Examination of Witnesses (Questions 280-299)|
WEDNESDAY 17 JULY 2002
280. Dr Tobin, you have been taking part in
one of the pilot studies in Portsmouth. Is there anything you
would like to add to the debate so far as to what you found or
where you go from here?
(Dr Tobin) The results have not yet been published,
so they are not generally available, although a lot of them are
known. We have already heard that this was an opportunistic screening
for chlamydia in Portsmouth and The Wirral and it lasted one year
from September 1999 to August 2000. We were trying to screen people
mostly in primary care. General practice produced 70 per cent
of our positive tests and after that the remaining were from girls
attending family planning clinics, GU medicine and termination
of pregnancy clinics.We also did a small amount of work in gynaecology
out-patients. The target group was sexually active women, aged
between 16 and 25 and we screened some men but they were only
men who attended GU medicine and youth clinics. We also screened
some of the under 16s if they attended for sexual health reasons,
but not otherwise. To give you some idea of the scale of this,
it was thought that in Portsmouth there were 26,000 sexually active
women in that age group and about 13,000 in The Wirral. The result
at the end of the year was that in Portsmouth we had tested 50
per cent of those women and in The Wirral we had tested 40 per
cent. We discovered that about 80 per cent of the target group
attended their general practitioner at some point during that
year so they were available to be offered a test. One of the main
things about the chlamydia pilot was whether people would accept
the test. Were they prepared to be screened for a sexually transmitted
infection which had not been tried in our population at large
before? We found they were very keen to be tested. The acceptance
rate in Portsmouth was 76 per cent and 84 per cent in The Wirral.
In Portsmouth we had major problems because we were overwhelmed
with specimens as so many people wanted to be tested. The highest
acceptance rate was in GU medicine, which is understandable. We
had about a 98 p seemed very odd and it was down to a level of
38 per cent in one of the TOP clinics. When we enquired as to
why these people had not accepted a simple urine test for chlamydia,
it was mostly because they had already been screened elsewhere
or they could not produce a specimen of urine. The overall feeling
was that people were very willing to have this test performed
because it was no longer an invasive test. Our findings were that
overall ten per cent of the population targetted were positive
and most of those came from primary care. Our highest rate was
in the youth clinics, where 17 per cent were found to be positive.
Our antenatal clinic rate was ten per cent. Previously chlamydia
had not been deemed a problem in antenatal women. We also found
that if somebody was screened just once during the year the overall
rate was 8.3 per cent, but if they came back and wanted to be
screened again, usually in terms of partner change, the rates
shot up to 27 per cent positivity in Portsmouth and 30 per cent
in The Wirral. Those people were perhaps opting in, realising
that they were at increased risk. We have been talking about sensitivity
of the test and we have some very interesting figures on those
tests. We were able to use LCR , a DNA technique and, a very sensitive
test. In GU medicine, we double screened everyone. We used our
other test, an ELISA technique which is the standard test still
in GU medicine clinics in this country, with only ten per cent
haveing the extra sensitive tests. We found that using the ELISA
test we would have missed 30 per cent of our women and 46 per
cent of our men had we been relying on this test alone which is
in standard use in this country. That was a very significant finding.
We had been worried that having found that somebody was positive
for chlamydia they might not be prepared to come back to be treated.
The treatment rates were 98 per cent and 92 per cent in the two
sites, so these were highly motivated people.
281. Were partners treated as well?
(Dr Tobin) Yes. We did contact tracing. There were
better results with contact tracing if patients were seen in GU
medicine clinics. Overall, for traceable partners, we had a rate
of around 80 per cent of those being seen. The rate was lower
if contact tracing was attempted outside GU medicine clinics.
282. When are the results going to be fully
(Dr Tobin) They have been submitted for publication.
They have not at this moment been accepted but we hope they will
be within the next week.
283. The government is planning a further ten
sites. Do you think this is enough or should we be pressing for
(Dr Tobin) Those involved in the chlamydia screening
saw what an enormous problem it was because the figures were almost
twice as high as we anticipated. We rather hoped we might go straight
on to a general role-out of the chlamydia screening programme
nationwide. It is going to take a while to roll out the programme,
anyway but I would much rather that than just another ten sites
and expanding very slowly afterwards, because an awful lot of
people are going to be able to get an asymptomatic infection during
284. What about the costs of this because there
will be a cost implementation of national screening. Are you able
to put a figure on that?
(Dr Tobin) I cannot. It depends entirely what is going
to be included in a screening programme. The costs of the tests
and the treatment are very easy to estimate but we are going to
have a look at partner notification and partner treatments also-as
well as possible screening for other STIs. I cannot tell you what
I think that figure will be. I think the Department of Health
has a fairly good idea. It has tried to cost this.
