In November 2023 the UK’s Joint Committee on Vaccination and Immunisation issued advice to the government on a routine targeted vaccination programme for the prevention of gonorrhoea alongside advice on a routine vaccination programme against mpox for those at greatest risk. JCVI recommends that both programmes should be offered on an “opportunistic” basis through specialist sexual health services with experience in assessment and identification of people at increased risk of infection with bacterial STIs. The UKHSA and Department of Health and Social Care state that ministers will consider the advice before making policy decisions.
The JCVI states that gonorrhoea is a bacterial STI caused by the Neisseria gonorrhoea bacterium and is the “second most commonly diagnosed” STI in England; around 80,000 cases are diagnosed a year. It is transmitted through unprotected anal, oral, or vaginal sex, or genital contact with an infected partner. People who are infected may not display symptoms but can still transmit infection.
“Typical” symptoms include thick green or yellow discharge from the vagina or penis, and painful urination. The infection can also cause pelvic inflammatory disease, ectopic pregnancy and infertility, or painful infection in the testicles and prostate.
“Gonorrhoea causes significant morbidity and remains a public health concern globally.”
This concern increases as resistance to antibiotics increases; WHO considers the pathogen a priority pathogen due to the widespread antimicrobial resistance. In the UK, the recommended first-line therapy is ceftriaxone, to which resistance remains “very low”. However, resistance is increasing.
The UK has been conducting surveillance for “over 100” years, and the number of diagnoses in 2022 was the “highest annual number on record”. These rates are “consistently disproportionately higher” in “specific communities”. These include:
- Those who live in the most deprived areas
- People of black Caribbean ethnicity
- People born in Central or South America (this measure is used as a proxy for being of Latino, Latina, or Latine ethnicity)
- Young people 15-24 years old and gay, bisexual, and other men who have sex with men (GBMSM)
“Natural infection does not give protection against future infections, and among both GBMSM and heterosexuals, a recent history of gonorrhoea is a reliable predictor of future reinfection with gonorrhoea or other STIs.”
The latest advice suggests that a targeted vaccination programme should use the 4CMenB vaccine to prevent gonorrhoea. It is a 4-component serogroup B meningococcal vaccine containing:
- 3 main Neisseria meningitidis proteins
- Neisseria heparin binding antigen (NHBA)
- Neisserial adhesion A (NadA)
- Factor H binding protein (fHbp)
- Meningococcal serogroup B outer membrane vesicles (OMVs)
There is one licensed 4-component vaccine in the UK: Bexsero. This is manufactured by GSK and authorised for the prevention of meningococcal disease in patients over the age of 2 months. It’s used in the routine childhood programme administered at 8 weeks, 16 weeks, and 1 year for the prevention of meningococcal disease.
“Neisseria meningitidis and Neisseria gonorrhoeae are closely genetically related with between 80 to 90% sequence homology. This homology gives the potential for cross-protection from OMV containing meningococcal B vaccines against Neisseria gonorrhoeae.”
The JCVI agreed that the targeted programme should be “initiated” using the 4CMenB vaccine for gonorrhoea prevention in those who are “at greatest risk”. It emphasises that individuals who are offered vaccination must understand that real world studies have estimated that the vaccine has “between 32.7% to 42% effectiveness against gonorrhoea”. Therefore, although it would “be expected to reduce the chance of becoming infected”, it would “not completely eliminate the possibility”.
“Vaccinated individuals could expect to have some reduction in their own risk of contracting gonorrhoea; however, the main benefit of a vaccination programme is expected to be at a community level.”
Professor Andrew Pollard, Chair of the JCVI, hopes that the programme would not only “be a world first” but “should significantly help to reduce levels of gonorrhoea, which are currently at a record high”. Dr Katy Sinka, Head of Sexually Transmitted Infections at UKHSA, described a vaccination programme that would reduce gonorrhoea cases as a “hugely welcome intervention”.
“We saw a rapid rise last year with more cases than ever before and with gonorrhoea becoming increasingly resistant to antibiotics, tackling this infection is a serious concern.”
Mpox (previously called monkeypox) is a “rare disease caused by infection with the mpox virus”, an orthopox virus related to the viruses that cause smallpox and cowpox. JCVI states that before early 2022, cases of mpox in the UK were “either associated with travel to or from countries where mpox is endemic”. However, in May 2022 there was a “large outbreak” in the UK that presented a “different” pattern and scale to what had previously been observed.
During this outbreak, cases were “primarily identified among gay, bisexual, and other men who have sex with men” (GBMSM) without a history of travel to endemic countries. From this it was inferred that there was community transmission; epidemiological surveillance suggested that this occurred from person-to-person contact in “defined sexual networks of GBMSM”.
In response, although there was no licensed vaccine for protection against mpox, there was “good evidence” that the Modified Vaccinia Ankara – Bavarian Nordic (MVA-BN) provided cross-protection to mpox when given pre-exposure. The MHRA approved this vaccine for immunisation against mpox in September 2022. However, due to a limited supply of vaccines, intial recommendations focused on first doses.
For mpox, the JCVI advises an “ongoing routine vaccination strategy” to prevent outbreaks and protect those at risk of exposure. This advice encourages the strategy to “target GBMSM who are at highest risk of exposure”; they will be identified via sexual health services through “markers of high-risk behaviour” such as those used to assess eligibility for HIV pre-exposure prophylaxis (PrEP). These criteria include:
- A recent history of multiple partners
- Participating in group sex
- Attending sex-on-premises venues
- A proxy marker such as a bacterial STI within the last year
Furthermore, JCVI encourages efforts to “ensure” that the vaccine is “offered equitably to those at equivalent risk”, including “transgender women or gender-diverse people assigned male at birth”. Dr Sinka commented that “while mpox case numbers across England remain very low” the community should “not be complacent”.
“Any routine vaccination offer to those at highest risk of infection will help ensure we remain on top of the disease and prevent any major future outbreaks.”
Updates to the latest advice are expected as further information about “vaccine effectiveness and duration of protection” becomes available.
How might these recommendations influence policy for better infection control in the UK, and can we expect to see other areas follow this decision? If your country has a better approach to infection management, why not share it? For more on vaccination policy and practice don’t forget to subscribe here.