Transcript Slide 1

BASHH 2012 UK Re-Audit of
Asymptomatic Screening
Dr Hugo McClean
1
BASHH 2012 Audit standards
• Sexually Transmitted Infections: UK National
Screening and Testing Guidelines August 2006
http://www.bashh.org/guidelines
• Recommended Tests for Asymptomatic
Patients
• This presentation builds upon the
recommendations from the 2009 audit
BASHH 2012 Audit- presentation
scheme
•
•
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Standards
Methods
Results
Key messages
Recommendations for improvement
Conclusions 2009 Audit
• High overall rates of testing with BASHH CEG first line
recommended tests for chlamydia, syphilis and HIV
• High overall rates of testing for gonorrhoea in women when
NAATs included
• Important number of cases having N. gonorrhoeae NAATs,
including urine GC NAATs (45% MSM)
• Urethral microscopy ~ 20% men
• Cervical microscopy ~ 10%
• Most MSM tested for HepB (80%)
• Predominance of hepatitis C testing in MSM
Suggested Areas for Practice
Improvement/Interventions 2009 Audit
• Increased documentation of discussion about oral and anal sex,
as recommended in the BASHH recommendations on sexual
history taking to identify which anatomical sites need to be
sampled for infection
• Regional strategies should be considered to balance nucleic
acid amplification testing for gonorrhoea with culture testing to
monitor antibiotic sensitivity
• Increased screening for hepatitis B in MSM is needed in some
regions.
• Increased screening for HIV is needed in some regions,
particularly for women
Standards
6
Asymptomatic heterosexual men
Test
CEG 2006 Recommends
Chlamydia
(Urine NAAT or urethral NAAT)
Yes
Gonorrhoea
(Urethral culture* or urine NAAT**)
Yes
Syphilis
Yes
HIV
Yes
Hep B
No, unless in risk group
Urethral microscopy
No
*
**
Urethral culture only for gonorrhoea: 1194 (58%, 2-98%)
Recommended if urethral specimen not available
Asymptomatic MSM
Test
CEG 2006 Recommends
Chlamydia
(Urine NAAT or urethral NAAT)
Yes
Gonorrhoea
(Urethral culture* or urine NAAT**)
(Oropharyngeal and rectal testing if
indicated by the sexual history)
Yes
Syphilis
Yes
HIV
Yes
Hep B
Yes
Urethral microscopy
No
*
**
Urethral culture only for gonorrhoea
Recommended if urethral specimen not available
Asymptomatic women
Test
CEG 2006 Recommends
Chlamydia
(Cx, v/vagina, urethra or urine* NAAT)
Yes
Gonorrhoea
(Cervical culture)
(Oropharyngeal and rectal testing if
indicated by the sexual history)
Yes
Syphilis
Yes
HIV
Yes
Hep B
No, unless in risk group
Cervical microscopy
No
* recommended if urethral specimen not available
Case definition
• No symptoms offered on presentation (either
on a triage form, or similar form, or on direct
questioning by a healthcare worker)
• Seen during a first meeting in a new or rebook episode
Data collection- 1
• Audit interval:
– Clinic policies: on day of audit
– Cases seen 1 October to 31 December 2011
• Data collection
– Launched 7 Jan 2012
– Closed 15 April 2012
• Participation:
– Level 3 services: BASHH NAG Regional Chairs network
– BASHH website, emails, BASHH Newsletter
Data collection- 2
• Data submitted using an online form
• Clinic policy data
• Case note data:
– Up to consecutive 40 cases*
*RCP Local Clinical Audit: handbook for physicians: http://old.rcplondon.ac.uk/clinicalstandards/ceeu/Documents/Local-clinical-audit-handbook-for-physicians-August-2010.pdf
Results
• Case, clinic, regional and national level data
• National aggregate composed of regional-level
data
• Percentage of clinics in each BASHH Region
meeting performance levels
• Overall national performance
Questions asked
1. Recording of oral sex: occurrence, nonoccurrence, patient declined to answer,
