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Implementing a chlamydia pilot screening programme

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VOL: 98, ISSUE: 50, PAGE NO: 34

Toni Gleave is community health adviser/research nurse, St Catherine's Hospital, Birkenhead, Wirral

Chlamydia trachomatis is a common sexual infection with serious long-term morbidity. A recent chlamydia pilot screening programme carried out on the Wirral and Portsmouth revealed that opportunistic screening for genital Chlamydia trachomatis in a targeted group of 16-24-year-olds was a feasible, acceptable and effective model for the initiation of a national chlamydia screening programme.

Chlamydia trachomatis is a common sexual infection with serious long-term morbidity. A recent chlamydia pilot screening programme carried out on the Wirral and Portsmouth revealed that opportunistic screening for genital Chlamydia trachomatis in a targeted group of 16-24-year-olds was a feasible, acceptable and effective model for the initiation of a national chlamydia screening programme.

Aetiology, signs and symptoms
It has been widely documented that genital Chlamydia trachomatis infection is the most common, curable, bacterial sexually transmitted infection in England and Wales (Simms et al., 1998). It can have devastating effects in women, who may not even be aware that they are infected.

Unfortunately, the long-term morbidity associated with this infection can be under-estimated, as up to 70 per cent of infected women and 50 per cent of infected men remain asymptomatic, or symptoms may remain non-specific. In women, symptoms may include pelvic pain, a vaginal discharge, menstrual disturbances and dysuria. Symptoms in men may include urethral discharge and dysuria.

Chlamydia is a well-established cause of pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility. There is also a risk of transmission to neonates (ophthalmia neonatorum, pneumonitis) (DoH Expert Advisory Group on Chlamydia trachomatis, 1998).

While chlamydia can affect women and men of all ages, prevalence studies have found positivity rates to be highest in younger age groups and especially in teenagers (Fenton et al., 2001).

Chlamydiae are obligate, intracellular pathogens with an incubation period of one to three weeks. Because the pathogen exists within the cell, there are problems with obtaining a sufficient sample for diagnosis. This also explains the paucity of symptoms, as there is a reduced inflammatory response.

Traditionally, Chlamydia trachomatis has been diagnosed using an endo-cervical or urethral swab, with immunological methods used for testing. However with the advent of molecular technologies, nucleic acid-based amplification techniques have become the method of choice. These offer improved standards of care for diagnosis and have opened up the possibility of screening using non-invasive, patient-acceptable means (Tong and Mallinson, 2002).

Developing a screening programme
In 1998, the Chief Medical Officer's Expert Advisory Group on Chlamydia trachomatis published the report of its findings (DoH Expert Advisory Group on Chlamydia trachomatis, 1998). It concluded that steps should be taken to reduce both the prevalence and the morbidity linked with Chlamydia trachomatis, and recommendations were made to initiate an opportunistic screening programme directed at sexually active women aged under 25.

Two sites were selected to pilot this screening programme (Wirral and Portsmouth), and it was launched in 1999, funded by the Department of Health.

The aim of the project was to assess the feasibility and acceptability of an opportunistic screening programme for Chlamydia trachomatis in a range of healthcare settings. Opportunistic screening involved identifying an at-risk population (16-25 years and sexually active) and offering a screening test on their attending a healthcare setting (both primary and secondary) for an unrelated reason.

In total, over 200 sites took part; these included family planning clinics, general practices, genitourinary medicine (GUM) clinics, antenatal clinics, gynaecology services and the colposcopy service. Women aged between 16 and 24 years (inclusive) and men in specific settings were offered the opportunity of being screened for chlamydia from a urine specimen tested using nucleic acid amplification technology.

The Wirral chlamydia pilot
The pilot team had two specific aims:

1. To ascertain the number of individuals who attended a range of healthcare settings and the proportion of women offered and accepting screening.

2. To evaluate the pilot as a means of developing a model for a national screening programme.

The pilot team comprised a doctor, two health advisers/research nurses; laboratory staff and one administrative staff member.

Our first task was to look at other screening programmes, chiefly the National Health Service Cervical Screening Programme (NHSCSP) because we felt that there were many issues in common that we could use in our planning. We did recognise, though, that there would be certain differences in the way the programmes were organised because we were involved in screening for a sexually transmitted infection. The main similarity with the NHSCSP was that we would also ensure that results were forwarded to all those we tested. The main difference was that we would not send a copy of results to GPs if they had not initiated the test. This was so that confidentiality could be maintained.

