Transcript Slides

Evaluation of a Novel
Internet-based Partner
Notification Program
National STD Prevention Conference
Chicago, Illinois
Wednesday, March 12, 2008
Daniel C. Ehlman, MPH
Public Health Prevention Specialist
Public Health Prevention Service
Centers for Disease Control and Prevention
Co-authors
• Gonzalo Saenz, MD, MPH
• Marcus Jackson
• B W Furness, MD, MPH
Note:
The findings and conclusions in this presentation have not been
formally disseminated by the Centers for Disease Control and
Prevention and should not be construed to represent any agency
determination or policy.
Objective
To evaluate the first 10 months of the
Washington, DC, STD Control
Program’s novel Internet-based
partner notification (IPN) program,
which went into effect March 2007.
Outline
•
•
•
•
Background
Methods
Results
Conclusions
Background
• Internet = sex seeking
• Need for protocol to work on Internet
• Protocol integrated into syphilis case
management
Background (cont.)
Internet-based partner notification uses
Internet locating information (e.g.,
e-mail address) to notify partners of
individuals who have been diagnosed
with an STD.
Background (cont.)
• IPN with syphilis case management
• Internet partners
– No physical locating information
– E-mail address obtained
Methods
Analysis of Field Record STD Disposition
Codes
– Cases of early syphilis (710, 720, 730) with
≥1 Internet partner
– March to December 2007
Methods (cont.)
STD Disposition Codes
• “Traditional” Codes: A, B, C, D, E, F, G, H, J, K, L
• Internet-specific Codes*:
– L1: Informed of Syphilis Exposure
– L2: Informed of STD Exposure
– L3: Not informed/ Unable to Confirm Receipt of E-mail
* We created a local field in STD*MIS to capture IPN Disposition Codes.
Methods (cont.)
• STD*MIS 4.0e
• Microsoft® Office Access 2003
• SAS® 9.1
Results
23 early syphilis cases with ≥1 Internet partner
474 Field Records
151 (32%) initiated by visit/phone
47 = physical locating information
323 (68%) initiated by e-mail
276 = no additional information
Number of IPN Field Records Initiated from 23
Early Syphilis Cases, by Case Number,
Washington, DC, 2007
140
131
120
100
Number
80
of Field
Records
60
(n=323)
40
77
40
25
20
6
12 11
1
1
2
1
3
1
1
1
1
1
1
1
1
2
2
1
07
-0
10
07
-0
21
07
-0
71
07
-1
03
07
-1
08
07
-1
14
07
-1
16
07
-1
23
07
-1
42
07
-1
44
07
-1
45
07
-1
46
07
-1
65
07
-1
68
07
-1
75
07
-1
84
07
-1
85
07
-1
93
07
-2
06
07
-2
09
07
-2
22
07
-2
37
07
-2
52
0
Case Number
Open vs Closed E-mail Systems
• Open e-mail systems
– E-mails can be sent within and outside of
these websites.
– E.g., earthlink, aol, yahoo, hotmail.
• Closed e-mail systems
– E-mails can be sent only within the website.
– E.g., manhunt, adam4adam, men4now.
Number of IPN Field Records Initiated, by
Website, Washington, DC, 2007
200
180
179
160
140
Number
of Field
Records
(n=323)
120
99
100
80
60
40
9
20
2
0
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Number of IPN Field Records Initiated from 23
Early Syphilis Cases, by Disposition,
Washington, DC, 2007
120
106
100
Number
of Field
Records
(n=323)
85
85
80
60
40
18
18
20
2
3
4
2
0
)
)
)
)
)
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(F)
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Disposition
IPN Case Management Indices for 23 Early
Syphilis Cases, Washington, DC, 2007
Contact Index
(# contacts / # cases)
Disease
Intervention
Index
(# cases with at least 1
A or C / # cases)
New Treatment
Index
(# A or C dispo / #
cases)
New Exam
Index
(# A, C, F dispo / #
cases)
Field Records
initiated by
telephone/visit
Field Records
initiated by IPN
Total Field
Records
Washington,
DC-specific
program goals
6.6
(151/23)
14.0
(323/23)
20.6
(474/23)
1.5
0.35
(8/23)
0.35
(8/23)
0.48
(11/23)
0.5
0.83
(19/23)
0.91
(21/23)
1.7
(40/23)
1.0
1.7
(38/23)
1.7
(39/23)
3.3
(77/23)
N/A
Number of IPN Field Records Initiated, by
Disposition within "Informed of Syphilis
Exposure (L1)", Washington, DC, 2007
60
50
40
Number
of Field
30
Records
(n=85)
50
20
29
10
0
5
1
Self-reported
prevent. tx.
