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The results of the Prevention Of Pelvic Infection (POPI) trial,1 published soon after criticism about the value for money of the chlamydia screening programme in England,2 should make us think even harder about how to investigate and control chlamydia and its associated morbidity. Should we be doing more of the same, but better? Should we be developing new approaches? Or do we need both? The innovative trial by Oakeshott et al in female college students in London provides new information about the effects on pelvic inflammatory disease (PID) of a single round of screening for Chlamydia trachomatis .1 By collecting specimens from all participants at baseline, Oakeshott and colleagues have provided the first data comparing the incidence of PID according to chlamydia infection status in women receiving immediate testing and treatment with those for whom testing and treatment were deferred by 12 months. The ethical decision to allow deferred testing is justified by the uncertainty about the incidence of PID in the community before the start of the trial, the low observed incidence in practice and the advice for all study participants about the availability of free chlamydia testing. The investigators randomised and followed 2529 women (mean age 20.9 years) and collected outcome data on 2377 (94%) from the women or their GPs. They obtained information from medical records of suspected PID cases and …

Masturbation is a common sexual practice in men, and saliva is often used as a lubricant during masturbation by men who have sex with men. However, the role of saliva use during masturbation in the transmission of chlamydia is still unclear. We developed population-level, susceptible-infected-susceptible compartmental models to explore the role of saliva use during masturbation on the transmission of chlamydia at multiple anatomical sites. In this study, we simulated both solo masturbation and mutual masturbation. Our baseline model did not include masturbation but included transmission routes (anal sex, oral-penile sex, rimming, kissing and sequential sexual practices) we have previously validated (model 1). We added masturbation to model 1 to develop the second model (model 2). We calibrated the model to five clinical datasets separately to assess the effects of masturbation on the prevalence of site-specific infection. The inclusion of masturbation (model 2) significantly worsened the ability of the models to replicate the prevalence of C. trachomatis. Using model 2 and the five data sets, we estimated that saliva use during masturbation was responsible for between 3.9% [95% confidence interval (CI) 2.0–6.8] and 6.2% (95% CI 3.8–10.5) of incident chlamydia cases at all sites. Our models suggest that saliva use during masturbation is unlikely to play a major role in chlamydia transmission between men, and even if it does have a role, about one in seven cases of urethral chlamydia might arise from masturbation.

Prior studies have demonstrated that both bacterial vaginosis (BV) and sexually transmitted infections (STIs) are strong independent risk factors for subsequent STI. In observational studies of this biological enhancement (BE) hypothesis, it is important to adjust for the risk of STI exposure so that the independent effect of BE can be assessed. We sought to model if two markers of local sexual network (partner concurrency and cumulative number of STIs) represented residual confounding in the models of risk for subsequent infection in a study that screened 3620 women for STIs every 3 months for a year. Mixed-effects logistic regression was used to calculate the odds ratios for an incident diagnosis ofChlamydia trachomatis,Neisseria gonorrhoeae,Trichomonas vaginalisand BV following a diagnosis of any of these four at the prior visit, controlling for the cumulative number of STIs and partner concurrency variables. We found that partner concurrency and cumulative number of STIs were each associated with incident infection, and in general, controlling for these variables reduced the strength of the association between prior and incident infections. We conclude that the frequently found association between prior and incident STIs is associated with both BE and sexual network structure.

Background: Public health reporting is the cornerstone of public health practices that inform prevention and control strategies. There is a need to leverage advances made in the past to implement an architecture that facilitates the timely and complete public health reporting of relevant case-related information that has previously not easily been available to the public health community. Electronic laboratory reporting (ELR) is a reliable method for reporting cases to public health authorities but contains very limited data. In an earlier pilot study, we designed the Public Health Automated Case Event Reporting (PACER) platform, which leverages existing ELR infrastructure as the trigger for creating an electronic case report. PACER is a FHIR (Fast Health Interoperability Resources)-based system that queries the electronic health record from where the laboratory test was requested to extract expanded additional information about a case. Objective: This study aims to analyze the pilot implementation of a modified PACER system for electronic case reporting and describe how this FHIR-based, open-source, and interoperable system allows health systems to conduct public health reporting while maintaining the appropriate governance of the clinical data. Methods: ELR to a simulated public health department was used as the trigger for a FHIR-based query. Predetermined queries were translated into Clinical Quality Language logics. Within the PACER environment, these Clinical Quality Language logical statements were managed and evaluated against the providers’ FHIR servers. These predetermined logics were filtered, and only data relevant to that episode of the condition were extracted and sent to simulated public health agencies as an electronic case report. Design and testing were conducted at the Georgia Tech Research Institute, and the pilot was deployed at the Medical University of South Carolina. We evaluated this architecture by examining the completeness of additional information in the electronic case report, such as patient demographics, medications, symptoms, and diagnoses. This additional information is crucial for understanding disease epidemiology, but existing electronic case reporting and ELR architectures do not report them. Therefore, we used the completeness of these data fields as the metrics for enriching electronic case reports. Results: During the 8-week study period, we identified 117 positive test results for chlamydia. PACER successfully created an electronic case report for all 117 patients. PACER extracted demographics, medications, symptoms, and diagnoses from 99.1% (116/117), 72.6% (85/117), 70.9% (83/117), and 65% (76/117) of the cases, respectively. Conclusions: PACER deployed in conjunction with electronic laboratory reports can enhance public health case reporting with additional relevant data. The architecture is modular in design, thereby allowing it to be used for any reportable condition, including evolving outbreaks. PACER allows for the creation of an enhanced and more complete case report that contains relevant case information that helps us to better understand the epidemiology of a disease. Trial Registration

