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Laboratory diagnosis of Neisseria gonorrhoeae in St Petersburg, Russia: inventory, performance characteristics and recommended optimisations

Objectives: To perform a comprehensive inventory of the number of samples, performance characteristics, and quality assurance of the laboratory diagnosis of Neisseria gonorrhoeae at five laboratories in St Petersburg and Leningradskaya Oblast, Russia, in 2004, and to recommend optimisations for an increased adherence to international evidence based recommendations of diagnostics. Methods: Surveillance data were obtained with questionnaire and site visits. For evaluation of the culture media utilised at the laboratories, N gonorrhoeae reference strains (nu200a=u200a29) were used. Results: During 2004 the total numbers of N gonorrhoeae samples analysed at the five laboratories using microscopy of stained smears and culturing were 330 879 (407 positive) and 38 020 (420 positive), respectively. Four laboratories used a Russian non-selective culture medium—that is, Complegon, and one laboratory utilised Biocult-GC. Both media seemed suboptimal. Only two of the laboratories used any species confirmative assay. Antibiotic susceptibility testing of N gonorrhoeae was performed at only two of the laboratories and each year only occasional isolates were analysed. None of the laboratories comprised a complete laboratory quality assurance system. Conclusions: According to international recommendations, the diagnosis of N gonorrhoeae in St Petersburg and Leningradskaya Oblast, Russia, is suboptimal. More samples need to be analysed by culturing on a highly nutritious and selective medium and, furthermore, species confirmation and antibiotic susceptibility testing should be more frequently performed. In addition, the utilised methods for culturing and antibiotic susceptibility testing, including medium and interpretative criteria used, ought to be optimised, standardised, and quality assured using systematic internal and external quality controls.

Diagnosis of non-viral sexually transmitted infections in Lithuania and international recommendations

The aim of this study is to evaluate the range, quality and availability of diagnostic services for non-viral sexually transmitted infections (STIs), i.e. C. trachomatis, N. gonorrhoeae, T. vaginalis and T. pallidum, in Lithuania from September 2002 to December 2003. Surveillance data describing the organisation and performance characteristics of non-viral STI diagnostic services in Lithuania were collected using a questionnaire and subsequent site-visits. International evidence-based recommendations for non-viral STI diagnosis were used to evaluate the quality of the STI diagnostics. There were 171 facilities providing non-viral STI diagnostic services for the 3.5 million inhabitants of Lithuania. However, only 6% (n=9) of the respondents (n=153) could provide a confirmatory diagnosis, in accordance with international recommendations, for the full minimum range of relevant non-viral STIs in Lithuania, i.e. C. trachomatis, N. gonorrhoeae, T. pallidum, and T. vaginalis. In addition, accessibility to STI diagnostic services differed significantly among the different counties in Lithuania. Several of the respondents analysed low numbers of samples each year, and overall the sampling size was extremely low, especially for C. trachomatis diagnostics. In Lithuania, optimisation of non-viral STI diagnostics as well as of epidemiological surveillance and management of STIs is crucial. It may be worth considering a decrease in the number of laboratories, with those remaining having the possibility of performing STI diagnostic services that are optimised, in concordance with international recommendations, standardised, and quality assured using systematic internal and external quality controls and systems. In addition, establishment of national inter-laboratory networks and reference centres for non-viral STIs is recommended.

Diagnosis of Chlamydia trachomatis in Russia--in-house PCR assays may be effective but overall optimization and quality assurance are urgently needed.

In the present study, the performance of the cell culture method, two non‐Russian direct immunofluorescence (DIF) assays, and three different in‐house polymerase chain reaction (PCR) tests used in St. Petersburg, Russia, for detection of Chlamydia trachomatis in urogenital specimens was evaluated. A total of 650 patients were examined and it was most disquieting that previous C. trachomatis positivity with Russian DIF assays could – 7 days later – be confirmed only in 26% of the women and 30% of the men. Overall, the highest diagnostic sensitivity was obtained using PCR analysis. However, the sensitivity varied significantly: from 79% to 100% between the different PCR assays, sex of the patients, and type of samples. The highest sensitivity was obtained for female vaginal and male urine samples (100%). The specificity of the PCR assays varied from 97% to 100%. The sensitivity of cell culture and both the examined DIF assays was low, i.e. it varied from 46% to 56% and 55% to 75%, respectively. Meanwhile, cell culture was 100% specific and the DIFs showed a specificity varying from 99% to 100%. In conclusion, in a Russian perspective, adequate in‐house PCR methods may be used quite effectively for detection of C. trachomatis in invasive as well as non‐invasive clinical material. Simultaneous analysis of two different specimens from women resulted in a significantly increased detection rate of C. trachomatis. Nevertheless, in Russia the need for optimization and quality assurance of diagnostic methods for C. trachomatis, especially Russian DIF assays, has to be emphasized.

