Report on global sexually transmitted infection surveillance 2015

Report on global sexually transmitted infection surveillance

2015

Report on global sexually transmitted infection surveillance 2015

WHO Library Cataloguing-in-Publication Data : Report on global sexually transmitted infection surveillance 2015. 1.Sexually Transmitted Diseases – epidemiology. 2.Epidemiological Monitoring. 3.Epidemiologic Methods. I.World Health Organization. ISBN 978 92 4 156530 1 (NLM classification: WC 140))

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Acknowledgments The World Health Organization would like to thank the Member States working to collect and share data on the STI burden in their countries. It is the work of dedicated health-care providers at the local and national level that comprise this report. Teodora Wi and Lori Newman in the WHO Department of Reproductive Health and Research coordinated the development of the document. James Kiarie, Nathalie Broutet, and Melanie Taylor contributed further input. We would like to express our gratitude to the following WHO consultants: Celine Daly who drafted this report; Francis Ndowa and Saman Wijesooriya who contributed to the data shared in this report; and Eline Korenromp and Lee Sharkey who provide technical support and inputs for this work. The Department acknowledges the support of the WHO regional staff members on HIV and STI surveillance and programmes, including Monica Alonso Gonzalez, Massimo Ghidinelli, Hamida Khattabi, Lali Khotenashville, Linh-Vi Le, Ying-Ru Lo, Franck John Lule, Razia Pendse, Harilala Nirina Razakaoa, Gabriele Riedner and Dongbao Yu. In addition we would like to thank our colleagues in the Department of HIV/AIDS, UNAIDS and Reproductive Health and Research for their support in collecting data, producing this report and strengthening STI surveillance: Maria Babovic, Michel Beusenberg, Jesus Maria Garcia Calleja, Gottfriend Hirnschal, Daniel Low-beer and Mary Mahy. We also would like to thank our WHO Gonococcal Antimicrobial Surveillance Programme (GASP) regional focal points and national partners: Manju Bala, Michelle Cole, Jo Ann Dillon, Amina Hancali, Sarah Kidd, Monic Lahra, Irene Martin, Pillar Ramon Pardo, Magnus Unemo and Tom Wong. We are grateful for the financial and technical support provided by the United States Centres for Disease Control and Prevention (US CDC) and our thanks go to Gail Bolan, Mary Kamb and Hillard Weinstock for strengthening STI surveillance and ensuring that STI surveillance remains a priority. We thank Green Ink, United Kingdom (www.greenink.co.uk) for editing and Oceantranslations for assistance with layout.

Contents Abbreviations and acronyms Executive summary 1. Introduction Box 1. STI indicators for Global AIDS Response Progress Reporting 1.1 Data sources and interpretation

viii 1 3 5 5

2. General population STI incidence: case reporting 2.1 Data quality and interpretation Box 2. Case reporting: a key component of STI surveillance in India 2.2 Syndromic case reporting Indicator 1.17.9: Urethral discharge rate (adult males) Indicator 1.17.10: Genital ulcer disease rate (adult males and females) 2.3 Etiological case reporting Indicator 1.17.8: Gonorrhoea rate (adult males) Indicator 1.17.6: Syphilis rate (adult males and females)

6 6 7 7 8 9 10 11 12

3. Towards elimination of mother-to-child transmission of syphilis Box 3. Declines in maternal and congenital syphilis, 2008–2012 Box 4. Rapid syphilis tests may increase coverage of ANC syphilis testing 3.1 Country validation of EMTCT of syphilis and HIV Box 5. Required indicators for validation of EMTCT of syphilis 3.2 Monitoring the ANC cascade 3.3 Data quality and interpretation Indicator 1.17.1: ANC syphilis testing coverage Indicator 1.17.2: ANC syphilis seroprevalence Indicator 1.17.3: ANC syphilis treatment Indicator 1.17.7: Congenital syphilis rate

14 14 16 17 17 17 19 20 21 22 23

4. Syphilis prevalence among key populations 4.1 Data quality and interpretation Indicator 1.17.4: Syphilis in sex workers Indicator 1.17.5: Syphilis in men who have sex with men

24 25 26 27

5. Gonococcal antimicrobial susceptibility 5.1 Gonococcal Antimicrobial Surveillance Programme (GASP) 5.2 Antimicrobial susceptibility data 5.3 Data quality and interpretation 5.4 Extended-spectrum cephalosporins 5.5 Azithromycin 5.6 Quinolones

28 28 29 30 30 31 32

6. Conclusion

33

Annexes 34 Annex 1. Reported cases of STI syndromes: genital ulcer disease (GUD) in males and females and urethral discharge (UD) in males (cases per 100 000 adults), based on most recently reported Global AIDS Response Progress Reporting (GARPR) system data, 2012–2014 Annex 2. Male gonorrhoea rates (cases per 100 000 adult males) based on most recently reported Global AIDS Response Progress Reporting (GARPR) system data, 2012–2014 Annex 3. Syphilis rates: Female, male, female primary, male primary and total rates (cases per 100 000 adults) based on most recently reported Global AIDS Response Progress Reporting (GARPR) system data, 2012–2014 Annex 4: Cascade of indicators for elimination of mother-to-child transmission (EMTCT) of syphilis using most recent data reported through the Global AIDS Response Progress Reporting (GARPR) system, 2008–2014* Annex 5. Syphilis prevalence reported for female sex workers and MSM using most recent data reported through Global AIDS Response Progress Reporting (GARPR) system, 2008–2014 Annex 6. Reported percentage of gonoccocal isolates with resistance to azithromycin and ciprofloxacin/quinolones and elevated minimum inhibitory concentrations (MICs) of cefixime (> 0.25μg/ml) or ceftriaxone (> 0.125 μg/ml), 2012 and 2013

35 37 39 41 45 48

References 51

Abbreviations and acronyms AMR ANC EMTCT FSW GARPR GASP GUD MDG MIC MSM MTCT NGO PID PMTCT RST STI UD UNPD WHO XDR antimicrobial resistance antenatal care elimination of mother-to-child transmission female sex worker Global AIDS Response Progress Reporting Gonococcal Antimicrobial Susceptibility Programme genital ulcer disease Millennium Development Goal minimum inhibitory concentrations men who have sex with men mother-to-child transmission nongovernmental organization pelvic inflammatory disease prevention of mother-to-child transmission rapid syphilis tests sexually transmitted infections urethral discharge United Nations Population Division World Health Organization extensively drug-resistant

Report on global sexually transmitted infection surveillance – 2015 | 1

Executive summary The global burden of sexually transmitted infections (STIs) remains high. In 2012, there were an estimated 357 million new infections (roughly 1 million per day) of the four curable STIs – chlamydia, gonorrhoea, syphilis and trichomoniasis. Prevention and control of STIs are an integral component of the comprehensive sexual and reproductive health services needed to attain the Sustainable Development Goals (SDGs) to reduce child and neonatal mortality (3.2), to end the epidemics of AIDS and other communicable diseases (3.3), to reduce noncommunicable diseases, and to improve mental health (3.4), sexual and reproductive health (3.7) and to achieve universal health coverage (3.8). Surveillance is a key element of the World Health Organization (WHO) STI prevention and control strategy and is an important component of second-generation surveillance systems for human immunodeficiency virus (HIV). The WHO STI surveillance guidelines were updated in 2012 to take into account the changing epidemiology of STIs and the development of new technologies. This report summarizes the latest country-reported data from Global AIDS Response Progress Reporting (GARPR) and the Gonococcal Antimicrobial Susceptibility Programme (GASP), and provides updates to two previous reports on STI surveillance for 2012 and 2013. Overall, the comparability of surveillance data between countries is limited by varying case definitions and completeness of reporting. When consistently measured over time, results are best used for assessment of trends within countries.

• UD in males: 143.5 (range 5.0–3579.2) • GUD in males and females: 27.4 (range 0–2195.5) • gonorrhoea in males: 25.5 (range 0.5–385.5) • syphilis in males and females: 25.1 (range 0.1–1664).

Towards elimination of mother-to-child transmission of syphilis Antenatal care (ANC) syphilis reporting is generally more robust and is incorporated into health information systems in more countries. Substantial progress has been made towards global elimination of congenital syphilis. A recent analysis showed more than a one third global reduction in maternal and infant syphilis between 2008 and 2012. Cuba achieved elimination of mother-to-child transmission of syphilis and HIV in 2015 and several more countries are promising candidates for elimination of vertical syphilis transmission. Over the period 2008–2014, antenatal syphilis screening coverage increased globally and syphilis seropositivity among pregnant women decreased by nearly half. The syphilis prevalence among ANC attendees was 1% or more in nearly half of the countries reporting in 2014. Efforts to increase testing are needed urgently in many countries with continued low coverage of ANC syphilis screening, especially in the African Region.

Syphilis prevalence among key populations Monitoring syphilis seroprevalence among key populations is an important indicator of progress on STI control since they are at high risk of exposure to and transmission of STIs and HIV. Targeted interventions with sex workers are conducted in the majority of countries, ranging from 53% of countries in the European Region to over 90% of countries in the South-East Asia and Western Pacific Regions. In general, fewer countries reported working with men who have sex with men. Syphilis seroprevalence remains high in key populations worldwide, with at least one country in every WHO region reporting over 5% prevalence among female sex workers and men who have sex with men. In 2014, 28 countries reported data on syphilis among female sex

General population STI incidence: case reporting Case reporting indicators based on STI syndromes and etiological causes were incorporated into GARPR in 2013. The STI indicators are of two types: syndromic case reporting based on clinical diagnosis for urethral discharge (UD) and genital ulcer disease (GUD); and etiologic case reporting based on laboratory diagnosis for syphilis and gonorrhoea. Overall, 53–56 countries reported on each indicator. The greatest number of countries reporting on STI syndromes was from the African Region, with only one country reporting from the European Region. For etiological case reporting, few countries reported from Africa, reflecting the difference in availability of laboratory diagnosis. Case rates varied widely within and across regions and probably underestimate the burden of STI due to limitations and inconsistencies in reporting and diagnosis, as well as barriers to health care seeking behaviours. The median case rates per 100 000 adults were:

2 | Report on global sexually transmitted infection surveillance – 2015

workers with a median seroprevalence of 2.3% (range 0.1–53.0%) and 30 countries reported syphilis data for men who have sex with men with a median seroprevalence of 5.3% (range 0.3–32.2%). More effort is needed to scale up programmes to increase coverage of prevention and treatment services for these most at-risk populations.

Gonococcal antimicrobial susceptibility GASP results show continued widespread resistance to quinolones and azithromycin and emergence of decreased susceptibility to extended spectrum cephalosporins. Gonococcal antimicrobial resistance (AMR) continues to increase worldwide and could lead to a pandemic of extensively drug-resistant (XDR) Neisseria gonorrohoeae with serious public health consequences. Decreased susceptibility to the extended spectrum (third-generation) cephalosporins, the last option for monotherapy, is becoming more widespread and several countries have reported treatment failures. However, less than half of countries report conducting AMR testing for N. gonorrhoeae in the past five years. GASP data show a steady decline in the number of reporting countries, from 60 in 2009 to 50 in 2013. Overall, surveillance for gonococcal AMR is currently suboptimal and faces many challenges, especially in the most burdened countries. The situation is alarming since there are no new antimicrobials under development for the treatment of gonorrhoea. There is an urgent need to increase the number of countries participating in GASP through laboratory capacity building, as well as renewed advocacy to increase national commitment to monitoring antimicrobial susceptibility as part of routine STI management. Overall, stronger surveillance is needed to provide the information and data needed to guide the next phase of the STI control strategy post-2015. More funding is needed for prevalence studies (especially among key populations), etiological assessments of STI syndromes and AMR studies, as well as capacity building to improve completeness and consistency of reporting on core STI indicators.

Report on global sexually transmitted infection surveillance – 2015 | 3

1. Introduction The global burden of sexually transmitted infections (STIs) remains high. In 2012, there were an estimated 357.4 million new infections (roughly 1 million per day) of the four curable STIs – chlamydia, gonorrhoea, syphilis and trichomoniasis (see Table 1.1). Due to the use of different methods, the number of incident cases cannot be compared with previous World Health Organization (WHO) estimations. However, the syphilis data is more robust and studies using similar methodology suggest a decreasing trend over time. The burden of viral STIs is similarly high, with an estimated 417 million prevalent cases of herpes simplex virus infection and approximately 291 million women infected with human papillomavirus (1). On the other hand, other previously common infections, such as chancroid and lymphogranuloma venereum, have nearly disappeared in many countries. Table 1.1 Global estimates of new cases of curable STIs in 2012 Sexually Transmitted Infection Chlamydia trachomatis Neisseria gonorrhoeae Syphilis Trichomonas vaginalis Total Source: Newman et al. (2015) (2).

Surveillance provides information on the STI burden at global, regional and country levels; identifies vulnerable population groups; monitors the impact of interventions; and provides information to inform treatment recommendations and for use in programme planning, management and advocacy. STI surveillance is also an important component of second-generation surveillance systems for HIV. Since STIs are markers of unprotected sexual intercourse, surveillance for incident cases could provide an early warning of the epidemic potential of HIV transmission in low-prevalence populations, or indicate a need to intensify interventions in specific populations with high-risk sexual activity. The WHO STI surveillance guidelines were updated in 2012 to take into account the changing epidemiology of STIs and the development of new technologies such as rapid syphilis tests (RST) (4). The four core components of STI surveillance are: •  case reporting using syndromic and etiological approaches • prevalence assessments in specific populations • assessment of etiologies of STI syndromes • antimicrobial resistance (AMR) monitoring. As shown in Table 1.2, the majority of countries (108 out of 198) have an STI surveillance system in place. Most countries conduct universal case reporting and some countries also use sentinel sites. However, there is a general lack of standardization among countries and many have yet to implement STI surveillance systems. It is of great concern that fewer countries conduct gonococcal AMR monitoring in light of the global threat of untreatable gonorrhoea; Neisseria gonorrhoeae is already showing decreased susceptibility to all available antibiotics with no new drugs in the development pipeline. Even fewer countries have carried out etiological assessments of STI syndromes in recent years despite recommendations for studies every three to five years to ensure that syndromic management guidelines keep pace with the changing epidemiology of STIs (1).

n (million) 130.9 78.3 5.6 142.6 357.4

STI prevention and control has widespread public health benefits. Left untreated, STIs increase the risk of HIV transmission during unprotected sexual contact and lead to complications, such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, miscarriage, foetal death and congenital infections. STI control contributes to progress towards multiple Millennium Development Goals (MDGs), including MDG 4 (reducing neonatal mortality), MDG 5B (universal access to reproductive health) and MDG 6 (combating HIV/AIDS). In 2007, WHO published the Global strategy for prevention and control of sexually transmitted infections: 2006–2015 (3). An assessment of progress on the global strategy conducted in 2013 found that 88% of countries have updated their national STI guidelines or recommendations since 2006, and over 75% of countries have a national strategy or action plan in place for STI prevention and control. See Table 1.2 for regional findings. Surveillance is a key element of the WHO STI strategy, since reliable data are essential for measuring the success of prevention and control interventions.

