Pharyngeal and Rectal Testing for Chlamydia trachomatis in MSM:
Evidence Base
Dr Watson requests the evidence base that screening asymtomatic Men
who have Sex with Men (MSM) for C. trachomatis in the throat and the
rectum confers either the patient or their contacts any benefit. When
considering this question it is important to remember that our current
knowledge regarding the natural hi...
Pharyngeal and Rectal Testing for Chlamydia trachomatis in MSM:
Evidence Base
Dr Watson requests the evidence base that screening asymtomatic Men
who have Sex with Men (MSM) for C. trachomatis in the throat and the
rectum confers either the patient or their contacts any benefit. When
considering this question it is important to remember that our current
knowledge regarding the natural history of chlamydia infection is
currently incomplete and consequently when Chlamydia is detected -
irrespective of site or symptomatology- it is always regarded as a
pathogen.
To date there is strong evidence base that the rectum is a very
important reservoir of Chlamydia infection in MSM.1,2,3,4,5,6,7 In recent
years several large studies have been undertaken and the prevalence of
rectal Chlamydia in MSM attending sexual health clinics has been
determined to be in the range of 6.96 - 11%. 1,2,3,4,5,6,7 Whilst it is
undeniable that the vast majority of the non-LGV associated rectal
Chlamydia infection seen, is asymptomatic,2,4 it is widely acknowledged
that it is a reservoir for potential onward transmission. 1,2,3,4,5,6,7
Currently fewer studies have been undertaken examining the pharynx as
a site for C. trachomatis infection. However it is noteworthy that in the
studies that have been undertaken, the prevalence of pharyngeal C.
trachomatis has been consistently found to 1-2% 5,6,7,8. Interestingly
studies have also shown that ~66-100% of chlamydia infections in the
pharynx occurred without concurrent urethral Chlamydia infection, and
consequently if urine testing alone had been performed the infection would
have gone undetected. 5,8
Several studies examining MSM behaviour have highlighted that
urethral Chlamydia infection can be associated with insertive unprotected
anal intercourse, insertive oral sex and other non-intercourse receptive
anal practises9,10. This information suggests that extra-genital
Chlamydial infection (both pharyngeal and rectal) is transmitted to sexual
contacts. These contacts may go on to develop symptoms - this is more
likely if a urethral infection is acquired- or maybe in turn, will exist
as a further reservoir of Chlamydia infection. Both scenarios are
undesirable and where possible would be ideally avoided.
Finally it is important to put this discussion into context: in my
original editorial I advocated for the increased use of dual NAATs to test
extra-genital specimens (which would enable the detection of both
chlamydia and gonorrhoea) and improving the availability of rectal and
pharyngeal testing to all MSM who are at risk of infection.11 This is
important because any patient attending a sexual health service for an STI
screen does so to ensure that they are either (i) absent from infection or
(ii) if an STI is detected- to receive appropriate therapy-. Given the
high prevalence of asymptomatic extra-genital Chlamydia and gonococcal
infections in MSM, offering both pharyngeal and rectal screening would be
undeniably beneficial to both the individual concerned and their sexual
contacts.
Yours Sincerely
Sarah Alexander
Sexually Transmitted Bacteria Reference Laboratory
Health Protection Agency
References
1. Clinic-based testing for rectal and pharyngeal Neisseria
gonorrhoeae and Chlamydia trachomatis infections by community-based
organizations--five cities, United States, 2007. Centers for Disease
Control and Prevention (CDC). MWR Morb Mortal Wkly Rep. 2009 Jul
10;58(26):716-9.
2. Ward H, Alexander S, Carder C, Dean G, French P, Ivens D, Ling C,
Paul J, Tong W, White J, Ison CA. The prevalence of lymphogranuloma
venereum infection in men who have sex with men: results of a multicentre
case finding study. Sex Transm Infect. 2009 Jun;85(3):173-5.
3. van der Helm JJ, Hoebe CJ, van Rooijen MS, Brouwers EE, Fennema
HS, Thiesbrummel HF, Dukers-Muijrers NH. High performance and
acceptability of self-collected rectal swabs for diagnosis of Chlamydia
trachomatis and Neisseria gonorrhoeae in men who have sex with men and
women. Sex Transm Dis. 2009;36(8):493-7.
