Chlamydia Screening in New Zealand: Report for the National Screening Unit July 2006




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Chlamydia Screening
in New Zealand: Report for the National Screening Unit


July 2006

Dr Jillian Sherwood

Public Health Medicine Registrar
Published in December 2006 by the
Ministry of Health
PO Box 5013, Wellington, New Zealand

ISBN 0-478-30090-5

This document is available on the Ministry of Health’s website:
http://www.moh.govt.nz


Contents


Contents iv

List of Tables vi

1 Executive summary 1

1.1 Background 1

1.2 Aim and objectives 1

1.3 Methods 1

1.4 Results 2

1.5 Recommendations 5

2 Introduction 7

2.1 Aim of report 7

2.2 Objectives 7

2.3 Methods and structure of the report 7

3 Background 9

4 Examination of chlamydia screening using the NHC screening assessment criteria 11

4.1 Criterion 1: The condition is a suitable candidate for screening 11

4.2 Criterion 2: There is a suitable test 15

4.3 Criterion 3: There is an effective and accessible treatment or intervention identified for the condition through early detection 16

4.4 Criterion 4: There is high-quality evidence, ideally from randomised controlled trials, that the screening programme is effective in reducing mortality or morbidity 17

4.5 Criterion 5: The potential benefit from the screening programme should outweigh the potential physical and psychological harm (caused by the test, diagnostic procedures and treatment) 18

4.6 Criterion 6: The health care system will be capable of supporting all necessary elements of the screening pathway, including diagnosis, follow-up and programme evaluation 19

4.7 Criterion 7: There should be consideration of social and ethical issues 21

4.8 Criterion 8: There should be consideration of cost-benefit issues 22

5 Chlamydia screening policies and programmes in other OECD countries 26

5.1 Chlamydia screening programme in England 26

5.2 Chlamydia screening in other European countries 28

5.3 Chlamydia screening programme in Australia 29

5.4 Chlamydia screening in the United States 30

5.5 Chlamydia screening in Canada 30

5.6 Conclusions 31

6 Review of New Zealand-based research and specific projects on chlamydia screening 32

6.1 Chlamydia Screening in Wellington FPA Clinics 32

6.2 Whangarei Chlamydia Trachomatis Screening Project 34

6.3 Health Research Council Proposal: Tackling the chlamydia epidemic in New Zealand youth: an RCT in primary care 36

6.4 Health Research Council Proposal: Feasibility study for a national Chlamydia trachomatis prevalence survey 36

6.5 Current Ministry of Health work relevant to chlamydia screening 37

7 Review of current policies and practices for chlamydia screening in New Zealand 39

7.1 Policies 39

7.2 Current practice 41

7.3 Stakeholder opinions 43

8 Discussion and recommendations 45

8.1 Discussion 45

8.2 Recommendations 50

References 51

Appendix 1 Summary of New Zealand chlamydia studies 55

Appendix 2: Chlamydia Pilot Program Timeline (Australia) 57



List of Tables


Table 1: Comparison of Australian and New Zealand chlamydia statistics 13

Table 2: Assessment of chlamydia screening using the NHC framework 46

Table 3: Summary of New Zealand chlamydia prevalence studies 55




1 Executive summary

1.1 Background


The bacterial sexually transmissible infection (STI) Chlamydia trachomatis (chlamydia) is regarded as a serious public health problem due to its relatively infectious nature and the long-term effects which can result from untreated chlamydial infection. Chlamydia is reported to be the most common, treatable STI diagnosed in young adults in New Zealand (NZ). Although there are significant gaps in the information available on the epidemiology of chlamydia in NZ, the data suggest the incidence is increasing and this represents a considerable burden of disease.
Sexual health physicians, other health care providers and researchers in NZ have voiced alarm at the increased diagnoses of a chlamydial infection in recent years and have called for a screening programme for chlamydia.

