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. 1998 Sep 5;317(7159):680. doi: 10.1136/bmj.317.7159.680a

Screening for Chlamydia trachomatis

New methods are needed to assess the burden of illness from chlamydia

I Simms 1, G Hughes 1, M Catchpole 1
PMCID: PMC1113849  PMID: 9728010

Editor—Boag and Kelly’s editorial is a useful review of some of the issues raised in the recently published summary of the findings of the chief medical officer’s expert advisory group on genital chlamydial infection.1 If successfully implemented, these recommendations would be one of the most important public health interventions in controlling communicable diseases of the past 25 years. However, they do not address the issue of how the proposed screening programme might be evaluated.

Boag and Kelly imply that successful intervention would reduce the incidence of infertility. Although this may be true, monitoring rates of infertility is unlikely to provide a reliable or timely measure of the true impact of intervention. Firstly, genital chlamydial infection is associated with only about 75% of cases of tubal factor infertility, which in turn is thought to account for only 36% of all cases of infertility.2,3 Secondly, the highest prevalence of genital chlamydial infection is seen in women aged 16 to 19, but more women are becoming pregnant later in life.4 Women are thus likely to seek advice about infertility many years, perhaps even decades, after infection. Thirdly, other factors such as expectations of the success of treatment might influence the number of women seeking infertility treatment.

Boag and Kelly also imply that the promised pilot studies would show whether reductions in morbidity could be achieved through intervention. This is unlikely to be the case until new measures are developed for monitoring the burden of illness associated with chlamydial infection, particularly pelvic inflammatory disease, which accounts for much of the illness associated with this infection. Although the prevalence of chlamydial infection may be reduced in the short term by screening, this would not necessarily reflect a corresponding decrease in pelvic inflammatory disease. Short term reductions in prevalence may be associated with reduced duration of infection rather than reduced incidence of disease.

Monitoring trends in pelvic inflammatory disease will require large investment in the development of suitable, widely applicable diagnostic tools and surveillance systems. Only through the development of such systems will the effectiveness of genital chlamydial screening be able to be assessed. This is one of the main challenges if the proposals embodied in the expert advisory group’s report are to be realised.

References

  • 1.Boag F, Kelly F. Screening for Chlamydia trachomatis. BMJ. 1998;316:1474. doi: 10.1136/bmj.316.7143.1474. . (16 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Cates W, Fairley TMM, Rowe PJ. Worldwide patterns of infertility: is Africa different? Lancet. 1985;i:596. doi: 10.1016/s0140-6736(85)90594-x. [DOI] [PubMed] [Google Scholar]
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BMJ. 1998 Sep 5;317(7159):680.

Genitourinary medicine clinics in Scotland give high priority to contact tracing

C Thompson 1

Editor—In their editorial Boag and Kelly imply that contact tracing for chlamydia currently does not receive high priority in genitourinary medicine clinics.1-1 If that is the case in their hospital, the Chelsea and Westminster Hospital, London (and Clarke’s recent review suggests that this may be so for some clinics in London1-2), I do not think it is representative of the United Kingdom as a whole. The document Clinical Guidelines and Standards for the Management of Uncomplicated Genital Chlamydial Infection published in November last year by the Central Audit Group in Genitourinary Medicine states quite clearly that partner notification must be undertaken in all cases.1-3

Contact action figures for chlamydial and gonococcal infections in genitourinary medicine clinics in Scotland are published annually.1-4 The most recent data (for 1996-7) show that 896 contacts were sought from a total of 1856 index episodes of chlamydial infection, of whom 553 (62%) were subsequently seen at a genitourinary medicine clinic. The proportion of contacts sought (48% of index cases) was identical with that for gonococcal infections, for which 193 contacts were sought from a total of 397 index episodes, of whom 127 (66%) subsequently attended a genitourinary medicine clinic. These figures support the fact that partner notification for chlamydial infections in Scottish genitourinary medicine clinics is given as high a priority as that for gonococcal infections.

I agree with Boag and Kelly that partner notification outwith genitourinary medicine clinics and their integral health adviser network is currently not given high priority and that the success of a national screening programme would depend on the effectiveness of this aspect of patient management. Close collaboration between genitourinary medicine clinics, local primary care, and the laboratory services in rapidly communicating positive results will facilitate the contact tracing process and help control this silent epidemic.

