New research (1) launched at the 29th EADV Congress, EADV Virtual, has found that despite the COVID-19 (SARS-CoV-2) lockdown restrictions, diagnosis of sexually transmitted infections (STIs), including gonorrhoea, secondary syphilis and mycoplasma genitalium (MG), have increased.
The research, conducted in two main STI centres in Milan, Italy, compared the number of confirmed diagnoses of the most common STIs in patients with symptoms for the period 15 March 2020 to 14 April 2020 following social isolation measures (lockdown) adopted to control the epidemic, with the same period in 2019.
The results revealed that despite a reduction in the total number of attendances by over a third (37%, 233 in 2019 vs 147 in 2020), the number of acute bacterial infections, most associated with men who have sex with men (MSM), increased during the observational period, including secondary syphilis and gonorrhoea. Cases fell, however, in the non-acute cases, such as genital warts and Molluscum Contagiosum.
It concludes that the COVID-19 pandemic, despite lockdown and advice on Social/Physical distancing, did not inhibit risky behaviours and that acute STIs actually increased.
Dr Marco Cusini, La Fondazione IRCCS Ca’ Granda Ospedale Maggiore di Milano Policlinico, Milano, Italy, explains: “It was assumed that the lockdown would reduce the opportunity for sexual encounters and STIs. However, I was surprised by the number of new acute infections diagnosed in this short period of time. Gonhorrhea and syphillis are typically more prevelant in people in their 30s, so infection may have increased because the concentration of COVID-19 morbidity and mortality in the elderly made the younger, more active, cohort feel protected and so less risk averse. Whilst it is unrealistic to prevent people from having sex, even in this extraordinary pandemic, close contact during sexual intercourse inevitably involves an increased risk of SARS-CoV-2 contagion.The findings show the importance of ongoing screening for STIs and the real benefit of having these types of services open and available during these unprecedented times.”
While gonorrhoea is still highly susceptible to the mainstay antibiotic treatment option ceftriaxone, the emergence of antimicrobial resistant gonorrhoea remains of concern. Recommended combinations with antibiotics such as azithromycin should be avoided in the light of antibiotic stewardship, necessitating new treatment guidelines. Dr Henry J.C. de Vries of the STI outpatient clinic Health Service Amsterdam presented on The threat of antimicrobial resistant gonorrhoea at 12:00-12:15 CET on Thursday 29th October 2020.
Gonorrhoea is caused by the bacterium Nesisseria gonorrhoeae (2). It often, but not always, presents no symptoms in females and is mostly symptomatic in males (3). Common symptoms in men include urethral discharge and pain upon urination (dysuria), and women may present with odourless vaginal discharge, dysuria and pain during sexual intercourse (3). Symptoms usually appear between 1-10 days after infection (4). Gonorrhoea is on the rise across Europe, in 2017 alone, there were more than 89,000 confirmed cases (240 per day), of which MSM accounted for almost half of all the cases (47%) (5). The United Kingdom reported 55% of all cases (75 per 100 000) followed by Ireland (47), Denmark (33), Iceland (29), Norway (27) and Sweden (25) (4).
The first symptoms of syphilis usually develop around 2 or 3 weeks after infection, although they can start later than this. the main symptom is a small, painless sore or ulcer typically on the penis, vagina, or around the anus, although it can sometimes appear in the mouth or on the lips, fingers or buttocks (6). Secondary syphilis is a progression of the disease and symptoms, however is curable with treatment (7). In 2018, there were 33,927 confirmed cases in Europe. The highest rate was observed in Malta (17.9 cases per 100 000 population), followed by Luxembourg (17.1), the United Kingdom (12.6) and Spain (10.3) (8).
(1) Cusini, M, Benardon, S, Vidoni, G, et. al. COVID-19 and STIs. Abstract no 1790, EADV Virtual, 29-31 October 2020
(2) Pharmaceutical Journal. Gonorrhoea infection: diagnosis and treatment. Available at: https://www.pharmaceutical-journal.com/cpd-and-learning/cpd-article/gonorrhoea-infection-diagnosis-and-treatment/20208209.cpdarticle?firstPass=false Accessed October 2020
(3) NCBI. Gonorrhea. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4366410/ Accessed October 2020
(4) Web MD. Gonorrhoea. Available at: https://www.webmd.com/sexual-conditions/do-i-have-gonorrhea#1 Accessed October 2020
(5) ECDC. Gonorrhoea. Available at: https://www.ecdc.europa.eu/sites/default/files/documents/gonorrhoea-annual-epidemiological-report-2017.pdf Accessed October 2020
(6) NHS Choices. Syphilis. Available at: https://www.nhs.uk/conditions/syphilis/symptoms/. Accessed October 2020
(7) CDC. Syphilis. Available at: https://www.cdc.gov/std/syphilis/stdfact-syphilis.htm Accessed October 2020
(8) ECDC. Syphilis. Available at: https://www.ecdc.europa.eu/sites/default/files/documents/syphilis-aer-2018.pdf Accessed October 2020