This study suggests that few STI outbreaks are currently recognised in Wales because few health professionals are trying to identify them. Even fewer STI outbreaks get reported to public health authorities and result in a multidisciplinary response. Furthermore, substantial uncertainty exists about confidentiality of patient information in STI outbreak situations. Since surveillance schemes for STIs are similar throughout the UK, it is conceivable that a comparable situation exists in areas of the other UK countries.
To our knowledge, no study has yet addressed the issue of alertness of health professionals to identify STI outbreaks. Of interest, identifying and investigating STI outbreaks is not explicitly mentioned as an objective of STI surveillance schemes in the UK [3].
The control of unrecognised outbreaks and, according to this survey, of some of the recognised outbreaks, is by routine partner notification and treatment only. These interventions, however, are limited in their effectiveness [5]. For example, anonymity of sexual partners, particularly for men who have sex with men [5], and delays in partner notification and treatment [6] (e.g., because of waiting times at GUM services for initial consultation [7], or delayed notification of partners by the index patient) are impediments for timely interruption of onward transmission. A systematic outbreak investigation, usually by a multidisciplinary outbreak control team, can facilitate a multifaceted response to the outbreak that is adapted to the size and circumstances of the incident. This might include, for example, active case finding by prompting awareness among providers and outreach workers, and selective screening of patients with similar or milder clinical presentations. A more network-informed approach could identify central persons in the sexual network (likely to be core group members), and extend case finding efforts to nonsexual contacts of cases [8]. Together with descriptive epidemiology, approaches like this could lead to more complete ascertainment and timelier identification of outbreak cases and their contacts, and a more accurate description of the population at risk. In consequence, earlier treatment and education of a larger number of outbreak-related cases could reduce spread of infection and promote the number of persons that modify their risk-behaviour. Furthermore, the use of analytical epidemiological studies may identify risk factors that allow for a more targeted intervention approach [9].
Although patient confidentiality is a central tenet of GUM practice, the law allows sharing of patient information with other health professionals in the interests of controlling spread[4]. It is noteworthy that only half of the survey respondents thought this was true and should be practiced in STI outbreaks. This indicates not only difficulties for an effective multidisciplinary response to STI outbreaks in many instances, but also that a common conceptual framework of how to cooperate with public health authorities in STI outbreaks does not currently exist in Wales. Clearer definition of roles in STI outbreak identification and control, particularly on the local level, are needed. Setting up of regular sexual health liaison meetings involving GUM physicians, public health officials (e.g., CCDC and public health nurses), and representatives of Local Health Boards may increase mutual understanding and thereby help in defining the roles of these groups – not only in outbreak situations. Furthermore, improved surveillance methods based on individual data with a more timely data flow to regional epidemiologists or to local public health authorities (i.e., the Health Protection Team in the UK) would enable these professionals to identify increases in notification data indicative of STI outbreaks.
This study targeted health professionals across the whole of Wales that might potentially identify STI outbreaks. Yet, the number of survey recipients was small. Extending the study to other UK countries would provide the statistical power to compare among health professions, and possibly reveal regional differences in practice in the UK. This would help in identifying areas where, in particular, STI surveillance efforts need to be strengthened.
