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#Study flow diagram.
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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).
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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.
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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).
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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).
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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).
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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.
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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 -
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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.

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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)
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