Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Expanding Chlamydia Screening Beyond the Doctor's Office
- Margaret Polaneczky (18 May 1998)
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Chlamydia Screening and Treatment demand commitment
- A A Opaneye (21 May 1998)
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Contact tracing for chlamydial infections
- C Thompson (10 June 1998)
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Chlamydia trachomatis, screening the men
- B Stanley (15 June 1998)
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Tests for Chlamydia trachomatis in the Genitourinary Medicine service
- Angela Robinson (25 August 1998)
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Margaret Polaneczky, Assistant professor of obstetrics and gynecology The New York Hosital - Cornell Medical Center
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The efforts of the British chief medical officer and advisory committee to develop a plan for chlamydia screening and treatment in the United Kingdom are to be applauded. Their 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, they have limited themselves to the screening only women, and then only at doctor's offices. Such an approach misses the opportunities created by the new DNA amplification technology for Chlamydia screening. Using PCR techniques, chlamydial can be reliably detected in urine specimens from both men and women (1,2), and in specimens from the vaginal introitus in women (3,4). We recently demonstrated that women and adolescents, using only an illustrated brochure as an instructional aid, are capable of obtaining their own specimens from the vaginal intoitus, and that these specimens are as good as, if not better, than those obtained by a clinician from the endocervix (5). Together, these data mean that we need no longer confine Chlamydia screening to the doctor's office, thus greatly expanding the opportunities for community-based screening. In fact, urine-based screening has recently been successfully used in a local school-based chlamydial screening program in the United States.(6) Others have successfully used peer-educators to seek obtain urine specimens from their high-risk peers in the community, thus capturing a population of infected males unlikely to ever visit a doctor's office. (7) New technologies create new opportunities. I urge the advisory committee to expand their pilot plan for chlamydia screening by adding both community and school-based screening sites for both young men and women. We in the United States must also begin a nationwide approach to Chlamydia screening. By combining creative and aggressive screening with effective partner notification and use of single-dose therapy for infection, the potential exists to markedly reduce rates of infection with this serious pathogen. (1) Higgins SP, Klapper PE, Struthers JK, Bailey AS, Gough AP, Moore R, Corbitt G, Bhattacharyya MN. Detection of male genital infection with Chlamydia trachomatis and Neisseria gonorrhoeae using an automated multiplex PCR system (Cobas Amplicor). Int J STD AIDS 1998 Jan;9(1):21-24. (2) Gaydos CA, Howell MR, Quinn TC, Gaydos JC, McKee KT JrJ Use of ligase chain reaction with urine versus cervical culture for detection of Chlamydia trachomatis in an asymptomatic military population of pregnant and nonpregnant females attending Papanicolaou smear clinics. Clin Microbiol 1998 May;36(5):1300-1304 (3) Witkin SS, Inglis SR, Polaneczky M. Detection of Chlamydia trachomatis and Trichomonas vaginalis by Polymerase Chain Reaction in Introital Specimens from Pregnant Women. Am J Obstet Gynecol 1996; 175: 165-7. (4) Wiesenfeld HC, Rideout A, Macio I, DiBasi F, Sweet RL. The Vaginal Intoitus:A Novel Site for Chlamydia trachomatis Testing in Women. Am J Obstet Gynecol 1996; 174: 1542-6. (5) Polaneczky MM, Witkin SS, Pollock L, Quigley C, Dulko D. "Self-Testing for Chlamydia Trachomatis Infection in Women." Obstetrics and Gynecology. 1998; 91 (3): 375-378. (6) Cohen DA, Nsuami M, Etame RB, Tropez-Sims S, Abdalian S, Farley TA, Martin DH. A School-based Chlamydia Control Program Using DNA Amplification Technology. Pediatrics 1998 Jan 1;101(1):E1 (7) Gunn RA, Podschun GD, Fitzgerald S, Hovell MF, Farshy CE, Black CM, Greenspan JR. Screening high-risk adolescent males for Chlamydia trachomatis infection. Obtaining urine specimens in the field. Sex Transm Dis 1998 Jan;25(1):49-52 |
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A A Opaneye, Consultant G U Medicine Middlesbrough General Hospital
