1
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Clay PA, Pollock ED, Copen CE, Anyalechi EG, Danavall DC, Hong J, Khosropour CM, Galloway E, Spicknall IH. Using infection prevalence, seroprevalence and case report data to estimate chlamydial infection incidence. Sex Transm Infect 2023; 99:513-519. [PMID: 37648446 PMCID: PMC11323310 DOI: 10.1136/sextrans-2023-055808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/12/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVES To measure the effectiveness of chlamydia control strategies, we must estimate infection incidence over time. Available data, including survey-based infection prevalence and case reports, have limitations as proxies for infection incidence. We therefore developed a novel method for estimating chlamydial incidence. METHODS We linked a susceptible infectious mathematical model to serodynamics data from the National Health and Nutritional Examination Survey, as well as to annual case reports. We created four iterations of this model, varying assumptions about how the method of infection clearance (via treatment seeking, routine screening or natural clearance) relates to long-term seropositivity. Using these models, we estimated annual infection incidence for women aged 18-24 and 25-37 years in 2014. To assess model plausibility, we also estimated natural clearance for the same groups. RESULTS Of the four models we analysed, the model that best explained the empirical data was the one in which longer-lasting infections, natural clearance and symptomatic infections all increased the probability of long-term seroconversion. Using this model, we estimated 5910 (quartile (Q)1, 5330; Q3, 6500) incident infections per 100 000 women aged 18-24 years and 2790 (Q1, 2500; Q3, 3090) incident infections per 100 000 women aged 25-37 years in 2014. Furthermore, we estimated that natural clearance rates increased with age. CONCLUSIONS Our method can be used to estimate the number of chlamydia infections each year, and thus whether infection incidence increases or decreases over time and after policy changes. Furthermore, our results suggest that clearance via medical intervention may lead to short-term or no seroconversion, and the duration of untreated chlamydial infection may vary with age, underlining the complexity of chlamydial infection dynamics.
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Affiliation(s)
- Patrick A Clay
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Emily D Pollock
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Casey E Copen
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - E Gloria Anyalechi
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Damien C Danavall
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jaeyoung Hong
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Eboni Galloway
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ian H Spicknall
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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2
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Han Y, Chen S, Xu W, Shi M, Chen K, Liu J, Kim P, Chen X, Yin Y. A Nationwide Survey on Detection of Chlamydia trachomatis in Health Facilities in China. Sex Transm Dis 2023; 50:420-424. [PMID: 36920285 DOI: 10.1097/olq.0000000000001799] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND This study evaluated the clinical laboratory capacity for the diagnosis of Chlamydia trachomatis (CT) in China to provide recommendations to improve the diagnostic capacity and quality of this clinically important sexually transmitted disease. METHODS An electronic questionnaire-based cross-sectional, survey study was conducted by the National Center for STD Control among different types of healthcare facilities in China from July to December 2021. RESULTS The surveyed laboratory facilities were located in 332 cities in 31 provinces in China. A total of 4640 records from clinical laboratories were included in the data set for the final analysis. Less than half of the laboratories (41.6% [1931 of 4640]) performed the CT diagnostic test; of these, 721 laboratories (15.5% [721 of 4640]) carried out nucleic acid amplification test (NAAT) methods, and 1318 laboratories (28.4% [1318 of 4640]) performed antigen-based immunochromatographic assays. Most laboratories were equipped with biological safety cabinets (93.7% [4348 of 4640]), 49.2% (2283 of 4640) were equipped with fully automated nucleic acid extractors, and 55.2% (2560 of 4640) were equipped with polymerase chain reaction amplification instruments. The laboratories from Southern China or third-class hospitals (i.e., the highest rated hospitals) had the highest proportion using NAATs to diagnose CT among the surveyed health facilities. CONCLUSIONS Advancing laboratories to use NAAT to detect CT should be phased step-by-step by different areas and levels of hospitals according to the current situation.
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Affiliation(s)
| | | | | | | | | | - Jun Liu
- Brigham and Women's Hospital, Boston, MA
| | - Peter Kim
- Brigham and Women's Hospital, Boston, MA
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3
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Dukers-Muijrers NHTM, Evers YJ, Hoebe CJPA, Wolffs PFG, de Vries HJC, Hoenderboom B, van der Sande MAB, Heijne J, Klausner JD, Hocking JS, van Bergen J. Controversies and evidence on Chlamydia testing and treatment in asymptomatic women and men who have sex with men: a narrative review. BMC Infect Dis 2022; 22:255. [PMID: 35287617 PMCID: PMC8922931 DOI: 10.1186/s12879-022-07171-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/03/2022] [Indexed: 11/19/2022] Open
Abstract
Background Chlamydia trachomatis (CT) is the most common bacterial sexually transmitted infection (STI) worldwide. CT is mainly asymptomatic. Test-and-treat strategies are widely implemented to prevent transmission and complications. Strategies are not without controversy in asymptomatic women and men who have sex with men (MSM). Concerns are emerging to test and treat asymptomatic persons for urogenital CT (‘Controversy 1’) and pharyngeal or rectal CT (‘Controversy 2’), whereby testing symptomatic persons is not under debate. Opposed views in CT treatment involve using azithromycin versus doxycycline (‘Controversy 3’). The objective of this review is to provide coverage of these public health and clinical controversies by reviewing the current scientific evidence. Methods A literature search was performed using PubMed for relevant publications between 2018 and September 2021, and iterative retrieval of additional relevant publications. Results Controversy 1. In women, the majority of asymptomatic CT are at the urogenital site, and detections mostly include viable CT. CT easily transmits to a partner and potentially also between the vaginal and rectal areas; the clinical impact of urogenital CT is established, although risks for adverse outcomes are uncertain. Wide-scale testing in asymptomatic women has not resulted in reduced prevalence. In MSM, evidence for the clinical impact of asymptomatic urogenital CT is lacking. Controversy 2. Rectal CT is common in women diagnosed with urogenital CT, but the clinical impact of asymptomatic rectal CT is uncertain. In MSM, rectal CT is common, and most CT infections are at the rectal site, yet the risk of longer term complications is unknown. In both sexes, pharyngeal CT is uncommon and has no documented clinical impact. Controversy 3. In the treatment of rectal CT, doxycycline has superior effectiveness to azithromycin. Evidence has also accumulated on the harms of test-and-treat strategies. Conclusions Current practices vary widely, from widescale test-and-treat approaches to more individual patient- and partner-level case management. Choosing which asymptomatic people to test at what anatomic site, and whether to test or not, requires an urgent (re-)definition of the goals of testing and treating asymptomatic persons. Treatment guidelines are shifting toward universal doxycycline use, and clinical practice now faces the challenge of implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07171-2. Test-and-treat is a key strategy in the control of Chlamydia trachomatis (CT). We discuss recent controversies and present scientific evidence regarding urogenital, rectal, and pharyngeal CT test-and-treat strategies in women and in men who have sex with men (MSM). This should inform best practices for the prevention and management of the most common bacterial sexually transmitted infection (STI) worldwide.
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Affiliation(s)
- Nicole H T M Dukers-Muijrers
- Department of Sexual Health, Infectious Diseases, and Environmental Health, South Limburg Public Health Service, PO Box 33, 6400 AA, Heerlen, The Netherlands. .,Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.
| | - Ymke J Evers
- Department of Sexual Health, Infectious Diseases, and Environmental Health, South Limburg Public Health Service, PO Box 33, 6400 AA, Heerlen, The Netherlands.,Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Christian J P A Hoebe
- Department of Sexual Health, Infectious Diseases, and Environmental Health, South Limburg Public Health Service, PO Box 33, 6400 AA, Heerlen, The Netherlands.,Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Petra F G Wolffs
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Henry J C de Vries
- Epidemiology and Surveillance Unit, Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands.,Department of Infectious Diseases, Public Health Service of Amsterdam (GGD Amsterdam), Amsterdam, The Netherlands.,Department of Dermatology, Amsterdam Infection & Immunity Institute (AII), Amsterdam University Medical Center (UMC), Amsterdam, The Netherlands
| | - Bernice Hoenderboom
- Epidemiology and Surveillance Unit, Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands.,Institute for Public Health Genomics, Genetics & Cell Biology, Maastricht University, Faculty of Health and Medicine and Life Sciences, Maastricht, The Netherlands
| | - Marianne A B van der Sande
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Janneke Heijne
- Epidemiology and Surveillance Unit, Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Jeffrey D Klausner
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Jane S Hocking
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Jan van Bergen
- Epidemiology and Surveillance Unit, Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands.,Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,STI AIDS Netherlands, Amsterdam, The Netherlands
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4
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Han Y, Chen K, Liu JW, Zhu BY, Zhou K, Shi MQ, Xu WQ, Jhaveri TA, Yin YP, Chen XS. High Prevalence of Rectal Chlamydia trachomatis Infection With the Same Genotype as Urogenital Infection in Female Outpatients in Sexually Transmitted Disease Clinics in China. Open Forum Infect Dis 2022; 9:ofab569. [PMID: 35146037 PMCID: PMC8826247 DOI: 10.1093/ofid/ofab569] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/16/2021] [Indexed: 11/17/2022] Open
Abstract
Background Little is known about rectal Chlamydia trachomatis (CT) infection in outpatients attending sexually transmitted disease (STD) clinics in China. In this study, we aimed to explore the clinical and epidemiologic features of rectal CT infection in this population. Methods A cross-sectional study was conducted among patients attending STD clinics in Tianjin and Guangxi provinces of China from June 2018 to August 2020. Bivariate and multivariate logistic regression analysis were developed to explore the association of different risk factors for urogenital and rectal CT infection. Results The prevalence of urogenital and rectal CT was 11.2% (154/1374) and 4.9% (68/1377), respectively. The rectal CT prevalence among female and male patients was 7.8% (60/767) and 1.3% (8/610), respectively. The most common genotype in urogenital CT–positive samples was genotype E (29.9%), while the most common genotype among rectal CT–positive samples was genotype J (23.4%). More than 85% (52/60) of women infected with rectal CT were co-infected with urogenital CT. About 90.0% (36/40) of women shared similar genotypes between rectal and urogenital samples. Females and patients infected with urogenital CT were deemed to be at an increased risk for rectal CT infection. A high proportion of rectal CT infection had concurrent urogenital CT infection, especially in women, and most of the co-infections were shared among the same genotypes. Conclusions It would be prudent to encourage awareness and introduce detection tests and treatment strategies for rectal CT infection particularly in female patients visiting STD clinics in China.
