At least three people in three different countries have turned up with cases of completely incurable gonorrhea—and it’s unclear what happened to all of them and if they’re spreading the infection to others, officials at the World Health Organization report.

These cases highlight two big concerns about gonorrhea: one is that resistance to last-line drugs is alarmingly popping up around the world and appears to be increasing; and the second is that we have lousy surveillance and data on this.

In two reports in PLOS Medicine, the WHO warned of the dangers of drug-resistant gonorrhea infections, which can cause infertility and increase the risk of contracting other infections in those left untreated. Summarizing the latest surveillance data, WHO researchers found worldwide incidence of drug-resistant infections and announced that these are on the rise. However, while the data is worrying, it doesn’t actually demonstrate international increases—because there just isn’t enough data to do so.

The reports include spotty and cumulative data from 77 of the world’s 195-or-so countries that provided data at least one year between 2009 and 2014. The WHO’s main data analysis focused on whether certain types of drug resistance occurred at least once in that whole span of time. For instance, key takeaways include: 66 percent of reporting countries saw at least one case of gonorrhea with some level of resistance to cephalosporin antibiotics in that time frame. (Those cephalosporins include oral cefixime and injectable ceftriaxone.) And about 81 percent of reporting countries saw at least one strain with resistance or decreased susceptibility to oral azithromycin.

These are concerning statistics because the most recent recommended treatment for gonorrhea is a combination of azithromycin and the cephalosporin ceftriaxone. And these are last-line antibiotics. Gonorrhea has already proven too resistant to other antibiotics, including penicillin, tetracycline, and ciprofloxacin.

Stats, stat

Still, just because a drug-resistant strain has appeared somewhere, maybe just in one year’s worth of data, doesn’t mean it’s widespread. And this data is not enough to discern the changing prevalence of drug-resistant infections in many of those reporting countries. The WHO did provide maps of some of the most recent prevalence figures. But the graphs represented data from a hodgepodge of years (from 2011 to 2014) because many countries don’t report data consistently.







Without year-by-year breakdowns, there’s no way to identify trends. In all, the data doesn’t show if, where, or at what rate drug resistance is increasing. And this problem of incomplete data doesn’t seem to be improving, either. In fact, although the organization had collected data from 77 countries total from 2009 to 2014, the number of countries reporting data each year actually fell during that time, from 56 countries reporting in 2009 to 52 in 2014.

In a teleconference with reporters, WHO officials admitted that they simply don’t have the data they need to assess the scope of the problem. High-income countries with solid surveillance may act as a barometer for global gonorrhea trends, the officials noted. But many countries thought to have the highest rates of gonorrhea infections and drug resistance, including many in Africa, reported no data to the organization at all.

The data we have is likely “the tip of the iceberg,” according to Dr. Teodora Wi, medical officer of human reproduction at the WHO and first author on one of the new reports.

Smacking the clap

Dr. Wi emphasized that, despite the dearth of data, we have every reason to suspect that drug-resistant gonorrhea is indeed on the rise and a critical problem. Gonorrhea is caused by Neisseria gonorrhoeae bacteria, which can infect the genitals, rectum, and throat. N. gonorrhoeae strikes an estimated 78 million people each year worldwide, and many countries are seeing upswings in infections. Yet, many infections go undetected, and the bacteria can easily develop resistance.

The three countries that reported completely untreatable infections were also high-income countries—France, Spain, and Japan. And some countries have already started increasing the recommended doses of the combination therapy to thwart mounting resistance, Wi noted. This strategy can work for a while, she said, but at some point, not even high doses will remain effective.

Moreover, if things are taking a turn for the worse in high-income countries, Dr. Wi reasoned, they’re undoubtedly grimmer in low-income countries that have higher infection rates. “We need to be more vigilant,” she said. Without changes, she expects untreatable infections will become common in just a few years.

Although factors driving increases in infections and drug resistance are different in different places, overall problems include decreasing condom use, people not completing their courses of antibiotics (allowing for resistance to develop), increased urbanization, poor infection detection, and global travel.

Along with the data, the WHO outlined steps that nations can use to address these problems, specifically improving surveillance, public awareness, and diagnostics. The WHO is also working with a non-profit to spur the development of new drugs. Three drugs for gonorrhea infections are currently in various stages of clinical trials.

PLOS Medicine, 2017. DOI:10.1371/journal.pmed.1002344 (About DOIs).