Gang-related Outbreak of Drug Resistant Gonorrhea in Colorado, 1990

Description of the outbreak

The health department of Colorado reported an outbreak of Sexually Transmitted Disease (STD) in April 1990. In early 1990s, Gonorrhea was one of the major STDs reported in Colorado, Western United States. The El Paso County Health Department (EPCHD) identified the outbreak of penicillinase-producing Neisseria Gonorrhea (PPNG) in April 1990 with other STDs. Together with the health department of Colorado; EPCHD investigated patients and revealed 56 cases of PPNG including new patients who were never identified with any STDs before. Different methods from traditional referrals were used to extract details from patients; Ethnographic method to identify other patients who may have affected by the disease. In addition, they used network analysis to gain further information.

These investigations revealed further details of the adolescent association within 578 individuals. Out of 578, 410 were associated with street gangs and connected with cocaine trade in Los Angels, California and moved to Colorado after May, 1988. They also reported that most of them were between 19-20 years old, most men were black in color and women were diverse in race and ethnicity. Additionally they reported that the individuals from the gang had multiple sex partners and involved in multiple risky activities resulted in the transmission of STDs. The department revealed further information; women who involved in frequent sexual encounters with multiple partners and exchanged cocaine for sex. Further investigations revealed that men were heavily using cocaine and had numerous risky sexual activities with multiple sex partners. In the subset of 410 who were associated with street gangs, 77.5% (300) were screened for other STDs in medical facilities, clinics and health departments. The health department revealed that 83% (248) were diagnosed with one or more STDs. Further laboratory diagnostic assays revealed total of 390 confirmed sexually transmitted infections (STI). Also they reported 2 persons out 248 had early syphilis infection with PPNG. Statistical analysis revealed that, relatively higher proportions of patients who had PPNG (39) were also infected with chlamydia trachomatis; 46% (18) and, 29% (64 out of 200) were diagnosed with non-resistant gonorrhea and Chlamydia trachomatis.

Further investigation of 248 patients who had one or more STDs revealed that they had 558 sex partners and 571 others from socio-sexual associations. Of 571, 390 sexually transmitted infected patients were identified. In the subset of 91 out of 390 were diagnosed with PPNG (12), genital chlamydia infection (55), gonococcal infection (62), and one syphilis infection in the socio-sexual network. The health department of Colorado’s study unravelled that, 70% of the PPNG cases reported in the period of 1989 to 1991 were gang-related; 39 were gang-related in the total of 56 cases. Sex partners of this gang were identified with other infections as well; gonorrhea infection (261 in a total of 1170), chlamydia infection (127 in a total of 1164) and syphilis infection ( 2 in a total of 18) in the period of 1990s. RG et al, 1993 also stated that, previously PPNG was a sporadic case; only 105 cases reported between 1976-1989 and identified only in military personnel who returned from Asia. This was the first epidemic PPNG outbreak, revealed further information of previously unidentified major group who contributed to the transmission of STDs in the period of 1990s and the importance of awareness in youngsters.

Description of the organism

Emergence of antimicrobial resistant strains is one of the major threats to our health. One of such organisms is Neisseria gonorrhea (N.Gonnorhea) or gonococcus, gram-negative aerobic bacteria classified under Proteobacteria phylum and Betaproteobacteria class. N.Gonnorhea, is a non-spore forming, non-motile bacterium, appears as kidney shaped beans under microscope. N.Gonnorhea has long pili and commonly seen in neutrophils of the host, appears in pairs hence called as diplococci. Gonococcus has a thin outer membrane made up of phospholipids, proteins and lipo-oligosaccharides that lack usual o-antigen repeats. N.Gonnorhea is believed to spread pathogenesis through outer membrane fragments called ‘blebs’ during infection. There are seventy strains of Neisseria. However, only eleven strains could inhabit humans. Of eleven types, only two types can cause serious illnesses; gonorrhea by N. gonorrhoeae and N. meningitides cause bacterial meningitis. N.Gonnorhea can cause serious STDs like gonorrhea or other forms of diseases; arthritis and gonnococcemia. One of the crucial structural advantages of N.Gonnorhea is pili which are used to penetrate into host, genetic alteration by recombination and movement.

N.Gonnorhea is transmitted through sexual/ oral interaction with the asymptomatic carriers or patients. Males get infected in urethritis, hardly the infection could affect other areas and cause epididymitis and penile lymphangitis. Females get infected through endocervix, could lead to vaginal discharge and irregular menstrual cycles. Generally gonorrhea is asymptomatic in male and female. However sometimes, females show mild symptoms and mistaken for other regular health implications. If left untreated N.Gonnorhea has the ability cause pelvic inflammatory disease (PID) and infertility in women. If a pregnant woman is infected with N.Gonnorhea, she can pass it to baby through the birth canal which may result in blindness or blood infection of the baby. In male untreated gonorrhea could lead to epididymitis and at times infertility.

