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Background: As most chlamydia cases are asymptomatic, regular testing and timely management may be important for control. We aimed to determine the preferences of people living in Hong Kong for chlamydia testing and management services. Methods: An online panel of sexually active individuals living in Hong Kong completed the survey with two discrete choice experiments (DCEs). The first DCE examined the preferred attributes of a chlamydia testing service (cost, location, appointment time, speed of results, delivery of results and availability of other STI testing). The second DCE examined the preferred attributes of a chlamydia management service (cost, access to patient-delivered partner therapy (PDPT), location, travel time, type of person consulted, and attitude of staff). Results: In total, 520 individuals participated: average age 36·8 years (SD 9·9), 40% males and 66% had a bachelor’s degree or higher. Choosing to test was most influenced by cost, followed by speed of results, delivery of results, extra STI testing, appointment available, and the least important was location of testing. Choosing to attend for management was most influenced by the attitude of staff, followed by cost, who they consult, access to patient-delivered partner therapy, travel time and the least important was treatment location. Conclusion: To design effective chlamydia testing and management services, it is important to be responsive to patient needs and preferences. For people living in Hong Kong, cost and staff attitude were the most important factors for deciding whether to test or be managed for chlamydia, respectively. Funding Information: This research was funded by the Hong Kong Medical Research Fund (18171282). JJO is supported by an Australian National Health and Medical Research Council (NHMRC) Emerging Leadership Investigator Grant (GNT1193955). CKF is supported by an NHMRC Leadership Investigator Grant (GNT1172900). Declaration of Interests: All authors declare there are no conflicts of interest. Ethics Approval Statement: Ethics approval was obtained from the University of Hong Kong Institutional Review Board (UW 19-130).

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 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.

A recent Australian paper suggests that chlamydia screening in pregnant women aged

The recent report from Public Health England describes persistently high rates of sexually transmitted infections (STIs) in young people in the London Borough of Lambeth, with those from ethnic minorities particularly vulnerable.1 In a service evaluation pilot to inform clinical outreach in Lambeth, we explored how often (if at all) young, ethnically diverse, male further education (FE) students get tested for chlamydia, and how chlamydia testing could best be advertised and organised at an FE college. In May 2015, male students aged 16–24 years in the public areas at Lambeth …

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.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.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 (p0.001), with positivity double among Māori (24.2% vs 12.5%; p0.001).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.

OBJECTIVES: To evaluate pooling of first catch urine (FCU) specimens as a cost effective strategy for chlamydia testing. METHODS: Mock specimens were pooled with and without dilution to determine optimal pool size and ease of work flow. The performance of the Amplicor Chlamydia trachomatis PCR assay on pooled specimens was compared with individual testing using 370 FCU specimens from asymptomatic men presenting to an STD clinic. Cost savings associated with pooling were estimated. RESULTS: Using mock specimens, the sensitivity and specificity of the Amplicor PCR assay were not affected by pool sizes of two and five, but at a pool size of 10 decreased sensitivity due to inhibition was observed in one of five mock pools when the pooling method which involved no dilution was used. Archived FCU specimens from a study of 370 asymptomatic men were combined consecutively into 74 pools of five and tested by PCR. Of the 18 pools that contained positive specimens, 17 were PCR positive. Compared with testing FCU specimens individually, pooling resulted in a sensitivity of 95%, specificity of 100%, and a cost savings of 57% based on reduced number of tests required. CONCLUSION: Depending on the prevalence of infection, pooling of FCU specimens for PCR testing may result in cost savings compared with testing specimens individually. Further evaluations to validate this strategy using fresh FCU specimens are needed.

In their topical editorial, Jain and Ison state that ‘testing (for chlamydia) is a crucial part of any effective control strategy’.1 In January 2013 we conducted a pilot study of Chlamydia trachomatis and Neisseria gonorrhoea testing in female students at Lambeth Further Education College, London to assess recruitment to a possible prevention of pelvic infection-2 screening trial.2 Two female general practitioners approached consecutive female students in the common room and asked them to help with a women's health study. We explained that only women aged …

Introduction The current Australian National Cervical Screening Program involves regular screening of sexually active women ≥18 years using a Pap test but changes to the program, effective in 2017, will only include women aged ≥25 years. These changes could inadvertently reduce chlamydia screening which is recommended in 15–29 year-olds and often occurs during reproductive visits. Using the ACCESS surveillance system we measured the proportion of chlamydia tests that may no longer occur in primary care following changes to the National Cervical Screening Program. Methods Consultation, Pap and chlamydia testing data were extracted from patient management systems of 18 general practice and family planning clinics in Victoria and NSW. We calculated concurrent Pap and chlamydia testing (within 7 days) by age group, and chlamydia testing frequency among concurrent testers. Results Between January 2009 and September 2014, 10,105 chlamydia tests were conducted among 44,694 women aged 18–30 years; 63% in 18–24 year-olds and 37% in 25–30 year-olds. In the same period, 10,178 Pap tests were conducted; 47% in 18–24 year-olds and 53% in 25–30 year-olds. The proportion of chlamydia tests conducted concurrently with a Pap test was 20% (2058/10,105), similar in both age groups. For 63% (1154/1835) of women with concurrent chlamydia/Pap tests it was their only chlamydia test during the study period. Conclusion One in five chlamydia tests among 18–30 year-olds occurred concurrently with a Pap test and the majority of them had no other chlamydia test during the study period. Our results suggest changes to the National Cervical Screening Program could reduce opportunistic chlamydia testing in a particularly high risk group such as sexually active women aged 18–24 years. As chlamydia is mostly asymptomatic, regular and opportunistic screening is considered a key public health strategy in chlamydia control. New strategies will be needed to increase chlamydia testing in young women. Disclosure of interest statement None.

