bluuebunny/crossref_metadata_2025 huggingface dataset:
S10.1 Addressing sexual health in Canada
Authors: Smylie L , Clarke B
Published: July 2011

Following a decline in reported rates of reportable sexually transmitted infections into the late-1990s in Canada, rates have been rising steadily with over two-thirds of reported chlamydia and gonorrhoea cases occurring among young people under 25 years of age. These increases have paradoxically occurred in the face of a decline in teenage pregnancy, an increase in condom use, a stable age of first sexual intercourse, and fewer lifetime sexual partners. Up to 35% of women and 15% of men report being coerced into sexual intercourse. Sexual minority adults experience higher rates of violent victimisation, including sexual assault, and rates of discrimination three times higher than heterosexuals. Sexual minority and gender variant individuals are up to seven times more likely to attempt suicide than heterosexuals. The burden of poor sexual health in Canada is unevenly distributed across the population with a concentration of poor sexual health outcomes among the economically disadvantaged, in more isolated areas, and among sexual minority and gender variant populations.

Our approach to addressing sexual health embraces a population health philosophy. The approach does not focus solely on sexual behaviour, but on determinants that influence the contexts within which decisions and choices affecting sexual health are made. It is a multi-sectoral approach fostering partnerships across government departments and with community organisations. It is a holistic approach that does not focus solely on the physical aspects of sexual health, but on the emotional, mental, and social aspects as well.

As part of a symposium on national approaches to sexual health, this presentation will examine key experiences, challenges and opportunities encountered in the Public Health Agency of Canada's approach to protecting and enhancing the sexual health of Canadians. In particular, it will highlight Public Health Agency of Canada's leadership and commitment to sexual health through its investment in research to develop national indicators of sexual health and to collect baseline national data; present exemplary health and social interventions to create supportive environments to promote the sexual health of all Canadians; and share innovative methods used to engage members of vulnerable populations in the development and implementation of sexual health interventions.
S10.2 Developing and implementing a public health approach to improve sexual health in the USA
Authors: Douglas J , Fenton K
Published: July 2011

Background

The first formal U.S. government recognition of the importance of a sexual health framework for enhancing STD/HIV prevention—The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behaviour –was published in 2001. Since then, many measures of adverse health outcomes of sexual behaviour have improved only minimally or worsened, including HIV, STD, and teen pregnancy. CDC is committed to enhancing program impact for STD/HIV prevention and other programs by complementing traditional prevention efforts with a health promotion framework that comprehensively addresses the broader issue of sexual health.

Methods

We have developed a cross-CDC Sexual Health Steering Committee including Divisions of STD Prevention, HIV/AIDS Prevention, Viral Hepatitis, Adolescent/School Health, Reproductive Health, and Violence Prevention which works collaboratively with a Sexual Health Workgroup of the CDC/HRSA Advisory Committee on HIV and STD.

Results

Key objectives of the CDC sexual health effort include increased knowledge and awareness of and healthy/respectful attitudes regarding sexual health; increased use of high-quality, coordinated and integrated educational, programmatic, and clinical services; increased healthy, responsible, and respectful sexual behaviours; improved healthy and respectful sexual relationships, free of coercion; and decreased adverse health outcomes, including HIV/STD, viral hepatitis, unplanned pregnancy, and sexual and intimate partner violence. Initial efforts focused on a policy discussion paper and expert consultation on “A Public Health Approach for Advancing Sexual Health in the USA” Subsequent steps have included expanding engagement of stakeholders from a broad range of perspectives; steps to evaluate a sexual health communication framework; an expanded CDC sexual health website; efforts to incorporate sexual health into key U.S. policy documents (eg, National HIV AIDS Strategy, Healthy People 2020 key indicators; National Prevention Strategy); planning a national coalition to address sexual health in the general population, adolescents/young adults, and among MSM; and development of a conceptual framework, logic model, and CDC definition of sexual health to inform a final white paper on sexual health.

Conclusions

Developing and implementing a sexual health framework in a society with diverse values is challenging, but core public health prevention efforts must be enhanced by a renewed effort to address issues of sexual health and responsible sexual behaviour as an intrinsic part of human health. The use of a sexual health framework has great potential for improving public health outcomes by providing messages that are more effective at reaching the public and providers, enhancing the efficiency and effectiveness of services, and facilitating societal dialogue around sexuality and sexual behaviour.
S10.4 Sexual health and public policy in Latin America and the Caribbean (LAC)
Authors: Mazin R
Published: July 2011

Background

Sexual health and its determinants are central to overall well-being and development. Thus, sexual health should be considered by public health as a critical element not only of the population's health, but also as an essential component of the health generated by the population. Regrettably, strict social norms and traditions in LAC have maintained the public discussions about sexuality in secretive and private domains. Moreover, rigid and stereotyped gender roles and social mores and values regarding sexuality have limited the incorporation of this area in the public health agendas, with the only exception of issues related to reproduction.

