Recent eLetters

In their topical editorial, Jain and Ison state that "testing (for chlamydia) is a crucial part of any effective control strategy"1. In January 2013 we conducted a pilot study of Chlamydia trachomatis and Neisseria gonorrhoea testing in female students at Lambeth Further Education College, London to assess recruitment to a possible POPI (prevention of pelvic infection) 2 screening trial.2

Two female general practitioners approached consecutive female students in the common room and asked them to help with a women's health study. We explained that only women aged 16-27 who were sexually experienced were eligible. Those who consented completed a questionnaire and provided a self-taken vaginal swab. We explained that as samples might not be tested for six months, it was participants' responsibility to get tested independently if they were at risk of STIs. Subjects were given a small honorarium (?5 and a lollipop) when they returned the samples.

Of 40 women approached, eight were aged >27 and seven refused: response rate 78% (25/32). Responders were broadly similar to non- responders in the proportion of black ethnicity (56%, 14/25 versus 86%, 6/7) but were younger (mean (sd) 19.3 (2.7) years versus 22.9 (3.5) years, p<0.01)). Unlike our difficulties in the POPI trial2, we recruited our target of 25 women in 90 minutes and had to turn away potential participants as we had run out of packs. Three women were later excluded as their questionnaire responses showed they had never had sex. Of the 22 sexually active women, 41% reported two or more sexual partners in the previous year and 45% were smokers. Mean age of sexual debut was 15.5 years (range 13 to 19). Four women reported a history of STI.

Within a week, samples were randomly allocated to immediate or deferred testing. Two of 16 participants in the immediate testing group were positive - one for chlamydia and one for gonorrhoea. They were easily contactable by mobile phone and email and referred for treatment. We will return to the college in six months to request a further vaginal swab and questionnaire from the 22 eligible participants. Although we need to ensure only those who are sexually experienced are recruited, our study suggests small financial incentives may be useful.

Ethics review: Bromley REC: 12/LO/0855

Acknowledgements: We thank students and staff at Lambeth College.

References

1. Jain A, Ison CA. Chlamydia point-of-care testing: where are we now? Sex Transm Infect 2013;89(2)88-89.

2. Oakeshott P, Kerry S, Aghaizu A et al. Randomized control trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ. 2010;340:c1642

Conflict of Interest:

None declared

Acute nongonococcal urethritis (NGU) is one of the commonest sexually transmitted infections affecting man and woman. The diagnosis of NGU has traditionally required microscopic evidence of urethritis. However, a significant proportion of patients with urethral symptoms do not have microscopic evidence of urethritis. A recently published article by Orellana MA et al [1] highlighted the low sensitivity of Gram stain in the diagnosis of urethritis in men, and the low negative predictive value of microscopic results in symptomatic patients. Whereas, we recently evaluated the analytical performance of the UF-1000i (Sysmex Co, Japan, Supplied by Dasit SpA, Cornaredo, Italy), a recently introduced fluorescence flow cytometer intended for urinalysis purposes [2], which provides new analytical features that seem particularly suitable for microbiological diagnostics, for ruling out NGU or predicting the presence of infection [3]. The Sysmex UF-1000i is a flow cytometry analyzer capable of quantifying a lot of particles, including bacteria and white blood cells (WBCs). To evaluate the analytical performance of the UF-1000i as a method for ruling out NGU, we examined 200 urethral smear samples, collected in a liquid transport medium (Eswab, Copan, Brescia, Italy). We compared the UF-1000i results with microscopic Gram stain, and with results obtained from standard cultures and molecular methods available in our laboratory to detect NGU main pathogens (Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis, Trichomonas vaginalis, Adenovirus, Herpes simplex) . With instrument cut-off values of 200 BACT x10^6/L and 500 WBCs x10^6/L, we obtained a sensitivity of 84%, a specificity of 82%, and a high negative predictive value (96%). Our data demonstrated that Sysmex UF-1000i represents a real tool for ruling out NGU, capable of improving the efficiency of NGU presumptive diagnosis, providing results in a few minutes, with a good value of sensitivity and, above all, a very high negative predictive value.

