Gonorrhea

Last updated

Gonorrhea
Other namesGonorrhoea, gonococcal infection, gonococcal urethritis, the clap
Gonococcal lesion on the skin PHIL 2038 lores.jpg
Gonococcal lesion on the skin
Pronunciation
  • /ˌɡɒn.əˈɹi.ə/
Specialty Infectious disease
SymptomsNone, burning with urination, vaginal discharge, discharge from the penis, pelvic pain, testicular pain [1]
Complications Pelvic inflammatory disease, inflammation of the epididymis, septic arthritis, endocarditis [1] [2]
Causes Neisseria gonorrhoeae typically sexually transmitted [1]
Diagnostic method Testing the urine, urethra in males, or cervix in females [1]
Prevention Condoms, having sex with only one person who is uninfected, not having sex [1] [3]
Treatment Ceftriaxone by injection and azithromycin by mouth [4] [5]
Frequency0.8% (women), 0.6% (men) [6]

Gonorrhea, colloquially known as the clap, is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae . [1] Infection may involve the genitals, mouth, and/or rectum. [7] Infected men may experience pain or burning with urination, discharge from the penis, or testicular pain. [1] Infected women may experience burning with urination, vaginal discharge, vaginal bleeding between periods, or pelvic pain. [1] Complications in women include pelvic inflammatory disease and in men include inflammation of the epididymis. [1] Many of those infected, however, have no symptoms. [1] If untreated, gonorrhea can spread to joints or heart valves. [1] [2]

Sexually transmitted infection Infection transmitted through human sexual behavior

Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs), are infections that are commonly spread by sexual activity, especially vaginal intercourse, anal sex and oral sex. Many times STIs initially do not cause symptoms. This results in a greater risk of passing the disease on to others. Symptoms and signs of disease may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain. STIs can be transmitted to an infant before or during childbirth and may result in poor outcomes for the baby. Some STIs may cause problems with the ability to get pregnant.

<i>Neisseria gonorrhoeae</i> species of bacterium

Neisseria gonorrhoeae, also known as gonococcus (singular), or gonococci (plural) is a species of Gram-negative diplococci bacteria isolated by Albert Neisser in 1879. It causes the sexually transmitted genitourinary infection gonorrhea as well as other forms of gonococcal disease including disseminated gonococcemia, septic arthritis, and gonococcal ophthalmia neonatorum.

Rectum final section of intestine

The rectum is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. The adult human rectum is about 12 centimetres (4.7 in) long, and begins at the rectosigmoid junction, the end of the sigmoid colon, at the level of the third sacral vertebra or the sacral promontory depending upon what definition is used. Its caliber is similar to that of the sigmoid colon at its commencement, but it is dilated near its termination, forming the rectal ampulla. It terminates at the level of the anorectal ring or the dentate line, again depending upon which definition is used. In humans, the rectum is followed by the anal canal which is about 4 centimetres (1.6 in) long, before the gastrointestinal tract terminates at the anal verge. The word rectum comes from the Latin rectum intestinum, meaning straight intestine.

Contents

Gonorrhea is spread through sexual contact with an infected person. [1] This includes oral, anal, and vaginal sex. [1] It can also spread from a mother to a child during birth. [1] Diagnosis is by testing the urine, urethra in males, or cervix in females. [1] Testing all women who are sexually active and less than 25 years of age each year as well as those with new sexual partners is recommended; [3] the same recommendation applies in men who have sex with men (MSM). [3]

Urethra tube that connects the urinary bladder to the external urethral orifice

In anatomy, the urethra is a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body. In males, the urethra travels through the penis and also carries semen. In human females and other primates, the urethra connects to the urinary meatus above the vagina, whereas in marsupials, the female's urethra empties into the urogenital sinus.

Cervix the lower part of the uterus in the human female reproductive system

The cervix or cervix uteri is the lower part of the uterus in the human female reproductive system. The cervix is usually 2 to 3 cm long and roughly cylindrical in shape, which changes during pregnancy. The narrow, central cervical canal runs along its entire length, connecting the uterine cavity and the lumen of the vagina. The opening into the uterus is called the internal os, and the opening into the vagina is called the external os. The lower part of the cervix, known as the vaginal portion of the cervix, bulges into the top of the vagina. The cervix has been documented anatomically since at least the time of Hippocrates, over 2,000 years ago.

Men who have sex with men (MSM), also known as males who have sex with males, are male persons who engage in sexual activity with members of the same sex, regardless of how they identify themselves. They may identify as gay, homosexual, bisexual, pansexual, heterosexual, or dispense with sexual identification altogether.

Gonorrhea can be prevented with the use of condoms, having sex with only one person who is uninfected, and by not having sex. [1] [3] Treatment is usually with ceftriaxone by injection and azithromycin by mouth. [4] [5] Resistance has developed to many previously used antibiotics and higher doses of ceftriaxone are occasionally required. [4] [5] Retesting is recommended three months after treatment. [3] Sexual partners from the last two months should also be treated. [1]

Condom Birth control device

A condom is a sheath-shaped barrier device, used during sexual intercourse to reduce the probability of pregnancy or a sexually transmitted infection (STI). There are both male and female condoms. With proper use—and use at every act of intercourse—women whose partners use male condoms experience a 2% per-year pregnancy rate. With typical use the rate of pregnancy is 18% per-year. Their use greatly decreases the risk of gonorrhea, chlamydia, trichomoniasis, hepatitis B, and HIV/AIDS. They also to a lesser extent protect against genital herpes, human papillomavirus (HPV), and syphilis.

Sexual abstinence Act of refraining from sexual activity

Sexual abstinence or sexual restraint is the practice of refraining from some or all aspects of sexual activity for medical, psychological, legal, social, financial, philosophical, moral, or religious reasons. Asexuality is distinct from sexual abstinence; and celibacy is sexual abstinence generally motivated by factors such as an individual's personal or religious beliefs. Sexual abstinence before marriage is required in some societies by social norms, or, in some countries, even by laws, and is considered part of chastity.

