Gonorrhea Outbreak in New Hampshire

January 23, 2017

Key Points and Recommendations:

  • New Hampshire is experiencing an outbreak of gonorrhea. There has been a more than 250% increase in the number of gonorrhea cases in 2016 compared with prior baseline.

  • Many clinicians are not treating correctly and we ask you to urgently review the current treatment guidelines, which specify the need for dual antibiotic therapy to prevent antibiotic-resistant gonorrhea.

  • Healthcare providers should routinely ask their gonorrhea patients to estimate the number of sexual partners they have had in the past 60 days, and help communicate the need for partners to be tested and treated for gonorrhea.

  • Clinicians should offer clinic appointments for sex partners, or instruct partners to be evaluated by their own primary care providers or through other low/no-cost options. Options are listed in the STD Partner Agencies list below and should be given to patients to give to their sex partners. Additional resources for patients and sex partners can be found on our website.

  • Please report all cases of gonorrhea, along with any information about sex partners, to the NH Department of Health and Human Services (DHHS), Division of Public Health Services (DPHS) at 603-271-4496.

  • DPHS will support clinicians by:

    1. Contacting sex partners of individuals diagnosed with gonorrhea

    2. Reviewing patient treatment regimens and offering clinicians and practices in-service training on the current treatment guidelines

Situation:

New Hampshire has seen an unprecedented increase in the number of gonorrhea cases. Between 2007 and 2013, approximately 130 cases per year were reported to DPHS. For 2016, 465 cases have been reported, which represents a more than 250% increase. Most cases have been in males and in those under 40 years of age. The greatest number of cases has been seen in Hillsborough County, followed by Rockingham, Merrimack, and Strafford Counties.

The majority of gonorrhea cases (75%) were diagnosed in either private clinician offices, or in an emergency department or urgent care setting. Based on preliminary data, approximately 25% of patients diagnosed with gonorrhea in 2016 were not correctly treated initially according to current Centers for Disease Control and Prevention (CDC) recommendations; this is similar whether a patient was treated in a clinician office, or in an emergency department or urgent care setting.

CDC 2015 Sexually Transmitted Diseases (STD) Treatment Guidelines:

The CDC has identified drug-resistant gonorrhea as one of the top three urgent national threats for antibiotic-resistance infections. Because of concern for increasing antibiotic resistance, the current CDC 2015 STD treatment guidelines require treatment of gonorrhea infections with two different antibiotics to prevent antibiotic resistance. Single drug regimens should not be used.

Due to emerging antibiotic resistance, the only recommended treatment for gonorrhea (cervical, urethral, rectal, or pharyngeal infection) is a two-drug regimen consisting of IM ceftriaxone and oral azithromycin:

Recommended Regimen

Ceftriaxone 250 mg IM in a single dose

PLUS

Azithromycin 1 g orally in a single dose

 

Oral cefixime is no longer routinely recommended because blood and tissue levels are lower than with IM ceftriaxone, and gonococcal isolates with reduced susceptibility to cefixime have been increasing. Oral cefixime (in combination with oral azithromycin) is only recommended if IM Ceftriaxone is not available. Doxycycline is also no longer a recommended therapy due to increasing tetracycline resistance, but can be considered as a part of dual therapy for azithromycin allergic patients.

Alternative Treatment Regimens for Gonorrhea:

  • Cefixime 400 mg orally in a single dose PLUS azithromycin 1g orally in a single dose is an alternative regimen only if IM Ceftriaxone is not available, and should only be considered for uncomplicated urethra, cervix, and rectum infections (not pharyngeal infections).

  • For patients with an azithromycin allergy, doxycycline 100 mg orally twice daily for seven days can be substituted for azithromycin (in combination with ceftriaxone 250 mg IM).

  • For patients with a cephalosporin allergy, the following regimens can be considered:

    1. Gemifloxacin 320 mg orally in a single dose PLUS azithromycin 2g orally in a single dose (note, there is currently a national shortage of Gemifloxacin).

    2. Gentamicin 240 mg IM in a single dose PLUS azithromycin 2g orally in a single dose.

Screening for Gonorrhea:

Healthcare providers should take sexual histories on all patients and test for STDs based on patient risk. Patients should be screened at the site of exposure. If patients engage in oral or anal sex, for example, they should be screened for gonorrhea in the oropharynx and rectal areas, respectively. Screening should include, but is not limited to, the follow:

  • Persons who are sexually active with a partner who was diagnosed with gonorrhea should be evaluated, tested, and empirically treated (i.e., do not wait for test results to return before treating).

  • Any patient reporting high-risk sexual activity should be screened. This includes new or multiple sex partners, unprotected sex, a sex partner with an STD, exchanging sex for money or drugs, men who have sex with men (MSM), etc.

  • All sexually active females aged <25 years, regardless of risk, should be screened annually for Chlamydia trachomatis and Neisseria gonorrhoeae.

  • Men who have sex with men (MSM) should be screened at least annually or sooner depending on risk.

  • Women ≤35 years old and men <30 years old in correctional facilities.

