上海市某医院艾滋病合并梅毒病例特征分析及影响因素探讨

为了解近年来上海市艾滋病合并梅毒患者的特征及变化趋势,探讨艾滋病患者合并梅毒的影响因素,本研究收集了2013—2019年上海市(复旦大学附属)公共卫生临床中心(简称临床中心)诊断为艾滋病合并梅毒的病例作为研究对象。经详细查询研究对象的住院登记资料和病史,本文整理出用于研究的资料,并将研究对象分为艾滋病合并梅毒组和艾滋病不合并梅毒组。结果显示,临床中心艾滋病患者中有10.55%合并梅毒;2013—2019年临床中心艾滋病合并梅毒感染率总体呈上升趋势(χ2＝17.640,P<0.05),每年7—8月份为收治高峰期。患者主要来源于本地居民(占55.49%),男女性别比为14∶1,平均年龄为38±12岁。通过Logistic回归分析发现,影响艾滋病合并梅毒的因素有性别、年龄、病例来源和CD4^＋T细胞计数,其中本地来源、年龄在21～40岁、男性和CD4^＋T细胞计数≤500 /μL是艾滋病患者合并梅毒感染的高危因素。研究提示,上海市艾滋病合并梅毒感染病例数呈上升趋势,重点防控人群是上海市青壮年男性居民,应提高对此类人群的主动监测能力,加大筛查力度,做好健康教育;重点防控时间是每年7、8月份,应精准防控以期取得明显效果。本研究为上海市此类疾病防控提供了一定的科学依据。     

A spatial analysis of county-level variation in syphilis and gonorrhea in Guangdong Province, China

Background

Sexually transmitted infections (STI) have made a resurgence in many rapidly developing regions of southern China, but there is little understanding of the social changes that contribute to this spatial distribution of STI. This study examines county-level socio-demographic characteristics associated with syphilis and gonorrhea in Guangdong Province.

Methods/Principal Findings

This study uses linear regression and spatial lag regression to determine county-level (n = 97) socio-demographic characteristics associated with a greater burden of syphilis, gonorrhea, and a combined syphilis/gonorrhea index. Data were obtained from the 2005 China Population Census and published public health data. A range of socio-demographic variables including gross domestic product, the Gender Empowerment Measure, standard of living, education level, migrant population and employment are examined. Reported syphilis and gonorrhea cases are disproportionately clustered in the Pearl River Delta, the central region of Guangdong Province. A higher fraction of employed men among the adult population, higher fraction of divorced men among the adult population, and higher standard of living (based on water availability and people per room) are significantly associated with higher STI cases across all three models. Gross domestic product and gender inequality measures are not significant predictors of reported STI in these models.

Conclusions/Significance

Although many ecological studies of STIs have found poverty to be associated with higher reported STI, this analysis found a greater number of reported syphilis cases in counties with a higher standard of living. Spatially targeted syphilis screening measures in regions with a higher standard of living may facilitate successful control efforts. This analysis also reinforces the importance of changing male sexual behaviors as part of a comprehensive response to syphilis control in China.     

Epidemiological surveillance of syphilis patients in Colentina Hospital (Bucharest, Romania)

Syphilis remains a global health problem with an estimated 12 million people infected each year. In Romania a decrease in the syphilis prevalence can be observed. From 2002 (12,702 cases) and 2003 (9,698 cases) until 2006 (5,657 syphilis cases) the reduction can be explained through the intensified efforts of the Ministry of Pubic Health to fight STI. The decrease is probably not related to an improvement of the general health status and not a consequence of some epidemiological prevention and control measures but probably was done by the reorientation of the patients to the general practitioners and to the private practice medical offices and to the lack of reporting of the cases. In Colentina Hospital a similar abrupt decrease of new cases was registered from 2004 (259 cases) to 2006 (110 cases). General problems related to syphilis cases recorded at Colentina Hospital included the patient presentation for consultation in the advanced stages of the disease, the socio-economic and educational factors, proxenetism and the sexual aggression of minors. There is a need in strengthening of the public health component in the control and surveillance of HIV/AIDS and STI. This may need changes in the legal framework to improve reporting and to target vulnerable groups in prevention activities. Laboratory capacity needs to be increased in order to be able to properly diagnose STI and improve the control and patient management. The reporting needs to be improved and simplified as for reporting protocol, reporting forms, case definitions to be taken into account in the renewed STI surveillance.     

Congenital syphilis in the past: slaves at Newton Plantation, Barbados, West Indies.

