We read with interest the recent report by Kampman et al, 2016 [1] on
the effect of text reminders on patients attending for repeat chlamydia
tests and chlamydia diagnosis.
In our service, the St. Ann's Sexual Health Centre, a GUM clinic in
London, UK, our routine practice was to verbally advise patients treated
for chlamydia to re-attend 6-8 weeks after treatment for re-testing.
Sexual health appointments are...
We read with interest the recent report by Kampman et al, 2016 [1] on
the effect of text reminders on patients attending for repeat chlamydia
tests and chlamydia diagnosis.
In our service, the St. Ann's Sexual Health Centre, a GUM clinic in
London, UK, our routine practice was to verbally advise patients treated
for chlamydia to re-attend 6-8 weeks after treatment for re-testing.
Sexual health appointments are available either by booking in advance or
on the day depending on timing and capacity. We reviewed our overall
practice in managing chlamydia infections against the British Association
for Sexual Health and HIV (BASHH) national guidelines, but with a
particular focus on repeat testing. BASHH recommend a test of cure
(testing at 3-5 weeks) in certain groups (e.g. pregnant women) and repeat
testing 3 months after treatment in under 25 year olds, and considered, in
high risk groups. All patients with a positive chlamydia NAAT result over
a two month period in 2014 were identified and their clinical care
evaluated.
108 patients were identified compared to 838 analysed by Kampman et
al spanning over a year as well as from ten STI clinics. Our cohort
represented our local demographics; 54% female, 72.6% under the age of 25
years old, 41.6% of Black Afro-Caribbean or Black British ethnicity and
96.6% heterosexual. 39% were symptomatic compared to 32% in the
Netherlands cohort.
36% (65/180) attended for a repeat test in our cohort compared to the
Netherlands group where 9.2% (140/1530) returned without reminder and
30.6% (253/838) in the study group who received a text message after 6
months. The median time to attendance for a repeat test after treatment
was 6 weeks (IQR (6-8) in our cohort, compared to re-testing being
concentrated within 5-8 months in the study group of Kampman et al. At our
centre only one patient tested positive for CT which was due to re-
infection, whereas 20.4% (56/275) of the Netherlands study group had a
repeat infection.
Our data reflects that of the other UK data highlighted, from Burton
et al, 2014, with a re-test rate in their control group who did not
receive a text message, of 35% (92/226). Although the authors state a
comparison cannot be made given the higher re-test rate of the UK group
compared to their control group, some inferences can be made. It is
interesting that there is an increase of 26.8% in those attending for a
repeat test without a text reminder in our group. Although the total
number included in the Netherlands group is larger compared to ours, the
former was data collated over a year at ten sites, compared to over two
months at our site alone. Kampman et al do not mention whether patients
were advised to have a repeat test, unlike our patients who are all
informed about repeat testing after 6-8 weeks at the time of treatment.
This is a simple intervention which could enhance their rate of re-
attendance. Furthermore, the number of re-infections was significantly
greater than our rate. This may reflect the varying denominators and/or
the greater length of time before re-testing (6 months compared to 6-8
weeks after treatment), as this potentially allows for a greater time
period to acquire re-infection. The higher numbers re-testing in our group
may also be due to the shorter interval between treatment and re-testing.
Overall our centre met the BASHH 2015 standards in the management of
chlamydia. However, we felt that a move from re-testing at 6 weeks to re-
testing at 3 months in high risk groups (patients aged < 25 years and
MSM) would be more cost effective as it will identify any treatment
failures and potentially more re-infections.
We continue to inform patients about re-testing when they are being
treated and have also introduced text reminders at 3 months. Text
reminders are an acceptable, easy and cost-effective strategy to increase
efficiency especially given NHS targets and cuts to public health funding.
References
1)Kampman CJG, Koedijk FDH, Driessen-Hulshof HCM, et al. Retesting young
STI clinic visitors with urogenital Chlamydia trachomatis infection in the
Netherlands; response to a text message reminder and reinfection rates: a
prospective study with historical controls.Sex Transm Infect 2016;92:124-
9.
