Gonorrhea in Canada

This transcript is the automated English captions in the recordings. The text may not align with the audio and there may be errors the transcript.

Tatum Le: Perfect. Well, good afternoon and welcome everyone. my name is Tatum Le and I'm pleased to be moderating today's session as part of the Public Health Agency of Canada's Communicable Diseases Infection Control webinar series. 

Thank you so much for making the time to be with us today. While we do meet virtually today, I want to take a moment to acknowledge the lands we are gathered on. So from coast to coast to coast we are each situated on the traditional and unsurrendered unceded territories of the First Nations, Inuit and Metis people. 

I, myself, am joining you today from Tiohtià:ke, also known as Montréal, which is located on the  territory of the Kanien’kehà:ka Nation. This land has long served as a place of meeting and exchange among many Indigenous Peoples. 

So as we move forward with today's session, let us reflect on our shared commitment to walk in partnership with Indigenous Peoples and to promote culturally safe person- centered care that respects diverse languages, traditions and lived experiences. 

So this webinar will be conducted in English and simultaneous interpretation in French can be accessed through selecting the interpretation button in the menu at the bottom of your screen. Following today's webinar, a copy of the presentation deck and recording as well as a feedback form will be sent to you.  

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We'll address as many as possible during the panel discussion at the end of the presentations. And one last thing, if you prefer to remain anonymous, you can always check the send anonymously box when submitting your question.  

Now I'm pleased to introduce our speakers for today's session. 

Lillian Lourenço is a Senior Epidemiologist at the Public Health Agency of Canada, where she collaboratively strategizes to advance national surveillance of gonorrhea and antimicrobial-resistant gonorrhea (AMR-GC). She leads the Enhanced Surveillance of Antimicrobial-resistant Gonorrhea (ESAG) initiative, working closely with colleagues at the National Microbiology Laboratory who spearhead the complementary Gonococcal Antimicrobial Surveillance Programme (GASP-Canada). Her work focuses on monitoring resistant gonorrhea trends to support public health action and inform federal STI treatment guidelines. 

Dr. Andrea Chittle is a Medical Advisor in the Sexually Transmitted and Blood-borne Infections Surveillance Division at the Public Health Agency of Canada (PHAC). In addition to her work with PHAC, Andrea works in the City of Hamilton’s Sexual Health Clinics and is a Consultant Physician with the Sexual Assault and Domestic Violence Care and Treatment Centre at Guelph General Hospital. 

So please join me in welcoming Lillian who will begin today's presentation.  

Lillian Lourenço: All right. 

Thank you so much Tatum that nice introduction. It was very kind of you. So, hi everybody. 

It is lovely to be here today with you. As mentioned, my name is Lillian and I will begin today's presentation with an overview of national gonorrhea and antimicrobial resistant gonorrhea surveillance methods in Canada. Afterwards, my colleague Andrea will walk us through two case examples that will highlight recent updates to PHAC gonorrhea and chlamydia screening and treatment guidelines. 

And finally, we'll close by sharing some STBBI resources that you can apply in your practice or organization. All right, let's begin with a short background on gonorrhea or GC for short. gonorrhea is one of the most common sexually transmitted infections. 

It's caused by the bacteria Neisseria gonorrhea which can infect the urogenital tract, the throat and the rectum. Gonococcal infections often present without symptoms especially in the throat rectum, and in females the urogenital tract. in contrast in males urogenital infections are more likely to cause noticeable symptoms. 

We treat gonorrhea with appropriate antibiotics. However, in the case of untreated infections, some may clear on their own, but others can lead to serious complications, including pelvic inflammatory disease. Sometimes, but not often, the infection can spread through the bloodstream and joints, causing what's known as disseminated Gonococcal infection. 

Finally, untreated gonorrhea can be passed to an infant during delivery, posing additional health risks for the newborn. Alongside the potential for serious complications, gonorrhea poses another major public health challenge, which is growing antibiotic resistance. Over time, the causative pathogen Neisseria gonorrhea has developed resistance to every class of antibiotics used to treat it, including those currently recommended in Canada and internationally. 

As a result, the World Health Organization has warned that if resistance continues to rise, the infection could become untreatable without the development of new and effective antibiotics. As a part of the national response to this growing threat, the Public Health Agency of Canada or PHAC for short leads national surveillance efforts to monitor gonococcal  infections as well as antibiotic resistant cases so as to assess treatment effectiveness and inform care guidelines and public health action. All right. 

