Why is it so important to have an STD outbreak plan?

Sexually transmitted diseases (STDs) are a major public health problem. They place a significant burden on the healthcare services and on the individuals involved. STDs can pass quickly from person to person, and it is vital that any outbreak is dealt with as quickly and efficiently as possible to try and curb the transmission. Effective forward planning is essential to ensure that this can happen and that everyone knows their specific role in the case of an outbreak, both at a local and national level.

What is different about STD outbreak management compared to other diseases?

Compared to other infectious diseases, sexually transmitted diseases (STDs) have particular features that need to be taken into account when planning the outbreak plan.

• Disease stigma – there is often a certain amount of stigma attached to contracting an STD and this may mean that those infected or at risk are reluctant to seek help or treatment.
• Confidentiality – the levels of confidentiality are very important to those that have or treat STDs and this may restrict the availability of the disease data.
• Management of sexual partners – many STDs require effective treatment of both the infected individual and all current and recent sexual partners to ensure that the disease does not reinfect or is passed on to others via the sexual partner. Identification and treatment of all partners may prove difficult.
• Sexual behaviour – unlike many other diseases, effective treatment does not always eradicate the disease. As many STDs are asymptomatic, carriers can pass the infection on without knowing it. It is therefore important that any plan is focused on an altering of sexual behaviour in order to halt the spread of the disease as early as possible.

In general, the basic principles involved in an STD outbreak plan are the same for an outbreak of any other infection. However, the nature of the STDs means that a slightly different approach is needed in certain areas of the plan.

• Identification – many different healthcare professionals are involved in the identification and investigation of the STD. It is important that the plan takes this into account and that all healthcare professionals are aware of their responsibility in helping to prevent the spread and to curb the disease. Often an outbreak will not be noticed in one particular region, as patients will travel to clinics outside their local area to avoid being recognised. This potential problem needs to be taken into account when putting together a plan.
• Multidisciplinary approach necessary – due to the nature of an STD outbreak and the range of potential healthcare professionals involved, it is important that as many teams as possible are involved in the investigation, and not just the public health team. It is very important that members from the genito-urinary medicine (GUM) services are involved at every stage.
• Interventions to suit the particular need – the interventions required at the time of an outbreak will depend upon the type of disease and the population at risk. Effective interventions to try and prevent the spread of the infection will rely upon identifying the sexual contacts and networks involved.
• Time involved – the timescale involved in an STD outbreak will be significantly longer than for other infectious diseases.

Who is responsible for the outbreak plan?

Within the different local Primary Care Trusts (PCTs), the Genito-Urinary Medicine (GUM) Consultant is responsible for the control of sexually transmitted diseases (STDs). At regional and national levels, surveillance and control of STDs falls to the Communicable Disease Surveillance Centre (CDSC).

Strategic Health Authorities are responsible for ensuring that effective plans are in place for the local surveillance of STDs. The Health Authorities should make sure that these plans are agreed with the Consultant in Communicable Disease Control (CCDC) and the GUM physicians. It is very important that these plans include an agreed method of alerting the CCDC to a potential outbreak as soon as possible.

The CDSC assists the PCTs, on behalf of the Department of Health, with performing their roles in the control of communicable diseases. The prevention of STDs and the investigation and management of any outbreak of infections depends on the quality of information gathered. Therefore it is important that there is a good solid outbreak plan in place that works alongside sound surveillance systems, and that everyone involved is aware of their roles and responsibilities in the control of STDs.

What actually happens when there is an outbreak of an STD?

In the event of a local outbreak, the CCDC will determine if and when to inform the CDSC regional units, the head office of the Health Protection Agency Centre for Infections and the Department of Health. Generally, the CDSC will be informed when the outbreak crosses district boundaries, involves a large amount of cases, involves HIV or congenital cases, or is likely to attract media attention.

In general, the outbreak plan falls into three phases – the preliminary, the control and the evaluation phase. The preliminary phase involves the following objectives:

• identifying whether a problem exists
• assessing the nature and extent of the outbreak
• determining what immediate steps should be taken in order to identify those who are ill, identify the contacts of the infected individuals and to ensure that the patients receive the appropriate type of care
• assessing whether the outbreak is significant enough to need special arrangements for investigation and management.

The control phase aims to develop and implement strategies that will stop the spread of the disease. The objectives of this phase include:

• identifying and treating all sexual contacts of infected individuals to prevent the disease from spreading any further
• identifying the network of transmission and putting appropriate interventions in place to disrupt it
• identifying any linked cases
• providing effective management for the patients
• preventing the infection from recurring.

The final phase of the outbreak plan is the evaluation phase. The objectives here are to:

• monitor how effective the plans have been
• make any changes necessary based on their evaluation.

For more detailed information on an STD outbreak plan see Guidelines for managing outbreaks of sexually transmitted infections at a local, district or regional level by the HIV/STI Division, the PHLS Communicable Disease Surveillance Centre in collaboration with the Medical Society for the Study of Venereal Diseases, The Association of Genito-urinary Medicine and the Public Health Medicine Environmental Group.

