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Divergent Approaches to Partner Notification for Sexually Transmitted Infections Across the European Union

Arthur, Gilly MB, BS, BMedSci (hons), MD*†; Lowndes, Catherine M. BA (hons), PhD*; Blackham, Jodi BSc, MSc*; Fenton, Kevin A. MB, BS (hons), MSc*‡ the European Surveillance of Sexually Transmitted Infections (ESSTI) Network

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doi: 10.1097/01.olq.0000175376.62297.73
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PARTNER NOTIFICATION (PN), ALSO KNOWN as contact tracing, has been practiced in some European countries since the early 1900s (Swedish legislation appeared in 1918). It was further developed in the United States in the 1930s1 and has been integral to the control of sexually transmitted infections (STIs) for decades in many countries. PN is the process by which sexual partners of an index case who has been diagnosed with a STI are informed of their exposure to infection and invited to attend for testing and/or treatment. PN may be by patient referral, provider referral (instigated, respectively, by patient or provider) or by contract referral, in which provider referral is carried out conditional on the patient failing to trace partners after some time.2 Patient referral can be usefully split into simple patient referral (diagnosing clinic advises patient to inform partners and tell partners to get treated) or supported patient referral when patient receives some help, for example, receives contact slips or has an interview with a public health worker/counselor to explain and motivate for PN. In most countries, the index patient's confidentiality is usually paramount throughout the PN process and naming the index case is avoided.2

PN contributes to STI prevention by the interruption of transmission within sexual networks, in particular by identifying asymptomatic disease and reducing the duration of infectivity in the community.3,4 The potential benefits of PN include reduced morbidity and decreased onward transmission in contacts as a result of earlier treatment and education, and decreased reinfection rates in index cases.5

The recent rise in the incidence of STIs across Europe is a challenge to effective provision of STI control measures.6,7 Because the changes in STI epidemiology and the factors driving these changes are broadly consistent across the European Union (EU), and given current patterns of population movement within and across borders, developing Europe-wide collaboration on these issues is appropriate and timely.8 Limited information is available regarding current approaches to PN in Europe. It is vital to know how European countries differ in current practice to identify strengths and weaknesses of different systems and to promote good practice across Europe. The aim of the current study was to characterize STI (excluding HIV) PN policy and practices in Europe, including their nature, range, and performance characteristics.

Materials and Methods

This study is part of a cross-sectional survey of STI surveillance, care, and prevention systems, which was carried out as part of a European Commission-funded project on European Surveillance of STIs (ESSTI).9 The survey involved 14 EU Member States (i.e., all except Luxembourg) and Norway, and was carried out between November 2002 and July 2003 using a structured questionnaire.

The aim of the overall study was to gain a comprehensive understanding of current STI surveillance systems; to describe STI diagnostic, treatment and care services; and STI prevention policies and practices in participating countries. The survey also looked at the organization of healthcare systems for STI management, legislation concerning STI care, and PN policies and practices. This article focuses on the results of the PN section of the questionnaire. It also summarizes information on provision of STI care in the countries surveyed. Other results have been published elsewhere.9 PN question topics included: what (if any) PN was carried out and for which diseases; policy issues such as the legal framework, national guidelines, and national promotion of PN; and practical issues such as referral method, which service sites practicing PN, management of contacts, and level of PN activity. This work focuses on bacterial STIs and viral STIs (except HIV and the hepatitides). A copy of the questionnaire is available from the corresponding author.

STI surveillance leads in the 15 collaborating countries were sent a paper copy of the questionnaire, which, after completion, in collaboration with additional in-country informants, was returned by mail. Questionnaire data were analyzed and summarized in a standard format, and sent to survey participants for validation and clarification when necessary. Further validation of questionnaire data was carried out through face-to-face, telephone, and/or e-mail discussions between the principle investigator and respondents. Additional material was provided by survey participants to supplement questionnaire data, including reporting forms, surveillance reports and data, published papers, and conference abstracts.

Results

All the questionnaires were returned with a generally high level of item completion.

