Contact tracing

Contact tracing or partner notification is the process of identifying relevant contacts of a person identified with an infectious disease so they can be informed about their exposure and be offered physical examination, investigations and treatment. Contact tracing is an essential part of the clinical management of patients diagnosed with STIs and blood-borne infections.

Health care providers have a professional responsibility to ensure contact tracing takes place. In most cases contact tracing can be undertaken by the index case with assistance from health care providers as required.

When performed well, contact tracing supports sexual health education,and is an opportunity to provide individual interventions that bring about sustained behaviour change e.g safer sex/injecting, alcohol and other drugs

Contact tracing definitions

Contact

A person who has had sex with, shared injecting equipment with, or has had some other high-risk exposure to the index case.

Sexual contact

Contact may be oral, vaginal, anal or some other form of sexual contact with the index case during the period when there was risk of transmission of infection.

Index case

The original person identified with an infection. The index case may or may not have infected other persons but represents a starting point for the process of contact tracing.

Contact tracing

The process of identifying relevant contacts of a person with an infectious disease and ensuring that they are aware of their exposure.

Principles of contact tracing
  • Health care providers should respect the human rights and dignity of the index case and the identified contacts.
  • Contact tracing is an important element of STI/HIV care and prevention for communities, and this must be addressed by the diagnosing clinician.
  • Nurses and other clinical staff treating patients with STIs may also have responsibility for contact tracing.
  • If there are any difficulties undertaking this, assistance may be sought from the local Population Health Unit (PHU) (see contacts for patients – where to go, for contact details) or metropolitan-based contact tracers at the North and South Metropolitan Public Health Units (see contacts for specialist advice on STIs and HIV).
  • Contact tracing should be voluntary and without coercion. The index case and contacts should have equitable and appropriate access to all available services, regardless of their willingness to cooperate with the contact tracing process. When an index case refuses to notify or permit notification of contacts, assistance is available from regional Public Health Unit's (PHUs), Aboriginal Community Controlled Health Services (ACCHS) and the Communicable Disease Control Directorate (CDCD), particularly in cases of confirmed HIV.
  • All aspects of contact tracing must be confidential, including written and database records. The anonymity of the index case must be protected unless written permission has been given to release this information to contacts.
  • Contact tracing is best undertaken when appropriate and culturally sensitive support services are readily available to both the index case and contacts. Insensitive contact tracing can be counterproductive.
  • Epidemiological treatment is effective in reducing the prevalence of disease within a community. Treating contacts at the first interview reduces disease transmission.
Information for contact tracing

Information concerning recent sexual contacts is required from patients with a confirmed STI/HIV diagnosis for contact tracing purposes.

The primary care provider is responsible for ensuring that reasonable efforts are made to identify, and subsequently screen, identified sexual contacts.

Rationale: Contact tracing is necessary to interrupt the transmission of infection. The prime purpose is to identify people who may have an infection and require treatment.

When performed well, contact tracing supports sexual health education and prevention counselling, and can help bring about sustained behaviour change among people with an STI/HIV infection.

Consent for contact tracing

  • Refer to the principles of contact tracing.
  • Work with the index case to obtain their consent to contact tracing. When an index case refuses to notify or permit notification of contacts, assistance should be obtained from an experienced health service provider, such as local PHUs and ACCHS.

Eliciting a risk history to identify contacts

  • To assist the patient to identify likely contacts, particularly in rural and remote areas, ask about attendance at recent local events (e.g. sports weekends or trips to the regional town), and then specifically about whether they had a sexual encounter.
  • Do not simply focus the index case on the most recent or apparent risk encounter. A general understanding of the index case's risk history will assist in counselling to avoid future risk.
  • When taking a social and sexual history for STIs/HIV:
    • ask open-ended questions
    • do not presume the sex of contacts
    • do not ask questions which imply a judgement
    • ask for explicit information which indicates the relationship with contacts
    • ask about substance use that may have contributed to risk
    • if necessary, repeat questions at subsequent visits
    • attempt to get further information about contacts, e.g. email contacts of partners or mobile telephone numbers may help. Offer assistance in contact tracing if practical.
Choosing a method for contact tracing

Patient (index case) referral

The index case personally notifies his or her contacts. This requires specific instructions including advice on which contacts to inform and what information to be communicated, including appropriate agencies for assessment and counselling. Patient referral is recommended for well-informed, motivated and self-confident index cases. Discussion of various scenarios and how they can be dealt with may be helpful if the index case fears embarrassment or reprisal from contacts. It is important to use follow-up consultations to confirm that the contacts have been notified and assessed adequately.