Table 1.2 Progress on implementation of the Global Strategy for Prevention and Control of Sexually Transmitted Infections: 2006–2015, by region, 2013

WHO region

No. countries surveyed (no. countries responding)

No. (%) countries with surveillance systems

No. (%) countries conducting gonococcal AMR monitoring in past 5 years 10 (21%) 10 (29%) 2 (9%) 19 (35%) 7 (64%) 4 (14%) 3 (10%) 3 (27%) 0 (0%) 19 9 12 4 (18%) 11 9 (26%) 25 4 (9%) 33 19 (40%) 16 (46%) 9 (41%) 22 (41%) 9 (82%) 11 (38%)

No. (%) countries conducting etiological studies in past 5 years

No. (%) countries that have updated national STI guidelines or recommendations since 2006

No. (%) countries with national strategy or action plan for STI prevention and control

African Region 16 (46%) 10 (45%) 30 (56%) 9 (82%) 10 (34%)

47 (26)

20 (43%)

Region of the Americas

35 (18)

Eastern Mediterranean Region

22 (13)

European Region

54 (30)

South-East Asia Region

11 (10)

Western Pacific Region

29 (11)

4 | Report on global sexually transmitted infection surveillance – 2015

a

Number of countries surveyed (N=198) is used as denominator for percentages. Sources: WHO (2015) (1) and GARPR (2013) (5)

Report on global sexually transmitted infection surveillance – 2015 | 5

This report summarizes the latest data from Global AIDS Response Progress Reporting (GARPR) and the Gonococcal Antimicrobial Susceptibility Programme (GASP). It covers the major components of STI surveillance, with the exception of etiology assessments of STI syndromes. It follows on and provides updates to two previous reports of STI surveillance in 2012 and 2013 (6, 7). The 10 key STI indicators included in annual GARPR reporting cover

general population case reporting of syndromes and etiological diagnoses, mother-to-child transmission (MTCT) of syphilis and prevalence of syphilis among key populations (see Box 1). Among these, the six most critical indicators are included in the recently released Consolidated strategic information guidelines for HIV in the health sector: two as priority national indicators and four as additional indicators (8).

Box 1. STI indicators for Global AIDS Response Progress Reporting 1.17.1 Percentage of women accessing antenatal care (ANC) services who were tested for syphilis* 1.17.2 Percentage of antenatal care attendees tested who were positive for syphilis 1.17.3 Percentage of antenatal care attendees positive for syphilis who received treatment* 1.17.4 Percentage of sex workers with active syphilis 1.17.5 Percentage of men who have sex with men with active syphilis 1.17.6 Number of adults reported with syphilis (primary/secondary and latent/unknown)in the past 12 months** 1.17.7 Number of reported congenital syphilis cases (live births and stillbirth) in the past 12 months** 1.17.8 Number of men reported with gonorrhoea in the past 12 months** 1.17.9 Number of men reported with urethral discharge in the past 12 months** 1.17.10 Number of adults reported with genital ulcer disease in the past 12 months * National indicators in WHO Consolidated strategic information guidelines for HIV inthe sector (8) ** Additional indicators in WHO Consolidated strategic information guidelines for HIV in the sector (8) Source: UNAIDS (2014) (9)

1.1 Data sources and interpretation Data for the 10 core STI indicators were obtained from the GARPR system database for 2013 and 2014. For countries that did not report in 2013 or 2014, data from prior years were obtained from previous reports on global STI surveillance and included in tables in the annexes (6, 7). Additional data on the proportion of pregnant women with at least one ANC visit was obtained from the Global Health Observatory (10). WHO GASP provided updated data from regional reference laboratories participating in the programme between 2009 and 2013. Missing population denominators for STI and congenital syphilis rate indicators were obtained from United Nations Population Division (UNPD) 2015 population estimates (11). In addition, reported population denominators were checked for countries with extremely high STI rates and replaced with the UNPD 2015 estimates if obvious errors were found. Missing live birth denominators were obtained from most recent estimates at UN data UNPD (12). Several considerations need to be taken into account when interpreting surveillance data. In general, comparability between countries is limited by varying case definitions and completeness of reporting. Routine programme data may be reported from limited geographical areas or types of facilities and data quality control varies. Special studies, such as integrated bio-behavioural surveys, may be limited to intervention areas and consequently biased towards persons who are accessing services. In general, surveillance data are most useful for monitoring trends within a given country when procedures remain constant over time. A discussion of data quality and interpretation is included in each chapter.

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2. General population STI incidence: case reporting Key points: •  Case rates varied widely within and across regions. They are likely to underestimate the burden of STIs due to limitations in reporting and diagnosis, as well as barriers to health care seeking behaviours. •  Variations in methodologies and completeness of reporting limit the comparability of results between countries. When measured consistently, results are best used for assessment of trends within countries. Case reporting is an essential component of STI surveillance and provides information on the facilitybased burden of STIs. STI case reporting indicators were added to the GARPR in 2013. Although other published and unpublished sources of national case report data were available prior to 2013, this report relies solely on GARPR data. Diseases are prioritized for surveillance and reporting according to the burden of the disease and its impact on health, epidemic potential, changing patterns of disease, preventability of the disease and its social and economic impact. Based on these criteria, two types of STI case reporting are included in the core STI indicators: syndromic case reporting based on clinical diagnosis for urethral discharge (UD); and genital ulcer disease (GUD) and etiological case reporting based on laboratory diagnosis for syphilis and gonorrhoea. Case definitions may vary between countries. Some countries include results of active case finding, such as screening asymptomatic women in antenatal clinics, contact tracing or screening among higher-risk key population groups, while others do not. The completeness of reporting is a major factor affecting interpretation of reported case rates. Some countries report cases based on a limited geographical area or restricted to a limited number or type of facilities. As a result, low case rates may indicate either a low burden of STI or a high burden of undiagnosed and untreated infections. When consistently measured over time, STI case rates are best used within a country to monitor trends rather than for comparison between countries. Even so, an increase in cases in a given country could signal better case finding and diagnosis rather than a worsening STI problem. The local situation needs to be taken into account when interpreting findings. Triangulation with other sources of data, such as prevalence assessments, screening interventions and special studies, will lead to a better understanding of the actual STI burden. An example of case reporting and triangulation is shown in Box 2 and Fig. 2.1. Since these are new GARPR indicators, countries need to build their capacity to report data accurately, particularly on selection of the denominator. Population sizes that resulted in extremely high case rates were checked against UNPD population estimates and replaced with the 2015 estimate of adult population (over 15 years) for calculation of the indicator value.

2.1 Data quality and interpretation Facility-based case reporting has many advantages. It covers the entire facility-based population, is simpleto implement, is easily integrated into other disease surveillance systems and provides important information for health planning for STI services. However, it has limitations. Case rates are often underestimated due to underreporting, undetected asymptomatic infections and variable health care seeking behaviours.

Report on global sexually transmitted infection surveillance – 2015 | 7

Box 2. Case reporting: a key component of STI surveillance in India India’s commitment to STI surveillance and case reporting allows demonstration of patterns and trends of major STIs from over 1000 sentinel sites across the country. With the expansion of STI/HIV prevention programmes and STI screening and treatment, the syphilis seroprevalence has measurably declined in different subpopulations. Regular analysis of STI case report data, including trend analysis and triangulation of multiple data sources, suggests that the prevalence of common curable STIs are at a record low in India. The case reporting data showing declines in syphilis cases among high-risk groups, STI clinic attendees and pregnant women from 2005/2006 to 2012/2013 are shown in Fig. 2.1, along with the concomitant decline in new HIV infections. However, more investigation is needed to validate the data, including an assessment of completeness of reporting, consistency of case definitions and laboratory quality, to determine the true epidemiological situation (13). Figure 2.1 Declining syphilis seroprevalence among different subpopulations in India

Source: WHO (2015) (13)

2.2 Syndromic case reporting Most countries have adopted syndromic management of STIs in accordance with the WHO global strategy for STI prevention and control. Over 90% of countries use syndromic management in most regions, with the exception of the European Region, where the greater availability of laboratory resources allows for the use of etiological diagnosis (1, 3). Two syndromes are recommended for monitoring: UD in men and GUD in men and women. UD is a key syndrome for STI surveillance, affecting only males. It is a preventable and treatable syndrome with an overall high burden, most commonly caused by N. gonorrhoeae and Chlamydia trachomatis. Left untreated, UD leads to complications in men and in their female partners and unborn children. GUD is the second key syndrome for STI surveillance because of the high burden of disease in males and females and because it facilitates HIV transmission. The classical causes of GUD are syphilis and chancroid; since both are treatable, strengthening STI management could be expected to lower rates of disease. However, incurable viral infections, such as herpes simplex virus, are becoming more prevalent worldwide. Periodic studies to determine the etiology of STI syndromes are recommended (4).

8 | Report on global sexually transmitted infection surveillance – 2015

Indicator 1.17.9: Urethral discharge rate (adult males) In 2014, 56 countries reported male UD case data to GARPR, mostly from the African Region, the Region of the Americas and the Western Pacific Region. Only one country reported data from the European Region. The overall median UD rate was 143.5 cases per 100 000 adult males (range 5.0–3579.2). The highest case rates were reported in the African Region, followed by the Western Pacific Region (see Table 2.1). As shown in Fig. 2.2, a wide range of rates were reported. The most recently reported UD case rates for 66 countries are shown in Annex 1. Table 2.1 Urethral discharge rate (cases per 100 000 adult males) reported by 56 countries, by region, 2014

WHO region African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall Source: GARPR database (2015) (5)

No. countries reporting 20 11 8 1 5 11 56

Median male UD case rate (range) 568.6 (30.1–3579.2) 74.6 (10.0–400.4) 24.1 (7.3–614.0) 222.7 12.1 (5.0–314.2) 140.6 (9.0–1170.9) 143.5 (5.0–3579.2)

Figure 2.2 Urethral discharge rate (cases per 100 000 adult males, median and range) reported by 56 countries, by region, 2014 4000 3500 3000 2500 2000 1500 1000 500 0 568,6 74,6 African Region Region of the Americas

Eastern European Region South-East Asia Mediterranean Region Region

24,1

222,7

12,1

140,6 Western Pacific Region

Source: GARPR database (2015) (5)

Report on global sexually transmitted infection surveillance – 2015 | 9

Indicator 1.17.10: Genital ulcer disease rate (adult males and females) In 2014, 56 countries reported data to GARPR on GUD. The total GUD rate was reported by 55 countries, with 44 countries providing sex-disaggregated data (44 countries reported male GUD rate, 43 reported female GUD rate), with the African Region and the Region of the Americas accounting for over half of the reporting countries. Only one European Region country reported data. The overall median GUD rate was 27.4 cases per 100 000 adult population (range 0–2195.5). The highest rates were reported by the African Region (see Table 2.2). The median case rate was higher for females than males in most regions, although the overall median was slightly lower for females. Among men, GUD rates were generally lower than reported UD rates. A wide range of GUD rates were reported (see Fig. 2.3 and 2.4). The most recently reported GUD case rates for 66 countries are shown in Annex 1. Table 2.2 Genital ulcer disease rates (cases per 100 000 adult population) reported by 56 countries in 2014, by region: total rate and disaggregated by sex

WHO region

No. countries reporting*

African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall * reporting total and/or sex-disaggregated data Source: GARPR database (2015) (5)

20 13 8 1 5 9 56

Median GUD case rate (range) Total Males Females (n=55) (n=44) (n=43) 202.0 195.4 308.9 (1.3–2195.5) (2.6–2270.5) (0–2127.7) 20.7 24.2 16.7 (3.6–1436.1) (5.5–123.9) (1.4–2710.2) 12.0 10.6 17.5 (0.5–52.2) (0.4–47.9) (1.4–56.2) 9.8 3.4 16.2 14.6 (1.2–69.9) 19.8 (0–156.5) 27.4 (0–2195.5) 7.4 (1.1–36.2) 24.8 (0–162.7) 24.5 (0–2270.5) 9.8 (1.3–104.5) 11.7 (0–150.2) 24.1 (0–2710.2)

Figure 2.3 Total genital ulcer rate (cases per 100 000 adult population, median and range) reported by 56 countries, by region, 2014 2500

2000

1500

1000

500 202,0 0 African Region Region of the Americas

20,7

Eastern European Region South-East Asia Mediterranean Region Region

12,0

9,8

14,6

Western Pacific Region

19,8

Source: GARPR database (2015) (5)

10 | Report on global sexually transmitted infection surveillance – 2015

Figure 2.4 Genital ulcer rate (cases per 100 000 adult population, median values) reported by 56 countries, by region and sex, 2014

350 300 250 200 150 100 50 0

308,9

202 195,4

20,7 24,2 16,7 African Region Region of the Americas

12 10,6 17,5 Eastern Mediterranean Region

9,8 3,4 16,2 European Region

14,6 7,4 9,8 South-East Asia Region

19,8 24,8 11,7 Western Pacific Region

Total Source: GARPR database (2015) (5)

Male

Female

2.3 Etiological case reporting Etiological case reporting is feasible in countries with widespread availability of laboratory services. Two STI etiologies are included in surveillance guidelines: N. gonorrhoeae and Treponema pallidum, causative agents of UD and GUD. Both infections are preventable and treatable, although high levels of gonococcal resistance to antimicrobials may result in untreatable infections in the future (see Chapter 5: Gonococcal antimicrobial susceptibility). Left untreated, gonorrhoea leads to severe complications and sequelae in both men and women. Syphilis causes stillbirths and neonatal deaths, even in low prevalence settings, and is a cofactor for HIV transmission. Syphilis data are reported for both males and females, while gonorrhoea data are limited to males due to the high rate of asymptomatic infections in women coupled with the low sensitivity of diagnosis by cervical Gram stain and culture. Several factors may influence reported case rates of gonorrhoea and syphilis. In addition to those described in the introduction to case reporting (section 2.1), the sensitivity and specificity of the diagnostic tests are an important factor. Some countries continue to rely on Gram stain and culture for the diagnosis of gonorrhoea, Treponemal tests include rapid syphilis tests, fluorescent treponemal antibody-absorption (FTA-ABS), treponema pallidum hemaglutination assay (TPHA) and treponema pallidum particle agglutination assay (TPPA). Non-treponemal tests include Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR).  1

while others have replaced it with newer nucleic acid amplification tests with higher sensitivity and specificity. RST are increasingly being used for initial screening. However, the diagnosis of active syphilis requires a positive result on both treponemal and non-treponemal tests.1 Reporting based solely on screening by nontreponemal tests (such as rapid tests) results in high rates of false positives, while screening based solely on treponemal tests measures lifetime syphilis infection (whether treated or not) rather than active syphilis. In addition, the reported disease rates may be more reflective of the availability of laboratory diagnosis than actual disease rates; countries that lack universal access to laboratory diagnosis may report low case rates even in a setting with high burden of disease.