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The plan by the Chief Medical Officer of the UK for an immediate action on chlamydia trachomatis is a step in the right direction. However it does not go far enough. Nearly all of the main recommendations are already going on in several parts of the country. Several studies have identified age as an independent predictor of sexually transmitted infections after controlling for behavioural characteristics (1). There is evidence that screening women under 30 years of age missed only 7% (2). Likewise in the report from Coventry (3) the recommendation was to screen women under 30 years of age. As such it may be prudent to use 30 years rather than 25 years. Following a diagnosis in a female patient, every effort should be made to contact and treat the male partner/partners otherwise these men will serve as untreated reservoirs of sexually transmitted infections (4) since many of these men will be asymptomatic. On the issue of difficulties with contact tracing, the use of modern techniques for detecting chlamydia trachomatis eg from urine (5) and various self sampling methods should increase the population being screened. Further application of these methods in the community should increase yield. Patients (males and females) can then take samples themselves and submit these to their GP's, school nurses or family planning clinics. Finally, there is the issue of commitment by several groups. These include doctors - G U Physicians, Gynaecologists (hospital and community), GP's; the politicians and the press for community education on this subject. The contribution of the pathogen to the nation's morbidity is substantial and can no longer be ignored. Where there is a will, there is a way. 1 ARNO J.N.; KATZ B.P.; McBride R et al: Age and clinical immunity to infections with chlamydia trachomatis. Sex Trans Dis. 1994; 21:47-52. 2 HOWEL M.R.; QUINN T.C.; GAYDOS C.A.; Screening for Chlamydia trachomatis in asymptomatic women attending family planning clinics. Ann Intern Med 1998; 128:277-284 (Medline). 3 OPANEYE A. A.; Sexually transmitted diseases among women in Coventry, England. J Roy. Soc. Hlth 1997;117(1):37-40. 4 HARRY T.C.; Reproductive tract infections and abortions among adolescent girls in rural Nigeria. Lancet 1995; 345:869. 5 HIGGINS S.P.; KLAPPER P.E.; STRUTHERS J.K.; BAILEY A.S.; GOUGH A.P.; MOORE R.; CORBITT G.; BHATTACHARYYA M.N. Detection of male genital infection with Chlamydia trachomatis and neisseria gonorrhoea using an automated multiplex PCR system (Cobas Amplicor). Int JSTD AIDS 1998 Jan;9(1):21-24. |
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C Thompson, Consultant GU Medicine Victoria Hospital, Kirkcaldy, Fife, UK
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I was concerned to read in her recent article on ‘Screening for Chlamydia trachomatis’ that Fiona Boag felt that contact tracing for chlamydia currently does not receive high priority in Genitourinary Medicine clinics.[1] If that is the case in the Chelsea and Westminster Hospital, and Clarke’s recent review suggests that this may be so for some clinics in London,[2] I do not think it is representative of the country 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.[3] Contact action figures for chlamydial and gonococcal infections within Genitourinary Medicine Clinics in Scotland are published annually.[4] The most recent data (for 1996/97) show that 896 contacts were sought from a total of 1856 index episodes of chlamydial infection, of which 553 (62%) were subsequently seen at a GU clinic. The proportion of contacts sought (48% of index cases) was identical to that for gonococcal infections, for which a total of 193 contacts were sought out of 397 index episodes of whom 127 (66%) subsequently attended the GU clinic. These figures support the fact that partner notification for chlamydial infections within Scottish GUM clinics is given as high a priority as that for gonococcal infections. I agree with Boag that partner notification outwith GUM clinics and their integral Health Adviser network is currently not given high priority and the success of a National Screening programme would depend upon the effectiveness of this aspect of patient management. Close collaboration between GUM clinics, their local primary care colleagues and the laboratory services to rapidly communicate positive results will facilitate the contact tracing process, and help control this silent epidemic. References 1. Boag F, Kelly F. Screening for Chlamydia Trachomatis. BMJ 1998; 316:1474 2. Clarke J. Contact tracing for chlamydia: data on effectiveness. Int J STD & AIDS 1998; 9:187-191. 3. Central Audit Group in Genitourinary Medicine. Clinical Guidelines and Standards for the Management of Uncomplicated Genital Chlamydial Infection. Publications Office of Royal College of Physicians 1997. 4. Genitourinary Medicine Statistics, Scotland. Year ending 31 March 1997. Information & Statistics Division, National Health Service in Scotland, Edinburgh 1998. |
