Syphilis in China: results of a national surveillance programme

Social contexts of heterosexual transmission of HIV/STI in Liuzhou City, China

In this special issue of AIDS and Behavior, we focus on the social contexts of sexual transmission of HIV/STI in one South China city. Our multiple projects grew from partnerships across the social and biomedical sciences, and with public health experts in Liuzhou City, to address critical gaps in knowledge about how social factors drive heterosexual transmission. The eleven articles that comprise this special issue feature multidisciplinary and mixed method approaches, collecting data in Liuzhou from different populations, environments, and social venues where individuals often find sexual partners. They document heterosexual behaviors and their meanings. They investigate the experiences and behaviors of women and men in social venues, exploring the networks of people within these venues, how they relate to one another, share information, and influence each other. The articles also examine the experiences of people living with HIV, again collecting data from multiple levels and sources, and revealing the ongoing power of stigma to shape these lives. Taken together, the articles demonstrate the critical role of social contexts in shaping behaviors and meanings, which are linked to heterosexual transmission of HIV/STI, and which must be taken into account for the development of appropriate and effective public health interventions.

Exploring venue-associated risk: a comparison of multiple partnerships and syphilis infection among women working at entertainment and service venues

The re-emerging syphilis epidemic in China is documented among sex workers, but little is known about STI risk among the broader group of women who work at entertainment and service venues, many of whom do not self-identify as sex workers. In 2009 in Liuzhou, China, community informants identified venues where people meet sexual partners. Characteristics of a stratified random sample of venues were collected during venue visits. Female staff at 42 venues were interviewed and tested for syphilis. The results showed that venue characteristics, worker behaviors, and syphilis prevalence differed by venue type. Service venue workers had more sexual partners, were more likely to report sex work, and more likely to have a positive syphilis test than entertainment venue workers (prevalence ratio: 5.4; 95% CI 1.4-20.6). To conclude, risk of syphilis differs by venue type and is higher at service venues, even among women who do not report commercial sex.

Sexually transmitted infection testing practices among 'money boys' and general men who have sex with men in Shanghai, China: objective versus self-reported status

Little is known about sexually transmitted infection (STI) testing among Chinese men who have sex with men (MSM). This study describes the prevalence of STI testing, associated factors and the validity of STI self-reporting among Chinese MSM. Findings indicated a high prevalence of STIs and low testing rates among MSM in Shanghai. Monthly income was significantly associated with STI testing (odds ratio: 0.37, 95% confidence interval (CI): 0.18 to 0.76). Depression was significantly associated with STI testing for general MSM (odds ratio: 1.09, 95% CI: 1.01 to 1.17). Syphilis self-reported status had the highest validity (k=0.33, χ(2)=3.76, 95% CI: -0.003 to 0.65). Efforts are needed to ensure that STI testing services are accessible to MSM in China. Future HIV and STI interventions should be tailored to the needs of different subsets of MSM.

Epidemiology of syphilis infection among drug users at methadone maintenance treatment clinics in China: systematic review and meta-analysis

Illicit drug trade has re-emerged in China since 1979 and the number of drug addicts had increased. Syphilis is mainly spread through sexual contact and blood. The incidence of syphilis is high among drug users. Methadone maintenance treatment (MMT) clinics have been implemented in China since 2004. The aim of this study was to estimate the prevalence and risk factors of syphilis among drug users at MMT clinics in China between 2004 and 2013. Chinese and English databases (CBM, CNKI, Weipu, Pubmed) of literature were searched for studies reporting syphilis among drug users in MMT clinics from 2004 to 2013. The prevalence estimates and risk factors were summarized through a systematic review and meta-analysis of published literatures. In all, 29 eligible articles with a total of 8899 drug users, were selected in this review. The pooled prevalence of syphilis infection was 7.78% (95%CI: 5.83%-9.99%). The meta-analyses demonstrated significant differences in syphilis infection rates between men and women (OR = 0.34 [95%CI: 0.26-0.45]) but not between drug users and non-intravenous drug users (OR = 0.82 [95%CI: 0.51-1.32]). Enhanced detection of syphilis and health promotion is warranted in MMT clinics in China.

Regulatory T cells in peripheral blood and cerebrospinal fluid of syphilis patients with and without neurological involvement

BACKGROUND

Syphilis, a sexually transmitted disease caused by spirochetal bacterium Treponema pallidum, can progress to affect the central nervous system, causing neurosyphilis. Accumulating evidence suggest that regulatory T cells (Tregs) may play an important role in the pathogenesis of syphilis. However, little is known about Treg response in neurosyphilis.

METHODOLOGY/PRINCIPAL FINDINGS

We analyzed Treg frequencies and Transforming Growth Factor-β (TGF-β) levels in the blood and CSF of 431 syphilis patients without neurological involvement, 100 neurosyphilis patients and 100 healthy donors. Suppressive function of Tregs in peripheral blood was also assessed. Among syphilis patients without neurological involvement, we found that secondary and serofast patients had increased Treg percentages, suppressive function and TGF-β levels in peripheral blood compared to healthy donors. Serum Rapid Plasma Reagin (RPR) titers were positively correlated with Treg numbers in these patients. Compared to these syphilis patients without neurological involvement, neurosyphilis patients had higher Treg frequency in peripheral blood. In the central nervous system, neurosyphilis patients had higher numbers of leukocytes in CSF compared to syphilis patients without neurological involvement. CD4(+) T cells were the predominant cell type in the inflammatory infiltrates in CSF of neurosyphilis patients. Interestingly, among these neurosyphilis patients, a significant decrease in CSF CD4(+) CD25(high) Treg percentage and number was observed in symptomatic neurosyphilis patients compared to those of asymptomatic neurosyphilis patients, which may be associated with low CSF TGF-β levels.

CONCLUSIONS

Our findings suggest that Tregs might play an important role in both bacterial persistence and neurologic compromise in the pathogenesis of syphilis.

Prevalence and risk factors of syphilis infection among female sex workers in Shenzhen, China: an observational study (2009-2012)

OBJECTIVE

To investigate prevalence and risk factors of syphilis infection among female sex workers (FSWs) in Shenzhen, China.

METHODS

Observational study among (2009-2012) 1653 FSWs recruited by venue-based sampling using questionnaire-based interviews for socio-demographics, behaviours and syphilis testing results. Logistic regression was used to assess risk factors of syphilis infection.

RESULTS

The overall syphilis prevalence was 4.7%, showing a slightly decreasing trend. Factors significantly associated with syphilis infection were inconsistent condom use (OR = 1.87, P = 0.015), illicit drug use (OR = 5.45, P < 0.001) and older age in years (OR = 1.08, P < 0.001). Venues where FSWs were recruited and duration of commercial sex work were not significantly associated with syphilis infection (P > 0.05).

CONCLUSIONS

Syphilis is still common among FSWs in Shenzhen, China. Current comprehensive prevention programmes (e.g. condom promotion and peer education) should be continued to maintain and increase safe sexual practices and to reduce illicit drug use among FSWs. Expanding point-of-care syphilis screening programmes may be an important strategy for early diagnosis. We recommend timely and effective treatment programmes to be linked to such screening programmes.

