Epidemiology of gonorrhoea: a global perspective

Review of mathematical models of Neisseria gonorrhoeae vaccine impact: Implications for vaccine development

An effective prophylactic vaccine for prevention of Neisseria gonorrhoeae infection would have a major impact on sexual and reproductive health worldwide. Interest in developing gonorrhoea vaccines is growing due to the reported high rates of N. gonorrhoeae infections globally, and the threat of antimicrobial resistance. Several gonorrhoea vaccine candidates are currently under evaluation and various mathematical models have been used to assess the potential population-level impact a gonorrhoea vaccine may have once available. Here we review key aspects of gonorrhoea vaccine mathematical modelling studies, including model structures, populations considered, and assumptions used as well as vaccine characteristics and implementation scenarios investigated. The predicted vaccine impact varied between studies, ranging from as little as ∼17 % reduction in N. gonorrhoeae prevalence after 30 years up to 100 % reduction after 5 years. However, all studies predicted that even a partially effective gonorrhoea vaccine could have a substantial impact in reducing N. gonorrhoeae prevalence or incidence, particularly when high coverage is achieved within either important risk groups or the overall sexually active population. As expected, higher vaccine efficacy against acquisition of N. gonorrhoeae and longer duration of protection were linked to greater reductions in infections. A vaccine that alters onward transmission could also substantially reduce infections. Several gaps and research needs have been identified by researchers in the field and via this narrative literature review. For example, future modelling to inform gonorrhoea vaccine development and implementation should consider additional populations that are at high risk of N. gonorrhoeae infection, especially in low- and middle-income settings, as well as the impact of vaccination on the potential adverse sexual and reproductive health outcomes of infection. In addition, more detailed and robust epidemiological, biological, and behavioural data is needed to enable more accurate and robust modelling of gonorrhoea vaccine impact to inform future scientific and public health decision-making.

Vaccine value profile for Neisseria gonorrhoeae

Neisseria gonorrhoeae infection (gonorrhoea) is a global public health challenge, causing substantial sexual and reproductive health consequences, such as infertility, pregnancy complications and increased acquisition or transmission of HIV. There is an urgency to controlling gonorrhoea because of increasing antimicrobial resistance to ceftriaxone, the last remaining treatment option, and the potential for gonorrhoea to become untreatable. No licensed gonococcal vaccine is available. Mounting observational evidence suggests that N. meningitidis serogroup B outer membrane vesicle-based vaccines may induce cross-protection against N. gonorrhoeae (estimated 30%-40% effectiveness using the 4CMenB vaccine). Clinical trials to determine the efficacy of the 4CMenB vaccine against N. gonorrhoeae are underway, as are Phase 1/2 studies of a new gonococcal-specific vaccine candidate. Ultimately, a gonococcal vaccine must be accessible, affordable and equitably dispensed, given that those most affected by gonorrhoea are also those who may be most disadvantaged in our societies, and most cases are in less-resourced settings. This vaccine value profile (VVP) provides a high level, holistic assessment of the current data to inform the potential public health, economic and societal value of pipeline vaccines. This was developed by a working group of subject matter experts from academia, non-profit organizations, public private partnerships and multi-lateral organizations. All contributors have extensive expertise on various elements of the N. gonorrhoeae VVP and collectively aimed to identify current research and knowledge gaps. The VVP was developed using published data obtained from peer-reviewed journals or reports.

Antimicrobial Resistance in Gonorrhea

Antimicrobial resistance is a global public health emergency. The World Health Organization recently highlighted the growing number of new sexually transmitted infections such as gonorrhea, syphilis, and Chlamydia, which are resistant to common antibiotics. The phenomenon is also on the rise due to increasing intercontinental travel. Emerging antibiotic-resistant strains of gonorrhea are particularly associated with international spread from Southeast Asian travelers. Infection with Neisseria gonorrhoeae can cause a wide spectrum of associated diseases such as dermatitis, arthritis and septic arthritis, and pelvic inflammatory disease, and can even lead to serious health consequences for the individual. Natural infection confers no immunity, and vaccination is not available currently, although in several countries, it has been reported that the antimeningococcal vaccine may protect against gonorrhea. Implementing all necessary preventive measures is crucial, as well as appropriate and timely diagnostic methods and effective antimicrobial therapeutic treatments in the correct modalities to avoid the increase of forms of gonorrhea that are resistant to common antibiotics and difficult to eradicate.

A systematic review of Neisseria gonorrhoeae drug resistance development in South Africa

In South Africa, basic healthcare centres treat sexually transmitted infections (STIs) using a syndromic approach. In line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations, a complete study of all randomised controlled trials and surveillance data relevant to N. gonorrhoeae antibiotic resistance was conducted. To discover papers published between 2002 and 2022, searches were undertaken using PubMed, EMBASE and any other relevant databases. This systematic review extracted a total of 463 articles published between 2002 and 2022 from a variety of online research sources. Seven South African provinces were represented in the studies that were assessed. Mpumalanga and the North West Province did not have any studies that described the identification and monitoring of antimicrobial resistance (AMR). This study presents data obtained from a comprehensive analysis of 2140 isolates, in which we examined the presence of one or more antibiotic resistance. Our findings revealed that out of these samples, 1891 isolates exhibited antimicrobial properties; tetracycline was the antimicrobial resistance that was found the most often (30%), followed by ciprofloxacin (19%) and penicillin (17%). The mean of the isolates was 143, the upper 95% mean was 243, and the standard deviation (SD) was 181.6. All microbiological identification and susceptibility testing processes must be standardised and improved so national organisations can monitor AMR. The nation's health community must address all identified areas of concern to avoid AMR.

Characterization of outer membrane vesicles released by clinical isolates of Neisseria gonorrhoeae

The sexually transmitted pathogen Neisseria gonorrhoeae releases membrane vesicles including outer membrane vesicles (OMVs) during infections. OMVs traffic outer membrane molecules, such as the porin PorB and lipo-oligosaccharide (LOS), into host innate immune cells, eliciting programmed cell death pathways, and inflammation. Little is known, however, about the proteome and LOS content of OMVs released by clinical strains isolated from different infection sites, and whether these vesicles similarly activate immune responses. Here, we characterized OMVs from four N. gonorrhoeae isolates and determined their size, abundance, proteome, LOS content, and activation of inflammatory responses in macrophages. The overall proteome of the OMVs was conserved between the four different isolates, which included major outer membrane and periplasm proteins. Despite this, we observed differences in the rate of OMV biogenesis and the relative abundance of membrane proteins and LOS. Consequently, OMVs from clinical isolates induced varying rates of macrophage cell death and the secretion of interleukin-1 family members, such as IL-1α and IL-1β. Overall, these findings demonstrate that clinical isolates of N. gonorrhoeae utilize membrane vesicles to release proteins and lipids, which affects innate immune responses.

Time trends in positive gonorrhoea diagnoses at the Christchurch Sexual Health Service (2012-2022): a data audit study

Background Gonorrhoea infections and antimicrobial resistance are rising in many countries, particularly among men who have sex with men, and an increasing proportion of infection is detected at extragenital sites. This study assessed trends in gonorrhoea diagnoses and antibiotic resistance at a sexual health service in New Zealand that followed national guidelines for specimen collection. Methods Routinely-collected data from Canterbury Health Laboratories of specimens taken at the Christchurch Sexual Health Service 2012-2022 were audited. Descriptive results included the number of patient testing events positive for gonorrhoea per year and site of infection (extragenital/urogenital). Annual test-positivity was calculated (number of positive patient testing events divided by total number of testing events) and the Cochran-Armitage Test for Trend was used to assess whether there was an association between test-positivity and year. Results Of 52,789 patient testing events, 1467 (2.8%) were positive for gonorrhoea (81% male). Half (49.3%) of people (57.9% of males, 12.2% of females) with a gonorrhoea infection had an extragenital infection in the absence of a urogenital infection. The number of extragenital infections increased at a faster rate than urogenital among males. Test-positivity increased from 1.3% in 2012 to 5.8% in 2022 (P Conclusions This study highlights the importance of extragenital sampling and maintaining bacterial culture methods for accurate diagnosis and treatment. The observation that gonorrhoea positivity rate and antimicrobial resistance rates are rising in New Zealand calls for urgent action.

Seroprevalence of Treponema pallidum infection in Brazilian indigenous people: a cross-sectional study

Indigenous communities in Brazil have a complex epidemiological profile, which increases their chances of contracting sexually transmitted diseases. However, limited data is available on Treponema pallidum infections in this population. We investigated the seroprevalence and risk factors associated with T. pallidum infection in an indigenous population of Dourados, Mato Grosso do Sul. Blood samples were collected from September 2017 to March 2020, and the participants were interviewed to obtain comprehensive data on demography and sexual behavior. Serological tests were performed to detect T. pallidum infection. Besides conducting descriptive analysis, we performed Chi-squared tests and determined the bivariate odds ratio. The data were also analyzed using logistic regression. Among the 2190 invited individuals, 1927 (88%) were included in this study. The seroprevalence of T. pallidum infection was 2.91%. The results of a multivariate analysis showed that individuals who were 30-39 years old, with up to 4 years of school education, living in households without piped water, with a history of genital lesions, multiple sexual partners, and having a history of STIs had the highest seroprevalence of T. pallidum. This study showed that behavioral, social, and economic factors play an important role in the transmission of T. pallidum within the indigenous population. Thus, targeted intervention, including imparting education in the native language, mass testing initiatives, and implementing public policies to improve socioeconomic indicators, is needed to reduce the cases of syphilis in this community.

Understanding Risk Factors for Oropharyngeal Gonorrhea Among Sex Workers Attending Sexual Health Clinics in 2 Australian Cities: Mixed Methods Study

BACKGROUND

The risk factors for oropharyngeal gonorrhea have not been examined in sex workers despite the increasing prevalence of gonorrhea infection.

OBJECTIVE

This study aims to determine the risk factors for oropharyngeal gonorrhea in female and gender-diverse sex workers (including cisgender and transgender women, nonbinary and gender fluid sex workers, and those with a different identity) and examine kissing, oral sex, and mouthwash practices with clients.

