If the sexual partner of a client with an STD is not treated, then your client is likely to be re-infected. Partner notification is not only a key component in preventing re-infection, but also in reaching out to those at risk to provide early diagnosis and treatment and prevent complications of untreated STDs. Partner notification can take any number of forms, depending on the client’s relationship with that partner:
- Ask your clients with STDs to bring their partners with them when returning for treatment or follow-up. You, the healthcare provider, can offer care and treatment as well as couples counseling, if both partners give permission.
- Encourage persons with STDs to notify their sex partners and urge those partners to seek medical evaluation and treatment.
- Tell your clients that the New Jersey Department of Health and Senior Services (NJDHSS) STD Program (STDP) sponsors a program referred to as “inSPOT” where clients can have their sexual partners notified anonymously or confidentially that they have been exposed to an STD. The target population for this program is clients with gonorrhea or chlamydia; those with syphilis are interviewed by public health representatives (see next bullet point). Find out more by going to www.inspot.org.
- Ensure that the New Jersey Department of Health and Senior Services (NJDHSS) is notified of all reportable STDs within 24 hours of diagnosis (see “STD Reporting Requirements” in this article). NJDHSS will ensure that partners of those diagnosed with syphilis are notified of their risk and referred into care. In cases where no identifying information is available because the partner was met online, the NJDHSS may be able to conduct formal internet partner notification (IPN). Physicians needing assistance with Partner Services can contact the STDP at (609) 826-4869 or e-mail the Surveillance Coordinator at firstname.lastname@example.org. See also http://www.state.nj.us/health/std/index.shtml.
ROUTINE SCREENING TESTS
Clients seeking treatment or screening for a particular STD should be evaluated for all common STDs. Inform all clients of the STDs for which they are being tested and notified; also inform them about tests for common STDs (e.g., genital herpes) that are available but not being conducted. Screen for the following infections in clients who are sexually active:
- C. trachomatis in all sexually active females aged ≤25 years (annually). Consider screening of all sexually active young men in clinical settings associated with high prevalence of chlamydia (e.g., adolescent clinics, correctional facilities, and STD clinics).
- N. gonorrhea in all sexually active women at risk for infection (annually); women aged <25 years are at highest risk for gonorrhea infection.
- HIV in all sexually active clients and those who use injection drugs.
- Cervical cancer, beginning at age 21 years.
In addition to the prior list, men who have sex with men (MSM) should also be screened for:
- Herpes simplex virus (HSV) infection with type-specific serologic tests, if infection status is unknown
- Anal cytologic abnormalities
- HBsAg to detect HBV infection
- HCV if a past or current drug user
Encourage MSM who have multiple or anonymous partners to be screened for STDs at 3–6 month intervals.
Additional information on STD screening, including screening of pregnant women, women who have sex with women and children who have been abused, is available in the CDC Sexually Transmitted Disease Treatment Guidelines, 2010.2
Although USPSTF made the decision to change its recommendation for screening of chlamydia from persons aged ≤25 years to those aged ≤24 years; CDC has not changed its age cutoff, and thus continues to recommend annual chlamydia screening of sexually active women aged ≤25 years.
STD REPORTING REQUIREMENTS
All healthcare providers should be familiar with the reporting requirements of their state. New Jersey requires that both healthcare providers and laboratories report confirmed cases of STDs, including chancroid, chlamydia, gonorrhea, granuloma inguinale, lymphogranuloma venereum, and all stages of syphilis. Submit completed reports directly to the New Jersey Department of Health and Senior Services (NJDHSS).
Human Papilloma Virus, Trichomonas, and Herpes Simplex Viral infections are not reportable diseases in New Jersey.12
As required by Chapter 2 of the State Sanitary Code (N.J.A.C. 8:57-1.2); all STD reports are to be faxed to (609) 826-4870 or reported by telephone to (609) 826-4869.
STD reports must be submitted within 24 hours; directions for reporting are available at the NJDHSS STD Website: http://www.nj.gov/health/std/tech.shtml (or go to the home page at http://www.nj.gov/health/std/ and click on “Technical Information” in the left navigation).
