CDC Epi Aid Report
CDC Epi Aid Report
CDC Epi Aid Report
DATE:
FROM:
Elizabeth A. Torrone, PhD, MSPH, EIS Officer, Epidemiology and Surveillance Branch,
Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention, Centers for Disease Control and Prevention
James Keck, MD, MPH, EIS Officer, Arctic Investigations Program, Division of Preparedness
and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases,
Centers for Disease Control and Prevention
SUBJECT:
TO:
Douglas H. Hamilton, MD, PhD, Director, EIS Program, Division of Applied Sciences (proposed)
Scientific Education and Professional Development Program Office, Office of Surveillance,
Epidemiology and Laboratory Services, Centers for Disease Control and Prevention
BACKGROUND
In August 2009, Alaska state health officials reported an increase in gonorrhea infection in the
Southwest region of the state and in March 2010 reported that the gonorrhea infection rate was increasing
statewide. The 2009 case rate of 145 cases per 100,000 persons was a 71% increase from the 2008 rate of 85
cases per 100,000 persons, the largest single year increase in Alaska since the 1970s. From January 2008 to
June 2009, gonorrhea testing completed in the Alaska State Public Health Laboratory did not increase, but the
proportion of specimens which tested positive increased by 1.3% per month. A review of sexually transmitted
disease (STD) control operations identified difficulties in treating sex partners, particularly for patients in remote
areas. Additionally, Alaska has had the first or second highest chlamydia case rate in the United States each
year since 2000 and rates have increased nearly every year since 1996. Co-infection is also common; in 2009,
296 (30%) reported gonorrhea cases occurred in persons who were co-infected with chlamydia.
Little is known about the knowledge, attitudes, and practices regarding expedited partner therapy (EPT) in
Alaska. EPT is the clinical practice of treating the sex partners of patients diagnosed with chlamydia or
gonorrhea by providing prescriptions or medications to the patient to take to his/her partners. While existing
state law does not explicitly prohibit EPT in Alaska, the State Medical Board has proposed regulation that will
support its use. The proposed regulatory change states that prescribing EPT for sexually transmitted diseases
is not considered unprofessional conduct.
In May 2010, the Alaska Department of Health & Social Services Section of Epidemiology (ADHSS SOE)
requested assistance from the Centers for Disease Control and Prevention (CDC) in identifying opportunities
for enhanced partner services through EPT. On June 3, 2010, an EIS officer from the Division of STD
Prevention (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention) traveled to Alaska and
was joined by an EIS officer from the Arctic Investigations Program (National Center for Emerging and
Zoonotic Infectious Diseases) to assist the state in this investigation.
The primary objectives of this investigation were to:
1. Determine knowledge, attitudes, and practices of expedited partner therapy for gonorrhea and
chlamydia control among policy makers, healthcare providers, patients, and other key stakeholders.
2. Develop a plan for implementing and evaluating expedited partner therapy as a gonorrhea and
chlamydia control effort.
METHODS
The investigation consisted of five activities.
To determine knowledge, attitudes, beliefs, practices about expedited partner therapy (EPT) and barriers to
case treatment and partner notification, we conducted
1. An online statewide survey of healthcare providers;
2. In-person or phone semi-structured interviews with key stakeholders at the state level and at the
community level in purposefully sampled areas based on STD morbidity;
3. A self-administered survey of patients receiving STD services or at-risk for STDs in purposefully
sampled areas based on STD morbidity; and
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4. In-person or phone semi-structured interviews with patients in two purposefully sampled areas based
on STD morbidity.
To develop a plan for implementing and evaluating EPT as a gonorrhea and chlamydia control effort, we
conducted
5. Meetings with key personnel at the Alaska Department of Health & Social Services Section of
Epidemiology (ADHSS SOE) and other key stakeholders.
Stakeholders at the community level (e.g. healthcare providers, clinic managers) in purposefully sampled
areas based on gonorrhea and chlamydia morbidity:
Concentrated on areas with highest rates (Anchorage/Mat Su and Southwest) using convenience
sample of providers at public, private, tribal and non-profit venues in each region
Limited coverage in remaining 4 areas (Southeast, Gulf Coast, Northern, Interior) using a
convenience sample of providers in tribal health clinics and public health centers
Stakeholders were identified by ADHSS SOE staff with additional key stakeholders identified through local
partners and interviews.
Data collection
Participants were contacted by phone and asked to participate in person or by phone. In some cases, a
local contact (e.g. hospital medical director, community health aide/practitioner assistant program director)
facilitated and/or scheduled interviews with participants. Interviews were conducted by CDC or ADHSS
SOE staff. Interviewers took notes, but did not audio record the interviews. Responses were usually
summarized rather than written verbatim. Some interviews were conducted in a group setting to
accommodate time constraints. Interviews were conducted between June 4th and July 12th. CDC and
ADHSS SOE staff traveled to the Southwest region to conduct in-person interviews with key stakeholders
in Bethel from June 14th 16th.
Data analysis
Interview notes were transcribed and were reviewed by the two CDC EIS officers. Themes were identified
using content analysis.
period. Surveys were distributed to clinics/venues beginning June 14th (varying start dates) and data
collection continued until July 12th (varying stop dates). Most clinics/venues assisted in data collection for
two weeks.
Data entry and analysis
Hard copy surveys were data entered in surveymonkey.com. The complete dataset was outputted from
surveymonkey.com into SAS. Descriptive statistics of responses were calculated using SAS v9.13.
Responses to an open ended question were reviewed by the two CDC EIS officers and themes identified
using content analysis.
4. In-person or phone semi-structured interviews with patients in two purposefully sampled areas
Survey development
We developed a 5 question semi-structured interview guide based on input from content experts at CDC
and the ADHSS SOE. (Attachment 2.4) Local service providers reviewed the interview guide for cultural
competency.