Ceftriaxone chemical compound

Ceftriaxone, sold under the trade name Rocephin, is an antibiotic used for the treatment of a number of bacterial infections. These include middle ear infections, endocarditis, meningitis, pneumonia, bone and joint infections, intra-abdominal infections, skin infections, urinary tract infections, gonorrhea, and pelvic inflammatory disease. It is also sometimes used before surgery and following a bite wound to try to prevent infection. Ceftriaxone can be given by injection into a vein or into a muscle.

Gonorrhea affects about 0.8% of women and 0.6% of men. [6] An estimated 33 to 106 million new cases occur each year, out of the 498 million new cases of curable STI – which also includes syphilis, chlamydia, and trichomoniasis. [8] [9] Infections in women most commonly occur when they are young adults. [3] In 2015, it caused about 700 deaths. [10] Descriptions of the disease date back to before the Common Era within the Old Testament. [2] The current name was first used by the Greek physician Galen before 200 CE who referred to it as "an unwanted discharge of semen". [2]

Syphilis Sexually transmitted infection

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum subspecies pallidum. The signs and symptoms of syphilis vary depending in which of the four stages it presents. The primary stage classically presents with a single chancre though there may be multiple sores. In secondary syphilis, a diffuse rash occurs, which frequently involves the palms of the hands and soles of the feet. There may also be sores in the mouth or vagina. In latent syphilis, which can last for years, there are few or no symptoms. In tertiary syphilis, there are gummas, neurological problems, or heart symptoms. Syphilis has been known as "the great imitator" as it may cause symptoms similar to many other diseases.

Chlamydia Sexually transmitted infection caused by the bacterium Chlamydia trachomatis.

Chlamydia, or more specifically a chlamydia infection, is a sexually transmitted infection caused by the bacterium Chlamydia trachomatis. Most people who are infected have no symptoms. When symptoms do develop this can take a few weeks following infection to occur. Symptoms in women may include vaginal discharge or burning with urination. Symptoms in men may include discharge from the penis, burning with urination, or pain and swelling of one or both testicles. The infection can spread to the upper genital tract in women causing pelvic inflammatory disease which may result in future infertility or ectopic pregnancy. Repeated infections of the eyes that go without treatment can result in trachoma, a common cause of blindness in the developing world.

Trichomoniasis gagoparasitic protozoa infectious disease that is caused by the parasites Trichomonas vaginalis or Trichomonas tenax

Trichomoniasis (trich) is an infectious disease caused by the parasite Trichomonas vaginalis. About 70% of women and men do not have symptoms when infected. When symptoms do occur they typically begin 5 to 28 days after exposure. Symptoms can include itching in the genital area, a bad smelling thin vaginal discharge, burning with urination, and pain with sex. Having trichomoniasis increases the risk of getting HIV/AIDS. It may also cause complications during pregnancy.

Signs and symptoms

Gonorrhea infects of mucosal membranes can cause swelling, itching, pain, and the formation of pus. [11] The time from exposure to symptoms is usually between two and 14 days, with most symptoms appearing between four and six days after infection, if they appear at all. Both men and women with infections of the throat may experience a sore throat, though such infection does not produce symptoms in 90% of cases. [12] [13] Other symptoms may include swollen lymph nodes around the neck. [11] Either sex can become infected in the eyes or rectum if these tissues are exposed to the bacterium.

Pus Phenomenon of inflammatory infection

Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection of pus within or beneath the epidermis is known as a pustule, pimple, or spot.

Incubation period time between an infection and the onset of disease symptoms

Incubation period is the time elapsed between exposure to a pathogenic organism, a chemical, or radiation, and when symptoms and signs are first apparent. In a typical infectious disease, incubation period signifies the period taken by the multiplying organism to reach a threshold necessary to produce symptoms in the host.

Sore throat symptom

Sore throat, also known as throat pain, is pain or irritation of the throat.

Women

Half of women with gonorrhea are asymptomatic but the other half experience vaginal discharge, lower abdominal pain, or pain with sexual intercourse associated with inflammation of the uterine cervix. [14] [15] [16] Common medical complications of untreated gonorrhea in women include pelvic inflammatory disease which can cause scars to the fallopian tubes and result in later ectopic pregnancy among those women who become pregnant. [17]

Asymptomatic condition or state of disease

In medicine, a disease is considered asymptomatic if a patient is a carrier for a disease or infection but experiences no symptoms. A condition might be asymptomatic if it fails to show the noticeable symptoms with which it is usually associated. Asymptomatic infections are also called subclinical infections. Other diseases might be considered subclinical if they present some but not all of the symptoms required for a clinical diagnosis. The term clinically silent is also used.

Vaginal discharge mixture of liquid, cells, and bacteria, produced in the vagina and cervix, lubricating and protecting the vagina; typically clear or white in color, with consistency varying from thin to thick, typically without a strong odor

Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricates and protects the vagina. This mixture is constantly produced by the cells of the vagina and cervix and it exits the body through the vaginal opening. The composition, amount, and quality of discharge varies between individuals as well as through the various stages of sexual and reproductive development. Normal vaginal discharge may have a thinner, watery consistency or a thick, sticky consistency, and may be clear or white in color. Normal vaginal discharge may be large in volume but typically does not have a strong odor, nor is it typically associated with itching or pain. While most discharge represents normal functioning of the body, some changes in discharge can reflect infection or other pathological processes. Infections that may cause changes in vaginal discharge include vaginal yeast infections, bacterial vaginosis, and sexually transmitted infections. The characteristics of abnormal vaginal discharge vary depending on the cause, but common features include a change in color, a foul odor, and associated symptoms such as itching, burning, pelvic pain, or pain during sexual intercourse.

