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A prominent theme today is the influence of dynamically changing demographic and sociocultural forces on the spread of sexual transmitted diseases (STDs). In most industrialised countries the incidence of classic STDs such as gonorrhoea has been declining rapidly among the educated middle and upper classes.1,2
The aim of this study was to evaluate a gonorrhoea case finding programme which took place in Athens from 1974 to 1998 (25 years).
Patients and methods
The study was approved by the Greek ethics committee.
The gonorrhoea case finding and treatment programme took place between 9 am and 12 noon on 6 days per week between 1 January 1974 and 31 December 1998. People were recruited for examination in “A Syngros” Hospital, Athens, then taken to the same hospital for further investigation and treatment.
Direct microscopy and culture were the mainstay of gonorrhoea diagnosis. Samples could be Gram stained and examined by light microscopy to yield a diagnosis within 5 minutes. Accuracy varied with the site sampled and the experience of the microscopist. If there was a strong likelihood of infection and if presumptive treatment had not been given, a second or even third set of cultures performed on subsequent occasions maximised detection.3
Isolation of gonococci was also improved by the parallel use of selective and non-selective media. In practice, acceptable results were active with moderately selective media. Carbohydrate utilisation tests or newer methods such as co-agglutination and chromogenic enzyme substrates were used.
Patients were interviewed, informed of potential side effects, and asked to sign a form allowing treatment. Penicillin cured more than 90% of all gonorrhoea infections. By the late 1980s, penicillin therapy for gonorrhoea was no longer recommended because of widespread gonococcus resistance. Instead, another relatively inexpensive drug, such as tetracycline, ciprofloxacin, ofloxacin, cefriaxone, or quinolones, became widespread in Greece. Because clinical series have historically documented co-infection with Chlamydia trachomatis in patients with gonorrhoea—as high as 20%—routinely co-treating for chlamydia in all cases of gonorrhoea has been an important public health measure for chlamydia control. Consequently, either azithromycin or doxycycline should be given.4–6
Figure 1 shows new gonorrhoea cases for each year between 1974 and 1998 in men and women. During this programme 1 643 823 subjects were examined, of whom 858 879 (52.2%) were males and 784 944 (47.8%) were females. Among positive cases 9834 (98.6%) were males and only 143 (1.43%) were females, 735 (7.5%) males and 14 (9.79%) females were asymptomatic (carriers) when discovered.
In addition, the median age of the total examined subjects was 20 years (range 18–39 years). For men, all age strata remained stable from 1974 to 1981 followed by a sharp drop, the minimum occurring in 1996. In contrast, the notified women were on average younger than men. Although the total number of the identified cases declined to a minimum, from 1989 up to the end of this study, 50/690 (7.3%) males and 2/14 (14.4%) females were discovered to have both gonorrhoea and chlamydia infection.
As was expected urethritis was the predominant clinical finding (95%) among men followed by a gonorrhoea infection of the rectum which was very common among male homosexuals (41%). The cervix was most often affected in women (43%).
Additionally, data available from this programme for active gonorrhoea among occupational groups are presented in table 1.
During the past 25 years major changes have been made in the notification of new gonorrhoea cases, especially those related to the male population. From 1974 to 1984 the new cases among males were over 450 per year and thereafter gradually declined.
In contrast, during the same period of study the number of cases among women remained almost stable. It is estimated that the affected males visited our hospital much more often because their symptoms were obvious and severe and they had not been afraid of social stigma associated with their examination for the disease. Interestingly, the observed very small number of female patients could be because of self treatment, the fear of a social stigma, and/or a general unwillingness to be examined by a doctor.
In addition, the observed continuing decline in the incidence of the disease as well as in the absolute number of the identified cases, especially in men, from 1984 up to the end of 1998 could be due to the following reasons: (a) the better standard of living, (b) the use of a condom as a preventive measure against AIDS,7 (c) a higher education level, and/or (d) the opportunity of a medical examination in a private venereal clinic, avoiding self presentation to our department.
On the other hand, the median age of gonorrhoea cases as well as the number of the identified cases showed a continuing decline, which stopped from 1981 to the end of 1984, when a strong wave of immigration from eastern Europe, especially from Russia, moved to Greece. It is well documented that during this period STDs had shown a rapid and substantial increase in eastern Europe.8
The incidence of co-infection with gonococci and chlamydia (7.3% and 14.4% for men and women, respectively) was not greater compared with that in other countries.6
Furthermore, serial surveys provided the useful information that prostitutes and especially people (clients), who had sexual contacts with them, shared the greatest proportion of gonorrhoea cases as a consequence of the Greek law which obliged this occupational group, but not the clients, to be “followed up” monthly. The hotel workers, who might indirectly relate to the previous occupational group, were found as the third most affected occupational group whereas the seafarers, who could directly relate to the above occupational groups in Greece and other foreign countries, were also highly affected.9–11 Homosexuals and the users of illicit drugs were similarly affected.
However, people with better education and higher standard of living such as workers in schools, nurseries, food retailers and wholesalers shared a low proportion of the positive cases in this study.12
The high percentage of early diagnosed cases (which were asymptomatic) among the case patients suggested that this preventive measure reduced transmission, since asymptomatic men accounted for a disproportionate share of STD transmission and were unlikely to seek medical attention on their own.10,11
Thus, an approach, such as the present study, might be recommended for people recruited for examination. Furthermore, the possibility of incorporating other cities in this programme could also offer a valuable nationwide profile of STDs.
Contributors: SG followed up the gonorrhoea cases; KHS analysed the positive cases and wrote the manuscript; CG enrolled a number of the participants of the programme and found the recent references; GAK did the laboratory tests.