Additional Information and Resources:

  1. CDC 2015 STD treatment (and screening) guidelines

  2. STD screening recommendations

  3. CDC report on emerging Neisseria gonorrhoeae antibiotic resistance

  4. CDC STD home page

  5. CDC: A Guide to Taking a Sexual History

  6. NH STD/HIV Surveillance Report 2011-2015

  7. NH Gonorrhea Outbreak website

  8. National Network of STD Clinical Prevention Training Centers (NNPTC) maintains an online clinical consultation service called the STD Clinical Consultation Network (STDCCN)

For any questions regarding the contents of this message, please contact NH DHHS, DPHS, Bureau of Infectious Disease Control at 603-271-4496 (for urgent matters after hours: 603-271-5300).

Sexually Transmitted Disease (STD) Partner Agencies

These agencies provide full STD testing and treatment services, as well as testing for Human Immunodeficiency Virus (HIV) and Viral Hepatitis C (HCV). Please contact the agency directly for more information about walk-in hours and appointment availability.

If you are concerned that you have been exposed to gonorrhea or a partner has told you that they have gonorrhea, please notify the agency when you call and testing and treatment for gonorrhea will be provided at no cost. Additional STD, HIV and HCV services are provided at low-to-no cost.

MANCHESTER HEALTH DEPARTMENT

1528 Elm Street
Manchester, NH
Tel: 603-624-6466

NASHUA DIVISION OF COMMUNITY AND PUBLIC HEALTH SERVICES
18 Mulberry Street
Nashua, NH
Tel: 603-589-4500

 

Primary Care and/or Family Planning Partner Agencies

Please contact these agencies to learn more about affordable testing and treatment for gonorrhea and other STDs, including HIV:

 

AMMONOOSUC COMMUNITY HEALTH SERVICES
25 Mt Eustis Road
Littleton, NH 03561
Tel: 603-444-2464
LAMPREY HEALTH CARE – RAYMOND
128 Route 27
Raymond, NH 03077
Tel: 603-895-3351
CAP BELKNAP/MERRIMACK COUNTY
121 Belmont Road
Laconia, NH 03246
Tel: 603-524-5453
MANCHESTER COMMUNITY HEALTH CENTER
145 Hollis Street
Manchester, NH 03101
Tel: 603-626-9500
CONCORD HOSPITAL - FAMILY HEALTH CENTER
250 Pleasant Street
Concord, NH 03301
Tel: 603-227-7000
MANCHESTER COMMUNITY HEALTH CENTER (CHILD HEALTH SERVICES)
1245 Elm Street
Manchester, NH 03101
Tel: 603-629-9707
COOS COUNTY FAMILY HEALTH SERVICES
54 Willow St.
Berlin, NH 03570
Tel: 603-752-3669
MANCHESTER HEALTH DEPARTMENT (Manchester Healthcare for the Homeless)
1528 Elm Street
Manchester, NH 03101
Tel: 603-624-6466
EQUALITY HEALTH CENTER (formerly CONCORD FEMINIST HEALTH CENTER)
38 South Main Street
Concord, NH 03301
Tel: 603-225-2739
MID-STATE HEALTH CENTER
101 Boulder Drive, Suite 1
Plymouth, NH 03264
Tel: 603-536-4099
FAMILIES FIRST OF THE GREATER SEACOAST
100 Campus Drive, Suite 12
Portsmouth, NH 03801
Tel: 603-422-8208
NEW LONDON HOSPITAL ASSOCIATION, INC (Newport Health Center)
273 County Road
New London, NH 03257
Tel: 603-526-5512
FEMINIST HEALTH CENTER OF PORTSMOUTH/LOVERING HEALTH CENTER
559 Portsmouth Avenue
Greenland, NH 03840
Tel: 603-436-7588
PLANNED PARENTHOOD OF NORTHERN NEW ENGLAND - DERRY
4 Birch St.
Derry, NH 03038
Tel: 603-434-1354
GOODWIN COMMUNITY HEALTH CENTER
311 Route 108
Somersworth, NH 03878
Tel: 603-516-2550
PLANNED PARENTHOOD OF NORTHERN NEW ENGLAND - EXETER
108 High St.
Exeter, NH 03833
Tel: 603-772-9315
HEALTH FIRST FAMILY CARE CENTER
841 Central St.
Franklin, NH 03235
Tel: 603-934-0177
PLANNED PARENTHOOD OF NORTHERN NEW ENGLAND - KEENE
8 Middle St.
Keene, NH 03431
Tel: 603-352-6898
HARBOR HOMES
45 High Street
Nashua, NH 03060
Tel: 603-882-3616
PLANNED PARENTHOOD OF NORTHERN NEW ENGLAND - MANCHESTER
24 Pennacook St.
Manchester, NH 03104
Tel: 603-669-7321
INDIAN STREAM HEALTH CENTER
141 Corliss Lane
Colebrook, NH 03576
Tel: 603-237-8336
WEEKS MEDICAL CENTER - LANCASTER
173 Middle Street
Lancaster, NH 03584
Tel: 603-788-4911
LAMPREY HEALTH CARE - NASHUA
22 Prospect Street
Nashua, NH 03060
Tel: 603-659-2494
WEEKS MEDICAL CENTER – WHITEFIELD
24 Lancaster Road
Whitefield, NH 03598
Tel: 603-837-9005
LAMPREY HEALTH CARE – NEWMARKET
207 South Main Street
Newmarket, NH 03857
Tel: 603-659-3106
WHITE MOUNTAIN COMMUNITY HEALTH CENTER
298 White Mountain Highway
Conway, NH 03818
Tel: 603-447-8900

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