Jane Morgan

Chlamydia infection, pelvic inflammatory disease, ectopic pregnancy and infertility: cross-national study.

Objectives To describe, using routine data in selected countries, chlamydia control activities and rates of chlamydia infection, pelvic inflammatory disease (PID), ectopic pregnancy and infertility and to compare trends in chlamydia positivity with rates of PID and ectopic pregnancy. Methods Cross-national comparison including national data from Australia, Denmark, the Netherlands, New Zealand, Sweden and Switzerland. Routine data sources about chlamydia diagnosis and testing and International Classification of Disease-10 coded diagnoses of PID, ectopic pregnancy and infertility in women aged 15–39 years from 1999 to 2008 were described. Trends over time and relevant associations were examined using Poisson regression. Results Opportunistic chlamydia testing was recommended in all countries except Switzerland, but target groups differed. Rates of chlamydia testing were highest in New Zealand. Chlamydia positivity was similar in all countries with available data (Denmark, New Zealand and Sweden) and increased over time. Increasing chlamydia positivity rates were associated with decreasing PID rates in Denmark and Sweden and with decreasing ectopic pregnancy rates in Denmark, New Zealand and Sweden. Ectopic pregnancy rates appeared to increase over time in 15–19-year-olds in several countries. Trends in infertility diagnoses were very variable. Conclusions The intensity of recommendations about chlamydia control varied between countries but was not consistently related to levels of chlamydia diagnosis or testing. Relationships between levels of chlamydia infection and complication rates between or within countries over time were not straightforward. Development and validation of indicators of chlamydia-related morbidity that can be compared across countries and over time should be pursued.

CAN TEXT MESSAGING RESULTS REDUCE TIME TO TREATMENT OF CHLAMYDIA TRACHOMATIS

We assessed the impact of text messaging as the preferred method of communicating positive Chlamydia trachomatis test results in an urban sexual health clinic. Following the introduction of a text messaging service to communicate positive C trachomatis test results to patients, the time between test and treatment in 293 consecutive patients was compared with 303 historic controls. No significant difference was found in either median time to treatment for all patients (3 days in 2005; 4 days in 2007) or median time to treatment (both 7 days) for those not treated immediately. There was no significant difference in time to treatment between those using a landline or mobile phone. Mobile phone use was significantly higher in 2007. Overall, we treated more cases within 4 weeks in 2007 (98.6% cf 96%). The lack of difference in time to treatment showed the use of this technology is as effective as more traditional means of communication. The increase in cases of C trachomatis treated within 4 weeks may reflect the significant increase in mobile phone use and improved ability to contact people rather than simply the introduction of text messaging.

Trends of reported chlamydia infections and related complications in New Zealand, 1998–2008

AIM To compare trends in chlamydia (Chlamydia trachomatis) testing and detection with trends in hospital discharge rates of chlamydia-related diseases in the upper North Island of New Zealand during 1998-2008. METHODS Analysis of trends in chlamydia testing and detection rates and age-specific hospital admission rates per 100000 females for pelvic inflammatory disease (PID), female infertility and ectopic pregnancy, and per 100000 males for epididymo-orchitis. RESULTS Regional laboratory testing volumes increased from 3732 tests per 100000 population in 1998 to 9801 tests per 100000 in 2008. Two of three regions had a significant increase in percent test positivity over time. The highest detection rates and greatest increase in reported cases were amongst women aged 15-24 years, at 1992 per 100000 in 1998, to 5737 per 100000 in 2008. For women aged 15-24 years, the rate of hospital admissions for PID and chlamydia-related pelvic infections declined during 1998-2004 but rose in 2005-08, the rate of publicly-funded infertility admissions fell and the ectopic pregnancy rate was unchanged. The age-specific rate for epididymo-orchitis admissions amongst 15-44-year-old men remained stable. CONCLUSION Chlamydia testing volumes from three New Zealand regions have trebled since 1998, as have reported infection rates, although disease complication rates do not appear to have increased. Test positivity increases may reflect better targeted testing of those more at risk or a rising chlamydia incidence. The recent rise in hospital admissions for PID among women aged 15-24 is a concern; ongoing monitoring of these trends, despite data limitations, is important.

