Harriet Wallace

Adverse pregnancy outcomes following syphilis treatment in pregnancy in the UK

Syphilis infection in pregnancy is known to cause a number of severe adverse pregnancy outcomes, including second-trimester miscarriage, stillbirth, very pre-term delivery and neonatal death, in addition to congenital syphilis. A retrospective review of women with positive syphilis serology and a pregnancy outcome between 2005 and 2012 in Leeds, UK, was performed. In all, 57 cases of positive syphilis serology in pregnancy were identified: 24 with untreated syphilis treated in the current pregnancy (Group 1); seven with reported but unconfirmed prior treatment who were retreated (Group 2); and 26 adequately treated prior to pregnancy (Group 3). The rate of severe adverse pregnancy outcomes in Group 1 at 21% was significantly higher than the 0% outcome of Group 3 (p = 0.02). The severe adverse pregnancy outcomes were two second-trimester miscarriages, two pre-term births at 25 and 28 weeks and one stillbirth at 32 weeks. There were no cases of term congenital syphilis or term neonatal death, but we observed high rates of other adverse pregnancy outcomes despite treatment during pregnancy. Rapid referral for treatment is needed before 18 weeks in order to minimise adverse pregnancy outcomes.

O022 Rectal chlamydia infection in women – have we been missing the point?

Background/introduction BASHH standards recommend rectal chlamydia sampling in women with increased risk. However, studies show high rates of rectal chlamydia in women, with concerns over treatment failures and risk of genital re-infection Aim(s)/objectives To determine if rectal chlamydia screening in females should be universal. Methods As part of a selfswab versus clinician trial we asked females about frequency of vaginal, receptive anal, and oral sex, and correlated this with chlamydia NAATs from these sites. Results Recruitment to February 2016 included 1041 women. All consented to rectal sampling; none had rectal symptoms. 53% reported no prior receptive anal sex. 204 women had chlamydia (CT) positive NAATs at one or more sites: 176 (16.9%) VVS positive (86% of all CT positives); 190 (18.3%) rectal positive (93% of total CT positives); 49 (4.7%) pharyngeal positive. Rectal swabs were significantly more likely to detect CT than VVS: OR 2.75 (95% CI 1.22–6.18) p = 0.02 McNemar test. The table shows percentage women by positive site(s) reporting no anal sex. 92/190 (48.4%) of those with one site or combination rectal CT reported no previous anal sex. Of the 168 with VVS and rectal positive NAATs, the AC2 Reactive Light Units levels were equivalent, suggesting active infection at both sites.Abstract O022 Table 1 Sites of chlamydia in women Site(s) of chlamydia positive NAATs Number confirmed positive by site(s) [total 204] Percentage women with’infection at site(s) reporting never having had receptive anal sex (%) VVS only 7 43 VVS and rectal 132 50 VVS, rectal, pharyngeal 36 47 Rectal only 17 41 Rectal and pharyngeal 5 40 Pharyngeal and VVS 1 100 Pharyngeal only 6 0 Discussion/conclusion In this sample of women with no rectal symptoms, the rectum was the most prevalent site for chlamydia infection, and rectal swabs found significantly more infections than VVS. There was no association with reported anal sex indicating sexual risk history is unreliable for targeted screening in women.

Serological follow-up of infants born to mothers with positive syphilis serology - real-world experiences.

The 2008 UK syphilis guideline recommends infants born to women with any positive syphilis serology be followed up until both treponemal and nontreponemal tests are negative to exclude congenital syphilis, whereas Centers for Disease Control and Prevention guidelines recommend using only nontreponemal tests. Historically, we had low infant follow-up rates with no coherent pathways. We initiated a change in multidisciplinary team practice of infant testing for syphilis in 2011 and evaluated the results before and after by retrospective review of testing of infants born to women with positive syphilis serology between 2005 and 2012. A total of 28 infants’ mothers were treated in pregnancy (termed ‘high risk’); 26 had adequate treatment prior to pregnancy (termed ‘low risk’). There was a significant increase in serological testing after 2011 compared with before (83% versus 48%; OR 5.07 [95% CI 1.22–22.77] p = 0.01) but mainly in low risk infants with no significant improvement in high risk infants who are the priority group. Using nontreponemal tests only in the infants would have reduced the tests required by at least 50%, allowing health resources to be concentrated on achieving adequate follow-up for those infants most at risk.

