Practice Nurses Role in Treating Chlamydia

The practice nurses role in treating chlamydia and improving the sexual health of the nation

Introduction

Chlamydia treatment has been the focus of considerable research interest in the past few years. A huge proportion of what used to be called NSU, or was even undiagnosed non-specific pathology, is now recognised as being due to the chlamydia pathogen. It has now achieved the unenviable status of being considered responsible (numerically) for the greatest amount of sexually transmitted disease in the UK today (Duncan 1998)

Given the fact that it is now therefore recognised as being a major contributing factor in the overall picture of sexual health, we must examine ways in which the NHS is set up to tackle the problem. (HPA 2003)

As with many health related issues such as this there are a number of subsidiary issues that must be considered in relation to the main theme. These include the role of the screening process in trying to contain the prevalence of chlamydial infection, the practice nurse’s role in that screening process, the current thoughts on the treatment of chlamydia and the practice nurse’s role in not only the treatment, but also the partner tracing activity that is vital to try to stop the spread of the disease. (Fenton et al 2001)

The practice nurse is generally ideally placed within the primary healthcare team to act as a central liaison point for many of these activities

If we start by considering the whole issue of screening. On one level, one could be forgiven for thinking that the issues relating to screening are actually rather simple. We know that many cases of chlamydia are actually asymptomatic (see on). Given the fact that it can cause considerable damage and is eminently treatable, why not screen for it and get rid of it? Sadly, it is not as simple as that. (Simms et al 1996)

The National Institute for Clinical Excellence (NICE) has set up the National Chlamydia Screening Programme (NCSP). It quotes its rationale for doing so as:

• Genital Chlamydia trachomatis is the commonest Sexually Transmitted Infection (STI) in England

• Genital chlamydial infection is an important reproductive health problem ~ 10-30% of infected women develop pelvic inflammatory disease (PID).

• A significant proportion of cases, particularly amongst women, are asymptomatic and so, are liable to remain undetected, putting women at risk of developing PID.

• Screening for genital chlamydia infection may reduce PID and ectopic pregnancy.

The study itself was exemplary in design with an entry cohort of nearly 8,000 patients. The authors considered the efficacy of several different methods of screening and then compared the results of the programmes against the costs of allowing the disease to continue untreated in the community and these include all the sequelae of infertility, pelvic inflammatory disease and ectopic pregnancy in women together with the complications that can occur in the male partners (infertility again) and prostatitis. (Berry et al 1995)

The paper even covered the incidence of both pneumonia and eye infections in their children. The structure of the study was quite comprehensive insofar as it compared the results of four separate groups

One group received no screening at all, a second group were screened if they exhibited mucopurulent cervicitis, the third group included all women who were less than 30 yrs. old and the last group was all women irrespective of symptoms.

The actual screening tool was the Polymerase chain reaction (PCR) which is a very specific and sensitive antibody based test. It was performed on either urine or direct cervical samples. (Barlow et al 2001)

The study protocol then called for all positive testing patients to receive treatment with doxycycline for seven days.

The analysis section of the paper is both long and complex. We shall therefore condense our examination of this part of the study into an examination of the results.

The overall treatment costs of treating all of the medical complications of chlamydial infection was calculated as $676,000.

Each of the positive screening strategies produced a significant reduction in the expected cost of complications that was greater than the cost of the actual screening exercise. A condensation of the tabulated results is shown here:

The results need little explanation, as it can be clearly seen that both the costings and the number of cases prevented argue strongly for a case for screening. The only point of contention is the decision on the population that the health care system will fund for screening.

Overall, the authors state that their regime reduced the incidence and prevalence of pelvic inflammatory disease by 60% when compared to the unscreened group.

The other significant factor was that, taking all groups as an average, they noted a total healthcare saving of about $50 per woman screened, and this clearly does not take any account of any associated comorbidity, pain and suffering that is caused by the chlamydia infection

A further corollary can be drawn from the results. The authors went on to provide an impressive statistical analysis of the comparative costs of different community groups with different rates of prevalence. Of great importance to our considerations here was the fact that the authors concluded that the cost of screening was cost effective when the incidence of infection in a population of asymptomatic women was above 1.1%. when the incidence rose above 11% then they found that the screening of all women and their partners became the most effective strategy. To some extent, this study can be considered the “gold standard” for most of the studies in this area. It is well conceived, meticulously executed and well and thoughtfully analysed to give meaningful results which are of great practical importance.