285. I wondered if the sort of figures you were
reaching were the percentage figures you need to reach in order
to get the disease down to not being a problem. You say Sweden
has had success. I cannot remember the percentage but in public
health terms is that sufficient to get a grip on the problem of
(Professor Johnson) You will only get a grip on the
problem if this is true across the country, with these very high
prevalences, by opportunistic screeningi.e., trying to
screen those at highest risk. A 10 per cent prevalence I would
regard as very high. The only way we can get that down is by ensuring
that we are identifying people, treating them and avoiding them
becoming reinfected. This is an iterative process because the
more chlamydia is out there the more likely you are to catch it
if you have unprotected sex with a new partner. The aim of the
public health programmes is to try and keep one step ahead of
the curve and drive down the case reproduction number. That is,
the number of new cases that an infected person transmits their
infection onto. If you can drive that down so on average one person
does not go on to infect at least one other, gradually you will
push down the level of infection in the community. As you drive
down that level of infection, hopefully by a concerted public
health programme to diminish the amount of infection in the community,
you will be able to change your control strategy. For example,
gonorrhea and syphilis. We see relatively little syphilis in the
population now because we have penicillin and we have control
programmes and good tests. These things are now getting pushed
into the core group of the highest activity population. At this
point in time, we are at the stage of a widespread infection in
the population and we need, therefore, to have a population-based
strategy for screening to push that prevalence down. It may be
that if we are successful we could then change our policy to something
different once we have got the infection under control.
286. If the Department of Health did say that
they were going to go national with the pilot, as happened in
the Wirral, and concentrate on the 16-25 group, in your view would
that be enough to get us one step ahead or not?
(Professor Johnson) That depends on being able to
identify a sufficiently high proportion of those that are infected
and getting sufficient numbers of people in to be screened. I
think Dr Tobin has suggested 75 per cent rates which are very
high levels of acceptability. One can model these issues by mathematical
methods, by saying, "if we screen this many people, will
this begin to drive down the epidemic?" I do not have those
287. Has that been done?
(Dr Tobin) We have one major problem. At this moment
we do not know how often we need to offer re-screening to the
target population. There is a study being undertaken in Portsmouth
and Wirral to look at that, but we are not going to have those
figures for a couple of years.
288. We cannot do modelling until we have done
(Professor Johnson) We can. There are cost-effectiveness
studies, which you may have at your fingertips but I do not.
(Dr Hughes) The study looking at infection rates is
something we look at to refine the opportunistic screening model
to make it more effective and efficient. I would not think it
was a reason to postpone screening now because I think we have
established that there is a big enough problem, that there is
a lot of untreated infection.
289. My question is whether that is enough.
Is the way it has been done enough to get to the problem, now
that it has been done in Portsmouth and the Wirral, or will we
still not be a step ahead and need to have a wider focus on younger
people and so on?
290. What have the Swedes done that we have
(Professor Johnson) Again, I do not have all the detail.
My understanding, which is a broad understanding, is that the
Swedes have taken an opportunistic approach for a number of sexually
transmitted diseases. The studies I am thinking of are those that
are population-based associations where , once they have introduced
screening, they have looked at their chlamydia rates and then
they have also looked at their pelvic inflammatory disease rates
and noted that those have been coming down at the same time as
their chlamydia rates have come down. They have done a lot of
opportunistic testing for STDs across a number of services. We
would have to look at those in detail. Their gonorrhoea rates
are particularly low, but I think they have tried to screen across
a number of services for STDs. They also have very good and quite
firm partner-notification systems. Dr Fenton may know more about
them. A note of caution: as we have said with the education programmes,
one needs to be constantly vigilant because if behaviours change,
some of these things re-emerge and many countries are seeing the
same problem of re-emergence of STDs.
(Dr Fenton) On the comprehensive nature of the prevention
of control programme in Scandinavia, it is not just about screening.
It starts with sex education in schools and preparing young children
about STIs and chlamydia, straight through to professionals, through
to screening programmes. It is a comprehensive package and not
just a shot in the arm.
291. Dr Cassell mentioned the particular importance
of education in schools. Do you have a view as to who is best
positioned to carry out that education, and is that resource there?
School nurses were mentioned in part of you answer. Do you see
school nurses as the key?
(Dr Cassell) There needs to be close liaison between
health professionals and school staff as to who, and at what age,
in whatever context, should be providing that education, and that
will be constantly under review. Clearly, it is important that
there is a link between the education provision, which may be
provided to some extent by teachers, and the clinical provision
within the schools. I think that is not something that one can
take a comprehensive view about.
292. You mentioned schools and the health side.
You have not mentioned parents. What role is there for parents,
and who do you think are the most important of the groups to provide
the impetus, or should it be a combination of all three?
