Contact tracing in the control of STD in Ibadan, Nigeria

Partner referral as a component of integrated sexually transmitted disease services in two Rwandan towns

OBJECTIVE

To document partner referral rates at health centres with improved STD services, and to determine factors contributing to successful referral.

METHODS

Partner referral was initiated as part of the upgrading of STD services in primary care health facilities in two semi-urban Rwanda towns. After syndromic management of the presenting complaint, index patients received prevention education and condom demonstration, and were urged to refer sexual partners to the health centre for a free examination. Partner referral coupons linked by code number to the symptomatic index patient were given to facilitate referral; no identifying information was collected on partners from the index patients.

RESULTS

Three quarters of the symptomatic patients seen at the two primary health care facilities were women. Overall, the ratio of referred partners to index patients was 26%. Only 58% of index patients accepted partner referral coupons. The referral rate for those who did accept coupons was 45%. Partner referral worked best for regular partners. Most index patients and partners were married and only four index patients referred more than one partner. Women index patients, especially when pregnant, were more successful in referring partners than men. Index patients who referred partners tended to be older than those who did not. Awareness of STD symptoms in the partner, and diagnosis of cervicitis were associated with a higher rate of STD symptoms in the partner, and diagnosis of cervicitis were associated with a higher rate of partner referral.

CONCLUSIONS

Efforts to improve rates of partner referral should begin at the clinic level with improved counselling to convince more index patients of the importance of partner referral. Partner symptom recognition may be useful for increasing rates of partner referral. Supplementary strategies are needed to reach non-regular partners. When syndromic management is used, counselling should take into account the lower predictive values of identifying STD in women in order to avoid partner accusation. Despite limitations, patient referral of sexual partners can be an effective strategy for reaching a population at high risk for STD with minimal additional investment in health worker staff time.

Reinforcement of health education and counselling by doctors in treatment and control of sexually transmitted disease

The health education and medical counselling given by the social health worker to index patients with sexually transmitted disease (STD) attending our clinic were reinforced by a doctor attending a "treatment group" of patients in a randomised controlled trial. Sixty four patients were randomised into two groups of 32. Of the 96 follow up visits required four each group (three per patient), there were 20 defaults in the control group compared with only four in the patients whose health education had been reinforced by the doctor. Four of the control patients had been re-exposed to risk of infection during follow up compared with none in the reinforced group. Also five of the primary and none of the secondary sexual contacts of the control patients came for investigation and treatment (without the need for extra field contact tracing by the social worker) compared with eight primary and two secondary sexual contacts of the reinforced group. The appreciable impact of counselling reinforcement by a doctor shown in this study leads us to emphasise the importance of this practice, especially in developing countries where various infrastructural and cultural factors usually make contact tracing an unrewarding exercise.