Conditions: Chlamydia Trachomatis Infection
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 200
Healthy volunteers: yes

Brief summary:
This study aims to identify the relationship between genital C. trachomatis and adverse pregnancy outcomes, and investigate whether screening and treatment of genital C. trachomatis in pregnant women can reduce adverse pregnancy outcomes.

Approximately 200 pregnant women from Nanhai Hospital of Southern Medical University in Guangzhou, China will be enrolled and randomized to the intervention or control group.

Detailed description:
Women recruited for the study will be randomized to the intervention or control groups. Women in the intervention group will be tested in real time for C. trachomatis and Neisseria gonorrhoeae. Patients who test positive for either infection will be linked to physicians at the Center for treatment. For the control group, women will be tested immediately after childbirth or in the event of an adverse pregnancy outcome. In the event of a positive test result, a confirmation test will be run and if positive, the patient will be referred for treatment. The endpoint of the study is defined as either the occurrence of an adverse pregnancy outcome or delivery of a newborn.

Qualitative in-depth interviews will also be conducted with 20 of the women to explore their opinions, attitudes and feedback on the study process. University of North Carolina at Chapel Hill (UNC) investigators will work with the Nanhai Hospital of Southern Medical University and staff at Dermatology Hospital of Southern Medical University to oversee the study.

Arms:
arm 1: At the time of recruitment and prior to delivery, this group will have immediate testing for C. trachomatis and N. gonorrhoeae. Physicians will notify C. trachomatis positive results to pregnant women and suggest them and their spouses to get treated according to the national standard treatment plan for Chlamydia (Azithromycin 1g, single oral administration). Patients will be followed up to confirm cure of C. trachomatis in one month. Partner notification and treatment will be suggested for pregnant women who test positive for Chlamydia. arm 2: This group will have testing after delivery (immediately following childbirth) or in the event of an adverse pregnancy outcome for C. trachomatis and N. gonorrhoeae. In the event of a positive test, patients will be informed of the positive test results the same way as the intervention group. Specific treatment options will be the same as the intervention group. Physicians will ask patients to return to Nanhai Hospital one month after treatment for test of cure. Partner notification and treatment will be suggested for pregnant women who test positive for Chlamydia.

Interventions: intervention 1: C. trachomatis and N. gonorrhoeae intervention 2: Azithromycin intervention 3: Partner notification and treatment
Intervention descriptions: intervention 1: In vitro nucleic acid amplification test for the qualitative detection of Chlamydia trachomatis and/or Neisseria gonorrhea in patient specimens utilizing amplification of target DNA by the Polymerase Chain Reaction (PCR) and nucleic acid hybridization for the detection of C. trachomatis and N. gonorrhoeae. intervention 2: Azithromycin 1g administered as a single oral dose intervention 3: Pregnant women who test positive for Chlamydia will also be suggested to take Azithromycin home to treat their spouses

Protocol document:
Prot_SAP_000.pdf: 
 
Providing Chlamydia Screening and Treatment to Pregnancy Women 
to Prevent Adverse Pregnancy Outcomes: A Randomized Control Trial 
 
 
 
NCT number NCT03862495 
Document Date 02/12/2018 
 


1 
 
Providing Chlamydia Screening and Treatment to 
Pregnancy Women to Prevent Adverse Pregnancy 
Outcomes: A Randomized Control Trial 
 
 
Dermatology Hospital, Southern Medical University, 
Guangdong Provincial STD Research and Innovation Center 
UNC-South China STD Research and Training Center 
University of North Carolina Project-China 
 
 
Version 1.0 (February 12, 2018) 


2 
 
Contents 
Contents 
I. 
Background ........................................................................................................................................... 3 
II. 
Purpose ................................................................................................................................................. 6 
III.    Hypotheses ............................................................................................................................................ 6 
IV.    Content ................................................................................................................................................. 6 
V. 
Pilot Study ........................................................................................................................................... 18 
VI.    Research Foundation .......................................................................................................................... 18 
VII.    Quality Control ................................................................................................................................... 21 
VIII.   Annual Plan ........................................................................................................................................ 22 
IX.    References ........................................................................................................................................... 23 
 
 
 
 
 


3 
 
I. 
Background 
Chlamydia trachomatis (henceforth referred to as C. trachomatis), is not only one of the most 
common sexually transmitted diseases, but also a global public health crisis. It is estimated, that 
every year the number of new Chlamydia cases exceeds 100 million worldwide[1]. Since the 
1990’s in North America, Northern Europe, and other developed nations, chlamydial infections 
have presented long-term trends[2 3]. Due to physiological sex differences, the number of 
infected women is significantly higher than infected men. Additionally, up to 70-95% of women 
infected with chlamydia are often clinically asymptomatic[4]. In women infected with chlamydia 
for long periods of time without proper treatment, the infection may spread to the cervix and 
fallopian tubes, which could lead to pelvic inflammatory disease, tubal factor infertility and other 
adverse reproductive outcomes. 
The prevalence of Chlamydia in pregnant women is also high. In Africa, the prevalence of 
pregnant women infected with Chlamydia fluctuates between 0-30%. In Asia, the prevalence is 
as high as 41-44% in some countries[5]. Some studies have shown that chlamydia infection 
during pregnancy is associated with adverse outcomes such as ectopic pregnancy, miscarriage, 
stillbirth, premature birth, pre-labor rupture of membranes (PROM), low infant birth weight 
(LBW) and others. A previously conducted meta-analysis (mostly non-experimental studies) also 
suggests a significant correlation between chlamydial infection in pregnant women and 
miscarriage, stillbirth, premature birth, and ectopic pregnancy (unpublished). A few individual 
intervention studies have shown that regular chlamydia screening and treatment in pregnant 
women can reduce the incidence of LBW, PROM, and increase perinatal survival[6]. However, 
these studies were not randomized control trials (RCT). One RCT study examined the treatment 
effect of erythromycin on Chlamydia infected women with premature and low birth weight 


