The chlamydia care cascade of young people attending Australian general practices; a descriptive study to assess gaps in care

BACKGROUND

Most chlamydia infections in Australia are diagnosed in general practice. The care cascade concept (testing, treatment and re-testing) can be utilised to explore the management of chlamydia infections. We explored the chlamydia care cascade among young people attending general practices in Australia.

METHODS

We analysed de-identified electronic medical record data for 16-29-year-old individuals attending 70 Australian general practices between January 2018 and December 2020. Five outcomes: (1) chlamydia testing, (2) positivity, (3) treatment, (4) re-testing and (5) re-infection were summarised as annual counts and proportions per calendar year. Logistic regression was used to investigate the association of age, gender and clinic location with each outcome.

RESULTS

During the study period, a total of 220909 clinical episodes involving 137358 16-29-year-olds were recorded. Of these episodes, 10.45% (n =23077, 95% CI 8.73-12.46) involved a chlamydia test. Of 1632 chlamydia cases, 88.79% (n =1449, 95% CI 86.37-90.82) had appropriate antibiotics recorded as defined in Australian sexually transmitted infection management guidelines. Of 183 chlamydia cases that did not have appropriate antibiotics recorded, 46.45% (n =85) had re-attended the clinic within 90days of diagnosis. Among 1068 chlamydia cases that had appropriate antibiotic recorded in 2018 and 2019, 22.57% (n =241, 95% CI 20.15-25.18) were re-tested within 6weeks to 4months of their diagnosis. One-third of episodes of chlamydia cases that did not have a re-test recorded (n =281) had re-attended the clinics within 4months of diagnosis.

CONCLUSION

Our study provides insight into chlamydia management by analysing general practice medical records, indicating substantial gaps in testing and re-testing for 16-29-year-olds. These data can also be used to explore the impact of future interventions to optimise chlamydia management.

Measuring school level attributable risk to support school-based HPV vaccination programs

Background

In Australia in 2017, 89% of 15-year-old females and 86% of 15-year-old males had received at least one dose of the HPV vaccine. However, considerable variation in HPV vaccination initiation (dose one) across schools remains. It is important to understand the school-level characteristics most strongly associated with low initiation and their contribution to the overall between-school variation.

Methods

A population-based ecological analysis was conducted using school-level data for 2016 on all adolescent students eligible for HPV vaccination in three Australian jurisdictions. We conducted logistic regression to determine school-level factors associated with lower HPV vaccination initiation (< 75% dose 1 uptake) and estimated the population attributable risk (PAR) and the proportion of schools with the factor (school-level prevalence).

Results

The factors most strongly associated with lower initiation, and their prevalence were; small schools (OR = 9.3, 95%CI = 6.1–14.1; 33% of schools), special education schools (OR = 5.6,95%CI = 3.7–8.5; 8% of schools), higher Indigenous enrolments (OR = 2.7,95% CI:1.9–3.7; 31% of schools), lower attendance rates (OR = 2.6,95%CI = 1.7–3.7; 35% of schools), remote location (OR = 2.6,95%CI = 1.6–4.3; 6% of schools,) and lower socioeconomic area (OR = 1.8,95% CI = 1.3–2.5; 33% of schools). The highest PARs were small schools (PAR = 79%, 95%CI:76–82), higher Indigenous enrolments (PAR = 38%, 95%CI: 31–44) and lower attendance rate (PAR = 37%, 95%CI: 29–46).

Conclusion

This analysis suggests that initiatives to support schools that are smaller, with a higher proportion of Indigenous adolescents and lower attendance rates may contribute most to reducing the variation of HPV vaccination uptake observed at a school-level in these jurisdictions. Estimating population-level coverage at the school-level is useful to guide policy and prioritise resourcing to support school-based vaccination programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13088-x.

Differences in school factors associated with adolescent HPV vaccination initiation and completion coverage in three Australian states

BACKGROUND

Schools are the primary setting for the delivery of adolescent HPV vaccination in Australia. Although this strategy has achieved generally high vaccination coverage, gaps persist for reasons that are mostly unknown. This study sought to identify school-level correlates of low vaccination course initiation and completion in New South Wales, Tasmania, and Western Australia to inform initiatives to increase uptake.

METHODS

Initiation was defined as the number of first doses given in a school in 2016 divided by vaccine-eligible student enrolments. Completion was the number of third doses given in a school in 2015-2016 divided by the number of first doses. Low initiation and completion were defined as coverage ≤ 25thpercentile of all reporting schools. We investigated correlations between covariates using Spearman's rank correlation coefficients. Due to multicollinearity, we used univariable logistic regression to investigate associations between school characteristics and low coverage.