Methods

With the purpose to initiate a process aimed at incorporated the notion of sexual health into the public agenda, in May 2000, the Pan American Health Organization, in association with the World Association for Sexology/WAS (which has since changed its name to World Association for Sexual Health), held a consultation in Guatemala in which a definition of sexual health was coined: a state of physical, psychological, and socio-cultural well-being related to sexuality. The sexual health and the quality of sexual life of individuals, families and communities and the various factors that can affect them were also discussed and avenues for action were proposed.

Since then PAHO has also been engaged in several processes to further advance the sexual health agenda in the Americas, among which the collaboration with WAS in their initiative “Sexual Health for the Millennium”, the explicit incorporation of indicators on sexual health in PAHO's Strategic Plan for the Region, active support to the Mexico City Declaration, and several others intended to improve the health of members of sexual minorities and to rekindling of STI programs in LAC.

Results

Preliminary empirical evidence seems to indicate that the use of a public health rationale contributes to create convergence in an open debate that would be impossible to hold if other approaches were to be used (eg, based on moral, tradition or assumptions and beliefs). The discussion should lead to the realisation of sexual health, which means adoption of healthy lifestyles and the creation of supportive environments conducive to well-being for all. It would also contribute to the reorientation of the health services to better respond to the sexual needs of individuals through the life cycle, families, and communities.
S11.1 Problems encountered with reverse sequence syphilis screening
Authors: Hoover K W
Published: July 2011

CDC has long recommended screening for syphilis with a non-treponemal test such as the RPR test and, if reactive, confirming with a treponemal test. Non-treponemal antibody levels rise during active infection and tend to decline after treatment, so non-treponemal screening identifies persons with active disease who are likely infectious and require clinical and public health interventions. Although treponemal antibodies rise slightly earlier than non-treponemal antibodies, they tend to remain elevated after treatment so their presence does not always indicate active infection. Thus, treponemal tests have not been recommended for initial screening. Also, older treponemal tests that utilise native treponemal antigens, such as the TP-PA and FTA-ABS tests, were thought to have a high false positive rate due to binding of cross-reacting serum antibodies. Newer treponemal tests, enzyme immunoassays (EIAs) and chemiluminescence immunoassays (CIAs), utilise recombinant treponemal antigens which should result in tests with high sensitivity and specificity, capable of detecting small quantities of antibody without nonspecific binding of cross-reacting antibodies. Because EIA/CIA can be automated, U.S. laboratories have begun to screen for syphilis using a reverse sequence with EIA/CIA screening and confirmation of EIA+ sera with an RPR test to identify active infection.

Using this reverse sequence for syphilis screening, discordant sera (EIA+/RPR−) would be expected in patients with previous infection or early primary infection. CDC studies have found that more than half of all EIA+ sera were discordant with EIA+/RPR− results. A recent CDC epidemiologic study found that 32% of discordant sera were due to false-positive EIA/CIAs (eg, EIA+/RPR−/TP-PA−), with rates that ranged from 12% in a high prevalence population to 60% in a low prevalence population.

Discordant sera cause uncertainty about patient management, and the TP-PA test might be a useful confirmatory test with these sera. Recent studies suggest that the TP-PA test has equivalent sensitivity but higher specificity than EIA/CIAs, performance characteristics that are necessary for a confirmatory test. The FTA-ABS should not be used because it has low specificity, its interpretation is inherently subjective, and its performance requires trained personnel and a dedicated fluorescence microscope. Research is needed to better understand the variation in treponemal test performance.
S11.3 Performing a treponemal test to confirm a reactive EIA test: before or after the non-treponemal test?
Authors: Ison C
Published: July 2011

Detection of the host's immune response to infection has been the mainstay of the diagnosis of syphilis for decades. Serological characterisation ofTreponema palliduminfection presents a number of challenges including the life-long antibody response to treponemal antigens following primary infection, absence of a test specific only toT pallidumand lack of a test detecting treponemal antibody that indicates newly acquired infection or response to treatment. Non-treponemal or reagin-based tests offer the best indication of infectious syphilis but themselves can show cross-reactivity to other infections and conditions. These challenges are coupled in much of the developed world with very low rates of infection.

The choice for screening or testing individuals for syphilis can be difficult in that the treponemal tests such as the enzyme immunoassays and chemiluminescent assays, are highly sensitive, can be automated and allow screening of large numbers of sera, whereas the rapid plasma reagin (RPR) test is an agglutination test, cannot be automated and does not easily lend itself to large scale testing. In England & Wales, the National Standard Operating Procedure (VSOP 44) and the Antenatal Screening Committee Laboratory Standards both recommend screening using an enzyme immunoassays, or chemiluminescent assays, followed by confirmation by the Treponemal Passive Particle Assay, to eliminate any non-specific reactivity. Sera giving a positive reaction with both tests will then be immediately tested using the RPR.