Chlamydia spp. are a group of obligate intracellular pathogens causing a number of diseases in animals and humans. Avian chlamydiosis (AC), caused by Chlamydia psittaci (C. psittaci) as well as new emerging C. avium, C. gallinacea and C. ibidis, have been described in nearly 500 avian species worldwidely. The Crested Ibis (Nipponia nippon) is a world endangered avian species with limited population and vulnerable for various infections. To get a better understanding of the prevalence of Chlamydia spp. in the endangered Crested Ibis, faecal samples were collected and analysed. The results confirmed that 20.20% (20/99) of the faecal samples were positive for Chlamydiaceae and were identified as C. ibidis with co-existence of C. psittaci in one of the 20 positive samples. In addition, ompA sequence of C. psittaci obtained in this study was classified into the provisional genotype Matt116, while that of C. ibidis showed high genetic diversity, sharing only 77% identity with C. ibidis reference strain 10-1398/6. We report for the first time the presence of C. ibidis and C. psittaci in the Crested Ibis, which may indicate a potential threat to the endangered birds and should be aware of the future protection practice.

SUMMARYIdentification of priority populations such as men who have sex with men (MSM) is important in surveillance systems to monitor trends of sexually transmitted infections (STIs). We explored using routinely collected non-behavioural data as a means to establish MSM status in surveillance by assessing anorectal swab as a marker of male-to-male sexual exposure. We used chlamydia testing data from a sexual health clinic, 2007–2012. Men reporting any male sexual partner(s) in the previous 12 months were considered MSM. The dataset was split into development and validation samples to develop a univariate predictive model and assess the model fit. The dataset included 30 358 individual men and 48 554 episodes of STI testing; 45% were among reported MSM and an anorectal swab was performed in 40% of testing episodes. Anorectal swabbing had good diagnostic performance as a marker for MSM status (sensitivity = 87%, specificity = 99%, positive predictive value = 98·6%, negative predictive value = 90·3%). The model showed good fit against the internal validation sample (area under the curve = 0·93). Anorectal swabs are a valid marker of MSM behaviour in surveillance data from sexual health clinics, and they are likely to be particularly useful for monitoring STI trends among MSM with higher risk behaviour.

SUMMARYRepeat rectal chlamydia infection is common in men who have sex with men (MSM) following treatment with 1 g azithromycin. This study describes the association between organism load and repeat rectal chlamydia infection, genovar distribution, and efficacy of azithromycin in asymptomatic MSM. Stored rectal chlamydia-positive samples from MSM were analysed for organism load and genotyped to assist differentiation between reinfection and treatment failure. Included men had follow-up tests within 100 days of index infection. Lymphogranuloma venereum and proctitis diagnosed symptomatically were excluded. Factors associated with repeat infection, treatment failure and reinfection were investigated. In total, 227 MSM were included – 64 with repeat infections [28·2%, 95% confidence interval (CI) 22·4–34·5]. Repeat positivity was associated with increased pre-treatment organism load [odds ratio (OR) 1·7, 95% CI 1·4–2·2]. Of 64 repeat infections, 29 (12·8%, 95% CI 8·7–17·8) were treatment failures and 35 (15·4%, 95% CI 11·0–20·8) were reinfections, 11 (17·2%, 95% CI 8·9–28·7) of which were definite reinfections. Treatment failure and reinfection were both associated with increased load (OR 2·0, 95% CI 1·4–2·7 and 1·6, 95% CI 1·2–2·2, respectively). The most prevalent genovars were G, D and J. Treatment efficacy for 1 g azithromycin was 83·6% (95% CI 77·2–88·8). Repeat positivity was associated with high pre-treatment organism load. Randomized controlled trials are urgently needed to evaluate azithromycin's efficacy and whether extended doses can overcome rectal infections with high organism load.

SUMMARYChlamydiae are frequently encountered intracellular Gram-negative bacteria. In pigs, these bacteria in combination with other pathogens contribute to the induction of a multi-aetiological syndrome. One of the major characteristics of Chlamydia spp. is their ability to cause prolonged, often subclinical infections. While the economic consequences of Chlamydia spp. infections in pig farms are not fully established, we know that reproductive disorders and other syndromes correlated with Chlamydia infection can lead to financial loss as a result of a reduction in pork production. Additionally, Chlamydia spp. presents a potential zoonotic hazard, therefore determining the prevalence of Chlamydia in pig populations is critical. In the present study 97 pig herds from Poland were involved. To determine the prevalence of Chlamydia PCR and CFT tests were used. In total 797 vaginal samples, 797 conjunctival samples, and 235 serum samples were collected and tested. The study took place from 2011 to 2014. We found Chlamydia spp. present in 71·2% of all tested farms. The percentage of animals testing positive on any given farm varied from 20% to 100%.

SUMMARYSeveral infections have been linked to telomere shortening and in some cases these associations have varied by sex. We assessed the association between seropositivity to four persistent pathogens (cytomegalovirus (CMV), herpes simplex virus-1,Helicobacter pylori,Chlamydia pneumoniae), and total pathogen burden on leukocyte telomere length in a diverse US sample. Data came from the Multi-Ethnic Study of Atherosclerosis, a population-based cohort study. We utilized cross-sectional survey data, and biological samples from participants tested for pathogens and telomere length (N= 163). Linear regression was used to examine the association between seropositivity for individual pathogens as well as total pathogen burden and telomere length, adjusting for various confounders. CMV seropositivity and increased total pathogen burden level were significantly associated with shorter telomere length among females (β= −0·1204 (standard error (s.e.) 0·06),P= 0·044) and (β= −0·1057 (s.e.= 0·05),P= 0·033), respectively. There was no statistically significant association among males. Our findings suggest that prevention or treatment of persistent pathogens, in particular CMV, may play an important role in reducing telomere shortening over the life course among women. Future research is needed to confirm these novel findings in larger longitudinal samples.

