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Lyu H, Tang H, Feng Y, Hu S, Wang Y, Zhou L, Huang S, Li J, Zhu H, He X, Tang W, Zhou Y, Zhang L. Incidence and spontaneous clearance of gonorrhea and chlamydia infections among men who have sex with men: a prospective cohort study in Zhuhai, China. Front Public Health 2024; 12:1348686. [PMID: 38770362 PMCID: PMC11102956 DOI: 10.3389/fpubh.2024.1348686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/22/2024] [Indexed: 05/22/2024] Open
Abstract
Background Men who have sex with men (MSM) face significant risks of Chlamydia trachomatis (CT) and/or Neisseria gonorrhoeae (NG) infection. Nevertheless, only limited studies have looked into the site-specific infection and clearance of CT/NG. In order to prevent transmission, it is essential to understand the underlying factors that drive infection and spontaneous clearance. Methods A 12-week cohort study examined the association between CT/NG infection, self-clearance, and sexual behaviors among MSM. The Willingness Service recruited participants who completed weekly questionnaires and provided urine, throat, and rectal swab samples. Results The study involved 151 men, in which 51 (33.8%) were diagnosed with CT/NG infection during the study period. HIV (OR = 11.31), kissing (OR = 1.59), receptive oral sex (OR = 36.64), and insertive anal sex (OR = 19.73) constituted significant risk factors. 100% condom use (OR = 5.78) and antibiotic (OR = 7.53) were more likely to cause spontaneous clearance. Discussion MSM may engage in riskier sexual behaviors due to insufficient knowledge and awareness of STI prevention, leading to increased susceptibility to NG/CT. It is crucial to concentrate on enhancing health education for MSM. Conclusion This study found that the rectum was the most prevalent site of CT/NG and sexual behavior can influence the infection. Additionally, the appropriate use of antibiotics and consistent condom use may contribute to clear spontaneously.
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Affiliation(s)
- Hang Lyu
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Haotong Tang
- Jieyang Center for Disease Control and Prevention, Jieyang, China
| | - Yunlong Feng
- Longhua District Center for Disease Control and Prevention, Shenzhen, China
| | - Shuyan Hu
- Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, China
| | - Yuyu Wang
- Longhua District Center for Disease Control and Prevention, Shenzhen, China
| | - Lanlan Zhou
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Shanzi Huang
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Jiarun Li
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Huamei Zhu
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Xi He
- Zhuhai Xutong Voluntary Services Center, Zhuhai, China
| | - Weiming Tang
- University of North Carolina Project-China, Guangzhou, China
- Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Yi Zhou
- Zhuhai Center for Disease Control and Prevention, Zhuhai, China
| | - Lei Zhang
- China-Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Artificial Intelligence and Modelling in Epidemiology Program, Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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Sánchez-Torres M, Espadafor-López B, Llavero-Molino I, Álvarez-Serrano MA, García-García I, Hueso-Montoro C, Pérez-Morente MÁ. Sexually Transmitted Infections in 2000-2018 in a Specialised Centre: Comparison between Pre-Crisis, Crisis, and Post-Crisis Period. J Clin Med 2023; 12:5254. [PMID: 37629296 PMCID: PMC10455687 DOI: 10.3390/jcm12165254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
(1) Background: Sexually Transmitted Infections (STIs) are a major public health problem due to their consequences in sexual and reproductive health. There is a close link between the crisis and the increase in communicable diseases. The objective of this study was to analyse the evolution of Sexually Transmitted Infections during the period 2000-2018 in the population attending the Centre for Sexually Transmitted Diseases and Sexual Orientation in Granada (Spain), specifically comparing the pre-crisis, crisis, and post-crisis periods. (2) Methods: A retrospective, observational, and analytical study was conducted by reviewing medical records. The sample analysed comprised 1666 cases. (3) Results: During the pre-crisis period (2000-2007), the percentage of diagnoses was 41.6% (n = 126) compared to 58.4% (n = 177) of negative results; during the crisis, the percentages were 63.5% (n = 183) and 36.5% (n = 105), respectively; and during the post-crisis period, the percentages were 42.9% (n = 157) and 57.1% (n = 209), respectively. The variables that were significantly associated with STI diagnosis were the time periods analysed, sexual orientation, occupation, and age at first intercourse. The evolution of the number of positive diagnoses during the entire study period showed a trend of progressive increase in Sexually Transmitted Infections from 2000 to 2018. (4) Conclusions: The period of economic crisis presented a higher risk of infection, although this is a finding with certain limitations due to the lack of homogeneity between the periods analysed.
