An update on the National Chlamydia Screening Programme

1. An update on the National Chlamydia Screening Programme Wednesday 13 March, 2013 London

2. Welcome Dr. Paul Cosford Director for Health Protection and Medical Director, Public Health England Deputy Chief Executive, Health Protection Agency

3. Overview of the National Chlamydia Screening Programme – challenges, successes and future direction Kate Folkard NCSP Programme Manager kate.folkard@hpa.org.uk

4. The National Chlamydia Screening Programme (NCSP) in England • Aims to control chlamydia thus reducing transmission and sequelae • Opportunistic screening of sexually active < 25 year olds • Annually • Change of sexual partner • Clinical and non-clinical venues • Routine offer at every consultation • Standards for treatment and partner notification

5. The NCSP: achievements to date • High volumes screened - deliver around 2 million tests and 150,000 diagnoses per year • Expansion of sexual health services into community with range of providers • Early adoption of new technologies • Quality assurance programme • Involvement of men • Reaching those at higher risk and the socio-economically deprived

6. What are young people’s views? • Don’t always see chlamydia as relevant to them • Prefer a blanket approach to testing • Want to be asked rather than have to ask for a test • Don’t want to have to give a sexual history • Need to be sure of confidentiality • Want options – healthcare professional/ ’virtual’ testing • Want results quickly • Want support to be available to manage positive results Chlamydia Screening and Sexual Health Marketing – COI for DH. Define, 2008

7. Roles and responsibilities

8. Trends in chlamydia screening: the impact of transition? Decline in screening activity: • Drop in test volume and diagnoses over 2011/12 • National diagnosis rate: 1,850 per 100,000 (Jul-Sep’12) Advice to local areas: • Maintain sufficient investment in screening • Integrate screening within primary care, SRH and GUM services (& reduce outreach) • Ensure repeat screening annually/change of partner • Achieve PN standards

9. Future direction of the programme • Emphasis on integration and delivery models; embed within primary care, SRH and GUM services • Deliver synergies with young adults’ sexual health interventions such as contraceptive advice, condom use and wider health promotion • Chlamydia Testing Activity Dataset (CTAD) • From coverage target to diagnostic indicator • Public Health Outcome Framework • Evaluation framework

10. Objectives of the day • To bring together HPA, PHE, public health and commissioning colleagues with a remit for sexual health to: • Present the latest evidence on chlamydia screening approaches and outcomes • Provide an update on recent NCSP developments and future plans • Ensure confidence in making the case for chlamydia screening at a local level • Explore ways to ensure the NCSP can deliver effectively during the transition year and beyond

11. Agenda

12. Workshop Session: Delivering the NCSP during the transition 30 minute facilitated discussion around three questions: • What are the priorities for the NCSP over the next two years? What do you want to deliver locally? • What support do you need from NCSP nationally to deliver? • Who is going to help you deliver at a local level / what are your new emerging local network?

13. The chlamydia screening evidence base – overview Kate Soldan kate.soldan@hpa.org.uk

14. Chlamydia trachomatis • Common sexually transmitted infection • Majority of infections are asymptomatic • Highest rates of infection among young people • Easy to detect using NAAT tests • Easy to treat with antibiotics Chlamydia infected culture (Wellcome Images)

15. Rationale for chlamydia screening • Chlamydia infection is a known risk factor for a number of serious health problems: • Pelvic inflammatory disease • Ectopic pregnancy • Tubal factor infertility • Neonatal pneumonia and neonatal conjunctivitis • Epididymitis in men • Treating chlamydia infections prevents the development of sequelae • RCT showed 83% reduction in PID among treated compared to untreated chlamydia infection (p>0.05)[1] [1] Oakeshott et al. BMJ 2010;340:c1642

16. Rationale for chlamydia screening • Asymptomatic screening to detect chlamydia trachomatis should: • Reduce the prevalence and incidence of infection • Reduce the risk of developing health problems

17. What do we want to know? • Impact of widespread screening for asymptomatic chlamydia infections on • Prevalence and incidence of chlamydia • The incidence of complications • Young adults’ sexual health and wellbeing • The predicted impact • The impact in practice

18. What do we want to know? • Optimal models of service delivery • Partner notification • Testing frequency • Testing the right people • Sustainable service configuration • Cost effectiveness

19. The evidence base on outcomes of chlamydia screening

20. Reducing transmission and prevalence Sarah Woodhall sarah.woodhall@hpa.org.uk

21. How should chlamydia screening affect prevalence and incidence? • Asymptomatic screening to detect chlamydia trachomatis (plus subsequent partner notification) should: • Reduce prevalence of infection by removing cases from the pool of infections • Identify infections earlier in the course of infection • Reduce incidence of infection by preventing onward transmission to sexual partners

22. Natural course of chlamydia infection End of infection without screening Infection Natural clearance Develop symptoms/complications, treated

23. Screening reduces the duration of infection End of infection without screening End of infection with screening Infection Natural clearance Develop symptoms/complications, treated Screening test

24. Chlamydia screening can prevent transmission End of infection without screening Infection Natural clearance Develop symptoms/complications, treated Chlamydia passed on to sexual partner

25. Chlamydia screening can prevent transmission End of infection without screening End of infection with screening Infection Natural clearance Develop symptoms/complications, treated Screening test Chlamydia not passed on to sexual partner

26. What do we know about the impact of chlamydia screening on prevalence and transmission in practice? • Mathematical modelling • Randomised controlled trials • Analysis of routinely collected data • Prevalence surveys

27. What do we know about the impact of chlamydia screening on prevalence and transmission in practice? • Mathematical modelling • Randomised controlled trials • Analysis of routinely collected data • Prevalence surveys

