Abstract
Between November 2014 and May 2018, 118 laboratory-confirmed cases of high-level azithromycin resistant Neisseria gonorrhoeae were identified in England. Cases emerged among heterosexuals in Leeds but spread across England and into sexual networks of men who have sex with men as the outbreak progressed. The few epidemiological links identified indicate substantial under-diagnosis of cases and this, along with the upturn in cases in 2017, highlights the difficulties in controlling the outbreak.
Highlights
Between November 2014 and May 2018, 118 laboratory confirmed cases of HL-AziR were identified in England
There were very few direct links identified between heterosexual cases (Figure 2A) and no direct links identified between any men who have sex with men (MSM) cases (Figure 2B)
Despite the lack of direct links identified between most cases, the early geographic clustering, and multiple bisexual cases potentially linking heterosexual and MSM sexual networks, strongly suggested
Summary
There has been sustained transmission of HL-AziR in England since November 2014. Few cases had identified epidemiological links and this, along with the limited effectiveness of PN, suggests there is likely a considerable reservoir of undiagnosed infection fuelling transmission. These cases belonged to a discrete outbreak, which was confirmed by whole genome sequencing (WGS) [9]. The HL-AziR clonal spread among initial outbreak cases in Leeds [9] may have been facilitated by an identified sexual network including four cases, one of whom became re-infected and indicated ongoing transmission over several months. A brief resurgence of cases in Leeds in 2016 (one case diagnosed in June and three cases in October and November) were not identified as having epidemiological links to the initial outbreak cases. WGS demonstrated that the isolates from the later cases had evolved, but were still closely related,
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