2) Burton J, Brook G, McSorley J, et al. The utility of short message
service (SMS) texts to remind patients at higher risk of STIs and HIV to
reattend for testing: a controlled before and after study. Sex Transm
Infect 2014;90:11-13.?
I am flabbergasted that this public health article exists at all.
Where is the peer review. The problem lies in the appropriateness of
source data which was used. In an email exchange I confirmed that I
understood that the authors did indeed divide interviewed sex workers into
two groups, one that experienced violence in the single preceding week and
a second group that did not. They then compared health data for
diff...
I am flabbergasted that this public health article exists at all.
Where is the peer review. The problem lies in the appropriateness of
source data which was used. In an email exchange I confirmed that I
understood that the authors did indeed divide interviewed sex workers into
two groups, one that experienced violence in the single preceding week and
a second group that did not. They then compared health data for
differences between the two groups. The source data came from the 2007
Survey of Sexual and Reproductive Health of Sex Workers in Thailand. This
was a huge project with many volunteers to conduct 120 question
interviews. The result is 815 in depth personal interviews. The abstract
of this study I am criticizing says that 14.6% of these 815 experienced
violence on the job in only one week before their interview. This is a
huge red flag for anyone knowledgable regarding this issue. There are
other studies including my own that might agree that violence reported is
in the low to mid teens but that is true when asking about violence over
one year, but not one week. My own micro-research survey of 100 sex
workers in the Nana Plaza area of Bangkok reported 13% violence over a
year. But when the response of "a raised voice or argument" (no physical
contact) was discarded, the level of physical violence in one year dropped
to less than 2% out of 98 good surveys.
This tells me it is time to ask how the 2007 study in Thailand
defined violence. I have a copy. Of 120 questions, only one can claim to
speak to levels of violence. Question Q804 says: In the last seven days,
have any of the following happened to you at work? There are six possible
choices. Only two choices involve physical contact between the sex worker
and her customer. Here are the choices: Yelled at / Hit / Forced to
perform sex acts you did not want to perform / Not paid / Paid less than
agreed / Made to do other things you didn't want to do. Two of the six
choices are about payment. Yet a YES answer to any of these six choices
will put this interviewee in the "violence" group. So, you be the judge.
Is this a proper way to create two discrete groups appropriate for
comparison? When four of the six choices used to define violence do not
necessarily involve any physical contact, at least none that is different
then the other group experienced, there are no grounds to assume anything
about health differences between these fatuously assembled groups based on
violence.
Just my opinion. Respond to tell me what you think.
Conflict of Interest:
My only competing interest is that I oppose the hyperbole and exaggeration surrounding the issues of sex trafficking and sex work. This is a minor offense but claiming 14.6% violence in one week based on only poorly designed question is inflammatory.
Whilst it is comforting that some research is finally being carried
out in depth on the risk of STIs amongst women who have sex with women
(WSW), any conclusions drawn from this study for WSW in general need to be
handled with a great deal of caution when one looks at the make-up of the
subjects and controls.
For example, over twice as many of the WSW as the control group were
current sex workers;...
Whilst it is comforting that some research is finally being carried
out in depth on the risk of STIs amongst women who have sex with women
(WSW), any conclusions drawn from this study for WSW in general need to be
handled with a great deal of caution when one looks at the make-up of the
subjects and controls.
For example, over twice as many of the WSW as the control group were
current sex workers; 38% of the WSW had had a previous termination of
pregnancy; nearly six times as many of the WSW had a history of injecting
drug use.
The researchers themselves say their "clinic population... may not be representative of the WSW in the general community". This is an understatement - and any reporting of this study must make very clear statements about the dangers of inappropriate conclusions about STIs
amongst women who have sex with women generally.