Spatial analysis of primary and secondary syphilis incidence in China, 2004-2010

China has recently experienced an increase in the incidence of syphilis. Effective spatial monitoring of syphilis incidence is important for successful implementation of control and prevention programmes. This study monitored county-level primary and secondary (P&S) syphilis incidence rates for all of mainland China by examining spatial patterns. Exploratory spatial data analysis (ESDA) methods were used to characterize the spatial distribution pattern of syphilis cases. During the seven-year study period, the average annual P&S syphilis incidence was 8.82 cases per 100,000 people. Using Empirical Bayes smoothed rates, the local Moran test identified many areas of high syphilis risk (all P values ≤0.01). The number of high-risk counties increased from 73 counties in 2004 to 134 counties in 2010. An eastern coastal cluster of high-risk counties persisted throughout 2004-2010. ESDA methods can assist public health officials in identifying high-risk areas. Allocating more resources to high-risk areas could more effectively reduce syphilis incidence.

Syphilis screening among 27,150 pregnant women in South Chinese rural areas using point-of-care tests

Objectives

To determine the prevalence and correlates of syphilis among pregnant women in rural areas of South China.

Methods

Point-of-care syphilis testing was provided at 71 health facilities in less developed, rural areas of Guangdong Province. Positive samples were confirmed at a local referral center by toluidine red unheated serum tests (TRUST) and Treponema pallidum particle agglutination (TPPA) tests.

Results

Altogether 27,150 pregnant women in rural Guangdong were screened for syphilis. 106 (0.39%) syphilis cases were diagnosed, of which 78 (73.6%) received treatment for syphilis. Multivariate analysis revealed that older pregnant women (31–35 years old, aOR 2.7, 95% CI 0.99–7.32; older than 35 years old, aOR 5.9, 95% CI 2.13–16.34) and those with a history of adverse pregnant outcomes (aOR 3.64, 95% CI 2.30–5.76) were more likely to be infected with syphilis.

Conclusions

A high prevalence of syphilis exists among pregnant women living in rural areas of South China. Enhanced integration of syphilis screening with other routine women's health services (OB GYN, family planning) may be useful for controlling China's syphilis epidemic.

Sexually transmitted infections among heterosexual male clients of female sex workers in China: a systematic review and meta-analysis

BACKGROUND

Female sex workers have been the target of numerous sexually transmitted infection (STI) prevention strategies in China, but their male clients have attracted considerably less public health attention and resources. We sought to systematically assess the prevalence of HIV, syphilis, gonorrhea, and chlamydia among heterosexual male clients of female sex workers in China.

METHODS/PRINCIPAL FINDINGS

Original research manuscripts were identified by searching Chinese and English language databases, and 37 studies analyzing 26,552 male clients were included in the review. Client STI prevalence across studies was heterogeneous. Pooled prevalence estimates and 95% confidence intervals were 0.68% (0.36-1.28%) for HIV, 2.91% (2.17-3.89%) for syphilis, 2.16% (1.46-3.17%) for gonorrhea, and 8.01% (4.94-12.72%) for chlamydia.

CONCLUSIONS/SIGNIFICANCE

The pooled prevalence estimates of HIV, syphilis, gonorrhea, and chlamydia among clients in this review exceed the prevalences previously reported among population-representative samples and low-risk groups in China. However, heterogeneity across studies and sampling limitations prevent definitive conclusions about how the prevalence of STIs in this population compares to the general population. These findings suggest a need for greater attention to clients' sexual risk and disease prevalence in China's STI research agenda in order to inform effective prevention policies.

An integrated individual, community, and structural intervention to reduce HIV/STI risks among female sex workers in China

Background

We assessed the effectiveness of an integrated individual, community, and structural intervention to reduce risks of HIV and sexually transmitted infections (STIs) among female sex workers (FSWs).

Methods

The integration individual, community, and structural intervention was implemented from 2004 to 2009 in six counties of Shandong Province. Post-intervention cross-sectional surveys were conducted in six intervention counties and 10 control counties.

Results

Of 3326 female sex workers were recruited and analyzed in the post-intervention survey with 1157 from intervention sites and 2169 from control sites. No HIV positive was found in both intervention and control counties. The rate of syphilis was 0.17% for intervention sites and 1.89% for control sites (OR = 11.1, 95% CI: 2.7, 46.1). After adjusted for age, marital status, education, economic condition, recruitment venues, the rates of condom use in the last sex with clients(AOR = 2.7; 95% CI: 1.9, 3.8), with regular sex partners(AOR = 1.5; 95% CI: 1.1, 1.9) and consistent condom use in the last month with clients (AOR = 3.3; 95% CI: 2.6, 4.1) and regular sex partners (AOR = 1.7; 95% CI: 1.3, 2.3) were significantly higher in intervention sites than that in control sites. The proportion of participants correctly answered at least six out of eight HIV-related questions (83.3%) in intervention sites is significant higher than that (21.9%) in control sites (AOR = 24.7; 95% CI: 2.5, 42.7), the five indicators related to HIV-related intervention services ever received in the last year including HIV testing(AOR = 4.9; 95% CI: 2.8, 6.7), STD examination and/or treatment(AOR = 5.1; 95% CI: 4.2, 6.4), free condom(AOR = 20.3; 95% CI: 14.3, 28.9), peer education(AOR = 4.3; 95% CI: 3.5, 5.4), education materials(AOR = 19.8; 95%CI: 13.1, 29.8) were significantly higher in intervention sites than that in control sites, the participants in the intervention sites are more likely to seek medical treatment when they had any disorders (AOR = 3.2; 95% CI: 2.5, 4.2).

Conclusion

This study found that the integrated individual, community, and structural intervention showed positive impact in reducing HIV and STI risks among FSWs.

An Empirical Analysis of the Impact of Recruitment Patterns on RDS Estimates among a Socially Ordered Population of Female Sex Workers in China

Respondent-driven sampling (RDS) is a method for recruiting "hidden" populations through a network-based, chain and peer referral process. RDS recruits hidden populations more effectively than other sampling methods and promises to generate unbiased estimates of their characteristics. RDS's faithful representation of hidden populations relies on the validity of core assumptions regarding the unobserved referral process. With empirical recruitment data from an RDS study of female sex workers (FSWs) in Shanghai, we assess the RDS assumption that participants recruit nonpreferentially from among their network alters. We also present a bootstrap method for constructing the confidence intervals around RDS estimates. This approach uniquely incorporates real-world features of the population under study (e.g., the sample's observed branching structure). We then extend this approach to approximate the distribution of RDS estimates under various peer recruitment scenarios consistent with the data as a means to quantify the impact of recruitment bias and of rejection bias on the RDS estimates. We find that the hierarchical social organization of FSWs leads to recruitment biases by constraining RDS recruitment across social classes and introducing bias in the RDS estimates.

Factors associated with serological cure and the serofast state of HIV-negative patients with primary, secondary, latent, and tertiary syphilis

BACKGROUND

Some syphilis patients remain in a serologically active state after the recommended therapy. We currently know too little about the characteristics of this serological response.

