Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 280-299)



  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 available?
  (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 nation-wide provision?
  (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 that time.

  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.

Julia Drown

  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 chlamydia?
  (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 screening—i.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 re-screening.
  (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?

John Austin

  290. What have the Swedes done that we have not done?
  (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.

Mr Burns

  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) onset—the 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 report.

  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 involve—how 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.

Andy Burnham

  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 evidence.
  (Dr Cassell) I do not particularly want to answer that first.

  Dr Maysmith: It is not the unanimous view of this Committee.

  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.

Jim Dowd

  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 Natsal—the first national survey on attitudes and lifestyles—that 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 early—but 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 respect.

Dr Naysmith

  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 warts?
  (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 are.
  (Dr Hughes) Yes, other types of human papilloma virus, which are also sexually transmitted, are—

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