The advantages of this approach are that large numbers of sera can be screened in local laboratories, where most will give a negative result, allowing the small number of potentially infected individuals to be quickly identified for further testing. There may be a resulting delay in identifying an infectious case particularly in low prevalence populations, where the laboratory may not perform the confirmatory tests and refers to a regional centre and therefore standards for turnaround times and rapid referral to a specialist physician to ensure timely treatment, especially in maternal syphilis, are essential. In high prevalence areas the RPR is likely to be more cost-effective as a screening test, however, the approach taken should address the population to be tested, the laboratory resources for screening / testing and the prevalence of infection to identify and treat the maximum number of cases for the public health control of syphilis.
S11.4 Serological screening for syphilis: research needs
Authors: Lukehart S A
Published: July 2011

Background and problem

The recent development and implementation of serological screening for syphilis using recombinant protein-based immunoassays has resulted in much confusion about the interpretation of positive results, particularly in low prevalence settings. Early experience suggests that a high proportion of positive tests are not confirmed by either non-treponemal or other treponemal tests. Many questions remain about the accuracy and relevance of these results.

Research needs

We will discuss research questions related to the performance, utility, and effectiveness of these tests.

Performance of the existing tests

Sensitivity, specificity, and positive predictive value in high- and low-prevalence populations. What gold standard should be used for evaluation of these tests?

Can performance of the existing tests be improved by simple modifications?

Reactivity in persons with past treated syphilis—how can this be determined?

Effectiveness of using the current tests for screening

Does screening with the EIA tests result in the need for more additional, unnecessary testing? Does the delay in receiving prompt complete serological results result in delayed treatment and increased transmission of syphilis? How much unnecessary treatment results from the use of these tests for screening? What is the impact of EIA screening on public health time and dollars spent on contact tracing? What is the real cost of EIA screening, including the need for additional testing, possibility of additional transmission, and required public health follow-up?

Biological basis for the unconfirmed reactivity in the existing tests

WhichTreponema pallidumantigens are recognised by patient sera that are reactive only in the EIA tests?

Do such antisera have cross-reactivity with antigens of other treponemal species found in humans?

Next generation recombinant protein-based antibody tests

Are thereT pallidum-specific antigens? How can we identify them? Are there antigens for which antibody disappears or declines significantly following treatment?

Conclusions

The increasingly widespread use of recombinant protein-based immunoassays has contributed to much confusion in serological testing for syphilis. Research efforts to understand the source of the problems with these first-generation tests are needed to provide clinicians with appropriate algorithms and tools to accurately and rapidly diagnose untreated syphilis in their patients.
S12.2 Screening for cervical cancer in the era of HPV vaccination
Authors: Franco E L
Published: July 2011

Two efficacious prophylactic vaccines against infections with human papillomavirus (HPV) types 16 and 18 have become available since 2006. Universal pre-exposure HPV vaccination has the potential to reduce the incidence of cervical cancer by up to 75%. Vaccination is also expected to have an impact on the rate of cervical cytological abnormalities and of diagnostic and treatment procedures required to manage women with such precancerous lesions. The traditional paradigm of Pap cytology screening may not be a suitable complementary preventive strategy in the era of HPV vaccination. Once the cohorts of young women who are being vaccinated reach the age of screening the prevalence of Pap smear-detectable abnormalities will decrease substantially, which will ultimately affect the positive predictive value of cytology and decrease its cost-effectiveness. It is now widely accepted that testing cervical exfoliated cells for DNA of high oncogenic risk HPVs is a much more sensitive screening tool than cytology to detect high grade cervical lesions and cervical cancer. Cytologic or HPV-typing triage of HPV-positive women can reveal cases that should undergo colposcopic examination and biopsy and will largely obviate the concerns related to false-positives. With the improved sensitivity to detect existing lesions and the more “upstream” focus on cervical carcinogenesis this strategy could be implemented via longer screening intervals than are currently possible with cytology alone, and thus be cost-saving especially after HPV testing is deployed as a screening tool. However, it is in the post-vaccination era when the cohorts of women vaccinated in their teens enter screening age that this approach may prove most valuable by permitting a surveillance system that can serve two roles simultaneously: monitoring duration of vaccine protection (with HPV typing for those who are positive) and screening for cervical cancer. The author will present the arguments for an integrated approach that involve the two prevention strategies against this disease: HPV vaccination and molecular testing in cervical cancer screening.
S12.3 What is the latest data from the 2 commercially available prophylactic cervical cancer vaccines?
Authors: Garland S
Published: July 2011

Since 2007 two prophylactic HPV vaccines (a bivalent incorporating VLPs 16 and 18, plus a quadrivalent vaccine with VLPs 16, 18, 6, 11) have been licensed for use. This was based on excellent efficacy, immunogenicity and safety data from phase 3 clinical trials. In addition there is also some cross protection for disease for phylogenetically related genotypes. Where these vaccines have been incorporated into public health programs with high coverage, (particularly targeted school based programs), already reductions in those disease those with the shortest incubation periods, are being seen that is, genital warts for the quadrivalent vaccine.

