Challenges of Sexually Transmitted Disease Prevention and Control: No Magic Bullet, but Some Bullets Would Still Be Appreciated

Received 1 June 2005; accepted 1 June 2005; electronically published 12 August 2005. Reprints or correspondence: Dr. Alfred DeMaria, Jr., Massachusetts Dept. of Public Health, State Laboratory Institute, 305 South St., Jamaica Plain, MA 02130 (Alfred.DeMaria@state.ma.us). Clinical Infectious Diseases 2005; 41:804–7 2005 by the Infectious Diseases Society of America. All rights reserved. 1058-4838/2005/4106-0006$15.00 In his social history of venereal disease in the United States, No Magic Bullet [1], Brandt makes the case that, despite the germ theory, an understanding of disease control, and even effective antimicrobials, sexually transmitted diseases (STDs) have not been in control. He asserts that societal tension between morality and rationalism, as well as the difficulty in dealing simultaneously with both privacy and social responsibility in the context of sexual behavior, have been barriers to control. With regard to antibiotics, he makes the following point: “Unfortunately, however, the promise of the magic bullet has never been fulfilled... . even those infections that respond to antibiotics are still prevalent ... the magic bullet cannot combat the social and cultural determinants of these infections” [1, p. 161]. Although there is no “magic bullet,” those of us who treat patients with STDs and those of us who are charged with controlling the spread of these infections in the community certainly appreciate any ammunition we can get. Effective antimicrobial therapy for bacterial STDs cures infection and prevents shortand long-term complications. Although public health STD-control programs encourage and support the use of effective treatment as secondary prevention (for preventing disease and complications) and tertiary prevention (for preventing disability and long-term complications), a major objective is to prevent transmission by curing infection. Antibiotics provide cure and recovery to the patient, as well as a reduced incidence and prevalence of infection for the community. Antibiotics may not be the answer to STDs, especially as the more prevalent viral STDs are unaffected by antibiotic therapy, but they remain the mainstay for treatment of gonorrhea, chlamydial infection, and syphilis. The progressive acquisition of antibiotic resistance in Neisseria gonorrhoeae over the past 30–35 years, and difficulties acquiring and administering remaining antibiotics have brought us to a point of increasingly limited options. Bullets, of any sort, are getting scarcer. The article by California state and county public health sexually transmitted disease control officials and persons at the Centers for Disease Control and Prevention (CDC) in this issue of Clinical Infectious Diseases [2] documents the emergence of endemic quinolone-resistant N. gonorrhoeae (QRNG) in California during the period of 2000–2002 and describes the characteristics of its spread. The authors construct a picture of the introduction and spread of QRNG, starting with a first indication of an increase over a stable, low prevalence of QRNG among isolates from male STD clinic patients collected as part of the national Gonococcal Isolate Surveillance Project (GISP) to a level of 20%, with a preceding shift from intermediate susceptibility to resistance. They were able to determine that an early cluster of 6 patients in Orange County in 2000 were all born outside of the United States; 5 of these patients were heterosexual, and 3 had exposure to commercial sex; none reported antibiotic use, and there were no common exposures. Expanded surveillance revealed an association between QRNG infection and travel, an increasing association with antibiotic use, and a high rate of multiple partners. In a case series, 40% of the patients with QRNG reported travel outside the continental United States within the previous 6 months. A cross-sectional study of 952 STD clinic patients with gonorrhea from 4 counties, 70 (7.4%) of whom had QRNG isolated, suggested variation in patterns of spread of QRNG in terms of