THIS ARTICLE IS PART OF a series examining the case for screening males for chlamydia in the United States. Whenever the issue of screening is raised, the issue of partner management should follow. Partner notification (PN) is the process of notifying and bringing to treatment the sex partners of a person infected with a sexually transmitted disease (STD). There are essentially 3 types of PN: public health-mediated, patient-based referral, and contract referral, which is a combination of the first 2 methods. The notification and bringing to treatment of sex partners of persons infected with an STD or infection has been a fundamental principle of US infection control since at least the 1930s.1 PN was first introduced to combat syphilis and was later applied to human immunodeficiency virus.
When resources are available, public health departments have sometimes applied public health-mediated PN to STDs such as gonorrhea and chlamydia, but the large number of cases of these STDs make PN for the management of sex partner impractical. An earlier discussion of PN for gonorrhea has been presented,2 but a separate discussion of this method for chlamydia is warranted because both the epidemiology and magnitude of the diseases differ. Chlamydia is the most common bacterial STD reported in the United States; many persons who are infected are asymptomatic, and the populations at most risk are adolescents and young adults. These issues pose unique challenges to PN for this infection.
In this article, we review the reasons for conducting STD PN and summarize the major strategies. We then examine the effectiveness of relevant strategies, reviewing literature published between 1997 and 2007 and focusing on the female partners of chlamydia-infected men as a target group. In the course of the review, the reader will see that public health-mediated PN, the strategy with the best evidence of effectiveness in bringing in partners for treatment, is applicable to chlamydial infection, but largely infeasible because of lack of resources. This issue is especially salient considering significant chlamydial prevalence outside public settings, as shown elsewhere in this issue.3 For that reason, more emphasis is placed on evaluating the effectiveness of patient-based referral strategies, with some additional discussion of evidence supporting the role of network analyses in infection control.
PN Rationale and Strategies
Because reviews of PN are both recent and extensive,4–9 we will be brief. Through PN, public health is served by accessing a population likely to have an elevated rate of chlamydial infection8 and therefore suitable for testing and treatment (presumptive or otherwise). Notification and bringing partners to treatment is also a tool for identifying exposed persons' needs and requirements, for assessing comorbid infection, for conducting educational and risk counseling intervention, and for connecting those who are infected to proper care. PN of persons exposed to chlamydia may be the only way that partners will know they are infected because most of the chlamydial cases are asymptomatic. The results of notification can also aid in establishing local epidemiology and subsequent resource allocation.
The core formal strategy, the use of public health professionals to gather identifying and locating information about sex partners of infected persons, is most widely known as public health-mediated or provider referral and is described in Centers for Disease Control and Prevention's Program Operation Guidelines and other training manuals.10,11 Those who conduct provider referral are most widely known as disease intervention specialists (DIS); they receive formal training before beginning work and often subsequent on-the-job training and refresher training. Systematic reviews of PN strategies suggest that provider referral is the most effective means of ensuring a personal evaluation of partners across STD, and that provider referral reaches patients with chlamydial infection.7–9 It is also, however, labor intensive in absolute terms as well as relative to other strategies.12
Virtually all strategies not using DIS rely on asking patients to notify their partners of their putative exposure. This is known variously as self, patient, and client referral. A combination of widespread diagnosis of chlamydia outside public settings and typically minimal public health resources available for provider referral with chlamydia has left self-referral as the most common referral strategy for chlamydial infection.13,14 One survey of 60 health departments in high-morbidity areas (any of chlamydial infection, gonorrhea, syphilis, or acquired immunodeficiency syndrome) found only 12% of index cases with chlamydial infection were even interviewed for partners.13 Analyses from a national survey of 4233 physicians in private (88%) and public (12%) settings revealed very little provider referral for any STD (<6% collected any partner information, let alone contacted partners), although giving patients self-referral instructions was common (>85%).14 In that same survey, as in others, health care providers reported they felt little responsibility to engage in PN beyond providing basic self-referral instruction.15,16 Although estimates are not available for chlamydial provider referral, the average cost of syphilis provider referral was $405 per case detected.17 Given that there were nearly 1 million cases of chlamydia reported in 2005, compared with fewer than 10,000 primary or secondary cases of syphilis, provider referral for chlamydia is generally cost prohibitive.
