Controlling genital chlamydial infection

BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7079.516a (Published 15 February 1997) Cite this as: BMJ 1997;314:516

Figures are underestimates because men are not tested

  1. M J Bolam, Clinical assistant in genitourinary medicinea
  1. a Greenwich District Hospital, London SE10 9HE
  2. b Department of Public Health, Leicestershire Health, Leicester LE5 4QF
  3. c Department of Genitourinary Medicine, Leicester Royal Infirmary, Leicester LE1 5WW

    Editor—Anne M Johnson and colleagues are right to say in their editorial on controlling genital chlamydial infection that screening, diagnosis, and treatment remain inconsistent.1 Returns from genitourinary medicine clinics cannot give any useful estimate of the true incidence of chlamydial infection while so many clinics do not routinely screen male patients; the figure of 39 000 treated cases in England and Wales in 1995 must be far short of the true figure.

    In some clinics screening for chlamydia is rationed because of cost. These clinics usually accept that men will not be given a chlamydia test because they are, in any case, going to receive antibiotic treatment effective against chlamydia. This includes men whose symptoms and signs, together with the presence of pus cells on urethral microscopy, are sufficient to indicate non-gonococcal urethritis and those who are given antibiotic treatment because their partners have proved chlamydia, or in conjunction with treatment for proved gonorrhoea.

    Thus those men who would be most likely to have a positive result of a chlamydia test, while being adequately treated, will not be included as having a proved chlamydial infection in returns from genitourinary medicine clinics. This underreporting will lower the national figures.


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    Integrated approach is needed

    1. Tim Stokes, Registrar in public health medicineb,
    2. Rashmi Shukla, Consultant in communicable disease controlb,
    3. Sumit Bhaduri, Registrarc,
    4. Paul Schober, Consultantc
    1. a Greenwich District Hospital, London SE10 9HE
    2. b Department of Public Health, Leicestershire Health, Leicester LE5 4QF
    3. c Department of Genitourinary Medicine, Leicester Royal Infirmary, Leicester LE1 5WW

      Editor—Jonathan D C Ross and colleagues report that the attendance rate at genitourinary medicine clinics of patients with genital infection with Chlamydia trachomatis diagnosed in general practice in Lothian is low (13%).1 Genital chlamydial infection, however, is not just a problem in general practice: it is seen in family planning clinics, gynaecology outpatient clinics, antenatal clinics, and ophthalmology clinics (a recent study from the Netherlands showed that most adults with chlamydial conjunctivitis have concomitant genital chlamydial infection2). Unless patients with the infection identified in each of these settings are treated and their sexual contacts traced, a control programme for genital chlamydial infection will be ineffective.3 Effective surveillance of chlamydial infection at district level therefore requires information about positivity rates and referrals to genitourinary medicine clinics from all other sources.

      We have obtained figures for chlamydial infection diagnosed outside genitourinary medicine clinics for 1995 (table 1) from our local microbiology laboratory, which serves the whole of Leicestershire (population 927 000). The usual method of testing was by enzyme immunoassay. Confirmatory testing with another non-culture test (direct fluorescence antibody) of all samples that were positive on enzyme immunoassay was performed to increase the specificity of the test. Chlamydial infection diagnosed outside a genitourinary medicine clinic accounted for a quarter (173/729) of all positive results in 1995. Figures for the first half of 1996 for gynaecology showed a considerable increase in rates of referral of positive cases to genitourinary medicine clinics: from 3/27 (10%) to 15/47 (32%).

      Table 1

      Proportion of patients who yielded positive result on testing for chlamydial infection, and proportion of those who attended genitourinary medicine clinic in Leicester, 1995. Figures are numbers (percentages)

      View this table:

      Our data for Leicestershire highlight two important points. Firstly, chlamydial infection diagnosed in settings other than genitourinary medicine clinics accounts for a sizeable proportion of all patients known to have chlamydial infection. Secondly, the attendance rate of such patients at genitourinary medicine clinics is not uniformly low. We attribute the high attendance rate of patients from family planning clinics (76%) to close collaboration with genitourinary medicine clinics in terms of treatment and follow up. Other family planning clinics with similar arrangements have also achieved high rates of referral.4

      The challenge facing us in Leicestershire is to obtain uniformly high rates of referral to genitourinary medicine clinics of cases of chlamydial infection diagnosed elsewhere. The departments of genitourinary medicine and public health are currently working with gynaecology, family planning, and interested general practitioners to develop an integrated approach to the management and control of genital chlamydial infection.


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