Improved partner notification for genital chlamydia can be achieved by centralisation of the duty to a specially trained team

Abstract

Partner notification is mandatory for Chlamydia trachomatis infections in Sweden. A significant quality improvement of partner notification for genital chlamydia was achieved by increasing the skills and reducing the number of individuals conducting partner notifications. By centralisation of the partner notification to a specially trained team of nurses, an additional 12% of genital chlamydia cases were found. Routine partner notification achieved a score of 3.3 notified partners per index case, and shows how important this activity is for detection of asymptomatic chlamydia infections in the community.

Keywords

Contact tracing partner notification genital chlamydia sexually transmitted infections

Introduction

Infection caused by Chlamydia trachomatis is a notifiable infection in several European countries and partner notification is essential for control of the disease.¹ In Sweden, it has been compulsory to notify and perform partner notification (PN) since 1988.² It has been shown that efficient PN performed by specially trained personnel is an effective means of revealing new chlamydia cases.^3–6 Centralisation of PN for chlamydia was organised in an attempt to find more cases and reduce the spread of the disease in Norrbotten, the northernmost county in Sweden. The aim of this study was to evaluate whether PN could be improved by centralisation to a smaller group of experts.

Material and methods

Norrbotten County has a population of 250,000 inhabitants, 2.6% of Sweden’s population, and represents 22% of Sweden’s total land area.

Since 2005, a routine was established where a questionnaire was sent to all health care personnel that conducted PN for chlamydia. By means of the questionnaire they were asked to report the number of sexual partners for each index case (P/I) to the county medical officer. The answers from those questionnaires soon revealed that a vast number of personnel were performing very few PNs each. With the aim of improving the quality of the PNs, a reduction of the number of persons involved was found necessary. Thus, from 2007, a specially trained PN team was formed. The PN team consisted of five nurses, with 50% of their time with the PN team, and 50% in a youth clinic: a clinic with focus on sexual health for teenagers. The training given was covering open attitudes, motivational interviewing, and interviewing technique. The PN was performed through telephone interviews as previously described.⁵ All health care personnel in the community were advised to refer PNs from all chlamydia cases to the PN team. Results from chlamydia tests of partners were not studied.

This work is a retrospective descriptive study where anonymised data from the County Medical Officer’s database were studied. Chi square and paired t-tests were performed using the software Primer of Biostatistics.

Results

Information on PNs from 6845 out of 7357 (93%) chlamydia cases during the period from 2005 to 2012 was obtained (Figure 1). The proportion of PNs performed by the PN team gradually increased to 89% in 2012. The sudden drop in the number of reported chlamydia cases seen between 2009 and 2010 was caused by a reduction of social interaction among young adults during the 2009 pandemic influenza A (H1N1), as previously described.⁷

Figure 1.

Reported cases of chlamydia cases in Norrbotten County, Sweden, 2005–2012. Black bars represent the cases where partner notification (PN) was performed by personnel in the specially trained PN team; dark grey bars where PN was performed by health care personnel not belonging to the PN team; and light grey bars indicate cases where information about PNs were missing.

The advantages with centralised PN

To achieve efficient PN there is a need for high motivation, proper training, practice, and sufficient time for the task. That was the rationale for a centralisation of PN to fewer people. The number of individuals performing PN for chlamydia decreased from an average of 180 to 18 during the study period, with a marked reduction of individuals that conducted few PNs (Figure 2).

Figure 2.

Number of partner notifications (PNs) conducted by individual PN conducting personnel in Norrbotten County, Sweden, 2005–2012.

During the study period there was a gradual concentration to a few individuals performing an increasing number of PNs. The partners notified per index case (P/I score) increased simultaneously with the increasing numbers of PNs per PN-conducting personnel (Figure 3). The time period of PN backwards beginning with the partner with whom the index person had had sexual intercourse most distantly prior to the index person’s positive test were strikingly constant and similar for the PN team and the comparison group throughout the period 2008–2012, with a mean time of 11.5 months and 11.3 months, respectively. In 2012, the P/I score for PN in Norrbotten County reached 3.3, a very good result compared to P/I scores in the range of 1.2 to 2.6, as have typically been reported in other studies from different countries as well as from Sweden.^5,6,8–11 Our results are in agreement with a recent modelling study, which found that detection of three or more partners to an index case in the previous 18 months yields a substantial number of new cases.¹² It could be estimated that PN by the PN team added another 12% to the total number of reported chlamydia cases that otherwise would not have been revealed in 2012. This is done by using the formula N*p*(St/So-1)/T, where the following abbreviations are used: number of chlamydia cases that were found through PNs (N); proportion of PNs performed by the PN-team (p); P/I score by the PN team (St); P/I score by others (So); total number of chlamydia cases (T).