METHODS

This mixed methods case-control study was conducted from 2018 to 2020 at 2 sexual health clinics in Melbourne, Victoria, and Sydney, New South Wales, Australia. We recruited 83 sex workers diagnosed with oropharyngeal gonorrhea (cases) and 581 sex workers without (controls). Semistructured interviews with 19 sex workers from Melbourne were conducted.

RESULTS

In the case-control study, the median age of 664 sex workers was 30 (IQR 25-36) years. Almost 30% of sex workers (192/664, 28.9%) reported performing condomless fellatio on clients. Performing condomless fellatio with clients was the only behavior associated with oropharyngeal gonorrhea (adjusted odds ratio 3.6, 95% CI 1.7-7.6; P=.001). Most participants (521/664, 78.5%) used mouthwash frequently. In the qualitative study, almost all sex workers reported kissing clients due to demand and generally reported following clients' lead with regard to kissing style and duration. However, they used condoms for fellatio because they considered it a risky practice for contracting sexually transmitted infections, unlike cunnilingus without a dental dam.

CONCLUSIONS

Our study shows that condomless fellatio is a risk factor for oropharyngeal gonorrhea among sex workers despite most sex workers using condoms with their clients for fellatio. Novel interventions, particularly targeting the oropharynx, will be required for oropharyngeal gonorrhea prevention.

IL-17C is a driver of damaging inflammation during Neisseria gonorrhoeae infection of human Fallopian tube

The human pathogen Neisseria gonorrhoeae ascends into the upper female reproductive tract to cause damaging inflammation within the Fallopian tubes and pelvic inflammatory disease (PID), increasing the risk of infertility and ectopic pregnancy. The loss of ciliated cells from the epithelium is thought to be both a consequence of inflammation and a cause of adverse sequelae. However, the links between infection, inflammation, and ciliated cell extrusion remain unresolved. With the use of ex vivo cultures of human Fallopian tube paired with RNA sequencing we defined the tissue response to gonococcal challenge, identifying cytokine, chemokine, cell adhesion, and apoptosis related transcripts not previously recognized as potentiators of gonococcal PID. Unexpectedly, IL-17C was one of the most highly induced genes. Yet, this cytokine has no previous association with gonococcal infection nor pelvic inflammatory disease and thus it was selected for further characterization. We show that human Fallopian tubes express the IL-17C receptor on the epithelial surface and that treatment with purified IL-17C induces pro-inflammatory cytokine secretion in addition to sloughing of the epithelium and generalized tissue damage. These results demonstrate a previously unrecognized but critical role of IL-17C in the damaging inflammation induced by gonococci in a human explant model of PID.

Barriers to sexual health care for sexually diverse Muslim men: a scoping review

Sexually diverse Muslim men (SDMM) are seen to present later and with more advanced symptoms of HIV and other sexually transmitted infections (STIs). The limited access to sexual healthcare services is attributed to the stigma associated with their multiple intersecting identities. We conducted a scoping review to synthesise research on barriers impeding SDMM's access to sexual health care. We used Arksey and O'Malley's five-stage framework as the methodology for the review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses' extension for scoping reviews, was used as a guide for the presentation of the results. Searches conducted in EBSCOhost, Scopus, MEDLINE, Embase, CINAHL, Global Health, and Google Scholar yielded 1382 results, of which 18 studies were deemed eligible for this review. Bronfenbrenner's socioecological model was employed as a framework to analyse the studies. Through analysing the eligible studies, we identified factors operating at three different levels that can impede SDMM's access to sexual health care. Limited awareness and low-perceived risk of HIV/STIs, coupled with the fear of sexual identity disclosure might act as individual-level barriers to sexually diverse Muslim men's access to sexual health care. The experiences of discrimination within clinical settings were presented as a healthcare system-related issue discouraging SDMM from revisiting those services. Heteronormative and religious ideologies, homophobic government programs, and poverty might manifest in the more intimate domains of healthcare delivery, creating hostile spaces for SDMM. Intensive research and advocacy efforts are required to improve SDMM's access to sexual health care, which can reduce their risk of HIV/STIs.

Clinical Decision Support System for Guidelines-Based Treatment of Gonococcal Infections, Screening for HIV, and Prescription of Pre-Exposure Prophylaxis: Design and Implementation Study

BACKGROUND

The syndemic nature of gonococcal infections and HIV provides an opportunity to develop a synergistic intervention tool that could address the need for adequate treatment for gonorrhea, screen for HIV infections, and offer pre-exposure prophylaxis (PrEP) for persons who meet the criteria. By leveraging information available on electronic health records, a clinical decision support (CDS) system tool could fulfill this need and improve adherence to Centers for Disease Control and Prevention (CDC) treatment and screening guidelines for gonorrhea, HIV, and PrEP.

OBJECTIVE

The goal of this study was to translate portions of CDC treatment guidelines for gonorrhea and relevant portions of HIV screening and prescribing PrEP that stem from a diagnosis of gonorrhea as an electronic health record-based CDS intervention. We also assessed whether this CDS solution worked in real-world clinic.

METHODS

We developed 4 tools for this CDS intervention: a form for capturing sexual history information (SmartForm), rule-based alerts (best practice advisory), an enhanced sexually transmitted infection (STI) order set (SmartSet), and a documentation template (SmartText). A mixed methods pre-post design was used to measure the feasibility, use, and usability of the CDS solution. The study period was 12 weeks with a baseline patient sample of 12 weeks immediately prior to the intervention period for comparison. While the entire clinic had access to the CDS solution, we focused on a subset of clinicians who frequently engage in the screening and treatment of STIs within the clinical site under the name "X-Clinic." We measured the use of the CDS solution within the population of patients who had either a confirmed gonococcal infection or an STI-related chief complaint. We conducted 4 midpoint surveys and 3 key informant interviews to quantify perception and impact of the CDS solution and solicit suggestions for potential future enhancements. The findings from qualitative data were determined using a combination of explorative and comparative analysis. Statistical analysis was conducted to compare the differences between patient populations in the baseline and intervention periods.

RESULTS

Within the X-Clinic, the CDS alerted clinicians (as a best practice advisory) in one-tenth (348/3451, 10.08%) of clinical encounters. These 348 encounters represented 300 patients; SmartForms were opened for half of these patients (157/300, 52.33%) and was completed for most for them (147/300, 89.81%). STI test orders (SmartSet) were initiated by clinical providers in half of those patients (162/300, 54%). HIV screening was performed during about half of those patient encounters (191/348, 54.89%).

CONCLUSIONS

We successfully built and implemented multiple CDC treatment and screening guidelines into a single cohesive CDS solution. The CDS solution was integrated into the clinical workflow and had a high rate of use.

Children with perinatally acquired HIV exhibit distinct immune responses to 4CMenB vaccine

Children with perinatally acquired HIV (PHIV) have special vaccination needs, as they make suboptimal immune responses. Here, we evaluated safety and immunogenicity of 2 doses of 4-component group B meningococcal vaccine in antiretroviral therapy-treated children with PHIV and healthy controls (HCs). Assessments included the standard human serum bactericidal antibody (hSBA) assay and measurement of IgG titers against capsular group B Neisseria meningitidis antigens (fHbp, NHBA, NadA). The B cell compartment and vaccine-induced antigen-specific (fHbp+) B cells were investigated by flow cytometry, and gene expression was investigated by multiplexed real-time PCR. A good safety and immunogenicity profile was shown in both groups; however, PHIV demonstrated a reduced immunogenicity compared with HCs. Additionally, PHIV showed a reduced frequency of fHbp+ and an altered B cell subset distribution, with higher fHbp+ frequency in activated memory and tissue-like memory B cells. Gene expression analyses on these cells revealed distinct mechanisms between PHIV and HC seroconverters. Overall, these data suggest that PHIV presents a diverse immune signature following vaccination. The impact of such perturbation on long-term maintenance of vaccine-induced immunity should be further evaluated in vulnerable populations, such as people with PHIV.

Anorectal Neisseria gonorrhoeae infections in women with and without reported anal sex and sex workers in sexual health centres in the Netherlands: a retrospective cohort study

BACKGROUND

Control of Neisseria gonorrhoeae infection (gonorrhoea) depends on effective testing strategies. Anorectal testing in women is often done on indication of anal sex; however, anorectal infections are seen with and without anal exposure, possibly caused by autoinoculation. This study aims to enhance understanding of anorectal infections in women, by identifying risk factors for anorectal diagnosis.

METHODS

In this retrospective cohort study we used national surveillance data from Dutch sexual health centres from Jan 1, 2016, to Dec 31, 2021. We included cisgender women having sex with men who were tested urogenitally and anorectally for gonorrhoea. Due to different testing policies, we identified three groups: women who had not reported recent anal sex (in the past 6 months), women who had reported recent anal sex, and sex workers. Extracted data for analyses included demographics, sexual behaviour, and diagnosis of a sexually transmitted infection (STI). Per group, multivariable models using Firth's penalised maximum likelihood logistic regression were constructed, identifying determinants of anorectal gonorrhoea among all women and among gonorrhoea-positive women only. Variables included in model construction were age, education level, migration background, number of partners, condom use, partner notification, STI symptoms, having a partner who has sex with men (MSM) or a migrant partner, previous STI test, anal sex, and chlamydia and gonorrhoea diagnoses per anatomical location.

FINDINGS

In total, 117 693 women were included: 43 757 women without reported recent anal sex, 51 728 women with reported recent anal sex, and 22 208 sex workers. In all three groups, around 2% of women were gonorrhoea positive, and 70% or more of women had an anorectal infection. The strongest determinant of anorectal gonorrhoea was a concurrent urogenital gonorrhoea diagnosis (adjusted odds ratios [aOR] 782 [95% CI 605-1018]) among women without reported recent anal sex (612 [490-768] among women with reported recent anal sex, and 464 [335-652] among sex workers). Among gonorrhoea-positive women, determinants of anorectal gonorrhoea were urogenital and anorectal chlamydia co-infection (aOR 2·03 [95% CI 1·38-3·02], for women without reported anal sex) and migration background (1·44 [1·02-2·06], for women with reported anal sex). Determinants among sex workers were condomless sex (2·43 [1·55-3·82]), anal sex (1·71 [1·10-2·66]), MSM or migrant partner (1·78 [1·13-2·79]), and urogenital and anorectal chlamydia co-infection (2·28 [1·11-5·14]).

