Gonorrhea prevalence in adults in Brazil: Spectrum-STI trend estimation, 2000-2020

ABSTRACT Background: Gonorrhea is not a notifiable disease in Brazil, and the national health information system does not collect data on reported cases or infection prevalence. Methods: We compiled published data on gonorrhea prevalence in Brazil from cross-sectional surveys and clinical trials between 2000 and 2020. The study entry criteria included a sample size of 50 or more, and Neisseria gonorrhoeae infection detected in urine, urethral, anal, or cervicovaginal specimens using either Nucleic Acid Amplification Test or culture. Gonorrhea prevalence trends between 2000 and 2020 were generated using Spectrum-STI, a statistical trend-fitting model. Results: Forty-five studies with 59 gonorrhea prevalence data points were identified. Fifty data points were for women and represented 21,815 individuals, eight for men encompassing a total of 4,587 individuals, and one for transgender people comprising 345 individuals. The Spectrum-STI estimate for the prevalence of urogenital infection with gonorrhea in women 15-49 in 2020 was 0.63% (95% confidence interval (CI): 0.13-2.23) and was lower than the 1.05% estimated value for 2000 (95% CI: 0.36-2.79). The corresponding figures for men were 0.70% (95% CI: 0.16-2.44) and 1.14% (95% CI: 0.34-3.15). Anal prevalence estimates could not be generated because of insufficient data (three data points). Conclusions: These results suggest that the overall prevalence of genitourinary gonococcal infections in Brazil is less than 1%. Data on gonorrhea prevalence in men and in populations at increased STI vulnerability are limited.

Prevalence and incidence estimates for syphilis, chlamydia, gonorrhea, and congenital syphilis in Colombia, 1995-2016 / Estimaciones sobre la prevalencia y la incidencia de sífilis, clamidiasis, gonorrea y sífilis congénita en Colombia, 1995-2016 / Estimativas da incidência e prevalência de sífilis, clamídia, gonorreia e sífilis congênita na Colômbia, 1995-2016

ABSTRACT Objectives To estimate adult (15-49 years old) prevalence and incidence of active syphilis, gonorrhea, and chlamydia, and incidence of congenital syphilis (CS) and adverse birth outcomes (ABOs) in Colombia, over 1995-2016. Methods The Spectrum-STI epidemiological model tool estimated gonorrhea and chlamydia prevalences as moving averages across prevalences observed in representative general population surveys. For adult syphilis, Spectrum-STI applied segmented polynomial regression through prevalence data from antenatal care (ANC) surveys, routine ANC-based screening, and general population surveys. CS cases and ABOs were estimated from Spectrum's maternal syphilis estimates and proportions of women screened and treated for syphilis, applying World Health Organization case definitions and risk probabilities. Results The Spectrum model estimated prevalences in 2016 of 0.70% (95% confidence interval (CI): 0.15%-1.9%) in women and 0.60% (0.1%-1.9%) in men for gonorrhea and of 9.2% (4.4%-15.4%) in women and 7.4% (3.5%-14.7%) in men for chlamydia, without evidence for trends over 1995-2016. The prevalence of active syphilis in 2016 was 1.25% (1.22-1.29%) in women and 1.25% (1.1%-1.4%) in men, decreasing from 2.6% (2.1%-3.2%) in women in 1995. Corresponding CS cases in 2016 (including cases without clinical symptoms) totaled 3 851, of which 2 245 were ABOs. Annual CS and ABO estimates decreased over 2008-2016, reflecting decreasing maternal prevalence and increasing cases averted through ANC-based screening and treatment. Conclusions The available surveillance and monitoring data synthesized in Spectrum-STI— and the resulting first-ever national STI estimates for Colombia—highlighted Colombia's persistently high STI burden. Adult syphilis and congenital syphilis are estimated to be falling, reflecting improving screening efforts. Strengthened surveillance, including with periodic screening in low-risk populations and future refined Spectrum estimations, should support planning and implementation of STI prevention and control, including CS elimination.