documented not asked, no record, not
applicable
2. Receptive anal sex: same as for oral sex
3. Offer of HIV testing: offered & done, offered &
declined, not offered, not applicable
4. Tests for hepatitis B, or immune or chronic
infection or not appliacable
5. Tests for gonorrhoea
14
Gender and sexual preference
• Total 6669 cases
– Women: 3321 (50%)
– Men: 3348 (50%)
• Het men: 3020 (90%)
• MSM: 328 (10%)
15
Number (%) of clinics participating, by Region
Branch
North Thames
South East Thames
South West
West Midlands
Wales
Northern
Yorkshire
Anglia
South West Thames
North West
Trent
Oxford
Wessex
Northern Ireland
Essex
Cheshire and Merseyside
Scotland
National
Number of cases submitted
804
602
511
499
487
447
443
408
398
384
361
279
279
205
204
196
162
6669
Documentation about oral sex
17
Documentation about receptive oral sex- women
National, N=3321
Northern Ireland, n=91
North West, n=197
Wales, n=234
Wessex, n=142
Essex, n=101
Cheshire and Merseyside, n=99
Northern, n=226
North Thames, n=394
South West, n=246
Anglia, n=200
Yorkshire, n=236
South East Thames, n=300
West Midlands, n=257
South West Thames, n=204
Trent, n=170
Scotland, n=85
Oxford, n=139
52%
97%
87%
77%
61%
59%
59%
52%
50%
49%
48%
45%
44%
43%
42%
38%
2009: 45% (8-65%)
29%
29%
0%
20%
40%
60%
80%
100%
Percentage of cases having a record made about occurrence or non-occurrence of
18
receptive oral sex
Documentation about receptive oral sex- het men
Northern Ireland n=99
North West n=162
Wales n=235
Northern n=205
Essex n=94
Yorkshire n=196
Cheshire and Merseyside n=85
National, N=3020
South West n=238
Wessex n=126
South East Thames n=277
North Thames n=339
South West Thames n=168
West Midlands n=226
Scotland n=68
Trent n=181
Oxford n=128
Anglia n=193
91%
81%
69%
60%
59%
56%
54%
50%
50%
49%
49%
47%
38%
37%
34%
34%
27%
27%
0%
20%
40%
60%
80%
100%
Percentage of cases having a record made about occurrence or non-occurrence of
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receptive oral sex
Documentation about receptive oral sex- MSM
National, N=266
West Midlands, n=14
Trent, n=8
Northern Ireland, n=15
Northern, n=14
Essex, n=8
North West, n=19
South East Thames, n=21
South West Thames, n=23
Oxford, n=7
Cheshire and Merseyside, n=9
North Thames, n=62
Wales, n=15
South West, n=21
Anglia, n=10
Yorkshire, n=8
Wessex, n=7
Scotland, n=5
2009: 81% (50-100%)
0%
20%
40%
60%
92.1%
93.8%
100.0%
100.0%
100.0%
100.0%
96.0%
96.0%
92.3%
91.7%
91.7%
91.5%
88.9%
88.9%
86.7%
81.8%
81.8%
77.8%
80%
100%
Percentage of cases having a record made about occurrence or non-occurrence of
20
receptive oral sex
Documentation about anal sex
21
Documentation about receptive anal sex- women
National, N=3321
Northern Ireland, n=91
North West, n=197
Wales, n=234
Cheshire and Merseyside, n=99
Essex, n=101
Wessex, n=142
Yorkshire, n=236
North Thames, n=394
South West, n=246
South West Thames, n=204
Anglia, n=200
West Midlands, n=257
South East Thames, n=300
Northern, n=226
Oxford, n=139
Trent, n=170
Scotland, n=85
50%
95%
86%
73%
62%
58%
51%
49%
47%
44%
43%
42%
41%
40%
40%
37%
33%
28%
0%
20%
40%
60%
2009: 39% (8-49%)
80%
100%
Percentage of cases having a record made about occurrence or non-occurrence of
22
receptive anal sex
Documentation about receptive anal sex- MSM
National, N=328
South West Thames, n=26
Oxford, n=12
Northern Ireland, n=15
Northern, n=16
Essex, n=9
South East Thames, n=25
West Midlands, n=16
North West, n=25
Cheshire and Merseyside, n=12
Yorkshire, n=11
Trent, n=10
Wales, n=18
Scotland, n=9
North Thames, n=71
Wessex, n=11
South West, n=27
Anglia, n=15
91%
100%
100%
100%
100%
100%
96%
94%
92%
92%
91%
90%
89%
