Gonorrhoea in women and exposure to risk.

Data are presented on the characteristics of women with newly diagnosed gonorrhoea who attended Lydia Clinic, St. Thomas' Hospital, during a 6-month period. Although gonorrhoea in women is largely asymptomatic, there was strong circumstantial evidence to suggest that some women had attended because they had been exposed to risk. The proportion of women thus motivated was largest among those women who had attended a clinic for sexually transmitted diseases before--in which up to 40 per cent. of women had apparently attended entirely of their own accord. Women born in the West Indies differed from their counterparts born in the United Kingdom in three respects: they were younger, recorded fewer contacts, and referred themselves less frequently to the clinic for a first visit. Implications for health education and for future research are discussed.     

Reappraisal of Gram-staining and cultural techniques for the diagnosis of gonorrhoea in women.

A retrospective study of 209 consecutive cases of gonorrhoea showed that more than 98 per cent. of cases were detected by two sets of examinations at weekly intervals. This was compared with earlier results obtained at this clinic when only 86 per cent. of cases were detected by two examinations. It is believed that modifications in culture techniques were responsible for the improvement and that two tests are now sufficient to screen for gonococcal infection in the majority of patients when an efficient microbiological service is available. Because of the high incidence of infection in contacts of men with gonorrhoea, a third test is recommended for the small number of such patients who have negative results of their first two tests. This also serves to monitor the efficiency of the culture techniques. The majority of women with gonorrhoea attended because they were believed to be contacts of men with the disease but many attended of their own accord because they had symptoms. Mild symptoms were described by as many as 53-5 per cent. of all infected women. Nine cases of gonorrhoea were detected during the follow-up period. Three of the four cases which were thought to be due to treatment failure were detected at the first test, in contrast to the cases which were thought to be due to re-infection, the majority of which were diagnosed at subsequent tests. Constant surveillance of the accuracy of the diagnostic methods used in the detection of gonorrhoea in women is of great importance if errors are to be reduced to a minimum.     

Reappraisal of Gram-staining and cultural techniques for the diagnosis of gonorrhoea in women.

A retrospective study of 209 consecutive cases of gonorrhoea showed that more than 98 per cent. of cases were detected by two sets of examinations at weekly intervals. This was compared with earlier results obtained at this clinic when only 86 per cent. of cases were detected by two examinations. It is believed that modifications in culture techniques were responsible for the improvement and that two tests are now sufficient to screen for gonococcal infection in the majority of patients when an efficient microbiological service is available. Because of the high incidence of infection in contacts of men with gonorrhoea, a third test is recommended for the small number of such patients who have negative results of their first two tests. This also serves to monitor the efficiency of the culture techniques. The majority of women with gonorrhoea attended because they were believed to be contacts of men with the disease but many attended of their own accord because they had symptoms. Mild symptoms were described by as many as 53-5 per cent. of all infected women. Nine cases of gonorrhoea were detected during the follow-up period. Three of the four cases which were thought to be due to treatment failure were detected at the first test, in contrast to the cases which were thought to be due to re-infection, the majority of which were diagnosed at subsequent tests. Constant surveillance of the accuracy of the diagnostic methods used in the detection of gonorrhoea in women is of great importance if errors are to be reduced to a minimum.     

Gonorrhoea in 1972. A 1-year study of patients attending the VD Unit in Uppsala.

During 1972 a total of 2,090 men and 1,489 women were seen in the VD clinic in Uppsala, Sweden. The most frequent diagnosis among the men was non-gonococcal urethritis (38 per cent.) and among the women non-gonococcal vaginitis (34 per cent.), N. gonorrhoeae was found in 22 per cent. of the men and in 33 per cent. of the women, 68 per cent. of the men with gonorrhoea attended because of symptoms, but 67 per cent. of the men without gonococcal infections came for the same reason. 39 per cent. of the women with gonorrhoea attended after being told by their sexual partner; it was found that women coming because of symptoms were most likely to have non-gonococcal infection. Gonorrhoea without subjective symptoms was found in 23 per cent. of the men and 50 per cent. of the women. Gonorrhoea was found in association with scabies in 9 out of 18 men and in 3 out of 5 women. A rising incidence of pharyngeal gonococcal infections has been noticed at the clinic and the figures for 1972 were 6 per cent. of the men and 9 per cnet. of the women with gonorrhoea. The route of infection was usually oro-genital contact, but in some cases other routes had to be considered. It was not possible to define a promiscuous group of patients suitable for a planned study of prophylactic treatment, as only 2 per cent. of the men and 1 per cent. of the women had had nore than one gonococcal infection during the preceding year. The standard treatment for genital gonorrhoea (ampicillin 2 times 1 g. orally with a 5-hour interval) was very satisfactory and gave a 98 per cent. cure rate. This was possible because there were few gonococcal strains with decreased panicillin sensitivity. There were considerable problems in treating the pharyngeal infections, the standard treatment failing in 61 per cent.     

