CHLAMYDIA TRACHOMATIS (CT) IS THE MOST common bacterial sexually transmitted infection and is usually asymptomatic. In women, Ct infections are a major cause of pelvic inflammatory disease, ectopic pregnancy, infertility, and chronic abdominal pain. The mean duration of Ct infection is approximately 12 months. 1 Active case-finding and early treatment are the major strategies to reduce transmission. Simple home-based screening strategies to detect people with an asymptomatic infection have become feasible by improved detection methods of Ct in urine 2 and by the availability of effective single-dose treatment. 3–5 6
Effectiveness of any screening program is determined by adequate treatment of participants found Ct positive, as well as successful partner notification and treatment.
It has been shown that partner tracing and treatment contribute substantially to the reduction of prevalence. Even low percentages of treated partners may have a noticeable impact on the success of a screening program. 7 8
Reports on management of cases usually come from chlamydia screening programs where invitation for screening and management of cases is carried out by regular health care services, e.g., general practices,
sexually transmitted disease (STD) or family planning clinics. 9,10 11–14
We performed a large population-based Ct-screening study (CT PILOT), organized by Municipal Public Health Services (MHS) in the Netherlands, with referral of cases to regular health care. Ct prevalence and predictors for chlamydia, as well as the results of an acceptability study, were reported earlier.
In this paper, we report on the management of Ct-infected participants and their partners. 15–17 Methods
The current study is based on data from the CT PILOT project, which was designed to investigate prevalence of Ct infections in rural and urban areas in the Netherlands, and the feasibility of home-based screening organized by MHS with referral of cases to regular health care. Local general practitioners (GPs) and STD clinics were informed about the Ct screening program and their expected role. The study was implemented from September 2002 through March 2003 in 4 MHS areas, representing various degrees of urbanization.
A total of 21,000 women and men aged 15 to 29 years received a package by mail with a urine sampling kit and a questionnaire concerning sociodemographic data (age, sex, education, self-assigned ethnicity, symptoms and history of STD, and sexual behavior). Participants could return the coded urine sample and questionnaire by mail to a central laboratory. Urine analysis was done by a nucleic acid amplification test (PCR Roche Diagnostic Corp., Indianapolis, IN) in a central laboratory. Urine was pooled by 5 specimens and a chlamydia-positive result was based on a positive pool and a positive individual urine sample. 15
Laboratory results were transferred to the MHS concerned, where the results were linked to personal data and the participants informed by mail. Chlamydia-positive participants received information by mail about the infection and the need of treatment and partner notification and were asked to consult the regular medical services. In anticipation of waiting time problems, arrangements were made with alternative STD services to give preference to chlamydia-positive participants.
Participants could choose either their GP or the alternative available in their region (3 regions, MHS clinic; 1 region, STD clinic). An explanatory letter for the health care provider was included about the screening program and management of chlamydia infection (antibiotic choice, testing for confirmation in case of doubts about the diagnosis, and further STD examination if indicated).
Recommended treatment regimen of first choice was azithromycin 1 g stat., second choice doxycycline 2dd 100 mg for 7 days; in case of pregnancy amoxicillin 3dd 500 mg for 7 days. A test of cure is currently not advised in the Netherlands.
The letter referred to index treatment and notification of partners of the previous 6 months, with emphasis on the preference of direct treatment of the current partner by the GP/STD clinic through partner-delivered treatment. If the index patient’s physician did not provide a prescription for the current partner, the index was to be encouraged to notify the current and preferably also possible ex-partners during the previous 6 months. Assistance by the MHS nurses was offered. These instructions are in line with current practice guidelines in the Netherlands. Testing of partners before treatment was not obligatory, but a partner test kit was offered by the project. Alternatively, testing could be performed at a local laboratory. A return slip for the treating physician was included to obtain feedback on the management of cases, discussion of partner notification, and number of eligible and treated partners. On this evaluation form, GPs could request payment of a private consultation fee (22 Euro). When no feedback was received after 4 weeks, index cases received a reminder telephone call or a letter in order to obtain missing information. Outcome evaluation was performed within 2 months after sending the result. Index and partner management information was linked anonymously to the CT PILOT database.
index treatment rate was defined as the percentage of chlamydia cases with confirmation of antibiotic treatment as reported by the health care provider or the index patient. Determinants of confirmed treatment were investigated. Adequacy of antibiotic choice was assessed. Distribution of choices of health care was determined, as well as the period between mailing the result and consultation date (delay period), where consultation date was assumed to be treatment date.
Successful partner management rate was defined as the percentage of partners out of all partners elicited during counseling with confirmed treatment (patient-delivered treatment) or adequate management after testing. Potential treatment was defined as advice given to patients to refer their partners to their GP.