89%
89%
2009: 88% (50-100%)
82%
81%
80%
0%
20%
40%
60%
80%
100%
Percentage of cases having a record made about occurrence or non-occurrence of
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receptive anal sex
Recording of occurrence of anal sex in heterosexual men- national data
Region
Anal sex recorded as
‘occurred’
Anglia n=193
Cheshire and Merseyside n=85
Essex n=94
North Thames n=339
North West n=162
Northern n=205
Northern Ireland n=99
Oxford n=128
Scotland n=68
South East Thames n=277
South West n=238
South West Thames n=168
Trent n=181
Wales n=235
Wessex n=126
Yorkshire n=196
West Midlands n=226
National, N=3020
0.5%
0.0%
0.0%
0.3%
0.0%
4.4%
0.0%
1.6%
1.5%
1.1%
5.5%
0.6%
0.0%
0.9%
0.0%
0.0%
1.3%
1.2%
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HIV testing uptake
25
HIV testing uptake- eligible MSM
National, N=328
Yorkshire, n=11
Wales, n=18
Trent, n=10
South West Thames, n=25
South West, n=27
South East Thames, n=25
Northern Ireland, n=15
Northern, n=16
Essex, n=9
Cheshire and Merseyside, n=12
North West, n=25
North Thames, n=71
West Midlands, n=16
Anglia, n=15
Oxford, n=12
Wessex, n=11
Scotland, n=9
97%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
96%
96%
94%
93%
92%
91%
2009: 95% (90-100%)
78%
0%
20%
40%
60%
80%
100%
Percentage of eligible MSM having an HIV test (‘not applicable’ excluded)
26
HIV testing uptake- eligible women
National N=3269
Northern Ireland n=91
Trent n=169
West Midlands n=254
South West Thames n=198
Essex n=101
Wessex n=140
South West n=244
Oxford n=133
North Thames n=391
Yorkshire n=228
Anglia n=196
North West n=195
South East Thames n=294
Scotland n=85
Northern n=223
Cheshire and Merseyside n=98
Wales n=229
85%
93%
89%
89%
88%
88%
88%
86%
86%
86%
85%
84%
84%
83%
82%
81%
77%
75%
2009: 81% (66-98%)
0%
20%
40%
60%
80%
100%
Percentage of eligible women having an HIV test (‘not applicable’ excluded)
27
HIV testing uptake- eligible het men
National, N=2977
Northern Ireland n=99
Essex n=94
Trent n=179
West Midlands n=221
South East Thames n=274
North Thames n=335
Northern n=201
Wessex n=124
Yorkshire n=192
Anglia n=192
Scotland n=66
South West n=233
North West n=162
Oxford n=126
South West Thames n=164
Cheshire and Merseyside n=83
Wales n=232
88%
96%
95%
93%
93%
89%
89%
88%
87%
86%
86%
86%
86%
86%
85%
85%
84%
2009: 83% (70-96%)
77%
0%
20%
40%
60%
80%
100%
Percentage of eligible het men having an HIV test (‘not applicable’ excluded)
28
Hepatitis B testing uptake
29
Hepatitis B testing uptake- eligible MSM
National, N=221
West Midlands, n=10
Wessex, n=7
Wales, n=14
Trent, n=9
Northern Ireland, n=14
Essex, n=9
Cheshire and Merseyside, n=6
South West Thames, n=18
South East Thames, n=16
North Thames, n=40
Northern, n=12
Oxford, n=11
Anglia, n=9
Yorkshire, n=8
North West, n=16
South West, n=16
Scotland, n=6
92%
100%
100%
100%
100%
100%
100%
100%
94%
94%
93%
92%
91%
89%
88%
88%
2009: 83% (54-100%)
75%
67%
0%
20%
40%
60%
80%
Percentage of eligible MSM having a test for hepatitis B
(‘not applicable,’ ‘immune,’ ‘chronic infection ’ all excluded)
100%
30
Hepatitis B testing uptake- eligible women
National, N=561
South West Thames, n=35
Anglia, n=29
Scotland, n=7
Essex, n=21
South West, n=51
North West, n=29
Cheshire and Merseyside, n=21
West Midlands, n=40
Northern, n=20
Northern Ireland, n=52
Oxford, n=13
North Thames, n=86
Yorkshire, n=30
Wales, n=17
Trent, n=36
South East Thames, n=48
Wessex, n=26
68%
91%
86%
86%
86%
84%
83%
81%
80%
80%
77%
69%
65%
60%
2009: 29% (11-77%)
53%
50%
38%
4%
0%
20%
40%
60%
80%
Percentage of eligible women having a test for hepatitis B
(‘not applicable,’ ‘immune,’ ‘chronic infection ’ all excluded)
100%
31
Hepatitis B testing uptake- eligible het men
National, N=602
Wales, n=17
Essex, n=32
Anglia, n=32
South West, n=53
South West Thames, n=23
Scotland, n=7
Northern, n=27
Oxford, n=11
North West, n=47
Northern Ireland, n=56
Yorkshire, n=30
North Thames, n=84
Cheshire and Merseyside, n=30
West Midlands, n=36
Trent, n=37
South East Thames, n=53
Wessex, n=27
77%
94%
94%
94%
89%
87%
86%
85%
82%
81%
80%
80%
79%
77%
75%
2009: 24% (7-60%)
59%
47%
37%
0%
20%
40%
60%
80%
Percentage of eligible men having a test for hepatitis B
(‘not applicable,’ ‘immune,’ ‘chronic infection ’ all excluded)
100%
32
Gonorrhoea testing
33
Gonorrhoea testing- MSM, any test done
National, N=328
West Midlands, n=16
Yorkshire, n=11
Wessex, n=11
Wales, n=18
Trent, n=10
South West Thames, n=26
South West, n=27
South East Thames, n=25
Scotland, n=9
Oxford, n=12
Northern Ireland, n=15
Northern, n=16
North Thames, n=71
Essex, n=9
Cheshire and Merseyside, n=12
Anglia, n=15
North West, n=25
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
96%
2009: 97% (86-100%)
0%
20%
40%
60%
80%
100%
Percentage of MSM having any test done for gonorrhoea
34
Gonorrhoea testing- women, any test done
National, N=3321
Northern, n=226
South East Thames, n=300
Northern Ireland, n=91
North West, n=197
Wales, n=234
Essex, n=101
Cheshire and Merseyside, n=99
Wessex, n=142
Oxford, n=139
South West Thames, n=204
West Midlands, n=257
Anglia, n=200
South West, n=246
North Thames, n=394
Trent, n=170
Scotland, n=85
Yorkshire, n=236
97%
99%
99%
99%
98%
98%
98%
98%
98%
98%
98%
97%
97%
96%
95%
95%
93%
93%
2009: 93% (83-100%)
0%
20%
40%
60%
80%
100%
Percentage of women having any test done for gonorrhoea
35
Gonorrhoea testing- het men, any test done
National, N=3020
Northern n=205
North West n=162
Northern Ireland n=99
Essex n=94
Cheshire and Merseyside n=85
South West n=238
South West Thames n=168
South East Thames n=277
North Thames n=339
Anglia n=193
Scotland n=68
Oxford n=128
West Midlands n=226
Trent n=181
Yorkshire n=196
Wessex n=126
Wales n=235
97%
100%
99%
99%
99%
99%
99%
98%
98%
98%
97%
97%
97%
96%
96%
95%
94%
93%
2009: 96% (89-100%)
0%
20%
40%
60%
80%
100%
Percentage of het men having any test done for gonorrhoea
36
Gonorrhoea testing- women, tests done
(not oropharyngeal NAAT & culture)
Anatomical
site/test
Number 2012
(%, regional range %)
N=3321
Number 2009
(%, regional range %)
N=2131
Cervical culture
1310 (39%, 0-83%)
1393 (65%, 26-94%)
Vulvovaginal NAAT
1289 (39%, 0-81%)
244 (12%, 0-29%)
Urethral culture
872 (26%, 0-71%)
953 (45%, 16-82%)
Cervical NAAT
656 (20%,1-55%)
250 (12%, 0-44%)
Vulvovaginal culture
195 (6%, 0-34%)
-
Urine NAAT
181 (6%, 0-16%)
209 (10%,0-36%)
Urethral microscopy
130 (4%,0 -13%)
(%,-%)
Urethral NAAT
45 (1%, 0-16%)
33 (2%, 0-13%)
Cervical microscopy
7 (0.2%, 0-27%)
248 (12 %,0-42%)
1
5 (0.2%, 0-1.1%)
Rectal microscopy
37
Gonorrhoea testing- women, tests done:
oropharyngeal & rectal NAAT & culture
Anatomical site/test
Oropharyngeal culture (all women, N=3321)
Number (%, regional range %
151 (5%, 0-16%)
Receptive oral sex occurred, n=1038
115 (11%, 0-44%)
Oropharyngeal NAAT (all women, N=3321)
102 (3%, 0-24%)
Receptive oral sex occurred, n=1038
78 (8%, 0-39%)
Rectal culture (all women, N=3321)
Receptive anal sex occurred, n=177
Rectal NAAT (all women, N=3321)
Receptive anal sex occurred, n=177
40 (1%, 0-7%)
19 (11%, 0-50%)
28 (1%, 0-4%)
22 (12%, 0-100%)
38
2009 Audit. Asymptomatic women: oropharyngeal
& rectal gonorrhoea culture
Test
Done n (%,
regional range)
Oropharyngeal culture:
Receptive oral sex occurred n=549
Receptive oral sex did not occur/not
documented n=1582
65 (12%, 0-30%)
15 (1%, 0-6%)
Rectal culture:
Receptive anal sex occurred n=93
Receptive anal sex did not occur/not
documented n=2038
11 (12%,0-100%)
27 (1%, 0-13%)
Gonorrhoea testing- MSM, tests done
(not oropharyngeal NAAT & culture)
Anatomical
site/test
Number 2012
(%, regional range %) N=328
Number 2009
(%, regional range %) N=219
Urine NAAT
228 (70%, 0-100%)
98 (45%, 0-100%)
Urethral
culture
114 (35%, 9-100%)
119 (54%, 9-100%)
Urethral
microscopy
35 (11%, 0-44%)
38 (17%, 0-100%)
Rectal
microscopy
16 (5%, 0-44%)
9 (4%, 0-25%)
8 (2%, 0-46%)
7 (3%, 0-20%)
Urethral
NAAT
40
Gonorrhoea testing- MSM, tests done:
oropharyngeal & rectal NAAT & culture
Anatomical site/test
Oropharyngeal NAAT (all MSM, N=328)
Number (%, regional range %)
164 (50%, 0-92%)
Receptive oral sex occurred, n=279
150 (54%, 0-92%)
Oropharyngeal culture (all MSM, N=328)
170 (52%, 0-83%)
Receptive oral sex occurred, n=279
152 (54%, 0-91%)
Rectal NAAT (all MSM, N=328)
Receptive anal sex occurred, n=218
Rectal culture (all MSM, N=328)
Receptive anal sex occurred, n=218
163 (50%, 0-89%)
128 (59%, 0-100%)
136 (42%, 11-89%)
115 (53%, 0-100%)
41
2009 Audit. Asymptomatic MSM: oropharyngeal &
rectal
Test
Done n (%, regional
range)
Oropharyngeal culture:
Receptive oral sex documented n=156
Receptive oral sex did not occur/not
documented n=63
134 (86%, 75-100%)
41 (65%, 0-100%)
Rectal culture:
Receptive anal sex documented n=141
Receptive anal sex did not occur/not
documented n=78
119 (84%, 67-100%)
34 (44%, 0-100%)
Gonorrhoea testing- het men, tests done
Anatomical site/test
Urine NAAT
Number 2012
(%, regional range %)
N= 3020
Number 2009
(%, regional range %)
N= 2078
2017 (67%, 17-99%)
751 (36%, 0-100%)
Urethral culture
972 (32%, 0-85%)
1194 (58%, 2-98%)
Urethral microscopy
306 (10%, 0-22%)
459 (22%, 0-87%)
53 (2%, 0-10%)
84 (4%, 0-16%)
Oropharyngeal culture
60 (2%, 0-8%)
38 (2%, 0-8%)
Oropharyngeal NAAT
23 (1%, 0-6%)
3 (0.1%, 0-2%)
Rectal culture
3 (0.1%, 0-1%)
0
Rectal NAAT
6(0.2%, 0-1%)
0
0
0
Urethral NAAT
Rectal microscopy
Key points
Why do we ask fewer women than men about peno-oral sex?
Lack of documentation about receptive oral sex in MSM some regions
Should we ask ‘het men’ about receptive anal sex?
Half of female patients asked about receptive anal sex and, even
when this occurred, relatively few had rectal Gc testing. Similarly, for
receptive oral sex
Why do fewer women (still) have an HIV test?
Testing women for gonorrhoea: cervical NAAT or vulvovaginal NAAT?
44
Recommendations for improvement
• Review policies for gonorrhoea testing,
particularly in women, and re-audit
interventions aimed at improving uptake of
testing
• Consensus on sexual history taking questions,
reflected in training
• Consensus on anatomical site for NAAT
testing, reflected in training
45
Acknowledgements: BASHH Regional
Audit Chairs & Members
Chair Hugo McClean
Vice Chair Chris Carne
Hon Sec Ann Sullivan
Director of Development Anatole MenonJohansson
BCCG Representative Phil Kell
BHIVA Representative Alison Rodger, Ed
Wilkins
Scotland Daniel Clutterbuck
Wales Helen Baley, Sarah McAndrew,
Carys Knapper
Northern Ireland Say Quah
Anglia Raouf Moussa
Cheshire & Mersey Ravindra Gokhale
Essex Gail Crowe
North Thames Ann Sullivan, Alan Smith
Northern Sarup Tayal
North-West Ashish Sukthankar
Oxford Gill Wildman
South East Thames Cindy Sethi
South-West Zoe Warwick
South-West Thames Steven Estreich
Trent Jyoti Dhar
Wessex Neelam Radja, Leela Sanmani
West Midlands Sashi Acharya
Yorkshire Amy Tobin-Mammen
Co-opted Members David Daniels, Nicola
Low, Lindsay Emmett
Hilary Curtis for questionnaire design, collection, collation of data, user
support and production of regional & national aggregates