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Gonorrhea is a common sexually transmitted diseases. It is caused by the bacteriaNeisseria gonorrhoeae.
Bacterial infections occur in the reproductive tracts of both male and females and is passed on by anal, oral or vaginal sexual intercourse. Infection can also occur in the mouth, throat, anus and eye.
The symptoms of gonorrhea vary slightly in males and females and usually present from 1 day after contraction of the infection to 14 days after. However it is not common for the infection to show no symptoms.
In males the symptoms may consist of:
- Burning pain when urinating
- White/ yelow / green discharge from the Penis
- Uncomfortable anal discharge
- Swollen testicles
- Potent smelling/ thin/watery vaginal discharge
- Burning pain when urinating
- Pelvic tenderness
- Uncomfortable anal discharge
A nucleic acid amplification test is the recommended method of testing for gonorrhoea. This is a molecular test that detects the DNA of N. gonorrhoeae (the bacteria that causes the disease). It is more sensitive and specific than other gonorrhea tests and can be performed on a vaginal swab on women, or urine from both men and women, which eliminates the need for a pelvic exam in women.
Another test to detect gonorrhoea involves growing the bacteria, which is known as a gonorrhea culture. In men, a quick method is the gram stain, which allows the healthcare practitioner to look at a sample from the urethra for the presence of the bacteria using a microscope. While this method can diagnose gonorrhea, it is not sufficient to rule out an infection in asymptomatic men. This method is not reliable for women since other bacteria normally found in the female genital tract will look the same under the microscope.
The N. gonorrhoeae bacterial infection can be treated with antibiotics such as Amoxicillin or Ampicillin. However some strains are resistant to Penicillin so other forms of antibiotics may be taken.It is best to contact your local GP if any of the above symptoms presist due to the presense of strains of the bacteria that are have developed antibiotic resistance.
If the infection is not quickly diagnosed and treated complications may occur leading to serious health problems and ultimately infertility. However the best way to restrain from contacting this disease is to restrain from multiple sexual partners and practice safe sex.
Antibiotic resistance in gonorrhea
Neisseria gonorrhoeae, the bacterium that causes the sexually transmitted infection gonorrhea, has developed antibiotic resistance to many antibiotics. The bacteria was first identified in 1879.
In the 1940s effective treatment with penicillin became available, but by the 1970s resistant strains predominated. Resistance to penicillin has developed through two mechanisms: chromosomally mediated resistance (CMRNG) and penicillinase-mediated resistance (PPNG). CMRNG involves step wise mutation of penA, which codes for the penicillin-binding protein (PBP-2); mtr, which encodes an efflux pump that removes penicillin from the cell; and penB, which encodes the bacterial cell wall porins. PPNG involves the acquisition of a plasmid-bornebeta-lactamase.N. gonorrheoea has a high affinity for horizontal gene transfer, and as a result, the existence of any strain resistant to a given drug could spread easily across strains.
Fluoroquinolones were a useful next-line treatment until resistance was achieved through efflux pumps and mutations to the gyrA gene, which encodes DNA gyrase. Third-generation cephalosporins have been used to treat gonorrhoea since 2007, but resistant strains have emerged. As of 2010, the recommended treatment is a single 250 mg intramuscular injection of ceftriaxone, sometimes in combination with azithromycin or doxycycline. However, certain strains of N. gonorrhoeae can be resistant to antibiotics usually that are normally used to treat it. These include: cefixime (an oral cephalosporin), ceftriaxone (an injectable cephalosporin), azithromycin, aminoglycosides, and tetracycline.
Beta-lactams like penicillin were widely used to treat gonorrhea in the 1940s. There are three general mechanisms that may allow bacteria to become resistant to beta-lactam antibiotics:
- inability to access/target penicillin-binding protein (PBP) enzyme
- inhibition of binding to PBP via modification of the enzyme
- hydrolysis/inactivation of the antibiotic by beta-lactamases.
Overuse of penicillin contributed to Neisseria gonorrhoeae developing high resistance to penicillin through two main mechanisms: chromosomally mediated resistance (CMRNG) and penicillinase-mediated resistance (PPNG).
Chromosomally mediated resistance occurred through step-wise changes over many years. Chromosomal mutations in the penA, mtr, and penB genes are the major mechanisms for CMRNG. The penA gene encodes an alternative penicillin-binding protein, PBP-2. This mechanism falls under the second general mechanism for beta-lactam resistance. PBPs, also known as transpeptidases, are targets for beta-lactams. These enzymes (PBPs) are involved in peptidoglycan synthesis which is a major component of the bacterial cell wall. PBPs cross-link the amino acid strands of peptidoglycan during synthesis. Normally, beta-lactams bind the PBPs and thereby inhibit the cross-linking of peptidoglycan. When this occurs, the cell wall of the bacterium is compromised and often results in cell death. When N. gonorrhoeae encodes penA, the new PBP-2 that is synthesized is no longer recognized by the beta-lactams rendering the bacterium resistant.
The mtr (multiple transferable resistance) gene encodes for an efflux pump. Efflux pumps mediate resistance to a variety of compounds including antibiotics, detergents, and dyes. This mechanism falls under the first general resistance mechanism to beta-lactams. mtr encodes for the protein MtrD which is the efflux pump for N. gonorrhoeae. MtrD is among the Resistance Nodulation Division (RND) efflux pump superfamily. These pumps are proton antiporters where the antibiotic is pumped out of the cell while a proton is pumped into the cell.
The cell wall of N. gonorrhoeae contains porins which are holes within the cell wall in which some molecules are able to diffuse into or out of the cell membrane. This mechanism falls under the first general mechanism for beta-lactam resistance. The penB gene encodes the porins for N. gonorrhoeae and when this gene undergoes mutations, there is a decrease in permeability of the cell wall to hydrophilic antibiotics like penicillin.
Penicillinase-mediated resistance in N. gonorrhoeae is mediated by the plasmid borne TEM-1 type beta-lactamase which falls under the third general mechanism for beta-lactam resistance. There have been over 200 beta-lactamases described and some of them are antibiotic specific. TEM-1 is a penicillinase specific for penicillins. This enzyme will bind to the beta-lactam ring which is a structural characteristic for beta-lactams and hydrolyze the ring. This renders the antibiotic inactive. The spread of the penicillinase resistance was much faster compared to the chromosomal-mediated resistance mechanisms. The plasmids containing TEM-1 could be passed from bacterium to bacterium via conjugation 
Quinolones are a class of synthetic antibiotics that inhibit DNA replication, recombination, and repair by interacting with the bacterial DNA gyrase and/or topoisomerase IV. Second generation quinolones like ciprofloxacin and ofloxacin have been widely used to treat N. gonorrhoeae infections. Resistance to these antibiotics has developed over the years with chromosomal resistance being the primary mechanism.
Low-level quinolone resistance has been linked to changes in cell permeability and efflux pumps. The NorM efflux pump is encoded by the norM gene and provides resistance to fluoroquinolones. The NorM efflux pump is a member of the MATE (multidrug and toxic compound extrusion) family and functions by a Na+ antiporter. It is also known that a point mutation upstream of the norM gene will causes overexpression of NorM, and mediate elevated resistance.
High-level resistance to quinolones has been seen through target modification acting on the DNA gyrase and topoisomerase IV. Multiple amino acid substation mutations in the gyrA gene, which encodes for the DNA gyrase, have been seen extensively. DNA gyrase is an enzyme that binds to DNA and introduces negative supercoiling. This helps unwind the DNA for replication. If there is a mutation in the DNA gyrase, then the quinolone will not be able to bind to it resulting in the activity of DNA gyrase not being inhibited. Multiple mutations have also been noted in the parC gene which encodes for the topoisomerase IV. Topoisomerase IV acts similarly to DNA gyrase and is involved in unwinding DNA for replication.
Ceftriaxone and cefixime are third generation cephalosporins and are often used as treatments for N. gonorrhoeae infections. The cephalosporins are part of a larger beta-lactam family of antibiotics. The newly discovered H041 strain of N. gonorrhoeae, originally isolated from a commercial sex worker in Japan, was shown to be resistant to this antibiotic.
The possible mechanisms of resistance to this antibiotic are as follows:
- an alteration of more than four amino acids in the C-terminal end of the PBP-2, which would result in the antibiotic being unable to bind to its target
- mutations in the promoter regions of mtr, resulting in the overexpression of genes that code for efflux pumps
- mutations in the penB gene that encodes for the bacterial porin. This form of resistance has only been observed with ceftriaxone which is administered through an intramuscular injection.
