Many clinicians in Ireland have noted an increase in the number of patients being diagnosed with gonorrhoea. National surveillance information confirms that there has been a significant increase in gonorrhoea notifications in recent years, with 1,110 cases notified in 2012 – a 33% increase on 2011.¹ This situation is of major public health concern. 

Gonorrhoea can infect genitalia, rectum, throat, eyes.If untreated, it can lead to:

• In women: pelvic inflammatory disease, first trimester abortions, ectopic pregnancy and infertility
• In men: epididymo-orchitis or prostatitis
• In newborns: serious eye infection
• Uncommonly (<1%): spread through blood steam, affecting skin and joints.

Epidemiology

Since 2010 there has been a steady increase in gonorrhoea notifications. The availability of the more sensitive gonorrhoea nucleic acid amplification test (NAAT) has contributed to some of this increase but is unlikely to account for all of the recent increase. 

The situation in HSE East is of particular note as this area accounts for almost three quarters of all notifications nationally. Since 2010 there has been a statistically significant increase each year in HSE East, with the crude incidence rate more than doubling between 2010 and 2012 (23.5 and 50.6/100,000, respectively).

Looking at the national trends it can be seen that the annual notification rate has continued to rise in both males and females since 2010. In males, since 2009 there has been a 30% increase year on year. In females, the increase was initially not so pronounced, but a 50% increase occurred between 2011 and 2012.  

The notification rate increased in all age groups from 2010-2012: doubling in those <20 years and increasing by 87% in 20-29 year olds, by 69% in 30-39 year olds and by 53% in 40+ years age group. Information to date for the first half of 2013 indicates that gonorrhoea notifications continue to increase.

Reasons for concern

The increase in the number of notifications of gonorrhoea in Ireland is of particular concern because:

• Antimicrobial resistance is a major problem with gonorrhoea. Resistance is emerging to the extended spectrum cephalosporins and it is possible that multidrug resistant gonorrhoea may become untreatable in the near future 
• Untreated or inadequately treated gonorrhoea may lead to severe secondary sequelae
• Infection with gonorrhoea may facilitate the transmission/acquisition of HIV
• Many cases of infection are asymptomatic – approximately 50% of women and 10% of men with urogenital gonorrhoea have no symptoms; most individuals with infection of rectum or pharynx are asymptomatic.

Response to gonorrhoea problem

Gonorrhoea Control Group 

Following on from discussions with clinicians, public health specialists convened a Gonorrhoea Control Group at the end of 2012. The group has been established with a focus on the problem in the HSE East and HSE South East areas. It is a multidisciplinary group, with membership comprising genitourinary medicine (GUM) and infectious disease (ID) specialists, GPs (including GP for student health services), personnel from laboratory services, health promotion, health service management, patient advocacy and public health. 

The group has investigated the recent upsurge by carrying out enhanced surveillance on all notifications received in the first quarter of 2013. This work has identified that there is an outbreak of gonorrhoea among the following two groups: men who have sex with men (MSM) and young heterosexuals. 

Results of enhanced surveillance Q1 2013 in HSE East and HSE South East areas

The enhanced surveillance work included 223 cases of laboratory-confirmed gonorrhoea notified over a three-month period from January to March 2013 in HSE East and HSE South East areas. Of the total cases, 56% (n=125) of cases were in MSM, 28% (n=62) were in heterosexual males, and 16% (n=35) in heterosexual females. The age range was from 15-56 years. 

Cases in heterosexuals were younger than in MSM, median age 23 years and 29 years respectively, and 13.4% of cases in heterosexuals were <20 years of age compared with 3.2% of MSM. Primary care clinicians diagnosed 27% of all cases, 44% of all heterosexual cases and 12% of all MSM cases.

