Infectious Diseases Protocol Appendix A: Disease-Specific Chapters Chapter: Gonorrhoea Revised January 2014
Gonorrhoea Communicable Virulent Health Protection and Promotion Act, Section 1 (1) Health Protection and Promotion Act: Ontario Regulation 558/91 Specification of Communicable Diseases Health Protection and Promotion Act: Ontario Regulation 559/91 Specification of Reportable Diseases 1.0 Aetiologic Agent Causative agent is the Neisseria gonorrhoeae (N. gonorrhoeae), a gram-negative diplococcus, commonly known as gonococcus. 1 1.1 Surveillance Case Definition See Appendix B 1.2 Outbreak Case Definition The outbreak case definition varies with the outbreak under investigation. Consideration should be given to the provincial surveillance case definition and the following criteria when establishing an outbreak case definition: 1. Clinical, laboratory and/or epidemiological criteria; 2. The time frame for occurrence; 3. A geographic location(s) or place(s) where cases live or became ill/exposed; and, 4. Special attributes of cases (e.g., age, underlying conditions). Outbreak cases may be classified by levels of probability (i.e., confirmed, probable and/or suspect). 2.0 Identification 2.1 Clinical Presentation Many cases are asymptomatic. 2 In males the most common presenting symptom is a painful purulent urethral discharge; dysuria and frequency as well as redness, itching and swelling of urethra. 1 Females present with initial urethritis or cervicitis, frequently mild which can go unnoticed; abnormal vaginal discharge and post-coital bleeding may occur and then the infection can progress to pelvic inflammatory disease. 1 Pharyngeal and anorectal infections can occur among those engaging in oral and anal sex respectively. 1 If symptoms are present in rectal infections individuals often display rectal discharge and pain. 2
Can present as conjunctivitis (Ophthalmia neonatorum) in infants. 1 For more information regarding gonococcal conjunctivitis in infants, please refer to the Ophthalmia neonatorum Disease-Specific Chapter. 2.2 Diagnosis See Appendix B for diagnostic criteria relevant to the Case Definitions. For further information about human diagnostic testing, contact the Public Health Ontario Laboratories or refer to the Public Health Ontario Laboratory Services webpage: http://www.publichealthontario.ca/en/servicesandtools/laboratoryservices/pages/default.as px 3.0 Epidemiology 3.1 Occurrence Worldwide; affects predominantly sexually active adolescents and younger adults. 1 In Ontario, gonorrhea is a commonly reported STI. Rates of gonorrhea are higher among males compared to females, and have been rising. Reported rates are highest among males 20-24 years of age and among females 15-19 years of age. Between 2007 and 2011, an average of 3907 gonorrhea cases was reported each year. 3, 4 Multi-drug resistance in N. gonorrhoeae has been an ongoing concern. Currently, resistance patterns are threatening the ability to successfully treat N. gonorrhoeae infections with single-dose oral antibiotics. By 2013 in Ontario, there have been at least nine documented cases of clinical failures associated with the oral cefixime to treat gonorrhea. 5 For further information regarding multi-drug resistant gonorrhea please refer to the Guidelines for Testing and Treatment of Gonorrhea in Ontario, 2013 (or as current). 6 For more information on infectious diseases activity in Ontario, refer to the current versions of the Ontario Annual Infectious Diseases Epidemiology Reports and the Monthly Infectious Diseases Surveillance Report. 3, 4 3.2 Reservoir Humans 1 3.3 Modes of Transmission Sexual contact via oral, vaginal, cervical, urethral or anal routes; in children, consider the 1, 2, 6 possibility of sexual abuse; newborns: during delivery from infected mother. 3.4 Incubation Period In individuals who display symptoms, the incubation period is usually 1-14 days. 1 3.5 Period of Communicability May extend for months if untreated; effective treatment usually ends communicability within hours. 1 3
3.6 Host Susceptibility and Resistance General susceptibility. When considering re-infection, primary treatment failure and inadequate treatment please consider the following factors: Appropriate treatment provided considering Guidelines for Testing and Treatment of Gonorrhea in Ontario, 2013 (or as current); 6 Treatment adherence; Necessary follow up completed ( i.e. test of cure undertaken if recommended); Avoidance of sexual exposure during treatment period and 7 days post treatment. For surveillance purposes, if the above factors are met health units may consider 28 days for re-infection. 4.0 Reporting Requirements 4.1 To local Board of Health Individuals who have or may have gonorrhea shall be reported to the medical officer of health by persons required to do so under the Health Protection and Promotion Act, R.S.O. 1990 (HPPA). 