A chlamydia screening programme must be planned to deliver care effectively and equitably, taking into account the existing population and existing health services. We intended that the two pilot sites would develop almost identically, although we were aware of demographic differences between each site. For example, the Wirral is a peninsula with a relatively static population, high unemployment and few ethnic communities. Portsmouth, on the other hand, is a city with a university and a naval base and therefore a more transient population.

In both areas, steering groups were developed, comprised of members from all potential testing sites. This ensured that there was input from a range of healthcare professionals. Several months before testing began, meetings were held with members from all the services likely to be involved, and their comments were taken into consideration as the final details of the main protocol were developed. Staff from each service then drafted protocols appropriate for their area.

On the Wirral we estimated the maximum number of tests that would be possible, and the likely numbers of screened positive cases that we would see over 12 months of testing. There were 15,500 women in the target age range, and by using data from the National Survey of Sexual Attitudes and Lifestyles (Johnson, 1990) we estimated that 12,900 women would be eligible for screening. Taking into account that some women would be offered tests on more than one occasion and following the decision that tests could be offered to men in a few specific settings, planning was based on a maximum of 15,000 tests, with an estimated positivity of around eight per cent.

Local organisation and testing procedures
An infrastructure was put in place to allow for prompt, equitable treatment of any individuals who tested positive. A chlamydia pilot office was located in a community hospital in Birkenhead, six miles from the local GUM clinic. This arrangement offered a choice of treatment venue and also addressed the issues of potential non-attendance at the GUM clinic, or the overloading of both the GUM clinic and community services. Community health advisers (in this case nurses) were based at the office and treated those who tested positive but had no symptoms, using patient group directions. If symptoms were identified, the person was referred to the GUM clinic for a full sexual health screen. Partners were also encouraged to attend for treatment, and partner notification was carried out.

Our preferred method of treatment if the patient was not pregnant or at risk of pregnancy was azithromycin 1g stat. This removed issues of drug non-concordance, especially as the patient was offered the option of taking the stat dose in the chlamydia pilot office. If azithromycin was not appropriate, doxycycline 100mg twice daily for one week was given. If the patient was pregnant or at risk of pregnancy, erythromycin 500mg four times daily for one week was offered.

There were a number of advantages to using community health advisers:

- A consistent approach could be taken to the management of the infection because several different health professionals would not be involved;

- A less 'institutional' service could be offered, more suited to the needs of young clients;

- A flexible and 'mobile' service could be offered, covering evening home visits or meetings at convenient, local venues;

- The burden on other health professionals would be reduced.

Post-testing procedures
Our written protocols stated that those who had had a urine test should receive their results within two weeks. A case note was made for every person testing positive and was kept in the pilot office so that treatment and partner notification could be actioned and recorded. If there was no response, every effort was made to trace the client and ensure treatment was received. Follow-up of all results was undertaken by pilot office staff, thus relieving testing sites of this often time-consuming responsibility.

An NOP poll (2002) commissioned by both pilot teams and carried out in the Wirral, Portsmouth, and in another area where testing was being carried out revealed that the majority of the professionals who responded valued the help and support of the pilot teams, in particular the help received from the community health advisers/research nurses.

Publicity and data collection
Publicity in the form of leaflets, booklets, posters, condom holders and postcards was produced that was appropriate for both the public and for health professionals and was distributed widely around the Wirral. We also produced a website to publicise the screening programme (www.wow.nhs.uk) and held regular conferences to inform local professionals.

A modified request form to collect data to inform the screening programme was developed (Hopwood, 2002). The form had a pivotal multipurpose role in the pilot in that it provided information, requested the test, enabled the results to be sent to the patient, and collected most of the relevant data in one step. It was designed in the light of previous research (Gleave et al., 2001) with the assistance of the steering group.

Results
Treatment locations: Analysis of the data at the end of the pilot indicated that 37 per cent of all people with a positive result were treated in the pilot office and 40 per cent were treated in the local GUM clinic. If the community health adviser in the chlamydia pilot office identified symptoms, the person was referred directly to the GUM clinic. This situation arose in 10 per cent of all those who screened positive. A further six per cent of people with a positive test were treated 'elsewhere'; this included GP surgeries, GUM clinics in other health authorities and, occasionally, as an in-patient.

