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• In support of a structured approach to service design and evaluation in chlamydia screening
  Sarah C Woodhall
  Published on: 20 April 2017

• Published on: 20 April 2017

  In support of a structured approach to service design and evaluation in chlamydia screening

  • Sarah C Woodhall, Principal Scientist
  • Other Contributors:
    • Emma Hollis, Nicky Connor, Kate Folkard, Kevin Dunbar

  We read with interest the recent article by Chandrasekaran et al[1], which analysed national surveillance data on chlamydia testing and diagnoses among young adults in England in 2012. The paper raises a number of important points of relevance for the National Chlamydia Screening Programme in England.

  Firstly, the authors' findings further support the known association between deprivation and chlamydia infection...

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  We read with interest the recent article by Chandrasekaran et al[1], which analysed national surveillance data on chlamydia testing and diagnoses among young adults in England in 2012. The paper raises a number of important points of relevance for the National Chlamydia Screening Programme in England.

  Firstly, the authors' findings further support the known association between deprivation and chlamydia infection[2;3]. Although Chandrasekaran et al present an ecological study, this relationship has also been demonstrated in individual level analyses and emphasises the importance of chlamydia screening delivery in socioeconomically deprived areas. For local authorities thinking about the implications of these findings for their own populations, it is also worth noting that within a single local authority area, levels of deprivation will vary. Therefore decisions about focussing of resources need to be considered at several levels.

  The observation that areas with a lower proportion of tests carried out in GUM clinics were less likely to achieve a detection rate of 2,300/100,000 population is also an important one. Chlamydia infections are not restricted to young adults with higher risk sexual behaviours, such as multiple sexual partners, nor to those who attend GUM clinics[2;3]. Testing in non-GUM clinic settings such as sexual and reproductive health services, primary care and via the internet is therefore an essential component of comprehensive chlamydia control.

  Along with differences in infection risk in different populations, the other driver of variation in detection rates is testing coverage, as the authors themselves point out. Although the relationship between coverage and detection rates was not explored explicitly in this paper, we note that coverage was higher in more deprived local authorities. In national surveillance data from 2015, local authorities with higher coverage tended to have higher detection rates[4]. This suggests that in 2012, chlamydia screening activity was, to some extent, already focussed in areas at greatest need. However, more could be done to increase detection rates as we know that infections go undiagnosed3, with the consequent potential impact on reproductive health[5]. The old adage of 'seek and ye shall find' holds true to a large extent with chlamydia testing among young adults; the decision for local authorities is how best to use the available resources to maximise the benefit of every test.

  To that end, we also welcome the authors' recommendation that local authorities be encouraged to use their data to inform service planning and evaluation. As the authors conclude, this understanding of the data should not be limited to a narrow focus on the detection rate indicator alone. Diagnosis is only one step of the process by which chlamydia screening can identify and treat infections. Understanding of the population(s) at risk, rates of testing, diagnosis, treatment, partner notification and re- testing are all needed to ensure a quality service. In recognition of this, the NCSP is already working with local authorities and service providers to use both nationally- and locally-collated data relating to the whole of the chlamydia care pathway to inform service improvement activity[6]. We believe this structured approach to service design and evaluation will ensure that commissioners are best able to allocate limited resources to achieve the maximum benefit for the population.

  References

  [1] Chandrasekaran L, Davies B, Eaton JW, Ward H. Chlamydia diagnosis rate in England in 2012: an ecological study of local authorities. Sex Transm Infect 2016.

  [2] Sonnenberg P, Clifton S, Beddows S, Field N, Soldan K, Tanton C et al. Prevalence, risk factors, and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). Lancet 2013; 382(9907):1795- 1806.

  [3] Woodhall SC, Soldan K, Sonnenberg P, Mercer CH, Clifton S, Saunders P et al. Is chlamydia screening reaching young adults at risk of infection? Findings from the third National Survey of Sexual attitudes and Lifestyles (Natsal-3). Sexually Tranmitted Infections 2016; 92(3):218-227.

  [4] Public Health England. Sexually transmitted infections and chlamydia screening in England, 2015. Health Protection Report 2016; 10(22).

  [5] Price MJ, Ades AE, Soldan K, Welton NJ, Macleod J, Simms I et al. The natural history of Chlamydia trachomatis infection in women: a multi parameter evidence synthesis. Health Technology Assessment 2016; 20(22).

  [6] Public Health England. NCSP: Care pathway. 2016. Available at: https://www.gov.uk/government/publications/ncsp-chlamydia-care-pathway Accessed 2 Sep 2016

  Conflict of Interest:

  All authors are employed by Public Health England and contribute to the implementation, monitoring and/or evaluation of the National Chlamydia Screening Programme in England.

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  Conflict of Interest:
  None declared.

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