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Affiliation(s)
- María Sánchez-Torres
- Virgen de la Arrixaca University Clinical Hospital, El Palmar, 30120 Murcia, Spain;
| | - Beatriz Espadafor-López
- Virgen de las Nieves University Hospital, Center for Sexually Transmitted Infections, Andalusian Health Service, 18012 Granada, Spain;
| | | | | | | | - César Hueso-Montoro
- Department of Nursing, Faculty of Health Sciences, University of Jaén, 23071 Jaén, Spain;
- Instituto Biosanitario Granada (IBS. Granada), 18012 Granada, Spain
- Centro de Investigación Mente, Cerebro y Comportamiento (CIMCYC) of the University of Granada, 18011 Granada, Spain
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Li T, Liu Z, Zhang D, Liao Q, Fan S, Hao M, Hong Y, Huang X, Wang H, Xiong Z, Xu H, Xue F, Xue M, Yang X, Zhang J. Prevalence of and risk factors for chlamydia in female outpatients with genital tract infections: a nationwide multi-center, cross-sectional study in China. Front Public Health 2023; 11:1182108. [PMID: 37397732 PMCID: PMC10311204 DOI: 10.3389/fpubh.2023.1182108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/18/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Chlamydia trachomatis is the etiological agent of the commonest sexually transmitted bacterial infection. This study aimed to examine the prevalence of genital chlamydia and associated risk factors in Chinese female outpatients with genital tract infections. Methods A prospective, multicenter epidemiological study of genital chlamydia prevalence in 3008 patients with genital tract infections in 13 hospitals in 12 provinces of China was performed between May 2017 and November 2018. Vaginal secretion specimens were collected for the clinical diagnosis of vaginitis, whereas cervical secretion specimens were tested for Chlamydia trachomatis and Neisseria gonorrhoeae. All patients participated in a one-on-one cross-sectional questionnaire interview. Results Totally 2,908 participants were included. The prevalence rates of chlamydia and gonococcal infections in women with genital tract infections were 6.33% (184/2908) and 0.01% (20/2908), respectively. Multivariate analysis showed high risk factors for chlamydia were premarital sex behavior, first sexual intercourse before the age of 20 and bacterial vaginosis. Discussion Given that most chlamydia cases are asymptomatic and no vaccine is currently available, chlamydia prevention strategies should include behavioral interventions as well as early screening programs to identify and treat individuals with genital tract infections, especially those with the above identified risk factors.
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Affiliation(s)
- Ting Li
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Beijing Maternal and Child Health Care Hospital, Capital Medical University, Beijing, China
| | - Zhaohui Liu
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Beijing Maternal and Child Health Care Hospital, Capital Medical University, Beijing, China
| | - Dai Zhang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Qinping Liao
- Department of Obstetrics and Gynecology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Shangrong Fan
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Min Hao
- Department of Obstetrics and Gynecology, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Ying Hong
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Xiufeng Huang
- Department of Obstetrics and Gynecology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Huilan Wang
- Department of Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhengai Xiong
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hong Xu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Fengxia Xue
- Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, Tianjin, China
| | - Min Xue
- Department of Obstetrics and Gynecology, Third Xiangya Hospital of Central South University, Changsha, China
| | - Xingsheng Yang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
| | - Jianqing Zhang
- Department of Obstetrics and Gynecology, Qinghai Red Cross Hospital, Xining, China
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Nie MZ, Zhang RQ, Zhao MC, Tan H, Hu YX, Fan GH, Li JY, He AN, Tian FY, Li FY, Zheng YH, Shen XX, Tie YQ, Ma XJ. Development of a duplex recombinase-aided amplification assay for direct detection of Mycoplasma pneumoniae and Chlamydia trachomatis in clinical samples. METHODS IN MICROBIOLOGY 2022; 198:106504. [PMID: 35654228 DOI: 10.1016/j.mimet.2022.106504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pneumonia caused by Mycoplasma pneumoniae is common in the elderly and children, and pneumonia caused by Chlamydia trachomatis is prevalent in newborns. This study aimed to establish a rapid, sensitive, and simple method for the direct detection of M. pneumoniae and C. trachomatis in clinical samples without DNA extraction. METHODS We established a duplex recombinase-aided amplification (RAA) assay with the RNAseP gene as an internal control for detecting the P1 gene of M. pneumoniae and the ORF8 gene of C. trachomatis, respectively. The results were obtained at 39 °C within 15-20 min. A total of 130 clinical samples suspected of M. pneumoniae or C. trachomatis infection were collected and tested by duplex RAA and PCR. DNA extracted via a commercial kit or treated with a nucleic acid-releasing agent was used and compared, respectively. Standard recombinant plasmids were used to test the sensitivity of the duplex RAA assay. In addition, other similar common pathogens were used to verify the specificity of the duplex RAA assay. RESULTS The sensitivity of the duplex RAA assay for detecting M. pneumoniae and C. trachomatis was 10 copies/μL using recombinant plasmids. Compared with PCR, the sensitivity and specificity of duplex RAA assays for M. pneumoniae and C. trachomatis was 100% using clinical DNA samples extracted using a commercial kit and a nucleic acid-releasing agent, and the Kappa value was 1. CONCLUSION The advantages of this duplex RAA assay include high sensitivity and specificity, short duration, and simple extraction steps, with potential for use in the on-site detection of M. pneumoniae and C. trachomatis in resource-limited settings.