To distinguish between treatments of various partners, the treatment rate was calculated for all partners of the previous 6 months, stratified for the first partner and other partners. The number of partners during the previous 6 months as reported in the questionnaire and thus eligible for partner notification was compared with the number of elicited partners during counseling.
Data were analyzed using the SPSS package version 10.0 (SPSS, Inc., Chicago, IL). The χ
2 statistic was used to compare proportions. Statistical significance was considered to be P <0.05. Results
Management of Ct-Positive Participants (Index Cases)
Of the 8339 participants in the CT PILOT whose urine was examined, 165 (2.0%) were chlamydia positive (43 men and 122 women).
Treatment was confirmed in 150 cases (91%). No follow-up information was available for 13 Ct-positive cases. One remaining case still planned to consult a GP; another one was not yet treated. The rate of confirmed treatment was lower among persons with non-Dutch compared to Dutch ethnicity (81% [25/31] versus 93% [125/134]; 15 P = 0.03). No difference was found between Ct positives with confirmed treatment and those without follow-up information according to urbanization, age, sex, education, reporting symptoms, reported history of STI, recent partner change, and number of lifetime sexual partners. Choice of Health Care.
A majority of 82% (123 cases) consulted their GP, varying by region from 74% to 90% (
P = 0.49), as opposed to 18% (27 cases) who consulted an alternative STD clinic. No significant differences in preference of treatment location were found by age, sex, ethnicity, or urbanization. Treatment Delay.
Among 143 infected participants with known consultation date, the median delay period was 7 days (range 1–65 days). There was no difference in delay between GPs and alternative treatment facilities. Eighty-seven cases (61%) sought treatment within 1 week, 34 cases (24%) in the second week, and 8 cases (5%) within 3 to 4 weeks. Finally, 14 cases (10%) were treated more than 1 month after the result (
Fig. 1). In 7 of these 14 cases, additional information was available: 1 person visited the GP after 41 days without having received a reminder; 2 initially had not received the result due to change of address and consulted a GP after being reminded; 4 only consulted a physician after having received a reminder. Fig. 1:
Period between sending result to Ct-positive participants and consultation with health care provider (delay period).
Of all 150 confirmed treated cases, 128 (85%) received treatment of first choice; 20 (13.3%) treatment of second choice; and in 2 cases (1.3%), the antibiotic prescribed was unknown. Concluding, at least 148 (99%) of the treated cases received adequate prescription. A total of 107 out of 123 consulted GPs (87%) sent a return slip to the MHS. In the remaining cases, feedback was actively sought for from the index case.
Management of Partners
For 147 of the 150 treated index cases (98%), information was available with regard to partner management. All health care workers reported to have discussed partner notification. A total of 113 index cases (77%) reported 1 partner in the previous 6 months, 25 (17%) reported 2 or more partners, and in 3 cases the number of partners was unknown. With 6 index cases reporting no partners in the previous 6 months, 141 index cases remained where partner notification was indicated, with 176 partners eligible for partner notification and treatment (
Table 1). Per index case, the mean number of partners in the previous 6 months was 1.25 (women 1.21; men 1.35). TABLE 1:
Number of Index Patients and Corresponding Partners Eligible for Partner Notification (PN)
A total of 86 partners were treated successfully, with a mean number of partners per index case of 0.6 (86/141). Successful partner management rate was 49% (86/176). In addition, 16% (28) of all 176 partners were potentially treated (partner notification) (
Table 2). Concerning the first (current) partners of 141 index cases, 57% (81) were treated successfully (61%  current partners of 107 female index cases versus 47%  of 34 male index cases) ( P = 0.16). Eighteen percent (25/141) of current partners were treated potentially. The treatment rate of partners other than the first partners was 14% (5/35). Successful partner management rate seemed lower in index patients with recent partner change compared to those without recent partner change (40% [25/63] versus 54% [55/102]; P = 0.08). TABLE 2:
Partner Management According to Current Versus Other Partners by Sex and Recent Partner Change
Usually, treatment for the partners was provided during the first consultation, before or without Ct-testing. The physician waited for laboratory results in 10 out of 176 eligible partners (6%) before providing treatment. Only 15 diagnostic kits provided by the MHS were used, of which 6 (40%) were Ct positive. Direct treatment of at least 1 partner was done by GPs in 52% (60) of the index cases, while MHS/STD clinics treated current partners in 81% (21) of the index cases (
P = 0.02) ( Table 3). The offer of assistance by MHS nurses was not taken up by any of the GPs. TABLE 3:
Treatment Rates for Current Partners According to STD Care
Partner notification starts with the process of eliciting partners during counseling. In 139 cases where the necessary information was available, we could compare the number of partners reported in the return slip with the number reported in the original questionnaire. Nine index patients (6.4%) mentioned more partners in the previous 6 months during counseling than in the questionnaire. Those participants might have a new partner recently. In 27 index patients (20%), fewer partners were elicited during counseling than they had reported in the anonymous questionnaire. Twenty-two of these (81%) reported 1 partner during counseling, contrary to the 2 to 5 partners mentioned in the questionnaire.
