1. Jason Ybarra Disease Intervention Specialist
Direct Observed Therapy (DOT) by Disease Intervention Specialists (DIS)
Jason Ybarra
Disease Intervention Specialist

2. KANSAS
The City of Wichita (Sedgwick County) is located in the Southeastern portion of the state of Kansas (where the “C” is located). Wichita is the largest city in the State of Kansas and according to 2006 U.S Census Bureau, it has a population of 357,698. Sedgwick County has a population of 470, Keep in mind where Wyandotte and Johnson counties (Kansas City area) are as I will also be making reference to those counties.
Together these three counties make up approximately 54% of total morbidity for gonorrhea and chlamydia in the state.

3. Inception of DIS DOT EPT vs. DOT
Expedited Partner Therapy
- Patient Delivered
- No Partner Counseling and Referral Services (PCRS)
- No testing
DOT
Direct Observed Therapy
- DIS Delivered
- Partner Counseling and Referral Services (PCRS)
- RPR/HIV testing
EPT- Expedited Partner Therapy
The inception of DOT in Kansas began when we saw a need in our STD clinic for a more efficient and timely way to treat male contacts to GC and CTA. What we were seeing was individuals being identified as positive patients (primarily female) and coming in for treatment while their sexual partners could not make it into the clinic due to working 2, sometimes 3 jobs. The partners and/or contacts were not getting treated in a timely manner which raised the risk of re-infection of the female (original patient). Even though DOT was originally designed to treat male contacts to gc and cta only, we found through the process that DOT would work great on patients (both male and female) who have already tested positive as well.
Evaluation, testing and treatment at Sedgwick County Health Dept STD clinic is by appointment and we were seeing that appointments fill up 2, sometimes 3 days out and that there was a delay in the treatment of positive patients and their sex partners.
The Sedgwick County Health Dept, in collaboration with KDHE and the Wyandotte County Health Dept, looked at EPT and DIS DOT as a potential tool to augment timely treatment and partner management. We found that there was some uncertainty about EPT in Kansas regarding patients loosing meds, allergy history and things such as this. We found that working with local county health officer, and giving total authority and autonomy locally could provide a manageable substitute and in some ways it could work better in assisting patients receive those core elements of public health including prompt treatment, risk reduction activities, PCRS, and basic STD counseling thus augmenting the health of the public as a whole in our particular area.
EPT – Patient delivered (no counseling, no education), no PCRS that we are aware of and no patient evaluation.
DOT- DIS delivered, patients are getting assessed to a certain degree, provided std counseling including risk reduction practices, PCRS, and evaluation for HIV and syphilis (if not previously tested) through venipuncture by DIS.

4. Direct Observed Therapy Protocol and Procedure
Purpose:
To ensure clients with positive laboratory tests for
gonorrhea and/or chlamydia and their sexual partners
receive prompt treatment, decrease morbidity, improve
patient compliance, reduce disease complications and
reduce the infection period.
Wyandotte County blazed the trail for DIS DOT in Kansas beginning in June of In collaboration with that successful program and with the guidance of KDHE, Sedgwick County DIS began DOT soon after.
DIS DOT is not designed as a primary way of conducting business but rather as an efficient, cost effective way to fill in the gaps in the excellent, comprehensive STD clinical services that we already have in our Kansas STD clinics.
The most difficult process was the development of a complete protocol for DOT in Sedgwick County. Working with The Sedgwick County Health Department Director, The Health Protection and Promotion Division Director, The Director of Clinical Services, The STD Clinic Supervisor, The local County Health Officer and area DIS, a protocol was developed and signed into effect by the Health officer in September The Sedgwick County Health Officer is responsible for the health and well-being of the public in Sedgwick County and has complete control over the protocol- how it is worded and any changes or updates that may be required.
There are three main points of purpose: To ensure prompt treatment of patients with positive tests and their sex partners, to reduce disease complication and to reduce infection period.

5. Protocol and Procedure (Cont.)
Medication and Procedure:
Under the standing order and the
direction of local health officer
Azithromycin (Zithromax)1g for chlamydia
Cefuroxime Axetil (Ceftin) 500mg for gonorrhea
(MSM are not treated with Ceftin per protocol)
The standing delegation order (SDO) for treatment of infection is based on the standard-of-care and is from the latest version of the Morbidity and Mortality Weekly report (MMWR).
Oral antibiotics are given with water (DIS carried bottled water for this purpose when a DOT is planned).
Azithromycin (Zithromax) 1gm is given by mg tablets as a single dose for chlamydia.
Cefuroxime Axetil (Ceftin) 1gm is given by mg tablets as a single dose (Recently changed from Cipro 500mg due to quinolone resistance and CDC recommendation). Clients infected with gonorrhea who have not received a laboratory evaluation for chlamydia will also receive an additional 1 gm of Azithromycin as a single dose. If given Ceftin, patients are asked to be re-evaluated. Contacts/partners will also receive dual treatment under DOT protocol.
Due to only a 95.5% effective cure rate utilizing Ceftin for Pharyngeal and rectal Gonorrhea, MSM who have a history of oral and rectal sex in the interview period will be referred to the STD clinic for treatment with ceftriaxone.

