This document summarizes information about chlamydia control policies in Europe. It notes that in 2014, there were 396,128 reported chlamydia cases in Europe, most among 15-24 year olds. Control activities vary by country, from case management to opportunistic testing to organized screening programs. Chlamydia prevalence is estimated to be highest in Denmark, Netherlands, and UK. ECDC guidance recommends national control strategies including prevention, testing guidelines, surveillance, and monitoring. Main challenges to control include asymptomatic infections, participation barriers, limited implementation, and evidence gaps.

1. Control policies for chlamydia among
young adults in Europe
Otilia Mardh, ECDC
30th IUSTI-Europe Conference September 15-17, 2016 Budapest
ECDC SYMPOSIUM: STI CONTROL AT A EUROPEAN LEVEL FOCUS ON YOUNG PEOPLE

2. Overview
• Chlamydia among young Europeans
• Control activities in EU/EEA Member States
• ECDC Guidance 2015
• Challenges to chlamydia control

3. N= 396 128 reported cases (from 26/31 MS)
M: F 0.7
Age: 63% of cases among 15-24 year-olds
Highest rate (1.1%) among 20-24 year-old women!
Chlamydia in EU/EEA, 2014
EU/EEA rate 187/100 000, range 0.0- 549
83% cases DK, NO, SE, UK
Age- and gender-specific rates of reported cases per 100 000, 2014
Source: ECDC STI Surveillance report 2015
Notification rates (confirmed cases) per 100 000, 2014
Source: ECDC Surveillance Atlas http://ecdc.europa.eu/en/data-tools/atlas/Pages/atlas.aspx,
Rates not calculated-
either sentinel
surveillance or data
not reported

4. Trends of chlamydia among young women in six*
EU/EEA countries, 2006-2014
*countries with national notification rates above the EU/EEA rate in 2014 and consistent reporting
Source: The European Surveillance System (TESSy)
1000
1500
2000
2500
3000
3500
4000
4500
5000
5500
2006 2007 2008 2009 2010 2011 2012 2013 2014
Casesper100000population
15-19 year-old women
Finland Sweden United Kingdom
Norway Iceland Denmark
EU/EEA
rate 1246
1000
1500
2000
2500
3000
3500
4000
4500
5000
5500
2006 2007 2008 2009 2010 2011 2012 2013 2014
20-24 year-old-women
Finland Sweden United Kingdom
Norway Iceland Denmark
EU/EEA rate
1405

5. Trends of chlamydia among young men in six* EU/EEA
countries, 2006-2014
300
800
1300
1800
2300
2800
3300
2006 2007 2008 2009 2010 2011 2012 2013 2014
Casesper100000population
15-19 year-old men
Finland Norway United Kingdom
Sweden Iceland Denmark
300
800
1300
1800
2300
2800
3300
2006 2007 2008 2009 2010 2011 2012 2013 2014
20-24 year-old men
Finland Norway United Kingdom
Sweden Iceland Denmark
*countries with national notification rates above the EU/EEA rate in 2014 and consistent reporting
Source: the European Surveillance System (TESSy)
EU/EEA
rate 367
EU/EEA
rate 824

6. Factors driving chlamydia notification rates?
Rates of diagnoses by level of chlamydia control
Source: Chlamydia Control in Europe: a survey of Member States (2012) , TESSY for surveillance data
Percentage of chlamydia tests analysed using NAAT
>90% in 17/28 countries, <50% in 4/28 countries

