Assessing Trends in Chlamydia Positivity and Gonorrhea Incidence and Their Associations With the Incidence of Pelvic Inflammatory Disease and Ectopic Pregnancy in Washington State, 1988-2010

Sexually Transmitted Infections and the Risk of Reinfection Within 12 Months: A Population-Based Cohort

BACKGROUND

Chlamydia, gonorrhea, and syphilis are common sexually transmitted infections that disproportionately affect specific groups in New Zealand (NZ). Predictors of reinfection are not well studied in NZ but could inform public health strategies to decrease sexually transmitted infection (STI) incidence.

METHODS

New Zealand-wide chlamydia, gonorrhea, and syphilis cases during 2019 were identified using nationally collected data. Cases were followed-up to identify reinfection with the same STI within 12 months of initial infections. Logistic regression models were used to identify predictors for each STI reinfection.

RESULTS

Determinants identified for increased odds of chlamydia reinfection were age groups 16-19 and 20-24 years, females, Māori and Pacific peoples, cases in the Northern region, and cases with at least one test before the initial infection. Age 40 years and older was associated with lower odds of gonorrhea reinfection, as was being of Asian ethnicity, living in Midland or Southern regions, and reporting heterosexual behavior. Region was the only statistically significant predictor for syphilis reinfection, with higher odds of reinfection for people living in the Central region.

CONCLUSIONS

Our findings reflect disproportionate STI rates for some groups in NZ, with younger age groups, Māori and Pacific peoples, men who have sex with men, and people living in the Northern region experiencing higher odds of reinfection. Groups identified with higher odds for reinfection require increased access to culturally responsive health services to treat, understand, and prevent possible reinfection. Changes to current public health strategies could include culturally specific behavioral counseling, and improvements to and adherence to effective contract tracing.

Global burden of pelvic inflammatory disease and ectopic pregnancy from 1990 to 2019

BACKGROUND

Pelvic inflammatory disease (PID) is a widespread female public problem worldwide. And it could lead to infertility, preterm labor, chronic pelvic pain, and ectopic pregnancy (EP) among reproductive-aged women. This study aimed to assess the global burden and trends as well as the chaning correlation between PID and EP in reproductive-aged women from 1990 to 2019.

METHODS

The data of PID and EP among reproductive-aged women (15 to 49 years old) were extracted from the Global Burden of Disease study 2019. The disease burden was assessed by calculating the case numbers and age-standardized rates (ASR). The changing trends and correlation were evaluated by calculating the estimated annual percentage changes (EAPC) and Pearson's correlation coefficient.

RESULTS

In 2019, the ASR of PID prevalence was 53.19 per 100,000 population with a decreasing trend from 1990 (EAPC: - 0.50), while the ASR of EP incidence was 342.44 per 100,000 population with a decreasing trend from 1990 (EAPC: - 1.15). Globally, PID and EP burdens changed with a strong positive correlation (Cor = 0.89) globally from 1990 to 2019. In 2019, Western Sub-Saharan Africa, Australasia, and Central Sub-Saharan Africa had the highest ASR of PID prevalence, and Oceania, Eastern Europe, and Southern Latin America had the highest ASR of EP incidence. Only Western Europe saw significant increasing PID trends, while Eastern Europe and Western Europe saw increasing EP trends. The highest correlations between PID and EP burden were observed in Burkina Faso, Laos, and Bhutan. General negative correlations between the socio-demographic index and the ASR of PID prevalence and the ASR of EP incidence were observed at the national levels.

CONCLUSION

PID and EP continue to be public health burdens with a strong correlation despite slightly decreasing trends detected in ASRs globally. Effective interventions and strategies should be established according to the local situation by policymakers.

Global prevalence of Neisseria gonorrhoeae infection in pregnant women: a systematic review and meta-analysis

BACKGROUND

Neisseria gonorrhoeae infection (gonorrhoea) is associated with several pregnancy complications, including preterm labour, spontaneous abortion, stillbirth, miscarriage, growth retardation, and intrauterine death.

OBJECTIVES

We performed a systematic review and meta-analysis to estimate the global and regional prevalence of gonorrhoea in pregnant women as a scientific basis for further studies.

DATA SOURCES

We systematically searched PubMed/MEDLINE, Web of Science, Embase, Scopus, and SciELO databases from inception to 10 July 2022.