SUMMARYIn England, dual tests detecting chlamydia and gonorrhoea are used in specialist and community-based sexual health services (SHSs). Test performance is poor when prevalence is low, therefore UK national guidelines recommend against opportunistic gonorrhoea screening unless there is a clear local public health need. While surveillance data on gonorrhoea prevalence is comprehensive in specialist SHSs, it is sparse in community SHSs. We aimed to estimate gonorrhoea prevalence in heterosexual men and women aged 15–24 attending community SHSs to inform testing care pathways. We used linear and quadratic regression to model the relationship between prevalence in community and specialist SHSs in local authorities (LAs) with available surveillance data. We applied best-fitting models to predict prevalence in community SHSs in remaining LAs. Data from community SHSs were available for 102/326 LAs. There was a weak positive association between gonorrhoea prevalence in community and specialist SHSs in corresponding LAs within (R2 = 0·13, P = 0·058) and outside (R2 = 0·07, P = 0·02) London. Applying best-fitting models, we estimated a median gonorrhoea prevalence of 0·5% (mean 0·6%; range 0·2%–2·7%) in heterosexuals attending community SHSs. Despite some unexplained variation, our analyses suggest gonorrhoea prevalence in young heterosexuals attending community SHSs is below 1% in most English LAs. Our findings re-inforce the current national guidelines that recommend care pathways for gonorrhoea testing in community SHSs include confirmatory testing to reduce the risk of misdiagnosis and inappropriate management.

SUMMARYParrots are one of the most popular pet birds in China, and can harbour Chlamydia which has significance for human and animal health. We investigated, by indirect haemagglutination assay, the seroprevalence of Chlamydia infection in four species of parrots, namely budgerigars (Melopsittacus undulatus), lovebirds (Agapornis sp.), cockatiels (Nymphicus hollandicus) and Alexandrine parakeets (Psittacula eupatria) that were collected from Weifang and Beijing cities, North China and explored the association between potential risk factors and chlamydial seropositivity. We further determined the genotype of Chlamydia in 21 fresh faecal samples based on the ompA sequence by reconstruction of phylogenetic relationships. Of the 311 parrots examined, 35·37% (95% confidence interval 30·06–40·68) were seropositive, and species, gender, age, season and geographical location were identified as risk factors. Two PCR-positive samples represented Chlamydia psittaci genotype A. The occurrence of C. psittaci genotype A in the droppings of two pet parrots in China suggests potential environmental contamination with Chlamydiaceae and may raise a public health concern.

SUMMARYInformation on the incidence of Chlamydia trachomatis (CT) is essential for models of the effectiveness and cost-effectiveness of screening programmes. We developed two independent estimates of CT incidence in women in England: one based on an incidence study, with estimates ‘recalibrated’ to the general population using data on setting-specific relative risks, and allowing for clearance and re-infection during follow-up; the second based on UK prevalence data, and information on the duration of CT infection. The consistency of independent sources of data on incidence, prevalence and duration, validates estimates of these parameters. Pooled estimates of the annual incidence rate in women aged 16–24 and 16–44 years for 2001–2005 using all these data were 0·05 [95% credible interval (CrI) 0·035–0·071] and 0·021 (95% CrI 0·015–0·028), respectively. Although, the estimates apply to England, similar methods could be used in other countries. The methods could be extended to dynamic models to synthesize, and assess the consistency of data on contact and transmission rates.

SUMMARYNational health statistics report a 2·5-fold increase in laboratory-confirmed Chlamydia trachomatis (CT) cases over the last decade in Switzerland where no CT screening programme exists. We obtained essential denominator information to describe the epidemiology of CT in the canton of Basel-Stadt, an urban canton in north-western Switzerland. Laboratories reporting at least two CT infections from Basel-Stadt residents to the SFOPH in 2010 provided demographic and test-related data. CT positivity rates were calculated for 2002–2010. The influences of test year, age, sex and laboratory on CT positivity were investigated in a multivariable model. Positivity differed between sexes and age groups. In our sample of 32 034 records, female and male CT positivity rates were 4·7% and 11·1%, respectively. Test year was significantly associated with test outcome in the multivariable analysis but no time trend was observed. CT positivity did not change over the past 9 years in Basel-Stadt. In contrast to other European countries without CT screening, we found no evidence that the observed increase of Chlamydia cases in the national notification system represents an epidemiological trend, but rather results from an increased testing frequency.

Chlamydia pneumoniae, Mycoplasma pneumoniae, and Legionella spp. are common causes of atypical pneumonia; however, data about these atypical pathogens are limited in the refugee setting. Paired nasopharyngeal and oropharyngeal specimens were collected from patients with respiratory illness presenting to healthcare centers in two refugee camps in Kenya. The specimens were tested for C. pneumoniae, M. pneumoniae, and Legionella spp. as well as eight respiratory viruses. Atypical pathogens were detected in 5.5% of the specimens of which 54% were co-infected with at least one of the eight viruses tested. Patients positive for atypical bacteria co-infected with virus were significantly more likely to have severe acute respiratory illness than patients infected with only atypical bacteria (P = 0.04). While the percentage of atypical pathogens identified was lower than expected, we found a significant relationship between atypical bacterial-viral co-infection and severity of disease in this refugee population.

SUMMARYThis study examined the prevalence of HIV and other sexually transmitted infections (STIs) in pregnant women in Kinshasa, the Democratic Republic of the Congo (DRC). Between April and July 2004, antenatal attendees at two of the largest maternity clinics in Kinshasa were tested to identify HIV status, syphilis, Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). HIV seroprevalence was 1·9% in 2082 women. With PCR techniques, CT and NG infections were also uncommon in the first 529 women (1·7% and 0·4%, respectively). No active syphilis infection case was identified by Treponema pallidum haemagglutination assay (TPHA) and rapid plasma reagin test (RPR). A woman's risk of HIV infection was significantly associated with her reporting a male partner having had other female sexual partners (OR 2·7, 95% CI 1·2–6·2). The continuing low seroprevalence of HIV in pregnant women from Kinshasa was confirmed. Understanding factors associated with this phenomenon could help prevent a future HIV epidemic in low HIV transmission areas in Africa.