4. Annan, N.T., A K Sullivan, A Nori, P Naydenova, S Alexander, A
McKenna, B Azadian, S Mandalia, M Rossi, H Ward and N Nwokolo. Rectal
chlamydia_a reservoir of undiagnosed infection in men who have sex with
men. Sex Transm Inf 2009;85;176-179.
5. Ota KV, Tamari IE, Smieja M, Jamieson F, Jones KE, Towns L, Juzkiw
J, Richardson SE. Detection of Neisseria gonorrhoeae and Chlamydia
trachomatis in pharyngeal and rectal specimens using the BD Probetec ET
system, the Gen-Probe Aptima Combo 2 assay and culture. Sex Transm Infect.
2009 Jun;85(3):182-6. Epub 2009 Jan 6.
6. Benn PD, Rooney G, Carder C, Brown M, Stevenson SR, Copas A,
Robinson AJ, Ridgway GL. Chlamydia trachomatis and Neisseria gonorrhoeae
infection and the sexual behaviour of men who have sex with men. Sex
Transm Infect. 2007 Apr;83(2):106-12.
7. Kent CK, Chaw JK, Wong W, Liska S, Gibson S, Hubbard G, Klausner
JD. Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea
detected in 2 clinical settings among men who have sex with men: San
Francisco, California, 2003. Clin Infect Dis. 2005 Jul 1;41(1):67-74. Epub
2005 May 26.
8. D J Templeton, F Jin, J Imrie, G P Prestage, B Donovan, P H
Cunningham, J M Kaldor, S Kippax, A E Grulich. Prevalence, incidence and
risk factors for pharyngeal chlamydia in the community based Health in Men
(HIM) cohort of homosexual men in Sydney, Australia Sex Transm Infect
2008;84:361-363.
9. Jin F, Prestage GP, Mao L, et al. Incidence and risk factors for
urethral and anal gonorrhoea and chlamydia in a cohort of HIV-negative
homosexual men: the Health in Men Study. Sex Transm Infect 2007;83:113-9.
10. Lafferty WE, Hughes JP, Handsfield HH. Sexually transmitted
diseases in men who have sex with men. Acquisition of gonorrhea and
nongonococcal urethritis by fellatio and implications for STD/HIV
prevention. Sex Transm Dis. 1997 May;24(5):272-8.
11. Alexander, S. The challenges of detecting gonorrhoea and
chlamydia in rectal and pharyngeal sites: could we, should we, be doing
more? Sex Transm Infect. 2009;85:159-160.
For more than 50 years the etiology of bacterial vaginosis,
originally desribed as a sexually transmitted disease (1,2) has been
considered controversial. The mainstream of studies on BV have been
focused on the microbiology of vagina in concert with the original view
of a contagious disease. No doubt, those studies like the present one by
Haggerty et al.(3), discussed by Hay (4),have expanded our...
For more than 50 years the etiology of bacterial vaginosis,
originally desribed as a sexually transmitted disease (1,2) has been
considered controversial. The mainstream of studies on BV have been
focused on the microbiology of vagina in concert with the original view
of a contagious disease. No doubt, those studies like the present one by
Haggerty et al.(3), discussed by Hay (4),have expanded our knowledge and
have entertained possibilities of their pathogenic significance. Still,
those studies have failed to provide a concept that would explane the
basic nature of BV.
An alternative concept of BV as a physiological entity rests on the
premise that the female vagina is not only a reservoir of microbes; the
adult vagina is in the first place a copulatory organ with a function in
the physiology of reproduction (5).This concept derived from observations
on direct stained cervicovaginal smears in which the precoital
Lactobacilli morphotype flora was seen to be replaced by Haemophilus
vaginalis morphotype flora in postcoital smears.The phenomenon was
interpreted to indicate that in response to unprotected intercourse, i.e.
male ajaculate and vaginal transudate, the vaginal bacterial flora may
change rapidly and completely from the predominance of Lactobacilli
morphotype to that of Haemophilus ( Gardnerella) vaginalis morphotype and
that the change is reversible (6,7,8).
The change in bacterial dominance is in line with the observation
that the male ejaculate may immediately neutralize the basic vaginal
acidity to protect the ejaculated spermatozoa, and that a return to the
basic acidity may take place shortly after the effect of the ejaculate is
over (5).