Self-reported
infect. & tx.
Self-reported
not infect.
Disposition
No further
contact
Conclusions
• Without IPN, over 300 sex partners (within
the last 10 months) would not have been
investigated
• IPN augments traditional syphilis case
management and aids in location,
notification, testing, and treatment of
partners
Acknowledgements
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Colleen Crowley
Glasford Earlington
Phil Finley
Bruce Flippens
John Heath
Herman Jones
Abdul Mansaray
Emmanuel Puplampu
Florine Quarles
Corine Reid
Sharon Stone
Howard Tinker
Francoise Uwimana
Keith Wells
• Division of STD
Prevention, CDC
• Howard Brown Health
Center, Chicago, IL
• Massachusetts
Department of Public
Health
• Public Health Prevention
Service, CDC
• Washington, DC STD
Control Program
Thank you.
For further information:
Poster P95:
“Integration of Internet-based Partner Notification into Case Management”
Contact information
Dan Ehlman
202-442-4769
[email protected]
[email protected]
Extra Slides
Percentage of IPN Field Records Intitiated, by
Disposition per Website, Washington, DC, 2007
N=179
N=99
N=41
100%
90%
Not Informed
or Confirmed
19 %
2 5%
Informed of
STD Exp.
80%
46%
Informed of
Syphilis Exp.
70%
3 1%
60%
Percentage
of Field
Records
4 1%
2%
Unable to
Locate (H)
50%
Not Infected
(F)
40%
23%
3 7%
30%
20%
8%
26%
Infected,
Treated (C)
1%
10%
10 %
3%
0%
Previously
Treated (E)
1%
12 %
5%
2%
adam 4adam
m anhunt
Website
open e-m ail
Refused Prev.
Tx. (B)
Preventive
Treatment (A)
Risk Factor in STD*MIS 4.0e
Local Field Modification
Local Field Internet Dispositions
Shows how
Internet Partner
names are
recorded
Indicates Internet used
to initiate contact
IPN-specific
dispositions
1st E-mail to Partner
Dear <<screenname>>,
My name is Dan Ehlman, and I am from the Washington, DC, Department of Health,
STD Control Program. I’m e-mailing you because someone you met online was recently
diagnosed with a laboratory-confirmed sexually transmitted disease (STD).
You need immediate medical attention because this person identified you as a sex
partner during the infectious period of this STD. For confidentiality reasons, I cannot tell
you anything about the person you had sex with, including when it occurred.
Please call me at 202-442-4769, and I can tell you more about the specific infection
and where you can go to be tested and treated for free.
If I’m not there when you call, I will call you back. Be sure to leave a number and
time when I can reach you. My voicemail is private, confidential, and passwordprotected.
I check my voicemail and e-mail at the beginning and end of each business day (8am4:30pm, M-F).
If you want to check that this e-mail is real, call the Division of STD Prevention at 202442-4705 and ask to speak with our Medical Epidemiologist, Dr. B. W. Furness.
Thank you,
Dan Ehlman, MPH
Internet-based Partner Notification Coordinator
STD Control Program, Washington, DC, Department of Health
Notification E-mail
Dear <<screenname>>,
Thanks for getting back to me. I wrote to you because someone you met online was recently
diagnosed with laboratory-confirmed syphilis.
According to Centers for Disease Control and Prevention (CDC) guidelines, you need to be
treated immediately for this exposure. You also need to be tested because if you are infected, you
may need additional treatment.
To find out more about this disease:
1) You can call me at 202-442-4769 and I can tell you more, including where to get tested and
treated for free. Our communication is strictly confidential.
2) Print this e-mail and take it to your doctor; the clinician can contact me if necessary.
3) Go to http://www.cdc.gov/std/default.htm to read more about the disease.
It is important that you understand that many STDs are asymptomatic, which means that you
can be infected but not show any visible signs of infection. If an infection is not treated, some
STDs may cause serious long-term complications.
Finally, although we are notifying you about your potential exposure to syphilis, our
recommendation is that anyone getting tested for an STD should consider being tested for all
other common STDs (gonorrhea, chlamydia, and HIV).
If you have any further questions now or in the future about the disease you’ve been exposed
to or the treatment you received, please feel free to contact me at any time.
