Cape York with 297 per 100,000. Ectopic Pregnancy The lowest rates of ectopic pregnancies can be seen in the age bracket 41-50 and these In 2000, the rate of ectopic pregnancies was rates vary from 4.9-16.4 per 100,000. In the highest in the Torres Strait-Northern age bracket 21-30 for the years 2000-2008 Peninsula, with a rate of 210 per 100,000. the rate varies from 156 to 188. The second highest rate was Mt Isa with 180 and the third highest rate was in Cape York Tubal Infertility with 136 per 100,000. Mackay closely followed with 131 per 100,000. The region The highest rate of tubal infertility in 2000 with the lowest rate was South West with 47 was 187 per 100,000 in the South West per 100,000. district. The second highest was Metro North Ectopic pregnancies had a higher with 140.3 and third was Central Queensland prevalence generally in the age bracket 21- with 125. Central West did not have any 30. However in 2006 and 2008 the rate was notifications this year and the second lowest higher in the age bracket 31-40. In 2000 the region was Cairns and Hinterland with 19. Queensland rate was 55 for the age bracket The overall Queensland rate was 86.5. 15-20, 188 for ages 21-30 (which is also the The age bracket with the most notifications highest rate over the 9 year period), 123 for was 31-40 with a rate of 198.5. Over the 8 ages 31-40 and 9.2 for ages 41-50. The year period, the age bracket 31-40 average rate for female population of consistently had the highest notifications, Queensland aged 15-50 was 99.5 per generally around the mid 100’s. The age

 Page 9  PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008 bracket 15-20 had a rate of 2.38, the 21-30 2000-2008, with overall rates fluctuating rate was 62.91and the 41-50 rate was 33.53. minimally on an annual basis. Statistically, epididymitis was more prevalent in males In 2008, the rate of notification was the aged 41 years and over whilst the disease highest in Central Queensland with a rate of was least prevalent in males aged 15-20 122 and second highest in Metro North with years of age. a rate of 102. Metro South had the third highest rate with 93. Mt Isa and the Torres Pelvic Inflammatory Disease Strait-Northern Peninsula didn’t report any notifications and the region with the lowest In the year 2000, the overall average rate for rate was Townsville with 10.6. the State based on the female population The 31-40 age bracket had a rate of 152, was 166 per 100,000. The highest which is lower than in 2000, however after prevalence of PID was found in the Torres 2001the rate had remained relatively stable. Strait-Northern Peninsula (597 per 100,000), The 21-30 age bracket had a rate of 49.74 Cape York (375 per 100,000) and Metro and the overall Queensland rate was 65.5, North (206 per 100,000) regions. In 21.1 per 100,000 down from the year 2000. comparison, in 2008, the overall average The rates for each age bracket group stayed rate for the state based on the female relatively the same, only slightly decreasing population was 151 per 100,000 with the over the 8 year period. The metropolitan highest prevalence of PID being found in Mt regions along with the central west Isa (319 per 100,000), Gold Coast (284 per Queensland areas showed the highest rates 100,000) and Cape York (245 per 100,000). between 2000 and 2008. In 2005, Cape York The rates have varied from year to year from had the highest rate with 129 per 100,000 2000- 2008, fluctuating from 137 to 174 per diagnosed with tubal infertility. 100,000. According to the data, the 41 years of age and over age bracket has the highest Epididymitis rate of prevalence when measuring PID, with ages 15 to 20 years of age representing the In the year 2000, the overall rate of lowest level of prevalence of the disease. epididymitis based on the male population The highest notifications of PID is found in within Queensland was 34.86 per 100,000. Metro North and South regions with the In 2000, the highest prevalence’s of lowest notifications of PID being found in the epididymitis were found in Cape York (115 Torres Strait-Northern Peninsula and Central per 100,000), Torres Strait-Northern West regions, however these population Peninsula (81 per 100,000), Mt Isa (77.5 per rates were the highest for the state. 100,000) and South West (78.5 per 100,000) regions. Comparatively, in 2008, the overall Chlamydia average for the State based on the male population within Queensland was 30.8 per In 2000 the overall Queensland rate of 100,000 with the highest rates of prevalence notification for Chlamydia was 172.6 per being found in both the South West (82 per 100,000. The notification rate among 100,000) and Cape York (73 per 100,000) females (216.3 per 100,000) was 88.1 per regions. A significant change in the 100,000 more than males (128 per 100,000). prevalence of epididymitis within In 2008 the rate of notification of Chlamydia Queensland and its’ more rural areas is in was 432 per 100,000, an increase of 259.4 2006 whereby the region of Cape York does per 100,000. The notification rate among not report any notifications. Total females (529.8 per 100,000) was up by Queensland population rates of males with 313.5 per 100,000 from 2000. The epididymitis stayed relatively consistent from notification rate among males (332.5 per

