Need for screening for genital Chlamydia trachomatis infection in Australia

Genital Chlamydia trachomatis is the most common notifiable sexually transmissible infection in Australia and is associated with significant complications, particularly for women. There is no screening program for chlamydia in Australia despite this infection fulfilling the criteria for screening--it is easily diagnosed with acceptable self-administered tests and early treatment prevents complications. Screening for chlamydia reduces the prevalence of infection and the rate of complications and is recommended by several Western countries including the United States, England and Canada. If a screening program was introduced in Australia, several issues would first need to be addressed including who would be screened, how often would they be screened and where would screening be offered. We discuss these issues in this paper in an effort to advance the debate and the introduction of chlamydia screening in Australia.     

What needs to change to increase chlamydia screening in general practice in Australia? The views of general practitioners

Background  

Australia is considering implementing a chlamydia screening program in general practice. The views of general practitioners (GPs) are necessary to inform the design of the program. This paper aimed to investigate Australian GPs' views on how chlamydia screening could work in the Australian context.     

Pelvic examination leads to changed clinical management in very few women diagnosed with asymptomatic chlamydia infection

The present study aimed to determine whether pelvic examinations change clinical management of women with asymptomatic chlamydia infection. Records for women with asymptomatic chlamydia who underwent a pelvic examination at a sexual health clinic in Melbourne, Australia (January 2006 to June 2007) were analysed retrospectively. Of 91 cases, 31 (34%) warranted examination; one woman (1%; 95% confidence interval: 0.5%, 6.4%) had muco-purulent cervicitis and mild tenderness, and was treated for possible pelvic inflammatory disease. These data suggest that a pelvic examination will lead to changes in treatment for very few women diagnosed with asymptomatic chlamydia infection.     

Chlamydia trachomatis infection in women: a need for universal screening in high prevalence populations?

Chlamydia trachomatis is the most prevalent sexually transmitted bacterial pathogen. Nevertheless, selective, rather than universal, screening for chlamydia has been recommended, largely because testing is expensive and requires considerable technical expertise. A total of 1,348 women in four family planning clinics in San Francisco, California, were screened from March 1987 to January 1988 to identify criteria for selective screening. Of these, 9.2% had a positive chlamydia test using direct fluorescence. Logistic regression analysis identified five factors associated with infection: age less than 25 years, cervical friability, single marital status, a new sexual partner within the past 3 months, and lack of barrier contraceptive use. No single risk factor or combination of risk factors had both a high sensitivity and a high positive predictive value for infection. While screening all women who were unmarried would detect 93% of those with chlamydia, the positive predictive value of 10.7% was not much higher than the overall prevalence. Conversely, screening all women with cervical friability, which had a positive predictive value of 23.2%, would only detect 11% of those with chlamydia. On the basis of the authors' findings, selective screening should not be used in high prevalence populations in which all women are at risk and should be screened for chlamydia.     

Countywide survey of the current practice of chlamydia detection in primary care

BACKGROUND: The Chief Medical Officer's (CMO's) Advisory Group on Chlamydia trachomatis (chlamydia) published its report in 1998 and a national screening programme is anticipated. Meanwhile the Public Health Laboratory Service (PHLS) reports that the number of positive diagnoses of genital chlamydia continued to rise throughout the last decade. OBJECTIVES: To consider the current practice of Gloucestershire general practitioners (GPs) for detecting genital chlamydia infections, and based on the findings to help the development of local guidelines and sexual health service provision. DESIGN: Questionnaire survey. SETTING: Primary care groups within a single English county. METHODS: A questionnaire survey was sent to GPs. Responses were handled anonymously and pooled for analysis. MAIN OUTCOME MEASURES: Response rates from GPs on the types of tests used for detection of chlamydia infection, how frequently they test different patient groups for chlamydia infection and attitudes to contact tracing. RESULTS: In women, opportunistic screening is not routinely performed and the rate of diagnostic testing varies with presentation. The rate of testing is comparatively lower in men and over 50% of GPs refer symptomatic men directly to a genitourinary medicine (GUM) clinic. Fewer than 50% of respondents always or usually forward details to GUM for contact tracing. CONCLUSIONS: Opportunistic screening is performed by a proportion of GPs but there is scope for more screening in higher risk groups. There is scope to increase the number of tests for chlamydia infection in patients presenting with symptoms. A programme of training and education in conjunction with guidelines may have merit in unifying practice and making detection and management of chlamydia more effective. This will have financial and resource implications.     