Report on global sexually transmitted infection surveillance – 2015 | 11

Indicator 1.17.8: Gonorrhoea rate (adult males) As reported by 53 countries in 2014, the median male gonorrhoea case rate was 25.5 cases per 100 000 adult males (range 0.5–385.5), with the highest case rates reported in the Western Pacific Region. Although the Eastern Mediterranean Region had the lowest median case rate (3.2 cases per 100 000 adult males), Morocco reported the highest rate (385.5) overall. Only five countries in the African Region reported data on gonorrhoea cases compared to 20 countries reporting syndromic case data from the region. Although the reported UD case rates were much higher in the African Region than in other regions, the gonorrhoea rates were not the highest, most likely due to the lower availability of laboratory diagnosis (see Table 2.3 and Fig. 2.5). The most recently reported male gonorrhoea case rates for 65 countries are shown in Annex 2. Table 2.3 Male gonorrhoea rate (cases per 100 000 adult males) reported by 53 countries, by region, 2014

WHO region African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall Source: GARPR database (2015) (5)

No. countries reporting 5 18 6 9 4 11 53

Median male gonorrhoea case rate (range) 50.1 (7.2–238.0) 29.3 (1.9–153.3) 3.2 (0.9–385.5) 25.5 (2.9–61.2) 7.0 (2.4–20.4) 88.6 (0.5–317.1) 25.5 (0.5–385.5)

Figure 2.5 Male gonorrhoea rate (cases per 100 000 adult males, median and range) reported by 53 countries, by region, 2014 450 400 350 300 250 200 150 100 50 0 50,1 African Region

88,6 29,3 Region of the Americas

Eastern European Region South-East Asia Mediterranean Region Region

3,2

25,5

7,0 Western Pacific Region

Source: GARPR database (2015) (5)

12 | Report on global sexually transmitted infection surveillance – 2015

Indicator 1.17.6: Syphilis rate (adult males and females) The median syphilis rate was 25.1 cases per 100 000 adult population (range 0.1–1664) among the 55 countries that reported to GARPR in 2014. Sex-disaggregated rates were reported by 44 countries with similar median rates for males and females (17.2 versus 17.7, respectively). Reported syphilis rates were highest in the Western Pacific Region, followed by the African Region. The lowest median syphilis rate was in the Eastern Mediterranean Region; however, Afghanistan’s high rate (135.6) was an outlier (see Table 2.4 and Figs 2.6–2.7). Sex-disaggregated primary syphilis rates were reported by 18 countries. Primary syphilis rates are not included in the median values shown in Table 2.4 and Fig. 2.6, except for the few countries that reported primary syphilis data only. In some countries, the reported primary syphilis rate was similar to the overall rate, while in others the two rates were very different. This highlights the differences in case definitions used by countries and the degree of data cleaning they employ to separate cases of primary syphilis from other stages of syphilis, false positives and previously treated infections. The most recently reported general population syphilis rates for 75 countries (total, male, male primary, female and female primary) are shown in Annex 3. Key population syphilis rates are presented separately in Chapter 4.

Table 2.4 Syphilis case rates (cases per 100 000 adult population) reported by 55 countries, by region, 2014

WHO region African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall

No. countries reporting* 7 18 5 11 4 10 55

Median syphilis case rate (range) Total Males Females 46.6 22.5 43.1 (23.5–452.4) (1.5–358.7) (10.5–523.1) 34.1 34.2 17.7 (4.3–227.7) (2.4–223.7) (3.6–231.0) 2.8 2.6 8.1 (0.2–135.6) (0.1–205.3) (0.2–56.1) 6.2 10.1 6.6 (0.1–58.7) (0.1–68.8) (0–49.7) 5.9 6.7 5.1 (4.8–9.3) (5.3–12.7) (4.2–6.2) 93.0 54.6 81.0 (7.4–609.5) (4.4–232.8) (10.6–995.4) 25.7 17.2 17.7 (0.1–609.5) (0.1–358.7) (0–995.4)

* Not all countries reported sex-disaggregated rates. Source: GARPR database (2015) (5)

Report on global sexually transmitted infection surveillance – 2015 | 13

Figure 2.6 Total syphilis rate (cases per 100 000 adult population, median and range) reported by 55 countries, by region, 2014

700 600 500 400 300 200 100 0 46,6 African Region 34,1 Region of the Americas 6,2 5,9 2,8 Eastern European Region South-East Asia Mediterranean Region Region 93,0 Western Pacific Region

Source: GARPR database (2015) (5)

Figure 2.7 Syphilis rate (cases per 100 000 adult population, median values) reported by 55 countries, by region and sex, 2014

100 90 80 70 60 50 40 30 20 10 0

93 81

54,6 46,6 43,1 34,1 34,2 22,5 17,7 2,8 2,6 African Region Region of the Americas 8,1 6,2 10,1 6,6 5,9 6,7 5,1 Western Pacific Region

Eastern Mediterranean Region

European Region South-East Asia Region

Total Source: GARPR database (2015) (5)

Male

Female

14 | Report on global sexually transmitted infection surveillance – 2015

3. Towards elimination of mother-to-child transmission of syphilis Key points: •  Substantial progress has been made towards global elimination of congenital syphilis. Cuba achieved elimination of mother-to-child transmission of syphilis and HIV in 2015 and several more countries are promising candidates for elimination of vertical syphilis transmission. •  Antenatal syphilis screening coverage increased globally and syphilis seropositivity among pregnant women decreased by nearly half between 2008 and 2014. •  Continued efforts to increase testing coverage are needed urgently, since many countries still have low coverage of ANC syphilis screening, especially in the African Region. Untreated syphilis in pregnancy is a major cause of morbidity and mortality, resulting in fetal deaths and stillbirths, preterm or low-birth-weight infants, neonatal death and syphilis infections in infants, in addition to an increase in HIV transmission among pregnant women. Since the launch of The global elimination of congenital syphilis: rationale and strategy for action in 2007, a global effort has been under way by WHO and its partners to eliminate MTCT of syphilis (14). Overall, 60% of reporting countries have implemented a national strategy for elimination of mother-to-child transmission (EMTCT) of syphilis that is either vertical or integrated with other strategies (see Table 3.1). Table 3.1 Proportion of countries reporting a national EMTCT strategy in place, by region, 2014

WHO Region African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall Source: WHO (2015) (1)

% (no.) of countries with strategy for EMTCT of syphilis 45% (18) 89% (25) 50% (6) 50% (13) 70% (7) 64% (7) 60% (76)

Number of countries reporting in 2014 40 28 12 26 10 11 127

A recent analysis shows more than a one-third global reduction in maternal and infant syphilis between 2008 and 2012 (15) (see Box 3). Although progress has been made towards EMTCT, there is still a substantial burden of adverse outcomes of pregnancy due to maternal syphilis, even among women attending ANC (15). As presented in this chapter, nearly half (38 of 85) of the countries reported syphilis prevalence of 1% or more among women attending ANC services to GARPR in 2014. More effort is needed to strengthen and scale up interventions to increase ANC testing coverage and effective treatment of pregnant women with syphilis. An example of the increase in ANC syphilis screening, the key first step towards EMTCT, following introduction of RST is shown in Box 4.

Box 3. Declines in maternal and congenital syphilis, 2008–2012 Based on analysis of global data, the estimated total number maternal infections and adverse pregnancy outcomes attributed to congenital syphilis decreased by 38% between 2008 and 2012. Maternal infections decreased from 1.4 million to 930 000 over the period. Adverse pregnancy outcomes due to MTCT of syphilis decreased from 520 000 to 350 000 (143 000 early fetal deaths/stillbirths, 62 000 neonatal deaths, 44 000 preterm/low weight births and 102 000 infected infants). The declines were seen in all regions, particularly in South-East Asia, which experienced an 81% decline in maternal infections and 78% decrease in adverse outcomes, largely due to reductions in syphilis seropositivity in India (2.3–0.4%) and Indonesia (5.8–1.2%). Overall, India and Indonesia accounted for more than three quarters of the global decline in maternal infections and adverse outcomes, but the declines were evident even after excluding data from the two countries from the analysis (see Fig. 3.1).

Report on global sexually transmitted infection surveillance – 2015 | 15

Figure 3.1 Estimated number of maternal syphilis infections and associated adverse pregnancy outcomes, 2008 and 2012

Source: Wijesooriya et al. (2015) (15)

Over 90% of maternal infections and adverse outcomes were in low- and middle-income countries. Although the burden of syphilis in pregnancy is greatest in Africa (63% of maternal infections and 64% of adverse outcomes), the region showed the least degree of progress between 2008 and 2012 (see Fig. 3.2). Most of the adverse pregnancy outcomes occurred because of missed opportunities for screening and treatment. In 2012, 84% of pregnant women with syphilis attended ANC at least once. Over half of them (56%) were not tested for syphilis and accounted for 65% of adverse outcomes. Despite substantial progress towards EMTCT, there is still a large burden of adverse outcomes, even among women attending ANC. Figure 3.2 Estimated number of maternal syphilis infections and associated adverse pregnancy outcomes, by region, 2008 and 2012

16 | Report on global sexually transmitted infection surveillance – 2015

Source: Adapted from Wijesooriya et al. (2015) (15)

Box 4. Rapid syphilis tests may increase coverage of ANC syphilis testing Syphilis screening of pregnant women is a key first step in the EMTCT cascade of services. Most countries recommend screening all ANC attendees for syphilis. Nevertheless, coverage remains sub-optimal in many low- and middle-income countries. Rapid syphilis tests (RST) allow for point-of-care testing in settings with limited laboratory resources. A recent review of the literature suggests that introduction of RST can quickly increase ANC testing coverage. Substantial increases in antenatal syphilis screening were seen in all studies and settings – urban and rural, low-level health facilities and tertiary care hospitals – even in facilities with very low rates of screening before RST was introduced (see Fig. 3.3). Overall, RST were accepted by both pregnant women and health care workers and can contribute to EMTCT of syphilis in low-resource settings. Figure 3.3 Proportion of pregnant women screened for syphilis and HIV prior to and following the introduction of rapid syphilis testing.

Source: Swartzendruber et al. (2015) (16)

a Proportion of pregnant women screened who received their results in less than 45 minutes. b Proportion of first-time antenatal care attendees screened. c HIV results are for health facilities that did not experience stock-outs of HIV test kits. d Proportion of pregnant women screened. No data on HIV presented. e Proportion of expected number of pregnant women screened. Zero women were screened for syphilis before introduction of RST.

Report on global sexually transmitted infection surveillance – 2015 | 17

3.1 Country validation of EMTCT of syphilis and HIV Cuba became the first county to achieve EMTCT of syphilis and HIV in 2015. To be considered for EMTCT of syphilis, countries must meet WHO criteria for two years for process indicators and one year for impact indicators before review by a regional validation team to establish elimination (see Box 5). Several more countries are promising candidates for EMTCT of syphilis. Countries that meet criteria based on the most recently reported (but not validated) indicator data are listed in Table 3.2.

Box 5. Required indicators for validation of EMTCT of syphilis Impact indicator Case rate of congenital syphilis ≤ 50 cases per 100 000 live births Process indicators ANC coverage (at least one visit) of ≥ 95% Coverage of syphilis testing of pregnant women of ≥ 95% Source: WHO (2014) (17)

Treatment of syphilis-seropositive pregnant women of ≥ 95%

Table 3.2 Countries meeting or nearly meeting criteria for EMTCT, based on most recently reported GARPR data, 2007–2014

Meet all four criteria Antigua and Barbuda Cuba Czech Republic Dominica Malaysia Malta Oman Ukraine

Meet three criteria with missing data for the fourth criterion Burkina Faso Cook Islands Cyprus Denmark Kazakhstan Mauritius Saint Vincent and the Grenadines Sao Tome Seychelles Slovakia Swaziland Thailand

Nearly meet criteria* Armenia Cabo Verde Chile Kyrgyzstan Marshall Islands Nauru Palau Tuvalu

* Most recent country report revealed: > 90% pregnant women with at least one ANC visit; > 90 % of ANC attendees tested for syphilis; > 90% infected ANC attendees treated and congenital syphilis rate < 50 cases per 100 000 live births (for some countries). Source: GARPR database (2015) (5)

3.2 Monitoring the ANC cascade Since the 2007 launch of the global initiative for EMTCT of syphilis, 60% of reporting countries have implemented a national strategy, either as a vertical programme or integrated with other strategies (1). An increasing number of countries are monitoring the ANC cascade of syphilis testing and treatment. As shown in Table 3.3, the overall median ANC testing coverage has increased from 78% (based on 51 countries reporting in 2008) to 86% (based on 89 countries reporting in 2014). Over the same period, the median syphilis prevalence among ANC attendees decreased from 1.4% to 0.7% and the median treatment rate remained at more than 95% (see Table 3.3).

