Summary
- The Institute of Environmental Science and Research (ESR) have notified us that 11 cases of closely related antibiotic resistant Shigella have been identified in Aotearoa New Zealand (NZ) since November 2023. These are mostly in the Northern region, and have occurred primarily among gay, bisexual, and other men who have sex with men (GBM).
- Symptoms include bloody diarrhoea, fever, or stomach pain.
- Antibiotic treatment is often required for severe cases of shigellosis. Drug resistance limits the treatment options available.
- Shigella is very infectious and can be spread through faecal-oral contact (i.e. from faeces or unclean fingers of one person to the mouth of another person). This can happen through sexual activity, especially anal sex, rimming, fingering, oral sex etc.
- ESR, the National Public Health Service and Health New Zealand/Te Whatu Ora have requested Burnett Foundation Aotearoa to share key public health messaging on social media, Grindr broadcasts, and to develop posters for sex-on-site venues. Services and Outreach will also be providing an in-person training event for public health staff in Auckland (and participants will be expected to complete our online MSM Culture module before the training.)
Background Context
What is Shigella/ XDR Shigella?
- Shigella are a group of bacteria which cause a bowel/gastrointestinal infection. This infection is called shigellosis.
- Symptoms usually start 1-3 days after exposure, but can occur up to one week after being exposed to the bacteria.
- Most common symptoms are diarrhoea which may be bloody, fever, and abdominal/ stomach pain, however not everyone develops symptoms.
• Usually the infection settles without treatment within 5-6 days, but in some cases it can be severe and require antibiotics. - Extensively drug resistant (XDR) Shigella is resistant to all common antibiotics (ampicillin, trimethoprim/sulfamethoxazole, azithromycin, ciprofloxacin and ceftriaxione). This is where the germs/bacteria have developed the ability to resist the drugs designed to kill them and so continue to grow. It means that if someone with XDR shigella is unwell enough to need antibiotics, treatment is very difficult (though there are some options).
- People living with HIV who have a weakened immune system (i.e. if not on effective treatment, or have AIDS-related illnesses) are at an increased risk of severe or long-lasting infection.
How is Shigella transmitted?
- Very quickly and easily. It is very infectious (you only need a few bacteria to get sick).
- Shigella bacteria are spread from person to person by faecal-oral transmission (i.e. faeces getting into someone’s mouth). Traditionally it has been a foodborne/waterborne (spread through food, water, surfaces or objects which have been contaminated with faeces), but increasingly sexual transmission is occurring.
- Shigella can be spread through any type of sex that may involve contact with faeces. This can include direct sexual contact (e.g. anal sex, fisting, fingering, rimming, oral sex) or indirect sexual contact (handling contaminated objects such as a condom or sex toy).(2)
What's new?
Shigella in GBM
There have been outbreaks of XDR shigella in GBM in many other parts of the world (UK, Europe, USA) in the last few years, sometimes related to attendance at festivals or sex-on-site venues.
Since November 2023, 11 cases of closely related XDR Shigella have been identified in NZ. These cases are the same strain that has been affecting GBM overseas. They have occurred across NZ, but are mostly located in Auckland and mostly in GBM.
Information directly from people affected, and information from genomic/genetic testing of the bacteria show that some infections have occurred overseas and some in NZ. There are also other multi-drug resistant and extensively drug resistant Shigella cases that have been identified, though they are not in or related to this larger cluster.
How clinicians can help our communities
What information do community need?
- Awareness of the local outbreak, that is occurring among GBM, and that it can be sexually transmitted.
- How to reduce the risk of transmission and keep safe
- Awareness of symptoms to look out for
- Where to go for help (i.e. testing, treatment etc.)
What advice should we give communities to reduce their risk?
- Use condoms, dental dams, or latex gloves and change these between anal and oral sex.
- Wash genitals and anus before and after sex, if possible.
- Do not engage in sexual activities if you have diarrhoea.
- Do not share sex toys and ensure toys are cleaned with antibacterial soap after use and between partners.
- Wash hands regularly with antibacterial soap, especially before and after eating, using the bathroom or sex.
What should someone do if they are concerned they may have shigella?
- If you have symptoms of shigella talk to your GP or local sexual health service to arrange a test and any necessary treatment. Shigella is diagnosed from a faeces/poo sample/swab sent to a laboratory for testing.
- Drink plenty of water or other fluids and rest. Most people with shigella get better in 5-7 days.
- If you have had sex in the week before becoming unwell, contact your sexual partners to let them know they may have been exposed, and to seek medical attention if they become unwell.
- Do not have any form of sexual contact until 2 weeks after the diarrhoea has stopped to avoid passing shigella on to your partner/s. (The bacteria can continue to be shed for some time after your symptoms resolve).
Additional information
1. CDC. About Shigella Infection Among Gay, Bisexual, and Other Men Who Have Sex with Men 2024 [updated 10 April 2024].
2. CDC. Shigella Infection Among Gay, Bisexual, and Other Men Who Have Sex with Men 2024
3. CDC. CDC Health Advisory: Increase in Extensively Drug-Resistant Shigellosis in the United States 2024 [updated 24 February 2024].
4. Charles H, Prochazka M, Thorley K, Crewdson A, Greig DR, Jenkins C, et al. Outbreak of sexually transmitted, extensively drug-resistant <em>Shigella sonnei</em> in the UK, 2021–22: a descriptive epidemiological study. The Lancet Infectious Diseases. 2022;22(10):1503-10.
5. ECDC. Rapid risk assessment: Increase in extensively-drug resistant Shigella sonnei infections in men who have sex with men in the EU/EEA and the UK 2022 [updated 23 February 2022].
6. ECDC. Spread of multidrug-resistant Shigella in EU/EEA among gay, bisexual and other men who have sex with men 2023 [updated 18 July 2023].