Tetracyclines are a class of antibiotics that inhibit protein synthesis by binding to the 30s ribosomal subunit of bacterial cells, keeping transcription of the bacterial genome from occurring. Tetracyclines are bacteriostatic, which means that the growth of the bacterium will be slowed. Tetracyclines are not often recommended for the treatment of N. gonorrhoeae because the treatment regimen requires many doses, which may affect compliance and contribute to resistance. Tetracycline is still used as treatment for this infection in developing countries because the cost for the drug is low 
As with the penicillin resistance, the penB (porin formation) and mtr (efflux pump formation) mutations mediate chromosomal resistance. These adaptations will also affect the ability of the antibiotic to get into, or stay in the bacterial cell. High level resistance of N. gonorrhoeae to tetracyclines was first reported in 1986 with the discovering of the tetM determinant. The mechanism of resistance is still unknown.
N. gonorrhoeae has also shown resistance to the aminoglycoside class of antibiotics. These antibiotics bind to the 16s rRNA of the 30S subunit of the bacterial ribosome, thereby stopping transcription of the bacterial genome. Resistance appears to be acquired through porin-related mechanisms, much like the cephalosporin resistance mechanism. This mechanism would result in the access of the antibiotic to the bacterial cell being inhibited. There is a possibility of future enzymes (made by the bacterium) that will be able to denature and inactivate the aminoglycosides.
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- ^ abcRouquette-Loughlin, Dunham, Kuhn, Balthazar, Shafer (2003) The NorM Efflux Pump of Neisseria gonorrhoeae and Neissera meningitidis Recognizes Antimicrobial Cationic Compounds. Journal of Bacteriology 185:1101–1106
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- ^ abDrlica, Zhao (1997) DNA gyrase, topoisomerase IV, and the 4-quinolones. Microbiology and Molecular Biology Reviews 61:377–392
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- ^Unemo, Golparian, Nicholas, Ohnishi, Gallay, Sednaoui (2011) High-Level Cefixime- and Ceftriaxone-Resistant Neisseria gonorrhoeae in France: Novel penA Mosaic Allele in a Successful International Clone Causes Treatment Failure. Antimicrobial Agents and Chemotherapy 1273–1280
- ^Unemo (2008) Real-time PCR and subsequent pyrosequencing for screeing of penA mosaic alleles and prediction of reduced susceptibility to expanded-spectrum cephalosorins in Neisseria gonorrhoeae. Acta Pathologica, Microbiologica et Immunologica Scandinavica 116:1001–1008
Gonorrhea is a disease. It is transmitted by having sex. It is among the most widespread sexually transmitted diseases. Gonorrhea is also sometimes called "the clap." Gonorrhea can be cured using antibiotics but the entire course of antibiotics must be used.
Its presence was found up to 700 years ago. At that time, this disease was described by coming from the "Le Clapiers" part of the city of Paris. This part of the city was known to be where prostitutes lived.
Cleanup[change | change source]
It is caused by a bacterium, Neisseria gonorrheae. Since it is caused by a bacterium, it can be treated with antibiotics. The use of latexcondoms when having sex can prevent it from spreading. Sometimes antibiotics do not cure gonorrhea. This is because the bacterium is becoming immune or resistant to the medicine. When this happens, the infection is more difficult to cure.
References[change | change source]
- ↑ 1.01.1Baarda, Benjamin I.; Sikora, Aleksandra E. (2015). "Proteomics of Neisseria gonorrhoeae: the treasure hunt for countermeasures against an old disease". Frontiers in Microbiology. 6. doi:10.3389/fmicb.2015.01190. ISSN 1664-302X; Access provided by the University of Pittsburgh.CS1 maint: postscript (link)
"The clap" redirects here. For other uses, see Clap.
For the Lil Wayne song, see Gonorrhea (song).
Sexually transmitted infection
|Other names||Gonorrhoea, gonococcal infection, gonococcal urethritis, the clap|
|Gonococcal lesion on the skin|
|Symptoms||None, burning with urination, vaginal discharge, discharge from the penis, pelvic pain, testicular pain|
|Complications||Pelvic inflammatory disease, inflammation of the epididymis, septic arthritis, endocarditis|
|Causes||Neisseria gonorrhoeae typically sexually transmitted|
|Diagnostic method||Testing the urine, urethra in males, or cervix in females|
|Prevention||Condoms, having sex with only one person who is uninfected, not having sex|
|Treatment||Ceftriaxone by injection and azithromycin by mouth|
|Frequency||0.8% (women), 0.6% (men)|
Gonorrhea, colloquially known as the clap, is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae. Infection may involve the genitals, mouth, or rectum. Infected men may experience pain or burning with urination, discharge from the penis, or testicular pain. Infected women may experience burning with urination, vaginal discharge, vaginal bleeding between periods, or pelvic pain. Complications in women include pelvic inflammatory disease and in men include inflammation of the epididymis. Many of those infected, however, have no symptoms. If untreated, gonorrhea can spread to joints or heart valves.
Gonorrhea is spread through sexual contact with an infected person. This includes oral, anal, and vaginal sex. It can also spread from a mother to a child during birth. Diagnosis is by testing the urine, urethra in males, or cervix in females. 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; the same recommendation applies in men who have sex with men (MSM).
Gonorrhea can be prevented with the use of condoms, having sex with only one person who is uninfected, and by not having sex. Treatment is usually with ceftriaxone by injection and azithromycin by mouth.Resistance has developed to many previously used antibiotics and higher doses of ceftriaxone are occasionally required. Retesting is recommended three months after treatment. Sexual partners from the last two months should also be treated.
Gonorrhea affects about 0.8% of women and 0.6% of men. 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. Infections in women most commonly occur when they are young adults. In 2015, it caused about 700 deaths. Descriptions of the disease date back to before the Common Era within the Old Testament. The current name was first used by the Greek physician Galen before 200 CE who referred to it as "an unwanted discharge of semen".
Signs and symptoms
Gonorrhea infections of mucosal membranes can cause swelling, itching, pain, and the formation of pus. 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. Other symptoms may include swollen lymph nodes around the neck. Either sex can become infected in the eyes or rectum if these tissues are exposed to the bacterium.
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. 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.
Most infected men with symptoms have inflammation of the penile urethra associated with a burning sensation during urination and discharge from the penis. In men, discharge with or without burning occurs in half of all cases and is the most common symptom of the infection. This pain is caused by a narrowing and stiffening of the urethral lumen. The most common medical complication of gonorrhea in men is inflammation of the epididymis. Gonorrhea is also associated with increased risk of prostate cancer.
If not treated, gonococcal ophthalmia neonatorum will develop in 28% of infants born to women with gonorrhea.
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. In advanced cases, gonorrhea may cause a general feeling of tiredness similar to other infections. 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. 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.
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. 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.
The infection is usually spread from one person to another through vaginal, oral, or anal sex. 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. Insertive MSM may get a penile infection from anal intercourse, while receptive MSM may get anorectal gonorrhea. Women have a 60–80% risk of getting the infection from a single act of vaginal intercourse with an infected man.
A mother may transmit gonorrhea to her newborn during childbirth; when affecting the infant's eyes, it is referred to as ophthalmia neonatorum. It may be able to spread through the objects contaminated with body fluid from an infected person. The bacteria typically does not survive long outside the body, typically dying within minutes to hours.
Traditionally, gonorrhea was diagnosed with Gram stain and culture; however, newer polymerase chain reaction (PCR)-based testing methods are becoming more common. In those failing initial treatment, culture should be done to determine sensitivity to antibiotics.
Tests that use 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.
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. 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, rectum, eyes, blood, or joints—areas where PCR-based tests are not well established in all labs. Culture is also useful for antimicrobial sensitivity testing, treatment failure, and epidemiological purposes (outbreaks, surveillance).
In patients who may have disseminated gonococcal infection (DGI), all possible mucosal sites should be cultured (e.g., pharynx, cervix, urethra, rectum). Three sets of blood cultures should also be obtained. Synovial fluid should be collected in cases of septic arthritis.
