Gonorrhea refers to a group of clinical conditions caused by infection with Neisseria gonorrhea. N. gonorrhea is a sexually transmitted bacterial pathogen. Gonorrhea is an old disease that dates back to more than 2000 years ago (Walker & Sweet, 2011). It is the second most common sexually transmitted infection in the United States (US) after Chlamydia (LeFevre, 2014). The disease is gaining public health importance because N. gonorrhea has developed resistance to the antibiotic drugs previously used to treat it in the United States. Currently, only one class of drug, the cephalosporins, is recommended for its treatment (Walker & Sweet, 2011). This paper will review the issue of gonorrhea infections in the US with a focus on descriptive epidemiology, incidence and prevalence, and Healthy People 2020 objectives. Further, it will explore its impact on the community, an applicable theoretical model, preventive measures, and evidence-based recommendations related to the issue.
Descriptive Epidemiology
Gonorrhea refers to a cluster of clinical conditions that involve infection with N. gonorrhoeae, a sexually transmitted bacterial pathogen whose sole natural host is humans (Walker & Sweet, 2011). The pathogen, N. gonorrhoeae, is a gram-negative intracellular diplococcus. It is acquired at various mucosal sites of the lower genital tract such as the cervix, urethra, Bartholin’s and Skene’s glands. It is also transmitted through the pharynx, anorectal canal, and conjunctivae. It can spread from the sites of acquisition to the upper reproductive tract, fallopian tubes, abdominal cavity, and other systemic sites (Walker & Sweet, 2011). Although the condition spreads through engaging in unprotected sex, certain environmental factors favor its transmission. These factors are biological, social, economic, and behavioral in nature. The biologic factors that promote the spread of the disease include its asymptomatic nature in some individuals mostly women, gender and age differences, and lag time between infection and appearance of any noticeable symptoms and complications. The social, economic, and behavioral factors that contribute to the spread of the disease include racial and ethnic disparities, poverty, and marginalization. Others include substance abuse, access to health care, sexual networks, and sexuality and secrecy (US Department of Health and Human Services, 2014). Women and infants are disproportionately affected by gonorrhea infections as they are often subclinical or asymptomatic. Further, spread of the disease in these patient populations is associated with serious clinical sequaelea. The disease is more prevalent in urban locations, amongst African-Americans and Hispanics, and the young (15-24 years) (Walker & Sweet, 2011).
Incidence and Prevalence
Incidence refers to the number of new events for example disease cases that occur over a given period (Jenicek, 2010). Prevalence is closely related to incidence. It refers to the number of cases of a condition present at a specific time, in relation to the total number of individuals present in the population or group at that time (Timmreck, 2002). Incidence influences prevalence; as the number of new cases of a condition increase, both the incidence and prevalence rates go up (Jenicek, 2010). The incidence rate of gonorrhea in the united states in the year 2012 was 107.5 cases per 100 000 population. This is because a total number of 334 826 gonorrhea cases were reported that year (Centers for Disease Prevention and Control (CDC), 2014). During the same year, a total number of 33, 579 cases of gonorrhea were reported in the state of California. The incidence rate of the disease for California per 100, 000 population was 89.1 (CDC, 2014). This figure was substantially lower to the national rate of 107.5 cases per 100, 000 population. Provisional data shows that 417 cases of gonorrhea were reported in Solano County, California during the year 2013. At the time, the county had a population of 423, 265 persons (California Department of Public Health, 2014). The incidence rate of gonorrhea per 100 000 for Solano county for the year 2013, therefore, was 98.5 cases which is slightly higher than the state’s incidence rate for the year 2012 (89.1). Notably, the above rates may not be representative of the true rates of gonorrhea in the regions. The CDC estimates that only a half of new cases of gonorrhea are reported and most women with the infection are asymptomatic. According to the CDC, there are 700 000 new cases of gonorrhea in the US each year (CDC, 2011). Further, direct comparisons between different populations are not feasible as the gonorrhea cases reported are influenced by a number of factors. The factors include changes in health care access, public awareness, reporting practices, outbreaks of other sexually transmitted infections, and screening practices. Others include changes in resistance patterns and budgetary constraints that impair the ability of public health staffs to accurately monitor the disease’s patterns (Walker & Sweet, 2011).