Background Despite widespread, sustained testing for chlamydia in high income countries, there remain questions about the population impact of chlamydia screening. We analyse the epidemiological trends in chlamydia testing and chlamydia diagnoses in Denmark (1991 to 2011) and describe cases and controls for The Danish Chlamydia Study. Methods We describe the Danish Chlamydia Study; a unique database of individuals involving linkage of administrative health data, chlamydia tests and hospital records. We analyse trends in testing and diagnosed incidence of chlamydia and selected reproductive outcomes in men and women in Denmark. The laboratory dataset contained 4,150,498 test records from 1,348,058 individuals (1/1/1991 to 2/11/2011). Cases: individuals with a positive chlamydia diagnosis; controls: age and gender matched, selected from Danish population register. The proportion ever tested and test positivity were calculated by age, gender and calendar year. Results The cleaned laboratory dataset (1 confirmed test result per person, per day) consists of 3,298,104 test records with 264,410 (8%) positive chlamydia diagnoses. 1,277,463 individuals were tested (346,235 men and 904,587 women). Nearly all women and almost half of men in Denmark have been tested for chlamydia by age 30. Most individuals had only negative tests: 80% of men and 86% of women. Test coverage has increased and been sustained since 2008 but there has been no decline in positivity over time. Individuals included in the Danish Chlamydia Study dataset: Women: 574,679 (114,936 cases, 459,743 controls (279,905 only negative tests, 179,838 never tested)), contributing 1,807,618 tests and 20,912 reproductive outcomes; Men: 325,337 (65,068 cases, 260,269 controls) contributing 291,655 tests and 9,698 reproductive outcomes. Conclusion This large, rich dataset including long term follow up of a nationally representative sample of men and women from Denmark is a step forward in addressing some of the outstanding questions about the population impact of chlamydia screening.

Introduction ACCEPt is a randomised controlled trial of annual chlamydia testing for 16–29 year olds in general practice. Part of the trial examines whether practice nurses (PNs) can play a role in chlamydia testing. PNs previously identified education as an important facilitator to their involvement in testing. We evaluated the impact of education on PNs’ knowledge and attitudes in relation to chlamydia testing. Methods The 2-hour education program was delivered at clinics to PNs by ACCEPt staff. A survey was conducted at baseline and repeated 6–12 months post education; analysis focused on PNs who completed both surveys. The survey used Likert scales, which were analysed as continuous variables (scores). We used t-tests to assess if changes in mean scores between survey rounds were greater in the education group. Results In total 72 PNs completed both surveys (42 of which received education). Changes in mean scores between survey rounds in the education group were significantly different to the non-education group for the statements: most chlamydia infections in men are asymptomatic (p = 0.01); I would offer a chlamydia test to a 23-year old married female having a pap test (p = 0.04); I would like to be more involved in testing (p = 0.04); I would like to be more involved with managing a recall/reminder system (p = 0.05); and time/workload constraints are barriers to testing (p = 0.001). The increases in mean knowledge score (p Conclusion Our evaluation suggests PN participation in the ACCEPt education program improved chlamydia testing knowledge and attitudes among PNs and could be utilised more widely across primary care. The findings also suggest time/workload constraints became a stronger barrier after education, presumably due to greater involvement in testing. Future analyses will determine if the education program combined with other initiatives have increased testing rates. Disclosure of interest statement ACCEPt was commissioned and funded by the Australian Government Department of Health and Ageing. Additional funding has been received from the National Health and Medical Research Council, the Victorian Department of Health and NSW Health.

The Australian Chlamydia Control Effectiveness Pilot (ACCEPt) is a cluster randomised controlled trial that aims to measure the effectiveness of a chlamydia testing intervention in general practice. Over 140 general practice clinics are participating in ACCEPt in 54 geographical areas across four Australian states (Victoria, New South Wales, Queensland and South Australia). The primary outcome of ACCEPt is change in chlamydia prevalence among 16 to 29 year old men and women attending general practice. This will be assessed as the difference in chlamydia prevalence between a survey conducted prior to randomisation in all participating clinics (survey 1) and a survey conducted at the conclusion of the trial (survey 2). Both surveys have identical methodology. A research assistant employed by the research team is based in each of the participating clinics and invites consecutive patients to participate as they arrive for a consultation with a doctor. Men and women are eligible if they are 16–29 years old and have ever had vaginal and/or anal sex. Participants provide a self-collected urine specimen or vaginal swab for chlamydia testing and complete a questionnaire. The questionnaire includes items about demographic characteristics, sexual behaviour, reasons for attending and genital symptoms. Sexual behaviour questions includes number of partners in the last 12 months, concurrency (two or more overlapping partnerships), duration of most recent partnership and condom use (inconsistent or consistent use with most recent partner). The first survey was conducted between 2010 and 2012 with over 4000 men and women tested and an overall chlamydia prevalence of 4.6% (95% CI: 3.9%, 5.3%). The second survey commenced in July 2014 and will be completed in August 2015. Over 3,400 men and women had been recruited as of the end of June 2015. The results of the second survey will be presented and its findings compared with survey 1.

