Opportunism is NICE idea for chlamydia screening

Between 1995 and 2004, a frightening increase in most sexually transmitted diseases in the UK included a 223% rise in genital chlamydia, with 104,155 reported cases in 2004, making it the most commonly reported STD. Although many questions are yet to be answered after the release of the NICE review of the evidence for the effectiveness of screening for genital chlamydial infection in sexually active young women and men, the evidence seems to say a big ‘yes' to opportunistic screening of any patient under 25, whatever they have walked through the door for. However, NICE, in its evidence statements, did not consider the added value of partner notification/contact tracing - a job effectively managed in GUM clinics but not always undertaken by GPs.     

General practitioners' knowledge and attitudes to contact tracing for genital Chlamydia trachomatis infection in North Queensland

INTRODUCTION: Most diagnoses of genital chlamydia infection in Queensland are made by general practitioners (GPs). This study aimed to assess GP attitudes to and knowledge of contact tracing in rural North Queensland. METHOD: A single page questionnaire mailed to a database of 65 GPs in May 2007. RESULTS: Nearly all respondents (42/43, 97.7%) 'always' or 'mostly' told patients to advise their contacts to seek medical treatment. More than half (24/44, 54.5%) felt that contact tracing was 'sometimes' or 'never' the responsibility of GPs. Around half of respondents (19/39, 48.7%) thought that the local public health unit staff were conducting contact tracing, which is not actually the case. CONCLUSION: There is lack of clarity surrounding the respective roles and responsibilities of sexual health units, public health units and GPs regarding contact tracing for chlamydia infection. IMPLICATIONS: GPs would benefit from education clarifying current contact tracing procedures, methods and resources.     

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.      

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.     

Epidemiologic differences between chlamydia and gonorrhea.

To assess the prevalence, demographics, and transmission patterns of genital chlamydia infection, we screened 3,078 patients, and compared identified cases (N = 511) to gonorrhea cases (N = 291) diagnosed in the same setting. Chlamydia cases were younger and more likely to be White than their gonorrhea counterparts. Chlamydia cases were distributed diffusely; geographic overlap between the two diseases was only about 40 percent. Gonococcal coinfection was noted in less than 10 percent of patients with chlamydia. Nearly half of men with chlamydia and four-fifths of women were asymptomatic and most cases were identified through screening or contact tracing. Populations at high risk for chlamydia are seemingly different from those for gonorrhea. Differences may be due to control interventions (active for gonorrhea, passive for chlamydia). Chlamydia case reporting and control initiatives are recommended.     

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。     

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.     

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 audit of the process of referral to genitourinary medicine of patients found to be chlamydia positive in a family planning service

This paper describes a collaborative audit between a large family planning and genitourinary medicine (GUM) service undertaken to ensure that all women presenting for termination of pregnancy (TOP) or IUD fitting were offered screening for chlamydia, were informed of a positive result, and were subsequently referred to GUM for full sexual health screening and contact tracing. Over a six month period in 1996 1072 patients were seen for either TOP (763) or W1) fitting (309) and of these 999 were offered a test which was performed in 988. Overall 38 positive tests were reported (3.8 per cent) but only two of 259 patients tested prior to lUD fitting were found to have chlamydia (<0.8 per cent). Only 27 of these 38 women (74 per cent) had information recorded in their notes that they had been given their result and 24 patients (63 per cent) were seen in GUM. The audit uncovered problems with documentation and cross-referencing of information which largely accounted for the failure to reach some of the standards set. An action plan has been formulated in an attempt to improve this aspect of the screening service. If more widespread screening for chlamydia is to be effectively implemented as recommended by the 31st RCOG Study Group on the Prevention of Pelvic Infection, then it is of importance that workable local protocols are in place including arrangements for partner notification and treatment. This will involve close collaboration between a range of specialities working in the sexual health field.     

Genital Chlamydia trachomatis infection in Australia: epidemiology and clinical implications

Over the last decade, notification rates for genital Chlamydia trachomatis infection in Australia have been rising progressively. While chlamydia is common and possibly increasing in the general population, heterosexual adolescents, indigenous Australians in remote settings, and homosexually active men are at particular risk of infection. Few studies are available on the extent of morbidity from chlamydia-associated diseases. Australia urgently needs a national strategy to control chlamydia, with widespread, selective screening as a key component. As general practitioners have an important role to play, we proffer guidelines for selective testing in primary care.     

STD screening,testing, case reporting,and clinical and partner notification practices: a national survey of US physicians

OBJECTIVES: This study presents results from a national survey of US physicians that assessed screening, case reporting, partner management, and clinical practices for syphilis, gonorrhea, chlamydia, and HIV infection. METHODS: Surveys were mailed to a random sample of 7300 physicians to assess screening, testing, reporting, and partner notification for syphilis, gonorrhea, chlamydia, and HIV. RESULTS: Fewer than one third of physicians routinely screened men or women (pregnant or nonpregnant) for STDs. Case reporting was lowest for chlamydia (37 percent), intermediate for gonorrhea (44 percent), and higher for syphilis, HIV, and AIDS (53 percent-57 percent). Physicians instructed patients to notify their partners (82 percent-89 percent) or the health department (25 percent-34 percent) rather than doing so themselves. CONCLUSIONS: STD screening levels are well below practice guidelines for women and virtually nonexistent for men. Case reporting levels are below those legally mandated; physicians rely instead on patients for partner notification. Health departments must increase collaboration with private physicians to improve the quality of STD care.     

