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Press releases Saturday 31 March 2007

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(1) Opportunistic chlamydia screening ±not underpinned by sound evidence±

(2) Controlling C difficile in the community could cut infection rates in hospitals

(3) Row over study puts Korea±s scientific community under scrutiny again

(4) New standards could cut number of malnourished children on feeding programmes

(1) Opportunistic chlamydia screening ±not underpinned by sound evidence±
(Chlamydia screening programmes: when will we ever learn?)
http://www.bmj.com/cgi/content/full/334/7596/725
(Editorial: Screening for Chlamydia trachomatis)
http://www.bmj.com/cgi/content/full/334/7596/703

The value of opportunistic chlamydia screening is called into question in this week±s BMJ.

Dr Nicola Low, an epidemiologist at the University of Berne in Switzerland argues that claims about screening are not supported by rigorous research or practice.

And she shows how uncritical acceptance of the effectiveness of chlamydia screening in Sweden and the United States led to the funding of the National Chlamydia Screening Programme in England, before the balance of benefits and harms was understood.

Chlamydia trachomatis is a common, curable, easily diagnosed, sexually transmitted infection that usually causes no symptoms. It can, however, cause devastating complications, including infertility, ectopic pregnancy, neonatal infection, and facilitation of HIV transmission.

There are two types of screening programme ± proactive and opportunistic. Proactive screening uses population registers to invite people to be screened at regular intervals, while opportunistic screening targets people attending health services for unrelated reasons.

Chlamydia screening of selected groups is currently recommended in a range of health care settings in Sweden, the United States and Canada. In England, a programme offering opportunistic chlamydia screening to all sexually active women and men under 25 years is due to be implemented by 2008. Yet no randomised controlled trial has shown that this type of screening programme reduces long term illness.

Furthermore, most studies showing that chlamydia screening is cost effective do not satisfy accepted quality criteria for economic evaluations, says the author. They also tend to overestimate the cost effectiveness of chlamydia screening. Introducing a chlamydia screening programme is therefore likely to be an expensive intervention.

In Sweden, decreases in rates of chlamydia and its complications occurred at the same time as both widespread chlamydia testing and national HIV prevention efforts were introduced. This trend was widely attributed to opportunistic chlamydia screening. This has led to uncritical acceptance of the effectiveness of chlamydia screening, which still persists, despite increasing rates of diagnosed chlamydia since 1995, writes Low. In the US, screening has also been credited with decreases in rates of infection.

Belief in the success of opportunistic screening persists, despite an absence of evidence of effectiveness and increasing rates of chlamydia in countries that are assumed to have such programmes. Unsubstantiated belief also seems to have allowed the requirements of the National Screening Committee and the experience of other UK screening programmes to be over-ridden, she adds.

She believes that an agreed definition of a screening programme is needed, and that the same standards should be applied to all diseases for which screening is in place, or is being considered. Countries implementing or contemplating national chlamydia screening should conduct research to determine if such screening programmes do more good than harm at reasonable cost, she concludes.

±Despite multiple campaigns in the media, the diagnosis of sexually transmitted infections continues to increase,± write two senior doctors in an accompanying editorial. ±Most people who are affected are unlikely to seek sexual health testing and may only be assessed via a proactive approach rather than the opportunistic screening programme currently offered.±

Contacts:
Nicola Low, Reader in Epidemiology and Public Health, Department of Social and Preventive Medicine, University of Berne, Switzerland
Email: low@ispm.unibe.ch

Editorial: Rachael Jones, Consultant Physician, Department of HIV/Genitourinary Medicine, St Stephen±s Centre, Chelsea and Westminster NHS Foundation Trust, London, UK
Email: Rachael.jones@chelwest.nhs.uk

(2) Controlling C difficile in the community could cut infection rates in hospitals
(Editorial: Hospital acquired infection)
http://www.bmj.com/cgi/content/full/334/7596/708

Screening people for Clostridium difficile before they are admitted to hospital may be one way to help control rising rates of infection, says a doctor in today±s BMJ.

Recent data published by the Health Protection Agency (HPA) show that each year in England around 7,000 inpatients have MRSA infections and more than 50,000 inpatients aged 65 years and over have C difficile infections. Cases of C difficile rose by 5.5% in 2006, whereas MRSA cases fell by 4.3% over a similar period. And numbers are likely to continue rising because the population is ageing and the elderly are the most at risk, warns Dr John Starr.

One factor that may be driving infection rates is the community reservoir, he says.

He suggests one way to control C difficile would be to screen people before they are admitted electively to hospital to see if they carry the bacterium. Approximately 5% of the population carry C difficile without any ill effects. He says the percentage of carriers could be substantially higher in people connected with hospitals and this in turn could lead to infections being acquired in the community. This could be one reason, he argues, for the growing rate of infection. He points out that the relative increase in community acquired C difficile is far outstripping that seen in hospitals.

Thirteen thousand people become infected in the community every year, of those three quarters have not been to hospital in the previous 12 months, he adds. This raises the question of whether C difficile can still be thought of as purely a hospital acquired infection and, if not, whether other infection control measures are needed.

It is important to consider whether a C difficile infection control policy solely focused on hospitals remains appropriate, he concludes.