Chlamydia trachomatis is the most commonly reported bacterial sexually transmitted infection and its greatest burden is among young adults with community-based studies reporting prevalence estimates of 3 to 5% among 16 to 29 year olds in Australia. As over 80% of infections are asymptomatic, screening is the main way to detect cases. However, there is considerable debate about the effectiveness of chlamydia screening. In response to this concern, the Australian Government funded the Australian Chlamydia Control Effectiveness Pilot (ACCEPt) to assess the feasibility, acceptability, efficacy and cost-effectiveness of annual chlamydia testing for sexually active 16 to 29 year old men and women attending general practice. ACCEPt is being evaluated using a cluster randomised controlled trial design. A total of 143 general practice clinics in 52 geographical areas (clusters) are participating. An intervention to support increased chlamydia testing, including incentive payments for each test done, quarterly feedback on testing performance and computer prompts, has been allocated at the cluster level and all general practice clinics within each cluster are participating. The primary outcome of ACCEPt is change in chlamydia prevalence among 16 to 29-year-old men and women attending general practice. This will be assessed as the difference in chlamydia prevalence between a baseline prevalence survey conducted among a consecutive sample of 16- to 29-year-old men and women attending all participating clinics prior to randomisation and a follow-up survey conducted at the conclusion of the trial. The fundamental premise of this trial is that increased levels of testing can be achieved by providing support to clinics, and that once levels of chlamydia testing are sufficiently increased, the prevalence of chlamydia will fall. Preliminary results from ACCEPt will be presented.

Background/introduction Individuals who test positive for chlamydia are at increased risk of subsequently testing positive. NCSP standards recommend offering re-testing three months after treatment completion. Concerns have been raised that re-testing could undermine prevention messages. Aim(s)/objectives To elicit young adults’ views on the acceptability, and their preferred method, of being offered re-testing, as well as their reaction to and understanding of re-testing. Methods We conducted a cross-sectional web-based anonymous survey of 1,218 young adults aged 16–24 resident in England with a history of chlamydia testing. Respondents were recruited through a market research panel, and Likert-scale questions were based on a young adult focus group. Results The most acceptable and preferred methods of being offered re-testing were being given an appointment with initial test result (75%, 914/1,218 acceptable; 17%, 204/1,218 preferred) and being sent a text message reminder (72%, 875/1,218 acceptable; 20%, 244/1,218 preferred). Most said they would welcome an offer of re-testing (84%; 1024/1,218) and understand why they were offered this (82%, 994/1,218). Most agreed that if they were offered re-testing they would be more likely to complete the course of chlamydia treatment (83%, 1007/1,218) and use condoms with their partner until the test (80%, 970/1,218). Most disagreed that that they would be more likely to have one-night stands (63%, 772/1,218) or discourage their partner to get tested (60%, 735/1,218). Discussion/conclusion Young adults report they would welcome an offer of re-testing and understand the reasons for being offered this. There was little evidence that it would increase sexual risk behaviour.

Background Monitoring trends in chlamydia-related sequelae, such as epididymitis and pelvic inflammatory disease (PID), is an important aspect of the evaluation of chlamydia control initiatives such as the National Chlamydia Screening Programme (NCSP). Unlike PID, which can be difficult to diagnose, epididymitis may be a useful measure for evaluation purposes. The objective of this analysis was to examine trends in epididymitis diagnosis rates in the era of increased chlamydia testing. Methods Diagnoses of epididymitis among 15–35 year old males were obtained from the genitourinary medicine (GUM) clinic activity dataset version 2. Diagnosis rates were calculated, per year, using the number of new-episode male clinic attendances. This accounted for changes in clinic attendance over the years. Negative binomial regression was used to derive the incidence rate ratios (IRR) and test significance of the trends. Results Between 2009 and 2013, a total of 24,689 diagnoses of epididymitis were made among 15–35 year old males, of which 10% (2,506) were of chlamydial and 2% (473) of gonoccocal aetiology. Diagnosis rates of chlamydial epididymitis declined by an average of 12% per year (IRR = 0.88, 95% CI; 0.81–0.96, p Conclusion The decreased rate of chlamydial epididymitis diagnoses in men may be associated with increased chlamydia testing, however, the influence of other contributing factors should be explored.

Background/introduction Current clinic policy is to offer extra-genital testing to all patients reporting a history of active oral sex and/or receptive anal sex. These swabs are analysed using the Aptima Combo II platform for Chlamydia trachomatis (CT). Aim(s)/objectives With analysis costing £6.20 per swab we sought to explore the cost effectiveness and review positive case with collateral contact information and symptoms history to support a positive diagnosis. Methods Inclusion criteria were heterosexual patients with exclusively extra-genital CT who did not present as CT contact. We performed retrospective case note review of 63 sets of notes to determine symptom history, concurrent STI diagnosis and contact diagnosis. Results Over the year, a total of 12076 throat swabs were sent in this group. There were 39 confirmed positive results giving swabs sent per positive result ratio of 310:1. Or a cost of £1922 per positive result. For rectal swabs; a total of 1156 were sent. There were 24 positive results giving swabs sent per positive result ratio of 48:1, or a cost of £297.60 per positive result. 5% of patients with a positive extra-genital swab result gave a history of throat or rectal symptoms. 4% had a concurrent STI diagnosis, 40% of those with traceable contacts had at least one positive contact. Discussion/conclusion Routine extra-genital screening is costly but this review demonstrates its value for detection of individual cases which would have been missed. In addition the high proportion of positive contacts adds weight to the debate for extra-genital testing of all contacts.