STUDY ELIGIBILITY CRITERIA

We included cross-sectional, cohort, and case-control studies that reported the prevalence of gonorrhoea in pregnant women. In addition, we included baseline data for randomized controlled trials.

PARTICIPANTS

Pregnant women who were tested for gonorrhoea.

METHODS

Pooled prevalence estimates at 95% CIs were calculated using a random-effects meta-analysis model. We stratified countries according to WHO-defined regions and socio-economic factors. Moreover, sub-group-, meta-regression, and sensitivity analyses were conducted to investigate the effects of pre-determined factors on prevalence estimates and heterogeneity.

RESULTS

We identified 235 studies (249 datasets) on 19 104 175 pregnant women from 71 countries. The worldwide pooled prevalence of gonorrhoea in pregnant women was estimated at 1.85% (95% CI 1.73-1.97%), with the highest rate in the African region (3.53%) (2.84-4.29%) and the lowest rate in the European region (0.52%) (0.27-0.84%). Overall, the prevalence estimates were high among low-income countries (3.03%), pregnant women with HIV (2.81%), and pregnant women <20 years old (8.06%). A significant decreasing trend in prevalence was observed over time (β = -0.0008, 95% CI -0.0012 to -0.0004, p 0.001).

DISCUSSION

Our findings indicate that a substantial number of pregnant women have been infected with gonorrhoea globally, which calls for immediate public health measures to reduce the potential risk of infection. The study highlights the inadequacy or lack of data for many countries, emphasizing the need to expand systematic data collection efforts at national and regional levels.

Estimates of infertility in the United States: 1995-2019

OBJECTIVE

To estimate the changes in infertility from 1995-2019 and determine the association of individual-level characteristics with fertility in the United States.

DESIGN

Cross-sectional study.

SETTING

Periodic data from 1995, 2002, 2006-2010, 2011-2013, 2013-2015, 2015-2017, and 2017-2019 cycles of the National Survey for Family Growth were used for this analysis. The National Survey for Family Growth comprises samples of the household-level population of women aged 15-44 years in the United States.

PATIENT(S)

Surveyed married and cohabiting women aged 15-44 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcomes were the rates of infertility across subgroups of married or cohabiting women. For secondary outcomes, we performed bivariable and multivariable logistic regression models using the pooled sample (N = 53,764) to determine the association of individual-level characteristics, including age, parity, pelvic inflammatory disease treatment, education, income, race or ethnicity, and receipt of sexual and reproductive health services, with the odds of 12-month infertility among married or cohabiting women.

RESULT(S)

The fluctuations in infertility over this period, with a low of 5.8% in 2006-2010 and a high of 8.1% in 2017-2019, were not found to be statistically significant. This trend was present across nearly all subgroups. The multivariable model showed that women who were older and nulliparous, had fewer years of education, had lower income, were non-Hispanic black, or were not receiving sexual and reproductive health services were more likely to be infertile.

CONCLUSION(S)

This study confirms that parity, age, race, and education level continue to have an association with infertility. Further, the results demonstrate that access to sexual and reproductive health services plays an important role in infertility. In contrast to previous studies, infertility in the United States is no longer on the decline, and Hispanic ethnicity did not have a significant relationship with infertility. Given the rise of sexually transmitted infections and the persistent lack of access to sexual and reproductive health services, particularly among already vulnerable groups, the connection between access to care and infertility is ripe for further investigation.

Incidence Trends of Five Common Sexually Transmitted Infections Excluding HIV From 1990 to 2019 at the Global, Regional, and National Levels: Results From the Global Burden of Disease Study 2019

Objective

Sexually transmitted infections (STIs) are common worldwide and pose a challenge to public health. We conducted this study to assess the annual incidence of five common STIs, including syphilis, chlamydia, gonorrhea, trichomoniasis, and genital herpes at the global, regional, and national levels.

Materials and Methods

We obtained detailed data on STIs excluding HIV from 1990 to 2019 from the Global Burden of Disease (GBD) 2019 database. Estimated annual percentage change (EAPC) was calculated to quantify trends in age-standardized incidence rates (ASR) of STIs, stratified by gender, sociodemographic index (SDI) region, and pathogenic microorganism.