Hutchinson's incisors and Moon's molars are specific lesions of congenital syphilis. The extensive but fragmentary clinical literature on these conditions describes reduced dimensions and thin enamel in the permanent incisors and first molars, crowding and infolding of the first molar cusps, notching of the upper incisors, and apical hypoplasias of the permanent canines. A Barbados slave cemetery (ca. 1660-1820 AD) includes three individuals with these features, suggesting a frequency at birth of congenital syphilis in the population approaching 10%. These three cases show triple the frequency of all hypoplasias and more than seven times the frequency of pitting hypoplasia present in the remainder of the series. The recognizable congenital syphilis cases account for much of the remarkably high frequency of hypoplasias in the series as a whole. We infer that syphilis contributed substantially to morbidity, infant mortality, and infertility in this population. Presence or absence of congenital syphilis may account for much of the variability in health and mortality seen among nineteenth century African-American populations.     

Bridging the Epidemic: A Comprehensive Analysis of Prevalence and Correlates of HIV,Hepatitis C,and Syphilis,and Infection among Female Sex Workers in Guangxi Province,China

IntroductionFemale sex workers (FSWs) are at highest risk for contracting HIV and facilitating the current heterosexual HIV epidemic in Guangxi, China, yet little is known of the impact of recent harm reduction campaigns in the province. We analyzed sentinel surveillance data collected between 2010 and 2012 in Guangxi to explore correlations between the prevalence of HIV, hepatitis C (HCV), and syphilis and risk behaviors of different categories of FSWs in Guangxi.MethodsThe sentinel surveillance data for 5,1790 FSWs in all 14 prefectures and 64 city/county regions of Guangxi, China from 2010 to 2012 were collected. Differences between three categories of FSWs (grouped by venue) and disease trends (HIV, HCV, and syphilis) by year were analyzed using bivariate and multivariate logistic regression analyses as to evaluate risk factors correlated with HIV, HCV, or syphilis infection.ResultsHIV and HCV prevalence remained constant across the three FSW categories; however, syphilis prevalence showed a significant increase from 5.7% to 7.3% for low-tier FSWs. Most cases with HIV, HCV, syphilis and intravenous drug use were seen in low-tier FSWs. Testing positive for HIV and syphilis were most correlated with being HCV positive (AOR 4.12 and AOR 4.36), only completing elementary school (AOR 3.71 and AOR 2.35), low tier venues (AOR 2.02 and AOR 2.00), and prior STI (AOR 1.40 and AOR 3.56), respectively. HCV infection was correlated with ever injecting drugs (AOR 60.65) and testing positive for syphilis (AOR 4.16) or HIV (AOR 3.74).ConclusionsThis study highlights that low tier FSWs with lower formal education levels are the most vulnerable population at risk for acquiring and transmitting HIV, HCV, and syphilis in Guangxi, China. Condom distribution with evolution to safer sex practices are the reasons to explain the non-increasing prevalence of HIV, HCV in Guangxi for 2010–2012.     

3670 例早期妊娠妇女梅毒血清学检查及处理

目的:了解早期妊娠妇女梅毒感染情况,采取防治措施,减少先天梅毒的发生。方法:采用梅毒明胶颗粒试验(TPPA)和梅毒甲苯胺红试验(TRUST)对早期妊娠妇女进行梅毒血清学检查,两项结果均阳性者诊为妊娠期梅毒,可采取驱梅治疗或终止妊娠。结果:3670例早期妊娠妇女中,确诊为妊娠期梅毒的29例,其中TRUST滴度大于1:8的有8例,小于1:8的有21例;有12人接受驱梅治疗,有17人选择终止妊娠。结论:在早期妊娠妇女中进行梅毒血清学检查,可及早采取措施,减少先天梅毒的发生。     

Immuno-PCR法诊断早期梅毒的方法学建立及其应用

目的建立Immuno-PCR法诊断早期梅毒的方法学,评价其灵敏度、特异性、重复性及其临床应用。方法利用基因重组TpN47抗原免疫新西兰兔,制备抗体并用Weston blotting检测;利用抗TpN47抗体作为捕获抗体与血清中TpN47抗原结合,通过链霉亲和素、生物素化抗体、生物素化DNA和PCR扩增等建立Immuno-PCR法检测梅毒螺旋体抗原TpN47体系;评价该方法的灵敏度、特异性和重复性;收集200例临床标本通过Immuno-PCR法、ELISA、TPPA和TURST法进行临床应用比较。结果 Weston blotting结果显示TpN47抗体阳性;Immuno-PCR比ELISA法敏感性强103倍,比TPPA、TURST强105倍;特异性高,重复性好。临床标本中Immuno-PCR法敏感性和特异性分别为86.00%（P〈0.05）和100.00%,ELISA法为71.00%和98.00%,TPPA法为65.00%和100.00%,TRUST法为68.00%和95.00%。结论 Immuno-PCR法检测梅毒螺旋体TpN47抗原敏感性高,特异性强,重复性好,可作为梅毒螺旋体感染的早期诊断方法 。     

A humanistic library for physicians by physicians.