However, in case the restoration of the precoital physiology fails,
as has been observed in women who have engaged in unprotected intercourse
repeatedly and at short intervals (9), the low acidity associated with
Gardnerella flora would persist and invite an invasion of anaerobic
microbes and an inflammatory symptomatic form of BV would develope -
meaning in fact the return to the once abandoned "nonspecific" vaginitis
(1).
It seems feasible that BV is by origin a physiological postcoital
condition, not a contagious disease;consequently Hv/G vag. bacterium would
be a natural organism in the vagina rather than a contagious microbe and
the Hv/G vag. flora another physiological flora in women of reproductive
age.
Of note, the results of the inoculation experiments, presented as an
evidence for a contagious nature of Hv vaginitis (1,2) were likely to be a
coitus-induced change of Lactobacilli flora, as in those experiments the
sex life of the study subjects was not considered. Likewise the isolation
of Hv bacteria from most consorts of "infected" women and in one case from
a previously "healthy" wife and her husband immediately following marriage
would rather speak for a coitus-induced change of flora.
Bacterial vaginosis is a potential condition in sexually active women
worldwide and it is getting to be more of a problem each passing year. In
view of the prevaling concept of BV, the physiological concept should be
discussed and criticized in an open forum.
Pentti A. Leppäluoto
Finnish Cancer Society (ret.)
leppaluoto@kolumbus.fi
References
1. Gardner HL, Dukes CD. Haemophilus vaginalis vaginitis. A newly
defined specific infection previously classified "nonspecific" vaginitis.
Am J Obstet Gynecol 1955;69:962-76.
2. Criswell BS, Ladwig CL, Gardner HL, Dukes CD. Haemophilus
vaginalis. Vaginitis by inoculation from culture. Obstet Gynecol
1969;33:195-9.
3. Haggerty CL, Totten PA, Ferris M, Martin DH, Hoferka S,Astete SG,
Ondondo R, Norori J and Ness RB. Clinical characteristics of bacterial
vaginosis among women testing positive for fastidious bacteria. Sex Transm
Inf 2009;85:242-8.
4. Hay P. How important are the newly described bacteria in bacterial
vaginosis? Sex Transm Dis 2009;85:240-1.
5. Masters WH, Johnson VE. Human sexual response. London UK: J&A
Churchill Ltd;1966. p.88-100.
6. Leppäluoto PA.The etiology of the cocci-type "streptokokkentyp"
vaginal smear. Acta Cytol 1971;15:211-5. Errata: wrong pictures. Idem.
1971;15:577.
7. Leppäluoto PA.The coitus-induced dynamics of vaginal bacteriology.
J Reprod Med 1971;7:169-75.
8. Leppäluoto PA. Autopsy of bacterial vaginosis: a physiological
entity rather than a contagious disease. Acta Obstet Gynecol Scand
2008;87:578-9.
9. Döderlein A.Das Scheidensekret und seine Bedeutung fur das
Puerperalfieber. Die Arten des Scheidensekrets. Leipzig:Verlag Eduard
Besold (Arthur Georgi); 1892.p.46.
The locations on body of sexual transmited infections with Human
papilloma viruses, can corelate with "inovationes" in sexual behaviour. It
is logical that the viral afectiones (condilomata, precancerous lesions
and carcinoma) can be located on cervix, vulva, glans penis, anal region,
oral region and tongue, haed and neck, larinx, oesophagus and breast! Very
important is the maybe causal connection between human papilloma...
The locations on body of sexual transmited infections with Human
papilloma viruses, can corelate with "inovationes" in sexual behaviour. It
is logical that the viral afectiones (condilomata, precancerous lesions
and carcinoma) can be located on cervix, vulva, glans penis, anal region,
oral region and tongue, haed and neck, larinx, oesophagus and breast! Very
important is the maybe causal connection between human papilloma virus
infection and the breast carcinoma!
Data revealed that apart from the heart and the kidney, the virus has been
found in all other organs that have been analyzed so far, i.e., prostate,
urinary bladder, oral cavity, larynx, esophagus, stomach, colon, liver,
vagina/vulva, endometrium, ovary, breast, penis, anus, skin, and lung.
Some of the detection rates are remarkable, e.g., colon cancer up to 97%,
lung cancer 80%, and breast cancer 74% (Petersen I, Klein F., 2008)*.
Maybe the new antiviral therapy and the Gardasil vaccination can be
helpful by different type of malignancy, especially by very frequent and
dangerous brest, anal and ovarian cancers.
