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This study examined over-reporting bias in self-reported condom use and assessed its association with syphilis. A survey was conducted among 1245 female sex workers (FSWs) in three cities in China. Respondent's over-reported condom use was defined as reporting no unprotected sex for the past 24 h but testing positive for prostate specific antigen. The proportion of prevalent syphilis and active syphilis was 23 and 10 % respectively among FSWs. The proportion of over-reported condom use with sex clients only was 27-45 % among the three study sites. The proportion of over-reported condom use with all sex partners (clients, husbands, or boyfriends) was 26-46 %. FSWs who had active or prevalent syphilis were more likely to over report condom use. Self-reported condom use may not be a valid tool to measure the efficacy of HIV/STI intervention because the bias is associated with the outcome measure, i.e., syphilis.

The objective of this study was to examine risk characteristics among bridge and nonbridge drug users. A cross-sectional study was conducted among drug users. Drug users who shared needles and engaged in sex with both high-risk partners and low-risk partners were defined as bridgers. A total of 312 drug users were recruited among whom 49.4% (154) were bridgers. Among bridgers 83.1% injected drugs and 35% shared needles in the past month. Eighty-seven percent (134) of bridgers had one or more commercial sex partners in the past year. Only 3.9% of the bridgers and 4.6% of nonbridgers consistently used condoms with regular sex partners. Fifty-eight percent of bridgers and 46.8% of nonbridgers tested positive for hepatitis C virus whereas 15.6% of bridgers and 7% of nonbridgers tested positive for syphilis. The pervasiveness of bridgers among drug users and their risky sexual behavior underscore their role in the spread of sexually transmitted diseases. (authors)

To the Editor: Neisseria meningitidis colonizes the nasopharynx of humans and can cross the epithelial barrier of the nasopharynx, causing septicemia, meningitis, or both (1,2). In Anhui Province, China, there has been a previously high risk for epidemic cerebrospinal meningitis. Before 2012, all meningococcal diseases were caused by N. meningitidis serogroups A, B, and C, and the unique sequence type (ST) 4821 clone of serogroup C was first identified in this region during 2003–2004 (3). No widespread epidemics of cerebrospinal meningitis and no N. meningitidis–associated deaths have occurred in Anhui since bivalent meningococcal vaccines against serogroups A and C were first used in 2003 (4). During 2011–2013, however, 15 infections caused by N. meningitidis serogroup W135 ST11, which belongs to a hyperinvasive lineage (5), were reported in Hefei, Anhui Province. Two of the cases (1 each in 2012 and 2013) were fatal and occurred in patients who denied having recently traveled, which suggests that the clone may have spread in an endemic fashion. The 2 patients also had no history of vaccination with tetravalent polysaccharide vaccine (serogroups A/C/Y/W). The other 13 cases occurred in close contacts of the patients who died. The fatal cases of serogroup W135 infection were in 14- and 17-year-old boys. One of the boys had dropped out of school and worked in a hotel. He sought medical care for a headache with sudden onset, vomiting, and high fever (temperature 40°C). The other boy was a junior college student. At hospital admission, he had vomiting, diarrhea, and high fever (temperature 39°C). According to the Chinese surveillance system, meningococcal disease is reported by local hospitals to the local Center for Disease Control and Prevention and then to the provincial Center for Disease Control and Prevention, where specific measures are taken to control and prevent the disease. Serogroup W135 infection in the 2 boys in Hefei was identified and reported by different hospitals. Both boys reported that they had not traveled outside Hefei in the 2 months before illness onset or had any contact with persons with meningococcal disease. A total of 61 close contacts were identified for the boys. Despite treatment, the 2 boys died of disseminated intravascular coagulation and multiple organ failure. Cerebrospinal fluid and blood specimens were cultured on chocolate agar for 24 h; results showed bacterial growth consistent with the features of Neisseria spp. Four isolates were identified as serogroup W135 by using specific antiserum (Remel, Lenexa, KS, USA). Throat swab specimens were collected from the 61 close contacts of the 2 boys; all contacts were asymptomatic. Gram staining and biochemical tests confirmed the presence of N. meningitidis in 13 of the 61 samples, and slide agglutination, using specific antiserum, showed that all 13 isolates from contacts were serogroup W135. Pulsed-field gel electrophoresis (PFGE) (6), multilocus sequence typing, outer membrane protein gene (porA) variant region subtyping, and antimicrobial drug susceptibility tests were used to characterize the 17 isolates. PFGE patterns (pulse types 1 and 2) for the isolates were indistinguishable and shared >96% similarity with the dominant patterns, including patterns for isolates from Guangdong, Guangxi, and Jiangsu Provinces, China (Figure). All isolates had the same multilocus ST (ST11) and PorA subtype (P1.5,2), which belong to the multilocus ST11/electrophoretic type 37 complex (7). Results of Kirby-Bauer testing showed that all 17 isolates were resistant to sulfamethoxazole and sensitive to penicillin, ampicillin, ceftriaxone, cefotaxime, meropenem, minocycline, chloramphenicol succinate, and rifampin. Resistance to ciprofloxacin, which, to our knowledge, had not previously been reported for N. meningitidis from mainland China, was shown for 70.6% (12/17) of the isolates. Figure Pulsed-field gel electrophoresis (PFGE) pattern–based cluster analysis of 27 N. meningitidis serogroup W135 isolates from China: 17 isolates were collected from persons in Hefei City, Anhui Province, and 10 were collected from persons from other ... Since 2000, N. meningitidis W135 ST11 disease has become a serious problem worldwide (8,9). In mainland China, serogroup W135 ST11 cases have recently been reported in Guangdong, Guangxi, Zhejiang, Jiangsu, and Henan Provinces (10), but no deaths were reported until 2012, when the first of the 2 boys died in Anhui Province (Technical Appendix). According to the PFGE, multilocus sequence typing, and PorA typing results, the dominant clonal complex detected in Hefei matches the dominant type recently detected in other Chinese provinces. Pathogenicity characteristics of the isolates from Hefei and epidemiologic investigations indicate that the N. meningitidis W135 ST11 clone has emerged in Hefei, raising the possibility of its introduction into other regions. Meningococcal polysaccharide vaccines A and C are being used for routine vaccination in China. However, meningococcal diseases caused by N. meningitidis serogroups other than A and C, especially those belonging to hyperinvasive lineages, are an emerging problem that must be addressed. The 2 fatal meningitis cases in Hefei highlight the need for further epidemiologic surveillance to monitor the incidence of meningococcal disease caused by serogroup W135 and the need for better public health strategies to control the disease. Testing of the 17 isolates from Hefei for antimicrobial drug susceptibility indicated that sulfamethoxazole is not effective against serogroup W135 ST11 infection and that 70.6% of isolates were resistant to ciprofloxacin. Our findings indicate that changes in the molecular and epidemiologic characteristics of N. meningitidis in China should be monitored to enhance our ability to respond to emerging meningococcal disease. Technical Appendix: Cases of meningococcal disease caused by serogroup W135, China, January 2006–March 2013. Click here to view.(98K, pdf)