So how do we track gonorrhea cases across the country? In Canada Gonorrhea is a nationally notifiable disease. So this means that confirmed cases must be reported to public health. 

In practice, health professionals and laboratories first report cases to their provincial or territorial health authority and then each jurisdiction voluntarily shares annual case data by age, sex, and overall with the Public Health Agency of Canada through the Canadian Notifiable Disease Surveillance System or CNDSS for short. These data are made publicly available through the notifiable diseases online interactive tool available on canada.ca. Okay. 

So on this slide we see the latest gonorrhea data available from notifiable diseases online and it was published just last week on Thursday actually in case you want to take a look. in 2023 there were around 42,000 cases of gonorrhea reported across Canada for a national rate of 105 cases per 100,000 population. This made gonorrhea once again the second most reported notifiable STI in the country. 

These numbers likely underestimate the true burden of gonorrhea in Canada in part due to asymptomatic and self-clearing infections which may go undetected. So looking at the figure in the slide, you'll see that reported gonorrhea rates have steadily increased over the past two decades with a particularly sharp rise in the past 10 years. In fact, the 2023 rate is more than double what it was in 2014 and more than three times higher than the 2010 rate. 

There was a small dip in reported rates during the COVID era largely due to a reduced demand for and ability to test for STBBIs. However, in 2022, the rate was at prepandemic levels and by 2023, the rate has now exceeded prepandemic rates. When we look at CNDSS data by sex, which you can see in the figure on your left, we see that gonorrhea rates have consistently been higher among males than among females. 

However, this gap between the sexes has widened over the last decade. In fact, in 2023, the reported gonorrhea rate among males was more than double what it was in the among females. The figure on the right shows how rates vary by age group. 

In 2023, as in previous years, the highest reported rates were among males aged 25 to 29 and females aged 20 to 24. We'll now turn our attention to antimicrobial resistant gonorrhea, which some of you may more commonly know as antibiotic resistant gonorrhea surveillance in Canada. Okay, so PHAC monitors antimicrobial resistant gonorrhea through two complimentary systems. 

The first called Gonococcal Antimicrobial Surveillance Program or GASP-Canada for short is a passive national surveillance program which is led by the national microbiology laboratory or you may know them as the NML. It was established in the 1980s and collects approximately 3,000 gonorrhea culture isolates annually from provincial and territorial labs across Canada. Currently, its data set includes antibiotic susceptibility data on over 70,000 isolates. 

The NML performs both phenotypic and genomic antimicrobial susceptibility testing so as to determine which antibiotics remain effective against Neisseria gonorrhea. It also conducts molecular typing so as to monitor circulating strains and resistance trends across Canada. GASP is a valuable surveillance system which supports outbreak investigations, treatment failure assessments, as well as the development of evidence-based treatment guidelines. 

The program generates rich laboratory data. However, it collects limited epidemiologic and clinical data, specifically client age, sex, the reporting province or territory, and the swab site or infection site. But this is okay thanks to its complimentary program called the Enhanced Surveillance of Antimicrobial Resistant Gonorrhea or ESAG for short. Launched in 2013 ESAG gives us rich epi and clinical information on antibiotic resistant gonorrhea cases. It does this by linking client level data on prescription, travel history, and sexual behavior to the antimicrobial susceptibility data from approximately 20% of GASP Canada's cases. Participation in the program is voluntary and as of 2024, there are five provinces and one territory contributing data to the ESAG program. 

Together, GASP and ESAG provide a comprehensive view of antibiotic resistant gonorrhea in Canada. So, let's look at some data from the surveillance programs. In Canada, antimicrobial resistant gonorrhea is on the rise. 

This is shown by the red line in this figure which shows GASP results of the proportion of gonorrhea cultures which demonstrated resistance to at least one antibiotic between 2011 and 2022. In 2022, three and four isolates or 75% were resistant to at least one antibiotic compared to just 36% in 2013. These AMR results are based on cultures only which represent about 10% of annually reported gonorrhea cases. 

Now looking at ESAG data from 2022, we can see that the same measure of antimicrobial resistant gonorrhea burden. In other words, the prevalence of isolates resistant to at least one antibiotic was higher among GBMSM as shown in the green than among heterosexual males as shown in the blue and among females in purple. It was also above the GSAP national prevalence of 75.5%. 