SUMMARYIn 2009, we examined HIV and sexually transmitted infections (STIs) in 750 female sex workers (FSWs) in Shanghai using a cross-sectional survey. Participants (mean age 27 years) were interviewed and tested for HIV and selected STIs. Prevalence was: HIV 0·13%, chlamydia 14·7%, gonorrhoea 3·5% and syphilis 1·3%. In a demographic multivariate model, younger age, higher income and originating from provinces other than Zhejiang and Shanghai were independently associated with STI. In a social and sexual behavioural model, women working in small venues with fewer clients per week, use of drugs, and higher price charged per sex act indicated a greater risk for STI. Although HIV appears rare in Shanghai FSWs, chlamydial infection is common, especially in women aged

SUMMARYWe used data from the Genitourinary Medicine Clinic Activity Dataset (GUMCAD) over a 3-year period (2009–2011) to investigate the distribution and risk factors ofTrichomonas vaginalisinfection in England. Socio-demographic and clinical risk factors associated with a diagnosis ofT. vaginaliswere explored using multivariable logistic regression. Rates ofT. vaginalisinfection were highest in London and the West Midlands. For men and women,T. vaginalisinfection was significantly associated with: older age compared to those aged 20–24 years, non-white ethnicity (in particular black Caribbean and black ‘other’ ethnic groups), and birth in the Caribbeanvs. birth in the UK. Current gonorrhoea or chlamydia infection was associated with a diagnosis ofT. vaginalisin women. Further research is required to assess the public health impact and cost-effectiveness of introducing targeted screening for women at high risk of infection in areas of higher prevalence.

Background. Yukon, a territory in northern Canada, has one of the highest reported sexually transmitted chlamydia infection rates in the country. Objective. We examined screening practices among physicians and community nurses to elucidate factors that may be contributing to the high rates. Design. Cross-sectional survey. Methods. A questionnaire was distributed to all physicians in Yukon and all community nurses in Yukon’s communities. We surveyed sexual health assessment frequency, chlamydia testing frequency and barriers to screening. Comparison of physician testing practices was performed to another Canadian jurisdiction, which previously undertook a similar survey. Survey results were compared to the available laboratory data in Yukon. Results. Eligible physicians and nurses, 79% and 77%, respectively, participated in the survey. Physicians tested 15 to 24-year-old females more frequently than 15 to 24-year-old males for chlamydia (p0.007). Physicians who asked sexual health assessment questions were more likely to test for chlamydia in both females (pB0.001) and males (p0.032). More physicians screened females based on risk factors compared to males. General practice physicians in Yukon were more likely to test females for chlamydia than general practice physicians in Toronto, Canada (pB0.001). Community nurses had different testing patterns than physicians, with a lower overall frequency of testing, equal frequency of testing males and females, and in applying risk factor-based screening to both males and females. Barriers to screening included testing causing patient discomfort, patients reluctant to discuss screening, health provider uncomfortable conducting sexually transmitted infection tests and sexual health assessments, among others. Laboratory data in Yukon appear to confirm provider screening patterns. Conclusions. This survey provides valuable information on health provider screening patterns. We have some evidence which suggests that chlamydia testing rates may be higher among patients seen by physicians in Yukon in comparison to another Canadian jurisdiction. However, more consistent application of optimal screening methods with support to ‘‘start the conversation’’ around sexual health may assist in overcoming barriers to screening and in addressing Yukon’s high rate of chlamydia. Keywords: chlamydia; Yukon Territory; Canada; sexually transmitted diseases; screening; physicians; general practitioners; public health nursing; adolescent (Published: 5 August 2013) This paper is part of Supplement 1, 2013, ICCH15 Proceedings . More papers from this Supplement can be found here . Citation: Int J Circumpolar Health 2013, 72 : 21607 - http://dx.doi.org/10.3402/ijch.v72i0.21607

Introduction Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs. Methods Data for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS. Results Ever having anal sex was reported by 11.9% FSWs (95% CI: 11.3%–12.6%). Typology (AOR 2.20, 95% CI 1.64–2.95) and literacy (AOR 1.28, 95% CI 1.10–1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44–1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47–2.15), alcohol consumption (AOR 1.21, 95% CI 1.03–1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28–1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25–1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13–1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS. Conclusion Practice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed.

Background Sydney Sexual Health Centre (SSHC) partnered with a large sex-on-premises venue, South Eastern Sydney Local Health District HIV and Related Programs Unit and AIDS Council of NSW (ACON) to develop and implement a community-based sexually transmissible infection (STI) screening model co-located in a sex-on-premises venue. This paper describes the process, the outcomes and examines the cost of this model. Methods: A retrospective cross-sectional study of gay and bisexual men (GBM) attending a STI testing service co-located in a sex-on-premises venue in Sydney city between the 1 November 2012 and 31 May 2014. Results: A total of 402 patrons had 499 testing episodes in the study period. Testing patrons were a median of 39.5 years of age, 221 (55%) were born overseas, 85 (21%) spoke a language other than English at home and 54 (13%) had a STI at first testing. A total of 105 (26%) testing patrons had never tested for a STI before. Of the 297 (74%) who had been tested before, 83 (21%) had not been tested within the last 12 months. A total of 77 STIs were detected in 63 people over 499 testing episodes, giving a STI positivity rate of 15% in the testing episodes. The prevalence of rectal chlamydia was the highest at 8% followed by pharyngeal gonorrhoea at 3%. A total of 97% of testing patrons were successfully relayed their results via their preferred methods within a median of 7.5 days. Conclusion: This paper highlights that offering STI screening in a community-based setting was an effective and low-cost alternative to traditional testing services.

