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Rise in gonorrhoea in London, UK
RESEARCH LETTERS
Research letters
Rise in gonorrhoea in London, UK I M C Martin, C A Ison, London Gonococcal Working Group* (LGWG) We report an alarming 34·9% overall increase in the number of gonococcal infections diagnosed during the same 3 month study period during 3 years. Between 1997 and 1998, an increase of 12·1% was detected, with a larger increase between 1998 and 1999, of 20·4%.
Sexual health in the UK was put on the political agenda by the launch of the Government’s first ever strategy on sexual health in March, 1999.1 The UK Government’s aim is to develop an integrated sexual and reproductive health strategy covering all ages and high-risk groups. This report is due to be published this year. Gonorrhoea was chosen as a marker of unprotected sex, and, to monitor changes in sexual behaviour, as an indicator of HIV-1 transmission in the UK Government’s white paper, The health of the nation, in July, 1992.2 The incidence of gonorrhoea in heterosexuals seems to indicate unsafe sexual behaviour, but in homosexual and bisexual men this cannot always be implied. Rectal gonorrhoea does have implications for unsafe sexual behaviour and HIV-1, but in other genital sites gonorrhoea can be transmitted through practices not thought to be at high-risk for HIV-1 transmission.3 In the white paper, targets were set to reduce the rate of gonorrhoea in men and women by 20% on the basis of 1990 figures, which have since been met. This reduction was followed by a subsequent increase in the incidence of gonorrhoea in England and Wales between 1994 and 1997. In 1998 the number of cases remained static.4 There are 32 genitourinary medicine clinics in the Thames region and last year they treated 47% of all male, and 40% of all female infections of Neisseria gonorrhoeae in England and Wales. 58% of all homosexually acquired infections were treated in London genitourinary medicine clinics. The populations served by these clinics are diverse; some clinics treat a predominantly local population, whereas others attract Hospital
St Thomas’ Kings College Chelsea and Westminster total Charing Cross Victoria Clinic John Hunter Clinic University College London St Mary’s Homerton The Royal London Central Middlesex St George’s St Bartholomew’s Whittington Greenwich Royal Free Total Core† Total‡
1999
1998
1997
Het/hom (%)*
Change from 1998 to 1999 (%)
311 257 166 64 29 73 166 165 148 124 96 96 30 93 49 43
241 263 126 49 29 43 145 121 123 98 91 68 22 ·· ·· ··
222 179 169 ·· ·· ·· 119 149 82 107 63 69 26 ·· ·· ··
71/15 86/14 ·· 36/63 34/52 26/58 14/79 40/47 93/7 68/29 88/4 79/15 68/32 ·· ·· ··
29% ⫺2% 35% 28% 0 66% 14% 36% 20% 26% 5% 41% 36% ·· ·· ··
1559 1744
1295
1155
*Percentage of heterosexuals and homosexuals (Het/hom) for 1998, missing percentage= bisexuals and those of unknown sexual orientation. †1999 core refers to totals for the original ten hospitals within LGWG. ‡1999 total includes isolates from Greenwich, Royal Free, and Whittington Hospitals who joined the group in 1999.