Thank you,
Dan Ehlman, MPH
Internet-based Partner Notification Coordinator
STD Control Program, Washington, DC Department of Health
“Traditional” STD Disposition Codes
A
Preventive Treatment
B
Refused Preventive Treatment
C
Infected, Brought to Treatment
D
Infected, Not Treated
E
Previously Treated for This Infection
F
Not Infected
G
Insufficient Information to Begin Investigation
H
Unable to Locate
J
Located, Refused Examination
K
Out of Jurisdiction
L
Other
Limitations
• Spam-like appearance of e-mails sent to
open e-mail systems
• Inflexibility of disposition codes
– Program
– IT
• Loss to follow-up
• Lack of trust of DOH by Internet partners
• Lack of control over communication
medium
Recommendations
• Add dispositions to Field Record (CDC
73.2936S)
• Add electronic buffs to STD*MIS
• Work closely with MSM-friendly STD clinics
for patient referrals, perhaps even
contracting out to them
• Create new case management indices that
reflect the anonymous nature of IPN
Number of IPN Field Records, by Website per
Disposition, Washington, DC, 2007
80
70
adam4adam
60
Number
of Field
Records
(n=323)
50
manhunt
40
30
other closed
e-mail
20
10
open e-mail
0
)
2)
(F)
E)
(H
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Tx
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Website
Number of Field Records Initiated from 23
Early Syphilis Cases, by Disposition and Type
of Investigation, Washington, DC, 2007
120
100
80
Number
of Field
Records
Visit/
Telephone
IPN
60
40
20
0
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)
)
)
K)
F)
G)
H)
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Disposition
Number of IPN Field Records, by Disposition per
Website, Washington, DC, 2007
80
Preventive
Treatment (A)
70
Refused Prev.
Tx. (B)
60
Infected,
Treated (C)
Number 50
of Field
40
Records
(n=323) 30
Previously
Treated (E)
Not Infected
(F)
20
Unable to
Locate (H)
10
Informed of
Syph. Exp. (L1)
0
adam4adam
manhunt
other closed
e-mail
Website
open e-mail
Informed of
STD Exp. (L2)
Not Informed
/Confirmed (L3)
IPN Case Management Indices for 11 Cases
with ≥2 IPN-initiated Field Records,
Washington, DC, 2007
Contact Index
(# contacts / # cases)
Disease
Intervention
Index
(# cases with at least 1
A or C / # cases)
New Treatment
Index
(# A or C dispo / #
cases)
New Exam
Index
(# A, C, F dispo / #
cases)
Field Records
initiated by
telephone/visit
Field Records
initiated by IPN
Total Field
Records
Washington,
DC-specific
goals
11.8
(130/11)
28.3
(311/11)
40.1
(441/11)
1.5
0.27
(3/11)
0.64
(7/11)
0.73
(8/11)
1.5
(16/11)
1.8
(20/11)
3.3
(36/11)
1.0
2.7
(30/11)
3.5
(38/11)
6.2
(68/11)
N/A
0.5
Number of Early Syphilis Patients, by Selfreport of Internet Use to Meet Sex Partners,
Washington, DC, 2005-07
300
250
50
200
63
39
Number of
150
Patients
100
137
151
112
50
0
20
2005
38
2006
Year
64
2007
Not Interviewed/
Reviewed
Did Not Self-report
Internet Use
Self-reported
Internet Use
Number of Early Syphilis Contacts and
Clusters, by Investigation Type, Washington,
DC, 2005-07
1000
800
598
600
Number of
Contacts
Visit/ Telephone
IPN
400
200
0
433
0
2005
318
326
0
2006
2007
Year
Syphilis Trends in the District
Figure 1. Infectious Syphilis,
Washington, DC, 2002-2006
114
115
Number of Cases
120
100
69
80
57
49
60
40
20
0
2002
2003
2004
2005
Year
Primary
Secondary
2006
Syphilis Trends in the District (2)
Figure 2. Infectious Syphilis by
Sex, Washington, DC, 2002-2006
9.4
18.2
Number of Cases
120
M:F Ratio
100
80
16.3
6.1
15.3
60
40
20
0
2002
2003
2004
Year
Male
Female
2005
2006
Syphilis Trends in the District (3)
Figure 3.
4. Infectious Syphilis by
Race, Washington, DC, 2002-2006
Number of Cases
120
100
80
60
40
20
0
2002
2003
2004
2005
2006
Year
Asian/PI
Black
White
Other
AI/NA
Syphilis Trends in the District (4)
Number of Cases
Figure 4.
6. Infectious Syphilis by Age
Category, Washington, DC, 2002-2006
45
40
35
30
25
20
15
10
5
0
2002
2003
2004
2005
2006
Year
10-19 y.o.
20-29 y.o.
30-39 y.o
40-49 y.o.
> 50 y.o.