By Yifan Ding and Thomas MacDougall

Introduction

In April 2019, New Brunswick chief medical officer Dr. Jennifer Russell declared a provincial gonorrhea outbreak due to the steep increase of gonorrhea cases reported in the province. From 2013 to 2017, the average number of gonorrhea cases in New Brunswick was 54 annually. However, the number of cases in 2018 rose to 96; almost two times the average of the past 5 years. In addition to the spike in 2018, another 20 cases were reported in the first quarter of 2019 compared to the  previous 5 year average of 12 reported first quarter cases. Most patients are aged between 20 to 39 and reports of the disease are evenly distributed throughout the province.

Gonorrhea

Gonorrhea is a sexually transmitted infection (STI) caused by a bacterium called Neisseria gonorrhoeae. Not everyone infected with the bacterium will show symptoms, but those who do will commonly experience pain or a burning sensation while urinating. Between the sexes, women are more prone to being asymptomatic than men. Symptoms in women may include vaginal discharge, pelvic pain, and vaginal bleeding outside of regular periods, and men may experience testicular pain and creamy discharge from the penis. Like many other STIs, gonorrhea can be acquired by having vaginal, anal, or oral sex with an infected individual. Men and women aged 20 to 39 report the most instances of the disease of any age group. If not treated, severe cases may lead to infertility, and pregnant women carrying the disease may transfer it to their child at birth.

Figure 1: Visualization of a Neisseria gonorrhoeae cell. Source: Centers of Disease Control and Prevention. Gonorrhea. Last reviewed September 28th, 2017. https://www.cdc.gov/std/gonorrhea/default.htm (accessed 12 November 2019)

Source of the outbreak

Increasing antibiotic resistance in bacteria has played a role in the outbreak. It’s possible that an individual received treatment but the bacterial strain that they carried was resistant to the antibiotics, and without follow-up testing that person may not have confirmed that they were cured. The recent circulating strains of gonorrhea have shown resistance to all of the common antibiotics in Canada, including penicillins, macrolides, quinolones and tetracyclines. This resistance to antibiotics results in ineffective treatment and more difficulty in curing the infection. Ineffective treatments result in more severe infections and increase the transmission of resistant bacteria strains. A lax opinion in sexually active individuals about taking the time to get checked for STIs once a year is likely to have been a driving factor in the spread of the disease throughout the province, as early diagnosis and treatment of the disease is vital in reducing its ability to resist antibiotics.

Figure 2: History of antibiotic use in order to treat Gonorrhea. Source: Centers for Disease Control and Protection. Latest data on Antibiotic Resistant Gonorrhea. 2016.  https://www.cdc.gov/nchhstp/newsroom/2016/data-on-antibiotic-resistant-gonorrhea.html

Cause of the outbreak

The uptick in transmission from the popularity of dating apps will be the cause of the outbreak. In 2017, Cabecinha et al. conducted a research on the relationship between dating apps and STIs, their research showed that using dating apps to find sexual partners was strongly associated with sexual risk, increasing the probability of getting infected. Social media and dating apps are widely used among young adults in New Brunswick and the rest of Canada. These dating apps enable their users to communicate quickly to arrange anonymous sexual encounters. In most cases, individuals are not familiar with their sexual partners and do not know if their sexual partners are healthy or not because many people with gonorrhea may not show any symptoms. With accessible forms of contraception such as birth control or IUDs (intrauterine devices), many sexual encounters happen without protection, enabling the transmission of the disease by individuals not showing symptoms. Partners not knowing and disclosing their sexual health allows the bacteria to spread freely.

Measures taken to end the outbreak

The Office of Public Health has put out advertisements on dating apps and social media  in an attempt to spread awareness about the outbreak and to encourage the use of protection during sex. Practicing safe sex is the most useful way to prevent spreading of sexually transmitted infection like gonorrhea. The easiest and most effective method is to use condoms. Knowing about the health condition of the sexual partners is also important to not get infected by gonorrhea. It is recommended that people should have their regular sexual partners instead of anonymous sexual partners, ensuring that both are safe. People should also talk to their partners about their sexually transmitted infection status and the use of protection.

As not everyone who is infected with gonorrhea shows symptoms, the Chief Medical Officer recommends sexually active individuals to go to see a doctor or a public health office to get tested at least once per year.  A simple urine sample or swab test is helpful in diagnosing the disease. It is important for those concerned they might be infected to consult a doctor for treatment and adhere to any follow-up recommendations, as improper use of antibiotics can accelerate the spread of antibiotic resistance.

Aftermath

As of November 15 2019, the outbreak has yet to have been officially declared over. The persistable nature of gonorrhea makes it very difficult and unlikely for it to be completely eliminated from the province. As there is yet no publicly available vaccine for gonorrhea, the Office of Public Health may only continue to educate and offer treatment to the public in hopes of stemming the spread of the infection and reducing infection rates back to historical averages. 

References:

New Brunswick Office of Public Health. April 26 2019. Gonorrhea on the rise in New Brunswick. https://www2.gnb.ca/content/gnb/en/departments/health/news/news_release.2019.04.0252.html (Accessed 11 November 2019)

Ashleigh R Tuite, Thomas L Gift, Harrell W Chesson, Katherine Hsu, Joshua A Salomon, Yonatan H Grad, Impact of Rapid Susceptibility Testing and Antibiotic Selection Strategy on the Emergence and Spread of Antibiotic Resistance in Gonorrhea, The Journal of Infectious Diseases, Volume 216, Issue 9, 1 November 2017, Pages 1141–1149, https://doi.org/10.1093/infdis/jix450

Choudhri Y, Miller J, Sandhu J, Leon A, Aho J. Gonorrhea in Canada, 2010-2015. Canada Communicable Disease Report, Volume 44, Issue 2, 1 February 2018, Pages 37-42, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5933854/

Mackenzie K, Morgan MD, Catherine F, Decker MD. Gonorrhea. Disease-a-Month, Volume 62, Issue 8, August 2016, Pages 260-268. https://doi.org/10.1016/j.disamonth.2016.03.009

Cabecinha M, Mercer CH, Gravningen K, Aicken C, Johns KG, Tanton C, Wellings K, Sonnenberg P, Field N. Finding sexual partner online: prevalence and associations with sexual behaviour, STI diagnoses and other sexual health outcomes in the British population. 2017. Sexual transmitted infection, Volume 93, Issue 8, 10 April 2017, Pages 572-582. doi: 10.1136/sextrans-2016-052994