Mr McElborough considers it unfortunate that reference labs may have
developed their algorithms in the case of conventional syphilis diagnosis
and these do little to help with HIV coinfected patients. Guidelines for
serological diagnosis in coexisting HIV infection, neurosyphilis and
congenital infection are currently under preparation by the (Public Health Laboratory Service) PHLS Syphilis
Forum and will...
Mr McElborough considers it unfortunate that reference labs may have
developed their algorithms in the case of conventional syphilis diagnosis
and these do little to help with HIV coinfected patients. Guidelines for
serological diagnosis in coexisting HIV infection, neurosyphilis and
congenital infection are currently under preparation by the (Public Health Laboratory Service) PHLS Syphilis
Forum and will be available later this year.
In Edinburgh, the syphilis/HIV co-infected population may be much
smaller than in Brighton, but we have not experienced the serological
problems that Mr McElborough refers to. It would be most helpful if Mr
McElborough published details of the atypical serology that he has
encountered in coinfected patients.
Hugh Young
Medical Microbiology
Edinburgh University Medical School
Teviot Place, Edinburgh EH8 9AG, UK
Burstein and colleagues present interesting data concerning repeat
diagnosis of Chlamydia trachomatis in inner city women. Their data may
however not support all their conclusions. In their methods section they
state that “the frequency of diagnosis of first incident infection was
estimated by calculating the median time interval in months between first
test and first positive test during the study period a...
Burstein and colleagues present interesting data concerning repeat
diagnosis of Chlamydia trachomatis in inner city women. Their data may
however not support all their conclusions. In their methods section they
state that “the frequency of diagnosis of first incident infection was
estimated by calculating the median time interval in months between first
test and first positive test during the study period among all females
with negative results at first test and at least one subsequent positive
test.”
Using this approach they calculated an incidence of 20.3/1000 person
months for women aged <25 years and recommended to “screen ALL females
<_25 years="years" for="for" chlamydia="chlamydia" twice="twice" yearly="yearly" regardless="regardless" of="of" symptoms="symptoms" previous="previous" infections="infections" condom="condom" use="use" or="or" multiple="multiple" partner="partner" risk.="risk." however="however" their="their" population="population" studied="studied" was="was" not="not" representative="representative" the="the" total="total" women="women" aged="aged" _25="_25" years.="years." calculated="calculated" incidence="incidence" and="and" final="final" recommendation="recommendation" apply="apply" only="only" to="to" a="a" particular="particular" sub="sub" _-="_-" self="self" selected="selected" who="who" attend="attend" sexual="sexual" health="health" clinics="clinics" later="later" develop="develop" c="c" trachomatis="trachomatis" infection.="infection." we="we" suggest="suggest" that="that" members="members" this="this" should="should" be="be" screened="screened" even="even" more="more" frequently="frequently" they="they" clinics.="clinics." p="p"/>The data presented by Burnstein and colleagues does however not allow the
calculation of the ideal screening interval for members of other
populations (ie most women under the age of 25 years).
Low and colleagues present a very important paper. They should be given
the opportunity to remove my doubts about the validity of their findings:
They used a cross sectional design to determine incidence; however,
unless the average duration of conditions is known longitudinal studies
are required to determine this. The presented study assessed
disease status of self-selected participants over a period of...
Low and colleagues present a very important paper. They should be given
the opportunity to remove my doubts about the validity of their findings:
They used a cross sectional design to determine incidence; however,
unless the average duration of conditions is known longitudinal studies
are required to determine this. The presented study assessed
disease status of self-selected participants over a period of 2 years. For
most of the participants the disease status at the beginning of the 2-year
study period was unknown. This allows the calculation of the period
prevalence, “which represents the proportion of cases that exist within a
population at any point during a specified period of time. The numerator
thus includes cases tat were present at the start of the period plus new
cases that developed during this time”.[1]
For conditions with a long duration (such as asymptomatic infection in
women) the incidence may be considerably lower than the period prevalence.
The key message of the paper is that rates of gonorrhoea and chlamydia diagnosis differ between different black ethnic groups. As the
authors mention in their discussion “differential sexual heath service use
by the ethnic groups may account for some of the observed disparity”.
