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© 2003 American Public Health Association
LETTER |
Correspondence: Requests for reprints should be sent to Joshua R. Mann, MD, MPH, Dept of Family and Preventive Medicine, University of South Carolina School of Medicine, 6 Richland Medical Park, Columbia, SC 29203 (e-mail: joshua.mann{at}palmettohealth.org).
St. Lawrence et al. report that most physicians do not screen their patients for sexually transmitted diseases (STDs) or adequately ensure treatment of the sexual partners of infected patients.1 These findings seem to indicate a need for better education of physicians regarding guidelines for screening, treatment, and reporting in addition to the important connection between clinical practice and public health efforts. In my experience, many physicians lack understanding of how their clinical activities affect public health.
Efforts to increase physician screening activities may be more effective if they address these public health concepts, among others:
- The impact of screening activities on population levels of disease. Population prevalence can be estimated as the product of incidence and duration. Further, the rate at which an infectious disease spreads through a population depends on the infectivity of the disease, the rate of contact between infected persons and uninfected persons, and the duration of infectiousness.2 Screening reduces the average duration of infection and therefore reduces both incidence and prevalence of infectious diseases. Physicians who do not understand the importance of their work from a population perspective may be less likely to conduct screening.
- The impact of prevalence on screening test performance. Among nonobstetricians, screening for syphilis and HIV occurred at similar rates as screening for chlamydia and gonorrhea. Since increased prevalence is associated with increased positive predictive value and cost-effectiveness, one might expect an evidence-based strategy to include more-frequent screening for high-prevalence diseases (e.g., chlamydia) than for lowprevalence diseases (e.g., syphilis). Physicians may not be aware of differences in sexually transmitted disease (STD) prevalence or the impact of prevalence on screening performance. On the other hand, disease severity may explain high levels of screening for relatively rare infections (e.g., HIV).
- The impact of interpersonal and community factors on disease conditions, and the need for medical care to address these issues in addition to the technical aspects of diagnosis and treatment. St. Lawrence et al. found inadequate arrangement of appropriate counseling and testing of patients’ sexual partners. This despite the fact that most sexual partnerships are just that—partnerships. Patients treated for an STD are likely to continue having sexual contact with the same partner(s) to whom they were exposed prior to receiving treatment. These partners may still be infected, and infectious. Failure to treat infected partners is likely to render screening efforts ineffective.
References
1. St. Lawrence JS, Montaño DE, Kasprzyk D, Phillips WR, Armstrong K, Leichliter JS. STD screening, testing, case reporting, and clinical and partner notification practices: a national survey of US physicians. Am J Public Health. 2002;92:1784–1788.
2. Steen R. Eradicating chancroid. Bull World Health Org. 2001;79:818–826.[Medline]
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