It is a shame that Dr Alexander's opening sentence: "It is important
that all men who have sex with men (MSM) accessing sexual health-care are
tested for Neisseria gonorrhoeae and Chlamydia trachomatis (CT) at all
anatomical sites where they may be at risk of infection.", is not
referenced.
I should appreciate being directed to the evidence that screening
asymtomatic MSM for CT in the throat or rectum confers t...
It is a shame that Dr Alexander's opening sentence: "It is important
that all men who have sex with men (MSM) accessing sexual health-care are
tested for Neisseria gonorrhoeae and Chlamydia trachomatis (CT) at all
anatomical sites where they may be at risk of infection.", is not
referenced.
I should appreciate being directed to the evidence that screening
asymtomatic MSM for CT in the throat or rectum confers them or anyone else
with any benefit. A simple number needed to screen per defined benefit
would do.
The results published by Kalichman et. al. on anal intercourse (AI)
practices among heterosexuals in South Africa [1] and the associated
editorial by Boily et. al. [2] are important contributions to our
understanding of HIV transmission. While a small proportion of men (14%)
and women (10%) report engaging in heterosexual AI [1], this mode of
exposure could be important to overall HIV transmission rates because the
ris...
The results published by Kalichman et. al. on anal intercourse (AI)
practices among heterosexuals in South Africa [1] and the associated
editorial by Boily et. al. [2] are important contributions to our
understanding of HIV transmission. While a small proportion of men (14%)
and women (10%) report engaging in heterosexual AI [1], this mode of
exposure could be important to overall HIV transmission rates because the
risk of transmission through receptive AI is approximately 10-times
greater than through receptive vaginal intercourse (VI) [3-9]. In
particular, women who engage in AI may be at much higher risk of acquiring
HIV as ~43% of their reported sexual acts involve anal sex [1]. Based on
the results from the Kalichman et. al. cross-sectional study we estimate
the relative contribution of AI to HIV incidence among heterosexual
populations in South Africa.
The estimated risk of HIV transmission per unprotected act is
approximately 0.08% for receptive VI, 0.8% for receptive AI, and 0.04% for
insertive VI or AI [3-7]. Assuming condoms are 95% effective in reducing
the risk of HIV transmission [10-14] and using a binomial equation [15] we
estimate the cumulative risk of HIV transmission over numerous risk
exposures (at the median frequencies of VI, AI, and mean condom use
reported in [1]) for both men and women who engage in AI and for those who
only engage in VI.
The risk of HIV transmission to females in a discordant partnership is
greatly increased if they engage in AI. Assuming each female only has one
discordant sexual partner, we estimate that the 3-monthly risk of HIV
acquisition for females who only engage in VI is 0.2% but the risk
increases by 7.5-times, to 1.5%, if they also engage in AI, with 89% of
their risk attributable to AI.
Although only 10% of heterosexual women engage in AI, we estimate that 45%
of the total female population incidence of HIV occurs among these women.
Our estimates suggest that the prevalence of HIV in females who engage in
anal sex should be much higher than in the rest of the population.
Although Kalichman et. al. did not report prevalence by gender, their
study indicated that 9% of those who did not engage in anal intercourse
were HIV-positive compared with 22% among those who engaged in anal
intercourse [1].
Our simple calculations, underpinned by the frequency of reported AI and
VI among heterosexuals [1] and known transmission risk estimates,
highlight that heterosexual anal intercourse does not have to be very
common in a population to have a large impact on HIV incidence
particularly among females. The Kalichman et. al. study highlights the
importance of accurately surveying the type and frequency of sexual
behaviour within populations and the need to openly study and discuss
heterosexual anal intercourse. Heterosexual anal sex may contribute more
to HIV epidemics than previously assumed.
References
1. Kalichman, S., et al., Heterosexual Anal Intercourse among
Community and Clinical Settings in Cape Town, South Africa. Sexually
transmitted infections, 2009: p. 411-5.
2. Boily, M.-c. and R.F. Baggaley, The role of heterosexual anal
intercourse for HIV transmission in developing countries: are we ready to
draw conclusions? Sexually Transmitted Infections, 2009. 85: p. 6-8.
3. de Vincenzi, I., A longitudinal study of human immunodeficiency
virus transmission by heterosexual partners. European Study Group on
Heterosexual Transmission of HIV. N Engl J Med, 1994. 331(6): p. 341-6.