METHODS

We conducted a cohort study using the clinical database from Zhongshan Hospital, Medical College of Xiamen. In total, 1,327 HIV-negative patients with primary, secondary, latent, and tertiary syphilis were enrolled. Bivariate and multivariate analyses were utilised to identify factors associated with a serological cure and serofast state in syphilis patients one year after therapy. Chi-square tests were used to determine the differences in the serological cure rate across different therapy time points.

RESULTS

One year after the recommended therapy, 870 patients achieved a serological cure, and 457 patients (34.4%) remained in the serofast state. The serological cure rate increased only within the first 6 months. The bivariate analysis indicated that male or younger patients had a higher likelihood of a serological cure than female or older patients. Having a baseline titre ≤ 1∶2 or ≥ 1∶64 was associated with an increased likelihood of a serological cure. The serological cure rate decreased for the different disease stages in the order of primary, secondary, latent, and tertiary syphilis. A distinction should be drawn between early and late syphilis. The multivariate analysis indicated that a serological cure was significantly associated with the disease phase, gender, age, and baseline rapid plasma reagin (RPR) titre.

CONCLUSIONS

The serofast state is common in clinical work. After one year of the recommended therapy, quite a few syphilis patients remained RPR positive. The primary endpoint of the study indicated that disease phase, gender, age and baseline RPR titre were crucial factors associated with a serological cure.

A comparison between antenatal care quality in public and private sector in rural Hebei, China

Aim

To evaluate the quality of antenatal care (ANC) in Hebei Province and compare it between the public and private sector and within the public sector.

Methods

We conducted a Maternal, Newborn and Child Health Household Survey in 2010 using a two-stage sampling procedure and included 1079 mothers. The quality of ANC was assessed on the basis of the number of ANC visits, the time of the first ANC visit, 16 different ANC procedures, owning a maternal health care booklet, and the type of service provider.

Results

Almost all women (98%) received ANC services at least once, 80% at least four times, and 54% at least five times. About half of the women (46%) visited ANC facility within their first trimester. Neither public nor private sector provided all 16 standardized services, but significantly more women in public sector received ANC procedures. Most women received ANC in county or higher-level hospitals (75%) and very few in township hospitals (8%). Significantly fewer women were weighed and tested for HIV/AIDS in township than in county or higher-level hospitals.

Conclusion

The quality of ANC in Hebei was poorer than required by China’s national and World Health Organization norms. Although the public sector performed better than the private sector, the utilization and quality of care of ANC services in this sector varied and women generally visited county or higher-level health facilities.

Social determinants of syphilis in South China: the effect of sibling position on syphilis and sexual risk behaviours

OBJECTIVE

This study evaluated the relationship between sibling position and sexual risk based on behavioural and syphilis infection data from sexually transmitted infection (STI) patients in South China.

DESIGN

A cross-sectional study examining sexual behaviours and syphilis infection.

SETTING

4 STI clinics in the Pearl River Delta of South China.

PARTICIPANTS

1792 Chinese men and women attending STI clinics.

PRIMARY OUTCOME MEASURES

STI history, syphilis infection defined as positive non-treponemal and treponemal tests.

RESULTS

Among all clinic patients, 824 (46.3%) were first-born, 354 (19.9%) were middle-born and 602 (33.8%) were final-born. Middle-born individuals had a higher percentage of reported STI history (44.7% compared to 34.7%, p<0.001) and syphilis infection (9.7% compared to 4.9%, p=0.01) among men (n=1163) compared to other sibling positions in bivariate analyses, but not in the final multivariate model. The relationship between sibling position and syphilis was independent of income and education level. There was no trend observed between middle-born position and female sexual risk behaviours (n=626). Higher education was significantly associated with syphilis among women and men in respective multivariate models.

CONCLUSIONS

This study suggests that middle-born men in China may have an increased sexual risk compared to other sibling positions. As Chinese family and social structures change, a more thorough understanding of how demographic factors influence sexual risk behaviours is needed.

HIV and syphilis prevalence among men who have sex with men: a cross-sectional survey of 61 cities in China

BACKGROUND

Human immunodeficiency virus (HIV) has rapidly spread among men who have sex with men (MSM) in China in recent years; the magnitude of the epidemic is unclear. We sought to test 3 hypotheses: (1) The prevalence of both HIV and syphilis among MSM in China is high, (2) the 2 epidemics each have unique geographical distributions, and (3) demographic and sexual behavior characteristics are different among segments of the MSM population in China.

METHODS

A total of 47 231 MSM from 61 cities in China participated in a cross-sectional survey conducted from February 2008 to September 2009. Demographic and behavioral data were collected and analyzed and blood samples tested for HIV and syphilis. Three subgroups among the broader MSM sample were described. Main outcome measures were HIV and syphilis prevalence.

RESULTS

An overall prevalence of 4.9% (2314/47 231; 95% confidence interval [CI], 4.7%-5.1%) for HIV and 11.8% (5552/47 231; 95% CI, 11.5%-12.0%) for syphilis was found. Syphilis-positive MSM had the highest HIV prevalence, 12.5% (693/5552; 95% CI, 11.6%-13.4%). However, correlations between HIV and syphilis prevalence were found in only 3 of 6 geographical regions (Northwest: r = 0.82, P = .0253; East: r = 0.78, P = .0004; and South-central: r = 0.63, P = .0276). Three subgroups-nonlocal MSM, Internet-using MSM, and female-partnering MSM-were found to have different profiles of characteristics and behaviors.

CONCLUSIONS

HIV and syphilis prevalences among MSM in China are high and the 2 epidemics are largely separate geographically. Three segments of the Chinese MSM population each have different demographic and sexual risk "profiles" that suggest high potential for bridging infection across geographies, generations, and sexes.

Syphilis treatment response among HIV-discordant couples in Zambia and Rwanda

BACKGROUND

Syphilis continues to be a common sexually transmitted infection, despite the availability of inexpensive and effective treatment. Infection in human immunodeficiency virus (HIV)-discordant couples is important because syphilis increases the risk of HIV acquisition. Current US treatment guidelines recommend 1 dose of benzathine penicillin for early syphilis, irrespective of HIV status, but data from coinfected patients are limited.

METHODS

Retrospective analysis of 1321 individuals in 2 African HIV-discordant couple cohorts was performed. Cox proportional hazards analysis and multivariable modeling were used to assess predictors of serologic response to treatment at 180 days and 400 days. Modeling was performed for all episodes of positive rapid plasma reagin (RPR) test results and on a subset with higher RPR titers (≥1:4).

RESULTS

A total of 1810 episodes of syphilis among 1321 individuals were treated with penicillin between 2002 and 2008. Although a positive RPR was more common in the HIV-infected partners, HIV infection did not impact the likelihood of serologic response to therapy (odds ratio [OR], 1.001; P = .995). By 400 days, 67% had responded to therapy, 27% were serofast, and 6.5% had documented reinfection. Prevalent infections were more likely to remain serofast than incident infections (33% vs 20% at 400 days).

CONCLUSIONS

In 2 HIV-serodiscordant couple cohorts in Africa, incident syphilis had a very good likelihood of response to penicillin therapy, irrespective of HIV infection. This supports current Centers for Disease Control and Prevention treatment guidelines. A high proportion of prevalent RPR-positive infections remain serofast despite treatment.