Background/introduction Scottish chlamydia testing guidelines target symptomatic and high-risk asymptomatic individuals. Recent publications, indicating a low risk of progression to serious chlamydia-related outcomes, particularly tubal factor infertility (TFI), question the validity of high levels of opportunistic testing especially among asymptomatic individuals. Aim(s)/objectives To examine cost-effectiveness of current chlamydia testing to prevent TFI among those aged 15–24 in Scotland using cost per Quality-Adjusted Life Years (QALYs) gained and to consider alternative testing strategies. Methods A compartmental deterministic model of chlamydia infection in those aged 15–24 in Scotland was developed to examine the impact of testing coverage and partner notification (PN) on number and cost of TFI cases prevented. Cost-effectiveness calculations were informed by best estimates of the QALYs lost due to TFI. Results At 16.8% baseline testing coverage (laboratory data), 4.4% prevalence (NATSAL-3) and assumed PN rate of 0.4, the total testing cost is £5.4 million. This is estimated to prevent 258 TFI cases each year in young women. The cost per QALY gained is £40,034 compared with no testing, using a mid-range health state utility value (HSUV) for TFI (0.76 (±0.24)) and PID (0.9 (±0.22)). A 50% reduction in current testing would result in higher chlamydia prevalence and 84 more TFI cases. Discussion/conclusion Current chlamydia testing activities in Scotland do not appear cost-effective. However, the model is sensitive to several parameters, particularly the HSUV and there are uncertainties in the current testing costs and progression to serious sequelae. There appears potential to improve chlamydia testing cost-effectiveness by increasing PN.

Chlamydia trachomatis is the commonest bacterial sexually transmitted infection (STI) in Victoria, Australia, with the number of notifications increasing threefold in the past 8 years from 1287 in 1994 to 3977 in 2001.1 As infection with chlamydia is frequently asymptomatic, notification data underestimate population prevalence. Innovative study designs are necessary to investigate chlamydia prevalence and risk factors. We conducted a pilot study among women aged 18–32, to estimate the rate of response to a request to provide a mailed self collected urine specimen for chlamydia testing. Recruitment via mail was compared with recruitment via mail and follow up telephone contact. Between March and May 2002, the names and addresses of 150 Victorian women aged 18–32 were randomly selected from the electoral roll. …

Background US guidelines recommend chlamydia screening for all sexually active young women, HIV-infected persons, and men who have sex with men (MSM). Several types of chlamydia tests are available, including nucleic amplification tests (NAATs), DNA probe, and culture. Different assays have different sensitivity and specificity, and sensitivity and specificity also varies by specimen type. Because reported chlamydia trends could be impacted by shifts in the proportion of tests and specimen types used by providers and laboratories, it is important to monitor changes in test usage to help interpret reported trends in morbidity. We examined chlamydia testing data from one of the two largest commercial laboratories in the USA Methods Among chlamydia tests performed from June 2008—to July 2010 by this laboratory, we assessed the frequency of test types used by year, sex, specimen type, and positivity of these tests. Results During these 2 years, 2.9 million specimens were tested for chlamydia. Among those tested, 86% were women. Tests performed were: 77% NAATs, 23% DNA probes, and 0.3% cultures. Between year 1 and 2, NAATs increased from 73% to 80% of all tests, and DNA probes decreased from 27% to 19%. Test type varied by sex; 88% of tests among men were NAATs compared to 75% among women. The top specimen types among women tested by NAAT were: 45% cervical, 35% urine and 18% vaginal. Chlamydia positivity varied by test type: 5.1% NAAT, 1.4% DNA probe, and 2.3% culture. Conclusions NAATs were the most frequently used chlamydia test and their use increased over the evaluation period, creating a smaller market for other tests. Although vaginal swabs are the most sensitive specimen for testing women by NAAT, currently they are the least common specimen type used for testing. This may reflect the delayed introduction (FDA clearance) of the vaginal swab compared to other collection devices. Stocking the wide assortment of collection devices required for testing different specimens in different populations might also be a barrier for providers. Because these data are from one of the largest U.S. laboratories, with representation by insurance type and geography of the U.S. population, they can be useful for monitoring testing trends. Laboratory testing data also might be a valuable adjunct for national surveillance of chlamydia positivity trends that would not be dependent on provider or health department reporting nor small sample size from national surveys.