Results

Globally, incident cases of STIs increased by 58.15% from 486.77 million in 1990 to 769.85 million in 2019, but the annual change in ASR was only -0.04% (95% CI -0.09 to 0.01) per year. EAPC was 0.16 (0.06 to 0.26) for syphilis, 0.09 (0.05 to 0.13) for genital herpes, 0.06 (0.03 to 0.09) for trichomoniasis, -0.21 (-0.36 to -0.06) for chlamydia, and -0.14 (-0.19 to -0.08) for gonorrhea. High SDI regions reported significant increases in ASR of syphilis and chlamydia.

Conclusions

The burden of disease from STIs remains large, though control of STIs has contributed to the decreasing incidence in most regions, especially in the low-SDI regions. Globally, over the past 20 years, the ASR has remained stable for trichomoniasis and genital herpes decreased for chlamydia and gonorrhea, and increased for syphilis.

Strategies for successful designing of immunocontraceptive vaccines and recent updates in vaccine development against sexually transmitted infections - A Review

Background

Objective

Methods

Results

Conclusion

Burden of Mycoplasma genitalium and Bacterial Coinfections in a Population-Based Sample in New Mexico

ABSTRACT

In this population-based US study, the overall prevalence of Mycoplasma genitalium was 1.95% (95% confidence interval [CI], 1.62%-2.34%), declining from 6.12% (95% CI, 4.72%-7.92%) in women aged 21 to 24 years to 0.48% (95% CI, 0.25%-0.94%) in women aged 40 to 64 years. The prevalence of coinfections with Chlamydia trachomatis and Trichomonas vaginalis was low.

HIV pre-exposure prophylaxis and sexually transmitted infections: intersection and opportunity

Pre-exposure prophylaxis (PrEP) has revolutionized HIV prevention, but PrEP does not protect against other sexually transmitted infections (STIs). Rates of STIs are rising worldwide, with notably high incidences among PrEP-using men who have sex with men in high-income countries; in low-income and middle-income countries, data are sparse, but results from a limited number of studies among African women initiating and taking PrEP have shown high STI prevalence and incidence. Efforts aimed at markedly reducing HIV in populations worldwide include a major focus on increasing PrEP use, along with improving HIV testing and treatment in order to eliminate HIV transmission. Together, these efforts could augment continued expansion of the global STI epidemic, but they could alternatively create an opportunity to improve STI control, including the development of comprehensive sexual health programmes and research to develop new STI prevention strategies. The introduction of PrEP globally has been characterized by challenges and many successes, and its role as part of a range of robust strategies to reduce HIV infections is clear. Looking ahead, understanding rising rates of curable STIs and their relationship to HIV prevention, and considering the future directions for synergies in PrEP and STI prevention will be integral to improving sexual health.

Applying a novel approach to scoping review incorporating artificial intelligence: mapping the natural history of gonorrhoea

BACKGROUND

Systematic and scoping literature searches are increasingly resource intensive. We present the results of a scoping review which combines the use of a novel artificial-intelligence-(AI)-assisted Medline search tool with two other 'traditional' literature search methods. We illustrate this novel approach with a case study to identify and map the range of conditions (clinical presentations, complications, coinfections and health problems) associated with gonorrhoea infection.

METHODS

To fully characterize the range of health outcomes associated with gonorrhoea, we combined a high yield preliminary search with a traditional systematic search, then supplemented with the output of a novel AI-assisted Medline search tool based on natural language processing methods to identify eligible literature.

RESULTS

We identified 189 health conditions associated with gonorrhoea infection of which: 53 were identified through the initial 'high yield' search; 99 through the systematic search; and 124 through the AI-assisted search. These were extracted from 107 unique references and 21 International Statistical Classification of Diseases and Related Health Problems Ninth and Tenth Revision (ICD 9/10) or Read codes. Health conditions were mapped to the urogenital tract (n = 86), anorectal tract (n = 6) oropharyngeal tract (n = 5) and the eye (n = 14); and other conditions such as systemic (n = 61) and neonatal conditions (n = 7), psychosocial associations (n = 3), and co-infections (n = 7). The 107 unique references attained a Scottish Intercollegiate Guidelines Network (SIGN) score of ≥2++ (n = 2), 2+ (14 [13%]), 2- (30 [28%]) and 3 (45 [42%]), respectively. The remaining papers (n = 16) were reviews.

CONCLUSIONS

Through AI screening of Medline, we captured - titles, abstracts, case reports and case series related to rare but serious health conditions related to gonorrhoea infection. These outcomes might otherwise have been missed during a systematic search. The AI-assisted search provided a useful addition to traditional/manual literature searches especially when rapid results are required in an exploratory setting.

