Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 260-279)

DR GWENDA HUGHES, DR KEVIN FENTON, PROFESSOR ANNE JOHNSON, DR JACKIE CASSELL AND DR JEAN TOBIN

WEDNESDAY 17 JULY 2002

  260. You spoke earlier about some determinants of STI transmission. Is there anything else you want to add in terms of predetermined STI transmission, Dr Fenton?
  (Dr Fenton) The distribution of any STI in the population is an interplay between three main things. One is the degree of infectiousness of the organism. The second is the patterns of sexual behaviour in the individual or in that society. The third is their interaction with curative health services. In groups which classically have poor access to services or have been marginalised by services, they are far more likely to have higher rates of any infectious disease or condition. We see that as well in sexually transmitted infections and HIV. Some of the groups of concern are black and ethnic minority communities in Britain, where for some infections—for example, gonorrhea—we are seeing extremely high rates in these communities, exceeding many other developed and developing countries. These are key issues that we need to be looking at. The degree of interaction with services also will play a part in uncovering STIs in the community so interventions such as contact tracing, partner notification and outreach services are going to be vital in diagnosing infections in the community.

  261. On the effectiveness of the virus, presumably is it like we see in so many parts of medicine? It is getting increasingly difficult to control things because they are becoming more easily transmittable?
  (Dr Fenton) Not necessarily. One of the benefits of working at CDSC is that you see all the STIs in a spectrum. There are some infections which are highly infectious—for example, gonorrhea—and there are those which are less infectious—for example, HIV—and because of these variations in infectivity or infectiousness we are able to look at variations in trends. For example, gonorrhea has been argued to be a very good marker for sexual behaviour change because of its very high rate of infectiousness and the need for rapid partner change for it to be transmitted in the population. It is from that level that we are looking at some of the determinants of transmission.

  262. It is not that some of them are becoming easier to transmit?
  (Dr Fenton) No.

Dr Naysmith

  263. I wonder how the recommendations in Dr Cassell's report fit in with what we have just heard.
  (Dr Cassell) Would you like me to summarise the recommendations at this stage?

  264. That would be helpful.
  (Dr Cassell) The recommendations of the report are in four main areas. One is services for sexually transmitted diseases and treatment services. Secondly, adolescent education and service provision. That includes treatment services for young people, the education and training of health professionals and the prevention of STIs. In general, we are very much in agreement with the views of CDSC as expressed by Dr Fenton and Dr Hughes. I will summarise first the recommendations on treatment services. First of all, we think there should be more facilities in genitourinary medicine sexual health clinics. We think sexual health clinics should have longer hours, more trained staff and increased funding.

  265. Is that because you think they are Cinderella services at the moment and not properly funded?
  (Dr Cassell) Cinderella services is not a term that I would particularly use. These services certainly have improved and come out as the mainstream of health services over the last year, but there is evidence that there is an increasing problem of access with far higher numbers of diagnosed infections of chlamydia and gonorrhea being seen; and also strong evidence that people find it difficult to obtain quick appointments.

  That evidence has been obtained by CDSC and through independent research.