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RESUMO Objetivos Estimar a incidência e a prevalência na população adulta (com idade de 15-49 anos) de sífilis ativa, gonorreia e clamídia e a incidência de sífilis congênita (SC) e desfechos adversos congênitos na Colômbia no período de 1995 a 2016. Métodos O modelo epidemiológico Spectrum-STI foi o instrumento usado para estimar a prevalência de gonorreia e clamídia como médias móveis nas prevalências observadas em pesquisas representativas da população geral. A sífilis em adultos foi estimada com a regressão polinomial segmentada aplicada ao modelo Spectrum-STI com dados de prevalência obtidos de pesquisas da atenção pré-natal, exames pré-natais de rotina de detecção precoce e pesquisas da população geral. Casos de SC e desfechos adversos congênitos foram estimados a partir das estimativas de sífilis materna do modelo Spectrum e percentuais de mulheres que fizeram testes de detecção e foram tratadas para sífilis, segundo as definições de casos da Organização Mundial da Saúde (OMS) e probabilidades de risco. Resultados O modelo Spectrum estimou, para 2016, uma prevalência de gonorreia de 0,70% (intervalo de confiança de 95% [IC 95%] 0,15%-1,9%) no sexo feminino e 0,60% (0,1%-1,9%) no sexo masculino e uma prevalência de clamídia de 9,2% (4,4%-15,4%) no sexo feminino e 7,4% (3,5%-14.7%) no sexo masculino, sem evidência de tendências no período 1995-2016. A prevalência de sífilis ativa em 2016 foi de 1,25% (1,22-1,29%) no sexo feminino e 1,25% (1,1%-1,4%) no sexo masculino, demonstrando um declínio da prevalência de 2,6% (2,1%-3,2%) observada em 1995 para o sexo feminino. Houve, ao todo, 3.851 casos correspondentes de SC em 2016 (incluindo casos assintomáticos), dos quais 2.245 foram desfechos adversos congênitos. Observou-se uma redução nas estimativas anuais de SC e desfechos adversos congênitos em 2008-2016, refletindo a diminuição da prevalência materna e o número crescente de casos evitados com exames pré-natais de detecção e tratamento. Conclusões Os dados disponíveis de vigilância e monitoramento condensados no modelo Spectrum-STI, e as resultantes estimativas nacionais de infeções sexualmente transmissíveis (IST) obtidas pela primeira vez na Colômbia, evidenciam a alta carga persistente de IST no país. Estima-se que a ocorrência de sífilis do adulto e sífilis congênita esteja diminuindo em decorrência da melhoria nos esforços de detecção precoce. A vigilância reforçada, consistindo também de exames periódicos de detecção precoce nas populações de baixo risco e estimavas futuras aprimoradas do instrumento Spectrum, deve sustentar o planejamento e a implementação de controle e prevenção de IST e a eliminação da SC.

World health organization global health sector strategy on sexually transmitted infections: an evidence-to-action summary for Colombia / Estrategia global de la Organización Mundial de la Salud contra infecciones de transmisión sexual: de la evidencia a la acción. Resumen para Colombia

ABSTRACT Curable and incurable sexually transmitted infections (STI) are acquired by hundreds of millions of people worldwide each year. Undiagnosed and untreated STIs cause a range of negative health outcomes including adverse birth outcomes, infertility and other long term sequelae such as cervical cancer. In 2016, the World Health Organization (WHO) launched the Global STI Strategy (20162021). The WHO Global STI Strategy's public health approach focuses on three causative organisms of STIs that need immediate action and for which cost-effective interventions exist: (a) Neisseria gonorrhoeae as a cause of infertility, a risk factor for coinfection with other STIs and because of increasing bacterial resistance to antibiotic treatment, (b) Treponema pallidum given the contribution of syphilis to adverse birth outcomes including stillbirth and neonatal death and (c) Human papillomavirus due to its link to cervical cancer. The range of actions recommended for countries includes: (a) strengthening surveillance, with program monitoring and progress evaluation, (b) STI prevention, (c) early diagnosis of STIs, (d) patient and partner management, and (e) approaches to reach the most vulnerable populations. This summary describes the WHO Global STI Strategy alongside findings from a STI surveillance workshop held in Colombia in May of 2017. Observations related to the Global STI Strategy and findings from the STI estimation workshop are described here for stakeholders in Colombia to consider as they identify opportunities to improve STI services and surveillance.

