Select Committee on Health Appendices to the Minutes of Evidence

Attachment 3



  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.


  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.


  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.


  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.


  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.


  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.


  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.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2001
Prepared 28 March 2001