7 Refer to the Sexual Health and Sexually Transmitted Infections Prevention and Control Protocol, 2008 (or as current) for reporting requirements and data collection requirements. Refer to the Guidelines for Testing and Treatment of Gonorrhea in Ontario, 2013 (or as current) for reporting of gonorrhea clinical failures. 6 4.2 To the Ministry of Health and Long-Term Care (the ministry) or Public Health Ontario (PHO), as specified by the ministry Report only case classifications specified in the case definition. Cases shall be reported using the integrated Public Health Information System (iphis), or any other method specified by the Ministry within five (5) business days of receipt of initial notification as per iphis Bulletin Number 17: Timely Entry of Cases and Outbreaks. 8 The minimum data elements to be reported for each case is specified in the following: Ontario Regulation 569 (Reports) under the HPPA; 9 The disease-specific User Guides published by PHO; and, Bulletins and directives issued by PHO. Refer to the Guidelines for Testing and Treatment of Gonorrhea in Ontario, 2013 (or as current) for reporting of gonorrhea clinical failures. 6 4
5.0 Prevention and Control Measures 5.1 Personal Prevention Measures Preventative measures include education about safer sex practices including use of condoms and early detection of infection by screening those at risk. 2 Refer to Sexual Health and Sexually Transmitted Infections Prevention and Control Protocol, 2008 (or as current), and the Canadian Guidelines on Sexually Transmitted Infections, 2008 (or as current). 2 For screening and testing recommendations please refer to the Guidelines for Testing and Treatment of Gonorrhea in Ontario, 2013 (or as current). 6 5.2 Infection Prevention and Control Strategies Refer to Public Health Ontario s website at www.publichealthontario.ca to search for the most up-to-date Provincial Infectious Diseases Advisory Committee (PIDAC) best practices on Infection Prevention and Control (IPAC). PIDAC best practice documents can be found at: http://www.publichealthontario.ca/en/browsebytopic/infectiousdiseases/pidac/pages/pid AC_Documents.aspx. 5.3 Management of Cases Case management should consider the PIDAC Sexually Transmitted Infections Case Management and Contact Tracing Best Practice Recommendations, April 2009 (or as current). 10 Treatment as per attending health care provider; refer to the Guidelines for Testing and Treatment of Gonorrhea in Ontario, 2013 (or as current) for treatment and follow up recommendations. 6 Refer to Sexual Health and Sexually Transmitted Infections Prevention and Control Protocol, 2008 (or as current), Guidelines for Testing and Treatment of Gonorrhea in Ontario, 2013 (or as current), 6 and PIDAC Sexually Transmitted Infections Case Management and Contact Tracing Best Practice Recommendations, April 2009 (or as current). 10 5.4 Management of Contacts Contact management of cases should be guided by the Sexual Health and Sexually Transmitted Infections Prevention and Control Protocol, 2008 (or as current), Guidelines for Testing and Treatment of Gonorrhea in Ontario, 2013 (or as current), 6 and PIDAC Sexually Transmitted Infections Case Management and Contact Tracing Best Practice Recommendations, April 2009 (or as current). 10 5.5 Management of Outbreaks Consult with Public Health Ontario if an outbreak of gonorrhea is suspected. 5
Provide public health management of outbreaks or clusters in order to identify the source of illness and stop the outbreak. As per the Infectious Diseases Protocol, 2008 (or as current) outbreak management shall comprise of but not be limited to the following general steps: Confirm diagnosis and verify the outbreak; Establish an outbreak team; Develop an outbreak case definition; Implement prevention and control measures; Implement and tailor communication and notification plans depending on the scope of the outbreak; Conduct epidemiological analysis on data collected; Conduct environmental inspections of implicated premise where applicable; Coordinate and collect appropriate clinical specimens where applicable; and Prepare a written report. Declare the outbreak over in collaboration with the outbreak team currently reviewing them. 6.0 References 1. Heymann DL, editor. Control of communicable diseases manual. 19th ed. Washington, DC: American Public Health Association; 2008. 