Repeat chlamydia testing across a New Zealand district: 3 years of laboratory data

Objectives To investigate the impact of repeat chlamydia testing on annual population coverage estimates and to examine repeat testing patterns in a New Zealand district with high chlamydia testing rates. Methods Chlamydia testing data for 15–44-year-old men and women in a single New Zealand district during February 2008 to January 2011 were analysed. Annual coverage of testing was estimated in two ways, using the number of tests and the number of individuals as the numerator. Rates of repeat testing were calculated using survival analysis. Results There were 73 879 tests (12 251 men, 61 628 women) from 41 342 individuals (8437 men, 32 905 women) during 3 years. Coverage estimates in 2010 using the number of individuals as the numerator were 17% lower for men and 26% lower for women than when the number of tests was used (5.9% vs 4.9% for men and 28.7% vs 21.2% for women). The rate of repeat testing was 16.9 per 100 person-years among men (95% CI 16.2 to 17.7) and 31.6 among women (95% CI 31.1 to 32.2). Rates of repeat testing were higher among women, in younger age groups and following a positive rather than a negative baseline test (p<0.001). Conclusion Relatively high rates of repeat testing were observed among young women in Waikato district during 2008 to 2010. Estimates of population coverage by test for this group therefore considerably overestimate individual coverage. The findings will inform discussions about improving surveillance to capture more accurate chlamydia testing coverage rates in New Zealand.

Is everyone treated equally? Management of genital Chlamydia trachomatis infection in New Zealand

Health disparities often reflect inequitable access to appropriate health care. This study aimed to establish if cases of genital chlamydia infection were managed equitably by age, gender and ethnicity in a region of New Zealand with high rates of chlamydia infection (858 per 100,000 population). Clinical records of 415 genital chlamydia cases from 19 different health-care sites, including general practice and community settings, were reviewed. Data were analysed by demographic variables. For those treated, men were treated more quickly than women (median 3 days versus 6 days, P < 0.001), but there was no difference by ethnicity. Cases without documented treatment were more likely to be women (8.2% versus 2.1%, P = 0.037) and more likely to be Māori than non-Māori (13.6% versus 4.8%, P = 0.036). Overall, the most notable issue was the lack of effective partner notification across all demographic variables. Ongoing efforts are required to ensure equitable access to timely treatment and to ensure that more effective partner notification strategies are implemented.

General Practice funding to improve provision of adolescent primary sexual health care in New Zealand: results from an observational intervention

BACKGROUND Free general practice (GP) sexual health visits for registered adolescents have been introduced in parts of New Zealand with the aim of improving provision of primary sexual health care. Published evidence of the effectiveness of such health care interventions, particularly around any impact on uptake of testing and detection of Chlamydia trachomatis, is limited. METHODS In 2003-2004, additional funding enabled 20 practices in Waikato, New Zealand to offer free sexual health consultations for registered under-25 year olds. Practice selection was non-random and biased towards lower socioeconomic, Māori and rural populations. Registered population data were linked to laboratory testing for C. trachomatis from January 2003 to December 2005. Twenty-nine practices without additional funding served as controls. RESULTS Chlamydia testing among under-25 year olds at the 20 intervention practices increased over time, in contrast to non-intervention practices, with coverage of females aged 18-24 years within the intervention increasing from 13.9% in 2003, to 15.5% during the roll-out phase and to 16.8% in 2005. Intervention practices had higher test positivity rates than non-intervention practices (8.7% v. 5.9%, P < 0.01) with increases in test positivity, from 7.7% in 2003 to 10% in 2005, relating mainly to increases in positive tests among females aged less than 25 years. There was no increase in testing or detection among those aged 25 years and older at intervention practices. CONCLUSIONS Introducing free GP visits for under-25 year olds living in rural and lower socioeconomic areas in New Zealand was associated with a significant increase in testing and detection for C. trachomatis in the target age group. This observational intervention supports the ongoing provision of free adolescent primary sexual health care.

The highs and lows of opportunistic Chlamydia testing: uptake and detection in Waikato, New Zealand

