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Prevention and control of chlamydia in Europe – from data to policies and testing recommendations

Dr. Otilia Mårdh, ECDC

15th Congress of the European Society of Contraception and Reproductive HealthBudapest, May 2018

No conflicts of interest.

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Overview

Chlamydia epidemiology in EU/EEAEvidence-base for chlamydia testing

ECDC chlamydia guidance

Remaining challenges for chlamydia controlTake home messages

P re v e n t io n a n d c o n t ro l o f c h la m y d ia in E u ro p e – fro m d a ta to

p o lic ie s a n d te s t in g re c o m m e n d a t io n s

What is the European Centre for Diseases Prevention and Control (ECDC)?

A European U n ion independent agency active s ince 2005, based in Sw eden.

31 M em ber States countries

EU /EEA > 500 m illion popu lation

O ur m ission is to strengthen EU /EEA defences aga inst in fectious d iseases, though:

- surve illance, - sc ientific adv ice,

- techn ica l assistance

ECDC Programme for HIV/AIDS, STIs and viral hepatitis

http://atlas.ecdc.europa.eu/public/index.aspx

ECD C surve illance reports

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Chlamydia epidemiology EU/EEA 2016

• 4 0 3 8 0 7 d ia g n o s e d c a s e s , n o t if ie d b y 2 6 c o u n t r ie s

• E U /E E A ra te 1 8 5 /1 0 0 0 0 0 ; r a n g e 0 -6 6 2

Chlamydia epidemiology EU/EEA 2016

• 4 0 3 8 0 7 d ia g n o s e d c a s e s , n o t if ie d b y 2 6 c o u n t r ie s

• E U /E E A ra te 1 8 5 /1 0 0 0 0 0 ; r a n g e 0 -6 6 2

• S ta b le E U /E E A t r e n d

• 3 ,6 m il l io n c a s e s 2 0 0 7 -2 0 1 6

Chlamydia epidemiology EU/EEA 2016Demographics of notified cases

Source: Country reports from Bulgaria, Croatia, Cyprus, Denmark, Estonia, Finland, Iceland, Ireland, Latvia, Lithuania, Luxembourg, Malta, Norway, Portugal, Romania, Slovakia, Slovenia, Sweden and the United Kingdom

Cases by age and gender (n= 380 946)

M ale-to-fem ale ratio in 25 EU /EEA countries* (n= 401 078)

Chlamydia epidemiology EU/EEA 2016Demographics of notified cases

Chlamydia epidemiology EU/EEA 2016

H e te ro s e x u a l

fe m a le s ;

3 1 0 6 7 ; 5 2 %H e te ro s e x u a l

m a le s ; 2 1 1 5 8 ;

3 5 %

M S M ; 5 4 1 2 ;

9 %

M o t h e r- to -

c h ild , 4 4 , < 1 %

U n k n o w n ;

2 5 9 3 ; 4 %

N o t if ie d c a s e s b y t r a n s m is s io n ( n = 6 0 2 7 4 )

Note: EU/EEA countries with ≥60% completeness in the transmission category Data from Hungary, Latvia, Lithuania, Malta, the Netherlands, Portugal, Romania, Slovakia, Slovenia and Sweden

Percentage of chlamydia tests analysed using NAATNAAT used >90% in 17 countries, <50% in 4 countriesNAAT available in 28/28 countries responding ECDC survey, 2012

Factors driving chlamydia notification rates ?

Rates of diagnoses by level of chlamydia control

Source: *van den Broek,I et al. Eur J Public Health 2016; Chlamydia Control in Europe: a survey of Member States (2012); TESSY for surveillance data.

• Surve illance

• Intensity o f p revention and contro l activ ities

• Testing practice (inc l. ava ilab ility o f sensitive lab)

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How much chlamydia is really out there?

P o p u la t io n -b a s e d p re v a le n c e s tu d ie sPrevalence studies in EU/EEA countries

Chlamydia prevalence EU/EEA

L ite ra tu re r e v ie w (u p to 2 0 1 2 )

Source: ECDC. Chlamydia control in Europe - literature review; 2014

Prevalence studies in EU/EEA countries

Chlamydia prevalence EU/EEA

L ite ra tu re r e v ie w (u p to 2 0 1 2 ) M e ta -a n a ly s is

nationaly representative estimates, sexually experienced

W om en, ≤ 26 years

M en, ≤ 26 years

Source: ECDC. Chlamydia control in Europe - literature review; 2014

NOTE: Weights are from random effects analysis

.

.

.

.

National population, overallGermanyGermanyGermanyNetherlandsNetherlandsSloveniaUSAUSA (2007-2008)Subtotal (I-squared = 75.9%, p = 0.000)

Sub-national population, overallDenmarkNetherlandsSwedenUnited KingdomUnited KingdomSubtotal (I-squared = 81.1%, p = 0.000)

National population, sexually experiencedFranceGermanySloveniaUnited KingdomCroatiaUSASubtotal (I-squared = 0.0%, p = 0.580)

Sub-national population, sexually experiencedDenmarkDenmarkDenmarkNetherlandsNetherlandsNorwaySpainUnited KingdomUSAUSAAustraliaNew ZealandSubtotal (I-squared = 77.3%, p = 0.000)

Country

Haar/KIGGSHaar/DEGSHaar/DEGSvan Bergenvan BergenKlavsMillerDatta

Munkvan ValkengoedJonssonLowBracebridge

GouletHaar/KIGGSKlavsFentonBozicevicMiller

OstergaardAndersen/kitAndersen/postalvan den Broekvan den BroekKlovstadFranceschiStephensonKlausnerKlausnerHockingCorwin

Author

20122012201220052005200420042012

19992000199520072012

201020122004200120112004

199820022002201220122012200720002001200120062002

Year

2.11 (1.36, 3.13)4.50 (1.60, 12.10)2.00 (0.50, 7.40)2.60 (1.70, 3.40)1.90 (1.20, 2.70)4.10 (2.20, 7.40)4.74 (3.93, 5.71)3.80 (2.40, 6.00)3.05 (2.09, 4.01)

10.70 (7.18, 15.20)3.82 (2.51, 5.54)2.70 (1.50, 4.40)6.20 (4.90, 7.80)4.40 (3.50, 5.40)4.92 (3.33, 6.51)

3.60 (1.90, 6.80)4.44 (2.86, 6.53)4.70 (2.50, 8.50)3.00 (1.70, 5.00)5.30 (2.30, 10.20)4.70 (3.90, 5.70)4.32 (3.65, 4.99)

5.00 (3.61, 6.62)6.50 (4.70, 8.65)8.00 (5.82, 10.64)3.90 (2.75, 5.05)3.95 (3.35, 4.54)5.80 (4.48, 7.50)0.60 (0.00, 3.50)8.00 (2.30, 20.00)5.00 (2.80, 7.20)2.30 (0.80, 3.70)3.70 (1.20, 8.40)2.30 (0.40, 4.20)4.24 (3.25, 5.24)

in % (95% CI)CT Prevalence

1518201520181814

2015191617

181518181818

162121162018151818221816

minAge

1719241924242625

2425252425

241724242526

192323192425242521252419

max

2.11 (1.36, 3.13)4.50 (1.60, 12.10)2.00 (0.50, 7.40)2.60 (1.70, 3.40)1.90 (1.20, 2.70)4.10 (2.20, 7.40)4.74 (3.93, 5.71)3.80 (2.40, 6.00)3.05 (2.09, 4.01)

10.70 (7.18, 15.20)3.82 (2.51, 5.54)2.70 (1.50, 4.40)6.20 (4.90, 7.80)4.40 (3.50, 5.40)4.92 (3.33, 6.51)

3.60 (1.90, 6.80)4.44 (2.86, 6.53)4.70 (2.50, 8.50)3.00 (1.70, 5.00)5.30 (2.30, 10.20)4.70 (3.90, 5.70)4.32 (3.65, 4.99)

5.00 (3.61, 6.62)6.50 (4.70, 8.65)8.00 (5.82, 10.64)3.90 (2.75, 5.05)3.95 (3.35, 4.54)5.80 (4.48, 7.50)0.60 (0.00, 3.50)8.00 (2.30, 20.00)5.00 (2.80, 7.20)2.30 (0.80, 3.70)3.70 (1.20, 8.40)2.30 (0.40, 4.20)4.24 (3.25, 5.24)

in % (95% CI)CT Prevalence

1518201520181814

2015191617

181518181818

162121162018151818221816

minAge

Chlamydia prevalence, % (95% CI)

00 5 10 15

Source: Redmond S et al. PlosOne; 2014

Chlam yd ia p reva lence ≤ 26 years w om en, EU stud ies (up to 2012)

>1 million infections P ID - in fe r t i l i ty

ECDC Chlamydia control in Europe guidance

F r o m 2 0 0 9 t o 2 0 1 5 , s a m e a im :to s u p p o r t M e m b e r S ta te s to im p le m e n t e v id e n c e -b a s e d c o n t ro l s t ra te g ie s

M e t h o d s

L iterature Rev iew

Survey (2012)

Eva luation o f 2009 gu idance

Expert m eeting (2014)

Consensus on conclusions

Effect of chlamydia screening on PID incidence at 12 months

Effect of chlamydia screening on prevalence

Evidence review (2012)Q u e s t io n : s h o u ld c h la m y d ia s c re e n in g v s . u s u a l c a re b e u s e d in s e x u a lly a c t iv e a d u lt s < 3 0 y e a r s ?

