Journal club

Presenter: Dr Atreyo Chakraborty

Moderator: Dr Riti Bhatia
• Microscopic examination of gram stained
smears for anogenital gonorrhoea in men
who have sex with men is Cost effective:
Evidence from a modelling study
• Jollin M Zwart, Marrie-Josee J Mangen,
menne bartelsman, Martin S van Roojen,
Henry J C de Vries, Maria Xirdou. Sex
Transm Infect 2019; 95:13-20
• Gonorrhoea is a sexually transmitted
infection that causes serious mobidity
• Detected by gram staining, NAAT, culture
etc
• Many of these methods are costly
 Aim
• To assess the cost effective of Gram
Stained Smear (GSS) for detecting
anogenital gonorrhoe
 Study Rational
• NAAT as well as culture takes a long time
• Patients may be lost to follow up
• GSS offers immediate results- can be
used to treat patients instantly.
• However, its use in MSM gonorrhoea is
unvalidated still.
 Methodology
• Symptomatic men in clinic

GSS + NAAT done. Samples taken for Culture

Presumtive t/t based on GSS given awaiting

NAAT results

Analysis done in 3 models

 3 Testing Stategies
• 3 testing stategies:
A. Symptomatic MSM  GSS + NAAT.
Asymotomatic: Only NAAT

B. No GSS: Only NAAT for all

C. GSS + NAAT for both symptomatic and
A symptomatic
 Models
• The 3 tesing strategies are tested on
different models:
A. Transmission model
B. Economic model
 Transmission Model
• Assumes infected MSM
• 5 states of gonorrhoes defined:
A. Symptomatic Untested
B. Asymtomatic untested
C. Tested but untreated symptomatic
D. Tested but untreated asymptomatic
E. Untreated asymptomatic
 Parameters of the model
• 145 parameters used to calibrate the study
• Expected positivity rate in this model: 5.9
to 7.3%
• Closely mimics gonorrhoea positivity rate
of 6.6% among MSM
 Economic Model
• Developed using MS Excel and Risk v7.5
• Uses annual health expeniture of 10 states
in the US as input during the last 10 years
• Compared with Disease consequences of
untreated gonococcus infection as
outcome
• QALY is the output of this model
 QALY
• Quality adjusted Life Year
• 0 to 1
• 0 means death
• 1 means perfect health
• Metric scores from 0 to 1 based on
outcome
Cost Effectiveness calculation
 Results
• 6111 MSM tested positive for Gonorrhoea
among 73616 cases.
• Follow up revealed 10 MSM developed
epididymitis
• 18 QALY lost
• Euro 2.5 billion health care cost of single
infection
 Abandoning GSS in symptomatics
• 1899 additional tests
• 63 overtreated MSM
• 478 MSM lost to follow up
• 72 additional QALY lost
• Additional Euro 7000 costs
• Negative incremental cost in 57%
iterations
 Adding GSS for all
• Instead of ONLY symptomatics, all MSM
GSS done (from Urine)
• 195 less tests resulted
• 257 less over treated gonorrohoea
• But 80 overtreated cases
• 0.8 prevented epididymitis cases
• 1.1 QALY gained
Results-At a glance
 Figures say it all!
• 99.7% cases in North East of the figure (It
means, GSS for all is more cost effective)
and 0.3% cases in North West (GSS is not
cost effectve)
QALY gained due to GSS
 Conclusion
• GSS should be offered to all MSM no
matter whether they are symptomatic or
not
• It results in additional 1.1 QALY gained
and lower 61,000 Euros gained per annum
 Critical Appraisal
• Extremely well designed
analysis
• Graphical
• Efforts made to avoid
“Lost to follow up”
• Costs of latest 10 year
health based information
from 10 states in US
included
• Other high risk behaviour
included
• Large population size
• Poor selection criteria.
Symptomatic means
what?
• Ethical issues
• How GSS changes with
partially treated cases?
No information
• How they got hold of
MSM? It’s an iceberg
population
• No information in whether
treatment results in
decline of GSS scores
• How Exactly was
GSS done? Who
interpreted the slides?
• No information on use
of GSS for special
group MSM- like
Coexistent HIV
• Too much technical
jargons
• THANK YOU