“Gonorrhoea is a sexually transmitted disease which is caused by contracting Gram negative intracellular diplococcus Neisseria gonorrhoeae (NG). The primary sites of infection are the mucous membranes of the urethra, endocervix, rectum, pharynx and conjunctiva. Transmission is by direct inoculation of infected secretions from one mucous membrane to another. The main route is sexual contact with relevant anatomical sites, penile oral, penile anal and penile vagina...etc.”
“A positive culture for N gonorrhoeae from any site in a child without prior peer sexual activity is strongly suggestive of sexual abuse. The question of whether gonococcal infection in children can be acquired through fomites still arises. To date there are no convincing data to support nonsexual mode of transmission in children. Sexual abuse should be strongly considered when a gonorrhoea infection (i.e., genital, rectal, oral, or ophthalmologic) is diagnosed in a child after the newborn period and before the onset of puberty. In some publications sexually transmitted disease may be the only physical evidence of sexual abuse in some cases.”
“The likelihood that it could have been transmitted from an inanimate object in the house e.g., through shared bathwater, a towel, a toilet seat/potty, bed linen is uncommon and has not been widely supported in the literature but cannot be totally eliminated.”
“The most likely mode of transmission in this case (6 years of age) is sexual. Given the age of the child, vertical transmission is unlikely. As stated above, other non-sexual mode of transmission via fomite...etc are not widely supported in the literature in particular given the fragility of the organism and its susceptibility to dryness." Asked to comment on any other matter he felt might be of assistance to the court, he added: “It is recognised that gonorrhoea is a recognised sexually transmitted infection which cannot survive outside the host for significant length of time given the fragility of the organism and its susceptibility to dryness. Moisture is a main factor for its survival. It is worthwhile stating that the mere presence of the bacterium on a surface or object does not equate transmission. In addition, if N gonorrhoea is easily transmitted via the above nonsexual route, one would expect the other children to have been infected which was not the case.”
“… accidental transmission, including fomite transfer and auto inoculation, non-sexual close physical contact have also been proposed. Although there have been studies which have shown the presence of live organism on inanimate objects none have demonstrated the organism can then be transmitted to humans. STIs or sexually transmitted infections have also been detected on clinic surfaces and hands of national health service staff using the NAAT test but attempts to culture Neisseria Gonorrhoea … from these specimens have failed, suggesting that this material is non-viable and the transmission via this route is extremely unlikely.”
“it is my opinion that F’s infection was contracted more likely through sexual contact. Vertical transmission is unlikely given her age at the material time. Other modes of transmission through, inter alia, contaminated hands, toys, bath, and fomites (given the fragility of the organism and its susceptibility to dryness) have not been established/substantiated but cannot be totally excluded in their entirety due to lack of robust published research evidence.”
“the possibility of fomite transfer (transfer via an inanimate object), is considered rare because Neisseria gonorrhoeae is a fastidious organism which does not survive outside the human host in a dry environment.”
“Survival of the Neisseria gonorrhoea bacterium on an inanimate surface depends on it being a moist environment. Survival of gonococci has been demonstrated for up to 24 hours on a towel periodically rinsed with warm, physiologic saline …. “ Asked about the documented frequency of the mechanism, he said: “Studies indicating the environmental survival of bacteria on these surfaces does [sic] not indicate a mode of transfer; in other words the bacteria has to reach susceptible epithelial cells to cause infection …. There are no publications indicating the frequency of fomite transfer and infection which is considered to be rare.”