Source: ECDC. Chlamydia control in Europe - literature review; 2014; Redmond S et al. PlosOne; 2014

Q uality o f ev idence G R A D E

1 PID prevented per 1000 screened

M oderate

Low

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ECDC Chlamydia Guidance 2015Conclusions

• A nationa l strategy or p lan fo r STI contro l

• Prim ary prevention activ ities* • Evidence-based case m anagem ent

gu ide lines that address criteria fo r testing , d iagnostic m ethod, treatm ent, partner notification and reporting o f cases

• Surve illance o f d iagnosed ch lam yd ia cases

• M onito ring and eva luation

Widespread testing (<25 y/o) recommended if resources allow and M&E in place

R ecom m endations for m in im um leve l o f p revention and contro l

A national strategy or plan for STI

control

Primary prevention activities

Evidence-based case management guidelines

Surveillance of

diagnosed chlamydia

Monitoring and

evaluation

*No systematic reviews of clinical or cost-effectiveness. Expert opinion: broad benefit to sexual health, limited risk of harm

Screening for genital chlamydia infectionL o w N e t a l. 2 0 1 6S y s te m a t ic r e v ie w ( s e a r c h u p to F e b . 2 0 1 6 )

ObjectivesTo assess the effects and safety of chlamydia screening vs standard care on chlamydia transmission and infection complications in pregnant and non-pregnant women and in men.

Evidence review update!

K ey resu lts

359,078 adult women and men• no change in prevalence after three yearly invitations in general

population

• reduction in prevalence after four years in sex workers • <32% lower risk of PID in women invited to a single chlamydia

screening test vs. women not invited

• no effect on epididymitis in men

• no trials in pregnant women• no trials measuring harms of chlamydia screening

Chlamydia screening among MSM?

C O N C LU SIO N : O u r stu d y w as n o t ab le to p ro vid e e v id e n ce th at scre e n in g fo r ch lam yd ia an d

go n o rrh o ea lo w ers th e p revalen ce o f th ese in fectio n s in M SM . R an d o m ized co n tro lle d tria ls are re q u ire d to asse ss th e risks an d b e n e fits o f go n o rrh o ea/ch lam yd ia scre e n in g in h igh an d lo w risk M SM .

2015 European guideline on the management of Chlamydia trachomatis infectionsLanjouwE et al. 2015Indications for laboratory testing • Risk factors for chlamydia/other STI (age < 25

years, new sexual contact in the last year, > 1 partner in the last year)

• Cervical or vaginal discharge with risk factor for STI

• Acute pelvic pain and/or symptoms or signs of PID

• Proctitis/proctocolitis according to risk• Persons diagnosed with other STI• Sexual contact of persons with an STI or PID

• Termination of pregnancy• Any intrauterine interventions or manipulations

Laboratory diagnostics• NAATs in clinical specimens

• If not available or affordable, isolation in cell culture or direct fluorescence assays (DFA)

• Currently available rapid POCT not recommended in Europe!

Follow-up • Repeated testing in 3–6 months of

young women and men (<25 y/o) who test positive

Test of cure• Not routinely• Recommended in pregnancy,

complicated infections, extra-genital infections, etc.

Importance and benefit of using sensitive diagnostic platforms

2018

Retrospective observational study

272,105 women tested 1998–200145% by NAATs

Conclusion

W om en w ith a non-NAAT negative test have a 17% h igher ad justed risk o f P ID by 12

m onths com pared to a NAAT negative ch lam yd ia test.

Major challenges to chlamydia control and their implications/effects

• Asymptomatic infections

• No lasting immunity to infection • No vaccine

Natural history of infection

• Stigma (STIs)

• Resource lim itations

Societal influences

• Burden of disease in the population

• Timing of tubal damage• Contribution of chlamydia to complications

• Role of repeat infection in tubal damage

Gaps in the evidence

Ongoing transmission

Reduced participationLimited implementation

Design of control interventions

Clinical and cost-effectiveness measurements (M&E)

Source: ECDC gu idance on ch lam yd ia contro l in Europe

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Conclusions

D e f in in g c h la m y d ia e p id e m ic in E U /E E A is c h a lle n g in g

Y o u n g p e o p le a re m o s t a t r is k o f c h la m y d ia in fe c t io n in E U /E E A

T e s t in g y o u n g w o m e n c a n re d u c e th e r is k o f d e v e lo p in g P ID

S e n s it iv e d ia g n o s t ic s (N A A T ) - th e m e th o d s o f c h o ic e

T h e re a re s t i l l g a p s in e v id e n c e !

Contact

Otilia.Mardh@ecdc.europa.eu