Target population
Patients diagnosed with gonorrhea or chlamydia or at risk for STDs in a convenience sample of
clinics/venues in two purposefully sample areas based on STD morbidity (Anchorage/Mat Su and
Southwest).
Data collection
Participants were identified by a local contact (e.g. disease intervention specialist, nurse) who obtained
permission from the participant to be interviewed by a CDC or ADHSS SOE staff. Interviews were
completed in person or by phone. Interviews completed in person were conducted in a confidential setting
(e.g. a clinic exam room). Participants were provided a brief summary of the investigation prior to the
interview and told that all information would be kept confidential. Interviewers took notes, but did not audio
record the interviews. Responses were usually summarized rather than written verbatim. One group
interview was held in a local youth correctional facility. Interviews were conducted between June 11th and
June 30th. CDC and ADHSS SOE staff traveled to the Southwest region to conduct in-person interviews
with patients in Bethel from June 14th 16th.
Data analysis
Interview notes were transcribed and were reviewed by the two CDC EIS officers. Themes were identified
using content analysis.
5. Meeting with key personnel at the ADHSS SOE and other key stakeholders
We conducted interviews with ADHSS SOE STD/HIV program staff and other key stakeholders to
Identify existing infrastructure for partner notification/treatment monitoring
Identify possible infrastructure improvements for partner notification/treatment monitoring
Identify resources for EPT implementation
Develop process measures for EPT implementation
Develop outcome measures for EPT implementation
Interviews were conducted from June 4th to July 2nd.
Non-research determination
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Because this evaluation is part of a public health response to the ongoing gonorrhea and chlamydia
epidemics in Alaska, the project was determined to be public health practice by both the CDC
(Appendix 3.1) and Alaska Area (Appendix 3.2) institutional review boards.
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RESULTS
Summary of key findings
EPT practices and attitudes: healthcare providers and other key stakeholders
45% (53/119) of healthcare providers use EPT with 12% (14/119) using EPT more
than half the time.
88% (105/120) of healthcare providers thought EPT would prevent the spread of
STDs in Alaska although risk of allergies/adverse reactions was a concern.
88% (105/120) of healthcare providers said they would be willing to use EPT and
67% (80/120) said they would use it usually or always if there were a state
recommendation.
53% (64/120) of healthcare providers said giving antibiotics would be the most
effective EPT method to ensure partners are treated.
In qualitative interviews and open-ended survey questions, key stakeholders and
providers reported that EPT would be useful as a tool in the toolbox, but may result
in missed opportunities such as education, screening for other STDs and extended
partner notification.
EPT practices and attitudes: patients
62% (202/325) of patients would be willing to use EPT for all of their partners and
93% (301/325) would be willing to use EPT for at least one of their partners.
87% (283/325) of patients would be willing to take an antibiotic or get a prescription
filled if given to them by a sex partner.
86% (281/325) of patients said they knew the names of all of their sex partners.
25% (77/325) of patients would not be willing to give the names of all of their sex
partners to their healthcare provider.
8% (26/325) of patients reported that they would keep medication for themselves.
19% (63/325) of patients reported that they would prefer provider-conducted partner
notification for some partners.
In qualitative interviews and open-ended survey questions, patients reported that
going to the clinic is the best way for partners to get treated.
EPT facilitators and barriers: healthcare providers, other key stakeholders and patients
State and employer recommendations/guidelines, regulations to decrease liability
and easy-to-use patient/partner educational materials may facilitate EPT use.
Many clinics do not stock oral gonorrhea treatment and a formulary change would be
required.
Cost is a primary barrier with many providers unsure how medication would be
financed and if a prescription based model was used, how many patients could
afford to fill them.
Not knowing how to find partners was the most common patient-reported barrier to
using EPT (27%, 88/325) and was more often reported as a barrier by men
compared to women (40%, 34/86 vs. 23%, 50/222).
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EPT Practices
Some respondents indicated that they (or staff at their clinic/facility) were already using some form of
EPT for partner treatment, particularly in tribal health facilities where providers can check the medical
record system for partner allergies. Some clinics use a hierarchical approach to partner management,
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where providers encourage the patient to bring their partners in; but if they wont, EPT services are
offered. The majority of providers who had used EPT stated that they usually only provide medication
or prescription for one partner.
Attitudes to EPT
Respondents often stated its a good idea when asked what they thought of EPT. Some provided
specific examples of how EPT might facilitate partner treatment such as providing additional
confidentiality for the patient. Respondents described EPT as being a good tool in the toolbox and
that EPT may work best with specific populations. Among respondents with direct patient care, some
stated that they would use EPT based on their judgment or as long as certain policies or guidelines
were in place.
Some respondents expressed specific concerns about EPT. Respondents suggested that EPT might
increase antimicrobial resistance and that some partners may have allergic or adverse reactions to the
medications. Respondents also questioned patient compliance, suggesting that some patients may not
give medication/prescription to their partners or would keep the medication for themselves for future
use. Others noted that EPT would result in missed opportunities for education and extended partner
notification (e.g. reaching partners partners).
EPT method
Respondents noted that in many areas of Alaska there are not retail pharmacies and a prescriptionbased model would not work. Additionally, respondents thought that many partners would not fill
prescriptions due to the time required to go to the pharmacy, as well as cost of the medication.
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However, respondents noted that having a pharmacy based model might alleviate provider concerns
about allergic and adverse reactions and would provide more opportunities to document partner
treatment.
Respondents suggested that having a patient directly provide antibiotics to their partners was the model
that offered the least barriers to patients. However, respondents noted that this model may have the
greatest perceived risk of adverse outcomes and does not easily allow for tracking of partner treatment.
Respondents suggested some alternative models of EPT, including mail-order from a state pharmacy
and cooperative agreements with pharmacists.
sites returned completed surveys, but the number of surveys varied greatly by site with the majority of
the surveys coming from one public health center in the Anchorage/Mat Su region.