2. Expert Working Group on the Canadian Guidelines on Sexually Transmitted Infections; Public Health Agency of Canada. Canadian guidelines on sexually transmitted infections. Evergreen ed. Ottawa, ON: Her Majesty the Queen in Right of Canada; 2013 [cited 2013 Aug 27]. Available from: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/index-eng.php 3. Ontario. Ministry of Health and Long-Term Care. Ontario annual infectious diseases epidemiology report, 2009. Toronto, ON: Queen s Printer for Ontario; 2009 (or as current) [cited 2013 Aug 27]. Available from: http://www.health.gov.on.ca/en/common/ministry/publications/reports/epi_reports/epi_re port_2009.pdf 4. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Monthly infectious diseases surveillance report. Toronto, ON: Queen s Printer for Ontario; 2013. Available from: http://www.publichealthontario.ca/en/servicesandtools/surveillanceservices/pages/mo nthly-infectious-diseases-surveillance-report.aspx 5. Allen VG, Mitterni L, Seah C, Rebbapragada A, Martin IE, Lee C,et al. Neisseria gonorrhoeae treatment failure and susceptibility to cefixime in Toronto, Canada. JAMA. 2013;309(2):163 70. 6. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Guidelines for testing and treatment of gonorrhea in Ontario. Toronto, ON: Queen's Printer for Ontario; 2013 [cited 2013 Aug 27]. Available from: http://www.publichealthontario.ca/en/erepository/guidelines_gonorrhea_ontario_2013. pdf 7. Health Protection and Promotion Act, R.S.O. 1990, c. H.7. Available from: http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90h07_e.htm 6
8. Ontario. Ministry of Health and Long-Term Care. Timely entry of cases and outbreaks. iphis bulletin. Toronto, ON: Queen s Printer for Ontario; 2012:17 (or as current). 9. Reports, R.R.O. 1990, Reg. 569. Available from: http://www.e-laws.gov.on.ca/html/regs/english/elaws_regs_900569_e.htm 10. Provincial Infectious Diseases Advisory committee (PIDAC), Ontario. Ministry of Health and Long-Term Care. Sexually transmitted infections case management and contact tracing best practice recommendations. Toronto, ON: Queen s Printer for Ontario; 2009 [cited 2013 Aug 27]. Available from: http://www.publichealthontario.ca/en/erepository/stis%20case%20management%20c ontact%20tracing.pdf. 7.0 Additional Resources Ontario. Ministry of Health and Long-Term Care. Sexual health and sexually transmitted infections prevention and control protocol, 2013 (revised). Toronto, ON: Queen s Printer for Ontario; 2013 Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/sexual_health _sti.pdf Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Routine practices and additional precautions in all health care settings. 3rd ed. Toronto, ON: Queen s Printer for Ontario; 2012. Available from: http://www.publichealthontario.ca/en/erepository/rpap_all_healthcare_settings_eng2012.pdf 8.0 Document History Table 1: History of Revisions Revision Date Document Section Description of Revisions January 2014 General New template. 1.2 Outbreak Case Definition Title of Section 3.6 changed from Susceptibility and Resistance to Host Susceptibility and Resistance Title of Section 4.2 changed from To Public Health Division (PHD) to To the Ministry of Health and Long-Term Care (the ministry) or Public Health Ontario (PHO), as specified by the ministry Section 8.0 Document History added. 7
Revision Date Document Section Description of Revisions 2.1 Clinical Presentation First paragraph removed first sentence Presentation and severity differs in males and females. Fourth paragraph changed from Pharyngeal and anorectal infections are common among those engaging in oral and anal sex. to Pharyngeal and anorectal infections can occur among those engaging in oral and anal sex (respectively). If symptoms are present in rectal infections individuals often display rectal discharge and pain. Addition of fifth paragraph Can present as 2.2 Diagnosis Addition of the second paragraph: For further information 3.1 Occurrence First paragraph, replaced both genders especially with predominantly Second paragraph, addition of third sentence Between 2007 and 2011 Addition of third, fourth and fifth paragraph. 3.3 Modes of Transmission 3.4 Incubation Period First paragraph changed from Sexual contact via oral, vaginal, cervical, urethral or anal routes; in children, exposure to infected genitals (consider the possibility of sexual abuse in these cases); newborns: during delivery from infected mother. to Sexual contact via oral, vaginal, cervical, urethral or anal routes; in children, consider the possibility of sexual abuse; newborns: during delivery from infected mother. 3.6 Host Susceptibility and Resistance 5.1 Personal Prevention Measures First paragraph testing changed to screening Addition of the third paragraph: For screening 8
Revision Date Document Section Description of Revisions 5.2 Infection Prevention and Control Strategies 5.3 Management of Cases 5.4 Management of Contacts 5.5 Management of Outbreaks 6.0 References Updated. 7.0 Additional Resources Updated. 9
2014 Queen s Printer for Ontario