All people testing positive for gonorrhea should be tested for other sexually transmitted diseases such as chlamydia, syphilis, and human immunodeficiency virus. Studies have found co-infection with chlamydia ranging from 46 to 54% in young people with gonorrhea. Among persons in the United States between 14 and 39 years of age, 46% of people with gonorrheal infection also have chlamydial infection. For this reason, gonorrhea and chlamydia testing are often combined. People diagnosed with gonorrhea infection have a fivefold increase risk of HIV transmission. Additionally, infected persons who are HIV positive are more likely to shed and transmit HIV to uninfected partners during an episode of gonorrhea.
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). 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.
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.
See also: Safe sex
As with most sexually transmitted diseases, the risk of infection can be reduced significantly by the correct use of condoms, not having sex, or can be removed almost entirely by limiting sexual activities to a mutually monogamous relationship with an uninfected person.
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.
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.
Antibiotics are used to treat gonorrhea infections. As of 2016, both ceftriaxone by injection and azithromycin by mouth are most effective. However, due to increasing rates of antibiotic resistance, local susceptibility patterns must be taken into account when deciding on treatment.
Adults may have eyes infected with gonorrhoea and require proper personal hygiene and medications. Addition of topical antibiotics have not been shown to improve cure rates compared to oral antibiotics alone in treatment of eye infected gonorrhea. For newborns, erythromycin ointment is recommended as a preventative measure for gonococcal infant conjunctivitis.
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.
It is recommended that sexual partners be tested and potentially treated. 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.
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.
Main article: Antibiotic resistance in gonorrhea
Many antibiotics that were once effective including penicillin, tetracycline, and fluoroquinolones are no longer recommended because of high rates of resistance. 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. Public health officials are concerned that an emerging pattern of resistance may predict a global epidemic. The UK's Health Protection Agency reported that 2011 saw a slight drop in gonorrhea antibiotic resistance, the first in five years. In 2016, the WHO published new guidelines for treatment, stating "There is an urgent need to update treatment recommendations for gonococcal infections to respond to changing antimicrobial resistance (AMR) patterns of N. gonorrhoeae. High-level resistance to previously recommended quinolones is widespread and decreased susceptibility to the extended-spectrum (third-generation) cephalosporins, another recommended first-line treatment in the 2003 guidelines, is increasing and several countries have reported treatment failures."
Gonorrhea if left untreated may last for weeks or months with higher risks of complications. One of the complications of gonorrhea is systemic dissemination resulting in skin pustules or petechia, septic arthritis, meningitis, or endocarditis. This occurs in between 0.6 and 3% of infected women and 0.4 and 0.7% of infected men.
In men, inflammation of the epididymis, prostate gland, and urethra can result from untreated gonorrhea. In women, the most common result of untreated gonorrhea is pelvic inflammatory disease. Other complications include inflammation of the tissue surrounding the liver, 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.
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. The prevalence was highest in the African region, the Americas, and Western Pacific, and lowest in Europe. In 2013, it caused about 3,200 deaths, up from 2,300 in 1990.
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. 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.
In the US, it is the second-most-common bacterial sexually transmitted infections; chlamydia remains first. According to the CDC African Americans are most affected by gonorrhea, accounting for 69% of all gonorrhea cases in 2010.
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.
Some scholars translate the biblical terms zav (for a male) and zavah (for a female) as gonorrhea.
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 crewmen 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.
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.
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.
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". 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. 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.
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. After Pope Boniface completely secularized the practice of medicine, physicians were more willing to treat a sexually transmitted disease.
A vaccine for gonorrhea has been developed that is effective in mice. 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).
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. The vaccine efficiency was calculated to be 31%.
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Sexually transmitted diseases
- Dependent upon the infected organ
- PCR or culture on Thayer-Martin agar (most common)
Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)
Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.
- Ceftriaxone IM x 1
- 500 mg, if weight <150 kg
- 1 g, if weight ≥150 kg
- Ceftriaxone IM x 1
^Additional chlamydia coverage only needed if treated with cefixime only
Presumed GC/chlamydia of the pharynx (uncomplicated)
Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.
- Ceftriaxone IM x 1
- 500 mg, if weight <150 kg
- 1 g, if weight ≥150 kg
- Ceftriaxone IM x 1
- No reliable alternative treatments are available for pharyngeal gonorrhea
- For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended.
- For persons with an anaphylactic or other severe reaction (e.g. Stevens Johnson syndrome) to ceftriaxone, consult an infectious disease specialist for an alternative treatment recommendation.
Specific Disease Processes
- S susceptible/sensitive (usually)
- I intermediate (variably susceptible/resistant)
- R resistant (or not effective clinically)
- S+ synergistic with cell wall antibiotics
- U sensitive for UTI only (non systemic infection)
- X1 no data
- X2 active in vitro, but not used clinically
- X3 active in vitro, but not clinically effective for Group A strep pharyngitis or infections due to E. faecalis
- X4 active in vitro, but not clinically effective for strep pneumonia
- Depends on clinical features/presentation
- ↑Cyr SS et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
- ↑Cyr SS et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
- ↑CDC. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2015;64(No. RR-3). https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm.
- ↑Sanford Guide to Antimicrobial Therapy 2010
Sexually transmitted infection
Infection transmitted through human sexual behavior
"Sexual disease" redirects here. It is not to be confused with sexual dysfunction.
|Sexually transmitted infection|
|Other names||Sexually transmitted disease (STD);|
Venereal disease (VD)
|"Syphilis is a dangerous disease, but it can be cured." Poster encouraging treatment. Published between 1936 and 1938.|
|Symptoms||None, vaginal discharge, penile discharge, ulcers on or around the genitals, pelvic pain|
|Causes||Infections commonly spread by sex|
|Prevention||Not having sex, vaccinations, condoms|
|Frequency||1.1 billion (STIs other than HIV/AIDS, 2015)|
|Deaths||108,000 (STIs other than HIV/AIDS, 2015)|
Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs) and the older term venereal disease, are infections that are spread by sexual activity, especially vaginal intercourse, anal sex and oral sex. STIs often do not initially cause symptoms, which results in a risk of passing the infection on to others. Symptoms and signs of STIs may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain. Some STIs can cause infertility.
Bacterial STIs include chlamydia, gonorrhea, and syphilis. Viral STIs include genital herpes, HIV/AIDS, and genital warts. Parasitic STIs include trichomoniasis. STI diagnostic tests are usually easily available in the developed world, but they are often unavailable in the developing world.
Some vaccinations may also decrease the risk of certain infections including hepatitis B and some types of HPV.Safe sex practices, such as use of condoms, having a smaller number of sexual partners, and being in a relationship in which each person only has sex with the other also decreases the risk of STIs.Comprehensive sex education may also be useful. Most STIs are treatable and curable; of the most common infections, syphilis, gonorrhea, chlamydia, and trichomoniasis are curable, while HIV/AIDS is not curable.
In 2015, about 1.1 billion people had STIs other than HIV/AIDS. About 500 million were infected with either syphilis, gonorrhea, chlamydia or trichomoniasis. At least an additional 530 million people have genital herpes, and 290 million women have human papillomavirus. STIs other than HIV resulted in 108,000 deaths in 2015. In the United States, there were 19 million new cases of STIs in 2010. Historical documentation of STIs dates back to at least the Ebers papyrus around 1550 BC and the Old Testament. There is often shame and stigma associated with STIs. The term sexually transmitted infection is generally preferred over sexually transmitted disease or venereal disease, as it includes those who do not have symptomatic disease.
Signs and symptoms
This section needs expansion. You can help by adding to it. (July 2018)
Not all STIs are symptomatic, and symptoms may not appear immediately after infection. In some instances a disease can be carried with no symptoms, which leaves a greater risk of passing the disease on to others. Depending on the disease, some untreated STIs can lead to infertility, chronic pain or death.
The presence of an STI in prepubescent children may indicate sexual abuse.
A sexually transmitted infection present in a pregnant woman may be passed on to the infant before or after birth.
- Viral hepatitis (hepatitis B virus)—saliva, venereal fluids.
(Note: hepatitis A and hepatitis E are transmitted via the fecal-oral route; hepatitis C is rarely sexually transmittable, and the route of transmission of hepatitis D (only if infected with B) is uncertain, but may include sexual transmission.)