Early antenatal care: does it make a difference to outcomes of pregnancy associated with syphilis? A systematic review and meta-analysis

OBJECTIVE

Despite an increase in the proportion of women who access antenatal care, mother-to-child transmission of syphilis continues to be a consequence of undiagnosed, untreated, or inadequately treated maternal syphilis. We reviewed evidence on the optimal timing of antenatal interventions to prevent mother-to-child transmission of syphilis and its associated adverse outcomes.

DESIGN

Systematic review and meta-analysis of published literature. English-language articles were included if they (1) reported the gestational age at which the mother was screened or tested for syphilis; (2) reported on pregnancy outcome. No publication date limits were set.

RESULTS

We identified a total of 1,199 publications, of which 84 were selected for further review and five were included. All showed a lower prevalence of any adverse outcome among women who received an intervention (to include screening and treatment) in the first and second trimesters of pregnancy compared to the third trimester. The overall odds ratio for any adverse outcome was 2.24 (95% CI 1.28, 3.93). All sub-analyses by type of outcome presented important heterogeneity between studies, except for those studies reporting an infected infant (odds ratio 2.92, 95% CI 0.66, 12.87; I(2) = 48.2%, p = 0.165).

CONCLUSIONS

Our review has shown that the timing of antenatal care interventions makes a significant difference in the risk of having an adverse outcome due to syphilis. Women who sought care in the first two trimesters of their pregnancy, and received the appropriate intervention, were more likely to have a healthy infant, compared to women screened and treated in the third trimester. Encouraging ALL pregnant women to seek care in the first two trimesters of their pregnancy should be a priority for health programmes. For interventions to be effective within these health programmes, health systems and community engagement programmes need to be strengthened to enable pregnant women to seek antenatal care early.

Rates of HIV, syphilis, and HCV infections among different demographic groups of female sex workers in Guangxi China: evidence from 2010 national sentinel surveillance data

To examine the prevalence of HIV, syphilis, and hepatitis C virus (HCV) infections by demographic characteristics and identify the subgroups of female sex workers (FSW) who are at a higher risk of the infections. Secondary analysis of the 2010 National Sentinel Surveillance (NSS) data was conducted in the current study. A total of 12,622 FSW recruited from 35 NSS sites in Guangxi, China were included in the analysis. FSW were tested for HIV, syphilis, and HCV. The overall prevalence of HIV, syphilis, and HCV infections were 1.0, 6.1, and 1.0%, respectively. The prevalence of HIV and syphilis infections was significantly higher among women who were 40 years of age or older, worked in small commercial sex venues or on the street, were divorced or widowed, or had no formal schooling. A very high HIV infection prevalence (8.2%) was observed among a small number of cross-border foreign FSW (n=49). The prevalence of HCV infection did not differ by most of the demographic characteristics. Living in other provinces or being a Zhuang-ethnic served as protective factors for HCV. The multivariable analyses confirmed the bivariate results suggesting higher prevalence of HIV and syphilis infections among FSW who were older, divorced or widowed, or had no formal schooling. Future HIV intervention prevention efforts among FSW need to pay particular attention to these women in order to effectively curtail the infections among this most-at-risk population as well as to prevent the further spread of HIV and syphilis to other populations.

Safety of benzathine penicillin for preventing congenital syphilis: a systematic review

OBJECTIVE

To estimate the risk of serious adverse reactions to benzathine penicillin in pregnant women for preventing congenital syphilis.

METHODS

We searched for clinical trials or cohorts that assessed the incidence of serious adverse reactions to benzathine penicillin in pregnant women and the general population (indirect evidence). MEDLINE, EMBASE, Scopus and other databases were searched up to December 2012. The GRADE approach was used to assess quality of evidence. Absolute risks of each study were calculated along with their 95% confidence intervals (95% CI). We employed the DerSimonian and Laird random effects model in the meta-analyses.

RESULTS

From 2,765 retrieved studies we included 13, representing 3,466,780 patients. The studies that included pregnant women were conducted to demonstrate the effectiveness of benzathine penicillin: no serious adverse reactions were reported among the 1,244 pregnant women included. In the general population, among 2,028,982 patients treated, 4 died from an adverse reaction. The pooled risk of death was virtually zero. Fifty-four cases of anaphylaxis were reported (pooled absolute risk = 0.002%; 95% CI: 0%-0.003% I(2) = 12%). From that estimate, penicillin treatment would be expected to result in an incidence of 0 to 3 cases of anaphylaxis per 100,000 treated. Any adverse reactions were reported in 6,377 patients among 3,465,322 treated with penicillin (pooled absolute risk = 0.169%; 95% CI: 0.073%-0.265% I(2) = 97%). The quality of evidence was very low.

CONCLUSION

Studies that assessed the risk of serious adverse events due to benzathine penicillin treatment in pregnant women were scarce, but no reports of adverse reactions were found. The incidence of severe adverse outcomes was very low in the general population. The risk of treating pregnant women with benzathine penicillin to prevent congenital syphilis appears very low and does not outweigh its benefits. Further research is needed to improve the quality of evidence.

Health of China's rural-urban migrants and their families: a review of literature from 2000 to 2012

BACKGROUND

Socioeconomic transformation in China at the beginning of the twenty-first century has led to rapid urbanization and accelerated rural-urban migration. As a result, the concerns about public health problems triggered by increasing internal population mobility have been more widely studied in recent years.

SOURCES OF DATA

Published data in Chinese and English on health of migrants and their families in mainland China from 2000 to 2012.

AREAS OF AGREEMENT

The shifting patterns of disease distribution due to rural-urban migration, health equity and health reform strategies that cater for this specific yet substantial subpopulation are outstanding concerns. Infectious diseases, mental health, occupational health and women's health are emerging public health priorities related to migration.

AREAS OF CONTROVERSY

The high mobility and large numbers of Chinese rural-urban migrants pose challenges to research methods and the reliability of evidence gained.

GROWING POINTS

While the theme of working migrants is common in the literature, there have also been some studies of health of those left behind but who often remain unregistered. Migration within China is not a single entity and understanding the dynamics of new and emerging societies will need further study.

AREAS TIMELY FOR DEVELOPING RESEARCH

Social, economic, emotional, environmental and behavioural risk factors that impact on health of migrants and their families call for more attention from health policy-makers and researchers in contemporary China.

Prioritizing congenital syphilis control in south China: a decision analytic model to inform policy implementation

BACKGROUND

Syphilis is a major public health problem in many regions of China, with increases in congenital syphilis (CS) cases causing concern. The Chinese Ministry of Health recently announced a comprehensive 10-y national syphilis control plan focusing on averting CS. The decision analytic model presented here quantifies the impact of the planned strategies to determine whether they are likely to meet the goals laid out in the control plan.

