Evaluation of a Novel Internet-based Partner Notification Program National STD Prevention Conference Chicago, Illinois Wednesday, March 12, 2008 My name is Dan Ehlman. I am a Prevention Specialist with the Centers for Disease Control and Prevention assigned to the Washington, DC STD Control Program. I’ll be presenting today on the Evaluation of a Novel Internet-based Partner Notification Program. Daniel C. Ehlman, MPH Public Health Prevention Specialist Public Health Prevention Service Centers for Disease Control and Prevention

Co-authors Gonzalo Saenz, MD, MPH Marcus Jackson B W Furness, MD, MPH I would like to acknowledge the contributions of Dr. Saenz, Mr. Jackson, and Dr. Furness for their contributions in data management, partner elicitation, and overall program implementation. Extra… Dr. Saenz assisted tremendously with modification of the data management system. Mr. Jackson is a Disease Intervention Specialist whose strong DIS skills has helped the Internet-based Partner Notification program be as successful as it is. Dr. Furness is our Medical Epidemiologist who initiated the effort to conduct Internet-based Partner Notification in Washington, DC and provides oversight to the IPN program. Note: The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

Objective To evaluate the first 10 months of the Washington, DC, STD Control Program’s novel Internet-based partner notification (IPN) program, which went into effect March 2007. The objective of this abstract was to evaluate the first 10 months of the Washington, DC, STD Control Program’s novel Internet-based partner notification program, which went into effect March 2007.

Outline Background Methods Results Conclusions In the short time we have, I will touch on the background of IPN, the methods we used to evaluate the program, our results, and our conclusions.

Background Internet = sex seeking Need for protocol to work on Internet Protocol integrated into syphilis case management Thanks to Howard Brown’s earlier presentation, I only need to briefly touch on IPN background. Specifically, we pulled 2005 syphilis case files and determined that many syphilis patients were using the internet to meet sex partners, and thus, we were able to justify the need to create an IPN protocol. In March 2007, we completed our IPN protocol and began notifying partners of early syphilis cases via e-mail.

Background (cont.) Internet-based partner notification uses Internet locating information (e.g., e-mail address) to notify partners of individuals who have been diagnosed with an STD. IPN is a case management tool that uses Internet locating information (for example, e-mail addresses) to notify partners of individuals who have been diagnosed with an STD.

Background (cont.) IPN with syphilis case management Internet partners No physical locating information E-mail address obtained In DC, we are currently using IPN only with syphilis case management. Specifically, while interviewing the syphilis patient, we elicit sex partners and their corresponding locating information. We cut field records on all partners, meaning we investigate all partners. However, we send partner notification e-mails only to sex partners for whom the only identifying information is an e-mail address or for whom traditional field investigations have failed (for example, they were not located by home visit or phone call).

Methods Analysis of Field Record STD Disposition Codes Cases of early syphilis (710, 720, 730) with ≥1 Internet partner March to December 2007 To evaluate the IPN program’s first 10 months, we analyzed STD disposition codes of sex partner field records that resulted from interviews with early syphilis patients. We reviewed all field records of primary, secondary, and early latent syphilis cases that had at least one Internet partner and were initiated between March and December 2007.

Methods (cont.) STD Disposition Codes “Traditional” Codes: A, B, C, D, E, F, G, H, J, K, L Internet-specific Codes*: L1: Informed of Syphilis Exposure L2: Informed of STD Exposure L3: Not informed/ Unable to Confirm Receipt of E-mail We used the disposition codes found on CDC’s Field Record. If over the course of the investigation, we acquired physical locating information, we used the “traditional” disposition codes of A through K. If, however, we did not obtain physical locating information, we coded the Field Record as an L. However, we added an IPN local field to the Field Record to capture more specific IPN data. Specifically, if the sex partner entered into a conversation with us (either by phone or by e-mail) and it was confirmed that he had read the syphilis exposure information we had sent him, the field record was coded as L1. If it could be confirmed that the patient read the STD exposure information, the field record was coded as L2. And finally, if there was no confirmation that the sex partner received exposure information, the field record was coded as L3. * We created a local field in STD*MIS to capture IPN Disposition Codes.

