Coinfection and repeat bacterial sexually transmitted infections (STI) - retrospective study on male attendees of public STI clinics in an Asia Pacific city.

Without protective immunity, recurrent sexually transmitted infections (STI) could occur. In this study, we retrospectively collected STI diagnosis records from public STI clinics attended by an average of 6,000 male patients annually in Hong Kong in 2009-2019. We estimated the prevalence of three bacterial STI (syphilis, chlamydia and gonorrhoea) coinfection from 2009 to 2019, and examined the factors associated with coinfection in 2014/15 and repeat infection in 2009-2019. We observed an increasing coinfection prevalence in male attendees with bacterial STI over the years, which reached the highest level of 15% in 2019. Among 3,698 male patients in 2014-2015, chlamydia/gonorrhoea coinfection was the commonest among all coinfections (77%). Factors such as young age (29 or below), HIV-positive status, and a history of concurrent genital warts/herpes were positively associated with coinfection in 2014/15 in multivariable logistic regression. Of all male patients with STI coinfection in 2014/15, those of age 30-49 and who self-reported as men who have sex with men (MSM) were more likely to have been repeatedly infected in 2009-2019. The results support the implementation of regular multi-STI testing as an STI control strategy for selected communities like MSM and people living with HIV.

Guideline for the diagnosis, treatment and long-term management of cutaneous lupus erythematosus.

Cutaneous lupus erythematosus (CLE) is an inflammatory, autoimmune disease encompassing a broad spectrum of subtypes including acute, subacute, chronic and intermittent CLE. Among these, chronic CLE can be further classified into several subclasses of lupus erythematosus (LE) such as discoid LE, verrucous LE, LE profundus, chilblain LE and Blaschko linear LE. To provide all dermatologists and rheumatologists with a practical guideline for the diagnosis, treatment and long-term management of CLE, this evidence- and consensus-based guideline was developed following the checklist established by the international Reporting Items for Practice Guidelines in Healthcare (RIGHT) Working Group and was registered at the International Practice Guideline Registry Platform. With the joint efforts of the Asian Dermatological Association (ADA), the Asian Academy of Dermatology and Venereology (AADV) and the Lupus Erythematosus Research Center of Chinese Society of Dermatology (CSD), a total of 25 dermatologists, 7 rheumatologists, one research scientist on lupus and 2 methodologists, from 16 countries/regions in Asia, America and Europe, participated in the development of this guideline. All recommendations were agreed on by at least 80% of the 32 voting physicians. As a consensus, diagnosis of CLE is mainly based on the evaluation of clinical and histopathological manifestations, with an exclusion of SLE by assessment of systemic involvement. For localized CLE lesions, topical corticosteroids and topical calcineurin inhibitors are first-line treatment. For widespread or severe CLE lesions and (or) cases resistant to topical treatment, systemic treatment including antimalarials and (or) short-term corticosteroids can be added. Notably, antimalarials are the first-line systemic treatment for all types of CLE, and can also be used in pregnant patients and pediatric patients. Second-line choices include thalidomide, retinoids, dapsone and MTX, whereas MMF is third-line treatment. Finally, pulsed-dye laser or surgery can be added as fourth-line treatment for localized, refractory lesions of CCLE in cosmetically unacceptable areas, whereas belimumab may be used as fourth-line treatment for widespread CLE lesions in patients with active SLE, or recurrence of ACLE during tapering of corticosteroids. As for management of the disease, patient education and a long-term follow-up are necessary. Disease activity, damage of skin and other organs, quality of life, comorbidities and possible adverse events are suggested to be assessed in every follow-up visit, when appropriate.

Attribution of human papillomavirus types to cervical intraepithelial neoplasia and invasive cancers in Southern China.