METHODS AND FINDINGS

Our model incorporated data on age-stratified fertility, female adult syphilis cases, and empirical syphilis transmission rates to estimate the number of CS cases associated with prenatal syphilis infection on a yearly basis. Guangdong Province was the focus of this analysis because of the availability of high-quality demographic and public health data. Each model outcome was simulated 1,000 times to incorporate uncertainty in model inputs. The model was validated using data from a CS intervention program among 477,656 women in China. Sensitivity analyses were performed to identify which variables are likely to be most influential in achieving Chinese and international policy goals. Increasing prenatal screening coverage was the single most effective strategy for reducing CS cases. An incremental increase in prenatal screening from the base case of 57% coverage to 95% coverage was associated with 106 (95% CI: 101, 111) CS cases averted per 100,000 live births (58% decrease). The policy strategies laid out in the national plan led to an outcome that fell short of the target, while a four-pronged comprehensive syphilis control strategy consisting of increased prenatal screening coverage, increased treatment completion, earlier prenatal screening, and improved syphilis test characteristics was associated with 157 (95% CI: 154, 160) CS cases averted per 100,000 live births (85% decrease).

CONCLUSIONS

The Chinese national plan provides a strong foundation for syphilis control, but more comprehensive measures that include earlier and more extensive screening are necessary for reaching policy goals.

Increasing syphilis notifications in Mongolia: results from national surveillance for 2001-2011

BACKGROUND

In Western Pacific Region countries, sexually transmitted infections (STI) rates vary but are considered high. In Mongolia, syphilis incidence has increased between 2001 and 2011; therefore, the objective of this study was to describe the epidemiology of syphilis in Mongolia to provide evidence for prevention and control activities.

METHODS

A retrospective analysis of syphilis was conducted using STI data from the passive surveillance system. This included demographic and clinical information and laboratory test results. In addition, a test for the trend of syphilis notification rates over time was conducted.

RESULTS

Syphilis notification rates increased by twofold from 71 per 100 000 in 2001 to 152 per 100 000 in 2011 (P < 0.006), and there were significant differences observed between the capital city and the province rates over time (P = 0.011). Generally, notification rates among females were significantly higher than males (P < 0.001) except that male rates increased to 185 per 100 000, higher than female rates of 179 per 100 000 in 2009. The increase of notifications of latent syphilis for males (P < 0.009) and females (P < 0.006) was significant.

DISCUSSION

This is the first analysis of the overall situation of syphilis in Mongolia, and although the years with the largest number of cases corresponded to large-scale screening programmes, we observed a significant increase in syphilis notification rates over time. These results will be useful for evidence-based prevention and control activities such as awareness campaigns for young adults.

The prevalence and trends of transfusion-transmissible infectious pathogens among first-time, voluntary blood donors in Xi'an, China between 1999 and 2009

OBJECTIVES

The prevalence of infectious diseases is increasing in developing countries, and this may threaten the biological safety of donated blood. This study analyzed trends in the prevalence of transfusion-transmissible infectious pathogens among Chinese, first-time, voluntary blood donors from 1999 to 2009 to evaluate the potential for disease transmission.

METHODS

From 1999 to 2009, all first-time donors at the Xi'an Blood Service (XBS) were screened for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and syphilis infections using enzyme-linked immunosorbent assays (ELISA); results were confirmed using alternative commercial kits. The prevalence and temporal trends were analyzed using the Cochran-Armitage trend test and other appropriate methods.

RESULTS

From 1999 to 2009, 263 299 first-time blood donors were analyzed. The overall prevalence rates were 1.16% for HBV, 0.51% for HCV, 0.02% for HIV, and 0.31% for syphilis. There was a significant decrease in the trend for HBV and HCV infections, while a significant increase was found for syphilis. The prevalence of HIV infection remained low and stable during the study period.

CONCLUSIONS

These findings suggest that HBV infection is the primary threat to blood safety, while the increasing prevalence of syphilis might also be a potential threat.

Molecular typing of Treponema pallidum: a 5-year surveillance in Shanghai, China

Previously, a small study showed that 14f was the predominant subtype of Treponema pallidum in Shanghai, China. The result was quite different from the genotype distribution in other areas of China. This study aimed to identify the strain types of Treponema pallidum in samples collected over a 5-year period in Shanghai. From 2007 to 2011, genital swabs were collected from patients with syphilis from the Shanghai Skin Disease Hospital. Positive specimens were typed by the enhanced typing method by adding a tp0548 gene to the existing arp and tpr genotype system. In total, 304 of the 372 enrolled patients yielded fully typeable DNA. Ten arp types (4, 6, 8, 9, 11, 12, 13, 14, 15, and 19), 3 tpr types (a, d, and o), and 5 tp0548 types (a, c, f, g, and i) were identified. In total, 12 subtypes were identified with a combination of the arp and tpr genes. Subtype 14d was found in 270 samples (88.8%). When the combination included the tp0548 gene, the 12 CDC subtypes identified were divided into 14 strain types. The predominant type was 14d/f (88.8%), followed by 15d/f (3.6%), 13d/f (1.3%), and 19d/c (1.3%). Two of the 44 14d/f-infected patients and both of the 19d/c-infected patients who underwent a lumbar puncture were diagnosed with neurosyphilis. This study showed that the predominant type in Shanghai was 14d/f. While this is in keeping with data from other areas in China, it is different from an earlier report showing that 14f is the most common genotype in Shanghai. Further studies are needed to better understand the association between strain types and neurosyphilis.

Isolated Syphilitic Cervical Lymphadenopathy: Report of Two Cases and Review of the Literature

Isolated syphilitic cervical lymphaden -opathy (SCL) is a rare presentation of syphilis. Two patients with isolated SCL are presented here with a review of the literature. The first patient was a 72-year-old man with a mass (diameter 5 cm) in the right neck region for 26 days. Serological tests, imaging studies and pathological examination of the mass after surgical excision confirmed the diagnosis of isolated SCL. The second patient was a 48-year-old man with a mass (diameter 4 cm) in the right neck region for 1 month. The diagnosis of isolated SCL was made on the basis of serological tests, cervical ultrasound and pathological examination of the mass after surgical excision. Complete excision resulted in a satisfactory outcome in both patients. Isolated neck masses without associated clinical manifestations or adverse personal history are a diagnostic challenge, and SCL is easily overlooked in the differential diagnosis. Unusual masses should always remind clinicians of this infectious disease and a comprehensive diagnostic strategy is recommended. Nonroutine syphilitic serological tests should be performed in patients suspected of having SCL, and the histopathological and immunohistochemical characteristics may help to confirm the diagnosis.

Substance Use and Sexual Risks Among General MSM and Money Boys in Shanghai, China

In China, men who have sex with men (MSM) are at high risk for substance use, HIV, and other sexually transmitted infections (STIs). However, there has been little research into their drug use and the sexual behaviors they engage in after drug and alcohol use. Using respondent-driven sampling methodology, this cross-sectional study of 404 MSM described drug use and examined sexual behaviors after drug and alcohol use among general MSM and money boys (those who engage in same-sex commercial sex) in Shanghai, China. Money boys reported using more drugs in the last week, 3 months and ever, and having sex after drinking and sex after using drugs more frequently than general MSM. It is vital to continue research and begin science-based interventions in these high-risk and underserved populations.