Nonviral sexually transmitted infections in pregnancy: current controversies and new challenges

PURPOSE OF REVIEW

This review provides an update of nonviral, curable sexually transmitted infections (STIs) in pregnancy and summarizes our understanding of the current issues and controversies surrounding risk factors, screening, and treatment of STIs in pregnancy primarily in high-income countries (using the United States and the United Kingdom as examples). The infections covered in this review are syphilis, gonorrhea, chlamydia, trichomoniasis, and Mycoplasma genitalium infections.

RECENT FINDINGS

Overall, limited modern data is available to update researchers and clinicians on the epidemiology and care of STIs in pregnancy. Though common risk factors can be identified among these STIs, like socioeconomic status and inadequate antenatal care, specific screening and treatment challenges vary by geography and pathogen. Wherever available, surveillance data and research evidence are often limited to nonpregnant patients, leading to imperfect pregnancy-specific risk estimates and obstetric lags in the development and adoption of new guidelines. We have identified three areas of opportunity that may enhance the effectiveness of current approaches and inform new ones: improved data collection and evidence-based screening practices; prompt and comprehensive therapy, including partner services, and evaluations of new treatment modalities; and equitable antenatal and sexual healthcare for all pregnant persons and their partners.

SUMMARY

These findings highlight the need to revisit standards of screening and management of STIs in pregnancy in high-income countries.

Risk of Pelvic Inflammatory Disease in Relation to Chlamydia and Gonorrhea Testing, Repeat Testing, and Positivity: A Population-Based Cohort Study

Background

There is uncertainty around whether the risks of pelvic inflammatory disease (PID) differ following Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhea) infection. We quantified the risk of PID associated with chlamydia and gonorrhea infection and subsequent repeat infections in a whole-population cohort.

Methods

A cohort of 315123 Western Australian women, born during 1974-1995, was probabilistically linked to chlamydia and gonorrhea testing records and to hospitalizations and emergency department presentations for PID from 2002 to 2013. Time-updated survival analysis was used to investigate the association between chlamydia and gonorrhea testing, and positivity, and risk of PID.

Results

Over 3199135 person-years, 120748 women had pathology test records for both chlamydia and gonorrhea, 10745 chlamydia only, and 653 gonorrhea only. Among those tested, 16778 (12.8%) had ≥1 positive chlamydia test, 3195 (2.6%) ≥1 positive gonorrhea test, and 1874 (1.6%) were positive for both. There were 4819 PID presentations (2222 hospitalizations, 2597 emergency presentations). Adjusting for age, Aboriginality, year of follow-up, health area, and socioeconomic status, compared to women negative for chlamydia and gonorrhea, the relative risk (adjusted incidence rate ratio) of PID was 4.29 (95% confidence interval [CI], 3.66-5.03) in women who were both chlamydia and gonorrhea positive; 4.54 (95% CI, 3.87-5.33) in those only gonorrhea positive; and 1.77 (95% CI, 1.61-1.94) in those only chlamydia positive.

Conclusions

Gonorrhea infection conferred a substantially higher risk than chlamydia of hospitalization or emergency department presentation for PID. The emergence of gonorrhea antimicrobial resistance may have a serious impact on rates of PID and its associated reproductive health sequelae.

Chlamydia trachomatis infection among patients attending sexual and reproductive health clinics: A cross-sectional study in Bao'an District, Shenzhen, China

This study aimed to estimate the prevalence of chlamydial trachomatis (CT) infection and explore its risk factors among patients attending sexual and reproductive health clinics in Shenzhen, China. We collected demographic and clinical information from attendees (aged 18–49). CT and Neisseria gonorrhoeae (NG) infection was determined by nucleic acid amplification test (NAAT) on self-collected urine specimens. Of 1,938 participants recruited, 10.3% (95% confidence interval [CI]: 9.6%-11.0%) tested positive for CT. Prevalence was similar between men (10.6% [85/804]; 95% CI, 9.5%–11.7%) and women (10.1% [115/1134]; 95% CI: 9.2%–11.0%). Being 18–25 years old (adjusted odds ratio [aOR] = 2.52; 95%CI:1.35–4.71), never tested for CT before (aOR = 2.42; 95%CI: 1.05–5.61) and infected with NG(aOR = 3.87; 95%CI: 2.10–7.10) were independently associated with CT infection. We found that CT infection is prevalent among patients attending sexual and reproductive health clinics in Shenzhen, China. A comprehensive program including CT screening, surveillance and treatment is urgently needed.