“10. The burden of proof is on the local authority and must not be reversed. In Re A, B and C (Fact-Finding: Gonorrhoea)[2023] EWCA Civ 437 , a case with similar facts to this, and in which the medical evidence was very similar, (one of the experts was Dr Ghaly,) Baker LJ warned: ‘To my mind there is considerable force in the appellant’s criticism of the judge’s conclusion at paragraph 75 of the judgement that “despite the parents evidence they cannot be telling the truth, because the presence of the gonorrhoea infecting A itself is evidence of abuse”
“28. ….he emphasised the fragility of the gonorrhoea bacteria and stressed how susceptible it is to dryness. To support the doctor’s opinion that fomite transmission was unlikely he stressed that it is difficult for gonorrhoea to exist outside of the infected person as once the organism leaves its host it is compromised. 29. Regarding transmission from an object inserted into a child’s vagina, other than a penis, this he concludes is impossible as the object would have to be inserted past the hymen which would have caused the child significant pain. 30. Dr Ghaly went to lengths to explain that the mere presence of bacteria on a surface cannot itself pass gonorrhoea onto a person simply by that person coming into contact with the bacteria. There must be a mechanism by which the live bacteria can be transmitted to a mucous membrane. Merely sitting on the toilet seat or touching live bacteria with a finger would not result in a person contracting gonorrhoea unless the child, for example, placed their finger in their mouth or touched another mucous membrane. 31. When asked how long the gonorrhoea bacteria can live outside of its host Dr Ghaly said that it can live from minutes to hours depending on factors. Regarding transmission from a towel, Dr Ghaly said that the child would have to pick up a towel and then immediately touch a mucous membrane in order for the infection to be passed.”
“41. The family towel protocol was that bath towels were kept outside of the bathroom on shelves and a hand towel was retained in the bathroom hanging on the radiator, which would be changed once daily following the children’s bath time. While [the grandmother and her partner] would bring their towels down to be washed after a bath or shower it was common for her son X to either leave his (damp towel) on the bathroom floor or in his bedroom. It was [the grandmother’s] position that all would use separate towels save for the hand towel.”
“79. It is, in my judgment, likely that X made up this story to give a reason for the infection being present on the toilet seat or on towels he used in the bathroom. In my view it is likely that X has created a narrative which he thinks would tie in with the timings of the discovery of symptoms in F. X would be unlikely to understand the flaw in this explanation which is that it is most unlikely that F could have incubated the infection in this short period, sufficiently to show symptoms simultaneously with himself, so if this was his plan, it was destined to fail. The significance of this lie has to be regarded in the context of the Lucas principles outlined above. The fact that X has lied does not of itself negate the possibility of F having become infected by reason of X’s lack of personal hygiene.”
“80. The combined expert evidence does not exclude the possibility that F could have contracted the infection from fomite transmission. The collective evidence supports that the germ can survive on a surface for up to 12 hours in moist conditions. A damp towel located within a bathroom which is poorly ventilated and in which condensation forms, and is visible, is such a moist environment. For F to have contracted the infection from a fomite source, the germ must have been deposited on a surface and survived for a long enough period for F to come into contact with it. The germ must then have been conveyed to one of her mucus membranes for the infection to enter her body. This could be achieved directly by the object having been inserted into the body with such depth that it touches the membrane. In the case of the eye, this could be achieved by wiping the eye with an infected towel or by self infection from touching an infected part of the body and then touching the eye. In the case of the vulva, the infection would have had to have entered F’s vestibule area. It has been suggested that the germ could have survived on the toilet seat and then conveyed to F. If F had sat on the toilet seat within such proximity for the germ to have survived, it would still have had to enter her body. This is imaginable in the case of the eye. For the germ to be found in the vulva it would have had to be digitally inserted into the body. The evidence does not exclude the possibility of F’s eye and her vulva having been infected at the same time. Alternatively, each could have been infected before the other. 81. In light of F’s age, any sexual contact would necessarily be sexual abuse. The experts expressly do not rule out fomite transmission as being possible. The grandmother’s routine with the family’s towels was meticulous. Some would say exemplary. The bathroom humidity makes it unlikely to have sustained the germ living for the necessary period for it to be picked up by F either form towels or a toilet seat, but not impossible. 82. X’s evidence was unimpressive. The local authority points to aspects of X’s profile which it says paints a picture of someone who may commit sexual abuse against a young child. This is pure conjecture. The evidence in this case paints a picture of X as a person with low sexual standards. The manner in which X has conducted himself throughout the proceedings evidence someone who has little or no respect for authority: someone who admits to dealing drugs and collecting drug debts by stealing. Accepting X’s explanation as to how the infection passed is to accept that X continued to live in house with young children when he knew he was infectious with a sexual disease. While living in the house, X took few if any precautions not to pass the infection onto others. In fact, he continued with his usual low standards of hygiene of carelessly using towels and leaving infected clothing and bedding lying around. 83. I am satisfied that there is no cogent evidence to support that X spent sufficient or indeed any time alone with F to infect her physically in a way that would be necessary to pass the disease. The lack of a complaint from F is significant, as is no reference to such by B. The lack of supportive adverse evidence on X’s phone is significant.”