Background Facebook is the world9s largest social media site, and university students comprise one of the largest user groups. Sexually transmitted infections are also highly prevalent among university students in the USA. We evaluated a targeted Facebook advertisement for easy, inexpensive chlamydia testing at The Ohio State University (OSU), a public university with 55 000 students. Methods Over 2 weeks in May 2010, our advertisement for $25 chlamydia testing was displayed to Facebook users who had self-identified as OSU students between 19 and 28 years of age. Students provided a urine sample directly to the laboratory; a clinician visit was not required. To a separate convenience sample we administered a short survey capturing demographics, social media use and interest in future testing. Results The advertisement received 401 732 impressions” (displays of the advertisement to users). Nearly all 98%) impressions were to 19–24-year-olds. The daily impressions varied enormously, from 0 to more than 100 000. In the first week, although the advertisement received up to 2,900 daily impressions, no one clicked it. We gradually increased our “bid per click”—the amount we agreed to pay Facebook for each click—from $0.62 to $0.90. We also modified the advertisement format to depict a college student and to clearly specify the $25 cost of the test. Following these changes, both the number of impressions and “clicks” rose dramatically. Seventy-five individuals clicked the advertisement (25 women and 50 men), with an average cost per click of $0.84. Three students, all female, came for chlamydia testing; one tested positive. Among surveyed individuals (n=60), 75% reported using Facebook daily or more often. Few (10%) reported ever clicking on Facebook advertisements. Only one surveyed student noticed our Facebook advertisement. The direct-to-laboratory testing concept was popular, with 75% reporting willingness to use this service in the future. Conclusions In this short pilot study, 75 individuals clicked on a Facebook advertisement about chlamydia testing, three came for testing and one tested positive. Facebook advertisements are inexpensive, with high exposure to the target population. A small increase in bid per click can make a very large difference in total impressions. The format of the advertisement is critical for catching the attention of the target audience, because many students report never noticing or clicking Facebook advertisements.

Background Chlamydia infection is thought to increase the risk of infertility and ectopic pregnancy. Over the last 10 years in Australia, chlamydia testing and notifications have increased dramatically, particularly in young women. As it is unclear how much increasing notifications reflect a true increase in chlamydia incidence, we sought to investigate rates of hospitalisation for the chlamydia-related sequelae, infertility and ectopic pregnancy in New South Wales (NSW), Australia9s largest state with a population of 7 million. Methods Routine data on hospitalisations for infertility and ectopic pregnancy, perinatal data, and population census data from 2001 to 2008 were used to estimate annual age-specific hospitalisation rates for infertility and ectopic pregnancy in women aged 15 to 44 years for the entire state of New South Wales. Hospital separations occuring within each year belonging to the same woman were linked using probabilistic linkage of identifiers so that multiple admissions by one woman were only counted once. Results From 2001 to 2008 the number of women hospitalised for infertility increased from 7050 to 9978. The greatest increase was seen in women aged 35 to 44 years, from 6.4 [95% CI 6.2 to 6.6] to 11.2 [10.9 to 11.5] per 1000 population (p trend Conclusions Among women aged 25 to 44 years decreases in hospitalisations for ectopic pregnancy and increases in hospitalisations for infertility were observed. The relationships between chlamydia prevalence, testing and notifications do not appear to be straightforward.

The results of the Prevention Of Pelvic Infection (POPI) trial,1 published soon after criticism about the value for money of the chlamydia screening programme in England,2 should make us think even harder about how to investigate and control chlamydia and its associated morbidity. Should we be doing more of the same, but better? Should we be developing new approaches? Or do we need both? The innovative trial by Oakeshott et al in female college students in London provides new information about the effects on pelvic inflammatory disease (PID) of a single round of screening for Chlamydia trachomatis .1 By collecting specimens from all participants at baseline, Oakeshott and colleagues have provided the first data comparing the incidence of PID according to chlamydia infection status in women receiving immediate testing and treatment with those for whom testing and treatment were deferred by 12 months. The ethical decision to allow deferred testing is justified by the uncertainty about the incidence of PID in the community before the start of the trial, the low observed incidence in practice and the advice for all study participants about the availability of free chlamydia testing. The investigators randomised and followed 2529 women (mean age 20.9 years) and collected outcome data on 2377 (94%) from the women or their GPs. They obtained information from medical records of …

Background In England, the National Chlamydia Screening Programme aims to control chlamydia infection in young adults (aged 15–24 years old) through opportunistic testing. This study aimed to investigate the impact of testing on young adults’ subsequent healthcare seeking and sexual behaviour. Young adults’ attitudes to chlamydia and chlamydia testing are important barriers to screening, and thus questions on attitudes to testing and reasons for not testing were included. Methods A cross-sectional web-based anonymous survey of 1,521 young adults aged 16–24 resident in England was conducted using a nationally representative research panel. The impact of chlamydia testing on subsequent behaviour, and attitudes towards chlamydia testing, were assessed by asking respondents to use a Likert scale to score how well they agreed with a series of statements. Results Just under half (46%; 695/1,521) of respondents had been tested for chlamydia previously: of whom 14% (94/695) reported ever having received a positive result. Those tested (n = 695) reported a positive impact on subsequent healthcare seeking behaviour (e.g. 68% agreeing that they were more likely to test again), and a smaller impact on sexual behaviour (e.g. 40% agreeing that they were more likely to use condoms consistently). Having positive attitudes towards chlamydia testing was associated with a higher likelihood of having been tested (OR 4.9; 95% CI 3.9–6.1). Of those sexually active but not tested (32%; 488/1,521), 70% did not consider themselves to be at risk. Conclusions Young adults reported that being tested for chlamydia had a positive impact on their willingness to engage with future testing, and a smaller impact on subsequent sexual behaviour. The use of online surveys is warranted as the results were comparable to those of nationally representative population based surveys. Addressing young adults’ underlying attitudes towards testing and perceptions of risk could increase their willingness to test for chlamydia.