Infertility Prevention Project (IPP)
The New Jersey Department of Health, STDP implements the Infertility Prevention Project (IPP), a program funded by CDC to address increasing rates of chlamydia among young women age 26 years and younger. CDC, in collaboration with the Office of Population Affairs and the Department of Health and Human Services, supports the IPP. The IPP aims to prevent infertility caused by untreated chlamydia and gonorrhea. The IPP funds:
- Chlamydia and gonorrhea screening and treatment in family planning, STD, and other women’s healthcare clinics
- Increased distribution of condoms accompanied by safer sex messages
- Data collection systems to ascertain the most accurate chlamydia prevalence estimates
- The maintenance and improvement of quality of care
Find out more by contacting the STDP at the New Jersey STD Hotline: 1-800-624-2377.
The following is a summary of epidemiology, symptoms, diagnosis, treatment and follow up for nine STDs that are either common or reportable in New Jersey: chlamydia, HSV, gonorrhea, human papilloma virus (HPV), syphilis, trichomonas, granuloma inguinale, lymphogranuloma venereum, and chancroid.
Chlamydia is caused by bacterium Chlamydia trachomatis, which can infect the epithelium of the genital tract as well as the eye and respiratory tract.3
Chlamydia is the most frequently reported infectious disease and most commonly reported STD in the United States. In 2009 there were 1,244,180 reported cases of chlamydia of which 23,974 occurred in New Jersey. The CDC estimates, however, that the actual number of cases nationally each year is closer to 2.8 million.3 Chlamydial diagnoses have increased 19% nationally and by 29% in NewJersey4 since 2006. This is thought to be due to expanded screening rather than an increase in actual incidence – from 2000 to 2009, the screening rate has nearly doubled in young women. While this is promising news, the CDC suggests that most young women are still not receiving proper screening.1
Asymptomatic infection is common among both women and men. In women, infection of the urethra or cervix may cause symptoms of vaginal discharge and dysuria. Infection can ascend to the fallopian tubes, which may still be asymptomatic, or cause lower abdominal pain, back pain, nausea, fever, dyspareunia, or bleeding.3 In men, if symptomatic, complaints of penile discharge and dysuria are possible.3 Men and women who participate in anal intercourse may present with rectal pain, discharge, or rectal bleeding.
Urogenital infection can be diagnosed using a nucleic acid amplification test (NAAT), cell culture, direct immunofluorescence, or enzyme immunoassay (EIA) on endocervical specimens, male urethral swab, and/or urine specimens. NAATs are the most sensitive tests for these specimens but they are not approved by the Food and Drug Administration (FDA) for use on rectal or oropharyngeal swab specimens.2 NAAT testing may also be done on liquid based cytology specimens collected from Pap smears, although the sensitivity may be lower than cervical swab specimens.2
As the majority of infected women do not experience clinical symptoms, CDC recommends annual screening of asymptomatic women in the following groups:
- All sexually active women age 25 or younger.
- Sexually active women older than 25 years with certain risk factors: a new sex partner, more than one sex partner, inconsistent condom use, or history of STDs.
- Sexually active men in high prevalence settings (e.g., correctional facilities and STD clinics).
Treatment should be immediate, as any delay can increase the risk of complications, such as PID.2 Recommended treatment:
- Azithromycin 1 gm po as one single dose (treatment of choice for patients with poor compliance or unpredictable follow-up) or
- Doxycycline 100mg po BID x 7 days2
- Erythromycin base 500mg po QID x 7 days or
- Erythromycin ethylsuccinate 800mg po QID x 7 days or
- Levofloxacin 500mg po once daily x 7 days or
- Ofloxacin 300mg po BID x 7 days Patients should be instructed to abstain from sexual intercourse for 7 days after single dose therapy or until completion of a 7 day regimen. Patients should also abstain from sexual activity until their partner(s) have been treated.2
Treatment of partners
Any partners within 60 days of diagnosis and/or the most recent sex partner should be referred immediately for treatment.2
- HIV-positive patients should receive the same treatment as HIV-negative patients.
- Pregnant patients should not use fluoroquinolones or doxycycline as they are contraindicated in pregnancy. Azithromycin is safe for use.2
Test-of-cure: Except in pregnant women, test-of-cure (i.e., repeat testing 3 to 4 weeks after completing therapy) is not advised for persons treated with the recommended or alternative regimens, unless therapeutic compliance is in question, symptoms persist, or reinfection is suspected.2
Re-testing: Because of the high risk of reinfection, usually caused by a failure to treat sex partners or initiation of sexual activity with a new partner, retest 3 months after treatment (or whenever the person next presents for medical care in the 12 months following initial treatment), regardless of treatment status of partners. Repeat infections confer an elevated risk for PID and other complications.