Sexually transmitted diseases in Ulaanbaatar, Mongolia

Adult female syphilis prevalence, congenital syphilis case incidence and adverse birth outcomes, Mongolia 2000-2016: Estimates using the Spectrum STI tool

INTRODUCTION

Mongolia's health ministry prioritizes control of Sexually Transmitted Infections, including syphilis screening and treatment in antenatal care (ANC).

METHODS

Adult syphilis prevalence trends were fitted using the Spectrum-STI estimation tool, using data from ANC surveys and routine screening over 1997-2016. Estimates were combined with programmatic data to estimate numbers of treated and untreated pregnant women with syphilis and associated incidence congenital syphilis (CS) and CS-attributable adverse birth outcomes (ABO), which we compared with CS case reports.

RESULTS

Syphilis prevalence in pregnant women was estimated at 1.7% in 2000 and 3.0% in 2016. We estimated 652 CS cases, of which 410 ABO, in 2016. Far larger, annually increasing numbers of CS cases and ABO were estimated to have been prevented: 1654 cases, of which 789 ABO in 2016 - thanks to increasing coverages of ANC (99% in 2016), ANC-based screening (97% in 2016) and treatment of women diagnosed (81% in 2016). The 42 CS cases reported nationally over 2016 (liveborn infants only) represented 27% of liveborn infants with clinical CS, but only 7% of estimated CS cases among women found syphilis-infected in ANC, and 6% of all estimated CS cases including those born to women with undiagnosed syphilis.

DISCUSSION/CONCLUSION

Mongolia's ANC-based syphilis screening program is reducing CS, but maternal prevalence remains high. To eliminate CS (target: <50 cases per 100,000 live births), Mongolia should strengthen ANC services, limiting losses during referral for treatment, and under-diagnosis of CS including still-births and neonatal deaths, and expand syphilis screening and prevention programs.

Trends in adult chlamydia and gonorrhoea prevalence, incidence and urethral discharge case reporting in Mongolia from 1995 to 2016 - estimates using the Spectrum-STI model

OBJECTIVE

To estimate Mongolia's prevalence and incidence trends of gonorrhoea and chlamydia in women and men 15-49 years old to inform control of STIs and HIV, a national health sector priority.

METHODS

We applied the Spectrum-STI estimation model, fitting data from two national population surveys (2001 and 2008) and from routine gonorrhoea screening of pregnant women in antenatal care (1997 to 2016) adjusted for diagnostic test performance, male/female differences and missing high-risk populations. Prevalence and incidence estimates were then used to assess completeness of national case reporting.

RESULTS

Gonorrhoea prevalence was estimated at 3.3% (95% confidence interval, 1.6-3.9%) in women and 2.9% (1.6-4.1%) in men in 2016; chlamydia prevalence levels were 19.5% (17.3-21.9%) and 15.6% (10.0-21.2%), respectively. Corresponding new incident cases in women and men in 2016 totalled 60 334 (36 147 to 121 933) and 76 893 (35 639 to 254 913) for gonorrhoea and 131 306 (84 232 to 254 316) and 148 162 (71 885 to 462 588) for chlamydia. Gonorrhoea and chlamydia prevalence declined by an estimated 33% and 11%, respectively from 2001 to 2016.Comparing numbers of symptomatic and treated cases estimated by Spectrum with gonorrhoea case reports suggests that 15% of symptomatic treated gonorrhoea cases were reported in 2016; only a minority of chlamydia episodes were reported as male urethral discharge cases.

DISCUSSION

Gonorrhoea and chlamydia prevalence are estimated to have declined in Mongolia during the early 2000s, possibly associated with syndromic management in primary care facilities and improving treatment coverage since 2001 and scale up of HIV/STI prevention interventions since 2003. However, prevalence remains high with most gonorrhoea and chlamydia cases not treated or recorded in the public health system.