- Herpes simplex (Herpes simplex virus 1, 2) skin and mucosal, transmissible with or without visible blisters
- HIV (Human Immunodeficiency Virus)—venereal fluids, semen, breast milk, blood
- HPV (Human Papillomavirus)—skin and mucosal contact. 'High risk' types of HPV cause almost all cervical cancers, as well as some anal, penile, and vulvar cancer. Some other types of HPV cause genital warts.
- Molluscum contagiosum (molluscum contagiosum virus MCV)—close contact
- Zika virus
Sexually transmitted infections include:
- Chlamydia is a sexually transmitted infection caused by the bacterium Chlamydia trachomatis. In women, symptoms may include abnormal vaginal discharge, burning during urination, and bleeding in between periods, although most women do not experience any symptoms. Symptoms in men include pain when urinating, and abnormal discharge from their penis. If left untreated in both men and women, Chlamydia can infect the urinary tract and potentially lead to pelvic inflammatory disease (PID). PID can cause serious problems during pregnancy and even has the potential to cause infertility. It can cause a woman to have a potentially deadly ectopic pregnancy, in which the egg implants outside of the uterus. However, Chlamydia can be cured with antibiotics.
- The two most common forms of herpes are caused by infection with herpes simplex virus (HSV). HSV-1 is typically acquired orally and causes cold sores, HSV-2 is usually acquired during sexual contact and affects the genitals, however, either strain may affect either site. Some people are asymptomatic or have very mild symptoms. Those that do experience symptoms usually notice them 2 to 20 days after exposure which lasts 2 to 4 weeks. Symptoms can include small fluid-filled blisters, headaches, backaches, itching or tingling sensations in the genital or anal area, pain during urination, Flu like symptoms, swollen glands, or fever. Herpes is spread through skin contact with a person infected with the virus. The virus affects the areas where it entered the body. This can occur through kissing, vaginal intercourse, oral sex or anal sex. The virus is most infectious during times when there are visible symptoms, however, those who are asymptomatic can still spread the virus through skin contact. The initial infection and symptoms are usually the most severe because the body does not have any antibodies built up. After the primary attack, one might have recurring attacks that are milder or might not even have future attacks. There is no cure for the disease but there are antiviral medications that treat its symptoms and lower the risk of transmission (Valtrex). Although HSV-1 is typically the "oral" version of the virus, and HSV-2 is typically the "genital" version of the virus, a person with HSV-1 orally CAN transmit that virus to their partner genitally. The virus, either type, will settle into a nerve bundle either at the top of the spine, producing the "oral" outbreak, or a second nerve bundle at the base of the spine, producing the genital outbreak.
- The human papillomavirus (HPV) is the most common STI in the United States. There are more than 40 different strands of HPV and many do not cause any health problems. In 90% of cases, the body's immune system clears the infection naturally within two years. Some cases may not be cleared and can lead to genital warts (bumps around the genitals that can be small or large, raised or flat, or shaped like cauliflower) or cervical cancer and other HPV related cancers. Symptoms might not show up until advanced stages. It is important for women to get pap smears in order to check for and treat cancers. There are also two vaccines available for women (Cervarix and Gardasil) that protect against the types of HPV that cause cervical cancer. HPV can be passed through genital-to-genital contact as well as during oral sex. The infected partner might not have any symptoms.
- Gonorrhea is caused by bacterium that lives on moist mucous membranes in the urethra, vagina, rectum, mouth, throat, and eyes. The infection can spread through contact with the penis, vagina, mouth, or anus. Symptoms of gonorrhea usually appear two to five days after contact with an infected partner however, some men might not notice symptoms for up to a month. Symptoms in men include burning and pain while urinating, increased urinary frequency, discharge from the penis (white, green, or yellow in color), red or swollen urethra, swollen or tender testicles, or sore throat. Symptoms in women may include vaginal discharge, burning or itching while urinating, painful sexual intercourse, severe pain in lower abdomen (if infection spreads to fallopian tubes), or fever (if infection spreads to fallopian tubes); however, many women do not show any symptoms. Antibiotic resistant strains of Gonorrhea are a significant concern, but most cases can be cured with existing antibiotics.
- Syphilis is an STI caused by a bacterium. Untreated, it can lead to complications and death. Clinical manifestations of syphilis include the ulceration of the uro-genital tract, mouth or rectum; if left untreated the symptoms worsen. In recent years, the prevalence of syphilis has declined in Western Europe, but it has increased in Eastern Europe (former Soviet states). A high incidence of syphilis can be found in places such as Cameroon, Cambodia, Papua New Guinea. Syphilis infections are increasing in the United States.
- Trichomoniasis is a common STI that is caused by infection with a protozoan parasite called Trichomonas vaginalis. Trichomoniasis affects both women and men, but symptoms are more common in women. Most patients are treated with an antibiotic called metronidazole, which is very effective.
- HIV (human immunodeficiency virus) damages the body's immune system, which interferes with its ability to fight off disease-causing agents. The virus kills CD4 cells, which are white blood cells that help fight off various infections. HIV is carried in body fluids and is spread by sexual activity. It can also be spread by contact with infected blood, breastfeeding, childbirth, and from mother to child during pregnancy. When HIV is at its most advanced stage, an individual is said to have AIDS (acquired immunodeficiency syndrome). There are different stages of the progression of and HIV infection. The stages include primary infection, asymptomatic infection, symptomatic infection, and AIDS. In the primary infection stage, an individual will have flu-like symptoms (headache, fatigue, fever, muscle aches) for about 2 weeks. In the asymptomatic stage, symptoms usually disappear, and the patient can remain asymptomatic for years. When HIV progresses to the symptomatic stage, the immune system is weakened and has a low cell count of CD4+ T Cells. When the HIV infection becomes life-threatening, it is called AIDS. People with AIDS fall prey to opportunistic infections and die as a result. When the disease was first discovered in the 1980s, those who had AIDS were not likely to live longer than a few years. There are now antiretroviral drugs (ARVs) available to treat HIV infections. There is no known cure for HIV or AIDS but the drugs help suppress the virus. By suppressing the amount of virus in the body, people can lead longer and healthier lives. Even though their virus levels may be low they can still spread the virus to others.
Viruses in semen
Twenty-seven different viruses have been identified in semen. Information on whether or not transmission occurs or whether the viruses cause disease is uncertain. Some of these microbes are known to be sexually transmitted.
Many STIs are (more easily) transmitted through the mucous membranes of the penis, vulva, rectum, urinary tract and (less often—depending on type of infection) the mouth, throat, respiratory tract and eyes. The visible membrane covering the head of the penis is a mucous membrane, though it produces no mucus (similar to the lips of the mouth). Mucous membranes differ from skin in that they allow certain pathogens into the body. The amount of contact with infective sources which causes infection varies with each pathogen but in all cases, a disease may result from even light contact from fluid carriers like venereal fluids onto a mucous membrane.
Some STIs such as HIV can be transmitted from mother to child either during pregnancy or breastfeeding. Healthcare professionals suggest safer sex, such as the use of condoms, as a reliable way of decreasing the risk of contracting sexually transmitted diseases during sexual activity, but safer sex cannot be considered to provide complete protection from an STI. The transfer of and exposure to bodily fluids, such as blood transfusions and other blood products, sharing injection needles, needle-stick injuries (when medical staff are inadvertently jabbed or pricked with needles during medical procedures), sharing tattoo needles, and childbirth are other avenues of transmission. These different means put certain groups, such as medical workers, and haemophiliacs and drug users, particularly at risk.
It is possible to be an asymptomatic carrier of sexually transmitted diseases. In particular, sexually transmitted diseases in women often cause the serious condition of pelvic inflammatory disease.
Testing may be for a single infection, or consist of a number of tests for a range of STIs, including tests for syphilis, trichomonas, gonorrhea, chlamydia, herpes, hepatitis, and HIV. No procedure tests for all infectious agents.
STI tests may be used for a number of reasons:
- as a diagnostic test to determine the cause of symptoms or illness
- as a screening test to detect asymptomatic or presymptomatic infections
- as a check that prospective sexual partners are free of disease before they engage in sex without safer sex precautions (for example, when starting a long term mutually monogamous sexual relationship, in fluid bonding, or for procreation).