The attribution of individual human papillomavirus (HPV) types to cervical neoplasia, especially intraepithelial lesions, varies ethnogeographically. Population-specific data are required for vaccine cost-effectiveness assessment and type replacement monitoring. HPV was detected from 2,790 Chinese women (444 invasive cervical cancers [ICC], 772 cervical intraepithelial neoplasia [CIN] grade 3, 805 CIN2 and 769 CIN1. The attribution of each HPV type found in multiple-type infections was approximated by the fractional contribution approach. Multiple-type infection was common and correlated inversely with lesion severity (54.7% for CIN1, 48.7% for CIN2, 46.2% for CIN3, 27.5% for ICC). Vaccine-covered high-risk types (HPV16/18) attributed to 59.5% of squamous cell carcinoma, 78.6% of adenocarcinoma, 35.9% of CIN3, 18.4% of CIN2 and 7.4% of CIN1. Distinct features compared to worldwide were a higher attribution of HPV52 and HPV58, and a much lower attribution of HPV45. Inclusion of HPV52 and HPV58 in future vaccines would provide the highest marginal increase in coverage with 11.7% for squamous cell carcinoma, 14.4% for CIN3, 22.6% for CIN2 and 17.7% for CIN1. The attribution of HPV types in southern China is different from elsewhere, which should be considered in prioritizing HPV types for vaccine and screening assay development.

Surveillance of gonococcal antimicrobial susceptibility resulting in early detection of emerging resistance.

OBJECTIVES: To undertake laboratory and clinical surveillance of gonococcal antimicrobial susceptibility to various therapeutic agents in Hong Kong, so as to monitor for emerging resistance and to inform on appropriate choice of empirical therapy. METHODS: Trends in susceptibility of gonococci to ceftriaxone, spectinomycin, ceftibuten and azithromycin were monitored over time. Isolates with reduced susceptibility to oral extended-spectrum cephalosporins were further characterized by detection of the mosaic penA gene and typing by Neisseria gonorrhoeae multi-antigen sequence typing (NG-MAST). Correlation with clinical and epidemiological findings was undertaken on isolates positive for the mosaic penA gene. RESULTS: Trends in susceptibility of gonococci to ceftriaxone, spectinomycin and ceftibuten remained stable between 2005 and 2010. In 2010, 30.3% of tested strains were not susceptible to azithromycin. The percentage of gonococcal strains harbouring the mosaic penA gene increased from 1.0% during April to December 2010 to 8.2% during January to September 2011 (P < 0.0001). Review of available clinical records showed that, out of 35 patients infected by strains positive for the mosaic penA gene, 30 had laboratory-documented treatment failure. CONCLUSIONS: This study showed that ceftriaxone and spectinomycin remained effective against gonorrhoea in Hong Kong. There was an alarming increase in strains with reduced susceptibility to oral extended-spectrum cephalosporins associated with clinical treatment failure. One-third of gonococcal isolates were non-susceptible to azithromycin. The need to switch to agents other than oral extended-spectrum cephalosporins for empirical treatment is imminent. Continued surveillance with strain characterization is essential to monitor the effectiveness of currently recommended therapy.

Emergence of antibiotic-resistant Mycoplasma genitalium as the cause of non-gonococcal urethritis in male patients at a sexually transmitted infection clinic.

Mycoplasma genitalium is the cause of an emerging sexually transmitted infection (STI) with high propensity for development of antimicrobial resistance. In a prevalence study conducted at the public STI service in Hong Kong, the first void urine samples of 38 (8%) of 493 male patients with non-gonococcal urethritis (NGU) tested positive for M. genitalium using reverse transcription polymerase chain reaction. Patients with M. genitalium infection were younger [31 vs 33 years, odds ratio (OR) 0.96, 95% confidence interval (CI) 0.93-0.996; P=0.03], more likely to present with urethral discharge (12% vs 6%, OR 2.16, 95% CI 1.10-4.23; P=0.02) and had symptom duration >2 weeks (14% vs 6%, OR 2.34, 95% CI 1.10-4.97; P=0.03) compared with patients without M. genitalium infection. The prevalence of M. genitalium infection was lower in patients co-infected with Chlamydia trachomatis compared with patients with isolated infection (4% vs 10%, OR 0.38, 95% CI 0.17-0.84; P=0.02). The prevalence of M. genitalium infection was not higher in men who have sex with men. Antimicrobial-resistance-conferring mutations were present in 24 (63%) patients with M. genitalium - 23S rRNA 18 (47%) and parC 19 (53%). Similar to neighbouring countries in the Asia Pacific region, concurrent resistance mutations against both macrolides and fluoroquinolones were demonstrated in 14 (37%) patients. Histories of azithromycin and moxifloxacin use were significantly associated with a diagnosis of M. genitalium infection. Characteristically, NGU in Hong Kong featured the co-existence of mono-resistance against macrolides or fluoroquinolones, and the presence of dual class resistance. The geographic variability of antimicrobial resistance against M. genitalium is attributed not just to the different transmission networks formed in separate population groups, but the antimicrobial prescriptions for the treatment of urethritis in the community.