Number of isolates collected from each hospital during 3 years
THE LANCET • Vol 355 • February 19, 2000
patients of a specific sexual orientation from a larger geographic area. In particular, London, with its mobile population relative to the rest of England and Wales, has a correspondingly higher risk of importing resistant strains (table). The LGWG was formed in 1997 to monitor the susceptibility of gonococcal isolates to antibiotics currently used for treatment, and to instruct clinical practice. The group is a collaboration of 13 genitourinary medicine clinics and their supporting diagnostic laboratories. A surveillance system has been established for monitoring changes in the distribution and the trends of antibiotic resistance of gonorrhoea longitudinally in London.5 85% of all cases of gonorrhoea in the Thames region wee diagnosed in the 13 clinics, based on 1998 data (Mike Catchpole, personal communication), providing a representative sample for surveillance. This is the first surveillance programme for gonococcal antimicrobial susceptibility to be established in England and Wales. On completion of the 1999 collection of gonococcal isolates from consecutive patients, a 20·4% increase was detected compared with the same period in 1998. The number of isolates from ten hospitals, from whom isolates have been collected over 3 years increased from 1295 in 1998, to 1559 in 1999. This increase has occurred in men and women, and across all clinics regardless of patient type.* In women the greatest number of isolates were seen in the 16–19 years age group (33% of all cases), whereas 44% of all isolates from men were in the 25–34 years age group. These data are collected annually over the same period and are therefore not affected by seasonal variations. N gonorrhoeae is the second most common sexuallytransmitted bacterial infection in England and Wales, therefore any increase of this magnitude in cases should be of concern. We emphasise the need for continued surveillance of gonorrhoea in London: to inform appropriate therapy; to focus sexual health promotion activities; for understanding the epidemiology of the disease; and to control its rising incidence. These initial findings are particularly timely in the context of the Government’s forthcoming sexual health strategy. We thank the staff of all the genitourinary medicine clinics and the laboratories at each of the participating hospitals for their help. *Details can be seen on The Lancet website: www.thelancet.com 1 2 3
4 5
First ever government strategy on sexual health launched. Department of Health press release, 1999/0166. Secretary of State for Health. The Health of the Nation: a Strategy for Health in England. London, HMSO: 1992. Lewis DA, Forster GE, Goh B. Gonorrhoea in HIV seropositive homosexual men attending an East London genitourinary medicine clinic. Genitourin Med 1996; 72: 74. CDSC. Sexually transmitted disease quarterly report: gonorrhoea in England and Wales. Commun Dis Rep CDR Wkly 1999; 9: 270–71. Ison CA, Martin IMC and the London Gonococcal Working Group. Susceptibility of gonococci isolated in London to therapeutic antibiotics: establishment of a London surveillance programme. Sex Trans Inf 1999; 75: 107–11.
Department of Infectious Diseases and Microbiology, Imperial College School of Medicine St Mary’s Campus, London W2 1PG, UK (I M C Martin BSc, C A Ison PhD); and London Gonococcal Working Group Correspondence to: Dr C A Ison (e-mail: [email protected])
623
Research letters
Rise in gonorrhoea in London, UK I M C Martin, C A Ison, London Gonococcal Working Group* (LGWG) We report an alarming 34·9% overall increase in the number of gonococcal infections diagnosed during the same 3 month study period during 3 years. Between 1997 and 1998, an increase of 12·1% was detected, with a larger increase between 1998 and 1999, of 20·4%.
Sexual health in the UK was put on the political agenda by the launch of the Government’s first ever strategy on sexual health in March, 1999.1 The UK Government’s aim is to develop an integrated sexual and reproductive health strategy covering all ages and high-risk groups. This report is due to be published this year. Gonorrhoea was chosen as a marker of unprotected sex, and, to monitor changes in sexual behaviour, as an indicator of HIV-1 transmission in the UK Government’s white paper, The health of the nation, in July, 1992.2 The incidence of gonorrhoea in heterosexuals seems to indicate unsafe sexual behaviour, but in homosexual and bisexual men this cannot always be implied. Rectal gonorrhoea does have implications for unsafe sexual behaviour and HIV-1, but in other genital sites gonorrhoea can be transmitted through practices not thought to be at high-risk for HIV-1 transmission.3 In the white paper, targets were set to reduce the rate of gonorrhoea in men and women by 20% on the basis of 1990 figures, which have since been met. This reduction was followed by a subsequent increase in the incidence of gonorrhoea in England and Wales between 1994 and 1997. In 1998 the number of cases remained static.4 There are 32 genitourinary medicine clinics in the Thames region and last year they treated 47% of all male, and 40% of all female infections of Neisseria gonorrhoeae in England and Wales. 58% of all homosexually acquired infections were treated in London genitourinary medicine clinics. The populations served by these clinics are diverse; some clinics treat a predominantly local population, whereas others attract Hospital
St Thomas’ Kings College Chelsea and Westminster total Charing Cross Victoria Clinic John Hunter Clinic University College London St Mary’s Homerton The Royal London Central Middlesex St George’s St Bartholomew’s Whittington Greenwich Royal Free Total Core† Total‡
1999
1998
1997
Het/hom (%)*
Change from 1998 to 1999 (%)
311 257 166 64 29 73 166 165 148 124 96 96 30 93 49 43
241 263 126 49 29 43 145 121 123 98 91 68 22 ·· ·· ··
222 179 169 ·· ·· ·· 119 149 82 107 63 69 26 ·· ·· ··
71/15 86/14 ·· 36/63 34/52 26/58 14/79 40/47 93/7 68/29 88/4 79/15 68/32 ·· ·· ··
29% ⫺2% 35% 28% 0 66% 14% 36% 20% 26% 5% 41% 36% ·· ·· ··
1559 1744
1295
1155
*Percentage of heterosexuals and homosexuals (Het/hom) for 1998, missing percentage= bisexuals and those of unknown sexual orientation. †1999 core refers to totals for the original ten hospitals within LGWG. ‡1999 total includes isolates from Greenwich, Royal Free, and Whittington Hospitals who joined the group in 1999.