P238 Working the streets – targetting migrant sex-workers through dedicated outreach

Introduction Sex-workers do not always engage with traditional healthcare settings and migrant sex-workers are a growing vulnerable group. Our city uses a ‘managed approach’ to sex-working, with focus on identifying exploitation and trafficking. This gives a unique opportunity for outreach. Aim(s)/objectives Provide accessible sexual healthcare, health promotion and contraception to sex-workers not accessing care. Evaluate this outreach service after one year. Methods A partnership was established between the Integrated Sexual Health service and a local Third Sector Sex-work Project. Sex-workers were offered STI testing, treatment, HepB vaccination and contraception in an outreach setting (own homes/workplaces, charity premises, streets). Results (at one year): 129 sex-workers seen (289 contacts); 70/129 (55%) were migrant (majority Romanian), 113 contacts; 70% previously unknown to sexual health services. Contraception was extended over the first year and provided to 25 sex-workers; Hep B vaccination offered to all. 45 infections identified in 28/70 (40%) migrants (compared with 26 infections in 21/59 (36%) non-migrant sex-workers): 33/45 Chlamydia: 20 extra-genital (5 pharyngeal, 15 rectal); 5/45 Gonorrhoea (all extra-genital); 8/45 Trichomonas Vaginalis. 27/28 successfully treated (1 moved away). 4 women had re-infection on interval rescreening (all Chlamydia). 1 case of chronic HepB, 1 chronic HepC, no cases HIV or syphilis Discussion This new outreach service successfully targeted a vulnerable group with a disproportionately high STI burden (40%). Use of a dedicated outreach team achieved trusted relationships with sex-workers. Secondary benefits included a 250% increase in women identifying as sex-workers accessing mainstream clinics.

P045 Vaginal infections and contraception – results of a patient questionnaire

Introduction Bacterial vaginosis (BV) and candida are common problems among females using contraception. Associations between BV/candida and different contraception are described but not proven. Aim(s)/objectives Establish knowledge of BV/candida among contraceptive users. Assess whether future research on BV/candida and contraception would interest patients. Methods Surveys were distributed to females at two sexual health clinics and a student General Practice by staff not seeing patients. Responses were anonymous. Questions included knowledge of BV/candida, existing contraception, future contraceptive choices related to BV/candida and importance of research findings. Results 298 completed a survey; 157/298 attending for contraception (90% using/starting a method), 141/298 attending for other sexual health reasons/GP consultation. Of 157 contraception patients, 22% were <20yrs, 96% were <35yrs. Overall, 40% had heard of BV and 39% of candida but in <20yrs, 26% had heard of BV, 17% candida. 47% were interested in outcomes of further research between BV/candida and contraception (30% neutral, 17% not interested), rising to 56% in those who had heard of BV and/or candida. Similar results were seen in surveys from 141 females not attending for contraception (58% interested if heard of BV and/or candida). 81% stated they would definitely/probably change from a contraceptive if it was proven to increase the development of BV/candida, and they acquired the infection. Discussion There is patient interest in further research assessing associations between contraception and BV/candida, which would influence contraception choices. Patients preferred more knowledge on any links between contraceptive types and BV/candida rather than number of recurrences or persistence of symptoms.

P009 Risk of chlamydia/gonorrhoea naat contamination from clinic surfaces – need for patient and staff awareness in self-swabbing and pooling areas

Introduction A self versus clinician Chlamydia/gonorrhoea (CT/NG) NAAT swab trial, with pooling of self-taken samples, recruited January 2015–September 2016. There was concern that nucleic acid contamination of clinic surfaces could be a source of false-positive samples during the pooling process. Aim(s)/objectives To ascertain levels of environmental nucleic acid contamination within clinic environments. To determine number of false positive pooled samples throughout study. Methods Environmental samples of clinic rooms, sluices and toilets were performed and tested using Aptima Combo 2 throughout duration of study. In November 2015, the clinic relocated from old premises to a newly renovated site. Results were disseminated to staff throughout to raise awareness and to reduce risk of contamination during sampling/pooling. Posters in self-swab areas highlighted risk of contamination, importance of handwashing and no surface contact for swabs. Results Of 41 environmental sampling episodes over 12 months, 17 (41%) were CT/GC positive/indeterminate. These were distributed throughout the whole 12 months. Positive results were obtained from surfaces in all clinical examination rooms at the old site and toilets and sluices (where urines were pipetted) at both sites. 3/4 clinic rooms regularly used for examination at the new site remained contamination free. There were 7 false positive pooled samples (6 female, 1 male); all were in the first 6-months of the study. Discussion Nucleic acid contamination was repeatedly found throughout the clinic despite regular cleaning/decontamination. Raising staff and patient awareness did not reduce contamination but it did reduce false positive pooled samples, with none occurring after the first 6-months.