Setting up a surveillance system for sexually transmitted diseases in the general population with prospective data collection from private-practice and public-practice doctors in Hong Kong.

BACKGROUND: Existing surveillance systems for sexually transmitted diseases (STD) and reproductive tract infections (RTI) are important but often ineffective, as they tend to omit cases diagnosed by private-practice doctors METHODS: During a 15-day study period, 277 private-practice doctors and all public-practice doctors of all the eight local Social Hygiene Clinics (SHC) in Hong Kong filled out daily a standard log-form, recording the number of patients diagnosed with particular types of STD/RTI. Projections for all local private-practice and public-practice doctors were made by the stratification method. RESULTS: Data showed that 0.75% of private patients and 40.92% of public patients presented the listed STD/RTI syndromes. It is projected that 12,504 adults were diagnosed with such syndromes by all local private-practice (10,204) or public-practice doctors (2,300); 0.22% (male: 0.26%; female: 0.18%) of the local adult population would fall into this category. The ratio of STD/RTI cases, diagnosed by private-practice versus public-practice doctors, was 4:1. Of the participating private-practice doctors, 96% found the process easy to administer and 75% believed that it was feasible for such a STD/RTI surveillance system to be implemented annually. CONCLUSIONS: Surveillance of STD/RTI based only on data obtained from the public health system is inadequate. Data obtained from public-practice and private-practice doctors are very different and the majority of the patients presented their STD/RTI syndromes to private-practice doctors. The proposed, improved surveillance system is feasible and has the strengths of involving both private-practice and public-practice medical practitioners and being well accepted by private-practice doctors.

The spatial context of clinic-reported sexually transmitted infection in Hong Kong.

BACKGROUND: The incidence and prevalence of sexually transmitted infection (STI) in China has been on the rise in the past decade. Delineation of epidemiologic pattern is often hampered by its uneven distribution. Spatial distribution is often a neglected aspect of STI research, the description of which may enhance epidemiologic surveillance and inform service development. METHODS: Over a one month-period, all first time attendees of 6 public STI clinics in Hong Kong were interviewed before clinical consultation using a standard questionnaire to assess their demographic, clinical and behavioural characteristics. A GIS (geographic information system)-based approach was adopted with mapping performed. The cases attending the clinics in different locations were profiled. A comparison was made between neighbourhood cases (patients living near a clinic) and distant cases (those farther off), by calculating the odds ratio for demographic, behavioural and geographic characteristics. RESULTS: Of the 1142 STI patients evaluated, the residence locations of 1029 (90.1%) could be geocoded, of which 95.6% were ethnic Chinese and 63.4% male. Geographically only about a quarter lived in the same district as the clinic. STI patients aged 55 or above were more likely to be living in the vicinity of the clinic, located in the same or adjacent tertiary planning unit (a small geographic unit below district level). A majority of patients came from locations a few kilometers from the clinic, the distance of which varies between clinics. Overall, more syphilis cases were reported in patients residing in the same or adjacent tertiary planning unit, while distant cases tended to give a higher risk of inconsistent condom use. There were otherwise no significant clinical and epidemiologic differences between neighbourhood and distant STI cases. CONCLUSIONS: There was no specific relationship between STI and the residence location of patients as regards their clinical and epidemiologic characteristics in the territory of Hong Kong. Older STI patients were however more inclined to attend the nearby STI clinics. Most patients have travelled a variable distance to access the STI service. The relationship between STI clinic cases and distance could be a complex issue intertwined between psychosocial characteristics and STI service coverage.

Incidence of genital warts among the Hong Kong general adult population.