Figure 1 shows where those screened positive were treated during the pilot once they had received a positive chlamydia result.

Acceptability: Overall, screening for chlamydia using a urine sample proved acceptable to both women and men within the target age group (Pimenta et al., 2002). In total 6,132 eligible patients on the Wirral accepted screening and 13,029 in Portsmouth. Acceptance in women and men was 91 per cent and 76 per cent respectively.

The NOP poll (NOP, 2002) indicated that the urine test for chlamydia was found to be universally acceptable because of its simplicity. Key reasons for not being willing to have the test included embarrassment and privacy. A small number of respondents said that because they had only one partner they were not at risk; others said that they did not like doctors.

Following the Department of Health's Expert Advisory Group Report on Chlamydia trachomatis (DoH Expert Advisory Group on Chlamydia trachomatis, 1998), some professional groups had expressed unease with the introduction of sexual health issues into their area (Crowe, 1998) because it was felt that it may be inappropriate to offer a test at a GP consultation. However, the pilot has indicated that in most areas screening is considered acceptable.

Coverage: We found that health services were widely used by our target population and, as a consequence, high coverage was achieved. On the Wirral, 39 per cent of the target population were tested for chlamydia and in Portsmouth screening reached 50 per cent of the population. Such levels of coverage led us to conclude that opportunistic screening was an effective means of organising a screening programme.

Prevalence: The prevalence of infection on the Wirral in women aged 16-24 years was high, with an overall positivity rate of 11.2 per cent. Prevalence in Portsmouth was slightly lower at 9.8 per cent. In line with other studies (Public Health Laboratory Service, 2000; Public Health Laboratory Service, 2001), prevalence varied with age (Fig 2).

Moving the programme forward
Upon completion of the 12-month chlamydia pilot programme, both sites reported to the National Screening Committee. The message put forward was that opportunistic screening for chlamydial infection is acceptable to the public and to health professionals. The high prevalence rates shown in all testing sites clearly testified that chlamydia infection is an important public health problem and that action is required.

In July 2001, the Department of Health published the National Strategy for Sexual Health and HIV (DoH, 2001). This recognised that chlamydia was a serious problem and indicated that a nationwide chlamydia screening programme would be introduced, using infor-mation gained from the pilot and other ongoing research initiatives. Ten sites were selected from over 40 areas after their submitting an 'expression of interest' to the Department of Health. They have a wide geographical spread and represent an urban/rural mix (Box 1).

Currently, all sites are preparing for the start of the co-ordinated screening programme. We are proud that the success of the Wirral model has been recognised - the model has been adopted by the national pilot sites, which will operate with a central liaison office for all results and for health advisers offering treatment in the community.

Implications for nursing practice
The findings of the two chlamydia pilots and those to come from the 10 sites selected for a nationwide pilot have very important implications for nursing practice in both primary and secondary care. Nurses will be involved in all levels of chlamydia screening, including involvement in policy development around the issue of screening, offering the test, discussing results, discussing treatment and promoting safer sex.

Some nurses may feel uncomfortable introducing screening for a sexually transmitted infection into a general consultation. However, the NOP poll (NOP, 2002) revealed that three-quarters of the health professionals surveyed (including doctors, nurses and receptionists) reported being enthusiastic at being involved in the chlamydia project. Three-quarters also said that they did not find it embarrassing to raise the subject of chlamydia with patients. Ninety per cent of health professionals involved felt they were well equipped to answer questions and that they had a good understanding of the issues surrounding chlamydia. Reassuringly, the majority of respondents who had accepted a screening test felt that they had benefited from being screened.

Most clinicians believed that the offer of screening had not affected the quality of care they delivered in response to the patient's original reason for attending for a consultation.

Conclusion
We believe that a central office for advice about chlamydia for health professionals and the public along with treatment for those who test positive is essential if disparate management is to be avoided. An added benefit will be the removal of the concerns raised by many health professionals about the time required in each service for tracing, treating, counselling and partner notification.

Our pilot showed that urine testing was highly acceptable to the target population and to the health professionals offering screening. Prevalence of infection in the target age group was high, and over 95 per cent of all positive cases were known to have attended for antibiotics.

Next week: Erectile dysfunction

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