Preferences for partner notification and partner treatment strategies (Table P2)
Almost 80% of respondents stated that they would prefer to tell their sex partners themselves if they
had an STD. The majority said they would be willing to bring their partners in with them to the clinic or
tell them to get tested (54% and 51%, respectively).
Only 27% percent choose EPT from a list of methods they would be willing to do, but when asked later
in the survey for which partners they would be willing to do EPT, 62% of patients were willing to use
EPT for all of their partners and 94% were willing to use EPT for at least one of their partners.
Eighty-seven percent of patients said that they would fill a prescription or take medication if given to
them by a partner.
Perceived outcome of partner treatment strategies and disclosure of sex partner names (Table P3)
About half of respondents said that all of their partners would come with them to the clinic to be
tested/treated and almost 70% of respondents reported that all of their partners would take medication
if they gave it to them. The majority of respondents (86%) said they knew the names of all of the sex
partners. About a quarter of patients stated that they would not be willing to give the names of all of
their sex partners to their healthcare provider.
Barriers to EPT (Table P4)
Not knowing how to find partners was the most commonly reported barrier to using EPT (27%). Less
than 10% of patients reported that they would keep medication for themselves. A third of respondents
stated that there were not any barriers to doing EPT for all of their sex partners.
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Attitudes to EPT
Patients interviewed reported being willing to give a prescription or medication to their partners, but
some stated that there were some partners they would prefer to have public health notify. Some
participants said that they would be most willing to do EPT for their main partner or a partner that they
were planning on having sex with again. A few patients said that they would not be willing to deliver
medications to their partners, stating Im not a doctor and that they would be concerned about their
partner having an adverse reaction.
Barriers to EPT
Patients noted that some partners may not fill a prescription due to the challenges of getting to a
pharmacy or the cost. Patients reported that it might be difficult to do EPT for one night stands or
hook-ups.
5. Meeting with key personnel at the Alaska Department of Health & Social Services Section of Epidemiology
(ADHSS SOE)
Existing infrastructure for partner notification/treatment monitoring
There is no standardized method to monitor partner notification outcomes for chlamydia and gonorrhea
in Alaska. Some clinics and facilities use standardized interview records and mail them into the ADHSS
SOE where some are hand entered in STD*MIS and some are stored without data entry. Some clinics
and facilities have their own data management system (e.g. the Municipality of Anchorage clinic). Some
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clinics and facilities do not use standardized interview records, but have been encouraged by the
ADHSS SOE to track their own data.
when available.1
This investigation provides evidence of the knowledge, attitudes and practices of EPT among key stakeholders
in Alaska, including healthcare providers and patients. Similar to national and other state or city-based
surveys2-4 about half of healthcare providers in Alaska surveyed reported using EPT. The majority of providers
reported believing that EPT would prevent STDs in Alaska and that they would be willing to use EPT if there
were state recommendations. Similarly, the majority of patients surveyed reported that they would use EPT to
get their partners treated and would accept EPT if offered to them by a partner.
The investigation identified differences in EPT use by both provider type and facility setting. Nurses,
community health aides/practitioners and providers in publicly-funded sites reported the lowest prevalence of
EPT use. The majority of respondents from public health settings were nurses (85%). Nurses are not able to
dispense medications without standing orders and currently there is no medical directive for EPT in public
health centers, limiting EPT use. Similarly EPT is not currently part of the Community Health Aide Manual and
so community health aide/practitioners are not able to routinely use EPT. The differences in prevalence in
these two measures (provider type and setting) likely confound estimated prevalence of EPT use in other
variables (e.g. more public health nurses are in clinics which diagnose more than 10 STDs per month).
This investigation also identified perceived barriers and facilitators to EPT use. Many of the identified barriers
could be likely overcome by policy and regulation changes, such as creating standing orders. For example,
although only 35% of healthcare providers in publicly-funded sites reported a positive attitude toward EPT,
73% reported being willing to use EPT usually or always if there were a state recommendation. This suggests
that for providers working under medical directives, having policies and guidelines in place will facilitate use.
Additionally, formulary changes to stock oral treatment of gonorrhea would be required in some places in order
to use EPT for gonorrhea. Having easy to understand patient and partner education materials was often
named as a facilitator to EPT use. Existing materials from other states could be modified and made culturally
relevant to Alaskan populations.
When discussing the strengths and weaknesses of different partner notification strategies, including EPT, key
stakeholders described an inverse relationship between perceived patient/partner compliance and perceived
risks to providers and partners. Although many patients reported that they would prefer to have their partner
come in to the clinic with them, only half said that all of their partners would follow-through, in part because it
requires partners effort and resources (e.g. time and money). Partner effort is reduced by using an EPT
pharmacy-model (e.g. no clinical exam is required) and is further reduced if the patient is able to give partners
medication directly. Reducing barriers may increase the likelihood of partner treatment, or as one participant
stated the more accessible, the more successful.
However, as partner effort decreases, providers perceived risk increases. When partners come into a clinic for
treatment, providers can check for allergies, screen for other STDs, provide other services (e.g. family planning
services) and offer counseling. Without a clinical visit, these opportunities are lost and providers may feel they
are providing suboptimal care, perhaps at some legal risk. EPT models which are pharmacy-based are riskier
as the provider does not have contact with the partner, but partners could be screened for allergies by the
pharmacist which could be perceived as reducing provider liability and increasing patient safety. EPT models
which are medication based may be perceived as the riskiest as partners are receiving medication without
any interaction with a healthcare provider. Reducing providers perceived risk may increase the likelihood of
EPT use, particularly for those providers not operating under medical directives.
There is no clear best EPT delivery system and finding the most effective model is a balance between both
what patients/partners are willing to do and what providers are willing to do. Additionally, due to differences in
healthcare delivery systems across the state, it may be impractical to identify one specific EPT implementation
model. For example, a pharmacy model may work in cities, but is not feasible in rural settings in Alaska.