  266. Is it true that the service is rather patchy, depending on which part of the country you are in?
  (Dr Cassell) In the context of our report, I would not like to comment in detail but I know the CDSC have done surveys that address that directly. The second recommendation is that sexual health clinics should pay increasing attention to publicity, that we should make sure that people know about us and also it would be important that services are provided outside city areas. This is particularly important in areas of the country where there is a long distance between the cities that have services. At the moment, there is no other developed service and it can be a long way to go for specialist care. The third recommendation on treatment is that risk reduction counselling—in other words, advice on safe sex, on routes of transmission—should be a standard part of management of sexually transmitted infections, whether those are managed in primary care, in sexual health services or elsewhere. The second area is specifically about services and education for adolescents. We think that there should be improvement in school sexual education and this should cover the full spectrum of sexually transmitted infections, not just HIV, because these infections are very common amongst young people. Sexual health services need to be available for all people, including young people. This means there must be increased willingness to refer on the part of school nurses, for example, and other groups who young people contact more easily in their daily lives than clinic services. We also recommend improved and targeted services—for example, drop in clinics and perhaps dedicated young people sessions in family planning clinics and such like. Our main area of concern is the lack of representation of sexually transmitted infections as a significant health problem in the media. We think the Broadcasting Standards Committee should survey this and make recommendations that this is addressed and sexuality is raised and represented in programmes targeted at young people. Thirdly, we have some recommendations for training professionals which I am sure would be in line with what has been said so far. We think there should be increased training for GPs, for all primary care staff with regard to sexual histories, the management of sexually transmitted infections and referral. There should be increased awareness of the need to maintain confidentiality in this field and to be non-judgmental. There are many standards for confidentiality both for young people and for other people and these need to be respected and known to be respected in sexual health. Services outside sexual health services need to be proactive in the prevention of infection and detection through appropriate advice. Finally, we also make some recommendations about prevention. Firstly, we think it is important that policy makers take account of rising STI prevalence and particularly its costs. This is something that members of the Association have particularly talked about. The costs of infertility, ectopic pregnancy, and pelvic inflammatory disease to the general practitioner are very little. Particularly, people should realise that there is an overlap between the risks of STIs and HIV. We think the cost effectiveness of this is something that really needs to come out into the open at the top of the agenda. Finally, partner notification. That is, making sure that a patient is enabled to tell their partner and ensure their partner's treatment, which is extremely important in cases of sexually transmitted infections because without that we risk losing control of infections for onward transmission and patients continuing to suffer complications.

  267. Would it be fair to say that there is pretty good agreement between you all and not a lot of conflict?
  (Dr Cassell) I think so.

Jim Dowd

  268. I am a Member of Parliament representing an inner south London constituency. From what I have heard so far, particularly what Dr Fenton said about infectivity, I have heard a lot about the mechanics of dealing with STIs and their consequences. We are humankind. We surely must know more now than we ever did about sexual health. Why are we suffering such a problem when we should be wiser than we were? I do not wish to sound like somebody who has just stepped off The Mayflower but rather than the mechanics of it there is the essence of promiscuity—for example, the fewer partners you have, the less risk you are likely to face in incurring STIs and related diseases.
  (Professor Johnson) We do know a great deal more about sexual behaviour in the population than we did many years ago. There have been two major surveys done in this country, unlike many other countries in the world. One of the things that we found in the recent survey which was carried out in the year 2000, and we were able to compare this with data from 1990, is that there has been an increase in the numbers of partners that people report over that recent time period. It is important to understand and to refer back to what Dr Fenton said that, in the late 1980s, we saw plummeting rates of gonorrhea and other infections in this country. That was a result of concerns about the AIDS epidemic in the early 1980s. During that time, we were experiencing major education campaigns targeted at those at greatest risk, primarily gay men in the early1980s, but also more generally, in the general population. Probably, when we measured sexual behaviour in 1990, we may have been seeing lower rates of partner change than had we measured sexual behaviour in just before the AIDS epidemic. As you have heard, we are seeing now a higher rate of sexual partner change and that fits in with everything that we observe about increasing sexually transmitted infections. However, the rates of sexually transmitted infections—I will be corrected by Dr Fenton—I do not think are as high now as they were at their peak prior to the AIDS epidemic. The changes in numbers of partners we believe are genuine though we think they are partly a result of the improved methods and they are also partly a result of the changing of attitudes towards sex in this country. We are a society that has become more tolerant. For example, we are a less homophobic society. We are more tolerant of homosexual behaviour and I think that has been very important in the openness with which we can address homosexual health issues. People may be more happy now to report. Attitudes have changed. People have become more tolerant of casual sex. We live in a society exposed to sexual images from many different sources. We have become an increasingly intolerant society of sexual infidelity within long term relationships. We live in a society that is changing, in which the role of men and women has altered. People are getting married later. They have kids later. Women are increasingly involved in higher education and so on. There are good sides and bad sides to some of those changes. We live in a society in which women in particular suffer much less dangers of things like childbirth, termination of pregnancy and so on than we did 50 years ago. In the long term, there have been major benefits, but these are complex issues in society which are the interface between attitudes, demography and sexual practices.