Table 3.3 Proportion of pregnant women in antenatal care (ANC) who were tested for syphilis, who tested positive and who received treatment by WHO region, 2008 (or 2010), 2012 and 2014 Percentage of ANC attendees tested who were positive for syphilis 2008 Median value Median value 100% 85% 13 13 100.0% 80.5% Median value 40.10% 87.50% 14 0.90% 18 0.5% 21 0.40% 16 30 2.30% 22 1.9% 31 1.60% 15 No. reporting countries Median value Median value No. reporting countries Median value No. reporting countries No. reporting countries No. reporting countries No. reporting countries 21 19 2012 2014 2010 2012 2014 Median value 98.00% 92.90% Percentage of syphilis-positive ANC attendees who received treatment

  2014 No. reporting countries 34 19

Percentage of ANC attendees tested for syphilis

2008

2012

WHO region

No. reporting countries

Median value

No. reporting countries

Median value

African Region

18

58.50%

21

71.8%

Region of the Americas 5 42.60% 4 – 2 – 4 0.00% 0 – 0

14

73.00%

17

82.6%

Eastern Mediterranean Region 9 7 15 89 85.50% 71 1.40% 64 1.0% 85 0.70% 100.00% 8 0.30% 11 2.0% 13 1.80% 58.30% 6 1.30% 4   7 0.50% 3 7 44 93.40% 9 0.30% 7 0.1% 9 0.10% 3 – – 98% 99%

3

–

0

–

–

3

80.00%

European Region

9

100.00%

6

93.1%

4 4 9 43

– – 93.0% 94.2%

7 6 11 67

100% 89.90% 100% 95.60%

South-East Asia Region

3

–

7

37.4%

Western Pacific Region

4

–

10

98.3%

18 | Report on global sexually transmitted infection surveillance – 2015

Global

51

78.00%

61

86.1%

Source: WHO (2014) (7) and GARPR database (2015) (5)

Report on global sexually transmitted infection surveillance – 2015 | 19

3.3 Data quality and interpretation When interpreting ANC indicator data, it is important to take into account local factors affecting the quality, generalizability and representativeness. Data may be reported from routine programme monitoring or sentinel surveillance. Some countries only report data from prevention of mother-to-child transmission (PMTCT) intervention sites, sites with access to syphilis testing or limited geographical areas, limiting data generalizability. In addition, most countries do not include private sector data. How well ANC data represent all pregnant women also depends on the proportion of antenatal women who attend ANC services. In countries with low rates of ANC attendance, the indicators do not reflect the majority of pregnant women. Annex 4 illustrates the most recently reported data on the proportion of pregnant women with at least one ANC visit. The laboratory methods and case definitions used affect the comparability of ANC syphilis prevalence between countries. Two positive tests (one treponemal and one non-treponemal) are required to maximize the sensitivity and specificity of syphilis diagnosis. Most countries reporting in 2014 did not specify the test type or whether they confirmed all positive tests with a second, different type of test. To avoid overestimations, a recent analysis of diagnostic test type for syphilis reporting in pregnant women suggested correction factors of 52.2% for data based on a single reactive non-treponemal test, 53.6% for countries reporting only a reactive treponemal test, and 68.6% for countries not specifying the type of test used (18).

20 | Report on global sexually transmitted infection surveillance – 2015

Indicator 1.17.1: ANC syphilis testing coverage Based on 89 countries reporting in 2014, the median proportion of ANC attendees who were tested for syphilis was 85.5% (range 0.7–100%). The largest number of reporting countries (34) was from the African Region, which was also the region with the lowest median ANC testing coverage (40.1%, range 0.7–100%). The highest median ANC testing coverage (100%) was reported by countries in the Western Pacific Region, but a wide range of results were reported from every region, with the exception of the European Region (see Table 10). Overall, 31 countries reported at least 95% testing coverage (mostly in the Western Pacific and African Regions and the Region of the Americas), with 27 reporting less than 50% coverage (mostly in the African Region). Several differences in definitions and methods for ANC syphilis testing were noted between countries, limiting the comparability of results. Some countries reported testing coverage for the first ANC visit, others reported screening coverage at any visit, and some reported both values. Some countries reported the same data for both first-visit testing and testing on any visit, while others reported first-visit testing one year and testing on any visit the following year. Therefore, it is not clear whether the data were entered correctly. For the purpose of this analysis, either value (testing on first visit or on any visit) was used if countries reported one value; for countries that reported both values, screening at any visit was used. Other differences in definitions were also noted; for example, Jamaica only reports testing data for women who received same-day test results. The latest reported data on ANC syphilis testing coverage is shown in Fig. 3.4 and 3.5, and in Annex 4.

Table 3.4 Percentage of ANC attendees who were tested for syphilis (ANC syphilis testing coverage) as reported by 89 countries, by region, 2014

WHO region African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall Source: GARPR database (2015) (5)

No. countries reporting 34 19 5 9 7 15 89

Median ANC syphilis testing coverage (range) 40.1% (0.7–100) 87.5% (16.8–100) 42.6% (5.6–100) 93.4% (85.5–100) 58.3% (1.2–96.8) 100% (44.9–100) 85.5% (0.7–100)

Figure 3.4 Percentage of antenatal care attendees tested for syphilis at first visit based on most recent data available since 2007

Source: WHO Global Health Observatory (2015)

Report on global sexually transmitted infection surveillance – 2015 | 21

Indicator 1.17.2: ANC syphilis seroprevalence In 2014, 85 countries reported the percentage of ANC attendees tested for syphilis who were found to be positive. Among these, 26 provided age-disaggregated data. The greatest number of countries reporting was from the African Region, followed by the Region of the Americas. The median syphilis prevalence was 0.7% (range 0–13.5%) and was highest in the Western Pacific and African Regions (see Table 3.5 and Fig. 3.6). Overall, 38 (45%) countries reported ≥ 1% ANC seroprevalence. Methodologies varied between countries with some reporting results from routine programme data and others reporting data based on sentinel surveillance. Table 3.5 Proportion of ANC attendees who tested positive for syphilis (ANC syphilis seroprevalence) as reported by 85 countries, by region, 2014

WHO Region African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall Source: GARPR database (2015) (5)

No. countries reporting 31 21 4 9 7 13 85

Median ANC syphilis seroprevalence (range) 1.6% (0–11.3) 0.4% (0–3.1) 0.0% (0–1.5) 0.1% (0–1%) 0.5% (0.1–1.7) 1.8% (0–13.5) 0.7% (0–13.5)

Figure 3.5 Percentage of antenatal care attendees who tested positive for syphilis based on most recent data available since 2005

Source: WHO Global Health Observatory (2015) Available at: http://gamapserver.who.int/mapLibrary/Files/Maps/gho_sti_anc_syphilis_positive.png

22 | Report on global sexually transmitted infection surveillance – 2015

Indicator 1.17.3: ANC syphilis treatment Overall, 66 countries reported a median of 95.6% (range 6.1–100%) of ANC attendees who were positive for syphilis and who received treatment in 2014. Two additional countries (Cook Islands and Saudi Arabia) identified no cases of syphilis, making a total of 68 reporting countries. Countries that clearly indicated 100% treatment as per policy, as opposed to data on actual practice, were excluded from the analysis. The median proportion of women receiving treatment was 90% or greater in all regions except the Eastern Mediterranean (see Table 3.6. Half of the countries (33 out of 66) reported ≥ 95% treatment coverage in 2014. Less than 75% of syphilis-positive pregnant women were treated in 19 countries. Fig. 3.6 and Annex 4 show the most recently reported data on syphilis treatment. Table 3.6 Percentage of ANC attendees positive for syphilis who received treatment as reported by 66 countries, by region, 2014

WHO Region African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall Source: GARPR database (2015) (5)

No. countries reporting 21 19 3 7 6 10 66

Median % receiving treatment (range) 98.0% (6.1–100) 92.9% (50.0–100) 80.0% (46.7–100) 100% (28.8–100) 89.9% (20.9–100) 100% (63.5–100) 95.6% (6.1–100)

Figure 3.6 Percentage of antenatal care attendees positive for syphilis who received treatment as reported by countries, 2014

Source: WHO Global Health Observatory (2015) Available at: http://gamapserver.who.int/mapLibrary/app/searchResults.aspx

2

 tillbirth, live birth or fetal loss at > 20 weeks of gestation or > 500 grams to a syphilis-seropositive mother without adequate syphilis S treatment OR stillbirth, live birth, or child age < 2 years with microbiological evidence of syphilis infection. Microbiological evidence of congenital syphilis includes any one of the following: demonstration by dark field microscopy or fluorescent antibody detection of T. pallidum in the umbilical cord, the placenta, a nasal discharge, or skin lesion material; detection of T. pallidum-specific IgM; or infant with a positive non-treponemal serology titre greater than fourfold that of the mother (17).

Report on global sexually transmitted infection surveillance – 2015 | 23

Indicator 1.17.7: Congenital syphilis rate The congenital syphilis rate measures the adverse outcomes of untreated syphilis infection in pregnancy and is an indicator of progress in EMTCT of syphilis. The congenital syphilis rate was piloted as an indicator in two regions in 2012 and became a routine GARPR indicator in 2013. The global congenital syphilis case definition2 is recommended for monitoring and reporting. WHO tools are available to assist countries in incorporating congenital syphilis into existing reporting systems (19). Fewer countries were able to report data on congenital syphilis than for other indicators in the EMTCT cascade. Overall, 49 countries reported in 2014, mostly from the Region of the Americas and the European Region. The overall median rate was 4.9 cases per 100 000 live births (range 0–1233.5). As shown in Table 3.7 and Fig. 3.7, the reported median rate was highest in the Region of the Americas. Few countries in the African Region reported on congenital syphilis and the range of reported rates was very wide. Overall, 37 countries (75%) reported rates of less than 50 cases per 100 000 live births, the cut-off level to meet EMTCT criteria. However, the data on congenital syphilis have many limitations. Several factors result in underestimation of the scale of the problem, including lack of diagnosis and follow-up of syphilis-positive pregnant women and their infants, inconsistent case definitions for congenital syphilis and incomplete reporting.

Table 3.7 Congenital syphilis rate (cases per 100 000 live births) as reported by 49 countries, by region, 2014

WHO region African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall Source: GARPR database (2015) (5)

No. countries reporting 6 18 4 11 1 9 49

Median congenital syphilis rate (range) 5.0 (0–1233.5) 33.8 (0–472.2) 0 0.4 (0–19.8) 2.3 6.6 (0–235.0) 4.9 (0–1233.5)

Figure 3.7 Congenital syphilis rate (cases per 100 000 live births, median and range) as reported by 49 countries, by region, 2014

1400 1200 1000 800 600 400 200 0 5,0 33,8 Region of the Americas

African Region

Eastern European Region South-East Asia Mediterranean Region Region

0

0,4

2,3

Western Pacific Region

6,6

Source: GARPR database (2015) (5)

24 | Report on global sexually transmitted infection surveillance – 2015

4. Syphilis prevalence among key populations Key points: • Syphilis seroprevalence among key populations is an important indicator of progress in STI control. •  Syphilis seroprevalence remains high in key populations worldwide, with at least one country in every WHO region reporting more than 5% prevalence among female sex workers and men who have sex with men. •  Different laboratory methodologies and sampling frames limit the comparability of results between countries. Key populations are at high risk of exposure to and transmission of STIs and HIV due to their sexual risk behaviours. The WHO global STI control strategy prioritizes female sex workers (FSWs), people who inject drugs, men who have sex with men (MSM) and transgender women for prevention and treatment of STI and HIV through peer outreach, condom programmes, STI screening and treatment services. Structural interventions are also recommended to reduce legal and social barriers, including stigma and discrimination, that block access to quality STI services and prevent early diagnosis and treatment of STIs (3, 20, 21, 22). The sexual networks among key populations play a critical role in population-level transmission of STIs and HIV. FSWs transmit infections to clients, who in turn act as a bridging population as they pass the infection to lower-risk populations, including their wives and unborn children. In the same way, MSM often have female partners who become infected (see Fig. 4.1). Effective STI Figure 4.1 Transmission dynamics of STIs at the population level

control among key populations leads to a decline in STI incidence in the population as a whole. A recent review from Asia found that countries with high levels of condom use among sex workers had declining (or low and stable) trends for the incidence of both STIs and HIV. Importantly, the decreasing trends occurred in sex workers and in the general population. The greatest declines were found in countries that implemented largescale structural interventions (23). Targeted interventions with sex workers are conducted in the most regions, ranging from 53% of countries in the European Region to more than 90% of countries in the South-East Asia and Western Pacific Regions. In general, fewer countries reported working with MSM. Most countries promote and/or provide condoms (see Table 4.1). Two indicators of STIs among key populations are included among the core indicators to guide the national response to STIs: the seroprevalence of syphilis among MSM and that among FSWs.

Source: WHO (2007) (3)

Report on global sexually transmitted infection surveillance – 2015 | 25

Table 4.1 Proportion of countries with targeted interventions for FSW and MSM and condom promotion and provision, by region, 2013

WHO region

No. countries surveyed (no. of countries responding)* 47 (26) 35 (18) 22 (13) 54 (30) 11 (10) 29 (11)

No. (%) countries conducting targeted interventions for FSW 18 (38%) 16 (46%) 9 (41%) 18 (33%) 9 (82%) 9 (31%)

African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region

No. (%) countries conducting targeted interventions for MSM 12 (26%) 14 (40%) 7 (32%) 19 (35%) 9 (82%) 9 (31%)

No. (%) countries that promote condoms 23 (49%) 18 (51%) 8 (36%) 24 (44%) 9 (82%) 10 (34%)

No. (%) countries that provide condoms 24 (51%) 18 (51%) 10 (45%) 20 (37%) 10 (91%) 11 (38%)

* Number of countries surveyed (N=198) is used as denominator for percentages. Source: WHO (2015) (1)

4.1 Data quality and interpretation Data on syphilis seroprevalence among MSM and FSWs are obtained from special surveys, sentinel surveillance or routine health information systems. Since different methodologies may be used, it is not possible to compare results across countries. Even within countries, results are seldom representative of key populations overall. Many countries report special studies from limited geographical areas, such as urban areas, and that may be restricted to capital city data. Survey sampling often relies on nongovernmental organizations (NGOs) working with hard-to-reach populations, resulting in studies

that are limited to intervention areas and results that are biased towards members of key population groups who are in contact with services. While the definition of active syphilis requires two different test results (treponemal and non-treponemal), countries seldom specify laboratory methods when reporting data. Laboratory and data quality control also vary between countries. Nevertheless, the key population data show generally high levels of syphilis globally in key populations. In addition, the data can be used to assess trends over time in a given country when the same survey methods are used consistently.

26 | Report on global sexually transmitted infection surveillance – 2015

Indicator 1.17.4: Syphilis in sex workers In 2014, 28 countries reported data on syphilis prevalence among FSWs. Most countries reported results based on special surveys, including integrated bio-behavioural surveys. However, eight countries reported routine programme data without clarification on laboratory methods or definition of a positive test. The median reported syphilis seroprevalence was 2.3% (range 0.1–53.0%), as shown in Table 4.2 The highest levels were reported from the Region of the Americas and the African Region. Overall, 10 countries reported 5% or higher prevalence. Among them, six countries reported greater than 10% prevalence, including three (Lesotho, Mongolia and Panama) that reported more than 20% (see Annex 5 and Fig. 4.2 for the global distribution of syphilis prevalence among FSW based on the latest reported data since 2005). These data include a prevalence figure of more than 5% among FSWs and MSM in every WHO region.