Additionally it may be beneficial for specific clinics or practices to develop internal EPT guidelines. Based on
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experiences in Juneau and suggestions from key stakeholders, using provider champions and having followup meetings/trainings may help facilitate implementation. Educational materials for providers clearly describing
scientific evidence for EPT and actual risks (e.g. likelihood of adverse reactions based on other states
experiences) may decrease implementation barriers.
Evaluation of EPT outside of clinical trial settings is difficult. Primary challenges to evaluating an EPT program
in Alaska will be lack of an existing infrastructure to monitor partner notification outcomes. Collaboration with
other institutions, such as the University of Alaska-Anchorage Department of Health Sciences, may provide
opportunities for evaluation.
Survey respondents and interview participants provided some insight on challenges to STD control in Alaska.
Both healthcare providers and patients identified alcohol as a root cause of many sexually transmitted
infections. Sexual behaviors under the influence of alcohol increase opportunities for disease spread and can
hinder partner treatment, even if EPT is available, when sex partners are unable to be identified. Providers
perceptions that many patients are not concerned about STDs and patient reports of multiple infections
suggest that social norms around STDs may influence patients sexual risk behaviors. Key stakeholders,
including policy makers and patients, advocated for increasing sex education in both schools and villages to
prevent STDs. Although this investigation did not systematically examine the impact of sexual behaviors, social
norms, and availability of sex education on the chlamydia and gonorrhea epidemics in Alaska, these findings
suggest a need to strengthen primary prevention strategies.
This investigation is subject to several limitations. Respondents to both the healthcare provider and patient
survey were convenience samples and may not be representative of the target populations. There is no
denominator data available for either sample to calculate a response rate. No incentive was offered to
healthcare providers to complete the survey and consequently providers with strong opinions about EPT (for or
against) may have been more likely to respond. As the healthcare provider survey was distributed via preexisting listservs, the sample may be biased toward public health workers and nurses. The patient survey was
distributed in a sample of clinics, primarily in hub cities, and patients living in more remote areas may be
underrepresented. Additionally, the patient survey was completed by patients currently accessing a clinic and
may be biased toward a population with greater actual and perceived health care access.
CONCLUSIONS
Based on findings from this investigation, EPT would be an acceptable partner management tool for the
prevention and control of gonorrhea and chlamydia in Alaska. Alaska is one of the few program areas in the
United States in which the majority of patients diagnosed with chlamydia or gonorrhea are offered providerbased partner services. As the clinical trials of EPT have primarily compared EPT to patient referral (the
patient tells partners to be tested/treated) it is unknown how effective EPT will be in Alaska. However, it is also
unknown how effective partner services are in Alaska, as collection of partner services data and evaluation of
program efforts are inconsistent across the state due to limited and varied resources and infrastructures. EPT
may be a more effective partner management tool for specific populations (e.g. patients unwilling or unable
participate in timely partner services), for specific geographic areas where partners services are not available,
or when program resources may need to be redirected (e.g. during outbreak response or due to budget
changes). Monitoring and evaluation of partner services activities can inform where and how EPT may be most
useful.
RECOMMENDATIONS
1. Develop state guidance for EPT use in Alaska which is flexible enough to accommodate the multiple
healthcare delivery systems across the state;
2. Increase efforts to track and evaluate existing partner notification programs statewide;
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3. Promote EPT in areas where partner services are not available or not successful as indicated by
monitoring and evaluation data;
4. Consider piloting EPT in settings where information technology and personnel infrastructure is currently
in place to monitor partner treatment outcomes and use evaluation data to inform EPT
recommendations;
5. Collaborate with partners to provide technical assistance on EPT implementation and evaluation; and
6. Improve understanding of high-risk sexual behaviors and social norms to inform and target primary
prevention strategies.
FUTURE PLANS
Analyses of data from this investigation are ongoing. We plan work with Alaska Department of Health & Social
Services Section of Epidemiology to write an EPI Bulletin on the findings, present findings at the Alaska
HIV/STD Task Force Meeting in September and provide technical assistance as needed.
NOTE
This trip report summarizes the field component of our EPI-AID investigation. Because of the preliminary
nature of this investigation, future correspondence, EPI Bulletin articles, conference presentations or peerreviewed papers might present results, interpretations, and recommendations that are different from those
contained in this document.
Page 17 of 59
References
1. CDC. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US
Department of Health and Human Services, 2006. Available at:
http://www.cdc.gov/std/treatment/EPTFinalReport2006.pdf
2. Guerry, S. L., H. M. Bauer, et al. (2005). "Chlamydia screening and management practices of primary care
physicians and nurse practitioners in California." J Gen Intern Med 20(12): 1102-1107.
3. Hogben, M., D. H. McCree, et al. (2005). "Patient-delivered partner therapy for sexually transmitted
diseases as practiced by U.S. physicians." Sex Transm Dis 32(2): 101-105.
4. Rogers, M. E., K. M. Opdyke, et al. (2007). "Patient-delivered partner treatment and other partner
management strategies for sexually transmitted diseases used by New York City healthcare providers."
Sex Transm Dis 34(2): 88-92.
