A new HPSC Scientific Advisory Committee national guidance document Guidance on Management of Outbreaks of Sexually Transmitted Infections has been published on the HPSC website. The guidance is designed for health professionals involved in the prevention, investigation, and control of outbreaks of STIs. It is also relevant for Non-Governmental Organisations (NGOs) who may be asked to contribute to and/or support the work of outbreak control teams.
Outbreaks of an STI can occur in a range of diseases such as syphilis, gonorrhoea, HIV, hepatitis B, and lymphogranuloma venereum. The intensity and scope of the investigation and response required will vary depending on the disease involved.
Sometimes it can be difficult to decide whether or not an STI outbreak is occurring. Regardless of whether an increase in cases is labelled an “outbreak” some level of investigation should be initiated when an increase in cases is noted. Cases may be occurring locally, nationally or internationally and/or in a given community. An STI outbreak may also consist of epidemiologically linked cases that are of public health significance (e.g. LGV). The response should therefore be tailored to the individual circumstances surrounding the increase. The steps to be taken, number and types of staff involved, and who in the healthcare system and general community is informed and involved will be necessarily different depending on these circumstances.
Infections that are sexually acquired can be complex and challenging to investigate. Social stigma and confidentiality can complicate the collection of information and instigation of control measures. Therefore, the investigation and control of an STI outbreak will usually take longer than outbreaks of other infectious diseases. However, the components of an STI outbreak investigation are broadly similar to any other infectious disease outbreak investigation i.e. preliminary investigation, formation of outbreak control team, epidemiological and microbiological investigation, control measures, communications, review and evaluation and formal declaration that the outbreak is over.
The response to an STI outbreak requires a multidisciplinary approach. Consultants in Public Health Medicine, Surveillance Scientists and Officers, GUM/ID Physicians, Microbiologists, GPs, Health Promotion and Improvement Officers, Clinical Nurse Specialists and Sexual Health Advisors at STI clinics may all be involved in the investigation and response. Non-Governmental Organisations (NGOs) may also be involved. Mechanisms for regular contact between professionals working in sexual health services should be developed to enable the development of networks between key HSE staff and NGOs. These networks will help facilitate effective investigation and intervention in the event of an outbreak.
Developing and implementing control measures and campaigns can be very challenging and requires the combined expertise and resources of a wide range of disciplines within the statutory health service and NGOs. Constructive partnership working is key to maximising the contribution of all concerned to the ultimate goals of controlling the outbreak and distilling the learning for future use.
Interventions used to control STI outbreaks will depend on the specific disease and the population affected. In general the identification of sexual contacts and sexual networks will be crucial to effective intervention. Health promotion may need to be targeted to specific sub-populations or more widely, and will need to include primary (modify sexual risk taking behaviour) and secondary (find and treat secondary cases) prevention strategies.
The guidance also recommends that, once an outbreak is over, a final report is written so that the lessons identified from the investigation and recommendations made are shared with other colleagues and used to improve these guidelines.
Áine McNamara, Chair of STI guidelines subgroup of the HPSC SAC Sub-Committee on Managing Outbreaks of Infectious Disease