4 
 
children, showing no difference in the overall effect between the erythromycin and the 
placebo[7] . A recent publication in The Lancet Infectious Diseases reported that there are no 
significant correlations between genital chlamydia infection and premature birth, small for 
gestational age, and stillbirth in a prospective cohort study[8 9]. Additionally, a review published 
in Cochrane by Brocklehurst and Rooney mentions that the probability of genital chlamydia 
causing severe conjunctivitis and neonatal pneumonia in newborns, via mother-to-child 
transmission, is 15-25% and 5-15%, respectively[10]. Currently, there is a lack of prospective 
randomized controlled trials that investigate the role of chlamydial infection screening and 
treatment in the prevention of adverse pregnancy and neonatal outcomes. 
Although there is still debate within the international community on the cost-effectiveness of 
screening pregnant women for chlamydia, United States clinical guidelines recommend that 
pregnant women below the age of twenty-five, pregnant women twenty-five years/older but with 
behavioral risk factors should undergo chlamydia screening[11]. According to an Australian 
study, when the prevalence of Chlamydia in pregnant women is greater than 11%, the potential 
benefit from screening will be higher than the cost of screening itself.[12] A review published in 
2002 further suggests that when the prevalence of women is between 3.1-10%, screening of 
chlamydia can be cost-effective[13]. Previous studies have found that the prevalence of 
chlamydia in pregnant women in China was between 4.9% -14.0%[5 14], indicating a serious 
Chlamydia epidemic. In 2015, the reported incidence of genital Chlamydia in China was 37.18 / 
100,000. Guangdong province reported an incidence of 150.88 / 100,000, second highest among 
all provinces, autonomous regions, and municipalities throughout China. Additionally, the 
number of newly reported cases are increasing. In 2016, there were 65,988 newly reported cases. 
Concurrently, compared with other nations, the incidence of spontaneous abortion, premature 


5 
 
birth and low birth weight children in China is also high. In 2015, the incidence of spontaneous 
abortion in China was about 5-15%; preterm birth was 6.1% [15]; and low birth weight was 
6.3%[15]. In 2015 alone, there were 122,300 reported stillbirths in China, the fourth highest in 
the world[16], indicating a need for significant improvement in perinatal and neonatal health. 
Additionally, in January 2016, China completely liberalized its second child policy, welcoming a 
small fertility peak in 2017. In 2017, Guangzhou also saw increased childbirth with permanent 
resident births (including census registered and non-native residents living in Guangzhou more 
than 6 months) reaching 126,000. These increased births may also increase the burden of 
maternal, fetal, and newborn diseases in China.  
Despite the substantial burden of chlamydia and adverse pregnancy outcomes, no previous 
research has been conducted to examine the effects of genital chlamydia infection on adverse 
pregnancy outcomes in China. There is no clinical guideline on screening for genital Chlamydia 
infections in pregnant women. Therefore, it is important to understand the impact of genital 
Chlamydia in China through randomized controlled studies that explore the relationships 
between Chlamydial infection and adverse pregnancy outcomes, and the feasibility and 
effectiveness of screening and treatment. The purpose of this study is to 1.) clarify the causal 
relationship between genital C. trachomatis infection and adverse pregnancy outcomes and 2.) 
determine whether screening and treatment of genital C. trachomatis in pregnant women can 
reduce adverse pregnancy outcomes. The research team will screen pregnant women in 
Guangzhou for genital C. trachomatis to understand its prevalence. We will also conduct a 
randomized controlled trial to explore whether clinical treatment of C. trachomatis-positive 
patients can reduce adverse pregnancy outcomes, and neonatal chlamydial conjunctivitis and 
pneumonia. This study will have great scientific and social significance. Firstly, it will provide 


6 
 
an important reference for the formulation of public health policies, clinicians’ treatment of 
chlamydia infection in pregnant women, and prevention of chlamydial infection in newborns. 
Secondly, it will be a valuable resource for the prevention of adverse pregnancy outcomes and 
neonatal infection associated with sexually transmitted diseases in other developing countries.  
 
II. 
Purpose 
1. To examine whether screening and treatment of genital C. trachomatis in pregnant 
women can reduce adverse pregnancy outcomes  
2. To explore the effectiveness of screening and treatment of genital C. trachomatis  in 
reducing mother-to-child transmission  
3. To evaluate the cost-effectiveness of screening and treating chlamydial infections in 
pregnant women, and provide a basis for health policy decisions on how best to screen / 
treat 
 
III. 
Hypotheses 
1. Effective screening and treatment of pregnant women with genital C. trachomatis will 
reduce adverse pregnancy outcomes 
2. Effective screening and treatment of pregnant women with genital C. trachomatis will 
reduce neonatal chlamydial conjunctivitis and pneumonia 
3.  C. trachomatis screening and treatment of pregnant women is cost-effective. 
 
