1. Gonorrhea Testing, Diagnosis and Treatment
March 2017
Medical Assessment and Policy Team
Immigrant, Refugee, and Migrant Health Branch
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine

2. Learning Objectives Implement required testing for gonorrhea
After this session, you should be able to:
Implement required testing for gonorrhea
Treat gonorrhea
Complete the DS 3026 for gonorrhea

3. Neisseria gonorrhoeae diplococci from cervical smear
Gonorrhea
Neisseria gonorrhoeae
Neisseria gonorrhoeae diplococci from cervical smear

4. Gonorrhea Technical Instructions
Published May 2016
Start date
As soon as able after publication
No later than October 1, 2016
Based on CDC STD Treatment Guidelines

5. Screening for Gonorrhea
Medical history
Urine NAAT or self-collected vaginal swab NAAT
Treatment
Nucleic Acid Amplification Test
Document
NAAT=Nucleic Acid Amplification Test

6. Men may be asymptomatic Women may be asymptomatic
Question 1
Which of the following is true regarding the manifestation of gonorrhea in men and women?
Men may be asymptomatic
Women may be asymptomatic
Men with discharge are at risk of infertility
Discharge in women correlates with
infertility
Both A and B
Answer = E

7. Medical History and Physical Examination
Men
Burning sensation with urination
Discharge
Painful or swollen testicles
Some men are asymptomatic
Women
Most are asymptomatic
Mild or nonspecific
Painful urination
Vaginal bleeding between periods

8. Gonorrhea Complications
Men
Epididymitis
Infertility
Women
Pelvic inflammatory disease
Abdominal pain and fever
Abscess
Infertility/ Ectopic pregnancy
Intrapartum transfer leading to manifestations in infant
Blindness
Joint infection
Sepsis

9. Physical Examination
External genital examination is no longer required for all applicants
Genital exam is only required when an applicant tests positive for syphilis in order to stage the disease
Must be performed by a physician
Cannot be performed by nurse or physician assistant
Examination is a visual inspection only

10. We are using urine NAAT testing for both men and women
Question 2
Experience: What type of gonorrhea test is your practice currently using?
We are using urine NAAT testing for both men and women
We are using culture testing for both men and women
We are using another kind of gonorrhea testing
I am not a panel physician
Answer = A

11. Which types of samples can be used for gonorrhea culture testing?
Question 3
Which types of samples can be used for gonorrhea culture testing?
Self-collected vaginal swabs
Urine sample
Endocervical swabs
Blood sample
Answer=c

12. Culture Limitations
Requires endocervical swab specimens from women, which can be collected only by a speculum pelvic exam
Requires urethral swab specimens from men
Swabs must be plastic or wire with rayon, Dacron, or calcium alginate tips
Must be transported to laboratory properly and plated on selective media
Takes several days for result
Not ideal for routine use due to invasive and stringent collection and transport requirements
Swabs should be inserted 2–3 cm in the male urethra or 1–2 cm into the endocervical canal followed by two or three rotations.
Several nonnutritive swab transport systems are available, and some studies suggest that these transport systems might maintain gonococcal viability for up to 48 hours in ambient temperatures (53–55). However, environmental conditions might vary by location and season, which could affect the viability of gonorrhea in these transport systems; thus, additional local validation of transport conditions might be needed. Culture medium transport systems are preferred because there are some advantages over swab transport systems (e.g., extended shelf life and better recovery because cultivated isolates are being transported rather than a clinical specimen) (39). Culture medium is inoculated with the swab specimen and then placed immediately into a CO2-enriched atmosphere for transportation to the laboratory. Because N. gonorrhoeae has demanding nutritional and environmental growth requirements, optimal recovery rates are achieved when specimens are inoculated directly and when the growth medium is incubated in an increased CO2 environment as soon as possible.
Taken from pages 5-6 of Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae — 2014

13. Urine NAAT or culture in men and women
Question 4
Which of the following tests are preferred for panel physicians screening for gonorrhea?
Urine NAAT in men and women or self-collected vaginal swab NAAT in women
Urine NAAT or culture in men and women
Urethral DNA probe in men and women
Gram stain in symptomatic men and
physician-collected vaginal swab
NAAT in women
Answer=A

14. Gonorrhea Testing
Laboratory testing should be performed on applicants ≥15 years of age
Also perform testing on applicants <15 years of age if there is reason to suspect gonorrhea
Types of laboratory tests allowed for US panel use
Nucleic acid amplification tests (NAAT)
Gram stain for symptomatic men

15. NAAT Available for the detection of genitourinary infection
Some NAAT tests involve PCR amplification, but not all, and not all PCR tests are NAAT tests
The test you select should be approved by the regulatory authority in the country in which you practice

16. NAAT CDC recommends panel physicians use NAAT as screening test
Urine specimen from men and women
Self-collected vaginal swab from women
Use self-collected vaginal swab test kit that can also report if human DNA is present
Urine tests are what we recommend and involve “first catch”, not “clean catch” urine