1.2 Aim and objectives


The aim of this report is to provide information for the National Screening Unit (NSU) to assess and develop policy advice on a chlamydia screening programme.
The objectives of the report are:

  • To examine and summarise the evidence available on the need for a chlamydia screening programme in NZ, using the National Health Committee’s (NHCs) screening assessment criteria as framework.

  • To review policies and practices for chlamydia screening in other Organisation for Economic Cooperation and Development (OECD) countries as a comparison for chlamydia screening in NZ.

  • To provide information from specific research and projects in NZ relevant to chlamydia screening.

  • To review current policy, practice and stakeholder opinions on chlamydia screening in NZ.

1.3 Methods


1. Literature review.

2. Review of recent projects and research from NZ relevant to chlamydia screening.

3. Examination of the evidence for a chlamydia screening programme in NZ using the NHC framework.

4. Review of current policies and practices in other OECD countries.

5. Review of relevant government policy documents in NZ.

6. Consultation with key stakeholders.



7. Formulation of recommendations.

1.4 Results

1.4.1 Assessment using NHC framework


Assessment of Chlamydia trachomatis infection as a suitable candidate for screening using the NHC framework is summarised in the following table.


Criterion

Conclusion

The condition is a suitable candidate for screening

Chlamydial infection can cause serious long-term health problems. Although the surveillance data in NZ is limited, chlamydia is the most common curable STI diagnosed and reported and prevalence appears to be high in specific groups, representing a considerable burden of disease.

There is a suitable test

There is a safe, simple and reliable test but this test is not yet standard at all NZ laboratories. Standardised laboratory procedures and protocols for equivocal tests and confirmation of positive tests need to be discussed and developed.

There is an effective and accessible treatment or intervention identified for the condition through early detection

Chlamydial infection is easily treated with antibiotics. The antibiotics required for uncomplicated infection are now available on the Medical Practitioner Supply Order (MPSO).

There is high-quality evidence, ideally from randomised controlled trials, that the screening programme is effective in reducing mortality or morbidity

There is good evidence that early detection and treatment reduces the chances for an individual to progress to serious sequelae but more limited evidence (one Randomised Controlled Trial (RCT) and some observational studies) that screening will reduce prevalence and incidence of serious sequelae in the general population.

The potential benefit from the screening programme should outweigh the potential physical and psychological harm (caused by the test, diagnostic procedures and treatment)

Ad hoc opportunistic screening already occurs and is likely to increase in NZ. There is evidence that targeting of screening to high-risk populations and improving access for hard to reach high-risk groups will reduce the potential harm from screening.

The health care system will be capable of supporting all necessary elements of the screening pathway, including diagnosis, follow-up and programme evaluation

Not all elements are in place to ensure quality issues for a chlamydia screening programme would be met: there is evidence that high-risk groups are not likely to be accessed and screened; Nucleic Acid Amplification Techniques (NAATs) testing is not available in all laboratories; confirmatory tests for all positive and equivocal tests are not performed in all laboratories; there is limited contact tracing carried out and there is inadequate surveillance to support robust evaluation and monitoring of screening.

There should be consideration of social and ethical issues

Screening appears to be clinically and socially understood and acceptable. There is evidence that there are ethnic and gender inequalities in the current provision of ad hoc screening and that these inequalities may increase unless there is selective and targeted screening and the use of innovative approaches to improve access to services by specific high-risk groups.

There should be consideration of cost-benefit issues

Screening for chlamydia in pregnant or young women is shown to be the most cost-effective option when the outcome measured is sequelae averted. However, experience in other OECD countries suggests that inclusion of men may be required to reduce prevalence of this preventable infection in the population. A reduction in prevalence is required if we hope to be able to reduce the need for widespread screening in the future.