7. Chlamydia prevalence estimates among ≤26 years women,
high-income countries
NOTE: Weights are from random effects analysis
.
.
.
.
National population, overall
Germany
Germany
Germany
Netherlands
Netherlands
Slovenia
USA
USA (2007-2008)
Subtotal (I-squared = 75.9%, p = 0.000)
Sub-national population, overall
Denmark
Netherlands
Sweden
United Kingdom
United Kingdom
Subtotal (I-squared = 81.1%, p = 0.000)
National population, sexually experienced
France
Germany
Slovenia
United Kingdom
Croatia
USA
Subtotal (I-squared = 0.0%, p = 0.580)
Sub-national population, sexually experienced
Denmark
Denmark
Denmark
Netherlands
Netherlands
Norway
Spain
United Kingdom
USA
USA
Australia
New Zealand
Subtotal (I-squared = 77.3%, p = 0.000)
Country
Haar/KIGGS
Haar/DEGS
Haar/DEGS
van Bergen
van Bergen
Klavs
Miller
Datta
Munk
van Valkengoed
Jonsson
Low
Bracebridge
Goulet
Haar/KIGGS
Klavs
Fenton
Bozicevic
Miller
Ostergaard
Andersen/kit
Andersen/postal
van den Broek
van den Broek
Klovstad
Franceschi
Stephenson
Klausner
Klausner
Hocking
Corwin
Author
2012
2012
2012
2005
2005
2004
2004
2012
1999
2000
1995
2007
2012
2010
2012
2004
2001
2011
2004
1998
2002
2002
2012
2012
2012
2007
2000
2001
2001
2006
2002
Year
2.11 (1.36, 3.13)
4.50 (1.60, 12.10)
2.00 (0.50, 7.40)
2.60 (1.70, 3.40)
1.90 (1.20, 2.70)
4.10 (2.20, 7.40)
4.74 (3.93, 5.71)
3.80 (2.40, 6.00)
3.05 (2.09, 4.01)
10.70 (7.18, 15.20)
3.82 (2.51, 5.54)
2.70 (1.50, 4.40)
6.20 (4.90, 7.80)
4.40 (3.50, 5.40)
4.92 (3.33, 6.51)
3.60 (1.90, 6.80)
4.44 (2.86, 6.53)
4.70 (2.50, 8.50)
3.00 (1.70, 5.00)
5.30 (2.30, 10.20)
4.70 (3.90, 5.70)
4.32 (3.65, 4.99)
5.00 (3.61, 6.62)
6.50 (4.70, 8.65)
8.00 (5.82, 10.64)
3.90 (2.75, 5.05)
3.95 (3.35, 4.54)
5.80 (4.48, 7.50)
0.60 (0.00, 3.50)
8.00 (2.30, 20.00)
5.00 (2.80, 7.20)
2.30 (0.80, 3.70)
3.70 (1.20, 8.40)
2.30 (0.40, 4.20)
4.24 (3.25, 5.24)
in % (95% CI)
CT Prevalence
15
18
20
15
20
18
18
14
20
15
19
16
17
18
15
18
18
18
18
16
21
21
16
20
18
15
18
18
22
18
16
min
Age
17
19
24
19
24
24
26
25
24
25
25
24
25
24
17
24
24
25
26
19
23
23
19
24
25
24
25
21
25
24
19
max
2.11 (1.36, 3.13)
4.50 (1.60, 12.10)
2.00 (0.50, 7.40)
2.60 (1.70, 3.40)
1.90 (1.20, 2.70)
4.10 (2.20, 7.40)
4.74 (3.93, 5.71)
3.80 (2.40, 6.00)
3.05 (2.09, 4.01)
10.70 (7.18, 15.20)
3.82 (2.51, 5.54)
2.70 (1.50, 4.40)
6.20 (4.90, 7.80)
4.40 (3.50, 5.40)
4.92 (3.33, 6.51)
3.60 (1.90, 6.80)
4.44 (2.86, 6.53)
4.70 (2.50, 8.50)
3.00 (1.70, 5.00)
5.30 (2.30, 10.20)
4.70 (3.90, 5.70)
4.32 (3.65, 4.99)
5.00 (3.61, 6.62)
6.50 (4.70, 8.65)
8.00 (5.82, 10.64)
3.90 (2.75, 5.05)
3.95 (3.35, 4.54)
5.80 (4.48, 7.50)
0.60 (0.00, 3.50)
8.00 (2.30, 20.00)
5.00 (2.80, 7.20)
2.30 (0.80, 3.70)
3.70 (1.20, 8.40)
2.30 (0.40, 4.20)
4.24 (3.25, 5.24)
in % (95% CI)
CT Prevalence
15
18
20
15
20
18
18
14
20
15
19
16
17
18
15
18
18
18
18
16
21
21
16
20
18
15
18
18
22
18
16
min
Age
Chlamydia prevalence, % (95% CI)
00 5 10 15
Source: ECDC. Chlamydia control in Europe - literature review; 2014; Redmond S et al. PlosOne; 2014
≤26 years men