Systematizing planning and formative phases of HIV prevention research: Case studies from Brazil, Mongolia, and Kazakhstan

OBJECTIVES

International Community Based Participatory Research (CBPR) is vulnerable to contextual, political, and interpersonal issues that may hamper researchers' abilities to develop and sustain partnerships with local communities. This paper responds to a call for systematizing CBPR practices and to the urgent need for frameworks with potential to facilitate partnership-building between researchers and communities in both "developed" and "developing" countries.

METHODS

Using three brief case examples, each from a different context, with different partners and varied research questions, we demonstrate how to apply the International Participatory Research Framework (IPRF).

RESULTS

IPRF consists of triangulated procedures (steps and actions) that can facilitate known participatory outcomes: 1) community-defined research goals, 2) capacity for further research, and 3) policies and programs grounded in research.

CONCLUSIONS

We show how the application of this model is particularly helpful in the planning and formative phases of CBPR. Other partnerships can use this framework in its entirety or aspects thereof, in different contexts. Further evaluation of how this framework can help other international partnerships, studying myriad diseases and conditions, should be a focus of future international CBPR.

Metronidazole resistance in Trichomonas vaginalis from highland women in Papua New Guinea

BACKGROUND

The prevalence of the sexually transmissible protozoan parasite Trichomonas vaginalis in the highlands of Papua New Guinea (PNG) has been reported to be as high as 46% and although not previously studied in Papua New Guinea, clinical resistance against metronidazole (Mz), the drug most commonly used to treat trichomoniasis, is well documented worldwide. This study was primarily aimed at assessing resistance to Mz in T. vaginalis strains from the Goroka region.

METHODS

Consenting patients presenting at the Goroka Base Hospital Sexually Transmitted Diseases (STD) Clinic and local women were asked to provide two vaginal swabs: one for culturing of the parasite; and one for polymerase chain reaction detection of T. vaginalis, Chlamydia trachomatis and Neisseria gonorrhoeae. T. vaginalis isolates were assayed for Mz susceptibility and a selection was genotyped.

RESULTS

The prevalence of T. vaginalis was determined to be 32.9% by culture and polymerase chain reaction of swabs among 82 local women and patients from the STD clinic. An unexpectedly high level of in vitro Mz resistance was determined with 17.4% of isolates displaying unexpectedly high resistance to Mz. The ability to identify isolates of T. vaginalis by genotyping was confirmed and the results revealed a more homogeneous T. vaginalis population in Papua New Guinea compared with isolates from elsewhere.

CONCLUSION

T. vaginalis is highly prevalent in the Goroka region and in vitro Mz resistance data suggest that clinical resistance may become an issue.

High-risk status of HIV-1 infection in the very low epidemic country, Mongolia, 2007

Thirty-six HIV-1 cases had been reported by December 2007 in Mongolia. Therefore, Mongolia has been regarded as a very low HIV-1 epidemic country, although the surveillance system is not fully developed. The aim of this study was to evaluate the risk status of HIV-1 infection in Mongolia. A total of 1415 blood samples from high-risk populations including female sex workers, men who have sex with men, mobile men, tuberculosis patients and male sexually transmitted infection (STI) clinic clients and 1050 samples from healthy controls were collected. The seroprevalences of anti-HIV-1/2, anti- Treponema pallidum, hepatitis B surface antigen (HBs Ag), anti-hepatitis C virus and hepatitis B surface antibody in the high-risk populations were 0%, 23.1%, 15.5%, 8.0% and 48.2%, and those in the controls were 0%, 3.1%, 14.7%, 4.4% and 44.4%, respectively. HIV-1 prevalence is currently low. However, according to the high prevalence of STIs in the high-risk populations, the risk status for HIV-1 infection is estimated to be high.

Temporal associations with declining Trichomonas vaginalis diagnosis rates among women in the state of Victoria, Australia, 1947 to 2005

BACKGROUND

To investigate the temporal associations between Trichomonas vaginalis (TV) diagnoses in women at a large urban sexual health clinic and a major Papanicolaou (Pap) smear screening laboratory in Victoria, Australia with Pap smear screening rates and the introduction of nitroimidazole treatments.