Knowledge, attitudes, individual and group norms, resources and ease of
access determine care seeking. Ease of access should be similar for
members of different ethnic groups living is the same ward. Maybe Low and
colleagues would like to present the data controlling for confounding by
ward of residence.
References
(1) Hennekens CH, Burning JE. Measures of disease frequency in Epidemiology
in Medicine. Ed, Mayrent SL. Boston 1987:54-100.
Although our study population was homogeneous and Baltimore is known
to have high sexually transmitted disease (STD) rates, we believe
sufficient evidence exists to support our recommendation of twice yearly
chlamydia screening of sexually active females less than 25 years of age.
Chlamydia screening in most adolescent female populations yields
prevalence rates greater than 10%, except in areas wit...
Although our study population was homogeneous and Baltimore is known
to have high sexually transmitted disease (STD) rates, we believe
sufficient evidence exists to support our recommendation of twice yearly
chlamydia screening of sexually active females less than 25 years of age.
Chlamydia screening in most adolescent female populations yields
prevalence rates greater than 10%, except in areas with long-standing
chlamydia control programs, such as in the United States Pacific
Northwest.[1-5] In a large private sector managed care organization serving
a diverse adolescent population, including members residing in wealthy
suburban communities, we found chlamydia prevalence rates well above 10%
in adolescents chlamydia tested and a median time to reinfection of six
months among those with repeat tests.[1]
Drs. Pittrof and Kegg claim that our recommendation of twice yearly
chlamydia screening “apply only to … self selected women who attend sexual
health clinics.” In our study, the females with the highest rates of
infection were screened at school-based health centers providing
comprehensive primary care health services.[6]
Drs. Pittrof and Kegg advocate for screening practices to be dictated
by disease prevalence in specific populations. We agree in concept.
However, the chlamydia burden in private sector populations has not been
well described, and most health services do not have the resources or
technology to generate population-based incidence or prevalence data. In
addition, many chlamydia prevalence rates are determined with less
sensitive tests than were used in our study and may underestimate the true
disease burden.[2]
Chlamydia is mostly an asymptomatic infection with serious
consequences. We were unable to predict risk of infection among adolescent
females based on prior STDs, clinical presentation, or risk behaviors.
Since the risk of pelvic inflammatory disease and its sequelae increase
with the duration of untreated infection, we feel it is cavalier to assume
without supporting evidence that chlamydia is not a hidden problem in any
given adolescent population. Therefore, we recommend screening all
sexually active adolescent females for chlamydia infection twice yearly
until evidence to the contrary is generated.
Gale R Burstein, MD, MPH
Jonathan M Zenilman, MD
Johns Hopkins University
Baltimore, MD
Thomas C Quinn, MD
Johns Hopkins University
Baltimore
National Institute of Health
Bethesda, MD
(1) Burstein GR, Snyder MH, Conley D, Boekeloo B, Quinn TC, Zenilman
JM. Sexually transmitted disease screening practices and diagnosed
infections in a large managed care organization. Sex Transm Dis In Press
(2) Schacter J. Chlamydia trachomatis: the more you look, the more you
find – how much is there? Sex Transm Dis 1998;25:229-231.
(3) Winter L, Goldy AS, Baer C. Prevalence and epidemiologic
correlates of Chlamydia trachomatis in rural and urban populations. Sex
Transm Dis 1990;17:30-36.
(4) Fisher M, Swenson PD, Risucci D, Kaplan MH. Chlamydia trachomatis
in suburban adolescents. J Pediatr 1987;111:617-20.
(5) Cohen DA. Nsuami M. Etame RB. Tropez-Sims S. Abdalian S. Farley
TA. Martin DH. A school-based Chlamydia control program using DNA
amplification technology. Pediatr 1998 101:E1
(6) Burstein GR, Zenilman JM, Gaydos CA, Diener-West M, Howell MR,
Brathwaite W, Quinn TC. Risks of incident Chlamydia trachomatis infections
diagnosed by DNA amplification testing among inner city females with
repeat clinic visits. Sex Transm Infect 2001;77:26-32.