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Despite such comments it should be noted that there are a number of negative points to be considered in this particular study. The universal treatment constant was the seven day doxocycline treatment. We should note (as the authors did) that there is therefore a potential for non-compliance with the whole seven day regime, and this may introduce a potential source of bias in the figures(Haddix et al.1995). We can also point to other studies that have addressed this particular problem with a one dose treatment regime (azithromycin). It is fair to note that despite the potential for bias, extrapolation to these other studies does not appear to show significant differences in the overall results (Lea et al 1997)

The issue of screening, although covered reasonably comprehensively in the last paper, certainly as far as matters of cost are concerned, is examined further in the paper by (Duncan et al. 2001). This paper approaches the issues from a different perspective. It includes the issues of male screening

And takes an overview of the Public Health issues from a sociological viewpoint, which makes it, (in our examination of the current literature), almost unique.

We should note that we have already addressed the issues faced by the NCSP, but the other major public document in this area is the report commissioned by the Chief Medical Officer (CMO 1998). It is instructional to discuss the recommendations of this group as they differ significantly from the screening criteria used in the previous paper. The recommended groups for screening here are the following:

• Everyone with symptoms of chlamydia infection,
• All those attending genitourinary medicine clinics,
• Women seeking termination of pregnancy.1
• Opportunistic screening of young sexually active women under 25 years
• Women over 25 with a new sexual partner or two or more sexual partners in the past year.

In the context of our considerations here, we should note that the advisory group identified the optimum sites for screening as the primary healthcare team (family planning clinic) as well as the usual GUM clinics. (Stokes 1997)

The Duncan paper is particularly well written and a major point that comes from it is in sharp contrast to that found in the Howell study. One of the criteria that they suggest for screening males in the population is that women may find that being screened has connotations of being “dirty” and “unattractive” A positive result is said to be associated with promiscuity. The authors suggest that not screening men not only fosters gender inequalities but it reduces the Public Health impact on the Man’s responsibilities for sexual health. (Pierpoint et al 2000)

There is no argument that this is a valid point, but the paper does not produce any evidence to show that male screening has a positive impact on the cost-effectiveness of the screening procedure. (Stephenson et al 2000)

The paper does however, contrast these statements with the accepted fact that women are actually easier to target than men, as they are generally heavier health care users than men in the major at risk age range. (Oakeshott et al 1998)

The paper points to the need to tackle the issues of sexual inequality, as it could be considered that the screening programmes may have less than the desired effect if they are perceived by women to be little more than surveillance of their particular sexual habits.

It draws a clear analogy between a women only screening programme for chlamydia and the well established women only cervical cytology screening clinics. The paper quotes (Holgate et al 1998) in the comment:

“The potentially adverse consequences of sexual intercourse a private event can be surveyed and treated through screening services a publicly based and funded system …. It is women who transcend this private, public dichotomy and find their lives scrutinised in a manner alien to men …. The focus is commonly upon women both as transmitters and contractors of relevant viruses … as both those whose cervixes are surveyed and whose sexual activity comes under surveillance.”

The paper then has a long middle section which, as a critical analysis, is little more than a diatribe against women being singled out for screening. It is fair to say that all of the arguments put forward are valid, to a degree, but are presented with a strongly feminist viewpoint, which is both understandable and worthy of merit form a sociological standpoint. The arguments are not however, convincing from a scientific, financial or practical perspective.

The conclusions of the paper are entirely justified in calling for a greater understanding of the woman’s point of view when organising and running screening clinics, in order to broaden their appeal to the target groups. (Santer et al 2000)

With specific reference to the role of the nurse in the primary healthcare team screening for chlamydia we can now turn and examine an excellent paper by Grun (et al 1997) which looked at two different methods of screening for chlamydia in a nurse run primary healthcare setting.