Page 18 of 59
Tables
Table 1
Table 2
Table 3
Self-reported partner notification and partner treatment practices for patients with chlamydia or
gonorrhea, Alaska 2010
Table 4
Table 5
Table 6
Table 7
Table P1
Self-reported demographics of patients evaluated for STDs or at-risk for STDs, Alaska 2010
Table P2
Preferences for partner notification and partner treatment strategies, Alaska 2010
Table P3
Patient's perceived outcomes of partner treatment strategies and disclosure of sex partner
names, Alaska 2010
Table P4
Table P5
Preferences for partner notification and partner treatment strategies by patient age and
gender, Alaska 2010
Table P6
Patient's perceived outcomes of partner treatment strategies and disclosure of sex partner
names, by age and gender, Alaska 2010
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Provider type*
Community Health Aide/Practitioner
Nurse
Nurse practitioner
Physician
Physicians assistant
Missing
10
67
38
16
5
1
7%
49%
28%
12%
4%
1%
Gender
Female
Male
Missing
116
20
1
85%
15%
1%
Race**
Alaskan Native/American Indian
Asian/Pacific Islander
Black/African American
Hispanic
White
16
3
5
4
120
12%
2%
4%
3%
88%
Missing
3%
Race
Non-white
White only
Missing
22
111
4
16%
81%
3%
mean (sd)
19 (11)
25
range
0.5 - 45
18%
60
5
19
14
17
19
3
44%
4%
14%
10%
12%
14%
2%
Size of community
Less than 1000
21
15%
1000 - 5000
13
9%
5001 - 20,000
26
19%
More than 20,000
75
55%
Missing
2
1%
STD:
Sexually transmitted disease; EPT: Expedited partner
therapy
*Write in responses recoded to appropriate categories; **Not
exclusive; sd=standard deviation
Page 20 of 59
49
48
36
2
2
36%
35%
26%
1%
1%
4
32
2
19
3
10
3%
23%
1%
14%
2%
7%
32
33
2
23%
24%
1%
21
63
35
15
3
15%
46%
26%
11%
2%
Page 21 of 59
TABLE 3. Self-reported partner notification and partner treatment practices for patients with chlamydia or gonorrhea, Alaska 2010
Never
(0%)
Rarely
(1-10%)
Sometimes
(11-49%)
Usually
(50-90%)
Always
(91-100%)
n (%)*
n (%)*
n (%)*
n (%)*
n (%)*
3 (3%)
5 (4%)
2 (2%)
16 (13%)
93 (78%)
15 (13%)
7 (6%)
10 (8%)
19 (16%)
68 (57%)
73 (61%)
16 (13%)
17 (14%)
6 (5%)
7 (6%)
81 (68%)
20 (17%)
10 (8%)
6 (5%)
1 (1%)
31 (26%)
20 (17%)
21 (18%)
19 (16%)
27 (23%)
6 (5%)
0 (0%)
1 (1%)
4 (3%)
107 (90%)
Few
(1-10%)
Some
(11-49%)
Most
(50-90%)
All
(91-100%)
Page 22 of 59
None
(0%)
n (%)**
n (%)**
n (%)**
n (%)**
n (%)**
7 (6%)
46 (40%)
42 (36%)
17 (15%)
3 (3%)
16 (14%)
41 (35%)
42 (36%)
16 (14%)
1 (1%)
**Percents represent distribution among respondents who answered at least one question in this section (n=119). 18 respondents did not answer any
questions in this section. Of the 18, all but 1 did not diagnose any STDs in an average month or didn't know.
*Percents represent distribution among respondents who answered at least one question in this section (n=116). 21 respondents did not answer either
question in this section. Of the 21 all but four did not diagnose any STDs in an average month or didn't know.
TABLE 4. Healthcare providers attitudes and beliefs about EPT, Alaska 2010
Disagree
Neither
agree/
disagree
Agree
Strongly
agree
n (%)*
n (%)*
n (%)*
n (%)*
n (%)*
3 (3%)
3 (3%)
9 (8%)
54 (45%)
51 (43%)
4 (3%)
3 (3%)
12 (10%)
51 (43%)
50 (42%)
8 (7%)
7 (6%)
32 (27%)
34 (28%)
38 (32%)
10 (8%)
39 (33%)
38 (32%)
28 (23%)
5 (4%)
Strongly
disagree
Method that
would be
"most effective"
Never
(0%)
Rarely
(1-10%)
Sometimes
(11-49%)
Usually
(50-90%)
Always
(91-100%)
n (%)*
n (%)*
n (%)*
n (%)*
n (%)*
n (%)*
18 (15%)
10 (8%)
25 (21%)
32 (27%)
32 (27%)
64 (53%)
25 (21%)
14 (12%)
21 (18%)
28 (23%)
29 (24%)
12 (10%)
12 (10%)
20 (17%)
21 (18%)
28 (23%)
34 (28%)
27 (23%)
Other**
17 (14%)
Wouldn't affect my
decision to provide
prescription or
antibiotics
Necessary to
provide prescription
or antibiotics
n (%)*
n (%)*
n (%)*
n (%)*
0 (0%)
16 (14%)
52 (44%)
50 (42%)
2 (2%)
24 (20%)
59 (50%)
32 (27%)
4 (3%)
40 (34%)
48 (41%)
25 (21%)
2 (2%)
54 (46%)
44 (37%)
17 (14%)
2 (2%)
20 (17%)
67 (57%)
29 (25%)
1 (1%)
86 (73%)
24 (20%)
7 (6%)
1 (1%)
18 (15%)
54 (46%)
45 (38%)
Page 25 of 59
10/14/2010 Version 2.2
TABLE 7. EPT practices and attitudes by healthcare provider characteristics, Alaska 2010
Total
N
Used EPT
n
Positive
attitude
toward EPT*
Willing to do
EPT** "usually"
or "always"
Total
137
53 45%
62
52%
80
67%
Provider type
Community Health Aide/Practitioner
Nurse
Nurse practitioner
Physician
Physicians assistant
10
67
38
16
5
3
9
25
12
3
33%
18%
66%
75%
75%
3
19
22
13
4
33%
37%
58%
81%
100%
2
36
26
12
4
22%
71%
68%
80%
100%
Gender
Female
Male
116
20
43 42%
10 59%
49
13
48%
76%
70
10
69%
63%
Race
Non-white
White
22
111
9 45%
42 44%
12
49
57%
51%
11
67
52%
71%
41
40
31
17 45%
14 41%
11 41%
19
19
12
50%
86%
43%
27
22
18
69%
69%
67%
Region of Alask a
Anchorage/Mat-Su
Gulf Coast
Interior
Northern
Southeast
Southwest
60
5
19
14