It is important to remember that everyone in contact with patients has a responsibility to be vigilant about STDs. You should therefore make sure that you are aware of the processes to follow should you suspect an outbreak.

Outbreak plan - further web links

Health Protection Agency
www.hpa.org.uk

Outbreak plan - references

COMMUNICABLE DISEASE SURVEILLANCE CENTRE (2002) Guidelines for managing outbreaks of sexually transmitted infections at a local, district or regional level. An outbreak plan [on-line]. HIV/STI division, PHLS Communicable Disease Surveillance Centre, MSSVD, AGUM, PHMEG.
Available at: www.hpa.org.uk/infections/topics_az [Accessed 19 April 2005].

Outbreak plan - related resources

An internet-based toolkit for managing outbreaks and other acute incidents of infectious syphilis.
http://www.hpa.org.uk/infections/toolkit/managingsyphilis.htm

A toolkit for Primary Care Trusts and other healthcare workers working to promote good sexual health and HIV prevention.
http://www.dh.gov.uk/assetRoot/04/07/96/03/04079603.pdf

Why is surveillance necessary?

Sexually transmitted diseases (STDs) can spread through the community very quickly. Without effective monitoring and surveillance methods, healthcare professionals would be unaware of the extent of the spread of disease. By performing this monitoring, it is possible to keep an eye on the levels of disease, which population groups are affected and also to detect possible outbreaks at an early stage. This enables surveillance groups to make informed decisions about actions needed to control and prevent the disease, and to identify and control the source of the infection.

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Who is responsible for gathering the surveillance data?

At a national level, the Communicable Disease Surveillance Centre (CDSC) (on behalf of the Health Protection Agency) is responsible for the gathering and control of surveillance data relating to infectious diseases. In the event of a disease outbreak that is of national significance or that crosses several counties, the CDSC will co-ordinate the control methods.

In England and Wales, the national centre for surveillance of HIV and AIDS and other STDs is the HIV and STI division of the CDSC. The centre is made up of four main sections:

• HIV and AIDS reporting section – this section monitors previously diagnosed cases of HIV or AIDS
• unlinked anonymous section – this section monitors the unlinked anonymous programmes of HIV testing
• STI section – this section monitors all other STDs
• behavioural surveillance section – this section monitors trends in sexual behaviour.

There are also other more minor units within the centre such as those concerned with surveillance of STDs in prisons.

At a local level, all genito-urinary medicine (GUM) clinics have a statutory responsibility to report their data on STDs. Further information is also collected via NHS laboratories throughout the UK. The laboratories provide voluntary electronic reporting on diagnoses of selected STDs with information on age and sex.

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How are the surveillance data collected?

All genito-urinary medicine (GUM) clinics have a statutory responsibility to return completed KC60 forms to their regional CDSC when they have a positive diagnosis of a sexually transmitted disease (STD). Click here to see an example of a KC60 form. This provides data on the total number of diagnosed cases of STDs seen by the GUM clinic, by sex, age and, for selected conditions, sexual orientation. In Scotland, the data are collected via the Information and Statistics Division (ISD)(D)5 returns system. This provides data for all STDs diagnosed in Scottish GUM clinics. Click here for more information on the ISD(D)5 return system.

Click here to see an example of a ISD(D)5 form.

Completed KC60 and ISD(D)5 forms are sent to the regional CDSC offices for processing. This information is then transferred to the national CDSC or HIV and STI Division on a weekly basis. Currently, the surveillance data gathered by the CDSC do not necessarily include positive diagnoses made at other healthcare centres, such as in the GP’s surgery.

Click here for more detailed information on how surveillance data are collected.

What different surveillance systems are currently underway?

There are a number of different surveillance systems underway to try and collect specific information relating to STDs. These systems include:

• behavioural surveillance
• HIV/AIDS reporting – unlinked anonymous HIV surveys
• National Enhanced Laboratory Reporting of Infectious Syphilis
• programme for enhanced surveillance of STDs (ProgrESS)
• gonococcal resistance to antimicrobial surveillance programme (GRASP).

Behavioural surveillance

Behavioural surveillance is performed by the Behavioural Surveillance section of the National Centre for Surveillance of HIV and AIDS and other STDs. Behavioural surveillance is performed to try and define, collate and monitor the behavioural patterns responsible for the spread of HIV and other STDs. These programmes can help identify the patterns of risk behaviours within the general population and can be key in identifying the messages and target audience for sexual health related campaigns and when formulating disease control strategies.

HIV/AIDS reporting

Any new diagnoses of HIV or AIDS are reported to the relevant surveillance body by the GUM clinics via the KC60 or ISD(D)5 forms, or by laboratories or clinicians on a voluntary basis.

One survey being carried out on HIV prevalence is the annual Survey of Prevalent HIV Infections Diagnosed (SOPHID). This survey began in 1995 and provides a national view on the numbers of individuals with previously diagnosed HIV who are receiving HIV-related care within England, Wales and Northern Ireland. This information is used at both a national and local level when planning and financing HIV care services and in health promotions. Click here for further information on SOPHID.

