England is in a sexual health crisis, MPs say
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7402.1281 (Published 12 June 2003) Cite this as: BMJ 2003;326:1281
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Paul Davies,
In response to your request for see the evidence on effectiveness of
the two testing methodologies, you could rely on a recent systematic
review:
Watson EJ, Templeton A, et al. "The accuracy and efficacy of
screening tests for Chlamydia trachomatis: a systematic review." J Med
Microbiol. 2002 Dec;51(12):1021-31,
which would mention several studies, or just start with going back to
the 1995 Lancet article on diagnosis:
Lee HH, Chernesky MA, Schachter J, Burczak JD, Andrews WW, Muldoon S,
Leckie G, Stamm WE. “Diagnosis of Chlamydia trachomatis genitourinary
infection in women by ligase chain reaction assay of urine.” Lancet. 1995
Jan 28;345(8944):213-6.
You may also want to glance at a current examination of the impact of
switching diagnostic tests:
Forward KR. “The impact of switching to Polymerase chain reaction for
the diagnosis of Chlamydia trachomatis infections in women.” Can J Public
Health. 2003 May-Jun;94(3):229-32.
I agree on the need for funding for this in the UK, that is one thing
the report was trying to achieve.
The report from the health select committee, on which the BMJ news
item as based, and which was cited and linked to, also gave the expert
testimony on which their conclusion was based:
“Testing for chlamydial infection is by means of urethral samples in
men and women, or cervical samples, urine samples or self-administered
vulval swabs in women. Several of the memoranda draw attention to the
greater accuracy and sensitivity of the newer molecular amplification
test, such as the polymerase chain reaction (PCR) test, and to the fact
that, for cost reasons, this is not always available. In oral evidence, Dr
Tobin suggested that only 10% of clinics used the PCR test, and that the
enzyme immuno-assay (EIA) tests in common use would have missed 30% of
women and 46% of men. Dr Kinghorn estimated that fewer than 5% of GPs had
the PCR test available to them.… Professor Johnson pointed out that there
were potential long-term cost savings in the use of the more sensitive
test if PID and infertility were reduced as a consequence of its
introduction, given the very high costs of infertility treatment.”
Sincerely,
Eric Fretz,
(personal capacity)
Competing interests:
None declared
Competing interests: No competing interests
It is amazing how so many of us physicians have a blind spot when it
comes to sex. The sexual health crisis has been brought about by
unrestrained sexual activity, not by not talking about sex. Nothing will
improve, but can certainly get worse, until people learn self control.
That is what we, as health care providers should be teaching to adults and
children. We do so in other health areas such as smoking and eating. Many
young people feel offended and insulted when we assume that they are sex
maniacs. I recommend to your readers a publication recently released by
the Heritage Foundation (www.heritage.org) linking teen sex and suicide.
In the USA the teaching of abstinence to children is showing good results.
Lastly, there is hope: it is common knowledge that the main reason why
Uganda has reduced significatly its AIDS rate is because of its vigorous
and successful abstinence and fidelity promotion.
Liliana Alessandri, M.D.
Competing interests:
None declared
Competing interests: No competing interests
I have worked long in the Uk, and am of the opinion that the
integration of sexual health in some ear marked clinics in general
practice would help to sort out this problem.Teenagers in the UK are very
open with their doctors about sexual health problems if the doctor is non-
judgemental.It is indeed sad to hear stories of convent girls going to
parties , getting drunk and not knowing what happened to them after that,
and seeking medical advice.
There is loads of money in the Health Promotion units which could very
well be targeted through general practices to improve the sexual health of
the population by providing sexual health services targeted at teen-
agers.This may help in preventing teen-pregnancies.A more lenient view of
the morals of girls who have got pregnant per chance without realising it
from GPs would be an added advantage.
I hope the health service acts on the above suggestions.
regards
Mona
GP , New Delhi, India
Competing interests:
None declared
Competing interests: No competing interests
I was hoping to have some clarification of the enigmatic last line in
this article. What is the 'notoriously inaccurate test' that is used in
clinics? I know of very few clinics which do their own testing, they all
send it to the pathology department, where it is processed by state
registered biomedical scientists. I hope that the committee hasn't fallen
for that old chestnut that the doctors do the test themselves, rather that
forwarding it to another group of highly trained, if out of sight,
professionals? Most labs use ELISA techniques, and if these have been
found to be inaccurate it would be good to see the evidence, and some
funding,if they want every sample to be processed using PCR/LCR
techniques.
Paul Davies
Competing interests:
None declared
Competing interests: No competing interests
Zosia Kmietowicz describes the recent Pariamentary Report into Sexual
Health and the recommendation for an improved screening programme for
chlamydia. I would like to suggest an alternative strategy, namely that
there should be a national programme for all the 'at risk' population to
take a single dose of Azithromycin 1g orally simultaneously(perhaps on the
first day of the academic year). Azithromycin has been used widely for
many years both to treat established chlamydial infections and also at the
Royal Devon & Exeter Hospital's gynaecology department as universal
prophylaxis for young women undergoing gynaecological surgery. It is
generally free from major side-effects and if resistant organisms were
going to appear they would probably have done so by now. An alternative
might be a 'National Oxytetracycline Week', which would have the advantage
of lower cost and the fact that the compound is available over the
counter, but compliance may be an obstacle due to the need for a prolonged
course.
Competing interests:
None declared
Competing interests: No competing interests
Re: National Azithromycin Day
I am amazed that someone else has thought of and expressed seriously
a plan that I have advocated privately for years among those interested in
the "epidemics" of chlamydia and other sexually-transmitted diseases.
The expected objection to the idea of one day -- or week -- during
which the entire sexually active teen-age and young adult population takes
a dose of antibiotic is that it sends the opposite message and poses a
paradox to our campaign to minimize the unproved use of antibiotics for
fear of inducing microbial resistance in the population.
It is anyone's guess what the reality is. I can see where resistance
might even be lessened by such an approach.
Perhaps there is an animal model in which irrefutable evidence can be
obtained to show that the round robin spreading, then attempts at
eradicating in individuals, a sexually-spread disease is more conducive to
developing resistance than a one-time inoculation of simultaneous
antibiotic into the population.
Other objections might be the exposure to allergic reactions, cost
considerations and "buy-in" by the target population.
Again, the net benefit would likely outweigh those objections. But it
would be difficult to prove without pilot studies to show its efficacy.
The British system might be uniquely situated to study this. Why not
have one of your high schools do it (one day of Azithromycin a year for 3
years), another nearby, with similar disease rates, not. Observe disease
rate and go from there?
Pepi Granat, MD
South Miami, Florida, USA
Competing interests:
None declared
Competing interests: No competing interests