RESULTS

Median initiation was 84.7% (IQR: 75.0%-90.4%) across 1,286 schools and median completion was 93.8% (IQR: 86.0%-97.3%) across 1,295 schools. There were strong correlations between a number of school characteristics, particularly higher Indigenous student enrolments and lower attendance, increasing remoteness, higher postcode socioeconomic disadvantage, and smaller school size. Characteristics most strongly associated with low initiation in univariate analyses were small school size, location in Tasmania, and schools catering for special educational needs. Low completion was most strongly associated with schools in Tasmania and Western Australia, remote location, small size, high proportion of Indigenous student enrolments, and low attendance rates.

CONCLUSION

This study provides indicative evidence that characteristics of schools and school populations are associated with the likelihood of low initiation and completion of the HPV vaccination course. The findings will guide further research and help target initiatives to improve vaccination uptake in schools with profiles associated with lower coverage.

Chlamydia screening for pregnant women aged 16-25 years attending an antenatal service: a cost-effectiveness study

OBJECTIVE

Determine the cost-effectiveness of screening all pregnant women aged 16-25 years for chlamydia compared with selective screening or no screening.

DESIGN

Cost effectiveness based on a decision model.

SETTING

Antenatal clinics in Australia.

SAMPLE

Pregnant women, aged 16-25 years.

METHODS

Using clinical data from a previous study, and outcomes data from the literature, we modelled the short-term perinatal (12-month time horizon) incremental direct costs and outcomes from a government (as the primary third-party funder) perspective for chlamydia screening. Costs were derived from the Medicare Benefits Schedule, Pharmaceutical Benefits Scheme, and average cost-weights reported for hospitalisations classified according to the Australian refined diagnosis-related groups.

MAIN OUTCOME MEASURES

Direct costs of screening and managing chlamydia complications, number of chlamydia cases detected and treated, and the incremental cost-effectiveness ratios were estimated and subjected to sensitivity analyses.

RESULTS

Assuming a chlamydia prevalence rate of 3%, screening all antenatal women aged 16-25 years at their first antenatal visit compared with no screening was $34,931 per quality-adjusted life-years gained. Screening all women could result in cost savings when chlamydia prevalence was higher than 11%. The incremental cost-effectiveness ratios were most sensitive to the assumed prevalence of chlamydia, the probability of pelvic inflammatory disease, the utility weight of a positive chlamydia test and the cost of the chlamydia test and doctor's appointment.

CONCLUSION

From an Australian government perspective, chlamydia screening of all women aged 16-25 years old during one antenatal visit was likely to be cost-effective compared with no screening or selective screening, especially with increasing chlamydia prevalence.

TWEETABLE ABSTRACT

Chlamydia screening for all pregnant women aged 16-25 years during an antenatal visit is cost effective.

Oral and anal sex are key to sustaining gonorrhoea at endemic levels in MSM populations: a mathematical model

OBJECTIVES

Despite early treatment of urethral infection, gonorrhoea is endemic in urban populations of men who have sex with men (MSM) in Australia. By contrast, gonorrhoea is not common in urban heterosexual populations. Sexual activities among MSM usually involve anal or oral sex, and as these behaviours are becoming increasingly common among heterosexuals, there is a need to investigate their roles in transmission of gonorrhoea.

METHODS

We developed individual-based models of transmission of gonorrhoea in MSM and heterosexuals that incorporate anatomical site-specific transmission of gonorrhoea. We estimated the probabilities of transmission for anal sex and oral sex by calibrating an MSM model against prevalence of gonorrhoea and sexual activity data. These probabilities were then applied to a heterosexual model in order to examine whether gonorrhoea can persist in a heterosexual population through the addition of anal sex and oral sex.

RESULTS

In the MSM model, gonorrhoea can persist despite prompt treatment of urethral infections. The probability of gonorrhoea persisting is reduced if use of condom for oral sex is increased to more than 15% of acts. Assuming that treatment of symptomatic infections is prompt, gonorrhoea is unlikely to persist in a heterosexual population even with the addition of anal and oral sex.

CONCLUSIONS

Our models suggest that oral sex has an important role in sustaining gonorrhoea in a population of MSM by providing a pool of untreated asymptomatic infection. The importance of anal sex or oral sex in sustaining gonorrhoea in a heterosexual population remains uncertain due to the lack of information linking different types of sex acts and transmissibility.