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

Men

Most infected men with symptoms have inflammation of the penile urethra associated with a burning sensation during urination and discharge from the penis. [15] In men, discharge with or without burning occurs in half of all cases and is the most common symptom of the infection. [18] This pain is caused by a narrowing and stiffening of the urethral lumen. [19] The most common medical complication of gonorrhea in men is inflammation of the epididymis. [17] Gonorrhea is also associated with increased risk of prostate cancer. [20]

Infants

An infant with gonorrhea of the eyes Gonococcal ophthalmia neonatorum.jpg
An infant with gonorrhea of the eyes

If not treated, gonococcal ophthalmia neonatorum will develop in 28% of infants born to women with gonorrhea. [21]

Spread

If left untreated, gonorrhea can spread from the original site of infection and infect and damage the joints, skin, and other organs. Indications of this can include fever, skin rashes, sores, and joint pain and swelling. [17] In advanced cases, gonorrhea may cause a general feeling of tiredness similar to other infections. [18] It is also possible for an individual to have an allergic reaction to the bacteria, in which case any appearing symptoms will be greatly intensified. [18] Very rarely it may settle in the heart causing endocarditis or in the spinal column causing meningitis (both are more likely among individuals with suppressed immune systems, however). [13]

Cause

Multiple views of a Neisseria gonorrhoeae bacterium, which causes gonorrhea. Neisseria gonorrhoeae micrograph.jpg
Multiple views of a Neisseria gonorrhoeae bacterium, which causes gonorrhea.

Gonorrhea is caused by the bacterium Neisseria gonorrhoeae . [15] Previous infection does not confer immunity - a person who has been infected can become infected again by exposure to someone who is infected. Infected persons may be able to infect others repeatedly without having any signs or symptoms of their own.

Spread

The infection is usually spread from one person to another through vaginal, oral, or anal sex. [15] [22] Men have a 20% risk of getting the infection from a single act of vaginal intercourse with an infected woman. The risk for men that have sex with men (MSM) is higher. [23] Active MSM may get a penile infection, while passive MSM may get anorectal gonorrhea. [24] Women have a 60–80% risk of getting the infection from a single act of vaginal intercourse with an infected man. [25]

A mother may transmit gonorrhea to her newborn during childbirth; when affecting the infant's eyes, it is referred to as ophthalmia neonatorum. [15] It may be able to spread through the objects contaminated with body fluid from an infected person. [26] The bacteria typically does not survive long outside the body, typically dying within minutes to hours. [27]

Diagnosis

Traditionally, gonorrhea was diagnosed with Gram stain and culture; however, newer polymerase chain reaction (PCR)-based testing methods are becoming more common. [16] [28] In those failing initial treatment, culture should be done to determine sensitivity to antibiotics. [29]

Tests that use polymerase chain reaction (PCR, aka nucleic acid amplification) to identify genes unique to N. gonorrhoeae are recommended for screening and diagnosis of gonorrhea infection. These PCR-based tests require a sample of urine, urethral swabs, or cervical/vaginal swabs. Culture (growing colonies of bacteria in order to isolate and identify them) and Gram-stain (staining of bacterial cell walls to reveal morphology) can also be used to detect the presence of N. gonorrhoeae in all specimen types except urine. [30] [31]

If Gram-negative, oxidase-positive diplococci are visualized on direct Gram stain of urethral pus (male genital infection), no further testing is needed to establish the diagnosis of gonorrhea infection. [32] [33] However, in the case of female infection direct Gram stain of cervical swabs is not useful because the N. gonorrhoeae organisms are less concentrated in these samples. The chances of false positives are increased as Gram-negative diplococci native to the normal vaginal flora cannot be distinguished from N. gonorrhoeae. Thus, cervical swabs must be cultured under the conditions described above. If oxidase positive, Gram-negative diplococci are isolated from a culture of a cervical/vaginal swab specimen, then the diagnosis is made. Culture is especially useful for diagnosis of infections of the throat, recutum, eyes, blood, or joints – areas where PCR-based tests are not well established in all labs. [33] [34] Culture is also useful for antimicrobial sensitivity testing, treatment failure, and epidemiological purposes (outbreaks, surveillance). [33]

In patients who may have disseminated gonococcal infection (DGI), all possible mucosal sites should be cultured (e.g., pharynx, cervix, urethra, rectum). [34] Three sets of blood cultures should also be obtained. [35] Synovial fluid should be collected in cases of septic arthritis. [34]

All people testing positive for gonorrhea should be tested for other sexually transmitted diseases such as chlamydia, syphilis, and human immunodeficiency virus. [29] Studies have found co-infection with chlamydia ranging from 46 to 54% in young people with gonorrhea. [36] [37] For this reason, gonorrhea and chlamydia testing are often combined. [30] [38] [39] People diagnosed with gonorrhea infection have a fivefold increase risk of HIV transmission. [40] Additionally, infected persons who are HIV positive are more likely to shed and transmit HIV to uninfected partners during an episode of gonorrhea. [41]

Screening

The United States Preventive Services Task Force (USPSTF) recommends screening for gonorrhea in women at increased risk of infection, which includes all sexually active women younger than 25 years. Extragenital gonorrhea and chlamydia are highest in men who have sex with men (MSM). [42] Additionally, the USPSTF also recommends routine screening in people who have previously tested positive for gonorrhea or have multiple sexual partners and individuals who use condoms inconsistently, provide sexual favors for money, or have sex while under the influence of alcohol or drugs. [14]

Screening for gonorrhea in women who are (or intend to become) pregnant, and who are found to be at high risk for sexually transmitted diseases, is recommended as part of prenatal care in the United States. [43]

Prevention

As with most sexually transmitted diseases, the risk of infection can be reduced significantly by the correct use of condoms and can be removed almost entirely by limiting sexual activities to a mutually monogamous relationship with an uninfected person. [44] [45]

Those previously infected are encouraged to return for follow up care to make sure that the infection has been eliminated. In addition to the use of phone contact, the use of email and text messaging have been found to improve the re-testing for infection. [46]

Newborn babies coming through the birth canal are given erythromycin ointment in the eyes to prevent blindness from infection. The underlying gonorrhea should be treated; if this is done then usually a good prognosis will follow. [47]

Treatment

Antibiotics

Penicillin entered mass production in 1944 and revolutionized the treatment of several venereal diseases. PenicillinPSAedit.jpg
Penicillin entered mass production in 1944 and revolutionized the treatment of several venereal diseases.