METHODS

An ecological analysis of TV diagnosis rates at the Melbourne Sexual Health Centre and the Victorian Cytology Service, Pap smear screening rates and nitroimidazole prescription data.

RESULTS

Diagnoses of TV at the Melbourne Sexual Health Centre peaked in the 1950s at 20% to 30% and then rapidly declined through the 1960s and 1970s to below 1% in 1990. A similar pattern was observed at the Victorian Cytology Service. Metronidazole prescribing and opportunistic Pap smear screening began in Victoria in the 1960s coinciding with declining TV. The availability of tinidazole in 1976 led to further declines in TV in the late 1970s. A national cervical screening program introduced in 1991 was temporally associated with further declines in TV.

CONCLUSIONS

Our analyses suggest that the introduction of metronidazole was associated with a large reduction in TV among Victorian women in the 1960s. The subsequent availability of tinidazole and increased Pap smear screening may have contributed to the current low TV prevalence in Victoria.

Structural details and composition of Trichomonas vaginalis lipophosphoglycan in relevance to the epithelial immune function

Trichomonas vaginalis causes the most common non-viral sexually transmitted infection linked to increased risk of premature birth, cervical cancer and HIV. This study defines molecular domains of the parasite surface glycoconjugate lipophosphoglycan (LPG) with distinct functions in the host immunoinflammatory response. The ceramide phospho-inositol glycan core (CPI-GC) released by mild acid had Mr of approximately 8,700 Da determined by MALDI-TOF MS. Rha, GlcN, Gal and Xyl and small amounts of GalN and Glc were found in CPI-GC. N-acetyllactosamine repeats were identified by endo-beta-galactosidase treatment followed by MALDI-MS and MS/MS and capLC/ESI-MS/MS analyses. Mild acid hydrolysis led to products rich in internal deoxyhexose residues. The CPI-GC induced chemokine production, NF-kappaB and extracellular signal-regulated kinase (ERK)1/2 activation in human cervicovaginal epithelial cells, but neither the released saccharide components nor the lipid-devoid LPG showed these activities. These results suggest a dominant role for CPI-GC in the pathogenic epithelial response to trichomoniasis.

Human Papillomavirus Infection in Ulaanbaatar, Mongolia: A Population-Based Study

Data on human papillomavirus (HPV) and cervical cancer burden in Central Asia are scarce. To investigate HPV infection in Ulaanbaatar, the capital of Mongolia, we obtained cervical cell specimens from a population of 969 women ages 15 to 59 years. DNA of 44 HPV types was detected using a GP5+/6+ PCR-based assay. Seropositivity for L1 proteins of HPV 16, 18, 31, 33, 45, 52, and 58 was assessed using multiplex HPV serology. Cytologic abnormalities were detected in 127 women (13.1%), among whom 6 cervical intraepithelial neoplasia grade 3 and 2 invasive cervical cancers were diagnosed. Overall HPV DNA prevalence was 35.0%, being highest (48.5%) in women ages &lt;25 years. High-risk types were detected in 24.5% of women. HPV DNA prevalence declined with age but remained &gt;25% in all age groups. HPV seroprevalence was also very high (38.0%) and increased steadily from 33.2% to 48.9% in women ages &lt;25 and 50 to 59 years, respectively. However, the proportion of women positive for both HPV markers of any individual HPV type was low. HPV16 was the most frequently detected type by PCR (6.1%), serology (23.0%), or both (2.1%). Lifetime number of sexual partners and induced abortions were shown to be directly associated with HPV DNA and/or seroprevalence. HPV prevalence in Ulaanbaatar was higher than that detected by similar HPV testing protocols in other populations in Asia or elsewhere and would suggest an important, yet unquantified, cervical cancer burden. Improving cervical cancer prevention, through screening and HPV vaccination, is an important public health issue for Mongolia. (Cancer Epidemiol Biomarkers Prev 2008;17(7):1731–8)

Risk Factors and Prevalence of HIV and Sexually Transmitted Infections Among Low-Income Female Commercial Sex Workers in Mongolia

BACKGROUND

Mongolia has very low HIV prevalence despite high rates of sexually transmitted infections (STIs). Low-income female sex workers (FSWs) may be at high risk for acquiring and spreading the disease in Mongolia.

GOAL

The goal of this study was to assess the prevalence and risk factors associated with the acquisition of HIV, syphilis, gonorrhea, and trichomoniasis among low-income female commercial sex workers in 3 urban centers in Mongolia.

STUDY DESIGN

One hundred seventy-nine low-income FSWs were tested for HIV (enzyme immunoassay) and 132 were tested for syphilis (Treponema pallidum hemagglutination-confirmed), gonorrhea (Gram stain and culture), and trichomoniasis (wet mount microscopy). Questionnaires detailing socioeconomic characteristics, sexual behaviors, drug and alcohol use, general health, and STI/HIV knowledge were completed by 149 women.

RESULTS

No HIV infections were found in 179 women. Of 132 women, 57 (43%), 18 (14%), and 37 (28%) tested positive for syphilis, gonorrhea, and trichomonas, respectively; 88 (67%) tested positive for one or more STIs and 22 (17%) were multiply infected. Socioeconomic factors were correlated to reported condom use and infection status.

CONCLUSIONS

Low-income FSWs in Mongolia represent a unique population of very high-risk individuals with very low rates of HIV infection. Interventions targeting this population represent a unique opportunity to prevent a potentially rapid increase of HIV infection in urban Mongolia.

Current therapeutics, their problems, and sulfur-containing-amino-acid metabolism as a novel target against infections by "amitochondriate" protozoan parasites

The "amitochondriate" protozoan parasites of humans Entamoeba histolytica, Giardia intestinalis, and Trichomonas vaginalis share many biochemical features, e.g., energy and amino acid metabolism, a spectrum of drugs for their treatment, and the occurrence of drug resistance. These parasites possess metabolic pathways that are divergent from those of their mammalian hosts and are often considered to be good targets for drug development. Sulfur-containing-amino-acid metabolism represents one such divergent metabolic pathway, namely, the cysteine biosynthetic pathway and methionine gamma-lyase-mediated catabolism of sulfur-containing amino acids, which are present in T. vaginalis and E. histolytica but absent in G. intestinalis. These pathways are potentially exploitable for development of drugs against amoebiasis and trichomoniasis. For instance, L-trifluoromethionine, which is catalyzed by methionine gamma-lyase and produces a toxic product, is effective against T. vaginalis and E. histolytica parasites in vitro and in vivo and may represent a good lead compound. In this review, we summarize the biology of these microaerophilic parasites, their clinical manifestation and epidemiology of disease, chemotherapeutics, the modes of action of representative drugs, and problems related to these drugs, including drug resistance. We further discuss our approach to exploit unique sulfur-containing-amino-acid metabolism, focusing on development of drugs against E. histolytica.

Genotyping Trichomonas vaginalis

A genotyping method has been developed to distinguish each Trichomonas vaginalis isolate and has provided the first genome mapping studies of this protist with an estimated 180Mb genome. The technique was developed using high molecular weight DNA prepared from five laboratory isolates from Australia and USA and 20 clinical isolates from South Africa. Inhibition of the notorious T. vaginalis endogenous nucleases by addition of potent inhibitors was essential to the success of this study. Chromosomal DNA larger than 2.2Mb was macrorestricted to a minimum segment size of approximately 50kb, separated by pulsed field gel electrophoresis and hybridised with a variety of gene probes. Each isolate generated a unique pattern that was distinguished by each of the probes. Four single copy gene probes (fd, hmp35, ibp39 and pfoD) were identified but probes which identified several bands (pfoB and alpha-scs) per isolate were most informative for genotyping. The pyruvate:ferredoxin oxidoreductase B gene probe identified two to seven copies of pfoB (or its closely related homologue pfoA) per genome in different isolates and is an obvious candidate probe to identify epidemiological linkage between infections by this genotyping method. Cleavage of the genomes into smaller fragments failed to distinguish isolates from diverse locations indicating the proximal regions of genes are conserved.