Data on provision of STI care in the EU and Norway are presented in Table 1. Specialized confidential STI or dermatovenereology services, or services within dermatology clinics, exist in the large towns and cities of most countries, where the majority of STI cases occur. In Ireland, Italy, and the United Kingdom, the majority of bacterial and viral STI cases are seen at specialized STI care sites: in Sweden, this is the case for gonorrhea and syphilis, and in Denmark, for syphilis. Considerable proportions of STI cases, particularly chlamydia and viral STIs, are seen in primary care services in over half the countries surveyed (Table 1). The private sector is important in STI care provision in many countries.

T1-5
TABLE 1:
Provision of Sexually Transmitted Infection (STI) Care in the European Union and Norway

Respondents' knowledge of levels of PN activity and PN practices was in general better for specialized STI care sites than for primary care and other nonspecialist sites. Considerable variations were reported in PN policy and practice (Table 2). PN is compulsory in Norway and Sweden. In all other countries, PN is voluntary and partner notification styles and activity levels vary. In Norway and Sweden, PN is compulsory at all centers where STIs are diagnosed, i.e., in the case of compulsorily notifiable STIs, there is a legal obligation for physicians and patients to notify partners. PN became compulsory for gonorrhea and syphilis in Sweden in 1918 and in Norway in 1947 (and for genital chlamydial infection in Sweden in 1988 and in Norway in 1995). In these countries, if the diagnosing physician feels they cannot carry out PN, they must transfer the responsibility, in writing, to the medical officer in the patient's municipality. The physician can theoretically be sanctioned if noncompliant. If the patient refuses, no sanctions can be imposed; but if sexual partners are informed and then noncompliant, they receive follow up by a health worker and can be forced, by a court order, to have an examination.

T2-5
TABLE 2:
Partner Notification Policies in Europe

National guidelines for PN exist in over half the countries surveyed. When asked whether PN was promoted, that is, identified as an important practice, by national public health agendas, only 5 respondents reported that this was the case, although 2 respondents did not know (Table 2).

In most countries, some level of PN is routinely undertaken for gonorrhea, chlamydia, and syphilis, and in some instances viral STIs (Table 3). Approximately half of the countries surveyed do not carry out any PN for genital herpes or genital warts.

T3-5
TABLE 3:
Partner Notification Practices in Europe

Respondents supplied the most detailed information for PN undertaken in specialized STI care sites (Table 3). Information for other care settings was patchy with only some countries giving information on which types of clinic (e.g., primary care, family planning clinics) carry out anything beyond simple patient PN. Others felt unable to report on this, although they generally felt that simple PN was universal but that more active PN was less frequently undertaken at other sites, especially primary care sites (except in the case of Norway and Sweden). In Ireland, Italy, Greece, and the United Kingdom, supported patient PN is routine in specialist STI centers but rarely carried out at other sites. In Finland, supported patient PN is carried out in gynecology clinics but not in other nonspecialized settings.

Of the 3 methods of PN (patient, provider, or contract referral), patient referral is by far the most common (Table 3). Of those specifying a type of patient referral, more countries use simple rather than supported patient referral. Provider referral is offered as an additional service in 5 of 15 countries surveyed. Contract referral is sometimes used in Ireland, Sweden, and the United Kingdom. Method of PN varies by disease in Finland, with patient referral for chlamydia (as a result of the high numbers of infections occurring), and provider referral for gonorrhea and syphilis (Table 3). In Norway, provider referral is compulsory for syphilis too. However, in most other countries, syphilis is not treated any differently from other STIs and may often involve only simple patient referral.

With the exception of Denmark, data on the proportion of sexual contacts reached by PN for tests and treatment is not routinely collected by countries' STI surveillance systems (Table 4). In The Netherlands, data are available from the National STI registry; in Ireland, unpublished data are available; and in the United Kingdom, estimates from individual surveys are available.10,11 Some of those questioned gave estimates based on their personal experience of the field. Combining this data, the proportion of contacts reached at specialist STI care sites, for any acute STI, varied between <10% (in most countries where estimates were made) and >75% (Ireland, Norway, Sweden). In Sweden, where PN is compulsory, the proportion of chlamydia contacts identified and reached was in some regions as high as 90%. In Ireland, Norway, Portugal, the United Kingdom, Austria, and Sweden, proportions varied by STI type and tended to be lower for syphilis than gonorrhea and chlamydia.

