Gonorrhoea Prevention in the Australian Society - Research Proposal Example

Gonorrhoea Prevention in the Australian Society Abstract The purpose of this paper is to investigate the prevalence of gonorrhoea in Australia and the possible prevention approaches that are used. The paper focuses on services provided by the Royal Adelaide Hospital in relation to helping the public to prevent gonorrhoea infections. It is argued that because of failure of some conventional treatments of gonorrhoea infections such as ceftriaxone, there is need for more emphasis on prevention. This requires identification of at risk groups and intervention from family to the community and both local and national government levels. It is indicated that effective prevention lies in using multidisciplinary and multileveled approaches with focus on integrating gonorrhoea prevention approaches that already exist in the society and which are relevant to people’s specific social contexts. Such include relaying information using appropriate communication tools such as the Internet and availing facilities where at risk groups can be tested, treated and offered counselling seamlessly. Key words Neisseria gonorrhoeae, gonorrhoea, sexually transmitted infection, gonococcal infection, risk factors for gonorrhoea, prevention Introduction Gonorrhoea is a severe infection of the genital tract in both women and men, caused by the bacterium Neisseria gonorrhoeae (Government of South Australia 2012a). The disease is transmitted sexually through genital, oral or anal sex. Being a highly transmissible infection, the prevalence of gonorrhoea in the Australian society has generally been notable. This is in spite if the fact that the disease can easily be controlled through preventive measures. In addition, several studies conducted in relation to the use of ceftriaxone in the treatment of gonorrhoea have shown cases of failure of the drug in some cases. This implies that even where patients have been treated of the disease, there is a possibility of re-infection and further transmission due to inconclusive treatment of the illness. In view of the foregoing, this paper aims to present a brief overview of the epidemiology of gonorrhoea and then discuss the measures that can be adopted to prevent the transmission of the disease in Australia. While the paper presents information about the state of the gonorrhoea in Australia, it will also focus on specific cases in South Australia. The paper is structured into the following sections: a literature review, discussion of the findings from literature and conclusion based on the same. Recommendations are also provided on how to effectively enhance gonorrhoea prevention in the Australian society. Literature review Gonorrhoea is reported to be highly transmissible (Goldman & Schafer 2011). Goldman and Schafer (2011) also note that the high rate of transmission of the disease is attributable to the point that although not precisely determined, the risk of transmission from a man to a woman during one episode of unprotected vaginal intercourse is believed to be between 50 and 70 per cent, and the risk of transmission from a woman to a man is 20 per cent. High transmission is therefore possible if one person has more than one sexual partner. In addition, although the risks of transmission associated with fellatio, cunnilingus and anal sex are not well defined, anal sex is thought to be a potentially efficient mode of transmission (Goldman & Schafer 2011). Goldman and Schafer (2011) also give an account of how gonorrhoea is transmitted and how it affects different individuals. According to these authors, the mode of transmission of gonorrhoea involves the gonococci, which are responsible for the disease, getting attached to the epithelial cells of the host. The gonococci are then endocytosed into the cell in a progression believed to be facilitated by protein 1 (Por). They then multiply within the host cell and are released into the subepithelial space. Characteristic urethral infections end up in prominent inflammation, possibly due to the release of toxic peptidoglycan and lipo-oligosaccharide fragments and the release of chemotactic substances that attract neutrophilic leukocytes. According to Goldman and Schafer (2011), the reasons why some strains of gonococci selectively cause asymptomatic infection of the genital organs are not well understood, but this tendency may be due differences in the host’s ability to bind complement-regulatory proteins which reduce the production of chemotactic peptides. Various studies have shown a relatively notable prevalence of gonorrhoea among the Australian population (Graham et al. 2012; Pairman et al. 2010, p. 154; Field et al. 2010) and elsewhere in the world (Tapsall 2005, p. S263). Specifically, Field et al. (2010) indicate that gonorrhoea is the second most prevalent