Methods (cont.) STD*MIS 4.0e Microsoft® Office Access 2003 SAS® 9.1 To work with the data, we exported files from STD*MIS. Data sets were merged in Microsoft Access, and data was analyzed in SAS.

23 early syphilis cases with ≥1 Internet partner Results 23 early syphilis cases with ≥1 Internet partner 474 Field Records 151 (32%) initiated by visit/phone There were 23 early syphilis cases with at least one Internet partner. In those 23 cases, there were 474 field records that were initiated. 151 were initiated by home visits or telephone calls. And 323 were initiated by e-mail. Of those 323, 47 resulted in identifying other locating information, such as patient name, date of birth, and phone number. For the remaining 276, additional locating information was not obtained. 323 (68%) initiated by e-mail 47 = physical locating information 276 = no additional information

For the next few slides, we will focus on the 323 IPN Field Records. The average number of Internet partners elicited was 14. 12 cases had 1 Internet partner elicited. 6 cases had more than 10 Internet partners.

Open vs Closed E-mail Systems Open e-mail systems E-mails can be sent within and outside of these websites. E.g., earthlink, aol, yahoo, hotmail. Closed e-mail systems E-mails can be sent only within the website. E.g., manhunt, adam4adam, men4now. For the purposes of this presentation, I am going to define two categories of e-mail systems that we used for partner notification of the 323 Internet partners. The two categories are open e-mail systems and closed e-mail systems. Most of us are familiar with e-mail in open e-mail systems. They allow us to communicate with most everyone, from family to friends to work colleagues—most of us have a hotmail or yahoo or aol account. Specifically, on my yahoo account, I can receive e-mails from someone with a gmail account and I can send e-mails to him. While most of us are intimately familiar with open e-mail systems, not all of us might know about closed e-mail systems. You might also call them social networking sites or even Intranet websites or proprietary e-mail systems. The point is that in closed e-mail systems, you must be members of that website to be able to send e-mails to other members. You cannot e-mail from that account to someone who uses hotmail, for example. You also cannot send an e-mail from hotmail to one of these sites, like adam4adam.

That said, by far in DC we sent most e-mails within closed e-mail systems, especially adam4adam and manhunt. The number of e-mails sent to open e-mail systems totaled 41. The four websites on the left, adam4adam, bgclive, manhunt, and men4now, are closed e-mail systems that we have sent e-mails through. The Washington, DC STD Control Program created member accounts on these closed e-mail systems and thus sent e-mails to partners through those respective accounts. The six open e-mail systems were aol, gay, gmail, hotmail, mac, and yahoo. The Washington, DC STD Control Program sent e-mails to open e-mail systems via its DC Government e-mail account.

Of the 323 Internet partner Field Records initiated, 47 ended up with physical locating information, reflected in the first 6 columns. Of those, 18 were epi-treated for their syphilis exposure. 3 were infected with syphilis and brought to treatment. In one of those cases, we had a phone conversation with the patient about his syphilis exposure. He agreed to go to his primary care physician later in the week; he didn’t have any symptoms that we reviewed. However, the next day, he called us back about a rash that he had developed on his chest. We were able to send him to a community clinic that evening, where he was diagnosed with secondary syphilis. Fortunately, he recognized the symptoms, perhaps because of the conversation we had the day before. In contrast to this infected patient, there were 18 patients who were out of the incubation period and tested negative. Of the 276 Field Records with Internet-specific dispositions, represented in the last 3 columns, it can be confirmed that 85 were notified of a syphilis exposure and 106 were notified of an STD exposure. For 85 field records, we either had incorrect e-mail addresses, or we could not confirm if the patients received the e-mails. It is important to note that even though we sent more e-mails to Adam4Adam, the majority of traditionally-favored A, E, and F dispositions came from communications with Manhunt members. Compared to Adam4Adam members, Manhunt members seemed to be more open about their sexuality and more responsive to our e-mails.