This figure shows trends in antimicrobial resistance for individual antibiotics, based on GASP data from 2018 to 2022. It shows that the high overall gonorrhea resistance we saw in the previous slides is largely driven by resistance to tetracycline in orange and ciprofloxacin in dark green each showing resistance in over half of the tested isolates. These antibiotics –along with penicillin in dark blue are rarely prescribed in Canada, with usage ranging from less than 1% to 6%, annually, according to ESAG data for the same time period. 

Meanwhile, azithromycin-resistance prevalence averaged 8.2% over this period. In contrast to the other tested antibiotics, the prevalence of decreased susceptibility so a lowered drug response to cefixime and ceftriaxone was very low, below 0.5% annually over most of the 5-year period.  

Putting this in context from 2011 to 2024, PHAC and PT guidelines recommended treating gonorrhea with either 250 mg of ceftriaxone IM or 800 mg of oral cefixime alongside 1 g of azithromycin. According to ESAG data, these recommended combinations were used to treat the majority between 83% and 93% of gonorrhea cases over the same period. 

To help guide us in understanding these AMR trends, we can look to the WHO which recommends discontinuing a treatment if resistance prevalence reaches 5% or higher. Thus, over this five-year period, only cefixime and ceftriaxone remained below this WHO threshold. 

So let's take a closer look at these azithromycin resistance trends. Both nationally and internationally is resistance has been increasing. and PHAC along with an expert national advisory committee on STBBIs, also known as NAC STBBI, have been monitoring this trend for years since 2016 national azithromycin resistance prevalence has exceeded 5%. 

Before 2018 azithromycin resistance was mainly observed in central Canada. However, over time, more provinces showed increasing prevalence. Again, our surveillance data for the years 2020 and 21 were largely impacted by the COVID-91 prevention pandemic measures and this should be interpreted with this impact in mind. 

In 2020, PHAC and the next and the NAC-STBBI began an evidence review to update PHAC gonorrhea treatment guidelines which Dr. Andrea Chittle will speak to shortly. Currently 2023 surveillance data are being finalized but GASP and ESAG programs monitor ceftriaxone resistant cases in real time given its important role as a key firstline treatment against gonorrhea. 

In 2024 we received an unusual eight reports of ceftriaxone resistant gonorrhea which is as many as in the previous in the previous seven years combined. All cases were cefixime and multi-drug resistant and one was extensively drug-resistant meaning resistant to both ceftriaxone and azithromycin as well as two other antibiotics. Two infections failed initial treatment but were ultimately cured with ceftriaxone 500 mg. 

In one case as a monotherapy and the other combined with azithromycin. Genetic sequencing showed no direct links between cases though all were tied to resistant strains circulating in countries with high antimicrobial resistant gonorrhea rates. Half of the cases had recently traveled to China, Cambodia, Japan or Thailand. 

Two cases were locally acquired, and two had no travel history. So far in 2025, we have already received two reports of ceftriaxone resistant gonorrhea. If you become aware of a treatment failure or a ceftriaxone resistant gonorrhea case in your practice or jurisdiction, please report it to your provincial public health lab as well as to the National Microbiology Laboratory. 

So to recap, reports of gonorrhea and resistant gonorrhea continue to rise in Canada. While our surveillance systems are strong, we must remain vigilant, especially as resistance to one of our key last line treatments, ceftriaxone, increases. Ongoing monitoring and timely response are critical to preserving treatment options and guiding national care. 

Finally, we'd like to sincerely thank our provincial and territorial partners for their dedication and invaluable contributions towards gonorrhea surveillance.  

I'll now pass the presentation to my colleague Andrea.  

Andrea Chittle: Yes, thank you. 

I'm Andrea Chittle. As Tatum mentioned, I'm a Medical Advisor in the Sexually Transmitted and Blood-borne Infection Surveillance Division at PHAC. I also provide frontline STBBI care. 

I'm going to pivot a bit now to review some clinical cases to highlight recommendations for gonorrhea screening, diagnosis, and management. As Lillian highlighted, surveillance data and trends inform the development of national recommendations for health professionals. PHAC publishes evidence-based clinical guidance developed by the National Advisory Committee on Sexually Transmitted and Bloodborne Infections or NAC-STBBI, an external advisory group. 

You can find their recommendations in PHAC STBBI guides for health professionals. This information is also available in a mobile app. I want to flag that there is often a delay between posting content to the online version of the guides and updating the content in the mobile app. 

So, at this time, while some updates are still pending in the mobile app, I would recommend that people refer to the online version of the guides. There are a few polling questions in this portion of the presentation. The first question should be loading and it's a true or false question. 

