Baltimore's Health Department has ended the three-decade practice of tracing the sexual partners of people with gonorrhea, deciding to concentrate its efforts on the city's resurgent syphilis problem and its persistent AIDS epidemic.
Health Commissioner Peter Beilenson said the city has by no means conquered gonorrhea, even though cases have fallen substantially over the past decade. He said Baltimore remains one of the top four cities for gonorrhea, and there is no guarantee that the illness won't rebound with the easing of surveillance.
"We've had to prioritize what diseases we go after," Beilenson said. "Everybody has to live in this era of diminished resources."
As a low-cost alternative, the department has printed 100,000 booklets with tear-off coupons that gonorrhea patients can distribute to recent sexual contacts. People with chlamydia, another sexually transmitted disease (STD), are also being asked to issue the cards.
Each coupon begins with the bold-type message "Somebody CARES!" and then goes on: "You had sex with someone who had an infection (gonorrhea or syphilis)." The cards list symptoms of those two diseases and the phone numbers and locations of three clinics that offer free testing and treatment.
The city shifted away from gonorrhea tracing in January but began last month to mail the coupon booklets to doctors, who are being asked to distribute them to all patients with gonorrhea or chlamydia. The booklets cost less than 2 cents apiece to print.
Most people are relatively socially conscious, especially if you make it easy for them," said Beilenson, adding that patients can mail the cards anonymously to sex partners if they feel uncomfortable about confronting them.
The city has 14 health officers who are responsible for tracking people who may have been exposed to sexually transmitted diseases. David Akers, a federal health adviser assigned to Maryland, said he and state officials recommended late last year that the officers stop tracing people exposed to gonorrhea so they could spend more time tracking syphilis and HIV.
The decision was sparked by the sudden upsurge in syphilis, which, although less common, is a more serious disease than gonorrhea and can be transmitted in the womb to fetuses.
In 1995, 351 syphilis cases were reported in Baltimore -- an 83 percent increase over the previous year. Through June of this year, 218 cases were reported. Twelve babies were diagnosed with congenital syphilis through May.
"We're trying to head off the inevitability of congenital syphilis," said Frank Meyers, who coordinates the city's STD surveillance program and designed the booklets. "We're trying to shift resources to protect as many babies as possible."
"What's happening with syphilis is really counter to what's happening across the country and even across the state," said Akers, an employee of the federal Centers for Disease Control and Prevention in Atlanta. "We're also worrying that we may be seeing some impact in contiguous areas."
Akers said it is also much more difficult to stop the person-to-person transmission of gonorrhea because the disease develops quickly after sexual contact.
Both syphilis and gonorrhea can be cured with antibiotics.
The decision was also prompted by concerns that the syphilis outbreak could trigger increased transmission of the AIDS virus, said Kim Seechuk of the state Health Department. The genital sores of syphilis and gonorrhea provide entry points for human immunodeficiency virus, but she said syphilis patients appear to be particularly at risk.
"Early infectious syphilis has a lot of implications for enhanced HIV transmission," said Seechuk, the state's director of the sexually transmitted disease office.
Although the HIV transmission rate appears to be holding steady, Baltimore nonetheless has the eighth-highest AIDS rate in the country.
While syphilis cases have risen alarmingly, gonorrhea has fallen from 16,300 cases in 1986 to 8,727 cases last year.
However, Beilenson said it would be a mistake to assume that the downward trend will continue.
Baltimore, he noted, managed to stave off a new tuberculosis epidemic by continuing tough surveillance even when TB rates were falling. In contrast, cities that let down their guard have suffered new epidemics in the 1990s.
"It's generally penny-wise and pound-foolish" to pull back on public health controls, he said. "But in this era of diminished resources, [contact tracing for gonorrhea is] one area we can cut down on."
L Contact tracing is handled differently in syphilis and AIDS.
Typically, health officers contact syphilis patients to explain the need for treatment and the risk faced by their sexual partners. Officers will then speak with their partners if the patients refuse to do so themselves.
The same approach was used in gonorrhea cases until the recent policy shift.
Because of strict confidentiality laws, health officers intervene less often in acquired immune deficiency syndrome cases. Patients can ask the department for help talking to their partners.
Although the shift away from gonorrhea tracing is likely to spark debate, some experts said it's unclear that partner notification has ever made a difference.
"There's no evidence to indicate that contact tracing really helped reduce the occurrence of STDs at all," said Dr. Alfred Saah, an infectious-disease epidemiologist with the Johns Hopkins School of Hygiene and Public Health. "It was done because it was thought to be the right thing."
"On a communitywide basis, there's no data ever shown that contact tracing for gonorrhea actually reduces the number of cases," said Dr. Jonathan Zenilman, who ran the city's STD clinics until last year.
Baltimore's gonorrhea rate has consistently been in the top four nationwide -- with Atlanta, St. Louis and Washington, D.C.
Pub Date: 7/04/96