TMB Changes Rules to Fight Chlamydia, Gonorrhea
Public Health Feature - December 2009
Tex Med. 2009;105(12):55-58.
B y Crystal Conde
Texas physicians now have another treatment tool to break the cycle of chlamydia and gonorrhea infection that plagues hundreds of thousands of Texas residents annually. Doctors, confused by an ambiguous legal landscape in the past, have definitive clearance to treat the sexual partners of established patients with sexually transmitted diseases (STDs) without first examining the partners.
The practice, known as expedited partner therapy (EPT), is explicitly permitted, thanks to an amendment to Texas Medical Board (TMB) rules that took effect in June. TMB amended Chapter 22, Section 190.8 of the Texas Administrative Code to allow a physician to provide a prescription for an infected patient's partner with whom the physician doesn't have a "proper professional relationship."
The Texas Department of State Health Services (DSHS) follows Centers for Disease Control and Prevention (CDC) guidelines specifying that EPT be used in treating partners of patients diagnosed with chlamydia or gonorrhea. (See " How to Use Expedited Partner Therapy .") CDC also has information about state laws related to EPT on its Web site .
Before the TMB amendment, CDC categorized Texas as a state where EPT was "potentially allowable," meaning it didn't outlaw the practice but didn't have a law specifically allowing it. Currently, 20 states, including Texas, permit EPT, while nine prohibit the practice. Twenty-one states neither specifically outlaw nor permit it.
The change in Texas law couldn't have happened at a better time, says Nick Curry, MD, medical officer of the DSHS TB/HIV/STD/Viral Hepatitis Unit in the Infectious Diseases Prevention Section.
"Now is the perfect time for physicians to use EPT as a treatment option, as the transmission rates of chlamydia and gonorrhea have been growing in the state," he said.
Chlamydia is the most common bacterial STD in the United States, followed by gonorrhea. The 2008 Texas HIV/STD Surveillance Report by the DSHS TB/HIV/STD Epidemiology and Surveillance Branch shows that the number of chlamydia cases in Texas has climbed since 1999.
Ten years ago, DSHS received 62,526 reports of chlamydia. Last year, the case count was 98,707. The number of reported cases of gonorrhea in Texas has declined slightly since 1999 - from 32,680 to 31,569 last year. Reported gonorrhea cases reached a low point in 2003 at 24,327. View the full surveillance report [ PDF ].
According to CDC 2007 STD surveillance data, Texas ranks 20th in the rate of chlamydia infection, with 365 cases per 100,000 population. Data place Texas 15th among all states for rate of gonorrhea, with 136 cases per 100,000 population.
And the diseases are endemic among young adults and adolescents. (See " EPT and Adolescent Patients .")
Dr. Curry encourages physicians to consider EPT for treating the partners of patients diagnosed with chlamydia or gonorrhea because the therapy reduces reinfection rates, is an effective way for clinicians to reach and treat more partners, and saves money by reducing the cost of treating more advanced infections.
"The ability to employ EPT in Texas provides us with an opportunity to treat two very common STDs in a way that will hopefully decrease their transmission rate," Dr. Curry said.
DSHS has created a Web page to help clinicians understand EPT. Resources include an EPT fact sheet for physicians, treatment fact sheets for sex partners of patients with chlamydia and gonorrhea, and a brochure that explains the health professional's role in STD notification. Patient materials are available in English and Spanish.
CDC's Web site features EPT guidance documents, resources from health departments throughout the United States, and EPT position papers from a number of organizations.
Alicia Nelson, RN, a nurse consultant in the DSHS Family and Community Health Division, was part of the movement early on to make EPT an accepted disease prevention strategy in Texas. She worked with then-DSHS Commissioner Eduardo Sanchez, MD, in 2007 to draft a letter to Texas physicians endorsing EPT. After Dr. Sanchez left DSHS, she continued to advocate for EPT in Texas and worked closely with Dr. Curry to make it a reality.
Before that, a "Dear Colleague" letter published by CDC in 2005 and circulated among health departments nationally brought the concept of EPT to the forefront. Ms. Nelson says the CDC white paper that followed in 2006, Expedited Partner Therapy in the Management of Sexually Transmitted Diseases [ PDF ], hit home the public health problem of chlamydia and gonorrhea reinfections from untreated partners.
"It showed us reinfection was a real problem. Treating partners had been around for decades. EPT wasn't an unheard-of practice, but the liability issues made clinicians a little hesitant to give prescriptions to people they hadn't seen," she said.
Indeed, physicians worried they could be liable should a patient's partner have an allergic reaction to a medication. Dr. Curry says the risk of liability for employing EPT is no different from any other action taken by health care professionals when providing care, including prescribing or dispensing drugs for any condition.
He stresses, however, that physicians shouldn't fear prescribing medications for a patient's sex partner because the drugs prescribed to treat chlamydia and gonorrhea have few side effects and are effective in treating the diseases.
For treatment of chlamydia, physicians typically prescribe 1 gram of azithromycin. For gonorrhea, the routine course of treatment is a 400-mg tablet of cefixime. Patients take both single-dose medications orally.
To date, the Society for Adolescent Medicine reports there are no documented lawsuits or drug-related adverse events from EPT. As an additional safety step, physicians can give patients medication information on allergic reactions and side effects to pass on to their partners when providing a prescription or medication.
Dr. Curry adds that EPT has proven particularly effective in treating the male partners of female patients with chlamydia and gonorrhea. He says women are tested for the diseases more frequently, often at their annual gynecologic exams.
"Physicians do see a lot of chlamydia in the female population. It's not because females get more chlamydia; it's because women come in and are tested for it more often. Men aren't usually tested for chlamydia during a routine evaluation," he said.
