These guidelines have been produced as a working document for all Health Advisers based in Departments of Genito-Urinary Medicine. It is anticipated that they will also be of benefit to those interested in the issues of partner notification in sexually transmitted diseases.
PARTNER NOTIFICATION GUIDELINES
In 1993 the Society of Health Advisers in Sexually Transmitted Diseases (SHASTD) established a working group to produce guidelines on partner notification. This working group consisted of health advisers from Departments of Genito-Urinary Medicine (GUM) from within the United Kingdom, representing both urban and rural areas. Through this initiative these guidelines have been produced. For the purposes of these guidelines the term partner notification will be synonymous with contact tracing.
The United Kingdom saw the establishment of the first contact tracing projects for sexually transmitted diseases (STDs) over forty years ago. Initially these projects were developed to identify, diagnose and treat the contacts of persons with venereal diseases, essentially gonorrhoea and syphilis. It was during this period that the availability of treatment for all STDs highlighted the public health issues and identified contact tracing as an important part of control. Although these early initiatives were only a part of the wider public health approach, it is recognised that contact tracing has played and continues to play a fundamental role in the control of STDs in the UK. These continue to be the basis of the management of partner notification as we know it today, which has developed over the years to become a complex and challenging component of the role of the health adviser.
The partner should be given information on:
The approach whereby an infected patient is encouraged to notify partner(s) of their possible infection without the direct involvement of health care providers. The patient may: (i) provide the partner with information; (ii) accompany the partner to the clinic; or (iii) simply hand over a contact slip. The health care provider may counsel patients about the information to be passed on to their partners and the methods of providing it.
The approach whereby health care providers or other health care workers notify a patients partner(s). The infected patient provides information on partner(s) to a health care worker, who then confidentially traces and notifies the partner(s) directly.
(World Health Organisation Management of Patients with STDs)
Partner notification should be voluntary and not punitive in any way. Index patients should have full access to available services whether or not they are willing to co-operate in notification activities.
Confidentiality is of paramount importance in the area of GUM. All health professionals are bound by a common law duty of confidentiality. In addition to this the NHS (Venereal Diseases) Regulations 1974 and the National Health Service Trust (VD) Directive 1991 offer additional protection to patients rights of confidentiality. The records of all patients attending a GUM must remain confidential to that department.
The agreement and co-operation of the index patient must be established before partner notification can be undertaken. It is important that the index patient understands the need to inform partner(s)/contacts who have possibly been exposed to an STD. To enable this to happen clear, detailed and relevant information about the nature of the infection needs to be obtained and its modes of transmission clarified. The Society believes that all health advisers should work to the SHASTD Code of Ethics in order to provide a professional and ethical health advising service. Partner notification should be undertaken within the context of a full GUM service. This includes a full screening, diagnostic and treatment service to include not only partner notification but also health education/promotion and counselling. It is important that all patients have the opportunity to explore factors which affect the individual risk to their own sexual health.
Partner notification should be non-coercive, confidential
should not be seen as punitive
1. Patient referral
The majority of partner notification in the UK is patient referral based. The preferred method of patient referral is through the use of contact slips. These enable reliable and efficient cross-referencing and ensure appropriate screening and treatment of the contact. The use of Department of Health diagnostic codes for STDs on contact slips provides an anonymity and confidentiality for the index patient. All health advisers should be conversant with Department of Health diagnostic codes for STDs. Health advisers are the key health care professionals involved in patient referral partner notification other health care workers, e.g. doctors, may instigate patient referral partner notification with the issue of contact slips.
a) enable sexual contacts to seek medical advice and treatment
b) to inform the contacts clinic of index patients diagnosis, reference number and date of diagnosis.
c) to cross reference and enable evaluation of partner notification action.
