Gonorrhoea in Coventry 1991-1994: epidemiology, coinfection and evaluation of partner notification in the STD clinic

Partner Notification for Gonococcal and Chlamydial Infections in Men Who Have Sex With Men: Success Is Underestimated by Traditional Disposition Codes

BACKGROUND

Recent reports evaluating partner notification (PN) efforts among men who have sex with men (MSM) have observed relatively poor outcomes. However, the validity of traditional PN disposition codes is not known, possibly leading to overly pessimistic assessments of PN outcomes.

OBJECTIVES

To evaluate PN practices among MSM with gonococcal or chlamydial infection, assess the utility of offering MSM PN assistance and compare patient self-reported PN outcomes with those recorded using Disease Intervention Specialist (DIS) disposition codes.

STUDY DESIGN

We reviewed the records of all MSM with gonococcal or chlamydial infection interviewed by Public Health-Seattle and King County for purposes of PN in 2004. Men were asked to indicate whether each of their sex partners were already notified or treated at time of interview and were offered PN assistance.

RESULTS

DIS interviewed 409 of 628 (65%) MSM reported with gonococcal or chlamydial infection. Three hundred thirteen of the 409 (76%) interviewed men provided information about their number of sex partners in the 60 days before diagnosis and specific information about 1 or more of their potentially exposed partners. These index cases reported a total of 1037 sex partners, but provided information about only 634 (61%). Two hundred thirteen of the 313 (68%) index cases reported notifying at least 1 partner. Index cases reported that 295 of all 1037 (28%) reported partners had been notified, and that 170 (16%) were treated; DIS disposition codes documented the treatment of 111 (11%) partners. Only 18 (6%) index cases requested DIS assistance contacting a partner; DIS notified and assured the treatment of 24 of the 35 (69%) partners reported by these 18 men.

CONCLUSIONS

Although MSM with gonorrhea or chlamydia seldom accept assistance notifying partners, they report higher levels of partner treatment than suggested by DIS disposition codes, with 68% indicating that they had notified at least 1 sex partner and 46% reporting that at least 1 of their partners received treated.

The prevalence of chlamydia, gonorrhea, and trichomonas in sexual partnerships: implications for partner notification and treatment

BACKGROUND

Treatment of sex partners by patient-delivered partner therapy (PDPT) may prove to be an effective strategy in reducing reinfection and preventing the sequelae of sexually transmitted infections (STIs). However, limited data exists regarding STIs within sexual partnerships (dyads).

OBJECTIVE

The objective of this study was to determine the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (GC), and Trichomonas vaginalis (TV) in sexual dyads to estimate the potential yield and limitations of PDPT.

METHODS

Male and female STI clinic attendees were invited to participate. Index subjects and partners were interviewed and tested for CT, GC, and TV. All partners were sought regardless of infection status of the index subject.

RESULTS

Of 210 dyads, the prevalence in index subjects was CT, 46%; GC, 18%; and TV, 14%. Considering the partners of 72 CT-only-infected index subjects, 57% had CT, 6% had GC, and 11% had TV. Considering the partners of 35 index subjects with GC or GC-CT coinfection, 57% had GC and/or CT; however, in 20% of partners, unsuspected TV was present. Among 74 dyads with uninfected index subjects, 26% of partners had an STI. Among the partners of 19 index subjects with TV only, 11% had CT, 5% had GC, and 37% had TV.

CONCLUSION

In our clinic population, a substantial number of partners had infections different from or in addition to those infections in the index. Many of these infected partners would not be diagnosed and treated using PDPT. Partners of index attendees without detected infection were at high risk (26%) for STI, mostly CT.

Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection

BACKGROUND

Many sex partners of persons with gonorrhea or chlamydial infections are not treated, which leads to frequent reinfections and further transmission.

METHODS

We randomly assigned women and heterosexual men with gonorrhea or chlamydial infection to have their partners receive expedited treatment or standard referral. Patients in the expedited-treatment group were offered medication to give to their sex partners, or if they preferred, study staff members contacted partners and provided them with medication without a clinical examination. Patients assigned to standard partner referral were advised to refer their partners for treatment and were offered assistance notifying partners. The primary outcome was persistent or recurrent gonorrhea or chlamydial infection in patients 3 to 19 weeks after treatment.

