Screening for Chlamydia trachomatis infection in primary care Final Train-the-Trainer (TtT) prese Screening for Chlamydia trachomatis infection in primary care Final Train-the-Trainer (TtT) presentation from the CATTE project in France ChlAmydia Testing Training in Europe P Touboul, B Dunais, S Detanne, S Veringa, P Bruno,, V Lacroix-Hugues, P Khouri, A Mani, L Bentz Département de Santé Publique, CHU de Nice Contact:

222 Aims of TtT To provide trainers with the necessary background concerning screening in primary care in Europe and in France in order to encourage GPs to screen. To describe the European CATTE project and its results To inform about of available resources

333 Aims of the GP training Provide GPs with the adequate information to:  Initiate a dialogue with the patient around his/her sexual health  Facilitate screening for Chlamydia trachomatis (CT) infection in primary care All references can be found in the slide notes

444  The most frequent STI among year-olds in Europe and in France  NatChla 1 Study: prevalence among yr-olds Males 2.5% Females 3.2% Usually asymptomatic Resulting in potentially severe complications (~50% of cases of infertility 2,3 ) Re-infections among sexual partners persisting prevalence of chlamydia 4 Recurring infections increased risk of complications 5 Ct infection is easy to treat Treatment prevents:  transmission  complications Why test for chlamydia? Epidemiological context

555 According to the consultation site

666 According to symptoms

777 According to gender and age

888 Screening CT infection in primary care: What do patients think? Young people continue visiting their GP 1  French adolescents visit their GP 2-3 times/year  GPs see one adolescent/day on average  GPs « broaden » the scope of the consultation 50% of the time GPs are favoured health advisors for young people 2  Young people consider that GPs play a central role in terms of prevention counseling 2

99 Young peoples’ opinions Surveys conducted in various countries: Ireland, Australia, France: - IRE 1 : ” I think that's a good practice to get screened. ” ”I think once a year every person should really have this test done. You know. Just to make sure that they are clear and alright. ” AU 2 :” If there was something in the waiting-room that said your doctor may ask you about having the test, then you're a little bit more prepared for it, and if you saw in the paper that it was becoming a big issue and they'd probably ask you about it next time you go in...So it's much more a public health issue… » - FR 3 : Most GPs state they got rather positive reactions from their patients regarding CT screening in primary care: « They probably thought I was a modern GP who was interested in modern screening techniques and who was concerned about their health.» - -> A neutral, systematic approach, so as not to worry nor offend the patient

Screening CT infection in primary care: What do GPs think? Good acceptability of self-test 1,4,8 Better compliance with screening when offered by GPs 6,4,8 (cf screening for breast and colo-rectal cancer 2 ) GPs request professional training concerning Chlamydia 4,5,6,8 7 GPs consider they play a major role in public health 7 The subject of sexual health is readily approached by most GPs who consider their status as family physician a facilitating factor 7 The subject of sexual health is readily approached by most GPs who consider their status as family physician a facilitating factor 7 A national information and screening campaign such as “Chlamyweb” (INPES) was requested by GPs 1,2,3,4

Transmission and physiopathology Transmission:  vaginal + anal intercourse  oral-genital contact  mutual touching  sharing sex toys Physiology: Young cervix:  abundant columnar epithelial cells  major target for Ct  ascending infection

1212 Immune response Immune protection against C. trachomatis : re-infection is thus possible Immune protection against C. trachomatis is incomplete and brief : re-infection is thus possible Antibodies have limited effect due to the intracellular situation of the bacteria Antibodies have limited effect due to the intracellular situation of the bacteria Antibodies produced at the time of infection persist for many years after bacterial clearance. Antibody titers are thus difficult to interpret. Antibodies produced at the time of infection persist for many years after bacterial clearance. Antibody titers are thus difficult to interpret.

13 Infection Natural clearance Develop symptoms/ complications, treated Transmission without screening Chlamydia passed on to sexual partner Repeated infections - danger for long term issues

14 Chlamydia screening can prevent transmission End of infection with screening Screening test Natural clearance End of infection without screening Infection Develop symptoms/complications, treated Chlamydia NOT passed on to sexual partner

15 Symptoms Women   +/- 70% asymptomatic 1   Post-coïtal or intermenstrual bleeding   Lower abdominal pain   Purulent vaginal discharge   Muco-purulent cervicitis and/or contact bleeding   Dysuria Men 50% asymptomatic   Ur e thral discharge   Dysuria (of varying intensit y )   Epididymitis   Rectitis

16 Sequelae of Chlamydia infection Genital Chlamydia infection % of infections untreated 1,2,3 PID Chlamydia: 50% of cases of tubal factor infertility! 4,5 Female infertility( %) E ctopic pregnancy (4 - 9%) 1,3 PID: pelvic inflammatory disease

1717 The CATTE project (ChlAmydia Testing Training in Europe) European project: 1. England 2. Sweden 3. Estonia 4. France Pilot project in the Alpes Maritimes Screening performed between January and June 2014

The CATTE project in France Initial interviews  With GPs in the field 1  With experts and trainers Peer-conducted academic detailing visits to 105 randomized GPs 2 GP involvement (no retribution)  Offer screening for C. trachomatis infection in general practice and prescribe the test to ≥10 patients  Target group: young people aged years with a risk factor (>1 partner in the past year)  Facilitate a dialogue around the subject of sexual health and contraception during the consultation Quantitative and qualitative evaluation 2

1919 Quantitative evaluation randomized GPs (2 early drop-outs) from different districts in the area accepted to participate, 43 of which included at least one patient. 19

2020 Results Overall increase in screening trend (15%) but higher among GPs taking part in the project (73%). MGs received results for 47% of prescribed tests. Screening test offered by GP favours participation in spite of a complex procedure. Feasibility of CT screening in primary care from both GP and patient’s point of view.