IPN Case Management Indices for 23 Early Syphilis Cases, Washington, DC, 2007 Field Records initiated by telephone/visit Field Records initiated by IPN Total Field Records Washington, DC-specific program goals Contact Index (# contacts / # cases) 6.6 (151/23) 14.0 (323/23) 20.6 (474/23) 1.5 Disease Intervention Index (# cases with at least 1 A or C / # cases) 0.35 (8/23) 0.48 (11/23) 0.5 New Treatment Index (# A or C dispo / # cases) 0.83 (19/23) 0.91 (21/23) 1.7 (40/23) 1.0 New Exam Index (# A, C, F dispo / # cases) (38/23) (39/23) 3.3 (77/23) N/A We used traditional case management evaluation indices to evaluate the effect of IPN on the 23 cases that had at least one Internet partner elicited. To illustrate this, we produced this chart which has four evaluation indices running vertical on the left side. The Contact Index is determined by dividing the total number of contacts by the total number of cases. The Disease Intervention Index is the number of cases with at least one treated partner divided by the number of cases. The New Treatment Index is the total number of treated partners divided by the number of cases. And finally the New Exam Index is the total number of partners examined divided by the number of cases. On the top of the chart, running horizontally, we have four columns. In order to highlight the impact of IPN, we compared the results of Field Records initiated by telephone and/or home visit, represented in the first column of data, in red, to those of Field records initiated by IPN, represented in the second column, in green. The third column (in aqua) lists the total, by combining the red and green columns. The fourth column (in white) identifies Washington, DC-specific program goals. In summary, you can see that the Contact Index more than tripled because of IPN. The Disease Intervention Index increased by 37%. The New Treatment Index more than doubled. And the New Exam Index doubled. The take-home message of this chart is that IPN did improve important case management indices.

Of the 276 Field Records with an Internet-specific disposition, meaning we didn’t have traditional locating information, 85 partners e-mailed or called us to find out disease-specific information and thus likely sought medical attention. Of those 85 partners, 5 self-reported to have gone to their primary care physicians and were epi-treated. 1 self-reported to have been infected and treated. 29 said they were not infected. And 50 did not continue further communication with us.

Conclusions Without IPN, over 300 sex partners (within the last 10 months) would not have been investigated IPN augments traditional syphilis case management and aids in location, notification, testing, and treatment of partners In conclusion, without IPN, over 300 sex partners (within the last 10 months) would not have been investigated by the Washington, DC STD Control Program. IPN augments traditional syphilis case management, aiding in location, notification, testing, and treatment of partners, which has been shown here to improve traditional case management indices in Washington, DC.

Acknowledgements Colleen Crowley Glasford Earlington Phil Finley Bruce Flippens John Heath Herman Jones Abdul Mansaray Emmanuel Puplampu Florine Quarles Corine Reid Sharon Stone Howard Tinker Francoise Uwimana Keith Wells Division of STD Prevention, CDC Howard Brown Health Center, Chicago, IL Massachusetts Department of Public Health Public Health Prevention Service, CDC Washington, DC STD Control Program I would like to acknowledge the numerous individuals and organizations that have made it possible for us to initiate our IPN program.

For further information: Thank you. For further information: Poster P95: “Integration of Internet-based Partner Notification into Case Management” Contact information Dan Ehlman 202-442-4769 dehlman@cdc.gov daniel.ehlman@dc.gov Thank you.

Extra Slides

N=179 N=99 N=41 This chart highlights specific dispositions as a percentage of the total for adam4adam, manhunt, and open e-mail systems. Percentage-wise, we had the most success on manhunt, as 12% of partners were epi-treated, 1% were infected and brought to treatment, and 8% were not infected. E-mailing open e-mail systems had the next best rates, followed by adam4adam. Unfortunately, it is nearly impossible to track e-mails in open e-mail systems, thereby making it difficult to know if e-mails are being read, unlike manhunt and adam4adam, where we can confirm whether an e-mail has been read.

Risk Factor in STD*MIS 4.0e

Local Field Modification

Local Field Internet Dispositions Indicates Internet used to initiate contact Shows how Internet Partner names are recorded IPN-specific dispositions

1st E-mail to Partner Dear <<screenname>>, My name is Dan Ehlman, and I am from the Washington, DC, Department of Health, STD Control Program. I’m e-mailing you because someone you met online was recently diagnosed with a laboratory-confirmed sexually transmitted disease (STD). You need immediate medical attention because this person identified you as a sex partner during the infectious period of this STD. For confidentiality reasons, I cannot tell you anything about the person you had sex with, including when it occurred. Please call me at 202-442-4769, and I can tell you more about the specific infection and where you can go to be tested and treated for free. If I’m not there when you call, I will call you back. Be sure to leave a number and time when I can reach you. My voicemail is private, confidential, and password-protected. I check my voicemail and e-mail at the beginning and end of each business day (8am-4:30pm, M-F). If you want to check that this e-mail is real, call the Division of STD Prevention at 202-442-4705 and ask to speak with our Medical Epidemiologist, Dr. B. W. Furness. Thank you, Dan Ehlman, MPH Internet-based Partner Notification Coordinator STD Control Program, Washington, DC, Department of Health

