Karin Haar

Prevalence of pharyngeal and rectal Chlamydia trachomatis and Neisseria gonorrhoeae infections among men who have sex with men in Germany

Objectives To determine the prevalence of pharyngeal and rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among men who have sex with men (MSM) in Germany and describe associations between these infections, sexual practices and other factors to provide an evidence base for screening recommendations. Methods We conducted a cross-sectional study in 22 sentinel sites of sexually transmitted infections across Germany. Pharyngeal and rectal swabs were collected and tested for CT and NG with a nucleic acid amplification test (NAAT). Information on HIV status, number of sex partners and sexual practices was collected and linked to NAAT results. Results Overall, 2247 MSM were screened for pharyngeal or rectal CT and NG infections; median age was 34 years (range 16–83). Prevalence of CT was 1.5% in pharyngeal and 8.0% in rectal specimens. Prevalence of NG was 5.5% in pharyngeal and 4.6% in rectal specimens. Local symptoms were reported in 5.1% of pharyngeal and 11.9% of rectal infections. Altogether 90.8% of rectal or pharyngeal infections would remain undetected if only symptomatic cases were tested. Rectal infection was significantly more likely in men reporting multiple partners (2–5 partners, OR=1.85; 6–10 partners, OR=2.10; >11 partners, OR=2.95), men diagnosed with HIV (OR=1.60) and men practising receptive anal intercourse without a condom (OR=1.54). Pharyngeal infection was more likely in men reporting multiple partners (6–10 partners, OR=2.88; >11 partners, OR=4.96), and men diagnosed with HIV (OR=1.78). Conclusions Pharyngeal and rectal infections in sexually active MSM can remain undetected and thus transmissible if swabbing is not offered routinely. Screening should be offered particularly to MSM diagnosed with HIV and MSM reporting multiple partners.

Lymphogranuloma Venereum in Men Screened for Pharyngeal and Rectal Infection, Germany

To determine prevalence of lymphogranuloma venereum among men who have sex with men in Germany, we conducted a multicenter study during 2009–2010 and found high rates of rectal and pharyngeal infection in men positive for the causative agent, Chlamydia trachomatis. Many infections were asymptomatic. An adjusted C. trachomatis screening policy is justified in Germany.

STI tests and proportion of positive tests in female sex workers attending local public health departments in Germany in 2010/11

BackgroundIn Germany, local public health departments (LPHD) are required to offer low-threshold access to confidential counselling and testing for sexually transmitted infections (STI) for sex workers. We collected data from LPHD in Germany to estimate the number of performed STI tests and the proportion of positive STI tests among attending female sex workers (FSW) in order to formulate recommendations for improving STI testing and care for FSW in Germany.MethodsWe recruited LPHD across Germany to collect aggregated data on attending FSW between January 2010 and March 2011. Baseline characteristics, the number of attending FSW, STI tests (HIV, Chlamydia trachomatis, Neisseria gonorrhoea, syphilis and Trichomonas vaginalis) and the number of positive results were provided by participating LPHD. We described the number of STI tests per FSW visit and the proportion of positive test results, including interquartile range (IQR). We tested whether baseline characteristics of LPHD were associated with the proportion of positive test results.ResultsOverall, 28 LPHD from 14 of the 16 federal states reported 9284 FSW visits over the study period, with a median of 188 FSW visits (IQR 45–440) per LPHD. Overall, a median of 77.1% (IQR 60.7–88.0) of visiting FSW received a test for Neisseria gonorrhoea, followed by HIV (66.0%, IQR 47.9–86.8), Chlamydia trachomatis (65.4%, IQR 50.7–83.6) and syphilis (61.6, IQR 48.6–78.6). In total, 22,914 STI tests were performed. The proportion of positive tests was 3.1% (IQR 1.3–4.8), with the highest proportion of positive tests for Chlamydia trachomatis (6.8%, IQR 2.5–10.4), followed by Neisseria gonorrhoea (3.2%, IQR 0.0–5.3), Trichomonas vaginalis (3.0%, IQR 0.0–15.4), syphilis (1.1%, IQR 0.0–1.3) and HIV (0.2%, IQR 0.0–0.4). The proportion of positive tests varied between 0 and 13.9% between LPHD, with a higher variation of proportion of positive tests in LPHD with a smaller number of reported STI tests.ConclusionsParticipating LPHD varied in terms of performed STI tests and FSW visits. The proportion of positive STI tests was low, but varied between LPHD. This variation likely reflects different testing strategies. Existing testing guidelines should be used by all LPHD to ensure high quality care for FSW.