Adding heat to the live-high train-low altitude model: a practical insight from professional football

Objectives

To examine with a parallel group study design the performance and physiological responses to a 14-day off-season ‘live high-train low in the heat’ training camp in elite football players.

Methods

Seventeen professional Australian Rules Football players participated in outdoor football-specific skills (32±1°C, 11.5 h) and indoor strength (23±1°C, 9.3 h) sessions and slept (12 nights) and cycled indoors (4.3 h) in either normal air (NORM, n=8) or normobaric hypoxia (14±1 h/day, FiO₂ 15.2–14.3%, corresponding to a simulated altitude of 2500–3000 m, hypoxic (HYP), n=9). They completed the Yo-Yo Intermittent Recovery level 2 (Yo-YoIR2) in temperate conditions (23±1°C, normal air) precamp (Pre) and postcamp (Post). Plasma volume (PV) and haemoglobin mass (Hb_mass) were measured at similar times and 4 weeks postcamp (4WPost). Sweat sodium concentration ((Na⁺)_sweat) was measured Pre and Post during a heat-response test (44°C).

Results

Both groups showed very large improvements in Yo-YoIR2 at Post (+44%; 90% CL 38, 50), with no between-group differences in the changes (−1%; −9, 9). Postcamp, large changes in PV (+5.6%; −1.8, 5.6) and (Na⁺)_sweat (−29%; −37, −19) were observed in both groups, while Hb_mass only moderately increased in HYP (+2.6%; 0.5, 4.5). At 4WPost, there was a likely slightly greater increase in Hb_mass (+4.6%; 0.0, 9.3) and PV (+6%; −5, 18, unclear) in HYP than in NORM.

Conclusions

The combination of heat and hypoxic exposure during sleep/training might offer a promising ‘conditioning cocktail’ in team sports.

Integrating visual and tactile information in the perirhinal cortex

By virtue of its widespread afferent projections, perirhinal cortex is thought to bind polymodal information into abstract object-level representations. Consistent with this proposal, deficits in cross-modal integration have been reported after perirhinal lesions in nonhuman primates. It is therefore surprising that imaging studies of humans have not observed perirhinal activation during visual–tactile object matching. Critically, however, these studies did not differentiate between congruent and incongruent trials. This is important because successful integration can only occur when polymodal information indicates a single object (congruent) rather than different objects (incongruent). We scanned neurologically intact individuals using functional magnetic resonance imaging (fMRI) while they matched shapes. We found higher perirhinal activation bilaterally for cross-modal (visual–tactile) than unimodal (visual–visual or tactile–tactile) matching, but only when visual and tactile attributes were congruent. Our results demonstrate that the human perirhinal cortex is involved in cross-modal, visual–tactile, integration and, thus, indicate a functional homology between human and monkey perirhinal cortices.

Sex workers working within a legalised industry: their side of the story

OBJECTIVES

To examine the characteristics and work attitudes of female sex workers working in licensed brothels in Victoria, Australia.

METHODS

This was a cross-sectional study of sex workers working at 38 of the 92 licensed brothels operating in Victoria during 2006.

RESULTS

Of the 108 women approached, 97 (90%) completed the questionnaire. Women working in the legal sex industry in Victoria were generally aged between 23 and 35 years (51%), had completed high school (26%) and had worked in the industry for more than 5 years (43%). Half had dependent children and one third were in a relationship. Women's primary motivation for working in the sex industry was financial, whether this was the reason for their starting (56%), or the barrier to their leaving (61%). Although women valued the higher income and flexibility of this work, many were concerned about sexually transmitted infections (STI) (55%), community attitudes towards the industry (47%), their physical safety (38%) and maintaining their anonymity (37%). Over half of the women would like to leave the industry. The majority (95%) supported the monthly STI checks that are part of the Victorian regulations, with only one fifth reporting that the cost of these tests was prohibitive.

CONCLUSIONS

The findings of this study indicate that women working in licensed Victorian brothels come from a diverse range of backgrounds and circumstances and hold varying attitudes towards working in the sex industry. It is hoped that these findings go some way to redressing the assumptions commonly made about women working in the sex industry and reducing the stigma associated with this occupation.

More than just anal sex: the potential for sexually transmitted infection transmission among men visiting sex-on-premises venues

OBJECTIVES

This study aimed to obtain detailed data on the frequency of sexual practices among men who had sex with men (MSM) at sex-on-premises venues (SOPV) and to compare this with their sexual practices outside SOPV.