In 1986 the rate of infectious syphilis (primary and secondary) in Los Angeles County began to rise from previously stable levels of about 23.5 per 100,000 to peak at 55.6 per 100,000 in 1987. The incidence of congenital syphilis increased from 205 cases in 1987 to 575 cases in 1989. The county''s Sexually Transmitted Disease Program instituted a disease-specific plan to address the epidemic. Factors considered in designing the program included the high morbidity and mortality associated with congenital infection, the existence of latent infection, self-limiting symptoms, and the availability of an inexpensive screening test and curative treatment. Policy changes implemented comprised expanded screening, expanded surveillance, increased contact tracing, and the initiation of condom promotion programs. To evaluate the relative effectiveness of Los Angeles County''s syphilis control efforts, the epidemic curve for infectious syphilis was compared with trends in other urban areas. Although the rate of infectious syphilis climbed a year earlier in Los Angeles than in other cities, it returned to baseline levels when other cities'' rates remained at epidemic levels.     

A Cost-Benefit Analysis of California's Mandatory Premarital Screening Program for Syphilis

As do most states, California requires premarital serologic tests for syphilis. The Venereal Disease Research Laboratory (VDRL) test and a fluorescent treponemal antibody-absorbed (FTA-ABS) are often used in series for this purpose. In 1979 in California, there were approximately 300,000 persons tested premaritally, but only 35 were found to have asymptomatic infectious syphilis (incidence=0.012%). Including all the direct costs of this screening program, the yearly costs of premarital screening is $8.5 million or almost $240,000 per case found. If one takes into account the sensitivities and specificities of the tests, one still has 6 false-negative and 90 false-positive tests using the 1979 figures. The benefits of the program are the number of cases of congenital syphilis that are prevented. Using a worse-case method, no more than 1.5% of the cases of syphilis detected would result in a case of congenital syphilis. The estimated benefits would result in a savings of approximately $161,000. The economic costs of the premarital screening program far outweigh the benefits.     

Secondary Syphilis: Uncommon Manifestations a Common Disease

Reports of cases of primary and secondary syphilis are increasing in the United States, particularly in urban areas and among homosexual men. While primary syphilis poses little diagnostic difficulty, many physicians are unfamiliar with the multisystem nature of secondary lues. Patients who have secondary syphilis commonly present with systemic signs, skin rash, mucous membrane lesions and generalized adenopathy. Less commonly, secondary syphilis may occur as acute meningitis, sensorineural hearing loss, iritis, anterior uveitis, optic neuritis, Bell''s palsy, gastropathy, proctitis, hepatitis, pulmonary infiltration, nephrotic syndrome, glomerulonephritis, periostitis, tenosynovitis and polyarthritis. The diagnosis of secondary syphilis is easily confirmed. Its various manifestations are readily treated with penicillin and, if treated early, are entirely reversible. Two recent cases of secondary syphilis, one presenting as nephrotic syndrome and one as chorioretinitis and ptosis, illustrate the usual and unusual features of this common infection.     

Regional, social, and evolutionary perspectives on treponemal infection in the Southeastern United States

The origin and geographic distribution of syphilis, a form of treponemal infection, have long been regarded as among the most important medical riddles of prehistoric and historic disease evolution. In this study, we expand on previous discussions of the origin, evolution, and relationship of treponemal infections as they occur in the prehistoric southeastern United States. Individuals from 25 skeletal series (n = 2,410 individuals) were examined for cranial and dental lesions characteristic of treponemal infection. They lived between the Archaic period (8000-1000 BC) and protohistoric period (AD 1500-1600), and in physiographic zones from the coast to the mountains of Alabama, Florida, North Carolina, and Tennessee. Radial cranial scars were found for 47 individuals, but none of the four cases of dental lesions could be attributed to congenital syphilis. Differences in frequency of cranial lesions by region were minimal, with the least number of cases found for the mountains, but the frequency of positive cases tended to increase through time. It is suggested that increasing population density and changing behaviors, rather than novel strains of the treponemal pathogen, are responsible for the chronological increase in the frequency of positive cases.     