Objective: The uptake rate of Chlamydia trachomatis (Chlamydia) testing among young New Zealanders is unknown. The aim was to ascertain age-group Chlamydia testing and detection rates within the Waikato area. Methods: A retrospective study was undertaken of all Chlamydia tests within Waikato District Health Board during February to October 2008. Non-genital samples and duplicates for any individual were excluded. New Zealand 2006 census population data served as denominator data. Results: There were 21 104 Chlamydia tests carried out on Waikato residents during February to October 2008; of these, 10 847 (51.4%) tests were from 15–24-year-olds, and 82.3% were female. Based on tests, uptake among 15–24-year-olds was 22.2%, 36.9% among females and 7.7% among males, compared with 9.3% among 25–44-year-olds. Based on individuals, uptake among 15–24-year-olds was 17.4%: 28.4% for females and 6.7% for males, with similar rates for Māori (13.5%) and non-Māori (15%). Overall 15.8% of tests from 15–24-year-olds were positive, 14.4% in females and 23.0% in males (p<0.001), with positivity double among Māori (24.2% vs 12.5%; p<0.001). Conclusions: High rates of Chlamydia testing and uptake, particularly among local 15–24-year-old women, may explain the high Chlamydia surveillance rates in the Waikato district. While a high testing rate among young women is encouraging, lower testing among men is notable. This better understanding of existing Waikato testing and detection patterns helps prioritise local efforts during planned implementation of Chlamydia primary care guidelines, particularly around targeting testing, optimising case management and emphasising effective partner notification.

Two cases of group A streptococcal vulvovaginitis in premenopausal adults in a sexual health setting

Two cases of group A streptococcus (GAS) causing vulvovaginitis in premenopausal adults are described. A review of the literature of genital GAS is made, as this is an uncommon cause of vulvovaginitis in premenopausal adults. Contrasts are made between anogenital carriage of GAS and group B streptococcus (GBS) to highlight the differences in anogenital carriage between these two organisms.

Sexual health and the Rugby World Cup 2011: a cross-sectional study of sexual health clinics in New Zealand.

BACKGROUND We aimed to describe the characteristics of sexual health clinic (SHC) attendance and sexually transmissible infection (STI) diagnoses during the Rugby World Cup (RWC) in New Zealand in 2011. METHODS SHC attendance and STI diagnoses around the time of the RWC were compared with the 5 preceding years. A cross-sectional survey conducted at SHCs in four New Zealand cities collected information from attendees having RWC-related sex. RESULTS Although there was no statistically significant increase in clinic attendance or STI diagnoses during the RWC compared with previous years, in these four cities, 151 individuals of 2079 attending SHCs for a new concern reported RWC-related sex. The most frequently diagnosed STIs were chlamydial infection (Chlamydia trachomatis), genital warts and genital herpes. Most attendees (74%) who had RWC-related sex had consumed three or more alcoholic drinks; 22% had used a condom. Seven percent of women reported nonconsensual sex. RWC-related sex was associated with an increased risk of STI diagnoses in men: gonorrhoea (Neisseria gonorrhoeae): relative risk (RR)=4.9 (95% confidence interval (CI): 2.1-11.4); nonspecific urethritis: RR=2.8 (95% CI: 1.3-5.9); chlamydial infection: RR=1.8 (95% CI: 1.1-2.9). Using a condom was associated with a reduced risk (RR=0.3, 95% CI: 0.1-0.9) of diagnosis with any STI among those having RWC-related sex. CONCLUSIONS These findings highlight issues that are amenable to prevention. The continued promotion of condoms as well as a reduction in the promotion and availability of alcohol at such events may reduce sexual health risks as well as other harm.

Chlamydia trachomatis incidence using self-reports and serology by gender, age period, and sexual behavior in a birth cohort

Background Although understanding chlamydia incidence assists prevention and control, analyses based on diagnosed infections may distort the findings. Therefore, we determined incidence and examined risks in a birth cohort based on self-reports and serology. Methods Self-reported chlamydia and behavior data were collected from a cohort born in New Zealand in 1972/3 on several occasions to age 38 years. Sera drawn at ages 26, 32, and 38 years were tested for antibodies to Chlamydia trachomatis Pgp3 antigen using a recently developed assay, more sensitive in women (82.9%) than men (54.4%). Chlamydia incidence by age period (first coitus to age 26, 26–32, and 32–38 years) was calculated combining self-reports and serostatus and risk factors investigated by Poisson regression. Results By age 38 years, 32.7% of women and 20.9% of men had seroconverted or self-reported a diagnosis. The highest incidence rate was to age 26, 32.7 and 18.4 years per 1000 person-years for women and men, respectively. Incidence rates increased substantially with increasing number of sexual partners. After adjusting age period incidence rates for partner numbers, a relationship with age was not detected until 32 to 38 years, and then only for women. Conclusions Chlamydia was common in this cohort by age 38, despite the moderate incidence rates by age period. The strongest risk factor for incident infection was the number of sexual partners. Age, up to 32 years, was not an independent factor after accounting for partner numbers, and then only for women. Behavior is more important than age when considering prevention strategies.