Unusual Pathogens and Multidrug-Resistant Bacteria in Tsunami Survivors

Sir—We appreciate the comments by Romoren and Sundby [1] and their careful reading of the article by Paz-Bailey et al. [2] and our accompanying editorial [3]. In their comments, Drs. Romoren and Sundby raise 3 issues. First, they claim that our use of a decimal point in calculating percentage decreases in prevalence between the 2 family planning surveys is “simplifying and misleading.” Although we would not use these words and consider this issue to be a matter of style more than a matter of integrity of data presentation, we understand their point that to use a decimal point might imply more precision than the underlying data justify. Second, the authors validly note the relatively small sample sizes and potential heterogeneity among the patients practicing family planning who constituted the study groups, data from which led to the observed decreases in prevalences between the 1993 and 2002 surveys. Fair enough. But we would like to make 3 points. First, we calculated percentage decreases only for the patients practicing family planning who participated in the Paz-Bailey study precisely because we believed that, among several varying populations in the article, these were most likely to be homogeneous. Second, we used the word “considerable” to refer to these decreases and deliberately avoided the word “significant” because of the statistical implications this word can have. Third, it is also potentially misleading for researchers to believe that differences with a P value of .05 are believable and those with a value of 1.05 are not. Although the 95% CIs for the trichomonas prevalences quoted by Romoren and Sundby do (marginally) overlap, we ourselves would not interpret the differences in prevalences much differently had they not (marginally) overlapped. Last, the authors indicate that we should not be surprised that there were decreases, given the “massive treatment with multiple antibiotics for more than a decade” for reproductive tract infections. We appreciate this argument, which seems to indicate support for our view that there were, indeed, decreases. Although we agree that this is likely a reason for the observed decreases in prevalence, our editorial did not ascribe such decreases solely to antibiotic use for treatment of reproductive tract infections; rather, our editorial ascribed such decreases to multifaceted programs and interventions attempting to diminish rates of sexually transmitted infections, including messages to limit the number of sex partners, encouragement for condom use, and special, targeted interventions for high risk populations. Sexually transmitted pathogens, especially bacterial ones, can be controlled when sustained, consistent, standardized prevention and treatment protocols are put in place, as has been shown in a number of developed and developing countries.