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B Stanley, Consultant in Genitourinary Medicine Cumberland Infirmary, Carlisle
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The primary targets for screening for Chlamydia trachomatis infection will be sexually active women under 25 and similar women over 25 who have had two or more sexual partners in a year (in addition to users of Genitourinary Medicine services and women seeking termination of pregnancy) While the focusing of the programme on women because of the more severe long term consequences is understandable some men in the age group most at risk for this infection are easily accessible. We have in this country a large population of young men in prisons subject to random urinary testing for drug use. We now have good urinary screening tests for chlamydia.(1) Treatment of young men in custody is an optimal opportunity for treatment as risks of re-exposure during treatment are likely to be lower than in the community, and with care and good communication between prisons and Genitourinary Medicine departments, contact tracing and treatment of partner(s) could be offered while they are away from one another. There seem to be no current studies of the scale of chlamydia trachomatis infection in the prison population in England where the use of random urine testing for drug use should make acquiring prevalence data for chlamydia relatively easy. A recent study in Alabama of adolescents in detention had a refusal rate of 1.5% and a chlamydia positivity rate of 8.8% in male subjects.(2) Testing of prisoners always has ethical dilemmas attached, but pilot studies to obtain an estimate of prevalence could be anonymised and prisoners whose urine samples are being tested for drugs could be offered the opportunity of screening for chlamydia. Surely it could be argued that compared to asymptomatic women these accessible young men are being ignored and present a good opportunity for screening and treatment that should not be missed. (1) Gaydos CA, Howell MR, Quinn TC, Gaydos JC, McKee KT JrJ Use of ligase chain reaction with urine versus cervical culture for detection of Chlamydia trachomatis in an asymptomatic military population of pregnant and nonpregnant females attending Papanicolaou smear clinics. Clin Microbiol 1998 May;36(5):1300-1304 (2). Oh MK. Smith KR. O'Cain M. Kilmer D. Johnson J. Hook EW 3rd. Urine-based screening of adolescents in detention to guide treatment for gonococcal and chlamydial infections. Translating research into intervention. [Journal Article] Archives of Pediatrics & Adolescent Medicine. 152(1):52-6, 1998 Jan 5. |
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Angela Robinson, Consultant in Genito Urinary Medicine Mortimer Market Centre
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EDITOR: - Fiona Boag1 commented on the recommendations made by the Chief Medical Officer’s Expert Advisory Group on Chlamydia trachomatis2. It was pointed out that the case for screening all sexually active women under 25 years of age, those undergoing termination of pregnancy and others at high risk has been made, but details in terms of professional education, types of specimens, tests and treatments to use, as well as the most effective way of tracing partners, need to be addressed. Some of this ground will be covered in two pilot projects which will start later this year as part of a general feasibility study to judge the value of proposed screening. In these pilot schemes it has been agreed that urine samples will be examined because these provide a non-invasive approach to sampling. Since about 75% of urine samples from either symptomatic or asymptomatic women attending Genitourinary Medicine (GUM) clinics contain only a few chlamydial elementary bodies (< 10/10ml)3, it has been agreed that the most sensitive tests will be required, namely molecular procedures (ligase chain reaction or polymerase chain reaction). For