The 2008 Texas HIV/STD Surveillance Report shows 78 percent of chlamydia cases were among Texas women, compared with 22 percent of cases among men. Gonorrhea statistics from the report show women made up 53 percent of cases, compared with 47 percent among men.
While the change in Texas law doesn't dictate physicians use EPT, it does broaden their options for treating the partners of patients infected with chlamydia and gonorrhea.
"If the doctor feels it's unlikely the infected patient's partner will come in, EPT is one more tool to halt transmission of chlamydia and gonorrhea," Ms. Nelson said.
She recognizes that some health care professionals may prefer one of the standard methods of partner notification, which include:
- Patient or self-referral . Physicians ask patients to refer the partners to a clinician for treatment. Clinicians examine and treat the partners.
- Provider referral . The clinician or a disease intervention specialist (DIS) from the health department interviews the patient for information on how to contact the partner confidentially. Upon contacting the partner, the clinician or DIS refers the partner for testing or treatment or both.
- Conditional or contract referral . The patient conducts the initial partner notification. The clinician or DIS may follow up if the partner doesn't respond by a certain time.
The CDC's 2005 "Dear Colleague" letter maintains provider referral is the optimal strategy for partner treatment. The letter says the method isn't available to most patients due to limited resources, such as personnel shortages at clinics or physicians' offices.
Typically, EPT is carried out by using patient-delivered partner therapy (PDPT), which involves several arrangements. DSHS says clinicians may practice PDPT by providing drugs to infected patients to give to their partners, by prescribing extra doses of medications in the diagnosed patients' names, or by writing prescriptions in the partners' names. Dr. Curry says if a patient does not know the name of the partner, a final but least favored option would be to leave the name space blank on the prescription to be filled in by the partner.
Dr. Curry reminds physicians to report diagnosed cases of chlamydia and gonorrhea. Texas law requires reporting of a number of infectious diseases and conditions to local health departments and DSHS.
The list of reportable illnesses and conditions is available online .
Notifiable diseases generally can be reported with a simple phone call or fax to the local health authority or local health department. Both have a mechanism for health care professionals to report 24 hours a day, seven days a week.
In counties without a local health department, physicians may send reports to the DSHS health service region. Contact information for local health departments and for the health service regions is available online.
At press time, Dr. Curry did not know of any coding physicians can use to be reimbursed for counseling patients about EPT, writing extra prescriptions, or providing patients with extra medications.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
How to Use Expedited Partner Therapy
The Centers for Disease Control and Prevention (CDC) reports that expedited partner therapy (EPT) is at least equivalent to patient referral in preventing persistent or recurrent gonorrhea or chlamydia infection in heterosexual men and women and in its association with several desirable behavioral outcomes.
CDC has the following recommendations for employing EPT:
- Gonorrhea and chlamydia 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 chlamydia 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 chlamydia 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 be used only 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 sexually transmitted disease comorbidity in partners, especially gonorrhea and chlamydia infection. EPT should be used only 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.
Source: Centers for Disease Control and Prevention,Expedited Partner Therapy in the Management of Sexually Transmitted Diseases , 2006.
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EPT and Adolescent Patients
The 2008 Texas HIV/STD Surveillance Report [ PDF ] displays some frightening findings. Reported cases of chlamydia and gonorrhea were highest among 15- to 19-year-old girls and women, as well as among 20- to 24-year-old men.
The report shows 15- to 19-year old women accounted for 28,928 cases of chlamydia and 6,136 cases of gonorrhea. Men aged 20-24 years accounted for 7,831 chlamydia cases and 4,529 gonorrhea cases.
Janet Realini, MD, MPH, a San Antonio family physician and member of TMA's Council on Public Health, says sexually transmitted disease rates are typically higher in younger patients. Dr. Realini worked at a family planning clinic in San Antonio, where she routinely screened women for chlamydia and gonorrhea.
The Centers for Disease Control and Prevention (CDC) recommends sexually active women aged 25 years and younger be screened for chlamydia at least annually. It recommends screening in women older than 25 if they have risk factors.
All sexually active women at increased risk should also be screened for gonorrhea, including those who are younger than 25, have new or multiple partners, or have previously had sexually transmitted infections. Pregnant women should be screened for Chlamydia. Pregnant women at risk should be screened for gonorrhea.
Dr. Realini stresses the importance of screening women for chlamydia and gonorrhea because patients are so often asymptomatic. She says early treatment is necessary to prevent complications, such as pelvic inflammatory disease. She also supports using EPT in the adolescent patient population.
The Texas Family Code allows a minor with an infectious, contagious, or communicable disease that's reportable to the Texas Department of State Health Services to consent to his or her own medical treatment for that disease. Dr. Realini says, ideally, minor patients would involve their parents in their medical treatment, but Texas law doesn't require parental consent in this situation.
The Society for Adolescent Medicine supports EPT by physicians who care for adolescents when infected heterosexual patients' partners are unlikely or unable to receive treatment. Expedited Partner Therapy for Adolescents Diagnosed With Chlamydia or Gonorrhea: A Position Paper of the Society for Adolescent Medicine also suggests physicians collaborate with policymakers to facilitate reimbursement for EPT counseling and with health departments for implementation assistance.
To help decrease the probability that adolescent and young adult patients will ever contract chlamydia, gonorrhea, or any other sexually transmitted diseases, Dr. Realini urges physicians to talk to adolescents and parents early on about sexual health and reducing risks. She also stresses that physicians should follow up with patients who have been treated for chlamydia and gonorrhea three months after treatment to test for recurrence.
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