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.<br/

Scenarios of future mpox outbreaks among men who have sex with men:a modelling study based on cross-sectional seroprevalence data from the Netherlands, 2022

Background: Following the 2022–2023 mpox outbreak, crucial knowledge gaps exist regarding orthopoxvirus-specific immunity in risk groups and its impact on future outbreaks. Aim: We combined cross-sectional seroprevalence studies in two cities in the Netherlands with mathematical modelling to evaluate scenarios of future mpox outbreaks among men who have sex with men (MSM). Methods: Serum samples were obtained from 1,065 MSM attending Centres for Sexual Health (CSH) in Rotterdam or Amsterdam following the peak of the Dutch mpox outbreak and the introduction of vaccination. For MSM visiting the Rotterdam CSH, sera were linked to epidemiological and vaccination data. An in-house developed ELISA was used to detect vaccinia virus (VACV)-specific IgG. These observations were combined with published data on serial interval and vaccine effectiveness to inform a stochastic transmission model that estimates the risk of future mpox outbreaks.Results: The seroprevalence of VACV-specific antibodies was 45.4% and 47.1% in Rotterdam and Amsterdam, respectively. Transmission modelling showed that the impact of risk group vaccination on the original outbreak was likely small. However, assuming different scenarios, the number of mpox cases in a future outbreak would be markedly reduced because of vaccination. Simultaneously, the current level of immunity alone may not prevent future outbreaks. Maintaining a short time-to-diagnosis is a key component of any strategy to prevent new outbreaks. Conclusion: Our findings indicate a reduced likelihood of large future mpox outbreaks among MSM in the Netherlands under current conditions, but emphasise the importance of maintaining population immunity, diagnostic capacities and disease awareness.</p

Impact of varying pre-exposure prophylaxis programs on HIV and Neisseria gonorrhoeae transmission among MSM in the Netherlands: a modeling study

Background: In 2019, a 5-year pre-exposure prophylaxis (PrEP) program started in the Netherlands, in which up to 8500 men who have sex with men (MSM) can obtain PrEP and 3-monthly consultations with HIV/STI testing.Setting: We assessed the impact of the PrEP program on transmission of HIV and Neisseria gonorrhea (NG) among MSM in the Netherlands and examined prospective variations of the program after 2024.Methods: We used an agent-based model to estimate the effect of the PrEP program. For hypothetical prospective PrEP programs starting in 2024, we varied the capacity (8,500; 12,000; 16,000 participants) and consultation frequency (3-monthly; 6-monthly; 70% 3-monthly and 30% 6-monthly).Results: At a capacity of 8,500 participants and 3-monthly consultations, the PrEP program could lead to 3,140 [95% credible interval (95% CrI): 1,780–4,780] and 27,930 (95% CrI: 14,560–46,280) averted HIV and NG infections, requiring 316,050 (95% CrI: 314,120–317,580) consultations. At a capacity of 16,000 participants, the programs with 3-monthly consultations and 6-monthly consultations could lead to comparable number of averted HIV [3,940 (95% CrI: 2,420–5,460), and 3,900 (2,320–5,630) respectively] and NG infections [29,970 (95% CrI: 15,490–50,350), and 29,960 (95% CrI: 13,610–50,620) respectively], while requiring substantially different number of consultations: 589,330 (95% CrI: 586,240–591,160) and 272,590 (95% CrI: 271,770–273,290), respectively.Conclusions: Continuation of a PrEP program could lead to a substantial reduction in HIV and NG transmission. More infections could be averted if the number of participants is increased. In turn, the consultation frequency could be reduced without reducing the number of averted infections if capacity is increased.Development and application of statistical models for medical scientific researc

Methicillin-resistant Staphylococcus aureus (MRSA) in men having sex with men (MSM): a systematic review

Background: Outbreaks of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) have been documented at multiple sites worldwide. Several studies have reported an elevated infection rate of CA-MRSA infections in men having sex with men (MSM), suggesting CA-MRSA can behave as a sexually transmitted infection (STI). To assess the potential public health impact of CA-MRSA transmission amongst MSM, a systematic review of the literature was conducted to identify risk factors and prevalence of CA-MRSA colonization and infection in MSM. Methods: The electronic database Embase.com (containing Embase and Medline) was systematically searched to identify studies investigating CA-MRSA colonization and infection from inception up to 19 January 2024. Two independent reviewers selected potentially relevant articles for full-text screening. Only English-language articles meeting the inclusion criteria were considered. In case of reviewer disagreement, a third independent reviewer was consulted. Information regarding prevalence, strains, and risk factors for CA-MRSA colonization and infection were extracted by one reviewer and checked by a second reviewer. Results: 54 studies were screened; 18 were included for analysis. Notably, 3 distinct CA-MRSA clusters were observed in MSM in the USA and Japan. Screening in other MSM cohorts did not reveal an elevated prevalence of CA-MRSA colonization or infection. Identifying as MSM by itself is not a risk factor for MRSA colonization and infection, but specific behavior factors such as intravenous drugs use and high-risk sexual behavior do increase this risk. Discussion: Recognizing the potential presence of CA-MRSA in MSM experiencing (skin) infections is crucial for informed clinical decisions. In cases where a cluster of CA-MRSA infections occurs within a sexual network, eradication strategies and non-pharmaceutical interventions should be carefully considered to prevent further spreading. Given the limited available data on this topic and incomplete data on the prevalence on a global scale, further investigations should prioritize studying the impact of CA-MRSA transmission within sexual networks

