Where do STDs fit in the big scheme

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Where do STDs fit in the big scheme?

• Analogies to and lessons learned from the 2003
  IOM report Microbial Threats to
  Health-Emergence, Detection and Response
• Follows 1992 IOM report Emerging Infections
  Microbial Threats to Health in the United States

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Post-marked for Terror
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Popular Media Coverage
Image source WHO
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Leading Infectious Causes of Death Worldwide
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Recent Microbial Threats
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Microbial Threats to Health

• Identify, assess factors in emergence of ID
• Assess capacity of US to respond to ID
• Identify domestic and international public health
  actions to strengthen detection, prevention, and
  response to microbial threats to human health
• Global emphasis

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Convergence of Factors

• Many factors, interrelated, converge to create
  perfect storm scenario. The microbial perfect
  storm threatens to recur because the factors
  persist with few prospects for change.
• Applies equally well to STDs!

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Factors in emergence STDs

• Microbial adaptation, change
• Changing ecosystems, land use
• Human demographics and behavior
• International travel and commerce
• Technology and industry
• Breakdown in public health
• Poverty and social inequality
• War and famine
• Lack of political will
• Intent to harm

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The Human Population Explosion
Source UN, 1999
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International Tourists Arrivals
WTO, 2002
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World Urbanization Trends
Source UN, 1999
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Recommendations

• Think globally
• Improve surveillance
• Improve public health infrastructure
• Educate the public and workforce
• Develop vaccines and drugs
• Diminish inappropriate drug use
• Use better point of care diagnostics
• Create Interdisciplinary ID centers

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Enhanced Global Capacity

• The US should enhance global ID response
  capacity, focusing on the developing world best
  help by promoting training and local
  infrastructure
• Since many STDs are more prevalent in less
  developed world, recommendation applies equally
  well to STDs!
• There are Some international CDC and NIH
  Fogarty programs but there are many needs and
  opportunities in this arena

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Improve global surveillance

• The US should take a leadership role in
  implementing a comprehensive system of
  surveillance for global infectious diseases, that
  builds on the current global capacity of
  infectious disease monitoring
• Very similar to 1997 recommendation in IOM report
  for CDC to lead national effort to improve
  surveillance for STDs

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Bureaucratic intrusions?
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Rebuilding public health capacity

• Federal and state authorities should continue the
  effort to rebuild and sustain public health
  capacity to respond to ID
• Requires funds for salaries
• On the money as relates to public STD clinics,
  local and state HD needs
• BT funds have helped-sustainable?

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Antibiotic overuse is a problem that must be
addressed

• Problem is serious and is getting worse
• Resistant clones emerge and spread globally eg
  pneumococci
• Reduced availability of key drugs is occurring
  coincident with emerging resistance eg, cefixime
  withdrawn as ciproR GC appear

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Cipro resistance-a growing problem

• Prevalence over 90 in China and 60-70 in Korea
  and Japan only slightly less in Vietnam and
  Philippines
• 10-20 in Hawaii
• 2-3 in California-but much higher in certain
  cities in CA LA, SF 13-20
• Pockets in particular US cities of 10-20, and
  growing Mass 13, S Wang
• Cefixime less susceptible emerging too

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Promote antimicrobial sensitivity testing

• Educate the public and health care workers
• Develop and deploy better cheap sensitive
  specific rapid point of care tests to allow
  rational use of antimicrobials
• Detection of resistance is a problem in GC
  because of increasing reliance on NAATs

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Is decreased inappropriate antibiotic use
possible?

• Decreased use in developed world may make little
  difference if over the counter and indiscriminate
  use continues in much of the less developed
  world, which has no funds for physicians,
  diagnostics or pharmacies
• Clearly pertinent to STDs where resistance
  typically occurs where over the counter use is
  great eg, GC in East Asia, H ducreyi in Africa
  and E Asia

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Use of diagnostics

• Public health agencies and professional societies
  should develop and promulgate guidelines for
  intensive application of existing and new
  diagnostic modalities
• Inferred syndromic management may be cheaper in
  the short run but more costly in the long run
• Should we reexamine emphasis on STD syndromic
  management algorithms?

