930387128008IHS Prim Care ProvidIHS Prim Care ProvidThe IHS primary care provider1063-43981941-3602316021736785741HHSPA1053316ArticleTreating Sexual Contacts of Gonorrhea and Chlamydia Cases: A Critical Component of STD Control Among AI/AN PopulationsTaylorMelanieMD, MPHDivision of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GeorgiaArizona Department of Health Services, Phoenix, Arizona310201942013101020196846870

In the wake of rising gonorrhea cases amidst high background chlamydia rates among AI/AN populations,1,2 multiple Indian Health Service (IHS) Areas have been faced with the need to expand sexually transmitted disease (STD) services to accommodate increased demand and disease burden.3–6 National recommendations include chlamydia screening of young sexually active women ages 25 and under, and some service Areas have expanded this screening recommendation to include men, broader age groups, and additional infections, depending on local morbidity.7–10 Screening for gonorrhea among women tends to follow that of chlamydia as the widely used Nucleic Acid Amplification test (NAAT) for chlamydia is automatically paired with a gonorrhea test. However, within IHS Areas that do not have screening recommendations for asymptomatic men, diagnosis following symptomatic presentation or referral as a partner to a female case remain the predominant gonorrhea and chlamydia identification measures among males.

Patient Delivered Partner Therapy

Contact (partner) tracing and treatment is an evidenced-based component of STD control.11 Both men and women treated for chlamydia and gonorrhea have high rates of re-infection due to re-exposure to untreated partners.12 In addition to increasing the availability of STD screening to diagnose asymptomatic infection, many service units have adopted protocols for the use of Patient-Delivered-Partner-Therapy (PDPT) also known as Expedited Partner Therapy (EPT),7,10,13–15 and some have experienced subsequent declines in gonorrhea and chlamydia following implementation. As the name suggests, PDPT/EPT refers to the practice of providing an additional dose of medication or a prescription for a patient to deliver to their partner for empiric treatment of chlamydia or gonorrhea. PDPT/EPT is an IHS and Centers for Disease Control and Prevention (CDC) recommended tool to expand treatment for chlamydia and gonorrhea.12,16–17

Although any medical provider delivering care to AI/AN populations outside of the IHS must abide by state and other laws regarding PDPT/EPT, federally-employed practitioners within the IHS are able to provide PDPT/EPT to patients receiving care at IHS facilities, notwithstanding contrary state laws so long as IHS has approved the practice for use within its federally-operated facilities.18 In addition, IHS practitioners are able to provide PDPT/EPT to sexual partners that are non-IHS beneficiaries (non-tribal members) as an effort to prevent disease spread.19

Due to increasing concerns about the spread of antimicrobial resistance, CDC recently released updated guidelines for the treatment of gonorrhea.20,21 The use of intramuscular ceftriaxone (250mg IM x 1 dose) PLUS azithromycin (1 gram PO x 1 dose) or doxycycline (100mg PO BID x 7 days) are now the only recommended medication regimens. However, the oral use of cefixime (400mg PO x 1 dose) PLUS azithromycin (1 gram PO X 1 dose) or doxycycline (100mg PO BID x 7 days) remains an alternative treatment option. CDC continues to endorse the use of PDPT/EPT using oral cefixime “for heterosexual partners of patients diagnosed with gonorrhea who are unlikely to access timely evaluation and treatment” CDC recommends that patients and partners treated with an alternative regimen for gonorrhea should receive a test of cure one week following treatment.21,22

Protocol guidelines for the implementation of PDPT/EPT, including patient and partner information sheets, have been developed by IHS in collaboration with the CDC for use within IHS facilities and other clinical facilities providing care to AI/AN populations.17 Protocol excerpts related to the delivery of PDPT/EPT include the following specific guidance:

For heterosexual patients diagnosed with gonorrhea or chlamydia whose partners are unable or unwilling to present for testing and treatment, provide treatment to the patient to give to the partner(s) via expedited partner therapy (EPT).

Expedited Partner Therapy (EPT) is the clinical practice of treating the sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner. This practice is also called Patient-Delivered Partner Therapy or PDPT.

Patients with gonorrhea should be provided with the medication or a prescription(s) for cefixime (400mg to be taken orally for one dose) PLUS azithromycin (1 gram to be taken orally for one dose) to deliver to their partner(s).1

Patients with chlamydia should be provided with the medication or a prescription (s) for azithromycin (1 gram to be taken orally for one dose) to deliver to their partner(s)1. (Patient-Delivered Partner Therapy or PDPT),

Provide information sheets to the patient on PDPT to give to their partner.

Document this activity in the medical record.