References 1. Orellana MA, Gomez-Lus ML, Lora D. Sensitivit? of Gram stain in the diagnosis of urethritis in men. Sex Transm Infect 2012; 88: 284-287. 2. Grosso S, Bruschetta G, Camporese A. Experimental evaluation of the Sysmex UF-1000i for ruling out non-gonococcal urethritis. Infez Med 2012; 20 (3):188-194. 3. De Rosa R, Grosso S, Bruschetta G, et al. Evaluation of the Sysmex UF1000i flow cytometer for ruling out bacterial urinary tract infection. Clin Chim Acta 2010; 411 1137-1142.

Conflict of Interest:

None declared

Khryanin and Reshetnikov describe screening men and women in Siberia for M.genitalium and C.trachomatis 1. They suggest falls in detection rates in 2010-11 may be due partly to the increasing numbers of healthy persons who had attended medical clinics for routine examination. We investigated whether it might be possible to increase frequency of STI testing among female students in London, UK. This is particularly important in those with a new sexual partner or recently treated for a STI who may be more at risk2;3.

In September 2012 for a medical student project we conducted a confidential questionnaire survey of consecutive female students aged 20- 24 in the common room areas at St George's, University of London. The response rate was 100% (50/50). The students described their ethnicity as Asian 42%, white 28%, black 22% or other 8%. Over half (56%, 28) said they would be willing to post self-taken vaginal swabs for STI screening every 6 months. Incentives are often used in STI research4, and 93% (26/28) of responders said that an Amazon voucher would make them more likely to return samples. We also asked about a proposed pelvic inflammatory disease (PID) hotline which women could telephone for advice if they thought they had symptoms of possible PID: pelvic discomfort, pain during sex, abnormal vaginal discharge or bleeding between periods. Forty women (80%) said they would use a PID hotline if available.

Although superficially encouraging, results from this small sample may not apply to students from other universities: and agreeing to return samples is very different from actually doing it. However, we agree with Khryanin and Reshetnikov1 that increasing use of online services and texting may also be useful in increasing screening and treatment of STIs.

Ethical review: The protocol, patient information leaflet and questionnaire were reviewed by Dr Phillip Sedgwick, Reader in Statistics and course organiser at St George's, University of London.

Reference List

(1) Khryanin A, Reshetnikov O. Detection rates of Mycoplasma genitalium and Chlamydia trachomatis Sex Transm Infect 2012; 88(6):469.

(2) Woodhall SC, Atkins JL, Soldan K, Hughes G, Bone A, Gill ON. Repeat genital Chlamydia trachomatis testing rates in young adults in England, 2010 Sex Transm Infect 2012.

(3) Oakeshott P, Kerry S, Aghaizu A, Atherton H, Hay S, Taylor- Robinson D et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. Br Med J 2010; 340:1642.

(4) Walker J, Fairley CK, Urban E, Chen MY, Bradshaw C, Walker SM et al. Maximising retention in a longitudinal study of genital Chlamydia trachomatis among young women in Australia BMC Public Health 2011; 11:156.

Conflict of Interest:

None declared

The recently published editorial by Ingham highlights the importance of ascertaining etiologies of misuse of condoms to plan and implement effective public health interventions1.

Crosby et al. outline a prospective study demonstrating the effectiveness of condoms when used consistently and properly to considerably lower the acquisition of non-viral sexually transmitted diseases. The authors also address the global problem of incomplete and improper use of condoms requiring targeted education for improvement2.

Another recently published article discusses inconsistency of condom use and its ramifications. Goyal et al. have focused on high risk behavior and sexually transmitted infections among U.S. Active Duty Servicewomen and Veterans. The authors state that the group of unmarried, young and new to military service, in particular, inconsistently use condoms resulting in greater probability of acquisition of sexually transmitted infections. Potential barriers to condom use for these women have been proposed and include being stigmatized as promiscuous if requesting condoms and evidence of violation of the military policy prohibiting sexual intercourse during deployment. Binge drinking by women in the military may also be resulting in inconsistent use of condoms with resulting unwanted pregnancies and greater incidence of sexually transmitted infections. The rate of Chlamydial infection in female active duty soldiers is significantly greater than in comparative groups of women in the general population3.