The present communication highlights aspects on the aetiology, diagnosis and therapy of sexually transmitted infections (STIs) and some allied infections in which sexual transmission is regarded as possible. The aetiology of many genital infections is still unknown or rather, an aetiological relationship between a given agent and a clinical manifestation is in some infections still debated. The paper will discuss some shortcomings in the current surveillance systems for STIs, if these systems exist at all. Thus, the paper considers their value in estimating the extent of the problem on a general population basis. It also focuses on the discrepancy between the current high prevalence of diagnosed cases of some STIs, such as of genital chlamydia infections, and the relatively low number of complications and sequelae presently seen, in contrast to the comparatively high prevalence more commonly reported in the past. Recent discoveries of novel aetiological agents of STIs, including mycoplasmas, may explain a lack of recovery from infections, due to the common use of antibiotic drugs to which these agents have a natural resistance. The observation of a synergistic effect of a commonly used anti-inflammatory drug, which may overcome antifungal resistance in vulvovaginal candidiasis, will also be reviewed. Furthermore, other reflections concern some of the classic STIs, e.g. lymphogranuloma verenerium, syphilis, gonorrhoea, herpes and condyloma.

Abortive infections are a major health challenge affecting productive and reproductive performance of sheep and goats. However, there is no comprehensive summary on the occurrence and distribution of these infections in Algeria. This systematic review provides a comprehensive summary on the prevalence of different abortive diseases and assesses potential risk factors in small ruminants in Algeria. Five databases were used to search epidemiological data on the prevalence of different abortive diseases (bacterial, parasitic, and viral). Data were collected from 25 papers published between 2003 and 2020. The total mean sample size was 53,080 small ruminants. The majority of the diseases/infections were diagnosed by serological and molecular tests. The overall prevalence of brucellosis was 0.39% in sheep and 5.31% in goats. Chlamydia and Q fever were observed in 32.72% and 20.62% of small ruminants, respectively. The prevalence of peste des petits ruminants was 15.76% and the overall prevalence of bluetongue in sheep and goats was, respectively, 13.41% and 44.50%. Border disease and bovine viral diarrhea were detected in 22.68% and 1.01% of sheep examined, respectively. Toxoplasma gondii infection prevalence among sheep and goats was 21.43% and 32.31% respectively. This study is a comprehensive epidemiological analysis of abortion diseases in small ruminants in Algeria and will therefore be a useful tool for researchers. Larger and more robust prevalence studies are needed to adequately support risk assessment and management of animal and public health threats.

Trachoma is one of the most widespread blinding eye diseases, which is harmful to human visual health. The efforts to prevent and control trachoma in China can be divided into three periods, i.e., highly epidemic period, research on pathogenesis and control of trachoma, and blinding trachoma elimination and epidemiological evaluation. In 1956, Prof. Feifan Tang and Xiaolou Zhang first discovered and isolated Chlamydia trachomatis, which clarified the cause of trachoma, and kick-started a fresh chapter in trachoma research, prevention, and control around the world. Although, the prevalence of trachoma differed in different areas, the average prevalence once exceeded 50% and was as high as 90% in some areas before and at early liberation of China. Therefore, the government-led efforts were made to comprehensively prevent and control trachoma, including development of National Plan for the Prevention and Control of Trachoma, nationwide screening and treatment of trachoma, implementation of National Patriotic Health Campaign and improvement of water supply and lavatories. After decades of effort, China reached the goal of eliminating blinding trachoma in 2015. China has gained remarkable achievements in the prevention and treatment of trachoma, making outstanding contributions toward the goal of eliminating trachoma worldwide. The research, prevention, and control of trachoma in China were reviewed in this paper.

Background Infection with genital Chlamydia trachomatis (Ct) is the most common notifiable sexually transmitted infection (STI) in Sweden. A mutated Chlamydia, nvCT, has contributed to the increase. The occurrence of repeat infections is not investigated in Sweden. The current paper presents the study protocol for the first Swedish clinical investigation of repeat Chlamydial infection. The concern of the study is whether a Chlamydia infection at inclusion indicates an increased risk for Chlamydia at follow-up after 6–8 months, gender-specific risk factors for and clinical presentation of repeat infections. Methods and design Sesam City is a drop-in clinic in the city centre of Stockholm. Patients 20 years and older are admitted. During 2007, the clinic had 15 000 visits, 60% made by men. In December 2007, a cohort study began, and data collection was finished in April 2009. A total of 2813 study participants aged 20–39 years were recruited. Data collection included an anonymous self-administered paper-and-pen questionnaire on sexual behaviour, reproductive health and history of Chlamydia, and condom use. Chlamydia tests were performed by self-sampled specimens, analyzed by the ProbeTec (Becton Dickinson) method, Ct-positive specimens also analyzed with a nvCT-specific method. Data from medical records were summarized in clinical report forms. Patients positive for Chlamydia were retested 4 weeks after treatment. Contact tracing covered sexual contacts during the last 12 months. At follow-up 6–8 months after inclusion, Chlamydia tests were performed, and a new questionnaire and CRF completed. Discussion A STI-clinic-based prospective cohort study allowed us to survey 2813 adult patients. The collected data will provide gender-specific information on the occurrence of and risk for repeat Chlamydia infection, the occurrence of nvCT, and clinical data and information on sexual behaviour and reproductive health, risk-taking and condom use.

