What is the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period? A systematic review.

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.