Seroepidemiological study of gonorrhoea in Ethiopian women. 1. Prevalence and clinical significance.

OBJECTIVE--To measure the prevalence of gonorrhoea in Ethiopian women attending gynaecologic, obstetric and family planning clinics: to determine the reliability of patient self history of sexually transmitted disease (STD); to correlate the serological diagnosis of gonorrhoea with clinical evidence of pelvic infection in order to define a reliable clinical diagnosis of gonorrhoea in a country where pelvic inflammatory disease is very common but where routine laboratory culture and serological tests for gonorrhoea are unavailable. SUBJECTS--1851 Ethiopian women: 50% symptomatic, 50% asymptomatic. SETTING--Gynaecological outpatient department, antenatal, postnatal and family planning clinics (Ethiopian Family Guidance Association (EFGA)), in two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia. METHODS--The indirect haemagglutination test with gonococcal pilus antigen as an epidemiological tool was used in a cross-section study to screen 1851 sera for evidence of past or current gonococcal infection. The gonococcal antibody test (GAT) seropositivity was correlated with patient's history of STD, age, clinic attended and the clinical evidence of infection in "gonococcal target organs" urethra, salpinges or Bartholin glands. RESULTS--Fifty nine per cent of the study group were seropositive for the gonococcal antibody test, 22% with titres greater than or equal to 1/320, indicative of current, recent or recurrent infection. Seropositivity indicating past or present gonococcal infection was highest in those who gave a history of having had treated syphilis (85%), in women aged 40-49 (72%), and family planning attenders (EFGA) (66%) of whom 31% had titres greater than or equal to 1/320. Fifty per cent had clinical evidence of past or present infection in the urethra, salpinges or Bartholin glands. Gonococcal antibodies were present in 54% of women with no evidence of clinical infection, compared with 91% of those with pyosalpinx and 86% of those with triple infection of urethra, salpinges and Bartholin glands. CONCLUSION--The high prevalence of gonococcal antibodies in Ethiopian women, especially in asymptomatic clinic attenders must be of concern for all health workers especially those in gynaecology and obstetrics and the related disciplines of family planning and neonatal paediatrics. While seropositivity was highest in those giving a past history of syphilis, the patient's history of STD was unreliable, as of those who denied having any history of STD, fifty per cent were GAT seropositive. Despite a high correlation between GAT seropositivity with pyosalpinx and clinical evidence of infection in urethra, salpinges and bartholin glands, gonococcal antibodies were present in 54% of women with no clinical evidence of infection. Thus we were unable to define a diagnostic clinical picture of gonorrhoea in Ethiopian women.     

Sexually, transmitted disease in clinic patients in Salisbury, Zimbabwe

During the three months between December 1979 and February 1980, 2867 patients attended a sexually transmitted diseases clinic. Of the 929 (32.4%) patients examined and interviewed clinical and laboratory finding showed that chancroid was the commonest disease (38.4%) and gonorrhoea almost as common (35.3%) in men. Pelvic inflammatory disease was the commonest disease (47.0%) and gonorrhoea the next commonest (22.7%) in women.     

Sexually, transmitted disease in clinic patients in Salisbury, Zimbabwe.

During the three months between December 1979 and February 1980, 2867 patients attended a sexually transmitted diseases clinic. Of the 929 (32.4%) patients examined and interviewed clinical and laboratory finding showed that chancroid was the commonest disease (38.4%) and gonorrhoea almost as common (35.3%) in men. Pelvic inflammatory disease was the commonest disease (47.0%) and gonorrhoea the next commonest (22.7%) in women.     

Identification of chlamydia and gonorrhoea among women in rural Haiti: maximising access to treatment in a resource poor setting

