Oropharyngeal gonorrhoea among heterosexual men and women at a sexual health centre in Rotterdam, the Netherlands, 2023: reservoir for transmission?

Background: Sexual health centres (SHCs) in the Netherlands report a surge in gonorrhoea, especially among young women (notably oropharyngeal) and men who have sex with women (MSW) since the second half of 2022. MSW are not routinely oropharyngeal tested, and women only when reporting oral sex. This cross-sectional study aimed to assess oropharyngeal gonorrhoea in MSW and women, and potential underdiagnosis.

Methods: From 10 August to 10 November 2023, the SHC in Rotterdam, the Netherlands, extended its gonorrhoea testing protocol, requiring oropharyngeal tests for all MSW and women. Positive cobas nucleic acid amplification test (NAAT) results were followed by culture sampling. Oropharyngeal infections were confirmed with a second NAAT (opa gene-based PCR), and for discrepancies a third NAAT (GeneXpert CT/NG test) was employed. The impact of extended testing on detection rates, along with the corresponding 95% CIs, was analysed.

Results: The overall gonorrhoea detection rate was 6.4% (95% CI 4.7% to 8.8%) among MSW and 6.0% (95% CI 4.8% to 7.6%) among women, compared with 3.6% (95% CI 2.3% to 5.4%) and 6.0% (95% CI 4.8% to 7.6%) without expanded testing. Oropharyngeal rates were 6.4% (95% CI 4.4% to 9.2%) for MSW and 4.3% (95% CI 3.2% to 5.7%) for women. Highest positivity was among individuals notified, <25 years, without migratory background, with lower educational levels and more sex partners. Oropharyngeal cultures confirmed viable gonorrhoea in 39.1% of MSW and 35.5% of women. False positives were 7.4% among MSW and 10.8% among women. Confirmed oropharyngeal gonorrhoea positivity rate was 5.9% (95% CI 4.0% to 8.6%) among MSW and 3.9% (95% CI 2.8% to 5.2%) among women.

Conclusion: Oropharyngeal gonorrhoea is common and currently underdiagnosed among MSW. The impact of this underdiagnosis on transmission dynamics under the current testing policy remains unclear. Further research is needed to inform prevention and control strategies, especially given the recent surge in gonorrhoea.