Health Advisor Caroline Allsop BSc (hons) SCPHN, RGN, Dip Child.

1. Health Advisor Caroline Allsop BSc (hons) SCPHN, RGN, Dip Child.

2. Agenda • Aim of the NCSP • What is Chlamydia/history • Transmission • Symptoms • Complications of untreated chlamydia • Screening process and resources/ new venue info • Results • Central Office Function • Reading list • Contact details

3. Exclusions within this training • Other sexually transmitted infections • Behaviour change • Sexual Health Policies • Safeguarding • Fraser competencies

4. What is the message • Chlamydia is Invisible • Chlamydia is Serious • Chlamydia is Spreading

5. Opportunistic, Asymptomatic Programme AIM: National Chlamydia Screening Programme To control Chlamydia through the early detection and treatment of asymptomatic infection; to prevent the development of sequelae; and to reduce the onward disease transmission

6. GUM and Chlamydia Screening statistics 2010 (HPA 2011) • Health Protection Agency (HPA) reveal that as part of an overall rise in bacterial STI’s Chlamydia is now the most commonly diagnosed infection in England, Wales and Northern Island. • The peak age for an STI in men is 20-23 years. • The peak age for an STI in women is between 19-20 years. • Studies have shown that young adults are more likely to have unsafe sex and often lack the skills and confidence to negotiate safer sex. • In 2010, 65% of people with Chlamydia were under 25 years old • 217,570 new cases seen in GUM clinics in 2010 reflect an increase of 8% in women and 5% in men over the previous year

7. History of Chlamydia • 1909 - Chlamydia was recognised as the source of infection in neonates and adults with eye infections (Westcott). • 1911 - Recognised as an organism that could infect the cervix in women and urethra in men (Westcott). • 1950’s and early 1960’s that scientist discovered the magnitude of the problem (Westcott). • 1980’s - Advances in diagnostic testing lead to cheaper, more sensitive and specific tests which helped aid epidemiological and sequale research studies (Moss).

8. What is Chlamydia? Chlamydia Trachomatis is a bacterial infection. It is unique and different to all other micro-organisms as it requires a host cell to multiply. Chlamydia is the most common STI in young people 75% of women and 50% of men have no symptoms Anyone of any age can get Chlamydia. It effects both men and women, regardless of lifetime partners. You are at risk of catching chlamydia regardless of your sexual orientation

9. Younger age (especially <20 years) 2 or more partners in preceding 6 months Use of non barrier contraception Living in inner city Partner with symptoms Having current STI History of STI in the past Sexual orientation Ethnicity (for some STIs) Risk factors for STIs

10. Percentage of STIs diagnosed in under 25 age group in 2010

11. Transmission The most common way for people to become infected with Chlamydia is through unprotected vaginal or anal sex with an infected person (HPA 2010) Transmission can occur during: • vaginal sexual intercourse • anal sexual intercourse • oral-genital contact • mutual touching of genitals • sharing of sex toys • Genital Chlamydia infections may facilitate increased risk of HIV transmission • Condoms should be used to minimise risk of sexual transmission • Chlamydia can also be vertically transmitted – passed to baby during birth – which may result in neo-natal conjunctivitis or pneumonia, low birth weight baby or miscarriage

12. Symptoms of chlamydia in women Most people do not have symptoms but if they do, these are what they might be: A vaginal discharge that is different to usual The need to pee more often Pain and /or burning when passing urine Pelvic or lower abdominal pain Irregular bleeding between periods or after sexual intercourse Pain during sexual intercourse Joint pain Conjunctivitis

13. Consequences of Chlamydia infection in females (Q6) In females, chlamydia initially infects the cervix and the urethra where it can cause cervicitis (inflammation of the cervix) and urethritis (inflammation of the urethra). From the cervix, the bacteria can ascend to the upper genital tract where it may cause pelvic inflammatory disease (PID), with or without symptoms e.g. pelvic pain. It has been estimated that 10-20 per cent of untreated infections result in PID. Inflammation of the fallopian tubes associated with PID can cause damage (e.g. fibrosis and scarring) that may result in future ectopic pregnancy and/or tubal-factor infertility.