Ectopic pregnancy rate in Iranian midwifery clients and infertile patients treated by assisted reproductive technologies

OBJECTIVE

There are some studies on the prevalence of ectopic pregnancy (EP) in a different population of Iranian women. This study aimed to estimate the ectopic pregnancy prevalence in obstetrical clients and infertile patients treated by assisted reproductive technologies in Iran.

METHODS

International and national databases including PubMed, Web of Science, Ovid, Scopus, ScienceDirect, Magiran, Iran doc, and Iran Medex were searched up to January 2016. Also, conference databases were searched. All studies in which, the ectopic pregnancy prevalence in Iranian obstetrical clients and infertile patients treated by assisted reproductive technologies were reported, included and reviewed. Data of studies were extracted into a standard data sheet. Meta-analysis was conducted by a random-effects model with 95% confidence interval.

RESULTS

Eight studies were included, involving overall 571 826 women of whom 1446 had an ectopic pregnancy. The overall prevalence of ectopic pregnancy in obstetrical units of the hospitals and assisted reproductive technologies patients was 2.9 (95% CI: 2.1, 3.7) and 53 (95% CI: 20.4, 85.6) per 1000 clients, respectively.

CONCLUSION

There is limited evidence on the ectopic pregnancy prevalence in Iranian obstetrical clients and assisted reproductive technologies patients. Furthermore, a significant heterogeneity existed between the results. So, more population-based studies on national data are needed for the exact estimation of the ectopic pregnancy prevalence in Iran.

Racial/Ethnic Disparities in the Lifetime Risk of Chlamydia trachomatis Diagnosis and Adverse Reproductive Health Outcomes Among Women in King County, Washington

Background

Chlamydia trachomatis is the most common reportable infection in the United States and can cause pelvic inflammatory disease (PID) and tubal factor infertility (TFI).

Methods

We created life tables to estimate the "lifetime" risk of chlamydia diagnosis among women aged 15-34 years in King County, Washington, between 1992 and 2014. We estimated the lifetime risk of chlamydia-associated PID and TFI incorporating published estimates of the risk of sequelae.

Results

There were 51464 first chlamydia diagnoses in 1992-2014. For women born between 1980 and 1984, the lifetime risk of chlamydia diagnosis was 19.8% overall and 14.0% for non-Hispanic white, 64.9% for non-Hispanic black, and 32.6% for Hispanic women. The cumulative risk of chlamydia by age 24 increased overall from 13.9% to 17.3% among women born between 1975 and 1994 but declined among non-Hispanic black women, among whom risk by age 24 declined from 57.3% among women born between 1980 and 1984 to 38.6% among women born between 1990 and 1994. The lifetime risk of chlamydia-associated PID among women born between 1980 and 1984 ranged from 0.33% to 1.14%. Among non-Hispanic white, non-Hispanic black, and Hispanic women, the lifetime risk of chlamydia-associated TFI was 0.04%, 0.20%, and 0.10%, respectively.

Conclusions

Over 60% of non-Hispanic black women had at least 1 chlamydia diagnosis by age 34 in the birth cohorts most affected, a risk almost 5 times that in non-Hispanic whites. An estimated 1 in 500 non-Hispanic black women develops chlamydia-associated TFI. More effective control measures are needed.

Rates of pelvic inflammatory disease and ectopic pregnancy in Australia, 2009-2014: ecological analysis of hospital data

OBJECTIVE

To analyse yearly rates of pelvic inflammatory disease (PID) and ectopic pregnancy (EP) diagnosed in hospital settings in Australia from 2009 to 2014.

METHODS

We calculated yearly PID and EP diagnosis rates in three states (Victoria, New South Wales, Queensland) for women aged 15-44 years using hospital admissions and emergency department (ED) attendance data, with population and live birth denominators. We stratified PID diagnoses as chlamydial-related or gonorrhoeal-related (Chlamydia trachomatis (CT)-related or Neisseria gonorrhoeae (NG)-related), acute, unspecified and chronic, and analysed variations by year, age and residential area using Poisson regression models.

