Galveston 2000
I C G -- International Collaboration on Gonococci

Gonococcal Antimicrobial Susceptibility Surveillance
Meeting of Interested Parties at the International Pathogenic Neisseria Conference (IPNC), Galveston, Texas
14th November 2000
Sponsored By WHO and CDC

Attendance: Twenty-one persons attended all or part of the meeting and two were linked by teleconference facilities. Apologies were received from a number of others (see Appendix 1 for list of attendees; Appendix 2 is a list of interested parties with contact e-mail addresses).

Meeting record:
Dr Susan Wang of the CDC and Dr John Tapsall representing the WHO were co- chairpersons for the meeting.

Dr Wang outlined the genesis of the meeting, namely, contact between CDC and WHO with a view to enhancing data on gonococcal anti-microbial resistance (GC AMR). There have been several initiatives by WHO and CDC directed at addressing the problem of antimicrobial resistance

See:
  1. UNAIDS/WHO Guidelines for Sexually Transmitted Infections Surveillance (http://www.who.int/emc- documents/STId/docs/whocdscsredc993.pdf);
  2. WHO Surveillance Standards for antimicrobial resistance monitoring (in draft);
  3. WHO Global Strategy for Containment of Antimicrobial Resistance (http://www.who.int/emc/amr.html);
  4. U.S. Public Health Action Plan to Combat Antimicrobial Resistance (draft at: http://www.cdc.gov/drugresistance/actionplan/).
To further this end, it was arranged for this informal meeting of interested parties to be convened at this international gathering so that views and expressions of interest could be ascertained. The WHO issued invitations to IPNC conference registrants and others thought likely to respond positively to this initiative. The purpose of this meeting was primarily to document the amount and type of GC AMR surveillance undertaken at present (see meeting agenda - Appendix 3).

Dr Tapsall spoke on the importance of establishing quality GC AMR surveillance in terms of control of gonococcal disease and its complications which now include amplification of HIV transmission. The need to link GC AMR information generated by surveillance to disease control was emphasised.

Those attending provided information on the GC AMR surveillance programmes in their countries - a mapping exercise.

A number of programmes were described including those operating in Sweden, the USA, England, Scotland, Australia, Canada and China. Additionally regional WHO programmes in the Western Pacific, South East Asia and Central and South America were described. Many provided details of results of testing, but more relevant to the meeting, exercise details of the structure and organisation of programmes were provided. See Appendix 4 - Would those interested in this project kindly add to or correct this Table where necessary.

Many programmes have been extensively described in other sources (US GISP. Australian AGSP, Canadian programme, regional programmes WHO WPR GASP).

A list of some known references to established programmes of AMR surveillance in GC comprises Appendix 5. Again, if participants would be kind enough to list appropriate summaries that describe their programme and/or some recent published results it would be helpful.

The WHO has a Website that describes some of these details and provides other data on antimicrobial resistance - http://oms2.b3e.jussieu.fr/arinfobank/

[Some systems used intermittent, others continuous surveillance. Most relied on public sector sources for strains for examination although others utilised a variety of sources for gonococci to be tested. - see Table]

Most surveillance is at present carried out in more developed countries where gonorrhoea rates are often a fraction of those in less developed countries where AMR GC surveillance is performed rarely or not at all. In the past, AMR in GC has arisen in those areas where surveillance is less active. Surveillance data from several more developed countries suggest that AMR in GC in most developed countries is not as great a problem and often GC AMR which does exist is primarily imported rather than endogenous.

Other themes that emerged from these informal presentations included the need for quality control (internal) and quality assurance (external) programmes, increasing difficulties accessing isolates as the use of non-culture based testing increases, and the need to define sample populations and sample sizes for valid data generation.

Dr Knapp (CDC) provided a timely summary of the requirements for proper surveillance and suggestions for a way forward that included improving the WHO panel of GC control strains, global GC AMR proficiency testing, and routine data dissemination through use of a webpage. She and Dr Wang also described a US AIDS/LIFE initiative that currently includes 14 African countries and India but is likely to expand. This extensive HIV prevention effort is likely to include GC AMR surveillance.

Dr Susan Davis from the US DoD participated in the meeting by telephone link and expressed US military concerns regarding treatment needs for gonorrhoea in parts of the world where US forces were stationed. There was a strong possibility that co- operation with overseas US DoD laboratories (e.g., Egypt, Peru, Thailand, etc.) could be established regarding surveillance of AMR in GC. This will be actively explored with the CDC.

Dr Tapsall reported that many of the issues raised at this meeting had been addressed in a WHO-commissioned Technical Review that is now in its final editing stages. This document would be circulated as soon as practicable to those attending and was open to review and amendment as it was a ‘living’ document.