Use of the polymerase chain reaction to detect DNA sequences specific to pathogenic treponemes in cerebrospinal fluid

The polymerase chain reaction was used to detect Treponema pallidum in specimens of cerebrospinal fluid (CSF), as a means of diagnosing syphilis. Segments of the TmpA and 4D genes were amplified to provide an estimated threshold sensitivity of approximately 65 organisms in 0.5 ml. A spectrum of pathogens known to cause meningitis, and several non-pathogenic treponemes were unreactive. Treponema pertenue, and only one of 30 control specimens of CSF were positive. In contrast, 10 of 19 CSFs from patients being evaluated for latent or tertiary syphilis were positive, as were 7 of 28 specimens from HIV-positive patients.     

检测梅毒螺旋体抗体的纤维膜条方法的建立及其在诊断中的应用

目的：建立以纤维膜为载体的检测梅毒螺旋体抗体的方法,检查病人血清中对梅毒螺旋体多种抗原的抗体,用于梅毒感染的诊断。方法：将基因工程表达及纯化的梅毒螺旋体蛋白tp15、tp17、tp42和tp47分别结合在纤维膜上,用载抗原的纤维膜条检查血清中的抗体,抗体阳性者在相应抗原位置显示出特异条带。结果：梅毒螺旋体感染者血清中存在特异性抗体,在检查的460份临床诊断的患者血清中,对tp15、tp17、tp42和tp47抗原的抗体检出率分别为41.3%、100%、98.7%和51.7%;134份献血员血清抗体阴性。结论：建立的检测梅毒螺旋体感染的方法可同时检查对多种抗原的抗体,以纤维膜条作为诊断条检测血清抗体方法简便,用于临床诊断更特异、更敏感。     

梅毒住院患者63例血清学及脑脊液的临床分析

目的了解梅毒住院患者的流行病学、临床和血清学特征。方法对63例患者的临床资料及血清学、脑脊液等进行综合分析。结果87．30％（55例）患者血清TRUST呈低滴度表现（1：1～1：8）,14．29％（9例）为早期潜伏梅毒,15．87％（10例）为神经梅毒,52．38％（33例）为晚期潜伏梅毒,17．46％（11例）为无法判断病期的潜伏梅毒。73．02％（46例）传播途径为非婚性接触为主,性别分类中女性（49例）多于男性（14例）,低学历（54例）、待业者（18例）及性活跃期人群发病率高。结论潜伏（隐性）梅毒在梅毒分期中占有较大的比例;有必要对血清TRUST滴度持续（≥2年）不转阴患者进行神经梅毒的排查;有必要加强宣传性保护的重要性。     

巢式PCR法在早期梅毒诊断中的应用评价

目的：评价巢式PCR（nPCR）法在早期梅毒诊断中的临床应用价值,以提高早期梅毒诊断的灵敏度和特异性。方法：选择2010年10月至2011年11月来我院就诊,经临床综合分析为一期梅毒的患者195例和同期就诊的120例非梅毒患者为研究对象,采用nPCR法对棉拭子标本和血液标本中梅毒螺旋体特异性基因tpp47进行扩增检测,所有标本同时做暗视野镜检和Tp—ELISA血清学检测。结果：nPCR法共检测出阳性标本176例,其灵敏度和特异性分别为90．3％和100％,明显高于暗视野镜检和Tp-ELISA法,差异有统计学意义。结论：nPCR法在早期梅毒诊断中具有较高灵敏度和特异性,可以作为暗视野镜检和血清学检测的补充试验。     

梅毒螺旋体耐药性的研究进展

梅毒疫情成为全球普遍关注的公共卫生问题。由于缺乏疫苗预防,控制梅毒主要依赖对感染人群的诊断与抗生素治疗。虽然青霉素治疗梅毒仍然有效,但临床上对一线青霉素的替代药大环内酯类抗生素耐药的梅毒螺旋体(Tp)菌株已在许多国家普遍流行。了解Tp耐药性的遗传基础对于加强Tp耐药分子监测十分必要。就Tp对大环内酯类抗生素耐药性的遗传基础和对其他可能严重阻碍梅毒治疗和控制的抗生素潜在的耐药性进行了综述。     

CONGENITAL SYPHILIS IN CALIFORNIA

Routine serologic tests for syphilis (as required by California law governing prenatal examination) and penicillin therapy during pregnancy for infected mothers have been major factors in the prevention of congenital syphilis in California during the past ten years. In 1940 one of each 822 infants had the disease, as indicated by morbidity reports of congenital syphilis in infants under the age of one year. In 1950 the ratio was one in 8,148. To determine why congenital syphilis continues to occur, a study of the 134 cases reported over a two-year period was made with the cooperation of local health officers and practicing physicians. It showed that in 76 per cent of cases the mother did not consult a physician prior to delivery or reported so late in pregnancy that the infant was born before adequate penicillin therapy could be given. In another 15 per cent syphilis developed in the mother during pregnancy after a negative reaction to a prenatal serologic test. The other 9 per cent of cases were due to various factors, such as infectious relapse or reinfection in previously adequately treated mothers. The study indicated that most cases occur in the lower socioeconomic population groups. Seventy-four per cent of cases were in infants delivered in county hospitals.     