Currently gonorrhea is diagnosed in laboratories through microscopic studies-gram staining, nucleic acid amplification testing (NAAT)- polymerase chain reaction (PCR), quantitative PCR (qPCR). NAATs were introduced in late 1990s therefore during the outbreak of gonorrhea in 1990s, culture methods/microscopic studies were used to diagnose gonorrhea; swabs from affected area and urine were tested from patients. Due to serious health implications caused by N.Gonnorhea and high probability of other STIs, it is important to treat gonorrhea.

Historically during 1970s-1980s penicillin was one of the major drugs used to treat gonorrhea. However due to heavy use of penicillin N.Gonnorhea developed resistance through chromosomal mutation and penicillinase mediated resistant; PPNG has developed the ability to spread more in the presence of penicillin drug. Since N.Gonnorhea developed antimicrobial resistance against penicillin, Fluoroquinolones was suggested for the patients. However due to the resistance developed against quinolone currently dual drugs or cephalosporins are recommended to treat gonorrhea. Paola Stefanelli et al, 2017 states that N.Gonnorhea has developed numerous mechanisms against the drugs in the market through mutation and gene transfer. N.Gonnorhea that carries β-lactamase gene (blaTEM) resulted in PPNG. Paola Stefanelli et al, 2017 also revealed that PPNG is emerging with single or poly nucleotide mutation in the blaTEM gene. This pathogen has the ability to evade immune system through antigenic variations; changing the composition of the pili.

Impact on public health

EPCH and the health department of Colorado used network analysis and revealed that young group of men and women were associated with street gangs and these observations were within the same race and age. Especially patients with gonorrhea and other STDs were increasing ethnically with black men and women, and surprisingly white men and women who were predominantly affected by gonorrhea and other STDs were decreasing during 1990s.

The health department of Colorado and EPCH used network analysis to break the transmission chain to identify the patients (symptomatic), carriers (asymptomatic) and treated them. Although more details of preventative initiative taken in Colorado is not available in the article published by RG et al, 1993, another source from CDC states that department of health and human services of America introduced ‘Healthy people 2000’ in September 1990 to end the century with healthy people. Their main objectives were to promote health and wellness through preventative techniques; immunization, educational programs, mental health services for drug addicts. This was announced nationally, however the goals were accomplished through local provincial government’s efforts. Detailed information regarding Colorado’s efforts and how much they were able to control the outbreak of STDs and reduce the drug use during 1990s is not available.

Reflection and Analysis

Although this article discussing about an outbreak occurred in 1990s, I personally believe that they should have approached it differently regardless of the technologies available at that time. I strongly believe that the health department of Colorado should have announced for an immediate medical testing for STDs among teenagers and adults as the patients ages were between 15-40 years. Since the major contributors were from outside of Colorado, they should have introduced medical certificate of STIs screening for new comers of Colorado. Most importantly counselling regarding mental health and addiction for those who were affected with the disease, drug addicts, and other healthy teenagers, young adults to overcome their risky sexual activities with strangers and to stop using drugs.

I believe prevention is better than treatment; they should have promoted health care seeking behaviour in young adults especially women who were embarrassed about STDs and partner referrals. They should have educated patients about the mode of transition even if they were treated, they may still have infection which could transmit to others during intercourse. They should have promoted education regarding use of condoms and cheaper good quality condom access to those were sexually active. According to CDC published article there was an increase in the percentage of gonorrhea in 1997 suggesting that the government of the United states should have stressed local governments to promote STDs counselling. According to world health organization (WHO), to reduce expensive laboratory tests ‘syndrome management’ methods were used to treat patients during 1990s. for example patients who were ‘suspected’ to have STDs were directly treated for two or more STDs resulted in asymptomatic patients/carriers. Most importantly, the government of America should have initiated and invested money in research to study the sensitivity and specificity of drugs by monitoring patients for awhile.

References

1. Centers for Disease, C., & Prevention. (1993a). Gang-related outbreak of penicillinase-producing Neisseria gonorrhoeae and other sexually transmitted diseases--Colorado Springs, Colorado, 1989-1991. MMWR Morb Mortal Wkly Rep, 42(2), 25-28. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/8419788
2. Centers for Disease, C., & Prevention. (1993b). Gonorrhea--Colorado, 1985-1992. MMWR Morb Mortal Wkly Rep, 42(14), 267, 273-265. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/8459797
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8. Stefanelli, P., Carannante, A., Bonanno, C. L., Cusini, M., Ghisetti, V., Mencacci, A.Vacca, P. (2018). Molecular Characterization of Penicillinase-Producing Neisseria gonorrhoeae Isolated in Two Time Periods, 2003-2004 and 2014-2015, in Italy. Microb Drug Resist, 24(5), 621-626. doi:10.1089/mdr.2017.0218
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