Contact tracing to control infectious disease: when enough is enough

Contact tracing (also known as partner notification) is a primary means of controlling infectious diseases such as tuberculosis (TB), human immunodeficiency virus (HIV), and sexually transmitted diseases (STDs). However, little work has been done to determine the optimal level of investment in contact tracing. In this paper, we present a methodology for evaluating the appropriate level of investment in contact tracing. We develop and apply a simulation model of contact tracing and the spread of an infectious disease among a network of individuals in order to evaluate the cost and effectiveness of different levels of contact tracing. We show that contact tracing is likely to have diminishing returns to scale in investment: incremental investments in contact tracing yield diminishing reductions in disease prevalence. In conjunction with a cost-effectiveness threshold, we then determine the optimal amount that should be invested in contact tracing. We first assume that the only incremental disease control is contact tracing. We then extend the analysis to consider the optimal allocation of a budget between contact tracing and screening for exogenous infection, and between contact tracing and screening for endogenous infection. We discuss how a simulation model of this type, appropriately tailored, could be used as a policy tool for determining the appropriate level of investment in contact tracing for a specific disease in a specific population. We present an example application to contact tracing for chlamydia control.     

Estimating the sexual mixing patterns in the general population from those in people acquiring gonorrhoea infection: theoretical foundation and empirical findings.

STUDY OBJECTIVES--To describe mathematically the relationship between patterns of sexual mixing in the general population and those of people with gonorrhoea infection, and hence to estimate the sexual mixing matrix for the general population. DESIGN--Integration of data describing sexual behaviour in the general population, with data describing sexual behaviour and mixing among individuals infected with gonorrhoea. Use of these data in a simple mathematical model of the transmission dynamics of gonorrhoea infection. SETTING--The general population of London and a genitourinary medicine (GUM) clinic in west London. PARTICIPANT--These comprised 1520 men and women living in London who were randomly selected for the national survey of sexual attitudes and lifestyles and 2414 heterosexual men and women who presented to the GUM clinic with gonorrhoea. MAIN RESULTS--The relationship between sexual mixing among people with gonorrhoea and sexual mixing in the general population is derived mathematically. An empirical estimate of the sexual mixing matrix for the general population is presented. The results provide tentative evidence that individuals with high rates of acquisition of sexual partners preferentially select other individuals with high rates as partners (assortative mixing). CONCLUSIONS--Reliable estimates of sexual mixing have been shown to be important for understanding the evolution of the epidemics of HIV infection and other sexually transmitted diseases. The possibility of estimating patterns of sexual mixing in the general population from information routinely collected in gonorrhoea contact tracing programmes is demonstrated. Furthermore, the approach we describe could, in principle, be used to estimate the same patterns of mixing, using contact tracing data for other sexually transmitted diseases, thus providing a way of validating our results.     

Evidence-based guidelines for the management of genital chlamydial infection in general practice. (Leicestershire Chlamydia Guidelines Group).

BACKGROUND: Valid clinical guidelines can be effective in improving patient care. Genital Chlamydia trachomatis infection is the commonest curable sexually transmitted disease (STD) in England and Wales and is an important cause of pelvic inflammatory disease (PID), tubal infertility and ectopic pregnancy. No published guidelines exist on managing genital chlamydial infection in British general practice. OBJECTIVE: We aimed to develop valid guidelines for the management of genital chlamydial infection for use in British general practice. METHODS: A district-wide postal questionnaire survey was used to document current clinical practice. A critical review of the evidence concerning the management of genital chlamydial infection as it relates to British general practice was performed. The information gained from the critical review and survey was used to develop evidence-based guidelines within a multidisciplinary guideline recommendation group. RESULTS: The guidelines covered the diagnosis, investigation, drug treatment and referral of adult male and female patients with genital chlamydial infection in general practice. CONCLUSION: Valid guidelines for the management of genital chlamydial infection have been developed for use in British general practice. Appropriate dissemination and implementation of the guidelines should lead to earlier detection and treatment of men and women with chlamydial infection and thereby reduce the incidence of PID, tubal infertility and ectopic pregnancy in women.     