Antibiotics are used to treat gonorrhea infections. As of 2016, both ceftriaxone by injection and azithromycin by mouth are most effective. [4] [48] [49] [50] However, due to increasing rates of antibiotic resistance, local susceptibility patterns must be taken into account when deciding on treatment. [29] [51]

Adults may have eyes infected with gonorrhoea and require proper personal hygiene and medications. [47] Addition of topical antibiotics have not been shown to improve cure rates compared to oral antibiotics alone in treatment of eye infected gonorrhea. [52] For newborns, erythromycin ointment is recommended as a preventative measure for gonococcal infant conjunctivitis. [53] Among persons in the United States between 14 and 39 years of age, 46% of people with gonorrheal infection also have chlamydial infection. [54]

Infections of the throat can be especially problematic, as antibiotics have difficulty becoming sufficiently concentrated there to destroy the bacteria. This is amplified by the fact that pharyngeal gonorrhoea is mostly asymptomatic, and gonococci and commensal Neisseria species can coexist for long time periods in the pharynx and share anti-microbial resistance genes. Accordingly, an enhanced focus on early detection (i.e., screening of high-risk populations, such as men who have sex with men, PCR testing should be considered) and appropriate treatment of pharyngeal gonorrhoea is important. [4]

Sexual partners

It is recommended that sexual partners be tested and potentially treated. [29] One option for treating sexual partners of people infected is patient-delivered partner therapy (PDPT), which involves providing prescriptions or medications to the person to take to his/her partner without the health care provider's first examining him/her. [55]

The United States' Centers for Disease Control and Prevention (CDC) currently recommend that individuals who have been diagnosed and treated for gonorrhea avoid sexual contact with others until at least one week past the final day of treatment in order to prevent the spread of the bacterium. [56]

Antibiotic resistance

Many antibiotics that were once effective including penicillin, tetracycline, and fluoroquinolones are no longer recommended because of high rates of resistance. [29] Resistance to cefixime has reached a level such that it is no longer recommended as a first-line agent in the United States, and if it is used a person should be tested again after a week to determine whether the infection still persists. [48] Cases of resistance to ceftriaxone have been reported but are still rare, [5] [29] though public health officials are concerned that an emerging pattern of resistance may predict a global epidemic. [57] The UK's Health Protection Agency reported that 2011 saw a slight drop in gonorrhea antibiotic resistance, the first in five years. [58]

Prognosis

Disability-adjusted life year for gonorrhea per 100, 000 inhabitants.
no data
<13
13-26
26-39
39-52
52-65
65-78
78-91
91-104
104-117
117-130
130-143
>143 Gonorrhoea world map - DALY - WHO2004.svg
Disability-adjusted life year for gonorrhea per 100, 000  inhabitants.

Gonorrhea if left untreated may last for weeks or months with higher risks of complications. [15] One of the complications of gonorrhea is systemic dissemination resulting in skin pustules or petechia, septic arthritis, meningitis, or endocarditis. [15] This occurs in between 0.6 and 3% of infected women and 0.4 and 0.7% of infected men. [15]

In men, inflammation of the epididymis, prostate gland, and urethra can result from untreated gonorrhea. [59] In women, the most common result of untreated gonorrhea is pelvic inflammatory disease. Other complications include inflammation of the tissue surrounding the liver, [59] a rare complication associated with Fitz-Hugh–Curtis syndrome; septic arthritis in the fingers, wrists, toes, and ankles; septic abortion; chorioamnionitis during pregnancy; neonatal or adult blindness from conjunctivitis; and infertility. Men who have had a gonorrhea infection have an increased risk of getting prostate cancer. [20]

Epidemiology

Gonorrhea--Rates: United States, 1941-2007 Chart of gonorrhea infection rates (USA, 1941-2007).png
Gonorrhea—Rates: United States, 1941–2007

About 88 million cases of gonorrhea occur each year, out of the 448 million new cases of curable STI each year – that also includes syphilis, chlamydia and trichomoniasis. [9] In 2013, it caused about 3,200 deaths, up from 2,300 in 1990. [60]

In the United Kingdom, 196 per 100,000 males 20 to 24 years old and 133 per 100,000 females 16 to 19 years old were diagnosed in 2005. [15] In 2013, the CDC estimated that more than 820,000 people in the United States get a new gonorrheal infection each year. Fewer than half of these infections are reported to CDC. In 2011, 321,849 cases of gonorrhea were reported to the CDC. After the implementation of a national gonorrhea control program in the mid-1970s, the national gonorrhea rate declined from 1975 to 1997. After a small increase in 1998, the gonorrhea rate has decreased slightly since 1999. In 2004, the rate of reported gonorrheal infections was 113. 5 per 100,000 persons. [61]

In the US, it is the second-most-common bacterial sexually transmitted infections; chlamydia remains first. [62] [63] According to the CDC African Americans are most affected by gonorrhea, accounting for 69% of all gonorrhea cases in 2010. [64]

The World Health Organization warned in 2017 of the spread of untreatable strains of gonorrhea, following analysis of at least three cases in Japan, France and Spain, which survived all antibiotic treatment. [65]

History

During World War II, the U.S. government used posters to warn military personnel about the dangers of gonorrhea and other sexually transmitted infections. SheMayLookCleanBut.jpg
During World War II, the U.S. government used posters to warn military personnel about the dangers of gonorrhea and other sexually transmitted infections.

Some scholars translate the biblical terms zav (for a male) and zavah (for a female) as gonorrhea. [66]

It has been suggested that mercury was used as a treatment for gonorrhea. Surgeons' tools on board the recovered English warship the Mary Rose included a syringe that, according to some, was used to inject the mercury via the urinary meatus into any unfortunate crewman suffering from gonorrhea. The name "the clap", in reference to the disease, is recorded as early as the sixteenth century, referring to a medieval red-light district in Paris, Les Clapiers. Translating to "The rabbit holes", it was so named for the small huts in which prostitutes worked. [67] [68]

In 1854, Dr. Wilhelm Gollmann addressed gonorrhea in his book, Homeopathic Guide to all Diseases Urinary and Sexual Organs. He noted that the disease was common in prostitutes and homosexuals in large cities. Gollmann recommended the following as cures: aconite to cure "shooting pains with soreness and inflammation;" mercury "for stitching pain with purulent discharge;" nux vomica and sulphur "when the symptoms are complicated with hemorrhoids and stricture of the rectum. Other remedies include argentum, aurum (gold), belladonna, calcarea, ignatia, phosphorus, and sepia. [24]

Silver nitrate was one of the widely used drugs in the 19th century. However, it became replaced by Protargol. Arthur Eichengrün invented this type of colloidal silver, which was marketed by Bayer from 1897 onward. The silver-based treatment was used until the first antibiotics came into use in the 1940s. [69] [70]

The exact time of onset of gonorrhea as prevalent disease or epidemic cannot be accurately determined from the historical record. One of the first reliable notations occurs in the Acts of the (English) Parliament. In 1161, this body passed a law to reduce the spread of "...the perilous infirmity of burning". [71] The symptoms described are consistent with, but not diagnostic of, gonorrhea. A similar decree was passed by Louis IX in France in 1256, replacing regulation with banishment. [72] Similar symptoms were noted at the siege of Acre by Crusaders.