14. Consequences of Chlamydia infection in females • Other sequelae of chlamydia in females though very rare include Reiter’s syndrome (reactive arthritis) and Fitz-Hugh Curtis syndrome (also known as perihepatitis [inflammation of the lining of the liver]). • It is possible to be infected with chlamydia more than once, particularly if a sexual partner remains infected (i.e. is not tested/treated). • The risk of complications increases with repeated untreated infections.

15. Pregnancy • Post partum endometritis occurs in 30% of women with antenatal Chlamydia infection. If unrecognised and untreated secondary infertility may result. • Infants with mothers with Chlamydia infection will develop conjunctivitis in 18 – 50 % of cases. • Pneumonia can occur in 11 – 20 % of cases which may lead to severe respiratory failure with some evidence to suggest long term respiratory disease may occur. Reference • Moss, T. R. (2006), International Handbook of Chlamydia 2nd Addition.

17. Symptoms of chlamydia in men • Most people do not have symptoms but if they do, these are what they might be: • A discharge from the tip of the penis (Q5) • Pain and/or burning when peeing • Irritation at the top of the penis • Painful swelling of the testicles

18. Consequences of Chlamydia infection in males (Q6) Urethritis Epididymitis (inflammation of the epididymis [a coiled segment of the spermatic ducts]) Prostatis (inflammation of the prostate gland) Proctitis (rectal inflammation) Reiter’s syndrome. Infertility Conjunctivitis Treatment for chlamydia infection is highly effective and reduces the risk of complications.

20. Those with symptoms • Recommended a full screen for those who report symptoms • Advise that symptoms may be due to other STI’s and refer to service offering full STI screen However • Due to risk of loss to follow up: Screen and refer

21. Inclusion - Criteria for Screening • Asymptomatic male or female aged 15-24yrs who are sexually active and live in Newcastle, Northumberland or North Tyneside. • Have never been screenedfor chlamydia before • Recommend an annual screen • Changed their sexual partner (test 2 weeks after sexual contact) • Health Advisors test and give epidemiological treatment to All sexual partners regardless of age

22. Exclude… • Those not living in Newcastle,Northumberland and North Tyneside. • Women and men 25 years old or older or under 15years. • Those who are not deemed competent to give their informed consent. Under 16’s have to be assessed as Fraser Competent by the test initiator. DH policy – “If Fraser Assessment is Law and a DH requirement then it must be carried out” (Paula Baraister the Medical Advisor for the NCSP) • Women and men who have been treated for chlamydia in the previous 5 weeks (It is advised not to repeat a test within 5 weeks following completion of treatment for a positive result, as the test may still detect residual chlamydia nucleic acids from non viable organisms and give a false positive result. • Women and men who decline the offer of chlamydia screening

23. Swabs or Urine for Women? • Scottish Intercollegiate Guidelines Network (SIGN 2009) reviewed the literature and found: • There is little difference in the results of vaginal and endocervical swabs. • No significant difference in sensitivity between first catch urine specimens and vaginal swabs. The National Audit Office (NAO 2009) reported 67% of tests from 2008/2009 were urine samples. SIGN (2009) concluded that women not undergoing a speculum examination should be offered self vaginal swabs or first void urine as both are acceptable.

24. Taking Samples • Client to complete form/label on specimen • Advise they take form and urine bottle/swab to toilet (recommended not to have passed urine for 1 hour and first void of urine required). • Advise when sample taken for client to ensure lid is on secure and put into plastic bag at the back of the form (if postal put sample into transporter first) Advise client to remove strip and fold over to seal bag. • Ask client to drop into specimen collection bag or put into envelope to post to lab.

25. How to complete test form

26. Chlamydia Treatment • Azithromycin 1g stat (Can be given in pregnancy) • Doxycycline 100mg for 7 days • Erythromycin 500mg for 14 days if patient pregnant or unable to rule out pregnancy – repeat test 5 weeks after completing treatment • Advise no Sexual Contact for 7 days after treatment completed (not even with a condom) or until partner treated Treatment is provided by the CSO, however this is not always acceptable to the client who may choose to go to GUM or their GP.

