Disease Intervention Specialists  (DIS)

SEXUALLY TRANSMITED DISEASE (STD) INTERVENTION

STD intervention, prevention and control is a cooperative effort that involves private physicians, other health care providers, local and state health department personnel, and members of the community at large.

MEET THE DIS!

A key player in the public health STD field is the Disease Intervention Specialist (DIS). There are 11 DIS in Oregon and two field supervisors. The majority of DIS are based in the Portland area. The DIS is a trained professional with experience in the epidemiology of STDs. They must know how to take sexual histories, identify and locate contacts, and refer persons for evaluation and treatment. They also provide counseling about behavior that puts clients at risk for STDs, including HIV infection. STDs are very sensitive issues for many people. Therefore, the DIS must gain the confidence of the patients (and sometimes, their medical providers!). Many DIS possess special skills that enhance the case-finding and prevention efforts. Some are bilingual, and others are adept at providing services to specific populations.

The DIS is also available to assist medical providers locate patients who may have been seen but who failed to return to get positive test results or treatment. In those cases, they can act as an agent of the medical provider, using their own resources and experience to locate these patients. Once located, patients can be referred back to the original provider or to a county clinic as appropriate.

In addition to individual case investigations, DIS offer STD educational programs to various audiences, including colleges, correctional facilities, health care providers, specific communities and the general public. Bilingual skills broaden the audience range.

HOW CONTACT TRACING WORKS

Prevention and control of STDs require a blend of case identification, effective treatment, partner notification and referral, and education and behavior modification counseling. Contact tracing has been effectively used as a public health strategy in the U.S. to control STDs, notably syphilis, since the 1940s. The process is initiated when the health department receives a disease report, e.g., primary syphilis or gonorrhea, from a medical provider or laboratory.

Typically, the caseworker contacts the reporting physician to verify patient demographics, review treatment history, and inform them of the state laws concerning STDs. The health department is expected to contact the patient to discuss the infection and arrange for partner notification. The advantage of the DIS/provider partnership is total patient care coupled with action to prevent STDs in the community. While the provider's primary concern is to diagnose and treat, the DIS employs a comprehensive disease intervention approach through contact interviewing and partner field investigation. Patient/partner confidentiality is paramount as each case is worked.

The DIS focuses on:

• providing the patient with accurate education about his/her disease and the techniques to prevent infection in the future;
  
• identifying and solving problems;
  
• establishing a contract with the patient to afford unaware partners with confidential and expeditious diagnosis and treatment; and
  
• locating exposed partners and coordinating their medical follow-up.

Generally, the patient and the DIS arrive at a plan to assure that at-risk partners are notified. In some instances, the patient decides to notify and refer their own sexual partners. In this case the DIS provides coaching on how to do this successfully. In other cases, patients prefer that the DIS take the responsibility to notify their partners. When a DIS notifies exposed partners, identifying information about the original patient is never disclosed. Asymptomatic sex partners (especially males) are often reluctant to seek evaluation without additional motivation resulting from a successful interview. The DIS operates confidentially, maintains a sense of urgency, and persists without being aggressive. Patients and the partners they name are notified with 48 hours if at all possible.

Patients are always asked to provide names and other identifying/locating information for sexual contacts. The timeframe covered varies with the disease: a month before symptom onset for gonorrhea cases (3 month for gonococcal PID); 3 months for primary syphilis; 6 months for secondary syphilis; and up to a year for early latent syphilis. Chlamydial infections are more problematic. Investigators typically cover the month or two before onset, but in light of the long asymptomatic period that may occur, further look-back may prove necessary. HIV contact tracing is even more open-ended. Questions cover at least the previous year and often much longer.

Many persons contacted by DIS are less than enthusiastic about notification. However, almost all are cooperative once they understand the concerns of the DIS and are assured of the absolute confidentiality of the information they provide. Many individuals are unable to provide useful information about some of their contacts. They may know only partial or fictitious names, or the contact may have been anonymous.

Contacts of syphilis, gonorrhea, or chlamydia cases are offered a diagnostic work-up and are treated prophylactically based on exposure. Contacts of HIV-infected persons are referred for additional counseling and testing.

2002 INTERVENTION RESULTS

Over 3,150 persons reported with HIV, syphilis, gonorrhea, or chlamydia were case managed by DIS during 2002. This activity included STD education, risk reduction counseling, and interviewing for at risk sex partners. Additionally, DIS confidentially located and notified nearly 2,400 partners of their STD exposure and assisted these partners in accessing health care.

CONCLUSIONS

Partner notification has been shown to be an effective means of identifying, treating, and counseling infected at-risk individuals. It is an important adjunct to a broader-based campaign aimed at reducing the incidence of STDs and prevents pregnancy. Contact tracing is labor intensive and often an awkward business that many providers lack the time, inclination, and specialized training to do well. There is a continuing need for providers to report all cases of reportable STDs to their local health department and to assist the DIS or other STD control personnel in the required follow-up for these individuals. In addition, surveillance data allows for statistical assessment of disease trends and targeting of prevention resources.