Establishment of a voluntary electronic Chlamydia trachomatis laboratory surveillance system in Germany, 2008 to 2014

Chlamydia trachomatis (CT) infections are not reportable in Germany and limited data on prevalence are available. CT screening has been offered free of charge to pregnant women since 1995 and to all women under 25 years since 2008. For symptomatic women and men, diagnostic testing is covered by statutory health insurance. We describe the establishment of a nationwide, laboratory-based, voluntary sentinel that electronically collects information on all performed CT tests with test results, test reason and patient information. The sentinel represents one third of all performed CT tests in Germany. In the period from 2008 to 2014, 3,877,588 CT tests were reported, 93% in women. Women aged 20–24 years and men aged 25–29 years were the most frequently tested age groups. The overall proportion of positive tests (PPT) among women was 3.9% and among men 11.0%. The highest PPT among women was in the age groups 15–19 (6.8%) and 20–24 years (5.9%), and among men in the age groups 20–24 (19.2%), 15–19 (15.4%) and 25–29 years (14.8%). The PPT for CT was high among women and men younger than 25 years. Prevention is urgently needed. Monitoring of CT infection in Germany should be continued.

Low Sensitivity of Pooled Chlamydia Testing in a Sample of the Young German General Population

Objective: To compare sensitivity of pooled urine testing with single specimen testing using NAAT (nucleic acid amplification test). To determine Chlamydia prevalence among adolescents in Germany. Methods: Urine samples from 15-17 year old female and 16-17 year old male participants of a nationwide representative study in children and adolescents sampled between 2003 and 2006 were tested individually and in pools of 4 using BDProbeTec ET System (strand displacement amplification). Specificity, sensitivity, positive and negative predictive values (PPV, NPV) for pooled testing with 95%-confidence-intervals (95% CI) was calculated. Chlamydia prevalence with 95% CI was calculated for individual testing. Results: Among individually tested 1925 specimens, 27 were positive for chlamydia, resulting in a prevalence of 1.4%. Chlamydia prevalence ranged from 0.2% in 16-year old males to 3.2% in 17-year old females. Using individual testing as the standard, a specificity of 99.6% and a sensitivity of 56.0% was found for pooled testing. The PPV was 87.5% and the NPV 97.6%. Inhibition was higher in individual testing compared to pooled testing. Conclusion: In this setting of a national health survey the very low sensitivity of 56.0% for pooled testing is concerning and differs from previously reported results. Pooled chlamydia test results should be interpreted with caution, especially if urine samples were not collected or stored under optimal conditions. Possible causes such as dilution effects, lack of prior DNA purification, long-term-storage and the use of urines that may not be first-void should be ruled out. Recommendations for population screening to use pooled testing might need to be re-evaluated should larger studies on more recent samples confirm our findings.

An assessment of the current Chlamydia trachomatis laboratory practices in Germany.

BACKGROUND AND OBJECTIVES Currently, no information is available about the number of Chlamydia trachomatis (CT) tests performed, testing facilities available or diagnostic methods used in Germany. This study aimed to map CT diagnostic facilities so that representative laboratories can be recruited for CT sentinel surveillance. METHODS Using a questionnaire, we collected information about population coverage, the number of tests performed, accreditation and current testing methods and systems for German facilities that potentially offer CT diagnostics. RESULTS Overall, 725/1,504 (48%) facilities responded; of the respondents, 143 reported that they perform CT diagnostics. Of the laboratories performing diagnostics, 45% were privately owned, and 42% were located in a hospital. Of the laboratories that provided information about their catchment area, 61% received samples from at least one federal state and therefore covered more than their surrounding area. The median length of time that CT diagnostics had been performed was 11.5 years. Over half (54%) of the laboratories that provided information on their accreditation status were accredited, for a median duration of 6 years. In accordance with national guidelines, 77% used nucleic acid amplification tests (NAAT) for acute CT infections. CONCLUSIONS The long duration since Ct diagnostics have been performed and laboratories have been accredited can be seen as an indication of the high diagnostic quality of German laboratories. Additionally, laboratories mostly serviced doctors and patients from a large region and are not representative for people living in the area where the lab is located. This has to be considered when sampling representative labs for CT sentinel surveillance and further epidemiological studies.

P1-S2.07 STI rates and risk factors among female sex workers attending STI testing sites in Germany, January–December 2010

