Immediate access to antibiotics stems spread of sexually transmitted diseases

02/15/05

Hopkins scientists believe that repeat infections among couples can be effectively stopped, but legal issues are pitfall

In an editorial to be published in The New England Journal of Medicine, researchers at Johns Hopkins offer their support for a study which shows that providing faster, more direct access to antibiotics for partners of newly infected patients reduces re-infection rates and spread of sexually transmitted diseases, such as gonorrhea and Chlamydia, compared to standard practice.

In the study, treatment was accelerated by providing packets of antibiotics or mailing medication directly to partners from the pharmacy, without first requiring examination of the partner by a physician. This "expedited treatment" resulted in 68 percent fewer re-infections with gonorrhea and 18 percent fewer re-infections with Chlamydia (or 24 percent, overall, when results for both diseases were combined), according to the study report, which appears in the same edition of the NEJM online Feb 17.

The expedited approach is controversial, say the Hopkins researchers, because most state laws, with the exception of California and Tennessee, do not allow distribution of antibiotics without a physician's examination.

"Traditional approaches to informing partners - in which the patients themselves must notify their sexual partners, who are then expected to seek medical evaluation and treatment - simply do not work well enough, as many patients fail to properly inform their partners, and many partners fail to seek treatment, which leads to re-infection," says lead editorial author and infectious disease specialist Emily Erbelding, M.D., M.P.H., an associate professor at The Johns Hopkins University School of Medicine. "These STDs are persistent in the United States - we are not making much headway in further reducing their overall incidence, and the standard approach to treating partners is one obstacle. Currently, fewer than 20 percent of local health departments in the United States offer assistance with notifying partners to patients with gonorrhea and Chlamydia, leaving most patients, often those in the poorest communities with limited resources, to make arrangements on their own for the partner's care."

The 2003 rate for gonorrhea in the United States, the most recent available, is 117 per 100,000 people. This figure is nowhere near meeting the objectives of the federal Department of Health and Human Services' 2010 Healthy People Initiative, which is 19 per 100,000, Erbelding adds.

In the study, which was led by Hopkins-trained University of Washington researcher Matthew Golden, M.D., newly infected patients and their sexual partners were randomly assigned to one of two groups and offered either a standard referral for the partner or expedited treatment for the partner. Where a patient was not willing to talk to their partner about treatment, health workers attempted to notify and counsel the partner.

In the standard-referral group, patients and health workers advised the partners to seek treatment at a free clinic. For the group receiving expedited treatment, the health care team offered free packets of medication, a written prescription or directly mailed medication for up to three partners. Patients and partners in both treatment groups were retested and interviewed three months later to determine who had received treatment and whether anyone had been re-infected.

For gonorrhea, the expedited-treatment group showed a 3 percent re-infection rate compared to 11 percent among the standard-referral group. Results showed a similar trend for Chlamydia, with the expedited-treatment group showing an 11 percent re-infection rate, while the standard-referral group had 13 percent.

Packets contained the standard treatment for each STD, which is one tablet each of cefixime (400 milligrams) for gonorrhea and azithromycin (1 gram) for Chlamydia. Also included in the packets were condoms and health information on STD transmission and medication side effects.

More than 1,800 women and heterosexual men were involved in the study, all of whom were newly diagnosed with one or both STDs and claimed at least one untreated partner within the previous 14 days. The study was conducted solely at the University of Washington in Seattle and took place from September 1998 to March 2003.

"The study's results should encourage physicians and public health policy advocates to incorporate expedited, patient-delivered therapy of antibiotics into their practices to effectively treat partners and control the spread of STDs, such as gonorrhea and Chlamydia," says editorial co-author and infectious disease specialist Jonathan Zenilman, M.D., a professor at Hopkins. "This approach had the added benefit of serving as a model for public-private approaches to public health problems. With this approach, no additional public funding would be required to expand the number of field staff to offer partner notification services. Treatment was delivered to a high proportion of the group exposed to the STD. Privately run, local pharmacies willingly participated in the program. If legislators are prepared to relax current restrictions on dispensing, as did Washington state for this study, then it could be effective elsewhere in cities where high rates of gonorrhea and Chlamydia remain persistent problems despite efforts to apply standard health approaches."

Baltimore, Md., has among the nation's highest numbers for STDs. Recent statistics from 2002 show that the city had the third highest incidence (new cases per year) for Chlamydia (at 6,267 cases, behind Detroit, Mich., and Richmond, Va.) and gonorrhea (at 4,873 cases, behind St. Louis, Mo., and Richmond, Va.)

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