Examination of Witnesses (Questions 250-259)|
WEDNESDAY 17 JULY 2002
250. Could I welcome the witnesses today and
could I apologise for the absence of David Hinchliffe, the Chair
of the select committee? He is unavoidably away due to a family
problem. Could I ask the witnesses to briefly introduce themselves.
Tell us your designation and where you are from.
(Dr Tobin) I am Jean Tobin. I am a consultant in genitourinary
medicine at Portsmouth and I am involved in the Portsmouth arm
of the Hepartment of Health chlamydia screening pilot.
(Dr Cassell) I am Jackie Cassell and I represent the
British Medical Association. I work at University College, London
in research in sexual health.
(Professor Johnson) I am Anne Johnson. I am involved
in infectious disease epidemiology at University College, London,
in the Department of Primary Care and Population Sciences. I have
worked on HIV epidemiology for a number of years.
(Dr Fenton) I am Kevin Fenton. I am a consultant epidemiologist
at the Communicable Disease Surveillance Centre. I am a senior
lecturer at UCL Medical School and I currently head the HIV division
on communicable disease.
(Dr Hughes) I am Gwenda Hughes. I am a consultant
scientist at the Communicable Disease Surveillance Centre and
head of the section on transmittable infections.
251. The primary purpose of this session is
to examine the trends in the prevalence of sexually transmitted
infections and the possible factors underlying those trends. Firstly,
a question to Gwenda Hughes and Kevin Fenton. In your written
evidence, you outline the recent trends for acute sexually transmitted
infections. Could you summarise these and indicate what projections
you have made of what will happen in the next few years?
(Dr Fenton) We have seen substantial changes in the
epidemiology of sexually transmitted infections over the last
20 years. In part, a lot of these changes have been mediated by
behavioural modifications in the general population. There have
also been substantial changes in how individuals access care and
how they take up sexual health services. In the early 1970s and
towards the early 1980s, we were seeing some decline in STIs.
At that time, we were noticing for some infectionsfor example,
gonorrheaover 60,000 diagnoses each year. At the beginning
of the 1980s at the commencement of the global HIV pandemic we
noticed substantial declines in the numbers and rates of both
bacterial and viral sexually transmitted infections and these
declines have continued throughout the 1980s right up to the mid-1990s.
These declines were particularly marked across Britain and were
observed especially in so-called high risk groupsfor example,
gay and bisexual menand this adds credence to the fact
that these groups in particular had adopted a variety of behavioural
modifications during that time. As such, we saw some of the lowest
rates and numbers of sexually transmitted infections by the mid-1990s
and we often describe a nadir or a bottoming out of STI incidence
at about 1994 to 1996. This was seen across all STIs. Since 1995,
however, we have been noticing a gradual, sustained increase in
the numbers and rates of both bacterial and viral sexually transmitted
infections. Since 1995, we have seen a doubling of rates and numbers
of chlamydia, gonorrhea and syphilis. There are a variety of reasons
to explain why these infections have all increased. What we also
should remember is that, because the infections bottomed out in
1995, the initial rate of increase by the end of 1990 was seeing
approximately the same numbers of infections as we have seen at
the beginning of the decade as we did at the end of the decade.
However, since 2000, we have observed and we continue to observe
substantial increases in all sexually transmitted infections.
Undoubtedly, sexual behaviour will be a key determinant of the
increases in these STIs, but a number of ad hoc studies
as well as our surveillance data confirm that people are also
attending GUM services more. They are taking advantage of HIV
testing and sexual health screening. That may also contribute
to the increases in diagnosis that we are observing. We are also
aware that people are taking more interest in their sexual health,
partly because of the sexual health campaigns throughout the 1990s.
Clearly, this will also contribute to increasing diagnoses. Finally,
we have been seeing increases in the sensitivity of our diagnostic
tests. We are getting better at diagnosing a variety of STIs.
For example, genital chlamydial infection. That may also be contributing
to the increases in the numbers and rates of STIs which we are
observing. A large part of these increases has been mediated by
252. You said screening may have contributed
partly to these increases. What kind of screening? Has it contributed
to the detection or the increase?