- as a check prior to or during pregnancy, to prevent harm to the baby
- as a check after birth, to check that the baby has not caught an STI from the mother
- to prevent the use of infected donated blood or organs
- as part of the process of contact tracing from a known infected individual
- as part of mass epidemiological surveillance
Early identification and treatment results in less chance to spread disease, and for some conditions may improve the outcomes of treatment. There is often a window period after initial infection during which an STI test will be negative. During this period, the infection may be transmissible. The duration of this period varies depending on the infection and the test. Diagnosis may also be delayed by reluctance of the infected person to seek a medical professional. One report indicated that people turn to the Internet rather than to a medical professional for information on STIs to a higher degree than for other sexual problems.
Until the 1990s, STIs were commonly known as venereal diseases, an antiquated euphemism derived from the Latin venereus£, being the adjectival form of Venus, the Roman goddess of love. However in the post-classical education era the euphemistic effect was entirely lost, and the common abbreviation "VD" held only negative connotations. Other former euphemisms for STIs include "blood diseases" and "social diseases". The present euphemism is in the use of the initials "STI" rather than in the words they represent. The World Health Organization (WHO) has recommended the more inclusive term sexually transmitted infection since 1999.Public health officials originally introduced the term sexually transmitted infection, which clinicians are increasingly using alongside the term sexually transmitted disease in order to distinguish it from the former.
Main article: Safe sex
Strategies for reducing STI risk include: vaccination, mutual monogamy, reducing the number of sexual partners, and abstinence. Behavioral counseling for all sexually active adolescents and for adults who are at increased risk. Such interactive counseling, which can be resource-intensive, is directed at a person's risk, the situations in which risk occurs, and the use of personalized goal-setting strategies.
The most effective way to prevent sexual transmission of STIs is to avoid contact of body parts or fluids which can lead to transfer with an infected partner. Not all sexual activities involve contact: cybersex, phonesex or masturbation from a distance are methods of avoiding contact. Proper use of condoms reduces contact and risk. Although a condom is effective in limiting exposure, some disease transmission may occur even with a condom.
Both partners can get tested for STIs before initiating sexual contact, or before resuming contact if a partner engaged in contact with someone else. Many infections are not detectable immediately after exposure, so enough time must be allowed between possible exposures and testing for the tests to be accurate. Certain STIs, particularly certain persistent viruses like HPV, may be impossible to detect.[medical citation needed]
Some treatment facilities utilize in-home test kits and have the person return the test for follow-up. Other facilities strongly encourage that those previously infected return to ensure that the infection has been eliminated. Novel strategies to foster re-testing have been the use of text messaging and email as reminders. These types of reminders are now used in addition to phone calls and letters. After obtaining a sexual history, a healthcare provider can encourage risk reduction by providing prevention counseling. Prevention counseling is most effective if provided in a nonjudgmental and empathetic manner appropriate to the person's culture, language, gender, sexual orientation, age, and developmental level. Prevention counseling for STIs is usually offered to all sexually active adolescents and to all adults who have received a diagnosis, have had an STI in the past year, or have multiple sex partners.
Vaccines are available that protect against some viral STIs, such as Hepatitis A, Hepatitis B, and some types of HPV. Vaccination before initiation of sexual contact is advised to assure maximal protection. The development of vaccines to protect against gonorrhea is ongoing.
Condoms and female condoms only provide protection when used properly as a barrier, and only to and from the area that they cover. Uncovered areas are still susceptible to many STIs.
In the case of HIV, sexual transmission routes almost always involve the penis, as HIV cannot spread through unbroken skin; therefore, properly shielding the penis with a properly worn condom from the vagina or anus effectively stops HIV transmission. An infected fluid to broken skin borne direct transmission of HIV would not be considered "sexually transmitted", but can still theoretically occur during sexual contact. This can be avoided simply by not engaging in sexual contact when presenting open, bleeding wounds.
Other STIs, even viral infections, can be prevented with the use of latex, polyurethane or polyisoprene condoms as a barrier. Some microorganisms and viruses are small enough to pass through the pores in natural skin condoms but are still too large to pass through latex or synthetic condoms.
Proper male condom usage entails:
- Not putting the condom on too tight at the tip by leaving 1.5 centimetres (0.6 in) room for ejaculation. Putting the condom on too tightly can and often does lead to failure.
- Wearing a condom too loose can defeat the barrier
- Avoiding inverting or spilling a condom once worn, whether it has ejaculate in it or not
- If a user attempts to unroll the condom, but realizes they have it on the wrong side, then this condom may not be effective
- Being careful with the condom if handling it with long nails
- Avoiding the use of oil-based lubricants (or anything with oil in it) with latex condoms, as oil can eat holes into them
- Using flavored condoms for oral sex only, as the sugar in the flavoring can lead to yeast infections if used to penetrate
In order to best protect oneself and the partner from STIs, the old condom and its contents are to be treated as infectious and properly disposed of. A new condom is used for each act of intercourse, as multiple usages increase the chance of breakage, defeating the effectiveness as a barrier.
In the case of female condoms, the device consists of two rings, one in each terminal portion. The larger ring should fit snugly over the cervix and the smaller ring remains outside the vagina, covering the vulva. This system provides some protection of the external genitalia.
The cap was developed after the cervical diaphragm. Both cover the cervix and the main difference between the diaphragm and the cap is that the latter must be used only once, using a new one in each sexual act. The diaphragm, however, can be used more than once. These two devices partially protect against STIs (they do not protect against HIV).
Researchers had hoped that nonoxynol-9, a vaginal microbicide would help decrease STI risk. Trials, however, have found it ineffective and it may put women at a higher risk of HIV infection. There is evidence that vaginal dapivirine probably reduces HIV in women who have sex with men, other types of vaginal microbicides have not demonstrated effectiveness for HIV or STI's. 
There is little evidence that school-based interventions such as sexual and reproductive health education programmes on contraceptive choices and condoms are effective on improving the sexual and reproductive health of adolescents. Incentive-based programmes may reduce adolescent pregnancy but more data is needed to confirm this.
Specific age groups, persons who participate in risky sexual behavior, or those have certain health conditions may require screening. The CDC recommends that sexually active women under the age of 25 and those over 25 at risk should be screened for chlamydia and gonorrhea yearly. Appropriate times for screening are during regular pelvic examinations and preconception evaluations.Nucleic acid amplification tests are the recommended method of diagnosis for gonorrhea and chlamydia. This can be done on either urine in both men and women, vaginal or cervical swabs in women, or urethral swabs in men. Screening can be performed:
- to assess the presence of infection and prevent tubal infertility in women
- during the initial evaluation before infertility treatment
- to identify HIV infection
- for men who have sex with men
- for those who may have been exposed to hepatitis C
- for HCV
In the case of rape, the person can be treated prophylacticly with antibiotics.
An option for treating partners of patients (index cases) diagnosed with chlamydia or gonorrhea is patient-delivered partner therapy, which is the clinical practice of treating the sex partners of index cases by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner.[needs update]
See also: List of sexually transmitted infections by prevalence
In 2008, it was estimated that 500 million people were infected with either syphilis, gonorrhea, chlamydia or trichomoniasis. At least an additional 530 million people have genital herpes and 290 million women have human papillomavirus. STIs other than HIV resulted in 142,000 deaths in 2013. In the United States there were 19 million new cases of sexually transmitted infections in 2010.
In 2010, 19 million new cases of sexually transmitted infections occurred in women in the United States. A 2008 CDC study found that 25–40% of U.S. teenage girls has a sexually transmitted disease. Out of a population of almost 295,270,000 people there were 110 million new and existing cases of eight sexually transmitted infections.
Over 400,000 sexually transmitted infections were reported in England in 2017, about the same as in 2016, but there were more than 20% increases in confirmed cases of gonorrhoea and syphilis. Since 2008 syphilis cases have risen by 148%, from 2,874 to 7,137, mostly among men who have sex with men. The number of first cases of genital warts in 2017 among girls aged 15–17 years was just 441, 90% less than in 2009 – attributed to the national human papilloma virus immunisation programme.
AIDS is among the leading causes of death in present-day Sub-Saharan Africa. HIV/AIDS is transmitted primarily via unprotected sexual intercourse. More than 1.1 million persons are living with HIV/AIDS in the United States, and it disproportionately impacts African Americans.Hepatitis B is also considered a sexually transmitted disease because it can be spread through sexual contact. The highest rates are found in Asia and Africa and lower rates are in the Americas and Europe. Approximately two billion people worldwide have been infected with the hepatitis B virus.