17
19
21
3
2
8
9
10
44%
60%
11%
57%
60%
56%
27
3
5
8
8
11
55%
60%
28%
57%
57%
58%
33
4
11
10
11
11
70%
80%
61%
71%
73%
61%
Size of community
Less than 1000
1000 - 5000
5001 - 20,000
More than 20,000
21
13
26
75
7
7
16
22
37%
54%
70%
35%
9
6
15
31
45%
55%
65%
48%
11
8
19
42
55%
67%
86%
67%
49
48
36
27 57%
5 11%
20 80%
27
15
17
56%
35%
65%
29
32
18
62%
73%
75%
21
63
35
15
6 40%
33 53%
13 37%
0 0%
7
36
17
1
44%
59%
49%
14%
9
43
26
2
60%
69%
77%
33%
STD: Sexually transmitted disease; EPT: Expedited partner therapy; AK: Alaska
*A summary score of 16 or higher on four attitude questions
range: 4-20); **Provide
medication
Page 26 of(score
59
10/14/2010
Versionor2.2
prescription; denominator excludes missings
Gender
Female
Male
Missing
222
86
17
68%
26%
5%
Race*
Alaskan Native/American Indian
Asian/Pacific Islander
Black/African American
Hispanic
White
Missing
53
21
25
11
218
19
16%
6%
8%
3%
67%
6%
Race
Non-white
White (only)
Missing
107
199
19
33%
61%
6%
Age
Under 20
20-29
30-39
40 or older
Missing
103
147
34
24
17
32%
45%
10%
7%
5%
Region of Alask a
Anchorage/Mat-Su
Gulf Coast
Interior
Northern
Southeast
Southwest
Missing
198
10
52
8
20
16
16
61%
3%
16%
2%
6%
5%
5%
Size of community
Less than 1000
1000 - 5000
5001 - 20,000
More than 20,000
Missing
23
59
89
117
37
7%
18%
27%
36%
11%
Page 27 of 59
255
38
25
2
5
78%
12%
8%
1%
2%
175
167
87
71
53
5
54%
51%
27%
22%
16%
2%
202
78
7
14
18
6
62%
24%
2%
4%
6%
2%
278
32
15
86%
10%
5%
243
63
19
75%
19%
6%
Page 28 of 59
TABLE P3. Patient's perceived outcomes of partner treatment strategies and disclosure of sex partner names,
Alaska 2010
All of them
Some of
them
None of
them
Missing
n (%)
n (%)
n (%)
n (%)
170 (52%)
122 (38%)
27 (8%)
6 (2%)
207 (64%)
107 (33%)
6 (2%)
5 (2%)
205 (63%)
103 (32%)
12 (4%)
5 (2%)
218 (67%)
88 (27%)
11 (3%)
8 (2%)
281 (86%)
35 (11%)
4 (1%)
5 (2%)
227 (70%)
35 (11%)
42 (13%)
21 (6%)
Page 29 of 59
10/14/2010 Version 2.2
88
27%
61
19%
46
14%
35
11%
34
10%
26
8%
2%
13
4%
Other
15
5%
102
33%
No reported barriers
Page 30 of 59
TABLE P5. Preferences for partner notification and partner treatment strategies by patient age and gender, Alaska 2010
Under 20 years
(n=103)
20 - 29 years
(n=147)
30 years or older
(n=58)
Male
(n=86)
Female
(n=222)
%*
%*
%*
%*
%*
78
77%
121
83%
43
75%
67
83%
175
80%
9%
17
12%
16%
10%
27
12%
12
12%
5%
9%
7%
18
8%
52
50%
84
57%
26
45%
38
44%
124
56%
52
50%
66
45%
36
62%
46
53%
109
49%
30
29%
35
24%
17
29%
15
17%
68
31%
15
15%
35
24%
19
33%
18
21%
51
23%
8%
23
16%
17
29%
12
14%
37
17%
All of my partners
57
56%
95
65%
41
72%
56
67%
137
62%
Page 31 of 59
27
27%
34
23%
12
21%
13
15%
60
27%
5%
1%
0%
2%
2%
6%
5%
2%
5%
10
5%
None of my partners
6%
6%
5%
11%
4%
93
90%
129
88%
53
93%
75
88%
200
90%
75
74%
119
82%
46
81%
63
76%
177
80%
TABLE P6. Patient's perceived outcomes of partner treatment strategies and disclosure of sex partner names, by age and
gender, Alaska 2010
Under 20 years
(n=103)
n
%*
20 - 29 years
(n=147)
n
%*
30 years or older
(n=58)
n
%*
Male
(n=86)
n
%*
Female
(n=222)
n
%*
53
42
7
52%
41%
7%
84
52
9
58%
36%
6%
30
18
9
53%
32%
16%
40
38
7
47%
45%
8%
127
74
18
58%
34%
8%
64
37
1
63%
36%
1%
99
46
1
68%
32%
1%
38
15
4
67%
26%
7%
59
25
2
69%
29%
2%
141
73
4
65%
33%
2%
63
37
3
61%
36%
3%
98
43
4
68%
30%
3%
37
15
5
65%
26%
9%
53
29
3
62%
34%
4%
145
66
9
66%
30%
4%
67
31
4
66%
31%
4%
101
38
4
71%
27%
3%
41
13
3
72%
23%
5%
56
24
3
67%
29%
4%
153
58
8
70%
26%
4%
89
13
1
86%
13%
1%
130
14
2
89%
10%
1%
52
5
1
90%
9%
2%
66
17
3
77%
20%
3%
205
15
1
93%
7%
1%
78
13
11
76%
13%
11%
107
17
4
75%
12%
13%
11
19
12
72%
7%
21%
53
12
19
63%
14%
23%
172
22
23
79%
10%
11%
TABLE P7. Patient's reported barriers to EPT by age and gender, Alaska, 2010
Under 20 years
(n=103)
20 - 29 years
(n=147)
30 years or older
(n=58)
Male
(n=86)
Female
(n=222)
Page 33 of 59
n
28
%*
27%
n
41
%*
27%
n
15
%*
26%
n
34
%*
40%
n
50
%*
23%
22
22%
28
19%
11
19%
21
24%
40
18%
14
14%
21
14%
16%
11
13%
33
15%
16
16%
12
9%
12%
11%
26
12%
16
16%
13
9%
10%
8%
28
13%
12
12%
11
8%
6%
7%
20
9%
2%
3%
3%
2%
3%
5%
3%
5%
3%
10
5%
Other
4%
4%
3%
2%
10
5%
30
29%
45
31%
19
33%
21
24%
73
33%
No reported barriers
10/14/2010 Version 2.2
Attachment 1
Non-research determination materials
1.1
1.2
Page 34 of 59
Page 35 of 59
Page 36 of 59
Page 37 of 59
Attachment 2
OMB Clearance form
Page 38 of 59
Form Approved
OMB No. 0920-0008
Exp. Date 03/31/2013
EPI-AID 2010-064
Assessment of opportunities for enhanced
gonorrhea and chlamydia control Alaska, 2010
To determine knowledge, attitudes, and practices
of expedited partner therapy for gonorrhea and
chlamydia control among policy makers, health
care providers, patients, and other key
stakeholders and to develop a plan for
implementing and evaluating expedited partner
therapy as a gonorrhea and chlamydia control
effort.