Assessing the drivers of syphilis among men who have sex with men in Switzerland reveals a key impact of screening frequency: A modelling study

Over the last decade, syphilis diagnoses among men-who-have-sex-with-men (MSM) have strongly increased in Europe. Understanding the drivers of the ongoing epidemic may aid to curb transmissions. In order to identify the drivers of syphilis transmission in MSM in Switzerland between 2006 and 2017 as well as the effect of potential interventions, we set up an epidemiological model stratified by syphilis stage, HIV-diagnosis, and behavioral factors to account for syphilis infectiousness and risk for transmission. In the main model, we used ‘reported non-steady partners’ (nsP) as the main proxy for sexual risk. We parameterized the model using data from the Swiss HIV Cohort Study, Swiss Voluntary Counselling and Testing center, cross-sectional surveys among the Swiss MSM population, and published syphilis notifications from the Federal Office of Public Health. The main model reproduced the increase in syphilis diagnoses from 168 cases in 2006 to 418 cases in 2017. It estimated that between 2006 and 2017, MSM with HIV diagnosis had 45.9 times the median syphilis incidence of MSM without HIV diagnosis. Defining risk as condomless anal intercourse with nsP decreased model accuracy (sum of squared weighted residuals, 378.8 vs. 148.3). Counterfactual scenarios suggested that increasing screening of MSM without HIV diagnosis and with nsP from once every two years to twice per year may reduce syphilis incidence (at most 12.8% reduction by 2017). Whereas, increasing screening among MSM with HIV diagnosis and with nsP from once per year to twice per year may substantially reduce syphilis incidence over time (at least 63.5% reduction by 2017). The model suggests that reporting nsP regardless of condom use is suitable for risk stratification when modelling syphilis transmission. More frequent screening of MSM with HIV diagnosis, particularly those with nsP may aid to curb syphilis transmission.     

The Impact of Syphilis Screening among Female Sex Workers in China: A Modelling Study

Background

In China, female sex workers (FSWs) are at high risk of syphilis infection, but are hard to reach for interventions. Point-of-care testing introduces opportunities for expanding syphilis control measures. Modelling is used to estimate the impact of using rapid tests to screen FSWs for syphilis. In other settings, modelling has predicted large rebounds in infectious syphilis following screening, which may undermine any impact achieved.

Methods

A deterministic syphilis transmission model among FSWs and clients was fitted to data from Yunnan Province (FSW syphilis prevalence = 7.5%), and used to estimate the impact of rapid syphilis testing and treatment for FSWs. Impact projections were compared for different model structures that included risk heterogeneity amongst FSWs, incoming syphilis infections amongst new FSWs and clients and re-infection from FSWs'' regular non-commercial partners. The rebound in syphilis prevalence after screening ceased was explored.

Results

All model structures suggest yearly syphilis screening could substantially reduce (by 72–88%) syphilis prevalence amongst FSWs in this setting over five years. However, incoming syphilis infections amongst new FSWs and clients or re-infections from regular non-commercial partners of FSWs can considerably reduce (>30%) the proportion of infections averted. Including heterogeneity in risk amongst FSWs had little effect upon the proportion of infections averted. In this setting, the rebound in syphilis prevalence after screening ceased is predicted to be slight, but it could be large in high prevalence settings.

Conclusions

Rapid test screening could dramatically reduce syphilis prevalence amongst hard-to-reach groups, but strategies to reduce re-infection from regular non-commercial partners are needed to maximise impact.     

Gonorrhea in homosexual men.

Extragenital gonorrhea was seen in 65% of 54 cases of gonorrhea in 43 homosexual men attending a venereal diseases clinic between 1974 and 1977; in 21 cases the infection was extragenital only. This type of gonorrhea was often asymptomatic and was associated with a high rate of failure of initial treatment in 6 of the 50 cases in which the patient returned for follow-up assessment, and in 5 of the 6 the persistent infection was extragenital. Syphillis was seen concomitantly or had previously occurred in 6 of the 54 cases. Fifteen of 28 cases of primary, secondary or early latent syphilis seen in men during the same study period had occurred in homosexuals. Appropriate testing for extragenital gonorrhea and for syphilis is important in homosexual men who present for examination, and homosexuality with the possibility of extragenital gonorrhea should be considered in a man with syphilis of recent onset.