The greatest challenge today is to obtain wide vaccine coverage to those countries with the highest incidence of disease.
S12.4 Genital warts: prevention, diagnosis, treatment and counselling
Authors: Steben M
Published: July 2011

Genital warts (GW) are one of the most common reasons for consultation at an STI clinic. A majority of partners sexually exposed to GW will develop GW. Half of cases of GW will have cleared within 4 months. Condoms' efficacy has been demonstrated but need high compliance to achieve good protection. When lesions are not clearing reassessment of diagnosis may be necessary. Therapeutic options include patient applied and office base therapies. Some patients may need repeated cycles of therapy or combined modalities. Counselling for smoking cessation and HIV testing should be offered. High level of anxiety and sexual concerns are common. Partner notification is not recommended. Patients with GW and their actual and future partner(s) should be counselled about HPV quadrivalent prophylactic vaccine.
S13.2 Assessing respondent-driven sampling
Authors: Goel S
Published: July 2011

Respondent-driven sampling is a network-based technique for estimating traits in hard-to-reach populations, for example, the prevalence of HIV among drug injectors. In recent years RDS has been used in more than 120 studies in more than 20 countries, and by leading public health organisations, including the Centers for Disease Control and Prevention in the USA. Despite the widespread use and growing popularity of RDS, there has been little empirical validation of the methodology. In this talk, I investigate the performance of RDS by simulating sampling from 85 known, network populations. Across a variety of traits we find that RDS is substantially less accurate than generally acknowledged, and that reported RDS CI are misleadingly narrow. Moreover, it is unlikely RDS performs any better in practice than in our simulations as we model a best-case scenario in which the theoretical RDS sampling assumptions hold exactly. Notably, the poor performance of RDS is driven not by the bias, but by the high variance of estimates, a possibility that had been largely overlooked in the RDS literature. Given the consistency of our results across networks and our generous sampling conditions, we conclude that RDS as currently practiced may not be suitable for key aspects of public health surveillance where it is now extensively applied. This work is joint with Matthew Salganik.
S13.4 Use of respondent-driven sampling for monitoring HIV behaviours among injecting drug users in the United States
Authors: Lansky A , DiNenno E A , Wejnert C
Published: July 2011

Background

Approximately 1.1 million persons in the United States are living with HIV and for 18.5% their infections are attributable to injection drug use. In 2009 there were an estimated 5063 new HIV diagnoses attributed to injection drug use. In 2002, CDC developed the National HIV Behavioural Surveillance System (NHBS) to help state and local health departments in areas with high AIDS prevalence monitor behaviours and use of prevention services in groups at highest risk for HIV infection, including injection drug users (IDU). NHBS uses a sampling method most appropriate for each group; respondent-driven sampling (RDS) was chosen as the method for NHBS-IDU. We describe implementation and key monitoring indicators from the first two rounds of NHBS-IDU.

Methods

NHBS-IDU is implemented in more than 20 cities every 3 years using a standardised protocol for conducting surveys and HIV testing among persons who had injected drugs within the 12 months prior to interview. Data are analysed for each city independently and then aggregated and weighted to form national estimates.

Results

During the first IDU cycle (NHBS-IDU1, conducted 2005–2006), a total of 13 519 persons in 23 cities were recruited to participate, which resulted in 11 471 persons included in the final dataset. A total of 10 901 persons received 34 038 coupons to recruit others; 13 115 (62%) coupons were returned (range by city: 52.2%–75.3%). Challenges to the underlying assumptions of RDS included a somewhat high (5%) proportion of participants who reported their recruiter was “a stranger” and limited geographic cross-recruitment, suggesting IDU networks were not linked. These issues were found for some cities and were addressed in the operational guidance for NHBS-IDU2, conducted during 2009. Data from NHBS are used to monitor national progress in HIV prevention for IDU; in NHBS-IDU1, an estimated 32.8% of IDU shared syringes, and 63.4% had unprotected vaginal sex; 66.3% had been tested for HIV, and 29.7% had participated in an HIV behavioural intervention.

Conclusions

Use of RDS for NHBS-IDU has identified challenges in implementation and analysis that continue to further the development of this method for conducting behavioural surveillance among IDU in order to characterise the HIV epidemic in the USA.
S14.1 Genital and oral human papillomavirus in adolescent males
Authors: Weaver B A , Brown D , Fortenberry J D
Published: July 2011

Background

Human papillomavirus is a common STI which causes genital warts and cancers in males. Studies of HPV in adult males are underway, but the epidemiology and natural history of HPV in adolescent males has not been investigated. The purpose of this study is to describe genital and oral HPV infections in young men.

Methods

A subset of young men was recruited from an ongoing study of the male adolescent penile and urethral microbiome and sexual behaviours. Participant consent and parental permission were obtained. This study was approved by the Institutional Review Board at Indiana University. Approximately every 3 months, genital swabs and an oral rinse sample were collected from each participant. Genital swabs were collected using saline wetted cotton swabs rubbed over the entire skin surface of the participant's glans penis, penile shaft, and scrotum. Participants provided oral samples by a swish and spit method using 15 ml of mouthwash. Samples were tested for HPV using the 37 HPV type Linear Array HPV Genotyping Test (Roche). Participants completed daily cell phone diary entries and quarterly surveys about their sexual behaviours. Descriptive statistical analysis was performed using SPSS.