Condom use, intervention service utilization and HIV knowledge among female sex workers in China: results of three consecutive cross-sectional surveys in Shandong Province with historically low HIV prevalence

Heterosexual transmission of HIV through contact with female sex workers (FSWs) is a growing concern for the HIV/AIDS epidemic in China. Using consecutive cross-sectional surveys, we examined the prevalence of HIV and sexually transmitted infections (STIs), risk behaviours, HIV knowledge and the utilization of intervention services among FSWs in Shandong Province. Of 3460 participants, half reported ever having STI-related symptoms, 57.8% had ≥7 clients in the last week, half reported inconsistent use of condoms with clients and 11.2% reported ever using illicit drugs. Consistent use of condoms with clients was associated with higher education, being 20-24 years of age, being recruited from hotels, having ever received free condoms and was inversely associated with STI-related symptoms. HIV-related knowledge was associated with higher education, ever testing for HIV and inversely associated with self-reported STI-related symptoms. The low rates of condom use, high number and frequent turnover of clients, high prevalence of self-reported STIs and drug use highlight the urgency for more effective intervention in these FSWs.

Prevalence and prevalence trends of transfusion transmissible infections among blood donors at four Chinese regional blood centers between 2000 and 2010

Background

In China, high prevalence of HBV and HCV parallels with the growing epidemic of syphilis and HIV in the general population poses a great threat to blood safety. This study investigated the prevalence of serologic markers for transfusion transmissible infections (TTIs) among four Chinese blood centers.

Methods

We examined whole blood donations collected from January 2000 through December 2010 at four Chinese blood centers. Post-donation testing of TTIs (HIV, HBV, HCV and syphilis) were conducted using two different enzyme-linked immunosorbent assay kits for each seromarker. The prevalence of serologic markers for TTIs (%) was calculated and additional analysis was conducted to examine donor characteristics associated with positive TTIs serology.

Results

Of the 4,366,283 donations, 60% were from first-time donors and 40% were from repeated donors. The overall prevalence of HIV, HBsAg, HCV and syphilis was 0.08%, 0.86%, 0.51% and 0.47%, respectively. The prevalence profile of TTIs varied among different blood centers and appeared at relatively high levels. Overall, the prevalence of HBsAg and HCV demonstrated a decline trend among four blood centers, while the prevalence of HIV and syphilis displayed three different trends: constantly steady, continually increasing and declining among different centers.

Conclusions

This study reflects the risk of TTIs has been greatly reduced in China, but blood transfusion remains an ongoing risk factor for the spread of blood-borne infections, and further work and improvements are needed to strengthen both safety and availability of blood in China.

Multilevel and spatial analysis of syphilis in Shenzhen, China, to inform spatially targeted control measures

OBJECTIVES

The present study investigates the varied spatial distribution of syphilis cases in Shenzhen, China, and explores the individual-, neighbourhood- and district-level factors affecting the distribution.

METHODS

This study uses spatial analysis and multi-level generalised estimating equations to explore the spatial distribution of reported syphilis cases among individuals in Shenzhen, Guangdong Province, China. The spatial distribution of primary/secondary and latent cases was investigated using the Moran's I-statistic. Primary/secondary syphilis cases were compared with all syphilis cases using a three-level model with individual (n=6496), neighbourhood (n=55) and district (n=6) levels.

RESULTS

A total of 6496 syphilis cases were reported in 2009 with 35.8% primary and secondary syphilis cases. Both primary/secondary syphilis cases (Moran's I value=0.33, p<0.01) and latent syphilis cases (Moran's I value=0.19, p<0.01) showed significant spatial clustering at the neighbourhood level. Adjusting for the number of reporting hospitals, the best model found that the following characteristics were associated with primary/secondary syphilis infection: individuals who are younger in age (p=0.003), male (p<0.001), migrant labourers (p=0.047) and those who live in districts with a higher gross domestic product (p<0.001).

CONCLUSIONS

There is substantial clustering of primary and secondary syphilis cases at the neighbourhood level in Shenzhen, suggesting the need for greater STD health service provision in these clustered neighbourhoods. Spatially targeted syphilis control measures may be useful to optimise testing, treatment and partner services.

The effect of a structural intervention for syphilis control among 3597 female sex workers: a demonstration study in South China

BACKGROUND

Syphilis has made a rapid resurgence in China, especially among high-risk groups including female sex workers (FSWs).

METHODS

Two cities in each of 3 provinces in South China were chosen and allocated to intervention or control arms. The intervention consisted of enhancing community-based syphilis screening outreach intervention with comprehensive sexually transmitted infection services at designated clinics while the control maintained routine intervention activities. Generalized linear modeling was used to examine effect of the intervention on incident syphilis infection.

RESULTS

A total of 8275 women were eligible, and 3597 women enrolled (n = 2011 in control arm, n = 1586 in intervention arm) in the study. The median follow-up duration was 375 days (interquartile range, 267–475). Syphilis incidence density in the intervention group was reduced by 70% (95% confidence interval, 53%–81%) compared with the incidence in the control arm. The syphilis prevention intervention benefits were robust among FSWs at low-tier venues, individuals with less than high school education, migrants, and women who did not report condom use during the last episode of sex.

CONCLUSIONS

Integrated sexually transmitted infection and human immunodeficiency virus prevention strategies substantially reduce syphilis incidence among FSWs, especially among those at low-tier venues. This intervention suggests the need for scaling up comprehensive FSW programs in China.

Prevent cervical cancer by screening with reliable human papillomavirus detection and genotyping

The incidence of cervical cancer is expected to rise sharply in China. A reliable routine human papillomavirus (HPV) detection and genotyping test to be supplemented by the limited Papanicolaou cytology facilities is urgently needed to help identify the patients with cervical precancer for preventive interventions. To this end, we evaluated a nested polymerase chain reaction (PCR) protocol for detection of HPV L1 gene DNA in cervicovaginal cells. The PCR amplicons were genotyped by direct DNA sequencing. In parallel, split samples were subjected to a Digene HC2 HPV test which has been widely used for "cervical cancer risk" screen. Of the 1826 specimens, 1655 contained sufficient materials for analysis and 657 were truly negative. PCR/DNA sequencing showed 674 infected by a single high-risk HPV, 188 by a single low-risk HPV, and 136 by multiple HPV genotypes with up to five HPV genotypes in one specimen. In comparison, the HC2 test classified 713 specimens as infected by high-risk HPV, and 942 as negative for HPV infections. The high-risk HC2 test correctly detected 388 (57.6%) of the 674 high-risk HPV isolates in clinical specimens, mislabeled 88 (46.8%) of the 188 low-risk HPV isolates as high-risk genotypes, and classified 180 (27.4%) of the 657 "true-negative" samples as being infected by high-risk HPV. It was found to cross-react with 20 low-risk HPV genotypes. We conclude that nested PCR detection of HPV followed by short target DNA sequencing can be used for screening and genotyping to formulate a paradigm in clinical management of HPV-related disorders in a rapidly developing economy.

Improving reproductive health in rural China through participatory planning

China's new health reform initiative aims to provide quality accessible health care to all, including remote rural populations, by 2020. Public health insurance coverage for the rural poor has increased, but rural women have fared worse because of lower status and lack of voice in shaping the services they need. Use of prenatal care, safe delivery and reproductive tract infections (RTIs) services is inadequate and service seeking for health problems remains lower for men. We present findings from a study of gender and health equity in rural China from 2002 to 2008 and offer recommendations from over a decade of applied research on reproductive health in rural China. Three studies, conducted in poor counties between 1994 and 2008, identified problems in access and pilot tested interventions and mechanisms to increase women's participation in health planning. They were done in conjunction with a World Bank programme and the global Gender and Health Equity Network (GHEN). Reproductive health service-seeking improved and the study interventions increased local government commitment to providing such services through new health insurance mechanisms. Findings from the studies were summarised into recommendations on gender and health for inclusion in new health reform efforts.