RESUMEN En el mundo, cientos de millones de personas adquieren anualmente infecciones de transmisión sexual (ITS), algunas de ellas curables y otras incurables. Las ITS que no se diagnostican y no se tratan producen una serie de desenlaces negativos para la salud, entre los cuales se cuentan malos resultados perinatales, infertilidad y otras secuelas crónicas, además del cáncer de cuello uterino. En 2016, la Organización Mundial de la Salud (OMS) lanzó la Estrategia Mundial contras las ITS (2016-2021). El enfoque de salud pública contemplado en la Estrategia Global de la OMS se centra en tres microorganismos causantes de las ITS que requieren acciones inmediatas y para los cuales existen intervenciones costo-efectivas: (a) Neisseria gonorrhoea como causa de infertilidad y factor de riesgo para coinfección con otras ITS, y por su mayor resistencia al tratamiento con antibióticos; (b) Treponema pallidum por la contribución de la sífilis a resultados adversos al nacimiento, entre ellos muerte fetal y muerte neonatal; y (c) virus del papiloma humano debido a su relación con el cáncer de cuello uterino. Entre las acciones recomendadas para los países están las siguientes: (a) fortalecer la vigilancia, el monitoreo y la evaluación de los programas y los avances logrados; (b) prevención de las ITS; (c) diagnóstico temprano de las ITS; (d) manejo del paciente y la pareja; (e) mecanismos para llegar a las poblaciones más vulnerables. Esta síntesis de la política resume la Estrategia Mundial de la OMS contra las ITS, además de los hallazgos de un taller de vigilancia llevado a cabo en Colombia en mayo de 2017. Aquí se describen las observaciones relacionadas con la Estrategia, y los hallazgos del taller a fin de que los distintos grupos de interés en Colombia, los tomen en consideración a la hora de identificar las oportunidades de mejorar los servicios y la vigilancia en lo que atañe a las ITS.

Vitamin A Status Monitoring in Women and Children in Rural Indonesia: Serum Retinol and Retinolbinding Protein and their Correlation.

Objectives: To assess retinol binding protein (RBP) as an indicator of vitamin A status in children and women, during a pilot program fortifying cooking oil with retinyl palmitate in West Java. Methods: Surveys measured serum retinol using High-Performance Liquid Chromatography (as gold standard), and RBP using Enzyme-Linked Immunosorbent Sandwich Assay, among children 6-59 months (n=753) and 5-9 years (n=175), women 15-29 years not reportedly pregnant (n=170) and lactating mothers (n=303). C-reactive protein and α-1-acid glycoprotein were measured to adjust serum retinol for sub-clinical inflammation using established correction factors. Results: At baseline, serum retinol concentrations (μg/dL, mean and standard deviation) were 33.2±14.0, 33.0±0.91, 40.9±18.7, and 44.2±18.5 for children 6-59 months, 5-9 years, women and lactating mothers. Prevalences of vitamin A deficiency (retinol <20μg/dL) were 14.9%, 10.9%, 10.0% and 5.3%. Mean RBP concentrations (mg/kg) were 1.00±0.24, 1.01±0.22, 1.24±0.35, 1.34±0.37, respectively. Serum retinol and RBP concentrations correlated positively (Pearson's correlation coefficient r=0.54, 0.50, 0.51, and 0.48 in the four groups). In the 2nd survey a year later, retinol and RBP averages were 3.2-17.4% and 3.7-13.7% increased among groups; correlation patterns were similar. Using RBP<0.80 μmol/L as cut-off (lacking a WHO recommendation), deficiency prevalence, sensitivity and specificity of RBP were 15%, 36% and 88% in children 6-59 months. Conclusions: RBP can be an indicator of vitamin A status in child and woman populations, saving cost compared to serum retinol-based monitoring. The lesser retinol-RBP concordance compared to earlier studies suggest that precision of measurements in this study may have been less than typical.