4. Padian, N.S., et al., Heterosexual transmission of human
immunodeficiency virus (HIV) in northern California: results from a ten-
year study. Am J Epidemiol, 1997. 146(4): p. 350-7.
5. Vittinghoff, E., et al., Per-contact risk of human
immunodeficiency virus transmission between male sexual partners. Am J
Epidemiol, 1999. 150(3): p. 306-11.
6. Gray, R.H., et al., Probability of HIV-1 transmission per coital
act in monogamous, heterosexual, HIV-1-discordant couples in Rakai,
Uganda. Lancet, 2001. 357(9263): p. 1149-53.
7. Wawer, M.J., et al., Rates of HIV-1 Transmission per Coital Act,
by Stage of HIV-1 Infection, in Rakai, Uganda. J Infect Dis, 2005. 191(9):
p. 1403-9.
8. Koblin, B.A., et al., Risk factors for HIV infection among men who
have sex with men. AIDS, 2006. 20(5): p. 731-9.
9. Read, T.R.H., et al., Risk factors for incident HIV infection in
men having sex with men: a case-control study. Sexual Health, 2007. 4: p.
35-39.
10. Davis, K.R. and S.C. Weller, The effectiveness of condoms in
reducing heterosexual transmission of HIV. Family Planning Perspectives,
1999. 31: p. 272-9.
11. Weller, S.C. and K.R. Davis, Condom effectiveness in reducing
heterosexual HIV transmission. Cochrane Database Syst Rev, 2002. (1): p.
CD003255.
12. Pinkerton, S.D. and P.R. Abtramson, Effectiveness of condoms in
preventing HIV transmission. Social Science and Medicine, 1997. 44: p.
1303-12.
13. Weller, S.C., A meta-analysis of condom effectiveness in reducing
sexually transmitted HIV. Social Science and Medicine, 1993. 36(12): p.
1635-44.
14. Fitch, T.J., et al., Condom Effectiveness: Factors that influence
risk reduction. Sexually Transmitted Diseases, 2002. 29: p. 811-7.
15. Wilson, D.P., et al., Relation between HIV viral load and
infectiousness: a model-based analysis. Lancet, 2008. 372(9635): p. 314-
20.
Sir: The editorial by Sheldon R Morris1 concludes that the rationale
for a vaccine that includes HPV 6 and 11 is compelling. The British
Association for Sexual Health & HIV also thought the evidence was
compelling and said so in a press release2. The choice of Cervarix over
Gardasil was indeed a sad day for Sexual Health in the UK3. The key to
the decision in the UK was the perceived cost to the NHS of genital...
Sir: The editorial by Sheldon R Morris1 concludes that the rationale
for a vaccine that includes HPV 6 and 11 is compelling. The British
Association for Sexual Health & HIV also thought the evidence was
compelling and said so in a press release2. The choice of Cervarix over
Gardasil was indeed a sad day for Sexual Health in the UK3. The key to
the decision in the UK was the perceived cost to the NHS of genital warts.
This is explored extensively in the editorial by Morris, who concluded
that for the bivalent vaccine to be economic it would potentially need to
cost 50% less than the quadrivalent vaccine. Economic evaluation by Jit
et al4 on which the Joint Committee for Vaccination and Immunisation base
their conclusions, is inherently flawed. Jit et al only looked at one
small study from a DGH to make the extraordinary conclusion that genital
warts only cost the NHS £134 per episode. The burden of laryngeal
papilloma (also caused by types 6 and 11) was not considered. However, one
of the largest multi-centre studies done in the United Kingdom5, which
included two authors from that same DGH, concluded in 2003 that using one
of the cheapest and commonest treatments, ie. Podophyllotoxin cream, the
total average direct and indirect cost per patient was £573. Studies in
USA and Canada may not reflect costs in the United Kingdom where the vast
majority of warts are treated on the NHS. For example, if I was treating
a genital wart patient (which I don’t) using my own home as an office, I
could probably do it for £160 an episode (first visit – £80 for
trichloroacetic acid and a private prescription for Podophyllotoxin or
Imiquimod, and two follow-up visits of £40 plus / minus further
prescriptions. However, the NHS has to take into consideration the vast
structure and administrative costs that goes with running a public
service.
