Prevalence of Chlamydia trachomatis infections in the Middle East and north Africa, what next?
Authors: Jolande A Land, Elena Ambrosino
Journal: The Lancet Global Health (2019)

One of the goals of WHO's Global Health Sector Strategy On Sexually Transmitted Infections (STIs), 2016–21, is ending STI epidemics as major public health concerns.1WHOGlobal health sector strategy on sexually transmitted infections, 2016–2021. World Health Organization, Geneva2016Google Scholar To achieve this goal, strategic directions have been formulated. First, countries need to know their STI burden to understand where and among which population groups new infections are occurring. Only then can targeted and effective actions be taken. Thus far, few epidemiological data for STIs have been published by the Middle East and north African countries, possibly because of political and sociocultural sensitivities concerning sexual and reproductive health issues. Chlamydia trachomatis infection is one of the most common curable STIs worldwide, but if left untreated, it could compromise reproductive health by causing infertility and adverse pregnancy outcomes. In The Lancet Global Health, Smolak and colleagues2Smolak A Chemaitelly H Hermez JG Low N Abu-Raddad LJ Epidemiology of Chlamydia trachomatis in the Middle East and north Africa: a systematic review, meta-analysis, and meta-regression.Lancet Global Health. 2019; 7: e1197-e1225Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar present a comprehensive assessment of C trachomatis epidemiology in the Middle East and north Africa, by analysing more than 500 reports from 20 of 23 countries from the Middle East and north Africa. The pooled average C trachomatis prevalence for current infections was estimated at 3·0% (95% CI 2·3–3·8) in general populations. Several high-risk groups were identified with a pooled prevalence of 13·2% (95% CI 7·2–20·7) in female sex workers, 11·3% (9·0–13·7) in infertility clinic attendees, and 12·4% (7·9–17·7) in women with miscarriages. Smolak and colleagues conclude that, although the overall prevalence of C trachomatis infections in the Middle East and north Africa is similar to other regions in the world, it is higher than expected given the sexually conservative norms in the Middle East and north Africa. No explanation was offered for the high prevalence of C trachomatis infections in infertile women and women with miscarriages—ie, similar to the prevalence in female sex workers. The prevalence of current C trachomatis infections in infertile women (>10%) is three-times higher than in general populations in the Middle East and north Africa, and much higher than the 1·8% (95% CI 0·9–3·2) prevalence reported in infertile women in European countries.3Land JA Gijsen AP Evers JL Bruggeman CA Chlamydia trachomatis in subfertile women undergoing uterine instrumentation. Screen or treat?.Hum Reprod. 2002; 17: 525-527Crossref PubMed Scopus (17) Google Scholar Furthermore, sexual networks responsible for the spread of STIs are poorly investigated in the Middle East and north Africa, because of sociocultural and religious restrictions, although these same factors and gender differences might have an important role. In the Middle East and north Africa, married women without children are frequently stigmatised and have an increased risk of marital instability and polygamy.4Inhorn MC Patrizio P Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century.Hum Reprod Update. 2015; 21: 411-426Crossref PubMed Scopus (500) Google Scholar, 5Hasanpoor-Azghdy SB Simbar M Vedadhir A The social consequences of infertility among Iranian women: a qualitative study.Int J Fertil Steril. 2015; 8: 409-420PubMed Google Scholar Marital instability and polygamy might, in turn, increase the spread of STIs among infertile women. Additionally, the reported higher prevalence of C trachomatis infection in men in the Middle East and north Africa, as compared with women, is possibly related to a more unrestrained sexual conduct, making men important vectors for the spread of infections.6El-Kak F Sexuality and sexual health: constructs and expressions in the extended Middle East and north Africa.Vaccine. 2013; 31: G45-G50Crossref PubMed Scopus (23) Google Scholar More than one-third of the population of the Middle East and north Africa is younger than 25 years, and their proportion is likely to further increase in the coming decades.7UN Population DivisionWorld population prospects.https://population.un.org/wpp/Graphs/Probabilistic/POP/0-24/1833Date: 2019Date accessed: June 28, 2019Google Scholar The younger generations have increasing access to global media and social networks via the Internet. They might become progressively more exposed to different and more liberate sexual means and norms, and as a consequence change their sexual behaviour, in line with a recently observed shift in practices.8Hamdi S The impact of teachings on sexuality in Islam on HPV vaccine acceptability in the Middle East and north Africa region.J Epidemiol Glob Health. 2018; 7: S17-S22Crossref PubMed Scopus (5) Google Scholar The age of marriage is increasing in men and women, and especially young men are more sexually active before marriage and have multiple sexual partners.9Motamedi M Merghati-Khoei E Shahbazi M et al.Paradoxical attitudes toward premarital dating and sexual encounters in Tehran, Iran: a cross-sectional study.Reprod Health. 2016; 13: 102Crossref PubMed Scopus (21) Google Scholar These ongoing changes in sexual and reproductive behaviour in the Middle East and north African society highlight the importance of adequate responses to the changing risks and needs of young people. In order to combat STIs, WHO has recommended universal access to sexual and reproductive health-care services, comprehensive health information, education and health promotion programmes for adolescents, and interventions that empower women and stigmatised populations.1WHOGlobal health sector strategy on sexually transmitted infections, 2016–2021. World Health Organization, Geneva2016Google Scholar The question is, how do health-care professionals and policy makers implement these recommendations in the Middle East and north African region, where it still might be difficult to break the silence in public concerning issues of sexual behaviour, especially among women? In 2003, a regional eastern Mediterranean consultative meeting pledged to promote reproductive and sexual health at the individual, family, and community level.10WHOPromoting reproductive and sexual health: report of a regional consultative meeting, Beirut, Lebanon, 8–11 December 2003. World Health Organization, Geneva2003Google Scholar Promising developments have been reported since, including peer education programmes, STI counselling, and testing in dedicated centers,11DeJong J El-Khoury G Reproductive health of Arab young people.BMJ. 2006; 333: 849-851Crossref PubMed Scopus (41) Google Scholar and social media have obtained a more central role in offering accurate and culturally appropriate information to male and female target groups.12El Feki S The Arab bed spring? Sexual rights in troubled times across the Middle East and north Africa.Reprod Health Matters. 2015; 23: 38-44Crossref PubMed Scopus (4) Google Scholar A key achievement of Smolak and colleagues' study2Smolak A Chemaitelly H Hermez JG Low N Abu-Raddad LJ Epidemiology of Chlamydia trachomatis in the Middle East and north Africa: a systematic review, meta-analysis, and meta-regression.Lancet Global Health. 2019; 7: e1197-e1225Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar is to have raised awareness of the prevalence of C trachomatis infection in the Middle East and north Africa, and of the groups most vulnerable to such infection, especially infertile women without children. A high exposure to C trachomatis and sociocultural sensitivities to sexual and reproductive health issues combine to establish a high-risk situation. Addressing this situation is a first step to action. We declare no competing interests. Epidemiology of Chlamydia trachomatis in the Middle East and north Africa: a systematic review, meta-analysis, and meta-regressionC trachomatis prevalence in the Middle East and north Africa is similar to other regions, but higher than expected given its sexually conservative norms. High prevalence in infertility clinic attendees and in women with miscarriage suggests a potential role for C trachomatis in poor reproductive health outcomes in this region. Full-Text PDF Open Access