Emerging infectious diseases in Mongolia

Since 1990, Mongolia’s health system has been in transition. Impressive gains have been accomplished through a national immunization program, which was instituted in 1991. Nevertheless, the country continues to confront four major chronic infections: hepatitis B and C, brucellosis, tuberculosis, and sexually transmitted diseases (STDs). As of 2001, only two cases of HIV infections had been detected in Mongolia, but concern grows that the rate will increase along with the rising rates of STDs and increase in tourism. Other infectious diseases of importance in Mongolia include echinococcus, plague, tularemia, anthrax, foot-and-mouth, and rabies.

Drug-related HIV in South and South-East Asia

While there has been significant advancement in the knowledge on effective HIV prevention methods among injecting drug users (IDUs), and their demonstrated success, in particular the impact of availability and use of clean injecting equipment on reducing HIV prevalence among IDUs, in Australia, the US and the UK, progress made in implementation of actual interventions focused on IDUs in South and South-East Asia is less than satisfactory. This paper examines some of the critical issues related to the context and causes of inadequate drug-related HIV prevention programmes in Asia. It also raises questions relating to evidence-based interventions to be scaled up in the region, including the need for sufficient resources anda conducive policy and legalenvironment.

Drug resistance in the sexually transmitted protozoan Trichomonas vaginalis

Trichomoniasis is the most common, sexually transmitted infection. It is caused by the flagellated protozoan parasite Trichomonas vaginalis. Symptoms include vaginitis and infections have been associated with preterm delivery, low birth weight and increased infant mortality, as well as predisposing to HIV/AIDS and cervical cancer. Trichomoniasis has the highest prevalence and incidence of any sexually transmitted infection. The 5-nitroimidazole drugs, of which metronidazole is the most prescribed, are the only approved, effective drugs to treat trichomoniasis. Resistance against metronidazole is frequently reported and cross-resistance among the family of 5-nitroimidazole drugs is common, leaving no alternative for treatment, with some cases remaining unresolved. The mechanism of metronidazole resistance in T. vaginalis from treatment failures is not well understood, unlike resistance which is developed in the laboratory under increasing metronidazole pressure. In the latter situation, hydrogenosomal function which is involved in activation of the prodrug, metronidazole, is down-regulated. Reversion to sensitivity is incomplete after removal of drug pressure in the highly resistant parasites while clinically resistant strains, so far analysed, maintain their resistance levels in the absence of drug pressure. Although anaerobic resistance has been regarded as a laboratory induced phenomenon, it clearly has been demonstrated in clinical isolates. Pursuit of both approaches will allow dissection of the underlying mechanisms. Many alternative drugs and treatments have been tested in vivo in cases of refractory trichomoniasis, as well as in vitro with some successes including the broad spectrum anti-parasitic drug nitazoxanide. Drug resistance incidence in T. vaginalis appears to be on the increase and improved surveillance of treatment failures is urged.

Prevalence of sexually transmitted infections (Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and human papillomavirus) in female attendees of a sexually transmitted diseases clinic in Ulaanbaatar, Mongolia

BACKGROUND

Epidemiological data suggest that the prevalence of syphilis, gonorrhea and trichomoniasis has increased in both urban and rural areas of Mongolia. These data are primarily substantiated by notifications of cases of clinically apparent disease in both rural and urban areas, plus laboratory diagnoses from the AIDS/STD Reference Center, Ulaanbaatar. In the past 5 years, however, there has been a marked decline in the total number of patients being screened for sexually transmitted infections (STIs). An assessment of true prevalence of STIs in a female population attending an urban sexually transmitted diseases (STD) clinic was therefore commenced.

