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The natural history of Chlamydia trachomatis infection in women: a multi-parameter evidence synthesis

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Price, Malcolm J, Ades, AE, Soldan, Kate, Welton, Nicky J, Macleod, John, Simms, Ian, DeAngelis, Daniela, Turner, Katherine ME +1 more·2016·Health Technology Assessment
DOI 10.3310/hta20220PMC PMC4819202
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Abstract

Background and objectives: The evidence base supporting the National Chlamydia Screening Programme, initiated in 2003, has been questioned repeatedly, with little consensus on modelling assumptions, parameter values or evidence sources to be used in cost-effectiveness analyses. The purpose of this project was to assemble all available evidence on the prevalence and incidence of Chlamydia trachomatis (CT) in the UK and its sequelae, pelvic inflammatory disease (PID), ectopic pregnancy (EP) and tubal factor infertility (TFI) to review the evidence base in its entirety, assess its consistency and, if possible, arrive at a coherent set of estimates consistent with all the evidence. Methods: Evidence was identified using ‘high-yield’ strategies. Bayesian Multi-Parameter Evidence Synthesis models were constructed for separate subparts of the clinical and population epidemiology of CT. Where possible, different types of data sources were statistically combined to derive coherent estimates. Where evidence was inconsistent, evidence sources were re-interpreted and new estimates derived on a post-hoc basis. Results: An internally coherent set of estimates was generated, consistent with a multifaceted evidence base, fertility surveys and routine UK statistics on PID and EP. Among the key findings were that the risk of PID (symptomatic or asymptomatic) following an untreated CT infection is 17.1% [95% credible interval (CrI) 6% to 29%] and the risk of salpingitis is 7.3% (95% CrI 2.2% to 14.0%). In women aged 16–24 years, screened at annual intervals, at best, 61% (95% CrI 55% to 67%) of CT-related PID and 22% (95% CrI 7% to 43%) of all PID could be directly prevented. For women aged 16–44 years, the proportions of PID, EP and TFI that are attributable to CT are estimated to be 20% (95% CrI 6% to 38%), 4.9% (95% CrI 1.2% to 12%) and 29% (95% CrI 9% to 56%), respectively. The prevalence of TFI in the UK in women at the end of their reproductive lives is 1.1%: this is consistent with all PID carrying a relatively high risk of reproductive damage, whether diagnosed or not. Every 1000 CT infections in women aged 16–44 years, on average, gives rise to approximately 171 episodes of PID and 73 of salpingitis, 2.0 EPs and 5.1 women with TFI at age 44 years. Conclusions and research recommendations: The study establishes a set of interpretations of the major studies and study designs, under which a coherent set of estimates can be generated. CT is a significant cause of PID and TFI. CT screening is of benefit to the individual, but detection and treatment of incident infection may be more beneficial. Women with lower abdominal pain need better advice on when to seek early medical attention to avoid risk of reproductive damage. The study provides new insights into the reproductive risks of PID and the role of CT. Further research is required on the proportions of PID, EP and TFI attributable to CT to confirm predictions made in this report, and to improve the precision of key estimates. The cost-effectiveness of screening should be re-evaluated using the findings of this report. Funding: The Medical Research Council grant G0801947.

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  • Existing reviews highlight the effectiveness of a number of interventions for peripartum depression, including medication, health promotion interventions and psychological interventions.

    “Existing reviews highlight the effectiveness of a number of interventions for PPD including medication (eg, antidepressant medication), health promotion interventions (eg, educational home visits) and psychological interventions (eg, cognitive–behavioural therapy (CBT) and interpersonal therapy.16–27”

    From Effectiveness and acceptability of cognitive-behavioural therapy based interventions for maternal peripartum depression: A systematic review, meta-analysis and thematic synthesis protocol (2019) · cites this paper as [22]

    The passages on evaluating Chlamydia trachomatis screening discuss pelvic inflammatory disease, not peripartum depression. Searches for peripartum or postpartum depression and the named treatments found no relevant passage in our copy; because the copy is truncated, it cannot establish whether the missing text addresses them. (LLM, conf=0.76)