INTERPRETATION

These findings support the possibility of an autoinoculation process from the urogenital to the anorectal location due to the very strong correlation between urogenital and anorectal gonorrhoea, and due to the similarity of results across all three groups. Current testing strategies could miss anorectal infections, which should be considered when developing gonorrhoea prevention and control guidelines.

FUNDING

None.

Gonorrhea caused due to antimicrobial-resistant bacteria Neisseria gonorrhoeae treated using probiotic peptide

Neisseria gonorrhea is a sexually transmitted disease from gonorrhea that lacks treatment; despite the urgency, the absence of adequate drugs, lack of human correlates of protection, and inadequate animal models of infection have delayed progress toward the prevention of gonococcal infection. Lactobacillus crispatus is a lactic acid bacterium typically found in the human vaginal microbiota. Peptides from L. crispatus have shown a potential therapeutic option for targetting N. gonorrhea. Bioinformatics analysis is important for speeding up drug target acquisition, screening refinement, and evaluating adverse effects and drug resistance prediction. Therefore, this study identified an antimicrobial peptide from the bacteriocin immunity protein (BIP) of L. crispatus using the bioinformatics tool and Collection of Antimicrobial Peptide (CAMPR3). Based on the AMP score and highest ADMET properties, the peptide SM20 was chosen for docking analysis. SM20 was docked against multiple proteins from the genome of the AMR bacterium N. gonorrhea using an online tool; protein-peptide interactions were established and visualized using the PyMol visualizing tool. Molecular docking was carried out using the CABSdock tool, and multiple conformations were obtained against the membrane proteins of N. gonorrhoea. The peptide SM20 exhibited higher docking scores and ADMET properties. Therefore, SM20 could be further encapsulated with cellulose; it can be applied topically to the genital tract to target N. gonorrhea infection. The controlled release of the antimicrobial peptide from the gel can provide sustained delivery of the treatment, increasing its efficacy and reducing the risk of resistance development.

Neisseria gonorrhoeae vaccines: a contemporary overview

Neisseria gonorrhoeae infection is an important public health issue, with an annual global incidence of 87 million. N. gonorrhoeae infection causes significant morbidity and can have serious long-term impacts on reproductive and neonatal health and may rarely cause life-threatening disease. Global rates of N. gonorrhoeae infection have increased over the past 20 years. Importantly, rates of antimicrobial resistance to key antimicrobials also continue to increase, with the United States Centers for Disease Control and Prevention identifying drug-resistant N. gonorrhoeae as an urgent threat to public health. This review summarizes the current evidence for N. gonorrhoeae vaccines, including historical clinical trials, key N. gonorrhoeae vaccine preclinical studies, and studies of the impact of Neisseria meningitidis vaccines on N. gonorrhoeae infection. A comprehensive survey of potential vaccine antigens, including those identified through traditional vaccine immunogenicity approaches, as well as those identified using more contemporary reverse vaccinology approaches, are also described. Finally, the potential epidemiological impacts of a N. gonorrhoeae vaccine and research priorities for further vaccine development are described.

Clinical Performance of Cas13a-based Point-of-Care Lateral Flow Assay for Detecting Neisseria gonorrhoeae

Background

Diagnosis of Neisseria (N.) gonorrhoeae is dependent on nucleic acid amplification testing (NAAT), which is not available in resource-limited settings where the prevalence of infection is highest. Recent advances in molecular diagnostics leveraging the high specificity of CRISPR enzymes can permit field-deployable, point-of-care lateral flow assays. We previously reported on the development and in vitro performance of a lateral flow assay for detecting N. gonorrhoeae. Here we aimed to pair that assay with point-of-care DNA extraction techniques and assess the performance on clinical urine specimens.

Methods

We collected an additional urine specimen among individuals enrolling in an ongoing clinical trial at the Massachusetts General Hospital Sexual Health Clinic who presented with symptoms of urethritis or cervicitis (urethral or vaginal discharge, dysuria, or dyspareunia). We then assessed thermal, detergent, and combination DNA extraction conditions, varying the duration of heat at 95°C and concentration of Triton X. We assessed the efficacy of the various DNA extraction methods by quantitative polymerase chain reaction (qPCR). Once an extraction method was selected, we incubated samples for 90 minutes to permit isothermal recombinase polymerase amplification. We then assessed the performance of lateral flow Cas13a-based detection using our previously designed porA probe and primer system for N. gonorrhoeae detection, comparing lateral flow results with NAAT results from clinical care.

Results

We assessed DNA extraction conditions on 3 clinical urine specimens. There was no consistent significant difference in copies per microliter of DNA obtained using more or less heat. On average, we noted that 0.02% triton combined with 5 minutes of heating to 95°C resulted in the highest DNA yield, however, 0.02% triton alone resulted in a quantity of DNA that was above the previously determined analytic sensitivity of the assay. Given that detergent-based extraction is more easily deployable, we selected that as our method for extraction. We treated 23 clinical specimens with 0.02% triton, which we added to the Cas13a detection system. We ran all lateral flow detections in duplicate. The Cas13a-based assay detected 8 of 8 (100%) positive specimens, and 0 of 15 negative specimens.

Conclusion

Using point-of-care DNA extraction, isothermal amplification, and Cas13a-based detection, our point-of-care lateral flow N. gonorrhoeae assay correctly identified 23 clinical urine specimens as either positive or negative. Further evaluation of this assay among larger samples and more diverse sample types is warranted.

Propositive follow-up: Long-term immune responses to the 4CMenB and MenACWY vaccines in people living with HIV

BACKGROUND

People living with HIV have an increased risk of meningococcal disease. The Propositive trial evaluated co-administration of two doses of a four-component recombinant protein-based MenB vaccine (4CMenB) and a quadrivalent conjugate polysaccharide MenACWY vaccine (MenACWY-CRM197) given 1 month apart in people with HIV. The follow-up trial assessed the immunogenicity of these vaccines at 1.5 and 2.5 years after primary vaccination.

METHODS

Participants who completed the parent Propositive trial were invited to the follow-up study. Immunogenicity analysis was performed at 18 and 30 months after primary vaccination. Primary outcome measures were serum bactericidal antibody (SBA) geometric mean titres (GMTs) against three MenB reference strains and the proportion of participants maintaining a protective SBA titre of ≥4 at 18 and 30 months. Secondary outcome measures were SBA GMTs against MenA, C, W, and Y serogroups and the proportion of participants maintaining a protective SBA titre of ≥8 at 18 and 30 months. The trial is registered with Clinicaltrials.gov (NCT042394300).

RESULTS

A total of 40 participants aged 22-47 years were enrolled. Geometric mean titres waned by 18 and 30 months but remained higher than pre-vaccination for all MenB strains and MenA, C, W, and Y. In total, 75%-85% of participants retained protective SBA titres by 30 months against individual MenB strains, whereas 68.8% of patients retained protective antibody titres against all three MenB strains. Antibodies against MenC waned more rapidly than did those against MenA, W, and Y. The proportion of participants with protective titres against MenC at 30 months was also lower (46.9%) than that with protective titres against MenA (87.5%), W (78.1%), and Y (87.5%).

CONCLUSIONS

Immune responses against MenB in our cohort of people living with HIV at 2.5 years of follow-up were reassuring, with 68.8% of participants retaining protection against all three reference strains. However, responses against MenC were lower than those against MenA, W, and Y serogroups.

Sexually transmitted infections and dating app use

Incidence of sexually transmitted infections (STIs) is rising sharply in the United States. Between 2014 and 2019, incidence among men and women has increased by 62.8% and 21.4%, respectively, with an estimated 68 million Americans contracting an STI in 2018.a Some human behaviors impacting the expanding STI epidemic are unprotected sex and multiple sexual partners.b Increasing dating app usage has been postulated as a driver for increases in the numbers of people engaging in these behaviors. Using the proposed model, it is estimated that both STI incidence and prevalence for females and males have increased annually by 9%-15% between 2015 and 2019 due to dating apps usage, and that STI incidence and prevalence will continue to increase in the future. The model is also used to assess the possible benefit of in-app prevention campaigns.ahttps://www.cdc.gov/nchhstp/newsroom/fact-sheets/std/STI-Incidence-Prevalence-Cost-Factsheet.htmbA. N. Sawyer, E. R. Smith, and E. G. Benotsch. Dating application use and sexual risk behavior among young adults. Sexuality Research and Social Policy, 15:183-191, 2018.

Characterization of protective immune responses against Neisseria gonorrhoeae induced by intranasal immunization with adhesion and penetration protein

Drug-resistant N. gonorrhoeae is an urgent threat to global public health, and vaccine development is the best long-term strategy for controlling gonorrhea. We have previously shown that adhesion and penetration protein (App) play a role in the adhesion, invasion, and reproductive tract colonization of N. gonorrhoeae. Here, we describe the immune response induced by intranasal immunization with passenger and translocator fragments of App. The recombinant App passenger and translocator fragments induced high titers of IgG and IgA antibodies in serum and vaginal washes. Antibodies produced by App passenger and the combination of passenger and translocator mediated the killing of N. gonorrhoeae via serum bactericidal activity and opsonophagocytic activity, whereas antisera from translocator-immunized groups had lower bactericidal activity and opsonophagocytic activity. The antisera of the App passenger and translocator, alone and in combination, inhibited the adhesion of N. gonorrhoeae to cervical epithelial cells in a concentration-dependent manner. Nasal immunization with App passenger and translocator fragments alone or in combination induced high levels of IgG1, IgG2a, and IgG2b antibodies and stimulated mouse splenocytes to secrete cytokines IFN-γ and IL-17A, suggesting that Th1 and Th17 cellular immune responses were activated. In vivo experiments have shown that immune App passenger and transporter fragments can accelerate the clearance of N. gonorrhoeae in the vagina of mice. These data suggest that the App protein is a promising N. gonorrhoeae vaccine antigen.