Results

A total of 34 adolescent males were recruited, ages 14–18 at enrolment (mean 15.8; SD 1.18). The racial/ethnic identity of participants was: 19 (55.9%) black, 12 (35.3%) white, and 3(8.8%) other. At the time of their first HPV sample collection, 19 participants (55.9%) reported ever having vaginal sex, 8 participants (23.5%) reported ever giving oral sex, 16 participants (47.1%) reported ever receiving oral sex, and 5 (14.7%) reported ever having anal sex. In their enrolment genital samples, HPV (high risk (HR) plus low risk (LR)) was detected in 13 of 34 participants (38.2%); HR types were detected in nine participants and LR types were detected in eight participants. Seven participants had >1 HPV type. HPV was detected in both sexually active participants and those denying prior sexual contact. One participant had trichomonas at enrolment; no participants had gonorrhoea or chlamydia. In the enrolment oral samples, HPV was detected in one participant (HPV 6).

Conclusions

This study provides the first information about HPV genital and oral infections in adolescent males. Genital HPV can be detected in adolescent males, and is not predicted by prior vaginal or oral sex. Oral HPV was infrequently detected in this small sample.
S14.3 Evaluating the internet as an STD risk environment for teens: findings from the communication, health, and teens (CH@T) study
Authors: Buhi E R , Klinkenberger N , Blunt H , Daley E M , Baldwin J , Rietmeijer C
Published: July 2011

Background

TheCH@Tstudy aims to identify/characterise a group of teens reporting meeting sex partners online and a group reporting meeting sex partners in-person (not online) and examine the differences between the 2 groups in sexual health risks.

Methods

Youth aged 13–19 years (N=273) visiting a publicly-funded clinic completed a 20-min Audio-Computer Assisted Self-Interview. Included were global sexual behaviour questions (eg, oral/vaginal/anal sex experience, number of sex partners) and specific partnership history questions, including meeting partners online/offline. Participants were also tested for chlamydia/gonorrhea. Audio-Computer Assisted Self-Interview responses were anonymously linked to teens' biological STD results. A χ2test was performed to determine the association between meeting a sex partner online and current STD status.

Results

Participants identified as female (89.4%) and heterosexual (80.7%). Nearly 9 in 10 (88.6%) reported oral, 97.8% vaginal, and 28.6% anal sex experience. Of those with biological STD data (n=267), 14.2% had a current STD infection. Of all teens, 15.4% (n=42) reported having sex with a partner originally met online (of these, > half [57.1%] met >1 partner). Compared with teens reporting only partners met in-person, teens reporting an online partner had significantly greater numbers of oral, vaginal, and anal sex partners. However, analyses indicated no association between having a current STD and reporting an online partner, χ2(1, N=267)=0.95, p=0.34.

Conclusions

Theory-driven STD prevention and sexual health promotion interventions should be tailored to meet specific needs of young people seeking partners both online and offline. Sex-seeking, dating, and social networking websites may represent important intervention contexts.
S14.6 Prevalence and predictors of trichomonas infection in incarcerated women
Authors: Nijhawan A , Salloway R , Andrea S , Champion J , Seadale M , Chapin K , Clarke J G
Published: July 2011

Background

Trichomonas vaginalisis the most prevalent curable sexually transmitted infection in the United States and may lead to preterm delivery, infertility and increased HIV transmission. Illicit drug use, HIV infection and Black race have been associated with high rates of infection. Incarcerated women may be at especially high risk for infection, though few studies have examined routine screening for trichomonas in this population.

Methods

Women >18-years-old entering the Rhode Island Department of Corrections between September 2009 and December 2010 were recruited to participate. All women submitted a self-collected vaginal swab for trichomonas culture and Transcription Mediated Amplification testing. Each participant completed a survey addressing demographics, symptoms, sexual behaviour, and substance use by audio computer-assisted self-interview. Data analysis was completed using multivariate logistic regression in STATA.

Results

288 women enrolled in the study, mean age was 28 years. 59% of participants were White, 17% Hispanic, 12% Black and 12% other races. Forty-three per cent reported vaginal symptoms and 54% reported illicit drug use in the 30 days prior to incarceration. Among all participants, the prevalence of trichomonas was 8.7% by culture and 12.5% by NAAT. The strongest predictors of infection included Black race (OR 4.1, 95% CI 1.4 to 12.0), cocaine use in the 30 days prior to incarceration (OR 2.5, 95% CI 1.1 to 5.7), and >3 year since last pap smear (OR 5.2, 95% CI 1.5 to 17.8). Vaginal symptoms and age were not significantly associated with trichomonas detection.