Coincidental to, or dependent on, the appearance of a gonorrhea epidemic, several changes occurred in European medieval society. Cities hired public health doctors to treat afflicted patients without right of refusal. Pope Boniface rescinded the requirement that physicians complete studies for the lower orders of the Catholic priesthood. [73]

Medieval public health physicians in the employ of their cities were required to treat prostitutes infected with the "burning", as well as lepers and other epidemic victims. [74] After Pope Boniface completely secularized the practice of medicine, physicians were more willing to treat a sexually transmitted disease. [75]

Research

A vaccine for gonorrhea has been developed that is effective in mice. [76] It will not be available for human use until further studies have demonstrated that it is both safe and effective in the human population. Development of a vaccine has been complicated by the ongoing evolution of resistant strains and antigenic variation (the ability of N. gonorrhoeae to disguise itself with different surface markers to evade the immune system). [51]

As N. gonorrhoeae is closely related to N. meningitidis and they have 80–90% homology in their genetic sequences some cross-protection by meningococcal vaccines is plausible. A study published in 2017 showed that MeNZB group B meningococcal vaccine provided a partial protection against gonorrhea. [77] The vaccine efficiency was calculated to be 31%. [78]

Related Research Articles

Pelvic inflammatory disease infection of uterus, fallopian tubes, ovaries or the inner surface of pelvis

Pelvic inflammatory disease, also known as pelvic inflammatory disorder (PID), is an infection of the upper part of the female reproductive system, namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no symptoms. Signs and symptoms, when present, may include lower abdominal pain, vaginal discharge, fever, burning with urination, pain with sex, bleeding after sex, or irregular menstruation. Untreated PID can result in long-term complications including infertility, ectopic pregnancy, chronic pelvic pain, and cancer.

Urethritis is inflammation of the urethra. The most common symptom is painful or difficult urination. It is usually caused by infection with bacteria. The bacterial infection is often sexually transmitted, but not in every instance; it can be idiopathic, for example.

Conjunctivitis inflammation of the outermost layer of the eye and the inner surface of the eyelids

Conjunctivitis, also known as pink eye, is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid. It makes the eye appear pink or reddish. Pain, burning, scratchiness, or itchiness may occur. The affected eye may have increased tears or be "stuck shut" in the morning. Swelling of the white part of the eye may also occur. Itching is more common in cases due to allergies. Conjunctivitis can affect one or both eyes.

Nongonococcal urethritis (NGU) is an inflammation of the urethra that is not caused by gonorrheal infection.

Vaginitis, also known as vulvovaginitis, is inflammation of the vagina and vulva. Symptoms may include itching, burning, pain, discharge, and a bad smell. Certain types of vaginitis may result in complications during pregnancy.

Cervicitis is inflammation of the uterine cervix. Cervicitis in women has many features in common with urethritis in men and many cases are caused by sexually transmitted infections.Non-infectious causes of cervicitis can include intrauterine devices, contraceptive diaphragms, and allergic reactions to spermicides or latex condoms. The condition is often confused with vaginismus which is a much simpler condition and easily rectified with simple exercises. Cervicitis affects over half of all women during their adult life.

<i>Chlamydia trachomatis</i> species of bacterium

Chlamydia trachomatis, commonly known as chlamydia, is a bacterium that causes chlamydia, which can manifest in various ways, including: trachoma, lymphogranuloma venereum, nongonococcal urethritis, cervicitis, salpingitis, pelvic inflammatory disease. C. trachomatis is the most common infectious cause of blindness and the most common sexually transmitted bacterium.

Azithromycin chemical compound

Azithromycin is an antibiotic used for the treatment of a number of bacterial infections. This includes middle ear infections, strep throat, pneumonia, traveler's diarrhea, and certain other intestinal infections. It may also be used for a number of sexually transmitted infections, including chlamydia and gonorrhea infections. Along with other medications, it may also be used for malaria. It can be taken by mouth or intravenously with doses once per day.

Vertically transmitted infection infection caused by pathogens that uses mother-to-child transmission

A vertically transmitted infection is an infection caused by pathogens that uses mother-to-child transmission, that is, transmission directly from the mother to an embryo, fetus, or baby during pregnancy or childbirth. It can occur when the mother gets an infection as an intercurrent disease in pregnancy. Nutritional deficiencies may exacerbate the risks of perinatal infection.

Endometritis inflammation of inner lining of uterus

Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. It is also part of spectrum of diseases that make up pelvic inflammatory disease.

Neonatal conjunctivitis

Neonatal conjunctivitis, is a form of conjunctivitis and a type of neonatal infection contracted by newborns during delivery. The baby's eyes are contaminated during passage through the birth canal from either a chemical cause, or a bacterial infection such as Neisseria gonorrhoeae or Chlamydia trachomatis.

Antibiotic resistance in gonorrhea

The Gonorrhea bacterium Neisseria gonorrhoeae has developed antibiotic resistance to many antibiotics.