Notification E-mail Dear <<screenname>>, Thanks for getting back to me. I wrote to you because someone you met online was recently diagnosed with laboratory-confirmed syphilis. According to Centers for Disease Control and Prevention (CDC) guidelines, you need to be treated immediately for this exposure. You also need to be tested because if you are infected, you may need additional treatment. To find out more about this disease: 1) You can call me at 202-442-4769 and I can tell you more, including where to get tested and treated for free. Our communication is strictly confidential. 2) Print this e-mail and take it to your doctor; the clinician can contact me if necessary. 3) Go to http://www.cdc.gov/std/default.htm to read more about the disease. It is important that you understand that many STDs are asymptomatic, which means that you can be infected but not show any visible signs of infection. If an infection is not treated, some STDs may cause serious long-term complications. Finally, although we are notifying you about your potential exposure to syphilis, our recommendation is that anyone getting tested for an STD should consider being tested for all other common STDs (gonorrhea, chlamydia, and HIV). If you have any further questions now or in the future about the disease you’ve been exposed to or the treatment you received, please feel free to contact me at any time. Thank you, Dan Ehlman, MPH Internet-based Partner Notification Coordinator STD Control Program, Washington, DC Department of Health

“Traditional” STD Disposition Codes A Preventive Treatment B Refused Preventive Treatment C Infected, Brought to Treatment D Infected, Not Treated E Previously Treated for This Infection F Not Infected G Insufficient Information to Begin Investigation H Unable to Locate J Located, Refused Examination K Out of Jurisdiction L Other

Limitations Spam-like appearance of e-mails sent to open e-mail systems Inflexibility of disposition codes Program IT Loss to follow-up Lack of trust of DOH by Internet partners Lack of control over communication medium

Recommendations Add dispositions to Field Record (CDC 73.2936S) Add electronic buffs to STD*MIS Work closely with MSM-friendly STD clinics for patient referrals, perhaps even contracting out to them Create new case management indices that reflect the anonymous nature of IPN

IPN Case Management Indices for 11 Cases with ≥2 IPN-initiated Field Records, Washington, DC, 2007 Field Records initiated by telephone/visit Field Records initiated by IPN Total Field Records Washington, DC-specific goals Contact Index (# contacts / # cases) 11.8 (130/11) 28.3 (311/11) 40.1 (441/11) 1.5 Disease Intervention Index (# cases with at least 1 A or C / # cases) 0.27 (3/11) 0.64 (7/11) 0.73 (8/11) 0.5 New Treatment Index (# A or C dispo / # cases) (16/11) 1.8 (20/11) 3.3 (36/11) 1.0 New Exam Index (# A, C, F dispo / # cases) 2.7 (30/11) 3.5 (38/11) 6.2 (68/11) N/A

Syphilis Trends in the District Between 2000 and 2006, the number of primary and secondary syphilis cases reported in Washington, DC increased 200% (from 38 to 115, respectively). From 2005 to 2006, the number of Primary cases decreased but the number of secondary syphilis increased. Next slide.

Syphilis Trends in the District (2) In 1997, there were more infectious syphilis cases reported among females than males in Washington, DC. Since 2000, infectious syphilis cases were predominantly reported among men (Figure 2). In 2006, the male to female ratio of cases reported was at an all time high of 18.2 to 1, with only 6 cases reported among females. Next slide.

Syphilis Trends in the District (3) 3. In 2006, there were 60 infectious syphilis cases reported among African Americans and 51 reported among Caucasians.

Syphilis Trends in the District (4) 4. Unlike gonorrhea and chlamydia (which were predominantly reported among adolescents), for each of the past 6 years, the most number of infectious syphilis cases reported in the District has been among 30-39 year olds. Still, since 2003, the number of cases reported among 20-29 year olds has been gradually increasing.