17. Gram Stain
Urethral secretions with polymorphonuclear leukocytes with intracellular gram-negative diplococci can be considered diagnostic in symptomatic men
This is only an option with symptomatic men, so can’t be used as your primary screening method

18. She is not admissible to the US until she is treated for chlamydia.
Question 5
A 16 year old applicant tests positive for chlamydia during the medical screening. She says tearfully that she has never had sex, doesn’t want treatment and the result must be false. What do you tell her?
She is not admissible to the US until she is treated for chlamydia.
You are required by CDC to tell her parents she is sexually active.
Treatment for chlamydia is not required, and she can refuse, but it is recommended and easy
The test must be wrong because teenagers always tell the truth
Answer=C

19. Chlamydia Testing
Many gonorrhea tests automatically test for Chlamydia trachomatis
Chlamydia is not listed in the diseases of public health significance in 42 Code of Federal Regulations (CFR) part 34
Panel physicians may use test kits that screen for both gonorrhea and chlamydia if gonorrhea stand-alone test kits are unavailable
When combined test kits are used, applicants should be informed their chlamydia results do not affect admissibility

20. Chlamydia Testing (continued)
Applicants who test positive for chlamydia only should be offered treatment in accordance with CDC’s Sexually Transmitted Diseases Treatment Guidelines
If an applicant is diagnosed and treated for chlamydia, document this in the DS 3026 remarks section (but not under Section 8 where gonorrhea diagnosis and treatment are documented)
Give a Class B Other classification for applicants diagnosed and successfully treated for chlamydia

21. She was treated 4 weeks ago but symptoms did not improve.
Question 6
You diagnose gonorrhea in a 17-year old female applicant with painful urination and discharge. Which of the following are factors that may influence the recommended treatment regimen?
She was treated 4 weeks ago but symptoms did not improve.
Whether or not she’s pregnant
Number of partners
Number of gram-positive diplococci
Answer= A
Recommended Regimen
Ceftriaxone 250 mg IM in a single dose PLUS
Azithromycin 1 g orally in a single dose
This regimen is the same if pregnant

22. Gonorrhea Treatment
Uncomplicated infection of the cervix, urethra, rectum, and pharynx
Ceftriaxone 250 mg IM in a single dose
PLUS
Azithromycin 1g orally in a single dose

23. Resistance
Treatment failure – symptoms that persist after appropriate treatment (longer than 5 days)
Culture and drug susceptibility should be performed
True treatment failures are uncommon

24. Obtain cultures and DSTs because he is likely resistant to treatment.
Question 7
You diagnose gonorrhea in a 17-year male applicant. He says he took doxycycline a month ago for gonorrhea and continues to have sex with his partner who has not been treated. What should you do?
Obtain cultures and DSTs because he is likely resistant to treatment.
Treat him with Ceftriaxone and Azithromycin as you would for any case of gonorrhea
Treat him with gemifloxacin and azithromycin
None of the above
Answer= B
Recommended Regimen
Ceftriaxone 250 mg IM in a single dose PLUS
Azithromycin 1 g orally in a single dose
This regimen is the same if pregnant

25. Gonorrhea Classifications
No treatment
Class A (Inadmissible)
Treatment
Class B

26. Completing the DS 3026
Record screening test information under the Remarks section (Section 10, page 3)
Test used
Result
Record treatment under Section 8

27. Question 7
You diagnose gonorrhea in a 47-year old male applicant who agrees to be treated. His wife is also an applicant and she is negative for gonorrhea. What should you do next?
Tell the wife she must undergo culture testing because her results must not be correct.
Tell the husband he should wait 7 days post treatment before having sex, and encourage him to share this information with his wife.
Tell the wife she must be treated for gonorrhea or she is inadmissible.
Both A and C
Answer= B

28. CDC does not recommend further follow up.
Question 8
You treated a 17-year old male applicant with gonorrhea with Ceftriaxone 250mg IM and Azithromycin 1 g orally. Which of the following is true?
He should remain class A for gonorrhea until he returns in 2 weeks for retesting.
CDC does not recommend further follow up.
He should be advised to be retested in 3 months, however, this post-treatment follow up is a recommendation and does not prevent him from immigrating to the US.
Answer= C
Recommended Regimen
Ceftriaxone 250 mg IM in a single dose PLUS
Azithromycin 1 g orally in a single dose
This regimen is the same if pregnant
Ceftriaxone at this dose used alone is 99.2% effective
Azithromycin at 2 g is 99.2% effective

29. Thank you cdcQAP@cdc.gov http://www.cdc.gov/panelphysicians
For more information, please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA
Telephone: CDC-INFO ( )/TTY:
Visit: | Contact CDC at: CDC-INFO or
Web:
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
National Center for Emerging and Zoonotic Infectious Diseases
Division of Global Migration and Quarantine

30. Answers E A C B