title: Self-Collected versus Clinician-Collected Sampling for Chlamydia and Gonorrhea Screening: A Systemic Review and Meta-Analysis.
abstract: BACKGROUND
  The increases in STI rates since the late 1990s in Canada have occurred despite widespread primary care and targeted public health programs and in the setting of universal health care. More innovative interventions are required that would eliminate barriers to STI testing such as internet-based or mail-in home and community service testing for patients that are hard to reach, who refuse to go for clinician-based testing, or who decline an examination. Jurisdictions such as New Zealand and some American states currently use self-collected sampling, but without the required evidence to determine whether self-collected specimens are as accurate as clinician-collected specimens in terms of chlamydia and gonorrhea diagnostic accuracy. The objective of the review is to compare self-collected vaginal, urine, pharyngeal and rectal samples to our reference standard - clinician-collected cervical, urethral, pharyngeal and rectal sampling techniques to identify a positive specimen using nucleic acid amplification test assays.
  
  
  METHODS
  The hierarchical summary receiver operating characteristic and the fixed effect models were used to assess the accuracy of comparable specimens that were collected by patients compared to clinicians. Sensitivity and specificity estimates with 95% confidence intervals (CI) were reported as our main outcome measures.
  
  
  RESULTS
  We included 21 studies based on over 6100 paired samples. Fourteen included studies examined chlamydia only, 6 compared both gonorrhea and chlamydia separately in the same study, and one examined gonorrhea. The six chlamydia studies comparing self-collection by vaginal swab to a clinician-collected cervical swab had the highest sensitivity (92%, 95% CI 87-95) and specificity (98%, 95% CI 97-99), compared to other specimen-types (urine/urethra or urine/cervix). Six studies compared urine self-samples to urethra clinician-collected samples in males and produced a sensitivity of 88% (95% CI 83-93) and a specificity of 99% (95% CI 0.94-0.99). Taking into account that urine samples may be less sensitive than cervical samples, eight chlamydia studies that compared urine self-collected verses clinician-collected cervical samples had a sensitivity of 87% (95% CI 81-91) and high specificity of 99% (95% CI 0.98-1.00). For gonorrhea testing, self-collected urine samples compared to clinician-collected urethra samples in males produced a sensitivity of 92% (95% CI 83-97) and specificity of 99% (95% CI 0.98-1.00).
  
  
  CONCLUSIONS
  The sensitivity and specificity of vaginal self-collected swabs compared to swabs collected by clinicians supports the use of vaginal swab as the recommended specimen of choice in home-based screening for chlamydia and gonorrhea. Urine samples for gonorrhea collected by men had comparably high sensitivity and specificity, so could be recommended as they can be left at room temperature for several days, allowing for the possibility of mail-in home-based testing. In populations that may not go for testing at all, do not have the option of clinical testing, or who refuse a clinical examination, self-collected screening would be a good alternative. We recommend that guidelines on how to self-collect gonorrhea and chlamydia urine, vaginal, rectal and pharyngeal specimens be published.
authors.affiliation: Division of STI/HIV Prevention and Control, BC Centre for Disease Control, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada; Australasian Cochrane Centre, Monash University, Melbourne, Australia.
authors.forename: Carole
authors.initials: C
authors.lastname: Lunny
authors.affiliation: Division of STI/HIV Prevention and Control, BC Centre for Disease Control, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Darlene
authors.initials: D
authors.lastname: Taylor
authors.affiliation: Division of STI/HIV Prevention and Control, BC Centre for Disease Control, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada; BC Public Health Microbiology and Reference Laboratory, Vancouver, British Columbia, Canada.
authors.forename: Linda
authors.initials: L
authors.lastname: Hoang
authors.affiliation: Public Health Agency of Canada, Ottawa, Ontario, Canada.
authors.forename: Tom
authors.initials: T
authors.lastname: Wong
authors.affiliation: Division of STI/HIV Prevention and Control, BC Centre for Disease Control, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Mark
authors.initials: M
authors.lastname: Gilbert
authors.affiliation: Division of STI/HIV Prevention and Control, BC Centre for Disease Control, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Richard
authors.initials: R
authors.lastname: Lester
authors.affiliation: Division of STI/HIV Prevention and Control, BC Centre for Disease Control, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada; BC Public Health Microbiology and Reference Laboratory, Vancouver, British Columbia, Canada.
authors.forename: Mel
authors.initials: M
authors.lastname: Krajden
authors.affiliation: Division of STI/HIV Prevention and Control, BC Centre for Disease Control, Vancouver, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Gina
authors.initials: G
authors.lastname: Ogilvie
mesh_terms: D002690:Chlamydia Infections / Q000175:diagnosis*; D006069:Gonorrhea / Q000175:diagnosis*; D006801:Humans; D008297:Male; D012680:Sensitivity and Specificity; D013048:Specimen Handling