Tubal factor infertility

Tubal factor infertility (TFI) is female infertility caused by diseases, obstructions, damage, scarring, congenital malformations or other factors which impede the descent of a fertilized or unfertilized ovum into the uterus through the Fallopian tubes and prevents a normal pregnancy and full term birth. Tubal factors cause 25-30% of infertility cases. Tubal factor is one complication of Chlamydia trachomatis infection in women.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 "Gonorrhea - CDC Fact Sheet (Detailed Version)". CDC. 17 November 2015. Archived from the original on 2 September 2016. Retrieved 27 August 2016.Cite uses deprecated parameter |deadurl= (help)
  2. 1 2 3 4 Morgan, MK; Decker, CF (August 2016). "Gonorrhea". Disease-a-month : DM. 62 (8): 260–8. doi:10.1016/j.disamonth.2016.03.009. PMID   27107780.
  3. 1 2 3 4 5 6 Workowski, KA; Bolan, GA (5 June 2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control. 64 (RR-03): 1–137. PMC   5885289 . PMID   26042815.
  4. 1 2 3 4 5 "Antibiotic-Resistant Gonorrhea Basic Information". CDC. 13 June 2016. Archived from the original on 8 September 2016. Retrieved 27 August 2016.Cite uses deprecated parameter |deadurl= (help)
  5. 1 2 3 4 Unemo, M (21 August 2015). "Current and future antimicrobial treatment of gonorrhoea - the rapidly evolving Neisseria gonorrhoeae continues to challenge". BMC Infectious Diseases. 15: 364. doi:10.1186/s12879-015-1029-2. PMC   4546108 . PMID   26293005.
  6. 1 2 Newman, Lori; Rowley, Jane; Vander Hoorn, Stephen; Wijesooriya, Nalinka Saman; Unemo, Magnus; Low, Nicola; Stevens, Gretchen; Gottlieb, Sami; Kiarie, James; Temmerman, Marleen; Meng, Zhefeng (8 December 2015). "Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting". PLOS ONE. 10 (12): e0143304. Bibcode:2015PLoSO..1043304N. doi:10.1371/journal.pone.0143304. PMC   4672879 . PMID   26646541.
  7. Leslie Delong; Nancy Burkhart (27 November 2017). General and Oral Pathology for the Dental Hygienist. Wolters Kluwer Health. p. 787. ISBN   978-1-4963-5453-2.
  8. Global Burden of Disease Study 2013, Collaborators (22 August 2015). "Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013". Lancet. 386 (9995): 743–800. doi:10.1016/s0140-6736(15)60692-4. PMC   4561509 . PMID   26063472.
  9. 1 2 Emergence of multi-drug resistant Neisseria gonorrhoeae (PDF) (Report). World Health Organisation. 2012. p. 2. Archived from the original (pdf) on 12 September 2014.Cite uses deprecated parameter |deadurl= (help)
  10. GBD 2015 Mortality and Causes of Death, Collaborators. (8 October 2016). "Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1459–1544. doi:10.1016/s0140-6736(16)31012-1. PMC   5388903 . PMID   27733281.
  11. 1 2 "Gonorrhea - Symptoms and causes". Mayo Clinic. Retrieved 6 August 2019.
  12. Zakher, Bernadette; Cantor MD, Amy G.; Daeges, Monica; Nelson MD, Heidi (16 December 2014). "Review: Screening for Gonorrhea and Chlamydia: A Systematic Review for the U.S. Prevententive Services Task Force". Annals of Internal Medicine. 161 (12): 884–894. CiteSeerX   10.1.1.691.6232 . doi:10.7326/M14-1022. PMID   25244000.
  13. 1 2 Marr, Lisa (2007) [1998]. Sexually Transmitted Diseases: A Physician Tells You What You Need to Know (Second ed.). Baltimore, Maryland: Johns Hopkins University. ISBN   978-0-8018-8658-4. Archived from the original on 2 October 2015.Cite uses deprecated parameter |deadurl= (help)
  14. 1 2 Smith, L; Angarone, MP (November 2015). "Sexually Transmitted Infections". The Urologic Clinics of North America. 42 (4): 507–18. CiteSeerX   10.1.1.590.3827 . doi:10.1016/j.ucl.2015.06.004. PMID   26475947.
  15. 1 2 3 4 5 6 7 8 9 Moran JS (2007). "Gonorrhoea". Clin Evid (Online). 2007. PMC   2943790 . PMID   19454057.
  16. 1 2 Ljubin-Sternak, Suncanica; Mestrovic, Tomislav (2014). "Review: Clamydia trachonmatis and Genital Mycoplasmias: Pathogens with an Impact on Human Reproductive Health". Journal of Pathogens. 2014 (183167): 7. doi:10.1155/2014/183167. PMC   4295611 . PMID   25614838.
  17. 1 2 3 "What Complications Can Gonorrhea Cause?". WebMD. 2019.
  18. 1 2 3 Brian R. Shmaefsky (1 January 2009). Gonorrhea. Infobase. p. 52. ISBN   978-1-4381-0142-2. Archived from the original on 2 November 2015.Cite uses deprecated parameter |deadurl= (help)
  19. Liang Cheng; David G. Bostwick (24 January 2014). Urologic Surgical Pathology E-Book. Elsevier Health Sciences. p. 863. ISBN   978-0-323-08619-6.
  20. 1 2 Caini, Saverio; Gandini, Sara; Dudas, Maria; Bremer, Viviane; Severi, Ettore; Gherasim, Alin (2014). "Sexually transmitted infections and prostate cancer risk: A systematic review and meta-analysis". Cancer Epidemiology. 38 (4): 329–338. doi:10.1016/j.canep.2014.06.002. PMID   24986642.
  21. "Prophylaxis for Gonococcal and Chlamydial Ophthalmia Neonatorum in the Canadian Guide to Clinical Preventative Health Care" (PDF). Public Health Agency of Canada. Archived from the original (PDF) on 10 March 2010.Cite uses deprecated parameter |deadurl= (help)
  22. Trebach, Joshua D.; Chaulk, C. Patrick; Page, Kathleen R.; Tuddenham, Susan; Ghanem, Khalil G. (2015). "Neisseria gonorrhoeae and Chlamydia trachomatis Among Women Reporting Extragenital Exposures". Sexually Transmitted Diseases. 42 (5): 233–239. doi:10.1097/OLQ.0000000000000248. ISSN   0148-5717. PMC   4672628 . PMID   25868133.
  23. Howard Brown Health Center: STI Annual Report, 2009