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Affiliation(s)
- Yan Han
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Kai Chen
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Jing-Wei Liu
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Bang-Yong Zhu
- Institute of Dermatology, Guangxi Autonomous Region, Nanning, Guangxi, China
| | - Ke Zhou
- Tianjin Academy of traditional Chinese Medicine Affiliated Hospital, Tianjin, China
| | - Mei-Qin Shi
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Wen-Qi Xu
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Tulip A Jhaveri
- Division of Medical Microbiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Yue-Ping Yin
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Xiang-Sheng Chen
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, Jiangsu, China
- National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, Jiangsu, China
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5
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Han Y, Shi MQ, Jiang QP, Le WJ, Qin XL, Xiong HZ, Zheng HP, Tenover FC, Tang YW, Yin YP. Clinical Performance of the Xpert ® CT/NG Test for Detection of Chlamydia trachomatis and Neisseria gonorrhoeae: A Multicenter Evaluation in Chinese Urban Hospitals. Front Cell Infect Microbiol 2022; 11:784610. [PMID: 35047416 PMCID: PMC8762110 DOI: 10.3389/fcimb.2021.784610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background We aimed to evaluate the clinical performance of the GeneXpert® (Xpert) CT/NG assay for the detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) using urine and cervical swabs collected from patients in China. Methods This study was conducted from September 2016 to September 2018 in three Chinese urban hospitals. The results from the Xpert CT/NG test were compared to those from the Roche cobas® 4800 CT/NG test. Discordant results were confirmed by DNA sequence analysis. Results In this study, 619 first void urine (FVU) specimens and 1,042 cervical swab specimens were included in the final dataset. There were no statistical differences between the results of the two tests for the detection of CT/NG in urine samples (p > 0.05), while a statistical difference was found in cervical swabs (p < 0.05). For CT detection, the sensitivity and specificity of the Xpert test were 100.0% (95%CI = 96.8-99.9) and 98.3% (95%CI = 96.6-99.2) for urine samples and 99.4% (95%CI = 96.5-100.0) and 98.6% (95%CI 97.5-99.2) for cervical swabs, respectively. For NG detection, the sensitivity and specificity of the Xpert test were 99.2% (95%CI = 94.9-100.0) and 100.0% (95%CI = 99.0-100.0) for urine and 100% (95%CI = 92.8-100.0) and 99.7% (95%CI = 99.0-99.9) for cervical swabs, respectively. Conclusion The Xpert CT/NG test exhibited high sensitivity and specificity in the detection of CT and NG in both urine and cervical samples when compared to the reference results. The 90-min turnaround time for CT and NG detection at the point of care using Xpert may enable patients to receive treatment promptly.
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Affiliation(s)
- Yan Han
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China.,National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, China
| | - Mei-Qin Shi
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China.,National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, China
| | - Qing-Ping Jiang
- Depatment of Pathology, Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Wen-Jing Le
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
| | - Xiao-Lin Qin
- Dermatology Hospital, Southern Medical University, Guangzhou, China
| | - Han-Zhen Xiong
- Depatment of Pathology, Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - He-Ping Zheng
- Dermatology Hospital, Southern Medical University, Guangzhou, China
| | - Fred C Tenover
- Department of Medical and Scientific Affairs, Cepheid, Sunnyvale, CA, United States
| | - Yi-Wei Tang
- Department of Medical and Scientific Affairs, Danaher Diagnostic Platform China/Cepheid, Shanghai, China
| | - Yue-Ping Yin
- Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China.,National Center for STD Control, Chinese Center for Disease Control and Prevention, Nanjing, China
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6
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Horner PJ, Anyalechi GE, Geisler WM. What Can Serology Tell Us About the Burden of Infertility in Women Caused by Chlamydia? J Infect Dis 2021; 224:S80-S85. [PMID: 34396401 DOI: 10.1093/infdis/jiab047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Chlamydia trachomatis (CT) causes pelvic inflammatory disease, which may result in tubal factor infertility (TFI) in women. Serologic assays may be used to determine the proportion of women with and without TFI who have had previous CT infection and to generate estimates of infertility attributable to chlamydia. Unfortunately, most existing CT serologic assays are challenged by low sensitivity and, sometimes, specificity for prior CT infection; however, they are currently the only available tests available to detect prior CT infection. Modeling methods such as finite mixture modeling may be a useful adjunct to quantitative serologic data to obtain better estimates of CT-related infertility. In this article, we review CT serological assays, including the use of antigens preferentially expressed during upper genital tract infection, and suggest future research directions. These methodologic improvements, coupled with creation of new biomarkers for previous CT infection, should improve our understanding of chlamydia's contribution to female infertility.
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Affiliation(s)
- Patrick J Horner
- Population Health Sciences, University of Bristol, Bristol, United Kingdom.,National Institute for Health Research, Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom
| | - Gloria E Anyalechi
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - William M Geisler
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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7
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Lewis J, White PJ, Price MJ. Per-partnership transmission probabilities for Chlamydia trachomatis infection: evidence synthesis of population-based survey data. Int J Epidemiol 2021; 50:510-517. [PMID: 33349846 PMCID: PMC8128448 DOI: 10.1093/ije/dyaa202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 11/14/2022] Open
Abstract
Background Chlamydia is the most commonly diagnosed sexually transmitted infection worldwide. Mathematical models used to plan and assess control measures rely on accurate estimates of chlamydia’s natural history, including the probability of transmission within a partnership. Several methods for estimating transmission probability have been proposed, but all have limitations. Methods We have developed a new model for estimating per-partnership chlamydia transmission probabilities from infected to uninfected individuals, using data from population-based surveys. We used data on sexual behaviour and prevalent chlamydia infection from the second UK National Study of Sexual Attitudes and Lifestyles (Natsal-2) and the US National Health and Nutrition Examination Surveys 2009–2014 (NHANES) for Bayesian inference of average transmission probabilities, across all new heterosexual partnerships reported. Posterior distributions were estimated by Markov chain Monte Carlo sampling using the Stan software. Results Posterior median male-to-female transmission probabilities per partnership were 32.1% [95% credible interval (CrI) 18.4–55.9%] (Natsal-2) and 34.9% (95%CrI 22.6–54.9%) (NHANES). Female-to-male transmission probabilities were 21.4% (95%CrI 5.1–67.0%) (Natsal-2) and 4.6% (95%CrI 1.0–13.1%) (NHANES). Posterior predictive checks indicated a well-specified model, although there was some discrepancy between reported and predicted numbers of partners, especially in women. Conclusions The model provides statistically rigorous estimates of per-partnership transmission probability, with associated uncertainty, which is crucial for modelling and understanding chlamydia epidemiology and control. Our estimates incorporate data from several sources, including population-based surveys, and use information contained in the correlation between number of partners and the probability of chlamydia infection. The evidence synthesis approach means that it is easy to include further data as it becomes available.