(Dr Cassell) I think that Professor Johnson might
like to comment on recent findings of Natsal-2 survey in relation
to that. Clearly, parents have an important role in preparing
their children emotionally and morally for their future sexual
life, and that is clearly important and has shown to be important
in reducing risk of sexual intercourse for example. There is also
evidence that having information from school is associated with
reduced risk. That second point, that school education does not
lead to (inaudible) onsetthe evidence for that is the basis
on which the recommendation for school-based sex STI education
across all the spectrum of diseases was recommended in the BMA
293. Given that sex education in schools is
a highly emotive subject, rightly or wrongly, and given that there
is a group of parents who strenuously object to the thought of
their children receiving sex education- and probably the younger
the sex education starts the more parents it might involvehow
do you get the message across to parents that maybe there is a
role in schools with the health side of the equation as well,
working together to educate young people to try to minimise problems?
(Dr Cassell) We do not take a particular view on that
in this report because, clearly, its purpose is to raise the issue
of sexually-transmitted infections. There are other BMA reports
that have addressed this issue. It clearly runs right through
any education through schooling and it is a general problem with
education. It is clear that we would not be wishing to discourage
parental involvement but to ensure the best possible outcomes.
294. How do you think one can persuade those
parents who will not be very keen on sex education in schools,
that maybe there is an alternative beneficial way forward?
(Dr Cassell) As the representative of the BMA today
and this report, I would not like to make up an answer to that.
I am sure they would be happy to respond at length to that, but
it would be unwise of me to come up with an answer I might not
wish to defend at a later stage.
295. You said, Dr Cassell, that there is evidence
that access to good sex education in schools leaves children able
to make better choices. We heard last week from the Family Planning
Association, which caused some concern, myself included, that
sex education should begin in primary schools. What would you
say to that? It seems to me that there is a balance to be struck
here. Clearly, you can start too early. They were talking about
four and five-year olds. Is that too young? You said there was
(Dr Cassell) I do not particularly want to answer
Dr Maysmith: It is not the unanimous view of
Mr Burns: Let us not start arguing in public.
Andy Burnham: It is an interesting issue because
it is something that does not happen here.
296. At what age should we start raising these
things with children?
(Dr Hughes) To turn it on its head, what you can say
that from information in studies we have done, the risk of sexually-transmitted
infections is high in teenagers, and that that is the age with
the highest rate, so you certainly need to get to them before
they are teenagers. We did a study where we looked at how quickly
people came back with a sexually-transmitted infection and we
found that the highest rates were young teenagers, aged 12-15.
So if they had gonorrhoea, a quarter of them came back within
a year with another episode of gonorrhoea. I think you have to
recognise that they are an "at risk" group, and very
young age groups.
297. Quite clearly, it should be before 12,
but how much before 12?
(Dr Fenton) There are other issues here. What do we
mean by "sex education"? It may well be that at different
ages children will be more responsive to different types of education
about relationships and interaction between men and women, boys
and girls; and there are key life skills that are appropriate
at each age group, as we age. The qualitative work that we have
been doing at University College, London, and the Natsal survey,
suggest that young people do want to hear from their parents about
sex and sexual intercourse and sexual relationships. Unfortunately,
the reality is that most kids only learn about sex in schools
or from their peers in the school grounds. We also know from Natsalthe
first national survey on attitudes and lifestylesthat the
quality of sex education is going to be a key determinant of the
way you begin having sex and your happiness, your comfort with
the type of sexual relationships you have. This all argues towards
starting sex education earlybut also tailoring messages
so that they are appropriate for the particular age. Finally,
there is working with parents. Again, some of the qualitative
work suggests that the reasons why parents do not speak to their
children about sex is that they are embarrassed and feel ashamed
to talk about sex, or they simply do not have the skills to talk
about sex with their kids, because their parents did not speak
to them about it. The innovative work currently among African
communities is to help the workers to work with African parents,
to talk about HIV with their children and to get them to begin
to open the discussion and discourse around sexual health. There
are many facets to it, and it is not just about sex education;
there are other aspects of looking at relationships and life and
298. We wanted to ask a couple of questions
about genital warts. Now is the time to decide who is expert on
that! There is probably no dispute that there is an alarming growth
in the incidence of genital warts, but there is a little bit of
a difference in whether people think that is serious or not in
the quote from the BMA Board on Science and Education, where it
states that it is "little more than a cosmetic nuisance";
yet we know that the viruses of the type that cause genital warts
are associated with cancer. How serious a problem are genital
(Dr Hughes) In terms of diagnosis, they are the most
common diagnosis at the moment in GUM clinics; and chlamydia is
catching up. They are believed to be incredibly common infections.
As we said, they are caused by the human papilloma virus. The
types of virus that cause the warts are not usually the same types
as associated with cervical cancer.
299. There is some evidence that some of them
(Dr Hughes) Yes, other types of human papilloma virus,
which are also sexually transmitted, are