OBJECTIVES: To 1) create a space where men who have sex with men (MSM) feel comfortable accessing sexually transmitted infection/human immunodeficiency virus (STI/HIV) testing, and 2) reduce STI/HIV incidence. PARTICIPANTS: Gay men in Ottawa and its surrounding regions. SETTING: A preponderance of diagnoses of sexually transmitted infections and HIV continue to occur among MSM. Meanwhile, other literature identifies that many MSM are reluctant to access STI/HIV testing services or to disclose their sexual practices to primary care practitioners. INTERVENTION: In Ottawa, in an effort to surmount these issues and decrease STI/HIV incidence among MSM, the local public health unit in collaboration with community partners created “GayZone”, a three-hour-per-week STI/HIV testing and STI treatment clinic for gay men. In this paper, we report on the uptake and STI/HIV diagnosis outcomes for this clinic from January 2010 through December 2013. OUTCOMES: GayZone is a well-utilized clinic that yields a number of STI/HIV diagnoses per year. Overall, the positivity rates of the STI/HIV tests at this clinic are above-average, although lower than what might be expected by local epidemiological data. While the results of this clinic validate anonymous HIV testing, they bring into question the utility of pharyngeal swabs to test for gonorrhea and chlamydia. CONCLUSION: The results of our study demonstrate the utility of a gay men’s STI/HIV testing clinic and highlight some areas for improvement. Public health practitioners, frontline clinicians, and community workers in other regions who wish to implement such an STI/HIV clinic would do well to consider our results beforehand.

To compare three methods of data collection on case ascertainment of past chlamydia or gonorrhea diagnoses.Data collection for 361 adolescent females between 1998 and 2000 included: 1) face-to-face interviews; 2) computerized and paper medical record reviews; and 3) chlamydia and gonorrhea reports to the state health department. Statistical methods include latent class and composite reference standard analyses.The estimated prevalence of past diagnoses did not differ significantly by data collection method for chlamydia (20.5%, 23.0%, and 19.7% by self-report, medical record reviews, and state health department reports, respectively) or gonorrhea (4.7%, 6.9%, and 5.5%, respectively) during the 2-year study period. The estimated latent class and composite reference standard prevalences for chlamydia were 23.5% and 26.9%, respectively (p=.04 and p.01 for differences from self-report alone, respectively). For gonorrhea, the estimated latent class and composite reference standard prevalences were 7.8% and 6.9%, respectively (p.01 for both differences from self-report alone). Kappa scores for self-report compared with the latent class and composite reference standard prevalences ranged from .67 to .80, and the magnitude of under-reporting ranged from 21% to 47%.The similar case ascertainment from the three sources separately and high reliability of self-report, coupled with its feasibility and low cost, suggest that self-report is a viable data collection method for STD diagnoses. However, using multiple sources may be preferable when time and resources permit given that under-reporting by self-report is likely to occur (particularly for gonorrhea) and that greater case ascertainment can be achieved.

Over the past three decades, research focus on the development and evaluation of behavioural interventions aimed at reducing the spread of sexually transmitted infections (STIs) including HIV has expanded considerably. Individual, couple and group level interventions aimed at improving condom use, HIV testing, linkage to care and retention, medication adherence, partner counselling and referral services, and decreasing number of partners have been developed and evaluated for many subpopulations.1–5 The interventions have been evaluated among African–Americans, Asian and Pacific Islanders, drug users, heterosexual adults, high-risk youth, Hispanic populations, men who have sex with men, people living with HIV, STI clinic patients, and transgender populations. However, despite their availability, behavioural interventions are inadequately utilised, and evidence of their population level impact is lacking. In this paper we discuss issues related to the utility of behavioural interventions, including questions around feasibility of implementation, scale-up and maintenance, and suggest new directions for planning, implementation, evaluation and continuous improvement of social and behavioural interventions in the context of STI and HIV prevention programmes. Most evidence on the efficacy of behavioural interventions is based on self-reported behaviour, and change in self-reported behaviour, as outcome. Assessment and reporting of sexual behaviour is subject to ascertainment and reporting bias.6 Such bias is particularly important in the context of behavioural intervention trials, because the intervention directly manipulates the desirability of certain reported behaviours, and subjects cannot be effectively blinded to the intervention. For behavioural intervention trials, STI and HIV incidence are the outcome measures of greatest interest. Unfortunately, trials that use STI and HIV incidence as outcome measure have not shown high levels of efficacy. Of the seven randomised controlled trials of behavioural interventions that measured HIV incidence as outcome, none were found to be efficacious.7 Of …

Background Chlamydia infection is the most common notifiable sexually transmitted infection (STI) in Australia and mostly affects young people (15 – 25 years). This paper presents baseline data from a randomised controlled trial that aimed to increase chlamydia testing among sexually active young people. The objectives were to identify associations between sexual behaviour, substance use and STI history and explore attitudes to chlamydia testing. Methods This study was conducted in cyberspace. Study recruitment, allocation, delivery of interventions and baseline and follow up data collection all took place online. Participants were 16 – 25 years old and resided in Australia. Substance use correlates of sexual activity; predictors of history of STIs; barriers to and facilitators of chlamydia testing were analysed. Results Of 856 participants (79.1% female), 704 had experienced penetrative intercourse. Sexually active participants were more likely to smoke regularly or daily, to drink alcohol, or to have binge drunk or used marijuana or other illicit substances recently. Risk factors for having a history of any STI were 3 or more sexual partners ever, 6 or more partners in the past 12 months, condom non-use and being 20 years or older. Almost all sexually active participants said that they would have a chlamydia test if their doctor recommended it. Conclusions Sexually active young people are at risk of STIs and may engage in substance use risk behaviours. Where one health risk behaviour is identified, it is important to seek information about others. Chlamydia testing can be facilitated by doctors and nurses recommending it. Primary care providers have a useful role in chlamydia control. Trial Registration Australian and New Zealand Trials Registry ACTRN12607000582459