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Affiliation(s)
- Joanna Lewis
- MRC Centre for Global Infectious Disease Analysis and National Institute for Health Research (NIHR) Health Protection Research Unit in Modelling and Health Economics, Imperial College London School of Public Health, London, UK.,Centre for Applied Statistics Courses, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Peter J White
- MRC Centre for Global Infectious Disease Analysis and National Institute for Health Research (NIHR) Health Protection Research Unit in Modelling and Health Economics, Imperial College London School of Public Health, London, UK.,Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
| | - Malcolm J Price
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
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8
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Pillay J, Wingert A, MacGregor T, Gates M, Vandermeer B, Hartling L. Screening for chlamydia and/or gonorrhea in primary health care: systematic reviews on effectiveness and patient preferences. Syst Rev 2021; 10:118. [PMID: 33879251 PMCID: PMC8056106 DOI: 10.1186/s13643-021-01658-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We conducted systematic reviews on the benefits and harms of screening compared with no screening or alternative screening approaches for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in non-pregnant sexually active individuals, and on the relative importance patients' place on the relevant outcomes. Findings will inform recommendations by the Canadian Task Force on Preventive Health Care. METHODS We searched five databases (to January 24, 2020), trial registries, conference proceedings, and reference lists for English and French literature published since 1996. Screening, study selection, and risk of bias assessments were independently undertaken by two reviewers, with consensus for final decisions. Data extraction was conducted by one reviewer and checked by another for accuracy and completeness. Meta-analysis was conducted where appropriate. We used the GRADE approach to rate the certainty of the evidence. The Task Force and content experts provided input on determining thresholds for important effect sizes and on interpretation of findings. RESULTS Of 41 included studies, 17 and 11 reported on benefits and harms of screening, respectively, and 14 reported on patient preferences. Universal screening for CT in general populations 16 to 29 years of age, using population-based or opportunistic approaches achieving low screening rates, may make little-to-no difference for a female's risk of pelvic inflammatory disease (PID) (2 RCTs, n=141,362; 0.3 more in 1000 [7.6 fewer to 11 more]) or ectopic pregnancy (1 RCT, n=15,459; 0.20 more per 1000 [2.2 fewer to 3.9 more]). It may also not make a difference for CT transmission (3 RCTs, n=41,709; 3 fewer per 1000 [11.5 fewer to 6.9 more]). However, benefits may be achieved for reducing PID if screening rates are increased (2 trials, n=30,652; 5.7 fewer per 1000 [10.8 fewer to 1.1 more]), and for reducing CT and NG transmission when intensely screening high-prevalence female populations (2 trials, n=6127; 34.3 fewer per 1000 [4 to 58 fewer]; NNS 29 [17 to 250]). Evidence on infertility in females from CT screening and on transmission of NG in males and both sexes from screening for CT and NG is very uncertain. No evidence was found for cervicitis, chronic pelvic pain, or infertility in males from CT screening, or on any clinical outcomes from NG screening. Undergoing screening, or having a diagnosis of CT, may cause a small-to-moderate number of people to experience some degree of harm, mainly due to feelings of stigmatization and anxiety about future infertility risk. The number of individuals affected in the entire screening-eligible population is likely smaller. Screening may make little-to-no difference for general anxiety, self-esteem, or relationship break-up. Evidence on transmission from studies comparing home versus clinic screening is very uncertain. Four studies on patient preferences found that although utility values for the different consequences of CT and NG infections are probably quite similar, when considering the duration of the health state experiences, infertility and chronic pelvic pain are probably valued much more than PID, ectopic pregnancy, and cervicitis. How patients weigh the potential benefits versus harms of screening is very uncertain (1 survey, 10 qualitative studies); risks to reproductive health and transmission appear to be more important than the (often transient) psychosocial harms. DISCUSSION Most of the evidence on screening for CT and/or NG offers low or very low certainty about the benefits and harms. Indirectness from use of comparison groups receiving some screening, incomplete outcome ascertainment, and use of outreach settings was a major contributor to uncertainty. Patient preferences indicate that the potential benefits from screening appear to outweigh the possible harms. Direct evidence about which screening strategies and intervals to use, which age to start and stop screening, and whether screening males in addition to females is necessary to prevent clinical outcomes is scarce, and further research in these areas would be informative. Apart from the evidence in this review, information on factors related to equity, acceptability, implementation, cost/resources, and feasibility will support recommendations made by the Task Force. SYSTEMATIC REVIEW REGISTRATION International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018100733 .
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Affiliation(s)
- Jennifer Pillay
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| | - Aireen Wingert
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Tara MacGregor
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Michelle Gates
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
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9
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van Wees DA, den Daas C, Kretzschmar MEE, Heijne JCM. Modelling the impact of tailored behavioural interventions on chlamydia transmission. Sci Rep 2021; 11:2148. [PMID: 33495513 PMCID: PMC7835240 DOI: 10.1038/s41598-021-81675-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/07/2021] [Indexed: 11/09/2022] Open
Abstract
Behavioural interventions tailored to psychological characteristics of an individual can effectively achieve risk-reducing behaviour. The impact of tailored interventions on population-level chlamydia prevalence is unknown. We aimed to assess the impact on overall chlamydia prevalence five years after the introduction of an intervention aimed at increasing self-efficacy, social norms, attitudes and intentions towards condom use (i.e., condom intervention), and an intervention aimed at increasing health goals and decreasing impulsiveness (i.e., impulsiveness intervention). A pair model, informed by longitudinal psychological and behavioural data of young heterosexuals visiting sexual health centers, with susceptible-infected-susceptible structure was developed. The intervention effect was defined as an increased proportion of each subgroup moving to the desired subgroup (i.e., lower risk subgroup). Interventions tailored to subgroup-specific characteristics, assuming differential intervention effects in each subgroup, more effectively reduced overall chlamydia prevalence compared to non-tailored interventions. The most effective intervention was the tailored condom intervention, which was assumed to result in a relative reduction in chlamydia prevalence of 18% versus 12% in the non-tailored scenario. Thus, it is important to assess multiple psychological and behavioural characteristics of individuals. Tailored interventions may be more successful in achieving risk-reducing behaviour, and consequently, reduce chlamydia prevalence more effectively.
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Affiliation(s)
- Daphne A van Wees
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA, Bilthoven, The Netherlands.
| | - Chantal den Daas
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA, Bilthoven, The Netherlands
- Department of Interdisciplinary Social Science, Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands
| | - Mirjam E E Kretzschmar
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA, Bilthoven, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Janneke C M Heijne
- Center for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA, Bilthoven, The Netherlands
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Has Chlamydia trachomatis prevalence in young women in England, Scotland and Wales changed? Evidence from national probability surveys. Epidemiol Infect 2020; 147:e107. [PMID: 30869031 PMCID: PMC6518515 DOI: 10.1017/s0950268819000347] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We evaluate the utility of the National Surveys of Attitudes and Sexual Lifestyles (Natsal) undertaken in 2000 and 2010, before and after the introduction of the National Chlamydia Screening Programme, as an evidence source for estimating the change in prevalence of Chlamydia trachomatis (CT) in England, Scotland and Wales. Both the 2000 and 2010 surveys tested urine samples for CT by Nucleic Acid Amplification Tests (NAATs). We examined the sources of uncertainty in estimates of CT prevalence change, including sample size and adjustments for test sensitivity and specificity, survey non-response and informative non-response. In 2000, the unadjusted CT prevalence was 4.22% in women aged 18–24 years; in 2010, CT prevalence was 3.92%, a non-significant absolute difference of 0.30 percentage points (95% credible interval −2.8 to 2.0). In addition to uncertainty due to small sample size, estimates were sensitive to specificity, survey non-response or informative non-response, such that plausible changes in any one of these would be enough to either reverse or double any likely change in prevalence. Alternative ways of monitoring changes in CT incidence and prevalence over time are discussed.
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Gsteiger S, Low N, Sonnenberg P, Mercer CH, Althaus CL. Gini coefficients for measuring the distribution of sexually transmitted infections among individuals with different levels of sexual activity. PeerJ 2020; 8:e8434. [PMID: 31998566 PMCID: PMC6977500 DOI: 10.7717/peerj.8434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/19/2019] [Indexed: 01/08/2023] Open
Abstract
Objectives Gini coefficients have been used to describe the distribution of Chlamydia trachomatis (CT) infections among individuals with different levels of sexual activity. The objectives of this study were to investigate Gini coefficients for different sexually transmitted infections (STIs), and to determine how STI control interventions might affect the Gini coefficient over time. Methods We used population-based data for sexually experienced women from two British National Surveys of Sexual Attitudes and Lifestyles (Natsal-2: 1999–2001; Natsal-3: 2010–2012) to calculate Gini coefficients for CT, Mycoplasma genitalium (MG), and human papillomavirus (HPV) types 6, 11, 16 and 18. We applied bootstrap methods to assess uncertainty and to compare Gini coefficients for different STIs. We then used a mathematical model of STI transmission to study how control interventions affect Gini coefficients. Results Gini coefficients for CT and MG were 0.33 (95% CI [0.18–0.49]) and 0.16 (95% CI [0.02–0.36]), respectively. The relatively small coefficient for MG suggests a longer infectious duration compared with CT. The coefficients for HPV types 6, 11, 16 and 18 ranged from 0.15 to 0.38. During the decade between Natsal-2 and Natsal-3, the Gini coefficient for CT did not change. The transmission model shows that higher STI treatment rates are expected to reduce prevalence and increase the Gini coefficient of STIs. In contrast, increased condom use reduces STI prevalence but does not affect the Gini coefficient. Conclusions Gini coefficients for STIs can help us to understand the distribution of STIs in the population, according to level of sexual activity, and could be used to inform STI prevention and treatment strategies.
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Affiliation(s)
- Sandro Gsteiger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Nicola Low
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Pam Sonnenberg
- Institute for Global Health, University College London, London, UK
| | | | - Christian L Althaus
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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van Wees DA, den Daas C, Kretzschmar MEE, Heijne JCM. Double trouble: modelling the impact of low risk perception and high-risk sexual behaviour on chlamydia transmission. J R Soc Interface 2019; 15:rsif.2017.0847. [PMID: 29618527 DOI: 10.1098/rsif.2017.0847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/09/2018] [Indexed: 12/11/2022] Open
Abstract
Risk perception plays an important role in testing behaviour for sexually transmitted infections, but is rarely included in mathematical models exploring the impact of testing. We explored the impact of incorporating sexual behaviour (SB), risk perception (RP) and differential testing uptake in SB-RP groups on prevalence, using chlamydia as an example. We developed a pair model with a susceptible-infected-susceptible structure representing heterosexuals aged 16-26 years. The effect of testing on chlamydia prevalence was compared between a model with only SB (SB model) and a model with SB and RP (SB-RP model). In the SB-RP model, a scenario without differential testing uptake in SB-RP groups was compared to scenarios with differential testing uptake in SB-RP groups. Introducing testing into the SB-RP model resulted in a slightly smaller reduction in chlamydia prevalence (-38.0%) as compared to the SB model (-40.4%). In the SB-RP model, the scenario without differential testing uptake in SB-RP groups overestimated the reduction in chlamydia prevalence (with 4.8%), especially in the group with high SB and low RP (19.8%). We conclude that mathematical models incorporating RP and differential testing uptake in SB-RP groups improve the impact assessment of testing and treatment on chlamydia prevalence.