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Affiliation(s)
- Ming-Zhu Nie
- Hebei Medical University, Shijiazhuang 050031, Hebei, China; NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
| | - Rui-Qing Zhang
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
| | - Meng-Chuan Zhao
- Children's Hospital of Hebei Province, Shijiazhuang 050031, Hebei, China
| | - He Tan
- Hebei General Hospital, Shijiazhuang 050051, Hebei, China
| | - Ya-Xin Hu
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China; North China University of Science and Technology, Tangshan 063210, Hebei, China
| | - Guo-Hao Fan
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China
| | - Jing-Yi Li
- Hebei Medical University, Shijiazhuang 050031, Hebei, China; NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China
| | - An-Na He
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China; North China University of Science and Technology, Tangshan 063210, Hebei, China
| | - Feng-Yu Tian
- Hebei Medical University, Shijiazhuang 050031, Hebei, China; NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China
| | - Feng-Yu Li
- Hebei Medical University, Shijiazhuang 050031, Hebei, China; NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China
| | - Ye-Huan Zheng
- Autobio Diagnostics CO., Ltd, Zhengzhou 450000, Henan, China
| | - Xin-Xin Shen
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
| | - Yan-Qing Tie
- Hebei General Hospital, Shijiazhuang 050051, Hebei, China.
| | - Xue-Jun Ma
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, No. 155, Changbai Street, Changping District, Beijing 102206, China.
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Weng R, Zhang C, Wen L, Luo Y, Ye J, Wang H, Li J, Ning N, Huang J, Chen X, Cai Y. Chlamydia-related knowledge, opinion to opportunistic testing, and practices of providers among different sexually transmitted infections related departments in hospitals in Shenzhen city, China. BMC Health Serv Res 2022; 22:601. [PMID: 35509056 PMCID: PMC9067339 DOI: 10.1186/s12913-022-08012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/27/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Chlamydia trachomatis (CT) infection could lead to seriously adverse outcomes if left untreated. This study aimed to determine CT-related knowledge, opinion to testing, and practices of providers among different sexually transmitted infections (STI) related departments in hospitals in Shenzhen city, China, and also to explore the differences in these responses. MATERIALS AND METHODS From 1st April 2018 to 15th April 2018, a cross-sectional study was conducted in Shenzhen and 64 of 66 hospitals agreed to participate in this study. In the hospital sites, all the providers from the department of obstetrics and gynecology, department of dermatology and venereology, department of urology, and anorectal surgical department were recruited. A structured paper-based questionnaire was used to obtain data on CT-related information. RESULTS A total of 355 providers from 64 hospitals participated in the current study. Compared to providers from the department of dermatology and venereology, those from the department of obstetrics and gynecology (OR = 0.31, 95% CI 0.16-0.62), department of urology (OR = 0.32, 95% CI 0.16-0.65), and anorectal surgical department (OR = 0.25, 95% CI 0.09-0.71) were less likely to identify that "Be in a long-term mutually monogamous relationship with a partner who has been tested and has negative STI test results." is an appropriate way for a sexually active person to reduce risk of getting CT. Also, those from the department of obstetrics and gynecology (OR = 0.45, 95% CI 0.23-0.87) were less likely to identify that "Use latex condoms the right way every time you have sex" is another appropriate way. A high proportion of providers agreed that all sexually active patients attending to their department should be screened regularly (77.1%), and they are willing to offer opportunistic CT screening (96.0%). Only 11.4% of respondents correctly identified that the appropriate time frame of the CT retesting is three months. CONCLUSIONS Providers among STI-related departments in hospitals showed a very high willingness to offer opportunistic CT screening. However, this study showed important gaps in providers' knowledge and practices in China, targeted training in CT-related knowledge and practice is urgently needed.
