When we hear stories relating to ‘outbreaks’ of illnesses or ‘epidemics’ in the news, it can be tough to gauge how serious an issue they really are.
Some media outlets have in the past been known to overestimate (or underestimate) the scale of certain problems; and it’s natural now for many of us to react to stories with scepticism.
A subject which has made national news in recent weeks is ‘super-gonorrhoea’.
At time of writing, the number of UK cases was still in double figures (34 in total since November 2014). In the eyes of some, an outbreak on this scale may not seem worthy of national news.
However, behind the issue of this recent strain of gonorrhoea is a much bigger problem relating to the treatment of bacterial infections in general, which experts predict could have a drastic effect on global health in years to come.
The issue of antibiotic resistance isn’t one which is really possible to overstate. Some experts have even compared the scope of the problem to that of climate change, and rightly so.
Antibiotic resistance is a subject we’ve discussed before, and will undoubtedly discuss again in the future.
This week, in light of media reports on drug-resistant strains of the condition, we thought we’d explore the subject of gonorrhoea in more detail.
To do this, we enlisted the help of two experts on the subject of sexual health: Paul Casey, Head of Training and Programmes at the Family Planning Association (FPA); and Sue Burchill, Head of Nursing at young people's sexual health and wellbeing charity Brook.
Gonorrhoea: Who Does It Affect?
Public Health England regularly publish a report which details STI trends in order to help healthcare providers and the public understand them better. This identifies which specific groups have been affected more and, consequently, are likely to be at increased risk.
So what trends have been identified?
‘Statistics from Public Health England show that:
- Gonorrhoea was the third most commonly diagnosed sexually transmitted infection in England in 2014.
- Men who have sex with men accounted for 68% of gonorrhoea diagnoses
- While 55% of diagnoses of gonorrhoea among heterosexual people were found in those aged 15-24.
- Rates of gonorrhoea are highest in urban areas, especially in London.’
‘Men who have sex with men (MSM) are disproportionately affected by gonorrhoea,’ Paul tells us. ‘However, the recent outbreak of gonorrhoea in England, with strains that are resistant to antibiotic treatment, has been among both MSM and heterosexual people.’
Although gonorrhoea is more commonly associated with younger people, this doesn’t mean that older people can’t be affected too:
‘Anyone who is sexually active can get gonorrhoea.’ Paul explains. ‘It can be passed on during unprotected vaginal, anal or oral sex, or when sharing sex toys that have not been washed, or a new condom has not been used. Gonorrhoea is most common among people aged 20-24 but it does not discriminate by age. There were 3,193 diagnoses among people aged 45 and over in 2014, a 22.5% increase on 2,607 diagnoses in 2013.’
Perhaps the most problematic aspect of gonorrhoea is its tendency in many cases to be symptomless. Even in cases where symptoms do occur, there is often no consistent, uniform pattern to their development.
‘Different people will notice signs and symptoms of gonorrhoea at different times, if at all.’ Paul explains. ‘As with other STIs, it is possible to have gonorrhoea without noticing anything different. For some people, symptoms will come within 14 days of infection, or it could be months later, or not until the infection has spread to other parts of the body.’
These can also be different according to the gender of the patient, as Paul illustrates:
‘Typical symptoms, if they do appear, in women include:
- unusual vaginal discharge, which may be thin or watery, yellow or green;
- lower abdominal pain
- or, rarely, bleeding between periods or heavier periods.
In men symptoms include:
- unusual discharge from the tip of the penis, which may be white, yellow or green;
- rarely, pain or tenderness in the testicles.
- Both men and women may notice pain when passing urine.’
Sue also adds that:
- ‘Gonorrhoea can also infect the rectum or throat if you have unprotected anal or oral sex.’
- ‘In the throat, gonorrhoea usually causes no symptoms but can cause discomfort, pain or discharge in the rectum. If infected semen or vaginal fluid comes into contact with your eyes, this can cause conjunctivitis.’
- ‘One in 10 men and half of women with gonorrhoea experience no signs or symptoms.’
Long-term risks and complications
For those who don’t seek treatment, the effects of gonorrhoea don’t end there. As with other STIs, the condition can go on to cause more serious health issues if it goes undiagnosed or is simply ignored, as Paul tells us:
- ‘In women, gonorrhoea can spread to other reproductive organs causing pelvic inflammatory disease. This can lead to long-term pelvic pain, blocked fallopian tubes, infertility and ectopic pregnancy (when the pregnancy develops outside the uterus).’
- ‘In men, gonorrhoea can lead to a painful infection in the testicles and possibly reduced fertility.’