RESULTS

Persistent or recurrent gonorrhea or chlamydial infection occurred in 121 of 931 patients (13 percent) assigned to standard partner referral and 92 of 929 (10 percent) assigned to expedited treatment of sexual partners (relative risk, 0.76; 95 percent confidence interval, 0.59 to 0.98). Expedited treatment was more effective than standard referral of partners in reducing persistent or recurrent infection among patients with gonorrhea (3 percent vs. 11 percent, P=0.01) than in those with chlamydial infection (11 percent vs. 13 percent, P=0.17) (P=0.05 for the comparison of treatment effects) and remained independently associated with a reduced risk of persistent or recurrent infection after adjustment for other predictors of infection at follow-up (relative risk, 0.75; 95 percent confidence interval, 0.57 to 0.97). Patients assigned to expedited treatment of sexual partners were significantly more likely than those assigned to standard referral of partners to report that all of their partners were treated and significantly less likely to report having sex with an untreated partner.

CONCLUSIONS

Expedited treatment of sex partners reduces the rates of persistent or recurrent gonorrhea or chlamydial infection.

Case-Finding Effectiveness of Partner Notification and Cluster Investigation for Sexually Transmitted Diseases/HIV

OBJECTIVE

To assess the case-finding effectiveness of partner notification(PN) and cluster investigation for sexually transmitted disease (STD)/human immunodeficiency virus (HIV).

STUDY

Literature review and quantitative summary.

RESULTS

Since 1975, the median case-finding yield for syphilis, gonorrhea, and chlamydia PN reported in the literature is about 1 new case found for every 4 or 5 cases interviewed. The yield from HIV PN is approximately half as large, although there is substantial variability in yield across reports for each disease. Published reports underline the central role provider referral plays in effective PN and case-finding. Successful PN is more likely with index cases who are of majority ethnicity and detected through screening or spontaneous presentation for care with symptoms and with partners with whom index cases have had sexual contact that is recent, frequent, and of long duration. The case-finding yield for HIV PN also is much higher when cases are diagnosed through confidential, rather than anonymous, testing. Cluster investigation and related strategies tend to have lower case-finding yields than PN but can play a very useful case-finding role, especially in settings with high disease incidence.

CONCLUSIONS

STD/HIV PN and cluster investigation can contribute meaningfully to case finding. More research is needed to strengthen the empiric foundation of PN and related strategies, including the impact they have on disease transmission.

Developing national outcome standards for the management of gonorrhoea and genital chlamydia in genitourinary medicine clinics

BACKGROUND

Measuring clinical performance within a framework of clinical governance is increasingly important for monitoring improvements in patient care. Standards for quality indicators must, however, be achievable and evidence based. We describe an approach to the development of national standards for measuring outcomes of care for gonorrhoea and genital chlamydia in genitourinary medicine clinics.

METHODS

Two standards for each infection, one reflecting quality of case management and one reflecting partner management were chosen by consensus. A systematic review of published and unpublished UK studies about gonorrhoea and chlamydia management was carried out and weighted averages calculated for each parameter, stratified by location. Genitourinary medicine practitioners around the country were also asked for their opinion about desirable values for each standard and the results compared. Variability in performance between centres was examined using Shewhart's control charts.

RESULTS

We identified 17 reports about gonorrhoea outcomes and 14 about chlamydia. There was marked heterogeneity in results according to geographical location and different standards were set for clinics in and out of London. Opinions from practitioners suggested much higher standards than the values obtained from the systematic review. There was evidence for special cause variation related to management of gonorrhoea and chlamydia in London clinics.

CONCLUSIONS

Standards set using expert opinion are unrealistic when compared to evidence of what is achievable. Evidence based methods should therefore be used to derive outcome standards for case management gonorrhoea and chlamydia. The control chart method identified clinics where investigation to find reasons for special cause variation in performance should be undertaken to change practice.

Chlamydia and Gonorrhea Co-occurrence in a High School Population

BACKGROUND

Chlamydia and gonorrhea coinfection outside of healthcare facilities is less well known.

GOAL

To determine the co-occurrence of both sexually transmitted diseases (STDs) among high school students participating in a school-based screening and to assess the relevance of dual treatment recommendations in this population.

STUDY DESIGN

During the 1998 to 1999 school year, 5,877 students attending an urban U.S. school district were screened for chlamydia and gonorrhea using urine ligase chain reaction assays.

RESULTS

Overall, 451 students had chlamydia, 117 had gonorrhea, including 50 who had both STDs. The gonorrhea and chlamydia co-infections were 50/451 (11.1%) and 50/117 (42.7%), respectively. STD symptoms were reported by 16.0% of students having both infections, 7.7% of those having gonorrhea only, and 5.0% of students having chlamydia only (P = 0.01).

CONCLUSIONS

The rates of coinfection in this population exceeded those that justify dual treatment in patient-care settings. Chlamydia and gonorrhea co-occurrence may be highly prevalent among certain populations not attending patient-care settings.

Do the factors associated with successful contact tracing of patients with gonorrhoea and Chlamydia differ?