The first well-recorded European outbreak of what is now known as syphilis occurred in 1494 when it broke out among French troops besieging Naples in the Italian War of 1494–98. The disease may have originated from the Columbian Exchange. From Naples, the disease swept across Europe, killing more than five million people. As Jared Diamond describes it, "[W]hen syphilis was first definitely recorded in Europe in 1495, its pustules often covered the body from the head to the knees, caused flesh to fall from people's faces, and led to death within a few months," rendering it far more fatal than it is today. Diamond concludes,"[B]y 1546, the disease had evolved into the disease with the symptoms so well known to us today." Gonorrhoeae is recorded at least up to 700 years ago and associated with a district in Paris formerly known as "Le Clapiers". This is where the prostitutes were to be found at that time.
Prior to the invention of modern medicines, sexually transmitted diseases were generally incurable, and treatment was limited to treating the symptoms of the disease. The first voluntary hospital for venereal diseases was founded in 1746 at London Lock Hospital. Treatment was not always voluntary: in the second half of the 19th century, the Contagious Diseases Acts were used to arrest suspected prostitutes. In 1924, a number of states concluded the Brussels Agreement, whereby states agreed to provide free or low-cost medical treatment at ports for merchant seamen with venereal diseases. A proponent of these approaches was Dr. Nora Wattie, OBE, Venereal Diseases Officer in Glasgow from 1929, encouraged contact tracing and volunteering for treatment, rather than the prevailing more judgemental view and published her own research on improving sex education and maternity care.
The first effective treatment for a sexually transmitted disease was salvarsan, a treatment for syphilis. With the discovery of antibiotics, a large number of sexually transmitted diseases became easily curable, and this, combined with effective public health campaigns against STIs, led to a public perception during the 1960s and 1970s that they have ceased to be a serious medical threat.
During this period, the importance of contact tracing in treating STIs was recognized. By tracing the sexual partners of infected individuals, testing them for infection, treating the infected and tracing their contacts, in turn, STI clinics could effectively suppress infections in the general population.
In the 1980s, first genital herpes and then AIDS emerged into the public consciousness as sexually transmitted diseases that could not be cured by modern medicine. AIDS, in particular, has a long asymptomatic period—during which time HIV (the human immunodeficiency virus, which causes AIDS) can replicate and the disease can be transmitted to others—followed by a symptomatic period, which leads rapidly to death unless treated. HIV/AIDS entered the United States from Haiti in about 1969. Recognition that AIDS threatened a global pandemic led to public information campaigns and the development of treatments that allow AIDS to be managed by suppressing the replication of HIV for as long as possible. Contact tracing continues to be an important measure, even when diseases are incurable, as it helps to contain infection.
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Sexually transmitted infection
Syphilis is a sexually transmitted infection caused by the bacteriumTreponema pallidumsubspeciespallidum. The signs and symptoms of syphilis vary depending in which of the four stages it presents (primary, secondary, latent, and tertiary). The primary stage classically presents with a single chancre (a firm, painless, non-itchy skin ulceration usually between 1 cm and 2 cm in diameter) 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 (soft, non-cancerous growths), neurological problems, or heart symptoms. Syphilis has been known as "the great imitator" as it may cause symptoms similar to many other diseases.
Syphilis is most commonly spread through sexual activity. It may also be transmitted from mother to baby during pregnancy or at birth, resulting in congenital syphilis. Other diseases caused by Treponema bacteria include yaws (T. pallidum subspecies pertenue), pinta (T. carateum), and nonvenereal endemic syphilis (T. pallidum subspecies endemicum). These three diseases are not typically sexually transmitted. Diagnosis is usually made by using blood tests; the bacteria can also be detected using dark field microscopy. The Centers for Disease Control and Prevention (U.S.) recommend all pregnant women be tested.
The risk of sexual transmission of syphilis can be reduced by using a latex or polyurethanecondom. Syphilis can be effectively treated with antibiotics. The preferred antibiotic for most cases is benzathine benzylpenicillininjected into a muscle. In those who have a severe penicillin allergy, doxycycline or tetracycline may be used. In those with neurosyphilis, intravenousbenzylpenicillin or ceftriaxone is recommended. During treatment people may develop fever, headache, and muscle pains, a reaction known as Jarisch–Herxheimer.
In 2015, about 45.4 million people were infected with syphilis, with six million new cases. During 2015, it caused about 107,000 deaths, down from 202,000 in 1990. After decreasing dramatically with the availability of penicillin in the 1940s, rates of infection have increased since the turn of the millennium in many countries, often in combination with human immunodeficiency virus (HIV). This is believed to be partly due to increased promiscuity, prostitution, decreasing use of condoms and unsafe sexual practices among men who have sex with men.
Signs and symptoms
Syphilis can present in one of four different stages: primary, secondary, latent, and tertiary, and may also occur congenitally. It was referred to as "the great imitator" by Sir William Osler due to its varied presentations.
Primary syphilis is typically acquired by direct sexual contact with the infectious lesions of another person. Approximately 2–6 weeks after contact (with a range of 10–90 days) a skin lesion, called a chancre, appears at the site and this contains infectious spirochetes. This is classically (40% of the time) a single, firm, painless, non-itchy skin ulceration with a clean base and sharp borders approximately 0.3–3.0 cm in size. The lesion may take on almost any form. In the classic form, it evolves from a macule to a papule and finally to an erosion or ulcer. Occasionally, multiple lesions may be present (~40%), with multiple lesions being more common when coinfected with HIV. Lesions may be painful or tender (30%), and they may occur in places other than the genitals (2–7%). The most common location in women is the cervix (44%), the penis in heterosexual men (99%), and anally and rectally in men who have sex with men (34%).Lymph node enlargement frequently (80%) occurs around the area of infection, occurring seven to 10 days after chancre formation. The lesion may persist for three to six weeks if left untreated.
Secondary syphilis occurs approximately four to ten weeks after the primary infection. While secondary disease is known for the many different ways it can manifest, symptoms most commonly involve the skin, mucous membranes, and lymph nodes. There may be a symmetrical, reddish-pink, non-itchy rash on the trunk and extremities, including the palms and soles. The rash may become maculopapular or pustular. It may form flat, broad, whitish, wart-like lesions on mucous membranes, known as condyloma latum. All of these lesions harbor bacteria and are infectious. Other symptoms may include fever, sore throat, malaise, weight loss, hair loss, and headache. Rare manifestations include liver inflammation, kidney disease, joint inflammation, periostitis, inflammation of the optic nerve, uveitis, and interstitial keratitis. The acute symptoms usually resolve after three to six weeks; about 25% of people may present with a recurrence of secondary symptoms. Many people who present with secondary syphilis (40–85% of women, 20–65% of men) do not report previously having had the classical chancre of primary syphilis.
Latent syphilis is defined as having serologic proof of infection without symptoms of disease. It develops after secondary syphilis and is divided into early latent and late latent stages. Early latent syphilis is defined by the World Health Organization as less than 2 years after original infection. Early latent syphilis is infectious as up to 25% of people can develop a recurrent secondary infection (during which spirochetes are actively replicating and are infectious). Two years after the original infection the person will enter late latent syphilis and is not as infectious as the early phase. The latent phase of syphilis can last many years after which, without treatment, approximately 15-40% of people can develop tertiary syphilis.
Tertiary syphilis may occur approximately 3 to 15 years after the initial infection, and may be divided into three different forms: gummatous syphilis (15%), late neurosyphilis (6.5%), and cardiovascular syphilis (10%). Without treatment, a third of infected people develop tertiary disease. People with tertiary syphilis are not infectious.
Gummatous syphilis or late benign syphilis usually occurs 1 to 46 years after the initial infection, with an average of 15 years. This stage is characterized by the formation of chronic gummas, which are soft, tumor-like balls of inflammation which may vary considerably in size. They typically affect the skin, bone, and liver, but can occur anywhere.
Cardiovascular syphilis usually occurs 10–30 years after the initial infection. The most common complication is syphilitic aortitis, which may result in aortic aneurysm formation.
Neurosyphilis refers to an infection involving the central nervous system. Involvement of the central nervous system in syphilis (either asymptomatic or symptomatic) can occur at any stage of the infection. It may occur early, being either asymptomatic or in the form of syphilitic meningitis, or late as meningovascular syphilis, general paresis, or tabes dorsalis.
