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Cochrane Database of Systematic Reviews

Cribado para la infección por clamidia genital

Información

DOI:
https://doi.org/10.1002/14651858.CD010866.pub2Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 13 septiembre 2016see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:

  1. Grupo Cochrane de Enfermedades de transmisión sexual

Copyright:
  1. Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

  • Nicola Low

    Correspondencia a: Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland

    [email protected]

  • Shelagh Redmond

    Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland

  • Anneli Uusküla

    Department of Public Health, University of Tartu, Tartu, Estonia

  • Jan van Bergen

    Department of General Practice and Family Medicine, University of Amsterdam, Amsterdam, Netherlands

  • Helen Ward

    Department of Infectious Disease Epidemiology, Imperial College London, London, UK

  • Berit Andersen

    Department of Public Health Programmes, Randers, Denmark

  • Hannelore Götz

    Department of Infectious Disease Control, Rotterdam‐Rijnmond Public Health Service, Rotterdam, Netherlands

Contributions of authors

Nicola Low selected studies, extracted data, conducted statistical analyses and drafted and revised the review.

Shelagh Redmond conducted electronic databases searches, selected studies, entered data and conducted statistical analyses.

Berit Andersen, Hannelore Götz, Anneli Uusküla, Jan van Bergen and Helen Ward extracted data, commented on and revised the review.

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • European Centre for Disease Prevention and Control, Sweden.

    Financial support for staff to conduct review as part of a project Chlamydia Control in Europe (ECDC/2011/027).

Declarations of interest

Berit Andersen is coauthor of two completed trials that are included in the review.

Jan van Bergen, Hannelore Götz and Nicola Low are coauthors on a completed trial that is included in the review .

Authors of included studies will not be involved in assessing and extracting data of their own studies.

Acknowledgements

The authors would like to thank Marita van der Laar, Otilia Sfetcu and Andrew Amato of the the European Centre for Disease Prevention and Control for funding this review and for their support in developing the review questions and comments on an earlier version of the review (ECDC 2014).

Version history

Published

Title

Stage

Authors

Version

2016 Sep 13

Screening for genital chlamydia infection

Review

Nicola Low, Shelagh Redmond, Anneli Uusküla, Jan van Bergen, Helen Ward, Berit Andersen, Hannelore Götz

https://doi.org/10.1002/14651858.CD010866.pub2

2013 Dec 23

Screening for genital chlamydia infection

Protocol

Nicola Low, Shelagh Redmond, Anneli Uusküla, Jan van Bergen, Helen Ward, Berit Andersen, Hannelore Götz

https://doi.org/10.1002/14651858.CD010866

Differences between protocol and review

Types of outcome measures: there is an error in a part of the text of the protocol, but the outcomes stated under the headings 'Primary outcomes' and 'Secondary outcomes' in the protocol are correct and are the same as those reported in the review. The statement following the list of secondary outcomes, "The following outcome will not be included: uptake of chlamydia screening . . ." should read, "The following outcome will not be included as a primary outcome: uptake of chlamydia screening."

We did not calculate the number needed to treat for an additional beneficial outcome (NNTB) or the number needed to treat for an additional harmful outcome (NNTH).

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

#Study flow diagram.
Figuras y tablas -
Figure 1

#Study flow diagram.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Forest plot of comparison: 1 Offer of chlamydia screening vs usual care (inactive control), outcome: 1.2 Incidence of PID at 12 months (intention‐to‐treat).
Figuras y tablas -
Figure 4

Forest plot of comparison: 1 Offer of chlamydia screening vs usual care (inactive control), outcome: 1.2 Incidence of PID at 12 months (intention‐to‐treat).

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Comparison 1 Offer of chlamydia screening vs usual care (inactive control), Outcome 1 Prevalence of chlamydia infection (positivity) measured in the whole study population at least 12 months after start of screening.
Figuras y tablas -
Analysis 1.1

Comparison 1 Offer of chlamydia screening vs usual care (inactive control), Outcome 1 Prevalence of chlamydia infection (positivity) measured in the whole study population at least 12 months after start of screening.

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Comparison 1 Offer of chlamydia screening vs usual care (inactive control), Outcome 2 Incidence of PID at 12 months (intention‐to‐treat).
Figuras y tablas -
Analysis 1.2

Comparison 1 Offer of chlamydia screening vs usual care (inactive control), Outcome 2 Incidence of PID at 12 months (intention‐to‐treat).

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Comparison 1 Offer of chlamydia screening vs usual care (inactive control), Outcome 3 Incidence of PID at 12 months (per protocol analysis).
Figuras y tablas -
Analysis 1.3

Comparison 1 Offer of chlamydia screening vs usual care (inactive control), Outcome 3 Incidence of PID at 12 months (per protocol analysis).