男男性行为人群生殖道沙眼衣原体自我采样检测及相关因素研究进展

检测是生殖道沙眼衣原体（CT）感染综合防控工作中至关重要的环节,我国MSM的生殖道CT感染率高,检测率低。生殖道CT自我采样检测为MSM提供了一个新的选择,对扩大CT检测在该人群中的覆盖面具有重要作用。本文综述了国内外MSM的CT自我采样检测及相关因素,为CT自我采样检测在该人群中的推广提供依据。     

Nowhere near the point of diminishing returns: correlations between chlamydia testing and notification rates in New South Wales

OBJECTIVE: To examine the relationship between chlamydia testing and chlamydia detection rates in New South Wales, Australia, from 1999 to 2001. METHODS: Correlations between population-based chlamydia testing and notification rates--stratified by age group, area of residence, and year--were determined by linear regression. RESULTS: Strong positive correlations between chlamydia testing and notification rates were observed for both women (r = 0.91, p < 0.001) and men (r = 0.94, p < 0.001). Between 1999 and 2001, the chlamydia test positivity rate increased from 4.3% to 7.3% for women (p < 0.0001) and from 7.8% to 10.5% for men (p < 0.0001). CONCLUSIONS AND IMPLICATIONS: This study suggests that Australia could benefit from a major chlamydia screening program.     

GP's management of genital Chlamydia: a survey of reported practice

BACKGROUND: Genital chlamydial infection is the commonest curable sexually transmitted disease in the industrialized world. Little is known about how GPs manage this condition. OBJECTIVES: We aimed to determine current knowledge concerning genital chlamydia among GPs and to establish how patients with this infection are managed in primary care. METHODS: A confidential self-administered postal questionnaire survey was sent to all 494 GPs in one English health district (Leicestershire). RESULTS: Completed questionnaires were returned by 290 GPs (a response rate of 59%). A much higher proportion of GPs had tested and/or treated female patients for chlamydia [70%, 95% confidence interval (CI) 64-75%] as opposed to male patients (20%, CI 15-25%). Female patients (70%, CI 64-75%) were also more likely to be managed in general practice than male patients (56%, CI 50-62%). A majority of GPs (66%, CI 60-72%) routinely used an appropriate method of testing for chlamydia although a high vaginal swab, an inappropriate method of testing, was used by a fifth of GPs (19%, CI 15-24%). A large number of different treatment regimes were used by GPs. The majority of GPs (85%, CI 79-89%) prescribed an appropriate antibiotic although few GPs (19%, CI 14-25%) specified a chlamydia treatment regime in accordance with accepted international guidelines with respect to drug, dosage and duration of therapy. CONCLUSIONS: Female patients with known or suspected genital chlamydial infection are commonly managed in UK general practice. There is scope to improve the management of this infection in general practice.      

A comparison of the population diagnosed with chlamydia in primary care with that diagnosed in sexual health clinics: implications for a national screening programme

OBJECTIVES: To compare demographic, behavioural and HIV testing characteristics of individuals diagnosed with chlamydia infection in primary care with those in genitourinary medicine clinics, in the absence of a screening programme. The aim was to explore the current and potential contribution of primary care to the control of chlamydia. STUDY DESIGN AND METHODS: We analysed data on individuals who reported one or more chlamydia diagnoses in the past 5 years in a large probability sample survey of the resident, UK general population aged 16-44 years. Estimates were weighted and odds ratios calculated. RESULTS: Women diagnosed in primary care reported fewer sexual partners, and were less likely to have had an HIV test in the past 5 years than their counterparts diagnosed in genitourinary medicine clinics. Age, ethnicity, social class, educational attainment and urbanization of area of residence did not differ between the two groups. Too few men were diagnosed in primary care to allow for such a comparison. CONCLUSIONS: Primary care already diagnoses a large number of women with chlamydia infection, who may perceive themselves as low risk through age or sexual behaviour, yet are likely to comprise a substantial proportion of all infections. Few men are diagnosed in primary care. These groups need to be strategically targeted in the context of a future chlamydia screening programme, which will focus on the screening of younger women at high risk, and in which the role of primary care is still in development.     

