SORRY DUDES ITS LONG

By Stephen Smith, Globe Staff, 3/10/2004

A dangerous form of gonorrhea that can't be treated with standard antibiotics has swiftly established a foothold in Massachusetts, highlighting a resurgence of sexually transmitted illnesses across New England, disease trackers report.

The new germ was first detected in the state in 2002. By last year, one of every seven gonorrhea patients tested positive for the bacteria, which cannot be treated with the cheapest antibiotic pills. Maine reported its first case in January.

Though other New England health departments do not routinely examine blood samples for the new bug, health officers in those states said they suspect its presence.

Infectious disease specialists fear that the number of drug-resistant gonorrhea cases will grow exponentially, as patients with the new strain are unwittingly prescribed drugs that do them no good. Thinking they're cured, the patients may resume unsafe sex practices and pass on the infection.

"If the drug-resistant gonorrhea establishes that initial beachhead, it can become very hard to put the genie back into the bottle," said Dr. Stephen L. Boswell, executive director of the Fenway Community Health Center in Boston.

Federal infectious disease specialists are monitoring the spread of the drug-resistant bacteria -- which arrived in the United States about four years ago, on the West Coast -- with a mixture of surprise and alarm. Investigators from the US Centers for Disease Control and Prevention said the Massachusetts outbreak appears to be more severe than clusters recently reported in Seattle, Las Vegas, Chicago, Dallas, and Philadelphia.

They also predict that the new gonorrhea strain could be a harbinger of an increase in HIV infections: Because people with gonorrhea have open sores on their genitals, they can catch the AIDS virus more easily and spread it more efficiently if they're already infected. "We're really surprised at the speed of this," said Dr. Susan Wang, a CDC medical epidemiologist who is analyzing the Massachusetts gonorrhea cases. "We were hoping to have a little more time before it came to the East Coast. The amount that we're seeing in Massachusetts is quite a bit. We're quite concerned."

The difficult-to-treat gonorrhea is emerging as a problem as sexually transmitted diseases, once on the path to elimination, have begun rebounding and as the state Department of Public Health weighs further cuts in the amount it spends to test for such conditions.

As recently as 2002, the state ran 13 clinics inside hospitals and health centers to test for sexually transmitted diseases. Now, there are eight, operating on $750,000 a year, half of what was spent two years earlier. The state expects to test about 6,000 fewer patients this fiscal year than the 23,684 tested in 2002.

"These clinics are really essential, especially to detect drug-resistant gonorrhea," said Geoffrey Wilkinson, executive director of the Massachusetts Public Health Association, a consortium of public health officers and workers.

Under pressure from Governor Mitt Romney to reduce its budget, the Department of Public Health has proposed slicing $335,000 more from what it spends to test for sexually transmitted diseases. A department spokeswoman, Roseanne Pawelec, said that officials proposed the additional cut to sexually transmitted disease clinics because another part of the agency was already testing for those conditions. The HIV/AIDS Bureau operates its own clinics, which test for a variety of diseases, including gonorrhea. The $5 million spent each year on those tests is expected to remain steady.

Even though gonorrhea cases declined slightly the past two years in Massachusetts, the 3,010 diagnoses reported in 2003 represented a 45 percent increase since 1997, when the state reached a historic low. Rhode Island and Vermont each reported nearly a doubling of gonorrhea patients in the same time period, while Maine saw nearly a fourfold increase. In Connecticut and New Hampshire, gonorrhea cases have remained relatively stable.

Nationally, the tally of gonorrhea infections grew by 7 percent from 1997 to 2002.

Specialists in disease prevention said they believe the increases in sexually transmitted diseases can be traced, in part, to weariness with safe-sex practices adopted in the shadow of the AIDS epidemic.

The return to risky practices also reflects changing attitudes toward the threat posed by AIDS. With the arrival of potent drugs to control HIV infections, AIDS no longer commands the fear it once did. The result, said Charles Dwyer, manager of HIV services at the Maine Bureau of Health, can be witnessed on any Saturday night. "Ten years ago, at places like bars where people would go for hook-ups, it was not uncommon for people to have an automatic understanding that condoms would be used," he said. "It's not that way anymore."

Drug resistance has long been a problem with gonorrhea, a disease caused by bacteria that alter their genetic profile with particular ease, making them untreatable by whole classes of medicines once used to fight them. First, penicillin lost its effectiveness against the infection, then tetracycline.

Doctors then turned to a category of medicines known as fluoroquinolones. Foremost among that constellation of pills: ciprofloxacin, which gained fame during the anthrax attacks of 2001, and ofloxacin.

"They're one of the first things that doctors reach for when they prescribe antibiotics," said Dr. Jeffrey Klausner, director of sexually transmitted disease prevention and control services for the San Francisco Department of Public Health. "Generally they're safe. They're well-tolerated. They're given as a single dose."

But success may have doomed those drugs, with the gonorrhea germ being exposed to the medicines so often that it mutated and has outrun them. In San Francisco, where the new resistant germ was spreading by 2000, one in five gonorrhea infections last year was linked to that strain.

When the new germ landed in Massachusetts in 2002, the state lab reported that about 2 percent of infections were attributable to the strain. By 2003, the estimate was 14 percent.

If untreated or treated with an ineffective antibiotic, gonorrhea can cause permanent harm. In women, it can result in pelvic inflammatory disease, which in its most severe form produces abdominal pain and fever. In men, it can cause recurrent pain in the testicles. In both women and men, untreated gonorrhea can lead to infertility, joint disorders, and infections of the brain and eyes.

To stem a tide of drug-resistant infections, clinics with a high volume of gonorrhea patients have largely stopped prescribing drugs such as ofloxacin and ciprofloxacin. Today, at those offices, a gonorrhea patient is just as likely to get a shot of a drug called ceftriaxone, even though it costs about twice as much to pay for the injection and the equipment and time to administer it.

But at the office of a community physician not as steeped in issues regarding drug resistance and gonorrhea, patients are probably getting off-the-shelf pills, specialists said.

For infectious disease doctors, who lament that few new antibiotics have been introduced in recent years, the greatest fear of all is reaching a moment when gonorrhea has outsmarted so many drugs that none remains.

"We're burning through antibiotics," Klausner said. "What happens when we burn through them all?"

Stephen Smith can be reached at stsmith@globe.com.