On the basis of the above information, we surmise that provider referral should be used if feasible, but that it will rarely be feasible. This leaves one with self-referral (also known as patient referral), which, at least, is inexpensive and almost universally feasible as an instruction. A recent report on partner management cited several estimates of self-referral effectiveness in bringing partners in for evaluation and treatment (based around program evaluations and control conditions from trials): these ranged from 29% to 59% of all partners.18 The range of 29% to 59%, however, includes STD other than chlamydia, as well as index cases of both genders; therefore, this update for studies more specific to men with chlamydial infection is germane.
To update, we reviewed studies on PubMed using the following search terms and strategies: titles, keywords, or abstracts containing “chlamydia” and either “contact tracing” or any combination of partner, notify, and notification. (“chlamydia” also returns articles using the word “chlamydial.”) The search was limited to articles published in English, between 1997 and 2007, and including male patients or participants. This search yielded 169 articles.
As many countries have social, demographic, and cultural conditions that differ substantially from conditions in the United States, studies from most non-US countries were subsequently excluded, as were reviews, commentaries, and a large number of studies not assessing patient referral as the choice of PN for genital chlamydial infection. One study of PN for nongonococcal, nonchlamydial urethritis was retained because the instructions for index cases precisely mimicked those for confirmed chlamydial infection (Table 1).
Enough similarity in chlamydial rates and attitudes toward STD in the United Kingdom, Scandinavia, the Netherlands, and Canada, allied to substantial amounts of recent evaluation, suggested including studies in these countries while evaluating self-referral effectiveness. The patient-led referral process in the United Kingdom is more standardized and more rigorously monitored than in the United States, but those who receive patient referral are expected to perform essentially the same behaviors. The above exclusions, and others based around inability to abstract male-only index case data and corresponding partner data reduced the total number of articles with suitable data to 9.
Studies for which a percent of eligible partners of men who were notified or treated could be calculated are reported in Table 1 (the notes in Table 1 identify which estimates are based on self-report). Occasionally, only numerator data for partners treated were reported, that is, the study did not contain an estimate of total partners claimed by the male participants. Rather than eliminate those studies entirely, we calculated notification and treatment indices if data permitted. These statistics are the number of partners notified or treated divided by the number of index cases (men in the studies, i.e., the denominators, are the same for notification and treatment indices). Although these figures are not as germane to estimating the effect of patient referral in reaching partners or assuring evaluation or treatment, they do permit clear comparisons across all the studies in Table 1 and to indices commonly calculated for DIS-based referral efforts in the United States. We found other studies with relevant data that did not permit a calculation of either figure; these are summarized in the Results section. The most common reason for exclusion of these studies was inability to reliably abstract male index case data from total number of participants.
Table 1 contains 8 estimates of percent of partners notified and 10 of percent treated. These totals are drawn from 12 analyses in 9 studies (N = 1140 men) collecting data between 1986 and 2004 and published between 1997 and 2007.19–27 Two of these studies19,21 overlapped with those cited for the 29% to 59% range of treatment noted earlier.18 Estimates in the current analyses for notification ranged from 48% to 79% for partner referral, with the higher estimates mostly drawn from studies incorporating patient delivery of medications to partners (3 estimates, 65%, 76%, and 79%). Estimates for treatment ranged from 30% to 55% of partners (30%–61% if patient delivery of medications is included). Some heterogeneity in the range may be because of assessment methods, that is, confirmed or self-reported partner treatment and notification.
Across all studies for which a percent of partners notified could be calculated in Table 1, 632 men notified 558 of 806 female partners (69.2%). The composite notification index, based on 729 men, was 0.83. For evaluation or treatment, 515 of 1133 female partners (45.5%) were treated. The composite treatment index was 0.62.
From studies not reported in Table 1, of 87 men (M = 2.65 partners) enrolled in the control condition (patient referral) of a randomized, controlled trial in Brooklyn, NY, 76.1% notified all partners.28 Having a single partner and stating intentions to notify improved odds of notifying all partners (statistics were calculated across gender, but there was no gender interaction for these variables).