Research on the barriers to accessing sexual healthcare for sexually diverse Muslim men: protocol for a scoping review

INTRODUCTION

Sexually diverse Muslim men are seen to be at a higher risk for HIV and other sexually transmitted infections due to their limited access to sexual healthcare services. We outline a protocol to conduct a scoping review of research on the barriers that may impede these men's access to sexual healthcare.

METHODS AND ANALYSIS

To conduct this scoping review, we will follow the methodological framework developed by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses' extension for scoping reviews. To classify the barriers to sexual healthcare, we will employ Bronfenbrenner's socioecological model as a conceptual framework. We will conduct a literature search via Medline, Embase and Global Health (OVID); Scopus; CINAHL on EBSCOhost along with several other EBSCOhost databases (Academic Search Complete, Canadian Reference Centre, Alternative Press Index, Family & Society Studies Worldwide, Social Work Abstracts) and Google Scholar, published until November 2023. Journal articles, published in the English language, describing quantitative and qualitative research on sexual healthcare access barriers for sexually diverse Muslim men will be included in the review. Commentaries and correspondences, along with grey literature including research reports and conference abstracts, as well as studies that do not include men with the Muslim faith, will be considered ineligible. Following screening of titles and abstracts, we will conduct a full-text screening to determine the final number of studies to be included in the review. A Microsoft Excel spreadsheet will be used to extract study characteristics, and information on sexual healthcare access barriers will be classified according to the socioecological model's core concepts.

ETHICS AND DISSEMINATION

Our review does not require ethics approval. We will disseminate the review findings through peer-reviewed academic journals, seminars and conference presentations.

Building a Simple Model to Assess the Impact of Case Investigation and Contact Tracing for Sexually Transmitted Diseases: Lessons From COVID-19

Introduction

During the COVID-19 pandemic, the U.S. Centers for Disease Control and Prevention developed a simple spreadsheet-based tool to help state and local public health officials assess the performance and impact of COVID-19 case investigation and contact tracing in their jurisdiction. The applicability and feasibility of building such a tool for sexually transmitted diseases were assessed.

Methods

The key epidemiologic differences between sexually transmitted diseases and respiratory diseases (e.g., mixing patterns, incubation period, duration of infection, and the availability of treatment) were identified, and their implications for modeling case investigation and contact tracing impact with a simple spreadsheet tool were remarked on. Existing features of the COVID-19 tool that are applicable for evaluating the impact of case investigation and contact tracing for sexually transmitted diseases were also identified.

Results

Our findings offer recommendations for the future development of a spreadsheet-based modeling tool for evaluating the impact of sexually transmitted disease case investigation and contact tracing efforts. Generally, we advocate for simplifying sexually transmitted disease-specific complexities and performing sensitivity analyses to assess uncertainty. The authors also acknowledge that more complex modeling approaches might be required but note that it is possible that a sexually transmitted disease case investigation and contact tracing tool could incorporate features from more complex models while maintaining a user-friendly interface.

Conclusions

A sexually transmitted disease case investigation and contact tracing tool could benefit from the incorporation of key features of the COVID-19 model, namely its user-friendly interface. The inherent differences between sexually transmitted diseases and respiratory viruses should not be seen as a limitation to the development of such tool.

STI pathogens in the oropharynx: update on screening and treatment

PURPOSE OF REVIEW

The rise in antimicrobial resistance in several STI pathogens such as Neisseria gonorrhoeae has become a public health threat as only one first-line treatment remains. Reducing screening interval for gonorrhoea and chlamydia in high-prevalence populations has been proposed to address antimicrobial stewardship, but this remains controversial. This review aimed to revisit the epidemiology of infections at the oropharynx and review the current screening recommendations and treatment guidelines in different populations.

RECENT FINDINGS

Emerging evidence suggests that the oropharynx is the primary anatomical site for gonorrhoea transmission but maybe not for chlamydia transmission. Most international guidelines recommend 3-monthly oropharyngeal gonorrhoea and chlamydia screening for high-prevalence populations (e.g. men who have sex with men) but not low-prevalence populations (e.g. heterosexuals) given the clinical and public health benefits of screening in low-prevalence populations are still unclear. Doxycycline remains the first-line treatment for oropharyngeal chlamydia in most guidelines. However, some countries have moved from dual therapy (ceftriaxone and azithromycin) to monotherapy (ceftriaxone) for oropharyngeal gonorrhoea treatment to address antimicrobial stewardship.

SUMMARY

The transmission of gonorrhoea and chlamydia is still not fully understood. Further work will be required to evaluate the benefits and harms of reducing screening in high-prevalence populations.

Epidemiology of gonorrhoea: systematic review, meta-analyses, and meta-regressions, World Health Organization European Region, 1949 to 2021

BackgroundEpidemiology of Neisseria gonorrhoeae (NG) infection remains inadequately understood.AimWe aimed to characterise NG epidemiology in Europe.MethodsWe used Cochrane and PRISMA guidelines to systematically review, report, synthesise and analyse NG prevalence data from 1949 to 30 September 2021. Random-effects meta-analyses estimated pooled prevalence. Meta-regression analyses investigated associations and sources of heterogeneity.ResultsThe 844 included publications yielded 1,573 prevalence measures. Pooled prevalence of current urogenital infection was 1.0% (95% CI: 0.7-1.2%) among general populations, 3.2% (95% CI: 1.8-4.8%) among female sex workers, 4.9% (95% CI: 4.2-5.6%) among sexually transmitted infection clinic attendees and 12.1% (95% CI: 8.8-15.8%) among symptomatic men. Among men who have sex with men, pooled prevalence was 0.9% (95% CI: 0.5-1.4%), 5.6% (95% CI: 3.6-8.1%), and 3.8% (95% CI: 2.5-5.4%), respectively, for current urogenital, anorectal or oropharyngeal infection. Current urogenital, anorectal or oropharyngeal infection was 1.45-fold (95% CI: 1.19-1.77%), 2.75-fold (95% CI: 1.89-4.02%) and 2.64-fold (95% CI: 1.77-3.93%) higher among men than women. Current urogenital infection declined 0.97-fold (95% CI: 0.96-0.98%) yearly, but anorectal and oropharyngeal infection increased (1.02-fold; 95% CI: 1.01-1.04% and 1.02-fold; 95% CI: 1.00-1.04%), respectively.ConclusionsNeisseria gonorrhoeae epidemiology in Europe has distinct and contrasting epidemiologies for vaginal sex transmission in heterosexual sex networks vs anal and oral sex transmission in MSM sexual networks. Increased transmission may facilitate drug-resistant strain emergence. Europe is far from achieving the World Health Organization target of 90% incidence reduction by 2030.

Trend analysis and prediction of gonorrhea in mainland China based on a hybrid time series model

BACKGROUND

Gonorrhea has long been a serious public health problem in mainland China that requires attention, modeling to describe and predict its prevalence patterns can help the government to develop more scientific interventions.

METHODS

Time series (TS) data of the gonorrhea incidence in China from January 2004 to August 2022 were collected, with the incidence data from September 2021 to August 2022 as the validation. The seasonal autoregressive integrated moving average (SARIMA) model, long short-term memory network (LSTM) model, and hybrid SARIMA-LSTM model were used to simulate the data respectively, the model performance were evaluated by calculating the mean absolute percentage error (MAPE), root mean square error (RMSE), and mean absolute error (MAE) of the training and validation sets of the models.

RESULTS

The Seasonal components after data decomposition showed an approximate bimodal distribution with a period of 12 months. The three models identified were SARIMA(1,1,1) (2,1,2)12, LSTM with 150 hidden units, and SARIMA-LSTM with 150 hidden units, the SARIMA-LSTM model fitted best in the training and validation sets, for the smallest MAPE, RMSE, and MPE.

CONCLUSIONS

The overall incidence trend of gonorrhea in mainland China has been on the decline since 2004, with some periods exhibiting an upward trend. The incidence of gonorrhea displays a seasonal distribution, typically peaking in July and December each year. The SARIMA model, LSTM model, and SARIMA-LSTM model can all fit the monthly incidence time series data of gonorrhea in mainland China. However, in terms of predictive performance, the SARIMA-LSTM model outperforms the SARIMA and LSTM models, with the LSTM model surpassing the SARIMA model. This suggests that the SARIMA-LSTM model can serve as a preferred tool for time series analysis, providing evidence for the government to predict trends in gonorrhea incidence. The model's predictions indicate that the incidence of gonorrhea in mainland China will remain at a high level in 2024, necessitating that policymakers implement public health measures in advance to prevent the spread of the disease.

Ameliorating Gonorrhea: Recent Therapeutic Adaptations and Scope to Improve its Prevailing Condition

BACKGROUND

Gonorrhea is a sexually transmitted infection (STI) caused by the bacteria Neisseria gonorrhoeae. According to recent research, the prevalence of gonorrhea has been increasing in many parts of the world, with some areas reporting high rates of antibiotic resistance. In the United States, the Centers for Disease Control and Prevention (CDC) reported that the number of reported gonorrhea cases increased by 56% between 2015 and 2019. Globally, the World Health Organization (WHO) estimated that there were 87 million new cases of gonorrhea in 2016, with the highest burden of infection in low- and middle-income countries. Research has also shown that gonorrhea is becoming increasingly resistant to conventional antibiotics, increasing the prevalence of gonorrhea. This raises concerns and challenges in disease management.

OBJECTIVES

The present review gives updated insight on the current state of the disease, challenges, and shortcomings of existing approaches along with the modern and alternative direction like vaccine development, its challenges, and scope to confront the existing state of drug resistance and increased rate of incidence. Alternative strategies like immunotherapy and phage therapy along with recent antibiotics researched for the treatment of gonorrhea.

