Læknablaðið - 15.08.1995, Blaðsíða 41

LÆKNABLAÐIÐ 1995; 81
617
women will develop clinical PID. Of the re-
maining (9600) women at least 60% (5800) will
develop subclinical PID. This figure is based
on the prevalence of plasma cell endometritis
detected by endometrial biopsies in asympto-
matic women with Chlamydial cervicitis. Fur-
thermore, seroepidemiological studies suggest
that only one fifth of women with tubal factor
infertility have a history of a Chlamydial in-
fection or PID. Hence, both these observa-
tions suggest that a great proportion of PID is
asymptomatic and that a great proportion of
tubal damage is associated with asymptomatic
Chlamydial infection. Of the 8200 PID pa-
tients approximately 3000 will develop tubal
infertility and approximately 3000 will develop
mild tubal damage increasing the risk of tubal
pregnancy. Seventeen percent of all couples in
Finland suffer from involuntary infertility, and
approximately 25% of infertile women have
tubal factor infertility. Based on seroepidemi-
ological studies, two thirds of these are caused
by the sequelae of past Chlamydial infection.
In such infertility cases in vitro fertilization
(IVF) is the only effective treatment. The cost
of one IVF treatment is approximately 10,500
FIM, and the success rate varies from 20-35%
(up to three IVF attempts per patient) depend-
ing on the age group. In the Helsinki metropol-
itan area (population approximately one mil-
lion) at least 400 IVF treatments are perform-
ed per month, representing some 5000 IVF
treatments annually.
The incidence of tubal pregnancies in Fin-
land (175/100,000 in the age group of 15^4) is
higher than in other developed countries. Ap-
proximately one half of tubal pregnancies are
associated with past Chlamydial infection. The
cost for treatment and diagnosis of one tubal
pregnancy, using operative laparoscopy is ap-
proximately 8500 FIM. Thus, a very conserva-
tive estimate is that the direct annual costs
caused by the sequelae to Chlamydial infec-
tions in Finland are at least 129 million FIM
(table IV).
Secondary prevention of Chlamydial
infections is cost-benefícial
Primary prevention means education
(schools, media etc.) and counselling in order
to minimize exposure to and acquisition of C.
trachomatis. Secondary prevention means
more sensitive diagnostics (for instance PCR),
risk assessment, and screening of high risk
groups (antenatal clinics, adolescent clinics,
army recruits, family planning clinics, etc.). It
is also important to include in secondary pre-
vention the four Cs, i.e. condom use, counsel-
ling, compliance and contact tracing.
It has been estimated that if Chlamydial in-
fections could be prevented tubal factor in-
fertility would decline by at least 80%, and
tubal pregnancies by at least 50%. Some cases
of reactive arthritis, premature delivery, neo-
natal infections and postpartum infections
could also be prevented. Chlamydial screening
during pregnancy is important in order to pre-
vent pregnancy complications, postpartum in-
fections and perinatal morbidity. Recent stud-
ies suggest that approximately 3% of pregnant
women in Finland have Chlamydial infection.
However, Chlamydia screening programs in
the antenatal clinics do not exist.
Table III shows theoretical cost estimate of
universal Chlamydia screening program an-
nually in Finland. The cost of screening is only
one fifth of the total costs caused by undiag-
nosed Chlamydial infections. Efficient risk as-
sessment can further reduce the cost of screen-
ing programs by targeting screening to the high
risk groups. Studies have shown that screening
can be targeted so that when the total pop-
ulation screened is reduced by half only 10% of
Chlamydia positive cases are missed. In sum-
mary, the cost of screening is only a fraction of
costs created by the well-known sequelae of
undiagnosed Chlamydial infections. Thus, the
key message is that allocating less resources to
screening programs will evidently create major
costs to the health care system in the future.
REFERENCES
Márdh P-A, Paavonen J, Puolakkainen M. Chlamydia. Plen-
um Publishing Corporation, 1989.
Chlamydial Infections. Proceedings of the 8th International
Symposium on Human Chlamydial Infection, June 19-24,
1994, Chateau de Montvillargenne, France. J Orfila, et al
eds. Bolognia: Societa Editrise, Esculapio.
Robinson R. Cost-benefit analysis. Br Med J 1993; 307:
924-b.
Robinson R. Cost-effectiveness analysis. Br Med J 1993;
307: 793-5.
Robinson R. Cost-utility analysis. Br Med J 1993; 307: 859-
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Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical
Epidemiology a Basic Science for Clinical Medicine. Little,
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