Another HIV surveillance programme is the National CD4 Surveillance Scheme. This scheme aims to monitor the immunosuppression associated with HIV by monitoring the levels of CD4 counts. Data are provided by the laboratories. In Scotland, these data are used to estimate the number of patients in specialist HIV care. Click here for further information on the CD4 surveillance scheme.

The Unlinked Anonymous Prevalence Monitoring Programme (UAPMP) aims to investigate the prevalence of undiagnosed infections, particularly HIV, within accessible groups of adults. The tests are performed on samples taken from patients for other routine tests with all forms of identification removed. In recent years, over 800,000 samples have been tested annually. Results from the programme provide estimates of the prevalence of HIV and hepatitis B and C among those who are undiagnosed and may otherwise go undetected. These data are then used to target and evaluate future health promotions and to estimate the numbers of patients who may need treatment for the diseases in the future. This survey produces essential public health information that could not be obtained in any other way.

Click here for further information on the Unlinked Anonymous Prevalence Monitoring Programme (UAPMP).

National Enhanced Surveillance – Syphilis

The National Enhanced Laboratory Reporting of Infectious Syphilis protocol was set up following the rise in diagnosed cases in both homosexual men and heterosexual men and women. Syphilis is an STD that can have serious health consequences. The disease places a great burden on both the individual and the National Health Service. The surveillance system works to provide information on the geographical and demographical spread of the disease, the risk factors involved, and to monitor the levels and trends of infection in behavioural risk groups.

The information is collected from all laboratories in England and Wales on a voluntary basis. After receiving a positive result from the laboratory, detailed demographic, behavioural and clinical information is collected from GUM clinics by the CDSC.

Click here for further information on National Enhanced Laboratory Reporting of Infectious Syphilis.

In Scotland, surveillance data on syphilis are collected via the National Enhanced Surveillance of Infectious Syphilis in Scotland (NESISS).

Programme for enhanced surveillance of STDs (ProgrESS)

The programme for enhanced surveillance of sexually transmitted diseases (ProgrESS) collects detailed surveillance information from GUM clinics in London and parts of the former Thames region. It is planned that this will be extended to all computerised GUM clinics in England and Wales.

Gonococcal Resistance to Antimicrobial Surveillance Programme (GRASP)

Gonorrhoea is the second most common bacterial STD in England and Wales and its incidence is increasing. In general, treatment is effective with antibiotics, and 95% of cases should be successfully treated. However, problems are arising due to the development of resistant strains of Neisseria gonorrhoeae, the bacteria responsible for gonorrhoea.

To monitor this resistance, the Gonococcal Resistance to Antimicrobial Surveillance Programme (GRASP) was set up. GRASP started collecting information in 2000 and has given the first surveillance data on the prevalence of antimicrobial resistant gonorrhoea. This has meant that the numbers of resistant organisms can be monitored, as can their location around the country. Potential outbreaks or trends can be identified at an early stage and preventative measures put in place. Click here for further information on GRASP. Similar surveillance is underway in Scotland using the Neisseria gonorrhoeae reference library, which covers all gonococcal isolates identified in Scotland.

What about patient confidentiality in surveillance?

NHS Trust and Primary Care Trust (Sexually Transmitted Diseases) Directions 2000 state:

‘Every NHS Trust and Primary Care Trust shall take all necessary steps to secure that any information capable of identifying an individual obtained by any of their members or employees with respect to persons examined or treated for any sexually transmitted disease shall not be disclosed …’

This means that all surveillance systems have to have appropriate steps in place to ensure that the identity of the individuals giving the samples remains hidden at all times. Patient confidentiality is of utmost importance. There are areas where certain patient identifiable information can be released but this is only under certain circumstances and when it is absolutely necessary.

In 1997, the Caldicott report identified weaknesses within the confidentiality practices of the NHS and guidelines were recommended. The basic principles of the Caldicott report are:

• the use of patient data should be justified at all times
• patient-identifiable data should only be used if it is absolutely necessary
• when using patient-identifiable data, only use the minimum required for the task in hand
• access to these data should be restricted
• everyone involved with patients should be aware of their responsibility to patient confidentiality
• everyone involved should understand and comply with the law.

Click here for further information on patient confidentiality aimed at healthcare professionals.

Click here for general information on patient confidentiality.

In 2003, the guidance recommended in the Caldicott report was reviewed and the NHS Code of Practice for Confidentiality was published.

Surveillance - further web links

Health Protection Agency
www.hpa.org.uk

European Surveillance of Sexually Transmitted Infections
www.essti.org

Scotland’s Health on the Web
www.show.scot.nhs.uk

Health Protection Scotland
www.show.scot.nhs.uk/scieh

Department of Health
www.dh.gov.uk

This content is not intended nor does it replace individual professional advice. Please contact a healthcare professional or seek advice from NHS Direct (0845 46 47) NHS Direct Wales (0845 46 47) or NHS 24 in Scotland (08454 24 24 24).