SSHA welcomes the proposed BASHH statement on Partner Notification

30^th November 2011

Dear Hugo,

The Society of Sexual Health Advisers welcomes the proposed BASHH statement on Partner Notification.

Please find the below comments from the National Professional Committee of the Society of Sexual Health Advisers on the Proposed statement

Area of Interest: NPC Society of Sexual Health Advisers

Comments:

Paragraph 2 

At least one discussion (consultation) on PN SHOULD BE ADDRESSED (conducted) BY A sexual health adviser, or other professional trained in Sexual Health Advising or in PN  should be offered to(take place/be conducted) people found to have the infections listed below. Trained in PN means that the practitioner has attained documented competency in PN provision (this be linked to the SSHA competency document) PN is a core component in the management of HIV/STIs.  Therefore IF PN IS NOT ADDRESSED THE REASON FOR THIS SHOULD BE DOCUMENTED. 

After paragraph 2 we feel it would be important to mention that “PARTNER NOTIFICATION SHOULD BE ADDRESSED ON AN ONGOING BASIS FOR CHRONIC VIRAL INFECTIONS SUCH AS VIRAL HEPATITIS’S (hepatitides) AND HIV”

Look Back Intervals Paragraph

“The appropriate look-back interval for PN should be used. The table below lists the infections for which PN should be offered, along with the corresponding look-back intervals”.   SSHA feel it is important to clarify that these look back intervals are for guidance only and the sexual history and knowledge of infections should be looked at in a case by case basis as there may be sexual contacts that fall out of the parameters of these look back intervals.

Table

SSHA have added 2 columns for consideration for this document a column on PN needs actively reviewed out and whether the offer of provider referral is appropriate