IV. 
Content 
Target population and sampling 
This study will recruit pregnant women from a maternal/child health hospital in Guangzhou city 
and county. Guangzhou Women and Children Medical Center and Zengcheng Maternal and 


7 
 
Child Health Hospital (now Zengcheng Hospital of Guangzhou Women and Children Medical 
Center) are two key hospitals for perinatal health and pregnant women. In 2016, Guangzhou 
Women and Children Medical Center delivered 22,455 infants, the highest delivery volume 
among the hospitals throughout the city. Additionally, Zengcheng Hospital of Guangzhou 
Women and Children Medical Center provides prenatal care, delivery care, and other main 
medical services for pregnant women in Zengcheng district. Given the rich clinical research 
resources and experience of both hospitals, we have elected to conduct our large-scale 
randomized controlled clinical trial at these two hospitals.  
Inclusion criteria: 1) pregnant women on their first visit to the hospital (regardless of gestational 
age); 2) aged 18 or above; 3) agree to participate and sign an informed consent. Exclusion 
criteria: 1) systemic or topical vaginal antibiotics were used within 2 weeks prior to the first 
perinatal visit; 2) diagnosed adverse pregnancy outcomes at recruitment (e.g., stillbirth); 3) 
pregnant women who refuse to participate in this study. 
 
Sample size estimation 
The sample size calculation was based on the following assumptions: 1, the conservative 
estimate of prevalence of Chlamydia is around 6% among pregnant women in Guangzhou; 2, our 
meta-analysis showed that the odd ratio of adverse pregnancy outcomes in infected pregnant 
women versus non-infected pregnant women was 1.8; 3), assuming a 5% significance level on 
both sides, with a 80% efficacy test and a 2% loss- to-follow-up rate, in order to demonstrate a 
significantly lower incidence of adverse pregnancy outcomes in the intervention group than in 
the control group (estimated at 10%, from preliminary data, unpublished results), the sample size 


8 
 
should be approximately 7,725 for each group with an overall target sample size of 15,450 (when 
β = 0.8, the estimated sample size is 15,449).   
 
Alpha 
OR 
p2 
Power 
# of positive 
samples 
Prevalence 
(%) 
Total sample size (include 
2% loss-to-follow-up) 
0.05 
1.8 
0.
1 
0.9 
995 
5 
6 
8 
20,306 
16,922 
12,691 
0.05 
1.8 
0.
1 
0.8 
757 
5 
6 
8 
15449 
12874 
9656 
 
* The prevalence of abortion, stillbirth, premature birth, low birth weight, SGA and neonatal 
deaths was 10.1% in the same cohort recruited by Guangzhou Women's Center for 2012-2017. 
 
Questionnaire and follow-up 
We will obtain informed consent from participants. We will inform them of the main purpose of 
the study and the research process (Annex 1). We will emphasize that participation is completely 
voluntary.  Refusal or withdrawal will not affect medical treatment and health care services at the 
Center. All information obtained by the research group will be strictly confidential and shall not 
be shared with any other third parties prior to obtaining consent from the participants. After 
enrolment, we will conduct a baseline survey with all participants, collect relevant medical history, 
information, and urine samples. The survey will be carried out by the research staff at the Center. 
The survey content will be built on the questionnaire that is developed by the birth cohort at the 
Center. We will obtain information on socio-demographic characteristics, chronic medical history, 
other acute conditions during the first trimester of pregnancy(diagnosis and treatment), number of 
pregnancies, prior history of previous caesarean section, history of recurrent miscarriage, prior 


9 
 
history of ectopic pregnancy, history of psychiatric illness (e.g., depression), smoking/drinking 
habits, and history of second-hand smoke exposure. We will add other questions to collect 
information about history of sexually transmitted diseases and gynecological diseases (such as 
cervical surgery), whether or not systemic or topical antibiotics were used within the past one 
month, drug use, sexual behaviors, sexual partner history both before and during pregnancy, 
history of falls during pregnancy, previous experience of domestic violence, etc. (Annex 2).   
 
Participant recruitment and randomization 
We will adopt the block randomization approach. Specific randomization steps include: 1) After 
we recruit participants, we will group the them into blocks on a chronological basis. Each block 
will have 20 women who be numbered sequentially. 2) We will then randomly divide them in each 
block into intervention and control groups.  That is numbering the participants from 1 to 20, then 
generating 10 random numbers and the corresponding participants will be assigned to the 
intervention group. For participants in the intervention group, we will immediately test for C. 
trachomatis and Neisseria gonorrhoeae (See Figure 1 for the flowchart of the study design). 
Participants who test positive for either infection in the intervention group will be linked to 
physicians at the Center for treatment. For the control group, urine samples will be collected and 
tested immediately after childbirth or in the event of an adverse pregnancy outcome.  In the event 
of a positive test result, the participant will be suggested to return to the Center for further treatment.  
 


10 
 
 
Figure 1, Flow Chart of the study. 
 