28. Chlamydia prevalence among 16-24 year olds: Modelling the effectiveness of screening Testing coverage: 9% Chlamydia prevalence (%) Testing coverage: 26% Testing coverage: 43% Years after introduction of the screening programme Key assumptions: Baseline prevalence 6.5%; PN 20%; few cases treated in absence of screening programme NAO, 2009. Based on: Turner et al. STI 2006

29. What do we know about the impact of chlamydia screening on prevalence and transmission in practice? • Mathematical modelling • Randomised controlled trials • Analysis of routinely collected data • Prevalence surveys

30. Randomised controlled trial of chlamydia screening, Netherlands • RCT among >300,000 16-29 year old men and women • Annual postal invitation to chlamydia screening for 3 years • Lower than expected uptake (10% -16%) • No significant fall in prevalence was observed • some evidence for a fall in South Limburg Van den Broek et al. BMJ 2012

31. Ongoing randomised controlled trials of chlamydia screening • Australia • The Australian Chlamydia Control Effectiveness Pilot (www.accept.org.au) • Randomised controlled trial of chlamydia screening in primary care. • Finland • Cluster randomised controlled trial as part of an HPV vaccine trial

32. What do we know about the impact of chlamydia screening on prevalence and transmission in practice? • Mathematical modelling • Randomised controlled trials • Analysis of routinely collected data • Prevalence surveys

33. Chlamydia diagnosis rate (per 100,000 pys), 15-24 year old females GUM diagnoses represent uncomplicated CT; NNNG (Non-NCSP, non-GUM) diagnoses available from April 2008 onwards. GUM data as at Feb 2013; NCSP/NNNG data as at November 2012

34. Number of tests and proportion testing positive by gender (NCSP tests)

35. Number of tests and proportion testing positive by gender (NCSP tests)

36. What do we know about the impact of chlamydia screening on prevalence and transmission in practice? • Mathematical modelling • Randomised controlled trials • Analysis of routinely collected data • Prevalence surveys

37. Population based prevalence surveys • United States • National Health and Nutrition Examination Survey • Includes urine test for chlamydia • UK • National Surveys of Sexual Attitudes and Lifestyles • Chlamydia prevalence in 2000 and ~2010 • Comparability between survey years limited • Pilot postal survey among young women conducted in 2 PCTs in 2011[1] • Low response rate, therefore open to substantial bias • Unlikely to be a feasible or appropriate method of monitoring prevalence over time [1]Woodhall et al, Under review

38. Summary • In the absence of changes in any other risk factors, chlamydia screening should reduce the prevalence and incidence of chlamydia • Mathematical modelling and routine data are consistent with a fall in chlamydia prevalence in recent years • No empirical evidence to demonstrate a fall in prevalence • Changes in chlamydia in the context of testing and trends in other STI will become more informative in the future

39. Preventing sequelae Kate Soldan kate.soldan@hpa.org.uk

40. Chlamydia is an important cause of reproductive health problems in women Ectopic Pregnancy 7.6% Pelvic Inflammatory Disease 1% / 10% / 30% Chlamydia infection 10.8% Tubal Factor Infertility Source: Adams et al. STI 2007; 83;267-275

41. Chlamydia is an important cause of reproductive health problems in women • ~10% to 20% risk of developing PID after a chlamydia infection[1,2] • ~45% of tubal factor infertility is caused by chlamydia[3] [1] Oakeshott et al. BMJ 2010;340:c1642; [2] Price et al. Am J Epi. In press; [3] Price STD 2012;39(8)

42. Can chlamydia screening prevent PID? Chlamydia screen PID PID Chlamydia infection PID prevented PID not prevented

43. Can chlamydia screening prevent PID? • Synthesis of published studies has estimated that • ~41% to 61% of chlamydia-related ‘PID’ can be prevented by annual screening[2] • Three randomised controlled trials have evaluated the effect of a single round of chlamydia screening on PID 1 year later [2] Price et al. Am J Epi. In press

44. Can chlamydia screening prevent ‘PID’? [4] Scholes NEJM:1996;334:1362-6; [5] Ostergaard CID:2000;31:951–7; [6] Oakeshott BMJ:2010;340:c1642

45. Rate of PID diagnoses in General Practice by definition (Females 16 to 44 years old) Source: French et al. STD 2011: 38(3):158-62

46. Rate of PID diagnoses* in General Practice by age group (Females 16 to 44 years old) *Definite/probable PID diagnoses Source: French et al. STD 2011: 38(3):158-62

47. Summary • Asymptomatic screening to detect chlamydia trachomatis can prevent the subsequent development of sequelae • The proportion of PID and ectopic pregnancy episodes that can be prevented by screening depends on • levels of screening • natural history of infection

48. NCSP web survey 2012 –Attitudes to chlamydia screening and subsequent impact on behaviour Chlamydia Operations Group 13 Mar 2013 Tom Hartney, Paula Baraitser, Anthony Nardone Sexual Health Promotions Team thomas.hartney@hpa.org.uk

49. Web survey background • Little data on attitudes of young people to chlamydia screening • Qualitative study reported generally positive attitudes1 • Little information on impact of screening on subsequent behaviour. Self-reported changes in sexual behaviour following a positive result for STIs: • Increase of condom use post-treatment for STIs2,3. • Decrease in sexual partners2 1 Hogan et al 2010; 2 Sznitman et al 2009; 3 Fortenberry et al 2002

50. Aims • Aim: to inform the development of the NCSP through a survey of young people, both tested and non-tested. • What are young people’s attitudes towards chlamydia and chlamydia testing? • What impact does being tested have on future behaviour?