METHODS

A cross-sectional survey was undertaken of MSM at six SOPV between December 2006 and March 2007.

RESULTS

Of 604 men approached, 200 (33%) participated. Men reported sexual contact with a median of two other men (range 0-28). Receptive and insertive anal intercourse was reported by 19.5% and 34.0%, respectively, and was unprotected in 2.5% and 6.0%. The frequency of other practices included: unprotected insertive and receptive penile-anal touching or rubbing without penetration, or "nudging" (26.5% and 20.0%); unprotected, transient insertive and receptive anal intercourse, or "dipping" (6.0% and 5.0%) and insertive and receptive anal fingering (38.5% and 32.5%). Approximately 40% of men who reported "nudging" reported that they had not engaged in any "anal sex". Compared with their practices with casual male partners outside SOPV, men having sex at SOPV were less likely to have receptive oral intercourse with ejaculation (odds ratio (OR) 0.4; 95% CI 0.2 to 1.0, p = 0.04) and unprotected receptive anal intercourse (OR 0.3; 95% CI 0.1 to 0.8, p = 0.01), but were more likely to have group sex (OR 2.0; 95% CI 1.1 to 3.6, p = 0.03).

CONCLUSIONS

Substantial penile-anal contact not involving anal intercourse occurred at SOPV and may explain anal infections in the absence of reported anal sex. Some higher risk practices were reported more frequently with male partners outside of these venues than with partners within SOPV.

61. GP PERSPECTIVES ON PARTNER NOTIFICATION FOR CHLAMYDIA

As part of a larger, combined qualitative-quantitative study of partner notification, 40 semi-structured in-depth telephone interviews were conducted with General Practitioners (GPs), from Victoria, ACT and Queensland, who had diagnosed at least one case of chlamydia in the last year. Rural doctors and those who had experience working with Aboriginal patients were over-sampled to ensure their views were represented in the study. The interviews explored GPs' current practices with regard to partner notification for chlamydia, barriers they perceived to partner notification for chlamydia in the general practice setting and what resources/incentives they felt would improve partner notification for chlamydia. The GPs in our study primarily ask the index patient to carry out partner notification themselves. It was relatively rare for GPs to have experience of notifying partners on the patient's behalf. Half of the GPs report that they only encourage notification of the patient's current/immediate past partners. There was considerable confusion amongst the GPs interviewed as to the role of government partner notification officers. Many thought that support from a government agency would allow partner notification to occur more effectively. Some were under the impression that this process is automatically activated when they 'notify' that they have diagnosed someone with chlamydia. Some of the main barriers perceived include confusion about issues of privacy and confidentiality with regard to partner notification and the sense that there is a lack of clarity as to what is expected of them in terms of partner notification for chlamydia. Most GPs feel that access to decision support tools and clear guidelines would be helpful. Financial incentives for doing partner notification were seen as particularly important to fund allied health workers' time rather than to pay GPs themselves e.g. for practice nurses and Aboriginal health workers. GPs were enthusiastic about computer based resources to aid in partner notification

58. CHLAMYDIA SCREENING OF ANTENATAL WOMEN IN MELBOURNE BETWEEN 16-25 YEARS

Objective: Routine chlamydia screening of pregnant women is not widely practiced in Australia and limited data are available on the prevalence of infection in this population. This cross-sectional study sought to determine the prevalence of genital chlamydial infection among pregnant women aged 16-25 attending antenatal clinics in Melbourne. Methods: Consecutive women attending 4 major maternity services covering northern, western, eastern and south-eastern Melbourne were approached between October 2006 and May 2007. Of 931 eligible women (those aged 16-25 who had not already been tested for chlamydia) attending the clinics at the time of recruitment, 882 (95%) were approached and 845 (96%) agreed to participate. Participants completed a questionnaire which was translated into Chinese, Vietnamese and Arabic, and provided first-void urine which was tested for Chlamydia trachomatis using polymerase chain reaction. Results: Eighteen percent of women had a preferred language other than English. Of the 826 tests which were non assessable, 30 were positive representing a prevalence rate of 3.6% (95% CI: 2.5-5.1%). However, among women aged 16-20, 14 of 203 women were infected, representing a prevalence rate of 6.9% (95% CI: 3.8-11.3%). All infected women received treatment with azithromycin and all who have had repeat chlamydia tests to date have been negative. Conclusion: In this study of a wide cross-section of pregnant Melbourne women, chlamydial infection was common, particularly among teenagers. Screening was highly acceptable, with the great majority of women approached agreeing to be screened.