Intervention and Treatment  
This RCT will follow the principle of nonmaleficence. For pregnant women enrolled in the 
intervention group, after completing the test, laboratory personnel will inform the researchers of 
positive results. The sample number of the positive result will then be reported to the Guangzhou 
Women and Children Medical Center (GWCMC). The center’s physicians will match the result to 
the correct patient and notify them of their results. We will provide a training session to the 
physicians at the Center about the national standard treatment plan (Azithromycin 1g, single oral 
administration). They will be suggested to treat patients according to the Chinese clinical and 


11 
 
prevention guidelines for sexually transmitted diseases, and final decision will be made by the 
physician and patient together.   Physicians will ask patients to return to the women's center for 
test of cure and re-testing in one month and three months after treatment respectively. At each of 
these visits, we will collect urine samples for Chlamydia testing. Patients who still test positive 
will continue treatment until they test negative. Additionally, pregnant women who test positive 
for Chlamydia will also be suggested to bring Azithromycin home to treat their spouses. We will 
also caution them to avoid sexual activity during the treatment period (7-10 days starting from day 
of treatment). We will also provide consultation services for the participants to deal with intimate 
partner relationship under this circumstance.  
For pregnant women enrolled in the control group, we will delay the urine sample collection and 
the test until after delivery, or in the event of adverse pregnancy outcomes. In the event of a positive 
test, the patients will be informed of the positive test results the same way as the intervention group. 
In the event of a positive test, physicians will be suggested to provide patients and their spouses 
with treatment identical to the intervention group. In the event of a negative test, there will be no 
need for treatment. Specific treatment options will be the same to the intervention group. 
Physicians will ask patients to return to the Center one month after treatment for test of cure.  
Endpoint of the study is defined as either the occurrence of an adverse pregnancy outcome or 
delivery of a newborn.   
After delivery, all patients who tested positive will be informed of the risk of Chlamydia 
infection in neonates. About 1-week post-partum (including Caesarean newborns), neonatal 
conjunctival scrapings and nasopharyngeal/pharyngeal swabs will be collected. In addition, 
infants will be examined for neonatal conjunctivitis and / or pneumonia clinical symptoms (see 
details in secondary outcome). In the case of a confirmed diagnosis, treatment will be carried out. 


12 
 
If there is no confirmed diagnosis, family of the newborn will be advised to pay close attention 
for the emergence of signs of conjunctivitis and / or pneumonia, and promptly return to the 
hospital if the post-neonatal clinical symptoms appear. This study will follow the treatment 
guidelines for of the American Academy of Pediatrics Infectious Diseases and America Centers 
for Disease Control and Prevention for conjunctivitis and pneumonia: Erythromycin 12.5 mg/kg, 
oral, 4 times a day, for 14 days. For patients that do not return to the hospital for screening, the 
research team will call patients and verify the newborn infection status and whether treatment 
was provided at a different hospital.  
Justifications of the control strategy 
Currently in China, there are no clinical guidelines or policies that suggest routine genital 
chlamydia screening in pregnant women.15  The clinical standards for conducting a chlamydia test 
in pregnant women include relevant symptoms including urethritis, cervicitis and occurrence of 
adverse pregnant outcomes.15 Compared to current standard care (i.e., no routine screening and 
treatment), both  our intervention (free screening for chlamydia at recruitment and linkage to care) 
and control (free screening for chlamydia at delivery of the baby and linkage to care) strategies 
provide better care to the target group.  
Safety management plan 
Criteria for withdrawal: if participants want to quit the study for any reasons; occurrence of any 
adverse pregnancy outcomes or recommendation by their personal physician to stop participation; 
Data and safety monitoring will be done by The Center and the Dermatology Hospital of Southern 
Medical University. 


13 
 
In addition, the study complies with the following statements: Any risk is the least possible for 
achieving the objectives of the research; Each individual providing consent is fully informed 
regarding the reasonably foreseeable impact of the research on the fetus or neonate; No 
inducements, monetary or otherwise, will be offered to terminate a pregnancy; Individuals engaged 
in the research will have no part in any decisions as to the timing, method, or procedures used to 
terminate a pregnancy; and Individuals engaged in the research will have no part in determining 
the viability of a neonate. 
 
Primary Outcome  
Our primary outcome is the occurrence of adverse pregnancy-related outcomes between the two 
groups, which include: 1) stillbirth (the definition of stillbirth in this study will use International 
Classification of Diseases (ICD-11)：death prior to complete expulsion (pregnant >=28 weeks) 
and death during extraction [17] );  2) Spontaneous abortion (less than 1000gms or less than 28 
weeks);  3) Preterm labor (birth fewer than 37 weeks gestational age; Infants born before 28 
weeks are considered very early-preterm; 28-32 weeks early-preterm; 32-37 weeks late-preterm. 
4) Premature rupture of membranes (prior to onset of labor); 5) Low birth weight (2,499g or 
less); 6) Small for gestational age (weight below the 10th percentile); and 7) perinatal death. 
 