  269. Are you saying that in the 1980s the intervention or arrival of HIV, because of its cataclysmic potential, forced a serious rethink of how people behaved, not just those communities most readily associated with it, but for everybody, but because we prepared for a dreadful scenario which never arrived people then assumed that it never would arrive.
  (Professor Johnson) I think there is no doubt that this country achieved a great deal in terms of HIV control in the 1980s. We did better than many countries in Europe. We certainly did better than the developing world. However, with all prevention activity, this is not a one shot thing. You cannot just have a prevention campaign in the 1980s and think the problem has gone away. We have perhaps to some extent lost our focus in understanding that we have to continue these health education messages but change them in a way that is appropriate to the cultural attitudes and mores of the year 2000, not the year 1982. It is very easy to lose focus of that. I hear people often say that the AIDS epidemic is no longer a big problem but how shocked people were last week at the Barcelona AIDS conference to hear that we have an enormous epidemic internationally which is having a dramatic effect. We are not immune from that in this country in so far as we have very close interactions with many of the countries with big epidemics. We need investment in our local epidemic and we need to invest in prevention of the global epidemic which is really devastating in many countries.

Dr Taylor

  270. Can I go back to the BMA booklet because I think it is absolutely excellent and will inform our report tremendously. It is worth noting that three of our panel are acknowledged not as authors but are thanked for their contributions, so this has a very wide authorship. I want to go on to think about chlamydia specifically for a short time. The table that we have been given from the PHLS official report in March of this year shows that chlamydia cases in 1990 were about 30,000 and shot up by 2000 to double that, 60,000. We have already hinted that part of that is because of better availability of the tests, better awareness. How much of what we used to call non-specific urethritis is covered by a diagnosis of chlamydia and is it a true increase or is it just better diagnosis and better awareness?
  (Dr Hughes) We think the main reason we have seen this rise is because of a greater public and professional awareness of chlamydia. More people are aware of chlamydia and when you go to a GUM clinic now you will almost certainly be screened for it and also there are more sensitive tests. The main reason we are seeing this rise is because we are detecting more infections. However, we are still only seeing the tip of the iceberg as far as chlamydia is concerned. Because about 70 per cent of infections in women will show no symptoms, most people do not go to a GUM clinic and get diagnosed with it. The only way to get an idea of how common the infection is is to do a cross section survey of where you screen people. The sexual behaviour study shows that three per cent of 18 to 25 year olds in the population are infected with chlamydia. The chlamydia screening pilot looked at women under 25 attending various health care sessions, and if you look at the general practice population, between eight and nine per cent of those young women were infected with chlamydia. There are much higher rates with high risk groups like those attending genitourinary medicine clinics.

  271. Infected and probably unaware?
  (Dr Hughes) Most of those would have been unaware because most of them will not have had symptoms and therefore will not have perceived a problem. You can look at diagnosis in GUM clinics but you are not getting a full picture of the epidemiology in the community and it is a much more common infection than was previously believed. This highlights that if you want to control an infection like chlamydia you are going to have to screen for it because most people will not have symptoms.

  272. Is there widespread availability of the screening tests or is this limited by cost?
  (Dr Hughes) It is not widespread. If you go to a GUM clinic, you will be offered a chlamydia screening test.

  273. If somebody turns up to a physician or a GP with symptoms suggestive, even if it is eye problems, they will be able to get a test, will they?
  (Dr Hughes) If symptoms are suggestive of a chlamydia infection, yes, they should be offered a test but because most of them will not have the symptoms they will not be.

Dr Naysmith

  274. What is the incidence of false positives or is it a virtually 100 per cent successful test?
  (Dr Hughes) The tests are very sensitive and specific, particularly the new nucleic acid amplification tests being used in the pilot schemes.

Dr Taylor

  275. Dr Tobin, do you still diagnose NSU or has that diagnosis gone down?
  (Dr Tobin) It has gone down very much. A lot of it was chlamydia.