OBJECTIVE: To develop a risk assessment algorithm that will increase the identification and treatment of women with cervical infection in rural Haiti. METHODS: Study participants were randomly selected from new patients who accessed services at a women's health clinic in rural Haiti between June 1999 and December 2002. This case-control study included women who tested positive for chlamydia and/or gonorrhoea based on the Gen-Probe PACE 2 laboratory test as cases. Controls were women who tested negative for both of these infections. RESULTS: Women from this area of rural Haiti had a limited level of education and lived in impoverished housing conditions. The sensitivity estimates of Haitian Ministry of Health and WHO algorithms for detecting chlamydia and/or gonorrhoea were generally low (ranging from 16.1% to 68.1%) in this population. Risk scores based on logistic regression models of local risk factors for chlamydia and gonorrhoea were developed and sensitivity estimates were higher for algorithms based on these risk scores (up to 98.8%); however, specificity was compromised. CONCLUSIONS: A risk assessment algorithm to identify women with chlamydia and/or gonorrhoea is more sensitive and less specific than the syndromic management approach advocated by WHO and adapted by the Haitian Ministry of Health. Using a risk assessment tool with high sensitivity based on local risk factors of cervical infection will maximise access to care, improve outcomes, and decrease morbidity in women who have cervical infection in rural Haiti.     

Outpatient follow-up in women with HIV infection in Parkside Health Authority (UK).

OBJECTIVE--To describe patterns of attendance for follow-up among HIV infected women in Parkside, UK and their correlates. DESIGN--Retrospective cohort study. SUBJECTS--103 HIV infected women. MAIN OUTCOME MEASURES--Whether patients attended for follow-up between three and 18 months. RESULTS--31% of women were married and 46% had children. Women born in sub-Saharan Africa were significantly less likely to attend for follow-up after three months (56%) than women born in other areas who had acquired HIV either heterosexually (82%) or through injecting drug use (81%). This pattern persisted on multivariate analysis controlling for whether women were symptomatic, had had a previous positive test, were married or had children. CONCLUSIONS--HIV positive sub-Saharan African women are less likely to reattend for follow-up than women with heterosexually acquired HIV from other areas or those who acquired infection through intravenous drug use. Further studies are needed to identify barriers to follow-up for women and to shape the development of more appropriate and accessible services for HIV infected women, especially those of sub-Saharan African origin.     

Some factors affecting the incubation period and duration of symptoms of urethritis in men.

In a retrospective study of clinic records containing accurate information on the dates of infection and onset of symptoms, the mean (+/- SEM) incubation period of gonorrhea in men was 6.2 +/- 3.8 days and the mean duration of symptoms (3.1 +/- 2.3 days. For non-specific urethritis the mean (+/- SEM) figures were 7.7 +/- 4.1 and 4.0 +/- 3.4 days respectively; both were significantly longer than for gonorrhoea. Patients with a first episode of urethritis had longer than average incubation periods and duration of symptoms. Past experience of urethritis shortened the duration of symptoms; this was more significant in gonorrhoeae than in non-specific urethritis. "Anxious" men who had attended previously of their own accord when no abnormality had been found had the shortest times. The most notable factor in determining the interval between infection and attendance, however, was whether or not the sexual contact was known. Infections by known contacts were associated with prolonged duration of symptoms which negated the benefit of past experience and, to some extent, of anxiety. Thus, patients should be made more generally aware that known contacts may be a source of infection, especially after a break in a relationship, and that they should return to the clinic as soon as symptoms develop. Furthermore, doctors should examine carefully even the most persistently "neurotic" patients, because they may eventually become infected.     

Prevalence of cervical gonorrhoea in women with unwanted pregnancies.

Cervical specimens were collected from 1688 women attending a gynaecological clinic for induced abortion between February and December 1978. Thirteen (0.77%) women had positive culture results for Neisseria gonorrhoeae. Among those women who had a completed family or who came from outside Rotterdam or from outside the neighboring Rijnmond area, the isolation rate was very low. None of the women with positive culture results developed salpingitis after abortion; all of them had been treated prophylactically with tetracycline. No reasons appear to exist for considering women who seek abortions to be in a high-risk group for cervical gonorrhoea. Whether or not antibiotic prophylaxis should be given for the prevention of salpingitis following abortion requires further study of potentially pathogenic micro-organisms inhabiting the vagina and cervix for women applying for abortion.     

Cervical cytology in genital infection.

Papanicolaou-stained cervical smears taken from 203 female patients with either gonorrhoea, trichomoniasis, or candidosis were examined for the degree of inflammatory change. The results from these patients were compared with the results of smears taken from women who had no evidence of sexually-acquired infection after full assessment in the clinic. Gonorrhoea and trichomoniasis were associated with inflammatory changes but these were less marked in patients with candidosis. It is concluded that, before cytological inflammatory changes are attributed to non-specific genital infection, it is important to exclude gonorrhoea, trichomoniasis, and, to a lesser extent, candidosis.     

Serological diagnosis of gonorrhoea by an enzyme-linked immunosorbent assay (Elisa).