The study set out to try to accurately determine the prevalence of chlamydia in the North London area using the ligase chain reaction (LCR) technique which is similar to the PCR mentioned earlier. (Butt et al 2001)

This particular study used the rather labour intensive cervical scrape method for sampling, which had the added benefit that cervical cytology could be assessed at the same time. The paper is quite detailed in its description of its method and appears to be rigorous in its execution. It is worthy of our consideration here because of it’s direct relevance to our prime consideration. The results and conclusions of the paper make for interesting reading

One of the more significant conclusions was that, on the basis of their findings, if there was a policy of simply screening all women aged 25 and all women who had had two or more partners in the past year, they would have detected 20 out of a possible 23 positive chlamydia infections in their cohort. The authors make a salient comment that including other screening criteria such as marital status (which has been suggested by other authors [Lossick JG, et al 1996]), would have made no statistically significant impact on their detection rate.

They also make the comment, in line with the other authors we have examined, that selective screening appears to be more cost effective than universal screening, although the actual cost implications were not specifically considered in this paper. In contrast to the Howell paper, it suggests that screening become a viable tool when the community prevalence rate approaches 5%

The fourth paper to be reviewed is the more recent paper by Adams (et al 2004). This paper takes a more general overview of the whole issue of chlamydia in the UK. This is effectively a meta analysis of nineteen different papers (selected from 357 studies) which report the incidence of chlamydia as tested by the PCT method on urine samples. This is significant as it is the first meta analysis to be carried out on UK data. (Armitage et al 2001)

The results are extremely detailed and many are only of marginal relevance to our considerations here. We shall restrict our comments to those aspects that are specifically relevant. Firstly, the authors comment on the current prevalence of 8.1% of the population testing positive in the under 20 age group, progressively diminishing to 1.4% in the over 30 group. The significance of this is that it is very much lower than other studies. For example studies set in GUM clinics put the prevalence in the under 20 age group in the region of 17% and antenatal clinics at about 12%. (Piementa et al 2003)

This may therefore have relevance in targeting of specific at risk groups. It should be noted that this study gave no data with regard to the incidence of chlamydia in the male population. (Dixon et al 2002)

Our comments made earlier about the asymptomatic nature of the bulk of the infections, is borne out in the fact that only 8% of those tested and found to be positive, actually volunteered that they had any genital symptoms (of any sort).

Another important consequence of this study is the fact that it highlights the comparatively high detection rate to be found in attenders at primary healthcare team premises. This shows a gap in the reasoning and recommendations of the National Sexual Health and HIV Strategy for England (D of H 2002) which currently suggests targeting GUM clinics and family planning centres as prime sites for screening centres.

Following on from the reasoning expounded in the last paper, we can look at a provocatively entitled article by Kufeji (et al 2003)” Who is being tested for genital chlamydia in primary care?”

The paper makes the point that we already have enough evidence to clearly identify the target populations that are the most likely to give a good yield as far as screening is concerned (viz. the most “at risk” groups). The raison d’être of this paper was to compare the characteristics of the actual groups screened with the characteristics which we know to be representative of the groups most likely to be at risk. The corollary of this reasoning being that if the two groups do not match then all the calculations made about the cost effectiveness of a selective screening process do not hold water. (Kinn et al 2000)

The most striking feature of this paper is the fact that we know (Adams et al 2004) that the maximum age incidence for chlamydia is in the sexually active under 20 age group and the incidence rapidly decreases with age to the over 30 age group. Kufeji and his co-workers found that the majority of the tests done (63%) were done on the over 25 yr. age group where we would expect the results to be positive only in about 1.5% of the population. Adams’ findings were confirmed with a positive rate of 13.3% found in the under 20 yr. olds tested.

The paper also point to the fact that the practices studied had a comparatively high healthcare staff to patient ratio. In the practices where the ratio was lower, even less opportunistic testing was done. (Shefras et al 2002)

This correlates to the finding that the Townsend score ( of social deprivation) correlated highly with both a reduction in the amount of testing and an increase in the prevalence of chlamydia. In the words of the authors the study points to the fact that screening programmes for chlamydia in primary healthcare settings suffer from “a selection bias and social desirability bias, and they do not aim to provide complete descriptive information on testing patterns across a population.”

It should be noted that this particular study was not just on a small sample. The authors took as their entry cohort all of the 119 General Practices in Nottingham which collected a total of over 7,000 samples. The authors note that the number of tests done in General Practice is increasing at about 35% per year. It follows that if a significant number of these are inappropriately targeted, this has profound implications for the related costings of the exercise.