Expanding provider-initiated HIV testing at STI clinics in China

Despite expanding sexually transmitted epidemics in South China, the majority of patients presenting to sexually transmitted infection (STI) clinics are not routinely screened for HIV infection. Identifying barriers to offering HIV testing among STI care providers is an important public health priority. The aim of this study was to investigate the frequency of offering HIV testing among STI care providers in South China and reported physician barriers to offering HIV testing. More detailed operational data regarding HIV test offer frequency and barriers to testing may enhance routine HIV testing at STI clinics. A sample of 62 STI care providers within the Pearl River Delta Region of South China completed a survey including socio-demographic and training background information (including sex, age, medical education, year of terminal medical degree, and HIV-specific training), reasons for not offering HIV testing routinely, and physical examination and sexual history taking practices. Frequency of offering HIV testing was calculated based on reports from research assistants and operational data. STI care providers offered HIV testing to 3011/10,592 (28.4%) of their patients. There was substantial variability across providers in the frequency of offering testing, ranging from 3 to 100%. None of the identified physician factors were associated with offering HIV testing 100% of the time in the multivariate model. The most commonly physician reported barriers to HIV testing included: (1) low perceived prevalence of disease and (2) not recommended by current guidelines. Forty-seven providers (76%) reported asking about same sex behaviors rarely or never. Further research on HIV screening practices of STI care providers may help scale up HIV provider-initiated testing and counseling programs.

HIV testing and care systems focused on sexually transmitted HIV in China

BACKGROUND

Over three-quarters of new HIV infections in China during 2009 were estimated to be from sexual transmission. Over half of those living with HIV do not know their serostatus and identifying and treating individuals with sexually transmitted HIV infection has been challenging.

OBJECTIVE

This global assessment explores Chinese systems for detecting and treating those with HIV infection with a particular focus on groups at increased risk of sexually transmitted HIV.

METHODS

Published literature, grey sources and non-governmental reports were reviewed to describe HIV testing and care systems in China.

RESULTS

HIV testing and care in China involve several parallel health systems and have been largely successful in reaching large numbers of vulnerable individuals. Provider-initiated testing and counselling has been more effective than voluntary counselling and testing programmes for expanding HIV testing efforts in China. Individuals with sexually transmitted HIV infection are underrepresented in the antiretroviral care system compared with other high-risk groups.

CONCLUSIONS

Comprehensive HIV testing and care bring together a number of Chinese health systems, but there are still gaps and challenges. Research and programmes focused on HIV testing and care for those with increased sexual risk are needed.

Prevalence of syphilis infection in different tiers of female sex workers in China: implications for surveillance and interventions

BACKGROUND

Syphilis has made a dramatic resurgence in China during the past two decades and become the third most prevalent notifiable infectious disease in China. Female sex workers (FSWs) have become one of key populations for the epidemic. In order to investigate syphilis infection among different tiers of FSWs, a cross-sectional study was conducted in 8 sites in China.

METHODS

Serum specimens (n = 7,118) were collected to test for syphilis and questionnaire interviews were conducted to obtain socio-demographic and behavioral information among FSWs recruited from different types of venues. FSWs were categorized into three tiers (high-, middle- and low-tier FSWs) based on the venues where they solicited clients. Serum specimens were screened with enzyme-linked immunosorbent assay (ELISA) for treponemal antibody followed by confirmation with non-treponemal toluidine red unheated serum test (TRUST) for positive ELISA specimens to determine syphilis infection. A logistic regression model was used to determine factors associated with syphilis infection.

RESULTS

Overall syphilis prevalence was 5.0% (95%CI, 4.5-5.5%). Low-tier FSWs had the highest prevalence (9.7%; 95%CI, 8.3-11.1%), followed by middle-tier (4.3%; 95%CI, 3.6-5.0%, P < 0.001) and high-tier FSWs (2.2%; 95%CI, 1.6-2.9%, P < 0.001). Factors independently associated with syphilis infection included older age, lower education level, geographic location, lower tier of typology, and injection drug use.

CONCLUSIONS

This multi-site survey showed a high prevalence of syphilis infection among FSWs and substantial disparities in syphilis prevalence by the tier of FSWs. The difference in syphilis prevalence is substantial between different tiers of FSWs, with the highest rate among low-tier FSWs. Thus, current surveillance and intervention activities, which have low coverage in low-tier FSWs in China, should be further examined.

Prior HIV testing among STD patients in Guangdong Province, China: opportunities for expanding detection of sexually transmitted HIV infection

BACKGROUND

Expanding HIV testing is important among individuals at increased risk for sexual HIV transmission in China, but little is known about prior HIV testing experiences among sexually transmitted disease (STD) patients.

METHODS

This cross-sectional study of 1792 outpatients from 6 public STD clinics in Guangdong Province recorded detailed information about ever having been tested for HIV infection in addition to sociodemographic variables, health seeking, clinical STD history, and HIV stigma using a validated survey instrument.

RESULTS

A total of 456 (25.4%) of the STD patients in this sample had ever been tested for HIV infection. STD patients who were male, had higher income, more education, were at City A and City C, received STD services at public facilities, had used intravenous drugs, and had a history of an STD were more likely to ever receive an HIV test in multivariate analysis. Low perceived HIV risk was the most common reason for not receiving an HIV test. Only 7.7% of the sample reported fear of discrimination or loss of face as influencing their lack of HIV testing.

CONCLUSION

Incomplete prior HIV screening among STD patients in China suggests the need for broadening HIV testing opportunities at STD clinics and similar clinical settings attended by those with increased sexual risk.

The increasing prevalence of serologic markers for syphilis among Chinese blood donors in 2008 through 2010 during a syphilis epidemic

BACKGROUND

In China, the growing syphilis epidemic parallels the spread of human immunodeficiency virus (HIV) in the general population. This study evaluated the prevalence and incidence of serologic markers for syphilis among donors at five Chinese blood centers.

STUDY DESIGN AND METHODS

We examined whole blood and apheresis donations collected from January 2008 through December 2010. Postdonation testing of syphilis was conducted using two different Treponema pallidum antibody enzyme-linked immunosorbent assay kits. The prevalence of serologic markers for syphilis (%), and the rate of coinfection with HIV-1/2, hepatitis B virus (HBV), and hepatitis C virus (HCV) were calculated. A multivariable logistic regression analysis was conducted examining donor characteristics associated with positive syphilis serology. Seroconversion rate and syphilis incidence were estimated.