METHODS

Consecutive women attending an STD clinic in Ulaanbaatar had genital samples collected by the insertion and immediate removal of a tampon, which was then tested for the presence of Neisseria gonorrhoeae, Chlamydia trachomatis, human papillomavirus (HPV) and Trichomonas vaginalis, using polymerase chain reaction (PCR) amplification.

RESULTS

A total of 110 women were studied (mean age 26.7 years). Overall, 58 (53%) patients had one or more pathogens identified; 43 (39%) had a single pathogen, while 15 (14%) had mixed pathogens. C. trachomatis was found in 15 (14%), N. gonorrhoeae in 12 (11%), T. vaginalis in nine (8%) and HPV in 39 (36%). Among the 39 HPV-positive patients, oncogenicgenotypes (16, 18, 31, 33, 35, 39, 45, 51, 52) were found in 17(44%) patients.

CONCLUSIONS

Sexually transmitted infections as defined by PCR were common, and found in 53% of female attendees of an urban STD clinic in Mongolia. As infections with conventional STIs increase the risk of human immunodeficiency virus (HIV) transmission, it is imperative that strategies be introduced to reduce the prevalence of STIs. Furthermore, detection of oncogenic HPV was common, indicating that it is vital that a strategy to reduce cervical cancer such as a pre-cancer cervical cytology screening program also be introduced.

Drug targets and mechanisms of resistance in the anaerobic protozoa

The anaerobic protozoa Giardia duodenalis, Trichomonas vaginalis, and Entamoeba histolytica infect up to a billion people each year. G. duodenalis and E. histolytica are primarily pathogens of the intestinal tract, although E. histolytica can form abscesses and invade other organs, where it can be fatal if left untreated. T. vaginalis infection is a sexually transmitted infection causing vaginitis and acute inflammatory disease of the genital mucosa. T. vaginalis has also been reported in the urinary tract, fallopian tubes, and pelvis and can cause pneumonia, bronchitis, and oral lesions. Respiratory infections can be acquired perinatally. T. vaginalis infections have been associated with preterm delivery, low birth weight, and increased mortality as well as predisposing to human immunodeficiency virus infection, AIDS, and cervical cancer. All three organisms lack mitochondria and are susceptible to the nitroimidazole metronidazole because of similar low-redox-potential anaerobic metabolic pathways. Resistance to metronidazole and other drugs has been observed clinically and in the laboratory. Laboratory studies have identified the enzyme that activates metronidazole, pyruvate:ferredoxin oxidoreductase, to its nitroso form and distinct mechanisms of decreasing drug susceptibility that are induced in each organism. Although the nitroimidazoles have been the drug family of choice for treating the anaerobic protozoa, G. duodenalis is less susceptible to other antiparasitic drugs, such as furazolidone, albendazole, and quinacrine. Resistance has been demonstrated for each agent, and the mechanism of resistance has been investigated. Metronidazole resistance in T. vaginalis is well documented, and the principal mechanisms have been defined. Bypass metabolism, such as alternative oxidoreductases, have been discovered in both organisms. Aerobic versus anaerobic resistance in T. vaginalis is discussed. Mechanisms of metronidazole resistance in E. histolytica have recently been investigated using laboratory-induced resistant isolates. Instead of downregulation of the pyruvate:ferredoxin oxidoreductase and ferredoxin pathway as seen in G. duodenalis and T. vaginalis, E. histolytica induces oxidative stress mechanisms, including superoxide dismutase and peroxiredoxin. The review examines the value of investigating both clinical and laboratory-induced syngeneic drug-resistant isolates and dissection of the complementary data obtained. Comparison of resistance mechanisms in anaerobic bacteria and the parasitic protozoa is discussed as well as the value of studies of the epidemiology of resistance.

InTray GC medium versus modified Thayer-Martin agar plates for diagnosis of gonorrhea from endocervical specimens

A new self-contained medium system for the cultivation of Neisseria gonorrhoeae was compared to modified Thayer-Martin medium for the diagnosis of gonorrhea from endocervical specimens. There was no difference in the ability of the two methods to support the growth of N. gonorrhoeae.