Meningovascular syphilis involves inflammation of the small and medium arteries of the central nervous system. It can present between 1–10 years after the initial infection. Meningovascular syphilis is characterized by stroke, cranial nerve palsies and spinal cord inflammation. Late symptomatic neurosyphilis can develop decades after the original infection and includes 2 types; general paresis and tabes dorsalis. General paresis presents with dementia, personality changes, delusions, seizures, psychosis and depression. Tabes dorsalis is characterized by gait instability, sharp pains in the trunk and limbs, impaired positional sensation of the limbs as well as having a positive Romberg's sign. Both tabes dorsalis and general paresis may present with Argyll Robertson pupil which are pupils that constrict when the person focuses on near objects (accommodation reflex) but do not constrict when exposed to bright light (pupillary reflex).
Main article: Congenital syphilis
Congenital syphilis is that which is transmitted during pregnancy or during birth. Two-thirds of syphilitic infants are born without symptoms. Common symptoms that develop over the first couple of years of life include enlargement of the liver and spleen (70%), rash (70%), fever (40%), neurosyphilis (20%), and lung inflammation (20%). If untreated, late congenital syphilis may occur in 40%, including saddle nose deformation, Higouménakis' sign, saber shin, or Clutton's joints among others. Infection during pregnancy is also associated with miscarriage. The three main dental defects in congenital syphilis are Hutchinson's incisors (screwdriver shaped incisors), Moon's molars or bud molars, and Fournier's molars or mulberry molars (molars with abnormal occlusal anatomy resembling a mulberry).
Main article: Treponema pallidum
Treponema pallidum subspecies pallidum is a spiral-shaped, Gram-negative, highly mobile bacterium. Three other human diseases are caused by related Treponema pallidum subspecies, including yaws (subspecies pertenue), pinta (subspecies carateum) and bejel (subspecies endemicum). Unlike subspecies pallidum, they do not cause neurological disease. Humans are the only known natural reservoir for subspecies pallidum. It is unable to survive more than a few days without a host. This is due to its small genome (1.14Mbp) failing to encode the metabolic pathways necessary to make most of its macronutrients. It has a slow doubling time of greater than 30 hours. The bacterium is known for its ability to evade the immune system and its invasiveness.
Syphilis is transmitted primarily by sexual contact or during pregnancy from a mother to her baby; the spirochete is able to pass through intact mucous membranes or compromised skin. It is thus transmissible by kissing near a lesion, as well as oral, vaginal, and anal sex. Approximately 30% to 60% of those exposed to primary or secondary syphilis will get the disease. Its infectivity is exemplified by the fact that an individual inoculated with only 57 organisms has a 50% chance of being infected. Most new cases in the United States (60%) occur in men who have sex with men; and in this population 20% of syphilis cases were due to oral sex alone. Syphilis can be transmitted by blood products, but the risk is low due to screening of donated blood in many countries. The risk of transmission from sharing needles appears to be limited.
It is not generally possible to contract syphilis through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing. This is mainly because the bacteria die very quickly outside of the body, making transmission by objects extremely difficult.
Syphilis is difficult to diagnose clinically during early infection. Confirmation is either via blood tests or direct visual inspection using dark field microscopy. Blood tests are more commonly used, as they are easier to perform. Diagnostic tests are unable to distinguish between the stages of the disease.
Blood tests are divided into nontreponemal and treponemal tests.
Nontreponemal tests are used initially, and include venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR) tests. False positives on the nontreponemal tests can occur with some viral infections, such as varicella (chickenpox) and measles. False positives can also occur with lymphoma, tuberculosis, malaria, endocarditis, connective tissue disease, and pregnancy.
Because of the possibility of false positives with nontreponemal tests, confirmation is required with a treponemal test, such as treponemal pallidum particle agglutination (TPHA) or fluorescent treponemal antibody absorption test (FTA-Abs). Treponemal antibody tests usually become positive two to five weeks after the initial infection. Neurosyphilis is diagnosed by finding high numbers of leukocytes (predominately lymphocytes) and high protein levels in the cerebrospinal fluid in the setting of a known syphilis infection.
Dark field microscopy of serous fluid from a chancre may be used to make an immediate diagnosis. Hospitals do not always have equipment or experienced staff members, and testing must be done within 10 minutes of acquiring the sample. Two other tests can be carried out on a sample from the chancre: direct fluorescent antibody (DFA) and polymerase chain reaction (PCR) tests. DFA uses antibodies tagged with fluorescein, which attach to specific syphilis proteins, while PCR uses techniques to detect the presence of specific syphilis genes. These tests are not as time-sensitive, as they do not require living bacteria to make the diagnosis.
As of 2018[update], there is no vaccine effective for prevention. Several vaccines based on treponemal proteins reduce lesion development in an animal model but research continues.
Condom use reduces the likelihood of transmission during sex, but does not completely eliminate the risk. The Centers for Disease Control and Prevention (CDC) states, "Correct and consistent use of latex condoms can reduce the risk of syphilis only when the infected area or site of potential exposure is protected. However, a syphilis sore outside of the area covered by a latex condom can still allow transmission, so caution should be exercised even when using a condom."
Abstinence from intimate physical contact with an infected person is effective at reducing the transmission of syphilis. The CDC states, "The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to abstain from sexual contact or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected."
Congenital syphilis in the newborn can be prevented by screening mothers during early pregnancy and treating those who are infected. The United States Preventive Services Task Force (USPSTF) strongly recommends universal screening of all pregnant women, while the World Health Organization (WHO) recommends all women be tested at their first antenatal visit and again in the third trimester. If they are positive, it is recommended their partners also be treated. Congenital syphilis is still common in the developing world, as many women do not receive antenatal care at all, and the antenatal care others receive does not include screening. It still occasionally occurs in the developed world, as those most likely to acquire syphilis are least likely to receive care during pregnancy. Several measures to increase access to testing appear effective at reducing rates of congenital syphilis in low- to middle-income countries.Point-of-care testing to detect syphilis appeared to be reliable although more research is needed to assess its effectiveness and into improving outcomes in mothers and babies.
The CDC recommends that sexually active men who have sex with men be tested at least yearly. The USPSTF also recommends screening among those at high risk.
Syphilis is a notifiable disease in many countries, including Canada, the European Union, and the United States. This means health care providers are required to notify public health authorities, which will then ideally provide partner notification to the person's partners. Physicians may also encourage patients to send their partners to seek care. Several strategies have been found to improve follow-up for STI testing, including email and text messaging of reminders for appointments.
The first-line treatment for uncomplicated syphilis (primary or secondary stages) remains a single dose of intramuscularbenzathine benzylpenicillin.Doxycycline and tetracycline are alternative choices for those allergic to penicillin; due to the risk of birth defects, these are not recommended for pregnant women.Resistance to macrolides, rifampicin, and clindamycin is often present.Ceftriaxone, a third-generation cephalosporinantibiotic, may be as effective as penicillin-based treatment. It is recommended that a treated person avoid sex until the sores are healed.
For neurosyphilis, due to the poor penetration of benzathine penicillin into the central nervous system, those affected are given large doses of intravenouspenicillin G for a minimum of 10 days. If a person is allergic to penicillin, ceftriaxone may be used or penicillin desensitization attempted. Other late presentations may be treated with once-weekly intramuscular benzathine penicillin for three weeks. Treatment at this stage solely limits further progression of the disease and has a limited effect on damage which has already occurred. Serologic cure can be measured when the non-treponemal titers decline by a factor of 4 or more in 6–12 months in early syphilis or 12–24 months in late syphilis.
One of the potential side effects of treatment is the Jarisch–Herxheimer reaction. It frequently starts within one hour and lasts for 24 hours, with symptoms of fever, muscle pains, headache, and a fast heart rate. It is caused by cytokines released by the immune system in response to lipoproteins released from rupturing syphilis bacteria.
Penicillin is an effective treatment for syphilis in pregnancy but there is no agreement on which dose or route of delivery is most effective.