Conclusions

Trichomonas infection is common in incarcerated women, especially among Blacks, recent cocaine users and those not receiving routine gynaecologic care. Infection was not predicted by symptoms or by age. Routine screening for trichomonas infection in high-risk populations may lead to increased detection and treatment.
S15.2 European gonococcal antimicrobial surveillance programme (Euro-GASP): towards timelier monitoring
Authors: Cole M J , Chisholm S A , Unemo M , Hoffmann S , van de Laar M J W , Ison C A
Published: July 2011

Background

It is imperative that antimicrobial resistance (AMR) surveillance systems work in a timely manner and outcomes are translated into treatment guidelines without delay. For the first time in 2010, the European gonococcal antimicrobial surveillance programme (Euro-GASP) introduced biannual testing to allow more frequent reporting of trends and developments inNeisseria gonorrhoeaeAMR across Europe.

Methods

In the first half of 2010, 18 out of the 30 EU/EEA Member States contributed up to 55 consecutive gonococcal isolates to Euro-GASP. Susceptibility testing was performed by Etest or agar dilution for therapeutically relevant antimicrobials: azithromycin, cefixime, ceftriaxone, ciprofloxacin, gentamicin and spectinomycin. Biannual testing continued into the second half of 2010. Additionally 10 laboratories performed decentralised testing with the submission of AMR data into Euro-GASP instead of gonococcal isolates.

Results

In the first round of biannual testing 900N gonorrhoeaeisolates were tested. Eight per cent of the isolates displayed decreased susceptibility (>0.125 mg/l) to cefixime, which was an increase from 5% in 2009. No decreased susceptibility to ceftriaxone was detected. For ciprofloxacin, the overall incidence of resistant isolates decreased from 63% in 2009 to 52% in 2010 and azithromycin resistance decreased from 13% in 2009 to 5% in 2010. No resistance to spectinomycin was demonstrated. The MIC50 and MIC90 of gentamicin in the isolates remained at 8 mg/l in 2010.

Conclusions

The results from the first round of biannual testing have shown that isolates displaying decreased susceptibility to cefixime are rapidly increasing. This is a major concern as cefixime is a widely used, recommended therapy for gonorrhoea across Europe. Healthcare professions should be aware of cefixime treatment failures, particularly in light of the recent identification of treatment failures in Norway and the UK. The MICs of ceftriaxone need to be monitored continually to preserve this precious treatment option. Euro-GASP is currently being adjusted to allow for timely reporting and decentralised testing including representativeness and links to epidemiological data. All of which contribute to monitoring the ever changing gonococcus in timelier and more efficient ways, with the ultimate aim of treating infected individuals successfully.
S15.4 Re-emergence of lymphogranuloma venereum in Europe and the public health response
Authors: Ward H , de Vries H J C , van de Laar M
Published: July 2011

Background

In January 2004, public health officials in the Netherlands noted an outbreak of cases of lymphogranuloma venereum (LGV) among men who have sex with men (MSM). Since then a number of outbreaks and cases have been reported from European countries, North America and Australia. The re-emergence of LGV in this population remains poorly understood yet may have important health consequences.

Methods

Several EU countries have reported newly diagnosed cases of LGV to The European Surveillance System and a number of additional countries have reported LGV cases to the Epidemiological Information System on STI (hosted by ECDC). We have synthesised evidence from these surveillance reports together with results of clinical and epidemiological studies to better describe transmission and inform the public health response.

Results

An increasing trend of LGV has been reported in several Western European countries. In areas with well-established surveillance, LGV has become a significant and persistent infection in MSM. In the UK, there was a rapid rise in cases from 2009 to 2010, while in Amsterdam numbers continue to fluctuate. The European outbreaks appear to be caused by a single LGV variant (L2b) that has been around for several decades, having been detected in rectal swabs from MSM in San Francisco in 1981. The resurgence of LGV over the past decade is closely linked to the overlapping HIV epidemic which it may in turn fuel. A systematic review of 13 descriptive studies showed the prevalence of HIV in LGV cases ranging from 67% to 100%; compared to MSM with non-LGV chlamydia, there was a significant association between HIV and LGV (OR 8.19, 95% CI 4.68 to 14.33). It is likely that changes in sexual behaviour, including serosorting and unprotected anal sex, and an increase in the size of the HIV positive population, may have created the conditions for an explosive LGV outbreak after decades of quiescence.

Conclusion

The on-going LGV epidemic shows no signs of waning and requires a robust public health response. Primary prevention should be developed for MSM with HIV, together with awareness campaigns for the wide range of clinicians who may see men with symptoms. In addition, improved diagnostic methods are needed to allow widespread screening could reduce the infectious pool; they would also allow a better picture of the epidemic to be obtained from countries with limited diagnostic facilities.
S2.3 Screening high-risk populations using rapid syphilis tests: the importance of social and cultural contexts
Authors: Chen X S , Yin Y P , Wei W H , Peeling R
Published: July 2011

Background

Syphilis has made a dramatic resurgence in China during the past 2 decades with an increasing prevalence in high-risk groups. Screening of syphilis in the populations is critical for control of the disease.

