Is the chlamydia screening programme worthwhile?

BRITISH SOCIETY FOR MICROBIAL TECHNOLOGY

27th ANNUAL SCIENTIFIC MEETING

18 May 2012

Dr Angie Bone, Director NCSP

angie.bone@hpa.org.uk

http://www.chlamydiascreening.nhs.uk

Outline• Update on the National Chlamydia Screening

Programme• Is chlamydia still an important public health problem?• How do we know if screening is working?• Is it cost-effective?• What are young people’s views?• How is progress being monitored?• What do local areas need to do?

• Olympics and Sexual Health

Chlamydia trachomatis

• Commonest bacterial STI in England• Majority of infections are

asymptomatic• Highest rates of infection among young

people • Easy to detect using NAAT tests• Easy to treat with antibiotics• Untreated infections can cause PID,

ectopic pregnancy, infertility

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The National Chlamydia Screening Programme (NCSP) in England

• Aims to control chlamydia thus reducing transmission and sequelae

• Opportunistic screening of sexually active < 25 year olds - Annually - Change of sexual partner

• Clinical and non-clinical venues

• Standards for treatment and partner notification

5

The NCSP 2003 to 2010: What went well

• High volumes screened• Expansion of sexual health services into community

with range of providers• Early adoption of new technologies• Quality assurance programme• Involvement of men• Reaching those at higher risk and the socio-

economically deprived

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The NCSP 2003 to 2010: Areas for improvement

• Value for money, cost variations• Lack of integration with other sexual health services• Engagement of some providers e.g. GP’s• Scientific/policy controversies

So, is it worthwhile to continue…?

• Chlamydia remains a cause of serious reproductive morbidity, with costs to the service and individuals

• Evidence of impact on prevalence- Modelling- changes in percentage infected amongst those tested- Seroepidemiology

Proportion testing positive, community tests(15-24 year olds, England)

Source: NCSP and other community tests. Data as at 02.08.11

2003/4

2004/5

2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

0.0

5.0

10.0

15.0

20.0 Proportion positive - MalesProportion positive - Females

Year of test

Prop

ortio

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pos

itive

(%)

Proportion testing positive, community tests(15-24 year olds, England)

Source: NCSP and other community tests. Data as at 02.08.11

2003/4

2004/5

2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

0.0

5.0

10.0

15.0

20.0

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000Number of tests - MalesNumber of tests - FemalesProportion positive - MalesProportion positive - Females

Year of test

Prop

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Predicted chlamydia prevalence, 16 to 24 year olds (2000/01 to 2012/13)

From Dorey et al 2012, accepted for publication in STI

So, is it worthwhile to continue…?• Chlamydia remains a cause of serious reproductive

morbidity, with costs to the service and individuals• Evidence of impact on prevalence

- Modelling- changes in percentage infected amongst those tested- seroepidemiology

• Evidence of impact on sequelae- RCT evidence- Changes in PID rates

Rate of PID diagnoses* in General Practice by age group (females 16 to 44 years old)

*Definite/probable PID diagnoses

Source: French et al. STD 2011.

So, is it worthwhile to continue…?

• Remains a cause of reproductive morbidity, with substantial costs• Evidence of impact on prevalence

- Modelling

- changes in percentage infected amongst those tested

- seroepidemiology

• Evidence of impact on sequelae- RCT evidence

- Changes in PID rates

• Wider benefits- Awareness of chlamydia

- Expanding sexual health services into community

- Involving men

- Reducing stigma

Is it cost-effective?

• Three studies indicate screening may be cost-effective

• Depends on parameters used in model both for costs and benefits

• Several elements to screening pathway and huge variety of delivery methods

• Average cost per screen £27; per diagnosis £437*

• Recent policy initiatives to reduce costs and improve sustainability

• Emphasis on partner notification

Adams E and Turner K: Invest to Save in the South West 2012

What are young people’s views?

• Don’t always see chlamydia as relevant to them• Prefer a blanket approach to testing • Want to be asked rather than have to ask for a test• Don’t want to have to give a sexual history• Need to be sure of confidentiality• Want options for testing – hcp/remote testing• Want results quickly• Want support to be available to manage positive

results

So, is it worthwhile to continue…?

YES!

Where we are now

• DH “Future direction” statement July 2011• Drives to reduce outreach and integrate ct screening• Chlamydia Testing Activity Dataset (CTAD)• Move from coverage to diagnosis rate• PH outcomes framework

- A level of at least 2400 chlamydia diagnoses per 100,000 residents aged 15-24

- At present, aim is to achieve HIGH levels of diagnoses

- Recommended level only achievable through widespread testing

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England - Diagnosis Rate by SHA Q1-3 2010/11 Vs. Q1-3 2011/12

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What do local areas need to do?

1. Safeguard chlamydia screening and other sexual health services during transition

2. Know your data – available on the HPA/NCSP websites

3. Embed chlamydia screening in primary care and sexual health services – general practice is key

4. Enable remote testing

5. Focus outreach on hard to reach groups

6. Emphasise screening annually and on change of partner; partner notification very important

7. Listen to young people

The Olympics and Sexual Health – what might we expect?

• Mass gathering – increased risk of infectious diseases• In terms of STI, possibility of increased transmission:

- increase in casual workers- increase in sex workers- increase in sexual risk taking

• Increased demand on sexual health services• Sydney 2000 (McNulty et al 2003)

- Two fold increase in diagnoses of bacterial STI’s- Increase in new patient visits to sexual health services

(symptomatic or STI contacts)

The Olympics and Sexual Health - preparation and response

• Promotion of contraception, condom use & NHS Choices• LOCOG – Durex sexual health campaign• Effective sign-posting, rapid referral and extended

opening hours to sexual health services• Onsite sexual health services to construction workers• Temporary outreach centre in Stratford• GUM clinicians and labs to be alert to any new or rapidly

increasing infections – report to local HPU• Olympic codes in GUMCAD - surveillance

THANK YOU