Figure 3.

Average number of partner notifications (PNs) conducted per PN personnel, and average number of partners traced per index case (P/I-score), in Norrbotten County, Sweden, 2005–2012.

Table 1 summarises the outcome of the centralised PNs in Norrbotten County. The P/I-score also increased through the years among the PNs that had not been conducted by the PN team. This could be explained by an increasing number of partners and higher risk-taking, or increased consciousness and improved skills of all personnel performing PN in tracing sexual partners, or both. Regardless of the results achieved, PN conducted by the PN team resulted in a significantly higher P/I-score through the study period (p: 0.0021). During the period 2008–2012, when the PN team came into operation, the mean P/I score was 3.1 for the PN team and 2.6 for others performing PN (p < 0.0001).

Table 1.

Reported genital chlamydia cases, and results from contact tracings, in Norrbotten County, Sweden, 2005–2012.

	2005	2006	2007	2008	2009	2010	2011	2012
Reported chlamydia cases^a	908	959	869	947	926	715	721	800
Reported chlamydia cases revealed by PN (proportion of all reports)^a	362 (40%)	440 (46%)	392 (45%)	495 (52%)	495 (53%)	379 (53%)	402 (56%)	446 (56%)
Proportion of all contact tracings carried out by the PN team^b	0%	0%	30%	67%	70%	82%	87%	89%
P/I-score by PN team^b			2.8	2.7	3.0	3.3	3.3	3.4
P/I-score by others^b	2.2	2.3	2.3	2.4	2.7	2.5	2.9	2.7
Estimated chlamydia cases that would have been missed without the PN team	0	0	22	43	37	92	44	95

PN: partner notification. P/I-score: partners notified per index case.

Data from mandatory reports on notifiable diseases.

Data from 93% of all PNs (94% of PNs conducted by the PN team, and 93% conducted by others).

Discussion

A telephone interview is a good alternative to an interview at the clinic, and particularly useful in a setting of low-population density and long distances between care-takers and the health care facility.

From Table 1, a trend towards increasing P/I scores is seen during the study period. This trend is seen both among PNs carried out by the PN team and PNs carried out by other personnel. The trend could possibly be explained by an increasing sexual risk taking, more sexual partners, that people that have contracted chlamydia are increasingly prone to report sexual partners, a higher accessibility to information about the partners through social media, or a mixture of all these factors. However, we find it unlikely that these factors are confounders in this study. Centralisation per se seems to improve the quality of PN. In a study by Sylvan and coworkers,¹³ from Uppsala County in Sweden, experienced PN personnel at a youth clinic achieved the P/I scores 2.3 in 2004 and 2.6 in 2011. As seen in Table 1, the P/I scores achieved by personnel not belonging to the PN team in Norrbotten County were on the same level as those obtained by experienced personnel in Uppsala County. On the other hand, in a study by Carré and coworkers,⁵ a P/I score of 3.0 was achieved in a centralised PN setting.

In summary, PN increases the number of detected chlamydia cases, and facilitates antibiotic treatment for infected individuals. Furthermore, it limits an onward transmission of the disease in the general population. During the 7-year study period, the proportion of chlamydia cases revealed by PNs increased by 40%, to constitute 56% of all detected cases in 2012. Centralising chlamydia PN to a PN team was an efficient means to improve the PN quality. It could be estimated that PN by the PN team added another 12% to the total number of reported chlamydia cases that otherwise would not have been revealed in 2012. Finally, this study also shows that efficient PN alone is not enough to get the genital chlamydia epidemic under control.

Footnotes

Acknowledgements

All STI professionals in Norrbotten County are thanked for continually supplying data on contact tracing.

Conflict of interest

The authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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