Partner solicitation arid referral for clinical testing, diagnosis, and treatment remains the primary recommendation for partner management,11 and some service units have successfully expanded the role of public health nursing to include the field-delivery of medications to untreated cases and contacts of gonorrhea and chlamydia.8 However, need and national guidance highlight the role of PDPT/EPT as an evidence-based backup to contact tracing in circumstances where clients are unwilling to divulge partner information. Service units considering expansion of STD services to include the implementation of PDPT/EPT should review IHS protocols adopted for this purpose,17 as well as contact service units listed in the references sections to obtain information on experience and locally-adapted protocols and practices.7,9,10

Additional resources exist for areas experiencing outbreak-level increases in STDs including CDC epidemiologic assistance.3 Please contact Scott Tulloch for further information at scott.tulloch@ihs.gov.

Resources:Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta: US Department of Health and Human Services; 2012.Centers for Disease Control and Prevention and Indian Health Service. Indian Health Service Surveillance Report — Sexually Transmitted Diseases 2009, Atlanta, GA: US Department of Health and Human Services, 1 2012.HootsBH, TaylorMM, GirouxJA, Addressing increases in gonorrhea diagnoses in South Dakota: A collaboration between the state, IHS, tribes, and CDC. 2013 In Press. Indian Health Service Primary Care Provider.TaylorMM, ReilleyB, TullochS, Identifying opportunities for chlamydia screening among American Indian women. Sexually Transmitted Diseases. 2011;38 (12):1–2.20739911Arizona Department of Health Services. 2011 Annual Report: Sexually Transmitted Diseases in Arizona. Available at: http://www.azdhs.gov/phs/oids/std/pdf/2011-std-annual-report.pdf Accessed January 18, 2013.Alaska Department of Health and Social Services. Division of Public Health. Gonococcal Infection – Alaska, 2010 Available at: http://www.epi.hss.state.ak.us/bulletins/docs/b2011_11.pdf. Accessed January 18,2013.

Sells Service Unit, Tucson Area, Arizona, Pete Ziegler, MD, Clinical Director.peter.ziegler@ihs.gov.

Centers for Disease Control and Prevention. Syphilis outbreak among American Indians, Arizona, 2007–2009. Morbidity and Mortality Weekly Report. 201059 (6):158–61.20168294

Phoenix Indian Medical Center, Phoenix, Arizona. Doug Chang, MD, Clinical Director. dong.chang@ihs.gov.

White River Service Unit. Jonathan Slade Flitton, BSN, RN, VKN. jonathan.flitton@ihs.gov.

Centers for Disease Control and Prevention. Recommendations for partner services programs for HIV infection, syphilis, gonorrhea, and chlamydial infection. MMWR. Early release 2008;57 10 30:1–64.Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines, 2010. MMWR 201059:44–5.20094027Alaska Department of Health and Social Services. Division of Public Health. Expedited Partner Therapy Recommendations for Alaska Providers. 1 2011 Available at: http://www.epi.hss.state.ak.us/bulletins/docs/b2011_01.pdf Accessed January 18, 2013.Alaska Department of Health and Social Services. Division of Public Health. Gonococcal Infection – Alaska, 2011 Available at: http://www.epi.hss.state.ak.us/bulletins/docs/b2012_11.pdf Accessed January 18, 2013.TaylorMM, ReilleyB, YellowmanM, Use of Expedited Partner Therapy (EPT) among Chlamydia cases diagnosed at an urban Indian health center; Arizona. In press. International Journal of STD & AIDS. 10 2012.Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US Department of Health and Human Services, 2006 Available at: http://www.cdc.gov/std/treatment/EPTFinalReport2006.pdfIndian Health Service. Division of Epidemiology and Disease Prevention. STD Screening and Treatment Provider Tools, http://www.ihs.gov/epi/index.cfm?module=epi_std_resources Accessed January 18, 2013.U.S. Department of Health and Human Services, Indian Health Service. Medical Staff Credentialing and Privilege Guide, 9/05. http://www.ihs.gov/IHM/index.cfm?module=dsp_ihmj?c_p3c1 Accessed June 6, 2012.US Department of Health and Human Services. Indian Health Service. Indian Health Manual. Part 2. Chapter 4. Appendix E Statutes That Allow Health Services to Be Provided to Ineligible Individuals at IHS Facilities. Sec.813(c) IHCIA. http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p2c4_ap_e Accessed June 5, 2012.Centers for Disease Control and Prevention. Cephalosporin susceptibility among Neisseria gonorrhoeae isolates-United States, 2000–2010. MMWR. 2012;506;332–6.Centers for Disease Control and Prevention. Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR. 2012;61 (31):590–4.22874837Centers for Disease Control and Prevention. Guidance on the Use of Expedited Partner Therapy in the Treatment of Gonorrhea. Available at: http://www.cdc.gov/std/ept/GC-Guidance.htm. Accessed January 18, 2013.