[Chlamydia: from population screening to individual repeated screening]. / Chlamydia: du dépistage de la population au dépistage individuel répété.

Chlamydia trachomatis is a frequent sexually transmitted infection especially in young adults and adolescents. Its complications can impair a woman's reproductive potential. chlamydia control has several challenges. These include asymptomatic infections; a long duration of untreated infections; re-infections and partner treatments. Any person with infection is at high risk of re-infection. Repeated screening would decrease, at an individual level, the risk of complications. General practitioners, gynaecologists and centres for sexual health could participate in Chlamydia screening for asymptomatic infections, in Switzerland, the cost of the laboratory test is fixed by national tariff regulations. The cost is high and prohibitive for many, especially adolescents and young adults and needs to be lowered.

Comparison of two Gram stain point-of-care systems for urogenital gonorrhoea among high-risk patients: diagnostic accuracy and cost-effectiveness before and after changing the screening algorithm at an STI clinic in Amsterdam.

OBJECTIVES: To compare point-of-care (POC) systems in two different periods: (1) before 2010 when all high-risk patients were offered POC management for urogenital gonorrhoea by Gram stain examination; and (2) after 2010 when only those with symptoms were offered Gram stain examination. METHODS: Retrospective comparison of a Gram stain POC system to all high-risk patients (2008-2009) with only those with urogenital symptoms (2010-2011) on diagnostic accuracy, loss to follow-up, presumptively and correctly treated infections and diagnostic costs. Culture was the reference diagnostic method. RESULTS: In men the sensitivity of the Gram stain was 95.9% (95% CI 93.1% to 97.8%) in 2008-2009 and 95.4% (95% CI 93.7% to 96.8%) in 2010-2011, and in women the sensitivity was 32.0% (95% CI 19.5% to 46.7%) and 23.1% (95% CI 16.1% to 31.3%), respectively. In both periods the overall specificity was high (99.9% (95% CI 99.8% to 100%) and 99.8% (95% CI 99.7% to 99.9%), respectively). The positive predictive value (PPV) and negative predictive value (NPV) before and after 2010 were also high: PPV 97.0% (95% CI 94.5% to 98.5%) and 97.7% (95% CI 96.3% to 98.6%), respectively; NPV 99.6% (95% CI 99.4% to 99.7%) and 98.8% (95% CI 98.5% to 99.0%), respectively. There were no differences between the two time periods in loss to follow-up (7.1% vs 7.0%). Offering Gram stains only to symptomatic high-risk patients as opposed to all high-risk patients saved €2.34 per correctly managed consultation (a reduction of 7.7%). CONCLUSIONS: The sensitivity of the Gram stain is high in men but low in women. When offered only to high-risk patients with urogenital symptoms, the cost per correctly managed consultation is reduced by 7.7% without a significant difference in accuracy and loss to follow-up.

The association between racial disparity in income and reported sexually transmitted infections.

OBJECTIVES: We examined the association between racial disparity in income and reported race-specific county-level bacterial sexually transmitted infections (STIs) in the United States focusing on disparities between Blacks and Whites. METHODS: Data are from the US 2000 decennial census. We defined 2 race-income county groups (high and low race-income disparity) on the basis of the difference between Black and White median household incomes. We used 2 approaches to examine disparities in STI rates across the groups. In the first approach, we computed and compared race-specific STI rates for the groups. In the second approach, we used spatial regression analyses to control for potential confounders. RESULTS: Consistent with the STI literature, chlamydia, gonorrhea, and syphilis rates for Blacks were substantially higher than were those for Whites. We also found that racial disparities in income were associated with racial disparities in chlamydia and gonorrhea rates and, to a lesser degree, syphilis rates. CONCLUSIONS: Racial disparities in household income may be a more important determinant of racial disparities in reported STI morbidity than are absolute levels of household income.

The Philadelphia High-School STD Screening Program: key insights from dynamic transmission modeling.

BACKGROUND: The Philadelphia high-school STD Screening Program (PHSSP) represents an innovative approach to screening-based control of Chlamydia trachomatis infection. The program has been associated with significant reductions in Chlamydia trachomatis prevalence in young females in Philadelphia. We sought to assess program cost-effectiveness in a manner that allowed us to quantify the impact of including males students in the screened population. METHODS: We created a dynamic transmission model using a susceptible-infectious-resistant-susceptible framework. The model was parameterized using PHSSP program data, supplemented by available data from the medical and public health literature, and was used to project the impact of screening on disease burden, quality adjusted survival, and costs. RESULTS: A well-calibrated model suggests that high-school based screening is highly cost-effective in the Philadelphia context. Five important insights are gained through dynamic transmission modeling of the PHSSP: (i) the importance of screening males can be appreciated using a dynamic transmission model; (ii) the attractiveness of screening males is inversely related to equilibrium prevalence in males; (iii) including males enhances both effectiveness and economic attractiveness of screening; (iv) rebound in prevalence does not greatly diminish the cost-effectiveness of screening; and (v) increasing program expenditures via increased screening coverage decreases net societal costs, due to diminished disease transmission. CONCLUSIONS: The current PHSSP is highly cost-effective relative to other commonly accepted interventions. Effectiveness and cost-effectiveness of this program are enhanced by including males. This, and other important attributes of the program, is best appreciated when a dynamic transmission model is used for program evaluation.