Even using PBR (payment by results), it’s £153 for a new visit in Chester
with £90 per follow-up, bringing the cost up to £333 for just a first
visit and two follow-ups.
The BASHH press release emphasised the potential early pay back from
including 6 & 11, and indeed this has proved to be the case in
Australia where within a year of the vaccination programme being complete
there was a 48% reduction in new female genital wart cases presenting to
one of the biggest STD clinics6.
I have continued to write to Ministers of Health asking for an explanation
of this decision, but I can’t get an answer to the one simple question –
why was the key economic factor for the valuation of a multi million pound
contract, that had huge implications for NHS Sexual Health services, based
on one small study from a DGH ?
Dr Colm O'Mahony MD. FRCP. BSc. DIPVen.
Department of Sexual Health (GUM)
Countess of Chester Foundation Trust Hospital. Liverpool Road. Chester.
CH2 1UL
References
1. Morris, SR
HPV vaccine strategies: the cost of HPV and the choice of vaccine
Sex Transm Infect 2009;85:315-316
3. O’Mahony, C.
Government decision on national human papillomavirus vaccine programme is
a sad day for sexual health. Sex Transm Infect 2008;84:251
4. Jit M, Hong Choi Y, Edmonds WJ
Economic evaluation of human papillomavirus vaccination in the United
Kingdom
BMJ 2008;337:a769
5. Lacy CJN et al
Randomised controlled trial and economic evaluation of podophyllotoxin
solution, podophyllotoxin cream, and podophyllin in the treatment of
genital warts.
Sex Trasm Infect August 2003;79:270-275
6. Fairley, K.
Decline in presentations of genital warts one year after implementation of
quadrivalent Human Papillomavirus vaccination program in young women.
25th International Papillomavirus Conference, Malmo (Sweden), 8-14 May
2009
In a recent leading article Alexander (1) citing in particular recent work with men who have sex with men (MSM) in the USA (2), has suggested that
when examining extra-genital specimens from high risk patient groups, GC culture should be replaced by GC nucleic acid amplification tests (NAATs).
We agree with this conclusion but believe that the higher sensitivity of GC NAATs should be promoted to allow imp...
In a recent leading article Alexander (1) citing in particular recent work with men who have sex with men (MSM) in the USA (2), has suggested that
when examining extra-genital specimens from high risk patient groups, GC culture should be replaced by GC nucleic acid amplification tests (NAATs).
We agree with this conclusion but believe that the higher sensitivity of GC NAATs should be promoted to allow impact on wider populations. There is already growing evidence in the UK that GC NAATs (with alternative target confirmation to avoid issues of low positive predictive
value) can accurately detect substantial numbers of cases beyond those found by culture and by current diagnostic service structures. A Scottish study (3) found more than double the cases of GC when testing throat and
rectum of men by NAATs instead of culture but also reported extra cases among females tested.
We have recently reported on detection of GC (when testing for Chlamydia) by use of the APTIMA Combo2 (AC2) assay with alternative target confirmation (4). In a GU medicine clinic AC2 detected some 20% extra cases
of GC beyond culture. Also compared to self-referral at a GU medicine clinic, community tests made a substantial contribution to the overall number of GC cases found (40 community versus 35 Macclesfield GU clinic). There were no culture- positive but AC2 negative results in any of our
patients. Of over15000 tests performed both at the community and at the GU medine clinic, only one was positive for GC by AC2 but unconfirmed by the
alternative assay. In the community, over 60% of GC infections occurred in chlamydia negatives so dual testing at the outset would find more GC cases than reflex testing of those screened chlamydia positive. Wider considered use of GC NAATs should be encouraged.
