Gonorrhoea 2018

Gonorrhoea diagnosed in 2018

• A total of 3,251 cases were recorded, 2,015 men and 1,236 women, in 3,072 persons.

• Among 2,192 cases that were notified clinically to the SSI, 1,350 were men, 579 of whom stated having become infected by men. In all, 842 were women, of whom 11 stated that they had become infected by women.

• Three percent of the women notified with gonorrhoea were pregnant.

• The most frequently occurring age group was 20-24 years, and the City of Copenhagen was the area where most cases occurred.

• The frequency of ciprofloxacin resistance has followed a decreasing trend for a number of years, but has - unfortunately - now started increasing once again. The drug can be used only once susceptibility has been established.

• Using a condom prevents gonorrhoea, and the transmission chain may be broken by relevant testing with complete microbiological diagnostics, treatment with recommended antibiotics and partner tracking.

In Denmark, national monitoring of gonorrhoea is done by Statens Serum Institut (SSI) based on data extracted from the Danish Microbiology Database (MiBa); a nationwide auto-updated database of all test results from the departments of clinical microbiology (DCMs), EPI-NEWS 45/13. For gonorrhoea, this includes results from culture and/or PCR or any other nucleic acid amplification technique (NAT), as all DCMs perform combined NAT for gonococci and Chlamydia trachomatis. 

In case of repeated positive samples from a person, a new gonorrhoea case is defined as the passing of more than 21 days since the latest positive finding.

Monitoring of laboratory-confirmed gonorrhoea was supplemented by submission of isolates to the Department of Bacteria, Parasites and Fungi (BPF), Infection Preparedness, SSI.

Clinical notification is statutory, and notifications are made to the Notification System for Infectious Diseases (NSID), the Department of Infectious Disease Epidemiology and Prevention (DIDEP), SSI. The clinical notification forms request information that is not given as part of the laboratory data: Mode of infection, sexual orientation, country of origin, country of infection, HIV status, etc.

For a detailed epidemiological description of the incidence in 2018, please see the 2018 annual gonorrhoea report.

2018 saw the recording of 3,206 gonorrhoea cases in the MiBa. To this, another 45 cases should be added that were notified to the NSID only. Thus, a total of 3,251 cases were detected. The cases affected a total of 3,072 persons, as 2,915 had a single case, 139 persons had two cases, 15 persons had three cases, two persons had four cases and one person five cases detected. A total of 2,015 (62%) of the cases occurred in men and 1,236 (38%) in women.

The number of gonorrhoea cases has followed an increasing trend for a number of years, but has not increased since 2017. Several circumstances might explain this. For several years, the Danish Health Authority has been running campaigns promoting using a condom. These campaigns have targeted young people, who comprise a large share of gonorrhoea patients. Furthermore, campaigns by the Danish AIDS Foundation and the Danish Family Planning Association have encouraged frequent testing for sexually transmitted diseases in relevant risk groups. There may be other explanations why the increase has ceased, though the same trend has been seen for syphilis also, EPI-NEWS 34/19.

A considerable part of the diagnosed cases (33%) are not notified by the treating physicians. If the frequency of notification is uneven, the reports on mode of infection, country of infection, etc., may be misleading. Physicians are therefore encouraged to be aware of their duty to notify any patients diagnosed with gonorrhoea. This can be done by downloading and filling in Form 1510-G, which can then be enclosed to an e-mail sent from a secure digital mailbox to sygdomsanmeldelse@ssi.dk. If you do not have access to secure mail, the completed form may be printed off and sent to the Department of Infectious Epidemiology and Prevention, Statens Serum Institut, Artillerivej 5, 2300 Copenhagen S. Pre-paid reply envelopes can be obtained from sygdomsanmeldelse@ssi.dk or by contacting Section Secretary Linda Roth, 3268 3744.

It is worrying that, in line with 2016 and 2017, several cases of gonorrhoea were observed in pregnant women. Healthcare workers are encouraged to be attentive to gonococci as a cause of conjunctivitis in neonates, particularly in the first two weeks of life. Gonorrhoeal conjunctivitis (which is not exclusively seen in neonates) is a potentially very serious condition that may cause destruction of the eyeball if it goes untreated. These patients must therefore be referred urgently to a specialised department for eyesight-preserving treatment.

The frequency of ciprofloxacin resistance has followed a decreasing trend for a number of years, but has - unfortunately - now started increasing once again. The drug may only be used once susceptibility has been confirmed, see the 2018 annual gonorrhoea report.

As is the case for other sexually transmittable diseases, gonorrhoea is a so-called indicator condition for HIV, which means that more than 0.1% of patients with a sexually transmitted disease will also have become infected with HIV. It is therefore encouraging that a considerable share of the notified patients had been tested for HIV.

Furthermore, physicians are encouraged to test for other relevant sexually transmittable diseases, e.g. syphilis, chlamydia and, if relevant, lymphogranuloma venereum (LGV).

Thorough laboratory-based diagnostics is an important measure to counter further spreading of gonorrhoea. Diagnostics should include sampling from all relevant anatomical locations (urethra, rectum, throat and in women also the cervix) along with barrier protection by use of a condom, and partner tracking. Gonorrhoea can show few symptoms and be asymptomatic, and this is practically always the case for gonorrhoea of the throat and rectum. If the infection is located to these anatomical sites exclusively, and if it is not diagnosed, the patient constitutes an infection reservoir.

(A.K. Hvass, S. Cowan, Department of Infectious Disease Epidemiology and Prevention, K. D. Bjerre, the Data Integration and Analysis Secretariat, S. Hoffmann, Department of Bacteria, Parasites & Fungi)