100,000) was up by 204.5 per 100,000 from Gonorrhoea was males 20-24 (147.1 and 2000. In 2008 the female notification rate 176 per 100,000 respectively). In both 2000 was 197.3 per 100,000 more than males. and 2008 the female group with the highest rate was males between 15-19 (140.2 and In both 2000 and 2008 the age/gender group 152.4 per 100,000 respectively. In 2000 the showing the highest rate of notifications of age groups showing zero notifications of Chlamydia was females 15-19 (858 and Gonorrhoea was 75-79, 80-84 and 85+. In 2278.5 per 100,000 respectively). In both 2008 the age groups showing zero 2000 and 2008 the male group with the notifications of Gonorrhoea was 65-69 and highest rate was males between 20-24 80-84. (470.4 and 1365.3 per 100,000 respectively. In both years the only age group in that year In both 2000 and 2008, the notification rate showing zero notifications notification of of Gonorrhoea among those living in rural Chlamydia was 80-84. and remote regions is also markedly higher than either of the above mentioned rates. In In 2000 the notification rate of those living in 2000 the notification rate of those living in the Torres Strait-Northern Peninsula was the Torres Strait-Northern Peninsula was 3692.1 per 100,000, 1604.7 per 100,000 in 1445.7 per 100,000, 1140.0 per 100,000 in Cape York and 482.9 per 100,000 for those Cape York and 213.9 per 100,000 for those living in Mt Isa. In 2008 the notification rate living in Mt Isa. In 2008 the notification rate of those living in the Torres Strait-Northern of those living in the Torres Strait-Northern Peninsula was 3668.5 per 100,000, a drop of Peninsula was 709.7 per 100,000, a drop of 23.6 per 100,000. In Cape York it was 736.0 per 100,000. In Cape York it was 2283.1 per 100,000, a rise of 678.4 per 862.9 per 100,000, a drop of 277.1 per 100,000 and in Mt Isa in 2008 the rate of 100,000 and in Mt Isa in 2008 the rate of Chlamydia was 743.6 per 100,000, a rise of Gonorrhoea was 281.3 per 100,000, a rise of 268.4 per 100,000. 67.4 per 100,000. Gonorrhoea

In 2000 the Queensland rate of notification Discussion for Gonorrhoea was 39.9 per 100,000. The notification rate among females (30.2 per Overall, the rate of Chlamydia and 100,000) was 19.6 per 100,000 less than Gonorrhoea are continually increasing, males (49.8 per 100,000). In 2008 the rate of especially in the younger age groups. The notification of Chlamydia was 432.0 per rates of Chlamydia and Gonorrhoea are far 100,000, an increase of 259.4 per 100,000. higher among Indigenous populations than The notification rate among females (31.1 among non-Indigenous Australians and this per 100,000) was up by 0.9 per 100,000 can be seen in the graphical representation from 2000. The notification rate among on the map of Australia on page 17 of the males (59.6 per 100,000) was up by 9.8 per appendices. Chlamydia is increasing at a 100,000 from 2000. In 2008 the female much higher and faster rate than notification rate was 28.5 per 100,000 more Gonorrhoea. In 2001, Indigenous Australians than males. Between 2000 and 2008 the rate aged 15-19 had the highest notification rate difference between male and female of Gonorrhoea in Australia (2,500 per notification increased by 8.9, with males 100,000 population), a figure representing 26 being more dominant than in 2000. times the national rate of notification. In 2003, notification rates of Chlamydia among In both 2000 and 2008 the age/gender group Indigenous Australians were reported at 93 showing the highest rate of notifications of times the rates of non- Indigenous Australians (Australian Human Rights, n.d).

