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ORIGINAL ARTICLE
Year : 2012  |  Volume : 136  |  Issue : 6  |  Page : 1004-1010

Ocular Chlamydia trachomatis infections in patients attending a tertiary eye care hospital in north India: A twelve year study


1 Department of Ocular Microbiology, Dr R.P. Centre for Ophthalmic Science, New Delhi, India
2 "Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India

Date of Submission23-Jul-2010
Date of Web Publication4-Feb-2013

Correspondence Address:
Gita Satpathy
"Professor, Department of Ocular Microbiology, Dr R.P. Center for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029
India
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Source of Support: None, Conflict of Interest: None


PMID: 23391797

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   Abstract 

Background & objectives : Ocular infection with Chlamydia trachomatis is a major public health problem in densely populated countries like India. The true prevalence of such infections is uncertain due to insufficient data available from India. The aim of this study was to do a retrospective analysis of C. trachomatis eye infections in patients attending the outpatient department of Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, over a period of 12 years.
Methods: From 1997 to 2008, the Chlamydia laboratory received conjunctival swabs from 1281 consecutive patients for C. trachomatis detection after thorough clinical examination. Specimens were subjected to direct fluorescent antigen detection assay using monoclonal antibody based commercial kit to detect the presence of C. trachomatis antigen.
Results: Antigen positivity varied between 22-28 per cent. Children below 11 yr and people above the age of 60 yr showed comparatively higher antigen positivity (25.7 and 27.8%, respectively). As compared to males significantly (P<0.05) higher number of females in the age group of 31-60 yr were positive for C. trachomatis antigen. Patients with the clinical diagnosis of follicular/allergic conjunctivitis and trachoma showed higher rate of antigen positivity.
Interpretation & conclusions : Northern India having dry and arid climatic conditions in most parts of the year was considered in the past as one of the trachoma hyper-endemic foci. The study indicated that laboratory proven C. trachomatis eye infection still persisted in this part of the country throughout the study period of 12 years.

Keywords: Antigen detection - Chlamydia trachomatis - direct immunofluorescence assay - eye infections - trachoma


How to cite this article:
Sharma A, Satpathy G, Nayak N, Tandon R, Sharma N, Titiyal JS, Panda A, Vajpayee RB, Pandey RM. Ocular Chlamydia trachomatis infections in patients attending a tertiary eye care hospital in north India: A twelve year study. Indian J Med Res 2012;136:1004-10

How to cite this URL:
Sharma A, Satpathy G, Nayak N, Tandon R, Sharma N, Titiyal JS, Panda A, Vajpayee RB, Pandey RM. Ocular Chlamydia trachomatis infections in patients attending a tertiary eye care hospital in north India: A twelve year study. Indian J Med Res [serial online] 2012 [cited 2019 Aug 20];136:1004-10. Available from: http://www.ijmr.org.in/text.asp?2012/136/6/1004/106849

Ocular infection with Chlamydia trachomatis, especially trachoma, continues to be a major public health problem in many parts of the world. Recurrences often cause follicular/intense trachoma that may lead to trichiasis, corneal opacity and eventually blindness [1] . Despite the intense efforts by the World Health Organization (WHO) in the form of VISION 2020 and GET-2020, advocating multifaceted approach to interrupt transmission of C. trachomatis, the programme could truly be implemented only in 10 out of 55 trachoma endemic countries [2],[3] . Reasons were attributed to lack of insufficient information from the densely populated countries like India and China [2],[3],[4] . Although the disease has been eliminated from many developed countries, a large population in Africa, Middle-East, South America, Asia, The Pacific, and Australia still suffer from this blinding disease that accounts for nearly 15 per cent of the global blindness [5] .