Methods

A rapid syphilis test (RST) was introduced into STD services among patients attending STD clinics and existing outreach services to female sex workers (FSW) in Liuzhou and Jiangmen, China to test the feasibility of same-day test and treatment (STAT) and same-day test and referral (STAR) strategies. The STAT and STAR rates were evaluated regarding the different STD providers and outreach teams, respectively.

Results

Of 7283 patients from 3 STD clinics in Liuzhou—one public health clinic, one private reproductive health clinic and one general hospital clinic who were screened with a non-treponemal test, TRUST, and RST for syphilis, 291 (4.0%) had active syphilis, but only 69.8% of infected cases accepted the STAT. The acceptance rate was different between clinics, with 54.2% in public health clinic, 71.8% in reproductive health clinic and 100.0% in general hospital clinic. During the outreach services provided by the CDC intervention team (CIT), STD clinic team (SCT) and reproductive health clinic team (RCT), 75% of FSWs accepted to be tested with RST in sex work venues. Of 2780 FSWs screened with RST, 199 (7.2%) were positive and were referred to designated clinics for further testing and treatment. However, success in referring RST positive FSWs to designated clinics were significantly different between outreach teams. RCT had the highest referral rate (85.7%) followed by SCT (70.6%) and CIT (26.7%). Focus groups discussions among providers and high-risk populations regarding the introduction of RST indicated that social and cultural contexts were related to the successful introduction of RST among these populations. Trust of the target population in the clinics and outreach team was related to the acceptability of STAT and STAR. Belief in the results of a free RST test, confidentiality of syphilis status, social stigma, medical cost at the designated clinics for further test and treatment, and time spent for clinic visit were the main concerns of FSWs, especially in the referral advice.

Conclusions

Feasibility in introduction of STAT and STAR among high-risk groups is encouraging but the barriers still exist. Social and cultural contexts are important and should be considered when RST is introduced as one of strategies for prevention and control of syphilis in China.
S2.4 New technologies to support STI screening and syndromic management in resource-limited settings
Authors: Peeling R
Published: July 2011

Background

High quality tests for detection of STIs are available but they are neither affordable nor available to patients in resource-limited settings. For patients presenting with STI symptoms, WHO recommends the use of syndromic management in settings where laboratory services are not available. As most STI patients tend to have few or no symptoms, tests to screen for STIs is important for guiding treatment and prevention of onward transmission. However, in resource-limited settings, patients often have to travel long distances to reach a clinic with STI services, and many fail to return for test results and treatment after the initial visit.

Methods

In recent years, increased investment in the development of novel diagnostic technologies has resulted in advances that have made it possible to provide STI-testing at all healthcare settings. The development of multiplex tests to support screening and STI syndromic management in resource-limited settings is an urgent priority.

Results

Exciting new technologies may soon transform how STIs can be diagnosed in resource-poor settings in the next few years. Among them are duplex antigen/antibody tests that can be used for STI syndromes and rapid lateral flow tests that can be used with oral fluid instead of blood for syphilis and HIV. Nucleic acid amplified tests that are designed as integrated platforms providing sample- in- answer-out convenience and random access will soon be available for the detection of genital chlamydial and gonococcal infections. Simple isothermal nucleic acid amplification technologies are available for detection of bacterial and viral STIs in 15–60 min, using simple equipment that can be run on solar energy or batteries. A mathematical model developed by Aledortet al(2006) estimated that a test for syphilis that requires no laboratory infrastructure could save more than 201 000 adjusted lives and avert 215 000 stillbirths. A similar test could save approximately 4 million DALYs, avert more than 16.5 million incident gonorrhoea and chlamydial infections and prevent more than 212 000 HIV infections.

Conclusions

Recent investments in the development of point-of-care diagnostics for infectious diseases have produced novel technologies that can support STI screening and syndromic management in resource-limited settings. Quality assurance and implementation research are needed to ensure optimal uptake and full impact of these novel technologies in resource-limited settings.
S3.1 Challenges and key issues in evaluation of public health interventions
Authors: Dandona L
Published: July 2011

Interest in evaluating the impact of large-scale public health interventions has been increasing globally over the past few years to inform effective use of public resources. Consequently some high-profile evaluations of complex public health interventions to improve population health in low- and middle-income countries have been reported recently. This increased, and desirable, focus on evaluations has helped bring attention to some major challenges that are encountered when attempting to assess the impact of large-scale public health interventions. These include the process of planning or commissioning of the evaluation, the design and analytical approaches that are both robust and feasible, and the interpretation and dissemination of findings. Examples will be used to illustrate these challenges. The key issues that need to be dealt with for improving evaluations of large-scale and complex public health interventions in low- and middle-income countries and better utilisation of the findings will be discussed.
P1-S1.10 Microbiological surveillance for sexually transmitted infections in Windhoek and Oshakati, Namibia (2007)
Authors: Tobias S , Shonhiwa S , Norbert F , Oke O , Ndjavera C , Chikukwa S , Radebe F , Lewis D
Published: July 2011

Background

A microbiological survey was undertaken to enable review of Namibia's syndromic management-based STI treatment guidelines (1999).