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Affiliation(s)
- Daphne A van Wees
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Chantal den Daas
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.,Department of Interdisciplinary Social Science, Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands
| | - Mirjam E E Kretzschmar
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.,Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Janneke C M Heijne
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
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13
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Wijers JNAP, Hoebe CJPA, van Liere GAFS, Wolffs PFG, Dukers-Muijrers NHTM. Chlamydia trachomatis bacterial load, estimated by Cq values, in urogenital samples from men and women visiting the general practice, hospital or STI clinic. PLoS One 2019; 14:e0215606. [PMID: 31002729 PMCID: PMC6474615 DOI: 10.1371/journal.pone.0215606] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 04/04/2019] [Indexed: 01/29/2023] Open
Abstract
Background The bacterial load of Chlamydia trachomatis (CT) is assumed to play a role in transmission and sequelae. We assessed urogenital CT cycle quantification (Cq) values, as an indicator for CT load, of men and women diagnosed by general practitioners (GPs), hospital physicians and the STI clinic. Methods Urogenital CT-positive samples (n = 2,055 vaginal swabs, n = 77 cervical swabs, n = 1,519 urine samples and n = 19 urethral swabs) diagnosed by GPs, hospital physicians and the STI clinic from the Maastricht Medical Microbiology Laboratory were included (2012–2016). The outcome measure ‘urogenital Cq values’ was used as an inversely proportional measure for CT load. Among all patients, multivariate linear regression analyses were used to assess primary determinants for mean urogenital Cq values, stratified by sex. Additional clinical determinants were assessed among STI clinic patients. Results In men, mean urogenital Cq values were similar between GPs, hospital physicians and the STI clinic (32.7 and 33.5 vs. 32.7; p>0.05). Women visiting the GP had lower urogenital Cq values than women visiting the STI clinic (30.2 vs. 30.9; p = <0.001). Women visiting the hospital had higher urogenital Cq values than women visiting the STI clinic (32.4 vs. 30.9; p = <0.001). Among STI clinic women, urogenital Cq values were lower in women with concurrent anorectal CT and in rectally untested women compared to anorectal CT-negative women (30.7 and 30.6 vs. 33.9; p = <0.001). Conclusion Men visiting different STI care providers had similar urogenital Cq values, which could be an indicator for similar CT loads. The lower Cq values of women visiting the GP compared to women visiting the STI clinic could be an indicator for higher CT loads and likely higher transmission potential. Notably, urogenital Cq values of STI clinic women were much lower (>3 Cq) when STI clinic women also had anorectal CT. This finding could indicate higher urogenital CT loads and likely higher chances of transmission and sequelae.
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Affiliation(s)
- Juliën N. A. P. Wijers
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center (MUMC+), AZ Maastricht, the Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, the Netherlands
- * E-mail:
| | - Christian J. P. A. Hoebe
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center (MUMC+), AZ Maastricht, the Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, the Netherlands
| | - Geneviève A. F. S. van Liere
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center (MUMC+), AZ Maastricht, the Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, the Netherlands
| | - Petra F. G. Wolffs
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center (MUMC+), AZ Maastricht, the Netherlands
| | - Nicole H. T. M. Dukers-Muijrers
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center (MUMC+), AZ Maastricht, the Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Heerlen, the Netherlands
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Kasaie P, Schumacher CM, Jennings JM, Berry SA, Tuddenham SA, Shah MS, Rosenberg ES, Hoover KW, Gift TL, Chesson H, German D, Dowdy DW. Gonorrhoea and chlamydia diagnosis as an entry point for HIV pre-exposure prophylaxis: a modelling study. BMJ Open 2019; 9:e023453. [PMID: 30837248 PMCID: PMC6429744 DOI: 10.1136/bmjopen-2018-023453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) increase the risk of HIV transmission among men who have sex with men (MSM). Diagnosis of NG/CT may provide an efficient entry point for prevention of HIV through the delivery of pre-exposure prophylaxis (PrEP); however, the additional population-level impact of targeting PrEP to MSM diagnosed with NG/CT is unknown. DESIGN An agent-based simulation model of NG/CT and HIV cocirculation among MSM calibrated against census data, disease surveillance reports and the US National HIV Behavioral Surveillance study. SETTING Baltimore City, Maryland, USA. INTERVENTIONS PrEP implementation was modelled under three alternative scenarios: (1) PrEP delivery at NG/CT diagnosis (targeted delivery), (2) PrEP evaluation at NG/CT screening/testing and (3) PrEP evaluation in the general community (untargeted). MAIN OUTCOME The projected incidence of HIV after 20 years of PrEP delivery under two alternatives: when equal numbers of MSM are (1) screened for PrEP or (2) receive PrEP in each year. RESULTS Assuming 60% uptake and 60% adherence, targeting PrEP to MSM diagnosed with NG/CT could reduce HIV incidence among MSM in Baltimore City by 12.4% (95% uncertainty range (UR) 10.3% to 14.4%) in 20 years, relative to no PrEP. Expanding the coverage of NG/CT screening (such that individuals experience a 50% annual probability of NG/CT screening and evaluation for PrEP on NG/CT diagnosis) can further increase the impact of targeted PrEP to generate a 22.0% (95% UR 20.1% to 23.9%) reduction in HIV incidence within 20 years. When compared with alternative implementation scenarios, PrEP evaluation at NG/CT diagnosis increased impact of PrEP on HIV incidence by 1.5(95% UR 1.1 to 1.9) times relative to a scenario in which PrEP evaluation happened at the time of NG/CT screening/testing and by 1.6 (95% UR 1.2 to 2.2) times relative to evaluating random MSM from the community. CONCLUSIONS Targeting MSM infected with NG/CT increases the efficiency and effectiveness of PrEP delivery. If high levels of sexually transmitted infection screening can be achieved at the community level, NG/CT diagnosis may be a highly effective entry point for PrEP initialisation.
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Affiliation(s)
- Parastu Kasaie
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Jacky M Jennings
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen A Berry
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Susan A Tuddenham
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Maunank S Shah
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eli S Rosenberg
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Karen W Hoover
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Thomas L Gift
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Atlanta, Georgia, USA
| | - Harrell Chesson
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Atlanta, Georgia, USA
| | - Danielle German
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - David W Dowdy
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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Pillay J, Moore A, Rahman P, Lewin G, Reynolds D, Riva J, Thériault G, Thombs B, Wilson B, Robinson J, Ramdyal A, Cadieux G, Featherstone R, Burchell AN, Dillon JA, Singh A, Wong T, Doull M, Traversy G, Courage S, MacGregor T, Johnson C, Vandermeer B, Hartling L. Screening for chlamydia and/or gonorrhea in primary health care: protocol for systematic review. Syst Rev 2018; 7:248. [PMID: 30587234 PMCID: PMC6307186 DOI: 10.1186/s13643-018-0904-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 12/05/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Chlamydia trachomatis and Neisseria gonorrhoeae are the most commonly reported sexually transmitted infections in Canada. Existing national guidance on screening for these infections was not based on a systematic review, and recommendations as well as implementation considerations (e.g., population groups, testing and case management) should be explicit and reflect the quality of evidence. The aim of this systematic review is to synthesize research on screening for these infections in sexually active individuals within primary care. We will also review evidence on how people weigh the relative importance of the potential outcomes from screening, rated as most important by the Canadian Task Force on Preventive Health Care (CTFPHC) with input from patients and stakeholders. METHODS We have developed a peer-reviewed strategy to comprehensively search MEDLINE, Embase, Cochrane Library, CINAHL, and PsycINFO for English and French literature published 1996 onwards. We will also search trial registries and conference proceedings, and mine references lists. Screening, study selection, risk of bias assessments, and quality of findings across studies (for each outcome) will be independently undertaken by two reviewers with consensus for final decisions. Data extraction will be conducted by one reviewer and checked by another for accuracy and completeness. The CTFPHC and content experts will provide input for decisions on study design (i.e., when and whether to include uncontrolled studies for screening effectiveness) and for interpretation of the findings. DISCUSSION The results section of the review will include a description of all studies, results of all analyses, including planned subgroup and sensitivity analyses, and evidence profiles and summary of findings tables incorporating assessment based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods to communicate our confidence in the estimates of effect. We will compare our findings to others and discuss limitations of the review and available literature. The findings will be used by the CTFPHC-supplemented by consultations with patients and stakeholders and from other sources on issues of feasibility, acceptability, costs/resources, and equity-to inform recommendations on screening to support primary health care providers in delivering preventive care. SYSTEMATIC REVIEW REGISTRATION International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018100733.