References

  • 1-1.Boag F, Kelly F. Screening for Chlamydia trachomatis. BMJ. 1998;316:1474. doi: 10.1136/bmj.316.7143.1474. . (16 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Clarke J. Contact tracing for chlamydia: data on effectiveness. Int J STD AIDS. 1998;9:187–191. doi: 10.1258/0956462981921945. [DOI] [PubMed] [Google Scholar]
  • 1-3.Central Audit Group in Genitourinary Medicine. Clinical guidelines and standards for the management of uncomplicated genital chlamydial infection. London: Royal College of Physicians; 1997. [DOI] [PubMed] [Google Scholar]
  • 1-4.Information and Statistics Division, National Health Service in Scotland. Genitourinary Medicine Statistics, Scotland. Year ending 31 March 1997. Edinburgh: ISD; 1998. [Google Scholar]
BMJ. 1998 Sep 5;317(7159):680.

Contacts attendance rate is 70% in Hertfordshire

Harisadhan Maiti 1, Heather Bower 1, Jenny Norrie 1

Editor—We were surprised to read in the editorial by Boag and Kelly and elsewhere in the BMJ that contact tracing for Chlamydia trachomatis infection does not currently receive high priority, even in genitourinary medicine clinics.2-1,2-2 We strongly believe that it is an essential part of managing sexually transmitted infections alongside medical management. C trachomatis infection is the most prevalent treatable sexually transmitted infection in the United Kingdom. Its sequelae—pelvic inflammatory disease, chronic pelvic pain, infertility, and ectopic pregnancy in women—are well known. It can cause epididymitis, recurrent or persistent urethritis, and chronic prostatitis. However, the infection may remain asymptomatic.

As it is a sexually transmitted infection, treating one partner is of little benefit in controlling the infection. Genitourinary medicine clinics are well placed to undertake contact tracing (partner notification) as it is already built into their work programme. Contact tracing for chlamydia is taken seriously in our clinics at this hospital and at Lister Hospital, Stevenage. The service at Hertford started in 1990 and is part time, offering three clinic sessions a week, and the service at Lister Hospital was also, until recently, part time with three clinic sessions a week. We looked at all cases of chlamydial infection from 1990 to 1997 at this hospital and from 1996 to 1997 at Lister Hospital. Altogether, 268 patients had chlamydial infection (144 men, 124 women). The mean age of the men was 26.8 years (range 16-63) and of the women 23.6 years (16-45).

Contacts of 129 of the 144 male patients (90%) were notified either by contact slip or verbally by the index patient. Twelve patients were unable to inform partners as they were casual and unknown, and in three cases patients did not attend after the diagnosis of chlamydia was available and all attempts to contact them failed. Of the 129 contacts who were notified, 91 (70%) attended for investigation; 76 contacts came to our clinic and 15 to another clinic. We do not know whether the other 38 patients attended a clinic or not.

Contacts of 114 of the 124 female patients (92%) were notified. Ten patients were unable to notify contacts, in seven cases because they were casual and unknown. Two patients did not attend when the diagnosis was available, and attempts to contact them failed. One patient refused to see the health adviser. Of the 114 contacts who were notified, 83 (73%) attended for investigation; 72 contacts attended our clinic and 11 another clinic. Thirty one were unaccounted for.

References

BMJ. 1998 Sep 5;317(7159):680.

New technologies enable screening to be carried out in schools and the community

Margaret Polaneczky 1

Editor—Boag and Kelly describe the efforts of the chief medical officer and his advisory committee to develop a plan for screening for and treatment of chlamydial infection in the United Kingdom.3-1 This forward thinking and aggressive stance has the potential to dramatically decrease the incidence of this important pathogen in the United Kingdom. In designing a screening plan, however, the advisory group has limited itself to screening only women, and then only at doctors’ surgeries. Such an approach misses the opportunities created by the new DNA amplification technology in screening for chlamydia.

With techniques using the polymerase chain reaction, chlamydia can be reliably detected in urine specimens from both men and women.3-2 We recently showed that women and adolescent girls given only an illustrated brochure as an instructional aid were capable of obtaining their own specimens from the vaginal introitus and that these specimens were as good as, if not better, than those obtained by a clinician from the endocervix.3-3 Together, these data mean that screening for chlamydia need no longer be confined to doctors’ surgeries, thus greatly expanding the opportunities for community based screening. In fact, urine based screening has recently been successfully used in a screening programme for chlamydia in the United States based on local schools.3-4 Others have successfully used peer educators to obtain urine specimens from their peers at high risk in the community, thus capturing a population of infected males unlikely to ever visit a doctor’s surgery.3-5

New technologies create new opportunities. I urge the advisory committee to expand its pilot plan by including community and school based screening for both young men and women. We in the United States must also begin a nationwide approach to screening for chlamydia. The combination of creative and aggressive screening with effective partner notification and a single dose treatment for infection has the potential to markedly reduce rates of infection with this serious pathogen.

