Sexual and reproductive health

Partners’ meeting on Antimicrobial Resistance in N. gonorrhoeae and STI surveillance

Photo of the participants

From 25 to 27 August 2014, the WHO Department of Reproductive Health and Research convened a partners’ meeting in Geneva to advance the work on the public health challenges of controlling gonococcal antimicrobial resistance and strengthen STI surveillance to improve broader reproductive and maternal health outcomes. If not addressed, the increasing resistance of gonorrhoea will result in serious sexual and reproductive health consequences. Urgent action is needed, including strengthening surveillance efforts.

The partner’s meeting, brought together experts in gonococcal antimicrobial resistance, Sexually Transmitted Infection (STI) surveillance, microbiologists, and STI programme managers from all regions of the world, to:

  • Review implementation of the Global Action Plan on Antimicrobial Resistance (AMR) in N. gonorrhoeae including strengthening the Gonococcal Antimicrobial Surveillance Programme (GASP) and linkages with Global AMR initiative.
  • Review STI indicators implemented through the Global AIDS Response Progress Report (GARPR).
  • Discuss the feasibility of linking existing surveillance systems (GASP, GARPR) and to identify mechanisms to improve STI surveillance and estimation processes.

Conclusions and recommendations

  • There are high level of resistance in gonorrhoea to penicillin, tetracycline and ciprofloxacin. Resistance to azithromycin is being reported.. There are increasing proportions of strains with elevated minimum inhibitory concentrations (MIC) to cephalosporins, the last- line treatment for gonorrhoea, which is crucial to follow up. Gonococcal AMR will result to increase in disease rates, morbidity and transmission of HIV. Untreatable gonorrhoea is going to emerge as a silent infection with serious sexual and reproductive health consequences, if not monitored. Gonorrhoea prevention and control is essential and surveillance is paramount.
  • There is limited national leadership, commitment and funding in most countries. There is a need for greater involvement and increasing country ownerships through advocacy, capacity building, strengthening communication, and increasing linkages with broader AMR efforts.
  • It is essential to expand and strengthen gonococcal antimicrobial resistance monitoring in countries, especially in countries with high gonorrhoea burden, suboptimal diagnosis and surveillance, and where antimicrobials are easily available and lack quality control.
  • Improved AMR data are needed, including data which are comparable among countries. Efforts are needed to enhance sample size and representativeness of data, strengthen local laboratory capacity to culture N. gonorrhoeae and regularly monitor antimicrobial susceptibility of the pathogen and improve quality assurance and quality control.
  • Progress in research has been made, and understanding of the mechanisms of gonorrhoea pathogenesis has increased. New molecular methods offer opportunities for improved gonorrhoea strain detection and enhanced surveillance, however these cannot replace culture-based susceptibility testing. Further development and validation of molecular testing approaches should be promoted.
  • Current efforts to collect STI data from countries through the GARPR system should continue with no major changes to the 10 core indicators at this time. Any proposed future changes should be piloted prior to implementation in GARPR.
  • Increased support for strengthening STI surveillance in countries is needed. Incorporating input from meeting participants, WHO will work to finalize a tool for assessing STI surveillance at the country level, and support WHO Regional Office for Europe to finalize an STI surveillance training module.
  • WHO surveillance strengthening efforts should begin with a handful of countries through the establishment of a global STI sentinel surveillance system (GLOSS). The objectives of this network would be to build national STI surveillance capacity to better inform national STI programming, advocacy, and STI estimation processes, as well as contribute to the global understanding of how to strengthen STI surveillance systems. This system would build upon and be linked to efforts to strengthen GASP. Initial activities would involve implementation of a standardized gonococcal AMR monitoring protocol, and a broader STI surveillance assessment.
  • WHO global and regional estimates of the four curable STI (chlamydia, gonorrhoea, syphilis, and trichomonas) for 2012 should strive to increase the number of eligible studies, be reviewed by regional expert committees, and include discussion of uncertainty or sensitivity analyses. WHO should also work closely with global experts to improve methods for future estimates to ensure that improved data are available for a potential new global STI strategy.

Next steps

  • 1. Continue to strengthen advocacy to increase support and country engagement for AMR in gonorrhoea including strengthening communication at different levels.
  • Define the minimum package for gonococcal antimicrobial surveillance and laboratory antimicrobial susceptibility testing. Develop a standard training package and implement systematically through regional reference centres.
  • Update the WHO reference panels for external quality assessment and to ensure standardization of antimicrobial susceptibility testing of gonorrhoea.
  • Organize a GASP laboratory subcommittee that could provide immediate laboratory technical support
  • Ensure linkages between AMR in gonorrhoea and global AMR initiative.
  • Continue efforts to strengthen GARPR reporting for all countries.
  • Finalize a protocol for the establishment of a handful of initial sites for implementation of standardized global AMR monitoring and a broader national STI surveillance assessment.
  • Incorporate input from the August Geneva consultation before finalizing 2012 estimates of the four curable STI.
  • Establish a consultative group of experts to advise on improved methods for global and regional STI estimates for 2015 or beyond.