Table 4.2 Syphilis seroprevalence among FSWs reported by 28 countries, by region, 2014

WHO region African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall Source: GARPR database (2015) (5)

No. countries reporting 8 9 2 0 4 5 28

Median FSW syphilis prevalence (range) 5.2% (0.8–27.2) 2.3% (0.5–53.0) 2.9% (0.8–5.0) – 2.4% (0.3–8.7) 1.3% (0.1–29.6) 2.3% (0.1–53.0)

Figure 4.2 Percentage of FSWs with syphilis (latest reported data since 2005)

Source: WHO Global Health Observatory (2015) Available at: http://gamapserver.who.int/mapLibrary/Files/Maps/gho_sti_sexworkers_syphilis.png

Report on global sexually transmitted infection surveillance – 2015 | 27

Indicator 1.17.5: Syphilis in men who have sex with men Data on syphilis prevalence among MSM were reported to GARPR by 30 countries in 2014. The data were based mostly on special surveys, including integrated bio-behavioural surveys, although the reports from eight countries were based on routine programme data. Data based on survey sample sizes of less than 40 or Internet surveys with self-reported infections were excluded. The median reported syphilis seroprevalence among MSM was 5.3% (range 0.3–32.2%), with the highest values reported from the Region of the Americas, as shown in Table 4.3. Interestingly, only five countries reported from the African Region. Over half of the countries (16 out of 30) reported more than 5% prevalence, with seven countries reporting more than 10% and two countries (Plurinational State of Bolivia and Panama) reporting more than 20%. Based on the latest data reported since 2006, a prevalence of more than 5% in at least one country has been reported in every WHO region (see Fig. 4.3 and Annex 5).

Table 4.3 Syphilis seroprevalence among MSM reported by 30 countries, by region, 2014

WHO region African Region Region of the Americas Eastern Mediterranean Region European Region South-East Asia Region Western Pacific Region Overall Source: GARPR database (2015) (5)

No. countries reporting 5 12 1 4 5 3 30

Median MSM syphilis prevalence (range) 5.1% (1.1–9.4) 10.3% (1.0–32.2) 10.1% 2.3% (0.3–6.8) 1.2% (0.3–16.4) 6.0% (4.2–7.1) 5.3% (0.3–32.2)

Figure 4.3 Percentage of MSM with syphilis (latest reported data since 2006)

Source: WHO Global Health Observatory (2015) Available at: http://gamapserver.who.int/mapLibrary/Files/Maps/gho_sti_msm_syphilis.png

28 | Report on global sexually transmitted infection surveillance – 2015

5. Gonococcal antimicrobial susceptibility Key points: •  Gonococcal antimicrobial resistance (AMR) continues to increase worldwide and could lead to a pandemic of extensively drug-resistant (XDR) N. gonorrohoeae with serious public health consequences. •  Surveillance for gonococcal AMR is currently suboptimal and presents many challenges, especially in the countries with the greatest burden. •  No new drugs are under development for the treatment of XDR gonorrhoea. Gonococcal AMR has been a public health concern since sulphonamides became ineffective in the 1940s. Since then, N. gonorrhoea has developed resistance to penicillins, tetracyclines, spectinomycin, quinolones (e.g. ciprofloxacin) and macrolides (e.g. azithromycin) after showing initial high susceptibility to each class of drugs. Overuse and misuse of antibiotics and the widespread availability of counterfeit drugs with low levels of active compounds contribute to the development of resistance. It is further exacerbated by the inherent properties of N. gonorrhoeae that allow it to acquire and retain resistance to several classes of antibiotics at the same time, persisting even after use of those antibiotics has been discontinued. Many strains of N. gonorrhoeae are still resistant to penicillin, despite penicillin use being discontinued long ago (24). Decreased susceptibility to the extended spectrum (third-generation) cephalosporins – the last option for monotherapy – is becoming more widespread and ten countries have reported treatment failures (1). A WHO global partners meeting on AMR in N. gonorrhoeae in 2014 concluded that the increasing proportion of strains with elevated minimum inhibitory concentrations (MICs) for extended spectrum cephalosporins will eventually result in untreatable gonorrhoea, with serious sexual and reproductive health consequences (25). Two extensively drug-resistant (XDR) strains of N. gonorrhoeae have been reported from Japan and Europe, and a large proportion of the circulating strains worldwide are very close to developing into XDR strains3 (26, 27). The situation is alarming since there are no new antimicrobials under development for the treatment of gonorrhoea. Some countries are responding by implementing dual therapy with ceftriaxone plus azithromycin. There is also interest in exploring the effectiveness of some of the newer macrolides and other drugs on the market that have shown in vitro activity against gonorrhoea and to assess whether older drugs, such as gentamicin and spectinomycin, may offer effective treatment of gonorrhoea (26). Considering that gonorrhoea is among the most common STIs worldwide, with an estimated 85 million new cases in 2012, lack of effective treatment would result in a major public health problem. Untreated PID leads to severe reproductive complications, such as ectopic pregnancies and infertility. An increase in cases of gonococcal pharyngitis and proctitis would be expected and other rare conditions due to N. gonorrhoeae would become more common, including adult conjunctivitis, endocarditis, tenosynovitis, arthritis, meningitis, Fitzhugh-Curtis syndrome and disseminated gonococcal infection. An increase in asymptomatic cases would also occur, contributing to the spread of disease, and untreated gonorrhoea would increase the risk of HIV transmission (28).

5.1 Gonococcal Antimicrobial Surveillance Programme (GASP) Monitoring the susceptibility patterns of N. gonorrhoea is essential to detect and track emerging resistance and to adjust treatment recommendations for optimal outcomes. GASP is a global laboratory network of more than 60 countries in six regions, each with focal points and regional coordinating centres to monitor the antimicrobial susceptibility of gonorrhoea in participating countries. WHO is working to make GASP as effective as possible and to address its many challenges, which include limited national leadership, commitment and funding in many countries. The magnitude of the gonococcal AMR problem is incompletely known due to the lack of data in many countries. A recent survey of 108 countries found that less than half (46) had conducted AMR testing for gonorrhoea in the past five years (1). The lack of information is particularly acute in countries with the highest gonorrhoea burden and the greatest need for AMR monitoring. These are often countries with suboptimal diagnosis and surveillance

3

 DR strains are defined as resistant to two or more of the antibiotic X classes currently recommended for the treatment of gonorrhea, or three or more of the less frequently used antibiotic classes.

Report on global sexually transmitted infection surveillance – 2015 | 29

capacity, where antibiotics are freely available (including counterfeit drugs), and lack of drug quality control contributes to the rapid development of resistance. They are also the countries most likely to rely on syndromic management of STIs, leading to a shortage of samples for AMR monitoring and lack of capacity and supplies for specimen collection, culture and sensitivity testing. Cultures are also carried out less frequently in more developed countries as diagnosis is improved by the use of molecular methods (25). Countries in the African, South-East Asia and Eastern Mediterranean Regions (as well as Eastern Europe and Central Asia) particularly lack functioning programmes to assess gonococcal AMR (27, 29, 30). Recommendations to improve monitoring of AMR include advocacy to increase political support and engagement at the country level; improving countrylevel capacity by developing and implementing a minimum package for gonococcal AMR and laboratory antimicrobial susceptibility testing; and updating the WHO reference panels for external quality assessment and laboratory capacity building (25). In addition, new technologies may enhance surveillance by

molecular methods using samples that are positive by nucleic acid amplification testing in countries where cultures are not available (26, 27). These interventions need to be combined with a holistic public health approach, including prevention of transmission, improved services for key populations, improved drug quality control, and reduction in overuse/misuse of antibiotics.

5.2 Antimicrobial susceptibility data The cumulative number of countries reporting to GASP increased from 52 in 2009 to 68 in 2012 (1). However, the number of countries reporting susceptibility data for at least one antibiotic each year shows a declining trend, from 60 countries reporting in 2009 to 50 countries in 2013. The WHO European Region accounts for the majority of reporting countries, while the African and Eastern Mediterranean Regions are the least represented (see Fig. 5.1). Overall, the most recent GASP data from 2012 and 2013 show continued widespread gonoccocal resistance to quinolones and azithromycin and emergence of decreased susceptibility to extended spectrum cephalosporins (see Table 5.1).

Figure 5.1 Number of countries reporting data on antimicrobial susceptibility to cephalosporins, azithromycin or quinolones, 2009–2013

Source: WHO/GASP (2015) (31)

30 | Report on global sexually transmitted infection surveillance – 2015

Table 5.1 Number of countries reporting ≥ 5% of gonoccocal isolates with resistance to azithromycin and ciprofloxacin/quinolones and elevated minimum inhibitory concentrations of cefixime (0.25 μg/ml) or ceftriaxone (> 0.125 μg/ml), 2012–2013*

Reported % resistant isolates

Africa (n=1)

Americas Eastern Mediterranean. (n=11) (n=1)

Europe (n=24)

SouthEast Asia (n=5)

Western Pacific (n=14)

Total (n=56)

Ceftriaxone/ cefixime ≥ 5% decreased susceptibility Of which ≥ 10% decreased susceptibility Azithromycin ≥ 5% resistant isolates Of which ≥ 10% resistant isolates Ciprofloxacin/ quinolones ≥ 5% resistant isolates 50–90% resistant isolates > 90% resistant isolates

0 0

1 0

0 0

9 4

0 0

4 2

14 6

1 1

1 0

– –

13 9

0 0

1 1

15 10

1 1 0

10 2 0

– – –

24 14 1

5 0 5

15 3 6

55 20 12

* Several countries did not report test results for all antibiotics. Source: WHO/GASP (2015) (31)

5.3 Data quality and interpretation AMR data are based generally on small sample sizes, resulting in sampling bias. Quality control varies by country. Many countries do not provide data on an annual basis and the proportion of countries reporting varies by region. As a result, wide variations in results in a single country are noted from year to year and AMR data are not comparable across countries and regions.

than 0.25 μg/ml for cefixime in 5% or more of isolates, with four countries reporting elevated minimum inhibitory concentrations in 10% or more. Only seven countries reported no decreased susceptibility to cefixime; among these, five countries reported decreased susceptibility in previous years and one reported data for the first time in 2013. Decreased susceptibility to ceftriaxone was reported by 10 of the 12 Western Pacific Region countries submitting data for 2012/2013, with four reporting decreased susceptibility in 5% or more of isolates: the cut-off for changing treatment guidelines. An additional three countries in the region reported at least 5% decreased susceptibility in past years. Only two countries reported no isolates with decreased susceptibility (New Caledonia and the Philippines) in any reporting year. In the Region of the Americas, two countries reported decreased susceptibility to ceftriaxone – Canada and the United States of America (USA) – with Canada reporting over 5%. Decreased susceptibility to cefixime among less than 5% of isolates was also reported by Canada and the USA.

5.4 Extended-spectrum cephalosporins Since 2009, 46 countries have reported decreased susceptibility to extended-spectrum cephalosporins. Data on the susceptibility of N. gonorrhoeae to extended-spectrum cephalosporins was reported by 49 countries in 2012 and/or 2013, with 59% (29 of 49) countries reporting decreased susceptibility in 2012/2013 (see Fig. 5.2 and Annex 6). Antibiotic susceptibility monitoring is well established in the European Region, which accounted for half of the reporting countries in 2012/2013. Among the 23 countries reporting, less than 1% of isolates in the region overall exhibited decreased sensitivity to ceftriaxone. Nine countries in the region reported MICs greater

Report on global sexually transmitted infection surveillance – 2015 | 31

Ceftriaxone susceptibility data are more limited in the remaining regions. In the South-East Asia Region, only two countries reported ceftriaxone susceptibility data in 2012/2013. Of the seven countries that reported to GASP between 2009 and 2013, five reported some decreased susceptibility to ceftriaxone; among these, four reported decreased susceptibility in over 5% of isolates. Only one country in the African Region and

one in the Eastern Mediterranean Region reported in 2012 and/or 2013, and neither reported decreased susceptibility to ceftriaxone. Of note, only four countries have reported from the African Region and two from the Eastern Mediterranean Region since 2009. Among these, only two countries reported decreased susceptibility to ceftriaxone: Côte d’Ivoire (> 10%) and South Africa (< 5%).

Figure 5.2 Countries with documented elevated minimum inhibitory concentrations to cefixime and/or ceftriaxone, 2009–2013.

Source: WHO/GASP data 2015 (31)

5.5 Azithromycin Among 42 countries reporting azithromycin susceptibility in 2012/2013, 17 reported resistance in 5% or more of isolates. Across all regions, only seven countries reported no resistant isolates. The majority of countries reporting in 2012/3 were in the European Region. Among the 24 countries reporting from the region, 13 reported 5% or more resistant isolates. Among these, nine countries reported over 10%, including Cyprus and Greece with over 20% resistance. Three countries in the European Region reported no resistant isolates; however, two of them reported resistance in previous years and the third reported AMR data for the first time in 2013 (see Fig. 5.3 and Annex 6).

32 | Report on global sexually transmitted infection surveillance – 2015

Figure 5.3 Proportion of N. gonorrhoeae strains resistant to azithromycin reported in countries, 2009–2013

Source: WHO/GASP data 2015 (31)

Countries in Asia began reporting susceptibility data for azithromycin in 2011. In the four countries reporting from the South-East Asia Region between 2011 and 2013, three reported less than 5% resistant isolates and one reported no resistant isolates. Among the nine Western Pacific Region countries that have submitted data, six reported resistant isolates with only one country reporting over 5% resistant isolates (Japan reported over 10% in both 2012 and 2013). Four countries reported from the Region of the Americas and all of them (including Canada and the USA) found isolates resistant to azithromycin; only one country (Chile) reported over 5% resistance. No countries reported data from the Eastern Mediterranean Region. The first country to report on AMR for azithromycin in the African

Region was Côte d’Ivoire in 2013, which reported over 10% resistant isolates.

5.6 Quinolones In 2012 and 2013, 56 countries reported susceptibility data for ciprofloxacin. High levels of resistance were reported from all regions with nearly every country reporting over 20% resistant isolates. Very high levels of resistance (over 90% of isolates) were reported by 12 countries, mostly in Asia. Only four countries reported less than 5% resistant isolates – Dominican Republic, Fiji, New Caledonia and Panama (although the Dominican Republic reported > 20% resistance in previous years; see Fig. 5.4 and Annex 6).