If there are discrepancies between provincial and territorial or local guidelines and the recommendations from PHAC for STI care, clinicians should follow PHAC guidelines. Is that true or false? Okay. 

And so we see a pretty even split of respondents to that. But actually this is false. If there are discrepancies, you should follow the recommendations that are most local. 

Local recommendations take into consideration some important factors that are relevant to your context, including epidemiologic trends and antimicrobial resistance. I'm going to use two case examples to  highlight updated PHAC recommendations on gonorrhea screening and treatment. Gonorrhea and chlamydia screening recommendations are coupled because laboratory tests are commonly dual tests. 

So I will technically also be reviewing facts recommendations for chlamydia screening. The first case, Sam, is a fabricated case. Sam is a 23-year-old non-binary individual who was assigned female at birth. 

Sam uses they them pronouns. Sam's sexual partners are cisgender men. This means that Sam's partners are individuals who are assigned male sex at birth and who identify as men. 

Sam has oral sex and receptive vaginal sex using condoms for vaginal sex sometimes. They have had three partners in the last two months and have not recently traveled internationally. Sam is attending a public health sexual health clinic to request a renewal of birth control pills. 

Sam has a past history of urogenital chlamydia two years ago and has not been rescreened for any sexually transmitted infections since then. Sam also has generalized anxiety disorder. They take Sertraline and combined oral contraceptive pills and they don't have any known drug allergies. 

Another poll question here. According to PHAC guidelines, how frequently should non-pregnant sexually active adults and adolescents younger than 30 years of age be screened for chlamydia and gonorrhea? Should it be annually? 

Every 3 to 6 months if they have a new sexual partner or multiple sexual partners? As often as every 3 months if they belong to a population or community experiencing high chlamydia or gonorrhea prevalence? And most people were correct. The answer was the final one. 

All of the above. PHACs recommendations for chlamydia and gonorrhea screening for non-pregnant adolescents and adults were updated this year. 

To prevent complications and sexual transmission, the NAC-STBBI suggests annual screening for all sexually active persons younger than 30 years of age. For those with multiple sexual partners or a new partner since last testing, screening can be considered as frequently as every three to six months. In addition, in populations or communities experiencing high rates of sexually transmitted and bloodborne infections, the NAC-STBBI suggests opt-out screening as often as every 3 months. 

So, populations and communities experiencing high STBBI rates include gay, bisexual, and other men who have sex with men, people living with HIV, people who are or have been incarcerated, people who use substances or access addiction services, and some Indigenous communities. NAC-STBBI encourages consideration of approaches to increase the uptake of screening and that can include opportunistic screening and strategies to increase the accessibility of and to normalize testing like testing in outreach settings and the use of self-sampling for specimen collection. 

The STBBI guides contain some pragmatic suggestions regarding pharyngeal and rectal screening for gonorrhea and chlamydia. Pharyngeal site screening is indicated for individuals assigned female at birth who have performed oral sex and for others who've performed oral sex who are at high risk of exposure including gay, bisexual and other men who have sex with men, people with multiple sexual partners and people with sex partners at high risk of infection. And rectal site screening is indicated for people with a history of receptive anal sex regardless of condom use. 

And PHAC also suggests rectal screening for all gay, bisexual, and other men who have sex with men, regardless of their history of receptive anal sex. And I'll get into a little bit more detail about specimen collection containers and tests in a few slides. In general, chlamydia and gonorrhea testing can be through culture and antimicrobial susceptibility testing or nucleic acid amplification testing or NAAT. 

Available tests may vary by anatomical site and by lab and they often change over time. So I'll review the specimens for NAAT first and then highlight a few situations in which collecting a specimen for gonorrhea culture and susceptibility testing is also recommended when conducting screening. Urogenital specimens for NAAT can be a first void urine or urethral endocervical or vaginal swab. 

Pharyngeal and rectal specimens can be collected for NAAT and as approved by your lab can be self or clinician collected. The NAC-STBBI recommends collecting a specimen for gonorrhea culture and antimicrobial susceptibility testing along with a specimen for NAAT if you're screening someone who is a known gonorrhea contact, in the context of sexual assault or abuse or for someone who may have acquired an infection somewhere with high rates of AMR in gonorrhea. NAAT is more sensitive than culture and is accurate immediately after exposure, while culture may not detect an infection in the first 48 hours following exposure. 

Urethral swabs in people without symptoms are deeply unpleasant, and urine is a highly acceptable alternative. But as an example of jurisdictional variability, in Ontario where I practice, urethral NAAT swabs are not available. Urine specimens should be a first void urine, and it's important to ensure that the individual has not voided recently. 