John Austin

  276. Dr Taylor referred to the reported cases having more than doubled of male and female in the last ten years. There is also likely to be under reporting. It is suggested in some of the material that we might need to talk about the figures and that some of the increase shown in the figures may be because of increased public awareness; and yet your evidence shows that the most at risk group is the younger age group. The evidence suggests that there is a appalling level of ignorance in that age group, more than three-quarters of young people now knowing about the infection at all. Are these figures a considerable under-estimate of the prevalence of chlamydia, particularly in younger age groups?
  (Dr Fenton) There is quite likely to be an under-estimate because the surveillance data really depends on attendance to a GUM clinic. Therefore, we only get information from the STI surveillance systems on attendances and diagnoses in that setting. If we look at chlamydia diagnoses made in microbiological labs in the country, we do see even more diagnosis of chlamydia in young people, which reflects the fact that they are going to youth services, general practices etc., and are being screened for chlamydia in those settings as well. Yes, the STI surveillance data that we obtain from the GUM clinics are likely to under-estimate the truth occurrence of the disease in the general population. In this regard, the chlamydia study which was done as part of the second national survey of sexual actions and lifestyles for the first time gave us a picture of the burden of the disease in the general population. In that study, we were not able to ask young people under the age of 18 to provide a urine sample for chlamydia screening. I think this is an area for further work.

Sandra Gidley

  277. Dr Fenton and Dr Hughes, would you go as far as to say that chlamydia was a public health problem and, if so, how best can it be controlled?
  (Dr Hughes) Yes, I think it is a public health problem. Looking at pilots in general practice populations, the prevalence of infection in women under 25 was between eight and nine per cent so that does suggest that it is a public health problem. Also, most of those infections would not have been detected without screening because most of those women would not have symptoms, which suggests that if you are going to control this infection you need to be looking at screening women for the infection.
  (Professor Johnson) One of the points to emphasise to the Committee is that chlamydia is a major cause of pelvic inflammatory disease and tubal infertility in women. That is its major public health burden. You know how much the NHS is increasing spending on infertility problems. One of the things we have seen in this country is rather a piecemeal approach to testing for chlamydia outside of GUM clinics. We have talked about these new tests which are a tremendous advance in terms of having a better test that can also be carried out without having to do genital examinations on patients and therefore is much more applicable in general practice, but the new tests that we have been talking about are not widely available in general practice. People are still relying on less sensitive tests. If one wants to role out this programme, one of the differences between chlamydia and syphilis and gonorrhea is that we have had very good control of syphilis and gonorrhea over the last 50 years because of the availability of penicillin and tests which identify them. Chlamydia is still widely disseminated in the population and therefore we need a different strategic approach, one that relies more heavily on primary care by more active screening programmes, particularly amongst young people, and which engage not only women but also the men. Dr Fenton has pointed out the results of the national survey. One of the key findings is we have as much asymptomatic infection in men as in women. If we focus the screening solely on women, we will miss half of the problem. Partner notification is what one would like to do but this is much more difficult than one imagines, even in experienced hands. It is very difficult in general practice, where partners may not use the same general practitioner. We need to think not just of screening women but of screening men, of looking for chlamydia, raising awareness in young people. We need to raise awareness, dare I say it, in some of our professional bodies across the range of services. We need to look for chlamydia in antenatal settings, in abortion clinics and other settings and, in primary care, possibly also in the contraception service, if we are going to push the prevalence down in the population to the stage that we have now got to with gonorrhea and syphilis, where one could do much more focused work to try and drive some of these infections to extinction. The Swedes have done it and they have good public health indicators that they are driving down their rates of pelvic inflammatory disease. They are driving down their rates of gonorrhea almost to extinction by really well coordinated screening programmes and that is something we do not yet have in this country.

  278. Can I clarify why the tests are difficult and still not widely used? Are they difficult to obtain? Is it an ignorance on the part of practitioners or is it a cost issue?
  (Professor Johnson) I do not think it is ignorance; it is availability of tests. These tests have become developed in the last ten years and available in clinical practice perhaps in the last five years but have been available largely in laboratories with a specific interest in developing and buying the kit to do them. They are considerably more expensive than some of the previous technologies. However, this is a very rapidly advancing field. It is not my specialist area at all but one would hope to see some of the costs of these tests coming down. I think it is fair to say that in many health authorities the funding may not be available for widespread use of these tests, and certainly not in the context of broad base screening programmes.

  279. Are you implying that there is a long term cost saving because of the pelvic inflammatory disease?
  (Professor Johnson) Yes. There are questions about how best to deliver all these programmes because one wants to try and use them in those sectors of the population where we anticipate the prevalence would be highest and we know that is likely to be the youngest sectors of the population and those we predict might be changing partners more frequently.


 
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