When All Else Fails: State Health Officials Recommend New STD Therapy

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Public Health Feature - January 2007   

By   Erin Prather Stafford
Associate Editor  

The old method doesn't seem to be working all that well, so state health officials have joined their federal counterparts in embracing a new - albeit not perfect - strategy to reduce the state's alarming rate of sexually transmitted diseases (STDs). They're now recommending physicians try expedited partner therapy (EPT) - treating an infected patient's sexual partners without an intervening medical evaluation or professional prevention counseling.

In May, then-Department of State Health Services (DSHS) Commissioner Eduardo Sanchez, MD, sent a letter to colleagues endorsing EPT, typically accomplished by patients delivering either medications or prescriptions to their partners.

"Effective clinical management of patients with treatable STDs requires treatment of the patients' current or recent sex partners to prevent reinfection and curtail further transmission. Clinicians need additional strategies for partner management," Dr. Sanchez wrote.

"In Texas, as in the United States, emerging data indicate that many providers selectively employ EPT for gonorrhea and chlamydia infection and that some do so routinely. DSHS supports EPT as a strategy for partner management in our struggle to reduce STD morbidity in Texas."

DSHS also issued a position paper recommending the practice. The paper is online at www.dshs.state.tx.us/hivstd/ept/default.shtm.

 Chlamydia is the most reported bacterial STD in the United States, while gonorrhea is second. In Texas, DSHS reported 71,621 positive chlamydia tests in 2005, and officials suspect that many more cases go undetected. DSHS reported 26,016 positive tests for gonorrhea.   

A DSHS surveillance report for 2004-05 shows the Texas rate for chlamydia was 311.4 cases per 100,000 population. For gonorrhea, the rate was 113.1 per 100,000. The report is online at  www.dshs.state.tx.us/hivstd/stats/pdf/surv_2005.pdf.

The Centers for Disease Control and Prevention (CDC) reviewed EPT for treating gonorrhea and chlamydia. While individualized use of EPT for selected STDs has been common for many years, the CDC says, using it systematically as a public health recommendation is a new model for STD prevention.

In 2006, a CDC report concluded that EPT is useful in partner management (particularly for treating male partners of infected women). However, it also stressed the strategy should not replace physician-assisted referral. Physicians should contact patients' partners by telephone or in person or have an outreach worker contact the partners on behalf of the provider.

"Ongoing assessment will be needed to evaluate all partner management strategies," the CDC report says. "However, the available evidence indicates that EPT is at least equivalent in efficacy to standard partner management for gonorrhea and chlamydial infection; that traditional partner management by public health agencies and health care providers for these STDs is limited in scope; and that the benefits of EPT outweigh the risks. Therefore, EPT should be available to clinicians as an option for partner management for gonorrhea and chlamydial infection."  The CDC report says the legality of EPT is uncertain in some states and it is "clearly legal" in only a few. Texas law does not prohibit EPT, and the Texas Medical Board has not taken a stance on the matter. The Texas Medical Association has not endorsed EPT because of members' concerns about confidentiality, physician liability for nontreatment, and the lack of HIV testing.

The report is online at www.cdc.gov/std/treatment/EPTFinalReport2006.pdf

Silence Isn't Always Golden  

While physicians should always recommend their patients' partners seek treatment, DSHS Nurse Consultant Alicia Nelson, RN, points to the reality that partners seldom do.

"The Institute of Medicine says STD partner management in the United States is inadequate and in need of an overhaul. Many Texans do not seek treatment, even when their partner is diagnosed with an STD. Because our state has such an alarming infection rate, DSHS has embraced the CDC's position regarding EPT and encourages physicians to do so as well," she said.

Ms. Nelson stresses that physicians should document when they use EPT and that the prescription or medication be accompanied by information on how the partner can seek personal health care. The partner should not accept treatment if allergic to the drug and there should be written counsel about the medication's common side effects and the appropriate responses to them.

Regarding chlamydia, Ms. Nelson says erythromycin makes treating women via EPT easier.

"Erythromycin is an improvement over doxycycline. Doxycycline has been shown to have adverse effects on pregnant women, but that concern doesn't apply to erythromycin. It also takes just one dose of erythromycin to clear up chlamydia."

Gonorrhea treatments have also improved, but EPT is not recommended to treat syphilis, which must be treated with injections. Ms. Nelson acknowledges there are concerns about EPT. Among those is the potential for pelvic inflammatory disease or other health conditions to go undetected in the treated partners. Other worries include missed opportunities for prevention counseling for partners, risk of allergic reaction and other adverse drug effects, and limitations on third-party insurance coverage.

Yet, she maintains the benefits far outweigh the concerns.

CDC also says the benefits of improved STD partner management dictate that the risk of adverse events should not in itself prohibit the use of EPT.

State and federal officials say the bottom line is that while EPT is not a perfect way to treat a partner of a person with chlamydia or gonorrhea, the therapy is better than nothing. At least the person will get some treatment, and the possibility of reinfection will be reduced.

Erin PratherStafford can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629.   

SIDEBAR  

CDC Guidelines for EPT

Expedited partner therapy (EPT) is at least equivalent to patient referral in preventing persistent or recurrent gonorrhea or chlamydial infection in heterosexual men and women and in its association with several desirable behavioral outcomes. The U.S. Centers for Disease Control and Prevention says the following conclusions support these recommendations:

  • Gonorrhea and chlamydial infection in women: EPT can be used to treat partners as an option when other management strategies are impractical or unsuccessful. Symptomatic male partners should be encouraged to seek medical attention, in addition to accepting therapy by EPT, through counseling of the index case, written materials, and/or personal counseling by a pharmacist or other personnel.
  • Gonorrhea and chlamydial infection in men: EPT can be used to treat partners as an option when other management strategies are impractical or unsuccessful. Female recipients of EPT should be strongly encouraged to seek medical attention in addition to accepting therapy. This should be accomplished through written materials that accompany medication, by counseling of the index case and, when practical, through personal counseling by a pharmacist or other personnel. It is particularly important that female recipients of EPT who have symptoms that suggest acute pelvic inflammatory disease, such as abdominal or pelvic pain, seek medical attention.
  • Gonorrhea and chlamydial infection in men who have sex with men: EPT should not be considered a routine partner management strategy, because data are lacking on the efficacy in this population and because of a high risk of comorbidity, especially undiagnosed HIV infection, in partners. EPT should only be used selectively and with caution when other partner management strategies are impractical or unsuccessful.
  • Women with trichomoniasis: EPT is not recommended for routine use in the management of women with trichomoniasis because of a high risk of STD comorbidity in partners, especially gonorrhea and chlamydial infection. EPT should only be used selectively and with caution when other partner management strategies are impractical or unsuccessful.
  • Syphilis: EPT is not recommended for routine use in the management of patients with infectious syphilis.

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