  24. 1 2 Gollmann, Wilhelm (1854). Homeopathic Guide to all Diseases Urinary and Sexual Organ. Charles Julius Hempel. Rademacher & Sheek. Archived from the original on 8 September 2017.Cite uses deprecated parameter |deadurl= (help)
  25. National Institute of Allergy and Infectious Diseases; National Institutes of Health, Department of Health and Human Services (2001-07-20). "Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention". Hyatt Dulles Airport, Herndon, Virginia. pp14
  26. Goodyear-Smith, F (November 2007). "What is the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period? A systematic review". Journal of Forensic and Legal Medicine. 14 (8): 489–502. doi:10.1016/j.jflm.2007.04.001. PMID   17961874.
  27. Brian R. Shmaefsky (1 January 2009). Gonorrhea. Infobase. p. 48. ISBN   978-1-4381-0142-2. Archived from the original on 1 August 2017.Cite uses deprecated parameter |deadurl= (help)
  28. Barry PM, Klausner JD (March 2009). "The use of cephalosporins for gonorrhea: The impending problem of resistance". Expert Opin Pharmacother. 10 (4): 555–77. doi:10.1517/14656560902731993. PMC   2657229 . PMID   19284360.
  29. 1 2 3 4 5 6 Deguchi T, Nakane K, Yasuda M, Maeda S (September 2010). "Emergence and spread of drug resistant Neisseria gonorrhoeae". J. Urol. 184 (3): 851–8, quiz 1235. doi:10.1016/j.juro.2010.04.078. PMID   20643433.
  30. 1 2 "Final Recommendation Statement: Chlamydia and Gonorrhea: Screening - US Preventive Services Task Force". uspreventiveservicestaskforce.org. Retrieved 7 December 2017.
  31. "Gonococcal Infections - 2015 STD Treatment Guidelines". cdc.gov. Retrieved 7 December 2017.
  32. Levinson, Warren (1 July 2014). Review of medical microbiology and immunology (Thirteenth ed.). New York. ISBN   9780071818117. OCLC   871305336.
  33. 1 2 3 Ng, Lai-King; Martin, Irene E (2005). "The laboratory diagnosis of Neisseria gonorrhoeae". The Canadian Journal of Infectious Diseases & Medical Microbiology. 16 (1): 15–25. doi:10.1155/2005/323082. ISSN   1712-9532. PMC   2095009 . PMID   18159523.
  34. 1 2 3 https://www.cdc.gov/std/tg2015/clinical.htm section on prevention methods
  35. Gonorrhea~overview at eMedicine
  36. Kahn, Richard H.; Mosure, Debra J.; Blank, Susan; Kent, Charlotte K.; Chow, Joan M.; Boudov, Melina R.; Brock, Jeffrey; Tulloch, Scott; Jail STD Prevalence Monitoring Project (April 2005). "Chlamydia trachomatis and Neisseria gonorrhoeae prevalence and coinfection in adolescents entering selected US juvenile detention centers, 1997-2002". Sexually Transmitted Diseases. 32 (4): 255–259. doi:10.1097/01.olq.0000158496.00315.04. ISSN   0148-5717. PMID   15788927.
  37. Dicker, Linda W.; Mosure, Debra J.; Berman, Stuart M.; Levine, William C. (May 2003). "Gonorrhea prevalence and coinfection with chlamydia in women in the United States, 2000". Sexually Transmitted Diseases. 30 (5): 472–476. doi:10.1097/00007435-200305000-00016. ISSN   0148-5717. PMID   12916141.
  38. "Gonococcal Infections - 2015 STD Treatment Guidelines". 4 January 2018.
  39. Ryan, KJ; Ray, CG, eds. (2004). Sherris Medical Microbiology (4th ed.). McGraw Hill. ISBN   978-0-8385-8529-0.[ page needed ]
  40. Department of Reproductive Health and Research (2011). "Emergence of multi-drug resistant Neisseria gonorrhoeae – Threat of global rise in untreatable sexually transmitted infections" (PDF). FactSheet WHO/RHR/11.14. World Health Organization.
  41. "Gonorrhea - STD information from CDC". cdc.gov. 6 October 2017. Retrieved 5 December 2017.
  42. Meyers D; Wolff T; Gregory K; et al. (March 2008). "USPSTF recommendations for STI screening". Am Fam Physician. 77 (6): 819–24. PMID   18386598.
  43. Health Care Guideline: Routine Prenatal Care. Fourteenth Edition. Archived 5 July 2008 at the Wayback Machine By the Institute for Clinical Systems Improvement July 2010.
  44. section: Prevention Archived 20 July 2013 at the Wayback Machine
  45. section: How can gonorrhea be prevented? Archived 16 December 2016 at the Wayback Machine
  46. Desai, Monica; Woodhall, Sarah C; Nardone, Anthony; Burns, Fiona; Mercey, Danielle; Gilson, Richard (2015). "Active recall to increase HIV and STI testing: a systematic review". Sexually Transmitted Infections. 91 (5): sextrans–2014–051930. doi:10.1136/sextrans-2014-051930. ISSN   1368-4973. PMID   25759476.
  47. 1 2 Sadowska-Przytocka, A; Czarnecka-Operacz, M; Jenerowicz, D; Grzybowski, A (2016). "Ocular manifestations of infectious skin diseases". Clinics in Dermatology. 34 (2): 124–8. doi:10.1016/j.clindermatol.2015.11.010. PMID   26903179.
  48. 1 2 Centers for Disease Control and Prevention, (CDC) (10 August 2012). "Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections". MMWR. Morbidity and Mortality Weekly Report. 61 (31): 590–4. PMID   22874837.
  49. "Antibiotic-resistant gonorrhoea on the rise, new drugs needed". World Health Organization. 7 July 2017. Archived from the original on 9 July 2017. Retrieved 10 July 2017.Cite uses deprecated parameter |deadurl= (help)
  50. Sánchez-Busó, Leonor; Golparian, Daniel; Corander, Jukka; Grad, Yonatan H.; Ohnishi, Makoto; Flemming, Rebecca; Parkhill, Julian; Bentley, Stephen D.; Unemo, Magnus (29 July 2019). "The impact of antimicrobials on gonococcal evolution". Nature Microbiology. doi:10.1038/s41564-019-0501-y. ISSN   2058-5276.
  51. 1 2 Baarda, Benjamin I.; Sikora, Aleksandra E. (2015). "Proteomics of Neisseria gonorrhoeae: the treasure hunt for countermeasures against an old disease". Frontiers in Microbiology. 6: 1190. doi:10.3389/fmicb.2015.01190. ISSN   1664-302X. PMC   4620152 . PMID   26579097; Access provided by the University of Pittsburgh.