- ‘Less commonly, gonorrhoea can cause inflammation of the joints and tendons, and skin lesions.’
Paul reassures patients that these complications can be avoided where the patient takes prompt action:
‘Treated early, gonorrhoea is unlikely to cause any long-term problems. However, without effective treatment the infection can spread to other parts of the body, and the more times you have the infection, the more likely you are to have complications.’
What is 'super-gonorrhoea'?
The term ‘super’ has a sensational ring to it, and might lead some readers to assume that this recent strain of gonorrhoea is somehow more contagious, potent or invasive than those that have come previously, or even causes symptoms that are more pronounced.
However, this isn’t the case. This strain has been named as such due to its ‘superbug’ capacity to withstand conventional treatments, as Paul illustrates:
‘The current recommended treatment for gonorrhoea is two antibiotics used together: one in an injection and one in a pill. The phrase ‘super gonorrhoea’ is being used to describe strains of the bacteria which have developed resistance to one of the two antibiotics, azithromycin.’
‘If it develops resistance to the second antibiotic, ceftriaxone, then it could become untreatable. The current outbreak, which has been reported in parts of England since November 2014, involves 34 cases of gonorrhoea which is resistant to azithromycin.’
What is behind resistant strains?
This isn’t the first time we’ve seen a bacteria become impervious to certain types of antibiotic. It isn’t even the first time it’s happened with Neisseria gonorrhoeae, the bacteria responsible for gonorrhoea. Some resistant strains were even noted as early as the 1970s.
Simply put, the more an antibiotic is used, the more the bacteria it is engineered to combat learns to adapt and survive. As a result, the go-to treatment for gonorrhoea has been adjusted more than once in recent decades.
‘Gonorrhoea quickly develops resistance to antibiotics and we have seen a rise in the rate of gonorrhoea diagnoses,’ Paul explains, ‘in 2014 there were 34,958 new diagnoses of gonorrhoea across England, an 18.8% increase on 2013. It was the most common infection among men who have sex with men.’
Previously, new antibiotics have been developed as alternative forms of treatment to tackle resistant infections, but the supply of those available to us is nearing exhaustion.
‘The best treatment option we have is the current recommended dual therapy; a combination of azithromycin and ceftriaxone.’ says Paul. ‘Doctors have other treatment options available if that combination of antibiotics does not work or is not suitable, including different combinations or doses, but these are very limited.’
This is why antibiotic resistance poses such a significant global issue. While resistant gonorrhoea strains are a problem we’re beginning to see in the present, in the future we will likely see resistant strains of countless other bacterial strains too.
What can patients and doctors do?
Thankfully, action is being taken to tackle the growing threat of antibiotic resistance, as Paul highlights:
‘The government has a five-year plan to focus on conserving the treatments we do have and the much-needed development of new antibiotics and has also commissioned a review into the global problem of resistance, which is expected to inform policy going forward.’
But preventing the further development of resistant infections is something which patients and doctors have to take responsibility for as well.
In the case of gonorrhoea, Paul explains, limiting the spread of infection is obviously crucial, and this begins with safe sex practices:
‘It’s really important that people are aware of the importance of safer sex; of using condoms not just during anal or vaginal sex, but also during oral sex and when sharing sex toys. If they have had unprotected sex then getting tested as soon as possible is important, as well as completing the treatment course if they do have an infection.’
‘It is important to tell current and any recent sexual partners that you are being treated for gonorrhoea,’ Sue adds, ‘so that they go for treatment too. In the UK it is recommended you tell any sexual partners you have had over the last six months.’
Patients who receive a diagnosis for gonorrhoea should refrain from having sex in the meantime, and make sure they get tested again after having treatment, as Sue explains:
‘You will be advised to return for a repeat test two to four weeks later to ensure you are clear of gonorrhoea. This is really important, in order to make sure that the infection has been cured.’
Those whose infection is still present following treatment should let their doctor know, so that they can take the appropriate action.
‘Healthcare providers are responsible for ensuring that gonorrhoea diagnoses are monitored and cases of antibiotic resistance are reported.’ Paul says. ‘It’s also vital that patients are given the correct course of treatment; both the injection and the pill, including if they use online services to access support.’
On a final note, for those whose treatment is successful, adopting safer sex practices in future is still just as crucial. As Sue explains: ‘Treatment for gonorrhoea does not make you immune from getting it again.’
The Family Planning Association is a sexual health charity offering a range of services and information. To find out more or make a donation, visit their website.
Brook is a charity which provides sexual health services, advice and information for persons aged under 25. You can find more about their services, or make a donation, by visiting their website.