Gonorrhoea
By Dr. Colin Michie FRCPCH and Nigel O’Farrell (Consultant Infectious Diseases Specialist)
Carnival time may not be the most diplomatic time to talk about sex. However, take care - case numbers of gonorrhoea, a sexually transmitted infection, have been rising around the world for 20 years.
Infectious disease threatened all of us during the Covid-19 pandemic. We became fearful, aware of airborne bugs, their strains and resistances, their abilities to infect us and spread at terrifying speeds. Organisms spread by sexual activity are no different. They cause anxiety and worry; they are embarrassing and come with social stigmas. They too have dynamic genes: they have become resistant to antibiotics.
Gonorrhoea is an ancient disease that has infected humans throughout history. Formally Neisseria gonorrhoea, informally it is known as the “clap” or the “drip”. One of its close relatives, N. meningitidis, causes a serious and sometimes fatal meningitis. Other Neisseria species, their more distant cousins, do not cause illness and live harmlessly in our mouths.
Neisseria gonorrhoea bacteria infect the mucosal membranes lining the genital tract, as well as the mouth, eye, pharynx and anus. Sticky bacteria attach themselves to sperm and colonise the cervix. Neisseria usually cause local inflammation within one to six days of sexual contact, leading to painful urination and a discharge. Over time, these bacteria can inflame the epididymis behind the testicles. Infections in women may not always be obvious, but they can lead to pelvic inflammation and pain, potentially infect a pregnancy, or lead to infertility.
By aggravating mucosal membranes, gonorrhoea predispose to other sexually transmitted diseases. Neisseria may invade the bloodstream and spread around the body, for instance to the joints or heart valves, a situation seen most often in young women. Rates of gonorrhoea in some regions are now higher in men who have sex with men than in heterosexuals. In this group, oral and pharyngeal infection is an important source of infectious spread.
Lineages of gonorrhoea are tracked through international laboratory networks; the WHO set a 2030 goal to reducing case numbers by 90%. However, numbers are still escalating: There are 1.5 million new gonorrhoea infections in the United States each year; the global burden of disease is even greater in low- and middle-income countries. Gonorrhoea is second only to chlamydia in the numbers of sexually transmitted infections notified to US authorities. Further, organisms that are resistant to antibiotics are rapidly spreading in the countries where there are shortages of antibiotics for the populations that require them.
Traditional or herbal treatments have not limited the spread of gonorrhoea. Having been successful in treating syphilis, penicillin also began to deliver rapid control of gonococcus in the 1940s. However, increasing doses of penicillin were required to achieve a cure; resistance to penicillin was detected in both Liverpool and the Philippines in 1976. Gonococci have since become resistant to almost all other antibiotics and, today, penicillin is not usually effective. International travel, tourism and self-medication with low doses of antibiotic have contributed to the rapid spread of new resistant strains. Intravenous therapies and even Hospital admission may be required for some gonorrhoea. A novel antibiotic, zoliflodacin, prevents Neisseria unwinding its DNA may become available as a therapy in future.
Management of gonorrhoea must include checks of sexual contacts. Those with gonorrhoea should also be tested for chlamydia, syphilis and HIV then enlist into preventing sexually transmitted disease. For instance, condom use is a crucial and effective barrier, but shared condoms, or the use of unwashed sex toys can spread gonorrhoea.
Vaccines against gonococcus would be an advantageous way to stop the spread of this curse. They could be expected to protect all mucosal membranes against invasion, without increasing antibiotic resistance. Many possible vaccines have been tested, with no outstanding candidate. This contrasts with the situation with N. meningitidis, for which vaccines given to children have limited disease and reduced death rates dramatically. Combination vaccines efficiently protect young people against four or five strains of these Neisseria. Observations suggest that these vaccines additionally could be deployed to give valuable cross-protection against N. gonorrhoea infection in about a third of individuals.
Most people would like to manage sexually transmitted infections themselves, using online testing and treatment sites. However, tests for gonorrhoea may not be accurate (sometimes positive when there is no infection), while commonly available antibiotics such as doxycycline and azithromycin may not work and can increase chances of complications.
Are more cases of sexually transmitted diseases reported during carnivals? More babies were conceived in the French West Indies during their carnival period, but no increase in diseases was identified. A detailed study from Brazil in the early 1990s showed no link either. So the battle remains to prevent spread, as well as detect and treat cases of this infection – it is a growing threat!
Useful resources: www.nhs.uk/conditions/gonorrhoea
Dr. Colin Michie specializes in paediatrics, nutrition, and immunology. Michie has worked in the UK, southern Africa and Gaza as a paediatrician and educator and was the associate Academic Dean for the American University of the Caribbean Medical School in Sint Maarten a few years ago.