Contact:
Please note, Dr Starr is on holiday. A colleague will take calls on his behalf. Email: edickinson@bmj.com

(3) Row over study puts Korea±s scientific community under scrutiny again
(Duplicate publication: a bitter dispute)
http://www.bmj.com/cgi/content/full/334/7596/717

This week±s BMJ investigates a bitter row over a scientific paper that is putting Korea±s scientific community under scrutiny once again.

The dispute has pitted a young Korean doctor, Jeong Hwan Kim, against Kwang Yul Cha, a fertility specialist and one of the most powerful players in the country±s struggle for biotech supremacy, writes journalist Jonathan Gornall. It is also threatening to disrupt Korea±s efforts to recover scientific credibility in the wake of the recent scandal over Woo-Sok Hwang±s stem cell research.

Dr Kim claims a paper about premature ovarian failure that he originally published in the Korean Journal of Obstetrics and Gynaecology in January 2004 was translated and republished in the American journal Fertility and Sterility under a different title and with different authors in December 2005.

What is indisputable is that Dr Kim±s name was not present in the later version of the paper and that in his place as lead author was Dr Cha, his former employer and the head of CHA Health Systems, a ±global healthcare enterprise± whose interests include the CHA Stem Cell Institute and several hospitals and clinics in Korea and the US.

But the BMJ has learnt that the editor in chief of Fertility and Sterility has been threatened with legal action by Dr Cha, and that one of Dr Cha±s co-authors on the disputed paper, Dr Sook Hwan Lee, has been charged with criminal copyright infringement.

Dr Kim told the BMJ that the paper had begun life as his PhD thesis and that there were just two names on it when it was published by Korea University in May 2003. He then submitted this as a paper to the Korean Journal of Obstetrics and Gynaecology in July 2003 with five additional names, including Sook Hwan Lee.

But his surprise turned to shock when, in December 2005, he saw a similar paper in Fertility and Sterility. He was even more shocked to see that the number of authors had reduced to six and that he was no longer one of them. The lead author was Dr Cha.

In December last year, Dr Kim filed a lawsuit in Korea against Dr Cha and Dr Lee, alleging breach of copyright. Dr Lee responded by alleging that Dr Kim had defamed her. The CHA group also claims that Dr Kim stole the data used in the study.

In February, the co-director of the CHA Stem Cell Institute, Professor Kwang Soo Kim, wrote to Fertility and Sterility to express regret about the incident. He explained how ±our institution will serve a pivotal role in restoring the severely damaged reputation and credibility of stem cell and life science research in Korea after the Hwang scandal.±

Professor Kim±s intervention leaves little doubt about how seriously the CHA group views the potential of the incident to damage its bid to inherit Hwang±s crown, says Gornall. Before his fall from grace, Professor Hwang received the bulk of Korean government funding in stem cell research. But, in November last year, CHA Medical Group announced its plans to succeed Professor Hwang±s now defunct World Stem Cell Hub by building Korea±s largest stem cell institute on land provided by the Korean government.±

Contact:
Jonathan Gornall, freelance journalist, London, UK
Email: Jgornall@mac.com

(4) New standards could cut number of malnourished children on feeding programmes
(Operational implications of using 2006 World Health Organisation growth standards in nutrition programmes: secondary data analysis)
http://www.bmj.com/cgi/content/full/334/7596/733

(Editorial: The 2006 WHO child growth standards)
http://www.bmj.com/cgi/content/full/334/7596/705

It is time to close the gap between public discussion and political practice in New Labour±s NHS, says a doctor in this week±s BMJ.

The introduction of new standards to assess nutrition in children could lead to confusion and a cut in the numbers of malnourished children eligible for emergency feeding programmes, warn researchers in this week±s BMJ.

According to the UN World Food Programme, the number of nutritional emergencies has risen over the last twenty years, from an average of 15 per year during the 1980s to more than 30 per year since 2000. In 2005, around 73 million people were supplied with food aid.

The new World Health Organisation standards were released in April 2006 and are being advocated as a replacement for the currently used growth reference curves, produced by the National Centre for Health Statistics (NCHS) and WHO in 1978.

But research from Andrew Seal and Marko Kerac at University College London and the College of Medicine, Malawi, found that, whilst the new standards would increase the number of children identified as malnourished, it could also result in fewer children being admitted to feeding programmes.

The reason for this is the way nutritional status is calculated. It can be expressed by using either z scores or the percentage of the median. Most aid agencies use the median method to determine a child±s eligibility for admission on to a therapeutic feeding programme although the z score method is also used infrequently for this purpose.

The research team used both methods and found marked differences between the cut-offs used for defining severe acute malnutrition from the WHO standards and NCHS reference data.

Under the z score calculation, children were more likely to be diagnosed as severely malnourished, but under the median method calculation, children were less likely to be diagnosed as malnourished. This means that fewer children would be eligible for therapeutic feeding programmes and those already on programmes would be discharged sooner than at present.

A similar pattern emerged in the diagnosis of severe and moderate malnutrition.

The authors say the potential impact on mortality rates of the inappropriate use of the WHO Growth standards is, as yet, unknown. They suggest that a full assessment of the appropriate use of the new WHO standards is urgently required and should be completed before they are implemented by aid agencies running emergency nutrition programmes.

Contacts:
Andrew Seal, Lecturer in International Nutrition, Centre for International Health and Development, Institute of Child Health, University College London, UK
Email: a.seal@ich.ucl.ac.uk

Editorial: Martin Bloem, Chief of Nutrition, World Food Program, Rome, Italy
Email: martin.bloem@wfp.org

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