Attachment 3
INFERTILITY AND OTHER REPRODUCTIVE ILL-HEALTH
IN WOMEN DUE TO GENITAL CHLAMYDIA TRACHOMATIS INFECTION
PUBLIC HEALTH
IMPORTANCE
Chlamydia trachomatis infection is the
most common curable bacterial sexually transmitted infection (STI)
in England and is widespread in the younger sexually active population.
Recent data suggest that at least one in 14 sexually active women
between the ages of 16 and 24 years attending general practice
have this infection. It is usually asymptomatic and, in the absence
of treatment, a proportion of infected women (10 to 40 per cent)
develop pelvic inflammatory disease (PID) which in turn can lead
to ectopic pregnancy, tubal factor infertility, chronic abdominal
pain and ill health. Complications of infection have a high cost
on an individual level and the public health significance is predominantly
associated with the high economic cost of treatment and management
of these complications. Since 1988, the number of diagnoses of
IC-ROM seen in genitourinary medicine (GUM) clinics (also called
STD clinics) in England has risen by nearly 70 per cent from around
30,000 to 51,000 in 1999. Although there is increased professional
awareness of this infection, GUM clinics remain the only clinical
setting that undertakes any systematic screening. It is estimated
that less than 10 per cent of prevalent infections are diagnosed
at GUM clinics, thus substantial numbers are undetected and remain
at risk of developing severe complications. Chlamydial PID is
estimated to be the cause of nearly 30 per cent of all cases of
infertility and 40 per cent of cases of ectopic pregnancy. There
are important inequalities associated with infection. Infection
rates are highest in the younger sexually active population (16
to 19 year old females and 20 to 24 year old males) and in men
and women of Black Caribbean or African ethnicity.
POTENTIAL HEALTH
GAIN AND
THE DANGERS
OF NOT
ACTING
Infection is easily treated with readily available
antibiotics, if it is recognised. As the majority of cases are
asymptomatic, there is considerable potential for earlier detection
and treatment through screening. Screening programmes for chlamydial
infection in Sweden and the USA have demonstrated significant
reductions in the prevalence of genital tract infections and PID
cases. In the UK, health economic analyses have suggested that
screening will be cost-effective. As cases of infection are continuing
to rise, the reproductive health of women will deteriorate and
numbers of cases of infertility will rise unless measures are
taken, placing an increasing burden on health service resources.
IMPORTANT PLAYERS
AND CURRENT
ORGANISATIONAL ARRANGEMENTS
The Chief Medical Officer recently convened
an Expert Advisory Group (which included members of the PHLS)
on genital chlamydial infection. In the light of its conclusions,
the Department of Health, with advice from the National Screening
Committee, has funded a pilot of IC-ROM screening in two sites
in England (Wirral and Portsmouth). The PHLS co-ordinates the
analyses of data and all associated microbiological testing. Other
key agencies involved include primary care groups/trusts, family
planning (FP) clinics, GUM clinics, the British Pregnancy Advisory
Service, women's services in hospitals and other charitable and
voluntary agencies who target hard to reach groups such as adolescents
and drug users. Outwith the pilot, current interventions are limited
to screening in GUM clinics (where cases and their partners are
treated) and occasional screening of symptomatic women attending
GPs or FP clinics. In addition, the Royal College of Obstetrics
and Gynaecology has recommended screening and treatment of all
women presenting for termination of pregnancy (to reduce the risk
of ascending infection). However, as there is no national policy
on this issue, this practice has not been implemented in all clinics.
A large consortium, funded by the National Co-ordinating Centre
for Health Technology Assessment and based in Bristol and Birmingham,
has just started research into several methodological questions
raised by screening including best diagnostic test, partner notification
method and outcome measure. The local Public Health Laboratories
and the PHLS Genitourinary Infections Reference Laboratory are
active participants in this consortium.
CURRENT ORGANISATION
ISSUES/DIFFICULTIES
Although GPs and FP clinics are ideally placed
to detect cases, the lack of clear guidance, education initiatives
to raise professional awareness and the lack of funding for testing,
currently limit active case finding in these settings. In addition,
successful partner notification (contacting and treating sexual
partners) is essential to prevent re-infection; this requires
specially trained health advisors and is usually undertaken only
at GUM clinics. Clear local leadership is required to co-ordinate
testing across these different health care settings. Public education
campaigns to raise awareness in the sexually active population,
particularly the younger age groups, are also essential.
POTENTIAL SOLUTIONS
The initiation of a nation-wide screening programme
with close collaboration between primary and secondary health
care settings would provide a suitable model for care. Adequate
case detection, successful partner notification, and meeting the
cost of testing are the main issues to be addressed. The results
from the pilot will be evaluated this autumn and will be incorporated
in the Government's Sexual Health and Communicable Disease Strategies.
CONCLUSIONS
Interventions to reduce chlamydial prevalence
and prevent damaging consequences for women are necessary and
likely to be cost effective. Such interventions should involve
the encouragement of behavioural risk reduction and the introduction
of active case finding through screening in primary and secondary
health care settings. The role of the PHLS encompasses both surveillance
and microbiological R&D. Key roles of the PHLS are to develop
and deliver sensitive and cost-effective testing methods, monitor
outcomes, particularly ectopic pregnancies and PID and to develop
cost/benefit analyses to evaluate the programme efficacy.
REFERENCE
Chief Medical Officer's Expert Advisory Group.
Main report of the CMO's Expert Advisory Group on Chlamydia
trachomatis. London: Department of Health, 1998.
Prepared by Drs Jeanne Pimenta, Alan Herring
and Mike Catchpole; Public Health Laboratory Service.
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