27. Results (given by preferred method of contact usually within 7 days). Negative results (asymptomatic) - text, phone, letter Negative results (symptomatic) – as above but advised to go to GUM or GP for full screening. Positive Result (asymptomatic) Health Advisor to contact YP by preferred method, result given and appointment arranged. Advised not to have any sexual contact and advised partner (s) need epidemiological treatment. Positive Result (symptomatic) as above but referred to GUM or GP.

28. Summary of Initiator’s Role Opportunistic screening - Offer chlamydia test to anyone who fits the inclusion criteria Assess if Fraser competent if under 16 Clinical: Give out leaflet, obtain specimen (urine/ swab). Ensure microbiology form completed and sample labelled. Send to lab Non clinical: postal pack (test on site is preferrable and post to lab) Advise they will receive their results in 7 – 10 days by their chosen contact method. If results not received advise client to ring CSO. Advise if positive a Health Advisor will contact them and arrange an appointment – cureable with antibiotics Advise young people who have had recent unprotected sexual intercourse to have a repeat test in 1-3 weeks if result is negative

29. The target The target is only one component of controlling Chlamydia. Robust partner notification and prevention services are also essential to reduce the prevalence rate of chlamydia. VSI target is 35% of 15-24year old population (see local update for current figures)

30. Partner Notification an important part of reducing Chlamydia prevalenceratesAll partners in the last 6 months or to their last partner. The Health Advisor initiates partner notification after giving a positive result to a client (Q9) • Patient Referral: The patient decides to notify partner/s themselves. Contact cards can be used if the client accepts them. • Provider Referral: The Health Advisor traces the partner/s with information the client has given. • Contract Referral: An agreement with the client that if the partner has not accessed treatment then contact can be made by the Health Advisor via their chosen method.

31. The way forward Continued local support within all services that young people access. An integrated approach utilising core service providers is required to support expansion. Utilise existing capacity within core sexual health services to provide screening and treatment. National direction- continue to be a routine part of every primary care and sexual health consultation. Prioritise clinical caseload/ reduce re-infection/ partner notification To provide and maintain a quality and equitable service for all young people accessing chlamydia screening To provide a positive experience for young people when accessing sexual health services. Involve young people in needs assessment and service planning.

32. Central Office : It’s function The key function of the Chlamydia Screening Office (CSO) Central co-ordination of the programme. Screening venues are provided with required resources (fax required to admin staff) Data collection and reporting of positive and negative results. Treatments of positive patients and their partners Monitoring of quality/ audit. Training can be accessed through the Sexual Health Directory at Newcroft Centre.

33. Reference List • National Chlamydia ScreeningProgramme in England, Core Requriements 3rd Edition (Sept 2006) at: www.chlamydiascreening.nhs.uk • The National Strategy for Sexual Health and HIV (DH 2001) • Chief Medical Officer's Expert Advisory Group (1998). Main report of the CMO's expert advisory group on Chlamydia trachomatis. London: Department of Health. • Choosing Health: Making Healthier Choices Easier (DH 2004) • Society of Sexual Health Advisers at: www.ssha • British Association of Sexual Health and HIV at: www.Bashh.org • Medical Foundation for AIDS and Sexual Health at : www.medfash.org.uk • Moss, T. R. (2006), International Handbook of Chlamydia 2nd Addition. • National Institute for Health and Clinical Excellence at : www.nice.org.uk • Westcott P (1992). Pelvic Inflammatory Disease and Chlamydia. A guide to causes, treatment and prevention. World Health Organisation (2009). Sexually Transmitted Diseases. Chlamydia Trachomatis. Available at: http://www.who.org. (Accessed 25th October 2009). • Scottish Intercollegiate Guidelines Network (2009). Management of genital Chlamydia trachomatis infection. A national clinical guideline.

34. caroline.allsop@newcastle-pct.nhs.uk Julie.taylor@necastle-pct.nhs.uk Kate.morris@newcastle-pct.nhs.uk North of Tyne Chlamydia Screening Programme Hosted by Newcastle upon Tyne Hospitals NHS Foundation Trust The New Croft Centre Market Street East Newcastle NE1 6ND Tel: 0191 2292958