Background Current guidelines recommend that sexually active people aged under 25 are screened annually for Chlamydia. Those testing positive should be retested around 12 weeks later to detect re-infection. The Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) Laboratory Network has collected chlamydia testing data from 15 Australian public and private laboratories since 2008. This study reviews the frequency of repeat testing for C. trachomatis. Methods Chlamydia test results and associated demographic data were extracted from participating laboratories’ information systems, de-identified with a non-reversible unique code and sent to a central database using GRHANITE® software. Using the unique identifier, cases of multiple testing episodes from individuals were reviewed to determine the frequency of repeat testing. Results 641,302 chlamydia test results were collected from 547,761 individuals during the calendar years 2008–2010; 49,655 (7.7%) were positive. Overall, 9.6% individuals had multiple testing episodes, increasing to 23.4% among those with an initially positive result. The mean number of testing episodes per individual was 1.11 (range 1–29) and mean time between repeat tests was 201 days following negative samples but 95 days after a positive sample. Among individuals who had a repeat test, for those with a negative result 19.6% of repeat tests were performed within 42 days, 42.8% within 120 days and 86.0% within 13 months. This is compared with 41.9% (≤ 42 days), 76.6% (≤ 120 days) and 96.6% (≤ 13 months) for repeat tests following an initially positive result. Conclusion Individuals with positive test results were found to be re-tested more frequently and earlier than those with negative test results. However, less than one quarter of individuals who tested positive for chlamydia were re-tested and over 40% of these were re-tested too soon after initial diagnosis (

Background To study the efficiency of Chlamydia home collection kits for young people, in order to optimise care at the Amsterdam STI clinic. Methods Since 2012, young people under the age of 25 with a low risk profile for STIs are only tested for Chlamydia. Tests for other STIs are indicated after testing Chlamydia positive. From September-November 2012, young people using the online intake were offered two different ways of Chlamydia testing: receiving a home collection kit, or coming to the clinic. The collection kit is send to the client by mail and is used to collect a swab or urine sample. This sample is send back to the laboratory for testing. The client can retrieve the results online by using the provided login. Results In the study period, 523 online requests were done. Of these, 388 (74%) opted for the home collection kit and 135 (26%) preferred an appointment at the clinic. Of the requested kits, 86% were send back. All clients checked their test result online. Chlamydia was diagnosed in 5.5% of the clients receiving a home kit and in 2.9% of those tested at the clinic. Women were more likely to request a home collection kit (77% versus 60% of men, p Conclusions Young people prefer a home collection kit to a test at the clinic. Furthermore, offering home collection kits is time and cost saving. Because clients who test negative are not seen at the clinic, more time is left for high-risk groups. In conclusion, Chlamydia home collection kits optimise care efficiency at the STI clinic.

Background The National Get Yourself Tested (GYT) Campaign was launched in 2009 to promote STD communication and testing among youth (≤ 25 years) through multimedia platforms, on-the-ground outreach, and linking youth to free/low-cost STD testing. It is a public-private partnership effort between the U.S. Centers for Disease Control and Prevention (CDC), MTV Networks (MTV), the Henry J. Kaiser Family Foundation, and Planned Parenthood Federation of America, among other partners. This effort sought to evaluate campaign exposure and associations with STD testing and communication among youth during the first two years of implementation. Methods Media metrics tracked campaign-related television, web and social-media programmes in 2009–10; a national mail-panel consumer survey of youth assessed campaign recall and self-reported changes in STD testing and discussions in 2010; and STD patient data from partner health centres (n = 9 affiliate health centres) tracked STD testing in April 2008 (pre-campaign), 2009 and 2010. Results In its first two years, GYT received > 18 hours of airtime on MTV; its website received > 1.5 million views, and its testing locator made nearly 145,000 clinic referrals. Awareness of GYT among teenage respondents (n = 766) on a national survey was 18.3%, among whom roughly 1/5 reported having talked about STDs/testing with a family member (17.5%) or friend (21.2%). Among participating affiliates, there was a 71.0% increase in patients receiving STD testing in April 2010, compared to April 2008 (at a period when chlamydia testing rates nationally rose by Conclusion This data offers encouraging evidence that GYT is reaching and mobilising youth most in need of testing. Reported testing increases in GYT-partner health centres were greater than national-level trends which varied minimally from 2008–2010. Efforts are underway to conduct a national evaluation of the campaign.

Background ACCEPt, a large cluster randomised control trial, aims to determine if annual testing for 16 to 29 year olds in general practise can reduce chlamydia prevalence. ACCEPt is also the first trial investigating the potential role of the PN in chlamydia testing. To inform the intervention, GPs’ and PNs’ chlamydia knowledge and practises were explored. Methods GPs and PNs from 143 clinics were recruited from 54 postcodes in 4 Australian States and asked to complete a survey at time of recruitment. Survey responses were compared using conditional logistic regression to account for GPs and PNs from the same clinics participating. Results Of 607 GPs and 126 PNs enrolled in ACCEPt, 86% and 78% completed the questionnaire, respectively. A third of GPs (32%) compared to 23% of PNs (P = 0.076) correctly identified the two age groups with the highest infection rates in women and only 17% vs 16% (P = 0.942) identified the correct age groups in men. Fewer GPs than PNs would offer testing opportunistically to asymptomatic young patients, including women having a Pap smear (55% vs. 84%, P = Conclusion Our survey reveals more gaps in chlamydia knowledge and management among GPs than PNs, which may be contributing to low testing rates in general practise. PNs have a role in increasing chlamydia testing.

