February 10, 2017
The Windsor-Essex County Health Unit has observed increased rates of N. gonorrheae in Windsor-Essex County (WEC). We would like to take this opportunity to provide a brief update to you, as you may be seeing an increase in patients for assessment.
Notification: N. gonorrheae is a mandatory reportable disease, according to the Health Protection and Promotion Act, R.S.O., 1990. All suspected and confirmed gonorrhea cases and gonorrhea treatment failures must be reported to the Health Unit by the next working day.
Local: In 2016, there were 144 cases of gonorrhea reported in WEC, representing an incidence rate of 35.5 cases per 100,000 population. Case counts of gonorrhea in 2016 were significantly higher than the five-year average of case counts between 2011 and 2015 (i.e. average of 66 cases per year).The increase in case counts can be attributed to a significant increase in cases in the 20 to 29 year age group. Males accounted for 63.9% of cases in 2016. In 10-19 year olds, the incidence rate of gonorrhea was higher in females than males. From 20 years and onwards, incidence rates were higher in males than females.
Provincial comparison: In Ontario, the incidence rate of gonorrhea for 2016 was 48.5 cases per 100,000 population. The incidence rate of gonorrhea in WEC continues to be lower than Ontario (26.8% lower in 2016).
Percentage of cases treated according to guidelines: In 2016, 60% of cases in WEC were treated according to Public Health Ontario’s (PHO; 2013) “Guidelines for Testing and Treatment of Gonorrhea in Ontario”.
Note: The incidence rates presented are crude incidence rates (not adjusted to reflect the age-structure of a standard population).
DIAGNOSIS AND MANAGEMENT OF GONORRHEA CASES
Please refer to PHO’s (2013) “Guidelines for Testing and Treatment of Gonorrhea in Ontario, 2013: Quick Reference Guide” for symptoms, risk factors, and recommended screening and treatment algorithms related to gonorrhea.
Diagnosis: All symptomatic individuals who are sexually active should be tested. Screening should be considered for asymptomatic individuals presenting with risk factors for gonorrhea, as described in Appendix A.
- Clinical Evidence: Individuals with infection may not present with any symptoms. Other symptoms vary between men and women. Please ensure that you indicate the date of symptom onset.
- Lab Evidence: For suspected cases or contacts of gonorrhea, please collect the appropriate specimen based on patient gender and history and include requisition for chlamydia testing. Request test for reference identification and susceptibility, which is only available for culture samples. This allows us to monitor for multi-drug resistant strains. The following outlines the appropriate specimen and kits for the testing type.
- For N. gonorrhoeae culture, appropriate specimen consists of genital swabs, non-genital (rectal, throat/pharyngeal, conjunctival, joint fluids, aspirates), sexual abuse and/or sexual assault cases in peri-pubertal and pre-pubertal children. N. gonorrhoeae culture charcoal kit is the optimal collection kit, but a bacteriological transport kit is acceptable as well.
- For N. gonorrhoeae nucleic acid amplification test (NAAT), appropriate specimen consists of female endocervical and male urethral swabs and urine. It is not validated for adolescents (less than 16 years) and medico-legal specimens. For swabs, only the GEN-PROBE ® APTIMA ® Unisex Swab Specimen Collection Kit is acceptable. For urine, only the GEN-PROBE ® Urine Specimen Collection Kit is acceptable.
- Public Health Ontario Laboratory is available for consultation on laboratory testing with health care providers as needed at (toll free) 1-877-604-4567. To order collection kits, fax completed Requisition for Containers and Supplies form to the London Public Health Ontario Laboratory at 519-455-3363.
Treatment: N. gonorrhea in Ontario has developed resistance to drugs used to treat it, including cefixime. It is an important part of antimicrobial stewardship to test for sensitivity and to adhere to recommended treatment guidelines to prevent further resistance. The recommended first-line therapy consists of ceftriaxone 250 mg IM AND azithromycin 1 g PO, if not contraindicated. Suggested second-line therapy, if appropriate, are outlined further in Appendix A. Clinicians can have access to provincially funded drugs, at no cost, through the Health Unit. Complete and fax the STI Medication Request Form to order medications from the Health Unit for cases of gonorrhea or chlamydia.
Education and Counselling: Patients should be counselled about implications of infection and modes of transmission and prevention. Advise your patients and contacts:
About safer sex practices (e.g. use of condoms, screening if at risk), and
To abstain from unprotected sexual exposure until 7 days post treatment to prevent transmission.
Test of Cure and Rescreening:
Cases with specific risk factors: Test of cure, using culture (≥ 4 days post-treatment) or NAAT (≥ 2 weeks post-treatment)
Cases without risk factors: Rescreening at six months post-treatment, or when they seek medical care within the next 12 months.
Cases at continuing risk for gonorrheal infection: Regular screening at 3-month intervals.
Treatment Failures: If suspected or confirmed gonorrhea treatment failures (i.e. treated individuals with confirmed gonorrhea and a positive test of cure in the absence of risk of reinfection (i.e. no potential sexual re-exposure)), notify the Health Unit to maintain adequate surveillance of multi-drug resistant N. gonorrhoeae. Recommended therapy for treatment failures consists of higher dosing of first-line therapy (i.e. 1 g ceftriaxone IM AND 2 g azithromycin).
SCREENING OF CONTACTS
Encourage and support your patients to notify sexual partners for evaluation, testing and treatment as soon as possible to prevent further transmision. The Health Unit can help support follow up with gonorrohea contacts for screening and treatment. The Health Unit will also contact clinicians if your patient is deemed a contact and provide recommendations for empiric therapy. Reporting probable or diagnosed cases immediately to the Health Unit is essential. Please note a contact recommended for screening is defined as:
- A person who has had sex (includes anal and oral) or some other relevant exposure to the case within 60 days prior to symptom onset or date of specimen collection. The exposure may have been unprotected with no precautiosn taken or protected with varying degrees of precaution used.
Our website (www.wechu.org) is a reference for health care providers and patients. For additional information or consultation, please call the Health Unit during regular office hours at 519-258-246 ext. 3220. During after hours and weekends, please call 519-973-4510.
For more information, visit:
- Infectious Diseases Protocol for Gonorrhea
- Provincial Case Definition Gonorrhoea
- Guidelines for Testing and Treatment of Gonorrhea in Ontario
- Canadian Guidelines on Sexually Transmitted Infections
- Public Health Ontario Laboratory: Labstract – May 2011: Chlamydia trachomatic and Neisseria gonorrhoeae – Specimen Collection Guidelines