Rudy, Ellen T. PhD*; Aynalem, Getahun MD, MPH*; Cross, John BA†; Ramirez, Frank BA*; Bolan, Robert K. MD†; Kerndt, Peter R. MD, MPH*
Partner notification (PN) has been a core public health prevention strategy to find and treat persons infected with syphilis, to cure their infection, and to prevent transmission to others.1–4 Traditionally, Public Health Departments provide PN services to reported syphilis and HIV cases through trained county-employed Disease Investigator Specialists (DISs). In Los Angeles County (LAC), laboratories and providers report positive syphilis results to the Public Health Department sexually transmitted disease (STD) Program and, subsequently, the Sexually Transmitted Disease Program (STDP) Field Services assigns the cases to county DISs for investigation, interview, and partner follow-up. Primary syphilis cases are given the highest priority for case follow-up; however, DISs also follow up secondary and early latent cases. Many challenges impede the success of health department PN programs, including delays in reporting the case or positive laboratory result to the health department; delays in interviewing original cases;5–7 many reported anonymous partners from cases5; and, particularly among the gay community, distrust of the health department and fears of confidentiality.5,8–10
In LAC, >60% of early syphilis (ES) cases are among men who have sex with men (MSM), and approximately 10% of these cases are diagnosed by one community-based organization (CBO), the Los Angeles Gay & Lesbian Center's Sexual Health Program (LAGLC).11 Before 2008, LAGLC ES cases were assigned to STDP DISs through the traditional Public Health Department protocol. In efforts to improve PN outcomes among the LAGLC ES cases, in 2008 the STDP and LAGLC implemented a Community-Embedded Disease Investigation Specialist (CEDIS) partner notification program. The program was an effort to improve prompt identification and treatment of partners unaware of their syphilis exposure or infection and reduce further disease transmission in the community. Although the CEDIS was assigned all ES cases, this evaluation only focused on PN outcomes of the primary syphilis cases because some data suggest that the greatest public health impact may be achieved through identification and prompt treatment of primary syphilis cases and their partners.12,13
In 2007 STDP received funding from the third district of Los Angeles, where LAGLC and a large number of MSM reside, to address the district's syphilis epidemic. LAGLC is a long-standing CBO that provides sexual health care in an accepting environment for the gay and lesbian population; 85% of the patients report gay or bisexual sexual orientation. The clinic sees >13,000 patient visits per year (LAGLC unpublished data, 2011). Based on the successful CEDIS program at Chicago's Howard Brown Health Center,14 STDP directed approximately $60,000 to LAGLC for a CEDIS's salary and benefits for one year. LAGLC identified and interviewed a candidate who was a gay male younger than 30 years and who was already employed at LAGLC, and STDP approved his hiring for this position for one year. The CEDIS program as described here differs from the Howard Brown Health Center's CEDIS program: LAGLC's CEDIS was a Health Officer Without Pay of the STDP to ensure that the CEDIS was trained and received the same technical assistance, oversight, and feedback as do the STDP DISs and had access to the STDP surveillance database to look up and enter case information.
The CEDIS was trained by STDP in partner services and was assigned all of the LAGLC ES cases by the middle of 2008. Similar to STDP DISs, the CEDIS completed monthly activity reports, as well as documented outcomes of cases in the STDP Surveillance database. In addition, an STDP partner services supervisor met with the CEDIS on a regular basis, was available via phone during regular hours and on weekends for technical guidance on difficult cases, and reviewed his case completion and monthly activity reports. The CEDIS worked the same hours as the clinic's operation, which included afternoons and nights, although not weekends. However, at times, he called or received calls on the weekends. He primarily did most of his initial contact to schedule interviews through phone calls, as it was determined that he would be most effective stationed at the clinic rather than out in the field. STDP DISs were available to find difficult cases in the field. STDP provided a DIS to cover the CEDIS work when the CEDIS was on vacation or sick leave.
