Public health advocates headed to Congress last week to ask for $53.5 million to help state and local health departments prepare for the impending appearance of antibiotic-resistant gonorrhea in the United States.
Gonorrhea is one of the most common sexually transmitted infections (STIs), with over 700,000 cases in the United States each year. The infection may cause itching, burning, discharge, or pain during urination, but often has no symptoms. If left untreated, however, it can cause pelvic inflammatory disease and lead to infertility in both men and women. Gonorrhea, once known as “the clap,” has long been thought of as minor by many because it can be treated with antibiotics.
However, as I explained in a piece for RH Reality Check last year, Neisseria gonorrhoeae, the official name for this pesky bacterium, has steadily developed resistance to entire classes of antibiotics. As early as the 1940s, it was resistant to sulfanilamides, by the 1980s penicillins and tetracyclines no longer worked, and in 2007 the Centers for Disease Control and Prevention (CDC) stopped recommending the use of fluoroquinolones (the class of drugs that includes Cipro, which we may all remember as the thing to stockpile in case of an anthrax attack). Today, the only class of antibiotics that remains effective is cephalosporins, but the bacterium’s susceptibility to these drugs is rapidly declining.
Last summer, the CDC changed its treatment guidelines for gonorrhea because the bug is becoming resistant to oral ceftriaxone, which had been the recommended drug. Now, the CDC suggests that infection be treated with injectable ceftriaxone in combination with one of two oral antibiotics—doxycycline or azithromycin. The goal of this change is to preserve the effectiveness of ceftriaxone, because it is the last drug that works and there are no others in the pipeline.
The first U.S. case of gonorrhea that’s highly resistant to current antibiotics was discovered recently in Hawaii. Similar cases have been seen in other countries, including Norway and Japan. William Smith, the executive director of the National Coalition of STD Directors (NCSD) and one of the advocates who addressed Congress last week, told the Washington Times that this case was “worrisome.” He went on to say, “Experts agree that it’s not a matter of if gonorrhea-resistance will hit, it’s a matter of when it will hit.”
Deborah Arrindell, vice president of health policy at the American Sexual Health Association (ASHA), put it more dramatically, telling RH Reality Check, “Gonorrhea is a fighter. This is one of the most common infectious diseases, and it has an uncanny ability to resist antibiotics. It’s just a matter of time before there’s nothing left behind the pharmacy counter to treat it.”
Both ASHA and NCSD worked with Congress last year on the GAIN (Generating Antibiotic Incentives Now) Act, which was passed as part of the most recent Food and Drug Administration (FDA) User Fee Law. Under this act, the FDA will begin to work with drug companies to encourage the research and development of new antibiotics to combat gonorrhea and other emerging “super bugs.” While advocates agree that this is a good first step, it’s not enough, which is why ASHA, NCSD, and others went back to the Hill to ask for emergency funding. Smith explained the need for this money to RH Reality Check: “Due to drastic budget cuts, health departments across the country have had to furlough or layoff staff and as result have constricted the scope of their work over the past several years—to the point of being bare bones. The public health infrastructure simply can’t respond to this imminent threat without some new money coming in.”
The request to Congress specifies that the money is needed in five areas: diagnosis and treatment, surveillance and lab capacity, disease intervention specialists, evidence-based interventions, and education and awareness.
As I explained in my article last year, one of the problems with gonorrhea is how we currently diagnosis it. Most STD clinics use something called a Nucleic Acid Amplification Test (NAAT), which is very cheap and also tests for chlamydia. However, because it relies on urine, it can only detect genital infections and those of the urethra or cervix, but not those in other areas that bacteria can infect, such as the throat or anus. Moreover, it does not provide information on the strain of the bacteria, so a clinician has no way of knowing if a patient has a resistant strain; that would require culturing, which many clinics are no longer set up to do. This has repercussions for treatment—without this information, clinicians presume the prescription they gave worked, and if they see the same patient again they’re likely to assume it’s a new infection. It also has repercussions for tracking trends and following the super bug if and when it gets here. That’s where the money for surveillance and lab capacity will help.
As for disease intervention specialists, they are health department employees who work with patients to identify sexual partners who might have been infected. They then contact those partners to offer testing and treatment. Smith says that this work is crucial to “break the chain of disease transmission and protect the community’s health.” The money would also be used to scale up evidence-based interventions such as Expedited Partner Therapy (EPT), which also helps to break the chain by allowing physicians to prescribe medications to partners of infected patients without having to examine the partners. These measures are all part of the Cephalosporin-Resistant Gonorrhea Public Health Response Plan published by the CDC last summer.
Advocates argue that the plan can’t be put into place without additional funding, and that such funding would be a wise investment. Arrindell pointed out, “Untreated gonorrhea has high human costs in pain and suffering—it facilitates transmission of HIV and can cause problems that lead to infertility. But it also carries a high economic burden for our nation. The CDC estimates that in a mere seven years, drug-resistant gonorrhea could add about $780 million to our over-burdened health-care system. An investment of $53 million today is much cheaper than dealing with the clap run amuck.”
Smith also stressed that this isn’t like HIV, which we don’t know how to cure: “If we aren’t prepared when antibiotic-resistant gonorrhea hits, we will have a serious public health crisis our hands, with only our own lack of attention and investment to blame.”