This site is intended for health professionals only

Chlamydia: testing for and promoting awareness

Chris Faldon
MSc BSc(Hons) DipHV RGN
Vice President
Society of Health Advisers in Sexually Transmitted Diseases (SHASTD)
Newcastle
GUM Clinic E:chrisf@shastd.org.uk

A silent epidemic prevails among the sexually active population of the UK. There was a doubling of genital chlamydia infection detected in the genitourinary medicine (GUM) clinics up and down the country from 1995 to 2000. The greatest rise over the past 10 years has been in 15-year-old women and 20-year-old men, with rates of infection highest in these groups.(1)
A staggering 640,000 people in England, Wales and Northern Ireland are estimated to have genital chlamydia, yet only one in 10 will have it diagnosed at a GUM clinic.(2) Some will go to their GP or sexual health clinic. The vast majority will remain undetected - up to 80% of women and 50% of men will be unaware of their infection.
Symptoms of chlamydia (see Table 1), if they do emerge, generally surface one to three weeks after infection, although they can disappear several days later. Many experience them in a mild form and choose to ignore the problem.

[[NIP04_table1_17]]

Long-term morbidity occurs largely in untreated women who can go on to develop pelvic inflammatory disease (PID), a precursor to ectopic pregnancies and tubal factor infertility. It has been reported that 64% of cases of tubal infertility and 42% of ectopic pregnancies are caused by Chlamydia trachomatis.(4) Behind these statistics lie tragic tales of psychological and relationship distress. Men are less likely to experience long-term complications, but epididymoorchitis and sexually acquired reactive arthritis (Reiter's syndrome) can be observed. Transmission to the neonate during delivery may result in conjunctivitis and pneumonia.
The Department of Health is poised to publish the first ever National Strategy for Sexual Health and HIV, having acknowledged that some serious concerns, compounded by service inequalities, need to be addressed. GUM clinic attendance has more than doubled over the past decade, and staff struggle to meet the demand for open-access services.(5) For some individuals the stigma attached to these specialist ­services can act as a barrier to seeking help. The consultative document preceding the national strategy proposes a greater role for GPs and practice nurses in promoting the sexual health of their patients.(6)

The solution?
Evidence gathered from research studies of chlamydia screening programmes in the USA and Scandinavia indicates that they significantly reduced the prevalence of chlamydia and PID.
A national screening programme for chlamydia is to be launched later this year, although the details are yet to be announced.(7) It is likely that women attending for termination of pregnancy and community contraception clinics will be the first target population, although this will be broadened out to others in due course. Studies have shown that the prevalence of infection among women attending for smears in general practice ranges between 2% and 12%.(4) How are practice nurses to identify those most at risk? It is suggested that no single factor or combination of risk factors will reveal any more than 42% of infections in the population (see Table 2).(8)

[[NIP04_table2_18]]

Genital chlamydia infection satisfies most of the criteria needed for an effective screening programme, namely:

  • It is a serious condition and/or a potential ­outcome exists.
  • There is a latent or asymptomatic early phase.
  • Testing is relatively cheap, accurate and ­acceptable.

Early indications of acceptance rates from UK pilot programmes using urine tests are encouraging.(3) It is still unclear, however, whether the proposed opportunistic screening of young women in the UK can control this silent epidemic. Will the offer of a screening test and treatment suffice in the drive to push down infection rates? Unfortunately such a limited intervention ­strategy will most likely achieve very little.

The missing man?
There is an increasing need to engage and target men in screening programmes. It can be argued that offering a chlamydia test is the easy part. The greater challenge is in the management of positive results, which is an extremely complex business. The receipt of a positive diagnosis of chlamydia can have a profound impact on an individual. Anxieties are commonly raised around issues of reproductive health, social stigma and partner reactions. It is not uncommon for issues of HIV to surface at this time. A person requires time, space and skillful professional handling to work through the emotional trauma inflicted.(10)
It is a long-accepted fact that contact tracing is a crucial element in the control of sexual infection. This is compulsory in Sweden and as such complements any screening programme. Currently an NHS-funded project in Avon and the West Midlands is comparing partner notification in general practice with referral to GUM clinics, and the results are eagerly waited.(11)
The Department of Health has also commissioned the Society of Health Advisers in Sexually Transmitted Diseases (SHASTD) to produce national partner notification guidelines, which should be available mid-2002. They will contain material to assist practice nurses in their efforts to promote awareness and testing for chlamydia infection and thus improve the sexual health of their patients.

Conclusion
Statistics on the increasing prevalence of genital chlamydia make disturbing reading. The government is keen to promote wider community-based screening programmes to detect and manage infections. Much more collaborative work is required between primary care and specialist GUM services if the public is to benefit from the emerging urine-based tests for genital chlamydia. The practice nurse is a key professional to link with GUM clinics for training needs and facilitate the process of contact tracing. There is much work to be done, but to spare the devastating impact of fallopian tube damage in just one patient is surely worth it.

Summary
Genital chlamydia has doubled over the past 10 years
The vast majority of cases go undetected
Untreated infection can lead to infertility and ectopic regnancies
A national screening programme is to be launched later in 2002
Practice nurses will be expected to play a leading role in chlamydia management
Contact tracing is a key component in reducing the revalence of chlamydia

[[NIP04_pp_18]]

References

  1. CDSC. Sexually transmitted diseases quarterly report: genital chlamydial infection in the UK. Commun Dis Rep CDR Weekly 2001;11(26).
  2. Pimenta J, et al. Evidence based health policy report: Screening for genital chlamydial infection. BMJ 2000;321:629-31.
  3. Clinical Effectiveness Group. Clinical effectiveness guideline for the management of Chlamydia trachomatis genital tract infection. Sex Trans Inf 1999;75 Suppl:S4-8.
  4. Hicks N. Evidence based case report: chlamydia infection in general practice.  BMJ 1999;318:790-2.
  5. Foley E, et al. Access to genito-urinary medicine clinics in the United Kingdom. Sex Trans Inf 2001;77:12-4.
  6. Department of Health. The national strategy for sexual health and HIV. 2001. See www.doh.gov.uk/jointunit/jip.htm
  7. Department of Health. Sexual health and HIV strategy: chlamydia screening. 2001. See www.doh.gov.uk/chlamydscreen.htm
  8. Ezi N. Chlamydia screening in primary care. Br J Gen Pract 2000; 50(455). See www.rcgp.org.uk/rcgp/journal/issues/jun00/letters/letters4.asp
  9. Pimenta J, Fenton K. Recent trends in Chlamydia trachomatis in the United Kingdom and the potential for national screening. Eurosurveillance 2001;6:81-4.
  10. Duncan B, et al. Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening. BMJ 2001;322:195-9.
  11. ClaSS Study Group. Evidence is not (yet) enough for evidence based policy for chlamydia screening. BMJ 2001;322:364.

Resource
Society of Health Advisers in Sexually Transmitted Diseases (SHASTD)
W:www.shastd.org.uk