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Comparison 1 Offer of chlamydia screening vs usual care (inactive control), Outcome 4 Incidence of epididymitis in men at 12 months (intention to screen).
Figuras y tablas -
Analysis 1.4

Comparison 1 Offer of chlamydia screening vs usual care (inactive control), Outcome 4 Incidence of epididymitis in men at 12 months (intention to screen).

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Comparison 1 Offer of chlamydia screening vs usual care (inactive control), Outcome 5 Secondary outcomes for reproductive tract morbidity.
Figuras y tablas -
Analysis 1.5

Comparison 1 Offer of chlamydia screening vs usual care (inactive control), Outcome 5 Secondary outcomes for reproductive tract morbidity.

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Chlamydia screening compared with usual care for the prevention of C. trachomatis transmission and reproductive tract morbidity

Patient or population: healthy adults

Settings: general population, high schools or colleges

Intervention: chlamydia screening

Comparison: usual care

Outcomes

Absolute effect
(95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Chlamydia prevalence (general population)

Outcome was chlamydia test positivity after 3 yearly invitations in intervention clusters vs 1 invitation in control areas. Uptake was too low for chlamydia positivity to be considered an unbiased estimate of prevalence.

RD 0.0% (‐0‐01, +0.01%)

RR 0.96 (0.84 to 1.09)

30,122 (1 study)

⊕⊕⊝⊝1,2
Low

Chlamydia prevalence (high risk population)

Outcome was prevalence of positive chlamydia tests in repeated cross‐sectional surveys of women tested at sex venues after 4 years of intervention.

RD ‐3.7%

RR 0.72 (0.54 to 0.98)

4156 (1 study)

⊕⊕⊝⊝3
Low

Incidence of pelvic inflammatory disease (PID) at 12 months (intention‐to‐treat)

Outcome was clinically diagnosed PID reported by the participant or extracted from medical records, pharmacy records or hospital discharge coding. Outcome very likely to be affected by risk of detection bias.

RD 0.0% (0‐0, 0.0%)

RR 0.68 (0.49 to 0.94)

21,686 (4 studies)

⊕⊕⊕⊝4
Moderate

Incidence of epididymitis in men at 12 months (intention‐to‐treat)

Outcome was epididymitis diagnosed in hospital and abstracted from hospital discharge coding.

RD 0.0% (0.0, 0.0%)

RR 0.80 (0.45 to 1.42)

14,980 (1 study)

⊕⊝⊝⊝5,6
Very low

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

CI: confidence interval; PID: pelvic inflammatory disease; RR: risk ratio.

1. Selection, attrition and other bias

2. One large non‐randomized cluster‐controlled trial.

3. Single large trial in female sex workers and uncertainty about generalisability to other screening interventions and populations.

4. Selection bias might have overestimated intervention effect.

5. Low uptake of the screening intervention with an imprecise effect estimate and uncertainty about estimated effect of screening interventions with higher sustained levels of uptake.

6. Performance bias
Figuras y tablas -
Ir a la tabla de la revisión
Table 1. Effect of chlamydia screening interventions on chlamydia prevalence

Trial

Study population

Baseline

Follow‐up, 12 months

Reported effect (95% CI)

Follow‐up, subsequent

Reported effect (95% CI)

Intervention

Control

Intervention

Control

Intervention

Control

Ostergaard 2000

High school students, Denmark

43/867a

Not measured

13/443a

32/487

RD − 5.5% (− 10 to 0.95%)a

—

—

—

van den Broek 2012

General population, Netherlands

1851/43358

267/6223

1153/28803

Not measured

OR 0.93 (0.81 to 1.07)b

981/23899

Not measured

OR 0.96 (0.83 to 1.10)b

Garcia 2012

Female sex workers, Peru

13.8%

15.5%

—

—

—

9.9%

14.5%

RR 0.66 (0.47 to 0.94)c

CI: confidence interval; OR: odds ratio; RD: risk difference; RR: risk ratio.
aNumbers of infections and people are the numbers reported by the authors. Risk difference, as reported by authors (difference in mean incidence proportions across clusters). Confidence intervals for the difference did not take into account clustering.
bComparison is between intervention group at follow‐up and control group at baseline. Confidence intervals do not take into account intraclass correlation because, in a hierarchical multivariable model, clustering did not affect the results.
cTotal participants at baseline in 2002, 4130; total participants at follow‐up in 2006, 4156; RR adjusted for 2002 prevalence but not for pairing of cities.

Figuras y tablas -
Table 1. Effect of chlamydia screening interventions on chlamydia prevalence
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Table 2. Uptake of chlamydia screening

Trial

Eligibility (ratio intervention: control)

Group

Uptake in intervention

Uptake in control

Comment

Andersen 2011

Selected at random from register (1:4)

Intervention: invited for home‐sampling. Assessed after 3 months

Control: not contacted. Tests at GP and STI clinics assessed after 3 months

Women

4000 invited;

1175 (29.4%) sent home‐sample

11,459 not invited;

1076 (9.4%) opportunistic tests

Control group not aware of trial. Assume routine health‐seeking behaviour over 3 months. If control group testing behaviour continued at the same level over 12 months, the proportion tested by the time the outcome PID was measured could have been higher.