M Mahto
Department of GU Medicine
Cheshire East Community Health (Central and Eastern Cheshire PCT)
Macclesfield, SK11 6JL, UK
H Mallinson
Haytor
Crosby
Liverpool
L23, UK
Correspondence to: Dr M Mahto, Consultant Physician Genitourinary Medicine Department
Assura Health and Wellness Centre
Sunderland Street
Macclesfield, SK11 6JL, UK
Email - mrinalini.mahto@echeshire-tr.nwest.nhs.uk
References
1. Alexander S. The challenges of detecting gonorrhoea and chlamydia in rectal and pharyngeal sites: could we, should we, be doing more? Sex Transm Infect 2009;85:159-160
2. Ota KV, Tamari IE, Smieja M et al. Detection of Neisseria gonorrhoeae and Chlamydia trachomatis in pharyngeal and rectal specimens using the BD Probetec ET system, the Gen-probe Aptima Combo2 assay and
culture. Sex Transm Infect 2009;85;182-6
3. Scottish Guidelines for Molecular testing of Neisseria gonorrhoeae. See
http://www.hps.scot.nhs.uk/training/presentations.aspx?id=167
4. Mahto M, Zia S, Ritchie D and Mallinson H. Diagnosis, management and prevalence estimation of gonorrhoea: influences of Aptima Combo 2 assay with alternative target confirmation. International Journal of STD and AIDS 2009;20:315-319
Although lymphogranuloma venereum (LGV) as a cause of severe proctitis is well known amongst genitourinary and gastroenterological specialists, it remains absent from a common list of causes of rectal bleeding amongst General Practitioners and Surgeons. An example is a case of a homosexual man who presented as a 2 week rule urgent referral to the Colorectal clinic with painless rectal bleeding and went on...
Although lymphogranuloma venereum (LGV) as a cause of severe proctitis is well known amongst genitourinary and gastroenterological specialists, it remains absent from a common list of causes of rectal bleeding amongst General Practitioners and Surgeons. An example is a case of a homosexual man who presented as a 2 week rule urgent referral to the Colorectal clinic with painless rectal bleeding and went on to have endoscopy and biopsies for proctitis. It would not have been unreasonable
to start this patient on steroids or mesalazine enemas for symptom control while awaiting the results of biopsies. In this instance, however, it was only after telephone consultation with an HIV specialist and referral to
the Genitourinary Medicine clinic that a diagnosis of LGV proctitis was reached several weeks later. Steroids’ would almost certainly have made this condition worse and may even have resulted in a rectal perforation.
Helen Ward (3) ask the question about the extent of the Lymphogranuloma venereum (LGV) in the wider population than that of men who have sex with men (MSM). A rospective sentinel survey set up in France following the European alert in January 2004 tried to answer this question.
From April 2002 to December 2008, rectal samples from MSM were collected by the French National Reference Centre for Chlamydia infec...
Helen Ward (3) ask the question about the extent of the Lymphogranuloma venereum (LGV) in the wider population than that of men who have sex with men (MSM). A rospective sentinel survey set up in France following the European alert in January 2004 tried to answer this question.
From April 2002 to December 2008, rectal samples from MSM were collected by the French National Reference Centre for Chlamydia infections from mainly 3 labs in Paris and some labs in France. All the C. trachomatis-positive rectal samples were genotyped. Over 1041 positive specimens
genotyped, 725 L2 serovars and 316 non-LGV associated serovars (mainly Da,G, and J) were identified.
Simultaneously, C. trachomatis-positive genital specimens were tested for the presence of LGV strains by a specific genovar L Taqman Real-time PCR (2). A total of 2662 urogenital specimens (1095 urethral or male urine
specimens and 1567 vaginal, cervical or female urine specimens) were tested. These specimens were obtained between 2004 and 2008 in Paris, Bordeaux, and from Pasteur Cerba laboratory, a central French laboratory
that received specimens from all over the country. No LGV strain was found except one in the urethral male sample of one HIV(+) gay man. This is the second case of urethritis due to a C. trachomatis genovar L2 in France,
the first one having been already published in 2006 (1). We can conclude that, in France, LGV remains essentially a rectal infection in MSM.
Acknowledgments: we thank Dr Georges Kreplack, Patrice Sednaoui, Catherine Scieux Sabine Trombert, for providing C. trachomatis-positive specimens from Paris and Cerba laboratory.
References
1. Herida, M., G. Kreplack, B. Cardon, J. C. Desenclos, and B. de Barbeyrac. 2006. First case of urethritis due to Chlamydia trachomatis genovar L2b. Clinical Infectious Diseases 43:268-269.
2. Morre, S. A., J. Spaargaren, J. S. A. Fennerna, H. J. C. de Vries, R. A. Coutinho, and A. S. Pena. 2005. Real-time polymerase chain reaction to diagnose lymphogranuloma venereum. Emerging Infectious Diseases 11:1311-
1312.