Index Case Management
Our rate of confirmed index treatment was 91%, which is comparable to earlier findings from opportunistic
and systematic 19,20 screening programmers. The lower treatment rate of non-Dutch participants (81%) is in line with a population-based study in Amsterdam, 21 where participants of Surinamese and Antillean origin were also less often treated. This deserves special attention in view of the high prevalence and a lower acceptance of screening in these groups. 21 We may have underestimated our treatment rate of 91% because some of the 15 cases without information about treatment actually may have been treated. 15
The majority of cases with confirmed treatment (85%) were treated within 2 weeks. However, 10% were treated only after 1 month. Reports from follow-up of Ct-positive clinic attendees are comparable.
Our results indicate that for 10% of the cases, a reminder was necessary and that only 82% (136 cases) would have been treated without one. This suggests that active reminders are necessary to achieve optimal treatment results. 22
The MHS had facilitated management of cases by providing information for physicians. The quality of choice of treatment was very good; 99% of the treated patients received adequate treatment. Focus on the medication of first choice is important, as compliance in asymptomatic patients is expected to be better with the short treatment course.
We received feedback from 87% of the GPs. This result was probably influenced positively by introducing an incentive (payment of consultation). The majority (83%) of our index cases sought treatment with their own GP, reflecting the important role of GPs as providers of sexual health care. In our acceptability study, among a selection of participants at this home-based screening we found that 82% preferred to be invited by MHSs for regular testing.
Our data show that persons found infected preferred to be treated by their own GP but that an alternative STD service for persons preferring another health care worker or anonymous treatment is needed as well. 17 Partner Management
Treatment of current partners in order to avoid reinfections is crucial in STD control. For this reason, it was stressed in this project that physicians should give a prescription for index and current partner. Although all treating physicians indicated that partner notification was discussed, we wanted to distinguish confirmed treatment from advice for partner referral. The overall successful partner management rate was 49%, but direct treatment for at least 1 partner was given in 57% of all cases. Although this could mean that 43% of current partners were not treated, we know that 18% of first partners were referred to their own GP through patient referral resulting in a potential treatment of at least 1 partner in 75% of index cases.
A limitation of this study is that we do not have data about current versus ex-partners. We assume that if 1 partner was treated, this will most likely be the current partner. As reported partners in the previous 6 months may be ex-partners as well, reflecting less current partners, the actual treatment rate of current partners could be slightly higher. The results of our partner treatment are comparable to earlier screening studies in the Netherlands. In the opportunistic screening program in Amsterdam, where GPs screened and treated their own patients, at least 1 partner was managed adequately in 61% of the index patients.
In a systematic screening program performed by GPs in Amsterdam, 62% of index cases informed successfully at least 1 partner. 19 In a British opportunistic screening project, 41% to 52% of partners of the last 3 months had been managed adequately. 23 20
At STD/MHS clinics, relatively more partners were treated directly. GPs might restrict direct partner treatment to those who are actually within their practice. Encouraging direct partner treatment of current partners during GP consultation deserves more attention. Treating partners by patient delivered therapy has been feasible and beneficial.
Our data illustrate the challenge of notification of ex- and nonregular partners, as treatment in this group was confirmed in only 14%. The fact that partners of people with recent partner change and multiple ex-partners are less likely to be treated than partners of those with 1 steady partner concurs with previous findings. 24–27 Partner notification can be supported by MHS nurses and potentially by GP practice nurses. 12,23,28–30
Partner testing was not required, as we did not want to change regular practice. Partner testing by patient-delivered test kit could be potentially helpful in finding new index cases among multiple partners.
Eliciting partners however, is time consuming. This is illustrated by the discrepancies found in our study between partners reported in an anonymous questionnaire and reporting fewer partners to the GP. This might partially be due to the patients’ resistance to report a casual partner next to the steady partner to, for instance, their GP. In the daily practice, GPs probably restrict themselves to inquiring about the current partner. 31 Although we did not find significant differences, our data suggest that partners of female index patients are more likely to be treated than first partners of male index patients. This sex difference was noticed before 32 and should lead to specific attention in counseling men. Furthermore patient referral is described as less effective than provider referral, 29,33 and innovative methods should be developed. 34,35 Conclusion
A systematic home-based Ct screening organized by MHS with referral of infected participants to curative care can achieve high treatment rates. Without a reminder, the treatment rate would have been lower, particularly in non-Dutch risk groups. Information given to GPs and STD clinics led to adequate case management. In case of a large-scale screening program, training for GPs concerning counseling of unexpected STD results and partner notification appears necessary.
Given our treatment rate of current partners, it is to be expected that reinfections will occur. We recommend expansion of the practice of patient-delivered treatment for the current partner.
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