Men

5000 invited;

1033 (20.7%) sent home‐sample

9980 not invited;

140 (1.4%) opportunistic tests

Garcia 2012

Sex work venues identified and visited by mobile teams

Women

Could not be calculated

Could not be calculated

Not designed to measure uptake; no denominator

Oakeshott 2010

Approached in colleges;

all women enrolled were tested, randomised (1:1)

Women

1259 (100%) immediate screening;

269 (21%) opportunistic tests

1270 (100%) deferred screening;

258 (20%) opportunistic tests

Not designed to measure uptake

Ostergaard 2000

Schools randomised (1:1)

Intervention: allocated to home‐sampling

Control: allocated to offer of GP testing

Sexually active respondents eligible. Assessed after 4 months

Women

2603 allocated;

928 eligible responders;

867 (93.4%) sent home‐sample

2884 allocated;

833 eligible responders; 63 (7.6%) opportunistic tests

All students in school were allocated to intervention or control groups and asked if they would take part. Of the responders, only those who had ever had sex were eligible. The denominator of of all who had ever had sex was not known.

Intervention group given home‐sampling kits

Men

1733 allocated;

442 eligible responders;

430 (97.3%) sent home sample

1689 allocated;

246 eligible responders;

4 (1.6%)
opportunistic tests

—

Scholes 1996

Individuals randomised (1:2)

Respondents fulfilling criteria for high risk of chlamydia eligible

Women

36,457 randomised; 20,836 responded;
3111 at high risk

Numbers allocated to intervention and control not reported. Intervention group actively contacted

1009 invited

645 (64%) tested

1598 not invited;

% tested not known

van den Broek 2012

Postal areas allocated (5:1)

Intervention: allocated to yearly invitation x3

Control: allocated to single invitation

Women

1st

2nd

3rd

142,419 invited;
29,831 (21.3%) tested

141,078 invited;
20,246 (14.7%) tested

131,010 invited;
16,853 (17.4%) tested

24,172 invited;
4199 (17.4%) tested

Postal invitation contained secure login code. Recipients had to register on website to request home‐sampling kit. One reminder letter

Men

1st

2nd

3rd

129,462 invited;
13,617 (10.5%) tested

128,299 invited;
8,616 (6.7%) tested

121,156 invited;
6,970 (5.6%) tested

23,884 invited
2025 (8.5%) tested

All

1st

2nd

3rd

269,273 invited;
43,358 (16.2%) tested

265,979 invited;
28,803 (10.8%) tested

251,688 invited;
23,899 (9.5%) tested

48,031 invited
6,223 (13.0%) tested

GP: general practitioner; PID: pelvic inflammatory disease; STI: sexually transmitted infection.

Figuras y tablas -
Table 2. Uptake of chlamydia screening
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Comparison 1. Offer of chlamydia screening vs usual care (inactive control)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Prevalence of chlamydia infection (positivity) measured in the whole study population at least 12 months after start of screening Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.1 3rd invitation vs control

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 2nd invitation vs control

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.3 1st invitation vs control

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.4 Screening offer in high school students

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Incidence of PID at 12 months (intention‐to‐treat) Show forest plot

4

21080

Risk Ratio (M‐H, Fixed, 95% CI)

0.68 [0.49, 0.94]

2.1 Low risk of detection bias

2

18022

Risk Ratio (M‐H, Fixed, 95% CI)

0.80 [0.55, 1.17]

2.2 High risk of detection bias

2

3058

Risk Ratio (M‐H, Fixed, 95% CI)

0.42 [0.22, 0.83]

3 Incidence of PID at 12 months (per protocol analysis) Show forest plot

2

2749

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.35, 1.10]

3.1 Low risk of detection bias

1

2377

Risk Ratio (M‐H, Fixed, 95% CI)

0.65 [0.34, 1.24]

3.2 High risk of detection bias

1

372

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.17, 1.80]

4 Incidence of epididymitis in men at 12 months (intention to screen) Show forest plot

1

14980

Risk Ratio (M‐H, Fixed, 95% CI)

0.80 [0.45, 1.42]

5 Secondary outcomes for reproductive tract morbidity Show forest plot

1

Risk Difference (M‐H, Fixed, 95% CI)

Totals not selected

5.1 Female infertility

1

Risk Difference (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

5.2 Ectopic pregnancy

1

Risk Difference (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]
Figuras y tablas -
Comparison 1. Offer of chlamydia screening vs usual care (inactive control)
Ir a la tabla de la revisión