By Carol A. Kemper, MD, FACP

Surprise! My Kid Has Chlamydia

Various news alerts, May 2-5, 2015

Crane Independent School District has alerted parents to an outbreak of chlamydia in their school system. School officials became aware of a problem after Texas public health authorities noted 20 cases of chlamydia in school-aged kids residing in Crane and adjacent Upton County. This figure represents about 1 in 15 students at Crane High School. Chlamydia is a reportable disease in Texas.

The school district felt compelled to notify the parents of all junior high and high school students, although only high schoolers are known to be affected. The letter lists facts about chlamydia, including that it is a sexually transmitted disease and that most infections are asymptomatic. What the kids have been told is not clear from news reports.

According to the Crane Independent School District Student Handbook for 2014-2015, the district “does not offer a curriculum in human sexuality.” In 2012, the district’s School Health Advisory Committee had recommended Scott & White’s “Worth the Wait” Abstinence Plus curriculum.

Texas state law requires any sex-education course to spend more attention on abstinence than on other behavior. And students must be taught that abstinence until marriage is the best way to prevent sexually transmitted diseases.

According to KOSA-TV, Crane High School does offer three days of sexual education during the fall semester. The district’s Schools Health Advisory Committee was planning to meet to discuss how to deal with the chlamydia outbreak, and present their recommendations to the school board.

According to the National Campaign to Reduce Teen and Unplanned Pregnancy 2013 data, Texas rates 46th highest in teen births within the United States, and 47th highest in teen pregnancy rate (approximately 41 babies were born to 1000 Texas teens in 2013).

More on C. diff. Transmission

Eyre DW, et al. Diverse sources of C. difficile infection identified on whole-genome sequencing. N Engl J Med 2015;369(13):1195-1205.

Transmission of Clostridium difficile (CD) from a specific source is difficult to pinpoint, as genotyping or ribotyping is not sufficiently sensitive to distinguish between isolates. In an effort to establish genetic relatedness and specific sources for human infection, these authors went to great lengths to perform whole genome sequencing of all clinically significant isolates from symptomatic patients in the Oxfordshire area from 2007 to 2011. A total of 1250 CD cases yielded 1223 successfully sequenced isolates. Of these, 957 isolates obtained from 2008 to 2011 were compared to isolates from September 2007 onward. Transmission was presumed to occur when at least two isolates shared two or fewer single nucleotide variants (SNVs), consistent with genetic-relatedness, less than 124 days apart.

Epidemiologic investigation helped to define the nature of the potential exposure, using hospital data to fill in the blanks: Ward contact within a hospital was defined as transmission between two or more patients on the same hospital unit if infection occurred one week before or eight weeks after diagnosis of another case, and within an incubation period of 12 weeks. Hospital contact was defined similarly if within the same hospital but not the same unit, within 28 days of discharge (or infectivity). Community contact was defined as residing within the same postal address or within the same medical practice.

A total of 333 (35%) of the isolates were genetically related to at least one earlier case. Of these, 126 (38%) had ward contact, 29 (9%) had hospital-wide exposure, and 21 (6%) had both. In addition, 5 (2%) cases were genetically related to another hospital patient, but occurred following discharge of the case-patient, believed to be related to hospital exposure. Interestingly, only two or a few cases appeared to be genetically related, indicating that secondary transmission, even within hospitals, is limited. There were no large clusters or outbreaks of a single genetic strain.

Of the remaining 152 patients who shared a genetically similar isolate, no hospital link could be established. But 15 (10%) of these patients shared a common medical practice and 17 (11%) shared the same postal address. A good third had no obvious connection to another genetically similar case of CD infection. Even when the time frames for hospital exposure were broadened, at least 20% of the cases had no obvious link. Some of these patients (27%) were suspected of having been in close contact with an intermediate contact who had contact with a symptomatic CD patient. However, in examining all 190 date-based pairs of CD patients with ward contact, at least 54 (28%) had strains with more than 10 SNVs. In other words, a similar number of the date-based hospital CD cases had no genetic relatedness compared with those who did have related strains, suggesting a certain randomness to the process.

A total of 428 (45%) isolates were genetically distinct with more than 10 SNVs compared with other isolates — indicating a large number of varied sources for infection, even within their own community. (The authors believed that travel outside the area was not a likely risk factor for exposure, since the average age of the patients was 78 years [many of whom were ill]). Controlling exposures would therefore require identification of a larger number of diverse sources within any community — whether food, pets or other animals, etc.

An encouraging finding from this article was the gradual but statistically significant reduction in hospital-related cases from 2007 to 2011, indicating a change in hospital practices and improved source control in hospitals. One potential source for CD transmission in our area in Northern California, not mentioned in this article, is nursing homes or other long-term care facilities for the elderly. Routine surveillance screening of higher risk admissions at our hospital has found about 10% of long-term care facilities admissions are colonized with CD.

Staph. aureus Carriage and Moustaches

Soylu E, et al. Effect of a moustache on nasal Staphylococcus aureus colonization and nasal cytology results in men. J Laryngology and Otol 2015;129:155-158.

Some jobs, such as police, airlines, or the food industry, require men to be regularly clean shaven, which may have social and religious implications for some men. While not a health issue, Disney does not allow facial hair except for moustaches. But, presumably for many jobs, there is concern that moustaches may retain food or drink and be prone to colonization with bacteria. There may be some truth to this assertion: Moustaches do form a good mop and can absorb up to 20% of their weight in liquid. And, one of those odd little Internet tidbits, a man with a moustache touches his moustache an average of 760 times per day. Since nose picking is a risk factor for nasal carriage of S. aureus, does moustache hair affect nasal carriage of bacteria such as S. aureus?

In this study from Medipol University Hospital in Turkey, nasal colonization with S. aureus was examined in men with or without moustache hair. A total of 118 men who had worn a moustache for at least one year were compared to a control group of 123 men who had shaved this area daily for at least one year. Using a nasal speculum, specimens were collected from the right nasal cavity for cytology and from the left nasal cavity for culture. The swabs were soaked in saline and rotated within each nostril 5 times. The mean age of participants was 34 years. None of the men were smokers, had URI, or had chronic underlying disease or immune deficiency.

S. aureus nasal colonization was detected in 48 (20%) of the study participants. There was no difference in the frequency of MSSA or MRSA nasal carriage observed between the two groups of men. Twenty-three (19.5%) men with a moustache and 25 (20.3%) men without a moustache had a positive nares swab culture for S. aureus. Only two men with a moustache and three without had MRSA. These data are similar to other data for rates of Staph. aureus nasal carriage for the general population.

An interesting observation, however, was a greater frequency of eosinophils present in the nostrils of men with a moustache compared to those without. Nearly half (49%) of men with a moustache had nasal eosinophils on cytology, compared with 38% of men without a moustache, and 20% of moustached men had rich clusters of eosinophils compared with 7% of the control group (p = .012). Moustached men were also more likely to have nasal mast cells than their clean-shaven counterparts (17% vs 9%, p = .06).

Eosinophils and mast cells are believed to play an important role in allergic vs non-allergic rhinitis. Individuals with 20% or greater nasal eosinophilia but without evidence of atopy on allergy testing can develop chronic nasal inflammation and nasal polyposis, and they appear to be at greater risk for obstructive sleep apnea. In ENT speak, this is called nonallergic rhinitis with eosinophilia or NARES syndrome, and may contribute to episodes of sneezing, profuse watery rhinorrhea, and itchy noses. Maybe that’s why men with moustaches frequently touch their facial hair. Or maybe they just like to look thoughtful.