The cost-effectiveness of screening men for Chlamydia trachomatis: a review of the literature.

BACKGROUND: An important consideration in determining whether to implement or continue a program to screen men for chlamydia is its cost-effectiveness. A review of the literature on the cost-effectiveness of screening men for chlamydia could potentially provide guidance. METHODS: An Ovid Medline search was conducted for articles published between 1990 and July 2007 using terms for cost, chlamydia, and male. This search returned 175 articles; 25 were retained after eliminating those not relevant to cost-effectiveness studies of male chlamydia screening. We added 4 articles that were in-press or are published in this issue, for a total of 29. These articles were examined for common themes and their results summarized. RESULTS: The reviewed studies examined both proactive and opportunistic screening and included screening of risk groups and of the general population. Some older studies included enzyme immunoassays; more recent studies featured nucleic acid amplification assays. Six studies used dynamic transmission models. Fourteen studies analyzed male and female chlamydia screening interventions. Several contained sufficient data to examine the cost-effectiveness of male screening compared with female screening. Male screening was preferred to expanded female screening in 1 study. In other studies, combined male and female screening programs were cost-saving. CONCLUSIONS: Studies comparing chlamydia screening in men with chlamydia screening in women may be the most useful for guidance to programs. The studies which compare the 2 generally have found that screening men from the general population is not preferred to screening women from the general population, although 1 study found that screening of men from risk groups can be cost-effective compared with screening women from the general population.

A randomized controlled trial of azithromycin versus doxycycline/ciprofloxacin for the syndromic management of sexually transmitted infections in a resource-poor setting.

A randomized controlled trial was carried out to assess the effectiveness of azithromycin versus a standard regimen with doxycycline/ciprofloxacin in the treatment of sexually transmitted infections in a resource-poor environment. Infection with Chlamydia trachomatis was cured in 23/24 (95.8%) of women in the azithromycin arm versus 19/21 (90.5%) in the doxycycline arm (P = 0.6), resulting in three treatment failures. Gonorrhoea was cured in 55/56 (98.2%) women, with one treatment failure in a patient with concomitant C. trachomatis infection. These results indicate that a single oral dose of azithromycin may prove to be a more effective and convenient treatment for sexually transmitted infections in women in a resource-poor environment

A lifetime of campaigning: Ettie Rout, emancipationist beyond the pale.

H.G. Wells called her 'that unforgettable heroine'. But she was forgotten, most particularly in New Zealand, where she was banned from mention in the newspapers under the War Regulations for her 'safe sex' work during the First World War - a very hypocritical move as it happened just as her work was officially taken on by the army. For this work she was dubbed the 'guardian angel of the ANZACs' by a French venereal disease specialist and awarded the Reconnaissance Franaise by the French. After the war she settled in London, marrying her long-time friend and wartime colleague, physical culturist Fred Hornibrook. Rout went on with her venereal disease prophylaxis campaign after the war. She also entered the birth control movement in the 1920s, playing a major role in the last big birth control court case, a role often attributed to Dora Russell, while Rout again is 'forgotten'. In her books, like the best selling Safe Marriage, a safe sex guide (which was banned in New Zealand), she encouraged women to own their own bodies and take responsibility for their own sexual health. She linked exercise and sex, arguing in books like Sex and Exercise, that exercise would enhance women's sex lives. She and Hornibrook, who wrote a best-selling book entitled The Culture of the Abdomen, presaging the current obsession with rocklike 'abs', made a pair, teaching fitness techniques, holding 'native dance' evenings, and being hailed as modern dance proponents. Rout also wrote books on vegetarianism, wholemeal cookery and Maori culture. The word most commonly used by people describing her throughout her life was 'energy'. She herself was very fit. But she did not fit in. Once her marriage to Hornibrook was over, in 1936, she returned to New Zealand, was rebuffed by former friends. She sailed for Rarotonga and died there, of a self-administered overdose of quinine that September. As she had remarked to H.G. Wells, 'It is a mixed blessing to be born too soon'. She anticipated many of the enthusiasms of our own time - in diet, in dance, in ideas about exercise and sexuality. But because she was so far ahead of her own time in her 'safe sex' campaign, she became persona non grata in her own country. With the advent of AIDS her contribution snaps into focus - and the AIDS clinic in the city of Christchurch where she used to live has been named after her.