notifiable sexually transmitted infection (STI) in Queensland. This scenario is also replicated in other developed countries such as the United States (Newman, Moran & Workowski 2007, p. S84). In addition to this, some sources report that prevalence of the disease has increased in recent decades. For instance, Pairman et al. (2010, p. 154) argue that the rate of notified cases of gonorrhoea increased in both New Zealand and Australia in the late 1990s to a level not witnessed since the mid 1980s. Notably, the increase reported in this case was noted primarily in men who have sex with men – comprising two-thirds of the cases – as well as in heterosexual men. Similarly, Mindel et al. (2012, p. 31) present findings showing that cases of gonorrhoea increased between the 1990s and 2002 in urban areas such as London and similar results were reflected in many other industrialised nations in Europe and western Australasia, including Australia, Sweden, New Zealand and others. Further, in their study on gonorrhoea and chlamydia, Graham et al. note (2012, p. 643) that there were 73,480 notifications of gonorrhoea between 2000 and 2009. In 2012 alone, 13,649 cases of gonorrhoea were reported in Australia (Life Scientist Staff 2013). Details presented by Pairman et al. (2010, p. 154) suggest that in 2005 alone, there were 3564 notifications of gonococcal infection among young Australians – which translates to a rate of 93 per 100,000 young people. In addition, gonococcal infection among the young people in Australia contributed to 14 per cent of all sexually transmitted infections notified in the demographic. Moreover, women of ages under 25 years are believed to be at highest risk for gonorrhoea infection. These data are in tandem with figures released by the Australian Bureau of Statistics (2012), which suggest that gonorrhoea notification rates have generally increased over the past ten years. The Australian Bureau of Statistics data for 2011 however indicate that more men than women were diagnosed with gonorrhoea. Overall, the countrywide notification rate for people of ages between 15 years and over increased from 40 people per 100,000 population to 65 per 100,000 between 2001 and 2011. This information is illustrated in figure 1. Figure 1: Notifications of gonorrhoea in Australia by age – 2011 Source: Australian Bureau of Statistics (2012) In 2010, the Australian Gonococcal Surveillance Programme published data on the source and number of gonococcal isolates in Australia by region, site and sex. The figures are shown in the table 1 below. Table 1: source and number of gonococcal isolates in Australia by region, site and sex Source: Australian Gonococcal Surveillance Programme (2010, p. 230) The fact that gonorrhoea infection can sometimes be asymptomatic and also raises the chances of contracting other infections implies that more effective interventions need to be taken in regard to preventing transmission. Although there are many antibiotics that can cure the disease, evidence has shown that strains that are drug-resistant are increasing in many regions of the world and this makes successful treatment more difficult (Australian Bureau of Statistics 2012). Concerns have already been raised over the use of drugs like ceftriaxone in the treatment of gonorrhoea. Ceftriaxone is the drug that is commonly recommended for treatment of the illness (Field et al. 2010; Pairman et al. 2010, p. 155).) But disquiet has been increased by reports of the inability of treatment with oral extended-spectrum cephalosporins in male urethral gonorrhoea caused by multidrug resistant N. gonorrhoeae (Tapsall et al. 2009, p. 683). Tapsall et al. (2009, p. 683) also present two cases where ceftriaxone treatment failed to eradicate pharyngeal gonococci. Additionally, older therapies for gonorrhoea have also become ineffective, while those that remain effective are too expensive in many high-incidence settings (Tapsall 2005, p. S263). This increases the need for more effective prevention as more curative interventions are sought to deal with the resistant strains of gonococci. Discussion Seeing that gonorrhoea is becoming more difficult to treat because of the ineffectiveness of many of the treatments that have been in use, a sustained decrease in the gonococcal disease do doubt requires an integrated approach that combines prevention, diagnosis, and efficacious treatment. Without incessant commitment and effort, gonorrhoea may well turn out to be untreatable (Tapsall 2005, p. S263). The issues of prevention of gonorrhoea are more complicated. Because gonorrhoea is an STI, the major obstacle in prevention is ensuring behavioural change, which is a precondition for improved outcomes. In addition, prospects of getting a vaccine for the disease are still bleak. Further, the nature of the organism that causes gonorrhoea is such that it