Bailis does not support his claim that male circumcision provides significant protection against disease with recent data. He uses antique data that are highly suspect.1
The Diseker study uses data from inner city STD clinics.2 This introduces significant population bias due to the significantly uneven distribut...
Bailis does not support his claim that male circumcision provides significant protection against disease with recent data. He uses antique data that are highly suspect.1
The Diseker study uses data from inner city STD clinics.2 This introduces significant population bias due to the significantly uneven distribution of ethnic groups within the United States between urban and suburban areas. Moreover, Diseker et al. later reports a 15.6% clinician error in determination of circumcision status.3 Therefore, such data cannot be considered to be reliable. Van Howe's survey of the literature found only a slight reduction in genital ulcer disease (GUD) in circumcised men that was counterbalanced by an increase in urethritis.4 Van Howe reports that the rate of STDs in the United States has increased as the rate of circumcision has increased.4
Laumann et al. report that the United States adult male population is 77% circumcised.5 If circumcision reduced STIs, then one would expect to find the United States to be nearly free of STIs. Such is not the case. Tanne reports an epidemic of STDs in the United States.6
Circumcision is an injurious surgical procedure. There is a high rate of complications.7 Circumcision amputates significant amount of erogenous tissue and leaves a lifetime irreversible injury.8 Adverse sexual and psychological effects are documented.9 The current state of medical science contraindicates the prophylactic use of male circumcision.
George Hill
Executive Secretary
Doctors Opposing Circumcision
2442 NW Market Street, Suite 42
Seattle, Washington 98107
USA
Web: http://faculty.washington.edu/gcd/DOC/
References:
Bailis SA. Letter. Sex Transm Infect 2001;77(6):462-3.
We were interested in the case report, "Perianal Crohns Disease
masquerading as perianal warts"[1] (August)
In which the authors highlight the diagnostic difficulty with other
anogenital conditions such as perianal warts.
Plus the initial lack of obvious bowel symptoms considered to be the
hallmark of Crohns disease.
We too have recently seen a similar case, but in an older women aged
43 wh...
We were interested in the case report, "Perianal Crohns Disease
masquerading as perianal warts"[1] (August)
In which the authors highlight the diagnostic difficulty with other
anogenital conditions such as perianal warts.
Plus the initial lack of obvious bowel symptoms considered to be the
hallmark of Crohns disease.
We too have recently seen a similar case, but in an older women aged
43 who presented with a vulvitis of several months duration, the main
symptoms being pruritis vulvae and superficial dyspareunia. There was
absolutely no gastrointestinal symptoms or systemic upset and past general
health was good.
Initial clinical examination revealed diffuse erythema and swelling
of the Labia Majora, and some perineal fissuring was also noted.
All routine STI screening tests were negative, and a provisional diagnosis
of Vulval Dermatitis was made.
With agreement of the patient a therapeutic trial of Hydrocortisone 1 % was
tried but with no effect.
A vulval biopsy was therefore carried out which revealed histological
features consistent with Crohns disease,i.e. non-caseating granuloma,giant
cells and chronic inflammatory infiltrate.
A colonoscopy was reported as normal and the patient remains asymptomatic.
This case, in common with the reported case[1], reminds us that Crohns
disease can present initially as a common clinical condition to GU
Clinics, such as warts or vulvitis.
The diagnosis rests primarily on biopsy of the lesion,this is especially
so in cases of "metastatic disease"[2] either preceeding bowel involvement
by years,[3] or exclusive involvement of genital tract only.[2]
Is it possible that Crohns disease of the genital tract is an
underdiagnosed condition?
Benjamin Goorney
References
(1) Garg M, Kawsar M, Forster GE, and Medows NJ. Perianal Crohn’s disease masquerading as perianal warts. Sex Transm Infect 2002;78:302-303.