T4-5
TABLE 4:
Partner Notification (PN) at Specialized Sexually Transmitted Infection (STI) Care Sites in Western Europe: Estimated Proportions of Contacts Reached for Testing/Treatment by STI Type

There was limited European consensus on the management of identified contacts (Table 2). In the majority of countries (10 of 14), in a specialized setting, contacts are usually treated etiologically, that is, they are seen, assessed, and treated according to their test results. In 5 of 14 countries, contacts of patients diagnosed with bacterial STIs (chlamydia, gonorrhea, and syphilis; in The Netherlands, chlamydia and gonorrhea only) are largely treated epidemiologically. Although epidemiologic treatment of contacts is normally administered when the contact first visits the clinic, in some countries, laboratory tests are also carried out with treatment adjusted at subsequent visits if necessary. In some countries (Belgium, Denmark, Finland, Ireland, The Netherlands, Norway, Portugal, and Spain), patient-expedited therapy is practiced (the patient is given treatment or a prescription to pass on to their partners). However, this usually occurs only in a small percentage of cases and in most countries, only for chlamydia. Over-the-counter antibiotics are available in Greece and Spain, and it is assumed that some STI contacts may choose to use this rather than attend clinics.

Discussion

Our study has identified marked variation in the policy and practice of PN across the 15 European countries surveyed in this study. Two countries have compulsory PN and the other 13 have voluntary PN. Only 8 of 15 (53%) countries have national guidelines and 5 reported promotion of PN within the public health forum. In practical terms, the emphasis on patient versus provider referral, the level of PN activity, and the management of contacts (etiologic vs epidemiologic vs patient-expedited) were also diverse. However, there were some similarities with the majority of countries carrying out PN within specialist STI clinics and focusing on bacterial STIs.

The variation in PN policy in Europe is striking. These variations have also been noted on a wider European and global level.12 Variations in national policy across Europe have previously been documented in a survey of 45 countries in Europe and Central Asia.13 Dehne et al's survey was restricted to reviewing national policy rather than practice, and respondents were Ministry of Health officials. Only 11 of 18 (61%) of Western European countries have a national PN policy compared with 82% overall. Domeika14 reported wide variations in chlamydia PN when comparing Eastern and Western Europe in a survey of national STI administrators and researchers. Similarly to Western Europe, PN is voluntary in all countries in Eastern Europe except in Latvia, where it is compulsory. PN is carried out by venereologists and in exceptional circumstances by other doctors. In contrast to Western Europe, in Eastern Europe, PN is usually offered to regular partners only, and in most cases, partner treatment is epidemiologic.

PN referral methods did not in general vary by STI in most countries surveyed, although some variations were seen; for example, in Norway, provider PN is compulsory for syphilis but not for other STIs. In the United States, a survey of STD program staff members of 78 health departments in worst-hit areas showed PN services were provided to the majority of persons with infectious syphilis (mainly using provider referral), whereas in contrast, fewer than 20% of persons with gonorrhea or chlamydia received more than simple patient referral.15 This disease-variable approach was also noted in other U.S. studies.16,17

In Western European countries, contact tracing for syphilis has had limited success in the context of the recent outbreaks among men who have sex with men (MSM), in which very high proportions of contacts are casual and untraceable.7,18

Because STI rates and care structures vary widely by country, some variation in PN activity is perhaps not surprising. It may also reflect the weak, albeit supportive, evidence for efficacy of PN.19 Although observational studies have shown that PN can identify significant numbers of asymptomatic and therefore untreated cases,19–21 none have measured the impact on disease transmission within the community. Modeling studies have, however, shown promising results for PN, suggesting it is an effective prevention strategy for gonorrhea and chlamydia.22,23 Furthermore, all 3 available systematic reviews of the subject highlight the lack of information on potential harm caused by PN. Existing international guidelines do, however, show consensus in promoting PN.24–26 Further research to establish the impact of PN on disease incidence in the community may help build international consensus for PN in the future.