OBJECTIVE

To assess and compare factors which may be associated with successful contact tracing in patients with gonorrhoea and chlamydia.

STUDY DESIGN

Prospective observational study of patients attending a genitourinary medicine clinic with a diagnosis of gonorrhoea or chlamydia. Multivariate analysis model including demographic, socioeconomic, and behavioural variables.

RESULTS

The attendance of at least one sexual contact was associated with naming more contacts for patients with gonorrhoea (OR 1.44, 95% CI 1.04-2.01). A history of gonorrhoea was associated with successful contact tracing for patients with chlamydia (OR 1.46, 95% CI 1.12-1.9). Successful contact tracing, as defined by at least one confirmed contact attendance after the index case, was not associated with age, sex, sexual orientation, history of chlamydia, use of condoms, marital status, ethnicity, or socioeconomic status for either gonorrhoea or chlamydia.

CONCLUSIONS

Differences in the composition of the core groups infected with gonorrhoea and chlamydia are not explained by differences in contact tracing success. In the clinic setting studied, the outcome of contact tracing was not associated with a variety of demographic, socioeconomic, and behaviour factors.

Patient referral outcome in gonorrhoea and chlamydial infections

OBJECTIVE

To describe the outcome of patient referral at the STD clinic of the University Hospital Rotterdam. To study characteristics of heterosexual index patients and partnerships related to referral outcome.

METHODS

In 1994, patients with gonorrhoea and chlamydia were referred to public health nurses for interview and patient referral. Referral outcome was classified as "verified" if partners attended the STD clinic and as "believed" if partners were said to have attended elsewhere.

RESULTS

Of 454 patients, 250 (55%) participated in the study. The outcome of patient referral for the 502 eligible partners was 103 (20.5%) verified referrals, 102 (20%) believed referrals, and 297 (59%) with unknown follow up. Of the 103 partners examined, 43 had an STD of which 63% reported no symptoms. The contact finding ratio was higher for chlamydia patients and heterosexual men. Also, referral was more effective for index patients with recent sexual contact, with follow up visits to the public health nurse, for men who were not commercial sex worker (CSW) clients, and, to a lesser degree, for Dutch patients and patients who sometimes used condoms. For steady partners, referral was improved if the last sexual contact was more recent. Casual partners visited the clinic more often if sexual contact occurred more than once, if the last contact was more recent, if they were older, and if they were Dutch.

CONCLUSIONS

Patient referral was more effective for certain groups, such as chlamydia patients and steady partners, but was inadequate for others, including CSW and their clients, other "one night stands", young partners, and ethnic minorities.

Rapid decrease of endemic gonorrhea in Finland

OBJECTIVES

The incidence of gonorrhea has decreased in several European countries while a recent epidemic has occurred in Russia and the Baltic countries. In 1990, Finland had a higher gonorrhea incidence than the other Nordic countries. Therefore we studied prospectively the epidemiology of gonorrhea with special reference to the endemic or imported source of infection.

STUDY DESIGN

The study included three gonorrhea patient series from STD clinics in Helsinki in 1990 to 1995. Each series covered a 12-month period. Case controls with Chlamydia trachomatis infection were included. Demographic and epidemiological findings, including source partner profiles, were analyzed.

RESULTS

Gonorrhea decreased rapidly during the study period. In 1990 to 1991, there were 490 patients (3.3% of all patient visits); in 1992 to 1993, 162 (1.3%); and in 1994 to 1995, only 92 patients (0.9%) with gonorrhea. The change in the prevalence was highly significant (p < 0.0001) and was entirely because of the decreased number of endemic infections. The rate of imported gonorrhea remained constant with 50 to 60 patients, although traveling had increased markedly to Russia and Estonia where the incidence of gonorrhea was very high. Thirty-one percent of the patients with endemic gonorrhea but only 14% with imported gonorrhea (p < 0.0001) had a concomitant C. trachomatis infection. The prevalence of chlamydia decreased from 10.2 to 8.1% (p < 0.001), but in contrast to gonorrhea the source of infection was mainly endemic (89% to 97%) during the whole study period. The patients with gonorrhea were older and had a higher frequency of casual source partners than those with chlamydia. Overall, from 80% to 74%) of the men and from 48% to 33% of the women had contracted infection from a casual partner.

CONCLUSION

The present study documented a rapid decrease of endemic gonorrhea in Finland, whereas the rate of imported gonorrhea remained constant. Demographic findings or source partner profiles of patients with gonorrhea or chlamydia gave no obvious explanation for the rapid decline of endemic gonorrhea, which is in sharp contrast to C. trachomatis infection.