Ingham and Crosby et al. substantiate that the etiology of improper and inconsistent use of condoms must be identified to plan and implement effective public health interventions to eradicate the global problem of sexual transmission of infection. It is likewise imperative that the etiologies of risky sexual behavior of young women in the military be understood. This vulnerable group should have targeted education to prevent unwanted pregnancies and sexually transmitted infections. Clearly U.S. Active Duty Servicewomen and Veterans face unique and difficult challenges regarding their reproductive health and this issue needs more focus1-3.

References

1. Ingham R. Condoms, bloody condoms; yet more problems. Sex Transm Infect. 2012;8 :479-480. Published Online First: 23 October 2012 doi:10.1136/sextrans-2012-050793

2. Crosby RA, Chamigo RA, Weathers C, et al. Condom effectiveness against non-viral sexually transmitted infections: a prospective study using electronic daily diaries. Sex Transm Infect. 2012;88:484-489.Doi: 10.1136/sextrans-2012-050618.

3. Goyal V, Mattocks KM, Sadler AG. High Risk Behavior and Sexually Transmitted Infections Among U.S. Active Duty Servicewomen and Veterans. J of Women's Health. 2012; 21:1155-1169.DOI: 10.1089/jwh.2012.3605.

Conflict of Interest:

None declared

In their stratified random probability survey of 411 men aged 18-35 years, Saunders and colleagues found that 29% had been tested for a STI, mainly in genitourinary medicine (GUM) clinics (53%) or general practice (17%)1. In September 2012, for a medical student project, we conducted a questionnaire survey of young men and women at Lambeth Further Education College in south London. Lambeth is an area with one of the highest rates of STIs in the UK with 9.9% of 15-24 year olds screened testing positive for chlamydia in 2011 to 20122. Our aim was to find out how many students had been tested for chlamydia in the past year, where they had been tested and why they were tested. To make our findings comparable with Saunders and colleagues we focus mainly on results from male respondents.

The response rate was 79% (89/112). The mean age of participants was 23 years (range 16-54) and 67% were male. The 59 male responders described their ethnicity as black 55%, (comprising black-Caribbean 22%, black other 17%, black-African 16%), white 25%, Asian 3% and 14% other ethnicities. Most male responders (80%, 47/59) said they were sexually active of whom 55% (26/47) reported being tested for chlamydia in the past year. Half of them (50%, 12/24) said they had been tested at a GUM clinic, 17% in general practice, 12.5% at a Brook clinic, 8% at school, 8% at Tooting Bec Lido and 4% at a Walk-in clinic. Reasons for testing (n=22) included "for a check-up" (35%), "out of choice" (50%), "one night stand" (5%), "free condoms" (5%) and "unprotected sex" (5%). The proportion of young men in our study who were tested in GUM clinics and general practice was similar to results from the national survey by Saunders and colleagues1. In line with NCSP reports3, they point out that young men are perceived as hard to reach for STI screening1. Based on the high rates of reported testing found in our small survey of young, sexually active, mainly black males, we agree there may be potential to increase STI screening rates.

Ethical review: The protocol, patient information leaflet and questionnaire were reviewed by Dr Phillip Sedgwick, Reader in Statistics and course organiser at St George's, University of London.

Acknowledgements: The authors would like to thank Dionne Konstantinious and staff and students at Lambeth College for their help with this research.

References:

1. Saunders JM, Mercer CH, Sutcliffe LJ, et al. Where do young men want to access STI screening? A stratified random probability sample survey of young men in Great Britain. Sex Transm Infect. 2012 88(6): 427- 432 doi: 10.1136/sextrans-2011-050406

2. National Chlamydia Screening Programme. Chlamydia Testing Data 2011/12 [data tables]. NHS;2012. Available from URL: http://www.chlamydiascreening.nhs.uk/ps/resources/data-tables/CTD-Q1-4- 2011_2012.pdf

3. National Chlamydia Screening Programme. National Chlamydia Screening programme data [media information pack]. NHS;2010. Available from URL: http://www.chlamydiascreening.nhs.uk/ps/assets/pdfs/press/NCSP_media_pack_2010.pdf

Conflict of Interest:

None declared