Background In many countries, low Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) screening rates among young people in primary-care have encouraged screening programs outside of clinics. Nucleic acid amplification tests (NAATs) make it possible to screen people in homes with self-collected specimens. We systematically reviewed the strategies and outcomes of home-based CT/NG screening programs. Methods Electronic databases were searched for home-based CT and/or NG screening studies published since January 2005. Screening information (e.g. target group, recruitment and specimen-collection method) and quantitative outcomes (e.g. number of participants, tests and positivity) were extracted. The screening programs were classified into seven groups on the basis of strategies used. Results We found 29 eligible papers describing 32 home-based screening programs. In seven outreach programs, people were approached in their homes: a median of 97% participants provided specimens and 76% were tested overall (13717 tests). In seven programs, people were invited to receive postal test-kits (PTKs) at their homes: a median of 37% accepted PTKs, 79% returned specimens and 19% were tested (46225 tests). PTKs were sent along with invitation letters in five programs: a median of 33% returned specimens and 29% of those invited were tested (15126 tests). PTKs were requested through the internet or phone without invitations in four programs and a median of 32% returned specimens (2666 tests). Four programs involved study personnel directly inviting people to receive PTKs: a median of 46% accepted PTKs, 21% returned specimens and 9.1% were tested (341 tests). PTKs were picked-up from designated locations in three programs: a total of 6765 kits were picked-up and 1167 (17%) specimens were returned for screening. Two programs used a combination of above strategies (2395 tests) but the outcomes were not reported separately. The overall median CT positivity was 3.6% (inter-quartile range: 1.7-7.3%). Conclusions A variety of strategies have been used in home-based CT/NG screening programs. The screening strategies and their feasibility in the local context need to be carefully considered to maximize the effectiveness of home-based screening programs.

There are four major quantities that are measured in sexual behavior surveys that are thought to be especially relevant for the performance of sexual network models in terms of disease transmission. These are (i) the cumulative distribution of lifetime number of partners, (ii) the distribution of partnership durations, (iii) the distribution of gap lengths between partnerships, and (iv) the number of recent partners. Fitting a network model to these quantities as measured in sexual behavior surveys is expected to result in a good description of Chlamydia trachomatis transmission in terms of the heterogeneity of the distribution of infection in the population. Here we present a simulation model of a sexual contact network, in which we explored the role of behavioral heterogeneity of simulated individuals on the ability of the model to reproduce population-level sexual survey data from the Netherlands and UK. We find that a high level of heterogeneity in the ability of individuals to acquire and maintain (additional) partners strongly facilitates the ability of the model to accurately simulate the powerlaw-like distribution of the lifetime number of partners, and the age at which these partnerships were accumulated, as surveyed in actual sexual contact networks. Other sexual network features, such as the gap length between partnerships and the partnership duration, could–at the current level of detail of sexual survey data against which they were compared–be accurately modeled by a constant value (for transitional concurrency) and by exponential distributions (for partnership duration). Furthermore, we observe that epidemiological measures on disease prevalence in survey data can be used as a powerful tool for building accurate sexual contact networks, as these measures provide information on the level of mixing between individuals of different levels of sexual activity in the population, a parameter that is hard to acquire through surveying individuals., Author Summary Although many diseases spread so easily between humans that someone could be infected by any of his or her daily social contacts, such is not the case for sexually transmitted diseases. Most of us have a very limited number of concurrently ongoing sexual partnerships, and thus the contact network over which sexually transmitted diseases spread tends to be very sparsely connected. The exact structure of these sexual networks plays an important role in how easy and fast sexually transmitted diseases spread through a population, and how effective various health care interventions will be. In this paper we use a simulation model to understand how the collective sexual behaviour of individuals relates to the summary measures of network structure (such as “lifetime number of partners”, and “duration of previous partnership”) that are typically used to build models of disease transmission over sexual networks. Based on our understanding of this relationship, we simulated sexual networks which have summary measures of network structure that are very similar to that of a real sexual network. Using these networks in disease transmission models will increase our ability to predict the effectiveness of health care interventions.

Efforts to reduce hospitalization or the length of stay are common topics in papers published last year. Chlamydia pneumoniae is now recognized worldwide as a common pathogen in community-acquired pneumonia. A great variation in the frequency of various pathogens is found in different countries, stressing the importance of ascertaining the aetiological and epidemiological situation in each respective country.

Objectives: Chlamydia trachomatis (Chlamydia) is the most prevalent sexually transmitted bacterial infection and can cause considerable reproductive morbidity in women. Chlamydia screening programmes have been considered but policy recommendations are hampered by the lack of population based data. This paper describes the prevalence of Chlamydia in 15–29 year old women and men in rural and urban areas, as determined through systematic population based screening organised by the Municipal Public Health Services (MHS), and discusses the implications of this screening strategy for routine implementation. Methods: Stratified national probability survey according to “area address density” (AAD). 21 000 randomly selected women and men in four regions, aged 15–29 years received a home sampling kit. Urine samples were returned by mail and tested by polymerase chain reaction (PCR). Treatment was via the general practitioner, STI clinic, or MHS clinic. Results: 41% (8383) responded by sending in urine and questionnaire. 11% (2227) returned a refusal card. Non-responders included both higher and lower risk categories. Chlamydia prevalence was significantly lower in rural areas (0.6%, 95% CI 0.1 to 1.1) compared with very highly urbanised areas (3.2%, 95% CI 2.4 to 4.0). Overall prevalence was 2.0% (95% CI 1.7 to 2.3): 2.5% (95% CI 2.0 to 3.0%) in women and 1.5% (95% CI 1.1 to 1.8) in men. Of all cases 91% were treated. Infection was associated with degree of urbanisation, ethnicity, number of sex partners, and symptoms. Conclusion: This large, population based study found very low prevalence in rural populations, suggesting that nationwide systematic screening is not indicated in the Netherlands and that targeted approaches are a better option. Further analysis of risk profiles will contribute to determine how selective screening can be done.