3. Ward, H., and R. F. Miller. 2009. Lymphogranuloma venereum: here to stay? Sex Transm Infect 85:157.
From this paper we get a good idea on the medical and nursing costs for managing warts but a major cost for the NHS is the building, furnishings, equipment, phones, all other satffing i.e secretaries, reception, managers, finance, personnel etc. This is estimated at about 20% to 25% and should have been mentioned. Some detail about what drugs were used would have been good. In my clinic we treat 800 new...
From this paper we get a good idea on the medical and nursing costs for managing warts but a major cost for the NHS is the building, furnishings, equipment, phones, all other satffing i.e secretaries, reception, managers, finance, personnel etc. This is estimated at about 20% to 25% and should have been mentioned. Some detail about what drugs were used would have been good. In my clinic we treat 800 new warts per year and HPV drug costs are about £35,000 giving about £44 per patient. Using payment by results (PBR)calculations our cost per case is above £400 per case.
Dear Editors,
Pharyngeal and Rectal Testing for Chlamydia trachomatis in MSM: Evidence Base
Dr Watson requests the evidence base that screening asymtomatic Men who have Sex with Men (MSM) for C. trachomatis in the throat and the rectum confers either the patient or their contacts any benefit. When considering this question it is important to remember that our current knowledge regarding the natural hi...
Dear Editor,
For more than 50 years the etiology of bacterial vaginosis, originally desribed as a sexually transmitted disease (1,2) has been considered controversial. The mainstream of studies on BV have been focused on the microbiology of vagina in concert with the original view of a contagious disease. No doubt, those studies like the present one by Haggerty et al.(3), discussed by Hay (4),have expanded our...
The locations on body of sexual transmited infections with Human papilloma viruses, can corelate with "inovationes" in sexual behaviour. It is logical that the viral afectiones (condilomata, precancerous lesions and carcinoma) can be located on cervix, vulva, glans penis, anal region, oral region and tongue, haed and neck, larinx, oesophagus and breast! Very important is the maybe causal connection between human papilloma...
It is a shame that Dr Alexander's opening sentence: "It is important that all men who have sex with men (MSM) accessing sexual health-care are tested for Neisseria gonorrhoeae and Chlamydia trachomatis (CT) at all anatomical sites where they may be at risk of infection.", is not referenced.
I should appreciate being directed to the evidence that screening asymtomatic MSM for CT in the throat or rectum confers t...
The results published by Kalichman et. al. on anal intercourse (AI) practices among heterosexuals in South Africa [1] and the associated editorial by Boily et. al. [2] are important contributions to our understanding of HIV transmission. While a small proportion of men (14%) and women (10%) report engaging in heterosexual AI [1], this mode of exposure could be important to overall HIV transmission rates because the ris...
Sir: The editorial by Sheldon R Morris1 concludes that the rationale for a vaccine that includes HPV 6 and 11 is compelling. The British Association for Sexual Health & HIV also thought the evidence was compelling and said so in a press release2. The choice of Cervarix over Gardasil was indeed a sad day for Sexual Health in the UK3. The key to the decision in the UK was the perceived cost to the NHS of genital...
Dear Editor,
In a recent leading article Alexander (1) citing in particular recent work with men who have sex with men (MSM) in the USA (2), has suggested that when examining extra-genital specimens from high risk patient groups, GC culture should be replaced by GC nucleic acid amplification tests (NAATs). We agree with this conclusion but believe that the higher sensitivity of GC NAATs should be promoted to allow imp...
Dear Editor,
Although lymphogranuloma venereum (LGV) as a cause of severe proctitis is well known amongst genitourinary and gastroenterological specialists, it remains absent from a common list of causes of rectal bleeding amongst General Practitioners and Surgeons. An example is a case of a homosexual man who presented as a 2 week rule urgent referral to the Colorectal clinic with painless rectal bleeding and went on...
Dear Editor,
Helen Ward (3) ask the question about the extent of the Lymphogranuloma venereum (LGV) in the wider population than that of men who have sex with men (MSM). A rospective sentinel survey set up in France following the European alert in January 2004 tried to answer this question. From April 2002 to December 2008, rectal samples from MSM were collected by the French National Reference Centre for Chlamydia infec...
Dear Editor,
From this paper we get a good idea on the medical and nursing costs for managing warts but a major cost for the NHS is the building, furnishings, equipment, phones, all other satffing i.e secretaries, reception, managers, finance, personnel etc. This is estimated at about 20% to 25% and should have been mentioned. Some detail about what drugs were used would have been good. In my clinic we treat 800 new...
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