Quality Control to Enable Successful Vitamin A Fortification of Cooking Oil in Indonesia - A Pilot Program in Two Rural Districts.

Objectives: To describe prospects of successful fortification of unbranded cooking oil with vitamin A in Indonesia through public-private cooperation, based on a pilot program in 2 districts on West Java. Methods: Collaborating with Ministries of Health, Industry and Trade, Indonesia's Food Fortification Foundation and Food & Drug Agency, and GAIN, two producers covering a large market share on West Java piloted fortification of cooking oil with 45 IU/g retinyl palmitate, the National Standard (SNI) for oil at factory-level. For quality control, vitamin A in cooking oil was measured at a factory, distributors and retailers, and from households. Household surveys measured oil consumption. Results: Oil consumption among children 12-23 and 24-59 months averaged 12.5 and 22.3 g/day, and 29 g/day in women 15-29 years, similar before and after start of fortification. Oil samples contained retinyl palmitate at averages of 43.6 IU/g at the factory (68 samples), 33.8 IU/g among distributors (2 stores, 28 samples), 33.3 IU/g at retail shops (24 shops, 64 samples) and 19.2 IU/g among households (339 households, 6376 samples). Vitamin A content in oil varied over the 12 months of the pilot. Further work should determine if variations reflect degradation of vitamin A during storage (including varying storage times of samples before measurement), or mixing of fortified oil with non-fortified oil by retailers. Conclusions: Quality control and enforcement of compliance throughout the distribution chain of cooking oil by the Government, and a mandatory fortification standard supported by all stakeholders are essential for this program to be sustained and expanded.

Fortifying Cooking Oil with Vitamin A in Two Rural Districts of Indonesia: Impact on Vitamin A Status of Mothers and Children.

Objectives: To measure impact of fortifying unbranded palm oil with retinyl palmitate on vitamin A status in poor households through two surveys, just before fortification started (four months after the twice-yearly vitamin A capsule supplementation for children 6-59 months) and a year later. Methods: 24 villages from a pilot area on West Java were randomly selected, and poor families sampled. Serum retinol (adjusted for sub-clinical infections) was analyzed in lactating mothers and their infants 6-11 months, children 12-59 months and 5-9 years and women 15-29 years, in relation to socio-economic conditions, oil consumption, and food intake. Fortified oil was sold through existing market channels. Results: Fortified oil improved vitamin A intakes, contributing an estimated 34%, 77%, 55%, 42%, 50% of Recommended Nutrient Intake (RNI) for children 12-23 months, 24-59 months, 5-9 years, lactating and non-lactating women, respectively. Serum retinol increased by 13-17% across groups (p<0.02 except in 12-23 months). Deficiency prevalence (retinol <20 mg/dL) decreased by 67%, 64%, 96%, 89%, 79%, and 89% in infants 6-11 months, children 12-23 months, 24-59 months, 5-9 years, lactating and non-lactating women (p<0.011, all groups). Households' non-food expenditures, housing conditions and capital assets also improved from baseline to endline. However, in multivariate regressions, socio-economic variables did not independently influence retinol status, whereas RNI contributions from oil positively predicted improving retinol for children 6-59 months (p=0.003) and 5-9 years (p=0.03). Conclusions: Fortification of cooking oil proved an effective way to reduce the vitamin A intake gap in underprivileged women and children in rural communities.