Specific instructions will vary by lab. So confirm instructions with your specific lab. Vaginal NAAT may be more sensitive than cervical or urine specimens and self-collected vaginal swabs are more acceptable to patients than provider collected swabs which may be partly because self-collected swabs don't require a speculum exam. 

This slide depicts some of the different specimen collection containers for NAAT and culture testing. Again, because specimen kits, acceptable specimen types, and collection techniques vary even within jurisdictions depending on the lab processing the specimen, it's important to check with your lab. So, back to our case, Sam was not known to be a gonorrhea contact. 

And based on sexual behaviors, specimens are collected for pharyngeal and vaginal NAAT. And the results are negative for chlamydia and gonorrhea at all sites. So now we'll flash forward in Sam's life, three years later. 

Sam presents to primary care after a home pregnancy test was positive. They haven't experienced any new health concerns and Sam is now only taking Sertraline.  

PHAC’s screening recommendations for gonorrhea and chlamydia during pregnancy were updated in 2022 to prevent pregnancy related complications, sexual transmission and transmission to neonates in the perinatal period. NAC STBBI suggests screening all asymptomatic pregnant individuals during the first trimester or at the first antenatal visit and again in the third trimester. The NAC-STBBI also suggests screening at the time of labor if no prenatal screening has occurred, including no third trimester screening or if follow up of a positive chlamydia or gonorrhea result during pregnancy was not completed. 

Pregnancy is an indication for collecting a specimen for NAAT as well as for gonorrhea culture and antimicrobial susceptibility testing. Since the specimen for culture is an endocervical swab, logically an endocervical or vaginal swab can be collected for NAAT during the same exam. Alternatively, self-collected vaginal specimens or urine specimens can be submitted for NAT. 

Sam receives an endocervical swab for chlamydia and gonorrhea NAAT and an endocervical swab for gonorrhea culture. And these results are all negative. So I have reviewed gonorrhea and chlamydia screening recommendations for nonpregnant sexually active adolescence and youth. 

The NAC-STBBI suggests universal annual chlamydia and gonorrhea screening for those younger than 30 years. NAC-STBBI suggests screening those with multiple sexual partners or a new partner since last screening every 3 to 6 months. And finally, NAC-STBBI suggests opt-out screening as frequently as every 3 months in populations or communities experiencing a high prevalence of STBBI. 

The committee also identified some potential strategies to increase screening uptake, including self-sampling. For pregnant individuals, screening for gonorrhea and chlamydia is recommended during the first trimester or at the first antenatal visit and again in the third trimester. If third trimester screening was not completed or follow-up of chlamydia or gonorrhea detected in the pregnancy was not completed, screening is recommended again during labor. 

NAAT specimens are most sensitive and clinicians are encouraged to consider collecting specimens for both NAAT and gonorrhea culture when conducting screening for prenatal patients, people who are gonorrhea contacts or if sexual abuse or sexual assault are suspected. The next case is Mo, also a fabricated case. Mo is a 32year-old cisgender man. 

This means that Mo's assigned sex at birth was male and his gender identity is man. Mo uses the pronouns he him. His sexual partners are cisgender men and he has insertive and receptive anal and oral sex. 

He has had four partners in the last two months and has not traveled internationally recently. He has been recalled for treatment of urethral and pharyngeal gonorrhea which were detected during STI screening that was conducted as part of routine follow up for HIV pre-exposure prophylaxis or HIV PrEP. Mo was previously treated for early latent syphilis two years ago and his non-treponemal RPR titre has declined to a 1 to two. 

His medical history also includes an appendectomy 10 years ago. Mo's taking oral anti-retroviral therapy for HIV PrEP and doesn't have any drug allergies. This is a summary of the results from Moe's recent screening investigations for sexually transmitted and bloodborne infections. 

Gonorrhea was detected by NAAT on urine and throat specimens. As expected, Mo’s syphilis test results were positive with a reactive treponemal antibody screening test. Mo also had a reactive non-treponemal RPR test with a titre of 1 to two. 

As a sidebar, if Mo had a new syphilis infection, we would expect to see the RPR titre increase at least four-fold. So, this would be to a titre of at least one to eight. In discussing gonorrhea screening, I've already mentioned that there are some instances where the NAC-STBBI suggests collecting specimens for both gonorrhea NAAT and culture. 