These figures are similar to those presented investigations and treatment and this could by the Department of Health and Ageing be a reason why tubal infertility is rarely seen (2005) earlier, and are clearly shocking, in Cape York and Torres Strait- Northern especially when it is noted that the Peninsula regions. Indigenous population make up on 2.6% of the Australian population. Ectopic pregnancy notifications for the state In 2008, Torres Strait- Northern Peninsula are increasing slowly but constantly, with a reported an incidence rate of Chlamydia of rate difference of 15 notifications per 5566 per 100,000, Cape York with 3121 per 1000,000 over 2000-2008. The greatest 100,000 and Mt Isa with 999 per 100,000. In increase is seen in the 31-40 year age comparison the state average was 432 per group. An explanation for the increase in rate 100,000. These rates in the Indigenous ectopic pregnancies in the 21-30 age groups populated regions are at an average 10 can be explained by the fact that these years times higher than the Queensland overall account for the childbearing stage in a rate. For Gonorrhoea in 2008, the rate in woman’s life. Indigenous populated areas is on average The rates of ectopic pregnancy are seen to 25 times higher than the state rate. be higher in remote areas which have a high It is important to note that the increase in prevalence of Indigenous Australians. Some Chlamydia and Gonorrhoea notification may of the explanations for the higher rates of also be due to advances in PCR ectopic pregnancy in areas with high (polymerase chain reaction) and NAAT Indigenous populations may be because the (nucleic acid amplification testing) testing hospitals are the main healthcare point of (Queensland Health, 2006). contact for females in these areas as there are less general practices there compared to The overall rate of tubal infertility is metropolitan areas of Queensland, as decreasing for Queensland females as well diagnoses of ectopic pregnancies only from as in the areas which report the higher rates. hospital admissions appear in our statistics. The Queensland rate over 2000-2008 has In metropolitan areas, diagnosis would decreased by 20 notifications per 100,000. commonly occur in GPs and gynaecological However, there was a spike in notifications in specialist offices. Another likely explanation 2007 and 2008. The regions with is due to the fact that Indigenous women consistently high rates were Central tend to have a higher fertility rate and have Queensland, Metro North and South and babies at younger ages than did non- South West. Metro North and South had Indigenous women, therefore increasing the rates of tubal infertility consistently above the risk for ectopic pregnancy. In 2006, national Queensland rate and most of the other fertility rates were 2,118 births per 1,000 regions apart from those mentioned above Indigenous women and 1,814 per 1,000 for had rates well below the state average. For all mothers (ABS 2007). tubal infertility, it was Metro North and Metro Another plausible reason for the higher rates South that often showed high rates of tubal of ectopic pregnancy in these areas may be infertility. The reason for the high rates in related to the high rates of Chlamydia and metropolitan Brisbane may be because there Gonorrhoea, which can lead to infertility are more females who are trying to start complications. While some screening families and when they cannot conceive programs have reduced the prevalence of naturally they endeavour to seek a medical STIs in Aboriginal and Torres Strait Islander explanation and therefore are diagnosed communities, most communities continue to with tubal infertility. It is generally these have high rates of STIs and inadequate females who are from a higher social access to appropriate screening and economic background and can afford fertility treatment.

The higher rates of ectopic pregnancies greater exposure to other sexually occurred in Cape York, Torres Strait- transmitted infections may play an important Northern Peninsula, Mt Isa, South West and role. Central West. There were however some noticeable differences in rate trends, for The Queensland rate of epididymitis is example in 2001 Torres Strait- Northern declining at a very slow constant rate. In Peninsula had the lowest rate in the state 2000 the rate was 45 and in 2008 it was 39 with 39.88 per 100,000 as it only had one per 100,000. Again, higher prevalence’s ectopic pregnancy notification that year and were noted in Torres Strait-Northern the average notification rate was typically 5. Peninsula, Cape York and Mt Isa. The rate From these statistics it is therefore difficult to trend for these regions however does not ascertain whether there is an increase in indicate any significant decrease as the rates ectopic pregnancies in Indigenous areas as vary so much every year. Noticing a the rates vary so much from year to year, decrease may be more prevalent in looking however looking at the state level it is at the notification rates. evident that there is a continual slight The low rate of epididymitis in Cape York in increase in EP rates. This new evidence 2006 suggests that perhaps there were no supports Boufous et al (2001) claim to the reported cases given the historical fact that ectopic pregnancy rates may be prevalence of the disease in the region. stabilising. Over the Boufous study period, Overall, Torres Strait-Northern Peninsula, the incidence of ectopic pregnancy among Cape York and South West regions have the women aged 15-44 years remained relatively highest rates of epididymitis whilst the lowest constant, with 1521 admissions for ectopic rates vary considerably between 2000 and pregnancy in 1992 and 1321 in 2001. 2008; however, non-rural regions have seemingly lower rates of the disease. Again, The rates of PID overall in Queensland have higher rates were seen in 45+age group and been decreasing and this is also reflected in lower rates in 15-20. areas with high Indigenous populations. However the outstanding issue is that the As most of the health districts have a rates in the Indigenous areas are far higher relatively low population (eg. < 5000), the than metropolitan areas. The greatest rates are greatly influence by the number of decrease can be seen in the age group 21- notifications of disease and therefore may 30 suggesting that this group is reporting not always be truly representative. fewer notifications, or better treatment of This was the case in some years for ectopic Chlamydia and Gonorrhoea is having this pregnancies, epididymitis and tubal infertility result. In a study similar to this one Chen, whereby regions that usually had the highest Fairley and Donovan (2005) found that rate in the state displayed rates which were admission rates for PID among women aged relatively low. The areas with the highest 15-34 years fell from 165 per 100 000 in rates are those with small populations where 1992 to 64 per 100 000 in 2001. The highest high notifications have a large impact on the prevalence for Queensland overall was notification rate. Metro North and South have noticed in the age group 41+ with the lowest a large population and their rates were for all being 15-20 and this may be due to PID infections and their sequelae were requiring recurrent STI infections and a long consistent, therefore making the statistics latency period. This may also be the case for significant. tubal infertility and ectopic pregnancies as rates for these also occur in the latter stage One of the main significant issues is the fact of a woman’s reproductive life. In addition to that Chlamydia, Gonorrhoea, PID and tubal a long latency period between infection and infertility often do not show any clinical signs these diseases, a longer sexual history and and may be masked. Signs and symptoms