Because the CEDIS was stationed at the diagnosing clinic rather than at STDP headquarters, he had ready access to medical records and in many instances was able to interview newly identified syphilis cases in person, either at initial diagnosis or when they returned to the clinic for treatment. As a peer of the gay community and an employee of the clinic, not the Public Health Department, the CEDIS's job was fully integrated into the clinic's normal work flow, and, as a coworker, the CEDIS attended LAGLC staff development and operation meetings. After the first year of significant success, funding for the CEDIS was continued through a cooperative agreement with the Centers for Disease Control.
Although significant outcomes were similar for all of ES cases, for this article, we only focused on primary syphilis cases. We evaluated the CEDIS's performance on several key PN outcomes by using a before and after design using 2006–2007 baseline data versus 2009–2010 post-intervention data for LAGLC primary syphilis cases. We extracted data on demographics, stage of disease, and outcomes from the Los Angeles County STD*CASEWATCH Surveillance data system. This database contains data on all chlamydia, gonorrhea, and syphilis cases reported in LAC. Its data are used for local, regional, and national surveillance reporting purposes and is systematically reviewed and updated for data accuracy and integrity. Additionally, we compared relevant CEDIS outcomes with the average county DISs' PN outcomes for primary syphilis among MSM excluding LAGLC cases in 2009–2010.
We defined sex partners as the total number of partners reported by the case during the exposure period and contacts as the number of partners with sufficient locating information to start an investigation. Evaluation measures included the proportion of cases interviewed; the time from a new syphilis case's visit date to interview date; the number and range of contacts elicited; the contact index—the ratio of the number of contacts elicited to the number of original syphilis cases interviewed; the preventive index—the number of contacts tested and treated within the incubation period to the number of original syphilis cases interviewed; the brought-to-treatment index—the ratio of the number of contacts diagnosed and treated for ES to the number of original syphilis cases interviewed; and the outcomes of the contacts elicited. Data analysis was performed using SAS (v. 9.1, Cary, NC). Pearson χ2 was estimated to compare variables before and after the placement of the CEDIS. Additionally, we evaluated the number of sex partners of the cases who did not provide any partner information before and after placement of the CEDIS and countywide.
Table 1 presents the characteristics and outcomes of the primary syphilis cases identified at LAGLC and countywide and the outcomes of their elicited partners. In 2006–2007 before placement of the CEDIS, 72 primary syphilis cases were diagnosed at LAGLC and 64 were assigned, with 1 case unable to locate. In 2009–2010 after placement of the CEDIS, 90 primary syphilis cases were diagnosed and 87 were assigned, all cases were located. After placement of the CEDIS, 100% (87) of primary cases assigned were interviewed compared with 67% (43) before placement of the CEDIS; 33% of 2006–2007 cases were lost to follow-up. Countywide in 2009–2010, 94% of primary cases were interviewed.
Table 1-a. Character...Image Tools
Characteristics of cases interviewed were similar before and after placement of the CEDIS. In 2009–2010, all primary syphilis cases were MSM. The majority of cases (39%) were between ages 25 and 34, 22% were between 35 and 44, 18% were between 18 and 24, 18% were between 45 and 54, and 3% were 55 or older. An estimated 48% of primary cases racially/ethnically identified as white, 34% as Hispanic, 12% as black, and 5% other race/ethnicity. The median number of reported sex partners after placement of the CEDIS was 4 and before placement of the CEDIS was 2. After placement of the CEDIS, 28% (26) of primary syphilis cases were interviewed on the same day as their clinic visit and 64% (59) within 7 days. In comparison before placement of the CEDIS, only 2% (1) of primary cases were interviewed on the same day as the clinic visit (P < 0.01). Countywide 9% of primary cases were interviewed on the same day and 19% within 7 days.