Cases of gonorrhoea among MSM

Among MSM, 42% of cases were detected on routine STI screening. Sites of infection were: pharyngeal (61%); anorectal (42%); and urogenital (38%). The pharynx was the only site of infection in 35% of cases. Overall, 85% MSM cases were tested in all three sites, as is recommended practice, but this was achieved in only 27% of MSM cases diagnosed in primary care. 

The group has made recommendations that primary care clinicians be provided with more specific guidance on three site testing for MSM as well as being provided with improved access to laboratory testing of non-urogenital sites. 

Cases of gonorrhoea among heterosexual men and women

Among heterosexuals, the majority of females (80%) and almost half the males (42.5%) were under 25 years of age. The majority of females were asymptomatic (68.6%), indicating the importance of raising awareness regarding the need for an STI screen if there has been unprotected sex. In contrast, the majority of male cases were symptomatic (90.3%) and over half of these men had two or more sexual partners in the previous three months. Worryingly, one third of all heterosexuals were co-infected with another STI.

Next steps for the Gonorrhoea Control Group

The Gonorrhoea Control Group is now at advanced stages of planning a range of further control measures which will include an information campaign targeted at the two risk groups and provision of additional sexual health services for these groups. 

The information campaign will be tailored to the needs of each of the at-risk groups and will focus on safe sex, the symptoms of infections, advice on screening and information on sexual health services. The group is also alerting clinicians regarding the increase in gonorrhoea and requesting that additional resources are to be allocated for STI services at all levels of care.

Clinical management of cases of gonorrhoea

The ICGP is to launch a sexually transmitted infections (STI) elearning module this autumn. This module will cover the relevant clinical issues such as taking a sexual history, symptoms and signs of STIs, update on diagnostics, and guidance on the treatment and management of STIs, including contact tracing and notification. 

Appropriate management of cases is crucial for the control of this infection. The scale of antimicrobial resistance in Neisseria gonorrhoeae highlights the importance of all cases being treated with the recommended antibiotics at the recommended dose, currently ceftriaxone 500mg im plus azithromycin 2gr po² (single dose of each).

The current recommendations for management of suspected or confirmed gonorrhoea are:

1. All patients with suspected or diagnosed gonorrhoea should be offered further STI screening and contact tracing should be carried out. If these services are not available within the patient’s general practice, they should be referred to an STI clinic

2. Most cases are initially investigated by urine/swab NAAT testing. Whenever feasible, culture of specimens should be carried out so that susceptibility testing can be performed and resistant strains identified

3. All suspected or confirmed cases of gonorrhoea should receive:
ceftriaxone 500mg IM plus azithromycin 2gr po² (single dose of each)
– This treatment is also suitable for pregnant or breastfeeding women
– Those with cephalosporin/ penicillin allergy should be referred to an STI clinic for appropriate management
Please note: treatment with oral cefixime or ciprofloxacin are no longer adequate firstline treatments due to the changing antibiotic resistance profile of Neisseria gonorrhoeae

4. A test of cure, using NAAT, should be obtained two weeks after completion of antibiotic therapy. If the result is positive, refer to an STI clinic for appropriate management

5. If a patient has persisting symptoms or signs following treatment, they should be referred to an STI clinic for appropriate management

National sexual health strategy 

Gonorrhoea is a cause of public health concern in Ireland and timely action is required to control the spread of this infection. This situation clearly demonstrates the need for a national strategy on sexual health. 

Acknowledgements 

The Gonorrhoea Control Group wishes to thank all the personnel in primary care who provided assistance to Public Health in carrying out the enhanced surveillance work for Q1 2013

References

1. www.hpsc.ie/hpsc/A-Z/HIVSTIs/SexuallyTransmittedInfections/Publications/STIReports/STIAnnualandQuarterlyReports/2012/File,13971,en.pdf
2. Unemo M. The ‘2012 European guideline on the diagnosis and treatment of gonorrhoea in adults’ recommends dual antimicrobial therapy. Eurosurveillance 22nd Nov 2012, available at: www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20323