It was hoped that extensive sections of this document could contribute substantially to a framework for surveillance of AMR in GC.

It was agreed that interested meeting participants would form a core group that would communicate initially by e-mail to extend issues discussed at this meeting. Additional interested parties should be contacted and added to the group whenever they are identified.

It was noted that the ISSTDR conference in Berlin in June 2001 would be another opportunity to consolidate the exercise begun here. The ISSTDR conference organisers will be contacted to arrange a venue/symposium or both. The time frame of about 6 - 7 months was seen as realistic.

Those attending were thanked for their presence.

Appendix 1. Attendance

Magnus Unemo, Hans Fredlund, Per Olcen, Orebro, Sweden
Marilyn Roberts, Seattle, Washington, USA
Joan Knapp, CDC, Atlanta, USA
Jo-Anne Dillon, Sandra Ramirez, Jason Szeto, University of Ottawa
Cathy Ison, London, UK
Hugh Young, Edinburgh, Scotland
Lai-King Ng, Health Canada, Winnipeg, Canada
Waleria Hrynicwicz, Poland
Paula Kriz, Prague, Czech Republic
Stella Nowicki, Galveston, Texas, USA
Helen Palmer, Bristol, UK
Margaret Bash, FDA, Maryland, USA
Hanne Winther-Larsen, University of Oslo, Norway
Barbara Albiger, Stockholm, Sweden
Steve Dunham, Pfizer, Michigan, USA
Xiaohong Su, Nanjing, China
Susan Davis, US DoD, Maryland, USA (by telephone)
William Levine, CDC, Atlanta, Georgia, USA (by telephone)
Susan Wang, CDC, Atlanta, Georgia, USA
John Tapsall, Sydney, Australia
Apologies
Inga Lind, Copenhagen, Denmark
Dr S Kumari, WHO SEARO, Delhi, India
Dr Rafael Llanes, Cuba
Dr de Neeling, Netherlands

Appendix 2 List of interested parties:

Magnus Unemo, Sweden
Hans Fredlund, Sweden
Per Olcen, Orebro, Sweden
Marilyn Roberts, Seattle, Washington, USA
Joan Knapp, CDC, Atlanta, Georgia, USA
Jo-Anne Dillon, University of Ottawa, Canada
Sandra Ramirez, University of Ottawa
Jason Szeto, University of Ottawa
Cathy Ison, London, UK
Hugh Young, Edinburgh, Scotland
Lai-King Ng, Health Canada, Winnipeg
Waleria Hrynicwicz, Poland
Paula Kriz, Prague, Czech Republic
Stella Nowicki, Galveston, Texas, USA
Helen Palmer, Bristol, UK,
Margaret Bash, FDA, Maryland, USA
Hanne Winther-Larsen, University of Oslo, Norway
Barbara Albiger, Stockholm, Sweden
Steve Dunham, Pfizer, Michigan, USA
Xiaohong Su, Nanjing, China
Susan Davis, US DoD, USA (by telephone)
Susan Wang, CDC, Atlanta, Georgia, USA
John Tapsall, Sydney, Australia
Inga Lind, Copenhagen, Denmark
Dr S Kumari, WHO SEARO, Delhi, India
Dr Poumerol, WHO Manila,
Dr Rafael Llanes, Cuba
Dr de Neeling, Netherlands
Dr Rosamund Williams, WHO, Geneva
B. Garin, New Caledonia
Dr Celia Carlos, Philippines
Dr Rohani, Malaysia
Dr Ling, Singapore
Tony Lupiwa, Papua New Guinea
Dr Kam, Hong Kong
Mike Bokenshire, New Zealand
Andrew Darcy, Solomon Islands
Dr Grosjean, Cambodia
Prof Tanaka, Japan
Ane Ika, Tonga
Helen Wamle, Vanuatu
Port Moresby Hospital, Papua New Guinea
Dr Lee, Korea
Dr Insisiengmay
Dr Kuroki, Japan
Erdinechimeg Lakhsuram, Mongolia
William Levine, CDC, Atlanta, Georgia, USA

Appendix 3 Enhancing Gonococcal Antimicrobial Susceptibility Surveillance

Meeting of Interested Parties 8:00 - 10.00 pm Tuesday 14th November
The Vine Room Moody’s Hotel Galveston

Gonococcal antimicrobial resistance severely compromises control of gonococcal disease, preventing effective treatment of individuals, increasing the rate of morbidity and complications and enhancing the transmission of HIV.

Effective treatment of gonorrhoea depends to a significant degree on having available data on antimicrobial resistance patterns in Neisseria gonorrhoeae.