RESULTS

For PID, the rate of all admissions in 2014 was 63.3 per 100 000 women (95% CI 60.8 to 65.9) and of all presentations in EDs was 97.0 per 100 000 women (95% CI 93.9 to 100.2). Comparing 2014 with 2009, the rate of all PID admissions did not change, but the rate of all presentations in EDs increased (adjusted incidence rate ratio (aIRR) 1.34, 95% CI 1.24 to 1.45), and for admissions by PID category was higher for CT-related or NG-related PID (aIRR 1.73, 95% CI 1.31 to 2.28) and unspecified PID (aIRR 1.09, 95% CI 1.00 to 1.19), and lower for chronic PID (aIRR 0.84, 95% CI 0.74 to 0.95). For EP, in 2014 the rate of all admissions was 17.4 (95% CI 16.9 to 17.9) per 1000 live births and of all ED presentations was 15.6 (95% CI 15.1 to 16.1). Comparing 2014 with 2009, the rates of all EP admissions (aIRR 1.06, 95% CI 1.04 to 1.08) and rates in EDs (aIRR 1.24, 95% CI 1.18 to 1.31) were higher.

CONCLUSIONS

PID and EP remain important causes of hospital admissions for female STI-associated complications. Hospital EDs care for more PID cases than inpatient departments, particularly for young women. Updated primary care data are needed to better understand PID epidemiology and healthcare usage.

Pyosalpinges after hysterosalpingography in a patient with lower genital tract infection and managed by laparoscopic surgery in a resource low tertiary hospital case report and literature review

Background

Pyosalpinges (a complication of pelvic inflammatory disease) is infection of the fallopian tubes and the morbidity associated with it has major health implications. We are reporting a case of pyosalpinges diagnosed after hysterosalpingography and managed by laparoscopic surgery at the Douala General Hospital, Cameroon.

Case presentation

A 29-year-old single woman, an assistant nurse of the Douala tribe in Cameroon. She is G1P0010 and came to our attention because of secondary infertility of three years duration. She has a history consistent with four lifetime sexual partners, self-medication for chlamydia trachomatis infection and induced abortion by dilatation and aspiration. Furthermore, she is HIV positive and had an ultrasound scan suggestive of bilateral hydrosalpinges. After a hysterosalpingography examination she developed painless muco-purulent vaginal discharge and bilateral adnexal tenderness on bimanual examination suggestive of pyosalpinges. Vaginal and cervical cultures isolated Ureaplasma urealyticum and Gardnerella vaginalis sensitive to ofloxacin and metronidazole, respectively.At laparoscopy, bilateral pyosalpinges, pelvic adhesions and peri-hepatic adhesions were found. Bilateral salpingectomy with adhesiolysis including lysis of perihepatic adhesions and peritoneal toileting was done. She was discharged from hospital 72 h later and her hospital stay was uneventful. She was counseled for in-vitro fertilization and to register in the national HIV treatment programme. Her husband was prescribed ofloxacin empirically.

Conclusion

Antimicrobial prophylaxis should be given to patients prior to HSG, especially those with a history of chlamydia or evidence of hydrosalpinges. There should also be universal STI testing in high risk and HIV positive patients or the danger for suboptimal antibiotic usage in areas where self-medication is common.In resource-low tertiary hospitals where computed tomography or magnetic resonance imaging is not readily available and/or affordable, clinical examination and pelvic ultrasound remains the key diagnostic tool. Surgical treatment is the best option for pyosalpinges and when plausible, laparoscopic surgery is the treatment of choice. Laparotomy is the mainstay in most hospitals in Cameroon. The parent of the patient did not consent to histo-pathologic examination.

Trends in pelvic inflammatory disease emergency department visits, United States, 2006-2013

BACKGROUND

Pelvic inflammatory disease is a female genital tract disorder with severe reproductive sequelae. Because of the difficulties in diagnosing pelvic inflammatory disease, it is not a reportable condition in many states. Females seeking care in emergency departments are a sentinel population for pelvic inflammatory disease surveillance.

OBJECTIVE

The objective of the study was to determine trends in diagnoses of acute pelvic inflammatory disease in a nationally representative sample of emergency departments.

STUDY DESIGN

All emergency department visits among females aged 15-44 years with an International Classification of Diseases, ninth revision, Clinical Modification diagnosis code indicating pelvic inflammatory disease during 2006-2013 were assessed from the HealthCare Utilization Project Nationwide Emergency Department Sample. Total and annual percentage changes in the proportion of pelvic inflammatory disease emergency department visits were estimated using trend analyses.

