Letter to the Editor
To the Editor:
We thank Drs. Schillinger and Hogben for their thoughtful editorial related to Du et al.'s paper, “Effects of Partner Notification on Reducing Gonorrhea Incidence Rate,”1,2 and encourage discussion about improving gonorrhea control programs. As with any public health intervention, continued evaluation is important for refining strategies to suit the evolving context of disease transmission. Indeed, the environment has changed over the past 20 years, largely due to the crack and AIDS epidemics, resulting in fewer named partners. This decline in partner-locating information poses both increased public health challenges and increased difficulty interpreting program evaluations.
We propose that 2 questions are important to address in studies of partner notification (PN): (1) How does PN affect the sex partners of index patients identified with gonorrhea and (2) how does PN affect the incidence of gonorrhea in the community? This second question was the focus of Du et al.'s paper. Han and colleagues found changes in PN activities for gonorrhea were related to changes in gonorrhea rates in a small area.3 Given some variation but no substantial program changes in New York State (NYS), excluding New York City, we used recommended measures4 to assess associations between the PN activities and gonorrhea rates across NYS, including temporal changes. The findings suggest that PN is correlated with reduced gonorrhea rates. Evaluations of partner treatment programs are methodologically challenged. The primary source of potential bias for ecological studies is confounding. Individual-level studies are challenging to interpret because index patients who participate are likely different than those who do not for the key measure—reaching the partner for treatment.
We appreciate this opportunity to clarify several points. In NYS, limited funding necessitated a deliberate decision to target PN on geographic core STD areas.5 Although we prefer contacting all partners, NYS' targeted PN, with the majority of index cases in STD core areas being interviewed, seems to be a useful tool for disease control. Fewer cases were interviewed in other regions of NYS. Additional evidence pointing to the effectiveness of PN is that the greatest reductions in gonorrhea rates occurred in core areas with targeted PN; more modest declines were also realized in the areas adjacent to the core. Conversely, gonorrhea rates increased gradually in many areas falling outside the core STD and adjacent areas (BSTDC, unpublished data). Although confounding cannot be completely ruled out for these findings, partial penetration of PN in the community seems to have some desired effect.
As noted by Schillinger and Hogben,1 surrounding states and NYC also have seen changes in gonorrhea rates. The neighboring states also conduct PN by health department personnel with various targeting methodologies6; NYC conducts PN for infected individuals seen in public health clinics. Thus, variations in health department initiated PN methods may produce similar outcomes—a hypothesis worthy of investigation.
We agree with recommendations that creative new methods need to be integrated into STD control programs.1,7 Additional methods to reach partners with educational information and medical care need to be evaluated and the strongest methods integrated into STD control programs.
1. Schillinger JA, Hogben M. Partner notification for gonorrhea—time for new ideas [editorial]. Sex Transm Dis 2007; 34:195–196.
2. Du P, Coles FB, Gerber T, McNutt LA. Effects of partner notification on reducing gonorrhea incidence rate. Sex Transm Dis 2007; 34:189–194.
3. Han Y, Coles FB, Muse A, Hipp S. Assessment of a geographically targeted field intervention on gonorrhea incidence in two New York State counties. Sex Transm Dis 1999; 26:296–302.
4. Centers for Disease Control and Prevention. Program operations guidelines for STD prevention. Partner services. Atlanta, Georgia: US Department of Health and Human Services. Available at: http://www.cdc.gov/std/program/partner/TOC-PGpartner.htm
. Last accessed December 20, 2005.
5. Rothenberg RB. The geography of gonorrhea: Empirical demonstration of core group transmission. Am J Epidemiol 1983; 117:688–694.
6. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance morbidity for years 1984–2003. CDC WONDER Online Database. Available at: http://wonder.cdc.gov/std.html
. Last accessed March 26, 2007.
7. Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Disease. Washington, DC: National Academy Press, 1997.