Gonorrhoea during COVID-19 in London, UK

Abstract

It is unclear how the COVID-19 pandemic has affected sexual behaviour and the transmission of STIs. Reports suggest a decline in STIs during the first COVID-19 lockdown attributed variously to fewer sexual encounters and decreased testing or case reporting. However, in some settings, diagnoses of symptomatic STIs appeared to remain unchanged. Neisseria gonorrhoeae (NG) infection of the male urethra causes symptoms in >90% of individuals but is mostly asymptomatic at other sites. As symptoms usually present within 5 days of exposure and unpleasant enough to seek assistance, urethral NG is a potential marker of recent sexual behaviour. Firstline NG treatment is a singledose ceftriaxone injection administered at medical services, whereas other STIs are standardly treated using oral antibiotics which can be sent by post or purchased online. On 23 March 2020, following instructions to avoid unnecessary travel and nonessential contact with others, the UK government introduced measures to reduce the transmission of SARSCoV-2 including home isolation and social distancing, although individuals could travel for medical care. From 13 May 2020, England’s lockdown gradually eased. In 2018, 56 Dean Street (56DS), a sexual health clinic part of Chelsea and Westminster Hospital, diagnosed 14% (7689) of England’s 56 234 gonorrhoea infections. During lockdown, 56DS limited facetoface contact using telephone triage while preserving walkin consultations for STI emergencies. Those seeking asymptomatic STI testing were directed online to obtain a postal testing kit. Where possible, STI treatments were posted. However, inclinic ceftriaxone treatment was maintained. In order to facilitate staff redeployment, Chelsea and Westminster, like other hospitals nationally, temporarily closed two of its sexual health services; 56DS remained open with normal opening hours. We present the decrease in NG at 56DS during lockdown. We hypothesise that this fall was due to a mixture of fewer consultations and a change in the case mix of presentations with fewer asymptomatic (screening) cases. Using routine clinical data, we obtained the weekly number of individuals attending 56DS who tested for NG and the number diagnosed with NG and performed a case note review of NG cases. In 2019, weekly NG cases were stable around 220 apart from decreases with sharp rebounds over Easter and Christmas reflecting reduced capacity due to holiday closures. During lockdown, weekly cases dropped from 223 (week 11) to 75 (week 16) (figure 1A). The proportion tested who had NG remained stable at 0.13 throughout 2019 and early 2020, including holiday periods (figure 1B). During lockdown, this proportion rose to 0.49 (week 15) before returning to baseline. We performed a case note review of individuals with NG in order to see if we could observe any changes in their characteristics and sexual behaviour over lockdown. We chose week 18 of 2019 (n=250) and 2020 (n=79) as it included COVID-19 lockdown and excluded Easter or May bank holiday in either year. Baseline characteristics such as age, gender and HIV status were similar in both groups (online supplemental appendix). In lockdown compared with 2019, there were fewer NG diagnosed as contacts, 6 vs 44, fewer asymptomatic NG, 14 vs 144, and similar weekly number of symptomatic NG, 42 vs 46, and NG treatments, 17 vs 16. For symptomatic NG, there was no change in selfreported number of sexual partners in the last 3 months during lockdown compared with 2019: 3 (IQR 2–6) vs 4 (IQR 3–7) (p=0.44) and median time to last sexual intercourse: 7 Research letter