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  1. The available data on incidence in the UK agree with predictions based on duration (see Chapter 4) and UK prevalence.
  2. Dr Paddy J Horner (Consultant Senior Lecturer, co-investigator) was the main advisor on clinical and diagnostic issues, made a significant contribution to the study design, drafted sections of the report, had a leading role in interpretation of literature, and commented on drafts of the report. Publications Price MJ, Ades AE, Welton NJ, Macleod J, Turner K, Simms I, et al. How much tubal factor infertility is caused by chlamydia? Estimation based on serological evidence adjusted for sensitivity and specificity. Sex Transm Dis 2012;39:608-13.
  3. Price MJ, Ades AE, De Angelis D, Welton NJ, Macleod J, Soldan K, et al. Use of latent class models to explain heterogeneity in studies of duration of Chlamydia trachomatis infection. Stat Med 2013;32:1547-60.
  4. European Centre for Disease Control and Prevention (ECDC). Review of Chlamydia Control Activities in EU Countries: Technical Report. Stockholm: ECDC; 2008.
  5. Hocking J. Protocol 12PRT/9010:Australian Chlamydia Control Effectiveness Pilot (ACCEPt): a cluster randomised controlled trial of chlamydia testing in general practice (ACTRN1260000297022). URL: www.thelancet.com/protocol-reviews/12PRT-9010. 2010 (accessed 6 October 2015).
  6. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0 [updated February 2008]. Chichester: The Cochrane Collaboration, Wiley; 2008.
  7. 8,a] <-0 p[8,9,a] <-1 -p[8,10,a] p[,10,a] <-1 -exp(-lambda.PID2[,a]) p[9,9,a] <-1 -p[9,10,a] p[9,10,a] <-1 -exp(-lambda.PID2[1,a]) p[10,10,a] <-0 p[10,11,a] <-1 -p[10,13,a] p[10,13,a] <-1 -exp(-lambda.PID2[2,a]) p[11,11,a] <-0 p[11,12,a] <-1 -p[11,13,a] p[,13,a] <-1 -exp(-lambda.PID2[2,a]) p[12,12,a] <-1 -p[9,10,a] p[,13,a] <-1 -exp(-lambda.PID2[1,a]) p[,13,a] <-1 } # State occupancy proportions for (i in 16:37) { pi[i,1,i-1] <-1 DOI: 10.3310/hta20220 HEALTH TECHNOLOGY ASSESSMENT 2016 VOL. 20 NO. 22 · DOI

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Authors
Price, M. J., Ades, A., Soldan, K., Welton, N. J., Macleod, J., Simms, I., DeAngelis, D., Turner, K. M., & Horner, P. J.
Affiliations
  • University of Birmingham (GB)
  • School of Social and Community Medicine, University of Bristol, Bristol, UK
  • Public Health England (GB)
  • University of Bristol (GB)
  • Public Health England (formerly Health Protection Agency), Colindale, London, UK
  • University Hospitals Bristol NHS Foundation Trust (GB)
ORCID
Venue
Health Technology Assessment
Publisher
National Institute for Health and Care Research
Published
2016-03
Volume
20
Issue
22
Pages
1-250
ISSN
  • 1366-5278 (ISSN-L)
  • 2046-4924
DOI
10.3310/hta20220
PMC
PMC4819202
OpenAlex
W2309207579
Cited by
494
References
266
Citations by year
2026: 40 · 2025: 40 · 2024: 40 · 2023: 39 · 2022: 51 · 2021: 59 · 2020: 49 · 2019: 71 · 2018: 46 · 2017: 51 · 2016: 8
FWCI
6.56
Type
journal article
Language
en
Open access
Licence
Locations
  • Health Technology Assessment (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Bristol Research (University of Bristol) (publishedVersion, cc-by-nc)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • University of Birmingham Research Portal (University of Birmingham) (submittedVersion, other-oa)
  • Explore Bristol Research (submittedVersion, cc-by-nc)
Funders
Medical Research Council (G0801947)
Topics
  • Life Sciences › Immunology and Microbiology › Microbiology › Reproductive tract infections research
  • Health Sciences › Medicine › Epidemiology › Cervical Cancer and HPV Research
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Reproductive Health and Contraception
Keywords
Chlamydia trachomatis, chlamydia screening, pelvic inflammatory disease, ectopic pregnancy, tubal infertility, salpingitis, cost-effectiveness, natural history of infection, incidence and prevalence, attributable risk, reproductive outcomes, women's health, National Chlamydia Screening Programme
MeSH terms
Pelvic Inflammatory Disease, Adolescent, Adult, Bayes Theorem, Chlamydia Infections, Chlamydia trachomatis, Female, United Kingdom, Humans, Mass Screening, Pregnancy, Pregnancy, Ectopic, Incidence, Prevalence, Young Adult

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