Most respondents identified weakness in PN provision in nonspecialist centers compared with specialized care sites such as STI clinics. This is of particular concern in countries where most STIs are not treated in specialist settings, e.g., The Netherlands and Spain (Table 1),9,27 and for diseases that typically present to nonspecialist services such as chlamydia. This will become increasingly important as chlamydia screening programs, such as the U.K. national screening program, create a new focus for STI presentation in nonspecialist services. This weakness in PN services in nonspecialist clinics has been noted by others. In the United States, most PN programs (offering provider referral) for gonorrhea and chlamydia concentrate on specialist clinics that may manage as few as 10% of all STI cases.15,28 Clarke,29 in a U.K. review, also finds little PN beyond simple patient referral outside STI (genitourinary medicine [GUM]) services. In Denmark, where approximately 80% of chlamydia is managed by general practitioners,30 a survey found that less than 33% carried out more than simple PN and none offered provider referral.31 In Norway, before mandatory PN for chlamydia, a survey found that approximately half the physicians used patient-expedited therapy. Only one in 5 general practitioners reported initiating PN other than simple patient referral.32

Patient referral was the most common mode of PN and is also the mode recommended in the World Health Organization guidelines.25 This runs contrary to the evidence base, with the latest systematic review19 of 11 randomized, controlled trials (8014 participants) concluding that there was moderately strong evidence that provider referral for any STI (alone or as an option) and contract referral for gonorrhea were more effective than patient referral.However, provider referral has been noted as 4 to 8 times more costly than patient referral in the United States20 and may also be less popular with clients.33 Cost and staffing implications are likely to be influencing current approaches, particularly in the context of increasing STI incidence in many European countries.

This study surveyed the proportion of partners reached for testing/treatment by STI type. This varied widely between countries, with countries with mandatory PN reporting highest success rates. This has also been reported elsewhere. A study in Sweden found that 90% of partners of chlamydia cases were identified and 95% of these were examined.34 A similar study in the United Kingdom (where PN is voluntary) found that only 69.5% of contacts were identified.35 Of note, in the current study, respondents found it difficult to accurately report the success of PN because this data are not collected through surveillance systems routinely (except by Denmark).

Our survey indicates that patient-expedited therapy is not commonly used in Europe and when it is, it is almost always only for chlamydia. Epidemiologic and patient-expedited therapy may be more widespread in general practice and private practice. A study in France36 found presumptive treatment for gonorrhea without a laboratory test mainly occurred in private practice. The lack of utilization of patient-expedited therapy may reflect legal barriers as well as concern that it reduces the opportunities for prevention and patient education37; one study has shown adherence to treatment was reduced without a positive test result.38 This is perhaps less relevant now because single-dose treatment is available for chlamydia and gonorrhea. Studies in the United States, however, provide evidence for the acceptability and efficacy of patient-expedited therapy.37,39–41

It is important to note the limitations of this study. The study was directed toward lead surveillance personnel and therefore may reflect policy more than practice. It also concentrated on specialized services, because respondents were most familiar with these settings. However, respondents are highly experienced in this field and are likely to have excellent insights into practice in their country. The survey was confined to questions concerning national approaches and may therefore overlook local initiatives.

This study has found considerable variation and some similarities in PN policy and practice across 15 European countries. In view of the rising incidence of STIs in Europe and the important role PN could play in reducing this, it is important that countries across Europe revisit their approaches to PN and explore minimum standards for PN delivery in specialized centers. There is a need to explore ways of sharing experiences and outcomes of PN policies. Ways to build consensus may include better monitoring of PN activities, research to provide further evidence of the benefits and costs of PN, and a sharing of experiences in Europe. The ESSTI Network (www.essti.org) is one such forum and future plans include exploring ways of improving PN practice.