An observational study of GUM clinic attendees in the United Kingdom included 194 men diagnosed with chlamydial infection for whom at least 1 treated partner could be verified for 32.5%.29 In another UK study, male patients chose contact slips for most of their partners: 67.5% of contacts were seen (but no other numbers are abstractable from this study, so we do not know how many partners were reported or whether the 67.5% includes all the patients' partners in the denominator).30 A final UK study found 99 female partners evaluated from 403 male index cases, a “treatment index” of 0.24 (the patients were actually diagnosed with nongonococcal, nonchlamydial urethritis, but the notification instructions were the same as for chlamydial infection).31
An earlier Canadian study incorporating provider education reported that specific provider instructions to notify partners improved notification rates (this conclusion was based on small numbers and collapsed across gender).32 Few studies focused on negative outcomes such as relationship breakup or partner violence.
Data from several countries place most of the male notification rates between 50% and 60% and evaluation or treatment rates of known partners at close to 40% and 50%. Most of these data are based on clinic volunteers, among whom one expects to find higher rates of symptomatic cases than one would with screening. One might also expect higher rates of notification, because volunteers are more likely than those screened to suspect infection a priori. However, statistics from studies reporting screening were similar to those derived from clinic volunteers. As noted earlier, mere instruction to notify may improve self-referral rates, perhaps negating any underlying difference between referral as an outcome of screening and voluntary clinic attendance.
The populations of the studies reviewed include men with varying numbers of partners and sociodemographic characteristics, both of which fit the widespread profile of chlamydial infection in the United States. From those perspectives, results seem broadly applicable to US male screening prospects, but a number of the estimates were drawn from intervention studies with counseling and other enhancements; therefore, they may overestimate the more basic patient referral interventions typically on offer. Furthermore, these data were drawn almost exclusively from heterosexual men, so some conclusions below may be limited to the same group. Data on potential partner violence and other negative outcomes were relatively sparse: this fact does not preclude programmatic attention to these details. A general assessment of whether notification is likely to result in the index patient being the victim of violence remains warranted as it does for female index patients; providers should also pay attention to whether the male index is likely to become violent toward his partner(s). That is, with men, the persons perhaps most likely to engage in severe violence are now the persons carrying the message, not potentially receiving it.
As noted in the preceding paragraph, study conditions almost all incorporated more intensive intervention than is typically the case for US PN with men who are diagnosed with chlamydial infection.10,11 This means that, to some extent, our estimates are a mix of patient referral effectiveness as most commonly practiced and as what one might expect from intervention. Fortunately, the nature of the interventions is generally discernable from the studies, and thus, guides our subsequent discussion.
An overarching point in this discussion is that the substantial resources required for male screening, even targeted screening, suggest little point to relying upon interventions using in-person interviews and follow-up as general tactics. Instead, attention may be more profitably devoted to other aspects of self-referral visible in the studies.
Several of the studies used contact slips (referral cards) as a matter of program policy. A trial-based comparison in the data reviewed in this study revealed no reported increment in PN or treatment rates, although those randomized to receive referral cards had lower reinfection rates than those in the control arm of the study.24 A UK analysis compared a standard contact slip, which contained no infection-specific information, to a contact slip naming chlamydia as the infection. Results revealed equivalent acceptability to patients and substantially greater attendance rates by partners receiving the infection-specific contact slip: 84% (95% confidence interval, 79%–89%) versus 33% (26%–43%).33 Thus, contact slips may be useful in notification and even in prompting care-seeking, although the positive effects may be difficult to measure.
A useful addition to contact slips given to the patient could be some central location where generic referral card information is kept: hotline numbers and Websites are 2 possibilities. Electronic versions of referral cards have been used in the United States,34 although not yet evaluated, and an Australian study demonstrated that a website with material for providers to pass onto patient increased use of referral letters and brochures.35 Precise content of referral cards and variations in style would benefit from further evaluation taking into account the youthful age of many persons infected with chlamydia.