One other salient point in this study was the fact that only 1 in 40 tests were done on men. (Chernesky et al 1999)

The last major paper that we shall review in this section is the paper by Cassell (et al 2003) this deals with the thorny issue of partner notification when screening turns up a positive result. Hitherto contact tracing had largely been in the realms of the GUM contact tracing nurse. With the expansion of the screening role into the realms of General Practice and other clinics, the contact tracing role has also expanded and may well have lost some of it’s efficiency due to both a lack of skill, time and resources. (D of H 2002).

Cassell and her colleagues have tried to investigate the extent to which this perceived reduction in contact tracing may be responsible for the relentless increase in the overall incidence of chlamydia. (Radia et al 2001).

The study was done by postal questionnaire to all GPs in Nottinghamshire. They got a 56% response rate. Arguably the most significant finding of the study was the fact that 86% of respondents considered that chlamydia testing was part of the remit of the primary healthcare team, while only 40% considered that partner notification was a primary healthcare team role. The rationale for this was, that most of the non-contact tracing respondents felt that it was their role to inform the patient that they should inform their partners.

Given the fact that we have evidence from the Duncan paper that women tend to equate a positive test with promiscuity and being “dirty”, it is perhaps not surprising that a substantial number of partners do not get told. If you add to this number the unknown number of chlamydia infections that may have come from clandestine or extramarital liaisons, then this number may be higher still. This is clearly both hypothesis and conjecture but it would seem to be dictated by common sense.

The paper goes into considerable detail about the reasons why different primary healthcare teams have different practices, but rather worryingly a surprising 20% treat chlamydia with a dose of antibiotic which is less than the currently recommended therapeutic level recommended by the Central Audit Group for Genitourinary Medicine, (Stokes et al 1997)

The difficulty of a postal questionnaire study is that there is an intrinsic bias in the study design. It is quite conceivable that the 56% of primary healthcare teams who responded were the ones who may have been sufficiently motivated to be positive about matters to do with chlamydia and may therefore have been better informed that those who did not respond. In the words of the authors “our study probably over-represents primary healthcare teams already testing for chlamydia and may exaggerate the extent of good practice.”

The paradox outlined by this study is that while the majority of GPs and their teams are already willing to assume the mantle of diagnosing and managing chlamydial infection, the same majority agree that contact tracing is the main difficulty in managing these patients. The study made enquiries relating to the presence of follow up strategies which were designed to minimise the risk of further infection and found that there was “very little evidence to be found” other than by putting the onus on the patient to tell their partners.

It follows from this observation, and the authors put it quite succinctly:

If testing in primary care continues to increase without adequate support for partner notification, much of the resource used in testing women will be wasted. (Griffiths et al 2002)

If we accept the premise that an increasing amount of chlamydia screening will be done in General Practice in the future, it is likely that an increasing proportion will fall to the practice nurse or the family planning nurse specialist. (Stokes et al 2000). If this is the case, then it is common sense to maximise the benefit of chlamydia screening by supporting the healthcare professionals with time and resources to perform proper contact tracing to minimise the risk of re-infection. (EHC 1999)

Conclusions

In this review we have selected six primary papers which each represent a significant contribution to the evidence base in our knowledge of the rationale for screening and treatment of chlamydia infection. (Sackett 1996)

From our examinations it is clear that there is a considerable disparity in the figures pertaining to the prevalence of chlamydia infection in the community. The paper by Adams (Adams et al 2004) gives us a partial rationale for this and that is that studies done in different areas of health care practice will yield different results because they have a different clientele. It is not, perhaps, surprising that a study done in a GUM clinic will report different prevalences than a study done in a General Practice setting.

The common factor that runs through all of the papers examined is the fact that it is rare to find that men are screened. Generally the figures suggest about 2-5% of men are screened when compared to the number of women. There is no evidence to suggest that they have lower infection rates than women and, according to Duncan (et al 2001), there are a number of very good sociological reasons why men should be screened as frequently as women.

The fact of the matter is that women are subject to screening with much greater frequency than men and therefore bear the brunt of both the indignity and the responsibility.

There is no doubt however, that the case for screening and treatment and contact tracing is made on both economic and health grounds. It is equally clear that the practice nurse has a central role in the efficient administration of all of these vectors to varying degrees. The advent of nurse prescribing (Legge 1997) will make the practice nurse as valuable in this area as they already are in both the screening and contact tracing roles. The only concern here is that according to Kufeji (et al 2003) we are collectively targeting the wrong population in terms of efficacy and efficiency.

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