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Evidence based and minimally harmful management of screened positive people is an essential component of any screening programme.
In the pilot chlamydia programme the protocol for those who screened positive included testing for other genital tract infections.1,2 This policy is not evidence based and requires evaluation before roll out of the screening programme nationally.
During the 12 month period September 1999 to August 2000 in Wirral and Portsmouth women throughout the communities up to the age of 25 years were offered a urine LCR test, in general practices, family planning clinics, gynaecology, antenatal, and termination of pregnancy services. Departments of genitourinary medicine (GUM) also offered the test though clearly these were usually for diagnosis rather than true screening.
Results were sent to everyone tested, as in other screening programmes, and an overall positivity of some 10% was found.
Both pilot sites had a central office, which was the initial point of contact for all testing positive. This avoids disparate management by different health professionals and services and had the added benefit of removing concerns raised about time required in each service for managing results, treating, counselling, and partner notification. As our previous experience showed that many people delayed or did not attend a department of GUM when referred,3,4 two experienced health advisers were appointed on Wirral and based in the pilot office. These community health advisers had overall responsibility for ensuring and documenting that correct management occurred. People testing positive and reporting symptoms or risk factors were strongly advised to attend the department of GUM and were given a referral letter. However, those who were asymptomatic and who indicated that they did not wish to go were treated according to patient group directions with doxycycline, azithromycin, or erythromycin as appropriate. In these cases the health advisers undertook partner notification and sometimes their treatment. The pilot coordinator (JJH) undertook overall clinical responsibility and saw patients as needed.
During the 12 months of the pilot programme 112 women tested chlamydia positive by the “screening” test in GUM and most returned there for management. Sexually transmitted infections in these women comprised three cases of gonorrhoea, 30 of genital warts, and six of herpes simplex. There were also 11 cases of candida and 18 of bacterial vaginosis. These figures represent multiple infections for several women.
Bacterial co-infection of chlamydia diagnosed during screening outside STI clinic settings is low
Routine diagnostic testing should only be reserved for those symptomatic or with special risk
Testing of the original urine sample for gonorrhoea is an acceptable alternative
Four hundred and six women screened in other healthcare settings tested chlamydia positive. The community health advisers treated 321 of these and 85 agreed to attend GUM. Five of these women (5.8%) had another sexually transmitted infection comprising only one case of gonorrhoea, two cases of genital warts, and two cases of genital herpes. There were also nine cases of candida and 17 of bacterial vaginosis.
If efficient and effective treatment for chlamydia is to take place in the community then health advisers will be essential as in the Wirral pilot scheme. They will need to establish in each case whether there are symptoms or special risk factors that transform the process from screening to one of diagnosis. Although diagnosis should involve testing for all relevant causes of the symptoms, we have found no evidence to support this as routine in a screening programme if it is known that the community prevalence of other significant infections is low. The invasive nature and possible stigmatisation by seeking for other infections together with the cost to individuals and the health service could be balanced against any personal or community benefits from the strategy.5
The women who chose to be treated in the community were offered a test for gonorrhoea (by LCR) on the original urine sample which had been frozen in the Liverpool Public Health Laboratory. Two of 192 women accepting this were found to have a positive test and were then referred to GUM clinics. This appears to be an acceptable and efficient means of finding this infection in those who would not otherwise present for testing.6