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Affiliation(s)
- Jennifer Pillay
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Ainsley Moore
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Prinon Rahman
- Global Health and Guidelines Division, Public Health Agency of Canada, Edmonton, Canada
| | - Gabriel Lewin
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Donna Reynolds
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - John Riva
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | | | - Brett Thombs
- Faculty of Medicine, McGill University, Montreal, Canada
| | - Brenda Wilson
- Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Canada
| | - Joan Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Amanda Ramdyal
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | | | - Robin Featherstone
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Anne N. Burchell
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Jo-Anne Dillon
- Department of Microbiology and Immunology, University of Saskatchewan, Saskatoon, Canada
| | - Ameeta Singh
- Division of Infectious Diseases, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Tom Wong
- Public Health Agency of Canada, Edmonton, Canada
| | - Marion Doull
- Global Health and Guidelines Division, Public Health Agency of Canada, Edmonton, Canada
| | - Greg Traversy
- Global Health and Guidelines Division, Public Health Agency of Canada, Edmonton, Canada
| | - Susan Courage
- Global Health and Guidelines Division, Public Health Agency of Canada, Edmonton, Canada
| | - Tara MacGregor
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Cydney Johnson
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
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Can Chlamydia Serology Be Used to Help Inform a Potential Future Chlamydia Vaccination Strategy? Sex Transm Dis 2018; 44:722-724. [PMID: 29140889 DOI: 10.1097/olq.0000000000000732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Supplemental Digital Content is available in the text. Background: Understanding patterns of chlamydia prevalence is important for addressing inequalities and planning cost-effective control programs. Population-based surveys are costly; the best data for England come from the Natsal national surveys, which are only available once per decade, and are nationally representative but not powered to compare prevalence in different localities. Prevalence estimates at finer spatial and temporal scales are required. Methods: We present a method for estimating local prevalence by modeling the infection, testing, and treatment processes. Prior probability distributions for parameters describing natural history and treatment-seeking behavior are informed by the literature or calibrated using national prevalence estimates. By combining them with surveillance data on numbers of chlamydia tests and diagnoses, we obtain estimates of local screening rates, incidence, and prevalence. We illustrate the method by application to data from England. Results: Our estimates of national prevalence by age group agree with the Natsal-3 survey. They could be improved by additional information on the number of diagnosed cases that were asymptomatic. There is substantial local-level variation in prevalence, with more infection in deprived areas. Incidence in each sex is strongly correlated with prevalence in the other. Importantly, we find that positivity (the proportion of tests which were positive) does not provide a reliable proxy for prevalence. Conclusion: This approach provides local chlamydia prevalence estimates from surveillance data, which could inform analyses to identify and understand local prevalence patterns and assess local programs. Estimates could be more accurate if surveillance systems recorded additional information, including on symptoms. See video abstract at, http://links.lww.com/EDE/B211.
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Davies B, Turner KME, Benfield T, Frølund M, Andersen B, Westh H, Ward H. Pelvic inflammatory disease risk following negative results from chlamydia nucleic acid amplification tests (NAATs) versus non-NAATs in Denmark: A retrospective cohort. PLoS Med 2018; 15:e1002483. [PMID: 29293503 PMCID: PMC5749678 DOI: 10.1371/journal.pmed.1002483] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 11/27/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Nucleic Acid Amplification Tests (NAATs) are the recommended test type for diagnosing Chlamydia trachomatis (chlamydia). However, less sensitive diagnostic methods-including direct immunofluorescence (IF) and enzyme-linked immunoassay (ELISA)-remain in use in lower resourced settings. We estimate the risk of pelvic inflammatory disease (PID) following undiagnosed infection in women tested with non-NAATs and estimate the health gain from using accurate diagnostic tests. METHODS AND FINDINGS We used Denmark's national Chlamydia Study dataset to extract all chlamydia tests performed in women aged 15-34 years (1998-2001). Tests were categorised as non-NAAT (IF/ELISA) or NAAT and limited to each woman's first test in the study period. We linked test data to hospital presentations for PID within 12 months from the Danish National Patient Register. The study included 272,105 women with a chlamydia test, just under half (44.78%, n = 121,857) were tested using NAATs. Overall, 6.38% (n = 17,353) tested positive for chlamydia and 0.64% (n = 1,732) were diagnosed with PID within 12 months. The risk of PID following a positive chlamydia test did not differ by test type (NAAT 0.81% [95% CI 0.61-1.00], non-NAAT 0.78% [0.59-0.96]). The risk of PID following a negative test was significantly lower in women tested with NAATs compared to non-NAATs (0.55% [0.51-0.59] compared to 0.69% [0.64-0.73]; adjusted odds ratio (AOR) 0.83 [0.75-0.93]). We estimate that 18% of chlamydia infections in women tested with a non-NAAT were undiagnosed and that the risk of progression from undiagnosed chlamydia infection to PID within 12 months was 9.52% (9.30-9.68). Using non-NAATs could lead to an excess 120 cases of PID per 100,000 women tested compared to using NAATs. The key limitations of this study are under ascertainment of PID cases, misclassification bias in chlamydia and PID exposure status, bias to the association between clinical presentation and test type and the presence of unmeasured confounders (including other sexually transmitted infection [STI] diagnoses and clinical indication for chlamydia test). CONCLUSION This retrospective observational study estimates the positive impact on women's reproductive health from using accurate chlamydia diagnostic tests and provides further evidence for restricting the use of inferior tests. Women with a negative chlamydia test have a 17% higher adjusted risk of PID by 12 months if they are tested using a non-NAAT compared to a NAAT.
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Affiliation(s)
- Bethan Davies
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
- * E-mail:
| | - Katy M. E. Turner
- School of Veterinary Sciences, University of Bristol, Bristol, United Kingdom
| | - Thomas Benfield
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Maria Frølund
- Research Unit for Reproductive Tract Microbiology, Bacteria, Parasites & Fungi, Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Berit Andersen
- Department of Public Health Programmes, Central Region, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Henrik Westh
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | | | - Helen Ward
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
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Lewis J, Price MJ, Horner PJ, White PJ. Genital Chlamydia trachomatis Infections Clear More Slowly in Men Than Women, but Are Less Likely to Become Established. J Infect Dis 2017; 216:237-244. [PMID: 28838150 PMCID: PMC5854005 DOI: 10.1093/infdis/jix283] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 06/08/2017] [Indexed: 12/31/2022] Open
Abstract
Background Rigorous estimates for clearance rates of untreated chlamydia infections are important for understanding chlamydia epidemiology and designing control interventions, but were previously only available for women. Methods We used data from published studies of chlamydia-infected men who were retested at a later date without having received treatment. Our analysis allowed new infections to take one of 1, 2, or 3 courses, each clearing at a different rate. We determined which of these 3 models had the most empirical support. Results The best-fitting model had 2 courses of infection in men, as was previously found for women: “slow-clearing” and “fast-clearing.” Only 68% (57%–78%) (posterior median and 95% credible interval [CrI]) of incident infections in men were slow-clearing, vs 77% (69%–84%) in women. The slow clearance rate in men (based on 6 months’ follow-up) was 0.35 (.05–1.15) year-1 (posterior median and 95% CrI), corresponding to mean infection duration 2.84 (.87–18.79) years. This compares to 1.35 (1.13–1.63) years in women. Conclusions Our estimated clearance rate is slower than previously assumed. Fewer infections become established in men than women but once established, they clear more slowly. This study provides an improved description of chlamydia’s natural history to inform public health decision making. We describe how further data collection could reduce uncertainty in estimates.
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Affiliation(s)
- Joanna Lewis
- National Institute for Health Research (NIHR) Health Protection Research Unit in Modelling Methodology and Medical Research Council Centre for Outbreak Analysis and Modelling, Imperial College London School of Public Health.,Modelling and Economics Unit, National Infection Service, Public Health England, London
| | - Malcolm J Price
- Institute of Applied Health Research, University of Birmingham
| | - Paddy J Horner
- NIHR Health Protection Research Unit in Evaluation of Interventions, University of Bristol, United Kingdom
| | - Peter J White
- National Institute for Health Research (NIHR) Health Protection Research Unit in Modelling Methodology and Medical Research Council Centre for Outbreak Analysis and Modelling, Imperial College London School of Public Health.,Modelling and Economics Unit, National Infection Service, Public Health England, London
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20
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Pair formation models for sexually transmitted infections: A primer. Infect Dis Model 2017; 2:368-378. [PMID: 29928748 PMCID: PMC6002071 DOI: 10.1016/j.idm.2017.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 01/01/2023] Open
Abstract
For modelling sexually transmitted infections, duration of partnerships can strongly influence the transmission dynamics of the infection. If partnerships are monogamous, pairs of susceptible individuals are protected from becoming infected, while pairs of infected individuals delay onward transmission of the infection as long as they persist. In addition, for curable infections re-infection from an infected partner may occur. Furthermore, interventions based on contact tracing rely on the possibility of identifying and treating partners of infected individuals. To reflect these features in a mathematical model, pair formation models were introduced to mathematical epidemiology in the 1980's. They have since been developed into a widely used tool in modelling sexually transmitted infections and the impact of interventions. Here we give a basic introduction to the concepts of pair formation models for a susceptible-infected-susceptible (SIS) epidemic. We review some results and applications of pair formation models mainly in the context of chlamydia infection.
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21
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Thanh NX, Akpinar I, Gratrix J, Plitt S, Smyczek P, Read R, Jacobs P, Wong T, Singh AE. Benefit of adjunct universal rectal screening for Chlamydia genital infections in women attending Canadian sexually transmitted infection clinics. Int J STD AIDS 2017; 28:1311-1324. [PMID: 28534712 DOI: 10.1177/0956462417704344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Adding universal rectal screening to urogenital screening should positively impact rectal Chlamydia trachomatis (CT) incidence in affected populations. A dynamic Markov model was used to evaluate costs and outcomes of three rectal CT screening strategies among women attending sexually transmitted infection clinics in Alberta, Canada: universal urogenital-only screening (UG-only), additional selected (exposure-based) rectal screening (UG+SR), and additional universal rectal screening (UG+UR). The model included two mutually exclusive health states: infected and susceptible. Additionally, the model included two rounds of transmission: male sex partners of women infected with rectal-only CT and female sex partners of those men. CT complications impacting patients' quality of life (QALY) were considered. Alberta and Canadian data were used to estimate model inputs. We used a health care perspective, a time period of 10 years, and a discount rate of 3% for analyses. Compared to UG-only screening, the incremental cost effectiveness ratios (ICERs) were CA$34,000 and CA$49,000 per QALY gained for UG+SR and UG+UR screening strategies, respectively. Compared to UG+SR, the ICER was CA$62,000 per QALY gained for the UG+UR strategy. Both adjunct selected and universal rectal screening strategies are cost effective compared to UG-only screening, and UG+UR screening is cost effective when compared to UG+SR screening.