India is a vast country with diverse socio-economic and varied hygienic conditions, and hence it is not feasible for a single laboratory or a single centre to undertake countrywide surveillance. In 1986-1989, a nationwide survey showed a decrease in prevalence of trachoma, prevalence rates of active trachoma during this period being 11.9, 7.84 and 6.56 per cent as opposed to 18.2, 44.1 and 45.1 per cent in 1962 in Punjab, Rajasthan and UP, respectively [6] . However, prevalence of blindness attributed to trachoma was 0.39 per cent in 1989 [6] . Sporadic studies conducted in primary schools of Delhi in 1999 and 2004 reported that trachoma was the most common cause of ocular morbidity amongst the school going children [7],[8] . Community studies were conducted in 1998 in reportedly hyperendemic areas of UP in 837 children and clinical trachoma prevalence was found to be 8.5 per cent [9] . In 2007-2008 community studies were carried out in hyperendemic areas of Haryana on 1000 children and active trachoma was detected in 4 per cent of them [10] . A part of the same study conducted in 1000 adult women, found evidence of cicatricial trachoma in 35 per cent of women above 30 yr of age [11] . Hospital based studies from south India reported C. trachomatis eye infection prevalence to be 17 per cent in 1990 [13] , 34.6 per cent in 1991-1992 [13] , 20.9 per cent in 1999 [12] and 4.9 per cent in 2003 [13] . Sporadic reports available on limited number of samples did not seem to be enough to measure the exact magnitude of the problem.

In special situations like high vs. low endemicity or active vs resolved trachoma cases, there are often wrong interpretations while correlating clinical assessment with laboratory findings, ultimately landing up either with incorrect laboratory diagnosis or incorrect clinical diagnosis. In an Egyptian study using ligase chain reaction (LCR) assay, 31 per cent of clinically active children did not have laboratory evidence of infection and 31 per cent infected children did not have clinical trachoma [14] . An Ethiopian study showed that the positive predictive value of clinical examination identifying infection was 66 per cent while inter-examiner variance was 30 per cent [15] .

In the present study, we retrospectively analysed the information on all patients tested for the presence of C. trachomatis infection for the past 12 years (1997-2008). All consecutive patients likely to have C. trachomatis eye infections coming to a tertiary care eye hospital in north India during this period were tested using direct immunofluorescence assay (DFA), which is being routinely carried out in the Chlamydia laboratory.


   Material & Methods Top


A total of 1281 patients (763 females, 518 males) in the age-group of 1-90 yr were referred to the Chlamydia laboratory from the outpatient department (OPD) of Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi, for the laboratory confirmation of C. trachomatis eye infections from 1997 to 2008. Study protocol was approved by the AIIMS ethics committee. All consecutive patients coming to hospital during this period with acute or chronic follicular conjunctivitis and keratoconjunctivitis were included. Patients with frank purulent conjunctivitis and acute haemmorrhagic conjunctivitis coming during viral conjunctivitis outbreaks were not included.

Prior to referring the patients to our laboratory, experienced ophthalmologists performed clinical examination using slit lamp biomicroscopy of the anterior segment of the eye and ocular adenexa. WHO simplified diagnosis and grading system for trachoma was used in patients for diagnosis of clinical trachoma wherever it was possible [4] .

Specimens from the superior/inferior palpebral conjunctiva of both eyes were taken with sterile wet cotton swabs and smeared onto a clean Teflon-coated glass slide (one specimen from each eye). The slides were air-dried, fixed in cold acetone for 10 min and subjected to direct immunofluorescence assay for Chlamydia antigen detection.

Direct immuno-fluorescence assay (DFA): The monoclonal antibody based C. trachomatis direct specimen kit (MicroTrak, USA) was used for the detection of antigen using the standard protocol [16] . Briefly, conjunctival smears were covered with 30 μl of fluoresceine-isothiocynate (FITC)-conjugated murine monoclonal antibodies to C. trachomatis for 30 min at 37 o C in a humidified chamber. The slides were washed with double distilled water, air-dried, mounted and observed under the fluorescent microscope (Nikon, Japan). The positive-control was fixed mammalian cells containing Chlamydia elementary/reticulate bodies, (EB/RB) (provided with the kit) while the negative control contained normal uninfected mammalian cells. Chlamydia elementary bodies appeared as round, bright, apple green, fluorescent particles, regular in outline [Figure 1].
Figure 1. C. trachomatis particles observed under direct immunofluorescence assay (1a: x400, 1b: x1000).

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Statistical analysis: Antigen positivity was summarized by frequency (percentage). Test of proportions (Z-test) was used to compare differences in percentage antigen positivity amongst males and females for each age group separately. Also test of proportions (Z-test) with Bonferroni correction was used to compare C. trachomatis antigen positivity amongst the groups with various clinical diagnosis. STATA 11.0 statistical software was used for data analysis.