Sexual health in the United Kingdom has deteriorated in recent years with further increases in HIV and other sexually transmitted infections (STIs) reported in 2002. This paper describes results from the available surveillance data in the United Kingdom from the Health Protection Agency and its national collaborators. The data sources range from voluntary reports of HIV/AIDS from clinicians, CD4 cell count monitoring, a national census of individuals living with HIV, and the Unlinked Anonymous Programme, to statutory reports of STIs from genitourinary medicine (GUM) clinics and enhanced STI surveillance systems. In 2002, an estimated 49 500 adults aged over 15 years were living with HIV in the United Kingdom, of whom 31% were unaware of their infection. Diagnoses of new HIV infections have doubled from 1997 to 2002, mainly driven by heterosexuals who acquired their infection abroad. HIV transmission also continues within the United Kingdom, particularly among homo/bisexual men who, in 2002, accounted for 80% of all newly diagnosed HIV infections acquired in the United Kingdom. New diagnoses of syphilis have increased eightfold, and diagnoses of chlamydia and gonorrhoea have doubled from 1997 to 2002 overall; STI rates disproportionately affect homo/bisexual men and young people. Effective surveillance is essential in the provision of timely information on the changing epidemiology of HIV and other STIs; this information is necessary for the targeting of prevention efforts and through providing baseline information against which progress towards targets can be monitored.

Background With traditional specialist sexual-health services overstretched, community pharmacies have been deployed to provide chlamydia testing. We have undertaken a systematic-review to estimate prevalence of chlamydia infection among those screened for chlamydia in community pharmacies. We also reviewed the feasibility/acceptability of this service. Methods Systematic searches were conducted in electronic databases and grey literature was solicited from experts. Data were extracted on study population, sample size and prevalence of chlamydia to report pooled proportion of chlamydia infection using random effect model. Results 8 papers and reports which contributed to the final model. The proportional meta-analysis showed a pooled proportion positive for chlamydia of 7.7% (95% CI 5.2% to 10.6%). All the studies were reported on Conclusion The reported prevalence of chlamydia infection in pharmacy setting is similar to estimates from general practice thus giving wider choice of care to young people. This new approach is acceptable to both young people and pharmacists. Encouraging men and ethnic minorities to access community pharmacy based chlamydia services remains a challenge.

With the Global Elimination of Trachoma by 2020 program underway, it has become increasingly important to identify the prevalence of ocular chlamydia infection in communities. DNA amplification tests are the gold standard, but are prohibitively expensive. In the present paper, we investigate whether pooling multiple specimens into a single test is feasible. The conjunctivae of 170 children in western Nepal were examined and swabbed. The prevalence of chlamydial infection was estimated in two ways using the ligase chain reaction: by testing all 170 specimens individually, and by testing 34 pools of 5 specimens each. We show that the confidence interval for 34 pooled specimens approaches that of doing all 170 specimens as the prevalence decreases. We also determine the optimal number of specimens to pool into a single test to minimize the confidence interval of the estimate. If the population prevalence is expected to be around 10%, then 14 specimens should be pooled per test. Even at 50% prevalence, costs can be reduced by pooling two samples per test.

The association between infectious diseases and atherosclerosis is now well documented [1]. The evidence for involvement of Chlamydia pneumoniae in atherogenesis appears to be the strongest. Chlamydia pneumoniae infections have been recognized as an independent risk factor for coronary heart disease in a prospective nested case-control study within a cohort of symptom-free elderly men [2]. The number of reports studying the involvement of Chlamydia pneumoniae is rapidly rising. This paper summarizes epidemiological data and trends of most prevalent cardiovascular diseases and traditional risk factors in the Netherlands, epidemiological data of Chlamydia pneumoniae infections, and of respiratory tract infections as a new risk factor for cardiovascular disease. Combining all this information, we provide suggestions for future research to fill in the gaps in our knowledge of the relationship between Chlamydia pneumoniae infections and cardiovascular diseases.

The focus on chlamydia in this issue of STI is timely. A debate on the second day of the 17th International Society for STD Research and 10th International Union against STI meeting in Seattle on 30 July will address the topic “Epidemiology of chlamydial infection: are we losing ground?” The first “special issue” about sexually transmitted Chlamydia trachomatis in this journal, then called the British Journal of Venereal Diseases , was published in December 1972 when seven articles examined diagnostic and clinical aspects of a new sexually transmitted infection.1 Chlamydia is now the most commonly reported of all infections in countries like the USA and Sweden. The papers collected here address new aspects of C trachomatis but also articulate the growing uncertainties about our efforts to control this pathogen. Screening asymptomatic individuals seems to many people to be the obvious solution to prevent the transmission and adverse consequences of chlamydia,2 including preterm delivery and premature rupture of membranes in pregnant women. (see p 314)3 It is also a very expensive solution. (see p 267)4 The economic modelling and evaluation study by Adams et al shows that it is going to be difficult for the opportunistic strategy being implemented by the National Chlamydia Screening Programme in England to be cost effective. Proactive screening, using population registers to identify and invite people to be screened regularly, is usually assumed to be more expensive to run than opportunistic screening. Robinson et al 5 estimated the health service and patient costs of a postal chlamydia screening approach in England. (see p 276) The cost per invitation was actually similar to that of an organised opportunistic screening programme.6 We are learning the hard way that delivering chlamydia screening effectively and efficiently is easier than it sounds.7 If …