Expedited Partner Therapy
The term is a broad phrase describing the provision of therapy for partners of persons diagnosed with disease before their examination by a provider. Expedited partner therapy (EPT) methods have been tested in a variety of clinical settings, with several STD (including chlamydial infection), diagnosis conditions, and geographic variance. The Centers for Disease Control and Prevention has released guidance suggesting clinicians consider EPT for partners of men diagnosed with chlamydial infection,18 noting that this also the presence of potential structural barriers (e.g., legality). Female partners are also more likely than others to need physical examination to rule out or treat potential sequelae of chlamydial infection, such as pelvic inflammatory disease. Therefore, care is needed to ensure that EPT efforts do not reduce the chances of female partners seeking evaluation. Written materials can include the necessary educational messages, with the caveats noted earlier.
Beyond reduced reinfection, the strongest case for EPT with chlamydia-infected male index patients lies in the improved notification rates shown most clearly in the comparisons between the control (self-referral) and EPT conditions in Table 1, in which notification rises from 57% to 76%.24 If men having medication actually results in more women being notified than would be the case with self-referral alone, EPT confers an advantage. Again, efforts must be made to ensure that taking medication does not reduce overall care-seeking. The commensurate rise in self-reports of treatment (Table 1 contains the most conservative estimate of treatment) is helpful, but does not ensure care-seeking.
Linking cases, sexual and social contacts (infected and uninfected), and sociodemographic information at the individual and neighborhood level yields networks that present more immediately relevant portraits of infection patterns,36 and which can incorporate partner management. Retrospective analyses have shed light upon the course of outbreaks for gonorrhea and chlamydial infections,37,38 although this is not directly related to partner management, and at least 1 model of networks for STD infection control includes contact tracing data as a symbiotic concept.39 Programmatic resources and expertise pose substantial barriers to starting network analyses for prospective infection control, but network methods have been used successfully for a US syphilis outbreak40 and for improving the effectiveness of chlamydial screening in the Netherlands.41
Available evidence suggests provider referral is the most effective means of notifying partners and bringing them to treatment. But this method is rarely feasible for partner management of chlamydial infections because of lack of resources,13 so self-referral-based methods will have to suffice for most cases. However, if self-referral is enhanced, including with EPT and contact slips, more partners are likely to get treated. The slow uptake of enhanced methods (e.g., EPT efforts have been organized in a minority of states) is a barrier in enhancing even patient referral. It may make sense to conduct PN for certain high-risk persons, for example, repeatedly infected persons or those who seem closely embedded in networks of infection. We should also mention the rising profile of Internet-based PN. Recently published data and commentary suggest that Internet-based PN with syphilis, while not as effective as in-person notification, is sometimes the only means of notifying partners (whether the patient or provider handles the notification), and does result in some partners seeking evaluation.42–44
We have suggested minimum input from public sector in most of this discussion beyond episodic intervention (e.g., into dense networks or among repeatedly infected persons) and enabling provision of contact slips or EPT. However, concerted effort by jurisdictions to appraise the scope of PN and to focus the diagnosing provider's mind on the importance of notification is possible. In King County, WA, the case report form contains a section on PN in which the physician is given 3 choices (a) delegation to HD personnel, (b) ensuring all partners are treated, or (c) assuring all partners have already been treated. Completion of this section of the case report either enables the health department to contact patients or requires the physician to attend to some form of PN. Similar standards enable public health across Sweden to evaluate PN processes on a routine basis.45 Finally, in the United Kingdom, although PN methods vary, routine data gathering enables widespread evaluation of whether a provider or health advisor discussed PN with the patient, a recently established national standard.46 To do the above would at least allow US public health to gauge the extent of PN and various methods for chlamydial infection.
Therefore, as a first-line approach, patient-referral enhanced with either educational information or EPT is likely the most practical approach for management of sex partners of men infection with chlamydia in the United States. Public health-mediated PN can, then, be reserved for cases where patient-referral is unlikely to happen or where sexual networks are dense. Finally, public-private coordination and collaboration is essential to assure that all partners are treated.
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