 
Secondary Outcomes 
The secondary outcomes include: C. trachomatis infection of the newborn, Chlamydial 
conjunctivitis, and pneumonia in the newborn. Laboratory methods for the diagnosis of neonatal 


14 
 
chlamydial infection include: 1) Detection of C. trachomatis by sampling from conjunctival 
scraps and nasopharyngeal/ pharyngeal posterior through direct fluorescence (DFA); 2) PCR and 
3) chlamydia culture.  
Common Chlamydia conjunctivitis clinical symptoms and supplementary examinations include 
eyelid and nasal congestion, or 2) catarrhal or mucopurulent secretions, occurring within 5-14 
days after birth. It is possible for exudate adhesions to form pseudomembranes. If treatment is 
delayed more than two weeks, conjunctival follicles may also form.  
Chlamydia pneumonia infection may appear insidiously. However, symptoms will usually 
appear in 4-12 weeks. Common clinical manifestations include nasal mucus secretion, nasal 
congestion, intermittent cough, shortness of breath, rales on auscultation. There is usually no 
fever or change sin consciousness. Laboratory examinations may show normal white count but 
elevated eosinophils; moderate hypoxemia on arterial blood gas; bilateral interstitial markings on 
chest radiography. 
 
Clinical Data Collection  
Maternal: 1) mode of delivery: vaginal delivery or caesarean section; 2) whether twins or not; 
3)occurrence of complications of childbirth, such as fetal umbilical cord around the neck, dystocia, 
uterine rupture and amniotic fluid embolism; 4) occurrence of stillbirth, spontaneous abortion, or 
premature rupture of membranes; 5) development of fetus during prenatal period (occurrence of 
fetal malformations and types of malformations etc.); 6) history of chronic diseases during 
pregnancy, including gestational diabetes, hypertension, autoimmune diseases, etc.; 7) nutritional 
status of pregnant woman; 8) HIV and Syphilis test and treatment information for positive cases; 


15 
 
9)essential clinical data: chlamydia and gonorrhea test and treatment information; 10)other clinical 
information: general health information (height, weight, blood pressure, blood glucose, complete 
blood count, urine analysis). 
Neonatal: 1) Information on birth weight, neonatal death etc.; 2) occurrence of any symptoms 
such as conjunctivitis, pneumonia, genital infections etc. 
 
Urine collection and laboratory testing 
1) Sample collection for pregnant women with Chlamydia trachomatis / gonococcal: We 
will collect urine samples for testing. Before collection, we will ensure that the patient has not 
urinated within the last 1 hour. The patient also should not clean the sampling site in advance, 
such as washing etc. Patients will be instructed to collect urine in a urine cup. Urine in the urine 
cup cannot remain at room temperature (2-30℃) longer than 24 hours. We will use flexible pipes 
from the Rochecobas® PCR Urine Sample Kit, to transfer urine to the storage tube (Roche 
cobas® PCR Media tube). After tightening the lid, storage tubes will be turned over up and down 
five times. Samples will be transferred to the Dermatology Hospital of Southern Medical 
University for testing.  
2) Neonatal samples collection: We will collect eyelid swabs (sample needs to contain eyelid 
epithelial cells) and pharyngeal swabs. Samples will be maintained at 2-8°C and screened within 
24 hours. 
3) Chlamydia trachomatis / Neisseria gonorrhoeae test: Reagent: Roche Cobas CT / NG Test 
kit; Instrument: Roche Cobas Z480, Roche Cobas X4800. Detection principle: CT: detecting 
Chlamydia MOMP gene by FAM labeling probe; NG: detecting Neisseria gonorrhoeae DR-9 


16 
 
Variant gene by HEX labeling probe. The samples will be automatically extracted and loaded 
using the Roche X4800 and its processing reagents. The CT / NG will be detected by using the 
Roche Cobas Z480. The system will automatically interpret the positive and negative values. 
4) Chlamydia genotyping 
a. Sample Source:  Chlamydia trachomatis positive / Neisseria gonorrhoeae positive 
urine samples 
b. Extraction of Nucleic acid: Take 1 mL positive sample and centrifuge at 12000 rpm 
for 30 min. Discard the supernatant and add 50 μL of lysate (10 mmol / L Tris-HCl, 1 
mmol / L EDTA, 0.5 mmol / L Tween-20, pH 8.3). Mix and boil the sample at 100 ℃ for 
10 min, centrifuge at 12000 rpm for 10 min. Use the supernatant as PCR template. 
c. Chlamydia nucleic acid amplification PCR:  According to the literature [2, 3] 
synthesis of two pairs of primers, which the external is upstream 5'-
ATGAAAAAACTCTTGAAATCGG-3 'and downstream 5'-
TTTCTAGACTTCATTTTGTT-3'; amplified fragment of about 1.1kb. The internal 
primer sequence is upstream 5'-GGGAATCCTGCTGAACCAAG-3 'and downstream 5'-
AATTGCAACGAAACGATTTG-3', and the amplified fragment is about 0.9kb (all the 
above primers are synthesized by Shanghai Bioengineering Co., Ltd.). PCR reaction 
system was 50 μL (ddH20, 36.5 μL, 10 μL PCR buffer 5 μL, dNTP 1 μL, external primer 
2 μL, Taq DNA polymerase 0.5 μL); the reaction conditions include Pre-denaturate at 
94 °C for 3 min; denaturation at 94 ° C for 30 s, Annealing at 55 ℃ for 30 s, extension at 
72 ℃ for 40 s with 35 cycles in total; extension at 72 ℃ for 5 min. The amplified product 


17 
 
is purified and sequenced by Shanghai Bioengineering Co., Ltd. The sequencing primers 
are the same as the internal primers. 
d. Sequencing Analysis:  The following 10 types of Ct Omp1 sequences are used for 
BLAST analysis: B / M17342, D / X62920, E / X52577, F / X52080, G / AF063199, H / 
X16007, I / AF063200, J / AF063202, K / AF063204, Ja / AF063203. Sequence analysis 
is performed by using Bioedit and DNAStar molecular biology software. 
 