Examining the patterns of and reasons for sexual behaviors of patients with sexually transmitted diseases (STDs) while symptomatic may help to develop effective prevention strategies for both STDs and AIDS. However, little is known about patients' sexual activities after noticing STD symptoms in China, where AIDS and STDs are spreading rapidly. We conducted a cross-sectional study at four STD clinics in Hefei, China. Patients' reported sexual activities were queried, using a tape recorder and earphones. A consecutive sample of 406 male patients with STDs were interviewed. One hundred sixty-four (40%) men reported having sex after having STD symptoms; 45% were married, 27% were single, and 47% cohabiting or divorced. Their sex partners included spouses, girlfriends, and prostitutes. Only 10% of patients with STDs who had sex after noticing STDs reported frequently using condoms or using them for every act of sex. Approximately 60% had never used a condom. Logistic regression analysis indicated that having sex after noticing STD symptoms was associated with lower education, having a previous STD episode, having low HIV/STD knowledge, and having other urethral discharge not caused by C. trachomatis or gonorrhea. Our findings suggest that male patients with STDs may serve as a bridge population linking the STD, and potentially, HIV epidemic from individuals at higher risk to the general population. Intervention programs including health education and condom promotion need to target both those at high risk and those at apparently lower risk.

Background The syndromic treatment approach has not been evaluated in sexually transmitted disease (STD) clinics in China. Goal The goal was to evaluate and compare the validity and cost-effectiveness of syndromic management with current STD management for men in clinics in Hefei, China. Study design Diagnostic accuracy, treatment appropriateness, costs, and effectiveness of current clinical procedures and syndromic management were compared for 406 men attending four STD clinics. Results A modified World Health Organization (WHO) syndromic algorithm for urethral discharge yielded 100% sensitivity and a 69% positive predictive value (PPV). A syndromic algorithm for genital ulcers correctly treated all syphilis patients, with a 25% PPV. The average cost (in US dollars) per correct treatment by the current approach was 323.48 dollars for urethritis and 85.65 dollars for syphilis. For the syndromic approach, the average cost per correct treatment was 3.15 dollars for urethritis and 13.54 dollars for syphilis. Conclusion Syndromic management can provide better treatment for men with STDs at significantly lower cost in resource-poor settings such as China.