Healthy People 2020 Objectives
The Healthy People 2020 objectives related to gonorrhea fall under sexually transmitted diseases, STD -6, reduction of gonorrhea rates. The two objectives under STD-6 are STD-6.1 and STD-6.2. The objective STD-6.1 aims to reduce the rate of gonorrhea amongst females aged 15 to 44 years from the baseline of 279.9 new cases per 100 000 reported in 2008 to 251.9 new cases per 100 000. The objective STD-6.2 aims to reduce the rate of gonorrhea amongst males aged 15-44 years from 215.5 new cases per 100 000 reported in 2008 to 194.8 new cases. The target for both objectives is to reduce the incidence rate of gonorrhea in the two population groups by 10% (US Department of Health and Human Services, 2014). Untreated gonorrhea infections in pregnant women can lead to premature labor and ophthalmia neonatorum (LeFevre, 2014). Reduction of gonorrhea infections is, thus, also indirectly related to the maternal, infant, and child health objective of reducing preterm births (MICH-9) (US Department of Health and Human Services, 2014). It should be noted, however that no clinical trials have evaluated the benefits of early detection and management of gonorrhea in gravid women. Therefore, it is yet to be established whether early treatment of gonorrhea in asymptomatic women reduces morbidity from gonorrhea-related obstetric complications (LeFevre, 2014).
Analysis of Impact on the Community
Gonorrhea is second most common sexually transmitted infection in the US following Chlamydia infections (LeFevre, 2014). In 2012 alone, 334 826 gonorrhea cases were reported to the CDC. The true prevalence of gonorrhea is, however, thought to be much higher because most gonorrhea infections are asymptomatic and are thus never diagnosed or treated (LeFevre, 2014). According to CDC estimates, more than 700 000 individuals are infected with the condition in the country each year, and only a half of these infections are diagnosed and reported. The CDC further estimates that in their totality, sexually transmitted infections cost the American Healthcare system an approximated $16 billion each year in direct medical costs alone (CDC, 2013). With regards to human suffering, the disease predominantly affects the youth as more than a half of all new cases occur amongst persons aged 16-24 years (CDC, 2013). Further, asymptomatic infections have costly long-term health consequences as they cause cervicitis, pelvic inflammatory disease, and its associated complications like chronic pelvic pain, ectopic pregnancy, and infertility amongst females (LeFevre, 2014). In males, they can cause epididymitis and urethritis. Biologic and epidemiologic studies also indicate that infection with gonorrhea also facilitates the transmission of HIV in both men and women. Untreated gonorrhea infections amongst gravid women contribute to adverse neonatal outcomes such as preterm births and infection of neonates with gonorrhea e.g. gonococcal opthalmia (LeFevre, 2014). Most importantly though is the fact that N. Gonorrhea develops resistance to antimicrobial treatments. N. gonorrhea has developed resistance to most of the antibiotics medications that were its mainstay treatments in the US such as penicillin and quionolones. Currently, the treatment for gonorrhea recommended by the CDC is limited to only one class of antibiotics, the cephalosporins (Walker & Sweet, 2011).
Theoretical Model
The theoretical model appropriate for explaining the public health problem of gonorrhea is the epidemiological triangle. This model is appropriate for explaining gonorrhea because it reflects the issues essential to understanding the spread and control of this infectious disease (Goldsteen, Goldsteen, & Graham, 2010). Diagrammatically it is depicted as a triangle; the three points of the triangle represent the agent, host, and the environment. The agent is the microorganism that causes the disease while the host is the being that harbors the causative organism. The environment, on the other hand, represents the array of factors that facilitate transmission of the infective organism (agent) to the host (Goldsteen, Goldsteen, & Graham, 2010). The environmental factors in the epidemiological triangle are not specified but represent the whole range of physical, social, biologic, economic, and climatologic factors that allow the agent to infect the host. The model is, therefore, appropriate as it provides a framework for understanding how gonorrhea is spread and preventing its transmission. With regards to gonorrhea, the causative microorganism is the gram negative bacteria N. gonorrhea (Walker & Sweet, 2011). The environmental factors that favor transmission of the disease include biological, social, economic, and behavioral factors. The condition is spread through having unprotected sexual intercourse. The asymptomatic nature, gender and age disparities, and lag time between infection and any noticeable complications are some of the biologic factors that favor the spread of the condition. The social, economic, and behavioral factors that contribute to the spread of the disease include racial and ethnic disparities, poverty and marginalization, and substance abuse. Others include limited access to health care, sexual networks, and sexuality and secrecy (US Department of Health and Human Services, 2014). Race and ethnicity are correlated to other determinants of health status such as poor health seeking behaviors, limited access to healthcare, poverty, and living in communities with high rates of sexually transmitted infections. The disease is higher amongst African-Americans and Hispanic populations (Walker & Sweet, 2011). Poverty increases the tendency to engage in high-risk sexual behaviors and at the same time compromises access to health care services. Whilst access to health care services is crucial for early diagnosis and management of sexually transmitted infections, groups at high risk often have limited access to health care favoring the spread of these infections. The stigma associated with discussing intimate life issues like sex and use of illicit substances also contribute to the spread of gonorrhea infections (US Department of Health and Human Services, 2014).