  52. Epling, John (20 February 2012). "Bacterial conjunctivitis". BMJ clinical evidence. 2012. ISSN   1752-8526. PMC   3635545 . PMID   22348418.
  53. US Preventive Services Task Force; Curry, Susan J.; Krist, Alex H.; Owens, Douglas K.; Barry, Michael J.; Caughey, Aaron B.; Davidson, Karina W.; Doubeni, Chyke A.; Epling, John W. (29 January 2019). "Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: US Preventive Services Task Force Reaffirmation Recommendation Statement". JAMA. 321 (4): 394–398. doi:10.1001/jama.2018.21367. ISSN   1538-3598. PMID   30694327.
  54. Datta, SD; Sternberg, M; Johnson, RE; Berman, S; Papp, JR; McQuillan, G; Weinstock, H (17 July 2007). "Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002". Annals of Internal Medicine. 147 (2): 89–96. doi:10.7326/0003-4819-147-2-200707170-00007. PMID   17638719.
  55. "Expedited partner therapy in the management of sexually transmitted diseases" Archived 2 November 2009 at the Wayback Machine . February 2006. Centers for Disease Control and Prevention (CDC).
  56. CDC (14 July 2014). "Gonorrhea - CDC Fact Sheet". Archived from the original on 16 December 2016. Retrieved 17 October 2014.Cite uses deprecated parameter |deadurl= (help)
  57. Groopman, Jerome (1 October 2012). "Sex and the Superbug". The New Yorker. LXXXVIII (30): 26–31. Archived from the original on 9 October 2012. Retrieved 13 October 2012. ...public-health experts [see]...the emergence of a strain of gonorrhea that is resistant to the last drug available against it, and the harbinger of a sexually transmitted global epidemic.Cite uses deprecated parameter |deadurl= (help)
  58. "Gonorrhoea treatment resistance risk falls but new diagnoses rise". Health Protection Agency. 12 September 2012. Archived from the original on 14 July 2014.Cite uses deprecated parameter |dead-url= (help)
  59. 1 2 Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; & Mitchell, Richard N. (2007). Robbins Basic Pathology (8th ed.). Saunders Elsevier. pp. 705–706 ISBN   978-1-4160-2973-1
  60. GBD 2013 Mortality and Causes of Death, Collaborators (10 January 2015). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013". Lancet. 385 (9963): 117–71. doi:10.1016/s0140-6736(14)61682-2. PMC   4340604 . PMID   25530442.
  61. "Gonorrhea – CDC Fact Sheet". CDC. 29 May 2012. Archived from the original on 16 December 2016. Retrieved 20 December 2013.Cite uses deprecated parameter |deadurl= (help)
  62. "CDC – STD Surveillance – Gonorrhea". Archived from the original on 6 March 2008. Retrieved 21 August 2008.
  63. "CDC Fact Sheet – Chlamydia". Archived from the original on 16 December 2016. Retrieved 21 August 2008.Cite uses deprecated parameter |deadurl= (help)
  64. "STD Trends in the United States: 2010 National Data for Gonorrhea, Chlamydia, and Syphilis". Centers for Disease Control and Prevention (CDC). 22 November 2010. Archived from the original on 24 January 2012.Cite uses deprecated parameter |deadurl= (help)
  65. "Untreatable gonorrhoea 'superbug' spreading around world, WHO warns". The Daily Telegraph. 7 July 2017. Archived from the original on 7 July 2017.Cite uses deprecated parameter |deadurl= (help)
  66. "Daf Parashat Hashavua". Archived from the original on 3 October 2012. Retrieved 2 November 2012.Cite uses deprecated parameter |deadurl= (help)
  67. Higgins, John (1587). The Mirror for Magistrates. as cited in the Oxford English Dictionary entry for "clap"
  68. Baarda, Benjamin I; Sikora, Aleksandra E (2015). "Proteomics of Neisseria gonorrhoeae: The treasure hunt for countermeasures against an old disease". Frontiers in Microbiology. 6: 1190. doi:10.3389/fmicb.2015.01190. PMC   4620152 .
  69. Max Bender (1898). "Ueber neuere Antigonorrhoica (insbes. Argonin und Protargol)". Archives of Dermatological Research. 43 (1): 31–36. doi:10.1007/BF01986890.
  70. MedlinePlus Encyclopedia Neonatal Conjunctivitis
  71. W Sanger. History of Prostitution. NY, Harper, 1910.
  72. P. LaCroix. The History of Prostitution—Vol. 2. NY, MacMillan, 1931.
  73. Moen, Juliann (2017). Basic Healthcare Studies: Sexually Transmitted Disease. Lester Bivens. Alpha Editions. ISBN   9789386367570. Archived from the original on 8 September 2017.Cite uses deprecated parameter |deadurl= (help)
  74. WE Leiky. History of European Morals. NY, MacMillan, 1926.
  75. Moen, Juliann (2017). Basic Healthcare Studies: Sexually Transmitted Disease. Lester Bivens. Alpha Editions. ISBN   9789386367570. Archived from the original on 8 September 2017.Cite uses deprecated parameter |deadurl= (help)
  76. Jerse, AE; Bash, MC; Russell, MW (20 March 2014). "Vaccines against gonorrhea: current status and future challenges". Vaccine. 32 (14): 1579–87. doi:10.1016/j.vaccine.2013.08.067. PMC   4682887 . PMID   24016806.
  77. Gottlieb, Sami L.; Johnston, Christine (2017). "Future prospects for new vaccines against sexually transmitted infections". Curr Opin Infect Dis. 30 (1): 77–86. doi:10.1097/QCO.0000000000000343. PMC   5325242 . PMID   27922851.
  78. Petousis-Harris, Helen (2017). "Effectiveness of a group B outer membrane vesicle meningococcal vaccine against gonorrhoea in New Zealand: a retrospective case-control study". Lancet. 390 (10102): 1603–1610. doi:10.1016/S0140-6736(17)31449-6. PMID   28705462.
Classification
D
External resources