1.4.2 Chlamydia screening in other OECD countries


Chlamydia screening in OECD countries is generally on an ad hoc opportunistic basis with targeting of groups shown, or thought to be, high risk. Many countries are undertaking studies to inform changes in screening practices, including whether to introduce screening programmes.
Sweden introduced a programme in 1988 which observational studies indicate has reduced the rate of pelvic inflammatory disease (Kamwendo et al 1996). Early studies also indicated that prevalence had decreased but this has not been sustained (Gotz H et al 2002). It has been postulated that the resurgence in prevalence is due to the low rates of screening and the failure to include men comprehensively in the screening programme.
England introduced a screening programme in 2003 which is being progressively rolled out across the country. The RCT cited to support the introduction of the national chlamydia screening programme used a population register for recruitment of patients for screening, though England has opted to use opportunistic recruitment as the invitation to screen in its programme. It has been questioned by experts as to whether the same improvement in population outcomes can be expected with this difference.
The Australian Government launched a national STI strategy in July 2005 in which it is noted that STI prevention and control requires a range of behavioural and clinical tools. The launch coincided with the announcement that the Government would provide AU$12.5 million over four years for increased awareness, improved surveillance and a pilot testing programme for chlamydia. The aim of the chlamydia pilot testing programme is to determine if testing for chlamydia in Australia is sufficiently feasible, acceptable and cost effective to warrant the introduction of a national chlamydia testing programme. Evaluation of the pilot programme is expected to be completed by 2009.

1.4.3 New Zealand projects


The results of the Family Planning Association of New Zealand (FPA) project on chlamydia screening in their Wellington clinics indicate that it is practical and acceptable to offer screening to clients and that a reasonable uptake of the offer will occur. The test positivity rate of 8% cannot be extrapolated to the general under 25 year old age group but does support other studies which suggest that NZ has a significant burden of chlamydial infection in this age group and that this burden may be higher in Māori and Pacific peoples. The fact that testing rates returned to levels similar to those prior to the project suggests that an organised approach is more likely to result in the offer of screening being made.
The recently established Whangarei Chlamydia Trachomatis (CT) Screening Project will not be completed until late 2007, but is expected to give valuable information on screening in the general population across all health care settings with associated ethnicity data. Information will also be gained on the feasibility and effect of outreach activities on rates of screening of groups thought to be high risk but who are perceived to have low access of existing services.
The NSU has contributed some funding to both these NZ projects.

1.4.4 Review of New Zealand policies and practices


Concern over STI incidence and prevalence, and prevention and control strategies for STIs, have clearly been identified as a priority in government policy since in the 1990s. Targeted testing of asymptomatic people has been recommended as one strategy for chlamydia control since 2003, along with development of guidelines for STI management.

1.4.5 Review of current practices in New Zealand


It is difficult to estimate the amount of chlamydia screening and testing which currently occurs as this information is not currently collected by the STI surveillance system. Predicting future screening and testing volumes, regardless of whether there is a formal screening programme, is important as these costs will be incurred no matter whether a screening programme is implemented or not. There is evidence that testing rates for chlamydia have increased, at least in some District Health Boards (DHBs), in recent years. There is also good evidence that there is increasing interest and planning for prevention and control of STIs at the DHB and Primary Health Organisation (PHO) level. These plans generally provide for free sexual health visits for young people and encourage chlamydia screening. It is therefore likely that testing rates will increase further as a result of these strategies. Current surveillance does not allow either a breakdown of testing patterns to see if testing is appropriately targeted or the use of test positivity as a guide to prevalence in specific age or ethnic groups.

1.4.6 Stakeholder opinions


Discussions were held with a range of stakeholders as to their perception of the need for chlamydia screening in NZ, and whether this screening organised as a formal programme. There was widespread concern about the apparent high and increasing rates of chlamydial infection and the need for screening as a control measure. There is a general feeling that a ‘programme’ is needed because this will ensure commitment of the resources by the Ministry of Health that are considered necessary to provide needed research (including pilots of screening strategies), improved surveillance, national guidelines for STI management, funding of adequate personnel for all aspects of prevention and control activities and monitoring/evaluation of outcomes.
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