References

  • 3-1.Boag F, Kelly F. Screening for Chlamydia trachomatis. BMJ. 1998;316:1474. doi: 10.1136/bmj.316.7143.1474. . (16 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Marrazzo JM, White CL, Krekeler B, Celum CL, Lafferty WE, Stamm WE, et al. Community-based urine screening for Chlamydia trachomatis with a ligase chain reaction assay. Ann Intern Med. 1997;127:796–803. doi: 10.7326/0003-4819-127-9-199711010-00004. [DOI] [PubMed] [Google Scholar]
  • 3-3.Polaneczky MM, Witkin SS, Pollock L, Quigley C, Dulko D. Self-testing for Chlamydia trachomatis infection in women. Obstet Gynecol. 1998;91:375–378. doi: 10.1016/s0029-7844(97)00674-1. [DOI] [PubMed] [Google Scholar]
  • 3-4.Cohen DA, Nsuami M, Etame RB, Tropez-Sims S, Abdalian S, Farley TA, et al. A school-based chlamydia control program using DNA amplification technology. Pediatrics. 1998;101:E1. doi: 10.1542/peds.101.1.e1. [DOI] [PubMed] [Google Scholar]
  • 3-5.Gunn RA, Podschun GD, Fitzgerald S, Hovell MF, Farshy CE, Black CM, et al. Screening high-risk adolescent males for Chlamydia trachomatis infection. Obtaining urine specimens in the field. Sex Transm Dis. 1998;25:49–52. doi: 10.1097/00007435-199801000-00010. [DOI] [PubMed] [Google Scholar]
BMJ. 1998 Sep 5;317(7159):680.

Screening for and treatment of chlamydial infection demand commitment

A A Opaneye 1

Editor—In their editorial Boag and Kelly discuss the chief medical officer’s plan for immediate action on Chlamydia trachomatis.4-1 This plan is a step in the right direction, but it does not go far enough. Nearly all of the recommendations are already going on in several parts of the United Kingdom. A previous study identified age as an independent predictor of sexually transmitted infections after controlling for behavioural characteristics.4-2 Similarly, in my report from Coventry I recommended screening women under 30.4-3 As such, it may be prudent to use 30 rather than 25.

When chlamydial infection is diagnosed in a female patient, every effort should be made to contact and treat the male partner or partners. Untreated, these men will act as reservoirs of sexually transmitted infections since many of them will be free of symptoms.4-4

On the issue of difficulties with contact tracing, the use of modern techniques for detecting C trachomatis—for example, in urine4-5—and various self sampling methods should increase the population being screened. Further application of these methods in the community should increase yield. Patients (men and women) can then take samples themselves and submit these to their general practitioners, school nurses, or family planning clinics.

Finally, there is the issue of commitment by several groups. These include doctors (specialists in genitourinary medicine, gynaecologists (hospital and community), and general practitioners), politicians, and the press for community education on the subject. The contribution of the pathogen to the nation’s morbidity is substantial and can no longer be ignored.

References

  • 4-1.Boag F, Kelly F. Screening for Chlamydia trachomatis. BMJ. 1998;316:1474. doi: 10.1136/bmj.316.7143.1474. . (16 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4-2.Arno JN, Katz BP, McBride, Carty GA, Batteiger BE, Caine VA, et al. Age and clinical immunity to infections with chlamydia trachomatis. Sex Transm Dis. 1994;21:47–52. doi: 10.1097/00007435-199401000-00010. [DOI] [PubMed] [Google Scholar]
  • 4-3.Opaneye AA. Sexually transmitted diseases among women in Coventry, England. J R Soc Health. 1997;117:37–40. doi: 10.1177/146642409711700109. [DOI] [PubMed] [Google Scholar]
  • 4-4.Harry TC. Reproductive tract infections and abortions amongst adolescent girls in Nigeria. Lancet. 1995;345:869. [PubMed] [Google Scholar]
  • 4-5.Higgins SP, Klapper P, Struthers JK, Bailey AS, Gough AP, Moore R, et al. Detection of male genital infection with Chlamydia trachomatis and Neisseria gonorrhoeae using an automated multiplex PCR System (Cobas Amplicor) Int J STD AIDS. 1998;9:21–24. doi: 10.1258/0956462981921594. [DOI] [PubMed] [Google Scholar]

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