RESULTS

Of 801,511 donations, 60% were from first-time donors and 40% were from repeat donors. There was a significant increase in syphilis serologic markers among first-time donors with 0.41, 0.45, and 0.57% positivity over 3 years (p < 0.001). Approximately 2.8, 0.8, and 0.5% of HIV-1/2-, HBV-, and HCV-positive donations also tested reactive for syphilis. Logistic regression results suggest that first-time donors were nine times more likely to be syphilis positive than repeat donors. Higher syphilis positivity was associated with donors older than 25 years and with less education. Estimated incidence among repeat donations was 33 (95% confidence interval, 29-39) per 100,000 person-years.

CONCLUSION

The increase in syphilis serologic prevalence reflected the syphilis epidemic in the general population. Without screening, most of these syphilis-positive donations would get into the blood supply. Thus, during a syphilis epidemic, continued syphilis screening of blood donations may be important to maintain blood safety and public health.

Influence of temporary migration on the transmission of infectious diseases in a migrants' home village

The number of temporary migrant workers from rural areas to urban areas in emerging market economies like China has increased dramatically since the early 1980s. Temporary migrant workers have been labeled as the major driving force for the rising incidence of infectious diseases in cities. However, it has not been well recognized that temporary migration indeed may have tremendous impacts on the spread of infectious diseases in migrants' home villages. In this paper, by proposing a delay differential equation model, we provide a framework to study the influence of temporary migration on the transmission of infectious diseases in a migrant workers' home village. The model is shown to admit a unique positive equilibrium which is locally asymptotically stable and is globally asymptotically stable under certain conditions. This implies that the disease always persists at a constant level. Considering tuberculosis as an example, we explore various disease prevention and control strategies numerically to demonstrate how migration related parameters affect the early outbreak of the disease. We find that a single control strategy, such as reducing the migration time period alone, has little effect on reducing the disease endemic level. For disease prevention and control, temporary migrant workers should be identified as the top target group, and a combination of several prevention strategies should be implemented.

A case series of 130 neonates with congenital syphilis: preterm neonates had more clinical evidences of infection than term neonates

BACKGROUND

The early clinical manifestations of congenital syphilis (CS) vary from asymptomatic to florid lesions, involving multisystem damage. But little is known about the differences of early clinical features between preterm and term neonates with CS.

OBJECTIVES

To compare the clinical characteristics between preterm and term neonates with CS and analyze the possible underlying reasons for the differences.

METHODS

Consecutive medical charts of infants at risk for CS from January 1999 to December 2009 were retrospectively reviewed. Neonates with positive 19S-IgM in serum were included in the study.

RESULTS

Among the 1,670 cases at risk for CS, 130 neonatal cases with positive 19S-IgM in serum were included in the analysis, including 58 preterm ones and 72 full-term ones. Compared with term neonates with CS, preterm ones were more likely to have characteristic skin rash (36.2 vs. 9.7%, p < 0.001), hepatomegaly (51.7 vs. 25%, p = 0.02), splenomegaly (32.8 vs. 15.4%, p = 0.02), PRP titer ≥1:8 (96.6 vs. 70.8%, p < 0.001), thrombocytopenia (43.1 vs. 23.6%, p = 0.018), elevated CRP (65.5 vs. 36.5%, p = 0.002), and abnormal long bone X-ray results (94.6 vs. 68.1%, p < 0.001). Fewer mothers of preterm neonates with CS received treatment for syphilis (15.5 vs. 40.3%, p = 0.003). The rate of withdrawal of care was higher in preterm neonates with CS (31 vs.12.5%, p = 0.036).

CONCLUSIONS

Preterm neonates with CS had more clinical evidences and suffered more than term ones.

HIV/STD pattern and its associated risk factors among male STD clinic attendees in China: a foci for HIV intervention

BACKGROUND

Previous studies suggested a high prevalence of STDs including HIV among female sex workers and men who have sex with men in China, but little was known about the prevalence in male patients attending public STD clinics. The aim of this study was to investigate STD patterns and HIV prevalence among male STD clinic attendees in different areas in China and the associated risk factors. The feasibility of Provider-initiated HIV testing and counseling (PITC) was evaluated as well.

METHODS

A cross-sectional study was conducted at 46 public STD clinics in 4 provinces in China. Between July 2009 and September 2009, a total of 3243 eligible subjects were invited to participate in an interview with a structured-questionnaire for collecting socio-demographic characteristics and sexual behavioral information. They also were asked to provide venous blood samples for serological determinations of HIV and syphilis infection, and first void urine specimens for detecting Chlamydia trachomatis and Neisseria gonorrhoeae infections,

RESULTS

Out of the 3243 eligible patients, 2951(91%) men agreed to take part in the HIV and syphilis testing. The overall prevalence rate of HIV infection was 0.7% while the rates of syphilis, N. gonorrhoeae, C. trachomatis infections were 10.7%, 4.3% and 6.9%, respectively, with the highest syphilis and N. gonorrhoeae rates in Jiangsu Province. Patients from Guangxi province, homosexual/bisexual practices and intravenous drug use were significantly associated with HIV infection in multivariate logistic regression analyses. Provider-initiated HIV testing and counseling (PITC) was well accepted by attendees, with 91% of eligible attendees agreeing to undergo HIV testing and counseling. All HIV positive patients were properly managed accordingly.

CONCLUSIONS

A modest prevalence of HIV infection and substantial prevalence of other STD infections were found among male patients attending public STD clinics in China. The findings further support the introduction of HIV and syphilis PITC strategy into this important setting.

Molecular typing of Treponema pallidum: a systematic review and meta-analysis

BACKGROUND

Syphilis is resurgent in many regions of the world. Molecular typing is a robust tool for investigating strain diversity and epidemiology. This study aimed to review original research on molecular typing of Treponema pallidum (T. pallidum) with three objectives: (1) to determine specimen types most suitable for molecular typing; (2) to determine T. pallidum subtype distribution across geographic areas; and (3) to summarize available information on subtypes associated with neurosyphilis and macrolide resistance.

METHODOLOGY/PRINCIPAL FINDINGS

Two researchers independently searched five databases from 1998 through 2010, assessed for eligibility and study quality, and extracted data. Search terms included "Treponema pallidum," or "syphilis," combined with the subject headings "molecular," "subtyping," "typing," "genotype," and "epidemiology." Sixteen eligible studies were included. Publication bias was not statistically significant by the Begg rank correlation test. Medians, inter-quartile ranges, and 95% confidence intervals were determined for DNA extraction and full typing efficiency. A random-effects model was used to perform subgroup analyses to reduce obvious between-study heterogeneity. Primary and secondary lesions and ear lobe blood specimens had an average higher yield of T. pallidum DNA (83.0% vs. 28.2%, χ(2) = 247.6, p<0.001) and an average higher efficiency of full molecular typing (80.9% vs. 43.1%, χ(2) = 102.3, p<0.001) compared to plasma, whole blood, and cerebrospinal fluid. A pooled analysis of subtype distribution based on country location showed that 14d was the most common subtype, and subtype distribution varied across geographic areas. Subtype data associated with macrolide resistance and neurosyphilis were limited.

CONCLUSIONS/SIGNIFICANCE

Primary lesion was a better specimen for obtaining T. pallidum DNA than blood. There was wide geographic variation in T. pallidum subtypes. More research is needed on the relationship between clinical presentation and subtype, and further validation of ear lobe blood for obtaining T. pallidum DNA would be useful for future molecular studies of syphilis.