Surveillance for sexually transmissible diseases in Victoria, 1983 to 1992

Abstract: Surveillance systems have been developed in Victoria to determine trends in sexually transmissible diseases (STDs). Notifications to the Health Department (including laboratory notification since May 1990) have been supplemented by data about strains of Nasseria gonorrhoeae and cultures for Chlamydia trachomatis processed by the Microbiological Diagnostic Unit, enhanced laboratory surveillance of syphilis, and data on genital herpes and genital warts from the Melbourne Sexual Health Centre. During the period under review the incidence of gonorrhoea declined, rapidly at first, and then more slowly. For women, this trend has continued, while gonorrhoea acquired abroad by men has become relatively more important. Since 1988, gonorrhoea in homosexual men has increased, and rectal isolates have increased concurrently, raising concerns about HIV risk behaviour. Cases of syphilis are likely to be ascertained through STD, antenatal and refugee screening, rather than because of symptoms or contact tracing. Chlamydia is a the most common notifiable STD, despite underreporting and under-diagnosis. In 1991, 832 cases were notified, increasing to 1377 in 1992. In 1992, of the 73 cases (65 per cent of notifications) where the doctor identified a risk, 15 per cent was attributed to homosexual contact, and 27.4 per cent to heterosexual exposure. Limitations in the data include inadequate standard case definitions for many STDs, changes in the statutory requirement for notifications in 1990, underreporting, changes in diagnostic and screening patterns, and lack of detailed demographic data. Education of general practitioners is needed to improve diagnosis and notification of chlamydia.     

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.     

Urogenital Chlamydia trachomatis infections in general practice: diagnosis, treatment, follow-up and contact tracing

BACKGROUND: Patients with urogenital Chlamydia trachomatis infection are frequently seen in general practice. It is, therefore, important to assess GPs' management of these patients in order to ensure adequate control of the disease. OBJECTIVE: We aimed to evaluate the GPs' routines in diagnosis, medical treatment, follow-up and contact tracing according to knowledge/attitude (criteria) and actual performance. METHODS: The study comprised the 388 GPs in the County of Aarhus. Two questionnaires were used. The first questionnaire was mailed to each of 252 GPs who had attended a patient with urogenital C. trachomatis infection 4 weeks previously. Each GP was asked about his/her actual performance for that particular patient. In order to elucidate the GPs' criteria, the second questionnaire was mailed to each of the 388 GPs in the County of Aarhus, asking about their usual intended routines (criteria) for managing urogenital C. trachomatis infections. The questionnaires covered the same topics. RESULTS: Great variations among the GPs' management of urogenital C. trachomatis infection according to sampling-site, medical treatment, follow-up and contact tracing were found. Furthermore, a discrepancy between criteria and actual performance for obtaining an urethral swab-sample in women and for contact tracing of previous partners were demonstrated. The GPs stated that they had intended to obtain more urethral swab-samples and do more contact tracing than they actually did. CONCLUSIONS: We conclude that increasing the collection of urethral samples from women combined with greater emphasis on contact tracing procedures might limit the prevalence of the infection. In order to achieve this, continuous medical education and auditing procedures on urogenital chlamydial infections may be helpful.      

Prevalence of Chlamydia trachomatis infection among 'high risk' young people in New South Wales

International research on homeless adolescents has found that incidence and prevalence of sexually transmissible infections is relatively high. This study reports on a chlamydia prevalence survey conducted among high-risk young people (14-25 years) in New South Wales. The participants were recruited from youth health centres, which target homeless and high-risk youth. Of 333 clients (42.6% male), 84.1% were sexually active and mean number of sexual partners over the preceding 3 months was 1.4. Among sexually active participants, 24.6% claimed to use condoms always and 25% never. Sixteen of 274 available urine samples tested positive for Chlamydia trachomatis infection. Further research is warranted to better define high-risk groups and clarify the nature of associations between various factors impacting on sexual health. Most importantly, research is now called for into effective strategies for engaging and attracting young people to screening, treatment and contact tracing.     

Implementation of a pilot programme for screening for chlamydial infection in general practice

Objectives: To determine whether opportunistic screening for Chlamydia trachomatis, based on a selective screening algorithm, is possible in general practice in Belgium; to assess feasibility of the screening strategy with respect to workload, acceptability, and organisational aspects.

Methods: Implementation of a pilot screening programme by 37 GPs for a period of 15 weeks. GPs’ screening practices were registered and compared with the guidelines they had received. Outcome measures were: the number of patients included in the risk assessment, uptake of screening by eligible patients, prevalence of previously unidentified infection, and uptake of treatment. After the study period GPs evaluated a number of feasibility issues on a scoring form.

Results: 326 women underwent the risk assessment and 214 were tested by an amplification assay on a urine sample. Prevalence in women at risk was 6.4%. Overall effective screening rate was 77.6%; 9 of 11 positives took up treatment. Participating GPs found the strategy feasible and perceived that it was well accepted by their patients.

Discussion: The screening strategy was easily implemented by most GPs but some of them dropped out. The guidelines were followed relatively well and there were no major logistic problems. The uptake of treat ment was suboptimal. Efforts must be made to stimulate and educate more GPs to perform screening; laboratory and storage conditions should be optimised; refunding criteria should be revised; and overscreening must be avoided.