The issue of contact slips should include the following considerations:
ii) Each contact slip with contain the following information relating to the index patient; date of diagnosis, reference number; Department of Health diagnostic code; name and address of issuing clinic. The reverse of the contact slip ship should be completed with the contacts information, reference number; date of attendance, Department of Health diagnostic code and name and address of issuing clinic. If contacts attend other GUM, completed contact slips should be returned to the issuing clinic as soon as possible.
iii) All information from contact slips should be cross-referenced.
Patient referral partner notification may take place without the issuing of contact slips, for example, when the contact is only accessible by telephone or lives abroad (Department of Health diagnostic codes are not applicable outside the UK). World Health Organisation codes are available but, as these may not be widely used, naming the infection may be preferable.
Patients should be encouraged to use contact slips as this helps facilitate the management of partner notification.
2. Provider referral
This is where the index patient decides that they wish the health adviser to manage partner notification on their behalf.
To enable the health adviser to carry out provider referral the index patient must give full and accurate information regarding contact(s) sought. Provider referral should be offered by health advisers to those patients where other methods of partner notification are inappropriate.
As with all forms of partner notification the confidentiality of the index case must be protected, although it is important that possible loss of confidentiality is discussed with the index patient before any provider referral is commenced. Identification of the index patient must never be confirmed by a health adviser. However, if the contact has only one sexual partner, confidentiality may be compromised.
It may be necessary for the health adviser to seek the assistance of colleagues in other clinics in order to carry out provider referral.
Provider referral may take place by letter, telephone call or domiciliary visit.
There should be nothing specific in the letter to suggest STDs. The envelope should be marked Private and Confidential Addressee Only and the envelope should not be identifiable as being sent from a hospital. The full name and address provided the index patient should be used. It is sometimes possible to check addresses through the telephone directory, FHSA and electoral roles. A telephone number for easy access to a health adviser needs to be included in the letter in order to encourage swift resolution of partner notification.
The correct identify of the patient contact needs to be established by the health adviser. Issues to be taken into account include: convenient time for discussion of a personal nature and possible need for verification of the authenticity of the call. Checking correct identity over the phone is difficult, therefore one should disclose as little as possible and encourage a face to face interview.
The advantages and disadvantages of each individual domiciliary visit need to be carefully considered prior to undertaking this method of partner notification. Visits risk causing domestic upset to the partner/contact if other family members/friends or partners are present, but allow for the contact to be informed of their potential exposure and to be reassured. As with all domiciliary visits the safety of staff is of paramount importance.
Partner notification must take into account both current and ex-partners, as is appropriate to the aetiology of the infection. The amount of time and effort spent on partner notification will depend on the diagnosis, the probable duration of infection, individual patient factors, and resources.
There may be situations when it is impossible and/or inappropriate to instigate partner notification. Health advisers must document the reasons for not notifying partners.
Health advisers need confidential, soundproofed rooms to see patients for partner notification. It is important for private, uninterrupted consultation to take place in order to facilitate this process.
Health advisers involved in partner notification should have adequate professional supervision and support
It is important that the network of health advisers throughout the United Kingdom is utilised and strengthened and that information sharing between clinics is encouraged.
All health advisers should be actively encouraged to attend the National Health Advising Training courses that are available. In addition to this, health advisers should be supported in their professional development by management and the team within which they work. Health advisers should take responsibility for their professional development and the updating and enhancing of skills and knowledge.
The safety of health advisers, as with all health care workers, should be of paramount importance.
Documentation should be accurate and complete, to enable regular audits to take place.
The rights of the index patient and their partner/contact must be respected.
Partner notification can be complicated further by issues of sexuality. The health advisers should be aware of the need for sensitivity in relation to issues of sex and sexuality.
Health advisers are responsible for managing the processes and outcomes of partner notification. However, within the multidisciplinary setting, it may be appropriate for doctors and nurses to raise some of these issues.
It is hoped that these guidelines will facilitate partner notification and encourage good practice and management. In addition it is hoped that those clinics that do not have a written policy for partner notification will use these guidelines as a basis from which to work.