Mpox vaccination willingness, determinants, and communication needs in gay, bisexual, and other men who have sex with men, in the context of limited vaccine availability in the Netherlands (Dutch Mpox-survey)

IntroductionIn the 2022 multicountry mpox (formerly named monkeypox) outbreak, several countries offered primary preventive vaccination (PPV) to people at higher risk for infection. We study vaccine acceptance and its determinants, to target and tailor public health (communication-) strategies in the context of limited vaccine supply in the Netherlands. MethodsOnline survey in a convenience sample of gay, bisexual and other men who have sex with men, including transgender persons (22/07-05/09/2022, the Netherlands). We assessed determinants for being (un)willing to accept vaccination. We used multivariable multinominal regression and logistic regression analyses, calculating adjusted odds ratios (aOR) and 95 percent confidence-intervals. An open question asked for campaigning and procedural recommendations. ResultsOf respondents, 81.5% (n = 1,512/1,856) were willing to accept vaccination; this was 85.2% (799/938) in vaccination-eligible people and 77.7% (713/918) in those non-eligible. Determinants for non-acceptance included: urbanization (rural: aOR:2.2;1.2-3.7; low-urban: aOR:2.4;1.4-3.9; vs. high-urban), not knowing mpox-vaccinated persons (aOR:2.4;1.6-3.4), and lack of connection to gay/queer-community (aOR:2.0;1.5-2.7). Beliefs associated with acceptance were: perception of higher risk/severity of mpox, higher protection motivation, positive outcome expectations post vaccination, and perceived positive social norms regarding vaccination. Respondents recommended better accessible communication, delivered regularly and stigma-free, with facts on mpox, vaccination and procedures, and other preventive options. Also, they recommended, "vaccine provision also at non-clinic settings, discrete/anonymous options, self-registration" to be vaccinated and other inclusive vaccine-offers (e.g., also accessible to people not in existing patient-registries). ConclusionIn the public health response to the mpox outbreak, key is a broad and equitable access to information, and to low-threshold vaccination options for those at highest risk. Communication should be uniform and transparent and tailored to beliefs, and include other preventive options. Mpox vaccine willingness was high. Public health efforts may be strengthened in less urbanized areas and reach out to those who lack relevant (community) social network influences

A large multi-country outbreak of monkeypox across 41 countries in the WHO European Region, 7 March to 23 August 2022

Following the report of a non-travel-associated cluster of monkeypox cases by the United Kingdom in May 2022, 41 countries across the WHO European Region have reported 21,098 cases and two deaths by 23 August 2022. Nowcasting suggests a plateauing in case notifications. Most cases (97%) are MSM, with atypical rash-illness presentation. Spread is mainly through close contact during sexual activities. Few cases are reported among women and children. Targeted interventions of at-risk groups are needed to stop further transmission. © 2022 European Centre for Disease Prevention and Control (ECDC). All rights reserved.The authors affiliated with the World Health Organization (WHO) are alone responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the WHO. The co-author is a fellow of the ECDC Fellowship Programme, supported financially by the European Centre for Disease Prevention and Control (ECDC). The views and opinions expressed herein do not state or reflect those of ECDC. ECDC is not responsible for the data and information collation and analysis and cannot be held liable for conclusions or opinions drawn

Circulation, viral diversity and genomic rearrangement in mpox virus in the Netherlands during the 2022 outbreak and beyond.

Mpox is an emerEU Horizon 2020 project VEO. Grant Number: 8EU Horizon 2020 project VEO. Grant Number: 874735 NOW Stevin prize (Koopmans) Department of Medical Microbiology and Infection Prevention of the Amsterdam UMC74735 NOW Stevin prize (Koopmans) Department of Medical Microbiology and Infection Prevention of the Amsterdam UMCging zoonotic disease which has now spread to over 113 countries as of August 2023, with over 89,500 confirmed human cases. The Netherlands had one of the highest incidence rates in Europe during the peak of the outbreak. In this study, we generated 158 near-complete mpox virus (MPXV) genomes (12.4% of nationwide cases) that were collected throughout the Netherlands from the start of the outbreak in May 2022 to August 2023 to track viral evolution and investigate outbreak dynamics. We detected 14 different viral lineages, suggesting multiple introductions followed by rapid initial spread within the country. The estimated evolutionary rate was relatively high compared to previously described in orthopoxvirus literature, with an estimated 11.58 mutations per year. Genomic rearrangement events occurred at a rate of 0.63% and featured a large deletion event. In addition, based on phylogenetics, we identified multiple potential transmission clusters which could be supported by direct source- and contact tracing data. This led to the identification of at least two main transmission locations at the beginning of the outbreak. We conclude that whole genome sequencing of MPXV is essential to enhance our understanding of outbreak dynamics and evolution of a relatively understudied and emerging zoonotic pathogen.EU Horizon 2020 project VEO. Grant Number: 874735 NOW Stevin prize (Koopmans) Department of Medical Microbiology and Infection Prevention of the Amsterdam UM