Acknowledgments

The ESSTI Network: Members of the ESSTI Collaborative and Steering Groups

Reinhild Strauss, BM, for Social Security and Generations, Vienna, Austria

Angelika Stary, Outpatient Center for Diagnosis of Infectious Venerodermatological Diseases, Vienna, Austria

Andre Sasse, Epidemiology Section, Scientific Institute of Public Health, Brussels, Belgium

Marjan Van Esbroeck, Inst. voor Tropishe Geneeskunde, Antwerp, Belgium

Else Smith, Department of Epidemiology, Statens Serum Institut, Copenhagen, Denmark

Steen Hoffmann,* Sexually Transmitted Infections Unit, Department of Bacteriology, Mycology, and Parasitology, Statens Serum Institut, Copenhagen, Denmark

Matti Lehtinen, National Public Health Institute, Helsinki, Finland

Pentti Huovinen, Antimicrobial Research Laboratory, National Public Health Institute, Turku, Finland

Veronique Goulet, Francoise Hamers,* Institut de Veille Sanitaire, Dépt des maladies infectieuses, St. Maurice, France

Patrice Sednaoui, Laboratoire de Bactériologie, Institut Fournier, Paris, France

Osamah Hamouda, Infektionsepidemiologie/AIDS-Zentrum, Robert Koch Institut, Berlin, Germany

Peter Kohl, Department of Dermatology &Venereology, Neukolln Academic Hospital, Free University of Berlin, Berlin, Germany

Mina Psichogiou, Hellenic Center for Infectious Diseases Control, Department for Surveillance &Intervention, Athens, Greece

Eva Tzelepi, National Reference Center for N. gonorrhoeae, Hellenic Pasteur Institute, Athens, Greece

Mary Cronin, National Disease Surveillance Centre, Dublin, Republic of Ireland

Barbara Suligoi,* Laboratory of Epidemiology and Biostatistics, Istituto Superiore di Sanità, Rome, Italy

Paola Stefanelli, Department of Infectious, Parasitic &Immuno-mediated Diseases, Istituto Superiore di Sanità, Rome, Italy

Marita van de Laar,* National Institute of Public Health &the Environment (RIVM), Department of Infectious Disease Epidemiology, Bilthoven, The Netherlands

Joke Spaargaren, GG &GD Amsterdam, Public Health Laboratory, Amsterdam, The Netherlands

Hans Blystad, Norwegian Institute of Public Health, Oslo, Norway

Jorgen Lassen, Norwegian Institute of Public Health, Oslo, Norway

Jacinta Azevedo, Consulta de DST do Centro de Saude da Lapa, Lisbon, Portugal

Maria Jose Borrego, Centro de Bacteriologia, Instituto Nacional de Saude, Dr. Ricardo Jorge, Lisbon, Portugal

Jesús Castilla, Instituto de Salud Publica de Navarra, Leire, Pamplona-Navarra, Spain

Julio Vazquez, Centro Nacional de Microbiologia, Madrid, Spain

Torsten Berglund,* Swedish Institute for Infectious Disease Control, Solna, Sweden

Johan Giesecke,* Swedish Institute for Infectious Disease Control, Solna, Sweden

Hans Fredlund, Swedish Reference Laboratory for Pathogenic Neisseria, University Hospital, Örebro, Sweden

Mike Catchpole,* Health Protection Agency Communicable Disease Surveillance Centre, London, U.K.

Hugh Young,* Scottish Neisseria gonorrhoeae Reference Laboratory (SNGRL), Department of Medical Microbiology, Edinburgh University Medical School, Scotland, U.K.

Chris Bartlett,* UCL Centre for Infectious Disease Epidemiology, Department of Primary Care &Population Sciences, London U.K.

Cathy Ison,* Department of Infectious Diseases &Microbiology, Imperial College School of Medicine, London, U.K.

Anne Scoular, Scottish Centre for Infection and Environmental Health, Glasgow, U.K.

*Member of ESSTI Steering Group.

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