IgG antibody to an outer membrane protein extracted from Neisseria gonorrhoeae was measured in patients with gonorrhoea. The level in such patients was significantly higher than in normal controls or in patients with other conditions who were attending the clinic for sexually transmitted diseases. Significantly higher antibody levels were detectable in half the patients within a few days of infection and in a similar proportion of carriers--both male and female. Men with rectal gonorrhoea had particularly high antibody levels. Sixteen per cent of presumptively normal men and 11% of normal women gave positive results but the actual false positive rate could be lower.     

Cervical cytology in genital infection.

Papanicolaou-stained cervical smears taken from 203 female patients with either gonorrhoea, trichomoniasis, or candidosis were examined for the degree of inflammatory change. The results from these patients were compared with the results of smears taken from women who had no evidence of sexually-acquired infection after full assessment in the clinic. Gonorrhoea and trichomoniasis were associated with inflammatory changes but these were less marked in patients with candidosis. It is concluded that, before cytological inflammatory changes are attributed to non-specific genital infection, it is important to exclude gonorrhoea, trichomoniasis, and, to a lesser extent, candidosis.     

Gonorrhoea reinfection in heterosexual STD clinic attendees: longitudinal analysis of risks for first reinfection

OBJECTIVES: Gonorrhoea is associated with adverse reproductive health outcomes, including pelvic inflammatory disease and increased HIV transmission. Our objective was to determine the association of demographic factors, sexual risk behaviours, and drug use with incident gonorrhoea reinfection among public STD clinic clients. METHODS: A retrospective cohort study conducted from January 1994 through October 1998, of heterosexual public STD clinic attendees age >/=12 years having at least one gonorrhoea infection in Baltimore, MD. The outcome was first incident gonorrhoea reinfection over a maximum 4.8 years, compared in STD clinic clients with or without sexual risk behaviours and drug use at initial gonorrhoea infection. RESULTS: 910 reinfections occurred among 8327 individuals and 21 246 person years of observation, for an overall incidence of 4.28 reinfections per 100 person years (95% CI 4.03 to 4.53). Median time to reinfection was 1.00 year (95% CI 0.91 to 1.07 years). In multivariate Cox regression, increased reinfection risk was associated with male sex, younger age, greater number of recent sex partners, and having a sex partner who is a commercial sex worker. Injection drug use and coming to the clinic as an STD contact were protective. Among risk factors that differed significantly between men and women, injection drug use was protective of reinfection in men, and "any" condom use was a risk factor for reinfection in women CONCLUSIONS: Reinfection represents a significant proportion of STD clinic visits for gonorrhoea. Prevention counselling and routine screening for patients at high risk for reinfection should be considered to maximally reduce transmission and resource utilisation.     

Patient referral outcome in gonorrhoea and chlamydial infections

OBJECTIVE: To describe the outcome of patient referral at the STD clinic of the University Hospital Rotterdam. To study characteristics of heterosexual index patients and partnerships related to referral outcome. METHODS: In 1994, patients with gonorrhoea and chlamydia were referred to public health nurses for interview and patient referral. Referral outcome was classified as "verified" if partners attended the STD clinic and as "believed" if partners were said to have attended elsewhere. RESULTS: Of 454 patients, 250 (55%) participated in the study. The outcome of patient referral for the 502 eligible partners was 103 (20.5%) verified referrals, 102 (20%) believed referrals, and 297 (59%) with unknown follow up. Of the 103 partners examined, 43 had an STD of which 63% reported no symptoms. The contact finding ratio was higher for chlamydia patients and heterosexual men. Also, referral was more effective for index patients with recent sexual contact, with follow up visits to the public health nurse, for men who were not commercial sex worker (CSW) clients, and, to a lesser degree, for Dutch patients and patients who sometimes used condoms. For steady partners, referral was improved if the last sexual contact was more recent. Casual partners visited the clinic more often if sexual contact occurred more than once, if the last contact was more recent, if they were older, and if they were Dutch. CONCLUSIONS: Patient referral was more effective for certain groups, such as chlamydia patients and steady partners, but was inadequate for others, including CSW and their clients, other "one night stands", young partners, and ethnic minorities.     

Increase of sexually transmitted infections, but not HIV, among young homosexual men in Amsterdam: are STIs still reliable markers for HIV transmission?