5.) Chlamydia drug resistance gene test 
a. Sample source: urine samples positive for Chlamydia trachomatis / Neisseria 
gonorrhoeae 
b. Extraction of Nucleic acid: Take 1 mL positive sample and centrifuge at 12000 rpm 
for 30 min. Discard the supernatant and add 50 μL of lysate (10 mmol / L Tris-HCl, 1 
mmol / L EDTA, 0.5 mmol / L Tween-20, pH 8.3) , mix and boil the sample at 100 ℃ for 
10 min, centrifuge at 12000 rpm for 10 min, and take the supernatant as PCR template. 
c．Drug-resistant gene detection: Conduct PCR with drug resistance gene primers. 
Take 5 μL PCR amplification products and initiate electrophoresis separately in 2% 
agarose gel. Each test will have negative and positive controls. Under the UV light, a 
bright band in the same location as the positive control sample indicates the presence of 
Amplification products.  
c.1-tetracycline resistance plasmid tetM gene detection Primer design, PCR 
amplification detection. 


18 
 
c.2-Macrolides 23S rRNA gene 
c. 3-Ribosomal protein gene L4 
c.4-Ribosomal protein gene L22 gene 
c. 5-Quinolones gyrA gene 
 
V. 
Pilot Study  
We will conduct a pilot study to evaluate feasibility and acceptability of the study.  We will refine 
the study design based on the pilot research. Specifically, the pilot will evaluate possible harms 
arising from the study to the target group (such as self-reported drug side effects, psychological 
distress or difficulty in dealing with family relationship due to a positive result, and other 
unexpected harms), pretesting the questionnaire, understanding sample contamination between 
intervention and control group (ie. whether participants in the control group receive information 
distributed in the intervention group about chlamydia infection and adverse pregnancy outcomes, 
and request test and treatment afterwards), potential confounding factors (being classified as 
infectious diseases and non-infectious diseases factors), data collection process indicators, and 
required resources and budget. Solutions for problems identified, and refinement plan for the study 
and questionnaire will also be developed based on the pilot data. We intend to recruit a total of 
200 pregnant women for the pilot study. 
 
VI. 
Research Foundation 
The Dermatology Hospital of Southern Medical University (Guangdong Provincial Dermatology 
Hospital/ Guangdong Provincial Centers for Skin Diseases and STD Control) plays a key role in 
STD/HIV control related research. It is a collaborator for many national research projects and 


19 
 
international projects such as the national-level program for comprehensive syphilis control 
(initiated in 2013), WHO HIV testing program, and program of prevention of mother-to- child 
transmission of syphilis starting in 2012. These valuable projects have generated compelling 
results that have driven regional and national policy development. Additionally, it has developed 
an experienced platform to conduct large epidemiology studies. Launched in 2008 as a 
collaboration between the Guangdong Provincial Dermatology Hospital and the University of 
North Carolina at Chapel Hill, UNC-South China STD Research training center (Training Center) 
is a department within the Guangdong Provincial STD Control Center. Until now, the training 
center has trained 13 postdoctoral fellows on HIV/STD control, resulting in 100 publications in 
the past four years. Each year, there are more than ten internationally renowned HIV and STD 
experts who teach and provide guidance for STD/HIV research.  
For now, the Guangdong Provincial Centers for Skin Diseases and STD Control has the most 
complete STD control network in the nation. Specifically, it has 21 city-level control centers for 
STDs and 121 municipal and county-level control centers in charge of STD surveillance and 
prevention in Guangdong province. The STDs surveillance system of this center covers 1332 
hospitals throughout the province: 6 national STD surveillance sites; 3 national STD clinical 
sites; 10 chlamydia/Gonorrhea surveillance sites for STD patients; 6 MSM STD surveillance 
sites; and 7 comprehensive syphilis control districts. The center has published 10 scientific 
papers in international journals, and 44 papers in Chinese journals.  
Granted the Guangdong STD Central Laboratory by the Guangdong provincial health department 
in 2003, the unit currently has a comprehensive venereal disease laboratory center. This center is 
responsible for venereal disease prevention/treatment technical training and scientific research 


20 
 
throughout the province. As a tertiary standardized STD central laboratory of Guangdong province, 
the improved facility conditions, professional cell culture chamber,  immunology laboratory, and 
molecular biology laboratory are equipped with Roche (lightcycler2.0) by real-time fluorescence 
quantitative PCR (Bio-Rad Power Pac 3000); Bole  (Bio-Rad Power Pac 3000)Horizontal; 
electrophoresis Bole(Bio-Rad Power Pac 3000) vertical electrophoresis; The Capp hybrid 
instrument; (Thermo Revco) -80 C ultra-low temperature refrigerator; Bole (Bio-Rad Smart Spec 
Plus) nucleic acid / protein content determination apparatus; and other advanced instruments. The 
center has a variety of resources required for this project,  ensuring the smooth implementation 
and completion of this project. 
Guangzhou Women and Children's Medical Center (Guangzhou Woman & Infants Hospital, 
Guangzhou Maternal and Child Health Hospital, Children`s Hospital of Guangzhou, Guangzhou 
Woman & Infants Hospital) was founded in September 2006. It is integrated from the former 
Guangzhou Children's Hospital and Guangzhou Woman & Infants Hospital. The hospital has three 
key clinical specialties affiliated with the National Ministry of Health. There are seven Guangdong 
provincial key clinical specialties and subjects, and two Guangdong provincial 12th five-year 
Medical key laboratories; it is the base for the postdoctoral innovation practice of Guangdong 
Province, the teaching practice base for the Affiliated Hospital of Guangzhou Medical University, 
Zhongshan University, Southern Medical University, and the Graduate training base of Jinan 
University. The tertiary first class hospital, specialized for women and children, integrates 
prevention, medical care, health care, scientific research, and teaching. In 2016, the annual 
outpatient volume totaled 3761000 visits, 92919 of which were hospitalized patients and 22455 of 
which were childbirths. 