Clinical management of chlamydia in general practice: a survey of reported practice

BACKGROUND: Chlamydia trachomatis is the most common curable sexually transmitted infection (STI) in the UK. Prevalence of the infection in different health care settings has been found to be between 2% and 29% and diagnoses of the infection continue to rise significantly. It is estimated, however, that only 10% of all chlamydial infections are seen and treated in genitourinary medicine (GUM) clinics. Few data exist about the actual practice patterns of primary care providers in the management of chlamydia. The management of patients identified with the infection within this setting warrants attention. AIMS: To determine general practitioners' (GPs') and nurses' reported clinical practice in the management of genital chlamydial infection. To design a needs-based education guideline on the management of chlamydia in rural primary care. DESIGN: An anonymous, confidential, self-administered postal questionnaire was sent to all GPs and cervical cytology practice nurses in 84 practices in Dyfed Powys Health Authority (DPHA) area, Wales, UK. RESULTS: Following two mailings of the survey, responses were obtained from 75/84 practices (response rate 89%). A total of 130/307 GPs (response rate 42%) and 72/152 nurses (response rate 47%) in these practices responded. The data demonstrated that few tests for chlamydia are being carried out in general practice: 42% (55/130) of GPs and 54% (37/72) of nurses reported carrying out between one and four tests a month, and 35% (46/130) of GPs and 29% (21/72) of nurses reported performing less than one test a month. Very few positive results are being obtained. The majority of GPs (72%) and nurses (68%) routinely use the appropriate endocervical swab when testing for chlamydia, however 19% of GPs and 20% of nurses are using either an incorrect wooden-stemmed swab or are taking an inappropriate high vaginal swab. CONCLUSIONS: Few chlamydia tests are being performed in primary care in DPHA, Wales. Health professionals in general practice are in need of, and are in favour of, up-to-date training on all aspects of chlamydial identification and management in primary care. Attention needs to be focused upon resources and the paucity of GUM services and their access within the DPHA area.     

Gonorrhea and chlamydia infection among women visiting family planning clinics: racial variation in prevalence and predictors

CONTEXT: Black women are disproportionately infected with gonorrhea and chlamydia. Because of the potential impact of these infections on women's reproductive health, it is important to determine whether different factors are predictive of infection in women of different races. METHODS: Data from 31,762 women aged 15-24 who were tested for gonorrhea and chlamydia at Missouri family planning clinics in 2001 were used to calculate the prevalence of each infection by selected variables. Logistic regression analysis was used to assess factors associated with the risk of infection. RESULTS:Overall, 0.7% of women had gonorrhea, and 4% had chlamydia. The gonorrhea rate was 4% for blacks and 0.4% for whites; the chlamydia rate, 9% and 4%, respectively. Independent predictors of gonorrhea in both races were symptoms, recent sexual contact with a partner who had STD symptoms, and chlamydia infection. Predictors specific to whites were visiting the clinic for STD care and having a new partner or multiple partners in the past year. Being aged 15-21 was associated with an elevated risk of gonorrhea for blacks only. In both racial groups, chlamydia infection was associated with younger age, contact with a symptomatic partner, cervicitis, cervical friability and gonorrhea positivity. Additional predictors among whites were having a new partner, having multiple partners and having pelvic inflammatory disease; no other factors were significant for blacks. CONCLUSIONS: The prevalence and predictors of gonorrhea and chlamydia infection differ significantly between blacks and whites. Until these disparities are better understood, it will be difficult to establish screening criteria for gonorrhea.     

Willingness to offer chlamydia testing in general practice in New South Wales

OBJECTIVES: To assess willingness of general practitioners (GPs) to offer chlamydia testing to patients, and to identify demographic and practice correlates associated with willingness to offer chlamydia testing. METHODS: A postal survey of practising GPs in New South Wales was undertaken in 2002 to assess management of STIs in general practice. A 15% (n = 1,020) stratified random sample, based on sex and area of practice, was selected. The overall response rate was 45.4% (n = 409). RESULTS: More than four out of five study participants reported that chlamydia testing should usually be offered to patients who had recently changed sexual partners or inconsistently used barrier methods such as condoms. While 76% of GPs would like to offer testing to young women, 65% were in favour of testing young men. Just over half (56%) felt that chlamydia testing should usually be offered to patients at the time of a Pap smear. Multivariate analyses revealed that female GPs were more likely to offer testing to young patients and to female patients at the time of a Pap smear. GPs who had postgraduate training in STls had double the odds of offering testing to young men and to female patients at the time of a Pap smear. CONCLUSIONS AND IMPLICATIONS: This paper reveals variations in GPs' willingness to offer chlamydia testing to patients. Special education programs highlighting the adverse health effects of chlamydial infection have the potential to improve GP involvement in chlamydia screening.     