OBJECTIVES: The incidence of HIV and STIs increased among men who have sex with men (MSM) visiting our STI clinic in Amsterdam. Interestingly, HIV increased mainly among older (> or =35 years) MSM, whereas infection rates of rectal gonorrhoea increased mainly in younger men. To explore this discrepancy we compared trends in STIs and HIV in a cohort of young HIV negative homosexual men from 1984 until 2002. METHODS: The study population included 863 men enrolled at < or =30 years of age from 1984 onward in the Amsterdam Cohort Studies (ACS). They had attended at least one of the 6 monthly follow up ACS visits at which they completed a questionnaire (including self reported gonorrhoea and syphilis episodes) and were tested for syphilis and HIV. Yearly trends in HIV and STI incidence and risk factors were analysed using Poisson regression. RESULTS: Mean age at enrollment was 25 years. The median follow up time was 4 years. Until 1995 trends in HIV and STI incidence were concurrent, however since 1995 there was a significant (p<0.05) increase in syphilis (0 to 1.4/100 person years (PY)) and gonorrhoea incidence (1.1 to 6.0/100 PY), but no change in HIV incidence (1.1 and 1.3/100 PY). CONCLUSIONS: The incidence of syphilis and gonorrhoea has increased among young homosexual men since 1995, while HIV incidence has remained stable. Increasing STI incidence underscores the potential for HIV spread among young homosexual men. However, several years of increasing STIs without HIV, makes the relation between STI incidence and HIV transmission a subject for debate.     

Frequency of N. gonorrhoeae, T. vaginalis, and C. albicans in female venereological patients. A one-year study.

The frequency of Neisseria gonorrhoeae, Trichomonas vaginalis, and Candida albicans has been studied over a period of one year in women attending a venereal diseases clinic. A total of 1,347 women were investigated, all coming from the same catchment area. Gonorrhoea was established at the first visit in 506 patients (38 per cent.), who constituted 97.5 per cent. of the total number of cases of gonorrhoea. Trichomonas vaginalis was found in 272 (20 per cent.) and Candida albicans in 233 (17 per cent.). 176 patients (13 per cent.) had more than one pathogen. Of the patients attending, 22 per cent. (292 women) were so-called "named contacts". The frequency of gonorrhoea established at the first visit in these patients (64 per cent.), was significantly higher, but the frequency of symptoms did not differ from that in other gonorrhoea patients. The number of asymptomatic cases was so large that a single compulsory examination is undoubtedly very useful from the epidemiological point of view, but the value of repeated specimen collections for gonorrhoea is debatable. Complications of gonorrhoea were observed in 29 patients (6 per cent.) at the first visit.     

Who goes to sexually transmitted disease clinics? Results from a national population survey.

OBJECTIVES: To examine the pattern of attendance at sexually transmitted disease (STD) clinics in Britain. To compare the demographic characteristics, behaviours and attitudes of STD clinic attenders with those of non-attenders, and to assess the extent to which STD clinics are used by those with high-risk sexual lifestyles. DESIGN: Random sample general population survey of sexual attitudes and lifestyle. SUBJECTS: 18,876 randomly selected men and women resident in Britain aged 16-59 years. MAIN OUTCOME MEASURES: Demographic characteristics, pattern of homosexual partnerships, heterosexual partnerships, payment for sex, abortion, drug injection in the last five years, and attitudes to sexual behaviours amongst 512 respondents who had attended STD clinic in the last five years compared with those who had not. RESULTS: 8.3% of men and 5.6% of women had attended a clinic in their lifetime and 3.4% and 2.6% respectively in the last five years. Attendance rates varied substantially with area of residence. 11% of Inner London residents had attended in the last five years. In multivariate analysis, STD clinic attendance for men was most strongly associated with increased numbers of heterosexual partners, (OR = 6.01 (4.44-8.15) and homosexual partnerships (OR = 9.59 (5.83-15.8)) and more weakly associated with payment for sex, non-manual social class, age 25-44, unmarried status and smoking. Clinic attendance for women was most strongly associated with numbers of heterosexual partners (OR = 3.74 (2.76-5.08) and injecting drug use (OR = 4.39 (1.73-11.1)). A weaker independent association was found with a history of abortion, anal sex, non-manual social class, non-married status and age 16-24. From the total population, 1 in 6 men and 1 in 7 women in the top 5% of the distribution for numbers of heterosexual partners and 1 in 5 men paying for sex and 1 in 4 of those with a homosexual partner had attended a clinic in the last five years. The probability of attendance increased with multiple risk behaviours. Of women 64.2% and of men 69.7% attending clinics reported major risk markers for STD transmission. CONCLUSIONS: STD clinics in Britain are used by a wide demographic spectrum of the population. The behaviours, but not the attitudes, of attenders differed markedly from those of non-attenders. Clinics are relatively efficient in attracting only those with high-risk lifestyles, but, at a population level, the minority of those reporting risk-markers for STD transmission attend clinics. These findings suggest that STD clinics are an important focus for sexual health promotion, but that community programmes are also important for reaching non-attenders.