   Results Top


Of the total 1281 patients (763 males, 518 females age 1-90 yr) studied, 485 were clinically diagnosed as trachoma, 296 as cases of follicular, acute or allergic conjunctivitis, 94 kerato-conjunctivitis and the remaining 406 were labelled as probable cases of other eye infections/manifestations. Of the 1281 patients studied, 321 (25.05%) were found positive for Chlamydia antigen. Children below 11 yr of age and older people above the age of 50 yr showed comparatively higher positivity for chlamydia antigen (25.7, 25.0 and 27.9%, respectively) [Table 1]. Significantly larger number of females 222 (29.1%) were positive for C. trachomatis antigen than males 99 (19.1%). Females in the age group of 31-60 yr showed significantly higher rate of antigen positivity (P<0.05) as compared to males.
Table 1. Age and sex distribution of Chlamydia antigen positivity


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Although, the range of Chlamydia antigen positivity remained between 22-28 per cent during the study period, overall antigen positivity was above 21 per cent in our study population over a 12 year period, with higher rates in the years 1998, 2002 and 2004 [Table 2] and [Figure 2].
Figure 2. Number of specimens in different age group and Chlamydia antigen positivity during the years 1997-2008.

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Table 2. Year-wise break up with age groups for patients with Chlamydia antigen positivity


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Patients diagnosed with allergic, acute or follicular conjunctivitis showed significantly (P<0.01) higher positivity (33.4%) than patients labelled as trachoma (27.8%), kerato-conjunctivitis (10.6%) and other eye infections mimicking trachoma (18.9%) [Table 3].
Table 3. C. trachomatis antigen positivity in patients with different clinical diagnosis during 1997-2008


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   Discussion Top


Success of the global alliance for elimination of trachoma by 2020, (GET2020) initiated by WHO lies in the stringency and outcome of local efforts to contain the disease [2],[3] . Any such initiative will have the desired impact only if reliable data pertaining to the prevalence of the disease in an 'erstwhile endemic area' is generated periodically; in which clinical, laboratory and epidemiological accuracy play important roles [1],[4],[5] .

Trachoma prevalence in India has been reported to be varying between 0.5 to 80 per cent, according to studies [6],[9],[10],[11],[12],[13] conducted across various centers. Community studies were conducted to find out the true prevalence of C. trachomatis infection using laboratory support in the known hyperendemic belt of northern India by the Trachoma Study Group in 1998 (Uttar Pradesh) [9] and later in 2007-2008 (Haryana) [10],[11] . Hence, the data generated during the present hospital based study for 12 years could be useful and indicative of the trend of C. trachomatis eye infection in the region during these twelve years. Clinical diagnosis alone has often been misleading for various reason, like concurrent infections, non detection of C. trachomatis in clinically active patients and clinical positivity even after the complete antibiotic therapy because of continuing inflammation [14],[15],[17] .

In the present study, Chlamydia antigen was detected in 27.8 per cent of patients diagnosed as trachoma, in 33.4 per cent of patients clinically diagnosed as follicular/acute or allergic conjunctivitis and in 18.9 and 10.6 per cent in patients with other eye infections and kerato-conjunctivis, respectively. The laboratory testing provided definitive information about chlamydial infection in more patients than clinical examination alone. In our previous hospital based study in the last decade, in a separate small group of patients of chronic conjunctivitis, Chlamydia antigen could be detected in 38 per cent patients [18] . However, much lower rates of C. trachoamtis antigen detection was reported from hospital based studies from south India [12],[13] .