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Affiliation(s)
| | - Ilke Akpinar
- 1 Institute of Health Economics, Edmonton, Canada
| | - Jennifer Gratrix
- 2 STI Centralized Services, Alberta Health Services, Edmonton, Canada
| | - Sabrina Plitt
- 3 Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Canada
| | - Petra Smyczek
- 2 STI Centralized Services, Alberta Health Services, Edmonton, Canada
| | - Ron Read
- 4 STI Clinic, Alberta Health Services, Calgary, Canada
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22
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Price MJ, Ades AE, Soldan K, Welton NJ, Macleod J, Simms I, DeAngelis D, Turner KM, Horner PJ. The natural history of Chlamydia trachomatis infection in women: a multi-parameter evidence synthesis. Health Technol Assess 2016; 20:1-250. [PMID: 27007215 DOI: 10.3310/hta20220] [Citation(s) in RCA: 256] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The evidence base supporting the National Chlamydia Screening Programme, initiated in 2003, has been questioned repeatedly, with little consensus on modelling assumptions, parameter values or evidence sources to be used in cost-effectiveness analyses. The purpose of this project was to assemble all available evidence on the prevalence and incidence of Chlamydia trachomatis (CT) in the UK and its sequelae, pelvic inflammatory disease (PID), ectopic pregnancy (EP) and tubal factor infertility (TFI) to review the evidence base in its entirety, assess its consistency and, if possible, arrive at a coherent set of estimates consistent with all the evidence. METHODS Evidence was identified using 'high-yield' strategies. Bayesian Multi-Parameter Evidence Synthesis models were constructed for separate subparts of the clinical and population epidemiology of CT. Where possible, different types of data sources were statistically combined to derive coherent estimates. Where evidence was inconsistent, evidence sources were re-interpreted and new estimates derived on a post-hoc basis. RESULTS An internally coherent set of estimates was generated, consistent with a multifaceted evidence base, fertility surveys and routine UK statistics on PID and EP. Among the key findings were that the risk of PID (symptomatic or asymptomatic) following an untreated CT infection is 17.1% [95% credible interval (CrI) 6% to 29%] and the risk of salpingitis is 7.3% (95% CrI 2.2% to 14.0%). In women aged 16-24 years, screened at annual intervals, at best, 61% (95% CrI 55% to 67%) of CT-related PID and 22% (95% CrI 7% to 43%) of all PID could be directly prevented. For women aged 16-44 years, the proportions of PID, EP and TFI that are attributable to CT are estimated to be 20% (95% CrI 6% to 38%), 4.9% (95% CrI 1.2% to 12%) and 29% (95% CrI 9% to 56%), respectively. The prevalence of TFI in the UK in women at the end of their reproductive lives is 1.1%: this is consistent with all PID carrying a relatively high risk of reproductive damage, whether diagnosed or not. Every 1000 CT infections in women aged 16-44 years, on average, gives rise to approximately 171 episodes of PID and 73 of salpingitis, 2.0 EPs and 5.1 women with TFI at age 44 years. CONCLUSIONS AND RESEARCH RECOMMENDATIONS The study establishes a set of interpretations of the major studies and study designs, under which a coherent set of estimates can be generated. CT is a significant cause of PID and TFI. CT screening is of benefit to the individual, but detection and treatment of incident infection may be more beneficial. Women with lower abdominal pain need better advice on when to seek early medical attention to avoid risk of reproductive damage. The study provides new insights into the reproductive risks of PID and the role of CT. Further research is required on the proportions of PID, EP and TFI attributable to CT to confirm predictions made in this report, and to improve the precision of key estimates. The cost-effectiveness of screening should be re-evaluated using the findings of this report. FUNDING The Medical Research Council grant G0801947.
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Affiliation(s)
- Malcolm J Price
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - A E Ades
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kate Soldan
- Public Health England (formerly Health Protection Agency), Colindale, London, UK
| | - Nicky J Welton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - John Macleod
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Ian Simms
- Public Health England (formerly Health Protection Agency), Colindale, London, UK
| | - Daniela DeAngelis
- Public Health England (formerly Health Protection Agency), Colindale, London, UK.,Medical Research Council Biostatistics Unit, Cambridge, UK
| | | | - Paddy J Horner
- School of Social and Community Medicine, University of Bristol, Bristol, UK.,Bristol Sexual Health Centre, University Hospital Bristol NHS Foundation Trust, Bristol, UK
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Davies B, Turner KME, Frølund M, Ward H, May MT, Rasmussen S, Benfield T, Westh H. Risk of reproductive complications following chlamydia testing: a population-based retrospective cohort study in Denmark. THE LANCET. INFECTIOUS DISEASES 2016; 16:1057-1064. [PMID: 27289389 DOI: 10.1016/s1473-3099(16)30092-5] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 04/17/2016] [Accepted: 05/03/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Uncertainty in the risk of reproductive complications (pelvic inflammatory disease, ectopic pregnancy, and tubal factor infertility) following chlamydia infection and repeat infection hampers the design of evidence-based chlamydia control programmes. We estimate the association between diagnosed chlamydia and episodes of hospital health care (inpatient, outpatient, and emergency department) for a reproductive complication. METHODS We constructed and analysed a retrospective population-based cohort of women aged 15-44 years from administrative records in Denmark (1995-2012). We used a subset of the national Danish Chlamydia Study. The master dataset contains all residents of Denmark (including Greenland) who had a positive chlamydia test recorded by a public health microbiology laboratory from Jan 1, 1992, to Nov 2, 2011. Individuals were randomly matched (by age and sex) to four individuals drawn from the population register (Danish Civil Registration System) who did not have a positive chlamydia test during this interval. The outcomes in the study were hospital episodes of health-care (inpatient, outpatient, and emergency department) with a diagnosis of pelvic inflammatory disease, ectopic pregnancy, or tubal factor infertility. FINDINGS The 516 720 women (103 344 positive, 182 879 negative, 230 497 never-tested) had a mean follow-up of 7·96 years. Compared with women with only negative tests, the risk of each complication was 30% higher in women with one or more positive tests (pelvic inflammatory disease, adjusted hazard ratio [AHR] 1·50 [95% CI 1·43-1·57]; ectopic pregnancy, AHR 1·31 [1·25-1·38]; tubal factor infertility, AHR 1·37 [1·24-1·52]) and 60% lower in women who were never-tested (pelvic inflammatory disease, AHR 0·33 [0·31-0·35]; ectopic pregnancy, AHR 0·42 [0·39-0·44]; tubal factor infertility AHR 0·29 [0·25-0·33]). A positive test had a minor absolute impact on health as the difference in the lifetime incidence of complications was small between women who tested positive and those who tested negative (pelvic inflammatory disease, 0·6%; ectopic pregnancy, 0·2%; tubal factor infertility, 0·1%). Repeat infections increased the risk of pelvic inflammatory disease by a further 20% (AHR 1·20, 95% CI 1·11-1·31). INTERPRETATION A single diagnosed chlamydia infection increased the risk of all complications and a repeat diagnosed infection further increased the risk of pelvic inflammatory disease. Therefore, control programmes must prevent first and repeat infections to improve women's reproductive health. FUNDING Unrestricted partial funding from Frederiksberg Kommune, Frederiksberg, Denmark. BD held an Medical Research Council Population Health Scientist Fellowship (G0902120). KT held an National Institute for Health Research Post-Doctoral Fellowship 2009-02-055.
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Affiliation(s)
- Bethan Davies
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK.
| | - Katy M E Turner
- School of Veterinary Science, University of Bristol, Langford, Bristol, UK
| | - Maria Frølund
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Helen Ward
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Margaret T May
- School of Social and Community Medicine, University of Bristol, Langford, Bristol, UK
| | - Steen Rasmussen
- Department of Clinical Microbiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Hvidovre University Hospital, Hvidovre, Denmark; Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Westh
- Department of Clinical Microbiology, Hvidovre University Hospital, Hvidovre, Denmark; Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Horner PJ, Wills GS, Righarts A, Vieira S, Kounali D, Samuel D, Winston A, Muir D, Dickson NP, McClure MO. Chlamydia trachomatis Pgp3 Antibody Persists and Correlates with Self-Reported Infection and Behavioural Risks in a Blinded Cohort Study. PLoS One 2016; 11:e0151497. [PMID: 26974653 PMCID: PMC4790965 DOI: 10.1371/journal.pone.0151497] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/29/2016] [Indexed: 12/12/2022] Open
Abstract
Chlamydia trachomatis (Ct) serological studies in populations could help monitor changes in lifetime cumulative risk of infection. We developed a double-antigen sandwich ELISA based on the Ct-specific Pgp3 antigen, then tested blind stored sera from over 800 participants in a New Zealand birth cohort from Dunedin at ages 26, 32 and 38. The double-antigen sandwich ELISA was more sensitive than our previously characterised indirect Pgp3 ELISA. Pgp3 antibody was detected more often in women compared to men and correlated with increasing numbers of sexual partners, self-reported Ct, and younger age at sexual debut in both women and men. At age 26, 24.1% (99/411) of women were Pgp3 seropositive, as were 79.5% (35/44) of those reporting Ct infection; Pgp3 antibody persisted to age 38 in 96.5% (83/86). In men at age 26, the figures were 10.7% (47/442) and 25.0% (6/24), respectively, with high (83.9%) antibody persistence to age 38. At age 38, among those Pgp3 seropositive, 63.3% of women and 83.1% of men had not reported Ct infection. Thus, Ct-specific Pgp3 antibody was detected in most women reporting Ct infection and correlated with risk of infection in those who did not, with most infections remaining undetected. As this antibody persisted for at least twelve years in 96% of these women, serology could be used to evaluate Ct prevention programmes among women.