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Need for new drugs

• US Secretary of HHS should ensure formulation,
  implementation of strategy to develop new
  antimicrobials, and for an adequate supply of
  existing antimicrobials
• Big pharma is abandoning the antibiotic
  development business shortages exist
• What oral drug will replace cipro and cefixime
  for GC? Are we really going to use gentamicin or
  amikacin for GC?

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Ensure a vaccine supply

• Secretary of HHS working with Secretaries of
  Defense, and of Homeland Security should ensure
  the implementation of a national vaccine strategy
  for protecting the the US population from endemic
  and emerging microbial threats, as well as
  potential BT attacks
• HHS, USAID, and US Secretary of State should work
  with public and private partners here and abroad
  to help developing countries with their vaccine
  needs

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Vaccines-shortages

• Only 4 manufacturers among big pharma, only 2 in
  US, down sharply from past
• Expensive to develop-ca 800M for a new vaccine
• Litigation a post development expense
• Price controlled market for many due to
  government purchases
• No easy fix-but time for action

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Vaccines for STDs?

• HIV slow progress
• Human papilloma viruses promising results for
  HPV 16/18 pseudovirion vaccine
• HSV possible efficacy of recombinant subunit
  vaccine in women
• Little public or private interest in others
  although C trachomatis, T pallidum and GC
  vaccines are within possibility

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Can we see the future?

• It seems obvious that treatment of GC is going to
  be a bigger problem before too long. If
  cephalosporins go, there will be no oral drugs
  left. History teaches that cephalosprin
  resistance will emerge.
• Use of injectable aminoglycosides as a mainstay
  has a lot of problems

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Why meningococci but not gonococci

• Huge effort in Europe especially to develop
  meningococcal vaccine
• Very little effort to develop GC vaccine
• Animal model now exists
• No reason that strategies that work for mening
  should not work for GC

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Comprehensive research agenda

• NIH should develop a comprehensive research
  agenda for ID, in collaboration with CDC, DOD, US
  Dept Energy, NSF, academia and industry
• Implied research agenda is sometimes focused too
  much on the scare of the moment, influenced by
  congressional mandates that make little sense,
  and leaves out certain crucial areas

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Comprehensive research agenda for STDs

• Good news NIH has continued to defend and fund
  research centers and training grants CDC is
  expanding its research program on an NIH-like
  model
• Bad news advocacy groups such as Traditional
  Values Coalition target behavioral research on
  sexuality-even though this was cited as key need
  in 1997 report

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Behavioral Research-Difficult but Necessary

• Internet use and syphilis among MSM in San
  Francisco MMWR 52 1229, 12/19/2003
• Internet as a means for partner notification-Los
  Angeles MMWR 53 129, 2/20/2004

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Why do some men engage in risky behaviors?
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What is the funding future for STD programs?

• Funds are not likely to increase-we are in a huge
  budget deficit. Budgets could be pinched.
• Programs could be brought under larger umbrellas
  in name of cost efficiency.
• Increased multitasking may be expected-clinic
  personnel assigned to non-STD tasks career
  officers moved to other jobs as members of
  officer corps of PHS

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Interdisciplinary Centers?

• STI-TM-CRCs being renewed focus on interacting
  themes, prevention-but is this enough?
• Opportunity for broader scale of research,
  bringing together public health, medical
  anthroplogy, behavioral scientists, economics,
  epidemiology, as well as clinicians and basic
  scientists

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There are reasons to hope

• Ease of recruiting volunteers to HPV and HSV
  vaccine studies suggests great public acceptance
  if the experimental vaccines are efficacious and
  cost effective.
• HPV vaccine will be marketed as a cancer vaccine
• Common sense will rule, public will demand
  prevention and information

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Hope continued

• Eventually we will join the rest of the Western
  world in accepting need to investigate and
  discuss sexuality and sexual behaviors
• Hope that correlations of certain STDs HHV-8
  with prostate cancer JID189, 15-20, 2004 is
  correct and points the way to STDs as cause of
  prostate cancer.

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A Seat at the Table