Australia's notifiable diseases status, 2000. Annual report of the National Notifiable Diseases Surveillance System.

In 2000, there were 89,740 notifications of communicable diseases in Australia collected by the National Notifiable Diseases Surveillance System (NNDSS). The number of notifications in 2000 was an increase of 5.9 per cent over those reported in 1999 (84,743) and the largest reporting year since the NNDSS commenced in 1991. Notifications in 2000 consisted of 28,341 bloodborne infections (32% of total), 24,319 sexually transmitted infections (27%), 21,303 gastrointestinal infections (24%), 6,617 vaccine preventable infections (7%), 6,069 vectorborne infections (7%), 2,121 other bacterial infections (legionellosis, meningococcal infection, leprosy and tuberculosis) (2%), 969 zoonotic infections (1%) and only one case of a quarantinable infection. Steep declines in some childhood vaccine preventable diseases such as Haemophilus influenzae type b, measles, mumps and rubella, continued in 2000. In contrast, notifications of pertussis and legionellosis increased sharply in the year. Notifications of bloodborne viral diseases (particularly hepatitis B and hepatitis C) and some sexually transmitted infections such as chlamydia, continue to increase in Australia. This report also summarises data on communicable diseases from other surveillance systems including the Laboratory Virology and Serology Surveillance Scheme (LabVISE) and sentinel general practitioner schemes. In addition this report comments on other important developments in communicable disease control in Australia in 2000.     

稽留流产与支原体、衣原体感染及其相关因素的关系探讨(附107例病例分析)

目的:探讨孕妇稽留流产与解脲支原体(UU)、沙眼衣原体(CT)感染及其相关因素的关系。方法:采用分离培养法对107例稽留流产妇女进行宫颈分泌物解脲支原体、沙眼衣原体培养,并对其清宫或流产的绒毛及部分蜕膜组织进行病理学检查。结果:支原体、衣原体感染与年龄分组无显著相关性,与文化程度、居住条件、工作环境、孕周、孕产史和人员来源有相关性。在107例稽留流产孕妇中,支原体感染者中宫颈分泌物阳性42例,感染率为39.25%,组织物阳性10例,感染率为9.35%,衣原体感染者中宫颈分泌物阳性10例,感染率为9.35%,组织物阳性4例,感染率为3.74%。结论:文化程度、居住条件、工作环境、孕周、孕产史和人员来源等因素都与孕妇稽留流产有关,解脲支原体、沙眼衣原体感染可能通过上行传播引起宫内感染、绒毛膜炎,最终导致胚胎停止发育,造成稽留流产,故支原体、衣原体感染与稽留流产有密切的关系。     

Chlamydia screening in general practice: views of professionals on the key elements of a successful programme

OBJECTIVES: Chlamydia trachomatis is a common sexually transmitted infection with serious consequences if not treated. Chlamydia screening pilots in England have established feasibility in primary care but there are currently no examples of good practice in general practice. The objectives of the study were to understand issues of using general practice as a setting for chlamydia screening and to explore ways of implementing a successful screening strategy. METHODS: Based on findings of a literature review, a semi-structured schedule was constructed to interview a purposive sample of policymakers, consultants in sexual and reproductive health and primary care professionals. A thematic framework was used for qualitative analysis. RESULTS: Twenty-two themes were identified and were ranked in order of word count. The topic that generated most discussion was heterogeneity of knowledge, attitudes and skills in general practice. When broken down by professional group, this topic ranked the highest for practice nurses and consultants in sexual health; general practitioners (GPs) and the chlamydia screening coordinator spoke most about financial incentives while the public health consultant spoke most about access. CONCLUSIONS: Most believed screening can and should be done and general practice can offer better population coverage. It needs to have little impact on clinicians' workload, for example, by using urine tests and self-taken vaginal swabs. Financial recognition needs to reflect the administrative costs and the impact on reception staff, but this and the innovative tests might add to the cost of the screening programme. Incentives have to be handled sensitively to reduce inequity among GPs and other services offering screening.     

A sexual health strategy for Australia--time for action

Australia still does not have a national sexual health strategy. Sexually transmissible infections such as chlamydia continue to plague the community, and the incidence of HIV is increasing. But a cohesive sexual health strategy cannot merely be disease-focussed, it must include the broader social and cultural aspects of sexual behaviour and sexuality. We propose a public health framework for the development of a national sexual health strategy that will bring Australia in line with the United Kingdom and New Zealand.     

