Gonorrhea Surveillance in Ghana, Africa

BRIEF REPORTS MILITARY MEDICINE, 180, 1:17, 2015 Gonorrhea Surveillance in Ghana, Africa Christopher Duplessis*; Naiki Puplampu†; Edward Nyarko‡; Joh...
6 downloads 0 Views 463KB Size
BRIEF REPORTS MILITARY MEDICINE, 180, 1:17, 2015

Gonorrhea Surveillance in Ghana, Africa Christopher Duplessis*; Naiki Puplampu†; Edward Nyarko‡; John Carroll‡; Helena Dela†; Akussah Mensah‡; Akussah Amponsah‡; COL Jose Sanchez, MC USA (Ret.)§ ABSTRACT Objectives: We face the specter of global transmission of highly resistant Neisseria gonorrhoeae. The U.S. Department of Defense’s Armed Forces Health Surveillance Center has engaged many military and civilian partners (including Ghana) in a sexually transmitted infections (STI) program to address emerging needs in STI surveillance. We implemented gonorrhea surveillance in Ghana to fill the gap in knowledge regarding gonorrhea prevalence and antimicrobial resistance characterization in Ghana. Methods: Gonorrhea surveillance was conducted from June 2012 to March 2013 as one of the AFHSC surveillance network partners at two Ghana Armed Forces (GAF) military clinics. The population encompassed a convenience sampling of patients presenting with STI symptoms. Urine was taken for nucleic acid amplification testing (NAAT). A urethral or cervical/vaginal specimen was obtained for culture and antibiotic susceptibility testing. Results: 13/220 (6%) specimens tested were positive by culture (7 of which were confirmed); and 39/213 (18%) specimens tested were positive by NAAT. Positive results were biased toward men. Cultures were resistant to ciprofloxacin, penicillin and tetracycline and sensitive to cephalosporins. Conclusion: This investigation provides data on gonorrhea prevalence and resistance profiles in Ghana hitherto poorly characterized. We note significant resistance to fluoroquinolones without the presence of resistance yet to the cephalosporins.

INTRODUCTION Emergence of multidrug resistant (MDR) Neisseria gonorrhoeae is a major global public health issue. The WHO estimates over 498 million new cases of sexually transmitted infections (STI) annually in adults aged 15 to 49 years.1 STIs engender appreciable health care costs ranking among the top five indications for adults seeking medical treatment in developing countries. Gonorrhea is one of the most *Naval Medical Research Center, Biological Defense Research Directorate, Silver Spring, MD 20904. †U.S. Naval Medical Research Unit No. 3, NAMRU-3, PSC 452 Box 5000, FPO AE 09835-9998, 3A Imtidad Ramses Street, Adjacent to Abbassia Fever Hospital Abbassia, Cairo, Egypt 11517. ‡Ghana Armed Forces, Ghana Africa General Headquarters Burma Camp-Accra. §Armed Forces Health Surveillance Center (AFHSC) and Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), 11800 Tech Road, Suite 220, Silver Spring, MD 20904. Mention of any commercial product does not imply DoD endorsement or recommendation for or against the use of any such product. No infringement on the rights of the holders of the registered trademarks is intended The opinions stated are those of the authors and do not represent the official position of the U.S. Department of Defense, Ghana Ministries of Health, Agriculture, or Defense, or other contributing network partner organizations. doi: 10.7205/MILMED-D-13-00418

prevalent etiologies of STIs both in the United States and worldwide,2,3 an appreciable percentage of which is shouldered by developing countries. Well-described complications and morbidity include increasing HIV acquisition and transmission. N. gonorrhoeae has developed increasing resistance to antimicrobials, including the fluoroquinolones (FQ) and, more recently, cephalosporins necessitating increasing vigilance to STI surveillance. N. gonorrhoeae is particularly adept at developing resistance to antibiotics via a host of mechanisms including mutations, and promiscuous genetic transfer; seamlessly developing resistance to each class of antimicrobial introduced.4 FQs emerged in the 1980s, recommended as first-line treatment by the Center for Disease Control (CDC) in 1993.5 Alas, soon thereafter, resistant isolates emerged via mutations in the gyrA and parC genes.5 Mirroring trends in global resistance transmission, FQ resistance surfaced in the Far East and migrated westward.4 As of 2007, FQs were no longer recommended by the CDC, deferring to the third-generation cephalosporin antibiotics (including the orally administered cefixime and ceftriaxone).4,6 The inexorable resistance propensity of N. gonorrhoeae has engendered the emergence of strains resistant to cefixime and ceftriaxone. Treatment failures with cefixime have been

MILITARY MEDICINE, Vol. 180, January 2015 Downloaded from publications.amsus.org: AMSUS - Association of Military Surgeons of the U.S. IP: 037.044.207.154 on Jan 15, 2017. Copyright (c) Association of Military Surgeons of the U.S. All rights reserved.

