In an editorial 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 reinfection 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 reinfections with
gonorrhea and 18 percent fewer reinfections 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 Johns
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, an associate professor
at the 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 Johns Hopkins-trained
University of Washington researcher Matthew Golden, newly
infected patients and their sexual partners were randomly
assigned to one of two groups and offered either a standard
referral or expedited treatment for the partner. In
instances where a patient was not willing to talk to his or
her 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 direct mailing of 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 reinfected.
For gonorrhea, the expedited-treatment group showed a
3 percent reinfection 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 reinfection 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, a professor at Johns 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 has among the nation's highest numbers for
STDs. Statistics from 2002 show that the city had the third
highest incidence (new cases per year) for chlamydia (at
6,267 cases, behind Detroit and Richmond, Va.) and
gonorrhea (at 4,873 cases, behind St. Louis and Richmond,
Va.)