8. Chlamydia control policies in 28 EU/EEA countries,
2012
No organised
chlamydia
control
activities,
(6/28);…
Case
management
(3/28);
10%
Case finding*
(5/28);
23%
Opportunistic
testing of
selected groups
of asymptomatic
individuals**
(13/28);
43%
Organised chlamydia
screening programme
(1/28).
4%
Source: ECDC technical report on Chlamydia control in Europe, a 2012 survey
* case management AND partner notification
** includes case management AND partner notification

9. Population groups targeted for primary prevention
activities, EU/EEA
Includes data reported from 22 countries: Belgium, Bulgaria, Cyprus, Denmark, Estonia,
Finland, France, Germany, Iceland, Ireland, Italy, Latvia, Lithuania, Malta, Netherlands,
Norway, Portugal, Slovakia, Slovenia, Spain, Sweden, UK
Primary prevention strategies for STI/Chlamydia, EU/EEA 2012
Source: ECDC technical report on Chlamydia control in Europe, a 2012 survey
Availability of primary
prevention strategies
No. of
countries
(N=27)
Country has a strategy 12
Other national strategy includes
primary prevention activities
3
Not currently, but a strategy in
preparation
10
No strategy for primary prevention 2
“A single diagnose of chlamydia increase the risk of
all complications. Control programmes must prevent
first and repeat infections to improve women’s
reproductive health”. Davies et al. Lancet. 2016

10. Clinical services reporting chlamydia in 2014
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
STI and sexual health clinics* Outpatient clinic** Primary care Other Unknown
*STI and sex health clinics includes: family planning, dermatology-venereology, dedicated STI clinic, youth clinics
**Outpatient clinics include: hospital emergency departments, gynaecology, Infectious disease, urology
Source: the European Surveillance System (TESSy)
• Variations across and within
countries
• Important for case-management
guidelines adapted to healthcare
provider

11. ECDC Chlamydia Guidance 2015
Recommendations
• A national strategy or plan for STI control
• Primary prevention activities
• Evidence-based case management guidelines that
address criteria for testing, diagnostic method,
treatment, partner notification and reporting of cases
• Surveillance of diagnosed chlamydia cases
• Monitoring and evaluation
Widespread testing (<25 y/o) recommended if resources
allow and monitoring and evaluation in place
Minimum level of prevention and control should include
A national
strategy or
plan for STI
control
Primary
prevention
activities
Evidence-
based case
managemen
t guidelines
Surveillance
of
diagnosed
chlamydia
cases
Monitoring
and
evaluation
Source: ECDC Chlamydia control in Europe Guidance 2015
See ECDC report. Chlamydia control in Europe - literature review; 2014 for assessment of effectiveness of control strategies

12. Main challenges to chlamydia control and their effects
• Ongoing transmission
Asymptomatic infections
No lasting immunity
No vaccine
• Reduced participation
• Limited implementation
Societal influences
e.g. stigma, poorly-resourced populations,
availability of public-health funding
• Design of control interventions
• Clinical and cost-effectiveness
measurements (M&E)
Gaps in evidence-base
e.g. disease burden, risk of progression to
complications and attributable fraction
Source: ECDC Chlamydia control in Europe Guidance 2015

13. Thank you!
Acknowledgements
• Chlamydia Control in Europe project team
• ECDC collaborators: EU/EEA STI surveillance network