CONCLUSION

The review provides a thorough insight into the current state of the disease and various available methods used currently and recommended by WHO. To overcome disease prevalence, various alternate therapies are coming into the limelight. However, scientists and researchers show a lack of interest in the drug development and research of gonorrhea, due to less commercial scope, lack of funding, and limited scope in the scientific scenario. These hurdles need to be overcome to meet the WHO vision of reducing gonorrhea by 90% by 2030. So, there is a need to optimize the drug therapy (optimizing dosing schedule, and precision monitoring) to reduce the chance of drug resistance. Also, there is a wide scope for drug and therapeutic system development.

Sexually transmitted infections and HIV in ophthalmology

The ocular and periocular manifestations of sexually transmitted infections are heterogeneous in etiology, manifestations, and complications. Etiologic agents include bacteria, viruses, parasites, and protozoa, which are most frequently transmitted via direct ocular contact with an active lesion or infected bodily fluid, autoinoculation, or dissemination from a distant site. Vertical transmission most commonly occurs perinatally during vaginal delivery. The complications of ophthalmia neonatorum can be severe, with the potential for permanent blindness or life-threatening systemic involvement if untreated. Clinical features, diagnostic modalities, and therapeutic regimens vary based on etiology and are summarized in this review. Prompt diagnosis is imperative, given the severe sequelae that may result from ocular involvement in these infections, including permanent vision loss. A multidisciplinary approach, involving both ophthalmology and dermatology, to diagnosis and management is essential to mitigate the risk of morbidity associated with sexually transmitted infections resulting in eye disease.

Neisseria gonorrhoeae Antimicrobial Resistance: The Future of Antibiotic Therapy

The growing threat of antibiotic-resistant Neisseria gonorrhoeae, which causes gonorrhea, presents a current public health challenge. Over the years, the pathogen has developed resistance to different antibiotics, leaving few effective treatment options. High-level resistance to key drugs, including ceftriaxone, has become a concerning reality. This article primarily focuses on the treatment of gonorrhea and the current clinical trials aimed at providing new antibiotic treatment options. We explore ongoing efforts to assess new antibiotics, including zoliflodacin, and gepotidacin. These drugs offer new effective treatment options, but their rapid availability remains uncertain. We delve into two ongoing clinical trials: one evaluating the efficacy and safety of gepotidacin compared to the standard ceftriaxone-azithromycin combination and the other assessing the non-inferiority of zoliflodacin versus the combination therapy of ceftriaxone-azithromycin. These trials represent crucial steps in the search for alternative treatments for uncomplicated gonorrhea. Notably, gonorrhea has been included in the "WHO Priority Pathogens List for Research and Development of New Antibiotics". In conclusion, the urgent need for innovative treatment strategies is underscored by the rising threat of antibiotic resistance in N. gonorrhoeae; collaboration among researchers, industries, and healthcare authorities is therefore essential.

Commensal Neisseria cinerea outer membrane vesicles as a platform for the delivery of meningococcal and gonococcal antigens to the immune system

An affordable, accessible, and broadly protective vaccine is required to tackle the re-occurring bacterial meningococcal epidemics in Sub-Saharan Africa as well as an effective control of multi-drug resistant strains of gonococcus. Outer membrane vesicles (OMVs) secreted from Gram-negative bacteria represent an attractive platform for antigen delivery to the immune system and therefore for development of multi-component vaccines. In this study, we describe the generation of modified OMVs (mOMVs) from commensal biosafety-level 1 (BSL-1) Neisseria cinerea ATCC® 14685TM, which is phylogenetically close to the pathogenic bacteria Neisseria meningitidis and Neisseria gonorrhoeae. mOMVs were prepared from N. cinerea engineered to express heterologous antigens from N. meningitidis (factor H binding protein (fHbp) and Neisseria Heparin Binding Antigen (NHBA-2)) and from N. gonorrhoeae (NHBA-542). Mice immunised with the mOMVs produced antibodies against fHbp and NHBA. The work indicates that mOMV from N. cinerea can be used as a platform to induce immune responses against antigens involved in the protective immune response against meningococcal and gonococcal diseases.

A Systems Biology Approach for Investigating Significant Biomarkers and Drug Targets Common Among Patients with Gonorrhea, Chlamydia, and Prostate Cancer: A Pilot Study

Having a previous history of sexually transmitted diseases (STDs) such as gonorrhea and chlamydia increases the chance of developing prostate cancer, the second most frequent malignant cancer among men. However, the molecular functions that cause the development of prostate cancer in persons with gonorrhea and chlamydia are yet unknown. In this study, we studied RNA-seq gene expression profiles using computational biology methods to find out potential biomarkers that could help us in understanding the patho-biological mechanisms of gonorrhea, chlamydia, and prostate cancer. Using statistical methods on the Gene Expression Omnibus (GEO) data sets, it was found that a total of 22 distinct differentially expressed genes were shared among these 3 diseases of which 14 were up-regulated (PGRMC1, TSC22D1, SH3BGRL, NNT, CTSC, FRMD3, CCR2, FAM210B, VCL, PTGS1, SLFN11, SLC40A1, PROS1, and DSE) and the remaining 8 genes were down-regulated (PRNP, HINT3, MARCKSL1, TMED10, SH3KBP1, ENSA, DERL1, and KMT2B). Investigation on these 22 unique dysregulated genes using Gene Ontology, BioCarta, KEGG, and Reactome revealed multiple altered molecular pathways, including regulation of amyloid precursor protein catabolic process, ferroptosis, effects on gene expression of Homo sapiens PPAR pathway, and innate immune system R-HSA-168249. Four significant hub proteins namely VCL, SH3KBP1, PRNP, and PGRMC1 were revealed by protein-protein interaction network analysis. By analyzing gene-transcription factors and gene-miRNAs interactions, significant transcription factors (POU2F2, POU2F1, GATA6, and HIVEP1) and posttranscriptional regulator microRNAs (hsa-miR-7-5p) were also identified. Three potential therapeutic compounds namely INCB3284, CCX915, and MLN-1202 were found to interact with up-regulated protein C-C chemokine receptor type 2 (CCR2) in protein-drug interaction analysis. The proposed biomarkers and therapeutic potential molecules could be investigated for potential pharmacological targets and activity in the fight against in patients with gonorrhea, chlamydia, and prostate cancer.

Safety Aspects and Rational Use of Single Intramuscular Dose Ceftriaxone: Clinical Insights on the Management of Uncomplicated Gonococcal Infections

Gonorrhea, a sexually transmitted infection caused by Neisseria gonorrhoeae, is a grave public health concern. Gonorrhea is the second most reported sexually transmitted infection worldwide. The treatment of uncomplicated gonococcal infections has evolved dramatically in response to the emergence of antimicrobial resistance. Multiple resistance mechanisms (for example, beta-lactamase production, antimicrobial efflux, and target site modification) exist, some of which may cause multidrug-resistance. Ceftriaxone was first recommended as an option for uncomplicated gonococcal infections in 1985, and it is now a mainstay of therapy in all clinical practice guidelines. Ceftriaxone has consistently shown high microbiologic cure rates in clinical trials, and it has demonstrated an excellent safety profile. Although its use may be limited in patients with hypersensitivity to penicillins, the risk of using ceftriaxone in such patients is overestimated. The emergence of reduced ceftriaxone susceptibility in N. gonorrhoeae, coupled with a lack of diverse treatment alternatives and the limited pipeline of new antimicrobials, is a significant threat to the treatment of gonorrhea.

Development of Cas13a-based assays for Neisseria gonorrhoeae detection and gyrase A determination

Neisseria gonorrhoeae is one of the most common bacterial sexually transmitted infections. The emergence of antimicrobial-resistant N. gonorrhoeae is an urgent public health threat. Currently, the diagnosis of N. gonorrhoeae infection requires expensive laboratory infrastructure, while antimicrobial susceptibility determination requires bacterial culture, both of which are infeasible in low-resource areas where the prevalence of infection is highest. Recent advances in molecular diagnostics, such as specific high-sensitivity enzymatic reporter unlocking (SHERLOCK) using CRISPR-Cas13a and isothermal amplification, have the potential to provide low-cost detection of pathogen and antimicrobial resistance. We designed and optimized RNA guides and primer sets for SHERLOCK assays capable of detecting N. gonorrhoeae via the porA gene and of predicting ciprofloxacin susceptibility via a single mutation in the gyrase A (gyrA) gene. We evaluated their performance using both synthetic DNA and purified N. gonorrhoeae isolates. For porA, we created both a fluorescence-based assay and lateral flow assay using a biotinylated fluorescein reporter. Both methods demonstrated sensitive detection of 14 N. gonorrhoeae isolates and no cross-reactivity with 3 non-gonococcal Neisseria isolates. For gyrA, we created a fluorescence-based assay that correctly distinguished between 20 purified N. gonorrhoeae isolates with phenotypic ciprofloxacin resistance and 3 with phenotypic susceptibility. We confirmed the gyrA genotype predictions from the fluorescence-based assay with DNA sequencing, which showed 100% concordance for the isolates studied. We report the development of Cas13a-based SHERLOCK assays that detect N. gonorrhoeae and differentiate ciprofloxacin-resistant isolates from ciprofloxacin-susceptible isolates. IMPORTANCE Neisseria gonorrhoeae, the cause of gonorrhea, disproportionately affects resource-limited settings. Such areas, however, lack the technical capabilities for diagnosing the infection. The consequences of poor or absent diagnostics include increased disease morbidity, which, for gonorrhea, includes an increased risk for HIV infection, infertility, and neonatal blindness, as well as an overuse of antibiotics that contributes to the emergence of antibiotic resistance. We used a novel CRISPR-based technology to develop a rapid test that does not require laboratory infrastructure for both diagnosing gonorrhea and predicting whether ciprofloxacin can be used in its treatment, a one-time oral pill. With further development, that diagnostic test may be of use in low-resource settings.