Table 1-b. Character...Image Tools
There was a significant increase in the number of contacts elicited after placement of the CEDIS compared with before placement (P < 0.01). The range of contacts given per case is presented in Table 1. Overall, the CEDIS elicited 140 partners from the 87 original cases interviewed compared with 13 partners from 45 cases interviewed before placement of the CEDIS and 171 partners from 252 original cases interviewed countywide in 2009–2010. The contact index after placement of the CEDIS was 1.62; in 2006–2007 was 0.29 and countywide was 0.68. Of the 140 partners elicited after placement of the CEDIS, 15% (21) were infected with ES and brought to treatment compared with 0% before placement of the CEDIS and 15% (25) countywide. Thus, the brought-to-treatment index after placement of the CEDIS was 0.25; was 0.00 before placement of the CEDIS and was 0.09 countywide in 2009–2010. Additionally after placement of the CEDIS, 40% (56) of partners were preventively treated because of their exposure to syphilis within the incubation period compared with 0 partners before placement of the CEDIS and 20% (34) countywide in 2009–2010.
Table 2 presents the reported number of sex partners for cases who did not give partner information. After placement of the CEDIS, the number of primary cases who did not give any partner information decreased almost by half from 71% before placement of the CEDIS to 33% after placement of the CEDIS. Both after placement of the CEDIS and countywide, 13% of cases not reporting partner information reported at least 8 partners in the past 90 days.
Overall, the results of this evaluation indicate that the CEDIS significantly improved the PN outcomes and case finding effectiveness extended to MSM clients in LAC and corroborated the successful results of other embedded DIS programs.14,15 Of partners elicited after the placement of the CEDIS, 15% were infected with ES and brought for treatment. This estimate is almost double the 8% median case-finding effectiveness estimated in a literature review of syphilis PN programs among developed nations.2 Although the CEDIS's case-finding effectiveness was similar to countywide estimates for MSM primary cases, the CEDIS's brought-to-treatment index (the number of contacts identified and treated for ES by the number of cases interviewed) dramatically surpassed countywide estimates for 2009–2010.
We attribute the success of the CEDIS program to a couple of key factors. Primarily, prompt access to syphilis cases and laboratory results contributed to the significant decrease in the time to interview of new cases and the number of cases lost to follow-up. After placement of the CEDIS, no cases were lost to follow-up compared with 33% before placement of the CEDIS and 6% countywide. Moreover, after placement of the CEDIS, 30% of cases were interviewed on the same day as their clinic visit compared with 2% before placement of the CEDIS and 8% among countywide MSM primary syphilis cases. In the current county system, partner follow-up can be delayed by relying on timely reporting from providers and laboratories to the Public Health program and then by the time necessary to assign cases to county DISs. Additionally, community-based providers not consistently referring cases to PN programs has been a documented barrier to PN success in other programs.8,9
Prompt case interviewing that occurred after placement of the CEDIS could have lead to the documented increase in elicited contacts and the significant increase in finding new ES cases. An evaluation of an embedded DIS program in Arizona found that after part-time placement of an embedded DIS in a diagnosing clinic time to interview decreased by half and the contact index doubled from 0.30 to 0.60.15 A study in San Francisco of HIV PN found that new HIV cases interviewed within 2 weeks of diagnosis yielded more new positives per cases interviewed compared with cases interviewed more than 2 weeks after diagnosis (interviewed <2 weeks: 8 index cases interviewed for 1 new infection; interviewed >2 weeks: 21 index cases interviewed for 1 new infection).16
The rapport and trust developed between the CEDIS and the patients may also have been a key factor that contributed to the improved PN outcomes. Traditionally, MSM's lack of trust and rapport with a County Health Department's DIS5 has been a noted barrier to PN success. A phone, an email, or a text message from someone who identifies himself from a gay-sensitive community center rather than from the health department may receive a better response from the patient. Even the median number of reported sex partners of new primary cases increased from 2 to 4 after placement of the CEDIS. This may be due to the increase in number of high-risk cases who were interviewed after placement of the CEDIS.
