Recommendations on Screening for Chlamydia trachomatis and Neisseria gonorrhoeae for non-pregnant adults/adolescents

Preamble

The National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI) is an External Advisory Body that provides the Public Health Agency of Canada (PHAC) with ongoing scientific and public health advice and recommendations for the development of sexually transmitted and blood-borne infections (STBBI) guidance, in support of its mandate to prevent and control infectious diseases in Canada.

PHAC acknowledges that the advice and recommendations in this statement are based upon the best available scientific knowledge/evidence at the time of writing and is disseminating this document for information purposes to primary care providers and public health professionals. The NAC-STBBI statement may also assist policy makers or serve as the basis for adaptation by other guideline developers. The NAC-STBBI members and liaison members conduct themselves within the context of PHAC’s Policy on Conflict of Interest, including yearly declaration of interests and affiliations.

The recommendations in this statement do not supersede any provincial/territorial legislative, regulatory, policy and practice requirements or professional guidelines that govern the practice of health professionals in their respective jurisdictions, whose recommendations may differ due to local epidemiology or context. The recommendations in this statement may not reflect all the situations arising in professional practice and are not intended as a substitute for clinical judgment in consideration of individual circumstances and available resources.

Executive summary

Background

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are two of the most frequently reported bacterial sexually transmitted infections (STI ) in Canada, with rates increasing steadily over the last decade. In 2021, CT infections had an estimated rate of 273.2 cases per 100,000 population, which was highest among females 15 to 29 years old, and males 20 to 29 years old. NG infections had a reported rate of 84.2 cases per 100,000 population of which rates were highest among females 15 to 29 years old and males 20 to 39 years old. Given the high rates of asymptomatic infection, the increasing rates of CT and NG infections are more difficult to control. When not treated, CT and NG infections can lead to serious complications beyond the impact of the infection itself.

Rationale for the guidelines

In 2021, the Canadian Task Force on Preventive Health Care (CTFPHC) updated their CT/NG screening recommendations for adults and adolescents. This, along with the sustained high CT and NG infection rates, provided an opportunity for the NAC-STBBI and PHAC to review and adopt, or adapt as appropriate, the new CTFPHC recommendation.   

Objectives

The objectives of this work are:

• to assess new evidence for CT and NG screening in non-pregnant, sexually active individuals
• to update, as required, the existing CT and NG screening recommendations while considering the following recommendations from the CTFPHC:
  • increasing the screening age from <25 years to <30 years, regardless of the presence of risk factors for infection other than age;
  • using an opportunistic approach to screening

Methods

A working group comprised of NAC-STBBI members was formed to undertake this work. The guideline was developed following the methods outlined in the 2014 WHO handbook for STI experts, clinicians, researchers, and program managers. The GRADE-ADOLOPMENT method was applied in addition to the GRADE (the Grading of Recommendations, Assessment, Development, and Evaluations) methodology to determine the certainty of evidence and strength of the recommendations. Using the ECRI TRUST (Transparency and Rigor Using Standards of Trustworthiness) as an indicator of trustworthiness, the CTFPCH guideline obtained a score of “5” on all assessed domains, indicating the highest adherence to the National Academy of Medicine (NAM) Standards for Trustworthy Guidelines. Following a review of the key questions from the original systematic review, the key questions were approved with some modifications to the PICO (population, intervention, comparator, outcomes) elements, and consequently, the eligibility criteria for our guideline question “should any screening vs. no screening/ usual care/ any other screening be used for non-pregnant people?” was amended. The population eligibility criterion was expanded to include sexually active individuals less than 30 years and opportunistic screening was added as an intervention of interest. The updated search was conducted with the date range of October 1, 2019, to May 19, 2023, using the same search criteria as the CTFPCC systematic review. The studies included in the original systematic review were also screened against the new eligibility criteria. Furthermore, an environmental scan was performed and found 17 guidelines on CT and NG screening published between 2015 and 2023; of those 9 were international and 8 were Canadian. The Appraisal of Guidelines Research and Evaluation (AGREE) II instrument was used to evaluate the methodological quality of the identified guidelines. As well, PROGRESS-Plus (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status and Social capital - personal characteristics associated with discrimination features of relationships and time-dependent relationships) equity factors were identified in the guidelines to assess the range of social determinants and factors that contribute to health equity.

Conflicts of interest were managed according to PHAC guidelines. At the beginning of each NAC-STBBI WG meeting, the members disclosed their interests, if any. After analysing each declaration of interest, it was concluded that no conflicts were identified by the working group and NAC-STBBI members that would prevent them from participating in the discussion and voting on the committee’s recommendations.

Summary recommendations

This statement provides three screening recommendations for non-pregnant adults and adolescents. Screening is a process aimed at detecting a condition in an asymptomatic person. CT and NG screening recommendations are aimed at non-pregnant adults and adolescents, for adults and adolescents with multiple partners or a new partner, and for high prevalence groups and communities. Table 1 shows the summarized recommendations.

Table 1: Recommendations