Pooling of urine specimens allows accurate and cost-effective genetic detection of Chlamydia trachomatis in Lithuania and other low-resource countries

The aims of this study were to compare performance characteristics and cost-effectiveness of pooling urine samples for screening and diagnosis of Chlamydia trachomatis using Digene Hybrid Capture II CT/NG Test (HCII), and to examine the prevalence of C. trachomatis in male military recruits in Lithuania. A total of 410 urine samples were individually tested and pooled by 5 and 10 samples, respectively. The sensitivity and specificity of diagnosis were not affected by either pooling strategy. The estimated population prevalence of C. trachomatis infection was nearly identical, i.e. 4.4%, 4.4% and 4.1% based on individually tested samples, and samples pooled by 5 and 10, respectively. For this estimation of the population prevalence, pooling 5 samples reduced the costs by 80% and pooling 10 samples reduced the costs by 90%. For diagnosis of each individual sample, the pooling strategies resulted in cost savings of 60% (5 samples per pool) and 56% (10 samples per pool). The present pooling strategies were sensitive, specific and cost-efficient for screening and diagnosis of C. trachomatis infection in male military recruits in Lithuania. The strategies would be most useful for reasonably inexpensive large-scale screening, prevalence studies and even diagnostics in Lithuania and many other low-resource countries.

P3.032 Epidemiology of Sexually Transmitted Infections in Tver, Russia

Background Tver region belongs to the Central part of Russia, its territory is 84,200 km2 with a population of 1,342,200 inhabitants, including the city of Tver populated by 406,918 inhabitants. The aim of this paper is for the first time to internationally present the epidemiological trends of STIs in the region. Methods Site visits and yearly epidemiological reports of the Center. Results The peripheral laboratories are poorly equipped and therefore the diagnosis of STIs is mainly concentrated to the Center of the Specialized Medical Aid in Tver. However, the long distances for specimen transportation and lack of appropriate transport system are large obstacles for providing effective diagnosis of STIs. In 2009, vaccination against human papilloma virus (HPV) was introduced into the prevention programme against cervical cancer in Tver. The epidemiological trends of the main STIs in the Tver region are changing. A decrease in the incidence (cases per 100,000 inhabitants) of almost all STIs has been observed, namely during the years 2008 and 2012 the incidence of syphilis was 62.1 and 21.0, gonorrhoea - 42.5 and 19.2, genital chlamydial infection - 58.7 and 34.4 cases, T vaginalis - 120.5 and 73.6, genital herpes - 8.1 and 6.5, and anogenital warts 21.1 and 16.6, respectively. Since introduction in 2009, 373 girls, aged 12–13 years, have been vaccinated for HPV. Conclusion . In Tver, Russia, the difficulties to reach the population in most need for testing is of major concern. The reported epidemiologic data is also suboptimal due to many reasons such as lack of appropriate diagnostic methods, frequent use of self-treatment (antibiotics available over the counter), and private laboratories and outpatient clinics do commonly not report STI cases to the authorities. Accordingly, it is imperative to optimise the laboratory diagnosis and epidemiological surveillance of STIs, and introduce evidence-based STI guidelines.

P2.023 Organisation of the Laboratory Services For Diagnosis of Sexually Transmitted Infections in Tver, Russia

Background The structure of laboratory services differs among different regions of Russia. In order to apply to international standards initially analysis of the organisational structure, methods and methodologies used is necessary. This study reviewed the features of the laboratory diagnosis of STIs in the Tver region, central Russia. Methods A questionnaire-based survey concerning STI laboratory services in the Tver region was conducted. Results The Tver region consists of 36 districts, populated by 1.3 million citizens (406,000 in the Tver city). The wast majority of the laboratories are owned by the State, however, a few privately owned laboratories are also present. The State-owned laboratories are divided into peripheral-district branches, most of them run mainly serology of syphilis and microscopy of genital smears. The remaining laboratory diagnostics is performed at the centralised laboratory at Center of Specialized Medical Aid in Tver. This laboratory examines samples sent from the regional branches and different city medical institutions, as well as samples collected from patients consulting physicians at its own Center. The test result is delivered either to the treating physicians or directly to the patient. Microscopy of Gram and methylene blue stained smears were the main methods for diagnosis of Neisseria gonorrhoeae and Trichomonas vaginalis infections. However, PCR was available for testing for Chlamydia trachomatis, N. gonorrhoeae, Mycoplasma genitalium, Gardnerella vaginalis, M. hominis and Ureaplasma urealyticum using Russia-produced diagnostic tests. Serology remained in use for diagnosis of chlamydial infection and trichomoniasis. No appropriate and complete quality assurance and control system was available. Conclusions In Tver, Russia, the detection of several STI agents has to be optimised, and international evidence-based standards and appropriate quality management systems introduced. Beneficially, the laboratory diagnosis is further centralised, which makes it easier to implement appropriate international evidence-based STI guidelines.