Better acceptance and cooperation from the LAGLC staff in referring patients to the PN program may also have contributed to the successful CEDIS PN outcomes. According to the long-standing Medical Director of LAGLC's Sexual Health Program and the current LAGLC clinic manager and long-time LAGLC employee, there was often concern from the LAGLC staff that the health department did not have their clients' best interests in mind (B. Bolan, D. Kerrone, personal communication, 2011). Other studies have shown that community-based providers often attempt to satisfy perceived clients' wishes instead of encouraging PN.9,17 Without the CBO staff encouraging cases to participate in a PN program, little sustained success can be expected.3,5,9,17 The CEDIS's integration into the clinic's operational flow, his attendance at internal meetings, the discussion of the CEDIS's role and referral protocol at LAGLC clinic operation meetings, and the dissemination among staff of the results of the program may have contributed to the consistent referral of cases to the CEDIS (D. Kerrone, personal communication, 2011). Cooperation was extended in 2009 when senior management at LAGLC highlighted the CEDIS and the importance of his work in the CBO's monthly newsletter, which has a readership of >50,000 among the Los Angeles gay community.18
One of the first successful CEDIS models was recognized at Chicago's Howard Brown Health Center.14 Our model differed from Chicago's model because the LAGLC CEDIS was also made a Health Officer Without Pay of the STDP, which resulted in the CEDIS being held accountable to the same standards, case review, and completion as the STDP DISs. He also received the same technical assistance and oversight as did the STDP DISs, and the appointment allowed the CEDIS access to the county STD surveillance database. By making the CEDIS officially linked to the health department, the health department ensured its influence over the technical oversight, expertise, and review of the CEDIS's work. Access to the county STD database increased the efficiency of the CEDIS by allowing rapid lookup of whether a patient was previously diagnosed with syphilis and rapid data entry into the countywide surveillance system.
Another successful embedded DIS program was implemented in Arizona in 2008.15 Our CEDIS model differed from Arizona in that our DIS was an employee and peer of the community-based clinic, and the CEDIS's job activities were fully integrated into the clinic's normal daily work flow, whereas Arizona's embedded DISs were health department employees and placed part-time at the diagnosing clinics. A question remains whether the CEDIS could be a peer of the gay community but an employee of the health department and experience the same outcomes. More research is needed to understand the importance of this distinction.
This evaluation has limitations worth considering. This study may only be generalizable to clinics with high STD morbidities among MSM. It probably makes little economical sense to station a CEDIS at a setting with low STD morbidity, and it is unknown whether this program would work in a nonclinical setting or with the heterosexual or adolescent populations. Additionally, even with the success of the CEDIS program, 33% (29) of index cases did not provide contact information for any of their partners. More than half of these cases (16) reported 4 or more partners within the risk time. PN cannot be very effective if only a small percentage of index cases participate in the program. Participation and anonymous partners remain a challenge for PN programs.
Jurisdictions may differ in the access allowance to confidential, county STD data from employees outside central headquarters. Technical questions that address access to a confidential, countywide surveillance system and other security concerns need to be answered as part of the implementation process.
In 2011, this program was extended to follow up recently diagnosed HIV cases from LAGLC with the expectation to hire an additional CEDIS to assist with the increase caseload, as well as to ensure that new HIV cases are linked to care. Additionally, this program is being adapted to address the gonorrhea epidemic among the young, urban LAC population. In this adaptation, the CEDIS is employed by a CBO that oversees multiple family planning clinic sites, and the CEDIS moves among the multiple sites to follow up gonorrhea cases and partners. Evaluations of both adaptations of the CEDIS program will be forthcoming. The CEDIS program dramatically increased the number of contacts of primary syphilis cases who were preventively treated or diagnosed with ES and brought to treatment compared with the traditional public health DIS program. Community settings with high syphilis morbidity and accessible resources should consider implementing a similar program.
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