Provider referral

Provider referral may be selected either at the index case's request, or at the suggestion of the primary health care provider. In such cases the provider may undertake to notify contacts directly, or seek assistance from another agency (e.g. ACCHS, PHU or CDCD). Provider referral requires the explicit approval of the index case, but offers greater anonymity to the index case.

Approaches to contact tracing by health care providers

Approach by phone

Advantages

  • Quick, and allows an appointment to be made.
  • Cheap, especially if the contact is rarely home.
  • Confidential (provided that the source of the call is only revealed to the contact).

Disadvantages

  • Provides verbal clues only.
  • Can be uncomfortable disclosing full details.
  • Can be intercepted by a third person.
  • Not practical when language or cultural barriers operate, or for the hearing impaired.

Approach by letter

Advantages

  • Some anxiety can be allayed by providing limited information about testing and confidentiality.
  • Allows the person to phone when their confidentiality is assured.

Disadvantages

  • May create anxiety, especially if read when services are closed.
  • Inappropriate for disclosing details.
  • Difficult for people with literacy problems or for the visually impaired.

sample letter for patients to pass on to contacts is included. The health care provider should consider the appropriateness of using such a letter.

Approach in person

Advantages

  • The health care provider can give full details immediately, deal with the response and link in with appropriate supports.
  • Informal approaches in small communities will minimise confidentiality risks.
  • Depending on the circumstances and the health care provider's training, immediate testing may be offered.

Disadvantages

  • Physically seeing the provider might affect their perception of confidentiality, particularly in small rural communities.
  • Can give impression of policing.
  • Costly/time consuming.
  • Testing on site can work against the individual's willingness to accept referrals.

Referral to another agency

Advantages

  • Option for contact to attend another provider (not associated with the index case) may improve compliance with request.
  • Opportunity for the provider to limit their involvement to that of the index case.
  • May provide access to greater expertise/knowledge of social contexts.
  • Agencies may have other information about contacts.
  • Confidential if index case's identity not disclosed.

Disadvantages

  • Break in continuity of care.
  • Complication of involving another party.
Empirical treatment

For the curable, bacterial STIs, it is traditionally recommended that patients' partners be personally examined, counselled and treated. When practical, the partner should be managed by the health care provider or clinic that treats the index case.

Unfortunately, structural, geographical or other factors may make it difficult for follow-up of the partner to be undertaken by the same health care provider. In such cases, the partner should be referred to a specific health care provider or clinic known to be competent in STI management and sensitive to sexual health issues; it is probable that non-specific advice to the patient (e.g. "make sure your partner gets checked") often goes unheeded.

Public health agencies have a responsibility to ensure that clinical services are available to partners who cannot be treated by the index case's provider, by providing care at public clinics or facilitating referral to alternate sources of care.

One strategy that is effective in reducing the prevalence of infections within a community is empirical treatment. This is where the contact of a proven case of gonorrhoea, chlamydia, trichomoniasis or non-specific urethritis (NSU) is treated on the day they are interviewed and investigated, rather than waiting until the results are back. Treatment should be offered regardless of whether the contact is symptomatic or not, even if the contact declines testing.

The rationale for this treatment is:

  • these diseases are highly infectious so there is a high probability that the contacts are infected
  • the contact interview may be the only opportunity there is for treatment due to the high mobility of the patient group
  • the sooner treatment is initiated the less likely transmission is to occur
  • the treatment is simple (one dose) and has an acceptable side effect profile.

If GeneXpert point-of-care test is available, contacts can be treated on the basis of their point-of-care test result, i.e. if the contact of a proven case of gonorrhoea, chlamydia, trichomoniasis or non-specific urethritis (NSU) tests negative to the STI that his/her partner had, then treatment is not required.