Methods

This Government-approved survey took place at Katutura Health Centre (Windhoek) and Oshakati Intermediate Hospital over 9 months in 2007. Consecutive patients with urethral discharge (UDS), vaginal discharge (VDS) and genital ulcer (GUS) syndromes gave verbal consent to provide anonymous samples for the following tests—(i) real-time PCR (RT-PCR) forNeisseria gonorrhoeae(NG),Chlamydia trachomatis(CT),Trichomonas vaginalis(TV),Mycoplasma genitalium(MG) (UDS, urethral swabs; VDS, endocervical swabs) (ii) RT-PCR detection of herpes simplex virus (HSV),Treponema pallidum(TP),Haemophilus ducreyi(HD),Chlamydia trachomatisL1-L3 (LGV) (ulcer swabs), (iii) Giemsa staining of ulcer smears for granuloma inguinale (GI), (iv) Gram staining of vaginal smears for Candida (CA) and bacterial vaginosis (BV), (v) NG culture and determination of ciprofloxacin and ceftriaxone minimum inhibitory concentrations (MIC) by E test (urethral swabs), and (vi) HIV ELISA (blood). All patients were provided with STI syndromic treatment, offered same-day HIV counselling and testing, and partner notification was discussed. Data analysis was performed in STATA v10 and the χ2test used to assess difference by survey site.

Results

199 UDS, 200 VDS and 199 GUS episodes were surveyed among 598 patients (293, Windhoek; 305, Oshakati). The relative prevalence of pathogens/conditions by syndrome was—(i) UDS—NG 87% (173), CT 9% (18), TV 5% (9), MG 2% (4), (ii) VDS—NG 5% (9), CT 8% (15), TV 15% (29), MG 4% (8), BV 65% (127), CA 17% (33), and (iii) GUS—HSV 49% (97), TP 3% (5), LGV 2% (2), GI 0.5% (1), HD 0% (0). Syndrome-specific HIV prevalence was 36% (62) for UDS, 29% (57) for VDS and 53% (91) for GUS. Ciprofloxacin resistance (MIC=1) was detected in 28 (24%) of 118 viable NG isolates; all isolates were deemed susceptible to ceftriaxone. Ciprofloxacin resistance was significantly higher in Oshakati compared to Windhoek (48% vs 5%, p<0.001).

Conclusions

The survey highlighted the importance of gonorrhoea, genital herpes, HIV-coinfection and, in Oshakati, the high prevalence of ciprofloxacin resistant NG. As a result of this survey, Namibia's STI guidelines were revised in 2008 by adding acyclovir to existing GUS treatment and replacing ciprofloxacin with oral cefixime as treatment for presumptive gonorrhoea.
P1-S2.45 Clusters ofNeisseria gonorrhoeaeinfected patients are not linked to HIV infection within the homosexual population in Amsterdam, the Netherlands
Authors: Heymans R , Bruisten S , Matser A , Heijman T , de Vries H , van der Loeff M S
Published: July 2011

Background

Sexual risk behaviour increased since the introduction of antiretroviral treatment against HIV-1. Consequently, since the mid-90s the gonorrhoea transmission was raised posing a serious public health problem especially among men who have sex with men (MSM). We examined if separate sexual networks exist of HIV-infected and of HIV-negative MSM in relation to transmission of gonorrhoea. Using molecular typing ofNeisseria gonorrhoeae(NG) we aimed to identify clusters of patients with specific NG strains and examined possible linkage to HIV infection and other characteristics.

Methods

From July 2008 to August 2009, MSM visiting the Amsterdam outpatient clinic were recruited for a network study concerning sexually transmitted infections (STI). Inclusion criteria were age ≥18 years, homosexual contact in the preceding 6 months, and giving informed consent. After screening for STI the participants answered questions regarding sexual behaviour, meeting places, and characteristics of sexual partners (up to 4 sex partners). Only patients with an anal or genital NG infection (n=246) were included in the current analysis. NG cultures were amplified and genotyped using a published NG-MLVA typing method.

Results

Included patients (median age 36 years, IQR 30−42) were predominantly Dutch (83%). Coinfections with chlamydia (28%) and HIV (48%) were common. Hierarchical cluster analysis of 246 MLVA profiles classified 152/246 MSM in 13 large clusters (5 to 36 patients) indicating the circulation and ongoing transmission of different NG strains in this population. In three clusters a significantly (p<0.001) higher proportion of NG isolates had decreased susceptibility to cefotaxime. HIV infected MSM were older than HIV negative MSM and were evenly distributed over the NG clusters (see Abstract P1-S2.45 figure 1). There were no significant differences in age, nationality, nor in other coinfections between the various NG clusters.

Abstract P1-S2.45 Figure 1

GGD.

Conclusions

NG-MLVA revealed clusters of MSM reflecting distinct NG transmission networks in the Amsterdam population. As no NG clusters were identified that consisted predominantly of HIV infected or HIV negative MSM, it appears that there are no separate HIV infected and HIV negative sexual networks in the Amsterdam MSM population connected to gonorrhoea transmission.