This slide presents the comprehensive list of scenarios. So consider collecting specimens for chlamydia and gonorrhea NAAT as well as for gonorrhea culture when assessing symptomatic people, pregnant people, people who are gonorrhea contacts, when sexual abuse or sexual assault is suspected, and when an infection may have been acquired in a country or area with high rates of antimicrobial resistance. In addition, and with some caveats about timing that I'll review in more detail, if treatment failure is suspected, specimens for both NAAT and culture should be collected. 

Relevant to Mo, the NAC-STBBI advises collecting a specimen for gonorrhea culture before administering treatment when a gonorrhea infection was detected using NAAT only, if feasible and if doing so would not delay treatment. Practically in Mo's case, I would likely collect a pharyngeal swab for culture before treating, but would only collect a urethral specimen if Mo was experiencing discharge given the discomfort associated with urethral swabbing. And in this case, I would emphasize the importance of a test of cure for the urethral infection. 

According to the PHAC guides, what is the new preferred treatment regimen for uncomplicated gonorrhea in individuals 10 years of age and older? Is it dual therapy with ceftriaxone 250 and azithromycin 1 gram? Is it dual therapy with cefixime 800 mg and azithromycin 1 gram? Monotherapy with ceftriaxone 500 mg? Monotherapy with azithromycin 2 grams? Or all of the above are preferred regimens? Okay, so about half of participants were correct in identifying that monotherapy with ceftriaxone 500 mg IM is the preferred treatment. 

PHAC published a new interim recommendation for gonorrhea treatment in December of last year. The preferred treatment for uncomplicated gonorrhea infections in adults and adolescents 10 years of age and older is monotherapy with ceftriaxone 500 milligrams given intramuscularly as a single dose. This replaces a recommendation for dual therapy with a lower 250 mg dose of ceftriaxone and 1 gram of oral azithromycin both administered as single doses. 

If a co-infection with chlamydia has not been excluded at the time of treatment, the NAC-STBBI recommends ensuring the regimen administered includes chlamydia treatment and that would be either with azithromycin 1 gram as a single dose orally or doxycycline 100 milligrams orally twice daily for 7 days. In addition, a gonorrhea test of cure is recommended for all positive sites in all cases and is particularly important when a regimen other than monotherapy with ceftriaxone 500 mg was used for treatment. Alternative treatments for gonorrhea are currently under review. 

Clinicians can continue to refer to the alternatives listed in the web version of the STBBI guides until the review is completed, and the alternatives have been updated. There are no alternative regimens recommended in pregnancy. So clinicians caring for pregnant persons who have contraindications to monotherapy are advised to consult with a specialist. 

The regimens listed here for pharyngeal and anogenital infections would primarily be considered when there is a strong rationale for oral over injection treatment including treatment facilities that don't have injection capabilities or patients who decline an injection. The published alternatives vary by site because pharyngeal infections are more difficult to eradicate and because of concerns about tetracycline resistance in gonorrhea, a regimen containing doxycycline is not a listed alternative for pharyngeal gonorrhea infections. 

There are additional alternatives that can be considered when patients have contraindications to cephalosporins and to cephalosporins and macrolides. Finally, the STBBI guides indicate that ertapenem be considered in exceptional circumstances and likely in consultation with a specialist. As I mentioned, the NAC-STBBI recommends a gonorrhea test of cure for all positive sites in all cases. 

The choice of test depends on the interval between treatment completion and follow up. Specimens for culture testing should be delayed until at least 3 days after treatment and specimens for NAAT should be delayed until 3 to four weeks after treatment completion. So if an individual returns for a test of cure within 3 weeks of treatment completion, test of cure should be conducted using culture testing. 

And if an individual returns for a test of cure more than 3 weeks after treatment completion, test of cure can be with NAAT. If treatment failure is suspected more than 3 weeks after treatment completion, specimens for both NAAT and culture should be collected. This is the final poll. 

Our patient Mo returns for a test of cure four weeks after receiving the recommended treatment with ceftriaxone monotherapy. Which tests would be appropriate? A urethral swab for gonorrhea culture, urine for gonorrhea NAAT, pharyngeal swab for gonorrhea culture, pharyngeal swab for gonorrhea NAAT, or both B and D. The second and fourth options.  

And most people did select the correct response there. of urine for NAAT and pharyngeal swab for NAAT. 

And here are the follow-up test results for Mo, who returned four weeks after treatment and received testing with NAAT. His results indicate that the infection was cured. In addition to test of cure, there are a few other aspects of follow-up that I want to mention. 