patients with a positive result, the Advisory Group has advised that there should be referral to GUM clinics for full screening for sexually transmitted infections and for contact tracing. Furthermore, there is support for the notion that the laboratories associated with the GUM clinics in the pilot study should use molecular procedures and not the less sensitive tests (enzyme immunoassays) employed by almost all laboratories testing for C.trachomatis in England and Wales4. There will be difficulty in a screening programme if the “screening” test has greater sensitivity than the “diagnostic” test used on patients presenting with symptoms, for termination of pregnancy or attending GUM clinics for perceived higher risk. It is illogical to use inferior tests on high risk populations. Problems will follow if male partners attending GUM clinics have false negative results which may be due to sub-optimal test methodology. Discordant couples, where one partner has been identified as positive and the other as negative, are difficult to manage as the concerns raised about infidelity are usually greater. All of this, in turn, focuses on the fact that GUM clinics throughout England and Wales are supported by laboratories which in the main use insensitive tests for C. trachomatis. Since about 30% of women, symptomatic or asymptomatic, attending GUM clinics have small numbers of C.trachomatis organisms in cervical specimens3, most of these women will be diagnosed as chlamydia-negative because the tests are insufficiently sensitive to detect them. We calculate, on the basis of about 500,000 women attending GUM clinics each year, with a prevalence of C.trachomatis of about 10% and about 30% of these being mis-diagnosed, that in the last 10 years 150,000 women seen in GUM clinics will have had a C.trachomatis infection that would have been overlooked. There could not be a greater indictment of the service. Some of these chlamydia-positive women may have received treatment, but the majority will have remained untreated and falsely reassured. This is an important reason for C.trachomatis persisting in the community and why women suffer pelvic inflammatory disease, ectopic pregnancies and infertility as frequently as they do. Ten years ago, very sensitive detection tests were not available, but they are now. The usual reason for not using these tests is financial restriction. However, ultimately the introduction of DNA amplification tests will be cost effective5. The time has long been overdue for all clinics, not just those involved in the pilot projects, to be serviced by laboratories using DNA amplification tests. Now that there is to be a promised influx of money into the NHS, pressure should be put on Hospital Trusts to make sure that the best tests are available. The medico-legal consequences of infertility resulting from the failure to identify C.trachomatis because of inferior test methodology will be very costly. The current situation would not be tolerated if it happened to be HIV. C.trachomatis does not kill, but nevertheless it causes an immense amount of human suffering. David Taylor-Robinson Emeritus professor Department of Genito urinary Medicine and Communicable Diseases, Imperial College School of Medicine at St Mary’s, London W2 1NY. Angela J. Robinson Consultant physician Department of Genitourinary Medicine, Mortimer Market Centre, London WC1E 6AU. References 1. Boag F, Kelly F. Screening for Chlamydia trachomatis. Editorial. BMJ 1998; 316:1474. 2. CMO’s Expert Advisory Group. Chlamydia trachomatis. Department of Health 1998. 3. Thomas B J, Pierpoint T, Taylor-Robinson D, Renton A M. Quantification of Chlamydia trachomatis in cervical and urine specimens from women attending a genitourinary medicine clinic: implications for screening strategies. Int J STD/AIDS 1998; 9:448-51. 4. Simms I, Catchpole M, Robinson A J, Laas C. Provision of diagnostic services for genital chlamydial infection in Genito-Urinary Medicine clinics in England and Wales, 1996. Genitourin Med 1997; 73: 147-8. 5. Howell M R, Quinn T C, Braithwaite W, Gaydos C A. Screening women for Chlamydia trachomatis in family planning clinics: the cost effectiveness of DNA amplification tests. Sex Transm Dis 1998; 25:108-17. Consultant Physicians: The Mortimer Market Centre Dr E Allason-Jones FRCP MD Off Capper Street Dr P French MB ChB MRCP London WC1E 6AU Dr A Robinson MB BS FRCP Tel: 0171 530 5033 Fax: 0171 530 5044 Our ref: AR/ak/dtr.doc |
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