Evolutionarily conserved heat shock protein, HtpX, as an adjunct target against antibiotic-resistant Neisseria gonorrhoeae

The emergence of multiple drug resistance and extreme drug resistance pathogens necessitates the continuous evaluation of the pathogenic genome to identify conserved molecular targets and their respective inhibitors. In this study, we mapped the global mutational landscape of Neisseria gonorrhoeae (an intracellular pathogen notoriously known to cause the sexually transmitted disease gonorrhoea). We identified highly variable amino acid positions in the antibiotic target genes like the penA, ponA, 23s rRNA, rpoB, gyrA, parC, mtrR and porB. Some variations are directly reported to confer resistance to the currently used front-line drugs like ceftriaxone, cefixime, azithromycin and ciprofloxacin. Further, by whole genome comparison and Shannon entropy analysis, we identified a completely conserved protein HtpX in the drug-resistant as well as susceptible isolates of N. gonorrhoeae (NgHtpX). Comparison with the only available information of Escherichia coli HtpX suggested it to be a transmembrane metalloprotease having a role in stress response. The critical zinc-binding residue of NgHtpX was mapped to E141. By applying composite high throughput screening followed by MD simulations, we identified pemirolast and thalidomide as high-energy binding ligands of NgHtpX. Following cloning and expression of the purified metal-binding domain of NgHtpX (NgHtpXd), its Zn2+ -binding (Kd  = 0.4 µM) and drug-binding (pemirolast, Kd  = 3.47 µM; and thalidomide, Kd  = 1.04 µM) potentials were determined using in-vitro fluorescence quenching experiment. When tested on N. gonorrhoeae cultures, both the ligands imposed a dose-dependent reduction in viability. Overall, our results provide high entropy positions in the targets of presently used antibiotics, which can be further explored to understand the AMR mechanism. Additionally, HtpX and its specific inhibitors identified can be utilised effectively in managing gonococcal infections.

Efficacy and Safety of Gepotidacin as Treatment of Uncomplicated Urogenital Gonorrhea (EAGLE-1): Design of a Randomized, Comparator-Controlled, Phase 3 Study

INTRODUCTION

Gonorrhea, caused by Neisseria gonorrhoeae (NG), is the second most common bacterial sexually transmitted infection (STI). Rates of antimicrobial resistance to standard care are increasing worldwide, with many antibiotic classes now ineffective against NG. Gepotidacin is a first-in-class, bactericidal, triazaacenaphthylene antibiotic that inhibits bacterial DNA replication by inhibition of two enzymes, where a single target-specific mutation does not significantly impact susceptibility. Gepotidacin confers activity against NG, including most strains resistant to marketed antibiotics. Here, we describe the design of a phase 3 clinical trial (EAGLE-1; NCT04010539) evaluating gepotidacin for the treatment of uncomplicated urogenital gonorrhea.

METHODS

This phase 3, randomized, multicenter, sponsor-blinded, noninferiority study across six countries is comparing the efficacy of gepotidacin with ceftriaxone plus azithromycin in 400 patients with uncomplicated urogenital gonorrhea (microbiological intent-to-treat population) and assessing the safety of gepotidacin in approximately 600 patients (intent-to-treat population). Eligible participants 12 years of age or older with clinical suspicion of urogenital gonococcal infection and a NG-positive urogenital sample and/or purulent discharge are randomized 1:1 to receive oral gepotidacin (2 × 3000 mg 10-12 h apart) or ceftriaxone (500 mg, intramuscular) plus azithromycin (1 g, oral). The primary endpoint is culture-confirmed bacterial eradication of NG from the urogenital site at the test-of-cure (days 4-8) visit.

PLANNED OUTCOMES

This trial was designed in accordance with US Food and Drug Administration (2015) and European Medicines Agency (2011) guidance, particularly the primary endpoint and microbiological evaluability requirements. This study will help characterize the risk-benefit profile of gepotidacin for treating uncomplicated urogenital gonorrhea. Gepotidacin is an important potential treatment for gonorrhea to help address the urgent unmet need of multidrug resistance and the increasingly limited number of oral treatment options.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT04010539.

High-throughput bactericidal assays for monoclonal antibody screening against antimicrobial resistant Neisseria gonorrhoeae

Neisseria gonorrhoeae (gonococcus) is an obligate human pathogen and the etiological agent of the sexually transmitted disease gonorrhea. The rapid rise in gonococcal resistance to all currently available antimicrobials has become a significant public health burden and the need to develop novel therapeutic and prophylactic tools is now a global priority. While high-throughput screening methods allowed rapid discovery of extremely potent monoclonal antibodies (mAbs) against viral pathogens, the field of bacteriology suffers from the lack of assays that allow efficient screening of large panels of samples. To address this point, we developed luminescence-based (L-ABA) and resazurin-based (R-ABA) antibody bactericidal assays that measure N. gonorrhoeae metabolic activity as a proxy of bacterial viability. Both L-ABA and R-ABA are applicable on the large scale for the rapid identification of bactericidal antibodies and were validated by conventional methods. Implementation of these approaches will be instrumental to the development of new medications and vaccines against N. gonorrhoeae and other bacterial pathogens to support the fight against antimicrobial resistance.

Epidemiological Trends and Factors Associated With the Morbidity Rate of Gonorrhea: A CDC-WONDER Database Analysis

BACKGROUND AND OBJECTIVE

Gonorrhea is a prevalent sexually transmitted illness caused by the bacteria Neisseria gonorrhoeae, leading to serious health consequences such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and increased susceptibility to HIV infection. Despite advancements in prevention and treatment, gonorrhea remains a significant public health problem in the United States (US) due to its widespread incidence, potential consequences, and the growth of antibiotic resistance. This study investigates the epidemiological trends and morbidity rates of gonorrhea using the Centers for Disease Control and Prevention's (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER) database. The aim is to identify temporal patterns, demographic characteristics, and notable changes in gonorrhea epidemiology to inform targeted therapies and interventions.

METHODS

The CDC WONDER database, which provides extensive national and state-level data on reported causes of death in the United States, was utilized for this study. We examined the developments in gonorrhea morbidity rates over time, identified demographic differences based on age, gender, and race/ethnicity, and analyzed the disease's regional distribution through a systematic analysis of the database. Aggregate data for selected time periods (1996-2014) were summarized using the morbidity rate per 100,000 people and the total number of cases across the years.

RESULTS

This database analysis identified a total of 6,454,097 individuals diagnosed with gonorrhea between 1996 and 2014. The calculated total morbidity rate during this period was 115.4 per 100,000 individuals. The highest morbidity rates were observed in the years 1999 (129.2 per 100,000 people), 1998 (129.1 per 100,000 people), and 2001 (126.8 per 100,000 people), respectively. The District of Columbia reported the highest morbidity rate (478.25 per 100,000 people). In males, the overall morbidity rate over the years was reported to be comparable to females (114 per 100,000 people and 116.3 per 100,000 people, respectively). The analysis revealed consistently higher morbidity rates among individuals aged between 19 and 24 years (525.2 per 100,000 people). Moreover, black or African American individuals consistently exhibited higher morbidity rates (506.1 per 100,000 people) compared to white individuals (16.1 per 100,000 people).

CONCLUSION

The analysis of gonorrhea cases between 1996 and 2014 revealed that the highest rates occurred during specific years, with a particular concentration observed in the District of Columbia. Additionally, certain demographic groups, such as individuals aged 19-24 and the black or African American population, consistently exhibited higher morbidity rates compared to others. These findings emphasize the importance of targeted interventions to address the observed temporal patterns and demographic disparities, in order to effectively combat the spread of gonorrhea.

Analysis and prediction of the incidence and prevalence trends of gonorrhea in China

To understand the epidemiological trend of gonorrhea in China from 2004 to 2021, predict the prevalence of the disease, and provide basic theory and data support for monitoring and managing gonorrhea. Gonorrhea incidence data in China from 2004 to 2021 were collected through the China Public Health Science Data Center and National Administration of Disease Prevention and Control, and the incidence and epidemiological characteristics were analyzed. Statistical analysis was performed using Joinpoint and autoregressive integrated moving average (ARIMA) models. A linear correlation model was used to analyze the correlation between gross domestic product (GDP) and the incidence rate. From 2004 to 2021, a total of 2,289,435 cases of gonorrhea were reported in China, with an average reported incidence rate of 9.46/100,000 people and a downward followed by an upward trend. Individuals with gonorrhea were primarily 20-30 y of age, with 1,034,847 cases (53.38%) from 2004 to 2018. The trend of increasing incidence was most obvious in the 10-20 age group (5,811 cases in 2004 to 12,752 cases in 2018, AAPC = 6.1, P < .001). The incidence of gonorrhea in China was negatively correlated with GDP from 2004 to 2021 (r = -0.547, P = .019). The correlation coefficient between the average incidence growth rate of each region from 2012 to 2018 and the average growth rate of regional GDP was 0.673 (P < .01). The root mean square error (RMSE) of the ARIMA model was 4.89%, showing powerful performance. There would be 97,910 gonorrhea cases in 2023 as predicted by the model.

Enhancing Insights into Australia's Gonococcal Surveillance Programme through Stochastic Modelling

Continued surveillance of antimicrobial resistance is critical as a feedback mechanism for the generation of concerted public health action. A characteristic of importance in evaluating disease surveillance systems is representativeness. Scenario tree modelling offers an approach to quantify system representativeness. This paper utilises the modelling approach to assess the Australian Gonococcal Surveillance Programme's representativeness as a case study. The model was built by identifying the sequence of events necessary for surveillance output generation through expert consultation and literature review. A scenario tree model was developed encompassing 16 dichotomous branches representing individual system sub-components. Key classifications included biological sex, clinical symptom status, and location of healthcare service access. The expected sensitivities for gonococcal detection and antibiotic status ascertainment were 0.624 (95% CI; 0.524, 0.736) and 0.144 (95% CI; 0.106, 0.189), respectively. Detection capacity of the system was observed to be high overall. The stochastic modelling approach has highlighted the need to consider differential risk factors such as sex, health-seeking behaviours, and clinical behaviour in sample generation. Actionable points generated by this study include modification of clinician behaviour and supplementary systems to achieve a greater contextual understanding of the surveillance data generation process.