(2) Urbanek M, Neill SM, Mckee PH. Vulval Crohns disease: difficulties in diagnosis. Clinical and Experimental Dermatology 1996;21:211-214.
(3) Bruce L, Donaldson, MD. Crohns disease: its gynecologic aspect. Am J Obstet Gynecol 1978;131:196-202
This has been an interesting study of releasing information about the
reason for encouraging partner notification. I wonder whether it is
possible to have some information about what happened in practice.
Presumably, there were some male patients, who had non-gonococcal
urethritis diagnosed on their first visit, and, at that time, it was not
known whether Chlamydia trachomatis was the cause....
This has been an interesting study of releasing information about the
reason for encouraging partner notification. I wonder whether it is
possible to have some information about what happened in practice.
Presumably, there were some male patients, who had non-gonococcal
urethritis diagnosed on their first visit, and, at that time, it was not
known whether Chlamydia trachomatis was the cause. Was partner
notification encouraged and were contact slips issued then and, if so,
what information did they carry about the patient's diagnosis? If such
patients re-attended when the C. trachomatis result was known to be
positive, were revised contact slips issued?
We read with interest the recent report by Kampman et al, 2016 [1] on the effect of text reminders on patients attending for repeat chlamydia tests and chlamydia diagnosis.
In our service, the St. Ann's Sexual Health Centre, a GUM clinic in London, UK, our routine practice was to verbally advise patients treated for chlamydia to re-attend 6-8 weeks after treatment for re-testing. Sexual health appointments are...
I am flabbergasted that this public health article exists at all. Where is the peer review. The problem lies in the appropriateness of source data which was used. In an email exchange I confirmed that I understood that the authors did indeed divide interviewed sex workers into two groups, one that experienced violence in the single preceding week and a second group that did not. They then compared health data for diff...
Whilst it is comforting that some research is finally being carried out in depth on the risk of STIs amongst women who have sex with women (WSW), any conclusions drawn from this study for WSW in general need to be handled with a great deal of caution when one looks at the make-up of the subjects and controls.
For example, over twice as many of the WSW as the control group were current sex workers;...
Mr McElborough considers it unfortunate that reference labs may have developed their algorithms in the case of conventional syphilis diagnosis and these do little to help with HIV coinfected patients. Guidelines for serological diagnosis in coexisting HIV infection, neurosyphilis and congenital infection are currently under preparation by the (Public Health Laboratory Service) PHLS Syphilis Forum and will...
Burstein and colleagues present interesting data concerning repeat diagnosis of Chlamydia trachomatis in inner city women. Their data may however not support all their conclusions. In their methods section they state that “the frequency of diagnosis of first incident infection was estimated by calculating the median time interval in months between first test and first positive test during the study period a...
Low and colleagues present a very important paper. They should be given the opportunity to remove my doubts about the validity of their findings: They used a cross sectional design to determine incidence; however, unless the average duration of conditions is known longitudinal studies are required to determine this. The presented study assessed disease status of self-selected participants over a period of...
Dear Editor,
Although our study population was homogeneous and Baltimore is known to have high sexually transmitted disease (STD) rates, we believe sufficient evidence exists to support our recommendation of twice yearly chlamydia screening of sexually active females less than 25 years of age. Chlamydia screening in most adolescent female populations yields prevalence rates greater than 10%, except in areas wit...
Dear Editor
We were interested in the case report, "Perianal Crohns Disease masquerading as perianal warts"[1] (August) In which the authors highlight the diagnostic difficulty with other anogenital conditions such as perianal warts. Plus the initial lack of obvious bowel symptoms considered to be the hallmark of Crohns disease.
We too have recently seen a similar case, but in an older women aged 43 wh...
Dear Editor
This has been an interesting study of releasing information about the reason for encouraging partner notification. I wonder whether it is possible to have some information about what happened in practice. Presumably, there were some male patients, who had non-gonococcal urethritis diagnosed on their first visit, and, at that time, it was not known whether Chlamydia trachomatis was the cause....
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