17

Gonorrhea Surveillance in Ghana, Africa

verified in Japan, Norway, England, Austria, France, Canada, Vietnam, England, Wales, and Sweden.7–10 Cefixime resistance of 3.5% was reported in isolates acquired in Norway in 200911; and 1% cefixime resistance in British Columbia in isolates acquired between 2007 and 2011.12 European gonorrhea surveillance (Euro-GASP) noted that 31% of isolates in 2009/2010 exhibited decreased susceptibility to cefixime (MIC > 0.125 mg/L).13 Decreased susceptibility or frank resistance to cefixime increased from less than 1% to 8% in Sweden from 2007 to 2011.14 Per the Gonococcal Isolate Surveillance Project (GISP), from 2000 to 2010 in the United States, the percentage of isolates with elevated MICs (>0.25 mg/mL for cefixime) increased from 0.2% to 1.4%. The increases were most pronounced in known highrisk groups including men having sex with men (MSM).5 Recently, ceftriaxone-resistant isolates have been identified in Japan (2009), France (2010), Vietnam,9 Norway11 (2009), and Spain (2011).15,16 Decreased susceptibility to ceftriaxone was reported in Sweden (2007–2011),14 China17 (2005–2008), and Australia (2010).18 The GISP network in the United States revealed an increase in elevated MICs to ceftriaxone from 0% to 0.4% from 2006 to 2011. Ceftriaxone treatment failures of pharyngeal gonorrhoea have been verified in Sweden (2010), and Slovenia (2011).14,15 Thus, there is concern over the potential widespread emergence of N. gonorrhoeae resistance to cephalosporins. Gonorrhea resistance may be predicted in Ghana given contemporary (1) indiscriminate antimicrobial use, (2) lack of antimicrobial stewardship, (3) suspect antimicrobial compliance, (4) increase in cosmopolitan lifestyle and migration, and (5) lack of laboratory infrastructure. We implemented gonorrhea surveillance in Ghana as an integral component of the AFHSC-GEIS supported STI program to fill the gap in knowledge regarding gonorrhea prevalence and antimicrobial resistance characterization. METHODS Participating facilities included three outpatient military clinics of the Ghana Armed Forces in the port city of Takoradi, and the 37 Military Hospital (Accra, Ghana). These military clinics serve the military, their dependents, and civilian population in their catchment area (comprising about 80% of the census). Subjects were 12 years of age and older (those 0.001) and not significant for gender and Chlamydia NAAT ( p = 0.2). Age showed a trend toward significance by Fisher’s exact testing for gonorrhea NAAT ( p = 0.086) and for Chlamydia NAAT ( p = 0.663). The concordance rate (gonorrhea culture + accompanied by gonorrhea NAAT +) was 13/13 (100%); while the concordance rate (gonorrhea NAAT + accompanied by gonorrhea culture +) was 13/38 (34%). The seven confirmed specimens were all resistant to ciprofloxacin, penicillin, and tetracycline, and sensitive to ceftriaxone and cefixime. Six of seven specimens were sensitive to spectinomycin. DISCUSSION Treatment options are becoming limited given the increasing antibiotic resistance in the absence of novel antimicrobials in the pipeline. The emergence of MDR N. gonorrhoeae is ushering in an era of untreatable gonorrhea. Therefore, surveillance for gonorrhea and resistant gonococcal isolates coupled to an integrated public health response is required to (1) expedite identification and subsequent containment of resistant isolates mitigating transmission; (2) optimize individual-level treatment; (3) contribute to local, regional, TABLE I.

Results of Gonorrhea and Chlamydia Culture and NAAT Testing Stratified by Age and Gender* Culture +

Gender

a

and national surveillance networks; (4) support epidemiologic investigations, (5) facilitate lab capacity in cultures and AST; and (6) identify risk factors for harboring gonorrhea and resistant isolates that will assist policy makers in allocating limited resources for the adoption of prevention, health promotion, and educational campaigns targeting at-risk populations.20 This concerted surveillance strategy will extend the duration of efficacy of the few existing antimicrobial drug options in our armamentarium for treatment of gonorrhea.6 The preponderance of resistant gonococcal isolates has hitherto been identified through active surveillance networks thus substantiating the efficacy of maintaining global surveillance. The mission of the Global Emerging Infections Surveillance and Response System Division at the U.S. Department of Defense’s (DoD) Armed Forces Health Surveillance Center (AFHSC-GEIS), is to develop, implement, support, and evaluate an integrated global emerging infectious disease surveillance and response system that contribute to enhancement of U.S. Forces’ health, the collaborating host nations Public Health Systems, and the global public health community. The consortium’s objectives in establishing global STI surveillance networks have been described elsewhere.21 There is a dearth of cross-sectional and longitudinal gonorrhea surveillance in West Africa (including Ghana). These countries are not engaged in surveillance activities due to limited resources in addition to potential impeding cultural issues (possible aversion to stigmatization and clinical invasiveness). Cross-sectional investigations have been conducted in Uganda, Benin, Malawi, Tanzania, Zimbabwe, Ethiopia, and Kenya focusing on gonorrhea incidence and acquisition of risk factors, but longitudinal studies are lacking as are data on resistance levels. Mirroring developed nations, the emphasis on STI syndromic management has stagnated the development of clinical laboratory capacity to execute N. gonorrhoeae AST.5 Implementing surveillance networks throughout Africa will contribute to the global surveillance networks serving as a beacon on potential resistant isolates migrating into and out of the continent.

Gonorrhea NAAT +a

Chlamydia NAAT +a

Age

M

F

M

F

M

F

M

F

Age