西安地区新生儿衣原体感染的病原学及临床研究

为了解衣原体在新生儿感染频度并揭示其临床特征、提出诊治预防方案,我们对128例临床诊断新生儿感染患儿进行衣原体病原及血清学检查,对母血也进行追踪检查。表明西安地区新生儿感染中11/128(8.59％)显示衣原体感染情况。对其病例也进行了临床资料整理分析,提示出儿科工作者在今后工作中应重视预防新生儿衣原体感染情况。     

Incidence of trichiasis in a cohort of women with and without scarring

BACKGROUND: Blindness from trachoma is a significant problem for many underdeveloped countries. While active trachoma is common in children, trichiasis, the potentially blinding sequella, develops in adulthood and affects mainly women. Little is known about factors associated with the development of trichiasis. METHODS: The 7-year incidence of trichiasis and its association with ocular chlamydia infection was examined in a cohort of women from a hyperendemic area. A total of 4,932 women 18 years and older, living in 11 villages in Central Tanzania, were examined in 1989. A follow-up examination in 1996 was performed on all women with scars living in six of the 11 villages and on a random sample of women without scars from the same villages. Trachoma was graded clinically, chlamydia infection was ascertained at follow-up using polymerase chain reaction-enzyme immunoassay (PCR-EIA). RESULTS: A total 523 of the women with scars and 503 of the women without scars were re-examined. Forty-eight of the women with scars (incidence, 9.2%) and three of the women without scars (0.6%) developed trichiasis in the 7-year period. Prevalence of chlamydia infection was significantly higher in the group with scars (11.7% versus 7.1%). Trichiasis cases were more likely to be older, and to have chlamydia infection at follow-up odds ratio (95% confidence interval) 2.5 (1.1-5.7). CONCLUSION: The 7-year incidence rate in the population with scars was high, over 1% per year. Ocular chlamydia infection was more common in the group with scars at baseline and was also associated with being a trichiasis case, suggesting the importance of potentially long-term chlamydia infection in the progression to trichiasis. Antibiotic distribution programmes for trachoma control should include women with scars.     

Insights in Public Health: The Hidden Epidemic: Sexually Transmitted Diseases in 2014

Diseases caused by sexually transmitted agents are among the most common infectious diseases in the United States. Sexually transmitted diseases (STDs) have serious sequelae including physical pain, emotional distress, adverse reproductive outcomes, and cancer. They also pose an economic burden on society. STDs are challenging to prevent and control due to a general reluctance to address sexual health issues in an open manner. Human papillomavirus infection, chlamydia, and gonorrhea have recently been addressed by the Centers for Disease Control and Prevention in their Grand Rounds series reflecting their high-profile status on the national prevention and control agenda. This Insights column will focus on these three STDs.     

A new national Chlamydia Sentinel Surveillance System in Australia: evaluation of the first stage of implementation

The Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) was established with funding from the Department of Health and Ageing to trial the monitoring of the uptake and outcome of chlamydia testing in Australia. ACCESS involved 6 separate networks; 5 clinical networks involving sexual health services, family planning clinics, general practices, antenatal clinics, Aboriginal community controlled health services, and 1 laboratory network. The program ran from May 2007 to September 2010. An evaluation of ACCESS was undertaken in early 2010, 2 years after the program was funded. At the time of the evaluation, 76 of the 91 participating sites were contributing data. The jurisdictional distribution of the 76 sites generally matched the jurisdictional distribution of the Australian population. In 2008, the chlamydia testing rates in persons aged 16-29 years attending the 26 general practices was 4.2% in males and 7.0% in females. At the 25 sexual health services, the chlamydia testing rates in heterosexuals aged less than 25 years in 2008 was 77% in males and 74% in females. Between 2004 and 2008, the chlamydia positivity rate increased significantly in heterosexual females aged less than 25 years attending the sexual health services, from 11.5% to 14.1% (P < 0.01). Data completeness was above 85% for all core variables except Aboriginal and/or Torres Strait Islander status and country of birth, which ranged from 68%-100%, and 74%-100%, respectively, per network. There were delays in establishment of the system due to recruitment of 91 sites, multiple ethics applications and establishment of automated extraction programs in 10 different database systems, to transform clinic records into a common, pre-defined surveillance format. ACCESS has considerable potential as a mechanism toward supporting a better understanding of long-term trends in chlamydia notifications and to support policy and program delivery.