Background Chlamydia testing rates are low, with only about a third of sexually active young women tested at clinical encounters. Even fewer sexually active female adolescents are tested. Interventions to increase testing coverage have been moderately successful. In this study, we assessed the relative health and economic outcomes of patient-directed, universal, opt-out testing for women aged 15–24 years in the United States who have at least one clinical encounter each year when compared with current testing (30% coverage). Methods We used a basic dynamic compartmental model that included two groups based on their self-reported sexual activity in the past 12 months, with 72% being sexually active and 28% inactive. For our base case analysis, we assumed a 75% uptake of the intervention by sexually active women and 5% by sexually inactive women. All model parameters were obtained from the literature. The model was calibrated to produce a pre-intervention prevalence close to the national burden for those aged 15–24 years in the United States (≈2.5%). Health outcomes were measured in quality-adjusted life years (QALYs). Results Based on our model (including health insurance coverage and utilisation rates), the estimated effective annual testing rate increased to approximately 52%, and overall chlamydia prevalence decreased by 60% to ≈1% over a three-year period. The estimated cost per QALY gained was $1372. When we assumed an uptake rate ≥ 85%, the overall prevalence decreased to zero. Conclusion The universal, opt-out testing intervention was cost-effective because it did not require additional costs over and above testing and treatment. Our exploratory analyses suggest that implementation of opt-out testing of young women during clinical encounters might substantially increase testing coverage of sexually active young women. However, even with a higher uptake, testing gaps would remain because many women might not have health insurance coverage, or not utilise healthcare.

Background Chlamydia screening uptake rates in Australian and overseas pharmacies vary widely (11% to 58%). Aim To determine the effect on the uptake of chlamydia screening in community pharmacies when a cash reward is offered to young people and participating pharmacies. Methods The study was advertised in print and electronic media. People aged 16–30 years requested, or were offered, chlamydia testing kits by pharmacy staff (assistants and pharmacists). Participants who provided a urine sample and completed a questionnaire received AUD$10; pharmacies received AUD$10 per person recruited. Urine specimens were tested in pools using PCR, with reflex testing of individual samples when the pool tested positive. Positive cases were notified by sexual health nurses and offered treatment. Results Six urban community pharmacies took part in the study, each for 15 days. 979 testing kits were given out and 970 sample pots returned (99.1%); 66 (7%) did not contain urine. 74% (670/904) of the urine samples were determined to be from unique individuals, 65% of whom were male. 19 people (13 females and 6 males) tested positive; positivity rates were 5.2% (95% CI 2.8 to 8.8) for females and 1.4% for males. 11 (61%) of those testing positive were contacted and eight attended a local sexual health centre for treatment, three were treated elsewhere. Of the eight people treated at the sexual health centre, two females aged 15 and 20 years were diagnosed with pelvic inflammatory disease. Contact with the remaining eight positive individuals was not possible due to disconnected, incorrect or non-existent telephone numbers. Conclusion The 68% specimen return rate found in this study significantly exceeds those reported elsewhere. Strategies to prevent repeat testing, non-urine specimens and incorrect contact numbers are needed to ensure good clinical care and optimum use of resources.

Background Women treated for chlamydia have a high prevalence of infection several months later, likely caused by reinfection from an untreated or new infected sex partner. To prevent potential adverse outcomes of chlamydia, US guidelines recommend repeat testing 3 months after treatment, regardless of partner treatment. If retesting at 3 months is not possible, women should be retested at their next clinical encounter within 12 months. A chlamydia test-of-cure is also recommended for all infected pregnant women 3–4 weeks after treatment. We assessed adherence to retesting guidelines using data from a US laboratory corporation that has a large share of the US market. Methods Among tests performed from June 2008 to May 2010, we estimated the percentage of women who were retested ≥3 weeks later by test result, age and pregnancy status. We also estimated the positivity rate among repeat chlamydia tests and the mean time between an initial test and the first repeat test. We assumed that for each woman in the database all chlamydia tests during the study period were performed by this laboratory corporation. Results Among 2.90 million chlamydia tests performed in 1.77 million women, 4.0% (114 963) were positive. Among the 1.77 million women with tests, 1.34 million (75.7%) had only a single test and 0.43 million (24.3%) had at least one repeat test. If an initial test was positive, 48.6% were retested compared to 23.5% if the initial test was negative (p Conclusions These data from a large laboratory corporation provide insight into chlamydia testing practices among women in the USA, and suggest suboptimal adherence to retesting recommendations for both pregnant and nonpregnant women. These data can be useful to monitor the effectiveness of interventions to improve follow-up testing of women with chlamydia.