BACKGROUND: The objective of this study is to estimate the incidence of genital warts in Hong Kong and explore a way to establish a surveillance system for genital warts among the Hong Kong general population. METHODS: A total of 170 private doctors and all doctors working in the 5 local Social Hygiene Clinics (SHC) participated in this study. During the 14-day data collection period (January 5 through 18, 2009), the participating doctors filled out a log-form on a daily basis to record the number of patients with genital warts. The total number of new cases of genital warts presented to private and public doctors in Hong Kong was projected using the stratification sampling method. RESULTS: A total of 721 (0.94%) adults presented with genital warts to the participating doctors during the two-week study period, amongst them 73 (10.1%) were new cases. The projected number of new cases of genital warts among Hong Kong adults was 442 (297 male and 144 female) during the study period. The incidence of genital warts in Hong Kong was estimated to be 203.7 per 100,000 person-years (respectively 292.2 and 124.9 per 100,000 person-years for males and females). CONCLUSIONS: The incidence of genital warts is high among adults in Hong Kong. The study demonstrates the importance of collecting surveillance data from both private and public sectors.

Correction: Prevalence and risk factors of chlamydia infection in Hong Kong: A population-based geospatial household survey and testing.

[This corrects the article DOI: 10.1371/journal.pone.0172561.].

Prevalence and risk factors of chlamydia infection in Hong Kong: A population-based geospatial household survey and testing.

BACKGROUND: Chlamydia causes infertility and increases risk of HIV infection, and population-based studies provide essential information for effective infection control and prevention. This study examined Chlamydia trachomatis prevalence and risk factors among a representative sample of 18-49-year-old residents in Hong Kong. METHODS: Census boundary map of 412 constituency areas was used as primary sampling units to construct the sampling frame and, residential buildings and units were randomly selected using geospatial modelling. A questionnaire on sexual practice and health was conducted, and polymerase chain reaction was used to test the urine for genital chlamydial infection. Invitation letters were sent to the selected households and a team of interviewers were sent to recruit one subject per household. Prevalence data was weighted according to the 2011 census and risk factors identified through logistic regression. RESULTS: Among 881 participants (response rate of 24.5%), the overall Chlamydia trachomatis prevalence was low at 1.4% (95%CI 0.8-2.5%) but sexually active young (18-26 years) women had relatively high prevalence (5.8%, 95%CI 1.7-18.2%) in Hong Kong. A unique U-shape disease burden was observed with peaks in younger and older (40-49 years) women. Amongst the sexually active women, the risk factors of Chlamydia trachomatis infection were: younger age (aOR = 25.4, 95% CI 2.81-230); living alone (aOR = 8.99, 95% CI 1.46-55.40); and, among all the sexually active participants, males (including the male partners of the female participants) who had travelled out of Hong Kong in the previous 12 months had higher risks of infection (aOR = 5.35; 95% CI 1.25-22.8). A core-peripheral geographical distribution of Chlamydia trachomatis prevalence was also observed. CONCLUSION: Young and older sexually active women in Hong Kong have high prevalence of chlamydia. Routine screening for sexually active women and young men should be considered. Further research on testing feasibility and linkage-to-care are urgently needed to control the infection.

Hippocampal MR spectroscopic abnormalities in a cohort of syphilitic patients with HIV and neurosyphilis infection.

Co-infection of human immunodeficiency virus (HIV) and neurosyphilis (NS) has become a rising trend, but the extent of brain damage associated with the concomitant infections remains unknown. Proton magnetic resonance spectroscopy ((1)H-MRS) can evaluate metabolic changes underlying early brain infections. 25 syphilitic patients (7 HIV-positive with NS; 6 HIV-positive without NS; 5 HIV-negative with NS; 7 non-HIV, non-NS) and 17 healthy controls (HC) underwent single-voxel (1)H-MRS in the bilateral hippocampi. Absolute concentrations of major metabolites were measured using a 3T MRI scanner. No significant structural abnormality was detected in all patients. However, metabolic changes were found in the left hippocampus of both the HIV-positive and NS subgroups, showing significantly higher choline (Cho), creatine (Cr) and myo-inositol (mI) compared to HC. In the right hippocampus, HIV-positive subgroup showed significantly higher Cr and reduced NAA, while NS subgroup only showed significantly reduced NAA compared to HC. The non-HIV, non-NS syphilitic subgroup showed no significant difference compared to HC. Substantial metabolic changes occurred in bilateral hippocampi in HIV and NS co-infections. NAA reduction might represent early neuronal damage, while mI/Cho elevation reflects gliosis/inflammatory changes. (1)H-MRS could serve as a non-invasive tool to triage patients suspected of NS for lumbar puncture in non-HIV syphilitic patients.

