Chlamydia screening and partner notification in WA general practice

1. Chlamydiascreening and partner notification inWA general practice Prepared by: The Australasian Society for HIV Medicine Presented by:

2. Aim: Increase testing for chlamydia & enhance partner notification in general practice Objectives: Increase knowledge about chlamydia & importance of opportunistic testing Increase skills regarding offer of appropriate opportunistic testing for chlamydia Increase awareness of importance of partner notification and how to assist with this process Aim & Objectives

3. L1, L2, L3 Lymphogranuloma venereum (LGV) A, B, B-a, C Trachoma B, D, E – K Genital tract infection Proctitis Conjunctivitis (adult & neonatal) Neonatal pneumonia This presentation will focus on sexually transmitted anogenital Chlamydia trachomatis (CT) infection Chlamydia trachomatis - serovars

4. CT notifications in Australia & WA • Most frequently notified infectious disease in Australia • About 58,456 cases in 20081 • Real incidence about 200,000 per year?2 • WA had about 8,653 cases in 2008 (7,749 in 2007)3 • About 90% of CT is diagnosed in WA General Practice3 • Most cases in Perth metro area3 • In 2008, 71% of total CT cases from metro area • Only 16% from Kimberley, Pilbara, Goldfields 1National Notifiable Diseases Surveillance System 2Prof B Donovan, NCHECR 3K Kwan & D Mak, Communicable Disease Control Directorate, WA Health

5. Number and crude rate of chlamydia notifications, metropolitan region and WA total, 1999 to 2008 Source: Epi and Surveillance Program, Communicable Disease Control Directorate (CDCD)

6. Number of chlamydia notifications by age group and sex, WA 2008 Source: Epi and Surveillance Program, Communicable Disease Control Directorate (CDCD)

7. Prevalence in WA 1998-2008 • Most commonly diagnosed in youth <25yrs • 27% Pregnant teenagers (⅓ indigenous) Perth • 19-22% M&F STI contacts Kimberley (clinic) • 9% Indigenous women Kimberley (clinic) • 3.8% Men 15-29 yrs GP Clinics Perth • 3.3% Antenatal clinic Kimberley (⅔ indigenous) Mak MJA 2004 Vaidic Sexual Health 2005 Hince Perth SH Conf 2008

8. Transmission • Unprotected oral, vaginal or anal intercourse • Vertical transmission to neonate • Studies show very low rates of pharyngeal infection, role of oral sex in transmission overall is unclear • 75% of both male and female sexual partners of those diagnosed with infection are infected • Reinforces need for partner notification & epidemiological treatment for partners Schachter Chap 31 Sexually Transmitted Diseases, 4th Ed, McGraw-Hill, 2008 Stamm Chap 32 Sexually Transmitted Diseases, 4th Ed, McGraw-Hill, 2008 Templeton Sex Trans Inf 2008, Lister J Clin Micro 2004 Rogers Sex Trans Inf 2008, Markos Sexual Health 2005

9. Most infection is asymptomatic • Approximately 75% of CT infections in women and up to 50% in men are asymptomatic • Thus, large proportion of CT infections go undetected unless targeted screening programs are put in place BASHH Guidelines 2006 Cunningham Biology of Reproduction 2008

10. Clinical spectrum Women: Cervicitis Pelvic inflammatory disease Tubal factor infertility Ectopic pregnancy Pelvic adhesions & chronic pelvic pain Perihepatitis (FitzHugh-Curtis Syndrome) Men: Urethritis Epididymo-orchitis Proctitis Both: Conjunctivitis Reactive arthritis (Reiter’s disease) Enhanced HIV transmission Hocking & Fairley ANZJPH 2003 Chen & Donovan Sexual Health 2004 BASHH Guidelines 2006

11. Symptoms Women: Asymptomatic infection (approx 75%) Vaginal discharge Dysuria Pelvic pain & dyspareunia Post-coital & intermenstrual bleeding Men: Asymptomatic infection (up to 50%) Urethral discharge Dysuria Testicular pain & swelling BASHH Guidelines 2006 Stamm Chap 32 Sexually Transmitted Diseases, 4th Ed, McGraw-Hill, 2008