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Affiliation(s)
- Patrick J. Horner
- Jefferiss Trust Laboratories, Wright-Fleming Institute, Imperial College London, London, United Kingdom
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Gillian S. Wills
- Jefferiss Trust Laboratories, Wright-Fleming Institute, Imperial College London, London, United Kingdom
| | - Antoinette Righarts
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Sueli Vieira
- Jefferiss Trust Laboratories, Wright-Fleming Institute, Imperial College London, London, United Kingdom
| | - Daphne Kounali
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Evaluation of Interventions in partnership with Public Health England, University of Bristol, Bristol, United Kingdom
| | - Dhanraj Samuel
- Public Health for England, Colindale, London, United Kingdom
| | - Alan Winston
- Jefferiss Trust Laboratories, Wright-Fleming Institute, Imperial College London, London, United Kingdom
| | - David Muir
- Department of Infection and Immunity, Imperial College Healthcare Trust, London, United Kingdom
| | - Nigel P. Dickson
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Myra O. McClure
- Jefferiss Trust Laboratories, Wright-Fleming Institute, Imperial College London, London, United Kingdom
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Dirks JAMC, van Liere GAFS, Bogers S, Dukers-Muijrers NHTM, Wolffs PFG, Hoebe CJPA. Natural Course of Chlamydia trachomatis Bacterial Load in the Time Interval between Screening and Treatment in Anogenital Samples. PLoS One 2015; 10:e0145693. [PMID: 26713628 PMCID: PMC4701017 DOI: 10.1371/journal.pone.0145693] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/06/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Although Chlamydia trachomatis (CT) is the most common bacterial sexually transmitted infection worldwide, little is known about the natural course of the bacterial load during infection. We investigated the natural course of the bacterial load in the interval between screening and returning for treatment in genital and anorectal CT-infections. MATERIALS & METHODS CT-positive patients, visiting our STI-clinic in the Netherlands from June 2011-January 2014, provided a second urogenital and/or anorectal sample when returning for treatment (diagnostic sample = T1; treatment sample = T2). Patient-record provided data about the days between samples and the date of last unsafe sex. Included patients were ≥18 years old, HIV-negative and did not report antibiotic use in the study-interval. CT load was quantified using qPCR. CT load was log-transformed, and a CT load difference (Δ-CT load) of >1 log was deemed clinically relevant. Chi-square test compared load category distributions over time (decrease/equal/increase), between sample types. RESULTS 274 patients provided 296 paired samples. Majority of samples had a stable CT load in the interval T1-T2 (66.3%, 73.1% and 48.6% for vaginal swabs, urine and anorectal swabs resp. p = 0.07). Load decreased in 17-41% of patients, while ±10% of patients showed an increase in CT load. No association between Δ-CT load and the interval T1-T2 was observed. Large variations can be seen in CT load at T1 and over time. DISCUSSION The majority (±90%) of patients have a stable or decreasing CT load in the time interval between screening and returning for treatment. The number of days between sampling was not associated with change in CT load. In the first month after the last unsafe sex, only stable CT loads were seen. Our data seems to indicate that when most patients visit an STI-clinic, recommended 2 weeks after infection, the infection has already been established or is in its downward phase.
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Affiliation(s)
- J. A. M. C. Dirks
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, the Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service South Limburg, Geleen, the Netherlands
| | - G. A. F. S. van Liere
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, the Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service South Limburg, Geleen, the Netherlands
| | - S. Bogers
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, the Netherlands
| | - N. H. T. M. Dukers-Muijrers
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, the Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service South Limburg, Geleen, the Netherlands
| | - P. F. G. Wolffs
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, the Netherlands
| | - C. J. P. A. Hoebe
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, the Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service South Limburg, Geleen, the Netherlands
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Nwokolo NC, Dragovic B, Patel S, Tong CYW, Barker G, Radcliffe K. 2015 UK national guideline for the management of infection with Chlamydia trachomatis. Int J STD AIDS 2015; 27:251-67. [PMID: 26538553 DOI: 10.1177/0956462415615443] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 10/09/2015] [Indexed: 01/26/2023]
Abstract
This guideline offers recommendations on the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of Chlamydia trachomatis genital infection. It covers the management of the initial presentation, as well the prevention of transmission and future infection. The guideline is aimed at individuals aged 16 years and older presenting to healthcare professionals working in departments offering Level 3 care in sexually transmitted infections management within the UK. However, the principles of the recommendations should be adopted across all levels, using local care pathways where appropriate.
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Affiliation(s)
| | | | - Sheel Patel
- Chelsea and Westminster Hospital, London, UK
| | | | | | - Keith Radcliffe
- British Association for Sexual Health and HIV Clinical Effectiveness Group, London, UK
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Sacks-Davis R, McBryde E, Grebely J, Hellard M, Vickerman P. Many hepatitis C reinfections that spontaneously clear may be undetected: Markov-chain Monte Carlo analysis of observational study data. J R Soc Interface 2015; 12:20141197. [PMID: 25589564 DOI: 10.1098/rsif.2014.1197] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Hepatitis C virus (HCV) reinfection rates are probably underestimated due to reinfection episodes occurring between study visits. A Markov model of HCV reinfection and spontaneous clearance was fitted to empirical data. Bayesian post-estimation was used to project reinfection rates, reinfection spontaneous clearance probability and duration of reinfection. Uniform prior probability distributions were assumed for reinfection rate (more than 0), spontaneous clearance probability (0-1) and duration (0.25-6.00 months). Model estimates were 104 per 100 person-years (95% CrI: 21-344), 0.84 (95% CrI: 0.59-0.98) and 1.3 months (95% CrI: 0.3-4.1) for reinfection rate, spontaneous clearance probability and duration, respectively. Simulation studies were used to assess model validity, demonstrating that the Bayesian model estimates provided useful information about the possible sources and magnitude of bias in epidemiological estimates of reinfection rates, probability of reinfection clearance and duration or reinfection. The quality of the Bayesian estimates improved for larger samples and shorter test intervals. Uncertainty in model estimates notwithstanding, findings suggest that HCV reinfections frequently and quickly result in spontaneous clearance, with many reinfection events going unobserved.
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Affiliation(s)
- Rachel Sacks-Davis
- Centre for Population Health, Burnet Institute, Melbourne, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Emma McBryde
- Centre for Population Health, Burnet Institute, Melbourne, Australia Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jason Grebely
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Margaret Hellard
- Centre for Population Health, Burnet Institute, Melbourne, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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van Liere GAFS, Dirks JAMC, Hoebe CJPA, Wolffs PF, Dukers-Muijrers NHTM. Anorectal Chlamydia trachomatis Load Is Similar in Men Who Have Sex with Men and Women Reporting Anal Sex. PLoS One 2015; 10:e0134991. [PMID: 26262680 PMCID: PMC4532443 DOI: 10.1371/journal.pone.0134991] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 07/15/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Anorectal Chlamydia trachomatis (chlamydia) is frequently diagnosed in men who have sex with men (MSM) and in women, but it is unknown whether these infections are comparable in clinical impact and transmission potential. Quantifying bacterial load and identifying determinants associated with high bacterial load could provide more insight. METHODS We selected a convenience sample of MSM who reported anal sex (n = 90) and women with concurrent urogenital/anorectal chlamydia who reported anal sex (n = 51) or did not report anal sex (n = 61) from the South Limburg Public Health Service's STI unit. Bacterial load (Chlamydia/ml) was quantified for all samples and log transformed for analyses. Samples with an unquantifiable human leukocyte antigen (n = 9) were excluded from analyses, as they were deemed inadequately sampled. RESULTS The mean log anorectal chlamydia load (3.50) was similar for MSM and women who reported having anal sex (3.80, P = 0.21). The anorectal chlamydia load was significantly higher in these groups than in women who did not report having anal sex (2.76, P = 0.001). Detectable load values ranged from 1.81-6.32 chlamydia/ml for MSM, 1.74-7.33 chlamydia/ml for women who reported having anal sex and 1.84-6.31 chlamydia/ml for women who did not report having anal sex. Symptoms and several other determinants were not associated with anorectal chlamydia load. CONCLUSIONS Women who did not report anal sex had lower anorectal loads, but they were within a similar range to the other two groups. Anorectal chlamydia load was comparable between MSM and women who reported anal sex, suggesting similar transmission potential.
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Affiliation(s)
- Geneviève A. F. S. van Liere
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Geleen, the Netherlands
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center + (MUMC+), Maastricht, the Netherlands
- * E-mail:
| | - Jeanne A. M. C. Dirks
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center + (MUMC+), Maastricht, the Netherlands
| | - Christian J. P. A. Hoebe
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Geleen, the Netherlands
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center + (MUMC+), Maastricht, the Netherlands
| | - Petra F. Wolffs
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center + (MUMC+), Maastricht, the Netherlands
| | - Nicole H. T. M. Dukers-Muijrers
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, Geleen, the Netherlands
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center + (MUMC+), Maastricht, the Netherlands
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Dirks JAMC, Wolffs PFG, Dukers-Muijrers NHTM, Brink AATP, Speksnijder AGCL, Hoebe CJPA. Chlamydia trachomatis load in population-based screening and STI-clinics: implications for screening policy. PLoS One 2015; 10:e0121433. [PMID: 25826298 PMCID: PMC4380475 DOI: 10.1371/journal.pone.0121433] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 02/13/2015] [Indexed: 11/19/2022] Open
Abstract
Objectives If the Chlamydia trachomatis (CT) bacterial load is higher in high-risk populations than in the general population, this negatively affects the efficacy of CT screening incentives. In the largest retrospective study to date, we investigated the CT load in specimens collected from 2 cohorts: (1) attendants of a sexually transmitted infection (STI)-clinic and (2) participants of the Dutch population-based screening (PBS). Methods CT load was determined using quantitative PCR in CT-positive male urine and female cervicovaginal swabs. CT loads were converted into tertiles. Using multinominal logistic regression, independent association of cohort, symptoms, risk behaviour and human cell count on load were assessed. Results CT loads were determined in 889 CT-positives from PBS (n = 529; 71.8% female) and STI-clinics (n = 360; 61.7% female). In men, STI-clinic-cohort, human cell count and urethral discharge were positively associated with CT load. In women, PBS-cohort and cell count were positively associated with CT load. Both cohorts had the same range in CT load. Conclusions The general population has a similar range of bacterial CT load as a high-risk population, but a different distribution for cohort and gender, highlighting the relevance of population-based CT-screening. When CT loads are similar, possibly the chances of transmission and sequelae are too.
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Affiliation(s)
- Jeanne A. M. C. Dirks
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, The Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service South Limburg, Geleen, The Netherlands
| | - Petra F. G. Wolffs
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, The Netherlands
- * E-mail:
| | - Nicole H. T. M. Dukers-Muijrers
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, The Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service South Limburg, Geleen, The Netherlands
| | - Antoinette A. T. P. Brink
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, The Netherlands
| | | | - Christian J. P. A. Hoebe
- Department of Medical Microbiology, Maastricht University Medical Center, School of Public Health and Primary Care, Maastricht, The Netherlands
- Department of Sexual Health, Infectious Diseases and Environmental Health, Public Health Service South Limburg, Geleen, The Netherlands
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Looker KJ, Wallace LA, Turner KME. Impact and cost-effectiveness of chlamydia testing in Scotland: a mathematical modelling study. Theor Biol Med Model 2015; 12:2. [PMID: 25588390 PMCID: PMC4429484 DOI: 10.1186/1742-4682-12-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 01/02/2015] [Indexed: 01/05/2023] Open
Abstract
Background Chlamydia is the most common sexually transmitted bacterial infection in Scotland, and is associated with potentially serious reproductive outcomes, including pelvic inflammatory disease (PID) and tubal factor infertility (TFI) in women. Chlamydia testing in Scotland is currently targeted towards symptomatic individuals, individuals at high risk of existing undetected infection, and young people. The cost-effectiveness of testing and treatment to prevent PID and TFI in Scotland is uncertain. Methods A compartmental deterministic dynamic model of chlamydia infection in 15–24 year olds in Scotland was developed. The model was used to estimate the impact of a change in testing strategy from baseline (16.8% overall testing coverage; 0.4 partners notified and tested/treated per treated positive index) on PID and TFI cases. Cost-effectiveness calculations informed by best-available estimates of the quality-adjusted life years (QALYs) lost due to PID and TFI were also performed. Results Increasing overall testing coverage by 50% from baseline to 25.2% is estimated to result in 21% fewer cases in young women each year (PID: 703 fewer; TFI: 88 fewer). A 50% decrease to 8.4% would result in 20% more PID (669 additional) and TFI (84 additional) cases occurring annually. The cost per QALY gained of current testing activities compared to no testing is £40,034, which is above the £20,000-£30,000 cost-effectiveness threshold. However, calculations are hampered by lack of reliable data. Any increase in partner notification from baseline would be cost-effective (incremental cost per QALY gained for a partner notification efficacy of 1 compared to baseline: £5,119), and would increase the cost-effectiveness of current testing strategy compared to no testing, with threshold cost-effectiveness reached at a partner notification efficacy of 1.5. However, there is uncertainty in the extent to which partner notification is currently done, and hence the amount by which it could potentially be increased. Conclusions Current chlamydia testing strategy in Scotland is not cost-effective under the conservative model assumptions applied. However, with better data enabling some of these assumptions to be relaxed, current coverage could be cost-effective. Meanwhile, increasing partner notification efficacy on its own would be a cost-effective way of preventing PID and TFI from current strategy. Electronic supplementary material The online version of this article (doi:10.1186/1742-4682-12-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katharine J Looker
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | | | - Katherine M E Turner
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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van Aar F, de Moraes M, Morré SA, van Bergen JEAM, van der Klis FRM, Land JA, van der Sande MAB, van den Broek IVF. Chlamydia trachomatisIgG seroprevalence in the general population of the Netherlands in 1996 and in 2007: differential changes by gender and age. Sex Transm Infect 2014; 90:434-40. [DOI: 10.1136/sextrans-2013-051074] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Davies B, Anderson SJ, Turner KME, Ward H. How robust are the natural history parameters used in chlamydia transmission dynamic models? A systematic review. Theor Biol Med Model 2014; 11:8. [PMID: 24476335 PMCID: PMC3922653 DOI: 10.1186/1742-4682-11-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/18/2014] [Indexed: 11/10/2022] Open
Abstract
Transmission dynamic models linked to economic analyses often form part of the decision making process when introducing new chlamydia screening interventions. Outputs from these transmission dynamic models can vary depending on the values of the parameters used to describe the infection. Therefore these values can have an important influence on policy and resource allocation. The risk of progression from infection to pelvic inflammatory disease has been extensively studied but the parameters which govern the transmission dynamics are frequently neglected. We conducted a systematic review of transmission dynamic models linked to economic analyses of chlamydia screening interventions to critically assess the source and variability of the proportion of infections that are asymptomatic, the duration of infection and the transmission probability. We identified nine relevant studies in Pubmed, Embase and the Cochrane database. We found that there is a wide variation in their natural history parameters, including an absolute difference in the proportion of asymptomatic infections of 25% in women and 75% in men, a six-fold difference in the duration of asymptomatic infection and a four-fold difference in the per act transmission probability. We consider that much of this variation can be explained by a lack of consensus in the literature. We found that a significant proportion of parameter values were referenced back to the early chlamydia literature, before the introduction of nucleic acid modes of diagnosis and the widespread testing of asymptomatic individuals. In conclusion, authors should use high quality contemporary evidence to inform their parameter values, clearly document their assumptions and make appropriate use of sensitivity analysis. This will help to make models more transparent and increase their utility to policy makers.
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Affiliation(s)
- Bethan Davies
- School of Public Health, Imperial College London, St Mary's Campus, Praed Street, London W1 2PG, UK.
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Price MJ, Ades AE, De Angelis D, Welton NJ, Macleod J, Soldan K, Simms I, Turner K, Horner PJ. Risk of pelvic inflammatory disease following Chlamydia trachomatis infection: analysis of prospective studies with a multistate model. Am J Epidemiol 2013; 178:484-92. [PMID: 23813703 PMCID: PMC3727337 DOI: 10.1093/aje/kws583] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Our objective in this study was to estimate the probability that a Chlamydia trachomatis (CT) infection will cause an episode of clinical pelvic inflammatory disease (PID) and the reduction in such episodes among women with CT that could be achieved by annual screening. We reappraised evidence from randomized controlled trials of screening and controlled observational studies that followed untreated CT-infected and -uninfected women to measure the development of PID. Data from these studies were synthesized using a continuous-time Markov model which takes into account the competing risk of spontaneous clearance of CT. Using a 2-step piecewise homogenous Markov model that accounts for the distinction between prevalent and incident infections, we investigated the possibility that the rate of PID due to CT is greater during the period immediately following infection. The available data were compatible with both the homogenous and piecewise homogenous models. Given a homogenous model, the probability that a CT episode will cause clinical PID was 0.16 (95% credible interval (CrI): 0.06, 0.25), and annual screening would prevent 61% (95% CrI: 55, 67) of CT-related PID in women who became infected with CT. Assuming a piecewise homogenous model with a higher rate during the first 60 days, corresponding results were 0.16 (95% CrI: 0.07, 0.26) and 55% (95% CrI: 32, 72), respectively.
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Affiliation(s)
- Malcolm J Price
- School of Health and Population Sciences, Public Health Building, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom.
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Incidence of Chlamydia trachomatis infection in women in England: two methods of estimation. Epidemiol Infect 2013; 142:562-76. [PMID: 23759367 PMCID: PMC3915754 DOI: 10.1017/s0950268813001027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Information on the incidence of Chlamydia trachomatis (CT) is essential for models of the effectiveness and cost-effectiveness of screening programmes. We developed two independent estimates of CT incidence in women in England: one based on an incidence study, with estimates 'recalibrated' to the general population using data on setting-specific relative risks, and allowing for clearance and re-infection during follow-up; the second based on UK prevalence data, and information on the duration of CT infection. The consistency of independent sources of data on incidence, prevalence and duration, validates estimates of these parameters. Pooled estimates of the annual incidence rate in women aged 16-24 and 16-44 years for 2001-2005 using all these data were 0·05 [95% credible interval (CrI) 0·035-0·071] and 0·021 (95% CrI 0·015-0·028), respectively. Although, the estimates apply to England, similar methods could be used in other countries. The methods could be extended to dynamic models to synthesize, and assess the consistency of data on contact and transmission rates.
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