owes its survival to its ability to steer clear of the immune mechanisms of the human body through continual adaptation (Tapsall 2005, p. S263). Graham et al. (2012) concluded in their findings in a study that there is need for targeted prevention programmes for young people. The foregoing can be linked to the fact that the group with the highest notifications of gonorrhoea comprises people aged between 15 and 34 as indicated by the Australian Bureau of Statistics (2012) (figure 1 above). The risk factors for gonorrhoea include previous gonococcal infection, other sexually transmitted infections (STIs), new or many sexual partners, commercial sex work, inconsistent condom use, and drug use (Pairman et al. 2010, p. 155). These issues have to be understood in order to intervene in the most appropriate manner as regards prevention. The Royal Adelaide Hospital in South Australia is one of the institutions that are in charge of controlling the spread of gonorrhoea in Australia’s population. The institution produces guidelines on the management and prevention of gonorrhoea and other STIs. The key issues addressed in the educative guidelines produced by the Royal Adelaide Hospital are: the significance of immediate testing and treating of all sex partners, abstinence from sex until the latest cure of gonorrhoea is performed; patient education and provision of literature on the disease; and creating awareness that gonorrhoea is a notifiable disease (Government of South Australia 2012b). These points are corroborated by findings in the online magazine Life Scientist where it is recommended that prevention should take into account the need for frequent testing and promoting condom use (Life Scientist Staff 2013). While testing is critical in ensuring that infected people do not infect their partners, challenges arise from the unwillingness of some people to test for STI. For instance, while young people are the highest risk group, the younger they are the less likely they are likely to go for testing (Life Scientist Staff 2013). This is despite the fact that Australian adolescents as young as 12 are susceptible to STIs. Condom use is one well studied preventive measures against gonorrhoea and other STIs. According to Smith, Mailman and MacDonald (2012, p. 233), condoms and other barrier contraceptive methods offer a high degree of protection against STIs. This is particularly important for at risk groups such as commercial sex workers. This method can work well with other strategies such as gonococcal mass treatment programmes for the at risk groups. Such strategies have worked well in other health care facilities in Australia such as the Alfred Hospital in Melbourne. This is helped by the legislation in Victoria which requires sex workers to undergo monthly testing for gonorrhoea and other STIs such as trichomonas and chlamydia (ScholarlyBrief 2012, p. 4). Such interventions ensure that groups that are risk of infection or infecting others know their status and are hence able to take necessary measures to curb further transmission of STIs. The preventive measures that have been highlighted so far need to be supported by new and innovative intervention strategies. For instance, Smith et al. (2012, p. 233) suggest a movement towards multidisciplinary and multileveled approaches with emphasis placed on the integration of gonorrhoea prevention programmes that already exist in health care and community structures. This also requires the empowerment of individuals and communities to create and foster preventative strategies that are relevant to their specific social contexts. Since social networks affect the decisions and opinions of members (Smith et al. 2012, p. 233), it is suggested that targeted core group counselling may offer the opportunity for better dissemination of information within groups. For instance, peer-led as opposed to outsider-initiated sexual health intervention on issues such as condom use, testing and contact tracing are more likely to succeed in both adolescent and other populations (Smith et al. 2012, p. 233). Further, there is need to use appropriate communication tools as is the case of the Royal Adelaide Hospital through the Government of South Australia website. According to Smith et al. (2012, p. 233), the young population increasingly depends on the Internet and other social media as sources of health information. With this in mind, and because the people that are most affected by gonorrhoea are the young people, sexual health educators need to come up with creative ways of getting their messages across to young adults and teens. Finally, there is need to create more adolescent-friendly health care services. This is because adolescents and teens tend to live in the present and are unlikely to look for treatment at clinics that require appointments, especially if the wait times are