As syphilis is less infectious and the treatment more difficult, ideally serology results should be reviewed before treatment is commenced for asymptomatic contacts of syphilis. However persons who were sexually exposed to a patient with primary, secondary, or early latent syphilis should be treated presumptively if serological test results are not available immediately and the opportunity for follow-up serology to cover the window period is uncertain. If in doubt, err on the side of offering the contact empiric treatment, (e.g. Benzathine penicillin 1.8 g intramuscularly as a single dose) especially if there is potential for onward transmission if the contact is infected.

A sample letter for your patient's contact to pass on to their own GP is provided. The letter explains:

  • that they have been in contact with a person diagnosed with an STI
  • that they might have also contracted an STI
  • the importance and need for examination and testing, and that empirical treatment should be given for readily treatable bacterial STIs.
Follow-up
Follow-up for contact tracing is essential to ensure that the spread of infection is interrupted. If the primary health care provider is not in a position to ensure that identified contacts are traced and receive screening and treatment, contact tracing support may be obtained from other agencies (e.g. ACCHS, PHUs or CDCD).
Urgency of contact tracing

Undertake contact tracing as soon as the index case can provide the necessary information.

Urgent (or immediate) contact tracing is necessary when there is concern that a contact is placing others at immediate risk of infection and for antibiotic resistant organisms such as penicillin-resistant Neisseria gonorrhoeae.

It is also particularly important for male partners of women with proven or suspected pelvic inflammatory disease (PID) to ensure that she is not re-infected.

Rationale: The longer that contact tracing is delayed, the greater the likelihood of an infected contact transmitting the infection to other individuals (or re-infecting the index case). While it is accepted practice to await confirmation of the infection before starting contact tracing, this should be reconsidered for rural and remote areas, where laboratory results may not be received for a week. There is a risk that, after a week, it will be more difficult to locate and treat the contact quickly. Delays in treating contacts are considerably reduced if contact tracing is begun when the index case first presents.

Special considerations

  • If the index case is acutely physically ill or emotionally distressed, it may be better to defer the issue until a subsequent consultation, provided that the index case can be relied upon to return.
  • For many index cases, the issue of notifying contacts will have a high priority and the provider should assist them to deal with the issue immediately.
  • For readily treatable and very infectious diseases (e.g. chlamydia, gonorrhoea and syphilis), contact tracing is usually dealt with during the same visit. Contact tracing is more often deferred to a later consultation for chronic viral STIs, particularly HIV. This may avoid compounding the patient's acute crisis, and offer the counsellor the opportunity to ensure that the information provided by the index case to their contacts is accurate.
  • Penicillin-resistant gonorrhoea should be seen as a matter of urgency to reduce transmission and ensure that current treatment guidelines remain valid.
Uncooperative patients

Advise regional Public Health Unit's (PHUs) of uncooperative patients, particularly in the case of penicillin-resistant gonorrhoea, syphilis and HIV.

Inform the appropriate PHU representative directly and confidentially.

A strategy for a short-term management plan should be agreed between the primary health care provider and the PHU.

Patients should be reassessed to find out why they are reluctant to cooperate.

Rationale: Infectious diseases legislation places control of communicable diseases under the management of PHUs. However, this is a last resort, when counselling by the primary health care provider has been unsuccessful in persuading the index case to comply with contact tracing and treatment protocols. This decision is also largely dependent on the nature of the index case's diagnosis.

Problems and possible solutions for uncooperative patients

  • Fear of loss of confidentiality: Offer provider referral for greater anonymity.
  • Unassertive patient unwilling to confront contacts: Practise role playing (perhaps with counsellor assistance).
  • Patient not reconciled to diagnosis: Allow more time and support.
  • Unaware of seriousness of consequences: Provide appropriate education materials and discuss.
  • Little concern for consequences to contacts: Explain that contacts tend to find out eventually; emphasise the risk of re-infection and any legal requirements.
  • Socio-cultural differences between the health care provider and the patient: Seek the assistance of a culturally appropriate agency.
  • Fear of reprisal from partner/s: Explain disease process. Encourage and provide support. Discuss various scenarios and how they can be dealt with and also offer to inform the partner.
  • Shame of having a disease: Explain disease process.
Partner notification contact tracing modules

Providers can improve their skills using the WA partner notification (contact tracing) modules online. The modules are designed for nurses and Aboriginal Health Workers in WA. This course comprises 8 modules and can be done in any order.

View the WA partner notification (contact tracing) modules on the Australian Society for HIV Medicine website (external site).