21 Qualitative evaluation 1 The intervention was well received by GPs, considered interesting by the GPs and their patients Barriers encountered by the GPs Inappropriateness of consultation context Lack of time: Time-consuming to offer CT Awareness and practice change : CT is something new to remember and integrate into practice, there is a lack of awareness among GPs Lack of awareness among patients Season: this age group rather consult at the beginning of the school year Fears: Patients’ and GPs’ fear of vagina self-testing Flyers considered too complicated Sample delivery to laboratory Test not entirely free Confidentiality: fear of patients registered with their parents’ health insurance that parents would be informed about the test

2222 How can GPs approach the subject and offer screening? Facilitators described by CATTE participants in qualitative evaluation Reasons for consulting 1  General health check-ups  Consultations for STI/risk behaviour  Consultations for contraception / stable couple (discontinuing condom use)  Consultation for general immunizations or HPV vaccination  General preventive approach  Medical certificate Other facilitating factors 1  Season: consultations at start of school year  European initiative  GP convinced and trained  Adequate resources

Who should currently be screened for CT in France in primary care? In France, there is currently no specific recommendation for screening in primary care. The National Plan to combat HIV-AIDS and STI( ) 1 recommends to   encourage CT screening in populations with high prevalence such as those consulting various free/anonymous screening clinics.   extend CT screening to young women and persons with several partners to decrease complications.   encourage the offer of STI screening by GPs as well as other health professionals.   suggest specific tools and resources to assist health professionals in adapting their screening to the population and the situation. Screening for asymptomatic CT infection in at risk persons is reimbursed (65%) by the National health insurance since 04/11/

Identified risk factors reported in French publications Age: higher prevalence rates among year-olds and particularly among year-olds 1,2,3,4 Several partners during the year or new partner(s) 2,3,4 2,3,4,5 Populations attending free/anonymous screening clinics 2,3,4,5 1 24

For sexual health in general  Contraception, STI… resources for GPs and patients published by INPES 1 For communicating with adolescents  INPES 2 resource  Have you taken any risks lately? Condom, tobacco, alcohol, drugs… More specific resources developed and evaluated for CATTE to initiate a discussion and offer CT screening  A poster for the waiting room  A flyer to inform the patient and assist GPs in raising patient awareness Provision of condoms if possible Available resources for GPs to approach the subject

26 A poster for the waiting room 1

27 A flyer to help GPs raise patient awareness 1

How to screen for CT in general practice Prescription of Chlamydia trachomatis screening by PCR 1 First-catch urine or self-taken intra vaginal swab (inserted 3 cm in vagina). These tests are cheaper, have very good specificity and sensitivity but are not available in all French labs. Cervical sample collected at the lab. Or provide a list of screening facilities 2,3 Chlamydia PCR is 65% reimbursed by the French National Health Insurance Eventual complementary insurance covers the remaining 35% Lab test unspecified on reimbursement details. In certains areas, a « Health Pass » (Pass Santé) provides 100% coverage 4 Chlamydia self-test can also screen for gonocococcus if prescribed 28

29 Accuracy of nucleic acid amplification technique (NAAT) tests SensitivitySpecificity Urine ♂ - first catch urine % % Self-taken VulvoVaginal Swab % % Urine ♀ - first catch urine80.5 – 95.7% %

30 Vaginal swab easy to perform by the patient Insert 3 cm into the vagina, during seconds. Keep at room temperature and deliver to lab within 1 week

31 Results obtained within 10 days Negative Recommend new screening test if change of partner 1,2,3 Positive Treat the patient and discuss informing partner(s) ( by 4 that can be anonymous: link on flyer ) in view of screening and eventual treatment: Approximately 60% of partners are also positive 5-7 Counsel :  Avoid sexual intercourse (including oral sex) during 7 days following treatment  Or systematically use condoms Offer broader screening for STI either by GP or in screening facilities

32 Azithromycin 1g qd single dose, OR Doxycycline 100 mg bid for 7 days 1-4 Alternative 2,4 :  Erythromycin 500 mg (or other macrolide) qid for 7 days Pregnancy or breastfeeding 1,4 :  Azithromycin 1 g single dose or  Amoxicillin 500 mg, tid for 7 days  Control:  No international recommendations, good practice guidelines in some European countries (ECDC): repeat test 3 to 6 months after completing treatment. How should lower genital tract Chlamydia infection be treated?

33 Conclusion GPs are young peoples’ favoured advisors on health matters and play a major role in the management of their sexual health. Chlamydia screening is currently rarely performed in primary care in France. Pilot projects demonstrate the feasibility of CT screening by French GPs who could improve adherence and thus complement free screening facilities.