1. SW Chlamydia Support Every second slide has information for the trainer completing the coming slide which is the GP training slide

2. SW Chlamydia Support Modified for Sweden Ellie Ricketts Public Health England Primary Care Unit UK

3. SW Chlamydia Support C. trachomatis (CT) is the most prevalent STI in Sweden. Still we have no control of the spreading, as well as many other countries. The national chlamydia screening program in England suggest all sexually active men and women under 25 years old to be tested annually. This age group has the highest incidence of CT. An increase of testing is requested. This project is an English idea (Cliodna McNulty). The aim was to increase opportunistic chlamydia screening testing of patients 15-24 years old by educating GPs. They succeeded: an increase of chlamydia test rates was achieved as well as the number of detected infections. Information for the trainer:

4. SW Chlamydia Support  National chlamydia screening program in England:  CT testing annually for people < 25 years old  A structured education project for GPs:  The number of CT tests increased with 76%  The number of detected chlamydia infections increased with 40% McNulty, C.A., et al., Increasing chlamydia screening tests in general practice: a modified Zelen prospective Cluster Randomised Controlled Trial evaluating a complex intervention based on the Theory of Planned Behaviour. Sex Transm Infect, 2013.

5. SW Chlamydia Support Would the results be the same in others countries with different health care organisations as in the UK? To find out, the study was carried out in Sweden, Estonia and France. All four have high rates of chlamydia infections, but different rates of chlamydia testing in primary care. Many more chlamydia tests are analysed in Sweden and England than in France and Estonia. How do these differences in health care organisation and history of chlamydia testing affect the results of the education? Information for the trainer:

6. SW Chlamydia Support Would the results be the same in other countries as in the UK?

7. SW Chlamydia Support Health Care Centres from four countries participate in the project. All patients 15-24 years old will be offered a chlamydia screening test, independent of the reason for visiting the health care centre. The projects starts with an education at the health care centre. It is important that the trainer has a deep knowledge of STI. The test can be offered by anyone of the health care workers. Therefore it is important that all staff get the same education. We have ethical approval for the study. Information for the trainer:

8. SW Chlamydia Support  Health Care Centres  England, France, Estonia and Sweden  Offer chlamydia screening tests to all patients 15-24 years old  Independent of the reason for consultation.  January to June 2014

9. SW Chlamydia Support The main outcome measures are the numbers of chlamydia tests (total and positive), before and after the intervention. No patient identity is noted. From the local laboratory we get: The total numbers of tests /gender / month from each HCC The numbers of positive tests / gender / month from each HCC. Only patients15-24 years old. Monthly comparison January to June 2013 with the same period 2014, i.e. before and after the education. It is necessary to compare the same time period each year due to different testing and infection patterns in different months. We suppose that Sweden will get a smaller increase in positive tests than the UK, due to the opportunistic chlamydia testing at our Youth Health Centres and the effective and unique contact tracing. Information for the trainer:

10. SW Chlamydia Support  The total number of chlamydia tests/ gender /month/ Health Care Centre versus same month 2013.  The number of positive tests/ gender/month/ Health Care Centre versus same month 2013.  All data from laboratory statistics  No patient identity is noted  In Sweden we presume an increase in testing but less increase in positive tests  Contact tracing is unique for Sweden

11. SW Chlamydia Support C. trachomatis is the most frequent bacterial STI. The infection is often asymptomatic. Boys/men test less often for STI than women. There is probably many undetected infections among men. Sexual transmission only. A single sexual intercourse with an infected partner incurs a 40% risk of transmission. The higher the number of unprotected sexual contacts (i.e. without a condom), the higher the risk. Chlamydia is easy to treat with antibiotics. The risk of complications is uncertain: up to 10% for women, lower for men. The most common complication is salpingitis, which may cause infertility. Information for the trainer:

12. SW Chlamydia Support  Common  Often asymptomatic (and not diagnosed?)  Sexually transmitted  Complications (salpingitis, infertility)  Easy to treat

13. SW Chlamydia Support The number of chlamydia cases in Sweden decreased during the end of the 1980s and the beginning of the 1990s. Since the middle of the 1990s it has increased. Note the stagnation 2005-2006 and the rise 2007. The reason was a mutation in the C. trachomatis bacterium. Some diagnostic tests could not detect the mutated bacterium. New tests were developed 2007. The former missed infected cases were diagnosed, causing a rise in positive tests. Information for the trainer:

14. SW Chlamydia Support

15. Chlamydia is a contagious disease and you may get the infection regardless of sex technique. It takes several days from transmission until a diagnostic test turns positive. After a risk situation, you´ll have to wait a week before you can trust a negative test result. The chlamydia bacteria need to multiply several times before the test can detect them. The contact between mucus membranes is the most important way to be contaminated. That is why a condom has to be used during the intercourse from the very beginning to the end. Chlamydia can cause conjunctivitis through your own contaminated fingers (= autoinfection). Information for the trainer:

16. SW Chlamydia Support Transmission  vaginal sexual intercourse  anal sexual intercourse  oral-genital contact  mutual touching  sharing of sex toys But also:  from mother to child at delivery  autoinfection (eye) Incubation ~ 1 week

17. SW Chlamydia Support Usually the patient will not have any symptom. Next slide shows the signs and symptoms that may occur. Information for the trainer:

18. SW Chlamydia Support Signs & Symptoms Women  Usually asymptomatic  post coital or intermenstrual bleeding  lower abdominal pain  purulent vaginal discharge  mucopurulent cervicitis and/or contact bleeding  dysuria Men Usually asymptomatic  urethral discharge  dysuria (pain on passing urine) (extent of severity may vary)

19. SW Chlamydia Support Chlamydia is easily treated by antibiotics i.e. doxycycline for 9-10 days. You are recommended not having sex during treatment. You may be reinfected! A single dose azithromycin is an alternative treatment, but it is not the first choice in Sweden due to risk of resistance for Mycoplasma genitalium. Contact tracing is important. In Örebro County it is done by the Youth Health Centres or the STI clinic. Information for the trainer:

20. SW Chlamydia Support Doxycycline 10 days or (Azithromycin, single dose) ”No sex” during treatment Contact tracing

21. SW Chlamydia Support Early treatment decreases the risk for complications. Reinfection increases the risk for complications. The risk for complications is larger in women. The risk of long-term sequelae is not known. The rate differs widely in different studies. It seems as if the risk is lower today compared to the beginning of the 1970s. Information for the trainer:

22. SW Chlamydia Support Genital chlamydia infection Salpingitis Extrauterine pregnancy Infertility (~3%?) ~20% RISK Early treatment Reinfections - + Haggerty et al., Risk of sequelae after Chlamydia trachomatis genital infection in women. J Infect Dis, 2010.

23. SW Chlamydia Support The choice of chlamydia testing method depends on gender: In men it is best to use a first-void-urine sample, in women a self-collected vaginal swab. Urine sample for women is less sensitive. Sensitivity: If 100 women with a chlamydia infection give a urine sample 85-96 of them will get a positive test result. 4- 15 women will get a negative test result (false negative). Specificity: If 100 healthy women give a urine sample 95 of them will get a negative test result. 0-5 of the healthy women will get a positive test result (false positive). In clinical practice a person with a positive test result has a chlamydia infection and should be treated. Information for the trainer:

24. SW Chlamydia Support Self-collected vaginal swab 96-97 % Urine sample (first-void- urine) 85-96 % * >95 % 99 %95 % SBU Alert-rapport nr 2010-05 Urine Specimen in Diagnosing Chlamydia in Women *different methods Urine sample (first-void- urine)

25. SW Chlamydia Support Instructions for urine sampling for chlamydia analysis in Örebro County. Next slide shows the instructions for self- collected vaginal sampling. The chlamydia is an intracellular bacteria. The sample must contain some cells from the urethra or the vagina. Therefore it is important to get the first urine in the sample and not having urinate at least one hour before sampling. If not, the chlamydia bacteria may have been washed out and the test may be false negative. Information for the trainer:

26. SW Chlamydia Support First-void-urine in a small cup Pour urine into the tube up to between the lines The liquid must be left in the tube Do not urinate less than 1 hour before sampling - Important with early information

27. SW Chlamydia Support. Gently slide the swab into the vagina. Rotate the swab for 20 seconds. Place the swab into the tube Break the swab and cap securely

28. SW Chlamydia Support Chlamydia bacteria is an intracellular bacteria, i.e. it can only multiply itself within a cell. Cells will be washed out when urinating. Therefore it is important to get the first urine in the sample and not having urinate at least one hour before sampling. If not, the chlamydia bacteria may have been washed out and the test may be false negative due to too few cells in the sample. When using the first-void-urine in men and the vaginal swab in women we get cells from the urethra / vagina in the sample and have the best chance to detect an infection. Information for the trainer:

29. SW Chlamydia Support The bacteria hide in the cells in the mucus membrane Use first-void-urine 1 hour bladder incubation time

30. SW Chlamydia Support Age do matter. Social background and gender are less important. 57% of the patients 2012 was women. Median age was 21 years for women, 23 for men in Sweden. That is why we focus on age: 15-24 years. Information for the trainer:

31. SW Chlamydia Support We focus on both sexes 15-24 years of age! WomenMen Age Cases /100 000 habitants

32. SW Chlamydia Support All chlamydia samples in Örebro are routinely tested for gonorrhoea. Gonorrhoea is an STI with similar signs and symptoms as chlamydia, but the patients are often somewhat older. It is still uncommon in Sweden, but the incidence is increasing. The treatment for gonorrhoea is a course of antibiotics. Troublesome multiresistance is reported, and we are worried about the future. Patients infected with gonorrhoea should be referred to a STI clinic to get optimal treatment. Information for the trainer:

33. SW Chlamydia Support Dual test chlamydia and gonorrhoea! Cases /100 000 habitants WomenMen Age

34. SW Chlamydia Support Mean age of sexual debut is 16 years old. After first sex experience some of them have regular sex but others wait a long time for next sexual intercourse. In England many young people go to their GP each year. In Sweden 30% of all people 16-29 years old had visited a GP during the last three months. Regardless the reason for the consultation it is a possibility to offer a chlamydia test. Do young sexually active people come to your surgery? Do you offer chlamydia test? Information for the trainer:

35. SW Chlamydia Support Mean age for sexual debut: 16 years of age Forsberg, M., Ungdomar och sexualitet En forskningsöversikt 2005. 2006: Stockholm. Folkhälsoinstitutet, Resultat från Nationella folkhälsoenkäten 2006-2008 At your surgery/department?

36. SW Chlamydia Support Confidentiality is very important to young people. It is necessary that the health care personnel consider the confidentiality when meeting a young person accompanied by parents or friends. Information for the trainer:

37. SW Chlamydia Support Jeremy (accompanied by his mother) at the GP: The GP: ”Mrs Duncan, can you step out a while, when I am talking to Jeremy?” The GP: ”Is she listening by the door?” Jeremy: What do you think?” From the door: ”No, I am not!

38. SW Chlamydia Support Many young people are worried about the confidentiality: that the doctor tells their parents The right to confidentiality regarding sexual health is emphasized in the Convention of the Rights of the Child (UN 1989). In practice: always confidentiality regarding sexual health

39. SW Chlamydia Support GPs and staff are worried about other things than the young patients. GPs may think that adolescents do not want to be asked about sex but often they want to be asked instead of asking themselves. If we don´t ask we may miss an opportunity to discuss sexual health and chlamydia testing. Young people are more worried to be criticized or accused. See next slides. Information for the trainer:

40. SW Chlamydia Support “Don’t ask. They can be angry and worried.” What did the staff think of talking sex with young patients?

41. SW Chlamydia Support...just by offering it in a positive way, it is good for my health... Young people accept screening if it is offered by the staff GP or one of the staff should ask me about sex.

42. SW Chlamydia Support If it is normal to do the test it would be easier. Better to talk here than somewhere else The Health Care Centre is a suitable place for talking and testing

43. SW Chlamydia Support It depends on the person who offers the test, what they say and how they say. But they are worried about being accused......I don´t want to be criticized...

44. SW Chlamydia Support It does not matter who offers a chlamydia test at the surgery. The posters in the waiting room and the card in the reception are supposed to prepare the young woman/man for the question. The offer may come from the receptionist, from the nurse, doctor or lab technician who handle the sample or anyone else of the staff. Sometimes it is wise to be careful. Confidentiality is important. If needed, ask the parent / friend to leave the room. Information for the trainer:

45. SW Chlamydia Support Anyone of the staff :  in reception – give the card  the nurse/midwife/doctor  the laboratory staff

46. SW Chlamydia Support It has been proven that some people find it hard to talk about sexual health. Therefore it is good to have a training session to find the right words. How do I want to ask? Different people want to ask in different ways. What is suitable for you? Information for the trainer:

47. SW Chlamydia Support  ”At this surgery we offer chlamydia test to everybody at your age. Do you want a test today?”  Important to find your own words!

48. SW Chlamydia Support A summary is often a good idea when giving information. This is the “take-home-message” Information for the trainer:

49. SW Chlamydia Support  Offer every patient 15-24 years old a chlamydia test  Screening is normal!  You need be comfortable to offer a screening test  Young people want to be asked  The question takes not much time  All staff can do it  Questions?

50. SW Chlamydia Support Who knows more about the project…. If you need to know. Do not hesitate to ask. Information for the trainer:

51. SW Chlamydia Support Contacts www.STItraining.eu hans.fredlund@orebroll.se timmy.leijen@orebroll.se anne.lennell@orebroll.se johanna.haraldsson@gmail.com Phone: 019-602 3443, 602 3581 (Örebro)

52. SW Chlamydia Support