Rapid antigen detection by immunoflourescence assay was used in this study which is relatively quicker and easier to perform, and more affordable than PCR assay, and is time tested in other laboratories [19],[20],[21] . Although there has been reports on a decline in number of cases with C. trachomatis eye infections [13] , we found antigen positivity above 21 per cent in all age groups studied. This positivity rate was higher as compared to the findings from community studies [9],[10] , as this was a hospital based study where patients actively sought medical assistance and thus might not be true reflection of increased prevalence in community. There is a possibility that the patients might have clinical trachoma without having true infection, as was suggested by well established studies from other parts of the world [14],[15] . An Australian study found that only in 17 per cent of clinically active cases could C. trachomatis DNA be detected [22] . In a community study in Nepal [14] with 6 per cent clinical activity, C. trachomatis DNA could be detected in none of the subjects. Our study suggests that C. trachomatis eye infection is still continuing in the community, compelling patients for hospital visit. Previous reports indicated increased infectious load with decreasing endemicity and disease severity for trachoma [21],[23] . At the same time clinical overdiagnosis resulting in projection of unusually higher prevalence rates has always remained a point of criticism [24] . Therefore, it has become necessary to confirm the clinical diagnosis using one or more duly validated and affordable laboratory tests [15],[25] . Several researchers have suggested the use of nucleic-acid based assays including quantitative real-time PCR [26] including pooling of samples [27] to augment clinical assessment. Keeping in view the cost and technical expertise involved, the current generation gene detection assays may be used only for the diagnosis of referred cases or for the purpose of molecular subtyping of circulating strains whereas methods like rapid antigen detection using immuno-fluorescence may be preferred for epidemiological surveillance in developing countries.

In conclusion, the present study indicates that C. trachomatis eye infection is persisting in northern India, albeit at a lower level. However, a large population-based nationwide study is needed to identify the exact epidemiology of this infection.


   Acknowledgment Top


This study was supported by Departmental Funding from Dr R.P. Centre for Ophthalmic Sciences, New Delhi. Authors thank all the clinical faculty members and resident doctors of Dr R.P. Centre for Ophthalmic Sciences for sending the clinical specimens for investigations.

 
   References Top

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2.WHO Report on the 2 nd Global Scientific Meeting on Trachoma. WHO/PBD/GET03.1. Geneva: World Health Organization; 2003.  Back to cited text no. 2
    
3.Making progress toward the global elimination of blinding trachoma. Report of the tenth meeting of the WHO Alliance for the Global Elimination of Blinding Trachoma. Geneva, Switzerland: World Health Organization; 2006. Available from: http://www.who.int/blindness/publications/get2020/en/index.html, accessed on March 15, 2007.   Back to cited text no. 3
    
4.Mariotti SP, Pararajasegaram R, Resnikoff S. Trachoma: looking forward to global elimination of trachoma by 2020 (GET 2020). Am J Trop Med Hyg 2003; 69 : 33-5.  Back to cited text no. 4
    
5.Lansingh VC, Carter MJ. Trachoma surveys 2000-2005: Results, recent advances in methodology, and factors affecting the determination of prevalence. Surv Ophthalmol 2007; 52 : 535-46.  Back to cited text no. 5
    
6.Mohan M. Survey of blindness-India (1986-1989): Results at glance. In: Present status of the National Programme for Control of Blindness. New Delhi: Directorate General of Health Sciences, Ministry of Health and Family Welfare, Government of India; 1992. p. 81-100.   Back to cited text no. 6
    
7. Chaturvedi S, Aggarwal OP. Pattern and distribution of ocular morbidity in primary school children of rural Delhi. Asia Pac J Public Health 1999; 11 : 30-3.  Back to cited text no. 7
    
8.Kumar R, Mehra M, Dabas P, Kamlesh, Raha R. A study of ocular infections amongst primary school children in Delhi. J Commun Dis 2004: 36 : 121-6.   Back to cited text no. 8
    
9. Study Group Trachoma. Current trends in trachoma in a previously hyperendemic area. Indian J Ophthalmol 1998; 46 : 217-20.  Back to cited text no. 9
    
10.Khanduja S, Jhanji V, Sharma N, Vasist P, Murthy GVS, Gupta S, et al. Rapid assessment of trachoma among children living in rural Northern India. Ophthalm Epidemiol 2009; 16 : 206-11.  Back to cited text no. 10
    
11.Khanduja S, Jhanji V, Sharma N, Vasist P, Murthy GVS, Gupta S, et al. Trachoma prevalence in women living in rural Northern India: Rapid assessment findings. Ophthalm Epidemiol 2012; 19 : 216-20.  Back to cited text no. 11
    
