The control of gonorrhoea infection.

Britain is not alone in the increases in gonorrhoea rates experienced over the last 5 years. In the US, numbers of cases increased by 9% during he period 1997-8 following a 13 year decline. In Sydney, Australia, the Neisseria Refence Laboratory observed a staggering 332% increase in gonocoloccal isolates from men between 1994 and 1999, although this was chiefly due to an increase among the homosexual population. Although the incidences here do not yet appear to be returning to the very high levels seen before the HIV scare, rates among homosexuals at least are increasing more rapidly here than in London, which is worrying considering that London’s strategy had been believed ineffective.

Although there has been an increase in the incidence of gonorrhoea through all ages and in all areas of England and Wales, several studies have highlighted that higher rates of incidence are present amongst certain ethnic and socio-economic and geographic groups. A recent report which analysed patients attending GUM clinics in 1994 and 1996 revealed that although the bulk of diagnoses were in white heterosexuals, homo/bisexual men and the black population in England experienced a disproportionate burden of gonococcal infections.5 A study of residents of three south London boroughs attending GUM clinics demonstrated that at all ages, rates were higher in non-white minority ethnic groups. When corrected for age and deprivation score, the results showed that women from black minority groups were 10.5 times as likely and men 11.0 times as likely as white people to experience gonorrhoea.10 The adjusted risk ratio for gonorrhoea was twice as high in inner London compared with outer London and three times lower in the “shire” region compared with outer London.9 

Those at greatest risk from infection by gonorrhoea are teenage women, men, in particular young adults, black Afro-Caribbeans and other ethnic minority groups, Londoners and also homosexual males. The single factor linking all of these groups, which renders them more susceptible to gonococcal infection, is their sexual behaviour. Teenagers and young adults are generally much more likely to ‘experiment’ sexually than older age groups. In doing so, they exhibit risk taking behaviour such as unsafe sex (i.e. nonuse of barrier prophylaxis) and sexual promiscuity (i.e. high turnover of sexual partners). Similarly, homosexuals have zero risk of unwanted conceptions and thus there is far less impetus for the utilisation of contraception of any sort, including barrier methods. Again, this combined with a relatively high number of sexual partners results in an elevated risk of infection.

The high incidence present among black Afro-Caribbeans can be largely attributed to cultural variation in behavioural norms and perceptions of the risks and costs associated with genitourinary infections. One study compared the sexual behaviour of attendees at a GUM clinic belonging to black and white ethnic groups in terms of condom use. Only 21% of the black attendees reported consistent condom use, compared with 43% of the white attendees. In addition, sexual partners are likely to belong to the same ethnic group, which, if practising unsafe sex, is likely to result in a concentration of infection among that group. Ethnic influences on sexual behaviour are thus a key factor for increased incidence among certain ethnic groups. However, inequalities in access to healthcare services also play a key role in determining incidence in ethnic minority groups, which may be due to the relatively high proportion of underprivileged individuals within these groups. Lack of knowledge or limited access to healthcare facilities may result in a failure to recognise symptoms and an inability to act appropriately thereafter. The suggestion that genetic factors are accountable for the differences between ethnic groups needs to be approached with caution. One such suggestion links an individual’s susceptibility to infection to the presence of blood group B phenotype. It has been suggested that there is a higher occurrence among the black population of the group B phenotype than Caucasians and as such are more susceptible to gonococcal infection. Another theory is that certain strains of N. gonorhoeae that are likely to produce an asymptomatic infection are more likely to be found in the white population. However much doubt currently surrounds both of these hypotheses.

In London, several factors aforementioned prevail, in particular a high proportion of ethnic minorities and underprivileged individuals. The particularly high population density enhances the risk of transmission through risky sexual behaviour. Perhaps another reason for the particularly high incidence is the existence in large cities of a core group of highly sexually active persons who form a cluster within which infection persists through the re-infection of other members of the group. However, infection may also persist amongst those individuals who do not realise that they are infected, regardless of their sexual behaviour. There is no doubt that women more often than men develop an asymptomatic infection of the urinary tract. Whilst the infection remains uncomplicated, there may be no symptoms whatsoever, and as a result, women may not seek treatment, since they are unaware of their infection. This could explain the significant number of women identified by the study mentioned above, who had been left untreated in the community. If unprotected sexual activity then takes place, there is a high risk of the infection being passed on. Thus, asymptomatic women are an important ‘reservoir’ of infection, and as such, are key targets for interventions.

Studies have shown that transmission of gonorrhoea is wholly preventable if barrier contraception is employed, and thus the rate of unsafe sex is directly linked to the transmission of gonorrhoea. Sexual behaviour is therefore the most important area for intervention, which is best achieved by education. The NHS plan pledges to spread good sexual practice while the paper Our Healthier Nation specifically targets sexual behaviour., However, the interventions need to be targeted at those groups most at risk in order to be effective. Education in the secondary schools context will certainly reach some of those groups, considering that the 16-19 year age group has experience a rise in incidence of 53% between 1995 and 199715. Some of the methods indicated by the DfEE guidelines including providing them with information on specific STIs, their prevention, diagnosis and treatment, dealing with peer pressure to have unprotected sex and appropriate use of contraception. Education also takes place in the setting of the GUM clinic, on a one-to-one basis, thus dealing with individual concerns and advice is given on how to deal with peer and cultural pressures. As well as this, general information on STIs is given, about their symptoms, incubation periods and methods of transmission. The information given is consolidated by the availability of literature, to remind patients what has been said and answer any further queries, in the form of take-home leaflets. The media in general has an important role to play in the promotion of safe sex while telephone helplines such as Sexwise and Brook Advisory Centre and the many websites websites such as  which need to be more highly publicised.

Another important intervention that is widely employed is partner notification, when a patient who is diagnosed with gonorrhoea is encouraged to notify sexual partners who are possibly at risk. This can be by patient referral, where the patient makes contact personally or by provider referral, where a health care worker notifies those at risk. The latter may help to preserve anonymity, although it is quite likely that those notified will realise who has put them at risk. Notification is on a voluntary basis however, as the patients confidentiality is paramount and in some cases, they may be understandably unwilling to disclose information leading to their identification.

Other interventions include improving the rate of diagnosis and the efficacy of and compliance with treatment of infections. In London, outreach programmes could improve contact tracing and education of risk groups. The NHS plan highlighted the need to improve access to healthcare, diminishing inequalities between ethnic groups, which render even the most effective regimens of diagnosis and treatment ineffective. The government has pledged that by 2004 there will be a new sexual health strategy, ensuring standards for primary and secondary prevention, improving access to healthcare resources for underprivileged groups, while a new screening programme for women would reduce the number of undiagnosed asymptomatic cases, hence reducing the reservoir of infectivity. However, the cogs of action are only beginning to be set in motion, and it will be several more years before we can expect to see a fall in the incidence of gonorrhoea in this country.

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