Sexual contacts from the 60 days prior to symptom onset or the date of specimen collection for those without symptoms should be notified. Consideration can be given to treating partners empirically and potentially with a regimen that covers both chlamydia and gonorrhea. Individuals who have had a gonorrhea infection should be re-screened six months following the infection as they are at risk of reinfection. 

Depending on the population and circumstance, the rescreening interval may be shortened. For example, Mo is someone who would be considered for quarterly screening under the gonorrhea and chlamydia screening recommendations and that aligns with the existing Canadian guidelines for people taking HIV PrEP. Finally, individuals who are being evaluated or treated for gonorrhea should undergo screening for other sexually transmitted and bloodborne infections given shared risk factors and rates of co-infection. 

These are the key messages that I hope you will take away from my review of PHAC gonorrhea treatment and follow-up recommendations. For individuals whose gonorrhea infection was detected using NAAT only, the NAC-STBBI suggests collecting a specimen for gonorrhea culture before administering treatment when practical, feasible, and tolerable. Monotherapy with ceftriaxone 500 mg for one dose is the preferred treatment for uncomplicated gonorrhea infections in adolescents and adults 10 years and older. 

And a test of cure is recommended for all gonorrhea infections at all sites. Test of cure with culture if performed between three days and three weeks after treatment completion and with NAAT if performed more than three weeks after treatment completion. If treatment failure is suspected more than 3 weeks after treatment completion, collect specimens for both culture and NAAT. 

Finally, I want to spend a moment highlighting some additional resources that PHAC has developed for public health professionals, clinicians, and community-based organizations. For those interested in finding STBBI surveillance products, PHAC has an STBBI surveillance landing page. And in addition, there is an ESAG dashboard, which is an interactive data tool. 

The QR code depicted on this screen should take you to a canada.ca landing page where you can find syphilis resources. As you're likely aware, there has been a substantial and concerning increase in infectious syphilis and a resurgence of congenital syphilis in Canada. To support clinicians, we developed a double-sided infographic that reviews syphilis screening treatment and follow-up recommendations. 

We also developed a simplified algorithm for clinical staging and treatment of syphilis in adolescence and adults. And to support clinical staging, you will find a staging guide, which is a booklet that highlights key physical exam findings. For community-based organizations we developed a tip sheet on syphilis prevention and care. 

PHAC has also developed several resources to raise awareness about and support discussions about HIV prevention, including the message undetectable equals untransmittable or U=U. This slide showcases a double-sided PHAC sheet for health professionals that provides key messages about U=U as well as a public-facing resource that conveys that message. And then I believe we'll be sharing the deck after the presentation. 

And so I've included several resources and URLs in case folks want to go to those websites directly for more information.  

Tatum: Great. Thank you so much and Andrea for your presentation. 

We will now move into the Q&A portion of the webinar and as a reminder you can submit your questions for our presenters using the Q&A function located at the bottom of your screen in your Zoom toolbar at any time.  

But to get us started we'll begin with a few questions that were submitted in advance by audience members before today's session. So the first question I have here is what are some contributing factors to trends in gonorrhea particularly increases and how can we prevent them? 

Lillian: Okay. So I think I can take that question. It's a very good one. 

There are several factors that have likely contributed to rising gonorrhea rates in Canada. One is the improved detection of gonorrhea over time. So we moved from culture-based testing into anogenital NAAT based assessments in the early 2000s across Canada. 

And then more recently in 2018, Ontario began offering extragenital NAAT testing. So the pharyngeal and rectal to key populations and then other jurisdictions followed over the subsequent years around 2018 to 2021 and that was definitely thought to lead to increased detection of gonorrhea. So one study from an STI clinic in Ottawa found that by performing extragenital NAAT they before, or before performing extragenital NAATS the detected gonorrhea rates would increase about 13% annually and then after introducing pharyngeal and rectal NAAT based testing that increase from 13% annually to 65% annually. 

However for us for our CNDSS data we do get some infection site information but it's inconsistent. There's a lot of unspecified type of gonorrhea. So I can't comment on if this totally explains what we're seeing in Canada. 

Ontario did recently, in January, released a report describing the percentage of tests coming back positive, test positivity, and said that rose from 9% in 2014 to 2.7% in 2023 which is suggestive of a real spread or increase in transmission. There's also behavioral shifts that could play a role. So some surveys and correspondents suggest lower condom use and more sexual partners in some populations over the last decade. 