Figure 5.4 Proportion of N. gonorrhoeae strains resistant to ciprofloxacin and/or other quinolones reported in countries, 2009–2013

Source: WHO/GASP 2015 (31)

Report on global sexually transmitted infection surveillance – 2015 | 33

6. Conclusion This is the third global report on STI surveillance since the release of the WHO Strategies and laboratory methods for strengthening surveillance of sexually transmitted infection 2012 (4). STI surveillance systems are evolving and the majority of countries have a system in place. However, capacity building is needed to harmonize and strengthen STI reporting systems since they are not standardized or consistent between countries. As a result, the findings are best used to assess trends over time within countries. Case reporting data on syndromes and etiological causes are available for additional countries since the inclusion of the case rate indicators in the annual GARPR for the first time in 2013. However, the reported rates vary widely between countries and interpretation of results is limited by inconsistencies in reporting between countries. Case definitions and completeness of reporting vary by country. In general, case rates are likely to be underestimated due to incomplete reporting and barriers to health care seeking behaviours. ANC syphilis reporting is generally more robust and incorporated into health information systems in many countries. Between 2008 and 2014, substantial progress has been made towards global elimination of congenital syphilis. The median antenatal syphilis screening coverage increased globally and syphilis seropositivity among pregnant women decreased by nearly half. In addition, Cuba became the first country to declare EMTCT of syphilis in 2015 and several other countries are promising candidates for elimination. Nevertheless, many countries still report high rates of ANC syphilis and low rates of testing coverage. Continued efforts to increase antenatal syphilis testing coverage and treatment of infected pregnant women are urgently needed to continue advancing towards achievement of global EMTCT of syphilis. Syphilis seroprevalence remains high in key populations worldwide; for both FSWs and MSM, at least one country in every WHO region reported a prevalence of at least 5%. Existing programmes are only reaching a small fraction of the target population and struggle with persistent barriers to health care seeking behaviours among key populations, stigmatization, political interference and financial constraints. More effort is needed to scale up programmes to increase coverage of prevention and treatment services for these most at-risk populations. Despite efforts to improve antimicrobial susceptibility monitoring in response to the threat of a pandemic of XDR N. gonorrohoeae, surveillance for gonococcal AMR is currently suboptimal and faces many challenges, especially in the highest-burden countries. Widespread gonococcal AMR to quinolones and azithromycin and decreasing susceptibility to extended-spectrum cephalosporins have been documented with no new drugs under development for treatment of XDR gonorrhoea. There is an urgent need to increase the number of countries participating in GASP through laboratory capacity building, as well as advocacy to increase national commitment to monitoring antimicrobial susceptibility as part of routine STI management. Although most countries have adopted the syndromic approach to the management of STIs, as recommended by WHO, most are not carrying out the regular etiological assessments required to validate the management of the syndromes. In some countries, no etiological studies have been conducted in the last decade. As viral pathogens play an increasing role in the changing epidemiology of STIs, countries will need to respond by adjusting management guidelines and recommending locally appropriate prevention and treatment strategies. On a global level, research is needed to develop more effective prevention technologies, such as vaccines and microbicides. Increasing the availability of rapid diagnostic tests is another strategy that can augment syndromic management as the epidemiology changes. Stronger surveillance is needed to provide the necessary information and data to guide the next phase of the STI control strategy post-2015, which will focus on (i) increasing universal coverage of effective interventions and access to treatment of STI and (ii) developing improved methods for behaviour change interventions and new technologies, such as improved diagnostics, vaccines and microbicides. More funding is needed for prevalence studies (especially among key populations), etiological assessments of STI syndromes and AMR studies, as well as capacity building to improve completeness and consistency of reporting.

34 | Report on global sexually transmitted infection surveillance – 2015

Annexes

Report on global sexually transmitted infection surveillance – 2015 | 35

Annex 1. Reported cases of STI syndromes: genital ulcer disease (GUD) in males and females and urethral discharge (UD) in males (cases per 100 000 adults), based on most recently reported Global AIDS Response Progress Reporting (GARPR) system data, 2012–2014 Country African Region Botswana Burkina Faso Cabo Verde Central African Republic Comoros Côte d'Ivoire Equatorial Guinea Gabon Gambia Madagascar Mali Mauritius Mozambique Namibia Niger Senegal Seychelles South Africa Swaziland Togo Uganda Zambia Zimbabwe Region of the Americas Antigua and Barbuda Argentina Bahamas Belize Bolivia (Plurinational State of) Cuba Dominican Republic Ecuador El Salvador Guatemala Guyana Honduras Mexico Nicaragua Panama Peru Saint Lucia Suriname Trinidad and Tobago – – 3.6 25.1 1436.1 – 32.5 30.9 – 4.0 37.3 8.4 9.8 19.6 20.7 16.9 96.8 51.1 22.5 – – 6.0 32.5 123.9 – – – – 5.5 27.4 – 10.6 – 24.7 18.9 107.6 – 24.2 – – 1.4 17.9 2710.2 – – – – 2.7 48.8 – 9.0 – 16.7 15.1 86.4 – 20.7 – – 2014 2014 2014 – 2013 2014 – 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 79.8 10.0 11.2 19.2 135.9 37.8 174.6 74.6 0.4 – 400.4 45.7 – 146.5 – 54.0 – – 138.0 2014 2014 2014 2013 2014 2014 2013 2014 2013 – 2014 2014 – 2014 – 2014 – – 2014 1156.8 257.3 37.6 53.0 52.7 51.8 27.4 1.3 83.0 303.1 156.7 – 1134.9 468.5 138.1 247.2 47.6 6.8 2195.5 83.4 570.6 772.8 597.5 1263.1 195.4 16.0 3.5 18.2 31.7 – 2.6 – 262.2 104.8 – 1186.5 – – – 47.0 7.2 2270.5 76.7 427.9 934.5 669.7 1064.3 308.9 59.0 7.0 87.2 72.9 – 0.0 – 343.5 205.4 – 1089.3 – – 0.0 48.1 6.4 2127.7 89.2 710.9 618.3 533.9 2014 2014 2014 2013 2012 2014 2014 2014 2014 2014 2014 – 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 3579.2 445.4 291.0 – 24.2 389.1 151.2 30.1 816.9 1246.7 713.6 691.8 2379.1 2366.0 311.6 81.0 385.3 113.2 6155.2 342.1 723.8 986.3 1573.7 2014 2014 2014 – 2012 2014 2014 2014 2014 2014 2014 2013 2014 2014 2014 2014 2014 2014 2013 2014 2014 2014 2014 GUD rate Total Males Females Year* Males UD rate Year*

36 | Report on global sexually transmitted infection surveillance – 2015

Country Eastern Mediterranean Region Bahrain Djibouti Iran Jordan Morocco Oman Saudi Arabia Sudan Tunisia United Arab Emirates European Region Malta Slovakia Tajikistan South-East Asia Region Bhutan India Indonesia Maldives Myanmar Timor-Leste Western Pacific Region Cambodia Cook Islands Fiji Kiribati Lao People's Democratic Republic Malaysia Mongolia Papua New Guinea Singapore Solomon Islands Tonga Tuvalu * Year of data collection

GUD rate Total – 16.6 – – 52.2 4.8 0.8 12.0 17.5 0.5 31.4 2.1 9.8 52.6 14.6 1.2 18.9 2.6 69.9 35.2 – 19.2 – – 0.9 9.3 35.7 19.8 156.5 – 0.0 Males 2.8 11.7 10.6 0.0 47.9 2.6 0.4 8.6 10.8 – 6.3 – 3.4 35.7 19.2 1.1 7.4 3.5 36.2 41.6 0.0 – – 43.6 1.1 12.8 – 24.8 162.7 – 0.0 Females 2.9 19.7 – 91.1 56.2 9.8 1.4 15.3 24.1 – 5.4 – 16.2 73.0 9.8 1.3 35.2 1.8 104.5 29.4 0.0 – – 11.7 0.6 6.0 – 14.2 150.2 – 0.0 Year* 2012 2013 2014 2012 2014 2014 2014 2014 2014 2014 2013 2013 2014 2012 2014 2014 2014 2014 2014 2014 2014 2014 – 2014 2014 2014 2014 2014 2014 – 2013 Males 26.4 21.7 31.2 100.2 614.0 7.3 7.9 100.6 18.8 0.1 61.2 – 222.7 278.1 210.0 12.1 5.0 5.0 314.2 356.1 107.1 247.4 128.6 112.9 9.0 33.4 756.7 140.6 1170.9 1051.7 1170.9

UD rate Year* 2014 2013 2014 2012 2014 2014 2014 2014 2014 2012 2013 – 2014 2012 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2014 2013

Report on global sexually transmitted infection surveillance – 2015 | 37

Annex 2. Male gonorrhoea rates (cases per 100 000 adult males) based on most recently reported Global AIDS Response Progress Reporting (GARPR) system data, 2012–2014 Country African Region Burkina Faso Cabo Verde Central African Republic Comoros Equatorial Guinea Gabon Mauritius Seychelles Region of the Americas Antigua and Barbuda Argentina Bahamas Barbados Belize Bolivia (Plurinational State of) Chile Costa Rica Cuba Dominica El Salvador Grenada Guatemala Guyana Honduras Mexico Nicaragua Panama Peru Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago Eastern Mediterranean Region Bahrain Iran Morocco Oman Saudi Arabia United Arab Emirates European Region Armenia Belarus Georgia Kazakhstan Kyrgyzstan Montenegro Republic of Moldova Serbia Tajikistan 24.5 45.5 30.4 60.0 25.9 2.9 61.2 4.3 8.0 2013 2014 2014 2013 2014 2014 2014 2014 2014 3.7 2.2 385.5 3.9 2.7 0.9 2014 2014 2014 2014 2014 2014 29.9 2.5 153.3 149.8 10.0 3.4 19.6 60.4 59.2 0.6 22.9 78.6 2.7 8.2 27.9 1.9 28.7 68.9 2.5 35.9 56.9 74.6 2014 2014 2014 2014 2013 2014 2013 2014 2014 2013 2013 2013 2014 2014 2014 2014 2014 2013 2014 2014 2014 2014 4.5 7.2 2.0 24.2 86.4 50.1 20.8 238.0 2013 2014 2013 2012 2014 2014 2013 2014 Male gonorrhoea rate Year*

38 | Report on global sexually transmitted infection surveillance – 2015

Country Turkey Ukraine South-East Asia Region Indonesia Myanmar Sri Lanka Thailand Western Pacific Region Australia Brunei Darussalam China Cook Islands Fiji Kiribati Malaysia Micronesia (Federated States of) Mongolia Nauru Singapore Solomon Islands Tonga Tuvalu * Year of data collection

Male gonorrhoea rate 0.1 25.5 7.7 2.4 6.3 20.4 112.8 85.1 14.1 91.8 317.1 5.7 13.5 88.6 237.2 158.9 0.5 40.8 273.1 27.6

Year* 2013 2014 2014 2014 2014 2014 2013 2013 2014 2014 2014 2014 2014 2014 2014 2013 2014 2014 2014 2013

Report on global sexually transmitted infection surveillance – 2015 | 39

Annex 3. Syphilis rates: Female, male, female primary, male primary and total rates (cases per 100 000 adults) based on most recently reported Global AIDS Response Progress Reporting (GARPR) system data, 2012–2014 Country African Region Algeria Burkina Faso Cabo Verde Central African Republic Equatorial Guinea Gabon Mauritius Senegal Seychelles Uganda Region of the Americas Antigua and Barbuda Argentina Bahamas Barbados Belize Bolivia (Plurinational State of) Chile Costa Rica Cuba Dominican Republic Ecuador El Salvador Grenada Guatemala Guyana Haiti Honduras Mexico Nicaragua Panama Paraguay Peru Saint Vincent and the Grenadines Trinidad and Tobago Uruguay Eastern Mediterranean Region Afghanistan Bahrain Iran Jordan Oman Saudi Arabia Somalia Tunisia United Arab Emirates 135.6 16.0 0.2 0.0 2.8 0.2 10.2 0.3 5.2 56.1 12.4 – 0.0 4.8 0.2 – 70.8 11.3 – – 0.3 – 0.1 – – – – 205.3 17.9 – 0.0 1.9 0.1 – 30.1 3.3 – – 0.0 – 0.0 – – – – 2014 2013 2014 2012 2014 2014 2012 2013 2014 52.2 24.5 141.1 41.5 23.0 36.2 30.6 49.0 37.6 0.6 77.5 25.0 198.1 7.6 5.1 563.1 9.1 4.3 5.8 66.6 127.1 19.7 227.7 25.7 78.6 70.8 – 131.1 15.0 30.1 49.4 27.9 46.4 24.6 0.9 – 22.3 249.3 9.6 7.5 677.4 6.1 3.6 4.6 59.7 – 18.4 231.0 16.9 – – – – – 28.5 – – – 24.4 – – – – 9.3 – – – – – – – – – 2.9 – 30.1 – 151.8 53.7 15.8 22.6 33.5 51.8 50.8 0.2 – 28.2 147.7 5.7 2.4 442.9 12.4 5.1 7.2 73.5 – 21.1 223.7 34.8 – – – – – 13.3 – – – 50.5 – – – – 5.6 – – – – – – – – – 16.9 – 2013 2014 2014 2014 2013 2012 2014 2014 2014 2013 2014 2013 2013 2014 2014 2013 2014 2014 2014 2014 2014 2014 2014 2014 2014 1.4 – 24.4 0.7 452.4 23.5 46.6 23.9 65.7 372.8 – – 10.5 0.8 523.1 46.1 – 40.1 – – – – – – – – – – – – – – 38.3 6.2 358.7 1.5 – 6.7 – – – 13.6 – – – – – – – – 2013 2014 2014 2013 2014 2014 2013 2014 2014 2014 Total rate Female rate Female primary rate Male rate Male primary rate Year*

40 | Report on global sexually transmitted infection surveillance – 2015

Country European Region Albania Armenia Belarus Georgia Kazakhstan Kyrgyzstan Montenegro Republic of Moldova Serbia Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Ukraine South-East Asia Region Indonesia Myanmar Sri Lanka Thailand Western Pacific Region Australia China Cook Islands Kiribati Malaysia Micronesia (Federated States of) Mongolia Nauru Papua New Guinea Singapore Solomon Islands Tuvalu Vanuatu * Year of data collection

Total rate

Female rate

Female primary rate 3.1 – – 5.1 – 30.5 – 15.7 – – – 0.0 – – – 0.9 0.9 – – 14.3 30.2 – – 5.9 185.3 – – 0.5 – – –

Male rate

Male primary rate 8.2 – – 7.2 – 21.8 – 30.3 – – – 0.1 – – – 0.9 2.4 – – 13.4 30.6 – – 17.1 122.8 – – 9.2 – – –