A number of bodies have established programmes of AMR surveillance in gonococci.

This informal and open meeting hopes to bring together those currently performing AMR surveillance in gonococci and others interested in the activity to enhance outcomes and knowledge.

Your attendance is cordially invited.

Input into Item 3 of the Agenda (below) is especially encouraged.

Draft Agenda
1. Welcome
2. Introduction and Meeting Objectives
3. Mapping of existing GC AMR surveillance
Short presentations from invitees and attendees

4. Gaps and deficiencies in GC AMR surveillance
Why do these occur?

5. Discussion: Strategies for improving GC AMR surveillance

Enquries: John Tapsall e-mail: j.tapsall@unsw.edu.au OR Susan Wang e-mail: sjw8@cdc.gov

Appendix 4 Existing and potential sources of data

Country/ Region Coordinator/ Contact Surveillance type Comments
WHO WPR Gasp John Tapsall Continuous Linked programme with programme specific QA and QC Published standardised methodology Data published annually
Australia John Tapsall
Brunei Noraalia Rahim
Cambodia Dr Grosjean
China Prof Ye
Fiji M Shah
Hong Kong SAR Dr KM Kam
Japan Prof Tanaka Dr Kuroki
Korea Prof Lee
Laos Dr Insisiengmay
Malaysia Dr Rohani
Mongolia Dr Lhaksurman
New Caledonia Dr Garin
New Zealand Mike Brokenshire
Papua New Guinea Tony Lupiwa
Martin Honbhanje
Philippines Dr Carlos
Singapore Dr Ling
Solomon Islands Andrew Darcy
Tonga Ane Ika
Vanuatu Helen Taleo
Vietnam Dr Le
WHO SEARO Dr Kumari
India Dr Ray
Sri Lanka Dr Mananwatte Continuous
Myanmar Dr Lwin
Nepal
Thailand Dr Sirivongrang son
Bangladesh
Indonesia
Canada Lai-King Ng ongoing Includes all isolates in the country
United States GISP Susan Wang Continuous, monthly collection of isolates from 25 cities Published standardized methodology with QC and QA
Data published annually on CDC webpage

Appendix 5 published data/methods

Tapsall JW, Phillips EA, Cossins YM et al. Penicillin sensitivity of gonococci in Australia: the development of an Australian gonococcal surveillance programme. British Journal of Venereal Diseases 1984,60:226-230.

Tapsall JW, Phillips EA, Cossins YM et al. Use of a quality assurance scheme in a long-term multicentric study of antibiotic susceptibility of Neisseria gonorrhoeae. Genitourinary Medicine 1990,66:437-444.

The National Neisseria Network 1979 - 200?. Communicable Diseases Intelligence 2000;24:190-193.

Australian gonococcal surveillance programme. Annual report of the Australian gonococcal surveillance programme, 1999. Commun Dis Intell 2000;24:113-117.

WHO Western Pacific Region Gonococcal Antimicrobial Surveillance Programme. Surveillance of antibiotic susceptibility of Neisseria gonorrhoeae in the WHO Western Pacific Region 1992 - 1994. Genitourinary Medicine 1997;73:355-361.

The WHO Western Pacific Region Gonococcal antimicrobial surveillance Programme. Surveillance of antibiotic resistance in Neisseria gonorrhoeae in the WHO Western Pacific Region, 1999. Communicable Diseases Intelligence 2000;24:268-270.

Schwarcz SK, Zenilman JM, Schnell D, et al. National surveillance of antimicrobial resistance in Neisseria gonorrhoeae. Journal of the American Medical Association1990; 264:1413-1417.

CDC.Antibiotic-resistant strains of Neisseria gonorrhoeae: policy guidelines for detection, management, and control. Morbidity and Mortality Weekly Report 1987;36 (suppl no. 5S).

Fox KK, Knapp JS, Holmes KK, et al. Antimicrobial resistance in Neisseria gonorrhoeae in the United States, 1988-1994: the emergence of decreased susceptibility to the fluoroquinolones. Journal of Infectious Diseases 1997;175:1396- 1403.

Gorwitz RJ, Nakashima AK, Moran JS, Knapp JS. Sentinel surveillance for antimicrobial resistance in Neisseria gonorrhoeae - United States, 1988-1991. Morbidity and Mortality Weekly Report 1993;42 (suppl no.SS-3).

CDC. Sexually Transmitted Disease Surveillance 1999 Supplement: Gonococcal Isolate Surveillance Project (GISP) Annual Report - 1999. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, October 2000. [may be found on http://www.cdc.gov/nchstp/dstdp/Stats_Trends/99GISP.htm]