P3.095 Experiences from Working with Sexually Transmitted Infections and Related Issues Among Teenagers and Youth in Tver, Russia

Background The prevalence of sexually transmitted infections in Russia is high. Young sexually active individuals it is at highest risk to be infected, therefore increased access for consultations and testing is of great importance. Methods .The data was collected during the site visit from the records of the Center in February, 2013. Results The Regional Center for Prevention of the Reproductive Health of Teenagers and Youth “Your world.ru” (Твой мир.ru) was established in Tver, Russia in 2006. One of the multiple activities of the centre is prophylaxis and early detection of reproductive tract disorders, including STI and HIV infections. Medical and psychological help for the young population, aged from 15 to 24 years, of Tver city and region of Tver is provided free of charge by a team including young medical professionals, namely dermatovenereologists, gynaecologists, endocrinologists, urologists-andrologists and psychologists. In 2012, 2,000 young persons (more than 6,000 visits) attended the STI centre for testing and a genital tract infection was diagnosed in 15.3% of these. Chlamydia trachomatis was detected in 8.8% (71/805) and Neisseria gonorrhoeae in 4.0% (8/202) of the young persons tested. During the same year three new cases of syphilis and nine cases of HIV were also diagnosed. It is of grave concern that spread of HIV among the young population of Tver is exclusively sexual and is increasing! Conclusion The STI morbidity of the young population, aged 15–24 years, is high in Tver and Tver region, Russia. Among the risk factors for acquiring STIs in Tver and Tver region are early sexual debut, active sexual life with frequent change of sexual partners, casual sex and unprotected sex. More active sexual education within this young age group is essential.

P1-S1.34 First report of the Swedish new variant of Chlamydia trachomatis (nvCT) in Russia

Background The new variant of Chlamydia trachomatis (nvCT), first reported in Sweden in late 2006, has so far rarely been reported outside the Nordic countries. However, knowledge of the presence of nvCT beyond these countries is limited due to the few recent studies, many laboratories still cannot detect nvCT, and the ones that can detect nvCT do mainly not distinguish it from wild type CT. The aims were to i) investigate the presence of nvCT in St. Petersburg, the largest city of the Northwest of Russia and in close proximity to Sweden, and ii) assess nucleic acid amplification tests (NAATs) used in Russia to diagnose C trachomatis infections for their ability to identify nvCT. Methods June–December 2010, consecutive samples (cervical swabs from females and urethral swabs from males) found positive for C trachomatis during routine testing with commercial PCR assays able to detect nvCT were collected. For nvCT detection, DNA was isolated using NucliSens easyMAG (bioMérieux) or QIAamp DNA mini kit (Qiagen), and analysed with an international real-time nvCT-specific PCR. C trachomatis NAATs currently used in Russia was also examined regarding their ability to detect nvCT DNA. Results During the study period, 9517 samples were submitted from patients of gynaecological, urological and STI clinics for C trachomatis testing. Of these samples, 275 (2.9%) from 198 females and 75 males were positive for C trachomatis. The mean age of the patients was 26.4u2005years (range 19–51u2005years). nvCT was detected in one sample (0.4%), which was obtained from a 23-year-old Russian woman. Genotyping using variable number of tandem repeats (VNTR) typing showed that the nvCT was indistinguishable to the previously typed nvCT samples from the Nordic countries (type 8.7.1). Six NAATs, which are used in the majority of laboratories in Russia performing C trachomatis diagnostics, were assessed for the ability to detect nvCT (Abstract P1-S1.34 table 1). All evaluated assays, with exception of the Lytech PCR, tested positive with nvCT DNA. Conclusions This study is the first report of an nvCT case in Russia, and in general in Eastern Europe, and that evaluates most C trachomatis NAATs currently used in Russia for the ability to detect nvCT. Although the prevalence of nvCT is still considered low outside Northern Europe, wider geographic spread of nvCT cannot be excluded, and therefore regular monitoring and participation in external quality assessments of diagnostic methods in use are necessary. Abstract P1-S1.34 Table 1 Nucleic acid amplification tests (NAATs) developed and used in Russia for the detection of Chlamydia trachomatis and their ability to detect nvCT NAAT (Manufacturer, City) Gene target(s) Able to detect nvCT? Conventional PCR (DNA-Technology, Moscow) Cryptic plasmid Yes Real-time PCR (DNA-Technology, Moscow) 16S rRNA gene Yes Conventional PCR (Central Research Institute of Epidemiology, Moscow) Cryptic plasmid Yes Real-time PCR (Central Research Institute of Epidemiology, Moscow) Cryptic plasmid Yes Conventional PCR (Lytech, Moscow) Cryptic plasmid No Real-time PCR (Vector-Best, Novosibirsk) Cryptic plasmid and gyrA gene Yes