12.Madhavan HN. Laboratory investigations on viral and Chlamydia trachomatis infections of the eye: Sankara Netralaya experiences. Indian J Ophthalmol 1999; 47 : 241-6.  Back to cited text no. 12
    
13.Malathi J. Madhavan HN, Therese KL, Joseph PR. A hospital based study on the prevalence of conjunctivitis due to Chlamydia trachomatis. Indian J Med Res 2003; 117 : 71-5.  Back to cited text no. 13
    
14.Bird M, Dawson CR, Schachter JS, Miao Y, Sharma A, Osman P. Does the diagnosis of trachoma adequately identify ocular clamydial infection in trachoma-endemic areas? J Infect Dis 2003; 187 : 1669-73.  Back to cited text no. 14
    
15.Miller K, Schmidt G, Melese M, Alemayehu W, Elizabeth Yi, Ce valles V, et al. How reliable is the clinical exam in detecting ocular chlamydial infection? Ophthalmic Epidemiol 2004; 11 : 255-62.  Back to cited text no. 15
    
16.Mohile M, Deorari AK, Satpathy G, Sharma A, Singh M. Microbiological study of neonatal conjunctivitis with special reference to Chlamydia trachomatis. Indian J Ophthalmol 2002; 50 : 295-9.  Back to cited text no. 16
    
17.West SK, Munoz B, Mkocha H, Gaydos C, Quinn T. Trachoma and ocular Chlamydia trachomatis were not eliminated three years after two rounds of mass treatment in a trachoma hyperendmic village. Invest Ophthalmol Vis Sci 2007; 48 : 1492-7.  Back to cited text no. 17
    
18.Vanathi M, Sharma A, Satpathy G, Panda A, Angra SK. Role of Chlamydia trachomatis in the aetiological profile of chronic conjunctivitis in a tertiary care hospital. J CDR 2007; 1 : 500-4.  Back to cited text no. 18
    
19.Linder LE, Geerling S, Nettum JA, Miller SL, Altman KH, Wechter SR. Identification of Chlamydia in cervical smears by immunofluorescence: technic sensitivity and specificity. Am J Clin Pathol 1986; 85 : 180-5.  Back to cited text no. 19
    
20.Osama MB, Faten G, Ishrag T, Ahmad B. The value of Microtrack Chlamydia trachomatis diret specimen test in the diagnosis of trachoma. Baharain Med Bull 1995; 17 : 11-4.  Back to cited text no. 20
    
21.Salpietro CD, Bisignano G, Fulia F, Marino A, Barberi I. Chlamydia trachomatis conjunctivitis in the newborn. Archives de pediatrie 1999; 6 : 317-20.  Back to cited text no. 21
    
22.Resnikoff S, Pascolini D, Etya'ale D, Kocur I, Parajasegaram R, Potharel GP, et al. Gobal data on visual impairment in the year 2002. Bull World Health Organ 2004; 82 : 844-51.  Back to cited text no. 22
    
23.Soloman AW, Peeling RW, Foster A, Mabey CW. Diagnosis and assessment of trachoma. Clin Microbiol Rev 2004; 17 : 982-1011.  Back to cited text no. 23
    
24.Thein J, Zhao P, Liu H, Xu J, Jha J, Miao Y, et al. Does clinical diagnosis indicate ocular chlamydial infection in areas with a low prevalence of trachoma? Ophthalmic Epidemiol 2002; 9 : 263-9.  Back to cited text no. 24
    
25.Javaloy J, Ferrer C, Vidal MT, Alio JL. Follicular conjunctivitis caused by Chlamydia trachomatis in an infant Saharan population: molecular and clinical diagnosis. Br J Ophthalmol 2003; 87 : 142-6.   Back to cited text no. 25
    
26. Taylor HR, Dax EM. New precision in measuring trachoma infection. Lancet 2003; 362 : 181-2.   Back to cited text no. 26
    
27.Diamant J, Benis R, Schachter J, Moncada J, Pang F, Jha HC, et al. Pooling of Chlamydia laboratory tests to determine prevalence of ocular Chlamydia trachomatis infection. Ohthalmic Epidemiol 2001; 8 : 109-17.  Back to cited text no. 27
    


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