At least three people in three different countries have emerged with cases of completely incurable gonorrhea — and it’s unclear what happened to any of them, or whether they spread the infection to others, World Health Organization officials report.
These cases highlight two major concerns about gonorrhea: one is that last-line drug resistance is emerging alarmingly around the world and appears to be on the rise; and the second is we have poor oversight and data on this.
In two reports PLOS medicinethe WHO warned of the dangers of drug-resistant gonorrhea infections, which can cause infertility and increase the risk of contracting other infections in untreated patients. Summarizing the most recent surveillance data, WHO researchers noted that there is an incidence of drug-resistant infections worldwide and announced that they are on the rise. While the data is concerning, it doesn’t show international increases because there simply isn’t enough data to do so.
The reports include spotty and cumulative data from 77 of the world’s approximately 195 countries that provided data for at least one year between 2009 and 2014. WHO’s main data analysis focused on whether certain types of drug resistance occurred at least once in that whole. time span. Important conclusions are, for example: 66 percent of the reporting countries have seen at least one case of gonorrhea with some degree of resistance to cephalosporin antibiotics during that period. (Those cephalosporins include oral cefixime and injectable ceftriaxone.) And about 81 percent of reporting countries saw at least one strain with resistance or reduced susceptibility to oral azithromycin.
These are statistics because the most recent recommended treatment for gonorrhea is a combination of azithromycin and the cephalosporin ceftriaxone. And these are last-line antibiotics. Gonorrhea has already proven too resistant to other antibiotics, including penicillin, tetracycline, and ciprofloxacin.
Still, just because a drug-resistant strain has appeared somewhere, perhaps in just a year’s worth of data, doesn’t mean it’s widespread. And these data are not enough to discern the changing prevalence of drug-resistant infections in many of those reporting countries. The WHO has provided maps of some of the most recent prevalence figures. But the graphs represented data from a mix of years (from 2011 to 2014) because many countries report data inconsistently.
Without year-by-year breakdowns, there’s no way to identify trends. Overall, the data does not show if, where or at what rate drug resistance is increasing. And this problem of incomplete data doesn’t seem to be improving either. While the organization had collected data from a total of 77 countries between 2009 and 2014, the number of countries reporting data each year declined over that period, from 56 countries reporting in 2009 to 52 in 2014.
In a conference call with reporters, WHO officials admitted they simply don’t have the data they need to assess the magnitude of the problem. High-income countries with solid oversight can act as a barometer of global gonorrhea trends, the officials noted. But many countries believed to have the highest rates of gonorrhea infections and drug resistance, including many in Africa, reported no data at all to the organization.
The data we have is probably “the tip of the iceberg,” according to Dr. Teodora Wi, medical officer in human reproduction at WHO and first author of one of the new reports.
Dr. Wi emphasized that, despite the lack of data, we have every reason to suspect that drug-resistant gonorrhea is indeed emerging and is a critical problem. Gonorrhea is caused by Neisseria gonorrhea bacteria, which can infect the genitals, rectum, and throat. N. gonorrhea affects an estimated 78 million people worldwide each year, and the number of infections is increasing in many countries. Yet many infections go undetected and the bacteria can easily develop resistance.
Even in high-income countries with relatively good data and health care, public health officials have seen an increase in gonorrhea cases and drug resistance among those cases. For example, the Centers for Disease Control and Prevention reported last year that the prevalence of azithromycin-resistant cases of gonorrhea in the U.S. increased from 0.6 percent in 2000 to 2.5 percent in 2014. For ceftriaxone, the prevalence of resistance ranged from 0 .1 percent in 2000 to the peak of 0.4 percent in 2011 and 0.2 percent in 2014. But in 2015, the agency noted a 13 percent increase in the prevalence of gonorrhea, which infected about 395,000 people that year.
The three countries that reported completely untreatable infections were also high-income countries: France, Spain and Japan. And some countries have already started increasing recommended doses of the combination therapy to counter rising resistance, Wi noted. This strategy may work for a while, she said, but at some point even high doses will stop being effective.
Moreover, if things are worse in high-income countries, Dr. Wi reasoned, they are undoubtedly grittier in low-income countries that have higher rates of infection. “We need to be more vigilant,” she said. Without changes, she expects untreatable infections to become commonplace within a few years.
While the factors driving the increase in infections and drug resistance vary in different places, the common problems include declining condom use, people not completing their course of antibiotics (which can lead to resistance), increased urbanization, poor detection of infections and travel around the world.
Along with the data, WHO outlined steps countries can take to address these issues, particularly improving surveillance, public awareness and diagnostics. The WHO is also working with a non-profit organization to promote the development of new medicines. Three drugs for gonorrhea infections are currently in various stages of clinical trials.
PLOS medicine2017. DOI:10.1371/journal.pmed.1002344 (About DOIs).