Year*

5.6 2.3 10.0 37.7 48.6 26.9 1.4 58.7 1.6 7.6 6.2 0.1 0.7 10.1 4.8 6.0 9.3 5.7 15.7 39.4 30.4 97.8 7.4 273.9 323.6 438.5 88.2 35.7 609.5 120.5 238.1

3.1 – 8.4 35.1 44.2 31.2 0.4 49.7 0.5 – 4.7 0.0 0.6 8.5 4.2 5.7 6.2 4.5 6.1 42.4 30.2 – 10.6 308.8 417.5 – 119.5 21.3 995.4 – –

8.2 – 12.0 40.7 53.7 22.4 2.5 68.8 2.8 – 7.7 0.1 0.8 12.0 5.3 6.4 12.7 7.0 25.4 36.6 30.6 – 4.4 217.1 222.7 – 57.6 51.6 232.8 – –

2014 2013 2014 2014 2013 2014 2014 2014 2014 2013 2014 2014 2013 2014 2014 2014 2014 2014 2012 2014 2015 2014 2014 2014 2014 2014 2014 2014 2014 2013 2013

Report on global sexually transmitted infection surveillance – 2015 | 41

Annex 4: Cascade of indicators for elimination of mother-to-child transmission (EMTCT) of syphilis using most recent data reported through the Global AIDS Response Progress Reporting (GARPR) system, 2008–2014* Country % of pregnant women Year with at least 1 ANC visit % of ANC attendees tested for syphilis** Year % of ANC attendees positive for syphilis Year % of infected ANC attendees treated Year Congenital syphilis rate (cases per 100 000 live births) Year

African Region Algeria Benin Botswana Burkina Faso Burundi Côte d'Ivoire Cabo Verde Cameroon Central African Republic Chad Comoros Congo Democratic Republic of the Congo Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Lesotho Liberia Madagascar Malawi Mali Mauritania Mauritius Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone South Africa South Sudan 92.9 83.5 93.6 94.9 98.9 88.9 90.9 84.7 54.6 42.6 92.1 89.7 89.2 91.3 – 33.9 94.7 86.2 96.4 85.2 92.6 91.5 – 95.9 82.1 96.1 74.2 84.2 – 90.6 96.6 82.8 60.6 98.0 97.5 94.5 – 97.1 97.1 40.3 2012 2012 2007 2010 2010 2012 2011 2011 2010 2010 2012 2012 2014 2011 – 2011 2012 2013 2011 2012 2010 2009 – 2013 2013 2014 2013 2011 – 2011 2013 2012 2013 2010 2009 2013 – 2013 2008 2010 64.1 2.8 92.3 100.0 0.7 92.1 94.1 – 35.8 100.0 29.0 0.3 72.8 26.7 0.0 28.1 29.2 41.5 33.9 – 8.9 70.3 84.3 11.1 30.4 7.4 26.7 50.9 100.0 46.3 78.2 8.2 14.9 84.3 100.0 11.1 100.0 0.0 74.5 0.3 2014 2014 2011 2013-4 2014 2008 2014 – 2013 2014 2014 2012 2014 2014 2010 2014 2014 2012 2014 – 2014 2014 2014 2014 2014 2014 2014 2013 2014 2014 2014 2014 2014 2014 2014 2014 2014 2010 2010 2013 0.2 0.1 1.3 1.2 0.0 0.2 0.7 0.6 3.3 3.4 0.2 – 4.0 5.6 1.1 0.9 0.2 – 2.5 1.5 2.2 1.4 1.5 11.3 4.3 3.7 9.5 3.8 0.8 4.1 1.9 0.2 1.6 0.9 1.5 0.1 0.1 1.4 1.6 5.6 2014 2014 2011 2014 2014 2010 2014 2010 2013 2013 2014 – 2014 2014 2008 2012 2014 – 2014 2009 2014 2014 2014 2014 2014 2014 2014 2013 2014 2014 2014 2014 2014 2014 2014 2014 2014 2010 2011 2013 90.3 – – – 62.2 100.0 65.1 100.0 – 87.5 100.0 72.4 – 9.2 72.3 – 100.0 – 100.0 – – – 2014 – – – 2014 2013 2014 2014 – 2013 2014 2014 – 2014 2014 – 2014 – 2014 – – – 97.8 100.0 – – 6.1 98.9 – – 66.9 2011 2013 – – 2014 2014 – – 2014 100.0 100.0 – 100.0 – – 100.0 2014 2014 – 2014 – – 2012 – – – – – – 9.9 – – – – – – 1233.5 – – 0.0 – – – – – – – – – – – 0.0 417.5 – – – – – – 0.0 – – – – – – – – – 2014 – – – – – – 2014 – – 2014 – – – – – – – – – – – 2014 2014 – – – – – – 2014 – – –

42 | Report on global sexually transmitted infection surveillance – 2015

Country

% of pregnant women Year with at least 1 ANC visit 96.8 72.7 94.9 87.8 95.7 93.7 2010 2013 2011 2010 2014 2014

% of ANC attendees tested for syphilis** 97.8 10.6 17.2 98.0 50.2 91.2

Year

% of ANC attendees positive for syphilis 3.3 0.1 6.7 2.5 4.6 2.1

Year

% of infected ANC attendees treated 98 79.6 – 40.4 100.0 –

Year

Congenital syphilis rate (cases per 100 000 live births) – – – – – –

Year

Swaziland Togo Uganda United Republic of Tanzania Zambia Zimbabwe Region of the Americas Antigua and Barbuda Argentina Bahamas Barbados Belize Bolivia (Plurinational State of) Brazil Canada Chile Colombia Costa Rica Cuba Dominica Dominican Republic Ecuador El Salvador Grenada Guatemala Guyana Haiti Honduras Jamaica Mexico Nicaragua Panama Paraguay Peru Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Suriname Trinidad and Tobago Uruguay Venezuela (Bolivarian Republic of) Eastern Mediterranean Region Bahrain Djibouti Iran (Islamic Republic of)

2014 2014 2014 2014 2014 2014

2014 2014 2014 2014 2014 2014

2014 2014 – 2014 2014 –

– – – – – –

100.0 98.1 86.0 93.4 96.3 85.8 96.0 100.0 – 97.0 95.0 100.0 100.0 99.3 84.1 94.0 100.0 93.0 85.7 89.9 94.2 97.6 98.7 94.7 92.6 96.1 95.9 100.0 96.9 99.5 90.4 95.3 97.4 –

2009 2012 2011 2012 2011 2008 2012 2007 – 2010 2012 2009 2009 2013 2007 2008 2009 2009 2009 2012 2012 2011 2012 2012 2013 2008 2013 2007 2012 2008 2010 2006 2012 –

100.0 86.5 87.5 88.1 93.4 69.1 89.5 – 94.6 82.6 87.0 99.4 99.2 16.8 67.8 98.1 100.0 50.9 82.7 61.7 56.6 89.2 57.3 87.9 33.1 66.1 78.8 87.0 66.5 100.0 – 97.8 98.9 96.1

2014 2014 2014 2014 2013 2014 2011 – 2013 2012 2011 2014 2013 2014 2010 2014 2013 2012 2013 2013 2014 2014 2014 2014 2013 2014 2014 2014 2013 2014 – 2009 2014 2010

0.3 1.2 1.6 0.3 0.3 1.4 0.7 – 0.2 0.6 0.3 0.2 1.9 1.9 0.1 0.1 1.3 0.2 0.1 3.1 0.1 1.7 0.4 0.1 1.2 1.1 0.6 0.0 1.9 0.7 0.0 0.3 0.6 1.9

2014 2014 2014 2014 2013 2014 2011 – 2013 2012 2010 2014 2013 2014 2010 2014 2013 2014 2013 2014 2014 2013 2014 2014 2014 2014 2014 2014 2013 2011 2013 2014 2013 2010

100.0 84.7 100.0 100.0 42.9 92.9 86.3 – 93.6 93.8 73.3 97.6 100.0 82.7 – 29.9 100.0 100.0 100.0 86.5 100.0 64.6 – 100.0 9.2 82.5 59.8 No cases 50.0 – – 64.3 98.6 –

2014 2014 2013 2014 2013 2014 2013 – 2014 2014 2010 2014 2013 2014 – 2013 2013 2014 2010 2014 2014 2014 – 2014 2013 2014 2014 2013 2014 – – 2014 2014 –

0.0 121.7 0.0 0.0 0.0 5.5 472.2 2.1 16.2 164.1 133.7 4.9 0.0 8.3 38.5 2.5 490.5 0.3 0.0 – 25.6 11.9 6.3 3.5 140.9 424.1 42.0 0.0 190.7 0.0 0.0 227.5 205.6 4.68

2011 2014 2014 2013 2013 2012 2014 2009 2013 2014 2014 2014 2013 2013 2010 2014 2013 2014 2013 – 2014 2010 2014 2014 2013 2014 2014 2014 2014 2010 2010 2008 2013 2013

100.0 81.0 96.9

2012 2006 2010

– 5.6 0.0

– 2013 2010

– 8.1 0.0

– 2010 2011

– – –

– – –

– –

– – –

Report on global sexually transmitted infection surveillance – 2015 | 43

Country

% of pregnant women Year with at least 1 ANC visit 77.7 99.1 77.1 99.0 91.0 98.0 22.0 74.3 83.6 100.0 59.8 97.3 99.1 76.6 99.7 85.8 99.2 98.2 – 98.9 97.6 – – 99.9 98.1 97.9 98.4 98.4 100.0 100.0 – 91.7 – 100.0 – 98.3 – 78.8 98.6 – 98.7 2011 2012 2011 2010 2012 2011 2006 2010 2012 2011 2013 2009 2010 2006 2012 2008 2007 2012 – 2012 2010 – – 2012 2010 2011 2014 2012 2010 2010 – 2013 – 2011 – 2014 – 2012 2012 – 2006

% of ANC attendees tested for syphilis** 27.3 0.0 – 100.0 – 42.6 8.5 9.3 – 100.0 – – 93.4 100.0 85.5 – 100.0 100.0 98.9 – 87.5 94.9 100.0 – – 99.9 92.8 – – 100.0 100.0 – 100.0 87.7 30.1 – 100.0 97.8 95.9 97.9 –

Year

% of ANC attendees positive for syphilis 0.0 0.0 0.9 0.0 – 0.0 1.5 2.2 – 0.3 0.4 – 0.0 0.0 0.0 – 0.0 0.1 0.0 – 0.2 0.2 – – – 0.1 0.0 – 0.0 0.0 – – 0.1 0.4 1.0 0.0 0.0 0.1 0.1 0.0

Year

% of infected ANC attendees treated – – – 100.0 – – 46.7 – – 80.0 – – – – 100.0 – – 100.0 100.0 91.8 – – – – – 100.0 – – 100.0 – – – 100.0 28.8 100.0 77.1 100.0 – –

Year

Congenital syphilis rate (cases per 100 000 live births) – – – 0.0 – 0.0 – – 0.0 0.0 – 0.0 0.0 0.12 0.0 0.0 0.0 0.05 0.02 0.07 19.8 0.0 0.0 0.02 0.0 4.4 6.9 0.0 0.0 0.0 0.0 13.4 – 15.1 – 0.0 0.02 0.9 0.4 0.0 –

Year

Iraq Jordan Morocco Oman Qatar Saudi Arabia Somalia Sudan Tunisia United Arab Emirates Yemen European Region Albania Armenia Azerbaijan Belarus Bosnia and Herzegovina Cyprus Czech Republic Denmark Estonia Georgia Germany Hungary Ireland Italy Kazakhstan Kyrgyzstan Latvia Lithuania Malta Monaco Montenegro Netherlands Republic of Moldova Romania Serbia Slovakia Tajikistan Ukraine United Kingdom Uzbekistan South-East Asia Region Bangladesh Bhutan Democratic People’s Republic of Korea

2010 2010 – 2014 2014 2010 2014 – 2014 – – 2013 2008 2014 – 2011 2010 2012 – 2014 2012 2008 – – 2013 2014 – – 2013 2014 – 2007 2014 2008 – 2014 2014 2014 2012 –

2010 2009 2012 2014 2014 2014 2010 – 2014 2010 – 2014 2008 2014 – 2011 2010 2012 – 2014 2011 – – – 2013 2014 – 2014 2013 – – 2008 2014 2014 2013 2014 2014 2012 2009

– – – 2014 – 2014 – – 2014 – – – – 2014 – – 2010 2010 2014 – – – – – 2014 – – 2014 – – – 2014 2014 2013 2014 2014 – –

– – – 2014 2014 – – 2014 2014 – 2014 2013 2011 2014 2010 2011 2011 2011 2010 2014 2011 2011 2010 2011 2013 2014 2011 2011 2011 2014 2014 – 2014 – 2014 2011 2014 2014 2010 –

58.7 74.4 100.0

2013 2010 2009

58.3 97.3 0.3

2014 2010 2012

0.5 1.0 0.0

2014 2010 2012

100.0 – –

2014 – –

– 5.4 –

– 2009 –

44 | Report on global sexually transmitted infection surveillance – 2015

Country

% of pregnant women Year with at least 1 ANC visit 75.1 95.7 99.2 83.1 99.4 98.1 84.4 2008 2012 2009 2010 2007 2012 2010

% of ANC attendees tested for syphilis** 65.1 1.2 66.0 10.0 86.2 96.8 55.6

Year

% of ANC attendees positive for syphilis 0.2 1.7 0.1 0.7 0.1 0.1 0.5

Year

% of infected ANC attendees treated 20.9 50.37 100.0 85.8 82.1 97.79 –

Year

Congenital syphilis rate (cases per 100 000 live births) – – – – 2.3 – –

Year

India Indonesia Maldives Myanmar Sri Lanka Thailand Timor-Leste Western Pacific Region Australia Brunei Darussalam Cambodia China Cook Islands Fiji Japan Kiribati Lao People's Democratic Republic Malaysia Marshall Islands Micronesia (Federated States of) Mongolia Nauru Palau Papua New Guinea Philippines Republic of Korea Samoa Solomon Islands Tonga Tuvalu Vanuatu Viet Nam

2014 2014 2014 2014 2013 2014 2014

2014 2014 2014 2014 2012 2014 2014

2014 2014 2014 2012 2014 2014 –

– – – – 2014 – –

96.1 93.2 89.1 95.0 – 98.3 – 88.4 52.5 96.5 92.4 80.0 98.7 94.1 90.3 66.0 95.4 100.0 93.0 90.6 99.0 93.3 75.6 95.8