Infection	Look back intervals for partner notification	PN NEEDS REVIEW	OFFERPROVIDER REFERRAL
Chancroid	10 days prior to onset of symptoms. Consider epidemiological treatment.	YES	YES
Chlamydial infection	Symptomatic male index case: 4 weeks prior to the onset of symptomsFemale and asymptomatic male index cases: 6 months, or the last sexual contact, whichever gives rise to the longer intervalCURRENT PARTNER AND PREVIOUS 1 (1+1) CAN BE APPLIED WHERE THE SEXUAL HISTORY INDICATES ( SEE SSHA MANUAL) THIS STANDARD FALLS BELOW BEST PRACTICE AND COMMONLY MEANS THAT ONLY THE CURRENT PARTNER IS TRACED AND THEREFORE DOES NOT ADDRESS PUBLIC HEALTH		YES
Gonorrhoea	Symptomatic male index case: 2 weeks prior to the onset of symptomsFemale and asymptomatic male index cases: 12 weeks, or to the last sexual contact, whichever gives rise to the longer interval. (IS THERE NFORMATION ON THE CHANGE OF AETIOLOGY OF GC THAT IT HAS A LONGER INCUBATION PERIOD IE: NOW SEE CLIENTS WHO MAY HAVE HAD ASSYMPTOMATIC GC FOR UP TO 6/12	YES	YES
Hepatitis A	2 weeks prior to and one week after the onset of jaundice. Based on risk assessment of cases without jaundice.	YES	YES
Hepatitis B INFECTIOUS OR CHRONIC DIFFERS    WHAT ABOUT VL  TESTING	Contact tracing should include any sexual contact (vaginal or anal sex, or oro-anal sex) or INJECTING ( DIFFERENT FROM NEEDLE PARTNERS SHARING IE SHARING DRUG PARAPHERNALIA) needle-sharing partners during the period in which the index case is thought to have been infectious. The infectious period is from two weeks before the onset of jaundice until the patient becomes surface antigen negative. In cases of chronic infection, trace contacts as far back as any episode of jaundice or to the time when the infection is thought to have been acquired, although this may be impractical for periods of longer than two or three years. Arrange hepatitis B screening of children who have been born to infectious women, if the child was not vaccinated at birth. For screening of other non-sexual partners who may be at risk, discuss with the CCDC or equivalent. (? Consider testing contacts +/ children of patients with evidence of past infection)	YES	YES
Hepatitis C THIS NEEDS TO BE CONSISTENT WITH  NATIONAL HEPC GUIDANCE   WHAT ABOUT VL /RNA TESTING	Contact tracing should include any sexual contact (vaginal or anal sex, or oro-anal sex) or needle-sharing partners or INJECTING CONTACTS( DIFFERENT FROM NEEDLE SHARING IE SHARING DRUG PARAPHERNALIA (paraphernalia) during the period in which the index case is thought to have been infectious. The infectious period is from two weeks before the onset of jaundice in acute infection. If there was no acute infection trace back to the likely time of infection (e.g. blood transfusion, first needle sharing) although this may be impractical for periods longer than two or three years. Consider (advise) testing children born to infectious women. For other non-sexual contacts thought to be at risk, discuss with the CCDC or equivalent.	YES	YES
HIV infection	Contact tracing should include any sexual contact (vaginal or anal sex, or oro-anal sex) or needle-sharing partners or INJECTING CONTACTS ( DIFFERENT FROM NEEDLE SHARING IE SHARING DRUG PARAPHERNALIA (paraphenalia) during the period in which the index case is thought to have been infectious. Based on a risk assessment, which should take into account sexual and HIV testing history, history of possible seroconversion illness, recent infection testing algorithm (RITA) for HIV infection result (where available) and CD4 cell count.	YES	YES
LGV infection	30 days prior to the onset of symptoms. Consider epidemiological treatment of sexual contacts.	YES	YES
Non-specific genital infection (including non-chlamydial, non-gonococcal urethritis and cervicitis in men and women respectively)	Symptomatic index case: 4 weeks prior to the onset of symptomsAsymptomatic cases: 6 months, or the last sexual contact, whichever gives rise to the longer intervalA QUESTION:  WHOS DOING ASYMPTOMATIC SLIDES THESE DAYS.  and RE 6/12 WE HAD SOME DISCUSSION ABOUT WHETHER THIS IS STANDARD PRACTICE WE WOULD DEFINITELY ALL TREATE REGULAR PARTNERS AND ANYONE IN PAST MONTH BUT SOME  WOULD NOT OFFER PROVIDER REFERRAL.  MAY ALSO BE WORTH MENTIONING IF POSITIVE FOR ANOTHER STI THEN DOES NEED REVIEWED.	NO	NOUNLESS CURRENT PARTNER
Pelvic inflammatory disease / EPIDIDYMITIS	Use the look back intervals for chlamydial infection or gonorrhoea, if these are detected. If these infections are not detected, the look back interval is 6 months prior to the onset of symptoms or to the last sexual contact, whichever gives rise to the longer interval. WE HAD SOME DISCUSSION ABOUT WHETHER THIS IS STANDARD PRACTICE WE DEFINITELY ALL TREAT REGULAR PARTNERS AND ANYONE IN PAST MONTH HOWEVER IF NO STI IS FOUND IF YOU TREATE A PREVIOUS PARTNER THEN THEIR CONTACT WOULD NOT BE TREATED SO WHAT IS THE POINT… but  some clinics WOULD NOT OFFER PROVIDER REFERRAL	YES	NOUNLESS CURRENT PARTNER
Phthirus pubis infestation	3 months prior to the onset of symptoms. NOT NECESSARY TO FOLLOW UPRemove?  – PN not indicated	NO	NO
Scabies infestation	2 months prior to the onset of symptoms.Remove?  – PN not indicated PN FOLLOW UP AND RESOLUTION NOT REQUIRED PROVIDER REFERRAL not OFFERED	NO	NO
Syphilis	Early syphilis:Primary syphilis: 3 months prior to the onset of symptomsSecondary syphilis: up to two years prior to the onset of symptoms Sexual contacts of index cases with early syphilis should have serological testing for syphilis at the first visit, and have this repeated six weeks and three months (12 WEEKS FOR CONSISTENCY)  from the last sexual contact with the index case. IN THE HPA LEAFLET THERE IS A STATEMENT ON WHERE THERE IS A CHANCRE”  IS THIS EVIDENCE BASED HOWEVER THIS SEEMS TO MAKE SENSE BE GOOD PRACTICE …. Consider epidemiological treatment of sexual contacts, particularly for high risk events.   Latent and late syphilis: contact tracing (of sexual partners and children of female patients) should be done back to the date of the last negative syphilis serology, if available.  Otherwise, it should extend back over the patient’s sexual lifetime as far as is feasible.  Because of the possibility of congenital syphilis, consideration should also be given to the testing of mothers (of patients with late syphilis) who were born outside the UK in countries where sub-optimal antenatal care was a possibility	YES	YES
Trichomoniasis	Any partner(s) within the previous 4 weeks should be treated at the same time as the index case. Some clinics do not offer provider referral	NO	YES

Agreed Contact Actions Paragraph 1

SSHA feel it is important to add a comment that a “Not Traceable” outcome is agreed following a detailed and documented discussion with the index client.

Paragraph 2

Would recommend adding “No action is possible or no action is required because contact is already confirmed to be treated”  and that all level 3 services (relevant to England and Wales) should offer provider notification service provided by a sexual health adviser or other professional trained in sexual health advising another good place to link to the SSHA competency pack.

Partner Notification Resolution Paragraph 1

May be worth while adding which infections including BBV’s we are talking about.

An end of this paragraph important to add that PN outcomes should be verified by a clinician where ever possible.

Proposed Auditable PN outcome measures Paragraph

Point 4.  Would advise changing wording from proportion of contacts to the number of contacts per index case.  SSHA would also like it considered that dropping the outcome to 0.4 from 0.6 may mean that services will not carry out PN as effectively as standard has lowered.  If Standard 0.6 or 0.4 this should also apply to total numbers of partners attending whether verified by HCW or Index Patient but would be important to recommend underneath this outcome clinics detail how much of this was verified and non verified.  Also you may wish to increase outcome figure if including all outcomes of verified and non.

SSHA would also recommend adding other auditable outcomes such as,

5. The number of provider referrals given per index case of an infection.

6. The number of provider referrals whose attendance at Level 1-3 sexual health service was documented as verified by a healthcare worker as a proportion of those provider referrals contacted.

Best Wishes

Martin Murchie

President of the Society of Sexual Health Advisers