Novel approaches to non-clinic-based Chlamydia trachomatis testing

My daily work as a clinical nurse in a regional sexual health clinic regularly incorporated consultations with clients being tested and diagnosed with Chlamydia trachomatis (chlamydia) infection. Chlamydia infections are predominately diagnosed in the younger, sexually active segments of the population and are mostly asymptomatic, with the potential to progress to severe sequelae such as pelvic inflammatory disease (PID) (Westrom 1995). The current recommended treatment is azithromycin 1 gram orally as a single dose (British Association for Sexual Health and HIV (BASHH) 2002; Workowski and Levine 2002; The Royal Australasian College of Physicians, Australasian Chapter of Sexual Health Medicine et al. 2004). The challenge for health service providers/public health agencies is, therefore, the identification of those asymptomatic cases by testing, and the provision of timely and effective treatment.\ud \ud Reliable information on chlamydia testing rates or even numbers of tests performed is sparse, thus not allowing the calculation of prevalences or incidences. However, most health systems in developed countries have notification systems and population data that allow the calculation of notification rates. Notification rates in developed countries have been steadily increasing over recent years; for example, in the United States of America (US) notification rates per 100,000 population increased from 304 in 1999 to 392 in 2004, in the United Kingdom (UK) from 101 to 180, and in Sweden from 188 to 355, respectively. The situation seems especially dramatic in Australia, where notification rates between 1999 and 2004 more than doubled from 73 to 177 (Low 2004; Australian Government Department of Health and Ageing 2005; Centers for Disease Control and Prevention 2005). A more detailed analysis of the Australian notification rates reveals distinct differences between states. Notification rates are highest in the Northern Territory (437 in 1999 and 782 in 2004), followed by Queensland (125 in 1999 and 222 in 2004), where they are still well above the national average. A further breakdown of the Queensland data by Health Service District shows higher notification rates still for the northern districts, with the Townsville Health Service District notification rates also doubling over this five-year period – 213 in 1999 and 456 in 2004 – albeit on a considerably higher level than the overall Queensland rates. While the increase in notification rates may be due to many factors, including more sensitive tests, improvements in notification processes and more testing, and repeat testing it is very likely that they also reflect an increase in real infection rates in the community (Gotz, Lindback et al. 2002; Australian Government Department of Health and Ageing 2005; Chen and Donovan 2005). \ud \ud Attempts to manage the evident chlamydia epidemic in developed countries differ by jurisdiction. They include recommendations to opportunistically screen high-risk populations, systems to follow up positive cases, changes of legislation to make partner notification compulsory and plans for a systematic screening program. However, all these attempts seem to have had very limited success, as evidenced by the everincreasing notification rates.\ud \ud In Australia, attempts to curb this epidemic by means of more or less well-organised health promotion campaigns, relying on testing or screening by the general primary healthcare sector or the 'Well Persons' Health Check' in Indigenous communities between 1998 and 2000, were apparently without measurable success. None of the implemented measures have resulted in a sustained reduction in notification rates (Miller, McDermott et al. 2002; Miller, McDermott et al. 2003; Australian Government Department of Health and Ageing 2005). \ud \ud Some reasons for the failure of the measures undertaken in Australia relate to a lack of clear government commitment, with low resource allocation and the lack of a well-coordinated approach. The situation is further hampered by the mainly 'passive' methods undertaken; that is, relying on the initiative of the people at risk to get tested as opposed to actively approaching them. A further major general impediment, especially when only 'passive' approaches are employed, is the widespread nature of the population in Australia. The availability of health services decreases substantially in regional centres and even more so in remote areas