O005 Self-taken extra-genital samples compared with clinician-taken extra-genital samples for the diagnosis of gonorrhoea and chlamydia in women and MSM

Background Extra-genital tests for gonorrhoea and chlamydia are important in MSM and are increasingly important in women as vulvovaginal swabs (VVS) alone can miss infections. Self-sampling is frequently used but there has been no robust RCT against clinician-taken samples in MSM or women to assess its efficacy. Aim To compare self-taken extra-genital samples in women and MSM with clinician-taken samples for diagnostic accuracy. Methods Women and MSM attending a sexual health clinic were invited into a ‘swab yourself’ trial. Clinician and self-samples were taken from the pharynx and rectum (plus VVS in women and FCU in MSM) for gonorrhoea (NG) and chlamydia (CT) using NAATs. The sampling order was randomised. Patient infected status was defined as at least two positive confirmed samples. Results 1251 women and MSM were recruited to January 2016. Overall prevalence: NG 5.7% (rectal 4.3%, pharyngeal 3.1%), CT 17.8% (rectal 16.5%, pharyngeal 4.0%). 9.4% of female NG cases and 13.8% of CT cases were VVS negative. 72% of MSM NG cases and 89.5% of CT cases were FCU negative. Sensitivity, specificity, PPV and NPV are shown in the table:Abstract O005 Table 1 Sensitivity & specificity of extra genital samples Sensitivity(95% CI) Specificity(95% CI) PPV (95% CI) NPV (95% CI) NG rectal clinician 96.3 (87.3–99.6) 100.0 (99,7–100.0) 100.0 (93.2–100.0) 99.8 (99.4–100.0 NG rectal self 98.2 (90.1–100.0) 99.9 (99.5–100.0) 98.2 (90.1–100.0) 99.9 (99.5–100.0) NG pharynx clinician 95.1 (83.5–99.4) 100.0 (99.7–100.0) 100.0 (91.0–100.0) 99.8 (99.4–100.0) NG pharnyx self 97.6 (87.4–99.9) 100.0 (99.7–100.0) 100.0 (91.4–100.0) 99.9 (99.5–100.0) CT rectal clinician 96.6 (93.1–98.6) 99.9 (99.5–100.0) 99.5 (97.2–100.0) 99.3 (98.6–99.7) CT rectal self 98.1 (95.1–99.5) 99.8 (99.3–100.0) 99.0 (96.5–99.9) 99.6 (99.0–99.9) CT pharynx clinician 92.0 (80.8–97.8) 99.9 (99.5–100.0) 97.9 (88.7–100.0) 99.7 (99.2–99.9) CT pharynx self 96.0 (86.3–99.5) 99.9 (99.5–100.0) 98.0 (89.2–100.0) 99.8 (99.4–100.0) No statistical difference between self and clinician-taken rectal or pharyngeal samples by McNemar test. Conclusion This on-going work is the first randomised study showing that self-taken extra-genital samples have high sensitivity and specificity and are comparable to clinician-taken samples. High levels of extra-genital infections were found. In women 9% of NG and 14% of CT infections would be missed using VVS alone demonstrating the benefit of extragenital sampling.

O019 Extra-genital samples for gonorrhoea and chlamydia in women and MSM: Self-taken samples analysed separately compared with self-taken pooled samples

Background Extra-genital infections are common in MSM and women and are frequently the sole sites of infection. However, analysing samples from the rectum and pharynx, in addition to the urogenital tract, trebles the diagnostic cost. Aim Can samples from three sites be pooled into one NAAT container and still achieve the same sensitivity and specificity as the samples analysed separately? Methods Women and MSM attending a sexual health clinic were invited into a ‘swab yourself’ trial. Two self-taken samples (one for separate analysis and one for pooling) were taken from the pharynx and rectum with VVS in women and FCU in MSM. The sampling order of the pooled or analysed separately swabs was randomised. Gonorrhoea (NG) and chlamydia (CT) were diagnosed using NAATs. Patient infected status was defined as at least two positive confirmed samples. Results 1251 women and MSM were recruited to January 2016. Overall prevalence of infections was NG 5.7% and CT 17.8%. Sensitivity, specificity, PPV and NPV are shown in the table:Abstract O019 Table 1 Sensitivity & specificity of separate and pooled samples Sensitivity(95% CI) Specificity(95% CI) PPV (95% CI) NPV (95% CI) NG separate samples 98.6 (90.2–99.7) 99.9 (99.5–100.0) 98.6 (92.6–100.0) 99.9 (99.5–100.0) NG pooled 97.2 (90.2–99.7) 99.9 (99.5–100.0) 98.6 (92.3–100.0) 99.8 (99.4–100.0) CT separate samples 99.1 (96.8–99.4) 99.7 (99.2–99.9) 98.7 (96.1–99.7) 99.8 (99.3–100.0) CT pooled 95.5 (91.9–97.8) 99.5 (98.9–99.8) 97.7 (94.7–99.3) 99.0 (98.2–99.5) There was no difference between self-taken samples analysed separately or pooled by McNemar test. Conclusion This on-going study demonstrates that self-taken samples from the rectum, pharynx and urogenital tract are comparable in sensitivity and specificity if analysed separately or as a pooled sample. In MSM the diagnostic costs of three separate analyses are unaffordable for many health systems but a pooled sample has the same laboratory cost as a urogenital sample. These findings mean triple site testing could be expanded into women at no additional health service cost.