Multisite transformation in Neisseria gonorrhoeae: insights on transformations mechanisms and new genetic modification protocols

Natural transformation, or the uptake of naked DNA from the external milieu by bacteria, holds a unique place in the history of biology. This is both the beginning of the realization of the correct chemical nature of genes and the first technical step to the molecular biology revolution that sees us today able to modify genomes almost at will. Yet the mechanistic understanding of bacterial transformation still presents many blind spots and many bacterial systems lag behind power horse model systems like Escherichia coli in terms of ease of genetic modification. Using Neisseria gonorrhoeae as a model system and using transformation with multiple DNA molecules, we tackle in this paper both some aspects of the mechanistic nature of bacterial transformation and the presentation of new molecular biology techniques for this organism. We show that similarly to what has been demonstrated in other naturally competent bacteria, Neisseria gonorrhoeae can incorporate, at the same time, different DNA molecules modifying DNA at different loci within its genome. In particular, co-transformation of a DNA molecule bearing an antibiotic selection cassette and another non-selected DNA piece can lead to the integration of both molecules in the genome while selecting only through the selective cassette at percentages above 70%. We also show that successive selections with two selection markers at the same genetic locus can drastically reduce the number of genetic markers needed to do multisite genetic modifications in Neisseria gonorrhoeae. Despite public health interest heightened with the recent rise in antibiotic resistance, the causative agent of gonorrhea still does not possess a plethora of molecular techniques. This paper will extend the techniques available to the Neisseria community while providing some insights into the mechanisms behind bacterial transformation in Neisseria gonorrhoeae. We are providing a suite of new techniques to quickly obtain modifications of genes and genomes in the Neisserial naturally competent bacteria.

Pay-it-forward gonorrhea and chlamydia testing among men who have sex with men and male STD patients in China: the PIONEER pragmatic, cluster randomized controlled trial protocol

BACKGROUND

Gonorrhea and chlamydia are the most common sexually transmitted diseases (STDs) among men who have sex with men (MSM) in China. Previous studies have shown pay-it-forward (PIF) interventions to be associated with a substantial increase in gonorrhea and chlamydia test uptake compared to standard-of-care. We propose a 'pay-it-forward' gonorrhea and chlamydia testing randomized controlled trial (PIONEER). The trial would evaluate the effectiveness of two pay-it-forward strategies in promoting testing uptake compared to the standard of care (in which men pay for their tests out-of-pocket) among MSM and male STD patients in China.

METHODS

PIONEER will be a three-armed, pragmatic cluster randomized controlled trial (RCT), conducted across 12 clinics (six MSM-led and six public STD clinics) to compare the effectiveness of three implementation strategies. Each facility will be randomized to a standard pay-it-forward intervention of gonorrhea/ chlamydia testing with minimal encouragement for testing, a community-engaged pay-it-forward arm, or a control arm where men pay for their tests out-of-pockets. The primary outcome will be dual gonorrhea/chlamydia test uptake. Secondary outcomes will include syphilis testing, amount donated in pay-it-forward, number of positive gonorrhea and chlamydia tests, and measures of antimicrobial resistance. A sequential transformative mixed methods design will be used to evaluate the implementation process in type 2 effectiveness-implementation hybrid design. Data sources will include survey on acceptability, and feelings and attitudes towards the interventions among participants; testing and treatment uptake data from clinic records, WeChat records, and qualitative data to gain insights into men's perceptions and attitudes towards the pay-it-forward, mechanisms driving uptake, and donating behaviors. Implementers and organizers will be interviewed about fidelity and adherence to protocol, sustainability of pay-it-forward intervention, and barriers and facilitators of implementing the intervention.

DISCUSSION

PIONEER will substantially increase gonorrhea/chlamydia testing among MSM in China, providing an innovative and new financial mechanism to sustain STD screening among sexual minorities in low- and middle-income countries. This study will answer compelling scientific questions about how best to implement pay-it-forward and the individual and organizational characteristics that moderate it.

TRIAL REGISTRATION

The study with identification number NCT05723263 has been registered on clinicaltrials.gov/.

Burden of Disease of Gonorrhoea in Latin America: Systematic Review and Meta-analysis

INTRODUCTION

Neisseria gonorrhoeae causes gonorrhoea, a globally neglected but increasing disease. This systematic review and meta-analysis reviewed the epidemiology and economic burden of gonorrhoea in Latin America and the Caribbean (LAC).

METHODS

We searched PubMed, EMBase, Cochrane Library, EconLIT, CINAHL, CRD, LILACS, Global Health, Global Dissertations and Theses, SciELO, Web of Science databases, countries' ministries of health, and the IHME's Global Burden of Disease databases. Studies published in the last 10 years (20 years for economic studies) were included if conducted in any LAC country, without language restrictions. The main outcome measures were incidence/prevalence, proportion of co-infections, case fatality rates, specific mortality/hospitalisation rates, direct/indirect costs, and impact of gonorrhoea on quality of life. To assess evidence quality, we used a checklist developed by the US National Heart, Lung, and Blood Institute for observational studies and trial control arms, the Cochrane Effective Practice Organization of Care Group tool for randomised controlled trials, and the CICERO checklist for economic studies.

RESULTS

We identified 1290 articles; 115 included epidemiological studies and one included an economic study. Ministry of health data from Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay were identified. Gonorrhoea prevalence was 1.46% (95% confidence interval [CI] 1.00-2.00%) from 48 studies and 5.68% (95% CI 4.23-7.32%) from 58 studies for non-high-risk and high-risk populations, respectively. Cumulative incidence for the high-risk population was 2.05 cases per 100 persons/year. Few published studies were rated as "good" in the risk of bias assessments. Variations in the methodology of the sources and limited information found in the countries' surveillance systems hinder the comparison of data.

CONCLUSION

The burden of gonorrhoea in LAC is not negligible. Our results provide public health and clinical decision support to assess potential interventions to prevent gonorrhoea.

TRIAL REGISTRATION

The protocol is registered on PROSPERO (CRD42021253342). The study was funded by GlaxoSmithKline Biologicals SA (GSK study identifier VEO-000025).

Development of Cas13a-based Assays for Neisseria gonorrhoeae Detection and Gyrase A Determination

Background

Neisseria gonorrhoeae is one of the most common bacterial sexually transmitted infections. The emergence of antimicrobial-resistant N. gonorrhoeae is an urgent public health threat. Currently, diagnosis of N. gonorrhoeae infection requires expensive laboratory infrastructure, while antimicrobial susceptibility determination requires bacterial culture, both of which are infeasible in low-resource areas where prevalence is highest. Recent advances in molecular diagnostics, such as Specific High-sensitivity Enzymatic Reporter unLOCKing (SHERLOCK) using CRISPR-Cas13a and isothermal amplification, have the potential to provide low-cost detection of pathogen and antimicrobial resistance.

Methods and Results

We designed and optimized RNA guides and primer-sets for SHERLOCK assays capable of detecting N. gonorrhoeae via the por A gene and of predicting ciprofloxacin susceptibility via a single mutation in the gyrase A ( gyr A) gene. We evaluated their performance using both synthetic DNA and purified N. gonorrhoeae isolates. For por A, we created both a fluorescence-based assay and lateral flow assay using a biotinylated FAM reporter. Both methods demonstrated sensitive detection of 14 N. gonorrhoeae isolates and no cross-reactivity with 3 non-gonococcal Neisseria isolates. For gyr A, we created a fluorescence-based assay that correctly distinguished between 20 purified N. gonorrhoeae isolates with phenotypic ciprofloxacin resistance and 3 with phenotypic susceptibility. We confirmed the gyr A genotype predictions from the fluorescence-based assay with DNA sequencing, which showed 100% concordance for the isolates studied.

Conclusion

We report the development of Cas13a-based SHERLOCK assays that detect N. gonorrhoeae and differentiate ciprofloxacin-resistant isolates from ciprofloxacin-susceptible isolates.

Reverse vaccinology approaches to introduce promising immunogenic and drug targets against antibiotic-resistant Neisseria gonorrhoeae: Thinking outside the box in current prevention and treatment

Gonorrhea is an urgent antimicrobial resistance threat and its therapeutic options are continuously getting restricted. Moreover, no vaccine has been approved against it so far. Hence, the present study aimed to introduce novel immunogenic and drug targets against antibiotic-resistant Neisseria gonorrhoeae strains. In the first step, the core proteins of 79 complete genomes of N. gonorrhoeae were retrieved. Next, the surface-exposed proteins were evaluated from different aspects such as antigenicity, allergenicity, conservancy, and B-cell and T-cell epitopes to introduce promising immunogenic candidates. Then, the interactions with human Toll-like receptors (TLR-1, 2, and 4), and immunoreactivity to elicit humoral and cellular immune responses were simulated. On the other hand, to identify novel broad-spectrum drug targets, the cytoplasmic and essential proteins were detected. Then, the N. gonorrhoeae metabolome-specific proteins were compared to the drug targets of the DrugBank, and novel drug targets were retrieved. Finally, the protein data bank (PDB) file availability and prevalence among the ESKAPE group and common sexually transmitted infection (STI) agents were assessed. Our analyses resulted in the recognition of ten novel and putative immunogenic targets including murein transglycosylase A, PBP1A, Opa, NlpD, Azurin, MtrE, RmpM, LptD, NspA, and TamA. Moreover, four potential and broad-spectrum drug targets were identified including UMP kinase, GlyQ, HU family DNA-binding protein, and IF-1. Some of the shortlisted immunogenic and drug targets have confirmed roles in adhesion, immune evasion, and antibiotic resistance that can induce bactericidal antibodies. Other immunogenic and drug targets might be associated with the virulence of N. gonorrhoeae as well. Thus, further experimental studies and site-directed mutations are recommended to investigate the role of potential vaccine and drug targets in the pathogenesis of N. gonorrhoeae.

