Drug-Resistant Gonorrhea: WHO Agrees It's An Emergency

Image: KaptainKobold/Flickr

The World Health Organization has weighed in on the growing threat from antibiotic-resistant gonorrhea, saying in a statement this morning (emailed, and apparently not online):

Millions of people with gonorrhoea may be at risk of running out of treatment options unless urgent action is taken, according to the World Health Organization (WHO). Already several countries, including Australia, France, Japan, Norway, Sweden and the United Kingdom are reporting cases of resistance to cephalosporin antibiotics — the last treatment option against gonorrhoea. Every year an estimated 106 million people are infected.

The statement arrived as an adjunct to the launch of the WHO’s new global action plan for controlling the spread of resistant gonorrhea.

If you’ve been reading here for a while, the problem of resistant gonorrhea won’t be new to you. (Here are some past posts on data from the CDC and a call to action in the New England Journal of Medicine, along with a piece I wrote in Scientific American and a separate post by my SciAm editor Christine Gorman.) But in case you’ve just come in:

Since the late 1990s, a very small group of researchers worldwide has been sounding the alarm about gonorrhea becoming resistant to the last group of drugs, cephalosporins, that can cure the disease in an outpatient setting. That is, the drugs can be given by mouth and usually take a single dose or a small number of doses to effect a cure. Those requirements are important because they are the conditions on which community-clinic STD control is based. Community programs — single visits to low-cost clinics where drugs are dispensed relatively quickly — is what keeps the cost of STD control from spinning into unaffordability.

Community STD control has been so successful for so long that we’ve mostly forgotten how bad gonorrhea and similar diseases can get if they go untreated. The WHO plan reminds us:

[T]he long-term sequelae of untreated gonococcal infections, which include persistent urethritis, cervicitis, proctitis and disseminated infections that could lead to pelvic inflammatory disease, infertility, first-trimester abortion, ectopic pregnancy and maternal death. Health consequences to neonates include severe infections that may lead to blindness. In addition, gonococcal urethritis, like many other STIs, significantly increases the risk of acquiring and transmitting HIV infection.

The plan specifically calls out an aspect of the growing resistance problem that we highlighted at SciAm: Community control now depends on rapid molecular tests that identify the gonorrhea organism (Neisseria gonorrhaea) but cannot distinguish between drug-susceptible and antibiotic-resistant organisms. Hence, patients who were treated, and then went back to their doctors with the same symptoms, were assumed to have been cured and then reinfected. Physicians have not had the tools to identify ongoing infections that never responded to treatment — and patients who had those resistant, not-responding infections then went on to unknowingly infect others.

In order to address that problem, the plan calls specifically for improvements in lab capacity, diagnosis and surveillance, as well as asking for things that apply to the greater problem of antibiotic resistance: improved awareness, bigger efforts at prescribing antibiotics appropriately and better drugs. One thing that it particularly calls for — as the CDC did in the New England Journal last February — is for physicians to start applying a “test of cure,” actually checking microbiologically to see whether a patient who was prescribed an antibiotic for gonorrhea is clear of infection, or harboring a resistant strain.

The problem, of course — you can see this coming — is that once you start bringing patients back and giving them additional and different tests, STD control becomes more costly. (That’s not even to mention the additional, distributed costs of developing new education efforts, surveillance systems or drugs.) In my read, that’s the real news in the WHO’s decision to sound a global alarm: a tacit admission that the era of cheap STD control may be over.



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