12. Signs Women: Normal Mucopurulent cervicitis Adnexal & cervical motion tenderness Men: Normal Meatal inflammation Mucopurulent urethral discharge Epididymal & testicular swelling Paavonen International Congress Series 2004 Stamm Chap 32 Sexually Transmitted Diseases, 4th Ed, McGraw-Hill, 2008

13. Duration of infection • Most evidence suggests infection persists for >60 days (possibly years) in ♀ reproductive tract • Asymptomatic ♀ with new Dx CT infection have 29% risk of having been infected for > 2 yr • Duration of infection in ♂ unclear Cunningham Biology of Reproduction 2008 Fairley Sex Trans Dis 2007

14. Complications in women • Pelvic Inflammatory Disease (PID), tubal factor infertility, ectopic pregnancy & chronic pelvic pain common following infection • CT accounts for ~⅓ of PID cases in developed countries, up to 20% become infertile • Both symptomatic & asymptomatic infection can damage ♀ reproductive tract • Delayed treatment increases risk of permanent tubal damage & duration of infectiousness Hocking & Fairley ANZJPH 2003 Paavonen International Congress Series 2004 BASHH Guidelines 2006

15. Complications in men • Untreated CT urethritis in men leads to epididymitis & prostatitis in up to 4% • Evidence supports a link between CT infection & male factor infertility • Male CT infection serves as reservoir for transmission to females Van den Brule Int J STD AIDS 2002 Cunningham Biology of Reproduction 2008

16. Provider initiated testing in primary care • All sexually active men & women < 25 yrs • All reporting new sexual partner last 12 months or not using condoms all the time • Pregnant ♀ or those ♀ seeking termination • Those with CT associated symptoms & signs • Sexual contact of person with CT infection • Presence of another STI • Patient request for HIV or STI screening

17. CT testing by PCR Men: First-void urine OR Urethral swab Women: Self-obtained low vaginal swab (SOLVS), OR Endocervical swab, OR FVU for Chlamydia PCR Either: Throat swab and/or anal swab if indicated in sexual history High specificity > 99% & sensitivity 90-95% at the genital site in men & women BASHH Guidelines 2006 WA Health Silver Book 2006 Stamm Chap 32 Sexually Transmitted Diseases, 4th Ed, McGraw-Hill, 2008

18. In studies in WA, UK & US this has been shown to be both highly acceptable to women & highly sensitive for the diagnosis of genital CT infection Self obtained lowvaginal swab (SOLVS) Garrow Sex Trans Inf 2002 Gaydos Sexual Health 2006 Langille Can J PH 2008 Doshi Int J STD AIDS 2008

19. The case for practitioner initiated testing in general practice • Nearly 90% ♀ & 70% ♂ 15-24 yrs visit GP each year • 59%–70% ♀ 16–39 yrs have Pap test every 2 yrs, but • Only ~ 7% of ♀ 15-25 yrs tested for CT each year • Medicare Benefits Schedule does permit screening for CT among sexually active young people • RACGP Guidelines for preventive activities in general practice (“The Red Book”) recommends testing all sexually active ♀ < 25 years annually for CT Hocking MJA 2008 Fairley MJA 2005 Bowden MJA 2008

20. Opportunities for practitioner initiated testing • Adolescent & youth health • Antenatal screening: 1st visit & again at 36 weeks in women from endemic regions • Women’s health – Pap smear, contraception, etc. • Well men’s check • Identified risks – e.g. change of partner, etc. • On request, eg. “I’ve seen the ads” • Travel health consultations for vaccinations • Occupational health assessments Merritt Sexual Health 2007

21. Barriers to opportunistic practitioner initiated testing for CT identified by GPs • Insufficient time during standard consultation • Initiating CT test & pre-test discussion considered particularly time consuming • Difficulty raising concept of screening during unrelated consultations • Opportunities missed largely because GPs believed patients would be embarrassed • However, GPs noted that patients rarely declined testing when it was offered Merritt Sexual Health 2007 Temple-Smith BMC Family Practice 2008

22. Views of young women on practitioner initiated CT testing • Accept age-based CT screening in general practice in both sexual-health & non-sexual-health related consultations; trust in GP and practice nurse is major factor • Prefer screening to be offered to all young ♀ rather than targeted at "high risk" women based on sexual history • CT screening needs to be normalised & destigmatised Pavlin BMC Infectious Diseases 2008

23. Asking the question “Are you sexually active?” “We are offering a chlamydia test to all sexually active 15–25 year olds, would you like a test?” “Have you had a change of partner in the last 12 months? (or since your last Pap smear/chlamydia test?)” “Can I just check, is your partner male or female?” “Do you use condoms – always, usually, sometimes?”

24. Case study 1

25. The WA Health Notification Form

26. 99% of GPs in WA know that CT is notifiable, but only 85% state they would always complete a notification form Temple-Smith BMC Family Practice 2008

27. Most GPs believe that ticking this box in section 3 of the WA Health notification form means that WA Health will undertake contact tracing for the case of CT notified CT Partner Notification Project WA GP Key Informant Interviews 2008

28. What really happens? • 7,743 CT notifications in WA 2007 – impossible for DoH to follow up this number of cases • CT cases actively followed up by disease control nurses in Perth are in pregnant ♀, those < 14 yrs & those who acquired infection overseas only • Contact tracers focus on cases of HIV, syphilis & gonorrhoea which are higher priority • Currently very little capacity for contact tracing for CT by DoH in Perth Lisa Bastian, Kellie Kwan WA Health

29. Changes to the Notification Form to increase the role of GPs in encouraging Partner Notification for chlamydia "If your patient has chlamydia, ask him/her to contact as many of their sexual partners as possible and recommend that they see a doctor for testing & treatment. For complex and/or hard to reach contacts, please contact disease control nurses for advice or assistance…."

30. Partner notification: whose job is it?

31. Clarifying terminology 1. Partner notification - patient notifies their partners / contacts • Advantages: cheap, quick; ‘the right thing to do’ • Disadvantages: needs well-informed, motivated and self-confident patient; hard to know if done; ?risk of violence or harm 2. Contact tracing - primary care provider notifies contacts • Advantages: confidentiality, know if it is done • Disadvantages: can be time-consuming, expensive 3. Contact tracing can also be referred to Public Health Unit • Resources are limited • Many CT contacts are not followed up, esp. metro are Australasian Contact Tracing Manual 2006 p.7 WA Guidelines for Managing Sexually Transmitted Infections p.60

32. Partner notification matters! • The role of GPs and practice nurses to encourage the patient to notify the partner is vital • Encouraging partner notification prevents patients who have been treated from getting the infection back again & needing re-treatment • Reduces risk of complications for their partner • Prevents spread of infection in the community • The patient survey conducted to inform this project showed that patients are generally very good at contacting their partners to inform about the risk of infection ASHM, Partner Notification for chlamydia patient survey 2008

33. Partner notification in general practice in 3 simple steps • Encourage patient to inform current and most recent partners/contacts about high risk of infection • Advise most people with CT don’t know they have it as it is asymptomatic in most • Offer the patient a chlamydia fact sheet to give to their partner/s Remember! Partner notification is voluntary & confidential

34. Partner notification in general practice in 3 simple steps cont. For details about the Western Australia Partner Notification for Chlamydia Project and Resources please go to: http://www.ashm.org.au/partnernotification

35. The case for referral WA Health disease control nurses can be contacted to assist with particularly complex cases, for example: • patient not treated and practice unable to contact • patient requires assistance with contact tracing • at risk patient

36. Initiatives to assist CT screening & partner notification in general practice • Chlamydia fact sheets for general practice & patients/partners • Partner notification training for practice nurses • Link on the lab report of positive CT tests providing the notifying doctor with a website containing CT treatment guidelines, client brochure & a printable letter for index cases to pass on to exposed sexual partnerhttp://www.couldihaveit.com.au/professionals.asp • A new campaign in 2009 promoting CT screening in the community Merritt Sexual Health 2007 Temple-Smith BMC Family Practice 2008

37. Practice nurses (PNs) in partner notification • PNs well placed to take enhanced role in partner notification due to time constraints facing GPs • PNs may require initial training, but costs recouped over time as it becomes part of routine practice • Patients may be more comfortable discussing sexual history & partner notification with PN than with a GP • Patients more comfortable discussing partner notification with GP or PN immediately after Dx as opposed to being referred to a Sexual Health clinic Low BMJ 2005