Main article: Epidemiology of syphilis
In 2012, about 0.5% of adults were infected with syphilis, with 6 million new cases. In 1999, it is believed to have infected 12 million additional people, with greater than 90% of cases in the developing world. It affects between 700,000 and 1.6 million pregnancies a year, resulting in spontaneous abortions, stillbirths, and congenital syphilis. During 2015, it caused about 107,000 deaths, down from 202,000 in 1990. In sub-Saharan Africa, syphilis contributes to approximately 20% of perinatal deaths. Rates are proportionally higher among intravenous drug users, those who are infected with HIV, and men who have sex with men. In the United States about 55,400 people are newly infected each year. In the United States as of 2020, rates of syphilis have increased by more than threefold; in 2018 approximately 86% of all cases of syphilis in the United States were in men.African Americans accounted for almost half of all cases in 2010. As of 2014, syphilis infections continue to increase in the United States.
Syphilis was very common in Europe during the 18th and 19th centuries.Flaubert found it universal among nineteenth-century Egyptian prostitutes. In the developed world during the early 20th century, infections declined rapidly with the widespread use of antibiotics, until the 1980s and 1990s. Since 2000, rates of syphilis have been increasing in the US, Canada, the UK, Australia and Europe, primarily among men who have sex with men. Rates of syphilis among US women have remained stable during this time, while rates among UK women have increased, but at a rate less than that of men. Increased rates among heterosexuals have occurred in China and Russia since the 1990s. This has been attributed to unsafe sexual practices, such as sexual promiscuity, prostitution, and decreasing use of barrier protection.
Left untreated, it has a mortality rate of 8% to 58%, with a greater death rate among males. The symptoms of syphilis have become less severe over the 19th and 20th centuries, in part due to widespread availability of effective treatment, and partly due to virulence of the bacteria. With early treatment, few complications result. Syphilis increases the risk of HIV transmission by two to five times, and coinfection is common (30–60% in some urban centers). In 2015, Cuba became the first country to eliminate mother-to-child transmission of syphilis.
Main article: History of syphilis
The origin of syphilis is disputed. Syphilis was present in the Americas before European contact, and it may have been carried from the Americas to Europe by the returning crewmen from Christopher Columbus's voyage to the Americas, or it may have existed in Europe previously but gone unrecognized until shortly after Columbus's return. These are the Columbian and pre-Columbian hypotheses, respectively. The Columbian hypothesis is better supported by the evidence and findings from phylogenetic science suggest that it is, in fact, a New World disease.
The first written records of an outbreak of syphilis in Europe occurred in 1494 or 1495 in Naples, Italy, during a French invasion (Italian War of 1494–98). Since it was claimed to have been spread by French troops, it was initially called the "French disease" by the people of Naples. In 1530, the pastoral name "syphilis" (the name of a character) was first used by the Italian physician and poet Girolamo Fracastoro as the title of his Latin poem in dactylic hexameter describing the ravages of the disease in Italy. It was also called the "Great Pox".
In the 16th through 19th centuries, syphilis was one of the largest public health burdens in prevalence, symptoms, and disability,: 208–209  although records of its true prevalence were generally not kept because of the fearsome and sordid status of sexually transmitted diseases in those centuries.: 208–209 According to a 2020 study, more than 20% of individual in the age range 15–34 years in late 18th century London were treated for syphilis. At the time the causative agent was unknown but it was well known that it was spread sexually and also often from mother to child. Its association with sex, especially sexual promiscuity and prostitution, made it an object of fear and revulsion and a taboo. The magnitude of its morbidity and mortality in those centuries reflected that, unlike today, there was no adequate understanding of its pathogenesis and no truly effective treatments. Its damage was caused not so much by great sickness or death early in the course of the disease but rather by its gruesome effects decades after infection as it progressed to neurosyphilis with tabes dorsalis. Mercury compounds and isolation were commonly used, with treatments often worse than the disease.
The causative organism, Treponema pallidum, was first identified by Fritz Schaudinn and Erich Hoffmann, in 1905. The first effective treatment for syphilis was arsphenamine, discovered by Sahachiro Hata in 1909, during a survey of hundreds of newly synthesized organic arsenical compounds led by Paul Ehrlich. It was manufactured and marketed from 1910 under the trade name Salvarsan by Hoechst AG. This organoarsenic compound was the first modern chemotherapeutic agent.
During the 20th century, as both microbiology and pharmacology advanced greatly, syphilis, like many other infectious diseases, became more of a manageable burden than a scary and disfiguring mystery, at least in developed countries among those people who could afford to pay for timely diagnosis and treatment. Penicillin was discovered in 1928, and effectiveness of treatment with penicillin was confirmed in trials in 1943, at which time it became the main treatment.
Many famous historical figures, including Franz Schubert, Arthur Schopenhauer, Édouard Manet,Charles Baudelaire, and Guy de Maupassant are believed to have had the disease.Friedrich Nietzsche was long believed to have gone mad as a result of tertiary syphilis, but that diagnosis has recently come into question.
Arts and literature
See also: List of syphilis cases
The earliest known depiction of an individual with syphilis is Albrecht Dürer's Syphilitic Man, a woodcut believed to represent a Landsknecht, a Northern European mercenary. The myth of the femme fatale or "poison women" of the 19th century is believed to be partly derived from the devastation of syphilis, with classic examples in literature including John Keats' "La Belle Dame sans Merci".
The Flemish artist Stradanus designed a print called Preparation and Use of Guayaco for Treating Syphilis, a scene of a wealthy man receiving treatment for syphilis with the tropical wood guaiacum sometime around 1590.
Tuskegee and Guatemala studies
See also: Tuskegee syphilis experiment and Guatemala syphilis experiment
The "Tuskegee Study of Untreated Syphilis in the Negro Male" was an infamous, unethical and racist clinical study conducted between 1932 and 1972 by the U.S. Public Health Service. Whereas the purpose of this study was to observe the natural history of untreated syphilis; the African-American men in the study were told they were receiving free treatment for "bad blood" from the United States government.
The Public Health Service started working on this study in 1932 in collaboration with Tuskegee University, a historically black college in Alabama. Researchers enrolled 600 poor, African-American sharecroppers from Macon County, Alabama in the study. Of these men, 399 had contracted syphilis before the study began, and 201 did not have the disease. Medical care, hot meals and free burial insurance were given to those who participated. The men were told that the study would last six months, but in the end it continued for 40 years. After funding for treatment was lost, the study was continued without informing the men that they were only being studied and would not be treated. Facing insufficient participation, the Macon County Health Department nevertheless wrote to subjects to offer them a "last chance" to get a special "treatment", which was not a treatment at all, but a spinal tap administered exclusively for diagnostic purposes. None of the men infected were ever told that they had the disease, and none were treated with penicillin even after the antibiotic had been proven to successfully treat syphilis. According to the Centers for Disease Control, the men were told they were being treated for "bad blood"—a colloquialism describing various conditions such as fatigue, anemia and syphilis—which was a leading cause of death among southern African-American men.
The 40-year study became a textbook example of poor medical ethics because researchers had knowingly withheld treatment with penicillin and because the subjects had been misled concerning the purposes of the study. The revelation in 1972 of these study failures by a whistleblower, Peter Buxtun, led to major changes in U.S. law and regulation on the protection of participants in clinical studies. Now studies require informed consent, communication of diagnosis, and accurate reporting of test results.
Similar experiments were carried out in Guatemala from 1946 to 1948. It was done during the administration of American President Harry S. Truman and Guatemalan President Juan José Arévalo with the cooperation of some Guatemalan health ministries and officials. Doctors infected soldiers, prostitutes, prisoners and mental patients with syphilis and other sexually transmitted diseases, without the informed consent of the subjects, and treated most subjects with antibiotics. The experiment resulted in at least 83 deaths. In October 2010, the U.S. formally apologized to Guatemala for the ethical violations that took place. Secretary of State Hillary Clinton and Health and Human Services Secretary Kathleen Sebelius stated "Although these events occurred more than 64 years ago, we are outraged that such reprehensible research could have occurred under the guise of public health. We deeply regret that it happened, and we apologize to all the individuals who were affected by such abhorrent research practices." The experiments were led by physician John Charles Cutler who also participated in the late stages of the Tuskegee syphilis experiment.
It was first called grande verole or the "great pox" by the French. Other historical names have included "button scurvy", sibbens, frenga and dichuchwa, among others. Since it was a disgraceful disease, the disease was known in several countries by the name of their neighbouring country. The English, German and Italians called it "the French disease", while the French referred to it as the "Neapolitan disease". The Dutch called it the "Spanish pocks" during the Dutch Revolt. To the Turks it was known as the "Christian disease", whilst in India, the Hindus and Muslims named the disease after each other.
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