6. Protocol and Procedure (Cont.)
DOT activities are monitored by Clinic and DIS Supervisors.
Assessment of client
Observation of Medication Consumption
STD Counseling, risk reduction and Partner Counseling and Referral Services (PCRS)
Upon receipt of an assignment to follow an untreated positive test, or a documented contact to chlamydia and/or gonorrhea, the DIS will attempt to contact the client and arrange for an encounter in the public health clinic. If after documented attempts to contact the client the DIS is unable to reach the client or if the client has missed clinic appointments, the DIS will obtain the appropriate prepackaged medications from the clinic supervisor or staff nurse in his/her absence and initiate a field investigation.
The DIS will assess, advise and supply a translator, if necessary. Appropriate documentation will be gathered for DOT- Clinic chart, H&P form, HIPPA regulations, HIV counseling documentation and DOT protocol documents. The DIS will obtain an abbreviated medical history from the patient including any known drug allergies and other contradictions such as pregnancy status and disease complications (PID symptoms, testicular inflammation). Clients with unknown pregnancy status, a history of relevant drug allergies or possible disease complications are referred to the clinic for evaluation.
If all is okay, DIS will give the patient a medication information sheet and answer any questions the patient may have regarding drug complications. The DIS will go over Disclosure and Consent for Treatment of Sexually Transmitted Disease. The medications are then dispensed and the patient is observed taking the medications. Current protocol calls for observation of patients taking oral medications for a minimum of 15 minutes. DIS utilize this time by continuing STD counseling, partner notification activities and HIV/Syphilis testing. The patient is provided DIS and health department contact information for follow-up, if required.

7. Sedgwick County DOT Data January 1, 2007 – December 31, 2007
Total: 99
Sex
Male: 70
Female: 29
Age
14-24: 66
25-29: 21
30-39: 10
40-49: 2
87% of all DOT’s performed in Sedgwick County were on patients between the ages of 14 – 29.

8. Sedgwick County DOT Data (Cont.) January 1, 2007 – December 31, 2007
Positive chlamydia: 40
15 males, 25 females
Positive gonorrhea: 1
1 female
Positive gc and cta: 1
1 male
Contact to chlamydia: 51
48 males, 3 females
Contacts to gonorrhea: 4
4 male
Contacts to gc and cta: 2
2 males
Contact to chlamydia – female. Notice that only 3 female contacts were provided DOT during this period. This is because we only perform these actions when absolutely necessary. The goal for women is testing for both GC and CTA in accordance to Kansas Infertility Prevention Program (KIPP) guidelines.

9. Kansas as a Whole January 1, 2007 – December 31, 2007
Total: 133
Sex
Male: 86
Female: 47
Age
13-24: 88
25-29: 26
30-39: 15
40-49: 04
65% of all DOT’s were performed on males.
35% of all DOT’s were performed on females.
85% of all DOT’s in the state were performed on men and women between the ages of

10. Kansas as a Whole January 1, 2007 – December 31, 2007
Positive chlamydia: 52
Positive gonorrhea: 2
Positive gc and cta: 4
Contact to chlamydia: 68
Contact to gonorrhea: 5
Contact to gc and cta: 2
41% of DOT’s were performed for Positive chlamydia.
51% were performed on contacts to chlamydia.

11. Our Findings Very little resistance or difficulty with DOT’s
Well received by patients
DOT can be use to supplement STD Clinic
Our findings have been very promising in Sedgwick County! After going through several drafts of the protocol and getting everyone involved on the same page with what we were wanting to do locally, we have had very little difficulty with the DOT process.
To date, every DOT conducted has gone without incident or complication. We also found that although DOT was originally intended to be a field tool for DIS and used primarily for those patients who could not or would not return to the clinic for services, we found that DOT could also be used as an effective tool to supplement the STD clinic in times of overflow due to a full schedule and in times when patients could still make it to the clinic just not during clinic hours (if a DIS in in the building a patient can get treatment).

12. The Future of DOT
Sedgwick County – DIS urine testing / Rapid HIV Testing on contacts.
Adding DOT to patients who have positive tests through local emergency rooms.
Adding DOT in other high morbidity areas.
In the future we would like to assess the impact of DOT on surveillance Data. (even though the numbers seem to be relatively low at this point). Also we would like to asses and evaluate the behavior change in patients who qualify for DOT.
In the future, DIS in sedgwick County would like to begin performing urine based testing to contacts of positive cases along with field bloods currently being done.
Even though, to a small degree, we have begun performing DOT on positive ER patients, we would like to see more collaboration in the future with local ER’s as well as with local private providers for the timely treatment of positive patients and their partners.
For Kansas, introducing DOT to the county of Shawnee (major city- Topeka, Capital of Kansas) will encompass the 4 highest morbidity counties in Kansas in performing advanced disease intervention through Direct Observed Therapy.

13. Acknowledgements Doren Fredrickson Sedgwick County HD Cindy Burbach
Claudia Blackburn
Jennifer Edison
Pamela Martin
Christina VanCleave
Phineas Gitta
Jamie Collins
Jennifer VandeVelde
Sedgwick County HD
KDHE
Brenda Walker
Allen Mayer
Derek Coppedge
Greg Stephenson
Bertha (Beth) Tackitt
John Lucero Jr
Leslie Whitson

14. Jason A. Ybarra Lead Disease Intervention Specialist
Sedgwick County Health Department
Health Protection and Promotion
2716 West Central
Wichita Ks
Office: