Dissertation Title:  "Infectious Disease Policy in the Era of Antibiotic Drug Resistance: Decision Analytic and Historical Perspectives"

In the United States and abroad, infectious diseases constitute a significant public health problem. Costly new disease detection methods, increasingly constrained healthcare budgets, and unchecked disease among certain hard-to-reach populations frequently dictate changes in prevention policies. Moreover, the specter of antimicrobial resistance poses serious challenges to traditional assumptions about treatment efficacy. Applying both quantitative and qualitative methods, this thesis explores current issues related to screening and treatment of infectious diseases in an era of antibiotic resistance.

Chapter One uses decision analytic methods to contribute new insights into screening strategies for gonorrhea which have become increasingly important in light of the treatment challenges posed by antibiotic resistance in Neisseria gonorrhoeae. A decision analytic model was developed to investigate the cost-effectiveness of screening for gonorrhea with cheaper testing strategies associated with significant loss to follow-up compared to newer, more expensive strategies that provide immediate results in young women seeking care in inner city emergency departments (EDs) where disease prevalence is high. Our results suggest that inner city ED settings offer high-yield, cost-effective screening opportunities for detecting and treating gonococcal infections, and that rapid testing technologies offer value that justifies their higher cost.

Chapter Two addresses the problem of resistance to standard antibiotic treatment of gonorrhea in the Philippines, where the spread of quinolone-resistant N. gonorrhoeae through commercial sex workers poses an immediate threat to disease control, and limited healthcare resources prevent the use of effective cephalosporin antibiotics. We developed a deterministic, compartmental model of the transmission dynamics of drug-sensitive and drug-resistant gonorrhea to quantify the costs, health consequences, and cost-effectiveness associated with switching from quinolones to costly but effective cephalosporin antibiotics at different thresholds of quinolone resistance. We found that that preventing gonococcal resistance among high-risk sexual transmitters can effectively control the emergence of resistance in the general population.

Chapter Three employs qualitative methods of historical research to examine the broader problem of antibiotic resistance in society. Drawing from primary sources including scientific and medical articles, reports from the popular press, and Congressional testimony from the early 1900s to the present, this paper traces the historical sociology of antibiotic resistance in the 20th century, focusing primarily on the positions and practices.