“89. In conducting my analysis I must consider all the evidence in this case, I respectfully refer to the approach adopted by Mr Stonor KC in his submissions to the Court of Appeal in ABC. Baker LJ refers to Mr Stonor’s submissions in paragraph 33 of his judgment. His Lordship says, referring to Mr Stonor submission: ‘By formulating a presumption that the presence of gonorrhoea is in itself evidence of sexual abuse, the court prevented itself from considering each piece of evidence in the context of all the other evidence and therefore did not undertake an overview of the totality of the evidence in reaching its conclusion. A proper survey of the wider canvas would have shown the presence of gonorrhoea was the only evidence of sexual abuse. All the other features pointed the other way.’ Baker LJ then goes onto list the features of that case which were submitted as pointing the ‘other way’. The list is remarkably similar to this case which has the following features: a. A verbal 6 year old child had not made any allegations of having been sexually abused. b. There is no (other or corroborative) evidence of F having been sexually abused. c. There is no evidence to suggest that X had any sexual interest in children. d. There was no evidence of X having had an opportunity to abuse F. e. The expert evidence supports that fomite transmission is possible. f. The evidence supports that the germs to carry the infection could have survived in a form that they remain transferrable in the environment described by X and his mother. g. X (despite his cognitive limitations) has presented himself to court to give evidence and has denied an allegation of sexual abuse. In my judgment, if I were to find that F contracted gonorrhoea as a result of having been sexually abused by X, I would (to quote the words of Baker LJ in ABC): ‘Have concluded wrongly on the medical evidence that the mere presence of gonorrhoea in the child was determinative of sexual abuse and I would not sufficiently weigh it up against the substantial evidence pointing the other way.’” ‘By formulating a presumption that the presence of gonorrhoea is in itself evidence of sexual abuse, the court prevented itself from considering each piece of evidence in the context of all the other evidence and therefore did not undertake an overview of the totality of the evidence in reaching its conclusion. A proper survey of the wider canvas would have shown the presence of gonorrhoea was the only evidence of sexual abuse. All the other features pointed the other way.’ a. A verbal 6 year old child had not made any allegations of having been sexually abused. b. There is no (other or corroborative) evidence of F having been sexually abused. c. There is no evidence to suggest that X had any sexual interest in children. d. There was no evidence of X having had an opportunity to abuse F. e. The expert evidence supports that fomite transmission is possible. f. The evidence supports that the germs to carry the infection could have survived in a form that they remain transferrable in the environment described by X and his mother. g. X (despite his cognitive limitations) has presented himself to court to give evidence and has denied an allegation of sexual abuse. ‘Have concluded wrongly on the medical evidence that the mere presence of gonorrhoea in the child was determinative of sexual abuse and I would not sufficiently weigh it up against the substantial evidence pointing the other way.’”
“They submitted that this demonstrated that the judge had been drawn into error because her perception of the expert evidence was that there was a presumption that the presence of gonorrhoea in itself evidences sexual abuse. It was submitted that this amounted to a reversal of the burden of proof because it required the parents to rebut the presumption by establishing an innocent mode of transmission.”