Also there could be impacts from changes to even cervical screening guidelines which now have pap tests starting later and being done less frequently which means we could be missing asymptomatic infections at these routine visits giving an increased opportunity for transmission. All of these things could be impacting what we saw and then obviously during the COVID-19 pandemic years. We saw those dips in in our results and as I mentioned that was likely due to reduced access to testing and supplies. 

We have seen rates rebound and exceed this with the latest CNDSS data.  

So all of that are some of the contributing factors. Andrea, do you want to speak to some prevention methods? 

Andrea: Thanks, Lillian. I borrowed this slide from a previous webinar that we gave about STBBI prevention. The STBBI prevention toolbox contains a range of effective strategies that reduce the risk of acquiring STBBI and/or the impact and spread of STBBI. 

While some of the tools have broad use and benefit, others are more tailored. Generally, they complement each other and a comprehensive approach to STBBI prevention will incorporate all relevant tools. The prevention strategies that are particularly relevant for gonorrhea are in the darkly shaded boxes on the slide. 

Education refers to comprehensive sexual health education as well as counseling delivered by a health professional. Barrier methods include external and internal condoms and dental dams. Barriers are particularly effective for preventing infections spread through bodily fluids, including gonorrhea. 

Screening, testing, and treatment enable the timely detection and appropriate management of infections which can prevent complications and reduce the spread of gonorrhea. And then there are some emerging interventions that may have benefit for gonorrhea prevention. One intervention that has been getting a fair bit of buzz is doxycycline for STI prevention. 

You may have heard this referred to as Doxy-PEP, doxycycline postexposure prophylaxis and Doxy-PrEP, Doxycycline pre-exposure prophylaxis. The NAC-STBBI has prioritized the development of recommendations for the use of doxycycline to prevent chlamydia, gonorrhea and syphilis and that work is ongoing. 

In some jurisdictions including BC and Quebec, there are existing recommendations for Doxy-PEP that clinicians can consider. And I would just flag that for gonorrhea specifically the available evidence does not consistently support a protective effectiveness may be related to the background rate of tetracycline resistance in gonorrhea which is high in Canada.  

Tatum: Great. 

Thank you both so much that was a great overview of all the complex drivers of play. Let's move maybe to our next question which also touches on prevention but from a slightly different angle. So will PHAC make recommendations for doxycycline to prevent gonorrhea and generally how can we track the impact of Doxy-PEP guidelines on gonorrhea AMR. 

Andrea: Maybe we'll do things in the reverse order for this one and I can start. Just reiterating what I mentioned previously that the NAC-STBBI has prioritized the development of recommendations about doxycycline prophylaxis for preventing gonorrhea chlamydia and syphilis and that work is going on. If folks reside in British Columbia or Quebec, there are provincial level recommendations that they can refer to for doxycycline postexposure prophylaxis Doxy-PEP. 

And then again just flagging that there is not consistent evidence that this intervention is effective for the prevention of gonorrhea and the protective benefit may relate to background rates of antimicrobial resistance tetracycline resistance in gonorrhea which is quite high in Canada.  

I will maybe pass it to Lillian to talk a bit about how we may monitor for an effect of doxycycline use for antimicrobial resistance.  

Lillian: Thanks Andrea. 

Do you mind going to the next slide please? Great. Okay, so this is a good question. 

We got lots of good questions. Thanks everyone. yeah, so as mentioned the NML is already measuring tetracycline. 

and doxycycline is a part of the tetracycline antibiotic family. So it's already measuring tetracycline resistance in gonorrhea at a national and PT level and you can always learn more about that in the GASP products. 

Thanks to ESAG however we're able to explore tetracycline resistance trends by key populations like who may use Doxy-PEP. So in the slide in front of you for example you can see trends of tetracycline resistance from ESAG 2018 to 2022 and we see that in 2022 almost 50% of isolates collected from GBMSM demonstrated tetracycline resistance and that prevalence is approximately halved among heterosexual males as well as all females. So as Doxy-PEP continues to evolve, we'll be able to monitor tetracycline resistance using these programs. 

Tatum: Perfect. Thank you both so much.  

Unfortunately, we've reached the end of our time today, but thank you again to everyone who joined us today, and a special thank you to Lillian and Andrea for your time and insights. 

As a reminder, you will receive an email following the session with the recording, with the slides and a short feedback form. And we really value your input. So on behalf of the Public Health Agency of Canada, thank you again for your participation and we look forward to seeing you at future sessions in this series. 

And on that, take care and enjoy the rest of your day.