4. Date of Investigation:
Beginning: 6/2/2010
End: 7/12/2010
Complete this section for each instrument used during the investigation
Health care provider survey
A. Description of Respondents:
(i.e., individuals, households, physicians,
state and local government, etc.)
B. Estimated Number of Respondents:
Personal Interview
Telephone
Mail
Other (please specify): online survey
137
10 min
1370 minutes
Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer;
1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0920-0008)
Page 39 of 59
Form Approved
OMB No. 0920-0008
Exp. Date 03/31/2013
A. Description of Respondents:
Personal Interview
Telephone
Mail
Other (please specify):
70
15 min
1050 minutes
Patient survey
A. Description of Respondents:
Personal Interview
Telephone
Mail
Other (please specify): selfadministered survey
325
10 min
3250 minutes
Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer;
1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0920-0008)
Page 40 of 59
Form Approved
Form Approved
OMB No. 0920-0008
OMB No. 0920-0008
Exp. Date 03/31/2013
Exp. Date 03/31/2013
Patient interview
A. Description of Respondents:
Personal Interview
Telephone
Mail
Other (please specify):
20
10 min
200 minutes
Project Officer:
Return completed form and blank questionnaire with trip report to, MS-92
Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer;
1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0920-0008)
Page 41 of 59
Attachment 3
Data collection instruments
3.1
3.2
3.3
3.4
Page 42 of 59
Dear colleagueIn 2009, there was a 69% increase in reported cases of gonorrhea in Alaska, the greatest single-year increase
in reported gonorrhea infection since the 1970s. Since 2000, Alaska has had the first or second highest
chlamydia rate in the United States. The Alaska Section of Epidemiologys HIV/STD Program is working
collaboratively with federal, state, tribal, and local health partners to help control these diseases.
As part of this effort, we are conducting this survey to better understand the knowledge, attitudes, practices
and barriers regarding the use of expedited partner therapy among Alaska healthcare providers. Findings from
this survey will be used in part to guide the development of future STD prevention interventions. Your input is
crucial to help improve the health of our communities.
Your answers to this survey will not be linked to your name or any other identifying information. If you have any
questions concerning the survey, please contact Susan Jones, Alaska HIV/STD Program Manager, at 2698061 or susan.jones@alaska.gov
This survey should take you less than 15 minutes to complete.
Thank you,
Page 43 of 59
Page 44 of 59
6. How many years have you been providing healthcare? [numerical answer]
Years: ____
Prefer not to answer
7. In what region do you live? [choose one]
Anchorage/Mat-Su
Southwest
Southeast
Interior
Gulf Coast
Northern
Other:________________
8. What is your gender? [choose one]
Male
Female
Prefer not to answer
9. What is your race? [check all that apply]
Alaskan Native/American Indian
Asian/Pacific Islander
Black or African American
Hispanic
White
Other: ___________
Prefer not to answer
Page 45 of 59
10. When you diagnose a patient with chlamydia or gonorrhea, how often do you or your office staff do each of
the following:
Never
(0%)
Rarely
(110%)
Sometimes
(11-49%)
Usually
(5090%)
Always
(91100%)
Most
(5090%)
Almost all
(91100%)
Prefer
not to
answer
A few
(110%)
Some
(11-49%)
Prefer
not to
answer
Expedited partner therapy is the practice of treating partners of persons with STDs without medical
examination or counseling. Scientific studies have shown that giving patients with chlamydia or
gonorrhea a prescription or antibiotics to bring to their sexual partner(s) increases the number of
partners treated and reduces the patients risk of re-infection. The next few questions ask your
opinions on expedited partner therapy.
12. Below is a list of statements related to expedited partner therapy. Please rate how strongly you agree or
disagree with each of the following statements.
Expedited partner therapy for
chlamydia or gonorrhea
would help to prevent the spread of STDs
in Alaska
helps provide better care for patients by
preventing re-infection
should be considered the standard of
care
is too dangerous without knowing the
medical/allergy history of the partner(s)
Strongly
disagree
Disagree
Page 47 of 59
Unsure
Agree
Strongly
agree
Prefer
not to
answer
13. If there were a statewide recommendation to use expedited partner therapy for partners of patients with
chlamydia or gonorrhea, how often would you do each of the following?