21 
 
Currently, the center is the implementation department for the Guangzhou birth cohort project 
(Guangzhou Baby Plan). The cohort has successfully recruited 30,000 pairs of mothers and 
children for regular follow- ups and systemically collected half a million specimens. Follow-up 
visit are regularly conducted at 6 weeks, 6 months, 1 year, 2 years, 3 years, and 6 years of age. 
Follow-ups are planned up until 18 years of age. The birth cohort -centered research platform for 
maternal and child health supports more than 20 major scientific research projects at the national, 
provincial and municipal level. It has accumulated over twenty million RMB (31,240,000 USD) 
for scientific research. Since January 2010, the project team has had 29 scientific publications in 
international journals and 40 papers in Chinese journals. Guangzhou Women and Children's 
Medical Center (Zengcheng Campus) is the largest women and children's medical center within 
the district. The center focuses on prevention, medical care, health care, scientific research and 
teaching. Soon, they will also implement the birth cohort research for pregnant women at 
Zengcheng.  
In summary, the local collaboration institutions for this study have abundant experience conducting 
clinical and epidemiology research. They possess the skills and resources to monitor large clinical 
RCTs. The large birth cohort study in Guangzhou Women and Children's Medical Center and the 
experience of the Dermatology Hospital of Southern Medical University in STD research will help 
our project operate smoothly to achieve our final objectives.   
 
VII. Quality Control 
Clinician Training: The research team will invite the clinicians from Southern Medical 
University of Dermatology Hospital and Guangzhou Women and Children's Center to participate 
in a training course. The main training contents include: 1) the possible influence of genital 


22 
 
Chlamydia infection on pregnant women, fetuses and newborns 2) screening, diagnosis, 
treatment, and prognosis of chlamydial infection among pregnant women and 3) diagnosis and 
treatment of chlamydial conjunctivitis and pneumonia among neonates. The total training time 
will be 4 hours. Additionally, the research team will create a simple clinical manual which will 
distributed to the relevant clinicians for their reference. 
Urine Sample Collection Staff Training: Laboratories from Guangdong Dermatology Hospital 
will provide training to urine sample collectors and demonstrate how to properly collect and 
store urine samples. The total training time will be 2 hours. 
Questionnaire data entry: The research team will use Epidata, a data input software, to manage 
the questionnaire data. Two data processors will be responsible for dual entry to reduce input 
errors. 
Clinical Data Audit: Three clinicians from Guangzhou Women and Children Medical Center 
will be responsible for verifying the diagnosis and treatment plans of patients and their children 
according to the international classification of diseases and diagnostic criteria. 
 
VIII. Annual Plan 
Task/Year 
1st year 
2nd year 
3rd year 
4th year 
5th year 
Study design, project propose and preparation  
 
 
 
 
 
Start pilot study to understand the disease 
prevalence among the target population 
 
 
 
 
 
Recruit participants\ baseline survey and 
collecting urine sample 
 
 
 
 
 
Randomization 
 
 
 
 
 
CT detection for intervention group 
 
 
 
 
 


23 
 
patients and their partner CT treatment for 
intervention group 
 
 
 
 
 
primary report 
 
 
 
 
 
CT detection for control group 
 
 
 
 
 
patients and their partner CT treatment for 
control group 
 
 
 
 
 
Midterm report 
 
 
 
 
 
Follow up survey after delivery 
 
 
 
 
 
final report 
 
 
 
 
 
clinical data collecting 
 
 
 
 
 
Date input, management and analysis 
 
 
 
 
 
Manuscript writing and publishing 
 
 
 
 
 
Summary Report 
 
 
 
 
 