Background US guidelines recommend annual Chlamydia screening of the rectum and urethra among men who have sex with men (MSM) with sexual exposure at these anatomic sites. Routine pharyngeal chlamydia screening is not recommended. About 6% of US males have a history of sex with men. The prevalence of rectal chlamydia has consistently been high among MSM with a history of receptive anal sex. One study indicated that up to 53% of chlamydial infections would be missed and not treated if only urethral testing was performed among MSM. We examined data from a large commercial laboratory corporation with a substantial share of the US market and testing available across all 50 states, that also offers rectal and pharyngeal testing with nucleic acid amplification tests (NAAT), to estimate the frequency and positivity of specimens collected from men by anatomic site for chlamydia testing. Methods Data for all Chlamydia testing methods was obtained by a large commercial laboratory between June 2008 and July 2010. The data set was then queried to obtain testing performed on males and analysed for anatomic site, test type, test result and age. Urethral and urine specimens were assumed to be testing for urethral infections. Results Chlamydia testing was performed on 227 188 specimens from men: 98.2% urethral, 1.3% rectal, and 0.5% pharyngeal. The age distribution of those tested was: 2.4% 44 years. Chlamydia positivity varied by anatomic site (8.7% rectal, 6.9% urethral, and 3.5% pharyngeal), and by age (2.5% 44 years). Of 2918 rectal specimens, 17.8% were tested by culture and 75.5% by NAAT, compared to 93.5% of urethral specimens tested by NAAT. Conclusions Given the sexual practices of men in the US, it appears that only a small proportion of MSM are appropriately screened for rectal Chlamydia. Lack of FDA clearance for these specimen sources may contribute to the small proportion of MSM being screened for rectal Chlamydia. Interventions to increase rectal chlamydial testing among MSM are needed. Because data from this corporation represents a large proportion of testing in the US, it could be used to monitor changes in chlamydia testing practice among men in the future.

Background Annual chlamydia testing of all sexually active women aged 25 years and under followed by a repeated test 3 months after treatment is recommended by the US Centers for Disease Control and Prevention (CDC) guidelines. Data from the Healthcare Effectiveness Data and Information Set (HEDIS) estimate chlamydia test coverage at about 40% per year in the last 5 years. We used empirical data and mathematical models to determine whether observed patterns of chlamydia testing are consistent with CDC guidelines and with actual trends in chlamydia prevalence in US women aged 15–25 years. Methods First, published data from women enrolled in commercial health plans from 2002 to 2006 (n=1 985 920) were used to estimate the annual chlamydia testing rate in women aged 15–25. Second, trends in chlamydia prevalence in the same age group were studied using data from 1999/2000 to 2007/2008 (n∼600 each round) from the US National Health and Nutrition Examination Survey (NHANES). We used a Susceptible-Infected-Recovered-Susceptible (SIRS) model to estimate the annual screening rate that fit the chlamydia prevalence data best. The model described a closed population with behavioural parameters reflecting people aged 15–25 years. It explicitly incorporated sexual partnerships and took into account re-infection. Finally, the model was used to examine the effect of repeated chlamydia testing 3 months after treatment on chlamydia prevalence and to calculate repeat infection rates. Results The estimated rate at which women are tested for chlamydia ranges from 0.06 to 0.11 per year, which corresponds to a chlamydia test every 9 to 16 years on average and an annual coverage of roughly 10%. We found no statistical evidence that chlamydia prevalence changed between 1999 and 2008 in sexually active women aged 15–25 years taking part in NHANES. Predictions from the model of the impact of screening at a rate of 0.11 per year were consistent with the observed stable chlamydia prevalence. Repeat chlamydia testing 3 months after treatment at the estimated screening level hardly influenced population prevalence. The percentage of women with a repeat infection was highest 3.8 months after treatment. Conclusion Our study demonstrates the challenges of implementing chlamydia screening. This study suggests that low rates of chlamydia testing in the US have not reduced population chlamydia prevalence substantially.

McNamee et al 1 provide a timely analysis of chlamydia testing and notification rates in the context of increasing chlamydia notifications in Victoria and Australia.2 The national strategic response to sexually transmitted infections in Australia outlines a number of initiatives aimed at improving chlamydia prevention and detection. These include a pilot chlamydia testing programme targeting sexually active young people in general practice as well as the promotion of opportunistic testing in a variety of settings.3 4 For targeted chlamydia screening to be effective as a public health intervention it is important to understand testing patterns and health-seeking …

Background In the context of widespread opportunistic chlamydia screening among young adults, we aimed to quantify chlamydia testing and diagnosis among 16–24 year olds in Britain in relation to risk factors for prevalent chlamydia infection. Methods Using data from sexually experienced (≥1 lifetime sexual partner) 16-year-old to 24-year-old participants in Britain9s third National Survey of Sexual Attitudes and Lifestyles (conducted 2010–2012), we explored socio-demographic and behavioural factors associated with prevalent chlamydia infection (detected in urine; n=1832), self-reported testing and self-reported diagnosis in the last year (both n=3115). Results Chlamydia prevalence was 3.1% (95% CI 2.2% to 4.3%) in women and 2.3% (1.5% to 3.4%) in men. A total of 12.3% of women and 5.3% men had a previous chlamydia diagnosis. Factors associated with prevalent infection were also associated with testing and diagnosis (eg, increasing numbers of sexual partners), with some exceptions. For example, chlamydia prevalence was higher in women living in more deprived areas, whereas testing was not. In men, prevalence was higher in 20–24 than 16–19 year olds but testing was lower. Thirty per cent of women and 53.7% of men with ≥2 new sexual partners in the last year had not recently tested. Conclusions In 2010–2012 in Britain, the proportion of young adults reporting chlamydia testing was generally higher in those reporting factors associated with chlamydia. However, many of those with risk factors had not been recently tested, leaving potential for undiagnosed infections. Greater screening and prevention efforts among individuals in deprived areas and those reporting risk factors for chlamydia may reduce undiagnosed prevalence and transmission.