Background Epidemiological studies on female sex workers (FSW) in Europe are limited. Since January 2010, selected German local health departments (LHD) offering STI testing services, have collected test results and behavioural data among FSW attendees. Using the data collected from January to December 2010, we asses STI positivity rates and identify risk factors for acquiring STIs among FSW tested at LHDs in Germany. Methods 30 LHDs throughout Germany voluntary submit quarterly reports with the number of FSW tested and found positive for any of the following STIs—HIV, Chlamydia (CT), Gonorrhoea (GC), Syphilis, Trichomoniasis (Tvag) and bacterial vaginosis (BV). Physicians provide basic demographic data, medical history relating to STI and information on where the FSW meet clients. In a separate questionnaire FSW provide information on for example, number of clients per week, sexual practices and drug use. Data for the in total 123 variables is consolidated and validated at the Robert Koch Institute. Uni- and multi-variable logistic regressions were used to identify relevant risk factors for being infected with CT, GC, Syphilis and/or Tvag (STI positive) and OR with 95% CIs were calculated. Results In 2010, 6675 FSW were seen and a total of 19 557 STI tests were performed. Physicians provided background data for 1142 (17%) of all FSW seen and of these 399 provided additional behavioural data. Median age was 30 (range—15–77 years), 72% were born outside Germany. Overall 7% of all tests were positive. The most common diagnoses were—BV (32.1% of 2770 tests), CT (6.8% of 3807), Tvag (3.3% of 2529) and GC (3.0% of 4223). 1.3% (of 3191) were positive for Syphilis and 0.2% (of 3037) HIV positive. Risk factors associated with a higher chance of testing STI positive included—poor knowledge of German language, OR=3.6 (2.5 to 5.0), meeting clients on the street, OR=3.5 (2.3 to 5.3) and increased number of clients per week. The risk of STI decreased with year of age, OR=0.95 (0.93 to 0.97), and was lower among FSW meeting clients on the internet, OR=0.5 (0.3 to 0.7) and FSW with health insurance, OR=0.4 (0.3 to 0.5) see Abstract P1-S2.07 Table 1. Abstract P1-S2.07 Table 1 Association between selected risk factors and being “STI positive” (testing positive for Chlamydia, Gonorrhoea, Syphilis and/or Trichomoniasis) among female sex workers attending STI testing sites in Germany, 2010 (N=1142) STI positive (Chlamydia, Gonorrhoea, Syphilis and/or Trichomoniasis), N=233 NTotal NPositive OR (95% CI) p Value German language  Fluent (R) 437 59 1  Medium 301 34 0.82 (0.52 to 1.30) 0.376  Very poor / None 375 135 3.60 (2.55 to 5.10) 0.000 Age  Range 15–77 years 1142 233 0.95 (0.93 to 0.97) 0.000 Health insurance  No (R) 450 138 1  Yes 648 87 0.35 (0.26 to 0.47) 0.000 Meet clients on the street  No (R) 995 173 1  Yes 101 43 3.52 (2.30 to 5.40) 0.000 Meet clients through internet or adds  No (R) 908 195 1 0.002  Yes 188 21 0.46 (0.28 to 0.74) Number of clients per week  Range 1–75 270 37 1.02 (1.00 to 1.04) 0.028 Explanatory factor included as continuous variable in logistic regression. (R), Reference group. Conclusions STI positivity rates, especially for HIV and syphilis seem relatively low among the FSW attending STI testing sites in Germany in 2010. FSW are a heterogeneous group and public health efforts should target those most at risk such as the young, migrant, uninsured and street-based women who sell sex.

P3.183 BORDERNETwork: Bridging Gaps in Biobehavioural STI Surveillance in Europe

Background Within the BORDERNETwork-project a biobehavioural sentinel surveillance was established in Austria, Bulgaria, Romania and Slovakia in 2010–12. The objectives were to record lab-confirmed STI (chlamydia, gonorrhoea, syphilis, HIV) in clinical settings and merge them with demographic and behavioural data to assess migration aspects, vulnerable groups and risk factors and recognise necessity for targeted interventions. Methods On a monthly base, physicians reported aggregated STI testing data. Individual data was provided for each positive patient including demographics, re- and co-infections and assumed risk behaviour. Via patient questionnaires, information on socio-demographics, way of transmission and sexual behaviour was collected. All questionnaires were sent via regional to coordinating partners for merging and analysis. Results Overall, 467797 tests were performed in 45 sentinel sites (Austria 13, Slovakia 14, Romania 13, Bulgaria 5). The countries varied in the number of STI tests (range: 6071 – 298645), positivity rate (range: 2–13%), patient characteristics and sexual behaviour. 75% of all women with an STI in Austria were sexworkers, compared to 5% and 8% in Bulgaria and Romania. 34% of all men with an STI in Slovakia had sex with men, compared to 4% in Romania. STI patients, especially women had a migration background in 79% in Austria, but less than 7% in the other three countries. Casual partners were the presumed cause of infection in the majority of MSM in all countries, whereas condom use in the last 6 months with these partners varied significantly between the 4 countries. Conclusions Although not representative, sentinel surveillance gathers useful information on groups most at risk and can be compared between countries when using the same instruments. Legal and social issues can hinder disclosure of sexual preferences and practises and hamper targeted prevention. Enhancement of condom use with casual partners in MSM seems to be crucial, particularly in the East.