In 2006 I was asked to review a case gonorrhoea of the vagina and vulva in a baby. The parents were infected. They denied sexual abuse but admitted to sharing their bed, bath and towels with their infant. This was a young Pacific family living in a crowded housing situation. The mother used her sarong as a nappy on occasions. The authorities had removed the little girl from her parents on the basis that she must have been sexually abused by either her mother or her father.
Medical evidence provided to the court was that transmission of gonorrhoea could only occur “from infected mucus membrane to mucous membrane”. This was the prevailing belief at the time and one I also held. After on-going requests from the lawyer I agreed to conduct a literature review into whether it was also possible for this infection to have occurred non-sexually from contaminated hands or transmission via infected inanimate objects.
Getting gonorrhoea from sexual abuse was never in doubt. My aim was to examine the evidence to answer the question: Is there evidence of non-sexual transmission on occasion?
My systematic review revealed that this is certainly possible with large numbers of cases documented in the literature. Cases include epidemics of gonorrhoea in the eyes of children in outback Australia and Africa, epidemics of gonorrhoea in children’s wards prior to the discovery of penicillin and accidental transmissions from infected fluids.
What is the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period? A systematic review
Goodyear-Smith F. Journal of Legal and Forensic Medicine, 14 (8): 489-502. 2007 doi:10.1016/j.jlfm.2007.04.001
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.
One of the international guideline authors, Dr Kellogg wrote a scathing Letter to the Editor about my review
Evidence-based or evidence-biased? Letter to the Editor
Kellogg N. Anderst J. Journal of Forensic and Legal Medicine 15 (7): 471–472, 2008.
I was able to respond to their criticisms in my right of reply:
Evidence-based or evidence-biased? Author reply
Goodyear-Smith F. Journal of Forensic and Legal Medicine 15 (7): 473–475, 2008.