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Affiliation(s)
- Rongxing Weng
- Department of STD Control and Prevention, Shenzhen Center for Chronic Disease Control, No. 2021, Buxin Road, Luohu District, Shenzhen City, Guangdong Province, China
| | - Chunlai Zhang
- Department of STD Control and Prevention, Shenzhen Center for Chronic Disease Control, No. 2021, Buxin Road, Luohu District, Shenzhen City, Guangdong Province, China
| | - Lizhang Wen
- Department of STD Control and Prevention, Shenzhen Center for Chronic Disease Control, No. 2021, Buxin Road, Luohu District, Shenzhen City, Guangdong Province, China
| | - Yiting Luo
- Department of STD Control and Prevention, Shenzhen Center for Chronic Disease Control, No. 2021, Buxin Road, Luohu District, Shenzhen City, Guangdong Province, China
| | - Jianbin Ye
- Department of STD Control and Prevention, Shenzhen Center for Chronic Disease Control, No. 2021, Buxin Road, Luohu District, Shenzhen City, Guangdong Province, China
| | - Honglin Wang
- Department of STD Control and Prevention, Shenzhen Center for Chronic Disease Control, No. 2021, Buxin Road, Luohu District, Shenzhen City, Guangdong Province, China
| | - Jing Li
- Department of STD Control and Prevention, Shenzhen Center for Chronic Disease Control, No. 2021, Buxin Road, Luohu District, Shenzhen City, Guangdong Province, China
| | - Ning Ning
- Department of STD Control and Prevention, Shenzhen Center for Chronic Disease Control, No. 2021, Buxin Road, Luohu District, Shenzhen City, Guangdong Province, China
- Shantou University Medical College, Shantou, 515000, China
| | - Junxin Huang
- Department of STD Control and Prevention, Shenzhen Center for Chronic Disease Control, No. 2021, Buxin Road, Luohu District, Shenzhen City, Guangdong Province, China
| | - Xiangsheng Chen
- Chinese Academy of Medical Sciences & Peking Union Medical College Institute of Dermatology, Nanjing, China
- National Center for STD Control, China Center for Disease Control and Prevention, Nanjing, China
| | - Yumao Cai
- Department of STD Control and Prevention, Shenzhen Center for Chronic Disease Control, No. 2021, Buxin Road, Luohu District, Shenzhen City, Guangdong Province, China.
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Ning N, Weng R, Zhang C, Wen L, Wang H, Ye J, Li J, Chen X, Cai Y. Cluster analysis for symptomatic management of Neisseria gonorrhoea and Chlamydia trachomatis in sexually transmitted infections related clinics in China. Front Public Health 2022; 10:1005481. [PMID: 36466460 PMCID: PMC9714346 DOI: 10.3389/fpubh.2022.1005481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/17/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study aimed to perform a cluster analysis of symptoms linked with Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) and to identify which cluster of symptoms was associated with a higher risk of NG and CT. STUDY DESIGN From 15 April to 16 May 2018, a cross-sectional study was conducted, and patients attending sexually transmitted infections (STI) related clinics were recruited from 22 medical institutions in six districts of Shenzhen city. METHODS A structured questionnaire was used to collect social-demographic information as well as STI symptoms, and urine samples were collected for nucleic acid detection. Cluster analysis and logistic regression were applied. RESULTS Among 8,207 participants, the prevalence of CT and NG infection was 9.04% (742/8,207) and 2.36% (194/8,207), respectively. Among male outpatients, four clusters with distinct symptomatic patterns were identified. Unmarried, having casual sexual partners in the past 6 months, cluster 2 (OR = 6.70, 95% CI = 3.36-13.35) and cluster 4 (OR = 24.53, 95% CI = 12.96-46.44) were risk factors associated with NG infection. Unmarried, cluster 2 (OR = 2.54, 95% CI = 1.83-3.53) and cluster 4 (OR = 3.31, 95% CI = 2.37-4.61) were risk factors associated with CT infection. Among female outpatients, five clusters with distinct symptomatic patterns were identified. Aged 24 years or below and cluster 3 (OR = 3.68, 95% CI = 1.61-8.39) were risk factors associated with NG infection. Aged 24 years or below, unmarried, having a high school/secondary technical school education, and having junior high school or below education were risk factors associated with CT infection. CONCLUSION The cluster of symptoms integrated into risk assessment for CT and NG infections suggests a new strategy of symptomatic management. Healthcare providers in STI clinics and resource-limited places may use this strategy to identify more potential patients and deliver adequate, acceptable, and equitable STI care for outpatients with a high risk of STI.
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Affiliation(s)
- Ning Ning
- Shenzhen Center for Chronic Disease Control, Shenzhen, China
- Shantou University Medical College, Shantou University, Shantou, China
| | - Rongxing Weng
- Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Chunlai Zhang
- Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Lizhang Wen
- Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Honglin Wang
- Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Jianbin Ye
- Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Jing Li
- Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Xiangsheng Chen
- Chinese Academy of Medical Sciences, Institute of Dermatology, Peking Union Medical College, Nanjing, China
- National Center for STD Control, China Center for Disease Control and Prevention, Nanjing, China
| | - Yumao Cai
- Shenzhen Center for Chronic Disease Control, Shenzhen, China
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