long. For instance, there could be drop-in clinics near malls and schools where the young people are likely to frequent and thus get STI testing. Although “abstinence” or “abstinence until message” is an effective preventive strategy, it is argued that it has no scientific evidence and is unsound from a medical-ethical standpoint (Smith et al. 2012, p. 233). Given that STIs like gonorrhoea are prevalent among the young population, there is need for multispectral prevention strategies that range from the family unit to the community and to local as well as national governments. Conclusion It has been discussed that gonorrhoea treatments such as ceftriaxone are progressively becoming inefficacious; hence the need to strengthen prevention measures in the Australian society. To achieve this, the risk factors such as previous gonococcal infection, other STIs, new or multiple sexual partners, commercial sex work and inconsistent condom use must be understood. Effective prevention lies in using multidisciplinary and multileveled approaches with emphasis on the incorporation of gonorrhoea prevention approaches that already exist in the society. Importantly, the strategies need to be relevant to people’s specific social contexts. There is also a need to use appropriate communication tools to target at risk groups such as the young people. Creative ways of getting messages across to young adults and teens are necessary, including the internet and other social media. This is already happening at the Royal Adelaide Hospital. In addition, more adolescent-friendly health care services should be established to cater for the needs of the young population. Recommendations It recommended that more prevention approaches should target the people at risk and the society in general through innovative ways such as government and community websites, and social media like Facebook, Twitter and LinkedIn. Such initiatives can involve sending messages to encourage testing, condom use, partner tracing and conclusive treatment of gonorrhoea infection. In addition, medical facilities should have special areas where affected groups can go for testing and counselling without fear of embarrassment. More importantly, sex education should be emphasised in schools so that school-going children can be informed of the impacts of STIs from an early age. References Australian Bureau of Statistics 2012, ‘Sexually transmitted infections’, viewed 24 October 2013, Australian Gonococcal Surveillance Programme 2010, ‘Annual Australian Gonococcal Surveillance Programme Annual Report, 2010’, CDI, Vol 35, No. 3, pp. 229-236. Field, E, Heel, K, Palmer, C, Vally, H, Beard, F & McCall, B 2010, ‘Evaluation of clinical management of gonorrhoea using enhanced surveillance in South East Queensland’, Sex Health, Vol. 7, No. 4., pp. 448-452. Goldman, L & Schafer, A I 2011, Cecil Medicine: Expert Consult Premium Edition, 24th edn, Elsevier Health Sciences, New York. Government of South Australia 2012a, ‘Gonorrhoea - symptoms, treatment and prevention’, viewed 24 October 2013, Government of South Australia 2012b, ‘Sexually transmitted infection guidelines’, viewed 24 October 2013, Graham, S, Guy, R J, Donovan B, McManus, H, Su, J, El-Hayek,C, Kwan, K S H, Dyda, A, Wand, H C & Ward, J S 2012, ‘Epidemiology of chlamydia and gonorrhoea among Indigenous and non-Indigenous Australians, 2000–2009’, The Medical Journal of Australia, Vol. 197, No. 11, pp. 642-646. Life Scientist Staff 2013, ‘Disturbing infection trends’, Life Scientist, 25 October, 2013, viewed 24 October 2013, Mindel, A, Dwyer, D, Herring, B & Cunningham, A L 2012 ‘Global epidemiology of sexually transmitted diseases’, in L R Stanberry & S L Rosenthal (eds), Sexually Transmitted Diseases: Vaccines, Prevention, and Control, 2nd edn, Academic Press, pp. 4-33. Newman, L M, Moran, J S & Workowski, K A 2007, ‘Update on the Management of Gonorrhoea in Adults in the United States’, Clinical Infectious Diseases, Vol. 44, Supplement 3, pp. S84-S101. Pairman, S, Tracy, S K, Thorogood, C & Pincombe, J 2010, Midwifery: Preparation for Practice, Elsevier Australia, Chatswood NSW. ScholarlyBrief 2012, Immunologic Deficiency Syndromes: Advances in Research and Treatment: 2011 Edition, ScholarlyEditions, Atlanta. Smith, J C, Mailman, T & MacDonald, N E 2012, ‘How to get rid of gonorrhoea’, in N Curtis, A Finn & A J Pollard (eds), Hot Topics in Infection and Immunity in Children IX, Springer, New York, pp. 219-239. Tapsall, J W 2005, ‘Antibiotic Resistance in Neisseria gonorrhoeae’, Clinical Infectious Diseases, Vol. 41, Supplement 4, pp. S263- S268. Tapsall, J, Read, P, Carmody, C, Bourne, C, Ray, S, Limnios, A, Sloots, T & Whiley, D 2009, ‘Two cases of failed ceftriaxone treatment in pharyngeal gonorrhoea verified by molecular microbiological methods’, Journal of Medical Microbiology, Vol. 58, pp. 683–687. Read More