38. NEXT STEPS

39. Managing new CT Dx in general practice • Azithromycin 1g orally stat • Advise no sexual contact for 7 days • Discuss risk of re-infection/complications • Offer examination and/or tests for other STIs • Advise patient to notify sexual partners in last 6 months – use common sense with this • Educate & provide a copy of chlamydia fact sheet for patient/partner • Safe sex practices – consistent condom use • Emphasise need for follow up & retesting in 3 months Australasian Contact Tracing Manual 2006 US CDC Guidelines 2006, BASHH Guidelines 2006

40. Managing contacts of CT in general practice • Azithromycin 1g orally stat without waiting for test results • Advise no sexual contact for 7 days • Discuss risk of re-infection/complications • Offer examination and/or tests for other STIs • Educate & provide a copy of the Chlamydia fact sheet for patient/partner • Safe sex practices – consistent condom use • Emphasise need for follow up Confidentiality of index case must be maintained! Australasian Contact Tracing Manual 2006 BASHH Guidelines 2006

41. Case study 2

42. Phone numbers for advice Public Sexual Health Clinics • Royal Perth Hospital (08) 9224 2178 • KEM Hospital, Subiaco (08) 9340 1383/1014 • Fremantle Hospital (08) 9431 2149 • Mainly Men Clinic, Fremantle (08) 9430 4544 • Kalgoorlie-Boulder (08) 9080 8200 • Mandurah (08) 9534 8943 • Rockingham (08) 9527 7464 Population/Public Health Units • North Metropolitan Area Health Service (08) 9380 7749 / 7748 • South Metropolitan Area Health Service (08) 9431 0230 • Geraldton (08) 9956 1965/1985 • Albany (08) 9842 7500/7525 • Kalgoorlie-Boulder (08) 9080 8200 • Broome (08) 9194 1630 • Northam (08) 9622 4320 • Bunbury (08) 9781 2350/2500 • Carnarvon (08) 9941 0560 / 0570 • South Hedland (08) 9172 0250 / 8333

43. FURTHER INFORMATION ‘Silver Book’ = Guidelines for Managing Sexually Transmitted Infections - A guide for primary health care providers (2009) • Copies available free from Sexual Health and Blood-borne Virus Program, (08) 9388 4999, email cdc@health.wa.gov.au • OR download from www.public.health.wa.gov.au/3/634/3/guidelines_for_.pm Online resources WA Chlamydia campaign website: http://www.couldihaveit.com.au/professionals.asp

44. FURTHER INFORMATION Australasian Contact Tracing Manual 2006http://www.ashm.org.au/contact-tracing/ Think GP Active Learning Module on Sexual Health http://www.thinkgp.com.au/

45. WA Health: Lisa Bastian Lynda Blum Kellie Kwan Sue Laing Donna Mak Family Planning WA Robyn Wansbrough Dr Alison Creagh Sexual Health Physicians: A/Prof Katherine Brown Dr Marcus Chen Dr Damian Conway Dr Debbie Couldwell Prof Basil Donovan Dr Christine Dykstra Dr Lewis Marshall Dr Jenny McCloskey Dr Anna McNulty Dr Catriona Ooi Dr Cathy Pell Acknowledgements

46. Dr. Angela Cooney Dr. Sarah Cox Dr. Debbie McKay Dr. Stephen Hodby Dr. Bede Rogers Dr. Steven Wilson Dr. Daniel Leahy Dr. Alison Creagh Dr. Kim Jackman Dr. Ben Bradstreet Rosemarie Windsor Dr Simona Achitei (Project Coordinator) Dr Damian Conway (developing slide set) ASHM Team And the 28 GPs and practice nurses who participated in the course pilot Acknowledgements

47. WA Chlamydia Partner Notification Project Reference Committee. Please note this is not an exhaustive list of members as some committee members have previously been acknowledged: Rosemary Mcguckin David Hides Craig Szucs Terry Pitsikis Dr Ric Chaney Levinia Crooks Ann Larsen Acknowledgements

48. Any questions?