What is the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period? A systematic review

Abstract

International consensus guidelines state that Neisseria gonorrhoeae infection in pre-pubertal children is always, or nearly always, sexually transmitted. A systematic literature review does not concur with this. N gonorrhoea was believed to solely sexually transmitted when first identified in the 1880s. However it became recognised that when the infection was introduced into children’s institutions, it rapidly spread among pre-pubertal girls. The medical literature records over 40 epidemics involving about 2000 children in Europe and the United States. Communal baths, towels or fabric, rectal thermometers and caregivers hands were identified as means of transmission. Although sensitive to heat and drying, gonorrhoea may remain viable in pus on cloth for several days. Several unusual accidental transmissions are reported, often due to contamination from laboratory samples. Indirect transmission occurs in epidemics of conjunctivitis in third world rural populations. Spread of infection can occur via contaminated hands of infected caregivers. While all paediatric cases of gonorrhoea must be taken seriously, including contact tracking and testing, forensic medical examiners should keep an open mind about possible means of transmission. Doctors and lawyers need to be cognisant of the large body of literature demonstrating both sexual and non-sexual means of transmission of gonorrhoea in children.

Introduction

International guidelines and other authorities state that Neisseria gonorrhoeae infection in pre-pubertal children is always, or nearly always, a sexually transmitted disease.[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16] All these documents conclude that transmission after the neonatal period is likely to be sexual and are strongly supportive of sexual abuse.

In New Zealand, the finding of gonorrhoeal infection in a pre-pubertal child beyond the neonatal period is considered diagnostic of sexual abuse.¹⁷ The presence of this infection designates sexual abuse a medical certainty with urgent action required by the social agencies, police and the courts. It was assumed that all 14 reported cases of gonorrhoea in pre-pubertal children in Auckland between 1991 and 2002 must have been due to sexual abuse with the child requiring urgent placement ‘in a safe household’.¹⁸ In many cases there was no disclosure and the perpetrator was deduced ‘based on who was in contact with the child during the incubation period’. Several families fled the country; some children were taken into custody and some prosecutions occurred. One mother was considered to be the perpetrator and lost custody of her child.

Clearly sexual transmission should be immediately considered whenever gonorrhoea is found in a pre-pubertal child. Missing a case of sexual molestation has serious social and legal consequences. However what is the possibility that this organism can be spread non-sexually on occasion? Removing a child from its parents on the basis of a wrongful assumption of sexual abuse, or charging an adult with sexual assault, may have taken an equally damaging toll. What is the evidence on which the guidelines and other authorities base their statements?

Of concern, the guidelines either do not refer to primary studies to back their claims, or they rely on a 1984 review article which claims to have summarised ‘all studies of gonococcal infections in children since 1965’.¹⁹ However this is not a systematic review; it fails to refer to much of the published literature during that period and omits reference to a number of pertinent studies before their review time, as well as those published since.

Therefore the aim of this review is to systematically examine the literature on the possible non-sexual modes of transmission of Neisseria gonorrhoeae in children after the neonatal period.