WATCH ABOVE: Public Health Ontario reports a sudden spike in gonorrhea cases across the province. Sean Mallen reports
TORONTO – Gonorrhea’s making a comeback in Ontario.
That’s bad.
And the sexually transmitted infection public health officials used to consider little more than a nuisance could soon be untreatable as it becomes increasingly resistant to existing antibiotics.
That’s worse.
In the past 70 years, gonorrhea’s beaten every drug we’ve thrown at it. The antibiotics we now use are effectively the last ones in physicians’ arsenal.
“Gonorrhea has really been one of the first organisms really to potentially lose all therapies,” said Vanessa Allen, Public Health Ontario’s Chief Medical Microbiologist.
“This is really something that we should pay attention to.”
The first step: Measure it better.
Natalie Fawcett, a nurse practitioner with Toronto Public Health, sees gonorrhea cases in her Toronto sexual health clinic every day.
“Absolutely, yes, we have over the last few years been seeing more and more individuals with gonorrhea,” she said.
Fawcett attributes the increase in part to ignorance.
“I see a fair number of people coming in who swear up and down that their only possible exposure was oral sex. And I think a lot of people don’t realize that things like Chlamydia and gonorrhea can be contracted orally.”
Last year’s gonorrhea cases hit their highest point in a decade. There were 5,825 cases of gonorrhea reported in Ontario in 2014, up 28 per cent from the 4,542 found in 2013, up 42 per cent since the 4,097 reported in 2012.
The number of treatment-resistant gonorrhea cases is increasing. But public health officials can only guess by how much.
Last year, 10.1 per cent of the cases the province tested were resistant – up from 8.1 per cent the year before.
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But the province only tested 1,800 cases – barely 31 per cent of all the gonorrhea in the province last year. A few years earlier, it only tested 1,000 cases for resistance.
Ontario’s trying to do better and rely less on urine tests, which are less invasive, easier to transport and give a clear reading on whether you have the bacteria – just not much about it.
Culture tests, on the other hand, are more difficult, more painful and are generally only used when a person has gonorrhea symptoms.
“It’s like sticking a q-tip up somebody’s urethra,” Fawcett said. “And you actually have to collect some material on it for it to be cultured. So generally we don’t; it’s just too painful.”
But if you want to know not only whether a person has gonorrhea but also whether that gonorrhea is resistant to treatment, you need to send the cultured swab to a lab where the bacteria is isolated and grown.
“You can look at what type it is to see who might have transmitted it to who, you can see if it’s a clinical failure or potentially a new infection,” Allen said. “So there’s something very nice about having the organism itself.”
She notes Ontario is hardly the only jurisdiction where urine testing became the norm: A 2007 report from the U.S. Centre of Disease Control shows only 4.9 per cent of all gonorrhea tests in the United States were swabs, with more than 80 per cent urine tests.
Gonorrhea’s history of resistance
Gonorrhea has a long record of beating antibiotics.
It became resistant to penicillin in the 1980s, followed by another type of antibiotic, tetracyclines in the 1990s. In 2007, gonorrhea’s growing resistance to the antibiotic family fluoroquinolone led the CDC to recommend against using those antibiotics to treat the pesky STI.
Most jurisdictions, including Ontario, then moved to cephalosporins – the last class of gonorrhea-fighting antibiotic available – such as Ceftriaxone or Cefixime.
If gonorrhea becomes resistant to those, we’re in trouble.
“We’re at our last available drugs for the treatment of gonorrhea,” Allen said.
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By January 2013, public health officials in Ontario identified at least nine cases of oral Cefixime failing to treat gonorrhea. Given how few cases are tested, that’s likely a huge underestimation.
Public Health Ontario recommends an aggressive combination of two drugs; an intramuscular shot of 250 mg of ceftriaxone as well as one gram of another drug, azithromycin, taken orally.
Resistance is far worse in Asia, where stronger strains of gonorrhea have been spreading for years.
In 2010, Swedish healthcare workers were forced to treat a man who contracted the disease in Japan with four times the standard dose of ceftriaxone.
The following year, Japanese researchers found a strain of the infection in a Kyoto sex worker that was “highly resistant” to ceftriaxone and most other antibiotics, according to Scientific American. The person was eventually treated with intravenous antibiotics – an aggressive form of treatment.
“Canada is pretty fortunate in comparison to Japan,” Fawcett said.
Toronto Public Health does a swab test to anyone with gonorrhea symptoms, and checks back with everyone they treat about a week after treatment to ensure it actually worked.
So far, their first-line treatment has been working. But that won’t last. And they don’t yet have a backup plan.
“Gonorrhea is quite a malleable bacteria. It mutates constantly.”
An infection on the rise
Twenty-seven of Ontario’s 36 public health units have seen an increase in gonorrhea rates since 2010, according to data obtained by Global News.
The biggest increase was in Waterloo where the rate jumped from 20.3 in 2010 to 48.2 in 2014 – a 237 per cent increase.
Gonorrhea rates only fell in nine regions, the biggest shift was in Porcupine and Northwestern Ontario where the rates dropped from 102.2 to 6.9 and 162.3 to 38.2. However, both of those regions have fairly small populations, meaning a handful of gonorrhea cases can cause a dramatic shift in the rate per 100,000.
Toronto is Ontario’s gonorrhea capital, with 97.3 cases per 100,000 people in 2014 – an increase of 58 per cent since 2010.
WATCH: Education important to curb the rise of STDs like gonorrhea
In York, the rate more than doubled in the same time period. And in Peel, the rate went from 34.4 to 48.9 per 100,000.
Why so high? Public Health Ontario doesn’t know but is trying to figure it out. Officials are in the middle of an evaluation to figure out why the numbers are going up and whether the fight against drug resistance is working.
What are the symptoms of gonorrhea?
The symptoms of gonorrhea are varied and can lead to serious health problems if left untreated.
And they aren’t always easy to notice; a significant number of people who are infected show no symptoms at all or can be mistaken for a common bladder infection, according to Sexual Health Ontario.
But if symptoms do appear, they usually show within two to ten days after infection and, in women, can include pain, burning or discomfort during urination, bleeding during or after sex, abnormal bleeding between periods, vaginal discharge, and pain during sex.
For men, symptoms can include burning during urination, a white, yellow or green discharge, itching around the urethra, and painful or swollen testicles.
Oral sex can allow gonorrhea to affect a person’s throat and cause a sore throat or swollen glands. The disease can also infect the anus and lead to discharge, bleeding, itching and soreness.
What does gonorrhea do if left untreated?
The disease is oftentimes asymptomatic and can lead to people leaving it untreated. If allowed to linger, gonorrhea can cause serious health problems including a serious infection of the womb and tubes known as pelvic inflammatory disease, infertility, and ectopic pregnancy.
In men, the disease can cause sterility or prolonged burning or discomfort while urinating.
Gonorrhea can also cause eye infections or arthritis and if a woman is pregnant, it’s possible gonorrhea can be passed down to their child.
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