Levels of Prevention
Preventive measures for gonorrhea encompass primary, secondary, and tertiary interventions. Primary preventive measures aim at preventing new disease cases by minimizing risk factors (Merril & Timmreck, 2006). They are designed to avert the onset of new gonorrhea infections. Primary interventions include promotion of behavioral changes that minimize the risk of acquisition or transmission of infections. Examples include delaying the age of first sexual debut, use of condoms, partner selection, and minimizing the number of sex partners. Secondary preventive measures foster detection of disease and in effect, facilitate early treatment and improvement of a patient’s prognosis (Merril & Timmreck, 2006). They identify and manage asymptomatic individuals in whom gonorrhea is not yet clinically apparent and who have some specified risk factors present. Examples of secondary prevention interventions for gonorrhea include screening of women to identify and treat asymptomatic gonorrhea infections and treating females whose male partners have gonorrhea. Secondary prevention strategies for gonorrhea prevent the long-term consequences of asymptomatic gonorrhea infections in women such as chronic pelvic pain, pelvic inflammatory disease, and infertility. Tertiary prevention interventions manage an existing disease with the aim of restoring a patient to their highest function, minimizing the negative ramifications of the disease, and preventing disease-related complications (Merril & Timmreck, 2006). Examples of tertiary interventions include support and counseling services for patients infected with gonorrhea aimed at preventing risk behaviors and repeat infections.
Evidence-Based Practice Recommendations
In its current and previous (2005 and 2007) recommendations, the U.S. Preventive Services Task Force (USPSTF) recommends screening for gonorrhea in all sexually active females aged 24 years and below. It also recommends similar screening for older females at increased risk for infection with the disease (B recommendation) (Zakher et al., 2014). Other bodies that have provided guidance on the issue include the American Congress of Obstetricians and Gynecologists, American Academy of Pediatrics, and American Academy of Family Physicians. These bodies recommend routine annual screening for gonorrhea in females 25 years and less who are sexually active (LeFevre, 2014). They also recommend screening for asymptomatic gonorrhea in women aged more than 25 years considered at high-risk for the infection. The CDC, on the other hand, similarly recommends annual screening for gonorrhea in sexually active women at high-risk for the infection e.g. those aged > 25 years (Zakher et al., 2014). USPSTF bases its recommendations on convincing evidence that indicates that non–nucleic acid amplification tests (NAATs) are highly precise in diagnosing asymptomatic gonorrhea. Studies have shown that these tests have a specificity of 97% and more and sensitivity of 85% and more in diagnosing gonorrhea irrespective of the specimen, test, or site (LeFevre, 2014). The recommendations are also based on evidence on risk factors that increase one’s risk for infection with gonorrhea. Such risk factors include age (15-24 years), inconsistent condom use, history of previous sexually transmitted infections, multiple or new sexual partners, and race/ethnicity (LeFevre, 2014). These risk factors form the basis for screening recommendations for high-risk populations. There is also no evidence to suggest that annual screening for asymptomatic gonorrhea in high-risk populations is harmful. Notably though, there is insufficient evidence to support annual screening for gonorrhea in gravid and non-gravid women at low risk for the disease (Zakher et al., 2014).
Conclusion
In summary, this paper has established that gonorrhea, an infection with the sexually transmitted N. gonorrhea pathogen is a significant public health problem in the US. The infection predominantly affects human beings. Compared to national incidence rates, the cases of gonorrhea infections reported in the state of California and County of Solano in 2012 were lower than national estimates. It is possible, however, that the true number of gonorrhea cases during the particular year was higher due to underreporting and asymptomatic cases. Gonorrhea has significant impacts on the community in terms of direct medical costs as it is estimated to cost the American Health system $16 billion annually. It also has intangible costs such as human suffering from chronic pelvic pain and infertility. The theoretical model applicable to the issue of gonorrhea is the epidemiological triangle because it depicts how the disease is spread. It additionally provides a framework for understanding how the spread of the infection can be prevented. Preventive measures for gonorrhea include primary, secondary, and tertiary preventive measures. Primary prevention measures are aimed at preventing the onset of disease. Secondary preventive measures foster detection of disease and in effect, facilitate early treatment and improvement of a patient’s prognosis. Tertiary prevention measures manage an existing disease with the aim of restoring a patient to their highest function. Annual screening of women considered to be at high-risk for contracting gonorrhea is recommended by various bodies. This recommendation is based on evidence suggesting that screening tests for gonorrhea are highly accurate in diagnosing asymptomatic gonorrhea infections.
References
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