 
IX. 
References 
1. Newman L, Rowley J, Vander Hoorn S, et al. Global Estimates of the Prevalence and Incidence of Four 
Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global 
Reporting. PLoS One 2015;10(12):e0143304 doi: 10.1371/journal.pone.0143304[published 
Online First: Epub Date]|. 
2. Braxton J, Carey D, Davis DW, et al. Sexually transmitted disease surveillance 2014. 2015  
3. Low N, Redmond S, Alexander K, et al. Chlamydia control in Europe: literature review. 2014  
4. N L. Sexually Transmitted Infections in Primary Care 2013 (RCGP/BASHH), 2013. 
5. Adachi K, Nielsen-Saines K, Klausner JD. Chlamydia trachomatis infection in pregnancy: the global 
challenge of preventing adverse pregnancy and infant outcomes in Sub-Saharan Africa and Asia. 
BioMed research international 2016;2016  
6. Ryan GM, Abdella TN, McNeeley SG, et al. Chlamydia trachomatis infection in pregnancy and effect of 
treatment on outcome. American Journal of Obstetrics & Gynecology 1990;162(1):34-39  
7. Martin DH, Eschenbach DA, Cotch MF, et al. Double-blind placebo-controlled treatment trial of 
Chlamydia trachomatis endocervical infections in pregnant women. Infectious diseases in 
obstetrics and gynecology 1997;5(1):10-17  
8. Reekie J, Roberts C, Preen D, et al. <em>Chlamydia trachomatis</em> and the risk of spontaneous 
preterm birth, babies who are born small for gestational age, and stillbirth: a population-based 
cohort study. The Lancet Infectious Diseases  doi: 10.1016/S1473-3099(18)30045-8[published 
Online First: Epub Date]|. 
9. Reekie J, Roberts C, Preen D, et al. Chlamydia trachomatis and the risk of spontaneous preterm birth, 
babies who are born small for gestational age, and stillbirth: a population-based cohort study. 
The Lancet Infectious Diseases 2018  
10. Novikova N, Cluver C. Interventions for treating genital Chlamydia trachomatis infection in 
pregnancy. The Cochrane Library 2013  
11. Force RotUSPST. The Guide to Clinical Preventive Services 2014. Rockville (MD), 2014. 


24 
 
12. Ong J, Chen M, Hocking J, et al. Chlamydia screening for pregnant women aged 16–25 years 
attending an antenatal service: a cost‐effectiveness study. BJOG: An International Journal of 
Obstetrics & Gynaecology 2016;123(7):1194-202  
13. Honey E, Augood C, Templeton A, et al. Cost effectiveness of screening for Chlamydia trachomatis: a 
review of published studies. Sexually transmitted infections 2002;78(6):406-12  
14. Chen X-S, Yin Y-P, Chen L-P, et al. Sexually transmitted infections among pregnant women attending 
an antenatal clinic in Fuzhou, China. Sexually transmitted diseases 2006;33(5):296-301  
15. Luo Y, Jiang C, Liang T, et al. The birth weight of 590 infants and factors associated with low birth 
wegiht. Journal of Guangxi Medical University 2017;34(5):771-72  
16. Lawn JE, Blencowe H, Waiswa P, et al. Stillbirths: rates, risk factors, and acceleration towards 2030. 
The Lancet 2016;387(10018):587-603  
17. Lawn JE, Blencowe H, Waiswa P, et al. Stillbirths: rates, risk factors, and acceleration towards 2030. 
Lancet (London, England) 2016;387(10018):587-603 doi: 10.1016/s0140-6736(15)00837-
5[published Online First: Epub Date]|. 


25 
 
X. 
Verification of Foreign Language Translation 
 
Instructions:  The Principal Investigator is responsible for ensuring that UNC-CH IRB-approved study 
documents, e.g., recruitment materials and consent forms, are accurately translated into a language 
understandable to study participants. If any study documents will be administered in languages other 
than English, the Principal Investigator must, as relevant: 
 
• 
Submit this form with the initial application for IRB review. 
• 
Submit this form if, as part of a study modification, there is a request to add new study 
documents that will be translated. 
• 
Ensure that all translated documents are approved by the local IRB/Ethics Committee (EC) at the 
site(s) where the study will be performed, if any, prior to their use in the field. 
• 
Submit the translated documents to the UNC-CH IRB as soon as they become available. 
 
A. PROTOCOL INFORMATION 
 
 Initial Review   
 Modification Request (to add new documents) 
 
IRB Study Number (if known) 
18-1168  
Study Title 
IGHID 11818 - Providing Genital Chlamydia Trachomatis Treatment to 
Pregnant Women to Prevent Adverse Pregnancy Outcomes: A 
Randomized Control Trial Pilot Study 
Principal Investigator          
Weiming Tang  
B. LIST OF DOCUMENTS TO BE TRANSLATED (attach additional pages as needed) 
Document 
Name 
Name(s) of Local 
Reviewing IRB/Ethics 
Committee (if any) 
Translated 
Language(s) 
Person Preparing 
Translation(s) 
Name of 
Translator  
ICF v2018-09-
19 
Ethic Committee of 
Nanhai Hospital of 
Sountern Medical 
University 
Chinese 
 UNC-CH PI 
 Local Investigator  
 Certified Translator 
 Other, Specify: Research 
Assistant 
Xuewan Sun 


26 
 
      
      
      
 UNC-CH PI 
 Local Investigator  
 Certified Translator 
 Other, Specify:       
      
      
      
      
 UNC-CH PI 
 Local Investigator  
 Certified Translator 
 Other, Specify:       
      
      
      
      
 UNC-CH PI 
 Local Investigator  
 Certified Translator 
 Other, Specify:       
      
C. Certification by Principal Investigator and Translator  
 
 
By signing this form, I certify that I will fulfill my responsibility as Principal Investigator to ensure 
that IRB-approved study documents, e.g., recruitment materials and consent forms, are 
accurately translated in a language understandable to study participants. 
 
____________________________________________________      
  ____________________ 
Principal Investigator’s Signature  
 
                                         Date  
 
 
By signing this form, I confirm that translations of the documents listed above will be accurate 
and complete.   
                                                                                     2020. 07. 02 
____________________________________________________      
  
____________________ 
Translator’s Signature  
                                                                                 Date