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The National Chlamydia Screening Programme (NCSP) in England was established in 2003 with the following objectives:
- prevent and control chlamydia through early detection and treatment of infection
- reduce onward transmission to sexual partners
- prevent the consequences of untreated infection
- ensure all sexually active under 25 year olds are informed about chlamydia, and have access to sexual health services that can reduce risk of infection or transmission
- normalise the idea of regular chlamydia screening among young adults so they expect to be screened annually or when they change partner
In 1998, the Chief Medical Officer’s Expert Advisory Group on Chlamydia trachomatis considered the evidence-base associated with screening for genital chlamydial infection. This group concluded that chlamydia screening met the criteria for a screening programme and recommended that one be established.
Universally accessible chlamydia screening
Our vision is that all sexually active young adults should be offered chlamydia testing as a routine part of every primary care and sexual health consultation. Testing and treating young people infected with chlamydia will both reduce their risk of serious sequelae such as pelvic inflammatory disease and infertility and will prevent them transmitting the infection. Opportunistic screening of high numbers of sexually active under-25 year olds remains fundamental in reducing chlamydia prevalence. Whilst the NCSP focus is on finding and treating infections, it is important the programme remains universally accessible.
Chlamydia screening policy
Published in early 2012, the Department of Health Public Health Outcomes Framework 2013 to 2016 included an indicator on the chlamydia detection rate in 15 to 24 year olds, underlining the importance of reducing the prevalence of chlamydia infection in young adults in England.
Public Health England recommends that local areas should be working towards achieving a detection rate of at least 2,300 per 100,000. Local authorities have a statutory duty to ensure the provision of open access services including free STI testing and treatment. Chlamydia screening should be offered as an integrated component of existing sexual and reproductive health services including primary care based services. Local authorities should also consider commissioning internet based testing and pharmacy based testing to ensure that young people have universal access to testing as these services have high positivity and are readily accessed by young people.
In 2013 the NCSP changed the guidance for those found positive. We recommend that all those who test positive are retested 3 months after treatment. This is because people who test positive are at high risk of reinfection.
Reducing chlamydia prevalence in England
Looking at the impact of the NCSP in England, modelling suggests that the level of testing that has been achieved in England through opportunistic screening will probably have resulted in reductions in prevalence, and that achieving the Public Health Outcomes Framework chlamydia detection rate (≥2,300) will further contribute to control of chlamydia prevalence in coming years. Several different approaches are currently being taken to try to estimate and monitor prevalence.
We advise that local commissioners focus on providing universal access to services and use the data provided by PHE to focus resources on those services which are likely to identify greater numbers of chlamydia diagnoses.
Embedding chlamydia screening in core services
High volume, high quality screening is best delivered by considering chlamydia screening as an integral part of wider sexual health service planning and delivery. By embedding chlamydia screening within primary care and sexual health services, we can ensure young adults are offered screening as part of a routine consultation.
The NCSP has published guidance for commissioners and public health on integrating chlamydia screening services into existing community services professionals: Integrating the NCSP within local sexual health economies.
Commissioners and providers need to work together to ensure a focus on efficient models of delivery that yield good rates of diagnoses. To achieve this the focus needs to be on delivery through core services over activity that results in poor return rates or low proportions testing positivity (historically this has included untargeted outreach, grab bins or mailouts). Core services include:
Sexual and reproductive health services
Already providing confidential sexual health services for large numbers of sexually active young adults with appropriately trained staff experienced in discussing sexual health issues with this age group. The offer of screening can come from any one of the practice team, including receptionists, and should be accompanied by appropriate written information, such as the NCSP patient information leaflet.
In addition to these internet based services which post testing kits to young people can provide high positivity and ensure that young people are able to access testing through a medium they are familiar with. Internet based services should be complementary to existing core services. A contract for internet-based screening can be part of a wider sexual health contract or developed on a stand-alone basis with a different provider from other sexual health services.
Websites are the most commonly used approach to internet-based screening, but texting, smartphones and the use of applications (apps) are increasingly common. Internet testing has the advantage of being potentially less costly than services based in clinical settings. Guidance on commissioning internet based services can be found here.
Around 75% of young adults visit their GP every year, providing an ideal opportunity to offer an annual chlamydia screen. Staff training (eg raising screening during non-sexual health consultations) and developing pathways for the management of positives and partner notification must be considered.
Chlamydia screening should be part of all service specifications with abortion service providers, to ensure testing continues to be offered to all women undergoing abortion. If the abortion service provider cannot provide full management of positive cases (partner notification, testing and treatment to prevent re-infection), patients should be referred on appropriately.
Pharmacists are already established providers of sexual health services (eg pregnancy tests, emergency contraception provision) and chlamydia screening is an appropriate addition to these services. Following appropriate training and support pharmacists are also well placed to provide treatment and partner notification, with long opening hours and high-street presence.