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Dr Gwenda Hughes

Dr Gwenda Hughes, Head of Sexually Transmitted Infection (STI) Surveillance at Public Health England, sets out considerations around effective STI outbreak and incidents management for local authorities, service providers and other stakeholders.

Over the last 10 years there has been a steady rise in new diagnoses of STIs. While much of this rise is associated with the expansion of testing and screening (such as through the National Chlamydia Screening Programme), and improvements in diagnostic test sensitivity, it is clear that ongoing unsafe sexual behaviour is contributing to high rates of STI transmission. Of particular concern is the recent emergence of outbreaks of less common STIs - gonorrhoea, infectious syphilis (primary, secondary and early latent) and Lymphogranuloma venereum (LGV), together with shigellosis, which can be sexually transmissible - among young heterosexuals and men who have sex with men (MSM).

Comprehensive guidance is available for the management of STI outbreaks [1]. When an outbreak is identified, a local outbreak control team (OCT) should be formed with appropriate representation depending on the patterns of local transmission and likely public health impact. The OCT is usually convened by the local consultant in communicable disease control at the appropriate PHE Centre. These teams ensure locally relevant control measures are in place. A national OCT or incident group may be established where there is evidence that the outbreak is spreading beyond local and regional boundaries, as was the case for the recent shigellosis outbreak among MSM. For all outbreaks, control measures are likely to include expanded testing, treatment and appropriate patient notification (PN) exercises, as well as strategies for raising awareness in the local population and among health professionals. The promotion of safe sex, through leaflet campaigns and targeted press releases, is also often employed.

Even when such measures have been taken, control can be elusive. STI outbreaks can take months to develop as transmission is related to the density and structure of local sexual networks. Partner Notification (PN) is crucial to effective outbreak management but can be challenging where there are large numbers of untraceable sexual partnerships. This can result in a significant undiagnosed pool of infection and the potential for ongoing transmission within the wider sexually active population. In the recent heterosexual outbreaks, PN success rates were often poor and the outbreaks difficult to control. Where outbreaks were contained, effective PN almost certainly contributed to this. Service access by vulnerable groups may also be a problem, with many patients not registered with health services.

Effective sexual health networks require good clinical leadership to help manage OCTs, provide expertise and training and to ensure relevant guidelines (for example, local prescribing guidelines in response to increased levels of antimicrobial resistance) are implemented consistently across providers. Commissioners may also be required to commission additional services to support outbreak management and must ensure that experience from earlier outbreaks is built into future commissioning plans. For example, this might include targeted resources for work with high risk groups or  improving access to antenatal screening. The BASHH PN standards [2] should be included in contract specifications and monitored appropriately.

Improving sexual health, and controlling STI outbreaks in particular, requires the establishment of strong local sexual health networks that include all local providers and commissioners from across local authorities, PHE and Clinical Commissioning Groups (CCGs). Effective networks are necessary to ensure good working relationships across providers and to enable rapid communications about increased diagnoses that may indicate an outbreak. Service providers must report any concerns about increased STI cases to the local PHE Centre and local commissioners so that the significance of any increase can be determined.

1. Guidance for managing STI outbreaks and incidents. Available at:  http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1214553002033.

2. The British Association of Sexual Health & HIV (BASHH) 2012 Partner Notification Statement. Available at: http://www.bashh.org/documents/4445.pdf

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