(Dr Fenton) I am using that term in its widest application,
not in terms of the chlamydia screening programmes which are being
developed at present. If individuals are going to STI clinics
more, they will have a greater opportunity to be screened and
tested for STIs.
253. Not in the sense of people being screened
for other things and you are picking these up?
(Dr Fenton) That may also contribute to it. Another
good example is genital chlamydial infection where the diagnostic
technology has improved since the mid-1980s. We have been using
a succession of more sensitive tests to diagnose chlamydia and
therefore we are getting better at picking up asymptomatic infections.
254. You gave a very clear picture of the trends
to date and some of the underlying reasons. Have you made any
projections for the near future?
(Dr Fenton) We have not at the Communicable Disease
Surveillance Centre done any specific projections for STIs. We
tend to do projections for HIV and AIDS by using a variety of
(Dr Hughes) What we have seen is a consistent rise
particularly in infections like gonorrhea since about 1995. The
evidence that we have from the preliminary data for last year
is that that is continuing. It is rising at quite a sharp rate
and does not seem to be easing off.
255. Dr Cassell, you have published a report
on STIs. What prompted the BMA to produce that report?
(Dr Cassell) The Board of Science and Education of
the British Medical Association produced the report and that is
a standing committee of the BMA, which works at the interface
between the profession and the public and government and aims
to contribute to public health through education, particular of
professionals with a view to educating the public. It produces
a variety of reports in response to the concerns of members. For
example, at the annual representatives' meeting, debates might
be generated on issues of concern in members' working lives. A
number of issues of concern were raised over several years in
relation to sexual health, particularly the sexual health of young
people. As a consequence, the Board of Science and Education decided
to produce this report with a view to educating professionals
and raising awareness that this is an important health issue in
order to help professionals in talking to their patients about
risks, being aware that these risks are very real in their working
lives and also with a view to improving services at all levels.
256. We are expecting in March next year the
work of the Sexual Health Services Data Group to report, mentioned
at the beginning of the health implementation plan. Could you
give us any insight into the work that they are doing and possible
recommendations that might come out of that?
(Dr Hughes) What the group is trying to do is to find
out what information do we need to be able to monitor sexual health
in the population effectively so that we can develop appropriate
intervention strategies and monitor how effective they are once
they have been developed. What is likely to happen is that they
are going to recommend that there are new standards for data collection
across all health services which are providing sexual health services.
There will be a minimum amount of information that will be felt
to be necessary. That will need to come not just from the specialist
services but also from primary care, especially now we have the
sexual health strategy where there is a commitment to greater
delivery of services in primary care. We are clearly going to
need to get information from primary care to be able to monitor
how effective that is going to be. What is obvious is that these
are quite big changes and that there would need to be considerable
training involved and investment in information systems in order
for these changes to be realised. They are going to make recommendations
in relation to the data that should be collected. They are currently
looking at how different strategies could be used to try and get
that information. That is still under discussion.
257. That is about getting better data rather
than saying there should be different screening programmes to
get the data?
(Dr Hughes) The remit of that group is to look at
getting better quality information in order for us to be able
to monitor these programmes.
(Dr Fenton) Although we do have a very comprehensive
STI surveillance system, it does have its limitations. We are
very much hoping to get detailed information on inequalities in
sexual health and sexual ill health in the population and to target
our interventions quite closely to undertake targeted interventions.
One of the strategic visions the data group has for STI surveillance
is to take along term approach to see what we need to inform STI
prevention and control. What do we want to have in seven years'
time? What would we like to do in two years' time?
258. Can you see things that should be happening
that we as a Committee might want to recommend should happen that
perhaps might not have come out of the data group or other work?
(Dr Hughes) At the moment, we have broad, reasonable
information from genitourinary infection clinics but we have no
information from primary care currently. If we are going to address
that situation and particularly if we are going to have more services
delivered through general practice, we are going to have to monitor
that. There is going to need to be some investment put into information
systems to be able to collect that information, to train people
to gather that information and then to look at how that information
might be integrated across all the services.
259. It is about trying to make sure that, in
developing services into primary care, the proper data is picked
(Dr Hughes) That is right.