Integrated microscale immiscible phase extraction and isothermal amplification for colorimetric detection of Neisseria gonorrhoeae

Gonorrhea is the second most common sexually transmitted infection (STI) with around 87 million cases worldwide estimated in 2016 by the World Health Organization. With over half of the cases being asymptomatic, potential life-threatening complications and increasing numbers of drug-resistant strains, routine monitoring of prevalence and incidence of infections are key preventive measures. Whilst gold standard qPCR tests have excellent accuracy, they are neither affordable nor accessible in low-resource settings. In this study, we developed a lab-on-a-chip platform based on microscale immiscible filtration to extract, concentrate and purify Neisseria gonorrhoeae DNA with an integrated detection assay based on colorimetric isothermal amplification. The platform was capable of detecting as low as 500 copies/mL from spiked synthetic urine and showed no cross-reactivity when challenged with DNAs from other common STIs. The credit card-size device allows DNA extraction and purification without power or centrifuges, and the detection reaction only needs a low-tech block heater, providing a straightforward and visual positive/negative result within 1 h. These advantages offer great potential for accurate, affordable and accessible monitoring of gonorrhea infection in resource-poor settings.

Rapid Molecular Phenotypic Antimicrobial Susceptibility Test for Neisseria gonorrhoeae Based on Propidium Monoazide Viability PCR

Neisseria gonorrhoeae (NG) is an urgent threat to antimicrobial resistance (AMR) worldwide. NG has acquired rapid resistance to all previously recommended treatments, leaving ceftriaxone monotherapy as the first and last line of therapy for uncomplicated NG. The ability to rapidly determine susceptibility, which is currently nonexistent for NG, has been proposed as a strategy to preserve ceftriaxone by using alternative treatments. Herein, we used a DNA-intercalating dye in combination with NG-specific primers/probes to generate qPCR cycle threshold (Ct) values at different concentrations of 2 NG-relevant antimicrobials. Our proof-of-concept dual-antimicrobial logistic regression model based on the differential Ct measurements achieved an AUC of 0.93 with a categorical agreement for the susceptibility of 84.6%. When surveying the performance against each antimicrobial separately, the model predicted 90 and 75% susceptible and resistant strains, respectively, to ceftriaxone and 66.7 and 83.3% susceptible and resistant strains, respectively, to ciprofloxacin. We further validated the model against the individual replicates and determined the accuracy of the model in classifying susceptibility agnostic of the inoculum size. We demonstrated a novel PCR-based approach to determine phenotypic ciprofloxacin and ceftriaxone susceptibility information for NG with reasonable accuracy within 30 min, a significant improvement compared to the conventional method which could take multiple days.

Epidemiology and antimicrobial resistance profile of Neisseria gonorrhoeae in Catalonia, Spain, 2016-2019

Antimicrobial resistance data for Neisseria gonorrhoeae is globally sparse and resistant strains are emerging in Catalonia. We aim to describe epidemiological and antimicrobial resistance in all patients infected with N. gonorrhoeae during the period from 2016 to 2019, using available antimicrobial susceptibility data. We retrospectively analysed confirmed N. gonorrhoeae cases notified to Catalonia's microbiological reporting system. Antibiotic susceptibility testing (azithromycin, cefixime, ceftriaxone, ciprofloxacin, penicillin, spectinomycin, and tetracycline) was assessed using clinical breakpoints published by the European Committee on Antimicrobial Susceptibility Testing. Incidence rates were calculated and proportions were compared using the χ² test or Fisher's exact test, and analysed using the Statistical Package for Social Sciences (SPSS 18.0). A total of 14,251 confirmed cases of N. gonorrhoeae were notified. Incidence increased from 30.7 cases/100,000 person-years (p < 0.001) in 2016 to 64.7 in 2019. Culture was available in 6,292 isolates (44.2%), of which 5,377 (85.5%) were resistant to at least one of the antibiotics tested. Azithromycin resistance rose from 6.1% in 2016 to 16% in 2019 (p < 0.001). Only 1.0% (45 cases) were resistant to ceftriaxone. Multidrug-resistant N. gonorrhoeae increased from 0.25% in 2016 to 0.42% in 2019 (p = 0.521). One case presented extensively drug-resistant N. gonorrhoeae. In Catalonia, 10% of the N. gonorrhoeae isolates were resistant to azithromycin in the 2016-2019 period. According to World Health Organization guidelines, resistance above 5% indicates an alert to review treatment guidelines. Antimicrobial susceptibility testing in clinical practice followed by surveillance and interventions are essential to monitor trends and prevent the spread of antimicrobial resistance.

Assortative Sexual Mixing by Age, Region of Birth, and Time of Arrival in Male-Female Partnerships in Melbourne, Australia

BACKGROUND

Patterns of sexual mixing may be influenced by demographic factors where individuals show a preference for partners with particular traits and may have different levels of risk for HIV and sexually transmitted infection transmission. We aimed to explore age differences and mixing by region of birth among male-female partnerships.

METHODS

Male-female partnerships who presented to Melbourne Sexual Health Centre in Australia between 2015 and 2019 were investigated. Age and country of birth of sexual partners were collected. We calculated the age differences between partners and created tables demonstrating partnership mixing by age groups and by international region of birth.

RESULTS

A total of 2112 male-female partnerships (i.e., 4224 individuals) were included. The median age was 27 years (interquartile range, 23-31 years). Between men and women in partnerships, the median age difference was 1 year. Nearly half of all individuals (49.1% [2072 of 4224]) were in a partnership with another individual in the same 5-year interval age group as their own, and a majority of individuals (58.5% [2334 of 3988]) were in a partnership with another individual from the same region of birth when compared with other regions.

CONCLUSIONS

There is a strong assortative sexual mixing pattern by age and region of birth among male-female partnerships in Melbourne, Australia. These results may have applications in further research to understand sexually transmitted infection transmission among clients attending sexual health centers, particularly those born overseas.

Alarming incidence of reinfections after treatment for Chlamydia trachomatis and gonorrhoea: Can we predict and prevent them?

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are a public health problem, worsened by frequent reinfections, whose incidence rate is not known in Spain. The objective of this study is to estimate in patients diagnosed with NG, CT or mixed infection (NG and CT): (1) the incidence of reinfections by the same microorganism, (2) the total incidence of Sexually Transmitted Infections (STI), both by the same microorganism and by infections other than the initial one, and (3) to identify predictors of reinfection.

METHODS

Observational prospective case series involving 986 patients with CT and/or NG at specialized STI clinics in Biscay (Spain) between 2016 and 2019.

RESULTS

The six month cumulative incidence of reinfection by the same microorganism was 17.24% (CI95%: 14.9-19.7) and 24.65% (CI95%: 21.9-27.4) for any STI (reinfection or other). Being an immigrant (OR=1.8; CI95%: 1.3-2.6), men who have sex with men (OR=1.8; CI95%: 1.3-2.6), number of sexual partners (OR=4.3; CI95%: 2.7-6.8 for more than 5 partners), having a new partner (OR=1.7; CI95%: 1.08-2.6), not always using a condom (OR=1.4; CI95%: 1.02-1.9) and consumption of alcohol prior to sex (OR=3.8; CI95%: 1.5-9.5) were associated with reinfection by any STI.

CONCLUSION

These characteristics allow doctors to identify patients in whom to prioritize short-term rescreening for repeated infections with any STIs after initial treatment for NG or CT.

Bacterial Lesions of the Oral Mucosa

Nonodontogenic bacterial infections of the oral cavity are not a common finding in the United States. Nevertheless, there has been an increase in prevalence of certain bacterial sexually transmitted diseases, such as syphilis and gonorrhea, and conditions such as tuberculosis still pose a serious threat to certain segments of the population. Finally, given the uncommon nature and pathophysiology of these diseases, diagnosis is often delayed, resulting in more clinically significant disease and potential contamination of individuals. Thus, it is prudent that clinicians be familiar with these uncommon but potentially serious infectious diseases, so treatment can be instituted promptly.

Characteristics of Reported Gonorrhea Diagnoses During The COVID-19 Pandemic Compared With Pre-COVID-19 Pandemic, Baltimore City, Maryland

BACKGROUND

Sexual health service disruptions due to COVID-19 mitigation measures may have decreased gonorrhea screening and biased case-ascertainment toward symptomatic individuals. We assessed changes in reported symptoms and other characteristics among reported gonorrhea cases during pandemic versus prepandemic periods in 1 city with persistent gonorrhea transmission.

METHODS

Enhanced surveillance data collected on a random sample of gonorrhea cases reported to the Baltimore City Health Department between March 2018 and September 2021 was used. Logistic regression assessed differences in case characteristics by diagnosis period (during pandemic: March 2020-September 2021; prepandemic: March 2018-September 2019).

RESULTS

Analyses included 2750 (1090 during pandemic, 1660 prepandemic) gonorrhea cases, representing 11,904 reported cases. During pandemic versus prepandemic, proportionally fewer cases were reported by sexual health clinics (8.8% vs 23.2%), and more frequently reported by emergency departments/urgent care centers (23.3% vs 11.9%). Adjusting for diagnosing provider, fewer cases who were men with urethral infections (adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI], 0.55-0.77), aged <18 years (aOR, 0.64; 95% CI, 0.47-0.89), and women (aOR, 0.84; 95% CI, 0.71-0.99) were reported, and cases with insurance (aOR, 1.85; 95% CI, 1.40-2.45), living with human immunodeficiency virus (aOR, 1.43; 95% CI, 1.12-1.83), or recent (≤12 months) gonorrhea history (aOR, 1.25; 95% CI, 1.02-1.53) were more frequently reported during pandemic versus prepandemic. Reported symptoms and same-day/empiric treatment did not differ across periods.

CONCLUSIONS

We observed no changes in reported symptoms among cases diagnosed during pandemic versus prepandemic. Increased frequency of reported diagnoses who were insured, living with human immunodeficiency virus, or with recent gonorrhea history are suggestive of differences in care access and care-seeking behaviors among populations with high gonorrhea transmission during the pandemic.