2010 2012 2010 2012 – 2013 – 2009 2012 2012 2011 2008 2013 2007 2010 2012 2013 2009 2009 2009 2012 2007 2013 2014

– 100.0 44.9 99.5 100.0 100.0 – 100.0 – 98.9 100.0 97.2 97.2 100.0 100.0 8.9 – – 47.9 100.0 77.4 100.0 100.0 –

– 2013 2014 2014 2014 2013 – 2014 – 2014 2014 2014 2014 2014 2014 2011 – – 2014 2014 2014 2013 2014 –

– 0.2 0.0 0.2 0.0 0.9 – 6.4 0.8 0.1 5.1 2.8 2.6 4.6 0.9 6.7 0.1 – 0.1 13.5 0.1 1.8 0.2 0.3

– 2013 2014 2013 2014 2012 – 2014 2009 2014 2014 2014 2014 2014 2014 2011 2011 – 2014 2014 2014 2014 2013 2013

– – 97.3 68.1 No cases – – 100.0 – 100.0 100.0 63.5 89.3 – 100.0 – 43.3 – 100.0 63.8 100.0 100.0 93.5 –

– – 2014 2014 2014 – – 2014 – 2014 2014 2014 2012 – 2014 – 2011 – 2014 2014 2014 2013 2013 –

2.3 – – 61.6 0.0 235.0 22.2 – – 6.6 – 300.0 36.9 0.0 – – – 1.7 – – 0.0 0.0 – –

2013 – – 2014 2014 2014 2013 – – 2014 – 2013 2014 2014 – – – 2011 – – 2014 2013 – –

* Year of data collection ** ANC 1st visit data is from Global Health Observatory data (2015). http://apps.who.int/gho/data/view.main.1610?lang=en

Report on global sexually transmitted infection surveillance – 2015 | 45

Annex 5. Syphilis prevalence reported for female sex workers and MSM using most recent data reported through Global AIDS Response Progress Reporting (GARPR) system, 2008–2014 Country African Region Algeria Angola Botswana Burundi Burkina Faso Cameroon Cabo Verde Central African Republic Comoros Côte d'Ivoire Eritrea Gabon Ghana Guinea-Bissau Kenya Lesotho Liberia Madagascar Malawi Mali Mauritania Mauritius Niger Nigeria Sao Tome and Principe Senegal Seychelles Uganda United Republic of Tanzania Zimbabwe Region of the Americas Antigua and Barbuda Argentina Bahamas Barbados Belize Bolivia (Plurinational State of) Brazil Chile Colombia Costa Rica Dominican Republic Ecuador El Salvador Guatemala Guyana Honduras Jamaica Mexico Sex workers year 2008 2010 2012 2008 2014 2010 2013 2013 2014 2015 2008 2010 2011 2010 2011 2014 – 2013 2014 2010 2014 2010 2010 2008 2012 2014 2013 2008 2014 2012 – 2010 2010 – 2012 2014 2010 2013 2008 2013 2012 – 2014 2014 2014 2014 2010 2012 MSM % 0.3 – 2.9 1.1 1.1 0.4 – 10.5 – – – – 3.8 2.0 1.2 5.1 1.0 5.1 9.4 – 8.6 5.8 – 0.0 – 2.7 6.8 9.7 – – 10.0 17.7 44.1 13.6 0.0 29.0 8.3 – 3.3 13.7 12.9 6.2 3.8 1.4 1.0 4.5 15.0 10.0 year 2011 – 2012 2013 2014 2011 – 2013 – – – – 2011 2010 2010 2014 2013 2010 2014 – 2014 2010 – 2008 – 2014 2013 2008 – – 2012 2014 2010 2014 2012 2014 2009 – 2010 2010 2012 2011 2014 2014 2014 2014 2010 2012

% 18.4 3.7 3.5 28.1 1.4 17.5 0.9 5.0 0.8 0.9 1.3 2.1 6.3 19.6 0.9 27.2 – 16.7 20.0 0.0 2.5 4.4 2.3 1.4 4.7 19.6 6.9 20.4 7.8 12.3 – 22.4 0.0 – 0.5 3.0 2.5 11.1 18.0 4.5 9.5 – 1.0 0.5 1.6 2.3 1.2 3.5

46 | Report on global sexually transmitted infection surveillance – 2015

Country Nicaragua Panama Paraguay Peru Trinidad and Tobago Uruguay Eastern Mediterranean Region Afghanistan Armenia Djibouti Iran Jordan Morocco Somalia Sudan Yemen European Region Armenia Belarus Belgium Bosnia and Herzegovina Bulgaria Czech Republic Estonia Georgia Germany Hungary Italy Kazakhstan Kyrgyzstan Kosovo Latvia Lithuania Netherlands Republic of Moldova Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Ukraine United Kingdom Uzbekistan South-East Asia Region Bangladesh India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste

% 2.3 53.0 7.9 6.1 10.8 0.7 1.0 0.8 5.0 0.0 6.7 17.7 3.4 4.4 4.9 4.0 1.6 0.7 4.0 15.3 2.1 0.9 – 0.8 – – 17.7 10.4 3.5 – 5.7 0.2 10.1 – 9.6 1.1 2.9 4.4 – 5.4 3.8 0.3 4.1 0.0 8.7 0.7 0.6 0.7 9.8

Sex workers year 2014 2013 2012 2014 2011 2013 2012 2014 2014 2011 2008 2011 2008 2011 2008 2012 2013 2013 2011 2012 2010 2011 – 2011 – – 2008 2010 2011 – 2008 2010 2013 – 2010 2011 2010 2009 – 2011 2011 2014 2014 2008 2014 2011 2014 2013 2011

MSM % 5.5 32.2 14.1 11.1 8.9 – 10.1 – – – 1.8 8.3 – 2.5 – 1.8 2.0 7.7 0.6 3.0 9.6 6.8 – 8.1 4.4 9.1 4.1 5.7 2.7 1.6 0.3 2.3 5.4 7.0 5.1 0.5 – 1.9 2.5 1.3 1.2 0.3 16.4 0.0 4.4 0.8 0.8 21.6 8.3 year 2014 2014 2014 2014 2011 – 2012 – – – 2008 2011 – 2011 – 2014 2013 2010 2011 2012 2010 2014 – 2010 2010 2010 2008 2010 2014 2008 2014 2010 2013 2008 2011 2011 – 2010 2010 2011 2014 2014 2014 2008 2014 2012 2014 2008 2014

Report on global sexually transmitted infection surveillance – 2015 | 47

Country Western Pacific Region Cambodia China Fiji Kiribati Lao People's Democratic Republic Malaysia Mongolia Papua New Guinea Philippines Singapore Viet Nam

% 0.1 2.3 28.0 0.0 0.5 0.7 29.6 21.1 1.3 0.6 1.3

Sex workers year 2014 2014 2012 2014 2011 2012 2014 2010 2009 2014 2014

MSM % 0.9 6.0 26.5 – – 0.0 7.1 – 2.1 15.1 4.2 year 2012 2014 2010 – – 2011 2014 – 2010 2014 2014

* Year of data collection

Annex 6. Reported percentage of gonoccocal isolates with resistance to azithromycin and ciprofloxacin/quinolones and elevated minimum inhibitory concentrations (MICs) of cefixime (> 0.25μg/ml) or ceftriaxone (> 0.125 μg/ml), 2012 and 2013 Cefixime 2013 No. of isolates 36 606 891 61 60 20 46 0.0 0.0 0.0 0.0 0.0 767 8.0 767 65 60 21 5 18 14 4 1684 3195 5945 35 109 40 110 9 110 112 101 75 0.0 68 1.0 106 0.0 110 1.8 5.7 5.9 0.0 114 12.3 0.0 3 0.0 9 110 112 101 75 0.0 107 0.9 110 0.0 75 0.0 40 0.0 107 4.7 109 6.4 2.5 6.4 0.0 11.8 3.6 12.9 14.7 0.0 107 75 107 3 114 110 106 68 2.8 1.3 1.9 0.0 13.2 0.0 1.9 5.9 109 40 110 9 110 112 101 66 5.5 0.0 1.8 33.3 9.1 0.0 4.0 22.7 107 75 107 3 114 110 106 68 73.8 21.0 56.1 100.0 58.8 39.1 73.6 69.1 109 40 110 9 110 112 101 75 71.6 28.0 56.4 88.9 58.2 44.6 63.4 72.0 0.1 5495 1.0 5495 0.4 5495 3.5 3036 2.2 3195 1.8 3036 0.0 767 8.0 0.9 0.3 606 3195 5945 0.5 1.2 0.6 1358 3036 5495 0.0 606 0.5 404 0.0 36 13.6 49.0 30.9 40.0 46.7 0.0 0.0 66.7 42.9 0.0 37.3 28.5 14.7 2 1686 3195 5945 0.0 45.1 29.3 16.1 46 58.7 % No. of isolates % No. of isolates % No. of isolates % No. of isolates % No. of isolates % No. of isolates 36 606 891 61 60 20 2012 2013 2012 2013 2012 2013 % Azithromycin Quinolones/Ciprofloxacin

Region and country

Ceftriaxone

2012

No. of isolates

%

African Region 0.9 54.0 41.0 14.8 46.7 20.0

Côte d'Ivoire

Region of the Americas

Argentina

404

0.0

Chile

767

0.0

Columbia

65

Cuba

60

0.0

El Salvador

21

0.0

Panama

5

0.0

Paraguay

18

0.0

Venezuela

14

0.0

Dominican Republic

48 | Report on global sexually transmitted infection surveillance – 2015

Regional total

1354

0.0

Canada

3036

5.5

USA

5495

0.3

Eatern Mediterranean Region

Morrocco

European Region

Austria

107

0.0

Belarus

75

0.0

Belgium

107

0.0

Cyprus

3

0.0

Denmark

114

0.0

France

110

0.0

Germany

106

0.9

Greece

68

0.0

Region and country 2013 No. of isolates 88 5 103 100 38 31 139 108 112 110 106 110 73 119 100 240 2034 142 50 0.0 55 0.3 2110 3.6 2034 0.9 2216 0.0 262 0.0 240 0.8 262 1.9 5.2 0.0 3.6 0.0 110 0.0 100 0.0 110 6.4 5.0 105 15.2 119 15.1 105 9.5 0.0 47 4.3 73 1.4 47 14.9 73 119 100 240 2025 215 50 113 496 546 4658 239 0.8 0.6 0.4 0.4 749 946 4394 324 0.4 0.5 1.4 0.3 464 842 4658 239 0.0 108 3.7 110 4.5 108 2.8 110 17.0 1.8 0.0 8.4 9.0 0.4 5.3 0.0 2.0 1.8 0.9 4.7 2.2 0.0 0.0 110 0.0 110 0.0 110 1.8 110 18.2 0.0 110 5.5 112 4.5 110 12.7 112 10.7 0.0 108 10.2 108 110 110 106 108 47 105 110 262 2216 187 88 71 48 722 1116 4394 324 0.0 146 0.0 139 0.0 146 0.7 139 1.4 146 0.0 16 0.0 31 0.0 16 0.0 31 0.0 16 0.0 39 2.6 38 2.6 39 5.1 38 15.8 39 38.5 56.3 34.2 68.5 55.5 40.9 25.5 53.7 40.4 58.1 57.3 27.9 48.9 88.2 97.7 94.3 95.8 86.9 88.9 32.2 2.8 113 510 888 4658 239 97.3 92.2 93.2 35.8 2.1 110 73 119 100 240 2034 215 50 47.3 63.0 65.5 60.0 32.1 52.4 93.0 96.0 112 110 79.5 47.3 0.0 100 6.0 100 0.0 100 2.0 100 1.0 100 65.0 0.0 80 3.8 103 0.0 80 8.8 103 2.9 80 22.5 0.0 5 0.0 5 0.0 5 103 100 38 31 139 0.0 79 6.3 88 6.8 79 0.0 88 2.3 79 65.8 88 % No. of isolates % No. of isolates % No. of isolates % No. of isolates % No. of isolates % No. of isolates % 68.2 40.0 26.2 63.0 26.3 35.5 34.5 2012 2013 2012 2013 2012 2013

Ceftriaxone

Cefixime

Azithromycin

Quinolones/Ciprofloxacin

2012

No. of isolates

%

Hungary

79

0.0

Iceland

Ireland

80

1.3

Italy

100

0.0

Latvia

39

0.0

Malta

16

0.0

The Netherlands

146

0.0

Poland

108

0.0

Norway

110

0.0

Portugal

110

0.0

Russia

106

0.0

Slovakia

108

0.0

Slovenia

47

2.1

Spain

105

0.0

Sweden

110

0.0

United Kingdom

262

0.0

Regional total

2216

0.1

South-East Asia Region

Bhutan

India

88

0.0

Pakistan

Sri Lanka

Thailand

748

0.4

Regional total

836

0.4

Western Pacific Region

Australia (Urban)

4394

0.3

Report on global sexually transmitted infection surveillance – 2015 | 49

Australia (Remote)

324

0.0

Region and country 2013 No. of isolates 204 7 1236 168 1134 391 12 444 140 384 129 55 44 7630 2.3 6419 2.4 2.3 90 1.1 44 7073 1.8 2.3 3.3 0.0 89 0.0 1.0 74 0.0 0.0 0.2 444 4.1 517 150 345 23 160 90 8949 8.3 91 0.0 91 21.9 371 10.8 391 13.8 98 4.5 1149 4.2 1134 4.7 1149 96.1 72.4 96.7 43.7 0.7 41.7 95.7 71.9 100.0 52.4 0.0 99.6 120 1134 391 82 444 140 384 127 160 44 8032 0.0 93.7 70.8 93.9 19.8 0.7 35.4 93.7 83.1 93.2 45.9 83.8 102 % No. of isolates % No. of isolates % No. of isolates % No. of isolates % No. of isolates % No. of isolates % 70.6 100.0 2012 2013 2012 2013 2012 2013

Ceftriaxone

Cefixime

Azithromycin

Quinolones/Ciprofloxacin

2012

No. of isolates

%

Brunei

Cambodia

China

1236

12.8

Fiji

Hong Kong

1149

5.5

Japan

371

0.5

Korea

Mongolia

New Caledonia

New Zealand

401

0.3

Philippines

23

0.0

Singapore

160

0.0

Viet Nam

Regional total

8058

3.0

50 | Report on global sexually transmitted infection surveillance – 2015

Source: WHO/GASP (2015)

Report on global sexually transmitted infection surveillance – 2015 | 51

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For more information, please contact: Department of Reproductive Health and Research World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4171 E-mail: reproductivehealth@who.int www.who.int/reproductivehealth ISBN 978 92 4 156530 1