A behaviour sentinel surveillance for female sex workers in the Social Hygiene Service in Hong Kong (1999-2000).

Behavioural serial sentinel surveillance survey for female sex workers (FSWs) was carried out in the Government Social Hygiene Clinics in Hong Kong during 1999 and 2000. A total of 1366 and 1451 FSWs participated in the questionnaire survey respectively. The results showed that the majority of FSWs attending the clinics were of Chinese ethnicity (83.8%, 87.6%) while Thai (13.0%, 9.49%) and Filipino (2.1%, 2.7%) were the main foreign ethnic groups. The karaoke night club was the most frequent reported workplace (32.0%, 32.6%) followed by a club (8.9%, 11.7%) and free-lancing (8.6%, 9.0%). The proportion of FSWs who always used condoms in vaginal sex with commercial sex partners was 70.9% and 75.0% respectively (P=0.038). Compared with previous results, a rising trend of condom use by FSWs in commercial sex was observed. However, there was a relatively low condom use during commercial oral sexual intercourse (30.7%, 36.6%) and sex with their regular sex partners in all forms of sexual activities. Client dislike is the main attributed factor for not wearing condoms. The point prevalence of both infectious syphilis and HIV infection was 0.1% in both years. These data are useful for planning, resource allocation and evaluation of outreach activities and STI services targeting at FSWs and their clients. They provide a sampling framework for further surveillance.

Use of cerebrospinal fluid enzyme immunoassay for diagnosis of neurosyphilis.

Neurosyphilis is a difficult clinical stage of syphilis as there is no ideal method for diagnosis and workup requires lumbar puncture which may sometimes provide ambiguous results especially in HIV co-infected patients. Enzyme immunoassay is a widely used screening test for syphilis in serum, but its test performance was not well studied in cerebrospinal fluid. To examine the diagnostic performance of cerebrospinal fluid-enzyme immunoassay (CSF-EIA) in neurosyphilis, we conducted a prospective study for two years. All consecutive patients admitted for workup of neurosyphilis under the Social Hygiene Service, in Hong Kong, were included. Laboratory tests on CSF included several serological tests, CSF cell count, and protein. Forty-five patients were prospectively recruited, of which 29 people were living with HIV / AIDS. Using diagnostic case definition standard stipulated in the IUSTI 2008 guidelines, 17 patients satisfied the diagnosis of neurosyphilis. The CSF-EIA test provided 100% in both sensitivity and negative predictive value; its specificity was 46.4% (13/28, 95% CI 31.8-61%). Specificity improved to 80.8% (95% CI: 68.4-93.2%) with optical density cut-off value at 1.4 for cases with CSF red cell counts <600/mm(3) This is the first study on use of CSF-EIA in neurosyphilis. CSF-EIA showed high sensitivity and high negative predictive value in the study population and the presence of CSF red cells < 600/mm(3)might not affect its accuracy.

Distribution of human papillomavirus types in anogenital warts of men.

BACKGROUND: A wide spectrum of human papillomavirus (HPV) types can infect the male genitalia. An HPV vaccine covering HPV6 and 11 is now available. Detailed data on the distribution of these two types in anogenital warts is needed to assess the potential benefits of the vaccine. STUDY DESIGN: Anogenital wart specimens collected from 130 Chinese men were examined for HPV-type distribution by a method that covers a broad spectrum of high- and low-risk HPVs, and able to reveal multiple types from a single specimen. RESULTS: Forty-four (33.8%) of the 130 specimens had a coinfection with multiple HPV types. In 63.1% of cases, only HPV6 and/or HPV11 were/was found. In 26.2% of cases, HPV6 and/or HPV11 were/was found together with one or more other HPV types. In 10.8% of specimens, only non-6/11 HPV types were found. HPV16 and/or 18 were/was found in 12 (9.2%) specimens, with majority (8/12, 66.7%) of which existed as coinfections with HPV6/11. Other HPV types found included HPV39, 51, 52, 55, 59, 61, 62, 68, 58, 72, 81, 83, 84 and CP6108. CONCLUSIONS: A substantial proportion of HPV6/11-positive male anogenital warts are coinfected with other HPV types. The efficacy of HPV6/11 vaccine for preventing these lesions needs to be defined before the benefits of vaccinating men can be precisely assessed.