Number of isolates collected from each hospital during 3 years
THE LANCET • Vol 355 • February 19, 2000
patients of a specific sexual orientation from a larger geographic area. In particular, London, with its mobile population relative to the rest of England and Wales, has a correspondingly higher risk of importing resistant strains (table). The LGWG was formed in 1997 to monitor the susceptibility of gonococcal isolates to antibiotics currently used for treatment, and to instruct clinical practice. The group is a collaboration of 13 genitourinary medicine clinics and their supporting diagnostic laboratories. A surveillance system has been established for monitoring changes in the distribution and the trends of antibiotic resistance of gonorrhoea longitudinally in London.5 85% of all cases of gonorrhoea in the Thames region wee diagnosed in the 13 clinics, based on 1998 data (Mike Catchpole, personal communication), providing a representative sample for surveillance. This is the first surveillance programme for gonococcal antimicrobial susceptibility to be established in England and Wales. On completion of the 1999 collection of gonococcal isolates from consecutive patients, a 20·4% increase was detected compared with the same period in 1998. The number of isolates from ten hospitals, from whom isolates have been collected over 3 years increased from 1295 in 1998, to 1559 in 1999. This increase has occurred in men and women, and across all clinics regardless of patient type.* In women the greatest number of isolates were seen in the 16–19 years age group (33% of all cases), whereas 44% of all isolates from men were in the 25–34 years age group. These data are collected annually over the same period and are therefore not affected by seasonal variations. N gonorrhoeae is the second most common sexuallytransmitted bacterial infection in England and Wales, therefore any increase of this magnitude in cases should be of concern. We emphasise the need for continued surveillance of gonorrhoea in London: to inform appropriate therapy; to focus sexual health promotion activities; for understanding the epidemiology of the disease; and to control its rising incidence. These initial findings are particularly timely in the context of the Government’s forthcoming sexual health strategy. We thank the staff of all the genitourinary medicine clinics and the laboratories at each of the participating hospitals for their help. *Details can be seen on The Lancet website: www.thelancet.com 1 2 3
4 5
First ever government strategy on sexual health launched. Department of Health press release, 1999/0166. Secretary of State for Health. The Health of the Nation: a Strategy for Health in England. London, HMSO: 1992. Lewis DA, Forster GE, Goh B. Gonorrhoea in HIV seropositive homosexual men attending an East London genitourinary medicine clinic. Genitourin Med 1996; 72: 74. CDSC. Sexually transmitted disease quarterly report: gonorrhoea in England and Wales. Commun Dis Rep CDR Wkly 1999; 9: 270–71. Ison CA, Martin IMC and the London Gonococcal Working Group. Susceptibility of gonococci isolated in London to therapeutic antibiotics: establishment of a London surveillance programme. Sex Trans Inf 1999; 75: 107–11.
Department of Infectious Diseases and Microbiology, Imperial College School of Medicine St Mary’s Campus, London W2 1PG, UK (I M C Martin BSc, C A Ison PhD); and London Gonococcal Working Group Correspondence to: Dr C A Ison (e-mail: [email protected])
623