RESULTS

While the number of emergency department visits among females aged 15-44 years during 2006-2013 increased (6.5 million to 7.4 million), the percentage of visits due to pelvic inflammatory disease decreased from 0.57% in 2006 to 0.41% in 2013 (total percentage change, -28.4%; annual percent change, -4.3%; 95% confidence interval, -5.7% to -2.9%). The largest decreases were among those aged 15-19 years (total percent change, -40.6%; annual percentage change, -6.6%; 95% confidence interval, -8.6% to -4.4%) and living in the South (total percentage change, -38.0%; annual percentage change, -6.2%; 95% confidence interval, -7.8% to -4.6%). Females aged 15-19 years who lived in the South had a 47.9% decrease in visits due to pelvic inflammatory disease (annual percentage change, -8.4%, 95% confidence interval, -10.4 to -6.5). Patients living in ZIP codes with the lowest median income (<$38,000) had the highest percent of visits with a pelvic inflammatory disease diagnosis; the smallest declines over time were in patients living in ZIP codes with the highest median income (i.e., >$64,000, total percent change, -24.4%; annual percent change, -3.8%; 95% confidence interval, -5.2% to -2.4%). The percentage of emergency department visits due to pelvic inflammatory disease was highest among patients not charged for their visit, self-paying, or those covered by Medicaid, with total percentage changes in these 3 groups of -27.8%, -30.7%, and -35.1%, respectively. Patients with Medicaid coverage had the largest decrease in visits with a diagnosis of pelvic inflammatory disease (total percent change, -35.1%; annual percent change, -5.8%; 95% confidence interval, -7.2% to -4.3%).

CONCLUSION

Nationally representative data indicate the percentage of emergency department visits with a pelvic inflammatory disease diagnosis decreased during 2006-2013 among females aged 15-44 years, primarily driven by decreased diagnoses of pelvic inflammatory disease among females aged 15-19 years and among women living in the southern United States. Despite declines, a large number of females of reproductive age are receiving care for pelvic inflammatory disease in emergency departments. Patients with lower median income and no or public health insurance status, which may decrease access to and use of health care services, consistently had the highest percentage of emergency department visits due to pelvic inflammatory disease. Future research should focus on obtaining a better understanding of factors influencing trends in pelvic inflammatory disease diagnoses and ways to address the challenges surrounding surveillance for this condition.

Sexually transmitted infections: challenges ahead

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

The Influence of Asthma and/or Hay Fever on Pregnancy: Data from the 1995 National Survey of Family Growth

BACKGROUND

Asthma is associated with adverse pregnancy outcomes. At the same time there is a worldwide increase in asthma and hay fever.

OBJECTIVE

This study addresses whether asthma and/or hay fever adversely influence pregnancy outcomes.

METHODS

Data from the 1995 National Survey of Family Growth that include a history of diagnosed asthma, hay fever, and adverse pregnancy outcomes in 10,847 women representative of the US population aged 15 to 44 years were analyzed.

RESULTS

Women with the allergic phenotypes asthma and hay fever and hay fever only had no significant increase in adverse pregnancy outcomes (spontaneous pregnancy loss, preterm birth, infant low birth weight), whereas women with the nonatopic phenotype asthma only (without hay fever) did. The study did not evaluate endotypes.

CONCLUSIONS

This study provides new data that the allergic phenotypes, asthma and hay fever and hay fever only, are compatible with healthy pregnancy, whereas the nonatopic asthma phenotype, asthma only, adversely impacts pregnancy.

Sexually transmitted diseases and infertility

Female infertility, including tubal factor infertility, is a major public health concern worldwide. Most cases of tubal factor infertility are attributable to untreated sexually transmitted diseases that ascend along the reproductive tract and are capable of causing tubal inflammation, damage, and scarring. Evidence has consistently demonstrated the effects of Chlamydia trachomatis and Neisseria gonorrhoeae as pathogenic bacteria involved in reproductive tract morbidities including tubal factor infertility and pelvic inflammatory disease. There is limited evidence in the medical literature that other sexually transmitted organisms, including Mycoplasma genitalium, Trichomonas vaginalis, and other microorganisms within the vaginal microbiome, may be important factors involved in the pathology of infertility. Further investigation into the vaginal microbiome and other potential pathogens is necessary to identify preventable causes of tubal factor infertility. Improved clinical screening and prevention of ascending infection may provide a solution to the persistent burden of infertility.