I would
give a patient medication for their
partner(s)
give a patient a prescription for their
partner(s)
request that a public health worker
provide medication to the partner(s)
Never
(0%)
Rarely
(1-10%)
Sometimes
(11-49%)
Usually
(50-90%)
Always
(91100%)
Prefer
not to
answer
14. Which type of expedited partner therapy do you think would be most effective for making sure that
partner(s) of your patients are treated for gonorrhea or chlamydia? [choose one]
I give my patient antibiotics for their partner(s)
I give my patient a prescription for their partner(s)
I request that a public health worker provide medication to the partner(s)
Other method: ____________________
Prefer not to answer
Page 48 of 59
15. How would each of the following affect your decision to give your patient with chlamydia or gonorrhea a
prescription or antibiotics for their partner(s)?
Less likely
to provide
prescription
or antibiotics
Page 49 of 59
Wouldnt
affect my
decision
More likely
to provide
prescription
or
antibiotics
Necessary to
provide
prescription
or antibiotics
Prefer
not to
answer
Last questions!
16. What do you think would be the biggest barrier(s) to giving patients with chlamydia or gonorrhea
prescriptions or antibiotics for their partner(s)? [open ended]
17. What other factors would increase your willingness to provide patients with chlamydia or gonorrhea
prescriptions or antibiotics for their partner(s)? [open ended]
18. What other strategies would you consider for partner treatment for chlamydia or gonorrhea? [open ended]
19. Please tell us any comments or feedback you have on this survey. [open ended]
Thank you for your time! We appreciate your input into this important health issue in Alaska.
If you would like to learn more about expedited partner therapy, please visit:
www.cdc.com/std/ept
If you would like to learn more about the recent increases in gonorrhea in Alaska, please see this recent EPI
Bulletin:
http://www.epi.alaska.gov/bulletins/docs/b2010_06.pdf
Page 50 of 59
Page 51 of 59
Questions
1. What do you think about providers giving patients with chlamydia or gonorrhea antibiotics to give to
their partners? (probe on efficacy)
What do you think about providers giving patients a prescription to give to their partners? (probe on
efficacy)
If participant has direct patient contact: How likely it is that you would do give antibiotics or a
prescription to your patient to give their partners? What would influence your decision?
2. What do you think are the barriers to implementing a program where providers gave antibiotics or
prescriptions to their patients with chlamydia or gonorrhea?
4. Is there anything else youd like to tell us about how to prevent STDs in Alaska?
Page 52 of 59
Your answers will not be linked to your name and we will not share any of your personal details, but we
have just a few questions so that we can describe who we interviewed.
Gender [Check one]
Male
Female
Race [check all that apply]
White
Black or African American
Asian/Pacific Islander
Alaskan Native/American Indian
Hispanic
Other: ___________
No answer
Under 20
20-29
30-39
40-49
50-59
60+
Profession: ________________________________
Page 53 of 59
Gonorrhea and chlamydia, two common sexually transmitted diseases (STD), have been increasing in Alaska.
We want to know what you think are the best ways to prevent STDs in Alaska.
Page 54 of 59
5. If your healthcare provider gave you medicine or a prescription for your sex partner(s), who would you give
it to? (check one box)
All of my
Only my
Only my
Only partners
None of
partners
main partner
casual
that I thought
my
partners
had an STD
partners
6. If you were to give your sex partner(s) a prescription, do you think they would get it filled?
Yes, all of them
Yes, some of them
No, none of them
7. If you were to give your sex partner(s) medicine for an STD, do you think they would take it?
Yes, all of them
Yes, some of them
No, none of them
8. Which of the following are important reasons why you might not give a prescription or medicine to all of
your partner(s)? (check as many boxes as you want)
I dont know how to find some of my partner(s)
I dont want to tell some/all of my partner(s) that I have an STD
I dont want my partner(s) to think I have other partners
I dont think my partner(s) would get a prescription filled
I dont think my partner(s) would take the medicine
I would keep some or all of the medicine for myself in case I need it later
Other:___________________
9. Do you know the names of people youve had sex with in the last six months? (check one box)
Yes, I know all of
Yes, I know some
No, I dont know any
their names
of their names
of their names
Please turn over for a few more questions.
Page 55 of 59
Introduction
Im ____ and I work for the Centers for Disease Control and Prevention. I am working with the
Alaska Division of Public Health to help find ways to prevent sexually transmitted diseases (or
STDs) in Alaska. We are talking to people in your community to get their opinions about some
ways to get treatment to sexual partners of people who have an STD.
Thank you for agreeing to talk to me. We will not tell anyone about your recent infection, but we
want to know about your experience getting your partners treated. I may take notes on what you
say, but your name is not on this form. Your answers will be put together with answers from
everyone else we are interviewing. You can answer or not answer any or all of these questions.
Are you ready to hear the questions?
Page 57 of 59
Questions
1. When you were told about your infection, did anyone talk to you about getting your partners treated?
Who talked to you?
Do you think all, some or none of your partners were treated?
If all or some:
If some or none:
2. If your healthcare provider gave you medicine for you to give to your partners.
a) Would you be willing to give them the medicine?
b) Would there be some partners that you would not be able or willing to give the medicine?
c) What might keep you from giving the medicine to all of your partners?
3. If your healthcare provider gave you a prescription for you to give to your partners.
a) Would you be willing to give them the prescription?
b) Would there be some partners that you would not be able or willing to give the prescription?
c) What might keep you from giving the prescription to all of your partners?
d) What might keep your partners from getting the prescription filled?
5. Is there anything else youd like to tell us about how to prevent STDs in Alaska?
Page 58 of 59
Demographics
20. What is your sex? (check one box)
Male
Female
21. What is your age? (check one box)
Under 20
20-29
30-39
40 or older
22. What would you consider your race? (check all the boxes that apply)
Alaskan Native/American Indian
Black or African American
Asian/Pacific Islander
Hispanic
White
Other: ___________
23. What region do you live in? (check one box)
Anchorage/Mat-Su
Southwest
Southeast
Interior
Gulf Coast
Northern
Other:________________
Page 59 of 59