 Page 13  PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008 for the diseases may differ for each Gonorrhoea and their sequelae among individual and different predisposing factors Caucasian individuals and those with an such as smoking, IUCD use, familial history Indigenous background. and high risk sexual activity may play a role Evidence obtained from this study suggests in the development of PID, EP, TI and E. that more attention needs to be paid in the In addition, underreporting of the infections high risk groups in Queensland, notably and all the diseases may be present. A Indigenous Australian, adolescents and limitation of this study is that data presented young adults and homosexual men. is only for hospital admissions for PID, EP, TI and E in Queensland hospitals, and some As infection with Chlamydia and Gonorrhoea of these conditions do not require can lead to PID, tubal infertility, ectopic hospitalization and are treated in GP clinics, pregnancy and epididymitis, this is of public therefore the true incidence is not known. health concern as these infections can lead Further study to include data from general to infertility and ill health. practices is needed. Even though the results do not suggest that PID, TI and E are rising due to an increase in In the remote areas with a higher incidence Chlamydia and Gonorrhoea, it highlights that of Chlamydia and Gonorrhoea, the rates of current treatment regimes may perhaps be the sequelae are similar to those presented working and people are controlling for industrialised countries in the1970s and symptoms before they become more severe. 1980s. If these current rates are reliable and This may be due to the advancements in correct, then this may be another reflection antibiotics, especially the once off of the time lag and poor health between Azithromycin dose, rather than a full two Indigenous and non-Indigenous Australian’s. week course of another antibiotic. However, Chlamydia screening programs The federal government with its’ Chlamydia overseas have failed to reduce Chlamydia screening pilot program is targeting sexually prevalence despite screening 20%-30% of active young people less than 25 years of young sexually active women, especially age, its’ priority action group. Funding for the because Chlamydia control and prevention is project is declared at $12.5 million over 4 one of the three specific priority areas in the years which is aimed at increasing National Sexually Transmissible Infections awareness of Chlamydia, improving (STIs) Strategy 2005-2008. The surveillance and a pilot Chlamydia testing effectiveness of the recent strategy needs to program. It subsequently committed $3.5 be considered, bearing in mind it is the first million to Chlamydia prevention projects of its kind in Australia. targeting high-risk groups. The high burden of infertility and related problems in industrialised countries together with the associated high healthcare costs indicate that there are substantial health Conclusion gains to be made from the correct prevention of and screening strategies for Chlamydia The results of this study fit in line with the and Gonorrhoea and their sequelae. previous research conducted in Interventions to increase the populations and industrialised countries mentioned earlier on health professionals’ awareness of sexually in the paper, in that some of the sequelae transmitted infections and their impacts need are decreasing albeit the ever increasing to be implemented as most of these rates of Chlamydia and Gonorrhoea. In infections and diseases are asymptomatic. If addition, this study also confirms the they are not address, they will unknowingly difference in incidence of Chlamydia,

 Page 14  PID, EP, TI and E in the context of rising Chlamydia and Gonorrhoea rates in Queensland during 2000 and 2008 continue to be spread to the individual and Australian and New Zealand Journal of their sexual partner/s. Obstetrics and Gynaecology. 41(4), 436-8.

As the notifications and rates are highest in Bouyer, J., Coste, J. and Shojaei, T. 2003. Queensland, this indicates that there is an Risk factors for Ectopic Pregnancy: A increased problem of sexually transmitted Comprehensive Analysis Based on a Large infections in this state which needs to be Case-Control, Population-based study in addressed by national and state healthcare France. American Journal of Epidemiology. systems. 157(3), 185-194.

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